Endemic HBV among hospital in-patients in Bangladesh, including evidence of occult infection.

Bangladesh is one of the top-ten most heavily burdened countries for viral hepatitis, with hepatitis B (HBV) infections responsible for the majority of cases. Recombinant and occult HBV infections (OBI) have been reported previously in the region. We investigated an adult fever cohort (n=201) recruited in Dhaka, to determine the prevalence of HBV and OBI. A target-enrichment deep sequencing pipeline was applied to samples with HBV DNA >3.0 log10 IU ml-1. HBV infection was present in 16/201 (8 %), among whom 3/16 (19 %) were defined as OBI (HBsAg-negative but detectable HBV DNA). Whole genome deep sequences (WGS) were obtained for four cases, identifying genotypes A, C and D. One OBI case had sufficient DNA for sequencing, revealing multiple polymorphisms in the surface gene that may contribute to the occult phenotype. We identified mutations associated with nucleos(t)ide analogue resistance in 3/4 samples sequenced, although the clinical significance in this cohort is unknown. The high prevalence of HBV in this setting illustrates the importance of opportunistic clinical screening and DNA testing of transfusion products to minimise OBI transmission. WGS can inform understanding of diverse disease phenotypes, supporting progress towards international targets for HBV elimination.

Trichosporon Asahii fungaemia in an immunocompetent polytrauma patient who received multiple antibiotics.

Trichosporon asahii is a yeast-like fungus that is emerging as an important cause of invasive infections in tertiary medical centres. A 58-year-old Chinese man with no known medical illnesses presented with liver lacerations and multiple fractures following an alleged 12-foot fall at a construction site. The gravity of his injuries and poor haemodynamic status necessitated an intensive care unit (ICU) admission, during which several febrile episodes were detected and multiple antibiotics were administered. After being in the ICU for at least two weeks, a urease-positive yeast was isolated from the patient's blood. The yeast formed dry, fuzzy and wrinkled white colonies on Sabouraud dextrose agar following prolonged incubation, and produced blastoconidia, true hyphae, pseudohyphae and arthroconidia on slide culture. It was identified biochemically by the ID 32 C kit as T. asahii. The yeast had elevated minimal inhibitory concentration (MIC) values to fluconazole, amphotericin B, flucytosine and all echinocandins tested. In view of this, the patient was treated with voriconazole and was successfully transferred to the general medical ward.

An epidemiological study of injury in a rural community in Bangladesh.

Injuries are a focus of public health practice because they pose a serious health threat, occur frequently and are preventable. The evidence regarding injury, its contributing factor and its consequence in rural population of Bangladesh is scarce. Present study aimed to assess the epidemiology of injury in a rural area. The study was conducted in the 'Bairag' Union of Anwara upazilla in Chittagong district of Bangladesh. Data of 6256 individuals were collected from 1016 households. Three structured and standardized questionnaires were used for data collection. The questionnaires were pretested and validated prior to final survey. Severity of injury was assessed based on the number of days with restricted activity and consequences of injury were considered as a measure of severity of injury. A total of six people died due to injury in last one year in the survey, the death tolls to 0.096% (95% CI 0.037%-0.199%). A total of 392 experienced an injury that at least hampered one day's routine activity. Crude prevalence of injury over last one year is calculated to be 6.27% (95% CI 5.69%-6.89%). Of injured subject's majority (77.2%) were aged between 10 to 59 years, 73% were male, 55.6% were of lower class and among them 7.9 % suffered multiple injuries. More than 80% of the incident leading to injury happened during the day, (8 am to 6 pm). Daytime injury mostly occurs in afternoon. The mechanism of injury of 30% subjects were road accident, of 29.5% subjects was slip, trip or fall. In 17.9% victims' mechanism of injury was collision with a person or object. Around 10% had deep cut, 1.4% had superficial cut, and 3.3% patient had burn through contact with heat. Among the injured only 19.2% escaped any physical consequence, 27.2% suffered from decrease in work capacity, 48.1% developed temporary disability, 3.8% developed permanent disability, and 1.2% suffered disfiguration.

