Case of Mycotic Pseudoaneurysm of the Common Carotid Artery due to Salmonella typhi Bacteremia

Aneurysm of the extracranial carotid artery is a rare disease, mycotic pseudoaneurysms being even less common. They are a life-threatening complication of systemic infection and atherosclerosis. Immunocompromised people, including patients with HIV, uncontrolled diabetes melltus, those on immunosuppressants like high-dose steroids, and chemotherapy, are at a higher risk for development of mycotic pseudoaneurysms. Due to the high risk of potential complications like rupture and thromboembolic events, mycotic aneurysms always require surgical management. Early detection followed by restoration of blood flow is critical to minimize a fatal outcome. Here we report the case of a 52-year-old man with a past history of hypertension and dyslipidemia who presented with a pulsatile painful neck swelling. On evaluation, the patient was diagnosed to have Salmonella typhi bacteremia, HIV infection, and a mycotic aneurysm of the left common carotid artery.

Hoagland Sign as an Aid for Antimicrobial Stewardship—A Case Report

Hoagland sign is an early and transient bilateral painless upper eyelid edema observed in patients with Epstein-Barr virus (EBV)-related infectious mononucleosis. This sign can predate the appearance of exudative pharyngitis and cervical lymphadenopathy. Usually, this sign disappears by first week of infection. Here, we describe the occurrence of late onset Hoagland sign in a 14-year old boy who presented to us on 10th day of fever. Hoagland sign appeared after 10 days from symptom onset in our patient. Despite persistence of fever, the presence of Hoagland sign which appeared prior to confirmation of EBV infection was a helpful indicator for stopping antibiotics. In view of tonsillar hypertrophy with potential airway compromise and biochemical parameters suggestive of possible secondary hemophagocytic lymphohistiocytosis, he was initiated on steroids with which defervescence and prompt resolution of symptoms occurred. EBV can present as acute undifferentiated febrile syndrome which might result in inappropriate use of antibiotics. This case highlights the importance of using clinical clues like Hoagland sign to optimize antimicrobial stewardship.

Weil’s Disease Death Investigation and Outbreak Control Measures Instituted in the Field Area of a Family Health Center in Thiruvananthapuram, Kerala—A Case Report

Introduction: Weil syndrome, a rare infectious disorder, is a severe form of the bacterial infection caused by Leptospira bacteria known as leptospirosis. Weil syndrome is characterized by dysfunction of the kidneys and liver, abnormal enlargement of the liver (hepatomegaly), persistent yellowing of the skin, mucous membranes, whites of the eyes (jaundice), and/or alterations in consciousness. In most cases, Weil syndrome occurs among individuals who are exposed to affected animals. Case Presentation and Summary: The investigation of death was done by a team consisting of doctor, junior health inspector, and ASHA workers of the area. We did a qualitative approach of in-depth interview of the wife and daughter-in-law of the deceased for data collection. The patient’s name and other details are not revealed for anonymity. No particular statistical analyses are used for this case reporting. The CARE guidelines were followed for writing this report. Conclusion: Leptospirosis is a disease of outbreak potential and has high case fatality rate. Timely identification of cases and institution of preventive measures is very important in preventing outbreaks. The surveys conducted in the area did not reveal any signs of an imminent or ongoing outbreak of leptospirosis.

Perceived Stress Levels and Associated Factors Among SARS-CoV-2-Affected Young Adults Under Home Isolation—A Cross-Sectional Study From Kerala, India

