A Difficult Case of Cardio-Cerebral Infarction Syndrome With Left Ventricular Thrombus.

Left ventricular thrombus is a major complication following myocardial infarction, particularly in patients with anterior myocardial infarction or dilated cardiomyopathies regardless of coronary reperfusion therapy. Embolization of mural thrombus is one of the major causes of large vessel occlusion ischemic stroke. A combination therapy of antiplatelet (single or dual antiplatelet) and anticoagulant is mandatory in the management of myocardial infarction and left ventricular thrombus with or without stroke. To our knowledge, there are no guidelines on the optimal regimen (dual or triple therapies) and timing of administration in cases of cardio-cerebral infarction. It is difficult for clinicians to balance the risks of intracranial hemorrhage and coronary stent thrombosis. Here, we describe the case of a gentleman who had recently undergone coronary intervention and presented with ischemic stroke and left ventricular thrombus, along with the management challenges in this scenario.

Assessment of antimicrobial prescribing patterns, guidelines compliance, and appropriateness of antimicrobial prescribing in surgical-practice units: point prevalence survey in Malaysian teaching hospitals.

Objectives: This study sought to investigate the quality of antimicrobial prescribing among adult surgical inpatients besides exploring the determinants of non-compliance and inappropriate prescribing to inform stewardship activities. Methods: A cross-sectional point prevalence study employing Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) was conducted in April 2019 at two teaching hospitals in Malaysia. Results: Among 566 surgical inpatients, 44.2% were receiving at least one antimicrobial, for a total of 339 prescriptions. Antimicrobials belonging to the World Health Organization's Watch group were observed in 57.8% of cases. Both hospitals exhibited similar types of antimicrobial treatments prescribed and administration routes. A significant difference in antimicrobial choice was observed between hospitals (p < 0.001). Hospital with electronic prescribing demonstrated better documentation practice (p < 0.001). Guidelines compliance, 32.8% (p = 0.952) and appropriateness, 55.2% (p = 0.561) did not significantly differ. The major contributors of inappropriateness were incorrect duration, (15%) and unnecessary broad-spectrum coverage, (15.6%). Non-compliance and inappropriate prescribing were found to be 2 to 4 times significantly higher with antimicrobial prophylaxis prescription compared to empirical therapy. Conclusion: Antimicrobial stewardship efforts to improve appropriate surgical prescribing are essential. These initiatives should prioritize surgical prophylaxis prescribing, focusing on reducing unnecessarily prolonged use and broad-spectrum antimicrobials, raising awareness among prescribers and promoting proper documentation.

Clinical utility of procalcitonin in implementation of procalcitonin-guided antibiotic stewardship in the South-East Asia and India: evidence and consensus-based recommendations.

INTRODUCTION: The South-East Asian (SEA) region and India are highly susceptible to antibiotic resistance, which is caused due to lack of antimicrobial stewardship (AMS) knowledge, uncontrolled use of antibiotics, and poor infection control. Nonadherence to national/local guidelines, developed to combat antimicrobial resistance, is a major concern. A virtual advisory board was conducted to understand the current AMS standards and challenges in its implementation in these regions. AREAS COVERED: Procalcitonin (PCT)-guided antibiotic use was discussed in various clinical conditions across initiation, management, and discontinuation stages. Most experts strongly recommended using PCT-driven antibiotic therapy among patients with lower respiratory tract infections, sepsis, and COVID-19. However, additional research is required to understand the optimal use of PCT in patients with organ transplantation and cancer patients with febrile neutropenia. Implementation of the solutions discussed in this review can help improve PCT utilization in guiding AMS in these regions and reducing challenges. EXPERT OPINION: Experts strongly support the inclusion of PCT in AMS. They believe that PCT in combination with other clinical data to guide antibiotic therapy may result in more personalized and precise targeted antibiotic treatment. The future of PCT in antibiotic treatment is promising and may result in effective utilization of this biomarker.

Anxiety among hospitalized COVID-19 patients: a case-control study from a tertiary teaching hospital in Malaysia.

