Assessment of the Utility of Point-of-Care Testing Incorporating Ultrasound and Arterial Blood Gas in Patients with Acute Febrile Illness in the Emergency Department to Determine Disease Severity, Disposition, Need for Ventilation and Renal Replacement Therapy.

Introduction: Acute febrile illness (AFI) patients present to the emergency department (ED), with fever to multi-organ dysfunction. There is a lack of early point-of-care-based disposition criteria in AFI patients regarding the need for intensive care unit (ICU) or high dependency unit (HDU) care. Methods: We enrolled 100 patients with AFI presenting to the ED and evaluated using point-of-care ultrasound with two-dimensional echocardiography (ECHO), lung ultrasound score (LUS), renal arterial resistive index (RRI), and arterial blood gas. The need for ICU/HDU admission, ventilation (either noninvasive or invasive), and renal-replacement therapy (RRT) within 48 h of hospitalization was noted. Results: Ninety-five patients were included in the analysis. 72 (75.8%) patients required either ICU or HDU admission, 45 (47.4%) required ventilatory support (either noninvasive or invasive), and 32 (33.7%) required RRT. After logistic regression, LUS ≥16, and arterial lactate ≥12 mg/dL were independent predictors of the need for ICU or HDU admission. The respiratory rate (RR) ≥28/minute, LUS ≥16 and RRI ≥61 were the independent predictors of the need for ventilation. The MAP ≤73 mmHg, LUS (≥16), and RRI (≥67) were the predictors of the need for RRT. Conclusion: In AFI patients presenting to the ED, the MAP, LUS, and lactate are predictors of the need for ICU/HDU admission. The LUS and RRI were predictors of the need for RRT whereas the RR, LUS, and RRI were the predictors of the need for ventilation.

A ten-year retrospective analysis of nocardiosis in a tertiary care center of South-coastal India.

Nocardiosis is an uncommon life-threatening infection caused by Nocardia spp. This study aimed to review the distribution of risk factors, clinical characteristics, microbiological findings, treatment and outcome of patients diagnosed with nocardiosis. This study was a retrospective case record review of all nocardiosis cases that were diagnosed at our tertiary care hospital from January 2008 to December 2019. A total of 48 patients with a mean age of 52.2±16.28 years were included. Out of which forty one (85%) were diagnosed as pulmonary nocardiosis and seven (14.6%) as disseminated disease. Chronic lung disease 25 (52.1%), long term steroid use 22 (45.8%) followed by diabetes mellitus 11 (22.9%) were common predisposing factors. The common symptoms were fever (87.5%), cough (79.2%) and breathlessness (52.1%). The most frequent radiologic finding included consolidation in 38 (79.1%), cavitation with thickened wall in 2 (4.1%), reticulonodular shadows in 2 (4.1%), and unilateral pleural effusion in 5 (10.4%). Nocardia otitidiscaviarum (22.9%) was frequently isolated from cultures. Resistance to trimethoprim-sulfamethoxazole (TMP-SMX) was observed in 21% cases. Mortality was noted in 6 (12.5%) patients and all were with pulmonary involvement. The percentage of death among those with and without pulmonary tuberculosis was 33.3% and 5% respectively. Patients affected by pulmonary nocardiosis with previous history of pulmonary tuberculosis showed significant association with poor outcome (p-value=0.05). In conclusion, nocardiosis mainly affects patients with structural lung disease or immunocompromised hosts with adverse outcome. Awareness of this infection is crucial for a clinician, and any suspicion should lead to make an early diagnosis and choose an appropriate empirical treatment to improve the outcome in this population.

Spectrum of bacterial infections and predictors of mortality in adult cirrhotic patients.

