Hyponatremia-induced worsening of trigeminal neuralgia- When the sodium plays the game.

A 78-year-old elderly male who was on treatment for trigeminal neuralgia and hypertension was brought to the emergency with altered sensorium. His vital parameters were within normal limits; however, the arterial blood gas analysis showed severe hyponatremia. He was admitted to the ward, where further workup was carried out and hyponatremia correction started. He had a sudden worsening in his facial pain before he landed in encephalopathy. His medications (oxcarbazepine and chlorthalidone) that could cause hyponatremia were stopped, and judicious correction of hyponatremia was done. His baseline investigations, including a chest roentgenogram and electrocardiogram, were normal. After he regained consciousness, it was noted that the facial pain had regressed significantly despite stopping his first-line drugs. This case of worsening trigeminal neuralgic pain due to hyponatremia responded well to judicious sodium correction.

Mucormycosis and aspergillosis: The deadly duo in COVID-19-a case report.

COVID-19 disease has been associated with fungal infections such as aspergillosis and mucormycosis, especially in diabetic patients who have suffered from a moderately severe form of COVID-19 infection and are treated with steroids. Though there are multiple case reports describing co-infection with mucormycosis during the second wave of the COVID outbreak, the report of a dual fungal infection along with superadded bacterial infection is rare. Here we report a case where the same patient had a fungal storm with aspergillosis and mucormycosis and superadded Klebsiella. She was treated aggressively with antifungal agents, antibiotics, surgical debridement, and other supportive care. She improved and was discharged from the hospital after a long stay. She is being followed up regularly in the outpatient department and doing well.

Success rate of Remdesivir, Convalescent Plasma, and Tocilizumab in moderate to severe Covid-19 pneumonia: our experience in a tertiary care center.

INTRODUCTION: After the first case of Covid-19 was identified in Wuhan City, China, the numbers increased rapidly all over the world putting a huge burden on the entire healthcare system. Managing these cases posed a great challenge to the treating clinicians in the absence of targeted therapy. At this juncture, few modalities got approved as EUA (Emergency use under authorization) drugs namely Remdesivir, Convalescent Plasma (CP), and Tocilizumab (TCZ) to treat this deadly disease. AIM: To analyze the success rates of EUA therapies for Covid-19 pneumonia in our hospital. MATERIALS AND METHODS: This was a prospective observational study conducted from April 2020 to October 2020 in the department of Medicine at Tata Main Hospital, Jamshedpur, Jharkhand. All adults with moderate to severe Covid-19 as per the WHO criteria were enrolled in the study with their informed consent. Patients with estimated glomerular filtration rate <30 mL/min, deranged liver function tests, electrocardiographic abnormalities, and deranged hematological parameters were excluded from the study. Thorough clinical evaluation was done in all cases. Routine investigations together with CRP, LDH, serum Ferritin, D Dimer and IL6, Chest X-Ray, and HRCT thorax were done in all cases. ECG was done in all cases and 2D-ECHO in selected ones. Depending on their clinical and radiological criteria, patients were treated with various modalities approved under EUA with close monitoring of clinical, biochemical, and radiological parameters. Presenting symptoms, clinical findings, co-morbidities, laboratory parameters, and radiological assessment were analyzed, and statistical analysis was done. The survival rate and in-hospital mortality was analyzed. OBSERVATIONS AND RESULTS: We had a total of 448 patients who were included in our study, out of which 326 were males and 122 were females with a male to female ratio of 2.7:1. Their age varied between 16 and 91 years with an average age of 51.4 years with a standard deviation (SD) of +/- 6.4 years. About 255 patients (57%) received only Remdesivir (176 males, 79 females), 139 (105 males, 35 females) patients (31%) received Remdesivir along with two units of CP, and 38 (32 males, 6 females) patients received a combination of Remdesivir, CP, and TCZ. All patients in our study tolerated the drugs well. About 5% of cases who received CP had minor transfusion reactions. One patient had TRALI and three patients had TACO, which was managed aggressively. Asymptomatic transaminitis was seen in 36% patients. The survival rate in patients treated with Remdesivir was 78%, those with Remdesivir and CP was 44%, and those with all three was 13%. The mean length of stay was 14.23 days with a SD of 9.06 days in patients treated with TCZ in comparison to other two modalities, which was 13.88 days with a standard variation of +/- 8.71 days in Remdesivir and 13.88 days with a SD of 8.73 days in patients treated with CP that was stastically significant. CONCLUSIONS: Though the success rate of various drugs under EUA varies in different studies from all over the world, the data to support their use are encouraging. We also observed satisfying results in our study specially with the use of Remdesivir. Therefore, EUA agents should be used early to fight against COVID-19 along with the other measures as per the protocol laid by ICMR and MoHFW.

Lupus myocarditis-A rare case.

Myocarditis in patients of systemic lupus erythematosus is extremely rare and is potentially life threatening. This may be the first presentation of the disease. Here, we report a patient who presented with features of heart failure and was later diagnosed to have SLE.

Kounis syndrome: A rare case.

Allergic angina and allergic myocardial infarction are ubiquitous diseases covering a wide spectrum of mast cell activation disorders, which are associated with acute coronary syndromes and are referred to as ''Kounis Syndrome''. Here, we report a case admitted with dyspnea and mild chest heaviness secondary to bee sting, later diagnosed as Kounis syndrome.

