Erythrocyte miRNA-92a-3p interactions with PfEMP1 as determinants of clinical malaria.

Based on the recently added high throughput analysis data on small noncoding RNAs in modulating disease pathophysiology of malaria, we performed an integrative computational analysis for exploring the role of human-host erythrocytic microRNAs (miRNAs) and their influence on parasite survival and host homeostasis. An in silico analysis was performed on transcriptomic datasets accessed from PlasmoDB and Gene Expression Omnibus (GEO) repositories analyzed using miRanda, miRTarBase, mirDIP, and miRDB to identify the candidate miRNAs that were further subjected to network analysis using MCODE and DAVID. This was followed by immune infiltration analysis and screening for RNA degradation mechanisms. Seven erythrocytic miRNAs, miR-451a, miR-92a-3p, miR-16-5p, miR-142-3p, miR-15b-5p, miR-19b-3p, and miR-223-3p showed favourable interactions with parasite genes expressed during blood stage infection. The miR-92a-3p that targeted the virulence gene PfEMP1 showed drastic reduction during infection. Performing pathway analysis for the human-host gene targets for the miRNA identified TOB1, TOB2, CNOT4, and XRN1 genes that are associated to RNA degradation processes, with the exoribonuclease XRN1, highly enriched in the malarial samples. On evaluating the role of exoribonucleases in miRNA degradation further, the pattern of Plasmodium falciparum_XRN1 showed increased levels during infection thus suggesting a defensive role for parasite survival. This study identifies miR-92a-3p, a member of C13orf25/ miR-17-92 cluster, as a novel miRNA inhibitor of the crucial parasite genes responsible for symptomatic malaria. Evidence for a plausible link to chromosome 13q31.3 loci controlling the epigenetic disease regulation is also suggested.

Impact of baseline fluorescent antinuclear antibody positivity on the clinical outcome of patients with primary autoimmune hemolytic anemia.

INTRODUCTION: Autoimmune haemolytic anaemia (AIHA) is an autoimmune disorder that can present in primary or secondary forms. The literature looking at impact of baseline fluorescent antinuclear antibody (FANA) positivity on outcomes of AIHA patients is infrequent. OBJECTIVE: To study the impact of baseline FANA positivity in patients with primary AIHA. METHOD: A prospective cohort study involving 29 consecutive primary AIHA patients presenting to the Haematology department from 2013 to 2015 was analysed. After recording baseline investigations including fluorescent ANA, all patients were treated as per the standard therapeutic protocols. Clinical remission, disease free survival, relapse, mortality were compared between the FANA positive and FANA Negative AIHA groups. RESULTS: Baseline FANA positivity was found in 17 patients (58.62%). Both the groups were comparable in terms of age, sex, Hemoglobin, LDH at presentation, number of lines of treatment needed and duration of follow up. Evan's syndrome was seen in six of FANA positive patients which was statistically significant (0 v/s 6, p = 0.023). FANA positive patients had significantly higher rates of relapse per patient month follow up (1.22 v/s 3.57, p = 0.023) and lower rates of complete response (83.33% v/s 35.29%, p = 0.0118) and relapse free survival at five years. Morbidity and mortality were numerically higher in FANA positive patients. CONCLUSION: Baseline FANA positivity among AIHA patients was found to be associated with lower complete response rates and higher relapse rates with possible higher rates of morbidity. Presence of FANA will give us prognostic value and help us in deciding the treatment options.

Serum soluble interleukin-2 receptor (sIL-2R) is an accurate biomarker for dengue-associated hemophagocytic lymphohistiocytosis syndrome diagnosed by Hscore.

