A Primary Mediastinal Monophasic Spindle-Cell Synovial Sarcoma with Superior Venacaval Obstruction.

Primary mediastinal sarcoma is a rare tumour that usually presents with nonspecific symptoms such as hoarseness, dyspnoea, and chest pain. Superior vena cava (SVC) syndrome is an extremely uncommon complication that is caused by the compression, invasion, and thrombosis of the SVC or brachiocephalic veins. SVC syndrome can present as asymptomatic cases or as rare life-threatening emergencies with upper airway obstruction and increased intracranial pressure. This report describes the case of a 58-year-old female who presented with swelling of the face, neck, and upper limbs associated with dyspnoea on exertion. The radiological investigations revealed a large well-defined central necrotic peripherally enhancing lesion in the superior mediastinum extending anteriorly with the compression of brachiocephalic veins. A histopathological examination detected spindle cells arranged in fascicles with nuclear atypia with immunohistochemistry positive for creatine kinase (CK), smooth muscle actin (SMA), desmin and CD99. These findings established the diagnosis of a mediastinal monophasic synovial sarcoma with SVC obstruction. The patient was initiated on palliative radiotherapy for the management of the SVC, followed by systemic biological treatment with the tyrosine kinase inhibitor pazopanib, and was clinically improved. It is essential to promptly diagnose and treat this condition, especially when SVC syndrome manifests.

Profile of Secondary Bacterial and Fungal Infections in Hospitalized COVID-19 Patients in a Tertiary Care Centre.

Introduction: SARS CoV-2, a novel corona virus, has emerged in December 2019. The COVID-19 associated mortality is documented in elderly with co morbidities. To have better insight on this issue, the secondary bacterial infections with multi-drug-resistant bacteria in COVID-19 patients need to be studied to evaluate the impact of these infections on the outcome. Aim and objectives: To determine the proportion of secondary infections in COVID-19 patients. To study the spectrum of pathogens and antibiogram of the bacteria isolated from secondary infections in such patients. To evaluate the co-existing co-morbidities, treatment and outcome in these patients. Methodology: The retrospective study was conducted in Departments of Medicine and Microbiology, KMC hospitals Attavara and Ambedkar circle, Mangaluru, including all the hospitalized microbiologically confirmed cases of SARS CoV-2 infection. Details pertaining to the study population were collected using a structured proforma. Descriptive data were entered in the form of mean, median and proportions. The categorical values were analyzed using Chi square test. Values of p < 0.05 were considered as statistically significant. Results: Two hundred COVID-19 hospitalized patients were included.28 out of 200 patients (14%) studied developed secondary infections. The types of secondary infections were Respiratory infections (50%), blood stream infections (17%), UTI (14%), Rhinocerebral Zygomycosis (17%). The predominant organisms were Klebsiella pneumoniae (44%), Zygomycetes (17%). The rates of antibiotic resistance in Gram negative bacilli were 33% to Cefuroxime,25% to aminoglycosides and fluoroquinolones and 16% to carbapenems. The mortality of 42.8% was observed in patients with secondary infections. Conclusion: Close monitoring and follow up especially in high-risk group of severe COVID 19 patients is crucial for better management and outcome.

Early diagnostic markers in predicting the severity of dengue disease.

The aim of the present study was to determine whether the serum ferritin, the biomarker of an acute phase reactant and the gall bladder wall edema, an early indicator of capillary leakage can predict the severity of dengue fever. This study included 131 patients, who were between the age group of 18-80 years. The patients presented to our department with an acute illness, within the first four days of high temperature. The statistical analysis of this study was performed by using the Chi-square and independent Student's t tests. The diagnostic markers are considered statistically significant, if the serum ferritin level is higher than 500 ng/ml and the gall bladder wall thickness is more than 3 mm. The present study observed that, 39 patients (89%) who had severe dengue (n = 44) revealed a significant gall bladder wall thickening, and this correlation was significant statistically (p < 0.000). It was also observed that, the ferritin levels have a highly significant positive correlation with the severity of dengue. The severe dengue patients had a mean ferritin level of 9125.34 µg/l, whereas the non-severe group had 4271 µg/l. This comparison was also statistically significant, as the p value was 0.003. We report that the serum ferritin levels have a highly significant positive correlation with the severity of dengue. The gall bladder wall edema during the third and fourth day of the illness was also associated with severe dengue. However, diffuse gall bladder wall thickening and high serum ferritin levels are also reported in various other conditions and their exact cause have to be determined by the correlation of associated clinical findings and imaging features.

