Henoch-Schönlein Purpura in an Obese Adult with Elevated Transaminase: A Case Report and Literature Review.

Background: Henoch-Schönlein Purpura (HSP) cases are uncommon among adults due to their self-limiting nature and difficulty in diagnosis. The involvement of the hepatobiliary system and the effect of obesity is still not well understood among adults. Case Description: A 28-year-old obese male presented with an acute onset of generalized palpable purpura, fever, abdominal discomfort, and arthralgias. Laboratory examination indicated leukocytosis (43,100/µL), thrombocytosis (550,000/µL), and elevated transaminase levels (AST 125 U/L, ALT 131 U/L). Skin biopsy revealed perivascular inflammatory infiltrates in the superficial dermal vessels. Treatment of corticosteroids and antibiotics resulted in progressive clinical improvement. Conclusion: Although rare in adults, recognizing multiple presentations of HSP allows early diagnosis. This case highlights elevated transaminase levels and obesity contributed to increased inflammatory responses that may complicate HSP diagnosis. Despite severity, a complete recovery is possible if diagnosed early and managed appropriately.

High Pretreatment Level of Neutrophil to Lymphocyte Ratio, Monocyte to Lymphocyte Ratio and Other Factors Associated with Delayed Sputum Conversion in Patients with Pulmonary Tuberculosis.

Introduction: Patients with delayed intensive phase sputum conversion have a higher risk of multidrug resistant-tuberculosis (MDR-TB) and poorer treatment outcomes. Both, host (immune response and comorbidity) and pathogen factors play important roles in determining sputum conversion after treatment initiation. Impaired host immune response, especially the cellular components, as defined by the increased pre-treatment level of neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR) and other additional factors, were associated with severe active TB. Purpose: To evaluate whether impaired immune responses (high pre-treatment level of NLR and MLR) and other factors associate with delayed sputum conversion at the end of the intensive phase treatment. Patients and Methods: This was a case-control study from 2016 to 2020, which retrospectively analyzed the pre-treatment level of NLR, MLR and other factors among patients with new cases of pulmonary tuberculosis (PTB). Results: A total of 62 patients (31 cases and 31 control). The cut-off value of high pretreatment level of NLR and MLR was 5.065 and 0.585, respectively. Bivariate analysis showed that pretreatment NLR ≥5.065 (OR 8.23, CI 95% 2.48-27.32, p < 0.001), MLR ≥0.585 (OR 10.18, 95% CI 3.13-33.18, p < 0.001) and BMI <18.5 (OR 2.91, 95% CI 1.03-8.20, p = 0.041) were associated with an increased risk of delayed sputum conversion. Multivariate analysis, however, showed that pretreatment NLR ≥5.065 was not significantly associated with delayed sputum conversion (AOR 3.370, 95% CI 0.71-15.91, p value 0.125). A high pretreatment of MLR (AOR 30.802, 95% CI 3.22-287.55, p value 0.003) and lower BMI (AOR 10.942, 95% CI 1.121-98.563, p value 0.033) were significantly associated with an increased risk of delayed intensive phase sputum conversion. Conclusion: High MLR pretreatment and a low BMI were significantly associated with an increased risk of delayed sputum conversion at the end of the PTB intensive phase treatment. High NLR pretreatment, smoking, diabetes, and HIV were not associated with sputum conversion.

Factors associated with anti-retroviral therapy adherence among patients living with HIV during the COVID-19 pandemic: A cross-sectional study.

Background: The coronavirus disease (COVID-19) pandemic causes fear and anxiety symptoms on some vulnerable populations such as patients living with human immunodeficiency virus (HIV) (PLWH). Physical distancing (during consultation in the clinic) and isolation restrictions will likely have a negative impact on/disruption to all care continuum services of HIV diseases although healthcare services and access to anti-retroviral therapy (ART) have continued to operate. Objective: To investigate the factors associated with ART adherence among PLWH during the COVID-19 pandemic. Methodology: A cross-sectional study was conducted on 324 PLWH who had been on ART for at least 6 months between June 2020 and January 2021. A semi-structured questionnaire was used to interview participants to collect data on sociodemographic characteristics and other factors. Results: Of 324 PLWH taking ART, 264 (81.48%) had high adherence (≥95%) and 60 (18.52%) had low adherence (< 95%). Factors independently associated with high ART adherence were employment status (adjusted odds ratio (AOR): 0.030, 95% confidence interval (CI): 0.010-0.088; p < 0.001), type of antiretroviral (ARV) (AOR: 3.101, 95% CI: 1.137-8.456; p = 0.027), family support (AOR: 0.157, 95% CI: 0.052-0.475; p = 0.001), the perception that the COVID-19 pandemic negatively impacts the ability to attend clinics (AOR: 7.339, 95% CI: 1.46-36.79; p = 0.015), and the perception that the COVID-19 pandemic negatively impacts the ability to take ART (AOR: 10.611, 95% CI: 2.98-37.72; p < 0.001). Conclusions: During the COVID-19 pandemic, factors associated with high ART adherence among PLWH attending the Hospital of Wangaya in Denpasar, Bali, Indonesia were employment status, ART type [non-fixed dose combination (FDC)], family support, and the perception that the COVID-19 pandemic negatively impacts the ability to attend clinics and to take ART.

