Articles related to Impact of Covid-19 on Co-morbid condition

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Cryptococcus laurentii endogenous endophthalmitis post COVID-19 infection

Muthugaduru Jagadish Deepa,1 Chitta Megharaj,2 Santosh Patil,3 Padmaja Kumari Rani


A man in mid-50s presented with progressive blurred vision in his left eye for over 6weeks. He was a known diabetic with history of COVID-19 pneumonia treated with steroids and remdesivir. He had pyelonephritis and urinary culture grown Klebsiella. He was referred as a case of non-resolving vitreous haemorrhage. Visual acuity (VA) was hand movements with fundus showing dense vitritis. He underwent pars plana vitrectomy, vitreous biopsy with intraocular antibiotics (imipenem) suspecting as a case of endogenous bacterial endophthalmitis. Vitreous biopsy did not yield organisms on the smear/ culture. The patient’s condition worsened with perception of light and fundus showing dense vitritis with discrete yellowish white deposits on the surface of the retina. A repeat vitreous biopsy done along with intravitreal injection of voriconazole (suspecting fungal aetiology) grown fungal colonies and the organism was identified as Cryptococcus laurentii. At 4-month follow-up, the VA improved to 6/24.

3 comorbidity.pdf

Secondary osteonecrosis of the knee as a part of long COVID-19 syndrome: a case series

Sanjay R Agarwala, Mayank Vijayvargiya, Tushar Sawant


COVID-19 infection affects different organ systems with long-term sequelae, which has been termed as long COVID-19 syndrome. To the best of our knowledge, osteonecrosis of the knee as a part of long COVID-19 syndrome has not been documented. Corticosteroids are being used extensively in moderate and severe cases of COVID-19. We report two cases who developed osteonecrosis of the knee after being treated for COVID-19 infection. In our case series, the mean cumulative dose of prednisolone was 1156.5mg (900–1413mg), which is less than the cumulative dose reported in literature for osteonecrosis of the knee. In our case series, the patients developed symptomatic osteonecrosis at a mean interval of 73 days after initiation of steroid therapy, with the earliest presenting at 25 days. Early diagnosis of osteonecrosis of the knee on high clinical suspicion by MRI would help in early intervention with bisphosphonate therapy.

2 comorbidity.pdf

Definition, diagnosis, and management of COVID-19- associated pulmonary mucormycosis: Delphi consensus statement from the Fungal Infection Study Forum and Academy of Pulmonary Sciences, India

Valliappan Muthu, Ritesh Agarwal, Atul Patel, Soundappan Kathirvel, Ooriapadickal Cherian Abraham, Ashutosh Nath Aggarwal, Amanjit Bal, Ashu Seith Bhalla, Prashant N Chhajed, Dhruva Chaudhry, Mandeep Garg, Randeep Guleria, Ram Gopal Krishnan, Arvind Kumar, Uma Maheshwari, Ravindra Mehta, Anant Mohan, Alok Nath, Dharmesh Patel, Shivaprakash Mandya Rudramurthy, Puneet Saxena, Nandini Sethuraman, Tanu Singhal, Rajeev Soman, Balamugesh Thangakunam, George M Varghese, Arunaloke Chakrabarti


COVID-19-associated pulmonary mucormycosis (CAPM) remains an underdiagnosed entity. Using a modified Delphi method, we have formulated a consensus statement for the diagnosis and management of CAPM. We selected 26 experts from various disciplines who are involved in managing CAPM. Three rounds of the Delphi process were held to reach consensus (≥70% agreement or disagreement) or dissensus. A consensus was achieved for 84 of the 89 statements. Pulmonary mucormycosis occurring within 3 months of COVID-19 diagnosis was labelled CAPM and classified further as proven, probable, and possible. We recommend flexible bronchoscopy to enable early diagnosis. The experts proposed definitions to categorise dual infections with aspergillosis and mucormycosis in patients with COVID-19. We recommend liposomal amphotericin B (5 mg/kg per day) and early surgery as central to the management of mucormycosis in patients with COVID-19. We recommend response assessment at 4–6 weeks using clinical and imaging parameters. Posaconazole or isavuconazole was recommended as maintenance therapy following initial response, but no consensus was reached for the duration of treatment. In patients with stable or progressive disease, the experts recommended salvage therapy with posaconazole or isavuconazole. CAPM is a rare but underreported complication of COVID-19. Although we have proposed recommendations for defining, diagnosing, and managing CAPM, more extensive research is required.

