Hydrogen sulphide alleviates cadmium stress in Trigonella foenum-graecum by modulating antioxidant enzymes and polyamine content

Cadmium (Cd) toxicity reduces growth and yield of crops grown in metal-polluted sites. Research was conducted to estimate the potential of hydrogen sulphide (H₂ S) to mitigate toxicity caused by Cd in fenugreek seedlings (Trigonella foenum-graecum L.). Different concentrations of CdCl₂ (Cd1-1 mM, Cd2-1.5 mM, Cd3-2mM) and H₂ S (HS1-100 µM, HS2-150 µM, HS3-200 µM) were assessed. Seeds of fenugreek were primed with sodium hydrosulphide (NaHS), as H₂ S donor. Seedlings growing in Cd-spiked media treated with H₂ S were harvested after 2 weeks. Cd stress affected growth of fenugreek seedlings. Cd toxicity decreased leaf relative water content (LRWC), intercellular CO₂ concentration, net photosynthesis, stomatal conductance and transpiration. However, application of H₂ S significantly improved seedling morphological attributes by increasing the activity of antioxidant enzymes, i.e. APX, CAT and SOD, in Cd-contaminated soil. H₂ S treatment also regulated phenolic and flavonoid content. H₂ S-induced biosynthesis of spermidine (Spd) and putrescine (Put) could account for the enhancement of growth and physiological performance of fenugreek seedlings under Cd stress. H₂ S treatment also reduced H₂ O₂ production (38%) and electrolyte leakage (EL, 51%) in seedlings grown in different concentrations of Cd. It is recommended to evaluate the efficacy of H₂ S in alleviating Cd toxicity in other crop plants.

Probing CP symmetry and weak phases with entangled double-strange baryons

Though immensely successful, the standard model of particle physics does not offer any explanation as to why our Universe contains so much more matter than antimatter. A key to a dynamically generated matter-antimatter asymmetry is the existence of processes that violate the combined charge conjugation and parity (CP) symmetry1. As such, precision tests of CP symmetry may be used to search for physics beyond the standard model. However, hadrons decay through an interplay of strong and weak processes, quantified in terms of relative phases between the amplitudes. Although previous experiments constructed CP observables that depend on both strong and weak phases, we present an approach where sequential two-body decays of entangled multi-strange baryon-antibaryon pairs provide a separation between these phases. Our method, exploiting spin entanglement between the double-strange Ξ- baryon and its antiparticle2 [Formula: see text], has enabled a direct determination of the weak-phase difference, (ξP - ξS) = (1.2 ± 3.4 ± 0.8) × 10-2 rad. Furthermore, three independent CP observables can be constructed from our measured parameters. The precision in the estimated parameters for a given data sample size is several orders of magnitude greater than achieved with previous methods3. Finally, we provide an independent measurement of the recently debated Λ decay parameter αΛ (refs. 4,5). The [Formula: see text] asymmetry is in agreement with and compatible in precision to the most precise previous measurement4.

POS0916 A 10-YEAR JOURNEY OF CARING FOR PATIENTS WITH SYSTEMIC SCLEROSIS: FOLLOW-UP DATA ON DISEASE DURATION OF THE LEIDEN CCISS COHORT

Background

Combined Care in Systemic Sclerosis (CCISS) is a prospective cohort of patients referred to Leiden University Medical Center for Raynaud’s Phenomenon (RP), a suspicion of systemic sclerosis (SSc) or a connective tissue disease. This cohort is characterized by its standardized and extensive annual follow-up. Since initiation of the cohort in 2009, diagnostic criteria for SSc have been updated leading to a higher sensitivity for early SSc (ACR 2013 criteria). A recent Dutch study showed that there is a gap to time of diagnosis between men and women, despite of overall increase of SSc awareness (PMID: 31539063).

Objectives

To determine whether 1. time between first disease symptoms and diagnosis has changed over time, and 2. disease characteristics of SSc at first presentation in an expert clinic have changed over time for the total cohort, and between male and female patients.

