Kundavaram Paul Prabhakar Abhilash

Performance of clinical scoring systems in acute organophosphate poisoning

Abstract Introduction. Clinical scoring systems are used to predict mortality rate in hospitalized patients. Their utility in organophosphate (OP) poisoning has not been well studied. Methods. In this retrospective study of 396 patients, we evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the Simplified Acute Physiology Score (SAPS) II, Mortality Prediction Model (MPM) II, and the Poisoning Severity Score (PSS). Demographic, laboratory, and survival data were recorded. Receiver operating characteristic (ROC) curves were generated, and the area under the curve (AUC) was calculated to study the relationship between individual scores and mortality rate. Results. The mean (standard deviation) age of the patients was 31.4 (12.7) years, and at admission, their pseudocholinesterase (median, interquartile) level was 317 (222–635) U/L. Mechanical ventilation was required in 65.7% of the patients and the overall mortality rate was 13.1%. The mean (95% confidence interval) scores were as follows: APACHE-II score, 16.4 (15.5–17.3); SAPS-II, 34.4 (32.5–36.2); MPM-II score, 28.6 (25.7–31.5); and PSS, 2.4 (2.3–2.5). Overall, the AUC for mortality was significantly higher for APACHE-II (0.77) and SAPS-II (0.77) than the PSS (0.67). When patients were categorized, the AUCs were better for WHO Class II (0.71–0.82) than that for Class I compounds (0.60–0.66). For individual compounds, the AUC for APACHE-II was highest in quinalphos (0.93, n = 46) and chlorpyrifos (0.86, n = 38) and lowest in monocrotophos (0.60, n = 63). AUCs for SAPS-II and MPM-II were marginally but not significantly lower than those for APACHE-II. The PSS was generally a poorer discriminator compared to the other scoring systems across all categories. Conclusions. In acute OP poisoning, the generic scoring systems APACHE-II and SAPS-II outperform the PSS. These tools may be used to predict the mortality rate in OP poisoning.

Acute undifferentiated febrile illness in patients presenting to a Tertiary Care Hospital in South India: clinical spectrum and outcome

Background: Acute undifferentiated febrile illness (AUFI) may have similar clinical presentation, and the etiology is varied and region specific. Materials and Methods: This prospective observational study was conducted in a tertiary hospital in South India. All adult patients presenting with AUFI of 3-14 days duration were evaluated for etiology, and the differences in presentation and outcome were analyzed. Results: The study cohort included 1258 patients. A microbiological cause was identified in 82.5% of our patients. Scrub typhus was the most common cause of AUFI (35.9%) followed by dengue (30.6%), malaria (10.4%), enteric fever (3.7%), and leptospirosis (0.6%). Both scrub typhus and dengue fever peaked during the monsoon season and the cooler months, whereas no seasonality was observed with enteric fever and malaria. The mean time to presentation was longer in enteric fever (9.9 [4.7] days) and scrub typhus (8.2 [3.2] days). Bleeding manifestations were seen in 7.7% of patients, mostly associated with dengue (14%), scrub typhus (4.2%), and malaria (4.6%). The requirement of supplemental oxygen, invasive ventilation, and inotropes was higher in scrub typhus, leptospirosis, and malaria. The overall mortality rate was 3.3% and was highest with scrub typhus (4.6%) followed by dengue fever (2.3%). Significant clinical predictors of scrub typhus were breathlessness (odds ratio [OR]: 4.96; 95% confidence interval [CI]: 3.38-7.3), total whole blood cell count >10,000 cells/mm 3 (OR: 2.31; 95% CI: 1.64-3.24), serum albumin <3.5 g % (OR: 2.32; 95% CI: 1.68-3.2). Overt bleeding manifestations (OR: 2.98; 95% CI: 1.84-4.84), and a platelet count of <150,000 cells/mm 3 (OR: 2.09; 95% CI: 1.47-2.98) were independent predictors of dengue fever. Conclusion: The similarity in clinical presentation and diversity of etiological agents demonstrates the complexity of diagnosis and treatment of AUFI in South India. The etiological profile will be of use in the development of rational guidelines for control and treatment of AUFI.

