Early Clinical Suspicion and Early Use of Doxycycline Reduces Scrub Typhus Associated Complications.

BACKGROUND: Scrub typhus has emerged as an important cause of febrile illness in this Himalayan region of the country. However, it is under considered in the differential diagnoses of febrile illnesses and is not treated and thus, patients often land up with complications in this tertiary care hospital. METHODOLOGY: It was a retrospective observational study done in department of Medicine from august 2013 to October 2013. All the patients more than or equal to 18 yrs of age admitted during this period with scrub typhus were analysed and their outcome followed. S. ELISA was used to detect scrub typhus. RESULTS: Total of 106 patients were observed out of which only 10 patients had received anti scrub antibiotics (doxycycline or azithromycin) prior to admission. Seven patients died (6.6%) and none had received anti scrub antibiotics prior to hospitalisation and presented late with average duration of illness of 9.2 days and had more severe form of complications at presentation.Those patients who had received prior anti scrub treatment had fewer and mild complications and none died among that group. CONCLUSION: Doxycycline or azithromycin (pregnancy or in child <8 years) should be included in the initial empirical antimicrobial therapy in febrile patients during tick season to treat scrub typhus. The goal is to begin anti-scrub therapy early to reduce the morbidity and mortality associated with this illness.

Prevalence of Psychiatric Comorbidity among Patients of Type 2 Diabetes Mellitus in a Hilly State of North India.

BACKGROUND: Psychiatric comorbidity with diabetes mellitus is common. Comorbidity of diabetes and psychiatric disorders can present in different patterns, which are associated with impaired quality of life, increased cost of care, poor treatment adherence, poor glycaemia control and increased emergency room visits. The present study was planned to assess the psychiatric comorbidity in type 2 diabetic patients at tertiary care hospital in a hilly state of North India. OBJECTIVES: To study the prevalence of psychiatric comorbidity among patients of type 2 diabetes mellitus and to study the association between psychiatric comorbidity, sociodemographic and clinical variables in such patients. MATERIALS AND METHODS: A cross-sectional study was conducted after enrolling the eligible diabetic patients attending outpatient department services of medicine department, Indira Gandhi Medical College, Shimla. The Brief Illness Perception Questionnaire was used to assess the cognitive and emotional aspects of illness, Hamilton Depression Rating Scale for assessment of depression, Hamilton Anxiety Rating Scale for assessing severity of anxiety and Mini-International Neuropsychiatric Interview 6.0 for screening all major Axis I disorders. RESULTS: Out of 320 patients of type 2 diabetes mellitus screened, 202 eligible patients were enrolled. Depression was the most common psychiatric comorbid illness present in (41.9%) patients. Depression was slightly higher in female patients and persons aged >50 years. Greater prevalence of depressive episodes was there in people with longer duration of diabetes. CONCLUSION: There were a significant percentage of diabetic patients having psychiatric illnesses. Their attitude towards these comorbidities may be changed by psychiatric counselling at regular intervals.

Epidemiology, clinical profile and role of rapid tests in the diagnosis of acute bacterial meningitis in children (aged 1-59 months).

OBJECTIVES: To study the epidemiology, clinical profile, and the role of rapid tests in the diagnosis of acute bacterial meningitis (ABM) in children (1-59 months). MATERIALS AND METHODS: A total of 250 cerebrospinal fluid (CSF) and 187 blood samples received from clinically suspected cases of ABM were processed based on standard microbiological protocols. CSF samples were also subjected to antigen and nucleic acid detection. Antibiotic susceptibility testing was done according to the Clinical Laboratory Standards Institute guidelines. Children were also evaluated for outcomes and were followed up until 6 months after discharge. RESULTS: Eighty one cases were reported to be having clinically confirmed ABM, out of which group B Streptococcus was the most common pathogen detected in 49.3% (40) patients followed by Streptococcus pneumoniae, Staphylococcus aureus, Hemophilus influenzae type b, Escherichia coli, Klebsiella pneumoniae, and Neisseria meningitidis ACYW135 in 23.4% (19), 7.4% (6), 6.1% (5), 6.1% (5), 6.1% (5), and in 1.2% (1) patients, respectively. Complications were observed in 54.3% of the children. A follow-up of 6 months after discharge was possible in 39.5% (32) patients among whom sequelae were recorded in 93.7% (30) patients. CONCLUSION: ABM remains a major cause of neurological sequelae worldwide. Although culture is the gold standard test for its detection, the investigation takes a longer time and the results are influenced by prior antimicrobial therapy. In such cases, rapid tests aid in the early diagnosis of ABM for instituting appropriate management.

