Robed Amin

The greater black krait (Bungarus niger), a newly recognized cause of neuro-myotoxic snake bite envenoming in Bangladesh

Prospective studies of snake bite patients in Chittagong, Bangladesh, included five cases of bites by greater black kraits (Bungarus niger), proven by examination of the snakes that had been responsible. This species was previously known only from India, Nepal, Bhutan and Burma. The index case presented with descending flaccid paralysis typical of neurotoxic envenoming by all Bungarus species, but later developed generalized rhabdomyolysis (peak serum creatine kinase concentration 29,960 units/l) with myoglobinuria and acute renal failure from which he succumbed. Among the other four patients, one died of respiratory paralysis in a peripheral hospital and three recovered after developing paralysis, requiring mechanical ventilation in one patient. One patient suffered severe generalized myalgia and odynophagia associated with a modest increase in serum creatine kinase concentration. These are the first cases of Bungarus niger envenoming to be reported from any country. Generalized rhabdomyolysis has not been previously recognized as a feature of envenoming by any terrestrial Asian elapid snake, but a review of the literature suggests that venoms of some populations of Bungarus candidus and Bungarus multicinctus in Thailand and Vietnam may also have this effect in human victims. To investigate this unexpected property of Bungarus niger venom, venom from the snake responsible for one of the human cases of neuro-myotoxic envenoming was injected into one hind limb of rats and saline into the other under buprenorphine analgesia. All animals developed paralysis of the venom-injected limb within two hours. Twenty-four hours later, the soleus muscles were compared histopathologically and cytochemically. Results indicated a predominantly pre-synaptic action (β-bungarotoxins) of Bungarus niger venom at neuromuscular junctions, causing loss of synaptophysin and the degeneration of the terminal components of the motor innervation of rat skeletal muscle. There was oedema and necrosis of extrafusal muscle fibres in envenomed rat soleus muscles confirming the myotoxic effect of Bungarus niger venom, attributable to phospholipases A₂. This study has demonstrated that Bungarus niger is widely distributed in Bangladesh and confirms the risk of fatal neuro-myotoxic envenoming, especially as no specific antivenom is currently manufactured. The unexpected finding of rhabdomyolysis should prompt further investigation of the venom components responsible. The practical implications of having to treat patients with rhabdomyolysis and consequent acute renal failure, in addition to the more familiar respiratory failure associated with krait bite envenoming, should not be underestimated in a country that is poorly equipped to deal with such emergencies.

Temporal trends in severe malaria in Chittagong, Bangladesh

BackgroundEpidemiological data on malaria in Bangladesh are sparse, particularly on severe and fatal malaria. This hampers the allocation of healthcare provision in this resource-poor setting. Over 85% of the estimated 150,000-250,000 annual malaria cases in Bangladesh occur in Chittagong Division with 80% in the Chittagong Hill Tracts (CHT). Chittagong Medical College Hospital (CMCH) is the major tertiary referral hospital for severe malaria in Chittagong Division.MethodsMalaria screening data from 22,785 inpatients in CMCH from 1999–2011 were analysed to investigate the patterns of referral, temporal trends and geographical distribution of severe malaria in Chittagong Division, Bangladesh.ResultsFrom 1999 till 2011, 2,394 malaria cases were admitted, of which 96% harboured Plasmodium falciparum and 4% Plasmodium vivax. Infection was commonest in males (67%) between 15 and 34 years of age. Seasonality of malaria incidence was marked with a single peak in P. falciparum transmission from June to August coinciding with peak rainfall, whereas P. vivax showed an additional peak in February-March possibly representing relapse infections. Since 2007 there has been a substantial decrease in the absolute number of admitted malaria cases. Case fatality in severe malaria was 18% from 2008–2011, remaining steady during this period.A travel history obtained in 226 malaria patients revealed only 33% had been to the CHT in the preceding three weeks. Of all admitted malaria patients, only 9% lived in the CHT, and none in the more remote malaria endemic regions near the Indian border.ConclusionsThe overall decline in admitted malaria cases to CMCH suggests recent control measures are successful. However, there are no reliable data on the incidence of severe malaria in the CHT, the most endemic area of Bangladesh, and most of these patients do not reach tertiary health facilities. Improvement of early treatment and simple supportive care for severe malaria in remote areas and implementation of a referral system for cases requiring additional supportive care could be important contributors to further reducing malaria-attributable disease and death in Bangladesh.

