Comprehensive investigation of fever cases enrolled during 2019 dengue outbreaks from three hyperendemic regions of North 24 Parganas district of West Bengal, India.

For the past several decades, dengue fever has been emerging in epidemic proportions in several regions of the world. During August-September 2019, an increasing number of fever cases were being reported from some areas of North 24 Parganas district of West Bengal, India. Accordingly, outbreak investigation of fever cases from these affected areas of Bongoan, Barasat, and Habra was carried out. To characterize clinical and biochemical features of fever cases as well as to investigate the utility of CRP as a Dengue severity marker in resource-limited settings. We systematically enrolled 108 patients from the affected region of North 24 Parganas. Standard diagnostic assays along with routine serological and biochemical parameters were performed. Of the 108 patients, 77 (71%) were confirmed with Dengue infection followed by 22 (20%) DENV seronegative and 9 (8%) coinfected DENV cases. Among the 77 confirmed Dengue patients, 53 (69%) had primary infection while 24 (31%) had secondary infection. Among the DENV clinical symptoms, fever (r = 0.50; p = 0.004), headache (r = 0.40; p = 0.03) and abdominal pain (r = -0.40; p = 0.02) were found to bear significant correlation with DENV viral load. The predominant circulating serotype was found to be DENV2. CRP Dengue severity cut-off level of 10.15 mg/L (AUC: 0.85; 86% sensitivity, 77% specificity) was obtained. CRP had correlation with viral load (r = 0.4, p = 0.05) within febrile phase of infection. The performance of biomarkers can be influenced by local epidemiology, geography, and several patient factors, therefore, CRP Dengue severity cut-off value may be region-specific. This study for the first time attempts to estimate CRP Dengue severity cut-off value based on routine immunoturbidometric evaluation from Dengue Hyperendemic zones of North 24 Parganas, West Bengal, Eastern India.

Concomitant falciparum malaria and Hyperreactive Malarial Splenomegaly in an adolescent boy from eastern India: A tale of rare coincidences.

Hyperreactive malarial splenomegaly (HMS) is one of the important causes of massive splenomegaly in malaria endemic zones. It is thought to represent a dysfunctional immune response to recurrent malarial infection. It is usually reported due to physical symptoms of splenomegaly and hypersplenism and fever is classically absent. Concomitant malaria with HMS is a very rare finding in the Indian context. Here, we report a case of symptomatic falciparum malaria presented with fever, jaundice, massive splenomegaly and pancytopenia. Persistent massive splenomegaly led us to investigate thoroughly and finally diagnosed it as HMS with concomitant falciparum malaria. He received standard antimalarial treatment and 12 months of weekly chloroquine and completely recovered without any relapse or complications.

Outcome of Adult Malarial Co-infections in Eastern India.

Introduction: Co-infection with different agents such as bacterial, viral, and Rickettsia is being increasingly recognized due to greater availability and utilization of the diagnostic tests among malaria patients. Methods: Consecutive admitted malarial cases were included and were subjected to test for general investigations, bacteria, typhoid, dengue, chikungunya, and rest for specific diagnosis. All patients were followed up till discharge or death and appropriate statistical tests were performed. Results: A total of 152 malaria patients were recruited and 27 (18.8%) had concurrent infections. It included 40.7% dengue only, 18.7% pneumonia, 11.1% urinary tract infection (UTI), 7.4% enteric fever, 3.7% leptospirosis, chikungunya, and tuberculous meningitis each, and 3.7% each of dengue with pneumonia and UTI. The organisms isolated were Streptococcus pneumoniae, Klebsiella pneumoniae, Escherichia coli, Salmonella typhi, and Mycobacterium tuberculosis. The mean duration of fever was 6.33 ± 3.63 days with a range of 3-20 days. Blood culture grew in 2 cases S. typhi and K. pneumonia,e. Dengue co-infections had significantly higher clinical and laboratory features of dengue and complications such as bleeding, jaundice, and cholecystitis, whereas rest concurrent infections had a significantly higher proportion of nausea and vomiting, convulsion, altered sensorium, productive cough, urinary symptoms, shock, acute kidney injury, anemia, and mean neutrophil count. There was significantly higher mortality among malaria-dengue concurrent infection group with 2 (15.4%) than malaria mono-infection group 3 (2.4%). Conclusion: Co-infections with malaria are not uncommon, especially dengue fever and other bacterial infections. The dominant clinical picture is of the superimposed infection. Decision should be clinically guided adjunct with specific diagnostic tests, and timely treatment has favorable outcome.

Pulmonary tuberculosis and pneumocystis jirovecii concurrent pneumonia in HIV infected patients at a resource limited setting in Eastern India: A case series.

Pneumocytis jirovecii pneumonia (PJP) and Pulmonary TB (PTB) both are common opportunistic infections among HIV infected individuals. But concurrent infections pose a diagnostic challenge owing to similar clinical features. Data suggests a high prevalence of such concurrent infections in developing countries but limited diagnostic modalities especially in resource constraint setup limits accurate diagnosis. At our centre we came across 6 newly diagnosed PTB patients among HIV infected ones had persistent shortness of breath (SOB) and hypoxia despite starting anti-tuberculous treatment (ATT). We excluded concomitant bacterial pneumonia by imaging, sputum examination and blood culture. Serum lactate dehydrogenase (LDH) was estimated and hypoxia by arterial blood gas (ABG). We found all 6 patients had elevated serum LDH, hypoxia and imaging suggestive of PJP were offered sputum for Geisma stain and standard treatment for PJP in form of Bactrim-double strength and steroid. 1 patient had PJ cysts in sputum. 5 patient's classical radiologic findings in form of ground glass opacities in lower lobes along with bilateral infiltrates and 1 had honeycombing. Serum LDH was elevated all 6 subjects. 5 were newly diagnosed HIV and 4 had CD4 count below 50 cells/mm3 and 2 had below 200 cells/mm3.1 patient had developed bilateral pneumothorax as complication. 4 patients responded to treatment and 2 (33.3%) died of respiratory failure during treatment. We were able to diagnose only severe PJP cases as concurrent infection with PTB as there was no availability of broncho alveolar lavage (BAL) as well as direct fluorescent antigen (DFA) test for PJ detection. A high index of suspicion for PJP even in PTB patients with low CD4 count will guide to appropriate therapy for both infections and eventually reduces morbidity and mortality.