Scrub typhus in patients with acute febrile illness: a 5-year study from India

BACKGROUND

Scrub typhus was once thought to be a disease of rural origin and was confined to specific pockets in South Asia. Early diagnosis and treatment is extremely important as it is associated with high mortality if left untreated.

AIM

To delineate the clinical and molecular epidemiology of scrub typhus in patients presenting with acute febrile illness from various parts of India.

METHODS

During the study period of 5 years (October 2013 to October 2018), a total of 1742 patients with acute febrile illness <15 days were enrolled after taking informed consent. Patients were diagnosed using IgM Enzyme-linked immunosorbent assay (ELISA) based on the pre-determined region specific cut offs. Patients with positive IgM ELISA were also subjected to IgM Immunofluorescence assay and nested polymerase chain reaction (PCR) assay. The demographic and relevant clinical details of the patients were documented and analyzed.

RESULTS

A total of 210 (12.1%) patients were diagnosed with scrub typhus. Of these, nested PCR was positive in only 85 patients. Sequencing and phylogenetic analysis showed that the predominant circulating genotypes were Gilliam and Karp. On multivariate analysis, acute respiratory distress syndrome, myocarditis, encephalitis/encephalopathy, jaundice and splenomegaly were significantly more common in those patients who were diagnosed with scrub typhus. A total of 14 patients diagnosed with scrub typhus succumbed to the illness.

CONCLUSION

Patients with fever, headache, pulmonary manifestations, CNS manifestations, myocarditis, transaminitis or thrombocytopenia presenting in the monsoon and post-monsoon season should be evaluated for scrub typhus irrespective of the geographical location in India.

Hemoadsorption by extracorporeal cytokine adsorption therapy (CytoSorb®) in the management of septic shock: A retrospective observational study

INTRODUCTION

Sepsis results in immunologic disturbances with the release of various inflammatory mediators such as cytokines. Cytokines can damage the cells, and the continuous release of inflammatory mediators leads to severely impaired immunity. Therefore, the reduction in cytokine levels by hemoadsorption represents a new concept for blood purification. CytoSorb^® as a hemoadsorption device is a detoxification system, which aims to decrease the cytokines levels. This study was conducted to understand any beneficial effects of CytoSorb^® therapy in septic patients.

METHODOLOGY

This was a retrospective and observational study, approved by the scientific and ethics committee of Max Super Specialty Hospital, Patparganj, Delhi, India and conducted in compliance with current International Council for Harmonization, Good Clinical Practice, Schedule Y, and Indian Council of Medical Research guidelines. Subjects of either gender (age > 18 year) were included in the study. The data were presented as mean ± standard deviation and categorical as frequency and percentage (%). A p value less than 0.05 (p < 0.05) was considered to be statistically significant.

RESULTS

A total number of 36 patients were included in the study. Majority of the patients were male with mean age (56.36 ± 14.83). After therapy, procalcitonin and total leucocyte count levels decreased within 24 h. Post therapy, sepsis-related organ failure assessment (SOFA) score of Day (D)1, D2, and D3 reduced to 10.4 ± 3.63, 8.7 ± 4.02, and 7.8 ± 3.67, respectively. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality were lower in the survivor group as compared to the non-survivor group.

CONCLUSION

Hemoadsorption using the extracorporeal adsorption device (CytoSorb^®) might be an effective rescue therapy in stabilizing septic shock patients.

Anomalous origin of the right coronary artery from the main pulmonary artery: diagnosis and management

Anomalous origin of the right coronary artery (ARCA) from the main pulmonary artery (MPA) is a rare congenital anomaly, with only 18 reported cases in the pediatric age group. More than half of these had associated cardiac anomalies that masked the presence of ARCA. Conversely, in many patients with ARCA as an isolated anomaly, the diagnosis has been missed during lifetime. The only patient with an isolated ARCA who was diagnosed in infancy presented with congestive heart failure. Asymptomatic infants with ARCA from the MPA have not been previously reported. Three additional cases, two infants and a child with ARCA from the MPA, are reported in this paper. The diagnostic dilemmas and the prognosis are discussed and management is recommended.

