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   Table of Contents - Current issue
Coverpage
October-December 2021
Volume 9 | Issue 4
Page Nos. 197-275

Online since Wednesday, October 20, 2021

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EDITORIAL  

COVID-19 pandemic – What have we learned? Highly accessed article p. 197
Manjunath Premanath
DOI:10.4103/ajim.ajim_94_21  
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REVIEW ARTICLES Top

COVID-19 Vaccines: A weapon for global security Highly accessed article p. 200
Vasantha Kamath, B Nivea
DOI:10.4103/ajim.ajim_62_21  
Infectious agents are still in circulation in different parts of the world, and globalization, with travel on the agenda, migration, and poverty, makes vaccination a tool more than ever necessary. Despite the impressive number of studies carried out since the virus was first characterized, there are still many unknowns about this disease. Moreover, it is precisely these unknowns that fully justify the very different conceptual and technological strategies that are currently pursued in the preparation of vaccines against COVID-19. Due to the short development time and the novelty of the technologies adopted, these vaccines will be deployed with several unresolved issues that only the passage of time will permit to clarify. Technical problems connected with the production of billions of doses and ethical ones connected will be needed to ensure equitable global access, protection of diverse subjects, and immunity against viral variants.
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Can COVID-19 patients exercise? An insight p. 206
Sadananda B Naik, Kshama Susheel Shetty
DOI:10.4103/ajim.ajim_113_20  
Practice of mild-to-moderate physical exercise could be beneficial to patients recuperating from COVID-19, whereas vigorous physical exercise could result in opposite health effect. Evaluation of pulmonary and cardiac function could show silent functional impairment.
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Mucormycosis in COVID-19 p. 209
Vasantha Kamath, Manimegalai Mathivanan, RB Vinay, B Nivea
DOI:10.4103/ajim.ajim_74_21  
Mucormycosis has emerged as a disease of immense importance, especially owing to the surge of cases during the second wave of COVID pandemic. Various factors are being attributed to the sudden burst of cases in our country, such as higher fungal spore counts in tropical climate, uncontrolled diabetes mellitus, prolonged steroid therapy, contamination of oxygen facilities, respiratory equipment, reused face mask, and zinc supplements. The need of the hour is to emphasize on awareness of early warning signs, as the benefits appear to be time sensitive.
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ORIGINAL ARTICLES Top

Association of neutrophil-lymphocyte ratio with clinical outcome of COVID-19 patients: A prospective study p. 215
B Abhiman Shetty, TA Shilpa, Avinash Hanbe Rajanna, K Ravi, Medha Rao, Bhargav Bhat
DOI:10.4103/ajim.ajim_43_21  
Aim: This study aims to find the association of neutrophil-lymphocyte ratio (N-L ratio) of COVID-19 patients admitted in an Indian setting with clinical profile and disease outcomes. Background: The COVID-19 pandemic hit in early 2020 with the presentation of varied severity of acute respiratory illness. This study tries to use N-L ratio as a predictor of adverse outcome. Methodology: The prospective single-center study considered adults patients of both the gender, diagnosed with COVID-19 infection by reverse transcription-polymerase chain reaction technique. Necessary demographic and clinical data were collected, and selected subjects were followed up until discharge or death. Individuals were classified as those who survived and those who succumbed to death. t-test was used for comparing continuous variables and Chi-square test for categorical data for comparing different parameters between the groups. Results: The study included 1977 patients with a male:female ratio of 1:0.62. Fever, dyspnea, and cough were noted as the major symptoms prevalent among patients who succumbed to death when compared to those who survived (P < 0.00001). Statistically significant variables noted between the groups were age, total leukocytes count (TLC), neutrophil, lymphocytes, all the comorbidity variables, and the asymptomatic status. Variables identified as significant predictors of disease outcomes were TLC, neutrophils, lymphocytes, and N-L ratio. Most of the subjects belonging to the mortality group required oxygen and other intensive care unit facilities when compared to the survival group (P < 0.00001). Conclusion: TLC, neutrophils, lymphocytes, and N-L ratio are noted as significant predictors of COVID-19 outcome. The mean days of viral clearance noted in COVID subjects is around 8.98 ± 3.54 days.
