Mortality due to scrub typhus � report of five cases

Scrub typhus is largely ignored in India particularly during outbreaks of viral fever. The disease course is often complicated leading to fatalities in the absence of treatment. However, if diagnosed early and a specific treatment is initiated, the cure rate is high. We report here five cases of scrub typhus to highlight the fact that high clinical suspicion for such a deadly disease is an absolute necessity.

Current status of treatment of latent tuberculosis infection in India

In view of the high burden of latency of tuberculosis (TB) in India, tackling latent TB in the right way is a menace. All latent TB’s infection (LTBI) are treated in countries having low burden such as the United States. However, this approach cannot be implemented in high burden countries like India until concrete evidence or consensus by experts on this subject is made. There are very specific risk groups where these patients are to be treated as far as current evidence-based medicine is concerned. Hence, the need to develop a document was felt, through which the treatment of LTBI becomes homogeneous by each and every physician who is practicing and treating TB. The last attempt to review the topic was made in 2015, after which there have been many changes and update in this subject.

Progressive multifocal leucoencephalopathy in HIV/AIDS: Observational study from a tertiary care centre in northern India.

Background & objectives: Progressive multifocal leucoencephalopathy (PML) is seen mostly in advanced human immunodeficiency virus (HIV) infection. Little is known about the epidemiology and disease course of these patients from India. This study was aimed to determine the frequency of PML in patients with HIV/AIDS, and the clinical features and survival of these patients. Methods: The charts of HIV/AIDS patients with PML seen over a period of five years (2006-2011) at the Antiretroviral treatment (ART) centre at a tertiary care centre in New Delhi, India, were retrospectively reviewed. Results: Of 1465 patients with HIV/AIDS, 18 (1.2%) were diagnosed with PML; four were laboratory confirmed and 14 had consistent clinical and radiological features. PML was the initial presentation of HIV infection in 10 (56%) patients, and 16 (89%) patients had CD4 count less than 200/μl. Insidious onset focal limb weakness (78%) and visual disturbance (28%) were common symptoms. Magnetic resonance imaging (MRI) of the brain revealed characteristic white matter lesions in all the patients. The estimated median survival was 7.6 months (95% CI, 0-20 months). Interpretation & conclusions: Our results show that the patients present late to access treatment with advanced immunosuppression at presentation. PML is associated with high morbidity and mortality despite institution of highly active antiretroviral therapy (HAART). There is a need to address the lacuna in diagnostic and management services for these patients in India.

Screening for HIV infection by health professionals in India.

BACKGROUND: Stigma and discrimination, particularly in access to healthcare, remains a major problem for people Infected with HIV in most parts of India. METHODS: We did a multicentre study (n = 10) with a cross-sectional survey design using a standardized, interviewer-administered questionnaire. RESULTS: A total of 2200 healthcare providers participated. The knowledge, attitude and practice (KAP) related to HIV service delivery were very poor with a mean overall KAP score of only 49.7% (CI: 49.1-50.3). Only 5%, 5% and 1% of the participants scored more than 75% separately for the dimensions of knowledge, attitude and practice, respectively. Only 24.4% and 36.7% of responders knew that HIV screening was not recommended prior to surgery and pre-employment check-up. Many doctors (19.4%) had refused treatment to people living with HIV/AIDS (PLHA) at least some of the time and nearly half (47.2%) identified and labelled them; 23.9% isolated them in separate care areas and 13.3% postponed or changed treatment based on the patient's HIV status. Screening for HIV prior to elective surgery was done by 67% of providers. While 64.7% of responders were aware of the existence of national guidelines on and recommendations for HIV testing, only 38.4% had read the policy document. CONCLUSION: There is a growing need to provide care, support and treatment to a large number of PLHA. The capacity of healthcare providers must be urgently built up so as to improve their knowledge of and attitude to HIV to enable them to deliver evidence-based and compassionate care to PLHA in various healthcare settings.

Evaluation of CD4 counts and percentages in the HIV infected Indian population.

This study was designed to evaluate the absolute CD4+ counts and percentages in HIV subtype C infected patients at a tertiary care hospital in northern India. The CD4+ counts of 377 HIV seropositive subjects were estimated by a FACS Calibur (BD) flow cytometer. Dual color immunophenotyping was performed on each sample, which was acquired and analysed using CellQUEST software. Discordance between CD4+ counts and percentages were found more in the early stage ie Group A (37.2%) when compared with Group B (31.6%) and Group C (28.8%), with the counts remaining in the normal range but percentages being severely depressed.

