Dear Editor,
This case report presents a very important accompaniment of COVID-19 illness which has currently raised up to epidemic scale in India (1). There is sound empirical evidence that unsupervised use of steroids, uncontrolled blood sugar and existing immunosuppression in COVID-19 may predispose the patients to the opportunistic mucormycosis infection (2,3). Surprisingly, co-infection with mucormycosis were rarely reported during the first wave in India, although the pandemic had spread extensively in the country. There is a possibility that sudden and massive increase in the number of cases and consequently collapsing of the health system in the country may have contributed in the rise of mucormycosis cases in various ways, including multiple iatrogenic causes, such as no proper sterilization of the medical equipment and the hospital wards. Wearing unclean face masks carrying fungal spores and other unhygienic practices might have also contributed in rise of the cases (4). However, no significant reporting of mucormycosis cases during the first wave of COVID-19 pandemic poses some valid questions, whether the newer SARS-CoV-2 variants, particularly that of B.1.617 lineage which are being suggested as the driver of the second wave in India (5), are causing greater and/or early immunosuppression than the wild strain. Emerging evidence suggest that the new SARS-CoV-2 strains, including that of B.1.617 lineage, may have increased virulence (6,7). Although, certai...
Dear Editor,
This case report presents a very important accompaniment of COVID-19 illness which has currently raised up to epidemic scale in India (1). There is sound empirical evidence that unsupervised use of steroids, uncontrolled blood sugar and existing immunosuppression in COVID-19 may predispose the patients to the opportunistic mucormycosis infection (2,3). Surprisingly, co-infection with mucormycosis were rarely reported during the first wave in India, although the pandemic had spread extensively in the country. There is a possibility that sudden and massive increase in the number of cases and consequently collapsing of the health system in the country may have contributed in the rise of mucormycosis cases in various ways, including multiple iatrogenic causes, such as no proper sterilization of the medical equipment and the hospital wards. Wearing unclean face masks carrying fungal spores and other unhygienic practices might have also contributed in rise of the cases (4). However, no significant reporting of mucormycosis cases during the first wave of COVID-19 pandemic poses some valid questions, whether the newer SARS-CoV-2 variants, particularly that of B.1.617 lineage which are being suggested as the driver of the second wave in India (5), are causing greater and/or early immunosuppression than the wild strain. Emerging evidence suggest that the new SARS-CoV-2 strains, including that of B.1.617 lineage, may have increased virulence (6,7). Although, certain degree of lymphocytopenia irrespective of the severity status has been a characteristic of COVID-19, any significant immunosuppression was observed in only severe cases (8). We need to study if there has been a change in this pattern with new variants. A comparative retrospective study of the count of the immune cells, primarily lymphocytes, in the blood samples of COVID-19 patients infected during the first and second waves, may potentially inform on this. Also, a selective study of the COVID-19 patients who have recently developed mucormycosis may substantiate this further.
References:
1. Declare mucormycosis an epidemic, Centre tells States - The Hindu [Internet]. [cited 2021 May 25]. Available from: https://www.thehindu.com/news/national/declare-mucormycosis-an-epidemic-...
2. Ibrahim AS, Spellberg B, Walsh TJ, Kontoyiannis DP. Pathogenesis of mucormycosis. Clin Infect Dis [Internet]. 2012 Feb 1 [cited 2021 May 25];54(SUPPL. 1):S16–22. Available from: http://www.broadinstitute.org/annotation/genome/
3. Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev [Internet]. 2021 May 21 [cited 2021 May 25]; Available from: https://linkinghub.elsevier.com/retrieve/pii/S1871402121001570
4. What is mucormycosis, the fungal infection affecting COVID patients in India? [Internet]. [cited 2021 May 25]. Available from: https://theconversation.com/what-is-mucormycosis-the-fungal-infection-af...
5. Vaidyanathan G. Coronavirus variants are spreading in India - what scientists know so far. Nature [Internet]. 2021 May 11 [cited 2021 May 25]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/33976409
6. Grint DJ, Wing K, Williamson E, McDonald HI, Bhaskaran K, Evans D, et al. Case fatality risk of the SARS-CoV-2 variant of concern B.1.1.7 in England, 16 November to 5 February. Euro Surveill [Internet]. 2021 Mar 1 [cited 2021 May 25];26(11). Available from: https://pubmed.ncbi.nlm.nih.gov/33739254/
7. Yadav PD, Mohandas S, Shete AM, Nyayanit DA, Gupta N, Patil DY, et al. SARS CoV-2 variant B.1.617.1 is highly pathogenic in hamsters than B.1 variant. bioRxiv [Internet]. 2021 May 5 [cited 2021 May 25];2021.05.05.442760. Available from: https://doi.org/10.1101/2021.05.05.442760
8. Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z, et al. Viral and host factors related to the clinical outcome of COVID-19. Nature [Internet]. 2020 May 20 [cited 2020 May 27];1–7. Available from: http://www.nature.com/articles/s41586-020-2355-0
Do emerging SARS-CoV-2 variants cause early and greater immunosuppression which may contribute to co-infection with mucormycosis?
Dear Editor,
This case report presents a very important accompaniment of COVID-19 illness which has currently raised up to epidemic scale in India (1). There is sound empirical evidence that unsupervised use of steroids, uncontrolled blood sugar and existing immunosuppression in COVID-19 may predispose the patients to the opportunistic mucormycosis infection (2,3). Surprisingly, co-infection with mucormycosis were rarely reported during the first wave in India, although the pandemic had spread extensively in the country. There is a possibility that sudden and massive increase in the number of cases and consequently collapsing of the health system in the country may have contributed in the rise of mucormycosis cases in various ways, including multiple iatrogenic causes, such as no proper sterilization of the medical equipment and the hospital wards. Wearing unclean face masks carrying fungal spores and other unhygienic practices might have also contributed in rise of the cases (4). However, no significant reporting of mucormycosis cases during the first wave of COVID-19 pandemic poses some valid questions, whether the newer SARS-CoV-2 variants, particularly that of B.1.617 lineage which are being suggested as the driver of the second wave in India (5), are causing greater and/or early immunosuppression than the wild strain. Emerging...