Double-outlet left ventricle: A rare case.

Double-outlet left ventricle (DOLV) is a rare cardiac malformation in which both great arteries originate from the morphological left ventricle. DOLV is associated with high mortality, generally due to heart failure, myocardial infarction, or aortic thrombosis. With surgery, the 5-year survival rate is estimated at 70%-75%. Most patients will continue to present with residual cardiac anomalies, such as aortic or mitral valve regurgitation, arrhythmias, or hypertension. Here, we report a 25-year-old male with DOLV with pulmonary stenosis and patent ductus arteriosus who presented to us with hemoptysis, which was due to respiratory tract infection. He improved with standard therapy.

Cold agglutinin-induced hemolytic anemia as the primary presentation in SLE - A case report.

Cold agglutinin-induced hemolytic anemia as the primary presentation in systemic lupus erythematosus (SLE) is extremely rare. Only few cases have been reported in literature so far. Here, we report a 17-year-old girl who presented with features of hemolytic anemia and later diagnosed as a case of SLE.

Clinicolaboratory profile of expanded dengue syndrome - Our experience in a teaching hospital.

INTRODUCTION: Classic dengue fever presentation has expanded its horizon by involving various organ systems and is named as expanded dengue syndrome. This changing presentation and rising burden across the globe may lead to delayed diagnosis and under reporting of this syndrome. AIM OF STUDY: To analyze clinicolaboratory profile of patients with expanded dengue syndrome. MATERIALS AND METHODS: About 520 cases of expanded dengue syndrome as per World Health Organization definition criteria 2012 were studied with their informed consent. Detailed history, thorough clinical examination, and relevant investigations were done. Their clinical and laboratory parameters were analyzed. Standard treatment guidelines were followed in all cases. OBSERVATION: About 301 patients were male and 219 were female with male-to-female ratio of 3:2. Their age varied from 12 to 76 years with the average age of 47.5 years. About 92% of cases presented with various gastro hepatic manifestations. The commonest gastrohepatic manifestation was transaminitis (57.5%) that is asymptomatic elevation of liver enzymes followed by acalculous cholecystitis (21%) and acute pancreatitis (13.9%). Twenty-nine patients presented with various neurological manifestations. Three patients presented with acute kidney injury and eight patients had coinfection with malaria. Fever with nausea and vomiting was the most common presentation. About 15% of patients presented with bleeding manifestations. About 40.6% of patients presenting as abdominal manifestations had platelet count <20,000/mm3 and needed platelet transfusion versus 9.8% with other system involvement (central nervous system, cardiovascular system (CVS), renal). Hepatomegaly was the most common ultrasonography (USG) finding being present in 57.5% of patients followed by acalculous cholecystitis in 21.3%. Total mortality was 1.9% in our series. We lost eight patients presenting with neurological manifestations and two patients with coinfection with malaria. CONCLUSION: Atypical presentations should prompt us to investigate for dengue especially during ongoing epidemics so that expanded dengue syndrome can be diagnosed and treated early.

Systemic lupus erythematosus camouflaging: As refractory acne in a young girl.

Cutaneous manifestations of systemic lupus erythematosus (SLE) are important diagnostic criteria as described by the revised American College of Rheumatology and Systemic Lupus International Collaborating Clinics. Patients usually present with various lupus-specific cutaneous manifestations such as malar rash, discoid rash, photosensitivity, and alopecia. Acneiform presentation of SLE is extremely rare. Review of the literature using PubMed has found only nine other reports so far. Here, we report a case who was initially treated as acne and later diagnosed as SLE.

Rhabdomyolysis - Exercise induced nightmare.

The term rhabdomyolysis refers to the disintegration of striated muscle which results in the release of muscular cell constituents into the extracellular fluid and circulation. Exertional rhabdomyolysis is occasionally seen after strenuous exercise. The progression to compartmental syndrome or renal failure is a rare complication that requires prompt recognition and treatment to prevent morbidity. We present the case of a 35-year-old male who came to our emergency department after a strenuous workout followed by fasting for a day. He presented with generalized weakness, decreased urine output, and one episode of dark-colored urine. He was found to have rhabdomyolysis with acute kidney injury (AKI). His condition progressed to frank renal shutdown requiring several sittings of dialysis and a very stormy course in hospital lasting about a month.

Physiochemical parameters optimization for enhanced nisin production by Lactococcus lactis (MTCC 440)

The influence of various physiochemical parameters on the growth of Lactococcus lactis sub sp. lactis MTCC 440 was studied at shake flask level for 20 h. Media optimization (MRS broth) was studied to achieve enhanced growth of the organism and also nisin production. Bioassay of nisin was done with agar diffusion method using Streptococcus agalactae NCIM 2401 as indicator strain. MRS broth (6 percent, w/v) with 0.15ìg/ml of nisin supplemented with 0.5 percent (v/v) skimmed milk was found to be the best for nisin production as well as for growth of L lactis. The production of nisin was strongly influenced by the presence of skimmed milk and nisin in MRS broth. The production of nisin was affected by the physical parameters and maximum nisin production was at 30(0)C while the optimal temperature for biomass production was 37(0)C.