Postmortem findings in COVID-19 fatalities: A systematic review of current evidence.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the ongoing pandemic of coronavirus disease 2019 (COVID-19). Almost 17 months after the first COVID-19 case was reported, the exact pathogenesis of the virus is still open to interpretation. Postmortem studies have been relatively scarce due to the high infectivity rate of the virus. We systematically reviewed the literature available for studies that reported gross, histological, microscopic, and immunohistochemical findings in COVID-19 fatalities with the aim of reporting any recurrent findings among different demographics. PubMed and Scopus were searched up till the second of May 2021 and 46 studies with a total of 793 patients were shortlisted after the application of inclusion and exclusion criteria. The selected studies reported gross, histological, microscopic, and immunohistochemical autopsy findings in the lungs, heart, liver, gallbladder, bowels, kidney, spleen, bone marrow, lymph nodes, CNS, pancreas, endocrine/exocrine glands, and a few other miscellaneous locations. The SARS-CoV-2 virus was detected in multiple organs and so was the presence of widespread microthrombi. This finding suggests that the pathogenesis of this highly infectious virus might be linked to some form of coagulopathy. Further studies should focus on analyzing postmortem findings in a larger number of patients from different demographics in order to obtain more generalizable results.

Role of C- reactive proteins and liver function tests in assessing the severity of dengue fever.

OBJECTIVE: To determine whether C-reactive protein and liver function tests can serve as severity markers for dengue fever. METHODS: The cross-sectional study was conducted in 2015-16 in Karachi and comprised patients with dengue fever visiting a tertiary care hospital. World Health Organisation classifications 1997 and 2009 were used to categorise patients according to clinical signs and symptoms. Receiver Operating Characteristics curve was used to determine discriminative ability and optimum cut-off value of biochemical markers. Comparisons were done through one-way analysis of variance using SPSS 17. RESULTS: Of the 218 patients, 133(61%) were males and 85(39%) were females. The overall mean age was 35.07±15.96 years. Levels of C-reactive protein and total bilirubin were significantly higher for dengue haemorrhagic fever compared to dengue fever; dengue shock syndrome compared to dengue fever; dengue shock syndrome compared to dengue haemorrhagic fever; and dengue shock syndrome compared to dengue fever / dengue haemorrhagic fever (p<0.05 each). Levels of alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase were significantly higher for dengue shock syndrome compared to dengue fever; dengue shock syndrome compared to dengue haemorrhagic fever; and dengue shock syndrome compared to dengue fever / dengue haemorrhagic fever (p<0.05 each). Levels of C-reactive protein, total bilirubin, alanine aminotransferase and alkaline phosphatise in patients with severe dengue were significantly higher compared to non-severe dengue. CONCLUSIONS: C-reactive protein and liver function tests were found to be effective biochemical markers in assessing dengue fever severity.

Severe Bilateral Optic Neuritis: A Rare Presentation of Clinically Isolated Syndrome.

Multiple sclerosis (MS) is a disabling disease involving the myelin sheath of neurons in the brain and spinal cord. Optic neuritis (ON) is one of the common presentations of MS, and it typically presents as acute unilateral ON. In the absence of a prior history of MS, the first episode of clinically determined acute ON is considered as a clinically isolated syndrome (CIS). CIS presenting with bilateral acute ON resulting in complete vision loss is very rare. We present a case of a young female patient who presented with bilateral progressive vision loss and was ultimately found to have ON in the absence of a prior history of MS. Important differentials were ruled out. Significant improvement was observed in the patient with high doses of intravenous methylprednisolone. As compared to oral prednisone, intravenous steroids have been shown to be more effective in the treatment of ON in the Optic Neuritis Treatment Trial.

Knowledge, attitude and perception survey of doctors regarding antibiotic use and resistance in Karachi, Pakistan.

