Is cerebrospinal fluid lactate useful in differentiating scrub typhus meningitis from aseptic, bacterial and tuberculous meningitis?

Scrub typhus is one of the most common causes of meningo-encephalitis in endemic areas of the Indian subcontinent. Numerous studies have established the reliability of cerebrospinal fluid lactate for differentiation of bacterial meningitis from aseptic meningitis. However, there are no reported data on the predictive value of cerebrospinal fluid lactate in scrub typhus meningitis. We thus conducted a cross-sectional study to examine the diagnostic accuracy of cerebrospinal fluid lactate in the differentiation of different causes of acute meningitis. Over two years, we studied 119 patients, with almost equal gender distribution, whose mean age was 43.58 (±18) years and their overall mean duration of fever was 11.7 (±21.0) days. Commonest clinical features overall were neck stiffness; values of cerebrospinal fluid lactate were lowest in aseptic meningitis, followed by scrub typhus, TB and bacterial meningitis. We conclude that cerebrospinal fluid lactate levels may be a useful adjunct to clinical features and laboratory investigations to differentiate between bacterial, viral, tubercular and scrub meningitis.

Clinical Score to Differentiate Scrub Typhus and Dengue: A Tool to Differentiate Scrub Typhus and Dengue.

BACKGROUND: Dengue and scrub typhus share similar clinical and epidemiological features, and are difficult to differentiate at initial presentation. Many places are endemic to both these infections where they comprise the majority of acute undifferentiated febrile illnesses. MATERIALS AND METHODS: We aimed to develop a score that can differentiate scrub typhus from dengue. In this cross-sectional study, 188 cases of scrub typhus and 201 cases of dengue infection who presented to the emergency department or medicine outpatient clinic from September 2012 to April 2013 were included. Univariate followed by multivariate logistic regression analysis was performed to identify clinical features and laboratory results that were significantly different between the two groups. Each variable was assigned scores based on the strength of association and receiver operating characteristics area under the curve (ROC-AUC) was generated and compared. Six scoring models were explored to ascertain the model with the best fit. RESULTS: Model 2 was developed using the following six variables: oxygen saturation (>90%, ≤90%), total white blood cell count (<4000, 4001-7000 and >7000 cells/cumm), hemoglobin (≤14 and >14 g/dL), total bilirubin (<2 and ≥2 mg/dL), serum glutamic oxaloacetic transaminase (>200 and ≥200 IU/dL), and altered sensorium (present or absent). Each variable was assigned scores based on its strength of association. The AUC-ROC curve (95% confidence interval) for model 2 was 0.84 (0.79-0.89). At the cut off score of 13, the sensitivity and specificity were 85% and 77% respectively, with a higher score favoring dengue. CONCLUSION: In areas of high burden of ST and dengue, model 2 (the "clinical score to differentiate scrub typhus and dengue fever") is a simple and rapid clinical scoring system that may be used to differentiate scrub typhus and dengue at initial presentation.

Acute Undifferentiated Febrile Illness in Patients Presenting to a Tertiary Care Hospital in South India: Clinical Spectrum and Outcome.

