Frequency and Impact of Cerebral Infarctions in Patients With Tuberculous Meningitis.

Background and Purpose- Cerebral infarctions complicate a variable proportion of tuberculous meningitis (TBM) cases and adversely affect outcomes. The objective of this study was to evaluate the predictors of cerebral infarcts in patients with TBM and to assess their impact on mortality. Methods- The study was based on a retrospective chart review of all patients with TBM admitted to a tertiary care hospital between 2002 and 2013. Data were collected on basic demographics, conventional vascular risk factors, radiological findings, severity of TBM, and neurological outcomes. Data were analyzed using SPSS version 19.0. Binary logistic regression was done to determine the factors predictive of cerebral infarcts and of mortality in patients with TBM. Results- A total of 559 patients were admitted with TBM during the study period. Mean age was 41.9 years (SD, 17.7 years), and 47% were women. A quarter of the patients had stage III disease. One hundred forty-four (25.8%) patients had cerebral infarcts on brain imaging of which 3 quarters were acute or subacute. Those with cerebral infarcts were more likely to be >40 years of age (adjusted odds ratio [AOR], 1.7; 95% CI, 1.1-2.7) and to have hypertension (AOR, 1.8; 95% CI, 1.1-2.8), dyslipidemia (AOR, 9.7; 95% CI, 3.8-24.8), and diabetes mellitus (AOR, 2.2; 95% CI, 1.3-3.6). Presence of cerebral infarction was an independent predictor of mortality among patients with TBM (AOR, 2.1; 95% CI, 1.22-3.5). Conclusions- Cerebral infarcts complicate a substantial proportion of TBM cases. Conventional vascular risk factors are the most important predictors of infarction, and future efforts need to focus on these high-risk patients with TBM to reduce morbidity and mortality.

Frequency of G6PD Mediterranean in individuals with and without malaria in Southern Pakistan.

BACKGROUND: Pakistan has an estimated annual burden of 1.5 million malaria cases. The current situation calls for an effective malaria control and eradication programme in this country. Currently, primaquine is an attractive option for eliminating reservoirs of Plasmodium vivax hypnozoites and killing gametocytes of Plasmodium falciparum. However, this drug causes haemolysis in individuals who are glucose-6-phosphate (G6PD) deficient. It is important to map G6PD deficiency and malaria distribution in Pakistan to design an effective malaria eradication regimen. Frequency of G6PD deficiency (G6PDd) in malaria patients has not been reported from Pakistan in any meaningful way. The purpose of this study was to evaluate the frequency of G6PD c.563C>T (G6PD Mediterranean) in male individuals with and without falciparum malaria. METHODS: Two hundred and ten archived DNA samples from males (110 from falciparum malaria patients and 100 from healthy individuals) were utilized in this study. Healthy blood donors were selected based on stringent pre-defined criteria. Patients were confirmed for malaria parasites on microscopy and or immune chromatographic assay detecting P. falciparum histidine-rich protein 2. Parasitaemia was also computed. DNA samples were tested for G6PD c.563C>T mutation through PCR-RFLP according to the previously defined protocol and its allelic frequency was computed. RESULTS: G6PD c.563C>T was observed in four of 110 patients with falciparum malaria and in two of 100 healthy donors. Mean (± SD) haemoglobin, median (IQR) platelet and median (IQR) parasite count in G6PD-deficient malaria-patients were 8.9 ± 0.9 g/dL, 124 × 109/L (IQR 32, 171) and 57,920/µL of blood (IQR 12,920, 540,000) respectively. CONCLUSIONS: Cumulative allelic frequency for G6PD 563c.C>T was 0.0285 detected in 6 of 210 X-chromosomes in Southern Pakistan. Frequency for this G6PD allele was 0.0364 in malaria-patients and 0.0200 in healthy individuals. Large studies including females are needed to elucidate the true burden of G6PDd in malaria-endemic areas. The information will enable local health policy makers to design effective strategies for eliminating malaria form this region.

Cerebral infarction and tuberculoma in central nervous system tuberculosis: frequency and prognostic implications.

