Management of Hyperparasitaemia in Severe Malaria: A Sea Change With the Availability of Artesunate.

OBJECTIVE: This study aims to study the efficacy of exchange transfusion in complicated malaria with hyperparasitaemia. METHOD: This is a retrospective case-control study conducted in a tertiary care referral hospital in northeastern India. A retrospective chart review was done, and 34 children with hyperparasitaemia were identified. Of these, 16 children received only antimalarial chemotherapy, and 18 received adjunct exchange blood transfusion (EBT). The data was analyzed for survival benefit as the main outcome measure. RESULTS: The subjects in each of the groups were comparable in terms of age, sex distribution, and mean haemoglobin at presentation. The patients treated with EBT were more ill than those who did not receive EBT; they met a greater number of WHO criteria for severe malaria (2.94 ± 1.16 vs. 1.81 ± 0.83; p=0.002) and had higher levels of parasitaemia (23.96 ± 17.55 vs. 16.14 ± 6.89; p=0.0007). The mean volume exchanged was 44.88 ± 20.49 ml/kg, against a target of 70 ml/kg due to the unavailability of fresh, compatible whole blood. There was no difference in mortality in the exchange transfusion group compared to the chemotherapy alone group (22.22% vs. 31.25%; p=0.83). CONCLUSIONS: In resource-limited areas, lower volumes of fresh whole blood for exchange transfusion can reduce hyperparasitaemia to a significant degree, and this may give some mortality benefit in very sick cases. Artesunate, by virtue of its rapid action, is capable of reducing hyperparasitaemia and may question the very place of blood transfusion in complicated malaria. It may also be worthwhile to accumulate more data comparing EBT against artesunate instead of quinine.

Renal Thrombotic Microangiopathy: A Complication of Paediatric Systemic Lupus Erythematosus That Requires Attention.

Systemic lupus erythematosus (SLE) is a multi-system disorder with a variety of clinical presentations. A wide range of renal vascular lesions (VL) is described predominantly in adult patients. The exact prevalence of renal VL in the pediatric SLE (pSLE) population is yet to be determined. A 10-year-old female patient with lupus nephritis (LN) presented with deteriorating kidney function. An exhaustive array of clinical-biochemical and pathological evaluations resulted in a diagnosis of class IV LN with thrombotic microangiopathy (TMA) associated with malignant hypertension and hypocomplementemia. Renal VL is overlooked or underreported in SLE patients, as it is neither accorded much importance in the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification nor in the activity and chronicity scoring. The TMA lesions in LN patients can be managed following the recently devised PLASMIC score; hence, reporting such VL has therapeutic implications.

Clinical Profile of Pediatric Tuberculosis in a Tertiary Hospital in Northeast India: A Retrospective Analysis.

Context Tuberculosis (TB) is India's major public health problem. The profile of childhood TB in the northeast region of India is still limited. Aim To analyze the clinical, radiological, and bacteriological profiles of children with TB at a tertiary health care facility. Materials and methods A three years retrospective descriptive analysis of children admitted to a tertiary centre with TB before the introduction of cartridge-based nucleic acid amplification test (CBNAAT) for testing. Children below 18 years who were admitted from 2012 to 2014 and were diagnosed with TB were included. Relevant data were extracted in a predesigned format and entered into a Microsoft Excel sheet. Descriptive statistic was used for analysis. The results of variables are given in proportions and means and a Chi-square test was done for the test of significance using Epi-info tools. The study was done after getting ethical approval from the institute. Results A total of 150 children were included in the analysis with a Male: Female ratio of 1.1:1. A majority of the cases were under five years (n=46) and 11 to 15 years old (n=45) with a mean age of 9.3 ± 4.4 years. Fever was a common presentation (70%). Disseminated TB was seen in 31.3%, isolated central nervous system (CNS) TB was found in 30.6%, and all CNS TB with dissemination was found in 46 cases (40.7%) making extra-pulmonary TB a common finding in our study (83.3%). Isolated pulmonary TB was seen in 16.7% and total pulmonary cases along with dissemination was seen in 60 cases (40%). A bacteriological diagnosis was made in 23%. Overall mortality was 9.3%, out of which mortality in CNS TB was 13% with a p-value of 0.004 as compared to mortality other than CNS TB which was significant and mortality in under-five years was significant with a p-value of 0.001. Conclusions Pulmonary and extra-pulmonary were both causes of admission in the pediatric age group. We found that extra-pulmonary TB was the most common cause of admission in children, with CNS manifestation and disseminated TB, being the most common presentations and significant mortality was seen in under-five years and in children diagnosed with CNS TB.

