Multidrug-Resistant Musculoskeletal Tuberculosis: An Aggressive Clinical, Radiological and Molecular Confirmation With Genotypic Drug Susceptibility Testing Approach.

Introduction Increasing evidence suggests that musculoskeletal tuberculosis (MSTB) causes significant morbidity due to the late presentation of symptoms and lack of accurate diagnosis. We aimed to assess the utility of two modalities, viz. radiology and molecular methods, in the early diagnosis of MSTB. Also, the rate of resistance to two basic first-line antitubercular drugs in musculoskeletal TB cases among clinically suspected patients was analyzed. Methods Samples from 119 patients with clinical suspicion of musculoskeletal TB were included. A radiological workup of patient and smear microscopy, mycobacterial culture, real-time multiplex polymerase chain reaction (PCR), cartridge based nucleic acid amplification test (CBNAAT), and line probe assay (LPA) of samples were carried out. Results Maximum positivity (69.74%) was observed by real-time multiplex, followed by CBNAAT and LPA (68.9%), mycobacterial culture (40.3%), and smear microscopy (19.3%). One additional advantage of using multiplex PCR was the detection of non-tuberculous mycobacteria (NTM) isolate. Forty-five strains (54.9%) on LPA were susceptible to rifampicin and isoniazid, eight (9.8%) were rifampicin mono-resistant, seven (8.5%) were isoniazid (INH) mono-resistant, and 22 (26.8%) were multidrug resistant. Conclusions MSTB diagnosis can be expedited by the combination of radiology and molecular methods. The positivity rate escalates, turnaround time improves, and the additional advantage of detection of drug resistance is added when this algorithm is included for clinching the diagnosis of MSTB.

Clinical profile and in-hospital outcomes of COVID-19 patients: Findings from secondary data analysis.

Background: Uttarakhand, a hilly state in north India, reported the first coronavirus disease (COVID) case on 15 March 2020. Since then, the case numbers rose multiple folds. As Uttarakhand has been on a 'war-footing' amidst the recent second wave and is gearing up to fight against the third wave, the present study aims to uncover baseline clinical profile and in-hospital outcomes of COVID patients in Dehradun district (Uttarakhand) during the first wave. Methods: A record-based descriptive analysis was carried out for 671 COVID patients admitted to a private dedicated COVID hospital in Dehradun district between August 2020 and February 2021. Data was collected from medical records on a standardized abstraction form. Data was entered and analyzed using Statistical Package for Social Sciences (SPSS) version 20. Results: The present study showed most admitted COVID patients were males, aged 40 years and above, moderately ill, had co-morbidities with about one-fourth lately succumbed to death. The proportions of deaths, moderate-to-severe and severe category of illness were invariably high for those with co-morbidities irrespective of the gender. Females, age <60 years, and absence of co-morbidities had overall high mean survival estimates from COVID. Conclusion: Females, younger age group, and absence of co-morbidities are more likely to survive from COVID than males, older age groups, and those with co-morbidities.

Serum Interleukin-6 is Not Linked with Sleep-Quality, Restless Legs Syndrome, and Depression, But with 6-Month Survival in Hematological Malignancies.

