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   Table of Contents - Current issue
Coverpage
April-June 2022
Volume 13 | Issue 2
Page Nos. 73-137

Online since Thursday, March 31, 2022

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EDITORIAL  

Clinical teaching: How to make it effective p. 73
Aruna Nigam
DOI:10.4103/injms.injms_14_22  
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ORIGINAL ARTICLES Top

Unraveling scrub encephalitis: A study on the clinical profile and investigations of scrub encephalitis p. 77
Cynthia Amrutha Sukumar, Nandakrishna Bolanthakodi, Laawa Lakhmani, Ajit Singh, Sudha Vidyasagar
DOI:10.4103/injms.injms_110_21  
Introduction: Scrub encephalitis (SE) is one of the known causes of acute encephalitis syndrome (AES). Although central nervous system involvement is known in scrub typhus, its association with AES is less understood and lesser diagnosed. In the absence of a point of care test for scrub typhus, cases of SE can be easily missed. A clinical approach using detailed history and clinical profiling of SE will help to diagnose SE in our region, using minimum resources, within a reasonable period. Aims: To analyze the clinical spectrum in patients of SE and to evaluate the investigations required to diagnose SE. Methodology: This is a retrospective study that analyzed Scrub typhus patients over 2 years from January 2018 to December 2019. A total of 370 patients were screened and 23 patients who satisfied the study criteria were included in the study and analyzed. Results: Among the cases of scrub typhus admitted in the hospital, the prevalence of SE was 6%. The most common presenting complaint was fever in 21 patients (91%) followed by altered sensorium in 16 (70%) and seizures in 9 patients (39%). An eschar was noted in 66% of the cases. The mean Glasgow Coma scale was 11 among the cases with almost 70% of cases showing signs of meningeal irritation. Organ involvement was noted as thrombocytopenia in 21 patients (91%), 16 patients (69%) with jaundice, and 1 (4%) with acute kidney injury. Conclusion: SE is an AES which, if detected early, is easily treatable with no residual neurological sequelae. Hence, identification of this condition and prompt diagnosis of SE becomes crucial to the management of this complication of scrub typhus.
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Is chronic obstructive pulmonary disease different in females as compared to males? p. 82
Rita Vijaykumar Bothara, Madhuri Prashant Holay
DOI:10.4103/injms.injms_118_21  
Background: Recent years have witnessed a major shift in the sex profile of the chronic obstructive lung disease (COPD). In India, while smoking remains a significant risk factor, COPD due to nonsmoking causes (like biomass exposure) accounts for 30%–50% of all COPD cases. There is a lack of studies on characteristics of women with COPD exposed to biomass smoke and the degree to which they differ from COPD in men from the Indian context. Aim: The aim was to study clinical profile, risk factors, and severity of COPD in females and compare the same with COPD in males. Materials and Methods: 100 cases of COPD were divided into two groups – 50 Females and 50 males and were analyzed further for clinical profile and were graded as per the GOLD criteria and BODE index. Results: The mean age of presentation in females was 62 years. Biomass smoke exposure was the most common risk factor in females and that in males was smoking. Females had more severe dyspnea as compared to males (P = 0.022). There was a significant statistical difference in the performance of 6-min walk test (P = 0.005) and number of exacerbations in the past year in females (mean 4.5) and males (mean 3.58) (P = 0.034). Majority of female patients belonged to GOLD Groups B and D. Mean BODE index was 4.98 in females and 4.24 in males, and the difference was statistically significant (P = 0.014). Conclusion: There are gender-related differences in COPD risk, progression, and outcomes. Females have more symptoms, more severe obstruction, more number of exacerbations, and more functional disability as compared to males.
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Depression, anxiety, and stress among general public of india during post-COVID-19 second wave: A web-based cross-sectional survey p. 87
Jyothi Suchitra Mekala, Narayana Goruntla, Bharathi Nayaka, Kavyasree Velpula, Raghavendra Biswas, Kasturi Viswanathasetty Veerabhadrappa, Bhupalam Pradeepkumar
DOI:10.4103/injms.injms_103_21  
Background: Evidence suggests that one-third of respondents had a significant psychological impact in the lockdown period of the coronavirus disease 2019 (COVID-19) pandemic. This indicates a need for longitudinal assessment of the psychological needs of the public to plan holistic interventions. Aim: To investigate depression, anxiety, and stress (DAS) levels among the general public post-COVID-19 second wave. Materials and Methods: A web-based cross-sectional survey was conducted among the general public who were aged above 15 years. The data were collected through online mode by providing a link to fill Google Form. The survey tool was disseminated in various messenger groups and social media networks. The survey tool comprises demographics, COVID-19 stressors, and DAS Scale 21 (DASS-21). Multi and Univariate linear regression analysis was used to correlate patient characteristics and COVID-19 stressors with DASS-21 subscales. Results: A total of 2515 (males = 1274; females = 1241) people participated in this web-based survey. The mean age of the study respondents was 31.3 ± 13.4 years. The mean scores of depression, anxiety, and stress were 6.8 ± 8.6, 5.0 ± 7.3, and 7.3 ± 8.6, respectively. The majority of the participants are normal in all sub-scales of DASS-21. Very few are experiencing symptoms of severe or extremely severe depression (4.2%, 4.3%), anxiety (3.3%, 6.9%), and stress (3.0%, 2.3%). Geriatrics, females, health-care workers, homemakers/unemployed/retired people, rural residents, and people suffering from co-morbidities have a significant elevation of DAS scores with a P < 0.05. Conclusion: Even though most of the respondents are free from the DAS symptoms, few are still (post-COVID-19 second wave) experiencing symptoms of severe or extremely severe DAS subscales. More interview-based and probability sampling future studies are warranted to minimize the biases present in the study.
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Improvement of the nurses' awareness toward ventilator-associated pneumonia based on evidence guidelines p. 95
Zainab Mohamed ALaswad, Magda Bayoumi
DOI:10.4103/injms.injms_124_21  