OBJECTIVE: Hemophagocytic lymphohistiocytosis is a potentially fatal complication of severe dengue fever. Here we evaluated the serum soluble IL-2R levels as potential biomarker for identifying HLH in patients with dengue fever. METHODS: In this cross-sectional study conducted in a tertiary care center of a teaching hospital, subjects with dengue and fever of more than 5 days, leukopenia/thrombocytopenia and/or hepatosplenomegaly were studied. Data were collected to compare sIL-2R values and serum ferritin with Hscore and Histiocyte Society 2004 criteria. Relevant statistical methods were used. RESULTS: 80 subjects with severe dengue fever were analyzed with relevant investigations. Mean H score was 219.2 ± 17.6 in 18 dengue patients with HLH v/s 166.2 ± 11.2 in 62 patients without HLH (p = < 0.001). Serum ferritin (11,230.5 v/s 7853.5, p = 0.013) and sIL-2R (32,917.5 v/s 6210, p = < 0.001) were significantly higher in those patients with HLH. sIL-2R correlated very well with HScore (r = 0.98, p < 0.001) compared to ferritin (r = 0.51, p < 0.001) with an AUROC of 1.00 compared to 0.694 (95% CI 0.557-0.831) of serum ferritin for diagnosing HLH. A cut-off value of 10,345 pg/ml for sIL-2R had a sensitivity and specificity of 100% for HLH, whereas, a ferritin value of 8613 ng/ml had only 67% sensitivity and 55% specificity. CONCLUSION: sIL-2R could be a single most useful biomarker to differentiate dengue fever patients who are likely to progress to HLH, from those that are not. Full workup for HLH could be limited only to those patients with elevated sIL-2R, especially in resource limited settings.

Postural fall in systolic blood pressure is a useful warning sign in dengue fever.

Background: Capillary leak is the hallmark of development of severe dengue. A rise in haematocrit has been a major warning sign in WHO guidelines. Postural hypotension, which could reflect the intravascular volume reduction in capillary leak has been noted as warning sign in CDC and Pan American Health Organisation guidelines. We evaluated the diagnostic accuracy of postural hypotension as a marker of development of severe dengue. Methods: 150 patients admitted with dengue fever were recruited in this prospective observational study. Diagnostic accuracy of conventional warning signs (abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, increasing hematocrit with decreasing platelets) and postural hypotension was evaluated. Results: 23 (15.3%) subjects developed severe dengue. Multiple logistic regression analysis showed that ascites/pleural effusion and postural fall in systolic blood pressure of >10.33% had odds ratio of 5.024(95%CI:1.11 - 22.75) and 11.369 (95% CI:2.27 - 56.87), respectively. Other parameters did not reach statistical significance. Sensitivity and specificity of ascites/pleural effusion were 82.6% and 88.2% for development of severe dengue whereas postural fall in systolic blood pressure had sensitivity and specificity of 87% and 82.7%. Conclusions: These findings present a strong case for including postural hypotension as a warning sign in patients with dengue fever, especially in resource limited settings.

Impact of baseline fluorescent antinuclear antibody positivity on the clinical outcome of patients with primary autoimmune hemolytic anemia

Abstract Introduction Autoimmune haemolytic anaemia (AIHA) is an autoimmune disorder that can present in primary or secondary forms. The literature looking at impact of baseline fluorescent antinuclear antibody (FANA) positivity on outcomes of AIHA patients is infrequent. Objective To study the impact of baseline FANA positivity in patients with primary AIHA. Method A prospective cohort study involving 29 consecutive primary AIHA patients presenting to the Haematology department from 2013 to 2015 was analysed. After recording baseline investigations including fluorescent ANA, all patients were treated as per the standard therapeutic protocols. Clinical remission, disease free survival, relapse, mortality were compared between the FANA positive and FANA Negative AIHA groups. Results Baseline FANA positivity was found in 17 patients (58.62%). Both the groups were comparable in terms of age, sex, Hemoglobin, LDH at presentation, number of lines of treatment needed and duration of follow up. Evan's syndrome was seen in six of FANA positive patients which was statistically significant (0 v/s 6, p= 0.023). FANA positive patients had significantly higher rates of relapse per patient month follow up (1.22 v/s 3.57, p= 0.023) and lower rates of complete response (83.33% v/s 35.29%, p= 0.0118) and relapse free survival at five years. Morbidity and mortality were numerically higher in FANA positive patients. Conclusion Baseline FANA positivity among AIHA patients was found to be associated with lower complete response rates and higher relapse rates with possible higher rates of morbidity. Presence of FANA will give us prognostic value and help us in deciding the treatment options.

