Original article / research
Year :
2024 |
Month :
October
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Volume :
13 |
Issue :
4 |
Page :
MO06 - MO09 |
Full Version
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Seroprevalence and Co-infections of Different Infectious Aetiologies in Blood Culture Negative Febrile Patients Seeking Healthcare at a University Hospital in Northern India: A Cross-sectional Study
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Ashima Jamwal, Mohan Gurjar, Chinmoy Sahu, Atul Garg, Nidhi Tejan, Sangram Singh Patel, Ashutosh Pathak, Mohd Rashid Khan 1. Senior Resident, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
2. Professor, Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
3. Additional Professor, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
4. Associate Professor, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
5. Assistant Professor, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
6. Associate Professor, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
7. Research Scientist, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
8. Researc
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Correspondence
Address :
Ashima Jamwal, Mohan Gurjar, Chinmoy Sahu, Atul Garg, Nidhi Tejan, Sangram Singh Patel, Ashutosh Pathak, Mohd Rashid Khan, Dr. Sangram Singh Patel,
Associate Professor, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow-226014, Uttar Pradesh, India.
E-mail: sangramresearch968@gmail.com
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| ABSTRACT |  | : Introduction: The burden of acute febrile illness remains underestimated in many low- and middle-income countries. The rationale of this study revolves around the gaps in diagnostics for acute febrile illnesses in these regions.
Aim: To highlight the seroprevalence and co-infections of different infectious aetiologies in blood culture negative febrile patients.
Materials and Methods: This cross-sectional study was conducted at Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India from October 2021 to July 2022, involving 153 serum samples from patients presenting with fever for less than two weeks duration during outpatient and emergency visits. The blood culture negative samples were further tested for other aetiologies such as Leptospirosis, Dengue NS1 antigen, Dengue IgM antibody, Chikungunya, Scrub typhus IgM, and Widal, respectively. Convalescent sera were also tested for all positive Widal results. All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) statistical software (IBM SPSS version 26.0, Armonk, N.Y.).
Results: Out of the 153 patients enrolled, 120 patients were tested for a panel of serological tests. The majority 52 (43.3%) were aged between 21 and 40 years. Fifty-five patients (45.8%) exhibited positivity, among which Scrub typhus was the most common aetiology with 21 (17.5%) case, followed by Leptospirosis 19 (15.8%), Dengue 10 (8.3%), Chikungunya 3 (2.5%), and Enteric fever 2 (1.7%), with no cases of malaria reported. Overall, co-infections reported in present study included 7 (5.8%) cases, of which scrub typhus and Leptospirosis were the most prevalent in 5 (4.16%) cases. Two patients (1.6%) presented with a co-infection of dengue and chikungunya.
Conclusion: The diverse aetiologies causing acute febrile illness necessitate a syndrome-based disease surveillance approach, accompanied by strong clinical acumen, for the betterment of patient outcomes.
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Keywords
: Febrile illness, Neglected tropical diseases, Serological tests |
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DOI and Others
: DOI: 10.7860/NJLM/2024/68070.2882
Date of Submission: Oct 15, 2023
Date of Peer Review: Dec 07, 2023
Date of Acceptance: Jul 26, 2024
Date of Publishing: Oct 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 16, 2023
• Manual Googling: Jul 19, 2024
• iThenticate Software: Jul 25, 2024 (6%)
Etymology: Author Origin
Emendations: 7 |
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INTRODUCTION |
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India is home to a variety of aetiological agents causing Acute Undifferentiated Febrile Illness (AUFI) (1). AUFI represents a diagnostic challenge in clinical practice due to its diverse aetiology and overlapping symptomatology. Characterised by the sudden onset of fever without an apparent source or specific clinical features, AUFI encompasses a spectrum of infectious and non infectious diseases, making accurate and timely diagnosis paramount for effective management and prevention of complications. In addition to bacteraemia, various neglected tropical diseases such as malaria, dengue, scrub typhus, chikungunya, and leptospirosis are important differential diagnoses (2).
The clinical presentation of AUFI often includes fever accompanied by non specific symptoms such as headache, myalgia, arthralgia, malaise, and sometimes gastrointestinal or respiratory symptoms (3). This lack of specific clinical features makes it difficult to pinpoint the underlying cause based solely on clinical examination. Consequently, laboratory investigations and a systematic approach to differential diagnosis play a crucial role in identifying the causative agent. The non specific symptoms associated with these diseases, coupled with the lack of available diagnostic tools, further complicate the diagnostic process.
This study highlights a novel component of diagnosis by ruling out bacteraemia cases through blood culture and procalcitonin results. Additionally, various diagnostic modalities available have been discussed in detail. The study aims to estimate the burden of febrile illness in Northern India, highlighting common aetiologies and their changing epidemiologies over time. This research addresses the need to formulate a proper rationale for the diagnosis of febrile illnesses in our country, where the burden of infectious aetiologies is often underestimated. The aim of the study was to highlight the seroprevalence and co-infections of different infectious aetiologies in blood culture negative febrile patients.
