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Cabada MM, Aguilar PV, Rodas JD, Hidalgo M, Mozo K, Gonzalez-Diaz ES, Jimenez-Coello M, Diaz FJ, Dacso MM, Ortega-Pacheco A, Arboleda M, Walker DH, Weaver SC, Melby PC. Establishment of a multisite umbrella cohort study protocol to describe the epidemiology and aetiologies of acute undifferentiated febrile illness in Latin America. BMJ Open 2024; 14:e083560. [PMID: 39038857 DOI: 10.1136/bmjopen-2023-083560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2024] Open
Abstract
INTRODUCTION Acute undifferentiated febrile illnesses (AUFIs) impose a large burden in the tropics. Understanding of AUFI's epidemiology is limited. Insufficient diagnostic capacity hinders the detection of outbreaks. The lack of interconnection in healthcare systems hinders timely response. We describe a protocol to study the epidemiology and aetiologies of AUFI and pathogen discovery in strategic areas of Latin America (LA). METHODS AND ANALYSIS Global Infectious Diseases Network investigators comprising institutions in Colombia, Dominican Republic, México, Perú and the USA, developed a common cohort study protocol. The primary objective is to determine the aetiologies of AUFI at healthcare facilities in high-risk areas. Data collection and laboratory testing for viral, bacterial and parasitic agents are performed in rural and urban healthcare facilities and partner laboratories. Centralised laboratory and data management cores deploy diagnostic tests and data management tools. Subjects >6 years with fever for <8 days without localised infection are included in the cohort. They are evaluated during the acute and convalescent phases of illness. Study personnel collect clinical and epidemiological information. Blood, urine, nasal or pharyngeal swabs and saliva are collected in the acute phase and blood in convalescent phase. Specimens are banked at -80°C. Malaria, dengue and COVID-19 are tested onsite in the acute phase. The acute-phase serum is PCR tested for dengue, chikungunya, Venezuelan equine encephalitis, Mayaro, Oropouche, Zika, and yellow fever viruses. Paired convalescent and acute serum antibody titters are tested for arbovirus, Leptospira spp, and Rickettsia spp. Serum is used for viral cultures and next-generation sequencing for pathogen discovery. Analysis includes variable distributions, risk factors and regression models. Laboratory results are shared with health authorities and network members. ETHICS AND DISSEMINATION The protocol was approved by local ethics committees and health authorities. The results will be published in peer-reviewed journals. All study results are shared with local and regional health authorities.
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Affiliation(s)
- Miguel Mauricio Cabada
- Division of Infectious Diseases, The University of Texas Medical Branch at Galveston Department of Internal Medicine, Galveston, Texas, USA
- Cusco Branch - Alexander von Humboldt Tropical Medicine Institute, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Patricia Veronica Aguilar
- Department of Pathology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Center for Tropical Diseases, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | | | - Marylin Hidalgo
- Departamento de Microbiologia, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Karen Mozo
- Cusco Branch - Alexander von Humboldt Tropical Medicine Institute, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Eugenia Smirna Gonzalez-Diaz
- Laboratorio de Investigacion de Enfermedades Emergentes y Biología Molecular, Universidad Central del Este, San Pedro de Macoris, Dominican Republic
| | - Matilde Jimenez-Coello
- Departamento de Salud Animal y Medicina Preventiva, Universidad Autónoma de Yucatán, Merida, Mexico
| | | | - Mathew M Dacso
- Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Antonio Ortega-Pacheco
- Departamento de Salud Animal y Medicina Preventiva, Universidad Autónoma de Yucatán, Merida, Mexico
| | - Margarita Arboleda
- Instituto Colombiano de Medicina Tropical Antonio Roldan Betancur, Apartado, Antioquia, Antioquia, Colombia
| | - David H Walker
- Department of Pathology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Scott C Weaver
- Center for Tropical Diseases, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Institute for Human Infections and Immunity, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Peter C Melby
- Division of Infectious Diseases, The University of Texas Medical Branch at Galveston Department of Internal Medicine, Galveston, Texas, USA
- Center for Tropical Diseases, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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Silva-Ramos CR, Gil-Mora J, Serna-Rivera CC, Martínez Díaz HC, Restrepo-López N, Agudelo-Flórez P, Arboleda M, Díaz FJ, Faccini-Martínez ÁA, Hidalgo M, Melby PC, Aguilar PV, Cabada MM, Tobón-Castaño A, Rodas JD. Etiological characterization of acute undifferentiated febrile illness in Apartadó and Villeta municipalities, Colombia, during COVID-19 pandemic. LE INFEZIONI IN MEDICINA 2023; 31:517-532. [PMID: 38075419 PMCID: PMC10705856 DOI: 10.53854/liim-3104-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/02/2023] [Indexed: 03/28/2024]
Abstract
Background Acute undifferentiated febrile illness (AUFI) is one of the leading causes of illness in tropical regions. Although malaria is the most important cause, other pathogens such as Dengue (DENV), Leptospira and recently, Coronavirus Disease 2019 (COVID-19) have gained importance. In Colombia, few studies aimed to identify the etiology of AUFI. Most of them performed in Apartadó and Villeta municipalities, identifying the active circulation of several pathogens. Thus, we conducted a cross-sectional study in these municipalities to characterize the etiologies of AUFI during COVID-19 pandemic. Methods An active surveillance was conducted between September and December 2021 in local hospitals of Apartadó and Villeta municipalities. Febrile patients were enrolled after voluntarily agreeing to participate in the study. Ten different etiologies were evaluated through direct, serological, molecular and rapid diagnostic methods. Results In Apartadó a confirmed etiology was found in 60% of subjects, DENV (25%) being the most frequent, followed by leptospirosis (16.7%), malaria (10%), COVID-19 (8.3%), spotted fever group (SFG) rickettsiosis (6.7%) and Chikungunya (1.7%). In Villeta, a specific etiology was confirmed in 55.4% of patients, of which SFG rickettsiosis (39.3%) was the most frequent, followed by leptospirosis (21.4%), DENV (3.6%) and malaria (1.8%). No cases due to Mayaro, Yellow Fever, Oropouche and Venezuelan Equine Encephalitis viruses were detected. Conclusion We confirm the relevance of dengue fever, leptospirosis, SFG rickettsiosis, COVID-19 and malaria as causes of AUFI in the municipality of Apartadó, and highlight the great importance of SFG rickettsiosis as the main cause of AUFI in the municipality of Villeta.
