Rhinoorbital mucormycosis in COVID-19 pandemic: presentation and course of disease: An observational study

During the second wave of covid 19[SARS- Co V-] pandemic, there is a sudden increase in number of mucormycosis infection cases in India. The present study is an attempt to understand the presentation, course and outcome of rhinoorbital mucormycosis in a group of patients who reported to Ophtalmology and Otorhinolaryngology department of our Govt. District Hospital (secondary referral centre) for enhancing measures for prevention and management. Patients who reported to our Government district hospital with signs or symptoms suggestive of rhino orbital mucormycosis during May-June 2021 were included in the study with consent of ethical committee, patients and patient’s relatives. Total 17 cases were reported and followed. Clinical examination was done for all the patients. History of the presenting complaints and underlying illness with COVID -19 was elicited. Underlying comorbid status was recorded. Patients were followed as all of them were referred to higher centre for further management as per the guidelines issued by directorate medical and health services, rajasthan, Jaipur.13(76.4%) patients were from rural and 4 (23.5%) were from urban area. 11(64.7%) patients had RT-PCR +ve, 6 had RT-PCR _ve, 2 did not have RT-PCR report. 15(88.7%) patients had high blood sugar at presentation mean being 315.7mg%. 9 (52.9%) developed mucormycosis during their treatment for COVID in hospital. 8(47.05%) presented in OPD. 9 patients had treatment with inhalational Owhile 8 patients did not have treatment with O Death rate was high (70.5%) among our patients. Patients who survived (29.4%) had only initial symptoms and signs at presentation therefore could be managed earlier. None of our patient had vaccination for COVID. Our study was done at secondary referral centre, all the previous studies were done at tertiary referral centres; therefore it shows the course of disease mainly among rural population ; most of them presented very late and had poor outcomes. It shows the need of more awareness about COVID and mucormycosis among people especially in rural areas. High blood sugar either due to treatment with steroids or pre existing is a major risk factor for Rhino orbital mucormycosis. Being RT- PCR negative for COVID 19 does not rule out the associated possible complication of Rhino orbital mucormycosis. Early diagnosis and management remains the key factor for managing Rhino orbital mucormycosis.

Comparison of Clinical, Immunological And Radiological Characteristics In Autoimmune GFAP Astrocytopathy, MOGAD And AQP4-Igg +NMOSD Mimicking Infectious Meningitis As The Initial Manifestation

