Auramine-O Staining vs Ziehl Neelsen Staining: Advantages and Disadvantages

Background: Tuberculosis (TB) caused by Mycobacterium tuberculosis (Mtb) is still a major public health concern around the world. Prompt detection of active tuberculosis cases helps in timely therapeutic intervention and reduces community transmission. Despite limited sensitivity, conventional microscopy is still used to diagnose pulmonary tuberculosis in high-burden nations such as India. This study, therefore, was aimed at assessing the diagnostic performance of microscopy by Ziehl Neelsen (ZN) and auramine (AO) staining in the diagnosis of pulmonary tuberculosis. Materials and methods: A prospective comparative study was done on the sputum samples of 2,395 adult patients from November 2018 to May 2020 suspected of having pulmonary tuberculosis visiting the Designated Microscopic Centre of SGT Medical College, Budhera, Gurugram. Each sample was subjected to ZN staining, and AO staining as per NTEP guidelines. Results: Out of the 2,395 samples studied, 161 (6.76%) and 224 (9.35%) were positive by ZN and AO staining methods respectively. Pauci-bacillary cases detected by AO were more than ZN staining. There were 63 more sputum samples detected by AO staining which were missed by ZN microscopy. Conclusion: When compared to conventional ZN staining, the auramine staining technique is more sensitive and takes less time to diagnose pulmonary tuberculosis

Sinonasal NUT midline carcinoma: A new histological entity

Nuclear protein in testis (NUT) midline carcinoma is poorly differentiated carcinoma defined by rearrangement of NUT gene on 15 to other genes, usually BRD4 on 19. It is first described in 1991. These tumors are most commonly seen in the mediastinum and 35% occur in head and neck. It is a highly aggressive tumor with a median survival of 7 months because of ineffective chemotherapy and undefined treatment. Hence, we must differentiate these tumors from other poorly differentiated tumors. Here, we present a case of NUT midline carcinoma of 44-year male, who presented with headache and dizziness, confirmed by immunohistochemistry of NUT antibody. The aim of this case report is to increase the awareness about this entity in adults with brief review of relevant literature.

Respiratory syncytial virus infections in India: Epidemiology and need for vaccine

Respiratory syncytial virus (RSV) has been identified as a leading cause of lower respiratory tract infections in young children and elderly. It is an enveloped negative-sense RNA virus belonging to Genus Orthopneumovirus. The clinical features of RSV infection range from mild upper-respiratory-tract illnesses or otitis media to severe lower-respiratory-tract illnesses. Current estimates show that about 33.1 million episodes of RSV-acute lower respiratory infection (ALRI) occurred in young children in 2015, of these majority that is, about 30 million RSV-ALRI episodes occurred in low-middle-income countries. In India, the rates of RSV detection in various hospital- and community-based studies mostly done in children vary from 5% to 54% and from 8% to 15%, respectively. Globally, RSV epidemics start in the South moving to the North. In India, RSV mainly peaks in winter in North India and some correlation with low temperature has been observed. Different genotypes of Group A (GA2, GA5, NA1 and ON1) and Group B (GB2, SAB4 and BA) have been described from India. The burden of RSV globally has kept it a high priority for vaccine development. After nearly 50 years of attempts, there is still no licensed vaccine and challenges to obtain a safe and effective vaccine is still facing the scientific community. The data in this review have been extracted from PubMed using the keywords RSV and Epidemiology and India. The data have been synthesised by the authors.

A Comparative Study Between Cleavage Stage Embryo Transfer at Day 3 and Blastocyst Stage Transfer at Day 5 in IVF/ICSI on Clinical Pregnancy Rates.

