| Infectious Diseases |
1. Clinical Profile of A Recent Viral Epidemic in Ernakulam district of Kerala – A Study from MOSC Medical College, Kolenchery, Kerala K George, A Jacob, L Paul, V Abraham 100 cases of suspected Chikungunya fever (56 F and 44 M) admitted in the medical wards of our hospital during a period of one month (May 15th to June 28, 2007) were analysed. Though differentiation from other fevers like Dengue, Leptospirosis, Malaria etc., prevalent in this area was not easy, certain features pointed to Chikungunya fever. Onset was abrupt with high fever and chills in 100%. Joint pain preceded fever in 12%. The most characteristic feature was its association with crippling joint pain in 95%, mostly involving the wrist, fingers of the hand, knee, ankle and foot. Swollen joints were present in 30%. Other features were myalgia in 80%, conjunctival congestion in 75%, severe headache in 70%, itchy maculo-erythematous rashes in 52%, aphthous ulcer in 30% and leucopenia (3000-5000) in 90%. 2. Study of Endothelial Dysfunction, Insulin Resistance and Dyslipidemia in HIV Patients Receiving HAART in India Shailesh, S Kumar, D Manocha, RB Thandessary, S Debbarma,
D Kothari, V Sharma Introduction : With the introduction of Highly Active Anti-Retroviral Therapy (HAART) for HIV, patients of HIV/AIDS have increased survival but with increased incidence of metabolic and cardiovascular events as reported in the western countries. Since the Indian population is predisposed to insulin resistance and its metabolic and cardiac effects; this study was undertaken to evaluate these effects of HAART in Indian population. Material and Methods : 60 newly diagnosed cases of HIV were divided into 2 groups; study group (cases receiving HAART) and control group (not on any retroviral therapy). Baseline investigations including blood sugar (fasting and post prandial), fasting lipid profile and insulin levels were done for all patients and repeated after 6 months. Insulin resistance was calculated using HOMA method and endothelial dysfunction was measured by carotid intima media thickness (IMT). Results : Mean IMT in study group was 0.45 mm which
increased by 0.17 mm (P < 0.001) to 0.62 mm after 6 months of
HAART while, IMT was 0.44 mm in control group which increased
by 0.02 mm to 0.466 mm. Mean Insulin resistance was 0.74
mmol2/L2 at baseline in both groups, which increased to 3.25
mmol2/L2 (P < 0.001) in study group while it was 0.90 mmol2/L2
in control group. 3 (10%) patients developed fresh onset diabetes,
65% had impaired glucose metabolism and 60% had dyslipidemia
after taking 6 months of HAART. These effects of HAART were
more in the study group as compared to data from western
population. Conclusion : Increased insulin resistance, endothelial dysfunction and dyslipidemia are seen in Indian HIV patients receiving HAART; this needs initiative for early diagnosis and possible treatment of these complications to decrease mortality and morbidity in these patients. 3. Bone Marrow Evaluation in Patients with Fever of Unknown Origin (FUO) VR Srinivasan, RB Anand, Roshni Paul, PA Krishna,
MVS Subbalaxmi, Mallikarjuna Shetty Objectives : Evaluation of Bone Marrow Study in patients
with FUO Material and Methods : Sixty five patients with FUO were
subjected to Bone Marrow aspiration, Biopsy and Culture as a
part of regular workup. Results : The mean age was 36 years. Thirty seven (56.9%) were males. Bone marrow studies alone were positive for disease in 16 (24%). TB was seen in 6, Hodgkin’s disease in 2, Leukemia in 2, Metastatic Carcinoma in 3, Megaloblastic Anemia in 2, Hemophagocytic in 1. However, follow up and further investigations yielded more diagnosis in 37 (56%) TB in 20, connective tissue disorder in 6, spleenic abscess in 2, infective endocarditis in 1, UTI in 2, NHL in 1, Hodgkin’s disease in 2, Kikuchi’s lymphadenitis in 2 and Hashimoto’s thyroiditis in 1. Twelve (18.4%) remained undiagnosed. Conclusion : Bone marrow testing in patients with FUO is an important though not infalliable procedure. 4. Infective Lobular Panniculitis in an Immunocompetent Individual with Penicillium Non Marneffei Species Infection : A Rare and Unusual Case Report S Kanjilal, S Sankar, S Kumar, E Jayasheelan, G Singh The Panniculitides represent a group of heterogeneous inflammatory diseases that involve subcutaneous fat. Infective Panniculitis mostly occurs in immunosuppressed patients. Penicillium marneffei, endemic in SE Asia, is the only one to cause significant human disease in the immunocompetent. A rare and interesting case of infective lobular panniculitis in an immunocompetent Indian with no history of travel to Penicillium endemic area is described in this report. A 55 year old man presented repeatedly with an indurated subcutaneous plaque over his abdomen progressively spreading to trunk and thighs associated with intermittent fever. After extensive evaluation, histopathological examination of skin biopsy specimen clinched the diagnosis. Tissue fungal cultures grew non marneffei species of Penicillium. Patient responded to therapy with 2 weeks of Amphotericin B, followed by 10 weeks of Itraconazole. 5. A Rare Case of PUO Due to Brucella Suis : A Case Report K Naha, S Seshadri, V Pandit, V Rohith A 27 year old male presented with fever of prolonged duration
with chills and weight loss. Examination revealed 6. Prognostic Markers of Cryptococcal Meningitis in HIV S Majumder, D Bandyopadhyay, SK Mandal Introduction : Medical College Kolkata treats the largest
number of admitted HIV patients in Eastern India and Aims and Objectives : To identify prognostic markers in HIV patients with Cryptococcal meningitis. Material and Methods : 30 HIV patients were diagnosed to
have CM based on CSF studies (India Ink preparation and Antigen
assays). Clinical and laboratory parameters were regularly
recorded. Treatment was initiated with IV Amphotericin B.
