Study of clinical profile and outcomes in progressive multifocal leukoencephalopathy in acquired immunodeficiency syndrome patients in the highly active antiretroviral therapy era - An observational study.

Background and Objectives: Progressive multifocal leukoencephalopathy (PML) is a viral infection affecting the central nervous system (CNS) seen mostly in advanced human immunodeficiency virus (HIV) infection. There is limited data on the epidemiology and disease course of these patients from India. This study was aimed to determine the frequency of PML in patients with HIV/acquired immunodeficiency syndrome (AIDS) and the clinical presentation and prognosis of these patients. Materials and Methods: The study was conducted at a tertiary care HIV center in New Delhi. Data of 765 patients from our anti-retroviral therapy (ART) clinic during a span of 4 years were retrospectively analyzed and reviewed. The diagnosis was based on the clinical and radiological picture and exclusion of other differential diagnosis by cerebrospinal fluid and serological studies. Results: Of 765 patients with HIV/AIDS, 12 (1.56%) were diagnosed with PML on the basis of consistent clinical and radiological features after ruling out other differential diagnosis. PML was the initial presentation of HIV infection in 8 (55.5%) patients. 11 (89%) patients had CD4 count <200/µl. Insidious onset focal limb weakness (50%) and dysarthria (50%) were common symptoms. Magnetic resonance imaging of the brain revealed characteristic white matter lesions in all the patients. The estimated median survival was 40 months (95% confidence interval, 23.88-53.19 months). Interpretation and Conclusions: Our results show that PML is associated with high morbidity despite the institution of highly active ART (HAART), but mortality has significantly declined if ART is started early. Key to good response is early diagnosis and HAART.

High Prevalence of Vitamin D Deficiency in HIV Infected on Antiretroviral Therapy in a Cohort of Indian Patients.

OBJECTIVES: The main aim of this study was to assess vitamin D [25(OH)D]levels in an HIV infected adult population and to define HIV and antiretroviral-related factors associated with vitamin D deficiency. METHODS: This observational analytical study was conducted on 475 adult patients on follow up at Apex Immunodeficiency Center of Base Hospital, Delhi Cantt. We estimated the prevalence of vitamin D insufficiency/deficiency(<30 ng/ml). Age, gender, BMI, CD4 count, plasma viral load, HBV/HCV coinfection, smoking status, time since diagnosis of HIV infection and selected liver enzymes were recorded. Antiretroviral therapy regimen was taken into account and its relationship with vitamin D levels were noted. RESULTS: Vitamin D insufficiency/deficiency was noted in 92.63% of patients out of which 65.68 % were males. Median age of vitamin D sufficient group was slightly higher(52.11 vs 49.95). Patients with higher body mass index (BMI) had a slightly higher rates of Vitamin D insufficiency(24.2 vs 22.3). More the time interval from the date of diagnosis higher were the chances of deficiency/insufficiency. Co-infected patients with hepatitis B and C had sufficient vitamin D levels in 71.92% patients. Efavirenz(66.93%), nevirapine(79.02%), tenofovir(64.84%) and ritonavir(84.90%) containing regimens had consistently low levels of vitamin D. Abnormal liver enzymes viz alanine aminotransferase, alkaline phosphatase and gamma glutamyl transferase were associated with higher rates of deficient vitamin D levels. CONCLUSIONS: Vitamin D deficiency is very high in HIV patients on antiretroviral therapy. . Efavirenz (EFV), Nevirapine (NVP), Tenofovir (TDF) and Protease Inhibitors (PI's) were associated with high levels of deficiency/insufficiency of vitamin D levels. Vitamin D supplementation as a global strategy in all HIV positive patients on antiretroviral therapy is advocated.

Serum Alanine Aminotransferase Elevations in HIV Positive Patients on Antiretroviral Therapy in India.