Methods

Patients included in the CCISS cohort undergo annual evaluation and clinical, laboratory, and imaging variables are systematically recorded. For this study, patients fulfilling the ACR/EULAR 2013 SSc criteria were included, and categorized into three groups based on the cohort entrance year: 1) 2010 – 2013, 2) 2014 – 2017, and 3) 2018 – 2021. SSc patients with a baseline visit in 2009 (n=65) were excluded as these patients were often not newly referred. Disease duration was defined by months since first RP, since first non-RP symptom and months between first date of diagnosis by a physician and first non-RP symptom. Disease characteristics included presence of interstitial lung disease (ILD), pulmonary arterial hypertension, digital ulcers (DU), diffuse cutaneous SSc, anti-topoisomerase and anticentromere antibodies. At baseline, disease duration and disease characteristics were compared between the three groups using appropriate tests. In addition, disease duration was compared between males and females in the three groups.

Results

In total, 643 SSc patients were included of whom 229 (36%) had their baseline visit from 2010 until 2013, 207 (32%) from 2014 until 2017, and 207 (32%) from 2018 until 2021.

The proportion of female patients was significantly higher in the 2010 – 2013 group compared to the 2014 – 2017 and 2018 – 2021 group (Table 1). Over time, disease duration defined by RP duration and non-RP duration decreased as well as time between diagnosis and first non-RP symptom (Table 1). The proportion of patients presenting with ILD and DU was highest in the first group (Table 1).

Table 1.2010 - 2013 N=2292014- 2017 N=2072018 – 2021 N=207P-valueBASELINEAge, mean (SD)53 (15)57 (14)55 (14)0.003Female, %8676750.010RP duration, months (IQR)122 (46 – 240)93 (20 – 202)67 (20 – 210)0.003Non RP duration, months (IQR)43 (16 – 227)20 (5 – 112)17 (6 – 54)<0.001Diagnosis duration, months (IQR)116 (80 - 177)65 (45 – 105)25 (5 – 45)<0.001ΔRP and Non-RP, months (IQR)24 (0 – 99)18 (0 – 118)22 (0 – 120)0.337Anti-centromere antibodies, %3843490.092Anti-topoisomerase antibodies, %2424180.259Diffuse cutaneous SSc, %1923160.073Interstitial lung disease, %433131<0.001Pulmonary arterial hypertension, %3240.746Digital ulcers, %2013110.041

In both male and female SSc patients, disease duration and time between diagnosis and first non-RP decreased over time with a longer time in females for all durations which was significantly different for time between first RP and non-RP in 2014-2017 and 2018-2021 (Figure 1). For the 2018 – 2021 group, duration since diagnosis for female was 26 (4 - 46) and male 17 months (7 – 39; p=0.355), and time between RP and non-RP for female 24 (0 - 168) and male 12 months (0 – 48; p=0.029).

Figure 1.

Conclusion

Over time, we observe a decrease in disease duration and in SSc patients presenting with ILD or DU at cohort entrance. Our results indicate increased awareness of early SSc and identification of SSc patients before severe complications have occurred. At the same time our results show the urge for specific attention to improve timely diagnosis in female SSc patients.

Disclosure of Interests

None declared

LB0003 WITHDRAWING METHOTREXATE AFTER BOTH VERSUS ONLY SECOND DOSE OF THE ChAdOx1 nCoV-19 VACCINE IN PATIENTS WITH AUTOIMMUNE INFLAMMATORY ARTHRITIS: TWO INDEPENDENT RANDOMIZED CONTROLLED TRIALS (MIVAC I AND II)

Background

Pausing methotrexate (MTX) for two to four weeks, improved immunogenicity of influenza vaccination in patients with rheumatoid arthritis (RA), albeit a risk of disease flare (1). This guided the framing of guidelines on MTX withdrawal for COVID-19 vaccination (2). However, evidence for MTX withdrawal for COVID-19 vaccination is limited to observational studies only.

Objectives

To compare the efficacy and safety of holding MTX after each (MIVAC 1) and only after the second dose (MIVAC II) of the ChAdOx1 vaccine versus continuation of MTX in two randomized controlled trials (RCTs).

Methods

Two single centre, investigator-blinded, RCTs were conducted in patients with RA or Psoriatic arthritis (PsA) on stable doses of MTX without prior COVID-19 (CTRI reg. no. MIVAC I: CTRI/2021/07/03463 & MIVAC II: CTRI/2021/07/035307). In MIVAC I, unvaccinated patients were randomised (1:1) to hold or continue MTX for two weeks after each dose of the vaccine. MIVAC II included patients who had continued MTX during the first dose of ChAdOx1 and were randomised (1:1) to hold or continue MTX for 2 weeks after the second vaccine dose. The primary outcome for both the trials was the anti-Receptor Binding Domain (RBD) antibody titres measured four weeks after the second vaccine dose (per protocol analysis). Secondary outcome was the flare rate, defined as an increase in disease activity scores (DAS28/cDAPSA) or physician intent to hike DMARDs.