HIV: awareness of management of occupational exposure in health care workers.

BACKGROUND: There is need for safe working environment in both government and private hospitals for the safety of health-care workers (HCWs). The present study was conducted to know the present knowledge regarding occupational exposure to HIV amongst doctors in non-governmental hospitals and clinics across Delhi. METHODS: Seventy doctors from different medical and surgical specialties in various non-government hospitals/nursing homes in Delhi were given a structured questionnaire. RESULTS: Majority of them have suffered needle stick injuries. Many had also experienced splash over face, eyes. Some participants were still recapping needles most of times. 85.7% of participants were fully vaccinated for hepatitis B. 44.2% didn't know if they were responders to hepatitis B vaccine or not. Most of them didn't report the needle stick injuries. In majorities of incidents source patient was not tested for blood born infections. Many of participants were not aware of post exposure prophylactic measures to be taken if there is an occupational exposure to the blood of HIV positive patient. Awareness that drugs for postexposure prophylaxis are to be started immediately was low (36%). CONCLUSIONS: The study highlights the low awareness of postexposure prophylaxis measures amongst HCWs. Many HCWs were also not aware if they were responders to hepatitis B vaccine or not. Most of the needle stick injuries were neither reported nor investigated.

Awareness of brain death and organ transplantation among select Indian population.

BACKGROUND: With the improvement in transplant technology major organ transplantation is gradually becoming the treatment of choice in many conditions. The present study assesses the awareness of the concepts of brain death and organ transplantation among public. METHODS: Six hundred thirty six select populations, which included office-goers of Delhi, class 12th school children of a reputed public school and villagers, were interviewed to assess their knowledge in various aspects of brain death and organ transplantation. RESULTS: There was widespread acceptance of organ transplantation among this population. The most alarming feature was that the awareness of the concept of brain death and its importance for organ donation was extremely low. Only small number of individuals were aware that brain death is legal in India. Awareness about brain death was especially low among villagers. CONCLUSIONS: Education about various aspects of brain deaths, its immense importance for organ donation and legality of brain death in India needs to be highlighted.

Antiretroviral therapy: are we aware of adverse effects?

HIV/AIDS has become a chronic disease thanks to the availability of antiretroviral drugs. Many of these antiretroviral drugs are available in India. Many more will soon become available. The cost of these drugs is being reduced gradually and their use is increasing. However, there are both short term and long term side effects. This review focuses on the common potential toxicities of antiretroviral drugs and their management. The potential toxicities include gastrointestinal effects, hepatitis, hypersensitivity reactions, cytochrome P450 interactions, mitochondrial toxicity and lipodystrophy syndrome as well as more drug-specific adverse effects.

A clinico-bacteriological study of peripheral tuberculous lymphadenitis.

OBJECTIVE: Tuberculous lymphadenitis is the commonest form of extra-pulmonary tuberculosis. It is most often caused by M. tuberculosis though several reports from other countries have shown mycobacteria other than tuberculosis (MOTT) to be responsible for a significant proportion of tuberculous lymphadenitis cases. The present study was conducted to find the prevalence of M. tuberculosis and MOTT as aetiological agents in patients with peripheral tuberculous lymphadenitis. METHODS: A total of 138 patients with tuberculous lymphadenitis were included in the study. Diagnosis of tuberculosis was established on the basis of fine needle aspiration cytology, histopathology, presence of mycobacteria on Ziehl Neelson stain or auramine rhodamine stain, or aspiration of pus with negative Gram's stain and pyogenic cultute with radiologic evidence of pulmonary tuberculosis. Mycobacterial cultures were performed on aspirated material and species identified using standard methods. RESULTS: Of 138 patients, single lymph nodal enlargement was found in 48.6% patients while others had more than one lymph nodes. Lymph nodes were matted in 26.8% cases while fluctuation could be elicited in 12.3% patients. Chest X-ray showed evidence of active pulmonary lesions or mediastinal lymphadenopathy in 28.3% cases. The fine needle aspiration cytology was positive for tuberculous lymphadenitis in 41.3% cases while it revealed granulomas or necrosis in another 13% cases. The Ziehl-Neelson and the auramine-rhodamine staining were positive in 19.6% and 26.8% patients, respectively. On culture, the lymph node aspirate was positive for Mycobacterium species in 40.6% patients. In all but two cases, the culture revealed presence of Mycobacterium tuberculosis. The other two cultures revealed growth of Mycobacterium fortuitum chelonae complex. Of the two HIV-positive patients, M. tuberculosis could be isolated in one case. CONCLUSION: Findings of this study suggest that M. tuberculosis is still the most common cause of tuberculous lymphadenitis and MOTT are responsible for very few cases. However, such studies need to be carried out frequently at various centres so as to see any periodic and geographic variations within India.

