COVID-19 and Fungal Infection – An Opportune Time: A Case Series
Ivan A. Jones*, G. Dominic Rodriguez
Department of General Medicine, Kauvery Hospital, Trichy, Tamilnadu, India
Email: keitch.jones@gmail.com
Abstract
Background: The COVID-19 pandemic which originated in Wuhan, China in late 2019 and paralyzed the world in 2020 posed unique problems to certain high-risk groups, especially the elderly and the diabetics.
Case presentation: The increased incidence of fungal infections that were noted in COVID-19 patients deserve close attention and have to be managed expeditiously.
Conclusion: Four patients recovered and one patient succumbed to infection and thrombotic complication. Meticulous glycemic monitoring, insulin therapy, minimizing antibiotic use and very safe handling of intravenous lines should be practiced to prevent these serious infections.
Keywords: COVID-19, Hyperglycemia, Steroids, Fungal infections, Mucormycosis, Candida sp.
Background
Diabetics were among the high-risk group prone for developing severe COVID pneumonia [1–4]. Apart from viral disease, life threatening fungal infections also occurred either as co-infections or as a complication post treatment.
From our COVID care centre, we have compiled the data of five patients in whom we encountered fungal infections and its management.
Several causes for increased fungal infections in diabetic patients are postulated.
(1).Chronic hyperglycemia predisposes to rhinocerebral mucormycosis and patients could present with the same as co-infection, along with COVID-19 pneumonia [1].
(2).COVID-19 infection itself has been noted to cause hyperglycemia through several mechanisms [5].
(3).Medications used for treatment of COVID-19 such as steroids, tocilizumab (IL-6 receptor antibody) and antibiotics can lead to fungal superinfection.
(4).Prolonged hospital stays, indwelling urinary catheters and central venous catheters coupled with antibiotic use, leads to increased chance of fungal infection.
These infections manifest as Urinary Tract Infections (UTI), Blood Stream Infections (BSI), fungal pneumonia or fungal rhino-orbital-cerebral infection.
Prompt diagnosis, involvement of surgical and medical teams and appropriate antifungal therapy are crucial in determining patient recovery [4].
Case Presentation
Case 1
A 54-year-old male who was a diabetic, hypertensive and hypothyroid presented with history of fever and cough for 10 days, dyspnea for four days, black discharge from left nostril for two days, along with swelling of left eye. On examination, he had eschar and ulceration in left middle meatus, decreased infra-orbital sensations, ptosis and complete ophthalmoplegia in left eye. Pupils were sluggishly reacting on left side and finger counting was impaired. Nasal swab examination revealed aseptate broad based branching fungal hyphae with right angled branching suggestive of zygomycetes species.
CT thorax revealed features of COVID-19 pneumonia. Blood investigations revealed diabetic ketoacidosis and severe renal failure. A provisional diagnosis of rhino-orbital mucormycosis was made. Endoscopic debridement of sinuses, left maxillectomy and left orbital exenteration was done. He was treated with amphotericin B, antibiotics, insulin and hemodialysis. Post operatively patient developed seizures, aspiration and gastrointestinal bleeding requiring intubation and mechanical ventilation.
CT-brain revealed bifrontal infarcts with hemorrhagic transformation – likely due to cerebral venous thrombosis. Systemic anticoagulation could not be done due to active gastrointestinal bleeding. Subsequently patient developed features of DIC and succumbed to his illness in spite of treatment measures.
This was a case of COVID-19 pneumonia and rhino-orbital mucormycosis occurring as co-infection due to poor glycemic control in a diabetic patient and it was associated with diabetic ketoacidosis and renal failure.
Case: 2
A 67-years-old male was admitted with complaints of right sided chest pain of 10 days duration. He was a diabetic/hypertensive who was recently treated for COVID-19 pneumonia with steroids. CT thorax with contrast revealed thick-walled cavity in right upper and lower lobe. Cardiac assessment revealed CAD–LAD territory with moderate LV dysfunction. Bronchoscopy was done, aseptate fungal hyphae was identified in smear. TB-PCR was negative. Patient was diagnosed to have fungal pneumonia and was started on IV amphotericin B and then switched to oral posaconazole. He was also treated with insulin for glycemic control and cardiac medications were given. He was discharged on oral antifungal and complete resolution occurred after prolonged oral anti-fungal therapy.
