Complete sequencing of an IncX3 plasmid carrying blaNDM-5 allele reveals an early stage in the dissemination of the blaNDM gene.

Purpose: The aim of the present study was to perform molecular characterisation of the blaNDM plasmids and to understand the mechanism of its spread among pathogenic bacteria. Materials and Methods: Seventy-six non-repetitive carbapenem-resistant isolates which were collected during Nov 2011 to April 2013 from four hospitals in Chennai were analyzed for the presence of the blaNDM gene by PCR. Further, the genetic context of the blaNDM gene was analyzed by PCR specifi c to ISAba125 and bleMBL gene. One of the blaNDM plasmid was completely sequenced in the Illumina HiSeq platform. Results: Twenty-three isolates consisting of 8 Escherichia coli, 8 Klebsiella pneumoniae, 3 Klebsiella oxytoca, 3 Acinetobacter baumanii and 1 Pseudomonas aeruginosa were found to carry the blaNDM gene. In 18 isolates the blaNDM gene was associated with a bleMBL gene and the ISAba125 element. The complete sequencing of pNDM-MGR194 revealed an IncX3 replication type plasmid, with a length of 46,253 bp, an average GC content of 47% and 59 putative ORFs. The iteron region contained the blaNDM5 gene and the bleMBL, trpF and dsbC genes downstream and an IS5 inserted within the ISAba125 element upstream. Conclusion: This is the fi rst report where the blaNDM gene insertion in a plasmid is not accompanied by other resistance gene determinants. These observations suggest that the IncX3 plasmid pNDM-MGR194 is an early stage in the dissemination of the blaNDM.

Radiotherapy for benign diseases.

Radiotherapy mainly involves treatment of patients with malignant tumors. Even with recognition of the risks of late skin injury, carcinogenesis, leukemogenesis, and genetic damage from all ionizing radiation; radiation therapy also continues to be accepted treatment for benign diseases. Before initiation, the quality of irradiation, total dose, overall time, underlying organs at risk, and shielding factors should be considered. Children should be treated with ionizing radiation only in very exceptional cases and after weighing the pros and cons of the therapy. Direct irradiation of skin areas overlying organs that are particularly prone to late effects (e.g. thyroid, eye, gonads, bone marrow and breast) should be avoided. Radiation protection techniques should be used in all instances. The depth of penetration of the x-ray beam should be chosen according to the depth of the pathologic process. Choice of beam energy usually depends on the depth of the target volume; every effort is made to spare normal underlying tissue in superficial lesions. There are a number of other benign conditions that can be treated with radiotherapy; we present a brief overview of some of the commonly encountered conditions.

Cytological diagnosis of bancroftian filariasis in lesions clinically anticipated as neoplastic.

Filariasis is a common disabling parasitic disease in this region and cytological diagnosis is often not required. Cytology has important role in diagnosis of sub-clinical filariasis. Most cases of cytologically diagnosed filariasis are clinically unanticipated. Microfilaria, ova and fragments of adult worm of Wuchereria bancrofti, in exfoliative as well as aspiration cytology have been reported and are useful in cytological detection of bancroftian filariasis. Microfilaria is frequently detected in association with neoplasm, although the role in tumorogenesis is controversial. The objective of the study was to investigate importance of cytology in diagnosis of filariasis in lesions clinically anticipated to be of neoplastic and to review the cytomorphology of bancroftian filaria and its association with neoplasm. This is a retrospective study carried out in cytology department of Tribhuvan University Teaching Hospital. 14 cases of cytological specimen out of 4291 (0.3%) showed microfilaria; 12 cases were from FNAC from different sites and 2 cases were from pleural fluid. 2 cases showed ova in addition to microfilaria and one of them in addition showed fragment of adult worm. Microfilaria in 4 cases of FNAC and one case ofpleural fluid were associated with malignant cells.

Bone marrow examination in cases of pancytopenia.

This study was carried to identify the causes of pancytopenia and to find out the bone marrow morphology in cases of pancytopenia. It was a cross sectional study conducted over a period of two years in the Department of Pathology, Tribhuvan University Teaching Hospital. Bone marrow aspiration smears of patients fulfilling the criteria of pancytopenia were examined. The data obtained were analyzed using measures of central tendency. One hundred and forty eight cases underwent bone marrow aspiration and it constituted 15.74% of total cases. Mean age was 30 years (range, 1-79 years). 42 cases were children (28.37%). Male: female ratio was 1.5:1. The commonest cause was hypoplastic bone marrow seen in 43 cases (29%) followed by megaloblastic anemia in 35 cases (23.64%), and hematological malignancy in 32 cases (21.62%). Erythroid hyperplasia was seen in 29 cases (19.6%) and normal bone marrow was seen in 5 cases (3.38%). There was one case each of Niemann-Pick disease and metastatic neuroblastoma in children and chronic pure red cell aplasia and leishmaniasis in adults. Acute leukemia was the commonest hematological malignancy. In children, commonest finding was hypoplastic bone marrow (38.1%) while in adults megaloblastic anemia (30.18%) was commonest finding followed by hypoplastic anemia (25.47%). In present study bone marrow examination was able to establish diagnosis in 77% of cases. Hypoplastic marrow was the commonest diagnosis, followed by megaloblastic anemia, and hematological malignancies.

