Clinico-laboratory Profile and Outcomes of Megaloblastic Anemia presenting as Severe Pyrexial Illness mimicking Tropical Infection

Background: Anemia-causing fever has been described in patients with megaloblastic anemia. Although the exact mechanism of this is unknown, high-grade fever is relatively less reported. Materials and methods: This prospective observational study included all new cases of megaloblastic anemia presenting with febrile illness (>101°F) during a 3-year period. Patients with existing anemia, comorbidities, and other causes of macrocytosis were excluded. A detailed evaluation for megaloblastic anemia and workup for excluding tropical infections was done. The patients were treated with parenteral vitamin B12, folic acid, and other hematinics. Results: Around 24 cases of megaloblastic anemia presenting with high-grade fever were included, with 14 (58.3%) males, mean duration of fever 7.7 days (4–18 days), and 09 (37.5%) having temperature >103°F. The mean hemoglobin (Hb) was 8.15 g/dL (3.7–11.1 g/dL), the mean corpuscular volume (MCV) was 111 ± 7.8 fL, 18 (75%) had unconjugated hyperbilirubinemia, the mean lactate dehydrogenase (LDH) was 814 ± 24 IU/L, and 21 (87.5%) had low B12 or folate levels. Most showed good therapeutic response to B12 or folic acid with defervescence in 1–5 days (mean 2.6 days) and improvement in lab parameters in 1 week. The study population was divided into those with temperature ?103°F, and temperature <103°F it was seen that there was a significant association (p < 0.05) with leucocyte count of ?3000/cumm, and MCV ?110 fL, in patients with temperature ?103°F Conclusion: Megaloblastic anemia should be considered in the differentials of a patient presenting with a febrile illness with no clinical localization and a negative initial fever workup. Early identification and prompt therapy of this easily treatable disorder are very essential.

Is the clinicopathological profile of dengue syndrome changing?: a 6 year study of different epidemics at a tertiary care center in India

Background: As an arthropod-borne viral disease, dengue epidemics has created much public health hazards in tropical countries. In the national capital of India, there has been more than six epidemics. Dengue remains a notifiable disease in India. It is important that we understand the changing clinicopathological profile of this viral infection to prepare ourselves better for any impending future epidemic. This study done at a tertiary care center looks into the recent epidemics to understand the changing trends in the disease profile in two phases of three years each. Further, authors also assessed the utility of the tourniquet test in dengue syndrome.Methods: 260 serologically confirmed patients were recruited in two phases of the study. We evaluated them for clinical, epidemiological and pathological profile of dengue and trends in haematological, biochemical and radiological parameters during the course of the disease and its correlation with the severity of the disease.Results: Fever, headache, body ache, pharyngeal and conjunctival congestion, rhinitis, rash and diarrhea incidences were similar in both epidemics. Lymphadenopathy was seen in 18(18%) patients compared to 40(25%) in the second epidemic. More number of hemorrhagic manifestations with GI and retinal bleed was seen compared to earlier epidemics, which had higher liver involvement.Conclusions: Although the presentation of the disease has not shown a drastic change over the last decades, the severity varies depending on the predominant serotype. Patients with evidence of serositis, increased activated lymphocytes has a longer course in disease with poorer outcome. Early rising haematocrit, ALT/AST ratio, LDH and deranged coagulation parameters are important tools in triaging patients for priority of urgent care and hospitalization in a scenario of a future outbreak.

Efficacy of stem cell in improvement of left ventricular function in acute myocardial infarction - MI3 Trial.

Background & objectives: Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 108 autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy. Methods: In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI). Results: On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 X 108 (n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study. Interpretation & conclusions: Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

Sociodemographic characteristics and aggression quotient among children in conflict with the law in India: A case–control study.

Background. The incidence of juvenile delinquency has increased in the past decade in India and juvenile crimes are increasingly being reported. This has been attributed to many biopsychosocial factors. It is essential to understand these issues in the context of India to determine the response of acts of children in conflict with the law. We aimed to assess the sociodemographic characteristics and the aggression quotient of children in conflict with the law (juvenile delinquents) in observation homes across India and compare them with those who were not. Methods. We did a case–control study in five juvenile homes in the cities of Hyderabad, Lucknow and Pune. Ninety inmates (74 boys, 16 girls) were included in the study. Sociodemographic characteristics and aggression quotient of children in conflict with the law were evaluated using two separate questionnaires, i.e. a sociodemographic questionnaire and the modified Buss and Perry aggression questionnaire. These were compared with a control group of similar age, sex and income status. Results. All the children in conflict with the law surveyed belonged to the lower socioeconomic strata, had a significantly higher chance (p<0.05) of coming from broken homes, have addictions, jailed family members and suffered physical and sexual abuse than controls. They also scored higher on all domains of the aggression questionnaire than controls. Conclusion. A collection of sociodemographic attributes such as broken homes, addictions and abuse seem to have an

Heparin: Induced thrombocytopenia: Incidence and laboratory approach to diagnosis in Indians.

