Wali Jp

Transfusion‐transmitted kala‐azar in India

evaluated through large-scale clinical trials in blood bank settings. Although none of us were professionally involved in transfusion medicine during the time referenced in Dr. Bettigole’s letter, it is our understanding that consideration of the above factors led to the prospective follow-up studies of the late 1970s and early 1980s that produced data defining the incidence of and morbidity associated with non-A,non-B posttransfusion hepatitis and identified it as a disease for which a partial reduction in transmission would be worthwhile.2,3 The second issue raised by Dr. Bettigole has to do with the setting of cutoff values for unit acceptance. At first glance, it may appear that this consideration applies only to ALT testing, as this test generates a numerical value along a continuous scale rather than a positive or negative interpretation, as is the case with enzyme immunoassays. However, enzyme immunoassays also produce values on a continuous scale, which requires that cutoff value decisions be made. The difference is that such decisions are made by the manufacturer and the Food and Drug Administration rather than by blood centers. The aim of those decision makers is to strike a balance between the competing aims of optimizing both test sensitivity and specificity. For some tests, such decisions are appropriate at the time the test is implemented but should be modified as additional data are accumulated and as circumstances change. For example, many believe that the cutoff for blood donor screening for antibody to hepatitis C core antigen should be altered now that hepatitis C virus antibody testing is routinely p e r f ~ r m e d . ~ , ~ The issue of selecting optimal cutoff values also applies to ALT testing in the era of hepatitis C virus antibody screening. The data in our study can be used to reset the ALT cutoff value if such testing is to be continued. Our data show that setting the cutoff value at a higher level (i.e., twice the previous cutoff) will improve the tradeoff between sensitivity and specificity, although, in our opinion, not to a level that warrants retention of ALT testing.6 This cutoff change has been adopted, in the interim, by the many US blood banks that still continue ALT testing because of the European requirement for such testing of plasma manufactured into derivatives. Given the profound implications for donors and recipients and the impact on transfusion economics, we strongly believe that decisions regarding the implementation or elimination of donor screening tests should be made after a thorough analysis of test performance, predictive value, and cost-effectiveness. We hope that those making future test implementation decisions, both for previously identified and newly discovered agents, will carefully consider the full set of issues outlined in this letter.

Dengue haemorrhagic fever in adults : a prospective study of 110 cases

One hundred and ten adult patients hospitalized with dengue haemorrhagic fever (DHF) during the recent outbreak in North India were prospectively studied. Of these, 48 (43.6%) were grade 1, 40 (36.4%) grade II, 10 (9.1%) grade III and 12 (10.9%) grade IV DHF. Dengue shock syndrome (DSS) was seen in 22 (20%) patients. Fever, headache, myalgias and arthralgias were the common symptoms seen in 100%, 80.9%, 76.2% and 52.3% patients, respectively. Spontaneous bleeding was seen in 62 patients (56.4%) with mucocutaneous bleeding being the most common (46 patients). Gastrointestinal bleeding was seen in 38 (34.5%) patients. In as many as 40 patients, the haemorrhagic manifestations occurred after the fever had come down. Fifty-five patients (50%) required platelet transfusions. Twelve patients died, giving a mortality rate of 10.9% in the present study. Prompt recognition and supportive treatment can be lifesaving.

Hepatitis B, C and Human Immunodeficiency Virus Infections in Multiply-injected Kala-azar Patients in Delhi

