Journal of the Association of Physicians of India
JAPI
Editor : Dr. Siddharth N. Shah
February 2019 • VOL. 67
Abstracts : Free Papers – Platform Presentation (APICON-2019) - Infectious Diseases
A Study on Outcome of Fever with Thrombocytopenia in Dengue Positive and Negative Individuals
Introduction: Dengue is probably the most important
arthropod borne viral disease in terms of human morbidity
and mortality, most important reason being tendency of
bleeding. However, other viral infections can also cause
reduction of platelets. There are studies to show that dengue
causes thrombocytopenia and requires platelet transfusion.
However, certain non dengue individuals with febrile
illness also present with thrombocytopenia. So, there is a
need to compare these two groups to formulate prognosis
of dengue viral over non dengue viral cases.
Materials and Methods: Cross sectional study,
presenting with fever with thrombocytopenia admitted in
Gandhi hospital during period of june to September. The
patients with acute febrile illness with platelet count less
than 1.5 lakh were included in the study.All the cases of
fever with thrombocytopenia presented at Gandhi hospital
from June to September 2016 and 2018 were observed
and results were compared between dengue positive and
dengue negative individuals in these two years.
Results: In 2016, 156 patients were included in the
study with age above18 years. Out of 156 cases of acute
febrile illness, 42(26.9%) were dengue positive and
114(73.1%) were dengue negative. In 2018, 161 patients with
29.6% dengue positive and 70.4% were dengue negative.
The RDP units required were on an average 4.44 in dengue
positives and 3.404 in dengue negatives respectively.
Duration of hospital stay was around 7±3 days in dengue
positives and 4±2 days in negatives.
Conclusion: Though mean platelet count was higher
in dengue positives, complications, mean hospital stay
and outcome is graver when compared to seronegatives.
So, meticulous care is to be ensued while treating dengue
positive individuals over dengue negative individuals,
even at higher platelet counts, as they have higher risk
of bleeding manifestations which are life threatening and
requirement of RDPs is more in dengue patients over
non dengue.
Disseminated Tuberculosis with Drug Induced Lupus- A Case Report
Disseminated tuberculosis is involvement of two or
more non-contagious organ involvement of mycobacterial
infection without classical or radiological features. It
remains potentially lethal if not diagnosed and treated
earlier. Lupus or Systemic Lupus Erythematosus (SLE) is a
chronic collagen vascular disorder of autoimmune aetiology
with multisystem involvement. We report a case of
disseminated tuberculosis in an adult female with skeletal,
pleural involvement complicated with drug-induced lupus
erythematosus (DILE) while on antitubercular treatment
(ATT) and had a rapid downhill course to the death due to multiorgan failure.
A 68-year-old female presented to casualty with
altered sensorium of one day and systemic convulsions
prior to admission. Her vitals were stable. CT scan of
the brain and routine blood tests were normal except
for Serum Sodium=116 mEq/L which was corrected with
hypertonic saline over 48 hrs. She had left mild pleural
effusion which was exudative and negative for malignant
cells but having Adenosine deaminase level of 59 IU/L.
Low back pain which she complained about, on detailed
evaluation with X-ray and MRI of the vertebral spine
revealed anterior wedging of 4th and 5th lumbar vertebra.
The patient started on ATT with Isoniazid, Rifampicin,
Pyrazinamide and Ethambutol. But after 8 days, ATT has
to be discontinued due to persistent vomiting and elevated
hepatic enzymes. Only Tablet Ethambutol along with Inj.
Streptomycin was continued. After 5 days she developed
multiple erythematous plaques with erosion and crusting
over the face, upper torso with petechial lesions over lower
extremities. Serum ANA was positive with 1:90 dilution
with a homogenous pattern. She developed pancytopenia
and hypotension for which she was shifted to the ICU.
IV Methylprednisolone (1gm) for 3 days was given. She
succumbed to the death. Above case denotes atypical
presentation of disseminated tuberculosis complicated
with lupus.
The Mystery Behind Thrombocytes in Dengue
Introduction and Objectives: Dengue fever is endemic
in tropical and subtropical regions of the world and
almost 1.8 billion population at risk live in south east
Asian countries. Thrombocytopenia being one of the most
common haematological manifestation in these patients,
very low platelet count demands platelet transfusion.
Although platelet transfusion is life saving in some
patients it is necessary to prevent unnecessary transfusions.
Hence, there needs some parameters which can predict
platelet recovery in dengue patients. We aim to study the
relationship of these platelet indices like Immature platelet
fraction (IPF), Platelet Distribution Width (PDW), Platelet
Large Cell Ratio (P-LCR) and Mean Platelet Volume (MPV)
with Platelet Count (PC) in predicting the platelet response.
Materials and Methods: An observational descriptive
study has been conducted in a tertiary care centre who
presented with clinical features of Dengue fever with
microbiologically positive test for NS1 antigen or IgM
antibody during August 2018 to September 2018. 30 patients
have been included in the study. The platelet count and the
platelet indices (IPF, PDW, P-LCR, MPV) were retrieved
daily and statistical analysis was performed using spearman
correlation to analyse the relationship between platelet
Count and its indices.
Results: 93.33% showed improvement in platelet count
after 24 hours once the IPF reaches its maximum which is
statistically significant (p= 0.001). No significant correlation
has been obtained for other indices MPV (p=0.977),
PDW(p=0.877) and P-LCR(p=0.619) with platelet counts.
Conclusion: Among the platelet indices IPF can be
used to predict the platelet response and it can prevent
unnecessary transfusions in patients even with very low
platelet count without any bleeding manifestations.
Portal hypertension(PH) and Hemophagocytic Lymphohistiocytosis (HLH): rare manifestations of Visceral Leishmaniasis
Introduction: HLH associated with Visceral
leishmaniasis (VL) is a rare entity and difficult to
diagnose. While the literature regarding PH has also been
infrequently reported.
Report: A 14yr female, resident of Nepal, presented
with complaints of fever on and off along with pain
and distension of abdomen since, two months. She was
a diagnosed case of VL (partially treated) and was also
started on ATT for suspected concurrent disseminated
TB in GMC, Nepal following clinical features and CECT
abdomen findings. But patient had not shown any clinical
improvement on ATT. Further evaluation thereafter,
showed hepatosplenomegaly with ascites, pancytopenia,
raised ESR, positive RK-39, LD bodies on BMA/BMB, raised
serum ferritin with circumferential intestinal thickening
& pulled-up caecum without any lymphadenopathy
on CECT chest & abdomen. Treatment for VL was reinstituted
with addition of steroids during the course
of stay i/v/o HLH syndrome. Patient responded with regression of hepatosplenomegaly and ascites over three
months and discharged. Subsequently patient developed
recurrence of ascites with radio-imaging suggestive of PH
with UGIE showing large esophageal varices. Patient had
massive upper GI bleed during second hospitalization and
succumbed to her illness.
Discussion: At times VL can be difficult to manage
due to close mimickers like TB and rare complications
like HLH. In this case secondary HLH was diagnosed (5/8
positive criteria) and PH was diagnosed on basis of clinical
findings & radio-imaging.
Conclusion: Both TB and VL masquerade each other
to the extent making the diagnosis and management in
jeopardy. In our case, although the patient was managed
as per guidelines, misdiagnosis of disseminated TB delayed
the treatment and could have contributed to subsequent
serious complications and thus grave outcome.
A Rare Presentation of H1N1 with Pleural Effusion
Parapneumonic effusion has been reported to develop
either in typical bacterial infection or in viral pneumonia
with bacterial co-infection and to cause death. Swine-origin
influenza A (H1N1) virus infection can be accompanied
with pleural effusion; however, there are no reports about
the significance of pleural effusion in H1N1 pneumonia.
Introduction: Swine flu can present as a variety of
non specific presentation. Pleural effusion also can occur.
Case Report: A 19 years old female came with
complaints of fever, sore throat,cough and breathing
difficulty for seven days. No history of weight loss and
loss of weight. No specific past history.clinically her vitals
were stable except mild tachycardia and mild tachpnoea.
Systemic examination revealed decreased air entry in right
infrascapular region.Basic revealed Hb-11.2gm/do.TC-8000.
platelet-380000. Chest x ray revealed right pleural effusion.
Diagnostic tapping done revealed as Exudative Pleural
Effusion with predominant lymphocytes. Sputum for AFB
two samples were negative. Other causes of exudative
pleural effusion were ruled out. Throat swab for H1N1
were Positive. In CT chest -No ground glass opacities.she
were started on Oseltamivir. Her symptoms and general
condition improved.Repeat CXR showed decrease in pleural
effusion.She were followed up.
Discussion: This case report suggested that pleural
effusion in H1N1 pneumonia could develop without
bacterial co-infection and had mild clinical course.
Conclusion: The most common findings were groundglass
opacities and consolidations, or a combination of
both. Involvement was commonly bilateral with no axial or
craniocaudal predominance in the distribution. Although
the major tomographic findings in H1N1 infection are
nonspecific, it is important to recognize such findings
in order to include infection with the H1N1 virus in the
differential diagnosis of respiratory symptoms.
Diagnostic value and prognostic use of Presepsin vs Procalcitonin in Sepsis
Background: Sepsis is a medical problem beyond
belief despite the use of modern antibiotics and frequently
updated guidelines on resuscitation therapies. We studied
the role of Presepsin (CD-14 polypeptide), a new generation
inflammatory marker and Procalcitonin which has been for
some time been the inflammatory marker of choice in sepsis.
This is the first study of Presepsin as a sepsis biomarker
in Indian adults.
Methods: A prospective observational study was
conducted in 48 patients who were diagnosed to have
sepsis either on admission to the hospital or during their
stay in hospital according to the ACCP/SCCM guidelines
during the period from October 2015 to January 2017, after
fulfilling all inclusion and exclusion criteria. Efficacy of
both inflammatory markers were studied from blood drawn
from the patient at the same time, with the same prick.
Results: A total of 48 patients were included in this
study. The superiority of Presepsin over Procalcitonin over
was evident with Presepsin having a sensitivity of 46.2 and
Specificity of 100 and Procalcitonin having a sensitivity of
46.2 and specificity of 31.8. The P value of the Presepsin
results was significant at <0.001. Along with it, Presepsin
also proved to be a very reliable marker for 28 day mortality
with all 12 patients in the Presepsin positive group expiring
(P value: <0.001). An ROC curve was also plotted to try
and define an optimal normal value for Presepsin in an Indian population and the value calculated was 93.71 with
a sensitivity of 65.4 and a specificity of 68.2.
Conclusion: This study shows the superiority
of Presepsin over Procalcitonin as it has much better
specificity and a similar sensitivity than Procalcitonin and
is a better indicator of 28 day mortality. The new cut off
that we have postulated here for Presepsin improves the
efficiency of the inflammatory marker by increasing its
sensitivity at the cost of decreasing its specificity slightly.
The limitation of the study is with respect to the sample
size which is on the smaller side.
Hemolytic Anemia in Viral Fever: Three Uncommon Scenarios in Two Common Infections
Introduct ion: Dengue fever complicated by
autoimmune hemolytic anemia (AIHA), thrombotic
thrombocytopenia purpura (TTP) and hemolytic uremic
syndrome (HUS) were described in the literature. There
are no case reports discussing G6PD deficiency and diffuse
intravascular coagulation (DIC) induced microangiopathic
hemolytic anemia (MAHA) complicating dengue. A few
cases of varicella complicated by AIHA were reported
earlier. But all of them belonged to paediatric age group
except one. We describe the second case of varicella
complicated by AIHA in an adult.
Case report: Case 1: An adolescent male without
any previous history of hematological disorders suffered
G6PD deficiency precipitated by dengue fever. Hemolysis
was transient and subsided spontaneously after five days.
Case 2: A middle-aged woman presented with dengue
fever complicated by acute liver failure. In the course, she
developed MAHA secondary to DIC. She improved with
fresh frozen plasma. Case 3: A young male came with
fever of two weeks and jaundice of ten days duration. On
examination, he had vesicles characteristic of varicella.
Peripheral smear showed hemolysis. Direct and indirect
agglutination tests were positive for warm antibodies. He
recovered with acyclovir, corticosteroids.