Primary adrenal plasmablastic lymphoma presenting as lymphomatous meningitis - A diagnostic perplexity.

A rare presentation of primary plasmablastic lymphoma (PBL) of the adrenal gland, as lymphomatous meningitis in a patient living with HIV.

Association between Veterans Aging Cohort Study (VACS) index and neurocognitive function among people living with HIV-a cross sectional study in coastal South India.

BACKGROUND: HIV is an infectious disease affecting 36.7 million people worldwide. In recent times, Antiretroviral Therapy (ART) has become accessible to the majority of People Living with HIV (PLHIV) and this has transformed the course of infection to one that is chronic, characterized by fewer diseases pathognomonic of AIDS. In view of this, there is a pressing need for better markers, apart from the routine HIV indicators, to detect comorbidities such as Neurocognitive Impairment (NCI). The aim of this study was to find out the association between Veterans Aging Cohort Study (VACS) index and Neurocognitive function in HIV positive patients. METHODS: In our study, we included 97 HIV positive patients and their Neurocognitive function was assessed using a combination of Montreal Cognitive Assessment and Grooved Pegboard Test, while VACS index was calculated using the most recent laboratory values. Binomial Logistics Regression analyses, adjusting for potential confounding variables, was performed to determine the association between VACS score and Neurocognitive Impairment. RESULTS: We found that a higher VACS Index was associated with global and domain-wise Neurocognitive impairment (p < 0.01), specifically in the domains of attention (p < 0.01) and fine motor skills (p = 0.01). Our study also showed that among all the VACS components, older age (p = 0.02) and lower hemoglobin (p < 0.01) values were associated with global NCI. After plotting an ROC curve, a VACS cut-off score of 11.00 was identified as it had good sensitivity (87.0%) and specificity (71.4%) in identifying Global NCI. CONCLUSION: Our findings extend prior research on the use of VACS Index to predict global and domain-wise NCI in HIV-positive patients. However, further research with more comprehensive neurocognitive testing is required in our setting before VACS Index can be used as a tool to screen for neurocognitive dysfunction among PLHIV.

Profile of Secondary Bacterial Respiratory Infections in H1N1 Patients Admitted in a Tertiary Care Centre - A Four-year Retrospective Study.

BACKGROUND: H1N1 is known to cause periodic seasonal flu in the Indian subcontinent since 2009. The clinical course and the underlying immunity of the host contribute to the development of secondary bacterial infections in the infected patients. OBJECTIVES: This study aims to analyze the secondary bacterial infections in confirmed H1N1 cases admitted in our hospital (from 2015 to 2018) with respect to the comorbidities, complications, associated bacteria with its antibiotic susceptibility pattern, and the outcome of such episodes. MATERIAL AND METHODS: Data of 164 patients admitted in a tertiary care hospital with H1N1 was extracted from medical records using a semi-structured case report form. Data were entered and analyzed with SPSS version 17. A p-value of <0.05 was considered statistically significant. RESULTS: Most patients were aged above 40 years with female preponderance. In our study, 42% of patients had comorbidities. Only 14 (8.53%) had secondary bacterial infection confirmed by culture. Klebsiella pneumoniae and Acinetobacter baumannii were the most common bacteria that were isolated. They were treated based on the culture reports. There was no mortality in patients with a secondary bacterial infection. CONCLUSION: The early start of the antiviral agents and adherence to the antibiotic policy of the hospital contributed to lower secondary bacterial infections and zero mortality.

Synergistic role of susceptibility-weighted imaging with diffusion-weighted imaging and magnetic resonance angiography in the evaluation of acute arterial stroke.

