Acute pancreatitis - a rare manifestation in scrub typhus

Background: Scrub typhus is an acute febrile illness caused by the bacteria - Orientia tsutsugamushi, transmitted through the bite of an infected chigger. This infection is endemic in tropical countries like India, Pakistan, and Bangladesh. It usually presents with fever, headache, myalgia, nausea, vomiting, abdominal pain, and tender lymphadenopathy. The presence of an eschar clinches the diagnosis clinically. Commonly encountered complications in scrub typhus include acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), acute liver injury, and rarely acute pancreatitis. Case Presentation: We report a case of a 70 year-old teetotaller male, who presented with acute febrile illness and respiratory distress during the peak period of the COVID -19 pandemic. During the course of illness, the patient developed acute pancreatitis as evidenced by elevated serum amylase and lipase as well as features of pancreatitis in the CT abdomen. Common causes of acute pancreatitis were ruled out with necessary investigations. He tested negative for malaria, dengue fever, enteric fever, and leptospirosis, but his IgM and IgG ELISA for scrub typhus were positive with high titres. He also had AKI, ARDS, and acute liver injury. The patient was treated symptomatically and with doxycycline. His condition improved gradually. Conclusion: Even though acute pancreatitis is one of the rare manifestations of scrub typhus, it should be suspected early and treated promptly.

Differentiating Multisystem Inflammatory Syndrome in Children (MIS-C) and Its Mimics - A Single-Center Experience From a Tropical Setting

OBJECTIVES: Identifying clinical and laboratory indicators that differentiate multisystem inflam-matory syndrome in children (MIS-C) apart from other febrile diseases in a tropical hospital setting. METHOD(S): Review of hospital records done in a tertiary care exclusive children's hospital for children admitted from April, 2020 till June, 2021. Laboratory values, severe acute respiratory syndrome coronavirus (SARS-CoV-2) serological status, and clinical signs and symptoms of patients with MIS-C, and those with similar presentations were analyzed. RESULT(S): 114 children fulfilled the inclusion criteria (age group of 1 mo-18 y) for whom a diagnosis of MIS-C was considered in the emergency room based on the clinical features. Among them, 64 children had the final diagnosis of MIS-C, and the remaining 50 children had confirmatory evidence of infections mimicking MIS-C such as enteric fever, scrub typhus, dengue and appendicitis. CONCLUSION(S): Older age group, presence of muco-cutaneous symptoms, very high C-reactive protein, neutrophilic leukocytosis, abdominal pain and absence of hepatosplenomegaly favor a diagnosis of MIS-C.

Clinical profile of scrub typhus patients during COVID pandemic: a sub-Himalayan single center experience

Introduction: Scrub typhus is tropical zoonotic disease, commonly presented with multi organ dysfunction and high mortality rate in untreated patients. This study was done to identify clinical features commonly associated with scrub typhus during COVID pandemics, parameters associated with severe scrub typhus and mortality. Methods: This retrospective study was done in a tertiary care hospital with a total of 52 admitted scrub typhus positive patients in October 2020 to February 2022. Diagnosis was established by scrub IgM ELISA or Rapid antigen test. The clinical and laboratory data, duration of hospital stay and outcomes were collected. Common clinical and laboratory findings were of descriptive analysis. Factors associated with mortality were analysed using Chi-square test. Results: Fever was the most common presenting symptoms on admission (94.2%) followed by respiratory abnormalities (38.46%). Acute kidney injury was the most common organ failure on admission (67.3%), followed by acute liver injury (46.2%) and thrombocytopenia (32.7%). MODS was seen in 46.15%. Of the total, 30.8% were admitted in ICU. Mortality was seen in 7.7% of all patients. On Chi-square analysis, altered mental status and coagulopathy were associated with significant mortality with p value <0.05. Conclusion: Scrub typhus can manifest with potentially life-threatening complications such as acute kidney injury, acute liver injury, thrombocytopenia and MODS. The overall case-fatality rate was 7.7%, and presence of altered mental status and coagulopathy were associated with higher mortality. As per literature, COVID has changed few clinical profiles of scrub typhus compared to same center experience before.