Discussion: Viral fevers are rarely complicated
by hemolytic anemia of different mechanisms. G6PD
deficiency, DIC, TTP, HUS and immune-mediated are
mechanisms involved in hemolytic anemia precipitated
by viral infections. AIHA and hemolysis related to G6PD
deficiency are benign. DIC-induced MAHA and thrombotic
microangiopathies are severe and often patients take time
for recovery. No specific therapy is required for G6PD
deficiency. Removal of inciting factor is the mainstay.
Treatment of DIC – induced MAHA includes hydration,
fresh frozen plasma and treating the causative factor. AIHA
is treated with corticosteroids.
Conclusion: In this era of increasing viral outbreaks,
various unusual complications are encountered commonly.
We highlight one of the under reported complications
of viral fever that requires a systematic approach for
diagnosis.
Dengue Fever with Complicated MRSA Infection – A Case Series Report
Introduction: Bacteraemia in the course of dengue
infection is rarely described in medical literature. This is a
retrospective chart review of 3 patients developing MRSA
infection within a month following dengue fever.
Case 1: 37 year old diabetic female, referred with, fever
and sudden onset development of paraparesis and right
crural monoparesis. She was hospitalised with dengue
fever 2 weeks prior to the episode and had developed
thrombophlebitis and bacterial meningitis during IP stay.
Imaging showed bilateral psoas abscess with left gluteal
abscess; pus aspirated from gluteal abscess grew MRSA.
She improved with 4 weeks of IV Vancomycin. Subsequently
developed persistent back ache & raised ESR. Repeat
imaging revealed sacral osteomyelitis, which improved
with IV Teicoplanin and oral Minocycline.
Case 2: 50 year old pre diabetic female, developed
dengue fever without warning signs along with
thrombophlebitis and subsequent abscess which was
surgically drained. 4 weeks later, had severe cervical
spine tenderness and diagnosed with spondylodiscitis
C5-C6. It was drained, pus grew MRSA. Discectomy and
fusion was done. Her symptoms subsided with 6 weeks
of IV Vancomycin.
Case 3: 37 year old female, presented with Broncho
pneumonia, sepsis, thrombophlebitis and abscess dorsum of Right hand. She had dengue fever 3 weeks back.
Drained pus from abscess grew Acinetobacter, started on
IV Meropenem and Colistin. CT chest showed thin walled
cavities, secondary to septic emboli.
Discussion: Dengue and MRSA, two very common
conditions by itself, leading to high morbidity, but,
evidence regarding occurrence of bacterial superinfection
/ coinfection in dengue is limited.
Factors like reduction of phagocytic & migratory
capacity of macrophages, impaired interferon signalling
pathway, neutropenia, increased capillary leakage, all
contribute to facilitation of superinfections in dengue. In
case of prolonged fever not responding to routine treatment
/ unusual manifestations of dengue fever, look into other
causes for preventing mortality.
Conclusion: Post Dengue fever Staphylococcal
infections run a complicated and protracted course & thus
reiterates the importance of precaution against healthcare
associated infections.
Dengue Fever and a Scoring for Prognostication – A Cross Sectional Study
Introduction & Objectives: Dengue can potentially
develop into a lethal stage, severe dengue.Though there is
no specific therapy for dengue/severe dengue (case fatality
of 2.5%), early detection and proper medical care can lower
the fatality rate to below 1 %. Here we try assessing the
possibility of a scoring system, in an attempt to predict
patients at risk of capillary leaks such as pleural effusion
and/or ascites.
Materials and Methods: A cross sectional analysis
of data from patients admitted during November, 2017,
satisfying the inclusion criteria was done at Stanley Medical
College. The inclusion criteria included patients above 12
years of age, fever less than five days, serum NS1Ag or
IgM Dengue positive. The data regarding investigations
in the first five days of fever and imaging were recorded.
Validation of a ‘scoring system by Suwarto et al’ was done
and the possibility of AST-Platelet Ratio Index (APRI) as a
score for prognostication assessed.
Results: Of the 79 patients included, 17 had ascites and/
or pleural effusion. The Suwarto et al’s Dengue Scoring had
a sensitivity and specificity of 68% and 41% respectively in
this study. Thus, an alternative scoring using serum AST
levels and platelets in the form of APRI (AST Platelet Ratio
Index) was assessed. This has a sensitivity and specificity
of 75% and 60% respectively in predicting ascites and/or
pleural effusion.
Conclusions: APRI with relatively high sensitivity
and specificity is better in predicting the patients at risk
for ascites and/or pleural effusion even before the critical
phase of the illness. Thus, APRI has the potential for being
used as a screening tool during the febrile phase of Dengue,
though further studies may be warranted in this direction.
Clinicoetiological Profile of Acute Undifferentiated Febrile Illness with Multiorgan Failure and it’s Outcome in a Tertiary Care Center
Introduction: Acute undifferentiated fever is a common
cause of patients presenting to hospitals in India,between
months of June and September which is defined as fever
of two weeks or shorter in duration with no localizable or
organ-specific clinical features.
Objectives:
• To assess etiological and clinical profile of the patients
with multiorgan failure in acute undifferentiated
febrile illness
• To assess the treatment outcome among the study
subjects
Methodology: All patients more than 18 years of age
presenting with an Acute undifferentiated febrile illness
multi organ failure admitted as in-patients in JSS Hospital
were included into the study. These cases were validated
for above said inclusion and exclusion criteria.
Results: Out of 100 cases of in 65 cases diagnosis
was made of which 37 cases were diagnosed to have
Dengue fever and was the most common cause followed
by Leptospirosis in 13 patients, H1N1 in 10 patients
and Rickettsial fever in 4 cases.35 cases were remained
undiagnosed whose sera were screened for Hanta virus
which were negative. Average duration of stay was 6 days.
Most of these subjects belonged to younger age group of
18.Male subjects slightly outnumbered females. Among
these 100 patients, 48 patients recovered completely and
52 patients succumbed to the illness.
Conclusion: Acute undifferentiated fever is one of
the most challenging problems to the treating physician.
Among infection, Dengue fever was the commonest cause.
As the number of involved organs increased mortality and
morbidity in the form of need for life support, duration
of hospital stay were increased. we need advanced
investigations to find out the exact etiology of the same
in the future.
Clinical Profile and Outcome of Bilateral Pneumonia with Special Reference to H1N1 Pneumonia in a Tertiary Care Hospital
As the recent incidence of bilateral pneumonia has
been tremendously increasing, however clinical profile
and outcome in Bilateral pneumonia from varied etiology
remains under documented and requires comprehensive
study and there is a lack of scientific research about PSI
score and hyponatremia as the prognostic indicators for
outcome of the disease. H1N1 can present with flu like
symptoms/unilateral/bilateral pneumonia. Previously,
H1N1 pandemic 2009 and post pandemic 2014 has led
to a massive interest in H1N1 pneumonia which shows
seasonal variations. Now-a-days H1N1 incidence has
been decreasing due to lot of preventive measures taken.
But H1N1 causing bilateral pneumonia is a hazardous
disease threatening population which should need highly
effective measures.
Objectives:
1. To study the clinical,etiological and radiological
features of bilateral pneumonitis
2. To study the morbidity and mortality in patients with
bilateral pneumontis in relation to age,sex,clinical
condition and associated comorbidities.
3. To measure the serum sodium levels in patients with
bilateral pneumonitis and correlate it with severity of
pneumonitis
Materials & Methods: Observational Descriptive study
of 311 patients admitted in Department of Medicine and
Disaster wards, Gandhi hospital which is a nodal center for
H1N1 in Hyderabad; who were diagnosed with bilateral
pneumonia at admission during August 2017 to July 2018
and who fulfill the criteria were included in the study. All
the patients were subjected to routine investigations like
Complete blood count with ESR, Routine biochemistry
(RBS, RFT, LFT, Electrolyte), Sputum for Gram stain,
AFB, Sputum culture, Urine routine and microscopy, HIV,
Chest X ray, Ultrasonography of Chest and Abdomen,
and HbA1c. Also, other investigation as necessary such
as H1N1, Pneumopanel, Arterial blood gas analysis, and
Blood culture.
Results: Out of 311 patients,210 were males and 101
were females. 180 patients were of elderly age group >50
years;99 patients were of middle aged< 50 years and 32
patients were of young age < 25 years. 45% presenting
in PSI class-V are having more than 2 comorbidities
like COPD,renal,hepatic/cardiovascular comorbidities.
COPD and renal comorbidities are the most common
encountered ones.SOB is the most common manifestation
in elderly i.e seen in 88 patients(48%) followed by
cough and fever.In middle aged,fever and cough are
the most common ones seen in 61 patients(60%). Lung
pathology(30%),smoking(70%) and alcohol (65%) risk
factors are high in males while DM,Pulmonary TB,GERD
are equally prevalent in both males and females.30%
cases are of lobar pneumonia type mostly caused by
bacterial pathology (25%) and bronchopneumonia in
55% cases caused by bacterial(20%), H1N1(42%) and
unknown causes(40%) i.e mostly viral /hypersensitivity
which can’t be detected in our settings due to lack of
facilities in our hospital. Organisms isolated are klebsiella-
42,streptococcus-24, staphylococcus-25,pseudomonas-
11,AFB-17,aspergillus-1 and H1N1-99 cases.Complications
like Empyema in 5 cases, Pleural effusion in 100(30%), ARDS
in 56(15%), Respiratory failure in 210(75%), septic shock in
51(14%), AKI in 112(31%) are seen. Severe hyponatremia is
seen in 32(10%)cases who had shown 100% mortality rate.
The patients requiring NIV/MV are 60% of elderly,100%
of pseudomonas affected,82% of H1N1 affected, 100% of
PSI class-V and patients with more than 2 comorbidities.
Conclusion: H1N1 commonly associated with
secondary bacterial infections; mostly occurring in
immunocompromised patients; 82% of H1N1 patients
requiring NIV/MV itself shows the dangerosity of the
disease when compared to other causes of bilateral pneumonia.
PORT – PSI scoring and Classification of cases, Early
hospitalization of PSI Class IV and V, early antibiotic and
antiviral administration within 4-6 hours, Empiric antibiotic
treatment as per guidelines (IDSA / ATS), smoking
cessation, PaO2 assessment,blood culture and throat swab
for H1N1 collection in the first 24 h, and Pneumococcal
& Influenza vaccination can effectively treat and prevent
worse outcome of bilateral pneumonia.
A rare case of Tubercular arthritis of first metacarpophalyngeal joint presenting as Poncets disease
Tuberculosis is a common public health problem in
developing countries. Osteoarticular TB is rare consisting
of 1-4.3% of cases. Tuberculous spondylitis alone accounts
for 50% of cases. Extraspinal involvement is mono-articular
and often involves large joints (Knee and hip). Small joint
involvement is exceptional. This probably is the first
case reported of an erosive TB arthritis involving first
metacarpophalyngeal joint and later presented to be a
Poncets disease.
Case Report: Here we report a 38 year old male patient,
from Chennai, presented with persisting fever and the left
thumb base swelling increasing in size for past one year.
Along with, he had multiple joint pains for 3 weeks then
with major involvement of right knee, left big toe, multiple
MCP joints in both hands. On examination a firm, nontender,
first MCP joint swelling completely subluxated
with joint crepitus. There were also multiple, asymmetric,
tender joint swellings involving both large and small joints.
Roentogram showed complete subluxation of the first MCP
joint with bony erosions. MRI showed features of nonerosive
arthritis in multiple joints except for first MCP,
which was erosive. The workup for rheumatoid, crystal
induced arthritis and connective tissue disorders came
back negative. Montoux was negative and an ESR of 42.
GeneXpert of synovium from first MCP joint revealed low
positivity for Mycobacteria. FNaC of synovium revealed
no evidence of granulomatous lesions. Joint aspiration
from other joints showed no evidence of tuberculosis.
Patient was started on combination ATT under DOTS and
improved clinically.
Discussion: Since 1887, when Poncets described
symmetric inflammatory polyarthritis in patients with
tuberculosis, there has not been sufficient review in
literature, which led clinicians to question the existence
of such a disease. Since the presentation also mimics
connective tissue disorders, this condition is greatly
underdiagnosed. In our case, primary erosive osteoarticular
tuberculosis in first MCP joint, led to development of nonerosive
asymmetric inflammatory polyarthritis, which
could be explained as Poncets disease. The time frame for
presentation of polyarthritis was 3 weeks as against to the
left thumb base arthritis which was present for one year.
