Fatal Superadded Nocardia Infection in a Case of Pulmonary Aspergillosis.

Pulmonary nocardiosis is a severe opportunistic infection in which chronic lung disease along with long term steroid therapy is the most significant predisposing factor. Demonstration of Nocardia in even potentially contaminated sample like sputum, warrant strong warning signal of association of the organism with the clinical condition because Nocardia are rarely encountered as laboratory contaminants. Immediate initiation of appropriate treatment is absolutely essential since any delay in diagnosis or treatment may prove detrimental to the extent of complete fatal outcome.

Tortuous ulnar artery and Gantzer’s muscle: A rare presentation with clinical implications.

The ulnar artery, larger terminal branch of brachial artery is one of the principal arteries contributing to the vascular supply of forearm. It passes through a narrow tunnel, the Guyon’s canal, along with the ulnar nerve at the level of wrist. Ulnar artery is approached during surgical interventions like, coronary and cerebral angiography, ulnar-cephalic arteriovenous fistula etc., in situations where access to radial artery fails. The lesions of ulnar artery such as aneurysms, tortuosity, aberrancy, etc. may lead to entrapment neuropathies of the ulnar nerve. We have reported here a case of tortuous ulnar artery in the distal forearm and hand of the left side of a 62 years old male, which is a rare finding observed during routine educational cadaveric dissection. The tortuosity was observed in the form of twists and bends at various levels in 15cm long segment of ulnar artery in the distal forearm wrist and hand up to the commencement of superficial palmar arch. An aberrant head of flexor pollicis longus was seen crossing the ulnar artery. The ulnar artery of right side was normal and no other anatomical variations were seen. Such muscular variations may simulate soft tissue tumors resulting in nerve or vascular compressions and also influence the biomechanics of wrist and hand. An understanding of variations in the regional anatomy is essential for surgeons, cardiologists and neuroradiologists for preventing failure of surgical procedures.

Antimicrobial Resistance Profile of Bacterial Isolates in Patients of Chronic Suppurative Otitis Media in a Tertiary Care Hospital in India.

Introduction: CSOM is a massive public health problem with incidence higher in developing countries like India, especially among low socio-economic society because of malnutrition, overcrowding, poor hygiene, inadequate health care, and recurrent upper respiratory tract infections. It is associated with various complications like persistent otorrhoea, hearing impairment, mastoiditis, labyrinthitis, facial nerve paralysis to more serious intracranial abscesses etc. The knowledge of microbiological profile is essential to enable efficacious treatment of this disease & thereby reducing the potential risk of complications. Methodology: This study was aimed to determine the microbial profile & their antimicrobial resistance pattern using Kirby Bauer disc diffusion method among the patients suffering from CSOM between April 2013 to March 2014. Results: Out of 216 samples processed, isolates were seen in 145 (67.1%) cases with male to female ratio of 1.5: 1 and age group affected was 10-20 years. Most common organism isolated was Pseudomonas spp. (49%) followed by S. aureus (35.9%). Pseudomonas spp. showed high degree of resistance to gentamicin (57.7%) and ciprofloxacin (53.5%). Also, S. aureus was found resistant to ciprofloxacin (61.5%) and cotrimoxazole (40.4%). Conclusion: Management of CSOM consists mainly of eradicating infection and closure of tympanic membrane. Periodical monitoring of bacterial isolates and their antibiotic susceptibility pattern is necessary for administering appropriate antibiotics for empirical treatment and also helps in reducing the potentially disabling and fatal complications of CSOM.

Reproducibility and validity of a quantitative food frequency questionnaire in an urban and rural area of northern India.