Early Intensified Insulin Therapy in Newly Diagnosed Type 2 Diabetes Leads to Sustained Improvement in Glycemic Control and Improved Beta Cell Function.

AIM: Type 2 diabetes (T2D) is a progressive disease characterized by relentless deterioration of pancreatic ß-cell function. Traditionally, insulin is used in later stages of T2DM. This study looks at use of insulin at time of diagnosis of T2DM and its effect on glycemic control and beta cell function. METHODS: This is a prospective observational study conducted in symptomatic newly diagnosed type 2 diabetes adults (>18 years) who presented with glycated hemoglobin (A1C) levels > 9%. For the initial 8 weeks, patients were treated with pre-mix insulin after which they were changed over to oral agents, and followed up for next three years. RESULTS: Amongst 122 study participants, who completed the study, 50% were female and 90% were from rural areas. Average age of participants was 51.4 ± 9.6 years. Baseline mean fasting plasma glucose (FPG), post prandial plasma glucose (PPPG) and A1C were 267 ± 76 mg/dl, 408 ± 101 mg/dl and 11.5 ± 1.4% respectively. At the end of insulin therapy (8 weeks), the mean FPG, PPG and A1C reduced to 107 ± 10 mg/dl, 145 ± 24 mg/dl and 7.3 ± 0.8% respectively all of which were highly significant. The mean post-prandial C-peptide significantly increased from 1.8± 0.6 to 2.8± 0.9 ng/dl. An average of 1.7 kg weight gain and 0.97 episodes of mild to moderate hypoglycemia were observed. At the end of study (156 weeks), the mean FPG, PPG and A1C were 99 ± 14 mg/dl, 152 ± 12 mg/dl and 6.7 ± 0.4%. CONCLUSION: Early insulin therapy in treatment naïve patients with type 2 diabetes results in rapid improvement of glycaemia thus helps to maintain long term normoglycemia and improves ß-cell function.

Comparison of Safety and Efficacy of Glimepiride-Metformin and Vildagliptin- Metformin Treatment in Newly Diagnosed Type 2 Diabetic Patients.

OBJECTIVES: To compare the safety and efficacy of combination of Glimepiride - Metformin with Vildagliptin - Metformin in type 2 diabetic patients with HbA1c between 7.5to10. METHODS: A randomized, prospective, comparative and interventional study was conducted at Indira Gandhi Medical College, Shimla. The level of hemoglobin A1c (HbA1c), fasting blood sugar (FBS) and postprandial blood sugar (PP) were the primary outcomes, whereas, the evidence of hypoglycemia, quality of life and weight gain were recorded as secondary outcomes. 215 patients newly diagnosed with type 2 diabetes mellitus were randomized into Glimepiride-Metformin group (Group1) having 111 patients and Vildagliptin-Metformin group (Group 2) having 106 patients. Patients were followed up at 3 month, 12 month, 24 month and then after completion of 30 month of treatment. RESULTS: A comparable FPG, PPPG and HbA1c were observed from baseline at the end of 12 weeks in both groups. However, at the 130-week endpoint a significantly more pronounced reduction in HbA1c was observed in vildagliptin-metformin (1.96%) arm compared to Glimepiride-metformin (1.67%) arm. A similar significant more pronounced reduction was demonstrated in both FPG (48.25% vs. 41.70%) and PPPG (49.40% vs. 42.95%) in vildagliptin-metformin group compared to Glimepiride-metformin group. The proportion of patients who achieved an A1C < 7% at 130-weeks was 49% in the vildagliptin group and 41% in the Glimepiride group. Statistically significant more weight gain was observed in Glimepiride arm compared to vildagliptin arm (2.09 kg vs. 0.69 kg) and 8-fold lower incidence was observed in vildagliptin group. Conclusion: Vildagliptin -metformin represent a more effective combination in terms of number of patients achieving guidelines recommended A1C target of less than 7% at the end of 30 months, less weight gain, and a lower risk of hypoglycemia in newly diagnosed type 2 diabetic patients with moderate hypoglycemia. CONCLUSIONS: Vildagliptin -metformin represent a more effective combination in terms of number of patients achieving guidelines recommended A1C target of less than 7% at the end of 30 months, less weight gain, and a lower risk of hypoglycemia in newly diagnosed type 2 diabetic patients with moderate hypoglycemia.

