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   Table of Contents - Current issue
Coverpage
January-June 2020
Volume 34 | Issue 1
Page Nos. 1-52

Online since Monday, July 6, 2020

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EDITORIAL  

COVID-19: A global crisis p. 1
Nikhil Sarangdhar, SN Gaur
DOI:10.4103/ijaai.ijaai_16_20  
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RECOMMENDATIONS Top

Recommendations for allergy practice during COVID-19 pandemic in India p. 5
Mahendra K Agarwal, Anand B Singh, Shailendra N Gaur, PC Kathuria, VK Jain, Mahesh Goyal, KV Nagendra Prasad
DOI:10.4103/ijaai.ijaai_28_20  
We are living in an unprecedented difficult time due to the infectious COVID-19 pandemic, a global emergency. During the on-going pandemic, most allergy/immunology care could be postponed/delayed or handled through virtual care. Seven experts from different parts of India deliberated on this subject in 3 weekly webinars (May 10, 17, and 24, 2020) charted out consensus-based approach for diagnosis and management of patients suffering with allergic respiratory diseases in India during this COVID-19 pandemic. This publication includes these recommendations.
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REVIEW ARTICLES Top

Nebulization in the pandemic of coronavirus disease 2019 p. 8
Subodh K Katiyar, Sandeep Katiyar
DOI:10.4103/ijaai.ijaai_29_20  
Inhaled therapy is the cornerstone in the management of obstructive airway diseases (OADs). Nebulization is often used for the delivery of bronchodilators and corticosteroids among the elderly and children. The present pandemic of coronavirus disease 2019 (COVID-19), caused by a newly identified, highly contagious, novel coronavirus, called severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), is responsible for great morbidity and mortality globally. There is a great concern regarding person-to-person transmissibility of this virus. There is also a great concern of viral transmission of this virus to the health-care personnel and the bystanders through aerosol-generating procedures including frequently used nebulization therapy. Most of the patients with OAD, during the current pandemic, who were undergoing nebulization therapy, on getting infected with SARS-CoV-2 or on its suspicion, have been shifted to other handheld devices out of fear of transmission of infection. Presently, there exist not enough evidences either on the safety or on the risk of transmissibility of SARS-CoV-2 during nebulization in COVID-19 patients. In addition, there are concerns about nebulization in OAD cases even in the absence of COVID-19 and about the use of inhaled or systemic corticosteroids in these cases. We have made some observations based on all the current information available related to these issues, which may help provide some guidance in the use of nebulizer therapy and also discussed the measures to be taken to minimize the risk of infection, if any, during the procedure.
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Management of asthma and allergic diseases during the coronavirus disease 2019 pandemic in India p. 15
Nagaraju Kuravi, Karthik Nagaraju, Venkata Kasyapi Voorakaranam
DOI:10.4103/ijaai.ijaai_20_20  
Coronavirus disease 2019 (COVID 19) is caused by the novel coronavirus, which has affected 184 countries and the WHO has declared it a pandemic on March 2020. Allergic diseases such as allergic rhinitis and asthma are exaggerated by viral infections. Symptoms of allergic diseases overlap with COVID 19. Current recommendations include following social distancing and frequent hand washing. Confusion exists regarding the use of corticosteroids, biologicals, and immunotherapy for the treatment of allergic diseases during COVID 19 season. Due to the use of Personal Protective Equipments, reports of contact dermatitis are emerging among health-care workers. Remote consultation, like telemedicine, is a valuable tool in this pandemic. This article aims to provide guidance on the management of allergic diseases taking into consideration existing evidence and guidelines from international organizations and the feasibility of implementation in India.
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Covid-19 immune mechanisms: A systematic review p. 23
Shalini Gandhi, Sandeep Kumar Sharma, Purva Shoor, Jitender Sorout, Abhay Raina, Rohit Raina, Urvashi Miglani, Uma Kant Chaudhari, Shivi Srivastava
DOI:10.4103/ijaai.ijaai_22_20  
There is a new public health crises threatening globally with the emergence and spread of 2019 novel coronavirus or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is the seventh member of the coronavirus (CoV) family, which infects humans and to which the Middle East Respiratory Syndrome CoV (MERS)-and SARS-CoV also belong. SARS-CoV-2 is a newly emerging human infectious CoV that causes COVID-19, which has been recognized as a pandemic by the World Health Organization on March 11. The most recent outbreak initially presented as pneumonia of unknown etiology as COVID-19 is a pneumonia-like disease with a group of symptoms including fever, dry cough and shortness of breath in a cluster of patients in December 2019 Wuhan, China. The body's immune system tries to protect the body from this pathogen. And as due to its surge in the body, various respiratory and other system-related complications increased. Therefore, in this article, COVID-19 immunopathogenesis is briefly reviewed. Through this review, we try to explain the molecular immune pathogenesis and diagnosis of COVID-19 (SARS-CoV-2) infection, based on the recent research progress of SARS-CoV-2 and the knowledge from researches on SARS-CoV and MERS-CoV.
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ORIGINAL ARTICLES Top