Results

250 patients were randomized for MIVAC 1 and 178 for MIVAC II and after due exclusions, 158 and 157 were eligible for analysis respectively (Figure 1). In MIVAC I, median anti-RBD titres were significantly high in the MTX hold group [2484 (1050-4388) versus 1147(433-2360), p=0.001] but the flare rate was higher in the hold group [20 (25%) versus 6(8%) p=0.005] compared to continue group. In MIVAC II median anti-RBD titres were significantly high for the MTX hold group [2553 (1792-4823) versus 990 (356-2252), p=0.001] when compared to continue group but there was no difference in the flare rate between the groups [9(11.8%) and 4(7.9%), p=0.15] (Table 1). Since both were parallel studies in similar population, MTX hold arms across both the trials were compared for anti-RBD titres and flare. There was no difference in the anti-RBD titres [p=0.2] between the groups. In MIVAC I, 29(36.25%) patients had reported flare (19 in either first or second dose, 10 for both doses) when compared to MIVAC II where only 9(11.84%) patients had reported flare after the second dose (P <0.001).

Table 1.

Baseline demographics and key results

VariableMIVAC IMIVAC IIMTX HoldMTX ContinuePMTX HoldMTX ContinueP valueN=80N=78valueN=76N=81Age†48 (38-53.3)49 (39-59)0.1953 (42.3-59)53(50-62)0.14Female (%) ‡73 (91.3)75 (96.2)0.3365 (85.5)70 (86.4)>0.99RA (%) ‡69(86.3)69 (93.2)70 (85.6)80 (87.7)PsA (%) ‡11(13.8)6 (8.1)0.316 (7.9)1 (1.2)0.057DAS28†2.7 (2.4-3.2)2.6 (2-3.3)0.62.7(2.3-3.4)2.8 (2.1-3.5)0.78cDAPSA †2(3-4.5)2.5(1.3-3.8)0.463(2.8-3)30.15Prednisolone (%) ‡29 (36.3)23(31.1)0.424(31.6)26 (32.1)>0.99MTX mg/week†17.5 (10-25)15 (10-20)0.05715 (9.4-25)17.5(7.5-25)0.92Anti- RBD antibody titres post second dose (IU/mL) †2484 (1050-4388.8)1147.5 (433.5-2360.3)<0.0012553.5 (1792.5-4823.8)990.5 (356.1-2252.5)<0.001Flare (N%) ‡Post first dose20 (25)6 (8)0.005NANAPost second dose19 (23.8)10(13.3)0.19 (11.8)4 (7.9)0.15

All analysis as per protocol population.

†Median (interquartile range): Mann Whitney U test.

‡ N (%): Fisher Exact test

. Bolded if p<0.05.

Conclusion

Holding MTX after both the doses or only after the second dose of ChAdOx1 yields higher anti-RBD antibody titres as compared to continuing MTX. Comparing across the trials, holding MTX only after the second dose appears to be non-inferior to holding MTX after both doses of the vaccine with a lesser risk of flare.

References

[1]Park JK et al. Clin Rheumatol. 2020 Feb; 39(2):375-379.

[2]Curtis JR, et al. Arthritis & Rheumatology. 2021 Oct;73(10): e60-75.

Acknowledgements

Acknowledgments to all participating investigators, patients and their families

Disclosure of Interests

Anu Sreekanth: None declared, Teny Skaria: None declared, Sneha Joseph: None declared, Rashwith Umesh: None declared, Manju Mohanan: None declared, Aby Paul: None declared, Sakir Ahmed Speakers bureau: Sakir Ahmed had received honorarium as speaker from Pfizer, Dr Reddy’s, Cipla, and Novartis unrelated to this Comment, Pankti Mehta: None declared, Seena Oomen: None declared, Janet Benny: None declared, Justin George: None declared, Anagha Paulose: None declared, K Narayanan: None declared, Sanjana Joseph: None declared, Anuroopa Vijayan: None declared, Kaveri Nalianda: None declared, Padmanabha Shenoy: None declared

AB0551 CUTANEOUS LUPUS AREA AND SEVERITY INDEX(CLASI) CORRELATES WITH SELF-IMAGE SCORE BUT NOT QUALITY OF LIFE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Systemic lupus erythematosus (SLE) has multi-system involvement including skin. We explored how skin involvement influenced with the quality of life of patients with SLE.