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Affiliation(s)
- Carlos Ramiro Silva-Ramos
- Grupo de Enfermedades Infecciosas, Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Juliana Gil-Mora
- Grupo de Enfermedades Infecciosas, Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Cristian C. Serna-Rivera
- Grupo de Investigación en Ciencias Veterinarias Centauro, Universidad de Antioquia, Medellín, Colombia
| | - Heidy-C. Martínez Díaz
- Grupo de Enfermedades Infecciosas, Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Nicaela Restrepo-López
- Grupo de Investigación en Ciencias Veterinarias Centauro, Universidad de Antioquia, Medellín, Colombia
| | - Piedad Agudelo-Flórez
- Grupo de Investigación en Ciencias Básicas, Escuela de Graduados, Universidad CES, Medellín, Colombia
| | - Margarita Arboleda
- Instituto Colombiano de Medicina Tropical, Universidad CES, Medellín, Colombia
| | - Francisco J. Díaz
- Grupo de Inmunovirología, Universidad de Antioquia, Medellin,Colombia
| | - Álvaro A. Faccini-Martínez
- Servicio de Infectología, Hospital Militar Central, Bogotá, Colombia
- Servicios y Asesorías en Infectología - SAI, Bogotá, Colombia
- Facultad de Medicina, Universidad Militar Nueva Granada, Bogotà, Colombia
| | - Marylin Hidalgo
- Grupo de Enfermedades Infecciosas, Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Peter C. Melby
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
- Center for Tropical Diseases, University of Texas Medical Branch, Galveston, Texas, USA
| | - Patricia V. Aguilar
- Center for Tropical Diseases, University of Texas Medical Branch, Galveston, Texas, USA
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Miguel M. Cabada
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
- Center for Tropical Diseases, University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Juan David Rodas
- Grupo de Investigación en Ciencias Veterinarias Centauro, Universidad de Antioquia, Medellín, Colombia
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Khairkar M, Vagha S, Deotale V. Review on Scrub Typhus: An Important Etiology of Acute Undifferentiated Fever Illness. Cureus 2023; 15:e47290. [PMID: 38021775 PMCID: PMC10656281 DOI: 10.7759/cureus.47290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
One of India's predominant public health issues is acute undifferentiated fever illness (AUFI), a typical response to an infectious agent. Diagnosis becomes challenging when the disease has been reported with fever as the primary symptom. Among the cases presenting at a tertiary care hospital in central India, 88% had an acute undifferentiated fever, the most common being dengue infection. In India, rural communities are at more risk from AUFI than cities. Most of those in danger are those who reside in remote areas, and one of the most significant risks is for those who reside close to forests. AUFI is a complex condition for physicians to deal with and is one of the most frequent clinical conditions for which empirical treatment is required. Nowadays, AUFI can be managed by a syndromic approach with the judicial use of antibiotics. Symptoms of AUFI, along with myalgia, headache, and anorexia, can be caused by various illnesses. Patients are recommended to undertake a battery of investigations, which may delay the therapy and increase expenses because many diseases may present with the same symptoms. In the developed world, viral illness is the primary cause of AUFI. However, in developing countries like India, it can also be brought on by potentially curable but life-threatening conditions such as malaria, leptospirosis, hantavirus infection, and Japanese encephalitis. Lack of knowledge of the locally prevalent illnesses, which might be the cause of AUFI, and lack of preliminary screening and diagnostics at the point of care to identify the etiologies make it difficult to control these generally curable causes of the burden of AUFI, especially in tropical and subtropical countries. A deeper understanding of AUFI is required to develop better diagnostics and cures for various etiologies, especially scrub typhus.
