Validating a linear regression equation using mid-upper arm circumference to predict body mass index.

BACKGROUND: Estimating body mass index (BMI) in hospitalised patients for nutritional assessment is challenging when measurement of weight and height is not feasible. The study aimed to validate a previously published regression equation to predict BMI using mid-upper arm circumference (MUAC). We also evaluated the proposed global MUAC cut-off of ≤24 cm to detect undernutrition. METHODS: We measured standing height, weight, and MUAC prospectively in a sample of stable patients. Agreement between calculated and predicted BMI was evaluated using Bland-Altman analysis. RESULTS: We studied 201 patients; 102 (51%) were male. Median (IQR age was 42 (29-50) years. 95% limits of agreement between predicted and calculated BMI were +0.6767 to +1.712 and the bias was +1.076. MUAC ≤24 cm was 97% sensitive and 83% specific to detect undernutrition. CONCLUSION: BMI derived from MUAC had poor calibration for estimating actual BMI. However, low MUAC has good discriminative accuracy to detect undernutrition.

Impact of nutrition status and body mass index on mortality in hospitalized general medical patients: A prospective observational study.

BACKGROUND: Malnutrition and low body mass index (BMI) are risk factors for mortality in hospitalized patients. Data substantiating this are unavailable for hospitalized general medical patients in our setting. We studied the prevalence of malnutrition among patients admitted to general medical wards in a tertiary care hospital and its role as a risk factor for 1-month mortality. We also investigated the association of BMI with mortality. METHODS: In this prospective observational study, nutrition assessment using Subjective Global Assessment (SGA) and anthropometric measurements was performed in 395 hospitalized general medical patients. Charlson Comorbidity Index (CCI) and Modified Early Warning System (MEWS) score were calculated. Clinical course and vital status at 1 month after discharge was noted. Factors associated with mortality were identified using logistic regression. RESULTS: The mean age of the study population was 46.2 + 16.1 years; 247 (62.5%) were males. Of 395 patients, 129 (32.7%) belonged to SGA A, 155 (39.2%) to SGA B, and 111 (28.1%) to SGA C. Mean (±SD) BMI was 23.38 (±5.33); 141 (35.6%) were obese. Mortality was observed in 61 (15.4%) patients. Patients in the lowest BMI quartile had the lowest mortality. The adjusted regression analysis showed that higher age and MEWS scores were independently associated with mortality. Severe malnourishment (SGA C) was another important predictor. Further, the odds of death increased consistently across the consecutive BMI quartiles. CONCLUSION: Higher age, higher MEWS scores, severe malnourishment, and higher BMI scores were independent risk factors for 1-month mortality in hospitalized general medical patients.

Asymptomatic bacteriuria among medical inpatients: Data from an Indian teaching hospital.

Studies indicate that asymptomatic bacteriuria in medical inpatients is often inappropriately treated with antibiotics. We prospectively studied the proportion of asymptomatic bacteriuria among 200 positive urine cultures which were ordered in hospitalised medical inpatients of a teaching hospital in southern India. We used pre-defined criteria to classify patients as urinary tract infection and asymptomatic bacteriuria. Median age of patients was 53.5 (42-65) years, and 51% were male. In all, 157 (78.5%) patients had urinary tract infection (131 [66.5%] definite and 26 [13%] probable) and 43 (21.5%) had asymptomatic bacteriuria. In patients with asymptomatic bacteriuria, 18 (41.8%) received urinary tract infection-directed antibiotics; broad spectrum antibiotics were used in 10 (23%). Patients with asymptomatic bacteriuria were younger, more likely to be on a urinary catheter, had higher prevalence of chronic kidney disease and congestive cardiac failure and had lower prevalence of pyuria and lower total leucocyte counts. Urine cultures should be ordered only in indicated patients. Inappropriate antibiotic treatment in patients with asymptomatic bacteriuria should be avoided.

