TWO INTERESTING CASES OF FILARIASIS AT UNCOMMON SITES

Filariasis is a condition resulting from filarial parasites that affects both humans and animals.There are several hundreds of filarial parasites which have been mentioned in medical literature, out of which only eight species are known to cause natural infections in humans. Repeated episodes of inflammation and lymphedema cause lymphatic damage, persistent edema, and elephantiasis of the legs, arms, scrotum, vulva, and breasts. We have reported two cases of filariasis at unusual sites

A sociological study on stigma among TB patients in Delhi.

Setting : The study was carried out at Delhi State, New Delhi. Objectives : 1. To assess the effect of social stigma in TB patient’s treatment, their personality, emotions, feelings, changes in their thinking process and behaviour of their family members, friends. 2. To study the relationship of gender and to what extent social stigma affects their lives. Design : It was a prospective study. A total of 1977 newly diagnosed and registered cases under Revised National TB Control Programme for treatment during the period of March 2009 to May 2009 were included in the study. Out of a total population of 170 lacs, a proportion of 31 lacs of Delhi, distributed among five chest clinics of Delhi, comprised the study population. All the patients were interviewed according to a pre-designed & pre-tested questionnaire after taking informed consent of the patients. The data was collected and analysed after processing into MS excel sheets for statistical analysis. Results : There was an immense stigma observed at society level with 60% of the patients hiding their disease (p<0.05) from friends and neighbours. Stigma was observed more among middle and upper middle class when compared to lower middle class and lower class (p<0.05). Gender-wise further it was observed that stigma was more among females (p<0.05) than in males. Conclusion : The study has demonstrated that despite good performance of Revised National TB Control Programme the stigma in tuberculosis still remains a problem and we need to supplement the efforts in advocacy, communication and social mobalization for reducing the stigma problem among TB patients in effective control of tuberculosis.

Detection and identification of tridemorph fungicide by gas-liquid and thin layer chromatography: A case study.

Tridemorph is a widely used fungicide for crops, and is fairly frequently encountered in forensic toxicology. The aim of this paper is to describe the postmortem changes in a case of death due to tridemorph poisoning, the procedure of extraction from forensic samples, and detection and identification by thin layer and gas-liquid chromatography using a new solvent system and spray reagent, on the basis of an actual case of tridemorph fungicide exposure death.

Tuberculosis mortality trends in Delhi after implementation of RNTCP.

Objectives: To study the impact of Revised National TB Control Programme on mortality among tuberculosis patients in Delhi and to correlate mortality trends with programme indicators. Methods: Record based evaluation of mortality trends from TB registers of all chest clinics of Delhi after implementation of Revised National TB Control Programme. Results: The study showed a statistically significant decline in tuberculosis mortality among new smear positive cases after the implementation of Revised National TB Control Programme (z=4.478 p<0.05). The mortality among new smear negative and extra pulmonary cases also showed reduction, though not statistically significant. Conclusion: Mortality due to tuberculosis has been considerably reduced in Delhi over the years with the Revised National TB Control Programme implementation since 1997.

Efficacy of repeat sputum examination in RNTCP.

BACKGROUND: The guidelines of repeat sputum smear examination in initial smear negative patients (ISN), who also fail the antibiotic trial of three samples have been incorporated in the RNTCP diagnostic algorithm in India in 2005. This study was conducted to assess the utility of repeat sputum smear examination in symptomatic initial smear negative patients to detect new smear positives in the state of Delhi. MATERIAL AND METHODS: The monthly records of the laboratory abstracts for the six quarters for all the 24 districts of Delhi were analysed w.e.f. first of January 2006 to 30th June 2007. RESULTS: A total of 243,244 TB suspects were examined for diagnosis during the six quarters w.e.f. January 2006. Of these, 37,666 were found positive on sputum smear microscopy giving a positivity rate of 15.4%. During the same period, a total of 2,195 (1% of ISN ) TB suspects underwent repeat sputum examination, of which 272 were found positive giving a mean positivity of 12.3%. CONCLUSION: A significant number of apparently smear negative TB cases may in fact be smear positive due to various reasons and can be detected by a simple repeat sputum examination. Yield of sputum positive cases in sputum reexamination is almost the same as in initial sputum examination i.e. 10-15%. Therefore, the policy of repeat sputum examination in symptomatic initial sputum negative cases failing the antibiotic trial should be meticulously followed as advocated in the RNTCP diagnostic algorithm.

