Scrub typhus (ST), hitherto absent from many parts of India, is now recently being recognized as a significant cause of morbidity and mortality throughout the country. Its diverse clinical presentations, low of the index of suspicion by the treating physician, and lack of diagnostic testing in many parts of the country result in delayed treatment, leading to a host of complications. We here report such a complication, where ST manifested with a large intracerebral hemorrhage, of which, to the best of our knowledge, only nine cases have been reported in the English language worldwide. Family physicians, who are the often first point of contact for treatment of febrile illness, as ST typically manifests, need to be aware of this entity to prevent such catastrophic consequences.
Scrub typhus (ST), a zoonotic disease, is currently being recognized as a significant contributor to the changing landscape of infectious diseases in India. As one of the important causes of febrile illness, in many parts of the country, general practitioners need to include it as part of the workup for cases of fever of unknown origin. While very amenable to early treatment with a simple regime of doxycycline, delayed diagnosis can result in a spectrum of complications. We report here one such complication of a case of ST manifesting with isolated lateral rectus palsy, which, to the best of our knowledge, has been reported only thrice in the world previously. Family physicians also need to be aware of the availability in India of affordable serological testing for ST that is useful for rapid and inexpensive diagnosis, leading to timely treatment.
Upsurge of chikungunya cases in Uttar Pradesh, IndiaAhmad Ozair
Background & objectives: Chikungunya (CHIK) re-emerged in India in 2006 after a gap of three decades. In Uttar Pradesh (UP), <100 confirmed cases per million were reported during this outbreak. Based on an upsurge of CHIK cases at UP, this retrospective study was conducted to investigate clinical and serological profile of CHIK cases in UP. Methods: A retrospective study was done on all clinically suspected CHIK cases that had been tested by ELISA for anti-CHIK virus IgM antibodies from September 2012 to December 2017. Based on clinical features, a subset of patients had earlier been tested serologically for dengue and Japanese encephalitis (JE). Results: Of the 3240 cases enrolled, 771 (23.8%) were seropositive. Patients had a range of clinical manifestations with seropositivity highest in those exhibiting arthralgia with fever (40%), followed by fever of unknown origin (FUO) (22%), encephalitis (13%) and fever with rash (12%). Cases (total, seropositive) increased over 20-fold in 2016 (1389, 412) and 2017 (1619, 341), compared to 2012-2015. Nearly a third of dengue serology-positive cases and a fifth of JE serology-positive cases were co-positive for CHIKV. Interpretation & conclusions: Archival data from 2006-2011 and data from this study (2012-2017) indicated that UP experienced first CHIK outbreak in the decade in 2016, as part of a large-scale upsurge across northern India. CHIK should be considered as a differential diagnosis in patients presenting with fever of unknown origin or fever with rash or acute encephalitis, in addition to classical arthralgia.
Bilateral limb gangrene in an HIV patient due to vasculopathy: Managing the d...Ahmad Ozair
Patients with human immunodeficiency virus (HIV) have been reported to experience a spectrum of homeostatic dysregulation and resulting manifestations in their vascular system. This may be due to either disruption in the coagulation-anticoagulation pathways or due to damage to vessels from either HIV or other opportunistic infections. However, gangrene in an HIV-infected patient is an uncommon phenomenon. We herein report a case of a 30-year-old female, who had been taking antiretrovirals irregularly for 10 years, developing bilateral limb gangrene during her hospitalization for cryptococcal meningitis. Unfortunately, her condition continued to deteriorate and her attendants took her from the hospital against medical advice, with her death soon after. We illustrate how several biopsychosocial factors came together here to result in poor outcomes. To note, peripheral arterial disease (PAD) in HIV can rapidly lead to critical limb ischemia, resulting in limb gangrene. Aggravating risk factors for the same include smoking, poor glycemic control, and/or low CD4 T-cell count (<200 cells/mm3). General practitioners should be aware that HIV patients are far more prone to PAD than the normal population. Early recognition of at-risk patients, both medically and psychosocially, by family physicians is thus critical.
Anxiety, uncertainty, and resilience of medical students worldwide during the...Ahmad Ozair
The COVID-19 pandemic significantly impacted medical education worldwide. While healthcare professionals labored to ensure proper care for COVID-19 patients, medical students suffered from high rates of anxiety, uncertainty, burnout, and depressive symptoms. Whilst students in the pre-clinical phase of education faced disruption of didactic lectures and laboratory training, senior medical students faced uncertainty regarding their clinical rotations and internships, which are vital for practical exposure to healthcare. Several studies across the world demonstrated that clinical learning was significantly affected, with students in many countries completely cut off from in-person rotations. The disruption of the clinical curriculum coupled with a sense of failure to contribute at a time of significant need often led to despair. Reforms proposed and/or implemented by governments, medical advisory boards, medical schools, and other administrative bodies were felt to be insufficient by the medical student fraternity at large. Consequently, these students continue to face high rates of anxiety, depression, and a general sense of cynicism. In this student-authored perspective, we highlight the challenges faced by and the psychological impact on medical students directly or indirectly from the pandemic.
