Dissecting an Outbreak: A Clinico-epidemiological Study of Nipah Virus Infection in Kerala, India, 2018.

BACKGROUND: An outbreak of Nipah virus infection was confirmed in Kerala, India in May 2018. Five out of 23 cases including the first laboratory-confirmed case were treated at Baby Memorial Hospital (BMH), Kozhikode. The study describes the clinical characteristics and epidemiology of the Nipah virus outbreak at Kozhikode during May 2018. OBJECTIVE: To study the clinical and epidemiological profile of Nipah virus epidemic that occurred in Kerala in May 2018. METHODS: A collaborative team of physicians and epidemiologists from BMH, Medical College Hospital (MCH) Kozhikode and from the Indian Medical Association (IMA) conducted this study. The clinical and exposure history and the data on outbreak response were gathered from hospital medical records and through interviewing patient relatives and health workers using questionnaires. RESULTS: It was identified that out of the 23 patients with Nipah virus infection, 21 (91.3%) expired. Out of the 21 patients, 18 tested positive for Nipah virus by Real Time polymerase chain reaction (RT-PCR). It has been found that only the index case was infected in the community from fruit bats. Rest of the cases were due to transmission of the virus at three public hospitals. Median age was 45 years. 65% of them were males. Median incubation period was 9.5 days. Fever (100%), altered sensorium (84.2%), tachycardia (63.1%), hypertension (36.8%), segmental myoclonus (15.7%), segmental sweating (15.7%) and shortness of breath (73.6%) were common features. Mean duration of illness was 6.4 days. CONCLUSION: The rapid spread of infection uncovered the miserable state of health care system in implementing infection control measures. The case fatality and the socio-economic burden warrant developing appropriate treatments, vaccines and diagnostics.

Clinical Manifestations of Nipah Virus-Infected Patients Who Presented to the Emergency Department During an Outbreak in Kerala State in India, May 2018.

BACKGROUND: An outbreak of Nipah virus (NiV) disease occurred in the Kozhikode district of Kerala State in India in May 2018. Several cases were treated at the emergency medicine department (ED) of the Government Medical College, Kozhikode (GMCK). The clinical manifestations and outcome of these cases are described. METHODS: The study included 12 cases treated in the ED of GMCK. Detailed clinical examination, laboratory investigations, and molecular testing for etiological diagnosis were performed. RESULTS: The median age of the patients was 30 years and the male to female ratio was 1.4:1.0. All the cases except the index case contracted the infection from hospitals. The median incubation period was 10 days, and the case fatality ratio was 83.3%. Ten (83.3%) patients had encephalitis and 9 out of 11 patients whose chest X-rays were obtained had bilateral infiltrates. Three patients had bradycardia and intractable hypotension requiring inotropes. Encephalitis, acute respiratory distress syndrome, and myocarditis were the clinical prototypes, but there were large overlaps between these. Ribavirin therapy was given to a subset of the patients. Although there was a 20% reduction in NiV encephalitis cases treated with the drug, the difference was not statistically significant. The outbreak ended soon after the introduction of total isolation of patients and barrier nursing. CONCLUSION: The outbreak of NiV disease in Kozhikode in May 2018 presented as encephalitis, acute respiratory distress and myocarditis or combinations of these. The CFR was high. Ribavirin therapy was tried but no evidence for its benefit could be obtained.

Hematological Manifestations of SLE at Initial Presentation: Is It Underestimated?

SLE can present with hematological manifestations alone or along with features of other system involvement. With a low index of clinical suspicion or inadequate follow up the diagnosis may be delayed or missed at the time of presentation, in those with hematological abnormalities as the initial manifestation. An observational study was conducted among patients of SLE, in a tertiary referral centre of North Kerala, with the purpose of estimating the proportion of patients with hematological manifestations as the initial presentation of the disease and to study their nature. It was observed that 82% of the patients had hematological manifestations at presentation. It is the most common presenting manifestation of SLE in people of North Kerala. Autoimmune hypothyroidism was one of the common coexisting abnormalities in these patients, which is not included in the American College of Rheumatology (ACR) criteria for diagnosis. Arthritis was uncommon among those who presented with hematological manifestations. A significant number of patients do not satisfy the ACR criteria at the time of diagnosis but do so on follow up. The ACR criteria are weak to diagnose such patients and therefore need revision. We therefore propose an alternative to ACR criteria as "Kozhikode criteria for SLE".