COVID-19 Associated Stroke-A Single Centre Experience.

BACKGROUND AND PURPOSE: Various neurological complications have been reported in association with COVID-19. We report our experience of COVID-19 with stroke at a single center over a period of eight months spanning 1 March to 31 October 2020. METHODS: We recruited all patients admitted to Internal Medicine with an acute stroke, who also tested positive for COVID-19 on RTPCR. We included all stroke cases in our analysis for prediction of in-hospital mortality, and separately analyzed arterial infarcts for vascular territory of ischemic strokes. RESULTS: There were 62 stroke cases among 3923 COVID-19 admissions (incidence 1.6%). Data was available for 58 patients {mean age 52.6 years; age range 17-91; F/M=20/38; 24% (14/58) aged ≤40; 51% (30/58) hypertensive; 36% (21/58) diabetic; 41% (24/58) with O2 saturation <95% at admission; 32/58 (55.17 %) in-hospital mortality}. Among 58 strokes, there were 44 arterial infarcts, seven bleeds, three arterial infarcts with associated cerebral venous sinus thrombosis, two combined infarct and bleed, and two of indeterminate type. Among the total 49 infarcts, Carotid territory was the commonest affected (36/49; 73.5%), followed by vertebrobasilar (7/49; 14.3%) and both (6/49; 12.2%). Concordant arterial block was seen in 61% (19 of 31 infarcts with angiography done). 'Early stroke' (within 48 hours of respiratory symptoms) was seen in 82.7% (48/58) patients. Patients with poor saturation at admission were older (58 vs 49 years) and had more comorbidities and higher mortality (79% vs 38%). Mortality was similar in young strokes and older patients, although the latter required more intense respiratory support. Logistic regression analysis showed that low Glasgow coma score (GCS) and requirement for increasing intensity of respiratory support predicted in-hospital mortality. CONCLUSIONS: We had a 1.6% incidence of COVID-19 related stroke of which the majority were carotid territory infarcts. In-hospital mortality was 55.17%, predicted by low GCS at admission.

Tocilizumab improves survival in severe COVID-19 pneumonia with persistent hypoxia: a retrospective cohort study with follow-up from Mumbai, India.

BACKGROUND: Cytokine storm triggered by Severe Coronavirus Disease 2019 (COVID-19) is associated with high mortality. With high Interleukin -6 (IL-6) levels reported in COVID-19 related deaths in China, IL-6 is considered to be the key player in COVID-19 cytokine storm. Tocilizumab, a monoclonal antibody against IL-6 receptor, is used on compassionate grounds for treatment of COVID-19 cytokine storm. The aim of this study was to assess effect of tocilizumab on mortality due to COVID-19 cytokine storm. METHOD: This retrospective, observational study included patients of severe COVID-19 pneumonia with persistent hypoxia (defined as saturation 94% or less on supplemental Oxygen of 15 L per minute through non-rebreathing mask or PaO2/FiO2 ratio of less than 200) who were admitted to a tertiary care center in Mumbai, India, between 31st March to 5th July 2020. In addition to standard care, single Inj. Tocilizumab 400 mg was given intravenously to 151 consecutive COVID-19 patients with persistent hypoxia, from 13th May to 5th July 2020. These 151 patients were retrospectively analysed and compared with historic controls, ie consecutive COVID-19 patients with persistent hypoxia, defined as stated above (N = 118, from our first COVID-19 admission on 31st March to 12th May 2020 i.e., till tocilizumab was available in hospital). Univariate and multivariate Cox regression analysis was performed for identifying predictors of survival. Statistical analysis was performed using IBM SPSS version 26. RESULTS: Out of 269 (151 in tocilizumab group and 118 historic controls) patients studied from 31st March to 5th July 2020, median survival in the tocilizumab group was significantly longer than in the control group; 18 days (95% CI, 11.3 to 24.7) versus 9 days (95% CI, 5.7 to 12.3); log rank p 0.007. On multivariate Cox regression analysis, independent predictors of survival were use of tocilizumab (HR 0.621, 95% CI 0.427-0.903, P 0.013) and higher oxygen saturation. CONCLUSION: Tocilizumab may improve survival in severe COVID-19 pneumonia with persistent hypoxia. Randomised controlled trials on use of tocilizumab as rescue therapy in patients of severe COVID-19 pneumonia with hypoxia (PaO2/FiO2 less than 200) due to hyperinflammatory state, are warranted.

Dermatomyositis during COVID-19 Pandemic (A Case Series): Is there a Cause Effect Relationship?

