The 2003 outbreak of Dengue fever in Delhi, India.

Dengue fever (DF) and Dengue hemorrhagic fever (DHF) are widespread in Southeast Asia. An outbreak of DF/DHF in Delhi in 2003 started during September, reached its peak in October-November, and lasted until early December. This study describes the clinical and laboratory data of the 185 cases of DF/DHF admitted to Lok Nayak Hospital, New Delhi. The mean age of the patients was 26 +/- 10 years. Fever was present in all the cases with an average duration of fever being 4.5 +/- 1.2 days with headache (61.6%), backache, (57.8%), vomiting (50.8%) and abdominal pain (21%) being the other presenting complaints. Hemorrhagic manifestations in the form of a positive tourniquet test (21%), gum bleeding and epistaxis (40%), hematemesis (22%), skin rashes (20%) and melena (14%) were also observed. Hepatomegaly and splenomegaly were observed in 10% and 5% of cases, respectively. Laboratory investigations revealed thrombocytopenia (with a platelet count of < 100,000/microl) in about 61.39% of cases, Leukopenia (WBC <3,000/mm2) and hemoconcentration (Hct >20% of expected for age and sex) were found in 68% and 52% of the cases, respectively. The mortality rate was 2.7%. Despite widespread measures taken to control outbreaks of DF, it caused major outbreaks. More stringent measures in the form of vector control, improved sanitation and health education are needed to decrease morbidity, mortality and health care costs caused by a preventable disease.

Effect of low-dose omega-3 fatty acids substitution on blood pressure, hyperinsulinemia and dyslipidemia in Indians with essential hypertension: A pilot study.

The present study comprised 100 patients of essential hypertension who were screened for fasting hyperinsulinemia, which was detected in 77% cases. Twenty such hyperinsulinemic cases were subjected to 4 weeks of dietary control phase followed by 6 weeks of omega-3 fatty acids substitution [either 0.6 g/d (group 1) or 1.2 g/d (group 2)]. The mean basal fasting plasma insulin levels were significantly higher (p<0.001) in patients of hypertension when compared to normal controls (126.51±80.36 and 19.35±12.61 µU/ml respectively). At the end of 4 weeks of diet control only, no significant change was observed in any parameter. After substitution of omega-3 fatty acid, a significant reduction of fasting plasma insulin levels in both group 1 (29%) and group 2 (22.8%) was observed (p<0.001). Significant reduction of systolic and diastolic blood pressure (16.4% and 25% respectively), serum cholesterol, triglycerides and low density lipoprotein was also noted in both groups (p<0.001), while high density lipoprotein increased by ∼8 mg% in both groups. Thus omega-3 fatty acid substituion in low dose along-with curtailment of dietary omega-6 fatty acid may be used as an adjunctive measure in the management of essential hypertension.

A comparative evaluation of C-reactive protein as a short-term prognostic marker in severe unstable angina--a preliminary study.

OBJECTIVE: The present study was done to evaluate the short-term prognostic significance of C-reactive protein (CRP) in unstable angina (UA) and to compare it with other known prognostic markers of UA, as there is a paucity of data from our country. METHODOLOGY: This prospective study comprised of 44 UA patients (Braunwald Class II A, B) with age < 65 years, along with 40 age and sex matched healthy controls. Patients with h/o myocardial infarction (MI) in the preceding 1-month and evidence of infection, inflammation or neoplasm were excluded from the study. Complete clinical evaluation was done and presence of any prognostic variables of UA was noted (including Brauriwald high-risk variables). Apart from biochemical investigations and ECG, CRP was measured at the time of admission in the study group and controls using Microwell ELISA assay. Standard treatment protocol was followed for all patients and they were closely monitored during hospital stay and subsequently for 4 weeks for occurrence of any adverse cardiac events. RESULTS: There was a statistically significant difference in the mean level of CRP between study group (6.12 +/- 6.134 mg/L) and controls (1.52 +/- 0.751 mg/L); p = 0.000. Among the 44 patients, 19 (43%) experienced any one or more outcome measures. Of the three variables (i.e. ongoing chest pain, ST depression > or = 1 mm and CRP > or = 4 mg/L) which showed statistical significance on univariate analysis with respect to adverse outcome measures (p = 0.001, 0.027 and 0.000 respectively), only CRP > or = 4 mg/L and ST depression > or = 1 mm showed independent prognostic significance on multiple logistic regression analysis (p = 0.000 and 0.002 respectively). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and relative risk (RR) for CRP > or = 4 mg/L were 78.9%, 96%, 93.75%, 85.74% and 6.56 (95% CI; 2.62 - 16.4) and that for ST depression > or = 1 mm were 89.47%, 64%, 65.38%, 88.89% and 5.88% (95% CI: 1.54 - 22.38), respectively. Trop T could be done in eight patients only. CONCLUSION: CRP > or = 4 mg/L by ELISA is an independent predictor of adverse cardiac outcome in severe UA in the short-term follow up and, hence, is useful for risk stratification of these patients. CRP has a higher specificity, PPV and overall RR for prediction of an outcome than ST segment depression, although it is less sensitive.

