Tropical Infections Research Articles

СЛУЧАИ ЗАВОЗА ТРОПИЧЕСКИХ ИНФЕКЦИЙ НА ТЕРРИТОРИЮ ТЮМЕНСКОЙ ОБЛАСТИ

Abstract. At present, the sphere of tourism, migration and immigration is actively developed, which contributes to the import of infections into the territory of the Russian Federation, including a number of especially dangerous ones, such as Ebola. Hemorrhagic fever Ebola is an acute viral especially dangerous infectious disease characterized by a severe course, pronounced hemorrhagic syndrome and a high mortality rate. The spread of the virus is Central and West Africa. The reservoir of the virus is rodents that live near human dwellings. Pathogen transmission mechanisms: aspiration, contact, artifact. Routes of transmission: airborne, contact, infectious. The virus is found in blood, saliva, nasopharyngeal mucus, urine, semen. Infection of people occurs during the care of the sick; in a domestic environment through hands and household items contaminated with the patient's blood and urine. Human susceptibility to the Ebola virus is high; does not depend on age and gender. Many imported diseases from the category of especially dangerous infections occur in a subclinical form, which complicates clinical diagnosis. The nature of the spread of the Ebola virus on the territory of the Tyumen region, in patients who arrived from foreign countries with an unfavorable epidemiological situation, was analyzed. A prospective observation of 4 patients admitted to the "Regional Infectious Diseases Clinical Hospital" of the city of Tyumen in October - November 2014 from the Democratic Republic of the Congo with suspected subclinical course of an especially dangerous infection - Ebola fever was carried out. In the course of clinical trials, the diagnosis was confirmed. In order to prevent the spread of the disease, an algorithm was developed and approved when working with this group of patients at the Regional Infectious Disease Clinical Hospital in Tyumen. As the research data showed, the possibility of importing tropical infections to the city of Tyumen and to the territory of the Russian Federation was revealed. Timely organization and implementation of treatment, prophylactic and anti-epidemic measures made it possible to eliminate and prevent the spread of a particularly dangerous tropical infection in the Tyumen region.

Pre-clinical development of a vaccine for human lymphatic filariasis

This study was conducted to optimize a fusion protein vaccine for translational development as a vaccine against the human tropical parasitic infection, lymphatic filariasis (LF). The vaccine candidate, His-tagged rBmHAXT was developed previously in our laboratory and was tested in various animal models including mouse, gerbils and Rhesus macaque where it exhibited significant levels of vaccine-induced protection. However, for commercial manufacturing and for regulatory approval for human use, there was a need to modify the vaccine antigen and its production and analytical release methods. Therefore, the major focus of this study was to develop a process for manufacturing an affinity tag-free rBmHAXT and evaluate its immunogenicity, potency and protective efficacy in both inbred and outbred mouse models, as well as in outbred gerbil models. Our results demonstrate that the tag-free rBmHAXT vaccine produced with a process suitable for cGMP production had protective properties equivalent to the original His-tagged rBmHAXT.

POS-054 TRIAD OF "FEVER, LIVER AND KIDNEY INJURY(FLIKI)": ETIOLOGY AND OUTCOMES IN NORTHERN INDIAN SETTINGS

The spectrum of community acquired kidney injuries varies in different parts of the world. The triad of fever, acute liver injuries, and kidney injuries (FLIKI), have been reported several times. The tropical climate with multiple tropical infections and low-middle income countries makes people vulnerable to this triad, which makes it different from developed nations’ spectrum. In this study, we analyzed the FLIKI and its outcomes.

Integrated healthcare approach can curb the increasing cases of cryptococcosis in Africa.

Cryptococcosis is a neglected tropical infection and a major cause of morbidity and mortality, especially in HIV–positive persons in Africa. Efforts to manage HIV infection have not had any significant impact on the fatalities due to cryptococcosis. An integrated healthcare approach that includes universal care coverage for Africans, expanded national care guidelines to include CrAg screening for vulnerable groups in all African countries, collaborative research, infection surveillance, and data sharing within Africa will mark a turnaround point.