Optimizing survival in Russell's viper bite cases in low-resource setting: two case reports.

INTRODUCTION: Snakebite envenomation poses a significant health risk, particularly in low-resource settings where access to proper treatment is limited. CASE PRESENTATION: This study reports two cases of Russell's viper bites in rural Bangladesh, involving 48 and 35-year-old Bangladesh males, respectively, and highlights the difficulties in providing adequate medical care and in treating any complications that may arise. Both cases involved delayed access to healthcare, initial visit to traditional healers, and the development of severe complications such as coagulopathy, renal failure. After the intervention both cases survived which is scarce in low resource settings. CONCLUSION: The cases underscore the importance of early recognition, appropriate management, and improved healthcare infrastructure to optimize survival outcomes in snakebite cases in resource-limited settings. These cases will contribute valuable insights to the field of snakebite management and provide guidance for improving survival rates and outcomes among snakebite victims in Bangladesh.

Perceptions and treatment seeking behavior for dog bites in rural Bangladesh.

We conducted a study of the knowledge, attitudes and practices regarding dog bites among residents of a rural community in Bangladesh from September 2006 to February 2007 using face to face interviews with 1,973 adults from five villages. The mean age of the respondents was 34+/-16 years. Sixty-eight percent of subjects were female, 7.3% of respondents reported a history of dog bite in a family member; 10% had been bitten twice. Sixty-five percent of subjects were aware of rabies and 99.1% knew a dog bite was the cause of rabies. Seventy-one percent of subjects were aware of a rabies vaccine, 77.5% of respondents stated rabies can cause death. Ninty percent of dog bite victims received treatment by traditional healers, 25% were treated with a rabies vaccine and 2.1% of victims died. Greater awareness is needed in rural Bangladesh regarding prevention of rabies.

Predilection of zonal involvement and pattern of opacities in chest x-ray in post primary pulmonary tuberculosis.

A cross sectional analysis of chest radiograph was performed in 100 patients with tuberculosis to observe the recent trends of radiographic presentation. The study was done from April to December, 2009, in Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh. The chest x-ray findings were analyzed and zonal involvement and pattern of opacities were categorized and compared. Majority of patients (45%) showed involvement of the upper zone. Dominating lesion was consolidation (25%). Most of the patients were between 15-40 years. Forty-four percent patients were sputum positive for Acid Fast Bacilli and cavitation was the dominant lesion among them. Chest x-ray of patients with post primary tuberculosis shows involvement predominantly in the upper zone of lung. The most common opacity was consolidation. This correlates with different studies done over different population.

Treatment outcome of national guideline based antitubercular chemotherapy in tubercular ascites patients.

Adenosine De Aminase (ADA) is increased in tuberculous ascitic fluid due to the stimulation of T-cells by mycobacterial antigens. The treatment for abdominal tuberculosis including ascites as a presentation is a matter of controversy around the world. The study is aim at to see the outcome of antitubercular chemotherapy in selected tubercular ascites patients. This hospital based prospective study was done in 24 cases of adult (>13 years) tubercular ascites admitted in a tertiary hospital Dhaka, over one year. Increased ADA level (>37iu/L) in ascitic fluid evaluated after the colorimetric method of Galanti and Giusti and other supportive investigations were done for diagnosing tuberculosis. Patients were under treatment of ATT cat-1 for six months as per national guide line. Outcome was seen as predefined criteria as treatment completed, cured, improved and not improved. Total number of patient is 24. Of which range of age is 13-70 years and mean±SD (33.2±14.77) with male female ratio is 0.85:1. Ninety six percent patients presented with abdominal pain, 23(96%) with fever, 22 (91%) with anorexia. Abdominal tenderness in 22(91%), ascites on 24(100%), hepatomegaly on 2(8%). Hundred percent patients were evaluated after completion of treatment. Twenty three (96%) patients improved and 1(4%) not improved. There is effectiveness of standard chemotherapy suggested by national guideline. Outcome of the patients were highly satisfactory with short regimen of antitubercular chemotherapy.

