A STUDY OF EXPANDED INFECTIOUS FEVER - 100 CASES IN A

A STUDY OF EXPANDED INFECTIOUS FEVER - 100 CASES IN

A TERTIARY CARE HOSPITAL

Dissertation Submitted to

THE TAMILNADU Dr.M.G.R. MEDICAL UNIVERSITY

CHENNAI- 600 032

With Partial fulfillment of the requirement

for the award of degree of

M.D. DEGREE IN GENERAL MEDICINE

BRANCH – 1

Register Number : 201711210

THANJAVUR MEDICAL COLLEGE AND HOSPITAL

THANJAVUR

MAY 2020

CERTIFICATE FROM THE INSTITUTION

This is to certify that this dissertation entitled “A STUDY OF EXPANDED

INFECTIOUS FEVER - 100 CASES IN A TERTIARY CARE

HOSPITAL” submitted by Dr. RENGABASHYAM P appearing for M.D. Branch

I General Medicine Degree examination in May 2020 is a bonafide record of work

done by him under my direct guidance and supervision in partial fulfillment of

regulations of the Tamil Nadu Dr. M.G.R. Medical University, Chennai. I forward this

to the Tamil Nadu Dr.M.G.R. Medical University, Chennai, Tamil Nadu, India.

Prof. Dr. KUMUDHA LINGARAJ MD DA.,

The Honourable Dean

Thanjavur Medical College & Hospital

Thanjavur.

CERTIFICATE FROM THE HOD



HOSPITAL” submitted by Dr.RENGABASHYAM P appearing for M.D. Branch





Prof. Dr. K.NAMASIVAYAM MD .,

HOD and Professor of Medicine

Department of Internal Medicine


Thanjavur.

CERTIFICATE FROM THE GUIDE



HOSPITAL” submitted by Dr.RENGABASHYAM P appearing for M.D. Branch





Prof. Dr. G. BHASKAR MD .,

Associate Professor

Department of Internal Medicine


Thanjavur.

CERTIFICATE II

This is to certify that this dissertation work titled “A STUDY OF

EXPANDED INFECTIOUS FEVER - 100 CASES IN A TERTIARY

CARE HOSPITAL” Of the candidate Dr.RENGABASHYAM P with

registration number 201711210 for the award of M.D. in the branch of

GENERAL MEDICINE. I personally verified the urkund.com for the purpose

of plagiarism check. I found the uploaded thesis file contains from the

introduction to conclusion pages and result shows 10 percentage of plagiarism

in the dissertation.

Guide and Supervisor sign with Seal

ACKNOWLEDGEMENT

I would like to thank our respected Dean Prof.Dr.KUMUDHA

LINGARAJ MD DA., Thanjavur Medical college for permitting me to

utilize the facilities of Thanjavur Medical college and Hospital for this

dissertation.

I wish to express my respect and sincere gratitude to my

beloved teacher, Unit chief Prof. Dr.G.BHASKAR.M.D,Associate

Professor, Department of General Medicine for his valuable guidance,

support and encouragement during the study and also throughout

my course period.

My heartful thanks to unit Asst. Professors, Dr.S. HEMA

AKILANDESWARI M.D., Dr.S.VENNILA M.D., and Dr.N. RAMESH M.D,

for their valuable suggestions and support throughout the course of

the study.

I would like to express my whole hearted thanks to my

beloved father Mr.PIRAHALATHAN K and mother Mrs.MALARKODI P

for their constant support throughout my study and course period.

I extend my thanks to all my friends, batch mates, my

juniors and senior colleagues who supported me throughout my study

and course period.

I thank all the patients, who form the most vital part of my

work, for their extreme patience and co-operation, without whom this

project would have been a distant dream and I pray God for their

speedy recovery.

This acknowledgement is incomplete if I fail in my duty to

thank all the persons who have whole heartedly participated in the

study and have made the study complete

DECLARATION

I solemnly declare that the dissertation titled “A STUDY OF EXPANDED


HOSPITAL” is done by me at Coronary care unit, Thanjavur Medical College &

Hospital, Thanjavur during 2018-2019 under the guidance and supervision of

Prof.Dr.G.BHASKAR, MD

The dissertation is submitted to The Tamilnadu Dr. M.G.R. Medical University

towards the partial fulfillment of requirements for the award of M.D. Degree

(Branch I) in General Medicine.

Place; Thanjavur

Date:

Dr.RENGABASHYAM P

CONTENTS

CHAPTER

NO. TITLE

PAGE

NO.

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 2

3 REVIEW OF LITERATURE 4

4 MATERIALS AND METHODS 37

5 RESULTS AND INTERPRETATION 47

6 DISCUSSION 73

7 SUMMARY 85

8 SUMMARY 85

9 BIBLIOGRAPHY

10 PROFORMA`

11 MASTER CHART

1

INTRODUCTION

Infections are one of the leading cause of morbidity and mortality in

our country. The changing profile of infections need to be determined in

order to focus on specific investigative and therapeutic measures. This study

was undertaken to evaluate the changing profile in patients presenting with

infectious fevers.

2

AIM OF THE STUDY

To study the clinical and laboratory profile of patients with infectious

fever in the medical wards of Government Thanjvaur Medical College and

Hospital.

The groups analysed were:

1. Fever of less than 5 days with

a. Organ dysfunction

b. Temperature >40°C

2. Fever of more than 5 days with or without complications.

3

OBJECTIVES

1. To study the clinical profile like age, sex, fever duration and

associated systemic symptoms in patients with infectious fever.

2. To identify the common etiology of infectious fever.

3. The study the various complications of infectious fever and factors

contributing for it.

4. To analyze the causes of mortality in patients with infectious

fever.

4

REVIEW OF LITERATURE

FEVER1

Definition

Fever is an elevation of the body temperature that exceeds the normal

daily variation and occurs in conjunction with an increase in hypothalamic

set point, which controls the normal body temperature.

Mechanism

Once the hypothalamic set point is raised, neurons in the vasomotor

centre is activated and vasoconstriction commences, shunting of blood away

from the periphery decreasing heat loss. This mechanism increases the body

temperature by 1° to 2°C. Shivering begins at this point of time which further

increases the body temperature. Heat production by liver also increases.

Control of body temperature

Body temperature is controlled by hypothalamus. Neurous in both pre

optic anterior hypothalamus and the posterior hypothalamus receives two

kinds of signals; one from the peripheral nerves that reflect warmth and cold

receptors and other from the temperature of blood bathing the region, which

5

are integerated to maintain the normal body temperature. A normal body

temperature is ordinarily maintained despite environmental variations,

because of the balance between heat production and heat dissipation.

Normal Temperature

According to studies, the mean oral temperature is 36.8° ± 4°C (98.2

± 0.7°F) with low levels at 6 am and higher levels at 4 to 6 pm. In light of

these studies an AM temperature of >37.2°C (98.9°F) or a PM temperature

> 37.7°C (99.9°F) would define fever. Rectal temperatures are generally

0.4°C higher than oral readings. Lower oesophageal temperatures closely

reflect core temperature.

A fever of >41.5°C (>106.7°F) is called hyperpyrexia.

Fever Patterns

Intermittent fevers are temperature elevations that return to normal at

least once during most days.

Continous fevers do not vary more than 1°F. Remittent fevers do not

return to normal each day. Relapsing fevers are recurrent over days or weeks

and may have any undergoing fever pattern.

6

Studies of FUO (Fever of Unknown Origin)

Kejariwal et al.,2 in 2001 at Calcutta studied the etiological profile of

100 cases of FUO, the pattern was infections (53%) followed by neoplasm

(17%), collagen vascular diseases (11%), miscellaneous (5%) and

undiagonosed (14%).

De Kleijn et al.,3 in a study of 167 immunocompetent patients with

FUO found 43 (25.7%) had infections, 21 (12.6%) had neoplasms and 40

(24.0%) had inflammatory diseases.

Petersdorf et al.,4 in 1952 - 57, studied 100 cases, of which majority

(36%) were due to infections like, tuberculosis, abdominal abscess,

endocarditis, brucellosis and urinary tract infections. 26% were due to

lymphomas, leukemias and solid tumors. 15% were due to connective tissue

diseases.

Larson et al., 5 studied 105 cases of FUO patients of which infections

formed 30%. Malignancies formed 37% and 14.3% were due to connective

tissue disorders. Others were undiagnosed.

7

Knockaert et al., 6 studied 199 cases of FUO patients of which

infections formed 22.5%, followed by collagen vascular disorders (21.5%).

Neoplasms formed 7% while others were miscellaneous and undiagnosed.

Sharma et al., 7 studied 150 cases of FUO of which, infections formed

50%, followed by Neoplasms which formed 22%. 8% were due to collagen

vascular diseases, 15% formed miscellaneous causes and 5% were

undiagnosed.

Burke et al., 8 reviewed various studies on FUO and noted that

common treatable causes were tuberculosis, subacute bacterial endocarditis,

abscesses, salmonella and leptospirosis.

STUDIES ON ETIOLOGY OF FEVER

Definition: This entry lists major infectious diseases likely to be

encountered in countries where the risk of such diseases is assessed to be very

high as compared to the United States. These infectious diseases represent risks

to US government personnel traveling to the specified country for a period of

less than three years. The degree of risk is assessed by considering the foreign

nature of these infectious diseases, their severity, and the probability of being

affected by the diseases present. The diseases listed do not necessarily represent

8

the total disease burden experienced by the local population.

The risk to an individual traveler varies considerably by the specific location,

visit duration, type of activities, type of accommodations, time of year, and

other factors. Consultation with a travel medicine physician is needed to

evaluate individual risk and recommend appropriate preventive measures such

as vaccines.

Diseases are organized into the following six exposure categories shown

in italics and listed in typical descending order of risk. Note: The sequence of

exposure categories listed in individual country entries may vary according to

local conditions.

food or waterborne diseases acquired through eating or drinking on the

local economy:

Hepatitis A - viral disease that interferes with the functioning of the liver;

spread through consumption of food or water contaminated with fecal matter,

principally in areas of poor sanitation; victims exhibit fever, jaundice, and

diarrhea; 15% of victims will experience prolonged symptoms over 6-9

months; vaccine available.

Hepatitis E - water-borne viral disease that interferes with the functioning of

the liver; most commonly spread through fecal contamination of drinking

9

water; victims exhibit jaundice, fatigue, abdominal pain, and dark colored

urine.

Typhoid fever - bacterial disease spread through contact with food or water

contaminated by fecal matter or sewage; victims exhibit sustained high fevers;

left untreated, mortality rates can reach 20%.

vectorborne diseases acquired through the bite of an infected arthropod:

Malaria - caused by single-cell parasitic protozoa Plasmodium; transmitted to

humans via the bite of the female Anopheles mosquito; parasites multiply in

the liver attacking red blood cells resulting in cycles of fever, chills, and sweats

accompanied by anemia; death due to damage to vital organs and interruption

of blood supply to the brain; endemic in 100, mostly tropical, countries with

90% of cases and the majority of 1.5-2.5 million estimated annual deaths

occurring in sub-Saharan Africa.

Dengue fever - mosquito-borne (Aedes aegypti) viral disease associated with

urban environments; manifests as sudden onset of fever and severe headache;

occasionally produces shock and hemorrhage leading to death in 5% of cases.

10

Yellow fever - mosquito-borne viral disease; severity ranges from influenza-

like symptoms to severe hepatitis and hemorrhagic fever; occurs only in

tropical South America and sub-Saharan Africa, where most cases are reported;

fatality rate is less than 20%.

Japanese Encephalitis - mosquito-borne (Culex tritaeniorhynchus) viral

disease associated with rural areas in Asia; acute encephalitis can progress to

paralysis, coma, and death; fatality rates 30%.