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Affiliation(s)
- Mihika Khairkar
- Microbiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Sunita Vagha
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Vijayshri Deotale
- Microbiology, Mahatma Gandhi Institute of Medical Sciences, Wardha, IND
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Dev A, Kumar A, Kumar S, Gunjan G, Singh S, Arun N. Clinical and Etiological Profile of Acute Undifferentiated Fever With Thrombocytopenia in an Emergency Department. Cureus 2023; 15:e44719. [PMID: 37809143 PMCID: PMC10552881 DOI: 10.7759/cureus.44719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
INTRODUCTION Acute undifferentiated fever with thrombocytopenia is a common and challenging clinical presentation encountered in the emergency departments of tertiary care centers, particularly in tropical regions, often requiring prompt evaluation and management. The study aimed to explore the clinical and etiological profile of acute undifferentiated fever with thrombocytopenia in the Emergency Department of Indira Gandhi Institute of Medical Sciences, Patna. It investigates factors associated with patient outcomes and compares platelet transfusion requirements among different etiological groups. METHODS In this cross-sectional observational study, 350 patients with acute undifferentiated fever with thrombocytopenia were analyzed for one year from October '21 to September '22. Pre-existing chronic infectious diseases, liver cirrhosis, and autoimmune conditions were excluded. RESULTS Thrombocytopenia was observed in all patients, with 65% having platelet counts below 50,000/µL. Associations were found between the degree of thrombocytopenia and organ dysfunction, shock, and third space loss. Logistic regression analysis identified thrombocytopenia, organ dysfunction, and platelet transfusion requirement as significant predictors of the overall outcome. Etiological group comparisons revealed higher platelet transfusion requirements in the bacterial group. CONCLUSION Prompt recognition and management of thrombocytopenia in acute undifferentiated fever are vital. Thrombocytopenia, along with organ dysfunction and shock, significantly influence patient outcomes. Tailored interventions based on etiological factors are crucial. Further research should focus on specific viral aetiologies in acute undifferentiated fever with thrombocytopenia.
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Affiliation(s)
- Anand Dev
- Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Abhay Kumar
- Internal Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Santosh Kumar
- Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Gagan Gunjan
- Internal Medicine, Rajendra Institute of Medical Sciences, Ranchi, IND
| | - Siddharth Singh
- Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Nitali Arun
- Infectious Diseases, Radha Devi Jageshwari Memorial Medical College, Muzaffarpur, IND
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Grundy BS, Houpt ER. Opportunities and challenges to accurate diagnosis and management of acute febrile illness in adults and adolescents: A review. Acta Trop 2022; 227:106286. [PMID: 34953775 PMCID: PMC8920774 DOI: 10.1016/j.actatropica.2021.106286] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/29/2022]
Abstract
Acute febrile illnesses are common reasons to seek healthcare globally. They can be caused by diverse infectious diseases which require complex diagnostics. Current clinical guidelines provide guidance on how to manage severe illness, common localizing infections like pneumonia and urinary tract infections, as well as malaria. How to manage other cases of acute febrile illness is less clear and is the focus of this review. Without an etiologic diagnosis, clinicians frequently prescribe empiric antibiotics that may be unnecessary or inadequate. We reviewed recent studies on the etiology of acute febrile illnesses in adults and adolescents that employed multiple diagnostic modalities, including rapid diagnostic tests, serologies, and polymerase chain reaction. Although studies and etiologies were heterogenous, we enumerated the causes of febrile illness in these studies. Possible improvements in clinical decision-making algorithms are discussed.
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Affiliation(s)
- Brian S Grundy
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States of America.
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States of America.
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Misra U, Kalita J. Changing spectrum of acute encephalitis syndrome in India and a syndromic approach. Ann Indian Acad Neurol 2022; 25:354-366. [PMID: 35936627 PMCID: PMC9350753 DOI: 10.4103/aian.aian_1117_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/28/2022] [Accepted: 03/31/2022] [Indexed: 12/01/2022] Open
Abstract
Acute encephalitis syndrome (AES) refers to an acute onset of fever and clinical neurological manifestation that includes mental confusion, disorientation, delirium, or coma, which may occur because of infectious or non-infectious causes. Cerebrospinal fluid (CSF) pleocytosis generally favors infectious etiology, and a normal CSF favors an encephalopathy or non-infectious AES. Among the infectious AES, viral, bacterial, rickettsial, fungal, and parasitic causes are the commonest. Geographical and seasonal clustering and other epidemiological characteristics are important in clinical decision making. Clinical markers like eschar, skin rash, myalgia, hepatosplenomegaly, thrombocytopenia, liver and kidney dysfunction, elevated serum CK, fronto-temporal or thalamic involvement on MRI, and anterior horn cell involvement are invaluable clues for the etiological diagnosis. Categorizing the AES cases into neurologic [Herpes simplex encephalitis (HSE), Japanese encephalitis (JE), and West Nile encephalitis (WNE)] and systemic (scrub typhus, malaria, dengue, and Chikungunya) helps in rational utilization of diagnostic and management resources. In neurological AES, cranial CT/MRI revealing frontotemporal lesion is consistent with HSE, and thalamic and basal ganglia lesions are consistent with JE. Cerebrospinal fluid nucleic acid detection test or IgM antibody for JE and HSE are confirmatory. Presence of frontotemporal involvement on MRI indicates acyclovir treatment pending virological confirmation. In systemic AES, CT/MRI, PCR for HSE and JE, and acyclovir therapy may not be useful, rather treatable etiologies such as malaria, scrub typhus, and leptospirosis should be looked for. If smear or antigen for malaria is positive, should receive antimalarial, if negative doxycycline and ceftriaxone should be started pending serological confirmation of scrub typhus, leptospira, or dengue. A syndromic approach of AES based on the prevalent infection in a geographical region may be developed, which may be cost-effective.