Scrub typhus (ST), a zoonotic disease, is currently being recognized as a significant contributor to the changing landscape of infectious diseases in India. As one of the important causes of febrile illness, in many parts of the country, general practitioners need to include it as part of the workup for cases of fever of unknown origin. While very amenable to early treatment with a simple regime of doxycycline, delayed diagnosis can result in a spectrum of complications. We report here one such complication of a case of ST manifesting with isolated lateral rectus palsy, which, to the best of our knowledge, has been reported only thrice in the world previously. Family physicians also need to be aware of the availability in India of affordable serological testing for ST that is useful for rapid and inexpensive diagnosis, leading to timely treatment.
Upsurge of chikungunya cases in Uttar Pradesh, IndiaAhmad Ozair
Background & objectives: Chikungunya (CHIK) re-emerged in India in 2006 after a gap of three decades. In Uttar Pradesh (UP), <100 confirmed cases per million were reported during this outbreak. Based on an upsurge of CHIK cases at UP, this retrospective study was conducted to investigate clinical and serological profile of CHIK cases in UP. Methods: A retrospective study was done on all clinically suspected CHIK cases that had been tested by ELISA for anti-CHIK virus IgM antibodies from September 2012 to December 2017. Based on clinical features, a subset of patients had earlier been tested serologically for dengue and Japanese encephalitis (JE). Results: Of the 3240 cases enrolled, 771 (23.8%) were seropositive. Patients had a range of clinical manifestations with seropositivity highest in those exhibiting arthralgia with fever (40%), followed by fever of unknown origin (FUO) (22%), encephalitis (13%) and fever with rash (12%). Cases (total, seropositive) increased over 20-fold in 2016 (1389, 412) and 2017 (1619, 341), compared to 2012-2015. Nearly a third of dengue serology-positive cases and a fifth of JE serology-positive cases were co-positive for CHIKV. Interpretation & conclusions: Archival data from 2006-2011 and data from this study (2012-2017) indicated that UP experienced first CHIK outbreak in the decade in 2016, as part of a large-scale upsurge across northern India. CHIK should be considered as a differential diagnosis in patients presenting with fever of unknown origin or fever with rash or acute encephalitis, in addition to classical arthralgia.
Bilateral limb gangrene in an HIV patient due to vasculopathy: Managing the d...Ahmad Ozair
Patients with human immunodeficiency virus (HIV) have been reported to experience a spectrum of homeostatic dysregulation and resulting manifestations in their vascular system. This may be due to either disruption in the coagulation-anticoagulation pathways or due to damage to vessels from either HIV or other opportunistic infections. However, gangrene in an HIV-infected patient is an uncommon phenomenon. We herein report a case of a 30-year-old female, who had been taking antiretrovirals irregularly for 10 years, developing bilateral limb gangrene during her hospitalization for cryptococcal meningitis. Unfortunately, her condition continued to deteriorate and her attendants took her from the hospital against medical advice, with her death soon after. We illustrate how several biopsychosocial factors came together here to result in poor outcomes. To note, peripheral arterial disease (PAD) in HIV can rapidly lead to critical limb ischemia, resulting in limb gangrene. Aggravating risk factors for the same include smoking, poor glycemic control, and/or low CD4 T-cell count (<200 cells/mm3). General practitioners should be aware that HIV patients are far more prone to PAD than the normal population. Early recognition of at-risk patients, both medically and psychosocially, by family physicians is thus critical.
Anxiety, uncertainty, and resilience of medical students worldwide during the...Ahmad Ozair
The COVID-19 pandemic significantly impacted medical education worldwide. While healthcare professionals labored to ensure proper care for COVID-19 patients, medical students suffered from high rates of anxiety, uncertainty, burnout, and depressive symptoms. Whilst students in the pre-clinical phase of education faced disruption of didactic lectures and laboratory training, senior medical students faced uncertainty regarding their clinical rotations and internships, which are vital for practical exposure to healthcare. Several studies across the world demonstrated that clinical learning was significantly affected, with students in many countries completely cut off from in-person rotations. The disruption of the clinical curriculum coupled with a sense of failure to contribute at a time of significant need often led to despair. Reforms proposed and/or implemented by governments, medical advisory boards, medical schools, and other administrative bodies were felt to be insufficient by the medical student fraternity at large. Consequently, these students continue to face high rates of anxiety, depression, and a general sense of cynicism. In this student-authored perspective, we highlight the challenges faced by and the psychological impact on medical students directly or indirectly from the pandemic.
BJS commission on surgery and perioperative care post covid-19Ahmad Ozair
Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues’ experiences and published evidence. Methods: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. Results: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. Conclusion: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.
Central Nervous System Histoplasmosis Related to Bioprosthetic Endocarditisasclepiuspdfs
Endocarditis caused by Histoplasma capsulatum is a rare occurrence. Involvement of the central nervous system by Histoplasma is also relatively uncommon. This paper reports a case of a 62-year-old woman with a past medical history significant for a myocardial infarct 5 years prior which necessitated coronary artery bypass graft surgery, prosthetic aortic valve replacement 4 years prior, and sarcoidosis, diagnosed 1 year prior, which was treated with methotrexate. She presented with fevers, generalized weakness, night sweats, and chest and throat pain. An echocardiogram done as part of her evaluation showed a vegetation on her prosthetic aortic valve. H. capsulatum was identified on blood cultures, and she was started on antibiotics. She expired shortly thereafter. At autopsy, a diagnosis of Histoplasma endocarditis was confirmed with evidence of embolic disease involving kidneys and digits of the hand. Hilar lymph nodes showed evidence of the fungus. Examination of the brain showed multiple widespread microscopic foci of macrophages, lymphocytes, and microglial cells with associated Histoplasma organisms, highlighted on Gomori methenamine silver staining. This paper will discuss central nervous system involvement by Histoplasma.
