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2014; Vol.3,No.1 January -March
ISSN 2319 – 4154

Original Articles

Clinical profile of acute undifferentiated febrile illness in patients admitted to a teaching hospital in Kerala

MA Andrews, Aleena Elizabeth, Praveenlal Kuttichira
Department of Medicine, Government Medical College, Thrissur, Kerala, India
Correspondence to: anjulioness@gmail.com

  • Abstract

    In the last 5 years, Kerala witnessed fever epidemics during monsoon season resulting in severe physical, mental and financial strain to both individuals and society.

    Objective: To describe the pattern of AUFI in 2007 and 2012 in central Kerala and to see whether any change in the clinical profile has occurred.

    Materials and methods: AUFI cases admitted in the medicine wards of Government medical college Thrissur were studied in the months of June and July in 2007 retrospectively and in 2012 prospectively.

    Preset diagnostic criteria were used to classify the cases into the common etiologies involved. The demographic, clinical and laboratory parameters were analyzed.

    Results: There were 273 cases of AUFI in the months of June and July 2007. Out of the 273 patients, 113 (41.4%) were diagnosed to have leptospirosis, 41 (15%) to have dengue fever and 34 (12.5%) to have Chikungunya. Eighty five (31%) cases could not be classified. In June and July 2012 a total of 96 patients with AUFI were enrolled. Major etiologies identified were leptospirosis 23 (23.96%), dengue 12 (12.50%) and miscellaneous 61 (63.54 %). In 2007 and 2012 mortality in cases of leptospirosis was 24 (21.2%) and 6 (26.09%) respectively. No patients with either dengue fever or Chikungunya died in both epidemics.

    Conclusion: Leptospirosis constituted a significant proportion of cases in both series. Case fatality was less in 2012 but the percent of patients died due to leptospirosis among patients admitted to the hospital remained almost the same. In a large number of patients with AUFI, the exact cause could not be identified.

    Introduction

    Every year in Kerala, a large number of patients suffer from acute fever, especially during the rainy season.1 Acute fever cases in which no focus of infection can be pointed out by history, physical examination or routine investigations are common and are referred as Acute undifferentiated fever (AUFI).2

    The common presentations are fever of less than two weeks duration and non-specific symptoms like malaise, myalgia, headache and loss of appetite.3 In the western world AUFI is mainly due to viral illness, but in underdeveloped countries including India , it can be due to potentially treatable life threatening illnesses such as malaria, leptospirosis, Hanta virus infection and Japanese encephalitis.4 Since many diseases can have similar presentation, patients are advised to undergo various investigations which delay the treatment and increase the cost. In spite of the repeated epidemics in Kerala, published data on the experiences is scanty. This hinders the development of organizing preventive plans effectively.

    Aim of the study

    To compare the clinical features of AUFI in 2007 and 2012 in the rainy seasons in Kerala

    Materials and methods

    Patients admitted to the Government Medical College hospital, Thrissur formed the subjects of the study. The collegiate hospital served three adjoining districts of Kerala- Thrissur, Malappuram and Palakkad.

    The inclusion criteria of AUFI were temperature over 38.3oC, duration of fever less than 14 days, and non detection of specific single organ involvement by history, physical examination and routine investigations.

    2007 epidemic was studied by a retrospective analysis of the case sheets of all the patients who were admitted for AUFI during the months of June and July in the year 2007. Using a pre-designed proforma, data was extracted from the case sheets. The cases were grouped into leptospirosis, dengue fever, Chikungunya and miscellaneous based on the clinical features.

    2012 epidemic was studied prospectively. All adult patients, (13 years old and above) admitted to the hospital with acute febrile illness in June and July 2012 were considered.

  • For all the patients, a detailed clinical examination was done. The routine laboratory tests such as complete blood count, urine analysis, urea, creatinine, glucose and liver function tests were done. Additional investigations including peripheral smear, blood culture, chest X-ray, Widal, rapid card test for malarial antigen, serology for leptospirosis and dengue were done as per decision of the treating physician.

    Diagnosis was made using Modified Faine's criteria for leptospirosis, WHO 2009 criteria for dengue fever 5 and European Centre for Disease Control (ECDC) 6 for Chikungunya.

    Data was analyzed using Epi-Info 7. Demographic data and clinical characteristic were summarized with counts (percentages) for categorical variables, and mean with standard deviation (SD) for normally distributed continuous variables. Categorical variables were compared using chi square test and p values < 0.05 were taken as significant.

    Results

    Between 1st June and 31st July in 2007 and 2012 there were 273 and 96 in-patients respectively with a diagnosis of AUFI. In 2007, 166 were males (61%) and 107 (39%) were females while in 2011, 85 (88.54%) were males and 11 (11.5%) females. Majority among both the study samples were in the middle age group (Table 1).

    Table 1. The age distribution of AUFI patients in 2007 and 2012

      AUF*I in 2007 AUFI* in 2012

    Age

    Number

    Percentage

    Number

    Percentage

    10 to 20

    34

    12.5

    12

    12.5

    20 to 30

    49

    17.5

    22

    22.9

    30 to 40

    66

    24.2

    16

    16.7

    40 to 50

    42

    15.2

    21

    21.9

    50 to 60

    41

    14.8

    13

    13.5

    60 to 70

    28

    10.5

    9

    9.4

    > 70

    13

    5

    3

    3.1

    Total

    273

    100

    96

    100

    *AUFI-Acute undifferentiated fever

    Among AUFI patients of 2007 epidemic, the commonest symptom was myalgia and joint pain, followed by calf muscle tenderness, oliguria, diarrhea, cough and dyspnea (Table 2).

    Table 2. Clinical features of AUFI patients in 2007 and 2012 epidemics

    Clinical features AUFI* 2007 AUFI* 2012

    Myalgia/joint pain

    106

    39%

    49

    52.1%

    Diarrhoea

    37

    13.67%

    24

    25.5%

    Cough/Dyspnea

    27

    9.9%

    33

    34.37%,

    Oliguria

    46

    16.67%

    25

    27.08%

    Calf muscle tenderness

    85

    31.25%.

    21

    21.87%

    Total patients

    273

    100%.

    96

    100%

    *AUFI-Acute undifferentiated fever

    The 2007 epidemic was constituted by leptospirosis, Dengue, Chikungunya and miscellaneous groups. The 2012 epidemic was constituted by leptospirosis, Dengue and miscellaneous only. There were no cases of Chikungunya among the in-patients in 2012 (Table 3).

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