Melioidosis in an adult male.

Infection with Burkholderia pseudomallei has been described, albeit rarely, patients in Bangladesh. Infection usually follows percutaneous inoculation or inhalation of the causative bacterium, which is present in soil and surface water in the endemic region. A 35-year-young male farmer presented with prolonged fever and significant weight loss. Patient gradually deteriorated despite getting different antibiotics including intravenous ceftriaxone and metronidazole. Panels of investigations were done which revealed no diagnostic confirmation except uncontrolled diabetes and multiple abscesses in different organs. Melioidosis was suspected and serum samples were positive for Burkholderia pseudomallei antibody. The case illustrates the importance of non-specific nature of the clinical presentation and high index of suspicion of uncommon diseases like melioidosis where the disease has not been considered as an endemic.

An open randomized controlled trial to compare the efficacy of two fixed dose combinations of artemesinin based combinations for uncomplicated falciparum malaria in Bangladesh.

National Malaria Control Program (NMCP) of Bangladesh has introduced Artemisinin Based Combination (ACT), Coartem(R) (Artemether-Lumefantrine (AL), fixed dose combination, in the confirmed cases of uncomplicated P. falciparum malaria since 2004. Despite the reduction of mortality due to malaria, the development and spread of anti-malarial drug resistance wordwide posing a threat to the health services and will make it difficult to control malaria in Bangladesh in future. We need to have an alternative to Coartem which could be Artesunate-amodiaquine (AA) in a fixed dose combination (FDC), a cheaper altenative not yet evidenced to be effective and safe to our population. In this study we compared the efficacy and safety of Artemether + Lumefantrene (FDC, Coartem) with Artesunate +Amodiaquine tablets (100/270 mg FDC) for the treatment of uncomplicated P. falciparum malaria in three high risk multi-drug resistant malaria prevalent areas of Bangladesh. It was an open label randomized controlled trial conducted between December 2008 and November 2009 in 4 upazillas in patients over the age 12 to 60 years diagnosed as a case of uncomplicated P. falciparum malaria. The outcome of the cases were measured as clinical response, parasitological response, defervescence time and parasite clearance time. Drug safety was assessed by comparing the adverse events. A total of 252 cases were randomized to receive Artesunate + Amodiaquine (AA group, 147 cases) and Artemether + Lumefantrene (AL group, 106 cases), one lost to follow up at day 28 in AA group. The distribution of the cases was comparable by age, sex and study sites. Treatment success' response was observed 100% in the AL group and AA group had 99%, two failures with AA were late treatment failures and the difference was not statistically significant (p > .1). The parasitological sensitive (S) response was observed in 97% of cases in AL group and 95% in the AA group, and was not a statistically significant difference. There was no significant difference in deffervescence time and parasite clearance time between two groups of cases. No serious adverse events were observed. The frequencies of minor adverse events were insignificantly different between the two treatment groups. The two ACT regimen, AA and AL had no significant difference in efficacy and safety for treatment of Uncomplicated Malaria in Bangladesh. However, there were few more failures with AA regimen compared to AL regimen, which was not statistically significant. Both these regimens can be used alternatively by the NMCP of Bangladesh as first-line treatment option.

Survey on sea snakebite and related morbidity and mortality among Bangladeshi fishermen in the Bay of Bengal: A pilot study.