Objective: Several autoimmune CNS inflammatory diseases, including autoimmune glial fibrillary acidic protein astrocytopathy (A-GFAP-A), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) and aquaporin-4-immunoglobulin-G-positive neuromyelitis optica spectrum disorders (AQP4-IgG+ NMOSD) often presented initially with similar infectious meningitis-like symptoms. However, it was not easy to differentiate them at disease onset without antibody detection. The present study aimed to compare the clinical, immunological and radiological features among the three diseases. Methods: In our single-center cohorts, 9 A-GFAP-A, 17 MOGAD and 11 AQP4-IgG+ NMOSD patients mimicking infectious meningitis as initial symptoms were retrospectively included. The autoantibodies were detected with cell-based assays. The clinical, immunological and radiological characteristics of the three groups were summarized. Results: AQP4-IgG+ NMOSD patients were statistically more often in men (10, 90.9%, P=0.003). Tremor was predominated in A-GFAP-A (4, 44.4%) over MOGAD (1, 5.9%, P= 0.034) and never found in AQP4-IgG+NMOSD (0, P=0.026). The Modified Rankin Score (mRS) at the clinical nadir of diseases was lower in AQP4-IgG+NMOSD (2.2 [IQR, 1-3]) compared to A-GFAP-A (3.7 [IQR, 3-5], P=0.04). On CSF examination, white blood cell count (WBC) was higher in A-GFAP-A (median, 272×106/L [range, 0-1600]) compared to AQP4-IgG+NMOSD (median, 12×106/L [range, 0-48], P=0.049). Significant increase in CSF protein (1490.7±871.2 mg/L), lactic acid (3.43±0.81 mmol/L), IgG (130.9±60.4 mg/L), IgM (8.6±6.1mg/L) and IgA (23.0±11.4mg/L) levels in A-GFAP-A was found compared to MOGAD (CSF protein: 606.7±379.4 mg/L, P<0.001; lactic acid: 2.15 ± 0.62mmol/L, P<0.001; IgG: 77.9±71.3 mg/L, P=0.043; IgM, 2.7±2.9mg/L, P=0.002; IgA, 11.3±12.1mg/L, P=0.012) and AQP4-IgG+NMOSD (CSF protein: 441.8±178.0 mg/L, P<0.001; lactic acid: 2.40 ± 0.66 mmol/L, P=0.003; IgG, 53.2±30.3 mg/L, P=0.01; IgM, 2.1±3.9mg/L, P=0.003; IgA, 5.2±5.0mg/L, P=0.001). Over half of the A-GFAP-A patients (5/8, 62.5%) showed small (<2 cm), symmetrical lesions in ganglia and thalamus (5/8, 62.5%), but never in MOGAD (0%, P=0.001) and AQP4-IgG+NMOSD (0%, P=0.026). Diffuse meningeal enhancement was common in A-GFAP-A (8, 88.9%) compared to MOGAD (5, 29.4%, P=0.011) and AQP4-IgG+NMOSD (1/6, 16.7%, P=0.011). Acute disseminated encephalomyelitis (ADEM) -like lesions occurred frequently in MOGAD (6/16, 37.5%) but never in A-GFAP-A and AQP4-IgG+NMOSD (P=0.02). Conclusion: Our study demonstrated that several signs including the symptom of tremor, a more severe disease course, higher CSF immunological profiles and ganglia bilateral symmetrical lesions, diffuse meningeal enhancement were distinct features in A-GFAP-A, and ADEM-like lesions occurred only in MOGAD mimicking infectious meningitis as initial symptoms, providing possible clinical implications for patient differential diagnosis.

Lateral tarsal strip through osteotomies for recurrent ectropion and eyelid laxity correction

Objective to present a surgical technique for treating patients with recurrent ectropion and severe lower eyelid laxity. Methods Lateral tarsal strip and canthal fixation by osteotomy was performed in 6 patients with recurrent ectropion and 1 patient with extreme lower eyelid laxity secondary to an anophthalmic socket. Preoperative and postoperative photographs were evaluated in order to assess the outcomes of the procedure. Patients were followed up 4 weeks, 6 months, 12 months and 24 months of the postoperative period. The initial symptoms of the patients were eye redness, epiphora, foreign body sensation, aesthetic complaints, and facial asymmetry. Symptoms and aesthetic results were assessed by questioning, photographs, and fluorescein and lissamine green stains taken in each visit. Results No postoperative complications were observed. No recurrence episodes were reported during the follow-up period and physical appearance improvement and symptom severity reduction were maintained during the observation. Conclusion Lateral tarsal strip through osteotomies is an effective surgical procedure for treating severe recurrent ectropion cases or lower eyelid laxity and could be considered as an alternative treatment option or even a primary surgical technique in selected difficult cases.

Acute Basilar Artery Occlusion Presenting With Convulsive Movements: A Systematic Review

Background and Purpose: Convulsive seizures related to posterior circulation stroke are considered rare. However, some patients with acute basilar artery occlusion (BAO) can present with convulsive movements. Misdiagnosed as seizures may delay the reperfusion therapy for acute BAO. In this study, we have summarized the clinical features and possible mechanisms of BAO presenting with convulsive movements.Methods: We performed an Institutional Review Board-approved institutional database query from 2015 to 2020 and a literature search of the online database PubMed. Clinical data were collected and analyzed.Results: In total, 14 patients with acute BAO presented with convulsions. There were 10 men and 4 women, with a mean age of 53 (range, 23–77) years. All of these patients had different degrees of impaired consciousness (100.0%, 14/14). Convulsive movements were the initial symptoms in 78.6% (11/14) of patients. Further, 64.3% (9/14) of patients presented with paralysis or cranial nerve abnormalities, and 85.7% (12/14) of patients were treated with reperfusion therapy (thrombolysis, 35.7% [5/14]; endovascular thrombectomy, 64.3% [9/14]). The BAO etiology and mechanism were related to embolism, vessel dissections, and severe stenosis of the right vertebral artery in 57.1% (8/14), 21.4% (3/14), and 7.1% (1/14) of patients, respectively; they were undefined in 14.3% (2/14) of patients. Moreover, 42.9% (6/14) of patients had a 90-day modified Rankin Scale score of 0–2, and the mortality rate was 21.4% (3/14).Conclusions: Acute BAO, especially that related to embolism or vessel dissection, may present with convulsive movements. Acute BAO is a devastating, but treatable disease if diagnosed in time. Considering the possibility of BAO is important when dealing with patients presenting with acute-onset convulsive movements. Prompt diagnosis and reperfusion therapy may help achieve a better prognosis.

