Clinical Profile, Treatment, and Outcome of Patients with Secondary Hemophagocytic Lymphohistiocytosis in Critically Ill Patients: A Prospective Observational Study.

Introduction: The objective of the study was to evaluate the clinical profile and outcome of patients with secondary hemophagocytic lymphohistiocytosis (HLH) in critically ill patients. Materials and methods: A prospective observational study was conducted where critically ill adult patients presenting with fever and bicytopenia were evaluated according to the HLH-2004 diagnostic criteria for the presence of secondary HLH. The underlying trigger, clinical profile, treatment, and outcome of patients with HLH were analyzed. Results: Of the 76 critically ill patients with fever and bicytopenia, 33 (43%) patients were diagnosed with HLH. The following triggers for HLH were identified: bacterial infections (23%), fungal infections (10%), viral infections (10%), parasitic infections (10%), autoimmune diseases (13%), and malignancy (8%). A total of 78% of the HLH cases received steroids, but the use of steroids was not associated with improvement in mortality. Conclusion: There is a high prevalence of HLH in patients presenting with fever and bicytopenia in critically ill adult patients. Infections were identified as the most common trigger of HLH. How to cite this article: Fazal F, Gupta N, Soneja M, Mitra DK, Satpathy G, Panda SK, et al. Clinical Profile, Treatment, and Outcome of Patients with Secondary Hemophagocytic Lymphohistiocytosis in Critically Ill Patients: A Prospective Observational Study. Indian J Crit Care Med 2022;26(5):564-567.

Molecular & phenotypic characterization of Staphylococcus epidermidis in implant related infections.

BACKGROUND & OBJECTIVES: The discrimination between the Staphylococcus epidermidis colonizing the deep seated indwelling devices and those which are mere commensals has always been a challenge for the clinical microbiologist. This study was aimed to characterize the S. epidermidis isolates obtained from device related infection for their phenotypic and molecular markers of virulence and to see whether these markers can be used to differentiate the pathogenic S. epidermidis from the commensals. METHODS: Fifty five S. epidermidis isolates from various device related infections such as endophthalmitis following intra-ocular lens (IOL) implantation, intravascular (IV) catheter related sepsis and orthopaedic implant infections, were studied for slime production, biotyping, antibiotic sensitivity; and mec A and ica positivity by the recommended procedures. RESULTS: Twenty three (41.8%) isolates were multi-drug resistant, 26 (65.2%) were slime producers, 30 (54.5%) were adherent, 23 (41.8%) possessed the intercellular adhesin (ica) gene, and 28 (50.9%) harboured the mec A gene. Biotypes I and III were the commonest, most members of which were multi- drug resistant. Twenty two (73.3%) of the 30 adherent bacteria were slime producers as opposed to only 4 (16%) of the 25 non-adherent bacteria (P<0.001). A vast majority i.e. 21 (91.3%) of the 23 ica positive organisms were adherent to artificial surfaces in contrast to only 9 (28.1%) of the 32 non-ica positive organisms (P<0.001). Twenty (86.9%) of the 23 ica positive bacteria were slime producers, as opposed to only 6 (18.7%) of the 32 ica negative bacteria (P<0.001). Of the 23 multi-drug resistant isolates, 19 (82.6%) carried the mec A gene. INTERPRETATION & CONCLUSIONS: The present findings showed that ica AB and mec A were the two important virulence markers of S. epidermidis in implant infections and slime was responsible for the sessile mode of attachment on the devices.

The role of a commercial enzyme immuno assay antigen detection system for diagnosis of C. trachomatis in genital swab samples.

In the present pilot study, endocervical and urethral swabs collected from 100 patients attending sexually transmitted disease (STD) clinics and regional centre for STD in two referral hospitals in New Delhi were analyzed by enzyme immune assay (EIA), polymerase chain reaction (PCR) and direct fluorescent antibody (DFA) for detection of C. trachomatis. It was found that EIA could detect a very low number of cases (3/100) as against DFA (11/100) and PCR (9/100). Thus, in spite of the widespread availability, lower cost and ease of performance of the enzyme-linked-immunosorbent serologic assay, the present study highlights the need to employ sophisticated diagnostic tools like DFA and PCR for detection of Chlamydia trachomatis in STD patients.