African Trypanosomiasis - caused by the parasitic protozoa Trypanosoma;

transmitted to humans via the bite of bloodsucking Tsetse flies; infection leads

to malaise and irregular fevers and, in advanced cases when the parasites

invade the central nervous system, coma and death; endemic in 36 countries of

sub-Saharan Africa; cattle and wild animals act as reservoir hosts for the

parasites.

Cutaneous Leishmaniasis - caused by the parasitic protozoa leishmania;

transmitted to humans via the bite of sandflies; results in skin lesions that may

become chronic; endemic in 88 countries; 90% of cases occur in Iran,

Afghanistan, Syria, Saudi Arabia, Brazil, and Peru; wild and domesticated

animals as well as humans can act as reservoirs of infection.

11

Plague - bacterial disease transmitted by fleas normally associated with rats;

person-to-person airborne transmission also possible; recent plague epidemics

occurred in areas of Asia, Africa, and South America associated with rural

areas or small towns and villages; manifests as fever, headache, and painfully

swollen lymph nodes; disease progresses rapidly and without antibiotic

treatment leads to pneumonic form with a death rate in excess of 50%.

Crimean-Congo hemorrhagic fever - tick-borne viral disease; infection may

also result from exposure to infected animal blood or tissue; geographic

distribution includes Africa, Asia, the Middle East, and Eastern Europe; sudden

onset of fever, headache, and muscle aches followed by hemorrhaging in the

bowels, urine, nose, and gums; mortality rate is approximately 30%.

Rift Valley fever - viral disease affecting domesticated animals and humans;

transmission is by mosquito and other biting insects; infection may also occur

through handling of infected meat or contact with blood; geographic

distribution includes eastern and southern Africa where cattle and sheep are

raised; symptoms are generally mild with fever and some liver abnormalities,

but the disease may progress to hemorrhagic fever, encephalitis, or ocular

disease; fatality rates are low at about 1% of cases.

Chikungunya - mosquito-borne (Aedes aegypti) viral disease associated with

12

urban environments, similar to Dengue Fever; characterized by sudden onset

of fever, rash, and severe joint pain usually lasting 3-7 days, some cases result

in persistent arthritis.

water contact diseases acquired through swimming or wading in freshwater

lakes, streams, and rivers:

Leptospirosis - bacterial disease that affects animals and humans; infection

occurs through contact with water, food, or soil contaminated by animal urine;

symptoms include high fever, severe headache, vomiting, jaundice, and

diarrhea; untreated, the disease can result in kidney damage, liver failure,

meningitis, or respiratory distress; fatality rates are low but left untreated

recovery can take months.

Schistosomiasis - caused by parasitic trematode flatworm Schistosoma; fresh

water snails act as intermediate host and release larval form of parasite that

penetrates the skin of people exposed to contaminated water; worms mature

and reproduce in the blood vessels, liver, kidneys, and intestines releasing eggs,

which become trapped in tissues triggering an immune response; may manifest

as either urinary or intestinal disease resulting in decreased work or learning

capacity; mortality, while generally low, may occur in advanced cases usually

13

due to bladder cancer; endemic in 74 developing countries with 80% of infected

people living in sub-Saharan Africa; humans act as the reservoir for this

parasite.

aerosolized dust or soil contact disease acquired through inhalation of aerosols

contaminated with rodent urine:

Lassa fever - viral disease carried by rats of the genus Mastomys; endemic in

portions of West Africa; infection occurs through direct contact with or

consumption of food contaminated by rodent urine or fecal matter containing

virus particles; fatality rate can reach 50% in epidemic outbreaks.

respiratory disease acquired through close contact with an infectious person:

Meningococcal meningitis - bacterial disease causing an inflammation of the

lining of the brain and spinal cord; one of the most important bacterial

pathogens is Neisseria meningitidis because of its potential to cause epidemics;

symptoms include stiff neck, high fever, headaches, and vomiting; bacteria are

transmitted from person to person by respiratory droplets and facilitated by

close and prolonged contact resulting from crowded living conditions, often

with a seasonal distribution; death occurs in 5-15% of cases, typically within

24-48 hours of onset of symptoms; highest burden of meningococcal disease

occurs in the hyperendemic region of sub-Saharan Africa known as the

14

"Meningitis Belt" which stretches from Senegal east to Ethiopia.

animal contact disease acquired through direct contact with local animals:

Rabies - viral disease of mammals usually transmitted through the bite of an

infected animal, most commonly dogs; virus affects the central nervous system

causing brain alteration and death; symptoms initially are non-specific fever

and headache progressing to neurological symptoms; death occurs within days

of the onset of symptoms.

Shivakumar et al.,9 reported the study on etiology profile of fever, a study

carried out in Chennai during 2002 - 2003. Out of 195 diagnosed cases

tuberculosis formed 40% of cases, pneumonia 15.4%, meningitis and

malaria forming 12.8% each and leptospirosis forming 8.2%. The proportion

of undiagnosed cases was 46%.

Ruth D. Ellis et al.,10 studied to find out the etiological profile of fever in

the Thailand, which was carried out from 1999 to 2002. Etiologic diagnosis

was made in 48% cases. Malaria was the most common diagnosis accounting

for 25%, followed by leptospirosis, comprising about 17%. Other etiologic

diagnosis were intestinal infections, dengue fever and typhoid.

15

LITERATURE ON INDIVIDUAL FEVERS

MALARIA

PROBLEM STATEMENT

WORLD11

- 107 countries has areas of risk of malaria transmission.

- 3.2 billion people live in areas of risk of malaria transmission.

- 350 - 500 million malaria episodes occur annually.

- 1 million malaria deaths occur annually.

INDIA12

In 2006, there were 1.04 million vivax malaria cases and 0.46 million

falciparum cases reported in India. There were 890 deaths due to malaria.

MALARIAL SPECIES

There are four species of human malarial parasite i.e. Pl.vivax,

Pl.falciparum, Pl.malariae and P1.ovale. In India 60 - 65% of infections are

due to Pl.vivax and 35 to 45% are due to Plasmodium falciparum.

Antigenic diversity is present among different malarial parasites and

also within the species.

16

SEVERE MALARIA

Severe malaria is usually caused by Pl.falciparum but recently it has

been reported in Pl.vivax cases in Indian Subcontinent.

CLINICAL FEATURES

Uncomplicated malaria :

The clinical features of complicated malaria are common to all

species. Head ache, muscular ache, abdominal discomfort, lethargy and

lassitude often precede fever by about 2 days.

The fever in Plasmodium vivax and Plasmodium ovale regularises to

a two day cycle and in Plasmodium malaria to a 3 day cycle. The fever in

Pl.falciparum may never regularise to a classical tertian pattern.

DEFINITION OF SEVERE MALARIA BY WHO13

1. Renal failure : Sr.creatinine > 3 mgs / dl

Urine output < 400 ml / 24 hrs (or)

< 12 ml / hr

2. Severe Anaemia Hb% < 5 gms % (or)

Hct < 15%

3. Cerebral malaria : Unarousable coma with peripheral

parasitemia

17

4. Pulmonary Oedema or acute respiratory distress syndrome

5. Hypoglycemia : Blood sugar < 40 mg / dl

6. Shock - Systolic BP < 70 mm Hg (Adults)

< 50 mm Hg (Children - 1-5 yrs)

7. Acidemia - pH < 7.33, Hco3 < 15 mq / l

8. Spontaneous bleeding : Gums, Nose and GIT due to DIC

9. Macroscopic haemoglobinuria

10. Seizures > 3 episodes

11. Hyperparasitemia - More than 20%

12. Jaundice : Serum bilirubin > 3 mgs / dl is a marker of severe malaria,

only when combined with other vital organ dysfunction (i.e. cerebral

malaria and renal failure).

The 2000 WHO recommendation also include the following under

severe malaria.

1. Impairment of consciousness less marked than unarousable coma.

2. Prostration - Inability to sit unassisted in a child who is normally able

to do so. In a child not old enough to sit this is defined as inability to

feed.

18

STUDIES OF MALARIA

Bansode et al,14 conducted a prospective study of malaria at Bombay during

June 1993 to May 1994. All patients had fever, followed by head ache

(92%), vomitting (74%), cough (7%), diarrhoea (4.6%), icterus (3.8%) and

oliguria (1%) 70% were due to Plasmodium vivax and 30% due to

Pl.falciparum.

Madhu Muddaiah et al.,15 in mangalore in 2002 - 2004 studied the profile

of 190 admitted patients with smear positive malaria. Plasmodium vivax-

90, Plasmodium falciparum-71, mixed infections - 29. Jaundice occurred in

5 cases of vivax, 20 cases of falciparum and 3 cases of mixed infections.

Over all

28 (14.73%) had jaundice. Splenomegaly was seen in 30 (15.7%),

hepatosplenomegaly in 26 (13.6%), hepatomegaly in 8 (4.2%) and raised

serum creatinine in 14 (11.57%) cases.

Mohapatra et al.,16 from Berhampur has reported various atypical

presentation of malaria in their study of 110 cases of vivax malaria. They

were absence of malarial paroxysm (22.8%), migrainous head ache (4.5%),

myalgia (6.3%), episodic utricarial rash (1.8%), relative bradycardia

(13.6%) and postural hypotension (2.7%).

19

Chowta et al.,17 in 2003 studied 54 patients of both Plasmodium vivax

and Plasmodium falciparum and noted chloroquine resistance in 9(16%)

patients.

CHANGING TRENDS IN INDIA

The spectrum of severe falciparum malaria has changed world wide.

Currently a large proportion of cerebral malaria patients present with

multiple complications including acute renal failure and jaundice18.

Mohapatra et al.,16 in 2006 from Orissa observed that jaundice is an

important solitary complication. There were multiple complications and

majority had constellation of 3 complications. Cerebral malaria, jaundice

and renal failure (75.3%) were the most common combination. The mortality

rate was 14.6%, 21.3%, 30.9%, 38.5%, 100% and 100%, among patients

with 1, 2,

3, 4, 5 and 6 combinations respectively.

SEVERE VIVAX MALARIA

Pl.vivax is usually presumed to cause only uncomplicated malaria but

in the last few years there has been many reports regarding severe vivax

malaria. In a recent study from Bikaneer, Kochar et al.,19 reported 11 cases

20

of definite severe vivax malaria. In all these cases Plasmodium falciparum

infection was ruled out by PCR (polymerase chain reaction). All other

infectious causes were ruled out by appropriate tests. In this study the

manifestations observed were jaundice and hepatic dysfunction in four,

severe anaemia in four, cerebral malaria in three, ARDS in three, bleeding

diathesis in one and MODS (multi organ dysfunction syndrome) in five

patients. Recently in a monograph on treatment of malaria by WHO in 2006

the terminology of severe vivax malaria has been accepted seperately and it

had advocated the same regimen of treatment as for severe falciparum

malaria.

LEPTOSPIROSIS20

Epidemiology

It is caused by leptospira interrogans complex which has over 20

serogroups and more than 200 serovars. Rodents, domestic and wild animals

form the reservoir of infection, whereas domestic animals such as cattle,

dogs, pigs may act as carriers for several months (temporary carrier) and

rodents usually remain carrier through out life (permanent carrier).

1. Anicteric Leptospirosis

Presents with fever, head ache, body pain and biphasic illness. It has

abrupt onset with chills, rigor, fever, head ache and body pain. The most

21

characteristic finding on examination is severe myalgia and conjunctival

suffusion. A transient rash can occur. The septicemic phase subsides after 7

- 14 days. The second phase (immune phase) is characterized by severe

head ache and low grade fever lasting 4 - 30 days.