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Kavirayani V, Madiyal M, Aroor S, Chhabra S. Clinical profile and role of serology in pediatric acute febrile illness: Experience from a tertiary care hospital in South India. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2021. [DOI: 10.1016/j.cegh.2021.100898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Lu CT, Wang LS, Hsueh PR. Scrub typhus and antibiotic-resistant Orientia tsutsugamushi. Expert Rev Anti Infect Ther 2021; 19:1519-1527. [PMID: 34109905 DOI: 10.1080/14787210.2021.1941869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Scrub typhus is one of the most underdiagnosed and under-reported febrile illnesses requiring hospitalization, mainly occurring in Southeast and East Asia and the Pacific Islands, in an area referred to as the 'Tsutsugamushi Triangle.' Scrub typhus is a zoonotic rickettsial disease that is transmitted to humans by trombiculid mites.Areas covered: A MEDLINE/PubMed search of the available literature was performed to describe the role of antibiotic-resistant scrub typhus in therapy failure.Expert opinion: Scrub typhus is characterized by an eschar that may appear 2-3 days before sudden-onset fever with chills, headache, backache, myalgia, profuse sweating, vomiting, and enlarged lymph nodes. A macular or maculopapular skin rash can develop within 3-8 days after the onset of fever. Various antibiotics, such as chloramphenicol, tetracycline, doxycycline, macrolides, quinolones, and rifampicin, have been used to treat scrub typhus. Resistance to tetracycline has been proposed to underlie delayed clinical improvement since 1996, but recent reports have questioned the existence of doxycycline resistance. Nevertheless, the existence and importance of antibiotic-resistant scrub typhus remain uncertain and require further study.
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Affiliation(s)
- Chin-Te Lu
- Department of Infectious Diseases, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Lih-Shinn Wang
- Division of Infectious Diseases, Department of Internal Medicine, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Le Van N, Pham Van C, Nguyen Dang M, Dao Van T, Le T Do Q, Vu Hoang H, Tran Viet T, Nhu Do B. Clinical Features, Laboratory Characteristics and Prognostic Factors of Severity in Patients with Rickettsiaceae at Two Military Hospitals, Northern Vietnam. Infect Drug Resist 2020; 13:2129-2138. [PMID: 32753908 PMCID: PMC7351622 DOI: 10.2147/idr.s253540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/03/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Rickettsioses are diseases caused by intracellular Gram-negative bacteria of the Rickettsiaceae family and transmitted through the bite of infected ticks or mites. Aim of Study To investigate the clinical and subclinical characteristics and prognostic severe factors of the disease caused by Rickettsiaceae. Methods A prospective, descriptive cross-sectional study was conducted at Department of Infectious Diseases of two military hospitals in Northern Vietnam from May 2013 to June 2019, in which 88 adult febrile patients caused by Orientia tsutsugamushi (50 patients) or Rickettsia spp. (38 patients) were enrolled. We recorded information regarding epidemiological characteristics (age, geography, residence, occupation), medical history, clinical and subclinical findings, life-threatening complications during treatment, outcomes and some factors predicting serious life-threatening complications in a case record form. Results Scrub typhus (ST) patients had eschar (70%), skin-conjunctiva congestion (60%) and lymphadenopathy (44%). Rickettsia patients had a higher rate of maculopapular rash (39.5%), no ulcers and no lymphadenopathy detected. The majority of patients had elevated PCT >0.05 ng/µL and increase in liver enzymes and thrombocytopenia. Major prognostic factors for severe complications included diffuse infiltrates on lung X-ray (OR: 19.5; p = 0.014), coarse crackles (OR: 18; p = 0.016), respiratory rate ≥25 cycles/minute (OR: 18; p = 0.016), shortness of breath (OR: 7.44; p = 0.003), pleural fluid (OR: 4.3; p = 0.035) and increase in AST ≥ 200 UI/l (OR: 4.42; p = 0.012). The PCT value is able to distinguish between the two groups with quite high reliability (the area under the ROC curve is 0.75). Conclusion Eschar and peripheral lymphadenopathy were two valuable clinical symptoms for the diagnosis of scrub typhus and distinguishing 2 groups of diseases. Respiratory distress, increase in AST ≥ 200 UI/l and level of PCT were used as major prognostic factors in patients with Rickettsiaceae.
