Pattern of Drug of Resistance in Previously Treated Pulmonary Tuberculosis with Line Probe Assay

Background: Tuberculosis is global health problem known since ancient times. Drug-resistant TB has been known from the time of anti-TB drugs were first introduced for the treatment of TB. The emergence of drug resistant tuberculosis particularly MDR TB has become significant health problem worldwide and an obstacle to effective tuberculosis control. Line Probe Assay (LPA) is a Nucleic Acid Amplification Test (NAAT) which provides rapid diagnosis of R and H resistance and yield results in 72 hours.Literature on drug resistant pattern in patients who are previously treated for tuberculosis and/or suspected MDR cases with Line Probe Assay method are not studied hence this study was carried out. Aims and objectives: To know the drug resistance pattern of Rifampicin and Isoniazid in previously treated pulmonary tuberculosis cases and correlating with the demographic characteristics of patients. Methods: This study was carried out in department of Respiratory Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur in AFB smear positive patients of pulmonary tuberculosis who have previously taken treatment, before reporting at OPD/IPD. The exclusion criterion was new cases of pulmonary tuberculosis. Detailed history, examination and investigations were carried out. The diagnosis of active pulmonary TB was based sputum smear examination by Ziehl - Nelson staining method. Sputum smear positive cases were subjected to line probe assay to detect resistant pattern at RNTCP accredited laboratory (SMS Medical College and Hospital, Jaipur). Results: A total of 175 previously treated sputum smear AFB positive patients of pulmonary tuberculosis were taken in this study. Out of which 141(80%) were males and 34(20%) cases were females with male : female ratio 4:1 and maximum cases (43.4%) belonged to 31-45 age group with mean age 38 years. Majority of cases belonged to rural area and lower middle class group. More than 2/3rd cases were smokers (72%) among male. Out of 175 cases, 100(57.1%) cases were drug resistant, 75(42.8%) cases were drug sensitive. Line probe assay with regard to resistant pattern was highest in grade +3 sputum (100%) followed by grade +2(98%) and grade +1(96%), while least in scanty sputum positive cases (3%). Resistance to Isoniazid (H), Rifampicin(R) and Both (H+R) were seen in 27%, 14% and 59% respectively. Half of patients (56%) out of total resistance belonged to default category of previously treated pulmonary tuberculosis cases. Resistance to H (27 cases) were 62.5% in relapse, 33.3% in default and 11% in failure cases. Out of R resistance (14 cases), 63% and 37% were in relapse and default cases. Out of 59 cases of H+R resistance 65% belonged to failure category and 20% default and 15% relapse category. Conclusion: Line Probe Assay (LPA) provides accurate and rapid diagnosis of R and H resistance and is recommended for diagnosis of DR-TB in previously treated pulmonary tuberculosis patients.

Lyme disease in Haryana, India.

Lyme disease is a multiorgan animal‑borne disease caused by the spirochete Borrelia burgdorferi. This case series highlights its presence in Haryana, a nonendemic zone. The first case was a 27‑year‑old housewife who presented with an annular erythematous patch with a central papule following an insect bite on the left upper arm. The second case was a 32‑year‑old farmer who gave a history of insect bite on the right arm followed by the development of an erythematous patch with a central blister. The third case, a 17‑year‑old boy presented with a history of tick bite over right thigh and a typical bull’s eye lesion with central ulceration. These cases were managed with oral doxycycline 100 mg twice daily for 14 days. The fourth case was a 7‑year‑old boy with typical erythema migrans on the right check and neck while the fifth case, a 30‑year‑old housewife, presented with an erythematous patch with a central papule on the right buttock. These patients were treated with oral amoxycillin 25 mg/kg, thrice daily for 14 days. All patients showed IgM antibodies to B. burgdorferi. Treatment led to clearance of lesions in all the patients. Lyme borreliosis was diagnosed in these patients based on the history of established exposure to tick bites, presence of classic signs and symptoms, serology and the response to treatment.

hair an unusual foreign body in airways presenting with haemoptysis in an adult patient.

