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Therapies used to tide over acute crisis of COVID-19 infection may lower the immunity, which can lead to secondary infection or a reactivation of latent infection. We report a 75-years-old male patient who had suffered from severe COVID-19 infection three weeks earlier and who had been treated with corticosteroids and convalescent plasma along with other supportive therapies. At time of discharge he had developed leukopenia which worsened at 1-week follow up visit. On 18th day post-discharge, he became very sick and was brought to our hospital with complaints of severe persistent dysphagia. During evaluation he was diagnosed to have an acute cytomegalovirus infection and severe oropharyngeal thrush. Both COVID-19 and cytomegalovirus are known to cause synergistic decrease in T cells and NK cells leading to immunosuppression. The patient made complete recovery with a course of intravenous ganciclovir and fluconazole. Persistent leukopenia in high risk and severely ill cases should give rise to a suspicion of COVID-19 and cytomegalovirus co-infection.

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Atypical presentations of supraventricular arrhythmias constitute a diagnostic challenge which are not frequently reported in literature. Swallowing-induced supraventricular arrhythmia (SI-SVA), which was first described in 1926, is an intriguing presentation of supraventricular tachycardia and occurs during a wet or solid swallow. A 67-year-old man presented to our outpatient clinic complaining from recurrent episodes of sensation of palpitations and short duration pressure on his chest while swallowing since the last 2 weeks. Ambulatory rhythm Holter monitoring was suggestive of atrial fibrillation (AF) or atrial tachycardia attacks during swallowing. In addition, electrocardiography performed during solid food swallowing, showed short duration of AF consistent with the patient's symptoms. The patient was successfully treated with amiodarone. The main cause of SI-SVA is not known. Cross-talk of nerves during the impulse propagation might be the underlying cause of this phenomenon.

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This case report reviews the hospital course of a 15-month-old girl admitted to the PICU for acute respiratory failure due to enterovirus infection; who subsequently had multiple extubation failures secondary to acute transverse myelitis. This rare presentation highlights the importance of assessing the neurological status in a patient with rhino-enteroviral respiratory infection and of considering acute transverse myelitis as an etiology for difficulty with extubation.

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A 15-year-old boy presented with fever, skin, and oral lesions for 4 weeks. The cutaneous lesions were suggestive of subacute cutaneous lupus erythematosus and erythema multiforme. His clinical, histopathological, and immunological features were indicative of Rowell syndrome and he satisfied the diagnostic criteria of Rowell syndrome proposed by Zeitouni et al. He subsequently developed neurological manifestations and was diagnosed to have neuropsychiatric systemic lupus erythematosus. We report this case for the unusual occurrence of a rare entity like Rowell syndrome in an adolescent male with co-existence of neuropsychiatric systemic lupus erythematosus.

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Agraphia is defined as the disruption of the previously intact writing skills due to an acquired brain damage. Stroke remains the most common cause of language impairment; however, writing disorders, including agraphia, are underestimated in patients with stroke. In this regard, we report two patients presenting with pure agraphia as an early symptom of stroke. Both patients complained of at least two difficulties in visualizing letter formation beforehand, the frequent need for verbal cues, misuse of lines and margins, poorly legible signature, and writing and thinking at the same time (e.g., creative thinking and taking notes). They underwent brain magnetic resonance imaging which revealed a small lacunar infarction of the left insula and external capsule (patient 1) and a small hemorrhagic lesion in the posterior limb of the left internal capsule (patient 2). To our knowledge, this is the first report on pure agraphia as the presenting symptom of stroke. We suggest that all patients with acute agraphia, even when presenting as an isolated symptom, should be evaluated for stroke, in order to better facilitate its diagnosis and treatment.

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The new competency-based medical education curriculum for Bachelor of Medicine and Bachelor of Surgery is being implemented in a phased manner in medical colleges across India since the year 2019. The Graduate Medical Education Regulations enlist a total of 35 global competencies for the five roles expected of an Indian medical graduate, the roles being clinician, communicator, leader, professional, and life-long learner. Along with an effective implementation of the new curriculum, both in spirit and in action, it is imperative to assess the listed competencies. The new curriculum demands a more careful and mature selection of assessment tools, based on the competency and its expected level of achievement. It is these two variables that make choosing the right assessment method not just a matter of choice, but also of expertise. An array of tools in our armamentarium can sometimes separate confuse and the teachers. So, using the right tool, in the right context, at the right juncture, supplemented by other tools, and backed by constructive feedback, can help nurture the good intent ingrained in the competency-based curriculum. Hence, an attempt was made to compile an assessment toolbox for various global competencies. A PubMed, Science Direct and Google Scholar search, with relevant keywords was carried out. To the initially extracted 90,121 articles, limitations were applied, duplicates were removed and screening for assessment of global competencies and its attributes was done to select 232 articles. Finally, 31 articles were used for designing the proposed toolbox. Prioritization for the tools for the global competencies was based on thorough literature review and extensive discussion. The evolved assessment toolbox is presented in this article, which would help teachers pick the most useful methods of assessment for global competencies.

