Visceral Leishmaniasis In Adults

Visceral Leishmaniasis (also known as Kala Azar) is a parasitic infection caused by Leishmania Donovani in the East and Leishmania Infantum in the west. It is prevalent in many countries including India, Bangladesh, Nepal, Africa and part of America. The disease follows chronic course and is usually lethal if left untreated. It has also been reported from different parts of Pakistan, including Northern areas, Districts Mansehra & Abbottabad and Hilly areas of Khyber Pukhtoonkhawah. Most the cases have been reported in paediatric population. Except one case, reported previously from Abbottabad. The present two cases were also seen in adults.

Clinicohematological Study of Pancytopenia in a Tertiary Care Hospital of Western Region of Nepal

INTRODUCTION

Pancytopenia is a relatively common hematological entity and is a manifestation of many illnesses which can be life threatening at times. The severity of pancytopenia and the underlying pathology determine the management and prognosis. This study was conducted to evaluate hematological and bone marrow findings in patients presenting with pancytopenia.

METHODS

A prospective observational study was conducted in Department of Pathology, Manipal College of Medical Sciences, Pokhara from January 2011 to December 2016. Clinical and hematological parameters including bone marrow aspiration and biopsy were evaluated in all patients who presented with pancytopenia.

RESULTS

Among 138 cases studied, patients' age ranged from 2 to 82 years with a mean age of 43.95 years, and there was male predominance. Most of the patients presented with generalized weakness, pallor, dypnoea and fever. Hypoplastic marrow was seen in 38 (27.5%) cases, followed by 26 (18.8%) cases of megaloblastic anemia and 19 (13.76%) cases of acute leukemia. Other findings included one case each of hemophagocyosis, leishmaniasis, plasmodium vivex malaria and metastatic carcinoma.

CONCLUSIONS

This study highlights that pancytopenia is a common hematological problem and that the study of detailed primary hematological investigations along with bone marrow study in patients with pancytopenia will help to identify the cause for further planning and management.

Bone marrow involvement is not manifest in the early stages of childhood acute lymphoblastic leukaemia

INTRODUCTION

Acute lymphoblastic leukaemia (ALL) in children may have atypical presentations causing diagnostic delay. Guidelines for prompt referral have been published. The utility of the specified criteria is unknown.

MATERIAL AND METHODS

Symptoms, signs and laboratory findings at the time of diagnosis were reviewed in a consecutive series of 100 children with ALL in order to determine the frequency of atypical features and to evaluate the Danish referral guideline.

RESULTS

Only 36% had involvement of all three haematopoietic cell lines, and 23% presented with the classic clinical triad of pallor, fever and purpura. Symptoms of bone marrow insufficiency had been present in 77% for an average of two weeks as a late occurrence following musculoskeletal pains (in 49%, duration eight weeks) and constitutional symptoms (in 82%, duration four weeks). Organ infiltration was manifest in 71%. In 22%, only one or no cell count was abnormal; in this group, musculoskeletal symptoms were more frequent and symptom duration longer (two months versus one month). In 15%, lymphoblasts could not be detected in the blood. At the time of diagnosis, the Danish criteria for accelerated investigation were fulfilled in 98% of cases.

CONCLUSION

The clinical presentation of ALL is variable, and full-blown bone marrow insufficiency is a late occurrence as the disease progresses. Reduction of the diagnostic interval requires meticulous examination for organomegaly and attention to subtle haematologic changes.

FUNDING

Not relevant.

TRIAL REGISTRATION

Not relevant.

'Shouting from the roof tops': a qualitative study of how children with leukaemia are diagnosed in primary care

OBJECTIVES

To investigate the prehospital presentation of paediatric leukaemia and identify the disease and non-disease related factors which facilitate or impede diagnosis.

DESIGN

Thematic analysis of qualitative semistructured interviews.

SETTING

One tertiary referral centre in Southern England.

PARTICIPANTS

21 parents and 9 general practitioners (GPs) of 18 children (<18-year-old) with a new diagnosis of acute leukaemia.

RESULTS

The majority of children were first seen by GPs before the characteristic signs and symptoms of leukaemia had developed. In their absence, behavioural cues such as the child becoming apathetic or 'not themselves' often triggered parents to seek medical help. Most GPs were unclear about the nature and severity of the child's presentation: then, safety netting, thorough history-taking and examination, and reliance on contextual information about the parents or from prior hospital paediatrics experience were used to manage diagnostic uncertainty. The nature of the doctor-parent relationship helped and hindered the diagnostic pathway. GPs' prior perceptions of parents as being 'sensible' or 'worriers' influenced how gravely they treated parental concerns, with 'worriers' being taken less seriously. Some parents believed GPs failed to listen to their anxieties and discounted their expert knowledge of their child. Specific delay factors included lack of continuity of GP; some GPs' reluctance to take blood from children; and some parents feeling unable to voice effectively their concerns.

