S. K. Kar

An outbreak of hand, foot and mouth disease in Bhubaneswar, Odisha.

ObjectiveTo describe the epidemiology and clinical features of cases in an outbreak of Hand, Foot and Mouth Disease (HFMD).DesignDescriptive epidemiological study.SettingHospitals and community in urban areas of Bhubaneswar city, Odisha.MethodsUpon clinical suspicion of the first case as HFMD, local pediatricians and dermatologists were sensitized for case referral to Dermatology department of Institute of Medical Science and SUM hospital (IMS&SH) for evaluation and follow up. Community survey was undertaken by household visit by the team from Regional Medical Research Centre, Bhubaneswar in an outbreak area through hospital case tracing. Blood samples were tested for hematological counts and RT PCR assay done in a subset of samples for confirmation.ResultsSeventy eight cases of HFMD were detected between September 7 and November 6, 2009. Mean age (SD) was 5.13 (4.94) years (range 4 mo-31 yrs) and both sexes were equally affected. Fever and rash were the most common presenting symptoms with the rash distributed mostly over buttocks (83.3%), knees (77.5%), both surfaces of hands and oral mucosa (78.2%). Lesions healed in Mean (SD) 8.6 (1.5) days (range 7–15 d). Recovery was complete with minimal supportive treatment but, nail shedding was noted in three children within 4–5 weeks. CA16 was confirmed as the viral agent.ConclusionChildren (5–14 yrs) were majorly affected and complete recovery without neurological complications were noted. The characteristic clinical features described will be useful for early clinical diagnosis where laboratory confirmation is not feasible.

Association of TNF level with production of circulating cellular microparticles during clinical manifestation of human cerebral malaria

Microparticles (MPs) resulting from vesiculation of different cell types in Plasmodium falciparum infection correlate with the level of proinflammatory cytokine TNF that may thereby determine the disease severity. Using TruCount tube based flow cytometric method for the exact quantification of MP and enzyme linked immunosorbent assay for the measurement of TNF, we conducted a hospital based case control study on P. falciparum malaria patients to scrutinize and infer the link between the two. In 52 cerebral malaria (CM), 21 multi-organ-dysfunction (MOD), 12 non cerebral severe malaria (NCSM) and 43 uncomplicated malaria patients, the MP level was found to be significantly elevated in febrile malaria patients compared to healthy controls and a striking decrease in MP level was observed with the clearance of the P. falciparum infection in the patients upon follow-up. The lowering of the parasite density with the level of plasma TNF and the positive correlation of the cytokine with the cell derived MPs and negative correlation with the respective cell count in human malaria patients suggests that TNF may be a key stimulant to the cells resulting in the release of MPs in malaria infection.

The CCTTT pentanucleotide microsatellite in iNOS promoter influences the clinical outcome in P. falciparum infection

To assess the hypothesis that nitric oxide (NO) is critical in the pathogenesis of cerebral malaria, we analyzed those single nucleotide polymorphisms (SNPs) and microsatellite (MS) of the promoter region of inducible nitric oxide synthase (iNOS) gene which are known to enhance the NO production in vivo. A total of 428 (204 severe, 224 mild) adult patients living in the eastern part of India were analyzed. The single nucleotide substitutions −954G→C was found to be very rare, and −1173C→T was absent in this population. But interestingly, longer forms of MS were found to be significantly associated with severe malaria (OR = 2.89, 95% CI = 1.955–4.295, P < 0.0001), and the linear regression analysis revealed that the risk of severe malaria significantly increases as the summed repeat number in an individual increase (OR = 1.16, P = 0.0013). Further, the median plasma level of nitrate/nitrite (NOx) was observed to be high in mild patients compared to severe patients, and the level of parasitemia was significantly low among mild patients than severe ones. These findings suggest that the CCTTT repeats in iNOS may play a key role in the pathogenesis of severe malaria.

