Tropical Doctor

In common with Zika, Chikungunya and Dengue, Yellow Fever (YF) is an arthropod-borne flavivirus. It is transmitted between humans and from monkeys by mosquitoes of the Aedes aegypti (its principal vector), haemogogus and albopictus varieties. Three cycles of transmission may occur: urban; sylvatic; and intermediate. Recently, sub-Saharan Africa has seen the resurgence of this neglected disease. The current YF outbreak in Angola began in December 2015 in the capital Luanda and by October 2016 there had been > 4300 suspected cases, with 376 deaths (case fatality rate = 8.8%). A total of 884 were laboratory confirmed but it is likely that case numbers may be seriously underestimated. YF has subsequently quickly spread to neighbouring Congo and further afield to Kenya and also China, this being of grave concern as this was a first introduction of YF to Asia.

YF has recently hit Brazil, with 555 suspected cases and 107 deaths reported by the end of January 2017. Extremely rapid unplanned urban migration in Africa by non-immune rural populations to already densely populated cities, where high densities of mosquitoes co-exist with city dwellers in makeshift flimsy accommodation, poses a ready recipe for an epidemic of massive proportion. In such conditions, with enormously strained public services existing among the most needy and vulnerable populations, mosquito control programmes are nearly impossible. YF in Congo is a tempest barely restrained. However, it is one that can be controlled by focused and committed international collaboration, by intense and united political will and by the marriage of old and trusted techniques: a vaccine almost a century old and some of the most modern technologies available to man.

A cohort of 50 newly diagnosed patients with pulmonary tuberculosis was prospectively studied and compared with controls to assess and quantify their quality of life using the World Health Organization’s (WHO) Quality of Life (QOL)–BREF score before and after a Directly Observed Therapy Short (DOTS) course. It was concluded that health-related quality of life is impaired by tuberculosis and shows significant improvement with the DOTS treatment.

Tuberculosis (TB) and malignancy are among the most important current global health problems. Many authors suggest that their coexistence is a chance association owing to their high prevalence. There is, however, enough evidence that one condition may predispose the other. In our retrospective report of two cases, TB in draining lymph nodes was discovered incidentally on histopathology, following surgical resection for malignancy. The possibility of coexistent lesions, especially in regions endemic for TB, mandate a detailed histopathological examination to prevent the chances of diagnostic failure and thus therapeutic error.

Our study sought to determine the characteristics of antenatal patients with tuberculosis (TB) and their pregnancy outcomes. Case records of 50 antenatal women with extra-pulmonary and pulmonary TB at a tertiary centre in India were compared to 150 antenatal women not suffering from TB, for adverse medical, obstetric and neonatal outcomes. The prevalence of TB was 1.16 per 1000 deliveries. Of these, 62% had extra-pulmonary TB. There were two maternal deaths. TB in pregnancy was associated with a five times higher risk of prematurity and three times higher risk of intrauterine growth restriction than the norm. Maternal prognosis depends on the complications of tuberculosis and treatment compliance.

We sought to determine the incidence and clinical spectrum of the paradoxical reaction (PR) to treatment in 1000 children with tuberculosis (TB). Its incidence was 3.3%, presenting as mediastinal adenopathy (n = 12), central nervous system (CNS) tuberculoma (n = 8), increasing size of lymph nodes (n = 8) and serositis (n = 5). Symptoms included breathlessness (n = 7, 21.2%), neck swellings (n = 5, 15.2%), hemiplegia (n = 3, 9.1%), raised intracranial tension (n = 2, 6.1%) and fever or diabetes insipidus (n = 1, 3% each). The mean age of onset of PR was 3.5 months after the start of anti-TB medication. PR was seen predominantly in boys. Mediastinal lymphadenopathy was more common in children aged <2 years. Tuberculomas were more common in children aged 2–5 years. Nodal enlargement and serositis were seen equally in all age groups.

Differentiation of small bowel tuberculosis (SBTB) from Crohn’s disease (CD) is a diagnostic challenge. We studied 52 patients with suspected SBTB or CD with terminal ileal involvement, who were prospectively enrolled. After confirming patency of the gastrointestinal tract, 26 patients underwent capsule endoscopy (CE). A final diagnosis of CD was found in 18 patients and SBTB in eight patients. All SBTB patients had involvment of the ileocecal valve (ICV) with large (n = 6) and aphthous (n = 2) ulcers in the ileal segment. In CD, ICV involvement was seen in five (33%) patients. Large and aphthous ulcers were observed in seven (47%) and 15 (100%) patients, respectively. On comparison with CD, patients with SBTB had increased frequency of ICV involvement (P = 0.002) and lesser frequency of aphthous ulcers (P = 0.007). CE can help in differentiating CD from SBTB by the position of its involvement and the type of ulcers present.

