Guillain Barre syndrome mimicking brain death.

A 49-year-old female patient presented at the hospital with a history of herpetic blisters, frequent episodes of vomiting and loose stools, bilateral upper and lower limb weakness, and diminishing sensorium. She was diagnosed with hyponatraemia and respiratory failure and later became unconscious with absent brainstem reflexes. The patient was initially treated for herpetic encephalitis, a chronic obstructive pulmonary disease with acute exacerbation, hyponatraemia and neuroparalytic snake bite. Further evaluation, however, identified the uncommon Guillain Barre syndrome presentation with overlap of Bickerstaff brainstem encephalitis. This is an uncommon disorder characterised by the involvement of higher mental functions, fixed dilated pupils, absent brainstem reflexes and quadriplegia that resembles a neuroparalytic snake bite and brain death. After receiving intravenous immunoglobulins for treatment, the patient completely recovered.

Early empiric antibiotic use in COVID-19 patients: results from the international VIRUS registry.

OBJECTIVES: COVID-19 escalated inappropriate antibiotic use. We determined the distribution of pathogens causing community-acquired co-infections, the rate, and factors associated with early empiric antibiotic (EEAB) treatment among hospitalized COVID-19 patients. METHODS: The Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry including 68,428 patients from 28 countries enrolled between January 2020 and October 2021 were screened. After exclusions, 7830 patients were included in the analysis. Azithromycin and/or other antibiotic treatment given within the first 3 days of hospitalization was investigated. Univariate and multivariate analyses were performed to determine factors associated with EEAB use. RESULTS: The majority (6214, 79.4%) of patients received EEAB, with azithromycin combination being the most frequent (3146, 40.2%). As the pandemic advanced, the proportion of patients receiving EEAB regressed from 84.4% (786/931) in January-March 2020 to 65.2% (30/46) in April-June 2021 (P < 0.001). Beta-lactams, especially ceftriaxone was the most commonly used antibiotic. Staphylococcus aureus was the most commonly isolated pathogen. Multivariate analysis showed geographical location and pandemic timeline as the strongest independent predictors of EEAB use. CONCLUSIONS: EEAB administration decreased as pandemic advanced, which may be the result of intensified antimicrobial stewardship efforts. Our study provides worldwide goals for antimicrobial stewardship programs in the post-COVID-19 era.

The genus Ralstonia: The new kid on the block.

The genus Ralstonia comprises of aerobic, gram-negative, oxidase positive, nonfermentative, largely environmental organisms. They are an emerging pathogen in the hospital setting and are increasingly associated with opportunistic infections and outbreaks. We hereby present a case series of six patients diagnosed with bacteraemia caused by Ralstonia spp. and a brief review of literature. These cases highlight that isolation of a nonfermenting gram-negative bacillus from blood culture of a patient admitted in critical care setting should not be ignored as mere contaminant. Clinicians and microbiologists need to work as a team to combat this novel bug.

Seroprevalence of SARS-CoV-2 IgG antibody among healthy blood donors: a single centre study.

BACKGROUND: Severe acute respiratory syndrome corona virus 2(SARS-CoV-2), the causative agent of corona virus disease-2019(COVID- 19) which has led to a global pandemic. The true extent of the burden of COVID-19 may be underestimated, and there is need to know the current prevalence of SARS-CoV-2 antibody in population. METHODS: The present study was a cross-sectional study to assess prevalence of SARS-CoV- 2 IgG antibody among 586 healthy voluntary blood donors who donated whole blood between mid-December 2020 to January 2021. A chemiluminescence assay was used to detect the presence of SARS-CoV-2 IgG antibody in serum samples in addition to recommended transfusion transmitted infections tests and Signal to Cut Off (S/C) > 1 was considered as reactive for antibody as per manufacturer's instructions. RESULTS: In the present study, 586 healthy voluntary blood donors were enrolled and were screened for SARS- CoV-2 IgG antibody. Out of 586 donors, 52 donors had indeterminate values of SARS-CoV-2 IgG antibody. A total of 534 healthy voluntary blood donors' samples were included in the present study for analysis. Out of total 534 healthy blood donors, 42.88% (229) were found to be seropositive while 57.11% (305) were found to be seronegative. CONCLUSION: A 43% positivity of SARS-CoV-2 IgG antibody among healthy blood donors was detected which is an indication of presence of infection at community level and majority of the population already has been exposed to SARS-CoV-2 infection. However, there was no statistically significant association of type of blood group and age with seropositivity.

