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A 27-year-old woman presented with a history of excessive hair loss, loss of appetite, loss of weight, amenorrhoea and loss of axillary and pubic hair for 6 months followed by fever and vomiting for 5 months and abdominal pain for 1 month. During the course of her illness, the patient developed intravascular haemolysis as evidenced by a drop in haemoglobin, indirect hyperbilirubinaemia, raised lactate dehydrogenase (LDH) and haemoglobinuria. Examination revealed severe pallor, mild icterus, elevated jugular venous pressure, generalised lymphadenopathy and hyperpigmentation. Investigations revealed severe anaemia, indirect hyperbilirubinaemia, raised LDH and negative Coombs test. Antinuclear antibody and anti-dsDNA, anti-Sm and anti-SS-A/Ro antibodies were positive and complement C3 was low. The patient was diagnosed to have systemic lupus erythematosus and immune-mediated intravascular haemolysis and was treated with prednisolone and hydroxychloroquine. Haemolysis resolved following steroid therapy, and during follow-up, there were no further episodes of haemolysis.

Tuberculosis is a well-known entity in India with many implemented policies to ensure the cost-effective early management. Missed, delayed, and complicated presentations do occur, requiring expensive tertiary level of health care. Among many contributing factors, lack of antibiotic stewardship is at the top. We report a case of 65-year-old man who presented with on and off fever for six months, receiving cocktail treatments of antibiotics, analgesics, and steroids from a local dispensary. Our initial investigations revealed microcytic anemia with high erythrocyte sedimentation rate, leukocytosis, and bilateral pleural effusion on chest X-ray. Contrast enhanced computer tomography of chest and abdomen suggested disseminated tuberculosis including bilateral empyema. Frank pus was drained on thoracocentesis, which was negative for Gram stain, Ziehl-Neelsen stain, and bacterial culture, but positive CB-NAAT for tubercular bacilli with no resistance to rifampicin. Mantoux test and stool occult blood were positive. This case highlights an unusual presentation of tuberculosis and the ongoing lacunae in the society with importance to the primary care providers in the effective management of tuberculosis focusing on antimicrobial stewardship.

Expanded dengue syndrome (EDS) is a well-described entity in the literature (after 2009), with various new atypical presentations being identified each year. We report a case of 38-year-old man who presented to the emergency department with high-grade, intermittent fever for 7 days along with myalgia and headache. He had multiple painless palpable purpura over both lower limbs and breathlessness from the 4th day of fever. On admission, purpura progressed in the severity and dry impending gangrene of the toes of both feet developed. Blood cultures turned out to be sterile, and other infectious markers (malaria, scrub typhus, and chikungunya) were negative except for dengue serology (enzyme-linked immunosorbent assay-immunoglobulin M [ELISA-IgM]). Skin biopsy confirmed to be cutaneous small-vessel vasculitis. The respiratory distress was due to myocarditis (supported by raised NT-pro-BNP levels) and pulmonary edema. He also had possibly hemolytic anemia due to microangiopathy. Although there are many EDS cases of dengue myocarditis reported till date, dengue resulting in widespread endothelial activation and extensive vasculitis (small vessel due to purpura and medium vessel due to gangrene) is a rare phenomenon.

Background: Scrub typhus, a rickettsial zoonosis, is endemic in the Indian sub-continent but is rare in the Himalayan region due to natural geographic barriers to both organism and vector. Aims: To study the clinical profile of scrub typhus cases admitted in a tertiary care center. Patients and Methods: We did a retrospective observational study of the positive cases from July 2018 to June 2019 in a tertiary care center. All possible risk factors, demographic details, clinical presentations, laboratory parameters, treatment, and outcomes were analyzed. Results: A total of 80 cases were analyzed. The maximum number of cases was observed in September. Major symptoms noted were fever, abdominal pain, headache, cough, breathlessness, and myalgia. Atypical presentations including capillary syndrome and demyelinating polyneuropathy were observed. The eschar detection rate was low. Among organ involvement, hematology system (70%) was most commonly involved followed by liver, kidney, brain, lungs, and heart respectively. The case fatality rate was 6.82%. Himalayan and non-Himalayan cohorts (n = 32 vs 48 respectively) did not show any statistically significant differences in clinical profile, although one could observe that Himalayan cohorts had higher incidences of leukopenia, splenomegaly, and myocarditis, while fever for >7days at admission, hepatomegaly, acute respiratory distress syndrome, major organ involvement resulting admission in high dependency unit (HDU), and mortality were higher in non-Himalayan cohorts. Conclusion: The current study reveals few atypical presentations and complications differing from the classical scrub typhus. Raised ALP is noticed in majority of cases which can be established as a diagnostic marker in acute undifferentiated febrile illnesses in further study. The presence of leukocytosis has high predictive association with major organ involvement and complications.