Clinico-demographic Profile and Outcome of Scrub Typhus in North Eastern State of India

Scrub typhus is a form of bacterial Zoonosis caused by Orintia tsutsugamushi usually presents as Acute febrile illness with multiorgan involvement as a complication and is associated with significant mortality. This study aims to document the clinico-demographic profile, laboratory parameters and complication of Scrub Typhus in North Eastern Hilly State of Tripura with background of tropical climate. This retrospective study was conducted at Tripura Medical College, including 42 patients admitted with acute febrile illness between June, 2020 to December, 2021 during the era of COVID-19 Pandemic. The diagnosis was established by Rapid card test, Lateral Flow Metry Assay (LFA) followed by confirmation through IgM, ELISA test and pathognomic Eschar where feasible. The clinlical, demographic and laboratory profile were documented and analysed. Post rainy season and people from rural area with farming background were mostly affected population. Apart from Fever and Flu like symptom, respiratory and Gastrointestinal (GI) symptoms were more prominent feature. Pathognomic skin lesion eschar was found in maximum cases followed by shortness of breath, GI involvement and Renal failure. Acute Respiratory Distress Syndrome (ARDS), Acute Kidney Injury (AKI), Hepatic encephalopathy and meningitis were the serious complications. While evaluating cases of acute febrile illness with multiorgan involvement clinician should have high index of suspicion for Scrub typhus specially resource poor areas of North Eastern (NE) state of India so that early detection and time bound intervention may help to reduce the mortality.Copyright © 2022 Indian Medical Association. All rights reserved.

Concurrent Infection with SARS-CoV-2 and Orientia tsutsugamushi during the COVID-19 Pandemic in the Maldives.

The COVID-19 pandemic was the worst public-health crisis in recent history. The impact of the pandemic in tropical regions was further complicated by other endemic tropical diseases, which can cause concurrent infections along with COVID-19. Here, we describe the clinical course of a patient with concurrent COVID-19 and scrub typhus infection. The patient's de-identified clinical data were retrieved retrospectively. The patient had progressive breathlessness at the time of presentation and was hospitalized for COVID-19. Respiratory examination revealed dyspnea, tachypnea, and coarse crepitations bilaterally over the entire lung field. Oxygenation was impaired, and a PaO2/FiO2 ratio of 229 suggested acute respiratory distress syndrome. Laboratory tests indicated leukocytosis, thrombocytopenia, ferritinemia, hypoalbuminemia, and transaminitis. Upon revaluation for persistent fever, physical examination revealed an eschar in the right antecubital fossa. Serology further confirmed scrub typhus, with IgM and IgG antibody positivity. A remarkable clinical recovery was achieved with doxycycline. The COVID-19 pandemic might have masked endemic tropical diseases. Clinicians working in endemic regions must always consider common tropical diseases that may present as a co-infection, as in our case. Travel and exposure history are critical guides for narrowing down a differential diagnosis. Early diagnosis and treatment can prevent complications.

Care of non COVID patients in COVID-19 era

The consequences of the COVID-19 pandemic are extensive and far-reaching. Non COVID communicable diseases continue to spread and non-communicable diseases continue to progress. People may access healthcare facilities little bit late due to fear of contracting COVID-19 and present with severe symptoms, even with complications. Nepal has been facing dual burden of both non-communicable and communicable diseases. The number of COVID-19 patients has continuously been rising in Nepal since the start of May 2020. There is an anticipated surge of infectious disease such as malaria, dengue fever, enteric fever, scrub typhus, leptospirosis during summer and monsoon seasons in Nepal. There will be surge of cases of acute undifferentiated febrile illness (AUFI) during monsoon. As fever is one of the very common symptoms of COVID-19, so COVID-19 needs to be considered in differential diagnoses of acute undifferentiated febrile illness. Copyright © 2020, Kathmandu University. All rights reserved.

