Extensively drug-resistant Salmonella typhi Infection in Adults; Experience from A Tertiary Care Hospital.

Objectives: This study aimed to determine the epidemiology, clinical features, and complications of extensively drug-resistant Salmonella typhi (XDR S. typhi) infection in adults. Method: This cross-sectional study enrolled adults with culture-proven XDR S. typhi admitted to Hayatabad Medical Complex, Peshawar from 1st March to 10th September 2022. Their demographic characteristics, clinical features, treatment, and complications were recorded. Results: Out of 84 patients, 68 (80.9%) were male. The mean age of enrolled patients was 25.2 ± 11.3 years. The mean duration of fever at the time of admission was 13.6 ± 8.2 days, respectively. The most common symptom was loose stools (n=25, 29.8%). Most of the patients (n=69, 82.1%) had received empirical treatment before hospitalization. The majority of the patients (n=42, 50%) received meropenem and a combination of meropenem and azithromycin (n=35, 41.7%) during the study. The time to defervescence for both regimens was similar. Five patients (6%) developed complications of enteric fever. There was no mortality among the participants. Conclusions: Diarrhea was the most common associated clinical feature in XDR typhoid fever. Most of the patients received meropenem alone or in combination with azithromycin with a comparable time to defervescence. The majority of the patients recovered uneventfully and there was no mortality among the study participants.

Evaluation of the Protective Effects of Lugol's Solution in Rats Poisoned with Aluminum Phosphide (Rice Tablets).

Aluminum phosphide (AlP) is the main component of rice tablets (a pesticide), which produces phosphine gas (PH3) when exposed to stomach acid. The most important symptoms of PH3 toxicity include, lethargy, tachycardia, hypotension, and cardiac shock. It was shown that Iodine can chemically react with PH3, and the purpose of this study is to investigate the protective effects of Lugol solution in poisoning with rice tablets. Five doses (12, 15, 21, 23, and 25 mg/kg) of AlP were selected, for calculating its lethal dose (LD50). Then, the rats were divided into 4 groups: AlP, Lugol, AlP + Lugol, and Almond oil (as a control). After 4 h, the blood pressure and electrocardiogram (ECG) were recorded, and blood samples were obtained for biochemical tests, then liver, lung, kidney, heart, and brain tissues were removed for histopathological examination. The results of the blood pressure showed no significant changes (P > 0.05). In ECG, the PR interval showed a significant decrease in the AlP + Lugol group (P < 0.05). In biochemical tests, LDH, Ca2+, Creatinine, ALP, Mg2+, and K+ represented significant decreases in AlP + Lugol compared to the AlP group (P < 0.05). Also, the administration of Lugol's solution to AlP-poisoned rats resulted in a significant decrease in malondialdehyde levels and a significant increase in catalase activity (P < 0.05). Histopathological evaluation indicates that Lugol improves changes in the lungs, kidneys, brain, and heart. Our results showed that the Lugol solution could reduce tissue damage and oxidative stress in AlP-poisoned rats. We assume that the positive effects of Lugol on pulmonary and cardiac tissues are due to its ability to react directly with PH3.

Highly Tunable Cellulosic Hydrogels with Dynamic Solar Modulation for Energy-Efficient Windows.

Smart windows that can passively regulate incident solar radiation by dynamically modulating optical transmittance have attracted increasing scientific interest due to their potential economic and environmental savings. However, challenges remain in the global adoption of such systems, given the extreme variability in climatic and economic conditions across different geographical locations. Aiming these issues, a methylcellulose (MC) salt system is synthesized with high tunability for intrinsic optical transmittance (89.3%), which can be applied globally to various locations. Specifically, the MC window exhibits superior heat shielding potential below transition temperatures, becoming opaque at temperatures above the Lower Critical Solution Temperature and reducing the solar heat gain by 55%. This optical tunability is attributable to the particle size change triggered by the temperature-induced reversible coil-to-globular transition. This leads to effective refractive index and scattering modulation, making them prospective solutions for light management systems, an application ahead of intelligent fenestration systems. During the field tests, MC-based windows demonstrated a 9 °C temperature decrease compared to double-pane windows on sunny days and a 5 °C increase during winters, with simulations predicting an 11% energy savings. The ubiquitous availability of materials, low cost, and ease-of-manufacturing will provide technological equity and foster the ambition toward net-zero buildings.