Herpes zoster in a five month old infant subsequent to intrauterine exposure to varicella infection.

Herpes zoster is characterized by painful vesicular eruption in a dermatomal distribution of sensory nerves as a result of reactivation of latent herpes zoster virus in posterior root ganglia. The primary varicella infection is usually acquired in childhood and reactivation usually is seen in elderly. In rare instances herpes zoster can also occur in infancy as a result of reactivation of primary varicella infection acquired in utero or in early infancy. Here, we report a rare case of herpes zoster in a 5 month baby who acquired primary infection in utero from mother who had varicella infection at 6 months of gestation.

Diagnosis of subcutaneous cysticercosis in fine needle aspirates: a study of 10 cases.

The objective of this study is to document the value of Fine Needle Aspiration Cytology (FNAC) in the diagnosis of subcutaneous cysticercosis. Aspirates smears of 10 cases of subcutaneous swellings were studied over a period of 1 year between January 2004 and January 2005. The subcutaneous swellings were presented at different sites like cheek, neck, forearm, arm, chest wall and abdominal wall. In none of these cases was cysticercosis considered as diagnostic possibility. The characteristic cytomorphological features of parasitic tegument, parenchymatous portion, presence of epithelioid cells, giant cells and inflammatory cells in cytological smears help diagnose the cases of subcutaneous cysticercosis. Biopsy confirmation was possible in 5 cases, of which, two cases showed parenchymatous portion of the parasite. FNAC provides safe and rapid tool for diagnosis of subcutaneous cysticercosis. In endemic areas, cysticercosis should be considered one of the differential diagnosis of the subcutaneous swellings.

A rare case of juvenile fibrosarcoma of eyelid.

Juvenile fibrosarcoma is not an uncommon tumor in children; however, eyelid involvement is extremely rare. Very few cases have been reported in the literature. This is the first case of JFS of the eyelid in Tribhuvan University Teaching Hospital and the first diagnosed case in Nepal. Histologically, it is similar to adult fibrosarcoma but it has an excellent prognosis. Surgical excision is the mainstay of treatment; however chemotherapy has been proved effective. Here we present a case of juvenile fibrosarcoma of the eyelid in a four year female child presenting with a rapidly enlarging, painless, left upper eyelid mass. An incisional biopsy, from the eyelid mass, showed typical histopathological features of juvenile fibrosarcoma.

Intraoperative high field magnetic resonance imaging in neurosurgery: Our initial experience with the brain suite.

We present our initial experience with the high field (1.5T) intra-operative magnetic resonance imaging, the operating room set-up, our initial cases, the difficulties we faced and how this tool affected a change in the surgical strategy intra-operatively and finally our results. 11 patients were operated on from June 1st to August 1st 2006 of which there were astrocytomas (7), pituitary adenoma (1), craniopharyngioma (1) and meningiomas (2) Localization and lesion targeting were accurate, intra-operative imaging helped to assess the resection volumes, enable corrections for brain shift, perform further tumor resection at the same sitting and help preserve eloquent cortical areas. Gliomas formed 63.6% of the tumors operated on and in 71.4% of these, our surgical strategy changed intra-operatively. Meningiomas formed 9.1% of the tumors operated and image guidance enabled a minimally invasive approach, although no change in our surgical plan was required. One pituitary adenoma and a craniopharyngioma were also operated on with good outcome.

Histopathological analysis of hysterectomy specimens.

This was a retrospective study carried out on all hysterectomy specimens sent to Department of Pathology of Tribhuvan University Teaching Hospital, Kathmandu, Nepal from 1st September 2005 to 28th February 2006, to study the histopathological findings of these specimens. All informations used in the study were obtained from the records of Department of Pathology of the hospital. Out of 221 hysterectomy specimens received during the study period, 139 (62.9%) were total abdominal and 82 (37.1%) were vaginal hysterectomy specimens. Mean age of the patient was 53.4 years for vaginal hysterectomy group where as it was 37.6 years for total abdominal hysterectomy with unilateral salpingo-oophorectomy and 46.3 years for total abdominal hysterectomy with bilateral salpingo-oophorectomy group. Uterine prolapse was commonest indication of hysterectomy overall (37.1%) and accounted for 98.8% of vaginal hysterectomies. Other common indications of hysterectomy were uterine fibroid (24.9%), ovarian tumor (14.9%) and dysfunctional uterine bleeding (7.7%). Leimyoma was the most common pathology found in uterine corpus (27.1%). Chronic cervicitis in cervix, functional cysts in ovaries and paratubal cysts in fallopian tubes were most common histological findings. Ovarian neoplasms accounted for 18.3% of ovarian pathology. 38% specimens were unremarkable histopathologically. In Tribhuvan University Teaching Hospital, abdominal hysterectomies are more common than vaginal hysterectomies. Most vaginal hysterectomies are done for uterine prolapse and patients are older than those undergoing abdominal hysterectomies. Most abdominal hysterectomies are performed for uterine leiomyomas. Hysterectomy specimens may be unremarkable histopathologically, most of which are vaginal hysterectomies done for uterine prolapse.

