Acute Febrile Illness Patients Research Articles

Antibiotic trends in acute febrile illness

Background: Acute febrile illness has various etiologies. Different antimicrobials are used for different causes of fever to treat and there are interpersonal variations in prescription of antimicrobials. Therefore this study aims at to analyze the trends in the antimicrobial prescription in patients of acute febrile illness due to various etiologies in the medicine department of a tertiary care hospital.Methods: It is a record based observational study that was carried out at NKP salve institute of medical sciences and RC, Nagpur. 200 case record files of patients admitted with a diagnosis of acute febrile illness in the dept. of Medicine due to various etiologies were analyzed. Antibiotics prescribed for various causes of acute febrile illness like respiratory tract infections, urinary tract infection, gastrointestinal infection, malarial infections, septicemia, meningitis, pyrexia of unknown origin etc. were noted and data was analyzed for prescription pattern of antimicrobials.Results: Out of 200 patients of febrile illness the common clinical conditions for which antibiotics were prescribed were respiratory tract infections (upper respiratory tract infection 25.5% and lower respiratory tract infection 14%), acute gastroenteritis (20%), and urinary tract infection (13.5%) followed by, pyrexia of unknown origin (8.5%), viral fever (8%), malaria (7%), hepatitis A (1.5%), meningitis (1%) and rickettsial infection (1%). The commonly prescribed antibiotics were ceftriaxone in (19.37%) and cefixime (15.93%) followed by coamoxiclav (12.5%), azithromycin (11.87%), doxycycline (10.31%), ofloxacin and ornidazole (8.43%), levofloxacin (6.25%), ofloxacin (4.68%), ciprofloxacin (1.87%), artesunate (3.75%), artemether and lumefantrine (4.37%) and valacyclovir (0.625%).Conclusions: Our study concluded that most common disease for which antibiotics prescribed were respiratory tract infection and gasterointestinal infections. Most common antibiotic used were third generation cephalosporins especially ceftriaxone and cefixime.

Patterns of medication use and factors associated with antibiotic use among adult fever patients at Singapore primary care clinics.

BackgroundAntimicrobial resistance is a public health problem of global importance. In Singapore, much focus has been given to antibiotic usage patterns in hospital settings. Data on antibiotic use in primary care is lacking. We describe antibiotic usage patterns and assess factors contributing to antibiotic usage among adults presenting with acute febrile illness (AFI) in primary care settings in Singapore.MethodsWe analyzed data from the Early Dengue infection and outcome study. Adults with AFI presenting at 5 Singapore polyclinics were included. We used multivariable logistic regression to assess demographic, clinical and laboratory factors associated with antibiotic usage among adults with AFI.ResultsBetween December 2007 and February 2013, 1884 adult AFI patients were enrolled. Overall, 16% of adult AFI patients reported antibiotic use. We observed a rise in the use of over-the-counter medications in late 2009 and a decrease in antibiotic use during 2010, possibly related to the outbreak of pandemic influenza A H1N1 virus. After adjusting for age, gender, polyclinic and year of enrolment, the following factors were associated with higher odds of antibiotic use: living in landed property (compared to public housing) (OR = 1.73; 95% CI: 1.06–2.80); body mass index (BMI) <18.5 (OR = 1.87; 95% CI: 1.19–2.93); elevated white blood cell (WBC) count (OR = 1.98; 95% CI: 1.42–2.78); and persistence of initial symptoms at 2–3 days follow-up with OR (95% CI) for categories of 1, 2, 3, and ≥4 persisting symptoms being 2.00 (1.38–2.92), 2.67 (1.80–3.97), 4.26 (2.73–6.64), and 2.79 (1.84–4.24) respectively.ConclusionsOur study provides insights on antibiotic usage among adult patients presenting to primary care clinics with febrile illness, and suggests that high socio-economic status, and risk factors of a severe illness, that is, low BMI and persistence of initial symptoms, are associated with higher antibiotic use. Further work to understand trends of antibiotic usage in both private and public primary care clinics, and factors that influence patient expectation and physician prescribing of antibiotics is important.