Introduction The impact of SARS-CoV-2 is not only on physical health but also on mental health. This pandemic raised concerns of fear, anxiety, and stress among patients affected with the disease. Quarantine and home isolation might have created psychological distress and helplessness in patients due to social and economic reasons. This study aimed in assessing the level of perceived stress and factors associated with it among SARS-CoV-2-affected young adults who were under home isolation. Methodology A cross-sectional study was conducted among 147 SARS-CoV-2-affected young adults who were under home isolation during June 2021 to August 2021. A semi-structured proforma was created using KoBo Toolbox for humanitarian response for data collection. Perceived Stress Scale (PSS-10) was used for measurement of stress among COVID-19 patients. The questionnaire was shared in online platform. Data was analyzed using Statistical Package for Social Sciences version 23.0. Significance of association was tested using chi square test and independent sample t test. Logistic regression was done to predict the factors associated with perceived stress. Results Out of the 147 study participants, 56.5% were females and 43.5% were males. Symptoms were present in 94 (63.9%) of patients. The mean age of the study participants was 26 (10.5) years. The mean PSS score was 17.5 (6.4). Among the cases under home isolation, 24.5% had low stress levels, 68% had moderate stress levels, and 7.5% had severe stress levels. Feeling of loneliness during home isolation (odds ratio [OR]: 4.7, 95% confidence interval [CI] [1.9-11.63], P = .008), presence of elderly or under-5 children in the same house (OR: 15.45, 95% CI [2.03-117.5], P = .001), and presence of cough ( P = .05) were found to be significantly associated with higher PSS scores. Age and sleep were negatively correlated with stress score. Conclusion One-third of the study participants had moderate to severe levels of perceived stress. Age, sleep hours, presence of cough, presence of under-5 children or elderly in the same house, and feeling of loneliness during home isolation were found to be significantly associated with high perceived stress level scores.

Tigecycline: Role in the Management of cIAI and cSSTI in the Indian Context

The current millennium has witnessed an increased antimicrobial resistance which poses a mammoth challenge for public health management. This has resulted in an increase in morbidity and mortality, resulting in an increase in financial burden to the patients. A recent analysis from 10 hospitals in India reported that mortality rate increases by 1.57 times in patients suffering from multidrug resistance (MDR) bacterial infections as compared to patients infected with similar but susceptible infections. Due to the emergence of MDR and extensively drug-resistant (XDR) bacteria, most of the broad-spectrum antibiotics have been rendered ineffective. The mortality rate with Gram-negative strains is higher than with Gram-positive strains. Tigecycline is the first in class glycylcycline antibiotic with an expanded broad-spectrum activity. Tigecycline enters bacterial cells through energy-dependent pathways or via passive diffusion, to reversibly bind to the 30S ribosomal subunit. It has potent in vitro activity against Gram-negative carbapenemase producers, except Pseudomonas aeruginosa and Proteus spp. It also has good in vitro activity against Carbapenem-resistant Klebsiella pneumoniae strains. Hence, it is considered as a therapeutic option in XDR isolates. Recent meta-analyses have shown tigecycline to be as effective as its comparators with reducing mortality rates. Due to increased resistance reported in carbapenem-resistant isolates in Indian health-care settings, a colistin/polymyxin B-based combination therapy as a treatment option is being sought. A lower mortality rate has been reported with colistin-based combination therapy in Carbapenem-resistant Enterobacteriaceae-associated infections. Combinations with tigecycline, Fosfomycin, and chloramphenicol have shown to improve treatment outcomes. Tigecycline can be a good alternative in MDR and XDR complicated intra-abdominal and complicated skin and soft tissue infections. Appropriately designed clinical trials in Indian health-care setups will reinforce clinician’s confidence in using tigecycline in complex clinical situations.

Family Planning Practices in Kerala: A Critical Appraisal Using National Family Health Survey Data

Background Adequate attention to family planning can not only reduce poverty and hunger in countries with high birth rates but also avert maternal and childhood deaths. Kerala, the southernmost state of India, has achieved its replacement level fertility rate far ahead of India. The study aims to analyze the contraceptive prevalence of the state over the years and also at the district level and the choices of different family planning methods in the state. Methodology This study is a secondary data analysis using the available information from the National Family Health Survey (NFHS) available from “The demographic health survey program’s data distribution system.” Results The contraceptive prevalence rate (CPR) of Kerala showed an initial increase followed by a sudden fall by more than 10% in 10 years period during the 2015 survey, thereafter stabilized in 2019. Among the modern contraceptive methods, the most commonly used method consistently over the years was female sterilization (46.6%) and the least common method was male sterilization (0.1%). The unmet needs in family planning in the state varied across the districts from as high as 19.3% to 5.6% though it was reduced by 1.2 percentage units as compared to NFHS-4 data. Conclusion The findings contradict the assumption that the use of modern spacing techniques will increase with female literacy and a higher standard of living. Female-oriented nature of family planning practices in the state should be revisited and strategies should be brought to bring equal participation of males and females. Districts with reduced CPR should be prioritized and region-specific policy recommendations are necessary to address specific needs.

