Coagulation Abnormalities in Severe Scrub Typhus and Their Association with Complications

Aim: To describe coagulation abnormalities and their association with complications in patients with severe scrub typhus. Materials and methods: A cohort study was conducted among all patients of severe scrub typhus [immunoglobulin M (IgM) positive] who reported to this facility from 1st August 2019 to 31st July 2020 and met our inclusion criteria. We estimated the incidence of severe thrombocytopenia (<50,000/µL) and overt disseminated intravascular coagulation (DIC) (DIC score of ?5). We determined the association [risk (RR) ratios] of these abnormalities with complications of scrub typhus, namely—septic shock, multiple organ dysfunction syndrome (MODS), and septic shock with MODS. Results: In total, 71 patients were studied with a mean age of 50 ± 15.5 years, of which 45 (63.4%) were females. On presentation, fever 70 (98.5%), myalgias 22 (31.0%), loose stools 13(18.3%), cough, vomiting, headache 11 (15.5%), altered sensorium 10(14.1%), and pain abdomen 9 (12.7%) were main symptoms. On examination, hypotension 31 (43.7%), eschar 25 (35.2%), icterus 17 (23.9%), and rash 16 (22.5%) were noted. The d-dimer (>0.5 µg/mL) levels were increased in all (100%) patients. Thrombocytopenia (91.5%) was the commonest hematological abnormality and 31 (43.6%) of them had severe thrombocytopenia, 25 (35.2%) patients had low fibrinogen levels (<200 mg/dL) and prothrombin time (PT >16.7 seconds) was prolonged in 20 (28.1%). A total of 42 (59.1%) patients developed MODS, 33 (46.4%) developed septic shock, 24 (33.8 %) had MODS with septic shock, 17 (23.9%) developed overt DIC, and eight (11.2%) died. Severe thrombocytopenia (p = ?0.028) and overt DIC (p = 0.045) were significantly associated with septic shock development. Conclusion: In the patients admitted with severe scrub typhus; thrombocytopenia was the commonest hematological abnormality. The development of septic shock was significantly associated with severe thrombocytopenia and overt DIC.

Assessing clinical and molecular outcomes of prophylactic thermal pulsation therapy on ocular surface health following refractive surgery

Purpose: To study ocular surface signs, symptoms, and tear film composition following prophylactic thermal pulsation therapy (TPT) prior to refractive surgery, and to compare these outcomes with those who underwent TPT after refractive surgery. Methods: Patients with mild?to?moderate evaporative dry eye disease (DED) and/or meibomian gland dysfunction (MGD) undergoing refractive surgery were included. Group 1 patients received TPT (LipiFlow) prior to laser?assisted in situ keratomileusis (LASIK; n = 32, 64 eyes), and Group 2 patients received TPT three months after LASIK (n = 27, 52 eyes). Ocular Surface Disease Index (OSDI) score, Schirmer’s test (ST1, ST2), Tear Breakup Time (TBUT), meibography, and tear fluid were obtained preoperatively and at three months postoperatively in Groups 1 and 2. Additional postoperative evaluation was performed three months after TPT in Group 2. Tear soluble factor profile was measured by multiplex enzyme?linked immunosorbent assay (ELISA) using flow cytometry. Results: Postoperative OSDI score was significantly lower and TBUT was significantly higher when compared with matched preoperative values of Group 1 participants. On the other hand, the postoperative OSDI score was significantly higher and TBUT significantly lower when compared with matched preoperative values of Group 2 participants. TPT significantly reduced the postoperative elevation in OSDI and significantly reduced the postoperative reduction in TBUT in Group 2 participants. Tear Matrix metalloproteinase?9/ Tissue inhibitor matrix metalloproteinase 1 (MMP?9/TIMP1) ratio was significantly higher, postoperatively, when compared with matched preoperative levels in Group 2. However, MMP9/TIMP1 ratio remained unaltered in Group 1 participants. Conclusion: TPT prior to refractive surgery improved postsurgical ocular surface signs and symptoms and reduced tear inflammatory factors, thereby suggesting the plausibility of reduced post?refractive surgery DED in patients.