Do emerging SARS-CoV-2 variants cause early and greater immunosuppression which may contribute to co-infection with mucormycosis?
Dear Editor,
This case report presents a very important accompaniment of COVID-19 illness which has currently raised up to epidemic scale in India (1). There is sound empirical evidence that unsupervised use of steroids, uncontrolled blood sugar and existing immunosuppression in COVID-19 may predispose the patients to the opportunistic mucormycosis infection (2,3). Surprisingly, co-infection with mucormycosis were rarely reported during the first wave in India, although the pandemic had spread extensively in the country. There is a possibility that sudden and massive increase in the number of cases and consequently collapsing of the health system in the country may have contributed in the rise of mucormycosis cases in various ways, including multiple iatrogenic causes, such as no proper sterilization of the medical equipment and the hospital wards. Wearing unclean face masks carrying fungal spores and other unhygienic practices might have also contributed in rise of the cases (4). However, no significant reporting of mucormycosis cases during the first wave of COVID-19 pandemic poses some valid questions, whether the newer SARS-CoV-2 variants, particularly that of B.1.617 lineage which are being suggested as the driver of the second wave in India (5), are causing greater and/or early immunosuppression than the wild strain. Emerging evidence suggest that the new SARS-CoV-2 strains, including that of B.1.617 lineage, may have increased virulence (6,7). Although, certain degree of lymphocytopenia irrespective of the severity status has been a characteristic of COVID-19, any significant immunosuppression was observed in only severe cases (8). We need to study if there has been a change in this pattern with new variants. A comparative retrospective study of the count of the immune cells, primarily lymphocytes, in the blood samples of COVID-19 patients infected during the first and second waves, may potentially inform on this. Also, a selective study of the COVID-19 patients who have recently developed mucormycosis may substantiate this further.
References:
1. Declare mucormycosis an epidemic, Centre tells States - The Hindu [Internet]. [cited 2021 May 25]. Available from: https://www.thehindu.com/news/national/declare-mucormycosis-an-epidemic-...
2. Ibrahim AS, Spellberg B, Walsh TJ, Kontoyiannis DP. Pathogenesis of mucormycosis. Clin Infect Dis [Internet]. 2012 Feb 1 [cited 2021 May 25];54(SUPPL. 1):S16–22. Available from: http://www.broadinstitute.org/annotation/genome/
3. Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev [Internet]. 2021 May 21 [cited 2021 May 25]; Available from: https://linkinghub.elsevier.com/retrieve/pii/S1871402121001570
4. What is mucormycosis, the fungal infection affecting COVID patients in India? [Internet]. [cited 2021 May 25]. Available from: https://theconversation.com/what-is-mucormycosis-the-fungal-infection-af...
5. Vaidyanathan G. Coronavirus variants are spreading in India - what scientists know so far. Nature [Internet]. 2021 May 11 [cited 2021 May 25]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/33976409
6. Grint DJ, Wing K, Williamson E, McDonald HI, Bhaskaran K, Evans D, et al. Case fatality risk of the SARS-CoV-2 variant of concern B.1.1.7 in England, 16 November to 5 February. Euro Surveill [Internet]. 2021 Mar 1 [cited 2021 May 25];26(11). Available from: https://pubmed.ncbi.nlm.nih.gov/33739254/
7. Yadav PD, Mohandas S, Shete AM, Nyayanit DA, Gupta N, Patil DY, et al. SARS CoV-2 variant B.1.617.1 is highly pathogenic in hamsters than B.1 variant. bioRxiv [Internet]. 2021 May 5 [cited 2021 May 25];2021.05.05.442760. Available from: https://doi.org/10.1101/2021.05.05.442760
8. Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z, et al. Viral and host factors related to the clinical outcome of COVID-19. Nature [Internet]. 2020 May 20 [cited 2020 May 27];1–7. Available from: http://www.nature.com/articles/s41586-020-2355-0
The data that is represented in footnote 21 (rate of 6 in 42,000 vs. the rate of .08 - 1.1 in 100,000) is significant. It represents approximately a 1 in 7,000 rate! I think that this is worth highlighting in a separate article.
Dear Editor,
Mucormycosis is a fatal fungal infections that mainly affects people who are on medications for other health problems that reduces their ability to fight for environmental pathogens.India is a known to have high burden of mucormycosis cases especially in those with unconrolled type 2DM and prevalence of mucormycosis has gone this time up to 2.1times to 3 times during covid 19 pandemic in India. This may be termed as Covid Associated Mucormycosis or CAM.Prvalance of CAM amongst the covid-19 patients is 0.27/%,and in ICU or in CCU is 1.6% when they are treated with steroid and to those in patients who had high level of blood sugar due to covid- 19 or have high level of ferritin.Occasionally in patients with unconrolled DM ( whose neutrophils functions is impaired in diabetic and those who have neutropenia or altered NL ratio as in covid 19 , as primary defence of mucormycosis is done with neutrophils attached with hyphae ) or in hematlogical malignancies, or in hemopoietic stem cells transplant or in solid organ transplant or in patient's with vercanzole therapy or with immunomodulatory drugs or other immunosuppressive drugs develop fatal mucormycosis.
In covid 19 wards or in SARI wards mucormycosis may develop due to 1) That NL ratio is altered 2) from treatment of steroid dexamethasone injection 3) use of tocilizumab therapy 4) uses of Immunomodulatory drugs like Baricitinib ,tofacitinib and usually found in later part of treatment ....
