Actinomycosis is an indolent, slowly progressive infection caused by anaerobic or microaerophilic bacteria of the genus Actinomyces. Actinomycosis has a myriad of clinical presentations, inducing both a suppurative and granulomatous inflammatory response. The infection spreads contiguously through anatomical barriers and frequently forms external sinuses. The most common clinical presentations are cervicofacial, thoracic, abdominal and, in females, genital. Classic features include purulent foci surrounded by dense fibrosis that, over time, cross natural boundaries into contiguous structures, with the formation of fistulas and sinus tracts in some cases. Hepatic actinomycosis presents as single or multiple abscesses or masses. Reported here is the unusual occurrence of actinomycosis of the liver involving the diaphragm and right lung. The present case illustrates the difficulties in diagnosing this rare and unrecognized disease.

Thrombocytopenia and platelet dysfunction commonly occur in both dengue and COVID-19 and are related to clinical outcomes. Coagulation and fibrinolytic pathways are activated during an acute dengue infection, and endothelial dysfunction is observed in severe dengue. On the other hand, COVID-19 is characterised by a high prevalence of thrombotic complications, where bleeding is rare and occurs only in advanced stages of critical illness; here thrombin is the central mediator that activates endothelial cells, and elicits a pro-inflammatory reaction followed by platelet aggregation. Serological cross-reactivity may occur between COVID-19 and dengue infection. An important management aspect of COVID-19-induced immunothrombosis associated with thrombocytopenia is anticoagulation with or without aspirin. In contrast, the use of aspirin, nonsteroidal anti-inflammatory drugs and anticoagulants is contraindicated in dengue. Mild to moderate dengue infections are treated with supportive therapy and paracetamol for fever. Severe infection such as dengue haemorrhagic fever and dengue shock syndrome often require escalation to higher levels of support in a critical care facility. The role of therapeutic platelet transfusion is equivocal and should not be routinely used in patients with dengue with thrombocytopaenia and mild bleeding. The use of prophylactic platelet transfusion in dengue fever has strained financial and healthcare systems in endemic areas, together with risks of transfusion-transmitted infections in low- and middle-income countries. There is a clear research gap in the management of dengue with significant bleeding.

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The ongoing outbreak of Covid-19 presented with a wide variety of clinical manifestations. Apart from the common respiratory complications, acute renal impairment and bleeding complications on full anticoagulation has been also observed in some patients. Here we report a 67 year old male with COPD and CKD presented with symptoms of covid-19 and found ground glass opacity on CT scan and bibasilar opacity on chest X-ray, admitted to the hospital and he was initially stable after supportive management, discharged home on antibiotics but readmitted after 4 days with worsening shortness of breath, hypoxia, tachycardia (A-fib with Rapid Ventricular Response) and high ESR. He was started on High flow nasal cannula (HFNC), diltiazem, adenosine and antibiotics ultimately needed intubation. While he was on antibiotics, hydroxychloroquine, DVT prophylaxis and statin he developed septic shock two days after intubation. Next day he had to receive Continuous Renal Replacement Therapy (CRRT). He was placed on heparin infusion. With clinical improvement the patient was extubated to HFNC, but after one day of extubation he developed bradycardia, hypotension and gradually became unresponsive. He was given vasopressors and intubated again. CT scan showed retroperitoneal hematoma 10 x7 x 12 cm. His heparin was discontinued and was managed conservatively. With supportive treatment his clinical condition improved gradually and was extubated again. CRRT was switched from CVVH (Continuous Veno -Venous Hemofiltration) to HD and eventually he was discharged home. Clinicians should remain watchful at all stages of critical care management of COVID 19 because timely intervention and drug adjustment is lifesaving. J Bangladesh Coll Phys Surg 2020; 38(0): 136-140

COVID-19 pandemic is the highlight of the 21st century that took drastic effects on humanity. Over 23 million confirm infected with the majority with mild infection. However, over 62,000 cases are in critical condition with varying degrees of ARDS. A potential complication of severe ARDS could be Post COVID-19 Pulmonary fibrosis. Possible use of biomarkers to detect progression to fibrosis, along with prompt treatment of acute lung injury caused by COVID-19 and administration anti-fibrotic therapies, could be the next best method to treat this permanent and devastating sequela of COVID-19. Bangladesh Crit Care J September 2020; 8(2): 102-107

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Obstructive sleep apnea (OSA) is a common, chronic, sleep-related breathing disorder characterized by repetitive episodes of partial and complete airway obstructions during sleep with repetitive apneas and hypopneas as a result. Common symptoms of OSA include snoring, nocturnal choking or gasping, excessive daytime sleepiness, nonrefreshing sleep, fatigue, nocturia, morning headache, and cognitive impairment. Snoring has the most sensitivity(82.6%) while nocturnal choking or gasping is the most specific (84%) Undiagnosed and untreated OSA attributed to hypertension (30%-70% of OSA patients), heart failure (140% rise in risk), CAD (30% rise in the risk of blockage), and stroke (60% rise in risk). Other long-term health consequences include diabetes, memory loss (including Alzheimer’s), depression, and other psychiatric conditions. Depending on the broad or stringent definition of OSA based on the apnea-hypopnea index (AHI), the prevalence of the condition in North America can range from 20-30% or 15% in males, and 10-15% or 5% in females. Asians and Indians have been found to have similar OSA severity, despite lower rates of obesity. However, research conducted among South Asians in the UK shows a higher prevalence of OSA than white Europeans. Limited research is done on OSA among South Asians in the US, particularly in the Bangladeshi community. The proportion of the population showing a high risk for the disease noticeably increases from 46 years onward. Male gender was found to be the major risk factor determining whether the subjects are at high, intermediate, or low risk. This conforms with other studies done previously. Although the study shows 30% of the population posing an increased risk for OSA, the outcome may be the same, lower, or higher after polysomnography. The author recommends a broader study with a follow-up of the intermediate and high-risk groups with an appropriate sleep study. Based on the preliminary findings, questions regarding OSA should be incorporated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. Steps should be taken to increase awareness at the community level to improve compliance with annual physicals and reduce risk behaviors.