Prospective study of opportunistic infections among HIV infected patients in VSS Institute of Medical Science and Research, Burla, Sambalpur, Odisha, India

Background: HIV destroys the CD4+T cells progressively thus making the HIV infected persons susceptible to a number of opportunistic infections (OIs).Methods: The study was conducted in the Medicine Department and ART Centre, VIMSAR. It is a prospective study from July 2016 to September 2017.Results: 86 patients register, detail history, clinical examination and investigation were done and then the data is complying in detail. Most of the patients were male (72%) male female ratio is 2.6:1. The majority of patients presented with fever, weight loss and anorexia seen in more than 73% of the study population.Conclusions: (42%) cases belonged to the CD4+T cell count range of 101-200/µl with aCD4+T cell count of 183/µl, so there is increased chance of hospitalization in patients having CD4+T cell count below 200/µl. The most common OI was tuberculosis (51%) with pleural effusion as its commonest manifestation. The second most common OI was candidiasis (43%) with most cases suffering from oral candidiasis was seen to occur at higher CD4+T cell counts than tuberculosis.

Manifestation and outcome of concurrent malaria and dengue infection.

Objective: Studies on concurrent infection of dengue and malaria are uncommon in India. Therefore, in this study, we compared the clinical features and outcome of concurrent infection with mono-infection of dengue and malaria. Methods: All the patients of fever within 7 days duration were investigated for dengue, malaria and other causes of fever. Patients of concurrent dengue and malaria (Group A) were compared with dengue mono-infection (Group B) and malaria mono-infection (Group C). Biochemical and haematological investigations were done and compared. Results: During the study period 367 patients of dengue were admitted. Concurrent infection of dengue and malaria was found in 27 (7.4%) patients. There were 27 (5.8), 340 (72.5), and 102 (21.7%) patients in Groups A, B, and C respectively. The clinical features of concurrent infection were more like dengue than malaria. Unlike malaria the outcome of concurrent infection is good. Conclusion: Concurrent infection of dengue and malaria is not uncommon. For the diagnosis investigations for both the infections should be carried out routinely.

Delayed gastric emptying time in adult cerebral falciparum malaria.

Objective: We hypothesize that upper gastrointestinal symptoms in cerebral malaria are due to gastric motor dysfunction. But gastric motility studies in cerebral malaria are scarce. Methods: We determined gastric emptying half-time (GET½) of liquid meals quantitatively by radio isotope scintigraphy in 25 patients of cerebral malaria and 10 healthy controls. Results: GET½ was prolonged (46.5 ± 4.8 min) significantly (p <0.001) in patients of cerebral malaria compared to healthy controls (27.6 ± 5.3 min). Conclusion: Cerebral malaria can cause prolongation of gastric emptying time of liquid foods.

The malaria severity score: A method for severity assessment and risk prediction of hospital mortality for falciparum malaria in adults.

Back ground: There is paucity of research to quantify the severity and to predict the mortality risk of severe falciparum malaria even if it affects multiple organ systems during the course of the disease. Therefore, the aim of the present study is to develop a severity score for assessment of disease severity and risk prediction in adult patients of severe falciparum malaria on the first day of hospitalisation. Methods: A cohort of 2598 patients of falciparum malaria were enrolled in this study of which 2089 patients were included as developmental sample and 509 patients as validation sample. Physiological variables were analyzed for defining and assessment of severity of organ dysfunction (OD). The severity level and corresponding severity score for each organ dysfunction were determined by logistic regression analysis that took both the relative severity among the organ systems and the degree of severity within an organ system into account. Risk of mortality has been calculated for each score. Results: Physiological variables defined dysfunction in 7 organ systems with 3 levels of severity (I to III). Neurologic and renal dysfunction had 3 levels of severity. Hematologic, cardiovascular, and respiratory dysfunction had 2 levels of severity where as hepatic and metabolic dysfunction had 1 level of severity. 1,3, and 5 points were assigned to level I,II, and III severity of organ dysfunction respectively. Malaria without any abnormal physiological variables had been considered as no organ failure and assigned 0 score. The cumulative scores in a patient is known as malaria severity score (MSS) that ranged from 0 to 21. Risk of mortality had been calculated for each score. Conclusion: This prospective study provides an objective tool for assessing severity levels for organ dysfunction and prediction of risk of mortality in severe falciparum malaria which can be used for treatment and research. It has been observed that no two patients of falciparum malaria are same in severity. The severity varies over time and malaria can affect single or multiple organs with different levels of severity which can be quantified as level I, II, and III. Neurologic and renal dysfunction were the most severe with level III severity, followed by haematologic, cardiovascular, and respiratory dysfunction with level-II severity, as well as hepatic and metabolic dysfunction the least severe with level-I severity. Patient of malaria can be stratified as low, intermediate, and high risk depending on the MSS. With the help of MSS daily risk estimates and recovery time of OD can be determined. ©

The natural history of complicated falciparum malaria--a prospective study.

