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SCRUB TYPHUS - INDIA: (TAMIL NADU), CHENNAI, FATAL
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Date: Tue 10 Jan 2012
Source: Times of India [edited]
http://timesofindia.indiatimes.com/city ... 431002.cms


For almost 6 days, a girl's parents wondered why her fever did not come down despite taking medicines including some expensive antibiotics. Last week, she died at Apollo Hospitals following multiorgan failure.

It was only when a doctor at the intensive care unit noticed a tiny black scar on her thigh that she determined that her disease was scrub typhus, a rare zoonotic disease (which can be transmitted from animals to humans). Doctors say the disease is curable using antibiotics, but it can get out of hand when diagnosis is delayed.

"[The girl] was referred to us very late," said a doctor. In December 2011, doctors saw at least 3 very sick children with scrub typhus. All of them had to be ventilated, and one of them required dialysis. "This is dengue season. There were 4 patients with dengue, but they weren't as sick. They were discharged in 3 days, but those with scrub typhus were here for at least a week," the doctor said.

[Byline: Pushpa Narayan]

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[The following is excerpted from: Demma LJ, McQuiston JH, Nicholson WL, et al. Scrub typhus, Republic of Palau. Emerg Infect Dis. 2006; 12(2): 290-5. Available at http://wwwnc.cdc.gov/eid/content/12/2/pdfs/v12-n2.pdf:

"Scrub typhus is a zoonotic illness caused by _Orientia tsutsugamushi_. The pathogen is transmitted through the bite of larval mites (chiggers) of the _Trombiculidae_ family, which serve as both the vector and the reservoir (1,2). Rodents of the family _Muridae_ (rats and mice) are common hosts for trombiculid mites and may support _O. tsutsugamushi_. Geographically specific foci of scrub typhus are thus determined by the distribution of vector mites and their rodent hosts and by interactions of mites and rodents with humans (3). Scrub typhus has been reported from many regions of Asia and the Pacific islands, and known disease-endemic regions extend from Japan and eastern Russia southward to Australia and westward to Pakistan and Afghanistan (4,5).

"Scrub typhus is typically a nonspecific febrile illness; its severity may be influenced by the strain of _O. tsutsugamushi_, a person's immune status, and other factors. Diagnosis may be complicated in areas where the disease has not been documented recently or in regions lacking the capacity for laboratory confirmation. Illness develops after an incubation period of 6 to 21 days and usually begins with an eschar at the site of a chigger bite. Fever, headache, [lymphadenopathy], and myalgias are common, and a maculopapular rash may also be present. Nausea, vomiting, diarrhea, or lower respiratory symptoms can also occur. Manifestations such as pneumonitis, meningoencephalitis, jaundice, renal failure, and myocarditis can develop during the prolonged clinical course of untreated illness (6). Establishing the diagnosis and initiating prompt antimicrobial drug therapy are important, because death rates for untreated scrub typhus patients are 1-30 per cent (5). Scrub typhus is effectively treated with doxycycline, and treatment should begin immediately upon suspicion of illness without awaiting laboratory confirmation."

References
----------
1. Traub R, Wisseman CL, Jones MR, O'Keefe JJ. The acquisition of _Rickettsia tsutsugamushi_ by chiggers (trombiculid mites) during the feeding process. Ann NY Acad Sci. 1975; 266: 91-114.
2. Traub R, Wisseman CL. The ecology of chigger-borne rickettsiosis (scrub typhus). J Med Entomol. 1974; 11(3): 237-303.
3. Lerdthunsee K, Khuntirat B, Leepitakrat W, Tanskul P, et al. Scrub typhus: vector competence of _Leptotrombidium chiangraiensis_ chiggers and transmission efficacy and isolation of _Orientia tsutsugamushi_. Ann N Y Acad Sci. 2003; 990: 25-35; abstract available from http://www.ncbi.nlm.nih.gov/pubmed/12860596.
4. Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect Dis. 2003; 16(5): 429-36; abstract available from http://www.ncbi.nlm.nih.gov/pubmed/14501995.
5. Silpapojakul K. Scrub typhus in the Western Pacific region. Ann Acad Med Singapore. 1997; 26(6): 794-800; abstract available from http://www.ncbi.nlm.nih.gov/pubmed/9522982.
6. Corwin AL, Soeprapto W, Widodo PS, Rahardjo E, et al. Short report: surveillance of rickettsial infections in Indonesian military personnel during peace keeping operations in Cambodia. Am J Trop Med Hyg 1997; 57(5): 569-70; abstract available from http://www.ncbi.nlm.nih.gov/pubmed/9392597.

Rodents may serve as reservoirs, although transovarial transmission in mites is the dominant mechanism for maintenance of _O. tsutsugamushi_ (http://www.cdc.gov/ncidod/EID/vol9no12/03-0212.htm). Humans become infected when they accidentally encroach in an area where the chigger-rodent cycle is occurring, most often areas of low-lying scrub brush or transitional vegetation.

Patients with severe scrub typhus can develop multiorgan failure and disseminated intravascular coagulopathy with hemorrhage.

Chennai (formerly known as Madras), is the capital city of the Indian state of Tamil Nadu, located on the Coromandel Coast of the Bay of Bengal. Chennai is the 4th most populous metropolitan area and the 5th most populous city in India. A map of India showing the state of Tamil Nadu can be accessed at: http://healthmap.org/r/1ob7. - Mod.ML]