There was a similar case reported of a Poncets disease in
patient with tuberculous arthritis of sternoclavicular joint.
There were several diagnostic criteria developed such as
the Sharma and Pinto diagnostic criteria. Our case fit in
with two essential criteria 1) Inflammatory, non erosive
and non deforming arthritis 2) Exclusion of other causes of
inflammatory arthritis; and two major criteria 1) complete
response to antitubercular therapy 2) Concurrent diagnosis
of extra-articular tuberculosis (except for the erosive
first MCP joint, all the other joints were non-erosive and
harboured no Mycobacterium).
Conclusion: This case was presented for its rarity (as
for as our knowledge, this is the first case of a tuberculous
arthritis involving first MCP joint) and to emphasise on
the need for good clinical suspicion for Poncets disease
in patients presenting with inflammatory polyarthritis,
especially with foci of TB.
Developing a prognostic scoring system for dengue fever
Background & Objectives: Due to the recent upsurge
of dengue cases in our clinical setting, the need for a
prognostic scoring system for dengue fever was felt. The
objective of our study was to develop a scoring system for
predicting prognosis in patients with dengue fever at their
time of presentation to the health care system.
Methods: It was an observational study done in a
tertiary health centre of northern Kerala from August 2017
to July 2018. 570 patients who satisfied our inclusion criteria were studied. At the time of presentation the patients
various clinical and biochemical parameters were assessed.
The various parameters obtained at the time of presentation
were than compared with their eventual outcome. Chisquare
test was applied to find significant variables with
respect to outcome, esp. mortality. The scoring system
was developed using a binary logistic regression of the
significant variables using forward LR method. Beta
coefficient for each component was calculated and rounded
off to the nearest integer to allot weightage. A total score
of 12 was obtained for all components. An ROC analysis
was constructed based on the scoring system applied to our
study population. The cut-off was based on Youden Index.
Results & Discussion: In our study we found
Respiratory rate, Blood pressure, ARDS, Myocarditis
and Bleeding manifestation as significant parameters in
predicting mortality in dengue fever patients. Of these 5
components, ARDS was given a score of 4 and rest all had
a score of 2, giving a maximum score of 12. The ROC curve
showed a significant AUC of. 967 with p-value of less than
0.01. Based on Youden index, a cut off score of ≥ 3 was taken
with 100% sensitivity and 89.9% specificity, PPV of 19.7%
and NPV of 100%.
Conclusions: A prognostic scoring system for dengue
fever consists of 5 components – RR, BP, ARDS, Myocarditis
and Bleeding manifestation. Platelet count was not found
to be significant suggesting that treating patients based on
platelet count is unscientific.
Scrub Typhus – An Expanding Clinical Syndrome: Experience from the Sub-Himalayan Region
Introduction and Objective: Scrub typhus is a
Rickettesial zoonosis caused by Orienta tstsugamushi,
which is prevalent in the Asia-Pacific region. The study
sought to describe the clinical manifestations, atypical
presentations, complications, laboratory profile and
clinical outcomes in patients of Scrub typhus in the Sub-
Himalayan region.
Methodology: This is a retrospective observational
study of the clinical profile of all cases of Scrub Typhus,
tested positive at a tertiary care centre in the Sub-Himalayan
region, from July 2017 to November 2018(18 months).
Results: A total of 79 patients were included in the
study with a mean age of 44.2 years. Most of the cases
presented with an acute febrile illness. Most common
among non-specific symptoms were myalgia(39.2 %),
vomiting(24.05%) and headache(20.25%). Other common
symptoms were breathlessness(24%) and cough(21.5%).
ARDS was seen in 18 cases(22.7%), features of myocarditis
in 6(7.5%), polyserositis in 6(7.5%) and encephalopathy in
13(16.4%) cases. Only 2 cases showed a classical eschar.
Most cases showed mild transaminitis(63.2%) and 27.8%
showed acute kidney injury. Thrombocytopenia was
noted in 48.1% and leucopenia was noted in 11.3% cases.
Mortality occurred in a single case with late presentation,
due to ARDS, secondary bacterial sepsis and multi-organ
dysfunction. All other cases showed satisfactory clinical
response to Doxycycline or Azithromycin.
Conclusion: The clinical presentation of Scrub typhus
observed in the Sub-Himalayan region is highly variable
and often non-specific, with a wide spectrum of atypical
features, and shows good response to currently available
therapy. Scrub typhus should be an important differential
diagnosis in undifferentiated febrile illness and non-specific
syndromes in this region.
Study of Association between Severity of Dengue Fever and Hypocalcemia
Introduction and Objectives: Dengue is currently
regarded globally as the most important mosquito-borne
viral disease, contributing to significant morbidity and
mortality across the globe. Association between low
serum calcium levels and its positive impact on treatment
outcomes has been studied by multiple researchers. The
current study was conducted in this background, with an
objective to study the association between the severity of
dengue infection and serum calcium levels.
Materials and Methods: The current study was a cross
sectional study,conducted in the department of general
medicine, DR. Prabhakar Kore hospital, KLE University,
Belgaum. A total 100 dengue cases receiving treatment from the study setting between January 2017 to December
2017, selected by universal sampling were included in the
final analysis. The study included all the proved cases of
dengue fever admitted in the study setting.Confirmation
of diagnosis was done with one of the following laboratory
tests: IgM,,IgG antibody or dengue NS1 Antigen detection.
Hypocalcaemia was defined as the presence of serum
calcium < 8.5 mg/dl.
Results: A total of 100 subjects were included in the
final analysis. The mean age of the study population was
26.64 ± 10.65..Among the study population, 74 (74%)
participants were males, and the remaining 26 (26%)
were females.Among the Ns1 antigen was positive in
28%, 68% were IgM +, 71% of patients were IgG+ and 50
(50%) participants had both Dengue IgM + IgG +. Among
the study population, 72 participants had Dengue fever,
Dengue Hemorrhagic fever and Dengue shock syndrome
were 23(23%) and 5(5%).
A higher proportion of subjects in dengue shock
syndrome and DHF had lower levels of serum calcium as
compared to dengue fever.
Conclusions: The current study has documented a
strong association between the dengue severity and lower
serum calcium levels.
Assay of Proinflammatory Cytokines (IL-6, IFN Γ, TNF Α) and its Correlation with Disease Severity in Dengue Fever
Objective : To determine the serum levels of
proinflammatory cytokines in patients with documented
dengue infection and to determine correlation between
levels of cytokines and disease severity, platelet counts
and SGOT.
Methods: Blood samples were collected from 60
patients; 49 patients of dengue fever and 11 of severe
dengue from June - July 2016 at Pushpagiri Institute of
Medical Science and Research Centre. All the patients
were confirmed positive for dengue infection by serology.
Ten healthy individuals and ten other febrile illness were
included as controls. Serum levels of IL 6, IFN γ and TNF
α were determined by ELISA. Standard statistical methods
were used.
Results: Total 60 subjects were included in current
study. The mean age was found to be 43, 24 were males
and 36 were females. 49 patients had dengue fever and 11
patients had severe dengue. 27 cases belonged to primary
infection and 33 cases belonged to secondary infection. The
level of interleukin 6 was found to be elevated in the severe
form of dengue(133.46 ± 56.66), level of TNF α elevated in
the severe form of dengue(133.15 ± 109.32). All the three
cytokines: IL 6 TNF α, IFN γ showed an increased level in
secondary infection when compared to primary infection.
TNF α correlated with the degree of thrombocytopenia. IL
6 correlated with the level of SGOT.
Conclusion: IL 6 and TNF α correlated with disease
severity suggesting that these cytokines can be used as a
marker to predict the severity of the disease. Thus necessary
treatments and precautions can be taken in advance.TNF
α correlated with the degree of thrombocytopenia and IL
6 with the level of SGOT.
Lemierre’s Syndrome : A Rare Case of Sepsis
Introduction: Lemierre’s syndrome is a rare
anaerobic oropharyngeal infection predominantly
caused by Fusobacterium necrophorum, and characterised
by pharyngitis, sepsis and internal jugular vein(IJV)
thrombosis.
Report of case: A middle aged male was referred to our
ER for high grade fever with rigor, sore throat and myalgia,
for which he had been treated at multiple local clinics. Upon
admission he was febrile,tachypnic and tachycardic. His
throat was congested. Total WBC count was 16100/mm^3.
Other investigations were normal at that time. He was put
on IV Ceftriaxone and Amikacin empirically. Later he was
shifted on IV Ofloxacin and Linezolid after C/S of throat
swab. Meanwhile the patient started complaining of neck
pain. On examination a palpable strand like structure was
noted beside left carotid pulsation. Neck sonogram revealed
a non-compressible thrombus in IJV. Therefore we modified
the treatment to IV clindamycin which worked as a panacea
& he became afebrile from next day only. LMWH was added
for IJV thrombosis.
Discussion: Lemierre’s syndrome is caused by
oropharyngeal infection like pharyngitis & tonsillar/
peritonsillar abscess f/b thrombophlebitis of IJV which
leads to sepsis and distant metastatic abscess. The causative
agent is usually Fusobacterium necrophorum, other isolates
are Peptposteptococcus, Bacteroides, Propionibacterium
and Actinomyces species. In our case Staphylococcus
aureus was grown in throat culture which was not helpful
in management. As there is no facility to grow anaerobic
organism in our hospital therefore we considered anaerobic
infection as a causative agent after good response to
Clindamycin. Ultrasonography is a noninvasive and readily
available imaging tool, which was mainstay of diagnosis
in our case.
Conclusion: Despite being an uncommon disease, it is
important to diagnose this syndrome accurately because
of high mortality rate(>15%). Hence for management
of Lemierre’s syndrome a high level of suspicion, keen
observation and imaging along with prompt institution of
suitable antibiotics.
Tuberculoma of Brain- A Case Series
Introduction: The central nervous system (CNS)
tuberculosis has high mortality and morbidity. With the
HIV epidemic there is an increase in the prevalence, multidrug
resistance and disseminated forms of tuberculosis.
Intracranial tuberculomas can occur at any age usually
affecting adolescents and young adults in developing
countries.
We report a series of three cases of tuberculoma of
the brain to describe the varied clinical presentation,
radiological features and the outcome of treatment with
antitubercular drugs.
Case Report:
Case 1: A 20 year old female with throbbing headache
and vomiting for the past 2 months. Fundus showed early
stage papilloedema No other focal neurological deficits
present. Chest x-ray normal. MRI brain showed multiple
Conglomerate ring enhancement. She was started on
empirical ATT and showed symptomatic improvement.
Case 2: A 35 yr old female, chronic steroid abuser
presented with throbbing headache for 1month, fever for
4 days, altered sensorium for 1 day. On examination she
had focal neurological deficit. Multiple ecchymotic patches
over body. Her MRI revealed multiple granulomas. CSF
CBNAAT Positive. Patient started on ATT. But expired
on day 2.
Case 3:A 56 year old male newly detected PLWHA
presented with altered sensorium and seizures, for1 day.
MRI revealed multiple tuberculomas, started on ATT.
Showed clinical improvement.
Discussion: In contrast to the cerebral TB abscesses,
which require surgical and pharmacological treatment
tuberculomas respond well with only pharmacological
treatment. A bacteriological diagnosis of the lesions
requires invasive techniques and is rarely justified unless
empiric therapy fail. The conservative treatment of
tuberculomas usually determines a good outcome.
Conclusion: A high index of suspicion is necessary
especially in these three situations adolescent age
group, steroid users, HIV patients and other immunocompromised
individuals to initiate early treatment and
reduce mortality.
Clinical Score for Risk Stratification of Febrile Thrombocytopenia
Introduction: Febrile thrombocytopenia is frequently
encountered by physicians especially during monsoon.
There is no guidelines and precise cut-off level of platelets
at which transfusion is indicated. Unwarranted blood
transfusions may have adverse effects on patients whilst
also overwhelming blood banks.
Kshirsagar et al have developed a risk score for febrile
thrombocytopenia to aid in determining therapeutic
intervention.
Objectives: To validate clinical scoring system for
management of febrile thrombocytopenia.