Chronic myeloid leukemia presenting with avascular necrosis of femur head.

We report the case of a 15 years girl in whom avascular necrosis (AVN) of right femur head was the presenting feature of chronic stable phase of chronic myeloid leukemia (CML). To date, only three case of CML with AVN have been reported. So, in view of rarity of this condition, a similar case of CML presenting as AVN of femur head is being reported.

Effects of low-dose omega-3 fatty acid substitution in type-2 diabetes mellitus with special reference to oxidative stress--a prospective preliminary study.

BACKGROUND: A state of increased oxidative stress has been recognised in type 2 diabetes mellitus (DM). The present study was done to assess the effects of low dose omega-3 fatty acids substitution in patients with type 2 DM with special reference to oxidative stress. METHOD: Sixty-five patients with type 2 DM of body mass index (BMI) < 27 kg/m2 and thirty age and sex matched healthy controls were evaluated for blood glucose, blood pressure and lipid profile and oxidative stress was assessed in them by measuring lipid peroxides (LP), diene conjugates (DC) and reduced glutathione (RG) in the serum. Of the 65, 40 motivated patients were randomly divided into two groups--group 1 comprising of fifteen patients prescribed a diabetic diet along with a placebo and group 2 consisting of twenty-five patients on the same diet with the addition of 0.6 g omega-3 fatty acids as one capsule Maxigard (containing 180 mg eicosapentaenoic acid and 120 mg docosahexaenoic acid) twice daily. All parameters were reassessed after six weeks. RESULTS: The levels of lipid peroxides (micromol/L), diene conjugates (OD units) and reduced glutathione (mmol GSH/L) were significantly altered indicating increased oxidative stress in the diabetics compared to the healthy controls: 4.106 +/- 0.889, 2.751 +/- 0.424, 1.344 +/- 0.316 and 1.91 +/- 0.541, 1.735 +/- 0.315, 1.919 +/- 0.310, respectively (p < 0.001 for all the three). Patients in group 1 and 2 were comparable in all respects including oxidative stress at the start of therapy. After six weeks, on comparing the mean % changes in the three parameters of oxidative stress between the two groups, it was seen that the % change was significantly higher in group 2 (Maxigard group) compared to group 1 (Placebo; 5.22 +/- 1.056 (p = 0.05), 3.28 +/- 0.608 (p = 0.01), 5.27 +/- 0.585 (p < 0.001) and 0.82 +/- 0.123, 0.18 +/- 0.017, 0.56 +/- 0.035 (p < 0.001), respectively. The patients in group 2 also exhibited significantly greater improvement in glycemic status, blood pressure and lipid profiles. CONCLUSIONS: The present study documented the existence of a state of increased oxidative stress in type 2 diabetics. Significant beneficial effects of low dose omega-3 fatty acids substitution for PUFA-6 were observed not only on oxidative stress parameters but also on blood pressure and metabolic profile.

Reversible posterior leukoencephalopathy syndrome: a report of 2 cases.

Reversible posterior leukoencephalopathy syndrome (RPLE) is an increasingly recognised disorder, most commonly associated with malignant hypertension, toxaemia of pregnancy or the use of immunosuppressive agents. Two cases of RPLE syndrome occurring in the setting of accelerated hypertension and eclampsia are described. Both patients had seizures, altered sensorium and typical findings on neuroimaging. They had complete clinical and radiological recovery. The clinical course, pathophysiology and neuroimaging features of RPLE syndrome are discussed.

