Geographical distribution of primary & secondary dengue cases in India – 2017: A cross-sectional multicentric study

Background & objectives: Dengue virus infection is endemic in India with all the four serotypes of dengue virus in circulation. This study was aimed to determine the geographic distribution of the primary and secondary dengue cases in India. Methods: A multicentre cross-sectional study was conducted at Department of Health Research / Indian Council of Medical Research (DHR)/(ICMR) viral research and diagnostic laboratories (VRDLs) and selected ICMR institutes located in India. Only laboratory-confirmed dengue cases with date of onset of illness less than or equal to seven days were included between September and October 2017. Dengue NS1 antigen ELISA and anti-dengue IgM capture ELISA were used to diagnose dengue cases while anti-dengue IgG capture ELISA was used for identifying the secondary dengue cases. Results: Of the 1372 dengue cases, 897 (65%) were classified as primary dengue and 475 (35%) as secondary dengue cases. However, the proportion varied widely geographically, with Theni, Tamil Nadu; Tirupati, Andhra Pradesh and Udupi-Manipal, Karnataka reporting more than 65 per cent secondary dengue cases while Srinagar, Jammu and Kashmir reporting as low as 10 per cent of the same. The median age of primary dengue cases was 25 yr [interquartile range (IQR 17-35] while that of secondary dengue cases was 23 yr (IQR 13.5-34). Secondary dengue was around 50 per cent among the children belonging to the age group 6-10 yr while it ranged between 20-43 per cent among other age groups. Interpretation & conclusions: Our findings showed a wide geographical variation in the distribution of primary and secondary dengue cases in India. It would prove beneficial to include primary and secondary dengue differentiation protocol in the national dengue surveillance programme.

Depression among tuberculosis patients attending a DOTS centre in a rural area of Delhi: A cross-sectional study

Background: Studies have shown that the prevalence of psychiatric disorders, particularly depression, is high among tuberculosis (TB) patients, and may adversely affect treatment compliance. A person suffering from TB can develop depression in due course of time owing to a number of factors, namely the long duration of treatment for TB, stigmatization faced by the patient due to the disease and lack of family support to name a few. Objectives: The present study aimed to determine the prevalence of depression and its correlates among TB patients enrolled at a Directly Observed Treatment Short-course (DOTS) center in a rural area of Delhi. Methods: The study was a DOTS center-based, cross-sectional study, among 106 patients of pulmonary and extrapulmonary TB, above 18 years of age. An interviewer-administered questionnaire in Hindi was used to collect basic sociodemographic data and the Patient Health Questionnaire (PHQ)-9 was used for detecting depression. Those with a score of 10 or more were considered to be suffering from depression. Data analysis was done using SPSS licensed version 20. Chi-square was used to test for association between qualitative variables, and a P < 0.05 was considered statistically significant. Results: A total of 106 patients participated in the study, of which 61 (57.5%) were males. The median age was 30 years (inter-quartile range 24� years). Depression was found to be present in 25 (23.6%) participants. A higher proportion of patients with depression were unemployed currently, and also belonged to middle or lower class (P < 0.05). Depression was not found to be associated with religion, gender, marital status, HIV status, presence of diabetes, DOTS category nor with the phase of treatment. Conclusion: Depression among TB patients is common, affecting almost one in four TB patients. Physicians and DOTS providers should have a high index of suspicion for depression when assessing TB patients.

Evaluation of biomarkers: Galactomannan and 1,3-beta-D-glucan assay for the diagnosis of invasive fungal infections in immunocompromised patients from a tertiary care centre

