Sanjeeb Kakati

Heightened inflammation in severe malaria is associated with decreased IL-10 expression levels and neutrophils

Dysregulation of the cytokine network in severe malaria owing to variations in factors like parasite load, strains and host factors is well documented but the key cytokines that are dysregulated remain poorly elucidated. Longitudinal changes in cytokine levels in an individual with parasitemia and disease resolution is likely to identify the key cytokines. We have analyzed the mRNA expression of cytokines over a 7-d period in severe (SM) and uncomplicated (UM) Plasmodium falciparum malaria. We found up-regulated expression of TNF-α, IL-1β, IFN-γ and TGF-β in SM, with decreased expression of IL-10 on d 0. Further, we observed a negative correlation of IL-10 expression with parasitemia and pro-inflammatory cytokines, suggesting IL-10 to be the key cytokine in tilting the balance to an inflammatory response. Longitudinal analysis revealed that the key cytokines associated with disease were TNF-α, IL-1β, IFN-γ, IL-12α, RANTES and TGF-β, while TNF-α, IL-10 and TGF-β discriminated between SM and UM. A higher neutrophil count in SM and its positive association with parasite density and IL-1β and IL-8 provides support for neutrophils in inflammation in malaria. Our findings suggest subversion of anti-inflammatory response in SM by parasite factors towards an exaggerated pro-inflammatory response with involvement of neutrophils, the classical inflammatory cells.

The association of IL-8-251T/A polymorphism with complicated malaria in Karbi Anglong district of Assam

Amongst host genetic factors, cytokine gene polymorphism can be anticipated to be an important factor as qualitative, quantitative and time of secretion play an important role in disease outcome. We have investigated association of cytokine promoter SNPs with risk of Plasmodium falciparum malaria and disease severity in a case control study in malaria endemic Karbi Anglong district of Assam, India. Frequency of IL-8-251T/A (p=0.03 and p=0.01) and TGF-β1-509C/T (p=0.02 and p=0.03) was higher in malaria in comparison to control participants and non-malarial fever controls. Interestingly, a higher frequency of mutant allele of IL-10-819T/C was observed in non-malarial fever controls compared to malaria thus suggesting its role as a distinguishing marker of the two disease groups. Higher IL-8 expression and increased frequency of IL-8-251T/A in complicated malaria (p=0.002) was reported indicating its role in susceptibility to complicated malaria. In conclusion, our study suggests the role of mutant genotype of IL-8-251T/A as a marker of complicated malaria in our population. Surprisingly, decreased expression of TGF-β1 in uncomplicated malaria even in presence of high expressing mutant genotype was observed and needs to be investigated in context of the pool of activated cells producing the cytokine.

Registry of Youth Onset Diabetes in India (YDR) Rationale, Recruitment, and Current Status

Background: With the aim of addressing the relative scarcity of information on youth-onset diabetes in India, the Indian Council of Medical Research (ICMR) decided to establish the Registry of People with Diabetes with Young Age at Onset (YDR) in 2006. The major objectives of YDR are to generate information on disease pattern or types of youth-onset diabetes including their geographical variations within India and to estimate the burden of diabetes complications. Methods: YDR is an observational multicenter clinic based registry enlisting physician diagnosed diabetes in individuals below 25 years of age. Diabetes was classified using symptom based clinical criteria. YDR data collection is coordinated through regional collaborating centers and their interacting reporting centers across India. A baseline and an annual follow-up proformas are used to obtain information on sociodemographic details, clinical profile, and anthropometric and laboratory measurements of the patients. Results: In phase 1, the registry has enrolled 5546 patients, in which type 1 diabetes mellitus (T1DM) was the most prevalent (63.9%), followed by youth-onset type 2 diabetes mellitus (T2DM) (25.3%). Conclusion: This registry provides a unique opportunity to study the natural history of youth-onset diabetes in India.

Immunogenicity & safety of a single dose of live-attenuated Japanese encephalitis vaccine SA 14-14-2 in adults

