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Academic Medical Journal of India 88 Volume III - Issue 3 July - September 2015 www.medicaljournal.in ORIGINAL RESEARCH Socio-demographic, Clinical, and Laboratory Profile of Patients with Febrile Illness Admitted to a Tertiary Care Center in Kerala Padma Kumar Balasundaram,a Libu Gnanaseelan Kanakamma,b Kumari Jayageetha PB,b Retheesh Kollerazhikathu Haridasanb a. Department of Medicine, Government TDMC Medical College, Alappuzha, Kerala, India; b. Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India* Corresponding Author: Dr. Libu Gnanaseelan Kanakamma, Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India. Email: [email protected] Abstract Fever due to various infections is a common cause of outpatient visits and inpatient admissions in hospitals. We report a study on the socio-demographic, clinical, and laboratory profile of patients with fever admitted to a tertiary care center in Kerala.To study the sociodemographic, clinical, and laboratory profile of patients admitted with a febrile illness to the tertiary care hospital. It was a prospective cohort study of patients admitted with the febrile illness of less than 7 days duration, to the Medical College Hospital, Alappuzha from June 2013 to December 2013. Socio-demographic and clinical details were collected using a pre-designed proforma, and a detailed physical examination was performed followed by relevant laboratory investigations. The analysis was done using Epi-info software. Among the 150 patients with febrile illness, 82 (54.7%) were females and 68 (45.3%) were males. The mean age group of the patients was 37.65. Agriculture and fishing were the occupations of 63 (42%) patients, and 61 (40.7%) patients were homemakers. Among the Published on 28th August, 2015 150 patients with febrile illness, dengue fever was diagnosed in 46 (30.7%), leptospirosis in 45 (30%), viral fever in 36 (24%) cases, and lower respiratory tract infection in 9 (6%) patients, and other fevers which includes acute pyelonephritis 1 (0.7%), cellulitis 1 (0.7%), enteric fever 1 (0.7%), meningitis 1 (0.7%), pneumonia 2 (1.3%), sinusitis 3 (2%), urinary tract infection 1 (0.7%), and viral hepatitis 2 (1.3%). There were 3 (6.7%) deaths among the febrile illness patients, and all deaths occurred in patients with leptospirosis indicate that it is one of the most fatal infections among other febrile illnesses. Analysis of socio-demographic profile and history of patients with febrile illness followed by clinical examination and judicious use of investigations will help to make an early diagnosis and also to start timely treatment and reduce morbidity and mortality. Key Words: Febrile Illness, Dengue, Leptospirosis, Clinical Profile Cite this article as: Balasundaram PK, Kanakamma LG, Jayageetha PB, Haridasan RK. Socio-demographic, Clinical, and Laboratory Profile of Patients with Febrile Illness Admitted to a Tertiary Care Center in Kerala. Academic Medical Journal of India. 2015 Aug 28;3(3):88-93. Introduction F ever is a common and very important presenting symptom of patients admitted to the hospitals. There has been an unprecedented upsurge of vector-born viral diseases in Kerala since last two decades, and this has resulted in considerable morbidity and mortality. There is an increase in the number of febrile patients especially during the rainy seasons in Kerala.1 Dengue fever, chikungunya, leptospirosis, viral hepatitis, Japanese encephalitis (JE), typhoid, and malaria are the most common causes of febrile illness in the state. JE first appeared in Kuttanadu area in Alappuzha district in the year 1996. Dengue fever, which emerged as a new problem in the state in 1997, reached epidemic proportions in 2003 and is now seen in all districts of the state.2 Chikungunya fever, appeared in epidemic form during 2006, affected all parts of the state creating new challenges to the medical science in the scenario of vector-borne diseases. Though malaria was successfully eradicated from the state in 1965, resurgence occurred after a few years following the importation of cases from other endemic states. Leptospirosis, *See End Note for complete author details which started as an isolated public health problem of some of the water-logged areas of Alappuzha and