The association of antiphospholipid antibodies with ischaemic stroke and myocardial infarction in young and their correlation: a preliminary study.

AIM: The possible etiological role of antiphospholipid antibodies (APA) in thrombotic events on arterial side has become subject of interest. The present study was undertaken to determine the association and possible etiological role of APA in young Indian patients with acute ischaemic stroke and myocardial infarction (MI). MATERIAL AND METHODS: Forty six patients < 40 years of age including 22 with ischaemic stroke (excluding those with rheumatic heart disease and SLE), 24 with an acute MI and 21 age and sex matched healthy controls were enrolled in the study. All the patients and the controls were tested for the presence of lupus anticoagulant (LA) by a lupus sensitive activated partial thromboplastin time (APTT) and kaolin clotting time (KCT) and anti-caridiolipin antibodies (aCL) of IgM and IgG types using an ELISA technique. RESULTS: The screening tests for LA with APTT and KCT were negative in all the patients and the normal controls. In the stroke subgroup 18.18% patients (4/22) and in MI subgroup 4.16% (1/24) patients had raised aCL titers with statistically significant association only for stroke subgroup (p=0.0201) and not for MI subgroup. Significantly higher proportion of aCL positive cases were found in patients without any risk factor for atherosclerosis (4/12), compared to patients with one or more risk factor for atherosclerosis (1/34), p=0.001. CONCLUSION: Younger patients without identifiable risk factors for atheroscerosis presenting with stroke, are more likely to have an underlying antiphospholipid syndrome (APLS) as the etiology, and should be screened for it. No such association however was observed for MI patients.

Clinical, hematological and histomorphological profile of myelodysplastic syndrome.

AIM: The present study was designed to analyse clinical, haematological and histomorphogical features in 37 cases of myelodysplasic syndrome (MDS). MATERIAL AND METHODS: FAB criteria was used to diagnose MDS in 37 patients. Clinical details, peripheral blood findings, bone marrow aspirate and biopsy were reviewed. RESULTS: Of 37 cases, there were 25 females and 12 males in age range of 2 years to 75 years. There were three children. There were nine cases of refractory anaemia (RA), 18 of refractory anaemia with excess blasts (RAEB), nine of refractory anaemia with excess blasts in transformation (RAEB-t) and one of chronic myelomonocytic leukemia (CMML). All were denovo MDS. All patients had pallor. Hepato and/or splenomegaly was seen in 15 cases. Anemia, leukopenia and thrombocytopenia was seen in 37, 6 and 23 cases respectively. Bone marrow aspiration (BMA) was hyper to normo cellular in 35 cases. Dyshemopoiesis was seen in one or more cell lines in all cases. Bone marrow biopsy (BMB) was available in 16 cases. Abnormal localisation of immature precursors (ALIP) was seen in 11/12 biopsies of RAEB and 3/4 of RAEB-t. BMB was helpful in diagnosis of 3 doubtful cases (one RAEB and two RAEB-t), and upgrading of 2 cases of RAEB to RAEB-t. On follow up, 1 case of RA, 3 of RAEB, 1 of RAEB-t developed AML. One case of RAEB developed ALL and 2 progressed to RAEB-t. CONCLUSION: Primary MDS is seen in all age groups. Pallor is commonest presentation. RAEB was commonest subgroup seen. BMB is helpful in diagnosis of doubtful cases. ALIP is a reliable diagnostic feature of MDS. BMB is a diagnostic as well as prognostic tool in MDS cases which should be taken as a mandatory investigation.

Myoglobinuria and transient acute renal failure in a patient revealing hypothyroidism.

Muscle involvement in hypothyroidism commonly manifests as fatigue, myalgias, stiffness and slowed reflexes. We report a case of transient acute renal failure related to rhabdomyolysis and myoglobinuria in a 40 year old man that revealed the diagnosis of hypothyroidism with myopathy. The patient had proximal muscle weakness and tenderness, markedly raised muscle enzymes and deranged renal functions that normalised with thyroid replacement therapy. Hypothyroidism, though rare, should be considered a definite and authentic cause of rhabdomyolysis.

Symmetric peripheral gangrene and falciparum malaria--an interesting association.

Symmetric peripheral gangrene (SPG) is a rare syndrome in which disseminated intravascular coagulation (DIC) is the most common underlying condition. We report three cases of SPG in association with Plasmodium falciparum malaria and DIC, an association unreported so far.

