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INTRODUCTION: Cytokines and granulocyte elastase produced in sepsis cleave a disintegrin and metalloprotease with thrombospondin type I motif 13 (ADAMTS13) and deplete its levels. By this mechanism, sepsis results in microangiopathic hemolytic anemia (MAHA) with thrombocytopenia. Hence, the hypothesis is that plasmapheresis may help in sepsis-induced thrombotic microangiopathy (sTMA), by removing the factors responsible for low levels of ADAMTS13. In tropical countries like India, the contribution of sepsis to intensive care unit (ICU) mortality is high; and hence, it is essential to look out for newer modalities of sepsis treatment. There is abundant literature on the use of plasmapheresis in sepsis but data on its use in sTMA are limited, thus necessitating further research in this field. CASE DESCRIPTION: This case series studies the outcomes of five patients admitted with sTMA in the ICU and attempts to evaluate the effectiveness of plasmapheresis in improving their outcomes. All patients diagnosed with sTMA and treated with plasmapheresis, between January 2016 and August 2018 at our tertiary care center, were selected for the study. The diagnosis of sepsis was based on sepsis-3 definition. RESULTS: Four different gram-negative organisms were found to have caused MAHA, with the commonest source being either urinary tract infection (UTI) or lower respiratory tract infection. Three of five patients required hemodialysis and two had disseminated intravascular coagulation (DIC). All five had good outcome and recovered well from the acute episode post plasmapheresis. DISCUSSION: In two of five patients, the initial smear was negative and hence the need for repeated examination of the peripheral blood smear should be kept in mind in cases of sTMAs. The median of the number of plasmapheresis sessions required in sTMA is six, which is lesser than that required for primary thrombotic thrombocytopenic purpura (TTP). Hence, the duration of central line placement and the risk of catheter-related complications are low. Based on the observations made in this case study, further exploratory studies are required to evaluate the efficacy of plasmapheresis in sTMA secondary to tropical infections. HOW TO CITE THIS ARTICLE: Upadhya SRS, Mahabala C, Kamat JG, Jeganathan J, Kumar S, Prabhu MV. Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series. Indian J Crit Care Med 2020;24(3):195-199.

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INTRODUCTION: Azithromycin usage in patients with baseline cardiovascular risk is associated with increased risk of cardiovascular mortality, following which Food and Drug Administration (FDA) issued a black box warning regarding safety of azithromycin in patients with cardiovascular morbidity particularly with prolonged QTc. Cetirizine is a second generation anti histaminic and is found to be commonly used for Upper Respiratory Tract Infections (URIs) along with azithromycin on outpatient basis. Whether, usage of these two drugs in combination confers a similar risk, is unknown. AIM: To assess the effect on QTc among patients treated with azithromycin and cetirizine combination for upper respiratory tract infection. MATERIALS AND METHODS: We conducted a prospective longitudinal study from August 2014 to July 2016. The study was done on 45 patients above 18 years of age without any cardiovascular morbidity in whom azithromycin and cetirizine were prescribed for upper respiratory tract infections. We compared the QTc on day 1 and day 4. Data was analysed using Student's paired t-test. RESULTS: During three days of azithromycin and cetirizine for upper respiratory tract infections, we observed that on day 4 there was significant increase in QTc in 43 patients (95.6%) as compared with the QTc on day 1. We also observed that in 8 (17.8%) out of 45 patients, QTc on day 4 crossed the upper limit of normal {430 milliseconds (ms)}, but this was not statistically significant. However, analysing these eight patients, we obtained the baseline QTc of 377.50 ms above which if prescribed, this combination of drugs have a chance of prolonging the QTc above 430 ms with a sensitivity of 87.5% and specificity of 40.5%. CONCLUSION: During three days treatment with azithromycin and cetirizine, there was significant change in QTc between day 1 and day 4. Patients with baseline QTc greater than 377.5 ms were at risk of QTc prolongation above 430 ms on day 4.

