rare case of Kikuchi-Fujimoto Disease associated with systemic lupus erythematosus

Kikuchi-Fujimoto Disease [KFD], also known as histiocytic necrotizing lymphadenitis, is a self-remitting, immune-mediated rare disorder having unique histopathological characteristics which is commonly seen in young Asian females, but can occur in all ethnicities. There is a strong association between KFD and Systemic Lupus Erythematosus [SLE]. We present a case of a young Pakistani boy who presented with cervical lymphadenopathy, fever, blackish discoloration of finger tips, and Raynaud's phenomenon. His lymph node biopsy was suggestive of KFD. The American Rheumatology Association diagnostic criteria were not met as no other features of SLE were present. His autoimmune workup including Anti-Nuclear Antibodies [ANA] and Anti-Double Stranded DNA [Anti-Ds DNA] antibodies were positive and supported the diagnosis of SLE. He improved clinically with steroid therapy and nifedipine with resolution of symptoms

Hearing impairment after acute bacterial meningitis in children

Objective: To determine the incidence of hearing loss after acute episode of meningitis in children

Methods: A descriptive study carried out in the Department of Pediatric Medicine of The Children's Hospital Lahore, Pakistan from January 2014 to July 2016. A total of 175 children one month to 13 years of age admitted with diagnosis of meningitis were included. Complete blood count, CSF cytology, biochemistry and culture sensitivity were sent. CT scan brain was done if required. Hearing assessment was done two weeks after admission using otoacoustic emissions in the patients having normal tympanogram. Hearing impairment was classified as sensorineural if otoacoustic emissions were absent while tympanometry was normal

Results: Of 175 children, 58% were males and 42% were females. Mean age was 2.1 years. Orientation as assessed by Glasgow comma scale [GCS] was normal in 63% while 5% had GCS<8 and 32% had GCS between 8 and 15. Signs of meningeal irritation were seen in 58% while focal signs only in 4%. In 15 % cases CT scan was done, out of which 73% showed abnormal findings. Otoacoustic emissions were absent in 22% of cases. Risk factors of hearing deficit were stay duration of more than 10 days [p=0.04], low GCS at presentation [p=0.009] and meningitis with complications [p=0.008]

Conclusion: The frequency of hearing loss is 22% following acute episode of meningitis which necessitates the need for implementation of screening assessment after meningitis in Pakistan. Prolonged stay, low GCS and complicated meningitis are risk factors for hearing impairment

Insights into the intracellular mechanisms of citronellal in Candida albicans: implications for reactive oxygen species-mediated necrosis, mitochondrial dysfunction, and DNA damage

Abstract INTRODUCTION Citronellal (Cit) possesses antifungal activity and has possible implications for reactive oxygen species (ROS) generation in Candida albicans. In this study, the effects of Cit on ROS generation and the mechanisms by which Cit exerts anti-Candida effects were examined. METHODS A 2′,7′-dichlorodihydrofluorescein diacetate assay was used to assess oxidative damage. Cell necrosis was determined by flow cytometry after FITC-Annexin V staining. Mitochondrial function was studied based on mitochondrial potential, metabolic activity (MTT assay), and phenotypic susceptibility on a non-fermentable carbon source. Membrane intactness and DNA damage were estimated by a propidium iodide (PI) uptake assay and 4',6-diamidino-2-phenylindole (DAPI) staining. RESULTS ROS generation was enhanced in response to Cit, leading to necrosis (2%). Additional hallmarks of cell death in response to Cit, such as mitochondrial membrane depolarization and DNA damage, were also observed. Cit treatment resulted in dysfunctional mitochondria, as evidenced by poor labeling with the mitochondrial membrane potential-sensitive probe rhodamine B, reduced metabolic activity (61.5%), and inhibited growth on a non-fermentable carbon source. Furthermore, Cit induced DNA damage based on DAPI staining. These phenotypes were reinforced by RT-PCR showing differences in gene expression (30-60%) between control and Cit-treated cells. Finally, PI uptake in the presence of sodium azide confirmed non-intact membranes and suggested that Cit activity is independent of the energy status of the cell. CONCLUSIONS Cit possesses dual anticandidal mechanisms, including membrane-disruptive and oxidative damage. Taken together, our data demonstrated that cit could be used as a prominent antifungal drug.