Background and objectives: One of the most common complications of heparin administration is heparin-induced thrombocytopenia (HIT) which can also lead to catastrophic thrombotic events. The problem of identifying the cause of thrombocytopenia, as due to heparin, in patients with multiple co-morbid conditions is very essential for management. Thus, the laboratory investigations for diagnosis of HIT play a pivotal role. The objective of the study was to arrive at the incidence of HIT in ethnic Indian population and provide a decision after analysis of tests used to diagnose HIT. Materials and Methods: 125 consecutive patients (Power of study being 80%) undergoing open heart surgery and receiving unfractionated heparin were taken as subjects. Blood samples were collected a day before the surgery and days 1, 3, 5 and 7 after surgery. The cases were categorized into probable and unlikely groups depending on the clinical presentation and degree fall of platelet count. Antiheparin PF4-associated antibodies were detected using rapid-ID gel microtyping system and ELISA tests. HIT was also tested using functional assays:- heparininduced platelet aggregation test (PAT) and the rapid luminographic assay of heparin-induced ATP release. Results: Of the 125 patients, 11 patients were clinically labeled as probable HIT and 29 patients were clinically labeled as unlikely HIT. There were seven confi rmed cases of HIT cases that were positive for one functional and one immunological assay. Only one case of HITT was encountered. Accordingly, the incidence of HIT was found to be 5.6 % and that of HITT to be 0.8%. ELISA tests were positive in 21 cases (17%) which demonstrated the presence of anti-HPF4 antibodies in non-HIT cases as well. It was found that the rapid gel test had sensitivity comparable to functional assay with better specifi city than ELISA. Interpretation and conclusions: Incidence of HIT in ethnic Indian population is 5.6%. Patients with a drop of >50% in platelet count should be perused as a likely candidate of HIT. These cases should be subjected to the ID-HPF4 antibody assay as this is a rapid test, can be done for individual cases, and has better specifi city and similar sensitivity than ELSIA. Cases with clinically probable HIT and a positive ID-HPF4 assay can be taken as confi rmed cases of HIT. However, cases clinically unlikely for HIT and a positive ID-HPF4 assay should be subjected to another test to establish the diagnosis of HIT.

Survival After Immunosuppressive Therapy in Children with Aplastic Anemia.

Objective: To determine the survival of children ≤18y, treated with immunosuppresive therapy (IST) using equine antithymocyte globulin (e-ATG) and cyclosporine (CsA). Design: Prospective data entry as per a specified format. Setting: Tertiary care hospital. Patients: From January 1998 to December 2009, 40 children were diagnosed with acquired aplastic anemia; 33 patients, who received IST, were analyzed. 31 children (94%) received one course of e-ATG and CsA. 2 patients (6%) received two courses of ATG. Intervention: Immunosuppressive therapy using equine ATG and cyclosporine. Main Outcome Measures: Overall response and overall survival. Results: The overall response (complete response + partial response) to IST at 6 months was 87.9%. 8 (24.2%) patients achieved CR, 21 (63.6%) patients had PR and 4 (12.1%) patients did not respond to IST. Median follow-up was 24 (6-102) months. Overall survival at 24 months was 90%, with an acturial survival of 85.4% at 5 years. Seventeen patients (51.5%) received G-CSF for a median duration of 32 (23-64) days. The patients who received G-CSF had fewer infectious complications (P=0.002), but G-CSF administration did not influence survival/ outcome. No patient developed myelodysplastic syndrome or acute leukemia. Conclusions: The survival of patients who respond to IST is excellent. Also, G-CSF reduces the infectious complications without conferring any survival advantage.

Hereditary angioedema with recurrent abdominal pain.

Hereditary angioedema is a rare disorder characterized by quantitative or qualitative deficiency of complement C1 esterase inhibitor. We report a family whose members presented with recurrent angioedema and abdominal pain; the diagnosis was confirmed by quantitative assay of C1 inhibitor. The index patient was treated with danazol and was relieved.