Clinical Spectrum of Celiac Disease among Adult Population: Experience from Largest Tertiary Care Hospital in Karachi, Pakistan.

Introduction: Celiac disease (CD) is a systemic autoimmune enteropathy triggered by dietary gluten in genetically susceptible individuals. Celiac disease affects 0.6-1.0% of the population worldwide. The prevalence of CD in Pakistan is yet unknown due to under diagnosis and lack of awareness. Objective: To determine a vast variety of presenting features in subtypes of CD to overcome the burden of disease. Materials and methods: This was a prospective, comparative, cross-sectional study conducted at Gastroenterology department of Jinnah Postgraduate Medical Center, Karachi from December 2022 till June 2023. This study included all adult patients ≥18 years diagnosed with CD on the basis of clinical presentation, positive IgA and IgG anti-transglutaminase antibodies (value >12 IU/mL detected by ELISA followed by small intestinal biopsy classified as per Marsh criteria. The data obtained were analyzed on the statistical software SPSS version 23. Descriptive statistics were obtained by frequencies and percentages. Results: About 142 patients were enrolled in the study, 103 (91.5%) had classical CD (CCD) whereas 36 (25%) had non-classical (NCCD). About 89 (62.7%) were females and 53 (37.3%) were males. The mean age was found to be 23 ± 6 years. Nutritional deficiencies including anemia, B12, folate, osteopenia and low body mass index (BMI) <18 was found more in CCD group as compared with NCCD group with significant p-values. Titers of anti-TTG between CCD and NCCD were not statistically significant. Hypothyroidism and PCOS were the most common associated conditions observed in adult CD patients. Conclusion: In conclusion, CD in adults and has diverse presentations. Adults with unexplained extra-intestinal symptoms like anemia and bone pain should be investigated for CD. How to cite this article: Butt N, Shahid B, Butt S, et al. Clinical Spectrum of Celiac Disease among Adult Population: Experience from Largest Tertiary Care Hospital in Karachi, Pakistan. Euroasian J Hepato-Gastroenterol 2024;14(1):24-29.

Epidemiological and clinical characteristics of esophageal carcinoma: An experience from tertiary care hospital of Karachi, Pakistan.

Objectives: To describe current trends and characteristics of esophageal cancer (EC) over the past ten years largest tertiary care hospital of Karachi, Pakistan. Methods: This single center retrospective study was conducted at the Department of Gastroenterology and Oncology, Jinnah Postgraduate Medical Center, Karachi, Pakistan, between the period of ten years from 1st January 2010 to 31st December 2019. Patient data including epidemiological characteristics such as age, gender, education, residence, occupation, addictions, comorbidities, symptoms, location of EC, laboratory parameters and histopathological type were recorded. All patients with missing histological and radiological findings were excluded. Results: The mean age of all patients was 49.26±14.24 years and among them majority were females 566 (56.1%). Almost, 834 (82.7%) patients had SQC and 175 (17.3%) presented with ADS. Most common presenting symptom was dysphagia in both groups 327 (32.4%) followed by vomiting (22.8%) and weight loss 196 (19.4%). The Esophagogastroduodenoscopy (EGD) findings showed the distal esophagus involvement in most of the patients (36.3%) in both groups. CT scan findings showed that the lower region was the most involved region in 367 (36.4%) patients, followed by middle and upper in 227 (22.5%) and 156 (15.5%) patients respectively. The thickening of mass on CT- scan was circumferential in most of the patients (42.7%) in both groups. Conclusion: According to our findings, SQC is more prevalent than ADC. Female predominance especially at younger age was most common as compared to past studies. No significant association between a single risk factor has been found in our study however smoking and betel nut chewing were found as known putative risk factors.

Efficacy and Safety of Prunus mume and Choline in Patients with Nonalcoholic Fatty Liver Disease.