BACKGROUND: Serum interleukin (IL)-6 has been found to be associated with sleep quality, mood, and survival in patients with solid tumors. Results in these studies were confounded by knowledge of diagnosis to study subjects. Moreover, such data among subjects with hematological malignancies and data regarding restless legs syndrome is limited. The present study was, therefore, conducted to assess the sleep quality, depression, and restless leg syndrome in hematological malignancies and to study if there is any role of IL6 associated with it. METHODS: Sixty-six subjects having hematological malignancy were included in this study after excluding the potential confounders. Sleep quality was examined using Pittsburg Sleep Quality Index, depression by the Patient Health Questionnaire-9. Diagnosis of RLS was made through clinical examination. Serum for measurement of IL-6 was collected at baseline and after 1 month of initiation of chemotherapy. Patients were followed up for 6 months. RESULTS: Average age of study subjects was 50.16 years with male predominance. Nearly 22.7% had clinical depression, 28.8% had poor quality sleep, and restless legs syndrome (RLS) was reported in 6.1% cases. Nearly 22.7% patients died at 6 months. Disturbed sleep at baseline was associated with depression (odds ratio [OR] =7.89) and poor 6 months survival. Serum IL-6 did not show any association with sleep quality, restless-legs-syndrome, and depression. However, baseline high level of serum IL-6 (OR = 26.06) and low level after chemotherapy (OR = 0.03) were associated with poor survival at 6 months. CONCLUSION: Poor quality sleep, depression, and RLS are prevalent among adult subjects with hematological malignancies. Sleep disturbance, high pretreatment inflammatory and lowering of inflammatory load after chemotherapy increase likelihood for poor prognosis. Serum IL-6 did not show any association with sleep quality, restless legs syndrome and depression.

Diagnostic performance of automated liquid culture and molecular line probe assay in smear-negative pulmonary tuberculosis.

The diagnosis of smear-negative pulmonary tuberculosis (PTB) is particularly challenging, and automated liquid culture and molecular line probe assays (LPA) may prove particularly useful. The objective of our study was to evaluate the diagnostic potential of automated liquid culture (ALC) technology and commercial LPA in sputum smear-negative PTB suspects. Spot sputum samples were collected from 145 chest-symptomatic smear-negative patients and subjected to ALC, direct drug susceptibility test (DST) testing and LPA, as per manufacturers' instructions. A diagnostic yield of 26.2% was observed among sputum smear-negative TB suspects with 47.4% of the culture isolates being either INH- and/or rifampicin-resistant. Complete agreement was observed between the results of ALC assay and LPA except for two isolates which demonstrated sensitivity to INH and rifampicin at direct DST but were rifampicin-resistant in LPA. Two novel mutations were also detected among the multidrug isolates by LPA. In view of the diagnostic challenges associated with the diagnosis of TB in sputum smear-negative patients, our study demonstrates the applicability of ALC and LPA in establishing diagnostic evidence of TB.

ESBL and MBL in Cefepime Resistant Pseudomonas aeruginosa: An Update from a Rural Area in Northern India.

INTRODUCTION: Cefepime, a fourth generation cephalosporin, is widely used for the empirical treatment of serious infections in critically ill hospitalized patients. Pseudomonas aeruginosa (P. aeruginosa), one of the commonest bacteria causing nosocomial infections has a propensity to develop antibiotic resistance quite promptly. AIM: We undertook this study to assess the efficacy of cefepime against current clinical isolates of P. aeruginosa and to study existence of different beta-lactamase enzymes among cefepime resistant P. aeruginosa isolates. MATERIALS AND METHODS: Total of 618 isolates of P. aeruginosa recovered consecutively from various clinical samples of a tertiary care hospital were analysed. Their Antimicrobial sensitivity profile against piperacilin (100µg), piperacillin/tazobactam (100µg/10µg), ceftazidime (30µg), cefoperazone (75µg), cefepime (30µg), ciprofloxacin (5µg), gentamycin (10µg), amikacin (30µg) and imipenem (10µg) (Himedia) was tested by Kirby-Bauer disc diffusion method (Clinical and Laboratory Standards Institute guidelines). We further looked for ESBL, MBL and ESBL + MBL co producers among the cefepime resistant isolates by two different methods (combined double disc synergy test, imipenem-EDTA combined disc test and vitek2). RESULTS: Among 618 consecutive clinical isolates of P. aeruginosa, we observed resistance to cefepime in 457 (74%) isolates. We observed resistance to ciprofloxacin (n=506, 82%) in maximum number of isolates followed by that to Gentamycin (n=475, 77%), amikacin (n=366, 60%), and cefoperazone (n=350, 56.6%). Among all our cefepime resistant P. aeruginosa isolates only 27(6%) were ESBL producers, 18(4%) MBL producers and 2(0.4%) were ESBL+ MBL co-producers. All the ESBL and MBL isolates were also tested by VITEK 2 advanced expert system (bioMirieux Vitek Systems Inc, Hazelwood, MO, France) which revealed a 100% concordance with the phenotypic method tested. CONCLUSION: This paper highlights the need to reconsider prescribing empirical antibiotics for Pseudomonas infections in this region and formulate a strong antibiotic policy to curb the menace of spread of multidrug resistant strains.

