Trends and Pattern of Diseases Under Integrated Disease Surveillance Project in Jodhpur, Rajasthan: A Retrospective Observational Study.

Background: Progress of the Integrated Disease Surveillance (IDSP) is of utmost importance to ensure optimal performance in Jodhpur, Rajasthan, India. The purpose of the study was to document the physical performance of the surveillance system on its core and support functions. Material and Methods: Mixed method study was conducted between September 2020 to October 2020. Quantitative data was collected from the district IDSP unit of the Chief Medical and Health Office (CMHO) for various blocks of Rajasthan using syndromic, presumptive, and laboratory-confirmed reporting formats. Ethical clearance was obtained from the Institutional Ethical Committee of AIIMS, Jodhpur. Results: Rajasthan reported outbreaks between 0.55 to 1.2% of the national average between 2015-2019. Acute respiratory infections, fever of unknown origin, and acute diarrhea were the leading diseases under the presumptive reporting format. Major syndromic cases reported were cough with/without fever (more than three weeks) and fever less than seven days with the rash. Laboratory-confirmed Dengue, Malaria, and hepatitis were reported more in urban Jodhpur. Conclusion: Despite some pitfalls, IDSP has made satisfactory improvements in its core and support functions in the Jodhpur district of Rajasthan. The number of preventable morbidity and mortality cases associated with notifiable infectious diseases in our country can be effectively countered by strengthening the IDSP reporting system.

Pulmonary Tuberculosis Presenting As Septic Shock in an Immunocompetent Patient: Revisiting an Old Disease With New Perspectives.

Septic shock due to Mycobacterium tuberculosis (M. tuberculosis) in immunocompromised patients (particularly HIV) is a well-recognized clinical entity. However, tubercular sepsis in the immunocompetent is still underdiagnosed and under-discussed. Moreover, sepsis is usually associated with gram-negative and other gram-positive microorganisms that can cause similar pulmonary and disseminated disease and can further convolute the diagnosis. We herein discuss a case of an elderly female who presented with acute onset fever, cough, and altered talk from the last seven days. Her initial clinical and laboratory examination revealed features of lower respiratory tract infection with septic shock. She was started on broad-spectrum antibiotics based on severe community-acquired pneumonia management guidelines. Her blood and urine cultures were sterile. She did not respond to initial antibiotics. Furthermore, sputum production was not possible, which compelled us for gastric aspirate analysis, which came positive for cartridge-based nucleic acid amplification test (CBNAAT). In repeated blood cultures, M. tuberculosis was also isolated. She was started on antitubercular treatment; on the 12th day of antitubercular treatment, she developed acute respiratory distress and eventually succumbed to her illness on the 19th day of hospitalization. We highlighted the importance of early diagnosis and prompt antitubercular therapy in tubercular septic shock. We also discuss the possibility of tubercular-immune reconstitution inflammatory syndrome (IRIS) in such patients, which could be a contributing factor to mortality.

Right Atrial Thrombus in a Patient of Rheumatic Heart Disease with Severe Mitral Regurgitation: A Rare Association.

BACKGROUND: Right atrial thrombus is a rare phenomenon, and its incidence is not well- defined. It usually occurs in the presence of predisposing factors like tricuspid stenosis or following central venous catheterization. Isolated right atrial thrombus without any predisposing factors occurs rarely. CASE PRESENTATION: We herein report a 30-year-old male patient, a known case of rheumatic heart disease with mitral regurgitation, presented with severe breathlessness and orthopnea. He was diagnosed with acute pulmonary oedema with biventricular dysfunction and congestive symptoms. On transthoracic 2D echocardiography, he was found to have severe mitral and severe tricuspid regurgitation. All cardiac chambers were dilated, and an incidental finding of right atrial thrombus was noted. Patient The patient was managed conservatively, but he succumbed to his worsening heart failure. CONCLUSION: Treating physicians should be aware of the possibility of right atrial thrombus in rheumatic mitral valve disease because of its clinical implications, like life life-threatening pulmonary embolization and need of surgical management.

Post-Discharge Prophylactic Anticoagulation in COVID-19 Patients: A Clinical Dilemma.