Aim: The primary objectives of this study include evaluating changes in lipid profile and liver enzyme levels in nonalcoholic fatty liver disease (NAFLD) patients receiving Prunus mume and choline supplementation (Revolic). Materials and methods: Two-hundred patients were recruited from the hepatology outpatient department of a public hospital between January and June 2023. Patients who had confirmed diagnosis of NAFLD, proven with ultrasound (US) followed by biopsy or US alone with age >18 years were included in this study. The study variables were fasting blood sugar, cholesterol levels, low-density lipoprotein (LDL), triglyceride, alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transferase levels (GGT). All investigations were conducted and compared between baseline, 12 and 24 weeks following treatment. Results: The mean age of all participants was 40.49 ± 10.59 years with 34 males and 166 females. The mean cholesterol levels were reduced to 179.86 ± 35.63 mg/dL from the mean baseline of 197.57 ± 42.52 mg/dL (p = 0.001). There was also a statistically significant difference found between baseline and posttreatment levels of LDL and triglyceride (p < 0.001). The ATL levels were also reduced from baseline 44.91 ± 32.40 U/L to 44.25 ± 30.66 and 41.06 ± 22.15 U/L between 12 and 24 weeks after treatment respectively. There was a statistically significant reduction in ATL, AST, and GGT levels from baseline with p-value < 0.001. Conclusion: The combination of P. mume and choline (Revolic) gives promising results with a significant reduction in lipid profile and liver enzymes. Clinical significance: The combination of P. mume and choline can be considered a reliable option for the management of NAFLD due to its efficacy and safety at 24 weeks after treatment as evident in the present study. How to cite this article: Butt N, Masood M, Ali A. Efficacy and Safety of Prunus mume and Choline in Patients with Nonalcoholic Fatty Liver Disease. Euroasian J Hepato-Gastroenterol 2023;13(2):124-127.

Gender Differences in Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) has currently emerged as the most common liver disorder in both developed and developing countries. It has been observed that NAFLD exhibits sexual dimorphism, and there is limited understanding on the sex differences in adults with NAFLD. Nonalcoholic fatty liver disease shows marked differences in prevalence and severity with regards to gender. There are considerable biological disparities between males and females attributed to differences in the chromosomal makeup and sex hormone levels, distinct from the gender differences resulting from the sociocultural influences that lead to differences in lifestyle, which have a significant impact on the pathogenesis of this complex disorder. A multitude of factors contributes to the gender disparities seen and need to be researched in-depth to better understand the mechanisms behind them and the therapeutic measures that can be taken. In this article, we will review the gender disparities seen in NAFLD, as well as recent studies highlighting certain gender-specific factors contributing to its varying prevalence and severity. How to cite this article: Nagral A, Bangar M, Menezes S, et al. Gender Differences in Nonalcoholic Fatty Liver Disease. Euroasian J Hepato-Gastroenterol 2022;12(Suppl 1):S19-S25.

Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey.

BACKGROUND AND AIMS: Patient preference for a healthcare professional is mediated by physician gender. The primary aim of this study was to assess gender preference for an endoscopist in a cohort of Muslim patients. The secondary aim was to identify factors that influence gender preference. METHODS: This was a multicenter cross-sectional study conducted at 3 tertiary care hospitals in Pakistan. Consecutive patients scheduled for elective outpatient upper endoscopy or colonoscopy were asked to complete a questionnaire immediately before and after the procedure. Data collected included patient demographics, occupation, education level, procedure type, gender preference, and reason for preference. RESULTS: A total of 1078 patients completed the questionnaire (age 43.5 ± 15.8 years; 53.2% men). Upper endoscopy was the most frequent procedure, performed in 84% of patients. Gender preference was expressed by 707 patients (65.6%), of which 511 (72.3%) were willing to wait for an average of 7 days for an endoscopist of the preferred gender. Male patients' preferences (45.1% male endoscopist, 17.1% female endoscopist, 37.8% no preference) differed from female participants' (16.9% male endoscopist, 52.6% female endoscopist, and 30.5% no preference; P < .00001). No education was associated with having a gender preference (odds ratio, .55; 95% confidence interval, .37-.81; P = .003). Reasons for gender preference included religious values and family pressure, which were more frequently expressed by women (P < .0001). CONCLUSIONS: Most Muslims in Pakistan expressed a gender preference, and both female and male patients showed a preference for a same-gender endoscopist. No education was associated with having a gender preference.