Materials and Methods: Observational study where
patients are grouped into low, moderate and high risk
based on pulse, temperature, respiratory rate, BP, platelet
count, CNS, Respiratory, haematological, hepatic and renal complications
Inclusion criteria:
• Age >18 years.
• History of fever > 99.0oF.
• Platelet count < 1,50,000/mm3.
• Exclusion criteria:
Patients on drugs causing thrombocytopenia like
chemotherapy, immune suppressants and anti-platelets.
Previously diagnosed patients with chronic
thrombocytopenia like ITP.
Results: 465 patients were admitted with febrile
thrombocytopenia between June-December 2017 (monsoon
period).199 patients (43%) were in low risk group, 240
(52%) in moderate and 26 (5%) in high risk group based
on the clinical score.9 patients died in our study and all
of them were in high risk group which shows significant
association between high risk group and mortality (P value
<0.01). Patients who died in our study had a initial platelet
presentation between 2,000 to 1,05,000/cumm and Our study
showed that there is no significant relationship between
the initial platelet presentation and outcome of the patient.
135 patients were transfused platelets and atleast 16% of
platelet transfusion could have been avoided by following
the risk score in our study.
Conclusion: The total risk score can predict severity of
illness, need for transfusion and outcome. Platelet count is
not the only indicator for transfusion. When we use total
risk score instead of platelet count for classifying patients
who need transfusions, number of patients who fall in
severe risk category needing immediate transfusion reduces
and irrational use of platelets can be avoided.
Study of Platelet Indices in Patients of Dengue and its Impact on Morbidty and Mortality
Introduction and objectives: Dengue most prevalent
and endemic Arboviral diseases. Recently Platelet indices
(PIS) like Plateletcrit (PCT), Mean platelet volume (MPV),
Platelet distribution width (PDW), Platelet large cell ratio)
PLCR) may have diagnostic and prognostic significance
in dengue fever. Aims and objective was to study the
association of platelet indices in dengue infections and its
role in severity outcome.
Methods: It was prospective observational (cross
sectional) study conducted in tertiary hospital. MPV, PDW,
PCT, PLCR and Platelet (PLT) parameters of clinically
and laboratory confirmed dengue cases compared with
100 normal and serological negative controls. Study was
statistically analyzed and the values were expressed
as mean (SD) and a P value <0.005 was considered as
statistically significant.
Results: PLT and PCT was statistically low In case of
dengue (p<0.000).PDW and PLCR was significantly high in
dengue cases(p<0.002 and 0.000 respectively) and MPV not
statistically significant (p<0.778).
Conclusion: Low PLT,PCT and high PDW may be
used as indicators of dengue infectins.MPV may be used
as indicator of severity. Low MPV is a poor prognostic and
high MPV is a good prognostic indicator.
A Study on Acute Undifferentiated Fever – Clinical Profile & Response to Treatment
Introduction and objective: AUF is defined as
temperature of ≥38®C with history of febrile illness of 2-14
days duration and no localisable cause.
The objective of this study was to determine the clinical
profile, course, aetiology and response to treatment in a
tertiary care centre.
Methods and Material: During August 2017-Jan 2018,
patient aged >12 years with febrile illness of 2-14 days were
included in the study. Study population were evaluated
with detailed history, baseline investigations (CBC, serum
biochemistry, urine routine) and relevant investigations
(malarial films, serological test, blood culture) to identify
the specific aetiology were done.
Results: Total number of patients studied were 1012
(56.4% - males, 43.5% - females). Mean age was 34. Among
1012 patients (64% - rural area,36%-urban area). Average
duration of fever ranged from 4 to 6 days. Among 1012
patients with AUF 35% were undiagnosed and remaining
population had malaria positivity in 23%, dengue in 18%,leptospirosis in 6%, enteric fever in 10%, scrub typhus in
4% and H1N1 in 4%. Among the malarial positivity 80%
were caused by P.vivax and 20% were due to P.falciparum.
Among 1012, 64% of patients were treated symptomatically,
18% with anti malarials and 10% with antibiotics.
Conclusion: High prevalence of malaria and dengue
were found in this study. Overlap infections were not due to
coinfection alone but also due to subclinical infections, cross
reactivity, undefined and untreated previous infections.
High occurrence of AUF was due to limitation of available
diagnostics test. Around 50% of patients were treated
symptomatically and outcomes were good. Detailed history
taking, clinical examination and relevant investigations
will avoid irrational use of antibiotics and antimalarials.
Significance of APTT as Early Predictor of Bleeding In Comparision to Thrombocytopenia in Dengue Virus Infection
Introduction: Dengue is a systemic viral infection
transmitted by mosquitoes such as Aedes aegypti or
Aedes albopictus. Dengue Fever (DF) is characterized
by fever, headache, muscle or joint pain, and rash. The
spectrum of dengue virus infection spreads from an
undifferentiated fever and dengue fever (DF) to dengue
haemorrhagic fever (DHF) with shock. Factors responsible
for bleeding manifestations in dengue are vasculopathy,
thrombocytopenia, coagulopathy, and disseminated
intravascular coagulation (DIC). Ccoagulopathy results
in derangement of activated partial thromboplastin time
(APTT) which is an indicator of impending bleeding risk.
Materials and methods: Objectives: (1) To measure
APTT levels in dengue virus infection. (2) To identify the
role of APTT in comparison with thrombocytopenia as an
indicator of bleeding manifestation to assess the real need
of platelet transfusions.
Design: A prospective study was conducted from
june to December in 2017 in R L Jalappa Hospital. Patients
aged above 18 years with febrile thrombocytopenia who
are positive for dengue virus serology(NS1Ag and/ or
IgM) were included in the study. Serial daily monitoring
of platelet count and analysis of APTT levels were done.
APTT was considered abnormal if it was more than 33.8s.
Patients were followed up for evidence of leaking and
bleeding manifestations.
Results: Out of 170 patients 28.1% patients had
bleeding manifestations. Bleeding signs were seen on
clinical examination in 52.37% of patients. capillary leak
was found in the form of Pleural effusion in 35.3%, Ascites
in 41.2% and Periorbital edema in 31.2% of patients.
Elevated APTT levels were seen in 110(64.7%) patients.
Among patients with abnormal APTT platelet transfusion
was done in 78.9% of patients, and among those with
normal APTT levels platelet transfusion was done in 21.1%
of patients.
Conclusion: Our study showed significant correlation
between bleeding manifestations and prolonged APTT
levels as well as thrombocytopenia with abnormal APTT
levels. Study concluded that 21.1% of platelet transfusions
could have been prevented considering prolonged APTT
as a predictor of bleeding manifestation, thus saving
the resources and reactions due to platelet concentrate
transfusion.
Study of Clinical Profile in Patients with H1N1 Swine Flu in Ahmedabad
Introduction & Objectives: H1N1 flu is a catastrophic
viral infection which affects the young & middle
aged population which otherwise is healthy causing
fatal A.R.D.S. This study was conducted to assess the
demographic, clinical & radiological profile and outcomes
in patients with H1N1 Swine Flu presenting at a tertiary
care hospital of Ahmedabad.
Materials & Methods: A retrospective study was
carried out during 2017-2018 period on 50 confirmed
cases of H1N1 Flu. Cases were confirmed by their positive
respiratory samples assessed by Reverse Transcriptase
PCR test.
Results: Present study included 19 (38%) males and 31
(62%) females (including 3 pregnant) with 28 (56%) of them
between the age of 25 – 50 years and 46 (92%) belonging to
urban society. The most frequent presenting complain was
fever (92%) followed by cough (82%), dyspnoea (52%), sore throat (40%) & rhinitis (30%) in decreasing order. Hypoxia
on presentation (SPO2 <92%) was seen with 20% subjects
and a positive Chest X Ray finding was present in 38%
subjects. 46% patients of H1N1 Flu had associated other
medical comorbidities. Mortality was noted in 6% cases
with 33% of pregnant females and 18% of those above the
age of 50 years dying.
Conclusions: The incidence of H1N1 flu is high in
female gender, middle age group, urban residents and
subjects having other medical illnesses. Clinical Outcome
was negatively influenced by the pregnant status, presence
of hypoxia on presentation, positive chest X Ray findings,
old age & presence of other medical co morbidities. Early
detection of swine flu through meticulous screening in
the community with a high index of suspicion followed
by prompt and adequate treatment can prevent disease
transmission and mortality in various urban settings
Bilateral Adrenal Histoplasmosis and Pulmonarytuberculosis in Immunocompetent Person
Introduction: Histoplasmosis is a fungal infection
caused by dimorphic fungi, nonendemic in India.
Disseminated histoplasmosis may involve almost all
systems in immunocompramised individuals whereas
isolated adrenal involvement is rare.Tuberculosis is
most prevalent in india.Coinfection of tubercular and
histoplamosis in immunocompetent individual is a rare
presentation.
Case Report: A 60 year male known diabetic well
controlled presented with high grade fever for 2 months,loss
of weight approximately 6 kgs over 2 months associated with
loss of appetite.He was presented with similar complaints
1 year back and diagnosed as adrenal histoplasmosis
with adrenal insufficiency,treated with intravenous
amphotericin for 8 weeks,followed oral itraconazole.
Vital parameters were normal and systemic examination
revealed borderline splenomegaly.Investigations revealed
normal complete blood picture,renal and liver function
tests with elevated ESR.Blood and urine cultures were
sterile.HbA1C was 4.6%.CECT chest and abdomen
revealed patchy consolidation of right upper lobe of
lung,mediastinal lymphadenopathy and with bilateral
enlarged adrenal glands.HIV and other viral markers
negative and CD4 count was 862 cell/ul.Bronchoscopy
was normal.BAL examination revealed positive MTB
gene expert.EUS guided FNAC was done from from left
adrenal mass and purulent material was aspirated,which
on examination suggestive of histoplasmosis.Finally he
was diagnosed as bilateral adrenal histoplasmosis with
adrenal insufficiency and pulmonary tuberculosis.Patient
was started on amphotericin,ATT.Patient had improved
and better on follow up.
Discussion: Coinfection of tuberculosis and
histoplasmosis occurs in 8-15% in HIV infected individuals.
In immunocompetent individuals,generally we conclude
as single disease explaining as disseminated but it
requires high suspicion and extensive workup to diagnose
coinfection as done in our patient.In these patients
treatment should be monitored in view of drug interactions.
Conclusion: Probably this is the first case reporting
coinfection of histoplasmosis and tuberculosis in
immunocompetent individual.
Frequency and Pattern of Neurological Involvement in Chikungunya Patients
Introduction: Chikungunya virus is an insect borne
virus transmitted by aedes aegypti mosquito.Traditionally
Chikungunya is known to present with fever,myalgia and
joint pains but it was first reported to affect the nervous
system in the 1960s
Objective: To study the frequency and pattern of
neurological involvement in patients with confirmed
chikungunya admitted to a tertiary care hospital in North
India.
Methodology: The study was a retrospective and
prospective observational study.Patients admitted with
confirmed chikungunya were evaluated clinically &
investigations were noted to identify the neurological
involvement in the prospective arm (January 2017-August
2018). In the retrospective arm the medical records of confirmed chikungunya patients (January 2016-December
2016) were perused to look for symptoms, signs and
investigations suggestive of neurological involvement.
Patients with preexisting neurological issues,obvious
metabolic or septic causes for neurological involvement
were excluded from study.
Results: Total of 309 patients were included in the
study.Out of these,11(3.56%) patients were found to have
neurological involvement. Of these 11 patients, 45.45%
had encephalopathy, 18.18% had meningitis, 18.18% had
meningoencephalitis, 11.11% had meningoencephalitis with
peripheral neuropathy and 11.11% had meningoencephalitis
with seizures. Among the patients with neurological
involvement the most common presentations were altered
sensorium (100%), headache (81.81%), neck rigidity
(54.54%), vomiting(45.45%) followed by involuntary
movements and speech abnormalities (18.18% of each).
Chikungunya RTPCR in CSF was positive in 36.36% among
the patients with neurological involvement.Mortality was
significantly higher(45.50%) in patients with neurological
involvement when compared to patients without the
same(5.70%).
Conclusion: The recent epidemic of chikungunya
virus infection was associated with various neurological
complications,suggesting the neuropathic nature of the
virus. Neurological involvement of chikungunya was
identified to be a bad prognostic factor with significantly
higher mortality.