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Study of factors associated with COVID-19 mortality in a rural tertiary health care center p. 221
Josna Ganesh Teli, Satish Reddy, Vasantha Kamath, MJ Jacob, Dharani Mohan, Kushal Markanday
DOI:10.4103/ajim.ajim_38_21  
Background: COVID-19 has swiftly spread to emerge as a global pandemic with no visible signs of decline. It is imperative to identify the parameters contributing toward COVID-19 mortality to facilitate prompt evaluation and control measures. Materials and Methods: A total of 1754 patients with confirmed COVID-19 infection were admitted at MVJMC and RH, Bangalore, from July 1, 2020 to December 12, 2020. Various parameters such as demographical profile, symptomatology, risk factors, laboratory profile, and complications of 75 patients (4.27%) who succumbed were studied. Results: About 45.33% of the patients who died were older than 65 years. 77% of patients who died were males. About 61.33% had severe illness at the time of presentation. 84% of the patients who died had comorbid illnesses. Respiratory failure secondary to acute respiratory distress syndrome and bilateral pneumonia was the leading cause of mortality followed by sepsis/multiple organ dysfunction syndrome, myocarditis, coagulopathy, and acute cardiovascular event. The presence of lymphopenia elevated inflammatory markers, and comorbid conditions were identified as risk factors for the requirement of oxygen, mechanical ventilation, and death. Conclusion: Elderly patients (>65 years of age) and middle-age patients (45–65 years of age) comprised the highest and second-highest proportion of mortality respectively. The increasing proportion of deaths among the middle-aged patients and the narrowing gap of the same between these two groups are alarming. Old age, male gender, underlying chronic illnesses, and elevated inflammatory markers are some of the factors attributed to these trends. Hence, stringent preventive measures, early detection, and initiation of treatment pose a greater impact on reducing the burden of morbidity and mortality.
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Electrocardiographic findings in Coronavirus Disease-19 and its correlation with clinical severity of disease p. 227
Mumtaz Ali Khan, Anindita Menon, BS Nagaraja
DOI:10.4103/ajim.ajim_28_21  
Background and Aims: Most data on electrocardiographic (ECG) changes in patients with coronavirus disease-19 (COVID-19) have been presented without comparison to patients with other acute respiratory illnesses. The correlation of ECG changes with disease severity has also not been studied. Subjects and Methods: We compared forty COVID-19-positive and forty COVID-19-negative patients in terms of clinical presentation, ECG at admission, and cardiac biomarkers. Statistical analysis was presented as frequency (percentage) and continuous as mean ± standard deviation. Chi-square test/Fischer's exact test was used. Results: Mean age overall in the study was 52.4 ± 16 years, 67.5% data were males. About 87.5% of the COVID-positive patients and 70% of the COVID-negative patients had ECG changes at baseline. Sinus tachycardia was seen in 45% (18/40) of COVID-positive patients. About 95% (38/40) of COVID-19 positive patients had normal axis, 5% (2/40) had supraventricular tachycardia, 2.5% (1/40) had premature atrial contractions (PACs), and 7.5% (3/40) had premature ventricular contractions. One patient had ventricular bigeminy. About 7.5% (3/40) of COVID-positive cases had complete right bundle branch block (RBBB), one had complete left bundle branch block (LBBB), whereas one had incomplete LBBB. About 7.5% (3/40) of COVID-positive cases had ST-segment elevation, one of whom also developed postmyocardial infarction left ventricular thrombus. About 15% (6/40) had nonST-segment elevation acute coronary syndrome. Conclusions: COVID-19 patients have ECG changes of left-sided heart disease (PACs and LBBB) and right-sided disease (RBBB, right axis deviation, and right ventricular strain pattern) at presentation, however, right heart changes predominate. COVID-19 patients had a higher occurrence and a wider variety of ECG changes at presentation than other acute respiratory illnesses and these changes correlate well with clinical disease severity as does troponin I level.
