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INTRODUCTION: Acute undifferentiated fever with thrombocytopenia is a common and challenging clinical presentation encountered in the emergency departments of tertiary care centers, particularly in tropical regions, often requiring prompt evaluation and management. The study aimed to explore the clinical and etiological profile of acute undifferentiated fever with thrombocytopenia in the Emergency Department of Indira Gandhi Institute of Medical Sciences, Patna. It investigates factors associated with patient outcomes and compares platelet transfusion requirements among different etiological groups. METHODS: In this cross-sectional observational study, 350 patients with acute undifferentiated fever with thrombocytopenia were analyzed for one year from October '21 to September '22. Pre-existing chronic infectious diseases, liver cirrhosis, and autoimmune conditions were excluded. RESULTS: Thrombocytopenia was observed in all patients, with 65% having platelet counts below 50,000/µL. Associations were found between the degree of thrombocytopenia and organ dysfunction, shock, and third space loss. Logistic regression analysis identified thrombocytopenia, organ dysfunction, and platelet transfusion requirement as significant predictors of the overall outcome. Etiological group comparisons revealed higher platelet transfusion requirements in the bacterial group. CONCLUSION: Prompt recognition and management of thrombocytopenia in acute undifferentiated fever are vital. Thrombocytopenia, along with organ dysfunction and shock, significantly influence patient outcomes. Tailored interventions based on etiological factors are crucial. Further research should focus on specific viral aetiologies in acute undifferentiated fever with thrombocytopenia.

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Background Scrub typhus is an important cause of acute febrile illness in children. It is one of the re-emerging infections in the Asia Pacific region. It is caused by the gram-negative bacteria Orientia tsutsugamushi and is spread by the bite of trombiculid mites. The initial symptomatology is nonspecific with fever, headache, vomiting, etc. The presence of eschar is said to be pathognomic. It is a systemic illness, and vasculitis is the basic pathogenic mechanism. Materials and methods A retrospective observational study was conducted in two medical colleges and associated hospitals of western Uttar Pradesh (UP) and Rajasthan, India. Case files of 21 confirmed cases of scrub typhus admitted from April 2021 to October 2022 were reviewed. Scrub typhus was suspected in children with acute undifferentiated fever, and suggestive signs and symptoms were confirmed serologically with IgM enzyme-linked immunoassay (ELISA). Demographic and clinical details were noted. Results During the study period, a total of 335 cases of acute undifferentiated fever were seen, and 6.2% of them were diagnosed as having scrub typhus infection on detailed investigation. The most common symptom was fever in 100% of them, vomiting in 57.1%, abdomen pain in 42.8%, and diarrhea in 19%. Maculopapular, erythematous rash was present in 19% of cases. None of the patients had eschar. Microvascular leakage was the main complication in 28.5%. Unusual complications seen were empyema and valvulitis in 4.7% of patients. Conclusion Scrub typhus is also seen in urban setups and in dry arid areas like Rajasthan and North West UP. So, relevant investigations should be a part of the evaluation in pediatric patients with acute undifferentiated fever. Eschar can be absent, and empyema and valvulitis are some uncommon complications. A high degree of suspicion and early diagnosis are essential as an undiagnosed infection is rapidly fatal.

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BACKGROUND: Acute undifferentiated fever (AUF) ranges from self-limiting illness to life-threatening infections, such as sepsis, malaria, dengue, leptospirosis and rickettsioses. Similar clinical presentation challenges the clinical management. This study describes risk factors for death in patients hospitalized with AUF in India. METHODS: Patients aged ≥5 y admitted with fever for 2-14 d without localizing signs were included in a prospective observational study at seven hospitals in India during 2011-2012. Predictors identified by univariate analysis were analyzed by multivariate logistic regression for survival analysis. RESULTS: Mortality was 2.4% (37/1521) and 46.9% (15/32) died within 2 d. History of heart disease (p=0.013), steroid use (p=0.011), altered consciousness (p<0.0001), bleeding (p<0.0001), oliguria (p=0.020) and breathlessness (p=0.015) were predictors of death, as were reduced Glasgow coma score (p=0.005), low urinary output (p=0.004), abnormal breathing (p=0.006), abdominal tenderness (p=0.023), leucocytosis (p<0.0001) and thrombocytopenia (p=0.001) at admission. Etiology was identified in 48.6% (18/37) of fatal cases. CONCLUSIONS: Bleeding, cerebral dysfunction, respiratory failure and oliguria at admission, suggestive of severe organ failure secondary to systemic infection, were predictors of death. Almost half of the patients who died, died shortly after admission, which, together with organ failure, suggests that delay in hospitalization and, consequently, delayed treatment, contribute to death from AUF.