BACKGROUND: Acute undifferentiated febrile illness (AUFI) may have similar clinical presentation, and the etiology is varied and region specific. MATERIALS AND METHODS: This prospective observational study was conducted in a tertiary hospital in South India. All adult patients presenting with AUFI of 3-14 days duration were evaluated for etiology, and the differences in presentation and outcome were analyzed. RESULTS: The study cohort included 1258 patients. A microbiological cause was identified in 82.5% of our patients. Scrub typhus was the most common cause of AUFI (35.9%) followed by dengue (30.6%), malaria (10.4%), enteric fever (3.7%), and leptospirosis (0.6%). Both scrub typhus and dengue fever peaked during the monsoon season and the cooler months, whereas no seasonality was observed with enteric fever and malaria. The mean time to presentation was longer in enteric fever (9.9 [4.7] days) and scrub typhus (8.2 [3.2] days). Bleeding manifestations were seen in 7.7% of patients, mostly associated with dengue (14%), scrub typhus (4.2%), and malaria (4.6%). The requirement of supplemental oxygen, invasive ventilation, and inotropes was higher in scrub typhus, leptospirosis, and malaria. The overall mortality rate was 3.3% and was highest with scrub typhus (4.6%) followed by dengue fever (2.3%). Significant clinical predictors of scrub typhus were breathlessness (odds ratio [OR]: 4.96; 95% confidence interval [CI]: 3.38-7.3), total whole blood cell count >10,000 cells/mm3 (OR: 2.31; 95% CI: 1.64-3.24), serum albumin <3.5 g % (OR: 2.32; 95% CI: 1.68-3.2). Overt bleeding manifestations (OR: 2.98; 95% CI: 1.84-4.84), and a platelet count of <150,000 cells/mm3 (OR: 2.09; 95% CI: 1.47-2.98) were independent predictors of dengue fever. CONCLUSION: The similarity in clinical presentation and diversity of etiological agents demonstrates the complexity of diagnosis and treatment of AUFI in South India. The etiological profile will be of use in the development of rational guidelines for control and treatment of AUFI.

Profile of deliberate self-harm patients presenting to Emergency Department: A retrospective study.

BACKGROUND: Deliberate self-harm (DSH) is a major under-recognized epidemic in the low- and middle-income countries. This is a large retrospective study form the Emergency Department (ED) of Tertiary Care Center of South India to describe the clinicodemographic features of DSH cases. MATERIALS AND METHODS: This is a retrospective study conducted at ED of Christian Medical College, Vellore, India from January 01, 2011 to December 31, 2013. All cases of DSH were included in the study. The demographic details, mode of DSH and clinical outcome were extracted from the electronic medical record. Descriptive statistics are presented. Chi-square test was used to compare categorical variables. For all tests, a two-sided P ≤ 0.05 was considered statistically significant. RESULTS: Total of 1228 patients were admitted to ED for DSH during the study period. Male and female occurred in equal ratio. More than half of the cases occurred among age group below 30 years. Consumption of pesticides (agricultural chemicals) was the single most common mode of DSH (46%), especially among men, followed by medication overdose (29.8%). Consumption of plant poison and tablet overdose was higher among women. Overall mortality due to DSH was low (1.5%) in our study. CONCLUSION: DSH is under-recognized major public health problem in low-middle income countries like India. Most cases occur among young and productive age group and in equal frequencies among men and women. Timely and the appropriate institution of treatment can decrease the morbidity and mortality due to DSH remarkably.

Comparative evaluation of validity and cost-benefit analysis of rapid diagnostic test (RDT) kits in diagnosis of dengue infection using composite reference criteria: A cross-sectional study from south India.

BACKGROUND & OBJECTIVES: Rapid diagnostic test (RDT) kits are widely used in India for the diagnosis of dengue infection. It is important to evaluate the validity and reliability of these RDTs. The study was aimed to determine the sensitivity, specificity and predictive value of four commercially available RDTs [Panbio Dengue Duo cassette, Standard Diagnostics (SD) Bioline Dengue Duo, J. Mitra Dengue Day-1 test and Reckon Dengue IgG/IgM] against composite reference criteria (CRC), and compare the cost of the tests. METHODS: In this prospective observational study for diagnostic accuracy, we tested stored blood samples from 132 cases of dengue and 149 controls of other infections as classified based on CRC, with all the four RDTs. The CRC was based on the epidemiological considerations, common clinical features and laboratory abnormalities. The non-dengue controls were the cases of proven alternative diagnosis. The diagnostic performances of the tests were compared in terms of sensitivity, specificity and predictive value along with the cost involved per test. RESULTS: The sensitivity of the Panbio and SD RDT kits was found to be 97.7 and 64.3% respectively, and the specificities were 87.8 and 96.6% respectively. The sensitivity of the NS1 antigen capture by SD Duo, Reckon, J. Mitra RDTs was 20.9, 18.6 and 27.1% respectively. The prevalence of dengue specific IgG antibody with Panbio RDT kits was 49.3%. The cost per test for Panbio, SD, Reckon and J. Mitra is US$ 6.90, 4.27, 3.29 and 3.61 respectively. CONCLUSION: It was concluded that in dengue outbreak, Panbio IgM capture RDT alone is reliable and easily available test which can be used in acute phase of dengue infection in any resource limited set up. NS1 capture rates by any of the other three RDTs might not be reliable for the diagnosis of acute dengue infection.

