Revisiting the role of the slit-skin smear in the diagnosis of Indian post-kala-azar dermal leishmaniasis

Background: Post kala azar dermal leishmaniasis (PKDL) is a neglected dermatosis that develops as a sequel to kala azar after apparent complete treatment. Being a non life threatening condition, patients often delay treatment thereby maintaining a reservoir of infection. The diagnosis of PKDL rests on the demonstration of the parasite in tissue smears, immune diagnosis by detection of parasite antigen or antibody in blood, or detection and quantitation of parasite DNA in tissue specimens. Sophisticated molecular tests are not only expensive but also need skilled hands and expensive equipment. To be useful, diagnostic methods must be accurate, simple and affordable for the population for which they are intended. Aims: This study was designed to assess functionality and operational feasibility of slit-skin smear examination. Methods: Sensitivity and specificity was evaluated by performing slit-skin smear and histo-pathological examination in 46 PKDL patients and the results were compared with the parasite load in both the slit aspirate and tissue biopsy specimens by performing quantitative Real-time PCR (Q-PCR). Results: The slit-skin smear examination was more sensitive than tissue biopsy microscopy. The parasite loads significantly differed among various types of clinical lesions (P < 0.05). The threshold of parasite load for detection by SSS microscopy was 4 parasites/μl in slit aspirate and 60 parasites/μg tissue DNA in tissue biopsy while that for tissue microscopy was 63 parasites/μl and 502 parasites/μg tissue DNA respectively. As detection of Leishmania donovani bodies may be challenging in inexperienced hands, the microscopic structure of these has been detailed along with a comprehensive discussion of pre analytical, analytical and post analytical variables affecting its identification. To facilitate the diagnosis of PKDL, some scenarios have been suggested taking into consideration the clinical, epidemiological, immunological and microscopic aspects. Conclusion: Such evidence based medicine helps minimize intuition, systematize clinical experience and provides a diagnostic rationale as sufficient grounds for a clinical decision.

Anthropometric Comparison Of Ear Lobule Among Males Of Haryana And Himachal Region

In recent years, external ear and its prints have developed important role in medico-legal practice. It suggestedbeing an identification tool analogous to fingerprinting as well as facial recombustion. Different ethnic groupshave different parameters in relation to the various body parts and furthermore population specific standardscan give accurate statistical estimation of biological attributes. Therefore, this study was done to establish thecomparison of ear lobe dimensions in two population groups (Haryanvi and Himachali males). In present study,morphometry of ear lobule and its prints was done in 200 healthy males (100 Haryanvi and 100 himachali) in theage range 18-40 years. Significant difference was found in the lobular height in both the methods. Lobular heightis more in Haryanvi males as compared to the himachali males. No significant difference was seen in the lobularwidth in both methods. Lobular index was significantly higher in Haryanvi males than Himachali males.

Genital Chlamydia trachomatis: An update.

Chlamydia trachomatis is the most common cause of curable bacterial sexually transmitted infection (STI) worldwide. It manifests primarily as urethritis in males and endocervicitis in females. Untreated chlamydial infection in man can cause epididymitis and proctitis. Though most women with Chlamydia infection are asymptomatic or have minimal symptoms, some develop salpingitis, endometritis, pelvic inflammatory disease (PID), ectopic pregnancy and tubal factor infertility. It is associated with an increased risk for the transmission or acquisition of HIV and is also attributed to be a risk factor for the development of cervical carcinoma. Early diagnosis and treatment of infected individuals is required to prevent the spread of the disease and severe sequelae. Traditionally, tissue culture was considered the gold standard for the diagnosis. However, with the availability of newer diagnostic techniques particularly molecular methods which are not only highly sensitive and specific but are cost-effective also, the diagnosis has became fast and easy. The purpose of this review is to study the various aspects of genital C. trachomatis infection. Also the advances related to the clinical picture, various diagnostic modalities, prevention, treatment, drug resistance and control measures will be dealt with.