Indien - Malaria
13.01.2012

Im Bundesstaat Rajasthan (NW) sind aufgrund verstärkter Regenfälle ungewöhnlich viele Malariafälle aufgetreten. Bei Reisen in diese Region ist aktuell eine Prophylaxe mit Malariamedikamenten nach Rücksprache mit dem Arzt zu erwägen. Auch in großen Städten (Delhi, Mumbai) ist ein guter Mückenschutz wichtig, da in Indien nicht nur im ländlichen Bereich Malaria-Erkrankungen auftreten. In ganz Indien sank die Zahl der bestätigten Malaria-Fälle/Jahr von ca. 2. Mio. im Jahr 2000 auf ca. 1,6 Mio. im Jahr 2010 ab, die Zahl der malariabedingten Todesfälle stieg leicht an. In ganz Indien wurden bis Ende November 2011 offiziell etwa 1.180.502 Fälle bestätigt. Mindestens 430 Personen sind an der Erkrankung verstorben. Es ist davon auszugehen, dass die tatsächlichen Fallzahlen mehrfach höher sind. Dringend Mückenschutz und ggf. Malariaprophylaxe beachten. / Quelle: crm

Gruß
Birgitt

CHOLERA, DIARRHEA AND DYSENTERY UPDATE 2012 (03): ASIA
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Cholera - India (Puducherry)
Date: Tue 10 Jan 2012
Source: Express News Service
http://ibnlive.in.com/news/after-gastro ... 0-118.html

Puducherry: Out of the 106 people affected by gastroenteritis over the last 4 days, 9 were found to be suffering from cholera. Briefing newsmen at a press conference on Tue 10 Jan 2012, director of health and family welfare Dr K V Raman, said the patients were from Mudaliarpet, Boomianpet, areas affected by water contamination, and 3 patients from Gorimedu.

In the last 3 days 91 cases were admitted to the Indira Gandhi GGH and 15 cases to JIPMER with diarrhoea and vomiting. The people in the affected areas were being treated, at special camps, with oral dehydration packets and antibiotics.

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[How many of the other cases of enteric illness reported are also due to _Vibrio cholerae_ is unclear. Pondicherry, in the south of India as can be seen at the URL (http://en.wikipedia.org/wiki/Pondicherry>) since 2006 officially Puducherry, is a Union Territory of India. It is a former French colony, consisting of four non-contiguous enclaves, or districts, and named for the largest, Pondicherry. In September 2006, the territory changed its official name from Pondicherry to Puducherry, which means "new village" in the Tamil language. It is also known as "The French Riviera of the East" (La Cote d'Azur de l'Est). - Mod.LL


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SCRUB TYPHUS - INDIA: (TAMIL NADU)
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Date: Fri 20 Jan 2012
Source: Times of India [edited]
http://timesofindia.indiatimes.com/city ... 561048.cms


3 people in the Erode district are suspected to have died of scrub typhus causing concern among villagers. The disease spreads from mice.

During December 2011, the incidence of the disease was high in Dharmapuri district and now it is prevalent in Erode district. Mice which enter farms to eat groundnuts and grains spread the disease.

"2 of the victims were from Nambiyur in Erode district and one was from Puliyampatti," said a source. Doctors of the Indian Medical Association are now trying to spread awareness about the disease and its treatment through an SMS campaign," the source added.

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[The following is a previous moderation regarding scrub typhus by moderator ML and is excerpted from a report published by the United States Centers for Disease Control and Prevention (Demma LJ, McQuiston JH, Nicholson WL, Murphy SM, Marumoto P, Sengebau-Kingzio JM, et al. Scrub typhus, Republic of Palau. Emerg Infect Dis [serial on the Internet]. 2006 Feb [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol12no02/05-0967.htm):

"Scrub typhus is a zoonotic illness caused by _Orientia tsutsugamushi_. The pathogen is transmitted through the bite of larval mites (chiggers) of the _Trombiculidae_ family, which serve as both the vector and the reservoir (1,2). Rodents of the family _Muridae_ (rats and mice) are common hosts for trombiculid mites and may support _O. tsutsugamushi_. Geographically specific foci of scrub typhus are thus determined by the distribution of vector mites and their rodent hosts and by interactions of mites and rodents with humans (3). Scrub typhus has been reported from many regions of Asia and the Pacific islands, and known disease-endemic regions extend from Japan and eastern Russia southward to Australia and westward to Pakistan and Afghanistan (4,5).

"Scrub typhus is typically a nonspecific febrile illness; its severity may be influenced by the strain of _O. tsutsugamushi_, a person's immune status, and other factors. Diagnosis may be complicated in areas where the disease has not been documented recently or in regions lacking the capacity for laboratory confirmation. Illness develops after an incubation period of 6 to 21 days and usually begins with an eschar at the site of a chigger bite. Fever, headache [lymphadenopathy], and myalgias are common, and a maculopapular rash may also be present. Nausea, vomiting, diarrhea, or lower respiratory symptoms can also occur. Manifestations such as pneumonitis, meningoencephalitis, jaundice, renal failure, and myocarditis can develop during the prolonged clinical course of untreated illness (6). Establishing the diagnosis and initiating prompt antimicrobial drug therapy are important, because death rates for untreated scrub typhus patients are 1-30 percent (5). Scrub typhus is effectively treated with doxycycline, and treatment should begin immediately upon suspicion of illness without awaiting laboratory confirmation."

References
1. Traub R, Wisseman CL, Jones MR, O'Keefe JJ. The acquisition of _Rickettsia tsutsugamushi_ by chiggers (trombiculid mites) during the feeding process. Ann N Y Acad Sci. 1975;266:91-114.
2. Traub R, Wisseman CL. The ecology of chigger-borne rickettsiosis (scrub typhus). J Med Entomol. 1974;11:237-303.
3. Lerdthunsee K, Khuntirat B, Leepitakrat W, Tanskul P, Monkanna T, Khlaimanee N, et al. Scrub typhus: vector competence of _Leptotrombidium chiangraiensis_ chiggers and transmission efficacy and isolation of _Orientia tsutsugamushi_. Ann N Y Acad Sci. 2003;990:25-35.
4. Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect Dis. 2003;16:429-36.
5. Silpapojakul K. Scrub typhus in the Western Pacific region. Ann Acad Med Singapore. 1997;26:794-800.
6. Corwin AL, Soeprapto W, Widodo PS, Rahardjo E, Kelly DJ, Dasch GA, et al. Short report: surveillance of rickettsial infections in Indonesian military personnel during peace keeping operations in Cambodia. Am J Trop Med Hyg. 1997;57:569-70.

