Role of cardiovascular magnetic resonance imaging in COVID-19 recovered patients: A short-term follow-up study.

OBJECTIVE: Cardiac involvement in recovered COVID-19 patients assessed by cardiac magnetic resonance imaging (MRI). METHODS: Subjects recently recovered from COVID-19 and with an abnormal left ventricular global longitudinal strain were enrolled. Cardiac MRI in all the enrolled subjects was done at baseline (within 30-90 days following recovery from COVID-19) with a follow-up scan at 6 months in individuals with an abnormal baseline scan. Additionally, 20 age-and sex-matched individuals were enrolled as healthy controls (HCs). RESULTS: All the 30 enrolled subjects were symptomatic during active COVID-19 disease and were categorized as mild: 11 (36.7%), moderate: 6 (20%), and severe: 13 (43.3%). Of the 30 patients, 16 (53.3%) had abnormal CMR findings. Myocardial edema was reported in 12 (40%) patients while 10 (33.3%) had late gadolinium enhancement (LGE). No difference was observed in terms of conventional left ventricular (LV) parameters; however, COVID-19-recovered patients had significantly lower right ventricular (RV) ejection fraction, RV stroke volume, and RV cardiac index compared to HCs. Follow-up scan was abnormal in 4/16 (25%) with LGE persisting in three patients (who had severe COVID-19 [3/4;75%]). Subjects with severe COVID-19 had a greater frequency of LGE (53.8%) and myocardial edema (61.5%) as compared to mild and moderate cases. Myocardial T1 (1284 ± 43.8 ms vs. 1147.6 ± 68.4 ms; p < .0001) and T2 values (50.8 ± 16.7 ms vs. 42.6 ± 3.6 ms; p = .04) were significantly higher in post COVID-19 subjects compared to HCs. Similarly, T1 and T2 values of severe COVID-19 patients were significantly higher compared to mild and moderate cases. CONCLUSIONS: An abnormal CMR was seen in half of the recovered patients with persistent abnormality in one-fourth at 6 months. Our study suggests a need for closer follow-up among recovered subjects in order to evaluate for long-term cardiovascular sequelae. COVID-19 causes structural changes in the myocardium in a small segment of patients with partial spontaneous resolution.

Leishmaniasis.

Leishmaniasis is one of the chronic debilitating vector-borne diseases caused by obligate intracellular protozoa. The global burden of disease although not increasing but potential risk of spread is there. At least 20 species of Leishmania are pathogenic to human beings. The transmission is from female sandfly through a blood meal. The disease pathogenesis is dependent on parasite and host mechanism-primarily cell-mediated immunity. The three common forms are visceral, cutaneous, and mucocutaneous. The diagnostic tests are mainly based on aspiration from the spleen or bone marrow. The use of K39 antibodies is the best serodiagnostic test. Antimonial, amphotericin B, miltefosine, and paromomycin are the drugs used to treat leishmaniasis. Amphotericin therapy shows the response within 7 to 10 days in most subjects, and 2 weeks of therapy is sufficient. However, those going into relapse need new treatment regimes. There is a definite benefit of combination therapy. However, there is still no breakthrough on a vaccine for prophylaxis. How to cite this article: Daga MK, Rohatgi I, Mishra R. Leishmaniasis. Indian J Crit Care Med 2021;25(Suppl 2):S166-S170.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19.

INTRODUCTION: There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids. METHODS: A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round. RESULTS: Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs. CONCLUSION: The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring. HOW TO CITE THIS ARTICLE: How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.

Adrenomedullin and Its Possible Role in Improved Survival in Female Patients with Sepsis: A Study in the South East Asian Region.