Objective: To evaluate the efficacy of blastocyst transfer in comparison with cleavage stage transfer. Study design: A randomized, prospective study was conducted in Infertility Clinic, Dept. of Obstetrics and Gynecology, Mahatma Gandhi Hospital, Jaipur on 300 patients aged 25-40 years undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ ICSI) cycle from May 2010 to April 2011. When three or more Grade I embryos were observed on Day 2 of culture, patients were divided randomly into two study groups, cleavage stage transfer and blastocyst transfer group having 150 patients each. Primary outcomes evaluated were, clinical pregnancy rate and implantation rate. The results were analyzed using proportions, standard deviation and Chi-square test. Results: Both the groups were similar for age, indication and number of embryos transferred. Clinical pregnancies after blastocyst transfer were significantly higher 66 (44.0%) compared to cleavage stage embryo transfer 44 (29.33%) (p < 0.01). Implantation rate for blastocyst transfer group was also significantly higher (p < 0.001). Conclusion: Blastocyst transfer having higher implantation rate and clinical pregnancy rate leads to reduction in multiple pregnancies.

Fenestration of the posterior communicating artery.

A 21-year-old male presented with sudden onset of right-sided third nerve paresis. Angiogram showed a fenestrated posterior communication artery on the right side and no other vascular anomalies. There was no other lesion that could suggest a cause for the third nerve weakness. Fenestration of the posterior communicating artery has not been reported till date. The case is discussed and the literature on the subject is reviewed.

Magnetic resonance arthrography in recurrent anterior shoulder instability as compared to arthroscopy: a prospective comparative study.

AIM: To evaluate the accuracy of magnetic resonance (MR) arthrographic imaging in the diagnosis of glenoid labral and ligament tears in recurrent shoulder instability. SETTINGS AND DESIGN: Prospective, comparative study at a tertiary care centre. MATERIAL AND METHODS: Patients with three or more episodes of anterior shoulder dislocation were enrolled in the study. They were subjected to magnetic resonance arthrography (MRA) for delineation of abnormalities. The findings obtained at MRA were compared with those found at arthroscopy and surgical exploration. RESULTS: MRA detected glenoid tears in all 22 patients with 20 (90%) patients having antero-inferior tears, 3 (14%) patients had superior labral involvement and 2 (10%) patients had posterior labral abnormality. On arthroscopy, antero-inferior, superior and posterior labral tear were found in 21 (95%), 5 (22%) and 7 (32%) patients respectively. MRA showed a sensitivity of 95%, and a specificity of 100% for the detection of the antero-inferior labral tears. The sensitivity of MRA for the detection of superior, middle and inferior glenohumeral ligament tear was 83%, 80% and 86% with a specificity of 100%, 71% and 93% respectively. MRA was 100% sensitive for the detection of rotator cuff injuries and detection of bony lesions like Hill-Sach's and bony Bankart's lesion. CONCLUSIONS: MRA is a sensitive and specific modality for evaluation of anterior shoulder instability.

The lateralizing significance of version of head and dystonic limb posturing in epileptic seizures.

Several clinical signs have been described for lateralization and localization of seizure focus in complex partial seizures; however, the specificity of each of these has been widely debated upon. The present study was done to evaluate 'dystonic unilateral limb posturing' and 'versive head movements' for lateralization and localization of epileptic foci in patients with intractable partial complex seizures, being investigated with long term Video-EEG monitoring. Fifteen patients with 46 seizures, studied with long term Video EEG, had either one or both of these signs. The video recordings of the clinical behaviour were noted and later compared with the corresponding EEG. Unilateral dystonic limb posturing and versive head movements had good lateralising value in complex partial seizures, suggestive of temporal lobe origin, contralateral to the seizure focus, with a specificity of 87.5% and 86% respectively. In addition, turning of the whole body to one side was associated with a contralateral seizure focus in 100% cases. Appendicular automatisms were found to be of no lateralising significance, as they occurred on either side with equal frequency. These motor phenomena should, therefore, be enquired about in detail, during history taking for lateralization or localization of seizure focus.

Prenatal diagnosis of haemoglobinopathies.