QT Interval Changes in Children With Febrile Convulsion Compared With Healthy.

Introduction: Febrile seizure is a temperature-related seizure that affects the QT interval. The purpose of this study was to evaluate the changes in the QT interval caused by febrile convulsion (FC) compared with healthy children. Methods: This case-control study examined 180 children equally distributed between patients and controls. The study was conducted at the Ali Ebne Abi Talib Hospital in Zahedan City, Iran. The disease was diagnosed and confirmed based on standard definitions of FC. QT interval was measured by ECG and interpreted by a pediatric cardiologist, and collected data were analyzed using SPSS software, version 19 with a 0.05 significant level. Results: Among the ECG parameters, HR, R in aVL, S in V3, LVM, QTd, QTc, and QTcd were significantly different in children with FCs compared to their peers. From those who had abnormal QTd, FC children were more frequent which was not significant (χ2=1.053, P=0.248), while children with FC had significantly more abnormality regarding QTc (χ2=13.032, P<0.001) and QTcd (χ2=21.6, P<0.001). In children with FC, those who were less than 12 months had the highest level of HR which was not significant (χ2=4.59, P=0.101). Similar trends occurred for R in aVL and S in V3 that were higher in the age group >24 months (P>0.05). Children in the age group of >24 months had significantly had the highest LVM (χ2=52.674, P<0.001) and the other QT parameters were the same in FC children with different age groups (P>0.05). Conclusion: It is concluded that dispersion corrected QT, corrected QT, and dispersion QT changed significantly in children with FC in comparison with the healthy children with constant values in children with FC in different age groups. Highlights: Corrected QT, dispersion QT and corrected-dispersion QT changed in children with febrile convulsion.Among the children with abnormal dispersion QT, febrile convulsion were not seen more when children with febrile convulsion (FC) were more in abnormality levels of QTc and QTcd. Plain Language Summary: The study aimed to evaluate changes in electrocardiography parameters in children with febrile convulsion and found positive correlation.

Measurement and risk perception of non-ionizing radiation from base transceiver stations in Dhaka City of Bangladesh.

Multiple harmful health effects can have on the population from non-ionizing radiation (NIR) sources. To date, there has been no extensive data collection about NIR emitted from base transceiver stations in Dhaka City, Bangladesh. This study aims to remedy that by collecting data and comparing the processed data to the international standards, International Commission on Non-Ionizing Radiation Protection (ICNIRP) guidelines, and standards of other countries. For this, measurement data were collected from 361 different publicly accessible locations in Dhaka City applying a convenience sampling approach. The measured average electric field exceeded the 1800 MHz threshold values of 36.84, 33.5, and 7.5% of the time compared with the thresholds of China, India, and Japan, respectively, followed by the measured average electromagnetic field values, which were 57, 52, and 29%, respectively. No exceedance was seen for radiofrequency power flux for the investigated countries. Approximately 35% of the calculated average specific energy absorption rate values exceeded the ICNIRP recommended public exposure limit of 0.08 W/kg. Based on this data, it is suggested that detailed NIR exposure regulations need to be created and proper oversight and enforcement over operators are required to avoid potential health effects.

Accelerated Wound Healing with a Diminutive Scar through Cocrystal Engineered Curcumin.