Dear Editor,
Mucormycosis is a fatal fungal infections that mainly affects people who are on medications for other health problems that reduces their ability to fight for environmental pathogens.India is a known to have high burden of mucormycosis cases especially in those with unconrolled type 2DM and prevalence of mucormycosis has gone this time up to 2.1times to 3 times during covid 19 pandemic in India. This may be termed as Covid Associated Mucormycosis or CAM.Prvalance of CAM amongst the covid-19 patients is 0.27/%,and in ICU or in CCU is 1.6% when they are treated with steroid and to those in patients who had high level of blood sugar due to covid- 19 or have high level of ferritin.Occasionally in patients with unconrolled DM ( whose neutrophils functions is impaired in diabetic and those who have neutropenia or altered NL ratio as in covid 19 , as primary defence of mucormycosis is done with neutrophils attached with hyphae ) or in hematlogical malignancies, or in hemopoietic stem cells transplant or in solid organ transplant or in patient's with vercanzole therapy or with immunomodulatory drugs or other immunosuppressive drugs develop fatal mucormycosis.
In covid 19 wards or in SARI wards mucormycosis may develop due to 1) That NL ratio is altered 2) from treatment of steroid dexamethasone injection 3) use of tocilizumab therapy 4) uses of Immunomodulatory drugs like Baricitinib ,tofacitinib and usually found in later part of treatment .
Mucormycosis is a fatal fungal infections that mainly occurred during covid 19 pandemic in India. There have been multiple reports in news media's and in news papers across the country as termed it black fungus. Mucormycosis is not however a black fungus at all. Black fungus are rather different categories of fungus with melanin pigments. Mucormycosis fungi remain in the air and does not spread by contact or by oxygenation, humidifier,and water. The fungi remain in air indoor of wards or outdoor OPD system of hospital and in environment. The spores enters the respiratory tract via inhalation of air
Across the country india for last one month of very many incidence of mucormycosis against patients with covid -19 , especially who received dexamethasone with co morbidity diabetes mellitus and associated with high mortality and morbidities. The common presentation of covid 19 (active/recovering/or in post covid state) with mucormycosis are nasal blockade, nasal congestion, nasal discharge nasal bleeding ( bloody brown or black), local pain , facial pain, numbness,or swelling, head ache, orbital pain,tooth ache, loosening of maxillary tooth,jaw involvement,blurred or double vision with eye redness parasthesia, fever, skin rashes with eschar .When there is pulmonary involvement fever,cough, chest pain, pleural effusion,heamptosis, worsen respiratory symptoms.When HRCT lung is done may be confused with covid 19 related shadows ,reverse halo sign, cavity , multiple nodules,pleural effusion
The diagnosis is to be done either by pulmonary Bronchi alveolar lavage (BAL) ,mini BAL, nonbrochogenic lavage, sputum, larger transbronchial biopsy , CT guided biopsy from lung pleura by H&E stain followed by PAS stain and GMS or Grocot stain and culture in sabourdaud dextrose agar media. In GMS stain asptate or sparsely septate broad black hyphae found and in SDS agar media cottony rapid growth with or without black head. No serological or biochemical tests like galactomanan or beta D glycan tests will be positive. The treatment is control of blood sugar , diabetic ketoacidosis, in covid 19 patients, reduction of steroid with aim to sharp discontinue of steroid and other immunomodulators , if patients is receiving and use of liposomal amphotericin B promptly by IV infusion. There is no antifungal prophylaxis for mucormycosis
Acknowledgments 1)To Professor Dr Banya chakraborty , Prof and Head, microbiology of Calcutta School of Tropical Medicine ,108 Chittaranjan Avenue Kolkata 73 West Bengal India
2) To Prof . Dr Arunalok Chakraborty ,Prof and head microbiology at Post Graduate institutev of Medical Research ,Chandigarh India for discussion and formation of guidelines of diagnosis and treatment protocol for mucormycosis in covid 19 patients
References
1) RECOVERY Collaborative Group.
Dexamethasone in Hospitalized Patients with
Covid-19. N Engl J Med. 2021 Feb 25;384(8)
2). WHO Rapid Evidence Appraisal for COVID-19
Therapies (REACT) Working Group, . Association
Between Administration of Systemic
Corticosteroids and Mortality Among Critically
Ill Patients With COVID-19: A Meta-analysis.
JAMA. 2020 Oct 6;324(13):1330-1341
3.)https://www.mohfw.gov.in/pdf/ClinicalGuidanceonDiabetesManagementatCOVID... Facility.pdf
4.) Global guideline for the diagnosis &
management of mucormycosis. Lancet infectious disease
5) covid 19 associated mucormycosis (CAM) fungal infection study forum (FISF) recommendation http://www.fisttrust.org
Dear Editor,
Mucormycosis is a fatal fungal infections that mainly affects people who are on medications for other health problems that reduces their ability to fight for environmental pathogens.India is a known to have high burden of mucormycosis cases especially in those with un controlled type 2DM and prevalence of mucormycosis has gone this time up to 2.1times to 3 times during second wave of covid 19 pandemic in India. This may be termed as Covid Associated Mucormycosis or CAM.Prvalance of CAM amongst the covid-19 patients is 0.27/%,and in ICU or in CCU is 1.6% when they are treated with steroid and to those in patients who had high level of blood sugar due to covid- 19 or have high level of ferritin.Occasionally in patients with unconrolled DM ( whose neutrophils functions is impaired in diabetic and those who have neutropenia or altered NL ratio as in covid 19 , as primary defence of mucormycosis is done with neutrophils attached with hyphae ) or in hematlogical malignancies, or in hemopoietic stem cells transplant or in solid organ transplant or in patient's with vercanzole therapy or with immunomodulatory drugs or other immunosuppressive drugs develop fatal mucormycosis.
In covid 19 wards or in SARI wards mucormycosis may develop due to 1) That NL ratio is altered 2) from treatment of steroid dexamethasone injection 3) use of tocilizumab therapy 4) uses of Immunomodulatory drugs like Baricitinib ,tofacitinib and usually found in later pa...
