Optic Neuritis in Resolving Phase of COVID-19 Infection and Its Management: A Case Report.

Optic neuritis is assumed to be immune-mediated, although the specific antigens that cause demyelination are uncertain. Systemic T-cell activation is detected at the onset of symptoms, which occurs before alterations in cerebrospinal fluid (CSF). The optic nerve disease is a rare disease and can occur in one or both eyes, especially in those with no established inflammatory or autoimmune illnesses. Adult ophthalmic neuritis is usually unilateral and is frequently associated with multiple sclerosis (MS). Generally, it starts as a rapid loss of vision and pain in eye movement. It progresses and achieves the maximal deficiency over a week. The objectives of this paper were to determine the association between coronavirus disease 2019 (COVID-19) and optic neuritis and to study the management of optic neuritis in the resolving phase of COVID-19. A case study was done on a 38-year-old female complaining of sudden diminution of vision in her right eye for one week. She tested positive on the reverse transcriptase-polymerase chain reaction (RT-PCR) test for COVID-19 for which she was managed symptomatically and was started on antiretrovirals. This case report is based on an infrequent COVID-19 complication. It has been proposed that this virus has the probability of manifesting various neurological complications. In our case, optic neuritis occurs mainly three weeks after COVID-19 infection. Our patient was managed by intravenous methylprednisolone injection followed by oral prednisone for 14 days. So, further case studies will be required to support the above treatment plan for optic neuritis caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unilateral or bilateral optic neuritis can occur as a neurological complication in the resolving stage of COVID-19 infection. Early detection and treatment with steroids can result in the best visual outcome.

Transient Myelin Oligodendrocyte Glycoprotein Antibody-positive Acute Disseminated Encephalomyelitis Following Influenza A Infection: A Rare Case.

Acute disseminated encephalomyelitis (ADEM) is an uncommon disease generally with a preceding history of infectious illness. Here, we report a rare case of ADEM following influenza A infection with transient detection of anti-myelin oligodendrocyte glycoprotein (MOG) antibody in a young male patient who presented with extensive demyelination of brain and spinal cord, likely the result of dysregulated immune response from previous influenza A infection. The patient presented to the emergency with urinary retention and progressive ascending weakness of lower limbs. Magnetic resonance imaging (MRI) of the brain and spinal cord showed multiple ill-defined hyperintensities, suggestive of demyelination. The clinical presentation, MRI findings, cerebrospinal fluid examination, negative anti-aquaporin-4 antibody and metabolic and other viral infectious screening supported the diagnosis of ADEM. The patient had transiently positive anti-MOG antibodies (for 3 months) and was treated with intravenous immunoglobulin followed by oral prednisolone for 3 months. There was a significant recovery in the upper limb weakness and brainstem function. This case highlights the association of anti-MOG antibody with ADEM following viral infections and the need for prolonged follow-up to differentiate between transient antibodies from relapsing MOG antibody disease.

Euglycemic diabetic ketoacidosis: A missed diagnosis.

Euglycemic diabetic ketoacidosis (DKA) is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose (less than 11 mmol/L). The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units; it may delay diagnosis and treatment causing worse outcomes. Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus. With the addition of sodium/ glucose cotransporter-2 inhibitors in diabetes mellitus management, euglycemic DKA incidence has increased. The other causes of euglycemic DKA include pregnancy, fasting, bariatric surgery, gastroparesis, insulin pump failure, cocaine intoxication, chronic liver disease and glycogen storage disease. The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit, milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio. Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones. The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones and exclusion of other causes of high anion gap metabolic acidosis. Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration, electrolytes deficit and insulin replacement. The dextrose-containing fluids should accompany intravenous insulin to correct metabolic acidosis, ketonemia and to avoid hypoglycemia.

Cardioembolic Stroke with Peripartum Cardiomyopathy: An Unusual Presentation.

Cardioembolic stroke in a patient with peripartum cardiomyopathy (PPCM) patient is rare despite a higher incidence of thromboembolic events. We report a case of acute right middle cerebral artery territory cardioembolic stroke in a postpartum female as the initial presenting feature of PPCM. The patient was thrombolyzed with intravenous alteplase and had an almost complete neurological recovery. How to cite this article: Nasa P, Mortada M, Ali A, Malhotra V, Koul K, Singh A. Cardioembolic Stroke with Peripartum Cardiomyopathy: An Unusual Presentation. Indian J Crit Care Med 2021;25(1):97-99.

Thrombotic Microangiopathy Causing Acute Kidney Injury in a COVID-19 Patient.