Pharmaceutical cocrystals ( Regulatory Classification of Pharmaceutical Co-Crystals Guidance for Industry; Food and Drug Administration, 2018) are crystalline solids produced through supramolecular chemistry to modulate the physicochemical properties of active pharmaceutical ingredients (APIs). Despite their extensive development in interdisciplinary sciences, this is a pioneering study on the efficacy of pharmaceutical cocrystals in wound healing and scar reducing. Curcumin-pyrogallol cocrystal (CUR-PYR) was accordingly cherry-picked since its superior physicochemical properties adequately compensate for limitative drawbacks of curcumin (CUR). CUR-PYR has been synthesized by a liquid-assisted grinding (LAG) method and characterized via FT-IR, DSC, and PXRD analyses. In vitro antibacterial study indicated that CUR-PYR cocrystal, CUR+PYR physical mixture (PM), and PYR are more effective against both Gram-negative (Pseudomonas aeruginosa and Escherichia coli) and Gram-positive (Staphylococcus aureus and Bacillus subtilis) bacteria in comparison with CUR. In vitro results also demonstrated that the viability of HDF and NIH-3T3 cells treated with CUR-PYR were improved more than those received CUR which is attributed to the effect of PYR in the form of cocrystal. The wound healing process has been monitored through a 15 day in vivo experiment on 75 male rats stratified into six groups: five groups treated by CUR-PYR+Vaseline (CUR-PYR.ung), CUR+PYR+Vaseline (CUR+PYR.ung), CUR+Vaseline (CUR.ung), PYR+Vaseline (PYR.ung), and Vaseline (VAS) ointments and a negative control group of 0.9% sodium chloride solution (NS). It was revealed that the wounds under CUR-PYR.ung treatment closed by day 12 postsurgery, while the wounds in other groups failed to reach the complete closure end point until the end of the experiment. Surprisingly, a diminutive scar (3.89 ± 0.97% of initial wound size) was observed in the CUR-PYR.ung treated wounds by day 15 after injury, followed by corresponding values for PYR.ung (12.08 ± 2.75%), CUR+PYR.ung (13.89 ± 5.02%), CUR.ung (16.24 ± 6.39%), VAS (18.97 ± 6.89%), and NS (20.33 ± 5.77%). Besides, investigating histopathological parameters including inflammation, granulation tissue, re-epithelialization, and collagen deposition signified outstandingly higher ability of CUR-PYR cocrystal in wound healing than either of its two constituents separately or their simple PM. It was concluded that desired solubility of the prepared cocrystal was essentially responsible for accelerating wound closure and promoting tissue regeneration which yielded minimal scarring. This prototype research suggests a promising application of pharmaceutical cocrystals for the purpose of wound healing.

Extensively drug-resistant typhoid fever; it's not that simple: a case report.

Multi-drug resistant strains of Salmonella typhi (S. typhi) has remained endemic in developing countries for the last two decades. With irrational use of antibiotics, an extensively drug-resistant (XDR) strain of S. typhi, sensitive only to Carbapenems and Azithromycin, has evolved which was first reported in Sindh, Pakistan, in 2018. Most of the cases of XDR S. typhi infection treated with antibiotics improve without any complications. Failure to respond to appropriate antibiotics should raise the suspicion of visceral abscesses. Splenic abscess is a rare complication of S. typhi infection. A patient with splenic abscess due to XDR S. typhi has been reported who responded to prolonged antibiotic treatment. We report the case of a young boy from Peshawar with multiple splenic abscesses due to XDR S. typhi which did not respond to percutaneous aspiration and culture-guided antibiotics for two weeks. Eventually, he had to undergo splenectomy. He has remained afebrile since then.

Aortic elasticity changes in thalassemia due to heart and liver iron deposition.

Background: Iron overload is connected with an expanded prevalence of thalassemia due to heart impairment. This considers pointing to survey changes in thalassemia's aortic elasticity due to iron deposition in the heart and liver of children. Methods: This case-control study was performed on 80 healthy and 160 thalassemia patients. The subjects gathered from educational pediatric hospital of Ali Asghar in Zahedan, Iran, from 2019 to 2021. Echocardiography parameters were measured. Ferritin, lipids profile, cardiac and liver MRI T2 * measured in patients only. Aortic elasticity parameters were aortic strain, aortic stiffness ß index, aortic distensibility and pressure strain elastic modulus. Data analyzed by SPSS,p< 0.05 was considered as significant. Results: Diastolic blood pressure (p<0.001), aortic diameter in diastole (p<0.001), aortic diameter in systole (p<0.001), ferritin (p<0.001), aortic strain (p<0.001), aortic distensibility(p<0.001), pressure strain elastic modulus (p<0.001) and aortic stiffness ß index (p<0.001) were changed significantly in thalassemia patients compared to controls. From these variables, AoD, AoS, ferritin, AS and AD increased in thalassemia. Ferritin was higher in thalassemia patients with abnormal heart iron deposition (2131.89±1992.74 v.s 4887.66±3122.59 ng/ml). Considering the level of liver iron deposition, ferritin did not change in patients. Our highlighted variables did not change in patients based on the groups of ferritin. Conclusion: Concluded that AoD, AoS, ferritin, AS and AD increased in thalassemia patients. Ferritin increased in thalassemia with abnormal iron overload in the heart but did not change in the liver. Recommended MRI T2* to evaluate dynamic functions of liver and heart in thalassemia patients.