Study of relapse and failure cases of CAT I retreated with CAT II under RNTCP--an eleven year follow up.

OBJECTIVE: To analyse the treatment outcome of Cat I smear positive relapse and failure cases and their fate when treated with Cat II regimen under RNTCP. METHODS: All Cat I smear positive relapse and failure TB patients treated with Category II regimen from 1994 to 2005 in a chest clinic of Delhi were analysed in this retrospective study. The re-treatment outcome data for relapse and failure cases of Cat I when treated with Cat II regimen was reviewed. RESULTS: The study population included 5576 registered as Cat I sputum positive cases in Gulabi Bagh chest clinic from 1994 to 2005. A total of 190 (3.4%) failed on Cat I regimen. Further out of 4905 (87.9%) successfully treated Cat I patients, 442 (9%) presented as relapses. The treatment success rate for relapse and failure cases of Cat I when subsequently treated with Cat II regimen were 76.4% and 48.8% respectively, with a significantly higher failure rate (27.6%) among Cat I failures subsequently treated with Cat II regimen. CONCLUSION: The failure cases of Cat I subsequently treated with Cat II were observed to have a significantly lower success rates (p < 0.05) as compared to relapse cases. The need for reappraisal of Cat II re-treatment regimen for failure cases among Cat I is suggested.

DOTS in drug addicts with TB : Delhi experience.

BACKGROUND: Drug abuse is on the rise. Drug addiction lowers the general immunity of the body. Tuberculosis is known to be one of the major infectious diseases with a high incidence among drug addicts. Treatment of drug addicts suffering from tuberculosis is a challenge to the treating physician. METHODS: An interventional prospective study which involved free de-addiction drugs and motivation along with free anti tubercular drugs under Revised National Tuberculosis Programme was undertaken among drug addicts. Sixty drug addicts suffering from tuberculosis, registered under RNTCP in SPM marg TB Clinic (Pili Kothi) between 2002-2007 and treated under DOTS along with de-addiction treatment by an NGO (Sharan) formed the study sample. OBJECTIVES: Objectives of the study were: a) To study the profile of drug addicts with tuberculosis, b) To assess the success results of DOTS in drug addicts with tuberculosis (along with de-addiction treatment). RESULTS: Extensive counselling for de-addiction and motivation of the study patients along with nutritional food supplements improved the compliance and adherence to treatment with equal success rates as in non-addict tuberculosis patients. The overall success rate in drug addicts was 83.3%. The default rate of 3.3% and failure rate of just 1.7% among study group were also within the permissible range of RNTCP (< 4%). CONCLUSION: DOTS along with supplementary intervention was observed to be quite effective in drug addicts with TB.

Tuberculosis of the ilium: a case report.

A twenty year old man presented with pain in the upper part of right hip. CT scan showed multiple osteolytic areas in the right ilium, suggesting malignancy. CT guided needle biopsy was done and diagnosis of tuberculosis was made. The patient was cured with medical management only. Isolated tuberculosis of the ilium is an extremely rare condition. It is important to have a high clinical suspicion to diagnose early and manage the patient without surgical intervention.

Detection of ranitidine by thin layer chromatography technique: A case study.

In one case, viscera of a lady was received, who expired following injection given by doctor in urban area. After conducting elaborate analysis data were found similar to Ranitidine. Hence, it was thought worthwhile to concentrate on this drug .The present paper describes the extraction of Ranitidine from visceral material and its identification by thin layer chromatography using suitable solvent system and potassium iodo bismuthate as locating reagent.

Outcome of multi-drug resistant tuberculosis cases treated by individualized regimens at a tertiary level clinic.