AIMS AND OBJECTIVES: Serum adrenomedullin (ADM) as a prognostic biomarker to study the gender-related differences in mortality pattern and its correlation with the sequential organ failure assessment (SOFA) and acute physiologic assessment and chronic health evaluation II (APACHE II) scores in patients of sepsis. MEASUREMENTS AND MAIN RESULTS: Eighty patients of sepsis of which 36 were males and 44 were females, were taken in the study as per sepsis III guidelines. They were followed up for a period of 28 days. Serum ADM was measured on day 1 and day 5. The endpoint was mortality or survival at day 28 after admission. The death rate among males was higher, with 23 of the total 36 (63.89%) patients having died when compared with females in which 25 patients out of 44 (56.82%) had died. The observed mortality rates correlated well with average APACHE II scores. The average APACHE II score was slightly higher in males (29 ± 8.97) when compared with females (27.02 ± 8.69). Similarly, day 1 SOFA and mean SOFA values were higher in males (10.22 ± 5.36) and (10.73 ± 6.01) when compared with females (8.27 ± 4.79) and (8.89 ± 5.6), respectively. Males despite having higher mortality rates, higher APACHE II, SOFA, and mean SOFA values were still having less mean levels of serum ADM (454.40 ± 81.13 pg/mL) when compared with females (479.62 ± 126.97 pg/mL). CONCLUSION: Adrenomedullin is a protective neurohormone with antibacterial and anti-inflammatory properties. It is elevated in all patients with sepsis but the rise is more so in the female when compared with males. Higher ADM levels in females may suggest the protective effect of ADM as a part of the general protective neurohormonal stress response, which may explain the low death rate in females in sepsis. HOW TO CITE THIS ARTICLE: Daga MK, Kumar L, Mawari G, Kumar N, Singh S, Mishra TK. Adrenomedullin and Its Possible Role in Improved Survival in Female Patients with Sepsis: A Study in the South East Asian Region. Indian J Crit Care Med 2020;24(12):1180-1184.

Role of oestrogen and its receptors in HEV-associated feto-maternal outcomes.

BACKGROUND: Pregnant women infected with HEV develops adverse pregnancy outcomes like, abortions, intrauterine fetal death, still births, neonatal deaths, preterm delivery and maternal mortality. AIM: To correlate oestrogen and its receptors ESR1α and ESR2ß levels with HEV-associated feto-maternal outcomes. MATERIAL & METHODS: A total of 142 pregnant women with HEV infection and 142 pregnant controls were included in study from Department of Obstetrics & Gynaecology and Department of Medicine, Maulana Azad Medical College (MAMC) and associated Lok Nayak Hospital (LNH), New Delhi. Three millilitre of blood sample was collected in plain for quantification of oestrogen, and its receptors ESR1α and ESR2ß using commercially available third-generation ELISA kits. RESULTS: The levels of oestrogen, ESR1α and ESR2ß were considerably higher in HEV-infected pregnant women (20.11 ± 18.19 ng/mL, 10.58 ± 3.27 ng/mL, 10.42 ± 4.71 ng/mL respectively) than pregnant controls (11.74 ± 6.42 ng/mL, 9.11 ± 1.63 ng/mL, 9.01 ± 1.18 ng/mL respectively)(P < 0.0001). It was found that oestrogen levels were significantly higher in pregnant women infected with HEV who had preterm delivery, low birth weight babies and fetal loss (19.64 ± 17.60 ng/mL, 19.71 ± 17.63 ng/mL, 33.62 ± 23.20 ng/mL respectively) than who had full term delivery, average birth weight babies and live babies (11.71 ± 8.77 ng/mL, 11.99 ± 9.44 ng/mL, 16.58 ± 14.98 ng/mL respectively)(P < 0.05). A significant negative correlation was observed between baby birth weight and oestrogen levels in HEV-infected pregnant women. CONCLUSION: The high level of oestrogen plays an important role in preterm delivery, low birth weight babies and fetal mortality in pregnant women with HEV infection through placental dysfunction. Moreover, oestrogen level is a significant predictor for preterm delivery and maternal mortality and ESR2ß levels is a significant predictor for maternal mortality in pregnant women infected with HEV.

Study of gastro-oesophageal reflux disease in patients with mild-to-moderate chronic obstructive pulmonary disease in India.

