Colonization or spontaneous resolution: expanding the role for Burkholderia pseudomallei

A 19-year-old Asian Indian female presented with productive cough since the past one month and low grade fever since the past two weeks. She was diagnosed with pulmonary tuberculosis and treated with antitubercular drugs. Subsequently, delayed cultures of bronchoalveolar lavage fluid grew Burkholderia pseudomallei (B. pseudomallei). On follow up the patient reported significant subjective improvement and ESR progressively returned to normal. In summary, this case report raises two distinct and equally intriguing roles for B. pseudomallei, i.e. respiratory colonization and spontaneously resolving pulmonary infection. The pathogenic potential of B. pseudomallei, the etiologic agent of melioidosis, is well known. Confirmation of either colonization or spontaneous resolution, would potentially spare many patients unnecessary and expensive therapy with broad-spectrum antibiotics, and contribute to more rational usage of antibiotics, especially in co-infection with Mycobacterium tuberculosis and B. pseudomallei-two bacterial diseases with closely similar clinical, radiologic and histopathologic features.

HIV-tuberculosis co-infection in an Indian scenario: the role of associated evidence of immunosuppression

OBJECTIVE@#To determine the relationship between tuberculosis and the degree of immunosuppression as determined by CD4 count. The impact of immunosuppression on the severity of tuberculosis was also studied.@*METHODS@#A retrospective analysis was performed in patients newly diagnosed with HIV infection and antiretroviral therapy (ART)-naive patients with known HIV seropositivity. All patients were diagnosed with active tuberculosis between January 2008 and December 2010, based on review of their medical records. Patients on chemoprophylaxis for opportunistic infection were excluded. Pattern and severity of tuberculosis, associated stigmata of immunosuppression, and CD4 counts were noted.@*RESULTS@#Of 140 patients satisfying the inclusion criteria, 52 had mild tuberculosis with no other evidence of immunosuppression, 52 had tuberculosis of variable severity with associated evidence of immunosuppression, and 36 had severe tuberculosis with no other evidence of immunosuppression. The CD4 count was highest in the first group [(109.2±99.9) cells/μL] and least in the second group [(58.4±39.8) cells/μL], and the difference was statistically significant (P=0.004). No statistical difference was observed in the CD4 count between those with mild tuberculosis and those with severe tuberculosis.@*CONCLUSIONS@#In developing countries with a high prevalence of tuberculosis in the general population, the possibility of incidental tuberculosis in patients with HIV should always be considered. CD4 count does not appear to influence the severity of tuberculosis. The presence of concomitant evidence of immunosuppression in the form of category B and C conditions is indicative of underlying immunosuppression and associated with a significantly lower CD4 count.

Brucellosis and tuberculosis: clinical overlap and pitfalls

OBJECTIVE@#To identify characteristic features of tuberculosis in patients with culture proven brucellosis.@*METHODS@#A retrospective analysis was performed on patients diagnosed with culture proven brucellosis between January and December 2011, based on review of their medical records. Patients with demonstrable co-infection with tuberculosis were excluded. Clinical features, laboratory parameters and tissue histopathology reports where available were noted.@*RESULTS@#Thirty-two patients with brucellosis were included in the study. Twenty-one (65.63%) patients had chronic fever, thirteen (40.63%) had a productive cough, while significant weight loss, evening rise of temperature and night sweats were reported by eight (25.00%), eleven (34.38%) and five (15.63%) patients respectively. Nine (28.13%) patients had at least three of these symptoms. Lymphadenopathy, hepatomegaly and splenomegaly were noted on examination in seven (21.88%), fifteen (46.88%) and twelve (37.50%) patients respectively. Eight (25.00%) patients had hepato-splenomegaly, of these only two had associated significant lymphadenopathy. Respiratory examination was normal in all patients. Elevated ESR greater than 50 mm/hr was seen in eight (25.00%), it was greater than 100 mm/hr in five (15.63%) patients. Hypergammaglobulinemia was seen in eight (25.00%) cases. Bone marrow biopsy showed non-caseating granulomas in three (9.38%) cases, lymph node biopsy showed granulomas in one case. Overall, three (9.38%) patients had known risk factors for tuberculosis, while six (18.75%) had risk factors for brucellosis.@*CONCLUSIONS@#There is a clear overlap between brucellosis and tuberculosis both in terms of clinical presentation and laboratory parameters. It is essential to carefully rule out tuberculosis in all cases of suspected or proven brucellosis before initiating antimicrobial therapy, in order to forestall development of drug-resistant tuberculosis.