Prevalence of arterial hypertension in liver cirrhosis and correlation with the severity of liver disease

Background and aim: Metabolic diseases and hypertension have increased dramatically in recent years, so the prevalence of hypertension in patients with cirrhosis is expected to increase. The aim of the study was to estimate the prevalence of hypertension in patients with liver cirrhosis and to determine its association with the severity of the liver disease. Patients and methods: This was a descriptive, cross-sectional, analytical study conducted at the Tropical Medicine and Infectious Diseases Department, Tanta University Hospital, Egypt. A total of 2051 patients with liver cirrhosis of various etiology were screened for participation in this study. 2014 patients were enrolled. They underwent blood pressure evaluation, blood tests and abdominal ultrasonography. Patients were classified into hypertensive and non-hypertensive groups. Results: The prevalence of arterial hypertension in patients with liver cirrhosis was 30.8%. As regards Child-Pugh class, hypertensive patients in class A were significantly increased (72.9 versus 48.7% respectively) while patients in class B and C were significantly decreased when compared with non- hypertensive patients (25.5,1.6 versus 33.29,17.93% respectively) (P <0.001). Conclusions: The prevalence of arterial hypertension in Egyptian cirrhotic patients is 30.7%, lower than that of the general population. Arterial hypertension is inversely associated with the severity of liver disease.

Herbs as Antidote for Snake Bite Treatment- Traditional Practices and Its Future Prospects- A Review

Snake bite is a life-threatening neglected tropical infection reporting high mortality across the world including India. Out of the available yearly statistics of this occupational hazard caused 4.5-5.4 million people and nearly 1,38,000 fatalities were reported globally. Several factors such as the low availability of antivenom, inadequate health centres in rural areas, poor transportation facilities affected the higher number of morbidity and mortality cases of snake bite. The prognostic and diagnostic approach towards the snake bite infection is difficult due to its complexity in venom. The conventional therapy is polyvalent antivenom derived from horses or sheep, with its limitations. The traditional physicians use plants and other herbs as its sustainable remedy for snake bite treatment. Nearly, 523 plant species from 122 families reported their neutralizing property against toxic venom. The secondary metabolites extracted from plants, are capable of reducing the toxic effects of the venom. Many research works has been reported the inhibitory potential of the plant compounds against the snake venom enzymes. Therefore, there is a necessity for increasing therapeutic studies on plant metabolites and the development of an antidote for the better treatment of snakebite. This review article discusses various herbal plant used for snake bite in India.

Madurella mycetomatis grains within a eumycetoma lesion are clonal.

Eumycetoma is a neglected tropical infection of the subcutaneous tissue, characterized by tumor-like lesions and most commonly caused by the fungus Madurella mycetomatis. In the tissue, M. mycetomatis organizes itself in grains, and within a single lesion, thousands of grains can be present. The current hypothesis is that all these grains originate from a single causative agent, however, this hypothesis was never proven. Here, we used our recently developed MmySTR assay, a highly discriminative typing method, to determine the genotypes of multiple grains within a single lesion. Multiple grains from surgical lesions obtained from 11 patients were isolated and genotyped using the MmySTR panel. Within a single lesion, all tested grains shared the same genotype. Only in one single grain from one patient, a difference of one repeat unit in one MmySTR marker was noted relative to the other grains from that patient. We conclude that within these lesions the grains originate from a single clone and that the inherent unstable nature of the microsatellite markers may lead to small genotypic differences.Lay In lesions of the implantation mycosis mycetoma many Madurella mycetomatis grains are noted. It was unknown if grains arose after implantation of a single isolate or a mixture of genetically diverse isolates. By typing the mycetoma grains we showed that all grains within a single lesion were clonal and originated from a single isolate.

