Bajpai, Smrati MD; Bichile, Lata S. MD
Acute febrile illnesses in the city of Mumbai, during monsoon (July-October), rise to epidemic proportions. They lead to a significant level of morbidity among the population, but along with the morbidity they are also an important and major cause of mortality in the patients suffering during this period.
The major groups of these fever patients are the ones suffering from malaria, leptospirosis, dengue, chickungunya, and so on, but a significant number includes mixed infections with the previously mentioned agents, while a few others still remained unidentified. These patients of acute febrile illness presented a syndromic picture of jaundice, oliguria, thrombocytopenia, dyspnea, hemoptysis, myocarditis, and so on.
Data of these patients coming to the hospital who later died were analyzed to asses and conclude the clinical profile of the patients so as to obtain guidance for better management of such patients in the future.
Data indicating clinical status and blood investigations of the patients who died during monsoon in the premier teaching hospital of the city of Mumbai, India due to febrile illness was collected retrospectively from the medical files of the patients. The drainage population of this hospital includes the entire city of Mumbai with an approximate population of 13 million. The syndromic picture of the deceased patients was determined from these data. The post mortem findings of all those on whom an autopsy was done were also collected. All the findings were later assessed and χ2 test was used for the analysis.
Data of 160 patients of febrile illness who died during monsoon in 2006 were collected from the medical files and were assessed retrospectively.
The profile which was observed from the data showed that out of the total 6892 patients who were admitted in the hospital during this period, 2214 were of acute febrile illness of which 160 died (Table 1).
On application of χ2 test, it can be concluded that both at the P < 0.05 and P <0.01, there is a significant association between the number of deaths and acute febrile illness during monsoon (Table 1).
Very high percentage of males (81%) died as compared with females (19%). The age distribution of dead patients showed 59% in the age group of 15 to 35 years. The symptom duration was 2 to 4 days in 65% of patients.
The number of patients with 1 or more symptoms was dyspnea in 74, hypotension in 48, myalgia in 38, icterus in 34, and oliguria in 26. Bleeding manifestation was seen in 35 patients of whom 27 had hemoptysis (Table 2).
The blood investigation showed that 41% patients hadahemoglobin level in the range of 7 to 9.9 gm%. The average complete blood cell (CBC) count of deceased patients was around 8000. About 82.5% had thrombocytopenia,of which 64.3% had platelets in the range of 20,000 to 60,000 IU. The average investigative values for liver function were normal. Average blood urea nitrogen levels were 35.6 mg/dL, and S. creatinine were 2.21 mg/dL indicating prerenal nature of renal impairment (Table 3).
The syndromic picture showed that proportional mortality rate (PMR) due to ARDS was 28.12%, acute renal failure (ARF) along with ARDS was 23.12%, ARDS with hepatorenal failure was 15%, isolated ARF was 15.62%, hepatorenal was 11.25%, and only hepatitis was 6.25% (Table 4a).
This showed that majority of patients died of the severe syndrome of ARDS, and some had multiorgan failure along with it.
The cause of fever could not be determined in 53.75% deaths, whereas in 22.5%, it was malaria, 21.88% was leptospirosis, and in 1.88% it was dengue (Table 5).
Autopsy was done in 23% of those who died. Of these, 48.6% had ARDS, 10.8% had alveolar hemorrhages along with ARDS, 8% had ARF associated with ARDS, 8% had myocarditis along with ARDS and alveolar hemorrhages, whereas 5% had only ARF (Table 6). This clearly indicates that majority of fever patients who died had ARDS.
It may thus be concluded that in tropical infections during monsoon, large number of males compared with females died of illness, ARDS being the major complication and leptospirosis and malaria the main killers in the city of Mumbai.
Acute fever during monsoon in western India constitutes a significant ailment. This illness as we know has many differential diagnoses.1,2 We assessed those patients who died during monsoon of 2006 in the premier tertiary care teaching hospital of the city of Mumbai to formulate the pattern.
We found that case fatality rate of acute febrile illness in our study during monsoon in our hospital was 7.23% of the 160 patients who could not survive.
Every year, postmonsoon, the number of patients who suffer from fever increases. The total number of acute febrile illness patients during the study period of 3 months who got admitted to our hospital was 2214 patients. We found in our study that in the 160 patients who could not survive, from the total patients of fever, majority were males, their age being younger than 35 years. A study on acute undifferentiated febrile illness in rural Thailand also observed that majority were males and had a median age of 38 years.1
As in our study, we found that symptom duration was around 2 to 4 days in 65% of the patients; they also found in Thailand that duration was 3.5 days, showing that these patients had a very short history of fever.1
The etiology of this fever could not be determined in 54% of the cases who died, probably because of the too early demise of patients. Whereas in 22%, cause was leptospirosis, another 22% was malaria, dengue was observed only in 2% patients.