Polymyositis-like syndrome with rhabdomyolysis in association with brucellosis

Diffuse myositis with progression to rhabdomyolysis has been reported in association with wide range of viral infections. We report a case of polymyositis-like syndrome complicated by rhabdomyolysis secondary to brucellosis. This case report thus contributes yet another atypical presentation to a disease already infamous for its protean manifestations.

Spectrum of complications associated with Plasmodium vivax infection in a tertiary hospital in South-Western India

OBJECTIVE@#To determine the range and incidence of complications associated with Plasmodium vivax (P. vivax) malaria.@*METHODS@#A retrospective analysis was performed of all patients of P. vivax malaria admitted in Kasturba Medical College, Manipal between January and December, 2010. Patients with mixed malarial infection were excluded by appropriate tests. Clinical presentation and laboratory parameters were studied.@*RESULTS@#Medical records of 213 individuals who satisfied the inclusion criteria were reviewed. Anaemia was seen in 65 (30.5%), leucopenia in 38 (17.8%) and thrombocytopenia in 184 (86.4%) patients. Aspartate and alanine aminotransferases were elevated in 86 (40.4%), and 89 (41.9%) patients respectively. Hypoalbuminemia was observed in 157 (73.6%) cases. Elevated serum creatinine was noted in in 59 (27.5%) patients. Creatine kinase was elevated in 30 out of 59 patients (50.8%). Overall, 107 (50.2%) patients fulfilled WHO criteria for severe malaria. None of the patients succumbed to the disease.@*CONCLUSIONS@#P. vivax malaria is a potentially severe disease, and the term "benign" tertian malaria is a misnomer. Despite significant morbidity, with timely and appropriate treatment P. vivax malaria has an excellent outcome.

Spontaneous septicaemia with multi-organ dysfunction--a new face for Pantoe agglomerans?

Pantoe agglomerans (P. agglomerans) is an unusual cause for sepsis in immunocompetent individuals, especially in the absence of characteristic risk factors. We report one such case occurring in a farmer, manifesting with severe illness. The severe nature of illness and the apparently spontaneous origin of septicemia underline the pathogenic potential of this organism. When coupled with the ubiquity of the organism, there is a definite possibility that this disease may become increasingly frequent in the near future, especially in agronomic countries like India. Further studies on the epidemiology and natural history of this disease are required.

Dual infection with hepatitis A and E virus presenting with aseptic meningitis: a case report

We report the case of a young male who presented with features of aseptic meningitis and elevated serum liver enzymes, but no symptoms or signs suggestive of an acute hepatitis. Subsequently, he was diagnosed with dual infection with hepatitis A and E viruses, and recovered completely with symptomatic therapy. Isolated aseptic meningitis, unaccompanied by hepatitic features is an unusual presentation of a hepatotrophic viral infection, and is yet to be reported with hepatitis A and E virus co-infection.

A rare case of strychnine poisoning by consumption of Strychnos nux-vomica leaves

A 22-year-old male presented with severe myalgias and backache of acute onset, as well as one episode of opisthotonus. On repeated questioning, he admitted to having consumed leaves of Strychnos nux-vomica with suicidal intent. He was treated conservatively with intravenous diazepam and analgesia and made a complete recovery. Strychnine poisoning is rarely encountered and poisoning by consumption of leaves is even rarer. This case demonstrates the potent toxicity of strychnine as well as the effectiveness of therapy when initiated early.