OBJECTIVE: This study was performed to investigate whether diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) are more effective than conventional imaging modalities for evaluation of stroke and selection of candidates for thrombolytic therapy. METHODS: Eighty patients who presented within 12 hours of onset of symptoms of brain ischemia underwent 1.5T magnetic resonance imaging. DWI and SWI were compared with conventional sequences (T1, T2, and fluid-attenuated inversion recovery [FLAIR]) and time-of-flight magnetic resonance angiography (TOF-MRA) to assess factors that affect stroke management and prognosis. RESULTS: The volume of brain tissue showing hyperintensity was significantly greater than that showing diffusion restriction in patients with a >6-hour symptom onset. The hypointensity sign (susceptibility sign) on SWI showed a sensitivity of 66.7%, specificity of 87.5%, positive predictive value of 88.9, and negative predictive value of 63.6 compared with TOF-MRA. Micro-hemorrhagic foci were significantly associated with 27-mL infarcts on DWI (sensitivity, 71.4%; specificity, 85.0%). Patients with DWI-SWI mismatch showed better responses to thrombolytics. FLAIR-DWI mismatch helped to assess the time of stroke onset. CONCLUSION: DWI and SWI should be part of the routine imaging protocol in patients with acute stroke and serve as a decision-making tool for selection of patients for thrombolytic therapy.

Comparative assessment of clinic-laboratory profile of different species of severe malaria in a tertiary care institute in southern India.

BACKGROUND & OBJECTIVES: Majority of the studies on severe malaria in India have concentrated on falciparum and have been done in northern part. The objective of the study was to compare the clinical spectrum and laboratory profile among severe Plasmodium vivax, P. falciparum and mixed malaria patients admitted at a tertiary care center in southern India. METHODS: This prospective, observational study was done in adult patients with severe malaria hospitalized in a tertiary care centre in southern India. Malaria was diagnosed by either quantitative buffy coat test or peripheral blood smear. In the cases of P. vivax malaria, an antigen detection test was done to rule out coexistent falciparum infection. Severe malaria was defined as per the WHO guidelines. The malaria severity score (MSS) was calculated for all patients based on the clinical features and laboratory parameters. RESULTS: A total of 204 cases of severe malaria were studied. Among them, 105 (51.5%) had vivax infection, 30 (14.7%) had falciparum and 69 (33.8%) patients had mixed malaria. The mean age of the study population was 39.8±15.7 yr. The majority were males (71.6%). Hypotension and prostration were the most common complications noted in the patients, irrespective of species. The maximum mean MSS was found to be highest in falciparum malaria, followed by mixed malaria and vivax. In vivax malaria, majority of patients (71.4%) had one or two complications and only 28.57% of patients had three more complications, whereas in falciparum malaria, the majority (53.33%) had three or more complications. Around 44.93% of mixed infection malaria patients had three or more complications. The number of patients with multi-organ dysfunction (>2 complications) was significantly more in patients with falciparum infections compared to the remaining patients. INTERPRETATION & CONCLUSION: Severe malaria in south India is predominantly due to vivax. Hypotension and prostration were the most common complication of severe malaria irrespective of the plasmodium species. The entire spectrum of severe malaria complications described for falciparum are seen in severe vivax malaria.

Human Immunodeficiency Virus Infection: Does Highly Active Antiretroviral Therapy Influence Ear Nose Throat Manifestations?