Introduction: Anxiety has been increasingly recognized as part of the psychosocial health issues in COVID-19 patients. However, the impact of this topic may be underestimated in low- and middle-income countries. This study aimed to estimate the prevalence of and risk factors of anxiety in COVID-19 patients compared to controls in a local tertiary teaching hospital in Malaysia. Methods: In this case-control study, we analyzed data on adult patients aged 18 years and above hospitalized for COVID-19 infection with matched hospitalized controls. The demographic, clinical data and anxiety measures using the Generalized Anxiety Disorder-7 questionnaire were analyzed using univariate and multivariate analysis. Results: 86.6% in the COVID-19 group had anxiety, significantly higher than 13.4% in the control group (p = 0.001). The COVID-19 group was significantly associated with the GAD-7 severity (p = 0.001). The number of COVID-19 patients in the mild, moderate, and severe anxiety groups was 48 (84.2%), 37 (86%), and 18 (94.7%), respectively. Multiple logistic regression showed significant predictors for anxiety, including COVID-19 diagnosis and neurological symptoms. Anxiety was found 36.92 times higher in the patients with COVID-19 compared to those without COVID-19 (OR 36.92;95% CI 17.09, 79.78, p = 0.001). Patients with neurological symptoms were at risk of having anxiety (OR 2.94; 95% CI 1.03, 8.41, p = 0.044). Discussion: COVID-19 patients experience a significant disruption in psychosocial functioning due to hospitalization. The burden of anxiety is notably high, compounded by a diagnosis of COVID-19 itself and neurological symptomatology. Early psychiatric referrals are warranted for patients at risk of developing anxiety symptoms.

Neurological manifestations in SARS-CoV-2 infection: A single-center cross-sectional study in Malaysia.

Background: Neurological involvement associated with SARS-CoV-2 infection has been reported from different regions of the world. However, data from South East Asia are scarce. We described the neurological manifestations and their associated factors among the hospitalized COVID-19 patients from an academic tertiary hospital in Malaysia. Methods: A cross-sectional observational study of hospitalized COVID-19 patients was conducted. The neurological manifestations were divided into the self-reported central nervous system (CNS) symptoms, stroke associated symptoms, symptoms of encephalitis or encephalopathy and specific neurological complications. Multiple logistic regression was performed using demographic and clinical variables to determine the factors associated with outcome. Results: Of 156 hospitalized COVID-19 patients with mean age of 55.88 ± 6.11 (SD) years, 23.7% developed neurological complications, which included stroke, encephalitis and encephalopathy. Patients with neurological complications were more likely to have diabetes mellitus (p = 0.033), symptoms of stroke [limb weakness (p < 0.001), slurred speech (p < 0.001)]; and encephalitis or encephalopathy [confusion (p < 0.001), forgetfulness (p = 0.006) and seizure (p = 0.019)]. Unvaccinated patients had a 4.25-fold increased risk of having neurological complications (adjusted OR = 4.25; 95% CI: 1.02, 17.71, p = 0.047). Anosmia and dysgeusia were less associated with neurological complications (adjusted OR = 0.22; 95% CI: 0.05, 0.96, p = 0.044). The odds of neurological complications were increased by 18% in patients with leukocytosis (adjusted OR = 1.18, 95% CI: 1.003, p = 0.0460). Conclusions: Stroke, encephalitis and encephalopathy were the common neurological complications from our study. Diabetes mellitus, presence of symptoms of stroke, symptoms of encephalitis or encephalopathy, leukocytosis, and being unvaccinated against COVID-19 were the associated risk factors of developing neurological complications.

Whole-Genome Sequence of a Stenotrophomonas maltophilia Isolate from Tap Water in an Intensive Care Unit.

Here, we present a 4,508,936-bp complete genome sequence of Stenotrophomonas maltophilia strain HW002Y, which was isolated from the tap water in an intensive care unit at Sultan Ahmad Shah Medical Centre at the International Islamic University of Malaysia (Kuantan, Pahang, Malaysia). Sequencing was performed using a Nanopore Flongle flow cell.