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Headache in women in their late forties can be primary or secondary. We report a 48-year-old female with chronic slowly progressive left temporal headache for 1 year. She also had ipsilateral eye pain and facial numbness for 1 month, with restricted abduction in the left eye and diplopia. On neurological examination, she had isolated left abducent nerve palsy, with loss of corneal and conjunctival reflexes, localizing the pathology to the cavernous sinus or its adjacent structures. Anatomically, cranial nerves V and VI are in close proximity to each other in the region of Meckel's cave. In view of her age, insidious onset, progressive symptoms and clinical findings, the provisional diagnosis in this patient was a Meckel's cave tumor. Magnetic resonance (MR) imaging revealed a 2 cm × 2 cm × 1.7 cm enhancing dumb-bell-shaped mass lesion with mild restricted diffusion in the Meckel's cave projecting into cavernous sinus with alanine, myoinositol and glutamine peaks on MR spectroscopy. Intradural debulking was done; lesion was confirmed by histopathology and patient was cured of her symptoms. An algorithm for diagnosing this entity at the bedside is presented.

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Aims: To evaluate the prevalence of metabolic syndrome (MS) and whole-body composition in patients with congenital hypogonadism and investigate the effects of replacement therapy with testosterone undecanoate on MS, insulin resistance (IR), and whole-body composition in subset of patients. Methods: In a single arm prospective longitudinal intervention study, 33 patients with congenital hypogonadism, ages 20–39 years, were recruited and their parameters of MS, whole-body composition by DXA were compared with age and BMI matched healthy controls. In 21 patients, after 9 months we prospectively studied the effect (pre–post difference) of injection testosterone undecanoate (1,000 mg) replacement on MS, IR, and whole-body compositions. Results: The prevalence of MS was similar in patients and controls (27.3% vs. 9.1%, P = 0.05). Hypogonadism patients had higher prevalence of hypertension (33% vs. 3%, P < 0.01). Patients had decrease in lean body mass (P < 0.05) as compared to controls. After testosterone replacement, there was significant decrease in waist circumference (88.6 ± 13.1 cm vs. 83.9 ± 12.9 cm, P < 0.01), truncal fat (25.9 ± 7.3% vs. 24.0 ± 6.3%, P < 0.05), fasting C-peptide (2.1 ± 0.79 ng/ml vs. 0.68 ± 0.23 ng/ml, P < 0.01), serum proinsulin [1.43 (0.32–13.4) vs. 0.5 (0.5–3.2) pmol/l, P < 0.001] and a significant increase in lean body mass (46,906 ± 8,876 gm vs. 50,083 ± 7,590 gm, P < 0.001). Homeostasis model assessment of insulin resistance (HOMA-IR) (4.6 ± 1.7 vs. 0.5 ± 0.2, P < 0.001) and homeostatic model for assessment of insulin sensitivity (HOMA%S) [21 (12–65) vs. 206 (125–714), P < 0.001] were improved significantly following testosterone replacement. Conclusion: In this study, 36 weeks of testosterone replacement resulted in significant decrease in waist circumference, IR, truncal fat, total body fat and improvement in lean body mass, and insulin sensitivity.

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Background: The pharmacokinetics of primaquine [PQ] have been the subject of studies in both adults and healthy participants. However, there is no study on its pharmacokinetics in a setting of undernourishment. In India, there is evidence to show considerable malnourishment in children that in turn can affect drug pharmacokinetics. Given that the country is moving towards malaria elimination, the present study was planned with the objective of comparing pharmacokinetics of the drug in undernourished children relative to normally nourished children. Materials and Methods: After Institutional Ethics Committee approval, children of either gender between the ages of 5 and 12 years and smear-positive for Plasmodium vivax malaria were included. Nourishment status was determined using the Indian Academy of Pediatrics classification of protein energy malnutrition based on Khadilkar's growth charts. Twelve children each were enrolled in the two groups. PQ was given in the dose of 0.3 mg/kg/d and blood collections were made at 0, 1, 2, 3, 4, 6, 8 and 24 hours post-dosing. Levels were estimated by high-performance liquid chromatography. Chloroquine in the dose of 25 mg/kg was given over three days along with supportive care. Results: Of the 24 children, there were 17 boys and 7 girls. There was a statistically significant difference in the body weight between the undernourished and the normally nourished children [21.5 ± 5.52 vs. 28.8 ± 8.84, P < 0.05]. PQ levels showed wide inter-individual variation in both groups. No significant difference was seen in any pharmacokinetic parameter between the two groups. Discussion: This study adds to the limited body of evidence on the pharmacokinetics of PQ in children with malaria and indicates that the dosing of primaquine could potentially be independent of the nourishment status.

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Citations and validation of work play a crucial and integral role in a researcher's career. Ranking systems of scientists, on the other hand, potentially scratch and expose the fallible egoistic human face of science, leading to an unhealthy milieu of competition rather than the uplifting one of motivation. We have attempted to highlight and bring to fore these factors in our brief viewpoint. We critically analyze the reasons why ranking systems of scientists, especially in the field of medicine, will shift the focus from advancement of science to advancement of “self.”

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