Dengue Fever-Related Cardiac manifestation in Ibn-Sina Hospital Mukalla, Hadh...asclepiuspdfs
This study was done to evaluate cardiac manifestation of dengue fever (DF) and it is severity in a patient admitted in Ibn-Sina Hospital Mukalla, Hadhramout. Materials and Methods: This study was done for patients admitted in the medical department during the dengue outbreak from November 2015 to February 2016. A total of 147 patients with a clinical diagnosis of DF, DF with warning signs (WD), and severe dengue were included in the study. Data were collected from patient’s files and cardiac assessment according to history and clinical examination and electrocardiogram, chest X-ray. Cardiac biomarkers and echocardiography were done in little cases
Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by
infection with group A Streptococcus. The long-term damage to cardiac valves caused by ARF,
which can result from a single severe episode or from multiple recurrent episodes of the illness, is
known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in
resource-poor settings around the world. Although our understanding of disease pathogenesis has
advanced in recent years, this has not led to dramatic improvements in diagnostic approaches,
which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed,
penicillin has been the mainstay of treatment for decades and there is no other treatment that has
been proven to alter the likelihood or the severity of RHD after an episode of ARF. Recent
advances — including the use of echocardiographic diagnosis in those with ARF and in screening
for early detection of RHD, progress in developing group A streptococcal vaccines
Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
Sinusitis and Immunodeficiency - IDF Conferencesinusblog
This is Dr. Andrew Pugliese's powerpoint on the connection between chronic sinusitis and immunodeficiencies. This was specifically for an educational conference for the Immune Deficiency Foundation.
Methods: Two groups were selected by non-probability random sampling technique including case group of 154 patients with
suspected dengue (fever>2days and <10days) and control group of 146 patients with febrile illness other than dengue. Clinical,hematological and serologic markers of cases and control groups were analyzed. The frequency distribution was used to compare categorical serologic markers and paired sample T test was applied for hematologic variables before and after treatment of dengue using SPSS version 21.
BJS commission on surgery and perioperative care post covid-19Ahmad Ozair
Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues’ experiences and published evidence. Methods: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. Results: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. Conclusion: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.
Central Nervous System Histoplasmosis Related to Bioprosthetic Endocarditisasclepiuspdfs
Endocarditis caused by Histoplasma capsulatum is a rare occurrence. Involvement of the central nervous system by Histoplasma is also relatively uncommon. This paper reports a case of a 62-year-old woman with a past medical history significant for a myocardial infarct 5 years prior which necessitated coronary artery bypass graft surgery, prosthetic aortic valve replacement 4 years prior, and sarcoidosis, diagnosed 1 year prior, which was treated with methotrexate. She presented with fevers, generalized weakness, night sweats, and chest and throat pain. An echocardiogram done as part of her evaluation showed a vegetation on her prosthetic aortic valve. H. capsulatum was identified on blood cultures, and she was started on antibiotics. She expired shortly thereafter. At autopsy, a diagnosis of Histoplasma endocarditis was confirmed with evidence of embolic disease involving kidneys and digits of the hand. Hilar lymph nodes showed evidence of the fungus. Examination of the brain showed multiple widespread microscopic foci of macrophages, lymphocytes, and microglial cells with associated Histoplasma organisms, highlighted on Gomori methenamine silver staining. This paper will discuss central nervous system involvement by Histoplasma.
Dengue Fever-Related Cardiac manifestation in Ibn-Sina Hospital Mukalla, Hadh...asclepiuspdfs
This study was done to evaluate cardiac manifestation of dengue fever (DF) and it is severity in a patient admitted in Ibn-Sina Hospital Mukalla, Hadhramout. Materials and Methods: This study was done for patients admitted in the medical department during the dengue outbreak from November 2015 to February 2016. A total of 147 patients with a clinical diagnosis of DF, DF with warning signs (WD), and severe dengue were included in the study. Data were collected from patient’s files and cardiac assessment according to history and clinical examination and electrocardiogram, chest X-ray. Cardiac biomarkers and echocardiography were done in little cases
Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by
infection with group A Streptococcus. The long-term damage to cardiac valves caused by ARF,
which can result from a single severe episode or from multiple recurrent episodes of the illness, is
known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in
resource-poor settings around the world. Although our understanding of disease pathogenesis has
advanced in recent years, this has not led to dramatic improvements in diagnostic approaches,
which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed,
penicillin has been the mainstay of treatment for decades and there is no other treatment that has
been proven to alter the likelihood or the severity of RHD after an episode of ARF. Recent
advances — including the use of echocardiographic diagnosis in those with ARF and in screening
for early detection of RHD, progress in developing group A streptococcal vaccines
Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
Sinusitis and Immunodeficiency - IDF Conferencesinusblog
This is Dr. Andrew Pugliese's powerpoint on the connection between chronic sinusitis and immunodeficiencies. This was specifically for an educational conference for the Immune Deficiency Foundation.
