Fatal Cryptococcus gattii meningitis with negative cryptococcal antigen test in a HIV-non-infected patient

Cryptococcus gattii predominantly causes central nervous system and pulmonary infection in both immunocompromised and immunocompetent patients with substantial morbidity. We report a case of rapidly fatal meningitis by C. gattii in an HIV–non-infected man with CD4 lymphopenia who tested negative for cryptococcal antigen. This case may serve as an alert to its wider occurrence and less explored risk factors.

A rare glimpse into the morbid world of necrotising fasciitis: Flesh‑eating bacteria Vibrio vulnificus.

Necrotising fasciitis is one of the fatal skin and soft tissue infections. Vibrio vulnificus is a rare cause of necrotising fasciitis; however, the disease is one of the major manifestations of the bacteria. Here, we report one such case in a middle‑aged male patient. He presented with the signs of bilateral lower limb cellulitis and altered sensorium. V. vulnificus was isolated from blood culture and also from debrided tissue. Though the organism is well characterised, it is a rare causative agent of necrotising fasciitis. This case is a re‑emphasis on active look out for this bacterium in patients presenting with necrotizsing fasciitis.

The antibiotics of choice for the treatment of melioidosis in Indian set up.

Therapeutic options for the treatment of melioidosis caused by Burkholderia pseudomallei are limited due to the inherent resistance conferred by this pathogen to various groups of antibiotics. Witnessing an increase in the number of microbiological culture‑confirmed cases of melioidosis at our settings in the past few years, we undertook this study to estimate the minimum inhibitory concentrations of clinical isolates of B. pseudomallei against the four commonly employed antimicrobial agents in the patient management at our settings, namely, ceftazidime, meropenem, trimethoprim‑sulfamethoxazole and doxycycline. All isolates were susceptible to the antibiotics tested, except for one isolate which showed resistance to doxycycline (minimum inhibitory concentration [MIC]: 32 µg/ml). MIC50 and 90 for all the four antibiotics were estimated. From this study, we conclude that the clinical isolates of B. pseudomallei from the southern part of India are well susceptible to the commonly employed antimicrobial agents for therapy.

Native valve endocarditis and femoral embolism due to Granulicatella adiacens: a rare case report

The fastidious Gram-positive cocci Granulicatella adiacens, previously known as nutritionally variant streptococci (NVS) are unusual but significant cause of endocarditis due to increased mortality and morbidity. Difficulties in reaching correct bacteriological identification, increased resistance to beta-lactam antibiotics and macrolides and complicated clinical course have contributed to problems in management of cases of infective endocarditis caused by this bacterium. We present the first Indian case of endocarditis with arterial embolus by G. adiacens in an elderly male with no preexisting cardiac abnormality.

False-positive widal in melioidosis.

Enteric fever is endemic in this part of the world, and Widal test is one of the time-honored laboratory tests that are being used for years to diagnose the disease. On the other hand, melioidosis is a newly emerging disease from this region, which is most often misdiagnosed or underdiagnosed by clinicians. It is well accepted that false-positive Widal reactions following certain non-typhoid Salmonella infections may occur commonly. Three cases of high titers of Widal test are described, where melioidosis was the actual diagnosis in every occasion and was never suspected until diagnosed microbiologically. All the patients had shown a partial response to ceftriaxone. Blood and pus cultures grew Burkholderia pseudomallei, whereas Salmonella typhi was not isolated from blood in any patient. With appropriate antibiotics, the patients showed clinical and microbiological improvement with lowering of Widal titers. These 3 cases show that high Widal titer in any patient may mislead the diagnosis of melioidosis, and further laboratory workup should always be done to rule out melioidosis, especially in cases with nonresponsiveness to treatment.

Ventilator-associated pneumonia with Col-S strains: a successful comeback of colistin!

Emergence of multi and pan-drug resistant Gram-negative bacteria causing nosocomial infections in intensive care settings has become a challenge for clinicians. The mortality rate of ventilator-associated pneumonia (VAP) is known to increase when the initial microbiological diagnosis and antimicrobial therapy are inappropriate. We present a case of a 18-year-old man, who after being admitted following an accident, had developed VAP due to multi-drug resistant Pseudomonas aeruginosa and Acinetobacter spp. and had a downhill clinical course despite broad-spectrum antibiotic treatment. The strains were found to be Col-S, as the susceptibility was tested. Colistin was instituted, with remarkable recovery. It is imperative to diagnose VAP with multi-drug resistant strains as early as possible; colistin, the 'last resort' antibiotic, if instituted with proper monitoring at the right time, can be life saving.

Emerging extra-intestinal infections with Aeromonas hydrophila in coastal region of southern Karnataka.

BACKGROUND: Aeromonas species are gram-negative rods usually isolated from the gastrointestinal tract. They have been occasionally reported as a cause of extra-intestinal infections such as cellulitis, cholangitis, necrotizing fascitis, meningitis, bacteremia, or peritonitis in both immunocompetent and immunocompromised patients. AIM: To determine the role and possible pathogenesis of Aeromonas in extra-intestinal infections. SETTINGS AND DESIGN: Retrospective analysis carried out at Kasturba Hospital Manipal, Karnataka in the months of January and February 2007. MATERIALS AND METHODS: Clinical manifestations and management of eight cases of extra-intestinal infections caused by A. hydrophila , from the south Karnataka coastal region were reviewed. The isolates were identified with the help of biochemical tests using standard guidelines. RESULTS: All patients acquired Aeromonas infections in the community. Five (62.5%) had underlying illnesses, such as liver disease, diabetes mellitus or malignancy. Five (62.5%) had polymicrobial infections, and three (37.5%) were complicated with bacteremia. These included three patients with ulcers or abscess over the lower leg, two with cellulitis due to snake bite and one each with pelvic inflammatory disease, spontaneous bacterial peritonitis and pneumonia. A. hydrophila was found to be a causative agent of pelvic inflammatory disease or cellulitis following sea snake bite, and such a clinical scenario has not been previously described. Seven patients survived the illness. CONCLUSIONS: Isolation of A. hydrophila from extra-intestinal specimens demands utmost clinical and microbiological vigilance in diagnosis, since the organism can cause serious infections among immunocompromised as well as immunocompetent individuals.