BACKGROUND: Alanine aminotransferase (ALT) is commonly used to measure liver injury in resource limited settings. Elevations in ALT are predictive of increased mortality from liver disease and may be influenced by antiretroviral drugs and concomitant hepatitis B infection. METHODS: A cross-sectional analysis of the prevalence and predictors of elevated ALT (defined as> 40 IU/L) on HIV patients on antiretroviral therapy (ART) was conducted. Baseline ALT levels and at two weeks, six weeks, twelve weeks, twenty four weeks and one year were recorded for 320 patients on ART. Hepatitis B surface antigen was also recorded at baseline. RESULTS: Out of the total 320 patients, 249 were males and 71 females. A total of 252 patient records were used as controls who were not on ART. The mean ALT record before initiating ART was 30.6 IU/L. Peak rise in ALT was observed at twenty four weeks of therapy with mean ALT levels of 54.42 IU/L. Total toxicity was almost similar between the two regimes, nevirapine based being 17.62% and efavirenz based being 16.16%.Toxicty grades were lesser in Hepatitis B positive patients as compared with hepatitis B negative patients overall. CONCLUSIONS: This study concludes that elevated ALT levels are seen in patients on antiretroviral therapy and persist throughout the course of first year, though maximum levels are seen at around twenty four weeks of therapy. Total hepatotoxicity was found to be 16.89%. Longer follow up of patients is required to assess the effect of ALT elevations on morbidity and mortality of patients and a close monitoring of ALT is required in patients on ART and other hepatotoxic therapies.

Dengue Myocarditis Presenting as ST Segment Elevation MI.

Dengue myocarditis masquerading as ST segment elevation myocardial infarction and was thrombolysed is being discussed.

Clinical, immunological, and virological outcomes in HIV patients on raltegravir-based salvage therapy.

OBJECTIVES: The objective of the study is to assess the clinical, immunological, and virological outcomes in treatment-experienced HIV patients on raltegravir (RAL)-based salvage therapy. METHODS: This was a retrospective, observational study of patients with suspected second-line antiretroviral therapy failure who were followed up for at least 6 months, from January 2013 to January 2017, after switching to salvage regimen. A total of 20 patients who fulfilled the inclusion criteria and who had RAL-based salvage therapy were assessed for clinical, immunological and virological response. The data were picked up from the electronic database of the center and analyzed. RESULTS: Age, sex, date of initial diagnosis, date, and type of first line and second line regimens were documented, CD4 count, and plasma viral load at the time of initiation and after 3 and 6 months were recorded. Undetectable viral load was documented in all patients at 6 months. No noticeable adverse effects were noted. CONCLUSION: This study clearly shows that RAL containing regimens have a high degree of effectiveness in treatment-experienced patients and show effective and durable suppression of viral load with low adverse effect rates and reliable long-term safety.

Clinical and Biochemical Characteristics of Exertional Heat Stroke among Paratroopers in Agra, India.

OBJECTIVE: The purpose of this study was to assess the clinical profile, biochemical parameters and outcome in a series of 78 patients of heat stroke admitted and treated in a military hospital in India. METHODS: This was a prospective study in a military hospital. A total of 78 patients of exertional heat stroke admitted and treated over more than 2 years are reported. Cooling measures started immediately on site of occurrence, carried on during evacuation and in hospital, IV normal saline initiated, clinical symptoms and signs were noted. Blood was collected and sent for hematological, biochemical and coagulation parameters. RESULTS: Clinical features noted were violent behavior( 20.51%), confusional state (58.97%),coma (29.48%), seizure (33.33%),and vomiting (26.92%).Vital parameters were recorded and laboratory parameters revealed hypophosphatemia, hyponatremia, hypokalemia along with raised transaminases, creatinine kinase and lactic dehydrogenase. Patients were managed with cooling measures, IV fluids and supportive measures. All of them survived to be discharged in a mean of 8.34 days. CONCLUSIONS: Timely diagnosis, prompt intervention in form of effective cooling measures to reduce the temperature to acceptable levels within 30 mins, volume resuscitation, judicious use of ionotropes after adequate volume replacement and effective supportive care resulted in a favourable outcome.

Clinical and Laboratory Profile of Hospitalized Malarial Patients: An Agra-Based Study.