A Case of Polyautoimmunity: Celiac Hepatitis, Grave's Disease and Autoimmune Hemolytic Anemia.

Celiac disease (CD) is an autoimmune disorder with high incidence of multi organ involvement; especially, gastrointestinal manifestations and an increased risk of malignancies. Here we report a case of CD with celiac hepatitis, autoimmune hemolytic anemia (AIHA) and Grave's disease (GD) with their complications. Polyautoimmunity requires comprehensive analysis. While CD and GD were previously diagnosed, AIHA and cirrhosis were diagnosed during admission upon extensive work-up. Similarly, other autoimmune etiologies, such as autoimmune hepatitis (AIH), and/or primary biliary cholangitis were ruled out. All three diseases were treated afresh with strict adherence to a gluten-free diet (GFD) and carbimazole along with addition of medications for cirrhosis complicated by ascites. This was a rare case where non-adherence to a GFD led to such severe adverse events. A case of celiac hepatitis presenting with such a wide array of signs and symptoms has rarely been reported in the literature and the management of this patient was unique and challenging.

Safety and Efficacy of Sofosbuvir with Ribavirin® in Hepatitis C, Genotype 3 Patients with Cirrhosis: A Real-world Experience.

Introduction Hepatitis C virus (HCV) is the leading cause of cirrhosis. The advent of Directly Acting Antivirals (DAAs) like Sofosbuvir (SOF) has dramatized the treatment and is the cornerstone for the treatment of HCV. Most trials have been conducted in HCV genotype 1 (GT-1) and data for Interferon-free regimen in genotype 3 (GT-3) is limited especially in cirrhotic patients. Aim To evaluate the safety and efficacy of SOF plus Ribavirin® (RIB) in patients with compensated and decompensated cirrhosis. Methods This was a quasi-experimental study in HCV patients with compensated and decompensated cirrhosis. Each group (compensated and decompensated) was further subdivided into the treatment-naïve and treatment-experienced groups. Efficacy was assessed by end treatment response (ETR) and sustained viral response (SVR) in the treatment-naïve and experienced groups. Adverse events were recorded on designed proforma on serial follow-up visits. Results The study consisted of 110 consecutive patients. Among 110 patients, 51 had compensated cirrhosis and 59 had decompensated cirrhosis. The mean age was 53.8 ± 11 years. Males were n=56 (50.9%) and females were n=54 (49.1%). All the patients in Child-Turcotte-Pugh class A were in the compensated group. CTP B class was found to be 10.5% and 89.5% in the compensated and decompensated groups, respectively, whereas all the patients in CTP class C were in the decompensated group. In the compensated cirrhosis group, ETR was achieved in 36 (87.8%) treatment-naïve and 8 (88.9%) experienced patients. In decompensated cirrhosis, treatment-naïve and experienced patients achieved ETR in 28 (82.4%) and 18 (85.7%) patients, respectively. Whereas in compensated cirrhosis treatment-naïve and experienced patients, SVR was achieved in 25 (83.3%) and five (71.4%), respectively. In decompensated cirrhosis, 21 (77.8%) treatment-naïve and 12 (75%) experienced patients achieved SVR. The most common adverse events experienced by the patients were fatigue followed by myalgia, nausea, and diarrhea. The new onset of complications found due to cirrhosis were ascites, followed by hepatoma, upper gastrointestinal bleed, portosystemic encephalopathy, acute on chronic liver failure, and death. Conclusion Sofosbuvir in combination with Ribavirin® is safe but suboptimal in treatment outcomes, particularly in treatment-experienced patients with decompensated cirrhosis than in treatment-naive patients with compensated cirrhosis due to HCV GT-3.

