Molecular confirmation & characterization of Rickettsia conorii in north India: A report of three cases

Background & objectives: In India, spotted fever group rickettsiae (SFGR) are an underdiagnosed cause of acute febrile illness (AFI). The non-specific Weil-Felix test is the first diagnostic modality for the diagnosis of SFGR in many laboratories due to the lack of advanced diagnostic facilities in developing countries. The aim of this study was to detect SFGR using molecular methods in the patients, presenting with AFI in a tertiary care centre in north India. Methods: Consecutive patients (>14 yr of age) with AFI were enrolled over a six month period. Standard investigations for common pathogens causing AFI in India (malaria, dengue, scrub typhus, leptospirosis and enteric fever) were carried out. In patients who were negative for all of the above investigations, blood was subjected to polymerase chain reaction (PCR) targeting outer membrane protein A (ompA) gene of Rickettsia. Results: Of the 51 patients with an undiagnosed aetiology, three were positive by ompA PCR. Two of the PCR products produced good sequences and BLAST identification confirmed them as Rickettsia conorii. The sequences of R. conorii reported from south India clustered with two previously reported novel rickettsial genotypes. The study sequences clustered in a group different from that of Rickettsia spp. of the south Indian sequences reported earlier. Interpretation & conclusions: This study showed the existence of R. conorii in north India. Testing for SFGR may be included in the diagnostic workup of AFI for better disease management.

Use of eschar for the molecular diagnosis and genotypic characterisation of Orientia tsutsugamushi causing scrub typhus

Scrub typhus caused by Orientia tsutsugamushi presents as an acute febrile illness with a varied presentation from mild illness to fatal disease in the absence of appropriate antibiotic treatment. Performing polymerase chain reaction (PCR) on eschar sample acts a rapid diagnostic tool in the early stage of scrub typhus when blood is negative. A total of eight patients from whom both whole blood and eschar samples were collected and tested by nested PCR targeting 56 kDa trichostatin A (TSA) gene to detect O. tsutsugamushi DNA. All (100%) eschar samples and three whole blood samples tested positive. Genetic analysis of the 56 kDa TSA gene sequences showed that the majority were related to Karp reference strains, while one clustered with Kawasaki strain. When present, eschar should be favoured as a diagnostic sample over whole blood in the early phase of infection.

Post‑traumatic endophthalmitis caused by Streptococcus parauberis: First human case report.

A 12‑year‑old boy presented with trauma to left eye with a wooden stick. On examination, there was full thickness corneal laceration with cataractous lens behind the laceration. The laceration was sutured, and intravitreal injections of vancomycin, ceftazidime and clindamycin were administered. Vitreous tap grew Streptococcus parauberis. The isolate was sensitive to amoxicillin, erythromycin and vancomycin, and topical vancomycin was used to treat the infection. We present the first case of human post‑traumatic infective endophthalmitis caused by the rare agent S. parauberis.

Fatal cryptococcosis involving multiple sites in an immunocompetent child.

Disseminated cryptococcosis is less common in immunocompetent individuals. Herein, we report a fatal case of cryptococcosis in apparently immunocompetent child with multiple site involvement. The yeast isolated from cerebrospinal fl uid, blood, endotracheal, gastric and lymph node aspirate was identifi ed by molecular method as Cryptococcus neoformans var. grubii.

Screening Utility, Local Perceptions, and Care-seeking for Reported Jaundeesh among Respondents Lacking Signs of Icterus in Rural Bangladesh.