Polysaccharide enriched immunomodulatory fractions from Tinospora cordifolia (Willd) miers ax hook. F. & Thoms†.

Tinospora cordifolia is used in Ayurveda as "Rasayanas" to improve the immune system and the body resistance against infections. Polysaccharides are the main constituents which are considered to be responsible for immune enhancement. In this study, immunomodulatory activity of three polysaccharide enriched fractions was evaluated using the polymorphonuclear leukocyte function test. Sugar composition was determined by GC-MS analysis of the derivatised fractions. The active polysaccharide fractions mainly constitute glucose, fructose and arabinose as monomer units.

A pilot study for diagnosis of genital Chlamydia trachomatis infections by polymerase chain reaction among symptomatic Indian women.

Background: Chlamydia trachomatis is the most common bacterial etiology of sexually transmitted infection. Aim : A pilot study was designed using PCR for amplification and detection of a specific 517 bp sequence of the common endogenous plasmid of C. trachomatis from clinical swab specimens obtained from symptomatic female patients attending STD clinics of AIIMS and Regional STD Teaching, Training & Research Center, Safdarjang Hospital, New Delhi. Methods: 97 patients were recruited in the study, and endocervical swabs were collected following standard procedures. The samples were analyzed by PCR and direct fluorescence antibody (DFA) for detection of C. trachomatis, and the sensitivity, specificity, PPV and NPV of PCR were calculated taking DFA as gold standard. Results: Out of 97 samples tested, 9 were positive for C. trachomatis by PCR. 1 PCR positive patient was negative by DFA although a total of 11 patients were positive by DFA. The sensitivity, specificity, PPV and NPV of PCR with reference to DFA was 72.73%, 98.84%, 88.89% and 96.59%, respectively. This PCR had high specificity and NPV for detection of C.trachomatis. Conclusions : In light of the introduction of enhanced syndromic approach, which involves the use of laboratory techniques (wherever possible) to confirm clinical diagnosis, a diagnostic PCR with high specificity and NPV is particularly valuable for determination of etiological diagnosis and hence contribute to judicious use of antimicrobials in the community.

An insight into the drug resistance profile & mechanism of drug resistance in Neisseria gonorrhoeae.

Among the aetiological agents of treatable sexually transmitted diseases (STDs), Neissseria gonorrhoeae is considered to be most important because of emerging antibiotic resistant strains that compromise the effectiveness of treatment of the disease - gonorrhoea. In most of the developing countries, treatment of gonorrhoea relies mainly on syndromic management rather than the aetiological based therapy. Gonococcal infections are usually treated with single-dose therapy with an agent found to cure > 95 per cent of cases. Unfortunately during the last few decades, N. gonorrhoeae has developed resistance not only to less expensive antimicrobials such as sulphonamides, penicillin and tetracyclines but also to fluoroquinolones. The resistance trend of N. gonorrhoeae towards these antimicrobials can be categorised into pre-quinolone, quinolone and post-quinolone era. Among the antimicrobials available so far, only the third-generation cephalosporins could be safely recommended as first-line therapy for gonorrhoea globally. However, resistance to oral third-generation cephalosporins has also started emerging in some countries. Therefore, it has become imperative to initiate sustained national and international efforts to reduce infection and misuse of antibiotics so as to prevent further emergence and spread of antimicrobial resistance. It is necessary not only to monitor drug resistance and optimise treatment regimens, but also to gain insight into how gonococcus develops drug resistance. Knowledge of mechanism of resistance would help us to devise methods to prevent the occurrence of drug resistance against existing and new drugs. Such studies could also help in finding out new drug targets in N. gonorrhoeae and also a possibility of identification of new drugs for treating gonorrhoea.

Needle stick injuries among health care workers in a tertiary care hospital of India.

