Vector and rodent surveillance for Orientia tsutsugamushi in north India

Background & objectives: Scrub typhus or chigger borne typhus, caused by Orientia tsutsugamushi is an emerging vector-borne disease as large numbers of cases have been reported in various tropical countries. It is transmitted to humans through bites of infected chiggers (larval mites). The knowledge about the vector, its distribution, density and habitat are important so as to understand the epidemiology of scrub typhus in a given area. To control rickettsial infections, regular rodent-vector surveillance should be planned in areas where the disease transmission is occurring and it will also help to strengthen the existing entomological data related to the vector of scrub typhus in northern India. Methods: In the present study, rodent-vector surveillance was planned for one whole year, covering both mite active and non-active seasons (October 2019–December 2020) in selected areas of Chandigarh and Punjab in north India. Rodent tissues and mites were also examined for the presence of O. tsutsugamushi by nested PCR for 56 kDa gene and real-time PCR for 47 kDa outer membrane protein gene. 18S gene PCR was performed for molecular identification of mites. Results: In the surveillance, three types of ectoparasite, viz. mites, fleas and ticks were obtained in rodents. All mites found were of Laelapidae family. None of the pooled rodent tissue samples as well as mite samples were found positive for O. tsutsugamushi by nested PCR for rickettsial DNA. Interpretation & conclusion: In the present study, we did not get any evidence of carriage of O. tsutsugamushi in either mites or rodents collected and sampled in selected regions in Chandigarh and Punjab. We need to strengthen the entomological surveillance over a broader region and increase the frequency of trapping rodents to increase clarity on vector-reservoir dynamics in this geographical region.

Cost of National Vector Borne Disease Control Programme in North India

Background & objectives: Despite significant resources being spent on National Vector Borne Disease Control Programme (NVBDCP), there are meagre published data on health system cost upon its implementation. Hence, the present study estimated the annual and unit cost of different services delivered under NVBDCP in North India. Methodology: Economic cost of implementing NVBDCP was estimated based on data collected from three North Indian States, i.e. Punjab, Haryana and Himachal Pradesh. Multistage stratified random sampling was used for selecting health facilities across each level [i.e. subcentres (SCs), Primary Health Centres (PHCs), community health centres (CHCs) and district malaria office (DMO)] from the selected States. Data on annual consumption of both capital and recurrent resources were assessed from each of the selected facilities following bottom-up costing approach. Capital items (equipment, vehicles and furniture) were annualized over average life span using a discount rate of 3 per cent. The mean annual cost of implementation of NVBDCP was estimated for each level along with unit cost. Results: The mean annual cost of implementing NVBDCP at the level of SC, PHC and CHC and DMO was ? 230,420 (199,523-264,901), 686,962 (482,637-886,313), 1.2 million (0.9-1.5 million) and 9.1 million (4.6-13.5 million), respectively. Per capita cost for the provision of complete package of services under NVBDCP was ? 45 (37-54), 48 (29-73), 10 (6-14) and 47 (31-62) at the level of SC, PHC, CHC and DMO level, respectively. The per capita cost was higher in Himachal Pradesh (HP) at SC [? 69 (52-85)] and CHC [? 20.8 (20.7-20.8)] level and in Punjab at PHC level [? 89 (49-132)] as compared to other States. Interpretation & conclusions: The evidence on cost of NVBDCP can be used to undertake future economic evaluations which could serve as a basis for allocating resources efficiently, policy development as well as future planning for scale up of services.

Atrial Myxoma - An unusual cause of ischemic stroke in young

Atrial myxomas are rare primary cardiac tumours with neurological manifestations being reported in 30% of cases. Though a rare cause of ischemic stroke in young patients, considering it as a possibility in absence of any obvious risk factors can help avoid misdiagnosis at early stages. We present a case of left atrial myxoma in a 36-year-old male with no known co-morbidities, showing an unusual clinical presentation of isolated bilateral painless vision loss. With multiple infarcts on Non Contrast Computerised Tomography (NCCT) and a suspicion of Atrial Myxoma on Transesophageal Echocardiography (TEE), patient was successfully managed surgically with confirmation of diagnosis on histopathology.

Gelatinous transformation of bone marrow: rare or underdiagnosed?