This was a case of post COVID–fungal pneumonia occurring in a diabetic patient who received steroids for COVID-19 pneumonia.
Case: 3
A 74-years-old male who was diabetic and treated for severe COVID-19 pneumonia and had been discharged two weeks earlier without any oxygen requirement presented with symptoms of cough with expectoration, fever of one week duration. His current medications included oral steroids methylprednisolone8mg once daily. On evaluation, he was febrile, tachypneic, hypoxic requiring supplemental oxygen.
CT thorax revealed COVID pneumonia in resolution with cavitating consolidation in left lingular lobe.
Sputum analysis revealed mucor.
A provisional diagnosis of pulmonary mucormycosis was made and he was started on iv amphotericin and then switched over to oral posaconazole. His glycemic level was managed with insulin and steroid was tapered and stopped.
Patient improved symptomatically and was discharged on oral antifungal drugs. Follow up CT thorax done after three months of antifungal therapy revealed minimal residual pneumonia in resolution phase following which duration of oral antifungal therapy was extended to six months and follow up advice was given.
This was a case of post COVID fungal pneumonia occurring in a diabetic patient who received steroids for COVID-19 pneumonia.
Case: 4
A 47-years-old male who was a diabetic and was treated for severe COVID-19 two weeks earlier and discharged with oral steroids and domiciliary oxygen presented with complaints of pus discharge near maxillary molar region on the right side. On examination, mobility of maxillary molars was elicited. Pus was sent for microbiological analysis and bone scraping was done and sent for microbiological and HPE examination which revealed mucormycosis involving maxillary sinus.
MRI brain with contrast revealed no intracranial extension and there was pansinusitis with bony erosion involving alveolar recess of maxilla on right side and medial aspect of hard palate right side.
Patient underwent total maxillectomy and he was treated with iv amphotericin B and then switched over to oral posaconazole. Steroids were tapered and stopped and blood sugar level was controlled with insulin.
This was a case of post COVID fungal mucormycosis involving maxilla occurring in a diabetic patient who received steroids for COVID-19 pneumonia. He was treated with surgery and antifungal therapy.
Case: 5
A 63-years-old female who was diabetic, hypertensive presented with features of severe COVID-19 pneumonia. She was treated with oxygen, therapeutic anticoagulation, convalescent plasma transfusion, steroids, insulin and other supportive medications. With treatment, her oxygen requirements decreased and oxygen was tapered off.
During hospital stay, there was acute worsening in clinical status requiring increasing oxygen requirements. Secondary sepsis was considered and investigations were sent. Total count was elevated. Procalcitonin was normal. Blood culture (central and peripheral) grew Candida famata/Candida guilliermondi with rapid differential time to positivity in central line. (Central 12 h < peripheral 22 h). CLABSI (central line associated blood stream infection) was considered and central line was changed. She was started on intravenous anidulafungin as per sensitivity reports and steroids were tapered. She recovered completely with treatment.
This was a case of fungal blood stream infection – central line associated due to Candida sp. – non albicans species resistant to azoles and amphotericin B and required intravenous echinocandins.
It occurred in a diabetic patient who received steroids for COVID-19 pneumonia during hospital stay.
Conclusion
Fortunately, four patients recovered and one patient succumbed to infection and thrombotic complication despite best efforts from the team of physicians, ENT and ophthalmologic surgeon during the difficult restrictions faced due to COVID-19.
Prolonged antifungal therapy and cost of treatment made treatment challenging for the patients and physicians.
Prevention of fungal infections should be considered in all patients who become hyperglycemic after COVID-19.
Meticulous glycemic monitoring, insulin therapy, minimizing antibiotic use and very safe handling of Intravenous lines should be practiced to prevent these serious infections.