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Affiliation(s)
- Nam Le Van
- Department of Infectious Disease, Military Hospital 103, Vietnam Military Medical University, Ha Noi, Vietnam
| | - Chung Pham Van
- Institute of Clinical Infectious and Tropical Diseases, Military Central Hospital 108, Ha Noi, Vietnam
| | - Manh Nguyen Dang
- Institute of Clinical Infectious and Tropical Diseases, Military Central Hospital 108, Ha Noi, Vietnam
| | - Thang Dao Van
- Department of Infectious Disease, Military Hospital 103, Vietnam Military Medical University, Ha Noi, Vietnam
| | - Quyen Le T Do
- Department of Infectious Disease, Military Hospital 103, Vietnam Military Medical University, Ha Noi, Vietnam
| | - Hung Vu Hoang
- Department of Infectious Disease, Military Hospital 103, Vietnam Military Medical University, Ha Noi, Vietnam
| | - Tien Tran Viet
- Department of Infectious Disease, Military Hospital 103, Vietnam Military Medical University, Ha Noi, Vietnam.,Director Office, Military Hospital 103, Ha Noi, Vietnam
| | - Binh Nhu Do
- Department of Infectious Disease, Military Hospital 103, Vietnam Military Medical University, Ha Noi, Vietnam.,Division of Military Science, Military Hospital 103, Ha Noi, Vietnam
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Prevalence of scrub typhus in a tertiary care centre in Telangana, south India. IRANIAN JOURNAL OF MICROBIOLOGY 2020; 12:204-208. [PMID: 32685116 PMCID: PMC7340608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Scrub typhus is re-emerging as an important cause of acute undifferentiated fever in the last decade from various parts of India. Complexity in performing the "gold standard" immunofluorescent assay and the unreliable nature of Weil Felix test often results in delayed or misdiagnosis in a majority of cases. The present study seeks to integrate the results of rapid diagnostic tests, clinical and laboratory features to aid the diagnosis and management of scrub typhus patients. MATERIALS AND METHODS A total of 645 serum samples with suspected scrub typhus sent to the Department of Microbiology were included in the study. Scrub typhus was tested by rapid immunochromatographic test (SD Diagnostics) and IgM ELISA (Inbios International, USA). Clinical features, laboratory parameters and final outcome were analysed from the clinical records of positive patients. RESULTS Scrub typhus was diagnosed in 13.7% of patients and majority of them were observed in the month of August. 58.6% of scrub typhus patients presented with fever of one to two weeks duration. Eschar was documented in 13.7% of patients and 24% of patients gave a history of working outdoors or exposure to vegetation. All the patients responded to Doxycycline treatment and there was no mortality. CONCLUSION High index of suspicion for scrub typhus is necessary in febrile patients not responding to conventional antibiotics especially during outbreak situations. Rapid immunochromatographic tests with excellent specificity and acceptable sensitivity can be used as potential point of care tests for quick diagnosis of scrub typhus especially in delayed presentation.
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Dakappa PH, Rao SB, B G, Bhat GK, Mahabala C. Unique temperature patterns in 24-h continuous tympanic temperature in tuberculosis. Trop Doct 2019; 49:75-79. [PMID: 30782109 DOI: 10.1177/0049475519829600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Body temperature monitoring in most healthcare institutions is limited to checking the presence or absence of fever. Our present study evaluated the 24h continuous tympanic temperature pattern in patients with fever in order to detect typical patterns seen in tuberculosis (TB). This observational study was conducted on 81 undifferentiated fever patients whose recordings were stored using the TherCom device. Unique temperature patterns were analysed and compared. TB patients exhibited a unique temperature pattern, namely a slow temperature elevation followed by slow temperature fall seen in 78.5% (22/28) compared to 24.52% (13/53) of non-TB patients. Recognition of this pattern may therefore be useful as a valuable diagnostic aid in the early diagnosis of TB.
