This is the first report of the largest epidemic of dengue hemorrhagic fever (DHF) virus infection (2006) with IgM-confirmed cases from Karachi, Pakistan. Medical records of 172 IgM-positive patients were reviewed retrospectively for demographic, clinical and laboratory data. Patients were categorized into dengue fever (DF) and DHF according to the WHO severity grading scale. The mean+/-SD age of the patients was 25.9+/-12.8 years, 55.8% were males and the hemoconcentration was recorded in a small number of patients [10 (7.0%)]. Male gender [odds ratio (OR)=14.7, P=0.003), positive history of vomiting (OR=4.3, P=0.047), thrombocytopenia at presentation (OR=225.2, P<0.001) and monocytosis (OR=5.8, P=0.030) were independently associated with DHF, but not with DF. Five cases (2.9%) had a fatal outcome, with a male-to-female ratio of 1:4. Three were from a pediatric group (<15 years). Pulmonary hemorrhages, disseminated intravascular coagulation and cerebral edema preceded death in these patients. The results have highlighted significant findings, such as adult susceptibility to DHF, pronounced abdominal symptoms and lack of hemoconcentration at time of presentation in the study population. These findings may play an important role in the case definitions of future studies from this part of the world.

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A B S T R A C TBackground: The increasing incidence of pediatric food allergy results in significant health care burden and family stress. Oral immunotherapy (OIT) can induce tolerance to peanut, milk, and egg. OIT for other foods, particularly multiple foods simultaneously, has not been thoroughly studied. Objective: To summarize our experience with OIT for multiple foods in a pediatric allergy clinic setting. Methods: Medical records were reviewed for patients undergoing OIT for multiple foods. Methods and outcomes of OIT were summarized. Outcomes were analyzed for correlation with baseline food allergen skin prick tests (SPTs) and specific IgE (sIgE) test results. Results: Forty-five patients aged 1.5 to 18 years undertook OIT for up to 12 foods, including peanut, tree nuts, seeds, legumes, and egg. At the time of review, 35 patients were receiving daily maintenance dosing, 4 had completed OIT and were continuing to eat their foods 3 times weekly, and 6 had stopped OIT because of anxiety, inconvenience, or allergy symptoms. A total of 49% of patients had reactions during the up-dosing process, mostly oral itching (33%), perioral hives (40%), and abdominal pain (35%). There was no correlation of baseline skin prick test (SPT) and sIgE test results with reaction threshold for baseline food challenge, lowest dose causing reactions during up-dosing, or time to reach maintenance. Higher baseline sIgE level but not baseline SPT result was associated with an increased number of allergic reactions during OIT. Baseline SPT correlated with stopping OIT. Conclusion: A similar approach to that used for peanut OIT can be taken for nonpeanut foods and for multiple foods simultaneously. High baseline allergy test results are not a contraindication to OIT.

Background: Shigellosis is a common cause of morbidity, especially in the very young and old, in developing countries. The disease is treated with antibiotics. Surveillance of antimicrobial resistance trends is essential owing to the global emergence of antimicrobial resistance. Methodology: The study involved 1,573 isolates of Shigella species (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007) that were analyzed for trends in antimicrobial resistance. Results: The majority of the specimens (1046; 66.5%) were from the pediatric population, and of these 887 (84.8%) were under 5 years of age (p = 0.001). S. flexineri was the most frequent species (54.5%) isolated. Isolation of S. sonnei increased from 15.4 % (1996) to 39% (2007) (p = 0.001). Although none of the isolates was found sensitive to all the antibiotics tested, 58% (n =9 07) were resistant to ampicillin and 85% (n = 1,338) were resistant to trimethoprim-sulfamethoxazole (TMP-SMX). Out of a total of 198 (12.6%) nalidixic acid resistant isolates, 6 (3.0%) were also resistant to ofloxacin. Overall 1.7 % of isolates were resistant to ofloxacin, 2.4% to ceftriaxone and 2.3% were resistant to combination of ampicillin, nalidixic acid and TMP-SMX. Conclusion: Ofloxacin is still an effective drug for treatment of acute shigellosis in Pakistan. Emergence of resistance to ceftriaxone in Shigella may have grave implications in treatment of severe shigellosis in very young patients.

Bacteremia caused by Vibrio cholerae O1 has been a rare phenomenon. We report on eight cases of V. cholerae O1 bacteremia from Pakistan which occurred during 1992-2008. Six of the cases were seen in children (two neonates and four infants) and seven of the eight patients were female. Urogenital malignancy, hepatitis B virus-associated end-stage liver disease, concurrent Campylobacter enteritis and prematurity were the underlying conditions in four patients. Two of the eight patients died and one was lost to follow up and this outcome may be due to prior immunity leading to less severe illness.