Gastrointestinal basidiobolomycosis in pediatric age group: A single-center experience [Case Series

Basidiobolomycosis is a rare tropical fungal infection that affects mainly the skin. Gastrointestinal basidiobolomycosis (GIB) is extremely rare, especially in the pediatric age group with no history of immune deficiency diseases. Our patients have been diagnosed and managed between 2016 and 2019; diagnoses have been confirmed by histopathology. Six children were analyzed: 1 female and 5 males. Their age range was 15 months to 6 years of age. All patients came from Jazan governance, southwestern Saudi Arabia. None of the patients had a history of immune deficiency diseases. They all had a high level of eosinophil, erythrocyte sedimentation rate (ESR), and C-reactive protein. Three of them were diagnosed initially with GIT mass, 2 with acute appendicitis, and one with intussusception. Most of them were subjected to surgical procedures before definitive diagnosis: 2 had mass resection and 4 had a stoma. Only one case was diagnosed by simple biopsy, with no laparotomy, which reflects the difficulty of direct diagnosis of disease. All patients were managed properly post definitive diagnoses with antifungal and recovered completely. GIB is generally a lethal fungal infection, which can affect even immunocompetent individuals. Patients with GIB can present with variant complaints: constipation, vomiting, abdominal distention, or simply a palpable mass. Proper investigation, including complete blood count, ESR, and radiological examination, can prevent unnecessary surgery and catastrophic surgical management. Pediatric patients can recover completely after receiving antifungals if diagnosed early. • Voriconazole has a quick and good effect on disease. Early diagnosis helps avoid unnecessary operative management. • Before resecting intestinal mass in pediatric age group, a biopsy is mandatory to roll out other causes such as fungal mass. • Restoration of complete health in Gastrointestinal basidiobolomycosis can be achieved if treatment is initiated early. • Tihama plains has the highest rate of cases all over the world, needs more awareness of the disease among health professionals.

Artificial intelligence in differentiating tropical infections: A step ahead.

Background and objectiveDifferentiating tropical infections are difficult due to its homogenous nature of clinical and laboratorial presentations among them. Sophisticated differential tests and prediction tools are better ways to tackle this issue. Here, we aimed to develop a clinician assisted decision making tool to differentiate the common tropical infections.MethodologyA cross sectional study through 9 item self-administered questionnaire were performed to understand the need of developing a decision making tool and its parameters. The most significant differential parameters among the identified infections were measured through a retrospective study and decision tree was developed. Based on the parameters identified, a multinomial logistic regression model and a machine learning model were developed which could better differentiate the infection.ResultsA total of 40 physicians involved in the management of tropical infections were included for need analysis. Dengue, malaria, leptospirosis and scrub typhus were the common tropical infections in our settings. Sodium, total bilirubin, albumin, lymphocytes and platelets were the laboratory parameters; and abdominal pain, arthralgia, myalgia and urine output were the clinical presentation identified as better predictors. In multinomial logistic regression analysis with dengue as a reference revealed a predictability of 60.7%, 62.5% and 66% for dengue, malaria and leptospirosis, respectively, whereas, scrub typhus showed only 38% of predictability. The multi classification machine learning model observed to have an overall predictability of 55–60%, whereas a binary classification machine learning algorithms showed an average of 79–84% for one vs other and 69–88% for one vs one disease category.ConclusionThis is a first of its kind study where both statistical and machine learning approaches were explored simultaneously for differentiating tropical infections. Machine learning techniques in healthcare sectors will aid in early detection and better patient care.

Study of thrombocytopenia in patients of acute febrile illness

Introduction: Many viral and bacterial infections result in thrombocytopenia and are most common non-iatrogenic cause of thrombocytopenia. Infections can affect both platelet production and platelet survival. In addition, immune mechanisms can also be a cause, as in immune-mediated thrombocytopenia (ITP) in children following viral infection. In our setup, tropical infections like malaria, dengue and leptospirosis formed the most common and important causes of thrombocytopenia. Objectives: To correlate the bleeding manifestations of thrombocytopenia with platelet count in patients with acute febrile illness and to document the incidence of thrombocytopenia and most common cause of thrombocytopenia among patients with acute febrile illnesses. Methodology: A minimum of 200 patients admitted to tertiary care center with documented fever of >37.50C and platelet count <1,50,000/µL were selected using purposive sampling techniques. They were followed from admission till recovery, discharge or death. Correlation of bleeding manifestations like petechiae, gum bleeding, hematuria, menorrhagia, epistaxis in relation with lowest platelet count was done along with categorization of patients according to different platelet count ranges. Results: Out of total 200 patients 65% were male and 35% were female.

