Neurological Manifestations of Scrub Typhus Infection in Pediatric Patient: A Case Report From Tertiary Care Hospital in Central India.

Scrub typhus is a neglected tropical bacterial disease endemic in central India which can manifest as meningitis/meningoencephalitis in children. It is difficult to diagnose clinically, especially in the absence of eschar or rash. Scrub typhus is seldom considered the differential diagnosis of meningitis in the Indian subcontinent. Appropriate investigations can lead to early detection of infection and initiation of correct antibiotic treatment leading to better patient prognosis even when features of meningitis supervene. Here, we report a pediatric case of scrub typhus meningitis that could be saved due to timely investigations and initiation of appropriate antimicrobial agents.

Chaetomium globosum: Spotting a scarce saprophyte in bacterial-fungal co-infection of the sinuses in a post-COVID-19 patient.

Atypical fungal co-infections in post-COVID-19 patients may have been underreported due to limited diagnostic methods. We present a case of Chaetomium globosum sinusitis in a 55-year-old post-COVID-19 patient with pain in the left side of the face, mimicking rhino-cerebral mucormycosis. CT-paranasal sinuses showed mucosal thickening of left paranasal sinuses, biopsy of which grew a velvety, white colony. It was confirmed as Chaetomium globosum. The patient responded to oral Posaconazole therapy for three months. Prompt identification of atypical fungal agents is critical for appropriate treatment.

The Characteristics of Ocular Findings and the Presence of SARS-CoV-2 in the Tears of Coronavirus Disease 2019 Patients.

Purpose The purpose of the study is to observe the characteristics of ocular manifestations in coronavirus disease 2019 (COVID-19) patients and to analyze the presence of severe acute respiratory syndrome coronavirus 2 ribonucleic acid (SARS-CoV-2 RNA) in the tears of patients with moderate-to-severe COVID-19. Material and methods We conducted this prospective cross-sectional study from February to June 2021 at the All India Institute of Medical Sciences, one of the tertiary eye care centers in Nagpur, India. The study included confirmed COVID-19 patients based on real-time reverse transcription-polymerase chain reaction (RT-PCR) nasopharyngeal swabs, whether or not the patients exhibited ocular symptoms. We recorded detailed information regarding the patients' history, including demographic profile, ocular symptoms, systemic symptoms, and radiologic findings. We collected ocular samples within 48 hours of collecting naso-oropharyngeal samples from the patients' eyes. We used conjunctival swabs to obtain tear samples, which we then placed in viral transport media (VTM) for cold chain transportation to the microbiology department. We performed RT-PCR on the tear samples to detect the presence of the SARS-CoV-2 virus. Result We included 40 patients in the study, with 26 (65%) classified as having moderate COVID-19, six (15%) classified as having severe COVID-19, and the remaining having mild COVID-19. Out of the 40 patients, five (12%) tested positive for SARS-CoV-2 in the tear sample using RT-PCR, seven (17%) exhibited ocular signs and symptoms, and only one tested positive for SARS-CoV-2 in their tears. The ocular manifestations observed in COVID-19 patients included dry eye, conjunctivitis (including conjunctival hyperemia and epiphora), and lid edema. Notably, we detected a positive COVID-19 tear sample in patients both with and without ocular symptoms. Conclusion Limited reports have focused on ocular involvement in patients with COVID-19. However, our study demonstrates the detection of SARS-CoV-2 in conjunctival swabs from confirmed COVID-19 patients, albeit with a lower positivity rate. Despite the low prevalence of the virus found in tears, there is a potential risk of transmission through ocular routes. It is noteworthy that we observed a COVID-19-positive tear sample in patients with and without ocular symptoms. Therefore, it is important to consider the possibility of ocular transmission even in the absence of ocular manifestations. Medical personnel should take careful precautions during ocular examinations of patients diagnosed with COVID-19 to minimize the risk of transmission.

Incidence of COVID-19 infection and its variation with demographic and clinical profile: lessons learned at a COVID-19 RT-PCR laboratory in Nagpur, India.

