Tropical Doctor

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.

Chikungunya (CHIK) has re-emerged as a potential neurotropic virus, with outbreaks recently being reported from many parts of India. The present study was conducted to study the spectrum and outcome of neurological complications in patients of CHIK during the 2016 outbreak in Delhi. A total of 42 cases seropositive for IgM CHIK antibodies by MAC-ELISA and developing neurological complications were enrolled. The male:female ratio was 1:2 (age range = 18–90 years). The neurological manifestations observed were encephalitis (n = 12), bulbar palsy (n = 3), acute disseminated encephalomyelitis (n = 1), cerebellitis (n = 1), myelopathy (n = 1), radiculoneuropathy (n = 3), carpal tunnel syndrome (n = 9) and tremors (n = 1). Ten patients reported worsening of pre-existing neuropathic symptoms of diabetic peripheral neuropathy (n = 4) and carpal tunnel syndrome (n = 6). One patient had aggravation of myasthenia gravis leading to respiratory failure. The majority of patients (n = 32) showed a good outcome; ten had a poor prognosis, out of which four died, all from the encephalitis group, particularly the elderly with co-morbidities.

Folic acid is used in dengue patients. Our study aims to compare the duration of recovery of thrombocytopenia in patients with dengue infection who received folic acid and those who did not. We retrospectively reviewed the medical records of adult patients admitted over six years with a diagnosis of dengue. Of 2216 patients, 1464 fulfilled the inclusion criteria. Group A were those patients who received folic acid and group B were those who did not. A total of 1322 (90.3%) patients received folic acid. The mean time period required for platelets to double the nadir was 1.7 (±2.2) days in both groups A and B (P = 0.89). In conclusion, there is no significant difference in the recovery of thrombocytopenia in patients with dengue fever who received folic and those who did not receive folic acid.

Five-year clinico-laboratory data from 99 (one HIV seropositive) adults (mean age = 41.3 ± 20.4 years) who underwent bone marrow examination for fever persisting for ≥ 1 week were analysed and correlated with microbiological characteristics. Infections, reactive marrow changes and haematolymphoid malignancies were most commonly associated with fever. A high concordance rate of 71% was noted between aspiration and trephine biopsies. Bone marrow granulomas (BMG) were seen exclusively on sections and were most commonly of tubercular and typhoidal in origin (two Salmonella Typhi, one Salmonella Paratyphi A). The common aetiologies associated with fever and cytopenia(s) were BMG, acute leukaemia and haemophagocytic lymphohistiocytosis (HLH; n = 3). The yield from bone marrow culture was inferior compared to other body fluids. In conclusion, bone marrow histology is superior to smears in the evaluation of prolonged fever. Marrow culture may not be useful in immunocompetent individuals other than if Salmonellosis is suspected.

Diphtheria, a vaccine preventable disease in children, is still being reported from India. Details of 99 children with a clinical diagnosis of diphtheria admitted to a paediatric tertiary care teaching and referral hospital between January 2008 and December 2015 were collected retrospectively and analysed. The median (interquartile range [IQR]) age of the study group was 7.0 years (IQR = 5.0–8.0 years). Nearly two-thirds were unimmunised. Clinical features included fever (97%), dysphagia (82%), sore throat (67%), bull neck (54%), stridor (40%), neuropathy (27%) and nasal discharge (14%). Throat swab for Albert stain was positive in only 21% of cases and C. diphtheriae was isolated in only 28%. Complications included airway compromise (61.7%) followed by myocarditis (35.4%), acute kidney injury (22.3%), thrombocytopenia (25.3%) and neuropathy (27.3%). In all, 66% survived, 23% died and 11% opted for discontinuity of care owing to unfavourable prognoses. On multivariable logistic regression analysis, shorter duration of symptoms before presentation to our hospital was an independent predictor of unfavourable outcome (adjusted odds ratio = 0.88, 95% confidence interval = 0.79–0.99, P = 0.03).

Chlamydia trachomatis is an important agent of pelvic inflammatory disease (PID) globally. Laboratory diagnosis, which is vital for early and appropriate treatment, remains a challenge in resource-limited settings. Our study was undertaken to detect C. trachomatis in women with clinical features of PID. Three endocervical swabs, each obtained from 100 women clinically diagnosed with PID, were subjected to C. trachomatis antigen detection, microscopy and bacteriological culture. Logistic regression was used to assess the risk factors associated with PID. C. trachomatis antigen was present in 6%. The use of hormonal contraception, previous history of PID and a smoking habit were found to have statistically significant association in those who tested positive. Adjunctive use of rapid Chlamydia antigen test with a routinely practiced syndromic approach is beneficial for timely and appropriate antimicrobial therapy in women with PID.