Seroepidemiological surveillance of Burkholderia pseudomallei in Bangladesh

Melioidosis (Burkholderia pseudomallei infection) has yet to be demonstrated systematically in Bangladesh. A prospective, cross-sectional serological survey was conducted in 2010 at six Bangladeshi hospitals. Age, gender, occupation and residential address were recorded. Of 1244 patients, 359 (28.9%) were positive for B. pseudomallei by indirect haemagglutination assay. Farmers had an increased risk of seropositivity (risk ratio = 1.4, 95% CI 1.0–1.8; p = 0.03). There was no clear geographic clustering of seropositives. Melioidosis should be considered as a possible cause of febrile illness in Bangladesh. Further studies are needed to establish the incidence of clinical disease and distribution of environmental risk.

An ANKRD26 nonsense somatic mutation in a female with epidermodysplasia verruciformis (Tree Man Syndrome)

Epidermodysplasia verruciformis (EV) is an extremely rare hereditary skin disease characterized by an abnormal susceptibility to the human papilloma virus (HPV) with an increased risk of cutaneous malignancy. Here we report the first female severe EV case in Bangladesh, a 10‐year‐old girl with a nonsense somatic mutation impacting ANKRD26 gene.

Toxicology in Medical Practice- Time for revolutionary change

The toxicology has long been the neglected topic and dealt with less importance. But the burdon of the disease and the morbidity and mortality is biggest in this respect. According to Directorate General of Health service of Bangladesh health bulletin 2017 report the number of poisoning is 1.6%, 6.9% and 5.9% among all causes of morbidity in primary,secondary and tertiary health care centers. In tertiary care centre the poisoning related mortality is 1.97%, in district hospital it is 3.28% while in primary health care centre it is 4.9% among ages more than 5 yrs with national trends of mortality of 2.83%1.

Chikungunya - An Emerging threat for Bangladesh

Bangladesh J Medicine 2017; 28: 54-55 Chikungunya fever is an emerging viral disease transmitted to humans by mosquitoes. Chikungunya Virus (CHIKV) is an arbovirus of the alphavirus genus (Togaviridae family). The Aedes aegypti and Aedes albopictus mosquitoes are the main vectors responsible for transmission of Chikungunya. In 1952, a young man in Tanzania admitted to hospital with fever, rash and arthralgia. Eventually he was diagnosed as the first case of Chikungunya.1 In 2005– 2006, a severe outbreak occurred on Reunion Island in the southwestern part of the Indian Ocean. Other islands in this area were affected during the same period. Estimated 300,000 people was infected and 237 patients died. The factors favoring this epidemic included viremic travelers from Africa, to an immunologically naive population. Mutation of the Chikungunya virus that expanded the mosquito vector from the Aedes aegypti to the Aedes albopictus which was common on the island.2-4 Mutation (E1A226V) improves replication and transmission efficiency in Ades. albopictus as well as the original Ades. aegypti, outbreaks spread to the Indian subcontinent.3 India has been suffering from outbreaks of Chikungunya since 2005 with variable severity. India and Bangladesh are two neighboring countries which share some similar epidemiological pattern.

Experience with Serum Magnesium Estimations in Critically Ill Patients Admitted in High Dependency Unit of A Tertiary Care Hospital

