Risk factors, mortality, and predictors of survival in COVID-19-associated pulmonary mucormycosis: a multicentre retrospective study from India

OBJECTIVES

To compare COVID-19-associated pulmonary mucormycosis (CAPM) with COVID-19-associated rhino-orbital mucormycosis (CAROM), ascertain factors associated with CAPM among patients with COVID-19, and identify factors associated with 12-week mortality in CAPM.

METHODS

We performed a retrospective multicentre cohort study. All study participants had COVID-19. We enrolled CAPM, CAROM, and COVID-19 subjects without mucormycosis (controls; age-matched). We collected information on demography, predisposing factors, and details of COVID-19 illness. Univariable analysis was used to compare CAPM and CAROM. We used multivariable logistic regression to evaluate factors associated with CAPM (with hypoxemia during COVID-19 as the primary exposure) and at 12-week mortality.

RESULTS

We included 1724 cases (CAPM [n = 122], CAROM [n = 1602]) and 3911 controls. Male sex, renal transplantation, multimorbidity, neutrophil-lymphocyte ratio, intensive care admission, and cumulative glucocorticoid dose for COVID-19 were significantly higher in CAPM than in CAROM. On multivariable analysis, COVID-19-related hypoxemia (aOR, 2.384; 95% CI, 1.209-4.700), male sex, rural residence, diabetes mellitus, serum C-reactive protein, glucocorticoid, and zinc use during COVID-19 were independently associated with CAPM. CAPM reported a higher 12-week mortality than CAROM (56 of the 107 [52.3%] vs. 413 of the 1356 [30.5%]; p = 0.0001). Hypoxemia during COVID-19 (aOR [95% CI], 3.70 [1.34-10.25]) and Aspergillus co-infection (aOR [95% CI], 5.40 [1.23-23.64]) were independently associated with mortality in CAPM, whereas surgery was associated with better survival.

DISCUSSION

CAPM is a distinct entity with a higher mortality than CAROM. Hypoxemia during COVID-19 illness is associated with CAPM. COVID-19 hypoxemia and Aspergillus co-infection were associated with higher mortality in CAPM.

Late presenting complicated coronary stent infection of left anterior descending artery with antero-posterior communication

Coronary stent infections (CSI) are rare but a potentially life-threatening disease, the incidence of which has been on a rise over the last two decades. We report the case of a patient who presented with episodes of fever and discharging sternal wound. The patient was diagnosed as CSI arising from the left anterior descending artery stent which was communicating anteriorly to the skin and posteriorly as lobar-fistula. He was treated by stent removal and plication of the fistula. Blood culture, culture of the pus and infected stent, and coronary angiography are the preferred diagnostic modalities, followed by positron emission tomography (PET) scan and cardiac magnetic resonance imaging (MRI) for delineating the extent of pathology. Surgery seems to be the treatment of choice, providing a definitive diagnosis of CSI and removing the source of infection, repairing aneurysms, and providing bypass vascular grafts if feasible. Thorough evaluation and a multidisciplinary approach with the institution of appropriate medical and surgical therapy lead to timely detection and good outcome.

Off-Pump Resection of Giant Intramural Left Ventricular Hydatid Cyst by Pleuropericardial Approach: a Case Report

Primary cardiac hydatid cyst is a rare and fatal pathology, especially when involving the left ventricular free wall. A 44-year-old male was diagnosed with large intramural left ventricular hydatid cyst with wall thickness of 6 mm at the thinnest point. Cyst was accessed through pleuropericardial approach (left pleura opened, followed by entry into cyst directly through adjacent pericardium without removing the pericardial adhesions) which resulted in easy entry into the cyst, mitigating the risk of mechanical injury. This case report highlights that with detailed evaluation, cardiac hydatidosis can be addressed with off-pump technique, reducing the anaphylaxis risks and cardiopulmonary bypass-related effects.

Multicenter Case-Control Study of COVID-19-Associated Mucormycosis Outbreak, India

We found inappropriate glucocorticoid therapy and zinc supplementation were significantly associated with these illnesses.

