Pneumorrhachis associated with COVID-19: a rare observation

This paper describe a case of a 46-year-old male with a background of diabetes presented with a week's history of fever followed by breathlessness. On initial evaluation his oxygen saturation was found to be 82 % on ambient air. His chest X-ray showed bilateral peripheral heterogeneous opacities. COVID-19 PCR from nasopharyngeal swab was positive. He was started on high flow nasal cannula and was cared for in the intensive care unit (ICU) as a case of severe COVID-19 pneumonia. He received broad spectrum antibiotics, corticosteroids, low molecular weight heparin, remdesivir, convalescent plasma and off label tocilizumab. A week later, he developed worsening hypoxia, a CT Pulmonary angiogram was done to rule out possible pulmonary embolism but demonstrated extensive pneumomediastinum with surgical emphysema extending in neck, bilateral chest walls and air in the spinal canal, known as pneumorrhachis. He was managed conservatively on high flow nasal cannula and recovered after a long course of hospitalization.

Key preferences of tourists during COVID-19 pandemic in luxury hotels: Evidence from qualitative data

There is a decline in revenue and occupancy rates in the hotels during the pandemic. For the sustainable and long-term recovery of the hotel industry, the guests need to be analyzed for their stay preferences. This study attempts to find the preferred attributes of the travelers visiting the Indian luxury hotels during the COVID-19 pandemic. The research investigated the post-visit experiences from the online reviews published by tourists on TripAdvisor.com. Thematic salience valence analysis and lexical salience valence analysis was used to identify the vital attributes of the hotel industry. The study revealed staff, location, food, hygiene, and rooms as the preferred hotel attributes, in which the coastal locations were highly considered for location based marketing of luxury hotels, and non-compliance of COVID-19 standards and complaints for upgradations in the rooms were the non-recommenders for the luxury hotels. The dashboard-based salience valence zone analysis was used to provide suggestions to the hotel authorities by revealing the significant and critical hotel attributes simultaneously for prompt handling of the issues during the COVID-19 pandemic.

Secondary infections modify the overall course of hospitalized COVID-19 patients: A retrospective study from a network of hospitals across North India (preprint)

IntroductionSARS-CoV-2 infection increases the risk of secondary bacterial and fungal infections and contributes to adverse outcomes. The present study was undertaken to get better insights into the extent of secondary bacterial and fungal infections in Indian hospitalized patients and to assess how these alter the course of COVID-19 so that the control measures can be suggested. MethodsThis is a retrospective, multicentre study where data of all RT-PCR positive COVID-19 patients was accessed from Electronic Health Records (EHR) of a network of 10 hospitals across 5 North Indian states, admitted during the period from March 2020 to July 2021.The data included demographic profile of patients, clinical characteristics, laboratory parameters, treatment modalities, and outcome in those with secondary infections (SIs) and those without SIs. Spectrum of SIS was also studied in detail. ResultsOf 19852 RT-PCR positive SARS-CO2 patients admitted during the study period, 1940 (9.8%) patients developed SIs. Patients with SIs were 8 years older on average (median age 62.6 years versus 54.3 years; P<0.001) than those without SIs. The risk of SIs was significantly (p < 0.001) associated with age, severity of disease at admission, diabetes, ICU admission, and ventilator use. The most common site of infection was urinary tract infection (UTI) (41.7%), followed by blood stream infection (BSI) (30.8%), sputum/BAL/ET fluid (24.8%), and the least was pus/wound discharge (2.6%). As many as 13.4% had infections with more than organism and 34.1% patients had positive cultures from more than one site. Gram negative bacilli (GNB) were the commonest organisms (63.2%), followed by Gram positive cocci (GPC) (19.6%) and fungus (17.3%). Most of the patients with SIs were on multiple antimicrobials - the most commonly used were the BL-BLI for GNBs (76.9%) followed by carbapenems (57.7%), cephalosporins (53.9%) and antibiotics carbapenem resistant entreobacteriace (47.1%). The usage of emperical antibiotics for GPCs was in 58.9% and of antifungals in 56.9% of cases, and substantially more than the results obtained by culture. The average stay in hospital for patients with SIs was twice than those without SIs (median 13 days versus 7 days). The overall mortality in the group with SIs (40.3%) was more than 8 times of that in those without SIs (4.6%). Only 1.2% of SI patients with mild COVID-19 at presentation died, while 17.5% of those with moderate disease and 58.5% of those with severe COVID-19 died (P< 0.001). The mortality was highest in those with BSI (49.8%), closely followed by those with HAP (47.9%), and then UTI and SSTI (29.4% each). The mortality rate where only one microorganism was identified was 37.8% and rose to 56.3% in those with more than one microorganism. The mortality in cases with only one site of infection was 28.8%, which steeply rose to 62.5% in cases with multiple sites of infection. The mortality in diabetic patients with SIs was 45.2% while in non-diabetics it was 34.3% (p < 0.001). ConclusionsSecondary bacterial and fungal infections can complicate the course of almost 10% of COVID-19 hospitalised patients. These patients tend to not only have a much longer stay in hospital, but also a higher requirement for oxygen and ICU care. The mortality in this group rises steeply by as much as 8 times. The group most vulnerable to this complication are those with more severe COVID-19 illness, elderly, and diabetic patients. Varying results in different studies suggest that a region or country specific guideline be developed for appropriate use of antibiotics and antifungals to prevent their overuse in such cases. Judicious empiric use of combination antimicrobials in this set of vulnerable COVID-19 patients can save lives.