Correlation between maternal and childhood VitB12, folic acid and ferritin levels

Objective: To determine the correlation between serum folic acid, vitamin B12 and ferritin of mother and child and to study various neonatal risk factors as a cause of anemia in children

Methods: One hundred eighty children two months to two years of age admitted in the department of Pediatric Medicine of The Children's Hospital and The Institute of Child Health Lahore from January 2013 to January 2015 with common medical conditions having anemia were included. Complete blood count [CBC], serum ferritin level, folic acid and Vitamin [Vit] B12 level were sent of children and their mothers. Data was analyzed using SPSS version 20

Results: Out of 180 children with anemia, 66.7% were males. Mean age of children was 7.3months. Fifty-five percent children were malnourished according to z scoring. The mean Hemoglobin [Hb] of children was 8 g/dl. Only 4% children had low ferritin level while 60% had low folic acid and 45% had decreased VitB12. There was significant correlation between Hb of mother and child [p =0.02], Vit B12 deficiency [p=0.008] and iron deficiency [p<0.001]. Premature children had lower folic acid levels [p =0.02], while prematurity, IUGR, previous admission and history of sepsis showed no association with anemia in our study. Both breast-feeding and top feeding showed significant association with anemia with p-value of 0.042 and 0.003 respectively while dilution showed no impact on anemia

Conclusion: Maternal anemia has a significant impact on child's hemoglobin. As compared to previous concept of increased iron deficiency in children we found increased occurrence of folic acid and VitB12 deficiency in children and their mothers

Acute bacterial meningitis in children presenting to the children's hospital Lahore before and after pneumococcal vaccine in Pakistan national immunization program; a comparison

Objective: To describe bacteriological profile, morbidity and mortality of acute bacterial meningitis [ABM] in children and to compare these parameters before and after the introduction of Pneumococcal vaccine in Pakistan National Immunization Program

Methods: The present descriptive study was conducted at the Department of Paediatric Medicine of The Children's Hospital Lahore from January 2012 to December 2015. A total of 503 children one month to five years of age admitted with diagnosis of meningitis were included. Complete blood count, CSF cytology, biochemistry, culture sensitivity and blood culture sensitivity were performed

Results: Frequency of meningitis decreased by 50% in 2013-2015 [199 [2012] vs 304 [2013-2015]. Most children in both groups were under one year of age. More neurological complications were seen in the group 2, 20% vs 17%. CSF culture positivity decreased from 12% to 6.6%. Streptococcus pneumoniae isolation decreased from 5 [2.5%] in 2012 to 4 [1.3%] in 2013-2015. Refusal to take feed [p=0.002], impaired sensorium [p=<0.001], severe malnutrition [p=0.001], prolonged duration of symptoms [p=<0.001] and incomplete vaccination status [0.005] were associated with mortality. Mortality rate decreased from 20 [10%] in 2012 to 17 [5.6%] in 2013-2015 but more children developed neurological sequelae 2.7% versus 1%

Conclusion: Acute bacterial meningitis mostly affected children <1 year. Frequency of Streptococcus pneumoniae and mortality of meningitis decreased significantly after PCV but more neurological complications developed in those children who were unvaccinated in 2013-2015 compared to 2012

Influence of iron deprivation on virulence traits of mycobacteria

ABSTRACT Novel strategies to combat the ever increasing burden of drug resistance in Mycobacterium tuberculosis (MTB) causing tuberculosis (TB) remains a global concern. The ability of MTB to sense and adapt to restricted iron conditions in the hostile environment is essential for their survival and confers the basis of their success as dreadful pathogen. The striking and clinically relevant virulence trait of MTB is its ability to form biofilms and adhere to the host cells. The present study elucidated the effect of iron deprivation on biofilm formation and cell adherence of Mycobacterium smegmatis, a non-pathogenic surrogate of MTB. Firstly, we showed that iron deprivation leads to enhanced cell sedimentation rate and altered colony morphology depicting alterations in cell surface envelope properties. We explored that biofilm formation and cell adherence to polystyrene surface as well as human oral epithelial cells were considerably reduced under iron deprivation both in presence of 2,2 BP (iron chelator) and siderophore mutant Δ011-14 strain. We further investigated that the potency of three first line anti-TB drugs (Isoniazid, Ethambutol, Rifampicin) to inhibit both biofilm formation and cell adhesion were enhanced under iron deprivation in contrast to the drugs when tested alone. Taken together, by virtue of the indispensability of iron for functional virulence traits in mycobacteria, iron deprivation strategies could be further exploited against this notorious human pathogen to explore novel drug targets.