Methods: Two groups were selected by non-probability random sampling technique including case group of 154 patients with
suspected dengue (fever>2days and <10days) and control group of 146 patients with febrile illness other than dengue. Clinical,hematological and serologic markers of cases and control groups were analyzed. The frequency distribution was used to compare categorical serologic markers and paired sample T test was applied for hematologic variables before and after treatment of dengue using SPSS version 21.
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
IgA nephropathy is a condition characterized by deposition of IgA immunoglobulins in glomeruli. This condition is fairly common in Western countries. The scope of the disease is wide and case by case. Cases of IgA nephropathy are rare. Our case report is of a young man who developed rapid onset IgA nephropathy leading to end stage renal disease ESRD . This case report describes a 26 years age young man who presented and eventually presented with microscopic hematuria and severe proteinuria. Hemodialysis for his burned out IgA nephropathy. Dr. Thenmozhi. P | Yuvaraj. B "IgA Nephropathy (Burger's Disease): Case Report" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-7 | Issue-1 , February 2023, URL: https://www.ijtsrd.com/papers/ijtsrd52706.pdf Paper URL: https://www.ijtsrd.com/medicine/other/52706/iga-nephropathy-burgers-disease-case-report/dr-thenmozhi-p
Similar to Scrub typhus manifesting with intracerebral hemorrhage: Case report and review of literature (17)
Overseas Medical Students in Ukraine and War-Related Interruption in Educatio...Ahmad Ozair
Roy S#, Bhat V#, Ozair A# ***. Overseas Medical Students in Ukraine and War-Related Interruption in Education: Global Health Considerations from India. Annals of Global Health. 2022 Nov 3;88(1):98. doi: 10.5334/aogh.3926. ([Review Article], # Equal Contribution, PMID: 36380742, Available from: https://pubmed.ncbi.nlm.nih.gov/36380742)
COVID-19 Associated Mucormycosis in a Tertiary Care Hospital in India: A Case...Ahmad Ozair
Singh S, Basera P, Anand A, Ozair A. COVID-19 Associated Mucormycosis in a Tertiary Care Hospital in India: A Case Series. Cureus. 2022 Aug; 14(8): e27906. ([Case Report], PMID: 36110469, Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9464320/)
Inequities in Country and Gender Diversity-Based Authorship Representation in...Ahmad Ozair
Bhat V, Ozair A, Bellur S, Subash NR, Kumar A, Majumdar M, Kalra A***. Inequities in Country and Gender Diversity-Based Authorship Representation in Cardiology-Related Cochrane Reviews. JACC Advances. Published Online November 30, 2022. ([Research Letter], Available from: https://www.jacc.org/doi/10.1016/j.jacadv.2022.100140)
DNA Methylation and Histone Modification in Low-Grade Gliomas: Current Unders...Ahmad Ozair
Ozair A, Bhat V, Alisch RS, Khosla AA, Kotecha RR, Odia Y, McDermott MW, Ahluwalia MS***. DNA Methylation and Histone Modification in Low-Grade Gliomas: Current Understanding and Potential Clinical Targets. Cancers (Basel). 2023;15(4): 1342. ([Review Article], IF = 6.6, Available from: https://www.mdpi.com/2072-6694/15/4/1342)
Epidemiology and outcomes of hospital-acquired bloodstream infections in inte...Ahmad Ozair
Tabah A, Buetti N, Staiquly Q … EUROBACT-2 Study Group (including Ozair A). Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study. Intensive Care Medicine. 2023;1-13. doi:10.1007/s00134-022-06944-2. Published online 2023 Feb 10. (PMID: 36764959, I.F. = 41.7, Available from: https://link.springer.com/article/10.1007/s00134-022-06944-2)
The US Residency Selection Process After the United States Medical Licensing ...Ahmad Ozair
Ozair A, Bhat V, Detchou D. The US Residency Selection Process After the United States Medical Licensing Examination Step 1 Pass/Fail Change: Overview for Applicants and Educators. JMIR Medical Education. 2023;9: e37069. ([Review Article], PMID: 36607718, Available from: https://mededu.jmir.org/2023/1/e37069)
Workshop on Principles of Cancer Epidemiology 2018 Brochure - Christian Medic...Ahmad Ozair
Workshop on
Principles of Cancer Epidemiology.
October 11-13, 2018
Course offered by
Biostatistics Resource and Training Centre,
Clinical Epidemiology Unit,
Christian Medical College, Vellore, India.
In collaboration with the Department of Health Research Methods, Evidence, and Impact (previously Clinical
Epidemiology and Biostatistics) at McMaster University, Ontario, Canada, and the Division of Cancer Epidemiology
and Genetics at the National Cancer Institute, Maryland, United States.
This course’s main purpose is to impart foundational knowledge in
the principles and practice of cancer epidemiology, specifically in
the areas of cancer etiology, surveillance, and survival analysis. The
etiology module will cover the design, analysis, and interpretation
of observational studies. The surveillance module will contain an
overview of the infrastructure needed to conduct cancer
surveillance, aspects of data quality, and tools for using the data
(standardization, age-period-cohort models). Finally, the survival
analysis module will include material related to life tables, survival
curves, survival time models, and the application of survival analysis
to screening trials and evaluation.
Other topics that may be covered include: cancer etiology and
surveillance in the local Indian setting, sample size calculation, and
risk factor surveillance. An important aspect of this course will be
hands-on exercises using examples to understand the theory and its
applications in cancer epidemiology.