Aetiology and Clinical Profile of Infectious Causes of Febrile Jaundice at a Tertiary Care Hospital in Eastern Odisha-An Observational Prospective Study

Introduction: Fever with jaundice is one of the most common presentations seen in both outdoor and indoor patients. This manifestation is seen in many individuals infected with hepatotropic viruses (A to E), bacteria, protozoa, fungi, and non hepatotropic viruses. In viral hepatitis due to hepatotropic viruses the patient presents with a short febrile prodrome followed by jaundice, and is often self-limiting without any treatment whereas in patients other than viral hepatitis the patients present with ongoing fever and jaundice and need specific treatment. Aim: To evaluate clinical profile of patients presenting with febrile jaundice and finding the infections agent responsible for fever with jaundice baring viral hepatitis (A to E). Materials and Methods: This observational prospective study included 107 patients admitted in the Kalinga Institute of Medical Sciences, from September 2019 to August 2021, who were found to have febrile jaundice after initial evaluation, based on liver function tests and hepatotropic viral markers (hepatitis B surface antigen, Immunoglobulin M antibody against hepatitis C virus Immunoglobulin M antibody against hepatitis A virus, Immunoglobulin M antibody against hepatitis E virus). Routine laboratory parameters, chest radiograph, and electrocardiogram were performed in all cases. Appropriate investigations like specific serological, radiological investigations and cultures were performed to identify the causal pathogen. Statistical analysis of categorical variables was conducted by Statistical Package for Social Sciences (SPSS) 26.0 version. Results: Out of 107 patients, (23.3%) patients were found to have scrub typhus. Dengue was found in 23 (21.4%) patients (three had dengue associated with scrub typhus). Coronavirus Disease 2019 (COVID-19) was found in 11 patients (10.2%) of study population. Malaria, tuberculosis, S. typhi, K. pneumonia. E. coil, B. cepacia, E. feacalis were isolated in other individuals. Among these, 41.12% patients had associated transaminitis, whereas, 16 had elevated aspartate transaminase/ alanine transaminase (>3 times of ULN). Overall, 18.4% patients had hepatomegaly, and 6.5% were found to have splenomegaly. Eight patients had septic shock, and associated Multiple Organ Dysfunction Syndrome (MODS) was seen in six patients. No definitive aetiology was found in 25 patients. Conclusion: The study identified a variety of organisms in sera from the patients presenting with febrile jaundice. The most common clinical feature was anorexia followed by headache. The common aetiology for febrile jaundice was viral infections (barring viral hepatitis (A to E)) followed by bacterial Infections.

Development of a Novel Near-peer Surgical Simulation-based Teaching Programme for Intern Doctors

Background: Trends in healthcare have caused a shift in training towards more competency based programmes. The COVID-19 pandemic has reduced time available for direct exposure and clinical learning, necessitating incorporation of simulation in training. The objectives of this study were to develop, pilot and evaluate a four week simulation based surgical teaching programme. Method(s): Interns pursuing a career in Surgery joined a near-peer surgical training programme delivered by NCHDs. A survey established a baseline competency. Four skills workshops were delivered. Outcomes were measured using data from pre and post course surveys as well as a surgical skills competition. Result(s): Of The 12 trainees, 71% had scrubbed in theatre before. 50% were already confident to scrub independently, increased to 75% post training. 28% were confident gowning/gloving, increased to 75% post training. 28% were confident to place a Simple suture in theatre, this did not increase despite training. 42% were confident performing an instrument tie, increased to 75% post training. 14% were confident hand tying knots, this increased to 62%. 14% of participants were comfortable performing excisional biopsy in theatre, increased to 62% post training. Preparation and administration of local anaestetic could be performed confidently by 14% before training, this increased to 87%. on completion, a surgical skills competition showed that 100% were able to satisfactorily perform basic skills. Conclusion(s): Near-peer delivery of surgical training has enhanced The basic surgical skills of interns. Similar programmes in other sites would ensure that interns have The skills required to safely care for surgical patients.

