Undifferentiated febrile illness in Kathmandu, Nepal

Corinne N Thompson, Stuart D Blacksell, Daniel H Paris, Amit Arjyal, Abhilasha Karkey, Sabina Dongol, Abhishek Giri, Christiane Dolecek, Nick Day, Stephen Baker, Guy Thwaites, Jeremy Farrar, Buddha Basnyat, Corinne N Thompson, Stuart D Blacksell, Daniel H Paris, Amit Arjyal, Abhilasha Karkey, Sabina Dongol, Abhishek Giri, Christiane Dolecek, Nick Day, Stephen Baker, Guy Thwaites, Jeremy Farrar, Buddha Basnyat

Abstract

Undifferentiated febrile illnesses (UFIs) are common in low- and middle-income countries. We prospectively investigated the causes of UFIs in 627 patients presenting to a tertiary referral hospital in Kathmandu, Nepal. Patients with microbiologically confirmed enteric fever (218 of 627; 34.8%) randomized to gatifloxacin or ofloxacin treatment were previously reported. We randomly selected 125 of 627 (20%) of these UFI patients, consisting of 96 of 409 (23%) cases with sterile blood cultures and 29 of 218 (13%) cases with enteric fever, for additional diagnostic investigations. We found serological evidence of acute murine typhus in 21 of 125 (17%) patients, with 12 of 21 (57%) patients polymerase chain reaction (PCR)-positive for Rickettsia typhi. Three UFI cases were quantitative PCR-positive for Rickettsia spp., two UFI cases were seropositive for Hantavirus, and one UFI case was seropositive for Q fever. Fever clearance time (FCT) for rickettsial infection was 44.5 hours (interquartile range = 26-66 hours), and there was no difference in FCT between ofloxacin or gatifloxacin. Murine typhus represents an important cause of predominantly urban UFIs in Nepal, and fluoroquinolones seem to be an effective empirical treatment.

© The American Society of Tropical Medicine and Hygiene.

Figures

Figure 1.
Figure 1.
Flowchart of patients from the RCT and the substudy of UFIs. In total, 627 patients were enrolled into the clinical trial comparing gatifloxacin with ofloxacin in the treatment of enteric fever. In total, 316 patients were randomized to receive gatifloxacin, and 311 patients were randomized to receive ofloxacin. One patient was not randomized. There were 109 culture-confirmed enteric fever cases in each arm, leaving 207 and 202 culture-negative patients in the gatifloxacin and ofloxacin arms, respectively. In total, 125 patients were selected for the UFI diagnostic substudy; 29 of these 125 patients were selected from culture-positive enteric fever group, and an additional 96 patients from the culture-negative groups.

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Source: PubMed

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