First report of clinically significant bites due to Platyceps ventromaculatus (GRAY, 1834) from Thar Desert region, Rajasthan, India.

BACKGROUND: Platyceps ventromaculatus is a non-front-fanged colubrid snake of unknown medical significance. In this study, we highlight the clinical manifestations and outcomes of P. ventromaculatus bites. We also emphasise the need to create awareness among clinicians and the public for its potential to be confused with serious venomous bites such as Echis carinatus sochureki. METHODS: This series is part of an ongoing observational clinical study from our tertiary care hospital in Jodhpur, India on the profile and outcomes of snakebite envenoming. Data was collected after approval from Institute Ethics Committee. The date and time of the bite, geographical location, type of human-snake conflict, time-to-reach a healthcare facility, antivenom used (dose), and outcomes were recorded. We retrospectively examined our clinical data for images suggestive of P. ventromaculatus and present the clinical details of these patients. The photographs were identified utilising taxonomic keys for species identification. RESULTS: A total of four images and three patients with bites due to P. ventromaculatus were identified. The clinical effects included mild local erythema, pain, transient local bleeding, and edema. All bites occurred during daylight hours, 2 during agricultural activities, and one at home. Twenty-minute Whole Blood Clotting Test was persistently prolonged for 12 h after the bite in one patient. All patients were treated symptomatically, observed at the emergency department, and discharged within 24 h. None of the patients received antivenom. CONCLUSIONS: To our knowledge, P. ventromaculatus has so far not been reported to result in envenoming or medically significant bites. This study highlights that Platyceps bite can present with clinically significant local and possibly systemic findings that may lead to confusion with saw-scaled viper (Echis) envenoming. Clinicians must receive appropriate training so as to be aware and recognize regional snake species that do not require antivenom so as to avoid unnecessary antivenom administration.

Scorpion Sting Envenomation, a Neglected Tropical Disease: A Nationwide Survey Exploring Perspectives and Attitudes of Resident Doctors from India.

Scorpion sting envenomation (SSE) is a commonly encountered and a significant problem in the tropics, affecting rural and marginalized communities. However, it is not formally listed as a neglected tropical disease (NTD) by the WHO. We designed this cross-sectional study to explore medical graduates' and resident doctors' perspectives on SSE as an NTD and to assess their experiences, knowledge, and confidence in managing these patients. An online questionnaire was developed, validated, and administered to interns and resident doctors across India. Adjusted odds ratios were calculated for factors predicting high self-reported confidence scores for managing scorpion stings using multivariable logistic regression. The final questionnaire contained 26 items including participant background, perspectives about SSE being an NTD, experiences, knowledge, and skills needed to manage, and prevent stings effectively. Of 454 participants, 69% opined that SSE was an NTD, and > 60% felt that SSE was inadequately addressed within undergraduate training. Predictors of high self-reported confidence scores in management competencies were residency in a clinical branch that commonly encountered SSE (internal/emergency medicine or pediatrics, P < 0.0001), having ever managed an SSE patient alone or as a part of a team (P < 0.0001), and attending a class or teaching session on SSE during undergraduate training (P = 0.048). Our results suggest that residents across India believe that there is an urgent need to declare SSE an NTD to increase its visibility, further paving the way for innovative multilevel cross-cutting solutions for mitigation. Designing authentic learning experiences can help produce competent and empathetic physicians in managing and preventing SSE.

Effect of COVID-19 containment measures on access to snakebite care in India.

INTRODUCTION: The extensive spread of COVID-19 meant action to address the pandemic took precedence over routine service delivery, thus impacting access to care for many health conditions, including the effects of snakebite. METHOD: We prospectively collected facility-level data from several health facilities in India, including number of snakebite admissions and snakebite envenoming admissions on modality of transport to reach the health facility. To analyse the effect of a health facility being in cluster-containment zone, we used negative binomial regression analysis. RESULTS: Our findings suggest that that health facilities located within a COVID containment zone saw a significant decrease in total snakebite admissions (incidence rate ratio 0.64 (0.43-0.94), standard error 0.13, p≤0.02)) and envenoming snakebite admissions (incidence rate ratio 0.43 (0.23-0.81), standard error 0.14, p≤0.01) compared to when health facilities were not within a COVID containment zone. There was no statistically significant difference in non-envenoming admissions and modalities of transport used to reach health facilities. CONCLUSION: This article provides the first quantitative estimate of the impact of COVID-19 containment measures on access to snakebite care. More research is needed to understand how containment measures altered care-seeking pathways and the nature of snake-human-environment conflict. Primary healthcare systems need to be safeguarded for snakebite care to mitigate effects of cluster-containment measures.