Kottayam districts in 1990, has become a public health problem of all districts of Kerala during the last decades.2 This communicable disease is causing the highest number of deaths consistently for the last few years in the state. In spite of the repeated epidemics in Kerala, which has produced significant morbidity and mortality, published data on the socio-demographic and clinical profile of febrile illness is scanty, and this has adversely affected the development of preventive plans of the state. Objective of the Study To study the socio-demographic, clinical, and laboratory profile of patients admitted with the febrile illness to the tertiary care hospital. Materials and Methods It was a prospective cohort study; patients admitted with the febrile illness of less than 7 days duration, to the Medical College Hospital, Alappuzha from June 2013 to December 2013 were Academic Medical Journal of India included in the study. The patients, between 13 and 60 years of age, were medically observed since their admission until discharge. They were suffering from short febrile illness, headache, and myalgia. Socio-demographic and clinical details were collected using a pre-designed proforma, and a detailed physical examination was performed followed by relevant laboratory investigations. Occupational history, history of contact with animals and dirty water, bathing habits, source of drinking water and nature of drinking water (boiled or un boiled) were included in the socio-demographic profile. In the clinical history, the duration and pattern of fever, history of the headache, myalgia, skin rashes, and history of symptoms pertaining to eye, gastrointestinal, respiratory, cardiovascular, and nervous system were considered. This was followed by the general as well as a detailed systemic examination. All relevant investigations including blood counts, urine routine, liver and kidney function tests were done. All the above investigations were conducted on the day of admission. On the 7th day of fever, a blood sample was sent to the microbiology department for IgM ELISA for leptospirosis and dengue fever. Diagnosis was made using Modified Faine’s criteria for leptospirosis,3 the World Health Organization (WHO) 2009 criteria for dengue fever.4 The analysis was done using Epi-info software. Results Among the 150 patients with febrile illness, 82 (54.7%) were females and 68 (45.3%) were males. The mean age group of the patients was 37.65. Agriculture and fishing were the occupations of 63 (42%) patients, and 61 (40.7%) patients were homemakers. Among the patients, 81 (54%) were using public water supply for bathing, 50 (33.3%) well water, and 19 (12.7%) patients were using pond water. The source of drinking water was the public water supply for 92 (61.3%) patients and well water for 58 (38.7%) patients. 136 (90.7%) patients were using boiled water for drinking, and 14 (9.3%) patients were using unboiled water. The average duration of fever was 5 days for 49 (32.7%) patients, 3 days for 33 (22%) patients, and 7 days for 28 (18.7%) patients. The first symptom with which the patients presented includes fever in 135 (90%) patients, body ache in 10 (6.7%) patients, and headache in 5 (3.3%) patients. On clinical examination, the most important physical findings were conjunctival congestion 39 (26%) followed by pallor 18 (12%), jaundice 14 (9.3%), subconjunctival hemorrhage 10 (6.7%), and edema 5 (3.3%). Muscle tenderness was a common finding and was present in 51 (34%) patients, and the groups of muscles affected were calf muscles in 20 (13.3%), and calf and thigh muscles together in 14 (9.3%) patients. 89 Volume III - Issue 3 Laboratory investigations showed albuminuria in 49 (32.7%), leukocytosis in 47 (31.3%), in leukopenia 31 (20.7%) patients, and 72 (48%) patients had normal leukocyte count. 68 (45.3%) patients had neutrophilia and 13 (8.7%) patients had lymphocytosis. 58 (38.7%) patients had eosinophilia. 96 (64%) patients showed elevation of erythrocyte sedimentation rate (ESR) and of this 46 (30.7%) had mild, 35 (23.3%) had moderate, and 15 (10%) had marked elevation. 