Slime production is essential for the adherence of Staphylococcus epidermidis in implant-related infections.

A total of 32 Staphylococcus epidermidis isolates from indwelling device-related infections such as endophthalmitis following intraocular lens (IOL) implantation, intravenous catheter-related sepsis and orthopaedic implant infections, were studied for slime production and adherence to artificial surfaces. Of these, 21 (65.6%) isolates were slime positive by the Congo Red agar method and 24 (75%) were adherent to artificial surfaces by the quantitative slime test. The majority (19 out of 24; 79.1%) of the adherent bacteria were slime producers. Antibody to slime raised in rabbits was able to inhibit the adherence of all 24 bacteria designated as adherent by our quantitative test. It seems that slime is indispensable for the sessile mode of attachment, leading further to the development of biofilms on the indwelling devices.

Correlation of proteinase production with amphotericin B resistance in fungi from mycotic keratitis.

Two hundred fungal isolates (Aspergillus and Fusarium species) from mycotic keratitis were tested for in vitro susceptibilities to amphotericin B and proteinase production. Geometric mean MICs for all fungal species increased fourfold with thousandfold increase in the inoculum. The MIC(50) and MIC(90) values ranged between 3.12-6.25 and 3.12-12.5 microg/ml, respectively. Proteinase production was noted in 113 (56.5%) isolates. Ninety-eight (49%) showed MICs of > or =1.56 microg/ml that was above the criteria of > or =1 microg/ml for amphotericin B resistance (CLSI). Seventy-three (74.5%) of these 98 isolates were proteinase producers, whereas only 40 (39.2%) of the remaining 102 with low MICs (<1.56 microg/ml) were proteinase producers (p < 0.001). Proteinase seems to be an important virulence marker of filamentous fungi in mycotic keratitis, correlating significantly with amphotericin B resistance.

Ultrastructural analysis of slime positive & slime negative Staphylococcus epidermidis isolates in infectious keratitis.

BACKGROUND & OBJECTIVE: Slime is a major determinant of Staphylococcus epidermidis adherence. The established methods of laboratory detection of slime production by this organism i.e., Christensen's tube method and congo red agar plate method, can both yield inconclusive and/or intermediate results. We, therefore tried to find out electronmicroscopically the localization of slime in relation to the bacterial cell wall and look for the effect, if any of the slime location on the staphylococcal adherence as well as on the quantum of slime production. METHODS: A total of 132 coagulase negative staphylococci from cases of infectious keratitis were identified as S. epidermidis following the recommended protocol. Slime was detected both by Christensen's tube method and congo red agar plate method. Antibiotic sensitivity testing was performed by standardized disc diffusion method. Adherence of the organisms to artificial surfaces was determined by a quantitative method and transmission electron microscopy was carried out by the conventional techniques. RESULTS: Of the total 132 isolates, 57 (43.2%) were slime positive and 75 (56.8%) were slime negative. Twenty seven (47.4%) of the 57 slime producing organisms were multi drug resistant as compared to only 12 (16%) of 75 nonslime-producing organisms (P<0.001). A majority i.e., 45 (78.9%) of 57 adherent organisms were slime producers as against 12 (16%) of 75 nonadherent organisms. Electron microscopic study revealed a thick viscid layer of slime anchoring to the bacterial cell wall, especially in adherent organisms and those yielding positive slime test. Some of the organisms showed loose nonadherent slime and those were mostly nonadherent to artificial surfaces. INTERPRETATION & CONCLUSION: Slime and multi drug resistance were the important virulence factors of S. epidermidis in bacterial keratitis. It was the adherent slime (i.e., slime in intimate association with the bacterial cell wall as shown by electron microscopy) only, which was responsible for resistance to multiple antibiotics and for the adhesion phenomenon observed in the quantitative slime test.

Survival of Pseudomonas aeruginosa in M-K preserved corneas.