Humoral immune response during filarial fever in Bancroftian filariasis

Humoral immune responses against filarial parasitic infection were studied in 62 cases of acute filarial disease presenting with filarial fever with adenolymphangitis, in a community where Bancroftian filariasis was endemic, during and about one month before and after the febrile episode. Their total leucocyte and differential peripheral blood cell counts and anti-streptolysin O titre were determined and compared. Polymorphonuclear cellular responses and anti-streptolysin O titre did not show any significant alteration during and after fever. Three of 53 previously amicrofilaraemic subjects (9 of whom were initially microfilaraemic) had microfilaria in their circulation during fever, with a significant increase in their geometric mean microfilaria count. Titres of specific immunoglobulin (Ig) G and IgG4 antibody to Wuchereria bancrofti microfilarial excretory/secretory antigens (measured by enzyme-linked immunosorbent assay) decreased significantly during the fever and the lower levels were maintained one month after fever. The mean circulating immune complex level increased significantly during fever, and a significant percentage of cases demonstrated circulating filarial antigen during fever, which declined after one month, suggesting the release of filarial antigen into the circulation during fever which bound to antibodies to form immune complexes. These observations do not support the suggestion that bacterial infection is the aetiology of filarial fever. It is postulated that antigens released from parasites into the circulation during parturition by adult worms may evoke an allergic response in the host, causing periodic febrile episodes.

Leishmania donovani: CD2 biased immune response skews the SAG mediated therapy for a predominant Th1 response in experimental infection.

We have evaluated the effect of combining CD2 with conventional antimonial (sb) therapy in protection in BALB/c mice infected with either drug sensitive or resistant strain of Leishmania donovani with 3×10(7) parasites via-intra-cardiac route. Mice were treated with anti CD2 adjunct SAG sub-cutaneously twice a week for 4 weeks. Assessment for measurement of weight, spleen size, anti-Leishmania antibody titer, T cell and anti-leishmanial macrophage function was carried out day 0, 10, 22 and 34 post treatments. The combination therapy was shown boosting significant proportion of T cells to express CD25 compared to SAG monotherapy. Although, the level of IFN-γ was not statistically different between combination vs monotherapy (p=0.298) but CD2 treatment even alone significantly influenced IFN-γ production than either SAG treatment (p=0.045) or with CD2 adjunct SAG treatment (p=0.005) in Ld-S strain as well as in Ld-R strain. The influence of CD2 adjunct treatment was also documented in anti-leishmanial functions in macrophages. As shown, the super-oxide generation began enhancing very early on day 10 after SAG treatment with CD2 during which SAG action was at minimum. Interestingly, the super-oxide generation ability remained intact in macrophage after treatment with immuno-chemotherapy even in mice infected with Leishmania resistant strain. Unlike SAG treatment, treatment of SAG with CD2 also led to production of nitric oxide and TNF-α, resulting in resulting in most effective clearance of L. donovani from infected macrophages. Our results indicate that CD2, which can boost up a protective Th1 response, might also be beneficial to enable SAG to induce Macrophages to produce Leishmanicidal molecules and hence control the infection in clinical situation like Kala-azar. Drug resistance is the major impedance for disease control but the encouraging results obtained after infecting mice with resistant strain of the parasite strongly imply that this drug can be effective even in treating resistant cases of Kala-azar.

Association of angiotensin-converting enzyme and angiotensin-converting enzyme-2 gene polymorphisms with essential hypertension in the population of Odisha, India

Abstract Background: Hypertension is a serious health issue worldwide and essential hypertension, which includes 90–95% of the cases, is influenced by both genetic and environmental factors. Identification of these factors may help in control of this disease. The Insertion/Deletion (I/D) polymorphism in Angiotensin-Converting Enzyme (ACE) gene and rs2106809 (C > T) polymorphism in Angiotensin-Converting Enzyme 2 (ACE2) gene have been reported to be associated with essential hypertension in different populations. Aim: To investigate the association of ACE I/D and ACE2 rs2106809 polymorphisms with essential hypertension in the population of Odisha, an eastern Indian state. Subjects and methods: A total of 246 hypertensives (159 males and 87 females) and 274 normotensives (158 males and 116 females) were enrolled in the study. Detailed anthropometric data, tobacco, alcohol and food habits were recorded and 2 ml of venous blood was collected for biochemical and genetic analysis. Results: The DD genotype of ACE and TT genotype of ACE2 were significantly high among female hypertensives, while T allele of ACE2 was linked to male hypertensives. In the male population, alcohol was also identified as a potential risk factor. Conclusion: Among females, ACE I/D and ACE2 rs2106809 polymorphisms, while among males, ACE2 rs2106809 polymorphism and alcohol consumption are associated with essential hypertension in the study population.