Granzyme B as a diagnostic marker of tuberculosis in patients with and without HIV coinfection.

Immunodiagnostic tests for tuberculosis (TB) are based on the estimation of interferon γ (IFN-γ) or IFN-γ-secreting CD4(+) T cells following ex vivo stimulation with ESAT6 and CFP-10. Sensitivity of these tests is likely to be compromised in CD4(+) T-cell-depleted situations, like HIV-TB coinfection. CD4(+) and CD8(+) T cells, isolated from 3 groups, viz., HIV-negative patients with active TB, HIV-TB coinfected patients, and healthy household contacts (HHCs) were cocultivated with autologous dendritic cells, and the cytokine response to rESAT6 stimulation was compared between groups in supernatants. While CD4(+) T-cell stimulation yielded significantly elevated levels of IFN-γ and interleukin 4 in HIV-negative TB patients, compared to HHCs, the levels of both these cytokines were nondiscriminatory between HIV-positive TB patients and HHCs. However, CD8(+) T-cell stimulation yielded significantly elevated granzyme B titers in both groups of patients, irrespective of HIV coinfection status. Hence, contrary to IFN-γ, granzyme B might be a useful diagnostic marker for Mycobacterium tuberculosis infection particularly in HIV coinfected patients.

Amphotericin B Resistant Apophysomyces elegans Causing Rhino-oculo-Cerebral Mucormycosis in an Immunocompetent Host.

Mucormycosis, an angioinvasive infection is caused by the ubiquitous filamentous fungi of the order Mucorales and class Mucormycetes. Reports of this disease are on the rise over the past few decades. Rhino-oculo-Cerebral presentation associated with uncontrolled diabetes is the predominant characteristic of this entity. We report here a case of rhinooculocerebral mucormycosis (ROCM) due to Apophysomyces elegans (A. elegans) in a 45-year-old diabetic lady with background illness of hypothyroidism and polyradiculoneuropathy. Though this condition is usually managed with surgical debridement of the affected tissue and medical therapy with Amphotericin B, the isolate recovered in our case was found to be resistant to Amphotericin B.

Epidemiological and mycological characteristics of candidemia in patients with hematological malignancies attending a tertiary-care center in India.

BACKGROUND AND OBJECTIVES: We undertook the present study to ascertain the contributing risk factors and explore the epidemiological and mycological characteristics of opportunistic candidemia among patients with hematological malignancies. DESIGN AND SETTINGS: Observational cross-sectional study in a tertiary care center. PATIENTS AND METHODS: Consecutive patients with hematological malignancies reporting to the collaborating medical and pediatric units with a febrile episode were recruited and screened for candidemia by blood culture. Recovered Candida isolates were speciated and antifungal susceptibility testing was performed as per Clinical and Laboratory Standards Institute guideline (CLSI) guidelines M44-A. Further analysis was done for potential risk factors and compared between culture positive and negative patients. RESULTS: Of 150 patients recruited, the majority (n=27) were between 51 and 60 years and the male to female ratio was 1.63:1. Fifteen patients (10%) were culture positive. The culture positivity was significantly higher in acute lymphocytic leukemia (ALL) than in non-ALL patients (p=0.03). There was significant association of candidaemia with leucopenia, chemotherapeutic drugs, corticosteroids and presence of indwelling devices. Duration of disease (p=0.032) and duration of hospitalization (p=0.003) were significantly prolonged in culture positive patients. C. tropicalis was the commonest isolate (46.67%), with non- Candida albicans outnumbering C. albicans in all categories of hematological malignancies (2.75:1). All isolates of C. albicans were uniformly sensitive to all the azoles, but only 50% were sensitive to amphotericin B and none to nystatin and flucytosine. CONCLUSIONS: This observational study identifies ALL and chronic lymphocytic leukemia (CLL) as the forms of hematological malignancy predominantly associated with candidemia; specifies risk factors and chemotherapeutic agents predisposing patients towards its occurrence; reports a preponderance of C. tropicalis among the causative agents and finds voriconazole to be the most effective antifungal agent against the recovered isolates. This information could assist in tailoring prophylactic and therapeutic antifungal practices for this infection, according to local epidemiological and mycological characteristics.