Casemix, management, and mortality of patients receiving emergency neurosurge...Ahmad Ozair
Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49).
State of Accredited Endovascular Neurosurgery Training in India in 2021: Chal...Ahmad Ozair
The incidence of stroke has seen over a 100% rise in low- and middle-income countries (LMICs), from 1970-1979 to 2000-2008, while it has stayed nearly the same or decreased in several high-income countries (HICs). However, it has been primarily in HICs that endovascular neurosurgery has evolved to become the standard of care in the management of stroke along with becoming a key modality for managing aneurysms, vascular malformations, carotid artery disease, amongst others. With 30 million individuals suffering from the aforementioned conditions and 7.3% of overall deaths due to stroke alone, India has a particularly high disease burden that can be tackled by neurointerventional therapies. Despite stroke being a leading cause of death and a public health priority in LMICs like India, provision of endovascular neurosurgical care is extremely scarce, both in its infrastructure and the number of trained subspecialist practitioners. This opinion piece utilizes the case scenario of India to highlight how the disparity of endovascular neurosurgical care exists in the face of excellent training and delivery of general neurosurgery and its other subspecialties and highlights key recommendations. One major reason, which this article focuses upon, is the near complete lack of accredited subspecialty training in endovascular care for neurosurgeons in India in 2021. Given that the majority of neurosurgery fellowships in India are currently non-accredited in nature, professional neurosurgical societies in LMICs will play a key role in supporting fellowship accrediting bodies. With the absolute dearth of dedicated neuroendovascular training during neurosurgery residency in developing countries, coupled with the unique and specific needs of this subspeciality, it will be the establishment of high-quality, accredited fellowships that would be crucial for having the framework for delivering endovascular care.
Percutaneous image-guided cryoablation of spinal metastases: A systematic reviewAhmad Ozair
Percutaneous cryoablation (PCA) is a minimally invasive technique that has been recently used to treat spinal metastases with a paucity of data currently available in the literature. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective or retrospective studies concerning metastatic spinal neoplasms treated with current generation PCA systems and with available data on safety and clinical outcomes were included. In the 8 included studies (7 retrospective, 1 prospective), a total of 148 patients (females = 63%) underwent spinal PCA. Tumors were located in the cervical (3/109 [2.8%], thoracic (74/109 [68.8%], lumbar (37/109 [33.9%], and sacrococcygeal (17/109 [15.6%] regions. Overall, 187 metastatic spinal lesions were treated. Thermo-protective measures (e.g., carbo-/hydro-dissection, thermocouples) were used in 115/187 [61.5%] procedures. For metastatic spinal tumors, the pooled mean difference (MD) in pain scores from baseline on the 0–10 numeric rating scale was 5.03 (95% confidence interval [CI]: 4.24 to 5.82) at a 1-month follow-up and 4.61 (95% CI: 3.27 to 5.95) at the last reported follow-up (range 24–40 weeks in 3/4 studies). Local tumor control rates ranged widely from 60% to 100% at varying follow-ups. Grade I-II complications were reported in 9/148 [6.1%] patients and grade III-V complications were reported in 3/148 [2.0%]) patients. PCA, as a stand-alone or adjunct modality, may be a viable therapy in appropriately selected patients with painful spinal metastases who were traditionally managed with open surgery and/or radiation therapy.
Pediatric Brain Tumors: From Modern Classification System to Current Principl...Ahmad Ozair
Central nervous system (CNS) malignancies contribute significantly to the global burden of cancer. Brain tumors constitute the most common solid organ tumors in children and the second most common malignancies of childhood overall. Accounting for nearly 20% of all pediatric malignancies, these are the foremost cause of cancer-related deaths in children 0-14 years of age. This book chapter provides a state-of-the-art overview of pediatric brain tumors. It discusses their morbidity and mortality and introduces the WHO 2021 classification of CNS tumors, which is critical to therapeutic decision-making. It then describes the modern understanding of tumor grading and its clinical implications, followed by the general principles of diagnosis and management. The chapter then discusses, in detail, those brain tumors which have the highest disease burden in children, including medulloblastoma, astrocytoma, ependymoma, schwannoma, meningioma, amongst others. The landscape of treatment of pediatric brain tumors has been rapidly evolving, with several effective therapies on the horizon.
Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare ManifestationAhmad Ozair
We here present a case of scrub typhus (ST) manifesting with hemiparesis, which, to the best of our knowledge, has been reported few times prior. ST typically presents with headache, fever, cough, dyspnoea, and/or gastrointestinal symptoms. Early treatment ensures swift improvement. However, this common cause of febrile illness is often overlooked, even in endemic regions. This is due to a nonspecific presentation, low index of suspicion, and lack of diagnostic facilities. Even our institution, an apex public referral center of northern India, lacked affordable testing a decade ago. After testing began, a significant number of cases, which would have previously been labeled as “fever of unknown origin,” were found to be of ST and confirmed by response to doxycycline.