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Affiliation(s)
- Pradeepa H Dakappa
- 1 Assistant Professor, Department of Pharmacology, World College of Medical Sciences Research Hospital, Jhajjar, Haryana, India
| | - Sathish B Rao
- 2 Additional Professor, Department of Internal Medicine, Kasturba Medical College, Mangaluru, Manipal Academy of Higher Education, Manipal, India
| | - Ganaraja B
- 3 Additional Professor, Department of Physiology, Kasturba Medical College, Mangaluru, Manipal Academy of Higher Education, Manipal, India
| | - Gopalkrishna K Bhat
- 4 Additional Professor, Department of Microbiology, Kasturba Medical College, Mangaluru, Manipal Academy of Higher Education, Manipal, India
| | - Chakrapani Mahabala
- 5 Professor, Department of Internal Medicine, Kasturba Medical College, Mangaluru, Manipal Academy of Higher Education, Manipal, India
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Jain D, Nand N, Giri K, Bhutani J. Scrub typhus infection, not a benign disease: an experience from a tertiary care center in Northern India. Med Pharm Rep 2019; 92:36-42. [PMID: 30957085 PMCID: PMC6448495 DOI: 10.15386/cjmed-1088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/17/2018] [Accepted: 11/04/2018] [Indexed: 01/19/2023] Open
Abstract
Introduction Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi. It is characterised by fever, rash, myalgia and diffuse lymphadenopathy. Most common complications are sepsis, shock, acute respiratory distress syndrome (ARDS), hepatitis, pre renal azotemia and multi organ dysfunction syndrome (MODS). Mortality rates range from 7–30% in untreated cases. Scrub typhus is endemic to a part of the world known as ‘the tsutsugamushi triangle’. River banks, grassy areas generally harbour scrub typhus infection; however, recently there has been an increase in prevalence of infection from dry regions like Haryana. Objective To assess the clinical spectrum and complications of scrub typhus infection at a tertiary care centre in North India. Material and methods An observational study was conducted on patients >14 years old with acute febrile illness >7 days duration, admitted indoor from emergency department, from July to November 2017. Suspected cases were tested for specific IgM antibodies against Orientia tsutsugamushi by ELISA. Results Among the 230 patients, screened for scrub typhus infection, 39 (16.95%) came out to be positive. Most common patient complaints were fever followed by cough and breathlessness, myalgia, nausea, vomiting and behavioral abnormality. 15% of patients required inotropic support initially and 48% had oxygen saturation of less than 90% at the time of presentation. Pleural effusion and crepitations were present in 41% of patients. Most common biochemical alterations were: abnormal liver function tests (95%), followed by thrombocytopenia, anemia, abnormal renal function tests, and hyponatremia. 12 patients (30.7%) were shifted to intensive care unit, 8 of which (20.5%) needed invasive mechanical ventilation and 4 patients (10.3%) underwent hemodialysis. Various complications were noted in 89.7% of cases, the most common being ARDS followed by sepsis, acute kidney injury (AKI) and meningitis. The mortality rate in this study was 18%. Conclusions This study emphasizes that scrub typhus infection is on a rampant resurgence and it is associated with significant complications. High degree of suspicion as well as development of effective measures to treat, control and prevent is critical to lower the disease burden.
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Affiliation(s)
- Deepak Jain
- Internal Medicine Department, Pt. BD Sharma PGIMS, Rohtak, India
| | - Nitya Nand
- Internal Medicine Department, Pt. BD Sharma PGIMS, Rohtak, India
| | - Kajaree Giri
- Internal Medicine Department, Pt. BD Sharma PGIMS, Rohtak, India
| | - Jaikrit Bhutani
- Internal Medicine Department, Pt. BD Sharma PGIMS, Rohtak, India
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Bhargava A, Ralph R, Chatterjee B, Bottieau E. Assessment and initial management of acute undifferentiated fever in tropical and subtropical regions. BMJ 2018; 363:k4766. [PMID: 30498133 DOI: 10.1136/bmj.k4766] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Anurag Bhargava
- Department of Medicine, Yenepoya Medical College, Mangalore, Karnataka, India
- Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangalore, Karnataka, India
- Department of Medicine, McGill University, Montreal, Canada
| | - Ravikar Ralph
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Biswaroop Chatterjee
- Department of Microbiology, IQ City Medical College, Durgapur, West Bengal, India
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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14
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Shelke YP, Deotale VS, Maraskolhe DL. Spectrum of infections in acute febrile illness in central India. Indian J Med Microbiol 2018; 35:480-484. [PMID: 29405137 DOI: 10.4103/ijmm.ijmm_17_33] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Infectious agent when enters in the host results in febrile illness. This may lead to increase in morbidity or even mortality in undiagnosed/untreated cases. There are many aetiological agents which lead to acute febrile illness. Among these aetiological agents, important is bacterial or viral aetiology. OBJECTIVE The objective of this study is: (i) To know the aetiological agents responsible for acute undifferentiated febrile illness (AUFI) by serological test or by bacterial culture and (ii) To know the clinical profile of AUFI. METHODOLOGY A total of 270 patients were enroled in the study with a history of AUFI admitted in medicine and paediatric department from January 2015 to November 2016 of tertiary care hospital of central India. Blood sample was collected for blood culture, clot culture and serological tests for immunochromatographic tests (ICTs) and ICT-positive results were confirmed by respective enzyme-linked immunosorbent assay (ELISA). All negative serum samples by immunochromatography were retested for disease-specific ELISA as scrub typhus, dengue and leptospirosis. RESULTS Out of 270 patients, 127 (47%) were of scrub typhus, 33 (12%) were malaria cases, 47 (17.40%) were dengue, 12 (4%) were enteric fever, 5 (2%) were leptospirosis, undiagnosed were 18 (6.66%) and other infections (viz viral, urinary tract infection, upper and lower respiratory tract infection and acute gastroenteritis) accounts for 28 (10.37%) cases. We have also noticed that there was co-infection of scrub typhus and dengue, leptospirosis and scrub typhus. CONCLUSION It is important to know the cause and clinical profile of AUFIs for their proper management also it will help to prevent morbidity and mortality in AUFI cases.