Factors Associated With Normal Flow (TIMI 3) After Thrombolysis With Streptokinase in ST-Elevation Myocardial Infarction: A Prospective Observational Study.

Background Thrombolysis with streptokinase (STK) is the most widely used reperfusion strategy for ST elevation myocardial infarction (STEMI) in India. Achieving full reperfusion as evidenced by thrombolysis in myocardial infarction (TIMI) flow grade 3 in coronary angiography (CAG) is associated with better outcomes. Recent studies show that hematological indices like neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV) estimated before thrombolysis could predict TIMI 3 flow. We studied clinical, electrocardiographic and hematological parameters associated with TIMI 3 flow after thrombolysis with STK. Methods We prospectively studied 201 adult patients with STEMI presenting within 12 hours of onset of chest pain. Before thrombolysis, blood sample was collected for estimating NLR and MPV. Timing of CAG after thrombolysis was decided by consultant cardiologists. Patients were followed up for one month after discharge. Results Of 201 patients, 162 (81%) had relief of chest pain and 131 (65%) had ST segment recovery of ≥50% at 90 minutes after thrombolysis. CAG was performed within median (IQR) of four (3-5) days after thrombolysis. TIMI 3 flow was observed in 112 (56%) patients. NLR and MPV had no significant association with TIMI 3 flow. In multivariable analysis, ST-segment recovery of ≥50% at 90 minutes was associated with TIMI 3 flow (adjusted OR 3.47, 95% CI: 1.84-6.53, P= <0.001). Of 198 patients followed up for one month after discharge, 13 (6.5%) died. Conclusions In patients with STEMI, ST-segment recovery of ≥50% at 90 minutes after thrombolysis with STK predicted TIMI 3 flow independently. NLR and MPV values were not predictive of TIMI 3 flow.

Point-of-care infrared thermal imaging for differentiating venomous snakebites from non-venomous and dry bites.

BACKGROUND: Local envenomation following snakebites is accompanied by thermal changes, which could be visualized using infrared imaging. We explored whether infrared thermal imaging could be used to differentiate venomous snakebites from non-venomous and dry bites. METHODS: We prospectively enrolled adult patients with a history of snakebite in the past 24 hours presenting to the emergency of a teaching hospital in southern India. A standardized clinical evaluation for symptoms and signs of envenomation including 20-minute whole-blood clotting test and prothrombin time was performed to assess envenomation status. Infrared thermal imaging was done at enrolment, 6 hours, and 24 hours later using a smartphone-based device under ambient conditions. Processed infrared thermal images were independently interpreted twice by a reference rater and once by three novice raters. FINDINGS: We studied 89 patients; 60 (67%) of them were male. Median (IQR) time from bite to enrolment was 11 (6.5-15) hours; 21 (24%) patients were enrolled within 6 hours of snakebite. In all, 48 patients had local envenomation with/without systemic envenomation, and 35 patients were classified as non-venomous/dry bites. Envenomation status was unclear in six patients. At enrolment, area of increased temperature around the bite site (Hot spot) was evident on infrared thermal imaging in 45 of the 48 patients with envenomation, while hot spot was evident in only 6 of the 35 patients without envenomation. Presence of hot spot on baseline infrared thermal images had a sensitivity of 93.7% (95% CI 82.8% to 98.7%) and a specificity of 82.9% (66.3% to 93.4%) to differentiate envenomed patients from those without envenomation. Interrater agreement for identifying hot spots was more than substantial (Kappa statistic >0.85), and intrarater agreement was almost perfect (Kappa = 0.93). Paradoxical thermal changes were observed in 14 patients. CONCLUSIONS: Point-of-care infrared thermal imaging could be useful in the early identification of non-venomous and dry snakebites.

Acute kidney injury in patients hospitalized with febrile urinary tract infections: A prospective observational study.

