Nardeep Naithani

Current Trends in the Management of Typhoid Fever

Typhoid (cloudy) fever is a systemic infection, caused mainly by Salmonella typhi found only in man. It is characterized by a continuous fever for 3-4 weeks, relative bradycardia, with involvement of lymphoid tissue and considerable constitutional symptoms. In western countries, the disease has been brought very close to eradication levels. In the UK, there is approximately one case per 100,000 population per year. Each year, the world over, there are at least 13-17 million cases of typhoid fever, resulting in 600,000 deaths. 80% of these cases and deaths occur in Asia alone. In South East Asian nations, 5% or more of the strains of the bacteria may already be resistant to several antibiotics [1]. Antibiotics resistance, particularly emergence of multidrug resistant (MDR) strains among Salmonellae is also a rising concern and has recently been linked to antibiotic use in livestock. Many S typhi strains contain plasmids encoding resistance to chloramphenicol, ampicillin and co-trimoxazole, the antibiotics that have long been used to treat enteric fever. In addition, resistance to ciprofloxacin also called nalidixic-acid-resistant S typhi (NARST) strain either chromosomally or plasmids encoded, has been observed in Asia. A significant number of strains from Africa and the Indian subcontinent are MDR type. A small percentage of strains from Vietnam and the Indian subcontinent are NARST strains [2]. The changing pattern of multi drug resistance in typhoid fever was studied in Delhi in 1993 [3]. Out of 76 patients, 12 patients responded to a combination of chloramphenicol and gentamicin, 51 to ciprofloxacin while the remaining 9 responded to combination of cefotaxime and amikacin. This study re-emphasizes the changing pattern, and role of quinolone especially ciprofloxacin in the management of drug resistant typhoid fever, but at the same time indicates that ciprofloxacin is not the drug of choice in all cases of typhoid fever and resistance to it may be seen in some cases, where other drugs have to be used. 100 children (consecutive) with positive blood culture for S typhi were studied for clinical profile in Ahmedabad in 2000. 80% Salmonella isolates were resistant to amoxycillin, chloramphenicol and co-trimoxazole, but all were sensitive to ciprofloxacin and ceftriaxone [4]. In another study from Rourkela in 2000, out of 5410 blood samples 715 samples, were found positive for S typhi. The number of MDR strains of S typhi constituted almost 16.1% of the total isolates. In this study, chloramphenicol sensitivity was found quite high (86.5%) and ceftriaxone showed 100% sensitivity. Resistance to ciprofloxacin was found in 2.5% cases [5]. In the extended typhoid epidemic that affected more than 24,000 people in Tajikistan from 1996 through 1998, more than 90% of the organisms were MDR and 82% were resistant to ciprofloxacin. This is the first reported epidemic of quinolones-resistant typhoid fever [6]. Atypical and varied presentations often confuse the picture in enteric fever. Neuropsychiatric manifestations in particular, often may be mistaken for encephalitis, meningitis, cerebral malaria, psychosis, etc [7]. Recurrent salmonellosis (usually S typhimurium) is an AIDS defining criterion in HIV positive patients, though for reasons unknown this is rarely due to S typhi. HIV positive patients are more prone to develop enteric fever and its frequent relapses.

Emphysematous infections of the kidney and urinary tract: a single-center experience.

Emphysematous pyelonephritis (EPN) is a group of potentially life-threatening conditions seen particularly in diabetics, leading to high morbidity and mortality. Our aim was to study the profile of emphysematous infections of the kidney and urinary tract and evaluate the effect of early surgical intervention on mortality. This is an observational study conducted in a tertiary care hospital between January 2009 and January 2013, in which the clinical, laboratory, microbiological and radiological profiles of patients with EPN (diagnosed based on clinical, laboratory and imaging findings) was studied. A total of 12 patients were studied, including 10 with diabetes. A total of 66.6% had pyelonephritis, 25% had both cystitis and pyelonephritis and 8.3% had only cystitis; involvement of the left kidney was more common and bilateral involvement was seen in two cases. The clinical features seen in the patients included fever (100%), features of urinary infection (66.6%) and flank pain (50%). Culture positivity was seen in only 50% of the cases. Ten patients underwent percutaneous drainage (PCD) within 24 h, and two of these patients required nephrectomy subsequently. All patients were followed-up for one month. There was one death (mortality 8.3%), and all other patients responded well and recovered. Our study suggests that EPN is a potentially life-threatening condition that requires aggressive and prompt medical therapy with early PCD to reduce morbidity and mortality. Nephrectomy should be reserved for cases that do not respond to PCD.