BACKGROUND: Bacterial infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease and account for significant morbidity and mortality in them. Once an infection develops, it induces excessive production of pro-inflammatory cytokines leading to organ failure and death. AIMS: This study aims to identify the clinical characteristics and outcome of bacterial infections affecting various organ systems in patients with liver cirrhosis and to determine factors associated with mortality. METHODS: A cross sectional study was performed on subjects with cirrhosis having microbiologically proven bacterial infection involving various organ systems, admitted to a tertiary care hospital in southern India. Demographic, clinical data, laboratory parameters and outcome details were noted. Univariate associations and subsequent multivariate logistic regression analysis was performed to determine factors associated with mortality. RESULTS: The study included 158 patients. Chronic alcohol intake was the most common etiology of cirrhosis (66.4%). Community acquired infections occurred more frequently than hospital acquired infections (85.5% vs 14.5%). The common site of isolation of etiological agent was ascitic fluid (38.3%) followed by blood (24.3%), respiratory tract (15.5%) and urinary tract (14.5%). Gram negative bacterial infections were more common (74.3%), Escherichia coli being the most frequent pathogen (38.5%). Mortality was noted in 38 (24%) patients. The factors associated with mortality were the type of infection, Child Pugh category, acute kidney injury, hepatic encephalopathy, urinary tract infection, and creatinine and bilirubin levels. Multivariate logistic regression analysis revealed that type of infection (OR: 0.33, 95% CI: 0.11-1.01), ascitic fluid infection (OR: 2.81, 95% CI: 1.11-7.12), hepatic encephalopathy (OR: 0.17, 95% CI: 0.070-0.422) and acute kidney injury (OR: 0.19, 95% CI: 0.077-0.502) were significantly associated with in-hospital mortality. CONCLUSION: This study indicates that the type of infection, hepatic encephalopathy, ascitic fluid infection and acute kidney injury are associated with mortality in cirrhotic patients. Early effective treatment and prevention of these complications may help modify the outcome.

Pharmacokinetic Potentiation of Mixed Organophosphate and Pyrethroid Poison Leading to Prolonged Delayed Neuropathy.

Organophosphate (OP) and mixed pesticide poisoning remains an important cause of hospital admission. Therefore, physician must be aware of atypical presentations of delayed neurological complications of poisoning by taking proper patient history. We report a case of a 23-year-old female who presented with high stepping gait and muscle wasting in hands. Patient history revealed consumption of approximately 4ml of mixed pesticide, consisting of 50% chlorpyrifos with synthetic pyrethroid, 5% cypermethrin. The prolonged and severe nature of delayed peripheral neuropathy, persisting at two years of follow-up, suggests that even small quantities of OP taken in combination with a pyrethroid can result in significant morbidity and is irreversible.

Wernicke's encephalopathy in a patient with gastric carcinoma: a diagnosis not to miss.

We describe a case of a patient who presented with a 20-day history of vomiting, generalised weakness and loss of appetite and a 2-day history of altered sensorium. On examination, he was grossly emaciated and there were no palpable lymph nodes. Central nervous system examination revealed nystagmus with bilateral lateral recti palsy and abdominal examination showed mild hepatomegaly. MRI of the brain showed bilateral and symmetrical hypertense signal changes in T2-weighted and fluid-attenuated inversion recovery sequences with diffusion restriction in the paramedian ventromedial thalamus. These findings were compatible with Wernicke's encephalopathy. He was started on thiamine supplementation with which neurological signs improved. An ultrasound of the abdomen showed mild hepatomegaly with multiple hyperechoic lesions and wall thickening of the pyloric antrum. Upper gastroduodenoscopy showed ulcerative lesions involving the antrum, pylorus and duodenum. Biopsy revealed moderately differentiated adenocarcinoma. The patient underwent palliative gastrojejunostomy and was clinically better at discharge. It is important to consider Wernicke encephalopathy in patients with gastric cancer who have acute neurological symptoms.

Tuberculous mediastinal lymphadenopathy in an adult.

We describe a patient who presented to us with fever, decreased appetite, weight loss and dry cough for 1 month with no abnormalities on examination. A chest radiograph showed a mediastinal shadow. CT of the chest revealed multiple mediastinal lymph nodes. Bronchoalveolar lavage was negative for acid-fast bacilli and cytological examination did not show malignant cells. Serum ACE levels were high (93 U/L). Bone marrow aspiration and biopsy did not reveal any pathology. Mediastinoscopy-guided mediastinal lymph node biopsy showed features of granulomatous lymphadenitis. This case report summarises an unusual presentation of tuberculosis in an adult.