We performed a case–control study across 25 hospitals in India for the period of January–June 2021 to evaluate the reasons for an COVID-19–associated mucormycosis (CAM) outbreak. We investigated whether COVID-19 treatment practices (glucocorticoids, zinc, tocilizumab, and others) were associated with CAM. We included 1,733 cases of CAM and 3,911 age-matched COVID-19 controls. We found cumulative glucocorticoid dose (odds ratio [OR] 1.006, 95% CI 1.004–1.007) and zinc supplementation (OR 2.76, 95% CI 2.24–3.40), along with elevated C-reactive protein (OR 1.004, 95% CI 1.002–1.006), host factors (renal transplantation [OR 7.58, 95% CI 3.31–17.40], diabetes mellitus [OR 6.72, 95% CI 5.45–8.28], diabetic ketoacidosis during COVID-19 [OR 4.41, 95% CI 2.03–9.60]), and rural residence (OR 2.88, 95% CI 2.12–3.79), significantly associated with CAM. Mortality rate at 12 weeks was 32.2% (473/1,471). We emphasize the judicious use of COVID-19 therapies and optimal glycemic control to prevent CAM.

COVID-19 patients' clinical profile and outcome with respect to their vaccination status: A prospective observational multicentre cohort study during third wave in Western India

PURPOSE

To understand the benefits of COVID-19 vaccination (Covishield, Covaxin) on clinical features and outcome of COVID-19 during the third wave in India.

MATERIALS AND METHODS

The primary study aim was to describe the clinical profile and outcome of COVID-19 regarding their vaccination and to identify risk factors for disease progression in vaccinated patients. This was a prospective observational multicentric study of COVID-19 attended by Infectious Disease physicians during January 15, 2022 to February 15, 2022. Adult patients with positive RT-PCR or rapid antigen test for COVID-19 were enrolled. Patient received treatment as per local institutional protocol. Chi square test for categorical and Mann Whitney test for continuous variables were applied for the analysis. Logistic regression was used to calculate adjusted odds ratios.

RESULTS

A total of 788 patients were included in analysis out of 883 enrolled patients from 13 centers across Gujarat. By the end of two weeks' follow up, 22 patients (2.8%) had expired. The Median age of subjects was 54 years, with a (55.8%) male. 90% of the subjects were vaccinated, majority (77%) of them had received 2 doses of vaccine with Covishield (659, 93%). Mortality among the non-vaccinated was significantly (11.4%) higher than vaccinated (1.8%). Logistic regression analysis showed numbers of comorbidities (p ​= ​0.027), baseline higher WBC count (p ​= ​0.02), higher NLR (p ​= ​0.016), and Ct value (p ​= ​0.046) were associated with mortality while vaccination was associated with survival (p ​= ​0.001). The factors associated with mortality among vaccinated were age, comorbidities, baseline higher WBC, NLR, and CRP.

CONCLUSIONS

Omicron variant was associated with mild symptoms. Clinical and laboratory risk factors for getting severe disease with Omicron variant were the same with previous SARS CoV-2 strain. Two doses of vaccine protect people against severe disease and death. Age, comorbidities, baseline leucocytosis, high NLR, elevated CRP are the risk factors for poor outcome in vaccinated patients.

P232 Disseminated cryptococcosis in HIV due to different species — dissimilar yet alike!

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Objective

To present two cases of disseminated cryptococcosis caused by two different species in HIV patients, presenting from the same geographical location.

Introduction

Cryptococcal meningitis is the most frequent cause of adult meningitis in areas with a high prevalence of human immunodeficiency virus (HIV) and is one of the leading causes of HIV-related deaths worldwide. Cryptococcus gattii, the lesser prevalent species, ‘conventionally’ known to affect the non-HIV and otherwise immunocompetent population, may also cause disseminated infection in HIV patients. High MICs of antifungals, especially fluconazole, may pose challenges in the management. Here, we present two cases of HIV patients with disseminated cryptococcosis, who presented from the same geographical area of India in the months of February and March 2022, respectively.