Dear Editor,
Mucormycosis is a fatal fungal infections that mainly affects people who are on medications for other health problems that reduces their ability to fight for environmental pathogens.India is a known to have high burden of mucormycosis cases especially in those with un controlled type 2DM and prevalence of mucormycosis has gone this time up to 2.1times to 3 times during second wave of covid 19 pandemic in India. This may be termed as Covid Associated Mucormycosis or CAM.Prvalance of CAM amongst the covid-19 patients is 0.27/%,and in ICU or in CCU is 1.6% when they are treated with steroid and to those in patients who had high level of blood sugar due to covid- 19 or have high level of ferritin.Occasionally in patients with unconrolled DM ( whose neutrophils functions is impaired in diabetic and those who have neutropenia or altered NL ratio as in covid 19 , as primary defence of mucormycosis is done with neutrophils attached with hyphae ) or in hematlogical malignancies, or in hemopoietic stem cells transplant or in solid organ transplant or in patient's with vercanzole therapy or with immunomodulatory drugs or other immunosuppressive drugs develop fatal mucormycosis.
In covid 19 wards or in SARI wards mucormycosis may develop due to 1) That NL ratio is altered 2) from treatment of steroid dexamethasone injection 3) use of tocilizumab therapy 4) uses of Immunomodulatory drugs like Baricitinib ,tofacitinib and usually found in later part of treatment .
Mucormycosis is a fatal fungal infections that mainly occurred during covid 19 pandemic in India. There have been multiple reports in news media's and in news papers across the country as termed it black fungus. Mucormycosis is not however a black fungus at all. Black fungus are rather different categories of fungus with melanin pigments. Mucormycosis fungi remain in the air and does not spread by contact or by oxygenation, humidifier,and water. The fungi remain in air indoor of wards or outdoor OPD system of hospital and in environment. The spores enters the respiratory tract via inhalation of air
Across the country india for last one month of very many incidence of mucormycosis against patients with covid -19 , especially who received dexamethasone with co morbidity diabetes mellitus and associated with high mortality and morbidities. The common presentation of covid 19 (active/recovering/or in post covid state) with mucormycosis are nasal blockade, nasal congestion, nasal discharge nasal bleeding ( bloody brown or black), local pain , facial pain, numbness,or swelling, head ache, orbital pain,tooth ache, loosening of maxillary tooth,jaw involvement,blurred or double vision with eye redness parasthesia, fever, skin rashes with eschar .When there is pulmonary involvement fever,cough, chest pain, pleural effusion,heamptosis, worsen respiratory symptoms.When HRCT lung is done may be confused with covid 19 related shadows ,reverse halo sign, cavity , multiple nodules,pleural effusion
The diagnosis is to be done either by pulmonary Bronchi alveolar lavage (BAL) ,mini BAL, nonbrochogenic lavage, sputum, larger transbronchial biopsy , CT guided biopsy from lung pleura by H&E stain followed by PAS stain and GMS or Grocot stain and culture in sabourdaud dextrose agar media. In GMS stain asptate or sparsely septate broad black hyphae found and in SDS agar media cottony rapid growth with or without black head. No serological or biochemical tests like galactomanan or beta D glycan tests will be positive. The treatment is control of blood sugar , diabetic ketoacidosis, in covid 19 patients, reduction of steroid with aim to sharp discontinue of steroid and other immunomodulators , if patients is receiving and use of liposomal amphotericin B promptly by IV infusion. There is no antifungal prophylaxis for mucormycosis
Acknowledgments 1)To Professor Dr Banya chakraborty , Prof and Head, microbiology of Calcutta School of Tropical Medicine ,108 Chittaranjan Avenue Kolkata 73 West Bengal India
2) To Prof . Dr Arunalok Chakraborty ,Prof and head microbiology at Post Graduate institutev of Medical Research ,Chandigarh India for discussion and formation of guidelines of diagnosis and treatment protocol for mucormycosis in covid 19 patients
References
1) RECOVERY Collaborative Group.
Dexamethasone in Hospitalized Patients with
Covid-19. N Engl J Med. 2021 Feb 25;384(8)
2). WHO Rapid Evidence Appraisal for COVID-19
Therapies (REACT) Working Group, . Association
Between Administration of Systemic
Corticosteroids and Mortality Among Critically
Ill Patients With COVID-19: A Meta-analysis.
JAMA. 2020 Oct 6;324(13):1330-1341
3.)https://www.mohfw.gov.in/pdf/ClinicalGuidanceonDiabetesManagementatCOVID... Facility.pdf
4.) Global guideline for the diagnosis &
management of mucormycosis. Lancet infectious disease
5) covid 19 associated mucormycosis (CAM) fungal infection study forum (FISF) recommendation http://www.fisttrust.org
The association between heart failure and energy drink consumption is based on the entire clinical course rather than the presentation alone. The patient remains in renal failure with renal biochemistry similar to presentation and has not received renal replacement therapy for some time. Despite this, the patient is no longer in heart failure with a significant improvement in cardiac function occurring prior to the introduction of heart failure medications - carvedilol, hydralazine and isosorbide dinitrite. The clinical course of spontaneous recovery was similar to the cited case report from Belzile and colleagues and hence our reason for bringing this to attention and contributing to greater awareness. We welcome the comments and debate as there is no test to confirm the relationship to energy drink intake and therefore extensive clinical characterisation is required to exclude alternative causes of severe heart failure. Severe heart failure which improves spontaneously to this magnitude - LVEF 9% to 51% is particularly rare.
Please see below for clarification to your queries:
1) What was Central Venous Pressure:
The CVP pressure was not measured as the patient was relatively well. Are you perhaps referring to JVP which was unremarkable.
2) If patient was, presumably Conscious, Oriented, able to take Food and Fluids by Mouth, could the Intravenous Administration of Fluids be avoided?
It is possible that IV fluids could have been avoided but in view of his AKI it was felt prudent to rehydrate with IV fluids. We appreciate that management in this scenario will differ.
3) How did the Elevated Blood Pressure evolved during Hospitalization, either with or without Medications.
He had only one dose of amlodipine as inpatient and didn’t require any further doses for BP control. On discharge his Blood pressure was within normal limits and his GP was advised to continue monitoring his blood pressure as he had previously been doing.
4) What was Patient's Diet and Fluid Intake Both Quantitative and Qualitative during the Hospitalization?
AKI resolved within 24 hours of admission so exact fluid intake, urinary output and diet were not documented.
5) Whether the Patient took any Formal or Alternative Medicines or Home Remedies for Coryza he had Two Weeks before Episode of Shortness of Breath, that could have caused Autoimmune Hemolysis?