Prevalence of Dengue Serotypes and Its Correlation With the Laboratory Profile at a Tertiary Care Hospital in Northwestern India.

Background and aim Dengue fever is an emerging arboviral public health problem in a large endemic population in the tropical and sub-tropical areas of the world, with varying degrees of clinical presentation. This study was aimed at analyzing the clinical and laboratory dynamics of the four dengue serotypes. Methods This institutional review board (IRB)-approved hospital-based observational study was performed with 100 in-patients with dengue infection above 12 years of age, without co-morbidities or known malignancy, in a tertiary care center in Northern India. Results Out of 100 patients, four had concurrent infection with two serotypes. Dengue virus serotype-2 (DENV 2) was the most common serotype (34%) and had the maximum percentage of cases of severe dengue (20.6%). The mean total leukocyte count did not differ between the serotypes. DENV 4 had a significantly higher mean neutrophil percentage and a significantly lower mean lymphocyte percentage than DENV 1 (p-value 0.001 and 0.02, respectively), with a higher percentage of cases of severe dengue (20% vs 14.3%, non-significant). Thrombocytopenia was present in all serotypes of infection. There was a significant difference in the derangement of liver function in DENV 2, 3, and 4 as compared to DENV 1. Mean serum albumin levels were significantly lower in DENV 3 and 4 infections. Cases with co-infection had a much higher derangement of liver function and lower mean serum albumin than infections with a single serotype. The mean blood urea and creatinine levels were in the normal range for all serotypes. No mortality occurred in our study. Conclusion DENV 2 is the most common serotype with maximum severity at our hospital. DENV 2 and DENV 4 have a high percentage of cases with severe dengue (20.6% and 20%, respectively). The mean lymphocyte percentage was significantly lower while hepatic involvement and hypoalbuminemia were greater in DENV 4. Initial serotyping in patients with dengue can help monitor the epidemiological trends and help estimate the clinical and laboratory trends of the different serotypes of dengue infection. Particular care should be taken in patients with co-infection.

A Case Report on Acute Pancreatitis in a Patient With Coronavirus Disease 2019 (COVID-19) Pneumonia.

With the ongoing coronavirus disease 2019 (COVID-19) pandemic, there has been an explosion of scientific literature on the clinical manifestations and pathogenesis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Gastrointestinal symptoms occur in 15-20% of COVID-19 patients; however, there have not been many case reports on acute pancreatitis in COVID-19 patients. The expression of ACE-2 ([angiotensin-converting enzyme 2] the host receptor for SARS-CoV-2) is very high in the pancreas, which might be a contributing factor, but the high expression is mainly localized to endocrine pancreas. This case report describes a case of a 25-year-old Indian female with COVID-19 with acute pancreatitis in the absence of any other known risk factors for pancreatitis.

Acute cyanide Intoxication: A rare case of survival.

A 30-year-old male jewellery factory worker accidentally ingested silver potassium cyanide and was brought to the emergency department in a state of shock and profound metabolic acidosis. This patient was managed hypothetically with use of injection thiopentone sodium intravenously until the antidote was received. Cyanide is a highly cytotoxic poison and it rapidly reacts with the trivalent iron of cytochrome oxidase thus paralysing the aerobic respiration. The result is severe lactic acidosis, profound shock, and its fatal outcome. The patient dies of cardio-respiratory arrest secondary to dysfunction of the medullary centres. It is rapidly absorbed, symptoms begin few seconds after exposure and death usually occurs in <30 min. The average lethal dose for potassium cyanide is about 250 mg. We used repeated doses of thiopentone sodium till the antidote kit was finally in our hands, hypothesising that it contains thiol group similar to the antidote thiosulphate. Moreover, it is an anticonvulsant. We were successful in our attempts and the patient survived though the specific antidotes could be administered after about an hour.