Characteristics of acute febrile illness and determinants of illness recovery among adults presenting to Singapore primary care clinics.

BackgroundUndifferentiated acute febrile illness (AFI) is a common presentation among adults in primary care settings in Singapore but large gaps exist in the understanding of the characteristics of these patients. We studied clinical and epidemiological characteristics of AFI patients and factors associated with delayed recovery from AFI.MethodsWe performed a secondary data analysis using data from the Early DENgue infection and outcome (EDEN) study on 2046 adult patients presenting at 5 Singapore polyclinics between December 2007 and February 2013 with a history of fever (≥38 °C) for less than 72 h. We used an accelerated failure time model to investigate factors associated with delayed recovery from AFI.ResultsThe mean age of patients was 36.6 years, 65 % were male, 51 % were of Chinese ethnicity, and 75 % lived in public housing. Median illness duration was 5 days (interquartile range, 3–7). In multivariable analysis, the unemployed and white collar workers had longer illness duration compared with blue collar workers (time ratio (TR), 1.10; 95 % confidence interval (CI), 1.03–1.17 and TR, 1.08; 95 % CI, 1.02–1.15, respectively). Patients with more symptoms at initial consultation had slower recovery (TR, 1.03 per additional symptom; 95 % CI, 1.02–1.03). Other clinical factors were also associated with longer duration of illness, including use of analgesics (TR, 1.21; 95 % CI, 1.15–1.28); use of cough medicines (TR, 1.14; 95 % CI, 1.08–1.20); use of antibiotics (TR, 1.14; 95 % CI, 1.07–1.21); and hospitalization (TR, 1.59; 95 % CI, 1.39–1.82). Compared to patients with normal WBC count at first consultation, those with low WBC count had slower recovery (TR, 1.14; 95 % CI, 1.07–1.21), while the reverse was observed among patients with high WBC count (TR, 0.94; 95 % CI, 0.88–1.00).ConclusionsDifferences in illness duration among different types of employment may reflect differences in their underlying general health status. Early identification of factors delaying recovery could help triage management in a primary care setting. In-depth characterization of fever etiology in Singapore will improve surveillance and control activities.

Sentinel surveillance for influenza among severe acute respiratory infection and acute febrile illness inpatients at three hospitals in Ghana.

BackgroundInfluenza epidemiology in Africa is generally not well understood. Using syndrome definitions to screen patients for laboratory confirmation of infection is an established means to effectively conduct influenza surveillance.MethodsTo compare influenza‐related epidemiologic data, from October 2010 through March 2013, we enrolled hospitalized severe acute respiratory infection (SARI; fever with respiratory symptoms) and acute febrile illness (AFI; fever without respiratory or other localizing symptoms) patients from three referral hospitals in Ghana. Demographic and epidemiologic data were obtained from enrolled patients after which nasopharyngeal and oropharyngeal swabs were collected, and processed by molecular methods for the presence of influenza viruses.ResultsOf 730 SARI patients, 59 (8%) were influenza positive; of 543 AFI patients, 34 (6%) were positive for influenza. Both SARI and AFI surveillance yielded influenza A(H3N2) (3% versus 1%), A(H1N1)pdm09 (2% versus 1%), and influenza B (3% versus 4%) in similar proportions. Data from both syndromes show year‐round influenza transmission but with increased caseloads associated with the rainy seasons.ConclusionsAs an appreciable percentage of influenza cases (37%) presented without defined respiratory symptoms, and thus met the AFI but not the SARI definition, it is important to consider broader screening criteria (i.e., AFI) to identify all laboratory‐confirmed influenza. The identified influenza transmission seasonality has important implications for the timing of related public health interventions.

Sharp decline of malaria cases in the Burie Zuria, Dembia, and Mecha districts, Amhara Region, Ethiopia, 2012-2014: descriptive analysis of surveillance data.