Robust tag-free aptasensor for monitoring of tobramycin: Architecting of rolling circle amplification and fluorescence synergism.

With the unpredictable risks on human health and ecological safety, tobramycin (TOB) as an extensively applied antibiotic has embraced global concern. Herein, a label-free fluorescent aptasensor was developed that opened up an innovative sensing strategy for monitoring trace TOB levels. Based on the rolling circle amplification (RCA) process, a giant DNA building was established by the catalytic action of T4 DNA ligase and Phi 29 DNA polymerase with the cooperation of the specific aptamer as a primer skeleton. By having the role of signal amplifier template, the RCA product with the G-quadruplex sequence duplications was decorated by a high number of the thioflavin T (ThT) fluorescent dyes. The aptasensor with good selectivity toward TOB achieved a detection limit as low as 150 pM. Thanks to its accurate target quantification, ease of operation, economic manufacture, as well as high potency for real-time and point-of-care testing, the represented aptasensor is superb for clinical application and food safety control.

Predictors of Mortality in Patients With Dengue Fever: Insights From a Comparative Analysis.

Objective To determine the clinical and biochemical predictors of mortality in patients with dengue fever. Methods This was an analytical, cross-sectional study conducted at Hayatabad Medical Complex, Peshawar, Pakistan. The study participants were patients admitted to the hospital for the management of dengue fever. Clinical parameters (age, gender, duration of hospital stay, and the presence of complications) and biochemical parameters [white blood cells count (WBC), platelet count, serum c-reactive protein (CRP) level, serum alanine aminotransferase (ALT) level, and serum creatinine] were recorded. These parameters were compared between the survivors and non-survivors of dengue fever. Results Out of 115 patients, the majority (n=82, 71.3%) were up to 45 years and the mean age was 38.40 ± 18.1 years. Most of the patients (n=105, 91.3%) survived. On univariate logistic regression analysis, age more than 45 years [odds ratio (OR) 0.141, 95% confidence interval (CI) 0.034 - 0.585, p = 0.007), leukocytosis (> 11,000/mcL) (OR 0.187, 95% CI 0.049 - 0.719, p = 0.015), and acute kidney injury (creatinine > 1.5 mg/dL) (OR 0.124, 95% CI 0.029 - 0.531, p = 0.005)] at the time of admission reduced the likelihood to survive. Leukocytosis and acute kidney injury remained significant independent predictors of mortality on multivariate logistic regression analysis. [(OR 0.201, 95% CI 0.042 - 0.960, p = 0.044) and (OR 0.148, 95% CI 0.026 - 0.857, p = 0.033) for survival, respectively]. Gender, duration of inpatient stay, thrombocytopenia (platelets < 30,000/mcL), and acute liver injury (ALT > 200 IU/L) were not associated with mortality from dengue fever. Conclusion Age over 45 years, leukocytosis, and acute kidney injury at presentation increased the likelihood of mortality from dengue fever in this study. Gender, duration of hospital stay, thrombocytopenia, and acute liver injury did not affect the odds of mortality.

Assessment of aortic elasticity parameters in obese and overweight children.