The Superhero Scrub Project: Assembling Positive Paediatric Experiences

Aims Throughout the Covid-19 pandemic, several working practices were changed to allow for better infection control awareness and practice. St Richard's Hospital paediatric department adopted the use of medical scrubs as the standard workwear for medical staff. Children frequently find the hospital environment frightening and unfamiliar, and it is well recognised that practices that utilise play and 'fun' are effective in improving patient and parent engagement and outcomes.1 Furthermore, direct communication with the child and engagement of their interests and activities beyond their medical needs is also acknowledged as a critical element of patient centred care.2 The use of more child friendly imagery such as teddy bears or cartoons on medical clothing/devices within paediatrics is well established. The aim of this project was to trial a 'fun' but practical scrubs uniform that children and their parents would recognise and enjoy seeing, with the aim of providing a positive and less threatening experience for the child and to summarise early feedback as a proof of concept. Methods 5 sets of superhero themed scrubs were created, based on the appearances of Marvel's 'Avengers' and were worn as clinical workwear throughout the pandemic period. Verbal feedback from patients, parents and colleagues was documented and analysed for common themes. Results 'I liked Ben/Spiderman! He made me feel HAPPY!' - 8 year old female patient Feedback was positive overall. Patients generally responded positively to the superhero appearance, and frequently expressed excitement at recognising a character. However, this was sometimes short lived depending on the nature of the clinical encounter. For younger patients in particular, painful procedures remained a source of upset. Parents across the paediatric, A&E, maternity and neonatal departments frequently expressed positive sentiments about the scrubs and often made reference to their expectation that children would enjoy the appearance. No specific negative sentiment was directly fed back, however this may reflect withheld judgement and the need for a more anonymised assessment. Similar positive sentiments were fielded from medical and nursing staff across departments, though with occasional concerns expressed about the professionalism of the clothing, especially if there were a scenario of needing to break bad news. An unexpected effect was to cause amusement and anticipation of what outfit would be expected for the duty - which acted as a morale boost of sorts. Conclusion Incorporating familiar character appearances into medical workwear was well received by patients, parents and staff;and may help lessen feelings of a hospital environment seeming threatening to the child. This could benefit rapport, communication and patient outcomes. Scrub patterns are widely available and easily adaptable for different characters, though this is limited by sewing skill, cost and motivation. There are also limitations their use, particularly where the use of 'fun' imagery is emotionally incongruent. (Figure Presented).

A comparative study of cardiac involvement of kawasaki disease and multisystem inflammatory syndrome post COVID (MISC) in children

Background and Aim: Kawasaki Disease remains an enigma to the world to this day since first described by Dr. Tomisaku Kawasaki in 1967. In the last half a century there has been wide-spread global research elaborating the clinical aspects and patho-genesis of this disease entity. Multisystem Inflammatory Syndrome post Covid (MISC) is a relatively new disease which was described in literature in mid 2020. The striking resemblance as well as differences in spectrum of cardiac involvement of both the conditions has been elaborated in this study from a tertiary care centre in Eastern India. Method(s): The study was conducted over a period of 3 years from June 2018 to June 2021. Fiftyone patients with Kawasaki disease (including atypical and incomplete cases) and sixty children diag-nosed with MISC were included in the study. Echocardiography details were noted by a single observer. Data regarding the patient particulars, clinical aspects, lab parameters, imaging details and treatment particulars were collected and analysed. Patients were followed up for a minimum period of six months to one year. Result(s): In the Kawasaki group(51), infants(20) presented with multiple (and larger) aneurysms. Older children (gt;5 years) had more of single coronary involvement, (mostly LAD) and also had more atypical presentation(18) associated with infections like Dengue, Staphylococcal infection, Scrub Typhus. There were 4 cases of Kawasaki shock syndrome, all below 5 years. In the MISC group (60), there was also multiple coronary involvement in infants (11). But LV dysfunction was more common in older children and adolesecents (20), of whom 18 (90%) presented with severe dysfunction (LVEFlt;35%). Those with coronary involve-ment had normal function and those with dysfunction had no coronary involvement. Mild to moderate aneurysmal dilation of coronaries was found in children one to five years of age. No giant aneurysm was found in MISC. Overall, LMCA with LAD was the commonest pattern of involvement in both the conditions. Conclusion(s): KD and MISC had similar pattern of coronary involve-ment, but absence of giant aneurysm and significantly severe dys-function in older children in MISC indicates a likely different pathogenesis for myocardial involvement in MISC.

