Trends in clinical features and severity of Plasmodium vivax malaria among children at tertiary care center in North India

BACKGROUND

Malaria is a significant cause of morbidity and mortality in adults and children. Plasmodium falciparum is the primary cause of severe malaria, but recently Plasmodium vivax is also recognized to cause severe malaria-associated morbidity and mortality. The study focuses on determining the mortality related to severity parameters in individuals under 12 years and their critical presentation in P.vivax malaria-infected children.

METHODS

A prospective cross-sectional hospital-based study was conducted at Safdarjung Hospital, New Delhi, and ICMR-NIMR, New Delhi. All clinically suspected cases were admitted for screening. Exclusion criteria (rapid malaria antigen test, microscopy and medication history) were applied to all the admitted patients (n = 221) to obtain P.vivax patients only. Patients aged ≤ 12 years were included in the study. DNA was extracted from dried blood spots and amplified by nested PCR, followed by visualization on gel electrophoresis.

RESULT

A total of 221 clinically suspected cases of malaria were screened for P.vivax. After implementing various exclusion criteria, 45/221 cases were enrolled for the study, among which 44.4% (20/45) of children had the symptoms of severe malaria in terms of cerebral malaria, thrombocytopenia, anemia, pancytopenia, acute respiratory distress syndrome and hemophagocytic lymphohistiocytosis.

CONCLUSION

Plasmodium vivax mono-infection can cause severe manifestation and must be treated as P.falciparum without any delay because it may lead to increased morbidity and mortality. A changing trend in clinical symptoms has shown in P.vivax which was an earlier phenomenon of P.falciparum.

A Case-Control Study of Serum and Tissue Catalase among Morphological Variants of Vitiligo

Background

Role of oxidative stress in the pathogenesis of vitiligo.

Aim

Estimation of serum and tissue catalase levels in morphological variants of vitiligo.

Settings and Design

A prospective case-control study was conducted in the outpatient department of Dermatology in Safdarjung hospital.

Materials and Methods

We estimated levels of serum and tissue catalase in 30 vitiligo patients and 30 matched healthy controls.

Statistical Analysis

The data analysis was done in Statistical Package for Social Sciences (SPSS) version 21.0. Normality of data was tested by Kolmogorov-Smirnov test.

Results

Serum and tissue catalase was lower in vitiligo patients than controls. Serum catalase was lowest in vulgaris type, whereas in the acrofacial type had lowest tissue catalase levels.

Conclusion

Vitiligo patients have a generalized oxidative stress functioning at a higher pace as seen with decreased serum and tissue CAT which can well be taken as a marker of active disease and they can be helped with topical pseudoCAT preparations.

Scrub Typhus Co-Infections in a Young Boy With Varicella and Malaria: A Rare Case Report

Scrub typhus is one of the leading causes of acute febrile illness of unknown origin in India. Though several co-infections of other vector-borne diseases have been described in the literature, few such cases have been described in children. As such, it is challenging to diagnose scrub typhus alone and becomes that more complicated when a varicella infection precedes it. This is the first reported case where scrub with varicella infection also had concomitant malaria. In such cases, prompt diagnosis and initiation of the correct drug are imperative. Here we describe a six-year-old child with a past history of varicella infection and co-infected with scrub typhus and malaria.

Development of Two-Tube Loop-Mediated Isothermal Amplification Assay for Differential Diagnosis of Plasmodium falciparum and Plasmodium vivax and Its Comparison with Loopamp™ Malaria