BACKGROUND: Aortic elasticity is a predictor and recognized factor for future cardiovascular events in children. The aim of the study was to evaluate the aortic stiffness in obese and overweight children compared to healthy ones. METHODS: The study evaluated 98 sex matched children aged 4 to 16 years that were equally distributed in asymptomatic obese or overweight and healthy children groups. All the participants were free of any heart diseases. Arterial stiffness indices were determined using two-dimensional echocardiography. RESULTS: The mean ages in the obese and healthy children were 10.40±2.50 years and 10.06±1.53 years, respectively. Aortic strain was significantly higher in obese children (20.70±5.04%), compared to healthy (7.06±3.77%) and overweight children (18.59±8.08%, p < 0.001). Aortic distensibility (AD) was significantly higher in obese children (0.010±0.005 cm < sup > 2 < /sup > dyn-1x10-6), compared to healthy (0.0036±0.004 cm < sup > 2 < /sup > dyn-1x10 < sup > -6 < /sup > ) and overweight children (0.009±0.005 cm < sup > 2 < /sup > dyn-1x10 < sup > -6 < /sup > , p < 0.001). Aortic strain beta (ASß) index, was significantly higher in healthy children (9.26±6.17). Pressure-strain elastic modulus (PSEM) was significantly higher in healthy children (7.52±4.76 kPa). Systolic blood pressure increased with body mass index (BMI) significantly (p < 0.001) but diastolic blood pressure did not change (p=0.143). BMI had significant effect on arterial stiffness (AS) (ß=0.732, p < 0.001), AD (ß=0.636, p < 0.001), ASß index (ß=-0.573, p < 0.001) and PSEM (ß=-0.578, p < 0.001). Age had significant effect on systolic diameter of the aorta (ß=0.340, p < 0.001) and diastolic diameter of the aorta (ß=0.407, p < 0.001). CONCLUSIONS: We concluded that aortic strain and aortic distensibility increased in obese children when aortic strain beta index and PSEM decreased. This result suggests that, as atrial stiffness is a predictor for future heart diseases, dietary treatment for children with overweight or obese status is important.

Determining the periodontal phenotype-Probe transparency versus actual: A diagnostic study.

AIMS: Assessment of the validity of the transparency of the periodontal probe as a tool for determining the periodontal phenotype. MATERIALS AND METHODS: The periodontal phenotype was assessed at the six upper anterior teeth of 75 subjects using two methods. One is through assessing the transparency of the periodontal probe upon insertion into the gingival sulcus. The second method was through the assessment and clustering of the width of keratinized gingiva clinically and the gingival and buccal plate thickness on Cone Beam Computed Tomography scan. RESULTS: The probe transparency approach correctly identified thick periodontal phenotype in most cases (41 out of 43 [95%]). However, this was not the case for thin periodontal phenotype; probe transparency approach identified 64% of the thin sites (261 out of 407) and misclassified nearly one third of the patients. CONCLUSION: The probe transparency approach is a valid approach in identifying the phenotype in subjects with thick phenotype but not in subjects with thin phenotype. CLINICAL SIGNIFICANCE: The definition of periodontal phenotype has recently changed. Accurate designation has been shown to affect treatment outcomes especially esthetic ones in different disciplines of dentistry. Probe transparency is commonly used by clinicians and researchers. Assessment of the validity of this method based on the most recent definition and compared to actual assessment of bone and gingival thickness is of great clinical value.

Olfactory dysfunction in patients with Parkinson's disease: A systematic review and meta-analysis.

Background: Parkinson's disease (PD) is a progressive neuro-degenerative disease and olfactory dysfunction is considered as an important issue in these patients. The prevalence of olfactory dysfunction in patients with PD was reported variously in previous studies. Therefore, we designed this systematic review and meta-analysis to estimate the pooled prevalence of olfactory dysfunction in patients with PD. Methods: Two expert researchers systematically searched PubMed, Scopus, EMBASE, Web of Science, Google Scholar, references of the papers, and conference abstracts. The titles and abstracts of the potential studies were evaluated after deleting the duplicates. We extracted data regarding the total number of participants, first author, publication year, the country of origin, mean age, mean disease duration, female/male, number with olfactory dysfunction, and name of the test. We evaluated the risk of potential bias by the Newcastle-Ottawa Quality Assessment Scale (adapted for cross-sectional studies). All statistical analyses were done using Stata software. To determine heterogeneity between the findings of included studies, inconsistency (I2) was calculated. We applied random effect model when I2 was more than 50%. P-value less than 0.05 was considered significant. Results: The literature search revealed 1546 studies; after deleting duplicates, 894 remained. Finally, twelve studies remained for meta-analysis. Studies were published between years of 2009 to 2021, the sample size of studies ranged between 30 and 2097, and the mean age ranged between 61 and 70 years. The pooled prevalence of olfactory dysfunction in patients with PD was estimated as 64% [95% confidence interval (CI): 44-84, I2 = 99.7%, P < 0.001]. The pooled prevalence of olfactory dysfunction using Sniffin's test was 67% (95% CI: 51-83) and using other tests was 60% (95% CI: 28-92). Conclusion: The results of this systematic review and meta-analysis showed that the pooled prevalence of olfactory dysfunction in patients with PD was 64% which should be considered by physicians.