The epidemiological and trending pattern of nCOVID-19 in the state of Rajasthan, India p. 28
Sudhir Bhandari, Ajeet Singh, Subrata Banerjee, Raman Sharma, Govind Rankawat, Vishal Gupta, Prakash Keswani, Ashwin Mathur, Abhishek Agarwal, Shrikant Sharma, PD Meena
DOI:10.4103/ijaai.ijaai_17_20  
PURPOSE: The present study was undertaken to investigate the behavioral distribution pattern and progression of coronavirus disease 2019 (COVID-19) across age and gender in the state of Rajasthan, India, inherently distinctive and native to localized part of the globe giving requisite information and paraphernalia to designate advisory board of the state to design and frame customized policy for demands of the state as per the trending pattern relative to age and sex distribution, profile of new infected cases, recovery rate, and case fatality rate. METHODS: The present ongoing study assessed patients admitted till April 22, 2020, across the state of Rajasthan, India, with reverse transcriptase-polymerase chain reaction (RT-PCR)-confirmed COVID-19 test. Analyses of the patients included characteristic age and gender distribution through the geographic identities of state along with the time trending pattern of newly infected patients, recovered patients, and case fatality rate. RESULTS: A total of 1888 sample patient population of RT-PCR-confirmed COVID-19 was evaluated, with the majority of sample patient population being in young adult age group with a mean age of 34.42 years. Nearly 11.65% of the patients were below 15 years of age, 34.79% were in the age range of 16–30 years, 25.90% were in the age group of 31–45 years, and 17.69% were in the age group of 46–60 years, with only 9.95% of the patient population being in the age group of above 60 years. Interestingly, 11.65% of patients with COVID-19 were in the pediatric age group. The percent of affected females (37.35%) was much less than that compared to males (62.65%), with an average sex ratio of 0.59. Across the sample patient population of 1888, 543 patients recovered fully, 25 patients died, and 1320 cases were active in the said time frame, with an average recovery rate of 28.76% and a case fatality rate of 1.32%, and the remaining 69.91% of the patient population made up the active case group. The timeline and the trending pattern of COVID-19 in the state of Rajasthan was suggestive of an increasing rise of number of new cases with antecedent mortality, though a reassuring concomitant rise in the recovery rate of patients could also be appreciated. The infective COVID-19 dictum of spread through contact could very well be appreciated in select geographic hotspots and/or zones, and 108 sample patient population was from out of Rajasthan. CONCLUSION: It was interesting to observe that majority of the resident population of the state of Rajasthan that was COVID-19 positive was in the young adult age group of 30–50 years inclusive of pediatric patients, an observation that is different from reports as documented from across the world. Male population seemed to be more prone to infection. The time frame in which the evaluation was done is suggestive of an increasing trend in the number of new cases with antecedent case fatality, though recovery was also on the rise indicative of a potential decreasing load. The geographic mapping of COVID-19 patients could be established through contact tracing.
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Clinical, radiological, and immunological assessment of allergic bronchopulmonary aspergillosis p. 34
Anshika Jindal, Yogendra Singh Rathore, Shubhra Jain, VK Jain, Vinod Joshi
DOI:10.4103/ijaai.ijaai_28_19  
INTRODUCTION: Allergic bronchopulmonary aspergillosis (ABPA) is an immunologically mediated lung disease, predominantly in patients with asthma and is caused by hypersensitivity to colonized dimorphic fungus Aspergillus, commonly Aspergillus fumigatus. Early diagnosis with recognition and treatment of chest radiographic infiltrates appears to prevent progression to end stage fibrosis. Many cases are mistreated as pulmonary tuberculosis or recurrent pneumonia and are deferred for specific treatment of ABPA. AIM AND OBJECTIVES: This study aims to know the clinical, radiological, and immunological profile of patients diagnosed with ABPA reporting to the Institute of Respiratory Disease, SMS College, Jaipur and Mahatma Gandhi Medical College, Jaipur. MATERIALS AND METHODS: Hospital-based prospective, observational, cross-sectional study was conducted in 48 Patients having history of bronchial asthma, pulmonary infiltrate/shadows on chest X-ray were subjected to routine investigations, immunological tests including modified skin prick test with specific IgE against A. fumigatus and specific precipitins against A. fumigatus. RESULT: In this study, maximum predominance with age group of 21–40 years irrespective of sexpattern. Maximum patients were having bronchial asthma of 2–10 years duration. Cough, breathlessness, and wheezing were main clinical features. In 80% cases, total eosinophilic counts were more than 1000.58.4% sputum were fungal culture positive, maximum for A. fumigatus. All cases showed modified kinprick test positivity against A. fumigatus. Maximum patients high-resolution computed tomography chest had central bronchiectasis. 37% cases had raised total serum IgE (range 1000–5000). Specific IgE against A. fumigatus were positive in 24 patients. 87.5% patients were positive for specific precipitins. CONCLUSION: In this study, ABPA was found more commonly in people with chronic asthma of productive age group, i.e., 20–40 years and farmers by occupation. Most of the people were diagnosed as having pulmonary tuberculosis and deferred specific treatment for a long time. More knowledge about ABPA to physicians could possibly cut short the time between suffering, diagnosis, and proper treatment of these patients.
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Sensitization to indoor allergens in children with bronchial asthma p. 39
Komal Chauhan, Shetanshu Srivastava, Rajendra Prasad
DOI:10.4103/ijaai.ijaai_14_19  
BACKGROUND: Children with asthma have a high prevalence of environmental allergies. Sensitization to various allergens, especially to indoor allergens is crucial for effective measures for asthma management. Indian data on allergic sensitization in children is scarce, necessitating the need of the study. METHODS: A Cross-sectional study was conducted to determine the indoor allergen sensitization in 100 asthmatic children aged 5 to 15 yrs. They underwent skin prick test for indoor allergen house dust mite cockroach, cat, dog dander, house fly, candida, aspergillus, and mosquito. RESULTS: In the study sensitization to house dust mite was 93%. 39% were sensitized to Candida 36% to cockroach,23% housefly and 22%to dog dander and Aspergillus and 13% to mosquito and cat dander. Allergen sensitivity rate for atleast one allergen was 94% which was significant. Mean No. of allergens for which sensitization was seen is 2.57±1.77. Comorbidities were present in 35% of cases.7% had urticarial and allergic conjunctivitis each. CONCLUSION: Asthmatic children showed high sensitization to indoor allergen and the most common allergen found was house dust mite
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CASE REPORTS Top