BackgroundIn the Amhara Region of Ethiopia, a steep decline of malaria cases was seen in early 2014. This study verified the decrease of the malaria cases along with the positivity rates among acute febrile illness patients, from late 2012 through 2014 in selected districts of the Amhara Region of Federal Republic of Ethiopia.MethodsDescriptive epidemiological analysis was conducted on the routine malaria surveillance data from the World Health Organization epidemiological week 28 of 2012 to week 52 of 2014 in three districts: Burie Zuria, Dembia and Mecha, the Amhara Region in Ethiopia. The authors visited the three district health offices, and health centres, when necessary, and collected the surveillance data on malaria for that period.ResultsThe study found that the malaria cases, along with the positivity rates, decreased from late 2012 to early 2014 in all three districts. Though the situation had slightly reverted in late 2014, the numbers of cases were much smaller than in late 2012 in all three districts. Despite the different diagnostic techniques used at health centres (malaria microscopy) and health posts (rapid diagnostic tests), moderate to high correlations were found, suggesting that the trends were real and not caused by a defect in the reagent, differences in the technicians’ skills for microscopy, or a change of the health workers’ attitudes toward cases with acute febrile illness. The decrease in malaria cases in early 2014 may have resulted from successful implementation of the three pillars of malaria control—case management, indoor residual spraying and insecticide-treated nets—in the districts where a high percentage of households were protected by indoor residual spraying and/or insecticide-treated nets.ConclusionWhile the current efforts for malaria control should be strengthened and maintained, the review of malaria surveillance data should also be used to verify the malaria trend in the region.

Study of Aetiology and Outcome in Acute Febrile Illness Patients with Multiple Organ Dysfunction Syndrome.

Acute febrile illness with Multi Organ Dysfunction Syndrome (MODS) carries significant morbidity and mortality despite standard therapy in intensive care settings. Infections are the most common cause of MODS followed by polytrauma. Present study was undertaken in medical intensive care units of a tertiary hospital to study the aetiology and outcome among patients with acute febrile illness developing MODS. 1) To study the aetiology of acute febrile illness in patients developing MODS. 2) To study the final outcome among these patients. The present study was conducted at a tertiary care hospital in Mysuru, Karnataka, India, over a period of 6 months from July 2013 to December 2013. The Institutional Ethics Committee Approval (IEC) was obtained before the commencement of the study. A total of 213 cases admitted in intensive care unit with acute febrile illness with two or more organ dysfunction were screened for the inclusion and exclusion criterias. A total of 213 cases of acute febrile illness with one or more organ dysfunction were screened. Of the screened patients 75 patients were finally included in the study out of which 46 (61.3%) patients were males and 29 (38.7%) patients were females. Aetiology for acute febrile illness with MODS could be established in 49 (65.3%) patients and it was obscure in 26 (34.7%) patients despite repeated investigations. Dengue infection (29.3%) was the commonest cause of febrile illness with MODS followed by leptospirosis (22.7%). Majority of these patients had haematological derangements (78.7%) and liver function test abnormalities (68%). Out of these 75 cases, 54 (72%) patients recovered completely and 21 (28%) patients died. Among males (N=46), 35 (76.1%) patients recovered and 11 (23.9%) patients died where as among females (N=29), 19 (65.5%) patients recovered and 10 (34.5%) patients died. Mortality was proportionate with the number of organ dysfunction, especially Central Nervous System (CNS) involvement. Incidence of febrile illness with MODS is more prevalent in males but the outcome appears poorer among females. The diagnosis remained obscure in a sizable proportion of these patients. Prognosis was inversely dependent on the number of organs involved especially with CNS manifestations.

Spatial Distribution of Dengue in a Brazilian Urban Slum Setting: Role of Socioeconomic Gradient in Disease Risk.