Case 1: A 34-year-old patient from the state of Rajasthan with a past history of abdominal tuberculosis and a defaulter of ART (ABC/3TC/EFV) presented with headache and vomiting for 3 weeks. After an MRI brain and CT scan of the thorax, he was diagnosed to have pulmonary and meningeal cryptococcosis based on CSF examination with a positive Gram's, and India ink stain (Fig. 1), positive cryptococcal antigen (CRAG) by lateral flow assay, and fungal culture positive for C. gattii (MALDI-TOF); and a paratracheal lymph node biopsy showing granulomatous inflammation with cryptococci (Fig. 2). Fluconazole MIC was 16 μg/ml. He was treated with liposomal amphotericin B with flucytosine for 2 weeks. After good clinical recovery and negative fungal culture, a high dose (1200 mg) of fluconazole was started. He is asymptomatic with repeated negative fungal culture on 2 months follow-up.

Case 2: A 37-year-old patient from Rajasthan, on ART (TDF/3TC/DTV) for HIV-1 diagnosed a month ago, presented with cough, weight loss, and fever for 2 months with severe chest pain on drinking and eating. He was diagnosed to have cytomegalovirus esophagitis based on the CMV inclusion bodies in a biopsy from the esophageal ulcers and a positive quantitative serum CMV DNA PCR. Bronchoscopy with EBUS-guided lymph node biopsy was done to investigate cavitary lung consolidation and mediastinal lymphadenopathy. BAL CRAG was positive and biopsy showed inflammation with histiocytic aggregates and necrosis, and many encapsulated yeasts form suggestive of Cryptococcus, which was identified by MALDI-TOF as Cryptococcus neoformans. Serum CRAG was positive. Though patient did not have any neurological complaints, CSF examination was done and CRAG was positive. He was treated with injection of liposomal amphotericin B, flucytosine, and ganciclovir, along with ART.

Conclusion

Default of ART by the patients, initiation of ART without investigation and treatment of opportunistic infections, and co-existence of multiple opportunistic infections, are still major challenges in the management of HIV, especially in developing countries. Though C. neoformans is the commonly isolated species, more and more cases of C. gattii are being reported. Identification of the species is important as there are differences in the epidemiology, clinical presentation, antifungal susceptibilities, and hence the treatment and prognosis.

A Phase IV Study on Safety, Tolerability and Efficacy of Dolutegravir, Lamivudine, and Tenofovir Disoproxil Fumarate in Treatment Naïve Adult Indian Patients Living with HIV-1

Purpose

WHO recommends dolutegravir (DTG) based regimens as first-line treatment for HIV-1 infection. However, few studies have been conducted in Indian population. Hence, our study evaluated the safety, tolerability, and efficacy of DTG 50 mg with Tenofovir and Lamivudine (300/300mg) fixed dose combination in treatment naïve adult Indian patients.

Methods

This was an open label, multicenter, prospective, interventional, phase IV study conducted across 14 sites between February 2019 and July 2020. 24 weeks was the treatment duration for each subject. The primary end point was to assess the incidence of adverse events (AEs) and secondary end points were to assess the proportion of patients achieving plasma HIV-1 RNA levels <50 copies/mL at week 24 and change in CD4+ cell count from the baseline. Safety analysis was conducted using Safety Analysis Set and efficacy analysis was carried out using Full Analysis Set and Per protocol set.

Results

A total of 288 patients were screened; 250 were enrolled; and 229 completed the study. 389 AEs were reported from 58% of patients. Of these, 61 were related to study treatment. One event of decreased creatinine clearance led to study discontinuation. One serious event of pyrexia was reported, which was unrelated to the study drug. The most common AEs were headache (18%), pyrexia (14%), vomiting (6.4%) and upper respiratory tract infections (6%). No deaths were reported. At week 24, 86.8% of the patients achieved plasma HIV-1 RNA levels <50 copies/mL and the mean CD4 cell count increased from 350.2 (SD, 239.73) at baseline to 494.6 (SD, 261.40) with an average increase of 143.2 (SD, 226.14) cells.

Conclusion

This study demonstrated the safety and efficacy of DTG based regimen in treatment naïve HIV-1 patients in Indian population and support use of DTG as first-line treatment regimen.

Outcomes by Severity of Obesity During Extracorporeal Membrane Oxygenation Support for COVID-19

Purpose

Obesity adversely impacts outcomes during COVID-19 but its relation to mortality in those receiving extracorporeal membrane oxygenation (ECMO) is uncertain.