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Material and Methods |
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This cross-sectional study was conducted over a period of 10 months, from October 2021 to July 2022, at Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. The study protocol was approved by the Institutional Ethics Committee for Human Research at Sanjay Gandhi Post-Graduate Institute of Medical Sciences, with Registration Number 2021-109-IMP-EXP-38 and Reference Number PGI/BE/303/2021. Informed consent was obtained from the guardian for patients under 18 years of age.
Inclusion criteria: Blood sabmples of patients were primarily examined for blood cultures, which subsequently tested negative after five days of incubation using the BACTEC blood culture system (Becton Dickinson Diagnostic Instrument Systems, Sparks, MD®) were included in the study.
Exclusion criteria: The patients whose blood cultures were positive, patients with raised procalcitonin levels (>0.5 ng/mL) (4) and any lipemic and haemolysed samples were excluded from the study. Patients diagnosed with chronic and immunosuppressive illnesses such as tuberculosis, Human Immunodeficiency Virus (HIV), cancer, diabetes, or those undergoing chemotherapy were also excluded from the study.
Sample size: Out of 153 serum samples (after excluding lipaemic, haemolysed, and insufficient quantity samples), 120 samples from patients presenting with fever for less than two weeks in outpatient and emergency visits were considered.
Study Protocol
The serum samples from the included patients were tested using a panel of serological tests, including Malaria, Leptospirosis, Dengue NS1 antigen, Dengue IgM antibody, Chikungunya IgM antibody, Scrub typhus IgM, Widal, and Procalcitonin assay, to estimate the disease burden and co-infections (Table/Fig 1).
Procalcitonin, although a biomarker for bacterial infections, was tested in this study to rule out any other possibility of bacterial infection in blood culture negative samples. Since, it is a tertiary care hospital, by the time patients reach us, they have often already received antibiotics from local practitioners. Therefore, the chances of isolating bacteria from blood cultures further diminish. Procalcitonin levels were detected using a chemiluminescence assay (5). Additionally, the serological tests requested by the concerned clinicians were negative when tested in the routine laboratory. Subsequently, these serum samples were assessed using a panel of tests beyond those initially conducted. The fatality rates were not compared.
Sample collection and transport: The blood samples received for any of the serological tests mentioned above were further processed using the automated blood culture system, specifically the BACTEC blood culture system (6) (Becton Dickinson Diagnostic Instrument Systems, Sparks, MD). Blood was collected in a plain vial without anticoagulant, and serum was separated after centrifugation at 3000 rpm for five minutes. A minimum of 100 μL of serum was stored at -20ÂșC for present study. All blood cultures were sterile for the samples collected. Patients were followed-up, and blood in EDTA was collected for the malaria antigen detection test once the blood culture results were negative. There were 20 patients who did not follow-up and could not provide a blood sample for malaria testing; therefore, their serum samples were tested using a malaria antigen ELISA kit.
Statistical Analysis
Categorical variables were described using percentages, and all statistical analyses were performed using SPSS statistical software (IBM SPSS version 26.0, Armonk, NY).
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Results |
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Out of the total patients enrolled, 120 patients were tested for a panel of serological tests. The majority of patients 52 (43.3%) belonged to the 21-40 year age group. Females were affected more than males (Table/Fig 2).
Overall, acute febrile illness accounted for 45.8% (55 out of 120) of cases identified by serological tests in all blood culture negative patients presenting with fever.
No cases of malarial aetiology were detected (Table/Fig 3).
In present study, 16 patients (13.3%) had raised procalcitonin values despite being blood culture negative. Seven patients with dengue presented with fever alone, while three experienced associated joint pain. Leptospirosis was present in seven patients with fever, in four with fever and chills, and non specific joint pain was observed in four patients. Enteric fever was detected in two patients, both presenting with fever and abdominal pain (Table/Fig 4).
Deranged liver enzymes (n=35, 29.16%) were an important finding while investigating the infectious aetiologies, followed by elevated urea and creatinine levels (n=15, 12.5%) in the majority of the population (Table/Fig 5).
Overall, co-infections reported in present study were 7 (5.8%), with scrub typhus and leptospirosis being the most common co-infection encountered 5 (4.16%). Additionally, 2 (1.6%) reported a co-infection of dengue and chikungunya.
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Discussion |
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Acute febrile illness opens the door to a wide spectrum of bacterial and viral illnesses that are neither tested nor discussed in great detail. The diseases such as malaria, dengue, enteric fever, scrub typhus, and leptospirosis are the primary considerations for diagnosis in patients presenting with acute febrile illness in a healthcare setting (7),(8). However, bacteraemia is always suspected as a priority when a patient presents with fever; if the culture report is negative, the patient is usually treated empirically to relieve symptoms (9). The most affected age group in present study was 21-40 years. Similar findings were reported in the World Health Organisation (WHO) report on dengue in 2009 (10).