Leprous neuromyositis: A rare clinical entity and review of the literature.

Mycobacterium leprae, the causative agent of leprosy (Hansen's disease), is a slow growing intracellular acid-fast bacillus that affects the skin, peripheral nerves and respiratory tract. In patients with suppressed cell-mediated immunity, the infiltration of the Bacilli can produce disseminated illness such as leprous neuromyositis. We reported a case of 56-year-old gentleman presenting with pyrexia of unknown origin, asymmetric sensory motor axonal polyneuropathy and was on chronic exogenous steroid therapy. On evaluation, his skin, muscle, nerve and bone marrow biopsy showed numerous globi of acid-fast Bacilli suggestive of leprous neuromyositis, a rare form of disseminated Hansen's disease. We reported this case in view of its rarity, atypical manifestation of a relatively rare disease and literature review on poor electrophysiological correlation in the diagnosis of leprous neuromyositis as compared to the histopathological examination.

A prospective study from south India to compare the severity of malaria caused by Plasmodium vivax, P. falciparum and dual infection.

BACKGROUND & OBJECTIVES: Traditionally, Plasmodium falciparum has been attributed to cause severe malaria, whereas P. vivax is considered to cause "benign" tertian malaria. Recently, there has been an increasing body of evidence challenging this conviction. However, the spectrum and degree of severity of the disease caused by P. vivax, as per World Health Organization (2012) remains unclear. Thus, in this prospective study, we aimed at comparing the severity of malaria caused by P. vivax, P. falciparum and dual infection. METHODS: Adult patients presenting to Christian Medical College, Vellore from October 2012 to September 2013 with microscopically confirmed malaria were included in the study. Their clinical and laboratory parameters were recorded and analyzed. Paired t-test and chi-square with 95% CI and post-hoc analyses using the Scheffι post-hoc criterion were used to assess the statistical significance at the level of α <0.05. RESULTS: In total, 131 cases of malaria were identified during the study period, comprising 83 cases of P. vivax, 35 cases of P. falciparum and 13 cases of mixed vivax and falciparum infections. The spectrum and degree of hematological, hepatic, renal, metabolic, central nervous system complications of vivax malaria was not different from that of falciparum group. Thrombocytopenia and hyperbilirubinemia were the most common laboratory abnormalities identified in all the groups. INTERPRETATION & CONCLUSION: This cross-sectional comparative study clearly demonstrates that clinical features, complications and case-fatality rates in vivax malaria can be as severe as in falciparum malaria. Hence, vivax malaria could not be considered benign; and appropriate preventive strategies along with antimalarial therapies should be adopted for control and elimination of this disease.

Scrub typhus meningitis: An under-recognized cause of aseptic meningitis in India.

