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Acute undifferentiated fever in India: a multicentre study of aetiology and diagnostic accuracy.
BMC Infect Dis 2017; 17(1):665BI

Abstract

BACKGROUND

The objectives of this study were to determine the proportion of malaria, bacteraemia, scrub typhus, leptospirosis, chikungunya and dengue among hospitalized patients with acute undifferentiated fever in India, and to describe the performance of standard diagnostic methods.

METHODS

During April 2011-November 2012, 1564 patients aged ≥5 years with febrile illness for 2-14 days were consecutively included in an observational study at seven community hospitals in six states in India. Malaria microscopy, blood culture, Dengue rapid NS1 antigen and IgM Combo test, Leptospira IgM ELISA, Scrub typhus IgM ELISA and Chikungunya IgM ELISA were routinely performed at the hospitals. Second line testing, Dengue IgM capture ELISA (MAC-ELISA), Scrub typhus immunofluorescence (IFA), Leptospira Microscopic Agglutination Test (MAT), malaria PCR and malaria immunochromatographic rapid diagnostic test (RDT) Parahit Total™ were performed at the coordinating centre. Convalescence samples were not available. Case definitions were as follows: Leptospirosis: Positive ELISA and positive MAT. Scrub typhus: Positive ELISA and positive IFA. Dengue: Positive RDT and/or positive MAC-ELISA. Chikungunya: Positive ELISA. Bacteraemia: Growth in blood culture excluding those defined as contaminants. Malaria: Positive genus-specific PCR.

RESULTS

Malaria was diagnosed in 17% (268/1564) and among these 54% had P. falciparum. Dengue was diagnosed in 16% (244/1564). Bacteraemia was found in 8% (124/1564), and among these Salmonella typhi or S. paratyphi constituted 35%. Scrub typhus was diagnosed in 10%, leptospirosis in 7% and chikungunya in 6%. Fulfilling more than one case definition was common, most frequent in chikungunya where 26% (25/98) also had positive dengue test.

CONCLUSIONS

Malaria and dengue were the most common causes of fever in this study. A high overlap between case definitions probably reflects high prevalence of prior infections, cross reactivity and subclinical infections, rather than high prevalence of coinfections. Low accuracy of routine diagnostic tests should be taken into consideration when approaching the patient with acute undifferentiated fever in India.

Authors+Show Affiliations

National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway. kristine.moerch@helse-bergen.no. Department of Clinical Science, University of Bergen, Bergen, Norway. kristine.moerch@helse-bergen.no.Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India.Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India.Duncan Hospital, Raxaul, Bihar, India.Rural Development Trust Hospital, Anantapur, Andhra Pradesh, India.B.K.L. Walawalkar Hospital, Ratnagiri, Maharashtra, India.Christian Hospital, Mungeli, Chhattisgarh, India.Bethesda Hospital, Ambur, Tamil Nadu, India.Christian Fellowship Hospital, Oddanchatram, Tamil Nadu, India.Baptist Christian Hospital, Tezpur, Assam, India.Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India.National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway.National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway. Department of Clinical Science, University of Bergen, Bergen, Norway.National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway. Department of Clinical Science, University of Bergen, Bergen, Norway.Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India.Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India.