Delayed Compression Paralysis Following an Iliopsoas Hematoma 30 Days After Saw-Scaled Viper (Echis carinatus sochureki) Envenoming: A Case Report.

Snakebite envenoming is a neglected tropical disease disproportionately affecting the rural and marginalized population in low-middle-income countries. The saw-scaled viper (Echis carinatus) is a clinically important snake that causes serious morbidity and mortality in the Indian subcontinent. Even though it is within the so-called big-four snakes against which polyvalent antivenom is available throughout India, reports of antivenom ineffectiveness are emerging in saw-scaled viper envenoming, especially around Jodhpur, Rajasthan, India. This case report highlights a patient with saw-scaled viper envenoming with an ineffective antivenom response complicated by acute kidney injury as well as local and systemic bleeding complications, which subsequently resulted in a pelvic hematoma that compressed the lumbosacral nerves, causing lower-limb weakness and sensory deficits. He was successfully managed with hematoma aspiration and supportive care. This case brings into focus the challenges of managing saw-scaled viper envenoming in this region with antivenom ineffectiveness, resulting in delayed and significant coagulopathy and its complications leading to prolonged hospital stay and morbidity. Our report spotlights less emphasized aspects of long-term morbidity in snakebite survivors, such as loss of working days and productivity. We also highlight the need for an organized system of long-term follow-up of snakebite survivors to screen for possible complications and manage them early.

Redefining the role of therapeutic plasma exchange in complications of Echis carinatus sochureki envenomation refractory to anti-snake venom: A case series.

INTRODUCTION: Saw-scaled viper (Echis carinatus) belongs to the Viperidae family. Its venom is hemotoxic and contains several small peptides and proteins affecting the coagulation system. Commonly used anti-snake venom (ASV) products in India are reported to be ineffective or less effective in cases with bites by Echis carinatus sochureki which are commonly found in desert areas in Rajasthan. Although therapeutic plasma exchange (TPE) has been successful in patients with snakebite envenomation in the past, American Society for Apheresis guidelines 2019 included this indication under category III with grade 2C recommendation. AIM AND OBJECTIVES: To report the safety and efficacy of therapeutic plasma exchange procedures in the setting of ASV refractory E. c. sochureki envenomation. MATERIALS AND METHODS: Four patients admitted to our institute in 2021 September with an alleged history of snake bites and who underwent at least one cycle of therapeutic plasma exchange were assessed for clinical outcome, laboratory parameters, and blood product consumption. RESULTS: Three adult patients and one pediatric patient are included in this case series, all of them males. Indication for TPE in one case was suspected diffuse alveolar hemorrhage (DAH), while in all the other cases was thrombotic microangiopathy (TMA). All received a variable number of sessions from 2 to 5 and 1.3-1.5 plasma volume was removed on an average per cycle. The endpoint of TPE was the resolution of DAH in one while a reduction in lactate dehydrogenase and an increase in platelet count was in TMA cases. Consumption of blood products was drastically reduced in all four patients after starting the procedure. All the adult patients fared well on follow-up while the child had developed acute cortical necrosis and was dialysis-dependent. It has been noted in the previous studies too that a subset of snakebite-induced TMA cases was getting converted to chronic kidney disease and becoming dialysis dependent in the long run. CONCLUSIONS: In regions where ASV treatment failure is very common, therapeutic plasma exchange is a safe and effective complementary treatment modality along with supportive care.

Effectiveness of early awake self proning strategy in non-intubated patients with COVID-19 hypoxemia: an open-labelled randomized clinical trial from Jodhpur, India.

