Scrub typhus, a rare of cause of fulminant hepatic failure: A common disease with uncommon presentation

Scrub typhus (bush typhus) is a potentially lethal mite-borne, acute febrile infectious illness caused by Orientia tsutsugamushi, reported precipitating frequent outbreaks in the Asia-pacific belt. Usual presentation after a median incubation period of 10–14 days, stretches from pathognomonic eschar, high-grade fever, centrifugal skin rash, jaundice, regional lymphadenopathy to frontal headache, nevertheless complicated at times with myocarditis, acute respiratory distress syndrome, acute kidney injury, encephalitis, and shock. Although patients with scrub typhus invariably do display mild liver injury, fulminant hepatic failure (FHF) is rarely reported. We describe herein, a case of FHF in an elderly male that responded well to antibiotics. Early diagnosis and sensitive antibiotic administration aids in mortality prevention of the former.

Vincristine induced fever in a child with embryonal rhadbomyosarcoma

Introduction: Febrile episodes in oncology is common are mostly of infectious etiology requiring repeated investigations and escalation of antibiotics. But, drug induced fever occur more often than we think in oncological set-up. Case Report: A 5 year old male child with rhabdomyosarcoma, developed high grade fever spikes following Vincristine monotherapy. Infective etiology work up was negative and the fever responded to corticosteroids. Management and Outcome: He was treated with corticosteroids as premedication considering vincristine induced fever. The further courses of VCR- monotherapy were uneventful with steroids as premedication. Discussion: We present the case of vincristine induced fever in a child with embryonal rhabdomyosarcoma. Clinician’s should consider drug induced fever at appropriate conditions, to avoid leading to antibiotic resistance.

Magnetic resonance findings may aid in diagnosis of protracted febrile myalgia syndrome: a retrospective, multicenter study

Background Protracted febrile myalgia syndrome (PFMS) is a rare complication of Familial Mediterranean fever (FMF). The diagnosis is based on clinical symptoms and is often challenging, especially when PFMS is the initial manifestation of FMF. The aim of this report was to describe the magnetic resonance imaging (MRI) findings in pediatric patients with PFMS. Results There were three girls and two boys ranging in age from 6 months to 16 years, all of Mediterranean ancestry. Three had high-grade fever, and all had elevated inflammatory markers. MRI of the extremities yielded findings suggestive of myositis, which together with the clinical picture, normal CPK levels, and supporting family history of FMF, suggested the diagnosis of PFMS. Out of most common MEFV mutations tested, one patient was homozygous for M694V mutation, three were heterozygous for M694V mutation, and one was compound heterozygous for the M694V and V726A mutations. Conclusions MRI may serve as an auxiliary diagnostic tool in PFMS.

Conus myelitis associated with Covid 19 infection – a rare complication

Covid 19 pandemic has taken away millions of lives. Our understanding of this disease, till to date, is not complete. This disease has a wide variety of neurological manifestations. Acute transverse myelitis is one such rare neurological complication of Covid 19. The exact etiology is not clear. Auto immunity might be one of the possible mechanisms. We report a case of 39-year-old lady, who had recent history of high-grade fever and cough. This was followed by weakness of both legs and in- ability to pass urine. SARS-CoV-2 (PCR) from nasopharyngeal swab was positive. She was found to have features of acute non compressive myelopathy. MRI brain and MRI cervical spine with contrast was normal. MRI dorso lumbar spine with contrast was suggestive of diffuse hyper intensity of conus medullaris with contrast enhancement suggestive of conus myelitis. CSF analysis ruled out infection and autoimmune causes. She was pulsed with high dose steroids. There was some transient improvement in symptoms. Learning points: 1) Physicians should not consider Covid as a respiratory illness only. It can present with a variety of extra pulmonary manifestations. 2) Acute transverse myelitis is a rare complication of Covid 19 infection. Timely recognition and treatment can prevent permanent neurological damage and residual disability. 3) Conus myelitis might not present with classic upper motor neuron signs. Any new onset bladder dysfunction in a setting of a recent covid infection should be taken seriously and requires urgent imaging of the spine.