Evolution of Non-communicable Disease Programs in Kerala: Lessons Learnt and the Way Forward

Addressing the double burden of disease in a country like India is a massive challenge, especially when the system is tuned to do monitoring and surveillance of mainly communicable diseases. Achieving the sustainable development goal target 3.4 to bring down the premature mortality from non-communicable diseases (NCDs) to one-third will need to consider the requirement of robust indicators at the national level to keep track of the prevalence of NCD and its risk factors among its population. The state of Kerala in contrast has a strong primary health care system that it can build on to address the rising NCD burden.

Using Test Positivity Rate (TPR) as an Indicator for Strategic Action in COVID-19: A Situational Analysis in Kerala, India

Administrators and policymakers have relied on test positivity rate (TPR) for making policy decisions regarding local, regional, and national lockdowns. It has the advantage of easily available data with an easy technique for calculation on day-to-day basis. However, concerns are being raised regarding its use as a sole indicator for determining movement restrictions and lockdowns. The present review provides a perspective of the alterations in TPR in Kasaragod district of Kerala during the first half of 2021. The variations in the number of antigen and reverse transcription polymerase chain reaction (rt-PCR) tests along with the trend of proportion of rt-PCR test are depicted. In places like Kerala where primary care system and contact tracing is comparatively robust than several other regions, testing the appropriate persons in a timely fashion alone is sufficient to cause an upswing in the TPR. Rather than daily change, the overall change in a larger time frame of 1 to 2 weeks could give early warning regarding the emergence of a new wave. TPR alone may not be able to reflect the transmission patterns of COVID-19. Using 7-day median value of TPR along with weekly tests done per 10,000 population, 7-day rolling average of active cases per 10,000 population, or daily number of new positive cases per 10,000 population could bring out a more composite indicator. Such an indicator reflecting the disease dynamics at regional levels will enable people to improve their livelihood without compromising on COVID-19.

Early Symptoms of Patients With COVID-19 in Family Medicine Centers in South India: A Retrospective Study

Introduction: A recent Cochrane review on the diagnostic accuracy of initial signs and symptoms of COVID-19 reported on the lack of evidence from studies conducted in community-based health-care settings. Since a broad spectrum of patients present to primary health-care services, testing for patients with noninfluenza-like illness and atypical presentations is debatable. Hence, there is an urgent need for documenting the early presenting symptoms of COVID-19 among patients seeking medical care in primary health-care settings. Aim: In this study, we aim to document the early symptoms of patients with COVID-19 and the proportion of asymptomatic infection in family medicine centers in South India. Design: This is a retrospective study of the early symptoms of patients who tested positive between June and December 2020. The data and clinical notes of patients were retrieved from the hospital information system. Setting: This study was undertaken by the Department of Family Medicine (DFM) in a private not-for-profit academic institution in South India. The DFM provides primary and secondary health-care services to nearly 1,50,000 patients from the local urban communities. Results: A total of 330 patients were tested for COVID-19 and the study included 94 patients who tested positive. Around 37% participants were asymptomatic. The commonest symptom was fever (58.6%), followed by tiredness/myalgia (48.3%), loss of taste or smell or appetite (43.1%), and cough or cold (37.9%). Most participants (78.2%) were hospitalized and the rest (21.8%) were home-quarantined. Only 5 (5.7%) of them died due to COVID-19 infection. Conclusion: The results of the study reiterates the role of social distancing, self-isolation, proper masking, and greater vaccination coverage as significant public health interventions.

Celiac Disease Presenting as Hemolytic Anemia Mimic: A Case Report

Celiac disease, an immune-mediated enteropathy, results from gluten ingestion in the form of wheat, rye, and barley in genetically susceptible individuals. It is a systemic disorder characterized by a variable combination of gluten-related signs and symptoms, and disease-specific antibodies in addition to enteropathy. The clinical presentation of celiac disease is extremely variable: a small proportion of patients presenting with severe gastrointestinal symptoms and malabsorption, and extraintestinal symptoms, and a large proportion having no symptoms at all. Owing to the varied clinical presentation, diagnosing celiac disease remains a challenge. We present a case of celiac disease presenting with severe anemia and clinical features suggestive of hemolytic anemia, making diagnosis even more difficult.