Diversity and Dissemination of Methicillin-Resistant Staphylococcus aureus (MRSA) Genotypes in Southeast Asia.

Methicillin-resistant Staphylococcus aureus (MRSA) is a successful pathogen that has achieved global dissemination, with high prevalence rates in Southeast Asia. A huge diversity of clones has been reported in this region, with MRSA ST239 being the most successful lineage. Nonetheless, description of MRSA genotypes circulating in the Southeast Asia region has, until now, remained poorly compiled. In this review, we aim to provide a better understanding of the molecular epidemiology and distribution of MRSA clones in 11 Southeast Asian countries: Singapore, Malaysia, Thailand, Vietnam, Cambodia, Lao People's Democratic Republic (PDR), Myanmar, Philippines, Indonesia, Brunei Darussalam, and Timor-Leste. Notably, while archaic multidrug-resistant hospital-associated (HA) MRSAs, such as the ST239-III and ST241-III, were prominent in the region during earlier observations, these were then largely replaced by the more antibiotic-susceptible community-acquired (CA) MRSAs, such as ST22-IV and PVL-positive ST30-IV, in recent years after the turn of the century. Nonetheless, reports of livestock-associated (LA) MRSAs remain few in the region.

Corticosteroid effectiveness among hospitalised COVID-19 patients in Malaysia.

INTRODUCTION: Using steroids to manage hospitalised coronavirus disease 2019 (COVID-19) patients caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection has been shown to reduce the need for mechanical ventilation and mortality. To date, low-dose dexamethasone and methylprednisolone corticosteroids have been effective in reducing the infection's progress in hospitalised patients. However, it is unknown if high dosages of corticosteroids can achieve a better clinical outcome. This study aims to compare the clinical outcomes of hospitalised COVID-19 patients who are given a 10-day low-dose corticosteroid treatment (IV 2 mg/kg/day methylprednisolone loading dose (LD) then 0.25 mg/kg four times a day (q.i.d.)) with patients given a 10-day high-dose corticosteroid treatment (IV 20 mg dexamethasone once daily (o.d.) or a 1.5 mg/kg prednisolone tablet o.d.). METHODOLOGY: Retrospective data on hospitalised COVID-19 patients were collected for this study, and the primary outcome measure was the patients' clinical status based on the World Health Organization's (WHO) Ordinal Scale for Clinical Improvement (OSCI) on Day-5 and Day-10 post-steroid. RESULTS: The results demonstrated that using steroids significantly improved patients' clinical outcomes from a WHO OSCI level of 4 (0.1) on Day-1 to 2.6 (2.5) on Day-5 (p < 0.001). There was no significant difference in clinical outcome between low-dose and high-dose corticosteroid treatment on Day-5 (H = 2.15; p = 0.34) and Day-10 (H = 1.12; p = 0.58). CONCLUSIONS: This study concludes that using low-dose corticosteroids is recommended for hospitalised COVID-19 patients to ensure clinical outcomes are optimised.

Plethora of Antibiotics Usage and Evaluation of Carbapenem Prescribing Pattern in Intensive Care Units: A Single-Center Experience of Malaysian Academic Hospital.

Excessive antibiotic consumption is still common among critically ill patients admitted to intensive care units (ICU), especially during the coronavirus disease 2019 (COVID-19) period. Moreover, information regarding antimicrobial consumption among ICUs in South-East Asia remains scarce and limited. This study aims to determine antibiotics utilization in ICUs by measuring antibiotics consumption over the past six years (2016−2021) and specifically evaluating carbapenems prescribed in a COVID-19 ICU and a general intensive care unit (GICU) during the second year of the COVID-19 pandemic. (2) Methods: This is a retrospective cross-sectional observational analysis of antibiotics consumption and carbapenems prescriptions. Antibiotic utilization data were estimated using the WHO Defined Daily Doses (DDD). Carbapenems prescription information was extracted from the audits conducted by ward pharmacists. Patients who were prescribed carbapenems during their admission to COVID-19 ICU and GICU were included. Patients who passed away before being reviewed by the pharmacists were excluded. (3) Results: In general, antibiotics consumption increased markedly in the year 2021 when compared to previous years. Majority of carbapenems were prescribed empirically (86.8%). Comparing COVID-19 ICU and GICU, the reasons for empirical carbapenems therapy in COVID-19 ICU was predominantly for therapy escalation (64.7% COVID-19 ICU vs. 34% GICU, p < 0.001), whereas empirical prescription in GICU was for coverage of extended-spectrum beta-lactamases (ESBL) gram-negative bacteria (GNB) (45.3% GICU vs. 22.4% COVID-19 ICU, p = 0.005). Despite microbiological evidence, the empirical carbapenems were continued for a median (interquartile range (IQR)) of seven (5−8) days. This implies the need for a rapid diagnostic assay on direct specimens, together with comprehensive antimicrobial stewardship (AMS) discourse with intensivists to address this issue.

