Leptospirosis outbreak after a heavy rainfall typhoon in the Philippines: Clinical features, outcome and prognostic factors for mortality

@#<p style="text-align: justify;"><strong>BACKGROUND AND OBJECTIVES:</strong> In September 2009, Metro Manila was hit by a heavy rainfall typhoon Ketsana inundating several cities of Metro Manila causing an outbreak of leptospirosis. We analyzed the prognostic factors associated with mortality among leptospirosis patients admitted after the typhoon at nine tertiary hospitals from September to November 2009.<br /><strong>METHODS:</strong> We reviewed the charts of patients with probable and confirmed leptospirosis. Confirmed leptospirosis was based on any of the following: positive leptospiral culture of blood or urine, single high leptospira microagglutination titer (MAT) of 1:1600 or a fourfold rise in MAT antibody titers or seroconversion. Patients with negative serology or cultures but with history of wading in floodwaters plus any of the following signs and symptons: fever, headache, myalgia, conjunctival suffusion, diarrhea and abdominal pain, jaundice, oliguria and changes in sensorium were considered probable cases. <br /><strong>RESULTS:</strong> We analyzed 332 probable and 259 confirmed leptospirosis patients. Mean age was 37.95± 14.09, mostly males (80.2%). Almost all patients (98%) waded in floodwaters. Majority had moderate to severe form of leptospirosis (83%). Acute renal failure was the most common complication (87.1%). Mortality was 11.3% mostly due to pulmonary hemorrhage. On multivariate analysis of confirmed and probable cases, the factors independently associated with mortality were pulmonary hemorrhage (OR 2.75, 95% CI 1.46 to 5.20), severity of the disease (OR 3.85, 95% CI 1.60 to 9.26), thrombocytopenia (OR 3.16, 95% CI 1.22-8.16), duration of illness before admission (OR 0.88, 95% CI 0.78-0.99) and age (OR 1.03, 95% CI 1.00-1.06).<br /><strong>CONCLUSION:</strong> Pulmonary hemorrhage remains a poor prognostic factor and strong predictor of mortality among patients with severe leptospirosis. Early consult through heightened awareness of the public and prompt recognition of leptospirosis among clinicians can decrease the risk for progression to complications of leptospirosis and mortality. <br /><br /> </p>

The incidence, clinical characteristics and risk factors of tuberculosis among renal allograft recipients at National Kidney and Transplant Institute

OBJECTIVE: Renal allograft recipients are at higher risk of developing tuberculosis (TB) as compared to the general population. The infection also carries with it a significant morbidity and mortality. However, data is limited regarding its incidence and risk factor analysis in our setting. This study determined the incidence, characteristics and risk factors of post-transplant TB in National Kidney and Transplant Institute (NKTI).METHODS: This is a retrospective study involving chart review of 1,621 renal allograft recipients from 2003-2009. We recorded demographic information, transplant characteristics, median time to diagnosis of TB and forms of TB.RESULTS: The incidence of TB in renal allograft recipients is 2.6%. Median time to diagnosis of TB after transplant is 21 months (one to 105 months). Risk factors identified in this study were previous history of TB (OR 4.15, 95% CI 1.4-12.2), one episode of rejection (OR 2.33, 95% CI 1.2-4.6) and subsequent use of methylprednisolone as antirejection therapy (OR 2.36, 95% CI 1.3-4.4). Patients given a tacrolimus based regimen (OR 0.5, 95% CI 0.24-1.03) and those without episode of rejection (OR 0.43, 95% CI 0.22-0.84) had less tendency to develop post-transplant TB. There were no sufficient evidence to prove association between onset of TB and use of isoniazid prophylaxis, use of induction immunosuppression and type of immunosuppression. Eighty one percent (81%) had pulmonary and 19% had extrapulmonary forms of TB.CONCLUSION: Incidence of TB among renal allograft recipients is lower as compared to other high TB burden countries but is still higher as compared to the general Filipino population. The study identified multiple risk factors for post-transplant TB. Prevention of these diseases and identification of patients at risk are as important as early diagnosis and treatment of post-transplant TB.

Detection and characterization of mutations of multidrug-resistant tuberculosis isolates of the Philippine General Hospital

BACKGROUND: Emergence of multidrug-resistant tuberculosis (MDR-TB) poses a major challenge to prevailing disease management. MDR-TB arises from mutations in several genes comprising the resistance determining regions, including rpoB, katG and gyrA. OBJECTIVE: To detect and characterize mutations in rpoB, katG and gyrA. METHODS: Thirty selected Mycobacterium tuberculosis isolates from the IDS-PGH were subjected to PCR amplification and sequencing. Sequences were compared to the wild type strain H37Rv. RESULTS: Mutations were detected in codons 512, 513, 516, 522, 526, 531 and 533 of rpoB, codons 280, 281, 315 and 333 of katG, and codons 90 and 94 of gyrA sequences. The most frequently mutating codons for rpoB, katG and gyrA were 531, 315 and 94, respectively. A clustering analysis of the sequences showed occurrence of seven, four and three clusters for the genes rpoB, katG and gyrA, respectively. The eight clusters obtained from the concatenated sequences of the three genes represent the eight potential genotypes of local strains. One cluster represents the wild type strain genotype, another cluster represents the XDR strain genotype, and six clusters represent the MDR strain genotypes. CONCLUSION: These findings indicate the utility of multiple RDR sequence analysis in both identifying specific drug resistance mutation and genotyping of various M. tuberculosis isolates.

Detection and characterization of mutations of multidrug-resistant tuberculosis isolates of the Philippine General Hospital

Background. Emergence of multidrug-resistant tuberculosis (MDR-TB) poses a major challenge to prevailing disease management. MDR-TB arises from mutations in several genes comprising the resistance determining regions, including rpoB, katG and gyrA. Objective. To detect and characterize mutations in rpoB, katG and gyrA. Methods. Thirty selected Mycobacterium tuberculosis isolates from the IDS-PGH were subjected to PCR amplification and sequencing. Sequences were compared to the wild type strain H37Rv. Results. Mutations were detected in codons 512, 513, 516, 522, 526, 531 and 533 of rpoB, codons 280, 281, 315 and 333 of katG, and codons 90 and 94 of gyrA sequences. The most frequently mutating codons for rpoB, katG and gyrA were 531, 315 and 94, respectively. A clustering analysis of the sequences showed occurrence of seven, four and three clusters for the genes rpoB, katG and gyrA, respectively. The eight clusters obtained from the concatenated sequences of the three genes represent the eight potential genotypes of local strains. One cluster represents the wild type strain genotype, another cluster represents the XDR strain genotype, and six clusters represent the MDR strain genotypes. Conclusion. These findings indicate the utility of multiple RDR sequence analysis in both identifying specific drug resistance mutation and genotyping of various M. tuberculosis isolates.