Do Laboratory Biomarkers Predict Survival In Severe Covid-19? A Cross-Sectional Study.

Background: This study aims to compare lymphocyte count, C-reactive protein (CRP), ferritin, Lactate Dehydrogenase (LDH) and D-dimer among survivors and non-survivors of severe COVID-19. Methods: This retrospective cross-sectional analytical study included 69 patients for whom a record of the biomarkers and survival status was available. Baseline and peak values were selected for serum CRP, ferritin, LDH and D-Dimer. Baseline and trough lymphocyte counts were selected. Data were analyzed using SPSS version 21. Mean and standard deviation were used to compare the biomarkers with paired t-test. p-value <0.05 was taken as significant. Results: The mean age of the study population was 55.5±9.1 years and 50 (72.5%) were male. Among survivors, the increase in CRP level was not significant (from 15.80±9.8 mg/dl to 17.87±8.4 mg/dl, p=0.45) while it was significant in non-survivors (from 16.68±10.90 mg/dl to 20.77±12.69 mg/dl, p=0.04). There was no significant rise in LDH levels in survivors (from 829.59±499 U/L to 1018.6±468 U/L, p=0.20) while it increased significantly in non-survivors (from 816.2±443.08 U/L to 1056.61±480.54 U/L, p=0.003). The decrease in lymphocyte count and increase in D-Dimers in both the groups was significant (p=0.001). There was no significant elevation in ferritin in both the groups (p>0.05). Conclusion: In severe COVID-19 patients, serum CRP and LDH can be used for risk stratification and predicting survival. Lymphopenia, increase in serum ferritin and D-dimers may not predict survival.

Crimean-Congo Hemorrhagic Fever Case Series: a Chronology of Biochemical and Hematological Parameters.

Introduction Crimean-Congo hemorrhagic fever (CCHF) is a widespread tick-borne zoonotic disease. Sporadic outbreaks of CCHF occur in endemic regions, including Pakistan. The clinical spectrum of the illness varies from asymptomatic seroconversion to severe disease which may end in death. The treatment is supportive, including blood and blood products. There is multi-organ involvement in CCHF including acute hepatitis, thrombocytopenia, coagulopathy, acute kidney injury (AKI), and encephalopathy. Hematological and biochemical parameters may identify patients at substantial risk of worse outcomes. Early detection of the disease and forecasting the clinical course may be helpful. This case series aims to evaluate the trends of hematological and biochemical parameters among the survivors and non-survivors of CCHF. Methods All consecutive patients aged 16 years and above admitted to the isolation unit of Hayatabad Medical Complex, Peshawar, Pakistan between 1st July and 30th July 2022 with the diagnosis of CCHF were included in this case series. The diagnosis of CCHF was made by detecting viral ribonucleic acid by a polymerase chain reaction. For all patients, age, gender, address, occupation, clinical presentation, history of contact with animals, and travel history were recorded. All the vitals were taken regularly. The hematological (complete blood count) and biochemical parameters (serum creatinine, alanine aminotransferase (ALT), and C-reactive protein (CRP)) were documented daily. The blood group was determined for all the cases. Results Out of 17 cases, the majority (16 cases, 94.1%) were male and butchers (eight cases, 47.1%) by profession. All cases had significant contact with animals. Four patients (23.5%) died. Three out of the four non-survivors (75%) had ALT < 5 times the upper limit of normal with a static pattern of liver enzymes without much decline in ALT till death. One non-survivor (25%) had marked elevation of ALT at presentation, which had a declining trend till death. Seven out of 13 survivors (53.8%) had moderate to marked elevation in the level of ALT at presentation. The ALT showed a downward trend during the course of illness in all these patients. The remaining survivors (six out of 13, 46.2%) had a mild elevation of ALT and 50% of them showed improvement in the ALT level during hospitalization. All patients had thrombocytopenia at presentation. None of the non-survivors showed a persistent increase in the platelet count, and three cases remained severely thrombocytopenic at the time of death. However, the trend in platelet count among all the survivors was increasing. The CRP level in the majority (three out of four cases, 75%) of the non-survivors remained elevated till death, while all survivors showed a progressive decline in CRP level. A majority (11 out of 17 cases) had blood group B. Half of the non-survivors (two out of four cases) and the majority of the survivors (nine out of 13 cases) had blood group B. AKI was found in all non-survivors, while all the survivors had normal renal function throughout the course. Conclusion A persistently raised ALT and CRP level, a persistently low or decreasing platelet count, and AKI were associated with mortality. Blood group B was the commonest blood group among patients of CCHF, which is not reflective of the blood group distribution of the general population from which this case series has been reported.