Melioidosis is the disease caused by the soil and water bacterium, Burkholderia pseudomallei. Our study aimed to delineate its genitourinary manifestations. Over a 10-year period (2006–2016), 20 adults with culture-confirmed genitourinary melioidosis were identified. The patients were all men with a mean age of 45.3 ± 12.3 years. The common risk factors were diabetes mellitus (65%) and alcoholism (25%); a majority of patients (90%) had chronic melioidosis. Most had disseminated disease (n = 17) and 55% were bacteraemic. The prostate was the organ most frequently involved (60%, n = 12), followed by the kidney, bladder and seminal vesicles. Diagnosis was established by blood and urine cultures and imaging. Patients were successfully treated with ceftazidime intensive therapy followed by eradicative therapy, with surgical debridement and guided aspiration, when deemed necessary. There was one case fatality and no relapses. Melioidosis is an important differential to be considered in chronic genitourinary infections in the appropriate setting.

Most low-income nations have no practice guidelines for brain death; data describing brain death in these regions is absent. Our retrospective study describes the prevalence of brain death among patients treated in an intensive care unit (ICU) at a referral hospital in Malawi. The primary outcome was designation of brain death in the medical chart. Of 449 ICU patients included for analysis between September 2016 and May 2018, 43 (9.6%) were diagnosed with brain death during the ICU admission. The most common diagnostic reasons for admission among these patients were trauma (49%), malaria (16%) and postoperative monitoring after general abdominal surgery (19%). All patients diagnosed with brain death were declared dead in the hospital, after cardiac death. In conclusion, the incidence of brain death in a Malawi ICU is substantially higher than that seen in high-income ICU settings. Brain death is not treated as clinical death in Malawi.

Malnutrition continues to be a major killer of children, predominantly in low- and middle-income countries such as India. An ecological study was undertaken to correlate different demographic factors with the prevalence of underweight children. Based on findings from the National Family Health Survey 4 (2015–2016), 81 districts were analysed from three states in the eastern part of India. The findings suggest that female literacy (r = −0.556) and improved sanitation (r = −0.741) reduces the burden of malnutrition. Regarding childbirth, four antenatal visits (ANC), institutional deliveries, full immunisation, early breast feeding and adequate diet also reduce the degree of malnutrition among children. For preventing malnutrition, emphasis should be laid on improving social determinants and maternal health awareness.

A clinical association between exacerbation of asthma symptoms and Mycoplasma pneumoniae (M. pneumoniae) infection has long been suspected. We studied 80 children aged 5–15 years; 50 with asthma (Group 1) and 30 without an acute exacerbation of asthma (Group 2) for detection of M. pneumoniae by serology and polymerase chain reaction (PCR) on nasopharyngeal aspirates. Our study confirms that lower respiratory tract infections with M. pneumoniae are frequently associated with exacerbations of asthma in children.

Outcomes of arthroplasty in sub-Saharan Africa are not widely reported. To our knowledge, this systematic review is the first to explore this topic. Scopus, EMBASE, Medline and PubMed databases were searched, utilising MeSH headings and Boolean search strategies. All papers from South Africa were excluded. Twelve papers reporting 606 total hip replacements (THRs) and 763 total knee replacements (TKRs) were included. Avascular necrosis was the most common indication for THR, whereas osteoarthritis was the main indication for TKR. HIV prevalence of up to 33% was seen. Improvements were seen in patient-reported outcome measures in both THR and TKR. The dislocation rate in THR was 1.6%. The deep infection rate was 1.6% for TKRs and 0.5% for THRs. Positive results were reported, with comparable complications to high-income countries. However, there is likely to be significant reporting bias and the introduction of mandatory registries would enable more accurate monitoring across the region.

In Masanga, Sierra Leone, a multigravid woman presented with a urine pregnancy test negative molar pregnancy. This can be explained by the ‘hook-effect’. In resource-poor settings where quantitative serum hCG cannot be determined, it is of paramount importance to remain vigilant of the diagnosis of molar pregnancy. Clinical judgement and sonography remain key in diagnosing molar pregnancy in district hospitals in low- and middle-income countries (LMICs), especially since their occurrence is much more common in these countries.

