We report a case of subcutaneous panniculitis-like T-cell lymphoma (SPTCL) in a young man presenting with fever and facial swelling. He had pancytopenia and hemophagocytic syndrome (HPS) on evaluation. The histopathological examination of skin punch biopsy from the face and chest wall showed SPTCL. Given the associated HPS, he was started on steroid and multidrug chemotherapy following which he had symptomatic improvement.

Acute cerebellar ataxia (ACA) is a self-limited syndrome that is frequently post-infectious, most commonly following Varicella infection having an autoimmune mechanism. ACA is the commonest cause of childhood ataxia. We report a 14-year-old male who presented with acute onset wide-based gait and slurring of speech with dysdiadochokinesia, incoordination of voluntary movements, pendular knee jerk, and intentional tremors. He had worsening transaminitis and rising bilirubin during his hospital course and was subsequently found to be hepatitis A virus (HAV) immunoglobulin-M antibody positive. Thus, we report a case of ACA with HAV infection who developed jaundice after three weeks of onset of ataxia, a rarity that has not been reported so far in medical literature.

Objectives: Eosinophilia is a prevalent laboratory abnormality that we encounter in day-to-day practice both in outpatient and inpatient settings. The causes range from primary to secondary spanning from an allergic response to clonal neoplastic proliferations. Identifying an etiology may be challenging in many cases and may sometimes require extensive evaluation. We aimed to find the clinical and etiological profile of patients with eosinophilia and the association of eosinophilia with end-organ involvement and IgE levels. Material and Methods: The study was designed as a cross-sectional study over a period of two years (2019 to 2020). The study setting was outpatient and inpatient medical wards of a tertiary care center in north India. A detailed history and clinical examination were done on patients with eosinophilia detected in blood counts. Standard diagnostic protocols guided by positive clinical and diagnostic tests were followed to find etiologies in patients with eosinophilia. Results: In our study, the most common cause overall and in each category of eosinophilia was parasitic infections (35%) followed by allergic disorders (29.3%). The most frequent symptoms were cough (32%), generalized weakness (25.5%), dyspnoea (24%), and a history suggestive of atopy (21%). On clinical examination, the most common finding was rhonchi or wheeze (24.5%). The most commonly affected end-organ was the lungs (13.2%) followed by the skin (4.7%). Conclusion: Parasitic infections are the most common cause of eosinophilia in our population. IgE levels correlate with a diagnosis of atopy or asthma and do not show a correlation with AEC. The lungs were the most frequently involved as end-organ in eosinophilia followed by the skin. We found no significant association between end-organ involvement and the degree of eosinophilia which highlights the importance of working up symptomatic patients for end-organ damage irrespective of the eosinophil count.

Background: The coronavirus disease 2019 (COVID-19) pandemic has reached a staggering number of almost 280 million cases worldwide, with over 5.4 million deaths as of 29 December 2021. A further understanding of the factors related to the household spread of the infection might help to bring about specific protocols to curb such transmission. Objective: This study aims to find the secondary attack rate (SAR) and factors affecting SAR among the households of mild COVID-19 cases. Methods: An observational study was designed where data of patients admitted at All India Institute of Medical Sciences, New Delhi due to mild COVID-19 were collected, and outcome was noted after the discharge of the patient. Index cases who were the first in the household to have a positive infection only were included. Based on these data, the overall household SAR, factors related to the index case and contacts that affected transmissibility were noted. Results: A total of 60 index cases having contacts with 184 household members were included in the present study. The household SAR was measured to be 41.85%. At least one positive case was present in 51.67% households. Children below 18 years old had lower odds of getting a secondary infection compared to adults and elderly [odds ratio (OR) = 0.46, 95%CI = 0.22-0.94, p = 0.0383). An exposure period of more than a week was significantly associated with a higher risk of infection (p = 0.029). The rate of transmissibility drastically declined with effective quarantine measures adopted by the index case (OR = 0.13, 95%CI = 0.06-0.26, p < 0.00001). Symptomatic index cases contributed more to the SAR than asymptomatic primaries (OR = 4.74, 95%CI = 1.03-21.82, P = 0.045). Healthcare worker index cases had lower rates of spread (OR = 0.29, 95%CI = 0.15-0.58, P = 0.0003). Conclusion: The high SAR shows the household is a potential high-risk unit for transmissibility of COVID-19. Proper quarantine measures of all those exposed to the index case can mitigate such spread and lead to reduction of risk of COVID-19 within a household.