COVID-19 Prediction With Machine Learning Technique From Extracted Features of Photoplethysmogram Morphology.

At present, COVID-19 is spreading widely around the world. It causes many health problems, namely, respiratory failure and acute respiratory distress syndrome. Wearable devices have gained popularity by allowing remote COVID-19 detection, contact tracing, and monitoring. In this study, the correlation of photoplethysmogram (PPG) morphology between patients with COVID-19 infection and healthy subjects was investigated. Then, machine learning was used to classify the extracted features between 43 cases and 43 control subjects. The PPG data were collected from 86 subjects based on inclusion and exclusion criteria. The systolic-onset amplitude was 3.72% higher for the case group. However, the time interval of systolic-systolic was 7.69% shorter in the case than in control subjects. In addition, 12 out of 20 features exhibited a significant difference. The top three features included dicrotic-systolic time interval, onset-dicrotic amplitude, and systolic-onset time interval. Nine features extracted by heatmap based on the correlation matrix were fed to discriminant analysis, k-nearest neighbor, decision tree, support vector machine, and artificial neural network (ANN). The ANN showed the best performance with 95.45% accuracy, 100% sensitivity, and 90.91% specificity by using six input features. In this study, a COVID-19 prediction model was developed using multiple PPG features extracted using a low-cost pulse oximeter.

Comparison of Two Serological Assays in Detecting Strongyloides Infection in Immunocompromised Patients.

Strongyloides infection may develop into fatal hyperinfection and dissemination syndrome in immunocompromised hosts. Despite suboptimal specificity issues, the detection of IgG antibodies by ELISA has been central in the serodiagnosis of Strongyloides infection. Recently, an IgG4-based lateral-flow test (SsRapid) using recombinant NIE (rNIE) protein with good diagnostic performance has been reported. This study assessed the result concordance between a commercial IgG-ELISA and the SsRapid. Additionally, we determined the Strongyloides seroprevalence and its association with clinical manifestations. Immunocompromised patients (N = 200) were from Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia, and were diagnosed with HIV/AIDS, hematological malignancy, and solid organ cancers. Their plasma samples were tested using a commercial IgG-ELISA and SsRapid. A fair concordance (κ = 0.27-0.33; P < 0.05) among the tests was demonstrated. The SsRapid exhibited a significantly higher (P < 0.05) seroprevalence (10.5% [21/200]) compared with IgG-ELISA (7.5% [15/200]). After adsorption with rNIE, all SsRapid-positive samples tested negative with the rapid test, thus showing binding specificity. There was no significant association with clinical manifestations. This study revealed that SsRapid is a useful diagnostic tool for Strongyloides infection, and there is a notable seroprevalence among the immunocompromised patients.

Correlation of Dengue Warning Signs during Febrile Phase with Rotational Thromboelastometry, Cortisol and Feritin.