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The intersecting pandemics of tuberculosis and COVID-19: population-level and patient-level impact, clinical presentation, and corrective interventions

Keertan Dheda*, Tahlia Perumal*, Harry Moultrie, Rubeshan Perumal, Aliasgar Esmail, Alex J Scott, Zarir Udwadia, Kwok Chiu Chang, Jonathan Peter, Anil Pooran, Arne von Delft, Dalene von Delft, Neil Martinson, Marian Loveday, Salome Charalambous, Elizabeth Kachingwe, Waasila Jassat, Cheryl Cohen, Stefano Tempia, Kevin Fennelly, Madhukar Pai


The global tuberculosis burden remains substantial, with more than 10 million people newly ill per year. Nevertheless, tuberculosis incidence has slowly declined over the past decade, and mortality has decreased by almost a third in tandem. This positive trend was abruptly reversed by the COVID-19 pandemic, which in many parts of the world has resulted in a substantial reduction in tuberculosis testing and case notifications, with an associated increase in mortality, taking global tuberculosis control back by roughly 10 years. Here, we consider points of intersection between the tuberculosis and COVID-19 pandemics, identifying wide-ranging approaches that could be taken to reverse the devastating effects of COVID-19 on tuberculosis control. We review the impact of COVID-19 at the population level on tuberculosis case detection, morbidity and mortality, and the patient-level impact, including susceptibility to disease, clinical presentation, diagnosis, management, and prognosis. We propose strategies to reverse or mitigate the deleterious effects of COVID-19 and restore tuberculosis services. Finally, we highlight research priorities and major challenges and controversies that need to be addressed to restore and advance the global response to tuberculosis.


The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries

Martin Hoenigl*, Danila Seidel*, Agostinho Carvalho, Shivaprakash M Rudramurthy, Amir Arastehfar, Jean-Pierre Gangneux, Nosheen Nasir, Alexandro Bonifaz, Javier Araiza, Nikolai Klimko, Alexandra Serris, Katrien Lagrou, Jacques F Meis, Oliver A Cornely, John R Perfect, P Lewis White, Arunaloke Chakrabarti, on behalf of ECMM and ISHAM collaborators†

Reports of COVID-19-associated mucormycosis have been increasing in frequency since early 2021, particularly among patients with uncontrolled diabetes. Patients with diabetes and hyperglycaemia often have an inflammatory state that could be potentiated by the activation of antiviral immunity to SARS-CoV2, which might favour secondary infections. In this Review, we analysed 80 published and unpublished cases of COVID-19-associated mucormycosis. Uncontrolled diabetes, as well as systemic corticosteroid treatment, were present in most patients with COVID-19- associated mucormycosis, and rhino-orbital cerebral mucormycosis was the most frequent disease. Mortality was high at 49%, which was particularly due to patients with pulmonary or disseminated mucormycosis or cerebral involvement. Furthermore, a substantial proportion of patients who survived had life-changing morbidities (eg, loss of vision in 46% of survivors). Our Review indicates that COVID-19-associated mucormycosis is associated with high morbidity and mortality. Diagnosis of pulmonary mucormycosis is particularly challenging, and might be frequently missed in India.


Cutaneous mucormycosis: an unusual cause of decompensation in a patient with ethanol-related cirrhosis with COVID-19 exposure

Authors: Sherna Menezes,1 Janu Santhosh Kumar,2 Omkar S Rudra,3 Aabha Nagral 1

We describe a case of cutaneous mucormycosis in a middle-aged man with ethanol-related chronic liver disease. He presented with symptoms of fever, breathlessness for 10 days and altered mental status for 2 days. On admission, he was in septic shock and had acute respiratory distress syndrome (ARDS). He was noted to have ruptured blisters in his left axilla. Although he repeatedly had negative COVID-19 Reverse Transcription-PCR results, he had positive IgG antibodies for COVID-19. He was managed with broad-spectrum antibiotics, steroids, vasopressors and ventilation for ARDS. Over the course of his hospitalisation, the axillary lesion progressed to a necrotising ulcer with deep tissue invasion. Debridement and culture of the axillary ulcer revealed mucor species, and he was started on amphotericin and posaconazole for mucormycosis. Unfortunately, he continued to deteriorate despite aggressive management and died after a prolonged hospital stay of 40 days.

