Coagulase‑negative staphylococci causing blood stream infection at an Indian tertiary care hospital: Prevalence, antimicrobial resistance and molecular characterisation.

Introduction: Recent years have seen a rise of coagulase‑negative staphylococci (CoNS) from common contaminants to agents of nosocomial blood stream infections (BSI’s). Molecular typing and establishing a correlation with antibiotic resistance is essential particularly in countries like India where genotyping studies for drug‑resistant CoNS are sparse. Methods: A prospective study was done over 18 months, wherein 42,693 blood samples were received, and 59 patients with BSI due to CoNS were evaluated. The isolates recovered were identified by a biochemical test panel and matrix‑assisted laser desorption ionization – time of flight mass spectrometry followed by antimicrobial susceptibility testing by Kirby–Baur disc diffusion method and E‑test strips. Staphylococcal chromosomal cassette mec (SCCmec) element was characterised by multiplex polymerase chain reaction for all methicillin‑resistant (MR) isolates. Results: The majority of CoNS isolated were constituted by Staphylococcus haemolyticus (47.5%) followed by Staphylococcus epidermidis (33.9%), Staphylococcus hominis (11.86%), Staphylococcus cohnii (5.08%) and Staphylococcus warneri (1.69%). Among all isolates 57.6% were MR with statistically significant higher resistance versus methicillin sensitive‑CoNS. This difference was significant for erythromycin (76% vs. 44%, P = 0.011), rifampicin (50% vs. 12%, P = 0.002) and amikacin (26.5% vs. 4%, P = 0.023), ciprofloxacin (64.7% vs. 20%, P = 0.001) and cotrimoxazole (55.9% vs. 20%, P = 0.006). SCCmec type I was predominant (61.8%, P = 0.028) and exhibited multidrug resistance (76.2%). Coexistence of SCCmec type I and III was seen in 8.82% MR isolates. Conclusion: CoNS exhibit high antimicrobial resistance thereby limiting treatment options. The presence of new variants of SCCmec type in hospital‑acquired CoNS may predict the antibiotic resistance pattern. This is the first evaluation of the molecular epidemiology of CoNS causing BSI from India and can serve as a guide in the formulation of hospital infection control and treatment guidelines.

Molecular characterisation of antimicrobial resistance in Pseudomonas aeruginosa and Acinetobacter baumannii during 2014 and 2015 collected across India.

Background: Surveillance of antimicrobial resistance (AMR) is of great importance. Pseudomonas aeruginosa and Acinetobacter baumannii are important pathogens and emergence of resistance in these have increased the morbidity and mortality rates. This surveillance study was initiated by the Government of India ‑ Indian Council of Medical Research. The aim of this study is to determine the antimicrobial susceptibility profile and to characterise the enzyme mediated antimicrobial resistance such as extended spectrum beta‑lactamases (ESBLs) and carbapenemases among multidrug‑resistant (MDR) P. aeruginosa and A. baumannii. Materials and Methods: A multi‑centric study was conducted from January 2014 to December 2015 with a total number of 240 MDR P. aeruginosa and 312 MDR A. baumannii isolated from blood, cerebrospinal fluid, respiratory, pus, urine and intra‑abdominal infections. Kirby–Bauer disc diffusion was done to determine the antimicrobial susceptibility profile. Further, MDR isolates were characterised by multiplex polymerase chain reaction to determine the resistance genes for ESBLs and carbapenemases. Results: Among the ESBLs, blaVEB (23%), blaTEM (5%) and blaSHV (0.4%) in P. aeruginosa and blaPER (54%), blaTEM (16%) and blaSHV (1%) in A. baumannii were the most prevalent. Likewise, blaVIM (37%), blaNDM (14%), blaGES (8%) and blaIMP (2%) in P. aeruginosa and blaOXA‑23like (98%), blaOXA‑58like (2%), blaNDM (22%) and blaVIM (3%) in A. baumannii were found to be the most prevalent carbapenemases. blaOXA‑51like gene, intrinsic to A. baumannii was present in all the isolates tested. Conclusion: The data shown highlight the wide difference in the molecular mechanisms of AMR profile between P. aeruginosa and A. baumannii. In P. aeruginosa, plasmid‑mediated mechanisms are much lesser than the chromosomal mediated mechanisms. In A. baumannii, class D oxacillinases are more common than other mechanisms. Continuous surveillance to monitor the trends in AMR among MDR pathogens is important for implementation of infection control and to guide appropriate empirical antimicrobial therapy.