CONCLUSIONS

The presentation of paediatric leukaemia in primary care differs from that described in many hospital studies, with greater diversity and intermittency of symptoms, and the frequent absence of 'red flags' of serious illness. A wide range of non-disease related factors potentially delay the diagnosis of paediatric leukaemia, including tensions in the doctor-patient relationship and the doctors' cognitive biases. The identification and attempted modification of these factors may minimise diagnostic delay more successfully than raising awareness of 'red flags' of disease.

Clinicohaematological profile of aplastic anaemia in a rural medical college of Northern West Bengal

There is a scarcity of clinical data in the field of aplastic anaemia from rural India. Present study was conducted in North Bengal Medical College to find out the clinicohaematological profile and the possible aetiological factors in patients with aplastic anaemia. The study population (n = 83) included 21 children with male to female ratio 4.93:1. Weakness was present in all cases and pallor was present in 74.70% cases. Fever, bleeding episodes and localised infection were found in 55.42%, 48.19% and 27.71% cases respectively. There was no difference in clinical manifestations between children and adult except occurrence of fever (p = 0.0365). We identified possible aetiological factors in 32.53% cases as relevant drug intake in 10.84%, exposure to chemicals in 13.25% and hepatitis in 8.43% cases. We found low mean haemoglobin (3.81 +/- 1.71 g/dl), leucocyte and platelet (3.05 +/- 1.3 and 37.30 +/- 35 x 10(3)/cmm), neutrophil (30.28 +/- 21.76%) and high lymphocyte (67.27 +/- 22.50%) in peripheral blood. At the time of presentation, aplastic anaemia was moderate in 59.04% cases, severe in 48.19% cases and mild in 4.82% cases. We estimated the prevalence of aplastic anaemia in 4 districts of West Bengal including tea garden areas was 2.98/million populations per year. It was concluded that aplastic anaemia is a major non-malignant haematological disease in this part of India, and an increasing use of chemicals in agricultural and tea garden areas might be the responsible factor. Larger population based study is suggested.

Comparisons of late vaginal mucosal reactions between interstitial and conventional intracavitary brachytherapy in patients with gynecological cancer: speculation on the relation between pallor reaction and stenosis

BACKGROUND/AIM

To examine late vaginal mucosal reactions in patients following interstitial brachytherapy (ISBT) compared with that of intracavitary brachytherapy (ICBT).

PATIENTS AND METHODS

We introduced a modified Dische score to examine late reactions in vaginal mucosa of patients with gynecological cancer who underwent vaginal brachytherapy at 6, 12, 18, 24, 36, and 60 months after treatment. A comparison was made between patients who underwent ISBT (n=37) and those under conventional ICBT (n=63) with a median follow-up time of 41 months. The ICBT group included only patients with newly diagnosed cervical cancer, whereas the ISBT group included 17 patients with recurrent and 20 with newly-diagnosed cancer.

RESULTS

Grade 1 reactions of bleeding and discharge were exhibited by <12% of patients. Erythema was detected in approximately 30% (mainly grade 1) of the patients. A total of two (3%) patients developed superficial ulceration after ICBT, whereas three (8%) grade 1 ulcers were detected in patients after ISBT. Telangiectasias were detected in approximately 70% (60% grade 1 and 10% grade 2) of patients. No statistically significant difference was found between the patients after ISBT and ICBT. After ISBT, patients have a higher stenosis rate than after ICBT (p=0.003). The pallor scores showed a strong correlation with stenosis (p<0.0001) and were higher in patients after ICBT than in patients after ISBT (p=0.006).

CONCLUSION

After ISBT, patients exhibited milder but similar late mucosal reactions compared to those after ICBT, except the fact that the stenosis was more severe and the pallor reaction was milder in these patients. It can be, therefore, concluded that the pallor reaction is related to stenosis.

Primary cold agglutinin disease: a case report

Chronic cold agglutinin disease is a subgroup of auto-immune haemolytic anaemia. Primary cold agglutinin disease has traditionally been defined by the absence of any underlying or associated disease. It usually affects elderly. The term cold refers to the fact that the auto-antibody involved reacts with red cells poorly or not at all at 37 degrees C, whereas it reacts strongly at lower temperature. Here a case of severe pallor, jaundice and red colour urine in winter season for last 10 years diagnosed as a case of primary cold agglutinin disease is reported.The patient was managed conservatively.

Oral manifestations in chronic renal failure patients attending two hospitals in North Karnataka, India

AIM

To determine the nature, incidence, and severity of oral manifestations that occur in chronic renal failure (CRF) in patients attending two hospitals in North Karnataka, in comparison with healthy, disease-free controls.