Please see below for clarification to your queries:
1) What was Central Venous Pressure:
The CVP pressure was not measured as the patient was relatively well. Are you perhaps referring to JVP which was unremarkable.
2) If patient was, presumably Conscious, Oriented, able to take Food and Fluids by Mouth, could the Intravenous Administration of Fluids be avoided?
It is possible that IV fluids could have been avoided but in view of his AKI it was felt prudent to rehydrate with IV fluids. We appreciate that management in this scenario will differ.
3) How did the Elevated Blood Pressure evolved during Hospitalization, either with or without Medications.
He had only one dose of amlodipine as inpatient and didn’t require any further doses for BP control. On discharge his Blood pressure was within normal limits and his GP was advised to continue monitoring his blood pressure as he had previously been doing.
4) What was Patient's Diet and Fluid Intake Both Quantitative and Qualitative during the Hospitalization?
AKI resolved within 24 hours of admission so exact fluid intake, urinary output and diet were not documented.
5) Whether the Patient took any Formal or Alternative Medicines or Home Remedies for Coryza he had Two Weeks before Episode of Shortness of Breath, that could have caused Autoimmune Hemolysis?
The patient had not taken any over the counter medication/herbal medications for his symptoms. This was confirmed on patient’s records.
6) If the Patient's Blood Pressure before Present Illnesses was known and if he took any medications for it and any other conditions eg Bleeding per Rectum?
He had previously been started on antihypertensive medications. These were Bisoprolol and Ramipril. He stopped Bisoprolol himself, after discussion with the GP, because he felt tired and Ramipril was discontinued because of cough. His BP was monitored on further GP visits and was within normal limits without any medications.
He was reviewed by Gastroenterology team as inpatient and upper GI bleed was excluded.
For bleeding PR an outpatient colonoscopy was requested which subsequently showed first degree haemorrhoids and a few diverticulae in the sigmoid colon.
7) What were the instructions including those regarding medications diet and follow-up given to the Patient at the time of Discharge?
No specific advice was given regarding to diet. Repeat blood tests were advised which were kindly performed and followed up by the GP. These had returned to normal. It is an excellent point to comment on the role of diet in patients with high blood pressure. It is not current practice to discuss about diet as an inpatient unless there are compelling reasons to do so however discussions on healthy life style should be built into our regular practice.
Bisoprolol was restarted after discussion with patient because of an episode of SVT in the hospital.
We hope that these answer your queries and many thanks for bringing these to our attention.
Dear Dr. Biswas,
In their recent article ‘Anaplastic astrocytoma during pregnancy: the importance of an effective multidisciplinary approach’, Filippi and colleagues described the therapeutic strategy for a pregnant patient whose left parietal glioma was discovered after a new-onset generalized seizure [1]. Following the multidisciplinary conference, they planned to attain a full-term pregnancy with staged tumor resection. First, the mass reduction was performed with neuronavigation and fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) under general anesthesia. Then awake craniotomy was planned for the residual tumor removal after delivery. Although the authors have provided excellent perioperative care for this complicated case, we have some reservations about the therapeutic strategy for malignant glioma in a pregnant patient.
The guidelines for the diagnosis and treatment of gliomas, released by the European Association for Neuro-Oncology, present the following management options for newly diagnosed malignant glioma: resection or biopsy, followed by radiotherapy or chemotherapy (or combined modality treatment) [2]. In pregnant patients, the neurosurgical intervention for a malignant tumor is recommended regardless of gestational age, although the 32 week gestation point is generally used as the cutoff [3]. The extent of glioma resection is a decisive prognosis factor irrespective of tumor subtype [4]. In view of the absence of information on th...
Dear Dr. Biswas,
In their recent article ‘Anaplastic astrocytoma during pregnancy: the importance of an effective multidisciplinary approach’, Filippi and colleagues described the therapeutic strategy for a pregnant patient whose left parietal glioma was discovered after a new-onset generalized seizure [1]. Following the multidisciplinary conference, they planned to attain a full-term pregnancy with staged tumor resection. First, the mass reduction was performed with neuronavigation and fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) under general anesthesia. Then awake craniotomy was planned for the residual tumor removal after delivery. Although the authors have provided excellent perioperative care for this complicated case, we have some reservations about the therapeutic strategy for malignant glioma in a pregnant patient.
The guidelines for the diagnosis and treatment of gliomas, released by the European Association for Neuro-Oncology, present the following management options for newly diagnosed malignant glioma: resection or biopsy, followed by radiotherapy or chemotherapy (or combined modality treatment) [2]. In pregnant patients, the neurosurgical intervention for a malignant tumor is recommended regardless of gestational age, although the 32 week gestation point is generally used as the cutoff [3]. The extent of glioma resection is a decisive prognosis factor irrespective of tumor subtype [4]. In view of the absence of information on the long-term effects on newborns of mothers that received anticonvulsants, chemotherapeutics, or radiation during pregnancy [5], the fact that the patient could be safely monitored without the need for adjuvant therapies is commendable [4].
The surgical strategy for eloquent malignant glioma in a pregnant patient offers two options. One is the two-staged strategy, as Filippi and colleagues presented, and the other is a single-stage operation with awake craniotomy in order to achieve maximum tumor resection with minimum postoperative neurological deficits. While awake craniotomy in pregnant patients is still challenging, several reports show that extensive resection with neurological monitoring is the best way to preserve the patient's motor and speech function [6-7]. Compared with the tumor removal under general anesthesia, awake craniotomy has some advantages on fetal-maternal wellbeing. The higher reliability of functional reservation is considered the most significant benefit of awake craniotomy. Especially among pregnant patients, electrophysiological monitoring and functional mapping should be minimized to reduce the risk of seizure occurrence and subsequent fetal hypoxia. As our previous case shows, the patient's subjective movement is a substitute for motor-evoked potential monitoring [7]. Maternal use of 5-ALA can be avoided in cases of awake craniotomy. In the last two decades, 5-ALA-induced fluorescence was introduced as a valuable technique for intraoperative visualization and improved resection of malignant gliomas [8]. However, its use during pregnancy is still prohibited in the European Public Assessment Report released by European Medicines Agency [9]. Fluorescence-guided surgery using 5-ALA is helpful for the identification of residual malignant glioma intraoperatively, but in the case presented by the authors, cortical or subcortical stimulation is truly informative to determine the resectable edge from the eloquent area. Considering the possible adverse reaction of 5-ALA to both the patient and fetus, fluorescence-guided surgery cannot be considered the best approach. The last concern is the detrimental effects of general anesthetics. Propofol, the most common sedative in neuroanesthesia, caused maternal mild metabolic acidosis after prolonged infusion [10]. On the other hand, volatile anesthetics have a significant tocolytic effect. Thus, awake craniotomy can reduce these unfavorable effects of general anesthesia on the patient and the fetus.