Purpose: Due to limitations of traditional microbiological techniques, standardised fungal biomarker tests such as Galactomannan Index (GMI) and 1,3-beta-D-glucan (BDG) are being preferred for diagnosis of invasive fungal infections (IFIs). These tests have been extensively used in developed countries but seldom in developing countries. The present study was performed to evaluate these tests for the diagnosis of IFIs in immunocompromised patients at an Indian tertiary care centre. Materials and Methods: A retrospective hospital-based study was done in immunocompromised patients with clinical suspicion of IFI. The demographic, clinical, radiological and mycological details of the patients were recorded. The patients were categorised into proven, probable and no IFI (as per European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria). The sensitivity and specificity of BDG Fungitell and Platelia Aspergillus antigen assays was estimated. Results: A total of 70 consecutive patients were included, of which 41 had IFI (10 proven and 31 probable) while 29 had no IFI. A significant association was found between IFI and the presence of a central venous line (P = 0.035) and history of intake of T-cell immunosuppressants (P = 0.001). Median BDG values (pg/ml) in patients with proven IFI, probable IFI and no IFI were 300 (range: 70�0), 165 (range: 53�0) and 45 (range: 31�0), respectively. The receiver operating characteristic (ROC) curve analysis for BDG revealed an area under the curve of 0.995, sensitivity: 97.4% and specificity: 96.6% for IFI diagnosis. The ROC curve analysis of GMI revealed an AUC of 0.75 and 90% patients with invasive aspergillosis (IA) had positive GMI. Conclusion: BDG has good sensitivity and specificity for distinguishing IFI from no IFIs and GMI may be used for diagnosing IA.

Loop‑mediated isothermal amplification assay for detection of Mycobacterium tuberculosis complex in infertile women.

Background: Female genital tuberculosis (FGTB) has a profound impact on the reproductive health of patients including infertility. Conventional diagnostic techniques have low sensitivity and specificity as well as long turnaround time. There is a need of developing newer, rapid and practically adaptable technique, especially in low‑income countries. Objective: To standardize and evaluate loop‑mediated isothermal amplification (LAMP) technique for diagnosis of FGTB. Methods: A total of 300 endometrial biopsy samples from infertile females were subjected to Ziehl–Neelsen (ZN) staining, Lowenstein–Jensen culture, automated culture (BACTEC mycobacterial growth indicator tube), histopathological examination (HPE), nucleic acid amplification by polymerase chain reaction (PCR) and LAMP technique. Composite gold standard (either smear/culture/HPE/PCR positive) was considered for calculation of outcome parameters. Results: The observed sensitivities of ZN smear, culture, HPE, PCR and LAMP were 2.94%, 10.29%, 8.82%, 95.59% and 66.18%, respectively. Overall concordance between PCR and LAMP was 63%, which shows a good agreement. Conclusion: This study is the first to evaluate LAMP in the diagnosis of FGTB and found it to be a rapid and convenient technique, especially in low resource endemic settings.

Salivary gland imaging: A pictorial essay.

The major salivary glands are parotid, submandibular and sublingual glands. Imaging has an important role to play in detection, diagnosis, aiding biopsy and differentiating benign from malignant pathology. The traditional imaging modalities include plain radiography and sialography. With the advent of modern imaging methods like high resolution ultrasound with color doppler, contrast enhanced CT, MRI and MR sialography, the imaging has become increasingly reliable in making a confident diagnosis. A wide variety of conditions including obstructive, infectious, autoimmune and neoplastic pathologies affect the salivary glands, thus resulting in a wide imaging spectrum. This article is aimed at presenting the imaging appearances of common salivary gland diseases.

Initial experience of endobronchial silicon stents from a tertiary care centre in north India.

Background. Central airway obstruction (CAO) is defined as obstruction of trachea and principal bronchi. Therapeutic rigid bronchoscopy with tracheobronchial stenting using silicon stents is a well established procedure in the management of such conditions. However, there is limited experience with this technique in India. Methods. Between January 2010 and April 2010, Dumon stents were placed in four patients with CAO. Three patients had symptomatic tracheal stenosis while one patient had malignant obstruction at the carina. Rigid bronchoscopy under general anaesthesia was performed to relieve the CAO followed by placement of silicon stents. Pre- and post-stent placement symptom assessment was performed with a symptom-based visual analogue scale. Results. Four patients underwent silicon stent placement in the tracheobronchial tree. Three patients had benign postintubation tracheal stenosis and one had malignant tracheal obstruction at carina due to endobronchial growth. Significant improvement was achieved in all patients. There were no significant complications. Conclusions. Rigid bronchoscopy with silicon stent placement is an effective and suitable method of relieving the distressing symptoms due to benign or malignant airway obstruction.