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BACKGROUND: The Carotid Intima-Media Thickness (CIMT) is a simple and an inexpensive tool which can be used to assess the cumulative effect of atherosclerotic risk factors and it is also an independent predictor of the future cardiovascular risk. Nevertheless, criticism has been raised throughout the scientific community, based on the observations which indicated a weak correlation between CIMT and coronary atherosclerosis. It has been suggested by the International Atherosclerosis Project, that the atherosclerotic process occurs at the same time in the carotid, cerebral and the coronary arteries. Measurement of the Carotid Intima-Media Thickness (CIMT) of the Common Carotid Artery (CCA) by B-mode ultrasound was found to be a suitable non-invasive method, to visualize the arterial walls and to monitor the early stages of the atherosclerotic process. AIM: This study sought to determine the usefulness of B-mode ultrasound as a non-invasive marker to examine the association between CIMT and the extent and the severity of coronary artery disease and its association with the cardiovascular risk factors, if any. METHODS: A cross-sectional study was done among hundred cases and hundred age and sex matched controls who were in the age group of 30-65 years. The cases included those who had undergone coronary angiography. The controls included non-diabetic non-hypertensives with no cardiovascular risk factors. The CIMT was assessed by using a 7MHz linear array transducer. Fasting blood samples were collected for measuring the blood sugar and the lipid profiles. RESULTS: The statistical analysis was done by using the Student's t test and ANOVA and a p value of <0.001 was considered to be significant. The Average Carotid Intima Media Thickness (AVCIMT) was higher in the cases (0.90 vs 0.47 in controls, p<0.001, very highly significant). The AVCIMT was found to be higher in those with triple vessel disease (1.00mm)

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BACKGROUND: Studies mainly in the western population have compared central corneal thickness in primary open angle glaucoma and normal individuals have found variable results. We did this study to compare the central corneal thickness of primary open angle glaucoma patients with normal controls in a south Indian population. MATERIALS AND METHODS: This was a masked, cross-sectional study undertaken in a tertiary care center in South India. A total of 50 controls and 50 primary open angle glaucoma patients were studied. Central corneal thickness between the two groups was compared using Wilcoxon two sample test and the signed rank test. RESULTS: The mean central corneal thickness in the control group was 536 µm (462-608 µm) and in the primary open angle glaucoma group was 531 µm (476-609 µm). CONCLUSION: There was no significant difference in the central corneal thickness between primary open angle glaucoma patients and the normal controls.

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Fahr's syndrome refers to a rare syndrome which is characterized by symmetrical and bilateral intracranial calcification. We are presenting a 63 year old male, who complained of progressive dysarthria of 6 months, which was associated with slowness of movements. His neurological examination revealed Parkinsonian features. His CT scan revealed a symmetrical large area of calcification over the basal ganglia, the thalamus and the cerebellum. The secondary causes of the bilateral calcification were ruled out to make the clinical diagnosis of Idiopathic Bilateral Striopallidodentate Calcinosis, which is otherwise called as the Fahr's syndrome. Deposits of calcium and minerals cannot be linked to a single chromosomal locus and further genetic studies are in progress for identifying the chromosomal locus of the disease.

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This prospective study was undertaken to evaluate the distribution and pattern of glomerular diseases from a clinico-pathological perspective in our hospital, which is a tertiary care center in Southern India. Seventy-five consecutive patients who underwent renal biopsy and were diagnosed to have glomerular disease over a two-year period were studied and followed-up for one year. Primary glomerular disorders were more common than secondary glomerular disorders. Minimal change disease was the most common primary glomerular disease and lupus was the most common secondary glomerular disorder. Other common primary glomerular disorders were IgA nephropathy (16%) and post-infectious glomerulonephritis (10.7%), while focal and segmental glomerulosclerosis accounted for only 5.3% of the cases. In one-third of the cases, the initial clinical diagnosis did not correlate with the final biopsy diagnosis, further emphasizing the importance of renal biopsy in glomerular disorders.

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Glomerulonefritis por IGA/patología , Glomerulonefritis/patología , Glomeruloesclerosis Focal y Segmentaria/patología , Glomérulos Renales/patología , Centros de Atención Terciaria , Biopsia , Diagnóstico Diferencial , Femenino , Estudios de Seguimiento , Glomerulonefritis/epidemiología , Glomerulonefritis por IGA/epidemiología , Glomeruloesclerosis Focal y Segmentaria/epidemiología , Humanos , Incidencia , India/epidemiología , Enfermedades Renales , Masculino , Estudios Prospectivos

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BACKGROUND: Few studies in India as well as in most developing countries have compared the mortality and morbidity rates between chronic kidney disease patients who were referred early to nephrologists and those who were referred late. OBJECTIVES: To study the mortality and morbidity patterns and to compare the various clinical parameters between the abovementioned early and late referrals. PATIENTS AND METHODS: Fifty consecutive chronic kidney disease patients were followed up for one year. They were then classified as early referral (patients who underwent dialysis more than three months after the referral) and late referral (patients who underwent dialysis within three months of the referral). Clinical, laboratory parameters, and mortality patterns were compared between the two groups. RESULTS: The blood pressure, hemoglobin, glomerular filtration rate, and calcium and phosphate values were better in the early referral group. Among the 24 complications that occurred, 17 (70.8%) were seen among the patients who were referred late. Among the 13 deaths that occurred, only one belonged to the early referral group. CONCLUSIONS: We observed that the mortality rate and clinical parameters were better in patients who were referred early to nephrologists.