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S
everal parts of our country are now experiencing concurrent epidemics
of many infections like Dengue, Chikungunya, malaria, leptospirosis (rat fever), various hepatites etc. The arrival
of Novel Influenza A (H1N1) virus has further compounded the problem for the common man, the health care system as well
as the Govt. agencies alike, creating panic and confusion all over and logistical problems in the diagnosis and management
of these infections as well. A level headed and rational approach to decision making is the need of this critical hour
for health care delivery. Quick diagnosis and prompt treatment would help in minimising the complications and thereby
the mortality from these infections and the following information may be useful in that regard.
The Novel Influenza A (H1N1), Dengue and Chikungunya are caused by viruses
while malaria is caused by the malaria parasites and lepptospirosis by a coiled bacterium. Almost all viral infections
are self limiting diseases that remit within a week in most cases without any specific treatment and these three are no
exceptions. Leptospirosis also manifests as a mild, non-specific and self-limiting illness in the majority of cases and
treatment is needed only when it leads to complications in a few. Malaria, on the other, has to be treated with specific
anti malaria drugs and any delay in the treatment of falciparum malaria may result in complications that could be fatal.
Therefore, of all these diseases, it is the early and specific diagnosis of malaria that is most important.
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How do these diseases spread? |
Novel Influenza A (H1N1) spreads easily and very fast by simple contact
and therefore it is almost impossible to prevent the spread of this infection. With its dense population and easy
overcrowding, particularly in the urban areas, it will be no surprise if the new flu spreads quite rapidly. Measures such
as the use of face masks, consumption of herbal or homeopathic remedies or application of eucalyptus or neem oil etc., are
of no avail in preventing the spread of this new virus.
Dengue, Chikungunya and malaria are spread by mosquitoes. The female
Anopheles mosquito that spreads malaria bites predominantly indoors, after midnight. Dengue and Chikungunya are transmitted
by the female Aedes aegypti mosquito that bites at dawn and dusk, both inside and outside the households. Both these varieties
of mosquitoes breed profusely in clean, stagnant water that collects around human dwellings (buckets, tyres, bottles, coconut
shells etc. that are thrown out in the open as well as overhead tanks, wells etc.) Malaria and Dengue are more often seen in
the urban areas while Chikungunya can spread rapidly all across. Controlling mosquito breeding and protection from mosquito
bites are very essential to prevent the spread of these infections.
Influenza involves the respiratory tract and manifests with fever, body ache,
headache, sore throat and cough, with some patients also having vomiting or diarrhea. More than 99% patients recover in 3-5
days without any treatment. Severe illness, characterized by high fever or severe sore throat, vomiting or diarrhea, bloody
sputum, difficulty in breathing, bluish discoloration of the lips, tongue and nails etc. can occur in 1-2% of cases and would
require hospitalization.
Dengue fever presents with severe muscular pain, back ache, head ache, pain on
moving the eye balls and a fine rash over the trunk and extremities. Some patients may have bleeding from the nose or under
the skin and vomiting or diarrhea. Most patients recover within a week without any treatment. In about 0.5-1% of cases, the
platelet counts can drop significantly, bleeding can increase and the blood pressure may drop. Even among those who develop
complications, most patients make an uneventful recovery with careful supportive treatment.
Leptospirosis also manifests with sudden fever, muscular pain and back ache.
As the fever continues, redness of the eyes, head ache, cough etc. may appear in 4-7 days. In some the fever recurs after a
gap of 1-3 days and complications like jaundice, decreased urine output, bleeding tendencies etc., may occur. In most patients,
leptospirosis recovers spontaneously and passes off as a simple febrile illness. Only those patients who develop complications
involving the liver, kidney etc., require hospitalization and specific treatment and most of these patients also recover with
supportive care.
Chikungunya is characterized by sudden onset fever, pain and swelling of joints
and raised rashes over the face, trunk and extremities that may itch. The fever and rash usually disappear in 3-5 days; however
in about 12% of cases, the joint pain may remain for many weeks and may be severe enough to prevent them from moving out.
Deaths due to Chikungunya are extremely rare; however, patients already suffering from diseases of major organs may succumb
after contracting Chikungunya.
Malaria is characterized by high fever with or without chills that can occur
daily or on alternate days. Severe body ache, joint pain or rash are not seen in malaria. Some patients may have jaundice.