BACKGROUND AND OBJECTIVE: To study the incidence and pattern of gastro-oesophageal reflux disease (GORD) in patients with mild-to-moderate chronic obstructive pulmonary disease (COPD) using dual-probe 24-h oesophageal pH recording. METHODS: This was a prospective study of 50 patients with mild-to-moderate stage COPD based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. A detailed history of illness along with spirometry was done in all patients. In the study group, reflux symptoms were measured using a validated scoring system. All the patients underwent oesophageal manometry and dual-probe 24-h oesophageal pH recording. RESULTS: Symptoms of gastro-oesophageal reflux were present in 38 patients. Twenty-four-hour oesophageal pH monitoring revealed pathological reflux in 31 out of 38 symptomatic and 8 out of 12 asymptomatic patients. The overall rate of GORD was 78% in our study. Only distal GORD was observed in 11 (28.9%), and both distal and proximal GORD was observed in 20 (52.6%) out of the 38 symptomatic subjects. In the remaining 12 asymptomatic patients, eight had GORD. Distal GORD was present in six (50%) patients, and two (16.6%) had both distal and proximal GORD in this group. Isolated proximal GORD was not observed in any patient. CONCLUSIONS: There is an increased occurrence of GORD in patients with even mild-to-moderate COPD.

Clinical profile of hospitalised moderate category COVID-19 patients: Short study from a Tertiary Care Centre in Delhi.

Background: The clinical profile of hospitalized moderate-category COVID-19 patients has been understudied globally and in India. Aim: The present study was conducted to study the clinical profile and assess the proportions of patients who progressed to severe disease and its predictors among moderate COVID-19 patients. Materials and Methods: In this single-center observational study, 100 moderate-category COVID-19 patients as per Ministry of Health and Family Welfare (MoHFW) criteria of age ≥18 years of either sex, excluding pregnant females from February to November 2021, were studied by analyzing their clinical profiles and assessing Quick Sequential Organ Failure Assessment (qSOFA), National Early Warning Score 2 (NEWS-2), and chest computed-tomography severity score (CTSS) to predict progression to severe disease. Severe disease was defined as per MoHFW criteria. Results: Out of 100 moderate-category COVID-19 patients, progression to severe disease was seen in 11 patients (11%), among which eight patients had expired, three patients were discharged, and the rest of the 89 patients (89%) who did not progress to severe disease were discharged. A higher age (62.2± 19.5 vs 54.8 ± 14.6 years), along with multivariate analysis revealing male sex (1.25 times), chronic kidney disease (2.86 times), leukocytosis (6.10 times), thrombocytopenia (1.04 times), anemia (9.3 times), a higher qSOFA score (3.6 times), and a higher NEWS-2 score on admission (1.56 times) had higher odds of progression to severe disease. A significant correlation (P < .05) of qSOFA score with serum LDH, ferritin, and hs-CRP levels; CT severity score with the serum ferritin, IL-6, and LDH levels; and NEWS-2 with serum LDH, hs-CRP, and ferritin levels were found. Moreover, the NEWS-2 score was found slightly better than qSOFA on receiver operating characteristic (ROC) curve analysis, with an area under the curve of 85.8% and 83.2%, respectively, predicting progression to severe disease. Conclusion: Our study revealed male gender, chronic kidney disease, leukocytosis, anemia, thrombocytopenia, a higher qSOFA and NEWS-2 score on admission, and further, NEWS-2 score better than qSOFA on ROC curve analysis, with an area under the curve of 85.8% and 83.2%, respectively, in predicting severe disease among hospitalized moderate COVID-19 patients.

Lipid Pentad Index: A novel bioindex for evaluation of lipid risk factors for atherosclerosis in young adolescents and children of premature coronary artery disease patients in India.

