Emergence of decreased susceptibility to extended-spectrum cephalosporins in Neisseria gonorrhoeae in India.

Background. In the past, Neisseria gonorrhoeae has developed resistance to antimicrobial agents used for its treatment. Consequently, extended-spectrum cephalosporins form the mainstay of treatment for gonorrhoea. Methods. Samples from 88 patients attending the sexually transmitted diseases clinics from December 2009 to January 2011 in two referral hospitals in New Delhi were studied. Antimicrobial susceptibility testing was done using the disc diffusion method as per the calibrated dichotomous sensitivity technique against the following antibiotics: penicillin (0.5 i.u.), tetracycline (10 μg), nalidixic acid (30 μg), ciprofloxacin (1 μg), spectinomycin (100 μg), ceftriaxone (0.5 μg) and cefpodoxime (10 μg) (Oxoid UK). Azithromycin (15 μg) (Oxoid, UK) was tested as per the guidelines of the Clinical and Laboratory Standards Institute. Minimum inhibitory concentrations were determined using the Etest for penicillin, tetracycline, ciprofloxacin, ceftriaxone, spectinomycin and azithromycin as per the manufacturer’s instruction (Biomerieux, France). Results. Eighteen isolates of Neisseria gonorrhoeae were obtained. Three of these had decreased susceptibility to ceftriaxone and cefpodoxime by the disc diffusion method. The minimum inhibitory concentrations of ceftriaxone for two isolates were 0.064 μg/ml and for one isolate it was 0.125 μg/ml. Conclusion. Higher minimum inhibitory concentrations to extended-spectrum cephalosporins is of concern as it has been shown to precede treatment failure. This may warrant its use in increased/multiple dosages alone or possibly in combination (dual therapy), thereby complicating effective disease control. Our report is in accordance with earlier reports from different parts of the world. Therefore, a continuous surveillance of antimicrobial resistance is crucial to tailor treatment schedules for Neisseria gonorrhoeae in a particular geographical region.

An open labeled, comparative clinical study on efficacy and tolerability of oral minipulse of steroid (OMP) alone, OMP with PUVA and broad / narrow band UVB phototherapy in progressive vitiligo.

BACKGROUND: Several modalities of treatment have been tried in vitiligo with varied results; however, Indian data on comparative studies of two or more therapies are limited. AIMS: We compared different phototherapy methods with an oral steroid as an adjunct to determine the method with the best tolerability and efficacy. METHODS: Eighty-six patients with progressive vitiligo were randomly assigned to different study groups according to a continuous selection method over a period of one year. Group 1 was given OMP + PUVA, group 2 OMP + UVB (NB), group 3 OMP + UVB (BB) and group 4 was given OMP alone. Each patient was followed up for six months and then released from treatment. Clinical evaluation was made at the end of three and six months. RESULTS: In group 1 (OMP + PUVA), marked improvement was seen in 18.51% while moderate improvement was seen in 66.66% of the patients. Marked improvement was seen in 37.03% in group 2 (OMP + NB-UVB) while 44.44% had moderate improvement. In group 3 (OMP + BB UVB), 8.33% showed marked improvement while moderate improvement was seen in 25% of the patients. Marked and moderate improvement was seen in 5 and 10% of group 4 (OMP) patients, respectively. CONCLUSIONS: Our study compared four treatment modalities in vitiligo patients, out of which oral minipulse of steroids (OMP) only had an adjunct value and was not very effective by itself. Narrow band UVB has a definite edge over broad band UVB and should be preferred when both options are available. NB-UVB and PUVA showed comparable efficacy.

Oral ulcer as an unusual feature of visceral leishmaniasis in an AIDS patient.

Leishmaniasis, a globally prevalent parasitic disease, occurs in three forms, viz, visceral, cutaneous and mucocutaneous. It is transmitted by female Phlebotomus sandflies. Human immunodeficiency virus (HIV) infection is increasing worldwide and several reports indicate a rising trend of VL / HIV co-infection, modifying the traditional anthroponotic pattern of VL transmission. India is one of the countries having the largest burden of leishmaniasis; nevertheless, there are very few HIV / leishmania co-infection cases reported so far. We report a 35-year-old homemaker infected with the human immunodeficiency virus; she presented with an oral ulcer. The investigations carried out on her revealed that she was afflicted by visceral leishmaniasis and the oral ulceration was a part of the same. This is only the second such case from the Indian subcontinent and more significantly from a non-endemic area.

Does concomitant hiv infection has any epidemiological, clinical, immunopathological and therapeutic relevance in leprosy?