About 10% of patients with falciparum malaria may develop complications involving the brain, kidneys, lungs or drop in blood
pressure. Early diagnosis and prompt treatment with antimalarial drugs and life support (ventilation, dialysis etc.) will help
majority of patients to recover.
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With many of these infections that share several common
manifestations prevalent
amidst us, it may be difficult at times to
differentiate between them. However, a careful examination to identify certain subtle differences in their clinical
manifestations and some
simple blood and urine tests would help in the diagnosis.
Algorithm for
Diagnosis and Treatment of Febrile Disorders
(Click to open
enlarged image in new window) |
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Fever and Cough
Anyone suffering from fever, sore throat and cough these
days will be suspected of having the new H1N1 infection! Until a few weeks ago, anyone suffering these common
symptoms would have waited for a couple of days, may be taking some home remedies, for the ‘common cold’ to
subside on its own. But in these changed times, even this simple infection is forcing people to stand in hour
long queues in front of the hospitals, with masks on their faces!
Novel Influenza H1N1 being just one among the many causes
for respiratory tract infection and symptoms such as fever, sore throat, cough, body ache and head ache
are common for most of them. Significant body ache and headache is more common in viral infections while
pain on swallowing, presence of follicles over the throat or tonsils, enlarged and painful lymph nodes
beneath the lower jaw, yellowish or rusty sputum or pain on any side of the chest on breathing or coughing
are suggestive of a bacterial infection. A secondary bacterial infection is likely if the fever recurs after
tending to subside over 3-4 days following a viral infection. An elevated white cell count suggests a
bacterial infection and chest x ray is useful in identifying a consolidation due to pneumonia.
Patients with high fever, severe throat pain, bloody sputum,
difficulty in breathing, persistent vomiting or diarrhea, altered sensorium etc., should consult a specialist
and get admitted to a hospital. Patients of age >65 years or <5 years, pregnancy, pre-existing diseases of major
organs like the heart, kidneys, lungs, liver or the nervous system, diabetes, cancer, HIV/AIDS, immunocompromised
or immunosuppressed (on steroids, transplant recipients) and obesity have been associated with higher risk of
complications and should therefore be under observation or even hospitalized. Increased respiratory rate,
breathlessness and cyanosis of lips, tongue or nails indicate respiratory failure and such patients should be
immediately admitted in a well equipped tertiary care centre and treated with antibiotics, oxygen and if required,
artificial ventilation. Delay in initiating these life saving measures may prove fatal.
Fever and Aches/Pains
and rash
Severe body ache, back ache, pain behind the eyeballs on moving
them are common symptoms of Dengue fever and leptospirosis. A fine, macular rash over the trunk and extremities
appears after 1-2 days of onset in Dengue fever; in leptospirosis,
hemorrhagic rash may appear on the legs after 6-7 days. Chikungunya can be easily identified with its typical
manifestations of fever with severe joint pains and maculopapular rashes over the face,
trunk and extremities.
Fine, Macular
Rash in Dengue |
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Maculopapular Rash
in Chikungunya |
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Sub-conjunctival
Bleed in Dengue |
The total leukocyte count (TLC) and platelet count are usually
low in Dengue, whereas the TLC and ESR are significantly increased in leptospirosis. Presence of albumin and
cellular sediments in the urine is invariably found in leptospirosis and this simple test is a helpful hint.
The confirmatory tests for dengue, chikungunya and leptospirosis involve detection of antibodies against the respective
organisms and these tests are expensive, time consuming and not widely available and therefore are not of much
help in the early diagnosis and treatment of these diseases. Therefore the above mentioned differentiating
clinical features and simple blood and urine tests are of great help in the diagnosis of dengue and leptospirosis.
Malaria,
Leptospirosis, Hepatitis
Malaria is characterized by high fever, and the typical alternate
day fever with chills may occur only in some patients. As a delay in diagnosis and specific treatment may lead to
severe complications, it is important to test for malaria in all cases of fever. A simple and inexpensive peripheral
blood smear examination can confirm its diagnosis.