A novel method for measuring sublingual temperature using conventional non-contact forehead thermometer.

Background: Sublingual temperature measurement is a quick and accurate representation of oral temperature and corresponds closely with core temperature. Sub-lingual temperature measurement using non-contact infrared thermometers has not been studied for this purpose and if accurate they would be a reliable and convenient way of recording temperature of a patient very quickly. The aim of the study was to evaluate the utility of recording sublingual temperature using an infrared non-contact thermometer and establish its accuracy by comparing the readings with tympanic thermometer recordings. Methods: This cross-sectional study was carried out in 29 patients (328 paired recordings from sublingual and tympanic sites simultaneously). Subjects were requested to keep their mouth closed for five minutes before recording the temperature. Sublingual recordings were performed for each patient at different times of the day using an infrared thermometer. The infrared thermometer was quickly brought 1cm away from the sublingual part of the tongue and the recordings were then done immediately. Readings were compared with the corresponding tympanic temperature. Results: The non-contact sublingual temperature correlated very closely with tympanic temperature (r=0.86, p<0.001). The mean difference between the infrared sublingual and tympanic temperature was 0.21°C (standard deviation [SD]:0.48°C, 95% confidence interval [CI] of 0.16-0.27). The intra-class correlation co-efficient (ICC) between core and sublingual temperatures was 0.830 (95% CI: 0.794 to 0.861) p<0.001. The sensitivity of sublingual IR (infrared) temperature of 37.65°C was 90% and specificity was 89% for core temperature >38°C. Conclusions: This innovative modification of using the forehead infrared thermometer to measure the sublingual temperature offers an accurate, rapid and non-contact estimation of core temperature.

Core Stability Exercises Yield Multiple Benefits for Patients With Chronic Stroke: A Randomized Controlled Trial.

OBJECTIVE: This study examined the effect of core stability exercises on trunk control, core muscle strength, standing weight-bearing symmetry, and balance confidence of people with chronic stroke. DESIGN: This was an assessor-blinded randomized controlled trial involving 84 ambulatory patients with middle cerebral artery stroke, randomly assigned to three training groups. Two experimental groups practiced core stability exercises either on stable or on unstable support surfaces. In contrast, the control group received standard physiotherapy. All the participants underwent an hour-long training session a day, thrice a week over a 6-wk duration, and followed-up after 12 mos. Trunk Impairment Scale, core muscle strength, weight-bearing asymmetry in standing, and Activities-specific Balance Confidence scale were the outcome measures. RESULTS: Compared with the control group, the two experimental groups demonstrated a significant improvement on all the outcome measures from baseline to posttraining and from baseline to 12-mo follow-up (P < 0.001). The two experimental groups demonstrated no significant difference between them on all the measures (P > 0.05). CONCLUSIONS: Core stability exercises on stable and unstable support surfaces are equally beneficial in improving trunk control, core muscle strength, standing weight-bearing symmetry, and balance confidence of ambulatory patients with chronic stroke than the standard physiotherapy.

The Effect of Socioeconomic Factors and Indoor Residual Spraying on Malaria in Mangaluru, India: A Case-Control Study.

India faces 0.5 million malaria cases annually, including half of all Plasmodium vivax malaria cases worldwide. This case-control study assessed socioeconomic determinants of urban malaria in coastal Mangaluru, Karnataka, southwestern India. Between June and December 2015, we recruited 859 malaria patients presenting at the governmental Wenlock Hospital and 2190 asymptomatic community controls. We assessed clinical, parasitological, and socioeconomic data. Among patients, p. vivax mono-infection (70.1%) predominated. Most patients were male (93%), adult (median, 27 years), had no or low-level education (70.3%), and 57.1% were daily labourers or construction workers. In controls (59.3% male; median age, 32 years; no/low-level education, 54.5%; daily labourers/construction workers, 41.3%), 4.1% showed asymptomatic Plasmodium infection. The odds of malaria was reduced among those who had completed 10th school grade (aOR, 0.3; 95% CI, 0.26-0.42), lived in a building with a tiled roof (aOR, 0.71; 95% CI, 0.53-0.95), and reported recent indoor residual spraying (aOR, 0.02; 95% CI, 0.01-0.04). In contrast, migrant status was a risk factor for malaria (aOR, 2.43; 95% CI, 1.60-3.67). Malaria in Mangaluru is influenced by education, housing condition, and migration. Indoor residual spraying greatly contributes to reducing malaria in this community and should be promoted, especially among its marginalised members.

