A diagnostic challenge: Dengue vs Chikungunya

Couple of days back, a 30 yr old lady came to me in a panicky state for a second opinion, complaining of fever, joint pains and muscle pains since past 3 days.  A routine blood analysis for fever showed a Positive result  for the IgG anti- Dengue antibodies whilst the IgM anti-Dengue antibodies was Negative. The anti-Chikungunya antibodies were negative. So were the rest of the investigations. 

She was diagnosed as Dengue fever and advised hospitalization. 

I begged to differ as regards the diagnosis. At the outset, it seemed like a Viral episode and I prescribed her Paracetamol and advised bed rest. Over the next few days, her platelet counts remained normal and her fever subsided. She followed up after 2 weeks however, still complaining of joint pains and stiffness. A repeat analysis this time showed a positive result for Chikungunya IgM antibodies. 

Thus, the diagnosis changed from first Dengue, then to Viral fever and now finally Chikungunya. 

The question that would be on every body's mind is: 

1. Wouldn't a false diagnosis hamper the treatment and 

2. How would you differentiate clinically between all these three ailments? 

Let me explain. First and foremost, all the three are forms of Viral fever. So, the basic management remains same in all of them. 

Differentiating features:

The dengue and chikungunya viruses are both transmitted by Aedes species of mosquitoes.

The distinguishing feature of chikungunya includes potentially debilitating bilateral joint pains and, in some cases, arthritis. 

And a significant drop in platelet counts is mainly observed in dengue. 

Fallacies of testing:

During the first few days of the illness, the antibodies may remain undetected in blood and hence Dengue may be missed unless the Spot or Antigen test is performed. 

Clinicians should also be aware that detection of anti-Dengue IgG antibody has very little utility in the diagnosis of acute dengue, as IgG antibodies may be the result of an infection that occurred in previous months or years. In addition, IgG antibodies against other viruses can cross-react with Dengue, thereby yielding false-positive diagnostic results. 

Management:
Chikungunya is rarely fatal. In contrast, early identification and proper clinical management for dengue cases can significantly reduce the fatality. Therefore, patients suspected of having dengue or chikungunya should be managed as having dengue until dengue can be ruled out. 

Most patients who develop severe dengue do so in the 24-48 hours after fever subsides and this can occur rapidly. Hemodynamic status should be maintained with judicious use of isotonic intravenous fluids, which is the central component of dengue patient management. 

Pain and fever in patients with suspected dengue or chikungunya should be managed with acetaminophen or Paracetamol. Aspirin and other NSAIDs should not be given to such patients because of the increased risk for bleeding manifestations if the patient has dengue. If patients have been afebrile for at least 48 hours, have no warning signs of severe dengue, and still complain of joint pain, NSAIDs may be considered. 

The list of viral fevers is too exhaustive to elaborate and it is practically impossible to clinically differentiate one from the other. The prototype always would remain the Influenza virus or "flu". But most often than not, these are self limiting and unless there is an added bacterial infection, antibiotics wouldn't work for these viruses. 

Does Aspirin a day really keep the doc at bay?

The benefits of the common practice of taking an aspirin a day to keep the doctor away, are now under serious dispute. 

Various authors have argued for time immemorial that the benefits of aspirin far outweigh the risks. Not only does aspirin provide protection against cancer, but it also reduces the risk for heart disease and stroke. An aspirin daily can certainly seem like the ultimate supplement and it is very inexpensive.

There were also talks of Aspirin being included in the community water supply so that people would benefit from it. 

This practice is now all set for a change. 

Critics have started panning this molecule. 

Their claim is that there is no evidence that aspirin is effective for the primary prevention of  acute coronary syndromes and stroke. Even if benefit does exist, it may not outweigh the harm. Also, there is no evidence that long-term aspirin should be given to patients even with known cardiovascular disease. 

It is possible that when a stable plaque has ruptured, it becomes unstable, resulting in a coronary 'ulcer'. This is a focus for thrombus generation. Aspirin acts here by inhibiting thrombus propagation. However, once the acute event is over and the 'ulcer' has healed, any reduction in platelet aggregation by aspirin may be offset by inhibition of prostaglandin-mediated vascular wall defences and the increased risk of plaque haemorrhage.

Thus, aspirin, just like an antibiotic, should be given for an acute illness and stopped when the acute syndrome has settled. This could be for a period ranging from 1-6 months. 

Aspirin use is associated with an increased risk of 

• Dyspepsia, gastro-intestinal bleeding leading to anemia. In patients with cardiovascular disease, iron deficiency anemia is associated with a poor prognosis. 
• Chronic kidney disease and renal dialysis. 
• Haemorrhagic stroke. 
• Possibly deafness and age-related macular degeneration. 