Atypical Presentation of Kala Azar
Leishmaniasis is a major public health problem
in various part of world; it has also emerged in new
geographic areas and host populations. Visceral infection
can remain subclinical or become symptomatic, with an
acute, subacute or chronic course. Kala-azar, or visceral
leishmaniasis (VL), presents as fever, pancytopenia and
hypergammaglobulinaemia. The presence of splenomegaly
is characteristic of VL. However atypical presentations may
occur, although rare.
Hereby presenting a case of kalaazar in a 19 year old
female non resident of endemic area who presented as a
case of Meningitis.
Aspergillus Fumigatus Meningitis in an Immunocompetent Young Woman: A Case Report
Introduction: Aspergillus meningitis is a rare
clinical entity that is more frequently observed among
immunocompetent patients. Here we present the case of
a 28 year old immunocompetent lady with Aspergillus
fumigatus meningitis following spinal anaesthesia for
caesarean section.
Case Report: A 28 year old lady, post Caesarean section
2 months ago, was referred to our OPD with complaints of
fever and headache which started 2 weeks following the
surgery. Her blood and urine cultures were no growth. CSF
showed lymphocytic predominance with elevated proteins,
normal sugars, with significant RBCs. CSF culture was
negative. MR Brain+ Spine, showed a left lumbar nerve
root lesion with hydrocephalus. Based on this, empirical
ATT with Dexamethasone was started. As her symptoms
persisted, she was taken up for a theco-peritoneal shunt
and a biopsy with tissue culture from the left lumbar root
lesion, which showed septate fungus, later confirmed on
fungal culture to be Aspergillus fumigates. She was started
on high dose Voriconazole, dexomethasone was tapered
and ATT stopped. She developed hypotension and hence,
an Ommaya reservoir was placed and she was initiated
on Intraventricular Amphoterecin-B for a total of 14 days,
along with Voriconazole. However, she did not respond to
2 high dose antifungals and she succumbed 2 weeks later.
Discussion: A diagnosis of Aspergillus meningitis
during life was obtained only in 55.9% of patients although
with a much higher frequency among immunocompetent
patients (69.2%) as opposed to immunocompromised
individuals (39%). In our patient, the organism was grown
from a surgical tissue sample and even after diagnosis,
she did not respond to Voriconazole and intra-ventricular
Amphoterecin B.
Conclusion: We wish to highlight the need for high
index of suspicion for Fungal meningitis in patients
presenting with similar symptoms after procedures
involving invasion into the CSF compartment, and the need for strict aseptic measures.
A study of Isoniazid prophylaxis treatment in PLHIV on HAART
Introduction: Tuberculosis (TB) and Human
Immunodeficiency Virus (HIV) are the two well known
infections to cause severe morbidity and high mortality.
TB, the most common cause of death among HIV-infected
persons in the developing world. Antiretroviral therapy
(ART) reduces the risk of TB to a large extent, nevertheless
TB remains the most important cause of mortality and
morbidity in patients on ART.
There were many side effects noted and few patients
had to be discontinued Isoniazid prophylaxis therapy (IPT)
due to non- tolerability. The main side effects noted were
nausea, vomiting, drug rashes, hepatitis, psychosis and
peripheral neuropathy.
Objectives: To study the various side effects of
Isoniazid prophylaxis in people living with HIV (PLHIV)
on HAART and its association with CD4 counts.
Materials & Methods: This was a retrospective patient
records review of patients who were on HAART and
received IPT. IEC clearance was obtained. The patients with
deranged liver function tests(LFT), documented peripheral
neuropathy and advanced liver disease before initiation of
IPT were excluded. The following data was extracted from
patient records and analysed : demographic data, SGPT,
CD4 count, and details of side effects of isoniazid.
Results: We found that, among the 393 patients who
received IPT, 6 patients (1.5%) developed hepatitis (defined
as a 3 times elevation of AST). HBsAg positivity and
ethanol use did not have a statistically significant relation
with hepatitis in our study. The duration of HIV, the CD4
at diagnosis and the CD4 before IPT initiation did not
have a statistically significant relation with IPT. IPT was
discontinued for these six patients. The other side effects
of IPT were not noted in our subset of patients.
Conclusion: In comparison to other studies, our study
had lower incidence of hepatitis in PLHIV receiving IPT.
There was no significant association with CD4 count found
in the study.
Clinico Radiological Study in Patients with H1N1 Infection
Aim: The purpose of this study is to describe in detail
the clinical and radiological features in patients with
H1N1 infection.
Materials and Methods: This study was carried out in
CMCH, Coimbatore and 100 patients were included in the
study. The study population included patients admitted
with symptoms and signs of flu, RT PCR positive for
H1N1, and undergone CT chest imaging. Clinical signs
and symptoms at presentation were recorded. CT chest
images were analysed and the radiological findings was
described in detail in terms of oapcities and distribution.
These findings were correlated with disease severity.
Results: The predominant symptoms were fever, cough
and breathlessness. The disease is most commonly seen in
females than males. Nearly 30% of the study population
had comorbidities of which diabetes mellitus and systemic
hypertension were the most common. Nearly all patients
with comorbidities had abnormal CT chest findings. The
most common abnormalities noted were patchy areas of
consolidation, ground glass opacities, nodular opacities,
pleural effusions. They required ventilatory support
and prolonged hospital stay whereasmost of the patients
without comorbidities and normal CT chest recovered
quickly and did not require ventilatory support.
Conclusion: These clinical and radiological features
can help patient triage and can predict the severity of illness
and outcome earlier as early recognition and initiation
of treatment can reduce the morbidity and mortality
assosciated with H1N1 infection.
Practicing Antimicrobial Stewardship in a Tertiary Care Hospital
Introduction: The National Health policy by MoHFW
Govt. of India identifies Anti Microbial Resistance as serious problem and commits for Anti Microbial Stewardship
Program (AMSP).1,2 Antibiotic audits are one of the most
important start point of AMSP. We are presenting here the
baseline data derived from Dept. of Medicine in a newly
constructed tertiary care institute of national importance.
Materials and Method: This is a cross sectional
prescription audit among patients admitted to Dept. of
Medicine during a period of 6 weeks. None of the patients
were excluded.
Results: Out of all the 112 patients admitted in the
Department of General Medicine during the study period,
31.25% (35/112) were on various anti microbial agents. One
or more antibiotic was prescribed in 30 out of 112 patients
(26.7%). Among the various antibiotic groups, beta lactams
(BL) and/or beta lactam -beta lactamase inhibitors (BL-BI)
were prescribed in (29/30) 96.6% of cases either as a single
agent or in combination with other. A macrolide was
prescribed in (3/30) 10% of cases.
Fluoroquinolone was prescribed in (2/30) 6.6% and
glycopeptide in (1/30) 3.33%. Antifungal was the 2nd most
common anti microbial agent in (5/35) 14.3% cases.
Among the patients who were started on antibiotics,
the source of infection was suspected in urinary tract 23%,
GI Tract 20%, respiratory tract 17%, skin and soft tissue
11%, hepatobiliary 9% and non recognizable in 11%. On
examining the compatibility of the prescribed antibiotics
to either of the national guidelines (ICMR/NCDC), only 60
percent of the prescriptions were compatible.
Discussion: Our rate of prescription of antibiotics were
much less than other groups.3 BL / BL-BI antibiotics were
the preferred group.
Conclusions: Periodic antibiotic audit should be done
which incorporates anti microbial stewardship among
health care practitioners to make a change.
Study of electrolyte imbalance in Dengue fever
Introduction: Dengue fever is a tropical disease caused
by infection with dengue virus which is transmitted by
bite of Aedes aegypti mosquito. In a few studies done
on low sodium levels in dengue fever various causes like
peripheral fluid extravasation with salt depletion, increase
in renal excretion due to activation of rennin, transient
inappropriate secretion of ADH or influx of sodium in the
cells due to dysfunction of sodium potassium pump have
been stated. Hypokalemia can be due to redistribution of
potassium in cells or transient renal tubular abnormalities
causing increased urinary potassium loss. Increased
catecholamine levels due to stress and secondary insulin
release may also result in an intracellular shift of potassium.
Materials and methods: The is an observational study
conducted among fever cases presenting to medicine
department of RL Jalappa Hospital. Fever cases will be
tested for Dengue serology. Dengue Serology positive
patients will be taken as cases and fever cases other than dengue will be taken as controls. Levels of serum sodium
and potassium in cases and controls will be measured.
Results: Out of 50 cases of dengue fever studied,
hypokalemia and hyponatremia were found in 11 and
12 patients respectively. Out of 50 dengue cases, 2 cases
progressed to bleeding manifestations. Out of 50 fever cases
other than dengue hypokalemia and hyponatremia were
found in only 5 and 3 patients respectively.
Conclusions: This study showed that mild
hyponatremia and hypokalemia is more common in
dengue patients compared to fever cases other than dengue.
It was observed that hyponatremia and hypokalemia
are associated with longer hospital stay in patients with
dengue fever.
Efficacy of Chloroquine in Dengue Fever
Introduction and objective: Dengue is endemic in India
and worldwide 3.9 billion people in about 128 countries
are at a risk of infection with the virus. There is no specific
vaccine or treatment for dengue till date. Universally
available inexpensive drug, chloroquine, has been shown to
exert antiviral effects by inhibiting replication of flavivirus.
Material and Methods: Randomized double blind
study was conducted in 60 patients and only those who
were aged above 18 years, could give informed written
consent, had positive dengue serology and had dengue
related symptoms according to WHO criteria were
included, whereas, all other patients were excluded.
Diagnostic testing was done with dengue IgG, Ig M
antibody testing and NS1 antigen positivity on serology.
Patients were divided into two groups with one
receiving chloroquine 500mg and the other group receiving
placebo. Supportive treatment was the same for both
groups. Patients were followed up for improvement of
symptoms after a week and adverse effects of chloroquine
was noted. Unpaired t test and fisher exact test were used
for analysing results using SPSS v24.
Results: Out of the 60 patients, 10 did not give
consent. Among the remaining 50,25 received chloroquine
and 25 received placebo. No patient developed DSS/
DHF. 16 patients reported substantial reduction in pain
and improvement in daily activities (p<0.0001) with no
significant difference in duration of disease or intensity of
fever after a week (p>0.05).
Conclusion: Chloroquine, an anti-inflammatory drug
can be used with a novel indication in dengue patients for
alleviating their pain and improving quality of life.
Meningoencephalitis in Scrub Typhus :- A Case Series Report
Introduction: Scrub typhus caused by the organism
Orientia tsutsugamushi, transmitted by trombiculid mites,
is a common cause of acute febrile illness during the
monsoon months in our region. Meningoencephalitis as a
cause of mortality in cases of scrub typhus is becoming a
common entity now.
Objectives : To study the incidence of
meningoencephalitis in scrub typhus cases admitted to
our hospital and stress the importance of keeping it as a
common differential diagnosis.
Materials & Methods: A descriptive observational
study of 39 diagnosed cases of scrub typhus admitted in
our hospital during 6 months duration (may 2018 to October
2018) was conducted. Patients presenting with fever, altered
sensorium were evaluated by NCCT BRAIN followed by a
lumbar puncture and the diagnosis of scrub typhus being
confirmed by the ELISA test along with other clinical and
lab parameters. Data concerning the cases was recorded
and analysed using appropriate statistics.
Results: Out of 39 cases admitted, 11 patients were
diagnosed as having meningoencephalitis. Patients
with meningoencephalitis had severe thrombocytopenia
when compared to those without any CNS symptoms.
Hypoalbuminemia was indicative of poor prognosis in
general and decreased serum protein level was almost
always a hallmark in presence of meningoencephalitis.
All patients responded well to doxycycline therapy with
no mortality amongst cases under study.
Conclusions: There have been numerous outbreaks
of scrub typhus in our state of Rajasthan especially in
the Hadoti region. And in the recent years, scrub typhus
has been an important contributor among the newer
class of emerging infections causing mortality in India.
Meningoencephalitis although rare, forms a major part of
the complications of scrub typhus.
Triple Drug therapy for Dapsone resistant disseminated cutaneous Rhinosporidiosis
Introduction: Rhinosporidiosis is a chronic
granulomatous infection caused by Rhinosporidium
seeberi. We report the case of a patient who responded
to the new treatment regime following clinical failure
with dapsone.