Both malaria and leptospirosis can lead to jaundice. Viral
hepatitis are also common causes for jaundice in our country. In viral hepatitis, patient has fever, upper
abdominal discomfort and vomiting during the initial 3-4 days and these symptoms subside as the jaundice
increases and the urine and eyes turn yellowish. In malaria and leptospirosis, fever continues as the
jaundice increases. In cases of viral hepatitis, the liver enzymes are significantly increased and levels of
ALT more than 350 U should suggest a possibility of viral hepatitis. In malaria and leptospirosis, the liver
enzymes are moderately elevated and in addition, other alterations in the blood count, peripheral smear and
urine, as mentioned above, would be present.
Infections
of respiratory tract, including Novel Influenza A (H1N1): Most viral infections, including the Novel Influenza H1N1,
subside on their own over 3-7 days and antibacterial drugs are needed only in case of bacterial infection.
If high fever or severe body ache or head ache cause a lot of discomfort, antipyretics like paracetamol can
be used. As per the
new guidelines issued by the Dept of Health, Govt. of India,
only patients of suspected H1N1 infections who have developed or are
at risk of developing the manifestations of severe disease need to
take Oseltamivir and test for the virus; the
large majority of cases (99.9%) of the novel H1N1 infection would recover spontaneously without any specific
treatment and therefore would neither require the test nor the antiviral drugs. It is notable that even in
countries like the US, Canada and Australia wherein more than a million people have already been infected
with the new H1N1 virus, antiviral drugs and H1N1 tests have been used very sparingly and most of the patients
have recovered without any specific treatment [16,17,18] (no Tamiflu, Ayurveda, Homeopathy, Unani, onions, garlic, ginger,
neem, Amritaballi or else)!
Bacterial
infections of the upper respiratory tract can be treated with
penicillins or macrolides. Community acquired pneumonia can be
treated with penicillins, cephalosporins or macrolides. Hospital
acquired pneumonias would require a third generation cephalosporin
along with an aminoglycoside like gentamicin or co-amoxyclav.
All patients with
tachypnoea, hypoxemia, hypotension or acidosis should be
administered oxygen so as to maintain PaO2 at >60mmHg or
SaO2 at >92% as well as other supportive care. If hypoxemia fails to improve with adequate
oxygen therapy, assisted ventilation should be started early.
Other
infections:
Dengue and
Chikungunya: If the fever and/or
joint pains are very severe, simple analgesic like paracetamol can be used. Potent pain killers can cause more harm
than good. Reckless use of NSAIDs can result in gastrointestinal bleeding or
other haemorrhagic manifestations. Prescribing NSAIDs to patients with
pre-existing renal disease or cardiac failure may aggravate the condition.
Steroids have absolutely no role to play in the treatment of acute chikungunya and dengue. If the joint pain and swelling in
chikungunya persist
even after 10-15 days, hydroxychloroquine or salazopyrine have been found to be useful.
Leptospirosis:
If a diagnosis is made during the primary phase of the infection, penicillin
(1.5 million 6 hourly) or doxycyline (100mg 12 hourly) or
ceftriaxone (1 g 12 hourly) may be helpful. However, these may not
prevent the complications. Patients who develop complications should
be managed with careful supportive therapy.
Malaria
is treated with antimalarial drugs like
chloroquine or artemisinin based combinations. Patients who develop
complications require careful supportive therapy. Antibiotics (third
generation cephalosporins) are recommended for patients with algid
malaria.[See]
Viral hepatitis is
a self limiting illness that does not require any specific
treatment.
Complications: Malaria, Dengue and leptospirosis can result in many
serious complications that can be life threatening. Dengue Hemorrhagic Fever and Dengue Shock Syndrome
are well recognized complications of Dengue fever. Acute respiratory distress, renal failure, altered
sensorium or coma, convulsions, drop in blood pressure, jaundice, bleeding etc., can occur in both malaria
and leptospirosis.
Most of these patients can be saved by early diagnosis, prompt
treatment and careful supportive care. Overenthusiastic
transfusion of blood or platelets may do more harm than good; most
cases of thrombocytopenia recover spontaneously and watchful
expectancy and masterly inactivity is all that is needed. There is
no role for steroids in the management of any of these diseases or
their complications. There is no evidence to show
that homeopathy or ayurveda or any other alternative medicines have
any beneficial effects in the treatment of any of these diseases.
Therefore, with a
careful and rational approach, it is not difficult to promptly
diagnose and treat most of the infectious diseases that are
prevalent today. Only malaria and bacterial infections need specific
treatment and most cases of viral infections recover on their own.