Organophosphate-pyrethroid combination pesticides may be associated with increased toxicity in human poisoning compared to either pesticide alone

Abstract Background. Organophosphate (OP) poisoning results in significant toxicity while pyrethroid poisoning is associated with extremely low fatality. OPs can inhibit the detoxification of pyrethroid and increase the toxicity of the combination. We assessed whether mixed OP-pyrethroid poisoning impacted outcome in human poisoning. Methods. Patients were identified from a prospectively collected institutional poisoning database that incorporates demographic and outcome data of patients presenting with poisoning. Results. Of the 1177 poisoned patients admitted over 2 years, 32 presented with OP-pyrethroid (50% chlorpyrifos-5% cypermethrin mixture) poisoning (Group 1), 26 consumed 20% chlorpyrifos (Group 2), and 32 took 15% cypermethrin (Group 3). Seizures occurred in 15.6% (n = 5) with chlorpyrifos-cypermethrin poisoning, 18.8% (n = 6) with cypermethrin poisoning, and 3.9% (n = 1) with chlorpyrifos poisoning. Ventilatory requirements were 53.5% (17/32), 42.3% (11/26), and 15.7% (5/32) in Groups 1–3, respectively. Ventilator-free days (Mean ± SD) was significantly lower (p < 0.006) in Group 1 (20.9 ± 9.3 days) than those in Group 2 (26.1 ± 4.4 days) or 3 (27.8 ± 0.6). The median (inter-quartile range) hospital stay was 5.5 (4–19.5), 5 (5–6), and 1 (0.65–1.5) days, respectively, in the three groups. Four patients died in Group 1 (13%). None died in the other groups. Conclusion. Although confounded by the varying quantity of chlorpyrifos and cypermethrin in the different formulations, patients with mixed poisoning appear to have shorter ventilator-free days than patients poisoned by either of the pesticides alone. Further studies are required comparing patients poisoned by formulations with similar quantities of OP and pyrethroid or with analysis of blood pesticide concentration on admission.

Scrub typhus meningitis: An under-recognized cause of aseptic meningitis in India

BACKGROUND Central nervous system (CNS) involvement in scrub typhus is seen in up to a quarter of patients. However, the literature on cerebrospinal fluid (CSF) analysis and outcome in meningitis/meningo-encephalitis due to scrub typhus is scant. MATERIALS AND METHODS This retrospective study included patients who were admitted to a medical college hospital with scrub typhus meningitis/meningo-encephalitis between 2005 and 2011. The clinical and laboratory profile, details of CSF analysis and outcome were documented. RESULTS The study included 189 patients with meningitis/meningo-encephalitis due to scrub typhus. The mean age of the patients was 41 ± 4 years. The mean duration of fever before presentation was 9.4 ± 3 days. The common presenting complaints were headache (64.2%), nausea/vomiting (60%), altered sensorium (53.7%) and seizures (22.1%). The presence of an eschar was documented in 27.5% of the patients. The mean CSF white blood count was 80 cells/cu mm (range: 5-740). There was a clear lymphocyte predominance (mean 87.6%). The mean CSF protein level was 105 mg% (range: 13-640). The mean CSF sugar level was 63.9 mg% (range 25-350), and was less than 40 mg% in 11.1% of the cases. The case fatality rate was 5.8% (11/189). Univariate analysis showed the presence of an eschar (15.4% vs 2.2%; Odds Ratio [OR]: 8.1) and altered sensorium (9.8% vs 1.1%; OR: 9.2) to be significant predictors of mortality. CONCLUSIONS In endemic regions, scrub typhus should be considered in the differential diagnosis of aseptic meningitis. Modest elevation of cells in the CSF with lymphocytic pleocytosis and multi-organ involvement may indicate scrub typhus meningitis/meningo-encephalitis.