To study the change in trend of ear, nose and throat (ENT) manifestations in patients who were on treatment, before and after availability of highly active antiretroviral therapy (HAART). To find out the prevalence of ENT manifestations in human immunodeficiency virus (HIV) infected people who were on treatment, in the year of 2004 (before the availability of HAART) and in 2014 (after the availability of HAART). Design A combination of a retrospective and prospective study. Setting Anti Retroviral Therapy (ART) Center at Our Hospital. Subjects Patients with HIV infection on ART. Methods Retrospective review of case records of the patients visiting the center in the year 2004 and prospective study of the patients visiting in the year 2014 was conducted. Sample size was calculated as 200 in each group based on 95% confidence and 96% power. Convenience sampling was used in our study. The prevalence of ENT manifestations in HIV patients were found to be 86% in 2004 and 93% in 2014. Among ENT manifestations oropharyngeal manifestations were most common. Lesser the CD4 count more was the prevalence of disorders in oropharynx. Our study showed a high prevalence of ENT manifestations in HIV patients who were on treatment, irrespective of the gap of 10 years and introduction of HAART therapy. Most common ENT manifestation both in 2004 and 2014 was oropharyngeal candidiasis. Lesser the CD4 count more was the prevalence of disorders in oropharynx.

Correlates of Late Presentation to HIV care in a South Indian Cohort.

Late presentation to healthcare by HIV infected patients' is common in India despite access to free combination antiretroviral therapy (cART). We assessed risk factors for late presentation among patients with a recent HIV diagnosis in an academic university-based antiretroviral treatment center. This retrospective study included 474 recently diagnosed HIV-infected patients registered for cART between 2012 and 2013. Subjects with CD4+ T-lymphocyte (CD4) count ≤ 350 cells/µL or with an AIDS defining event were defined as late presenters (LP) and patients with CD4 count ≤ 200 cells/µL or with an AIDS defining event were defined as LP with advanced HIV disease (LPAD). Multivariable logistic regression analysis was used to investigate factors associated with late presentation. Of the 474 patients, 356 (75.1%) were LP. Of these, 299 (83.99%) were LPAD and 57 (16.01%) LP were AIDS-free. Median CD4 count among LP was 134 cells/µL (interquartile range 72.25-219). Mean age of LP was 42.50 ± 8.88 years; 256 (71.9%) were males. Increasing age (> 51 years; Adjusted odds ratio [aOR] 4.19; P = 0.014) and rural residence (aOR 3.19; P = < 0.001) were independently associated with late presentation. HIV-positive housewives (aOR 0.34; P = 0.027), HIV-positive individuals with negative partners (aOR 0.48; P = 0.006), and partners with unknown HIV status (aOR 0.43; P = 0.007) were less likely to present late compared with positive partners of people living with HIV/AIDS (PLWHA). Most patients were LP despite free access to cART. Rural population and older PLWHA should be targeted while implementing HIV care. There is a need to strengthen the HIV care cascade by linking PLWHA to cART immediately after diagnosis.

A "Handy" tool for hypertension prediction: Dermatoglyphics.

BACKGROUND: Fingerprints studied by dermatoglyphics are unique for a given individual. It depends on the genetic makeup of an individual. Hypertension, a harbinger of many complications, is determined by genetic and environmental factors. In this observational study, we tried to find an association of palmar dermatoglyphic parameters and hypertension. METHOD: Two hundred fifty known hypertensives as cases and 250 normotensives as controls were enrolled after considering inclusion and exclusion criteria. Dermatoglyphic patterns on tips of fingers obtained by digital imaging were noted in both the groups, and "atd" angle was calculated using "screen protractor" software. Collected data were statistically analyzed to find any association between dermatoglyphic qualitative and dermatoglyphic quantitative patterns and hypertension. RESULT: Mean "atd" angle was higher in cases than in controls. Comparison of dermatoglyphic patterns in both the groups in various ways-both hands together, the right hand and left hand separately, similar fingers on right and left hand together, and similar fingers separately-was performed which revealed that at every level, whorls were more frequent in cases than in controls and that distribution of dermatoglyphic patterns were statistically significant in cases than in controls. CONCLUSION: Fingerprint patterns can be reliably used to identify individuals likely at risk for hypertension, and accordingly, preventive measures can be targeted. This subject area demands a need for further research and analysis with large sample size to allow dermatoglyphics to evolve into a cost-effective and handy tool for identifying individuals at risk of hypertension.

Clinicoepidemiological Profile of Elderly PLHIV Attending a Tertiary Care Center in South India.