Clinical, pathological and molecular spectrum of patients with glycogen storage diseases in Pakistan

Objectives Evaluation of clinical, biochemical and molecular analysis of Pakistani patients with hepatic GSDs. Methods Medical charts, biochemical, histopathological and molecular results of patients with hepatic GSD were reviewed. Results Out of 55 GSD patients, 41 (74.5%) were males and 14 (25.5%) were females with consanguinity in 50 (91%) patients. The median age of initial symptoms, clinic diagnosis and molecular diagnosis were 450 (IQR: 270–960), 1,095 (IQR: 510–1,825) and 1717 (IQR: 796–3,011) days, respectively. Molecular analysis and enzyme activity was available for 33 (60%) and two patients, respectively. GSD III (n=9) was most prevalent followed by GSD Ib (n=7), GSD IXc (n=6), GSD VI (n=4), GSD Ia (n=3), GSD XI (n=3), GSD IXb (n=2) and GSD IXa (n=1). In patients (n=33) who underwent molecular analysis; 19 different variants in eight genes associated with GSD were identified. We also report five novel variants, two in SLC37A4, one in AGL and two in PYGL contributing to the diagnosis of GSD Ib, GSD III and GSD VI, respectively. Conclusions Fifty-five patients of GSDs in 26 families from a single care provider indicate a relatively high frequency of GSD in Pakistan, with multiple unrelated families harboring identical disease-causing variants, on molecular analysis, including two known pathogenic variants in SLC37A4 and PHKG2, and a novel variant in AGL.

Full title: COVID-19 disease progression according to initial symptoms. A telemedicine cohort study.

Objective COVID-19 progression to severe or critical illness may be related to initial clinical presentation. Main objective was to identify initial symptoms related to highest risk of disease progression, in mild or moderate suspected or confirmed COVID-19 patients or in asymptomatic subjects in contact with a recently diagnosed patient. Design and methods Historic cohort study of Mexican patients with suspected or confirmed mild or moderate COVID-19 or asymptomatic subjects in recent contact with positive patients. They sought medical attention in Centro Medico ABC or claimed for remote attention, and daily telemedicine follow up until recovery or illness progression, from April 17th to October 08th 2020. Data excerpted for analysis were sex, age, body mass index, comorbidities, and signs, and symptoms presented in first day of disease manifestations and during follow up. We used logistic regression to identify initial symptoms associated with progression disease and through a conjunctive consolidation analysis a symptom index was created. Results 120 of 1635 patients (7.2%) had clinical progression disease. By logistic regression we found as initial symptoms related to progression: fever OR 3 (1.89-4.77, p<0.001), cough OR 2.34 (1.56-3.52, p<0.001), myalgias or arthralgias OR 1.69 (1.09-2.63, p=0.018), and fatigue OR 1.65 (1.08-2.53, p=0.019). Conjunctive consolidation was processed with the previous symptoms, and a 3 groups score resulted C-19PAIS Index: 1) Fever with cough or fever with fatigue, with a probability of progression disease of 29% (31/106 patients), 2) Fever or cough or fatigue or cough with fatigue, 10.7% (66/615 patients) and 3) No fever, no cough, no fatigue, 2% (23/914). Conclusions Initial symptoms predict clinical progression in COVID-19 patients.