Background: Ventilator Associated Pneumonia (VAP) is a common hospital acquired infection that occurs as complication in patients who are connected to Mechanical Ventilation (MV). Nurses in intensive care unit (ICU) should be updated with the latest evidence-based practice to prevent such complication. This study aimed to assess improvement of the nurses' awareness toward ventilator-associated pneumonia based on latest evidence guidelines. Methods: A quantitative pretest-posttest design has been conducted. Using a convenience sample of 58 nurses who are working in the ICU were recruited. Tools: A self-administrative questionnaire was adapted to assess the nurse's knowledge about VAP and VAP prevention bundle. Results: The results highlighted that all ICU nurses had improvement of knowledge level pre-post regarding VAP (p <0.001), VAP prevention (p <0.001), and the overall knowledge score improvement revealed significantly higher after the educational program (p <0.001). Conclusion: Periodic refreshing on-services education program should be provided to nurses in ICU to improve their knowledge and to maintain high level of information, moreover hospital policies should include updated guidelines for VAP prevention bundle and protocol from international evidence.
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Relationship between height and arm-span of elderly persons in a rural area of Ballabgarh, Haryana p. 101
Sunanda Gupta, Rakesh Kumar, Mani Kalaivani, Baridalyne Nongkynrih, Shashi Kant, Sanjeev Kumar Gupta
DOI:10.4103/injms.injms_109_21  
Background: Progression in age causes gradual loss in height due to degenerative osteoporotic changes in bones and decrease in the disc space. Hence, proxy measures of height are required in elderly persons. Objective: The objective of the study is to study the relationship between height and arm-span of elderly persons. Materials and Methods: This community-based study was conducted in a rural area of Ballabgarh, Haryana, among elderly persons (age ≥60 years). Four hundred and twenty participants were selected by simple random sampling method. House-to-house visits were made. Height and arm-span were measured. Association between height and arm-span was assessed by Pearson's product-moment correlation coefficient and linear regression analysis. Scatter plot was also made to show the association by age and sex. Results: In both sexes and all age groups, arm-span was seen to be more than height. Linear relationship between height and arm-span was observed. There was strong correlation between height and arm-span in both sexes (correlation coefficient = 0.97, P < 0.001 in both sexes). Conclusion: Arm-span can be measured as an alternative to height in elderly population. Arm-span can be used as a substitute for height for calculation of body mass index, creatinine height index, basal energy expenditure, and pulmonary function test.
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Mortality in dermatology: A closer look p. 105
Prachi Bhandare, Annam Navya, Rakhi Ghodge, Pankaj Shukla, Taruna Gupta
DOI:10.4103/injms.injms_131_21  
Introduction: Contrary to the general perception that the field of dermatology rarely encounters managing critical patients and dealing with mortality, severe and extensive dermatological conditions can be lethal in the absence of timely intervention. Aims and Objectives: The aim was to study in detail regarding the deaths and the various factors associated with it in patients admitted with dermatological conditions in a tertiary care center over a period of 10 years. Materials and Methods: It was a retrospective, record-based, observational study over a period of 10 years (2011–2021) in a tertiary care hospital consisting of 49 cases. After obtaining institutional ethical clearance, the information was obtained from medical records section. The relevant details of patients were entered in a specially formulated proforma. Results: A total of 3491 patients were admitted to the Department of Dermatology, Goa Medical College, during the study period of 10 years from January 2011 to August 2021. Among these, 49 patients succumbed to their skin condition, with an overall mortality percentage of 1.4%. Drug reactions were the most commonly encountered diagnosis in 17 patients (34.69%) which was closely followed by vesiculobullous disorders with 14 (28.57%) cases and infections in 10 (20.40%) cases. Conclusion: Drug reactions, vesiculobullous disease, and infections were the main causes of mortality in our series of patients. Extensive skin and mucosal involvement, multisystem involvement, declining age, delay in treatment received, and onset of sepsis were some of the major factors contributing to mortality. In our study, a high proportion of 46.93% of the patients were above the age of 60 years, out of which 56.52% had vesiculobullous disease. Hence, a special focus on geriatric dermatology deserves attention, especially in tertiary care centers.
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Correlation of E1 lesions and CD68 count with proteinuria and clinical outcome in IgA nephropathy p. 109
Sistla Radha, Tameem Afroz, Y Sandeep Reddy, Gandhe Sridhar, KG Rajaram
DOI:10.4103/injms.injms_105_21  
Background: IgA nephropathy (IgAN) has variable course; few patients have a benign presentation and other patients present with late stage disease. Endocapillary hypercellularity has a prognostic significance in IgAN. It is important to identify E1 lesions accurately. The use of CD68 immunohistochemistry marker to identify glomerular macrophages will standardize the reporting and help the clinicians prognosticate the patients. Subjects and Methods: The material is from a referral laboratory for renal biopsies in a tertiary care hospital. Renal biopsies are processed as per protocol including light microscopy, immunofluorescence and electron microscopy where ever required. CD68 was used in this study to identify macrophages in E1 lesions. A total of 1220 primary glomerular diseases were diagnosed from January 2019 till date. Out of these, IgA constituted 11.9% of primary glomerular diseases. Renal biopsies received were from the department of nephrology and various other nephrology centers. Biopsies were received in 10% buffered formalin. Immunofluorescence is done on all biopsies, and electron microscopy was done in few cases to differentiate from other lesions with dominant IgA deposits. CD68 was done in 50 cases of IgAN. Apart from hematoxylin and eosin stains, periodic acid-Schiff, Masson trichrome, Jones silver stain were also done. Results: IgAN constituted 11.9% of cases. Twenty-five cases of E0 and twenty-five cases of E1 lesions were correlated with clinical and morphological features. There was correlation with proteinuria and hypertension in E1 lesions. There was no significant correlation with the morphological variants like crescents, focal segmental glomerulosclerosis. Conclusions: Inter observer correlation of E lesions is poor in classifying IgAN. Use of CD68 is a useful adjunct to identify macrophages. E1 lesions have more proteinuria requiring treatment for delaying the progression to end stage disease. Despite significant association of E1 lesions with progression, there may be many unmeasured factors which would influence the outcome.
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CASE SERIES Top