Chikungunya fever: a re-emerging viral infection

Chikungunya (CHIK) fever is a re-emerging viral disease characterized by abrupt onset of fever with severe arthralgia followed by constitutional symptoms and rash lasting for 1-7 days. The disease is almost self-limiting and rarely fatal. Chikungunya virus (CHIKV) is a RNA virus belonging to family Togaviridae, genus Alphavirus. Molecular characterization has demonstrated two distinct lineages of strains which cause epidemics in Africa and Asia. These geographical genotypes exhibit differences in the transmission cycles. In contrast to Africa where sylvatic cycle is maintained between monkeys and wild mosquitoes, in Asia the cycle continues between humans and the Aedes aegypti mosquito. CHIKV is known to cause epidemics after a period of quiescence. The first recorded epidemic occurred in Tanzania in 1952-1953. In Asia, CHIK activity was documented since its isolation in Bangkok, Thailand in 1958. Virus transmission continued till 1964. After hiatus, the virus activity re-appeared in the mid-1970s and declined by 1976. In India, well-documented outbreaks occurred in 1963 and 1964 in Kolkata and southern India, respectively. Thereafter, a small outbreak of CHIK was reported from Sholapur district, Maharashtra in 1973. CHIKV emerged in the islands of South West Indian Ocean viz. French island of La Reunion, Mayotee, Mauritius and Seychelles which are reporting the outbreak since February, 2005. After quiescence of about three decades, CHIKV re-emerged in India in the states of Andhra Pradesh, Karnataka, Maharashtra, Madhya Pradesh and Tamil Nadu since December, 2005. Cases have also been reported from Rajasthan, Gujarat and Kerala. The outbreak is still continuing. National Institute of Communicable Diseases has conducted epidemiological, entomological and laboratory investigations for confirmation of the outbreak. These have been discussed in detail along with the major challenges that the country faced during the current outbreak.

Development and evaluation of an In vitro isolation of street rabies virus in mouse neuroblastoma cells as compared to conventional tests used for diagnosis of rabies

In vitro isolation of rabies virus using mouse neuroblastoma cells (MNA) was evaluated. The sensitivity and reliability of in vitro procedure was performed in comparison with mouse inoculation test (MIT), the in vivo method of virus isolation, direct fluorescent antibody test (FAT) and Sellers staining. Of the 33 animal brain samples tested, 24 (72.72%) were positive by MIT. Sensitivity of Sellers stain, FAT and rapid tissue culture infection test (RTCIT) was found to be 54.16, 100 and 91.6% respectively. Concordance of Sellers stain, FAT, RTCIT with MIT was found to be 66.6, 100 and 93.93% respectively. Two samples which were positive by FAT and MIT showed gross contamination in cell lines, which is one of the drawbacks of RTCIT. However, rabies virus could be isolated in MNA cells from two of the eight human cerebrospinal fluid (CSF) samples from clinico-epidemiologically suspected cases of rabies. Both MIT and FAT showed negative results in the two CSF samples. RTCIT appears to be a fast and reliable alternative to MIT and holds promise in antemortem diagnosis of rabies, which is otherwise, a challenging task for a reference laboratory.

Diagnostic value of push-type enteroscopy: a report from India

OBJECTIVE

We sought to assess the diagnostic value of push-type enteroscopy in relation to indications.

METHODS

Ninety-nine consecutive patients (mean age, 42+/-15 yr; 65 men) with suspected small bowel disorders underwent push enteroscopy. The indications were chronic diarrhea (n = 54), obscure gastrointestinal (GI) bleeding (n = 21), abdominal pain (n = 10), abnormal radiological studies of small bowel (n = 5), iron deficiency anemia (n = 5), and others (n = 4). Push enteroscopy was performed using the Olympus SIF-10 (160-cm) enteroscope.

RESULTS

Endoscopic examination of the jejunum was successful in all the patients, except one with a distal duodenal stricture. The length of the jejunum examined ranged from 10 to 70 cm. The time taken to complete the procedure varied from 2 to 30 min. Lesions were found in nine (42.8%) patients with obscure GI bleeding; six (28.5%) had worms (Ascaris lumbricoides [n = 3], Ankylostoma duodenale [n = 3]) in the jejunum, producing multiple erosions and bleeding points. In the chronic diarrhea group, a diagnosis was made in 13 (24%) patients on enteroscopic visualization and jejunal histology: celiac disease (n = 6), tropical sprue (n = 3), Crohn's disease (n = 1), secondary lymphangiectasia (n = 1), strongyloidiasis (n = 1), and nodular lymphoid hyperplasia with giardiasis (n = 1). In patients with abdominal pain, enteroscopy provided a diagnosis in one (10%) patient. No positive diagnosis could be made on enteroscopy in patients with iron deficiency anemia and abnormal radiological studies of small bowel.