AIM: To determine the clinical, radiological and drug resistance profile as well as the factors associated with treatment outcome of Multi-Drug Resistant Tuberculosis (MDR-TB). MATERIAL AND METHODS: All newly diagnosed patients with pulmonary MDR-TB from August 2002 to December 2004 enrolled at New Delhi Tuberculosis Centre, were included in the study. They were followed up clinically, radiologically and bacteriologically by sputum smear, culture and Drug Susceptibility Testing (DST) at regular intervals. According to their DST pattern and previous history of Anti-Tubercular Treatment (ATT), individualized treatment regimens were tailored for each patient. RESULTS: Out of total 27 bacteriologically proven cases of MDR-TB included in this study, 19 were males (mean age and weight 38.5 years and 52.6 kgs, respectively) and eight females (mean age and weight 34.3 years and 40.7 kgs, respectively). A majority (18) were residents of Delhi and the rest hailed from different parts of North India. All of them had a history of previous treatment ranging from six to 34 months. Cavity on chest X-rays was seen in 81%, while 44% showed extensive involvement. The patients received at least four "second line drugs" during their treatment with a mean of 6.2 anti-tubercular drugs during their intensive phase. Of the 27 patients, 13 were cured, 10 defaulted, one died, one is still on treatment and two were referred for surgery. Radiological improvement was observed in two third of cases and chest X-ray of two patients showed a complete resolution. Six predictors were identified for successful outcome of MDR-TB. They include weight gain at six months, culture conversion, radiological improvement during treatment, disease with M. tuberculosis strains exhibiting resistance to less than or up to three anti-tubercular drugs, use of less than or up to three second line drugs in treatment and no change of regimen during treatment. CONCLUSION: Default from treatment was observed to be a major challenge in the treatment of MDR-TB due to long duration and expense of ATT.

Treatment of Tuberculosis in Liver Disease (A Clinician's view).

Co-existent hepatic disease poses a challenge for the physicians treating tuberculosis. The hepatic disease may either be pre-existent or may develop during the course of disease or as an adverse reaction to anti-TB drugs. Treatment may need modifications, stoppage or even change of drug regimens.

Health related quality of life (HRQL) scoring (DR-12 score) in tuberculosis--additional evaluative tool under DOTS.

The study was conducted among patients diagnosed as pulmonary or extra pulmonary tuberculosis attending DOTS facilities at New Delhi Tuberculosis Centre, Delhi. The objectives of the study are; to evaluate the impairment of health related quality of life in patients of tuberculosis by evolving a HRQL questionnaire (DR-12 score) and to validate the new scoring method by making serial assessments of health related quality of life of the patients during anti-tubercular therapy initially, at the end of intensive phase (IP) and at the completion of treatment. Seventy eight consecutive patients aged between 15-60 years put on DOTS treatment at New Delhi Tuberculosis Centre, Delhi were subjected to a HRQL questionnaire (DR-12 score) at 0 week, 8 weeks and at the completion of treatment. The new scoring method contained questions on twelve parameters related to symptoms, physiological, psychological and social well-being of TB patients. The patients were asked to evaluate these twelve parameters on a score of 1-3. All the individual parameters were equally weighted. The data so obtained regarding these scores was analysed using unpaired t-test, paired t-test, one way Anova test and Pearson corelation coefficient test. The patients who converted at the end of intensive phase had a significantly higher gain in scores as against, those who failed to convert even after extension of intensive phase (p=0.019). Significantly higher scores were observed among those who had a favourable outcome as against those who had unfavourable outcome at the completion of treatment (p=0.029). Thus, DR-12 score was found to have a strong construct validity and useful additional evaluative tool for patients under DOTS therapy.

Adverse drug reactions observed during DOTS.

A total of 8.37% of the 1195 patients treated at NDTB Centre with DOTS under RNTCP between January 2002 to June 2003 presented with adverse drug reactions. Patients showing any sort of adverse reactions were studied in detail by personal interviews and a semi-structured questionnaire. The profile of patients presenting with adverse reactions showed that majority of the patients (53%) had gastrointestinal reactions, the commonest presenting complaint being nausea and vomiting. General aches and pains were complained by about 35% and giddiness was the presenting complaint in 27% irrespective of the use of streptomycin, although giddiness was observed more often in Category II patients (59%). Skin rash and itching was complained by about 17% of patients and 11% complained of arthralgia, while only 1% had hepatotoxicity during treatment. Majority of the adverse reactions (67%) were observed within the first four weeks of treatment and only 0.25% of patients treated with DOTS had interruption of treatment for short periods.

Treatment of tuberculous pleural effusion patients and their satisfaction with DOTS - 1½ year follow up.