Scrub Typhus - The Most Common Cause of Febrile Jaundice in a Tertiary Care Hospital of Himalayan State.

BACKGROUND: Most common cause of jaundice in south east Asia is of infective etiology. Combination of fever with jaundice can cause diagnostic problem as this duo is present in many infective diseases. Timely diagnosis by simple laboratory investigations can save a lot of time and prevent morbidity and mortality. Our main aim was to determine the most common etiology of infectious jaundice in a tertiary care hospital of Himalayan state and to study their clinical profile. METHODOLOGY: This was a prospective observational study done in one year. All the patients more than 18 years of age presenting with jaundice with bilirubin >1.5mg/dl were taken. The clinical profile was observed and investigations for etiology were done. RESULTS: Total number of patients studied were 170. Maximum number of patients were 50 (39.4%) in age group less than 30 years and females outnumbered males with 1.8:1 ratio (64.7% v/s 35.3%). Fever was the most common presenting complaint in 127 (74.7%) patients and most common etiology was scrub typhus with 103 patients (60.6%) followed by hepatitis E in 36 patients (21.2%) and leptospirosis in 9 patients (5.3%). CONCLUSIONS: Scrub typhus is the commonest cause of febrile jaundice in Himachal Pradesh. The general physicians should be sensitized for the early diagnosis to reduce mortality.

Diabetes Drug Prescription Pattern and Awareness Among Health Care Providers in Sub-Himalayan Region of India: A Population Based Study.

BACKGROUND: To determine the pattern of diabetic drug prescription and awareness about diabetes among primary health providers in the rural areas of Himachal Pradesh situated in the western Himalayas at an elevation range from 350 meters (1,148ft) to 6900 meters (22,966ft) above sea level. METHODS AND MATERIAL: Study was conducted in 20 rural areas of Himachal Pradesh, located 50 to 400 Km from state capital, at 2200 to 10,000 feet altitude. Non-pregnant diabetic adults were surveyed through 31 diabetic camps. Detailed history, weight, height, waist circumference, body mass index recorded. Fasting or random blood glucose, glycated hemoglobin, lipid profile measured and blood pressure recorded. RESULTS: 894 diabetic patients were included in the study (59.83% male) with the mean age of 52.94±6.78 years. Two in three patients were on oral hypoglycemic agents (OHAs), and one in three on alternative approaches for diabetes control. Among OHAs, sulphonylureas (SU) were the most commonly prescribed oral agents in 76.09% of patients followed by metformin in 23.87%. Glibenclamide was the most commonly prescribed SU in 44.60%. Amlodipine and atenolol was the commonest anti-hypertensive drug prescribed in 77.85% either in combination or as individual drug. Only 10.59% were on lipid lowering therapy. For primary care providers glycemic target was the mainstay of diabetes treatment with little emphasis on blood pressure control and no emphasis on lipid reduction. CONCLUSIONS: Sulphonylureas were the commonest anti-diabetic drug prescribed by the primary care providers followed by metformin. Insulin was prescribed to 2.23% only. Combination of amlodipine and atenolol was the commonest anti-hypertensive drugs prescribed and only 10% of patients were prescribed statin.

Prevalence of Cardiovascular Risk Factors among Diabetic Population and Awareness of Diabetes among Diabetic Patients: A Population Based Himalayan Study.