Mucormycosis in the setting of the Covid-19 pandemic in patients without exposure to steroids and oxygen: A case series from a tertiary care center in North India p. 113
Sachin Gautam, Mradul Kumar Daga, Govind Mawari, Naresh Kumar, Ishan Rohatgi, Maryam Hussain, Vaishali Vinod Ramteke, Sandeep Garg, Suresh Kumar, Sarika Singh, Ishwar Singh
DOI:10.4103/injms.injms_133_21  
Background: Sudden surge of mucormycosis cases in India needs an urgent attention as multiple factors have been implicated. However, diabetes mellitus remains to be one of the most important and modifiable factors. Methodology: We prospectively followed 11 patients with mucormycosis in May 2021 and June 2021, admitted to our hospital to study the possible etiologies. Results: Out of the 11 patients, six were males and five were females, with an average age of 52.45 years. Type 2 diabetes mellitus was the ubiquitous comorbidity, and every patient presented with uncontrolled hyperglycemia (six out of them were in diabetic ketoacidosis). Glycated hemoglobin levels ranged from 10.2% to 15.1%. Out of 11 patients, four patients were non-COVID, whereas five patients had a history of COVID-19 infection. All these five post COVID-19 patients presented approximately 20 days after recovery, out of which one patient had severe infection who was hospitalized. The remaining two patients were COVID-19-positive. Out of 11 patients, 10 patients had rhino-orbital mucormycosis at presentation, among which four patients had cerebral involvement, and one out of them later developed invasive disease. However, one patient had only pulmonary mucormycosis at presentation. Serum ferritin was raised in all the patients, and six had serum zinc levels below the reference range. Serum flow cytometry showed leukopenia with normal CD4:CD8 ratio in seven patients. In the clinical outcome, six patients expired, whereas five patients responded to the treatment and were discharged on oral posaconazole therapy. Conclusion: From our study, it is quite evident that uncontrolled diabetes and its complications such as diabetic ketoacidosis were an important risk factor for the occurrence of mucormycosis in COVID-19 patients as well as non-COVID-19 patients, even without exposure to steroids or oxygen. Thus, blood glucose levels should be kept at optimum level during the management of COVID-19 patients.
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CASE REPORTS Top