Acknowledgement
We are thankful to Dr. Prabhaharan, Technical Editor, Kauvery Hospitals for carefully editing the manuscript, and the Department of Thoracic Medicine, Department of Microbiology, Department of Radiology, Department of ENT, Department of Anesthesiology, Department of Dental Sciences, Kauvery Hospital, Tennur for their co-management of our patients.
Authors’ contributions
Supervised by Dr. G. Dominic Rodriguez. Report written by Dr. Ivan A Jones and drafted by Dr. G. Dominic Rodriguez.
Competing Interest
The authors have no competing interests to declare.
References
[1]. Song G, Liang G, Liu W. Fungal co-infections associated with global COVID-19 pandemic: a clinical and diagnostic perspective from China. Mycopathologia. 2020;185(4):599–606.
[2].Kuehn BM. Pulmonary fungal infections affect patients with COVID-19. JAMA. 2020;324(22):2248.
[3].Kauffman CA, Malani AN. Zygomycosis: an emerging fungal infection with new options for management. Curr Infect Dis Rep. 2007;9(6):435.
[4].White PL, Dhillon R, Hughes H, Wise MP, Backx M. COVID-19 and fungal infection: the need for a strategic approach. Lancet Microbe 2020;1(5):e196.
[5].Wu L, Girgis CM, Cheung NW. COVID-19 and diabetes: insulin requirements parallel illness severity in critically unwell patients. Clin Endocrinol (Oxf). 2020;93(4):390.
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- Poem
- Editorial
- The Brave New World of Anaesthesia
- Anesthetic considerations in Wilson’s disease for fess: A case report
- The painful story behind modern anaesthesia
- Anesthesia considerations for Ankyslosing Spondylitis
- Total intravenous anaesthesia: An overview
- Risk stratification for cardiac patients coming for non-cardiac surgeries
- The Anaesthesiologist’s role in fluoroscopic guided epidural steroid injections for low back pain
- Awake Craniotomy
- Malpositioned central venous catheter: Step wise approach to avoid, identify and manage
- Benefits outweighing risk: Neuraxial anaesthesia in a patient with Spina Bifida with operated Meningomyelocele
- Pain free CABG: newer horizon of minimally invasive cardiothoracic surgery a walk through anaesthesiologist perspective
- Stellate Ganglion Block: A bridge to cervical sympathectomy in refractory Long QT Syndrome
- Venous Malformation in Upper Airway – Anesthetic Challenges and Management: A Case Report
- Editorial
- USG guided peripheral nerve block in surgery for hernia
- Anaesthesia and morbid obesity: A systematic review
- Patient-Controlled Analgesia
- Parapharyngeal abscess of face and neck: Anesthetic management
- 3D TEE, a boon for the diagnosis of Left Atrial Appendage thrombus!
- Anaesthetic management of difficult airway due to retropharyngeal abscess and cervical spondylosis
- Expect the unexpected – Breach in continuous nerve block catheter
- Lignocaine nasal spray: An easy remedy for Post Dural Puncture Headache
- Potassium permanganate poisoning and airway oedema
- Angioedema following anti-snake venom administration
- Editorial
- Editorial Board
- Ra Fx ablation of Atrioventricular nodal reciprocating tachycardia
- Pace and Ablate Strategy: Conduction system pacing with AV junction ablation for drug refractory atrial arrhythmia – A novel approach
- Why Cardiac Resynchronization Therapy (CRT) For complete heart block? A case discussion
- Pacemakers and Bradyarrhythmias in Diabetic Mellitus
- Outcomes of Total Knee Arthroplasty in patients aged 70 years and above
- An approach to CBC for practitioners
- Acute cerebral sinus venous thrombosis with different presentations and different outcomes: A case series
- Diet and nutritional care for DDLT: A case study
- Vaccine for Dengue (Dengvaxia CYD-TDV)
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 31 and 32
- Recommended Readings
- காவிரித்தாய்
- ATLAS OF HAEMATOLOGY AND HEMATOONCOLOGY
- Editorial
- Editorial Board
- Case reports and Case series:
- Usefulness of NEWS 2 score in monitoring patients with cytokine storm of COVID-19 pneumonia
- Treatment approach for extensively Drug-Resistant Tuberculosis (XDR-TB)
- Modified Lichtenstein mesh repair, for a patient of Coronary Artery Disease, Heart Failure and with Implanted Cardioverter- Defibrillator
- Fever-induced Brugada Syndrome
- Pulmonary Thrombo Embolism: When to Thrombolyse?