Dengue mortality remains high despite monitoring against warning signs (WS). The associations of WS at febrile phase (FP) and hemorrhage at defervescence with the levels and kinetics of ROTEM, platelet count, cortisol, and ferritin were analyzed. Patients with confirmed dengue serology and WS in two centers were screened (n = 275) and 62 eligible patients were recruited prospectively over 9 months. "Vomiting" was the commonest WS (62.9%), with shortened clotting time (CT) INTEM (p = 0.01). "Hematocrit increase" showed significant prolonged CT INTEM, EXTEM, and FIBTEM (p < 0.05). "Platelet decrease" showed reduced platelet function and reduced clot amplitude at 10 min (A10) and maximum clot firmness (MCF) in INTEM and EXTEM (p < 0.001). The kinetics were reduced in platelet count, CT EXTEM, and cortisol (p < 0.05) but increased in CT INTEM (p = 0.03). At FP, "vomiting", "hematocrit increase", and "platelet decrease" demonstrated impaired CT, clot strengths A10/MCF and platelet functions. Majority (60/62, 96.7%) had non-severe outcomes, consistent with increase in cortisol kinetics. In conclusion, "vomiting", "hematocrit increase" and "platelet decrease" at FP correlated with ROTEM. No conclusion could be made further regarding ferritin and cortisol. Larger study is required to study "hematocrit increase" with ROTEM as a potential marker for hemorrhage.

Comparing the appropriateness of antimicrobial prescribing among medical patients in two tertiary hospitals in Malaysia.

INTRODUCTION: Malaysia is an upper-middle-income country with national antimicrobial stewardship programs in place. However, hospitals in this country are faced with a high incidence of multidrug-resistant organisms and high usage of broad-spectrum antibiotics. Therefore, this study aimed to use a standardized audit tool to assess clinical appropriateness, guideline compliance, and prescribing patterns of antimicrobial use among medical patients in two tertiary hospitals in Malaysia to benchmark practice. METHODOLOGY: A prospective hospital-wide point prevalence survey was carried out by a multidisciplinary team in April 2019 at the University Malaya Medical Centre (UMMC) and the Hospital Canselor Tuanku Muhriz (HCTM), Kuala Lumpur, Malaysia. Data was collected from the patient's electronic medical records and recorded using the Hospital National Antimicrobial Prescribing Survey toolkit developed by the National Centre for Antimicrobial Stewardship, Australia. RESULTS: The appropriateness of prescriptions was 60.1% (UMMC) and 67% (HCTM), with no significant difference between the two hospitals. Compliance with guidelines was 60.0% (UMMC) and 61.5% (HCTM). Amoxicillin-clavulanic acid was the most commonly prescribed antimicrobial (UMMC = 16.9%; HCTM = 11.9%). CONCLUSIONS: The appropriateness of antimicrobial prescribing in medical wards, compliance with guidelines, and prescribing patterns were similar between the two hospitals in Malaysia. The survey identified several areas of prescribing that would need targeted AMS interventions.

Clinical Characteristics of Patients with Coronavirus Disease 2019 (COVID-19) in a Teaching Hospital in Malaysia.

INTRODUCTION: Information on the clinical characteristics of local patients with confirmed COVID-19 is limited. This study aims to report the clinical characteristics of 147 patients admitted and receiving treatment at a teaching hospital. METHODOLOGY: Patients' socio-demographic and epidemiological data, clinical features, laboratory findings and clinical outcomes were extracted using a data sheet. RESULTS: The median patient age was 25 [interquartile range (IQR)] 20-44) years, and most of patients were male (68.7%) and of Malaysian nationality (88.4%). Almost half of the patients were from a case cluster related to a religious event (48.3%) and 12.9% had a history of overseas travel. A total of 33.3% of patients were not related to any case cluster, i.e. sporadic cases. Radiological investigation showed that 13.6% of the patients had chest X-ray changes and all laboratory parameters were within the normal ranges. Sixty-six patients (44.9%) experienced symptoms. The most common symptoms were rhinitis (66.7%), followed by fever (19.7%) and cough (15.2%). Age, gender, case cluster, comorbidity status, haemoglobin, albumin, total protein, bilirubin total and alkaline phosphatase level were associated with symptomatic status. CONCLUSIONS: In this single-centre study, COVID-19 infection led not only to case clusters, but also to sporadic infections, with patients being either symptomatic or asymptomatic. These sporadic cases and asymptomatic patients may hamper effective contact tracing, leading to rapid human-to-human transmission in our population. Future studies on the prevalence and clinical significance of asymptomatic and presymptomatic COVID-19 patients would pre-emptively address issues on further containment of the pandemic.