Creating unnecessary panic only leads to confusion and unbearable
burden on the healthcare delivery system, thereby depriving the life
saving support to the needy. Let rationalism prevail.
References:
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Ann M. Powers, Christopher H. Logue. Changing patterns of chikungunya
virus: re-emergence of a zoonotic arbovirus Available at
http://www.sgm.ac.uk/jgvdirect/82858/82858ft.pdf
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Judith Green-McKenzie. Leptospirosis in Humans
Available at
http://www.emedicine.com/EMERG/topic856.htm
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Connelly CR, Mores CN, Smartt CT,
Tabachnick WJ.
Chikungunya. Available at
http://edis.ifas.ufl.edu/IN696
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Sathiavathy KA.
Chikungunya fever-Perceptive of Current Epidemic - 2007 Available at
http://www.articleset.com/health_articles_en_Chikungunya-fever-Perceptive-of-Current-Epidemic-2007.htm
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Chhabra M, Mittal V, Bhattacharya D, Rana U, Lal S. Chikungunya fever: A
re-emerging viral infection. Indian J Med Microbiol [serial online] 2008 [cited
2008 Jun 24];26:5-12. Available from:
http://www.ijmm.org/text.asp?2008/26/1/5/38850
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Ashok Swaroop, Arvind Jain, Maniram Kumhar, Naveen Parihar, Sachin
Jain.
Chikungunya Fever. JIACM 2007;8(2):164-8. Available at
http://medind.nic.in/jac/t07/i2/jact07i2p164.pdf
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MM Parida, SR Santhosh, PK
Dash, PV Lakshmana Rao. Rapid and Real-time Assays for Detection and
Quantification of Chikungunya Virus Available at
http://www.medscape.com/viewarticle/571272
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Mohan, Alladi "Chikungunya
fever: clinical manifestations & management". Indian Journal of Medical
Research. Nov 2006. FindArticles.com. 06 Jul. 2008. Available at
http://findarticles.com/p/articles/mi_qa3867/is_200611/ai_n19198542
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Robert V Gibbons.
Dengue: an escalating problem. BMJ 2002;324:1563-1566 (29 June) Available
at
http://bmj.bmjjournals.com/cgi/content/full/324/7353/1563
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Carlos CC, Oishi K, Cinco MTDD et
al.
Comparison Of Clinical Features And Hematologic Abnormalities Between Dengue
Fever And Dengue Hemorrhagic Fever Among Children In The Philippines. Am. J. Trop. Med. Hyg.
2005;73(2):435-440. Available at
http://www.ajtmh.org/cgi/content/full/73/2/435
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Sunil Karande, Dipak Gandhi, Madhuri Kulkarni, Renu Bharadwaj, Sae Pol, Jyotsna Thakare, Anuradha De.
Concurrent Outbreak of Leptospirosis and Dengue in Mumbai, India, 2002. Journal of Tropical Pediatrics 2005;51(3):174-181.
Abstract at
http://tropej.oxfordjournals.org/cgi/content/abstract/51/3/174
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Vinod H. Ratageri, T.A. Shepur, P.K. Wari, S.C. Chavan, I.B. Mujahid, P.N.
Yergolkar.
Clinical Profile and Outcome of Dengue Fever Cases. Indian J Pediatr
2005;72(8):705-706. Available at
http://medind.nic.in/icb/t05/i8/icbt05i8p705.pdf
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Leptospirosis. Available at
http://www.merck.com/mmpe/sec14/ch174/ch174c.html
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http://www.leptospirosis.org/topic.php?t=50
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New Guidelines for Screening, Testing, and Isolation for H1N1.
Available at
http://pib.nic.in/release/release.asp?relid=51875
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Public Health Agency of
Canada Guidelines on Novel H1N1. Available at
http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/faq_rg_swine-eng.php
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CDC Recommendations Guidelines on
Novel H1N1. Available at
http://www.cdc.gov/h1n1flu/recommendations.htm
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Statement of Australian Health
Minister. Available at
http://en.chinagate.cn/features/swineflu/2009-06/11/content_17930926.htm
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WHO Guidelines for Pharmacological
Management of Pandemic (H1N1) 2009 Influenza and other Influenza Viruses.
Available at
http://www.who.int/csr/resources/publications/swineflu/h1n1_guidelines_pharmaceutical_mngt.pdf
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