Around two million people are engaged in marine fishing in the Bay of Bengal. Bites by sea snakes were common hazards feared by millions fishing at sea in earlier days. Current morbidity and mortality are also not known. This study was conducted to document and describe sea snake bites among selected communities of sea-going fishermen in Bangladesh. A questionnaire-based cross-sectional survey was conducted from May to October 2019 among three communities of sea-going fishermen living along the coast of the Bay of Bengal in Cox's Bazar district. Fishermen were first asked by trained interviewers to recall any sea snakebites to themselves and among their fellows on board within the last year, then within the last 5 years and at any time before that. For any bite, related information including outcome was noted. Overall, 25.4% of respondents (62 out of 244) had been bitten by sea-snakes. Mean age was 37.6(±14) years; all males. 51.6% received some sort of treatment locally; 71% hot compress and 48% tourniquets. In 80.6% the affected limb was not immobilized. The bitten site was incised in 29%. 22.6% received treatment from traditional healers, 48.4% from local hospitals, 29% from district hospital. Six victims (9.7%) suffered from severe life-threatening consequences of the sea snakebite but none died. 32% of the fishermen had seen the offending snake. Sea snakebites are potentially dangerous; therefore, educating fishermen to avoid contact with sea snakes would dramatically reduce the incidence of sea snakebites. Most bites are treated initially by local measures which are often not scientific. Provision of proper first aid and treatment might reduce mortality and morbidity. A larger survey on sea snake bites among the fishermen in all coastal areas of Bangladesh is needed to determine the nationwide burden of morbidity and mortality related to sea snakebite.

Re-emergence Nipah - a review.

There was an outbreak of new emergence viral encephalitis caused by Nipah virus among humans in some areas of Bangladesh during 2001 - till to date. The disease affected mainly the young, had increased suspicion to spread from bat to man through eating of the same fruits. The risk of human-to-human transmission is thought to be low though many of the affected individuals belonged to the same family. The disease presented mainly as acute encephalitis with usually a short incubation period of less than two weeks, with the main symptoms of fever, headache, and giddiness followed by coma. Distinctive clinical signs include areflexia, hypotonia, hypertension, tachycardia and segmental myoclonus. Serology was helpful in confirming the diagnosis. Magnetic resonance imaging (MRI) showed distinctive changes of multiple, discrete or confluent small high signal lesions, best seen with fluid-attenuated inversion recovery (FLAIR) sequences. Mortality was as high as 32-92% and death was probably due to severe brainstem involvement. Relapse encephalitis was seen in those who recovered from acute encephalitis, and late-onset encephalitis was seen in those with initial non-encephalitic or asymptomatic diseases. Both these manifested as focal encephalitis arising from recurrent infection.

A simple score to predict the outcome of severe malaria in adults.

BACKGROUND: World Health Organization treatment guidelines recommend that adults with severe malaria be admitted to an intensive care unit (ICU). However, ICU facilities are limited in the resource-poor settings where most malaria occurs. Identification of patients at greater risk of complications may facilitate their triage and resource allocation. METHODS: With use of data from a trial conducted in Southeast Asia (n=868), a logistic regression model was built to identify independent predictors of mortality among adults with severe malaria. A scoring system based on this model was tested in the original dataset and then validated in 2 series from Bangladesh (n=188) and Vietnam (n=292). RESULTS: Acidosis (base deficit) and cerebral malaria (measured as Glasgow Coma Score) were the main independent predictors of outcome. The 5-point Coma Acidosis Malaria (CAM) score was simply derived from these 2 variables. Mortality increased steadily with increasing score. A CAM score <2 predicted survival with a positive predictive value (PPV) of 95.8% (95% confidence interval [CI], 93%- 97.7%). Of the 14 of 331 patients who died with a CAM score <2, 11 (79%) had renal failure and death occurred late after hospital admission (median, 108 h; range, 40-360 h). Substitution of plasma bicarbonate as the measure of acidosis only slightly reduced the prognostic value of the model. Use of respiratory rate was inferior, but a score <2 still predicted survival with a PPV of 92.2% (95% CI, 89.1%-94.7%). CONCLUSIONS: Patients with a CAM score <2 at hospital admission may be safely treated in a general ward, provided that renal function can be monitored.

Pre-referral rectal artesunate to prevent death and disability in severe malaria: a placebo-controlled trial.