Due to the limited evidence on the use of adjuvant therapy during pregnancy, tumors causing neurological symptoms and seizures must be treated to stabilize the maternal condition and enable a safe birth. As far as the extent of tumor resection in malignant glioma is a decisive prognosis factor, the single-stage strategy with awake craniotomy should be considered an alternative. The multidisciplinary discussion should take place within the decision-making process, and careful perioperative preparation is mandatory.
References
1. Filippi V, Leu SM, Marengo L, et al. Anaplastic astrocytoma during pregnancy: the importance of an effective multidisciplinary approach. BMJ Case Rep 2021;14:e242135.
2. Weller M, van den Bent M, Hopkins K, et al. EANO guideline for the diagnosis and treatment of anaplastic gliomas and glioblastoma. Lancet Oncol 2014;15:e395-403.
3. Lynch JC, Gouvêa F, Emmerich JC, et al. Management strategy for brain tumour diagnosed during pregnancy. Br J Neurosurg 2011;25:225-30.
4. Nitta M, Muragaki Y, Maruyama T, et al. Proposed therapeutic strategy for adult low-grade glioma based on aggressive tumor resection. Neurosurg Focus 2015;38:E7.
5. Zwinkels H, Dörr J, Kloet F, et al. Pregnancy in women with gliomas: a case-series and review of the literature. J Neurooncol 2013;115:293-301.
6. Al-Mashani AM, Ali A, Chatterjee N, et al. Awake craniotomy during pregnancy. J Neurosurg Anesthesiol 2018;30:372-3..
7. Kamata K, Fukushima R, Nomura M, et al. A case of left frontal high-grade glioma diagnosed during pregnancy. JA Clin Rep 2017;3:18.
8. Stummer W, Pichlmeier U, Meinel T, et al. Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomized controlled multicentre phase Ⅲ trial. Lancet Oncol 2006;7:392-401.
9. European Public Assessment Report (EPAR) GLIOLAN. Available at: https://www.ema.europa.eu/en/documents/overview/gliolan-epar-summary-pub.... Accessed 20 April 2021.
10. Sethuraman M, Neema PK, Rathod RC. Prolonged propofol infusion in pregnant neurosurgical patients. J Neurosurg Anesthesiol 2007;19:67-8.
We reported this case as a possible early association during the first wave when it was impossible to discern whether there was a true connection between COVID and SSNHL, let alone determine the incidence. The paper was clear that direct causation wasn’t proven, but it served to highlight the importance of prompt treatment of SSNHL which is often associated with viral aetiologies.
The case report was written to create early awareness of a possible link. Since then, a BRC funded team in Manchester have published a systematic review linking the two and are also undertaking a year-long study into the association. An NIHR/BRC team in Nottingham are doing similarly.
We reported this case as a possible early association during the first wave when it was impossible to discern whether there was a true connection between COVID and SSNHL, let alone determine the incidence. The paper was clear that direct causation wasn’t proven, but it served to highlight the importance of prompt treatment of SSNHL which is often associated with viral aetiologies.
The case report was written to create early awareness of a possible link. Since then, a BRC funded team in Manchester have published a systematic review linking the two and are also undertaking a year-long study into the association. An NIHR/BRC team in Nottingham are doing similarly.
Hopefully these studies will provide further clarification and answer the questions posed in your letter which our case report was never designed to do.”
The authors implicate caffeine as the causative agent of the cardiomyopathy in this case, caffeine being the main active ingredient within energy drinks. They ask that we enquire about energy drinks within our social histories; consumption of caffeinated products indeed not part of a standard cardiovascular history (1).
It is therefore conspicuous that within the article there are no calls to enquire about other, more widely used caffeine containing products, specifically tea and coffee. Dare I say, we would be unlikely to baulk at the idea of a patient drinking three or four coffees in a day. In fact, on the wards we offer patients tea or coffee eight times a day, yet think little of the caffeine burden we are imposing upon them. This almost tacit caffeine consumption is unlikely to make it into the medical notes, yet these patients would potentially be consuming levels of caffeine far in excess of the quantity consumed in this case report.
We seem to apply different value judgements to different drinks, assuming those drinking excess caffeine from expensive coffee machines are doing so knowingly, and as part of a healthy lifestyle. Yet we don’t afford those choosing to consume energy drinks with the same level of ability to make an informed choice. We medicalise the consumption of such drinks, assuming those using them must be doing so for sinister reasons.
We should treat all caffeinated products equally, given there is no pharmacological differen...
The authors implicate caffeine as the causative agent of the cardiomyopathy in this case, caffeine being the main active ingredient within energy drinks. They ask that we enquire about energy drinks within our social histories; consumption of caffeinated products indeed not part of a standard cardiovascular history (1).
It is therefore conspicuous that within the article there are no calls to enquire about other, more widely used caffeine containing products, specifically tea and coffee. Dare I say, we would be unlikely to baulk at the idea of a patient drinking three or four coffees in a day. In fact, on the wards we offer patients tea or coffee eight times a day, yet think little of the caffeine burden we are imposing upon them. This almost tacit caffeine consumption is unlikely to make it into the medical notes, yet these patients would potentially be consuming levels of caffeine far in excess of the quantity consumed in this case report.