Catheter-Related Bloodstream Infections and Catheter Colonization among Haemodialysis Patients: Prevalence, Risk Factors, and Outcomes.

INTRODUCTION: Catheter-related bloodstream infection (CRBSI) and catheter colonization (CC) are two complications among haemodialysis (HD) patients that lead to increased morbidity and mortality. This study aims to evaluate the prevalence of CRBSI and CC among HD patients registered at Universiti Kebangsaan Malaysia Medical Centre and to identify the factors involved by focusing on the demographic profile of the patients as well as their clinical characteristics and outcomes. METHOD: This is a retrospective study of end-stage renal disease patients with suspected CRBSI during the period from 1 January 2016 to 31 December 2018. Data on patients who fulfilled the blood culture criteria for CRBSI and CC diagnosis were further analysed for clinical manifestations, comorbidities, history of dialysis, catheter characteristics, and microbiological culture results. The outcomes of CRBSI and CC were also assessed. Findings. In the 3-year period under study, there were 496 suspected CRBSI cases with a total of 175 events in 119 patients who fulfilled the inclusion criteria. During that time, the percentage of patients who experienced CRBSI and CC was 4.2% and 4.8%, respectively. The majority of the cohort consisted of male (59.4%), Malay ethnicity (75%), and patients on a tunnelled dialysis catheter (83%). Patients who were fistula naïve and had an internal jugular catheter were more common in the CRBSI group than in the CC group. The predominant microorganisms that were isolated were Gram-positive organisms. In terms of clinical presentation and outcome, no differences were found between the CRBSI and CC groups. Patients with Gram-negative bacteraemia, high initial c-reactive protein, and catheter salvation were likely to have poor outcomes. Recurrence of CRBSI occurred in 31% of the cohort. Neither catheter salvation nor antibiotic-lock therapy were associated with the recurrence of CRBSI. On the other hand, the femoral vein catheter site was associated with risk of recurrence. The overall mortality rate was 1.1%. Discussion. From the analysis, it was concluded that clinical assessment and positive culture are crucial in diagnosing CRBSI with or without peripheral culture. This study provides essential information for the local setting which will enable healthcare providers to implement measures for the better management of CRBSI.

Point Prevalence Survey of Antimicrobial Use in a Malaysian Tertiary Care University Hospital.

Antimicrobial resistance remains a significant public health issue, and to a greater extent, caused by the misuse of antimicrobials. Monitoring and benchmarking antimicrobial use is critical for the antimicrobial stewardship team to enhance prudent use of antimicrobial and curb antimicrobial resistance in healthcare settings. Employing a comprehensive and established tool, this study investigated the trends and compliance of antimicrobial prescribing in a tertiary care teaching hospital in Malaysia to identify potential target areas for quality improvement. A point prevalence survey method following the National Antimicrobial Prescribing Survey (NAPS) was used to collect detailed data on antimicrobial prescribing and assessed a set of quality indicators associated with antimicrobial use. The paper-based survey was conducted across 37 adult wards, which included all adult in-patients on the day of the survey to form the study population. Of 478 patients surveyed, 234 (49%) patients received at least one antimicrobial agent, with 357 antimicrobial prescriptions. The highest prevalence of antimicrobial use was within the ICU (80%). Agents used were mainly amoxicillin/ß-lactamase inhibitor (14.8%), piperacillin/ß-lactamase inhibitor (10.6%) and third-generation cephalosporin (ceftriaxone, 9.5%). Intravenous administration was ordered in 62.7% of prescriptions. Many antimicrobials were prescribed empirically (65.5%) and commonly prescribed for pneumonia (19.6%). The indications for antimicrobials were documented in the patients' notes for 80% of the prescriptions; however, the rate of review/stop date recorded must be improved (33.3%). One-half of surgical antimicrobial prophylaxis was administered for more than 24 h. From 280 assessable prescriptions, 141 (50.4%) were compliant with guidelines. Treating specialties, administration route, class of antimicrobial, and the number of prescriptions per patient were contributing factors associated with compliance. On multivariate analysis, administering non-oral routes of antimicrobial administration, and single antimicrobial prescription prescribed per patient was independently associated with non-compliance. NAPS can produce robust baseline information and identifying targets for improvement in antimicrobial prescribing in reference to current AMS initiatives within the tertiary care teaching hospital. The findings underscore the necessity to expand the AMS efforts towards reinforcing compliance, documentation, improving surgical prophylaxis prescribing practices, and updating local antibiotic guidelines.