Rodents serve as a reservoir, although transovarial transmission in mites is the dominant mechanism for maintenance of _O. tsutsugamushi_ (http://www.cdc.gov/ncidod/EID/vol9no12/03-0212.htm). Humans become infected when they accidentally encroach in an area where the chigger-rodent cycle is occurring, most often areas of low-lying scrub brush or transitional vegetation. Patients with severe scrub typhus can develop multiorgan failure and disseminated intravascular coagulopathy with hemorrhage."

- Mod.LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1mm2.]

DENGUE/DHF UPDATE 2012 (04)
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- India (Thiruvananthapuram, Kerala state). 20 Jan 2012. Everyday, at least 5 cases of dengue have been reported from this area since last week. So far, 24 cases of dengue have been reported from these coastal areas http://articles.timesofindia.indiatimes ... reas-cases.

[A HealthMap/ProMED-mail interactive map showing the location of Thiruvananthapuram, Kerala state can be accessed at http://healthmap.org/r/00aD. - Mod.TY]

LEPROSY - INDIA: PERSISTENCE
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India

Date: Tue 24 Jan 2012
Source: Deccan Herald [edited]
http://www.deccanherald.com/content/221 ... -last.html


The World Health Organisation (WHO) and the Government of India claim that leprosy has been eliminated from the face of the earth. But the head of a rehabilitation centre for leprosy patients disagrees. Fr George Kannanthanam, Director, Sumanahalli Society for the [NGO] Welfare and Rehabilitation of Leprosy Patients, says, quoting a survey, that 2.28 lakh [lakh is a unit in the South Asian numbering system equal to 100 000] new cases of leprosy were reported in the world in 2010. Of them, 55 per cent or 1.27 lakh occurred in India alone. Of them, 15 000 cases were with deformities, and 5000 involved children.

As many as 4018 new cases were reported in Karnataka, including 419 in Bangalore. In 2011, the NGO reported and treated 131 new cases in the City. 23 of these cases were with deformities.

The disease might well be on its way out, but there is no room for complacency, Kannanthanam said in his welcome speech at the 35th anniversary celebration of the NGO [in Bangalore] on Tuesday [24 Jan 2012]. "The WHO and the GoI [Government of India] say leprosy has been eliminated, but that is not the reality,"_he pointed out. It may be recalled that WHO had declared, in 2010, that leprosy had been eliminated. Consequently, the Union government terminated the Survey, Education, and Treatment (SET) programme through which new cases of leprosy were detected and treated before they turned serious.

Kannanthanam said the termination of the SET programme caused a large number of cases to go undetected on time. Treating leprosy patients is now much more difficult as there is a dearth of sufficient infrastructure and facilities. Also, many agencies stopped their engagement in leprosy and the government cut down its programmes drastically, he added.

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[Bangalore, also called Bengaluru, is the capital of the Indian state of Karnataka. Bangalore, with a population of 8.5 million in 2011, is India's third most populous city and fifth-most populous urban agglomeration and is well known as a hub for India's information technology sector (http://en.wikipedia.org/wiki/Bangalore). A map of the states of India can be accessed at http://www.globalsecurity.org/military/ ... ourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/1Hg8. - Mod.ML]

LEPROSY - INDIA (02): BACKGROUND
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Date: Fri 27 Jan 2012
Source: Gideon (Global Infectious Disease & Epidemiology Network) [edited]
http://www.GideonOnline.com


re: Leprosy - India, Sri Lanka: persistence 20120126.1022946
------------------------------------------------------------
Southeast Asia continues to account for the most of the global leprosy burden, with more than 50 percent of the world's cases reported from India. In the following graph, I've compared regional data with those of India [1]:

http://www.gideononline.com/wp/wp-conte ... -India.png

References:
1. Graph tutorial at: http://www.GIDEONonline.com/wp/wp-conte ... Graphs.pps

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[ProMED-mail thanks Dr. Berger for his continuing contributions.

A map of the states of India can be accessed at http://www.globalsecurity.org/military/ ... ourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/1Hg8. - Mod.ML]

SCRUB TYPHUS - INDIA (03): (MAHARASHTRA)
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Date: Thu 2 Feb 2012
Source: The Times of India, Times News Network (TNN) [edited]
http://timesofindia.indiatimes.com/city ... 720693.cms


4 persons with fever, a rash over the body, and muscle pain that refused to respond to routine antibiotics, were treated at 3 hospitals in Pune [Maharashtra] in January 2012. One of the patients had a black scar, like a cigarette burn, on his thigh. A blood test diagnosed them with scrub typhus fever, a type of mite-borne rickettsial infectious disease. Doctors said that 1 or 2 cases of rickettsial infections crop up in the city every month.

Also known as 'tsutsugamushi fever' (derived from 2 Japanese words: 'tsutsuga', meaning something small and dangerous, and 'mushi', meaning creature), scrub typhus is curable only if a particular type of antimicrobial agent (tetracycline) is used, but it can get out of hand when diagnosis is delayed or a more routine antimicrobial [such as a penicillin - Mod.LL] is used.

It spreads when chiggers, which are mites found in forests, and now in urban shrubs, bite the person and inject a microorganism called _Rickettsia [now renamed _Orientia - Mod.LL] tsutsugamushi_ into the person. A blood test can confirm the infection.

"Farmers, shepherds, and mountaineers are usually at high risk of catching this infection which is transmitted from animals to humans. The disease epidemiology has been changing with increasing urbanization. The vectors of this disease, ticks and mites have now found their residence in urban bushes with increasing transport, influx of people, and city limits extending into nearby rural areas. Hence, we see scrub typhus cases," infectious disease expert Bharat Purandare said. He has treated 4 patients with the infection recently.