METHODS

The study was carried out with 200 individuals (100 CRF patients and 100 controls). The case group was randomly selected from a population of CRF patients whose glomerular filtration rate (GFR) values were between 15-30 mL/min; the control group was selected in the same age group with normal GFR and was apparently disease free. The patients were asked about dry mouth, taste and halitosis, and mucosal pain, and were examined for oral changes such as tongue coating, pallor, ulceration and enamel hypoplasia. The results obtained from the study were then compared with various other similar studies.

RESULTS

The most common oral findings in the CRF patients were dry mouth (91%), pallor (87%), altered taste (42%), and halitosis (34%). CRF patients showed significantly more oral changes than those in the control group. These changes could be attributed to metabolic disturbances due to renal failure.

CONCLUSION

In the patients studied, the impact of CRF on the oral cavity was evidenced by significant oral changes, which pointed to an inter-relationship between oral health and CRF. Further studies are required to relate the extent of such changes with disease progression.

Oral considerations in the management of sickle cell disease: a case report

The phenomenon of erythrocyte sickling observed in sickle cell anaemia is responsible for ischaemia and tissue infarction compromising several organs and systems including the mouth and face. This brief paper reports the case of a 17- year-old female with a complicated sickle cell anaemia, hypertension and paraplegia (after an ischaemic stroke at the age of six years). Oral examination revealed the absence of tooth 12, fractures of teeth 11, 21 and 22 (from trauma), active caries lesions in the enamel of teeth 36, 37 and 46, mucosal pallor, and a smooth tongue. Oral radiographs revealed bone rarefaction and trabecular bone coarsening. Dental surgeons and physicians should be aware of the general and oral abnormalities that can be present in individuals with sickle cell anaemia to allow for preventive measures and implementation of effective treatment options.

A pale Chinese boy with recurrent painful digital swelling

Thalassaemia is the most common haemoglobinopathy in the Chinese population. However, recurrent painful digital swelling is not a typical manifestation of this well-known hereditary condition. We describe a case of co-inheritance of beta-thalassaemia and sickle cell trait in a Chinese family and a child who suffered from sickle cell/beta-thalassaemia with recurrent dactylitis. This report highlights awareness of this rare condition in the Chinese population, since acute manifestations can be life-threatening and mimic other emergency conditions. Prompt management can prevent further complications and avoid unnecessary interventions due to delay in diagnosis. A detailed family history and examination of the patient's peripheral blood smear is crucial to reach a correct diagnosis.

Diagnostic accuracy of "pallor" for detecting mild and severe anaemia in hospitalized patients

OBJECTIVE

To determine the accuracy of pallor of conjunctiva, nailbed, and palm in detecting mild and severe anaemia.

METHODS

Three hundred and five consecutive patients admitted in the medical and surgical wards of Mayo Hospital, Lahore were enrolled in the study. Conjunctiva, nailbed, and palm of patients were assessed. Mild anaemia was defined as Hb < 11.5 g/dl for females and Hb <13 g/dl for males. Severe anaemia was defined as Hb <7 g/dl. Likelihood ratios (LR) and their 95% confidence intervals (CI) for both presence and absence of pallor at each site were calculated. To compare the accuracy of different pallor sites in diagnosing severe anaemia, their areas under receiver operating characteristics curves (AUC) were compared.

RESULTS

Mild anaemia was present in 64.3% patients while severe anaemia was present in 7% patients. Presence of nailbed pallor had moderate accuracy for diagnosing mild anaemia (LR 5.6, 95% CI 4.7-6.7) while absence of pallor at nailbed, conjunctiva, and palm (LR 0.6 for all) did not rule out mild anaemia. All sites had modest accuracy for detecting severe anaemia (LR 2.5-3.0). Absence of pallor at conjunctiva (LR 0.1, 95% CI 0.03-0.5) and palm (LR 0.1, 95% CI 0.03-0.5) convincingly ruled out severe anaemia. Comparison of the AUC for different pallor sites showed that all sites were equally useful for detecting severe anaemia.

CONCLUSION

Pallor is not an accurate sign for mild anaemia. Pallor of conjunctiva, palm, and nailbed has modest accuracy in detecting severe anaemia. Absence of pallor at conjunctiva and palm convincingly rules out severe anaemia.