92 (61.3%) patients showed thrombocytopenia. Among the 150 patients with febrile illness, dengue fever was diagnosed in 46 (30.7%), leptospirosis in 45 (30%), viral fever in 36 (24%) cases, and lower respiratory tract infection in 9 (6%) patients, and other fevers which includes acute pyelonephritis 1 (0.7%), cellulitis 1 (0.7%), enteric fever 1 (0.7%), meningitis 1 (0.7%), pneumonia 2 (1.3%), sinusitis 3 (2%), urinary tract infection 1 (0.7%), and viral hepatitis 2 (1.3%). Among the patients with leptospirosis, 25 (55.6%) were males, and 20 (44.4%) were females showing a slight male preponderance. In patients with dengue fever, females were more affected. 28 (60.9%) were females, and 18 (39.1%) were males. Respiratory infection was seen the highest 10 (71.4%) in middle-aged and elderly. Younger patients (<20) had maximum incidence of viral fever 14 (37.8%). Among the patients with febrile illness, patients with leptospirosis had maximum contact with animals 24 (53.3%), and dirty water 41 (91.1%). Other socio-demographic details of the patients were as shown in Table 1. Analysis of symptoms shows catarrhal symptoms in patients with respiratory infection 9 (64.3%) followed by viral fever 14 (37.8%). Other symptoms of the patients were as shown in Table 2. On examination, conjunctival congestion was present in 24 (53.3%) patients, and subconjunctival hemorrhage was present in 8 (17.8%) of patients with leptospirosis. Other clinical examination findings were as shown in Table 3. Blood examination showed leukocytosis in patients with leptospirosis and leukopenia in patients with dengue fever. Other investigation findings of the patients with various febrile illnesses were as shown in Table 4. There were 3 (6.7%) deaths among the febrile illness patients, and all deaths occurred in patients with leptospirosis indicates that it is one of the most fatal infection among other febrile illnesses. Discussion The most common cause of febrile illness in our study was dengue fever (30.7%) followed by leptospirosis (30%) showing a high incidence of vector-born disease and zoonosis in the state. Padma Kumar Balasundaram, et al. Socio-demographic, Clinical, and Laboratory Profile of Patients with Febrile Illness Admitted to a Tertiary Care Center in Kerala Academic Medical Journal of India 90 Volume III - Issue 3 Table 1: Socio‑demographic features of the patients with febrile illness Dengue fever (n=46) (%) Leptospirosis (n=45) (%) Viral fever (n=37) (%) Respiratory infections (n=14) (%) Other fevers (n=8) (%) Total (n=150) (%) 13 (28.3) 31 (68.9) 12 (32.4) 4 (28.6) 3 (37.5) 63 (42) 1 (2.2) 24 (53.3) 3 (8.1) 1 (7.1) 1 (12.5) 30 (20) Contact with dirty water 12 (26.1) 41 (91.1) 12 (32.4) 1 (7.1) 2 (25) 68 (45.3) Drinking unboiled water 1 (2.2) 11 (24.4) 1 (2.7) 1 (7.1) 0 (0) 14 (9.3) Respiratory infections (n=14) (%) Other fevers (n=8) (%) Total (n=150) (%) Findings Agriculture/fishing Contact with animal Table 2: Symptomatology of patients with febrile illness Dengue fever (n=46) (%) Leptospirosis (n=45) (%) Viral fever (n=37) (%) Catarrhal symptoms 9 (19.6) 5 (11.1) 14 (37.8) 9 (64.3) 0 37 (24.7) Cough 3 (6.5) 5 (11.1) 5 (13.5) 12 (85.7) 0 25 (16.7) 10 (21.7) 6 (13.6) 2 (5.4) 0 0 18 (12.1) 4 (8.7) 9 (20) 3 (8.1) 6 (42.9) 1 (12.5) 23 (15.3) Findings Arthralgia Breathlessness Nausea 7 (15.2) 7 (15.6) 2 (5.4) 0 2 (25) 18 (12) Vomiting 15 (32.6) 14 (31.1) 13 (35.1) 1 (7.1) 5 (62.5) 48 (32) Abdominal pain 11 (23.9) 12 (27.3) 5 (13.5) 2 (14.3) 1 (12.5) 31 (20.8) Diarrhea 5 (10.9) 10 (22.2) 1 (2.7) 1 (7.1) 1 (12.5) 18 (12) Table 3: Clinical examination findings of patients with febrile illness Findings Jaundice Dengue fever (n=46) (%) Leptospirosis (n=45) (%) Viral fever (n=37) (%) Respiratory infections (n=14) (%) Other fevers (n=8) (%) Total (n=150) (%) 0 9 (20) 2 (5.4) 0 3 (37.5) 14 (9.3) Pallor 4 (8.7) 4 (8.9) 4 (10.8) 2 (14.3) 4 (50) 18 (12) Conjunctivan congestion 5 (10.9) 24 (53.3) 7 (18.9) 1 (7.1) 2 (25) 39 (26) Subconjunctival hemorrhage 1 (2.2) 8 (17.8) 1 (2.7) 0 0 10 (6.7) Skin rashes 6 (13) 1 (2.2) 3 (8.1) 0 0 10 (6.7) Muscle tenderness 6 (13) 34 (75.6) 8 (21.6) 1 (7.1%) 2 (25) 51 (34) Hepatomegaly 5 (10.9) 15 (33.3) 4 (10.8) 0 4 (50) 28 (18.7) Tachypnea 15 (32.6) 17 (37.8) 3 (8.1) 4 (28.6) 2 (25) 41 (27.3) The WHO also reports that the incidence of dengue fever has grown dramatically around the world in recent decades.5 Jones et al. reports that 60-76% of the 400 emerging infectious diseases are zoonotic globally, and this