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Background: Urinary tract infection (UTI) is characterized by pathological invasion of the urinary tract by microorganisms. Majorities of organisms causing UTI are gram negative bacteria, most common of which is E. coli. Urine culture and sensitivity test is used to isolate the organism and to identify the susceptible drug of choice for appropriate treatment. This hospital-based study was carried out to analyze the spectrum and antibiotic susceptibility of microorganisms causing UTI. Methods: A retrospective study was done to analyze the results of urine culture and sensitivity test done at Chitwan Medical College Teaching Hospital over a period of two and half years. Standard guideline and protocol were used to collect the urine sample and to perform the test. Data analysis was done using SPSS version 21.0. Result: Out of 12, 925 urine samples submitted for culture and sensitivity test during the study period, bacterial pathogens were isolated from 3, 173 (24.54%) samples, which was significantly higher among females (28%) than the males (17%). The most common organism isolated on the culture was E. coli (68.5%) followed by Klebsiella (18.4%). Sensitivity of the uropathogens was seen highest with colistin (79.2%) followed by teicoplanin (64.58%), Aztreonam (63.25%) and Ni­trofurantoin (61.16%). Most common antibiotics that showed resistance to the microorganisms in this study were Ampicillin (60.93%), Cotrimoxazole (53.72%), Cefixime (40.57%) and Levofloxacin (32.93%). Conclusions: This study has found a usual pattern of UTI with higher prevalence among females and E. coli being the most common organism. Nitrofurantoin has been found to have a good sus­ceptibility for the treatment of UTI.

Background: Scrub typhus, an emerging rickettsial disease caused by the organism Orientiatsutsugamushi , is associated with multi-organ involvement. We prospectively studied the clinical manifestations of the disease during a major outbreak in central part of Nepal. Aims and Objective: This study was carried out with an aim to analyze the clinical presentations, laboratory parameters, complications and outcomes of scrub typhus. Materials and Methods: A prospective observational study was conducted in the Department of Medicine in a tertiary teaching hospital. A total of 1398 patients admitted with acute febrile illness were subjected for Scrub Typhus Detect™ IgM ELISA test, among which 502 (35.90%) patients tested positive and were included in the study. Acute kidney injury was defined according to KDIGO guideline. Statistical analysis was done with SAS University Studio package using t-test for continuous variables and chi-square test for categorical variables. Results: Mean age of the patients was 30.37±18.81 years with 26.29% in the pediatric age group (

Background The management of proliferative lupus nephritis (LN) comprises timely and coordinated immunosuppressive therapy. This study aimed to evaluate and compare the effectiveness and safety profile of low dose mycophenolate mofetil (MMF) and cyclophosphamide (CYC) in induction therapy of LN in Nepalese population. Methods We conducted a prospective, open-label, randomized trial over a period of one and half years. Forty-nine patients with class III to V lupus nephritis were enrolled, out of which 42 patients (21 in each group) could complete the study. CYC was given intravenously as a monthly pulse and MMF was administered orally in the tablet form in the maximum daily dose of 1.5 g in two divided doses. Results The mean age of the patients was 25.43 ± 10.17 years with female to male ratio of 7.3:1. Mean baseline serum creatinine was 1.58 ± 1.38 mg/dL and eGFR was 62.38 ± 26.76 ml/min/1.73m2. Mean 24-h urinary protein was 4.35 ± 3.71 g per 1.73 m2 body surface area. At 6 months, serum creatinine (mg/dL) decreased from 1.73 to 0.96 in CYC and from 1.24 to 0.91 in the MMF group with improvement in eGFR (ml/min/1.73 m2) from 60.33 to 88.52 in CYC and from 64.42 to 89.09 in MMF group. Twenty-four-hour urinary protein (gm/1.73m2) reduced from 4.47 to 0.94 in CYC and from 4.5 to 0.62 in the MMF group. Primary end point was achieved in higher percentage of patients with MMF than CYC (28.6% vs. 19%) while equal proportion of patients (67% in each group) achieved secondary end point in both groups. Number of non-responders was higher in CYC group than in the MMF group (14.3% vs. 4.8%). There was no difference in the rate of achievement of secondary end point in both CYC and MMF groups (3.16 vs. 3.05 months). The occurrence of adverse events was higher in the CYC than in MMF group (56 vs. 15 events). Conclusion Present study has concluded that MMF, used in relatively lower dose, is equally effective in inducing remission with reduction of proteinuria and improvement of kidney function with lesser adverse events than CYC in the induction therapy of proliferative lupus nephritis. Trial registration Retrospectively registered to ClinicalTrials.gov PRS. NCT03200002 (Registered date: June 28, 2017).