Large Cerebral Infarction in Tuberculous Meningitis: Case Report of an Uncomm...Ahmad Ozair
We here present an illustrative case of tuberculous meningitis (TBM) with a rare complication of large cerebral infarction. TBM is the most common type of chronic CNS infection in developing countries.[1] Strokes occur in 15–57% of TBM cases; mostly being associated with advanced illness.[2] An 18-year-old male was brought to a tertiary care centre in northern India with high-grade fever and headache for 3 months; followed by right-sided bodily weakness and inability to speak, for a week. He was conscious, having neck rigidity, positive Kernig's sign, global aphasia, and hemiplegia. Brain MRI suggested basal exudates, hydrocephalus, and tuberculoma in the left cerebellar hemisphere. Diffusion-weighted imaging indicated large infarct involving anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories [Figure 1]. Guarded lumbar puncture was done in view of focal deficit and mass effect. CSF analysis revealed protein 3.5 g/L, glucose 1.66 mmol/L (blood glucose 7.2 mmol/L), leukocyte count of 250 with lymphocytosis, and positive Gene Xpert MTB/RIF assay. He was started on first-line anti-tuberculosis therapy (ATT), steroids, and aspirin. After 3 months, his fever and headache had improved but he still had hemiparesis and aphasia, confirming the diagnosis of grade 3 TBM. After 12 months of ATT coverage and follow-up, his motor function had improved with some residual deficits.
Letter: Is the Stupp Protocol an expensive and unsustainable standard of care...Ahmad Ozair
Glioblastoma multiforme (GBM) is the most common and aggressive primary adult brain neoplasm with an age-adjusted incidence rate of 3.22 per 100 000 individuals and a 5-yr survival rate of 6.8%.1 In 2005, Stupp and colleagues proposed maximal safe resection, concomitant temozolomide (TMZ) with radiotherapy, and adjuvant TMZ as the optimal treatment. Implementation of the Stupp protocol in high-income countries (HICs) has resulted in increased survival compared to previous regimens. With little-to-no literature on the management and outcomes of patients with GBM in low- and middle-income countries (LMICs), it is unclear whether the Stupp protocol is being adopted or whether it is, or ever can be, the optimal strategy in LMICs...
Learning to practice medicine during COVID-19 and mucormycosis epidemics: an ...Ahmad Ozair
The COVID-19 pandemic has greatly affected medical education and training experiences for interns and resident doctors. As medical schools shifted their teaching curriculum to virtual platforms, most senior medical students lacked sufficient clinical exposure as they missed out on in-hospital rotations before beginning their intern year. In this article, we share our experience in transitioning from medical school to our intern year while working in COVID and non-COVID facilities. We discuss our challenges while learning basic skills in a resource-limited setting during a period of high patient mortality because of COVID-19 and Mucormycosis.
Medical Students in Global Neurosurgery: Rationale and RoleAhmad Ozair
Approximately 5 million essential neurosurgical cases are unmet each year, all in low- and middle-income countries (1). After the Lancet Commission on Global Surgery described the absence of global surgery from global health discourse in January 2014 (2), the field of neurosurgery quickly recognized the importance of increasing equity in care globally (3-5). Although existing initiatives in global neurosurgery have focused on neurosurgeons and trainees, medical students represent a promising group for sustainable long-term engagement. We characterize why medical students are fundamental to success, outline the importance of incorporating medical students, and delineate how to increase medical student interest and participation in global neurosurgery.
Impaled roadside guardrail in the neck: Case of a failed motorcycle stuntAhmad Ozair
Trauma is currently the leading cause of death in the age group 15 to 44 years globally, with road trauma now representing the sixth leading cause of death worldwide. We present a case of a young male, who was brought to the apex trauma centre of the province with a metallic roadside guardrail impaled in his neck up to his oral cavity, which had to be cut to transport him to the hospital. A meticulous local exploration resulted in the successful removal of the spiked guardrail, with no damage to critical structures. We discuss the paradigm changes in and the expertise required for the management of such penetrating neck injuries (PNIs). For family physicians, this case represents one of the wide variety of cases they will be called to help upon and administer prehospital care. Thus, utilization of principles of basic life support, recognition of the severity of road trauma cases, and ensuring urgency of referral by general practitioners are all critical.
Why are India’s Best Medical Graduates not Preferring ENT for Postgraduate Tr...Ahmad Ozair
The first-round seat allotment data of the National Eligibility-cum-Entrance Test-Post Graduation (NEET-PG) 2020 was published in April 2020 [1]. Apart from a few institutions having their own selection processes, this competitive examination has acted as the sole entrance to the majority of residency positions in India, since NEET-PG 2017. Additionally, since NEET-PG 2019, ranks here have served as the basis of Diplomate of National Board (DNB) counseling, adding even more significance to the outcomes of this exam. As of 2020, there are 299 institutions in India imparting the training and degree of Master of Surgery in Otorhinolaryngology [MS (ENT)] across 1151 seats [2]. We note with concern that students with the highest all-India ranks (AIRs) in the NEET-PG, a metric that only takes examination score into account, have continued to completely forsake ENT, similar to the previous years (Fig. 1). Amongst top-100 AIRs, not a single student chose ENT, as has been true for the past years. Over 89% of the top-100 AIRs this year gravitated towards ‘medical’ specialties. Similarly, amongst the top-500 AIRs, only one examinee chose ENT, with 78.8% of candidates preferring these four ‘medical’ fields: internal medicine, radio-diagnosis, pediatrics, and dermatology. Even amongst the top-2000 AIRs, merely four candidates chose ENT [1].