Sera from 164 patients with parasitologically confirmed kala-azar and 100 patients with non-kala-azar Delhite in 2 Delhi hospitals were tested for anti-human immunodeficiency (anti-HIV) and anti-hepatitis C virus (anti-HCV) antibodies and hepatitis B surface antigens to determine which group is more likely to contract these infections. The mean age of the patients was 32.5 y (+/-6.5 y), (120 M, 44 F). Two patients were from Nepal and the others from the kala-azar endemic state of Bihar, India. As geographical controls, 50 serum samples from sex- and age-matched healthy Bihar residents were also tested for the blood-borne viral infections. All patients had been treated with injectable medicines by 1 or more local physicians before they were referred to the Delhi hospitals. The prevalence of hepatitis B virus (HBV) and HCV infection was significantly different between the 2 patient groups. While 2 kala-azar patients (1.21%) were found to be HIV-1 positive, 54 (32.9%) patients had anti-HCV antibodies detected by ELISA and 51 (31.1%) by RIBA test. The seroprevalence of HCV was only 2% in hospitalized non-kala-azar cases and 4% in the geographical controls (p < 0.001). The seroprevalence of HBV was 13.2% in hospitalized kala-azar cases, but only 1.75% in disease control cases and 1.6% in geographical control cases. The difference in infection rates between cases and controls was significant (p < 0.001). The results indicate that kala-azar patients treated locally in Bihar have a greater chance of contracting blood-borne infections. Interestingly, we found that HCV was more prevalent than HBV. These infections were most likely acquired through the re-use of needles by local medical and paramedical practitioners for administering anti-leishmanial drugs. This trend, if not checked immediately, may have drastic consequences in the horizontal transmission of HIV in Bihar.Sera from 164 patients with parasitologically confirmed kala-azar and 100 patients with non-kala-azar Delhite in 2 Delhi hospitals were tested for anti-human immunodeficiency (anti-HIV) and anti-hepatitis C virus (anti-HCV) antibodies and hepatitis B surface antigens to determine which group is more likely to contract these infections. The mean age of the patients was 32.5 y (916.5 y), (120 M, 44 F). Two patients were from Nepal and the others from the kala-azar endemic state of Bihar, India. As geographical controls, 50 serum samples from sexand age-matched healthy Bihar residents were also tested for the blood-borne viral infections. All patients had been treated with injectable medicines by 1 or more local physicians before they were referred to the Delhi hospitals. The prevalence of hepatitis B virus (HBV) and HCV infection was significantly different between the 2 patient groups. While 2 kala-azar patients (1.21%) were found to be HIV-1 positive, 54 (32.9%) patients had anti-HCV antibodies detected by ELISA and 51 (31.1%) by RIBA test. The seroprevalence of HCV was only 2% in hospitalized non-kala-azar cases and 4% in the geographical controls (pB0.001). The seroprevalence of HBV was 13.2% in hospitalized kala-azar cases, but only 1.75% in disease control cases and 1.6% in geographical control cases. The difference in infection rates between cases and controls was significant (pB0.001). The results indicate that kala-azar patients treated locally in Bihar have a greater chance of contracting blood-borne infections. Interestingly, we found that HCV was more prevalent than HBV. These infections were most likely acquired through the re-use of needles by local medical and paramedical practitioners for administering anti-leishmanial drugs. This trend, if not checked immediately, may have drastic consequences in the horizontal transmission of HIV in Bihar.

Fibromyalgia in Indian patients with SLE

One hundred and fifty-eight patients with SLE were prospectively studied at a tertiary referral centre in India to ascertain the prevalence and clinical profile of fibromyalgia (FM) in Indian patients with lupus. An attempt was made to determine whether socio-demographic factors or disease characteristics differ in SLE patients with and without FM. Only 13 patients (8.2%) in our cohort were found to have fibromyalgia. Their clinical profiles were similar to that reported in other series. Corticosteroid withdrawal or dose reduction was the probable precipitating factor in nearly one-third of our patients. Age, sex, marital status, educational level, disease duration, disease activity and the organ involvement in patients with SLE and FM were comparable to those in patients not having FM. Fibromyalgia appears to be distinctly uncommon in Indian patients with lupus. A strong family support system, the virtual lack of disability benefits and/or racial variations in pain threshold could be the likely factors responsible for the low prevalence of the disease observed in Indian patients with SLE.

Lidocaine in refractory status epilepticus: A forgotten drug in the emergency department☆

Generalized tonic-clonic status epilepticus is usually treated with intravenous benzodiazepines and phenytoin. Patients who do not respond to this treatment are generally treated with phenobarbital or general anesthetics both of which may require intubation to maintain respiration. Our experience of four cases with status epilepticus treated with intravenous lidocaine who had failed to respond to diazepam and phenytoin therapy is presented. Two cases responded to a single dose of lidocaine, one required a second dose of lidocaine to control seizures, and the fourth patient failed to respond and died as a result of associated severe head injury. Therefore, there is a need to conduct further studies to establish the efficacy of intravenous lidocaine in the treatment of refractory status epilepticus.

Fever of unknown origin : a prospective study

Fever of unknown origin (FUO) is a problem frequently faced by clinicians all over the world. One hundred and twenty-one cases of FUO presenting to a large teaching hospital in northern India were prospectively studied over a period of 2 years. Infections were the commonest cause accounting for 43.8% cases of FUO, with tuberculosis (TB) being the commonest infection encountered. Collagen vascular diseases and tumours accounted for 15.7 and 8.3% cases, respectively. No cause could be found out in a substantial number of cases (19%) even after invasive investigations. Knowledge of the current patterns of FUO is important since many patients present with potentially treatable diseases.

Ulcerative colitis associated with Takayasu arteritis.