The mitosome of the anaerobic parasitic protist Entamoeba histolytica: A peculiar and minimalist mitochondrion-related organelle.

The simplest class of mitochondrion-related organelles (MROs) is the mitosome, an organelle present in a few anaerobic protozoan parasites such as Entamoeba histolytica, Giardia intestinalis, and Cryptosporidium parvum. E. histolytica causes amoebiasis in humans, deemed as one of the important, yet neglected tropical infections in the world. Much of the enigma of the E. histolytica mitosome circles around the obvious lack of a majority of known mitochondrial components and functions exhibited in other organisms. The identification of enzymes responsible for sulfate activation (AS, IPP, and APSK) and a number of lineage-specific proteins such as the outer membrane beta-barrel protein (MBOMP30), and transmembrane domain-containing proteins that bind to various organellar proteins (ETMP1, ETMP30, EHI_170120, and EHI_099350) showcased the remarkable divergence of this organelle compared to the other MROs of anaerobic protozoa. Here, we summarize the findings regarding the biology of the mitosomes in E. histolytica, from their discovery up to the present understanding of its roles and interactions. We also include current advances and future perspectives on the biology, biochemistry, and evolution of the mitosomes of E. histolytica.

A Study on Procalcitonin Levels in Patients having Sepsis with a Special Emphasis on Sepsis Due to Tropical Infections: A Cross-sectional Study

Background/Aims: To study the levels of Procalcitonin in patients presenting with sepsis, especially those with tropical sepsis at a rural population catering teaching hospital.
 Study Design: Cross-sectional study.
 Place and Duration of Study: This cross-sectional study was carried out at the Microbiology and General Medicine Department of SBKS Medical Institute & Research Centre affiliated to Sumandeep Vidyapeeth Deemed to be University. After obtaining necessary approval from the ethics committee this study was conducted between September 2012 and December 2015.
 Methodology: With the hypothesis that different microbiological agents, especially tropical infections, will evoke diverse host responses in sepsis, this study was undertaken. It was aimed at determining the levels of Procalcitonin in patients presenting with sepsis along with those having tropical sepsis. Patients with age >18 years and diagnosed clinically as sepsis by 1992/2001 definition were included in the study. PCT levels were determined in a total of 155 patients on admission. It was carried out by a semi-quantitative test till March 2015 and then later using a QDx Instacheck quantitative test kit and QDx Instacheck Reader. Ninety eight with tropical sepsis, 46 with non-tropical and 11 with sepsis due to unidentified etiologies were tested making a total of 155 patients.
 Results: Of the total 155 patients tested, 43 had values of ≤0.5ng/ml, 32 had values of >0.5 to <2 ng/ml, 55 had ≥2 to <10ng/ml and 25 had values of ≥10 ng/ml. Thus a larger number of patients showed the values ranging between 2ng/ml and 10ng/ml.
 Conclusions: Overall PCT was found raised in mainly bacterial, fungal and malarial infections especially with the values of ≥2 to <10 ng/ml whereas those with dengue had values of ≤0.5ng/ml. Thus PCT values were not much useful in differentiating infections due to bacteria, fungi or malaria but those with dengue had values ≤0.5ng/ml. Values of >10ng/ml were mainly associated with severity and mortality.

Genus Zanthoxylum as Sources of Drugs for Treatment of Tropical Parasitic Diseases

The tropical parasitic infections account for more than 2 billion infections and cause substantial morbidity and mortality, and account for several million deaths every year. Majorly parasitic infections in humans and animals are caused by protozoa and helminths. Chronic infections in the host can cause retardation, impairment of cognitive skills, development in young children and weaken the immune system. The burden is felt to a greater extent in developing countries due to poverty, inaccessibility to medicines and resistance observed to drugs. Thus, human health continues to be severely harmed by parasitic infections. Medicinal plants have received much attention as alternative sources of drugs. Zanthoxylum genus has been used ethnobotanically as an antiparasitic agent and the phytoconstituents in Zanthoxylum, show a wide variety of chemical substances with proven pharmacological actions such as alkaloids (isoquinolines and quinolines responsible for antitumor activity, antimalarial, antioxidant and antimicrobial actions), lignans, coumarins (antibacterial, antitumour, vasodilatory and anticoagulant activities), alkamide (strong insecticidal properties, anthelminthic, antitussive and analgesic anti antimalarial property). Therefore, this article is an attempt to review the existing literature that emphasizes on potential of genus Zanthoxylum as a source of lead compounds for the treatment of parasitic diseases.