To strengthen malaria surveillance, field-appropriate diagnostics requiring limited technical resources are of critical significance. Loop-mediated isothermal amplification (LAMP) based malaria diagnostic assays are potential point-of-care tests with high sensitivity and specificity and have been used in low-resource settings. Plasmodium vivax–specific consensus repeat sequence (CRS)-based and Plasmodium falciparum–specific 18S rRNA primers were designed, and a two-tube LAMP assay was developed. The diagnostic performance of a closed-tube LAMP assay and Loopamp™ Malaria Detection (Pan/Pf, Pv) kit was investigated using nested PCR confirmed mono- and co-infections of P. vivax and P. falciparum positive (n = 149) and negative (n = 67) samples. The closed-tube Pv LAMP assay showed positive amplification in 40 min (limit of detection, LOD 0.7 parasites/µL) and Pf LAMP assay in 30 min (LOD 2 parasites/µL). Pv LAMP and Pf LAMP demonstrated a sensitivity and specificity of 100% (95% CI, 95.96–100% and 89.85–100%, respectively). The Loopamp^TM Pan/Pf Malaria Detection kit demonstrated a sensitivity and specificity of 100%, whereas Loopamp^TM Pv showed a sensitivity of 98.36% (95% CI, 91.28–99.71%) and specificity of 100% (95% CI, 87.54–100%). The developed two-tube LAMP assay is highly sensitive (LOD ≤ 2 parasite/µL), demonstrating comparable results with the commercial Loopamp™ Malaria Detection (Pf/pan) kit, and was superior in detecting the P. vivax co-infection that remained undetected by the Loopamp™ Pv kit. The developed indigenous two-tube Pf/Pv malaria detection can reliably be used for mass screening in resource-limited areas endemic for both P. falciparum and P. vivax malaria.

Pancytopenia with hemophagocytic lymphohistiocytosis in Plasmodium falciparum: A unusual presentation

Hematological manifestations such as anemia and thrombocytopenia are known complications in malaria. Here, we report two cases presented as pancytopenia with hepatosplenomegaly and initial diagnosis kept as hematological malignancy like leukemia but later on its diagnosed as malaria-associated hemophagocytic lymphohistiocytosis which is a rare entity. The aim of this report is to draw the attention of physicians, especially in tropical countries such as India and Sub-Saharan nations to keep in mind this uncommon presentation of malaria, though the exact pathophysiological mechanism still remains obscure.

Etiological Trends and Epidemiological Profile of Tropical Fever in Children Presenting with Acute Undifferentiated Fever at a Tertiary Care Centre in North India

Introduction: The objective of this study was to determine the etiology of acute undifferentiated fevers (AUF) in hospitalised children with in a tertiary care centre in North India. The various causes of acute undifferentiated fevers included dengue, malaria, scrub typhus, enteric fever, leptospirosis and Chikungunya. The clinical spectrum and therapeutic outcome of these cases was also studied. Methods: This retrospective study was conducted over a period of 6 months from June 2019 to December 2019. The clinical information of 126 children who tested positive for any of the causes of AUF namely dengue, malaria, scrub typhus, enteric fever, chikungunya and leptospirosis was obtained from the Paediatrics Department. The information was recorded in a predesigned proforma. Various tests performed for the diagnosis of these illnesses were noted. They included dengue NS1 antigen ELISA and IgM ELISA, peripheral blood smear (PBS) for malarial parasite and rapid malarial antigen detection test (RMAT), scrub typhus IgM ELISA, leptospira IgM ELISA, and Chikungunya IgM ELISA. Results: The diagnosis of AUF were dengue (55.5%; 70/126), malaria (19%; 24/126) and scrub typhus (19%; 24/126), enteric fever (4.7%;6/126) and Chikungunya (1.5%; 2/126). The most common presenting symptom was fever or pyrexia followed by myalgia, generalised aches and pains in the body and vomiting. Commonly observed complications included thrombocytopenia, hepatitis and shock. Conclusions: Dengue, malaria and scrub typhus are the major causes of AUF in the hospitalised children with dengue being the most prevalent infection. The study further emphasises the need to develop a systematic approach to the diagnosis of AUFs. This should be using a combination of clinical, epidemiological and laboratory parameters, which will be very useful for developing a relevant action plan for treatment and prevention of such fevers in any hospital setup.

Neonatal Chikungunya: A case series

Chikungunya virus is an RNA virus that belongs to the family Togaviridae, genus Alphavirus, transmitted by Aedes mosquitoes. The disease usually manifests as fever, arthralgia and petechial or maculopapular rash. The illness is usually self-limiting. We report a series of neonates infected with Chikungunya virus, confirmed by ELISA test, showing that viral Chikungunya can be transmitted from mother to babies and its clinical presentation is that of septicemia or meningitis.