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Study of impact of comorbidities on patients with COVID-19 infection p. 233
MG Rohith, N Monika, Avinash Hannabe Rajanna, K Ravi
DOI:10.4103/ajim.ajim_69_21  
Aim: To study the impact of comorbidities on patients with COVID-19 infection. Materials and Methods: A single center, cross-sectional, observational study was conducted among SARS-CoV-2 infected patients from March 2020 to July 2020. The diagnosis was confirmed by real-time polymerase chain reaction. Various comorbidities were studied to know the treatment outcomes and mortality risk in COVID-19 positive patients. Results: A total of 1977 COVID-19 patients were studied. The mean age was 43.89 ± 15.58 years and had male preponderance of 61.56% of the total subjects. Death rates increased linearly with age in decades with highest fatality rate among those who are aged more than 70 years (21.9%). Among those who died, 73 (52.9%) had both hypertension and diabetes associated with microvascular or macrovascular complications. The overall case fatality rate (CFR) among patients with comorbidities was 12.38%. Among subgroup of comorbidities, Chronic kidney disease (CKD) patients had highest CFR (32%) followed by patients with both hypertension and diabetes (17.5%). Delayed viral clearance is seen in patients with diabetes (33.3%). Conclusion: COVID-19 infection seems to cause high mortality in older individuals (>50 years) with male preponderance. Patients with diabetes and hypertension associated with microvascular or macrovascular complications and CKD patients are at increased risk of disease severity and mortality. Recovery time is also increased in patients with comorbidities mainly diabetes mellitus.
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Occurrence of depression, anxiety, stress, and fear of COVID-19 among staff nurses of South India during COVID-19 pandemic p. 239
V Suganthi, V Kanchana, Panneerselvam Periasamy, R Saravanakumar, A Chandrabose, G Sasikala, C Bharathi, S Priyadharshini
DOI:10.4103/ajim.ajim_70_21  
Background: Besides the general population, the psychologically connected problems associated with COVID-19 had also affected the frontline health-care workers, such as nurses and doctors, who faced prominent challenges 'with respect to their mental health. According to recent studies concerning COVID-19, the nurses happened to be those health-care workers who faced the more psychological problems resulting from COVID-19 outbreak. Materials and Methods: This was a cross-sectional study evaluating the fear of COVID-19 using the fear of COVID-19 scale and depression, anxiety, and stress levels using Depression Anxiety and Stress Score. The participants' demographic data such as gender, age, working category, hospital unit, and work shift were collected in addition to the above-mentioned questionnaires. Results: There were 277 staff nurses, out of which 259 were females and 18 were males participated in this study. The common age of the study group was between 21 and 40 years and most of them (47%) worked at government primary health-care centers. Discussion: The nurses who were younger at age tend to be more stressed than the older nurses which could be due to the fact that younger nurses might have felt nervous due to their inexperience and poor preparation for their occupational role at work. Conclusion: Increasing the awareness and educating nurses toward the essential need for addressing their mental health issues with timely and adequate support measures is recommended.
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Comparative therapeutic efficiency of remdesivir in COVID in a tertiary care center p. 244
Mahendra Munirathnam, R Kishore, SN Sanjana, R Archita, CN Mohan, Preethi Rajeshwari Gandhi, Manjushree Mohan, Bhahuddin Mulla
DOI:10.4103/ajim.ajim_3_21  
Introduction: The catastrophic effects of corona in 2020 identified the use of broad-spectrum antiviral remdesivir (RDV). The beneficial effects of RDV are not proven and documented in many trials in COVID. Materials and Methods: Reverse transcriptase–polymerase chain reaction (RT-PCR)-confirmed cohort cases of COVID were retrospectively analyzed for outcomes including mortality and clinical improvement with and without RDV during the period September 21, 2020–October 9, 2020. The data were analyzed statistically for outcome in COVID. The present study was carried out to evaluate the clinical benefits of RDV and its outcomes in COVID. Results: A total of 91 RT-PCR positive COVID patients were grouped into 37 RDV (41%) and 54 non-RDV (51%). The mean age was 51 and 55. Male-to-female ratio of 67:32 and 65:35 in the RDV and non-RDV groups was found, indicating male predominance in the study. The recovery time for COVID was 11 days with a cure rate of 78% in the RDV group, while it was 21 days with 98% in the non-RDV group. A statistical significant association was found between RDV and the need for oxygen support (hypoxic patients) and noninvasive ventilation (NIV). Twenty-seven percent in RDV group needed NIV (P = 0.009). Morbidity and mortality were 19% (7) and 22% (8) and 7% (4) and 2% (1) in the RDV and non-RDV groups, respectively. Conclusion: RDV use in COVID was associated with increased mortality (22% vs. 2%) but reduced duration of hospitalization by 50% as compared to non-RDV group. Early identification of hypoxia plays an important role in COVID management for initiating RDV treatment.
