The Second COVID-19 Wave Is a Tsunami With Aftershocks: Mucormycosis Ire as Seen in a Tertiary Care Hospital in Uttarakhand, India

BACKGROUND

During the spread of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) or the coronavirus disease 2019 (COVID-19) pandemic in recent times, an upsurge of invasive fungal infections (IFIs) such as mucormycosis was witnessed by many countries like India. This COVID-19-associated mucormycosis (CAM) has presented as a menace to the already creaking health infrastructure. Clinical manifestations, risk factors, and end clinical outcomes varied for every other region/country. The aim of this study is to delineate and analyze plausible clinical and epidemiological factors and associated predictors of CAM in suspected patients presenting to a tertiary care hospital in Uttarakhand, India, during the second wave of COVID-19 in India.

MATERIAL AND METHODS

A total of 200 cases of suspected post‑COVID-19 mucormycosis were enrolled. Data were collected taking into account parameters such as hospitalization and ICU admissions during the episode of COVID-19 infection, steroid/antibiotics/oxygen requirement, and comorbidities such as diabetes mellitus, hypertension, or any chronic illness and outcome.

RESULTS

Participants diagnosed with CAM using KOH examination and fungal culture were analyzed in the study (n=46). The median age of patients included was 48, 73.9% were males, and 26% were females. The major predisposing factor was found to be diabetes mellitus type 2. Our work suggests that the mean duration between COVID-19 episodes and CAM was 11.86 days with a significant statistical association. Oxygen requirement and imprudent use of steroids/antibiotics were also allied with mucormycosis.

CONCLUSION

The burden of such IFIs is expected to be unveiled in tropical countries during pandemics such as COVID-19, which lead to immunosuppression in masses post-treatment. Comorbidities such as diabetes, chronic kidney disease, and hypertension add to the risk of acquiring other infectious disease. Such times require competent healthcare professionals such as diagnosticians, physicians, and surgeons who are skilled to manage such IFIs timely.

Bacterial Isolates and Their Antimicrobial Susceptibility Profile in Osteomyelitis Patients: An Experience From a Tertiary Care Center in a Hilly Area of Uttarakhand

Osteomyelitis, an infection related to bone and bone marrow, is very diverse in its pathophysiology and clinical presentation; hence, it is considered one of the most difficult-to-treat infections. The present study is aimed at assessing the microbiological profile of osteomyelitis and related antimicrobial susceptibility patterns in patients attending a tertiary care center in Uttarakhand, India, over a period of one year (January to December 2019). In aerobic culture, 58/105 (55.2%) bacterial isolates were detected. In addition, Staphylococcus aureus was the most common isolate, and amongst Gram-negative bacilli, most isolates that grew on culture were Escherichia coli (22.4%). Out of 21 S. aureus isolates, methicillin resistance was detected in nine [9/21 (42%)] cases, which is a matter of concern. Hence, proper training and application of antimicrobial stewardship are the need of the hour so that clinicians can initiate targeted therapy as early as possible.

Prevalence of Hepatitis B and Hepatitis C in patients undergoing hemodialysis at a teaching hospital in Uttarakhand

Introduction:

Hemodialysis (HD) requires blood exposure to infectious materials through the extracorporeal circulation for a prolonged period, and exposure to risk factors for nosocomial infections is always there.

Aims and Objectives:

To determine the prevalence of hepatitis B and hepatitis C in patients undergoing hemodialysis and evaluate the various modes of transmission involved in the causation of the infection.

Materials and Methods:

A total of 60 patients with chronic kidney disease, admitted to our hospital for HD, were screened for hepatitis B surface antigen (HBsAg) and anti-HCV antibodies. A questionnaire was designed to evaluate risk factors and data were generated to evaluate the significance of the association.

Results:

Out of 60 subjects, an anti-HCV antibody was detected in 31.68% of patients and 11.66% of patients were positive for HBsAg. The maximum anti-HBV-positive patients were in >60 years of age group (11.53%), whereas the maximum HCV-positive patients were between 41 and 50 age group (23.07%). Most of the HCV-positive patients (54.54%), as well as HBV-positive patients (23.52%), received hemodialysis 50 to 100 times. The major primary disease-causing end-stage renal disease (ESRD) included chronic nephritis (35%). The duration of dialysis, multiple blood transfusions, drug addiction, and body piercing/tattooing were also observed as significant risk factors.

Conclusion:

In HD patients, viral hepatitis poses a significant health hazard, particularly in developing countries. HBV vaccination, strict adherence to the universal precautions, segregation of HBV-positive patients can control HBV infection in HD units. However, for HCV, the absence of a specific vaccine and the nosocomial transmission of the virus increase the peril more.

