Changing Clinical Profile of Dengue Fever Epidemic in North Kerala- A Retrospective Study

Introduction: Dengue fever is one of the most common vector-borne infections worldwide and is now endemic in Kerala. Knowledge about changing clinical presentation of dengue fever is important for timely diagnosis and appropriate management. Aim: To document changing trends in clinical presentation and course of illness among patients admitted with dengue fever in Kerala, India. Materials and Methods: This hospital-based, retrospective, observational study was conducted at Government Medical College and Hospital, Kannur, Kerala, India, from September 2021 to June 2022. The patients with dengue fever, presented in seasonal epidemic of the year 2019 was compared to similar patients presented during the year 2014. Data regarding clinical presentation, duration of hospital stay, complications and haematological parameters of the study population was collected using prevalidated questionnaire. Descriptive data were expressed in frequency, percentage, mean and standard deviation. Continuous and discrete variables were compared by Welch’s t-test, whereas categorical variables were compared using Pearson’s Chi-square test. Results: Out of the total 184 patients studied, 91 were from 2014 and 93 from 2019. The major presenting complaints were fever, body aches, headache, nausea and vomiting, arthralgia, and retroorbital pain incidence of which were similar in both the study years. Patients admitted in 2019 have shorter duration of fever (5.78 vs 6.79 days), earlier onset of severe thrombocytopaenia (6.62 vs 7.27 days) and delayed onset of complications (5.56 vs 3.6 days) compared to those admitted in 2014. They also had higher incidence of thrombocytopaenia (70.97% vs 54.94%) and complications (49.46% vs 14.29%) during the course of their illness. Conclusion: The study indicates towards a significant shift in clinical presentation of dengue fever in Kerala which may influence the admission and monitoring protocol of dengue fever patients in the years to come

Attenuated cerebrospinal fluid leukocyte count and sepsis in adults with pneumococcal meningitis: a prospective cohort study

BACKGROUND: A low cerebrospinal fluid (CSF) white-blood cell count (WBC) has been identified as an independent risk factor for adverse outcome in adults with bacterial meningitis. Whereas a low CSF WBC indicates the presence of sepsis with early meningitis in patients with meningococcal infections, the relation between CSF WBC and outcome in patients with pneumococcal meningitis is not understood. METHODS: We examined the relation between CSF WBC, bacteraemia and sepsis in a prospective cohort study that included 352 episodes of pneumococcal meningitis, confirmed by CSF culture, occurring in patients aged >16 years. RESULTS: CSF WBC was recorded in 320 of 352 episodes (91%). Median CSF WBC was 2530 per mm(3 )(interquartile range 531–6983 per mm(3)) and 104 patients (33%) had a CSF WBC <1000/mm(3). Patients with a CSF WBC <1000/mm(3 )were more likely to have an unfavourable outcome (defined as a Glasgow Outcome Scale score of 1–4) than those with a higher WBC (74 of 104 [71%] vs. 87 of 216 [43%]; P < 0.001). CSF WBC was significantly associated with blood WBC (Spearman's test 0.29), CSF protein level (0.20), thrombocyte count (0.21), erythrocyte sedimentation rate (-0.15), and C-reactive protein levels (-0.18). Patients with a CSF WBC <1000/mm(3 )more often had a positive blood culture (72 of 84 [86%] vs. 138 of 196 [70%]; P = 0.01) and more often developed systemic complications (cardiorespiratory failure, sepsis) than those with a higher WBC (53 of 104 [51%] vs. 69 of 216 [32%]; P = 0.001). In a multivariate analysis, advanced age (Odds ratio per 10-year increments 1.22, 95%CI 1.02–1.45), a positive blood culture (Odds ratio 2.46, 95%CI 1.17–5.14), and a low thrombocyte count on admission (Odds ratio per 100,000/mm(3 )increments 0.67, 95% CI 0.47–0.97) were associated with a CSF WBC <1000/mm(3). CONCLUSION: A low CSF WBC in adults with pneumococcal meningitis is related to the presence of signs of sepsis and systemic complications. Invasive pneumococcal infections should possibly be regarded as a continuum from meningitis to sepsis

Community-acquired bacterial meningitis in adults: antibiotic timing in disease course and outcome

OBJECTIVES: Despite improvements in diagnostic and therapeutic approach to adult patients with bacterial meningitis, the overall mortality rate is still high. The aim of this study was to evaluate antibiotic timing in the course and outcome of bacterial meningitis. ----- METHODS: Two hundred and eighty six patients with community-acquired bacterial meningitis aged 14 years and more were included in this retrospective cohort study. Observational period was between 1 January 1990 and 31 December 2004. To assess the association of antibiotic timing and disease outcome we analyzed three timing periods (according to the onset of disease, onset of consciousness disturbance and the time of admission to hospital). Analysis was also performed in a subgroup of culture positive meningitis in 176 patients with altered mental status. ----- RESULTS: Unfavorable outcome was found in 125 (43,7%) patients. In this group, the start of appropriate antibiotic treatment in relation to the onset of first symptoms and particularly to the onset of consciousness disturbance was significantly delayed (p = 0.018 and p < 0.001, respectively) compared to the favorable group. Logistic regression analysis in a subgroup of culture positive meningitis in patients with altered mental status revealed that early adequate antibiotic treatment related to the onset of overt signs of meningitis was independently associated with favorable outcome (OR = 11.19; 95% CI 4.37-32.57; p < 0.001). Advanced age, lower GCS and seizures (OR = 1.05, OR = 1.45 and OR = 3.65, respectively) were other risk factors of poor outcome. The presence of chronic diseases, pneumococcal etiology and clinical and laboratory variables which are indicators of disease severity (renal and/or liver dysfunction, hypotension and low cerebrospinal fluid glucose) were not confirmed as independent risk factors of poor outcome. ----- CONCLUSIONS: Our study emphasizes the importance of early and adequate antibiotic treatment in the management of bacterial meningitis which significantly enhances the chances for favorable outcome