Preliminary study of coronavirus disease 2019 on pets in pandemic in Denpasar, Bali, Indonesia.

BACKGROUND AND AIM: Coronavirus disease 2019 (COVID-19) is an acute infectious respiratory disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and has spread rapidly globally, resulting in a pandemic. In humans, the main routes of transmission are respiratory droplets and close contact with infected individuals or through contact with an object infected with the virus, followed by touching mouth, nose, or eyes. It is assumed that SARS-CoV-2 was originated in wild animals and was then transmitted to humans. Although some wildlife and domestic animals can be naturally or experimentally infected with the virus, the intermediate hosts that transmitted it to humans are still unknown. Understanding the dynamics of SARS-CoV-2 associated with possible zoonotic transmission of intermediate hosts is considered critical. Reportedly, cats or dogs living with COVID-19-positive humans tested positive for the disease, suggesting that the virus was transmitted to the animals from humans. Information regarding the epidemiological investigation and comprehensive studies is limited. Therefore, it is still unclear how high is the correlation of infection in humans and pet animals, especially those living together. The aim of this study was to investigate the possibility of SARS-CoV-2 infection in the pets of patients with COVID-19 who were hospitalized at the Wangaya hospital, Denpasar, Bali, Indonesia. MATERIALS AND METHODS: A total of seven clinically asymptomatic pets (six dogs of different races and sexes and a cat [age, 360-2920 days]) were included in this study. These animals belonged to patients with confirmed SARS-CoV-2 infection from August to November 2020. Nasal swab and nasopharyngeal samples were collected from the pets individually under anesthetic condition and were collected 6-12 days after confirmed SARS-CoV-2 infection in owners and hospitalization at the Wangaya Hospital. The swab samples were then processed for RNA isolation and tested using reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2, in accordance with the World Health Organization manual 2020. RESULTS: RT-PCR results for all seven RNA samples, prepared from the swab samples, were negative. For the samples, all PCR products were below the threshold limit, suggesting no genetic material belonging to the samples tested. CONCLUSION: This was the first preliminary study of COVID-19 on pets in pandemic using RT-PCR. The study tested a very limited quantity of samples, and all of them were negative. However, the way in which the samples were prepared was considered appropriate. Therefore, in further studies, testing of more samples of pets of more individuals with confirmed SARS-CoV-2 infection is required.

A Challenge in Diagnosis of Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome (TB-IRIS).

Tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) in HIV-infected patients is the sign and symptom of exacerbation, or radiological manifestation of Mycobacterium tuberculosis (Mtb) infection, can describe the improvement of the immune system after initiating highly active antiretroviral therapy (HAART). No approved or explicit symptomatic tests for TB-IRIS exist, the diagnosis depends on the clinical manifestations. Here we report a TB-IRIS case with diagnostic challenges.

Lichenoid Reaction Caused by Antihistamines and Corticosteroids.

Lichenoid reaction (LR) is clinically and histopathologically similar to lichen planus (LP), which involves the skin and mucous membrane. LR has identifiable etiology and can be triggered by systemic drug exposure or any other agents. LR occurs in all racial groups and is predominantly observed in young adults aged 20-40 years, but can occur in any age group. Typically, the clinical manifestation of LR is an itchy rash of small (±3-5 mm) shiny, raised, reddish-purple papules. The rash appears suddenly and commonly affects the anterior surface of the arm and hand and the back part of the body. We report a rare case of LR to antihistamines (cetirizine, loratadine) and corticosteroid (methylprednisolone): an adult female 32-year-old patient, with a chief complaint of burning sensation, a few small rashes and itching on the anterior surface of the arm after eating seafood and eggs 7 days prior to admission. From the detailed and chronologic anamnesis of her dietary habits, routine use of drugs and oral hygiene, and from the histopathological results, we concluded the patient has lichenoid reaction caused by drugs (antihistamines and corticosteroids).

Factors Associated with Oral Candidiasis in People Living with HIV/AIDS: A Case Control Study.