Declining trends of Syphilis seroprevalance among antenatal clinic cases and STD clinic cases in a tertiary care centre: From January 2002 to December 2012.

Syphilis affects nearly 1.36 million pregnant women, majority of these cases being concentrated in the developing countries. We aimed at analysing the 11 years’ trends in syphilis seroprevalence in antenatal clinics (ANC) and STD clinic cases. Laboratory data of syphilis cases from 2002-2012 were retrospectively analysed. Out of the total 73642 cases, 393 (0.53%) tested positive for Syphilis. A statistically signifi cant decline in syphilis prevalence was found in both ANC and STD clinic cases. The efforts of various interventional programs should continue to make the screening and treatment facilities readily accessible to continue the decline in syphilis seropositivity.

Antigen sequence typing of outer membrane protein (fetA) gene of Neisseria meningitidis serogroup A from Delhi & adjoining areas.

Background & objectives: Meningitis caused by Neisseria meningitidis is a fatal disease. Meningococcal meningitis is an endemic disease in Delhi and irregular pattern of outbreaks has been reported in India. All these outbreaks were associated with serogroup A. Detailed molecular characterization of N. meningitidis is required for the management of this fatal disease. In this study, we characterized antigenic diversity of surface exposed outer membrane protein (OMP) FetA antigen of N. meningitidis serogroup A isolates obtained from cases of invasive meningococcal meningitis in Delhi, India. Methods: Eight isolates of N. meningitidis were collected from cerebrospinal fluid during October 2008 to May 2011 from occasional cases of meningococcal meningitis. Seven isolates were from outbreaks of meningococcal meningitis in 2005-2006 in Delhi and its adjoining areas. These were subjected to molecular typing of fetA gene, an outer membrane protein gene. Results: All 15 N. meningitides isolates studied were serogroup A. This surface exposed porin is putatively under immune pressure. Hence as a part of molecular characterization, genotyping was carried out to find out the diversity in outer membrane protein (FetA) gene among the circulating isolates of N. meningitidis. All 15 isolates proved to be of the same existing allele type of FetA variable region (VR) when matched with global database. The allele found was F3-1 for all the isolates. Interpretation & conclusions: There was no diversity reported in the outer membrane protein FetA in the present study and hence this protein appeared to be a stable molecule. More studies on molecular characterization of FetA antigen are required from different serogroups circulating in different parts of the world.

Analgesic and Anti-inflammatory Activities of the Fruit Extract of Ampelocissus latifolia (Roxb) on Laboratory Animals.

Aim of Study: This study was aimed to evaluate the possible analgesic and antiinflammatory properties of the ethanol extract of fruit of Ampelocissus latifolia (Roxb). Study Design: Assessment of analgesic and anti-inflammatory activities. Place and Duration of Study: Department of Pharmacy, North South University, Dhaka, Bangladesh, between June 2012 and March 2013. Methodology: The crude ethanol extract was investigated for the anti-inflammatory effect on Long Evans rats using carrageenan induced rat paw edema method. For antiinflammatory study, 20 rats were divided into 4 different groups, each receiving either distilled water, standard drug or the extract at the doses of 250 and 500mg/kg body weight (BW). The analgesic activity was evaluated by hot plate and acetic acid induced writhing method in Swiss albino mice divided into 4 different groups (control, standard and extract at two different doses of 250 and 500 mg/kg BW). Results: The results of preliminary phytochemical study revealed the presence of alkaloids, flavonoids, tannins, glycosides in significant amounts. The results of anti inflammatory activity study showed that the fruit extracts at a dose of 250 mg/kg and 500 mg/kg inhibited carrageenan-induced paw edema in Long- Evans rats. Both the extracts were able to show a dose dependent anti-inflammatory activity as compared to diclofenac sodium used as a standard drug. The extract elicited a highly significant (p<0.001) analgesic activity in a dose dependent manner on hot plate method, acetic acid-induced writhing test. In the hot plate method, the extract increased the reaction time of heat sensation to 94.71% and 82.7% at the doses of 250 and 500 mg/kg BW while that of the standard drug was 61.45% at the 3rd hour of study. In acetic acid induced writhing test, the percent inhibition of writhing response by the extract was 50.57% and 59.77% at 250 and 500 mg/kg doses respectively (p<0.001). Conclusion: The anti-inflammatory and analgesic effect of the ethanol fruit extract of Ampelocissus latifolia (Roxb) may be due to the presence of various chemical constituents especially flavonoids, tannins, alkaloids or terpenoids. These experimental findings would further establish the scientific basis of the traditional uses of the plant in the management of inflammatory conditions as well as control of pain.