Objectives

To correlate the domains of SLE QoL with skin involvement and total lupus disease activity.

Methods

A cross-sectional survey of patients with SLE was carried out to assess Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) and SLE-QoL. Lupus disease activity and damage were quantified using Mex-SLEDAI (Mexican SLE Disease Activity Index) and SLICC (Systemic Lupus International Collaborating Clinics) Damage Index respectively. Data is expressed as median (IQR).

Results

In the cohort of 35 patients with SLE, with an age of 26(IQR:17-32) years and including eight (22.8%) males, the CLASI score was 5.5(IQR:3-11.5) with an activity score of 3(1-5) and a chronicity score of 1(0-4). The disease duration was 4years (IQR: 2-3) while SLE-QoL was 73(62-86). Overall, most of the patients had active disease at inclusion with a mex-SLEDAI of 8(6.5-11.5). SLICC was 1(0-4).

The correlation matrix of different domains of the SLE-QoL with CLASI, and Mex-SLEDAI is presented in Table 1. Correlation with SLICC was not analysed since it was zero in the majority of participants. Multivariate analyses were not done since there was lack of association on univariate analysis.

Table 1.

Correlations between different domains of the SLE(Systemic Lupus Erythematosus) -QoL(Quality of Life) with CLASI (Cutaneous Lupus Area and Severity Index) and Mexican SLE-DAI(SLE Disease Activity Index).

SLE-QoL DomainsPhysical functioningPhysical activitySymptomsTreatmentMoodSelfimageTotalCLASI Activity.028-.062.242.103.113.252.102(p=0.87)(p=0.73)(p=0.16)(p=0.56)(p=0.52)(p=0.15)(p=0.56)CLASI Damage.125.010.257.239.233.446**.243(p=0.47)(p=0.95)(p=0.13)(p=0.17)(p=0.18)(p=0.007)(p=0.16)CLASI total.047-.062.448*.331.332.315.281(p=0.80)(p=0.75)(p=0.013)(p=0.07)(p=0.07)(p=0.09(p=0.13)Mexican SLEDAI SCORE.001.130.390*.251.115.197.200(p=0.99)(p=0.47)(p=0.025)(p=0.16)(p=0.52)(p=0.27)(p=0.27)

Conclusion

In this cohort of patients with active SLE, the SLE-QoL did not correlate with either the overall disease activity score nor the skin specific score. Only the Self-image domain correlated with the skin score. This implies that in active disease, the skin involvement may have only a minor effect on the quality of life.

References

[1]Klein R, Moghadam-Kia S, LoMonico J, Okawa J, Coley C, Taylor L, Troxel AB, Werth VP. Development of the CLASI as a tool to measure disease severity and responsiveness to therapy in cutaneous lupus erythematosus. Archives of dermatology. 2011 Feb 1;147(2):203-8.

[2]Leong KP, Kong KO, Thong BY, Koh ET, Lian TY, Teh CL, Cheng YK, Chng HH, Badsha H, Law WG, Lau TC. Development and preliminary validation of a systemic lupus erythematosus-specific quality-of-life instrument (SLEQOL). Rheumatology. 2005 Oct 1;44(10):1267-76.

Disclosure of Interests

None declared

P19 A service evaluation to assess antimicrobial resistance in penicillin allergy

Background

Antibiotic consumption is one of the main drivers for antimicrobial resistance (AMR). To improve clinical outcomes and tackle AMR, we need to improve antibiotic usage in patients with penicillin allergy (PenA). Patients with PenA have been found to have higher antibiotic usage, often requiring repeated courses of antibiotics compared with those without PenA. Additionally, patients with PenA are more likely to receive broad spectrum antibiotics.

Objectives

To determine whether patients who have PenA are more likely to be colonized or infected with resistant bacteria.

Methods

Data were extracted from the pathology reporting system (Telepath) for blood culture specimens isolating Staphylococcus aureus and Streptococcus pneumoniae between 2017 and 2019 at Leeds Teaching Hospitals NHS Trust. Sputum samples from 2019 that isolated S. pneumoniae and Haemophilus influenzae were also analysed. These organisms/samples were chosen as these would indicate the presence of an infection where a penicillin would normally be used as first-line therapy. Where patients had multiple samples only the first sample obtained during the study period was included in the analysis. Standard descriptive statistics was used to summarize the data and characteristics were cross tabulated with penicillin allergy status.

