An evaluation of the clinical features of measles virus infection for diagnosis in children within a limited resources setting.

BACKGROUND: Measles is a recurrent health problem in both advanced and developed countries. The World Health Organization (WHO) recommends anti-measles immunoglobulin M (Ig M) as the standard method of detecting the virus; however, many areas still present the inability to perform a serology test of anti-measles IgM. Therefore, a typical clinical feature is necessary to establish the diagnosis of measles. The objective of this study was to evaluate hyperpigmented rash and other clinical features as the diagnostic tools with respect to measles, especially in an outbreak setting. METHODS: In this observational diagnostic study, the inclusion criteria were as follows: between 6 and 144 months of age, fever, maculopapular rash for 3 days or more, accompanied by a cough, or coryza, or conjunctivitis. Those with a prior history of measles vaccination (1-6 weeks) were excluded, in addition to those with histories of corticosteroid for 2 weeks or more and immunocompromised conditions. The samples were taken from Dr. Soetomo General Academic Hospital in Surabaya, Indonesia. We evaluated the sensitivity, specificity, the positive predictive value, and the negative predictive value of such clinical features. Hyperpigmented rash was validated using Kappa and Mc Nemar tests. Anti-measles Ig M was considered as the gold standard. RESULTS: This study gathered 82 participants. The clinical manifestations of all subjects included fever, cough, coryza, conjunctivitis, Koplik spots, and maculopapular rash (which turns into hyperpigmented rash along the course of the illness). Most maculopapular rashes turn out to be hyperpigmented (89%). Sensitivity, specificity, positive predictive value, and negative predictive values ​​of the combination of fever, maculopapular rash, and hyperpigmented rash were found to be at 90.7, 28.6, 93.2, and 22.2%, respectively. The Mc Nemar and Kappa tests showed p values of 0.774 and 0.119, respectively. CONCLUSION: The combination of fever, maculopapular rash, and hyperpigmented rash can be used as a screening tool regarding measles infection in an outbreak setting, which can then be confirmed by anti-measles Ig M. Cough, coryza, and Koplik's spot can be added to this combination, albeit with a slight reduction of sensitivity value.

First-line antibiotic susceptibility pattern of toxigenic Corynebacterium diphtheriae in Indonesia.

BACKGROUND: Diphtheria has been reported as an outbreak in some regions in Indonesia, most especially in East Java Province. Resistance to penicillin, erythromycin, and other antibiotics, single or multiple, has been reported in several studies. This study aims to evaluate the first-line antibiotic susceptibility pattern of toxigenic Corynebacterium diphtheriae isolates. METHODS: This descriptive observational study was performed from August to November 2018. C. diphtheriae isolates were collected from diphtheria patients and carriers in East Java from 2012 to 2017 and kept at the Balai Besar Laboratorium Kesehatan Daerah Surabaya or the Public Health Laboratory of Surabaya. Sample selection was done by random cluster sampling. The sensitivity test by E-test®of the five antibiotics (penicillin, oxacillin, erythromycin, azithromycin, and clarithromycin) was done to determine the minimum inhibitory concentration (MIC). The Clinical and Laboratory Standards Institute M45A (2015) Corynebacterium spp. for penicillin and erythromycin was used as standard. RESULTS: From 114 targeted isolates, 108 were viable and toxigenic. The E-test was performed on the viable isolates. The majority of the hosts were male (58.3%), with median (range) age of 6.5 (1-14) years. Half of the samples were from the 1 to 5-year-old age group. The isolates were acquired much more from patients (78.7%) than carriers (21.3%) and from pharyngeal swab (74.1%). Most of these isolates were from Madura Island (47.2%) and the northern and eastern parts of the province (horseshoe area). Mitis isolates were the major variant (76.9%). The susceptibility pattern of C. diphtheriae to erythromycin was better than that to penicillin. The E-test result for penicillin was 68.52% susceptible, 31.48% intermediate, and 0% resistant (MIC range, < 0.016 to 2 µg/L) and for erythromycin (MIC range, < 0.016 to > 256 µg/L) was 85.2% susceptible, 12% intermediate, and 2.8% resistant The MIC range for oxacillin was 1 to 96 µg/L, while for both azithromycin and clarithromycin were <  0.016 to > 256 µg/L. CONCLUSION: The susceptibility rate of C. diphtheriae to erythromycin is higher than that to penicillin. The regular update of antibiotic selection to the national guidelines is recommended. The MIC reference standard to azithromycin and clarithromycin is also needed.

Application of revised dengue classification criteria as a severity marker of dengue viral infection in Indonesia.

A prospective study of dengue infected patients at Dr.Soetomo Hospital pediatric ward was carried out from October 2008 to April 2009 to evaluate the revised dengue classification system proposed by the Dengue Control (DENCO), for early detection of severe dengue infected patients using the WHO classification system for comparison, with the addition of clinical interventions as a tool to grade for severity. One hundred forty-five patients were included in the study. Using the WHO classification system, 122 cases (84.1%) were classified as having non-severe dengue, of which 70 (48.3%) were classified as having dengue fever (DF), 39 (26.9%) as having dengue hemorrhagic fever (DHF) grade I, and 13 (9%) as having DHF grade II. Twenty-three (15.9%) were classified as having severe dengue, of which 16 (11%) were classified as having DHF grade III and 7 (4.8%) as having DHF grade IV. With clinical interventions included, 8 cases (6.6%) originally classified as having non-severe dengue infection were reclassified as having severe infection (sensitivity = 74%, specificity = 100%, likelihood ratio (-) = 0.26). Using the new dengue classification system, 117 cases (80.7%) were classified as having non-severe dengue infection, of which 79 (54.5%) were classified as having dengue without warning signs and 38 (26.2%) were classified as having dengue with warning signs, while 28 (19.3%) were classified as having severe dengue infection. Using clinical intervention, 4 cases (3.4%) which were originally classified as having non-severe dengue infection were reclassified as having severe dengue infection (sensitivity = 88%, specificity = 99%, likelihood ratio (+) = 98.88, likelihood ratio (-) = 0.13). Binary logistic regression showed the revised dengue classification system (p = 0.000, Wald:22.446) was better in detecting severe dengue infections than the WHO classification system (p = 0.175, Wald:6.339).

A glance at the von Willebrand factor in dengue virus infection.

To identify the level of von Willebrand factor (vWF) in dengue infection, especially severe DHF, and correlate the increase in vWF with thrombocytopenia, children admitted with dengue fever/DHF were examined for hemoglobin, hematocrit, platelet, and vWF for three consecutive days. Anti-dengue IgM and IgG were determined. Correlations between vWF and thrombocytopenia were analyzed using multivariate analysis. Forty-one patients were eligible for the study; of whom almost three fourths had a secondary infection, as proved serologically. At the beginning of the study, a high level of vWF along with a low platelet count were seen, which seemed to fit the hypothesis that an increase in vWF in the serum will be followed by a decrease in platelets, as a result of the platelet aggregation process in the peripheral blood vessels, predisposed by the immune complex events in DHF. Observations for three consecutive days revealed significant changes of vWF levels (p = 0.000) as well as platelet counts (p = 0.002). However in the context of dengue infections, these changes did not correlate well (p = 0.988). Could there have been a significant correlation if cases were followed for a longer period of time? Being a part of a more comprehensive study, it appeared that in patients with dengue infections, vWF and platelets were not the only factors involved in bleeding, indicating that activation of endothelium is one factor in a multifactorial process.