- Ultra-Short Case Report
- Learning from the failure of Nebacumab
- Journal scan
- Learning From Experience Intra Operative Chapters 29 and 30
- Recommended Readings
- Poem
- Editorial
- Editorial Board
- Heart transplantation: Life beyond the end of life
- Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal
- Medial retropharyngeal nodal region sparing radiotherapy versus standard radiotherapy
- Proximie: Patient safety in surgery – the urgent need for reform
- Analysis of femoral neck fracture in octogenarians and its management
- Adult Immunisation in Clinical Practice: A Neglected Life Saver
- “Icing” The Eyes
- Doppler vascular mapping in Arterio Venous Fistula (AVF)
- Cosmesis and cure: Radiotherapy in basal cell carcinoma of the dorsum of nose – A case report
- Pulmonary Hypertension and Portal Hypertension
- Comprehensive review of Drug-Induced Cardiotoxicity
- Statistics – Data Collection – Case Study Method
- Atlas of Haematology and Hematooncology
- PRE-OPERATIVE Chapters 1 and 2 – Learning from Experience
- Chapter 2. Uncertainties in medicine in spite of advances
- No Splendid Child
- Editorial
- Editorial Board
- A Young Girl Lost in the Storm
- ECMO as a bridge to Transplant: A case report
- Renal anemia – from bench to bedside
- Mission Possible
- New kids on the block – Update on diabetic nephropathy therapy
- Infections – Trade off in Transplants
- To Give Or Not to Give – Primer on Bicarbonate Therapy
- Sialendoscopy: Shifting paradigms in treatment of salivary gland disease
- Gait imbalance in a senior due to Chronic Immune Sensory Polyneuropathy (CISP)
- Statistics – Mcnemar Test
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE Chapters 3 and 4 – Learning from Experience
- Changing trends a challenge to the already trained
- Journal scan
- Recommended Readings
- EDITORIAL
- EDITORIAL BOARD
- PREGNANCY POST-RENAL TRANSPLANT
- BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION
- REVERSE SHOULDER ARTHROPLASTY FOR ROTATOR CUFF ARTHROPATHY
- THE AMBUSH A TEAM APPROACH
- ENDOSCOPIC TRANS-SPHENOID APPROACH FOR PITUITARY ADENOMA EXCISION
- A STUDY ON PRESENTATION AND OUTCOME OF BULL GORE INJURIES IN A GROUP OF TERTIARY CARE HOSPITALS
- A CASE OF INTERNUCLEAR OPHTHALMOPARESIS AS THE FIRST MANIFESTATION OF MULTIPLE SCLEROSIS
- GRANULOMATOSIS WITH POLYANGITIS AND LUNG INVOLVMENT (WEGENER’S DISEASE)
- RITUXIMAB (RITUXAN, MABTHERA) IN THE TREATMENT OF B-CELL NON-HODGKIN’S LYMPHOMA
- STATISTICAL SIGNIFICANCE
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- Chapter 4: Diagnostic process often reversed
- Journal scan: A review of 25 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- ஆரோக்கியம் நம் கையில்
- வெற்றியின் பாதை
- Editorial
- Editorial Board
- Prevalence of vitamin D deficiency in a multi-speciality hospital orthopaedic outpatient clinic
- Esomeprazole induced Hypoglycemia
- Dynamic external fixator for unstable intra articular fractures of Proximal Interphalangeal Joint (PIP): “Suzuki” frame
- How to Practice Academic Medicine and Publish from Developing Countries? A Practical Guide, Springer Nature, 2022
- WINTNCON 2022 – Scientific Program
- Pulmonary Thrombo Embolism: A state of the art review
- Role of Artificial Intelligence in improving EHR/EMR and Medical Coding and billing
- Monoclonal Antibodies: Edrecolomab and Abciximab
- Atlas of haematology and hematooncology
- Journal scan
- Learning from Experience – Intra Operative, Chapters 31 and 32
- What doctors must learn: Doctor, look beyond science