Epidemiology, Clinical Presentation, and Prognosis of Pediatric Brain Tumors: Experience of National Center for Children’s Health

Objective Brain tumors have become the most common solid tumors in children. The epidemiology is poorly described in China. This retrospective study aimed to describe the epidemiologic characteristics, clinical presentation, and prognosis in national health center for children. Method From January 2015 to December 2020, 484 cases age 0-18 years old diagnosed with brain tumors and receiving neurosurgery treatment were enrolled into the database. Pathology was based on the World Health Organization 2012 nervous system tumor classification, and tumor behavior were classified on International Classification of Diseases for Oncology, third edition. A descriptive and comparative statistic was performed on clinical manifestation, symptom duration, sex, age, tumor location, tumor behavior, and survival time. Results Among the 484 brain tumors, the median age at diagnosis was 4.62 [2.19, 8.17] years old (4.07 [1.64, 7.13] for benign tumors and 5.36 [2.78, 8.84] for malignant tumors). The overall male to female ratios were 1.33:1, with 1.09:1 and 1.62:1 for benign and malignant tumors respectively. Nausea and vomiting, headache were the most frequent initial symptoms. The median symptoms duration was 4[2, 21] weeks. The three most frequent tumor type were embryonal tumors (22.45%), other astrocytic tumors (20.17%), and diffuse astrocytic tumors (11.02%). Supratentorial tumors comprise 57.38% of all brain tumors. And the most common tumor locations were cerebellum and forth ventricles (38.67%), sellar region (22.87%) and ventricles (10.60%). Male were more common among choroid plexus tumors (63.64%), embryonal tumors (61.11%), ependymal tumors (68.57%), and germ cell tumors (78.13%). Patients were followed for 1 to 82 months. The overall 5-year survival was 77.4%, with 90.0% for benign tumor and 65.3% for malignant tumors. log-rank test found significant different at p <0.001 level. Conclusion Brain tumors presented particularly sexual, age dependent, and regional dependent epidemiological characteristic. Our results were consistent with previous reports, and might reflect the real epidemiology status in China.

First Report of Penicillium digitatum causing Postharvest rot of Citron Fruit in Kunming, China