Introduction. The coronavirus disease 2019 (COVID-19) pandemic emerged as a global health crisis in 2020. The first case in India was reported on 30 January 2020 and the disease spread throughout the country within months. Old persons, immunocompromised patients and persons with co-morbidities, especially of the respiratory system, have a more severe and often fatal outcome to the disease. In this study we have analysed the socio-demographic trend of the COVID-19 outbreak in Nagpur and adjoining districts. Methods. The study was conducted from April to December 2020. Nasopharyngeal and oropharyngeal swabs collected from suspected cases of COVID-19 were tested using reverse-transcription polymerase chain reaction (RT-PCR) at a diagnostic molecular laboratory at a tertiary care hospital in central India. Patient-related data on demographic profile and indication for testing were obtained from laboratory requisition forms. The results of the inconclusive repeat samples were also noted. The data were analysed using SPSS v24.0. Results. A total of 46 898 samples were received from April to December 2020, of which 41 410 were included in the study; 90.6 % of samples belonged to adults and 9.4 % belonged to children. The overall positivity rate in the samples was 19.3 %, although it varied over the period. The yield was significantly high in the elderly age group (25.5 %) and symptomatic patients (22.6 %). On repeat testing of patients whose first test was inconclusive, 17.1% were positive. There was a steady increase of both the number of tests and the rate of positivity in the initial period of the study, followed by a sharp decline. Conclusion. We can conclude that rigorous contact tracing and COVID-appropriate behaviour (wearing a mask, social distancing and hand hygiene) are required to break the chain of transmission. Elderly people are more susceptible to infection and should follow stringent precautions. It is also important to perform repeat testing of those individuals whose tests are inconclusive with fresh samples so that no positive cases are missed. Understanding of demographics is crucial for better management of this crisis and proper allocation of resources.

Symptomatology and Relationship Between Symptoms and Duration Among COVID-19 Patients in a COVID-19 Care Hospital in Central India.

The COVID-19 pandemic has affected the world population across the globe. India has the second largest number of cases and the third largest number of deaths due to COVID-19 in the world. There have been close to 4.4 lakh deaths due to COVID-19 in India alone. The second wave in India has led to devastating consequences, particularly among the young population. The initial clinical symptoms of COVID-19 are similar to all types of viral pneumonia, with varying degrees of severity. The cases' clinical manifestations include fever, nonproductive cough, dyspnea, myalgia, and fatigue. This study was undertaken with the purpose of identifying the relationship between the symptoms and duration in COVID-19-affected patients. The common presenting symptoms were fever (44.5%), sore throat (38.7%), and cough (36.12%). Most of the cases presented with a combination of fever with cough (35%) and fever with sore throat (33%). The duration of symptoms varied from one to 17 days with a mean of 5.75 days. Despite vaccination being started, the risk of the imminent third wave in the country is existential. Mutations in the coronavirus pose a threat to the vulnerable population. It is important to identify the combination of symptoms most predictive of COVID-19 to help guide recommendations for self-isolation, testing, and preventing further spread of the disease. Further studies using these models can yield better results in surveillance and containing this infectious disease.

A comparison of swab types on sample adequacy, suspects comfort and provider preference in COVID-19.

AIM: This study was aimed to compare the virological, suspect reported outcomes and provider preferences during COVID-19 swab taking procedure used for sampling. METHODS: The COVID-19 suspects are subjected to nasopharyngeal (NP) and oropharyngeal (OP) swabs for testing. Two types of swabs (Nylon and Dacron) are used for sample collection. Prospectively each suspect's response is collected and assessed for self-reported comfort level. The provider's experience with each suspect and virological outcomes recorded separately. The sample adequacy was compared based on swab types and demographic characteristics. RESULTS: A total of 1008 COVID-19 suspects were considered for comparison of various outcomes. Dacron and flocked Nylon swab sticks are used for taking 530 and 478 samples, respectively. Suspects who underwent the procedure using Nylon swabs were six times more likely to have pain/discomfort compared to when Dacron swab was used (Adj RR (95% CI: 6.76 (3.53 to 13, p=0.0001))). The providers perceived six times more resistance with the Nylon swabs compared to Dacron Swabs (Adj RR (95% CI: 5.96 (3.88 to 9.14, p=0.0001))). The pediatric population had a higher rate of blood staining in Dacron swab [Dacron 66 (80.5%); Nylon 51 (54.8%) p=0.0001]. The sample adequacy rate and laboratory positivity rate were not significantly different from each other. CONCLUSIONS: Given the comparable virological outcomes, the difference in suspect and providers comfort should drive swab selection based on characteristics of the suspects. The bulbous Nylon swab caused more pain/discomfort in adults compared to Dacron.

Effectiveness of Presumptive Treatment of Acute Febrile Illness With Doxycycline or Azithromycin in Preventing Acute Encephalitis Syndrome in Gorakhpur, India: A Cohort Study.