Molecular monitoring of antimalarial drug resistance among Plasmodium falciparum field isolates from Odisha, India

In the absence of definite marker for artemisinin (ART) resistance, molecular monitoring of its partner drug sulfadoxine pyrimethamine (SP) in artemisinin based combination therapy (ACTs) together with chloroquine (CQ) for which ART is negatively correlated, may predict the effectiveness of ACT. We analyzed 201 Plasmodium falciparum field isolates for drug resistance markers for CQ (pfcrt and pfmdr1), pyrimethamine (pfdhfr) and sulfadoxine (pfdhps). Our study reveals high prevalence and non-random association of resistant mutants (K76T and N86Y) of CQ markers (pfcrt and pfmdr1). The predominance of highly resistant pfdhfr genotypes for SP with intragenic and intergenic pair-wise linkage disequilibrium between single nucleotide polymorphisms of resistant mutants of pfdhfr (C59R and S108N) and pfdhps (S436A, A437G, K540E) warn on further inclusion of SP in ACT. These findings suggest the replacement of SP in ACT with alternative partner drug for better efficacy.

The sheath of the microfilaria of Wuchereria bancrofti has albumin and immunoglobulin on its surface

Using direct fluorescent antibody analysis it was shown that the sheath of live microfilariae of Wuchereria bancrofti has human albumin and the immunoglobulin G subclasses IgG1 and IgG4 on its surface.

Side reactions following ivermectin therapy in high density bancroftian microfilaraemics

Side reactions following ivermectin treatment were evaluated in sixty males with high density bancroftian microfilaremia (GM 1388/ml). Following a single oral dose of ivermectin of different strengths (20, 50, 100 or 200 micrograms/kg), microfilariae clearance and side reactions were monitored in a double blind fashion. Microfilaria levels fell rapidly after ivermectin administration in all dosage groups and 98% of pretreatment microfilariae was cleared after 12 h of treatment. The rate of microfilaria (mf) clearance was slower with 20 micrograms/kg than with the highest dose (200 micrograms/kg) administered. Forty-six patients (77%) became amicrofilaraemic within 2 weeks of treatment. Side reactions were noted in 97% of cases. The most common reactions were fever, headache, weakness, myalgia and cough which appeared by 12 h and subsided by 72 h following treatment. The frequency and intensity of side reactions were related to pretreatment mf densities and were independent of the dose administered. Unusual side reactions were noted in a few patients with high density microfilaraemia. These included intense cough, shortness of breath, blood tinged mucoid expectoration associated with patchy pneumonitis of the lung. Itchy rashes, lymphatic nodules and raised alkaline phosphatase level were also observed in some patients. These side reactions were transient, self limiting and were not serious enough to warrant any treatment. These exaggerated unusual reactions were possibly due to allergic response of the susceptible host to rapid killing of large number of microfilariae.

Viral aetiology and clinico-epidemiological features of acute encephalitis syndrome in eastern India.

This study reports clinico-epidemiological features and viral agents causing acute encephalitis syndrome (AES) in the eastern Indian region through hospital-based case enrolment during April 2011 to July 2012. Blood and CSF samples of 526 AES cases were investigated by serology and/or PCR. Viral aetiology was identified in 91 (17·2%) cases. Herpes simplex virus (HSV; types I or II) was most common (16·1%), followed by measles (2·6%), Japanese encephalitis virus (1·5%), dengue virus (0·57%), varicella zoster virus (0·38%) and enteroviruses (0·19%). Rash, paresis and cranial nerve palsies were significantly higher (P < 0·05) with viral AES. Case-fatality rates were 10·9% and 6·2% in AES cases with and without viral aetiology, respectively. Simultaneous infection of HSV I and measles was observed in seven cases. This report provides the first evidence on viral aetiology of AES viruses from eastern India showing dominance of HSV that will be useful in informing the public health system.