Clinico-demographic profile of COVID-19 positive patients - first wave versus second wave - an experience in north-east India.

INTRODUCTION: India witnessed two distinct COVID-19 waves. We evaluated the clinico-demographic profile of patients infected during first wave (FW) and second wave (SW) in a hospital in north-east India. METHODOLOGY: Patients who tested positive for severe acute respiratory syndrome-coronavirus-2 specific gene by reverse transcriptase polymerase chain reaction across FW and SW were diagnosed as COVID-19 positive. The clinico-demographic data of these positive patients were retrieved from the specimen-referral-form. Vital parameters including respiratory rate, SpO2, data on COVID-19-associated mucormycosis (CAM), COVID-19-associated acute respiratory distress syndrome (CARDS) were obtained from hospital records for in-patients. Patients were categorized based on disease severity. The data obtained in both waves were analyzed comparatively. RESULTS: Out of a total of 119,016 samples tested, 10,164 (8.5%) were SARS-CoV-2 positive (2907 during FW, 7257 during SW). Male predominance was seen across both waves (FW: 68.4%; SW:58.4%), with more children infected during SW. Patients with travel history (24%) and contact with laboratory confirmed cases (61%) were significantly higher during SW relative to FW (10.9% and 42.1% respectively). Healthcare worker infection was higher in SW (5.3%). Symptoms like vomiting [14.8%], diarrhea [10.5%], anosmia [10.4%] and aguesia [9.4%] were more in SW. More patients developed CARDS in SW (6.7%) compared to FW (3.4%) with 85% and 70% patients expiring across FW and SW respectively. No case of CAM is documented in our study. CONCLUSIONS: This was probably the most comprehensive study from north-east India. Industrial oxygen cylinder usage may have been the source of CAM in the rest of the country.

Clinicopathological Profile of Immunoglobulin A Nephropathy: A Study from Northeast India.

Immunoglobulin A (IgA) nephropathy is the most common primary glomerulopathy, with wide variation in its prevalence as well as clinical symptoms. Among the laboratory parameters, increased serum creatinine (SCr) levels, mean arterial pressure (MAP), and a decreased estimated glomerular filtration rate (eGFR) point toward poorer renal function. The Oxford 2016 scoring system for IgA nephropathy identified various histopathological variables, which serve as indicators of renal outcomes. There is a paucity of studies on the prevalence as well as the various clinical laboratory parameters correlating with the 2016 Oxford scoring system in northeastern India. The present study showed that IgA nephropathy was more common in the second and third decades, more prevalent in females, and mostly presented with edema. Nephrotic proteinuria, higher SCr, MAP, and decreased eGFR levels at presentation suggested poorer renal function in most subjects. The endocapillary hypercellularity, segmental sclerosis, tubular atrophy, and crescent variables of the 2016 Oxford scoring system showed a statistically significant relationship with various laboratory parameters at presentation.

Plasma neutrophil gelatinase-associated lipocalin (NGAL): A candidate biomarker to detect early acute kidney injury (AKI) for at-risk intensive care admissions.

Introduction: Acute kidney injury (AKI) is a presentation of an underlying heterogeneous group of conditions that leads to impairment of filtration and excretion of nitrogenous waste products from the body. A prompt early diagnosis to detect AKI is a mandate due to the associated risk of high mortality and morbidity. We tested the sensitivity and specificity of plasma neutrophil gelatinase-associated lipocalin (NGAL), a potential biomarker of AKI, versus serum creatinine, the gold standard laboratory test. Materials and Methods: A cross-sectional diagnostic type study was conducted from February 2015 to January 2017 after obtaining the institutional ethics clearance certificate. Individuals admitted to the intensive care unit (ICU) of a tertiary care hospital of northeast India who were diagnosed with septicemia, heart failure, and ketoacidosis and individuals on nephrotoxic drugs such as aminoglycosides were included in the study. Serum creatinine and plasma NGAL of all individuals were estimated using suitable methods within 24 h of admissions. Results: Considering all inclusion and exclusion criteria, 138 individuals were included in the study. The area under the curve (AUC) for plasma NGAL on day 1 of admission was 0.800 (95% confidence interval [CI]: 0.712-0.882). In the study, we estimated a plasma NGAL cut-off value of 391 ng/mL (with an odds ratio of 9.89) within the day of admission. Conclusion: Plasma NGAL is a candidate biomarker of AKI with acceptable sensitivity and specificity (AUC of 0.80) that can predict AKI in our setup before serum creatinine is raised, thereby asking for a prompt intervention to reduce the mortality and morbidity associated with AKI.