OBJECTIVE: To estimate effectiveness of presumptive doxycycline or azithromycin treatment in preventing progression of Acute Febrile Illness to Acute Encephalitis Syndrome in Gorakhpur. STUDY DESIGN: Prospective cohort study. STUDY SETTING: Primary healthcare centers and Community healthcare centers of Gorakhpur district, Uttar Pradesh. PARTICIPANTS: Children aged 1 year to less than 15 years with fever of 3 days to less than 15 days duration attending three selected peripheral health facilities in Gorakhpur during August to October, 2018. PROCEDURE: 35 medical officers in three selected Primary Healthcare Centers/Community Healthcare centers were sensitized on the treatment strategy. After sensitization, study participants were enrolled and information about prescription of doxycycline or azithromycin was collected. Participants were telephonically followed-up to know their progression status from AFI to AES. MAIN OUTCOME MEASURE: Incidence of acute encephalitis syndrome among acute failure illness patients who received presumptive doxycycline or azithromycin treatment and those who did not receive this treatment. RESULTS: Of the enrolled 930 AFI patients, 801 (86%) were prescribed doxycycline or azithromycin and 725 (78%) could be telephonically followed-up. Progression to acute encephalitis syndrome was seen in 6 of the 621 patients who received presumptive treatment, and 5 of the 104 who did not receive the treatment. The relative risk of developing acute encephalitis syndrome among acute febrile illness patients who were prescribed presumptive treatment with doxycycline or azithromycin was 0.20 (95% CI: 0.06-0.65). The effectiveness of presumptive treatment with doxycycline or azithromycin strategy was 79.9% (95% CI: 35.4-94). CONCLUSIONS: PDA treatment to children presenting with fever in peripheral health facilities of the study blocks in Gorakhpur during August-November, 2018 had good effectiveness in preventing progression of acute febrile illness to acute encephalitis syndrome.

Exploration of population ecological factors related to the spatial heterogeneity of dengue fever cases diagnosed through a national network of laboratories in India, 2017.

Background & objectives: Dengue virus (DENV) transmission is known to be influenced by the environmental conditions. During 2017, the Viral Research and Diagnostic Laboratories (VRDLs) tested 78,744 suspected dengue fever (DF) patients, of whom, 21,260 were laboratory confirmed. The objectives of the study were to evaluate the hypothesis that spatial heterogeneity existed for DF patients and to identify significant determinants of DENV transmission in various districts across the Indian States during 2017. Methods: Laboratory confirmed DF cases were analysed from 402 districts spread across the Indian States. The determinants for DF transmission included in the model were population density, proportion of population living in rural areas, proportion o f forest cover area to the total geographical area, proportion of persons not able to read and write and who were aged greater than seven years; the climatic variables considered were minimum, maximum and average temperature, precipitation and cumulative rainfall. The spatial heterogeneity was assessed using spatial regression analysis. Results: DF cases showed strong spatial dependency, with Moran's I=4.44 (P <0.001). The robust measure for spatial lag (6.55; P=0.01) was found to be the best model fit for the data set. Minimum temperature and cumulative rainfall were significant predictors. Interpretation & conclusions: A significant increase in the number of dengue cases has occurred when the minimum temperature was 23.0-25.8°C and the cumulative rainfall 118.14-611.64 mm across the Indian districts. Further in-depth investigations incorporating more number of demographic, ecological and socio-economic factors would be needed for robust conclusions.

Space time analysis of dengue fever diagnosed through a network of laboratories in India from 2014-2017.

BACKGROUND & OBJECTIVES: The Department of Health Research and the Indian Council of Medical Research, Government of India, have established Virus Research and Diagnostic Laboratory Network (VRDLN) to strengthen the laboratory capacity in the country for providing timely diagnosis of disease outbreaks. Fifty-one VRDLs were functional as on December 2017 and had reported about dengue fever across Indian states. The objectives of the study were to detect space time clusters and purely temporal clusters of dengue using Kulldorff's SaTScan statistics using patient level information; and to identify regions at greater risk of developing the disease using Kriging technique aggregating at district level. METHODS: A total of 211,432 patients from 51 VRDLs were investigated for IgM antibodies or NS1 antigen against dengue virus during the period from 1 January 2014 to 31 December 2017 and among them 60,096 (28.4%) were found to be positive. Kulldorff's space time analysis was used to identify significant clusters over space and time. Kriging technique was used to interpolate dengue data for areas not physically sampled using the relationship in the spatial arrangement of the data set. Maps obtained using both the methods were overlaid to identify the regions at greater risk of developing the disease. RESULTS: Kulldorff Space time Scan Statistics using the Bernoulli model with monthly precision revealed eight statistically significant clusters (P <0.001) for the time period, 1 January 2014 to 31 December 2017. Eight significant clusters identified were districts of Nagpur, Jhunjhunu, Gadag, Dakshin Kannada, Kancheepuram, Sivaganga, Ernakulam and Malda. The purely temporal clusters occurred during the last quarter of 2015 and 2016. The Kriging technique identified north eastern part of the country (Arunachal Pradesh, Nagaland and Manipur) and Gujarat. INTERPRETATION & CONCLUSION: Dengue fever has spread in all directions in the country. Hence, it is need of the hour to perform an in-depth investigation.