Dengue Fever, Crimean-Congo Hemorrhagic Fever, and COVID-19 Triple Co-infection: Out of the Frying Pan Into the Fire.

In developing countries, infectious diseases are thriving due to poor hygiene, inadequate public health infrastructure, and socio-cultural factors. Generally, infections are due to a single pathogen, but due to the shared risk factors for transmission, co-infections are not uncommon. The severity and outcome of infections are adversely affected by co-infection. Co-infections present as diagnostic and therapeutic enigmas because of the complex interaction between different pathogens involved and distorted host responses. The southeast Asian region, particularly Pakistan, is known for unique combinations of different infections. We present a distinctive case of triple co-infection of dengue virus, Crimean-Congo hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. The index case was a 60-year-old gentleman who presented with fever, cough, shortness of breath, bruises, and hemoptysis. He had thrombocytopenia, deranged liver and renal function, coagulopathy, and infiltrates in both lung fields. Subsequent investigations revealed a positive polymerase chain reaction for ribonucleic acid of dengue virus, Crimean-Congo Hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. He received supportive treatment including antibiotics, blood products, ribavirin, and supplemental oxygen. He developed multi-organ failure and succumbed to the triple co-infection. This case will act as a wake-up call for clinicians, public health authorities, and infectious disease specialists to plan before the volcano of co-infections erupts.

Acute Kidney Injury Following Posaconazole for Mucormycosis: SARS-CoV-2 as a Back-Seat Driver.

Viruses have been implicated in the causation of several systemic illnesses, either directly or by immune modulation. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not an exception. Due to altered immune regulation, it is often associated with novel clinical manifestations and complications which have not been reported before. SARS-CoV-2 induces a pro-inflammatory state which makes the patient vulnerable to developing a variety of previously unreported adverse reactions to medications. Coronavirus disease 2019 (COVID-19) and its treatment have provided a fertile ground for various opportunistic infections including mucormycosis. The standard treatment for mucormycosis is surgical debridement and liposomal amphotericin B. Triazole antifungals such as posaconazole and isavuconazonium are the second-line agents for those intolerant to first-line therapy. Posaconazole is safer than amphotericin B as far as renal adverse effects are concerned. We report the case of a 60-year-old lady with type 2 diabetes mellitus, hypertension, ischemic heart disease, and osteoarthritis. She had severe COVID-19 requiring non-invasive ventilation four months ago. She presented with right rhino-orbital swelling, diplopia, and serosanguinous discharge from the right nostril. She had right third, sixth, and seventh cranial nerve palsies. Magnetic resonance imaging revealed right maxillary, ethmoid, and frontal sinusitis. Biopsy from the right nostril confirmed mucormycosis. Having normal renal and liver functions, she was started on oral posaconazole as she had an allergic reaction to a test dose of 1 mg amphotericin B (non-liposomal) in 20 mL of 5% dextrose water infused over 30 minutes. On day five, she developed acute kidney injury requiring renal replacement therapy. Her posaconazole was stopped. As she was not improving with conservative treatment, an ultrasound-guided, percutaneous renal biopsy was performed from the left kidney. The renal biopsy revealed thrombotic microangiopathy. She was started on liposomal amphotericin B as decided by the multidisciplinary team. Her renal function improved, and she continued on liposomal amphotericin B. We conclude that thrombotic microangiopathy, in this case, was likely due to posaconazole. This is a novel adverse effect presumably of posaconazole. This case report will alert physicians to be vigilant of the renal adverse effects of posaconazole in patients who have had COVID-19. Patients who develop renal injury while on posaconazole should undergo an early renal biopsy to ascertain the exact histopathology.

