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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Case report
Full Version
A Case of Sepsis-induced MODS in Disseminated Filariasis: Cause or Co-incidence
Correspondence Address :
Dr. Rashmi Mishra,
Assistant Professor, Department of General Medicine, Maulana Azad Medical College, New Delhi-110002, India.
E-mail: rashmi.virgo02@gmail.com
Filariasis, an affliction caused by thread-like filarial worms, poses a formidable health challenge in India, with diverse regional endemicities. It manifests in two distinct forms: lymphatic and extralymphatic. The former induces agonising limb swelling, while the latter, often overlooked due to its atypical presentation, can affect various organs. Here we, present a noteworthy case involving a 25-year-old woman who succumbed to septic shock, displaying Multiple Organ Dysfunction Syndrome (MODS). The patient exhibited bicytopaenia, leukocytosis, and progressively deteriorating liver and kidney functions, culminating in Acute Respiratory Distress Syndrome (ARDS). Postmortem examinations, conducted with proper consent, revealed sheathed microfilaria in liver and bone marrow tissues. This rare multisystem involvement in filariasis, leading to a fulminant course, raises questions about potential immunosuppression triggered by disseminated filarial dissemination. The hypothesis centres on the notion that the systemic spread of filaria might underlie the severe and rapid deterioration observed in this unique case, shedding light on the intricate dynamics of this parasitic disease and its implications for immune function.
Extra lymphatic, Immunosuppression, Multiple organ dysfunction syndrome
A 25-year-old female presented with complaints of high-grade fever with chills, documented up to 103°F, associated with a dry cough for 15 days, right upper quadrant pain for four days, which was dull aching in character, of moderate intensity, not radiating, and associated with non-projectile vomiting. She also experienced exertional shortness of breath, which was of a progressive nature. She noticed a decrease in her urine output for three days and developed irritable behaviour a day prior to presentation. There was no history of pedal oedema or facial puffiness. She had no history of co-morbidities such as diabetes or hypertension, and her family history was insignificant.
On examination, the patient was drowsy but arousable on presentation, visibly tachypneic (respiratory rate 34/min), had tachycardia and low BP (83/62 mmHg), and was febrile (102°F). She had oxygen saturation of 84% on room air, which improved to 97% with supplemental oxygen. She was pale and icteric but with no evidence or history of lymphoedema or lymphangitis. She also had no skin changes, genital swelling, or enlarged lymph nodes. Coarse crepitations were noted on auscultation, along with mild tenderness in the epigastric region on palpation but with no organomegaly. There was no focal neurological deficit, neck rigidity, or anisocoria on neurological examination.
The initial investigations were suggestive of bicytopaenia with leukocytosis (Hb 9.2 g/dL, WBC 30200/mm3, and platelets 83000/mm3) and deranged liver and kidney functions as provided in (Table/Fig 1). Blood gas analysis revealed metabolic acidosis with respiratory acidosis with type 1 respiratory failure. The X-ray showed diffuse fluffy, inhomogeneous, airspace opacities in bilateral lung fields (Table/Fig 2). Peripheral smear was suggestive of bicytopaenia with hypoochromic anaemia (MCV 57 fL) with the presence of eosinophilia (12%) and neutrophilia with left shift. The absolute eosinophil count came out to be 3800/mm3 (range: 30-300/mm3). Serum procalcitonin (14.9 ng/mL; range <0.5 ng/mL) and proBNP (635 pg/mL; range <125 pg/mL) were raised, as were the D-dimer values (3943 ng/mL; range <500 ng/mL). The echocardiography was normal. Urine routine revealed mild proteinuria, 10-15 pus cells with 20-30 normal RBCs.
The viral markers (HIV, hepatitis A, B, C, and E) were negative. Malarial antigen, dengue antigen, and IgM antibody were negative. Autoimmune screening revealed insignificant titres for Antinuclear Antibodies (ANA), perinuclear Antineutrophilic Cytoplasmic Antibody (pANCA), and cytoplasmic Antineutrophilic Cytoplasmic Antibody (cANCA). C3 and C4 levels were normal, and the Antistreptolysin O (ASO) titre was negative. The serology for leptospira, rickettsia, and scrub typhus were also negative, as were the Parvovirus and Cytomegalovirus (CMV). Her abdominal ultrasound revealed neither organomegaly nor any foci of infection. The blood and urine cultures showed no growth.
She was managed with broad-spectrum antibiotics (meropenem 1 gram 8 hourly, teicoplanin 400 mg 12 hourly, and doxycycline 100 mg 12 hourly), fluids, and inotropes. Due to progressively worsening kidney function, persistent metabolic acidosis, and oliguria, she underwent haemodialysis. However, there was no improvement in her condition, and she developed severe respiratory distress (PaO2/FiO2<100), requiring invasive ventilation. Despite the efforts, she succumbed to her illness on Day 3 of admission.
Postmortem biopsies were performed after obtaining written informed consent from the patient’s relative. The marrow biopsy (Table/Fig 3)a,b showed the presence of sheathed microfilaria, while the liver biopsy (Table/Fig 4) revealed sinusoidal dilatation with microfilarial larvae. The kidney biopsy was suggestive of acute tubular necrosis but showed no evidence of any microfilariae.