OBJECTIVE: To evaluate the role of non-conventional lipid risk factors like Lipoprotein(a) [Lp(a)], Apolipoprotein A-I (Apo A-I) and Apolipoprotein B-100 (Apo B-100) and other conventional lipid profile parameters in children and adolescents of premature coronary artery disease (CAD) patients in India; and thereby explain the highest occurrence of premature CAD in this population. METHODS: Forty-five children and adolescents of premature CAD patients (cases, mean age 12.08+/-3.71 years) and forty-five age and sex matched children and adolescents of healthy parents without any history or clinical evidence suggestive of CAD were studied (controls, mean age 12.14+/-3.91 years). RESULTS: We found a significant increase in mean levels of Lp(a), Apo B-100, Total cholesterol (TC), Low Density Lipoprotein-Cholesterol (LDL-C) and Triglyceride (TG) in cases than controls. In contrast, Apo A-I and High Density Lipoprotein-Cholesterol (HDL-C) values decreased. Lipid Tetrad Index (LTI) and Atherogenic Index in Indian children and adolescents were also calculated. Kolmogorov D statistic and cumulative probability plot suggest that the new Lipid Pentad Index (LPI) defined by us is able to discriminate case and control populations more precisely than the existing LTI and Atherogenic Index. CONCLUSIONS: The new proposed LPI appears to be a better indicator of lipid risk factors in children and adolescents of premature CAD patients from India, than the prior LTI and Atherogenic Index.

Effect of Dietary Supplementation on Body Composition, Pulmonary Function and Health-Related Quality of Life in Patients with Stable COPD.

BACKGROUND: Malnutrition is very common in patients with chronic obstructive pulmonary disease (COPD). Nutritional supplementation improves the patient's nutritional status by increasing the energy intake and providing anti-inflammatory elements which can relieve the patient's symptoms and delay the disease progression. This study sought to determine if energy and protein supplementation improves physical function, pulmonary function and health-related quality of life (HRQL) in stable COPD patients. MATERIALS AND METHODS: The study was carried out in an outpatient setting on 60 stable COPD patients over a period of one year. Patients were randomized to intervention group (n=30), receiving supplemental nutrition in the form of additional protein and carbohydrates or control group (n=30), receiving only the usual standard diet. Lung function, body mass index (BMI), exercise capacity (6-minute walk test or 6MWT), mid-upper arm circumference (MUAC) and skin fold thickness (SFT) were evaluated, and clinical assessment was carried out at baseline and after completion of 12 weeks. The HRQL was assessed using Seattle obstructive lung disease questionnaire. RESULTS: Twelve weeks of dietary supplementation resulted in a significant increase in weight and BMI of patients in the intervention group in comparison to the control group (P<0.005). Significant improvement was also observed in 6MWT and HRQL scores after nutritional intervention (P=0.002 and P=0.001, respectively). However, difference in MUAC, SFT and serum protein level after 12 weeks of follow up was not significant in any of the two groups. There was a similar degree of lung function improvement in both groups although it was not statistically significant. CONCLUSION: Nutritional supplementation with high protein and energy diet during 12 weeks of intervention improved body weight and composition, exercise capacity and quality of life in stable COPD patients.

Infection of human papillomavirus type 18 and p53 codon 72 polymorphism in lung cancer patients from India.

STUDY OBJECTIVES: Infection with specific high-risk HPV types 16 and 18 and polymorphism of p53 codon 72 has been strongly associated with the genesis of various neoplasms in humans, but such study in lung cancer is limited and the results are controversial. In India, the role of these two factors has been strongly implicated in cervical and other cancers, but the occurrence of HPV or p53 codon 72 polymorphism has not been examined in lung cancer, which is the most common cause of cancer-related death in India. DESIGN AND PATIENTS: A total of 40 tumor biopsy specimens from advanced lung cancer patients and blood samples from 40 matching control subjects were obtained for the analysis of high-risk HPV types 16 and 18 infection and p53 codon 72 polymorphism by polymerase chain reaction. RESULTS: Only HPV type 18 was detected in 5% (2 of 40 lung cancer patients), but no other HPV could be detected. A significantly increased frequency of Arg/Arg homozygotes was observed in patients with advanced lung cancer when compared to that of control subjects (p = 0.004; odds ratio, 5.13; 95% confidence interval, 1.59 to 17.26). However, no significant correlation could be made between p53 polymorphism and different clinical stages, except for advanced stage IV patients, who showed a higher proportion of Arg/Pro heterozygous genotype. CONCLUSIONS: HPV detected in a small proportion of lung cancer patients in India demonstrated an exclusive prevalence of HPV type 18, and there was a significantly higher frequency of p53 Arg/Arg genotype when compared to that of control subjects. Observation of a shorter duration of symptoms (< or = 4 months) in as many as 78% (seven of nine stage IV patients) with Arg/Pro genotype may be an indication that lung cancer patients with the heterozygous p53 genotype are more susceptible to early progression.

