eLetters

60 e-Letters

published between 2019 and 2022

  • 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, certai...

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  • Professor

    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...

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  • Rate of incidence...

    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.

  • Mucormycosis in covid 19 patients in India is in raise in second wave of covid 19 pandemic

    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 ....

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  • Incidence of mucormycosis is in raise in India due to covid-19 in second wave of2021

    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...

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  • Response from authors

    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.

  • Response from authors

    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...

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  • Therapeutic strategy of Malignant glioma and the fetal-maternal wellbeing

    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...

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  • Response from authors
    Thank you for your correspondence. 
     
    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. 
     
    ...
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  • Treat all Caffeinated Beverages Equally

    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...

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