Awake self-proning is being used widely as respiratory support in COVID-19 hypoxemia, in resource-limited settings. We aimed to investigate the effectiveness of early awake self-proning in preventing mortality and the need for intubation in adults with moderate COVID-19 hypoxemia. In this randomized clinical trial with inten-tion-to-treat analysis, we enrolled eligible adults with COVID-19 hypoxemia (SpO2 <94%), requiring supplemental oxygen via nasal prongs or facemask from a tertiary-care setting in Jodhpur, India between June 15 to December 24, 2020. Awake proning comprised of 4-hour cycles with prone position maintained 2 h per cycle. The control group did not maintain any specific position. All participants received standard care. The primary outcomes were 30-day mortal-ity and requirement for mechanical ventilation. Of 502 participants included, mean (SD) age was 59.7 (12.7) years with 124 women (24.6%); 257 were randomized to awake-proning, 245 to control group and all 502 were included for follow-up mortality analysis. Mortality at follow-up was 16.3% in the awake-prone and 15.1% in the control group [OR:1.10 (0.68-1.78), p=0.703). The requirement of mechanical ventilation was 10% in both groups (p=0.974). Survival time (in days) was not significantly different between the groups [Log-rank test, HR: 1.08 (95% CI, 0.70-1.68), p=0.726]. Likewise, time to intubation was comparable (Log-rank test, HR: 0.93 (95% CI, 0.56-1.70), p=0.974). Hence, awake self-proning did not improve survival or requirement of mechanical-ventilation in non-intubated patients with mild to moderate COVID-19 hypox-emia. Trial Registration: Clinical trial registry of India, ID: CTRI/2020/06/025804.   The trial is accessible from WHO's International Clinical Trials Registry Platform (ICTRP) at https://trialsearch.who.int ***************************************************************   *Appendix Authors list  Deepak Kumar1, Gopal Krishna Bohra1, Nishant Kumar Chauhan2, Nikhil Kothari3, Vijaya Lakshmi Nag4 Sanjeev Misra5  1Department of Internal Medicine; 2Department of Pulmonary Medicine; 3Department of Anaesthesiology and Critical Care; 4Department of Microbiology; 5Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, India.

Clinical characteristics and outcomes of digital gangrene in connective tissue disorders: a longitudinal single-centre experience from Jodhpur, India.

Epidemiology, clinical presentation, and outcomes for digital gangrene in connective tissue disorders (CTD) remain underreported from tropical countries like India. In this series, we aimed to explore the clinical profile and outcomes of patients who presented with digital gangrene and a diagnosis of CTD. Hospital-based longitudinal observational study. Patients with digital gangrene and underlying diagnosis of CTD presenting to our tertiary-care centre in Jodhpur, India between1st January 2018 and 31st June 2021 were included. Clinical outcomes including mortality, limb outcomes, functional status and other systemic involvement were assessed. Of the 312 patients registered in the rheumatology clinic during this period, 22 (7%) patients were found to satisfy the inclusion criteria. Mean age was 46 years and 90% were females. The most common underlying diagnosis was Mixed connective tissue disorder (MCTD). Digital gangrene was the presenting symptom in 13 (60%) patients. Half of the patients received only corticosteroids as immunosuppression. Two died due to systemic complications. Complete resolution occurred in 17 (85%), autoamputation in 3, and infection requiring surgical drainage in one patient. All surviving patients reported good functional limb outcome on 6 months follow-up. MCTD is an important cause of digital gangrene in rheumatology practice. In patients presenting with digital gangrene, an active search for an underlying CTD is imperative, as this could result in timely initiation of appropriate limb-saving therapy. Corticosteroids alone with rapid tapering may be an appropriate option to consider in the initial management of digital gangrene in CTD. Key Points • Mixed connective tissue disorder is an important cause of digital gangrene in rheumatology practice in western India. • In patients presenting with digital gangrene, an active search for an underlying connective tissue disorder is imperative, as this could result in timely initiation of appropriate therapy and can prove limb saving. • Corticosteroids alone with rapid tapering may be an appropriate option to consider in the initial management of digital gangrene in connective tissue disorders.

Impact of the COVID-19 Pandemic on the Frequency, Clinical Spectrum and Outcomes of Pediatric Guillain-Barré Syndrome in India: A Multicentric Ambispective Cohort Study.