Severe iron deficiency anaemia as a manifestation of silent coeliac disease: case report and literature review

Coeliac disease (CD) occurs in individuals sensitive to gluten protein contained in wheat products. It affects at least 1:100 children and may present with extra-intestinal manifestations such as iron deficiency anaemia, short stature and delay in puberty. A case of severe iron deficiency anaemia as a manifestation of CD is described here. There is a need to raise awareness among health professionals about CD and its extra-intestinal presentations. Suspicion of CD should lead to antibody screening tests and positive results should be followed by an intestinal biopsy for a definitive diagnosis. Involvement of a paediatric dietitian is vital in the management of CD and lifelong adherence to a gluten-free diet is necessary. We hope this article leaves the reader with a heightened awareness about CD and will lead to appropriate early referral to the paediatric services.

[Danger signs in the malaria patient]

Danger signs are clinical indicators of severity and are useful to predict complications or death. In the malaria patient, clinical or parasitological signs can be easily be recognized during the acute phase of the illness that indicate serious complications. Danger signs include neurological change, abnormal breathing pattern, persistent vomiting and diarrhea, jaundice, bleeding, dark urine, delayed capillary refill, intense pallor, hyperpyrexia, hyperparasitemia and schizontemia. Timely recognition of these signs can lead to a decrease in cases with complications and deaths.

[Clinical aspects with prognostic value in gastric cancer--analysis of 468 cases with gastric adenocarcinoma]

The aim of this study is to assess clinico-pathological parameters and find out the correlation between them and their possible prognostic value. We made a retrospective analysis of a group of 468 patients with gastric adenocarcinoma which were operated in the 3rd Surgical Clinic--Cluj Napoca--01.01.1998-31.12.2003. The median age was 62 years. Patients in pTNM 0 stage were significantly younger than the rest of patients, with an average of 7.5 years. The male/female ratio was 1.7:1, this ratio being significantly higher in cases with proximal gastric cancers. There was not found any significant correlation between the interval : onset of symptoms and surgery, and pTNM stage. The most frequent signs and symptoms were epigastric pain, weight loss, indigestion, fatigue, pallor and loss of appetite, each of them were found in more than 40% patients. Multivariate analysis of symptoms showed that weight loss (p=0.00638) was independently correlated to advanced pTNM stages. The number of signs and symptoms was significantly correlated to advanced pTNM stages (p=0.000026). This significant group of patients studied has maintained characteristics encountered in populations with higher incidence of gastric adenocarcinoma, men being more frequently affected, distal localization and intestinal histologic type being encountered more frequently.

The validity of pallor as a clinical sign of anemia in cases with beta-thalassemia

Pallor is deemed useful in the evaluation of patients suspected of anemia, although its perceived presence or absence may be misleading in cases with increased pigmentation with iron, melanin, or bilirubin. The purpose of this study was to determine the validity of pallor in the detection of anemia in children with beta-thalassemia as an iron overload model. Patients with beta-thalassemia A aged 2 to 32 years who were admitted to the Hematology Unit, Department of Pediatrics, Ihsan Doğramaci Children's Hospital, Ankara, Turkey were assessed for the presence of pallor in three anatomic sites (palm, conjunctiva, buccal mucosa) by a trained pediatrician. Overall, 105 observations were done. The mean age of the patients was 14.7 +/- 6.5 years. The mean hemoglobin (Hb) value was 10.0 +/- 1.2 g/dl (range: 5.4-12.6 g/dl). The sensitivities of palmar, buccal and conjunctival pallor for identifying thalassemic children with anemia were 93.2, 80.7 and 90.9%, respectively. Cases with Hb values less than 11 g/dl could be easily detected by conjunctival pallor, independent of serum ferritin levels. However, there were significant associations between the presence of palmar or buccal pallor and the presence of anemia in children with serum ferritin levels lower than 2500 microg/L. Palmar pallor alone had the highest sensitivity and lowest specificity to detect anemia in cases with beta-thalassemia. Conjunctival pallor was more useful than buccal and palmar pallor in cases with high ferritin levels. Further studies are necessary to detect the validity of pallor in different underlying diseases with anemia.

Late vitamin K deficiency bleeding: 16 cases reviewed

In this study, clinical and demographic features of 16 cases with late vitamin K deficiency bleeding are presented. Ages of infants were between 30 and 130 days. Their delivery histories were uneventful, and family histories for bleeding disorders were negative. All parents except one were unaware of whether their children received vitamin K at birth or not. All cases did not have any underlying illness to explain the abnormal coagulation profile. The common presenting finding was pallor (62.5%). Intracranial haemorrhage was the most common bleeding site (37.5%), and two patients (12.5%) died because of it. Late vitamin K deficiency bleeding is still an important handicap in infants. Parents and healthcare providers should be informed about the importance of vitamin K prophylaxis to prevent vitamin K deficiency in infants.