2. Icteric Leptospirosis

In some patients, the septicemic phase instead of subsiding progresses

to a severe icteric illness with renal failure. Some of the important clinical

features are as follows;

Kidneys : Renal involvement is the most serious complication and is

the commonest cause of death. Renal manifestations range from urinary

sediment changes (pyuria, haematuria and granular casts) to severe renal

failure. Renal manifestations are observed commonly in all forms of

leptospirosis regardless of the severity of disease or of the infecting sero -

group.

Liver : Jaundice is the most important clinical feature of severe illness.

Jaundice occurs between the fourth to sixth day but may occur as early as

the second day or as late as ninth day, deepens rapidly, reaching a peak

within a week. The liver is often enlarged and tender. Jaundice is mainly due

to hepatocellular damage. However, hepatocellular necrosis is usually mild

and additional factors include intrahepatic cholestasis and increased

22

bilirubin load from absorption of tissue haemorrhage. Marked elevation of

serum bilirubin with mildly elevated transaminases is characteristic. Death

is rarely due to hepatic failure.

DIAGNOSIS

Modified Faine's criteria is widely used to diagnose leptospirosis.

Faine's Criteria

Part A : Clinical

Data

Modified Faine's

Criteria Part A :

Clinical Data

Question Score Question Score

Headache 2 Headache 2

Fever 2 Fever 2

Temp > 39°C 2 Temp > 39°C 2

Conjunctival suffusion 4 Conjunctival suffusion 4

Meningism 4 Meningism 4

Muscle pain 4 Muscle pain 4

Conjunctival

suffusion Meningism

Muscle pain

10

Conjunctival suffusion

Meningism

Muscle pain

10

Jaundice 1 Jaundice 1

Albuminuria /

Nitrogen

Retention

2 Albuminuria

Retention / Nitrogen 2

Total score Total score

23

Part B:

Epidemiological

factors

Part B : Epidemiological

factors

Contact with animals

or

Rainfall

Contact with contaminated

environment

Animal contact

Tota

5

contact with known 10

4

1

10

contaminated water

Part C :

Bacteriological and

Lab Findings

Part C : Bacteriological

and Lab Findings

Isolation of leptospira

in

culture-Diagnosis

certain

Isolation of leptospira in

culture - Diagnosis certain

Positive Serology

(MAT)

Leptospirosis

Endemic

Positive Serology

Single positive-Low

titre 2

ELISA IgM positive

SAT - Positive

MAT - Single high titre

Rising titre (Paired sera)

15

Single positive-High

titre 10 15

Leptospirosis Non 15

Endemic

24

Single positive-Low

titre 5

Total (A+B+C)

Single positive-High

titre 15 25

Rising titre (Paired

sera) 25

Total (A+B+C)

Total score of more than 25 is considered to represent leptospiral

disease in modified Faine's criteria.

TREATMENT

Anicteric and milder forms of disease are treated with Doxycycline

while severe disease is treated with crystalline penicillin.

STUDIES ON LEPTOSPIROSIS

M.A.Muthusethupathi, S.Shivakumar21 studied the epidemiological and

clinical profile of leptospirosis patients admitted in Government General

Hospital, Chennai - 3, (1987 - 1995). Out of 206 patients most of them

presented during the monsoon months. The important clinical features noted

were :

25

a. Fever - 100%

b. Jaundice - 83%

c. Renal failure - 79%

d. Myalgia - 79%

e. Conjunctival Suffusion - 43%

f. CNS - 43%

g. Bleeding tendencies - 28%

Autumnalis was the most common serogroup noted then.

Overall icteric leptospirosis constituted the common group with

83% and mortality was 15.5%.

Sumathi G. et al.,22 reported the serodiagnosis results of leptospirosis

from 1995 - 1997, during which microscopic agglutination test revealed

that the predominant serovar to be autumnalis (48.3%) and ictero

haemorrhagiae (31.1%).

In 2006, Shivakumar S23 reported that severe leptospirosis has

declined, mild leptospirosis has increased. He reports that in a recent study

of 106 cases of leptospirosis from North Chennai, jaundice occurred in

17.8% and renal failure occurred in 10.3% showing a decline in

26

complication. Fever, head ache and myalgia were the common presentation.

Only 2 patients were dialysed and there were no deaths. Contaminated

environment (98%) and rainfall (50%) were the important epidemiological

risk factors.

Muthusethupathi et al.,24 studied the clinical and serological profile

in 57 patients. All had fever followed by jaundice (84%), mylagia (82%),

acute renal failure (72%) and conjunctival suffusion (58%). 23 cases

underwent dialysis. Autumnalis was the serogroup most commonly

recorded.

Lecour et al.,25 studied 50 cases of leptospirosis and reported renal

failure in 62%, aseptic meningitis in 24% with leptospira ictero

haemorrhagiae responsible for 78% of cases.

TUBERCULOSIS

PROBLEM STATEMENT26

WORLD

9 million cases occur world wide annually 54

million people are infected annually

2.4 million deaths occur annually

27

INDIA

- 20% of the total cases in the world.

- 1.8 million cases occur annually

- 30,000 patients become smear positive every year.

- Death rate is 100 - 200 / lakh / year.

- It is mostly prevalent in the productive age group of 25 - 45 yrs.

Even though TB is a major global health problem, there are only

a few studies about the pattern and profile of its presentation.

Samal et al.,27 analysed clinical features and evaluated

changing trends in 110 non - drug resistant sputum positive

pulmonary tuberuclosis between 1987 - 1989. Majority had

haemoptysis (60.7%), cough (47.06%) and fever (44.7%). Other

symptoms were hoarseness of voice and loss of weight. 18% had

clubbing and 3.5% had lymphadenopathy. Radiologically 98% had

fibro caseous lesions, cavity in 60% and bilateral opacities in 59%.

Dehankar et al.,28 studied X-ray changes in pulmonary

tuberculosis. 27% had bilateral lesions, 27% had right lower lobe

apical segment lesion, and 14% in basal segment. Lingula and whole

28

left lower lobe was less commonly involved. 41% was AFB positive

on smear examination.

PNEUMONIA

Community acquired pneumonia continues to be a common and

serious disease in both developed and developing countries.

Bansal .S et al.,29 studied the clinical and bacteriological profile of

community acquired pneumonia in a tertiary care hospital at Himachal

Pradesh. 70 patients were studied. Patients older than 40 years were

predisposed. Etiological diagnosis was obtained in 53(75%) cases. Among

that 19 cases of Streptococcus pneumoniae, 12 cases of Klebsiella

pneumoniae, 9 cases of Staphylococcus aureus, 8 cases of Mycoplasma

pneumonia and 6 cases of Escherichia coli were grown in culture.

CO-INFECTION OF MALARIA AND LEPTOSPIROSIS

In many parts of the world where both malaria and leptospirosis are

endemic co-infection with both malaria and leptospirosis is common. Ruth

D Ellis in a study in Bangkok from 1999 to 2003, reported 5.12% of

coinfection of malaria and serologically proven leptospirosis in a total of

613 cases10.

29

ENTERIC FEVER

Chowta MN et al.,30 in mangalore studied the clinical profile and

antibiotic response in typhoid fever from 1999 - 2001. In his study of 44

cases he noted ciprofloxacin resistance in 18.1% of cases. Yew et al.,31 in

his study of clinical profile of enteric fever reported splenomegaly in 47%.

BACTERIAL MENINGITIS

Pomeroy et al.,32 studied the clinical profile of meningitis and

reported seizures in 30% of cases.

CONTRIBUTIONS OF INFECTIONS IN INDIAN STUDIES ON

FUO

Study Sharma

(1992)7

Handa

(1994)33

Dhawan

(1994)34

Agarwal

(1998)35

Infection 50% 48% 81% 61%

DENGUE

Dengue is a mosquito-borne viral disease that has rapidly spread in all

regions of WHO in recent years. Dengue virus is transmitted by female

mosquitoes mainly of the species Aedes aegypti and, to a lesser extent, Ae.

albopictus. This mosquito also transmits chikungunya, yellow fever and Zika

30

infection. Dengue is widespread throughout the tropics, with local variations in

risk influenced by rainfall, temperature and unplanned rapid urbanization.

Severe dengue was first recognized in the 1950s during dengue epidemics in

the Philippines and Thailand. Today, severe dengue affects most Asian and

Latin American countries and has become a leading cause of hospitalization

and death among children and adults in these regions.

Dengue is caused by a virus of the Flaviviridae family and there are 4

distinct, but closely related, serotypes of the virus that cause dengue (DEN-1,

DEN-2, DEN-3 and DEN-4). Recovery from infection by one provides lifelong

immunity against that particular serotype. However, cross-immunity to the

other serotypes after recovery is only partial and temporary. Subsequent

infections (secondary infection) by other serotypes increase the risk of

developing severe dengue.

Global burden of dengue

The incidence of dengue has grown dramatically around the world in

recent decades. A vast majority of cases are asymptomatic and hence the actual

numbers of dengue cases are underreported and many cases are misclassified.

One estimate indicates 390 million dengue infections per year (95% credible

interval 284–528 million), of which 96 million (67–136 million) manifest

clinically (with any severity of disease).36 Another study, of the prevalence of

31

dengue, estimates that 3.9 billion people, in 128 countries, are at risk of

infection with dengue viruses.37

Member States in three WHO regions regularly report the annual number

of cases. The number of cases reported increased from 2.2 million in 2010 to

over 3.34 million in 2016. Although the full global burden of the disease is

uncertain, the initiation of activities to record all dengue cases partly explains

the sharp increase in the number of cases reported in recent years.

Other features of the disease include its epidemiological patterns, including

hyper-endemicity of multiple dengue virus serotypes in many countries and the

alarming impact on both human health and the global and national economies.

Dengue virus is transported from one place to another by infected travelers.

CLASSIFICATION

The WHO classifies DF into two groups: Uncomplicated and severe.

Severe cases are linked to excessive hemorrhage, organ impairement, or severe

plasma escape, and the remaining cases are considered uncomplicated.38

According to the 1997 classification, dengue can be divided into

undifferentiated fever, DF, and DHF.39 DHF was further subdivided into grades

I–IV.

Grade I: Only mild bruising or a positive tourniquet test

Grade II: Spontaneous bleeding into the skin and elsewhere

32

Grade III: Clinical sign of shock

Grade IV: Severe shock - feeble pulse, and blood pressure cannot be recorded.

Here, grades III and IV comprise DSS.

CLINICAL MANIFESTATIONS

Undifferentiated fever

This stage is seen mostly in the primary infection but may also occur following

the initial secondary infection. Clinically, it is difficult to differentiate from

numerous other viral diseases and often remains undiagnosed.

Dengue fever

DF follows both primary and secondary infections, and is most

frequently encountered in adults and older children. Onset of symptoms is

characterized by a biphasic, high-grade fever lasting for 3 days to 1 week. 38

Severe headache (mainly retrobulbar), lassitude, myalgia and painful joint,

metallic taste, apetite loss, diarrhea, vomiting, and stomachache are the other

reported manifestations. Dengue is also known as breakbone fever because of

the associated myalgia and pain in joints.39 Of patients with DF, 50–82% report

with a peculiar cutaneous rash.40 The initial rash is the result of capillary

dilatation, and presents as a transient facial flushing erythema, typically

occuring before or during the first 1–2 days of fever. The second rash is seen

33

at 3 days to 1 week following the fever, and presents as a asymptomatic

maculopapular or morbilliform eruption. Sometimes, individual lesions may

merge and present as widespread confluent erythematous areas with pinpoint

bleeding spots and rounded islands of sparing, giving a typical appearance of

“white islands in a sea of red.”41 The cutaneous rash is usually asymptomatic,

and pruritis is reported only in 16-27% cases.42 Bleeding episodes are

infrequently seen in DF, although epistaxis and gingival bleeding, substantial

menstruation, petechiae/purpura, and gastrointestinal tract (GIT) hemorrhage

can occur.43

Dengue hemorrhagic fever

DHF is frequently seen during a secondary dengue infection. However, in

infants it may also occur durring a primary infection due to maternally attained

dengue antibodies.44

The proposed diagnostic criteria for DHF includes:45

• a.Clinical parameters: Acute-onset febrile phase – high-grade fever

lasting from 2 days to 1 week. Hemorrhagic episodes (at least one of the

following forms): Petechiae, purpura, ecchymosis, epistaxis, gingival

and mucosal bleeding, GIT or injection site, hematemesis and/or malena

Positive tourniquet and hepatomegaly.