Fatal overdose of iron tablets in adults

Acute iron toxicity is usually seen in children with accidental ingestion of iron-containing syrups. However, the literature on acute iron toxicity with suicidal intent in adults is scant. We report, the first instance of two adults with fatal ingestion of a single drug overdose with iron tablets from India. Two young adults developed severe gastro-intestinal bleeding and fulminant hepatic failure 48 h after deliberate consumption of large doses of iron tablets. Serum iron levels measured 36 h after ingestion were normal presumably due to the redistribution of iron to the intracellular compartment. Despite aggressive supportive management in medical intensive care unit of a tertiary care hospital, the patients succumbed to the toxic doses of iron.

Magnetic resonance imaging findings in a fatal case of Salmonella typhi-associated encephalopathy: a case report and literature review.

We describe MRI findings in a fatal case of culture proven Salmonella typhi-associated encephalopathy. MRI findings included symmetrical diffuse abnormal signal in centrum semiovale, periventricular and deep white matter, splenium of corpus callosum and cerebellar deep white matter with central area of restricted diffusion. There was no contrast enhancement, significant edema or mass effect. Previous literature is also reviewed for imaging findings in Salmonella associated encephalopathy.

Listeria meningitis with disseminated tuberculosis in a HIV positive individual

Sir, We aimed to study the utility of C-Reactive Protein (CRP) in detecting serious bacterial infection (SBI) in children with fever as there is sparse data available, especially in India.[1-4] One hundred and nine children (1-36 months of age) with fever (≥ 39°C; < 7 days) without any focus of infection were enrolled in this prospective cohort study. Those with recent vaccination, immunodeficiency and antibiotic use were excluded. Investigations included Total Leukocyte Count (TLC) and Absolute Neutrophil Count (ANC) (Coulter MS 93 and Micros 60), Band count, CRP (Teco Diagnostics, USA), urinalysis and blood culture. Twenty-one children had SBI (Occult Bacteremia (OB)-10, Urinary Tract Infection (UTI)-6, pneumonia-3, meningitis-1 and enteric fever-1). Higher incidence of SBI suggests higher infection rate.[5] Main organisms found on cultures were Staphylococcus aureus(5), Staphylococcus epidermidis(3), Enterobacter faecalis(1) and Klebsiella species(1) for OB; Escherichia coli(5) and Citrobacter(1) for UTI and Acinetobacter species in meningitis. Duration of temperature, CRP and band count were significantly higher in children with SBI as compared to those without SBI (P value < 0.05) The two groups were not significantly different in characteristics like age, sex, degree of fever, TLC, ANC, and Yale observation score. Higher CRP suggests greater inflammatory response in SBI. CRP had higher sensitivity (95.2%) and negative predictive values (95%) than TLC, ANC and band count. The area under the Receiver Operating Characteristic curve (SE, 95% CI) was highest for CRP 0.7 (0.07; 0.550-0.841) and statistically significant (P value = 0.01). CRP> 12.8 mg/dL (multilevel likelihood ratio analysis-P value < 0.001) was highly significant in predicting SBI in our study which is comparable to other reports.[2] Thus, CRP may serve as a rapid screening tool in early recognition and management of children with SBI.

Role of emergency ultrasound screening in the management of acute pyelonephritis in emergency department: A large observational study from a tertiary care center of South India