BACKGROUND: Oral candidiasis (OC) is the most frequent opportunistic infection of the oral cavity caused by Candida species overgrowth. A wide variety of risk factor that contributes to yeast infection especially candidiasis. It might be acting as an early marker for people living with HIV/AIDS (PLWHA). There are some risk factors for PLWHA associated OC at Wangaya hospital in Denpasar, Bali, Indonesia. AIM: To identify risk factors of OC in PLWHA at Wangaya Hospital in Denpasar, Bali, Indonesia. SETTINGS AND DESIGN: Case control study was conducted from March 1, 2016 and July 30, 2019, included 448 participants (207 cases and 241 controls). Consecutive recruitment was employed. METHODS: Cases were PLWHA (18 to 60 years old) with OC and controls without OC. Diagnosis of OC based on the clinical features which are the pseudomembranous candidiasis; oral thrush. An interviewer administered a structured questionnaire used to collect information on risk factors. Statistical analysis used: bivariate analysis was performed on all variables. Chi-square test with statistically significant was at a level of 0.05. RESULTS: The participants included 207 (46.20%) PLWHA with OC and 241 (53.80%) PLWHA who did not have OC. The majority participants, 293 (65.40%) were male. OC was associated with age [p = 0.03; OR = 0.66 (95% CI:0.45-0.95)]; sex [p = 0.002; OR = 1.88 (95% CI:1.26-2.80)]; Xerostomia [p = 0.000; OR = 4.15 (95% CI:2.76-6.23)]; smoking [p = 0.000; OR = 6.83 (95% CI: 4.46-10.44)]; alcohol consumption [p = 0.000; OR = 5.76 (95% CI: 3.74-8.83)]; antibiotic usage [p = 0.000; OR = 4.49 (95% CI: 2.93-6.90)]; CD4 count [p = 0.000; OR = 3.29 (95% CI:2.24-4.86)]; HIV clinical stage [p = 0.000; OR = 3.58 (95% CI 2.39-5.37)]. No significant association between prothesis with OC. CONCLUSION: We found that age, sex, xerostomia, smoking, alcohol consumption, antibiotic usage, CD4 counts and advanced HIV Clinical stage (AIDS) were significant associated risk factors for OC in PLWHA.

Japanese encephalitis virus infection in non-encephalitic acute febrile illness patients.

Although Japanese encephalitis virus (JEV) is considered endemic in Indonesia, there are only limited reports of JEV infection from a small number of geographic areas within the country with the majority of these being neuroinvasive disease cases. Here, we report cases of JEV infection in non-encephalitic acute febrile illness patients from Bali, Indonesia. Paired admission (S1) and discharge (S2) serum specimens from 144 acute febrile illness patients (without evidence of acute dengue virus infection) were retrospectively tested for anti-JEV IgM antibody and confirmed by plaque reduction neutralization test (PRNT) for JEV infection. Twenty-six (18.1%) patients were anti-JEV IgM-positive or equivocal in their S2 specimens, of which 5 (3.5%) and 8 (5.6%) patients met the criteria for confirmed and probable JEV infection, respectively, based on PRNT results. Notably, these non-encephalitic JE cases were less likely to have thrombocytopenia, leukopenia, and lower hematocrit compared with confirmed dengue cases of the same cohort. These findings highlight the need to consider JEV in the diagnostic algorithm for acute febrile illnesses in endemic areas and suggest that JEV as a cause of non-encephalitic disease has likely been underestimated in Indonesia.

Factors Associated With Adherence To Anti-Retroviral Therapy Among People Living With HIV/AIDS At Wangaya Hospital In Denpasar, Bali, Indonesia: A Cross-Sectional Study.

BACKGROUND: Acquired Immunodeficiency Syndrome (AIDS) is a major public health problem. Recently AIDS was considered as a manageable chronic disease. High adherence to Anti-Retroviral Therapy (ART) is necessary to achieve undetectable viral load, reduce morbidity, mortality and to improve the quality of life. It is also preventing the drug resistance, reducing the transmission and finally leading to live longer and healthier. OBJECTIVES: To assess the factor associated with ART adherence among people living with HIV/AIDS (PLWHA) at Wangaya Hospital, in Denpasar, Bali, Indonesia. METHODOLOGY: A cross-sectional study was carried out during January 2015-December 2017 among 202 PLWHA taking ART for at least 6 months. The participants were interviewed using a semi-structured questionnaire to obtain data on socio-demographic characteristics. The data were analyzed using SPSS software for windows version 24.0. Chi-square test was done, the precision value of 95% (p<0.05) was considered statistically to be significant. RESULTS: A total of 202 PLWHA taking ART, 170 (84.16%) were reported with high adherence (≥95%), 32 (15.84%) were low adherence (<95%). Factors found to be independently associated with high adherence to ART were employment status/occupation (p = 0.011), type of ARV (due to adverse effect of ART) (p = 0.002) and family support (p < 0.001). CONCLUSION: This study found that the factor associated with ART adherence among PLWHA who visited Wangaya Hospital, in Denpasar, Bali, Indonesia, was employment status, type of ARV and family support.

