Concurrent malaria and enteric fever in Pakistan.

INTRODUCTION: The precise incidence of concurrent malaria and enteric fever in most geographical areas is largely unknown, and no data on such an association exists in Asia. Because both malaria and enteric fever are hyperendemic in Pakistan, we sought to determine the frequency, epidemiology, and clinical and laboratory features of dual malaria and enteric fever in a tertiary care setting. METHODS: We conducted a retrospective case-control study of 1,891 patients hospitalised with malaria over a ten-year period and identified 21 patients with concurrent culture-proven enteric fever. RESULTS: Cases with dual infection had significantly more gastrointestinal symptoms at the time of admission, including nausea, vomiting, abdominal pain, and/or diarrhoea compared to matched control subjects with uncomplicated malaria (p-value is less than 0.006). Cases were more likely to have a continuous rather than intermittent fever (p-value is less than 0.0001), delayed defervescence in response to antimalarial treatment (p-value is less than 0.006), normal or low white blood cell counts (p-value is less than 0.04), relatively higher platelet counts among cases versus control (p-value is less than 0.05) and serum haemoglobin (p-value is less than 0.06), elevated alanine aminotransferase levels (p-value is less than 0.02), and a prolonged hospital stay (p-value is less than 0.03). The negative predictive values for gastrointestinal symptoms, continuous fever pattern and delayed defervescence were 80 percent, 72 percent and 74 percent, respectively. CONCLUSION: Patients with malaria who have marked gastrointestinal symptoms, continuous pattern of fever and persistence of fever for more than 24 hours after appropriate antimalarial therapy, should be investigated or empirically treated for concurrent enteric fever. The absence of the above clinical features in patients with uncomplicated malaria should reassure physicians that there is no concurrent typhoid fever.

Extra temporal involvement in herpes simplex encephalitis.

Temporal lobe abnormalities on brain imaging have been described as strong evidence for herpes simplex encephalitis (HSE) in appropriate clinical settings. Extra temporal abnormalities are less well described in these patients. We retrospectively reviewed 20 patients of HSE and found extra temporal involvement in 11 (55%) patients. Three patients (15 %) had pure extra temporal abnormalities. Twelve patients (60%) had temporal lobe involvement, four patients (20%) had pure temporal lobe involvement and five patients (25%) had normal CT/MRI scans. Our study suggests that extra temporal involvement on brain imaging is common in HSE and in a significant minority of the patients this can even be the sole abnormality.

Invasive aspergillosis with polyarthritis.

We report a case of septic arthritis of multiple joints in an 18-year-old male caused by Aspergillus fumigatus. His initial presentation was of low-grade fever followed by involvement of both knee and ankle joints. Later, there was also involvement of metacarpophalangeal joints. Diagnosis was based on biopsy and culture of the skin and joint lesions. The symptoms resolved readily under administration of itraconazole. We recommend that clinicians should be alerted of potential fungal etiology in cases of fever and chronic arthritis, which is unresponsive to conventional medical therapy.

Radiocontrast nephropathy: is it dose related or not?

OBJECTIVE: To assess the safety of high dose non-ionic contrast media during a single radiological procedure in patients with pre-existing renal impairment. METHODS: One hundred eighteen patients, with serum Creatinine greater than 1.3 mg/dl who were undergoing coronary angiography or percutaneous transluminal coronary angiography (PTCA) were included in the study. All patients received the nonionic dye ULTRAVIST (lopromide). Serum creatinine were measured before, 48 hours and 1 week after the administration of contrast agent. An acute contrast induced reduction in renal function was defined as an increase in Serum Creatinine concentration of >=0.5 mg/dl, 48 hours after the administration of contrast agent. All patients with end stage renal disease or patients undergoing coronary bypass surgery within a week after coronary angiography or had any concomitant factors that could cause acute renal failure e.g., sepsis, hypotention, etc., were excluded. Patients receiving a dose of upto 100 ml of contrast agent (low dose group) were separated from those who received greater than 100 ml of contrast agent (high dose group). Patients in both groups had similar characteristics in terms of sex, age, weight and underlying disease. Student's t-test was used for statistical analysis. RESULTS: The mean age of our patients was 62.3+/-8.83 (range 40-84 years). There were 93 (78.8%) males and 25 (21.2%) females. The mean pre-contrast creatinine in the low contrast group was 1.97+/-0.92 and high dose group was 2.16+/-1.90 (p=0.48). The post-contrast Creatinine at 48 hours was 2.11+/-1.11 and 2.06+/-1.39 in the groups receiving low and high dose contrast agents respectively (p=0.830), while at 7 days post-contrast it was 2.17+/-1.28 and 1.95+/-1.43 respectively in the two groups (p=0.391). The contrast-induced reduction in renal function (rise in serum Cr >=0.5 mg/dl above base line) occurred in 14% (n=8) of patients in low dose and in 11% (n=7) in high dose contrast group (p=0.830, insignificant). CONCLUSION: The results of our study confirm that high dose non-ionic contrast is not associated with increased risk of contrast-mediated nephrotoxicity in patients with pre-existing renal insufficiency undergoing cardiac angiography (p=0.830, insignificant).