ObjectiveTo assess the nutritional status of patients on maintenance hemodialysis by using modified quantitative subjective global assessment (MQSGA) and anthropometric measurements.MethodWe Conducted a cross sectional descriptive analytical study to assess the nutritional status of fifty four patients with chronic kidney disease undergoing maintenance hemodialysis by using MQSGA and different anthropometric and laboratory measurements like body mass index (BMI), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), triceps skin fold (TSF) and biceps skin fold (BSF), serum albumin, C-reactive protein (CRP) and lipid profile in a government tertiary hospital at Kathmandu, Nepal.ResultsBased on MQSGA criteria, 66.7% of the patients suffered from mild to moderate malnutrition and 33.3% were well nourished. None of the patients were severely malnourished. CRP was positive in 56.3% patients. Serum albumin, MAC and BMI were (mean + SD) 4.0 + 0.3 mg/dl, 22 + 2.6 cm and 19.6 ± 3.2 kg/m2respectively. MQSGA showed negative correlation with MAC ( r = −0.563; P = < 0.001), BMI ( r = −0.448; P = < 0.001), MAMC ( r = −0.506; P = < .0001), TSF ( r = −0.483; P = < .0002), and BSF ( r = −0.508; P = < 0.0001). Negative correlation of MQSGA was also found with total cholesterol, triglyceride, LDL cholesterol and HDL cholesterol without any statistical significance.ConclusionMild to moderate malnutrition was found to be present in two thirds of the patients undergoing hemodialysis. Anthropometric measurements like BMI, MAC, MAMC, BSF and TSF were negatively correlated with MQSGA. Anthropometric and laboratory assessment tools could be used for nutritional assessment as they are relatively easier, cheaper and practical markers of nutritional status.

Sjögren’s syndrome is an autoimmune disease with multisystem involvement and varying clinical presentation. We report the clinical course and outcome of a case who presented with repeated episodes of hypokalemia mimicking hypokalemic periodic paralysis and metabolic acidosis, which was later diagnosed as distal renal tubular acidosis secondary to primary Sjögren’s syndrome. A 50-year-old lady, who was previously diagnosed as hypokalemic periodic paralysis, presented with generalized weakness and fatigue. She was found to have severe hypokalemia with normal anion-gap metabolic acidosis consistent with distal renal tubular acidosis. Subsequent evaluation revealed Sjögren’s syndrome as the cause of her problems. Kidney biopsy done to evaluate significant proteinuria revealed nonproliferative morphology with patchy acute tubular injury and significant chronic interstitial nephritis. The patient responded well to potassium supplementation and oral prednisolone. Presentation of this case highlights the necessity of close vigilance while managing a case of repeated hypokalemia, which could be one of the rare clinical manifestations of Sjögren’s syndrome.

Background and Aims - Dengue is a systemic viral infection, which is caused by any of the four strains of dengue virus and is transmitted between humans by the bite of Aides aegypti mosquito. Hepatic dysfunction is common in dengue infection with varying degree according to the severity of the disease. The aim of this study was to analyze the spectrum of liver involvement in dengue infection during a major outbreak that occurred in central Nepal between September and December 2010. Methods - A hospital based prospective study was conducted in the department of medicine at Chitwan Medical College. Patients who had fever in the ten preceding days (acute febrile illness) who had serologic evidence of Dengue and had no clinical evidence of bacterial infection anywhere in the body, were included in the study. Clinical, biochemical and radiological evaluation was done among 414 serologically confirmed Dengue cases to assess the spectrum of liver involvement. Statistical analysis of the data was done with SPSS version 16. Results - Dengue fever (DF) and dengue hemorrhagic fever (DHF) were present in 79.3% and 20.5% of the patients respectively. Only 2 out of 414 patients had dengue shock syndrome (DSS). The spectrum of hepatic manifestations included elevation of transaminases (raised ALT and AST in 81.9% and 57.7% respectively), abnormal abdominal ultrasound (49.3%), Hepatomegaly (39.1%), and Jaundice (4.1%). The intensity of hepatic involvement was significantly higher among patients with DHF than those with DF. Conclusion : Liver is one of the major organs to be involved in Dengue infection. Significant difference existed in the spectrum of liver involvement between DF and DHF. DOI: http://dx.doi.org/10.3126/jaim.v2i2.8775 Journal of Advances in Internal Medicine 2013;02(02):42-46