In several other studies of fever patients from India during monsoon, viz a study from Delhi has shown leptospirosis as the cause in 15% of the patients.3,4 A study in Mumbai on children has shown an incidence of 32% of leptospirosis after heavy rains.5 Another Delhi study in fever patients showed that 28% of the fever was because of malaria. Hence, these 2 etiologies seem to be quite common as the fever-causing agents in India.2
The presentation of this fever was not alone but it was associated in most case with symptoms of breathlessness, hemoptysis, hypotension, myalgia, and icterus. Some had oliguria as well.6
Investigation showed that their hemoglobin level was a little low but CBC was normal in most patients, and 64% had thrombocytopenia.2
They had a prerenal impairment, but their average alanine aminotransferase and aspartate aminotransferase levels were normal.6,7
The PMR was more in those who had ARDS, associated with renal and hepatic involvement or ARDS with hemoptysis, that is, 66.88%, whereas a PMR of 33.12% was observed in those who did not have ARDS as a part of their illness (Table 4b).
The syndrome which was observed in most febrile patients who died was ARDS, associated with renal and hepatic involvement or ARDS with hemoptysis.8 This indicates that presence of ARDS in itself mandates caution in such patients as it increases the mortality.8 If 2 or more organ impairment is observed, it further increases the risk.
The patients in whom autopsy was performed, a similar result was observed with 48% having ARDS and 10% with associated intraalveolar hemorrhages, 8% had ARF also and another 8% had myocarditis, along with ARDS. A study from Mumbai on the autopsies of patients of leptospirosis also showed similar findings.9 The observation of pathological features of myocarditis in significant number of autopsies made us conclude that physicians should keep myocarditis also as one of the predominant syndromic presentation of leptospirosis, more so because there is a significant degree of overlap between the clinical features of myocarditis and ARDS. Most of those who died were the ones who had ARDS or multiple organ dysfunction syndrome, similar to the reports from other parts of the country.10-12
Previous findings helped us to conclude that postmonsoon leptospirosis and malaria are the common etiologies of acute febrile illness in adults and ARDS is a major killer syndrome in Western India.
1. Suttinont C, Losuwanaluk K, Niwatayakul K, et al. Causes of acute, undifferentiated, febrile illness in rural Thailand: results of a prospective observational study. Ann Trop Med Parasitol. 2006;100(4):363-370.
2. Kothari VM, Karnad DR, Bichile LS. Tropical Infections in the ICU. JAssoc Physicians India. 2006;54:291-298.
3. Kaur IR, Sachdeva R, Arora V, et al. Preliminary survey of leptospirosis amongst febrile patients from urban slums of East Delhi. J Assoc Physicians India. 2003;51:249-251.
4. Mudur G. Mumbai braces itself for leptospirosis and waterborne infections. J Assoc Physicians India. 2004;52:623-625.
5. Karande S, Kulkarni H, Kulkarni M, et al. Leptospirosis in children in Mumbai slums. Indian J Pediatr. 2002;69(10):855-858.
6. Niwattayakul K, Homvijitkul J, Niwattayakul S, et al. Hypotension, renal failure, and pulmonary complications in leptospirosis. Ren Fail. 2002;24(3):297-305.
7. Mehta KS, Halankar AR, Makwana PD, et al. Severe acute renal failure in malaria. J Postgrad Med. 2001;47:24-610.
8. Hudson LD, Steinberg KP. Epidemiology of Acute Lung Injury and ARDS. Chest. 1999;116:74S-82S.
9. Salkade HP, Divate S, Deshpande JR, et al. A study of autopsy findings in 62 cases of leptospirosis in a metropolitan city in India. JPGM. 2005;51(3):169-173.
10. Pappachan MJ, Mathew S, Aravindan KP, et al. Risk factors for mortality in patients with leptospirosis during an epidemic in northernKerala. Southeast Asian J Trop Med Public Health. 2003;34(4):822-859.
11. Chawla V, Trivedi TH, Yeolekar ME. Epidemic of leptospirosis: an ICU experience. J Assoc Physicians India. 2004;52:619-622.
12. Udwadia FE. Multiple organ dysfunction syndrome due to tropical infections. Indian J Crit Care Med. 2003;7:233-236.
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