Intravenous administration of ulinastatin (human urinary trypsin inhibitor) in severe sepsis: a multicenter randomized controlled study.

PURPOSE: Ulinastatin, a serine protease inhibitor, inhibits several pro-inflammatory proteases and decreases inflammatory cytokine levels and mortality in experimental sepsis. We studied the effect of ulinastatin on 28-day all-cause mortality in a double-blind trial in patients with severe sepsis in seven Indian hospitals. METHODS: Patients with sepsis were randomized within 48 h of onset of one or more organ failures to receive intravenous administration of ulinastatin (200,000 IU) or placebo 12 hourly for 5 days. RESULTS: Of 122 randomized subjects, 114 completed the study (55 receiving ulinastatin, 59 receiving placebo). At baseline, the mean APACHE II score was 13.4 (SD = 4.4), 48 (42 %) patients were receiving mechanical ventilation, 58 (51 %) were on vasopressors, and 35 % had multiple organ failure. In the modified intention-to-treat analysis (patients receiving six or more doses of study drugs), 28-day all-cause mortality was 7.3 % with ulinastatin (4 deaths) versus 20.3 % (12 deaths) with placebo (p = 0.045). On multivariate analysis too, treatment with ulinastatin (odds ratio 0.26, 95 % CI 0.07-0.95; p = 0.042) independently decreased 28-day all-cause mortality. However, the mortality difference did not reach statistical significance in the intention-to-treat analysis [10.2 % (6/59 deaths) with ulinastatin versus 20.6 % (13/63 deaths) in the placebo group; p = 0.11]. The ulinastatin group had lower incidence of new-onset organ failure (10 vs. 26 patients, p = 0.003), more ventilator-free days (mean ± SD 19.4 ± 10.6 days vs. 10.2 ± 12.5 days, p = 0.019), and shorter hospital stay (11.8 ± 7.1 days vs. 24.2 ± 7.2 days, p < 0.001). CONCLUSIONS: In this pilot study, intravenous administration of ulinastatin reduced mortality in patients with severe sepsis in the modified intention-to-treat analysis, but not in the intention-to-treat analysis.

Sequence-specific cleavage of BM2 gene transcript of influenza B virus by 10-23 catalytic motif containing DNA enzymes significantly inhibits viral RNA translation and replication.

One of the hallmarks of progression of influenza virus replication is the step involving the virus uncoating that occurs in the host cytoplasm. The BM2 ion channel protein of influenza B virus is highly conserved and is essentially required during the uncoating processes of virus, thus an attractive target for designing antiviral drugs. We screened several DNA enzymes (Dzs) containing the 10-23 catalytic motif against the influenza B virus BM2 RNA. Dzs directed against the predicted single-stranded bulge regions showed sequence-specific cleavage activities. The Dz209 not only showed significant intracellular reduction of BM2 gene expression in transient-expression system but also provided considerable protection against influenza B virus challenge in MDCK cells. Our findings suggest that the Dz molecule can be used as selective and effective inhibitor of viral RNA replication, and can be explored further for development of a potent therapeutic agent against influenza B virus infection.

Rare association of Visceral leishmaniasis with Hodgkin's disease: A case report.