BACKGROUND: Febrile urinary tract infection (fUTI) can be associated with acute kidney injury (AKI). We aimed to study the risk factors for AKI, its pathophysiological categories, and the role of urinary neutrophil gelatinase-associated lipocalin (uNGAL) in differentiating these categories in patients hospitalized with fUTI. MATERIALS AND METHODS: We prospectively studied patients with fUTI admitted to the Department of Medicine of a tertiary care hospital in southern India from January 2017 to December 2018. Clinical evaluation, renal imaging, and estimation of fractional excretion of sodium (FeNa) and uNGAL were done at baseline. AKI was defined as ≥ 0.3 mg/dL rise in serum creatinine (SCr) within 48 hours during hospital stay (KDIGO criterion) or discharge SCr value 0.5 mg/dL or less compared to peak SCr after admission. RESULTS: We studied 100 patients. Their mean age was 52 (± 14) years; 45 were men. In all, 52 had AKI: pre-renal in 11 (21%), intrinsic renal in 24 (47%), post-renal in 16 (31%), and missing data 1 patient. uNGAL levels were significantly higher in the AKI group compared to the no-AKI group (median [IQR] 91.1 [13.2 - 188] vs. 264.9 [115.2 - 355.2] ng/mL; p < 0.001). On multivariable analysis, male sex (adjusted odds ratio, aOR [95% CI] 2.8 [1.09 - 7.14]), hypertension (4.12 [1.24 - 13.7]) and hydroureteronephrosis (7.82 [1.55 - 39.4]) were independently associated with AKI. There was an increasing trend of uNGAL across the three categories of AKI (pre-renal 106.1 [14.6 - 261.7] ng/mL, intrinsic renal 210.8 [8.5 - 353.8] ng/mL, and post-renal 335.5 [269.2 - 692.8] ng/mL; p = 0.001). Patients with pre-renal AKI had significantly lower levels of uNGAL compared to the other two categories combined (106.1 [14.6 - 261.7] vs. 284.6 [179 - 434.4] ng/mL; p = 0.016). CONCLUSION: Hospitalized fUTI patients should be evaluated for AKI, and obstructive uropathy should be ruled out in those with AKI. uNGAL levels may help in differentiating the pre-renal type of AKI from the other two categories.

An outbreak of Salmonella Enteritidis food poisoning following consumption of chicken shawarma: A brief epidemiological investigation.

BACKGROUND: Shawarma, a popular meat-based fast food could be a source of foodborne outbreak due to non-typhoidal Salmonella (NTS). A clustering of acute gastrointestinal (GI) illness following intake of chicken shawarma occurred primarily among the staff and students of a tertiary care hospital in southern India. METHODS: A case-control study was conducted among 348 undergraduate medical students (33 cases, 315 controls).  Data was collected using direct interviews and a simple online questionnaire. Epidemiological associations of GI illness were evaluated at three levels of exposure namely-eating food from any restaurant, eating food from the implicated food outlet, eating chicken shawarma from the implicated outlet. RESULTS: Of 33 cases, 26 had consumed food from a particular food outlet, 4 from other outlets, and 3 did not report eating out. Consumption of food from the suspected food outlet was significantly associated with GI illness (odds ratio 121.8 [95% CI 28.41 to 522.66]; P<0.001); all the 26 cases who had eaten from the particular outlet had eaten chicken shawarma. By comparison, only one of the 315 controls had eaten this dish. Of the 27 persons (cases as well as controls) who had consumed chicken shawarma from the outlet, 26 were ill. Culture of stool samples from 10 affected individuals and implicated food item yielded Salmonella Enteritidis. CONCLUSIONS: Meat-based shawarma is a potential source of NTS infection. Food safety authorities should enforce guidelines for safe preparation and sale of shawarmas and similar products.

Frequency and clinical significance of prostatic involvement in men with febrile urinary tract infection: a prospective observational study.