34

• b. Laboratory parameters: Thrombocytopenia (platelet count

<100,000/cu mm)

The hemorrhagic episodes in DHF are associated with multifactorial

pathogenesis. Vasculopathy, deficiency and dysfunction of platelets and

defects in the blood coagulation pathways are the attributed factors. Decreased

production of platelets and increased destruction of platelets may result in

thrombocytopenia in DHF. The impaired platelet function causes the blood

vessels to become fragile and this results in hemorrhage.46

The clinical course of DHF is characterized by three phases: Febrile,

leakage, and convalescent phase. High-grade fever of acute onset along with

constitutional signs and facial erythema characterizes the commencement of

the febrile illness. The initial febrile illness is marked by a morbilliform rash

and hemorrhagic tendencies. The fever persists for 2 days to 1 week and then

drops to normal or subnormal levels when the patient either convalesces or

advances to the plasma leakage phase. 47 High plasma escape cases are marked

by frank shock with low pulse pressure, cyanosis, hepatomegaly, pleural and

pericardial effusions, and ascites. Severe ecchymosis and gastrointestinal

bleeding followed by epistaxis may also be noted in a few cases. Bradycardia,

confluent petechial rashes, erythema, and pallor are seen during this phase.

35

Dengue shock syndrome

DSS is defined as DHF accompanied by a unstable pulse, narrow pulse

pressure (<20 mmHg), restlessness, cold, clammy skin, and circumoral

cyanosis. Progressively worsening shock, multiorgan damage, and

disseminated intravascular coagulation account for a high mortality rate

associated with DSS. The shock persists for a short span of time and the patient

promptly recovers with supportive therapy.48

Dengue hemorrhagic fever

At first, symptoms of DHF may be mild, but they gradually worsen

within a few days. As well as mild dengue symptoms, there may be signs of

internal bleeding.

A person with Dengue hemorrhagic fever may experience:

• bleeding from the mouth, gums, or nose

• clammy skin

• damage to lymph and blood vessels

• internal bleeding, which can lead to black vomit and feces, or stools

• a lower number of platelets in the blood

• sensitive stomach

• small blood spots under the skin

• weak pulse

36

Without prompt treatment, DHF can be fatal.

Dengue shock syndrome

DSS is a severe form of dengue. It can be fatal.

Apart from symptoms of mild dengue fever, the person may experience:

• intense stomach pain

• disorientation

• sudden hypotension, or a fast drop in blood pressure

• heavy bleeding

• regular vomiting

• blood vessels leaking fluid

Without treatment, this can result in death.

37

MATERIALS AND METHODS

STUDY DESIGN: A PROSPECTIVE QUESTIONNAIRE BASED

OBSERVATIONAL STUDY

B. STUDY PLACE :DEPARTMENT OF MEDICINE, THANJAVUR

MEDICAL COLLEGE THANJAVUR.

C. STUDY PERIOD: JANUARY 2018- DECEMBER 2018

D. STUDY INSTRUMENTS

A. A predesigned, pretested, semi structured questionnaire. Containing items

on

a) Identification data i.e. age, gender , educational status, area of residence,

socio- economic status of study subjects

Patients getting admitted to medical wards of Government Thabjavur

Medical College and Hospital, Chennai, with fever and satisfying the below

criteria were taken up for study. Patients of age group more than 12 years,

both male and female were included.

INCLUSION CRITERIA

I. The following patients were included with number of days of fever less

than 5 days and temperature >40°C or following complications

38

a. With altered sensorium, seizures, signs of meningitis.

b. Clinical signs suggestive of pneumonic consolidation.

c. Signs suggestive of pleural effusion.

d. Polyarthralgia

e. Rash

f. Purpura / ecchymoses

g. Oliguria or serum creatinine > 1.5 mg/dl

h. Jaundice or serum total bilirubin > 1.5 mg/dl

II. Fever of more than 5 days with or without organ dysfunction

EXCLUSION CRITERIA

1. HIV seropositivity

2. Non - infectious causes of fever like hematological malignancy.

connective tissue disorders and solid tumours were excluded from

the study.

39

THE FOLLOWING DATA WERE ANALYSED

PROFORMA

Name : Age : Sex : I.P.

No : Occupation and address :

1. SYMPTOMATOLOGY

FEVER

* Duration, pattern

* Rigors

* Other associated factors

RESPIRATORY SYSTEM

* Cough with expectoration

* Chest pain, hemoptysis

* Wheeze

CARDIOVASCULAR SYSTEM

* Chest pain, breathlessness

* Palpitations, syncope

ABDOMEN

* Nausea, vomiting, abdominal pain

* Loose stools, constipation

* Abdominal distension

40

* Jaundice

GENITOURINARY TRACT

* High coloured urine / hematuria

* Burning micturition

* Decreased urine output

NERVOUS SYSTEM

* Altered sensorium, head ache

* Seizures, motor weakness

* Cranial nerve symptoms

* Symptoms of in co-ordination

LOCOMOTOR SYSTEM

* Joint swelling / pain

* Muscle pain, back ache

SKIN / MUCOSA

* Rashes, purpuric spots, ecchymosis

* Vesications

* Oral mucosal lesions

EAR

* Ear ache / discharge

41

OTHERS

* Loss of appetite and weight

* Sore throat, neck swelling

* Leg swelling

PAST ILLNESS

* H/o. TB, DM, Rheumatic fever, Rheumatic heart

disease, seizure disorder, sexually transmitted disease.

* H/o jaundice, blood transfusion

* H/o drugs, previous surgeries

PERSONAL HISTORY

* Smoking, alcohol, drug addiction

* Exposure (high risk behaviour)

FAMILY HISTORY

* H/o jaundice, tuberculosis

VITAL SIGNS

* Pulse

* Blood Pressure

* Temperature pattern

* Respiratory rate

42

2. GENERAL EXAMINATION

* Level of consciousness

* Temperature, hydration

* Clubbing, lymphadenopathy

* Rashes / petechiae / ecchymosis

* Pedal edema, arthritis

* Bony tenderness, spine tenderness

EXAMINATION OF

* Cardiovascular system

* Respiratory system

* Abdomen

* Nervous system

INVESTIGATIONS

* Blood : TC, DC, Hb%, PCV, ESR, Platelets

* Peripheral smear, cytology and parasites

* Blood urea, sugar

* Liver function test

* Blood culture and sensitivity

* ECG in all leads

* X-ray chest : PA view

* USG - abdomen

43

* Urine - albumin, sugar, deposits

* Urine - culture and

sensitivity If fever is >1 week

* Blood Widal

* Serology for Leptospirosis

* ELISA for HIV

In relevant cases, the following investigations were done :

* Sputum AFB, sputum culture and sensitivity, pleural

fluid analysis

* Mantoux test

* Smear / QBC for malarial parasite

* CSF analysis

* Bone marrow study

* CT scan : Brain, chest, abdomen etc

* Lymph node : FNAC / Biopsy

* ANA, RF

44

DIAGNOSTIC CRITERIA

1. Tuberculosis

Patient was diagnosed to have pulmonary tuberculosis if any of the

following criteria is satisfied.

* 2 initial sputum smear examination positive for AFB.

* Sputum smear examination positive for AFB and radiological

abnormalities consistent with active pulmonary tuberculosis.

* Symptoms suggestive of TB with atleast 3 sputum examination

negative for AFB and radiological abnormalities consistent with

active pulmonary tuberculosis.

Extrampulmonary tuberculosis was diagnosed based on one culture

positive specimen from the extrapulmonary site (or) histological evidence

(or) strong clinical evidence consistent with active extrapulmonary TB.

2. Pneumonia was diagnosed based on clinical features, radiological

findings, positive gram stain and sputum culture.

3. Meningitis was diagnosed based on clinical features, cytology, gram

stain and culture of CSF, CSF - AFB and biochemistry.

4. Malaria was diagnosed based on clinical features, peripheral smear

and quantitative buffy coat.

45

5. Leptospirosis was diagnosed based on clinical features, MSAT

(macroscopic slide agglutination test) with a 2+ (or) 3+ positivity with

modified Faine's score more than 25.

6. Enteric fever was diagnosed with WIDAL test, using a cut-off of

> 1/200 for O/H agglutinin titres, (or) a positive blood culture.

7. Rheumatic fever was diagnosed based on Modified Jones Criteria.

8. Infective endocarditis was diagnosed based on Duke's Criteria.

9. Liver abscess was diagnosed based on clinical features and

ultrasonography.

10. Chikungunya fever was diagnosed by symptoms of fever with

polyarthralgia during the epidemic.

11. Urinary tract infection was diagnosed based on symptoms and

positive urine culture.

12. Other diseases were clinically diagnosed and confirmed by

appropriate biochemical and radiological investigations.

46

STATISTICAL ANALYSIS

The collected data was entered in MS-Excel and was analyzed and

statistically evaluated using SPSS-17 version.

Quantitative data was expressed by mean and standard deviation and

qualitative data was expressed by the percentages and difference between the

proportions was observed by chi square test or Fischer exact test.

p< 0.05 was considered significant.

ETHICAL CONSIDERATIONS

1. The protocol of the thesis was approved by the ethical committee of

Thanjavur Medical College in December 2017.

2. Informed written consent was taken from all study subjects. No pressure

coercion was exerted on subjects for participation in the study.

3. Confidentiality and privacy was ensured at all stages

The subject was free to leave the study at any time and no questions were

asked. They were not be debarred from getting any medical services similar to

the participants.m

47

RESULTS AND OBSERVATIONS

Total number of Cases : 100

Diagnosed Cases : 100

The results of the study are analysed according to etiology, duration

of fever, age and gender distribution.

TABLE - 1

ETIOLOGY OF FEVER

Sl.No. Diseases No. Percentage

1. Malaria 6 6

2 Dengue 32 32

2. Leptospirosis 02 2

3. Tuberculosis 12 12

4. Pneumonia 9 9

5. Malaria & Dengue 4 4

6. Scrub typhus 4 4

7. Liver abscess 2 2

8. Urinary tract infection 14 14

9. Enteric fever 5 5

10. Dengue & Scrub typhus 3 3

11. Bacterial meningitis 4 4

12. Influenza 3 3

Total 100 100%

48

Malaria formed the largest group contributing to 27.2% of cases,

followed by leptospirosis (16.8%), tuberculosis (14.4%) and

pneumonia (8.2%).

Fig 1: Etiology of fever among my study subjects

6, 6%

32, 32%

2, 2%12, 12%9, 9%4, 4%

4, 4%2, 2%

14, 14%

5, 5%

3, 3%

4, 4%3, 3%

Etiology

Malaria

Dengue

Leptospirosis

Tuberculosis

Pneumonia

Malaria & Dengue

Scrub typhus

Liver abscess

Urinary tract infection

Enteric fever

Dengue & Scrub typhus

Bacterial meningitis

Influenza

49

TABLE - 2

GENDER WISE DISTRIBUTION

Sl.No Disease Male Female Total

1. Malaria 2 4 6

2. Dengue 12 20 32

3. Leptospirosis 0 02 02

4. Tuberculosis 5 7 12

5. Pneumonia 6 3 9

6. Malaria & Dengue 1 3 4

7. Scrub typhus 2 2 4

8. Liver abscess 2 0 2

9. Urinary tract infection 5 9 14

10. Enteric fever 3 2 5

11. Dengue & Scrub typhus 2 1 3

12. Bacterial meningitis 2 2 4

13. Influenza 1 2 3

Total 43 57 100

Females were more than males forming 57% of cases.