Assessing the in vitro sensitivity with associated drug resistance polymorphisms in Plasmodium vivax clinical isolates from Delhi, India

The drug resistance of Plasmodium vivax in clinical cases remains largely unknown till date because of the difficulty in diagnosing the resistant P. vivax strains. The present study was undertaken to determine the prevalence of mutant alleles in drug resistance genes viz P. vivax multi-drug resistance (pvmdr-1), chloroquine resistance transporter (pvcrt-o), dihydrofolate reductase (pvdhfr) and dihydropteroate synthase (pvdhps) along with in vitro chloroquine (CQ) sensitivity in P. vivax clinical isolates. During August-October 2017 a total of 86 samples of the febrile patients were screened and 31 samples were found to be positive for P. vivax in Safdarjung hospital, New Delhi. Sequence genotyping of the drug resistance genes was carried out in these P. vivax samples and in vitro CQ susceptibility for 23 isolates was determined by the schizont maturation assay (SMA). The CQ inhibitory concentrations (IC₅₀) for the clinical isolates was found to be in the range of 25.6-176.7 nM. All the 31 clinical isolates analyzed for pvmdr-1 gene, showed mutant alleles and in only two isolates novel mutations at 861 and 898 codons were observed. Sequence analysis of pvcrt-o, pvdhfr and pvdhps genes revealed wild type genotypes in all the 31 studied isolates. The presence of mutations in pvmdr-1 gene and the increase in the CQ IC₅₀ value indicates the possibility of shift in drug tolerance where CQ with primaquine (PQ) is still the first line of treatment for P. vivax malaria in the country. The regular molecular surveillance in P. vivax would provide useful information for the policy makers of the malaria control programme.

Severe vivax malaria trends in the last two years: a study from a tertiary care centre, Delhi, India

Background

Plasmodium vivax, once considered benign species, is recently being recognised to be causing severe malaria like Plasmodium falciparum. In the present study, the authors report the trends in malaria severity in P. vivax among patients from a Delhi government hospital. The aim of the study was to understand the disease severity and the burden of severe vivax malaria.

Methods

A hospital based study was carried out from June 2017 to December 2018 at a tertiary care centre from Delhi, India. Patients were tested for malaria using peripheral blood smear (PBS) and/or rapid malaria antigen test (RMAT). The severe and non-severe vivax malaria categorization was done as per the WHO guidelines. Sociodemographic, clinic and paraclinical data were collected from patients and their medical records.

Results

Of the 205 patients, 177 (86.3%) had P. vivax infection, 22 (10.7%) had P. falciparum infection and six (2.9%) had mixed infection with both the species. Out of 177 P. vivax cases included in this study one or more manifestations of severe malaria was found in 58 cases (32.7%). Severe anaemia (56.9%), jaundice (15%) and significant bleeding (15%) were the most common complications reported in most of patients, along with thrombocytopenia.

Conclusions

In this study, it is evident that vivax malaria is emerging as the new severe disease in malaria patients, a significant shift in the paradigm of P. vivax pathogenesis. The spectrum of complications and alterations in the laboratory parameters in P. vivax clinical cases also indicate the recent shift in the disease severity.

Allelic variation of msp-3α gene in Plasmodium vivax isolates and its correlation with the severity of disease in vivax malaria