Background & objectives: Percutaneous injuries caused by needlesticks, pose a significant risk of occupational transmission of bloodborne pathogens. Their incidence is considerably higher than current estimates, and hence a low injury rate should not be interpreted as a non existent problem. The present study was carried out to determine the occurrence of NSI among various categories of health care workers (HCWs), and the causal factors, the circumstances under which these occur and to, explore the possibilities of measures to prevent these through improvements in knowledge, attitude and practice. Methods: The study group consisted of 428 HCWs of various categories of a tertiary care hospital in New Delhi, and was carried out with the help of an anonymous, self-reporting questionnaire structured specifically to identify predictive factors associated with NSIs. Results: The commonest clinical activity to cause the NSI was blood withdrawal (55%), followed by suturing (20.3%) and vaccination (11.7%). The practice of recapping needles after use was still prevalent among HCWs (66.3%). Some HCWs also revealed that they bent the needles before discarding (11.4%). It was alarming to note that only 40 per cent of the HCWs knew about the availability of PEP services in the hospital and 75 per cent of exposed nursing students did not seek PEP. Interpretation & conclusions: The present study showed a high occurrence of NSI in HCWs with a high rate of ignorance and apathy. These issues need to be addressed, through appropriate education and other interventional strategies by the hospital infection control committee.

Changing trends in sexually transmitted infections at a Regional STD Centre in north India.

BACKGROUND & OBJECTIVES: Sexually transmitted infections (STIs) a major public health problem in India show various trends in different parts of the country. However, there are limited data on the changing profile of laboratory proven STIs in the same clinic over the years. The present study was thus aimed to determine the changing trends of the profile of STIs and HIV seropositivity in STD clinic attendees over a 15 yr period, and also to detect change, if any, in the antimicrobial resistance pattern of Neisseria gonorrhoeae. METHODS: The STIs were diagnosed clinically and confirmed by standard laboratory techniques. Socio-demographic data were collected through pre-designed proformae. The STI profile and HIV seropositivity were compared between 1990-1993 (A), 1994-1997 (B), 1998-2001 (C) and 2002-2004 (D). Antimicrobial resistance pattern of N. gonorrhoeae was determined by standard techniques and compared between the last three periods. RESULTS: Of the 78,617 STD attendees, 12,709 (16.2%) had STIs. During period A, genital discharges and during B, C and D, genital ulcerative diseases were predominant. Syphilis was the commonest STI. There was significant rise in the cases of syphilis, herpes progenitalis and genital warts and reduction in that of chancroid, lymphogranulomavenereum (LGV), donovanosis, candidiasis, trichomoniasis and bacterial vaginosis cases. The number of cases with primary syphilis diminished significantly (P<0.001), with a concomitant rise in secondary and early latent syphilis. A rising trend was observed in the HIV seropositivity during the different periods. The association of HIV seropositivity was consistently more in patients presenting with genital ulcers specially syphilis, and rose significantly from A (0.6%) to C (8.8%), but became stationary during D. A drastic change in the antimicrobial resistance of N. gonorrhoeae from B to C and C to D and the emergence of less sensitive isolates to ceftriaxone during the later part of the study were observed. INTERPRETATION & CONCLUSION: Our study showed a definite changing trend in the profile of STIs in the clinic attendees of a major STD centre during a 15 yr period. However, the significant rise in the cases of viral STIs and syphilis contrasted with reduction in the rest.

CD4/CD8 lymphocyte counts in healthy, HIV-positive individuals & AIDS patients.