Background: Frequent asymptomatic involvement of the prostate has been demonstrated in men with febrile urinary tract infection (fUTI). In view of this, men with fUTI are often given a longer duration of antibiotic treatment; however, evidence to support this is limited. Methods: We prospectively studied adult men with fUTI admitted under the Department of Medicine in a tertiary care hospital in southern India.  fUTI was defined as fever of ≥38°C with at least one symptom/sign of UTI and pyuria, requiring hospitalization. We estimated serum total prostate-specific antigen (PSA) levels at enrollment, one month and three months after treatment completion. We assessed prostatic volume by transrectal ultrasonography (TRUS) and estimated the serum high sensitivity C-reactive protein (hs-CRP) levels at baseline and after three months. Results: We enrolled 64 men (median [IQR] age 53 [45-60] years); 50 patients completed follow-up. At baseline, the median (IQR) serum PSA level was 2.15 (1.18-3.02) ng/mL and median (IQR) serum hs-CRP level was 2.43 (2.28-2.58) mg/L. At three months, serum PSA levels decreased by ≥25% in 47 (94%) of 50 patients. The median (IQR) of prostatic volume was 25.4 (18.9-34) mL at baseline, and ≥10% decrease in prostatic volume was observed in 24 (48%) of 50 patients at three months. The change in the serum PSA levels did not correlate with clinical findings like prostatic tenderness or with prostatic volume changes. Further, serum PSA levels did not correlate with hs-CRP levels. On follow-up, seven patients had lower urinary tract symptoms; only one of them had recurrent fUTI.   Conclusions: Asymptomatic prostatic involvement, although common in men with fUTI, does not seem to influence the treatment outcomes.

Reevaluating the true diagnostic accuracy of dipstick tests to diagnose urinary tract infection using Bayesian latent class analysis.

OBJECTIVE: Previous studies on diagnostic accuracy of dipstick testing for leukocyte esterase (LE) and nitrite to diagnose urinary tract infection (UTI) had used urine culture, which is an imperfect gold standard. Estimates of diagnostic accuracy obtained using the classical gold standard framework might not reflect the true diagnostic accuracy of dipstick tests. METHODS: We used the dataset from a prospective, observational study conducted in the emergency department of a teaching hospital in southern India. Patients with a clinical suspicion of UTI underwent dipstick testing for LE and nitrite, urine microscopy, and urine culture. Based on the results of urine microscopy and culture, UTI was classified into definite, probable, and possible. Patients with microscopic pyuria and a positive urine culture were adjudicated as definite UTI. Unequivocal imaging evidence of emphysematous pyelonephritis or perinephric collections was also considered definite UTI. We estimated the diagnostic accuracy of LE and nitrite tests using the classical analysis (assuming definite UTI as gold standard) and two different Bayesian latent class models (LCMs; 3-tests in 1-population and 2-tests in 2-populations models). RESULTS: We studied 149 patients. Overall, 64 (43%) patients had definite, 76 (51%) had probable, and 2 (1.3%) had possible UTI; 7 (4.6%) had alternate diagnoses. In classical analysis, LE was more sensitive than nitrite (87.5% versus 70.5%), while nitrite was more specific (24% versus 58%). The 3-tests in 1-population Bayesian LCM indicated a substantially better sensitivity and specificity for LE (98.1% and 47.6%) and nitrite (88.2% and 97.7%). True sensitivity and specificity of urine culture as estimated by the model was 48.7% and 73.0%. Estimates of the 2-tests in 2-populations model were in agreement with the 3-tests in 1-population model. CONCLUSIONS: Bayesian LCMs indicate a clinically important improvement in the true diagnostic accuracy of urine dipstick testing for LE and nitrite. Given this, a negative dipstick LE would rule-out UTI, while a positive dipstick nitrite would rule-in UTI in our study setting. True diagnostic accuracy of urine dipstick testing for UTI in various practice settings needs reevaluation using Bayesian LCMs.