Profile of Mucormycosis Cases from a Network of Hospitals in North India Amidst COVID-19 Pandemic (preprint)

Incidence of mucormycosis suddenly surged in India after the second wave of COVID-19. This is a crippling disease and needs to be studied in detail to understand the disease, its course, and the outcomes. Between 1st March and 15th July 2021, our network of hospitals in North India received a total of 155 cases of COVID-associated mucormycosis cases as all of them reported affliction by COVID-19 earlier or concurrent. Their records were retrieved from the Electronic Health Records system of the hospitals and their demographics, clinical features, treatments, and outcomes were studied. More than 80% (125 cases) had proven disease and the remaining 30 were categorized as possible mucormycosis as per the EORTC criteria. More than two-thirds (69.0%) of the cases were males and the mean age was 53 years for either sex. Nearly two-thirds (64.5%) had symptoms of nose and jaws and 42.6% had eye involvement. Some had multiple symptoms. As many as 78.7% had diabetes and 91.6% gave history of use of steroids during COVID-19 treatment. The primary surgery was functional endoscopic sinus surgery (FESS) (83.9%). Overall mortality was 16.8%, which is one-and-a-half times the mortality in hospitalized COVID-19 patients in the corresponding population. Occurrence of mucormycosis was associated with diabetes and use of steroids, but mortality was not associated with either of them. Cases undergoing surgery and on antifungal had steeply lower mortality (11.9% vs. 50.0%, P < 0.001) than those who were exclusively on antifungal drugs. Treatment by different drugs did not make much of a difference in mortality.

Pneumomediastinum as a presenting feature of COVID-19 - an observation

This article aims to highlight an event of a COVID-19 pneumonia presenting as a Spontaneous Pneumomediastinum (SPM) and discuss the possible mechanism and prognosis of this association. A 67 year old gentleman, known hypertensive and a recently diagnosed Diabetic, presented to the Emergency Department of a tertiary care hospital, with complaints of acute onset chest tightness and breathlessness of 1 day duration, which had worsened over the last few hours. At presentation he had tachycardia (HR 110 beats/min), tachypnoea (RR - 26/min), blood pressure was 140/90 mmHg, and temperature was normal, with an oxygen saturation of 90% on room air. He was immediately started on oxygen with Non Rebreather mask, following which saturation improved to 94%. Random blood glucose was 285mg/dl and a complete blood count showed significant leukocytosis (Total leukocyte count 21,900 cells per uL), with neutrophilia (93%) and lymphopenia (3%). There was evidence of acute kidney injury (urea - 74.8 mg/dl, Creatinine - 2.4 mg/dl) and inflammatory markers were markedly elevated, with C Reactive Protein -263.4 mg/L and ferritin - 1559 ng/mL. D-dimer and NT-pro BNP were done, which were elevated as well (5043 ng/mL and 10400 pg/mL respectively). High Resolution Computerised Tomography (HRCT) thorax was done which showed diffuse ground glass opacities with interlobular septal thickening. Note of pneumomediastinum and pneumopericardium was also made. Due to the ongoing pandemic and the patients symptom profile, a COVID-19 RT-PCR was sent which was positive. Patient deteriorated rapidly in the emergency following which he was intubated and put into mechanical ventilation. He succumbed within 6 hours of arrival to the hospital.