Dengue fever in a south Asian metropolis: a report on 219 cases.

BACKGROUND AND OBJECTIVES: Yearly epidemics of Dengue fever occur post-monsoon in India's capital, Delhi. A prospective observational study was conducted during the outbreak months to understand the epidemiology and outcome of this infection and its economic impact. MATERIALS AND METHODS: Febrile hospitalized (n=219) patients with dengue fever diagnosed by a combination of MAC-ELISA, GAC-ELISA and NS1Antigen-ELISA were enrolled. Epidemiologic (including economic) parameters, clinical, radiological and laboratory manifestations were noted and patients followed up over the period of hospital stay. Patient management means and outcome were recorded and analysed. RESULTS: As per WHO-2009, 153 (69.9%) and 27 (12.3%) patients were classified as dengue with warning signs and Severe Dengue respectively while according to WHO-1997 guidelines 39 (17.8%) and 18 (8.2%) patients were classified as DHF and DSS respectively. 216 patients were from the city while three were travellers; hospitalization was more frequent among the young and male gender. Fever, vomiting, aches and abdominal pain were the most common troublesome manifestations; classical dengue triad was present in 55 (25.1%) patients; hemorrhagic, neurologic and mucocutaneous manifestations were present in 44 (20.1%), 8 (3.7%) and 70 (32%) patients. Ascitis, pleural effusion, and Gall bladder wall oedema was found in 53 (24.2%), 31 (14.1%) and 45 (20.5%) patients respectively. Mortality was 1.4% (3 deaths); in addition there was an intra-uterine fetal death; mean expenditure per patient during the illness was US$ 377.25. CONCLUSION: Dengue virus infection results in immense morbidity and substantial mortality.

Commercial Disinfectants During Disinfection Process Validation: More Failures than Success.

INTRODUCTION: Disinfection process validation is mandatory before introduction of a new disinfectant in hospital services. Commercial disinfection brands often question existing hospital policy claiming greater efficacy and lack of toxicity of their products. Inadvertent inadequate disinfection leads to morbidity, patient's economic burden, and the risk of mortality. AIM: To evaluate commercial disinfectants for high, intermediate and low-level disinfection so as to identify utility for our routine situations. MATERIALS AND METHODS: This laboratory based experiment was conducted at St Stephen Hospital, Delhi during July-September 2013. Twelve commercial disinfectants: Sanidex®, Sanocid®, Cidex®, SekuSept Aktiv®, BIB Forte®, Alprojet W®, Desnet®, Sanihygiene®, Incidin®, D125®, Lonzagard®, and Glutishield® were tested. Time-kill assay (suspension test) was performed against six indicator bacteria (Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, Salmonella Typhi, Bacillus cereus, and Mycobacterium fortuitum). Low and high inoculum (final concentrations 1.5X10(6) and 9X10(6) cfu/ml) of the first five bacteria while only low level of M. fortuitum was tested. RESULTS: Cidex® (2.4% Glutaraldehyde) performed best as high level disinfectant while newer quarternary ammonium compounds (QACs) (Incidin®, D125®, and Lonzagard®) were good at low level disinfection. Sanidex® (0.55% Ortho-pthalaldehyde) though mycobactericidal took 10 minutes for sporicidal activity. Older QAC containing BIB Forte® and Desnet® took 20 minutes to fully inhibit P. aeruginosa. All disinfectants effectively reduced S. Typhi to zero counts within 5 minutes. CONCLUSION: Cidex® is a good high-level disinfectant while newer QACs (Incidin®, D125®, and Lonzagard®) were capable low-level disinfectants.

Significance of IgG optical density ratios (index value) in single reactive anti-Dengue virus IgG capture ELISA.

BACKGROUND AND OBJECTIVES: A single reactive IgG anti-Dengue virus ELISA test in the absence of IgM antibodies or NS1 antigen may denote current infection or past exposure to the virus. To determine whether IgG index value can be used to identify true current dengue infection we conducted a prospective observational study. MATERIALS AND METHODS: Suspected dengue patients (n =1745) were tested in their first specimen by MAC-ELISA, GAC-ELISA and NS1 antigen ELISA. Patients with MAC-ELISA and NS1Antigen non-reactive but GAC-ELISA reactive results (n =57) in their first test were followed up and repeated sampling was asked for IgG index values were calculated according to the manufacturer's instruction and classified as: low (2.2-2.5), medium (2.5-4.0) and high (>4.0). RESULTS: 16 out of 57 patients (28.1%) had low IgG Index value whereas 26 cases (45.6%) were categorized as medium and 15(26.3%) were classified as patients with high IgG index. Nine patients with paired reactive serology or antigen positive status were categorised as serologically confirmed dengue fever, 11 patients as not dengue with categorical evidence of other infections while the rest 37 casas with clinical, radiological and laboratory parameters suggestive of dengue but no serological confirmation as possible dengue. Among confirmed, possible and non-Dengue cases, 33.3, 32.4 and 0.0% had high Index value in comparison with 22.2, 29.7 and 27.3% showing low Index values, respectively. CONCLUSION: Our results suggested a high IgG response in favour of true dengue infection than past exposure while no conclusions should drawn from a low or medium reactive GAC-ELISA results in the absence of IgM antibodies and NS1 Ag.

