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Background: Cryptococcus lives in the environment all over the globe. Although it spreads via inhalation route still most of the exposed individuals never get sick as the majority of cases are seen in immunocompromised. Objective of this clinical case report is to highlight the rare fungal etiology associated with iliac bone abscess to avoid incorrect diagnosis and prompt management of case. Case Presentation: A 70-year-old elderly female presented with hip pain for a month duration, not relieved with analgesics in September, 2021. In MRI a well-defined irregularly marginated hyperintense focal lesion was found in left iliac bone with joint effusion suggestive of infective etiology, tubercular, or less likely metastasis. CT-guided biopsy reported occasional hyphae-like fragments giving an impression of acute on chronic osteomyelitis with suspicion of fungalinfection.Culture reported Cryptococcus ne oformans.Fungal markers and Beta-dglucan were indeterminate and Galactomannan was found negative for the sample. Extrapulmonary TB was ruled out by AFB staining, MGIT Culture, and GeneXpert MTB. Bone scan, tumor markers, and PET scan ruled out osteolytic lesion secondary to metastasis. Though PET Scan and HRCT thorax confirm pulmonary involvement giving a picture of bilateral interstitial lung disease along with multiple enlarged lymph nodes. Patient serum was found negative for HIV, HBV, and HCV. Liver and renal function tests were within normal range and in hematology, ESR was raised (50;normal range:0-20). Patient is hypertensive with HbA1c of 5.3. There was no history of travel, avian exposure, weight loss, and COVID-19 infection. Patient was started on voriconazole and considering generalized lymphadenopathy, a therapeutic trial of anti-tubercular therapy was started which was stopped within a week on patient non-compliance. Abscess resolved with voriconazole and patient was discharged. In February 2022, Patient presented with similar complaints. CT scan of this fluctuant nodule depicted hypoechoic lesion which was ultrasound-guided drained.Sections show many rounds of oval fungal organism which were found PASpositive with mucicarmine and alcian blue positive capsule.Budding yeast cells were seen on KOH mount and India ink preparation demon-strated capsule which was confirmed by Cryptococcal Antigen test giving an overall impression in favor of Cryptococcosis. Patient was started on oral fluconazole and Injection liposomal amphotericin B 250 mg for 14 days. Discussion and Conclusion(s): This is the first case of skeletal Cryptococcosis at our institution which was managed by antifungals without surgical debridement resulting in resolution of abscess. Isolated focal iliac bone cryptococcosis is unusual but may occur in immunocompetent with everyday exposure to the organism. Herein, Patient had bilateral lung involvement along with multiple lymphadenopathies with no evidence of TB bacilli which inferences that the isolate most likely originated from environmental bird droppings and has disseminated from pulmonary lesion to the iliac bone. The radiological findings of iliac cryptococcosis abscess were nonspecific.A definitive diagnosis was made on histopathological and fungal examinations of ultrasound-guided drained abscess. Patient will be followed in the near future for relapse or any other medical issues related to the case.
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Background and aims: The COVID-19 pandemic has up-stretched a lot of constraints for both neurophysiotherapists (NeuroPT) and their clients. Majority of the NeuroPT have been shifted towards tele-consultation mode for their client's consultations and monitoring purposes. The current study intended to explore the various challenges faced by the Indian neuro-physiotherapists, during their tele-consultation sessions with their clients. Methods: A self-structured and validated questionnaire having a reliability of (Cronbach's alpha) - 0.9 were used in which 17 questions framed to obtain responses from the NeuroPT and these primarily constructed to explore challenges faced by neurophysiotherapist during consultations of their clients. The domains were- Satisfaction, Time-constraints, Handiness and Costeffectiveness of Tele-rehabilitation mode over traditional way of consultations. Results: The responses obtained through this crosssectional survey point out that the major challenges faced by NeuroPT are that, tele-rehabilitation is not a better option over orthodox consultations as their clients were not able to define their health condition accurately. In contrast to this, about 85% of NeuroPT agreed on the point that this mode is beneficial and very much cost-effective. Conclusion: The prominent challenges reported by NeuroPT's were time-consuming process, poor satisfaction and description of their health condition percentiles and network issues.
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Background: SARS CoV-2 infection took the whole world by storm in the final month of 2019.Different measures have been taken to reduce its spread by timely and accurate detection of COVID 19(coronavirus disease 2019) infection in suspected patients and theircontacts. Aim: This study was conducted to assess commercially available five Rt pcr (reverse transcriptase polymerase chain reaction) kits from different manufacturers available in our center for diagnostic testing ofSARS CoV-2 infection .94 oropharyngeal clinical samples, previously confirmed as 64 positive and 30 negative for SARS CoV-2 were extracted and amplified separately by each of the five Rt pcr kitsand the results compared. Results:The performance of different kits was in was satisfactory and above 90 percent in agreement with the standard kit for samples (n=47) with low Ct values (Ct values<30) . There was a significant variation in performance among the five kits while testing high Ct values (Ct value >30) samples (n=17).Significant variation in Ct values of E gene ,RdRp gene and N gene was observed in the Rt pcr kits results . Conclusion: We conclude that it is necessary to assess the diagnostic performance of different Rt pcr kits for COVID 19 clinical samples from time to time to study the variation in Ct values, sensitivity of different gene targets of SARS CoV2 virus, with proper co -ordination with other laboratories , for development of reliable COVID 19 diagnostic centers at every level.