BACKGROUND: Most malaria deaths occur in rural areas. Rapid progression from illness to death can be interrupted by prompt, effective medication. Antimalarial treatment cannot rescue terminally ill patients but could be effective if given earlier. If patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate can be given before referral and acts rapidly on parasites. We investigated whether this intervention reduced mortality and permanent disability. METHODS: In Bangladesh, Ghana, and Tanzania, patients with suspected severe malaria who could not be treated orally were allocated randomly to a single artesunate (n=8954) or placebo (n=8872) suppository by taking the next numbered box, then referred to clinics at which injections could be given. Those with antimalarial injections or negative blood smears before randomisation were excluded, leaving 12 068 patients (6072 artesunate, 5996 placebo) for analysis. Primary endpoints were mortality, assessed 7-30 days later, and permanent disability, reassessed periodically. All investigators were masked to group assignment. Analysis was by intention to treat. This study is registered in all three countries, numbers ISRCTN83979018, 46343627, and 76987662. RESULTS: Mortality was 154 of 6072 artesunate versus 177 of 5996 placebo (2.5%vs 3.0%, p=0.1). Two versus 13 (0.03%vs 0.22%, p=0.0020) were permanently disabled; total dead or disabled: 156 versus 190 (2.6%vs 3.2%, p=0.0484). There was no reduction in early mortality (56 vs 51 deaths within 6 h; median 2 h). In patients reaching clinic within 6 h (median 3 h), pre-referral artesunate had no significant effect on death after 6 h or permanent disability (71/4450 [1.6%] vs 82/4426 [1.9%], risk ratio 0.86 [95% CI 0.63-1.18], p=0.35). In patients still not in clinic after more than 6 h, however, half were still not there after more than 15 h, and pre-referral rectal artesunate significantly reduced death or permanent disability (29/1566 [1.9%] vs 57/1519 [3.8%], risk ratio 0.49 [95% CI 0.32-0.77], p=0.0013). INTERPRETATION: If patients with severe malaria cannot be treated orally and access to injections will take several hours, a single inexpensive artesunate suppository at the time of referral substantially reduces the risk of death or permanent disability. FUNDING: UNICEF/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases (WHO/TDR); WHO Global Malaria Programme (WHO/GMP); Sall Family Foundation; the European Union (QLRT-2000-01430); the UK Medical Research Council; USAID; Irish Aid; the Karolinska Institute; and the University of Oxford Clinical Trial Service Unit (CTSU).

Clinical and laboratory parameters of pleural tuberculosis.

This prospective observational clinical study was done to find out the clinical and laboratory parameters of pleural tuberculosis patients, to find out a sensitive and specific tool for diagnosis and to see the effectively of a standard anti-TB regime Isoniazide, Rifampicine, Pyrazinamide, Ethambutol, (2HRZE/4HR) for treatment of pleural tuberculosis in an adult medicine unit, department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh. A series of total thirty-three consecutive pleural tuberculosis patients admitted in that unit over a period of 6 months were enrolled. All thirty-three pleural tuberculosis patients were observed for their demographic and clinical parameters and undergone some relevant investigations like complete blood count, Mantoux test, pleural fluid study and pleural histopathological study. Later on, they were put on anti-tuberculosis therapy without steroid and followed their response after one month. All patients of pleural tuberculosis presented in this medicine unit had fever and cough associated with chest pain (87.9%), dysnoea (42.4%), haemoptysis (9.1%), weight loss (84.4%), anorexia (90.9%). Age of presentation was 34.1+/-16.2 years and of them, 60.7% patients were below 30. Mean Erythrocyte Sedimentation Rate (ESR) was 97.04 mm in 1st hour and 57.6% cases had ESR more than 100. 63.6% had Mantoux Test (MT) positive (>10 mm). Only 6.1% had hemorrhagic effusion and others had straw colored fluid. Mean pleural fluid protein is 5.9 gram/L and sugar 65.7 mg/dl. No Acid Fast Bacilli (AFB) was seen on microscopy in pleural fluid. Pleural biopsy revealed 54.5% granulomatous lesion with or without caseation and another 24.2% shows chronic inflammation. Seventy seven percentage (77%) patients were attended follow-up clinic after 1 month and all patients (100%) were improved with this anti-TB therapy. Of the total patient treated with anti TB drug, 53.5% had no pleural effusion, other had minimum effusion. Only 6.06% require subsequent steroid addition and other measures. Pleural biopsy is the investigations of choice for pleural tuberculosis especially in resource poor countries. Pleural tuberculosis can be treated with a standard anti-TB regime successfully without steroid.