Overall, acute febrile illness accounted for 55 (45.8%) of all blood culture negative patients presenting with fever, as determined by serological tests. Scrub typhus was the most common aetiology 21 (17.5%) responsible for acute febrile illnesses, followed by leptospirosis 19 (15.8%), dengue 10 (8.3%), chikungunya 3 (2.5%), enteric fever 2 (1.7%), and malaria (no cases). Scrub typhus was identified as the most common cause of acute febrile illness in India, as reported in a study by Devasagayam E et al., (11). Leptospirosis has emerged as one of the leading causes of febrile illness at our center, similar to findings by Sethi S et al., which highlight the increasing trends of leptospirosis in Northern India (12).
According to data published in the World Malaria Report 2021, India contributed 1.7% of global malaria cases and 1.2% of malaria-related deaths (13). In India, malaria cases have consistently declined from 2.09 million in 2001 to 0.19 million in 2020 (14). Similarly, no malaria cases were reported in present study. Furthermore, dengue NS1 testing revealed negative results for all patients under study, which can be attributed to the timing of the dengue NS1 testing after the blood culture results were negative, i.e., after 5-7 days. This ultimately led to poor antigen detection in serum after a 7-day period.
A study by Chrispal A et al., reported an incidence of 7% dengue fever in adult hospitalised patients in Southern India (15). The results were comparable to present study, where the incidence of dengue fever was 8.3%. In present study, co-infections were reported in 7 (5.8%) patients, with the most common being scrub typhus and leptospirosis. A case of co-infection of scrub typhus and leptospirosis was reported in 2013 from Northeast India by Borkakoty B et al., (16). The indirect Immunofluorescence Assay (IFA) is considered the gold standard in diagnosing scrub typhus (17). However, the lack of availability of IFA at most diagnostic facilities underscores the need for improved early diagnosis of scrub typhus using ELISA and PCR.
In present study, 16 patients (13.3%) had elevated procalcitonin values despite being blood culture negative. This discrepancy can be attributed to variations in sampling techniques, timing of sample collection, antibiotic intake, or conditions that may lead to transient bacteraemia. Therefore, relying solely on blood culture and delayed non bacterial testing for acute febrile illness may prolong the patient’s morbidity. Similarly, a study by Karlsson S et al., described the predictive efficacy of procalcitonin in sepsis (18). This study highlights the importance of strong clinical acumen in diagnosing the overlapping symptomatology of acute febrile illnesses. Additionally, it is essential for clinicians to have knowledge of the appropriate diagnostic tests to perform within the correct timeframe for the prompt management of such patients.
Limitation(s)
This study had several limitations, including a small sample size, limited laboratory parameters, and the fact that it was conducted at a tertiary care centre where patients typically visit on referral from other healthcare settings. As a result, the data regarding their prior empirical treatment for illness is limited. Additionally, testing on convalescent serum samples could not be performed due to infrequent patient follow-ups.
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Conclusion |
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Scrub typhus, being the most common infectious aetiology in blood culture negative patients, is often underdiagnosed, which can lead to serious complications when it is presented late. The increasing incidence of leptospirosis cases serves as a critical alert for clinicians to consider this disease in their differential diagnoses, despite it being less frequently reported in our state. The study concludes by addressing an important concern: blood culture-negative febrile patients are usually underdiagnosed and often overtly treated with antibiotics. Therefore, the spectrum of different aetiologies should be clearly understood to effectively treat this population.
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| 1. | Susilawati TN, McBride WJH. Acute undifferentiated fever in Asia: A review of the literature. Southeast Asian J Tropical Medicine and Public Health. 2014;45(3):719-26.
[ Google Scholar] | 2. | Shelke YP, Deotale VS, Maraskolhe DL. Spectrum of infections in acute febrile illness in central India. Indian J Med Microbiol. 2017;35(4):480-84. ?doi?https://doi.org/10.4103/ijmm.IJMM_17_33#doi#?pmid?29405137#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 3. | Subramanyam VN, Kaeley N, Kumar M, Pandey SK, Bhardwaj BB, Reddy KS. Acute undifferentiated febrile illness: Protocol in emergency department. J Family Med Prim Care. 2020;9(5):2232-36. ?doi?https://doi.org/10.4103/jfmpc.jfmpc_214_19#doi#?pmid?32754479#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 4. | Mazlan MZ, Wan Azman WN, Yaacob NM, Koon TS, Yahya NK. Analytical evaluation of point-of-care Finecare™ procalcitonin rapid quantitative test in sepsis population as compared with Elecsys® BRAHMS Procalcitonin Immunoassay. Diagnostics. 2024;14(11):1080. ?doi?https://doi.org/10.3390/diagnostics14111080#doi#?pmid?38893607#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 5. | Hubl W, Krassler J, Zingler C, Pertschy A, Hentschel J, Gerhards-Reich C, et al. Evaluation of a fully automated procalcitonin chemiluminescence immunoassay. Clin Lab. 2003;49(7-8):319-27.