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Affiliation(s)
- Yogendra Pandurang Shelke
- Department of Microbiology, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Vijayshri Suresh Deotale
- Department of Microbiology, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
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15
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van Eekeren LE, de Vries SG, Wagenaar JFP, Spijker R, Grobusch MP, Goorhuis A. Under-diagnosis of rickettsial disease in clinical practice: A systematic review. Travel Med Infect Dis 2018; 26:7-15. [PMID: 29486240 DOI: 10.1016/j.tmaid.2018.02.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/14/2018] [Accepted: 02/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rickettsial diseases present as acute febrile illnesses, sometimes with inoculation eschars. METHODS We performed a systematic review of studies published between 1997 and 2017 to assess the underestimation of non-eschar rickettsial disease (NERD) relative to eschar rickettsial disease (ERD), as a cause of acute fever in patients with rickettsial diseases that commonly present with eschar(s): scrub typhus (ST), Mediterranean spotted fever (MSF), and African tick-bite fever. We compared ERD/NERD ratios according to study design: 'complete approach' studies, with testing performed in all patients with 'unspecified febrile illness'; versus 'clinical judgement' studies, with testing performed if patients presented with specific symptoms. RESULTS In 'complete approach' studies, ERD/NERD ratios were significantly lower, suggesting a considerable under-diagnosis of NERD in 'clinical judgement' studies. Based on these results, we estimate that the diagnosis of rickettsial disease was missed in 66.5% of patients with ST, and in 57.9% of patients with MSF. CONCLUSIONS Study design influences the reported eschar rates in ST and MSF significantly. NERD is likely to be a vastly underdiagnosed entity, and clinicians should consider and test for the disease more often. PROSPERO REGISTRATION NUMBER CRD 42016053348.
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Affiliation(s)
- Louise E van Eekeren
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Sophia G de Vries
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Jiri F P Wagenaar
- Leptospirosis Reference Center, Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - René Spijker
- Medical Library, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Abraham Goorhuis
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands.
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Abstract
Scrub typhus is an acute febrile illness in the “tsutsugamushi triangle”, transmitted by chiggers that can be treated effectively if detected early. Laboratory testing, including molecular and serological assays, is needed for confirming the diagnosis, especially in the absence of the pathognomonic eschar. In this review, factors that play a role in disease occurrence and clinical clues for diagnosis, in addition to risk factors contributing to disease severity, including mortality, are discussed in detail. Moreover, issues related to diagnostic assays, treatment, and mixed infections are also enumerated and described.
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Singhi S, Rungta N, Nallasamy K, Bhalla A, Peter JV, Chaudhary D, Mishra R, Shastri P, Bhagchandani R, Chugh TD. Tropical Fevers in Indian Intensive Care Units: A Prospective Multicenter Study. Indian J Crit Care Med 2017; 21:811-818. [PMID: 29307960 PMCID: PMC5752788 DOI: 10.4103/ijccm.ijccm_324_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Infections in tropics often present as undifferentiated fevers with organ failures. We conducted this nationwide study to identify the prevalence, profile, resource utilization, and outcome of tropical fevers in Indian Intensive Care Units (ICUs). Materials and Methods This was a multicenter prospective observational study done in 34 ICUs across India (July 2013-September 2014). Critically ill adults and children with nonlocalizing fever >48 h and onset < 14 days with any of the following: thrombocytopenia/rash, respiratory distress, renal failure, encephalopathy, jaundice, or multiorgan failure were enrolled consecutively. Results Of 456 cases enrolled, 173 were children <12 years. More than half of the participants (58.7%) presented in postmonsoon months (August-October). Thrombocytopenia/rash was the most common presentation (60%) followed by respiratory distress (46%), encephalopathy (28.5%), renal failure (23.5%), jaundice (20%), and multiorgan failure (19%). An etiology could be established in 365 (80.5%) cases. Dengue (n = 105.23%) was the most common followed by scrub typhus (n = 83.18%), encephalitis/meningitis (n = 44.9.6%), malaria (n = 37.8%), and bacterial sepsis (n = 32.7%). Nearly, half (35% invasive; 12% noninvasive) received mechanical ventilation, a quarter (23.4%) required vasoactive therapy in first 24 h and 9% received renal replacement therapy. Median (interquartile range) ICU and hospital length of stay were 4 (3-7) and 7 (5-11.3) days. At 28 days, 76.2% survived without disability, 4.4% had some disability, and 18.4% died. Mortality was higher (27% vs. 15%) in patients with undiagnosed etiology (P < 0.01). On multivariate analysis, multiorgan dysfunction syndrome at admission (odds ratio [95% confidence interval]-2.8 [1.8-6.6]), day 1 Sequential Organ Failure Assessment score (1.2 [1.0-1.3]), and the need for invasive ventilation (8.3 [3.4-20]) were the only independent predictors of unfavorable outcome. Conclusions Dengue, scrub typhus, encephalitis, and malaria are the major tropical fevers in Indian ICUs. The data support a syndromic approach, point of care tests, and empiric antimicrobial therapy recommended by Indian Society of Critical Care Medicine in 2014.