BACKGROUND: Haemoglobinopathies constitute a major health problem in the Indian subcontinent. In the absence of any method for achieving complete cure and treatment being expensive, prenatal diagnosis and selective termination of an affected foetus is a feasible option to decrease the disease load. We report our experience with prenatal diagnosis of haemoglobinopathies over a two-and-a-half year period in 257 pregnancies. MEHODS: Amplification refractory mutation system (ARMS) was used to detect beta-thalassaemia, haemoglobin E and sickle cell mutations. RESULTS: Five mutations in the beta-globin gene which are common in the Indian population were detected in 92.3% of mutant chromosomes, whereas 3.1% of chromosomes carried rare mutations followed by 0.8% haemoglobin E and 0.4% sickle cell mutations. Mutations in 3.3% chromosomes were uncharacterized. The prenatal procedure, carried out early in pregnancy, was a chorionic villus sampling in most cases. A confirmed diagnosis based on ARMS-PCR was given in 241 (93.8%) cases. In 10 cases (3.9%) linkage analysis was required to confirm the foetal status, as mutations in both parents were not identified or the chorionic villus sample carried the single identified mutation. Four families with haemoglobin E-beta thalassaemia and one family with sickle cell disease were also included. Of the study population, 91.25% of the couples had a previous child with haemoglobinopathy, whereas 8.75% of the couples came before the birth of the first affected child. CONCLUSION: We conclude that ARMS-PCR is a highly sensitive technique for detecting mutations in the beta-globin gene and its efficacy in the prenatal diagnosis of haemoglobinopathies is proven.

Electrophysiological evaluation of 140 hands with carpal tunnel syndrome.

AIM: To study various electrophysiological parameters in clinically suspected carpal tunnel syndrome (CTS). MATERIAL AND METHODS: Electrophysiological (EPS) evaluation of 70 patients (140 hands) of clinically suspected CTS was done as per AAEM recommendation. EPS grading was done as described by Padua, et al. RESULTS: The mean age was 44.21 +/- 10.29 (range 24-66) years with female predominance (M:F 3:11). Sixty four (91.4%) patients had bilateral involvement. The mean EPS grade was 3.18 +/- 1.41. One hundred and six (75.5%) hands had moderate to severe (EPS grade 1-3) CTS. Median distal motor latency (DML) (mean 4.76 +/- 1.4 msec) was prolonged in 92 (65.71%) hands and was not recordable in seven (5%) hands. Median sensory distal latency (SDL) (mean 3.54 +/- 0.82 msec) was prolonged in 38 (27.1%) hands and not recordable in 49 (35%) hands. Sensory median mid-palm latency (MPL) (2.42 +/- 0.56 msec) was commonest EPS abnormality present in 128 (91.4%) hands. EMG was abnormal in 75% hands. CONCLUSION: This study suggests incorporation of median sensory midpalm latency as a screening test for electrophysiological diagnosis of CTS. In addition, bilateral studies are recommended as there is bilateral involvement in 64 patients.

Controlled trial of hypo-osmalar versus World Health Organization oral rehydration solution.

OBJECTIVE: To compare the safety and efficacy of a hyposmolar oral rehydration solution (H-ORS) (245 mmol/liter) with the World Health Organization oral rehydration solution (WHO ORS) in cholera and acute non-cholera diarrhea. DESIGN: Controlled clinical trial. SETTING: Diarrhea training and treatment unit. METHODS: Thirty-five culture proven cholera and 135 acute non-cholera diarrheal patients randomly received H-ORS or WHO-ORS. Intake and output were measured every 4 hours. RESULTS: Analysis of the total cases revealed rehydration phase (p=0.048, 95% CI 0.64-0.99) and overall (p=0.046, 95% CI 0.70-0.99) frequency of stools to be significantly less in the H-ORS group. In the severely malnourished, the rehydration phase (p=0.032, 95% CI 0.55-97), maintenance phase (p=0.035, 95% CI 0.51-0.97) and overall (p=0.011; 0.95% CI 0.55-0.93) stool frequency were significantly decreased in the H-ORS group. The amount of ORS consumed in the maintenance phase of the cholera cases was significantly (p=0.04, 95% CI 0.44-0.98) less in the H-ORS group. All other parameters, despite showing a decreasing trend, were statistically comparable in the cholera, non-cholera and total cases. The amount of intravenous fluid needed was significantly more in the noncholera and total cases on H-ORS. In the non-breastfed cases, under two years of age, the total duration of diarrhea was significantly decreased (p=0.03; 95% CI 11.07-11.45) but the need for intravenous fluids significantly increased (p=0.02; 95% CI 109.8-112.1) in the H-ORS group. The proportion of children vomiting, the weight gain, urine passed in 24 hours, serum sodium, caloric intake and failure rate were comparable. CONCLUSIONS: H-ORS is as safe and effective as the WHO-ORS and may have some additional benefits in malnourished children.