Effect of lamotrigine on fetal rat brain.

Studies on the effect of lamotrigine on fetal brain are limited. The present experimental study was conducted to explore any macroscopic or microscopic changes in fetal brain induced by lamotrigine. Pregnant albino wistar rats received 1.5 mg oral lamotrigine on day 9 to 11 of pregnancy and the pups were harvested on day 20. The mean body weight and length were lower and brain weight and volume were higher of the pups exposed to lamotrigine. However, the differences were not statistically significant. Some of the experimental pups had exencephaly and haemorrhages over the body. Histology of the brain revealed that in lamotrigine treated group, the lateral ventricles were dilated and the plexiform layer of the cerebral cortex was relatively less differentiated.

Multi locus sequence type comparison of invasive and commensal Haemophilus influenzae isolates from Delhi.

Haemophilus influenzae is a major public health concern in the developing world. The most virulent strain is H. influenzae Type b (Hib). Hib also constitutes a major portion of nasopharyngeal commensal flora in otherwise healthy individuals. Through dendogram based on composite gene sequences of seven multi locus sequence type genes, it was observed that invasive and commensal isolates made two completely separate clusters which are indicative of independent evolution of these two groups of H. influenzae in the Indian subcontinent.

Application of 16S rDNA based seminested PCR for diagnosis of acute bacterial meningitis.

BACKGROUND & OBJECTIVES: The diagnosis of bacterial meningitis remains a challenge to the clinician because of its rapid lethal course lacking the consistency to particular clinical signs and symptoms. Moreover, in many clinical settings use of rampant and short course antibiotic therapy prior to lumbar puncture reduces the chance of isolation of bacteria in CSF culture making the diagnosis difficult. The present study was done to evaluate a multiplex seminested PCR based method for rapid diagnosis of bacterial meningitis even after initiation of antibiotics. METHODS: A 16S rDNA based PCR technique was evaluated using universal bacterial primers to detect any bacterial pathogen in CSF samples. The simultaneous use of three species-specific primers in a multiplex and seminested PCR format was done to identify Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis within 4 h. RESULTS: Analysis of 267 CSF samples obtained from suspected cases of acute bacterial meningitis revealed 94 per cent concordance in results for conventional (Gram stain and culture) and molecular methods. Conventional techniques failed to detect five PCR positive samples where clinical diagnosis, cell count and biochemical findings of CSF supported the evidence of infection. The overall sensitivity, specificity, positive predictive value and negative predictive value of 16S rDNA PCR were 79.24, 97.6, 89.36 and 94.88 per cent respectively when culture was considered as gold standard. The detection limit of 16S rDNA PCR was determined to be 1000 cfu/ml of E. coli and 4000 cfu/ml of S. pneumoniae. INTERPRETATION & CONCLUSION: The results suggest that 16S rDNA PCR can be used as a valuable supplementary test in routine clinical practice for diagnosis of acute bacterial meningitis in hospital setting.

Kartagener's Syndrome.

Kartagener's Syndrome or Immotile Cilia Syndrome, a variant of Primary Ciliary Dyskinesia (PCD), is a rare autosomal recessive genetic disorder caused by defect in the tiny hair like structure, the cilia lining the respiratory tract (upper and lower), sinuses, eustachian tubes, middle ear and fallopian tubes. Here electron microscopy shows abnormal arrangement of ciliary tubules and patients with Kartagener's syndrome has an absence of dynein arms at the base of the cilia. The inability of cilia to move results in inadequate clearance of bacteria from the air passages, resulting in an increased risk of infection and causing bronchiectasis. Another result of ciliary immobility is infertility. A 60 years old lady was diagnosed as a case of Kartagener's syndrome. She had history of chronic cough for 20 years, irregular fever for 20 years and occasional shortness of breath for 5 years. Relevant investigations revealed dextrocardia, situs inversus, bilateral maxillary sinusitis with non pneumatised frontal sinus and bronchiectasis. She was treated with low concentration oxygen inhalation, antibiotic, bronchodilator, chest physiotherapy including postural drainage, vitamins and other supportive treatment.

Enterococcal infections & antimicrobial resistance.