Early markers of occult megaloblastosis for low-cost detection of hyperhomocysteinemia in patients with ischaemic stroke: preventive approach for primary health care.

Recent studies have focussed on the association between elevated homocysteine levels with megaloblastic changes and thromboembolic events, but the relationship between occult megaloblastosis (with normal haemoglobin levels) and ischaemic stroke has not been widely explored. The objective of this study is to establish a simple and economical marker for the detection of occult megaloblastosis at the community health care level in developing countries. A hundred patients who met the inclusion criteria were studied. At the 5% level of significance, the levels of cobalamin and folate were significantly lower, while the number of hypersegmented neutrophils on the peripheral smear was higher in patients from Group A (70 patients with high homocysteine) compared with the patients in Group B (30 patients with normal homocysteine). Forty-five (64.2%) of the 70 patients in Group A showed hypersegmentation of neutrophils in the peripheral smear. The high cost and difficulty in performing the vitamin assays limit their use as early markers of megaloblastosis. Hence, we conclude that in developing countries, the detection of hypersegmented neutrophils can be used at the primary healthcare level for early diagnosis of occult megaloblastosis, so that early therapeutic interventions with vitamins can prevent attacks of hyperhomocysteinemia-induced ischaemic stroke.

How benign is benign tertian malaria?

OBJECTIVE: This retrospective study was conducted to determine the incidence of various complications of Plasmodium vivax malaria based on review of case records. METHODS: The case records of all confirmed cases of malaria over the period of one year (September 2005-August 2006) were studied. Complete blood count, peripheral blood findings, liver and kidney functions were reviewed. The results of rapid diagnostic test for malaria (OptiMAL test, Diamed AG, Switzerland) were correlated with the peripheral blood smear findings in the patients in whom it was requested. All abnormal results like a positive direct Coomb's test were noted. Findings were clinically correlated. RESULTS: There were 265 confirmed cases by peripheral blood examination. Of these 221 were due to Plasmodium vivax and 41 due to P. falciparum. Two cases had mixed infection and in one case the species could not be identified as it showed only malarial pigment. The peak incidence of malaria was seen in September 2005 and August 2006. The complications in P. vivax were thrombocytopenia, biochemical evidence of hepatic dysfunction, renal damage, positive DCT and death due to ARDS. Thrombocytopenia was seen in 213 patients with counts < 20 x 103/microl in 13 patients. Nine (4%) patients had serum bilirubin >3 mg/dl with normal liver enzymes. Liver enzymes were elevated in 60 patients with seven patients showing liver enzymes level, three times the normal. Renal dysfunction was seen in 17 patients with serum creatinine ranging from 1.3-10.65 mg/dl. One patient went into acute renal failure following quinine therapy and showed red cell fragments in the peripheral blood. In two children DCT was positive with the peripheral smear showing RBC agglutinates around the parasitised RBC. There were three maternal deaths at about 32 weeks gestation due to ARDS. The peripheral blood smear in these patients showed WBC agglutinates. CONCLUSION: This paper is presented to highlight that P. vivax malaria though considered to be a benign entity can also have a severe and complicated course which is usually associated with P. falciparum malaria.

Megaloblastic anaemia: prevalence and causative factors.