Impact of Therapeutic Drug Monitoring on Once-Daily Regimen of Amikacin in Patients With Urinary Tract Infection: A Prospective Observational Study.

BACKGROUND: Amikacin is a semisynthetic antibiotic used in the treatment of gram-negative bacterial infections and has a narrow therapeutic index. Although therapeutic drug monitoring is recommended for amikacin, it is not routinely performed because of the use of a less toxic once-daily regimen. Only few studies have evaluated the role of therapeutic drug monitoring in patients treated with amikacin. The objective of our study was to find an association between the pharmacokinetic parameters of amikacin and the time required for a clinical cure, creatinine clearance, and frequency of ototoxicity in patients with urinary tract infection treated for 7 or more days. METHODS: A prospective study was conducted on patients with urinary tract infections who were administered amikacin for 7 or more days. Blood samples were obtained from the patients to measure the maximum drug concentration (Cmax) and trough concentration (Ctrough). Minimum inhibitory concentration (MIC) values were determined for patients with positive urine cultures. Serum creatinine levels were estimated every 3 days. The auditory assessment was performed using pure tone audiometry at baseline and weekly until the patients were discharged. Levels of amikacin were analyzed using a validated liquid chromatography-tandem mass spectrometry method. RESULTS: Of 125 patients analyzed, the median time required for a clinical cure was less in the group of patients who achieved a Cmax/MIC ratio ≥8 than it was in those who did not achieve this level [7 versus 8 days (P = 0.02)]. The Ctrough of amikacin was associated with the change in serum creatinine level (P = 0.01) and the incidence of nephrotoxicity (P = 0.004). CONCLUSIONS: In patients receiving short-term amikacin therapy, Cmax/MIC value can be used to predict the time required for a clinical cure. Ctrough can be used to predict the occurrence of nephrotoxicity in patients receiving amikacin therapy.

In vitro effect of fosfomycin on multi-drug resistant gram-negative bacteria causing urinary tract infections.

BACKGROUND: Rising rates of resistance to antimicrobial drugs among Enterobacteriaceae limit the choice of therapeutic agents to treat urinary tract infections. In this context we assessed the in-vitro effect of fosfomycin against extended-spectrum beta-lactamases, AmpC beta-lactamases and carbapenemase-producing strains of Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, and P seudomonas aeruginosa isolated from the patients with urinary tract infection (UTI) and also studied the effect of fosfomycin on their biofilm formation. MATERIALS AND METHODS: A total of 326 multidrug-resistant (MDR) isolates comprising of Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, and P seudomonas aeruginosa from the urine samples of the patients with a diagnosis of UTI were included in the study. MIC 50 and MIC 90 were detected by agar dilution method and the capacity to form biofilm in the presence of fosfomycin by these MDR isolates was assessed by the tissue culture plate method. RESULTS: The MIC50 for meropenem (0.5 µgm/mL) and nitrofurantoin (32 µgm/mL) was within the susceptible range only for E. coli. Fosfomycin was the only antibiotic that inhibited 100% E.coli, 70% Klebsiella spp, and 50% Pseudomonas spp and 40% Enterobacter spp which included the extended-spectrum beta-lactamases producers. It showed a similar effect on carbapenemase producers and AmpC producers. Fosfomycin disrupted biofilm in 67% (n=141) E.coli, 74% (n=50) Klebsiella spp, 88% (n=27) Pseudomonas spp and 36% (n=23) Enterobacter spp at 24 hrs of incubation with a concentration of 2 fold dilution lower than that of the MIC. CONCLUSION: Fosfomycin showed a good inhibitory effect on the biofilms produced by the MDR organisms studied here.

Prevalence and risk factors of gastro-esophageal reflux disease among undergraduate medical students from a southern Indian medical school: a cross-sectional study.