A fatal cobra-bite in a snake expert.

A 35-year-old so called snake-expert from Thakurgaon district was admitted in Medicine department of Rangpur Medical College Hospital (RpMCH), Rangpur, Bangladesh on 2nd November 2007 with history of bites by a cobra snake. He was famous for his outstanding works to establish a snake farm first ever in Bangladesh. He had a collection of more than one hundred snakes of different species. He used to hatch eggs of the snakes, feed the young-snakes, collect venoms and sell those. Everyday many visitors used to visit his farm to watch exciting games with poisonous snakes. Several satellite television (TV) channels and some daily newspapers had covered him on different occasions. He was accidentally bitten by a newly caught hungry cobra snake while recording for a satellite TV channel. Following bites he was brought to the hospital three and a half hours later. By that time, neurotoxicity developed. Repeated doses of Anti Snake Venom (ASV) along with respiratory support and other supportive cares were provided. Despite utmost care feasible at RpMCH, patient expired around 49 hours later.

Central nervous system tuberculosis and adjuvant corticosteroid therapy.

Tuberculous involvement of central nervous system is one of the important health issues causing high mortality and morbidity. Uncertainty and doubt dominate all aspects of CNS tuberculosis. Diagnosis is mainly based on clinical features, cerebrospinal fluid changes, and imaging characteristics. Few studies have shown that corticosteroids improve the clinical outcome, although the precise mechanism of action remains tentative. All the cases were selected on strong clinical suspicion of CNS tuberculosis. They were graded according to tuberculous meningitis (TM) severity grades. In this connection, we studied 13 patients in one medicine unit over 12 month's period to see the effect of corticosteroid as part of the outcome. Nine patients (69.23%) were in grade II, three (23.08%) patients were in grade III, and one (7.69%) was in grade I. Seven patients (53.85%) had tuberculous meningitis and six (46.15%) had tuberculoma (CT or MRI). Out of 13 cases 3 patients (23%) died in the hospital and 10 patients (77%) improved, of whom 2 patients (20%) recovered completely and 8 patients (80%) had residual neurological deficit. Our study suggests that the early detection of CNS tuberculosis is the most important prognostic factor. Timely started anti-Koch's treatment with adjuvant corticosteroid therapy has a direct bearing on patient outcome.

Neurological findings and outcome in adult cerebral malaria.

The neurological findings of 100 patients of adult cerebral malaria were studied. The commonest neurological feature was symmetrical upper motor neuron lesion as evidenced by exaggerated tendon reflexes and bilateral planter extensor (61%). Twenty two percent had features of meningeal irritation and/or meningism. Abnormal posturing occurred decerebrate rigidity (6%) and decorticate rigidity (4%) with or without opisthotonus, focal neurological deficit was noted in 5% cases. Pupillary size and reaction were normal in 86%, poor in 14%. Corneal reflexes were absent in 4% cases. Fundoscopy showed retinal hemorrhage in 16%, papilloedema is 3% and exudates in 1%. Majority of the patients recovered (80%) without any persistent neurological sequelae at the time of discharge from hospital and death rate was 20%. Patients having focal neurological deficit, disconjugate gaze, poor pupillary reaction, absent corneal reflex and papilloedema were more susceptible to death. Delay in hospitalization and deep coma were also associated with increased mortality, whereas early hospitalization and proper nursing care could reduce mortality.

