COVID Pneumonia in the Elderly - Not a Basket Case Always.

COVID 19 is a respiratory disease, caused by a novel coronavirus, which was christened as SARSCoV2. It has spread rapidly all over the globe, leading to a pandemic with high mortality, due to the lack of pre-existing immunity. The elderly population (old-old ; > 75 years) has been increasingly affected with more severe respiratory symptoms, as compared to the young old (60-75 years) and middle aged patients, probably due to the increasing presence of comorbidities. A greater proportion of the elderly have lymphopenia, raised inflammatory markers and increased D-dimer levels. We report two such cases with severe Adult Respiratory Distress Syndrome (ARDS), who improved with early diagnosis and management. Hence, prompt diagnosis and early intervention can avert a bad outcome.

sMAdCAM: IL-6 Ratio Influences Disease Progression and Anti-Viral Responses in SARS-CoV-2 Infection.

The role of sMAdCAM, an important gut immune migratory marker, remains unexplored in COVID-19 pathogenesis considering recent studies positing the gut as a sanctuary site for SARS-CoV-2 persistence. Thus, assimilating profiles of systemic inflammatory mediators with sMAdCAM levels may provide insights into the progression of COVID-19 disease. Also, the role of these markers in governing virus specific immunity following infection remains largely unexplored. A cohort (n = 84) of SARS-C0V-2 infected individuals included a group of in-patients (n = 60) at various stages of disease progression together with convalescent individuals (n = 24) recruited between April and June 2020 from Mumbai, India. Follow-up of 35 in-patients at day 7 post diagnosis was carried out. Th1/Th2/Th17 cytokines along with soluble MAdCAM (sMAdCAM) levels in plasma were measured. Also, anti-viral humoral response as measured by rapid antibody test (IgG, IgM), Chemiluminescent Immunoassay (IgG), and antibodies binding to SARS-CoV-2 proteins were measured by Surface Plasmon Resonance (SPR) from plasma. IL-6 and sMAdCAM levels among in-patients inversely correlated with one another. When expressed as a novel integrated marker-sMIL index (sMAdCAM/IL-6 ratio)-these levels were incrementally and significantly higher in various disease states with convalescents exhibiting the highest values. Importantly, sMAdCAM levels as well as sMIL index (fold change) correlated with peak association response units of receptor binding domain and fold change in binding to spike respectively as measured by SPR. Our results highlight key systemic and gut homing parameters that need to be monitored and investigated further to optimally guide therapeutic and prophylactic interventions for COVID-19.

Clots in COVID: A Case Series.

As the novel coronavirus-2019 (COVID-19) pandemic spreads across the world, early recognition of the spectrum of symptoms and patterns of clinical presentation is crucial for optimal management. Emerging evidence shows that COVID-19 leads to a prothrombotic state and its association with pulmonary thromboembolism is well established. However, clinicians and the vascular community, in particular, should watch out for the nonpulmonary targets of this lethal virus as the failure to do so could give rise to disastrous consequences. The significance of raised D-dimer levels, whether it translates into thrombotic events for all patients and the need for universal oral anticoagulation postdischarge are issues that need urgent answers. We report a case series of five patients with thrombosis involving nonpulmonary sites. How to cite this article: Kaneria MV, Nadaf S, Desai U. Clots in COVID: A Case Series. Indian J Crit Care Med 2021;25(7):817-821.

Sustained Release Formulation of Primaquine for Prevention of Relapse of Plasmodium vivax Malaria: A Randomized, Double-Blind, Comparative, Multicentric Study.

Background. Primaquine is used to eradicate latent Plasmodium vivax parasite from liver, with administration of standard dose daily up to 14 days. We studied efficacy, safety, and tolerability of sustained release (SR) formulation of primaquine in comparison with conventional primaquine in preventing relapse of P. vivax malaria. Methods. Microscopically confirmed cases of P. vivax malaria received chloroquine therapy for three days. Aparasitemic and asymptomatic patients were then randomized to receive either conventional primaquine 15 mg for 14 days or primaquine SR 15 mg for 14 days, or primaquine SR 30 mg for seven days. Results. Of the 360 patients, who received chloroquine therapy, 358 patients were randomized. Two-hundred eighty-eight patients completed six-month follow-up and four patients (three: conventional primaquine 15 mg (2.86%), one: primaquine SR 30 mg (0.93%)) showed relapse confirmed by PCR genotyping. Drug compliance was significantly better in primaquine SR 30 mg group (95.57%, p = 0.039) without any serious adverse events. Conclusion. Primaquine SR 15 mg and primaquine SR 30 mg could be an effective alternative to conventional primaquine 15 mg due to their comparable cure rates and safety profile. Shorter treatment duration with primaquine SR 30 mg may increase patient compliance and may further reduce relapse rates. Clinical Trial Registration. This trial is registered with CTRI/2010/091/000245.

Incidence of Clostridium difficile associated diarrhoea in a tertiary care hospital.

BACKGROUND AND OBJECTIVES: Rampant and injudicious use of broad spectrum antibiotics in hospitalized patients has increased the incidence of Clostridium difficile associated diarrhoea (CDAD). Though antibiotic use is the best known risk factor for CDAD, the occurrence of community acquired C. difficile suggests the presence of other risk factors too. However CDAD is still under-recognized in India and Asia. Therefore we undertook a prospective study to determine the incidence of Clostridium difficile associated diarrhoea in our hospital. METHODS: 50 patients of antibiotic associated diarrhoea (AAD) and 50 age and sex matched controls were studied prospectively over a period of 1 year. Controls were patients on antibiotics who did not have diarrhoea. All other causes of diarrhoea were ruled out. Fresh stool samples were examined for the presence of C. difficile toxin A and B by the enzyme-linked immunofluorescence assay. RESULTS: 5 patients in the AAD group (10%) and 3 patients in the control group (6%) were positive for C. difficile toxin A and B. 5 (10%) patients in the control group showed equivocal results. Out of the 5 CDAD patients, 4 (80%) were males and 1 was a female (p = 2, not significant). 3 patients were from the MICU and 2 were from the medical wards. The median age of the patients was 39 years. Only 1 male patient was > 60 years old (p = 0.781, not significant). All 5 CDAD patients were on proton pump inhibitors (PPIs) and 2 had Ryle's tube inserted (p = 0.22, not significant). Only 2 patients had leucocytosis (p = 1.67, not significant) and none showed faecal leucocytosis. So out of 100 patients on antibiotics, 8 (8%) tested positive for C. difficile toxins in their stools. However, only 5 (5%) had diarrhoea (CDAD) whereas 3 (3%) were asymptomatic carriers. INTERPRETATION AND CONCLUSIONS: The incidence of CDAD in our hospital was 10% of the 50 patients with AAD. The asymptomatic carriage rate was 6%. All the cases had mild to moderate diarrhoea and were responsive to metronidazole unlike the west where the incidence is higher and the disease more severe.

Subarachnoid haemorrhage: possibly caused by the illegitimate use of sildenafil citrate.

Sildenafil (Viagra) has been developed as a drug to treat male impotence. It has also been used to reduce symptoms (e.g. improved exercise capacity) in patients with pulmonary arterial hypertension. A case of subarachnoid haemorrhage (SAH) following the illicit use of sildenafil is reported.