Drivers of melioidosis endemicity: epidemiological transition, zoonosis, and climate change.

Melioidosis, caused by the soil-dwelling bacterium Burkholderia pseudomallei, is a tropical infection associated with high morbidity and mortality. This review summarizes current insights into melioidosis' endemicity, focusing on epidemiological transitions, zoonosis, and climate change. Estimates of the global burden of melioidosis affirm the significance of hot-spots in Australia and Thailand. However, it also highlights the paucity of systematic data from South Asia, The Americas, and Africa. Globally, the growing incidence of diabetes, chronic renal and (alcoholic) liver diseases further increase the susceptibility of individuals to B. pseudomallei infection. Recent outbreaks in nonendemic regions have further exposed the hazard from the trade of animals and products as potential reservoirs for B. pseudomallei. Lastly, global warming will increase precipitation, severe weather events, soil salinity and anthrosol, all associated with the occurrence of B. pseudomallei. Epidemiological transitions, zoonotic hazards, and climate change are all contributing to the emergence of novel melioidosis-endemic areas. The adoption of the One Health approach involving multidisciplinary collaboration is important in unraveling the real incidence of B. pseudomallei, as well as reducing the spread and associated mortality.

Severe Multi-inflammatory Syndrome in Children Temporally Related to COVID 19-Clinical Course, Laboratory Profile and Outcomes from a North Indian PICU.

Objective: We describe the trajectory of clinical course, laboratory markers and outcomes in children with severe multi-inflammatory syndrome temporally related to COVID-19 (MIS-C) admitted to our pediatric intensive care unit (PICU). Methods: This was a prospective case series of children admitted to PICU between May 1, 2020 and January 31, 2021, fulfilling the case definition of MIS-C published by World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC). We analyzed demographic, clinical, laboratory data and echocardiographic findings. We also plotted the variation in trends between survivors and nonsurvivors. Results: Of the 34 critically ill children referred to PICU with diagnosis of MIS-C only 17 fulfilled the WHO/CDC classification of MIS-C, rest were MISC mimickers albeit other tropical infections. Median age at admission was 4 years (range 1y 6 mo-8 years). Fever, rash and conjunctival redness were most prominent symptoms. Myocardial involvement was seen in 70.5% while 76.4% developed shock; Invasive mechanical ventilation was required in 64.7% cases. Inflammatory markers showed a downward trend such as-median C- reactive protein (mg/L) had a serial reduction in levels-from (median/IQR) 210 (132.60, 246.90) at admission to 52.3 (42, 120) on Day 3. Median Ferritin (ng/ml) (n = 12) was 690 (203, 1324), serum LDH (IU/L) (n = 12) was 505 (229.5, 1032) and Mean D-dimer (ng/ml) (n = 7) was 5093.85 (1991.65), suggestive of hyperinflammatory syndrome. Twelve patients received intravenous immune globulin, with adjunctive steroid therapy used in two third of the cases. Six children died, 4 of them were under-5 years of age. Tocilizumab was prescribed in two children with high vasotrope inotrope score (VIS), cardiogenic shock and oxygenation index more than 15, both survived. Conclusions: Severe MIS-C has a heterogenous presentation, local or regional outbreaks of prevalent infectious diseases often lead to confusion and overdiagnosis. Higher proportion of mortality was seen in Under -5 children with MISC. Shock-like presentation, presence of myocardial dysfunction or nonsurvivor status is associated with higher trend of inflammatory markers and more profound multi-organ dysfunction. If disease progresses rapidly despite first line therapy (IvIg and steroids), use of Tocilizumab should be considered-as a rescue therapy under resource limitations in the absence of extracorporeal support.