Bezoars are indigestible foreign material in the gastrointestinal tract (GIT). A phytobezoar is a mass of plant material, while a trichobezoar consists of matted hair. This is found most commonly in the stomach in children who chew their long hair. When a gastric trichobezoar extends to the duodenum or jejunum, this is known as Rapunzel syndrome (RS), after a famous Brothers’ Grimm fairy tale. Our patient presented with haematemesis, localised peritonitis, a palpable epigastric mass, coagulopathy, severe anaemia and deranged liver function tests. An abdominal computed tomography scan was suggestive of a bezoar; gastroduodenoscopy confirmed the diagnosis. Treatment of trichobezoars normally involve endoscopic removal or gastrotomy and psychiatric intervention. They may also cause haematemesis, gastric outlet obstruction, gastric ulceration and perforation, multiple jejuno-jejunal intussusception, acute pancreatitis and cholestatic jaundice. Trichobezoar was first reported in the 18th century by Baudamant in a 16-year-old boy. RS was first described in 1968.

Gall bladder tuberculosis (TB) is a rare entity and differentiation of gall bladder TB from gall bladder malignancy is difficult. We hereby present an unusual case of incidental diagnosis of gall bladder TB during the evaluation of a gall bladder with suspicion of gall bladder cancer in a 49-year-old woman. The diagnosis of gall bladder TB was made with fine needle aspiration cytology (FNAC) from the gall bladder mass as the disease was found unresectable after cross-sectional imaging. Even with the advancement of cross-sectional imaging, the differentiation of gall bladder TB from gall bladder malignancy is not possible without tissue diagnosis.

With increasing use of ultrasound screening, the prenatal diagnosis of congenital diaphragmatic hernia (CDH) in better resourced areas has become the norm. However, early diagnosis is still not universal in resource-poor settings and late presentations of CDH continue. We retrospectively analysed the medical records of children operated for late-presenting CDH from 2001 to 2016 at our tertiary care centre in North India. A total of 32 patients were operated during the period with a male-to-female ratio of 3:1. Of these, 78% presented with respiratory symptoms, 37% with recurrent vomiting and 18% with an acute abdomen. Nine (28%) had been treated erroneously for gastroenteritis and another six (18%) had received anti-tubercular therapy for variable periods. A plain chest radiograph with a Ryle’s tube in situ was confirmatory in 75% (24/32). In conclusion, initial misdiagnosis and subsequent unnecessary therapeutic interventions were the leading cause of morbidity.

Cutaneous leishmaniasis (CL) is a parasitic disease which has a biphasic life cycle; infection by promastigotes from the sandfly reaches a wound where it is phagocytosed by macrophages, producing the amastigote (the Leishmania donovani body) in the host. A protozoan parasite transmitted by the phlebotomous sandfly causes human leishmaniasis. Cutaneous forms include classical cutaneous, mucocutaneous and post-kala-azar dermal leishmaniasis. It affects c. 300 million individuals in more than 90 nations around the globe.

The cutaneous form in the Old World is caused at low altitudes mainly by L. major (which has an animal reservoir, rodents such as mouse) and in swampy regions and high altitudes by L. tropica (which has no animal reservoir). L. aethiopica and L. major lead to disseminated ulcers in Saudi Arabia, Yemen, Iraq, Iran, Pakistan, India, Tunisia, Sudan and Ethiopia, whose main electrophoretic isozyme pattern Zymodeme in Saudi Arabia is LON-4.

A combination of anaemia and knuckle pigmentation should always raise concern for megaloblastic anaemia. As the terminal ileum is the site of vitamin B₁₂ absorption and also the commonest site of abdominal tuberculosis, a clinical triad of prolonged fever, knuckle pigmentation and right lower quadrant abdominal tenderness should suggest ileocaecal tuberculosis in endemic areas.

We report a 46-year-old woman presenting with leprosy, HIV and active pulmonary tuberculosis (TB). It is advisable to screen for each one of TB, HIV and leprosy patients, especially when an extra feature emerges. Particularly in a leprosy case, if TB remains undiagnosed, the development of rifampicin resistance secondary to monotherapy in leprosy is a major concern.

An increasing use of immunosuppressant medication mandates clinicians to look for leishmaniasis even in non-HIV febrile patients. We report this case to highlight leishmaniasis as a cause of fever in patients undergoing chemotherapy in an endemic area.

Mucormycosis is a potentially fatal fungal infection with high prevalence in poor-resource settings. Besides being an extremely expensive disease to treat, the challenges range from lack of experienced mycologists or mycology department to knowledge and availability of treatment regimes.