BACKGROUND: Physicians are coming across a considerable number of HIV-positive patients belonging to older age-group, in practice. They pose a challenge as they might present with advanced forms and comorbid conditions. We aimed to describe the clinicoepidemiological profile of elderly people living with HIV. METHODOLOGY: We conducted a cross-sectional study at Kasturba Medical College, Mangalore. We analyzed the record of 120 patients from 2009 to 2014. Descriptive statistics were used to describe sociodemographic and clinical profile of patients. RESULTS: Of 786 HIV-positive patients, 120 were elderly. Mean age was 55.9 ± 6.1 years. Majority 68% were male. In all, 63.33% were male. Commonest route of transmission was heterosexual intercourse, most presented at World Health Organization (WHO) stage 1 (64.17%). In all, 77.5% had hypertension and 26.6% had tuberculosis. The median CD4 count at presentation was 245 cells/mm3 (145-426 cells/mm3). Forty-two percent were late presenters (CD4 <200 cells/mm3). CONCLUSION: Treating physician should have a high index of suspicion in diagnosing HIV among elderly age-group.

HIV-Related Knowledge among PLWHA Attending a Tertiary Care Hospital at Coastal South India-A Facility-Based Study.

BACKGROUND: Adequate knowledge about HIV/AIDS among people living with HIV (PLHIV) is essential for the prevention of HIV transmission. METHODS: A cross-sectional study consisting of 409 PLHIV aged ≥18 years were interviewed regarding their HIV-related knowledge, from April 2014 to April 2015. HIV-related knowledge was assessed using the HIV knowledge questionnaire 18 . Univariate and multivariate analyses were done to determine the factors associated with high HIV-related knowledge. Odds ratios with its corresponding 95% confidence intervals were reported. A value of P < .05 was considered to be statistically significant. RESULTS: Among 409 PLHIV, 46.2% had high HIV-related knowledge. Univariate analysis yields factors like upper socioeconomic status, those who are literates, unemployed, and adherent to antiretroviral therapy (ART) were associated with higher HIV-related knowledge. On multivariate analysis, upper socioeconomic status and adherence to ART were the factors that remained significantly associated with higher HIV-related knowledge. CONCLUSION: HIV-related knowledge among PLHIV can be improved through HIV educational programs.

In-Patient Mortality among PLHIV: A 7-Year Hospital-Based Retrospective Study in Coastal South India.

BACKGROUND: With the wide usage of highly active antiretroviral therapy, the morbidity and mortality due to HIV have declined gradually. The aim of our study was to determine the cause of mortality among HIV-infected patients and the factors causing early death. METHODS: Using medical records of 73 inpatients who are dead, data were collected and analyzed using SPSS version 19 (IBM SPSS Statistics). Chi-square test was performed to determine the factors contributing to early death. A P value <.05 was considered significant. RESULTS: Among 73 deaths, 50 (68.5%) were AIDS related and 23 (31.5%) were non-AIDS related. The most common opportunistic infection causing death was Pneumocystis carinii pneumonia. Early deaths were strongly attributed to low CD4 counts at admission (<100 cells), antiretroviral therapy-naive status, late presentation, and fewer admissions ( P value <.05). CONCLUSION: Although AIDS-defining illness remains the main cause of death in HIV, there is significant number of deaths due to non-HIV-related causes.

Factors Influencing Quality of Life among People Living with HIV in Coastal South India.

BACKGROUND: Antiretroviral therapy (ART) has increased life expectancy of HIV/AIDS patients, but the quality of life (QOL) still remains the same. METHODS: In this cross-sectional study, 356 people living with HIV (PLHIV) were interviewed to assess their QOL using WHOQOL-HIV BREF questionnaire. The association between QOL with sociodemographic, clinical and cohabitation status of the participants was tested using ANOVA and Student t-test, and p value < .05 was considered statistically significant. RESULTS: Physical domain of QOL showed maximum score of 16.4, while a minimum score of 12.2 was seen in social relationship domain. Participants with higher socioeconomic status (SES) and self-motivated to take ART had shown better scores across all the domains of QOL ( p < .05). CONCLUSION: In our study, quality of life was high among males, younger patients, married participants, higher socioeconomic status, longer duration of ART, self-motivation to take ART, absence of opportunistic infection, and with higher CD4 count.