OBJECTIVE: To establish a better understanding of physicians' knowledge and beliefs, and to compare distinctions in knowledge, attitude and perception of junior and senior doctors regarding rational use of antibiotics. METHODS: The cross-sectional study was conducted at a tertiary care hospital in Karachi, from June 1 to July 31, 2016, and comprised senior and junior doctors. A 26-item questionnaire divided in three sections was used to test knowledge, attitude and perception of the subjects regarding rational use of antibiotics. Data was analysed using SPSS 23. RESULTS: Of the 200 subjects, 132(66%) were senior doctors; 68(34%) were junior; 116(58%) were females; 84(42%) were males; and the highest number of respondents were from General Medicine 65(32.5%). While 182(91%) doctors realised that antibiotic resistance was a pressing issue, only 131(65.5%) felt confident about their prescriptions and 94(47%) admitted that they over-prescribed antibiotics. Among young physicians, 13(19.1%) believed that antibiotics did not cause side effects even when prescribed unnecesarily. Also, 47(69.1%) junior doctors felt that patients' demands influenced their prescriptions compared to 66(50%) senior doctors (p=0.01). CONCLUSIONS: Although physicians were found to be knowledgeable about rational use of antibiotics, there were gaps in knowledge and perception.

Not All Herbals are Benign: A Case of Hydroxycut-induced Acute Liver Injury.

Dietary supplements do not need prior Food and Drug Administration (FDA) approval before they are sold to the public per Dietary Supplement Health and Education Act of 1994 (DSHEA). Reporting serious dietary supplement related adverse reactions is voluntary. Hydroxycut is a brand of dietary supplements that are marketed as a popular weight loss product that contains multiple herbal constituents. Due to its potential hepatotoxic effects, FDA issued a warning in 2009 and recommended that consumers discontinue use of Hydroxycut. Hydroxycut was recalled from the market but a reformulated herbal mix is now available again. We are presenting a case of acute liver injury associated with Hydroxycut. The prominent pattern of liver injury is severe hepatocellular injury with the striking elevation of the aminotransferase levels and minimal abnormalities in alkaline phosphatase levels. It can sometimes cause severe hepatocellular necrosis.

Primary Synovial Sarcoma of the Mediastinum in an 18-year old male: A case report.

Primary mediastinal synovial sarcomas are very rare occurrences with only a few cases reported in literature to date. We present a similar case in an 18-year old male which proved challenging to diagnose and treat. Radiological imaging and tru-cut biopsy results gave rise to suspicion of an unusual malignancy. The sarcoma under went en bloc resection and subsequent immunohistochemical staining confirmed the diagnosis of synovial sarcoma. The patient was put on adjuvant chemotherapy after surgery to prevent recurrence. The purpose of this case report is to assist oncologists in the diagnosis and clinical management of this rare tumour.

Efficacy of serum blood urea nitrogen, creatinine and electrolytes in the diagnosis and mortality risk assessment of patients with acute coronary syndrome.

BACKGROUND: Although blood urea nitrogen (BUN), creatinine (Cr) and electrolytes are not the mainstay of diagnosis in acute coronary syndrome (ACS) patients but they may have a role in providing a more detailed view of the complications and mortality rates. The aim of this study was to determine the efficacy of these parameters in the diagnosis and mortality risk-assessment of patients with ACS. METHODOLOGY: A total of 200 patients with ACS were recruited in this prospective study. The relationship of serum BUN, Cr and electrolytes with cardiac enzymes, Global Registry of Acute Coronary Events (GRACE) and mortality was assessed during a 6-months follow-up. Statistical test like multivariate linear regression and binary logistic regression analysis were applied. RESULTS: On multivariate linear regression analysis, serum potassium (K) (Unstandardized Coefficient B=-3.77; p=0.04) showed significant negative association with Creatine Kinease and serum BUN (Unstandardized Coefficient B=0.52; p=0.001) showed significant positive association with Troponin I. The patients with GRACE>105 had significantly higher levels of serum BUN and Cr. Receiver operating characteristic curves showed that area under curve (AUC) of BUN (0.7) was higher than AUC of Cr (0.5). Multiple adjusted model showed that patients with BUN>32.5mg/dl were almost 20 times more likely to be associated with mortality as compared to reference group. CONCLUSION: In addition to cardiac enzymes, K along with BUN and Cr may serve as important aid in diagnosis of ACS. BUN and Cr may also serve as important tools in mortality-risk assessment of ACS patients.