50

TABLE - 3

AGE WISE DISTRIBUTION IN FEVER CASES

Sl.No. Disease Age in Years

14-20 21-40 41-60 >60

1. Malaria 0 2 4 0 6

2. Dengue 6 15 9 2 32


4. Tuberculosis 1 2 9 12

5. Pneumonia 1 3 5 9

6. Malaria & Dengue 1 3 0 4


8. Liver abscess 1 1 2

9. Urinary tract

infection 1 4 5 4 14

10. Enteric fever 1 1 3 5

11. Dengue & Scrub

typhus 3 3

12. Bacterial

meningitis 2 2 4

13. Influenza 3 0 0 0 3

Total 13 35 45 7

Age group of 41-60 constituted the most common age group

in our study forming about 42% of total cases studied.

51

TABLE - 4

FEVER DURATION AND DISEASE DISTRIBUTION

Sl.

No. Disease

<5

days

5-10

days

11-30

days

>30

days Total

1. Malaria 3 2 1 0 6

2. Dengue 3 27 2 0 32

3. Leptospirosis 0 2 0 02

4. Tuberculosis 9 3 0 12

5. Pneumonia 3 4 2 0 9

6. Malaria &

Dengue

3 1 0 4


8. Liver abscess 0 2 0 2

9. Urinary tract

infection

3 10 1 0 14

10. Enteric fever 5 0 5

11. Dengue & Scrub

typhus

3 3

12. Bacterial

meningitis

2 2 0 4

13. Influenza 2 1 0 3

Tota

l

14 70 16 0

Most cases were admitted with fever durations of 5 - 10 days, forming

70% of cases.

52

MALARIA

- 50% had fever less than 5 days

- 33% were male

- 33% were within 40 yrs. of age

- Total cases : 6

Plasmodium vivax: 4 cases

Plasmodium falciparum : 2

cases

Survived : 6 cases

Died : 0 cases

53

TABLE - 5

MALARIA - SYMPTOMATOLOGY

S.

No. Malaria Total=6

1. Chills & rigor 5

2. Head ache 6

3. Vomiting 4

4. Jaundice 3

5. Loss of consciousness 1

6. Seizures 1

7. Oliguria 0

8. Splenomegaly 2

9. Hepatosplenomegaly 3

Head ache and vomitting were most common symptoms along with

fever.

54

Fig 2: Distribution of symptoms of malaria

TABLE - 6

JAUNDICE IN MALARIA

Sr. Bilirubin

(mg/dl) PV PF Total

1.5 - 3 2 1 3

> 3 2 2

Jaundice occurred in 83.33% (5 out of 6) cases of malaria.

vivax species contributrd for 66.6% of jaundice cases

5

6

4

3

1

1

0

2

3

Malaria Symptoms

Chills & rigor

Head ache

Vomiting

Jaundice

Loss of consciousness

Seizures

Oliguria

Splenomegaly

Hepatosplenomegaly

55

TABLE - 7

RENAL FAILURE IN MALARIA

Sr. Creatinine

(mg/dl) P.V PF Total

1.5 - 3 2 0 2

> 3 1 0 1

No patients were dialysed

Renal failure occurred in 50% cases of vivax malaria.

LEPTOSPIROSIS

2% of total cases studied

- Females constituted 100%

- 50% were in age group of 21 - 40 years

- Everyone had fever of more than 10 days

-

56

TABLE - 8

LEPTOSPIROSIS - SYMPTOMATOLOGY

Symptom Total Male Female

Myalgia - 1

Conj. Suffusion - 1

Jaundice -

Oliguria -

Myalgia and conjunctival suffusion were the most common

symptoms along with fever.

TABLE – 9

LEPTOSPIROSIS - TOTAL BILIRUBIN

Sr. Bilirubin

(mg/dl)

No. of

cases

1.5 - 3 1

> 3.0 0

Total 1 (50%)

About 50% of leptospirosis patients had icteric hepatitis.

57

TABLE - 10

LEPTOSPIROSIS – CREATININE

Sr.Creatinine

(mg/dl)

No. of

cases

1.5 - 3 0

> 3.0 0

Total

No cases of leptospirosis had renal failure TUBERCULOSIS

- 12% of cases contributed for Tb

- 75% had fever for less than 30 days

- 58.3% were females and 75% belongs to 41-60 age group

TABLE - 11

ORGAN WISE DISTRIBUTION AMONG

TUBERCULOSIS PATIENTS

Organ M F Total

Pulmonary 3 4 7 (58.4)

Pleural.effussion 2 2 4

Lymphadenitis 0 1 1

5 7 12

58.3% of the cases were pulmonary tuberculosis among total tuberculosis

cases.

58

Fig 3: Distribution of patterns of tuberculosis

TABLE - 12

PULMONARY TUBERCULOSIS : SPUTUM STATUS

N=7 %

Sputum +ve for AFB 5 71

Sputum -ve for AFB 2 29

Sputum positivity was found in 71% of pulmonary tuberculosis patients.

0

10

20

30

40

50

60

Pulmonary Pleural.effussion Lymphadenitis

74

1

58.4

33.3

8.3

N

%

59

Fig 4: Distribution of sputum for AFB in my study subjects

TABLE - 13

PULMONARY TUBERCULOSIS - SYMPTOMATOLOGY

Symptom Total (7)

Cough with sputum 6

Breathlessness 3

Loss of weight and loss of

appetite 4

Haemoptysis 2

Sputum production was present in 85.8% of pulmonary

tuberculosis patients.

5

2

sputum for AFB

Positive

Negative

60

Fig 5: Distribution of symptoms of pulmonary tuberculosis

TABLE - 14

SIGNS - CREPITATIONS

Lobe No. Percenta

ge

Unilateral upper

lobe 8 66.6

Bilateral upper

lobe 3 25

Lower lobe 1 8.3

Total

Unilateral upper lobe crepitations were common.

0

10

20

30

40

50

60

70

80

90

Cough with

sputum

Breathlessness Loss of weight

and loss of

appetite

Haemoptysis

63 4 2

85.7

50

57.1

28.5

Number

Percent

61

TABLE - 15

REGION OF OPACITIES / CAVATIES IN CHEST - X-RAY

IN PULMONARY TUBERCULOSIS

Site No

Bilateral apical opacity 2

Bilateral lower zone opacity 2

Right upper zone opacity 4

Left upper zone opacity 1

Right upper zone cavity 1

Right lower zone opacity 1

Left lower zone cavity 0

Left lower zone opacity 1

Bilateral extensive opacity 0

Bilateral cavity 0

Right upper zone opacity was the most common lesion

constituting about 18%.

EXTRAPULMONARY TUBERCULOSIS

TUBERCULOUS PLEURAL EFFUSION

Total cases = 4

50% were males

62

TABLE - 16

SYMPTOMATOLOGY IN TUBERCULOUS PLEURAL

EFFUSION

Symptoms No (%)

Cough with sputum 2 (50)

Loss of weight and

appetite 3 (75%)

Chest pain 1 (25)

Loss of weight and appetite were the most common symptoms

occurring in 75% of the cases.

TUBERCULOUS LYMPHADENITIS

1 Cases

- Had cervical lymphadenopathy with low grade fever

PNEUMONIA

Total Cases – 9

66, 6% were male

44.4% had fever for 5- 10 days

55.5% were in age group 40 - 60 years

63

TABLE - 17

PNEUMONIA - SYMPTOMATOLOGY

S.No. Symptom No (%)

1. Fever 8

2. Cough with sputum 8

3. Breathlessness 7

4. Chest pain 4

5. Haemoptysis 5

Fever with cough and sputum were present in 88% of cases of pneumonia.

Fig 6: Vertical bar diagram showing Distribution of symptoms of

pneumonia

0

10

20

30

40

50

60

70

80

90

Number

Percent

64

TABLE - 18

PNEUMONIA - BACTERIOLOGICAL PROFILE

Sl.No. Organism No. (%)

1. K.pneumoniae 2 (22.2)

2. S.pneumonia 5(55.5)

3. E.Coli 1 (11.1)

4. S.aureus 1 (11.1)

Total 9

S. Pneumonia was the most common organism isolated constituting about

55.5% of isolates.

Fig 7: Distribution of bacteriological profile of pneumonia

2

5

1

1

Organism

K.pneumoniae

S.pneumonia

E.Coli

S.aureus

65

TABLE - 19

RADIOLOGICAL PROFILE IN PNEUMONIA CASES

Lung zone

Unilateral

Bilateral

Total Right Left

Upper zone 2 1 3 6

Lower zone 4 1 5 10

Mid zone 1 0 1 2

Lower zone was the most common site of opacity in pneumonia

constituting 55% of cases.

DENGUE

- Total Cases - 32

- Fever less than 5 days - 12 cases (84%)

- All had high grade fever

- 62.5% were Female

66

TABLE - 20

DENGUE SYMPTOMATOLOGY

Symptom No

Fever 32

Joint Pain 32

Rash 7

Pedal edema 2

Puffiness of face 1

Headache 17

Retroorbital pain 15

Myalgia 12

Fever & Join pain was notable feature occurring in almost all

casesof cases.

No organ dysfunction was noted in dengue cases.

67

Fig 8: Vertical Bar diagram showing Distribution of symptoms

of dengue fever

0

10

20

30

40

50

60

70

80

90

100

32 32

7

2 1

1715

12

100 100

22

6.23.1

53

47

38 Numer

Percentage

68

TABLE - 21

DENGUE- JOINT INVOLVEMENT

Joint No (%)

Knee Joint 26 (65)

Ankle Joint 8 (20)

Wrist Joint 14 (35)

Small joints of hand 6 (15)

Small joints of foot 8 (20)

Knee joint was the most common joint

involved. Dengue NS 1 was positive in 17

cases.

0

10

20

30

40

50

60

70

Knee Joint Ankle Joint Wrist Joint Small joints

of hand

Small joints

of foot

26

8

14

68

65

20

35

15

20

Number

Percent

69

LIVER ABSCESS

- Total Cases – 2

- Solitary abscess was present in 50% cases

- All of them had uncomplicated course

- 50% cases were managed conservatively and in 50% ultrasound

guided aspiration of the fluid was done.


- Total Cases - 4

- Males were 50%

- 50% had fever 5 to 10 days

- All had meningeal signs

- 1 patient had features of raised intracranial tension

URINARY TRACT INFECTION

- Total Cases - 14

- 64% were females

- 50% had E.coli and 50% had klebsiella grown in culture

- Most common group was 20 - 40 yrs.

- All of them responded to ciprofloxacin and cefotaxim.

70

SCRUB TYPHUS FEVER

- Total Cases - 4

- Most of them were in age group of 41-60

- All of them had fever with rash

ORGAN DYSFUNCTION IN FEVER CASES

TABLE - 22

JAUNDICE: 5 CASES

Sl.No

.

Disease Total Bilirubin

1.5-3

mg/dl > 3mg/dl Total


2. Malaria 2 2 4

3. Dengue 0 0 0


Total 4 0 5

Leptospirosis and malaria was the most common cause of

fever with jaundice. Malaria constituting 80% of cases.