Methods

A retrospective multicenter study was conducted. Adult patients (≥18 years old) with severe COVID-19 infection placed on ECMO between March 1, 2020 to April 30, 2021, across the United States were included. A web-based database application, REDCap, was utilized to capture clinical characteristics and outcomes. Patients were grouped into tertiles of body mass index (BMI). The primary outcome was in-hospital mortality after ECMO placement assessed by a time-to-event analysis.

Results

Overall 444 patients (age 49, IQR: 38-57 years, 29% female, BMI: 33, IQR: 29-39 kg/m2) from 17 centers comprised the study cohort. Patients that expired during hospitalization had a similar BMI in comparison to those that were discharged (33, IQR: 29-38 vs. 34, IQR: 30-40 kg/m2, p=0.13). BMI across groups was 27, IQR: 25-29 (lowest tertile), 33, IQR: 32-34 (middle tertile), 41, IQR: 38-45 kg/m2 (highest tertile). At 90 days, in-hospital mortality between BMI tertiles was 53%, 59%, and 53%, p=0.99 (figure). After adjustment for clinical covariates including age, sex, presence of preexisting co-morbidities, cardiopulmonary arrest prior to ECMO, serum creatinine and arterial partial pressure of oxygen (PaO2) to inspired oxygen concentration (FiO2) ratio, there was no difference in hospital mortality in the middle (aHR:1.13, CI: 0.79-1.63, p=0.5) and highest (aHR: 1.38, CI: 0.95-2.01, p=0.09) tertiles in comparison to the lowest BMI tertile.

Conclusion

Severity of obesity is not associated with death during hospitalization in patients placed on ECMO for COVID-19

Determinants of severity among hospitalised COVID-19 patients: Hospital-based case-control study, India, 2020

Background

Risk factors for the development of severe COVID-19 disease and death have been widely reported across several studies. Knowledge about the determinants of severe disease and mortality in the Indian context can guide early clinical management.

Methods

We conducted a hospital-based case control study across nine sites in India to identify the determinants of severe and critical COVID-19 disease.

Findings

We identified age above 60 years, duration before admission >5 days, chronic kidney disease, leucocytosis, prothrombin time > 14 sec, serum ferritin >250 ng/mL, d-dimer >0.5 ng/mL, pro-calcitonin >0.15 μg/L, fibrin degradation products >5 μg/mL, C-reactive protein >5 mg/L, lactate dehydrogenase >150 U/L, interleukin-6 >25 pg/mL, NLR ≥3, and deranged liver function, renal function and serum electrolytes as significant factors associated with severe COVID-19 disease.

Interpretation

We have identified a set of parameters that can help in characterising severe COVID-19 cases in India. These parameters are part of routinely available investigations within Indian hospital settings, both public and private. Study findings have the potential to inform clinical management protocols and identify patients at high risk of severe outcomes at an early stage.

Multicenter Epidemiologic Study of Coronavirus Disease-Associated Mucormycosis, India

During September-December 2020, we conducted a multicenter retrospective study across India to evaluate epidemiology and outcomes among cases of coronavirus disease (COVID-19)-associated mucormycosis (CAM). Among 287 mucormycosis patients, 187 (65.2%) had CAM; CAM prevalence was 0.27% among hospitalized COVID-19 patients. We noted a 2.1-fold rise in mucormycosis during the study period compared with September-December 2019. Uncontrolled diabetes mellitus was the most common underlying disease among CAM and non-CAM patients. COVID-19 was the only underlying disease in 32.6% of CAM patients. COVID-19-related hypoxemia and improper glucocorticoid use independently were associated with CAM. The mucormycosis case-fatality rate at 12 weeks was 45.7% but was similar for CAM and non-CAM patients. Age, rhino-orbital-cerebral involvement, and intensive care unit admission were associated with increased mortality rates; sequential antifungal drug treatment improved mucormycosis survival. The COVID-19 pandemic has led to increases in mucormycosis in India, partly from inappropriate glucocorticoid use.