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A cross-sectional study of pulmonary and extrapulmonary manifestations of COVID-19 p. 250
B Nivea, Vasantha Kamath, Kushal Markanday, MJ Jacob, Dharani Mohan
DOI:10.4103/ajim.ajim_46_21  
Background: While the name of the virus indicates respiratory disease, and the respiratory spread of COVID-19 has been well documented in the literature, the ongoing pandemic has shown that the virus is not confined to just the lung. Hence, physicians should be aware of the “many faces” that this singular disease can present with, for timely diagnosis and prompt initiation of best treatment options. Materials and Methods: A total of 1754 patients with confirmed COVID-19 infection were admitted at a rural tertiary care center, Karnataka, India. This study is a cross-sectional study done for a period of 6 months from July 2020 to December 2020. Demographic data, clinical manifestations, laboratory parameters, management, and outcomes were recorded and compared. Results: Out of 1754 COVID-19 patients, pulmonary manifestations were seen in 1222 patients, extrapulmonary manifestations in 360 patients, and 172 patients were asymptomatic. Males were affected more than females, with a male-to-female ratio of 1.2:1. Most common pulmonary manifestation seen was cough in 83.06%, followed by fever in 67.59%. Most common extrapulmonary manifestation seen was neurological followed by gastrointestinal in 60.83% and 35.8% patients, respectively. Fatality in patients with pulmonary manifestations was 5% and extrapulmonary manifestation was 3%. All patients were managed according to standard COVID-19 treatment protocol. Conclusion: Early recognition of COVID-19 infections remains a big challenge. COVID-19 can have diverse range of clinical manifestations. Hence, COVID-19 infection should be considered in the differential of any systemic disease during the current pandemic, even in the absence of pulmonary manifestations like fever or cough.
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CASE REPORTS Top

Hepatic vein thrombosis secondary to COVID-19 p. 256
Kushal Markanday, Nitin Bhardwaj, Buvana Radhakrishnan, P Gopinath Kumar
DOI:10.4103/ajim.ajim_27_21  
COVID-19 is known to cause both arterial and venous thromboembolism. Although a lot of attention is being given to those presenting with myocardial infarction and stroke, splanchnic vein thrombosis which includes portal, mesenteric, splenic, and hepatic vein thrombosis is often underreported. A 21-year-old female presented with progressive abdominal distension and obstipation for the past 2 weeks. The patient was diagnosed as a case of moderate COVID-19 illness 2 weeks before the onset of these symptoms and recovered on receiving treatment according to the COVID protocol. Physical examination revealed pallor and bilateral pitting pedal edema up to ankles. Systemic examination revealed uniformly distended abdomen with signs of free fluid and tenderness in the right hypochondrium. Hematological investigations showed moderate-grade microcytic hypochromic anemia. Biochemically, indirect hyperbilirubinemia and transaminitis with moderately elevated D-dimers and Lactate dehydrogenase (LDH) was noted. Radiological imaging of the abdomen (including USG with doppler and CT contrast Scans) revealed gross ascites, nutmeg appearance of liver with completely obscured hepatic veins indicating no flow of blood, multiple intrahepatic portosystemic collaterals and a partially thrombosed inferior vena cava with no evidence of portal hypertension. All other workup to rule out other causes of hepatic vein thrombosis was inconclusive. The patient was treated with low-molecular-weight heparin and then continued with oral warfarin at discharge. On a 4-week follow-up, the patient showed marked clinical improvement with partial resolution of presenting symptoms.