[ Google Scholar] | 6. | Weinstein MP. Current blood culture methods and systems: Clinical concepts, technology, and interpretation of results. Clin Infect Dis. 1996;23(1):40-46.?doi?https://doi.org/10.1093/clinids/23.1.40#doi#?pmid?8816127#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 7. | Iroh Tam PY, Obaro SK, Storch G. Challenges in the etiology and diagnosis of acute febrile illness in children in low-and middle-income countries. J Pediatric Infect Dis Soc. 2016;5(2):190-205. ?doi?https://doi.org/10.1093/jpids/piw016#doi#?pmid?27059657#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 8. | Smith DA, Nehring SM. Bacteremia. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441979/
[ Google Scholar] | 9. | Das D, Das B, Roy AD, Singh TSK. Common infectious etiologies of acute febrile illness in a remote geographical location: Could scrub typhus be the Most common cause. Br J Med Med Res. 2015;10(10):01-10. ?doi?https://doi.org/10.9734/BJMMR/2015/19822#doi#
[ Google Scholar] [ CrossRef] | 10. | World Health Organization. Dengue: Guidelines for Diagnosis, Treatment, Prevention, and Control. World Health Organization; 2009 [Internet]. [cited 2023 Nov 11]. Available from: https://www.who.int/publications/i/item/9789241547871.
[ Google Scholar] | 11. | Devasagayam E, Dayanand D, Kundu D, Kamath MS, Kirubakaran R, Varghese GM. The burden of scrub typhus in India: A systematic review. PLoS Negl Trop Dis. 2021;15(7):e0009619. ?doi?https://doi.org/10.1371/journal.pntd.0009619#doi#?pmid?34314437#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 12. | Sethi S, Sharma N, Kakkar N, Taneja J, Chatterjee SS, Banga SS, et al. Increasing trends of leptospirosis in northern India: A clinico-epidemiological study. PLoS Negl Trop Dis. 2010;4(1):e579. ?doi?https://doi.org/10.1371/journal.pntd.0000579#doi#?pmid?20084097#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 13. | World Health Organization. World Malaria Report 2021. World Health Organization; 2021 [Internet]. [cited 2023 Dec 20]. Available from: https://www. who.int/teams/global-malaria-programme/reports/world-malaria-report-2021.
[ Google Scholar] | 14. | Chattopadhyay R, Surendran D, Lekshmi S, Guhathakurta P, Hosaliker KS, Pai DS, et al. A threshold criteria for seasonal amplification and outbreaks of Mosquito-Borne Disease (MBD) cases in Kerala using climate parameters. medRxiv. 2022:2022-11. Available from: https://doi.org/10.1101/2022.11.10.2 2282112. ?doi?https://doi.org/10.1101/2022.11.10.22282112#doi#
[ Google Scholar] [ CrossRef] | 15. | Chrispal A, Boorugu H, Gopinath KG, Chandy S, Prakash JA, Thomas EM, et al. 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(4):230-34. ?doi?https://doi.org/10.1258/td.2010.100132#doi#?pmid?20870680#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 16. | Borkakoty B, Jakharia A, Biswas D, Mahanta J. Co-infection of scrub typhus and leptospirosis in patients with pyrexia of unknown origin in Longding district of Arunachal Pradesh in 2013. Indian J Med Microbiol. 2016;34(1):88-91. ?doi?https://doi.org/10.4103/0255-0857.174116#doi#?pmid?26776126#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 17. | Blacksell SD, Bryant NJ, Paris DH, Doust JA, Sakoda Y, Day NP, et al. Scrub typhus serologic testing with the indirect immunofluorescence method as a diagnostic gold standard: A lack of consensus leads to a lot of confusion. Clin Infect Dis. 2007;44(3):391-401. ?doi?https://doi.org/10.1086/510585#doi#?pmid?17205447#pmid#
[ Google Scholar] [ CrossRef] [ PubMed] | 18. | Karlsson S, Heikkinen M, Pettilä V, Alila S, Väisänen S, Pulkki K, et al. Predictive value of procalcitonin decrease in patients with severe sepsis: A prospective observational study. Crit Care. 2010;14(6):R205.?doi?https://doi.org/10.1186/cc9327#doi#?pmid?21078153#pmid# [ Google Scholar] [ CrossRef] [ PubMed]
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TABLES AND FIGURES |  |
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