Background: Under the Revised National Tuberculosis Control Programme, patients who are sputum negative after 3 smear examinations are subjected to radiological examination after they fail to respond to a course of antibiotics for a period of two weeks. Those showing radiological evidence of pleural effusion are examined physically and investigated further by tuberculin testing and diagnostic aspiration. Those confirmed to be suffering from tuberculous pleural effusion by naked eye examination, biochemical tests and cytology of pleural fluid are given a fixed schedule of drugs. The treatment is stopped after six or eight months as per category, and outcome is reported as “Treatment Completed”. Many a time, patients question the validity of stopping treatment without radiological examination. Physicians treating are also at times not confident themselves and often fail to reassure such patients. Presence of residual symptoms in such patients before stopping treatment creates further uneasiness among the treating physicians. Methodology and Results: A study carried out among 58 patients of TB pleural effusion, of which 36 (62.1%) could be followed for a period of 1½ years, revealed that 63.9% were satisfied with the DOTS policy of stopping treatment without x-ray at the end of treatment whereas 36.1% expressed dissatisfaction with this policy. As many as 16.7% even got their x-rays elsewhere before stoppage of treatment, for their own satisfaction. Conclusion: The 1½ year follow up revealed only one case of relapse i.e. a relapse rate of 2.8% after DOTS therapy. Almost all (97.2%) were, however, satisfied with the medicines dispensed under DOTS.

Tuberculosis in the elderly and their treatment outcome under DOTS.

Summary: A retrospective study of the profile and treatment outcome in the elderly TB patients taking DOTS was carried out in an urban TB clinic of Delhi. Out of 2118 tuberculosis patients treated between 1999-2001, a total of 238 (11.4%) patients were over 50 years of age and of these 45(2.2%) were over 65 years of age. A total of 78.6% of the 283 TB patients of all the categories included in the study had a successful outcome (cure/ completion). The overall case fatality, default and failure rates among the TB patients over 50 years were found to be 7.1%, 8.8% and 4.6%, respectively, despite directly observed treatment being given under RNTCP. The case fatality rate was significantly higher (15.6%) in the age group >65 years as compared to patients between 50-65 years (5.2%). The failure rate was significantly higher (13.3%) in the age group >65 years than among patients in the 50-65 years age-group (2.6%). This emphasizes the need for intensive motivation and stringent monitoring among tuberculosis patients over 65 years of age.

Prevalence of initial drug resistance to M. tuberculosis in new sputum positive RNTCP patients.

There is an increased prevalence of drug resistant M. tuberculosis strains and of these, multi drug resistant organisms are of particular concern. With the implementation of Revised National Tuberculosis Control Programme (RNTCP) allover the state of Delhi, Initial drug resistance (IDR) to Isoniazid and Rifampicin assumes great importance and needs to be monitored on a regular basis. We undertook to study the IDR against the first line essential drugs i.e. Isoniazid (H), Rifampicin (R), Ethambutol (E) and Streptomycin (S) from April 1999 to March 2000 in newly diagnosed sputum positive cases of pulmonary tuberculosis attending TB clinics under RNTCP in Delhi. A total of 157 consecutive new smear positive patients attending TB clinics under RNTCP were taken into the study. All sputum samples were subjected to culture and drug sensitivity tests on LJ medium after decontamination of samples by Petroff's method. Resistance was expressed as the percentage of colonies that grow on critical concentration of the drugs. To determine the proportion of resistance, the number of colonies on the control and the number of colonies on the drug medium were determined. A total of 94.77% samples were sensitive to the four first line essential drugs and IDR to any drug was 5.22%. The resistance to Rifampicin alone was nil but the resistance to Isoniazid alone was 2.24%. Combined resistance to both Rifampicin and Isoniazid was 2.98 %. The incidence of resistance to first line drugs in tuberculosis is not very high among new sputum positive patients attending TB clinics under RNTCP.

Health care seeking pattern of tuberculosis patients attending an urban TB clinic in Delhi.

The study of pattern of health care seeking of tuberculosis patients is important for identification of factors which might influence delayed reporting of tuberculosis cases, especially the open pulmonary cases. Consecutive 301 pulmonary TB patients, belonging to any of the categories under RNTCP, diagnosed at New Delhi Tuberculosis Centre or its sub-centres over a six-month period were assessed for health care seeking pattern. "Delay" was defined as the time over 3 weeks that a case took to report to the area TB facility. 43.2% patients reported to the TB health facility on their own and others were referred by government hospitals (34.9%) and general practitioners (21.9%). Median delay over 3 weeks was 2.69 weeks for all three categories combined, with a significantly higher delay (3.41 weeks) for retreatment cases as compared to new cases (2.13 weeks). No significant differences were observed in health seeking delay in relation to sex, income, literacy status and source of referral and sputum status. Extensive health education activities can reduce this period of delay in health seeking and result in reduction of transmission of tuberculosis to healthy members of the family and community.