We seem to apply different value judgements to different drinks, assuming those drinking excess caffeine from expensive coffee machines are doing so knowingly, and as part of a healthy lifestyle. Yet we don’t afford those choosing to consume energy drinks with the same level of ability to make an informed choice. We medicalise the consumption of such drinks, assuming those using them must be doing so for sinister reasons.
We should treat all caffeinated products equally, given there is no pharmacological difference between them. Indeed, the caffeine found in energy drinks is extracted from coffee; a by-product of decaffeinated coffee production.
Further, I feel it unfair to suggest manufactures should provide warnings on cans, given that they already do – displaying both caffeine content, and warnings about its excessive consumption in certain groups. Indeed, these warnings and caffeine contents are absent from the sides of tea and coffee packaging, therein further preventing us from quantifying caffeine consumption.
That said, it is undeniable that the caffeine content of these drinks has increased over time, and it is not an unreasonable assumption that caffeine is to blame for the symptoms described in this case. Twenty years ago, the humble initial offerings of these drinks were a 250ml can with 75mg of caffeine. Today the bar has shifted to 200mg of caffeine in one can, and the market trend of increasing caffeine shows no signs of abating. This could be problematic, and lead to unwitting excess consumption as in this case report.
Direct regulation of these markets is often a wise solution. Rather than posting unheeded warnings of sugar content on the side of cans, the tax on sugar forced the hand of the market to adapt and reduce the sugar content within energy drinks, often to nil, and therein obviating the detrimental effects of sugar outright (2).
The same could be done for caffeine content; a cap of 20mg/100ml, or an overall cap of 100mg in any one drink would seem appropriate, though admittedly little can be done to stop people drinking multiple cans as in this case.
Like them or loathe them, these products do at least appeal to an ideal of activity, which should be celebrated in our overly sedentary society.
(1) Innes, J.A. et al., 2018. Macleod's Clinical Examination, Elsevier, pp.39-74
(2) Pell, D., Mytton, O., Penney, T.L., Briggs, A., Cummins, S., Penn-Jones, C., Rayner, M., Rutter, H., Scarborough, P., Sharp, S.J., Smith, R.D., White, M., Adams, J., 2021. Changes in soft drinks purchased by British households associated with the UK soft drinks industry levy: Controlled interrupted time series analysis. The BMJ 372. https://doi.org/10.1136/bmj.n254
Dear Editor,
Show MoreThis case report presents a very important accompaniment of COVID-19 illness which has currently raised up to epidemic scale in India (1). There is sound empirical evidence that unsupervised use of steroids, uncontrolled blood sugar and existing immunosuppression in COVID-19 may predispose the patients to the opportunistic mucormycosis infection (2,3). Surprisingly, co-infection with mucormycosis were rarely reported during the first wave in India, although the pandemic had spread extensively in the country. There is a possibility that sudden and massive increase in the number of cases and consequently collapsing of the health system in the country may have contributed in the rise of mucormycosis cases in various ways, including multiple iatrogenic causes, such as no proper sterilization of the medical equipment and the hospital wards. Wearing unclean face masks carrying fungal spores and other unhygienic practices might have also contributed in rise of the cases (4). However, no significant reporting of mucormycosis cases during the first wave of COVID-19 pandemic poses some valid questions, whether the newer SARS-CoV-2 variants, particularly that of B.1.617 lineage which are being suggested as the driver of the second wave in India (5), are causing greater and/or early immunosuppression than the wild strain. Emerging evidence suggest that the new SARS-CoV-2 strains, including that of B.1.617 lineage, may have increased virulence (6,7). Although, certai...
Do emerging SARS-CoV-2 variants cause early and greater immunosuppression which may contribute to co-infection with mucormycosis?
Dear Editor,
Show MoreThis case report presents a very important accompaniment of COVID-19 illness which has currently raised up to epidemic scale in India (1). There is sound empirical evidence that unsupervised use of steroids, uncontrolled blood sugar and existing immunosuppression in COVID-19 may predispose the patients to the opportunistic mucormycosis infection (2,3). Surprisingly, co-infection with mucormycosis were rarely reported during the first wave in India, although the pandemic had spread extensively in the country. There is a possibility that sudden and massive increase in the number of cases and consequently collapsing of the health system in the country may have contributed in the rise of mucormycosis cases in various ways, including multiple iatrogenic causes, such as no proper sterilization of the medical equipment and the hospital wards. Wearing unclean face masks carrying fungal spores and other unhygienic practices might have also contributed in rise of the cases (4). However, no significant reporting of mucormycosis cases during the first wave of COVID-19 pandemic poses some valid questions, whether the newer SARS-CoV-2 variants, particularly that of B.1.617 lineage which are being suggested as the driver of the second wave in India (5), are causing greater and/or early immunosuppression than the wild strain. Emerging...
The data that is represented in footnote 21 (rate of 6 in 42,000 vs. the rate of .08 - 1.1 in 100,000) is significant. It represents approximately a 1 in 7,000 rate! I think that this is worth highlighting in a separate article.
Dear Editor,
Show MoreMucormycosis is a fatal fungal infections that mainly affects people who are on medications for other health problems that reduces their ability to fight for environmental pathogens.India is a known to have high burden of mucormycosis cases especially in those with unconrolled type 2DM and prevalence of mucormycosis has gone this time up to 2.1times to 3 times during covid 19 pandemic in India. This may be termed as Covid Associated Mucormycosis or CAM.Prvalance of CAM amongst the covid-19 patients is 0.27/%,and in ICU or in CCU is 1.6% when they are treated with steroid and to those in patients who had high level of blood sugar due to covid- 19 or have high level of ferritin.Occasionally in patients with unconrolled DM ( whose neutrophils functions is impaired in diabetic and those who have neutropenia or altered NL ratio as in covid 19 , as primary defence of mucormycosis is done with neutrophils attached with hyphae ) or in hematlogical malignancies, or in hemopoietic stem cells transplant or in solid organ transplant or in patient's with vercanzole therapy or with immunomodulatory drugs or other immunosuppressive drugs develop fatal mucormycosis.