Prenatal diagnosis of Duchenne muscular dystrophy.

BACKGROUND: Duchenne muscular dystrophy (DMD) is one of the most common X-linked genetic disorders seen in children. Mutations in the DMD gene coding for the protein dystrophin causes the severe muscle-wasting disorder leading to death in the second decade of life. In the absence of a cure, prenatal diagnosis (PND) appears to be the best approach to reduce the burden of this disease on the individual family and ultimately on society. There are few published reports worldwide on PND and very few from the developing countries. We report our experience with PND for families with DMD using multiplex polymerase chain reaction (PCR) and microsatellite polymorphic marker analysis. METHODS: From August 1997 to October 1999, PND was offered on request to 23 families with one or two boys affected with DMD. A total of 26 foetuses were screened for DMD. Initially the deletions in the DMD gene in the affected child were identified by multiplex PCR screening for 23 exons in 6 sets. In patients where deletions were not identified, microsatellite repeat analysis was carried out to follow the inheritance of the mutant allele. DNA was extracted from chorionic villus samples obtained by chorionic villus biopsy performed at 10-15 weeks of gestation in 17 families, and at 16-20 weeks in 6 families. RESULTS: Deletions were identified in 20 affected boys. In 2 families, microsatellite repeat analysis was done to identify the mutant allele. Of the 26 foetuses, 5 were found to be affected with DMD and the parents opted for termination of pregnancies. CONCLUSIONS: Multiplex PCR technology and microsatellite repeat analysis can be used effectively for PND of DMD.

Usefulness of short term video-EEG monitoring in children with frequent intractable episodes.

A prospective study was done to evaluate the role of short-term Video EEG (VEEG) recording in assessing the nature of clinical behaviour and in classification of seizures in children with frequent intractable seizure episodes. Forty five children upto 12 years of age with frequent intractable seizure episodes (> or =3/week) were included in the study. VEEG was done on an outpatient basis until an event was recorded or for a minimum period of 6 hours. The events were detected in 78% of cases. The seizures were classified in all children with recorded events and seizure classification was changed in 22%. Anti-epileptic drugs could be stopped or reduced in 11%. Short term VEEG monitoring was useful in characterising events and in classification of seizures in children with frequent, intractable seizure episodes. Use of this investigation as a screening procedure for diagnosis in children with frequent episodes is stressed, thereby reducing the cost associated with prolonged VEEG recordings and disability associated with misdiagnosis of epilepsy.

Epilepsy surgery in India: All India Institute of Medical Sciences experience.

OBJECTIVES: Surgical treatment of epilepsy should be considered an important alternative to medical therapy. The identification of a suitable candidate, pre-operative evaluation requires a multidisciplinary team. The specific diagnostic studies required depend on the operative strategy and objective of surgical treatment. METHODS: In twenty patients with medically intractable epilepsy, who had clinical evaluation, electroencephalography (EEG), video-EEG monitoring using scalp electrodes, high resolution magnetic resonance imaging (MRI), neuropsychology, single photon emission computed tomography (SPECT) was done to localise the seizure focus. If the investigations were concordant resective surgery was performed. In case of frequent falls, atonic and tonic seizures, with generalised/multifocal discharges on EEG, a callostomy was done. Surgical outcome was assessed using Engel's 4 point scale. RESULTS: In 18 patients the seizure focus was localised, 13 had temporal lobectomy, five extra-temporal resection, and two had callosotomy. Fifteen patients had a follow-up of more than eight months, mean 20.5 (range 8-35 months), 13 had outcome I (seizure free), two had outcome II (occasional seizures), one-outcome III. Three were lost to follow-up and one patient died. There were no major post-operative complications. CONCLUSIONS: Surgical treatment of epilepsy is a safe, effective mode of therapy. Suitable candidates should be identified early and referred to appropriate centres.