Delayed liver toxicity and delayed gastroenteritis: A 5 year retrospective analysis of the cause of death in Mushroom poisoning.

Introduction: Mushroom poisoning occurs from consumption of the wild variants of mushroom containing varied forms of toxins. Among those toxins, amatoxin containing mushrooms are known for the significant morbidity and mortality from hepatic toxicity and delayed gastroenteritis. Although not a very common cause of poisoning, it is prevalent in the north-eastern region of India, especially during the rainy summer seasons when the wild variants are found abundantly and often confused with the edible variants. Aims and Objectives: To study the clinical and biochemical profiles and short term outcomes of patients with mushroom poisoning admitted to a tertiary care hospital. Materials and Methods: We analyzed the data of patients with mushroom poisoning admitted to a tertiary care institute in north-eastern India between January 2015 to December 2020 to study their clinical and biochemical profiles, and short-term outcomes. Their clinical features, biochemical parameters, management, and in-hospital outcomes were noted. All data was recorded in Microsoft MS Excel and analyses done using SPSS version 22. Results: Of the 44 patients with mushroom poisoning, 23 (52%) were male and 21 (47%) were female, with a mean age of 20.13 years. Seventeen patients (38%) had delayed liver failure and delayed gastroenteritis, 19 patients (43%) had acute gastroenteritis syndrome, 5 patients (11%) had cholinergic symptoms, one patient (2%) each had acute kidney injury and a disulfiram-type reaction with headache. The mean hospital stay of the patients was 5 days. In-hospital mortality occurred in 10 (58%) patients with delayed liver failure and none of the patients with the other complications died. Conclusion: This study revealed a high prevalence of mushroom poisoning that caused delayed liver toxicity and delayed gastroenteritis, probably amatoxin-induced, which is fatal, thus accounting for high mortality and poor outcomes in these patients.

Utility of reticulocyte indices in the diagnosis of pancytopenia.

Introduction: Pancytopenia is a hematological condition in which there is a reduction in all three cell lines of blood. This study aims to evaluate the utility of reticulocyte indices such as reticulocyte % (retic %), immature reticulocyte fraction (IRF), and mean reticulocyte volume (MRV) in identifying the cause of pancytopenia. Materials and Methods: Reticulocyte indices were measured by an automated coulter. These values were then correlated with relevant biochemical and bone marrow results and cases were stratified into different etiological groups. Receiver operator curve (ROC) analysis was performed and various cut-off values were derived based on the reticulocyte indices. ROC was repeated to further classify cut-off values at every level to help formulate a diagnostic algorithm. Results: A total of 154 cases of pancytopenia were obtained. Ages ranged from 7 months to 87 years with a mean of 42, the male:female ratio was 1.08:1. The majority of the cases were megaloblastic anemias in which the cut-off values for retic % was <0.91 with a sensitivity of 78.1% and specificity of 70%, IRF was 0.45 with a sensitivity of 76.7% and specificity of 64%, and MRV was >121.8 fl with a sensitivity of 83.6% and specificity of 80%. The values on ROC could segregate nutritional from nonnutritional causes. The IRF and MRV also helped to differentiate megaloblastic anemia from dual deficiency anemia. Conclusion: Reticulocyte indices help identify the cause of pancytopenia. They can segregate nutritional anemia from other causes of pancytopenia allowing presumptive treatment to be initiated and may obviate invasive procedures such as bone marrow examination.

Clinical and Demographic Profile of COVID-19 Patients: A Tertiary Level Hospital-Based Study From Northeast India.

Background and objective The coronavirus disease 2019 (COVID-19) outbreak, which was first detected in Wuhan, China, has turned into a rapidly spreading global healthcare crisis. The clinical and laboratory features of COVID-19 are associated with significant regional variations. In this study, we aimed to describe the clinical and demographic profile of COVID-19 patients from a tertiary care hospital in Northeast India. Materials and methods This was a hospital-based cross-sectional study that included all laboratory-confirmed COVID-19 cases admitted to the institution from 1st July to 31st October 2020. The information was collected on a predesigned proforma, which included patients' demographic profiles, clinical presentations, and outcomes as per treatment by trained doctors. Results The study included 180 laboratory-confirmed COVID-19 cases. A history of contact with laboratory-confirmed COVID-19-affected individuals was found in 92 (51.1%) patients. The median age of the patients was 37.17 years (range: 18-80 years), and there were 104 (57.78%) males in the cohort. Of the total enrolled patients, 102 (56.67%) were asymptomatic from the time of exposure till their admission. The common presenting complaints were fever (n=55, 70.51%), cough (n=42, 53.85%), and shortness of breath (n=32, 42.02%). The case fatality rate among the admitted cases was 15%. Comorbidities were found in 84 (46.67%) patients with the most common one being diabetes mellitus (n=31, 36.9%) followed by hypertension (n=29, 34.52%). Patients with advanced age (more than 60 years) and coexisting comorbidities were at higher risk of progression of disease and death. Conclusion The COVID-19 pandemic is not only a huge burden on healthcare facilities but also a significant cause of disruption in societies globally. The majority of the patients with COVID-19 infection presenting to our hospital were young and asymptomatic. Patients of advanced age with comorbidities were found to have more complications. An analysis of the trends related to COVID-19 in different hospital and institutional settings will help to achieve better preparedness and lead to improved patient care to combat the COVID-19 pandemic in a more efficient manner.