Performance of the Brighton collaboration case definition for hypotonic–hyporesponsive episode (HHE) on reported collapse reactions following infant vaccinations in the Netherlands

We reviewed collapse (sudden onset of pallor, limpness and hyporesponsiveness) following the first infant (DPTP+Hib) vaccination reported to the enhanced passive surveillance system of the Netherlands in 1994-2003. All 1303 reports identified by the current RIVM (National Institute for Public Health and Environment) case definition were captured by the Brighton Collaboration (BC) case definition, with in 17 (1.3%) reports insufficient information. Over the years the proportion of the highest level of diagnostic certainty (level 1) increased due to more complete data from 70% to over 90%. We checked the BC case definition also on a sample of cases (with pallor or hyporesponsiveness) not meeting RIVM's case definition for collapse at the time. Sixty out of 200 cases were captured by BC but again rejected by RIVM. The sensitivity BC levels 2 and 3 appeared too high. We recommend a more restrict case definition by the Brighton Collaboration with certain exclusion criteria to make it more specific. Furthermore a change in the specifications for levels 2 and 3 will increase specificity and accommodate for the loss of sensitivity.

Coeliac disease in Sudanese children with clinical features suggestive of the disease

Our prospective hospital-based study examined frequency, clinical presentation and serological indicators of coeliac disease that correlated with intestinal biopsy among high-risk Sudanese children. From July 2001 to July 2002, 80 children aged 15 months-18 years presented with poor appetite, weight loss, pallor and proximal muscle wasting. We diagnosed coeliac disease in 18 (22.5%). Antigliadin antibodies (AGA-IgG, AGA-IgA or both) were high in 44; endomysial antibody retest was high in 30. Guardians of 12 children refused consent for biopsy. The other 18 were biopsied: 5 had total villous atrophy, 8 subtotal and 5 partial. All improved with gluten-free diet. Degree of villous atrophy did not correlate with diarrhoea duration or severity, anaemia severity or serological titres.

Accuracy of clinical pallor in the diagnosis of anaemia in children: a meta-analysis

BACKGROUND

Anaemia is highly prevalent in children of developing countries. It is associated with impaired physical growth and mental development. Palmar pallor is recommended at primary level for diagnosing it, on the basis of few studies. The objective of the study was to systematically assess the accuracy of clinical signs in the diagnosis of anaemia in children.

METHODS

A systematic review on the accuracy of clinical signs of anaemia in children. We performed an Internet search in various databases and an additional reference tracking. Studies had to be on performance of clinical signs in the diagnosis of anaemia, using haemoglobin as the gold standard. We calculated pooled diagnostic likelihood ratios (LR's) and odds ratios (DOR's) for each clinical sign at different haemoglobin thresholds.

RESULTS

Eleven articles met the inclusion criteria. Most studies were performed in Africa, in children underfive. Chi-square test for proportions and Cochran Q for DOR's and for LR's showed heterogeneity. Type of observer and haemoglobin technique influenced the results. Pooling was done using the random effects model. Pooled DOR at haemoglobin <11 g/dL was 4.3 (95% CI 2.6-7.2) for palmar pallor, 3.7 (2.3-5.9) for conjunctival pallor, and 3.4 (1.8-6.3) for nailbed pallor. DOR's and LR's were slightly better for nailbed pallor at all other haemoglobin thresholds. The accuracy did not vary substantially after excluding outliers.

CONCLUSION

This meta-analysis did not document a highly accurate clinical sign of anaemia. In view of poor performance of clinical signs, universal iron supplementation may be an adequate control strategy in high prevalence areas. Further well-designed studies are needed in settings other than Africa. They should assess inter-observer variation, performance of combined clinical signs, phenotypic differences, and different degrees of anaemia.

Ictal pallor is associated with left temporal seizure onset zone in children

PURPOSE

To describe the frequency, localizing and lateralizing value of ictal pallor (IP) in children with focal epilepsy.

METHODS

A retrospective review of medical charts and 514 archived seizures from 100 children < or =12 years old was performed. All patients had a history of therapy-resistant partial epilepsy and a seizure-free postoperative outcome. The presence and attributes of IP were analyzed.

RESULTS

No IP was detected by reviewing the archived seizures. According to medical charts, IP was reported in 11/100 children (six girls) aged 14 months to 12 (mean 5.5+/-4.1) years. Ten of them had temporal lobe epilepsy (p=0.046) - including nine temporo-medial and one temporo-lateral cases - while only one child had an extratemporal (parietal lobe) seizure onset zone. All but one children had left-sided operation (p=0.01). Presence of IP had a positive predictive value of 91% for both lateralizing (left) and localizing (temporal lobe) the seizure onset zone. History of IP was neither age-, epilepsy onset-, nor gender-related.

CONCLUSIONS

Ictal pallor is a frequently reported autonomic symptom during childhood focal seizures but difficult to assess purely by video-monitoring. It has a high predictive value to localize the seizure onset zone to the left temporal region already in very young patients.