Screening of patients with acute febrile illness for leptospirosis using clinical criteria and serology.

BACKGROUND: Leptospirosis is one of the common zoonoses but, in most instances, the infection goes unnoticed. Rapid diagnostic modalities are needed to diagnose the disease in the early stages. We assessed the usefulness of clinical criteria and compared these with enzyme-linked immunosorbentassay (ELISA) for the early detection of leptospirosis. METHODS: One hundred patients with a febrile illness for > 7 days were screened by Faine criteria and their sera were subjected to both IgM and IgG ELISA using a commercially available kit (Institut Virion Serion GmbH, Warburg, Germany). RESULTS: Twenty-six patients satisfied the clinical criteria for leptospirosis and 8 of them tested positive for IgM antibodies while 1 patient who was clinically negative tested positive by serology. Thus, Faine criteria had a sensitivity of 88.9%, specificity of 80.2%, positive predictive value of 30.8% and a negative predictive value of 98.6%. Paired serum samples were obtained from 70 patients but the IgG levels of only 2 showed a 4-fold rise. CONCLUSION: Faine criteria has moderate sensitivity and specificity but a high negative predictive value in comparison with IgM ELISA. The high negative predictive value may help to screen patients with acute febrile illness for leptospirosis during the early phase of the disease.

Vibrio cholerae diarrhoea in a three-day-old breastfed neonate.

A confirmed case of cholera in a 3-day-old neonate is being reported. Possible source of infection could be by holy water (Chamamrit) given to the baby, which is common ritual in India. Mother's milk has never been reported to transmit cholera, even though mother herself may be suffering from cholera. Contaminated water can transmit the disease as there is no maternally transmitted immunity.

Klippel-Trenaunay syndrome.

Klippel Trenaunay syndrome is a rare congenital disorder characterised by vascular anomalies and life threatening complications. Clinical recognition, prenatal diagnosis and counselling is important in these cases. Here we present a case of Klippel-Trenaunay syndrome and emphasize upon the clinical significance of such cases.

Mycobacterium fortuitum wound infection following laparoscopy.

During a six week period in 1999, seven patients who underwent laparoscopic tubectomies at small town health centres near Chandigarh developed chronic discharging sinuses at the site of incision. Mycobacterium fortuitum was isolated from wound discharge of the five patients by standard methods and two patients were smear positive. Environmental samples e.g., tap water, and a variety of fluids did not yield any mycobacteria and swabs from different parts of the laparoscope were sterile. All patients responded to ciprofloxacin and amikacin therapy. Our observation demonstrates that M. fortuitum is a clinically important nosocomial pathogen in setting of surgical wound infection in our country.

Rhinocerebral mucormycosis in a patient of acute renal failure.

Mucormycosis is the name for invasive fungal infection caused by mucorales. The disease is uncommon and produces serious and rapidly fatal infection in patients with serious pre-existing illness. The classical presentation of rhinocerebral mucormycosis is involvement of nasal mucosa with invasion of paranasal sinuses and orbit. We report a case of mucormycosis in an otherwise healthy female who had developed acute renal failure following gastroenteritis.

Diagnostic potential of histochemical demonstration for copper-orcein stain.

The histochemical demonstration of hepatic copper is important in the diagnosis of paediatric copper storage disorders. Conflicting results have been published regarding ability of different histochemical stains to demonstrate copper storage in the liver. Hence the authors retrospectively analysed eighty-two liver biopsies from 82 patients of Indian childhood cirrhosis (ICC), 59 males and 23 females aged between 1-4 years (mean age 3.1 years). All cases were stained with orcein stain. On the basis of histological picture the liver biopsies were divided into the three histological grades I, II and III. Orcein positively was graded from I to IV. All cases showed positivity with orcein stain. Most cases showed grades II and III of orcein positivity. The association between histological and orcein grades was significant. The present study demonstrates the diagnostic utility of orcein stain in liver copper storage disorder, Indian childhood cirrhosis. Variable copper content in the same histological grade of the disease could be due to individual factors such as genetic milieu which determine the amount of copper liver can store without toxicity.