Citronellal-induced disruption of membrane homeostasis in candida albicans and attenuation of its virulence attributes

Abstract: INTRODUCTION There is an increasing burden of multidrug resistance. As a result, deciphering the mechanisms of action of natural compounds with antifungal activity has gained considerable prominence. We aimed to elucidate the probable mechanism of action of citronellal, a monoterpenoid found in the essential oil extracted from Cymbopogon plants, against Candida albicans. METHODS Drug susceptibility was measured by broth microdilution and spot assays. Ergosterol levels were estimated using the alcoholic potassium hydroxide method and H+ extrusion was assessed by monitoring the glucose-induced acidification of the external medium. Virulence traits were studied by hyphal morphogenesis and biofilm formation, along with fungal cell adherence to polystyrene surface and human oral epithelial cells. RESULTS Citronellal showed anticandidal activity against C. albicans and non-albicans species of Candida at a minimum inhibitory concentration of 1 mg/ml. Citronellal interfered with membrane homeostasis, which is the major target of known antifungal drugs, by increasing the hypersensitivity of the fungi to membrane-perturbing agents, reducing ergosterol levels, and diminishing glucose-induced H+ extrusion. In addition, oxidative and genotoxic stresses were induced via an increased production of reactive oxygen species. Furthermore, citronellal inhibited the virulent attributes of yeast-to-hypha transition and biofilm formation. It also reduced cell adherence to polystyrene surface and the human oral epithelial cells. CONCLUSIONS This is the first study to propose the cell membrane, morphogenetic switching, biofilm formation, and cell adherence of Candida albicans as potential targets for the anticandidal activity of citronellal. However, clinical investigations on the therapeutic applications of citronellal are required.

Childhood acute bacterial meningitis: clinical spectrum, bacteriological profile and outcome

Objective: To determine the disease pattern, etiological agents and outcome of childhood acute bacterial meningitis. Study Design: A descriptive study. Place and Duration of Study: Department of Paediatric Medicine. The Children's Hospital. Lahore, from January to December 2012

Methodology: A total of 199 children between the ages of 1 month and 5 years, admitted with the diagnosis of meningitis on the basis of clinical findings and positive cerebrospinal fluid [CSF], were included. In all patients, complete blood count [CBC], CSF culture sensitivity, and blood culture sensitivity were performed. Data was analysed using SPSS version 20

Results: Out of 199 children. 127 [63.8%] were males with M:F ratio of 1.7:1. Mean age was 11.33 +/-12 months. Maximum numbers of children were < 1 year of age, 136 [68.3%]. Only 90 [45.2%] children were fully vaccinated according to Expanded Program of Immunisation [EPI] schedule. Presentations with refusal to take feed [p=0.008] and with impaired conscious state were independent predictors of death [p=0002]. Complications were noted in 34 [17%] and were significantly associated with severe malnutrition [p=0.006] and altered conscious level at presentation [p<0.001]. The common pathogens identified on CSF culture were coagulase negative staphylococci [CoNS] in 11 [5.5%] and streptococcus pneumoniae in 5 [2 5%]. Overall mortality was 10.1%. The commonest pathogen isolated from children who died was streptococcus pneumoniae [p=0.039]

Conclusion: Acute bacterial meningitis mostly affected children under the age of 1 year. CSF culture revealed both Gram- positive and Gram-negative bacteria. The most common pathogen in children who died was streptococcus pneumoniae