HDV seroprevalence in HBsAg positive patients.

OBJECTIVE: To find out the frequency of HDV seroprevalence and the demographic characteristics or HBsAg-HDV positive patients. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Jinnah Postgraduate Medical Centre and Civil Hospital, Medical Unit-III, Karachi, from March 2007 to April 2011. METHODOLOGY: Patients with positive HBsAg were included in the study. Those having co-infection with HCV or HIV, autoimmune hepatitis, alcoholic hepatitis, Wilson's disease and haemochromatosis were excluded. After detailed history and physical examination all the patients underwent laboratory workup including complete blood count, liver function test, viral profile (HAV, HCV, HIV and anti-HDV) and prothrombin time. While in selected patients, HBc (core) antibodies, ultrasound abdomen, serum iron profile, ANA and liver biopsy were also carried out whenever needed to establish a clinical stage of liver disease. RESULTS: There were 374 patients with 266 (71.1%) males and 108 (28.9%) females with overall mean age of 31.64 ± 8.66 years. Overall frequency of anti-HDV antibodies positivity was found in 28.1% (n = 105) patients. HDV seropositivity was slightly more prevalent in males as compared to females (28.57% vs. 26.57%). HDV seropositivity frequency was significantly higher in patients who presented with acute hepatitis/hepatic failure as compared to other clinical diagnoses (p = 0.027) and in those sub-sets of patients who had raised ALT levels (p = 0.012). CONCLUSION: There was a high frequency of HDV seropositivity in the studied population particularly in males with acute hepatitis or hepatic failure, having raised ALT levels. The emphasis should be on preventive measures taken by other countries to reduce the prevalence of these treatment challenging infections.

Liver histology of chronic hepatitis C patients who relapsed or not responded to conventional interferon and ribavirin therapy.

OBJECTIVE: To evaluate liver histology of chronic hepatitis C patients, who were relapsers or non-responders to previous conventional therapy. METHODS: The descriptive case series was conducted in the Hepatology section of Medical Unit-III at the Jinnah Postgraduate Medical Centre, Karachi, Pakistan, from January to December 2008. The study had 109 hepatitis C patients who had relapsed or not responded to the conventional interferon and ribavirin for at least 24 weeks. All the patients were subjected to liver biopsy. The inflammatory activity and fibrosis shown by the liver biopsies were assessed according to the Batts-Ludwig classification. SPSS version 15 was used to analyse data. RESULTS: A majority (n = 57; 52.3%) of the 109 patients were female with hepatitis C virus genotype 3. Among these, 100 (91.7%) patients were non-responders and 9 (8.3%) were relapsers. The mean age of the patients was 38.9 +/- 8.8 years. The non-responders had elevated levels of serum aminotransferase. According to Batts-Ludwig classification, Grade 0 inflammation was not present in the non-responders and relapsers; grade 1 in 51 (46.8%); grade 2 in 47 (43.1%); grade 3 in 10 (9.2%); and grade 4 in 1(0.9%). Stage 0 fibrosis was present in 10 (9.2%); stage 1 in 34 (31.2%); stage 2 in 36 (33.0%); stage 3 in 13 (11.9%); and stage 4 in 16 (14.7%). CONCLUSION: Results suggested that even if it failed to eradicate hepatitis C virus, the conventional interferon and ribavirin therapy was able to halt the progress of necroinflammation and fibrosis.

An incidentally discovered asymptomatic para-aortic paraganglioma with Peutz-Jeghers syndrome.

Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder characterized by mucocutaneous melanin pigmentation and gastrointestinal (GI) tract hamartomatous polyps and an increased risk of malignancy. In addition to polyposis, previous studies have reported increased risk of GI and extraGI malignancies in PJS patients, compared with that of the general population. The most common extraintestinal malignancies reported in previous studies are pancreatic, breast, ovarian and testicular cancers.We report the case of a 17-year-old boy who presented with generalized weakness, recurrent sharp abdominal pain and melena, had exploratory laparotomy and ileal resection for ileo-ileal intussusception. Pigmentation of the buccal mucosa was noted. An abdominal computed tomography scan (CT) revealed multiple polyps in small bowel loops. Gastroscopy revealed multiple dimunitive polyps in stomach and pedunculated polyp in duodenum. Colonoscopy revealed multiple colonic polyps. Pathological examination of the polyps confirmed hamartomas with smooth muscle arborization, compatible with Peutz-Jeghers polyps. CT scan guided left para-aortic lymph node biopsy revealed the characteristic features of extra-adrenal para-aortic paraganglioma. Although cases of various GI and extra GI malignancies in PJS patients has been reported, the present case appears to be the first in literature in which the PJS syndrome was associated with asymptomatic extraadrenal para-aortic paraganglioma. Patients with PJS should be treated by endoscopic or surgical resection and need whole-body screening.

Corelation of serum alpha fetoprotein and tumor size in hepatocellular carcinoma.

OBJECTIVE: To determine the correlation of elevated serum Alpha feto-protein with tumour size in hepatocellular carcinoma. METHODS: A cross-sectional analytical study was done at Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7 from January 2009 to June 2010. Patients enrolled in study were known cases of chronic liver disease and were complicated by development of hepatocellular carcinoma; those having metastasis in liver from any where were excluded. Demographic data such as age, gender, residence, were recorded. Detailed clinical history and examination were carried out and recorded in a preformed Performa. Complete blood count, liver function test, total protein, Albumin/Globulin (A/G) ratio, serum Albumin, HBsAg, anti HCV, alpha fetoprotein, ultrasound guided liver biopsy, ultrasound whole abdomen and/or CTscan Abdomen for size and number of tumour were also done. On the basis of alfa fetoprotein level patients were divided in to 3 groups; Group I with normal AFP (< or = 20IU/ml), Group II with moderately elevated AFP (20-399IU/ml), and Group III with markedly elevated AFP (> or =400 iu/ml). On the basis of tumour size patients were also divided in to 3 groups; group A <3 cm, group B 3-5 cm and group C >5 cm. Correlation of serum AFP levels with tumor size was analyzed by applying Spearman's rank correlation with r-values of 0.01 being considered significant. RESULTS: Review of the clinical data of 98 patients male 69 (70.4%) and female were 29 (29.6%) with mean age of 53.89 +/- 12.511 ranging from 32 to 82 years was done. Of these there were 22 (22.4%), 25 (25.5%), 51(52%) cases in group 1, 2, 3 respectively. While in tumour size groups, 17 (17.3%) were in group A, 35 (35.7%) in group B and 46 (46.9%) in group C. There was a significant correlation of serum AFP level with tumour size in hepatocellular carcinoma. (r=0.472, 0.0001). CONCLUSION: Our study suggests that serum AFP has significant correlation with the size of tumour. AFP level may serve as a useful marker for detection of Hepatocellular carcinoma and to differentiate between early and advance stage. On the basis of this proper treatment strategy can be planned.

Hepatic vein waveform in liver cirrhosis: correlation with child's class and size of varices.