Co-infection with HIV-1 and M. Leprae is a rare event in endemic areas for leprosy and HIV, such as India. Neither an increased HIV prevalence among leprosy cases, nor any rapid progression to AIDS was observed among dual HIV-leprosy infections. The current situation concerning continued new leprosy case-detection and gradual increase in HIV infection in India and a few other developing countries, such as Brazil, emphasizes the importance of monitoring the occurrence of co-infections. There is so far no change in the clinical spectrum of leprosy, PB/MB ratio, leprosy reactions and neuritis among co-infected patients. All types of leprosy occur in HIV patients [except in one study (Borgdorff et al, 1993) where more MB leprosy cases with HIV infection were seen]. Histopathological observations reveal a normal spectrum of appearance in biopsies of leprosy lesions from co-infected patients suggesting that cell-mediated immune response to M leprae is preserved at the site of the disease, despite evidence that these responses are abrogated systemically. All dual infection cases respond to regular treatment, except in three studies which noted more relapses. Therefore, a longer duration of surveillance is advisable after fixed duration therapy, for the detection of early relapse. Type 2 reaction can be managed with a higher dose of clofazimine. Type 1 reaction when developed as such, or as IRIS, needs oral steroids in adequate doses, particularly when associated with neuritis and motor loss, since lower doses may not be able to reverse the motor loss even of early onset. However, higher doses of corticosteroid when given need to be monitored closely. The impact of immune restoration in co-infected patients receiving ART is commonly observed in cases with borderline leprosy.

Angiosarcoma of scalp: a case report.

Cutaneous angiosarcomas are rare and constitute less than 1% of all malignant mesenchymal tumours. Most angiosarcomas of skin arise in the following clinical settings: 1. face and scalp of elderly 2. following lymphoedema and 3. post radiation. We present a case of an elderly man presenting with scalp lesion of 18 months duration. Histological examination of the biopsy revealed features of an angiosarcoma, which showed imunohistochemical positivity for factor VIII related antigen.

Late-onset polymyositis in a case of poikilodermatomyositis.

A case of poikiloderma developed polymyositis ten years after the onset of skin changes. This rare case of poikilodermatomyositis, hitherto not reported from Asian continent, is documented.

Leprosy in HIV infection: a study of three cases.

The course of leprosy in patients with HIV infection has been a controversial issue for a long time. It is still a matter of debate whether the HIV status of an individual has any impact on the natural history of leprosy and response to anti-leprosy treatment. We report here three HIV-positive leprosy cases (two BT and one BB) along with their CD4 counts and HIV staging with anti-leprosy therapeutic response. Both BT cases responded well to conventional WHO MDT (PB) for 6 months, whereas the BB case relapsed 3 months after completion of MDT (MB) for one year. However, he became inactive again following a further one-year course of MDT (MB).

Efficacy of beta-carotene topical application in melasma--an open clinical trial.

Beta-carotene, a structural analogue of vitamin A, works as an agonist of this vitamin, by reversibly sticking the chemical mechanism of melanogenesis by saturating the nuclear receptors of melanocytes and/or binding protein. To study the safety and efficacy of Beta-carotene lotion on topical application in melasma, clinically diagnosed 31 adults (26F and 5M) with melasma were included in this trial. All of them applied Beta-carotene lotion daily, morning and evening to the affected areas. Twenty six of them, completed regular 8 weeks treatment. Nine of them continued same treatment for 16 more weeks. All cases were evaluated clinically using melasma intensity (MPI) index (Grade I, II, III) and size of the lesion. Clinical photograph was taken for each case at 0 week, 8th week and 24th week. Initial 8 weeks treatment revealed that the single case with grade-I pigmentation included in this study recovered completely. Two out of 13 cases with grade-II pigmentation, showed no change, in 10 cases, pigmentation became lighter to grade-I (76.9%) and one case recovered completely. Out of 12 grade-III cases, one did not show any change, 10 (83.3%) converted to grade-II and one to grade-I. At the end of 24 weeks, all the nine cases (2 grade-II and 7 grade-III) showed further clearing of the pigmentation to the next lower grade. Side effects like mild erythemo and local irritation were observed in two cases each, who were advised to discontinue treatment as per the protocol. In control group, out of 12 (two with grade-II, six in grade-II, and four in grade-III) cases 11 showed no improvement, only one case with grade-II melasma revealed reduction of pigmentation to grade-I. One case developed local irritation. In conclusion, topical application of Beta-carotene lotion appears to be an effective and safe for melasma. Longer duration of application is associated with better result.

Histoid leprosy with ENL reaction.

A 23-year old man presented with firm cutaneous and subcutaneous nodules of histoid leprosy. Some of the nodules suppurated after multidrug therapy (MDT) and these nodules showed features of erythema nodosum leprosum (ENL) on histopathological examination. ENL is a rare phenomenon observed in histoid leprosy.