AIM: To present seven eyes of suspected donor to host transmitted Pseudomonas sp corneal graft infection after corneal and scleral graft leading to corneal melting within 24 hours, in a span of 10 months. METHODS: Case series. Seven eyes, operated for either penetrating or lamellar keratoplasty or scleral patch graft for different indications and which developed massive corneal/corneoscleral infection within 24 hours, were studied prospectively. RESULTS: Pseudomonas aeruginosa, resistant to almost all antibiotics except polymyxin B in all and vancomycin in two, was identified as the causative organism from all the specimens obtained from the infected graft. CONCLUSION: Post-keratoplasty infection is a disaster. The source of early infection is invariably iatrogenic. Use of empirical antibiotics in the media is not always sufficient to prevent such infection. Thus, measures must be taken in the form of strict maintenance of asepsis and revision of antibiotics added to the storage medium. Further, early recognition and energetic therapy for such infection could reduce the ophthalmic morbidity.

Encapsulation of chlorothiazide in whey proteins: effects of wall-to-core ratio and cross-linking conditions on microcapsule properties and drug release.

A model drug with limited water-solubility, chlorothiazide, was successfully encapsulated in whey protein-based wall systems cross-linked by glutaraldehyde-saturated toluene via an organic phase. The effects of drug content of the core-in-wall suspension and of cross-linking conditions on core retention and on microcapsule size, structure and core release properties were investigated. Spherical, surface cracks-free microcapsules ranging in diameter from approximately 200-1300 microm were obtained. Particle size distribution of microcapsules was affected by core content and cross-linking conditions. Core retention in microcapsules prepared at different cross-linking conditions and different wall-to-core ratios ranged from 48.9-81%, from 42.2-76.1% and from 37.3-67.2% in large (L), medium-size (M) and small (S) microcapsules, respectively. In all cases, drug crystals were physically entrapped and embedded throughout the cross-linked protein matrix. Core release from the microcapsules into enzyme-free simulated gastric fluid was governed by a diffusion-controlled mechanism and did not involve erosion or softening of the wall matrix. Rate of core release was significantly affected by a combined influence of core content, microcapsule size and cross-linking density. Complete core release from L, M and S microcapsule prepared at different wall-to-core ratios and cross-linking conditions ranged from 28.6-81.2 h, from 16.8-28.6 h and from 7.2-15.9 h, respectively. Results suggested that whey protein-based wall matrix cross-linked by GAST may provide significant opportunities in modulating the release of an encapsulated core with a limited water solubility.

Necrotizing periorbital Fusarium infection--an emerging pathogen in immunocompetent individuals.

Fungal infections of the skin and deeper tissues of the periorbital region are quite rare. We report a case of a localized, deep periorbital necrotizing Fusarium infection in an otherwise healthy, elderly lady. Since the clinical features and histopathological findings of Fusarium infection are by no means characteristic, the definitive diagnosis was achieved with the help of microbiological examination of cultured organisms. A combined medical and surgical therapy led to adequate control of infection. To conclude, localized, deep periorbital necrotizing soft tissue infection by Fusarium in an immunocompetent lady is not reported in literature. One should have a high index of suspicion for emerging fungal pathogens in the differential diagnosis of necrotizing orbital or adnexal conditions, even in an immunocompetent patient. The histologic findings of septate, branching hyphae and vascular invasion cannot distinguish Fusarium species from various other moulds such as Aspergillus species; microbiologic studies are essential for confirming the diagnosis.

Risk factors for graft infection in India: a case-control study.

AIM: To study the demographic, clinical, and microbiological profile and the risk factors for graft infection following penetrating keratoplasty. METHODS: 50 eyes of 50 consecutive patients with graft infection after an optical penetrating keratoplasty were included as cases; 50 eyes of 50 patients with no graft infection were included as controls. The main variables evaluated in this study included the clinical and microbiological profile, sociodemographic status, suture related problems, persistent epithelial defects, and ocular surface disorders. RESULTS: Cultures were positive in 43 (86%) eyes and Staphylococcus epidermidis (67.4%) was the most common organism isolated. Infection could be resolved with treatment in 37 (74%) eyes. In eight (16%) eyes the graft melted and a repeat penetrating keratoplasty had to be performed. Only 6% of the cases could achieve a best corrected visual acuity of 6/18 or better after resolution of the infection. In multivariate logistic regression analysis persistent epithelial defect (OR (95% CI): 3.0 (1.17 to 8.33)), suture related problems (OR (95% CI): 3.6 (1.39 to 9.25)), and ocular surface disorders (OR (95% CI): 2.4 (0.93 to 6.03)) were found to be statistically significant risk factors for graft infection following an optical penetrating keratoplasty. CONCLUSIONS: Staphylococcus epidermidis is the commonest organism responsible for post-keratoplasty microbial keratitis. Persistent epithelial defects, suture related problems, and ocular surface disorders are the major risk factors predisposing to graft infection.

