Perturbations of immune landscape in COVID-19 associated mucormycosis.

BACKGROUND: A rise in secondary fungal infections during the COVID-19 pandemic necessitates a deeper understanding of the associated immunological perturbations. OBJECTIVES: To evaluate the clinical and immunological characteristics observed in patients with COVID-19 associated mucormycosis (CAM) infection. PATIENTS/ METHODS: Cases of mucormycosis with or post-COVID-19 infection were compared with cases of acute COVID-19 and convalescent COVID-19. Lymphocyte subsets, cytokines and other laboratory markers were compared between the groups. RESULTS: The frequency of proposed risk factors for CAM was diabetes mellitus (77%), recent history of steroid use (69%) and hypoxia during COVID-19 infection (52%). Iron metabolism was dysregulated in CAM patients with low TIBC and total iron. Further, CAM was accompanied with lymphopenia with drastic reduction in B cell counts; however, plasmablasts were not altered. Further, CAM patients had low immunoglobulin levels and antibodies specific to mucor peptide did not increase in CAM suggesting dysfunction in B-cell response. There was increase in activated effector cytotoxic CD8 T cells and NK cells in CAM compared with COVID-19 infection and healthy controls. Among T helper cells, Tregs were reduced and Th-1 frequency was increased in CAM compared with COVID-19 infection. A distinct cytokine signature was evident in CAM with increase in IL-1ß, IFN-γ, IL-6, IL-22, IL-17A, IL-10, IL-2, IL-8, IL-7, IL-21 and GM-CSF. CONCLUSION: This is the first study on immunophenotyping in CAM suggesting the need for long-term monitoring of B-cell function after SARS-CoV-2 in patients with dysregulated glycaemic control and the possible benefit of therapeutic supplementation with intravenous immunoglobulins in CAM.

Anterior Jugular Vein Hemangioma: A Diagnostic Conundrum and Report of a Rare Case.

Hemangioma is a common tumor accounting for 8 to 10 % of benign neoplasm. However, hemangioma arising from blood vessels is rare and even rarer if the vessel involved is anterior jugular vein (AJV). AJV hemangioma can be confused with jugular phlebectasia, laryngocele, thyroglossal cyst, simple cyst, or other vascular malformation of same origin. They should be considered in differential of midline/paramedian neck swelling. Surgical resection is the treatment of choice whenever possible, and even allows for histopathological evaluation and a confirmatory diagnosis. Being an extremely rare entity, there is paucity in literature about it and more publications are required to extend understanding and eliminate existing doubts about the pathology. We present an extremely rare case of AJV hemangioma that presented as a painless midline swelling and was initially confused as simple neck cyst on radiological assessment. We believe that this is the second only case of AJV hemangioma reported in English literature.

S-100 Immuno-Positive Low Grade Myofibroblastic Sarcoma of Nasal Cavity: A Rare Case Presentation and Review of Literature.

Introduction: Myofibroblastic neoplasms comprise a spectrum of benign/malignant neoplasms. Only low-grade malignant forms have been reproducibly characterized as a diagnostic entity in the WHO classification. Low grade myofibroblastic sarcoma (LGMFS) confined to the nasal cavity is extremely rare. Objective: To review previously reported cases of nasal cavity LGMFS and provide a better insight regarding its clinical and immunohistochemical features. Data synthesis: A review was performed involving two databases (PubMed and Google Scholar). Four cases of nasal cavity LGMFS were included. The lesion showed no gender or nasal-side predilection. All cases underwent wide excision. None showed distant metastasis while half recurred locally. Histologically, mitotic rate ranged from 1 to 3/10 high-power-field (HPF) and none exhibited spontaneous necrosis. Immuno-expression of calponin, smooth muscle actin (SMA) and vimentin were seen in either all four or three-fourth of cases. Diffuse S-100 expression was a unique finding in present case and not reported previously, that caused a diagnostic dilemma with schwannomas. Conclusion: LGMFS of nasal cavity is extremely rare. A wide resection is the primary treatment of choice. Adjuvant therapies (chemotherapy or radiotherapy) are of uncertain significance. Distant metastasis is rather unusual. Calponin, SMA and vimentin are highly sensitive immuno-markers. Diffuse S-100 expression is a possible finding. Mitotic rate < 6/10 HPF and absence of spontaneous necrosis are characteristic indolent features differentiating from high grade lesions. Trifecta of clinical and morphological features plus immunohistological phenotype, are sufficient for a definitive diagnosis. Electron microscopy is the most definitive confirmation test, however, should be reserved only for equivocal/atypical immunostaining pattern.

Emergence of Invasive Fungal Rhinosinusitis in Recently Recovered COVID-19 Patients.