OBJECTIVE: To determine the correlation of hepatic venous waveform changes with severity of hepatic dysfunction and grading of oesophageal varices. METHODS: A cross-sectional analytical study was conducted at Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7 from January 2009 to December 2009. Cirrhotic patients with portal hypertension were included in study. Patients presented with acute variceal bleeding, previous treatment with beta blockers or nitrates, sclerotherapy endoscopic band ligation, portal vein thrombosis, severe clotting defects, hepatic encephalopathy grade III or IV and noncirrhotic portal hypertension; were excluded from the study. Upper G I endoscopy was carried out in all patients after informed consent. Oesophageal varices were classified according to Baveno III while hepatic function was assessed and grouped by Child-Pugh classification. Colour Doppler ultrasound was carried out on all patients. Their waveforms were classified as monophasic, biphasic triphasic and the correlation of these hepatic vein waveforms with Child-Pugh class and size of oesophageal varices was evaluated. Statistical significance was defined as P?0.05. RESULTS: Total of 65 patients who met the inclusion criteria and included in the study with mean age of 47.39 +/- 10.91 (range 23-70) years. Among these 51 (78.5%) were males while 14 (21.5%) were females. On the basis of hepatic function 32 (49.2%) patients presented in Child-Pugh Class A, 23 (35.4%) with Class B and 10 (15.4%) patients had Class C. Hepatic venous waveform was triphasic in 5 (7.7%), biphasic in 18 (27.7%), and monophasic in 42 (64.6%) cases. The relationship of these waveforms had significant relation with hepatic dysfunction (p < 0.012) while insignificant with grading of oesophageal varices (p 0.29). Upper GI endoscopy revealed large grade varices in 37 (56.9%) patients, 17 (26.2%) patients had small grade varices while no varices were found in 11 (16.9%) patients. CONCLUSION: Hepatic venous waveform pressure changes have significant relation with severity of hepatic dysfunction but insignificant relation with grading of oesophageal varices. Further studies using a combination of various Doppler parameters are required to create indices with a better predictive value.

Hepatocellular carcinoma: a clinicopathological study.

OBJECTIVE: To describe the clinico-pathological and radiological profile of hepatocellular carcinoma. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Medical Unit-III Ward-7, Jinnah Postgraduate Medical Centre, Karachi, from January to December 2008. METHODOLOGY: All consecutive patients suspected of having hepatocellular carcinoma (HCC), were admitted and included in this study. Diagnosis of HCC was established by clinical, biochemical, ultrasonographic and histopathologic findings. Patients with primary carcinoma elsewhere in the body, metastatic in the liver, fibrolamellar carcinoma and benign tumours were excluded from the study. At ultrasonography, the details of tumour size and number, portal vein thrombosis and presence of ascites were recorded. Patients were staged according to Okuda staging system. Results were described in mean and percentage values. RESULTS: There were 82 patients with hepatocellular carcinoma including 58 males and 24 females, with male to female ratio of 2.8:1. The mean age of patients was 56.24+/-13.65 years. Right hypochondrial pain was the main symptom in 52 (63.4%) patients. The duration of symptoms varied from 1 month to 2 years. Tumour size was larger than 50% of liver size in 42 (51.2%) with portal vein thrombosis in 10 (12.19%). Anti HCV was positive in 44 (53.7%), HBsAg in 26 (31.7%) and both were found positive in 2 (2.44%) patients. Ten patients (12.2/%) found negative both for anti-HCV and HBsAg. According to Okuda staging system 18 patients had stage 1, 50 had stage 2 and 14 had stage 3 hepatocellular carcinoma. CONCLUSION: The mean age of presentation of hepatocellular carcinoma was younger as compared to western countries with potentially large non-resectable lesions. Chronic hepatitis C and B was found to be the major known factors. Patients with chronic hepatitis C and B should undergo vigorous HCC surveillance to detect early, potentially respectable HCC.

Correlation of thrombocytopenia with grading of esophageal varices in chronic liver disease patients.