indicates that zoonosis like leptospirosis is a major public health problem in many countries including India.6 The present study is different from a study in a tertiary care hospital in south India where bacterial infection (38%) and tuberculosis (19%) were the most common etiological diagnoses.7 In our study, 52.25% of patients with dengue fever were homemakers, and 60.9% of patients were females showing a slight female preponderance. This may be due to the fact that Aedes aegypti, the vector that transmits dengue rests indoors. The housewives and homemakers having more indoor activities will be more exposed to the mosquito bite. This highlights the necessity of implementing proper mosquito control measures in the premises of houses and imparting health education. Among the 150 patients with febrile illness, 53.3% patients with leptospirosis had contact with both domestic animals and pet animals as part of their occupational and recreational activities, whereas only 2.2% of dengue fever patients had contact with animals indicating that leptospirosis is the most widespread zoonosis in the world as shown in WHO report.8 Rearing domestic animals at home was identified as a risk factor leptospirosis in an Indian study.9 There is a strong belief in the community that leptospirosis spreads mainly through contact with rodents only and widespread health educational activities have to be initiated to spread the message that other domestic animals also may be a source of infection. In our study, 91.1% who had leptospirosis had contact with contaminated water during their occupational and recreational activities. A study from southern Chile shows that leptospirosis can survive in the peridomestic water samples collected from rural households.10 High incidence Padma Kumar Balasundaram, et al. Socio-demographic, Clinical, and Laboratory Profile of Patients with Febrile Illness Admitted to a Tertiary Care Center in Kerala Academic Medical Journal of India 91 Volume III - Issue 3 Table 4: Investigation findings of patients with febrile illness Findings Dengue fever (n=46) (%) Leptospirosis (n=45) (%) Viral fever (n=37) (%) Respiratory infections (n=14) (%) Other fevers (n=8) (%) Anemia 9 (19.6) 14 (31.1) 12 (32.4) 2 (14.3) 5 (62.5) 42 (28) Leukocytosis 2 (4.3) 35 (77.8) 3 (8.1) 3 (21.4) 4 (50) 47 (31.3) 27 (58.7) 1 (2.2) 2 (5.4) 1 (7.1) 0 31 (20.7) Neutrophilia 7 (15.2) 33 (73.3) 16 (43.2) 7 (50) 5 (62.5) 68 (45.3) Eosinophilia 21 (45.7) 19 (42.2) 11 (29.7) 4 (28.6) 3 (37.5) 58 (38.7) Mild 17 (37) 6 (13.3) 17 (45.9) 5 (35.7) 1 (12.5) 46 (30.7) Moderate 2 (4.3) 25 (55.6) 3 (8.1) 2 (14.3) 3 (37.5) 35 (23.3) 0 13 (28) 1 (2.7) 0 1 (12.5) 15 (10) Elevated blood urea 5 (10.9) 24 (53.3) 4 (10.8) 1 (7.1) 2 (25) 36 (24) Creatinine 7 (15.2) 24 (53.3) 5 (13.5) 2 (14.3) 2 (25) 40 (26.7) SGOT 37 (80.4) 40 (88.9) 22 (59.5) 6 (42.9) 6 (75) 111 (74) SGPT 32 (69.6) 39 (86.7) 14 (37.8) 4 (28.6) 6 (75) 95 (63.3) Alkaline phosphatase 31 (67.4) 39 (92.9) 34 (91.9) 10 (71.4) 5 (71.4) 119 (81.5) Hypoprotenemia 24 (52.2) 34 (75.6) 13 (35.1) 5 (35.7) 4 (50) 80 (53.3) Hypoalbuminemia 14 (30.4) 29 (64.4) 11 (29.7) 3 (21.4) 4 (50) 61 (40.7) Leukopenia Total (n=150) (%) Elevated ESR Marked SGOT: Serum glutamic‑oxaloacetic transaminase, SGPT: Serum glutamate pyruvate transaminase, ESR: Erythrocyte sedimentation rate of leptospirosis in-house wives12 (26.7%) in our study is explained by this finding. manifestation and helps to differentiate from other febrile illnesses. Although all age groups were affected by dengue fever, patients under 21-40 had maximum incidence (43.5%) similar to a study by Ahmed et al., where maximum number of dengue cases (30.8%) were from the age group 21-30 years.11 All the patients with dengue infection had a fever, headache, and myalgia and WHO case-defining criteria 4 such as arthrralgia 10 (21.7%), nausea 7 (15.2%), vomiting 15 (32.6%), rashes 6 (13%), also were present in our patients. Leptospirosis occurred mainly in 41-60 age group 30 (66.7%) as patients in this age group are physically more active and are more likely to be exposed to a contaminated environment as a part of their occupational activities. Among the 14 patients who use unboiled water for drinking 11 were leptospirosis patients showing that drinking contaminated water also may be a source of