High levels of serum IL-6 and serum hepcidin and low CD4 cell count were risk factors of anemia of chronic disease in HIV patients on the combination of antiretroviral therapy.

Purpose: This study aimed to determine whether high levels of serum IL-6 and serum hepcidin and CD4<350 cells/ul were risk factors for the anemia of chronic disease (ACD) in HIV-infected patients on the combination of antiretroviral (cARV) therapy with successful clinically and immunological responses. Patients and Methods: A matched case-control study was conducted in the VCT clinic of Sanglah General Hospital, Indonesia, between January 1 and September 1, 2016. The case group was HIV patients with ACD, while the control group was HIV patients without ACD. Purposive consecutive sampling was employed in HIV patients aged 15-65 years who have received cARV therapy for >6 months, had >95% adherence of cARV within 6 months, did not have any clinical failure, did not have any immunological failure and did not receive switch therapy within 6 months. Chi-square test and logistic regression analysis were performed. Results: A total of 42 cases and 42 controls were included in this study. Significant differences were found between case and control, which included serum IL-6, serum hepcidin, smoking, creatinine clearance, anemia at the initiation of cARV, CD4 at the initiation of cARV and actual CD4 (cell/µL). High levels of serum IL-6, high levels of serum hepcidin and CD4< 350 cells/µl were risk factors for ACD. After adjusted with anemia at cARV initiation and BMI, we found that high levels of serum IL-6 (adjusted OR: 17.682; 95% CI: 3.442-90.826), high levels of serum hepcidin (adjusted OR: 10.562; 95% CI: 2.531-44.076) and CD4 <350 cells/µl (adjusted OR: 4.181; 95% CI: 5.6-12.381) remain as risk factors for ACD. Conclusion: High levels of serum IL-6, high levels of serum hepcidin and CD4 count <350 cells/µL were risk factors for ACD in HIV patients with cARV therapy.

Anaphylaxis: lesson learned from five cases.

Anaphylaxis is a severe hypersensitivity reaction. Its clinical manifestations vary, affecting several organs at once. Skin symptom is the most frequent manifestation; however, diagnosis of anaphylaxis will only be established when involving one or both vital organs, which are cardiovascular and respiratory system. Other symptom, such as that involving central nervous system or gastrointestinal tract, may accompany. We present five cases of anaphylaxis which vary in onset of symptoms, allergen, degree of severity, therapeutic response and clinical manifestation. Anaphylactic reaction to drugs in these cases is mainly manifested as anaphylactic shock and reaction to food allergen causing obstruction of respiratory tract. Four anaphylactic events occurred at home and only one occurred in a hospital, thus education on anaphylaxis to general community is very important, especially for the patients and their families. Prompt medical assistance in patients with anaphylactic symptoms determines their therapeutic response. Skin test prior to administration of cephalosporin does not give negative predictive value toward anaphylactic event.

Dengue in Bali: Clinical characteristics and genetic diversity of circulating dengue viruses.

A high number of dengue cases are reported annually in Bali. Despite the endemicity, limited data on dengue is available for Bali localities. Molecular surveillance study was conducted to explore the clinical and virological characteristics of dengue patients in urban Denpasar and rural Gianyar areas in Bali during the peak season in 2015. A total of 205 adult dengue-suspected patients were recruited in a prospective cross-sectional study. Demographic and clinical information were obtained, and dengue screening was performed using NS1 and IgM/IgG ELISAs. Viral RNA was subsequently extracted from patients' sera for serotyping using conventional RT-PCR and Simplexa Dengue real-time RT-PCR, followed by genotyping with sequencing method. We confirmed 161 patients as having dengue by NS1 and RT-PCR. Among 154 samples successfully serotyped, the DENV-3 was predominant, followed by DENV-1, DENV-2, and DENV-4. Serotype predominance was different between Denpasar and Gianyar. Genotyping results classify DENV-1 isolates into Genotype I and DENV-2 as Cosmopolitan Genotype. The classification grouped isolates into Genotype I and II for DENV-3 and DENV-4, respectively. Clinical parameters showed no relationship between infecting serotypes and severity. We observed the genetic diversity of circulating DENV isolates and their relatedness with historical data and importation to other countries. Our data highlights the role of this tourist destination as a potential source of dengue transmission in the region.