Evaluation of Sphingomonas paucimobilis as an emerging nosocomial pathogen in a teaching hospital in Uttarakhand

Background and Objectives:

Sphingomonas paucimobilis is an opportunistic pathogen and was rarely encountered in clinical specimens previously. This study aimed to investigate the clinical features, associated co-morbidities, and antimicrobial susceptibility patterns of S. paucimobilis infection in a tertiary hospital in Uttarakhand.

Materials and Methods:

S. paucimobilis isolates cultured from various sections of hospital and OPDs were identified and analyzed for their antibiograms in the microbiology laboratory for a duration of one year from January 2020 to December 2020.

Results:

S. paucimobilis was isolated from 49 samples (0.01%) out of 3792 samples processed in VITEK 2 Compact automated ID/AST instrument. The maximum number of isolates were obtained from urine samples (31%), followed by blood (24%). Septicemia (41%), meningitis (17%), lower respiratory tract infections and ventilator associated pneumonia (14%) constituted a major portion of infections caused by this organism. Diabetes mellitus (22%) and steroid usage (16%) were major associated co-morbid conditions. Third and Fourth generation cephalosporins like ceftriaxone (81%) and cefepime (86%) were found to be the most susceptible drugs whereas 61% of isolates were resistant to colistin.

Conclusion:

This organism is an up-and-coming pathogen and should not be simply labeled as a contaminant. Although the organism is not grossly virulent and still might not be associated with serious life-threatening infections; however their evolving resistance patterns and increased spectrum of infections should be seriously taken into account.

Clinico-epidemiological profile of Influenza A H1N1 cases at a tertiary care institute of Uttarakhand

Introduction:

The swine (H1N1) virus responsible for worldwide pandemics since 2009 is now causing seasonal epidemics. Since then alarming spikes of swine flu cases have been reported from Uttarakhand every year. There are limited studies conducted in this Himalayan belt to evaluate the clinical and epidemiological profile of the patients admitted in tertiary care hospitals.

Aims & Objectives:

This study aims to summarize the clinical and epidemiological attributes of swine flu and to approximate the burden of Influenza A H1N1 (Swine Flu) cases in this Himalayan belt.

Material and Methods:

Clinical and epidemiological characteristics of influenza A H1N1 cases from October 2018 to April 2019 were retrospectively and descriptively analyzed using data from the Medical Records Section and the isolation ward at Shri Guru Ram Rai Institute of Medical and Health Sciences; Shri Mahant Indiresh hospital.

Results:

A total of 1126 (51.6%) patients were tested of which 30% (338) patients were found to be H1N1 positive. Maximum cases and positivity were detected in the months of January (26.4%), February (50.3%), and March (14.8%), and the patients in the age groups of 41–50 (21.9%) and 51–60 years (19.3%) accounted for majority of the cases. The most common symptoms were fever (85.8%), cough (82.2%), sore throat (82%), and breathlessness (71.3%). A case fatality ratio of 10.9% was observed. A significant statistical association (p value < 0.00001) was reported between co-morbid conditions and death.

Conclusion:

According to the results of this study, close caution should be exercised in case of patients infected with H1N1 particularly those with co-morbidities.

MUC1-C activates the TAK1 inflammatory pathway in colon cancer

The mucin 1 (MUC1) oncoprotein has been linked to the inflammatory response by promoting cytokine-mediated activation of the NF-κB pathway. The TGF-β-activated kinase 1 (TAK1) is an essential effector of proinflammatory NF-κB signaling that also regulates cancer cell survival. The present studies demonstrate that the MUC1-C transmembrane subunit induces TAK1 expression in colon cancer cells. MUC1 also induces TAK1 in a MUC1(+/-)/IL-10(-/-) mouse model of colitis and colon tumorigenesis. We show that MUC1-C promotes NF-κB-mediated activation of TAK1 transcription and, in a positive regulatory loop, MUC1-C contributes to TAK1-induced NF-κB signaling. In this way, MUC1-C binds directly to TAK1 and confers the association of TAK1 with TRAF6, which is necessary for TAK1-mediated activation of NF-κB. Targeting MUC1-C thus suppresses the TAK1NF-κB pathway, downregulates BCL-XL and in turn sensitizes colon cancer cells to MEK inhibition. Analysis of colon cancer databases further indicates that MUC1, TAK1 and TRAF6 are upregulated in tumors associated with decreased survival and that MUC1-C-induced gene expression patterns predict poor outcomes in patients. These results support a model in which MUC1-C-induced TAK1NF-κB signaling contributes to intestinal inflammation and colon cancer progression.

