Avinash Agrawal

Incidence, risk stratification, antibiogram of pathogens isolated and clinical outcome of ventilator associated pneumonia

Background: The initial empirical therapy of Ventilator Associated Pneumonia (VAP) modified based on the knowledge of local microbiological data is associated with decreased morbidity and mortality. The objective was to find the incidence and risk factors associated with VAP, the implicated pathogens and their susceptibility pattern as well as to assess the final clinical outcome in VAP. Materials and Methods: This was a prospective cohort study of 107 patients taken on ventilatory support for two or more days and those not suffering from pneumonia prior were to be taken on ventilator. The study was done over a period of one year. VAP was diagnosed using clinical pulmonary infection score of >6. The mortality, incidence of VAP, frequency of different pathogens isolated, their antibiotic sensitivity pattern, duration of mechanical ventilation and duration of hospital stay were assessed. Statistical Analysis: Univariate analysis, χ2 test and paired t-test. Results: The incidence of VAP was 28.04%. Mortality in VAP group was 46.67%, while in the non-VAP group was 27.28%. High APACHE II score was associated with a high mortality rate as well as increased incidence of VAP. The most common organisms isolated from endotracheal aspirate of patients who developed VAP were Pseudomonas aeruginosa, Methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae and Acinetobacter baumannii. Most strains of Pseudomonas (55.56%) were resistant to commonly used beta-lactam antibiotics known to be effective against Pseudomonas. All strains of Staphylococcus aureus were MRSA and most isolates of K. pneumoniae (85.71%) were extended-spectrum beta-lactamase producing. About 50% isolates of Acinetobacter were resistant to carbapenems. Mortality was highest for infections caused by A. baumannii (83.33%) and K. pneumoniae (71.42%). Conclusions: APACHE II score can be used to stratify the risk of development of VAP and overall risk of mortality. Drug-resistant strains of various organisms are an important cause of VAP in our setting.

Drug-resistant tuberculous meningitis

Drug-resistant tuberculosis, including drug-resistant tuberculous meningitis, is an emerging health problem in many countries. An association with Beijing strains and drug resistance-related mutations, such as mutations in katG and rpoB genes, has been found. The pathology, clinical features and neuroimaging characteristics of drug-resistant tuberculous meningitis are similar to drug-responsive tuberculous meningitis. Detection of mycobacteria in cerebrospinal fluid (CSF) by conventional methods (smear examination or culture) is often difficult. Nucleic acid amplification assays are better methods owing to their rapidity and high sensitivity. The Xpert® MTB/RIF assay (Cepheid, CA, USA) is a fully-automated test that has also been found to be effective for CSF samples. Treatment of multidrug-resistant tuberculous meningitis depends on the drug susceptibility pattern of the isolate and/or the previous treatment history of the patient. Second-line drugs with good penetration of the CSF should be preferred. Isoniazid monoresistant disease requires addition of another drug with better CSF penetration. Drug-resistant tuberculous meningitis is associated with a high mortality. HIV infected patients with drug-resistant tuberculous meningitis have severe clinical manifestations with exceptionally high mortality. Prevention of tuberculosis is the key to reduce drug-resistant tuberculous meningitis.

Comparative study of effectiveness of Pap smear versus visual inspection with acetic acid and visual inspection with Lugol's iodine for mass screening of premalignant and malignant lesion of cervix

Background and Objective: Cancer of the cervix is a leading cause of morbidity and mortality among women worldwide. Therefore, to curb the disease, there is a need to develop a screening test that has good sensitivity and specificity. The present study is aimed to compare the effectiveness of the Pap smear, visual inspection with acetic acid (VIA) and visual inspection with Lugols iodine (VILI) for mass screening of premalignant and malignant lesions of the cervix; to evaluate the usefulness of VIA and VILI as an adjunct to improve sensitivity of cervical cytology; and to evaluate the role of VILI as a parallel screening method with VIA to enhance its test performance. Design and Setting: This was a prospective, analytical study in which 210 patients of the reproductive age group attending the gynecology OPD were enrolled. Patients and Methods: Patients were first subjected to Pap smear followed by VIA, VILI, colposcopy and biopsy for confirmation of lesion, if needed. Data was obtained and statistically analyzed. Results: Of the 210 patients, 34 (16.27%) had positive Pap test, 29 (13.87%) had positive VIA and 24 (11.43%) had positive VILI and 31 (14.75%) showed features of cervical intraepithelial neoplasia (CIN) on colposcopy. Of the total of 48 patients in whom either of the screening tests was positive and had undergone cervical biopsy, one had CIN-3, three had CIN-2, 12 had CIN-1, three had carcinoma in situ CIS and 29 reported normal. In our study, 40 patients were picked up as positive by combination of these tests, of which 19 (47.50%) had CIN on biopsy. Conclusion: Our study showed that VIA and VILI had sensitivity comparable to Pap smear and can thus be a suitable potential alternative/adjunctive screening test not only in a resource-poor setting but in well-equipped centers also. And, use of a combination of tests (Pap+VIA+VILI) had 100% sensitivity but at cost of low specificity and more false-positive results.