COVID-19 presenting as acute pericarditis

Authors: Soumitra Ghosh ,1 Prashant Panda ,1 Yash Paul Sharma,1 Neha Handa

COVID 19, caused by SARS-CoV-2, is a highly infectious disease, mainly affects the respiratory system. In this article, we have presented a case of COVID-19, who presented solely with pericarditis without myocarditis, without any respiratory symptoms. The diagnosis was made based on clinical, electrocardiographic, radiological and biological findings. He was treated successfully with aspirin and colchicine. Our case highlights an atypical presentation of COVID-19, which should be kept in mind in the present pandemic and to diagnose and isolate early to limit the spread of infection.

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A meta-analysis of comorbidities in COVID-19: Which diseases increase the susceptibility of SARS-CoV-2 infection.

Authors: Manoj Kumar Singh , Ahmed Mobeen , Amit Chandra , Sweta Joshi , Srinivasan Ramachandran.

AUTHORS: Comorbidities in COVID-19 patients often lead to more severe outcomes. The disease-specific molecular events, which may induce susceptibility to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, are being investigated. To assess this, we retrieved array-based gene expression datasets from patients of 30 frequently occurring acute, chronic, or infectious diseases. Comparative analyses of the datasets were performed after quantile normalization and log2 transformation. Among the 78 host genes prominently implicated in COVID-19 infection, ACE2 (receptor for SARS-CoV-2) was positively regulated in several cases, namely, leukemia, psoriasis, lung cancer, non-alcoholic fatty liver disease (NAFLD), breast cancer, and pulmonary arterial hypertension (PAH). FURIN was positively regulated in some cases, such as leukemia, psoriasis, NAFLD, lung cancer, and type II diabetes (T2D), while TMPRSS2 was positively regulated in only 3 cases, namely, leukemia, lung cancer, and T2D. Genes encoding various interferons, cytokines, chemokines, and mediators of JAK-STAT pathway were positively regulated in leukemia, NAFLD, and T2D cases. Among the 161 genes that are positively regulated in the lungs of COVID-19 patients, 99–111 genes in leukemia (including various studied subtypes), 77 genes in NAFLD, and 48 genes in psoriasis were also positively regulated. Because of the high similarity in gene expression patterns, the patients of leukemia, NAFLD, T2D, psoriasis, and PAH may need additional preventive care against acquiring SARS-CoV-2 infections. Further, two genes CARBONIC ANHYDRASE 11 (CA11) and CLUSTERIN (CLU) were positively regulated in the lungs of patients infected with either SARS-CoV-2, or SARSCoV or Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: A systematic review of literature

Authors: Rimesh Pal , Mainak Banerjee , Urmila Yadav , Sukrita Bhattacharjee.

Background and aim: To conduct a systematic literature review and analyze the demographic/ biochemical parameters and clinical outcomes of COVID-19 patients with diabetic ketoacidosis (DKA) and combined DKA/HHS (hyperglycemic hyperosmolar syndrome). Methods: PubMed, Scopus, Embase, and Google Scholar databases were systematically searched till August 3, 2020 to identify studies reporting COVID-19 patients with DKA and combined DKA/HHS. A total of 19 articles reporting 110 patients met the eligibility criteria. Results: Of the 110 patients, 91 (83%) patients had isolated DKA while 19 (17%) had DKA/HHS. The majority of the patients were male (63%) and belonged to black ethnicity (36%). The median age at presentation ranged from 45.5 to 59.0 years. Most of the patients (77%) had pre-existing type 2 diabetes mellitus. Only 10% of the patients had newly diagnosed diabetes mellitus. The median blood glucose at presentation ranged from 486.0 to 568.5 mg/dl, being higher in patients with DKA/HHS compared to isolated DKA. The volume of fluid replaced in the first 24 h was higher in patients with DKA/HHS in contrast to patients with DKA alone. The in-hospital mortality rate was 45%, with higher mortality in the DKA/HHS group than in the isolated DKA group (67% vs. 29%). pH was lower in patients who had died compared to those who were discharged. Conclusion: DKA in COVID-19 patients portends a poor prognosis with a mortality rate approaching 50%. Differentiating isolated DKA from combined DKA/HHS is essential as the latter represents nearly one-fifth of the DKA cases and tends to have higher mortality than DKA alone.

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Poor outcomes in patients with cirrhosis and Corona Virus Disease-19

Authors: Shalimar1 & Anshuman Elhence1 & Manas Vaishnav1 & Ramesh Kumar2 & Piyush Pathak1 & Kapil Dev Soni3 & Richa Aggarwal3 & Manish Soneja4 & Pankaj Jorwal4 & Arvind Kumar4 & Puneet Khanna3 & Akhil Kant Singh3 & Ashutosh Biswas4 & Neeraj Nischal4 & Lalit Dar5 & Aashish Choudhary5 & Krithika Rangarajan6 & Anant Mohan7 & Pragyan Acharya8 & Baibaswata Nayak1 & Deepak Gunjan1 & Anoop Saraya1 & Soumya Mahapatra1 & Govind Makharia1 & Anjan Trikha3 & Pramod Garg1.