Non traumatic keratitis due to colletotrichum coccodes: a case report.

Colletotrichum species, a rare and emerging fungus is a well- known plant pathogen and an uncommon cause of human infection. It has been implicated as the etiological agent of cutaneous phaeohyphomycosis and keratitis, particularly following colonization of traumatized tissues or in immunocompromised patients. However, it has hardly ever been reported in the absence of such predisposing risk factors. Here, we report a case of keratitis with Colletotrichum coccodes occurring in a middle- aged, immunocompetent person without any history of trauma or co-morbidity. The isolate was sensitive to Amphotericin B and Voriconazole, and accordingly the patient was treated successfully with ocular administration of Amphotericin B.

Ibuprofen-mediated reversal of fluconazole resistance in clinical isolates of Candida.

INTRODUCTION: In view of the increasing prevalence of invasive Candidiasis in today's health-care scenario and the emergence of fluconazole resistance among clinical isolates of Candida, we sought to determine if Ibuprofen could elicit a reversal of fluconazole resistance and thereby offer a potential therapeutic breakthrough in fluconazole-resistant Candidiasis. MATERIALS AND METHODS: We selected 69 clinical isolates of Candida, which demonstrated an MIC of >32 µg/ml for fluconazole, and subjected them to broth microdilution in presence and absence of Ibuprofen. RESULTS: Forty two of the 69 isolates (60.9%) demonstrated reversal of Fluconazole resistance with concomitant use of Ibuprofen. This was characterized by significant species-wise variation (p=0.00008), with all the C. albicans isolates and none of the C. glabrata isolates demonstrating such reversal. Only 22.2% and 37.7% of C. krusei and C. tropicalis isolates respectively showed Ibuprofen-mediated reversal of Fluconazole resistance. CONCLUSION: Since Ibuprofen is a known efflux pump inhibitor, our findings hint at the possible mechanism of Fluconazole resistance in most of our Candida isolates and suggest a potential therapeutic alternative that could be useful in the majority of Fluconazole-resistant clinical isolates of Candida.

Fluconazole Resistant Candida Oesophagitis in Immunocompetent Patients: Is Empirical Therapy Justifiable?

INTRODUCTION: C. albicans (Candida albicans) is the foremost cause of fungal oesophagitis, however other species such as Candida tropicalis, Candida krusei and Candida stellatoidea have also been implicated to cause this condition. Although, numerous studies have identified risk factors for C. albicans oesophagitis, data for non- C. albicans species is still sparse. AIM: To determine the aetiology of Candida oesophagitis in our medical centre over a two year period. Additionally, to investigate predisposing conditions for oesophageal candidiasis caused by different Candida species. MATERIAL AND METHODS: All consecutive patients posted for upper gastrointestinal endoscopy at the endoscopy unit of a tertiary care hospital in north India with findings consistent with oesophagitis were screened for the presence of Candida oesophagitis by performing KOH (potassium hydroxide) examination and culture on SDA (Sabouraud's dextrose agar). Antifungal susceptibility testing as per CLSI guidelines was performed for fluconazole, a most common empirically prescribed antifungal for the condition. RESULTS: A total of 1868 patients with no known immune-compromised condition underwent upper gastroscopy at our centre during the study period. The prevalence of Candida oesophagitis was 8.7% (n = 163). C. albicans was recovered from majority of infections (52.1%), followed by C. tropicalis (24%), C. parapsilosis (13.4%), C. glabrata (6.9%) and C. krusei (3.6%). Alarmingly, among the C. albicans isolates 8.6% were resistant to fluconazole. CONCLUSION: With rising reports of antifungal drug resistance among the isolates of Candida species, an increasing prevalence of this organism could have an impact on the treatment of Candidal oesophagitis and it should be approached with caution by the clinician.