Ceftriaxone induced drug rash with eosinophilia and systemic symptoms

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a drug reaction commonly occurring in association with aromatic anticonvulsants and allopurinol. It is characterized by triad of fever, skin eruption, and systemic involvement. DRESS is rare with beta-lactam antibiotics and even rarer with ceftriaxone. We describe a case of pneumonia who developed ceftriaxone-induced rash, bicytopenia, eosinophilia, transaminitis and was eventually diagnosed and managed successfully as a case of DRESS.

Tuberculosis of breast: unusual manifestation of tuberculosis

Tuberculosis affects almost every organ of the body, and the breast is no exception. However, tuberculosis of the breast is rare, and the varied presentation requires a high index of suspicion, especially in middle-aged women for whom a clinical diagnosis of malignancy is likely to be made. We report two cases of primary tuberculosis of breast with different manifestations. One case presented as tuberculous mastitis and the other presented with a lump masquerading as breast carcinoma. The diagnosis in both cases was based on demonstration of acid-fast bacilli on histopathological examination. Resolution was complete with antitubercular therapy, and major surgical intervention was not necessary.

Profile of HIV patients on second line antiretroviral therapy: the Indian experience.

Background: The proportion of patients on second line in resource limited settings are estimated between 1-5%. The present study describes the profile and outcomes of Indian patients receiving second line ART. Methods: Information on HIV patients on second line ART was gathered. Socio demographic data, probable transmission route, baseline clinical parameters and comorbidities during therapy are studied along with first-line ART regimen initially introduced, its adherence and the reason for switch and components of the second-line ART regimen. Results: Out of the total 2174 HIV patients 53% were on first line ART and of these 51 patients on second line ART were studied. The average time of initiation of first line ART was 17.67 months with median of 2 months whereas switch to second line ART was in 53.75 months with median of 60 months. Almost 71% of the patients on second line ART had been diagnosed with HIV infection with low CD4 count of <200. However 54%, 67% and 58% patients show more than 50% rise in their CD4 count post switch to second line after 3, 6 and 12 months of treatment which is a substantial improvement. Twenty-five per cent of patients showed non adherence. Tenofovir based regimens had a slight advantage with lesser number of side effects being reported. Conclusion: Early diagnoses of infection, early initiation of ART and drug adherence are the cornerstones for success in managing HIV patients. Understanding the profile and drug resistance pattern is necessary for ensuring effective and long term survival.

Resistant Malaria : Current Concepts and Therapeutic Strategies

Malaria is by far the worlds most important tropical parasitic disease, and kills more people than any other tropical disease except tuberculosis. 40% i.e. 500 million persons of the worlds population live in malaria endemic zone. There are 300-500 million new cases of malaria annually. Every year, there are 1.5-2.7 million deaths due to malaria, globally. 200-300 children die every hour. Between 1981 and 1996 there were 20-40 million deaths due to malaria alone as against 2.5 million deaths due to HIV infection [1]. Most deaths are due to delay in diagnosis and treatment. The disease affects the otherwise vulnerable section of the society, the children and the poor.

Rare site for tubercular osteomyelitis with HIV infection

Tuberculosis of the scapula is a rare clinical entity. Few cases have been reported in the literature so far. We report a case of tuberculosis of the scapula in a HIV positive patient, which was managed successfully with antitubercular drugs. This case illustrates the difficulties in diagnosing tubercular osteomyelitis of the scapula as it has an insidious onset, paucity of constitutional symptoms and frequent absence of associated pulmonary involvement. Pitfall in diagnosis is the delay in considering the diagnosis of bony tuberculosis, especially in patients who have normal chest radiographs.

The Revaccination of Ty 21a: Reply

I appreciate the keen interest shown by the reader in our article titled “Current trends in the management of typhoid fever” published in MJAFI 2003;59(2):130-5. Our clarification to the observations made by the reader are as under: (a) Recommendations regarding use of vaccinations including Typhoral Oral Vaccine (Ty 21a) are constantly revised based on experience gathered with ongoing use of the vaccine. “S typhi 21a strain in an enteric coated capsule has given a 67% protection rate in Chili lasting for 3 years after 3 doses given on alternate days. A four dose schedule which appears to better protect is preferred in the USA. On the other hand one recent trial in Indonesia had found the vaccine to confer 47% efficacy” [1]. It is advisable to look up latest guidelines for vaccines as article sent for publication comes up for print after a period of 1-2 years when recommendations may have changed. (b) Most standard text books of Medicine and Pharmacology continue to mention dose of Quinolones as absolute values and not in per Kg body weight. This may be due to low MIC 90, compared to high serum levels achieved by most Quinolones [1, 2, 3, 4]. Only recently per Kg recommendations have been issued for treatment of Anthrax.