OBJECTIVE: To determine the severity of thrombocytopenia in different grades of esophageal varices. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7 from January to December 2008. METHODOLOGY: Subjects were eligible if they had a diagnosis of cirrhosis. Patient with advanced cirrhosis (Child-Pugh class C), human immunodeficiency virus (HIV) infection, hepatocellular carcinoma, portal vein thrombosis, parenteral drug addiction, current alcohol abuse and previous or current treatment with b-blockers, diuretics and other vasoactive drugs were excluded from the study. All patients under went upper gastrointestinal endoscopy after consent. On the basis of platelet count patients were divided into four groups. Group I with platelets (2) 20000/mm(3), Group II with values of 21000- 50000/mm(3), Group III with count of 51000-99000/mm(3) and Group IV with count of 100000-150000/mm(3). Correlation of severity of thrombocytopenia with the grading of esophageal varices was assessed using Spearman's correlation with r-values of 0.01 considered significant. RESULTS: One hundred and two patients with thrombocytopenia and esophageal varices were included in the study. There were 62 (60.8%) males and 40 (39.2%) females. The mean age of onset of the disease in these patients was 49.49 + or - 14.3 years with range of 11-85 years. Major causes of cirrhosis were hepatitis C (n=79, 77.5%), hepatitis B (n=12, 11.8%), mixed hepatitis B and C infection (n=8, 7.8%) and Wilson's disease (n=3,2.9%). Seven patients had esophageal grade I, 24 had grade II, 35 had grade III, and 36 had grade IV. Gastric varices were detected in 2 patients. Portal hypertensive gastropathy were detected in 87 patients. There was an inverse correlation of platelet count with grading of esophageal varices (r=-0.321, p < 0.001). CONCLUSION: The severity of thrombocytopenia increased as the grading of esophageal varices increased. Thrombocyte count was significantly and inversely correlated with the grade of esophageal varices.

Clinical features, diagnostic techniques and management of dual dengue and malaria infection.

OBJECTIVE: To find out clinical features, diagnostic techniques and management outcome of patients having dual dengue and malaria infection. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Medical Unit-III, Ward- 7, Jinnah Postgraduate Medical Centre, Karachi, from September 2007 to January 2008. METHODOLOGY: Patients presented with fever of less than or equal to 10 days duration, severe body aches, rash and bleeding manifestations were included. Patients with obvious features of other diseases like typhoid, hereditary bleeding diathesis and hematological malignancies and only malarial parasite positive with high grade intermittent fever without rash and myalgia were excluded from the study. Diagnosis of dengue and malaria was based on history, clinical features, laboratory parameters and malarial parasite test by thin and thick films. Serological evaluation was done by dengue IgM and IgG by ELISA test kit. Patients were divided into three groups. Group A was dengue IgM positive plus MP positive, group B was dengue IgM positive and MP negative and group C was dengue IgM negative and MP negative and were clinically suspected dengue and malaria. The clinical manifestations and laboratory parameters of dual dengue and malaria positive patients were compared with malaria and dengue negative patients. RESULTS: One hundred and fourteen patients were seen during the study period. Antibody titer (IgM) tested in all patients was found positive in 78 patients (69.64%). Among those 78 patients, 26 (23.21%) were concomitantly positive for malarial parasite (Group A). Plasmodium vivax was positive in 25 patients and falciparum in one patient. Fifty-two patients (46.42%) were dengue IgM positive and MP negative (Group B). Thirty four (30.35%) patients were MP and dengue IgM negative (Group C) but were strongly suspected for DHF and malaria on clinical and hematological basis. The hemoglobin of 34.61% of patients of group A, 5.76% of group B and 14.7% of group C were low, hematocrit level was also low in group A (92.3%), group B (15.38%) and group C (70.58%) patients. The platelet count was markedly low in 84.61% of patients of group A, 57.69% of group B and 94.11% of group C. Leukopenia was found in 34.61% of patients of group A, 78.84% in group B and 29.411% in group C. The liver function tests were deranged in all groups. CONCLUSION: The frequency of dual dengue and malaria infection was 23.21%. The serology of the dengue and malaria showed negative results in 30.35%. The diagnosis of dual infections could be made on the basis of history, clinical examination supported by hematological results. It is recommended that all the patients suspected for dual infections should be treated concomitantly for dengue and malaria in malaria endemic areas.