BACKGROUND: To determine the prevalence of modifiable cardiovascular risk factors among adults with diabetes in the remote Himalayan areas, at elevation range from 350 meters (1,148ft) to 6900 meters (22,966ft) above sea level, in the Indian state of Himachal Pradesh. MATERIAL AND METHODS: Study was conducted in 21 rural areas of Himachal Pradesh situated at 2200 to 10,000 feet altitude. Non-pregnant diabetic adults (>18years) were surveyed, through 32 diabetic camps. The date and place of the camp was decided one month in advance and advertised. Detailed history including smoking status, weight, height, waist circumference, body mass index recorded. Fasting or random blood glucose, glycated hemoglobin, lipid profile measured and blood pressure recorded. RESULTS: Total 909 eligible adult diabetics were surveyed (59.73% male) with a mean duration of disease 38.14±4.56 months.35.54% adults were smoker and 67.55% were either overweight or obese 54.04% males and 77.53% females had waist circumference above Indian standards. 78.35% had A1C >7% and 61.50% had blood pressure measurements above target (>140/80mmhg). 56.74% had elevated LDL and only 6.32% had all blood glucose, blood pressure and cholesterol at recommended levels. CONCLUSIONS: High prevalence of modifiable cardiovascular risk factors in addition to uncontrolled blood glucose is widespread, placing diabetics at higher risk for cardiovascular disease. Improved disease management system in addition to public awareness campaign is needed for people with diabetes in this region of the country.

High incidence of abnormal glucose metabolism in acute coronary syndrome patients at a moderate altitude: A sub-Himalayan study.

BACKGROUND: Abnormal glucose metabolic status at admission is an important marker of future cardiovascular events and long-term mortality after acute coronary syndrome (ACS), whether or not they are known diabetics. OBJECTIVE: The aims were to study the prevalence of abnormal glucose metabolism in ACS patients and to compare the different methods of diagnosing diabetes in ACS patients. METHODS: We did a prospective study. About 250 consecutive nondiabetic patients (200 men and 50 women) with ACS admitted to a tertiary care institute of Himachal Pradesh in 1 year were enrolled. Admission plasma glucose, next morning fasting plasma glucose (FPG), A1C, and a standardized 75-g oral glucose tolerance test (OGTT) 72 h after admission were done. Glucose metabolism was categorized as normal glucose metabolism, impaired glucose metabolism (impaired fasting glucose or impaired glucose tolerance [IGT]), and diabetes. Diabetes was arbitrarily classified further as undiagnosed (HBA1c ≥6.5%) or possibly stress diabetes (HBA1c <6.5%). A repeat OGTT after 3 months in objects with IGT and stress hyperglycemia at a time of admission was done. RESULTS: The mean age was 54 ± 12.46 years. The mean plasma glucose at admission was 124 ± 53.96 mg/dL, and the mean FPG was 102 ± 27.07 mg/dL. The mean 2-h postglucose load concentration was 159.5 ± 56.58 mg/dL. At baseline, 95 (38%) had normal glucose metabolism, 95 (38%) had impaired glucose metabolism (IGT and or IGT) and 60 (24%) had diabetes; 48 (19.2%) were undiagnosed diabetes and 12 (4.8%) had stress hyperglycemia. At follow up 58.66% and 55.55% of patients with impaired glucose tolerance and stress hyperglycemia continued to have impaired glucose tolerance respectively. About 75 gm OGTT has highest sensitivity and specificity to diagnose diabetes, whereas A1C most specific to rule out stress hyperglycemia. CONCLUSIONS: In this small hilly state of India, abnormal glucose metabolism (previously undiagnosed diabetes and IGT) is common in patients admitted with ACS. Abnormal glucometabolic status can be detected early in the postadmission period. Our results further suggest that 75-g OGTT remained the gold standard test to detect diabetes and could be used before discharge to diagnose diabetes.

Insulin Myths and Impact of Round-Tree Group Education Programme on Acceptance of Insulin in Persons with Diabetes: A Study from the Himalayas.

BACKGROUND: Insulin is the natural treatment of diabetes mellitus. It is the oldest, most potent and natural therapy of diabetes mellitus; if used timely and in appropriate doses. Most diabetic patients either do not receive it or do not receive it timely. This study was conducted to assess the myths about insulin therapy among type 2 diabetes patients and the impact of open-air discussion on its acceptance in the rural areas of Himachal Pradesh. METHODOLOGY: Study was conducted in 21 rural areas of the state. 909 non-pregnant diabetic adults were surveyed through 32 diabetes camps organized between April 2008 to August 2013. The date and place of camp decided one month in advance. Group education programmes, including 'lectures' and "round tree" discussions conducted. RESULTS: The mean age was 53.94 ± 6.87 years (27-84 years). 49.91 % (279) were eligible for insulin therapy (59.49% male) based on A1C >9 %, and/or >7% despite maximum doses of oral hypoglycemic drugs. Only 7.88% (13males and 9 females) agreed to take insulin at first suggestion. Economic status and educational standard inversely related to the acceptance of insulin. After this educational activity, 34.76% (67 males and 30 females) more patients agreed for insulin therapy, increasing total number to 42.65%. CONCLUSION: This study reveals the myths regarding insulin and suggests that community-based group education programs help increase in acceptance of insulin. Sensitization of local health care providers is necessary to ensure persistence with insulin therapy.