BackgroundFew studies of dengue have shown group-level associations between demographic, socioeconomic, or geographic characteristics and the spatial distribution of dengue within small urban areas. This study aimed to examine whether specific characteristics of an urban slum community were associated with the risk of dengue disease.Methodology/Principal FindingsFrom 01/2009 to 12/2010, we conducted enhanced, community-based surveillance in the only public emergency unit in a slum in Salvador, Brazil to identify acute febrile illness (AFI) patients with laboratory evidence of dengue infection. Patient households were geocoded within census tracts (CTs). Demographic, socioeconomic, and geographical data were obtained from the 2010 national census. Associations between CTs characteristics and the spatial risk of both dengue and non-dengue AFI were assessed by Poisson log-normal and conditional auto-regressive models (CAR). We identified 651 (22.0%) dengue cases among 2,962 AFI patients. Estimated risk of symptomatic dengue was 21.3 and 70.2 cases per 10,000 inhabitants in 2009 and 2010, respectively. All the four dengue serotypes were identified, but DENV2 predominated (DENV1: 8.1%; DENV2: 90.7%; DENV3: 0.4%; DENV4: 0.8%). Multivariable CAR regression analysis showed increased dengue risk in CTs with poorer inhabitants (RR: 1.02 for each percent increase in the frequency of families earning ≤1 times the minimum wage; 95% CI: 1.01-1.04), and decreased risk in CTs located farther from the health unit (RR: 0.87 for each 100 meter increase; 95% CI: 0.80-0.94). The same CTs characteristics were also associated with non-dengue AFI risk.Conclusions/SignificanceThis study highlights the large burden of symptomatic dengue on individuals living in urban slums in Brazil. Lower neighborhood socioeconomic status was independently associated with increased risk of dengue, indicating that within slum communities with high levels of absolute poverty, factors associated with the social gradient influence dengue transmission. In addition, poor geographic access to health services may be a barrier to identifying both dengue and non-dengue AFI cases. Therefore, further spatial studies should account for this potential source of bias.

Human Anaplasmosis in Acute Febrile Patients during Scrub Typhus Season in Korea.

Dear Editor, Scrub typhus is an infectious disease caused by Orientia tsutsugamushi, and has become one of the most prevalent human diseases in Korea; since 2004, the disease has spread widely in the southwestern provinces of the country and is becoming endemic [1]. Anaplasmosis is caused by the bacterium Anaplasma phagocytophilum, and leads to human granulocytic ehrlichiosis (HGE) (human granulocytic anaplasmosis). A. phagocytophilum has been detected in Haemaphysalis longicornis, Ixodes nipponensis and I. persulcatus ticks in Korea [2]. The clinical presentations of scrub typhus/anaplasmosis are similar; symptoms that typically develop within 1-2 weeks of infection include fever, headache and malaise. Evidence has been suggesting the presence of A. phagocytophilum infections in South Korea [3]. Although scrub typhus is very common, to date, there has been only one confirmed report of anaplasmosis in Korea [4]. Serum specimens from 100 patients (≥ 18 years old) with acute febrile disease were studied using indirect immunofluorescence assay against O. tsutsugamushi for scrub typhus and real-time PCR for human anaplasmosis. The serum enrolled in this study was collected during the scrub typhus season in Korea from September 2011 to December 2012. The mean age of patients with febrile disease was 57.3 years. Forty-one acute febrile illness patients were positive for O. tsutsugamushi (41%), but none tested positive for A. phagocytophilum. HGA was first identified in the United States in 1994 [5] and subsequently in countries in Europe and Asia. A high percentage of Korean water deer (63.6%) were found to host A. phagocytophilum [6]. In a previous study, 1.8% of serum samples from patients with acute fever were positive for A. phagocytophilum on immunofluorescence antibody test [7]. The number of anaplasmosis cases reported to the CDC has increased steadily since the disease became reportable, from 348 cases in 2000, to 1,761 cases in 2010. The incidence of anaplasmosis has also increased, from 1.4 cases per million persons in 2000 to 6.1 cases per million persons in 2010 [8]. Since the presence of human anaplasmosis has been confirmed in Korea, this information provides a basis for treating and monitoring febrile patients with a history of contact with ticks. As both scrub typhus and anaplasmosis are potentially serious illnesses, urgent medical attention is required on suspicion of infection. In this study, we found acute febrile illness patients in Korea to have scrub typhus, with no evidence of anaplasmosis. Detailed studies are needed to isolate and identify Anaplasma spp. from humans, animals and vector ticks/mites in Korea from different regions to confirm their presence and capacity to cause disease.

Serological evidence of flaviviruses infection among acute febrile illness patients in Afghanistan.