BACKGROUND: Megaloblastic anaemia is not uncommon in India, but data are insufficient regarding its prevalence, and causative and precipitating factors. We did a prospective study to document such data for patients of megaloblastic anaemia. METHODS: All patients presenting to our hospital over a period of 6 months with a haemoglobin < 10 g/dl and/or mean corpuscular volume > 95 fL and blood film findings consistent with megaloblastosis were included in the study. Demographic data, diet, drug intake, previous blood transfusion and presenting symptoms were recorded. Clinical findings were obtained from medical records of patients. Complete blood counts, blood film examination, reticulocyte count and cobalamin and folate assays were done. Results of liver function tests and bone marrow slides were available for review. RESULTS: Megaloblastic anaemia was diagnosed in 175 patients with anaemia. Assays were done on 120 patients (55 were lost to follow up) and results showed cobalamin deficiency in 78 patients (65%), combined cobalamin and folate deficiency in 20 patients (12%) and pure folate deficiency in 8 patients (6%). Fifteen per cent of patients had normal or high values of both vitamins, having received blood or haematinics before the diagnosis was established. The peak incidence of megaloblastic anaemia was in the age group of 10-30 years (48%), with female preponderance (71%). The predominant symptoms were fatigue, anorexia and gastritis, low grade fever, shortness of breath, palpitations and mild jaundice. Twenty-five per cent of patients were on acid-suppressing medication and 15% had previous transfusion for anaemia. Eighty-seven per cent of patients with cobalamin deficiency and 75% with folate deficiency were lactovegetarians. In the combined deficiency cohort, 71% were vegetarians and 29% were occasional non-vegetarians. Physical findings were pallor (85%), glossitis (29%), mild icterus (25%) and hyperpigmentation (18%). Abnormal haematological findings were mean corpuscular volume 77-123 fL (9 patients had iron deficiency), red cell distribution width 16%-44%, pancytopenia in 62% of patients, reticulocyte count > 2% in 42% of patients and typical megaloblastic blood films in all patients. Bone marrow smears available in 22 patients showed moderate-to-severe megaloblastosis. Thirty-two per cent of patients in whom liver function tests were done showed indirect bilirubinaemia with normal enzymes. CONCLUSION: Megaloblastic anaemia was diagnosed from complete blood counts, red cell indices, blood film examination and assays of the two vitamins. Bone marrow examination was not essential for diagnosis. Cobalamin deficiency was the major cause of megaloblastosis. Aetiological factors were a diet poor in cobalamin or folate, increased requirements during the growth period and pregnancy, and the use of acid-suppressing medication. Physicians managing these patients need to be aware of the timing of blood sampling for assays, that haematinics and transfusions provide only short term benefits, and that long term follow up and diet counselling is crucial.

Occult cobalamin and folate deficiency in Indians.

BACKGROUND: Our aim was to assess cobalamin and folate levels in normal Indian subjects before undertaking a prospective study of megaloblastic anaemia. METHODS: We took samples from 25 men and 25 women to establish the normal range. The exclusion criteria for subjects were age below 18 years and above 65 years, haemoglobin < 12 g/dl, and those who were pregnant, lactating or on any medication including vitamin supplements. A complete blood count and blood film examination for hypersegmented neutrophils were done. Serum cobalamin and folate assays were performed by a competitive immunoassay. The reference range supplied with the kits for serum cobalamin was 100-700 pg/ml and for serum folate it was 3-22 ng/ml. RESULTS: Since many 'normal' subjects in the sample showed values below the normal reference range, the numbers sampled were increased to 46 men and 50 women. Of all the subjects tested, 46.9% had subnormal values of one of the two vitamins. The normal ranges for serum cobalamin established in this study were--men 100-388 pg/ml and women 105.3-434 pg/ml. Of the 46 men tested, 17 (36.9%) had low cobalamin levels and of the 50 women tested, 23 (46%) had low cobalamin levels. Levels < 50 pg/ml were seen in 46.9% of these subjects. The normal ranges for serum folate in the study were--men 3.1 to > 22 ng/ml, women 3-12.26 ng/ml. In the study group, 8 men (17.3%) and 6 women (12%) had folate deficiency. Eight subjects (17%) had combined deficiency of the two vitamins. The mean corpuscular volume was not informative and was elevated in only 1 subject. Hypersegmentation of neutrophils was present in 75% of deficient subjects. CONCLUSION: We established normal levels for serum cobalamin and folate in our study group. Of the subjects studied, 46.9% had subnormal levels of serum cobalamin or serum folate, cobalamin deficiency being five times more common than folate. Hypersegmentation of neutrophils was a better indicator of occult megaloblastosis than the mean corpuscular volume.

Unique red cell abnormality in a case of fatal methylene blue induced haemolysis.

The appearance of a single blob of denatured haemoglobin in red cells staining prominently with supravital dyes is described in a case of fatal haemolysis following infusions of methylene blue (MB) for the treatment of toxic methaemoglobinaemia. This unique inclusion hitherto unreported may be used to predict impending haemolysis.