The diagnosis of smear-negative pulmonary tuberculosis (PTB) is particularly challenging, and automated liquid culture and molecular line probe assays (LPA) may prove particularly useful. The objective of our study was to evaluate the diagnostic potential of automated liquid culture (ALC) technology and commercial LPA in sputum smear-negative PTB suspects. Spot sputum samples were collected from 145 chest-symptomatic smear-negative patients and subjected to ALC, direct drug susceptibility test (DST) testing and LPA, as per manufacturers’ instructions. A diagnostic yield of 26.2% was observed among sputum smear-negative TB suspects with 47.4% of the culture isolates being either INH- and/or rifampicin-resistant. Complete agreement was observed between the results of ALC assay and LPA except for two isolates which demonstrated sensitivity to INH and rifampicin at direct DST but were rifampicin-resistant in LPA. Two novel mutations were also detected among the multidrug isolates by LPA. In view of the diagnostic challenges associated with the diagnosis of TB in sputum smear-negative patients, our study demonstrates the applicability of ALC and LPA in establishing diagnostic evidence of TB.

Leptospirosis is a zoonosis and a major public health problem. Blood sampling was done in the province of Kurdistan from 250 members of different groups, including hunters and their families, butchers and slaughterhouse workers, healthcare workers (HCWs) and those referred to medical diagnostic laboratories for routine testing. Sera were tested using an ELISA method to detect specific Leptsopira IgG antibodies. We found 20.80% (95% confidence interval, 16.23–26.25%) to be positive. The highest and lowest seroprevalence were in hunters (26%) and HCWs (18%). There was significant positive correlation between age and seropositivity (P = 0.01). Hunting and eating the meat of the hare and exposure to dead or dying wild animals were found to be the main risk factors (P < 0.05).

Leptospirosis has been recognised as an emerging global public health problem. The aim of our study was to explore the epidemiological and clinical pattern of disease occurrence in suspected cases and to search for any existing co-infections. Ours was a retrospective study in patients with acute febrile illness in north India over a period of three years (April 2011 to June 2014). Serological diagnosis of leptospirosis was made using the PanBio IgM ELISA kit. Using modified Faine’s criteria, presumptive and possible diagnosis was made in 57% and 34% cases, respectively. Most of the affected population was resident in north and central India. Nineteen patients showed co-infection with other common pathogens prevailing locally. There is a need to increase awareness and understand the local sero-epidemiological pattern of leptospirosis so that timely preventive and curative action may be taken by healthcare authorities.

Much epidemiological information concerning brucellosis generally depends on the evaluation of hospital-based retrospective data. The aim of this study was to determine the prevalence and risk factors of brucellosis in female farmworkers in the south-eastern region of Turkey (GAP) in order to obtain a more representative analysis. Our representative community-based cross-sectional study was conducted during four months of 2013, in all nine GAP provinces. An optimum sample size was determined and blood samples were analysed from 707 reproductive-age female farmworkers using the Rose Bengal (RBT) and standard (SAT) agglutination tests. Sociodemographic information was collected during face-to-face interviews with consenting subjects. Crude odds ratios and 95% confidence intervals were calculated, and chi-square analyses and logistic regression were performed. Employment as a seasonal farmworker and having had five or more pregnancies were the only risk factors found to be significant. This study implies much greater priority needs be given to the control, early diagnosis and treatment in this population.

Dengue fever is of great concern to public health in India as it contributes significantly to the burden of healthcare. The aim of our study was to measure mortality in dengue and its association with hepatitis and thrombocytopenia. Our study was performed in a tertiary care setting in the state of Kerala in southern India. Adult patients admitted in the year 2013 were included. Among 1308 confirmed dengue patients, the mortality rate was 1.76%. Hepatitis and thrombocytopenia were present in over 80% of all patients, but severe hepatitis was seen in 11.4% and severe thrombocytopenia in 9.3%. These were markers of fatal outcome. Other factors significantly associated with mortality were age >60 years, male sex, diabetes and the presence of any co-morbidity.

Dengue is endemic in more than 100 countries, giving rise to an increased number of deaths in the last five years in the South-East Asian region. We report our findings from a retrospective study of adults admitted with confirmed dengue at our institution. We studied the clinical and laboratory parameters associated with mortality in these patients. Of the 172 hospitalised patients studied, 156 (90.69 %) recovered while 16 (9.3%) died. Univariate analysis showed altered sensorium on presentation, lower haemoglobin and haematocrit levels, higher serum creatinine, higher serum transaminase and lower serum albumin levels to be significantly associated with mortality in dengue. Further, using stepwise multivariate logistic regression, altered sensorium (P = 0.006) and hypoalbuminemia (P = 0.013) were identified as independent predictors of mortality in dengue. Identification of these parameters early in the course of disease should prompt intensification of treatment in dengue cases.