OBJECTIVE: Gastro-esophageal reflux disease (GERD) affects all age groups, and various lifestyle as well as psychological factors are recognized as risk factors for GERD. Undergraduate medical students are exposed to lifestyle changes and psychological stressors. We aimed to study the prevalence of GERD among undergraduate students of a medical school in southern India in a cross-sectional survey using a validated symptom score. RESULTS: A total of 358 undergraduate medical students participated in the study. There were 188 (52.5%) males and 170 (47.4%) females; the mean (SD) age of the participants was 20.3 (1.5) years. A total of 115 (31.2%) participants had at least one episode of heartburn per week, while 108 (30.1%) participants had at least one episode of regurgitation per week. Heartburn or regurgitation of at least mild severity was present in 115 (32.1%) and 108 (30.16%) of participants respectively. Based on the symptom score, a diagnosis of GERD was made in 18 (5.02%) students. Frequent consumption of carbonated drinks (OR = 3.63 [95% CI 1.39-9.5]; P = 0.008) and frequent consumption of tea or coffee (OR = 4.65 [95% CI 1.2-17.96]; P = 0.026) were significantly associated with a diagnosis of GERD.

Stopping the effective non-fluoroquinolone antibiotics at day 7 vs continuing until day 14 in adults with acute pyelonephritis requiring hospitalization: A randomized non-inferiority trial.

OBJECTIVE: To evaluate whether stopping the effective antibiotic treatment following clinical improvement at Day 7 (Truncated treatment) would be non-inferior to continued treatment until Day 14 (Continued treatment) in patients with acute pyelonephritis (APN) requiring hospitalization treated with non-fluoroquinolone (non-FQ) antibiotics. METHODS: Hospitalized adult men and non-pregnant women with culture-confirmed APN were eligible for participation after they had clinically improved following empirical or culture-guided treatment with intravenous non-FQ antibiotic(s). We excluded patients with severe sepsis, abscesses, prostatitis, recurrent or catheter-associated urinary tract infection, or urinary tract obstruction. We randomized eligible patients on Day 7 of effective treatment and assessed them at Weeks 1 and 6 after treatment completion. The primary outcome was retreatment for recurrent urinary tract infection. The prespecified non-inferiority margin was 15%. RESULTS: Between March 17, 2015 and August 22, 2016, we randomly allocated 54 patients-27 patients in each arm. Twenty-four (44%) patients were male, and 26 (48%) had diabetes mellitus. Escherichia coli was the most common urinary isolate (47 [87%] patients); 36 (78%) were resistant to ciprofloxacin. In all, 41 (76%) patients received amikacin-based treatment. At the end of 6 weeks, no patient in the truncated treatment arm required retreatment, whereas 1 patient in the continued treatment arm was retreated. Difference (90% CI) in retreatment was -3.7% (-15.01% to 6.15%). Upper bound of the difference (6.15%) was below the prespecified limit, establishing non-inferiority of truncated treatment. Asymptomatic bacteriuria at Week 6 was similar between the two arms (3/24 vs. 3/26; P = 1.0). Patients in the truncated treatment arm had significantly shorter hospital stay (8 [7-10] vs. 14 [14-15] days; P < 0.001) and less antibiotic consumption per patient (8.4 ± 2.8 vs. 17.4 ± 8.3 DDDs; P < 0.001). CONCLUSION: Stopping the effective non-FQ antibiotics following clinical improvement at Day 7 is non-inferior to continued treatment until Day 14 in selected patients with APN requiring hospitalization. TRIAL REGISTRATION: Clinical Trials Registry-India; CTRI/2016/04/006810.

Case-Mix, Care Processes, and Outcomes in Medically-Ill Patients Receiving Mechanical Ventilation in a Low-Resource Setting from Southern India: A Prospective Clinical Case Series.