Background & objectives: Japanese encephalitis (JE) caused by mosquito-borne Flavivirus is one of the leading causes of viral encephalitis in Asia. Control strategies include vector control and human vaccination. Due to lack of immunization programmes in endemic regions, there are still high mortality and morbidity. A live-attenuated SA 14-14-2 JE vaccine (LAJEV) has been licensed and used in Asian countries, including India. We report the assessment of immunogenicity and safety of the vaccine in adults during the first mass adult vaccination campaign carried out in Assam, India. Methods: One thousand and seventy five adults (aged ≥15 yr) who received LAJEV were monitored for adverse events following immunization for one year. The safety assessment of vaccinated population was evaluated till 28 days and at 6 and 12 months. Blood samples collected from the enrolled participants were tested by plaque reduction neutralization test (PRNT50) to assess the neutralizing antibody titres (NATs) before vaccination and 28 days, six and 12 months post-vaccination (PV). Results: Among the 1075 vaccinated individuals, four reported minor adverse effects from 30 min to 28 days PV. Based on the pre-vaccination NAT, the study participants were categorized as seronegative, moderately seropositive and strongly seropositive. Nearly 85.5 per cent of JE seronegative participants seroconverted by 28 days PV. The geometric mean titre (GMT) in all the three groups increased by 28 days and decreased by six and 12 months PV. Nearly 60 per cent of the moderately positive individuals exhibited four-fold rise in GMT, 28 days PV. Almost 95.5 per cent of the participants in the study population remained seroprotected at the end of 12 months PV. Interpretation & conclusions: This study on immunogenicity and safety of LAJEV in adults showed that a single dose of the live-attenuated vaccine was safe and induced protective immunity to both JE seronegative and naturally seropositive adults. Further study is required to find out long term protective efficacy of this vaccine.

Incidence of Japanese Encephalitis amongst acute encephalitis syndrome cases in upper Assam districts from 2012 to 2014: A report from a tertiary care hospital

Background & objectives: Japanese encephalitis (JE) is a major public health problem in India because of high mortality rate and residual neuropsychiatric damage in the survivors. The present study was undertaken to investigate JE positivity amongst patients admitted with acute encephalitis syndrome (AES) in upper Assam districts and different parameters with their changing trends related to it. Methods: It was a hospital-based prospective cross-sectional study conducted from January 2012 to December 2014. A total of 1707 consecutive non-repetitive hospitalized patients, satisfying the clinical case definition of AES as per the WHO guidelines, were included in the study. Cerebrospinal fluid (CSF) and serum samples were tested for JEV-specific IgM antibodies. Results: Of the 1707 patients admitted, 696 (40.77 %) were diagnosed as JE with male-to-female ratio 1.7:1 and adult to paediatric ratio 2.2:1. Fever (100%), change in mental status (100%), headache (80.02%), neck rigidity (52.01%), unconsciousness (48.99%), seizure (37.64%) and paralysis (11.06%) were the major clinical findings. The majority of cases (94%) were from rural areas. There was a significant association of JE cases with rainy season of the year i.e., June to August (P <0.001). Overall, 14.94 per cent deaths were reported in JE positive cases. Interpretation & conclusions: A higher occurrence of JE was observed in above 15 yr age group. Cases were mainly from rural areas, and there was clustering of cases in rainy season.

A clinical study of hemoglobin E with special reference to serum ferritin level

Introduction: The spectrum of anaemia is modified in many parts of world, due to prevalence haemoglobinopathies. The common haemoglobinopathies includes HbS, HbC, D (Punjab) and E. In Assam with its population consisting of diverse ethnic groups, is a rich reservoir of abnormal haemoglobin and thalassaemia. The incidence of HbE from various population survey of Assam showed that 20% among Indig Assamese, 57.4% among Ahoms and as high as 80% among Bodo-Kacharis. Iron therapy is hazardous in haemoglobinopathies due to risk of tissue iron toxicity, so needs evaluations of iron status before iron therapy. The size of the stored iron in the body is accurately indicated by serum ferritin estimation, which is single most sensitive and non-invasive method for iron status evaluation. Keeping all in minds the aim of the our study is to study the serum ferritin level of patients with HbE attending AMCH, Dibrugarh. Materials and Methods: This study was conducted in the department of medicine, AMCH for 1-year. 80 HbE patients of various religions and tribes were selected for study. Patients with HbE having malignancy, end stage renal disease, arthritis, chronic liver disease, and sepsis were excluded from the present study by careful history taking and laboratory investigations. Serum ferritin level was estimated by IRMA technique. Result and Observation : The incidence of HbE disease (E/E), trait (A/E) and HbE-thalassaemia (E/F) was 47.5%, 42.5%& 10% respectively. Most of the patients were in their second and third decade (57.5%). Male female ratio was 13:7, most being Ahom (60%) and Kochari (12.5%). The haemoglobin concentration in A/E, E/E and E/F were 8.94±0.928, 8.04±0.8840 and 6.02±0.1500; serum ferritin level 24.95±11.90, 162.26±59.5 and 1017±322.19 respectively. E/E patients on blood transfusions have a higher level of serum ferritin (122.85±4.95) than those without transfusions (95.75±9.54). Again those cases of E/F on regular blood transfusions have a higher ferritin (1260±188.14) level than those with occasional transfusions (715±155.80). Conclusion : Serum ferritin assay IRMA technique is simple and suitable for evaluation of serum iron status. Iron deficiency may be seen among HbE trait but normal or higher serum ferritin in E/E and E/F cases in this study suggests that indiscriminate iron therapy could be harmful in most of the patients without prior evaluation of serum ferritin.