Anuja P Makan^1*, Gajanan Kurundkar²

¹Post graduate Resident, ²Professor, Department of Medicine, Smt Kashibai Navale Medical College and Hospital, Narhe, Dist. Pune, Maharashtra, INDIA.

Email: makanapoorva@gmail.com

No significant association was seen between the diagnosis and outcome of the patient. (p=0.69)

The deaths observed in the patients according to the infections were

5 out of 15 patients of Dengue died (33.33%).

2 out of 4 patients of Swine flu died (50%).

2 out of 5 patients of Leptospirosis died (40%).

One each out of 3 cholera and 3 Enteric Fever patients died (33.33% each).

There was one patient of scrub typhus who died (100%) due to septic shock.

DISCUSSION

We studied 50 patients of locally endemic infectious diseases admitted in the Intensive Care Unit of our tertiary care hospital and medical college. Many studies have described a single endemic disease. In our study we are including patients from nine endemic diseases which satisfied our study selection criteria. Tthere were 15 females (30%) and 35 males (70%). Male to female ratio was 2.33:1. Juneja D et al. in their study had 61.1% males and Sivarajan S et al. had 52.2 % males, which was comparable to our study.^5,6 Table number 2 of our study showed that the Intensive Care Unit (ICU) stay duration was 11.52 ± 9.01 days with a minimum of 2 and a maximum of 50 days. Longest ICU stay in this study has been seen in a patient of dengue shock syndrome. While the study of Kartik Ramakrishna et al. revealed that the required ICU admission stay was 5.8 ± 2.7 days.⁷ The mean age in our study was 40.52 ± 15.08 years with a minimum of 19 years and maximum of 63 years. The most common presenting symptom was fever in all 50 cases (100%) as seen in table number 4 followed by jaundice in 19 cases (38%), acute kidney injury in 15 cases (30%), septicemia and joint pains in 12 patients each (24%), bleeding, shock and retro orbital pain in 11 patients each (22%) followed by other symptoms. The study by Ambika Sharma revealed that patients of H1N1 commonly presented with symptoms of cough and fever (95%). Most common findings were increased temperature, tachycardia, tachypnea and crepitation on auscultation.⁸ The study by Frederico Figueiredo Amâncio showed the most common presentation as shock (22.7%) followed by severe thrombocytopenia with or without minor bleeding and respiratory failure. These were the main causes of ICU admission in dengue patients. Hemorrhagic manifestations were seen in 73.2% patients such as petechiae, ecchymosis and suffusion. Other bleeding manifestations such as mucosal bleeding, gum bleeding, epistaxis and hematuria were also noted. Fever and myalgia were the other common symptoms.⁹ Sivarajan S et al. reported that fever of <7 days (83.3 %) was the most common presentation followed by myalgia, pain abdomen, headache, nausea/vomiting, dry cough, hepatomegaly, splenomegaly and lymphadenopathy as the other predominant clinical features amongst their patients.⁶ Our study showed that qSOFA score of 2 or more than 2 at presentation was common. This was seen in 23 patients each (46%) while score of 1 was seen in 4 patients (8%), who had abnormalities in their biochemical profile, thus requiring close monitoring. Kartik Ramakrishna et al. in his study details the profile and outcomes of patients admitted to the intensive care unit (ICU) with pandemic Influenza A (H1N1). Sequential organ failure assessment (SOFA) scores were calculated daily.⁷ SOFA score at 24 hours of presentation showed that mean SOFA score at presentation for patients admitted in the ICU for management of endemic infectious diseases was 13.6 ± 5.3. Maximum SOFA score was 23.Mean SOFA score in patients who did not survive was 21.4 ± 0.9 while mean SOFA score in discharged patients was 11.24 ± 3.3. Higher SOFA scores at 24 hours of presentation led to longer duration of hospital stay. Most patients in our setup had a ICU stay extending into the second week. The most common organ failure during the course of the ICU stay was renal failure in 29 patients (28%) followed by hepatic failure in 17 patients (34%) and respiratory failure seen in 12 patients (24%). Sivarajan S et al. reported one third of the patients developed at least one systemic complication. Acute hepatitis (16.7 %), followed by pneumonitis, and acute kidney injury were the common complications.⁶ Ambika et al. study revealed that consolidation was seen in nearly half of the patients on radiological imaging. Complications noted in their patients were pneumonia (45%), followed by respiratory failure and ARDS.⁸ Juneja D et al. in their study on dengue patients found 13.1% cases had respiratory failure.⁵ Ramesh Holla et al. study showed acute renal failure as the most common complication at 79.2%.¹⁰ 23 patients (46%) had comorbidities in our study. Arunkumar et al. study showed that 35% had co-morbid condition with the influenza A H1N1 disease. Their study found that in patients with associated comorbid conditions, 84% were discharged. Mortality was 16% among patients with co morbidity.¹¹ Anish Gupta et al. in their study found that fifty-one patients had underlying comorbidities.¹²