In covid 19 wards or in SARI wards mucormycosis may develop due to 1) That NL ratio is altered 2) from treatment of steroid dexamethasone injection 3) use of tocilizumab therapy 4) uses of Immunomodulatory drugs like Baricitinib ,tofacitinib and usually found in later part of treatment ....
Dear Editor,
Show MoreMucormycosis is a fatal fungal infections that mainly affects people who are on medications for other health problems that reduces their ability to fight for environmental pathogens.India is a known to have high burden of mucormycosis cases especially in those with un controlled type 2DM and prevalence of mucormycosis has gone this time up to 2.1times to 3 times during second wave of covid 19 pandemic in India. This may be termed as Covid Associated Mucormycosis or CAM.Prvalance of CAM amongst the covid-19 patients is 0.27/%,and in ICU or in CCU is 1.6% when they are treated with steroid and to those in patients who had high level of blood sugar due to covid- 19 or have high level of ferritin.Occasionally in patients with unconrolled DM ( whose neutrophils functions is impaired in diabetic and those who have neutropenia or altered NL ratio as in covid 19 , as primary defence of mucormycosis is done with neutrophils attached with hyphae ) or in hematlogical malignancies, or in hemopoietic stem cells transplant or in solid organ transplant or in patient's with vercanzole therapy or with immunomodulatory drugs or other immunosuppressive drugs develop fatal mucormycosis.
In covid 19 wards or in SARI wards mucormycosis may develop due to 1) That NL ratio is altered 2) from treatment of steroid dexamethasone injection 3) use of tocilizumab therapy 4) uses of Immunomodulatory drugs like Baricitinib ,tofacitinib and usually found in later pa...
The association between heart failure and energy drink consumption is based on the entire clinical course rather than the presentation alone. The patient remains in renal failure with renal biochemistry similar to presentation and has not received renal replacement therapy for some time. Despite this, the patient is no longer in heart failure with a significant improvement in cardiac function occurring prior to the introduction of heart failure medications - carvedilol, hydralazine and isosorbide dinitrite. The clinical course of spontaneous recovery was similar to the cited case report from Belzile and colleagues and hence our reason for bringing this to attention and contributing to greater awareness. We welcome the comments and debate as there is no test to confirm the relationship to energy drink intake and therefore extensive clinical characterisation is required to exclude alternative causes of severe heart failure. Severe heart failure which improves spontaneously to this magnitude - LVEF 9% to 51% is particularly rare.
Dear Sir/Madam,
Thank you for your comments
Please see below for clarification to your queries:
1) What was Central Venous Pressure:
The CVP pressure was not measured as the patient was relatively well. Are you perhaps referring to JVP which was unremarkable.
2) If patient was, presumably Conscious, Oriented, able to take Food and Fluids by Mouth, could the Intravenous Administration of Fluids be avoided?
It is possible that IV fluids could have been avoided but in view of his AKI it was felt prudent to rehydrate with IV fluids. We appreciate that management in this scenario will differ.
3) How did the Elevated Blood Pressure evolved during Hospitalization, either with or without Medications.
He had only one dose of amlodipine as inpatient and didn’t require any further doses for BP control. On discharge his Blood pressure was within normal limits and his GP was advised to continue monitoring his blood pressure as he had previously been doing.
4) What was Patient's Diet and Fluid Intake Both Quantitative and Qualitative during the Hospitalization?
AKI resolved within 24 hours of admission so exact fluid intake, urinary output and diet were not documented.
5) Whether the Patient took any Formal or Alternative Medicines or Home Remedies for Coryza he had Two Weeks before Episode of Shortness of Breath, that could have caused Autoimmune Hemolysis?
The patient had not...
Show MoreDear Dr. Biswas,
Show MoreIn their recent article ‘Anaplastic astrocytoma during pregnancy: the importance of an effective multidisciplinary approach’, Filippi and colleagues described the therapeutic strategy for a pregnant patient whose left parietal glioma was discovered after a new-onset generalized seizure [1]. Following the multidisciplinary conference, they planned to attain a full-term pregnancy with staged tumor resection. First, the mass reduction was performed with neuronavigation and fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) under general anesthesia. Then awake craniotomy was planned for the residual tumor removal after delivery. Although the authors have provided excellent perioperative care for this complicated case, we have some reservations about the therapeutic strategy for malignant glioma in a pregnant patient.
The guidelines for the diagnosis and treatment of gliomas, released by the European Association for Neuro-Oncology, present the following management options for newly diagnosed malignant glioma: resection or biopsy, followed by radiotherapy or chemotherapy (or combined modality treatment) [2]. In pregnant patients, the neurosurgical intervention for a malignant tumor is recommended regardless of gestational age, although the 32 week gestation point is generally used as the cutoff [3]. The extent of glioma resection is a decisive prognosis factor irrespective of tumor subtype [4]. In view of the absence of information on th...
The authors implicate caffeine as the causative agent of the cardiomyopathy in this case, caffeine being the main active ingredient within energy drinks. They ask that we enquire about energy drinks within our social histories; consumption of caffeinated products indeed not part of a standard cardiovascular history (1).
It is therefore conspicuous that within the article there are no calls to enquire about other, more widely used caffeine containing products, specifically tea and coffee. Dare I say, we would be unlikely to baulk at the idea of a patient drinking three or four coffees in a day. In fact, on the wards we offer patients tea or coffee eight times a day, yet think little of the caffeine burden we are imposing upon them. This almost tacit caffeine consumption is unlikely to make it into the medical notes, yet these patients would potentially be consuming levels of caffeine far in excess of the quantity consumed in this case report.
We seem to apply different value judgements to different drinks, assuming those drinking excess caffeine from expensive coffee machines are doing so knowingly, and as part of a healthy lifestyle. Yet we don’t afford those choosing to consume energy drinks with the same level of ability to make an informed choice. We medicalise the consumption of such drinks, assuming those using them must be doing so for sinister reasons.
We should treat all caffeinated products equally, given there is no pharmacological differen...
Show MorePages