Background. Food frequency questionnaires (FFQs) have been used in epidemiological studies across the world to capture the usual food intake of individuals. As food habits vary in different population groups, FFQs should be validated before use. Hence, we determined the reproducibility and validity of FFQs designed for urban and rural populations of northern India. Methods. Separate FFQs, designed for urban and rural populations using standard methods, were administered to a sample of 200 subjects (100 urban and 100 rural) in the age group of 35–70 years in the beginning (baseline FFQ) of the study and after an interval of 1 year (1-year FFQ) to assess their reproducibility. Six 24-hour dietary-recalls, taken at an interval of 2 months over a period of 1 year, were used as a reference method to test the validity. Crude and energyadjusted nutrient intakes estimated from FFQs and 24-hour dietary-recalls were compared using Pearson correlation coefficients. Bland and Altman plots were also used to test the agreement between the two methods. Results. Nutrient intakes were found to be similar at the baseline and 1-year FFQs in urban and rural areas. The unadjusted Pearson correlation between 24-hour dietaryrecalls and 1-year FFQ ranged from 0.22 for vitamin C to 0.63 for iron in the urban area. It ranged from 0.06 for vitamin C to 0.74 for energy in the rural area. The correlations lowered after adjusting for energy and there was a minimal increase after de-attenuation. Conclusion. The FFQs were reproducible and valid for assessing nutrient intakes except for some micronutrients.

Genetic polymorphism in Plasmodium falciparum: Differentiation of parasite isolates of high & low virulence by RAPD.

Background & objectives: The increase in Plasmodium falciparum infections which are associated with severe and complicated malaria and drug resistance has made control of malaria a difficult task. Extensive genetic polymorphism in P. falciparum has been reported from several parts of the world which affects the efficacy of sub-unit vaccines. The knowledge of genotypes of the parasite in a geographical region is therefore, important for effective management and control. The aim of the present study was to investigate the usefulness of random amplified polymorphic DNA (RAPD)-PCR technique for differentiation of P. falciparum isolates from patients presenting with severe (cerebral malaria) and mild malaria. Methods: Genetic polymorphism in 21 P. falciparum isolates obtained from patients found positive for P. falciparum by light microscopy was studied by RAPD-PCR analysis. Eleven RAPD primers were used for analysis of 21 P. falciparum isolates obtained from cerebral and non-cerebral malaria patients. Results: Of the 11 primers, only three (E-4, E-8, and R-8) produced useful polymorphic patterns. The cluster analysis based on UPGMA demonstrated that isolates causing cerebral malaria cluster separately from those causing uncomplicated malaria. However, the analysis of phylogenic tree showed that P. falciparum isolates causing non-cerebral and cerebral malaria clustered separately but showed relatedness. Interpretation & conclusions: The results of the present study showed that the RAPD-PCR was able to differentiate the isolates causing severe and mild malaria. The cluster analysis of the phylogenic tree suggested that the virulent strains evolved from less virulent strains as it clustered separately. RAPD technique may be useful in discriminating between the different isolates of the same species resulting in different clinical profiles.

Anaemia & expression levels of CD35, CD55 & CD59 on red blood cells in Plasmodium falciparum malaria patients from India.

Background & objectives: Severe anaemia in Plasmodium falciparum (Pf) associated malaria is a leading cause of death despite low levels of parasitaemia. In an effort to understand the pathogenesis of anaemia we studied expression level of RBC complement regulatory proteins, CR1 (CD35), CD55 and CD59 with haemoglobin status in a group of malaria cases from Assam, Goa and Chennai, and in healthy controls. Methods: Flowcytometry was used to study expression of CR1, CD55 and CD59 in 50 Pf cases and 30 normal healthy volunteers. Giemsa stained thick and thin blood films were used for microscopic detection and identification of malarial parasites and parasite count. Results: No correlation was found between degree of expression of RBC surface receptors CR1, CD55 and CD59 with haemoglobin level. However, expression of CD55 was less in malaria cases than in healthy controls. Interpretation & conclusions: The present findings indicate that malaria infection changes the expression profile of complement regulatory protein CD55 irrespective of severity status of anaemia. Further studies are needed to explore the pathophysiology of anaemia in malaria cases in Assam where expression of RBC complement receptors appears to be low even in normal healthy population.

Case of sparganosis: A diagnostic dilemma.

Sparganosis, also known as larval diphyllobothriasis, is a rare disease of humans as man is not a natural host in the life cycle of Spirometra spp. Diagnosis of the latter is difficult as it mimics other conditions that commonly cause subcutaneous or visceral fluid collection. Clinical diagnosis of this particular case was also erroneously labelled as tuberculosis but later labelled as a case of sparganosis. To the best of our knowledge, this is the first case from India where a sparganum-like parasite was isolated in drain fluid from the perinephric area.

KatG protein: A novel marker for differential diagnosis of Myobacterium avium complex infection.

