Scrub typhus and spotted fever among hospitalised children in South India: Clinical profile and serological epidemiology.

Background: Rickettsial infections are re-emerging. In India, they are now being reported from several areas where they were previously unknown. Objectives: The objective of this study was to describe the epidemiology, clinical profile and outcome of serologically-confirmed scrub typhus and spotted fever among children in a tertiary care hospital in Bengaluru. Materials and Methods: Hospitalised children aged <18 years, with clinical features suggestive of rickettsial disease admitted between January 2010 and October 2012 were included prospectively. Diagnosis was based on scrub typhus and spotted fever-specific IgM and IgG by enzyme-linked immunosorbent assay (ELISA). Results: Of 103 children with clinical features suggestive of rickettsial illness, ELISA test confirmed 53 cases for scrub typhus, 23 cases for spotted fever group and 14 with mixed infection. The average age was 7.3 (±3.9) years and 44 (71.0%) children were male. Majority of cases were from Karnataka (50%), Andhra Pradesh (32.3%) and Tamil Nadu (17.7%). Common clinical features included fever (100%, average duration 11 days), nausea and vomiting (44%), rash (36%); eschar was rare. Compared to the ELISA test, Weil-Felix test (OX-K titre of 1:80) had a sensitivity and specificity of 88.7% and 43.9%, respectively. Treatment with chloramphenicol or doxycycline was given to the majority of the children. Complications included meningoencephalitis (28%), shock (10%), retinal vasculitis (10%) and purpura fulminans (7%). Conclusions: These findings suggest that the burden of rickettsial infection among children in India is high, with a substantially high complication rate. Rickettsial-specific ELISA tests can help in early diagnosis and early institution of appropriate treatment that may prevent life-threatening complications.

Risks of routine iron and folic acid supplementation for young children.

Context: Almost 70% of young children in India are anemic. Current policy recommends routine iron-folic acid (IFA) supplementation to all under 5 children. A potential risk of this approach is an increase in infectious diseases in general, and malaria in particular. Evidence acquisition: An extensive literature search including PubMed, the World Health Organization (WHO) docu-ment library, and the Indian Government database, for documents regarding IFA supplementation in under-5 children. Results: Previously, systematic reviews had suggested adverse effects of IFA supplementation in malaria endemic settings. However, a recent large trial in Tanzania has found clear evidence of increased mortality, chiefly due to malaria, among children receiving routine IFA, whilst a simultaneous study in Nepal (a non-malarious region) found no adverse effects on morbidity or mortality from infectious disease attributable to IFA. These findings have prompted the World Health Organization to revise recommendations regarding IFA supplementation in malaria endemic areas. Conclusions: India has a non-homogenous distribution of malaria endemicity. We propose that although no change to IFA supplementation be made in non-malarious regions, routine IFA should be provided in malarious regions once malaria control and primary health care infrastructure are functioning well.

Melioidosis.

Melioidosis is an emerging infectious disease in India acquired through percutaneous inoculation or contaminated water. Known risk factors include diabetes mellitus, renal failure, cirrhosis, and malignancy. Melioidosis presents with a febrile illness, with protean manifestations ranging from septicemia to localized abscess formation. We present the case of a 42-year-old male from a non-endemic region who presented with fever of 2 months duration, sepsis, persistent pneumonia, right hip joint pain and hepatic and splenic abscesses. Aspiration of the joint and soft tissue fluid collection and subsequent culture yielded gram negative bacilli identified as Burkholderia pseudomallei. The epidemiology, clinical features, and laboratory diagnosis of this rare infection and its treatment is reviewed.

Valvular dysfunction in uraemia.

Regurgitation of the pulmonary, mitral, tricuspid and aortic valves have been observed frequently in chronic renal failure (CRF) and dialysis patients. Two dimensional, M mode and doppler echocardiography were performed on 35 CRF patients and 37 end stage renal failure (ESRD) patients on maintenance haemodialysis. Though structurally normal, valvular dysfunction was noted in 50 per cent of the patients with renal failure. Mitral regurgitation was the commonest abnormality, occurring in 36.1 per cent of the patients. Calcification of the valve was observed in only 5.6 and 16.7 per cent of CRF and dialysis patients respectively. Multiple regression analysis underscored the large contribution of diabetic status in the development of valvular dysfunction. Though end systolic volume was higher in patients with valvular abnormalities, the ejection fraction was well preserved. However, follow up studies are required to assess the significance of the functional valvular regurgitation on the cardiac function of the patients.