BACKGROUND: COVID-19 pandemic has taken a great toll on the health care system worldwide. Along with the pandemic, there is also a concern regarding post COVID-19 complications in recovered patients. Thromboembolism (TE) has been reported as a fatal complication in recovered patients with COVID-19. There is still a great dilemma in post-discharge TE prophylaxis and its long-term benefits. CASE DESCRIPTION: We reported three cases of post COVID-19 with complications related to both diseases as well as post discharge anticoagulant therapy. The first case is about a 60-yr-old male who developed Covid-19 pneumonia (moderate disease) and was discharged on rivaroxaban after initial improvement. 3 weeks later, the patient was readmitted with lower gastro-intestinal bleeding. The other two cases developed pulmonary thromboembolism within a span of 2-3 months (after recovered from COVID-19 pneumonia). Both these patients were not prescribed anticoagulants for TE prophylaxis. CONCLUSION: There is an imperative need for effective guidelines for post discharge TE prophylaxis in COVID-19.

Prevalence of Asymptomatic Cryptococcal Antigenemia and Association with Follow-up Risk of Cryptococcal Meningitis and Mortality among HIV Infected Patients in North West India: A Prospective Cohort Study.

OBJECTIVE: Cryptococcal meningitis is an important cause of morbidity and mortality in HIV infected individuals. In the era of universal antiretroviral therapy, the incidence of immune reconstitution inflammatory syndrome (IRIS) related cryptococcal meningitis has increased. Detection of serum cryptococcal antigen in asymptomatic PLHIV (People Living With HIV) and preemptive treatment with fluconazole can decrease the burden of cryptococcal disease. We conducted this study to find the prevalence of asymptomatic cryptococcal antigenemia in India and its correlation with mortality in PLHIV. METHOD AND MATERIALS: This was a prospective observational study. HIV infected ART naïve patients with age of ≥ 18 years who had CD4 counts ≤ 100 /µL were included and serum cryptococcal antigen test was done. These patients were followed for six months to look for the development of Cryptococcal meningitis and mortality. RESULTS: A total of 116 patients were analyzed. Asymptomatic cryptococcal antigenemia was detected in 5.17% of patients and is correlated with increased risk of cryptococcal meningitis and mortality on follow-up in PLHIV. CONCLUSION: Serum cryptococcal antigen positivity is correlated with an increased risk of Cryptococcal meningitis and mortality in PLHIV. We recommend the screening of asymptomatic PLHIV with CD4 ≤ 100/µL for serum cryptococcal antigen, so that pre-emptive treatment can be initiated to reduce morbidity and mortality.

Metabolic changes in the patients on second-line highly active antiretroviral therapy (HAART): A prospective cohort study from north India.

INTRODUCTION: In India, there is a genetic predisposition to insulin resistance and cardiovascular risk, the impact of ART (antiretroviral therapy) on lipid profile and blood sugar may be significant. The study of potential implications of highly active antiretroviral therapy (HAART)-associated metabolic syndrome is critical to prevent cardiovascular diseases in the Indian population. AIMS: This study was done to determine the prevalence of metabolic changes (dyslipidaemia, hyperglycemia and insulin resistance) among HIV patients on second-line ART. SETTINGS AND DESIGN: A prospective cohort study. METHODS AND MATERIALS: We enrolled 150 patients, who were started on second-line HAART. Patients were investigated for fasting blood sugar, lipid profile and insulin level at baseline and after 6 months. STATISTICAL ANALYSIS: The data were analysed using SPSS software (version 20; IBM Corp., Armonk, N.Y., USA). Student's t-test was used to compare numerical variables in the two groups. P value < 0.05 was considered as statistically significant. RESULTS: There was a significant increase in serum cholesterol, LDL and triglyceride in patients with protease inhibitors (PIs) containing regimens. LDL levels were increased from 65 to 80 mg/dL (P = <.003) after treatment. Triglycerides were increased from 138 to 152 mg/dL. (P = <0.001). Median fasting blood sugar was increased from 85 to 96 mg/dL (P = <0.002). HOMA-IR was also significantly increased in the PI group (1.54 vs. 2.1, P <.003). However, serum HDL did not change significantly. CONCLUSIONS: Appropriate drug selection with timely switching of ART is crucial to prevent metabolic complications in patients taking long-term PIs.

Study of the prevalence of Multidrug-Resistant Pulmonary Tuberculosis (MDR-TB) in Western Rajasthan using line probe assay.