Acute respiratory distress syndrome complicating scrub typhus in pregnancy p. 119
Amit Kumar, Shweta Tanwar, Sudhish Gupta, Rajesh Chetiwal
DOI:10.4103/injms.injms_106_21  
Scrub typhus is caused by Orientia tsutsugamushi (formerly Rickettsia) and is transmitted to humans by an arthropod vector of the Trombiculidae family. Recent reports suggest that there has been resurgence of rickettsial infections in the Indian subcontinent. As the clinical features of scrub typhus are nonspecific and closely mimic that of other tropical infections, its diagnosis is often delayed or missed. It may cause serious complications such as myocarditis, meningoencephalitis, acute renal failure, acute liver failure, pneumonia, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation, and multiorgan dysfunction syndrome. Early diagnosis is important because the response to treatment is excellent and may help prevent complications. Here, we report a case of scrub typhus in a pregnant woman complicated by ARDS; however, timely diagnosis and institution of therapy helped save two precious lives.
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Scleroderma renal crisis as initial presentation of scleroderma p. 122
Sahil Bagai, Scienthia Sanjeevani, Dinesh Khullar, Bhavna Bansal, Vipra Malik
DOI:10.4103/injms.injms_123_21  
Scleroderma renal crisis (SRC) is characterized by the development of severe or worsening arterial hypertension associated with the abrupt onset of progressive renal failure in the absence of any other cause. Only 1% of limited and 4–11% of diffuse scleroderma cases have SRC. We report a case of SRC as an initial presentation in a newly diagnosed case of scleroderma.
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A fatal disease hidden behind a common symptom: Neuromyelitis optica spectrum disorder p. 124
Vishal Chandra Sharma, Anisha Umashankar
DOI:10.4103/injms.injms_99_21  
Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory demyelinating disorder of the central nervous system. Recently, a number of clinical features have been identified in the diagnosis, and this disorder has been expanded to include a wider spectrum. It is important to have knowledge of these syndromes to diagnose this condition. One such presentation is intractable vomiting and hiccoughs, which is categorized as area postrema syndrome (APS) and is often misdiagnosed as a digestive disorder. We present a case of young female presenting with unresolving vomiting and hiccoughs. Magnetic resonance imaging done showed lesions in the dorsal medulla, suggestive of APS. A positive immunoglobulin G aquaporin-4 antibody confirmed the diagnosis of NMOSD. With this case report, we try to reiterate the importance of knowing the varied presentations of NMOSD and vigilance in identifying that a common symptom such as vomiting/hiccough can be due to an uncommon disorder.
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Artesunate-induced vasculitis in an empirically treated patient with febrile illness p. 127
Ritika Sud, Ridhi Chhabra, Niharika Aggarwal, Lalit Kumar Gupta
DOI:10.4103/injms.injms_117_21  
A 55-year-old female presented to the emergency department with maculopapular rashes involving whole body following administration of intravenous artesunate for an acute febrile illness. Leukocytoclastic vasculitis (LCV) was diagnosed with the help of a biopsy, and causes for the condition other than drug induced were investigated and ruled out. Almost 10% of the LCV cases are caused by drugs; however, a literature search did not reveal any documented case of Artesunate-induced vasculitis. We suggest that patients on Artesunate therapy should be monitored for signs and symptoms of LCV.
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Hand sanitizer: A double-edged sword used in the COVID-19 pandemic p. 130
S Sidharth, Ramesh Aggarwal, LH Ghotekar, Shubha Laxmi Margekar, Omprakash Kumar
DOI:10.4103/injms.injms_127_21  
The COVID-19 pandemic has taught us the emphasis of personal hygiene which was long being ignored. Measures such as hand sanitizer which were predominantly used in health-care facilities in the past have seen recent surge in its usage everywhere. The availability of hand sanitizer in almost all the settings in this pandemic including the household has heralded a new step in personal hygiene. People across the world are using hand sanitizer everywhere. As much is known about its beneficial effect in preventing the spread of pathogens, its injudicious use has resulted in discovering its adverse effect if misused. We hereby present a case where the patient with Type 1 diabetes mellitus presented with hand sanitizer ingestion. This case highlights the unwanted effects and lethality of hand sanitizer if used in an unintended manner and hence alert us for its judicious use in the pandemic.
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LETTERS TO THE EDITOR Top

Pathophysiological mechanism of stroke secondary to bee sting p. 132
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
DOI:10.4103/injms.injms_6_22  
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White dots syndrome and pseudoxanthoma elasticum: An unusual association p. 134
Belfaiza Soukaina, Taoufiq Abdelaoui, Imane Jeddou, Yassine Mouzari, Karim Reda, Oubaaz Abdelbar
DOI:10.4103/injms.injms_5_22  
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Vaccines are ray of hope, but who is the torch-bearer? p. 136
Harish Gupta
DOI:10.4103/injms.injms_129_21  
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