- Recommended Readings
- I Whisper Secrets In My Ear
- EDITORIAL
- Instructions for Authors
- Mismatched Haploidentical Bone Marrow Transplantation in a 10-year-old boy with relapsed refractory acute lymphoblastic leukemia, at Trichy
- ST-Segment Elevation is not always Myocardial Infarction
- Acyanotic Congenital Heart Disease, repaired, evolves into a Cyanotic Congenital Heart Disease and presents with an atrial tachycardia
- Family medicine – caring for you for the whole of your life. A Lost and Found Art
- The Principles and Practice of Family Medicine
- Complete Heart Block
- Sick Sinus Syndrome (SSS)
- The First Ever National Award Comes to Kauvery Hospital Chennai & Heart City for Safety and Workforce Category in IMC RBNQA Milestone Merits Recognition 2022
- Diagnostic Image
- PRE-OPERATIVE CHAPTERS 7 AND 7 – LEARNING FROM EXPERIENCE
- Chapter 5: Super-specialist – boon or bane
- Journal scan: A review of 42 recent papers of immediate clinical significance, harvested from major international journals
- RECOMMENDED READINGS
- நேரம் ஒதுக்கு
- மருத்துவரின் மகத்துவம்
- EDITORIAL
- Instructions for Authors
- Surgical Management of Covid-19 Associated Rhino-Orbito-Cerebral-Mucormycosis (Ca-Rocm) – A Single Centre Experience
- Knee Joint Preservation Surgeries
- Guest Editorial Comments
- Ventricular Septal (VSR) closure with ASD device
- Newer Calcium Debulking Angioplasty technique of Orbital Atherectomy
- An hour-long CPR to restart the heart
- VT or SVT with aberrancy?
- Pituitary Neuroendocrine Tumor (PitNET)
- VSD Device Closure
- PDA Device Closure
- Iron Deficiency Anemia, Post MVR
- Torsades de Pointes
- Quality improvement project to Reducing the Malnutrition Rate of ICU patients from 43% to 20%
- Long term use of Amiodarone in Cardiac patients: A Clinical Audit
- Statistical Independent Events and Probability
- PERI-OPERATIVE Chapters 9 and 10 – Learning from Experience
- Journal scan: A review of 40 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- Kauverian Medical Journal
- First da Vinci Robotic Surgery in Carcinoma Prostate: A Case Report
- Black burden or Taylor the saviour: A case report
- Analysis of differences in Oncology practice between the United Kingdom and India
- A Case of Takayasu Arteritis
- Idiopathic Dilated Pulmonary Artery (IDPA)
- ECG Atlas
- Unusual cause of Dysphagia: A case report
- Tu Youyou: The scientist who discovered artemisinin
- Continuing Nursing Education (CNE) on Risk assessment tools, to assess vulnerable patients at Kauvery Hospital, Tennur
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 11 AND 12 – LEARNING FROM EXPERIENCE
- OLD AND NEW – MAKE THE BEST OF THE TWO
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- EDITORIAL
- INSTRUCTION TO AUTHORS
- A pregnant patient with DKA, septic shock and a lactate mystery
- Radical Thymectomy in Myasthenia Gravis through Partial Sternotomy approach: A report on three patients
- In-utero blood transfusion in two etiologically distinct anaemic fetus
- RARE CAUSE OF PULMONARY HYPERTENSION
- Acute Rheumatic fever is still an enigma
- A remarkable journey: Managing LQTS in a 43-year-old female with recurrent syncope and seizure
- An unusual case of Acute Coronary Syndrome
- Reversible cause of severe LV Dysfunction in Left Bundle Branch Block
- A case study on Rhino-Orbital-Cerebro- Mucormycosis
- Snakebite and its management
- Total Elbow arthroplasty in Post Traumatic arthritis
- Wellens Syndrome: An ECG finding not to miss!
