Jaypee Hospital

Background: Dabigatran is a direct oral anticoagulant (DOAC) that acts by blocking thrombogenic activity and preventing thrombus formation.However, dabigatran induced oesophageal mucosal injury is often neglected as one potential complication of dabigatran.Here we present a rare case report of an elderly Asian male presenting with dysphagia, diagnosed as dabigatran induced keratosis with oesophageal mass extending into stomach revealing carcinoma cuniculatum on histopathology.Case Presentation: A 62-year-old Asian male came to hospital with history of dysphagia and sticking sensation in the throat for 2 years and recent onset recurrent fall in haemoglobin with black coloured stools.The patient was a known case of type II diabetes for 25 years (on regular medication) and peripheral vascular disease, had stent placement in the left superficial femoral artery 10 years back and was on dabigatran since then.Endoscopy showed significant ulcerations with whitish flakes starting from the 29 cm and extends till the GE junction.At 32 cm, there was a large fungating lesion causing luminal compromise.Fungating lesion was extending up to the fundus with an area with adherent clot over it.As the clot was removed, a spurter was noted which was coagulated with APC probe.Patient was planned for resection of the mass.Intraoperatively a 3cm x 3cm ?? oval shaped mass lesion of oesophageal origin extending into lesser curvature of the stomach was found.Partial gastrectomy with resection of the mass lesion was done.Post operatively patient developed pulmonary complications which were managed conservatively with supportive care. Conclusion:Our case highlights the importance of awareness on the part of the physician about the esophagitis as a possible complication of dabigatran and reporting Carcinoma cuniculatum of oesophagus extending into stomach which is an extremely rare and often indolent cancer.

Introduction: T cell depletion agents, Thymoglobulin (ATG) and Grafalon (ATLG), are commonly employed as induction agents in kidney transplantation. This study aims to assess the short- and long-term outcomes of kidney transplants at our centre focusing on the use of these agents. Method: This retrospective study analysed data from kidney transplant patients at a tertiary care hospital in INDIA, between 2017 and 2024. Of the 581 patients included, 375 received Thymoglobulin and 206 received Grafalon as induction therapy. All patients were maintained on standard triple immunosuppressive therapy. Follow-up included monitoring for graft rejections, infections, de novo disease, and overall graft survival. Results: The average duration of follow-up spanned 60 months. The mean doses of Grafalon and Thymoglobulin were 5.4±1.4 mg/kg and 2.37±1.2 mg/kg, respectively. Baseline characteristics were consistent across both groups. Figure 1 depicts the serum creatinine levels at discharge and during subsequent follow-up intervals. Table 1 provides a comprehensive overview of rejection outcomes over a 5-year follow-up period, distinguishing between the Thymoglobulin and Grafalon cohorts. Notably, there was a higher incidence of de novo diseases observed within the Thymoglobulin cohort (12 cases, 3.2%) compared to the Grafalon cohort (3 cases, 1.4%). However, the incidence of infections exhibited comparability between the two groups. Conclusion: Both the short-term and long-term outcomes of kidney transplant recipients receiving Thymoglobulin or Grafalon as induction therapy were similar in terms of graft rejection incidence. However, Thymoglobulin was associated with a higher occurrence of de novo diseases (this may be an incidental finding or due to some unexplained reasons).

Guillain–Barre syndrome (GBS) is an acute, usually symmetrical, and typically de myelinating polyneuropathy, characterized by progressive, ascending paralysis and areflexia, with or without abnormal sensory function. Therapeutic plasma exchange(TPE) was the first therapeutic modality to impact the disease favorably, and several major randomized controlled trials (RCTs) have confirmed its efficacy. Our case is unique, as this critically ill patient admitted in the intensive care unit (ICU), developed a rare form of GBS, the PCB variant of the disease, and was successfully treated with TPE. The diagnosis of PCB can be challenging due to atypical clinical features but its unique presentation does provide sufficient clues to narrow the differential diagnosis, which is helpful in starting empirical therapy at the earliest. Immunomodulation with plasma exchange and IVIG have been found to improve treatment outcomes; 70%–80% of patients usually have a complete recovery. Early diagnosis is very important in the case of the PCB variant of GBS to enable timely intervention. Diagnosis can be made on history and neurological findings alone.

There is no robust evidence-based data for ABO-incompatible kidney transplantation (ABOiKT) from emerging countries. Data from 1759 living donor ABOiKT and 33 157 ABO-compatible kidney transplantations (ABOcKT) performed in India between March 5, 2011, and July 2, 2022, were included in this retrospective, multicenter (n = 25) study. The primary outcomes included management protocols, mortality, graft loss, and biopsy-proven acute rejection (BPAR). Protocol included rituximab 100 (232 [13.18%]), 200 (877 [49.85%]), and 500 mg (569 [32.34%]); immunoadsorption (IA) (145 [8.24%]), IVIG (663 [37.69%]), and no induction 200 (11.37%). Mortality, graft loss, and BPAR were reported in 167 (9.49%), 136 (7.73%), and 228 (12.96%) patients, respectively, over a median follow-up of 36.3 mo. In cox proportional hazard model, mortality was higher with IA (hazard ratio [HR]: 2.53 [1.62-3.97]; P < 0.001), BPAR (HR: 1.83 [1.25-2.69]; P = 0.0020), and graft loss (HR: 1.66 [1.05-2.64]; P = 0.0310); improved graft survival was associated with IVIG (HR: 0.44 [0.26-0.72]; P = 0.0010); higher BPAR was reported with conventional tube method (HR: 3.22 [1.9-5.46]; P < 0.0001) and IA use (HR: 2 [1.37-2.92]; P < 0.0001), whereas lower BPAR was reported in the prepandemic era (HR: 0.61 [0.43-0.88]; P = 0.008). Primary outcomes were not associated with rituximab dosing or high preconditioning/presurgery anti-A/anti-B titers. Incidence of overall infection 306 (17.39%), cytomegalovirus 66 (3.75%), and BK virus polyoma virus 20 (1.13%) was low. In unmatched univariate analysis, the outcomes between ABOiKT and ABOcKT were comparable. Our largest multicenter study on ABOiKT provides insights into various protocols and management strategies with results comparable to those of ABOcKT.

How to cite this article: Magoon R, Puri S, Bandyopadhyay A. Harmonizing the Septic Shock Terminology: Need of the Hour. Indian J Crit Care Med 2023;27(4):294-295.

Chronic Graft-Versus-Host Disease (GvHD) is one of the most common cause of poor quality of life after Hematopoietic Stem Cell Transplantation (HSCT). Chronic GVHD can present with vulvovaginal symptoms which is usually under reported. Only small series have been reported so far and its incidence, pathophysiology, clinical manifestations and management are not well understood. So also, there are currently no vvGVHD screening guidelines for children who undergo HSCT. In this report, we describe our experience of managing an adolescent girl who developed hematometrocolpos as a complication of chronic GVHD after bone marrow transplant.