Multisystem Inflammatory Syndrome in a Young Adult During the Second Wave of COVID-19 Pandemic in India ABS0116)

Aim and background: Since June 2020, there have been several reports of multisystem inflammatory syndrome in adults (MIS-A). There is a paucity of a description of MIS-A from India. Materials and methods: A 26-year-old, healthy male, with a previous history of COVID-19, without any known history of chronic disease, with clinical characteristics resembling MIS-A was hospitalised on May 30, 2021. Results: Case presentation: The patient presented with 1 week of persistent high-grade fever (102-degree F) with chills and rigor. The concomitant complaints were left-sided pain in the buccal cavity, left facial swelling, intra-orbital pain, and watery eyes. The respiratory rate was 24/minute, SpO2 was 96% on room air. Ever since the recovery from COVID-19 (1 week back), there was severe pain in the throat with difficulty in breathing, generalised weakness, and loss of appetite. BP was 130/80 mm Hg. The hospital course was notable for profound systemic inflammation, requiring ICU admission. MRI revealed discrete subcentimetric bilateral deep cervical lymph nodes. Blood tests at admission revealed, lymphopenia 15.3%, CRP 61.84 mg/L, total leucocyte count 12.93 (1000/μL), neutrophils 78.7%. Red distribution width (RDW) was marginally elevated to 15%. The patient was managed by IV fluids, IV immunoglobulin. Scrub typhus was excluded by IgM ELISA IgM with a negative titre (0.095). Widal test was negative and excluded enteric fever. d-dimer was within normal limits (125 ng/ mL). Borderline elevation of hepatic enzymes was noted. There was a high SARS-CoV-2 IgII titres (12050.4). The patient improved following intravenous immunoglobulin (IVIG), IV ascorbic acid, dexamethasone, supportive care and was discharged on day 4, with methylprednisolone for 1 week. Conclusion: Specific treatment is yet to be determined. However, dexamethasone and IVIG allowed controlling the inflammatory process. MIS-A, as a delayed immune complication, requires early recognition, with a multidisciplinary approach and aggressive therapeutic intervention, to yield favourable outcomes. MIS-A should be considered in adults, during the recovery phase from COVID-19. This is perhaps, the first description of MIS-A from India during the second wave of the COVID-19 pandemic. The role of IVIG needs further exploration.

Multisystem Inflammatory Syndrome in Indian Children Associated with SARS-CoV-2 Infection: A Case Series ABS0026)