Objective: To study impact of COVID-19 pandemic on frequency, clinical/electrophysiological profile and treatment outcomes in pediatric Guillain-Barré syndrome (GBS). Background: GBS is the most frequent cause of pediatric acute flaccid paralysis. The effect of the COVID-19 pandemic on pediatric GBS is unclear in the literature. Methods: We conducted an ambispective, multicentric, cohort study involving 12 of 27 centres in GBS Consortium, during two periods: pre-COVID-19 (March-August 2019) and during COVID-19 (March-August 2020). Children ≤12 years who satisfied National Institute of Neurological Diseases and Stroke criteria for GBS/variants were enrolled. Details pertaining to clinical/laboratory parameters, treatment and outcomes (modified Rankin Scale (mRS) at discharge, GBS Disability score at discharge and 3 months) were analysed. Results: We enrolled 33 children in 2019 and 10 in 2020. Children in 2020 were older (median 10.4 [interquartile range 6.75-11.25] years versus 5 (2.5-8.4) years; P = 0.022) and had more sensory symptoms (50% versus 18.2%; P = 0.043). The 2020 group had relatively favourable mRS at discharge (median 1 (1-3.5) versus 3 (2-4); P = 0.042) and GBS disability score at 3 months (median 0 (0-0.75) versus 2 (0-3); P = 0.009) compared to 2019. Multivariate analysis revealed bowel involvement (P = 0.000) and ventilatory support (P = 0.001) as independent predictors of disability. No child in 2020 had preceding/concurrent SARS-CoV2 infection. Conclusions: The COVID-19 pandemic led to a marked decline in pediatric GBS presenting to hospitals. Antecedent illnesses, clinical and electrophysiological profile of GBS remained largely unchanged from the pre-pandemic era.

A simple mortality risk prediction score for viper envenoming in India (VENOMS): A model development and validation study.

BACKGROUND: Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings. We aimed to develop and validate a mortality-risk prediction score for patients of viper envenoming from Southern India. METHODS: We used clinical predictors from a prospective cohort of 248 patients with syndromic diagnosis of viper envenoming and had a positive 20-minute whole blood clotting test (WBCT 20) from a tertiary-care hospital in Puducherry, India. We applied multivariable logistic regression with backward elimination approach. External validation of this score was done among 140 patients from the same centre and its performance was assessed with concordance statistic and calibration plots. FINDINGS: The final model termed VENOMS from the term "Viper ENvenOming Mortality Score included 7 admission clinical parameters (recorded in the first 48 hours after bite): presence of overt bleeding manifestations, presence of capillary leak syndrome, haemoglobin <10 g/dL, bite to antivenom administration time > 6.5 h, systolic blood pressure < 100 mm Hg, urine output <20 mL/h in 24 h and female gender. The lowest possible VENOMS score of 0 predicted an in-hospital mortality risk of 0.06% while highest score of 12 predicted a mortality of 99.1%. The model had a concordance statistic of 0·86 (95% CI 0·79-0·94) in the validation cohort. Calibration plots indicated good agreement of predicted and observed outcomes. CONCLUSIONS: The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell's viper envenoming burden is high. The score may have potential applications in triaging patients and guiding management after further validation.

Case Report: Delayed Diffuse Alveolar Hemorrhage in Echis sochureki Envenoming, Jodhpur, India.

Snakebite envenoming is a common occupational hazard in the tropics. Venom-induced consumption coagulopathy and acute kidney injury are the most frequently encountered complications of viper bites. Diffuse alveolar hemorrhage (DAH) is an unusual presentation reported rarely in the literature. Our case report highlights the uncommon presentation of delayed pulmonary hemorrhage after snakebite envenoming. A 40-year-old healthy man presented to our emergency department after 6 hours of Echis sochureki (a saw-scaled viper subspecies) bite. He had abnormal coagulation parameters and thrombocytopenia with no signs of acute kidney injury. Transfusion protocols were initiated because of active bleeding and a rapid decrease in hemoglobin levels over next few days. Around day 10, his coagulation profile and hemoglobin were corrected, but he developed hemoptysis with rapidly progressive respiratory distress. Computed tomography of the chest was suggestive of DAH and the patient was started on plasma exchange with pulse methylprednisolone. After the initial worsening, he had rapid symptomatic improvement and radiological resolution. The patient had persistent hypofibrinogenemia, which resolved, and was discharged and remained healthy at the 60-day follow-up. This case highlights a presentation with an initial phase of venom-induced consumption coagulopathy followed by delayed DAH in saw-scaled viper envenoming that was treated successfully with immunosuppressants and plasma exchange.

Impact of COVID-19 on Guillain-Barre Syndrome in India: A Multicenter Ambispective Cohort Study.

