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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.
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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
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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
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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.
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