Early detection of multi-drug resistance and common mutations in Mycobacterium tuberculosis isolates from Delhi using GenoType MTBDRplus assay.

Purpose: There is scarcity of prevalence data of multi-drug–resistant tuberculosis (MDR-TB) data and common mutations responsible in North India. This study aimed to detect MDR-TB among MDR-TB suspects from Delhi and mutation patterns using GenoType MTBDRplus assay. Materials and Methods: All MDR suspects in fi ve districts of New Delhi were referred to the laboratory from 1st October 2011 to 31st December 2012 as per criterion defi ned by Programmatic Management of Drug Resistant Tuberculosis (PMDT). GenoType MTBDRplus assay was performed on 2182 samples or cultures and mutations in the rpoB gene for rifampicin (RIF) and katG and inhA genes for isoniazid (INH) were analyzed. Results: A total of 366 (16.8%) MDR-TB cases were diagnosed. MDR rate was found to be 32%, 16.6% and 10.2% during criterion A, B and C respectively. The most common mutation detected for RIF was S531L (59.0%) and for INH was S315T1 (88.3%). Mutations S531L and S315T1 occurred signifi cantly higher in MDR strains as compared to RIF mono-resistant and INH mono-resistant strains, respectively. Average laboratory turn-around time (TAT) for dispatch of result to districts for test conducted on samples was 4.4 days. Conclusion: GenoType MTBDRplus is a useful assay for rapid detection of MDR-TB. The common mutations for RIF and INH were similar to those seen in other regions. However, mutations determining MDR strains and mono-resistant strains differed signifi cantly for both RIF and INH.

Occurrence of Non-Tuberculous Mycobacterium in clinical samples - a potential pathogen.

Background: Silent presence of non-tuberculous mycobacterium (NTM) has been observed since the last 100 years, but now the increasing incidence of NTM is of great concern for clinical microbiologists as well as clinicians. Although many advanced efforts are being made for identification and control of Mycobacterium tuberculosis, still the silently growing menace of non-tuberculous mycobacteria is receiving negligible attention. Objectives: This study was aimed to find NTMs in positive cultures and identify them up to species level. Material & Methods: During the study period, i.e. from January 2009 to June 2011, a total of 4104 positive cultures were subjected to species identification by different morphological and biochemical tests. All the tests for identification were performed as per standard procedure along with the standard strains of NTM provided by JALMA, Agra. Results: The identification of positive cultures showed 4044/15581 (25.95%) Mycobacterium tuberculosis complex and 60/15581(0.38%) NTM. The mycobacterium species identification results showed that out of total 60 NTM, 21 different species of NTM were found and they belonged to all the four groups of runyon. The most common species identified in this study was M.simiae (07) followed by M.avium(06), M.gordonae(05), M.kansasii(05), M.fortuitum(05), M.chelonae(05), M.pheli(05), M.terrae(04), M.szulgai(02), M.vaccae(02), M.flavescens(02), M. trivale(02), M.malmoense(01), M.scrofulaceum(01), M.intracellulare(01), M.xenopi(01), M.ulcerans(01), M.tusciae(01), M.triplex(01), M.septicum(01), M.mucogenicum(01). Conclusion: The isolation of NTMs from different clinical samples indicated that they may be the causative agents for pulmonary and extra-pulmonary non-tuberculous diseases. Elaborate and focused studies are needed to differentiate NTMs amongst commensal/colonizer, pathogen and laboratory contaminants.

Presumptive identification of Mycobacterium tuberculosis complex based on cord formation in BACTEC MGIT 960 medium.

We considered samples received for culture of mycobacteria using BACTEC MGIT 960 system over a period of 1 year. Tubes flagged positive by MGIT were evaluated for presence of serpentine cording. The cord formation was compared with isolates identified as Mycobacterium tuberculosis complex (MTC) based on p-nitrobenzoic acid (PNB) test. Cords were found in 591 isolates of which 584 (98.8%) were confirmed as MTC. The sensitivity and specificity of cord formation were found to be 99.7% and 89.9%, respectively.

Prevalence of XDR TB cases - A retrospective study from a tertiary care TB Hospital.

Background: The emergence of XDR –TB strains is a major roadblock in the successful implementation of TB control programmes. This further leads to high morbidity and mortality, especially in immuno-compromised patients. Identification and observation of resistance patterns of XDR-TB strains may help clinicians manage MDR-TB cases, the treatment line of which is expensive, time-taking and involves intake of toxic drugs with many side-effects. Our study is aimed to find out the prevalence of XDR-TB among the MDR-TB strains isolated in a tertiary care hospital. Material & Methods: The study population consisted of 223 patients of tuberculosis who were culture positive and Mycobacterium tuberculosis was resistant to Rifampicin and Isoniazid during January 2007 to December 2009. Each patient had submitted two sputum samples i.e. spot and morning. The identified Mycobacterium tuberculosis complex was subjected to drug sensitivity testing by first and second line drugs by proportion and absolute concentration methods as per standard procedure . Results : The results showed that 20.17% strains (45/223) were XDR-TB strains. Most of these strains showed resistance to four drug combination viz. KM, ETH, OFX & PAS (5.82%), KM & OFX (3.13%), OFX, KM and ETH (1.79%), 1.34% strains showed resistance to all the drugs i.e. pan resistance and other combinations in the remaining strains. Nearly 80% of the XDR-TB strains showed resistance to three or more drugs combination pattern. Conclusion: The multidrug resistant TB cases need urgent and timely sensitivity report for second line ATT drugs to help clinicians start proper drug combinations to treat MDR-TB patients.