Acute Kidney Injury (AKI) in COVID-19 patients is common and independently associated with higher mortality. The pathophysiology of AKI is multifactorial and may be either direct viral trophism or immune mediated injury and hypercoagulability. This case highlights AKI in a young female with severe COVID-19 due to complement-3 mediated thrombotic microangiopathy with pre-existing chronic kidney disease likely because of IgA nephropathy.

Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers.

INTRODUCTION: Cytokine-release syndrome (CRS) in COVID-19 patients can cause multiorgan failure and higher mortality. We used a structured protocol based on clinical, biochemical, and interleukin 6 (IL-6) criteria for the identification of the subset of patients with CRS and analyzed the use of tocilizumab for their treatment. MATERIALS AND METHODS: We did a retrospective case-control analysis of all COVID-19 patients between 15 March and 15 May 2020 with severe to critical disease in ICU. They were evaluated for CRS, and 22 patients who met the criterion were given tocilizumab. The primary objective was to evaluate the effect of tocilizumab on escalation of respiratory support and ICU mortality. The secondary objectives were ICU length of stay, trends of inflammatory markers, and any adverse effects. RESULTS: The need for escalation of respiratory support was significantly lower in the tocilizumab group as compared to standard treatment (p = 0.001). The mortality at day 7 and 28 was also significantly lower in the tocilizumab group (p = 0.007 and p = 0.001 respectively). There was a significant reduction in C-reactive protein (CRP) who received tocilizumab (p = 0.033). CONCLUSION: In our limited number of patients, timely intervention with tocilizumab in COVID-19 patients with CRS significantly improved overall ICU outcome by reducing the need for invasive ventilation and mortality. HOW TO CITE THIS ARTICLE: Nasa P, Singh A, Upadhyay S, Bagadia S, Polumuru S, Shrivastava PK, et al. Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers. Indian J Crit Care Med 2020;24(9):771-776.

Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol.

BACKGROUND: Coronavirus disease-2019 (COVID-19) pandemic has inundated healthcare systems globally especially resources in intensive care units (ICUs). Tracheostomy may be required in critically ill COVID-19 patients to facilitate weaning and to optimize resources like ventilator and ICU beds. Percutaneous tracheostomy (PCT) has become the standard of care globally in ICUs; however, it is considered a high-risk procedure in COVID-19 patients because of the inherent risk of aerosol generation. MATERIALS AND METHODS: Patients with severe COVID-19 who were on mechanical ventilation because of respiratory failure for ≥10 days were evaluated for PCT. We developed a four-step approach from patient selection and timing, preparation, performance, and postprocedure for PCT in these patients. RESULTS: We evaluated our four-step protocol in four patients. One of them was non-COVID patient and rest three were COVID patients. The procedure was uneventful in all of the patients with median time of procedure and apnea is 10 minutes 30 seconds and 2 minutes 20 seconds, respectively. The tracheostomy was decannulated in two of these patients and one patient is still on ventilator. CONCLUSION: We believe our four-step protocol for PCT in critically ill COVID-19 patient is simple, safe, and easily adapted in any setting with limited training and available resources. We recommend further studies to evaluate this approach in selected critically ill COVID-19 patients who need tracheostomy. HOW TO CITE THIS ARTICLE: Nasa P, Singh A, Ali A, Patidar S, Georgian A. Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol. Indian J Crit Care Med 2020;24(9):832-834.

Validation of RP-HPLC Method for Simultaneous Quantification of Bicalutamide and Hesperetin in Polycaprolactone-Bicalutamide-Hesperetin-Chitosan Nanoparticles.

Bicalutamide is a non-steroidal anti-androgen drug used for the treatment of androgen-dependent prostate cancer. Hesperetin is a natural bioflavonoid that can be used in combination with bicalutamide to improve efficacy and decrease tolerance. The aim of the present work was to develop and validate a simple, sensitive, rapid reverse phase-high performance liquid chromatographic method for simultaneous estimation of bicalutamide and hesperetin. The validation parameters such as specificity, linearity, precision and accuracy, limit of detection (LOD) and limit of quantification (LOQ) were determined according to International Conference on Harmonization ICH Q2 (R1) guidelines. Chromatographic separation was achieved on Lichrocart(®) CN column (250 × 4 mm, 5 µm, MERCK) with isocratic elution. The retention times and detection wavelength, for hesperetin and bicalutamide were 4.28 min, 288 nm and 5.90 min, 270 nm respectively. The intra-day and inter-day assay precision and accuracy were found to be <2% over linearity of 50-2000 ng/mL with R(2) 0.999. LOD and LOQ, of bicalutamide and hesperetin was 14.70, 44.57 ng/mL and 16.11, 48.84 ng/mL, respectively. The method was successfully applied for encapsulation efficiency and drug release studies from bicalutamide and hesperetin loaded nanoparticles.