Patient with false negative RT-PCR for COVID-19 referred to cancer hospital for lung cancer screening: A case report

Background: Even though RT-PCR tests are generally considered the gold standard for diagnosing SARS-CoV-2, they are not without flaws, and the likelihood of detecting an infection varies depending on when the test is performed. There is chance of false negative due to different pitfalls. So there is essential of correlation of radiological characteristics, abnormalities in biochemical tests and symptoms of suspected patient during COVID-19 epidemic. Case presentation: Herein, we report a 42-year-old male patient with high-grade fever, dry cough, headache and dizziness. He went for the RT-PCR test two times and reported negative. On the chest X-Ray, there was opacity on both lungs and referred to cancer-hospital for lung-cancer screening. The patient underwent chest-HRCT and laboratory tests for further evaluation and was identified as typical COVID-19 findings. Then the patient was isolated and treatment of given according to COVID-19 treatment guidelines Conclusion: It is concluded that a clinically symptomatic patient with typical chest HRCT and abnormal lab findings for COVID-19 should be considered as a COVID-19 patient and isolated even with two negative RT-PCR tests.

Symptom-Based Predictive Model of COVID-19 Disease in Children

Background: Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is neither always accessible nor easy to perform in children. We aimed to propose a machine learning model to assess the need for a SARS-CoV-2 test in children (<16 years old), depending on their clinical symptoms. Methods: Epidemiological and clinical data were obtained from the REDCap® registry. Overall, 4434 SARS-CoV-2 tests were performed in symptomatic children between 1 November 2020 and 31 March 2021, 784 were positive (17.68%). We pre-processed the data to be suitable for a machine learning (ML) algorithm, balancing the positive-negative rate and preparing subsets of data by age. We trained several models and chose those with the best performance for each subset. Results: The use of ML demonstrated an AUROC of 0.65 to predict a COVID-19 diagnosis in children. The absence of high-grade fever was the major predictor of COVID-19 in younger children, whereas loss of taste or smell was the most determinant symptom in older children. Conclusions: Although the accuracy of the models was lower than expected, they can be used to provide a diagnosis when epidemiological data on the risk of exposure to COVID-19 is unknown.

VEXAS syndrome with cutaneous nodules

Recently, a rare severe autoinflammatory Vacuoles, E1 enzyme, X-linked, autoinflammatory, Somatic (VEXAS) syndrome caused by somatic variants in the UBA1 gene was discovered. The clinical features of VEXAS syndrome are heterogeneous, including high-grade fever, polychondritis and skin lesions. In 2020, Beck DB et al described an original cohort of 25 patients, of whom 22 (88%) had cutaneous findings, namely, neutrophilic dermatitis, and vasculitis. We report a case of VEXAS syndrome and cutaneous nodules with confirmed UBA1 mutation.

Lemierre’s syndrome in a child

Lemierre’s Syndrome (LS) is a rare syndrome most frequently due to an anaerobic organism, Fusobacterium Necrophorum. It is commonly a complication of an acute oropharyngeal infection, but there are exceptions to its presentations. In our case the cause of LS was otitis media caused by Streptococcus species. This is a rather unusual presentation of LS. LS is caused due to septic complications of oropharyngeal infections, which lead to thrombophlebitis of internal jugular vein leading to thrombosis formation. In this case report, we present a case of Lemierre’s syndrome in a seven-year-old male child. The patient presented with high grade fever spikes and earache, which were unresponsive to oral antibiotics. LS was diagnosed in this patient on the basis of clinical, microbiological and radiological findings. After the diagnosis, treatment involved using broad spectrum antibiotics and anticoagulants, followed by surgery. Though role of anticoagulants is controversial in LS, but there is no specific guideline contraindicating the use of anti-coagulants. In our case, timely diagnosis and management enabled us to discharge the patient without any symptoms. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5773 How to cite this:Hemani F, Naveed A, Akhtar S, Shahid S. Lemierre’s syndrome in a child. Pak J Med Sci. 2022;38(2):433-435. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5773 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Burkholderia cepacia: An unusual cause of pneumonia