Fever Time Series Analysis Using Slope Entropy. Application to Early Unobtrusive Differential Diagnosis.

Fever is a readily measurable physiological response that has been used in medicine for centuries. However, the information provided has been greatly limited by a plain thresholding approach, overlooking the additional information provided by temporal variations and temperature values below such threshold that are also representative of the subject status. In this paper, we propose to utilize continuous body temperature time series of patients that developed a fever, in order to apply a method capable of diagnosing the specific underlying fever cause only by means of a pattern relative frequency analysis. This analysis was based on a recently proposed measure, Slope Entropy, applied to a variety of records coming from dengue and malaria patients, among other fever diseases. After an input parameter customization, a classification analysis of malaria and dengue records took place, quantified by the Matthews Correlation Coefficient. This classification yielded a high accuracy, with more than 90% of the records correctly labelled in some cases, demonstrating the feasibility of the approach proposed. This approach, after further studies, or combined with more measures such as Sample Entropy, is certainly very promising in becoming an early diagnosis tool based solely on body temperature temporal patterns, which is of great interest in the current Covid-19 pandemic scenario.

Asymptomatic malaria carriers and their characterization in hotpops of malaria at Mangalore.

OBJECTIVE: This study aimed to identify asymptomatic malaria carriers and study the differences in local and migrant population in Mangalore. MATERIALS AND METHODS: This study was conducted using two-stage cluster sampling. In the first stage, wards were randomly selected. The sample size for each cluster (wards) was determined using the probability proportionate to size method. In the second stage, required number of households was selected using a simple random sampling technique from each cluster. From the selected clusters, samples from 140 participants were collected. RESULTS: Of the 140 cases, 106 (75.7%) were male and 34 (24.3%) were female. Six cases (4.3%) of the 140 cases were positive for malarial parasites, of which gametocytes of Plasmodium falciparum were noted in three cases and schizonts of Plasmodium vivax in three cases. From the total number of cases, 56 (40%) constituted the migrant population and the remaining 84 (60%) were the local population. All the six patients with asymptomatic carriers belonged to the migrant population. CONCLUSION: A more sound malaria elimination strategy needs to be implemented, for which active surveillance for cases would form a backbone. This study shows that the migrant population seems to show a predilection for asymptomatic malaria, thus targeting malaria elimination programs to areas with a high migrant population would help.

Massive hemoptysis: A rare case with uncommon presentation and rapid response - A case report.

We report an unusual case of massive haemoptysis in young patient with mass lesion in left upper lobe. Bronchoscopic biopsy, percutaneous CT guided biopsy & serum marker confirmed the lesion to be granulomatous with polyangiitis (GPA). Rarity of the case was endoluminal bronchial lesion in GPA and radiographic presentation of mass lesion on the Computed Tomography. Also this case highlights that massive haemoptysis can be a sole and initial manifestation of GPA. Prompt diagnosis & pulse therapy led to dramatic symptomatic, clinical & radiological improvement, emphasizing the fact that GPA can present as acute emergency and rapid diagnosis with early treatment initiation with pulse steroid therapy & rituximab can be life saving measure.

Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series.

