Typhoid myopathy or typhoid hepatitis: A matter of debate

Myositis associated with Salmonella paratyphi A bacteremia appears to be common

Background

Fever and severe myalgia in a tropical country like India bring to mind leptospirosis, rickettsioses, dengue, and other viral fevers. Enteric fever is widely prevalent in Asia, but myositis has not been previously described in Salmonella paratyphi A bacteremia.

Materials and Methods

Retrospectively, we recruited patients with enteric fever admitted to our treating unit over a 6-month period. Demography, historical, clinical, and laboratory data were obtained. Data of culture-positive S. paratyphi A patients were analyzed and were compared with those patients with culture-negative enteric fever.

Results

Forty-three cases were found in total with 19 of S. paratyphi A bacteremia. Elevations in creatine kinase (CK) ranged from one-and-half to six times normal. Forty-seven percent had thrombocytopenia and alanine transaminase elevations, while aspartate transaminase elevations were seen in 17 patients, which corresponded to those with elevated CK levels.

Conclusions

Myositis associated with S. typhi and S. paratyphi is very rare and is more often due to non-typhoidal Salmonellae. Elevated creatine kinase was seen in most of our patients with S. paratyphi A bacteremia. Such myositis has not been described previously and hence, myalgia with fever in a tropical country could be a harbinger of paratyphoid fever.

Evaluation of synergistic effect of biodegradable polymeric nanoparticles and aluminum based adjuvant for improving vaccine efficacy

Aluminum based adjuvants have been used widely to induce long lasting protective immunity through vaccination. But reported incidences of toxicity and side effects of aluminum have raised concerns regarding their safety in childhood vaccines. The present study demonstrates the synergistic effect of admixture of polylactic acid-polyethylene glycol (PLA-PEG) based biodegradable nanoparticles (NPs) and aluminum phosphate as a potential adjuvant system using tetanus toxoid (TT) as a model antigen. The immunological activity of the admixture formulation was maintained up to 180 days of storage at 5 °C±3 °C. Percent adsorption/encapsulation of tetanus toxoid increased to nearly 90% in admixture formulation as compared to 55% in conventional vaccine. Admixture preparation (PLA-PEG-Al 0.2 mg-TT and PLA-Al 0.2 mg-TT) showed 80% and 50% survival respectively, even at 180 days as compared to 30% survival observed in the conventional tetanus vaccine. The present study established the feasibility to formulate a dosage form with improved efficacy and reduced aluminum concentration for vaccination.

ASL/ALT ratio as a triage marker for enteric fever in the emergency department

Objective: Early differentiation of enteric (typhoid) fever from other febrile conditions has been difficult due to the non-specific clinical presentations and lack of substantiating laboratory clues. Transaminase alterations in enteric fever were thought to be non-specific and have not been investigated before in comparison with other febrile conditions with regards to their prevalence and the aspartate amino transferase/alanine amino transferase (AST/ALT) ratio. We sought to examine these parameters as triage markers for enteric fever. Methods: We retrospectively studied 106 patients with enteric fever diagnosed by positive blood culture. 112 febrile patients tested negative for malaria were taken as controls. The controls were matched to the test group with respect to demographic and baseline clinical features. Serum AST, ALT values on first visit to the emergency department was noted and AST/ALT ratio was determined. The values between the test and control groups were compared and the results were analyzed using appropriate statistical methods. Results: The mean AST and ALT levels were found to be significantly higher for enteric fever patients than the control group (109.91 U/L ± 76.07 vs. 29.93 U/L ± 16.74; p < 0.0001) and (83.60 U/L ± 68.04 vs. 32.12 U/L ± 21.79; p < 0.0001) respectively. The mean AST/ALT ratio was found to be higher among enteric fever patients compared to the control group (1.42 ± 0.60 vs.1.07 ± 0.44; p < 0.0001). AST/ALT ratio of ≥ 1 combined with AST of ≥ 40 U/L was found in 72.6% of enteric patients vs. 6.2% in the control group (p < 0.0001). Conclusions: As compared to other common febrile conditions, transaminase alterations in enteric fever seem to follow a specific pattern characterized by higher prevalence of mild elevations (mean levels < 3 fold the upper limit of normal) with a general trend of AST/ALT ratios ≥ 1. In the febrile adult, having an AST/ALT ratio of >1 combined with an AST level of >40 U/L, may provide a simple and cheap triage marker for blood cultures and closer observation especially in the emergency department.