71

TABLE 23

RENAL FAILURE (N=3)

Sl.No. Disease Total Creatinine

1.5-3

mg/dl > 3mg/dl Total


2. Malaria 2 1 3

3. Dengue 0 0 0


Total 2 1 3

All the cases of renal failure were reported to be associated with malaria

TALE 24

MORTALITY - TOTAL MORTALITY 3 CASES (40%)

Sl.No. Diseases No. Percentage

1. Malaria 0 6

2 Dengue 3 32 93.8%

2. Leptospirosis 0 02

3. Tuberculosis 0 12

4. Pneumonia 00 9

5. Malaria & Dengue 0 4

6. Scrub typhus 000 4

7. Liver abscess 0 2

72

8. Urinary tract infection 0 14

9. AGE 0 5

10. Dengue & Scrub typhus 0 3

11. Bacterial meningitis 0 4

12. Influenza 0 3

Total 100 100%

Dengue was the most common cause of mortality constituting for all.

73

DISCUSSION

100 patients, both male and female fulfilled the entry criteria and were

included in the study. The patients were clinically examined and investigated

following which all cases were diagnosed. However fever subsided in most

undiagnosed cases after empiric antimalarial and antibiotic therapy.

Among the total cases dengue was the major contributor forming 32%

of cases, followed by UTI 12% and tuberculosis (12%). Pneumonia formed

9%, co-infection with malaria and dengue formed 4%, liver abscess - 2%,

malaria 6%, enteric fever - 1%, scrup typhus - 4%, influenza - 3% and

bacterial meningitis - 4% (Table - 1).

74

COMPARISION WITH OTHER STUDIES OF INFECTIOUS FEVERS

Similar study on clinical profile of infections fevers was carried out in

Chennai in which there were more undiagnosed fevers9.

The increased numbers of diagnosed cases in the present study (100%)

in comparsion to previous study (54%) is probably due to increased

diagnostic facilities

Among the diagnosed cases number of malaria cases diagnosed in

present study was 6% while it was 12.8% in the previous study. The incidence

of malaria is due to use of peripheral smear and quantitative buffy coat method

which was carried out at malaria laboratory of Chennai Corporation..

Leptospirosis is diagnosed in the present study was 2% less than the

previous study (8.2%) due to awareness of the disease and picking up of

anicteric leptospirosis and increased diagnostic facilities for doing slide

agglutination test.

Scrub typhus fever which was not present in the previous study was

picked up in the present study due to the wide spread epidemic which

occurred from July 2018 - December 2018.

The incidence of other causes of fever are more or less the same.

A similar study on etiological profile of fever was carried out in

Thailand between 1999 - 2002, the results of which are similar to our study.

Malaria constituted 25% of diagnosed cases in their study, whereas in our

75

study it was 31%; leptospirosis was about 17%, in our study it constituted

19% of cases10.

MALARIA

Malaria was contributing for 6% of the total cases studied, which

amounted to 6 cases. Plasmodium vivax occurred in 4 (67%) cases,

Plasmodium falciparum occurred in 2(33%) cases and mixed infection is

nil. Hazara et al.,49 from calcutta has reported 73.3% PV and 26.7% PF in

their study of 225 cases. Tamil Nadu is in low risk category with regard to

Plasmodium falciparum infection.

CLINICAL FEATURES

In malaria, all 6 (100%) patients had fever. Typical paroxysms

occurred in very few patients. Fever was associated in 83% cases with chills,

in 83% head ache was severe and consistently associated with fever (Table

- 5). Mohapatra et al.,16 from Orissa reported migrainous head ache of 4.5%

in a study of 110 cases of vivax malaria.

CEREBRAL MALARIA

Cerebral malaria was a not a common complication noted in our study.

Omly 2 patients (33.3%) had neurological dysfunction in the form of altered

76

sensorium, loss of consciousness and generalized convulsions. 1 patients

(16%) had loss of consciousness. 1 (16%) had convulsions. (Table-5) .

Kochar50 reported generalised convulsion in 21.31% of 441 cases of cerebral

malaria from Rajasthan. 3 patients died of cerebral malaria all of which were

caused by Pl.vivax. Cerebral malaria was associated with DIC in one case

and one case was associated with jaumidce.

JAUNDICE

Jaundice occurred in 5(83%) cases when the serum bilirubin cut off of

more than 1.5 was taken. As per WHO criteria serum bilirubin of more than

3 mg% occurred in 2 cases (33%) (Table - 6). Bilirubinemia was

predominantly direct, with only slight elevation of transaminases.

It occurred in 26.6% cases of falciparum malaria and 8.33% cases of

vivax malaria. Hazara et al.,49 reported jaundice in 9.09% of PV cases and

40% of PF cases. Harris VK et al., from South India reported 37% of

jaundice in PF cases50. Kochar et al., from Rajasthan has reported jaundice

in 58.85% of PF cases in 200151.

RENAL FAILURE

Acute renal failure occurred in 3 (50%) cases. As per WHO criteria

severe renal failure occurred only in 1 (16) % of cases and all the cases were

77

due to PV (Table - 7). In our study it has been found that renal failure also

occurs in PV in significant numbers. This has been proved by kochar in his

study of 11 cases of complicated vivax malaria by documenting the presence

of PV and absence of PF by PCR study19. No patient was dialysed in our

study. In India reported incidence of ARF in Malaria is 17.8% from Delhi,

17.2% from Orissa, 13% from North East India and 5.9% from Mumbai52.

Madhu Muddaiah from Mangalore reported renal failure in 11.57% of

190 cases studied in 2002 - 200415.

TREATMENT

Cases of plasmodium vivax malaria with organ dysfunction like

jaundice, renal failure and cerebral malaria was treated with quinine and

other cases were treated with chloroquine. Among the cases treated with

chloroquine 1 (16%) showed chloroquine resistance while Chowta et al.,17

noted chloroquine resistance in 16% of the cases.

MORTALITY

There were no deaths in malaria.

78

LEPTOSPIROSIS

Leptospirosis contributed to 2% of total cases studied. All were

females 100%. Majority were in the age group of 21 - 40 years. Anicteric

leptospirosis was about 50% while icteric leptospirosis formed 50% of cases.

All of them were diagnosed using macroscopic slide agglutination > 2+

along with modified Faine's score of more than 25. Duration of fever was

more than 5 days in 80% cases.

In our study no patients had renal failure while it was 79%

(Muthusethupathi et al.,)54 and 49% (Edward et al.,)53 in other studies.

The decreased renal failure in present study is probably due to decreased

prevalence of serogroup autumnalis.

50% of patients had bilirubin of >1.5 mg/dl while it was 83%

(Muthusethupathi et al.,)54 95% (Edward et al.,)53 and 28% (Gendron

et al.,)55 in other studies.

All patients recovered with doxycycline and patients who had

complication was treated with crystalline penicillin. No mortality in

leptospirosis.

CO-INFECTION OF MALARIA AND DENGUE

A total of 4(4%) patients had co-infection with both malaria and

dengue. Similar study on fever profile conducted in Thailand showed a co-

79

infection of 5.5%10. An important observation was that of co- infection

patients had jaundice and renal failure.

TUBERCULOSIS

Tuberculosis was the third major contributor in our study constituting

12% of cases.

* 75% had fever for 5-10 days

* 41.7% were males and 58.3% females

* Pulmonary tuberculosis contributed 58.3% cases with

extrapulmonary TB forming 42.7% cases.

The contribution of tuberculosis was 54% (Sharma et al.,)7, 45%

(Agarwal)35 and 54% (Dhawan et al.,)34 in other studies.

PULMONARY TUBERCULOSIS

* Total - 7 cases

* Males constituted 43% and females 57%.

Among pulmonary tuberculosis, other symptoms along with fever was

sputum which was present in 6 cases (85.88%). Samal et al.,27 reported

cough with expectoration in 92.7% of pulmonary tuberculosis cases.

Haemoptysis was present in 25.5% while Samal et al.,27 reported in 20.3%

cases. Breathlessness was a complaint in 70.2% cases (Table - 13).

80

The most common radiological finding was unilateral upper zone

opacity (66.6%), while Samal et al.,27 most commonly reported bilateral

scattered opacities in all zones in 77.5% cases.

Sputum AFB positivity was present in 41.6% of cases while

Dehankar et al.,28 reported sputum positivity in 42.34%.

EXTRAPULMONARY TUBERCULOSIS

Tuberculous pleural effusion formed 33.3% of tuberculosis cases.

Most (50%) were male. Fever duration in maximum number of patients

between 5-10. Majority of them (56.25%) were in age group of 20 - 40 years.

Next to fever chest pain was the most common symptom.

The other groups of extra pulmonary TB which constituted a minority

was 1 cases of TB lymphadenopathy.

PNEUMONIA

Pneumonia formed significant number of cases in our study. It

constituted about 9% (9 cases). Majority (66.6%) were male. Majority had

fever of 5 - 10 days (44.4%).

Etiological diagnosis was obtained in 68.2% while Bansal et al.,

obtained etiological diagnosis in 75% of cases29.

81

Patients older than 40 years were more predisposed as in the study by

Bansal et al29. Cough with expectoration was present in 100% while

Narendra et al.,43 reported cough in 97.6%. In our study 77% had

breathlessness 44.4% had chest pain (Table - 17). Most of the organisms

isolated from the present study was s.pneumoniae and sensitive to

ciprofloxacin and gentamycin (Table - 18). Similar to study done in North

American studies44 in which S.pneumoniae was most common.

DENGUE

32% of cases in our study were due to Dengue fever. All of them had

polyarthralgia with majority involving the knee joint (81%) and small

joints of the hand (19%) (Table -21). Majority (84%) had fever less than 5

days duration. Headache 53.1% and retroorbital pain 47% were next most

common symptom followed by rash and myalgia. In the cases fever subsided

with antipyretics though there was prolonged joint pain.

LIVER ABSCESS

Liver abscess formed 2% of total cases. Most (75%) had fever of 5-

10 days; with females forming all cases. 50% were in the age group of 20 -

40 years.

82

Abdominal pain (100%) was the most common symptom along with

fever. Diagnosis was confirmed by ultrasonography.

50% cases was managed conservatively while 50% of cases were

aspirated with ultrasonogram guidance.

URINARY TRACT INFECTION

UTI formed 14% of total cases. Diagnosis was based on

symptomatology and urine culture. 60% were females. E.coli (50%) was the

most common organism and none of them had complications.

SCRUB TYPHUS FEVER

Scrub typhus formed 4% of cases.50% were males and all were more

than 40 years old.

ENTERIC FEVER

Enteric fever was present in 5% of cases all had fever more than 5

days. 80% were female. Along with fever headache, vomiting and diffuse

abdominal pain, splenomegaly was present in 40% of cases. Blood widal

was positive in 100% of cases.

40% of patients responded to ciprofloxacin, while 60% of patients

who did not respond to ciprofloxacin was treated with ceftriaxione. 1 had

83

(20%) elevated creatinine at admission which recovered after treatment.


Bacterial meningitis cases were 4 (4%) in our study. 2 (50%) had

altered sensorium and none had seizures, while seizures was reported in 30%

by Pomeroy et al.,32 100% had neck stiffness and Kernigs Sign. 1 had

bilateral sixth nerve palsy. CSF examination showed predominant

polymorphs and Gram stain was negative in all the three. All had low sugar

and high protein and showed clinical improvement when cefotaxim 2 gm

was used.

ORGAN DYSFUNCTION IN FEVER CASES JAUNDICE

Of the total patients studied 3 patients (3%) had raised bilirubin of >1.5

mg %. Of these 2% (2 cases) had bilirubin >3 mg%. Of the total leptospirosis

constituted 20% of cases , and malaria 80% of cases (Table - 22).

84

RENAL FAILURE

Renal failure with creatinine >1.5 mg/dl was present in 75% (2 cases),

of which severe renal failure with creatinine >3 mg/dl was present in 25%

of total renal failure cases. Of the total renal failure cases was constituted by

malaria (Table - 17).

MORTALITY

The overall mortality is 3 cases of 100 cases, the most common cause

is dengue constituting for all deaths.