Introduction: The coronavirus disease 2019 pandemic has affected all the countries and age groups alike. However, during the initial part of a pandemic, COVID-19 affected children with a milder form of the disease and had better clinical outcomes than adults.1 Subsequently, a rising number of previously well children with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) induced hyperinflammatory states resembling macrophage activation syndrome, toxic shock syndrome, and Kawasaki disease were reported.2 Here, we describe four children with COVID-19-associated MIS-C presenting to a tertiary care center between May 17 and June 17, 2021. They had distinct clinical features, but similar laboratory and radiological findings. However, none of them were positive for SARS-CoV-2 nucleic acid on real-time polymerase chain reaction but all of them had elevated immunoglobulin G titers against SARS-CoV-2. Case description: Four previously well children, aged 13-14 years, including equal number of males and females, presented to us with complaints of fever with rash, abdominal pain for 5-6 days. None of the patients had comorbidities, except patient 2, who was a known case of type 1 diabetes mellitus and was receiving huminsulin. At presentation, patients 1 and 4 had hypovolemic shock and dyspnea. There was mild global hypokinesia with mild tricuspid and mitral regurgitation in patient 3 and biventricular dysfunction (ejection fraction: 54%) with mild pericardial effusion in patient 4. Laboratory investigations revealed negative for malaria, dengue, scrub typhus, and leptospira in all the patients. Neutrophilia and lymphocytosis were observed in every patient. All, except patient 2, had thrombocytopenia. The international normalization ratio was raised in patients 1 and 2. All patients had negative RT-PCR for SARS-CoV-2. While, the levels of COVID-19 IgG antibody, C-reactive protein, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate. They were managed in the medicine intensive care unit (MICU). The shock and hypoxia was managed with fluids and inotropes and 6-8 L O2 through bag-mask-ventilation (BMV). Additionally, in all the patients, MIS-C was suspected and intravenous immunoglobulin (IVIG, 2 mg/kg), intravenous methylprednisolone, low molecular weight heparin, broad spectrum antibiotics, fluid therapy, and supportive care was initiated. One of them developed cardiorespiratory arrest. Resuscitation was done but the patient could not be revived back. While other patients responded well over the next 48-72 hours with a gradual decrease in titers of inflammatory markers. Steroids were slowly tapered off and patients were discharged. Conclusion: The findings of our series suggest that COVID-19 can trigger a hyperinflammatory state resulting in shock and pulmonary involvement, in some of the patients. The patients presented with distinct clinical features, with some mimicking atypical KD, the underlying mechanism for which still remain unclear. The physicians should be suspicious of MIS-C in children presenting with fever, rash, and gastrointestinal symptoms.

The Temporal Lagged Relationship Between Meteorological Factors and Scrub Typhus With the Distributed Lag Non-linear Model in Rural Southwest China.

Background: Meteorological factors can affect the emergence of scrub typhus for a period lasting days to weeks after their occurrence. Furthermore, the relationship between meteorological factors and scrub typhus is complicated because of lagged and non-linear patterns. Investigating the lagged correlation patterns between meteorological variables and scrub typhus may promote an understanding of this association and be beneficial for preventing disease outbreaks. Methods: We extracted data on scrub typhus cases in rural areas of Panzhihua in Southwest China every week from 2008 to 2017 from the China Information System for Disease Control and Prevention. The distributed lag non-linear model (DLNM) was used to study the temporal lagged correlation between weekly meteorological factors and weekly scrub typhus. Results: There were obvious lagged associations between some weather factors (rainfall, relative humidity, and air temperature) and scrub typhus with the same overall effect trend, an inverse-U shape; moreover, different meteorological factors had different significant delayed contributions compared with reference values in many cases. In addition, at the same lag time, the relative risk increased with the increase of exposure level for all weather variables when presenting a positive association. Conclusions: The results found that different meteorological factors have different patterns and magnitudes for the lagged correlation between weather factors and scrub typhus. The lag shape and association for meteorological information is applicable for developing an early warning system for scrub typhus.

Pediatric Scrub Typhus Manifesting with Multisystem Inflammatory Syndrome: A New Cause for Confusion or Concern-A Case Series.

The pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has discovered a new disease called multisystem inflammatory syndrome in children (MIS-C). In developing nations, pediatricians must be mindful of the similarities between MIS-C and other tropical fevers such as scrub typhus. Not only should such patients be kept on high alert to rule out tropical diseases and receive appropriate treatment, such as steroids or immunomodulatory medications, but this is also concerning because, if rickettsial or bacterial infection is not detected through cultures and serology, steroid, or immunomodulatory treatment alone can be fatal. How to cite this article: Bhardwaj P, Sood M, Singh R. Pediatric Scrub Typhus Manifesting with Multisystem Inflammatory Syndrome: A New Cause for Confusion or Concern-A Case Series. Indian J Crit Care Med 2022;26(6):723-727.