BACKGROUND: Mechanical ventilation is a resource intensive organ support treatment, and historical studies from low-resource settings had reported a high mortality. We aimed to study the outcomes in patients receiving mechanical ventilation in a contemporary low-resource setting. METHODS: We prospectively studied the characteristics and outcomes (disease-related, mechanical ventilation-related, and process of care-related) in 237 adults mechanically ventilated for a medical illness at a teaching hospital in southern India during February 2011 to August 2012. Vital status of patients discharged from hospital was ascertained on Day 90 or later. RESULTS: Mean age of the patients was 40 ± 17 years; 140 (51%) were men. Poisoning and envenomation accounted for 98 (41%) of 237 admissions. In total, 87 (37%) patients died in-hospital; 16 (7%) died after discharge; 115 (49%) were alive at 90-day assessment; and 19 (8%) were lost to follow-up. Weaning was attempted in 171 (72%) patients; most patients (78 of 99 [79%]) failing the first attempt could be weaned off. Prolonged mechanical ventilation was required in 20 (8%) patients. Adherence to head-end elevation and deep vein thrombosis prophylaxis were 164 (69%) and 147 (62%) respectively. Risk of nosocomial infections particularly ventilator-associated pneumonia was high (57.2 per 1,000 ventilator-days). Higher APACHE II score quartiles (adjusted HR [95% CI] quartile 2, 2.65 [1.19-5.89]; quartile 3, 2.98 [1.24-7.15]; quartile 4, 5.78 [2.45-13.60]), and new-onset organ failure (2.98 [1.94-4.56]) were independently associated with the risk of death. Patients with poisoning had higher risk of reintubation (43% vs. 20%; P = 0.001) and ventilator-associated pneumonia (75% vs. 53%; P = 0.001). But, their mortality was significantly lower compared to the rest (24% vs. 44%; P = 0.002). CONCLUSIONS: The case-mix considerably differs from other settings. Mortality in this low-resource setting is similar to high-resource settings. But, further improvements in care processes and prevention of nosocomial infections are required.

Dengue Virus Infection Triggering Thrombotic Thrombocytopenic Purpura in Pregnancy.

We report a case of thrombotic thrombocytopenic purpura (TTP) that immediately followed symptomatic dengue virus infection in a pregnant lady. The patient developed dengue fever at 16 weeks of gestation, resulting in spontaneous abortion. Subsequently, fever reappeared with persistent thrombocytopenia and jaundice. Investigations revealed microangiopathic hemolysis; there was no evidence of disseminated intravascular coagulation. The TTP episode resolved after six cycles of therapeutic plasma exchange with fresh-frozen plasma. An ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motif 13 repeats) activity assay, done during convalescence, showed normal activity. The patient had an uneventful second pregnancy and has remained free of TTP recurrence for more than 2 years now. We review the pathophysiological basis of TTP in dengue infection, and suggest that jaundice with disproportionate elevation of serum aspartate aminotransferase level in a patient with dengue should arouse the suspicion of TTP.

Role of corticosteroids in the treatment of tuberculosis: an evidence-based update.

Corticosteroids are often used as an adjunct in the treatment of various forms of tuberculosis (TB) and for the prevention of complications, such as constrictive pericarditis, hydrocephalus, focal neurological deficits, pleural adhesions, and intestinal strictures. Notwithstanding, they have been proven in clinical trials to improve the following outcomes only--death or disability in human immunodeficiency virus (HIV)-seronegative patients with tubercular meningitis and tubercular pericarditis. Despite a lack of specific evidence for efficacy in HIV co-infected patients with tubercular meningitis or pericarditis, corticosteroids are generally recommended in them as well. Corticosteroids significantly decrease the risk of pleural thickening in patients with tubercular pleural effusion; the clinical significance of this finding, however, is unclear. Recently, it has been demonstrated that use of corticosteroids improve the morbidity in HIV co-infected patients with paradoxical TB immune reconstitution inflammatory syndrome (IRIS). However, evidence favouring the use of corticosteroids in other clinical situations is sparse or lacking. Likewise, the biological mechanisms underlying their beneficial effect in TB meningitis and pericarditis remain poorly understood.