Haemoptysis is defined as expectoration of blood originating from the lungs or tracheo-bronchial tree. It is attributed to various causes like tuberculosis, bronchiectasis, lung cancer, mycetoma, foreign bodies etc. Various types of foreign bodies have been reported in the literature. We report the case of an adult female patient who presented with an episode of haemoptysis (150 mL) in whom flexible fibreoptic bronchoscopy revealed a single long hair at the carina going to left main bronchus. Following successful removal of this hair there were no further episodes of haemoptysis and the patient manifested clinical and radiological improvement.

Diagnostic yield of computed tomography-guided percutaneous fine needle aspiration cytology of radiological suspected cases of lung mass lesions.

Computed tomography (CT)-guided fine needle aspiration cytology (FNAC) provides high diagnostic yield in lung mass lesions, with acceptable rate of complications. In a retrospective review of data of 32 patients, the cytological diagnostic yield was found to be 90.7% of which 93% were malignant and remaining 7% were tubercular. Procedure-related complications were observed in three cases (9%); minimal haemoptysis in two and pneumothorax in one. The study confirms that CT-guided FNAC of lung mass lesions is a very useful procedure with minimal complications.

Angiokeratoma Circumscriptum of the Tongue.

Angiokeratoma circumscriptum is rare cutaneous disorder. It usually presents as multiple,red, blue or black asymptomatic papules on lower extremities. Oral involvement, common in systemic form, is rare in localized forms. We report a case of angiokeratoma circumscriptum of tongue, involving both dorsal and ventral aspects.

Comparative efficacy of narrow-band ultraviolet B phototherapy alone and its combination with topical 8-methoxypsoralen in psoriasis.

Background: Very few studies using the combination of topical 8-methoxypsoralen (8-MOP) and narrow-band ultraviolet B (NBUVB) have been performed, especially in Indian patients. A combination of oral psoralen with NBUVB has been shown to have a superior efficacy as compared with NBUVB alone in psoriasis. Aims: Comparison of the efficacy of topical psoralen NBUVB (combination) versus NBUVB alone in psoriasis. Methods: Thirty patients with plaque psoriasis were taken up for the study and NBUVB phototherapy was given twice weekly. The target lesions on one side were treated with 0.1% topical 8-MOP 15 min before the irradiation. The treatment period was 12 weeks or 24 exposures. Results: The number of treatment sessions and cumulative NBUVB doses were lower in the combination therapy as compared with NBUVB monotherapy, although the differences were not statistically significant. Conclusion: To conclude, topical 8-MOP enhances the therapeutic effects of NBUVB therapy without increasing the incidence of adverse effects.

Comparative evaluation of NBUVB phototherapy and PUVA photochemotherapy in chronic plaque psoriasis.

Background: Psoralen UV-A (PUVA) is an established therapy for psoriasis, but there is a well-documenated risk of melanoma and nonmelanoma skin cancer. Narrow-band Ultraviolet-B (NBUVB) therapy has a lower carcinogenic risk, has equal therapeutic potential and is considerably safe in the long term than PUVA. Aim: The aim of present study was to compare the efficacy and side-effects of PUVA and NBUVB in chronic plaque psoriasis. Methods: Sixty patients of chronic plaque psoriasis were taken up for the study and were randomly divided into two groups of 30 each. They were well matched in terms of age, sex, psoriasis extent and pretreatment psoriasis area severity index (PASI) scoring. One group was treated with twice-weekly narrow-band UV-B (TL-01) phototherapy and the other group received twice-weekly oral 8-Methoxsalen PUVA for a period of 3 months. Results: Both the groups achieved >75% reduction in the PASI score or complete clearance at the end of 3 months, but PUVA group patients required significantly fewer number of treatment sessions and fewer number of days to clear the psoriasis as compared to the NBUVB group, while the mean cumulative clearance dose and adverse effects were significantly lower in the NBUVB group. Conclusion: We concluded that PUVA group patients achieved a faster clearance, but the adverse effects were significantly lower in the NBUVB group.