Polymyositis: The Comet Tail After COVID-19.

Infectious agents have been implicated in the pathogenesis of autoimmune disorders for decades. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is no exception. This became evident as the pandemic evolved. Once considered a respiratory pathogen only, SARS-CoV-2 is now linked to a variety of autoimmune rheumatic disorders such as rheumatoid arthritis, systemic lupus erythematosus, reactive arthritis, spondyloarthropathies, vasculitis, and inflammatory myopathy. Although the exact cause for muscle injury in the setting of coronavirus disease 2019 (COVID-19) is not established, autoimmune inflammatory damage is the most accepted mechanism. Moreover, SARS-CoV-2 can cause direct muscle damage and indirectly through a cytokine storm. Inflammatory polymyositis in relation to COVID-19 has seldom been reported in developing countries. Here, we report a unique case of inflammatory polymyositis in a 52-year-old lady. The patient presented with muscle weakness, generalized body aches, and fatigue occurring four months after recovering from mild COVID-19. She had muscle weakness of Medical Research Council (MRC) grade 3/5 involving the shoulders and pelvic girdle with elevated muscle enzymes. Electromyography revealed an active irritable myopathic process consistent with inflammatory polymyositis. She underwent magnetic resonance imaging-guided muscle biopsy from the right thigh which revealed findings consistent with inflammatory myopathy. She was offered prednisolone and azathioprine. After four weeks of treatment, she had a remarkable improvement in her muscle strength to MRC grade 5/5.

COVID-19 Associated Illnesses From Alveoli to Glomeruli: A Case Report.

Hypoxemic respiratory failure is the most frequent complication of severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) infection. Coronavirus disease-19 (COVID-19) is no longer considered a standalone respiratory infection. It can involve other organs, including kidneys by direct invasion or indirectly through immune activation, cytokine storm, microthrombi and hemodynamic instability. Multiorgan involvement carries a worse prognosis in COVID-19. Tubulopathy is the most frequently reported renal pathology, followed by glomerulopathies. Among the glomerulopathies, immunoglobulin A (IgA) nephropathy is less often reported. Differentiating tubulopathy from glomerulopathy is important from the management and prognostic point of view. Laboratory investigations, including urine microscopy, cannot predict glomerulopathy as a cause of renal involvement. Therefore, it is important to proceed with renal biopsy early to make a definite diagnosis. We report a case of a 33-year-old male who presented three weeks after recovery from COVID-19 with proteinuric acute kidney injury. Subsequent renal biopsy revealed IgA nephropathy.

Extensively Drug-Resistant Salmonella typhi Infection: From Pill to Scalpel.

Water-borne infections like typhoid fever are common in the developing world. The emergence of extensively drug-resistant Salmonella typhi (XDR S. typhi) is of great concern for both local and global public health. Fever, diarrhea, and abdominal pain are the commonest manifestations of typhoid fever. Abdominal pain may be due to ileal and colonic inflammation/ulceration and mesenteric lymphadenitis. Sometimes, abdominal pain in typhoid is due to ileal perforation leading to peritonitis, and acute appendicitis which needs urgent surgical intervention. Delayed surgical intervention can result in morbidity and sometimes even death. We report a case of XDR S. typhi infection in a 17-year-old female who presented with fever and abdominal pain. During the course of the hospital stay, while she was on appropriate antibiotics, her abdominal pain worsened due to acute appendicitis. She underwent an appendectomy and had an uneventful recovery. This is the first case, to our knowledge, of acute appendicitis caused by XDR S. typhi. Although appropriate antibiotics are the mainstay of treatment for typhoid fever, physicians should be mindful that surgical consultation may be necessary in certain cases.