Academic quality of incoming ophthalmology residents in India: Concerns for t...Ahmad Ozair
We note with concern, for ophthalmology, the results of round-1 seat allotment for National Eligibility-cum-Entrance Test—Post-Graduation (NEET-PG) 2020, declared in April 2020.[1] Except for a few institutions, all-India ranks (AIRs) on the NEET-PG perform as the sole admission criterion to the majority of residency positions in India, and thereby to a career as specialist. Top rankers here represent the finest candidates offered by our medical education system. Currently, India has 1616 MD/MS, 103 Diploma, and 292 DNB (post-MBBS) positions for ophthalmology training.[2] Unfortunately, top AIRs have continued to ignore ophthalmology, as per last available data since NEET-PG 2017, when the exam began. In 2020, not a single examinee under-100 AIR chose ophthalmology, while seven of top-10 AIRs picked general medicine.[1] Similarly, no more than 2 in top-500 AIR and 10 in top-1000 AIR in each year have chosen ophthalmology. This year also saw the least number of candidates in both top-2500 and top-5000 AIRs choosing ophthalmology [Figure 1].
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. Kotwal, et al.: Scrub typhus manifesting with intracerebral hemorrhage
Journal of Family Medicine and Primary Care 2536 Volume 9 : Issue 5 : May 2020
K+
3.4 mmol/L, hemoglobin 10.6 g/dL, total leucocyte count
(TLC) 21,100 cells/mm3
, platelet count 1.04 lakhs/mm3
,
serum bilirubin 0.9 mg/dL, aspartate aminotransferase (AST)
97.16 IU/L, alanine aminotransferase (ALT) 72.28 IU/L, blood
urea nitrogen (BUN) 25.27 mg/dL, serum creatinine 2.1 mg/dL,
serum albumin 2.53 mg/dL, international normalized ratio (INR)
2.1, procalcitonin 2.54 ng/mL, creatinine kinase‑MB 2.05 IU/L,
and myoglobin 135.7 ng/mL. Abdominal ultrasonography (USG)
had revealed hepatosplenomegaly with mild ascites, with
2D‑echocardiography demonstrating a left ventricular ejection
fraction of 61%. The patient had been intubated and shifted
to ICU. He had then developed acute respiratory distress
syndrome (ARDS), stage‑3 acute kidney injury (AKI) requiring
four hemodialyses, and septic shock. Disseminated intravascular
coagulation (DIC), however, was not present. He had then been
diagnosed with multi‑organ dysfunction syndrome (MODS) for
which the hospital did an extensive workup, but could not locate
the etiology. After a week of mechanical ventilation, correction
of hemodynamic status, and broad‑spectrum antimicrobial
administration, the patient had stabilized enough to have an MRI
of the brain performed. Unfortunately, it revealed a resolving
intracerebral hematoma in the left temporal lobe [Figure 1],
although the patient had no history of hypertension nor had any
abnormal coagulation studies and/or platelet counts, throughout
this illness. Upon this discovery, the private hospital promptly
referred the patient to a higher center. At our institution,
we continued ventilatory support, intensive monitoring,
neuroprotective strategies, mannitol, and wide‑spectrum
antimicrobial administration, while investigating with a broad
differential. As part of the institutional protocol for workup of
complicated febrile illness, a broad panel of serologic testing
was done, which found him found positive only for anti‑ST IgM
antibody. He was negative for HIV, hepatitis B surface antigen,
hepatitis C, anti‑Japanese encephalitis IgM antibody, real‑time
PCR for HSV‑1, anti‑chikungunya IgM antibody, anti‑dengue
IgM antibody, and malaria rapid test. On lumbar puncture, the
CSF sample was xanthochromic, having 10–15 erythrocytes/high
power field (HPF), CSF glucose of 80 mg/dL (corresponding
serum glucose of 124 mg/dL), protein 462 mg/dL, cell count
of 60/mm3
with 95% lymphocytes, and negative Gram staining,
and Ziehl‑Neelsen staining.
However, despite administering intravenous doxycycline,
progressive multi‑organ dysfunction syndrome (MODS) brought
about his death after five days of ICU stay, primarily due to
worsening renal function and severe respiratory acidosis.
Discussion
At our public referral hospital, we regularly receive referred
patients with such “pyrexia of unknown origin (PUO)” with
extensive workup having occurred outside yet a lack of diagnosis.
From 2015, after the introduction of the inexpensive and rapid ST
serology kit in India, we have found, like many other north Indian
academic medical institutions, a considerable number of PUO
cases to have been positive for ST, as in this case. Unfortunately,
most ST patients that are referred to us are found to not have been
ever worked‑up for ST. We are also finding significant neurological
complications of ST, which can occur in 14–83% of cases,[9]
and
which unfortunately are preventable with opportune treatment.
This is due to the delayed administration of doxycycline, as in this
case, which resulted from not having been tested for ST.
A comprehensive review of the MEDLINE database and
searching of reference lists suggests that only nine such cases
have been reported prior to the literature in the English language,
whose salient features have been summarized in Table 1. However,
we do acknowledge that given ST is rampant in Asia, such cases
may also have been reported in Chinese, Korean, or Japanese
languages, which we were unable to account for due to logistical
challenges. In this case, intracerebral hemorrhage, with normal
coagulation studies and normotension, may have been due to
either uremic platelet dysfunction or due to pre‑existing cerebral
aneurysms. While the patient had expired prior to performing any
angiographic study, poor autopsy protocols at our institution, as is
common in India, also resulted in failure to identify any aneurysms.