INTRODUCTION: Cytokines and granulocyte elastase produced in sepsis cleave a disintegrin and metalloprotease with thrombospondin type I motif 13 (ADAMTS13) and deplete its levels. By this mechanism, sepsis results in microangiopathic hemolytic anemia (MAHA) with thrombocytopenia. Hence, the hypothesis is that plasmapheresis may help in sepsis-induced thrombotic microangiopathy (sTMA), by removing the factors responsible for low levels of ADAMTS13. In tropical countries like India, the contribution of sepsis to intensive care unit (ICU) mortality is high; and hence, it is essential to look out for newer modalities of sepsis treatment. There is abundant literature on the use of plasmapheresis in sepsis but data on its use in sTMA are limited, thus necessitating further research in this field. CASE DESCRIPTION: This case series studies the outcomes of five patients admitted with sTMA in the ICU and attempts to evaluate the effectiveness of plasmapheresis in improving their outcomes. All patients diagnosed with sTMA and treated with plasmapheresis, between January 2016 and August 2018 at our tertiary care center, were selected for the study. The diagnosis of sepsis was based on sepsis-3 definition. RESULTS: Four different gram-negative organisms were found to have caused MAHA, with the commonest source being either urinary tract infection (UTI) or lower respiratory tract infection. Three of five patients required hemodialysis and two had disseminated intravascular coagulation (DIC). All five had good outcome and recovered well from the acute episode post plasmapheresis. DISCUSSION: In two of five patients, the initial smear was negative and hence the need for repeated examination of the peripheral blood smear should be kept in mind in cases of sTMAs. The median of the number of plasmapheresis sessions required in sTMA is six, which is lesser than that required for primary thrombotic thrombocytopenic purpura (TTP). Hence, the duration of central line placement and the risk of catheter-related complications are low. Based on the observations made in this case study, further exploratory studies are required to evaluate the efficacy of plasmapheresis in sTMA secondary to tropical infections. HOW TO CITE THIS ARTICLE: Upadhya SRS, Mahabala C, Kamat JG, Jeganathan J, Kumar S, Prabhu MV. Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series. Indian J Crit Care Med 2020;24(3):195-199.

MiRNA-146a Polymorphism Was Not Associated with Malaria in Southern India.

Micro-RNAs (miRNAs) play a crucial role in immune regulation, and a common miRNA-146a polymorphism (rs2910164) increased the odds of falciparum malaria in pregnant African women. Here, we examined whether this association holds true in a different population, that is, 449 mainly male and adult malaria patients and 666 community controls in southwestern India. Plasmodium vivax malaria (67%) predominated over falciparum malaria (11%) and mixed species infections (22%). Overall, 59% of the study participants carried the miRNA-146a polymorphism. However, it was not associated with the odds of malaria, irrespective of parasite species. This underlines the importance of considering the complexities of clinical manifestations of malaria, genetic background, and parasite species when disentangling the role of human genetic variation, including those of miRNAs in malaria.

Classification of fever patterns using a single extracted entropy feature: A feasibility study based on Sample Entropy.

Fever is a common symptom of many diseases. Fever temporal patterns can be different depending on the specific pathology. Differentiation of diseases based on multiple mathematical features and visual observations has been recently studied in the scientific literature. However, the classification of diseases using a single mathematical feature has not been tried yet. The aim of the present study is to assess the feasibility of classifying diseases based on fever patterns using a single mathematical feature, specifically an entropy measure, Sample Entropy. This was an observational study. Analysis was carried out using 103 patients, 24 hour continuous tympanic temperature data. Sample Entropy feature was extracted from temperature data of patients. Grouping of diseases (infectious, tuberculosis, non-tuberculosis, and dengue fever) was made based on physicians diagnosis and laboratory findings. The quantitative results confirm the feasibility of the approach proposed, with an overall classification accuracy close to 70%, and the capability of finding significant differences for all the classes studied.

Duffy antigen receptor for chemokines gene polymorphisms and malaria in Mangaluru, India.