Introduction/Aims: Studies conducted during the coronavirus disease 2019 (COVID-19) pandemic have reported varied data regarding the incidence of Guillain-Barre syndrome (GBS). The present study investigated demographic and clinical features, management, and outcomes of patients with GBS during a specified period of the COVID-19 pandemic, and compared these features to those of GBS in the previous year. Methods: A multicenter, ambispective cohort study including 26 centers across India was conducted. Data from a pre-COVID-19 period (March 1 to August 31, 2019) were collected retrospectively and collected ambispectively for a specified COVID-19 period (March 1 to August 31, 2020). The study was registered with the Clinical Trial Registry India (CTRI/2020/11/029143). Results: Data from 555 patients were included for analysis: pre-COVID-19 (n = 334) and COVID-19 (n = 221). Males were more commonly affected during both periods (male:female, 2:1). Gastroenteritis was the most frequent antecedent event in 2019 (17.4%), whereas fever was the most common event in 2020 (10.7%). Paraparesis (21.3% versus [vs.] 9.3%, P = 0.001) and sensory involvement (51.1% vs. 41.3%; P = 0.023) were more common during COVID-19 in 2020, whereas back pain (26.3% vs. 18.4%; P = 0.032) and bowel symptoms (20.7% vs. 13.7%; P = 0.024) were more frequent in the pre-COVID period. There was no difference in clinical outcomes between the two groups in terms of GBS disability score at discharge and 3 months after discharge. Independent predictors of disability in the pre-COVID period included areflexia/hyporeflexia, the requirementfor intubation, and time to bulbar weakness; in the COVID-19 period, independent predictors included time from onset to admission, intubation, and intubation requirement. The mortality rate was 2.3% during the entire study period (13/555 cases). Discussion: Results of this study revealed an overall reduction in the frequency of GBS during the pandemic. The lockdown likely reduced the risk for antecedent infections due to social distancing and improved hygiene, which may have resulted in the reduction of the frequency of GBS.

Integrating health planning and primary care infrastructure for COVID-19 and tuberculosis care in India: Challenges and opportunities.

Tuberculosis (TB) is the leading cause of death from a single infectious agent worldwide. The COVID-19 pandemic has overburdened healthcare services around the world especially in resource constrained settings. It has shaken already unstable foundation of TB control programs in India and other high burden states. A 25% decline is expected in TB detection while estimates suggest 13% increase in TB deaths due to the impact of the pandemic. However, the significant intersections between the two diseases perhaps offer potential opportunities for consolidating the efforts to tackle both. The widespread implementation and acceptance of universal masking and social distancing in India has helped limit transmission of both diseases. Integrating the capacity building strategies for the two diseases, optimizing the existing the surveillance and monitoring systems which have been achieved over the years will result in a single vertically integrated national program addressing both, rather than multiple parallel program which utilize the already sparse primary care manpower and infrastructure. In this article, we explore the impact of the COVID-19 pandemic on tuberculosis in India and offer suggestions on how effective health planning can efficiently integrate infrastructure and manpower at primary level to provide care for both COVID-19 and tuberculosis.

Endocrine Dysfunction among Patients with COVID-19: A Single-center Experience from a Tertiary Hospital in India.

OBJECTIVE: COVID-19 has emerged as a multi-system disease with the potential for endocrine dysfunction. We aimed to study the hormonal profile of hospitalized patients with COVID-19 at a tertiary care referral hospital at Jodhpur, India. DESIGN: A hospital-based clinical study of endocrine profile of COVID-19 patients conducted from 15th May to 30th June 2020 after ethical approval. MEASUREMENTS: Fasting blood samples for free thyroxine (T4), free tri-iodothyronine (T3), thyroid stimulating Hormone (TSH), serum prolactin; basal and 1 h post-intramuscular adrenocorticotropic hormone (ACTH) stimulated cortisol, interleukin-6 (IL-6), and high sensitivity C-reactive protein (hsCRP) were collected within 24 h of admission after written informed consent. All hormones and IL-6 were analyzed by chemiluminescent immunoassay. hsCRP was measured by immune-turbidimetric assay. RESULTS: Of 235 patients studied, 14% had severe disease and 5.5% died. Adrenal insufficiency was present in 14%, most of whom had mild disease. A robust adrenal response was observed in those with severe disease. Basal and post-ACTH serum cortisol were significantly increased in severe disease or those who died compared to those who were mild or asymptomatic. Basal and post-ACTH serum cortisol showed a significant positive correlation with hsCRP but not with IL-6. Low T3 and low T4 syndrome were documented in 25% and 5%, respectively. Serum TSH and FT3 levels declined significantly from asymptomatic to severe category. Hyperprolactinemia was found in 21 patients. hsCRP showed a rising trend with disease severity while IL-6 did not. CONCLUSIONS: Endocrine dysfunction in the form of adrenal insufficiency, low T3, and low TSH syndrome and hyperprolactinemia were common COVID-19 hospitalized patients.