Abstract Background and Aim There is a paucity of data on the clinical presentations and outcomes of Corona Virus Disease-19 (COVID19) in patients with underlying liver disease. We aimed to summarize the presentations and outcomes of COVID-19-positive patients and compare with historical controls. Methods Patients with known chronic liver disease who presented with superimposed COVID-19 (n = 28) between 22 April 2020 and 22 June 2020 were studied. Seventy-eight cirrhotic patients without COVID-19 were included as historical controls for comparison. Results A total of 28 COVID-19 patients (two without cirrhosis, one with compensated cirrhosis, sixteen with acute decompensation [AD], and nine with acute-on-chronic liver failure [ACLF]) were included. The etiology of cirrhosis was alcohol (n = 9), non-alcoholic fatty liver disease (n = 2), viral (n = 5), autoimmune hepatitis (n = 4), and cryptogenic cirrhosis (n = 6). The clinical presentations included complications of cirrhosis in 12 (46.2%), respiratory symptoms in 3 (11.5%), and combined complications of cirrhosis and respiratory symptoms in 11 (42.3%) patients. The median hospital stay was 8 (7–12) days. The mortality rate in COVID-19 patients was 42.3% (11/26), as compared with 23.1% (18/78) in the historical controls (p = 0.077). All COVID-19 patients with ACLF (9/9) died compared with 53.3% (16/30) in ACLF of historical controls (p = 0.015). Mortality rate was higher in COVID-19 patients with compensated cirrhosis and AD as compared with historical controls 2/17 (11.8%) vs. 2/48 (4.2%), though not statistically significant (p = 0.278). Requirement of mechanical ventilation independently predicted mortality (hazard ratio 13.68). Both non-cirrhotic patients presented with respiratory symptoms and recovered uneventfully. Conclusion COVID-19 is associated with poor outcomes in patients with cirrhosis, with worst survival rates in ACLF. Mechanical ventilation is associated with a poor outcome.
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Risk and outcomes of coronavirus disease in patients with inflammatory bowel disease: A systematic review and meta‐analysis.

Authors: Anupam Kumar Singh | Anuraag Jena | Praveen Kumar‐ | Vishal Sharma | Shaji Sebastian.

Abstract Background: The risk of severe acute respiratory syndrome‐related coronavirus 2 (SARS‐CoV‐2) infection and clinical outcomes of coronavirus disease (COVID‐19) in inflammatory bowel disease are unclear. Methods: We searched PubMed and Embase with the keywords: inflammatory bowel disease, Crohn's disease, ulcerative colitis and COVID‐19, novel coronavirus and SARS‐CoV‐2. We included studies reporting the frequency of COVID‐19 infection and outcomes (hospitalisation, need for intensive care unit care and mortality) in patients with inflammatory bowel disease. We estimated the pooled incidence of COVID‐19 in inflammatory bowel disease and comparative risk vis‐a‐vis the general population. We also estimated the pooled frequency of outcomes and compared them in patients who received and did not receive drugs for inflammatory bowel disease. Results: Twenty‐four studies were included. The pooled incidence rate of COVID‐ 19 per 1000 patients of inflammatory bowel disease and the general population were 4.02 (95% confidence interval [CI, 1.44–11.17]) and 6.59 [3.25–13.35], respectively, with no increase in relative risk (0.47, 0.18–1.26) in inflammatory bowel disease. The relative risk of the acquisition of COVID‐19 was not different between ulcerative colitis and Crohn's disease (1.03, 0.62–1.71). The pooled proportion of COVID‐19‐positive inflammatory bowel disease patients requiring hospitalisation and intensive care unit care was 27.29% and 5.33% while pooled mortality was 4.27%. The risk of adverse outcomes was higher in ulcerative colitis compared to Crohn's disease. The relative risks of hospitalisation, intensive care unit admission and mortality were lower for patients on biological agents (0.34, 0.19–0.61; 0.49, 0.33–0.72 and 0.22, 0.13–0.38, respectively) but higher with steroids (1.99, 1.64–2.40; 3.41, 2.28–5.11 and 2.70, 1.61–4.55) or 5‐aminosalicylate (1.59, 1.39–1.82; 2.38, 1.26–4.48 and 2.62, 1.67–4.11) use.

