1. Causes of persistent febrile illnesses in eastern Nepal
*Kanika Deshpande Koirala1,2,3, Basudha Khanal1, Nisha Keshary Bhatta1, Narayan Raj Bhattarai1, Kristien Verdonck2, Marleen Boelaert2, Francois Chappuis3, Suman Rijal1 *
1B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal;
2Institute of Tropical Medicine, Antwerp, Belgium;
3University of Geneva, Geneva, Switzerland

2. Introduction

3. Nepal
Area: 800 kilometres (497 mi) long and 200 kilometres (124 mi) wide, area of 147,181 km2 (56,827 sq mi) Population: approx 27 million

6. Introduction
Persistent (>7 days) febrile illnesses (PFIs) represent a difficult and common presentation to healthcare Part of a EU funded multi-country NIDIAG study

7. Introduction
We studied the differential diagnosis and associated clinical and laboratory predictors in patients with PFIs in eastern Nepal

8. Methods
Inclusion: Patients ≥5 years old Fever > 7 days Study duration: January Oct 2014 Study site: District & tertiary hospital, Eastern Nepal

9. Methods Case report forms maintained
Medical history, physical examination, and laboratory investigations noted
Follow up in 1 month
Follow up blood sample taken

10. Tests performed
Haemoglobin White blood cell count Kidney function tests Liver function tests Blood cultures Urine routine and culture Malaria RDT HIV serology

11. Other investigations
Chest X-ray Abdominal ultrasound Sputum examination

12. Testing of samples
National reference labs International reference labs

13. Target conditions
Malaria HIV Tuberculosis Brucellosis Leptospirosis Rickettsial diseases Relapsing Enteric fever Visceral Leishmaniasis

14. Formulating Diagnosis
Final case-ascertainment by experienced physicians based on pre-specified case-definitions

15. Results
578 patients recruited (427 BPKIHS, 151 Dhankuta)

16. Target conditions (BPKIHS)

17. BPKIHS - Final diagnosis
Target conditionsa
Diagnosis
Count (n=)
Proportion VL 54
12.7%
Tuberculosis (all types) 23
5.4%
Rickettsiosis 17 4%
Scrub typhusa 12
2.8%
Leptospirosisa 10
2.4%
Enteric fever 7
1.6%
HIV 4
0.9%
Relapsing fever
Brucellosis 0%
Malaria
Any target condition
131
30.8%
a Serologies for Leptospira & PCR scrub typhus awaited

18. Other conditions (BPKIHS)

19. BPKIHS - Final diagnosis
Other conditions
System
Diagnosis
Count (n=)
Proportion
Respiratory
Pneumonia 13
3.1%
Tonsillitis/pharyngitis 7
1.6%
Other RTI 24
5.6%
Urinary
UTI 31
7.3%
Cancer
Leukemia 4
0.9%
Solid tumor 2
0.5%
Other (defined) 17 4%
Mixed infections
Undefined
205a
48.2%
a 129/205 (63%) have suspicion of enteric fever +/- other condition; 6 death (CFR: 2.9%); 173 (84%) received Abx

20. Target conditions (Dhankuta)

21. Dhankuta - Final diagnosis
Target conditionsa
Diagnosis
Count (n=)
Proportion VL 0%
Tuberculosis (all types) 5
3.3%
Rickettsiosis
Scrub typhusa 1
0.7%
Leptospirosisa
Enteric fever
HIV
Relapsing fever
Brucellosis
Malaria
Any target condition 9 6%
a Serologies for Leptospira & PCR scrub typhus awaited

22. Other conditions (Dhankuta)

23. Dhankuta - Final diagnosis
Other conditions
System
Diagnosis
Count (n=)
Proportion
Respiratory
Pneumonia 8
5.3%
Tonsillitis/pharyngitis 16
10.7%
Other RTI 32
21.3%
Urinary
UTI 4
2.7%
Other (defined) 0%
Mixed infections 1
0.7%
Undefined
82a
54.7%
a 70/82 (85%) have suspicion of enteric fever +/- other condition(s); 0 death; 91% received Abx

24. Way forward
Development of a diagnostic guideline to assist healthcare workers in improving diagnosis of PFIs at primary healthcare centres

25. Fever > 7 days LP KalaAzar (VL) Tuberculosis Rickettsiosis
History taking
Duration of fever
H/O VL
Pallor/Jaundice
H/O Travel
Cough, bloody sputum, SOB
Abdominal complaints
Family H/o TB/VL
On examination
Hepatosplenomegaly
Vital signs
Skin examination
Lung auscultation
Abdominal palpation
Stiff neck
Lab
WBC/HB
ASAT/ALAT
Malaria if H/O travel
Blood culture
Urine analysis
Using dipstick
Chest Xray
Respiratory symptoms
RDT
rK39 (if no H/O VL and splenomegaly
Abdominal Ultrasound
Abominal tenderness LP
Signs of meningitis
KalaAzar (VL)
Tuberculosis
Rickettsiosis
Splenomegaly RDT -
Hb<10
RDT +
BM +
Fever > 2wks
Pneumonia
AFB Genexpert -
Genexpert+
Abnormal Chest Xray
Fever > 2 wks
Scrub typhus
Abnormal Chest Xray Normal Chest Xray
Respiratory signs /symptoms
Blood culture+
Eschar+
Fever > 7 days
Enteric fever
Leptospirosis
Blood culture +
Abdominal tenderness
Acute Leukaemia
Urinary tract infection
Intra-abdominal infections
Liver abcess /Cholelithiasis/Appendicitis
WBC
Bone marrow
Meningitis
Lumbar puncture
Meningeal signs
Urine analysis +
Urine routine , culture +

26. Conclusion
Common causes of PFIs in the eastern part of Nepal differed from those in parts of Nepal non-endemic for Visceral Leishmaniasis
This is the first study to report the causes of PFIs in a VL-endemic region of Nepal