OBJECTIVE: The clinical presentations and laboratory profile of malaria has been changing over the years. Therefore this study was undertaken to study the clinical profile and laboratory parameters of malarial patients. METHODS: This prospective observational study was undertaken in military hospital with high prevalence of malaria. A total of 320 patients were studied. All patients tested positive by peripheral blood smear or rapid diagnostic test were included. Clinical presentations, hematological and biochemical parameters were noted. RESULTS: Of the total 320 patients, 249 had P vivax, 43 had P falciparum and 28 had mixed malaria.79% patients were male. Maximum (51.56%) patients were in 21-30 age group. The mean duration of symptoms was 2.54 days in vivax to 3.03 days in mixed malaria. Fever was observed in 97.8% of patients of vivax. Thrombocytopenia was observed in 99% of all patients. Splenomegaly was noticed in 24.84% patients of vivax and 34.5% of falciparum malaria. Herpes labialis was observed in 23.64% patients of vivax and 5.94% had urticaria. CONCLUSIONS: High index of suspicion should be maintained in picking up the diagnosis. Any patient with thrombocytopenia, leucopenia, headache, herpes labialis, pain epigastrium and urticaria deserves exclusion of malaria.

Clinical and Laboratory Profile of Dengue Fever.

OBJECTIVE: Dengue fever is one of the most common arboviral mediated outbreaks reported with increased prevalence year after year with considerable morbidity and mortality. This study was designed to assess the clinical and biochemical parameters of dengue fever patients. METHODS: Prospective observational study was undertaken among adult patients in a military hospital. Five hundred fiteen patients were studied and analysed. All patients who were NS1 antigen/IgM dengue positive were included in the study. Clinical features, hematological and biochemical parameters were noted. RESULTS: Of the 515 patients studied, majority were males (72.81%). Fever was the major symptom (100%) followed by headache (94.75%), myalgia (90.67%), retroorbital pain (18.25%), conjunctival injection (39.41%), rash (37.86%), abdominal pain (24.46%), pleural effusion (20%) and ascites (16.31%). Significant derangements in platelet (69.51%), leucocyte counts (20.19%) and serum transaminases (88.54%) were noted. Mortality rate was 0.77%. CONCLUSIONS: Fever associated with headache, retroorbital pain, erythematous morbilliform rash, conjunctival suffusion and itching in palms and soles along with thrombocytopenia, leucopenia, elevated liver transaminases should prompt a clinician on the possibility of dengue infection. Platelet transfusions have little role in management of dengue patients.

Nifedipine for the treatment of high altitude pulmonary edema.

OBJECTIVE: The purpose of this study was to assess the risk factors, patient profile, clinical features, and oral nifedipine as a treatment option for a series of 110 patients with high altitude pulmonary edema (HAPE) in a military hospital in India. METHODS: This was a prospective cross-sectional study in a military hospital. In all, 110 patients with HAPE admitted and treated over a period of 3 years are reported. The following measurements were noted: dyspnea, cough, chest pain, cyanosis, pulse rate, blood pressure, respiratory rate, crepitations, radiographic abnormalities, electrocardiogram, peripheral pulse oximetry (Spo(2)) at admission, Spo(2) normalization time, total leukocyte count, and length of hospital stay. RESULTS: The risk factors identified for development of HAPE in our patients were improper acclimatization/faster rates of ascent, higher defined height (10 500 feet [3200 m]) for first stage acclimatization due to logistic reasons (usually 9000 feet [2743 m]), cold exposure, severe exercise, and respiratory infection. All patients were treated with reduction of altitude, supplemental oxygen therapy with nasal prongs, and bed rest. Oral nifedipine or placebo was administered to alternating patients. None of the patients deteriorated during their hospital stay, and all recovered fully to be discharged an average of 4.01 days (range 2-6 days) after admission. Patients were monitored for time taken for normalization of oxygen saturation, duration of hospital stay, time needed for resolution of lung crepitations, and radiographic infiltrates. Nifedipine administration was not found to be better than placebo for any of these variables (P > .05). CONCLUSIONS: Improper acclimatization remains the foremost risk factor for HAPE. In addition to descent and supplemental oxygen, nifedipine appears to provide no additional benefit in the resolution of HAPE.