Malaria is a global socio-economic burden of which Plasmodium vivax contributes for about 70-80 million cases on an annual basis worldwide and 60-65% cases in India. Diversity observed in highly polymorphic Merozoite Surface Protein-3α (msp-3α) encoded by MSP-3 gene family, has been used efficiently for genotyping of P. vivax infection. This study aims to correlate the severity of clinical symptoms with parasite load, genotype of P. vivax and multiplicity of infection. Based on clinical symptoms classification, 31 (67.9%) out of 46 cases were found to be severe while 15 (32.6%) were non-severe and correlation of the severity of vivax infection with parasite load was not observed. Analysis of msp3-α allele genotype showed that out of 31 severe cases, 19 (61.2%) were single-clone infection cases whereas 12 (38.7%) were multi-clone infections. Similarly, out of 15 non-severe cases, 9 (60%) were single clone and 6 (40%) were multi-clone infections indicating the absence of a correlation between the multiplicity of infection and disease severity. Allele frequency observed was 65.9%, 23.4%, 23.4%, and 28.2% for allele A, B, C and D, respectively. An important finding was the greater distribution of allele D than alleles B and C, which has been reported as a rare allele otherwise. Further, of 13 cases with allele D, 76.9% (10/13) cases were severe. This study showed the absence of a correlation between the severity of clinical symptoms with parasite load and multiplicity of infection but at the same time drives a possibility of severe vivax malarial symptoms to have an association with the persistence of allele D in the population. This upon exploration can lead to the development of a target in detection of severe cases of malaria.

Transfusion-Transmitted Malaria (TTM) in a Neonate - A Case Report

Transfusion-transmitted malaria in neonates is uncommon entity. Here we report a case of severe malaria in a term neonate after exchange transfusion successfully treated with intravenous artesunate.

Early treatment failure in concurrent dengue and mixed malaria species infection with suspected resistance to artemisinin combination therapy from a tertiary care center in Delhi: a case report

Background

Concurrent dengue and mixed malaria infections in a single patient present with overlapping clinical manifestations which pose a diagnostic challenge and management dilemma in areas of common endemicities.

Methods

We report a case of a young male who tested positive for both Plasmodium vivax and Plasmodium falciparum along with dengue infection. He showed signs of early treatment failure to artemisinin combination therapy (artesunate with sulfadoxine+pyrimethamine). Molecular analysis for the drug resistance genes viz: chloroquine resistance (pfcrt), multidrug resistance (pfmdr-1), sulfadoxine (pfdhps), pyrimethamine (pfdhfr), and artemisinin resistance (keltch 13) was performed.

Results

A rise in parasitemia from <2% to 5% was observed after 3 days of treatment. Mutations in pfcrt, pfmdr-1, pfdhfr, and pfdhps genes were detected as a possible cause of treatment failure.

Conclusion

Increased severity, overlapping symptoms, and suspected resistance to treatment warrants a multidimensional diagnostic approach and diligent therapeutic monitoring.

Linezolid-resistant mucoid Staphylococcus haemolyticus from a tertiary-care centre in Delhi

We report an unusual morphological mucoid variant of Staphylococcus haemolyticus associated with linezolid resistance from a patient with sepsis. Linezolid resistance and mucoid character together made this pathogen difficult to treat. To our knowledge this is the first such report.

HIV-TB Cross-referral and Collaborative Strategy: 8 Years of Our Experience from An Urban Health Centre in North India

BACKGROUND

Human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics continue to fuel each other and with dual infections with these two deadly diseases on the rise, it becomes imperative to devise effective HIV-TB collaborative strategies. The present study was designed to evaluate the existing HIV-TB cross-referral mechanism at an urban health centre; to determine HIV sero-prevalence among pulmonary TB patients referred from chest clinic to the integrated counselling and testing centre (ICTC); and to evaluate the TB suspects referred from ICTC to the chest clinic for a possible TB aetiology.

METHODS

The present study was a retrospective analysis of HIV-TB cross-referrals whereby a line list of all the patients referred under this strategy from January 2006 to December 2013 was retrieved and analysed.

RESULTS

A total of 3726 TB cases were referred to the ICTC and 641 TB suspects were identified by ICTC counsellors and referred to the chest clinic during this period. HIV sero-prevalence among TB patients was 2.8% (106 of 3726) and TB prevalence among HIV sero-positive and sero-negative TB suspects was 9.3% (10/108) and 4.3% (9/211), respectively (p=0.07). HIV prevalence was found to be significantly higher among male (n=2024) than among female (n=1702) TB patients (4.4% versus 0.9%; p<0.0001). Only 319 of 641 (49.8%) ICTC patients referred to the chest clinic reached there.