Background: Magnesium deficiency has been a common, but easily ignored, electrolyte abnormality. Studies on magnesium in our country are lacking. Here, we have estimated and correlated serum magnesium levels with outcomes and other electrolyte imbalance in critically ill patients with respect to the mortality, in hospital outcome and length of high dependency unit (HDU) stay. Methods: A prospective, observational study was conducted in patients who had been admitted to the HDU. Patient’s demographic profile, medical history, serum magnesium, calcium and electrolytes were enrolled on admission. Patients were divided into normomagnesemic, hypomagnesemic hypermagnesemic groups and compared for various parameters. Results: Out of 60 critically ill-patients, 32 patients (53.33%) were hypomagnesemic, 20 patients (33.33%) were normomagnesemic and 8 patients (13.33%) were hypermagnesemic. The duration of stay of the patients in HDU, in hospital outcome and mortality showed significant variation between these groups. Associated electrolyte abnormalities in hypomagnesemic patients were hypokalemia (56.25%) and hypocalcemia (62.50%). Most of the hypomagnesemic patients were hypertensive (62.50% vs 40%) and was presented in drowsy state (50% vs 40%) compared to normomagnesemic group. Mortality of hypomagnesemic group was 37.50% while that of hypermagnesemic group was 25%. In hospital, arrythmia (18.75%) and convulsion (12.50%) developed in hypomagnesemic groups. Mean duration of length of stay in HDU was 7.45 days in hypomagnesemic, 6.83 days normomagnesemic, and 8.67 days in hypermagnesemic group. Conclusion: Development of magnesium imbalance in critically ill patients is associated with bad prognosis. Monitoring of serum magnesium levels may have prognostic, perhaps therapeutic implication. Bangladesh J Medicine Jul 2018; 29(2) : 69-74

Acute arsenic poisoning diagnosed late

Acute arsenicosis, although having a ‘historical’ background, is not common in our times. This report describes a case of acute arsenic poisoning, missed initially due to its gastroenteritis-like presentation, but suspected and confirmed much later, when the patient sought medical help for delayed complications after about 2 months.

Training in infectious diseases in India

586 www.thelancet.com/infection Vol 12 August 2012 Several studies have shown that nasopharyngeal carriage of vaccine-type S pneumoniae strains is negatively associated with Staphylococcus aureus carriage in the nasopharynx. Selva and co-workers described an antistaphylococcal mechanism whereby S pneumoniae kills S aureus by producing hydrogen peroxide. van Gils and colleagues report that use of the vaccine increased carriage of S aureus in a cohort of Dutch children. Could use of polyvalent pneumococcal vaccines be driving the increased incidence of community-acquired meticillin-resistant S aureus (MRSA) infection? Although Miller and colleagues did describe S pneumoniae serotype replacement, they did not investigate S aureus carriage. To show a negative association between S pneumoniae and S aureus carriage in a UK cohort of heptavalent pneumococcal conjugate vaccine recipients would be useful. Further studies should explore the link between vaccination and staphylococcal disease, both in vaccine recipients and the people they contact. Meticillin-resistant and meticillin-sensitive strains should be distinguished in investigations of S aureus carriage. The Panton-Valentine leukocidin status of the isolate should also be investigated because it is linked epidemiologically with communityacquired MRSA infection. These data would help to clarify any role that pneumococcal vaccines might have in S aureus infection.

Patterns of Self Poisoning by Household Substances ............................................................................IJMTFM (2011) 1(2):59-64

Background: Poisoning is an important public health problem in developing countries like Bangladesh; self poisoning with organophosphorous compound (OPC) used in agriculture is particularly common. However, tertiary level hospitals in urban settings, self-poisoning with different household substances is also frequent, especially in teenagers. This study aims to identify the common household substances used for self harm and describe their clinical profile. Methods: A prospective study was performed in five adult medicine units of Dhaka Medical College Hospital over a period of six months from January 2008 to June 2008. Data were collected purposefully in a standard case record forms. Results: One hundred and twenty eight patients with a definite history of self poisoning were enrolled. Majority of patients came from urban areas (77.4%); mean age was 20 years and 48.1% were unmarried. Most patients (102, 76.7%) were female. A suicidal intention was mentioned in 88.7% of cases and family disharmony (70.7%) was the main reported reason. Most of the patients (119, 89.4%) were educated with at least Primary school. The most commonly used compounds were Savlon (Chlorhexidine 0.05%, Cetrimide 0.5%) in 50.4% of cases and Harpic(Sodium alkyle benzene sulphonate & sodium alkene sulphonate) in 30.8% of poisoning cases. 92.5% of patients sought treatment in a public hospital. All patients received supportive and symptomatic treatment, commonly with intravenous fluids and omeprazole. Recovery was usually fast; 92.9% improved within two days. All patients survived and no complications were noted. Conclusion: Though poisoning due to household substances is usually mild, prompt recognition and early treatment is important. An effort should be made to define preventive measures that can be implemented in order to reduce this common form of self poisoning.