A Study of Etiological Pattern in an Epidemic of Acute Febrile Illness during Monsoon in a Tertiary Health Care Institute of Uttarakhand, India
Ragini Singh1, S P Singh2, Niaz Ahmad3
1 Associate Professor, Department of Pediatrics, SGRR Institute of Medical & Health Sciences, Patel Nagar, Dehradun, Uttarakhand, India.
2 Professor, Department of Medicine, SGRR Institute of Medical & Health Sciences, Patel Nagar, Dehradun, Uttarakhand, India.
3 Assistant Professor, Department of Medicine, SGRR Institute of Medical & Health Sciences, Patel Nagar, Dehradun, Uttarakhand, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Ragini Singh, Associate Professor, Department of Pediatrics, Sri Mahant Indiresh Hospital & SGRR Institute of Medical & Health Sciences, Patel Nagar, Dehradun-248001, Uttarakhand, India.
Phone: 09897688538,
E-mail: drspsingh6@gmail.com
Background: Many parts of India are endemic for the dengue, malaria, typhoid and scrub typhus infections. The relative contribution of these illnesses in an outbreak of acute febrile illness is not known in this region.
Objective: The present study was conducted to find out the etiological pattern in an epidemic of acute febrile illness in Uttarakhand during the monsoon period. The study also focuses on concurrent infections and tries to find out the mortality outcomes.
Materials and Methods: A retrospective study of four months was conducted on 1141 patients who presented with fever, and were suspected to have dengue, malaria, typhoid or scrub typhus. Patients of 12-years of age or above were included in the study. Serological tests for dengue, malaria, typhoid and scrub typhus were performed. Slides for malaria parasite were examined. In case of enteric fever only culture positive cases were included in the study.
Result: Among the 1141 febrile patients dengue was detected in 812(71.2 %), malaria in 146(12.8%), typhoid in 92(8.1%) and scrub typhus in 69(6.0%) cases. Mixed infection was noted in 22(1.9%).Conclusion: Maximum (71.2 %) cases of fever were caused by dengue but significant number (32.3%) of patients suffered from malaria typhoid and scrub typhus. Many (1.9%) suffered from concurrent and multiple infections.
Introduction
Fever is a common presenting symptom in developing countries. During the rainy season it becomes the commonest presenting symptom in our hospital. Epidemics of acute febrile illness have been causing major concerns in India [1,2]. Dengue, malaria, typhoid and scrub typhus have been reported in such epidemics. Every year during and after the rainy season an epidemic of acute febrile illness is witnessed in Uttarakhand but the relative contribution of various etiological agents remains unknown. There is no published data on this topic from this region.
Materials and Methods
This retrospective study was conducted at Sri Mahant Indiresh hospital and Sri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, India. The hospital is a tertiary referral centre of Uttarakhand where the patients reach not only from Dehradun but also from the neighboring districts and bordering states. The study period was of five months, ranging from July 2013 to November 2013. Patients of 12-years age or above, presenting with acute febrile illness, who tested positive for dengue serology, malaria antigen or slide test, salmonella typhi or paratyphi and scrub typhus were included in the study. All such admitted patients underwent detailed history and examination. Dengue infection was diagnosed using a commercial ELISA NS 1 antigen test and IgM antibody. Only culture proven cases of enteric fever were included in the study. Serology positive but culture negative cases were considered as clinically diagnosed typhoid and were excluded from the study. Malaria was confirmed on the basis of positive slide test or positive antigen. Patients with positive IgM antibody against O. tsutsugamushi in their serum were diagnosed as scrub typhus. Patients suffering from more than one infective etiology were considered as mixed infection.
Results
A total of 1141 patients were found to be suffering from acute febrile illness. 618(54.2%) were male and 523(45.8%) were female . Male female ratio was 1:2 [Table/Fig-1]. 1006(88.2%) patients reported from September to November [Table/Fig-2]. Dengue was detected in 812(71.2 %), malaria in 146(12.8%), typhoid in 92(8.1%), and scrub typhus in 69(6.0%) cases. Mixed infection was noted in 22(1.9%) [Table/Fig-3,4]. Out of these 9(0.79%) had dengue with malaria, 5(0.44%) had dengue with scrubtyphus, 3(0.26%) had dengue and typhoid. 1(0.09%) patient was found to be each in the category of malaria with scrub typhus, dengue with malaria and typhoid, dengue with typhoid and Scrub typhus, malaria with typhoid, typhoid with scrub typhus. Ninteen (1.7%) patients died. Maximum mortality was caused by dengue12(1.1%) followed by malaria 3(0.26%) and 2(0.18%). 1(0.09%) patient died by scrub typhus and another 1(0.09%) by mixed infection. One person who died of mixed infection was suffering from dengue with malaria [Table/Fig-5,6].