Results

S. pneumoniae isolated from blood cultures: A total of 297 patients were included in the analysis, 33/297 (11.1%) had PenA, 50.8% were female and the median age was 60 years (IQR 37–75). Susceptibility results are summarized in Figure 1. Resistant isolates are comprised of isolates with resistant or intermediate susceptibility. S. aureus isolated from blood cultures: Analysis included 783 isolates from first patient encounters, 97/783 (12.4%) patients had PenA, 35.1% were female and the median age was 58 years (IQR 39–74.5). Susceptibility results are summarized in Figure 2. S. pneumoniae isolated from sputum: A total of 156 isolates were included in the final analysis: 29/156 (18.6%) patients had PenA, 53.3% were female and the median age was 67 years. Susceptibility results are summarized in Figure 3. H. influenzae isolated from sputum: A total 719 samples were included, 122/719 (15.8%) patients had PenA, 55.9% were female and median age was 67 years. Susceptibility results are summarized in Figure 4.

Conclusions

PenA prevalence differs across different patient populations. A higher proportion of patients with PenA had resistance in S. pneumoniae sputum isolates compared with those without, however this finding did not meet statistical significance. Further studies evaluating the impact of PenA on AMR need to be conducted.

Observation of the Singly Cabibbo Suppressed Decay Λ_{c}^{+}→nπ^{+}

The singly Cabibbo-suppressed decay Λ_{c}^{+}→nπ^{+} is observed for the first time with a statistical significance of 7.3σ by using 3.9  fb^{-1} of e^{+}e^{-} collision data collected at center-of-mass energies between 4.612 and 4.699 GeV with the BESIII detector at BEPCII. The branching fraction of Λ_{c}^{+}→nπ^{+} is measured to be (6.6±1.2_{stat}±0.4_{syst})×10^{-4}. By taking the upper limit of branching fractions of Λ_{c}^{+}→pπ^{0} from the Belle experiment, the ratio of branching fractions between Λ_{c}^{+}→nπ^{+} and Λ_{c}^{+}→pπ^{0} is calculated to be larger than 7.2 at the 90% confidence level, which disagrees with most predictions of the available phenomenological models. In addition, the branching fractions of the Cabibbo-favored decays Λ_{c}^{+}→Λπ^{+} and Λ_{c}^{+}→Σ^{0}π^{+} are measured to be (1.31±0.08_{stat}±0.05_{syst})×10^{-2} and (1.22±0.08_{stat}±0.07_{syst})×10^{-2}, respectively, which are consistent with previous results.

Predictors of Malignancy in Thyroid Nodules

Thyroid swellings are common clinical problem throughout the world and also in Bangladesh. Most of thyroid swellings are multinodular, but a good percentage is solitary thyroid nodule. There is no robust, feasible method for malignancy differentiation has not been well established. The study evaluated thyroid nodules for risk of malignancy and compared history, clinical, sonographic features and FNAC findings with histopathology. This was a cross sectional study on 160 consecutive subjects of thyroid nodules done in the department of ENT and Head Neck Surgery of Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh during from July 2018 to December 2019. All patients were admitted and diagnosed by detail history, clinical examination, investigations and underwent thyroidectomy. Detailed history, clinical examination, ultrasonographic finding and FNAC variables were documented retrospectively and a mathematical model was established for malignancy prediction. In this study mean age of the patients of thyroid nodules was 37.54±11.49 years and majority of the patients were within 21-40 years of age. Frequency of thyroid nodules is more in female with male female ratio 1:7. Most of the thyroid nodules appeared in this study within 0-2 years (61.9%). In this series of thyroid nodules constituted 88.1% firm, 8.8% hard, 3.1% cystic. Among the patients 89(55.6%) cases have solitary thyroid nodule and 71(44.4%) cases have multinodular goitre Majority of the nodules were warm 57.5% followed by cold 42.5%. FNAC showed nodular goitre 72.5%, Follicular neoplasm 1.3%, Papillary carcinoma of thyroid 7.5%, colloid goitre 9.4%, suspicious papillary carcinoma 3.8% and lymphocytic thyroiditis 1.3%. In this study out of 85 solid nodule, 69(81.18%) were benign and 16(18.82%) was malignant and out of 3 cystic nodule 3(100%) were benign. In this study most of the benign and malignant nodules were predominantly solid. Study showed the malignancy is significantly (p=0.001) more in solid than cystic nodules. Final diagnosis in this study was done on the basis of histopathological reports. Out of 160 patients, histopathologically benign lesion was 120(75%) and malignant was 40(25%). Among malignant cases 36(22.5%) cases were papillary carcinoma, 1 case was medullary carcinoma and 3 cases were follicular carcinoma.