Tuberculous Arthritis of the Elbow Joint: An Uncommon Location with a Diagnostic Dilemma.

Musculoskeletal tuberculosis accounts for 1%-3% of all cases of tuberculosis (TB) worldwide with elbow involvement being even less common. The most cases of tuberculous arthritis occur in patients born in and emigrated from endemic regions, especially in patients who are co-infected with human immunodeficiency virus (HIV). We present a rare case of tuberculous septic arthritis of the elbow joint in a 78-year-old African-American female from the United States, with no history of travel abroad. Her presenting symptoms included pain, swelling, and decreased range of motion of the right elbow for six months. She underwent incision and debridement of the elbow joint and was started on empiric intravenous antibiotic therapy for suspected pyogenic septic arthritis. Several weeks later, surgical cultures demonstrated acid-fast bacilli, identified as Mycobacterium tuberculosis (M. tuberculosis) and a four-drug anti-tuberculosis regimen was initiated. Based upon culture results, additional imaging evaluation was undertaken. She did not have any symptoms of a pulmonary disease but was found to be positive for Mycobacterium tuberculosis in sputum cultures and bronchoalveolar lavage. We emphasize the importance of considering a tuberculosis infection in the differential diagnosis of monoarticular arthritis, especially in elderly patients with immune deficient states since early recognition and treatment result in good functional outcomes.

Superior mesenteric artery syndrome in an 18-year old female: Case report.

We report an unusual case of an 18-year old woman, who presented to Civil Hospital Karachi in May 2016 with complaints of vomiting, abdominal pain, dysphagia, altered bowel habits, loss of appetite and chronic weight loss. On examination, abdomen was found to be soft and non-tender with discomfort on breathing. CT angiogram revealed reduction of aortomesenteric angle and aortomesenteric distance which were both consistent with superior mesenteric artery syndrome. Reduction in angle was thought to be because of weight loss and adipose tissue depletion so patient was started on enteral and parenteral nutritional supplements. Upon seeing little to no improvement, duodenojejunostomy was performed and patient was kept under observation. Nutritional supplements were continued. The after procedure course was uneventful.

Prevalence and Severity of Depression in a Pakistani Population with at least One Major Chronic Disease.

INTRODUCTION: Diabetes, anaemia, hypertension and asthma are major contributors to morbidity in our society. Depression is the commonest psychological malady diagnosed in hospital settings. There tends to be some overlap between certain chronic systemic illnesses and depressive disorders, this point towards the need to determine relationships between them, if any. AIM: To determine the prevalence and compare the severity of depression among individuals diagnosed with four of the most common chronic diseases in our community. MATERIALS AND METHODS: This cross-sectional study was carried out among patients with chronic diseases visiting a tertiary care hospital in Karachi, Pakistan from August 2015 to August 2016. The Beck Depression Inventory-II*, a 21-item self-report instrument was used to assess the severity of depression. Categorical variables were compared using Chi-square test while intergroup comparisons were performed using one way ANOVA test. Logistic regression was employed to estimate the odds of Category B depression (moderate and severe levels of depression) in chronic diseases. RESULTS: The prevalence of anaemia, hypertension, diabetes and asthma was 90%, 47%, 26% and 23% respectively. Predictors of Category B depression were anaemia (OR=4.21, 95% CI: 1.30-13.56) and diabetes (OR=2.03, 95% CI: 1.09-3.77). Asthma predicted Category B depression in males (OR=1.26, 95% CI: 0.29-5.42) but not in females (OR=0.77, 95% CI: 0.39-1.52). Individuals with hypertension were less likely to report Category B depression than non-hypertensive (OR=0.72, 95% CI 0.43-1.21). Female gender had a greater influence to develop Category B depression than males (OR= 2.96, 95% CI: 1.93-4.55). CONCLUSION: Our study points towards a strong correlation between depression and chronic diseases especially anaemia and diabetes. This cautions medical practitioners against treatment of depressive disorders and chronic diseases as separate, independent entities.

Infantile metachromatic leukodystrophy in an 18 month old girl.