Enterococci have traditionally regarded as low grade pathogens, have emerged as an increasingly important cause of nosocomial infections in the last decade. Although about a dozen enterococcus species have been identified, only two are responsible for the majority of human infections, i.e., Enterococcus faecalis and E. faecium. The most common nosocomial infections produced by these organisms are urinary tract infections (associated with instrumentation and antimicrobial resistance), followed by intra-abdominal and pelvic infections. They also cause surgical wound infections, bacteraemia, endocarditis, neonatal sepsis and rarely meningitis. A major reason why these organisms survive in hospital environment is the intrinsic resistance to several commonly used antibiotics and, perhaps more importantly, their ability to acquire resistance to all currently available antibiotics, either by mutation or by receipt of foreign genetic material through the transfer of plasmids and transposons. The emergence of vancomycin-resistant enterococci (VRE) is a cause of concern, as once established, it is very difficult to control. Moreover, there can be transfer of resistant gene from enterococci to Staphylococcus aureus thereby posing a threat to the patient safety and also challenges for the treating physicians. This review highlights the shifting spectrum of enterococcal infections, along with their geographical distribution and growing nosocomial importance. Emergence of antimicrobial resistance, pathogenicity and virulence factors, current preventive, control and treatment modalities of severe enterococcal infections are also dealt with.

Characterization of Streptococcus pneumoniae ophthalmic, systemic & commensal isolates by pulsed-field gel electrophoresis & ribotyping.

BACKGROUND & OBJECTIVE: Streptococcus pneumoniae is common in ocular and systemic infections and is a part of normal nasopharyngeal flora. Very few studies regarding genetic analysis of S. pneumoniae isolates causing eye infections are available. This study was undertaken to do pulse field gel electrophoresis (PFGE) analysis and ribotyping of S. pneumoniae isolates obtained from eye infections, systemic infections and nasopharyngeal flora. METHODS: Sixty one well characterized S. pneumoniae isolates (38 from ophthalmic infections, 9 from systemic infections and 14 commensals) were characterized using PFGE of the whole genome after SmaI, restriction enzyme digestion and conventional ribotyping using Escherichia coli rRNA operon as the probe. Phylogenetic tree was drawn using unweighted pair group method analysis (UPGMA). RESULTS: The 38 S. pneumoniae isolates from eye infections belonging to 15 serotypes were placed in to 11 PFGE types and 15 ribotypes. The 9 systemic isolates (7 seotypes) were distributed in 7 PFGE types and 6 ribotypes. The 14 commensal isolates were placed in 11 serotypes, 5 PFGE types and 6 ribotypes. Most of the PFGE types and ribotypes consisting of ocular isolates also contained systemic and commensal isolates. INTERPRETATION & CONCLUSION: Considerable genetic similarity was observed between the isolates from ocular and systemic infections and those colonized in nasopharynx. PFGE analysis could differentiate majority of the isolates according to site of infections. There was a considerable DNA polymorphism within the studied bacterial population.

Coexistence of carcinoma breast and Paget's disease of bone.

We report a case of a patient with carcinoma breast who was incidentally diagnosed to be also suffering from Paget's disease of bone on a routine radionuclide bone scan. CT-guided biopsy and histopathology later confirmed the diagnosis.

Oxidative stress in benign prostate hyperplasia.

Benign Prostate Hyperplasia (BPH) is the common health problem in ageing male. Free radicals and reactive oxygen species (ROS) are produced more with advancement of age leads to oxidative stress. This study aims to assess Malondialdehyde (MDA), the marker of lipid peroxidation and vitaminic antioxidants e.g. alpha-Tocopherol (Toc) and Ascorbate (Asc) status in plasma of BPH patients. This is a case control study conducted in Department of Biochemistry in collaboration with Dept of Surgery, BPKIHS. Forty eight (n = 48) confirmed patients of BPH and forty six (n = 46) healthy age matched controls were enrolled. Plasma MDA, Asc and alpha-Toc were estimated. Plasma MDA level showed 4.81 +/- 1.87 nmol/ml in BPH patients compared to 3.69 +/- 1.56 nmol/ml in healthy controls (p < 0.001). There were significant decrease in plasma alpha-Toc and Asc level which were 0.85 +/- 0.12 mg/dl and 0.93 +/- 0.13 mg/dl in BPH patients compared to 1.37 +/- 0.31 mg/dl and 1.44 +/- 0.38 mg/dl in healthy controls respectively. Inverse correlation of plasma MDA with a- Toc (r = -0.09) and Asc (r = -0.51) was found in BPH patients. There was mild elevation of PSA in BPH patients compared with control but was not statistically significant. Thus, our study showed the evidence of association of oxidative stress in BPH patients.