More cases are being diagnosed than before because of increasing awareness among physicians and easier availability of the diagnostic test, Purandare said. Physicians who have been trained in internal medicine usually do not have difficulty in identifying this infection. The level of awareness among other, particularly primary-care physicians is improving, Purandare said. The gold standard test for diagnosis of rickettsial infections (including scrub typhus) is specific antibody testing. "This test is not available widely. Christian Medical College, Vellore has been doing this test. The other test, which is widely available in Pune, is the Weil-Felix test," Purandare said. Weil-Felix test can diagnose the infection with good sensitivity, but sometimes may be falsely positive due to urinary tract infection.

At Golwilkar Metropolis laboratory, one of the few accredited labs in Pune, the Weil-Felix test was carried out on 267 samples between January 2011 and January 2012. "Of them, 86 samples tested positive. More samples, almost 10 to 12 per month, tested positive for the infection between August and December [2011], while there were sporadic cases during March and April," pathologist Aditi Golwilkar-Mehendale said. Western countries use the rickettsial polymerase chain reaction [PCR] test. "We don't have access to this test except in some rare research setting," Purandare said.

Solapur district and large areas of interior Marathwada are the endemic areas in Maharashtra state. The disease has been endemic also in large areas of south India, particularly Tamil Nadu. Northern areas of India are less affected.

"If closely examined, many patients do have a black necrotic mark or eschar (classically described as cigarette burn mark) on mainly lower limbs due to the tick or mite's bite, which marks the entry point of the infecting organisms," Purandare said. Sometimes the eschar may be present on genitals and may be missed. Many patients do not remember any insect bite and lack of such a history or eschar mark does not rule out possibility of rickettsial infection, he added. "Late diagnosis of this infection is common particularly if patients do not have the typical rash and delay may be fatal in some cases. Routine antibiotics do not work in this infection. The disease can rarely be self-resolving," Purandare said.

A case of scrub typhus, the most common of the rickettsial diseases in India, has high grade fever, a measles-like rash all over the body particularly on palms and soles, eschar at mite bite site, regional lymph node enlargement, increased white cell count, decreased platelet count, and [abnormal] liver and kidney function tests.

"Routine antibiotics do not help. Patients can die of brain involvement (encephalitis), heart involvement (myocarditis), liver or kidney failure, disseminated intravascular coagulation, or lung failure," said intensivist Prasad Rajhans.

At Ruby Hall Clinic, there were 3 clinically diagnosed cases of scrub typhus in the last 4 months. "Scrub typhus is a one of the forms of rickettsial infection and such Weil-Felix positive cases could be about 12 to 15 per year," said intensivist Prachee Sathe, director, ICU at Ruby Hall Clinic.

"There are some other tropical illnesses manifesting in similar manner involving the same organs (malaria, dengue, viral fevers, leptospirosis). So it becomes difficult to diagnose immediately. Besides, we do not have specific tests. Serological tests take some time. So it is not unusual to miss the diagnosis in the early stages," said Sathe.

Only the tetracycline group of antibiotics or chloramphenicol work in these cases. If diagnosed early, 7 days of oral treatment is sufficient. Very rapid response with resolution of fever in 48 hours of starting therapy is characteristic. Treatment of complicated disease and treatment of pregnant patients is challenging and requires a multidisciplinary approach.

[Byline: Umesh Isalkar]

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[Weil and Felix described the classical assay for rickettsial antibody detection in 1916. The methodology took advantage of heterophilic (cross-reacting) antigens of members of the genus _Rickettsia_ and several species of the Gram negative bacillus _Proteus_. In the Weil-Felix test, bacteria of _Proteus vulgaris_ OX-19 agglutinate with sera of those infected with typhus group organisms as well as from the Rocky Mountain spotted fever (RMSF) organism _Rickettsia rickettsii_. Cells of _P. vulgaris_ OX-2, on the other hand, agglutinate with sera from individuals with spotted fever infection, except RMSF. The OX-19 agglutination is seen in epidemic typhus, but usually not in Brill-Zinsser recrudescent disease. _P. mirabilis_ OX-K can be similarly used in the serological diagnosis of scrub typhus. Because of the relatively poor sensitivity and specificity of this test, more specific assays can be used for diagnosis, including [one for] complement fixation antibodies. - Mod.LL]

[Photos of eschar:
http://www.japi.org/february_2009/images/pc_02.jpg
- Mod.JW]

[The state of Maharashtra can be located on the HealthMap/ProMED-mail interactive map of India at http://healthmap.org/r/1JYp. - Sr.Tech.Ed.MJ]

PRION DISEASE UPDATE 2012 (02)
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[With the continuing decline in the number of cases in the human population of variant Creutzfeldt-Jakob disease -- abbreviated previously as vCJD or CJD (new var.) in ProMED-mail -- the scope of the occasional ProMED-mail updates has been broadened to include other prion-related diseases. In addition to vCJD, data on other forms of CJD: sporadic, iatrogenic, familial, and GSS (Gerstmann-Straussler-Scheinker disease) are included also since they may have some relevance to the incidence and etiology of vCJD. - Mod.CP]

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Turkey: 1st probable vCJD case
Date: Sat 24 Dec 2011
Source: Dementia and Geriatric Cognitive Disorders Extra [edited]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265806


[ref: Adapınar DO et al: The first report of a patient with probable variant Creutzfeldt-Jakob disease in Turkey. Dement Geriatr Cogn Dis Extra. 2011; 1(1): 429-32]
-------------------------------------------------------
[Interested readers should access the original paper via the source URL to view the full text, the figures, and the references cited. - Mod.CP]

Abstract
--------
Variant Creutzfeldt-Jakob disease (vCJD) was first reported in the UK in 1996. Here, we report the 1st Turkish case of vCJD. A 47 year old man, who has never lived outside of Turkey and had had no transfusion, was admitted to the University Hospital with speech disorder, cognitive decline, and ataxia following depression, irritability, and personality change. The immunoassay of the 14-3-3 protein in the cerebrospinal fluid (CSF) was negative. [The presence of 14-3-3 protein in CSF has been shown to be highly sensitive and specific for the diagnosis of Creutzfeldt-Jakob disease. - Mod.CP]. Brain magnetic resonance imaging revealed high-signal lesions involving the bilateral caudate and lentiform nucleus on T2- and diffusion-weighted imaging. The patient developed akinetic mutism 10 months after disease onset. The clinical presentation and neuroimaging findings were compatible with the vCJD cases reported since 1996 and met the World Health Organization's case definition for probable vCJD.