Viruses have been shown to modify the clinical picture of several autoimmune diseases, including type 1 diabetes, systemic lupus erythematosus (SLE), rheumatoid arthritis and multiple sclerosis. Viral infections have also been considered as a possible trigger for autoimmune disorders like myositis through myositis specific antibodies. Dermatomyositis is an acquired inflammatory myopathy which is relatively rare with incidence of 9.3 per 1 million persons. Usually we come across 1-2 patients of dermatomyositis per year, amongst 800-1000 new patients in our tertiary care rheumatology services. A surge in the incidence was noted this year during the months of April-August of 2020, the period coinciding with the occurrence of corona virus (COVID-19) pandemic in the city of Mumbai, the total number of cases encountered being five in a span of six months. The following case series includes five such cases with review of available literature on virus-triggered autoimmunity with special reference to SARS-CoV-2 and the challenges of immunosuppression during this pandemic.

Non-ischemic Cardiomyopathy: Role of Immunologic Work-up and Cardiac MRI in Etiologic Diagnosis and Outcomes.

OBJECTIVE: Study etiology of Non ischemic cardiomyopathy (NICMP) and role of cardiac MRI in diagnosis and outcomes. METHODS: prospective observational study. INCLUSION CRITERIA: 1. Clinical feature of cardiac failure, 2. 2D ECHO Systolic dysfunction, EF <45% OR Diastolic dysfunction without regional wall motion abnormality, 3. Absent ischemic changes on ECG and/ or coronary angiography. Exclusion: Valvular & congenital heart disease, Cor pulmonale, Renal failure. Patient were subjected to CBC with absolute eosinophil count(AEC), ESR, Urine-r/m, NT-Pro-BNP, ANA, ANCA, ACE, Bone marrow, Amyloid fat pad biopsy etc., chest x ray, 2DE. HRCT Chest and coronary angiography, Cardiac MRI by 3 tesla MRI machine. Patients were treated with antic-failure drugs & as per etiology and followed at 6wk clinically (NYHA) and 2DE. RESULT: forty four Patients, mean age 36 yrs F: M(22:22), many patients had feature other than cardiac failure like Raynaud's.

A Patient of Tumour Induced Osteomalacia Undiagnosed for 11 years.

We report a 45 years old woman, bedridden due to severe bone pain, back pain, multiple spontaneous fractures over 10 years. She had low serum Phosphates. We detected a swelling in her right groin and suspected tumour induced osteomalacia. Resection of the tumour led to reversal of metabolic bone disease. Patient became ambulatory within 6 weeks of tumour resection.

Pulmonary Renal Syndrome: Experience from Tertiary Centre in Mumbai.

INTRODUCTION: Pulmonary Renal Syndrome (PRS), is characterized by diffuse alveolar haemorrhage (DAH) and glomerulonephritis (GN), occurring simultaneously. It has high mortality and dialysis dependence at one year, if not timely diagnosed and aggressively treated. OBJECTIVES: To study etiology and short term outcome of PRS in India. MATERIALS AND METHODS: This study included patients of PRS seen in a tertiary care center in Mumbai, by one consultant from 1997- 2013, analyzed retrospectively and from January 2014 to December 2015 collected prospectively from six medical units, intensive care unit, nephrology and respiratory units. Patients with DAH (haemoptysis, breathlessness and x-ray chest with bilateral alveolar shadows with sparing of apices) and glomerulonephritis (Proteinuria, heamaturia, hypertension with or without raised serum Creatinine) were included in the study after carefully excluding other causes of haemoptysis and breathless like tuberculosis, pulmonary oedema, pneumonia, ARDS. During prospective enrollment of patients, in all admitted patients with haemoptysis, urine examination was carried out to specifically look for proteinuria and red blood cells in urine, same was also followed in those admitted for breathlessness with chest x-ray suggestive of alveolar haemorrhage. Patients were extensively investigated for etiology and were treated with steroids and pulse cyclophosphamide (after ruling out infectious etiology). Supportive care with ventilator or dialysis was given as per usual indications. Palsmapheresis was initiated in those with serum Creatinine ≥ 5.7mg/dl. Rituximab was used in refractory cases, as per treating physicians' choice. Final outcome was death or discharge. RESULTS: There were 25 patients of PRS (13 retrospective, 12 prospective), with following etiology : Granulomatosis with polyangiitis (GPA) 7, Microscopic polyangiitis (MPO) 4, Churg Strauss Syndrome (EGPA) 1, Goodpasture's syndrome 1, lupus 5, leptospirosis 5, dengue 2. All were given steroids, 18 (72%) were given pulse Cyclophosphamide (barring those with leptospirosis and dengue), ventilator support in 14 (56%) patients (8 invasive, 6 non-invasive), haemodialysis 3, plasmapheresis 1, Rituximab 2. Seventeen (68%) patients survived, mortality was high in those requiring invasive ventilator. CONCLUSION: Most common etiology of PRS is ANCA positive vasculitis in India. With high degree of suspicion for DAH in patients presenting with haemoptysis, breathlessness and alveolar opacities in chest x-ray and carefully investigating by simple urine examination for evidence of GN, timely diagnosis of PRS can be made. With timely appropriate treatment survival is 68%. Patients with PRS due to leptospirosis or dengue have features suggestive of underlying disease (like icterus with raised bilirubin but < 200U SGOT/SGPT, subconjunctival haemorrhage, typical rash of dengue with thrombocytopenia).

