Mucormycosis and diabetes in the times of COVID-19: A Mumbai-based observational study.

Background: There is a significant increase in the number of mucormycosis cases in the setting of the coronavirus disease 2019 (COVID-19) pandemic. This study was undertaken to understand the clinical profile of such patients and the risk factors associated with increased mortality of this already deadly infection. Materials and Methods: A retrospective observational study was conducted by including microbiologically confirmed cases of mucormycosis with the background of COVID-19 infection (COVID-19-associated mucormycosis [CAM]). Data was segregated into those of survivors versus non-survivors and the two groups were analyzed for various risk factors. Early and late CAM were also compared. Results: The case fatality rate was 21.73% (5/23 patients). Case fatality in early CAM was 33.3% versus 9.1% in late CAM. Rhino-orbital-cerebral mucormycosis (P = 0.01) and cranial nerve involvement (P = 0.0482) were associated with increased mortality. Diabetes and poor glycemic control were the common factors in all patients. Early CAM patients were more likely to have orbital or cerebral involvement (P = 0.0065). Patients having chronic liver disease had a higher risk of mortality (P = 0.0395). Sequential treatment or concurrent dual drug therapy with a combination of antifungal drugs was independently associated with better survival (P = 0.0395). The average duration of treatment with amphotericin-b required for cure by survivors was 29.05 ± 17.05 days. The average duration of treatment with isavuconazole/posaconazole for survivors was 50.32 ± 25.23 days. Conclusion: Early CAM had a higher case fatality rate. Patients had better recovery rates with sequential or dual antifungal treatment. The raised incidence and mortality in the COVID-19 pandemic is probably related to the COVID-19-induced immunosuppression with associated diabetes and excessive use of steroids.

A Case of CNS Actinomycosis: Rarer than Rare!

We report a case of cerebral actinomycosis in a 62-year-old male who presented with right-sided weakness and focal convulsions. MRI scan showed a solid intra axial space occupying lesion in the left frontal lobe. Left parietal craniotomy with intra-operative USG guided aspiration and excision of the mass (containing necrotic material) was done. Actinomyces israelii was isolated from the aspirated material. Patient received ceftriaxone and clindamycin for 12 weeks. Physiotherapy and anti-epileptic drugs were continued. On subsequent follow-up visits, his power improved to 5/5 in lower limb, 4/5 in proximal upper limb, 2/5 in distal upper limb. Actinomycosis can cause diverse clinical manifestations, and therefore clinical suspicion is key to diagnosis. Early diagnosis and treatment can lead to good treatment outcomes.

Limitation and withdrawal of intensive therapy at the end of life: practices in intensive care units in Mumbai, India.

OBJECTIVE: To describe the practices in intensive care units in Mumbai hospitals regarding limitation and withdrawal of care at the end of life. DESIGN: Review of prospectively collected data. SETTINGS: Intensive care units of four major hospitals (two private tertiary referral general hospitals, one mixed public and private cancer referral hospital, and one large public hospital). PATIENTS: Hospital and intensive care unit patients who died during the study period. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We measured the percentage of hospital deaths occurring inside and outside intensive care units and the incidence of withholding intubation, withholding other therapy, and withdrawing therapy for deaths in the intensive care unit. The proportion of hospital deaths that occurred in an intensive care unit was 14% in the cancer hospital, 23% in the public hospital, and 58-73% in the two private hospitals (chi-square test for trends, p < .0001). Of the 143 deaths that occurred in intensive care unit, limitation of care occurred in 49 patients. Twenty-five percent of these patients were not intubated terminally, 67% were initially intubated and ventilated but failed to recover and subsequently had no further escalation of therapy, and 8% had withdrawal of therapy. Therapy was limited in 19% of deaths in the public hospital intensive care unit (odds ratio, 0.44; 95% confidence interval, 0.2-0.97) vs. 40%, 41%, and 50% of deaths in the other three intensive care units. CONCLUSIONS: Therapy is limited in a significant proportion of intensive care unit patients. Significant differences in the practice of limitation of therapy exist between public and private hospitals. Lack of access to a limited number of intensive care unit beds, especially in the public hospital, may constitute implicit limitation of care.