CONCLUSION

Our study highlights the strong need to scale up the integration and partnership between HIV and TB programmes for better and integrated diagnosis and care of HIV-TB co-infected patients.

Onychomycosis due to rhizomucor in psoriatic patient with HIV infection

Onychomycosis is frequently seen in dermatological clinical practice worldwide. The causative agents are usually two pathogenic groups of fungi namely, dermatophytes and yeasts of the genus Candida. In some cases, non-dermatophytic molds belonging to different genera and species may be the etiological agents. We report an unusual case of onychomycosis in an HIV-positive psoriatic patient caused by Rhizomucor pusillus, which has not been mentioned in the literature before. Our finding underline the fact that fungal species appearing as contaminants should be evaluated by proper clinical-mycological correlation to ensure an accurate diagnosis.

Cytomegalovirus infection: an Indian perspective

Human cytomegalovirus (CMV) poses an important public health problem as it may cause serious morbidity and mortality in congenitally infected newborns and immunocompromised patients, most notably transplant recipients and HIV-infected persons. It is probably one of the most common infections known to humans and is characterized by a self-limiting infection in healthy individuals. CMV infection is the single most frequent cause of infectious complications in the early period following kidney transplantation Post-transfusion cytomegalovirus infection is of concern in the immunocompetent as well as in certain categories of immunocompromised individuals such as neonates, pregnant women, recipients of bone marrow and other organ transplants and individuals with immunodeficiency disorders. The emergence of AIDS in India has necessitated the establishment of reliable tests for diagnosis of cytomegalovirus infection as a damaged immune system permits cytomegalovirus reactivation. The magnitude of this problem in India and the various diagnostic modalities used have not been adequately investigated and, hence, CMV infection is still a major health problem warranting strong preventive measures. The ultimate goal of the prevention program is to develop a vaccine that can be administered to seronegative women of childbearing age to prevent primary infection during pregnancy.

Clinico-laboratory findings of patients during dengue outbreak from a tertiary care hospital in Delhi

There are outbreaks of dengue every year in India. They vary in the predominant serotype involved, clinical features and predominant laboratory findings. This study of the 2006 outbreak in Delhi highlights clinical features and laboratory parameters of dengue cases and compares the clinical features among the adult and paediatric age groups. The 2006 outbreak had higher bleeding manifestations and a greater involvement of the adult male population than in previous outbreaks. No correlation was observed between platelet count and different bleeding manifestations until they dropped <20,000 per μL. Few patients developed a florid picture before seroconversion, highlighting a greater stress on the haematological rather than immunological profile of such patients. Atypical symptoms, such as diarrhoea, menorrhagia and seizures were often the presenting complaints rather than the typical clinical features of dengue.

Immunodiagnosis of dengue virus infection using saliva

Keeping in view the complications and the case fatality associated with dengue virus, several serologic tests have been developed. However, the major drawback of these serologic tests is the need for a venous blood sample obtained by invasive venipuncture. As a noninvasive alternative, saliva provides a body fluid that contains antibodies of diagnostic importance. Hence, the detection of DEN-specific IgM and IgG antibodies in serum and saliva from 80 patients was compared. Salivary IgM antibodies were detected in 100% of the serum IgM-positive samples and in 30% of the serum samples that were negative for IgM antibodies. Salivary IgG antibodies were detected in 93.3% of the serum samples that were positive for anti-dengue IgG antibodies and in none of the serum IgG-negative cases. None of the specimens from the healthy controls showed the presence of IgM or IgG antibodies. The detection of both IgG and IgM antibodies in saliva correlated well with the serum IgG and IgM detection by the ELISA test (r = 0.6322 and r = 0.4227). Detection of salivary IgM antibodies by ELISA showed 100% sensitivity, 70% specificity, 90.9% positive predictive value, and 100% negative predictive value. The detection of IgG in saliva proved to be a promising tool as the sensitivity, specificity, positive predictive value, and negative predictive value were found out to be 93.3%, 100%, 100%, and 83.3%, respectively. Thus, from this study we conclude that the detection of DEN-specific salivary IgG and IgM antibodies are useful markers for dengue infection.