MISDIAGNOSIS OF KIKUCHI-FUJIMOTO DISEASE: THE IMPORTANCE OF TIMELY HISTOPATHOLOGY IN LYMPHADENITIS

Background: Febrile lymphadenopathy not responding to first line antibiotics in a patient hailing from or with a history of travel to tuberculosis endemic countries is often primarily diagnosed as extra-pulmonary tuberculosis. However, histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto Disease(KFD) presents with similar clinical features. Etiological theories of KFD include viral agents, autoimmunity, and physicochemical factors such as leaking implants. Although KFD has classically been described in young Asian females, recent studies show men and women can be equally affected, with cases increasingly being reported from the USA and Europe as well. Availability bias amongst physicians can lead to misdiagnoses, especially in patients from tuberculosis endemic countries. Objectives: To describe a case of misdiagnosis of KFD in an adolescent. Design/Method: Case report. Results: A 16-year-old male from a tuberculosis endemic country, with a history of asthma, eczema and excision of omental infarct, presented with sub-occipital lymphadenopathy which resolved with antibiotics. Six months later, he complained of tender left cervical lymphadenopathy, associated with fever and fatigue, which lasted for a month. Two courses of antibiotics failed to decrease symptoms. Based on his clinical history, he was started on empirical anti-tubercular medications despite negative tests for tuberculosis. However, his symptoms began to worsen after three weeks of this treatment, and he developed high evening rise of temperature associated with chills, night sweats, frontal headache, pedal edema and generalized pruritic maculopapular rash. Laboratory workups revealed leukopenia (WBC:3830/μL);elevated Erythrocyte sedimentation rate (29 mm/h), C-reactive protein (68.6 mg/dL), Aspartate Aminotransferase(95 U/L) and Alanine Aminotransferase(61 U/L). Rapid antigen test for SARS-CoV2 was negative, and no appreciable levels of SARS-CoV-2 IgG antibodies were detected. Investigations for Tuberculosis, EBV, CMV, Dengue, Malaria, Typhoid, Leptospirosis and Scrub typhus were all negative. Chest X-ray and abdomen ultrasound scan were normal. Histopathological analysis of the excised cervical lymph nodes demonstrated crescentic histiocytes and karyorrhexis in a background of coagulative necrosis. Neutrophils, granulomas and acid-fast bacilli were absent. Immunohistochemistry was positive for CD3, CD20, CD68;and negative for CD15, CD30 and PAX-5. A diagnosis of KFD was made, and patient was given supportive treatment only. His symptoms rapidly resolved within 48 hours, with complete resolution by three months. Conclusion: It is important to raise awareness of KFD, a benign and self-limiting condition with good prognosis, which has many clinical symptoms mimicking grave conditions like extra-pulmonary tuberculosis, SLE and lymphomas. Timely histopathological analysis can help avoid anxiety surrounding a misdiagnosis and adverse reactions due to unnecessary toxic treatments.

Scrub Typhus and COVID-19 Coinfection Unmasking Antiphospholipid Antibody Syndrome.

Scrub typhus is an acute febrile disease caused by Orientia tsutsugamushi with a clinical course varying from mild to fatal. Vascular thrombosis is rare in scrub typhus. There is an increased risk of thrombotic events in Coronavirus disease 19 (COVID-19). We report a young diabetic female who presented with pulmonary embolism, followed by deep venous thrombosis (DVT) and was found to have coinfection with scrub typhus and COVID-19 with underlying antiphospholipid antibody syndrome.

Technology-enhanced learning in orthopaedics: Virtual reality and multi-modality educational workshops may be effective in the training of surgeons and operating department staff.