Successful treatment of Acanthamoeba meningitis with combination oral antimicrobials.

Acanthamoeba was implicated as the causative agent of chronic meningitis in three apparently immunocompetent children. Diagnosis was established by cerebrospinal fluid wet mount examination and culture. Two children improved rapidly with combination oral therapy composed of trimethoprim-sulfamethoxazole, rifampin and ketoconazole.

Role of aprotinin in the management of experimental fungal keratitis.

In an experimentally induced Aspergillus fumigatus fungal keratitis in 20 rabbits, aprotinin, an antiplasmin agent, was studied to find out its role as an adjuvant when given along with other established antifungal agents like natamycin and fluconazole. The 20 rabbits included in this study were randomly divided into four equal treatment groups. Once the ulcer was produced after intrastromal injection of 0.03 ml of A. fumigatus (5.5 x 10(4) spores/ml), different drugs/agents in combination were used in a randomized manner. These were natamycin (5%) + placebo, natamycin + aprotinin (40 IU/ml), fluconazole (0.3%) + placebo and fluconazole + aprotinin. The rabbits were followed up every day to note the signs of healing which included subsidence of corneal infiltration, disappearance of stromal abscess and subsidence of corneal oedema till complete healing. Results showed that the average healing time was 28.2, 28.4, 49.8 and 49.0 days for natamycin + placebo, natamycin + aprotinin, fluconazole + placebo and fluconazole + aprotinin, respectively. It suggests that aprotinin as an adjuvant has no definite role in the management of fungal keratitis. The plasminogen activator-plasmin system which is inhibited by aprotinin may not be the pathway through which filamentous fungi like A. fumigatus cause tissue destruction.

Species specific chlamydiae antibodies in voluntary blood donors of Delhi.

BACKGROUND & OBJECTIVES: Different species of genus Chlamydia have been associated with ocular, genitourinary and respiratory infections, and coronary artery disease. Since the majority of these infections remain asymptomatic or subclinical, antibodies may be present in apparently healthy individuals, and the determination of species specific Chlamydia antibodies in a healthy population may reflect exposure. We therefore screened the sera of healthy blood donors for species specific Chlamydia antibodies by microimmunofluorescence assay. METHODS: Sera of 844 voluntary blood donors from Delhi were screened by microimmunofluorescence assay using specific antigens of C. trachomatis (18 serovars divided in 3 pools of serotypes A-C, D-K and L1-L3), C. psittaci and C. pneumoniae for Chlamydia antibodies. RESULTS: A total of 470 (55.69%) blood donors were found positive for Chlamydia antibodies. Of these, 361(42.77%) were positive for C. pneumoniae, 106 (12.5%) for C. trachomatis [of which 72 (8.5%) were against serotypes D-K and 34(4%) were against serotypes A-C]. There donors (0.3%) had antibodies to C. psittaci. INTERPRETATION & CONCLUSION: The results suggested that more than half of the study population (55.69%) is exposed to one or other species of chlamydiae. Majority of the donors (44.7%) had C. pneumoniae antibodies, suggesting the presence of widespread apparent or inapparent C. pneumoniae infection. The findings also suggest that Chlamydia antibody testing for the diagnosis of chlamydial infections may not be helpful due to the presence of antibodies in a large proportion of healthy individuals.

A simple alternative method for rapid detection of slime produced by Staphylococcus epidermidis isolates in bacterial keratitis.