- Dr. C.R. Rao Wins Top Statistics Award a look back at his pioneering work
- PRE-OPERATIVE Chapters 13 and 14 – Learning from Experience
- Chapter 7. Doctor-patient relationship
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- INSTRUCTION TO AUTHORS
- FROZEN ELEPHANT TRUNK (FET) PROCEDURE IN A 52 YEARS OLD CHRONIC AORTIC DISSECTION PATIENT
- DIAGNOSING AND MANAGING EISENMENGER SYNDROME IN A YOUNG MALE
- STEMI EQUIVALENT BUT STEMI!
- TEMPORARY HEAL CAN POSSIBLY KILL!
- UNDERSTANDING PUBERTY
- THE IMPORTANCE OF STATISTICS IN HEALTHCARE
- JOURNAL SCAN: A REVIEW OF 44 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 15 AND 16 – LEARNING FROM EXPERIENCE
- CHAPTER 8. DOCTOR-DOCTOR RELATIONSHIP
- EDITORIAL
- GUEST EDITORIAL
- CLINICAL AUDIT: AN INTRODUCTION
- YOUNG ACS AUDIT
- CLINICAL AUDIT: ANAESTHESIA
- CLINICAL OUTCOME IN ICU PATIENTS
- RATE OF MALIGNANCY IN INDETERMINATE OVARIAN CYST – A PROCESS AUDIT
- PATTERNS OF NEEDLE DISPOSAL AMONG INSULIN USING PATIENTS WITH DIABETES MELLITUS: AN AUDIT
- CONTINUOUS PATIENT MONITORING – LIFE SIGNS
- AGE IS JUST A NUMBER!
- SVT WITH LEFT BUNDLE BRANCH BLOCK FOLLOWING GASTRECTOMY
- COMPLEX AORTIC DISSECTION WITH MULTIFACETED CLINICAL PRESENTATIONS
- EDITORIAL
- POST-OPERATIVE SORE THROAT IN GA: A CONCERN
- NEONATAL HLH: OUR EXPERIENCE
- CLINICAL REVIEW MEET 16TH NOV 2023: CHALLENGES IN SETTING UP A NEW HSCT CENTRE IN A TIER-2 CITY IN INDIA
- CARDIAC BIOMARKERS: CLINICAL UTILITY
- HIRAYAMA DISEASE: A CLINICAL-RADIOLOGICAL REVIEW
- ECG AS A WINDOW OF OPPORTUNITY: FOR HYPERKALEMIA
- EFFECTIVENESS OF ROOD’S APPROACH BASED PAEDIATRIC OCCUPATIONAL THERAPY MANAGEMENT: ON CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS
- ELTROMBOPAG, A NOVEL THROMBOPOIETIN (TPO) RECEPTOR AGONIST: AN OVERVIEW
- HENOCH-SCHONLEIN PURPURA
- SUBMANDIBULAR GLAND SIALADENITIS SECONDARY TO SUBMANDIBULAR CALCULUS
- LEAN HOSPITALS
- STATISTICS BLACK-SCHOLES MODEL
- PERI-OPERATIVE CHAPTERS 17 AND 18 – LEARNING FROM EXPERIENCE
- CHAPTER 9. BUILDING BLOCKS OF PATIENT CARE
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- ROTATHON-SERIES OF SUCCESSFUL ROTA CASES LAST 2 MONTHS: AN AUDIT
- OUTCOMES OF AKI AUDIT IN KAUVERY
- ETIOLOGY, CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH ACUTE PANCREATITIS IN KAUVERY CANTONMENT HOSPITAL (KCN), TRICHY
- USE OF BLOOD PRODUCTS AND STEROIDS IN THE MANAGEMENT OF DENGUE AT KAUVERY TRICHY HOSPITALS: A CLINICAL AUDIT
- A CLINICAL AUDIT: ON THE MANAGEMENT OF ECTOPIC PREGNANCY
- DIABETIC KETOACIDOSIS WITH HIGH ANION GAP METABOLIC ACIDOSIS
- HYPOKALEMIC PARALYSIS FROM DISTAL RENAL TUBULAR ACIDOSIS (TYPE-1)
- DELAYED PRESENTATION OF INTERMEDIATE SYNDROME IN A PATIENT WITH ORGANOPHOSPHORUS POISONING: A CASE REPORT
- SCAPULA FRACTURES: DO WE NEED TO FIX THEM?