Introduction
------------
Creutzfeldt-Jakob disease (CJD), which is characterized by progressive dementia with a fatal and incurable course, is the most common human prion disease. There are 4 types of this disease: the sporadic (85 per cent), familial (10-15 per cent), iatrogenic (1 per cent), and variant types [1]. Variant Creutzfeldt-Jakob disease (vCJD) was first reported in 1996 in the United Kingdom and has been causally linked to the consumption of cattle products contaminated with the bovine spongiform encephalopathy (BSE) agent [2]. To date, more than 215 cases of vCJD have been identified worldwide, including in the UK, France, Ireland, Italy, the USA, Canada, Saudi Arabia, Japan, The Netherlands, Portugal, Spain, and Taiwan. In the present paper, we report the clinical and radiological data of the 1st Turkish case of vCJD.

Case report
-----------
A 47 year old man, who was previously healthy and had no history of psychiatric or neurological disorders before the onset of this disease, presented with a 6 month history of progressive behavioural and personality changes, depression, and cognitive decline. His relatives reported that personality changes were his 1st symptoms. He had been a rigorous, disciplined, and frugal person, who was dependable at work and a valued member of his family; however, he became aggressive, extravagant, foul-mouthed, sexually disinhibited, and angry. His wife reported that the patient would have sudden outbursts of agitation, and 2 months later, these outbursts were followed by paranoid behaviours and possessiveness. Due to the psychiatric nature of his complaints, he was admitted to a psychiatry clinic, where he was diagnosed as having a manic disorder and was given atypical antipsychotic drugs. 3 months later, the patient exhibited gait changes, ataxia, and dysarthria, severe forgetfulness, difficulties in swallowing and eating, and incontinence. The patient developed involuntary movements in both of his feet, with dystonic aversion-inversion posturing and occasional erratic movements. He became dependent and apathetic and exhibited regressive behaviours. The patient also exhibited visual hallucinations, during which he reported seeing animals. Some of these complaints may have been side effects from his medication and, consequently, several of the patient's medications were stopped or changed.

As a result of the progressive deterioration of the patient's general status, his relatives transferred him to the Psychiatry Department of our University Hospital. After the neurological examination conducted at the Psychiatry Clinic, he was diagnosed as having rapid progressive dementia with early onset and was hospitalized at the Neurology Clinic. As reported in the patient's medical history, he had never been exposed to cadaveric pituitary hormones, had never undergone a neurosurgical procedure, organ or tissue grafts, or a blood transfusion, and had never travelled to the UK or to any country with reported incidences of BSE.

The neurological examination revealed that the patient was disorientated in place and time. In addition, he was mute. Nystagmus and conjugate gaze dysfunction were present, as were cerebellar ataxia, dysmetria, and dysdiadochokinesia. The patient's tone was slightly increased in his lower limbs, and his plantar responses were extensor.

The level of protein in his cerebrospinal fluid was increased, and no 14-3-3 protein was detected. An electroencephalogram showed a generalized slowing of wave, which was more evident in the left hemisphere, but did not have any periodic complexes. He was referred to the Radiology Department for cerebral MRI. On T2-weighted images and fluid-attenuated inversion recovery (FLAIR) images, hyperintense signal changes in the bilateral caudate nuclei (white arrows) and the lentiform nucleus (black arrows) were seen. In addition, hyperintensity in the bilateral thalamic region was less prominent than in the previously described areas. Cortical hyperintensity was noted on diffusion-weighted imaging.

Genotyping of the prion protein gene (PRNP) identified a P102L mutation and heterozygosity for methionine at codon 129. The patient did not want to undergo a brain biopsy, and we continued to follow his progress at his home. At the time this report was written, the patient was alive, mute, and on bed rest.

Discussion
----------
The patient described in the present report was the 1st probable case of vCJD in Turkey. The clinical features of this patient are consistent with the vCJD cases that have been identified in the UK and France, including psychiatric manifestations at the disease onset, a delayed occurrence of neurological signs, ataxia, and dementia [3]. In addition to the pulvinar sign that was present on the MRI and EEG, the patient fulfilled the WHO case definition for probable vCJD, the specificity of which is 100 per cent [4]. Of note, a tonsil biopsy is not necessary if the clinical features and the MRI findings are compatible with vCJD, as the pulvinar sign is highly characteristic [5].

Sequencing analysis revealed that the patient had 2 different nucleotide changes in the coding region of the PRNP gene. The 1st one is the M129V polymorphism, and our patient was heterozygous for this alteration. Interestingly, all the patients who have undergone genotyping up to now have been homozygous for methionine at codon 129. This polymorphism is associated with susceptibility to prion diseases [6]. The 2nd one is the P102L mutation, which was first identified in affected members of 2 unrelated families with Gerstmann-Straussler disease. P102L is one of the most common PRNP mutations and also related to CJD.

This case highlights the difficulties in achieving an early diagnosis of vCJD. At the initial presentation, a variety of diagnoses were proposed, but vCJD was not considered in this patient. Instead, he was diagnosed as having an affective disorder at the psychiatry clinic. The delayed neurological signs in this patient pointed to the possibility of progressive dementia, which is not surprising given the frequency of psychiatric features that are observed by primary care physicians. These clinical features are often misleading. Almost half of the cases of vCJD were reviewed by a psychiatrist prior to the patients' neurological referral [7]. A neurological etiology was usually suspected promptly after the patients developed objective neurological features, which resulted in a neurological referral in all of the cases. The single most important determinant of early diagnosis was the presence of objective neurological features. For this reason, all physicians must be careful when diagnosing rapidly progressing dementia that begins at a young age.