BACKGROUND: Tuberculoma and cerebral infarctions are serious complications of central nervous system (CNS) tuberculosis. However, there are no studies comparing prognostic value of tuberculoma and infarcts alone and in patients diagnosed with CNS tuberculosis. OBJECTIVE: The objective of this study was to identify frequency and prognostic value of tuberculoma and cerebral infarcts in a large sample of CNS tuberculosis patients. METHODS: Retrospective chart review of patients diagnosed with CNS tuberculosis in a tertiary care hospital in Pakistan over 10-year period was carried out. RESULTS: There were 404 patients included in this study (mean age of 43 years). There were 209 (52%) men and 195 (48%) women. Tuberculoma were present in 202 subjects (50%) while infarcts were present in 25% patients. 147 (36%) had tuberculous meningitis (TBM) without tuberculoma or infarction on CT or MRI, 158 (39%) had TBM with intracranial tuberculomas, 60 (15%) had TBM with cerebral infarction while 39 (10%) had TBM with both tuberculoma and infarction. At discharge, 249 patients (62%) were either normal (Modified Rankin Score (MRS)=0) or mild to moderately disabled (MRS=1-3) while 82 patients (20%) had severe disability (MRS=4-5). 73 (18%) patients died (MRS=6) during hospitalisation. Using logistic regression analysis, significant predictors of poor outcome included old age, high TBM grading, presence of infarction and presence of hydrocephalus. CONCLUSIONS: Tuberculomas were present in 50% of patients, while infarcts were present in 25%. Old age, TBM grading, presence of infarction and hydrocephalus were all predictors of poor outcome.

Severe Plasmodium vivax malaria in Pakistan.

To compare the severity of Plasmodium vivax malaria with that of P. falciparum malaria, we conducted a retrospective cross-sectional study of 356 adults hospitalized with malaria (2009-2011) in Pakistan. P. vivax and P. falciparum accounted for 83% and 13% of cases, respectively; 79.9% of patients with severe malaria were infected with P. vivax.

Microsporidial infections due to Encephalitozoon intestinalis in non-HIV-infected patients with chronic diarrhoea.

We determined the prevalence of microsporidia Enterocytozoon (Ent.) bieneusi and Encephalitozoon (E.) intestinalis infection in patients with chronic diarrhoea and hepatocellular carcinoma (HCC). A total of 330 stool samples were examined from 171 (52%) patients with chronic diarrhoea, 18 (5%) with HCC while 141 (43%) were controls. Stool microscopy, polymerase chain reaction (PCR) with species-specific primers for Ent. bieneusi and E. intestinalis and sequencing were carried out. Microsporidia were found by trichrome staining in 11/330 (3%) and E. intestinalis by PCR in 13/330 (4%) while Ent. bieneusi was not detected. PCR for E. intestinalis was positive in 8/171 (5%) stool samples from patients with chronic diarrhoea, 2/141 (1·4%) samples from healthy controls and in 3/18 (17%) samples from patients with HCC. In the chronic diarrhoea group, E. intestinalis was positive in 4/171 (2·3%) (P=0·69) stool samples compared to 2/18 (11%) (P=0·06) in the HCC group and 2/141 (1·4%) from healthy controls. E. intestinalis infection was significantly associated with chronic diarrhoea and HCC in these patients who were negative for HIV. Stool examination with trichrome or species-specific PCR for microsporidia may help establish the cause of chronic diarrhoea.

Neuroimaging Findings in Tuberculosis: A Single-Center Experience in 559 Cases.

BACKGROUND AND PURPOSE: There is a paucity of literature related to the neuroimaging of CNS tuberculosis (TB) and largely covers pediatric CNS TB. The objective of this study was to determine the frequency of different forms of CNS TB and its associated complications and to study longitudinal disease course using computed tomography (CT) and MRI. METHODS: Retrospective chart and imaging review of patients diagnosed with CNS TB in a tertiary care hospital in Pakistan over a 10-year period. A total of 452 initial brain MRI and 209 CT scans were reviewed by an expert radiologist specialized in neuroimaging. This was followed by review of 53 MRI/52 CT and 7 MRI/14 CT first and second follow-up scans, respectively. RESULTS: Note that 559 patients, 296 males and 263 females were included in the study. On the initial CT scans, tuberculomas were found in 25 (12%), infarction in 54 (25%), basal meningeal enhancement in 29 (14%), and hydrocephalus in 84 (40%). On initial MRI, tuberculomas were found in 182 (40%), infarction in 120 (27%), basal meningeal enhancement in 184 (41%), and hydrocephalus in 116 (26%). On review of follow-up CT scans, 13 (25%) showed new or worsening hydrocephalus, 8 (15%) showed new infarcts, 1 exhibited new tuberculoma, and 5 showed worsening cerebral edema. On review of follow-up MRI scans, new or worsening hydrocephalus was seen in 3 (6%), new infarcts in 3 (6%), new tuberculoma in 10 (19%), worsening cerebral edema in 7 (13%), and TB myelitis in 4 (8%) patients. CONCLUSIONS: Tuberculoma, hydrocephalus, and cerebral infarcts are the most prominent findings in CNS tuberculosis. Our study showed development of new lesions on subsequent neuroimaging suggesting a dynamic and progressive nature of the disease process in some individuals.