85

SUMMARY

1. 100 patients were analysed, 43% were males and 57% were females.

2. Etiology of febrile illness could be diagnosed in all cases.

3. The common causes of infectious fever were dengue (32%), folloed

by Urinary tract infection 14%, tuberculosis (12%) malaria (6%),

leptospirosis (2%and pneumonia (9%). Other causes were bacterial

meningitis 4% , influenza 3%, liver abscess (2%), scrub typhus (4%)

and enteric fever (5%).

4. Age group of 41-60 constituted the most common age group in our

study forming about 42% of total cases studied.

5. Most cases were admitted with fever durations of 5 - 10 days, forming

70% of cases.

6. Fever & Join pain was notable feature occurring in almost all cases

of cases.

7. No organ dysfunction was noted in dengue cases.

8. Knee joint was the most common joint involved.

9. Dengue NS 1 was positive in 17 cases.

10. Plasmodium vivax formed 67% of malaria cases while plasmodium

falciparum occured in 33%. Head ache and vomitting were most

common symptoms along with fever.

86

11. Common complications of malaria were jaundice and renal failure in

our study

12. In Leptospirosis cases, Myalgia and conjunctival suffocation were the

most common symptoms along with fever.

13. The most common presentation of tuberculosis was pulmonary

tuberculosis (58.3%). Extrapulmonary tuberculosis occured in 41.7%

14. Sputum positivity was found in 71% of pulmonary tuberculosis patients.

15. Sputum production was present in 85.8% of pulmonary tuberculosis

patients followed by breathlessness and loss of weight and appetite .

16. Pneumonia constituted about 9% of cases in our study, Fever with cough

and sputum were present in 88% of cases of pneumonia.

17. S. Pneumonia was the most common organism isolated constituting

about 55.5% of isolates followed by klebsiella

18. Urinary tract infection constituted about 14% cases, among which 50%

had E.coli and 50% had klebsiella grown in culture. All of them

responded to ciprofloxacin and cefotaxim.

19. All 4 cases of scrub typhus presented with fever with rash

20. Co-infection with malaria and dengue occurred in 4 (4%) patients.

21. Jaundice with fever occurred in 5(5%) patients. Leptospirosis

contributed to 20% and malaria to 80%.

22. Fever with renal failure occurred in 3(30%) patients. Malaria

87

contributed to all reported cases

23. Mortality was 3(3%) cases in the study, dengue contributing to all 3

cases

88

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1 KUMAR 34 M 734527 Y NO NO Y NO NO Y NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

2 girija 30 F 188895 Y Y NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

3 RAJESH 33 M 380813 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

4 sharmila 36 F 404697 Y Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

5 vimala 41 F 435634 Y NO NO Y NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

6 THANGAVEU 26 M 425116 Y NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

7 kamali 32 F 367120 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO Y NO NO NO NO NO NO NO NO NO NO

8 suganya 28 F 245173 Y Y NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

9 VELU 36 M 475355 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

10 ramya devi 30 F 517960 Y NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

11 sandya 29 F 471341 Y Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

12 RAMAN 36 M 443236 Y Y NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

13 mangayarkarasi 26 F 139821 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

14 yasmin 33 F 452014 Y Y NO Y NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

15 PRADEEP 18 M 29613 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

16 arul priyadharshini 23 F 444757 Y NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

17 ranjitha 32 F 502522 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

18 loganayagi 35 F 518160 Y Y NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO

19 gomathy 44 F 516919 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

20 kavitha 37 F 492043 Y NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

21 sivaroja 22 F 934168 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

22 sangeetha 24 F 488650 Y Y NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

23 sushmitha 24 F 394124 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

SN

O

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ME

AG

E

SE

X

SYMPTOMS

IPN

O

24 reka 31 F 7689 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

25 kavitha 41 F 830123 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

26 jayamani 52 F 52871 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

27 rajamani 57 F 15995 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

28 celsia felcia 54 F 28763 Y NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

29 kirutiga 34 F 171519 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

30 revathy 41 F 12202 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

31 SURESH 30 M 414392 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

32 anbu 20 F 12343 Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

33 krishnaveni 34 F 476198 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

34 malarselvi 38 F 214108 Y NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

35 RAMAMOORTHY 48 M 1545071 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO

36 amsavalli 29 F 923451 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

37 susila 45 F 1634350 Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

38 tamilmangai 55 F 712987 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

39 KARUPPAIA 54 M 345900 Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

40 vinodhini 44 F 419000 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

41 usha 37 F 319980 Y Y Y NO NO NO Y NO NO Y NO Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

42 KANAN 29 M 481900 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

43 mahalakshmi 34 F 700 Y Y Y NO Y Y Y Y Y Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

44 ishwarya 28 F 1751470 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

45 suganya 65 F 1401212 Y Y Y NO NO Y Y NO NO N NO NO NO Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

46 RAMASAMY 42 M 1575435 Y NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

47 meena 35 F 201348 Y Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

48 prasanna 43 F 289451 Y NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

49 VADIVELU 62 M 139023 Y Y Y NO Y Y Y Y Y Y Y Y NO Y Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y

50 maladevi 37 F 1749060 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

51 sangeetha 34 F 19000 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

52 SUNDAR 45 M 222530 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

53 saradha 31 F 1761601 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y

54 vijayakumari 24 F 199123 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

55 ARIVU 30 M 289001 Y Y Y NO NO NO NO NO NO NOVOMITING NO NO Y Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y

56 kavibharathy 32 F 411670 Y Y Y NO NO NO NO NO NO NO Y NO NO Y Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y

57 rani denis mary 28 F 191220 Y Y Y NO NO NO Y NO NO NO Y NO NO Y Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y

58 MAHESH 37 M 21456 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

59 rajarajeswari 28 F 165404 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

60 sumathy 30 F 19921 Y Y Y Y Y Y Y Y Y Y Y NO NO NO Y NO NO Y Y Y Y Y Y Y Y Y Y Y Y Y

61 MANI 33 M 62545 Y Y Y NO NO NO Y Y NO N NO NO Y Y NO Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y

62 surya 29 F 50921 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

63 selvanayagi 41 F 213450 Y Y Y Y Y Y Y Y Y N NO NO NO NO NO NO NO Y Y Y Y Y Y Y Y Y Y Y Y Y

64 MANIKANDAN 41 M 198546 Y NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

65 neelavathy 28 F 220020 Y Y NO Y Y NO Y Y NO Y NO Y NO Y NO NO Y NO Y Y Y Y Y Y Y Y Y Y Y Y

66 pappathy 21 F 185131 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

67 PREM 40 M 267730 Y Y NO Y NO Y NO Y Y Y NO Y Y NO Y Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y

68 asma 34 F 134578 Y Y NO Y NO Y Y Y NO Y Y NO Y NO Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y Y

69 kavitha 43 F 284501 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

70 rajeswari 29 M 38345 Y Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

71 senthamil selvi 47 F 40827 Y Y Y Y Y Y Y NO NO N NO NO NO NO NO Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y

72 SRIDHAR 42 M 431678 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

73 KUMARESAN 30 M 283904 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

74 SENTHIL 21 M 246633 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

75 SURYA 35 M 213784 Y Y Y Y NO Y Y Y NO Y Y Y NO Y NO Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y

76 KARTHI 49 M 260455 Y NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

77 kanimozhi 42 F 184952 Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

78 ammu 22 F 1641678 Y Y Y Y NO NO NO NO NO N NO NO NO NO NO Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y

79 KAVIN 24 M 100127 Y Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

80 jenifer mary 27 F Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

81 RAM 42 M Y NO NO NO NO NO NO NO NO NO NO NO NO Y NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

82 RAMANAN 42 M Y Y NO NO NO NO NO NO NO N NO NO NO NO NO NO NO NO Y Y Y Y Y Y Y Y Y Y Y Y

83 KANDAN 42 M Y NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

84 MANI 41 M Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

85 MOHAN 44 M Y Y Y Y Y Y NO NO NO N NO NO NO NO NO Y NO NO Y Y Y Y Y Y Y Y Y Y Y Y

86 rajeswari 45 F Y NO NO NO NO NO Y NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