Gelatinous transformation of the bone marrow (GTBM) is a rare hematologic entity, which was first described by Paul Michael in 1930. GTBM is mostly associated with caloric intake/anorexia nervosa, although it also has been described accompanying other pathologic conditions, such as malignancy, systemic lupus erythematosus and HIV infections. Even though the diagnostic features of the hematopoietic tissue, such as hypoplasia, adipose cell atrophy, and deposition of a gelatinous substance in the bone marrow (which stains with Alcian blue at pH 2.5) are quite specific, the underlying pathogenic mechanisms remain poorly understood. Considering the evidence of reversibility­notably in cases of malnutrition and anorexia­this entity should be kept high on cards as a possible differential diagnosis of patients presenting with cytopenias and associated weight loss or starvation, especially in developing countries with nutritionally deprived populations. On an extensive review of the literature aimed at comprehensively addressing the evolution of the GTBM from the past century until now, we conclude that the lack of clinical suspicion and awareness regarding this pathologic entity has led to misdiagnosis and delayed diagnosis.

Black-Tongued Witch – Really?

Black hairy tongue (BHT) also known as Lingua villosa nigra is an acquired, benign condition which is characterized by abnormally hypertrophied and elongated papilliform papillae on the dorsal surface of the tongue. Apart from black; it may also appear brown, yellow, green or blue. BHT typically causes aesthetic concerns to the patient. Gagging, nausea, dysgeusia, xerostomia, burning mouth syndrome and halitosis can be the very rare presenting complaints in some patients. In India, however, black tongue is believed to associate with witches and unfortunate doom spellers. We are reporting a case of olanzapine induced BHT who became a victim of very popular but irrational myth in Indian society.

Relationship between Olfactory Dysfunction and Cognitive Impairment in Elderly Patients with Type 2 Diabetes Mellitus.

Background: Olfactory dysfunctions albeit commonly studied in research study are rarely tested in clinical practice and commonly overlooked in elderly. With ageing, rate of decline in olfactory and cognitive functions increases. Diabetic patients are more prone to develop these olfactory and cognitive dysfunctions. Elderly diabetic patients with olfactory dysfunction were found to have increased incidence of cognitive impairment as compared to patients without olfactory dysfunction. So olfactory function testing can be used as screening tool to detect cognitive impairment at earliest and can halt the progression of cognitive impairment by appropriate measures. Methods: A cross-sectional study done on 200 elderly diabetic patients. Olfactory dysfunctions were detected by open essence test and cognitive testing was done with MMSE. Patients with psychosis, apparent dementia, any nasal disease were excluded. Results: Out of 200 patients total number of patients with MMSE <23, 24-26 and >26 were 19, 51 and 150 with average Open Essence (OE) score 6.05±, 6.74±0.92 and 8.5±0.54 respectively indicating that patients with lower OE score were found to have lower MMSE score. Conclusion: With ageing, olfactory as well as cognitive dysfunction increases. Diabetes accelerates these processes substantially. Olfactory dysfunction precedes the development of cognitive impairment. So elderly patients with diabetes should be screened for olfactory functions so that proper measures could be taken to decrease the incidence or severity of cognitive dysfunction.

Study of Cardiac Manifestations in Patients with HIV Infection and Their Correlation with CD4 Count in Indian Population.

Background: HIV continues to be a major global public health issue. In 2014 an estimated 36.9 million people were living with HIV, a global prevalence of 0.8 %. The clinical spectrum of HIV infection encompasses a spectrum ranging from an acute syndrome associated with primary infection to a prolonged symptomatic state to an advanced cardiac disease in HIV affected patients is becoming more prevalent as therapy and longevity improve Infection HIV is one of the causes of acquired heart disease in these patients. With advances in the management of patients living with HIV and AIDS (PLHA), not only survival has increased but manifestations of late stage HIV infection are encountered more often including cardiovascular complications. Aims and Objectives: To determine the prevalence and characteristics of cardiac manifestations in patients with HIV infection and to evaluate their correlation with CD4 count. Methods: During the period of 1 year from July 2015 to September 2016, total 100 cases of HIV/AIDS were included. The occurrence of cardiac involvement in HIV/AIDS cases was determined based on cardiac enzymes, ECG findings & 2D Echocardiography findings. An attempt was made to correlate various cardiac findings with CD4 T cell count. Results: Male to female ratio was 3:1. Common clinical symptoms were fever (68%), cough (44%) & extertional breathlessness (33%) Echocardiographic abnormalities were seen in 54.3% of patients. Reduced ejection fraction (below 50%) and fractional shortening below 30% were the most common cardiac abnormality (46.3%) followed by pericardial effusion (16.66%), pulmonary artery hypertension (11.11%), dilated cardiomyopathy (9.25%), diastolic dysfunction (9.25%), regional wall motion abnormality (1.85%) and valvular regurgitation (5.55%) respectively. Significant statistical positive correlation was observed between low CD4 count and echocardiographic abnormalities (p < 0.001). Pericardial effusion was seen more in patients with CD4 count below 200 (p < 0.05). Maximum number of echocardiographic abnormalities was seen in WHO clinical stage IV. Conclusion: Echocardiographic abnormalities are more prevalent in HIV/AIDS patients and their prevalence increases as the CD4 count falls andoccur more in advanced stage of the disease. So we should aim at starting ART early in HIV infected patients so as to improve the quality of life of people living with HIV/AIDS.