Renal lesions associated with AIDS--an autopsy study.

Kidneys from 55 cases (20 with HIV infection and 35 with AIDS) were studied by routine Haematoxylin and Eosin stains and special stains (PAS, PASM GMS, ZN, Mucicarmine and Congo red) to evaluate, glomerular, interstitial and vascular pathology. Twenty-four of the 35 (68.6%) cases of AIDS showed infective aetiology which included 17 cases (48.5%) of tuberculosis, 5 cases (14.4%) of fungal infection (3 cryptococcus neoformans and 2 candida species) and 2 cases (5.7%) of CMV infection. Other lesions noted were amyloidosis and tubular calcinosis. HIV associated nephropathy (HIVAN) was not detected in any of the cases. Intravenous drug abuse was not a risk factor in our cases which probably explains the absence of HIV associated nephropathy in the present study.

Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome.

Acute encephalitis caused by Toxoplasma gondi was diagnosed at autopsy in 10 (20.4%) of the 49 patients. All patients had under lying immunodeficiency due to AIDS and showed selective involvement of central nervous system at autopsy. Sexual promiscuity was the risk factor in nine cases while one case had a history of blood transfusion. Diagnosis of toxoplasmosis was hampered by a lack of suspicion that Toxoplasma could be the agent causing necrotising encephalitis. The large number of cases of CNS toxoplasmosis appearing in AIDs patients emphasize the necessity of including toxoplasmosis in the differential diagnosis of encephalitis of unknown aetiology.

Distribution of vascular lesions in ischaemic stroke: a magnetic resonance angiographic study.

BACKGROUND: Carotid endarterectomy is now an accepted modality for reducing the threat of recurrence of ischaemic strokes in patients with severe carotid artery stenosis. However, the incidence of carotid artery stenosis, and hence the applicability of carotid endarterectomy in the Indian population is not known. We conducted a prospective study to detect and quantify extracranial and intracranial arterial lesions using magnetic resonance angiography in consecutive patients with ischaemic strokes. METHODS: All patients with recent onset of ischaemic stroke (< 4 months) had a magnetic resonance angiography done to evaluate the neck vessels as well as the circle of Willis and its branches. The degree of stenosis of the internal carotid or common carotid artery was measured according to the criteria described by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) collaborators. The site and extent of the extracranial and intracranial arterial lesions were correlated with the clinical features and the pattern of infarcts on magnetic resonance imaging or computerized tomographic scan of the brain. RESULTS: The magnetic resonance angiography was abnormal in 56 out of 100 patients included in the study. Severe stenosis (> 70%) of the extracranial carotid arteries was seen in 26 patients. Lesions suitable for carotid endarterectomy were present in only 11 patients (42.3% of those with severe stenosis). CONCLUSION: Our results are in contrast to those reported from western countries where the likelihood of a surgically correctable lesion being present is 60%-70%. We found operable lesions in only 11%. Intracranial atherosclerotic disease causing strokes is probably more common in India. Therefore, although carotid endarterectomy is the only accepted surgical procedure for secondary prophylaxis of stroke, there is a need to find an alternative surgical intervention for the predominantly intracranial pathology found in the Indian population.

Bilateral renal angiomyolipoma in association with tuberous sclerosis.

Renal angiomyolipoma with tuberous sclerosis has not yet been reported in Indian literature. We report a case of bilateral angiomyolipoma associated with tuberous sclerosis in a 25 year old man.