Efficacy of beta-carotene topical application in melasma: an open clinical trial.

B-carotene, a structural analogue of vitamin A, works as an agonist of this vitamin, by reversibly sticking the chemical mechanism of melanogenesis by saturating the nuclear receptors of melanocytes and/or binding protein. To study the safety and efficacy of b-carotene lotion on topical application in melasma, clinically diagnosed 31 adults (26F and 5M) with melasma were included in this trial. All of them applied b-carotene lotion daily, morning and evening to the affected areas. Twenty six of them completed regular 8 weeks treatment. Nine of them continued same treatment for 16 more weeks. All cases were evaluated clinically using melasma intensity (MPi) index (Grade I, II, III) and size of the lesion. Clinical photograph was taken for each case at 0 week, 8th week and 24th week. Initial 8 weeks treatment revealed that the single case with grade-I pigmentation included in this study recovered completely. Two out of 13 cases with grade-II pigmentation, showed no change, in 10 cases, pigmentation became lighter to grade-I (76.9%) and one case recovered completely. Out of 12 grade-III cases, one did not show any change, 10 (83.3%) converted to grade-II and one to grade-I. At the end of 24 weeks, all the nine cases (2 grade-II and 7 grade III) showed further clearing of the pigmentation to the next lower grade. Side-effects like mild erythema and local irritation were observed in two cases each, who were advised to discontinue treatment as per the protocol. In conclusion, topical application of b-carotene lotion appears to bean effective and safe for melasma. Longer duration of application is associated with better result.

Epidemic dropsy: a study of cutaneous manifestations with histopathological correlation.

Clinical and histopathological features of epidemic dropsy were studied in 19 patients. Bilateral pitting pedal oedema, erythrocyanosis and tachycardia without fever were the predominant clinical features. Histology revealed deposition of hyaline material on the walls of dermal blood vessels.

Abdominal hernia following abdominal herpes zoster.

We report a case of abdominal hernia in TIO and 11 segments following herpes zoster at T11 segment.

Disabilities in multibacillary leprosy patients: before, during and after multidrug therapy.

One hundred fifty-one patients (125 males and 26 females) of multibacillary leprosy (LL 88, BL 40, BB 23), registered during 1986-1992 for multidrug therapy (MDT), were analysed with reference to their disabilities before, during and after MDT. At induction 48 (31.7%) had no disability (Gr 0), 59 (39.0%) had only peripheral anaesthesia (Gr 1) and 44 (29.1%) had Gr 2 and 3 deformities with or without anaesthesia. The parallel analysis of the three groups, with nearly equal duration of symptoms, revealed that new deformities developed in only a few cases during and after MDT, least in the Gr 0 group. The crude fresh deformity incidence was 59.2 per 1,000 person years of observation. The rate of recovery from anaesthesia was higher (64%) in Gr 1 group than that (44%) in group with Gr 2, 3 deformities. No significant difference was observed between the incidence of Gr 2 deformities developed before, during and after MDT (incidence of claw-hands 9.2% before and 7.9% during and after MDT, trophic ulcers 13.9% before and 17.8% during and after MDT). Out of 19 cases which developed motor weakness during MDT and follow-up, 10 (52.6%) were instances of quite nerve paralysis. Occupational factors influenced the development of deformities but not the sex and bacterial load. Generally, the lower the Grade of disability at induction of patient for MDT, the lower the chances of new disability development and higher the chances of recovery from sensory impairments.

Induction of lepromin positivity by a candidate anti-leprosy vaccine Mycobacterium w in lepromin negative healthy contacts of multibacillary leprosy patients.

In a hospital based study, 362 household contacts of multibacillary leprosy patients were screened for evidence of leprosy and 54 (14.9%) were found to be having leprosy. The remaining 308 apparently healthy contacts were lepromin tested and 109 (35.4%) were observed to be negative to Mitsuda lepromin. M.w vaccine was administered intradermally to 95 of these 109 lepromin negative contacts. Sixty eight of them could be retested for lepromin A reactivity. Fifty six (82.35%) manifested lepromin conversion. The twelve subjects who did not show lepromin conversion, received a second dose of the vaccine, and eleven subsequently became lepromin positive. The overall lepromin conversion rate was thus 98.5% (67 out of 68). Follow-up of these contacts upto a period of 30 months did not demonstrate reversion of lepromin positivity back to negativity status. No untoward effects of vaccination were observed except for local ulceration at the site of vaccine administration.

Type 1 (reversal) lepra reaction in borderline leprosy with unusual clinical presentation--a case report.