Marrow histomorphology and clinical staging of chronic lymphocytic leukemia--a rare disease in India: experience with 26 cases.

Chronic Lymphocytic Leukemia is a relatively uncommon hemopoietic malignancy in the Indian subcontinent. We have made an attempt to correlate the morphology of the marrow with staging and clinical course of the disease in 26 cases. Four out of 6 cases in Stage A showed a nodular/interstitial marrow pattern, while 18 out of 20 cases of stage B and C demonstrated a mixed/diffuse involvement of marrow. Cases showing a nodular/interstitial pattern had a relatively benign clinical course even without chemotherapy, while patients with diffuse/mixed marrow pattern required chemotherapy. Trephine histological pattern was found to be a good prognosticator and was useful in segregating cases requiring chemotherapy from those which do not.

A clinico-hematological study of iron deficiency anemia and its correlation with hyperviscosity symptoms in cyanotic congenital heart disease.

The present study was carried out in 33 cases of cyanotic congenital heart disease (CCHD) to determine the prevalence of iron deficiency anemia (IDA) and its correlation to hyperviscosity symptoms in terms of hematocrit levels. Furthermore, the study was aimed at assessing the response to low dose iron therapy (60 mg of elemental iron once daily) in relieving symptoms of hyperviscosity. All these cases were evaluated for presence of symptoms of hyperviscosity and later subjected to various hematological & biochemical parameters of iron deficiency anemia including hemoglobin (Hb), pack cell volume (PCV), mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), serum iron, total iron binding capacity respectively. Results showed presence of IDA in 6/33 cases (18.2%) and hyperviscosity symptoms in 10/33 cases (30.3%). Amongst the group with symptoms of hyperviscosity, in the subset having IDA these symptoms were observed at PCV levels of 0.52 L/L to 0.58 L/L in contrast to the subset not deficient in iron where the symptoms occurred at a PCV 0.68 L/L. Relief of symptoms of hyperviscosity was evident with a minimal rise of mean hemoglobin by 2.1 gm/dl. It was concluded that IDA was not an uncommon finding in CCHD cases and that it leads to symptoms of hyperviscosity at a level of PCV much lower than those known to produce these symptoms. Finally low dose iron therapy was found effective in relieving the symptoms of hyperviscosity.

Aortic aneurysm presenting as Budd Chiari syndrome.

Budd Chiari Syndrome is the eponymic designation of symptomatic post sinusoidal venous obstruction, whether or not this is associated with hepatic vein occlusion or vena caval obstruction. Dutta and associates (1) classified the syndrome into two distinct types. Type I involves obstruction to the hepatic veins while Type II pertains to an obstruction in the inferior vena cava above the entry of hepatic veins. We report a case of thoraco-abdominal aortic aneurysm presenting as Type II Budd Chiari Syndrome.

Iron status in patients of rheumatoid arthritis with special reference to serum ferritin levels.

Thirty patients of rheumatoid arthritis comprising 16 classical and 14 definite cases based on the ARA criteria were evaluated in a prospective and controlled study for iron status with special reference to serum ferritin levels. Serum ferritin levels were estimated by RIA technique and marrow iron status was ascertained by semi-quantitative estimation after Pearl's staining of marrow aspirate (G 0-6). Marrow iron stores were found absent to decreased in 17 patients (56.7%), normal in 2 (6.7%) and increased in 11 patients (36.6%). The serum ferritin levels in the iron depleted rheumatoid arthritis patients were significantly lower in comparison to patients with normal to increased marrow iron stores (23.91 +/- 11.45 ug/L vs 69.94 +/- 24.7 ug/L, p less than 0.001). There was a strong positive correlation between serum ferritin levels and marrow iron stores (r = +0.08, p less than 0.001). A serum ferritin value of less than or equal to 32 ug/L was a good predictor of decreased iron stores in the bone marrow, with a sensitivity of 88.2% and specificity of 84.5%. The test had a predictive value of 83.33%. There was no correlation between marrow iron stores and conventional indicators or iron status i.e. serum iron, TIBC, transferrin saturation and MCHC. It is concluded that serum ferritin correlates well with marrow iron stores and can be used as a simple non-invasive test for predicting iron-deficiency in patients of rheumatoid arthritis.