Pattern of hospital admission and outcome in Parkinson’s disease: A study from Punjab, India

Background: The hospitalization rates of patients with Parkinson’s disease (PD) are 1.45 times higher than for age matched controls. We studied the causes for admission, hospital course and outcomes in PD population so that preventive measures could be developed. Methods: We prospectively studied patients with the diagnosis of PD admitted to a tertiary care hospital in Ludhiana, India from January, 2012 to December, 2014. Etiology for hospitalization was determined and the patients were divided into two groups, admission due to causes related to PD or not associated with PD. The PD related admissions were further categorized into Group I: directly disease related causes and Group II: indirectly disease related causes. The primary outcome was mortality. The secondary outcome measures were duration of hospitalization, requirement for ICU, need for mechanical ventilation and complications. Results: There were 146 patients of PD out of 25,326 hospital admissions. Forty two patients (28.7%) had direct cause, 73(50%) had indirect cause and 31(21.2%) were non-PD related admissions. The mean age was 68.5+9.9 years, 97males (66.7%). There were 16(10.9%) deaths. The commonest cause of admission was infections and encephalopathy. The indirect PD related admission had significantly higher age (p= 0.0014), increased risk of ICU admission (p=0.011), need for mechanical ventilation (p < 0.005) and longer duration of hospital stay (p=0.0001) as compared to group I. Also there was a six fold increased risk of death in this group (p 0.034). Conclusion: As disease progresses, the indirect reasons for admission becomes more troublesome than the initial motor complaints.

Losartan Induced Angioedema – A Case Report.

Angiotensin converting enzyme inhibitors (ACE I) and angiotensin receptor blockers (ARBs) are commonly prescribed as antihypertensive drugs and they also show similar side effects. However ARBs are well tolerated than ACE I with low incidence of side effects. Both these classes of drugs can rarely cause angioedema but it is extremely rare with ARBs. The exact pathogenesis of angioedema with ARBs is not known but it has been postulated to be due to activation of complement system and or other pro inflammatory cytokines like prostaglandins and histamine. We report a case of 30 year old male patient who was taking losartan for control of blood pressure but presented with facial swelling and submandibular edema thus suggestive of losartan induced angioedema.

A case of spontaneously resolved primary congenital glaucoma.

Primary congenital glaucoma usually presents as enlarged and hazy cornea at birth or early childhood. The diagnosis is based on a thorough clinical examination under anesthesia. Most cases require surgical intervention as the definitive treatment. In very rare instances, primary congenital glaucoma may arrest and resolve spontaneously. We describe a case of spontaneously arrested and resolved primary congenital glaucoma in a 37‑year‑old male presenting with large cornea, Haab’s striae, and normal intraocular pressure in one eye. Such a case has not been previously described from the Indian subcontinent.

A Case Report of Visceral Leishmaniasis in Punjab, India.

Leishmaniasis, a vector-borne disease, has been endemic in India since ancient times 1, 2. At present, it is a serious public health problem in Indian subcontinent, especially in state of Bihar. It is caused by obligate intracellular protozoa of the genus Leishmania and is responsible for a broad spectrum of clinical syndromes: Cutaneous lieshmaniasis (CL), Visceral leishmaniasis (VL) and Mucocutaneousleishmaniasis (ML). VL, locally known as kala-azar in India, is the most aggressive form and if undervalued is fatal. Here we describe an imported case of visceral leishmaniasisreported in the State of Punjab which is non-endemic for the disease. The importance of the case lies in the fact that, a case of Visceral Leishmaniasis has been reported after a gap of 4 years in the State.

Pain characteristics in Parkinson’s disease: An Indian experience

Background & Objective: Parkinson’s disease (PD) is a chronic neurological disease, many a times presenting with non-motor symptoms. Pain is one of the most important non-motor symptom and there is no consensus regarding its exact mechanism and characterisation. This study was planned to evaluate the characteristics of pain and possible factors influencing it, in a cohort of patients with established Parkinson’s disease. Methods: 104 patients consenting to participate were included in the study. Data regarding age of onset, duration of disease, treatment, Hoehn-Yahr scale, phenotype of PD, UPDRS scores, pain type and distribution of pain were noted. Single and multiple logistical regression models with pain (1/0) as the outcome variable were used to check the association of pain with the above mentioned variables. Results: 54.8% of patients with PD experience pain. Presence of sensory symptoms was significantly associated with the pain group (42.1%) than the no pain group (21%). Pain was more pronounced on the side with predominant motor symptoms (72%) and in 68.4 % patients pain responded to dopaminergic treatment. Musculoskeletal pain (82.5%) was the commonest type and lower limbs were the commonest site of pain (43.2%). Conclusion: Pain in Parkinson’s disease has multiple dimensions and characteristics. Pain itself may be the reason for early diagnosis. Proper classification of pain will help in improved management of these patients.