Purpose: Biochemical or nucleic acid based diagnostic techniques for MAC infection are unsatisfactory. This study aims to identify and evaluate M. avium secretory protein(s) of diagnostic potential, so as to develop a rapid and simple method for diagnosis of MAC infection. Material and Methods: Initially, a specific protein band of ~80-85 kDa was recognised by differential immunoblotting; which was subjected to anion exchange column chromatography for purification of proteins. After fractionisation using SDS-PAGE and electroelution, blast search was carried out. Further immunoreactivity studies were done with M. avium and Mtb infected mice sera. Clinical utilisation of separated protein was evaluated by conducting indirect ELISA with serum samples from mycobacterial infected patients. Results: A specific 81.6 kDa protein, shown to be catalase-peroxidase protein (KatG) by blast search was separated. Immunoreactivity studies of purified KatG proteins with mice sera confirmed it to be specific for M. avium infection. Indirect ELISA with patient samples further confirmed it to be M. avium infection specific. Conclusion: KatG protein is specifically recognised by MAC patients and can be used as a marker for simple and rapid ELISA based tests for differential diagnosis of M. avium infection.

Female genital TB and HIV co-infection.

HIV-induced immunosuppression paves the way for several infections, tuberculosis being very common in our country. Female genital tuberculosis (FGTB), presenting as menstrual irregularities, is a diagnostic challenge in an adolescent female when these may be considered normal. The present case is of a young female who presented with menstrual irregularities, diagnosed subsequently as a case of genital tuberculosis. Microbiological relapse after anti-tubercular treatment of six months caused suspicion of a co-existing immunodeficiency and investigations revealed HIV co-infection; thus emphasizing the need of HIV testing in all patients of tuberculosis for timely diagnosis and treatment support thereafter.

Cytological diagnosis of pulmonary nocardiosis in an immunocompromised patient.

We report a case of pulmonary nocardiosis in an immunosuppressed patient having vasculitis who presented with fever, cough and chest pain. A suspicion of nocardiosis was made on auramine O staining of material procured by CT guided fine needle aspiration cytology right lung. Modified Ziehl-Neelsen staining was useful in confirming the diagnosis. The patient showed remarkable recovery after treatment with co-trimoxazole. Quick identification of this uncommon pathogen in the cytological material using special stains helped in timely diagnosis and successful treatment of the patient.

Recent outbreak of meningococcal meningitis--a microbiological study with brief review of literature.

Meningococcal disease presents in various clinical forms, most common being meningitis and meningococcemia. A spurt of meningococcal cases was seen in medicine and pediatric wards of Dr. Ram Manohar Lohia Hospital during the recent outbreak from Dec 2005 - June 2006. These had presented either with the classical features of acute purulent meningitis or as fever with rash. The patients were investigated microbiologically for the causative organism which was identified as Neisseria meningitidis in 257 out of 531 cases (48.39%). The classic finding of gram negative diplococci on gram stain remained the mainstay of diagnosis. N. meningitidis isolates from culture were sensitive to all commonly used antibiotics.

Kinetics of microfilaraemia & antigenaemia status by Og(4)C(3) ELISA in bancroftian filariasis.