In comparison, most prior case reports had reported a state of
deranged coagulation profile, DIC, and/or HLH.
For family physicians in India, ST now should be considered an
important contributor to the changing landscape of infectious
diseases. Presenting nonspecifically, it can wreak havoc if not
tested for and thereby not diagnosed early. Such testing will
occur routinely when ST is kept as a differential for workup
Figure 1: Resolving intracerebral hemorrhage in left temporal lobe
seen on (a) axial FLAIR imaging, (b) axial T2‑weighted image,
(c) axial diffusion‑weighted imaging, and (d) left parasagittal
T2‑weighted imaging
d
c
b
a
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3. Kotwal, et al.: Scrub typhus manifesting with intracerebral hemorrhage
Journal of Family Medicine and Primary Care 2537 Volume 9 : Issue 5 : May 2020
of undifferentiated acute febrile illness. General practitioners
and private hospitals urgently need to be made aware of the
significance of early and affordable serological testing to prevent
complications of ST.[9]
It is also to be recognized that IgM
ELISA‑based testing and SD Bioline rapid testing have been
found to have over a 97% correlation in India.[10]
Statement of human rights
All ethical procedures were duly followed and informed consent
was taken. The patient cannot be identified by any part of the
text or image.
Acknowledgments
Nil.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient (s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and
due efforts will be made to conceal their identity, but anonymity
cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Yang SH, Wang LH, Liang CC, Ho YH, Chang ET, Cheng CH.
Scrub typhus complicated by intracranial hemorrhage‑A
case report. Tzu Chi Med J 17:111‑4.
2. Lin YH, Lin YH, Shi ZY. A case report of scrub
typhus‑associated hemophagocytic syndrome and a review
of literature. Jpn J Infect Dis 2014;67:115‑7.
3. Chung JH, Yun NR, Kim DM, Lee JW, Yoon SH, Kim SW.
Scrub typhus and cerebrovascular injury: A phenomenon
of delayed treatment? Am J Trop Med Hyg 2013;89:119‑22.
4. Kim HC, Yoon KW, Yoo DS, Cho CS. Hemorrhagic
transformation of scrub typhus encephalitis: A rare entity.
Clin Neuroradiol 2015;25:415‑8.
5. Sood S, Sharma S, Khanna S. Role of advanced MRI brain
sequences in diagnosing neurological complications of
scrub typhus. J Clin Imaging Sci 2015;5:11.
6. Neyaz Z, Bhattacharya V, Muzaffar N, Gurjar M. Brain MRI
findings in a patient with scrub typhus infection. Neurol
India 2016;64:788‑92.
7. Kalita J, Mani VE, Bhoi SK, Misra UK. Spectrum and outcome
of acute infectious encephalitis/encephalopathy in an
intensive care unit from India. QJM 2017;110:141‑8.
8. Tuteja V, Nawal CL, Singh A, Chejara RS, Singh R. Intracranial
haemorrhage: A rare manifestation of scrub typhus. J Med
Sci Clin Res 2018;6:948‑51.
9. Mahajan SK, Mahajan SK. Neuropsychiatric manifestations
of scrub typhus. J Neurosci Rural Pract 2017;8:421‑6.
10. Pathania M, Amisha, Malik P, Rathaur VK. Scrub typhus:
Overview of demographic variables, clinical profile, and
diagnostic issues in the sub‑Himalayan region of India and
its comparison to other Indian and Asian studies. J Family
Med Prim Care 2019;8:1189‑95.
Table 1: Prior reported cases of scrub typhus with intracerebral hemorrhage in the English language and the current
case
Author (Year) Age (years), sex of
patient
Eschar present
(yes/no)
Location of intracerebral
hemorrhage
Antimicrobial
given
Associated complications
Yang et al.[1]
(2005)
56, M Yes, left scrotum Left thalamic area Tetracycline DIC, thrombocytopenia
Lin et al.[2]
(2013)
34, F No Unreported Mino-cycline HLH, DIC, multi-organ failure, death
Chung et al.[3]
(2013)
53, F Yes, left axilla Right cerebral hemisphere Rifampin None (patient cured)
Kim et al.[4]
(2014)
53, F Yes, right ear Right cerebellum Doxycycline
Subarachnoid and intraventricular
hemorrhage
Sood et al.[5]
(2015)
18, F
Yes, right pubic
region
Micro-hemorrhages in corpus
callosum, subcortical white
matter
Azithromycin Loss of consciousness
Neyaz et al.[6]
(2016)
55, M No Right frontal opercular region Doxycycline
Refractory septic shock, ARDS, DIC,
multi-organ failure
Kalita et al.[7]
(2017)
Unreported (case was a part of large descriptive ICU study of infectious encephalopathy/encephalitis)
Tuteja et al.[8]
(2018)
53, F No Frontal lobar region
Doxycycline +
azithromycin
Subarachnoid hemorrhage, severe
thrombocytopenia
Tuteja et al.[8]
(2018)
26, M No Left frontoparietal lobe
Doxycycline +
azithromycin
Intraventricular hemorrhage
Current case 28, M No Left temporal lobe Doxycycline
Subarachnoid hemorrhage, multi-
organ failure, death
HLH: hemophagocytic lymphohistiocytosis; DIC: disseminated intravascular coagulation; M: male; F: female
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