Takayasu arteritis is a chronic vasculitis involving the left upper limbs, respectively. Left carotid was mainly the aorta and its branches. It is often complifeeble as compared to the right carotid. Rectal and cated with other systemic manifestations. Renal proctoscopic examinations revealed blood mixed with involvement is commonly in the form of renovascular stools coming from above without any evidence of hypertension though mesangial proliferative glomerulocal pathology. A clinical diagnosis of Takayasu lonephritis, crescentic glomerulonephritis and arteritis with renal and mesenteric ischemia was amyloidosis can also occur [1]. Skin changes include made. erythema nodosum, facial lupus rash and erythema Routine investigations revealed hemoglobin of 9 3 induratum. Dilated cardiomyopathy, myocarditis and g/dl, total leukocyte counts 15 000/mm with 70% pericarditis have been reported. Rarely, ulcerative neutrophils and ESR 60 mm/1st hour. Renal funccolitis has been reported with Takayasu arteritis [2]. tions, electrolytes and liver functions were normal. We report a patient with Takayasu arteritis who Urine examination showed 15–20 red blood cells developed ulcerative colitis and renal involvement without any dysmorphic cells or casts. Ultrasound of nearly 1 year after the initial diagnosis. The HLA the abdomen documented healthy appearing kidneys type in this patient is also presented. with the right larger (11 cm) than the left (9 cm). A 15-year-old boy was diagnosed to have A repeat DSA showed subtle narrowing of proximTakayasu arteritis 1 year ago when he presented with al part of bilateral subclavian arteries and wavy a fever of 4 months duration. A digital subtraction contour of abdominal aorta. Left renal artery showed angiography (DSA) at that time revealed involvement a short stenotic segment at its origin along with of descending thoracic aorta, abdominal aorta, left stenosis of the branch arising from it. Only the upper common carotid and left brachial artery. He respondpart of the left kidney was seen on nephrogram ed to steroids which were tapered off in 8 months. suggesting that another artery was supplying the At this admission, he presented with complaints of lower part of the left kidney (Fig. 1). However, this fever for 3 months, and hematuria and hematochezia artery could not be visualized indicating a tight osteal for 3 days. On examination, blood pressure was stenosis or occlusion. Superior and inferior mesen146/100 mmHg and 124/94 mmHg in the right and teric arteries were normal. These findings were consistent with renal infarction as the cause of hematuria. A colonoscopy done at this point revealed *Corresponding author. Tel.: 191-11-653-1201; fax: 191-11-686an edematous and erythematous mucosa with multi2663. E-mail address: peekay 124@hotmail.com (P. Aggarwal). ple small superficial erosions throughout the length of ]

Intravascular hemolysis in aluminium phosphide poisoning

Intravascular hemolysis is most often secondary to exposure to a variety of drugs or infections, and usually occurs in patients who are deficient in glucose-6-phosphate dehydrogenase (G-6-PD) enzyme. Aluminium phosphide, a fumigant widely used in India, has been reported to produce intravascular hemolysis in only one patient who also had concomitant G-6-PD deficiency. This report describes the occurrence of intravascular hemolysis with aluminium phosphide poisoning in a patient with normal G-6-PD levels. This is of significance as jaundice in patients with this poisoning is often attributed to hepatic damage alone.

Poncet's disease in a north Indian hospital.

Although the entity of tuberculous rheumatism or Poncets disease has sometimes been the subject of debate, it has been reported infrequently in the English literature. We discuss here seven patients (5 women, 2 men; age 18–48 years) who presented primarily with polyarthritis and fever and developed pulmonary, pleural or nodal tuberculosis later in the course of disease. Rheumatoid arthritis, collagen vascular diseases and other common causes of polyarthritis were ruled out by appropriate investigations. Polyarthritis resolved in all the patients after the institution of antitubercular treatment and did not recur, thus providing a therapeutic confirmation of the clinical diagnosis.

Kala-azar--new developments in diagnosis and treatment.

Kala-azar is an endemic, disease in many parts of India. Traditionally diagnosis of this disease was based on demonstrating the parasites in various tissues like bone marrow or splenic aspirates. However, lack of high sensitivity of these methods led to the use of various immunodiagnostic methods in the diagnosis of kala-azar. Antigen detection and polymerase chain reaction to detect parasitic DNA have been found to be useful in patients with an underlying immunosuppressive disease like AIDS. For treating kala-azar, pentavalent antimonial compounds are still the first-line agents. However, due to increasing resistance to this agent, many patients at present requie other drugs including amphotericin B and pentamidine. Toxic effects of these second-line agents have led to development of drug dellvery systems like liposomal amphotericin B, which has shown uniform efficacy in clinical trials. Combining stibogluconate with either paromomycin or interferon-γ has also been shown to be useful in many patients with drug-resistant kala-azar.