Aetiology and Outcome of Resection and Primary Anastomosis in Multiple Ileal Perforation

Background: Ileal perforation is a very frequent surgical emergency in surgery wards. In tropical country infection is the commonest cause. Repair of perforation, primary repair with loop ileostomy and resection and primary anastomosis are the commonly performed methods.
 Objectives: To identify the aetiology and assess the outcome of resection and primary anastomosis in multiple ileal Perforation.
 Study Procedure: This Quasi experimental study was carried out in the Department of Surgery, Rajshahi Medical College Hospital, Rajshahi. 92 patients were included in this study. Thorough clinical, Radiological and biochemical parameters evaluation with postoperative histopathology were performed. All patients treated with resection and primary anastomosis. Different types of Data and variables were recorded through data collection sheet. Mean and frequency of all quantitative and categorical variables were determined.
 Results: The mean age 42.60±4.44 (age range:18-69) years. Out of 92 patients 74(80.43%) were male and 18(19.56%) were female and ratio was 4.11:1.Presentation were 92(100%) abdominal pain, vomiting 74(80.43%), fever 60(65.21%) and abdominal distension 56(60.86%). Common Cause were typhoid fever 43(46.73%) and nonspecific inflammation 28(30.43%). Patient suffered from wound infection 18(19.44%), dehiscence 7(7.56%), anastomosis leakage 6(6.68%) and 5(5.43%) patient experienced incisional hernia. 74(80.43%) recovered uneventfully, 17(18.47%) recovered with complication and only 1(1.08%) died.
 Conclusion: Among the infections, typhoid fever is still the prime cause of multiple ileal perforation. Wound infection, wound gap, burst abdomen & primary repair leakage are the common complications. Uneventful outcome is present in majority cases. Delayed presentation, nutritional status and anastomosis from ileocaecal valve are the important deciding factor of worst outcome.
 Sir Salimullah Med Coll J 2021; 29(2): 153-157

Clinical spectrum and outcome of elevated serum transaminases in tropical infections among children aged one month to 18 years in an urban tertiary care centre: a prospective observational study

Background: Tropical infections are common in our country and occur with a variable elevation of transaminases in a majority of them and they pose as a differential diagnosis to the viral infections affecting the liver including COVID-19 and complications like HLH and also paracetamol toxicity. Aim was to study the clinical profile and degree of elevation of liver enzymes in tropical infections in children aged one month to18 years.Methods: A prospective observational study of children from one month to 18 years of age with tropical infections in Mehta's multispeciality hospitals, Chennai, India between June 2017 and May 2019 was analyzed. Elevation of liver enzymes was categorized as mild (1-3 fold), moderate (3-20 fold) and severe (>20 fold).Results: Dengue was the most common infection in our study and the majority (49.07%), followed by enteric fever (78.06%), malaria (27.27%) and leptospirosis (25%), all had a mild elevation of SGOT. Severe elevation of SGOT was seen in 25% of leptospirosis and less than 10% in malaria and none with scrub typhus. SGPT elevation was severe in 50% of leptospirosis. Dengue shock syndrome had a severe elevation of transaminases.Conclusions: The most common infection was dengue and the majority had mild elevation and those with shock had a severe elevation of transaminases whereas shock was not a feature in leptospirosis even in severe elevation in our study. Though liver enzymes were very much elevated, children recovered without any residual liver damage.

Phylogeny, Antifungal Susceptibility, and Point Mutations of SQLE Gene in Major Pathogenic Dermatophytes Isolated From Clinical Dermatophytosis.