A male 26 years old patient with BB type of leprosy was encountered with a typical clinical presentations of up-grading (reversal) Type 1 Lepra Reaction. These included sudden appearance of tender, erythematous nodular eruptions mimicking ENL, severe constitutional symptoms like high grade fever, malaise, vomiting, epistaxis, joint pain and tenosynovitis simulating Type 2 Lepra Reaction. To the best of our knowledge, this may be the first such case in our hand.

Evaluation of levamisole, an immunopotentiator, in the treatment of lepromatous leprosy.

Twenty subpolar lepromatous leprosy patients under multidrug therapy for a period of 1 to 3 years, who continued to be bacteriologically positive (BI 2 to 1 in Dharmendra's grade) were taken in the study. Ten cases (trial group) were given levamisole as an immuno-stimulator for 1 year along with chemotherapy. Another 10 cases (control group) continued to take chemotherapy alone. There was no conversion of Mitsuda reactivity in any of the cases from both the groups. There was no improvement of leucocyte migration inhibition in either group. In both trial and control groups, statistically significant clinical and bacteriological improvements and increase of E. rosette counts are found at the end of one year. However, only the bacteriological improvement in the trial showed statistical significance, when the improvements were compared with those of the control group. No adverse effect due to levamisole therapy was encountered.

Anaerobic flora in trophic ulcers in leprosy patients.

Material from 108 trophic ulcers from leprosy cases were studied bacteriologically. 4 cases showed growth of pure anaerobes and 69 showed mixed growth of aerobic and anaerobic bacteria. The predominant anaerobes were Fusobacteria (41), anaerobic cocci (30) and Bacteroides (25). Clostridia were isolated only in 10 cases. Metronidazole, chloramphenicol, penicillin and ampicillin were found effective against anaerobes in in-vitro studies.

Hepatitis and multi-drug therapy in leprosy with special reference to prothionamide.

Hepatotoxicity in two drug regimens was studied at Central Leprosy Teaching and Research Institute, Chengalpattu (Tamil Nadu) during 1983-84. In 'P' regimen-prothionamide 350 mg daily, dapsone 100 mg daily and rifampicin 600 mg at monthly intervals were given. In' C' regimen-dapsone 100 mg daily, rifampicin 600 mg once a month and clofazimine 300 mg once a month and 100 mg alternate day were given. Trial was started with fifty multibacillary adult leprosy patients in each group. Enzymatic hepatic dysfunction was noted in 52-58 per cent of the cases even before the therapy was started. In 'P' regimen, four cases of clinical jaundice and six cases of high bilirubinaemia was noticed during the trial as against two cases each of clinical jaundice and high bilirubinaemia in 'C regimen. Of the two cases of clinical jaundice in 'C' regimen, one turned out to be a case of HBV infection. The study which is in progress, indicated higher hepatotoxicity in 'P' regimen which is probably explained by the simultaneous use of two hepatotoxic drugs. Viral hepatitis is endemic in this area and might have aggravated the hepatotoxicity observed.

Reversible acute renal failure due to monthly administration of rifampicin in a leprosy patient.

Special complications due to intermittent rifampicin administration have been well documented, specially for the treatment of tuberculosis. Multi-drug therapy recommended for the treatment of leprosy by W.H.O. (1982) advocates the administration of rifampicin at monthly interval and at this level of infrequent administration, complications linked with intermittent therapy are seldom noted. An adult male put on W.H.O. regimen for the treatment of lepromatous leprosy developed acute renal failure at the time of second and third monthly doses of rifampicin therapy, but recovered completely due to prompt treatment.

Gynaecomastia in leprosy in three districts of Tamil Nadu.

The prevalence of Gynaecomastia (GM), a well known complication of leprosy in adult male patients was studied in 790 cases of whom 641 were the inmates of five leprosy hospitals and the remaining 149 mostly from the clinics of field area attached to the Central Leprosy Teaching and Research Institute, Chengalpattu during 1982-83. The overall prevalence rate was found to be 19.24%. Among the hospitalised patients, it was 22.15% against 6.71% among the patients attending the clinics in the field area. The youngest and the oldest patient in this study was 16 years and 83 years respectively. The highest rate of 32.89% was in the 36-45 age group. Only 152 GM cases were detected; the rates in the lepromatous, borderline lepromatous, borderline tuberculoid were 29.21%, 9.64% and 3.68% respectively. Those who gave a history of frequent ENL reactions had a higher rate of GM i.e. 34.55 as against 21.52 without or with very infrequent ENL reaction. Early treatment had a remarkable effect in the reduction of GM. Only 14% developed GM when the treatment was started within 2 years after the onset of leprosy as against 46.9% when the same was started after 16 years. In the latter group, the longer duration of the disease could also play a contributory role. Sterility rate was more than double in those with GM i.e. 34.14% against 14% without it.