Filariasis is an illness caused by slender, thread-like nematode parasites, specifically Wuchereria bancrofti, Brugia malayi, and Brugia timori, which reside in the tissues beneath the skin and the lymphatic system. Filariasis poses a significant public health risk and is endemic in the Indian population. Wuchereria bancrofti can be distinguished by certain identifying characteristics, including the presence of a hyaline sheath, elongated terminal nuclei, a cephalic space ranging from 5 to 15 μm in length, and a pointed posterior end, which may or may not have terminal or subterminal swelling. Common lymphatic manifestations of filariasis include asymptomatic microfilariaemia, elephantiasis, acute adenolymphangitis, hydrocoele, and chronic lymphatic disease, none of which were present in our patient on presentation, nor was there any history of such complaints (1). Additionally, microfilariae have been found in locations outside the lymphatic system, such as subcutaneous swellings, breast tissue, the thyroid gland, lymph nodes, body cavity effusions, and bronchial washings (2). The precise mechanism by which microfilariae traverse from the vascular system into extravascular tissue spaces is not fully understood. One plausible hypothesis suggests that microfilariae may cross blood vessel walls through their capacity to penetrate tissues, effectively reaching the tissue spaces (3).
Parasitic infections induce eosinophilia, with differentials encompassing inflammatory, allergic, and neoplastic causes. Eosinophil counts exceeding 1500/mm3 warrant evaluation for hypereosinophilic syndromes (1). Tropical Pulmonary Eosinophilia (TPE), a manifestation of lymphatic filariasis, arises from an immune hyper-responsiveness to lung-trapped microfilariae. The diagnosis of TPE involves eosinophilia >3000/mm3, IgE levels >1000 U/mL, and elevated filarial antibody titers. In such cases, acute eosinophilic pneumonia should be considered, featuring neutrophilic leukocytosis, elevated CRP, and chest radiograph infiltrates. Confirmatory analysis of bronchoalveolar lavage fluid (>25% eosinophilia) was impeded in this case due to clinical deterioration (2).
The detection of microfilariae in bone marrow aspirate is a rare occurrence. The earliest recorded instance of microfilariae in bone marrow aspirate in the literature dates back to 1976, attributed to Pradhan S et al., (4). Notably, none of the documented cases featuring microfilariae in bone marrow aspirate displayed the typical clinical presentation of lymphatic filariasis (2),(5),(6). The reports also suggest that the presence of microfilariae may lead to the release of potentially toxic metabolites, resulting in bone marrow suppression characterised by pancytopenia (7). The bicytopaenia in our patient can be attributed to filarial infestation.
Limited case reports have described the incidental discovery of filaria in the liver, even in individuals displaying no signs or symptoms of filariasis (8). This anomalous migration to such locations is likely influenced by factors such as lymphatic obstruction due to scarring or tumours, as well as vessel wall damage caused by inflammation, trauma, or stagnant blood flow. A plausible explanation could be that larvae are present in the vasculature, and the act of aspiration leads to vessel rupture, resulting in haemorrhage and the release of microfilariae (9). The isolation of microfilariae from the liver in the case confirmed the disseminated nature of the disease.
About half of untreated microfilaremic patients exhibit kidney abnormalities, characterised by microscopic haematuria (35%) and proteinuria (20%) (10),(11). Renal issues can be due to physical damage to the glomeruli or the deposition of immune complexes (more common). In a study conducted by Rath RN et al., nine out of 14 filariasis patients displayed histopathological changes, with mesangial cell hyperplasia being the most consistent finding (12). Furthermore, research by Langhammer J et al., has shown that microfilariae can lead to tubular damage in the kidneys, potentially resulting in renal failure. This can also be the cause of worsening renal function in our case, in addition to sepsis (13).
Filarial parasites intricately modulate host immune responses through antigen-specific and generalised immunomodulation mechanisms, inducing profound immunoregulatory effects. Prominent features include immunosuppression and the induction of immunological tolerance, involving cytokine-induced immune response suppression and the induction of immune tolerance in effector T cells (14). Notably, a modified Th2 response manifests with antibody isotype switching to non-inflammatory IgG4 and the induction of alternatively activated macrophages. Patients with lymphatic filariasis exhibit diminished responses to parasite antigens and non-specific inhibition of bystander antigen responses. The secretion of immunomodulatory products, such as ES-62 containing Phosphorylcholine (PC), demonstratesdiverse properties and is key to immune evasion. Regulatory T cells, especially those associated with IL-10 and TGFβ, play pivotal roles in filarial immunoevasion, influencing host immune function (15).
The presence of microfilariae in both the liver and bone marrow provides a plausible explanation for the patient’s bicytopaenia. Furthermore, the patient experienced acute tubular necrosis in the kidneys, potentially influenced by the combined impact of sepsis and filarial infection, although the biopsy did not reveal the presence of the organism. The probable hypothesis is that disseminated filaria resulted in immunosuppression, making the patient vulnerable to a secondary infection, leading to a severe septic condition with MODS. However, it is impossible to completely rule out the possibility of a coincidental association of disseminated filariasis. Nevertheless, despite an exhaustive review of the literature, we were unable to uncover any case reports detailing the concurrent presence of filarial infestation across multiple sites within a single patient, although there are case reports of isolated extralymphatic filariasis in the liver, kidney, and bone marrow as mentioned above (6),(7),(8),(10).
The present case highlighted the rare but significant occurrence of extralymphatic filariasis in various tissues and the associated tubular injury to the kidneys. Disseminated filariasis led to an immunosuppressive state, which can predispose to life-threatening serious infections. Clinicians in endemic areas should maintain a high index of suspicion and actively screen for filarial parasites in various tissues to facilitate timely intervention, thus preventing severe complications. Early diagnosis of filariasis can be crucial, as it is a treatable condition.
DOI: 10.7860/JCDR/2024/67876.19124
Date of Submission: Oct 05, 2023
Date of Peer Review: Dec 08, 2023
Date of Acceptance: Jan 17, 2024
Date of Publishing: Mar 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 05, 2023
• Manual Googling: Dec 14, 2023
• iThenticate Software: Jan 12, 2024 (4%)
ETYMOLOGY: Author Origin
EMENDATIONS: 6
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
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- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com