Outcome was recorded either as death (Group A) or clinical cure
(Group B). Results : Group A had lower mean GCS and higher incidence of papilledema as compared to Group B (7.2 versus 13.9 and 100% versus 13.8%, respectively). India Ink positivity and CD4 counts were all significantly lower in Group A while CSF cell counts were higher in this group. A prior diagnosis of HIV infection was not contributory to this prognostic assessment. Conclusion : We conclude that low GCS and presence of papilledema at admission, India Ink positivity, high CSF cell counts and low CD4 counts are poor prognostic markers of CM in HIV. 7. Diagnosis of Tuberculous Meningitis in Adults B Harikishan, A Ganesh To date, there is no diagnostic tool to diagnose tuberculous meningitis which is rapid, reliable, inexpensive and easily available in developing countries where TBM (tuberculous meningitis) is very common. This study looked at the admission parameters which independently predict TBM. Study design : A prospective study involving all adult patients presenting with clinical features of meningitis with CSF (cerebrospinal fluid) abnormalities on laboratory testing (All meningitis patients admitted to the medical wards between March 2003 and April 2005 were enrolled in the study). Material and Methods : This study was done to validate already proposed diagnostic algorithm or indices to diagnose TBM early in the course with more confidence which would result in prompt initiation of anti tuberculosis therapy. Results : Sensitivity and specificity of the diagnostic index derived by Thwaites1 et al was 97% and 56% respectively for the diagnosis of tuberculous meningitis. According to diagnostic algorithm proposed by Rashmikumar,2 for a patient with 3 or more features, sensitivity and specificity to diagnose tuberculous meningitis was found to be 35% and 85.3% respectively. 8. Hypertension Outcome and Physician Awareness Study (HOPAS) I Ramya, G Alka, B Harikishan Introduction : High blood pressure is a well-known cardiac risk factor, it is associated with stroke, visual impairment, and renal failure. The awareness of the advantages of adequate blood pressure control among patients and physicians may be lacking. Aim : (1)Adequacy of blood pressure control as per blood pressure reading in 3 OPD visits, assessment of target organ damage, (2) Anti-hypertensive preference and favored drugs for combination therapy, (3) Physician assessment of treatment adequacy and (4) Most common drug side effects reported. Material and Methods : The patients attending the medicine out patient department (med 3) who are hypertensives will be included in the study. It is a cross sectional study. Then their blood pressure reading at current OPD was assessed, their drug list, side effect profile of drugs, co morbidities and target organ damage due to hypertension were noted. Then patients were followed up for a period of 3 months to see their adequacy of control. Results : The most common anti hypertensive used among our patients was ACE inhibitors. 28% of the patients had their blood pressure in adequate control (120/80 – 130/90 mmhg) and around 18% had very high blood pressure (< 160/110 mmhg), the remaining patients blood pressure fell within the range of 140-150/90-109 mmhg. Target organ damage assessment, all patients had their creatinine checked in the last one year, 50% of patients had an ECG and 71% had an urine routine, but < 0.01% of patients only had an fundus evaluation. 9. Rare Manifestation of Immune Reconstitution Inflammatory Response Syndrome M Vidhate*, S Yadav**, Rosemarie de’Souza*** Introduction : Immune reconstitution inflammatory response syndrome (IRIS) occurs in 17-25% of patients after starting on Highly Active Antiretroviral therapy (HAART). Infectious agents are common etiologies. Noninfectious etiologies like malignancies are rare. We report two cases of lymphoma (B-cell and T-cell) developed after starting HAART. Case 1 : First patient presented with left ankle swelling 3
months after starting HAART. Tissue biopsy showed T-cell
lymphoma. Case 2 : Second patient presented with swelling of hard palate
4 months after starting HAART Tissue biopsy showed B-cell
lymphoma. Both patients had CD4 count above 200 at presentation. Both patients responded to chemotherapy. Conclusion : Malignancies presenting as IRIS is rare. In IRIS new malignancies can develop previously treated malignancies can relapse. 10. Stavudine Induced Optic Neuritis M Vidhate*, S Yadav**, Rosemarie de’Souza*** Introduction : Peripheral neuropathy is common side effect of
stavudine. Stavudine causing optic neuritis is rare. We report a
case of stavudine induced optic neuritis. Case : Our patient presented with diminution of vision and tingling numbness of lower limbs 3 months after starting stavudine based antiretroviral therapy. Visual Evoked potential (VEP) showed bilateral optic neuritis. All infectious causes; demyelination causing optic neuritis were excluded. Stavudine was stopped and was replaced by zidovudine. Patient noticed fifty percent improvement in vision after stopping stavudine. Conclusion : Optic neuritis following stavudine based Highly Active Anti Retroviral. Therapy is rare. 11. Neurological Manifestations in AIDS Cases V Magesh, TK Anand, M Jubilee, G Usha, SE Dhanasekaran,