Aspirin may also lessen the benefits of drugs that are known to reduce cardiovascular risk, such as angiotensin-converting enzyme (ACE) inhibitors and possibly beta-blockers. 

On a positive side, aspirin prevents vascular proliferation in tumours preventing their growth, thus retarding the progression of bowel and other cancers. 

There is no denying the blood thinning properties of Aspirin for those with heart problems but there is very little justification to insist that everyone needs to take an aspirin. 

"Advice for the day: If you have a headache, follow the instructions on the bottle. Take 2 and KEEP AWAY FROM CHILDREN. "

Drug- Drug War: Clarithro vs CCB

The antibiotic clarithromycin prescribed for patients already taking antihypertensive calcium-channel blockers is associated with increases in hospitalization for acute kidney injury, hypotension, and death, according to new research.

Clarithromycin is an inhibitor of the cytochrome P453A4, the enzyme that metabolizes calcium-channel blockers. The antibiotic can send blood concentrations of calcium-channel blockers soaring by as much as 500% leading to severe hypotension. 

Patients on regular treatment with calcium channel blockers like Amlodipine, Felodipine, Nifedipine, Diltiazem or Verapmil were prescribed Clarithromycin or Azithromycin. These macrolide antibiotics are commonly used for upper respiratory infection, pneumonia, eradication of H. Pylori, and atypical mycobacteria. 

Because azithromycin is only a weak inhibitor of CYP34A, the type of intensification of the calcium-channel blocker that occurs with clarithromycin is not expected.

Also, due to the role of the kidneys in eliminating clarithromycin, guidelines call for reduced dosing of the antibiotic in patients with chronic kidney disease. 

Thus, it is highly advisable, in patients suffering from high blood pressure and on regular medications, to be wary of the antibiotics prescribed or used over the counter. 

Published: November 9 in JAMA 

Asepsis and Dementia: Can there be a possible interaction?

I have always been taught by my parents the virtues of staying clean and maintaining a good hygiene all through out my life. Being a Muslim, we have to offer prayers 5 times a day. But these cannot be offered without the ablutions. So that means we need to cleanse ourselves at least five times in the day. 

Being a doctor, our professors have always harped on the compulsory aseptic precautions, be it the out patient department, regular routine rounds, or the peri operative wash up.  

The benefits of cleanliness are endless. 

Thus, when my hospital staff showed me this news clipping, I was taken aback. 

Shocking but true. 

An obsession with being too clean and hygienic could lead to a higher risk of dementia, researchers have warned.

Researchers say that people living in wealthier countries may be at higher risk of developing Alzheimer's disease, according to a study published in the journal Evolution, Medicine, and Public Health.

The researchers suggested the ‘hygiene hypothesis’ was behind the difference. This is the theory that an excessively clean lifestyle doesn't allow us to develop immunity levels and thus we are unable to combat many germs.

Results of the analysis revealed that countries with higher levels of sanitation and those with significantly lower rates of infectious disease also had higher rates of Alzheimer's disease.   

Shocking but true.

Thus, I would conclude on this note that   the people suffering from OCDs (Obsessive Compulsive disorders), who repeatedly get the urge to wash and clean themselves, are in for a rude shock. They now have to deal with another neurological issue - Dementia. 

First time lucky, or unlucky

Whoever would have thought that the first child born (primogeniture) would be a riskier one?

The first one is more intelligent with a higher IQ than the later siblings probably due to the fact that he or she is the 'pearl of the eye' and gets lavish attention from parents that boosts the intellectual development. 

But medical literature antagonizes this. 

Recently, evidence has emerged on the consequences of primogeniture on long-term metabolic and cardiovascular health risks.

There has been a steady decline in the birth rates in the world owing to many factors which include family planning measures, government policies (one child norm) or economic constraints. As a result of this, we have a large percentage of one-child families. Since the first child is prone to health issues, we are now staring at a future population with a high proportion of risk factors. 

Despite similar gestational ages, first borns are 250g lighter than the later siblings at birth. Changes in the placentation are accounted for this difference in birth weights. 

Low birth weight is an indirect indicator of poor intrauterine milieu and adverse health outcomes have been demonstrated in association with decreasing birth weight. Offspring of mothers exposed to nutritional or physiological stress during pregnancy are at increased risk of metabolic and cardiovascular disease in later life. There is extensive evidence linking a reduction in birth weight with increased risk of insulin resistance, Type 2 diabetes mellitus, hypertension, cardiovascular disease, stroke and cancer.

First-born children are taller than the second or third child. Taller stature in childhood is positively associated with overweight status and obesity later in life. 

Various statistics suggest that first-borns were more likely to develop Type 1 diabetes mellitus, hypertension, heart disease, allergic disorders and psychological issues. 