Valeur diagnostique de la pâleur des téguments dans l'anémie chez les femmes enceintes au Bénin

Anemia in pregnant women is a common and severe public health problem encountered in developing countries. Its detection is most often based upon clinical examination and observation of conjunctive pallor; however, little is known or documented on the performance indicators of this clinical method in Africa. This work aims assess the value of performance indicators in detecting moderate and severe anemia by means of tegument pallor examination in a maternity ward in rural Benin. To this end, 480 pregnant women were recruited at random during their prenatal visits to a rural maternity clinic. Two independent observers had noted conjunctive or other forms of teguments in all of the women selected, and a concentration of hemoglobin was confirmed by a blood test. An analysis of the results indicated that 67.4% of pregnant women were biologically anemic (Hb < 11.0 g/dl) while only 49% among them were clinically anemic. The sensitivity of the clinical observation method for conjunctive pallor is 87.5% for severe anemia and 74% for moderate anemia. Its positive predictive value is 62.5% for moderate anemia and very weak for light cases of anemia, at only 3%. The accuracy of this clinical method varies from 51-71%, when the likelihood is determined as 1.8 to 2.3. Its reproducibility appears equally weak and clinical observer variability seems to be poor to fair agreement at k = 0.34 (p = 0.00). For practical reasons, the authors suggest the strengthening of the teaching of this method to obstetrics' care providers and medical students in training in order to improve its more effective use and practice in rural maternity units without laboratories.

[Reliability and validity of palmar and conjunctival pallor for anemia detection purposes]

OBJECTIVE

To evaluate the reliability and the validity of the use of simple clinical signs as a method of anemia detection.

METHODS

The study was carried out in a S o Paulo, Brazil, day-care center, and included 135 children from ages 3 months-6 years. Hemoglobin level results and palmar and conjunctival pallor assessment were used. Children with Hb under 11g/dl were considered as anemic; subjective criteria were used for the assessment of palmar and conjunctival pallor. Kappa statistics were used in order to verify agreement, and, in order to evaluate the technique's validity, sensitivity and specificity levels were calculated.

RESULTS

The results show low levels of agreement. There was a greater level of sensitivity to conjunctival pallor than to palmar pallor. Specificity results may be considered as good.

CONCLUSIONS

It is still early to recommend the routine use of this technique. However, it could promote substantial savings if perfected.

Performance of the Haemoglobin Colour Scale in diagnosing severe and very severe anaemia

OBJECTIVE

To assess the accuracy of Haemoglobin Colour Scale (HCS) in identifying severely anaemic [haemoglobin (Hb) <7 g/dl] and very severely anaemic (Hb <5 g/dl) individuals, and to compare the performances of a group of health workers using HCS after training with a standard method.

METHOD

The study consisted of two parts. In part 1, the performance of HCS was compared with clinical examination in a hospital population of which more than 450 individuals were severely anaemic and more than 120 very severely anaemic. Part 2 of the study was conducted in eight dispensaries where the performances of 13 health workers using the colour scale were compared with the performances of eight other health workers using clinical signs to estimate Hb.

RESULTS

The colour scale was 92% sensitive for both severe anaemia and very severe anaemia and performed better than clinical examination. Health workers who used the colour scale did better in identifying anaemic and severely anaemic individuals, than those who used clinical examination.

CONCLUSIONS

The colour scale improves health workers' capacity to identify severely anaemic individuals and could be used as a basis for referral. Although the diagnostic accuracy of the workers using HCS varied widely, in most cases they did significantly better than those who used clinical investigation alone.

Dyspnea on exertion, fatigue, and pallor in a 50-year-old active duty soldier

OBJECTIVE

To discuss a comprehensive diagnostic approach to an active duty patient presenting with dyspnea on exertion, fatigue, and pallor. A 50-year-old active duty E-6 white male in Al Udeid, Qatar, presented with progressive dyspnea on exertion, fatigue, and new pallor. This case illustrates the course of events from Al Udeid to the Walter Reed Army Medical Center, where the final diagnosis was made. Along the way, questions with discussions explore the various diagnostic and management aspects of his case and highlight military relevant issues that include efficient diagnostic algorithms in the field and transfusion of scarce blood products.

Passive malaria surveillance in a low endemic area of India: validation of a clinical case definition

BACKGROUND

In India, 2.55 million cases of malaria were reported during 1997; roughly one-third were due to Plasmodium falciparum. Malaria cases are identified by passive and active surveillance and all patients with fever are treated with chloroquine (10 mg/kg body weight). Since all fevers are not malaria, this results in overtreatment and has a bearing in terms of the parasites developing resistance. We aimed to test the validity of a clinical algorithm for passive malaria surveillance by primary care doctors (fever with pallor or splenomegaly) in a low endemic, Plasmodium vivax-predominant area of Ballabgarh block in Faridabad District, Haryana.