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Profile of co-infections & secondary infections in COVID-19 patients at a dedicated COVID-19 facility of a tertiary care Indian hospital: Implication on antimicrobial resistance.

Authors: Surbhi Khurana a , Parul Singh a , Neha Sharad a , Vandana V. Kiro a , Neha Rastogi b , Amit Lathwal c , Rajesh Malhotra d , Anjan Trikha e , Purva Mathur.

Background: The COVID-19 pandemic has raised concerns over secondary infections because it has limited treatment options and empiric antimicrobial treatment poses serious risks of aggravating antimicrobial resistance (AMR). Studies have shown that COVID-19 patients are predisposed to develop secondary infections. This study was conducted to ascertain the prevalence and profiles of co- & secondary infections in patients at the COVID-19 facility in North India. Methods: We studied the profile of pathogens isolated from 290 clinical samples. Bacterial and fungal pathogens were identified, and antimicrobial susceptibility was determined by the Vitek2® system. Additionally, respiratory samples were tested for any viral/atypical bacterial co-infections and the presence of AMR genes by FilmArray test. The clinical and outcome data of these patients were also recorded for demographic and outcome measures analyses. Results: A total of 151 (13%) patients had secondary infections, and most got infected within the first 14 days of hospital admission. Patients aged >50 years developed severe symptoms (p ¼ 0.0004) and/or had a fatal outcome (p ¼ 0.0005). In-hospital mortality was 33%.K.pneumoniae (33.3%) was the predominant pathogen, followed by A. baumannii (27.1%). The overall resistance was up to 84%.Majority of the organisms were multidrug-resistant (MDR) harbouring MDR genes. Conclusion: A high rate of secondary infections with resistant pathogens in COVID-19 patients highlights the importance of antimicrobial stewardship programs focussing on supporting the optimal selection of empiric treatment and rapid-de-escalation, based on culture reports.

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Role of comorbidities like diabetes on severe acute respiratory syndrome coronavirus-2: A review

Authors: Subham Dasa , Anu K.R.a , Sumit Raosaheb Birangala , Ajinkya Nitin Nikamb , Abhijeet Pandeyb , Srinivas Mutalikb , Alex Josepha.

Abstract: Pandemic coronavirus disease-2019, commonly known as COVID-19 caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a highly contagious disease with a high mortality rate. Various comorbidities and their associated symptoms accompany SARS-CoV-2 infection. Among the various comorbidities like hypertension, cardiovascular disease and chronic obstructive pulmonary disease, diabetes considered as one of the critical comorbidity, which could affect the survival of infected patients. The severity of COVID-19 disease intensifies in patients with elevated glucose level probably via amplified pro-inflammatory cytokine response, poor innate immunity and downregulated angiotensin-converting enzyme 2. Thus, the use of ACE inhibitors or angiotensin receptor blockers could worsen the glucose level in patients suffering from novel coronavirus infection. It also observed that the direct β-cell damage caused by virus, hypokalemia and cytokine and fetuin-A mediated increase in insulin resistance could also deteriorate the diabetic condition in COVID-19 patients. This review highlights the current scenario of coronavirus disease in pre-existing diabetic patients, epidemiology, molecular perception, investigations, treatment and management of COVID-19 disease in patients with preexisting diabetes. Along with this, we have also discussed unexplored therapies and future perspectives for coronavirus infection.

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Clotting disorder in severe acute respiratory syndrome coronavirus

Authors: Sujit Pujhari1,2 | Sanjeeta Paul3 | Jasmina Ahluwalia4 | Jason L. Rasgon.

Abstract: The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is a novel human respiratory viral infection that has rapidly progressed into a pandemic, causing significant morbidity and mortality. Blood clotting disorders and acute respiratory failure have surfaced as the major complications among the severe cases of coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV‐2 infection. Remarkably, more than 70% of deaths related to COVID‐19 are attributed to clotting‐associated complications such as pulmonary embolism, strokes and multi‐ organ failure. These vascular complications have been confirmed by autopsy. This study summarizes the current understanding and explains the possible mechanisms of the blood clotting disorder, emphasizing the role of (1) hypoxia‐related activation of coagulation factors like tissue factor, a significant player in triggering coagulation cascade, (2) cytokine storm and activation of neutrophils and the release of neutrophil extracellular traps and (3) immobility and ICU related risk factors.