Background: Role of emergency ultrasound screening (EUS) in the evaluation of all patients with clinically suspected acute pyelonephritis (APN) in the emergency department (ED) remains unclear. The aim of the study was to describe the frequency of abnormal EUS findings in APN presenting to ED and ascertain the laboratory abnormalities associated with significant abnormal findings to identify the subgroup of patients who will benefit from EUS in ED. Methodology: In this retrospective study, electronic medical records were searched to identify all adult patients who underwent EUS screening from ED for initial clinical diagnosis of APN over 1 year. The EUS findings were categorized into normal, major abnormalities (hydronephrosis, renal abscess, and emphysematous pyelonephritis), and mild abnormalities (cysts, calculi, and renal edema). Results: A total of 1218 patients with initial clinically diagnosed APN underwent EUS. Nearly 49% had a normal EUS while 51% had at least one major or minor abnormality. The frequency of hydroureteronephrosis, renal calculi emphysematous changes, and renal abscess was 19.1%, 8.9%, 2.1%, and 1.9%, respectively. Only 72 (5.9%) patients required emergency percutaneous nephrostomy or drainage of an abscess. Among these patients, EUS was able to identify a major abnormality in sixty (83.3%) patients. Male gender, presence of diabetes mellitus, peripheral white blood cell (WBC) count >10,000 cells/cumm, serum creatinine >1.4 mg%, and urine WBC count >100 cells/hpf were found to independently predict the presence of an abnormality on an EUS. Conclusion: A large proportion of APN patients have only normal or minor abnormalities and do not need additional screening and intervention.

Clinical score to differentiate scrub typhus and dengue: A tool to differentiate scrub typhus and dengue

Background: Dengue and scrub typhus share similar clinical and epidemiological features, and are difficult to differentiate at initial presentation. Many places are endemic to both these infections where they comprise the majority of acute undifferentiated febrile illnesses. Materials and Methods: We aimed to develop a score that can differentiate scrub typhus from dengue. In this cross-sectional study, 188 cases of scrub typhus and 201 cases of dengue infection who presented to the emergency department or medicine outpatient clinic from September 2012 to April 2013 were included. Univariate followed by multivariate logistic regression analysis was performed to identify clinical features and laboratory results that were significantly different between the two groups. Each variable was assigned scores based on the strength of association and receiver operating characteristics area under the curve (ROC-AUC) was generated and compared. Six scoring models were explored to ascertain the model with the best fit. Results: Model 2 was developed using the following six variables: oxygen saturation (>90%, ≤90%), total white blood cell count (<4000, 4001–7000 and >7000 cells/cumm), hemoglobin (≤14 and >14 g/dL), total bilirubin (<2 and ≥2 mg/dL), serum glutamic oxaloacetic transaminase (>200 and ≥200 IU/dL), and altered sensorium (present or absent). Each variable was assigned scores based on its strength of association. The AUC-ROC curve (95% confidence interval) for model 2 was 0.84 (0.79–0.89). At the cut off score of 13, the sensitivity and specificity were 85% and 77% respectively, with a higher score favoring dengue. Conclusion: In areas of high burden of ST and dengue, model 2 (the “clinical score to differentiate scrub typhus and dengue fever”) is a simple and rapid clinical scoring system that may be used to differentiate scrub typhus and dengue at initial presentation.

Acute pancreatitis due to malaria: A case report of five patients and review of literature

Malaria is endemic in large parts of India and can cause multiorgan failure and death. Acute pancreatitis as a complication is rare and is potentially fatal. This case series describes five adult patients between 2005 and 2010 who presented with a short duration febrile illness and diagnosed to have malaria with acute pancreatitis. The mean age of the five patients with acute pancreatitis was 40.4 years and four of them were males. None of them were alcohol consumers and did not have any other risk factor for acute pancreatitis. Plasmodium falciparum was responsible for all the cases. Pancreatic enzymes were significantly elevated in all the patients with a mean serum lipase level of 1795 U/L (normal value: <190 U/L) and a mean serum amylase level of 584 U/L (normal value: <100 U/L). Ultrasonography evidence of acute pancreatitis (bulky pancreas) was seen in two patients, and a further two patients had minimal left-sided pleural effusion. Thrombocytopenia (platelet count <100,000/cumm), renal dysfunction (serum creatinine >1.4 mg/dl), and hyperbilirubinemia were seen in all the patients. One patient died due to multiorgan failure. Acute pancreatitis is a very rare complication of malaria, and a high index of suspicion is required in patients presenting with severe malaria and abdominal pain.