A Spuriously Negative Cryptococcal Antigen Assay Result in Disseminated Cryptococcosis: the Deception of the Postzone Phenomenon.

Cryptococcus is a basidiomycetous yeast responsible for considerable HIV-related morbidity and mortality. A cachectic 26-year-old HIV-positive man with a CD4 count of 103 cells/µl presented with fever, breathlessness, and bilateral lower limb weakness. A brain computed tomography scan could not elucidate the neurological deficit. His blood was sent for culture and serum cryptococcal antigen detection, with the latter testing as negative. By the fourth day of admission, the patient's condition had deteriorated drastically. A lumbar puncture was performed, and like his serum sample, the cerebrospinal fluid also tested negative for cryptococcal antigens. By this time, Cryptococcus neoformans was isolated from the admission blood culture. The laboratory diluted both the serum and cerebrospinal fluid specimens to retest for cryptococcal antigens, and finally, an antigen titer of ≥1:2560 was recorded.

The prevalence and clinical significance of Presymptomatic COVID-19 patients: how we can be one step ahead in mitigating a deadly pandemic.

BACKGROUND: Presymptomatic COVID-19 patients have been identified as a major stumbling block in efforts to break the chain of transmission. Studies on temporal dynamics of its shedding suggests it peaks 1-2 days prior to any symptom onset. Therefore, a large proportion of patients are actively spreading the disease unknowingly whilst undetected. However, lengthy lockdowns and isolation leads to a host of socioeconomic issues and are impractical. Conversely, there exists no study describing this group and their clinical significance despite their key role in disease transmission. METHODS: As a result, we devised a retrospective study to look at the prevalence of presymptomatic patients with COVID-19 from data sourced via our medical records office. Subsequently, we identify early indicators of infection through demographic information, biochemical and radiological abnormalities which would allow early diagnosis and isolation. In addition, we will look into the clinical significance of this group and their outcome; if it differs from asymptomatic or symptomatic patients. Descriptive statistics were used in addition to tabulating the variables and corresponding values for reference. Variables are compared between the presymptomatic group and others via Chi-square testing and Fisher's exact test, accepting a p value of < 0.05 as significant. RESULTS: Our analysis shows a higher proportion of presymptomatic patients with atypical symptoms like chest pain while symptomatic patients commonly present with respiratory symptoms like cough and shortness of breath. Besides that, there were more females presenting as presymptomatic patients compared to males (p = 0.019) and these group of patients were likely to receive treatment (p < 0.001). Otherwise, we were not able to identify other statistically significant markers suggesting a patient is presymptomatic. CONCLUSION: As we have little means of identifying these silent spreaders, it highlights further the importance of general measures implemented to stop COVID-19 transmission like social distancing, face mask, and widespread testing.

Pulmonary Embolism in an Asymptomatic COVID-19 Patient Detected on Ventilation/Perfusion SPECT/CT.

ABSTRACT: Severe COVID-19 infection is associated with significant coagulopathy. We would like share a case of an asymptomatic 26-year-old man who tested positive for COVID-19 and had elevated d-dimer levels. Because of inconclusive CTPA findings, V/Q (ventilation/perfusion) SPECT/CT was performed, which confirmed the presence of pulmonary embolism. This case highlights the fact that pulmonary embolism should not be overlooked in a COVID-19 patient who has raised d-dimer levels, even in the absence of symptoms. It also highlights the importance of performing a V/Q study when CTPA results are inconclusive or when there are contraindications for iodinated contrast media.