METHODS

Passive surveillance was carried out at the general and paediatric outpatient departments (OPDs) of Ballabgarh hospital. All persons with fever attending the OPD were examined for the presence of fever, pallor and splenomegaly by the treating doctor. A blood smear was prepared and examined in all these cases.

RESULTS

A total of 3119 slides for malaria were made at Ballabgarh hospital but clinical details in the requisition form were available for only 2616 patients who form the subjects of this analysis. A total of 59 malaria cases (30 P. vivax cases and 29 P. falciparum) were diagnosed. The presence of fever with pallor or splenomegaly had a sensitivity of 28.8% (95% CI: 18.1-42.3); specificity of 88.6% (95% CI: 87.3-89.8), positive predictive value of 5.5% (95% CI: 3.3-8.8) and negative predictive value of 98.2% (95% CI: 97.5-98.7).

CONCLUSION

The algorithm did not have sufficient sensitivity to detect malaria cases by passive surveillance.

[Value of touch in the diagnosis of fever and of paleness in the diagnosis of anemia. Observational study in adults]

Estimation of fever by touch and of pallor as a sign of anemia are common practices during physical examination. The diagnostic value of these procedures has been extensively studied in children, but there are fewer studies in adults.

OBJECTIVE

To evaluate the diagnostic value of physician's estimation of fever and anemia by touch and pallor, respectively.

PATIENTS AND METHODS

The study included 600 patients (mean age 66 years, range 14-94 years, 58% males) admitted to a hospital (n = 300) or seen at its Emergency Department (n = 300). Two physicians independently estimated the presence of fever by touch, as well as the presence of anemia by pallor (in the skin, nail or conjunctiva). Axillary temperature and peripheral blood hemoglobin were employed as standards for comparison.

RESULTS

Specificity of touch was higher than 90%, both for the diagnosis of axillary temperatures > or = 37.2 degrees C and > or = 38 degrees C, with a lower sensitivity. Interobserver concordance was fair (Kappa index, 0.47). Negative predictive value of touch was also high (99%) for the observed prevalence of fever (5%), with a very much lower positive predictive value. Similarly, specificity of pallor was high, particularly for hemoglobin values lower than 10 g/dL, with a substantially lower sensitivity. The best diagnostic values were obtained with conjunctival pallor. The Kappa index of concordance for the various types of pallor (skin, nail or conjunctiva) ranged between 0.39 and 0.44. Negative predictive value of pallor was high (98%) for the observed prevalence (9%) of significant anemia (hemoglobin < 10 g/dL), with a lower positive predictive value.

CONCLUSIONS

In adult patients of a hospital, physi-cian's estimation of fever by touch and anemia by pallor have a relatively low diagnostic value. Nevertheless, the estimation that the patient is afebrile or not pale make very improbable the presence of fever and significant anemia, respectively.

The influence of experience and specialisation on the reliability of a common clinical sign

OBJECTIVES

To explore the influence of experience and specialisation on clinical judgement by comparing accuracy in diagnosing anaemia between a consultant general surgeon, a consultant ophthalmologist and their registrars.

PATIENTS AND METHODS

Conjunctival inspection of 101 patients, subsequent correlation with haemoglobin concentration.

MAIN OUTCOME MEASURES

Number of correct and incorrect diagnoses of anaemia.

RESULTS

54 patients were anaemic and 47 were not. Overall accuracy in diagnosing anaemia ranged from 0.61-0.69, sensitivity 0.52-0.65 and specificity 0.62-0.83. Agreements between pairs of examiners were 0.68-0.81, with kappa values of 0.36-0.60 when adjusted for chance agreement.

CONCLUSIONS

Neither experience nor specialisation significantly influenced our ability to diagnose anaemia, based on conjunctival inspection. Without critical analysis of clinical signs, we are unaware of their diagnostic limitations.

Palmar pallor as an indicator for anthelminthic treatment among ill children aged 2-4 years--Western Kenya, 1998

Infections with the soil-transmitted intestinal helminths (i.e., Ascaris lumbricoides, Trichuris trichiura, and hookworm), estimated to affect approximately 1 billion persons, are among the most common and widespread human infections. Among children aged <5 years, intestinal helminth infections cause malnutrition and anemia, two important causes of mortality. Anthelminthic treatment (deworming) improves nutritional status of school-aged children. The World Health Organization and the United Nations Children's Fund (UNICEF) have developed guidelines that include interventions for anemia and malnutrition in the integrated management of childhood illness (IMCI) for children aged <5 years seen at first-level health-care facilities in developing countries. Under the IMCI guidelines, in geographic areas where hookworm or Trichuris infections are endemic, children aged 2-4 years with palmar pallor are treated with an anthelminthic drug. This report summarizes an investigation of the use of palmar pallor as an indication for anthelminthic treatment among ill children aged 2-4 years seen at first-level health-care facilities in rural western Kenya; the investigation found that palmar pallor was associated with anemia but not with intestinal helminth infection.