BACKGROUND: Duffy blood group antigens serve as receptors for Plasmodium vivax invasion into erythrocytes, and they are determined by polymorphisms of the Duffy antigen receptor for chemokines (DARC), also known as Fy glycoprotein (FY). Duffy negativity, i.e., absence of the antigens, protects against P. vivax infection and is rare among non-African populations. However, data on DARC polymorphisms and their impact on Plasmodium infection in India are scarce. METHODS: In a case-control study among 909 malaria patients and 909 healthy community controls in Mangaluru, southwestern India, DARC polymorphisms T-33C (rs2814778), G125A (rs12075), C265T (rs34599082), and G298A (rs13962) were genotyped. Associations of the polymorphisms with the odds of malaria, parasite species and manifestation were assessed. RESULTS: Among patients, vivax malaria (70%) predominated over falciparum malaria (9%) and mixed species infections (21%). DARC T-33C was absent and C265T was rare (1%). FYB carriage (deduced from DARC G125A) was not associated with the risk of malaria per se but it protected against severe falciparum malaria (P = 0.03), and hospitalization (P = 0.006) due to falciparum malaria. Vice versa, carriage of DARC 298A was associated with increased odds of malaria (aOR, 1.46 (1.07-1.99), P = 0.015) and vivax malaria (aOR, 1.60 (1.14-2.22), P = 0.006) and with several reported symptoms and findings of the patients. CONCLUSION: This report from southern India is the first to show an independent effect of the DARC 298A polymorphism on the risk of malaria. Functional studies are required to understand the underlying mechanism. Moreover, FYB carriage appears to protect against severe falciparum malaria in southern India.

Characterization of Plasmodium vivax pvmdr1 Polymorphisms in Isolates from Mangaluru, India.

India accounts for approximately half of the global Plasmodium vivax cases, but information as to the presence of chloroquine (CQ) resistance is scarce. In an observational study in Mangaluru, south-western India, of 116 vivax malaria patients analyzed, 89.5% (102/114) had cleared parasitemia on days two or three of CQ treatment. Two remaining patients presented on days four and five without parasitemia. One hundred eight isolates of these 116 patients were successfully sequenced for pvmdr1 polymorphisms. Eight non-synonymous polymorphisms but no wild-type isolate were detected. Ten pvmdr1 haplotypes were observed with mutations T958M and F1076L occurring in all isolates, whereas the candidate CQ resistance marker Y976F was present in one isolate only. Pvmdr1 polymorphisms were not associated with early parasite clearance. The high proportion of early parasite clearance and the virtual absence of pvmdr1 Y976F and of sextuple pvmdr1 mutants suggest that CQ in the study area is still sufficiently effective. However, the abundance of pvmdr1 mutations in the local parasite population warrants monitoring.

Unique temperature patterns in 24-h continuous tympanic temperature in tuberculosis.

Body temperature monitoring in most healthcare institutions is limited to checking the presence or absence of fever. Our present study evaluated the 24h continuous tympanic temperature pattern in patients with fever in order to detect typical patterns seen in tuberculosis (TB). This observational study was conducted on 81 undifferentiated fever patients whose recordings were stored using the TherCom device. Unique temperature patterns were analysed and compared. TB patients exhibited a unique temperature pattern, namely a slow temperature elevation followed by slow temperature fall seen in 78.5% (22/28) compared to 24.52% (13/53) of non-TB patients. Recognition of this pattern may therefore be useful as a valuable diagnostic aid in the early diagnosis of TB.

Molecular Evidence for Plasmodium falciparum Resistance to Sulfadoxine-Pyrimethamine but Absence of K13 Mutations in Mangaluru, Southwestern India.

In most of India, sulfadoxine-pyrimethamine (SP) plus artesunate serves as first-line treatment for uncomplicated falciparum malaria. In 112 clinical Plasmodium falciparum isolates from Mangaluru, southwestern India, we sequenced molecular markers associated with resistance to SP, lumefantrine, and artemisinin (pfdhfr, pfdhps, pfmdr1, and K13). The pfdhfr double mutation 59R-108N combined with the dhps 437G mutation occurred in 39.3% and the pfdhfr double mutation plus the pfdhps double mutation 437G-540E in additional 24.1%. As for pfmdr1, the allele combination N86-184F-D1246 dominated (98.2%). K13 variants were absent. No evidence for artemisinin resistance was seen. However, the antifolate resistance alleles compromise the current first-line antimalarial sulfadoxine-pyrimethamine plus artesunate, which may facilitate the emergence of artemisinin resistance. Artemether-lumefantrine, introduced in northeastern parts of the country, in the study area faces the predominant pfmdr1 NFD genotype, known to impair lumefantrine efficacy. Further monitoring of resistance alleles and treatment trials on alternative artemisinin-based combination therapies are required.