OBJECTIVE: To determine the prevalence of MDR-TB and find out the incidence of drug resistance using molecular diagnostic method. Line probe assay (LPA) is based on the principle of multiplex PCR is used to detect MTB (Mycobacterium tuberculosis) complex as well as its sensitivity to rifampicin and isoniazid. METHOD: This is a hospital-based prospective observational study. The sputum of MDR-TB suspected patients was subjected to Ziehl-Neelsen staining and smear positive samples were analyzed by LPA. Decontamination and digestion of the samples was done using the NALC- NaOH method (as defined in RNTCP guidelines). DNA extraction was done from the decontaminated samples using Geno Lyse kit. After DNA extraction, detection of MTB complex and rifampicin and/or INH resistance was done with the help of line probe assay (LPA) using GenoType ® MTBDRplus version 2.0. RESULTS: Out of the 156 smear-positive sputum samples, 140 samples had LPA valid results. The most common age group of positive TB samples in this study was 30-40 years (26.42%). Twenty-five samples (17.85%) were found to be rifampicin resistant and 22 (15.71%) samples were found resistant to isoniazid. Sixteen patients (11.42%) were detected MDR. Nine patients (6.42%) were monoresistant to rifampicin and six patients (4.28%) were monoresistant to isoniazid. "Sputum positive retreatment cases" had the highest detection rate for MDR TB. CONCLUSION: Line probe assay is an economical and time saving method for the detection of MDR-TB and serves as a lifesaving tool for early diagnosis and treatment. This calls for a widespread national use of this assay. The detection of around 10% ZN-positive patients, who were not showing MTB complex in LPA may be a hidden iceberg for non-tubercular mycobacteria.

Hypoalbuminemia and generalized edema as an atypical presentation of celiac disease.

The clinical presentation of celiac disease has evolved significantly over the last few decades. Previously defined as a malabsorption syndrome in pediatric patients, now it is considered an autoimmune disorder with diverse systemic manifestations among all age groups. We report a case of 56-year-old male presented with pedal edema and gradually progressive abdomen distention for the last 3 months. Serological evaluation and duodenal biopsy reports were suggestive of celiac disease. The patient was advised gluten-free diet, after 12 weeks, the patient became asymptomatic with the resolution of ascites and peripheral edema. According to the literature, there are few reports of protein-losing enteropathy as an initial presentation of celiac disease. The possibility of celiac disease should be considered even in the setting of atypical symptoms.

A 37-year-old male with unilateral hydronephrosis: A forgotten cause of secondary hypertension.

The evaluation of Secondary hypertension is laborious, expensive and of low yield, though screening of reversible causes, is important to prevent target organ damage. Hypertension secondary to hydronephrosis is rarely described in clinical studies. We herein report a 37-year-old male with a history of resistant hypertension. Initial evaluation for a secondary cause of hypertension was negative. CT abdomen showed unilateral hydronephrosis (Right). After surgical correction, his blood pressure begins to normalize in 3 weeks with a reduction in antihypertensive drugs. The patient was off medications at 6 months of follow-up. The relief of obstruction was parallel to the normalization of blood pressure, which suggest a causal link between hydronephrosis and hypertension. Our case illustrates hydronephrosis as an important cause in the evaluation of hypertension.

Clinical Evaluation of Febrile Thrombocytopenia in Western Rajasthan - a Hospital-based Study.

A number of patients of febrile thrombocytopenia increase during monsoon and postmonsoon period. Diseases like dengue fever, malaria, chikungunya fever, etc. are responsible for the clustering of febrile thrombocytopenia cases during this period. The diagnosis of fever with thrombocytopenia cases can be challenging and physicians should be aware of the regional and endemic seasonal cause of this syndrome. STUDY DESIGN: It is a prospective observational study. MATERIAL AND METHODS: The study included 103 consecutive patients. The patients admitted with acute febrile illness defined by a duration of less than 2 weeks with thrombocytopenia were evaluated. RESULTS: The present study included 103 consecutive cases of febrile thrombocytopenia. Out of these, 71.84% were male and 28.16% were female. The most common etiology for febrile thrombocytopenia was dengue fever (44.66%) and malaria (31.06%). Among clinical evaluation of the cases, fever was the inclusion criteria. Myalgia was the most common symptom found after fever, which was observed in 83.5% of the patients. The most common bleeding manifestation was petechiae/ purpura (12.62%) followed by hematuria (6.80%). Renal dysfunction was present in all 8(100%) cases of sepsis, followed by 14(43.75%) cases of malaria. All sepsis cases also had liver dysfunction, followed by 91.3% cases in dengue fever and 90.62 % cases in malaria had liver dysfunction. CONCLUSION: The study showed that acute febrile thrombocytopenia is an important seasonal syndrome. The common causes are dengue fever and malaria. Early identification of these diseases and prompt treatment decreases complications and reduces mortality.