Burkholderia Cepacia is a gram negative organism, an uncommon cause of pneumonia. When isolated, it usually represents colonisation. In the presence of immunocompromising conditions, it can cause disease, ranging from mild illness to the highly fatal Cepacia syndrome. The organism is intrinsically resistant to many antibiotics. We report a 57 years old male farmer, who has diabetes mellitus and bronchial asthma, who presented with a acute history of high grade fever, pain abdomen and cough. He was diagnosed with a ruptured liver abscess, with the infection spreading to the right lower lobe. Laparotomy was performed. Pus culture grew Pseudomonas aeruginosa. He improved upon antibiotic therapy, only to return after one month with severe cough, chest X-ray revealing a lung abscess in the right lower lobe. Bronchoalveolar lavage culture grew Burkholderia cepacia, and sensitive antibiotics were initiated, however the patient succumbed to the illness. The implicated source of the organism was the nebulisation solution which he was using regularly. Emphasis should be laid on the need for improved aseptic practices while using medical solutions at either hospital or home setting. An index of suspicion may guide optimal antibiotic prescription practices in susceptible individuals.

Study of Cardiac Manifestation in Patients with Seropositive Dengue Fever and to Find Correlation with Subclinical Cardiac Involvement

Objective: The main objective of the present study was to observe the electrocardiogram (ECG) changes in dengue fever and to find correlation with subclinical cardiac involvement. Methods: This was an observational, prospective, non-randomized study. High grade fever for one to five days diagnosed as dengue infection later confirmed by dengue tests (NS1, IgG and IgM ELISA) were included in this study. Prior to the commencement of the study informed consent was taken from all the participants. With 12 lead ECG taken during the febrile phase of dengue fever randomly selected serologically confirmed cases of dengue fever were evaluated at an interval of 24 hrs. for a total of five days. On the day of admission when the patient was afebrile, echocardiography was done. Plasma leakage was diagnosed by presence of any one of four: subcutaneous oedema (pedal oedema, facial puffiness) or pleural effusion or pericardial effusion or ascites. Result: A total 80 patients who were admitted to hospital during study periods due to symptoms of dengue fever and IgM dengue positive status were included in this study. Among this total population of 80 patients (N=80) 48 were male and 32 were female. Out of these, majority were diagnosed as DF 52 (65%), 23 (29%) were diagnosed as DHF and rest only 5 (6%) were diagnosed as DSS. Total 54 patients were found to have normal ECG among which 35 were having dengue fever, 16 were having DHF and 3 were having DSS. Total 2 patients were diagnosed to have left ventricular hypertrophy among which one had dengue fever and rest two had DHF. ST depression was observed in total 7 patients in which 5 were had dengue fever and 2 were had DHF. Relative bradycardia was found in 14, tall t waves in 2 and ventricular ectopics in 1 patient (table 2). Abnormal ECG findings were compared using Chi-square test and were found to be statistically significant (P < 0.05) in dengue fever and DHF. There was statistically significant correlation between ECG abnormalities and abdominal pain and mucosal bleed. The presence of plasma leakage were observed among 77 (96.3%) patients. Proportion of echocardiography abnormalities were higher among patients with plasma leak 6 (30%) as compared to without plasma leak 9 (15%), this difference was not found to be statistically significant Conclusion: In all type of Dengue infections incidence of cardiac involvement was quite high. Due to the overlapping clinical manifestations such as capillary leak associated with DENV infection, tachycardia, pulmonary edema, and hypotension as well as due to the low index of clinical suspicion cardiac involvement in dengue fever is often underdiagnosed. Keywords: Cardiac manifestation, dengue infection, echocardiography, electrocardiography.