SUMMARY Aim To compare the influence of demographic and clinical variables on quality of life (QOL) amongst haemodialysis (HD) and renal transplantation clients in Nepal. Background Renal replacement therapy in the form of renal transplant is a newer modality in Nepal. In this study, effectiveness of renal transplant and maintenance HD in clients with end-stage renal disease were evaluated in a Nepalese context. Method A descriptive, cross-sectional study was conducted to compare the QOL of clients undergoing HD and renal transplantation in two treatment centres in Nepal. Information on QOL was collected by using the WHOQOL-BREF instrument through interviews. Result The clients in the transplantation groups were significantly younger, highly educated and employed. The QOL score of clients with renal transplantation was significantly higher in the physical, psychological and social relationship domains. While assessing QOL score in transplantation groups, females scored significantly higher score in the environmental domain compared with males. Conclusion The QOL score in renal transplant recipients was significantly better than that of clients on HD in three of the four WHOQOL-BREF domains. The limited resources and facilities for renal transplantation and the post-transplant follow-up service in Nepal might have contributed to a poorer outcome on the environmental domain in this group.

Renal involvement and acute kidney injury (AKI) are common clinical manifestations seen in scrub typhus, a vector-borne tropical disease. There are no data on renal manifestation in scrub typhus in Nepal. We conducted a prospective study to analyze the incidence, urinary abnormalities, course, severity, outcome, and the predictors of AKI in patients with scrub typhus during a major outbreak in Central Nepal. Total 1398 patients admitted with acute febrile illness were subjected for Scrub Typhus Detect™ Immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) test, of which 502 (35.90%) patients tested positive and were included in the study. Mean age of the patients was 30.37 ± 18.81 years (range, 1–79 years) with 26.29% in the pediatric age group. Female-to-male ratio was 1.26:1. Mean duration of fever was 6.8 ± 3.1 days. Mean IgM ELISA value for scrub typhus was 2.17 ± 1.70 without difference in AKI and non-AKI groups (2.17 ± 1.76 vs. 2.16 ± 1.62; P = 0.94). Urinary abnormalities were seen in 42.3% of patients. Mean serum creatinine was 1.37 ± 0.69 mg/dl with significant difference in two groups (1.85 ± 0.87 vs. 1.03 ± 0.17; P = 0.003). AKI was seen in 35.8% of patients with majority having Stage 1 AKI (68.3%) followed by Stage 2 (34.1%) and Stage 3 (1.2%). Hemodialysis was required for 3.94% of patients. In 54% of patients, AKI occurred in fifth and sixth day of fever. ICU admission was required for 18.73% of patients and 8.57% required ventilator support. Mortality rate was 1.79%, which was higher among patients with AKI (2.96% vs. 1.0%; P = 0.106). Multivariate analysis revealed that the presence of pneumonia, shock, and acute respiratory distress syndrome predicted the development of AKI.

Dengue Fever (DF) is only rarely considered as a cause of acute liver failure even globally and only a few case reports of acute hepatic failure and encephalopathy occurring in DF in adults are available. We report a case of Acute Liver Failure due to Dengue during a major outbreak in 2010 in Chitwan. A 20 year old previously healthy female presented to the emergency department of Chitwan Medical College with fever, jaundice and altered sensorium. She was tested positive for Dengue IgM. Her biochemical and clinical parameters were suggestive of acute liver failure with total billirubin of 10.1 mg/dL, direct billirubin of 5.2 mg/dL, ALT 5760 IU, AST 14100 IU, alkaline phosphatase of 1250 IU, PT INR of 1.76 and platelet count of 30,000 /mm3. Other causes for acute hepatic failure like acute viral hepatitis, leptospirosis, malaria, Reye’s syndrome were ruled out. The patient was admitted and managed in the ICU with supportive care and platelet transfusion. With treatment she made a significant clinical and biochemical improvement with AST of 105 IU, ALT of 120 IU and platelet count of 150,000/mm3. She was discharged after 11 days of hospital stay.DOI: http://dx.doi.org/10.3126/kumj.v9i2.6293 Kathmandu Univ Med J 2011;9(2):73-5