Current published reports on the causative agents of acute febrile illness (AFI) in Afghanistan are scarce, and the burden of disease due to flaviviruses is unknown. A hospital-based surveillance study for AFI was established in 2008 through 2010 to determine the seroepidemiology of West Nile virus (WNV), tick-borne encephalitis virus (TBEV) and dengue viruses (DENV) using commercial ELISA kits. Due to major logistical challenges, only acute sera were collected. Serological analysis for IgG were as follows: WNV 30.4% (277/913); TBEV 23.4% (214/913); DENV 19.7% (180/913). Single positive IgG reactions for WNV, TBEV and DENV were noted in 11% (100/913), 7.2% (66/913), and 5% (47/913), respectively. Reactivity for all three screened flaviviruses was detected in 44.5% (406/913) of sera. IgM positivity was uncommon, with only 0.5% (5/913), 2.2% (20/913) and 2.6% (8/312) of samples positive for WNV, TBEV, and DENV, respectively. Serological findings were confirmed in random positive samples by neutralization assay. These serological results suggest circulation of WNV, TBEV, and DENV within Afghanistan, with evidence of current or prior infection noted in a significant proportion of patients seeking care for AFI. Obtaining additional information on the prevalence of these and other causes of AFI is paramount for improving the distribution of available limited syndromic treatment and improving the existing health protection policy in Afghanistan.

Scrub typhus associated acute kidney injury—a study from a tertiary care hospital from western Himalayan state of India

Objective: To report the clinical profile of acute kidney injury (AKI) associated with scrub typhus. Methods: Retrospective study of hospitalized patients of acute febrile illness who were diagnosed scrub typhus and had AKI. Results: 174 (35%) patients (75.9% female), mean age (41.4 ± 15.9 years) were studied. The laboratory abnormalities were: anemia (63.2%), leukocytosis (44.3%), thrombocytopenia (61.5%), hyponatremia (35.6%), hypernatremia (2.9%), and hypokalemia (12.1%), hyperkalemia (11.5%), hypoalbuminemia (56.9%), hepatic dysfunction (70%) and metabolic acidosis (28.7%). The complications of hypotension (5.7%), septic shock (3.4%), pneumonia (10.9%), acute respiratory distress syndrome (ARDS) (11.5%), meningoencephalitis (6.9%), encephalopathy (5.2%), gastrointestinal bleed (1.3%), myocarditis (3.4%), disseminated intravascular coagulation (2.9%) and multi organ failure (MOF) (10.3%) developed during course of hospitalization in these patients. Twenty-five (14.4%) patients required intensive care support (ICU) support and seven (4%) patients were dialyzed. 146 (83.9%) patients survived. Twenty-eight (16.1%) patients died. There was a significant difference in the age, various hematological & biochemical abnormalities, complications and need for ICU support in the non-survival group as compared the survival group. Conclusion: This study shows that AKI in scrub typhus is common and a severe disease. Age, a shorter hospital stay, severities of leukocytosis, thrombocytopenia, azotemia, hypoalbuminemia, hepatic dysfunction and the complications of ARDS, encephalopathy, MOF and need for ICU support are the factors associated with mortality.

Characteristics and outcome of dengue infection; clinical perspective from a secondary care hospital of Karachi.

Objective: To determine the frequency and characteristics of dengue fever (DF) in patients of acute febrile illness presenting at a secondary care hospital. Methodology: The observational cross sectional study was carried out from May to October 2010 in Remedial Centre Karachi and included patients above the age of 12 years who presented with acute febrile illness. The WHO classification and case definitions were used to classify the disease as Dengue Fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Clinical, hematological and biochemical findings were recorded serially until discharge. Results: During the study period, 90 (34.75%) presented with typical features of DF, 28 (31.11%) were dengue proven, seven (7.7%) proved to be of malaria in which malarial parasites were found positive in the peripheral blood, while the remaining 55 (61.11%) patients were dengue probable. Age of the patients ranged from 13 to 76 years. Fever was the most common clinical presentation (100%) followed by vomiting 50 (55.56%), body ache 31 (34.44%) abdominal pain 17 (18.89%) and headache 9 (10%). Maculopapular rash was seen in 4(4.44%) patients. Laboratory findings included thrombocytopenia, leucopenia and raised alanine aminotransferase levels. Eighty one patients (90%) improved clinically and hematologically and were discharged in stable condition. Conclusion: Fever and thrombocytopenia were the most common presentation of dengue fever (DF). The overall mortality of DF is low, if treated appropriately. Awareness of health care professionals and public regarding preventive strategies is essential to fight against this disease.