Etiology and Outcomes of Lower Limb Ulcers in Non-Diabetic Patients, An Experience from Government Hospital in Western India.

AIM: To study the Etiology and Outcomes of Lower Extremity Ulcer in Non- Diabetic Patients. METHOD: A total number of 40 patients were collected from Rheumatology services (Department of Medicine), Venous Clinic (Department of Surgery) and Dermatology Clinic (Department of Dermatology) of a tertiary care hospital in Mumbai over a period of 48 months from January 2013 to December 2016. The study included serial recruitment of lower limb ulcer fulfilling inclusion criteria. RESULTS: Patients with lower limb ulcers presented with a wide range of pathology. Ulcers due to Vasculitis was the most common etiology (40%) and affected females predominantly (12/16). Venous ulcers were the second most common etiology and predominantly affected men (8/10). CONCLUSION: It is important to consider differential diagnosis of Vasculitic ulcer in chronic non healing ulcers as they show rapid response to treatment with immunosuppressant. If such ulcers are not promptly diagnosed and treated properly, systemic vasculitis can cause end organ damage or even endanger patient life.

Reproductive Health in Systemic Lupus Erythematosus, An experience from Government Hospital in Western India.

AIM: Systemic lupus erythematosus is an autoimmune disease which affects the reproductive health of women pertaining to disease or its treatment. However, Indian data is limited. Objective is to study menstrual disturbances and maternal and fetal outcome during pregnancy in SLE patients. METHODS: This retrospective and prospective observational study was conducted for a period of 18 months from March 2012 to September 2013 in a tertiary care hospital in Mumbai. The study included serial recruitment of SLE patients fulfilling inclusion criteria. RESULTS: Out of 52 patients studied, 13(25%) developed amenorrhea; 10 of them reversed and 3 patients developed premature menopause (5.77%). The higher mean age (30 years or more) at initiation of Cyclophosphamide therapy was associated with higher incidence of irreversible amenorrhea and this difference was statistically significant (p=0.0001). Out of 16 SLE pregnancies in 16 different patients, 9 pregnancies were successful while 7 were unsuccessful including IUFDs, abortions and maternal mortality. The incidence of successful pregnancies was significantly higher in low disease activity group (6/N=6, 100%) when compared to high disease activity group (3/N=10, 30%) (p=0.0114). CONCLUSIONS: High disease activity and Cyclophosphamide therapy are the two most important factors causing amenorrhea in SLE patients. Cyclophosphamide therapy when initiated in patients older than 30 years can lead to irreversible amenorrhea. Successful pregnancy is possible even in lupus nephritis patients if disease is well controlled at the time of conception.

Higher Incidence of Pulmonary Hypertension in Antiphospholipid Antibody Positive Lupus.

BACKGROUND: Antiphospholipid antibodies (APAs) are detected in 30-40% of SLE patients, but only few develop APLA syndrome. Incidence of pulmonary hypertension (PH) is reportedly high in APA positive patients; however, Indian data is missing. MATERIALS AND METHODS: This cross-sectional, observational study was conducted from Jan 2009 - Dec 2011, on 50 SLE patients, fulfilling ACR criteria. SLE patients were selected serially from OPD and IPD. Pregnant females and children were excluded.Tests for presence of anticardiolipin antibody, lupus anticoagulant and anti-ß2 glycoprotein antibody were performed in all patients. Pulmonary artery pressure, was measured on transthoracic 2DECHO, by TR jet and graded as, mild (25-40mm), moderate (40-60) and severe (> 60mm). CT - pulmonary angiography and lower limb venous Doppler were performed in patients of moderate and severe PH. RESULTS: Out of 50 patients, 46 were females, 4 males, aged 17-50 yrs. Twenty-three were positive for at least one APA, 14/23 ACLA positive, 3/23 positive for LA, 16/23 positive for anti ß2 glycoprotein antibodies, 11 were positive for 2 or more antibodies. Pulmonary hypertension was present in 11 out of 23 APA and 2 out of 27 APA negative patients, with moderate to severe PH in 7 out of 11 APA positive patients. Four out of 7 patients with moderate to severe PH tested positive for more than one APA and in higher titers. CT pulmonary angiography and lower limb venous Doppler were performed in 4 out of 7 patients with moderate and severe PH and were normal. Three patients with moderate PH expired. CONCLUSIONS: Lupus patients with APAs are more prone to develop PH, with a possibility of formation of microthrombi in the pathogenesis of PH. As regards treatment of PH, in addition of PH lowering drugs, place for anticoagulants or antiplatelet agents needs to be studied in PH with APA positive patients.