We present here a case of young male with complaints of fever and swelling in the neck for eight months. History of progressive weakness associated with weight loss was present. Physical examination revealed pallor, multiple enlarged cervical lymph nodes and hepatosplenomegaly. Investigations showed pancytopenia, hyperglobinemia and Leishman-Donovan bodies on bone marrow aspiration. Serological test confirmed diagnosis of visceral leishmaniasis. However, cervical lymph node aspiration and biopsy were suggestive of Mixed cellularity Hodgkin's disease. This made it a very rare case of Leishmaniasis as an opportunistic infection in a patient of pre-chemotherapy Hodgkin's disease. There was marked improvement in haematological profile and regression of hepatosplenomegaly with Amphotericin B treatment followed by favourable response to chemotherapy. The case emphasizes the suspicion for leishmaniasis as a masquerader and as an opportunistic infection in haematological malignancies.

Urinary catheterization in medical wards.

AIMS: THE STUDY AIMS TO DETERMINE THE: 1. frequency of inappropriate catheterization in medical wards and the reasons for doing it. 2. various risk factors associated with inappropriate catheterization, catheter associated urinary tract infections (CAUTI) and bacterial colonization on Foley's catheters (BCFC). SETTINGS AND DESIGN: Hospital-based prospective study. MATERIALS AND METHODS: One hundred and twenty five patients admitted consecutively in the medical wards of a tertiary care hospital, who underwent catheterization with a Foley's catheter, at admission, have been included in the study. Patient profiles were evaluated using the following parameters: age, sex, diagnosis, functional status, mental status, indication, duration and place of catheterization, development of BCFC and CAUTI. STATISTICAL TESTS USED: Chi-square test. RESULTS: Thirty-six out of 125 (28.8%) patients included were inappropriately catheterized. BCFC developed in 52.8% and 22.4% were diagnosed with a CAUTI. The most frequent indication for inappropriate catheterization was urinary incontinence without significant skin breakdown (27.8%). The risk factors for inappropriate catheterization were female sex (RR=1.29, 95% CI=0.99, 1.69, P<0.05) and catheterization in the emergency (RR=0.74, 95% CI=0.61, 0.90, P<0.05). The risk factors for developing a BCFC were age>60 years (RR=0.65, 95% CI=0.48, 0.89, P<0.05), non-ambulatory functional status (RR=0.57, 95% CI=0.39, 0.84, P<0.01), catheterization in the emergency (RR=2.01, 95% CI=1.17, 3.46, P<0.01) and duration of catheterization>3 days (RR=0.62, 95% CI=0.43, 0.89, P<0.01). The risk factors for acquiring a CAUTI were age>60 years (RR=0.47, 95% CI=0.25, 0.90, P<0.05), impaired mental status (RR=0.37, 95% CI=0.18, 0.77, P<0.01) and duration of catheterization>3 days (RR=0.24, 95% CI=0.10, 0.58, P<0.01). CONCLUSIONS: Inappropriate catheterization is highly prevalent in medical wards, especially in patients with urinary incontinence. The patients catheterized in the medical emergency and female patients in particular are at high risk. Careful attention to these factors can reduce the frequency of inappropriate catheterization and unnecessary morbidity.

Metastatic malignant melanoma in bone marrow with occult primary site--a case report with review of literature.

BACKGROUND: Metastases of malignant melanoma to the bone marrow are very rare. A few case reports are published in the literature with a known primary site. CASE PRESENTATION: Herein we present a case of metastatic malignant melanoma in bone marrow with occult primary site in a 22-year-old-male. Diagnosis was confirmed by morphology and immunohistochemistry. A pertinent review of literature is also presented by using relevant articles indexed in PubMed (National Library of Medicine) database. The search was based on the following terms: metastasis or metastases, malignant melanoma and bone marrow. CONCLUSION: In this report we discuss a rare case of metastatic malignant melanoma to the bone marrow with an unknown primary. Clinicians must be aware of the varied clinical manifestations of disseminated malignant melanoma even if the primary site is not evident.

A limited form of Churg-Strauss syndrome presenting without asthma and eosinophilia.

We report a young woman presenting with digital gangrene, paranasal sinusitis, mononeuritis multiplex, and rapidly progressive glomerulonephritis without asthma and eosinophilia - an extremely rare variant of this disease.