Epidemiology of chikungunya based on laboratory surveillance data-India, 2016-2018.

BACKGROUND: We analysed the laboratory surveillance data generated by the network of virology laboratories from January 2016 to July 2018 to describe the epidemiology of chikungunya in India. METHODS: Suspected patients reporting to virology laboratories are investigated for the presence of immunoglobulin M (IgM) antibodies against chikungunya virus (CHIKV) as evidence of recent infection. We analysed the data to describe the distribution of seropositive individuals by time, place and demographic characteristics. RESULTS: Of the 49 380 sera tested from suspected patients, 20.5% were seropositive. CHIKV IgM positivity was seen throughout the year, with a peak between September and December. The laboratories diagnosed 28 outbreaks of chikungunya during the study period. CONCLUSIONS: Laboratory surveillance data indicate continued transmission of CHIKV in many regions of India.

Epidemiology of dengue fever in India, based on laboratory surveillance data, 2014-2017.

OBJECTIVES: The Indian Council of Medical Research and the Department of Health Research have established a network of Virus Research and Diagnostic Laboratories (VRDL) to strengthen laboratory capacity in India. We analyzed the data generated by the 52 VRDLs during 2014-2017 to describe the epidemiology of dengue fever (DF) in India. METHODS: As per the laboratory protocol, suspected DF patients reporting to various hospitals where VRDLs are located, or samples from suspected DF outbreaks are investigated for the presence of NS1 antigen or IgM antibodies against dengue. The data were analyzed to describe the distribution of DF by time (month and year), place (district and state) and person (age and sex) characteristics. RESULTS: Between 2014-2017, VRDLs investigated 211,432 suspected DF patients, 28.4% of whom were serologically confirmed. The median age of dengue positive patients was 25 years (IQR: 16-36). Dengue positivity was significantly higher among males. The mean monthly dengue positivity ranged from 7.7% to 37%, with higher positivity reported during September and October months. VRDLs provided diagnosis to 190 suspected outbreaks. CONCLUSIONS: The data from the VRDL network indicate dengue was the etiology in one-fourth of AFI cases. Dengue was the second commonest etiology of suspected outbreaks diagnosed by VRDLs.

Epidemiology of Hepatitis A and Hepatitis E Based on Laboratory Surveillance Data-India, 2014-2017.

Hepatitis A and hepatitis E viruses (HAV and HEV) are the most common etiologies of viral hepatitis in India. To better understand the epidemiology of these infections, laboratory surveillance data generated during 2014-2017, by a network of 51 virology laboratories, were analyzed. Among 24,000 patients tested for both HAV and HEV, 3,017 (12.6%) tested positive for HAV, 3,865 (16.1%) for HEV, and 320 (1.3%) for both HAV and HEV. Most (74.6%) HAV patients were aged ≤ 19 years, whereas 76.9% of HEV patients were aged ≥ 20 years. These laboratories diagnosed 12 HAV and 31 HEV clusters, highlighting the need for provision of safe drinking water and improvements in sanitation. Further expansion of the laboratory network and continued surveillance will provide data necessary for informed decision-making regarding introduction of hepatitis-A vaccine into the immunization program.

Analysis of Aminoglycoside Modifying Enzyme Genes Responsible for High-Level Aminoglycoside Resistance among Enterococcal Isolates.

Enzymatic modification results in high-level resistance to aminoglycoside (HLAR), which eliminates the synergistic bactericidal effect of combined exposure to a cell wall-active agent and an aminoglycoside. So aim of the study was to determine prevalence of HLAR enterococcal isolate and to study distribution of aminoglycoside modifying enzyme genes in them. A total of 100 nonrepeat isolates of enterococci from various clinical samples were analyzed. As per Clinical and Laboratory Standards Institute guidelines enterococci were screened for HLAR by Kirby-Bauer disc diffusion method. Minimum inhibitory concentration of all isolates for gentamicin and streptomycin was determined by E-test. Multiplex polymerase chain reaction (PCR) was carried out for HLAR enterococcal isolates to identify aminoglycoside modifying enzymes genes responsible for resistance. 60% isolates were found to be high-level gentamicin resistant (HLGR) whereas 45% isolates were found to be high-level streptomycin resistant (HLSR). By multiplex PCR 80% HLGR isolates carried bifunctional aminoglycoside modifying enzyme gene aac(6')-Ie-aph(2'')-Ia whereas 18 out of 45 high-level streptomycin resistant, that is, 40%, isolates carried aph(3')-IIIa. However, aph(2'')-Ib, aph(2'')-Ic, aph(2'')-Id, and ant(4')-Ia genes which encode other aminoglycosides modifying enzymes were not detected. Bifunctional aminoglycoside modifying enzyme gene aac(6')-Ie-aph(2'')-Ia is the predominant gene responsible for HLAR.