infection as the organism also can enter the body via mucus membrane of the alimentary tract.12 Proper health educational activities have to be initiated in the community to ensure the intake of properly boiled water for drinking purpose. Catarrhal symptoms such as rhinitis and sore throat were present only in 9 (19.6%) of patients with dengue fever and 5 (11.1%) with leptospirosis and this finding will help to differentiate dengue fever and leptospirosis from other febrile illnesses such as respiratory infection and viral fever where catarrhal symptoms were common and present in 9 (64.3%) and 14 (37.8%), respectively. Our finding was similar to the inference by Nimmanitya et al.13 where showing that catarrhal symptoms were present only in 13% of the patients with dengue fever. The presence of a cough in 12 (85.7%) of patients with respiratory infection shows that it is a common Maximum incidence of joint pain was present in febrile illness patients with dengue fever 10 (21.7%). In a study by Restrepo et al. from Colombia,14 the incidence of arthralgia was (48.9%) showing that arthralgia is a common manifestation of dengue fever and helps to differentiate from other febrile illnesses. Gastrointestinal manifestations such as nausea, vomiting, abdominal pain, and diarrhea were common in patients with leptospirosis as mentioned in the report by the WHO.8 Skin rashes were present in 13% patients with dengue fever similar to the finding by Daniel et al. where 13.2% had skin rashes. Hepatomegaly was present in 10.9% of patients with dengue fever and in the study by Daniel et al.15 17.6% had hepatomegaly. In a study by Sharma et al. from India,16 12.5% had hepatomegaly and Nimmanitya et al. from Thailand13 13.5% had hepatomegaly. Hepatomegaly usually occurs in patients with dengue hemorrhagic fever as reported by Ahluwalia and Sharma17 even though none of our patients had clinical features of dengue hemorrhagic fever. While leukocytosis was present in 35 (77.8%) patients with leptospirosis, leukopenia was the predominant finding in Padma Kumar Balasundaram, et al. Socio-demographic, Clinical, and Laboratory Profile of Patients with Febrile Illness Admitted to a Tertiary Care Center in Kerala Academic Medical Journal of India dengue fever 27 (58.7%), and this simple laboratory finding helps to differentiate dengue fever from leptospirosis. In the study by Daniel et al.,15 leukopenia was present in 40%. In viral fever, total leukocyte count was normal in 32 (86.5%) patients, and this finding is useful to differentiate it from dengue fever and leptospirosis. ESR was normal in 16 (43.2%) of patients with viral fever and 27 (58.7%) of patients with dengue fever unlike in leptospirosis where it was normal only in 1 (2.2%) only and this basic laboratory finding also can be used for the diagnostic purpose in the febrile illness. In the present study, 44 (95.7%) patients with dengue fever had got thrombocytopenia similar to the finding by Daniel et al.15 where 90% of the patients with dengue fever had thrombocytopenia. In a study by Raikar et al.,18 also dengue fever was the most common cause of thrombocytopenia among other febrile illnesses. Platelet-associated immunoglobulins involving antidengue virus activity is attributed as the cause of thrombocytopenia by Oishi et al.19 Liver function tests and kidney function tests were abnormal in 55.6% and 53.3% of patients with leptospirosis, respectively, whereas it was normal in patients with viral fever, respiratory infection, and dengue fever. Various mechanisms were attributed to the cause of nephropathy and study by Cerqueira et al.20 shows a role of ion transport defects. In our study of patients with febrile illness, leptospirosis had maximum mortality 3 (6.7%). In patients with dengue fever even though, the mortality rate is high (20%) in untreated cases if timely admitted to a hospital, the mortality rate would be less than 1% as shown in the WHO report.21 Conclusion Proper analysis of socio-demographic profile and history of patients with febrile illness followed by clinical examination and judicious use of investigations will help to make an early diagnosis and also to start timely treatment and reduce morbidity and mortality. End Note Author Information 1.Padma Kumar Balasundaram, Department of Medicine, Government TDMC Medical College, Alappuzha, Kerala, India 2. Libu Gnanaseelan Kanakamma, Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India 3.Kumari Jayageetha PB, Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India 92 Volume III - Issue 3 4.Retheesh Kollerazhikathu Haridasan, Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India Conflict of Interest None declared. References 1. Pappachan MJ, Sheela M, Aravindan KP. Relation of rainfall pattern and epidemic leptospirosis in the Indian state of Kerala. J Epidemiol Community Health 2004;58:1054. 