Results of intraocular lens implantation with capsular tension ring in subluxated crystalline or cataractous lenses in children.

Purpose: To evaluate the outcome of intraocular lens (IOL) implantation using capsular tension ring (CTR) in subluxated crystalline or cataractous lenses in children. Setting: Tertiary care setting Materials and Methods: We prospectively studied 18 eyes of 15 children with subluxation of crystalline or cataractous lenses between 90° up to 210° after phacoemulsification, CTR and IOL implantation. Each child was examined for IOL centration, zonular dehiscence and posterior capsular opacification (PCO). Results: Age of the patient ranged between five to 15 years. Out of 18 eyes, seven had traumatic and 11 had spontaneous subluxation of crystalline or cataractous lens. Phacoemulsification was successfully performed with CTR implantation in the capsular bag. Intraoperative zonular dialysis occurred in two eyes. Anterior vitrectomy was performed in six eyes to manage vitreous prolapse. IOL implanted was polymethyl methacrylate (PMMA) in eight eyes, hydrophobic acrylic in seven and hydrophilic acrylic in three. Follow-up ranged from 24 months to 72 months. Sixteen eyes had a best corrected visual acuity of 20/40 or better. Nine eyes developed significant PCO and were managed with Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser posterior capsulotomy. One eye with acrylic IOL in the capsular bag had IOL dislocation after two years which was managed with vitrectomy and secondary trans-scleral fixation of IOL. Conclusions: Phacoaspiration with CTR implantation makes capsular bag IOL fixation possible in most of the eyes with subluxated crystalline or cataractous lenses. PCO still remains a challenge in children with successful phacoaspiration with CTR implantation

Scheimpflug imaging of pediatric posterior capsule rupture.

We report a case of an 11-year-old boy who presented two days after blunt trauma to the left eye with a slingshot. On examination his best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/400 in the left eye. Slit-lamp examination of the left eye revealed a Vossius ring, traumatic cataract, traumatic posterior capsule tear (PCT). The contour of the posterior capsule bulge corresponded to the edges of the PCT. Rotating Scheimpflug imaging (Pentacam 70700:Oculus, Wetzlar Germany) confirmed the traumatic cataract in the region of the PCT visualized as increased lens density at the cortex-vitreous interface. The extent of the PCT in the greatest and least dimensions was documented before and after intraocular lens (IOL) implantation. Intra-operatively, the PCT was evident and phaco-emulsification with an IOL implant was performed. Postoperatively, his BCVA improved to 20/20 in the left eye with a well-centered in-the-bag IOL as found on slit-lamp and Scheimpflug images.

Primary intraocular lens implantation in the first two years of life: safety profile and visual results.

PURPOSE: To study the safety profile of primary intraocular lens (IOL) implantation in the first two years of life. MATERIALS AND METHODS: A prospective nonrandomized, interventional study was done at the tertiary care center. Forty-five eyes of 27 children (aged three weeks to two years) with congenital cataract who underwent phacoaspiration with continuous curvilinear capsulorrhexis combined with primary posterior capsulotomy and anterior vitrectomy with in the bag placement of IOL at primary surgery were included. Outcome measures were clarity of visual axis, postoperative inflammation, fixation pattern and retinoscopy. RESULTS: The mean IOL power was 23.95 +/- 0.87 diopter (D) (range 22D to 27D). Follow-up ranged from 12 months to 48 months (mean 18 +/- 9.13 months). In infants, hypermetropia decreased from 6.60D +/- 2.64D at one week postoperatively to 3.03D +/- 2.53D at one year following surgery and 4.78D +/- 1.93D to 2.56D +/- 1.5D in children older than one year at the time of surgery. Re-opacification of the central visual axis was observed in six eyes (13.3%). Significant posterior synechiae due to irido-capsular adhesion was seen in seven eyes (15.6%). Five of these seven eyes also had significant posterior capsular opacification. CONCLUSIONS: Meticulously performed primary IOL implantation and primary posterior capsulorrhexis with anterior vitrectomy in the first two years of life is a safe and effective method of aphakic correction.