- SPONTANEOUS CSF RHINORRHEA
- DANCING WITH DIABETES: AN UNUSUAL CASE OF CHOREA HYPERGLYCEMIA BASAL GANGLIA SYNDROME
- CONVALESCENT RASH OF DENGUE
- ECG ATLAS 2
- MI MIMICKER
- PERFORATION PERITONITIS-A CASE REPORT
- APPLICATION OF EVIDENCE BASED PRACTICE CARE FOR INDIVIDUALS WITH SPINAL CORD INJURY WITH FUNCTIONAL DIFFICULTIES: ROLE OF THE OCCUPATIONAL THERAPY PRACTICE GUIDELINES
- METHOTREXATE INDUCED MUCOSITIS AND PANCYTOPENIA: A CONSEQUENCE OF MEDICATION ERROR IN A PSORIASIS PATIENT
- POST OPERATIVE CHAPTERS 1 AND 2 – LEARNING FROM EXPERIENCE
- CHAPTER 10. NURTURING SELF
- விடாமுயற்சி வெற்றி தரும்
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- EDITORIAL BOARD
- LIMB SALVAGE IN EXTREMITY VASCULAR TRAUMA: OUR EXPERIENCE
- MANAGEMENT OF URETHRAL CATHETER RELATED PAIN IN RENAL TRANSPLANT RECIPIENTS: A CLINICAL AUDIT
- NO PAIN VEIN GAIN WITH PRILOX IN PAEDIATRIC POPULATION
- GUIDELINE-DIRECTED MEDICAL TREATMENT (GDMT) OF HEART FAILURE AT KAUVERY HOSPITALS: A CLINICAL AUDIT
- PATIENTS STORY: DIGNITY MATTERS
- PATIENTS STORY: DIGNITY MATTERS
- VIDEO PRESENTATION- CT CORONARY ANGIOGRAPHY
- DRUG INDUCED HYPERKALEMIA
- ADULT NEPHROTIC SYNDROME
- EXPLORING COMPLEX CARDIAC CASES: INSIGHTS FROM DIVERSE PRESENTATIONS IN MID-AGED WOMEN
- EFFECTIVENESS OF ACTIVITY CONFIGURATION APPROACH BASED OCCUPATIONAL THERAPY INTERVENTION FOR CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS: A CASE STUDY
- CARDIOMYOPATHY AND ITS ECHO FINDINGS
- THE STRESS TEST ON THE TREADMILL
- POST OPERATIVE CHAPTERS 3 AND 4 – LEARNING FROM EXPERIENCE
- CHAPTER 11. BALANCE IN LIFE BEYOND BANK BALANCES
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காணும் பொங்கலும் மனித மன மாற்றமும்
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- PREVALENCE OF STREPTOCOCCUS PNEUMONIAE SEROTYPES IN AND AROUND TRICHY AND ITS CLINICAL RELEVANCE
- ANAESTHETIC MANAGEMENT OF A PATIENT WITH HUGE GOITER: A CASE REPORT
- EUGLYCEMIC DIABETIC KETOACIDOSIS A RARE CAUSE FOR DELAYED EXTUBATION
- SUCCESSFUL PREGNANCY IN ASD PATIENT – COMPLICATED BY SEVERE PULMONARY ARTERIAL HYPERTENSION
- ENDOCRINE COMPLICATION OF GROWTH HORMONE SECRETING TUMOR: A CASE REPORT
- EFFICACY OF EARLY DIAGNOSIS AND DEVELOPMENT APPROACHES OF PAEDIATRIC OCCUPATIONAL THERAPY ON ACUTE DISSEMINATED ENCEPHALOMYELITIS: A CASE REPORT
- POST OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- CHAPTER 12. MILES TO GO – BEFORE TEACHING BECOMES LEARNING
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காவேரி – 25
- POEM – மண்ணில் பிறந்தது சாதிப்பதற்குத்தான்