Influenza PCR testing was done in all patients with upper respiratory symptoms such as a cough, rhinorrhea, and breathlessness. By protocol, all patients with fever <7 days were followed up and serological tests were sent only on or after the 7 th day of fever. These serological tests were done on or after the 7 th day of fever and included dengue IgM ELISA (Dengue Duo Cassette, PanBio), scrub typhus IgM ELISA (In Bios International Inc., Seattle, WA, USA), leptospira IgM ELISA (Virion/Serion GmbH, Germany) and a Widal test. All commercial ELISA tests were performed for agents believed to be endemic to the region and interpreted according to the manufacturer's instruction as positive, equivocal, and negative. A single blood culture was obtained from all enrolled patients in an aerobic BacT/Alert 3D (BioMerieux, Hazelwood, MO, USA) bottle and incubated for up to 7 days in the BacT/Alert blood culture system. A thin smear was performed to detect malarial parasites. Pulse oximeter saturation (SpO 2) was measured for all patients at presentation and recorded. The routine baseline investigations included complete blood count analysis, serum electrolytes, liver and renal function tests. Adult patients (age ≥16 years) presenting to the emergency department (ED) or medical outpatient clinic between September 2012 and April 2013 with acute febrile illness (temperature ≥101☏ of 3–14 days duration) and diagnosed to have scrub typhus or dengue were enrolled.Ī detailed history and results of a thorough physical examination were entered on a standard data collection sheet after obtaining a written informed consent. This cross-sectional observational study was conducted at Christian Medical College, Vellore, which is 2700 bedded tertiary care teaching hospital in South India. In this prospective study, we aimed to investigate the differences in clinical features and easily available laboratory parameters between scrub typhus and dengue febrile illness and develop a scoring model, “clinical score to differentiate scrub typhus and dengue (CSSD),” which can aid in differentiating scrub typhus from dengue at presentation.
They are time-consuming, labor intensive, expensive and not available at the point of care in most centers in developing countries. Diagnostic tests for scrub typhus (enzyme-linked immunosorbent assay for immunoglobulin M ) and dengue (reverse transcriptase-polymerase chain reaction or IgM ELISA) have many limitations. In its absence, scrub typhus and dengue are virtually indistinguishable at presentation.
A pathognomonic eschar, which is probably the most important diagnostic clue for scrub typhus can be identified in only 20%–54% of patients. Both these infections peak during the monsoon season in many parts of India. Early diagnosis can improve patient outcomes and promote timely public health interventions. Despite supportive management, mortality rate due to dengue hemorrhagic fever and dengue shock syndrome (DSS) ranges from 3% to 11% among adults.
Dengue is a mosquito-borne infection caused by one of the four dengue virus serotypes that belong to the genus Flavivirus. Hence, early recognition and prompt antibiotic therapy is crucial in the management of ST. Delay in diagnosis and initiation of appropriate antibiotic therapy can be associated with mortality in 14%–20% of patients. The pathogenesis is immune mediated lymphohistiocytic vasculitis and frequently results in multiple organ dysfunction. The causative agent of scrub typhus is a Gram-negative intracellular bacterium, Orientia tsutsugamushi, which is inoculated into humans by the bite of an infected larva of trombiculid mites ( Leptotrombidium species). Both the infections share similar clinico-epidemiological features and are difficult to differentiate at initial presentation. In many parts of India, these two infections together comprise more than half of all acute undifferentiated febrile illnesses. Scrub typhus and dengue are two major causes of acute undifferentiated febrile illness and are endemic in many parts of India and the Asia Pacific region.
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