COVID-19, long COVID, phenotypes, predictors A variable proportion of patients develop persistent/prolonged symptoms of Coronavirus Disease 2019 (COVID-19) infection (long COVID). We aimed to study the clinical predictors of persistent symptoms in patients with mild COVID-19 at 30 days post discharge (long COVID-19). We also tried to identify symptom clusters among mild COVID-19 patients. Fifty-seven patients admitted at a tertiary care centre after a positive RT-PCR report over a period of 2 months, were enrolled in the study. Details of presentation, history of illness, laboratory investigations and disease outcomes were recorded from documented medical records and discharge slip. The patients were contacted (telephonically) at 30 days after discharge and enquired regarding persistent symptoms, if any. Follow up data at 30 days post-discharge was available for 53 patients. Among them, the most common persistent symptom was fatigue (22.6%), followed by cough (9.4%) and myalgias (7.5%). There was a significant association of persistent symptoms with diarrhoea at presentation ; p = 0.009] and gap between symptom onset and admission [OR 1.40 (95% CI 1.08-1.93; p = 0.020] on multivariate logistic regression analysis. On cluster analysis, three phenotypes of mild COVID-19 were identified, which may have implications on monitoring and management. There appears to be a positive association of diarrhoea as a presenting manifestation and gap between symptom onset and admission with the persistence of symptoms classified as long COVID-19, even in mild illness. We also identified multiple phenotypes of mild COVID-19 illness, which warrant further exploration.

Background & objectives: In the present scenario, the most common sample for diagnosis of COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) is nasal and throat swab (NTS). Other sampling options such as gargle lavage have found limited application in clinical use mostly because of unavailability of an appropriate gargling liquid. This study was conducted to assess the stability of SARS-CoV-2 RNA in normal saline at 4°C that can serve as a gargling liquid as well as a transport medium. The study also looked at the agreement between NTS and gargle lavage/saliva for the detection of SARS-CoV-2. Methods: In 29 consecutive real-time RT-PCR (rRT-PCR) positive COVID-19 patients, paired NTS, gargle and saliva samples were taken. Samples were processed by rRT-PCR for the detection of SARS-CoV-2 RNA. To assess the SARS-CoV-2 RNA stability in normal saline, gargle lavage specimens were divided into two aliquots; one subset of the specimen was run within 4-6 h along with the routine samples (NTS and saliva) and the other subset was stored at 4°C and processed after 24-30 h. Agreement between cycle threshold (Ct) values from both the runs was compared using Bland–Altman (BA) analysis. Results: The positivity rates of rRT-PCR in NTS, saliva and gargle lavage samples were 82.7 (24/29), 79.3 (23/29) and 86.2 per cent (25/29), respectively. BA plot showed a good agreement between the Ct values of fresh and stored gargle samples, stipulating that there were no significant differences in the approximate viral load levels between the fresh and stored gargle lavage samples (bias: E gene −0.64, N gene −0.51, ORF gene −0.19). Interpretation & conclusions: Our study results show stability of SARS-CoV-2 RNA in the gargle samples collected using normal saline up to 24-30 h. Gargle lavage and saliva specimen collection are cost-effective and acceptable methods of sampling for the detection of SARS-CoV-2 RNA by rRT-PCR. These simplified, inexpensive and acceptable methods of specimen collection would reduce the cost and workload on healthcare workers for sample collection.

Background: Acanthamoeba is a rare cause of granulomatous amoebic encephalitis (GAE) associated with high mortality. There have been few case reports of Acanthamoeba meningoencephalitis worldwide. Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory condition caused by abnormally active macrophages and cytotoxic T lymphocytes; its secondary form is due to infections or malignancies. However, HLH is rather an unknown complication of GAE. We describe an unusual and previously unreported case of Acanthamoeba meningoencephalitis in a young immunocompetent female culminating in secondary HLH. Case presentation: A 19-year-old female from southern India residing in Uzbekistan presented with low grade fever for 20 days and altered sensorium for 8 days. On examination, she was febrile, had pallor, neck stiffness, irritable with GCS 12/15. A provisional diagnosis of acute meningoencephalitis was made. Cerebrospinal fluid (CSF) wet mount for free-living amoeba demonstrated organisms resembling Acanthamoeba spp. trophozoites which was confirmed by CSF polymerase chain reaction for Acanthamoeba. The patient was started on combination therapy. On admission she had anaemia and thrombocytopenia which progressed to worsening pancytopenia and significantly raised ferritin, triglycerides and transaminase. Clinical diagnosis of HLH was made, her clinical condition kept on worsening, necessitated intubation and mechanical ventilation. She succumbed to her illness with multi-organ dysfunction. Postmortem minimally invasive tissue sampling (MITS) was done to collect specimens from brain, lung, liver and spleen for histopathological examination. Splenic specimen showed congestion of red pulp with collection of macrophages and hemophagocytes with areas of micro-abscess. The final impression from MITS of all organs was septicaemia-induced changes with hemophagocytes. Conclusions: To the best of our knowledge, we report the first case of Acanthamoeba meningoencephalitis causing secondary HLH. Our case highlights this rare association and the need for extensive clinical and laboratory evaluation of suspected patients by a multidisciplinary team.

The diagnosis of Chronic pulmonary aspergillosis (CPA) is established by combined clinic-radio-microbiological criteria. Out of the different microbiological criteria, usually a positive serology for Aspergillus-specific IgG levels is the cornerstone of diagnosis . Alternatively, other microbiological evidence can also be employed viz. significantly positive Aspergillus antigen (broncho-alveolar lavage fluid/BALF galactomannan ≥ 1.0), histopathological demonstration of the fungi following lung biopsy or resection, or demonstration of hyaline septate hyphae in direct microscopy resembling Aspergillus spp. or its growth on respiratory specimen. However the role of BALF- GM and the newer BALF-PCR have not been confirmed by studies till date. The study enrolled 210 patients overall of suspected CPA. Of the participants, 88 patients met the criteria for chronic pulmonary aspergillosis, whereas 122 patients had an alternative diagnosis. The sensitivity - specificity of AsperGenius® PCR and "in-house” PCR were 52.27(36.69-67.54) % - 33.78(23.19-45.72) % and 36.36(22.41-52.23) % - 39.19(28.04-51.23) % respectively. The sensitivity / specificity of BALF(>1.0) and serum galactomannan(>1.0) were 46.55%(33.34-60.13) / 64.08%(54.03-73.3) and 62.96%(54.7671.17) / 62.96%(54.76-71.17) respectively. The optimal cut-off value for BALF Galactomannan and serum galactomannan in diagnosing CPA was found to be 0.69 (sensitivity: 64%; specificity: 53%) and 0.458 (sensitivity: 67%; specificity: 64%) respectively. Aspergillus PCR from BAL may not be a good “rule-in” test for diagnosing CPA. While the performances of GM in BAL and serum may be better than PCR, it is to be used in conjunction with other clinical, radiological and other microbiological characteristics.