Combining Autologous Peripheral Blood Mononuclear Cells with Fibroblast Growth Factor Therapy Along with Stringent Infection Control Leading to Successful Limb Salvage in Diabetic Patient with Chronic Renal Failure and Severe Toe Gangrene

Peripheral arterial disease (PAD) is a common complication of Diabetes Mellitus (DM) and often culminates in amputation of the affected foot. Pseudomonas aeruginosa infections associated with PAD are difficult to treat due to their multi-drug resistance. Herein we report a 38 year old male who reported with DM, chronic kidney disease (CKD) and rest pain of the right second toe in October 2011. He underwent percutaneous transluminal angioplasty (PTA) which was unsuccessful. The gangrene of the toes worsened and amputation of the right second toe was done. Bacteriological examination showed presence of P. aeruginosa which during the course of antibiotic therapy became multi-drug resistant. Gangrene and abscess of the foot worsened and amputation of the right third toe was performed. Then autologous peripheral blood mononuclear cell (PBMNC) therapy was performed but as infection control could not still be achieved, the fourth toe was amputated. A protocol of foot bath using carbonic water, local usage of antibiotics (Polymyxin-B), and basic fibroblast growth factor (b-FGF) spray was then employed after which the infection could be controlled and improvement in vascularity of the right foot could be observed in angiography. This combined approach after proper validation could be considered for similar cases.

MYCOBACTERIUM TUBERCULOSIS AND gyrA VARIATION IN ZAMBIA

<I>M. tuberculosis</I> strains were isolated from clinically and bacteriologically confirmed patients to evaluate the susceptibility of clinical <I>M. tuberculosis</I> isolates to fluoroquinolone and to obtain molecular epidemiological information in Zambia,. The pathogens were subjected to susceptibility testing with isoniazid, rifampicin, ethambutol and streptomycin. The minimum inhibitory concentrations to ciprofloxacin, sparfloxacin and levofloxacin were also evaluated. The <I>gyrA</I>, fluoroquinolone resistance-determining region (QRDR), was sequenced and analysed. As a result, three of the 16 strains examined were resistant to isoniazid, rifampicin and⁄or streptomycin. All of the strains were susceptible to ciprofloxacin, levofloxacin and sparfloxacin. However, a unique <I>gyrA</I> gene variation of<I> M. tuberculosis</I> was identified in the isolates. One strain had a mutation (T73A) in QRDR. Additionally, 81.25% (13⁄16) of the strains tested had Thr at codon 88. Several variations of <I>gyrA</I> gene have been reported in relation to drug resistance. The <I>gyrA</I> variation data will be useful as epidemiological information. It may be important to monitor fluoroquinolone susceptibility even in developing countries for use against resistant <I>M. tuberculosis</I> infection, even though no fluoroquinolone resistance was observed in this study.