Role of ICT malaria immunochromatographic test for rapid diagnosis of malaria.

OBJECTIVE: To evaluate the sensitivity and specificity of immunochromatographic test (ICT) malaria p.f/p.v using microscopy as the gold standard diagnosis. METHODS: Five hundred and sixty patients of both sexes and all age groups with clinical suspicion of malaria were studied. Venous blood was collected for microscopy and ICT. Thick and thin films prepared and stained with Leishman's stain were examined. ICT malaria test was performed and interpreted according to manufacturer's instructions. Data was analyzed using Epi-6. RESULTS: A total of 560 cases were studied, 339 males and 221 females with age ranges between 2 to 73 years. Seventy two (12.85%) cases had parasitaemia (with or without sexual forms). On microscopy 65 (11.6%) cases had asexual-stage parasitaemia and 7 (1.25%) cases had P. falciparum gametocytes only. Thirty two cases were infected with P. falciparum, 29 with P. vivax and 4 had mixed infection. For P. falciparum the ICT was 97.0% sensitive, 98.3% specific, with positive predictive value (PPV) of 78.0% and a negative predictive value (NPV) of 99.8%. For P. vivax the sensitivity was only 89.7%, specificity 97.9%, PPV was 70.3% and NPV 99.4%. CONCLUSION: Our results are in concordance with previous studies. Rapid tests though expensive are simple to perform and effective diagnostic tools of malaria. They can be used selectively, though microscopy remains the gold standard diagnosis, economical and accurate if performed by skilled technologists.

Percutaneous aspiration-injection-reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis.

Using meta-analysis methodology, we compared the clinical outcomes for 769 patients with hepatic cystic echinococcosis treated with percutaneous aspiration-injection-reaspiration (PAIR) plus albendazole or mebendazole (group 1) with 952 era-matched historical control subjects undergoing surgical intervention (group 2). The rate of clinical and parasitologic cure (P<.0001) was greater in patients receiving PAIR plus chemotherapy. Disease recurrence (P<.0001), major complications (anaphylaxis, biliary fistula, cyst infection, liver/intra-abdominal abscess, and sepsis; P<.0001), minor complications (P<.0001), and death (P<.0824) occurred more frequently among surgical control subjects. Fever (P<.002) and minor allergic reactions subjects (P<.0001) were more common among PAIR-treated subjects. The mean durations of hospital stay were 2.4 days for group 1 and 15.0 days for group 2 (P<.001). Compared with surgery, PAIR plus chemotherapy is associated with greater clinical and parasitologic efficacy; lower rates of morbidity, mortality, and disease recurrence; and shorter hospital stays.

Irritable bowel syndrome: in search of an etiology: role of Blastocystis hominis.

This study was designed to examine stool specimens of irritable bowel syndrome (IBS) patients for Blastocystis hominis, a common intestinal parasite. One hundred fifty patients were enrolled, 95 IBS cases and 55 controls. These patients provided a medical history, and underwent physical and laboratory evaluations that included stool microscopy and culture for B. hominis and colonoscopy. The 95 cases (51 males and 44 females) had a mean +/- SD age of 37.8 +/- 13.2 years. Stool microscopy was positive for B. hominis in 32% (30 of 95) of the cases and 7% (4 of 55) of the controls (P = 0.001). Stool culture was positive in 46% (44 of 95) of the cases and 7% (4 of 55) of the controls (P < 0.001). Stool culture for B. hominis in IBS was more sensitive than microscopy (P < 0.001). Blastocystis hominis was frequently demonstrated in the stool samples of IBS patients; however, its significance in IBS still needs to be investigated. Stool culture has a higher positive yield for B. hominis than stool microscopy.

Emerging drug--resistance and guidelines for treatment of malaria.

The increasing prevalence of multi-resistant Plasmodium falciparum malaria worldwide is a serious public health threat to the global control of malaria, especially in poor countries like Pakistan. In many countries choloroquine-resistance is a huge problem, accounting for more than 90% of malaria cases. In Pakistan, resistance to choloroquin is on the rise and reported in up to 16- 62% of Plasmodium falciparum. four to 25% of Plasmodium falciparum also reported to be resistant to sulfadoxine-pyrimethamine and several cases of delayed parasite clearance have been observed in patients with Plasmodium falciparum malaria treated with quinine. In this article we have introduced the concept of artemisinin- based combination therapy (ACT) and emphasize the use of empiric combination therapy for all patients with Plasmodium falciparum malaria to prevent development of drug resistance and to obtain additive and synergistic killing of parasite.

Infectious diseases in the aftermath of monsoon flooding in Pakistan.