In vitro antibiotic susceptibility testing of Brucella isolates from Egypt between 1999 and 2007 and evidence of probable rifampin resistance

BackgroundBrucellosis poses a significant public health problem in Mediterranean countries, including Egypt. Treatment of this disease is often empirical due to limited information on the antibiotic susceptibility profiles of Brucella spp. in this region of the world. The aim of this study was to determine the antibiotic susceptibility profiles of Brucella blood isolates in Egypt, a country endemic for brucellosis.MethodsBrucella spp. isolates were identified from the blood cultures of acute febrile illness (AFI) patients presenting to a network of infectious disease hospitals from 1999–2007. Minimum inhibitory concentrations were determined for tetracycline, gentamicin, doxycycline, trimethoprim-sulfamethoxazole, streptomycin, ceftriaxone, ciprofloxacin and rifampin using the E-test. Interpretations were made according to Clinical and Laboratory Standards Institute (CLSI) guidelines.ResultsA total of 355 Brucella spp. isolates were analyzed. All were susceptible to tetracycline, doxycycline, trimethoprim-sulfamethoxazole, streptomycin and ciprofloxacin; probable resistance to rifampin and ceftriaxone was observed among 277 (64%) and 7 (2%) of the isolates, respectively. Percentages of isolates showing probable resistance to rifampin were significantly lower before 2001 than in the following years (7% vs. >81%, p < 0.01).ConclusionsDespite the high burden of brucellosis in Egypt and frequent empirical treatment, isolates have remained susceptible to the majority of tested antibiotics. However, this is the first report of high rates of probable resistance to rifampin among Brucella isolates from Egypt. Patients should be closely monitored while following standard treatment regimens. Continued surveillance, drug susceptibility studies and updated CLSI interpretive criteria are needed to monitor and update antibiotic prescribing policies for brucellosis.

Evaluation of a newly developed ELISA against Widal, TUBEX-TF and Typhidot for typhoid fever surveillance

Typhoid fever is endemic in many parts of the world and represents a major cause of acute febrile illness (AFI). Rapid and accurate laboratory methods for diagnosis of this disease are needed for both patient care and surveillance situations. Serum samples were collected from AFI patients and used to evaluate the performance of a newly developed ELISA assay that uses a mixture of somatic and flagellar antigens to detect the total antibody response against Salmonella enterica subspecies enterica serovar Typhi (S. Typhi) infection. The levels of Ig isotype response (IgG, IgM and IgA) were also evaluated, and results were compared to those of TUBEX-TF and Typhidot commercial kits. Of 234 culture-confirmed typhoid patients, the total Ig ELISA diagnosed 93% compared to 71% using Widal test. This sensitivity level (93%) is higher than that observed for the individual Ig ELISAs (IgG 75%; IgM 79%; IgA 57%) and the commercial tests TUBEX-TF (75%), Typhidot IgM (63%) and Typhidot IgG (28%). An agreement of 78% was achieved between the total Ig ELISA and Widal test. The average specificity of the ELISA was 96%. Using ELISA, up to 200 samples can be tested per run with cost per test at US$0.20. The developed ELISA shows superior sensitivity and specificity, when compared to Widal, TUBEX-TF and Typhidot assays, is more cost effective and allows higher throughput. This method is highly recommended for active surveillance studies or outbreak investigations of typhoid fever.