Association of SNP rs9939609 in FTO gene with metabolic syndrome in type 2 diabetic subjects, rectruited from a tertiary care unit of Karachi, Pakistan

To determine the association of SNP in FTO gene, rs9939609, with Metabolic Syndrome [MS] in type 2 diabetic subjects at a tertiary care unit of Karachi, Pakistan. We genotyped FTO rs9939609 SNP in 296 patients with type 2 diabetes from the Out Patient Department [OPD] of Baqai Institute of Diabetology and Endocrinology [BIDE]. MS was defined on the basis of International Diabetes Federation [IDF] and National Cholesterol Education program [NCEP]criterion. Association between the rs9939609 SNP and MS was tested through chi-square and Z-tests by using odds ratio [OR] with 95% confidence intervals. The frequency of MS as defined by IDF criterion was significantly higher in female subjects as compared to male subjects [p= 0.006]. Carriers of ? 1 copy of the rs9939609 A allele were significantly more likely to had MS [69.6%] than non-carriers [30.4%], corresponding to a carrier odds ratio [OR] of 0.52 [95% confidence interval [CI] [0.29-0.93], with a similar trend for the ATP III-defined MS."A" allele carriers under dominant model, carry all the criterion of MS more significantly as compared to non-carriers. The FTO rs9939609 SNP was associated with an increased risk for Metabolic Syndrome in type 2 diabetic populations at a tertiary care unit of Karachi, Pakistan

Yield of suprapubic aspirate versus bag collection in diagnosis of UTI in children 0 to 6 months of age

Objective: To evaluate the accuracy of urine sample collection methods among children suspected of having urinary tract infection

Subjects and Methods: Urine samples were collected in infants 0-3 months of age presenting with features of sepsis. Two methods of collection were used, one was bag attached to perineal skin and the other was suprapubic aspirate. Within 30 minutes of collection, all specimens were sent to the laboratory, refrigerated and processed according to standard hospital microbiological procedures. Urine samples were analyzed using routine culture technique

Setting: This cross sectional study was conducted at Shaikh Zayed hospital Lahore. The duration of study was six months. A total of 100 cases fulfilling the inclusion criteria were included in this study. Results were analyzed according to SPSS 16

Results: Out of 100 patients [n=100] 17 had positive bag culture, only 4 out of 17 had culture positive by SPA, so there were 13 false positives while using bag collection method

Conclusion: Suprapubic aspiration showed the positive yield in 4 SPA which does not indicate contamination and sterile urine bag showed the highest contamination rate among the two methods of urine sample collection. So urine bag leads to unnecessary treatment burden on the child and family. There fore we cannot rely on bag samples for diagnosis of urinary tract infections specially the bag collection method because the specificity of bag collection method is very low

Frequency of meningitis among children 6-18 months of age with first episode of fever and fit

Objective: to determine the frequency of meningitis in children, 6 to 18 months of age, presenting with first episode of fit and fever

Study Design and Setting: this was a descriptive case series performed as a cross sectional survey carried out in the Department of Paediatrics, Sheikh Zayed Hospital Lahore

Patients and Methods: this study was; carried out from 1-04-2009 to 30-03-2010. 423 patients, who fulfilled the inclusion criteria, were selected for this study. Blood glucose was recorded before lumbar puncture to compare with CSF glucose. CSF was sent for analysis of protein, glucose and white blood cell count to assess the presence of meningitis

Results: mean age of the patients was 11.9+/-3.5 months with age range of6 to 18 months. There were 262 [62%] males and 161 [38%] female patients. The mean blood sugar at the time of lumbar puncture was 104.8+/-10.9 mg/di. There were 9 [2%] patients who had raised CSF leucocyte count, 9[2%] patients h11d raised CSF protein and 9 [2%] patients had reduced CSF Glucose There were 9 [2%] patients who had meningitis so frequency of meningitis was 2% in our population under study

Conclusion: frequency of meningitis in children presenting with first episode of fit and fever in the absence of any other symptoms is very low. Majority of children are, therefore, cases of simple febrile seizures rather than meningitis. It is suggested that unuecessary lumbar puncture can be avoided as this invasive procedure has its own complications