High Prevalence of Hypovitaminosis D in Patients Presenting with Proximal Muscle Weakness: A Sub-Himalayan Study.

BACKGROUND: Hypovitaminosis D has emerged as a major public health problem and 25-50% of patients encountered in clinical practice are deficient in vitamin D. This study was conducted to estimate the prevalence of hypovitaminosis D among patients presenting with proximal muscle weakness. STUDY DESIGN: It was a cross-sectional study done on patients ≥18 years presenting in outdoor clinic from May 2008 to April 2013, with difficulty in standing and going up stairs/ diffuse musculoskeletal pains. Proximal muscle weakness due to other causes were excluded through investigations and those taking steroids and/or indigenous drugs were also excluded. Vitamin D levels measured by radioimmunoassay (RIA) in all eligible patients and individuals included in the study were those with hypovitaminosis D (<30ng/dl) and proximal muscle weakness. Patients reassessed after supplementation with vitamin D at 2 and 6 months. RESULTS: 99 patients with hypovitaminosis D associated proximal myopathy included in study. Of these 55 (55.55%) were males and 44 (44.44%) were females. Age ranged from 22 to 82 years with a mean of 52.84 ± 12.6 years. Of 99 patients, 55 (55.55%) were from the rural area and 44 (44.44%) from urban area. Mean duration of symptoms was 22.7 months (range 6-60 months). The level of 25(OH) Vitamin D ranged from 2.0 ng/dl to 35.7 ng/dl with the mean level of 13.18 ± 5.80 ng/dl (males = 12.76± 4.85ng/dl and females = 13.60±6.70ng/dl). Hypovitaminosis D was present in 98.98%. A direct relationship was found between the vitamin D levels (<10 ng/dl) and severity of weakness. Of 83 patients, who reported at the end of two and six months of treatment, 71 (85.54%) patients were able to stand-up from squatting position. CONCLUSION: Muscle weakness is common among vitamin-D deficient individuals. Our study indicates that more focus should be on muscle symptoms in at risk population groups. The vitamin D deficiency related myopathy should not be missed due to its potential reversibility with vitamin D supplementation.

Sheehan's Syndrome-The Most Common Cause of Panhypopituitarism at Moderate Altitude: A Sub-Himalayan Study.

Background: Panhypopituitarism is a rare disorder with varied clinical presentation having various etiologies. Sheehan's syndrome (SS) is decreasing in frequency worldwide and is a rare cause of panhypopituitarism in developed nations. Methodology: A retrospective study done between May 2011 and May 2015 in tertiary care hospital. We reviewed the records of patients with hypopituitarism. Clinical features, hormonal profile and radiological investigations noted. Results: Total 14 patients of panhypopituitarism included with average duration of symptoms 1.93± 1.96 years. four (28.57%) were males and ten (71.43%) were females with mean age of diagnosis 37.78± 13.68 years. Sheehan's syndrome (SS) was the most common cause of panhypopituitarism in 57.14%(8 patients), followed by post surgery in 14.28% (2 patients). 80% of women had SS with a mean duration of symptoms 2.39±1.54 years. Conclusion: Sheehan's syndrome is not uncommon in developing countries, High degree of clinical suspicion is desired as clinical features are most often subtle.

Cushing's Disease presenting as Suicidal Depression.

A case of Cushing disease, who presented with suicidal depression as the main complaint is reported. Prompt diagnosis and early management of the underlying cause of Cushing's disease, not only relieved features of hypercortisolaemia but also remitted depression fully.

Inducible Clindamycin Resistance among Clinical Isolates of Staphylococcus aureus from Sub Himalayan Region of India.