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A case report of pleural effusion in a COVID-19 patient with multiple comorbidities p. 259
M Mahendra, N Siddesh, CN Mohan, M Narayanaswamy
DOI:10.4103/ajim.ajim_82_20  
We report a case of coronavirus disease 2019 (COVID-19) infection in a patient with multiple comorbidities diabetes, hypertension, ischemic heart disease, and chronic liver disease. Although pleural effusion is rarely seen in COVID-19 infection, the presence of which should be interpreted carefully. In this case report, our patient presented with complaints of fever, cough, and dyspnea, and focused clinical examination revealed fullness in the left hemithorax compared to right; reduced chest movements in the left hemithorax and trachea deviated to the right; dullness in the left hemithorax and right infrascapular, infra-axillary, and mammary area; and absent breath sounds in areas where dullness was noted. A chest X-ray done revealed left massive pleural effusion with right mild pleural effusion and pleural fluid analysis on both sides revealed transudate picture; this was also similar to the ascitic fluid analysis that was done in this patient; at this point of time, a computed tomography of the thorax was done to rule out other causes of pleural effusion. Meanwhile, other laboratory investigations revealed evidence of liver cell failure showing hyperbilirubinemia, hypoalbuminemia, and deranged prothrombin time and international normalized ratio (INR) and imaging evidence of cirrhotic liver; the patient was treated accordingly. Therapeutic pleural tapping was done after INR normalized; the patient improved symptomatically. Pleural effusion although is a rare manifestation of COVID-19, the etiologies are varied, it is important for us to consider other possible comorbidities associated in a patient who is hospitalized for acute illness, in this case, the patient had multiple comorbidities such as diabetes, hypertension, ischemic heart disease, and chronic liver disease, and the cause for pleural effusion is attributed to decompensated chronic liver disease and ischemic heart disease. In this case, the acute infection has resulted in the decompensation of his preexisting chronic disease.
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Guillain-Barré Syndrome Associated with COVID-19: A Neurochallenge!! p. 264
TS Ravindra, Dilmo Yeldo, BS Arjun
DOI:10.4103/ajim.ajim_76_21  
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent for Coronavirus disease 2019 (COVID-19), originated in Wuhan, China in the fall of 2019 which has soon become a global pandemic engulfing the entire world, presents with a myriad of symptoms from asymptomatic to severe disease with acute respiratory distress syndrome and multiple organ dysfunction and severe inflammatory response. New associations and clinical problems keep appearing with the new virus and here, we are reporting a case of Guillain-Barré syndrome (GBS) presented to us with complaints of progressive proximal muscle weakness and bilateral facial paralysis. The initial nerve conduction study was normal, but clinical examination showed us a picture of acute inflammatory demyelinating polyradiculoneuropathy and the patient was treated with intravenous immunoglobulin to which the patient responded dramatically. Repeat nerve conduction study showed typical features of GBS. Thus, a differential diagnosis of GBS should be kept in mind by all physicians/neurologists who encounter any neurological symptoms (especially muscle weakness) while treating or post-COVID-19 infection.
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Co-infection of scrub typhus and COVID-19: A diagnostic challenge Highly accessed article p. 268
Gautam Jesrani, Ankit Chhabra, Aman Garg, Amandeep Kaur, Monica Gupta
DOI:10.4103/ajim.ajim_81_21  
Scrub typhus is a bacterial disease, caused by Orientia tsutsugamushi and has widespread clinical presentations. Coronavirus-19 disease (COVID-19) is an ongoing pandemic, which can demonstrate clinical symptoms similar to the scrub typhus. Herein, we are describing two such cases of scrub typhus and COVID-19 co-infection. A 35-year-old male and a 42-year-old female presented with respiratory failure, for which COVID-19 was diagnosed, but both of them had persistent thrombocytopenia. The patients were investigated for other tropical co-infections and the diagnosis of scrub typhus was established in both of the cases. Doxycycline was added to their ongoing treatment, which led to an uneventful recovery. The cases highlight the importance of keeping a high index of suspicion of concurrent infection in the regions where seasonal tropical infections are endemic.
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LETTERS TO THE EDITOR Top

Pulmonary artery catheter in left pulmonary artery: Should we worry p. 272
Kunal Sarin, Vikas Kumar Shankhyan, Paul Varghese
DOI:10.4103/ajim.ajim_68_21  
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Circulating cell-free DNA biomarkers p. 273
Jose Rafael Villarreal Escorcia
DOI:10.4103/ajim.ajim_85_21  
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Role of ARNI upgraded in treatment of heart failure with reduced ejection fraction p. 274
Swetha Amaresh Biradar
DOI:10.4103/ajim.ajim_53_21  
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