Case Report: This 62 years old immunocompetent
male was diagnosed with Rhinosporidiosis 45 years ago.
His initial presentation was a nasal swelling. He continued
to have recurrences of the nasal swellings for the next 38
years for which he underwent surgical resections at least
twice every year and 7 years ago he started developing
multiple cutaneous swellings. In spite of multiple surgical
resections and oral dapsone the lesions kept increasing in
size and numbers.
At presentation he was noted to have multiple
cutaneous swellings with areas of ecchymosis. His
hematological parameters revealed pancytopenia. We
reconfirmed the diagnosis by histopathology and also did
a bone marrow aspiration study to exclude bone marrow
infiltration. Bone marrow study was normal. On the basis
of reports in the literature we initiated him on a triple drug
therapy with Cycloserine, Dapsone and Ketoconazole.
Hematological parameters normalized within a month.
The swellings decreased in size. He underwent sequential
resection of the swelling. He had marked response with
this new treatment regimen. He did not develop any new
lesions and following resection of the swellings there was
no recurrence. He was continued on this therapy for 1 year
with close monitoring.
Discussion: Surgical resection has been the main stay
for treatment and dapsone was the only drug which was
used earlier for this disease. Leni etal treated a case of
disseminated rhinosporidiosis in an immunocompromised
individual non-responsive to Dapsone with Cycloserine,
Dapsone and Ketoconazole with good response as in
our case.
Conclusion: Triple drug therapy along with surgical
resection is a promising treatment for patients with
disseminated rhinosporidiosis resistant to Dapsone.
Hemophagocytic Lymphohistiocytosis in Tropical Fevers – Under recognised problem
Introduction: HemophagocyticLymphohistiocytosi
s(HLH) is a clinico pathological syndrome characterized
by prolonged fevers,cytopenias, organomegaly, histiocyte
infiltrate of marrow and coagulopathies which are either a
result of genetic mutations (primary) or systemic illnesses
like infections, autoimmune or malignancies (secondary).
Much of literature available today is for primary HLH, very
less is known about HLH secondary to tropical fevers. This
study aims at characterizing HLH secondary to common
tropical fevers and identifies markers for HLH.
Methodology: 534 tropical fever cases were screened
over a period of 2 years and 178 cases were included based
on clinical suspicion of HLH. Fever days, temperature,
immunosupressed state, hepatomegaly, splenomegaly,
AST, Hb, TLC, Platelet counts, Ferritin levels and
triglycerides were taken into account and H Score was
calculated. Serum Soluble CD25 levels were also estimated
in randomly chosen 80 subjects by ELISA method. A H
Score of 185 and above was considered diagnostic of HLH.
Outcomes in the form of mortality, recovery, hospital days,
steroid use and transfusions given were looked into.
Results and discussion: 11.2 % (20/178) patients with
tropical fevers developed HLH (Dengue: 18, Malaria:1, Viral
Hepatitis:1). There was statistically significant correlation
between H score and days of hospital stay, least platelet
count, least total count, organomegaly, serum ferritin,
triglyceride, AST and soluble CD25 levels. CD25 value of
10435pg/ml was highly diagnostic of HLH in tropical fevers
with 100% sensitivity and 100% specificity. Patients with
tropical fevers who develop a sudden altered course in the
natural history of the disease in the form of organomegaly
and fresh cytopenias will need a serious workup for HLH
in the form of soluble CD25 testing. Soluble CD25 can be taken as a single best test in diagnosis of HLH.
Conclusion: Soluble CD 25 can identify the subgroup
of patients with tropical fevers that might improve with
steroids since the underlying pathogenetic mechanism is
the profound inflammatory state of HLH.
Evaluation of Thrombocytopenia In Various Common Infections
Aims and Objective: To study etiology, severity,
complications and mortality due to thrombocytopenia in
commonly encountered infections in a tertiary care hospital.
Material and Methods: This was a hospital based,
observational descriptive study. About 310 patients of
Pyrexia with thrombocytopenia presenting to tertiary
care hospital, SMS Hospital, Jaipur, in 2014 and 2015 were
included in the study.
Observations and Results: The study revealed that
majority (37.4%) of patients was in age group of 21 to 30
years, amongst whom 65.2% were males and 34.2% were
females. Dengue fever (50.9%) was found to be the most
common cause of thrombocytopenia followed by malaria
(17.1%), scrub typhus (16.1%), HIV (4.5%), sepsis (2.9%)
and enteric fever (2.6%). Very severe thrombocytopenia
(< 20,000/μl) was seen in 23.2% patients, 47.1% had severe
thrombocytopenia (20,000-50,000/μl), 25.8% patients had
moderate thrombocytopenia (51,000-1, 00,000/μl) and
mild thrombocytopenia (1, 00,000-1, 50,000/μl) was seen
in 3.9% patients. 50.3% patients presented with bleeding
manifestations of which petechial rash (15.5%) was the
most common. Most serious bleeding manifestation was
intracranial bleed and it was observed in 2(0.65%) patients.
Overall mortality was 3.5% which was higher in patients
with very severe thrombocytopenia (platelet count < 20,000/
μl), in patients of P. falciparum malaria, scrub typhus and
those having mixed infections.
Conclusion: Pyrexia with thrombocytopenia is the
most common condition with myriad connotations. It is
important to find out the cause of the thrombocytopenia.
Mortality in severe thrombocytopenia is related to
multiorgan dysfunction syndrome (MODS) associated with
the underlying infection. Early diagnosis and appropriate
treatment is rewarding and reassuring.
Mycoplasma Pneumonia with Extra Pulmonary Manifestations
Introduction: Mycoplasma pneumonia is atypical
bacteria that manifests as respiratory tract infections which
may be mild as tracheobronchitis,pharyngitis or severe
as pneumonia.It can also manifests with extrapulmonary
manifestations including hepatic,neurologic,dermatologic,c
ardiac,rheumatologic and hematologic due to disseminated
infection.
Case Report: 45 yr female agriculturer presented
with fever for 13days,cough,sob for 5days.Admitted in
local hospital took inj cefaperazone and sulbactum for
5days and referred here.On general examination icterus
present vitals : temp-100 F, respiratory rate-38/min,
saturation-86% roomair. On systemic examination bilateral
crepitations heard. On evaluation routine investigations
were normal except platelet-90,000.ESR-80mm in 1hr.
Total bilirubin-3.5mg/dl.Chest xray-patchy opacity right
midzone,bilateral pleural effusion.Ct chest-multifocal
consolidation in bilateral lung fields predominantly
in right upper lobe,bilateral minimal pleural effusion.
Direct coombs-positive.LDH-632.Blood,sputum cultures
were sterile.In view of bilateral pneumonia,positive
direct coombs; Mycoplasma suspected and confirmed by
mycoplasma IGM serology-positive(11).patient treated with
inj clarithromycin 500mg IV 12 th hourly for 7 days and
discharged. 1 month Followup showed her Hb improved
to 12.50gms%,direct coombs was negative.
Discussion: We report a case of mycoplasma
pneumonia presenting as bilateral pneumonia,hemolytic
anemia which is self limiting.cold agglutination is feature
of mycoplasma pneumonia,cause not clear.It has been
postulated that antibodies are directed against I antigen on
RBC causing complement and immunoadhrence mediated
hemolysis which can be diagnosed by increased indirect
bilirubin and LDH and decreased haptoglobin.organism
is difficult to grow in culture which can be confirmed by
serological tests or PCR.
Conclusion: Mycoplasma pneumonia with
extrapulmonary manifestations is rare. Hematologic manifestations like cold agglutin, autoimmune hemolytic
anemia occurs in 2nd -3rd week of illness.Degree of hemolysis
is related to high titre of cold agglutin.
Fatal Chicken Pox - A Case of Primary Varicella Infection with Fulminant Hepatic Failure
Introduction: Chicken Pox is a common, mostly benign
infection of childhood and adolescence.
It is caused by Varicella Zoster virus which is a double
stranded DNA virus belonging to the family Herpesviridae.
It has a more severe presentation when it occurs in
adults and immunocompromised individuals.
Mild hepatitis is not uncommon in patients with
primary varicella infection. However, fulminant liver
failure is very rare and there are only a few reported cases.
We present a young, morbidly obese, diabetic
gentleman who presented with chicken pox and succumbed
to the fulminant hepatic failure that followed.
Case Summary: A 29 year old morbidly obese
gentleman with uncontrolled diabetes presented to the
emergency with severe abdominal pain, nausea, generalised
weakness.
Examination revealed normal vital signs with
cardiovascular and respiratory systems being unremarkable;
the abdomen revealing mild hepatomegaly and tenderness
in the epigastric region
I n i tial routine investigations revealed mild
transaminitis without hyperbilirubinemia and markedly
raised HBA1c.
The patient developed a papulovesicular rash on the
third day of admission and was diagnosed with chicken
pox on the basis of serology and tzanck smear.
Antiviral therapy was initiated. The patient went on to
develop fulminant hepatic failure, multi-organ dysfunction;
his condition deteriorated rapidly, culminating in his death.
In our view, his morbid obesity, uncontrolled diabetes
mellitus and probable NASH contributed to the fatal
outcome.
Discussion: Chicken pox is a common infection in the
developing world.
Most cases of chicken pox follow a benign course.
However, a few of them are associated with certain
complications.
Hassan et al studied 102 patients with Varicella and
found the following complications
Raised SGPT levels (51.9%);
The levels were greater than 10-folds of normal value
in 4.9%
Thrombocytopenia (42.1%)
Varicella pneumonia (28.4%)
Skin infection (25.4%),
Septicaemia (10.7%),
Encephalitis/Meningitis (8.8%),
Acute Respiratory Distress Syndrome (ARDS) (6.8%),
Acute renal failure (2.9%)
Acute hepatic failure (1.9%)
Hepatic dysfunction is common in chicken pox.
The patients with hepatic dysfunction also have high
frequency of involvement of the other organs leading to
increased morbidity and mortality rate.
Pishvaian et al and Roque-Afonso et al each reported a
case of acute liver failure in patients on steroids for asthma
and sinusitis respectively. The latter case could be saved
due to timely liver transplant.
Most reported cases with acute liver failure were
immunocompromised. Only 2 cases have been reported to
have survived after liver transplantation.
Okamoto et al reported lower cell mediated immunity
to varicella zoster virus in diabetics as compared to healthy
individuals.
We believe uncontrolled diabetes mellitus and
morbidly obesity were responsible for lower immunity in
our patient, which predisposed him to severe hepatic injury
culminating in his death.
Conclusion: Acute Liver failure is a very rare
complication in primary varicella infection.
Very few cases of such an occurrence have been reported.
Majority of these cases were fatal.
Immunocompromised patients due to HIV infection,
corticosteroid use, haematological malignancies, bone
marrow or solid organ transplant, have more risk of
developing acute liver injury in primary varicella infection.
Comorbidities like obesity, diabetes and fatty liver
may also contribute to the incidence of acute liver failure.
Timely antiviral therapy and liver transplantation may
prevent the fatal outcome.
Electrolyte Abnormalities in Patients with Dengue Infection in a Tertiary Care Teaching Hospital in Southern India
Introduction & Objectives: Dengue fever is an acute
febrile illness, caused by a flavivirus, and is transmitted by
Aedes aegypti and Aedes albopictus mosquitoes.
The objectives of this study werea.
To assess serum sodium and potassium levels in adult
patients with dengue fever and dengue hemorrhagic
fever
b. To correlate the electrolyte abnormalities in patients
with dengue infection with the severity of illness
Materials & Methods: 95 patients admitted to the
medical wards and casualty of JIPMER with confirmed
dengue infection (by NS1 antigen test or IgM antibody
test) were included in the study after obtaining written
informed consent.
Based on clinical examination, the severity of illness
was graded as uncomplicated dengue fever (DF) or
dengue hemorrhagic fever (DHF) graded as I, II, III & IV.
Hemoglobin, hematocrit, platelet count, serum sodium and
potassium were also noted.
One way ANOVA test was used to compare the
electrolyte levels with severity of dengue infection. Chisquare
test was used to compare the categorical variables.
Results: Hyponatremia (36%) and hypokalemia (34%)
were found to be commonly present in patients with dengue
infection. However, only hypokalemia showed a significant
correlation with the severity of illness.