Age and sex wise distribution of febrile patients
| Age group | Male | Female | Total |
|---|
| 12-20 | 140(12.3%) | 118(10.3%) | 258 (22.6% ) |
| 21-30 | 163(14.3%) | 128(11.2%) | 291(25.5%) |
| 31-40 | 131(11.5%) | 105(9.2%) | 236 (20.7%) |
| 41-50 | 112(9.8%) | 102(8.6%) | 214(18.8%) |
| 51-60 | 53(4.7%) | 51(2.1%) | 104(9.1%) |
| 61-70 | 14(1.2%) | 13(1.1%) | 27(2.4%) |
| 70-80 | 5(0.4%) | 6(0.6) | 11(1.0%) |
| Total | 618(54.2%) | 523(45.8%) | 1141 (100 %) |
Month wise distribution of febrile patients
| Month | No. (%) |
|---|
| July | 42(3.7%) |
| August | 93(8.2%) |
| September | 280(24.5%) |
| October | 386(33.8%) |
| November | 340(29.8%) |
| Total | 1141(100.0%) |
| 70-80 | 5(0.4%) |
| Total | 618(54.2%) |
Etiological pattern of febrile patients
| Disease | No. (%) |
|---|
| Dengue | 812(71.2%) |
| Malaria | 146(12.8%) |
| Typhoid | 92(8.1%) |
| Scrub typhus | 69(6.0%) |
| Mixed infections | 22(1.9%) |
| Total | 1141 |
Breakup of mixed infection
| Disease | No. (%) |
|---|
| Dengue +Malaria | 9(0.79%) |
| Dengue + Scrub typhus | 5(0.44%) |
| Dengue+ typhoid | 3(0.26%) |
| Malaria+ Scrub typhus | 1(0.09%) |
| Dengue +Malaria +typhoid | 1(0.09%) |
| Dengue +typhoid+ Scrub typhus | 1(0.09%) |
| Malaria + Typhoid | 1(0.09%) |
| Typhoid + Scrub typhus | 1(0.09%) |
| Total | 22(1.9%) |
| Age group | Total | Improved | Mortality |
|---|
| 12-20 | 258 (22.6% ) | 256(22.4%) | 2(0.2%) |
| 21-30 | 291(25.5%) | 288(25.2%) | 3(0.3%) |
| 31-40 | 236 (20.7%) | 233(20.4%) | 3(0.3%) |
| 41-50 | 214(18.8%) | 210(18.4%) | 4(0.4%) |
| 51-60 | 104(9.1%) | 100(8.8%) | 4(0.4%) |
| 61-70 | 27(2.4%) | 25(2.2%) | 2(0.2%) |
| 70-80 | 11(1.0%) | 10(0.9%) | 1(0.1%) |
| Total | 1141 (100 %) | 1122(98.3%) | 19(1.7%) |
| Disease | Total | Mortality |
|---|
| Dengue | 812(71.2%) | 12(1.1%) |
| Malaria | 146(12.8%) | 3(0.26%) |
| Typhoid | 92(8.1%) | 2(0.18%) |
| Scrub typhus | 69(6.0%) | 1(0.09%) |
| Mixed infections | 22(1.9%) | 1(0.09%) |
| Total | 1141 (100%) | 19(1.7%) |
Discussion
Males were more commonly suffering from fever. This may be due to their easy exposure to mosquitoes and mites because of their outdoor activities. Maximum number of cases were noted from September to November. Mixed infections are not uncommon in the tropics [3]. Monsoon period is a convenient time for mosquitoes to breed and infected mites to thrive. Drinking water also gets easily contaminated during this period. All these lead to clustering of dengue, malaria, typhoid and scrub typhus. Scrub typhus and leptospirosis have been reported in around 10%–20% cases of acute febrile illness in South east Asia [4–7].
Dengue, malaria, scrub typhus, typhoid and leptospirosis have been identified as major causes of acute undifferentiated febrile illness inThailand, Malaysia, and Nepal [8–12]. One third of all cases of acute undifferentiated non-malarial fever in Vietnam are caused by dengue [13]. In a similar study from Karnataka, 100 patients of acute febrile illness were diagnosed with: scrub typhus (33%); dengue (25%); enteric fever (14%); malaria (8.0%) [14]. Only culture positive cases were considered as enteric fever because false positive widal test is well known in cases of malaria and dengue [15,16].
Concurrent infections with more than one etiological agent can result in an illness with overlapping symptoms, resulting in a situation where the diagnosis and management of such a patient could be challenging [17–20]. The symptoms of dengue may mimic other diseases such as malaria and scrub typhus which are also prevalent in areas where dengue is endemic [21]. The similarity in symptoms between these infections may complicate the diagnosis of acute fever. Patients presenting with acute febrile illness should not be automatically assumed to have mono infection alone. The clinician should look for other causes of fever especially if atypical presentations arouse suspicion of other possible etiologies.
Conclusion
Maximum patients suffered from dengue in this epidemic of Uttarakhand making it primarily a dengue epidemic. Other infections in order of frequency were malaria, typhoid and scrub typhus. Significant numbers of patients were found to be suffering from various combinations of these infections. There is a need of greater awareness among clinicians for the possibility of co infections in a patients presenting with acute febrile illness.