Drug resistance is one of the major challenges to skin fungal infections, especially in tropical and subtropical infections caused by dermatophytes. This study aimed to determine the antifungal susceptibility of clinically dermatophytes and evaluate point mutations in terbinafine-resistant isolates. A total number of 123 clinical dermatophyte isolates in eight species were evaluated in terms of sensitivity to seven major antifungals. Furthermore, the point mutation in squalene epoxidase (SQLE) gene responsible for terbinafine resistance was studied. The dermatophytes species were identified by morphological characteristics and confirmed by the ITS sequencing. Also, the phylogenetic tree was drawn using the RAxML analyses for 123 dermatophytes isolates. A new XXIX genotype was also found in 4 Trichophyton mentagrophytes isolates. Based on the results obtained, terbinafine was the most effective antifungal drug followed by itraconazole and voriconazole. Trichophyton rubrum and Trichophyton tonsurans were the most susceptible species (MIC50 = 0.01, 0.09 μg/ml), and T. mentagrophytes was the most resistant species (MIC50 = 0.125 μg/ml) to terbinafine. Of the 123 dermatophytes isolates, six isolates showed reduced susceptibility to terbinafine, and only Trichophyton indotineae had a mutation in SQLE gene as a Phe397Leu substitution. Overall, the antifungal susceptibility test is necessary for managing dermatophytosis. These results help physicians to control the course of the disease and provide further insights to select effective drugs for patients with dermatophytosis, especially in tropical and subtropical regions of the world, where dermatophytosis is still a public health problem.

Sulfasalazine induced atypical drug reaction with eosinophilia and systemic symptoms syndrome: a case report

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a type IV b hypersensitivity reaction characterized by cutaneous manifestations, fever, lymphadenopathy, hematologic abnormalities, and multiple organ manifestations. We report a case of sulfasalazine induced DRESS syndrome who was admitted with a complaint of morbilliform rash all over the body, a fever of 100oF, and severe abdominal pain. Initially the patient did not mention about intake of sulfasalazine while taking the drug history as he could not remember the past medication. The laboratory investigations revealed elevated eosinophils, WBC, and liver function tests. The patient was treated with antibiotics assuming tropical infection, but the patient’s condition was not improving. Later while taking proper drug history from a patient representative over the telephone revealed that the patient was in 4th week of tablet sulfasalazine 500 mg treatment for polyarthritis. Further, the J-SCAR scale was used to diagnose it as Sulfasalazine induced atypical DRESS syndrome. The patient was treated with topical and intravenous corticosteroids and antihistamine; the patient exhibited surprising symptomatic improvement. The patient was given a tapering dose of oral corticosteroid tablet prednisolone 20 mg for three weeks and topical corticosteroid mometasone lotion for two weeks upon discharge.

Circulating Histones and Severity of Illness in Children with Sepsis: A Prospective Observational Study.

To measure circulating histone H3 levels in children with severe sepsis and explore its relationship with severity of illness and organ failures. Children aged 3 mo to 12 y with severe sepsis admitted to pediatric intensive care unit (PICU) were prospectively studied. Healthy controls were enrolled from the outpatient department for comparison. Levels of H3 histones were measured on day 1 and day 3. Thirty-seven patients and 14 controls with median (IQR) age 5 (0.67, 8) and 5 (3, 7) y, respectively were enrolled. Common diagnoses included severe pneumonia (n = 9), staphylococcal sepsis (n = 6), and seasonal tropical infections (n = 4). Two-third (n = 26, 70%) had septic shock. One third (35%) had an unfavorable outcome; 11 died and 2 discontinued care. Median (IQR) H3 levels were not statistically different among patients with sepsis and controls [0.84 (0.62, 1.13) vs. 0.72 (0.52, 0.87) ng/mL; p = 0.10]. There was no significant change in H3 between day 1 and day 3 [0.84 (0.62, 1.13) vs 0.74 (0.5, 0.98)ng/mL; p = 0.22]. Children with thrombocytopenia (n = 27) showed a trend towards higher H3 compared to those without thrombocytopenia (n = 10) [0.9 vs. 0.67ng/mL; p = 0.06]. However, H3 levels were not elevated in patients with cardiovascular dysfunction, those needing renal-replacement therapy, or unfavorable outcomes. The present data provides early evidence that in children hospitalized with severe sepsis, histone H3 is not elevated as compared to healthy controls. H3 levels during initial days of sepsis requiring PICU admission were not different with regards to severity of illness, organ dysfunction, and clinical outcome. There was a trend towards elevated H3 in children with thrombocytopenia, which needs further evaluation.