Diagnosis of typhoid fever by polymerase chain reaction.

OBJECTIVE: To determine the efficacy of nested polymerase chain reaction (PCR) in detecting Salmonella typhi gene sequences in blood and urine specimens and to determine the cut-off titer of Widal test using PCR as gold standard test for diagnosis of typhoid fever. METHODS: Study included 71 children between the ages of 8 months and 14 years; 52 of them were suspected cases of typhoid fever, 11 were febrile non-typhoid controls and 8 were apparently healthy children. Nested PCR in Blood and Urine, Blood culture, Widal test and Urine culture were done and their results analyzed. RESULTS: Among suspected typhoid cases, PCR in blood and urine had positivity of 82.7% each. Blood culture, Widal test (at cut off titer TO and/or TH > 1:160) and urine culture had positivity of 26.9%, 50% and 3.8% respectively. In one case, urine PCR was positive and blood PCR was negative. Similarly, in another case, PCR in blood was positive however urine tested negative. Considering PCR as gold standard, the antibody cut off titer was evaluated. A cut-off titer of TO > 1:80 and/or TH > 1:160 had sensitivity and specificity of 72.7% and 84.2%, while the respective figures were 50% and 89.5% when the cut-off titer was TO and/or TH > 1:160. CONCLUSION: The sensitivity, specificity, positive and negative predictive values, likelihood ratios were same for PCR based detection of S. typhi in blood and urine samples. Nested PCR had higher efficacy in detecting typhoid fever than Widal test, blood and urine cultures. A cut off titer of TO > 1:80 and/or TH > 1:160 was found to have better diagnostic value in this region.

Clinico-laboratory profile of haemolytic uremic syndrome.

OBJECTIVE: To study the clinical profile, the spectrum of functional abnormalities, prognostic factors and outcome of children with haemolytic uremic syndrome (HUS). MATERIALS AND METHODS: This is a prospective, descriptive, single centre, cohort study, conducted on 42 children during the period of January 2004 to January 2005. RESULTS: The maximum numbers of cases were below 24 months of age with mean age of 26.6 months and male: female ratio of 2.8:1. Most of the cases (79%) occurred in the warmer months (April-September). The common clinical presentations were bloody diarrhoea, pallor, oliguria & anuria, fever, vomiting, abdominal distension and pain, involvement of central nervous system, chest and cardiovascular system and bleeding manifestations. The common haematological abnormalities were leucocytosis, thrombocytopenia, anaemia and features of haemolysis in the peripheral blood. Electrolyte abnormalities observed were in the form of hyponatremia, hypokalemia and hyperkalemia. Arterial blood gas analysis showed metabolic acidosis in 64% cases, where the estimations were done. The mean blood urea and serum creatinine levels were 113.7 mg/dL and 2.5 mg/dL, respectively. Stool examination showed blood in all cases. Urine examination showed microscopic haematuria and significant proteinuria in 74% and 38% cases, respectively. E. coli and Shigella were isolated in stool in three cases each and one case showed mixed growth of E. coli and Salmonella. The mortality rate was 21%. Significantly higher mortality was observed in females, patients presenting with complete anuria, leucocytosis, hyperkalemia and systemic involvement like central nervous system, cardio vascular system and chest. CONCLUSIONS: Female sex, complete anuria, leucocytosis, extra renal involvement and hyperkalemia were associated with poor outcome.

Clinical and Bacteriological Profiles of Blood Culture Positive Sepsis in Newborns.

Neonatal infections currently cause about 1.6 million deaths annually in developing countries1. Sepsis and meningitis is responsible for most of these deaths. This study was undertaken to determine the clinical presentations, bacteriological profiles and antibiotic sensitivity patterns of isolates from blood cultures of neonates admitted in a tertiary care hospital in Eastern Nepal. All blood culture reports (n=103) during January 2006 - February 2007 from newborns admitted in neonatal division at BP Koirala Institute of Health Sciences, Nepal were analyzed and antibiotic sensitivity patterns were studied. The positive blood culture was 20% (103/513). Most (97.1%) of the sepsis was caused by single organism, while polymicrobial aetiology was observed in 2.9% cases. Meningitis was documented in 9(8.7%) cases. Staphylococcus aureus (38.8%) and coagulase negative staphylococcus (CONS) (21.3%) are the commonest isolates in blood culture. Among gram-negative organisms, Klebsiella species (11.6%) and Enterobacter species (9.7%) were the leading cause of neonatal sepsis. Majority of newborns with neonatal sepsis presented with refusal to feeds (42.7%), fever (41.7%) and jaundice (41.7%). Most of the organisms showed sensitivity with amino glycosides (gentamicin and amikacin) and third generation cephalosporins. It is concluded that Staphylococcus aureus, CONS, and Klebsiella species remain the principal organisms causing neonatal sepsis and first line antibiotics like amino glycosides should be first choice of drugs.