In rural Bangladesh, acute viral hepatitis presents a significant burden on the public-health system. As part of the formative work for a large epidemiologic study of hepatitis E in rural Bangladesh, we sought to identify local terms that could be used for population-based screening of acute viral hepatitis. Exploration of the local term jaundeesh for screening utility identified a high burden of reported jaundeesh among individuals without symptoms of icterus. Recognizing that local perceptions of illness may differ from biomedical definitions of disease, we also sought to characterize the perceived aetiology, care-seeking patterns, diagnostic symptoms, and treatments for reported jaundeesh in the absence of icteric symptoms to inform future population-based studies on reported morbidities. We conducted a cross-sectional survey among 1,441 randomly-selected subjects to identify the prevalence of reported jaundeesh and to test the validity of this local term to detect signs of icterus. To characterize the perceived aetiology and care-seeking patterns for jaundeesh among the majority of respondents, we conducted in-depth interviews with 100 respondents who self-reported jaundeesh but lacked clinical signs of icterus. To describe diagnostic symptoms and treatments, in-depth interviews were also performed with 25 kabirajs or traditional faith healers commonly visited for jaundeesh. Of the 1,441 randomly-selected participants, one-fourth (n=361) reported jaundeesh, with only a third (n=122) reporting yellow eyes or skin, representative of icterus; Jaundeesh had a positive predictive value of 34% for detection of yellow eyes or skin. Anicteric patients with reported jaundeesh perceived their illnesses to result from humoral imbalances, most commonly treated by amulets, ritual handwashing, and bathing with herbal medicines. Jaundeesh patients primarily sought folk and spiritual remedies from informal care providers, with only 19% visiting allopathic care providers. Although the local term jaundeesh appeared to have limited epidemiologic utility to screen for acute symptomatic viral hepatitis, this term described a syndrome perceived to occur frequently in this population. Future population-based studies conducting surveillance for acute hepatitis should use caution in the use and interpretation of self-reported jaundeesh. Further study of jaundeesh may provide insight into the appropriate public-health response to this syndrome.

Infectious diseases and vaccine sciences: strategic directions.

Despite substantial progress, infectious diseases remain important causes of ill-health and premature deaths in Bangladesh. Bangladesh has experienced a > 90% reduction in the incidence of deaths due to childhood diarrhoea over the last 25 years. Further reductions can be achieved through the introduction of effective vaccines against rotavirus and improvements in home hygiene, quality of drinking-water, and clinical case management, including appropriate use of oral rehydration solution and zinc. Pneumonia is now the leading cause of childhood deaths in Bangladesh, and the pneumonia-specific child mortality is largely unchanged over the last 25 years. Reductions in mortality due to pneumonia can be achieved through the introduction of protein conjugate vaccines against Haemophilus influenza type b and Streptococcus pneumoniae, improvements in case management, including efforts to prevent delays in providing appropriate treatment, and the wider use of zinc. Tuberculosis is responsible for an estimated 70,000 deaths each year in Bangladesh. Although services for directly-observed therapy have expanded markedly, improved case finding and involvement of private practitioners will be important to reduce the burden of disease.

Relationship of uterine artery with ureter.

The study was done to see the relationship of right and left uterine artery with corresponding ureter. Their distance from lateral border of uterus and site of crossing in relation to internal os in Bangladeshi female were observed. Sixty post mortem specimens containing uterus, uterine tube, ureter and surrounding structures were collected from cadavers of different age groups and fixed in 10% formol saline solution. Gross and fine dissections were carried out to study the relationship and distance of uterine artery where it crosses the corresponding ureter and the site of crossing in relation to internal os. In the present study our findings were compared with those of the standard text books. In this study, there were no variations regarding relations of right and left uterine artery with corresponding ureter. In all cases of all age groups, ureters were found to cross the uterine artery anteriorly on both sides. Site of crossing of uterine artery of both sides with ureter at the level of internal os was 50% in 2-12 years (Group A) 20.45% in 13-45 years (Group B) and 12.50% in 46-80 years (Group C) age group. Below the level of the os was found in remaining cases except one which crosses above the level of the os in group B. In this study mean distance of uterine artery where it crosses the ureter from lateral border of uterus was more on right side in all age groups, which was 1.67 cm, 2.30 cm and 2.11 cm in age Group A, B & C respectively.

A population-based study of hospital admission incidence rate and bacterial aetiology of acute lower respiratory infections in children aged less than five years in Bangladesh.

