Rodenticide ingestion is an important cause of acute hepatotoxicity in Tamil Nadu, southern India.

BACKGROUND AND AIM: Though rodenticidal hepatotoxicity is reported from India, there is no systematic study to assess its magnitude. This study aimed to assess exposure to rodenticide as a risk factor for acute hepatotoxicity in Tamil Nadu, India. METHODS: We retrospectively analyzed acute hepatotoxicity caused by ingestion of hepatotoxin or potentially hepatotoxic drug overdose across 15 hospitals in 6 districts of Tamil Nadu from 1 January 2019 to 30 June 2019. Study exclusion criteria were idiosyncratic drug-induced liver injury and chronic liver diseases. RESULTS: Of the 702 patients, 685 gave history of consuming rodenticide; hepatotoxicity in the other patients resulted from paracetamol overdose (n=10) and due to other drugs (n=7); 97% patients had a suicidal intent. Of 671 patients with complete data, ratio of number of patients with hepatotoxicity due to rodenticide to paracetamol overdose was 450:6 (i.e. 75:1). The 451 rodenticidal hepatotoxicity patients (255 males, 75% were 15-34 years old) underwent conservative management (n=396), plasma exchange (n=54) and plasma exchange followed by liver transplant (n=1); 159 patients (35%) had poor outcome (131 died, 28 discharged in moribund state). Based on our observations, we estimate a case burden of 1584 rodenticidal hepatotoxicity patients (95% CI: 265-6119) with poor outcome in 554 patients in Tamil Nadu from January 2019 to June 2019. Population attributable risk for rodenticide as cause of hepatotoxicity was 22.7%. CONCLUSION: Rodenticide ingestion was an important cause of acute hepatotoxicity in Tamil Nadu. Most patients were young and one-third had poor outcome. Public health interventions are needed to address this.

Low dose versus high dose anti-snake venom therapy in the treatment of haematotoxic snake bite in South India.

Most of the studies on the appropriate dose of anti-snake venom (ASV) are from tertiary hospitals and the guidelines are unclear. Our observational study compared the outcomes of two prevalent treatment regimes for haematotoxic snake bite in a secondary care hospital in South India. The time to normalisation of whole blood clotting time, mortality and complications were not different between the groups. The average dose of ASV required in the low and high dose groups were 106 mL and 246 mL, respectively. Consequently, patients who received low dose ASV incurred approximately 50% less expense. Urticarial rashes were also significantly fewer in the low dose group.

Validity of tuberculous pleuritis diagnosed in a resource-constrained setting in Dindigul district of Tamil Nadu.

CONTEXT: Majority of the Indians live in rural areas where resource constrained settings depend on cheaper and less invasive tests to diagnose extrapulmonary tuberculosis (TB). The decline in prevalence of TB in the country could affect the validity of the diagnosis. The aim was to measure validity of the pleural fluid study of proteins, lactate dehydrogenase (LDH), and cell counts in diagnosis of tuberculous pleuritis. MATERIALS AND METHODS: This was a cross-sectional study conducted in a 300 bedded secondary care hospital in rural Tamil Nadu. Exhaustive sampling was performed during April 2013 to March 2014. Pleural fluid study of 54 patients with exudative pleural effusion was conducted. Diagnosis was established by closed needle pleural biopsy. Receiver operator curves were plotted and area under curve (AUC) was calculated for various parameters. Sensitivity, specificity, and predictive values were calculated for different cut-off values of the parameter with significant AUC. RESULTS: Prevalence of tuberculous pleural effusion was 56% (95% confidence interval [95% CI] - 42.5-69.5%). Lymphocyte predominance in pleural fluid was the only valid test, and cut-off >80% had sensitivity of 70.0% (95% CI - 53.3-86.7%) and specificity of 70.8% (95% CI - 52.2-89.4%). Pleural fluid pH, protein or its ratio with serum protein, sugar, total leukocyte count, LDH or its ratio with serum LDH; erythrocyte sedimentation rate were not valid screening tests. CONCLUSIONS: Lymphocyte predominance > 80% can be used as a marker of tuberculous pleuritis. Since the prevalence of tuberculous pleuritis in India has come down considerably, newer tests need to be included to make a valid diagnosis.

Acute pancreatitis and subdural haematoma in a patient with severe falciparum malaria: case report and review of literature.

Plasmodium falciparum infection is known to be associated with a spectrum of systemic complications ranging from mild and self-limiting to life-threatening. This case report illustrates a patient who had a protracted course in hospital due to several rare complications of falciparum malaria. A 21-year old man presented with a five-day history of high-grade fever, jaundice and abdominal pain and a two-day history of altered conscious state. A diagnosis of severe falciparum malaria was made based on the clinical presentation and a positive blood smear with parasitaemia of 45%. Despite adequate anti-malarial therapy with artesunate, the patient had persistent and worsening abdominal pain. Investigations suggested a diagnosis of acute pancreatitis, a rare association with falciparum malaria. However, in spite of supportive therapy for acute pancreatitis and a 10-day course of intravenous artesunate and oral doxycycline at recommended doses, he continued to be febrile with peripheral blood smear showing persistence of ring forms. Antimalarial therapy was, therefore, changed to quinine on the suspicion of possible artesunate resistance. On the 17th day of stay in hospital, the patient developed generalized tonic-clonic seizures. Computerized tomography of the brain showed bilateral fronto-parietal subdural haematomas that were surgically drained. His fever persisted beyond 30-days despite broad-spectrum antibiotics, quinine therapy and negative malarial smears. A possibility of drug fever was considered and all drugs were ceased. He subsequently became afebrile and was discharged on the 38th hospital admission day. Recognition of complications and appropriate management at each stage facilitated successful outcome. This report has been presented to highlight the occurrence of several rare complications of falciparum malaria in the same patient.