The Hajj, a mass-gathering of over 3.5-million pilgrims, faces challenges to global health-security, housing, food, water, transportation, communication, sanitation, crowd-control and security. The Indian Medical Mission extended health-security to approximately 140,000 pilgrims, through outreach medical teams, primary-care clinics, tent-clinics, secondary-care hospitals and evacuation capabilities. Data on medical attendance, bed-occupancy, investigations, referrals, medication usage and deaths was compared. Outpatient attendance was 374,475 in static-clinics, 5135 in tent-clinics and 13,473 through task-forces. 585 (62.90%) in-patients were hospitalized amongst 930 secondary-care referrals. Secondary-care bed-days were 2106 with average bed-occupancy being 77.78%. 495 patients were institutionalized in tertiary-care Saudi-Arabian hospitals. Infectious diseases were most commonly (53.26%) encountered due to overwhelming respiratory-infections, followed by trauma (24.40%). Analgesics (66.38/100 patients) and antibacterials (48.34/100 patients) were frequently prescribed. Crude mortality amongst Indian pilgrims was 11.99/10,000. Risk-factors associated with high morbidity were old-age and pre-existing comorbidities. Overwhelming surge of patients facilitates transmission of communicable infections and leads to stress induced physical, mental and compassion fatigue amongst healthcare personnel. Respiratory infections are highly prevalent and easily transmissible during Hajj leading to significant morbidity, increased burden to existing health facilities, overwhelming costs on health systems and globalization of multiresistant pathogens. Diabetic patients should avoid heat exposure and use protective footwear during Hajj rituals. Mass-gathering medicine at Hajj can be optimized by improving patient knowledge on performing Hajj at a younger age, medicine compliance, avoiding self-medication, self-monitoring of hypertension, blood glucose, and preventive health measures; screening of pre-existing comorbidities; and resource augmentation with telemedicine networks and decision-support systems.

IntroductionHajj is an annual mass gathering of over 3.5 million pilgrims from 200 countries who congregate in densities of 9 people/ m2 and endure strenuous rituals, compromised living standards, and a harsh desert climate in an alien ethnocultural and sociolinguist milieu for spiritual enlightenment. Mass gathering medicine at Hajj is challenged by issues of healthcare accessibility, infection control, on-site treatment, referral, evacuation, and response to disasters and public health emergencies in addition to challenges to providing support such as shelter, food and water, transportation, mass communication, interpersonal communication, sanitation, overcrowding, and human security. 1,2Hajj has historically experienced high morbidity and mortality owing to pre-existing comorbidities, outbreaks, accidents, and disasters such as such as stampedes, fires, AbstractIntroduction: Hajj is an annual mass gathering of over 3.5 million pilgrims congregating from 200 countries in the desert climate of Saudi Arabia. Mass gathering medicine at Hajj is challenged by issues of healthcare accessibility, infection control, on-site treatment, referral, evacuation, and response to disasters and public health emergencies. The Indian Medical Mission at Hajj 2016 established, operated, and coordinated a strategic network of mass gathering medical operations, the proceeds of which are discussed herein. Methods:The mission was designed to provide holistic health security through health intelligence for pre-existing chronic diseases, epidemic intelligence for endemic and exotic diseases, public-health and disaster-health preparedness, and tiered healthcare through mobile medical task forces, static clinics, tent clinics, secondary care hospitals, and evacuation capabilities. Results: Primary care, secondary care, and tertiary care treated 374 475, 930, and 523 patients, respectively. Patients exhibited limited compliance with pre-instituted treatments and precautionary protocols. Respiratory and gastrointestinal infections, cardiorespiratory, trauma, and heat illnesses were seen. Epidemic intelligence revealed an outbreak of food poisoning. Respiratory infections were reported by 90% of the healthcare personnel. Surge capacity was overwhelmed with patient throughput and ambulance transfers. Crude unadjusted mortality was 11.99/10 000. Conclusion:The Indian Medical Mission at Hajj 2016 yielded solutions to the challenges faced during the 2016 Hajj pilgrimage. The mission posture of the Indian Medical Mission in Hajj presents a modus operandi for handling crisis scenarios in mass gathering. The situational analysis of the Hajj health mission calls for dynamic interventions in preparedness, clientele, and health systems.

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Pulmonary hyalinising granuloma (PHG) is a benign lung disease. It is a rare disease of unknown aetiology. Less than 150 cases are reported. Its aetiology has not been established but the underlying cause is thought to be the deposition of an immune complex in lung parenchyma or autoimmune process. It usually presents as solitary or multiple lung nodules. PHG has a good prognosis. Solitary lesions are treated by resection and multiple lesions are treated with immunosuppressive drugs with variable responses. Here, we report a case of a 68-year-old female who presented with two episodes of haemoptysis. On investigation, chest computed tomography (CT) reveals multiple lung nodules on both sides, 18 F fluorodeoxyglucose (FDG) positron emission tomography and CT scan reveal mildly FDG avid and non-FDG avid subpleural and parenchymal nodular lesions of varying sizes with calcification noted scattered diffusely in both lung fields. Pathology findings are suggestive of fibrocollagenous tissue with tiny foci of epithelial cells arranged as papillae, cuboid cells with minimal atypia, mitosis, and necrosis not seen and no lymphoid tissue seen, suggestive of PHG.

Brucellosis is a zoonotic infectious disease, which mainly involves lymphoreticular system. Our case report describes an isolated splenic lesion diagnosed in a 48-year-old individual who is a farmer by occupation, had a history of animal contact, and has the habit of consuming raw milk. He was admitted as a case of pyrexia of unknown origin (PUO) and detected to have splenic Space occupying lesion (SOL) on imaging. His serum Brucella IgM was positive and ultrasonography-guided fine-needle aspiration cytology of splenic SOL showed features of necrotizing granulomatosis inflammation or an organizing abscess. The patient was successfully treated for brucellosis with oral doxycycline and rifampin for 6 weeks. Hereby, we report a case of PUO with splenic SOLs, Diagnosed on the basis of clinical, radiological, histopathological, and serological basis as a case of spleenic brucellosis. This case required a very high index of clinical suspicion and further highlighted the fact that even in present times of advanced diagnostic modalities, clinical inputs cannot be overlooked. Thereby, we were able to demystify a case of PUO successfully.