Arthroscopic treatment of femoroacetabular impingement following slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) may lead to symptomatic femoroacetabular impingement (FAI). We report our experience of arthroscopic treatment, including osteochondroplasty, for the sequelae of SCFE. Data were prospectively collected on patients undergoing arthroscopy of the hip for the sequelae of SCFE between March 2007 and February 2013, including demographic data, radiological assessment of the deformity and other factors that may influence outcome, such as the presence of established avascular necrosis. Patients completed the modified Harris hip score (mHHS) and the non-arthritic hip score (NAHS) before and after surgery. In total, 18 patients with a mean age of 19 years (13 to 42), were included in the study. All patients presented with pain in the hip and mechanical symptoms, and had evidence of FAI (cam or mixed impingement) on plain radiographs. The patients underwent arthroscopic osteoplasty of the femoral neck. The mean follow-up was 29 months (23 to 56). The mean mHHS and NAHS scores improved from 56.2 (27.5 to 100.1) and 52.1 (12.5 to 97.5) pre-operatively to 75.1 (33.8 to 96.8, p = 0.01) and 73.6 (18.8 to 100, p = 0.02) at final follow-up, respectively. Linear regression analysis demonstrated a significant association between poorer outcome scores and increased time to surgery following SCFE (p < 0.05 for all parameters except baseline MHHS). Symptomatic FAI following (SCFE) may be addressed using arthroscopic techniques, and should be treated promptly to minimise progressive functional impairment and chondrolabral degeneration.

TAKE HOME MESSAGE

Arthroscopy of the hip can be used to treat femoroacetabular impingement successfully following SCFE. However, this should be performed promptly after presentation in order to prevent irreversible progression and poorer clinical outcomes.

Multimodal and time-lapse skin registration

BACKGROUND/PURPOSE

Computational skin analysis is revolutionizing modern dermatology. Patterns extracted from image sequences enable algorithmic evaluation. Stacking multiple images to analyze pattern variation implicitly assumes that the images are aligned per-pixel. However, breathing and involuntary motion of the patient causes significant misalignment. Alignment algorithms designed for multimodal and time-lapse skin images can solve this problem. Sequences from multi-modal imaging capture unique appearance features in each modality. Time-lapse image sequences capture skin appearance change over time.

METHODS

Multimodal skin images have been acquired under five different modalities: three in reflectance (visible, parallel-polarized, and cross-polarized) and two in fluorescence mode (UVA and blue light excitation). For time-lapse imagery, 39 images of acne lesions over a 3-month period have been collected. The method detects micro-level features like pores, wrinkles, and other skin texture markings in the acquired images. Images are automatically registered to subpixel accuracy.

RESULTS

The proposed registration approach precisely aligns multimodal and time-lapse images. Subsurface recovery from multimodal images has misregistration artefacts that can be eliminated using this approach. Registered time-lapse imaging captures the evolution of appearance of skin regions with time.

CONCLUSION

Misalignment in skin imaging has significant impact on any quantitative or qualitative image evaluation. Micro-level features can be used to obtain highly accurate registration. Multimodal images can be organized with maximal overlap for successful registration. The resulting point-to-point alignment improves the quality of skin image analysis.

Successful management of highly drug resistant tuberculosis with individualised drug susceptibility testing

INTRODUCTION

Many tuberculosis (TB) patients have resistance patterns intermediate between multidrug-resistant (MDR) and extensively drug-resistant (XDR). We defined MDR+ as resistance to rifampin (RMP), isoniazid (INH) and at least one more drug other than fluoroquinolone (FQ) and second-line injectable agent (IA); and Pre-XDR as MDR with additional resistance to either FQ or IA. Such patients too, have compromised treatment options that require various combinations of second line drugs (SLD). The aim of our study was to assess the clinical outcome of patients having such resistance patterns, managed on the basis of prior drug exposure and drug susceptibility testing (DST).

METHODOLOGY

52 consecutive patients were studied. Treatment regimen was devised as per DST and predominantly consisted of a second-line injectable agent (IA), para-aminosalicylic acid (PAS) and clofazimine. Additionally, cycloserine, linezolid, co-amoxiclav and clarithromycin were used to complete a regimen of four to five drugs. Clinical and radiological outcome was evaluated at follow-up and at the end of treatment.

RESULTS

49/52 (94%) patients had good outcome. However, 34 different regimens had to be used, as options for individual patients were limited.

CONCLUSION

Management on the basis of prior drug exposure and individualised DST led to good clinical outcomes. No single regimen emerged as having a wide applicability. This study supports the clinical relevance of DST of oral second line drugs.