Secondary Hemophagocytic Lymphohistiocytosis in Post-COVID-19 Patients: A Report of Two Cases.

Hemophagocytic lymphohistiocytosis (HLH) is a disease that can affect both children and adults. HLH can be categorized as primary or secondary. Secondary HLH (sHLH) may be secondary to various viral infections. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus infection is a pandemic with multi-system involvement. HLH in COVID-19 positive patients is a recognized entity. However, in post-COVID-19 patients who have recovered and are negative by serological tests and reverse transcription-polymerase chain reaction test may present with sHLH due to dysregulation of the immune system. We highlight this unusual finding of post-COVID-19 sHLH in two cases, who were diagnosed by the new revised H-score.

Association of Co-dominant Immunoglobulin G Deposit in Immunoglobulin A Nephropathy With Poor Clinicopathological and Laboratory Parameters.

INTRODUCTION: Immunoglobulin A (IgA) nephropathy is the commonest primary glomerulonephritis with a wide range of clinical presentations and laboratory findings. There is a paucity of studies regarding the significance of co-dominant immunoglobulin G (IgG) deposition in IgA nephropathy. METHODS: The study included retrospective and prospective biopsy-proven cases of IgA nephropathy from 2013-2020 with a minimum of eight glomeruli. Clinical and laboratory parameters were analysed for the IgA and IgG co-dominant cases as compared to those of the non-IgG group. RESULTS: A total of 58 cases of IgA nephropathy were included in the study out of which 25 biopsies (43.1%) were categorized as IgA plus IgG, and the rest 33 biopsies (56.8%) as the non-IgG group. A significant correlation was noted amongst the IgA plus IgG group with respect to the elevated mean arterial pressure (MAP) (p=0.038) and proteinuria (p=0.002) as compared to the non-IgG group. Amongst the MEST-C (mesangial hypercellularity, endocapillary hypercellularity, segmental sclerosis, tubular atrophy/interstitial fibrosis, crescents) variables, endocapillary hypercellularity correlated with elevated MAP (p=0.04), raised serum creatinine (p=0.005), and decreased estimated glomerular filtration rate (eGFR) (p=0.002). CONCLUSION: Co-dominant IgG deposit serves as an adverse marker pointing towards a deranged renal function in IgA nephropathy.

Pottels Equation for Estimation of Glomerular Filtration Rate.

The retrospective study was carried out to examine performance of Pottels height- independent equation compared to Schwartzs height-dependent equation to estimate glomerular filtration rate in 115 children in Indian setting. The Pottels equation performed well compared to updated Schwartz equation (R2=0.94, mean bias 0.25, 95% LOA=20.4, -19.9). The precision was better at lower range of estimated GFR.

Comparative evaluation of the role of single and multiple blood specimens in the outcome of blood cultures using BacT/ALERT 3D (automated) blood culture system in a tertiary care hospital.

INTRODUCTION: Bloodstream infection (BSI) is a leading cause of mortality in critically ill patients. The mortality directly attributable to BSI has been estimated to be around 16% and 40% in general hospital population and Intensive Care Unit (ICU) population, respectively. The detection rate of these infections increases with the number of blood samples obtained for culture. The newer continuous monitoring automated blood culture systems with enhanced culture media show increased yield and sensitivity. Hence, we aimed at studying the role of single and multiple blood specimens from different sites at the same time in the outcome of automated blood culture system. MATERIALS AND METHODS AND RESULTS: A total of 1054 blood culture sets were analyzed over 1 year, the sensitivity of one, two, and three samples in a set was found to be 85.67%, 96.59%, and 100%, respectively, which showed a statistically significant difference (P < 0.0001). Similar findings were seen in few more studies, however, among individual organisms in contrast to other studies, the isolation rates of Gram-positive bacteria were less than that of Gram-negative Bacilli with one (or first) sample in a blood culture set. In our study, despite using BacT/ALERT three-dimensional continuous culture monitoring system with FAN plus culture bottles, 15% of positive cultures would have been missed if only a single sample was collected in a blood culture set. CONCLUSION: The variables like the volume of blood and number of samples collected from different sites still play a major role in the outcome of these automated blood culture systems.