[1]. Anthony DR, Balsari S, Clark S, Straff DJ, Rajavelu P, Rajagopalan A, The EMcounter Project: A Study of the Epidemiology of Medical Emergencies in India Ann Emerg Med 2007 50:129-30. [Google Scholar]
[2]. Chrispal A, Boorugu H, Gopinath KG, Chandy S, Prakash JA, Thomas EM, Acute undifferentiated febrile illness in adult hospitalized patients: the disease spectrum and diagnostic predictors - an experience from a tertiary care hospital in South India Trop Doct 2010 40:230-4. [Google Scholar]
[3]. Yong LS, Koh KC. A Case of Mixed Infections in a Patient Presenting with Acute Febrile Illness in the Tropics. http://dx.doi.org/10.1155/2013/562175 [Google Scholar]
[4]. Tangkanakul W, Kingnate D, Leptospirosis epidemic in north–eastern provinces, 1997 Journal of Health Sciences 1998 3:386-95. [Google Scholar]
[5]. Brown GW, Shirai A, Jegathesan M, Burke DS, Twartz JC, Saunders JP, Febrile illnesses in Malaysia: an analysis of 1,629 hospitalized patients American Journal of Tropical Medicine and Hygiene 1984 33:311-5. [Google Scholar]
[6]. Bishai FR, Galli R, Enzyme-linked immunosorbent assay for detection of antibodies to influenza A and B and parainfluenza type 1in sera of patients Journal of Clinical Microbiology 1978 8:648-58. [Google Scholar]
[7]. Berman SI, Irving GS, Kundin WD, Gunning I, Watten RH, Epidemiology of the acute fever of unknown origin in South Vietnam: effect of laboratory support upon clinical diagnosis American Journal of Tropical Medicine and Hygiene 1973 22:796-801. [Google Scholar]
[8]. Sripanidkulchai R, Lumbiganon P, Etiology of obscure fever in children at a university hospital in northeast Thailand Southeast Asian J Trop Med Public Health 2005 36:1243-6. [Google Scholar]
[9]. Murdoch DR, Woods CW, Zimmerman MD, Dull PM, Belbase RH, Keenan AJ, The etiology of febrile illness in adults presenting to Patan Hospital in Kathmandu, Nepal Am J Trop Med Hyg 2004 70:670-5. [Google Scholar]
[10]. Leelarasamee A, Chupaprawan C, Chenchittikul M, Udompanthurat S, Etiologies of acute undifferentiated febrile illness in Thailand J Med Assoc Thai 2004 87:464-72. [Google Scholar]
[11]. Ellis RD, Fukuda MM, McDaniel P, Welch K, Nisalak A, Murray CK, Causes of fever in adults on the Thai-Myanmar border Am J Trop Med Hyg 2006 74:108-13. [Google Scholar]
[12]. Pradutkanchana J, Pradutkanchana S, Kemapanmanus M, Wuthipum N, Silpapojakul K, The etiology of acute pyrexia of unknown origin in children after a flood Southeast Asian J Trop Med Public Health 2003 34:175-78. [Google Scholar]
[13]. Phuong HL, de Vries PJ, Nga TT, Giao PT, Hung le Q, Binh TQ, Dengue as a cause of acute undifferentiated fever in Vietnam BMC Infect Dis 2006 6:123 [Google Scholar]
[14]. Kashinkunti MD, Gundikeri SK, Dhananjaya M, Acute undifferentiated febrile illness- clinical spectrum and outcome from a tertiary care teaching hospital of north Karnataka Int J Biol Med Res 2013 4(2):3399-402. [Google Scholar]
[15]. Sharma JR, Parmar I B, Sharma S J, Kesavan A, False positive Widal action in malaria Indian Pediatr 1993 30:1343-7. [Google Scholar]
[16]. Olopoenia LA, King AL, Widal agglutination test — 100 years later: still plagued by controversy Postgrad Med J 2000 76:80-4. [Google Scholar]
[17]. Mushtaq Mohsin Bin, Qadri Mehmood I, Rashid Aaliya, Concurrent Infection with Dengue and Malaria: An Unusual Presentation Case Reports in Medicine vol. 2013 doi:10.1155/2013/520181 (Cited on) [Google Scholar]
[18]. Suresh V, Krishna V, Raju CH N, Teja PS, Usha V, A rare case of triple infection with dengue, malaria and typhoid Int J Res Dev Health 2013 Vol 1(4):200-3. [Google Scholar]
[19]. Singhsilarak T, Phongtananant S, Jenjittikul M, Possible acute coinfections in thai malaria patients Southeast Asian J Trop Med Public Health 2006 37:1-4. [Google Scholar]
[20]. Sharma A, Raina R, Dhiman P, Adarsh Madhabhavi I, Panda P, Rare Coinfection of Scrub Typhus and Malaria in Immunocompetent Person Online J Health Allied Scs 2012 11(2):12(Cited on) [Google Scholar]
[21]. Monath TP, Tsai TF, Flaviviruses, in Clinical Virology 1997 New York, NY, USAChurchill Livingstone:1133-86.DD Richman, RJ Whitley, and FG Hayden, Eds [Google Scholar]