Targeting the MUC1-C oncoprotein downregulates HER2 activation and abrogates trastuzumab resistance in breast cancer cells

Patients with HER2 positive breast cancer often exhibit intrinsic or acquired resistance to trastuzumab treatment. The transmembrane MUC1-C oncoprotein is aberrantly overexpressed in breast cancer cells and associates with HER2. The present studies demonstrate that silencing MUC1-C in HER2-overexpressing SKBR3 and BT474 breast cancer cells results in downregulation of constitutive HER2 activation. Moreover, treatment with the MUC1-C inhibitor, GO-203, was associated with disruption of MUC1-C/HER2 complexes and decreases in tyrosine phosphorylated HER2 (p-HER2) levels. In studies of trastuzumab-resistant SKBR3R and BT474R cells, we found that the association between MUC1-C and HER2 is markedly increased (~20-fold) as compared to that in sensitive cells. Additionally, silencing MUC1-C in the trastuzumab-resistant cells or treatment with GO-203 decreased p-HER2 and AKT activation. Moreover, targeting MUC1-C was associated with downregulation of phospho-p27 and cyclin E, which confer trastuzumab resistance. Consistent with these results, targeting MUC1-C inhibited the growth and clonogenic survival of both trastuzumab-resistant cells. Our results further demonstrate that silencing MUC1-C reverses resistance to trastuzumab and that the combination of GO-203 and trastuzumab is highly synergistic. These findings indicate that MUC1-C contributes to constitutive activation of the HER2 pathway and that targeting MUC1-C represents a potential approach to abrogate trastuzumab resistance.

Lubiprostone used with polyethylene glycol in diabetic patients enhances colonoscopy preparation quality

AIM: To assess the additive effect of lubiprostone on the quality of colon preparation in diabetics given single-dosed polyethylene glycol electrolyte (PEG) for colonoscopy.

METHODS: This was an investigator-initiated, single-center, single-blinded prospective trial comparing the efficacy of L + PEG to PEG alone on colon preparation quality in diabetics undergoing screening colonoscopy. The study was approved by our institution’s IRB. The PEG was given as a single-dose to address patient-compliance concerns voiced by our IRB with split-dosing. All patients received only clear liquids the day prior to colonoscopy. Experimental group (Grp L) received PEG + 1 dose L 2 h prior to and 2 h after PEG completion. Control group (Grp C) received only PEG the evening prior to the colonoscopy. Patients were randomly assigned to one of the 2 groups. The endoscopist was blinded to which colon prep was given and all colonoscopies were complete. Upon colonoscopy completion, the endoscopist rated the colon prep-quality by a validated 5-point Likert scale (1-excellent to 5-inadequate).

RESULTS: Sixty patients were enrolled in the study; 30 Grp L and 30 Grp C. Overall, patients were excluded due to study non-completion in 12 (41%) Grp L and 5 (17%) Grp C, P = 0.04. Average colon preparation score Grp L = 2.47 and Grp C = 3.00, P = 0.09. Although this was not statistically significant, there was a trend towards improved colon prep in Grp L. Statistical significance may have been achieved if completion rates had been similar between both study groups.

CONCLUSION: Use of 2-L capsules with PEG resulted in a trend towards improved colon prep over PEG alone in diabetic patients when given as a single-dose regimen.

Hepatitis C: diagnosis and treatment

Hepatitis C, a common chronic bloodborne infection, is found in approximately 2 percent of adults in the United States. Chronic infection is associated with serious morbidity and mortality (e.g., cirrhosis, hepatocellular carcinoma). Testing for hepatitis C is recommended for at-risk populations, and confirmatory testing includes quantification of virus by polymerase chain reaction. The U.S. Preventive Services Task Force recommends against routine screening for hepatitis C virus infection in asymptomatic adults who are not at increased risk of infection (general population). It found insufficient evidence to recommend for or against routine screening in adults at high risk of infection. Current therapy for chronic hepatitis C virus includes pegylated interferon and ribavirin. Therapy is based on factors that predict sustained virologic response, and the goal of therapy is to slow or halt progression of fibrosis and prevent the development of cirrhosis. In the future, multidrug regimens in combination with current therapies may be developed. Patients with chronic hepatitis C virus infection should be advised to abstain from alcohol use. Currently, there is no vaccine available to prevent hepatitis C virus infection; however, persons infected with hepatitis C virus should be vaccinated for hepatitis A and B. The American Association for the Study of Liver Diseases recommends ultrasound surveillance for hepatocellular carcinoma in persons with chronic hepatitis C virus infection and cirrhosis.

Colonoscopy polypectomy management in Glanzmann’s thrombasthenia

Glanzmann's thrombasthenia (GT) is a rare autosomal recessive bleeding syndrome characterized by abnormal Glycoprotein IIb/IIIa complex (GIIb/IIIa) on platelets with resultant abnormality in platelet aggregation. There is very little information regarding polypectomy management in GT. We report a single patient with this rare disease, who underwent sequential endoscopic management of large colon polyps. Polypectomy in our GT patient was complicated by immediate and delayed bleeding. Multiple clips used after standard cautery polypectomy for a polyp 10 mm or larger in our GT patient, was most effective in preventing immediate and delayed post-polypectomy bleeding than other known therapeutic approaches. We favor preemptive use of multiple clips in large polypectomy defects for GT patients and we may argue the added cost may be offset by the reduction in the need for blood products, and by averting or shortening potential hospitalizations.