Late onset isotretinoin resistant acne conglobata in a patient with acromegaly.

A 55 year-old male presented with multiple pus-discharging abscesses and sinuses and mutilating scarring on the gluteal region and back prevalent for the last ten years with exacerbations and remissions. Physical examination revealed acromegaly with frontal bossing, prognathism, a barrel chest and acral hypertrophy. Dermatological examination revealed cutis verticis gyrata, thick eyelids, a large triangular nose, a thickened lower lip, macroglossia, widely spaced teeth and widened skin pores with wet and oily skin. Hair was fine and nails were flat and wide. There were multiple inflammatory papules, tender nodules, draining sinuses, and grouped, polyporous comedones as well as multiple and extensive depressed and keloidal scars localized predominantly over the gluteal region with a few scattered lesions over the back. A computed tomography (CT) scan showed widened sella turcica. His basal fasting growth hormone (GH) levels were markedly raised (230 ng/mL; normal 1-5 ng/mL) while the prolactin levels were moderately raised (87 ng/mL; normal 2-5 ng/mL). These findings were consistent with a diagnosis of acromegaly. The patient was put on antibiotics, nonsteroidal antiinflammatory drugs and isotretinoin at a dose of 1 mg/kg/day, which was increased to 1.5 mg/kg/day. Except for an initial mildly beneficial response, the skin lesions were largely resistant to high doses of isotretinoin at the end of four months.

An estimation of annoyance due to various public modes of transport in Delhi.

Measurements of noise levels associated with different types of vehicles plying the roads in Delhi were made. From the data, noise level indices L(10) , L(90) and Leq were determined. In addition, spectra of noise for different vehicles at 1- octave band frequencies were also obtained. The time-averaged noise spectra reveal that the noise intensities are significantly higher in the frequency range of 0.5 kHz to 2 kHz for all types of vehicles. Perceived noise levels (PNdB) and the total noisiness measured on NOY scale indicate that rural transport vehicles (RTVs) are most annoying, followed by buses, auto-rickshaws and taxis.

Isolated breast mucormycosis.

Mucormycosis is unusual in surgical practice. Awareness of the classical findings leads to early detection. Excisional therapy whenever possible along with systemic antifungal treatment is the key to successful outcome. A 70 year old female, a known case of diabetes mellitus and chronic obstructive pulmonary disease, on inhalational steroids and oral hypoglycemic agents, presented to us with complaints of sudden onset pain, redness and swelling of left breast. A diagnosis of severe mastitis was made and a release incision was taken. The entire breast became gangrenous in next 24 hours and simple mastectomy had to be performed as a life saving measure. Histopathology revealed mucormycosis of breast. To the best of our knowledge this is the first reported case of mucormycosis of breast in the English literature.

A study to characterize the influence of outdoor SPM and associated metals on indoor environment in Delhi.

In order to understand the influence of outdoor SPM and its associated metals on indoor environment, a study was carried out for 24 residential, sensitive, commercial and heavy traffic sites in Delhi. In the first phase, the samplings of SPM were conducted simultaneously indoors and outdoors at a reference site during February to March 2000 and later at all other sites from February to July 2001. Atomic Absorption Spectrometry (AAS) was used to determine the heavy metal composition of SPM, analyses of Ca, Mg, Cu, Cd, Pb, Cr, Mn, Fe and Ni were done. It is observed that, depending upon the nature of the site, the outdoor SPM concentrations affect the indoor SPM concentrations in varying degrees. In case of metals such as Cu, Cr, Cd and Ni, very good correlation between the indoor and outdoor concentrations was observed irrespective of the nature of the site. The correlation between indoor and outdoor for Mg, Fe, Mn and Pb depends upon the nature of the site. No correlation was observed between indoor and outdoor Ca at any of the chosen sites.

C3-4 level cervical spondylotic myelopathy.