Accidental phosgene gas exposure: A review with background study of 10 cases

Here, authors present a review on clinical presentation and management of exposure of phosgene gas after reviewing the literature by searching with keywords phosgene exposure on Google, Cochrane, Embase and PubMed with a background of experience gained from 10 patients who were admitted to our institute after an accidental phosgene exposure in February 2011 nearby a city in India. Phosgene is a highly toxic gas, occupational workers may have accidental exposure. The gas can also be generated inadvertently during fire involving plastics and other chemicals and solvents containing chlorine, which is of concern to emergency responders. Phosgene inhalation may cause initially symptoms of respiratory tract irritation, patients feel fine thereafter, and then die of choking a day later because of build up of fluid in the lungs (delayed onset non-cardiogenic pulmonary edema). Phosgene exposure is associated with significant morbidity and mortality. Patients with a history of exposure should be admitted to the hospital for a minimum of 24 h for observation because of the potential for delayed onset respiratory failure and acute respiratory distress syndrome.

Scorpion bite, a sting to the heart!

Scorpion bites are common in India. Usually, these bites are harmless but sometimes have serious clinical sequelae, including death. We report herein a case of scorpion bite with electrocardiographic abnormalities simulating early myocardial infarction. Pulmonary edema and congestive heart failure accompanied these electrocardiographic changes as well as serum cardiac markers. The etiology of cardiovascular manifestations in severe scorpion sting is related to venom effect on sympathetic nervous system and the adrenal secretion of catecholamines as well as to the toxic effect of the venom on the myocardium itself. It is a rare case of scorpion sting presented as myocardial infarction and heart failure, successfully treated with Intensive Care Unit care, noninvasive ventilation, vasopressors, and antiischemic treatment.

Comparative study of dopamine and norepinephrine in the management of septic shock

Objective: The objective was to compare the ability of norepinephrine and dopamine in reversing the hemodynamic and metabolic abnormalities of septic shock using Edwards Vigileo Monitor with Flotrac Sensor. Design: Prospective randomized control study. Methods: Fifty consecutive patients presenting with hyperdynamic septic shock who fulfilled the inclusion criteria were randomly allocated to either group I or group II. The goal of therapy was to achieve and maintain for 6 hours, all of the following - systolic blood pressure (SBP) >90 mmHg, systemic vascular resistance index (SVRI) >1800 dynes.s/cm5m2, cardiac index (CI) >4.0 lt/min/m2, index of oxygen delivery >550 ml/min/m2, index of oxygen uptake >150 ml/min/m2. The patients in group I were started on dopamine infusion at 10 μg/kg/min which was increased by 2.5 μg/kg/min, every 15 minutes till the goals were achieved. The patients in group II received norepinephrine infusion started at a dose of 0.5 μg/kg/min with a dose increment of 0.25 μg/kg/min, every 15 minutes till the goals were achieved. Results: Post-treatment heart rate showed an increase in the mean value in group I patients and a decrease in group II patients. The post-treatment mean SBP and SVRI in group II was significantly higher than that in group I. Patients in group I showed a significantly higher increase in post-treatment CI and index of oxygen delivery compared to patients in group II. Nineteen out of 25 patients responded to the treatment in group II while only 10 out of 25 responded in group I. Conclusion: Norepinephrine was more useful in reversing the hemodynamic and metabolic abnormalities of hyperdynamic septic shock compared to dopamine.

MR spectroscopy in tuberculoma of brain

A 26 year-old-man developed progressive weakness of all limbs, hoarseness of voice and dysphagia over a period of 10 days. The patient was conscious, oriented and vital parameters were within normal limits. Neurological examination revealed; horizontal and torsional nystagmus, bilateral 9th and 10th cranial nerve involved, 3/5 muscle power in all limbs and sensory system was intact. MRI brain showed multiple small conglomerated ring enhancing lesions displaying hyperintense core on T2 weighted images (WIs) and hypointense on T1WIs and fluid attenuated inversion recovery …

Cerebral-autoregulatory dysfunction syndrome

Reversible cerebral vasoconstriction syndrome and reversible posterior leukoencephalopathy syndrome are distinct clinicoradiological disorders which share certain features in terms of aetiology, pathogenesis and symptomatology. We present a case of a young primigravida with eclampsia who developed severe headache, vision loss and hemiparesis in the postpartum phase. MRI of the brain was suggestive of the involvement of anterior as well as posterior circulation and reversibility of widespread angiographic constrictions could be documented on follow-up. Despite the resolution of vascular changes, vision loss did not improve significantly in our case. Such an overlap of findings is unusual and probably represents the spectrum of cerebral-autoregulatory dysfunction occurring in these two syndromes.

Acute accidental phosgene poisoning

Phosgene is a highly toxic gas to which accidental exposure may occur in occupational workers. This case report describes the clinical presentation and management of accidental phosgene poisoning happened after the leakage of phosgene gas from nearby pipeline. The need to suspect phosgene gas exposure and observe such patients is crucial for life saving, especially in view of the delay in clinical deterioration observed in some patients who subsequently develop adult respiratory distress syndrome.

5-Fluorouracil-induced bilateral persistent serpentine supravenous hyperpigmented eruption, bilateral mottling of palms and diffuse hyperpigmentation of soles

A 42-year-old woman being treated with 5-fluorouracil for carcinoma of the sigmoid colon developed persistent serpentine supravenous hyperpigmented eruption (PSSHE), bilateral mottling of the palms and diffuse hyperpigmentation of the soles. To the best of our knowledge, such a combination of findings has not been reported earlier. Recognition and knowledge of this side effect are important as the dose of the drug need not be altered nor is there a need to replace the drug on worries about a serious adverse effect. However, changing the peripheral venous route to the central line can be useful in management of PSSHE.