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BACKGROUND: Children with acute febrile illness with no localizing signs often receive antibiotics empirically in most resource-poor settings. However, little is known about the burden of bacteremia in this category of patients, and an appraisal is thus warranted. This will guide clinical practice and promote rational antibiotics use. METHODS: We prospectively followed up 140 under-five children who presented with acute undifferentiated fever at the emergency/outpatient pediatric unit of a secondary healthcare facility. Baseline clinical and laboratory information was obtained and documented in a structured questionnaire. We compared baseline characteristics between participants with bacteremia and those without bacteremia. We further fitted a multivariable logistic regression model to identify factors predictive of bacteremia among the cohort. RESULT: The prevalence of bacteremia was 17.1%, and Salmonella Typhi was the most frequently (40.9%) isolated pathogen. The majority (78.6%) of the study participants were managed as outpatients. The participants who required admission were four times more likely to have bacteremia when compared to those managed as outpatients (AOR 4.08, 95% CI 1.19 to 14.00). There is a four times likelihood of bacteremia (AOR 4.75, 95% CI 1.48 to 15.29) with a fever duration of beyond 7 days. Similarly, participants who were admitted with lethargy were six times more likely to have bacteremia (AOR 6.20, 95% CI 1.15 to 33.44). Other significant predictors were tachypnea and lymphopenia. CONCLUSION: Among under-five children with acute undifferentiated fever, longer duration of fever, lethargy, inpatient care, tachypnea, and lymphopenia were the significant predictors of bacteremia.

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BACKGROUND AND OBJECTIVES: Scrub typhus is re-emerging as an important cause of acute undifferentiated fever in the last decade from various parts of India. Complexity in performing the "gold standard" immunofluorescent assay and the unreliable nature of Weil Felix test often results in delayed or misdiagnosis in a majority of cases. The present study seeks to integrate the results of rapid diagnostic tests, clinical and laboratory features to aid the diagnosis and management of scrub typhus patients. MATERIALS AND METHODS: A total of 645 serum samples with suspected scrub typhus sent to the Department of Microbiology were included in the study. Scrub typhus was tested by rapid immunochromatographic test (SD Diagnostics) and IgM ELISA (Inbios International, USA). Clinical features, laboratory parameters and final outcome were analysed from the clinical records of positive patients. RESULTS: Scrub typhus was diagnosed in 13.7% of patients and majority of them were observed in the month of August. 58.6% of scrub typhus patients presented with fever of one to two weeks duration. Eschar was documented in 13.7% of patients and 24% of patients gave a history of working outdoors or exposure to vegetation. All the patients responded to Doxycycline treatment and there was no mortality. CONCLUSION: High index of suspicion for scrub typhus is necessary in febrile patients not responding to conventional antibiotics especially during outbreak situations. Rapid immunochromatographic tests with excellent specificity and acceptable sensitivity can be used as potential point of care tests for quick diagnosis of scrub typhus especially in delayed presentation.

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Acute undifferentiated fever (AUF) is frequently observed in tropical settings, but diagnosing the cause of AUF is often a challenge for local physicians and the physicians treating returning travellers. We conducted a case-control study in central Vietnam in 2016. A total of 378 febrile adult patients (AUFs) with a fever for ≤21 days, no evidence of localized infection and negative screening tests for dengue and malaria, and 384 afebrile adult patients (Controls) were prospectively enrolled. Whole blood, plasma, eschar swab, throat swab and urine specimens were collected and analysed. Quantitative PCR and RT-PCR were used to test for 55 bacteria, viruses and their subtypes. Serological tests were also used to test for rickettsial agents. The most common aetiology was influenza virus (20.9% in AUFs vs. 0% in Controls), followed by rickettsial agents (mainly Orientia tsutsugamushi and Rickettsia typhi) (10.8% vs. 0.3%), dengue virus (7.7% vs. 0.5%), Leptospira (4.8% vs. 0.8%), adenovirus (4.8% vs. 1.0%), and enterovirus (2.1% vs. 0%) (p < .05). The real proportion of dengue in AUF cases was underestimated because patients with dengue-positive rapid diagnosis tests were excluded from the study. The emerging agent Rickettsia felis, which had not been previously observed in Vietnam, was detected in this study. In total, 216 patients (57.1%) were given causative diagnoses, comprising 143 (66.2%) monoinfections and 73 (33.8%) coinfections. The infections caused by these agents should be considered in clinical practice and further studies. Additionally, agents susceptible to doxycycline were detected in 15.6% of AUFs; thus, this drug should be included in the panel used to treat AUF patients.