Application of lipoarabinomannan antigen in tuberculosis diagnostics: current evidence.

Tests based on the detection of mycobacterial lipoarabinomannan (LAM) antigen in urine have emerged as potential point-of-care tests for tuberculosis (TB). We aimed to assimilate the current evidence regarding the diagnostic performance of LAM assays and to ascertain their clinical indication in settings with high and low prevalence of HIV-TB co-infection. Owing to suboptimal sensitivity, the urinary LAM assays are unsuitable as general screening tests for TB. However, unlike traditional diagnostic methods, they demonstrate improved sensitivity in HIV-TB co-infection which further increases with low CD4 counts. Accordingly, these assays are indicated as rule-in tests for TB in patients with advanced HIV-induced immunosuppression, and facilitate the early initiation of antituberculous treatment in them. They also offer incremental sensitivity and specificity when used as adjunct tests to smear microscopy and chest radiography in HIV-TB co-infection. They obviate the biohazards associated with sputum samples and provide an alternative diagnostic tool in sputum-scarce patients. Notwithstanding these advantages, the specificity of these assays is variable, which is mostly attributable to misclassification bias and cross-reactivity with non-tuberculous mycobacteria or other commensal flora. Furthermore, the inability to detect low titres of antigen in HIV-uninfected patients makes these assays unsuitable for use in settings with a low HIV prevalence. Future research targeted towards inclusion of specific monoclonal antibodies and more sensitive immunoassay platforms might help to improve the diagnostic performance of these assays and extend their applicability to the general population of patients with TB.

An observational study on the epidemiological and mycological profile of Candidemia in ICU patients.

BACKGROUND: This study aimed to analyze the epidemiological and mycological profile of candidemia in intensive care unit (ICU) patients attending a tertiary care teaching hospital in the Himalayan region of northern India. MATERIAL/METHODS: A 15-bed medico-surgical ICU and a 5-bed pediatric ICU. Ninety-one consecutively admitted ICU patients were screened for the presence of candidemia by performing blood cultures at periodic intervals. RESULTS: The recovered Candida isolates were speciated and subjected to antifungal susceptibility testing using standard procedures. Forty-one of the recruited patients (45%) were found to be candidemic, with the majority of patients being in the extremes of age (13 neonates and 15 >65 years of age). Four risk factors were found to be significantly associated with the occurrence of candidemia in our patients - a period of hospitalization exceeding 7 days (p=0.0008), previous use of antibiotics (p=0.001), presence of chronic renal failure (p=0.003), and ongoing cancer chemotherapy (p= 0.041). Ninety-six Candida isolates were recovered from the 41 culture-positive patients, with Candida albicans being the commonest isolate recovered (n=75, 78.1%), followed by Candida tropicalis (n=15, 16%), and Candida glabrata (n=6, 6.5%). Fluconazole resistance was observed among 26% of all Candida isolates and 17.3% of C. albicans isolates. CONCLUSIONS: Contrary to the majority of recent reports, species shift towards non-albicans candidemia has not been observed in our center, though the prevalence of azole resistance is alarmingly high even among the C. albicans isolates.