Cervical spondylotic myelopathy (CSM) is uncommon at the C3-4 level. Fourteen patients with C3-4 CSM were treated over a period of 3 years. The radiological factors contributing to CSM at the C3-4 level were studied. These factors included the assessment of static and dynamic canal diameters, retrolisthesis, posterior osteophytes and degenerative spinal segmental fusion on plain X-rays; and, the antero-posterior cord compression ratio (APCR) on magnetic resonance imaging (MRI). The clinical status of the patients was assessed by the modified Japanese orthopedic association scale (mJOAS). The mean difference between the static and dynamic canal diameters was statistically significant at C3-4 (p < 0.01). The APCR obtained at different levels showed a significant compression at the C3-4 level in comparison to the lower level. There was a correlation between the APCR and the preop mJOAS, r=0.6 (p< 0.05). The mean mJOAS improved from 9.35 to 14.35 at follo-up. The recovery rate calculated using the modified Hirabayashi rate was 66.9%. Degenerative changes at lower cervical segments predispose to increased mobility and spondylotic changes at the C3-4 level. The patients in this study were young as compared to those reported in the international literature.

Comparative study of oral and topical ketoconazole therapy in pityriasis versicolor.

INTRODUCTION: Both topical and systemic ketoconazole are reported to be effective against pityriasis versicolor. MATERIAL AND METHODS: Forty patients suffering from pityriasis versicolor were treated either with oral ketoconazole 200 mg per day or 2% ketoconazole cream topically once daily for 2 weeks. RESULTS: On global assessment, after 2 weeks of start of therapy, 18 (90%) out of 20 patients treated with oral ketoconazole were cured while 2 patients had considerable residual disease. In the ketoconazole cream group, 16 (80%) out of 20 patients were cured and 4 patients had considerable residual disease. CONCLUSION: No significant difference was observed in the response rates in the two groups. Relapse occurred in two patients of the systemic ketoconazole group and six patients of the topical ketoconazole group during the follow-up period of three months.

Comparative study of ketoconazole versus selenium sulphide shampoo in pityriasis versicolor.

Forty patients suffering from pityriasis versicolor were treated with either 2% ketoconazole shampoo (20 patients) or 2.5% selenium sulphide shampoo (20 patients), once a week for three weeks. On global assessment after one month of start of therapy, 19 (95%) out of 20 patients treated with ketoconazole shampoo were cured while one case had mild residual disease. In selenium sulphide shampoo group, 17 (85%) out of 20 patients were cured, one had mild residual disease and two had considerable residual disease. No significant difference was observed in the response rates in the two groups. Relapse occurred in one patient of ketoconazole group and two patients of selenium sulphide group during the follow-up period of three months.

Palmo-plantar lichen sclerosus et atrophicus.

A case of lichen sclerosus et atrophicus (LSA) in a male patient who presented with multiple hypopigmented to depigmented macules, polygonal in shape, distributed in a bilaterally, symmetrical manner over the hands, feet and flexor aspect of wrists is being reported. Histopathology confirmed the diagnosis of LSA.

Management of congenital atlanto-axial dislocation: some lessons learnt.

Congenital atlantoaxial dislocation (AAD) has a high incidence in India. In these patients, even a minor trauma may precipitate severe morbidity. The management of mobile AAD consists of posterior stabilization. In fixed AAD, the offending compressive element is present anterior to the cervicomedullary junction, which should be generously removed by the transoral approach. In many of these patients, the assimilated posterior arch of atlas or the incurving posterior margin of the foramen magnum or associated Chiari I malformation also adds to the compromise of the canal diameter at the foramen magnum. Thus, in cases of fixed AAD, the hour glass appearance of the spinal canal at the craniovertebral junction should be converted into a funnel shaped appearance which is close to normal. Since these procedures require a generous removal of the osteoligamentous structures, posterior fusion should be done in all cases after decompressive surgery. In this review, the observations that emerged during the management of congenital AAD are presented with a special focus on the assessment scales modified to the Indian settings, hypermobile AAD, rotary C1-2 dislocation, and AAD associated with Chiari I malformation and syringomyelia.