 The most common co morbidity was diabetes in 10 patients (20%) followed by thyroid disorders in 5 cases (10%), Chronic Liver Disease (CLD) in 3 cases (6%) followed by chronic kidney disease and hypertension. There were no comorbidities in 27 patients (54%). Ambika Sharma et al. study depicted that the associated comorbidities were Diabetes mellitus (19.5%), chronic kidney disease (17%) and immunosuppression (9.8%).⁸ Majority of the patients – 15 patients had dengue ( 30%), followed by malaria in 8 patients (16%), leptospirosis in 7 patients (14%), swine flu in 6 patients (12%), enteric fever in 4 patients (8%), cholera in 4 patients (8%), amoebiasis in 3 patients (6%), scrub typhus in 2 (4%) and lymphatic filariasis in 1 patient (2%). According to the outcome, 38 patients (76%) survived while 12 patients in our study died (24%). Mortality rate in the study by FredericoFigueiredoAmâncio was 18.6 % and 19.6% in ICU and hospital respectively.⁹ There was significant association between the poor outcome of the patients and higher qSOFA score (p = 0.011) at presentation. Poor outcome was noted in patients who presented with a qSOFA score of 2 or more. A total number of 12 deaths were reported in our study of which 10 patients had a qSOFA score of 3. Amongst the 38 patients who were discharged in our study, 25 patients presented with a qSOFA score of 1 or 2 while 13 patients presented with a qSOFA score of 3. There was a significant association between the occurrence of renal failure and poor outcome in our study (p=0.014). Of the 12 patients who succumbed, 7 patients had renal failure, whereas of the 38 patients who survived 8 had renal failure. Kartik Ramakrishna et al. in his study concluded that need for dialysis was independently associated with mortality (P=0.019).⁷ Sivarajan S et al. also reported significant association between the renal failure and multi organ failure with outcome in terms of mortality.⁶ The mean age and mean duration of ICU stay were not showing any significant difference in outcome of the disease (p > 0.05). There was no significant association between the diagnosis and outcome of the patients. (p=0.69). The deaths observed in patients according to the infections were as follows:

CONCLUSION

Endemic infectious diseases in the study had varied clinical presentation. The course in the Intensive Care Unit (ICU) was often complicated by multisystem involvement and organ failure. SOFA score more than 20 at 24 hours of presentation was associated with higher mortality rate. qSOFA score of 2 or above at the time of hospitalisation was an important predictor of mortality. Other associated factors were bleeding manifestations, acute kidney injury, hypotension requiring inotropic support and respiratory compromise requiring mechanical ventilation. Understanding these clinical features and complications will help to identify patients at high risk and treat them with optimal intensive care to reduce mortality.

REFERENCES

1. Balfour A Some British and American pioneers in tropical medicine and hygiene Trans R Soc Trop Med Hyg 1925
2. Fauci AS, Touchette NA, Folkers GK. Emerging Infectious Diseases: a 10-Year Perspective from the National Institute of Allergy and Infectious Diseases. Emerging Infectious Diseases 2005;11:519–25.
3. WHO. Research priorities in communicable diseases. Report of a regional meeting WHO/SEARO,New Delhi. 2010.
4. DGHS. Directorate General Of Health Services. https://dghs.gov.in/content/1364_3_NationalVectorBorneDiseaseControlProgramme.aspx (accessed December 6, 2019).
5. Juneja D, Nasa P, Singh O, Javeri Y, Uniyal B, Dang R. Clinical profile, intensive care unit course, and outcome of patients admitted in intensive care unit with dengue.J Crit Care. 2011 Oct;26(5):449-452
6. Sivarajan S, Shivalli S, Bhuyan D, Mawlong M, Barman R. Clinical and paraclinical profile, and predictors of outcome in 90 cases of scrub typhus, Meghalaya, India.Infect Dis Poverty. 2016 Oct 5;5(1):91.
7. Ramakrishna K, Sampath S, Chacko J, et al.. Clinical Profile and Predictors of Mortality of Severe Pandemic (H1N1) 2009 Virus Infection Needing Intensive Care: A Multi-Centre Prospective Study from South India. J Glob Infect Dis. 2012;4(3):145–152.
8. Ambika Sharma, R. S. Mathur et al.Clinical profile and outcome of patients admitted with swine-origin Influenza A H1N1 virus infection at a tertiary care hospital in Western India – volume 6 number 4, 2019
9. Amâncio FF, Heringer TP, Oliveira CdCHBd, Fassy LB, CarvalhoFBd, Oliveira DP, et al.. (2015) Clinical Profiles and Factors Associated with Death in Adults with Dengue Admitted to Intensive Care Units, Minas Gerais, Brazil. PLoS ONE 10(6): e0129046
10. Ramesh Holla et al.. Leptospirosis in Coastal South India: A Facility Based Study, BioMed Research International Volume 2018, Article ID 1759125
11. Arunkumar Ishwarbhai Chaudhari, Jitendra R Zaveri, NileshThakorProfile of confirmed H1N1 virus infected patients admitted in the swine flu isolation ward of tertiary care hospitals of Baroda district, Gujarat, India volume 3, number 9, 2015
12. Gupta A, Juneja D, Singh O, Garg SK, Arora V, Deepak D. Clinical Profile, Intensive Care Unit Course, and Outcome of Patients Admitted in Intensive Care Unit with Chikungunya. Indian J Crit Care Med. 2018;22(1):5–9.
13. Cook GC Tropical medicine – An illustrated history of pioneers London Academic press 2007.
14. Harrison M. A Global Perspective: Reframing the History of Health, Medicine, and Disease. Bulletin of the History of Medicine 2015;89:639–89.
15. Baradari A, Firouzian A, Davanlou A, Aarabi M, Daneshiyan M, Kiakolaye A. Comparison of Patients Admission, Mean and Highest Sofa Scores in Prediction of ICU Mortality: a Prospective Observational Study. Materia Socio Medica 2016;28:343.

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