Selective immunoglobulin M deficiency: An underestimated immunodeficiency disorder – not so rare p. 43
Arun Agarwal
DOI:10.4103/ijaai.ijaai_34_19  
Immunoglobulin M (IgM) is the first antibody to be produced during an immune response, and most of the primary humoral immune response is mediated by IgM. Selective IgM deficiency (sIgMD) is a rare immune disorder that has been reported in the association with serious infections. Patients with sIgMD may be asymptomatic; however, approximately 80% of patients present with infections with bacteria, viruses, or protozoa or with an associated allergic, malignant, or autoimmune condition. sIgMD is usually identified when evaluating a patient for recurrent or serious infections. Attempts should be made to document the infection, as well as the responsible organism, whenever possible. It is a diagnosis of exclusion, and formal diagnostic criteria have not been established. We report three adult cases that were diagnosed to have sIgMD during the evaluation for serious polymicrobial infections with bacteria, fungi, mycobacterium, and viruses. One of them was diagnosed to have associated lymphocytic leukemia. All were successfully managed with intravenous Immunoglobulin (Ig), antibiotics, antiviral, supportive treatment, and discharged. We conclude that patients presenting with polymicrobial infections with encapsulated bacteria, fungi, mycobacterium, and viruses should be evaluated for specific antibody deficiency responses, and they appear to improve clinically on Ig therapy. It appears that the disorder is underdiagnosed.
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Spectrum of diagnosis of hereditary angioedema: Seven case reports p. 49
PC Kathuria, Manisha Rai, Neelam Kathuria
DOI:10.4103/ijaai.ijaai_33_19  
Hereditary angioedema (HAE) is a potentially life-threatening disorder, due to a mutation in complement one-inhibitor (C1-INH) gene, which blocks the activity of various components of complement – fibrinolytic and bradykinin control system. Our seven cases of HAE give different clinical presentations of TYPE I/II/III HAE as facial, abdominal, laryngeal, and genital involvement along with comorbidities (5 cases) such as hypothyroidism, rhinosinusitis, and hypothalamic–pituitary–adrenal suppression, and four cases have had history of recurrent abdominal attacks. Treatment with Pdc-INH concentrate and self-administrated Icatibant provides consistent and reliable efficacy in those who have had multiple successive HAE attacks, with the involvement of all body parts. However, if pdc-INH concentrate is not available, then fresh frozen plasma and androgens (Danazol) can be used in emergency. Our cases demonstrate the importance of diligent clinical and family history with special tests: C4, C1-INH quantitative, and C1-INH functional.
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