Pseudo-pseudo Meigs' syndrome (PPMS) in chronic lupus peritonitis: a case report with review of literature.

Gastrointestinal involvement in systemic lupus erythematosus (SLE) usually occurs in the form of mesenteric vasculitis, protein-losing enteropathy, intestinal pseudo-obstruction, and pancreatitis. We describe a 23-year-old female, a known case of SLE presented with significant ascites and pleural effusion. Further evaluation showed elevated CA-125 levels without evidence of malignancy. The patient was treated with corticosteroids, hydroxychloroquine, and azathioprine resulting in the resolution of ascites in 2 weeks. The triad of ascites, pleural effusion, and increased CA-125 is known as pseudo-pseudo Meigs' syndrome, which is rarely reported in the literature. Clinicians should be aware of this entity while evaluating an SLE patient with low serum-ascites albumin gradient (SAAG) ascites.

Effect of plasma glucose at admission on COVID-19 mortality: experience from a tertiary hospital.

OBJECTIVE: Plasma glucose has been correlated with in-hospital mortality among many diseases including infections. We aimed to study the plasma glucose at the admission of hospitalized patients with COVID-19 at a tertiary care referral hospital at Jodhpur, India and its relation with mortality. DESIGN: A hospital-based clinical study of plasma glucose of COVID-19 patients conducted from May 15 to June 30, 2020 after ethical approval. MEASUREMENTS: Random blood samples at admission were collected for plasma glucose, interleukin-6 (IL6) and high sensitivity C-reactive protein (hsCRP) after written informed consent was obtained. Plasma glucose was analyzed by the automated analyzer, IL6 by chemiluminescent immunoassay and hsCRP by immune-turbidimetric assay. RESULTS: A total of 386 patients were studied (female 39.6%); 11.1% had severe disease and 4.1% expired. There were 67 (17.4%) patients with known diabetes mellitus (DM). Patients with a history of DM had three times higher mortality (6/67, 9%) than those without DM (10/309, 3.1%). Patients with moderate and severe disease according to ICMR and WHO grading had higher plasma glucose than those with asymptomatic or mild disease (P < 0.0001). Plasma glucose levels at admission were significantly higher in non-survivors when compared to those who survived (297 ± 117 vs 131 ± 73; P < 0.0001). COVID-19 patients showed increased mortality with incremental plasma glucose levels. The hazard ratio for mortality was 1.128 (95% CI 0.86-14.860), 1.883 (95% CI 0.209-16.970), and 4.005 (95% CI 0.503-32.677) in random plasma glucose group of >100-200, >200-300 and >300 mg/dL, respectively, compared to those with random plasma glucose of <100 mg/dL at admission. Plasma glucose was strongly correlated with hsCRP (P < 0.001) and IL6 (P < 0.0001). CONCLUSIONS: Plasma glucose at admission in hospitalized COVID-19 patients is a strong predictor of mortality.

Venom-Induced Consumption Coagulopathy Unresponsive to Antivenom After Echis carinatus sochureki Envenoming.

Snakebite envenoming is a serious and life-threatening but neglected problem in the tropics. The focus in the Indian subcontinent is usually on the Indian cobra (Naja naja), common krait (Bungarus caeruleus), Russell's viper (Daboia russelii), and Indian saw-scaled viper (Echis carinatus). The Indian polyvalent antivenom contains hyperimmunized horse antibodies against only these 4 species. However, regional intraspecific variations are important in viper envenomings, leading to marked differences in clinical presentation and response to the available polyvalent antivenom. Echis carinatus sochureki, a subspecies of Echis carinatus, has been linked to serious morbidity in the Thar Desert regions of Rajasthan, although consistent reports are lacking. We report a patient with prolonged venom-induced consumption coagulopathy owing to Echis carinatus sochureki envenoming who did not respond to Indian polyvalent antivenom in Jodhpur, India. Features of local and hemotoxic envenoming resolved after a week with supportive care. Echis sochureki venom has been shown to be different from Echis carinatus in terms of composition and in vitro neutralization by antivenom. Clinicians in the tropical desert regions must suspect Echis sochureki envenoming in the setting of nonresponsiveness to Indian polyvalent antivenom. This will help optimize antivenom use in these patients, preventing potentially life-threatening antivenom associated reactions. Because the usefulness of Indian polyvalent antivenom appears to be limited in this setting, there is an urgent need to advocate for region-specific antivenom or monovalent antivenom for this area.