AIM: The aims were to assess the utility of: 1) virtual reality-mediated simulation, and 2) a multi-modality 'Bootcamp' in the delivery of total knee arthroplasty (TKA) teaching to orthopaedic surgical trainees. BACKGROUND: Surgical training opportunities are diminished as a result of the COVID-19 pandemic which may result in delays to training completion and gaps in the permanent workforce. Modern and technology-enhanced learning methods have been identified as having the potential to support high-quality and sustainable education. METHODS: This mixed-methods study assessed the educational benefit of two activities designed to teach TKA to junior (ST1-3) orthopaedic trainees. A multi-modality training Bootcamp was delivered that included: virtual reality (VR) and saw-bone simulation; tutorials, and case-based symposia. The VR component was delivered to different participants (surgical trainees, scrub nurses, and consultants) on a further two separate occasions. Qualitative and quantitative data were collected pertaining to utility and performance. RESULTS: Trainees reported that the Bootcamp improved comprehension of arthroplasty principles including component alignment, knee balancing, and intraoperative strategies. Case-based discussions helped develop diagnostic and decision-making skills. The VR activity improved understanding of the surgical process map, increased ability to anticipate steps, and consider the procedure strategically. All staff groups found the VR activity beneficial and would recommend it as a useful addition to a surgical department. CONCLUSION: VR-mediated simulation could augment the education of surgical trainees and scrub team staff by improving comprehension of the surgical process map. Integrated multi-modality 'Bootcamp-style' training activities constructed around trainees' needs may provide a sustainable solution to bridge the experience gap related to reduced exposure to elective orthopaedic practice.

Protocol for scoping review on well-being among theatre nurses in large public hospitals in low-income and middle-income countries

IntroductionTheatre nurses report higher levels of stress and burn-out due to the nature of their work environment. Workplace stress among nurses is associated with decreased well-being resulting is poor health outcomes for patients. However, evidence on well-being among nurses varies considerably, due to the multiple perspectives, definitions and focus on different aspects of well-being. Existing literature has not been consolidated to map out well-being concepts and instruments. In addition, due to limited research in low-income and middle-income countries, the most contextually relevant instruments for this context has not been identified. The aim of this scoping review is to map out existing literature on well-being, key concepts and instruments used to measure well-being among theatre nurses working in public hospitals in low-income and middle-income countries.Methods and analysisA scoping review guided by the Joanna Briggs Institute’s methodological approach will be used. PubMed, Scopus, Ebscohost, Web of Science, Emerald Insight, Informa World, Oxford Journals, ScienceDirect and Google scholar will be searched for literature published from 2000 to date. Reference lists of selected articles will also be reviewed. Two reviewers will conduct the screening of articles and data extraction independently and differences will be resolved through a discussion. Data analysis will be guided by both qualitative and quantitative methods.The scoping review will take place from 1 May 2022 to 1 November 2022, completing the screening, data extraction and analysis phases.Ethics and disseminationThe study does not require ethical approval. Findings will be published and shared at events to raise awareness on the importance of monitoring well-being among theatre nurses as a strategy to improve surgical outcomes. The review could shed light on an instrument most suitable for low-income and middle-income contexts.

Electrocardiographic abnormalities in prevalent infections in tropical regions: A scoping review

Cardiovascular manifestations and electrocardiographic abnormalities have been reported among some prevalent infections in tropical regions, which lead to a great amount of morbidity and mortality. The major infectious diseases include chikungunya, dengue fever, H1N1 influenza, and coronavirus disease-19 (COVID-19) in the viral category, leptospirosis, salmonellosis, scrub typhus and tuberculosis in the bacterial category, and malaria in the protozoan parasite category. All these infirmities constitute a foremost infection burden worldwide and have been linked to the various cardiac rhythm aberrancies. So we aimed to identify and compile different studies on these infections and associated acute electrocardiographic (ECG) changes. The search was made in online international libraries like PubMed, Google Scholar, and EMBASE, and 38 most relevant articles, including original research, systematic reviews, and unique case reports were selected. All of them were evaluated thoroughly and information regarding ECG was collected. Myocarditis is the predominant underlying pathology for rhythm disturbance and can be affected either due to the direct pathogenic effect or the abnormal immune system activation. ECG variabilities in some infections like chikungunya, scrub typhus, and leptospirosis are associated with longer hospital stay and poor outcome. Tropical infective diseases are associated with prominent acute cardiac rhythm abnormalities due to myocarditis, which can be identified preliminarily by ECG changes.