BACKGROUND & OBJECTIVES: The enumeration of CD4 and CD8 positive cells, surrogate markers for HIV disease progression, is helpful in management and follow up of immunocompromised HIV-positive patients. In assessing the degree of immune deficiency in HIV-positive patients of a particular region, knowledge of reference range of T-cell subset counts of healthy individuals of that particular region is essential. The present cross-sectional study was undertaken to determine the reference range of T-cell subsets in healthy north Indians and to compare the values with those in HIV-positives. METHODS: Blood samples from 125 HIV seronegative healthy volunteers comprising group I (88 males, 37 females) and 452 HIV- positive patients, divided into group II of asymptomatic (n=137; 93 males, 44 females) and group III of AIDS patients (n=315; 253 males, 62 females) in the age group of 17-60 yr, were analysed for enumeration of CD4+, CD8+ cells/microl by flow cytometry. RESULTS: In group I, the CD4 and CD8 levels were 687 +/- 219 and 611 +/- 288 cells/microl in males and 740 +/- 255 and 546 +/- 246 cells/microl in females. Overall, a significant depressed level of CD4 (525 +/- 207 cells/microl) and elevated level of CD8 (1174 +/- 484 cells/microl) in group II and (170 +/- 115 and 1051 +/- 586 cells/microl) respectively in group III were observed. Group II patients had highest level of CD8 cells. No asymptomatic women had CD4 count of <200 cells/microl. INTERPRETATION & CONCLUSION: Our findings on T-cell subset reference ranges of normal healthy north Indians validate the utility of determination of CD4 cell count as a useful predictor of AIDS in Indian conditions and confirm that a significant per cent of AIDS patients had CD4 cell count below 200/microl.

Comparison of disc diffusion results with minimum inhibitory concentration (MIC) values for antimicrobial susceptibility testing of Neisseria gonorrhoeae.

BACKGROUND & OBJECTIVE: objectives: As antimicrobial susceptibility testing of Neisseria gonorrhoeae provides guidance for appropriate treatment, there is a need for simple, reliable and cost-effective method for susceptibility testing. The present study was aimed to compare the results of two methods of susceptibility testing, minimum inhibitory concentration (MIC) values by E test with disc diffusion results by Australian Gonococcal Surveillance Programme (AGSP) method in N. gonorrhoeae isolates. METHODS: Susceptibility testing for ciprofloxacin, penicillin and ceftriaxone using AGSP method was carried out for 301 confirmed consecutive isolates of N. gonorrhoeae. MIC of ciprofloxacin, penicillin and ceftriaxone was determined by E test in 301, 198 and 128 isolates respectively. The results of the two methods were compared by using Kappa statistics. RESULTS: Moderate levels of agreement for ciprofloxacin (kappa=0.44) and penicillin (kappa=0.54) were observed between the two methods. For ceftriaxone, 96.1 and 0.8 per cent isolates were found to be susceptible and less sensitive respectively by both the methods and per cent agreement between the two methods was 96.9 per cent. INTERPRETATION & CONCLUSION: Both the methods were easy to perform and gave reproducible results. However, disc diffusion method was cost-effective and more feasible in routine diagnostic laboratories in developing countries like India.

Evaluation of beta2 microglobulin level as a marker to determine HIV/AIDS progression.

Levels of beta2 microglobulin (beta2M) were evaluated to monitor the progression of HIV disease, as an alternate economical marker to RNA viral load and CD4 cell count in resource poor situations. A cross sectional study of 32 HIV sero-negative controls (Group I), 43 asymptomatic HIV sero-positives (Group II-A), 44 HIV sero-positives with clinical and/or laboratory proven STDs (Group II-B) and 30 with AIDS indicator conditions (Group III) was carried out. beta2M levels were determined using an enzyme immuno assay. Mean +3 SD (3.04mg/l) of concentration of beta2M in sero-negative controls was chosen as threshold of abnormality. A significant rise (p<0.001) in mean beta2M levels (mg/l) from 1.87 +/- 0.39 (Group I) to 2.59 +/- 1.09 (Group IIA), 3.01 +/- 1.27 (Group IIB) to 5.16 +/- 2.48 (Group III) was observed. Higher values of beta2M in the symptomatic phase than those in the asymptomatic phase indicated that elevated levels of beta2M parallel progression of HIV disease and suggest its use as an alternate marker for determining HIV progression.