BACKGROUND & OBJECTIVE: Bancroftian filariasis caused by Wuchereria bancrofti is endemic in many parts of India. In recent years diagnosis of W. bancrofti infection has been revolutionized with the availability of filarial antigen tests, which is important in monitoring success of chemotherapy. We carried out this study to measure microfilariaemia and antigenemia levels in bancroftian microfilariae (mf) carriers at 1 yr follow up after chemotherapy, in lymphoedema patients and in endemic controls from a filariasis endemic area in Tamil Nadu State using Og(4)C(3) ELISA to identify the best marker to assess success of chemotherapy. METHODS: Serum samples were collected from 30 bancroftian microfilaremic (Mf) carriers pre-treatment and at sequential intervals (7,30,60,90,180 and 365 days) following treatment with diethylcarbamazine (DEC:6mg/kg body weight, single dose), 30 lymphoedema patients (without treatment) at periodic intervals, and 68 control subjects (24 endemic normal subjects in filariasis endemic area in Tamil Nadu State, 24 non-endemic normal subjects residing in Chandigarh, India; 5 brugian filariasis, 5 endemic control subject in brugian filariasis endemic area and 10 other disease controls). The circulating antigen of W. bancrofti was measured quantitatively using Og(4)C(3) ELISA kit. RESULTS: In Mf carriers, there was no significant difference in microfilariae count in pre- and post-treatment (PT) samples till day 30 while significant differences were observed in pre- and sequentially collected post-treatment (PT) samples day 60 to 180 (P<0.001), day 365 (P<0.005). However, there was no significant difference in antigenaemia levels between pre-treatment (day 0) and PT samples collected on day 7 onwards till day 365. Though of the 19 patients who could be followed up till 365 days PT, 4 (21%) were amicrofilaraemic, none became antigen negative. No significant difference was found in antigenaemia levels in sequentially collected samples from lymphoedema patients. Significant differences were observed in antigenaemia levels in samples collected at the start of study in mf carriers as compared to lymphoedema patients and endemic normal subjects (P<0.001). Subjects (non-endemic control) residing in filariasis free area (24), brugian endemic area (5), B.malayi infected patients (5) and patients with other parasitic diseases (10) were found antigen negative. INTERPRETATION & CONCLUSION: Annual single dose of DEC therapy alone may not result in complete clearance of infection and detection of antigenaemia rather than microfilaraemia may be taken into consideration as an indicator of successful chemotherapy. The study supports the earlier view that filarial antigenaemia is relatively common in amicrofilaraemic and asymptomatic subjects in endemic areas and further studies are needed to determine the clinical significance, prognosis and effective management of such infections in endemic areas.

Multidrug resistance in amoebiasis patients.

BACKGROUND & OBJECTIVES: Amoebiasis, caused by Entamoeba sp. a protozoan parasite, is a major public health problem in tropical and subtropical countries. The symptomatic patients are treated by specific chemotherapy. However, there are reports of treatment failure in some cases suggesting the possibility of drug resistance. The present study was therefore planned to assess the presence and expression of mRNA of multidrug resistance (MDR) gene in clinical isolates of Entamoeba histolytica and E. dispar. METHODS: Forty five clinical isolates of Entamoeba sp. [E. histolytica (15) and E. dispar (30)] were maintained in polyxenic followed by monoxenic medium. DNA and total RNA were extracted from clinical isolates of Entamoeba sp. and from sensitive strain of E. histolytica (HM1: IMSS) and subjected to polymerase chain reaction (PCR) and multiplex reverse transcription (RT)-PCR techniques. RESULTS: The 344 bp segment of E. histolytica DNA was seen by PCR using primers specific to EhPgp1 in all clinical isolates and sensitive strain of E. histolytica. Over expression of EhPgp1 was observed only in resistant mutant of E. histolytica; however, transcription of EhPgp1 was not seen in any clinical isolates and sensitive strain of E. histolytica. INTERPRETATION & CONCLUSION: The findings of the present study indicate that, so far, drug resistance in clinical isolates of E. histolytica does not seem to be a major problem in this country. However, susceptibility of clinical isolates of E. histolytica against various antiamoebic drugs needs to be investigated for better management.

Pathophysiology of visceral leishmaniasis - some recent concepts.

Visceral leishmaniasis is characterized by diversity and complexity of clinical manifestations ranging from asymptomatic infection to life threatening illness. Experimental evidence and clinical studies indicate multifaceted role of various factors leading to parasite survival and multiplication. In early stage of infection, generation of reactive oxygen and nitrogen intermediates play significant role in curtailing the parasite multiplication while in later phase on one hand, hepatic resistance is expressed by the dominant role played by nitric oxide synthase (NOS)-2 gene regulation and on the other hand, production of inhibitors of NOS-2 gene expression, interleukin 10 (IL-10) and transforming growth factor beta (TGFbeta) correlate well with reduced parasite killing. The hepatic infection is usually self-limiting due to production of multiple cytokine responses including moderate level of tumour necrosis factor (TNF) while in spleen excess TNF mediates destructive pathology. CD8+ T cells appear to play multiple roles comprising both cytotoxic activity and secretion of cytokines and chemokines. Capacity to produce ThI cytokines is associated with asymptomatic or subclinical self-healing infection. However, in symptomatic patients, Th I cytokine production is not depressed but there appears to be unresponsiveness to the stimuli of these cytokines. Experimental evidences indicate genetic basis for such a phenomenon.