Pakistan is ranked 9th in terms of flood-affected countries worldwide. In the summer of 2010, the northern province of Khyber-Pakhtunkhwa received more than 312 mm of rain in a 56 hour period. This resulted in over 1 600 deaths across the region. In addition, over 14 million people were directly affected by this record-breaking deluge. Flood affected regions serve as ideal breeding grounds for pathogens, leading to the spread of diseases. The poor standards of hygiene in camps set up for individuals displaced by the floods also contribute to this. It is essential that those involved in relief efforts are aware of the epidemiology of diseases that have historically seen a sudden upsurge after natural disasters. Keeping this in mind, we conducted a simple review of literature. An extensive literature search was conducted using the PubMed data base and online search engines. Articles published in the last 20 years were considered along with some historical articles where a background was required. Seven major diseases were identified to increase substantially in the aftermath of natural disasters. They were then classified into acute and sub-acute settings. Diarrhea, skin & eye infections and leptospirosis were identified in the acute setting while malaria, leishmaniasis, respiratory infections and hepatitis were identified in the sub-acute setting.

Neurological involvement in patients with falciparum malaria; frequency and prognostic value.

OBJECTIVE: The objective of this study was to evaluate the prognostic significance of neurological manifestations in falciparum malaria. METHODS: We analyzed adult patients with malaria admitted from 2001 to 2003, diagnosed by asexual forms of Plasmodium falciparum in peripheral blood films and identified cases of malaria with neurological involvement. A patient was classified as having neurological involvement if they reported or had one or more of the following symptoms; headache, altered mental status, seizures, neck rigidity, brisk reflexes, cranial neuropathy and hyper or hypotonia. RESULTS: A total of 454 patients were included in the study. Out of these, 123 (27%) were diagnosed as complicated (severe) malaria and 331 (73%) as uncomplicated malaria at admission. Overall 70 (15.4%) patients had evidence of neurological involvement at initial evaluation. Twenty-seven patients out of 123 (22%) with complicated malaria and 43 patients out of 331 (13%) with uncomplicated malaria had neurological involvement. Over all, 16 (4%) patients died, 13 (11%) had complicated malaria (n=123) and 3 (1%) had uncomplicated malaria (n=381). Mortality in patients having neurological involvement (n=70) was 9 (13%) as compared to 7 (2%) in patients with malaria having no neurological involvement (n=384). This difference was statistically significant (p=0.012). Seizure was identified as predictor of mortality on Univariate analysis [OR 5.091 (1.835-14.121)]. CONCLUSION: Fifteen percent of patients with falciparum malaria admitted to our hospital had neurological symptoms and neurological involvement was associated with increased mortality.

A case of cellulitis of the hands caused by a predatory bird attack.

Many species have been drastically affected by rapid urbanization. Harris's hawks from their natural habitat of open spaces and a supply of rodents, lizards and other small prey have been forced to change their natural environment adapting to living in open spaces in sub- and peri-urban areas. Specific areas include playgrounds, parks and school courtyards. The migration of this predatory species into these areas poses a risk to individuals, and especially the children are often attacked by claws, talons and beaks intentionally or as collateral damage while attacking rodent prey. In addition, the diverse micro-organisms harbored in the beaks and talons can result in wound infections, presenting a challenge to clinical management. Here we would like to present a case of an 80-year-old man with cellulitis of both hands after sustaining minor injuries from the talons of a Harris's hawk and review the management options. We would also like to draw attention to the matter that, even though previously a rarity, more cases of injuries caused by birds of prey may be seen in hospital settings.

Assessing the need for training: general practitioners' knowledge, attitude and practice concerning dengue and malaria in Karachi, Pakistan.

Changing environmental conditions have increased the transmission period for both dengue and malaria. Annual incidence of malaria in 2006 alone was 247 million cases leading to nearly 881 000 deaths; whereas another 50 to 100 million dengue infections, associated with an overall mortality of 2.5%, are expected each year. In Pakistan, like many developing nations with endemic malaria, an empirical clinical diagnosis is usually made, due to a lack of resources and availability of diagnostic facilities. Since both diseases are endemic in the same population and presenting symptoms are similar a thorough knowledge of both diseases is essential for improving diagnosis on clinical grounds. Thus our study aims were to evaluate knowledge, attitudes and practices of family medicine practitioners with regard to dengue and malaria and thereby assess the need for further training. Ninety consenting general practitioners (GPs) in different towns of Karachi, Pakistan were administered an extensive questionnaire of 50 questions regarding their knowledge, attitudes and practices on management of dengue and malaria. The authors concluded that despite possessing basic knowledge of the disease, the majority of GPs in the area needed training regarding both diseases and their management. Key targets identified for training programs included clinical diagnosis and management of endemic vector borne diseases.