Metachromatic leukodystrophy is a rarely occurring neurodegenerative metabolic disorder with an incidence of 1-9 individuals out of 1,000,000. We present a similar case in an eighteen month old child which was extremely challenging to diagnose. Clinical symptoms suggested motor regression and developmental delay which gave rise to suspicion of a neurodegenerative disorder. An MRI scan of the brain revealed cortical demyelination with tigroid appearance which confirmed the diagnosis of Metachromatic leukodystrophy. Due to the lack of availability of a treatment option like bone marrow transplant, the patient could only be given physiotherapy to help with the musculoskeletal manifestations of the disorder. The purpose of this case report is to identify clinical presentation and classical MRI findings to diagnose MLD in absence of enzyme assay and gene mutation analysis.

Assessment of Blood Glucose and Electrolytes during Cardiopulmonary Bypass in Diabetic and Non-Diabetic Patients of Pakistan.

INTRODUCTION: Perioperative hyperglycemia has been shown to be related to higher levels of morbidity and mortality in patients on cardiopulmonary bypass (CPB) undergoing coronary artery bypass grafting (CABG), both diabetic and non-diabetic. Blood electrolytes, like sodium, potassium, calcium, and chloride play a very important role in the normal functioning of the body and can lead to a variety of clinical disorders if they become deficient. A minimal number of studies have been conducted on the simultaneous perioperative changes in both blood glucose and electrolyte levels during CPB in Pakistan. Therefore, our aim is to record and compare the changes in blood glucose and electrolyte levels during CPB in diabetic and non-diabetic patients. MATERIALS & METHODS: This was a prospective, observational study conducted on 200 patients who underwent CABG with CPB, from October 2014 to March 2015. The patients were recruited from the Cardiac Surgery Ward, Civil Hospital Karachi after they complied with the inclusion criteria. Repeated-measures analysis of variance (ANOVA) was used to compare the trend of the changes perioperatively for the two groups. RESULTS: There was no significant difference in changes in blood glucose between the two groups (P = 0.62). The only significant difference detected between the two groups was for PaCO2 (P = 0.001). Besides, further analysis revealed insignificant group differences for the trend changes in other blood electrolytes (P > 0.05). CONCLUSION: Our findings highlighted that there is no significant difference in blood electrolytes changes and the increase in blood glucose levels between diabetic and non-diabetic patients.

Anomalous right coronary artery arising from left coronary cusp with coexisting valvular heart disease.

We report an unusual case, a 50 year old female with an abnormal right coronary artery originating from the left coronary cusp. The patient, who had a history of hypertension presented with chest pain and shortness of breath to the emergency department. She was diagnosed with ischaemic heart disease (IHD) and had hypertension as one of the coronary risk factor. Echocardiography revealed poor progression of R waves. She was scheduled for echocardiography thereafter which revealed severe aortic stenosis with aortic root dilatation. The patient was discharged due to absence of any complications or other anomalies. This case is unique because of the simultaneously presenting valvular pathology, along with the anomalous origin of the right coronary artery which was detected, as an incidental finding, during coronary angiography.

Comparison of the Postprocedural Quality of Life between Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Intervention: A Systematic Review.

The treatment of choice between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) has remained unclear. Considering quality of life (QOL) increases life expectancy, we believe QOL should be important in determining the optimum treatment. Thus the objective of this review was to illustrate the comparative effects of CABG and PCI on postprocedural QOL. Methods. We searched PubMed (Medline) and Embase from inception of the databases to May 2014 using "PCI versus CABG quality of life", "Percutaneous Coronary intervention versus Coronary artery bypass graft surgery Quality of life", "PCI versus CABG health status", "Angioplasty versus CABG", "Percutaneous coronary intervention versus coronary artery bypass surgery health status", and different combinations of the above terms. 447 articles were found. After applying strict exclusion criteria, we included 13 studies in this review. Results. From the 9 studies that compared QOL scores at 6 months after procedure, 5 studies reported CABG to be superior. From the 10 studies that compared QOL among patients at 1 year after procedure, 9 reported CABG to be superior. Conclusion. It can be established that CABG is superior to PCI in improving patient's QOL with respect to all scales used to determine quality of life.