Clinical profile of scrub typhus patients in a tertiary care centre in Himachal Pradesh, India

Background: Scrub typhus a zoonotic disease caused by gram negative bacteria O. tsutsugamushi, is endemic in Himachal Pradesh. This illness occurs mainly in monsoon and post monsoon season. study design of  this study was conducted in a tertiary care centre in Himachal Pradesh between July 2015 and June 2016. All the indoor patients with age above 18 years with a diagnosis of scrub typhus were included in this study.Results: Out of total 180 patients, 130 were female patients. Most patients were in the age group 21-30 (23.3%). All the patients presented with history of fever, but 54 patients presented with high grade fever. Other Most common symptom was chills and rigours (81%), followed by vomiting and headache each 32%, cough 31%. On examination 21% patients had eschar,14% patients had lymphadenopathy. Most number of patients presented in the month of September (51.6%), followed by August (33.3%).Conclusion: Scrub typhus being an important differential of acute undifferentiated fever in this region, should not be missed by primary care physicians, as once multi organ dysfunction sets in, mortality rate starts rising. So, there is a high need of sensitization of doctors and people about this illness so that early diagnosis and early treatment can be ensured.

Cardiovascular abnormalities in severe scrub typhus

Background: Himachal Pradesh is an endemic area for scrub typhus. If not treated early, it can lead to life threatening complications, affecting various systems of the body. Hence, this study was done with an objective to study the cardiovascular abnormalities in patients of severe scrub typhus.Methods: Authors conducted a hospital-based study in Departments of Medicine and Cardiology, of a tertiary care hospital in Sub-himalayan region in patients of severe scrub typhus from June 2016 to May 2017.Results: Thirty-two (55%) patients were aged <60 years with female preponderance (72%).   Electrocardiographic changes included sinus tachycardia in 56 (97%), axis deviation in 5(9%), ST-T changes in 3(5%) and atrial fibrillation in 1(2%). Echocardiographic changes included tricuspid regurgitation in 14(24%), pericardial effusion in 4(7%), myocarditis in 1(2%) and Regional wall motion abnormality in 1(2%). Left ventricular ejection fraction >45% in 47 (81%) and <45% in 11(19%).  Fifty-one patients had hypotension at presentation and 49 (90%) of them improved. Interestingly, 10 of 11 patients with reduced EF (<45%) survived whereas 6 of total 7 patients, who died, had preserved EF (>45 %).Conclusions: Severe scrub typhus manifested with ST/T changes, myocarditis, pericardial effusion, arrhythmias, shock and patients with reduced EF on Echocardiography had better outcome.

Pediatric scrub typhus in Indian Himalayas.

To retrospectively confirm the suspected rickettsial disease (Scrub typhus) using a gold standard diagnostic test i.e. microimmunofluorescence in pediatric patients with acute febrile illness of unknown etiology. Two serological tests, Weil-Felix and Microimmunofluorescence were used to confirm infection. All five children had fever, vomiting and generalized lymphadenopathy, but none had eschar or rash. One was cured with doxycycline, remaining four patients treated with azithromycin and one died despite treatment. Scrub typhus is a cause of fever of unknown origin in Himalayan region of India and azithromycin is an effective alternative to doxycycline in treating this disease.

Endobronchial metastasis of follicular thyroid carcinoma presenting as hemoptysis: a case report.

Endobronchial metastasis secondary to follicular thyroid carcinoma is extremely rare. Here, we report a case of follicular thyroid cancer in 58-year-old male who presented with hemoptysis. Computed tomography of the chest revealed multiple lung metastases. Flexible fiberoptic bronchoscopy revealed a fragile polypoid mass 5 cm distal to the vocal cords; biopsy taken from this mass revealed follicular thyroid carcinoma.

Kala-Azar at high altitude.

Kala-azar or Visceral leishmaniasis (VL) is a disease of low altitude (approximately 500 meters mean sea level). In India, however cases have been reported from sub-Himalayan region (350-960 meters MSL) of Kumaon region of Uttaranchal. We present two patients of VL, natives of tribal district of Kinnnaur (2000-3000 meters MSL), Himachal Pradesh, who had never visited known endemic area for Leishmaniasis. These are probably first indigenous cases of VL being reported from an area situated at an altitude of 3000 meters and 2300 meters MSL.

Life threatening unilateral pulmonary oedema at moderate altitude.

A-23-year-old medical student, resident of an altitude of 700 meters, developed dyspnea and cough during a temple visit at an altitude of 2200 m within 10 hours of arrival and his symptoms improved on descending and with 100% oxygen. Chest skiagram and CT scan chest revealed soft fluffy shadows on the left side with small right lung and absent right pulmonary artery. Absent right pulmonary artery was responsible for development of pulmonary oedema at moderate altitude.