The aim of the study was to study the neurological manifestation in the patients with coronavirus disease 2019 (COVID-19).

AbstractThere is paucity of evidence related to mechanical ventilation in the general ward setting. We aimed to study the clinico-etiological profile, outcomes and prognostic factors of patients receiving invasive mechanical ventilation in non-ICU (ward) setting, and compare these parameters with that of patients in the ICU, wherever it was reported. A systematic review and meta-analysis was done on articles published till June 2020. Two authors independently extracted the data. The study population included patients who received mechanical ventilation in ward setting. Fourteen studies reporting on 20833 patients were included (20252 exclusively ventilated in ward), with most of the studies being from Israel, USA, Japan and Taiwan. Risk of bias was estimated using the Newcastle-Ottawa Scale for observational studies, and was found to be low. Most common reason for intubation was respiratory illness. Most common variables predicting mortality were prognostic scores like APACHE-II and Acute Physiology Score (APS). Pooled mortality rate in ward across 6 studies was 0.72 (95% CI 0.69-0.74) with no heterogeneity among these 6 studies (I2=0.0). Mortality rate varied significantly with study population characteristics, and was lower among patients being weaned in ward. A major limitation of our study was the paucity of studies and significant heterogeneity among existing studies, with respect to outcomes like duration of ventilation, hospital stay, rates of complications, and prognostic factors. This systematic review and meta-analysis found that mortality among patients receiving invasive mechanical ventilation in ward settings remains high. Data regarding other outcomes and prognostic factors predicting mortality was very heterogeneous highlighting the need for future studies concentrating specifically on these aspects.Systematic review registration: PROSPERO 2020 (CRD42020166775)

BackgroundPatients with COVID-19 can develop acute respiratory distress syndrome (ARDS), which is associated with high mortality. The aim of this study was to examine the functional and morphological features of COVID-19-associated ARDS and to compare these with the characteristics of ARDS unrelated to COVID-19.MethodsThis prospective observational study was done at seven hospitals in Italy. We enrolled consecutive, mechanically ventilated patients with laboratory-confirmed COVID-19 and who met Berlin criteria for ARDS, who were admitted to the intensive care unit (ICU) between March 9 and March 22, 2020. All patients were sedated, paralysed, and ventilated in volume-control mode with standard ICU ventilators. Static respiratory system compliance, the ratio of partial pressure of arterial oxygen to fractional concentration of oxygen in inspired air, ventilatory ratio (a surrogate of dead space), and D-dimer concentrations were measured within 24 h of ICU admission. Lung CT scans and CT angiograms were done when clinically indicated. A dataset for ARDS unrelated to COVID-19 was created from previous ARDS studies. Survival to day 28 was assessed.FindingsBetween March 9 and March 22, 2020, 301 patients with COVID-19 met the Berlin criteria for ARDS at participating hospitals. Median static compliance was 41 mL/cm H2O (33–52), which was 28% higher than in the cohort of patients with ARDS unrelated to COVID-19 (32 mL/cm H2O [25–43]; p<0·0001). 17 (6%) of 297 patients with COVID-19-associated ARDS had compliances greater than the 95th percentile of the classical ARDS cohort. Total lung weight did not differ between the two cohorts. CT pulmonary angiograms (obtained in 23 [8%] patients with COVID-19-related ARDS) showed that 15 (94%) of 16 patients with D-dimer concentrations greater than the median had bilateral areas of hypoperfusion, consistent with thromboembolic disease. Patients with D-dimer concentrations equal to or less than the median had ventilatory ratios lower than those of patients with D-dimer concentrations greater than the median (1·66 [1·32–1·95] vs 1·90 [1·50–2·33]; p=0·0001). Patients with static compliance equal to or less than the median and D-dimer concentrations greater than the median had markedly increased 28-day mortality compared with other patient subgroups (40 [56%] of 71 with high D-dimers and low compliance vs 18 [27%] of 67 with low D-dimers and high compliance, 13 [22%] of 60 with low D-dimers and low compliance, and 22 [35%] of 63 with high D-dimers and high compliance, all p=0·0001).InterpretationPatients with COVID-19-associated ARDS have a form of injury that, in many aspects, is similar to that of those with ARDS unrelated to COVID-19. Notably, patients with COVID-19-related ARDS who have a reduction in respiratory system compliance together with increased D-dimer concentrations have high mortality rates.FundingNone.