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TOPIC: Disorders of the Mediastinum TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lymphoma is the fourth most common malignancies in pregnancy, and a high portion is primary mediastinal (thymic) large B-cell lymphoma (PMBCL). It presents many challenges to diagnose lymphoma during pregnancy while avoiding fetal harm. CASE PRESENTATION: 41-year-old G2P1 female without significant past medical history experienced shortness of breath starting in her second trimester. She only had a telehealth appointment amid the COVID19 pandemic. The patient was offered a chest X-ray (CXR) but declined due to her concern of radiation. She was empirically managed as asthma triggered by acid reflux. At 39W of gestation, she presented to the hospital for labor and delivery. She was hypoxic and required three liters of oxygen. The physical exam was unremarkable. Lab were pertinent for mild leukocytosis and anemia. The patient still declined CXR. She was taken for C-section after failing trial of vacuum. The newborn was healthy. After delivering, she developed profound hypoxia in the OR requiring intubation. Tracheal compression was noted during intubation. CXR after intubation showed mediastinal widening. Following intubation, patient developed tachycardia, hypotension and ultimately cardiac arrest requiring CPR. Extracorporeal membrane oxygenation was activated. CT angiogram of the chest showed a 15 cm x 12 cm x 13 cm mass in the superior mediastinum that encases the aorta and great branches and was associated with direct extension into the sternum and invasion of the pericardium. The tumor also encased the trachea and left main bronchus. During her hospitalization, no neurological recovery was observed. The family decided to transition to comfort. The patient unfortunately passed away. The autopsy revealed neoplastic medium to large-size lymphoid cells in mediastinal mass, positive for CD45, CD20, BCL2, PAX-5, MUM-1, and MYC rearrangement negative for other markers. The final diagnosis was PMBCL. DISCUSSION: PMBCL is an aggressive B cell lymphoma arises from the thymus. Airway obstruction and superior vena cava syndrome are common due to local invasion. Dyspnea, B symptoms (fever, night sweats, weight loss) are possible symptoms. Labs may reveal elevated lactate dehydrogenase. Imaging studies typically illustrate an anterior mediastinal mass originating in the thymus. Final diagnosis can be made with biopsy and immunohistochemistry or flow cytometry analysis. Early recognition is important since these patients are at risk of cardiac and respiratory arrest during general anesthesia due to the mass location in the mediastinum. Pregnant patients should be informed that there is no evidence of fetal adverse outcome with imaging studies that expose the fetus to less than 50 mGy (CXR fetal dose: 0.0005 to 0.01 mGY). CONCLUSIONS: PMBCL should be identify early in pregnancy due to increased risk of cardiac and respiratory arrest. CXR is safe and harmless to the fetus. REFERENCE #1: Brenner B, Avivi I, Lishner M. Haematological cancers in pregnancy. Lancet. 2012;379(9815):580-587. REFERENCE #2: Dunleavy K, McLintock C. How I treat lymphoma in pregnancy. Blood. 2020 Nov 5;136(19):2118-2124. doi: 10.1182/blood.2019000961. PMID: 32797210. REFERENCE #3: Brent RL. The effect of embryonic and fetal exposure to x-ray, microwaves, and ultrasound: counseling the pregnant and nonpregnant patient about these risks. Semin Oncol. 1989 Oct;16(5):347-68. PMID: 2678486. DISCLOSURES: No relevant relationships by John Chronakas, source=Web Response No relevant relationships by Patrice Gillotti, source=Web Response No relevant relationships by Tien-Chan Hsieh, source=Web Response No relevant relationships by Oluwaseyi Olayinka, source=Web Response No relevant relationships by Nusrat Pathan, source=Web Response No relevant relationships by Akash Shah, source=Web Response No relevant relationships by Amanda Tissot, source=Web Response
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Introduction: Coronavirus Disease 2019 (COVID-19) has been haunting the world since December 2019 and has grown to pandemic proportions from March 2020. Even after a full year of research and study, the most effective way to control the spread of this infection is early diagnosis and isolation of the cases. Real-time Reverse Transcription Polymerase Chain Reaction (RT-PCR) is considered the standard test all over the world for the diagnosis of Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) infection. All the sample collection guidelines have recommended stringent maintenance of the cold chain for the sample transport. However, it is not possible for the resource constrained developing countries with inadequate infrastructure to comply with these guidelines all the time. Aim: To determine necessity of these stringent transport criteria and the effect of temperature on the clinical sensitivity of a RT-PCR assay for diagnosis of SARS-CoV-2 infection. Materials and Methods: In this prospective experimental study conducted in November 2020, 49 positive samples were kept at ambient room temperature and were tested everyday with RT-PCR for the detection of SARS-CoV-2 Ribonucleic Acid (RNA). The samples were also kept under refrigeration at the 4°C and were also tested by RT-PCR and the results were compared with their respective counterparts kept at room temperature till nine days. Python Jupiter notebook SciPy and Anaconda software was used for statistical analysis. Results: It was observed that the positivity of the RT-PCR results were not deteriorated till five days and there was no significant deterioration even after nine days of samples being stored at room temperature suggesting that even if the viral RNA itself is not stable outside strict temperature control but small fragment or target genetic sequences are enough for detection of virus by RT-PCR. Conclusion: It is possible to keep samples at this ambient temperature for five days without any loss of positivity in RT-PCR.