Primogeniture are the largest identifiable study group (accounting for more than half of the world's population), so that any associated health risks could have enormous public health consequences.

Obesity: The Pandemic

Obesity is defined as abnormal or excessive fat accumulation that may impair health.

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person's weight in kilograms divided by the square of his height in meters (kg/m2).

The WHO definition is:

a BMI greater than or equal to 25 is overweight

a BMI greater than or equal to 30 is obesity.

Obesity is a major public health problem in the world. Two thirds of adults in the  US are overweight, and one third are obese. Being obese increases the risk for other diseases: high blood pressure, heart disease, type 2 diabetes, osteoarthritis, sleep apnea, and even some cancers.

The American Medical Association (AMA) House of Delegates has in June 2013 redefined Obesity from a major public health problem to a Disease. After much debate, the majority ruled that obesity is a disease state with multiple pathophysiologic aspects requiring a range of interventions to advance obesity treatment and prevention. 

This has now given an entirely different perception to this potentially hazardous malady. 

"OBESITY IS A DRIVER OF MUCH SUFFERING, ILL HEALTH, AND EARLIER MORTALITY."

The two sides of the coin : 

• Here's the downside of calling obesity a disease. Some worry that this would medicalize obesity and intensify reliance on drugs and surgical treatments rather than relying on diet and exercise to attain a healthy weight. Another concern is that calling obesity a disease could alienate some obese individuals, especially if the emphasis is on achieving ideal weight rather than focusing on healthy eating and increasing physical activity. 

The Body mass index (BMI), that obesity is defined on the basis of, has many limitations. It was originally designed as a research tool: a rough population-level indicator. It's not a great way of measuring body fatness. Some people with a BMI in the so called "normal" range can have too much body fat, as well as metabolic problems. Some with BMIs over 30 kg/m2 -- the so-called obese range -- have plenty of muscle and no excess fat . Some with high BMIs are normal metabolically and also have normal blood pressure and cholesterol levels.

The BMI defines size, not health. 

The National Heart, Lung, and Blood Institute is now working on new guidelines on overweight and obesity in adults. 

• Here's the pro side. Calling obesity a disease could mean greater investments by the government and the private sector: more research into causes, triggers, and treatments, including more US Food and Drug Administration (FDA)-approved drugs for treatment. Another benefit of making obesity a disease is that it could make it harder for third-party payers to deny coverage.

Obesity paradox: 

A collection of studies suggests that BMIs in the overweight or obese range may have protective effects on mortality risk. 

Experts have suggested that body fat may play a protective role, perhaps in secreting certain beneficial cytokines and hormones. Extra body fat also means extra padding and thus a physical protective barrier from traumatic injuries. In times of illnesses, the additional caloric reserve may give patients more nutritional backup in the healing process. 

However, the ill effects of the excess fat are too pronounced to be ignored. 

The most important advanced technology with which to fight obesity is the bathroom scale, used every day. Don't let that number rise. 

Obesity, after being categorized as a disease, we can now expect that the development of gray hair or the aging process- Senility, to be the next condition considered as a disease.

Use it or Lose it

What does this phrase imply? 

It means that if you don't continue to practice or use an ability, you might lose the ability. For example, if a person doesn't exercise his or her physical body, he or she will likely lose strength, endurance, and stamina. Similarly, if a person doesn't practice a new skill, such as driving a car or speaking a foreign language, he or she may forget or lose that skill. 

Jean Baptiste Lamarck, a French scientist, proposed that species change because of the use or disuse of features, such as tails or arms. He purported the “use it or lose it” idea. He believed that excessive use of a feature would cause it to grow and lack of use would invite atrophy. 

Let us thus, use this principle to have a positive bearing on the society and impart some quality of life enhancing tips to our elderly population. 

"Erections make erections". Sex is not unlike sports. If you want to be a good tennis player, play lots of tennis; if you want to be a good lover, make lots of love.

The American Journal of Medicine reports that older men who have sex more than once a week are less likely to develop Erectile dysfunction.  

Why does having more sex keep the male organ in trim instead of wearing it out? The likely elixir is oxygen here. 

Coming to a different sort of exercise for the seniors. 

Brief sessions of exercise for the aging brain like crossword puzzles and reading can have long-lasting benefits for elderly people, helping them stay mentally fit for at least five years. 

Retirement may not be good for your brain, according to a new study from France, which links older age at retirement to a reduced risk of developing dementia.

Mounting evidence suggests that engaging in intellectually stimulating activity throughout life may protect against the development of Alzheimer's disease and other dementias. 

"So if you are old and you are not contributing...maybe there is some penalty attached to that..., encourage older people, not just to be a negative burden on the State but to actually be a positive part of the Society."