Citron (Citrus medica L.) is a perennial evergreen woody tree of Rutaceae family and Genus of Citrus. The citron is cultivated for its economic, medicinal and ornamental values in the south of China. (Yang et al., 2015). The shapes range from spherical to ovate and the sizes range from 3 to 5 kg (Klein et al., 2016). In June 2021, some postharvest citron fruits (Citrus medica var. medica) were found to have decay with a green or greyish mycelium on part or whole citron in 2 farmer’s markets in Kunming city, Yunnan Province (N 25°02′; E 102°42′), southwest China. Initial symptoms appeared as white, brown, and irregular necrotic spots in the pericarp. The lesions enlarged gradually and developed into green, water-soaked areas which extend rapidly. Eventually, the diseased fruits were rotten, soften, and the green spore masses confined to the surface (Fig. 1A). The incidence of this disease in postharvest citron fruits ranges from 15 % to 35 %, which is extremely destructive to the fruit of Rutaceae family plants (Chen et al., 2019). Small pieces (5 mm2) of symptomatic citron fruits were surface disinfected in 75 % ethanol and 0.3 % NaClO for 30 s and 2 min respectively, rinsed with distilled water for three times, blotted dry, placed onto potato dextrose agar (PDA) medium aseptically and incubated in a growth chamber at 25 ± 1 ℃, after 7 days, different colonies grew on PDA plates that were isolated and purified on new PDA medium at 25 ± 1 ℃ for 7 days. Inoculating repeatedly until six single-strain (XY01 to XY06) were obtained, and these isolates were stored in 15 % glycerol at –80 ℃ in a refrigerator in the State Key Laboratory for Conservation and Utilization of Bio-Resources in Yunnan Agricultural University. The selected pathogens (XY01 to XY06) were inoculated on PDA medium, incubated at 25 ± 1 ℃. After 7 days, colonies of the isolate obverse are olive green, the white margin and greyish-green spores on the surface, and the reverse colorless to cream yellow or pale dull brown. Colonies texture was velutinous, with a special fragrance. The conidia structure was very fragile and break up easily into many cellular elements. Conidiophores were terverticillate, produced by subsurface or aerial hyphae, irregularly branched and composed of short stipes with few metulae and branches that terminate in whorls of three to six phialides, which are often solitary, cylindrical with a short neck. Conidia are hyaline to pale green, smooth-walled, without septate, partially ellipsoidal, or obovate (4.9 to11.9× 4.3 to 8.9 μm). Partial cylindrical (8.2 to 10.5× 2.7 to 5.3 μm), there are some small conidia, which were ellipsoidal or spherical (3.9 to 5.2× 2.7 to 5.2 μm). According to morphological characteristics, the fungus was identified as Penicillium digitatum (Pers.) Sacc. Isolate XY01 and XY02 were used for molecular identification and genomic DNA was extracted using the CTAB method (Aboul-Maaty & Oraby, 2019). The universal primers ITS1 and ITS4 were used to amplify and sequence the ITS1, 5.8S, and ITS2 rDNA region. Using NCBI’s BLASTn tools, the nucleotide sequences of XY01 and XY02 (Gen-Bank accessions MZ976843 and OK513274) show 100 % identity to MK450692 (P. digitatum strain CMV010G4). Pathogenicity tests have used the fruits (Citrus medica), which maturity was more than 80%. The pathogens (XY01, XY02) were cultured for 7 days on PDA medium, washed with sterilized water the resulting spore suspensions diluted to 1.0 × 106 spores/ml. Wounds (0.5 × 0.5 cm) were made on the surface of citron fruits by scraping with a sterile scalpel and then treated with 200 µl of spore suspension (Wild, 1994). Control citron fruits were treated with sterile water. citron fruits were incubated at 24-26 °C. Each treatment was performed in triplicate with 6 citron fruits. After 3 days, all fruits had developed lesions, in a water-stained, pale brown, and rapidly formed white hyphae, white mold layer was observed with a length of 1.5-2.5 cm and a width of 1-2 cm (Fig.1C), but control did induce infection. After 7 days, decay developed more quickly, the hyphae rapidly expanded on the surface of the pericarp, with vague and irregular edges, then a green mold layer was formed, the whole fruit was observed to rot and soften, When the citron was cut, the white flesh inside turned black and rotted (Fig.1B). P. digitatum was consistently reisolated from the inoculated plants but not from the controls. No symptoms developed on the control (Fig.1D). According to Koch’s postulates, the inoculated strains of XY01 and XY02 were the isolates causing citron decay disease. Based on symptoms, morphological characteristics, rDNA-ITS sequence analysis, and pathogenicity, this fungus was identified as P. digitatum. To our knowledge, this is the first report of the distribution of P. digitatum on Citron (Citrus medica) in China.

Cerebral Venous Thrombosis: A Challenging Diagnosis. A New Nonenhanced Computed Tomography Standardized Semi-Quantitative Method

Cerebral venous sinus thrombosis (CVST) on non-contrast CT (NCCT) is often challenging to detect. We retrospectively selected 41 children and 36 adults with confirmed CVST and two age-matched control groups with comparable initial symptoms. We evaluated NCCT placing four small circular ROIs in standardized regions of the cerebral dural venous system. The mean and maximum HU values were considered from each ROI, and the relative percentage variations were calculated (mean % variation and maximum % variation). We compared the highest measured value to the remaining three HU values through an ad-hoc formula based on the assumption that the thrombosed sinus has higher attenuation compared with the healthy sinuses. Percentage variations were employed to reflect how the attenuation of the thrombosed sinus deviates from the unaffected counterparts. The attenuation of the affected sinus was increased in patients with CVST, and consequently both the mean % and maximum % variations were increased. A mean % variation value of 12.97 and a maximum % variation value of 10.14 were found to be useful to distinguish patients with CVST from healthy subjects, with high sensitivity and specificity. Increased densitometric values were present in the site of venous thrombosis. A systematic, blind evaluation of the brain venous system can assist radiologists in identifying patients who need or do not need further imaging.