Artesunate Resistance - An Emerging Threat.

Drug resistant malaria represents a challenging health problem in developing countries like India. The failure of drug artemisinin, which is the cornerstone of malaria therapy will rapidly compromise the treatment and prognosis of malaria. Resistance should be suspected if inspite of full treatment with Artesunate Combination Therapy and with no history of vomiting or diarrhoea, there is no clinical or parasitological response in the patient after 72 hours. The emergence of partial artemisinin resistant parasites were previously reported from West Bengal in the form of resistance to drugs. Presence of mutations in molecular markers was reported from different parts of India (Uttar Pradesh,Andhra Pradesh,Odisha and Jharkhand). MATERIAL: We report four cases of complicated malaria in Eastern India between January 2020 and July 2021, with apparent treatment failure with artemisinin drugs. Case1 A 45 old male known diabetic and hypertensive presenting with fever with loose stools since 5 days and seizures since 1 day. Case 2 A 59 year old male patient, known diabetic admitted with fever,black stools and decreased urination for 10 days. Case 3 A 35 year old male patient admitted with fever, headache, vomiting and hematuria for 5 days. Case 4 A 25 year old pregnant female admitted with complaints of bleeding per vaginum since 10 days with fever and vomiting for 6 days. In all cases malaria was confirmed with rapid card test and peripheral smears showed ring forms of plasmodium falciparum.Parasite levels were estimated to be between 30% to 45% in all cases.The patients were treated with injectable artesunate and once they tolerated oral medication they were started on oral artesunate combination therapy. OBSERVATION: After 4 days repeat peripheral smears showed persistence of parasites. Organ dysfunction did not subside. Hence Injectable Quinine and clindamycin was started in all cases. On day 7 all obtained microscopic parasite clearance. Cases 2 and 4 attained complete recovery,but the other two cases developed multiorgan dysfunction followed by septic shock and succumbed on 11th and 14th day of admission respectively. We could not confirm artemisinin resistance in any of these cases due to lack of availability of gene testing in our area. CONCLUSION: This report emphasizes the need for increased surveillance to identify artemisinin resistance in India. It will aid the treating physician for more selective use of drug-combinations which are less likely to foster resistance.

Clinico-Microbiological Profile and Culture Sensitivity Pattern of Micro-Organisms Isolated from Diabetic Foot Ulcers: Study from a Tertiary Care Centre.

Worldwide, diabetic foot lesions are a major medical, social and economic problem and are the leading cause of hospitalization for patients with diabetes. The organisms causing the ulcers vary from different geographical regions and initiation of empiric antibiotics depends on the prevalence of the local pathogens and their sensitivity pattern, With this background the present study was carried out to evaluate the bacterial diversity and their culture sensitivity patterns in diabetic foot ulcers. MATERIAL: Medical records of 65 cases of diabetes mellitus with diabetic foot ulcer admitted to hospital during the period from January 2019 to December 2020 were retrieved from the Medical Records Department. Demographic, clinical profile and microbiological profile with antibiotic sensitivity pattern were analyzed. OBSERVATION: Out of 65 cases (n=65), 54 (83.07%) were male and 11 (16.92%) were female. Age range of the patients was from 39 years to 80 years with mean age of 59=/-9.65years. The mean duration of diabetes was 9.4=/-5.7 years and 52.4% had diabetes for more than 10 years. Hypertension was present in 84.5% of the cases. Nearly 62.5% had lesions for 3 months before presenting to the hospital. Peripheral neuropathy was present in all the cases. More than 60% cases were surgically treated with debridement. Osteomyelitis was present in 44.5% cases. Out of 65 cases, 64 were culture positive. Pseudomonas aeruginosa was the leading pathogen in 23.3% cases (n=15), Staphylococcus aureus, E.coli, Acinetobacter baumannii and Klebsiella pneumoniae were isolated in 15.38% cases each followed by Burkholderia cepacia which constituted 10% of all cases. Multiple organisms were isolated in 11 cases (16.92%). CONCLUSION: Burkholderia cepacia, which was earlier an uncommon infection in Diabetic foot ulcer, was found in significant (10%) number of cases. This may be due to improper waste management and change in environmental conditions.

Spectrum of infections occurring in patients of autoimmune rheumatic diseases on treatment with biological versus conventional disease-modifying antirheumatic drugs: A comparative study.

Background: The era of biological therapy has revolutionized in the management of autoimmune rheumatic diseases. There have been conflicting results about the incidence of infections related to these drugs. The purpose of this study was to compare the spectrum and severity of infection between patients on biological disease-modifying antirheumatic drugs (bDMARDs) versus conventional disease-modifying antirheumatic drugs (cDMARDs). Materials and Methods: This hospital-based prospective observational study was conducted in a tertiary care hospital, and a total 200 patients were enrolled in this study. Patients on either bDMARDs or cDMARDs for at least six weeks presenting with evidence of infection were included. Patients with known immunodeficiency states, multiple comorbidities, and patients on prednisolone >7.5 mg were excluded. Data was expressed as percentage and mean ± SD. Kolmogorov-Smirnov analysis was performed for checking linearity of the data, and analysis of variance (ANOVA) followed by Tukey's HSD test were used to test the significance of difference between more than two parameters in parametric data. Results: Rheumatoid arthritis in 58 patients (29%) were the commonest ones presenting with infections, followed by systemic lupus erythematosus in 37 patients (18.5%). 135 patients (67.5%) were on cDMARDs and 65 patients (32.5%) on bDMARDs. Respiratory tract infection in 47 (34.8%) patients was found to be the commonest infection due to cDMARDs. Incidence of infection was higher with biologics, and types of infection in patients receiving infliximab and etanercept were significantly different from that of cDMARDs. Patients receiving etanercept had higher risk of infections and re-infections, but they were milder compared to cDMARDs. A significantly higher frequency of re-infection was found in patients who had not received vaccination. Conclusion: This study emphasizes that TNF-α inhibitors are significantly associated with higher risk of infections. Patients on etanercept have significantly higher but milder infections as compared to cDMARDs. Vaccination plays a pivotal role in prevention of re-infections.

Co-existence of Thrombotic Thrombocytopenic Purpura and Megaloblastic Anaemia: A Case-Based Review.

Introduction: Thrombotic thrombocytopenic purpura is a rare and fatal thrombotic microangiopathy characterised by a pentad of microangiopathic haemolytic anaemia, thrombocytopenia, renal abnormalities, neurological abnormalities, and fever. Due to ineffective erythropoiesis, vitamin-B12 deficiency may rarely present as haemolytic anaemia. Case report: We report a case of a 42-year-old vegetarian female presenting as vitamin B12 deficiency anaemia found to have concomitant TTP, responding to plasmapheresis, corticosteroids, and rituximab therapy. Discussion: In this case of vitamin B12 deficiency with co-existent TTP, we hypothesise vitamin B12 deficiency as a contributory or precipitating factor for TTP. We reviewed similar cases in the literature to support this hypothesis. Timely detection of TTP and the initiation of treatment is of utmost importance as TTP has a high mortality when left untreated. The possible relationship with Vitamin B12 deficiency needs further exploration.