Altered serum levels of thyroxine, triiodothyroinine and thyroid stimulating hormone in patients with depression.

OBJECTIVE: To assess serum level of Thyroxine (T4), Triiodothyronine(T3) and thyroid stimulating hormone(TSH) in patient with depression. METHODS: Thirty one clinically diagnosed depressed patients and equal number of healthy, age and sex matched control subjects were included in this study. Ham-D scale was used to classify the degree of depression into mild, moderate and severe grades. The biochemical parameters (T3, T4 and TSH) were estimated using commercially available kits. The data were analyzed by using (SPSS-10 software), one way ANOVA and chi2 test. RESULT: Female depressed (n=17) cases outnumber the male depressed cases. The distributions of patients in mild, moderate and severe categories were similar. The T3 and T4 level were found to be significantly raised in the moderate depression as compared to the healthy controls. ANOVA with multiple comparisons testing among the patient group showed a significant high TSH level (F>3.17) at 5% level of significance. A total of six depressive patients were found to have thyroid abnormalities. CONCLUSION: This study therefore points towards presence of thyroid dysfunction among the depressive which most often characterized as a "Lower Thyroid Syndrome". Thus inclusion of thyroid screening test among depressive patients may be helpful in proper management of cases.

Acid base and electrolyte disturbance in diarrhoea.

OBJECTIVE: The present study was undertaken to study the frequency of electrolyte imbalance in children with diarrhoea and the relationship between electrolyte abnormalities and mortality. MATERIALS AND METHODS: This is a retrospective, observational hospital based study. Fifty seven children admitted to paediatric ward with diarrhoea and dehydration was evaluated for electrolyte and acid base status at presentation. The variables were analyzed using chi-square and student t- test. RESULTS: Majority (70%) of patients were below 2 years of age. There were 37 (65%) males and 20(35%) females. Electrolyte disturbance was observed in 46 (80%) patients while acid base disturbance was observed in all (100%) where the estimations were done. The major electrolyte disturbances noted were hyponatremia (56%), which was either isolated (26%) or associated with hypokalemia (26%). The second common abnormality was hypokalemia (46%) which was again either isolated (14%) or associated with hyponatremia (26%). About 10% patient had hypernatremia and about 3% had hyperkalemia. Twenty one (37 %) patients had mixed electrolyte imbalance. ABG analysis was performed only in 16 patients. Arterial blood gas analysis could be performed only in 16 patients. Metabolic acidosis was present in 15 (94%) while one (6%) had metabolic alkalosis. Out of 57, five patients (8.7%) expired. All of them had electrolyte abnormalities. Out of five patients who died one had isolated hyponatremia, 2 had hyponatremia + hypokalemia, while one each had hypernatremia + hypokalemia and hypernatremia+ hyperkalemia. Statistically significant mortality was observed in patients presenting with either hyponatremia or hypokalemia as compared to the group with normal electrolytes. CONCLUSION: Hyponatremia, hypokalemia and metabolic acidosis are common electrolyte and acid-base abnormalities in children with diarrhoea and dehydration and often responsible for mortality.

Pyrexia of unknown origin with neutropenia, cervical lymphadenopathy, pneumonia and marrow hypoplasia.

A 56 years adult male presented with fever for 3 weeks with neutropenia and cervical lymphadenopathy with left sided pneumonitis. Histopathology of lymphnode was consistent with Kikuchi's Necrotizing Lymphadenitis. Kikuchi's disease is usually a self- limiting illness characterized by pyrexia, neutropenia and cervical lymphadenopathy in young women of Asian decent. This often leads to the misdiagnosis of lymphoma or tuberculosis. The notable feature here is an older male presented with severe neutropenia and pneumonia with hypoplastic marrow.