--
communicated by:
Terry S Singeltary Sr


[The results presented in this report, if confirmed, indicate that patients with vCJD are still being detected by the medical community. The 1st presumptive Turkish case of vCJD has made its appearance 15 years after the 1st case in the United Kingdom. The source of this infection of a patient who had no contact with the UK or any of the other countries previously reporting vCJD, remains to be established. - Mod.CP]

KYASANUR FOREST DISEASE - INDIA (KARNATAKA)
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[1] Date: Fri 3 Feb 2012
Source: IBN [edited]
http://ibnlive.in.com/news/kfd-claims-1 ... 0-115.html


Department of Health and Family Welfare of Shimoga confirmed the death of one person of Kyasanur Forest disease (KFD) in Konandur hobli of Tirthahalli taluk on 17 Jan [2012]. District Health and Family Welfare officer Dr Channabasappa told Express that of the 30 blood smears [whole blood or serum samples?] tested in December 2011 and January 2012, 6 samples confirmed KFD [virus or antibody?].

The person (age 65 years) died due to KFD [virus infection] and the remaining 5 cases were recovering.

The DHO said blood smear [samples] of 6 cases were tested in 2 different laboratories. 5 cases tested positive for KFD at Shimoga's Virus Diagnostic Laboratory and one case at National Institute of Virology, Pune. The death of the person was confirmed by the Shimoga lab. Cases of fever were reported in Chittinakoppa, Hirekallalli, Chickakallalli, Kadegodu and Agashinakoppa of Konandur hobli.

The Health Department has taken precautions to check the spread of the disease. A mobile check-up-cum-treatment van is being sent to the area besides check-ups at primary health centre, Konandur.

--
Communicated by:
Shamsudeen Fagbo


******
[2] Date: Fri 10 Feb 2012
Source: IBN [edited]
http://ibnlive.in.com/generalnewsfeed/n ... 61531.html


In the past 15 days, 9 persons have tested positive for Kyasanur Forest disease (KFD), known as Monkey disease in Theerthahlli taluk in the a top district official said here today [10 Feb 2012].

Kyasanur Forest Disease is a tick-borne viral hemorrhagic fever endemic to South Asia. The disease is caused by a virus belonging to the family flaviviridae, which also includes yellow fever and dengue fever. "9 of the 89 samples sent to virus testing laboratory in Bangalore tested positive," Shimoga Zilla Parishad CEO Sanjay Bijjur told reporters after a review meeting with health officials here today. He said he has directed all medical staff to complete the inoculation of KFD vaccine to all villagers before 14 Feb [2012] in all 3 primary health divisions covering Konandur, Hombuja and Rippenpet in the taluks. Bijjur said there is sufficient quantity of vaccine and vehicles with paramedics, doctors and health staff are visiting all areas to provide immediate relief to people.

--
Communicated by:
Shamsudeen Fagbo


[The number of KFD cases has increased by 3 in 7 days. Apparently, the Shimoga district in Karnataka state is an endemic focus for KFD virus. There have been human cases there in 2011 and 2009. In the 28 Feb 2009 post on KFD in India (ProMED-mail archive number 20090302.0860), Mod.CP posted this excellent comment:

"Kyasanur forest disease (KFD) is caused by Kyasanur forest disease virus (KFDV), a member of the family _Flaviviridae_. KFDV was identified in 1957 when it was isolated from a sick monkey from the Kyasanur forest in Karnataka (formerly Mysore) state, India. The main hosts of KFDV are small rodents, but shrews, bats, and monkeys may also carry the virus. KFD is transmitted from the bite of an infected tick (_Haemaphysalis spinigera_ is the major vector). Humans can get this disease from a tick bite or by contact with an infected animal, such as a sick or recently dead monkey. Larger animals such as goats, cows, and sheep may become infected with KFD, but they do not have a role in the transmission of the disease. Furthermore, there is no evidence of the disease being transmitted via the unpasteurized milk of any of these animals. It occurs principally in the Shimoga and Kanara district of Karnataka, India and is common in young adults exposed during the dry season in the forest.

After an incubation period of 3-8 days, the symptoms of KFD begin suddenly with fever, headache, severe muscle pain, cough, dehydration, gastrointestinal symptoms and bleeding problems. Patients may experience abnormally low blood pressure and low platelet, red blood cell, and white blood cell counts. After 1-2 weeks of symptoms, some patients recover without complications. However, in most patients, the illness is biphasic, and the patient begins experiencing a 2nd wave of symptoms at the beginning of the 3rd week. These symptoms include fever and signs of encephalitis (inflammation of the brain). The diagnosis is made by virus isolation from blood or by serologic testing using enzyme-linked immunosorbent serologic assay. There are approximately 400-500 cases of KFD per year with a case fatality rate of 3-5 percent.

Some of this information has been extracted from the CDC fact sheet (see:
http://www.cdc.gov/ncidod/dvrd/spb/mnpa ... estDis.pdf)."

KFD virus and its variants are found in a wider geographic area than just India. A variant of KFD virus, Alkhurma virus, was isolated in Saudi Arabia. The gene sequence of a Nanjianyin China virus isolate obtained from a febrile patient is highly homologous to that of KFD virus. ProMED-mail archive number 20090303.0871 cites Prof. Steve Berger saying, "... 22.4 percent of persons living in the Andaman and Nicobar Islands were found to be seropositive for KFD in 2002," and that "there is a safe and effective inactivated vaccine available in India."

References:
Zaki AM. Isolation of a flavivirus related to the tick-borne encephalitis complex from human cases in Saudi Arabia. Trans R Soc Trop Med Hyg. 1997;91:179-181.

