Previously prone positioning (PP) was described in addition to invasive mechanical ventilation and it has been known to reduced mortality and improve oxygenation in patients of ARDS. Recently novel timing of prone positioning was described with the use of high-frequency nasal cannula (HFNC) and noninvasive ventilation (NIV) in patients of acute respiratory distress syndrome (ARDS) to avoid the intubation. Here we would like to share a case of severe ARDS where prone positioning was used in a step further ahead.

A 38-year-old gentleman presented with the complaints of progressive breathlessness, dry cough and fever for 7 days. Patient was diagnosed as a case of H1N1 pneumonia with severe ARDS. check details Patient was initially managed with invasive mechanical ventilation according to ARDS-Net protocol. Despite persistent hypoxia he was put on prone positioning for consecutive 4 days. Patient was extubated after 10 days of mechanical ventilation and put on HFNC in view of persistent high oxygen requirement. At this point of time, we attempted prone positioning in addition to HFNC. Patient was comfortable on prone position and put himself in the same condition for prolonged periods. His oxygenation showed a remarkable improvement from PaO

of 63 (before prone positioning) to 136 mm Hg (after prone positioning). Oxygen supplementation was later tapered off and subsequently, he improved and was shifted to ward.

Prone positioning is a harmless and still extremely effective intervention which can and should be utilized at all steps of ARDS-management.

Lalwani LK, Sharma V, Chaudhry D, Singh PK. Indications for Proning in Acute Respiratory Distress Syndrome Expanding the Horizon! Indian J Crit Care Med 2020;24(7)589-591.

Lalwani LK, Sharma V, Chaudhry D, Singh PK. Indications for Proning in Acute Respiratory Distress Syndrome Expanding the Horizon! Indian J Crit Care Med 2020;24(7)589-591.

Critically ill patients may present with prothrombotic manifestations. Carcinoma cervix with prothrombotic manifestations are not common. Arterial thrombosis in such cases is very rare. We present a case of carcinoma cervix which posed a diagnostic dilemma and difficulty in localizing primary. This patient also had recurrent strokes and cardiac metastasis with metastatic arterial thrombosis.

A 34-year-old lady presented with a history of acute lower limb ischemia and recurrent strokes. Transthoracic echocardiography showed valvular vegetations. Prothrombotic and infective endocarditis workup were negative. Histopathological examination (HPE) of clot showed metastatic squamous cells. Contrast CT of chest and abdomen only showed mediastinal lymphadenopathy. Endobronchial ultrasound (EBUS) with mediastinal lymph node biopsy showed metastatic squamous cells. As the patient gave a history of hysterectomy, Pap smear from the vault was sent, which was suggestive of high grade squamous intraepithelial neoplasia. aurasia S. A Unique Case of Arterial Thrombosis and Recurrent CVA in ICU Unfathomable Presentation of an Occult Malignancy. Indian J Crit Care Med 2020;24(7)585-588.Typhonium is a genus belonging to the Araceae family, native to southern Asia and Australia. In folk medicine, Typhonium is used for its analgesic, anti-inflammatory, antidiarrheal, and wound-healing properties. We report a toxidrome of airway compromise due to Typhonium trilobatum tuber ingestion. We present an interesting case series of four patients who consumed raw tuber of T. trilobatum with suicidal thoughts. They exhibited a constellation of symptoms such as swelling of lips and tongue, drooling of saliva, and severe throat pain. One patient had significant upper airway edema and severe respiratory distress requiring emergency endotracheal intubation. Laboratory investigations were grossly normal in all four individuals, expect for mild asymptomatic hypokalemia in one and eosinophilia in another patient. We successfully managed all our patients with repeated adrenaline nebulization, antihistamines, and steroids. Typhonium is believed to be a beneficial herb. Toxicity of Typhonium is not reported much in the literature till date. An emergency department (ED) physician should be aware of this tuber toxicity as it presents with airway compromise, which resolves over hours. The symptoms are due to the local effects of calcium oxalate crystals in the tuber. Airway management is the priority and repeated adrenaline nebulization together with supportive care is advised.

Anandhi D, Prakash Raju KNJ, Vivekanandan MP, Kumaresan V. The First Case Series Report of

Tuber Poisoning in Humans. Indian J Crit Care Med 2020;24(7)581-584.

Anandhi D, Prakash Raju KNJ, Vivekanandan MP, Kumaresan V. The First Case Series Report of Typhonium trilobatum Tuber Poisoning in Humans. Indian J Crit Care Med 2020;24(7)581-584.Typical manifestations of coronavirus disease (COVID-19) involve the upper and lower respiratory tract. But as the pandemic surges, we are encountering numerous case reports and series of extrapulmonary presentations of COVID-19 in the outpatient department. Abundant retrospective data have also cited various extrapulmonary complications in the hospitalized COVID-19 patients. This knowledge needs to be condensed and disseminated in order to improve COVID-19 surveillance and to reduce the accidental exposure of healthcare workers. Our review suggests that gastrointestinal tract, cardiovascular system, nervous system, renal system, and manifestations due to hematological abnormalities are common masqueraders to watch out for.

Adukia SA, Ruhatiya RS, Maheshwarappa HM, Manjunath RB, Jain GN. Extrapulmonary Features of COVID-19 A Concise Review. Indian J Crit Care Med 2020;24(7)575-580.

Adukia SA, Ruhatiya RS, Maheshwarappa HM, Manjunath RB, Jain GN. Extrapulmonary Features of COVID-19 A Concise Review. Indian J Crit Care Med 2020;24(7)575-580.In the current COVID-19 pandemic, evidence to justify the use of any specific antiviral drug with proven efficacy is not yet available. Antiviral drug development always remains a challenge to the scientists. Remdesivir has emerged as a promising molecule, based on results of clinical trials and observational studies and has receieved marketing approval for COVID-19 treatment under “emergency use authorization” in countries such as United States. Remdesivir is a newer antiviral drug that acts as an RNA-dependent RNA polymerase (RdRp) inhibitor targeting the viral genome replication process. Therapeutic efficacy was first demonstrated by suppressing viral replication in Ebola-infected rhesus monkeys. It is available for parenteral use with reasonable safety and tolerability profile. Multiple clinical trials are going on in many countries to evaluate its safety, efficacy and tolerability. Positive outcome will make the drug capable of meeting the demand generated by both the current pandemic and future outbreak.