V Rajiv, VK Rajamani, SP Thirumalaikolundu Aim : To study the pattern of neurological manifestations in AIDS patients and to correlate with their CD4 count. Methods : A total of 100 (M=75, F=25) consecutive new cases of AIDS admitted to Government General Hospital during 2005-2007 after institutional ethical clearance and informed consent were subjected to detailed History, physical examination including mini mental score and relevant investigations (complete Blood count, Renal function test, Liver function test, Chest X-ray and CD4 counts). CSF analysis including VDRL, Serum Creatinine Phosphokinase, Imaging, Nerve conduction study, Electro encephalogram were also carried out among selected cases. The data were analysed statistically. Results : Among them 32 (M=29, F=3) had one or other neurological manifestations. Clinical presentations were headache (n=13), altered sensorium (n=14), seizures (n=8), hemiplegia (n=4), Paraparesis (n=4), parasthesias (n=2), Cerebellar syndrome (n=2), quadriparesis (n=1), and involuntary movements (n=1). CD4 count varied from 9 to 539 with median of 180. The neurological disorders were in many forms. Tuberculous meningitis was the most commonest opportunistic infection and noticed in 10 patients. 18 of them expired, five improved and nine left home with sequale. Comments : Neurological illness were more in males and was significant Even though neurological manifestations were independent of CD4 cell count, if below 100, their prognosis was grave. Hence it is suggested that physicians should be alert if CD4 cell count is low when AIDS patients develop neurological manifestations. 12. A Study of Hepatitis B and C Co-infection in HIV Positive Patients GK Sojan, B Sreejesh, D Rajasekaran, Subbaragavalu,
SP Thirumalaikolundu Aims : To find out the prevalence of Hepatitis B and Hepatitis C co-infection in HIV patients and to assess the impact co-infection on hepatic status in HIV patients. Material and Methods : After ethical committee clearance and informed consent, one hundred HIV positive patients attending antiretroviral treatment centre who satisfied a rigid inclusion and exclusion criteria were selected and screened for Hepatitis B surface antigen and anti HCV using third generation ELISA. Liver function tests and ultrasonography of abdomen was done. The data was analyzed statistically and compared with the prevalence of co-infection in healthy controls. Results : The prevalence of HBV co-infection was 8%, HCV co infection was 4% and both together was 1% which was statistically significant when compared to healthy controls. There was also a statistically significant elevation of liver enzymes in HIV patients with co-infection. Conclusion : On the basis of higher prevalence rates for hepatitis co-infection, routine screening of these viruses is necessary in HIV positive population. The high prevalence of co-infection may be due to same route of infection. Close monitoring of hepatic status is recommended in those with co-infection. A Study of NT-Pro BNP Levels in Patients of Septic Shock : Prognostic Implications and Relationship to Myocardial Dysfunction Shaily Singh, SK Saxena Objective of the Study : In patients of septic shock, factors other than myocardial stretch may be responsible for the release of NT-Pro BNP. Thus, rise in NT-pro BNP in these patients does not essentially co-relate with myocardial dysfunction. In this study our objective is to study levels of NT-Pro BNP in patients of septic shock and to assess its correlation with myocardial dysfunction. We also intend to study the role of NTpro BNP as a prognostic marker in pts of septic shock. Methodology : 30 patients with septic shock (in accordance with the criteria of the American College of Chest Physician and Society of Critical Care Medicine)without any prior history of cardiac illness were selected. Levels of NT-Pro BNP were done (sandwich immunoassay method – Elecsys 2010 (Roche Diagnostics, Mannheim, Germany) from blood sample drawn at presentation. Ejection fraction was assessed by echocardiography on day of presentation. Summary of Results : NT-pro BNP levels were elevated in all the pts of septic shock. Ejection fraction was decreased in 14 of the 30 patients (46.6%). Levels at admission were significantly high in hospital nonsurvivors (median , 7908 pg/mL) compared with survivors (median, 3479 pg/mL). Conclusion : NT-pro BNP values are frequently increased in septic shock. Values are significantly higher in nonsurvivors than survivors. Levels were increased in patients with septic shock regardless of the presence or absence of cardiac dysfunction. Thus, NT pro-BNP levels cannot be used as a marker for the presence of myocardial dysfunction in septic shock, but it does serve as a prognostic marker. |