Evaluation of leukergy test as an indicator of infection in hip joint in children.

This new blood test (leukergy) for infection is based on the fact that white cells agglomerate in peripheral blood of patients with inflammatory diseases. We evaluated leukergy in 25 children with proven septic arthritis of hip. It was found to be the efficient and earliest indicator of septic arthritis than the erythrocyte sedimentation rate (ESR), total leucocyte count (TLC), polymorphs and C-reactive protein (CRP). It also correlated well with the clinical severity of infection and the prognosis of disease. Thus leukergy is a simple, rapid and inexpensive slide test which was found as the best indicator profile for the presence of septic arthritis.

Evaluation of E test for susceptibility testing of Mycobacterium tuberculosis to primary anti tubercular drugs.

BACKGROUND & OBJECTIVES: Antimicrobial susceptibility tests for tuberculosis take weeks and delayed therapy can lead to an increase in disease incidence. The E test is a new concept for minimum inhibitory concentrations (MIC) determinations for antimicrobial agents that is based on a predefined antibiotic gradient on a plastic strip calibrated with a continuous logarithmic MIC scale covering 15 two-fold dilutions. The present study was undertaken to evaluate E test strips for susceptibility testing of Mycobacterium tuberculosis. METHODS: Twenty five clinical isolates of M. tuberculosis were tested for the four first line antitubercular drugs by E test and were compared with standard proportion method. The inoculum turbidity was adjusted to McFarland 3.0 standard and agar plates (Middle brook 7H11 agar) were inoculated and preincubated (37 degrees C in 7-10% CO2) for 24 h after which time, the E test strips were placed on the agar surface which were incubated under same conditions. The MIC was interpreted as the point at which the ellipse intersected the 'E test' strip as described in E test technical guide. RESULTS: Of the 25 strains, susceptibility as determined by both methods for isoniazid (INH), rifampin, ethambutol and streptomycin was found in 22 (88%), 20 (80%), 24 (96%) and 18 (72%) strains respectively. Agreement between E test and proportion method was 96 per cent for INH, 92 per cent for rifampin and 100 per cent for ethambutol and streptomycin each. However, sensitivity could be predicted after 7-10 days by E test and exact MIC could also be determined. INTERPRETATION & CONCLUSIONS: E test method was found to be rapid, accurate, reliable and easy to perform. It can be employed for routine susceptibility testing for antitubercular drugs.

Cryptosporidiosis in a tertiary care hospital.

BACKGROUND: Cryptosporidium, an important cause of diarrhoea, has been reported worldwide both in immunocompetent and immunocompromised individuals and has emerged as a serious public health problem. This study was undertaken to assess the present status of cryptosporidiosis in children and adults with diarrhoea who attended the Nehru Hospital, Chandigarh which is a tertiary care hospital. METHODS: Routine stool examination was done using saline and iodine stained preparations for various parasites. Modified Ziehl-Neelsen and rapid safranin-methylene blue techniques were used to detect Cryptosporidium in 2000 stool samples (1645 adults, 355 children) from March to November 1998. RESULTS: Of the 2000 samples, 205 (10.2%) were positive for various parasites. Five (1.4%) children were positive for Cryptosporidium and one child was positive for human immunodeficiency virus. In adults, Cryptosporidium was found in only one patient (0.06%). Giardia lamblia was the commonest parasite detected both in adults (4%) and children (15.2%). CONCLUSION: The present study highlights the importance of Cryptosporidium as a cause of diarrhoea, especially in children. Thus, there is a need for specific staining techniques to detect Cryptosporidium in routine diagnostic laboratories.