Jinglin Wang, Hailin Zhang, Shihong Fu, Huanyu Wang, Daxin Ni, Roger Nasci, Qing Tang, and Guodong Liang. Isolation of Kyasanur Forest Disease Virus from Febrile Patient, Yunnan, China. Emerg Infect Dis 2009; 15, 326-328. "

A HealthMap/ProMED-mail interactive map showing the location of the Shimoga district, Karnataka state, can be accessed at http://healthmap.org/r/1L-v. - Mod.TY]

TYPHOID FEVER UPDATE 2012 (05): INDIA
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India (Himachal Pradesh)
Date: Fri 10 Feb 2012
Source: The Times of India [edited]
http://articles.timesofindia.indiatimes ... ge-sirmaur

A village in Himachal Pradesh's Mandi district has reported more than 15 typhoid patients, a health official said Friday [10 Feb 2012].

According to the official, contamination in the drinking water pipeline could be the reason for the disease outbreak.

30 people of Nau Pnau village with symptoms of nausea and high fever were reported in the past 24 hours. 16 of them were confirmed to be suffering from typhoid, Mandi's chief medical officer Ajay Bhanu Gupta said.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Himachal Pradesh is a state in the north of India bordered by the Indian states of Jammu and Kashmir on the north, Punjab on the west and south-west, Haryana and Uttar Pradesh on the south, Uttarakhand on the south-east and by the Tibet Autonomous Region on the east. The literal meaning of Himachal Pradesh is In the lap of Himalayas. A map showing the state's location can be found at http://en.wikipedia.org/wiki/Himachal_Pradesh. - Mod. LL]

DENGUE/DHF UPDATE 2012 (07)
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- India (Kerala). 12 Feb 2012. The state capital is battling a dengue outbreak after the city recorded 139 cases in the last 2 months. Out of the 139 cases, 98 cases have been reported from the corporation area.
http://articles.timesofindia.indiatimes ... ty-garbage

[A HealthMap/ProMED-mail map of Kerala can be accessed at http://healthmap.org/r/1dR5. - Mod.TY]

CHICKENPOX - INDIA: (MUMBAI)
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Date: Sat 25 Feb 2012
Source: Mid Day [edited]
http://www.mid-day.com/news/2012/feb/25 ... orried.htm


Chickenpox outbreak in adults has docs worried
-----------------------------------------
Blame it on the change in temperature, increasing number of Mumbaikars are being diagnosed with chickenpox. The city's only hospital for infectious diseases, Kasturba, has admitted over 90 cases in the last week. However, contrary to the norm, only eight patients are children and the rest are adults.

Dr Umesh Aigal, medical superintendent, Kasturba hospital, said, "Majority of the patients who have been admitted to the hospital are male adults and most of them are migrants. They may have not been exposed to the virus in their childhood and must have contracted the disease after coming to the city."

Private hospitals in the city do not admit patients suffering from chickenpox, as it is highly contagious and requires isolation. Admission is advised only in cases where the patient has developed complications. Consultant physician Dr Pratit Samdani of Jaslok hospital said, "Chickenpox is mild in children, but it can lead to a variety of complications like pneumonia and encephalitis when adults contract it. A second attack happens only in 10-12 per cent of patients."

Dr S R Shenoy, who runs a clinic in Goregaon (East), said, "In the last few days, I have seen six adult cases of chickenpox, which is ironical. There is a need for awareness of vaccination. Latest recommendations suggest that a booster dose should be taken after four years which not many are aware of."

The varicella virus vaccine has been known to prevent the disease in up to 90 per cent of cases. People who contract chickenpox after getting the shot suffer from a milder form of it. The cost of the vaccine ranges between Rs 1,150 and Rs 1,450 and it is optional in India.

Explaining the cause behind the rising number of cases, Dr Samdani said, "Humidity is favourable for [transmission of] the virus. There will be cases of chickenpox in the next few months."

(By: Priyanka Vora)


[Chickenpox is a very contagious disease caused by varicella-zoster virus (VZV) -- a herpes virus. It causes a blister-like rash, itching, tiredness, and fever. Chickenpox can be serious, especially in babies, adults, and people with weakened immune systems. It spreads easily from infected people to others who have never had chickenpox or received the chickenpox vaccine. Chickenpox spreads in the air through coughing or sneezing. It can also be spread by touching or breathing in the virus particles that come from chickenpox blisters.

Varicella-zoster virus also causes shingles. A person with shingles can spread the virus to others who have never had chickenpox or received the chickenpox vaccine. In these cases, the exposed person might develop chickenpox.

A person with chickenpox can spread the disease from 1 to 2 days before they get the rash until all their chickenpox blisters have formed scabs. This may takes from 10 to 21 days after exposure to a person with chickenpox or shingles for someone to develop chickenpox. For most people, getting chickenpox once provides immunity for life. However, for a few people, they can get chickenpox more than once, although this is not common.

Ultraviolet (UV) rays help prevent the spread of chickenpox, therefore people in milder climates should be more at risk of catching the disease. However the peak incidence of chickenpox in India and Sri Lanka is during the hot, dry, sunny season. This anomaly has been explained because UV rays are actually much lower in the dry season compared with the monsoon period. In the dry season, the pollution in the atmosphere reflects the UV rays back into space. Whereas in the monsoon season, the rains wash away the pollution, and UV irradiation is increased. (For further discussion see: Science Daily 15 Dec 2011 http://www.sciencedaily.com/releases/20 ... 094921.htm.

Mumbai in the Indian state of Maharashtra can be located in the interactive HealthMap at http://healthmap.org/r/1pr7.- Mod.CP
]

KYASANUR FOREST DISEASE - INDIA (02): (KARNATAKA)
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Date: Mon 27 Feb 2012
Source: The Hindu [edited]
http://www.thehindu.com/todays-paper/tp ... 937147.ece


As Kyasanur Forest disease, popularly known as monkey fever, has created havoc on Tirthahalli and Hosanagar taluks in the [Shamoga] district this year, people in the affected region have demanded the Government to avoid releasing monkeys captured in urban areas into the forest, and to modernise the Viral Diagnostic Laboratory in the district at the earliest.

The monkey fever is a transmitted through the ticks from monkeys to human beings.

It is said that the monkeys captured in urban areas lack the skills to survive in the forest. Moreover, the resistance power in such monkeys against viral infections was low.