87 sangeetha 39 F Y NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

88 MARIMUTHU 60 M Y Y NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO

89 KARUPUSAMY 55 M Y Y Y Y Y Y NO NO NO N NO NO Y NO Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y Y

90 AYYAPAN 42 M Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

91 ARUSAMY 44 M Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

92 NALLATHAMBI 45 M Y Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Y NO NO NO NO NO NO NO NO NO NO

93 NARESH 4 M Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

94 VENKATESH 6 M Y NO Y Y Y Y NO Y Y N NO NO NO NO Y Y NO NO Y Y Y Y Y Y Y Y Y Y Y Y

95 SUREKA 54 F Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

96 KANAN 63 M Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

97 MANIKANDAN 43 M Y Y Y Y Y Y Y Y NO Y NO Y Y NO Y Y NO Y Y Y Y Y Y Y Y Y Y Y Y Y

98 RAJESH 42 M Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

90 BHUVANESH 42 M Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

91 ARJUN 44 M Y NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

1 KUMAR

2 girija

3 RAJESH

4 sharmila

5 vimala

6 THANGAVEU

7 kamali

8 suganya

9 VELU

10 ramya devi

11 sandya

12 RAMAN

13 mangayarkarasi

14 yasmin

15 PRADEEP

16 arul priyadharshini

17 ranjitha

18 loganayagi

19 gomathy

20 kavitha

21 sivaroja

22 sangeetha

23 sushmitha

SN

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OL

PU

LSE

BP

TE

MP

RR

TC

/1

00

0

DC

HB

PA

LTE

LET

LA

KH

S

MP

/MF B

LO

OD

U

RE

A

LF

T

BLO

OD

CU

LT

UR

E

EC

G

X R

AY

CH

ES

T

SP

UT

UM

FO

R A

FB

MA

NT

OU

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CS

F

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INE

PU

S C

ELLS

NO NO 77 130/9038.1 N 11 DECREASED15NORMALNORMALND N N ND ND N D <5

NO NO 80 130/9838.8 T 9 NORMAL 1NORMALNORMALND N N ND ND N D 10-15DA

NO NO 6 120/7037.5 N 8 NORMAL1.5NORMALNORMALND N N ND ND N D 15-Jan

NO NO 86 110/9038.6 N 9 NORMAL 2NORMALNORMALND N N ND ND N D 5

NO NO 84 110/9038.5 N 5 NORMAL1.5NORMALNORMAL N N N NEGATIVE ND N DENGUE <5

NO NO 68 120/7039.2 N 6 NORMAL 1NORMALNORMALND N N ND ND N DENGUE <5

NO NO 78 130/8037.5 T 7 NORMAL1.5NORMALNORMALND NEFFUSION ND ND N DENGUE 6

NO NO 64 140/8037.8 N 8 NORMAL 1NORMALNORMALND N N ND ND N DENGUE 8

Y NO 96 130/8038.3 N 5 NORMAL40NORMALNORMALND N N NEGATIVE ND N DENGUE 9

NO NO 52 130/8039.4 N 6 NORMAL65NORMALNORMALND N N ND ND N DENGUE 5


NO NO 68 130/8038.3 N 8 NORMAL1.5NORMALNORMALND NEFFUSION ND ND N DENGUE 8

NO NO 78 120/8038.6 N 6 NORMAL 2NORMALNORMAL N N N ND ND N DENGUE 10

NO NO 80 110/7038.9 T 10 NORMAL 2NORMALNORMALND N N ND ND N DENGUE 15

NO NO 90 110/7037.5 N 11 NORMAL2.4NORMALNORMALND N N NEGATIVE ND N DENGUE 20

Y NO 68 90/70 37.2 N 12 NORMAL 3NORMALNORMALND N N ND ND N ENTERIC 12

NO NO 76 80/60 37.5 N 12 NORMAL 3NORMALNORMALND N N ND ND N INFLUENZA 14

NO NO 78 130/8038.6 T 12 DECREASED3NORMALNORMAL N N N ND ND N INFLUENZA 15

NO NO 84 110/7038.1 N 14 NORMAL 3NORMALNORMALND N N ND ND N INFLUENZA 4

NO NO 88 120/80 38 N 6 NORMAL 2NORMALNORMALND N N NEGATIVE NDINCREASEDLIVER ABSCESS 6

Y NO 87 130/8037.8 N 5 NORMAL 2NORMALNORMALND N N ND ND N LIVER ABSCESS 7

NO NO 76 120/8038.9 N 7 NORMAL 2DETECTEDELEVATEDNORMALND N N ND ND N M 8

NO NO 74 120/8037.8 T 8 NORMAL 1DETECTEDELEVATEDNORMALND N N ND ND N MALARIA 10

VIT

ALS

INV

ES

TIG

AT

ION

S

PE

RS

ON

AL

HIS

TO

RY

24 reka

25 kavitha

26 jayamani

27 rajamani

28 celsia felcia

29 kirutiga

30 revathy

31 SURESH

32 anbu

33 krishnaveni

34 malarselvi

35 RAMAMOORTHY

36 amsavalli

37 susila

38 tamilmangai

39 KARUPPAIA

40 vinodhini

41 usha

42 KANAN

43 mahalakshmi

44 ishwarya

45 suganya

46 RAMASAMY

47 meena

48 prasanna

49 VADIVELU

50 maladevi

51 sangeetha

52 SUNDAR

53 saradha

Y Y 70 130/8038.1 N 9 NORMAL1.8DETECTEDELEVATEDNORMALND N N NEGATIVE ND N MALARIA 18

NO NO 80 120/8038.2 N 5 NORMAL1.6NORMALNORMALND NINFILTRATES ND P N MENIGITIS 4

NO NO 76 110/8038.6 N 11 NORMAL2.5NORMALNORMALND N N ND P N MENINGITIS 5

NO NO 86 120/8037.9 N 5 NORMAL 2NORMALNORMAL N N N ND ND N PNEUMONIA 7

Y NO 84 130/8037.5 T 4 NORMAL 2NORMALNORMALND N N ND ND N PNEUMONIA 8

NO NO 68 130/8038.2 N 6 NORMAL1.8NORMALNORMALND N N NEGATIVE ND N PNEUMONIA 14

NO NO 78 110/8039.4 N 7 DECREASED2NORMALNORMALND N N ND ND N PNEUMONIA 10

NO NO 64 110/80 40 N 8 NORMAL 2NORMALNORMALND N N ND ND N PNEUMONIA 5

Y Y 96 130/8039.4 N 9 NORMAL 2NORMALNORMALND N N ND ND N SCRUB 14

NO NO 52 90/70 38.3 T 7 NORMAL 2NORMALNORMALND N N P ND N TB 15

NO NO 65 110/8038.6 N 6 DECREASED2NORMALNORMALND N N P ND N TB 4

NO NO 68 160/9037.9 N 5 NORMAL3.5NORMALNORMAL N N N P ND N TB 6

Y NO 78 90/70 37.4 N 6 NORMAL3.5NORMALNORMALND N N P ND N TB 7

NO Y 80 120/9039.5 N 7 NORMAL2.2NORMALNORMALND N N P ND N TB 8

NO NO 90 110/8038.2 T 8 DECREASED2NORMALNORMALND N N ND NDINCREASED UTI 10

NO Y 68 110/9037.9 N 9 NORMAL 2ELEVATEDNORMALND N N ND NDINCREASED UTI 18

NO NO 76 130/80 38 N 6 NORMAL 2NORMALNORMAL N N N NEGATIVE NDINCREASED UTI 4

NO Y 78 120/8037.9 N 7 NORMAL2.6NORMALNORMALND N N ND NDINCREASED UTI 5

Y NO 84 120/8039.2 T 8 NORMAL2.5NORMALNORMALND N N ND NDINCREASED UTI 7


NO NO 87 130/8038.6 N 10 NORMAL 2NORMALNORMAL N N N NEGATIVE NDINCREASED UTI 14


NO NO 74 130/8038.2 N 7 NORMAL1.7DETECTEDELEVATEDNORMALND N N ND ND N MALARIA ,DENGUE5

Y NO 70 110/8038.1 T 8 DECREASED2NORMALNORMALND N N NEGATIVE ND N TB 14


NO Y 68 110/8037.5 N 5 NORMAL 1NORMALNORMALND N N ND ND N DENGUE,SCRUB 4

NO NO 76 130/8038.6 N 11 DECREASED2ELEVATEDNORMALND N N ND ND I UTI 6

NO NO 78 160/9038.5 N 5 NORMAL 3NORMALNORMALND N N ND ND N PNEUMONIA 7

Y NO 84 200/10039.2 T 4 NORMAL 2NORMALNORMAL N N N ND ND N MALARIA, DENGUE8

NO Y 88 110/8037.5 N 6 NORMAL 3NORMALNORMALND N N NEGATIVE ND N TB 6

54 vijayakumari

55 ARIVU

56 kavibharathy

57 rani denis mary

58 MAHESH

59 rajarajeswari

60 sumathy

61 MANI

62 surya

63 selvanayagi

64 MANIKANDAN

65 neelavathy

66 pappathy

67 PREM

68 asma

69 kavitha

70 rajeswari

71 senthamil selvi

NO NO 87 120/8037.8 N 7 NORMAL 2NORMALNORMALND N N ND ND I ENTERIC 6

NO Y 76 110/8038.3 N 8 NORMAL 3NORMALNORMALND N N ND ND N DENGUE 4

NO Y 74 120/8039.4 N 9 NORMAL1.2NORMALNORMAL N NEFFUSION ND ND N DENGUE,SCRUB 5

NO Y 70 110/8038.1 T 7 NORMAL1.2DETECTEDELEVATEDNORMALND N N NEGATIVE ND N MALARIA 7

NO NO 90 130/8038.3 N 6 NORMAL 2NORMALNORMALND N N ND ND N PNEUMONIA 8

Y NO 68 120/8038.6 N 5 NORMAL 1NORMALNORMALND N N ND ND I UTI 14

NO Y 76 110/8038.9 N 6 NORMAL75NORMALNORMALND N N ND ND N DENGUE 10

NO Y 78 110/7037.5 N 7 NORMAL90NORMALNORMAL N N N ND ND N DENGUE,SCRUB 5

NO NO 84 90/60 37.2 T 8 NORMAL60NORMALNORMALND N N ND ND N DENGUE 5

NO Y 88 90/60 37.5 N 9 NORMAL 1NORMALNORMALND N N NEGATIVE ND N TB 6

NO NO 87 80/80 38.6 N 5 NORMAL 2NORMALNORMALND N N ND ND I PNEUMONIA 8


Y NO 74 110/70 38 N 8 NORMAL 3NORMALNORMALND NINFILTRATES NEGATIVE ND N TB 5

NO Y 70 120/8037.8 T 9 DECREASED2NORMALNORMALND N N ND ND N DENGUE 6

NO Y 90 110/7038.9 N 5 NORMAL1.1NORMALNORMAL N N N ND ND N PNEUMONIA 8

NO NO 68 110/8037.8 N 11 NORMAL1.1NORMALNORMALND N N ND ND N DENGUE 7

NO NO 76 110/8038.1 N 5 DECREASED2NORMALNORMALND N N NEGATIVE ND N TB 6

NO Y 78 130/8038.2 N 4 NORMAL 2NORMALNORMALND N N ND ND I UTI 8

72 SRIDHAR

73 KUMARESAN

74 SENTHIL

75 SURYA

76 KARTHI

77 kanimozhi

78 ammu

79 KAVIN

80 jenifer mary

81 RAM

82 RAMANAN

83 KANDAN

84 MANI

85 MOHAN

86 rajeswari

87 sangeetha

88 MARIMUTHU

89 KARUPUSAMY

90 AYYAPAN

91 ARUSAMY

92 NALLATHAMBI

93 NARESH

94 VENKATESH

95 SUREKA

96 KANAN

97 MANIKANDAN

98 RAJESH

90 BHUVANESH

91 ARJUN

NO NO 84 110/7038.6 T 6 NORMAL 2NORMALNORMALND N N ND ND N DENGUE 6

NO NO 88 120/8037.9 N 7 NORMAL1.1NORMALNORMALND N N NEGATIVE ND N DENGUE, SCRUB7

NO NO 87 120/8037.5 N 8 NORMAL1.1DETECTEDELEVATEDNORMALND N N ND ND N MALARIA 5

Y Y 76 110/8038.2 N 9 DECREASED2NORMALNORMAL N N N ND ND N DENGUE 8

NO NO 74 130/8039.4 T 7 NORMAL 2NORMALNORMALND N N ND ND I UTI 10

NO NO 70 110/80 40 N 6 NORMAL 2NORMALNORMALND NINFILTRATES POSITIVE ND I TB 5

NO Y 90 110/8039.4 N 5 NORMAL1.5NORMALNORMALND N N ND ND N DENGUE 5

NO NO 68 120/8038.3 N 7 NORMAL 1NORMALNORMALND N N ND ND I DENGUE 6

NO NO 76 130/8038.6 T 8 NORMAL 2NORMALNORMALND N N POSITIVE ND N TB 8


NO Y 84 110/8037.4 N 5 NORMAL2.2DETECTEDELEVATEDNORMALND NEFFUSION ND ND N MALARIA , DENGUE5

NO NO 88 110/8039.5 T 11 NORMAL2.2NORMALNORMAL N N N ND ND I UTI 6

NO NO 87 120/8038.2 N 5 NORMAL2.4NORMALNORMALND N N NEGATIVE ND N DENGUE 8

NO Y 76 120/8037.9 T 4 NORMAL2.2ELEVATEDNORMALND N N ND ND N LEPTO 7

Y NO 74 120/80 38 N 6 NORMAL 1NORMALNORMALND N N ND ND N DENGUE 6

NO NO 70 130/7837.9 N 7 NORMAL 1NORMALNORMALND N N NEGATIVE ND N UTI 8

NO NO 90 110/7039.2 N 8 NORMAL1.5ELEVATEDNORMALND N N ND ND N PNEUMONIA 6

NO Y 68 130/8039.1 N 9 NORMAL1.5NORMALNORMALND N N ND ND N INFLUENZA 7

NO NO 76 130/7838.6 N 7 NORMAL 2NORMALNORMALND N N ND ND N SRUB 5

NO NO 78 124/7038.4 N 6 NORMAL 2NORMALNORMALND N N ND ND N ENTRIC FEVER 8

NO NO 84 110/8038.2 N 5 DECREASED45NORMALNORMALND N N ND ND N DENGUE 10

NO NO 88 110/7037.8 N 6 NORMAL40DETECTEDELEVATEDNORMALND N N NEGATIVE ND N MALARIA, DENGUE6


NO NO 76 110/8037.5 N 8 NORMAL 1NORMALNORMALND NEFFUSION ND ND I UTI 9

NO NO 74 90/70 37.9 N 9 NORMAL 1NORMALNORMALND N N ND ND N DENGUE 10

NO Y 70 110/80 N 6 NORMAL 2NORMALNORMALND N N ND ND N LEPTO 12

NO NO 78 120/80 7 1NORMALNORMALND N N NEGATIVE ND N DENGUE 12

NO NO 76 130/7838.6 N 7 NORMAL 2NORMALNORMALND N N ND ND N SRUB 5

NO NO 78 124/7038.4 N 6 NORMAL 2NORMALNORMALND N N ND ND N ENTRIC FEVER 8

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A STUDY OF EXPANDED INFECTIOUS FEVER - 100 CASES IN A