Mortality Analysis of Patients of Acute Febrile Illness During Monsoon in a Tertiary Care Hospital of Mumbai

To assess clinical profile, etiology, and postmortem findings of patients who died with short febrile illness during monsoon in Mumbai, the data of 160 deceased patients was collected and analyzed. A sex ratio of 1:4 favoring male was noted. About 54% below 34 years. Majority had symptom duration of 2 to 4 days. The average hemoglobin level being 7 to 9 g%, 51% had thrombocytopenia. The renal parameters including average blood nitrogen being 36 and creatinine level being 2.2 mg%. Among deceased 28.12% had acute respiratory disease syndrome (ARDS), 23% with associated renal failure, 15% isolated renal failure, 6% had hepatitis, and 11% had both hepatorenal involvement. About 22% deaths were due to malaria, 22% due to leptospirosis, 2% due to dengue, whereas in 54% no etiological agent identified. Autopsy done on 23% of the patients revealed that 48.6% had ARDS, 10.8% had associated alveolar hemorrhages, 8% had renal failure with ARDS, another 8% had myocarditis, and 5% had renal and 3% hepatorenal failure.

Childhood scrub typhus in eastern Taiwan: ten-year experience from a medical center

Scrub typhus, a potentially fatal rickettsial infection, is endemic in western Pacific Rims including Taiwan. Most reports have been concerned about mainly adult patients, whereas serologic surveys suggested that as many as one-half of cases of scrub typhus might be in children. We conducted a retrospective study of childhood scrub typhus in our hospital from January 1997 to December 2006. Scrub typhus was diagnosed on the basis of serology tests or polymerase chain reaction (PCR) examination in fifteen children. Fever and chigger bite history were presented in all 15 cases, and eschar lesion was identified in 12 patients (80%). Nine (60%) patients had headache and six (40%) complained of abdominal pain. Three patients (20%) had meningoencephalitis, and two (13%) hemophagocytic syndrome were confirmed by bone marrow biopsy. One patient died of progressive acute respiratory distress syndrome (ARDS) and pulmonary hemorrhage. Myocarditis was revealed in autopsy. All surviving patient responded well to antibiotic therapy, and the average duration to defervescence after treatment was 1.8 days. We conclude that scrub typhus should be taken into consideration among patients of acute systemic febrile illness, especially those with suspected exposure history and typical skin lesion. Although most patients responded well to treatment, severe complications such as meningoencephalitis, interstitial pneumonia, acute respiratory distress syndrome, hemophagocytic syndrome, and myocarditis might lead to morbidity and mortality.

Concurrent Infections in Acute Febrile Illness Patients in Egypt

We report the occurrence of concurrent infections with multiple acute febrile illness (AFI) pathogens during an ongoing prospective laboratory-based surveillance in four infectious disease hospitals in urban and rural areas of Egypt from June 2005 to August 2006. Patients were screened for Leptospira, Rickettsia typhi, Brucella, or Salmonella enterica serogroup Typhi by various methods including serology, culture, and PCR. One hundred eighty-seven of 1,510 patients (12.4%) evaluated had supporting evidence for the presence of co-infections; 20 (1%) of these patients had 2 or more pathogens based upon confirmatory 4-fold rise in antibody titer, culture, and/or PCR. Most coinfected patients lived or worked in rural agricultural areas. The high coinfection rates suggest that defining the etiologies of AFI is imperative in guiding proper disease treatment, prevention, and control strategies in Egypt.

Brucellosis as a cause of acute febrile illness in Egypt

To develop better estimates of brucellosis incidence, we conducted population-based surveillance for acute febrile illness (AFI) in Fayoum governorate (population 2347249), Egypt during two summer periods (2002 and 2003). All hospitals and a representative sample of community healthcare providers were included. AFI patients without obvious etiology were tested for brucellosis by culture and serology. Incidence estimates were calculated adjusting for sampling methodology and study period. Of 4490 AFI patients enrolled, 321 (7%) met the brucellosis case definition. The estimated annual incidence of brucellosis per 100000 population was 64 and 70 in 2002 and 2003, respectively. The median age of brucellosis patients was 26 years and 70% were male; 53% were initially diagnosed as typhoid fever. Close contact with animals and consumption of unpasteurized milk products were associated with brucellosis. The high incidence of brucellosis in Fayoum highlights its public health importance, and the need to implement prevention strategies in humans and animals.