Autoimmune hepatitis triggered by statins

Although the cause of autoimmune hepatitis (AIH) is unknown, drugs are believed to be potential triggers in some patients. In isolated case reports, statins have been considered such triggers. Here we describe 3 patients in whom it is probable that statins initiated the development of AIH. Two men (aged 47 and 51) and one woman (aged 57) developed AIH after the initiation of statin therapy. They developed positive titers of antinuclear antibodies, antismooth muscle antibodies (1/40 to 1/160), and hypergammaglobulinemia. Features of all 3 patients met the criteria for AIH according to the International Autoimmune Hepatitis Panel. Liver biopsies in all 3 showed varying stages of fibrosis and plasma cell infiltration, compatible with AIH. The woman developed hepatitis due to statins on 2 separate occasions: the first in 1999, due to simvastatin, and the second in 2001 to 2002, due to atorvastatin, which was severe and persisted even after discontinuing medication. Similarly, in the 2 other cases, exposure to statins preceded development of AIH, which persisted despite discontinuing medications. All 3 patients responded well to prednisone and azathioprine or mycophenolate therapy. 3 similar previously reported cases are reviewed. We conclude that the 3 cases reported here and 3 similar previously reported cases, indicate that severe, ongoing AIH on rare occasions can be triggered by statins.

MUC1 oncoprotein is targeted to mitochondria by heregulin-induced activation of c-Src and the molecular chaperone HSP90

The MUC1 heterodimeric transmembrane glycoprotein is aberrantly overexpressed by most human carcinomas. The MUC1 C-terminal subunit localizes to mitochondria and blocks stress-induced activation of the intrinsic apoptotic pathway. How MUC1 is delivered to mitochondria is not known. The present studies demonstrate that MUC1 forms intracellular complexes with HSP70 and HSP90. We show that the MUC1 cytoplasmic domain binds directly to HSP70 in vitro. By contrast, binding of MUC1 to HSP90 in vitro is induced by c-Src-mediated phosphorylation of the MUC1 cytoplasmic domain. c-Src also increases binding of MUC1 to HSP90 in cells. In concert with these results, we show that heregulin (HRG), a ligand for ErbB receptors, activates c-Src and, in turn, stimulates binding of MUC1 to HSP90. We also show that inhibitors of c-Src or HSP90 block HRG-induced targeting of MUC1 to mitochondria and integration of MUC1 into the mitochondrial outer membrane. These findings indicate that MUC1 is delivered to mitochondria by a mechanism involving activation of the ErbB receptor-->c-Src pathway and transport by the molecular chaperone HSP70/HSP90 complex.

Targeting of the c-Abl tyrosine kinase to mitochondria in the necrotic cell death response to oxidative stress

The ubiquitously expressed c-Abl tyrosine kinase is activated in the response of cells to genotoxic and oxidative stress. The present study demonstrates that reactive oxygen species (ROS) induce targeting of c-Abl to mitochondria. We show that ROS-induced localization of c-Abl to mitochondria is dependent on activation of protein kinase C (PKC)delta and the c-Abl kinase function. Targeting of c-Abl to mitochondria is associated with ROS-induced loss of mitochondrial transmembrane potential. The results also demonstrate that c-Abl is necessary for ROS-induced depletion of ATP and the activation of a necrosis-like cell death. These findings indicate that the c-Abl kinase targets to mitochondria in response to oxidative stress and thereby mediates mitochondrial dysfunction and cell death.

Effect of Aegle marmelos and Hibiscus rosa sinensis leaf extract on glucose tolerance in glucose induced hyperglycemic rats (Charles foster)

In an effort to test the hypoglycemic activity of Aegle marmelos and Hibiscus rosa sinensis in glucose induced hyperglycemic rats, their alcoholic leaf extracts were studied. Both the groups of animals receiving either. A. marmelos or H. rosa sinensis leaf extract for seven consecutive days, at an oral dose equivalent to 250 mg kg-1 showed significant improvements in their ability to utilize the external glucose load. Average blood glucose lowering caused by A. marmelos and H. rosa sinensis was 67% and 39% respectively, which shows that former significantly (p < 0.001) improves the glucose tolerance curve. The magnitude of this effect showed time related variation with both the plants. Efficacy of A. marmelos and H. rosa sinensis was 71% and 41% of glybenclamide, respectively. These data throw some light on the possible mechanism of hypoglycemic activity of both the plants. The mechanism of action could be speculated partly to increased utilization of glucose, either by direct stimulation of glucose uptake or via the mediation of enhanced insulin secretion.