The utility of pallor detecting anemia in under five years old children

The diagnosis and management of anemia, which affects a significant proportion of young children in developing countries, largely depends on the clinical assessment for pallor. This study was conducted with the aim of evaluating the utility of pallor in detecting anemia. Children aged 2 to 60 months who visited the pediatric outpatient department of Jimma Hospital over 3 months period were assessed for the presence and degree of pallor in 4 anatomic sites (conjunctivae, tongue and buccal mucosa, nailbeds, palm) by trained nurses. Hemoglobin was then determined using the HemoCue method. Individuals involved in clinical examination did not have access to the laboratory results before documenting their findings. The mean hemoglobin in the 574 children examined was 11.03 gm/dl, and about 46% had anemia. Children younger than 2 years were found to have a higher prevalence of anemia as compared to older children (p < 0.001). Palmar pallor, with a sensitivity of 58%, had the highest sensitivity to detect moderate anemia as compared to other anatomic sites. The presence of either palmar or conjunctival pallor increased the sensitivity to 73%. The inter-observer agreement was highest for conjunctival pallor (kappa value = 0.81). The findings of the study suggest that pallor of a single anatomic site does not have adequate sensitivity to detect moderate anemia. We recommend further studies to look at the performance of severe pallor in correctly identifying severe anemia. Furthermore, the magnitude and causes of anemia need to be studied in a community setting.

Clinical case definition of malaria at a secondary level hospital in northern India

Malaria has re-emerged as a major public health problem in India. At present, under the National guidelines; all fevers are presumed to be due to malaria and chloroquine is given as presumptive treatment. This results in overtreatment. We did a pilot study to see whether some clinical predictors of malaria could be identified in the Indian setting. This case control study was done in a secondary level hospital. All those with fever who were smear positive for malaria were enrolled as cases and other patients fever who were smear negative for malaria served as the controls. All the factors under study were ascertained by a history or detailed clinical examination. A total of 41 cases and 95 controls were enrolled. Of the 41 cases, 35 were positive for P. vivax and six were positive for P. falciparum. After multivariate analysis, only splenomegaly (OR = 2.11; 95% CI = 1.27-3.50) and pallor (OR = 2.01; 95% CI = 1.16-3.48) were significantly associated with malaria. It appears that history of fever along with one or both of these two signs can be a useful predictor of malaria in a secondary level hospital in India. The utility and feasibility of a similar approach in a field setting needs to be studied further.

Intracranial haemorrhage due to factor V deficiency

Factor V deficiency is a rare coagulation disorder which is inherited autosomal recessively. Factor V deficiency should be considered in infants with bleeding disorders and prolonged prothrombin and activated partial thromboplastin times if bleeding continues in spite of vitamin K injection. In this article, the case of an infant with an intracranial haemorrhage due to congenital factor V deficiency is reported.

Presenting features and treatment outcome of 78 Malaysian children with neuroblastoma

To study the distribution of presenting features and their prognostic significance in neuroblastoma treated in a single institution in Malaysia. A retrospective study was made of 78 neuroblastoma cases diagnosed and treated in the University Hospital, Kuala Lumpur, Malaysia between June 1982 and February 1997. Diagnosis was established by standard histological criteria. The presenting features were evaluated for their distribution and prognostic influence. Disease-free survival from diagnosis was the outcome variable of interest. The ages ranged from 0.1 to 11 years old (median: 3 years old). The tumor originated from the adrenal glands in 83% and the majority of cases presented in advanced stage (stage III 22%, stage IV 66%). Bone marrow was the commonest site of distant metastasis occurring in 45% of patients. The main presenting signs and symptoms in decreasing order were pallor, fever, abdominal mass, weight loss, and bone/joint pain. Univariate analysis conferred age, initial stage and Hb level as significant prognostic factors. No influence in disease-free survival was found for sex, race, primary site, urinary vanillylmandelic acid level, white cell count and platelet count. Overall 2-year disease-free survival was achieved in 27 (39%) patients. Four patients underwent bone marrow transplant, three of whom achieved 2-year disease-free survival. The results suggest that age, initial stage and hemoglobin level are significant prognostic factors based on univariate analysis. In addition, more Malaysian children presented with adrenal primary site and advanced disease compared to previous reported studies.