Inherited factor X deficiency in two brothers.

Two brothers born to same parents were diagnosed with inherited factor X deficiency of severe type. Clinical presentation in both the cases were haemarthrosis. The elder brother was diagnosed in the year 1991 when he was four and half years old. Recently the youngest child in the family also presented with haemarthrosis at age of one and half years. Diagnosis was made by abnormal results of Coagulation factors screening mainly Prothrombin time, Activated partial thromboplastin time, Russell's viper venom test, mixing tests factor X assay. Both the brothers had Factor X activity less than one percent.

Modified Levinson's test in rapid diagnosis of tuberculous meningitis.

Modified Levinson's precipitation test was done in 64 cases of TBM, 54 cases of TBM with inconsistent CSF finding, and 32 cases of pyogenic meningitis. The test was positive in 93.7% cases of TBM (sensitivity, 93.7%), 85.5% cases of TBM with doubtful diagnosis and in 9.4% cases of pyogenic meningitis (specificity 90.6%) compared to 79.7%, 72.2% and 18.8% in original Levinson's test, respectively. With CSF examination only 66% cases of TBM could be diagnosed while with modified Levinson's test and CSF analysis 89% cases could be diagnosed (p < 0.001). So modified Levinson's test for diagnosis of TBM is better than Levinson's test (p < 0.05) with an added advantage of time saving.

Breastfeeding in babies delivered by cesarean section.

One hundred mothers undergoing cesarean section and their infants were studied regarding various factors affecting the establishment of breastfeeding during their stay in hospital (mean = 11 +/- 3.6 days). Nearly two-thirds (65.7%) of mothers who underwent elective cesarean section, and 62.8% of mothers who received spinal anesthesia were breastfeeding exclusively; while only 53.8% mothers who had undergone an emergency cesarean section and 28.6% who received general anesthesia were exclusively breastfeeding their neonates. All 9 mothers who initiated breastfeeding within 12 h of the surgery were practicing total breastfeeding. In contrast only 5.8% of mothers who initiated breastfeeding after 96 hours, were exclusively breastfeeding their neonates. Total breastfeeding was more frequent (86.8%) in newborn infants who received prelacteal feeds by spoon as compared to those who received by feeding bottle (33.3%). Babies separated from the mothers in hospital were less likely (35.5%) to be on total breastfeeding as compared to those (68.1%) who were not separated from their mothers. This study suggests that for proper establishment of breastfeeding in mothers undergoing cesarean section an elective procedure under spinal anesthesia promotes, early initiation of breastfeeding. Early initiation of breastfeeding has highly significant correlation with establishment of breastfeeding while separation of babies from mothers discourages breastfeeding.

Lactation failure.

Seventy five mothers with lactation failure were studied, whose less than 4-month-old babies were admitted to the hospital. Partial lactational failure (94.7%) was noted more often than complete lactational failure (5.3%). Initiation of breastfeeding was delayed for 2 to 5 days usually for traditional reasons (77.3%) and because the mothers felt that the milk output was inadequate (92%). The various causes of lactation failure were determined and the relationship to various factors was analyzed. The commonest cause of lactation failure was insufficient milk or no milk (80%). The age, parity, education, socio-economic status, religion, family structure and urban vs rural status of mother--all had a bearing on the occurrence of lactation failure. An attempt was made to relactate all these mothers. The outcome was successful in 69.3 cases and failed in only 4% cases. In 26.7% cases, we cannot predict the outcome as the mothers hospital stay was very brief with no follow up.

Hepatitis B virus infection and its transmission in preschool children.

In the present study, 2.5% of 367 preschool children has HBsAg positivity. Of 11 mothers who were HBsAg positive during the third trimester of pregnancy, 4 had babies (36.4%) who developed HBsAg positivity by 2.5-3 months of age (vertical transmission). Two babies born of HBsAg negative mothers, with history of jaundice during first trimester, were HBsAg negative. All the relatives of HBsAg positive cases screened were negative for HBsAg.

Poliomyelitis with special reference to immunization status.

One hundred ninety one children below 5 years of age suffering from poliomyelitis were analyzed to find out the immunization status and its correlation with the incidence of poliomyelitis. Effects of age, sex, immunization status and seasonal variation on the morbidity and mortality status were studied. The maximum number of cases were admitted during the months of July (23.6%) and August (23.1%). Of 191 cases, 143 (74.9%) had no immunization and 48 (25.1%) were partially immunized. A total of 155 (81.2%) cases had spinal polio, 23 (12.01%) bulbo-spinal polio, and 13 had (6.8%) bulbar polio. Serious illness (bulbospinal and bulbar type) was more in partially immunized children (25%) as compared to unimmunized children (16.8%). The mortality rate was more than two times higher in the partially immunized (29.6%) as compared to unimmunized children (11.2%). The possible explanation for high mortality in partially immunized children could be due to the adverse effect of OPV which has not been studied so far.