INTRODUCTION: Clindamycin is an alternative antibiotic in the treatment of Staphylococcus aureus (S.aureus) infections, both in infections by methicillin susceptible and resistant (MSSA and MRSA) strains. The major problem of use of clindamycin for staphylococcal infections is the presence of inducible clindamycin resistance that can lead to treatment failure in such infections. AIM: To determine inducible and constitutive clindamycin resistance among clinical isolates of S. aureus in a tertiary care centre of sub Himalayan region of India. MATERIALS AND METHODS: A total of 350 isolates of S. aureus from various clinical samples were subjected to routine antibiotic sensitivity testing by Kirby Bauer disc diffusion method. Methicillin resistance was detected by cefoxitin (30µg) disc. All isolates were subjected to inducible clindamycin resistance was by Clinical Laboratory Standards Institute (CLSI) recommended D test. RESULTS: Among 350 S.aureus isolates, 82 (23.42%) were MRSA and 268 (76.57%) were MSSA. Erythromycin resistance was detected in 137 (39.14%) isolates. Erythromycin resistance in MRSA and MSSA was 71.6% and 29.36% respectively. Overall clindamycin resistance was seen in 108 (30.85%) isolates. Constitutive MSLB phenotype predominated (29.62% MRSA; 13.38% MSSA) followed by iMLSB (28.39% MRSA; 9.29% MSSA) and MS phenotypes (13.58% MRSA; 6.69%MSSA). Both inducible and constitutive clindamycin resistance was significantly higher (p=0.00001, 0.0008 respectively) in methicillin resistant strains than in methicillin susceptible strains. CONCLUSION: The present study gives a magnitude of clindamycin resistance among clinical isolates of S. aureus from this region of the country. Our study recommends routine testing of inducible clindamycin resistance at individual settings to guide optimum therapy and to avoid treatment failure.

Group B streptococcal meningitis in children beyond the neonatal period in sub-Himalayan India.

OBJECTIVES: To evaluate clinicolaboratory profile and the outcomes in children (1 to 59 months) diagnosed with Group B streptococcus (GBS) meningitis over a period of 1 year. MATERIALS AND METHODS: Cerebrospinal fluid (CSF) samples of 250 pediatric patients (1 to 59 months) admitted with suspected acute bacterial meningitis(ABM)were subjected to cell count, biochemical profile, culture, latex particle agglutination (LPA) and polymerase chain reaction (PCR). They were also evaluated for complications and were followed-up till 6 months after discharge. RESULTS: Forty patients (25 boys and 15 girls), 16% of total suspected cases of ABM were diagnosed with GBS by LPA method and 30 (75%) out of these were above 3 months of age. The median duration of hospital stay was 7 days (range 1 to 72 days). State of coma was observed in two (5%) and one (2.5%) died, while 20 (50%) patients recovered completely. CONCLUSION: GBS should be considered as an important cause of ABM in Indian children beyond the neonatal period and further studies are warranted to determine the actual problem of the disease in our country.

Emergence of travel: Associated dengue fever in a non-endemic, hilly state.

BACKGROUND: We assessed the occurrence of dengue fever in association with travel in a non-endemic hilly region. The clinical presentation and laboratory parameters of febrile patients with a travel history to an endemic region were studied, and the role of the laboratory in the diagnosis was affirmed. MATERIALS AND METHODS: Febrile patients presenting with clinical features defining dengue with a history of travel to an endemic area constituted the study group. Serum samples were tested for dengue-specific NS1 antigen and IgM, IgG antibodies. The demographic data were retrieved from the hospital information system. A hematological and biochemical workup was done and the results analyzed using percentage, proportion, mean, and median. RESULTS: Out of 189 febrile patients, 58 were reactive to serological tests for dengue, with 47 (81%) males. The presenting features were chills and rigors, myalgia, cough, sweating, and vomiting. Thrombocytopenia (74.35%), lymphopenia (52.94%), and leucopenia (47.05%) were present in early disease, with AST >34 IU/L in 58.97% of the patients. The NS1 antigen was detectable between three and seven days of fever and the IgM antibodies after five days. The positivities to only NS1, both NS1 and IgM, and IgM alone were 60.34, 27.58, and 10.34%, respectively, and the median duration of fever was five, seven, and ten days, respectively. One case of dengue hemorrhagic fever and one of probable secondary dengue infection with detectable IgG were encountered. CONCLUSION: Dengue fever remains unsuspected in febrile cases in non-endemic regions. History of travel is an essential criterion to suspect dengue. A non-specific clinical presentation eludes diagnosis. Serological tests for antigen and antibodies, and hematological and biochemical markers are vital for distinguishing the diagnosis.