CONCLUSION

Push-type enteroscopy is a useful test in the evaluation of patients with obscure GI bleeding and chronic diarrhea. In developing countries, in patients with obscure GI bleeding, the presence of worms in the jejunum is an important finding on enteroscopy. Tropical sprue, giardiasis, and strongyloidiasis are distinct findings in patients with chronic diarrhea in the present series.

Diagnostic value of push-type enteroscopy: a report from India

OBJECTIVE

We sought to assess the diagnostic value of push-type enteroscopy in relation to indications.

METHODS

Ninety-nine consecutive patients (mean age, 42+/-15 yr; 65 men) with suspected small bowel disorders underwent push enteroscopy. The indications were chronic diarrhea (n = 54), obscure gastrointestinal (GI) bleeding (n = 21), abdominal pain (n = 10), abnormal radiological studies of small bowel (n = 5), iron deficiency anemia (n = 5), and others (n = 4). Push enteroscopy was performed using the Olympus SIF-10 (160-cm) enteroscope.

RESULTS

Endoscopic examination of the jejunum was successful in all the patients, except one with a distal duodenal stricture. The length of the jejunum examined ranged from 10 to 70 cm. The time taken to complete the procedure varied from 2 to 30 min. Lesions were found in nine (42.8%) patients with obscure GI bleeding; six (28.5%) had worms (Ascaris lumbricoides [n = 3], Ankylostoma duodenale [n = 3]) in the jejunum, producing multiple erosions and bleeding points. In the chronic diarrhea group, a diagnosis was made in 13 (24%) patients on enteroscopic visualization and jejunal histology: celiac disease (n = 6), tropical sprue (n = 3), Crohn's disease (n = 1), secondary lymphangiectasia (n = 1), strongyloidiasis (n = 1), and nodular lymphoid hyperplasia with giardiasis (n = 1). In patients with abdominal pain, enteroscopy provided a diagnosis in one (10%) patient. No positive diagnosis could be made on enteroscopy in patients with iron deficiency anemia and abnormal radiological studies of small bowel.

CONCLUSION

Push-type enteroscopy is a useful test in the evaluation of patients with obscure GI bleeding and chronic diarrhea. In developing countries, in patients with obscure GI bleeding, the presence of worms in the jejunum is an important finding on enteroscopy. Tropical sprue, giardiasis, and strongyloidiasis are distinct findings in patients with chronic diarrhea in the present series.

Choledochal cysts in infants and children

OBJECTIVE

To study the clinical spectrum and management of choledochal cyst in children below 12 years of age.

DESIGN

Descriptive study.

SETTING

Tertiary care hospital.

METHODS

Twenty three children with choledochal cysts were managed between January 1991 to September 1997 and their clinical details, investigations and management were recorded. Choledochal cyst was diagnosed by ultrasonography and confirmed by ERCP or peroperative cholangioram (POC) Children were treated with antibiotics and/or percutaneous transhepatic biliary drainage if there was cholangitis and subsequently subjected to surgery (excision of the cyst and jejunal loop interposition hepaticoduodenostomy).

RESULTS

The median age of these children was 3 years with an almost equal sex ratio. Predominant presentation was jaundice in 18, pain abdomen in 15, fever in 12, and lump abdomen in 9 cases. The classical triad of jaundice, pain and lump was present in only 4 cases. ERCP conducted in 7 and POC in 14 cases yielded positive findings in all. Clinically there were two distinct forms of presentation: (i) infantile form (< or = 1 year) comprised 9 infants which presented with jaundice in all, acholic stool in 6, lump abdomen in 4 but only one had classical triad; and (ii) childhood form (> 1 year) presented with pain abdomen in 12 and jaundice and cholangitis in 9 subjects each. Type I cyst was seen in 20 and type IVa in 3. Two children refused surgery, and the rest underwent surgery. Three infants died after surgery, the remaining 18 were alive and well on follow-up (median 25 months). Secondary biliary cirrhosis was seen in 6, extra hepatic biliary artresia in 2 and congenital hepatic fibrosis in 1 on histology.

CONCLUSIONS

Choledochal cysts present in two clinically distinct forms. Infantile form is an important cause of cholestasis of infancy. Early diagnosis and referral is essential to prevent complications and death, and prognosis after surgery is good.