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Anaplasma phagocytophilum-the causative agent of human granulocytic anaplasmosis (HGA)-is a tick-borne pathogen transmitted by Ixodid ticks infecting wild and domestic mammals as well as humans. Despite the availability of evidence regarding this emerging infection among vectors, host animals, and individuals in China, there is limited knowledge on the prevalence and distribution of A. phagocytophilum in the Yunnan Province. The aim of this study was to assess the seroprevalence of A. phagocytophilum in healthy adults and patients with acute undifferentiated fever from four regions in the Yunnan Province. The enzyme-linked immunosorbent assay and indirect immunofluorescence assay were used to detect immunoglobulin (Ig) G and IgM antibodies against A. phagocytophilum in sera obtained from 1185 healthy blood donors and 245 patients with acute undifferentiated fever, respectively. Demographic variables were assessed as potential risk factors using the chi-squared test. The rates of seropositivity rates were 7.59% and 4.49% in healthy donors and fever patients, respectively. Analysis of risk factors such as gender, age groups, and place of residence showed statistically significant differences. Infections with A. phagocytophilum occur widely among individuals residing in southwestern China. Our results indicate that there is serological evidence of HGA in this population and presence of acute A. phagocytophilum infections in patients with undifferentiated fever in the Yunnan Province.

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Chikungunya virus (CHIKV) infection is spatiotemporally related to dengue virus (DENV) infection and mostly undiagnosed due to similar primary symptoms. In 2013, a high rate (36%) of coinfection of DENV and CHIKV was reported in Odisha. Hence, the hospital-based study was continued to synthesis current epidemiological understanding of their single distribution or coinfection. Suspected DENV patients serum samples were tested for DENV and CHIKV by serology and reverse-transcription polymerase chain reaction. The positive samples were used for analysis of mutation, selection pressure, and phylogenetic relationship. Clinical information was also analyzed. Among 648 (2015 and 2016) suspected DENV patients, 141 (21.7%) were positive for DENV (serotypes 1-3), 22 (3.4%) were positive for CHIKV (ECSA) and 4 (2.8%) were coinfected with both. Sequence analysis showed four consistent mutations (M104V, V112A, K166N, and F169L) in CprM gene of DENV 2 and two consistent mutations (M269V, D284E) in E1 gene of CHIKV. Interestingly, the CHIKV- E1 A226V mutation was absent in the studied population. It was also noticed that the peak incidence of both the infections occurs in August-September in 2015-16. Moreover, Plasmodium species, Salmonella typhi, and Rickettsial typhi infections were also observed in DENV patients. Different etiology was also detected in other undifferentiated fever patients as mixed infections (malaria, S. typhi, and R. typhi ). Hence, this investigation shows the significant reduction of DENV-CHIKV coinfection as compared with previous report, the burden of arboviruses and acute undifferentiated fever in Odisha in 2015-2016, highlighting the importance of epidemiological picture of febrile patients for appropriate patient management.

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To save the life of both mother and fetus, the risks and benefits of the few antibiotics considered effective in the treatment of severe scrub typhus require consideration. In this case, chloramphenicol treatment averted maternal but not fetal mortality. Evidence-based guidelines appropriate for resource-limited endemic areas are required.

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The System for Early-warning based on Emergency Data (SEED) is a pilot project to evaluate the use of emergency call data with the main complaint acute undifferentiated fever (AUF) for syndromic surveillance in India. While spatio-temporal methods provide signals to detect potential disease outbreaks, additional information about socio-ecological exposure factors and the main population at risk is necessary for evidence-based public health interventions and future preparedness strategies. The goal of this study is to investigate whether a spatial epidemiological analysis at the ecological level provides information on urban-rural inequalities, socio-ecological exposure factors and the main population at risk for AUF. Our results displayed higher risks in rural areas with strong local variation. Household industries and proximity to forests were the main socio-ecological exposure factors and scheduled tribes were the main population at risk for AUF. These results provide additional information for syndromic surveillance and could be used for evidence-based public health interventions and future preparedness strategies.

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