Citrobacter freundii infection in glutaric aciduria type 1: adding insult to injury.

Glutaric aciduria type 1 (GA1) is an inborn error of organic acid metabolism, where the brain is the principal organ affected with exposure to toxic metabolic product, 3-hydroxyglutaric acid (3-OHGA). A 2-year-old boy with GA1 and delayed developmental milestones had an acute neurological crisis leading to massive brain abscess with Citrobacter freundi infection, a rare cause of neonatal meningitis and often associated with brain abscess. Both 3-OHGA and C. freundii can damage the blood-brain barrier and can cause significant trauma which demands immediate and appropriate management. Encephalopathic manifestations of GA1 may consequently increase the risk of meningeal infection and it has not been previously documented.

Intestinal protozoal infestation profile in persistent diarrhea in children below age 5 years in western Nepal.

Unlike acute diarrhea, the role of pathogens in persistent diarrhea in children in Nepal is unclear. Protozoal parasites are suspected to be a major cause. The study was carried out to find the association between protozoal agents and persistent diarrhea in children below age 5 years from western Nepal. Stool samples were collected from 253 children with persistent diarrhea, from 155 children with acute diarrhea (disease controls) and from 100 healthy children from the community (normal controls). Of 253 children with persistent diarrhea, 90 (35.5%) had protozoal infections, 63 (24.9%) helminthic infections, 32 (12.6%) had bacterial infections and 16 had mixed infections. Giardia lamblia was the most prevalent (67.7%), followed by Entamaeba histolytica (27.7%). HIV infection and severe malnutrition were associated with Cyclospora cayetanensis and Cryptosporidium spp causing persistent diarrhea. We conclude that stool microscopy should be routinely performed in children with persistent diarrhea since protozoal infections can be cured with effective treatment and control can be achieved by proper health education.

Persistence of parvovirus B19 IgM antibodies and DNA in pure red cell aplasia resulting in myelodysplasia--a case report.

Human erythrovirus B19 (B19), previously known as parvovirus B19, is a small spherical, non-enveloped single stranded DNA virus. It has been shown to cause a wide spectrum of clinical conditons including various hematological disorders. We report here for the first time from Inida a case of pure red cell aplasia in a 45-year-old female for last 7 years due to chronic persistent B19 infection leading to myelodysplasia after 4 years. Her sera were positive for two times 4 months apart for B19 IgM and B19 DNA at the initial stage. Presently the patient is on repeated blood transfusion on every 15-20 days.

Ralstonia mannitolilytica infection in renal transplant recipient: First report.

Ralstonia mannitolilytica is being increasingly identified as an opportunist pathogen in immunocompromised patients. We report the first case of post renal transplant infection by R. mannitolilytica, in a 14-year-old recipient. The graft and the patient were saved with prompt microbiological identification, sensitivity testing and subsequent administration of appropriate antibiotic.

Prevalence of HIV among low and high risk population of eastern part of northern India.

A total of 7,904 persons visiting University Hospital of Banaras Hindu University (BHU), Varanasi, were screened for HIV antibody by ELISA and/or rapid test. The overall seroprevalence of HIV (3.17%) in this area was higher than that of Uttar Pradesh and India as a whole. The seroprevalence of HIV/AIDS among the high risk group (HRG) (6.42%) being significantly higher than low risk group (LRG) (0.37%). In the LRG, the prevalence among medical and surgical patients; and ANC (antenatal cases) was 1.17% and 0.14%, respectively. However, HIV infection was not detected in HCWs (healthcare workers), BHU students and foreigners. Among HRG, CSWs (commercial sex workers) had the highest prevalence (14.0%) and STD (sexually transmitted diseases) patients, the lowest prevalence (1.99%). The STD patients had significantly lower prevalence rate as compared to others in HRG. Majority of the HIV positive were found to be within the age group 15-44 years, with heterosexual mode as the main route of transmission. Seven HIV positive children were of 2-5 yr old age group. Majority of seropositive women (62.52%) were working in a low income jobs and were mainly infected by their spouses who was mostly migrating labourers of lower socioeconomic group and with less than primary level of education. Married females, being mainly the spouses of HIV positive males had the highest seropositivity (60.25%). These population people were directly transmitting the infection from the metropolitan cities to the rural areas of this region. Prevalence of HIV-2 was negligible as compared to HIV-1, the actual reason is yet to be explored.

Molecular modelling of MHC class I carbohydrates.

In this article we present the results of molecular modelling of four complex carbohydrates which have been found in the MHC class I proteins. Though these proteins show diversity in their sequences, the glycosylation sites are highly conserved indicating a possible structural/functional role of the glycan chain. Similar glycan chains have been found linked with other proteins of completely different function, such as IgG, and erythropoeitin. Thus, the molecular modelling of these carbohydrates will not only provide structural/dynamic information of these complex molecules but will also provide conformational information which can be utilised to build the glycoprotein models. The results presented here indicate that although several linkages show less conformational flexibility, terminal linkages can be quite flexible.