Critical Care WAarticles

30/04/2025

*PRACTICE CHANGING UPDATE*
*Revised diagnostic criteria for Allergic Bronchopulmonary Aspergillosis (ABPA) 2024

• There is no individual test to establish the diagnosis of allergic bronchopulmonary aspergillosis, and the diagnosis is usually confirmed by a combination of clinical, radiographic, and immunologic findings. We favor using the 2024 revised diagnostic criteria proposed by the International Society for Human and Animal Mycology (ISHAM) that simplify prior diagnostic scheme.

• Allergic Bronchopulmonary Aspergillosis (ABPA), a complex hypersensitivity reaction to airway colonization with _Aspergillus fumigatus_ can be hard to distinguish from difficult-to-treat asthma or cystic fibrosis. The International Society for Human and Animal Mycology (ISHAM) working group for ABPA recently published in May 2024 , a revised diagnostic criteria as shown in table below that make some key changes to improve the sensitivity and specificity of the diagnosis:

•Total serum immunoglobulin (Ig) E levels of ≥500 international units/mL are sufficient for the diagnosis, rather than the previously higher threshold of 1000 international units/mL.

•Elevated Aspergillus IgG levels by enzyme immunoassay or lateral flow assay are more sensitive for detecting sensitivity to Aspergillus antigens and should be used preferentially over Aspergillus serum precipitins.

*TABLE*

📋 ABPA Diagnostic Criteria (ISHAM)

🔹 Predisposing Conditions (≥1):
- Asthma
- Cystic fibrosis

🔹 Obligatory Criteria (both required):
- Serum IgE to Aspergillus ≥ 0.35 kU/L
or skin test positive
- Total IgE ≥ 500 IU/mL

🔹 Other Criteria (≥2 of the following):
- Elevated Aspergillus IgG
- Pulmonary opacities (HRCT or X-ray)
- Eosinophil count > 500 cells/μL

📝 Notes:
- IgE < 500 IU/mL allowed if all other criteria met
- IgG preferred over precipitins
- HRCT: Bronchiectasis

*Reference*
1. Agarwal R, Sehgal IS, Muthu V, et al. _Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary
aspergillosis/mycoses. Eur Respir J 2024; 63(4):2400061.

==
Summary contributed by
*Dr. Ashutosh Bhardwaj*
HOD Critical Care
Dharamshila Narayana Superspeciality Hospital, Delhi.

*Dr. Prashant Kumar*
Editor Critical Care WAarticles

29/05/2021

*COVID-19: Dry gangrene of lower limb leading to amputation and partial of vision*

*The case*
A 75 year old M known case of HTN, Post PTCA now a COVID-19 patient presented to another hospital with gradual blackening of the left lower limb gradually progressing to dry gangrene. Below knee amputation was required to save life. He developed mild AKI and vision has reduced to 50% as complained by him. He is fully conscious oriented with oxygen saturation adequate. After 25 days of initial symptoms his systemic symptoms have not resolved.

Hb- 10.7 gm/dl
TLC-12.22/ mm
N77
Urea 68 mg/dl
Cr- 1.4 mg/dl
UA 4.1 mg/dl
Na- 129 meq/L
K 4.03 meq/L
PO4 4.49 mg/dl
Alb 2.65 gm/dl
Ferritin 222 ng/ml
IL6 18.88 pg/ml
CRP 4.17
D-dimer 2.44
LDH 272 IU/L
Vit D3 121 nmol/L

==
COVID-19 is now recognized to involve almost every organ of the body. The most common classification of severity is based on oxygen requirements.
Generalized symptoms such as fatigue, neuropsychiatric illness, and depression have persisted.

Loss of taste has been well recognized.

*Changes in vision and limb gangrene are less commonly seen*

At this moment it is difficult to separate if the present condition resulted from COVID-19 or anything else.
==
Dr. Prashant Kumar

https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/

Learn how SARS-CoV-2 infection is categorized by severity of illness.

24/12/2020

*How often do you test Vitamin D levels and does it matter in your ICU?*

Vitamin D is essentially needed in general population and the critically ill as well. This vitamin has significant role in maintaining immune function, cardiovascular state, glucose control and mucosal barrier function etc.

70 to 100 % have vitamin D deficiency in ICU.
Vitamin D supplementation is safe in general population and ICU patients. Hypervitaminosis D should be avoided through correct replacement regimen.

*Normal desirable levels:*
Labs report Vitamin D3 levels in two different units; ng/mL & nmol/L
1 ng/mL = 2.5 nmol/L
Normal value 30-100 ng/mL (75 to 250 nmol/L)

Anything over 100 ng/ml (250 nmol/l) over prolonged periods may be harmful.

Dietary supplement upto 4,000 IU or less per day is considered safe.

*Supplements comparisons and dose schedules*

*Oral*
Orally administered Vitamin D3 partially gets metabolized by the hepatic 25- hydroxylase enzyme and therefore the rise is ill sustained.

Replacement regimen in deficient adults
Oral replacement
Advantage- Easy, Non invasive
Disadvantage – ill sustained correction, poor compliance in long term

Large oral dose - 300000 IU- Continue maintenance dose after 3 months - 60000 per week
or
Weekly dose - 60000 IU per week

*Intramuscular*
IM route advantages- Low cost good compliance, sustained level, need not pass through the liver metabolism
300,000 IU Vitamin D3 monthly for 3 months followed by the same dose every 6 months

600000 IU stat then 300000 IU every 6 months.

*Preparations*
Cap D Rise (60K), Uprise (60K) etc
Inj Arachitol 6L, 3L, 1L, 60K etc for IM injection

====
*Dr. Prashant Kumar*
MD, IDCCM, FNB (Critical Care), EDIC, ADHCA, DOA
Editor 'Critical Care WAarticles'
https://criticalcarewaarticles.blogspot.com/2020/12/how-often-do-you-test-vitamin-d-levels.html

17/05/2020

https://radiopublic.com/dr-prashant-kumar-69zpKQ/episodes

Critical Care WAarticles - is an academic platforms in critical care providing discussions in Critical Care.

04/05/2020

*Easy steps to make Face Shields with simple materials easily available at home/ workplace*
https://youtu.be/Vhh0MbN2KZA

*Materials needed:*
1. Transparent plastic folder or similar material
2. Scissors s
3. Stapler
4. Elastic band

*How to:*
Take a cut out of transparent portion of the file
Measure elastic length
Staple on both sides
Wear while doing aerosol generating procedures

--
*Dr. Prashant Kumar*

24/04/2020

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--
Dr. Prashant Kumar

MD, IDCCM, FNB (Critical Care), EDIC, ADHA, DOA

Editor 'Critical Care WAarticles'

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24/04/2020

https://www.dropbox.com/s/dvtazf0t528dc8b/36%20MYTHS%20AND%20FACTS%20ABOUT%20COVID-19.pdf?dl=0

Shared with Dropbox

17/04/2020

We need a Vaccine against COVID-19 urgently, but it will be available after 12-16 month only, why? == The entire world is fighting against a pandemic caused ...

14/04/2020

13/04/2020

References: 1. World Health Organization. WHO declares COVID-19 a pandemic. 2020 [cited 2020 March 13]. Available from: https://www.who.int/dg/speeches/detai...