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

28978319

Citation

Mørch, Kristine, et al. "Acute Undifferentiated Fever in India: a Multicentre Study of Aetiology and Diagnostic Accuracy." BMC Infectious Diseases, vol. 17, no. 1, 2017, p. 665.
Mørch K, Manoharan A, Chandy S, et al. Acute undifferentiated fever in India: a multicentre study of aetiology and diagnostic accuracy. BMC Infect Dis. 2017;17(1):665.
Mørch, K., Manoharan, A., Chandy, S., Chacko, N., Alvarez-Uria, G., Patil, S., ... Mathai, D. (2017). Acute undifferentiated fever in India: a multicentre study of aetiology and diagnostic accuracy. BMC Infectious Diseases, 17(1), p. 665. doi:10.1186/s12879-017-2764-3.
Mørch K, et al. Acute Undifferentiated Fever in India: a Multicentre Study of Aetiology and Diagnostic Accuracy. BMC Infect Dis. 2017 10 4;17(1):665. PubMed PMID: 28978319.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Acute undifferentiated fever in India: a multicentre study of aetiology and diagnostic accuracy. AU - Mørch,Kristine, AU - Manoharan,Anand, AU - Chandy,Sara, AU - Chacko,Novin, AU - Alvarez-Uria,Gerardo, AU - Patil,Suvarna, AU - Henry,Anil, AU - Nesaraj,Joel, AU - Kuriakose,Cijoy, AU - Singh,Ashita, AU - Kurian,Siby, AU - Gill Haanshuus,Christel, AU - Langeland,Nina, AU - Blomberg,Bjørn, AU - Vasanthan Antony,George, AU - Mathai,Dilip, Y1 - 2017/10/04/ PY - 2017/05/04/received PY - 2017/09/25/accepted PY - 2017/10/6/entrez PY - 2017/10/6/pubmed PY - 2018/1/9/medline KW - Bacteraemia KW - Chikungunya KW - Dengue KW - Diagnosis KW - India KW - Leptospirosis KW - Malaria KW - Prevalence KW - Scrub typhus SP - 665 EP - 665 JF - BMC infectious diseases JO - BMC Infect. Dis. VL - 17 IS - 1 N2 - BACKGROUND: The objectives of this study were to determine the proportion of malaria, bacteraemia, scrub typhus, leptospirosis, chikungunya and dengue among hospitalized patients with acute undifferentiated fever in India, and to describe the performance of standard diagnostic methods. METHODS: During April 2011-November 2012, 1564 patients aged ≥5 years with febrile illness for 2-14 days were consecutively included in an observational study at seven community hospitals in six states in India. Malaria microscopy, blood culture, Dengue rapid NS1 antigen and IgM Combo test, Leptospira IgM ELISA, Scrub typhus IgM ELISA and Chikungunya IgM ELISA were routinely performed at the hospitals. Second line testing, Dengue IgM capture ELISA (MAC-ELISA), Scrub typhus immunofluorescence (IFA), Leptospira Microscopic Agglutination Test (MAT), malaria PCR and malaria immunochromatographic rapid diagnostic test (RDT) Parahit Total™ were performed at the coordinating centre. Convalescence samples were not available. Case definitions were as follows: Leptospirosis: Positive ELISA and positive MAT. Scrub typhus: Positive ELISA and positive IFA. Dengue: Positive RDT and/or positive MAC-ELISA. Chikungunya: Positive ELISA. Bacteraemia: Growth in blood culture excluding those defined as contaminants. Malaria: Positive genus-specific PCR. RESULTS: Malaria was diagnosed in 17% (268/1564) and among these 54% had P. falciparum. Dengue was diagnosed in 16% (244/1564). Bacteraemia was found in 8% (124/1564), and among these Salmonella typhi or S. paratyphi constituted 35%. Scrub typhus was diagnosed in 10%, leptospirosis in 7% and chikungunya in 6%. Fulfilling more than one case definition was common, most frequent in chikungunya where 26% (25/98) also had positive dengue test. CONCLUSIONS: Malaria and dengue were the most common causes of fever in this study. A high overlap between case definitions probably reflects high prevalence of prior infections, cross reactivity and subclinical infections, rather than high prevalence of coinfections. Low accuracy of routine diagnostic tests should be taken into consideration when approaching the patient with acute undifferentiated fever in India. SN - 1471-2334 UR - https://www.unboundmedicine.com/medline/citation/28978319/Acute_undifferentiated_fever_in_India:_a_multicentre_study_of_aetiology_and_diagnostic_accuracy_ L2 - https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-017-2764-3 DB - PRIME DP - Unbound Medicine ER -