Cutaneous Melioidosis.

Melioidosis is an emerging infection in India. It usually presents as pneumonia. Melioidosis presenting as cutaneous lesions is uncommon. We present a case of cutaneous melioidosis from Southern India. Cutaneous melioidosis can present as an ulcer, pustule or as crusted erythematous lesions. A 22-year-old gentleman known case of diabetes mellitus was admitted in our hospital with an ulcer over the left thigh. Discharge from the ulcer grew Burkholderia pseudomallei. He was successfully treated with ceftazidime. Melioidosis must be considered in the differential diagnosis of nodular or ulcerative cutaneous lesion in a diabetic patient.

Mastication Frequency and Postprandial Blood Sugar Levels in Normoglycaemic and Dysglycaemic Individuals: A Cross- Sectional Comparative Study.

INTRODUCTION: Mastication has potential to affect postprandial blood glucose levels by affecting cephalic phase of insulin release. However, limited number of studies done in this regard has yielded conflicting results. AIM: To evaluate effects of mastication on postprandial blood glucose levels. MATERIALS AND METHODS: We compared routine and thorough mastication in 2 separate groups: dysglycaemic (prediabetics and diabetics) and normoglycaemic in prospective interventional study. Blood glucose levels were measured pre-prandial and postprandial (after 2 hours) on separate days after routine and thorough mastication in both groups. RESULTS: In normoglycaemic group, thorough mastication significantly reduced postprandial blood glucose levels at 2 hours (128.25± 7.82 mg/dl on routine mastication vs 119.74±9.08 mg/dl on thorough mastication, p<0.05). Comparatively, in dysglycaemic group, thorough mastication had little effect on postprandial blood glucose levels at 2 hours (244.07±22.37 mg/dl vs. 243.55±22.87 mg/dl). CONCLUSION: In normoglycaemic group, postprandial blood glucose concentration upon thorough mastication was significantly lower, due to early-phase insulin secretion. This simple lifestyle modification of thorough mastication can be a useful preventive measure against diabetes in people with a strong family history and other risk factors for diabetes who have not yet developed diabetes or prediabetes.

Fertility Desires and Intentions among People Living with HIV/AIDS (PLWHA) in Southern India.

INTRODUCTION: The desire of people living with HIV/AIDS (PLWHA) to have children can have significant public health implications. Combination Antiretroviral Therapy (cART) has increased the life expectancy of PLWHA as a result of which they may consider child bearing. There are hardly any studies from India addressing the fertility desires among PLWHA. AIM: This study was done to assess the fertility desires of PLWHA in Southern India. MATERIALS AND METHODS: It was a cross-sectional study conducted among 230 HIV-positive men and women who presented to Kasturba Medical College (KMC), Mangalore, India. Study was conducted between October 2012 and October 2014. Statistical analysis was performed using SPSS software version 11.5. Chi-square test, Fisher's exact test and student t-test was used to find out the association of various factors affecting fertility desire. A p-value of less than 0.05 was considered statistically significant. RESULTS: The mean age of our study population was 36.3±5.5 years. The mean age of males was 37.3±6 years and for female 34.9±5 years. In our study 132 (57.4%) were males. Majority were literate 229 (99%). Majority of patients were employed 166 (72%). In our study 195 (84.7%) were on cART. Out of 230 PLWHA 39 (16.95%) were unmarried and 151(65.5%) married PLHIV were living with partners at the time of study. In our study 77 (33.5%) patients had fertility desire. Age, gender, marital status, number of children, partner's fertility desire and HIV status of partner had an association with fertility desire. CONCLUSION: Providing universal access to cART is the main aim of national programs. It is high time that these programs focus on fertility issues of PLWHA. Reproductive rights of PLWHA need to be respected. Physicians and HIV counselors should proactively discuss and address reproductive issues of PLWHA.