Ethnobotanical, phytochemical and toxicological studies of Xanthium strumarium L.

The present study describes the ethnobotanical, phytochemical, and toxicological evaluations of Xanthium strumarium L. growing in Bangladesh. In toxicity evaluation on rats, the methanol extract of seedlings showed mortality, while both seedling and mature plant extracts raised the serum alanine transaminase and aspartate transaminase values and produced significant abnormalities in the histopathology of liver and kidney of rats. On the other hand, the aqueous soluble fraction of methanol extract of mature plant (LC50 = 0.352 microg/mL) and methanol crude extract of seedlings (LC50 = 0.656 microg/mL) demonstrated significant toxicity in the brine shrimp lethality bioassay. A total of four compounds were purified and characterized as stigmasterol (1), 11-hydroxy-11-carboxy-4-oxo-1(5),2(Z)-xanthadien-12,8-olide (2), daucosterol (3) and lasidiol-10-anisate (4). The present study suggests that X. strumarium is toxic to animal.

Miltefosine Induced Reduced Male Fertility Capacity after Treatment of Post Kala-azar Dermal Leishmaniasis, Bangladesh.

Post Kala-azar Dermal Leishmaniasis (PKDL) is the sequel of visceral leishmaniasis in Indian subcontinent and may appear among patients with or without previous history of visceral leishmaniasis (VL). The aim of the study is to understand the male reproductive safety profile of miltefosine used for the treatment of Post Kala-azar Dermal Leishmaniasis (PKDL) in Bangladesh. From January 2017 to March 2017, an exploratory study was carried out on male fertility capacity in Bangladesh among male patients above 14 years old with PKDL treated with miltefosine. Twenty nine male patients were included to observe the effect of miltefosine on reproductive health. All PKDL patients had history of visceral leishmaniasis (VL) in different time periods. Among them three (10.3%) patients were unable to ejaculate semen. In semen analysis, 3 patients (10.3%) were found azoospermia (sperm count & motility- 0, viscosity- good, pH- 7 to 8), microscopically there was presence of RBC (5-15/HPF), WBC (8-15/HPF). Another 3 patients (10.3%) were found oligospermia (sperm count- 4.2 to 15.3 million/ml, motility- 20 to 50%, viscosity- good, pH- 6 to 9, RBC- 4 to 15/HPF, WBC- 4 to 15/HPF). The study documented some important findings in evaluating male infertility and selection of drug regimens in treating PKDL patients with miltefosine for 12 weeks.

The relationship between age and the manifestations of and mortality associated with severe malaria.

BACKGROUND: The reported case-fatality rate associated with severe malaria varies widely. Whether age is an independent risk factor is uncertain. METHODS: In a large, multicenter treatment trial conducted in Asia, the presenting manifestations and outcome of severe malaria were analyzed in relation to age. RESULTS: Among 1050 patients with severe malaria, the mortality increased stepwise, from 6.1% in children (age, <10 years) to 36.5% in patients aged >50 years (P<0.001). Compared with adults aged 21-50 years, the decreased risk of death among children (adjusted odds ratio, 0.06; 95% confidence interval, 0.01-0.23; P<0.001) and the increased risk of death among patients aged >50 years (adjusted odds ratio, 1.88; 95% confidence interval, 1.01-3.52; P<0.001) was independent of the variation in presenting manifestations. The incidence of anemia and convulsions decreased with age, whereas the incidence of hyperparasitemia, jaundice, and renal insufficiency increased with age. Coma and metabolic acidosis did not vary with age and were the strongest predictors of a fatal outcome. The number of severity signs at hospital admission also had a strong prognostic value. CONCLUSION: Presenting syndromes in severe malaria depend on age, although the incidence and the strong prognostic significance of coma and acidosis are similar at all ages. Age is an independent risk factor for a fatal outcome of the disease.