Ours was a descriptive observational cross-sectional study carried out in a tertiary care hospital in eastern India over a period of one year to study the profile of neurological involvement in paediatric dengue patients. Of 71 laboratory-confirmed cases, 20 (28.17%) had neurological involvement. Common forms observed were acute encephalopathy (40%), encephalitis (30%), pure motor weakness (15%), transverse myelitis (5%), acute disseminated encephalomyelitis (5%) and Guillain–Barré syndrome (5%). The dengue IgM antibody could be detected in the cerebrospinal fluid of only two patients with encephalitis. Neurological involvement was present in all four patients who died during the study period (two-tailed P value = 0.005).

A 30-year-old woman presented to our outpatient department with complaints of pain and swelling in bilateral infrapatellar regions and a discharging sinus in the right knee over the duration of one year. Radiographs showed lytic regions in bilateral patellae. Samples sent from material curetted from sinus yielded no organism but histopathology reported granulomatous inflammation. Following a fresh magnetic resonance imaging (MRI) scan that revealed the infrapatellar pad of fat communicating with the patellar lesions, an exploration and evacuation was done. Material sent revealed epithelioid cell granulomas with caseous necrosis consistent with tuberculosis (TB). The patient was put on first line anti-tubercular treatment (ATT) and has responded favourably with healing of sinus and patellar lesions. Bilateral infrapatellar bursitis is not rare. However patellar TB as a cause for OMIT is not a common diagnosis. A bilateral patellar involvement has not been reported in literature to the best of our knowledge.

Infections are an important differential diagnosis in patients presenting with features of systemic vasculitis. We report a young lady with constitutional features, leg ulcers, digital gangrene and absent peripheral pulses with cervical adenopathy. Chest imaging revealed multiple necrotic lung lesions and involvement of left subclavian artery at its origin from the aorta, Histopathology from cervical lymph nodes showed multiple caseated lymph nodes, which in the context of a positive Mantoux test led us to diagnose tuberculosis and institute appropriate therapy. This is only the second report of tuberculosis presenting as peripheral gangrene, cutaneous ulcers and absent pulses, and serves to educate rheumatologists regarding the need to consider infections as mimics of vasculitis, especially in the developing countries.

Brucellosis is a common zoonotic infection worldwide and a major public health problem in developing countries including China. The aim of our study was to investigate the seroprevalence of Brucella infection in humans in Yixing, located at the centre of the Yangtze River Delta Urban Agglomeration.

A total of 895 sera from apparently healthy abattoir workers and 3303 sera from general healthy people living in rural areas were collected in Yixing, screened by Rose-Bengal plate agglutination test (RBPT) and the positives were confirmed by standard tube agglutination test (SAT) according to official Chinese diagnostic criteria.

Seropositivity among abattoir workers was 16.42% compared to zero among the general population living in rural areas. No significant difference of seropositivity was observed in age groups.

Contact or inhalation of Brucella organisms from infected animals, principally goats, was found to be a significant risk factor. Education in occupational hygiene and public healthcare programmes are needed to control this emerging problem.

We report a case of expanded dengue syndrome, where three uncommon presentations occurred concomitantly. A patient with dengue haemorrhagic fever presented initially with acute acalculous cholecystitis along with acute pancreatitis, but later on, during resolution of pancreatitis and cholecystitis, developed pancytopenia, most likely due to haemophagocytic syndrome. Such presentations, besides being rare themselves, have not been reported to occur concomitantly, in the same patient, during the same disease process.

As original tribal ways of living have morphed from a forest dweller existence, dengue is no longer an urban infection but is now also found in rural hilly areas. The spread of dengue is enhanced by the frequent movement of people to endemic areas where there is a vector mosquito presence. The impact of the virus is known to be great in the immunologically naive population. Our study reports on the threat of the dengue virus in these hilly areas.

Dengue fever has classically been described as a disease of children and young adults. Infants are naturally protected by virtue of maternally derived immunoglobulins, especially in endemic countries. The resurgence of dengue, coupled with the availability of early and sensitive diagnostic methods and a high degree of clinical suspicion, has led to an increasing number of infants being diagnosed. There is a wide spectrum of clinical manifestations, particularly in infancy. Here we describe three cases presenting with diverse clinical features, their subsequent management and outcome.

Tuberculosis (TB), being a global health problem, represents variedly. Its presentation as a labial swelling secondary to pubic bone TB has been reported rarely in literature. We report a case of pubic bone TB presenting as a labial swelling in a woman of reproductive age. Early diagnosis with fine needle aspiration cytology, acid-fast bacillus (AFB) staining, AFB culture and magnetic resonance imaging with early initiation of treatment resulted in a favourable outcome.