Conclusion: Hyponatremia and hypokalemia are
common electrolyte abnormalities in dengue patients,
possibly due to vomiting and fluid loss.
Clinical and Laboratory Profile of Scrub Typhus in Manipur Defense Forces Hospital
Objective: The present study was done to ascertain
the presentations of Scrub typhus in defense force hospital
in Manipur and to compare the clinical & laboratory
features among patients with or without complications
in scrub typhus.
Methods: A total of 16 patients of Scrubs typhus
admitted to Medical wards were included in the study. A
detailed history as well as general and systemic clinical
examinations were carried out. Hematological profiles,
biochemical investigations, CXR & USG abdomen were
done on admission and were followed daily or alternate
day. Lab diagnosis of Scrub typhus was established by
Immuno-chromatography. Patients were classified as
Scrub Typhus without complication or with complications
Results: Of 16 patients,Scrub typhus positive, all were
male who travelled in jungle area being defense personnel
along Indo Myanmar border. Mean age of patients was
41.5+12.5. Duration of illness was 4-26 days. All patients had
symptoms and signs in numbers with percentages {fever-16
(100%),Headache-12(75%),Myalgia-7(43.5%),Escharmark-
8(50%),Pain abdomen-2(12.5%),Vomiting-4(25.0%)
Dyspnoea- 2 (25%)}. Among 16,three had leukocytosis (more
than 11000/cumm )and One had lekocytopenia(2530/cumm),
Lymphocytosis(40-80%) was prominent in 8 (50%),6 (37.5%)
had thrombocytopenia (platelets less than1.5 Lakh).12(75%)
had transaminitis with 2(12.5) had raised bilirubin (>2.5mg/
dl) with one raised INR-1.79. 2 patients(12.5%) had regional
lymph adenopathy,4 (25%) had hepatoslenomegaly and
2 (12.5%) had solitary hepatomegaly /slenomegaly (1
each).Complications reported in 6 patients (37.5% of
total,Pneumonia-2 (12.5%),liver dysfunction-2 (25%),kidney
dysfunction(creat-1.5 mg/dl) -1(12.5%), Intra Cerebral
Haemorrhage-1 (12.5%). Among above 6,2 patients (out of 3 who had prolonged duration of Illness more than 10 days)
developed Multiorgan failure.It was significant statistically
(p value <0.002).Nil mortality was observed, all patients
recovered well during hospital stay (10-14 days). Montoux
test,Serum widal test, dengue serology, HIV ELISA and
malaria antigen were negative in all patients.
Conclusion: Early diagnosis and prompt initiation of
Standard therapy can reduce mortality & complications
in Scrub Typhus. In present study, it was found that, in
endemic region like Manipur Scrub Typhus should be high
on card in probable diagnosis.
Burkholderia Infections in Diabetics-A Diagnostic Dilemma for Physicians
Introduction and Objectives: Medically important
members of Burkholderia genus are B.cepacia,B.
pseudomallei . Fatal combination of necrotising
pneumonia,respiratory failure and bacteremia is Cepacia
Syndrome. B.cepacia can cause pneumonia,brochiectasis,
pyopneumothorax in immunosuppressive individuals.
Melioidosis can occur as localized infection(pneumonia,
musculoskeletal), sepsis and death with risk factor being
diabetes.We present two cases of Melioidosis and three
cases of Cepacia Syndrome in diabetics.These reports raises
the concern regarding the potential severity of Burkholderia
infections and prompts early diagnosis by physicians.
Materials and Methods: All cases presented as PUO
to our hospital and later diagnosed with Burkholderia
sepsis were included.
Results: All five patients were diabetics, four of them
were middle aged and one is 68 years old.
Among three cases of Cepacia Syndrome,two patients
presented as PUO and arthralgia and their hospital course
is complicated by ARDS and subsequent intubation.Third
patient presented as PUO.
All three cases developed cavitatory lesions in lungs.
One patient developed pneumothorax.
Repeated blood and sputum cultures showed B.cepacia.
Along with supportive therapy, intravenous meropenem
was given for 2 weeks.Oral cotrimoxazole in two patients
and oral doxyxycline in one patient was continued for 12
more weeks.
Both cases of Melioidosis presented as PUO and
swelling of knee joint.Cultures from blood and pus from
knee joint in both showed B.pseudomallei.
One patient’s CT Thorax showed pulmonary nodules.
Subsequently patient developed ARDS and was intubated.
In both patients of Melioidosis,surgical debridement
of knee joint was done and treated with iv ceftazidime for
2 weeks followed by oral doxycycline.
All five patients survived and improved after
appropriate treatment.
Conclusion: High index of suspicion in all cases of
septicaemia with conditions such as diabetes will be useful
in detecting Burkholderia infections.These infections are
difficult to treat and patients need long-term antibiotic
therapy as recurrences are common with inadequate
treatment.Physicians need to be careful as Burkholderia
infections are dreadful.
A Case of Isolated Renal Hydatid
Introduction: Human Echinococcosis is a cyclozoonotic
parasitic infestation caused by the larval stage of the
tapeworm Echinococcus.Liver is the most common site
of involvement.Renal hydatid is generally secondary
to disseminated hydatidoses or associated with hepatic
involvement. Isolated renal involvement is far less common
and reported in 2 to 3% of all hydatid cases.
Report of Case: A 42-year-old male cattle rearer,
resident of Khammam presented with mild Left Loin
pain of about a month, with no other symptoms.On
examination, patient was Afebrile,vitals were stable;with
normal systemic examination.In routine blood and urine
analysis,all biochemical and pathological investigations
were within normal limits.
Discussion: USG abdomen showed enlarged left
kidney with Anechoic cystic lesion measuring 10*8cm with
multiple daughter cysts.CT abdomen showed 10*8cm well
defined exophytic hypodense cystic lesion noted arising
from upper pole of eft kidney with multiple daughter
cysts of varying sizes;suggesting a hydatid cyst. AntiEchinococcol antibodies were negative.Left Nephrectomy
was done. Patient was given a periperative course of
Albendazole with a view to sterilize the cyst preoperatively
and to decrease the risk of recurrence of the cyst post
operatively. Multiple flat membranous and oval cysts
seen, grayish white, translucent and soft with smooth
surfaces noticed on gross appearance; with sections from
cyst showing a lamellated cyst wall,being dense fibrous at
places. Follow up showed no recurrence.
Conclusion: There are no specific clinical symptoms
or signs that will reliably confirm the diagnosis of renal
echinococcosis. Routine blood investigations are usually
normal except for eosinophilia, which is found in 50%
of the cases. Radiological studies have a more important
place in the preoperative diagnosis of renal hydatid
disease. Though hydatidosis is not uncommon among the
rural population,isolated primary renal hydatidosis still
remains a rarity.
A Multicentre, Open Label, Randomized, Comparative, Parallel Group, Active-Controlled, Phase III Clinical Trial to Evaluate Safety and Efficacy of Arbekacin Sulphate Injection Versus Vancomycin Injection in Patients Diagnosed with MRSA Infection
Introduction & objectives: Increasing resistance
to currently available antimicrobials has led to the
development of new agents. Arbekacin is aminoglycoside
antibiotic primarily used in Japan and Korea for the
treatment of infections caused by multi-resistant bacteria
including MRSA. Currently there is no published data
available for use of Arbekacin in Indian patient population,
thus the present study was conducted to evaluate the safety
and efficacy of Arbekacin Indian population.
Materials and Methods: The study was a phase
III, multi-centre, open-label, randomised comparative,
active control study. Subjects with microbiologically
confirmed MRSA infection were admitted and treated
with either Arbekacin sulphate 200 mg OD or Vancomycin
hydrochloride 1000 mg BD both as IV. Clinical and
microbiological cure were evaluated at various time points
during the study period.
Results: Total 162 patients were randomized in two
treatment groups (81 patients in each group). Out of these
microbiologically confirmed MRSA patients, 153 were
admitted for SSTI and 9 patients were admitted for CAP.
Overall cure rate of MRSA infection (clinical as well as
microbiological cure) was comparable in both the treatment
groups i.e. 97.5% (79/81) in Arbekacin group & 100 % (79/79)
in Vancomycin group (p value: 0.32). Both Arbekacin and
Vancomycin were well tolerated by the patients during
the study period.
Conclusion: Arbekacin can be considered as safe and
effective alternative to vancomycin in the management of
MRSA infections.
Conflict of interest: Alkem Laboratories Ltd. Mumbai
has sponsored the study. The authors are employees of
Alkem Laboratories Ltd.
A Rare Case of Disseminated Cysticercosis
Introduction, Aims & Objectives: Cysticercosis is a
common tropical disease caused by Cysticercus Cellulosae,
larval form of Taenia solium. DCC is an uncommon
manifestation as a result of dissemination of embryos
from intestines via hepatoportal system to various tissues
& organs of body.
Conclusion: DCC should always be kept as a D/D
when a Ptatient presents with subcutaneous swellings,
Intramuscular swellings & seizures, this condition is
treatable.
Hepatitis in Dengue Fever and its Impact on Hospitalisation Stay and Bleeding Outcomes in a South Indian Population
Introduction & Objectives: Dengue in its various
modes of presentation has found to have some effect on liver
function. This study was conducted to correlate hepatitis in
dengue and its impact on duration of hospital stay, bleeding
manifestations and platelet count.
Materials and methods: This prospective randomized
study was done on 200 patients in age group of 2 to 75 years
including both sexes who confirmed to the predetermined
inclusion and exclusion criteria. Investigations included
measurements of serum aspartate transaminase (AST)
and serum alanine transaminase (ALT). Degree of liver
involvement bases on transaminase levels were classified
in three groups(A/B/C).
Results: Out of 200 cases, 65% were diagnosed as
dengue fever, 24% as dengue hemorrhagic fever (DHF)
and 11% as dengue shock syndrome(DSS). On assessment
of AST levels, it was observed that those in Grade C group
showed higher propensity towards increased duration
of hospital stay and bleeding manifestations(72 & 32%).
However, though 30% of Grade C in the ALT group
developed bleeding manifestations, duration of hospital
stay remained almost equivocal among the other grades.
Conclusion: Liver involvement in the form of elevation
of transaminases is quite common in dengue infections.
Serum AST more than ALT maybe a useful surrogate marker
to bleeding outcome and duration of hospitalisation in
patients with dengue patients.
Clinical and Microbiological Profile of Urinary Tract Infection in Diabetic Patients
Introduction & objectives : To determine the clinical
pattern of urinary tract infections in diabetic patients & to
study the pattern of antimicrobial susceptibility amongst
the isolated microorganisms.
Materials & Methods : The prospective observational
cross sectional study involving 384 patients full filling
the various inclusion & exclusion criteria were selected &
studied for the purpose of the study.
Results: The study showed that the classical features
of UTI may not always be present in diabetic patients due
to various factors, hence index of suspicion should be high
to diagnose the condition especially in elderly patients. The
emergence of multi drug resistant microorganisms among
both the Gram positive & negative organisms is also a cause
of worry. The incidence of isolation of fungus was also high
& anti fungal resistance was also high among the isolates.
Conclusions: Rampant & indiscriminate use of
antibiotics has lead to emergence of multi drug resistant
species of microorganism which are getting increasingly
difficult to manage and leading to higher morbidity &
mortality.
Hurdles to Managing a Case of MSSA : A Clinical Nightmare
Introduction: Staphylococcus aureus (SA), the most
virulent of the many staphylococcal species, has been
rightly described to be a cause of malignant infections.
Its versatility for invading any tissue evades a range of
host immune mechanisms. This makes it a major cause for
morbidity and mortality worldwide.
With the current focus being on methicillin-resistant
SA, the hurdles to management of methicillin – susceptible SA (MSSA) are underestimated and often overlooked.
Here, we present a case of MSSA, a probable skin
colonizer, transforming into an invasive infection following
a fall and later progressing to Sepsis with MultiOrgan
Dysfunction (MODS), inspite of culture appropriate
antimicrobial therapy.
Case Report: 79 year gentleman, presented with fever
and altered sensorium. He had a history of injury to the
knee 2 weeks prior to current illness, which was treated and
culture from knee was negative. But blood cultures now,
confirmed MSSA blood stream infection (BSI). He soon
progressed into sepsis with MODS - Septic arthritis, Lobar
Pneumonia and possible Infective Endocarditis, despite
being on Daptomycin and Cefazolin. But, patient did not
respond to the treatment and unfortunately succumbed
to infection.