Endocavitary radiotherapy in carcinoma oesophagus.

Radiation therapy is often used in an attempt to palliate or cure oesophageal neoplasms. However, the radiation tolerance of the normal structures around the oesophagus (heart, lung and spinal cord) restricts the radiation dose that can be delivered. We used a nasogastric catheter to deliver High Dose Intra-luminal Iridium-192 irradiation for carcinoma of the oesophagus using HDR-Varisource machine. This technique for treatment of carcinoma of the oesophagus can help overcome the dose restraints. The external beam radiation dose was about 46 Gy and the intra luminal dose was 5 Gy at 1 cm from central axis. These after loading procedures are simple, fast and accurate and can be used to boost external radiation therapy doses. Since the intra luminal boost delivers a high-localized dose with little side effects, this simple technique should be used to obtain palliation, delay tumour progression, reduce overall treatment time and attempt to improve survival in patients with oesophageal neoplasm. Intra luminal brachytherapy helps achieve good palliation in these neoplasms.

Curative interstitial brachytherapy for early stage carcinoma lip.

Brachytherapy is potentially useful in the treatment of head-and-neck cancers, because most tumor sites, such as the lip, tongue, floor of mouth, tonsil, pharynx, nasopharynx, sinuses, and neck, are accessible for the placement of afterloading applicators and catheters. It has the advantage of delivering a higher radiation dose to the tumor while sparing surrounding normal tissue from radiation. Furthermore, the overall treatment duration is shorter, and the dose distribution confirms to tumor shape. Brachytherapy is used as "monotherapy" for the treatment of small primary tumors or recurrent disease after external beam radiation therapy (EBRT). Small cancers of the lip (less than 2 cm) are treated equally well with surgery or radiation therapy with excellent cosmetic and functional results seen in radiation therapy. We treated an 18-year old male diagnosed as stage I carcinoma lip with curative interstitial brachytherapy. He was treated to a dose of 3 Gy per fraction, two fractions per day at interval of 6 hours between the two fractions for 6 days. He therefore received a total dose of 36 Gy with High Dose Rate (HDR) Brachytherapy, which is equivalent to 58.36 Gy conventional radiotherapy dose. At two months follow, the patient is clinically disease free and has no complaints.

Radiotherapy for splenomegaly.

Radiotherapy for massive, symptomatic splenomegaly has been used in a palliative setting since the early 1990's. Massive splenomegaly may be seen in CML, CLL, hairy cell leukemia and splenic marginal zone lymphomas, prolymphocytic leukemia, myeloproliferative disorders such as polycythaemia rubra, polycythaemia vera or essential thrombocytosis or myelofibrosis. Splenic radiation therapy has been shown to be effective in palliation of the signs and symptoms due to massive splenomegaly. We present here one such case of myelofibrosis where the patient was treated with radiotherapy to the spleen for symptomatic relief. The patient achieved excellent response to the treatment.

Hereditary punctate palmoplantar keratoderma--a clinical study.

28 patients of hereditary punctate palmoplantar keratoderma (HPPK) were selected from DermatoVenereology out patients of Rajindra Hospital, Patiala. Cases were divided into group A with PPK as major feature and group 6 with PPK as minor feature. 11/28 belonged to group A and 17/28 to group B. Group A patients revealed scattered pundate PPK in 6 and scattered pundate plus focal plaques in 5, while in group B patterns seen were KPPC (6), KPPC with focal (6), focal plus scattered punctate (3) and diffuse with superimposed KPPC (2).

Pyoderma gangrenosum and urinary tract infection.

A case of pyoderma gangrenosum is reported in a 52-year-old man who had skin lesions without any association. On investigation urinary tract infection was detected. Treatment of UTI led to spontaneous healing of the lesions in short period thus avoiding the need of oral corticosteroids.

Primary fibrosarcoma of brain.

This is a case presentation of a young patient with an intracranial space-occupying lesion following multiple episodes of generalised tonic clonic seizures for the last 20 years. Such a long latency period between the onset of fits and the discovery of an intracranial lesion is highly unusual in malignant brain tumours. This lesion was excised completely and proved to be a primary lesion of the brain - fibrosarcoma. These rare tumours of mesenchymal origin in the central nervous system are very rare.