Even after being released in the forest, these monkeys return to these villages in search of food. The people are now demanding that the Government stop releasing these monkeys in the nearby forests.

Meanwhile, the reports of monkey fever are pouring in steadily from Tirthahalli and Hosanagar taluks even after completion of the vaccination drive by the Department of Health and Family Welfare.

The Viral Diagnostic Laboratory (VDL) in the city is receiving blood samples of suspected cases daily. As many as 176 blood samples of suspected cases were subjected to test at VDL in 2012 of which 38 blood samples were tested positive.

Sources in the Department of Health and Family Welfare have said that of the 37 tick samples collected in the district this year so far, 13 tested positive.

As monkey fever has become a regular phenomenon in the district, there is a growing demand to modernise the VDL in the city. At present, mouse inoculation method is used to test the blood samples under which at least seven days is required to get the results. A proposal has been sent to the Government to introduce rapid polymerase based chain reaction testing facility here at an estimated cost of Rs. 75 lakh under which the result of test conducted on blood samples of suspected cases can be known in a span of 24 hours. Training on the new investigation procedure has been provided for very few staff members of VDL.

Meanwhile, a team of experts from the National Institute of Virology, Pune, have visited the VDL recently and assessed the facilities available there to introduce the new investigation procedure.

The team has provided the list of equipment and machines that need to be purchased for the purpose. People in the affected region have demanded that the Government allocate ample funds in the budget for 2012-13 to modernise the VDL.

--
Communicated by:
Ronan Kelly




[The number of KFD [Kyasanur Forest Disease] cases continues to increase over the past month. Apparently, the Shimoga district in Karnataka state is an endemic focus for KFD virus. Translocating monkeys is unlikely to be successful, and runs the risk of moving pathogens to new areas along with animals. Apparently, the animals are not moved to areas unpopulated by people to prevent them from returning to villages. If culling or translocation are unacceptable socially, the only long-term measure to reduce monkey numbers may be sterilization or contraception.

There have been human cases in the Shimoga district in 2011 and 2009. In the 28 Feb 2009 post on KFD in India (ProMED-mail archive number 20090302.0860), Mod.CP posted this excellent comment:

"Kyasanur forest disease (KFD) is caused by Kyasanur forest disease virus (KFDV), a member of the family _Flaviviridae_. KFDV was identified in 1957 when it was isolated from a sick monkey from the Kyasanur forest in Karnataka (formerly Mysore) state, India. The main hosts of KFDV are small rodents, but shrews, bats, and monkeys may also carry the virus. KFD is transmitted from the bite of an infected tick (_Haemaphysalis spinigera_ is the major vector). Humans can get this disease from a tick bite or by contact with an infected animal, such as a sick or recently dead monkey. Larger animals such as goats, cows, and sheep may become infected with KFD, but they do not have a role in the transmission of the disease. Furthermore, there is no evidence of the disease being transmitted via the unpasteurized milk of any of these animals. It occurs principally in the Shimoga and Kanara district of Karnataka, India and is common in young adults exposed during the dry season in the forest.

After an incubation period of 3-8 days, the symptoms of KFD begin suddenly with fever, headache, severe muscle pain, cough, dehydration, gastrointestinal symptoms and bleeding problems. Patients may experience abnormally low blood pressure and low platelet, red blood cell, and white blood cell counts. After 1-2 weeks of symptoms, some patients recover without complications. However, in most patients, the illness is biphasic, and the patient begins experiencing a 2nd wave of symptoms at the beginning of the 3rd week. These symptoms include fever and signs of encephalitis (inflammation of the brain). The diagnosis is made by virus isolation from blood or by serologic testing using enzyme-linked immunosorbent serologic assay. There are approximately 400-500 cases of KFD per year with a case fatality rate of 3-5 percent.

Some of this information has been extracted from the CDC fact sheet (see:
http://www.cdc.gov/ncidod/dvrd/spb/mnpa ... estDis.pdf)."

KFD virus and its variants are found in a wider geographic area than just India. A variant of KFD virus, Alkhurma virus, was isolated in Saudi Arabia. The gene sequence of a Nanjianyin China virus isolate obtained from a febrile patient is highly homologous to that of KFD virus. ProMED-mail archive number 20090303.0871 cites Prof. Steve Berger saying, "... 22.4 percent of persons living in the Andaman and Nicobar Islands were found to be seropositive for KFD in 2002," and that "there is a safe and effective inactivated vaccine available in India."

References:
Zaki AM. Isolation of a flavivirus related to the tick-borne encephalitis complex from human cases in Saudi Arabia. Trans R Soc Trop Med Hyg. 1997;91:179-181.

Jinglin Wang, Hailin Zhang, Shihong Fu, Huanyu Wang, Daxin Ni, Roger Nasci, Qing Tang, and Guodong Liang. Isolation of Kyasanur Forest Disease Virus from Febrile Patient, Yunnan, China. Emerg Infect Dis 2009; 15, 326-328. "

ProMED thanks Ronan Kelly for sending in this report.

A HealthMap/ProMED-mail interactive map showing the location of the Shimoga district, Karnataka state, can be accessed at http://healthmap.org/r/1L-v. - Mod.TY]

DENGUE/DHF UPDATE 2012 (10)
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*****

- Pakistan (Lahore, Punjab province). 29 Feb 2012. As many as 82 cases of unconfirmed dengue, 59 in Lahore alone, have been reported in Punjab within the past few days. Around 41 dengue-suspected patients have been admitted to Mayo Hospital Lahore, 13 to Ganga Ram Hospital, 3 to Services Hospital, one to Jinnah Hospital, and one to Lahore General Hospital (LGH).

Also at least 5 other cases were reported in Sheikhupura, 3 in Gujranwala, 2 in Sialkot. http://www.brecorder.com/top-stories/0/1160121/

[A HealthMap/ProMED-mail interactive map showing the location of Lahore in Punjab province can be accessed at http://healthmap.org/r/1kdh. - Mod.TY]