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Affiliation(s)
- Sunit Singhi
- Professor Emeritus Pediatrics, PGIMER, Chandigarh, Haryana, India
| | - Narendra Rungta
- Critical Care Medicine, Jeevanrekha Critical Care and Trauma Hospital, Jaipur, Rajasthan, India
| | | | - Ashish Bhalla
- Department of Internal Medicine, PGIMER, Chandigarh, Haryana, India
| | - J V Peter
- Critical Care Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dhruva Chaudhary
- Department of Pulmonology and Critical Care, PGIMS, Haryana, India
| | - Rajesh Mishra
- Critical Care Medicine, Sanjivani Super Speciality Hospital, Ahmedabad, Gujarat, India
| | - Prakash Shastri
- Critical Care Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | | | - T D Chugh
- Professor Emeritus Pathology, PGIMS, Rohtak, Haryana, India
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Abstract
The obligate intracellular bacterium Orientia tsutsugamushi is responsible for more than one million cases of scrub typhus annually throughout the Asia-Pacific region. Human infection occurs via the bite of the larval form (chigger) of several species of trombiculid mites. While in some patients the result of infection is a mild, febrile illness, others experience severe complications, which may even be fatal. This review discusses the genome and biology of the causative agent, the changing epidemiology of scrub typhus, the challenges of its diagnosis, and current treatment recommendations.
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Affiliation(s)
- Sunil Thomas
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania USA
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Muthaiah B, Thippeswamy T, Kondareddy S, Chikkegowda P. Study of Aetiology and Outcome in Acute Febrile Illness Patients with Multiple Organ Dysfunction Syndrome. J Clin Diagn Res 2016; 10:OC16-8. [PMID: 27656479 DOI: 10.7860/jcdr/2016/21376.8301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/17/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Acute febrile illness with Multi Organ Dysfunction Syndrome (MODS) carries significant morbidity and mortality despite standard therapy in intensive care settings. Infections are the most common cause of MODS followed by polytrauma. Present study was undertaken in medical intensive care units of a tertiary hospital to study the aetiology and outcome among patients with acute febrile illness developing MODS. AIM 1) To study the aetiology of acute febrile illness in patients developing MODS. 2) To study the final outcome among these patients. MATERIALS AND METHODS The present study was conducted at a tertiary care hospital in Mysuru, Karnataka, India, over a period of 6 months from July 2013 to December 2013. The Institutional Ethics Committee Approval (IEC) was obtained before the commencement of the study. A total of 213 cases admitted in intensive care unit with acute febrile illness with two or more organ dysfunction were screened for the inclusion and exclusion criterias. RESULTS A total of 213 cases of acute febrile illness with one or more organ dysfunction were screened. Of the screened patients 75 patients were finally included in the study out of which 46 (61.3%) patients were males and 29 (38.7%) patients were females. Aetiology for acute febrile illness with MODS could be established in 49 (65.3%) patients and it was obscure in 26 (34.7%) patients despite repeated investigations. Dengue infection (29.3%) was the commonest cause of febrile illness with MODS followed by leptospirosis (22.7%). Majority of these patients had haematological derangements (78.7%) and liver function test abnormalities (68%). Out of these 75 cases, 54 (72%) patients recovered completely and 21 (28%) patients died. Among males (N=46), 35 (76.1%) patients recovered and 11 (23.9%) patients died where as among females (N=29), 19 (65.5%) patients recovered and 10 (34.5%) patients died. Mortality was proportionate with the number of organ dysfunction, especially Central Nervous System (CNS) involvement. CONCLUSION Incidence of febrile illness with MODS is more prevalent in males but the outcome appears poorer among females. The diagnosis remained obscure in a sizable proportion of these patients. Prognosis was inversely dependent on the number of organs involved especially with CNS manifestations.
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Affiliation(s)
- Bhanukumar Muthaiah
- Associate Professor, Department of Medicine, J.S.S Medical College (A constituent college of JSS University) , Mysuru, Karnataka, India
| | - Thippeswamy Thippeswamy
- Assistant Professor, Department of Medicine, J.S.S Medical College (A constituent college of JSS University) , Mysuru, Karnataka, India
| | - Srinivas Kondareddy
- Consultant Physician, Department of Medicine, Kond Hospital , Kadapa, Andhra Pradesh, India
| | - Prathima Chikkegowda
- Assistant Professor, Department of Pharmacology, J.S.S Medical College (A constituent college of JSS University) , Mysuru, Karnataka, India
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Khalili M, Naderi HR, Salehnia N, Abiri Z. Detection of Coxiella burnetii in acute undifferentiated febrile illnesses (AUFIs) in Iran. Trop Doct 2016; 46:221-224. [PMID: 26767385 DOI: 10.1177/0049475515624855] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There are limited data on the aetiology of acute undifferentiated febrile illnesses (AUFIs) in Iran. Moreover, Coxiella burnetii has not previously been detected in clinical samples in this country. Previous studies have highlighted the importance of considering C. burnetii as a cause of AUFI. In this retrospective study, in 92 cases of AUFI where Q fever was suspected, C. burnetii DNA was detected in seven samples (7.36%). This is the first molecular confirmation of C. burnetii from clinical samples from Iran.
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Affiliation(s)
- Mohammad Khalili
- Department of Pathobiology, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran Research Center of Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamid Reza Naderi
- Department of Infectious Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasim Salehnia
- Department of Infectious Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zeinab Abiri
- Department of Pathobiology, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran
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