There has been an increasing incidence of fungal infections in recent years. Rarely joints are also affected by fungal infections. Mainly, these infections develop in prosthetic joints, but sometimes native joints are also involved. Candida infections are mostly reported, but patients may also develop infections secondary to non-Candida fungi, especially Aspergillus. Diagnosis and management of these infections is challenging and may involve multiple surgical interventions and prolonged antifungal therapy. Despite this, these infections are associated with high morbidity and mortality. This review described the clinical features, risk factors, and therapeutic interventions required to manage fungal arthritis.
An increasing number of cases of lead toxicity are being reported among patients taking Ayurvedic and other alternative medicines. These medicines may have varying amounts of heavy metals, making the diagnosis confusing and treatment challenging. The unavailability of certain chelating agents in resource-poor settings limits therapeutic options. A 38-year-old, recently diagnosed diabetic male, presented with complaints of vomiting, abdominal pain, and constipation. There was a history of consumption of Ayurvedic medications and other herbal supplements for the past 2 months. Serum lead levels were 120 µg/dL, for which intramuscular dimercaprol was initiated. Other heavy metals, selenium, nickel, and zinc, were also in the higher range. Due to worsening neurological symptoms and unavailability of calcium disodium edetate (CaNa2EDTA), D-penicillamine was added to the therapy. Clinical improvement was noted, but D-penicillamine was replaced with CaNa2EDTA after a few days, when it became available. The patient was discharged from the hospital with no neurological sequelae. Lead poisoning should be suspected in patients taking Ayurvedic or herbal medicines and presenting with unexplained abdominal or neurological symptoms. Early diagnosis and chelation therapy may improve outcomes. Combination therapy may be tried in patients with severe poisoning.
Hypertriglyceridemia can cause severe diseases such as acute pancreatitis (AP) and coronary artery disease. The routine management of hypertriglyceridemia is dietary restriction of fat and lipid-lowering medications to manage the secondary or precipitating causes of hypertriglyceridemia. However, in cases of AP with severe hypertriglyceridemia (SHTG) (triglycerides [TG] >1000 mg/dl) rapid reduction of TG levels to well below 1000 mg/dl can improve outcome and prevent further episodes of pancreatitis. Plasmapheresis is a therapeutic option in such medical emergencies. We discussed 2 cases of severe AP with SHTG where we used early plsmapheresis along with other supportive management.
Since its description in 1790 by Hunter, the nasogastric tube (NGT) is commonly used in any healthcare setting for alleviating gastrointestinal symptoms or enteral feeding. However, the risks associated with its placement are often underestimated. Upper airway obstruction with a NGT is an uncommon but potentially life-threatening complication. NGT syndrome is characterized by the presence of an NGT, throat pain and vocal cord (VC) paralysis, usually bilateral. It is potentially life-threatening, and early diagnosis is the key to the prevention of fatal upper airway obstruction. However, fewer cases may have been reported than might have occurred, primarily due to the clinicians' unawareness. The lack of specific signs and symptoms and the inability to prove temporal relation with NGT insertion has made diagnosing the syndrome quite challenging.
There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids.A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round.Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs.The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring.How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.
Malaria is a worldwide health concern, but a great majority of cases occur in tropical countries like India. With almost 95% of Indian population living in malaria endemic regions, India contributes to most of the global malaria cases and deaths, outside of African countries. Despite significant advances towards malaria control and eradication, mortality associated with severe malaria remains particularly high. Changing epidemiology, vulnerable patient population, overlapping symptomatology, and limited availability of parenteral preparations of artemisinin derivatives pose significant challenges in management of severe malaria. Further, the dearth of large-scale randomized trials from the developing countries makes it difficult to establish evidence-based guidelines pertaining to their situation. Thus, this position paper aims to provide guidance to critical care physicians across the country on managing patients with severe malaria in intensive care units (ICUs).
Introduction: In the absence of high-quality evidence for Coronavirus disease-2019 (COVID-19), supportive care is advocated during this pandemic. We aim to develop a consensus statement from global experts for pharmacological management, based on the pathophysiology of COVID-19. Material and Methods: We used a modified Delphi methodology in three steps: 1) Formulation of the steering committee and questionnaire; 2) Delphi methodology and selection of experts; 3) Final meeting of the steering committee and analysis, discussion, preparation, and presentation of captured data. Results: 34 (73·9%) experts accepted the invitation for the study. We conducted two rounds of Delphi and consensus (>70% votes) was achieved on 11 out of 24 statements after the end of round two. Conclusion: This global consensus suggests that “Anti-viral therapy should be administered in the early infection phase of COVID-19 followed by low dose steroid therapy in pulmonary phase. Prophylactic dose anticoagulation should be used in hospitalized, mild to moderate COVID-19 patients. We make no suggestions for the use of immune modulation therapy”.
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