Molecular docking-based interactions in QSAR studies on Mycobacterium tuberculosis ATP synthase inhibitors

Tuberculosis (TB) is a global threat with a large burden across the continents in terms of mortality, morbidity, and financial losses. The disease has evolved into multi-drug-resistant (MDR-TB) and extensively drug-resistant (XDR-TB) tuberculosis owing to numerous factors ranging from patients' non-compliance to demographical implications. There have been very few new drugs for resistant TB. Resistance has already been reported even for the newly introduced drug bedaquiline. An attempt has been made to integrate both structure-based and QSAR drug design techniques (QSAR-SBDD) for the identification of novel leads. The docking scores normally do not correlate with the activity. Hence, the docking results have been analysed in terms of the number of interactions rather than docking scores. The parameters derived from interactions have been used in developing the QSAR models. The best model shows a good correlation (r = 0.908) between the activity and interaction parameter 'C' describing the sum of all the interactions with each amino acid residue. This model also predicts external dataset with a good correlation (r_ext = 0.851) and can be used for the identification of novel chemical entities (NCEs) and repurposed drugs for TB therapeutics.

Finding gaps in routine TB surveillance activities in Bangladesh

BACKGROUND :

TB was the leading cause of death from a single infectious pathogen globally between 2014 and 2019. Fine-scale estimates of TB prevalence and case notifications can be combined to guide priority-setting for strengthening routine surveillance activities in high-burden countries. We produce policy-relevant estimates of the TB epidemic at the second administrative unit in Bangladesh.

METHODS :

We used a Bayesian spatial framework and the cross-sectional National TB Prevalence Survey from 2015–2016 in Bangladesh to estimate prevalence by district. We used case notifications to calculate prevalence-to-notification ratio, a key metric of under-diagnosis and under-reporting.

RESULTS :

TB prevalence rates were highest in the north-eastern districts and ranged from 160 cases per 100,000 (95% uncertainty interval [UI] 80–310) in Jashore to 840 (UI 690–1020) in Sunamganj. Despite moderate prevalence rates, the Rajshahi and Dhaka Divisions presented the highest prevalence-to-notification ratios due to low case notifications. Resolving subnational disparities in case detection could lead to 26,500 additional TB cases (UI 8,500–79,400) notified every year.

CONCLUSION :

This study is the first to produce and map subnational estimates of TB prevalence and prevalence-to-notification ratios, which are essential to target prevention and treatment efforts in high-burden settings. Reaching TB cases currently missing from care will be key to ending the TB epidemic.

Concurrent Infection of Orientia Tsutsugamushi with Rickettsia spp. Including Rickettsia felis in North Central Bangladesh

Rickettsial diseases are one of the leading causes of treatable acute febrile illness in Asia pacific region. This cross-sectional descriptive study was conducted at Department of Microbiology, Mymensingh Medical College to diagnose scrub typhus by rapid Immunochromatographic Test (ICT) and Nested PCR followed by molecular identification of possible Rickettsial coinfection among suspected febrile patients in Mymensingh, Bangladesh from March 2019 to February 2020. Among the enrolled 402 patients, 89 samples (22.13%) were seropositive by Immunochromatographic Test (ICT) and 65 samples (16.16%) were positive for O. tsutsugamushi DNA by Nested PCR, targeting 47KDa gene. Therefore, 113/402 (28.10%) samples were positive for scrub typhus by PCR and/or ICT. All the scrub typhus positive samples were further subjected to Nested PCR targeting 17 KDa gene for identification of Rickettsial co-infection and 13/113 (11.50%) were documented as positive. Then 13 Rickettsial co-infected samples were undertaken to automate sequencing and all were genetically confirmed as Rickettsia felis. Findings of the study may help clinicians to expand their list of differential diagnoses for undifferentiated fever and detection of Rickettsial co-infection may guide them to prescribe effective antimicrobials.