Tumor necrosis factor-alpha polymorphisms in women with idiopathic recurrent miscarriage

We investigated the association of tumor necrosis factor-alpha (TNFalpha) gene polymorphisms with idiopathic recurrent miscarriage (RM). TNFalpha -1031T/C, -863C/A, -857C/T, -376G/A, -308G/A, -238G/A, and +488G/A single nucleotide polymorphisms (SNPs) were investigated in 204 RM women and 248 age-matched parous women by PCR-restriction fragment length polymorphism. Significantly higher frequencies of -1031C and -376A alleles were seen in RM patients; significant differences were also noted in the distribution of -1031T/C, -376G/A, and -238G/A genotypes between case and control subjects. Haploview analysis revealed high linkage disequilibrium between -857C/T and +488G/A SNPs, but was lower between the other polymorphisms. Of the possible 52 seven-locus haplotypes constructed, 10 were common, and were included in subsequent analysis. Increased frequency of CCCGGGG and CCCGGAA haplotypes, and reduced frequency of TCCGGGG and TCCGGGA haplotypes were seen in RM patients than in controls. When the Bonferroni correction was applied, differences were significant for the CCCGGAA haplotype, which was higher (OR=4.14; 95% CI=1.84-8.95), and the TCCGGGA haplotype, which were lower among RM cases (OR=0.09; 95% CI=0.02-0.68), thereby conferring RM susceptibility and protection to these haplotypes, respectively. Multivariate analysis confirmed the positive association of only CCCGGAA haplotype with RM (P=0.010; aOR=2.03; 95% CI=1.18-4.47), after controlling for a number of covariates. These results demonstrate that the TNFalpha polymorphisms, in particular the -1031T/C variant, are significantly associated with idiopathic RM. Additional replication studies on other racial groups are needed to confirm our findings.

Natural history of multiple myeloma (MM) relapsing after autologous stem cell transplantation (ASCT)

e19513

Background: The outcome of patients with MM relapsing after ASCT used early in the disease course or after failure of initial therapy, is not well defined. We undertook this study to understand treatment approaches for patients relapsing after single ASCT. Methods: Patients relapsing after single ASCT were identified from a prospectively maintained database and relevant clinical data were extracted from medical records. Relapse and treatment responses were according to IMWG Uniform Response Criteria. Patients relapsing between Jan 2000 and 2008 were included in order to capture a recent cohort contemporaneous to availability of novel drugs. Results: We studied 487 patients who had relapsed following a single ASCT, of whom 351 (72%) had an early SCT (≤ 12 mos from diagnosis). The median estimated follow up for all patients was 27 mos, 50 mos and 69 mos from relapse, SCT and diagnosis respectively. The median overall survival (OS) from the time of relapse was 30 mos for the early SCT group and 21 months for the late SCT group. The median time to relapse following transplant was 15 mos (3–119) among early SCT group and 12 mos (3–76) among the late SCT group. Longer time to relapse as well as longer time from relapse to initiation of therapy were independent predictors of better outcome. Among the early group, nearly a third of the patients achieved a PR or better to first salvage therapy (Table), with another third achieving stable disease and 25% of patients did not have response data. The median progression free survival for the first salvage regimen was 8 mos; 18 mos for those with PR or better and 5 mos for those with SD as the best response. Data on the regimen 2, 3, 4, 5, and 6 were available for 211, 133, 84, 53 and 28 patients respectively. As expected, the response rates and the response duration decreased with increasing number of relapses. Conclusions: Patients relapsing after ASCT can obtain prolonged response duration with the currently available treatments. Those with a durable response to transplant and those not requiring initiation of therapy for long periods after disease relapse have favorable disease biology and have prolonged survival after relapse. The natural history of the disease provides a valuable benchmark for evaluation of newer treatment approaches.

No significant financial relationships to disclose.

Improvement and innovation through collaborative partnerships

This paper provides a conceptual background for future research in the area of innovation and continuous improvement (CI) in the facilities management supply chain. In a modern, rapidly changing business environment, it is important for businesses to sustain innovation and continuous improvement through active collaboration with suppliers and service providers. The paper provides a synthesis of the theories of CI and an evaluation of the practical implications of its implementation and management. It also provides further insights into the different levels of CI capabilities of organisations as well as the critical success factors in forming collaborative alliances between clients, suppliers and other service providers.