Obstructive sleep apnea (OSA), characterised by apnea or hypopnea, often presents with symptoms such as gasping or snoring. However, these symptoms can be nonspecific and are frequently overlooked, particularly in pregnant women, where they are often attributed to normal physiological adaptations, leading to underdiagnosis and negative maternal and fetal outcomes. This narrative review examines the implications of OSA during pregnancy, highlighting the importance of early screening and evaluating available treatment options. We reviewed various articles on PubMed and Google Scholar about the impact of OSA during pregnancy, screening methodologies, and treatment effectiveness. OSA often increases sympathetic activity along with immune dysfunction, resulting in adverse outcomes like gestational hypertension, preeclampsia, gestational diabetes, cardiomyopathy, depression, and higher rates of cesarean deliveries, while the fetus suffers from intrauterine growth restriction (IUGR), preterm births, and perinatal mortality. Various screening tools, such as the Berlin Questionnaire, Epworth Sleepiness Scale (ESS), STOP-BANG, and Wisconsin questionnaires, aid in early diagnosis. Treatment options include lifestyle modifications, positive airway pressure (PAP) therapy, either continuous (CPAP) or bilevel (BiPAP), hypoglossal nerve stimulation (HGNS), mandibular advancement devices (MAD), and maxillomandibular advancement (MMA) surgery, with CPAP being identified as the preferred treatment. To reduce adverse outcomes for both the mother and the fetus, early detection and treatment of OSA in pregnant women are essential. Increased awareness among expectant mothers, routine screening using validated questionnaires, and appropriate treatment selection can not only decrease fetal complications but also reduce the risk of long-term adverse effects of OSA on maternal health.

BACKGROUND Klebsiella pneumoniae invasive syndrome (KPIS), a rare severe multi-site infection, typically caused by hypervirulent Klebsiella pneumonia, has a high mortality rate, usually ranging from 10% for antimicrobial-sensitive strains to 24% for resistant strains, and often requires prolonged treatment. Most cases have been reported in East Asia, with a handful documented in India, to date. The incidence is also rising in Western countries. CASE REPORT We report the case of a 45-year-old Indian man who presented with fever, low back pain, and asymmetric arthralgia for the past 20 days, along with new acute-onset right-sided hemiparesis and slurred speech. Laboratory test results were significant for elevated leukocyte counts and inflammatory markers (ESR and CRP). MRI of the brain revealed multiple lesions, with accompanying hemorrhage and edema at grey white-matter junction. PET-CT revealed septic collections at multiple sites, including the spleen, kidney, left knee joint, and L5-L6 vertebrae, along with paravertebral and psoas abscesses. Cultures of vertebral abscess confirmed Klebsiella pneumoniae, with a positive string test, consistent with a hypermucoviscous phenotype; however, genetic testing for hypervirulent genes could not be performed, due to unavailability. Given these findings, KPIS diagnosis was likely. Treatment was 6 weeks of antibiotics, empiric vancomycin and gentamicin, followed by de-escalation to amoxicillin-clavulanic acid. CONCLUSIONS KPIS can occur in immunocompetent hosts and should be considered in cases of unexplained systemic inflammation with multifocal abscesses. Hepatic involvement, while characteristic, is not essential for diagnosis. When genotypic testing is unavailable, a positive string test can serve as a useful surrogate marker for identifying hypervirulent strains.

BACKGROUND Guillain-Barre syndrome (GBS) is a rare disorder arising due to immune-mediated damage to the peripheral nervous system. It most commonly occurs as a sequela of respiratory or gastrointestinal infections; however, in rare instances, cases may arise after snakebite envenomation. Several variants of GBS have been identified, with acute inflammatory demyelinating polyneuropathy (AIDP) being the most common, including our case. Other forms, such as acute motor axonal neuropathy (AMAN), are also more prevalent in tropical regions of Southeast Asia, as well as Central and South America. CASE REPORT A 52-year-old farmer from rural northern India presented with ascending palsy progressing for the past 3 days, along with bulbar symptoms and respiratory involvement for 1 day. He had been recently hospitalized a few weeks ago for snake-bite-associated neuroparalysis that had gradually resolved without any complications before discharge. Laboratory investigations and chest X-ray on presentation were suggestive of aspiration pneumonia, leading to initiation of empiric antibiotics. A diagnosis of AIDP variant of GBS was reached on the second day of admission, based on CSF studies showing albuminocytologic dissociation, and nerve conduction studies suggestive of axonal neuropathy in lower-limb nerves, and demyelination that was more pronounced in the lower limbs than in the upper limbs. He subsequently received a dose of IVIG, and was intubated for mixed hypoxic-hypercapnic respiratory failure. However, the worsening hemodynamic instability due to sepsis and GBS-related autonomic dysfunction, despite the antibiotic escalation and vasopressor support, eventually culminated in death. CONCLUSIONS This case underscores the importance of recognizing Guillain-Barre syndrome (GBS) as a neuroimmune sequela of snakebite envenomation, and the need for close neurological monitoring, patient and caregiver education, and physician awareness for early symptom recognition, and prompt initiation of empiric treatment to avoid delayed diagnoses and subsequent fatal complications.

Cervicofacial actinomycosis is a well-recognized infectious disease caused by Actinomyces, a Gram-positive filamentous bacterium. In contrast, Nocardia, a morphologically similar, hyphae-forming organism, is an exceedingly rare cause of cervicofacial abscesses, and even more uncommon associated osteomyelitis of mandible. We present such a case involving a kidney transplant recipient who presented with opioid-induced constipation, along with left jaw pain and swelling. CT scan of the soft tissue in the neck revealed a complex cervicofacial abscess with enhancement of underlying mandible. Culture growth and RNA sequencing of USG-guided aspirate identified a Nocardia species closely related to N. beijingensis/exalbida. The patient initially received broad-spectrum antibiotics, including ceftriaxone, imipenem, and trimethoprim-sulfamethoxazole (TMP-SMX). Imipenem was later discontinued in view of new-onset unexplained encephalopathy and replaced with linezolid, which was subsequently switched to minocycline following thrombocytopenia development. Minocycline therapy was intended for a total of 12 months. TMP-SMX was avoided long-term due to avoid nephrotoxicity risk in kidney transplant patients. On six-month follow-up, the patient showed clinical and radiological improvement; minocycline was discontinued after additional six months. This case highlights the importance of considering Nocardia as a differential diagnosis in immunosuppressed patients presenting with cervicofacial symptoms, especially following orofacial surgery or trauma. Early recognition, prompt diagnosis, and appropriate antibiotic therapy with adequate bone penetration seem crucial for optimal management and may help avoid the need for surgical intervention.

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