Discussion: In our scenario, a precedent trivial injury
progressed to septic arthritis and subsequently to sepsis
and ultimately death, which might be due to progression
of infection to involve a more serious organ such as the
heart in the form of an infective endocarditis, which could
not be ascertained due to poor underlying cardiac function.
Conclusion: The management guidelines to treating
SA infections are clearly defined by IDSA and NHS. This
case highlights the significance of host and pathogen
factors contributing to an unfortunate clinical outcome
and to remind physicians of the devastating infective
potential of MSSA.
The PUO Conundrum - Revealing a Slow to Grow Culprit a Case of PUO not to Neglect – Neurobrucellosis
Introduction: Brucellosis is a multisystem disease
that commonly presents as a febrile illness with variable
spectrum of clinical manifestations. Neurobrucellosis
presents as a complication of systemic brucellosis. Although
neurobrucellosis can present with meningoencephalitis,
or psychiatric manifestations; this patient presented only
with fever.
Case Report: A 33 year old DJ, with extensive travel
history; contact with pets and ingestion of meat, dairy
products; presented with intermittent fever since 2 months;
associated with chills, myalgia, arthralgia, headache and
weight loss of 6kgs. He was febrile, malnourished with
bilateral enlarged, tender, submandibular lymph nodes.
Inflammatory markers were elevated. Widal, Dengue,
Leptospira, HIV ELISA, IgM toxoplasma were negative.
ECHO, MRI and PET were normal. First blood culture
grew coagulase negative Staphylococci which was a
contaminant. Lumbar Puncture revealed elevated protein,
normal glucose and was predominantly lymphocytic. CSF
culture grew Brucella melitensis. Soon after, the 2nd and 3rd
blood cultures, after 5-7days, also grew Brucella melitensis.
Discussion: The diagnosis is made by culture of
brucella from blood or sites like bone marrow/liver biopsy
specimens. Most blood cultures are positive between
7-21days. Serum agglutination and ELISA are common
serologic tests. Brucella agglutination test with a fourfold or
greater rise in titre in 4 weeks highly indicates brucellosis.
Bone marrow culture is the gold standard for diagnosis;
is more sensitive than blood culture and the time taken
for growth is shorter. As it is invasive, this is reserved for
patients with abnormal hematologic findings, PUO and
negative brucella serology
Conclusion: Neurobrucellosis is diagnosed by either
both symptoms and signs that are consistent; isolation of
brucella from CSF; presence of lymphocytosis, increased
protein, decreased glucose in CSF; or by diagnostic
findings in cranial MRI or CT. This patient was treated
with doxycycline, rifampin and ceftriaxone until the CSF
became normal
Clinical, Demographic and Biochemical Profile of Rikettsial Infections from a Tertiary Care Hospital
Introduction: Rickettsial diseases are unique in various
aspects. The mortality they account for is more than all
infections put together. This group of infections can be
classified into spotted fever, typhus, scrub typhus and
miscellaneous groups. As there are very less studies on
these infections in adults from south India, this study was
planned and performed.
Materials and methods: this study is a prospective
observational study with a study duration of two months.
Any adult more than 18 years of age with fever more than 5
days with no identifiable infectious etiology were included.
All cases defined as rickettsial diseases were included
who had a positive Weil felix test result of (1: 80 or more)
with one or more of the following clinical features, rash,
edema, fever, hepatomegaly, ronchi, hypotension., eschar
or tick exposure
Results: Out of the 51 patients with undiagnosed
fever of more than 5 days, 17 cases met the criteria for
rickettsial infections. Others were dengue fever (22
cases), typhoid fever (10 cases), and malaria (2 cases).
Age of presentation ranged from 18 – 75 years. Male to
female was 6: 11. Demographically, patients were mostly
from Ballari (52.9%). The most common presentation
seen were fever, splenomegaly, hepatomegaly, rashes,
vomiting, pain abdomen and pedal edema. Other rare
manifestations included acute pyelonephritis, acute renal
failure, meningioencepahlitis, ARDS, or lymphadenopathy
was seen in this series. All patients responded to tablet
Doxycycline 100 mg twice a day for 7 days. No mortality
was noted in this study.
Conclusion: Any patient who presents with
undiagnosed fever with any one of the clinical manifestations
despite the absence of eschar or lymphadeopathy, the case
should be investigated for Rickettsial diseases
Pit Falls in Diagnosis of Disseminated Tuberculosis
Introduction: Disseminated Tuberculosis still remains
a diagnostic and therapeutic challenge. The vague clinical
manifestations, atypical radiographic findings and
difficulties in establishing tuberculosis as the etiological
diagnosis, among others, are challenges in diagnosis and
treatment of disseminated TB. Despite of effective therapy,
mortality from this disease is still high. We are presenting
the challenges to diagnose disseminated tuberculosis.
A 62 years old gentleman presented with complaints
of low grade fever, cough over 1 month and breathlessness
for 3 days. He had mild thrombocytopenia, elevated liver
enzymes and normal chest x-ray initially. Sputum AFB,
tests for tropical fevers, TB QuantiFERON-TB Gold were
negative. His clinical condition deteriorated rapidly after
admission. On fundus examination, choroid tubercles
were present. On further investigations, CT thorax showed
miliary mottling and aortitis with saccular aortic aneurysm.
We confirmed disseminated tuberculosis by doing bone
marrow aspiration and biopsy, which showed caseating
granuloma and presence of acid fast bacilli. Patient
improved on ATT.
Discussion: Disseminated TB accounts for less than
2 percent of all cases of TB. Tuberculous aortitis (TA) is
a rare entity that is invariably indicative of disseminated
tuberculosis. Before the antibiotic era, the majority of TA
were diagnosed incidentally at autopsy. With increasing
clinical awareness, improved imaging and successful
therapy, early diagnosis has increased. A choroidal mass
or granuloma is a feature of ocular tuberculosis (TB).
Tubercles can arise in the early stages of progression of
TB and indicate hematogenous dissemination before the
development of symptomatic disease.
Conclusion: Good clinical suspicion with thorough
clinical examination and fundus examination can be helpful
in diagnosis of disseminated TB even in sputum negative
and normal X-ray cases. Investigation like CT abdomen and
CT chest also aid us to derive a diagnosis of disseminated
tuberculosis.
A Single Centre Experience of Scrub Typhus in a Tertiary Care Centre - A Re-Emerging Infection
Introduction and Objectives: Scrub typhus is
grossly under diagnosed owing to the nonspecific clinical
presentation, lack of access to specific diagnostic facilities
in most areas and low index of suspicion. It’s public health
importance is under-estimated. It is a documented disease
in Himachal Pradesh, but very few clinico-epidemiological
studies exist in our area. The present study is done with
IgM ELISA as a diagnostic test which has higher sensitivity
and specificity as most of previous studies had used Weil
Felix test as a diagnostic test.
Materials and Methods: This was a prospective
observational study from July 2016 to December 2016. All
the patients more than 18 years of age with acute febrile illness and positive IgM ELISA for scrub typhus with or
without eschar were included. The patients diagnosed
to have some other infection were excluded. The clinical
profile was observed with detailed history, examination,
investigations and response to treatment.
Results: Total 39 patients were observed. 56% were
males. 77% patients came from agricultural background.
Maximum patients were observed in September, October
and November. Eschar was present in 8% patients.
Complications were seen in 76.92%. 82% patients had
hepatic dysfunction, followed by ARDS (53%). Mortality
rate was 0 %.
Conclusion: Scrub typhus is now a re-emerging
infection in our country with variable clinical manifestation
and multiple organ system involvements, which can be
serious enough to be fatal, unless diagnosed early and
treated. It requires a high index of suspicion. The general
physicians should be sensitized for the early diagnosis and
treatment to reduce morbidity and mortality.
Clinical Profile of Rickettsial Infections in Rural Bangalore
Introduction: Rickettsial diseases are veiled reemerging
infections, which pose a serious threat to public
health if not meticulously diagnosed. Rickettsial infections
are enlisted among the etiological factors attributed to cause
pyrexia of unknown origin.
Aims and Objectives: To identify Rickettsial infections
and study their clinical manifestations, trend and outcome
of all confirmed cases.
Materials and Methods: All patients aged 18 years and
above, admitted with acute febrile illness to MVJ MC&RH,
Bangalore between June 2017 to March 2018 were evaluated.
The patients were again divided into scrub typhus group,
spotted fever group and typhus group based on Weil Felix
titres. The outcome of patients with complications in each
group was evaluated.
Results: Out of 532 patients with acute febrile illness,
98 patients were found to have Rickettsial infections. Of
which 49 patients were diagnosed to have Scrub typhus,
24 patients as Spotted fever and 25 patients as Typhus
group fever. Most of them were young adults with mean
age of 37.7 years and male: female ratio of 1.2:1. All the
patients presented with fever (100%), Scrub typhus group
patients had myalgia(87%), headache(79%), Spotted fever
group had vomiting(79%) and macular rash(70%) and
typhus group had cough(76%) and abdominal pain(40%)
as predominant symptom.
Complications were more common in scrub typhus.
There were no mortality and most patients responded to
Doxycycline.
Conclusion: Rickettsial infections are a re-emerging
infection in India. It is an important cause of community
acquired undifferentiated febrile illness.
Is it Really Dilemma between Tuberculoma & Multiple NCC or Something Else ????
Introduction & Objectives: To study case series of
cases of tuberculoma and multiple NCC(neurocysticercosis)
as the uncertainty regarding their clinical & radiological
diagnosis is going on inspite of advances in the medical
and radiological sciences.
Materials & Methods: Blood investigations, USG,
EEG, ECG, CT- SCAN, MRI, MR SPECTROSCOPY, LP-CSF.
Results: We studied 5 cases present ing to us
with radiological finding suggestive of inflammatory
granulomas with confusion regarding diagnosis. We treated
these cases and repeat MRI after 6 wks. Out of these five
cases, two cases resolved by the symptoms clinically &
their lesions improved radiologically so we concluded
them to have multiple NCC but in remaining 3 cases
uncertainty continued as lesions persist even after 6 wks &
pts deteriorated clinically so we add ATT(Anti tuberculosis
treatment) as the LP-CSF (Lumbar puncture cerebrospinal
fluid )picture suggestive of tubercular meningitis &
concluded that these pts must have lesions of NCC with
tubercular meningitis.
Conclusions: Dilemma between tuberculoma &
multiple NCC might be there since long but tubercular
meningitis may be present in association with multiple
NCC in same pt or as dual pathology even in nonimmunocompromised
peoples.
A Review of Concurrent Infection with Dengue
Introduction: Acute undifferentiated febrile illness
is the most common presenting symptom during the
monsoon. Incidence of both vector and water-borne diseases
are highest during these seasons, co-infections of dengue
with enteric, malaria, scrub typhus, chikungunya and
other arboviruses can occur in endemic areas. Concurrent
infection with two agents can result in a illness having
overlapping symptoms creating diagnostic dilemma with
more complications.
Aims & Objectives: To study various coinfections of
dengue fever, their clinical manifestation and complications.
Materials and Methods: All cases of dengue with
coinfection (rickettsiae, enteric, malaria, Chikungunya),with
positive serology are considered for the study from MVJ
Medical College from the period of June 2017 to February
2018.
Results: In our study a total of 532 acute febrile
thrombocytopenia cases and 56 had dengue with
coinfection, most cases of coinfection are from Kolar belt,
of which most common was with Rickettsiae 26(46.4%),
with typhoid 15 (26.7%), with malaria 9(16%), with
chickungunya 6(10.7%).
Patients having Dengue with Rickettsial coinfection
presented with high grade fever(76.9%) with jaundice(34.6 )
and bleeding manifestations(19.2), dengue with typhoid had
predominantly gastrointestinal symptoms(53%), dengue
with malaria presented with bleeding(44%) manifestation
and myositis (22%), dengue with Chikungunya had
arthralgia(100%) and morning stiffness (22%).
Conclusion: Concurrent coinfection is not uncommon
and presents with overlap symptoms creating diagnostic
dilemma. Timely initiation of treatment and close
monitoring is advisable to avoid complication.
