BackgroundAcute Encephalitis Syndrome (AES) is a major seasonal public health problem in Bihar, India. Despite efforts of the Bihar health department and the Government of India, burden and mortality of AES cases have not decreased, and definitive etiologies for the illness have yet to be identified.ObjectivesThe present study was undertaken to study the specific etiology of AES in Bihar.MethodsCerebrospinal fluid and/or serum samples from AES patients were collected and tested for various pathogens, including viruses and bacteria by ELISA and/or Real Time PCR.FindingsOf 540 enrolled patients, 33.3% (180) tested positive for at least one pathogen of which 23.3% were co-positive for more than one pathogen. Most samples were positive for scrub typhus IgM or PCR (25%), followed by IgM positivity for JEV (8.1%), WNV (6.8%), DV (6.1%), and ChikV (4.5%).M. tuberculosis and S. pneumoniae each was detected in ~ 1% cases. H. influenzae, adenovirus, Herpes Simplex Virus -1, enterovirus, and measles virus, each was detected occasionally. The presence of Scrub typhus was confirmed by PCR and sequencing. Bihar strains resembled Gilliam-like strains from Thailand, Combodia and Vietnam.ConclusionThe highlights of this pilot AES study were detection of an infectious etiology in one third of the AES cases, multiple etiologies, and emergence of O. tsutsugamushi infection as an important causative agent of AES in India.

The report benefited from useful inputs and feedbacks from World Bank colleagues, including Tekabe Ayalew Belay (Program Leader), Sereen Juma (Country Program Coordinator) and Bushra Binte Alam (Sr. Health Specialist). The authors particularly thank D.H.C Aturupane (Lead Economist); Xiaonan Cao (Senior Education Specialist) and Jason Allen Weaver (Senior Education Specialist) for their insightful review and thoughtful comments as peer reviewers.

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Primary tuberculous sternal osteomyelitis is a rare condition, presenting as painful swelling and discharging sinuses over the chest wall. Diagnosis is based on radiological findings and histological examination of debrided infected tissues, with specific cultures for mycobacteria. Two cases were successfully treated by surgical debridement and reconstruction using pectoralis major muscle flaps, followed by antituberculous therapy.