Scrub typhus diagnosis on acute specimens using serological and molecular assays - a 3-year prospective study.

Scrub typhus (ST) is an underdiagnosed acute febrile illness in the Asia Pacific region with recent reemergence. Clinical diagnosis is difficult, and laboratory confirmation is largely based on serological and molecular tests. However, Weil-Felix test still remains the only test available in much of the rural tropics where a disproportionate number of cases occur. Sensitive and affordable assays are important for broader use and accurate diagnosis. We evaluated the diagnostic capabilities of serological and molecular assays on single acute clinical samples. Out of 1036 cases, 319 were confirmed as ST, and the sensitivities of immunofluorescent assay (IFA), IgM enzyme-linked immunosorbent assay (ELISA), nested polymerase chain reaction (n-PCR) and WFT were 93.4%, 80.3%, 75.2%, and 54.2%, respectively. IgM ELISA + n-PCR combination demonstrated highest degree of agreement (κ = .911) in the absence of IFA. Additionally, 16 cases were detected by n-PCR only. Our study emphasizes the diagnostic challenges in the developing world, importance of molecular tests, and best alternate assays in ST diagnosis.

Therapeutic assessment of chloroquine-primaquine combined regimen in adult cohort of Plasmodium vivax malaria from a tertiary care hospital in southwestern India.

BACKGROUND: Of late there have been accounts of therapeutic failure and chloroquine resistance in Plasmodium vivax malaria especially from Southeast Asian regions. The present study was conducted to assess the therapeutic efficacy of chloroquine-primaquine (CQ-PQ) combined regimen in a cohort of uncomplicated P. vivax mono-infection. METHODS: A tertiary care hospital-based prospective study was conducted among adult cohort with mono-infection P. vivax malaria as per the World Health Organization's protocol of in vivo assessment of anti-malarial therapeutic efficacy. Participants were treated with CQ 25 mg/kg body weight divided over 3 days and PQ 0.25 mg/kg body weight daily for 2 weeks. RESULTS: Of a total of 125 participants recruited, 122 (97.6%) completed day 28 follow up, three (2.4%) participants were lost to follow-up. Eight patients (6.4%) were ascertained to have mixed P. vivax and Plasmodium falciparum infection by nested polymerase chain reaction test. The majority of subjects (56.8%, 71/125) became aparasitaemic on day 2 followed by 35.2% (44/125) on day 3, and 8% (10/125) on day 7, and remained so thereafter. Overall only one therapeutic failure (0.8%, 1/125) occurred on day 3 due to persistence of fever and parasitaemia. CONCLUSIONS: CQ-PQ combined regimen remains outstandingly effective for uncomplicated P. vivax malaria and should be retained as treatment of choice in the study region. One case of treatment failure indicates possible resistance which warrants constant vigilance and periodic surveillance.

Parietal bone osteomyelitis in melioidosis.

We report a case of a 55-year-old man with uncontrolled diabetes who presented with pneumonia. During his hospital stay his clinical status worsened and he had a focal seizure. MRI showed central nervous system involvement and parietal bone osteomyelitis. As the patient's blood culture and endotracheal aspirate grew Burkholderia pseudomallei, melioidosis was diagnosed. He was treated with meropenem after failure to respond to ceftazidime. He gradually improved over a period of 4 weeks and was discharged. Early diagnosis and therapy resulted in improved outcome.

Simultaneous occurrence of internal capsule infarct and cerebellar haemorrhage in a patient with hemiplegia.

A 68-year-old woman with hypertension with no history of cerebrovascular events presented with a left-sided hemiplegia which had developed acutely 2 days ago. She was not on maintenance therapy with antiplatelets or anticoagulants. A CT scan showed acute ischaemic infarction of the right internal capsule and cerebellar haemorrhage. Cardiac evaluation was normal. Doppler ultrasonography of the extracranial carotid and vertebral arteries showed diffuse arteriosclerotic changes, but did not reveal any haemodynamic occlusion. The simultaneous development of dual strokes was considered to be an extension of the same arteriosclerotic process to the intracranial carotid and basilar arteries.

Plasmodium vivax remains responsive to chloroquine with primaquine treatment regimen: a prospective cohort study from tertiary care teaching hospital in southern India.

We conducted this prospective study among 110 symptomatic Plasmodium vivax patients attending the Kasturba Hospital, Manipal, India, in order to evaluate their clinico-laboratory profile during July 2007-July 2009. Complications observed among patients were: anaemia (46.4%; 95% confidence interval [CI], 37.08-55.72%); thrombocytopenia (68.2%; 95% CI, 59.5-76.9%); leucopenia (29.1%; 95% CI, 20.61-37.59%); hyperbilirubinaemia (20%; 95% CI, 12.53-27.47%); non-oliguric renal failure (10.9%; 95% CI, 5.08-16.72%); elevated serum transaminases (33.6%; 95% CI, 24.77-42.43%); hypotension (8.2%; 95% CI, 3.07-13.33%); hepatomegaly (27.3%; 95% CI, 18.97-35.63%); and splenomegaly and jaundice in 12.7% (95% CI, 6.48-18.92%). The 99% chloroquine response and zero mortality observed in this study of vivax malaria are encouraging points for practicing physicians.

An unusual presentation of pulmonary cryptococcosis with co-existing disseminated tuberculosis in an AIDS patient.

Although cryptococcosis with lung involvement is not rare in patients with HIV, it is rarely considered in the differential diagnosis of an abnormal chest roentgenogram. Pulmonary cryptococcosis with concomitant opportunistic infections is frequently seen among AIDS and its association with tuberculosis (TB) has been previously reported. Untreated pulmonary cryptococcosis in immunocompromised hosts usually becomes disseminated and results in considerable mortality despite antifungal therapy. We report a case of cryptococcosis with pulmonary involvement in a patient with coexisting disseminated TB in HIV infection.

Secondary syphilis mimicking cutaneous lymphoma.

Atypical features of secondary syphilis are more common in patients with human immunodeficiency virus infection. We report this case in which the clinical features, serology and response to therapy were clearly suggestive of secondary syphilis but histopathology raised concerns about cutaneous lymphoma. A 30-year-old male presented with history of fever and cough of one month duration. He was seropositive for human immunodeficiency virus infection one year back. He had discrete multiple papular and papulonodular patches all over the body. VDRL and TPHA tests were positive. HIV infection was confirmed by two ELISA tests. Skin biopsy report raised the possibility of lymphomatous infiltration. He was treated with penicillin and responded favourably. He was also instituted antiretroviral therapy later.

Pulmonary nocardiosis presenting with cardiac tamponade and bilateral pleural effusion in a HIV patient.

Nocardiosis induces a high mortality rate in those infected with HIV. It is now being increasingly described in patients with AIDS. Nocardia infection usually involves the lungs. In immunocompromised individuals it tends to disseminate. It mimics pulmonary TB both clinically and radiologically and many a time is wrongly treated with anti-tubercular drugs. Involvement of the pericardium is uncommon, having only been reported infrequently in the past. We describe a patient who presented with a cardiac tamponade and was confirmed as having pulmonary parenchymal and pleural disease.