Methicillin-Sensitive Staphylococcus aureus Pyogenic Iliopsoas Abscesses: A Case Series from Jodhpur, India.

Early recognition of iliopsoas abscess is important for limiting morbidity and mortality. Mycobacterium tuberculosis remains an important cause of iliopsoas abscess in developing countries and most patients are initiated on empirical anti-tubercular therapy. In this context, methicillin- sensitive Staphylococcus aureus (MSSA) as a cause of iliopsoas abscess is rare in India. Four cases were diagnosed with pyogenic iliopsoas abscesses caused by MSSA. Half of the patients had a typical clinical triad of fever, difficulty in walking and backache. Primary iliopsoas abscesses were present in three patients. All patients were managed with percutaneous drainage and antibiotics with a favourable outcome. MSSA as a cause of primary iliopsoas abscesses is rare in India. Early diagnosis of microbial aetiology also minimizes the non-judicial use of antibiotics and anti-tubercular therapy.

Role of Pigtail Catheter Drainage Versus Percutaneous Needle Aspiration in the Management of Liver Abscess: A Retrospective Analysis.

Introduction A liver abscess is an important health concern in tropical countries. Effective management of liver abscesses includes appropriate antibiotics and drainage of the abscess cavity. Percutaneous abscess drainage by pigtail catheterization is now gaining popularity. We analyzed the role of pigtail catheter drainage over percutaneous aspiration in the treatment of liver abscesses. Methods and material This was a retrospective analytical study conducted in a tertiary care center in western India. Patients of age ≥ 18 years admitted with the diagnosis of liver abscess were included in this study. To find the effectiveness of different treatment modalities, data were analyzed in three groups: Group A (Conservative treatment), Group B (Percutaneous needle aspiration), and Group C (Pigtail catheter drainage). Results A total of 64 patients with a liver abscess were analyzed. There was male predominance (93.75%). Mean abscess volume in Group C (307.9 ± 212.8 ml) was significantly higher when compared to Group A (130.8 ± 72.9 ml, p = 0.03) and Group B (177.2 ± 129.5; p = 0.024). The duration of hospital stay and residual abscess volume at the time of discharge did not show a statistically significant difference between treatment groups. Pigtail catheterization of abscesses with volume >150 ml shortened the hospital stay, whereas it prolonged the hospital stay in patients with abscess volume <150 ml. Conclusion Percutaneous pigtail catheterization would be an operative decision for the management of liver abscess. We concluded that the use of pigtail catheterization of patients with abscess volume > 150 ml improved the clinical outcome.

Purulent pericarditis in a patient with community-acquired methicillin-resistant Staphylococcus aureus: a case report with mini-review.

INTRODUCTION: The etiopathogenesis of purulent pericarditis has changed significantly in modern antibiotic era with the emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in the last few decades. Pericarditis due to MRSA is rarely reported in the literature without risk factors like immunosuppression, thoracic surgery, chest trauma or pre-existing pericardial diseases. CASE REPORT: We describe an 18-year-old male who presented with 5 days history of fever, chest pain and shortness of breath. Echocardiogram and thorax CT showed significant pericardial effusion. The patient underwent pericardiocentesis, MRSA was isolated from blood and pericardial fluid. The patient improved with intravenous antibiotics (linezolid). Follow-up echocardiography at 3 months was unremarkable, without any residual fluid or features of constrictive pericarditis. DISCUSSION: In the absence of known risk factors, MRSA is an extremely rare cause of pericarditis in modern antibiotics era. The possibility of MRSA pericarditis should be sought in every case of pericarditis to achieve prompt diagnosis and treatment. CONCLUSIONS: Our case highlights the role of aggressive pericardiocentesis and appropriate antibiotic therapy in purulent pericarditis.