Prevalence of Rheumatological Manifestations in Diabetic Population from North-West India.

INTRODUCTION: An increased prevalence of rheumatological manifestations is recognised in diabetes and is a common source of disability. The relationship with other risk factors and glycaemic control is uncertain. We designed this study to find out the prevalence of rheumatological manifestations, association with various risk factors and to assess differences between type 1 and type 2 diabetes. MATERIAL AND METHODS: The study was conducted from Jan 2010 to Dec 2011 at tertiary care hospital. We recorded type of diabetes, various risk factors viz age, duration of diabetes, glycaemic control (HbA1C) and BMI and noted prevalence of various rheumatological manifestations by clinical examination, X-ray and if needed CT scan/MRI. We explored correlation between rheumatological manifestations and these variables using logistic regression. RESULTS: The prevalence of rheumatological manifestations was estimated at 570 per 1000 population. The manifestations were more common in type 1 diabetes (62.7%). The various complications observed in the present study were DISH (13%), Frozen Shoulder (20%), Dupuytren's Contracture (7.2%), Osteoarthritis (36.1%), Neuroarthropathy (2.9%), Chieroarthropathy (22.6%) and Flexor Tenosynovitis (8.1%). Among various risk factors, duration of diabetes (odd ratio: 5.127), BMI (odd ratio: 7.429) and age (odd ratio: 4.731) were common risk factors. Poor glycaemic control was also associated with increased prevalence of rheumatological manifestations. CONCLUSION: Rheumatologic manifestations are very common in diabetics and are associated with poor glycaemic control, BMI, duration of diabetes and age of the patients.

A randomized, comparative, multicentric clinical trial to assess the efficacy and safety of zileuton extended-release tablets with montelukast sodium tablets in patients suffering from chronic persistent asthma.

Leukotriene (LT) modifiers are anti-inflammatory drugs that are useful as an add-on therapy with first-line asthma-controller medications. This group includes LT synthesis inhibitors (eg, Zileuton) and receptor antagonists (eg, Montelukast), whose direct comparative clinical data are not available. This study was conducted to assess the comparative efficacy and safety of orally administered Zileuton extended-release (ER) with Montelukast sodium in patients suffering from chronic persistent asthma. Patients of 18-65 years of age with mild to moderate chronic stable asthma were randomized to treatment with Zileuton ER 2400 mg/d or Montelukast 10 mg/d for 12 weeks. Peak expiratory flow rate (PEFR) and asthma symptoms (cough, wheeze, chest tightness, and shortness of breath each on a 4-point scale) were assessed on monthly scheduled out-patient visits. Safety assessments by clinical and laboratory parameters were carried out during the course of the study. Among 210 patients eligible for efficacy assessment, PEFR improved by 64.8 ± 52.8 (95% confidence interval: 54.8-74.7) L/min with Zileuton ER (n = 109) and 40.6 ± 47.5 (31.3-49.9) L/min with Montelukast (n = 101; P < 0.001), whereas percent improvements were 27.0% (22.6%-31.5%) versus 18.4% (14.1%-22.7%), respectively (P = 0.006). Zileuton ER lead to ≥12% PEFR improvements in 74 of 109 [67.9% (59.1%-76.7%)] patients, whereas the same was noted in 52 of 101 [51.5% (41.7%-61.2%)] patients receiving Montelukast (P = 0.015). The reduction in the mean overall symptom intensity score was also significantly better with Zileuton ER [-5.0 ± 2.1 (4.6-5.4) versus -4.2 ± 2.3 (3.8-4.7)] (P = 0.018); however, the same was not observed for the decline in the individual symptom scores. A lesser but not significantly different adverse event rate was reported in the Zileuton ER group than the Montelukast group with the commonest events being headache and gastrointestinal effects in both the groups. Thus, Zileuton ER seems to be more efficacious than Montelukast and well tolerated for the treatment of mild to moderate chronic persistent asthma in adult patient population. Further studies can elucidate the comparative treatment benefits of these LT modifiers in asthma management.