BACKGROUND: Central nervous system (CNS) involvement in scrub typhus is seen in up to a quarter of patients. However, the literature on cerebrospinal fluid (CSF) analysis and outcome in meningitis/meningo-encephalitis due to scrub typhus is scant. MATERIALS AND METHODS: This retrospective study included patients who were admitted to a medical college hospital with scrub typhus meningitis/meningo-encephalitis between 2005 and 2011. The clinical and laboratory profile, details of CSF analysis and outcome were documented. RESULTS: The study included 189 patients with meningitis/meningo-encephalitis due to scrub typhus. The mean age of the patients was 41 ± 4 years. The mean duration of fever before presentation was 9.4 ± 3 days. The common presenting complaints were headache (64.2%), nausea/vomiting (60%), altered sensorium (53.7%) and seizures (22.1%). The presence of an eschar was documented in 27.5% of the patients. The mean CSF white blood count was 80 cells/cu mm (range: 5-740). There was a clear lymphocyte predominance (mean 87.6%). The mean CSF protein level was 105 mg% (range: 13-640). The mean CSF sugar level was 63.9 mg% (range 25-350), and was less than 40 mg% in 11.1% of the cases. The case fatality rate was 5.8% (11/189). Univariate analysis showed the presence of an eschar (15.4% vs 2.2%; Odds Ratio [OR]: 8.1) and altered sensorium (9.8% vs 1.1%; OR: 9.2) to be significant predictors of mortality. CONCLUSIONS: In endemic regions, scrub typhus should be considered in the differential diagnosis of aseptic meningitis. Modest elevation of cells in the CSF with lymphocytic pleocytosis and multi-organ involvement may indicate scrub typhus meningitis/meningo-encephalitis.

Clinico-epidemiological Profile of Snake Bites over 6-year Period from a Rural Secondary Care Centre of Northern India: A Descriptive Study.

Estimated deaths due to snake bites are more than 46,000 annually in India. Ninety-seven percent bites occur in rural areas. Data on snake bites from Jharkhand rural area are sparse. This study describes 6 years profile of snake bite patients from January, 2007 to December, 2012 at Nav Jivan Hospital in Palamu district, Jharkhand.

Renal tubular dysfunction associated with tenofovir therapy.

OBJECTIVE: To describe the i ncidence a nd cha racteristics of Tenofovir (TDF) induced nephrotoxicity among people living with HIV AIDS (PLHA) receiving TDF based anti-retroviral therapy (ART) at Christian Medical College, Vellore. METHOD: Medical record review of all the PLHA who is being enrolled and followed up at the ART clinic at CMC, Vellore. RESULTS: From 2006-11, a total of 274 PLHA have been initiated on TDF based ART. 10 (3.6%) patients developed TDF induced renal dysfunction after a mean duration of 42.6 (SD 19.5) months. 5 patients were female. At the time of initiation of TDF, the mean age was 41.2 (SD 6.1) years and CD4 T-cell count was 281.2 (SD 241.3) cells/µL. 9 patients were started on an NNRTI-based regimen, while only 1 was on a Pl/r-based regimen. 5 patients were asymptomatic. Out of the 5 symptomatic patients, 3 patients complained of anorexia and tiredness only; 1 patient had bone pains and proximal pelvic girdle muscle weakness only while 1 patient had both anorexia and proximal pelvic girdle muscle weakness. Urine examination of 8 patients (all symptomatic and 4 asymptomatic patients) revealed proteinuria on urine dip stick assay (1+ to 3+) without active sediments. 9 patients had decline in the estimated creatinine clearance from mean of 84.1 (SD 21.0) to 62.1 (SD 26.3) mL/min/1.73 m2. The mean plasma phosphate level was 2.08 (SD 0.45) mg/ dL. The mean alkaline phosphatase level increased from 130.7 to 290.8 U/L. Seven patients had features of Fanconi syndrome. All symptomatic patients showed clinical improvement within 2-7 months of discontinuation ofTDF and supplementation of phosphate and calcium. CONCLUSION: TDF-associated renal dysfunction has a long incubation period during which the patients are largely asymptomatic and reversible. Hence laboratory confirmation is essential with creatinine clearance, urine examination, and phosphate levels. Prompt change of TDF leads to almost complete resolution of the tubular dysfunction.