OBJECTIVE: Despite a substantial disease burden, little is known about the natural history of complicated falciparum malaria. Therefore, the present prospective study was undertaken to assess the clinical course, outcome, and resolution time of various complications of falciparum malaria. METHODS: This prospective study has been conducted in a tertiary health care institution with high prevalence of malaria. A cohort of 608 patients of complicated falciparum malaria with single and multiple complications were enrolled. After discharge, all patients were followed up for 1 month except patients with anaemia who were followed up for 3 months. The onset time, interval of progression of one complication to other, resolution time of complications and mortality were determined. RESULTS: At the time of admission there were 288 (46.8%) patients with single complication (SC) and 320 (53.2%) patients with multiple complications (MC). Majority (n=214, 74.3%) of patients with SC had cerebral malaria, followed by jaundice (14.6%), anaemia (6.9%), hypoglycaemia (2.1%), and respiratory distress (2.1%). The multiple complications were found in various combinations and majority (n=136, 42.5%) had constellation of 3 different complications. Cerebral malaria, jaundice, and renal failure (102 of 136, 75.3%) were the most common combination. Regardless of number of complications, cerebral malaria was present in 91.6% (293 of 320) patients with MC. As the population of patients progressed from single to multiple complications, increasing proportions had jaundice, renal failure, and anaemia. 12.8% to 36.2% of patients in any category progressed from one complication to other complication within 72 hrs. There mortality rate was 14.6%, 21.3%, 30.9%, 38.5%, 100%, and 100% among patients with 1, 2 , 3, 4, 5, and 6 complications respectively. CONCLUSION: This is the first prospective study that provides the clinical evidence that complicated malaria represents a hierarchical continuum of abnormalities resulting from malaria infection. All complications developed within 5 days (median 72 hrs, range-2 to l20 hrs.) of onset of fever. Pre-pernicious stage had been recognised in cases of cerebral malaria. Each complication is unique in its onset and recovery time. Not only the number but also the type of complication influences the outcome of complicated malaria.

Type 1 diabetes mellitus in homozygous sickle cell anaemia.

For reasons unknown, the association of diabetes mellitus with sickle cell anaemia is uncommon. A patient of sickle cell anaemia with diabetes mellitus, complicated with ketoacidosis is being reported in view of its rarity.

Pseudobulbar paralysis--a sequelae of cerebral malaria.

Demyelination may be a pathogenic mechanism of post-malarial neurological sequelae. It can cause pseudobulbar palsy, which has not been documented earlier. In the present communication we report two cases of pseudobulbar palsy after cerebral malaria with evidence of demyelination.

Hypohaptoglobinaemia as a biochemical and epidemiological marker of falciparum malaria.

OBJECTIVES: The study was conducted in two parts to find out the usefulness of hypohaptoglobinemia (Hpo) as a biochemical and epidemiological marker of malaria. Part-I study was conducted in a Medical College Hospital to find out Hpo in malaria and the time required for normalization of Hpo. Part-II study was undertaken in two endemic areas of malaria to find out the prevalence of Hpo and haptoglobin index (HI) throughout the year along with other indicators of malaria. METHODS: In Part-I study, 172 patients of malaria constituting 58, 52 and 62 patients of cerebral malaria, uncomplicated falciparum malaria and vivax malaria, respectively were enrolled. Along with routine haematological and biochemical investigations, haptoglobin (Hp) estimation was done by endoplate haptoglobin test kit on admission and at 15 days interval for 3 months. In Part-II study Hp was estimated is 305 subjects in two endemic areas of malaria. HI, parasitic index, slide positivity rate (SPR), slide falciparum rate (SFR) were estimated throughout the year and HI was compared with these epidemiological markers. RESULTS: Hpo was present in 102 (92.7%) cases of falciparum malaria which was significantly more than vivax malaria and non-malarial fever. The normalisation of Hpo took about a month or more. The incidence of Hpo was 32.1% is endemic and 4.7% in nonendemic area of malaria. The HI varied between 12.4 to 25.2% throughout the year and was found to be a better marker than other classical markers of malaria. CONCLUSION: Hypohaptoglobinemia may be considered as a useful indirect indicator of falciparum malaria. HI can be used as an epidemiological maker which is better than classical markers of malaria used at present.

Clinicopathological profile of subacute hepatic failure.

Twenty two patients of subacute hepatic failure (SAHF), diagnosed when jaundice progressed for more than 8 weeks with appearance of ascites, with or without encephalopathy, along with biochemical evidence of hepatocellular damage, were studied. The male and female ratio was 4.5:1 and majority (45.4%) of cases were between the age group of 41-50. The mean biochemical values were: S.bilirubin; 9.2 +/- 3.8 mg/dl SGOT; 94.4 +/- 25.0 I.U./lit., SGPT; 107.8 +/- 32.7 I.U./lit., S.Protein; 5.2 +/- 3.5 secs. Ascitic fluid analysis showed transudate in 16 (72.7%) and exudate in 6 (27.2%) patients. Bacterial peritonitis was found in 5 (22.7%) patients. Liver biopsy showed bridging and submassive necrosis. The complications developed in the hospital were: renal failure (36.3%), infection (27.2%), G.I. bleeding (18.1%) and encephalopathy (13.6%). The mortality was (86.3%). Out of 3 (13.6%) patients who survived, only two recovered completely and one had biochemical evidence of hepatocellular necrosis after 6 months of follow up.