The research was carried out to study the rate of population-based hospital admissions due to acute lower respiratory infections (ALRIs) and bacterial aetiology of ALRIs in children aged less than five years in Bangladesh. A cohort of children aged less than five years in a rural surveillance population in Matlab, Bangladesh, was studied for two years. Cases were children admitted to the Matlab Hospital of ICDDR,B with a diagnosis of severe ALRIs. Bacterial aetiology was determined by blood culture. Antimicrobial resistance patterns of Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (Spn) isolates were determined using the disc-diffusion method. In total, 18,983 children aged less than five years contributed to 24,902 child-years of observation (CYO). The incidence of ALRI-related hospital admissions was 50.2 per 1,000 CYO. The incidences of ALRI were 67% higher in males than in females and were higher in children aged less than two years than in older children. About 34% of the cases received antibiotics prior to hospitalization. Of 840 blood samples cultured, 39.4% grew a bacterial isolate; 11.3% were potential respiratory pathogens, and the rest were considered contaminants. The predominant isolates were Staphylococcus aureus (4.5%). Hib (0.4%) and Spn (0.8%) were rarely isolated; however, resistance of both these pathogens to trimethoprim-sulphamethoxazole was common. The rate of ALRI-related hospitalizations was high. The high rate of contamination, coupled with high background antibiotic use, might have contributed to an underestimation of the burden of Hib and Spn. Future studies should use more sensitive methods and more systematically look for resistance patterns of other pathogens in addition to Hib and Spn.

Zinc therapy for diarrhoea increased the use of oral rehydration therapy and reduced the use of antibiotics in Bangladeshi children.

Excessive use of antibiotics for diarrhoea is a major contributing factor towards increasing rates of antimicrobial resistance in developing countries. Zinc therapy for diarrhoea has been shown to be beneficial in controlled efficacy trials, and it is of interest to determine if availability of zinc syrup for treatment of diarrhoea would satisfy the demand for a 'medicine' for diarrhoea, thus reducing the use of antibiotics, without competing with the use of oral rehydration therapy (ORT). This community-based controlled trial was conducted from November 1998 to October 2000, and all children aged 3-59 months in the study area were included. In this trial, the availability of zinc supplements, along with ORT and appropriate education programmes, was associated with significantly higher use of ORT and lower use of antibiotics.

Acute lower respiratory infections in rural Bangladeshi children: patterns of treatment and identification of barriers.

A study conducted in rural Bangladesh examined the patterns of health seeking behavior, mothers' recognition of symptoms, the perceived causes and barriers to timely treatment of acute lower respiratory infections (ALRI). A total of 194 children under 5 years of age suffering from ALRI in an intensive maternal child health and family planning area was prospectively followed. About 62% of the mothers sought allopathic treatment for their children within 24 hours of case detection. No treatment of any kind was sought in 45 (23.2%) cases. Most of the mothers could recognize the different symptoms of ALRI. Cold was reported as the most common cause of ALRI. No significant difference was observed in the reported symptoms or perceived cause of the disease between those who sought no treatment and those who sought allopathic, homeopathic, spiritual or combined treatments. Failure to recognize severity followed by work loss were the most common reasons identified for not seeking any medical care. Whether or not a mother sought allopathic treatment was not associated with the child's age, sex, mother's age, mother's education, duration of illness, birth order, housing type or distance from the health center. The study indicates the potential value of giving parents clear guidelines on recognition of severity of symptoms of ALRI and motivating them to seek treatment quickly when these symptoms present. Health service providers should be aware of the heavy work loads which rural women have and the severe time constraints which deter them from seeking timely treatment from the appropriate sources.

Study of makeshift hospital during cholera outbreak.

This is a report on the study of utilization pattern of a makeshift hospital during a major cholera outbreak, by analyzing data on dehydration status, distance covered, number of deaths averted, and operation-wise comparison with other permanent facilities. To avoid unnecessary deaths due to dehydration and to ensure prompt and adequate care to suddenly accumulated debilitated patients, the makeshift hospital intervened. Subsequent to the intervention, a gradual reduction in patient admissions and cholera case accumulations was noted. Nearly half the cholera cases attending the makeshift hospital came from relatively far (13 + miles). The reporting of the majority (72%) of cholera patients with none-to-mild dehydration indicates an increased awareness of the need for early treatment during a cholera outbreak. Early attendance of diarrhoeal patients probably saved more patients by preventing shock and complications. Para-professionals given a short training accomplished similar efficacy as in a permanent facility. Nearer the affected areas, a simple but effective temporary facility is more effective than a sophisticated facility which is further away and takes several hours to reach, with risk to patients.