We report a rare case of cardiac angiosarcoma in a young boy who presented with cardiac tamponade. His initial symptoms were non-specific. He was initially being managed in the line of fungal infection, with a possibility of malignancy. Cardiac imaging was also not conclusive and he worsened on antibiotics and antifungals and succumbed to the illness. After his death tissue biopsy from heart and lung was done and histopathological examination revealed the diagnosis of metastatic angiosarcoma. The case highlights the importance of considering the diagnosis of cardiac angiosarcoma in the patients presenting with haemorrhagic pericardial effusion and non-specific symptoms.

Internal Medicine JournalVolume 51, Issue 9 p. 1545-1546 Letter to the Editor ‘Locked-in’ despite slow treatment: pontine and extrapontine demyelination in hypernatraemic encephalopathy Ananthu Narayan, Ananthu Narayan Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this authorUmang Arora, Umang Arora orcid.org/0000-0002-4366-0776 Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this authorPrerna Garg, Prerna Garg orcid.org/0000-0002-6589-2754 Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this authorPrayas Sethi, Corresponding Author Prayas Sethi prayassethi82@gmail.com Department of Medicine, All India Institute of Medical Sciences, Delhi, India Correspondence Prayas Sethi, Department of Medicine, All India Institute of Medical Sciences,3rd floor teaching block, AIIMS, Ansari Nagar, Delhi, India-110029. Email: prayassethi82@gmail.comSearch for more papers by this authorArvind Kumar, Arvind Kumar Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this authorNaveet Wig, Naveet Wig Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this author Ananthu Narayan, Ananthu Narayan Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this authorUmang Arora, Umang Arora orcid.org/0000-0002-4366-0776 Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this authorPrerna Garg, Prerna Garg orcid.org/0000-0002-6589-2754 Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this authorPrayas Sethi, Corresponding Author Prayas Sethi prayassethi82@gmail.com Department of Medicine, All India Institute of Medical Sciences, Delhi, India Correspondence Prayas Sethi, Department of Medicine, All India Institute of Medical Sciences,3rd floor teaching block, AIIMS, Ansari Nagar, Delhi, India-110029. Email: prayassethi82@gmail.comSearch for more papers by this authorArvind Kumar, Arvind Kumar Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this authorNaveet Wig, Naveet Wig Department of Medicine, All India Institute of Medical Sciences, Delhi, IndiaSearch for more papers by this author First published: 19 September 2021 https://doi.org/10.1111/imj.15475Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume51, Issue9September 2021Pages 1545-1546 RelatedInformation

Background & objectives: In the present scenario, the most common sample for diagnosis of COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) is nasal and throat swab (NTS). Other sampling options such as gargle lavage have found limited application in clinical use mostly because of unavailability of an appropriate gargling liquid. This study was conducted to assess the stability of SARS-CoV-2 RNA in normal saline at 4°C that can serve as a gargling liquid as well as a transport medium. The study also looked at the agreement between NTS and gargle lavage/saliva for the detection of SARS-CoV-2. Methods: In 29 consecutive real-time RT-PCR (rRT-PCR) positive COVID-19 patients, paired NTS, gargle and saliva samples were taken. Samples were processed by rRT-PCR for the detection of SARS-CoV-2 RNA. To assess the SARS-CoV-2 RNA stability in normal saline, gargle lavage specimens were divided into two aliquots; one subset of the specimen was run within 4-6 h along with the routine samples (NTS and saliva) and the other subset was stored at 4°C and processed after 24-30 h. Agreement between cycle threshold (Ct) values from both the runs was compared using Bland–Altman (BA) analysis. Results: The positivity rates of rRT-PCR in NTS, saliva and gargle lavage samples were 82.7 (24/29), 79.3 (23/29) and 86.2 per cent (25/29), respectively. BA plot showed a good agreement between the Ct values of fresh and stored gargle samples, stipulating that there were no significant differences in the approximate viral load levels between the fresh and stored gargle lavage samples (bias: E gene −0.64, N gene −0.51, ORF gene −0.19). Interpretation & conclusions: Our study results show stability of SARS-CoV-2 RNA in the gargle samples collected using normal saline up to 24-30 h. Gargle lavage and saliva specimen collection are cost-effective and acceptable methods of sampling for the detection of SARS-CoV-2 RNA by rRT-PCR. These simplified, inexpensive and acceptable methods of specimen collection would reduce the cost and workload on healthcare workers for sample collection.