Drug resistance in amoebiasis.

Amoebiasis caused by Entamoeba histolytica, is a major public health problem in developing countries. Morphologically similar E. dispar is non pathogenic. Because of the redefinition of E. histolytica and E. dispar, and the limited number of antiamoebic drugs available, a new approach to treat such individuals is necessary. The cost of treating asymptomatic individuals is highly exorbitant and not justifiable. The indiscriminate use of antiamoebic drugs can result in increased minimum inhibitory concentration (MIC) values against Entamoeba species, and treatment failure may emerge as an important public health problem. Development of new antiamoebic drugs is still in infancy and vaccine development appears to be distant dream. In future, the development of drug resistance may seriously affect the control of disease. This review discusses the factors involved in drug resistance mechanisms developed by the parasite.

Genetic polymorphism in Plasmodium falciparum vaccine candidate antigens.

Malaria is still a major public health problem in many tropical and subtropical countries. Malaria vaccine is highly desirable as an adjunct to existing malaria control measures. The polymorphisms in malaria vaccine candidates antigens might be a hurdle in developing an effective vaccine. The present article reviews the genetic polymorphism in several antigens expressed on the parasite surface, which are targets for immunological responses of the host and are good candidates for vaccine development against P. falciparum. Variable regions of most genes are generally dimorphic probably as a result of intragenic recombinations. Each allele in turn shows polymorphism resulting from point mutations, or other mechanisms. Several antigens like merozoite surface protein-1 and 2 (MSP-1 and MSP-2) and S antigen show high polymorphism while in others like circumsporozoite protein (CSP), apical membrane antigen-1 (AMA-1) and erythrocyte binding antigen-175 (EBA-175) functional constraints limit the degree of polymorphism. Polymorphism reported in these genes is discussed.

Drug resistance in malaria.

Ever since the discovery of the first case of chloroquine resistance along the Thai-Combodian border in the late 1950s, Southeast Asia has played an important role as a focus for the development of drug resistance in Plasmodium falciparum. Although the first case of quinine resistance had been reported much earlier from South America, the onset of chloroquine resistance marked the beginning of a new chapter in the history of malaria in Southeast Asia and by 1973 chloroquine finally had to be replaced by the combination of sulphadoxine and pyrimethamine (SP) as first line drug for the treatment of uncomplicated malaria in Thailand and more than 10 African countries have also switched their first line drug to SP. In 1985, eventually SP was replaced by mefloquine. The rapid development of resistance to this new drug leads to the introduction of artemisinin as a combination drug in the mid-1990s. It is mandatory to mention here that therapeutic regimens for prevention and treatment of chloroquine-resistant P. falciparum are associated with higher costs and side-effects compared to chloroquine. Additionally, some of these alternative treatments are associated with more side-effects, take longer time for cure and are more difficult to comply with than chloroquine. Urgent efforts are needed to identify effective, affordable, alternative antimalarial regimens. Molecular markers for antimalarial resistance have been identified, including pfmdr-1 and pfcrt polymorphisms associated with chloroquine resistance and dhfr and dhps polymorphisms associated with SP resistance. Polymorphisms in pfmdr-1 may also be associated with resistance to chloroquine, mefloquine and artemisinin. Use of such genetic information for the early detection of resistance foci and future monitoring of drug resistant malaria is a potentially useful epidemiological tool, in conjunction with the conventional in vitro and in vivo drug sensitivity assessments. The purpose of this review is to describe the state of knowledge regarding drug resistant malaria and to outline the changing patterns of drug resistance including its determinants, current status in diverse geographical areas, molecular markers and their implications to limit the advent, spread and intensification of drug resistant malaria.

Transfusion associated infections: a threat to life.

Blood transfusion is indispensable in the management of many haematological diseases and has become the mainstay in major surgical procedures. Transfusion-transmitted infections have been a major threat to life since the dawn of transfusion therapy. The authors have highlighted the different viral, parasitic and bacterial infections associated with transfusion and have focussed on the precautionary measures that can be implemented for prevention of the infections along with a brief review of the literature.