Burden of extensively drug-resistant and pandrug-resistant Gram-negative bacteria at a tertiary-care centre.

The emergence of resistance to multiple antimicrobial agents in Gram-negative bacteria is a significant threat to public health, as it restricts the armamentarium of the clinician against these infections. The aim of this study was to determine the burden of extensively drug-resistant (XDR) and pandrug-resistant (PDR) Gram-negative bacteria at a tertiary-care centre. Antimicrobial susceptibility testing of 1240 clinical isolates of Gram-negative bacteria obtained from various clinical samples during the study period was carried out by the Kirby-Bauer disc diffusion method. Minimum inhibitory concentration of all antibiotics including tigecycline and colistin was determined by Vitek-2 automated susceptibility testing system. Out of 1240 isolates of Gram-negative bacteria, 112 isolates (9%) were resistant to all the antibiotics tested by Kirby-Bauer disc diffusion method. This finding was corroborated by Vitek-2. In addition, Vitek-2 found that 67 isolates were resistant to all antibiotics except tigecycline and colistin. A total of 30 isolates were susceptible to only colistin, and four isolates were susceptible to only tigecycline. It was also found that six isolates (excluding five isolates of Proteus spp.) were resistant to both colistin and tigecycline. Thus, 101 (8.1%) out of 1240 isolates were XDR and 11 isolates (0.9%) were PDR. The findings of this study reveal increased burden of XDR and PDR Gram-negative bacteria in our centre. It also highlights the widespread dissemination of these bacteria in the community. This situation warrants the regular surveillance of antimicrobial resistance of Gram-negative bacteria and implementation of an efficient infection control program.

Multi-drug resistant Acinetobacter ventilator-associated pneumonia.

BACKGROUND: Ventilator-associated pneumonia (VAP) due to a multi-drug resistant (MDR) Acinetobacter is one of the most dreadful complications, which occurs in the critical care setting. AIMS AND OBJECTIVES: To find out the incidence of Acinetobacter infection in VAP cases, to determine various risk factors responsible for acquisition of Acinetobacter infection and to determine the antimicrobial susceptibility pattern of Acinetobacter. MATERIALS AND METHODS: A total of 60 endotracheal aspirate specimens from intubated patients diagnosed clinically and microscopically as VAP were studied bacteriologically. All clinical details and prior exposure to antibiotics were recorded. RESULTS: An incidence of 11.6% of Acinetobacter VAP cases was recorded. Various underlying conditions like head injury, cerebral hemorrhage and chronic obstructive pulmonary disease (COPD) were found to be associated with Acinetobacter VAP. Acinetobacter strains exhibited MDR pattern. CONCLUSION: Strict infection control measures, judicious prescribing of antibiotics, antibiotic resistance surveillance programs and antibiotic cycling should be adopted to control infections due to these bacteria in patients admitted to intensive care units.

Acinetobacter septicemia in neonates admitted to intensive care units.

BACKGROUND: Acinetobacter species are gaining importance as potential pathogens in neonatal septicemia because of their frequent isolation and multidrug resistance. AIMS AND OBJECTIVES: The aim of the present study was to evaluate the role of Acinetobacter spp. as important pathogens in neonatal blood stream infection, to identify the associated risk factors, and to evaluate the drug sensitivity pattern. MATERIALS AND METHODS: Blood samples of infected neonates were studied bacteriologically. Cases of Acinetobacter septicemia were identified. Speciation of Acinetobacter species was done. Various risk factors were identified. The drug-sensitivity test was done. RESULTS: A total of 26 Acinetobacter septicemia cases were identified by blood culture. Acb complex strains predominated. Institutional birth and preterm birth were identified as the most frequent significant risk factors. 11.3% mortality rate was recorded. Acb complex strains exhibited a multi-drug resistant pattern. No carbapenem resistance was observed. CONCLUSION: Acinetobacter should be added to the list of organisms causing severe nosocomial infection in neonatal intensive care units. Continuous bacteriological surveillance, implementation of infection control policies, careful disinfection of intensive care equipment, and rational antibiotic use are required for control of such infections.