Effective ultrafiltration with acute peritoneal dialysis in a child with diuretic-resistant nephrotic edema.

Edema is a cardinal feature of the nephrotic syndrome and sometimes merits independent treatment. The use of diuretics is usually sufficient in the treatment of edema. Ultrafiltration (UF) may sometimes be needed in diuretic-resistant states. The use of UF for steroid-resistant nephrotic edema is scarce in children. We report a child with steroid-resistant nephrotic syndrome with diuretic-resistant nephrotic edema treated successfully using acute peritoneal dialysis as a means of UF.

Exchange transfusion in complicated pediatric malaria: A critical appraisal.

Complicated falciparum malaria is a killer disease resulting in high mortality in spite of appropriate treatment. Some workers have reported improved survival when adjunct exchange blood transfusion is included in the treatment modality while others opine against it. This review is an effort to address and critically appraise current evidence for the treatment mode for severe malaria. The literature was searched with a specified search strategy to identify reports of children who underwent exchange transfusion for severe malaria. Total 23 children who underwent exchange transfusion for severe falciparum malaria published by 9 authors were identified. Age ranged from 5 months to 16 years with a mean age of 6.4 years. The average preprocedure parasite index (PI) was 41.4% (95confidence interval [CI]; 31.2-51.4). The average blood volume exchanged was 118.6% (95% CI; 94.7-143) of the circulating blood volume. The average postexchange reduction in PI was 34.1% (95% CI; 25.4-42.8). Three out of 23 children encountered some complications. All the children survivedKeywords: Exchange blood transfusion, parasite index, pediatric Intensive Care Unit, red cell exchange, severe falciparum malaria.

Invasive meningococcal infection: analysis of 110 cases from a tertiary care centre in North East India.

OBJECTIVES: To report an outbreak of invasive meningococcal disease from Meghalaya, in the north east India, from January 2008 through June 2009. METHODS: Retrospective review of case sheets was done. One hundred ten patients with invasive meningococcal disease were included for the study. RESULTS: Of the total patients, 61.8 % were boys and 38.2 % were girls (boy to girl ratio = 1.62:1). The average age of presentation was 8.48 ± 5.09 y. Meningococcal meningitis was seen in 61.8 % of cases, meningococcemia in 20 % and 18.2 % had both. Fever was the most common manifestation (100 %) followed by meningeal signs (78.2 %), headache (56.4 %), vomiting (53.6 %), shock (38.2 %), low Glasgow coma scale (GCS) (25.5 %), purpura and rashes (23.6 %), seizures (9.1 %), abdominal symptoms (4.5 %), irritability and excessive crying (4.5 %) and bulging anterior fontanalle (23 %) in those below 18 mo of age. Raised intracranial pressure (ICP) was the most common complication (28.2 %) followed by coagulopathy (16.4 %), hepatopathy (10 %), herpes labialis (9.1 %), syndrome of inappropriate ADH secretion (SIADH) (8 %), pneumonia (7 %), arthritis (6 %), purpura fulminans, respiratory failure, sixth nerve palsy and diabetes insipidus in 4.5 % each, subdural empyema, optic neuritis, ARDS and ARF in 1.8 % each, cerebral salt wasting syndrome, third nerve palsy, cerebritis and hearing impairment in 0.9 % each. Culture was positive in 35.5 %. Patients were treated initially with ceftriaxone and dexamethasone but later on with chloramphenicol due to clinical drug resistance. Mortality was 6.4 %. CONCLUSIONS: This is the first epidemic report of invasive meningococcal disease from the north east India. Chloramphenicol acts well in areas with penicillin or cephalosporin resistance. Mortality reduces significantly with early diagnosis and prompt intervention.

Immune complex reaction after successful treatment of meningococcal disease: an excellent response to IVIG.

The convalescence phase of severe meningococcal sepsis is complicated by immune complex reactions with arthritis being the commonest. No standard guidelines exist for management of such complications, but non-steroidal anti-inflammatory drugs and steroids have been used with varying success. We report excellent response to intravenous immunoglobulin in a child with immune complex reaction following meningococcal sepsis.