2. Epidemiological Situation of Communicable Diseases in Kerala (2006 - 2010) Integrated Disease Surveillance Project (IDSP), Directorate of Health Services Thiruvananthapuram, Kerala. Available from: http://www.dhs.kerala.gov.in/docs/part1.pdf. 3. Faine S. Guidelines for the Control of Leptospirosis. Geneva: World Health Organization; 1982. 4. Capeding MR. Dengue Update: WHO 2009 Guidelines; 2009. 5. Dengue and Severe Dengue. Fact Sheet N 117, Updated May 2015. WHO Media Centre. Available from: http://www.who.int/mediacentre/ factsheets/fs117/en/. 6. Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, et al. Global trends in emerging infectious diseases. Nature 2008;451:990-3. 7. Abrahamsen SK, Haugen CN, Rupali P, Mathai D, Langeland N, Eide GE, et al. Fever in the tropics: Aetiology and case-fatality - A prospective observational study in a tertiary care hospital in South India. BMC Infect Dis 2013;13:355. 8. Leptospirosis worldwide, 1999. Wkly Epidemiol Rec 1999;74:237-42. 9. Kamath R, Swain S, Pattanshetty S, Nair NS. Studying risk factors associated with human leptospirosis. J Glob Infect Dis 2014;6:3-9. 10.Muñoz-Zanzi C, Mason MR, Encina C, Astroza A, Romero A. Leptospira contamination in household and environmental water in rural communities in southern Chile. Int J Environ Res Public Health 2014;11:6666-80. 11.Ahmed NH, Broor S. Dengue Fever outbreak in Delhi, north India: A clinico-epidemiological study. Indian J Community Med 2015;40:135-8. 12. Nadkar MY, Bajpai S. Leptospirosis: An emerging infection In: Rao MS, editor. Medicine Update. New Delhi: Association of Physicians of India; 2010. Available from: http://www.apiindia.org/pdf/medicine_ update_2010/infectious_disease_04.pdf. 13. Nimmanitya S, Kalayanarooj S. Guidelines for DHF Case Management for Workshop on Case Management of DHF, Queen Sirikit National Institute for Child Health. Bangkok, Thailand: Ministry of Public Health; 2002. 14. Restrepo BN, Beatty ME, Goez Y, Ramirez RE, Letson GW, Diaz FJ, et al. Frequency and clinical manifestations of dengue in urban medellin, Colombia. J Trop Med 2014;2014:872608. 15. Daniel R, Rajmohanan, Philip AZ. A study of clinical profile of dengue fever in Kollam, Kerala, India. Dengue Bull 2005;29:197-202. 16. Sharma S, Sharma SK, Mohan A. Clinical profile of dengue haemorrhagic fever in adults during 1996 outbreak in Delhi, India. Dengue Bull 1998;22:20-7. 17.Ahluwalia G, Sharma SK. Dengue fever in India: An overview. In: Rao MS, editor. Medicine Update. New Delhi: Association of Physicians of India; 2010. Available from: http://www.apiindia.org/ pdf/medicine_update_2010/infectious_disease_01.pdf. Padma Kumar Balasundaram, et al. Socio-demographic, Clinical, and Laboratory Profile of Patients with Febrile Illness Admitted to a Tertiary Care Center in Kerala Academic Medical Journal of India 18.Raikar SR, Kamdar PK, Dabhi AS. Clinical and laboratory evaluation of patients with fever with thrombocytopenia. Indian J Clin Pract 2013;24:361-3. 19. Oishi K, Saito M, Mapua CA, Natividad FF. Dengue illness: Clinical features and pathogenesis. J Infect Chemother 2007;13:125-33. 20.Cerqueira TB, Athanazio DA, Spichler AS, Seguro AC. Renal 93 Volume III - Issue 3 involvement in leptospirosis – New insights into pathophysiology and treatment. Braz J Infect Dis 2008;12:248-52. 21.Infectious Diseases. WHO/CDS/CSR/ISR/2000.1 World Health Organization Department of Communicable Disease Surveillance and Response. Available from: https://www.extranet.who.int/iris/restricted/ bitstream/10665/66485/1/WHO_CDS_CSR_ISR_2000.1.pdf. Padma Kumar Balasundaram, et al. Socio-demographic, Clinical, and Laboratory Profile of Patients with Febrile Illness Admitted to a Tertiary Care Center in Kerala