Classical polyarteritis nodosa and microscopic polyangiitis--a clinicopathologic study.

OBJECTIVE: To describe the clinical spectrum, laboratory features, histopathological findings and treatment outcome in patients with classical polyarteritis nodosa (PAN) and microscopic polyangiitis (MPA). MATERIAL AND METHODS: Patients with PAN and MPA seen at a large teaching hospital in north India over a period of five years (1994-99) were included in the present study. RESULTS: We encountered five patients with PAN and six patients with MPA during the study period. Of the five patients with PAN, two had systemic disease while three had limited PAN. The patients with limited PAN included two with cutaneous PAN and one with PAN confined to the nerves. Constitutional symptoms, musculoskeletal complaints, peripheral neuropathy and skin lesions dominated the clinical picture. Fifty percent of the MPA patients presented as pulmonary renal syndrome. All the patients with PAN were HBsAg and ANCA negative and had normal urinalysis findings. In contrast, all patients with MPA demonstrated an active urine sediment and 83.3% were pANCA positive. Some of the rare features encountered by us were the presence of antiphospholipid syndrome and extensive interstitial lung disease in MPA, and spontaneous recovery in one patient with systemic PAN. Treatment outcome was better in PAN as compared with MPA. CONCLUSIONS: The clinical spectrum of PAN and MPA is quite varied. A good outcome is possible with the use of corticosteroids and cyclophosphamide.

A new focus of visceral leishmaniasis in sub-Himalayan (Kumaon) region of northern India.

A localised focus of visceral leishmaniasis is reported for the first time from Kumaon region of North India. During a period of 18 months from July 1997 to December 1998 several cases of pyrexia of unknown origin with unresponsiveness to antibiotics and anti-tubercular treatments were referred to the All India Institute of Medical Sciences, New Delhi. Five of these were diagnosed to have visceral leishmaniasis. One of these was also co-infected with HIV-1. All the five cases came from an adjoining area falling under Almora (4) and Nainital(1) districts. Of these four were males and one female. One patient died within 48 hours of hospitalization at AIIMS while rest of four responded completely to sodium stibogluconate therapy.

Awareness of brain death and organ transplantation among high school children.

The objective of this study was to assess the awareness of the concepts of brain death and organ transplantation among high school children. One hundred and eighty eight students of class 12th of a reputed public school were studied. Structured questionnaires were used to assess their knowledge in various aspects of brain death and organ transplantation. Following the questionnaire, they were provided with educational information on brain death and organ transplantation. This was followed by similar questionnaires to assess any change in awareness of brain death and organ transplantation. Results spoke of widespread awareness and acceptance of organ transplantation in the high school children. However, the awareness of various aspects of brain death was quite low. There was significant increase in awareness and acceptance of brain death after educating the students. Education about various aspects of brain death, its immense importance for organ donation and legality of brain death needs to be highlighted.

Validity of tourniquet test in dengue haemorrhagic fever.

OBJECTIVE: Dengue haemorrhagic fever (DHF), a public problem in most of the tropical countries of South-East Asia, is diagnosed on the basis of demonstrating an increased capillary permeability and thrombocytopenia with concurrent haemoconcentration. Tourniquet test has been recommended as the initial screening procedure of patients with suspected DHF, particularly grade I DHF. The objective of the present study was to study the value of this test as an indicator of haemorrhagic tendencies in patients of DHF. METHODS: One hundred and ten adult patients hospitalized with DHF during outbreak of DHF in 1996 in north India were prospectively studied. The diagnosis of DHF was considered on the basis of haemoconcentration > 20%, evidence of transudation, or presence of shock along with thrombocytopenia. A tourniquet test was conducted in these cases in the standard method. RESULTS: Of the 110 patients of DHF studied, 62 patients (56.4%) had bleeding but tourniquet test was positive in only half of these patients. Forty eight patients (43.6%) did not have any bleeding and the tourniquet test was positive in only 27% cases. CONCLUSIONS: The tourniquet test was positive in only 39.1% of all DHF cases. It is concluded that a negative tourniquet test may not be sufficient to exclude a diagnosis of DHF in a febrile patient. This necessitates the need for the re-defining the clinical criteria for the diagnosis of DHF, particularly grade I DHF.