OBJECTIVE: The risk of invasive fungal rhinosinusitis is increased in Coronavirus disease 2019 (COVID-19) because of its direct impact in altering innate immunity and is further exacerbated by widespread use of steroids/antibiotics/monoclonal antibodies. The study aims to describe this recently increased clinical entity in association with COVID-19. METHOD: A prospective, longitudinal study including patients diagnosed with acute invasive fungal rhinosinusitis (AIFRS) who recently recovered from COVID-19 infection or after an asymptomatic carrier state. A single-center, descriptive study investigating demographic details, clinical presentation, radio-pathological aspects, and advocated management. RESULT: A total of 21 patients were included with a mean age of 49.62 years (SD: 14.24). Diabetes mellitus (DM) was the most common underlying disorder (90.48%), and 63.16% of all patients with DM had a recent onset DM, either diagnosed during or after COVID-19 infection. Nineteen patients (90.48%) had recently recovered from active COVID-19 infection, and all had a history of prior steroid treatment (oral/parenteral). Remaining 2 patients were asymptomatic COVID-19 carriers. Surprisingly, 2 patients had no underlying disorder, and 5 (23.81%) recently received the Covishield vaccine. Fungal analysis exhibited Mucor (95.24%) and Aspergillus species (14.29%). Most common sign/symptom was headache and facial/periorbital pain (85.71%), followed by facial/periorbital swelling (61.90%). Disease involvement: sinonasal (100%), orbital (47.62%), pterygopalatine fossa (28.58%), infratemporal fossa (14.29%), intracranial (23.81%), and skin (9.52%). Exclusive endoscopic debridement and combined approach were utilized in 61.90% and 38.10%, respectively. Both liposomal amphotericin B and posaconazole were given in all patients except one. CONCLUSION: A high suspicion of AIFRS should be kept in patients with recent COVID-19 infection who received steroids and presenting with headache, facial pain, and/or facial swelling. Asymptomatic COVID-19 carriers and COVID-19 vaccinated candidates are also observed to develop AIFRS, although the exact immuno-pathogenesis is still unknown. Prompt diagnosis and early management are vital for a favorable outcome.

Risk Indicators for Hearing Impairment in Neonates.

To identify relation between prevalence of hearing impairment and risk factors at the time of birth in high risk neonates. A year-long study is performed at HBT Medical College and Dr. R. N. Cooper Municipal General Hospital, Vile Parle (west), Mumbai. The Study comprised of 478 high risk babies born between March 2016 and February 2017 and admitted in NICU of the hospital. Out of these 68 babies were either transferred to higher centre or took discharge against medical advice. A total of 410 babies completed the study. Additional 21 eligible babies died in NICU during the study. A Prospective Observational Study is used to analyse the findings of the study. Skew analysis of spread of prevalence across risk factors is used to establish higher prevalence of hearing impairment in high risk neonates. Cramer's Moment Coefficient of Skewness and Corresponding Test Statistics are used for studying the skewness. Out of 410 babies screened during the study 5 babies were diagnosed with profound SNHL. The risk factors associated with babies is plotted against frequency of babies with Profound SNHL. The plot is found to be un-uniformly distributed and shows inclination towards higher prevalence with high risk babies. Sample skewness (G1) value - 0.81 indicates moderately negative skewed sample. This means the number of babies with profound SNHL found by 3 stage screening is moderately concentrated at high risk weightage.

External carotid artery pseudoaneurysm with arteriovenous fistula: A rare complication of glass shrapnel injury.

Posttraumatic external carotid artery pseudoaneurysm with arteriovenous fistula is a rare condition. An 8-year-old child presented with painful pulsatile swelling in the preauricular region following a penetrating glass shrapnel injury. Detailed evaluation showed distal external carotid artery pseudoaneurysm with fistula, which was draining into the retromandibular vein. Endovascular treatment was performed. This case highlights the role of endovascular intervention for such rare complicated vascular pathologies.

Stylalgia: A Missed Diagnosis.

AIMS AND OBJECTIVE: To study the occurrence of stylalgia in patients presenting with pain in the head and neck region and appropriate management options. MATERIALS AND METHODS: This was a hospital-based study. This study analyzed prospectively patients who presented to the otolaryngology outpatient department with complaints of throat pain, globus, neck pain, facial pain, odynophagia, throat pain associated with earache, and neuralgic pain, and were diagnosed with stylalgia and managed with styloidectomy or subjected to medical treatment. RESULTS: Out of 20 patients (4 males and 16 females), 14 patients became symptom-free, while 6 patients experienced relief of symptoms. There was no worsening of symptoms in any of the patients. CONCLUSION: The incidence of Stylalgia is higher in a female population. Elective management of patients after assessing the response to treatment, and then offering surgical management is of value for adequate patient care, prevention of unnecessarily delayed diagnosis and appropriate treatment.