BACKGROUND & OBJECTIVES: Slime is a known virulence factor of Staphylococcus epidermidis. The conventional Christensen's method for detection of slime in the laboratory takes at least 48 h. We, therefore, tried to evaluate the efficacy of the Congo red agar method as a routine procedure for detecting slime among isolates from corneal ulcers. METHODS: A total of 244 isolates from corneal ulcers were identified as S. epidermidis by the standard procedures. Slime was detected both by the conventional Christensen's method as well as by the Congo red agar method. RESULTS: Ninety two (37.7%) isolates were positive and 86 (35.2%) were negative for slime by both the techniques. Fifty four (22.1%) isolates were positive in Congo red agar, but negative by Christensen's method; whereas only 12 (4.9%) were negative by Congo red but positive by Christensen's method. Detection of slime by Congo red agar method was rapid i.e., all the 146 strains were positive within 24 h of incubation. On the other hand, Christensen's method had a delayed response; 42.3 per cent (44/104) strains being negative during the first 24 h of incubation. INTERPRETATION & CONCLUSION: Our results suggested that culture on Congo red agar was a sensitive and rapid test for detecting slime. This might help in the quick identification in a routine laboratory of slime positive isolates in bacterial keratitis.

Slime production as a virulence factor in Staphylococcus epidermidis isolated from bacterial keratitis.

A total of 126 coagulase negative staphylococci (CONS) isolated from corneal scrapings of patients of bacterial keratitis and 50 isolates from healthy eyes (controls) were tested for slime production. Eighty eight (69.84%) of 126 isolates from patients and 11 (22%) of 50 isolates from controls were slime producing (P < 0.001). Of these 88 isolates, 42 were Staphylococcus epidermidis biotype II, 30 were S. epidermidis biotype I, 8 were S. epidermidis biotype III and the rest belonged to CONS other than S. epidermidis. Amongst the corneal ulcer isolates, multidrug resistance (resistance to 3 or more antibiotics) was observed in 82.9 per cent (73/88) slime producing organisms as against only 18.4 per cent (7/38) nonslime producing organisms (P < 0.001). Similarly, of the total 99 slime positive and 77 slime negative isolates, 79 (79.8%) and 22 (28.6%) respectively were multidrug resistant (P < 0.001). Although, slime production is known to be one of the major virulence factors of CONS in extraocular systemic staphylococcal infections, the present study detected slime in isolates from ocular infections. It was found that S. epidermidis I and II were the common biotypes associated with bacterial keratitis and, slime production and multidrug resistance were the two important virulence factors. These observations have clinical and therapeutic significance.

Risk factors for pediatric presumed microbial keratitis: a case-control study.

PURPOSE: To evaluate risk factors for pediatric presumed microbial keratitis and to describe the clinical picture, microbiologic spectrum, treatment modalities, posttreatment sequelae, and visual outcome in cases of pediatric presumed microbial keratitis. METHODS: A case-control study design was used to identify the risk factors associated with pediatric presumed microbial keratitis. Fifty cases of fresh corneal ulceration aged 12 years or younger were compared with 50 controls. The study variables included were age, gender, immunization status, nutritional status (weight for height), and socioeconomic status. The clinical presentation of the cases with corneal ulceration, microbiologic spectrum, and treatment modalities also were evaluated. All the cases were followed up for a minimum of 3 months, and the posttreatment sequelae and visual outcome were analyzed. RESULTS: The mean (+/- standard deviation) age of children with corneal ulceration and controls was 4.8 (+/-3.8) years and 5.1 (+/-2.8) years, respectively. Incomplete immunization status (AOR [95% confidence interval (CI)], 1.34 [0.62-2.9]) and poor nutritional status [AOR (95% CI) 1.06 (0.68-1.6)] were not found to be the predictors of corneal ulceration. Lower socioeconomic status was significantly associated with the occurrence of corneal ulceration [AOR (95% CI) 1.52 (1.1-2.3)]. Corneal trauma (38%) and systemic illness (24%) were the most often associated predisposing factors. Seventy percent of the cases were culture positive. Staphylococcus (70%) species was the most frequently isolated, followed by Pseudomonas aeruginosa (10%). Fungi were isolated in five eyes. Postresolution visual acuity at 3 months could be recorded only in 31 eyes and a visual acuity of 6/18 or better was achieved in 22% of these cases. CONCLUSION: Corneal ulceration in pediatric age group in India is associated with poverty.

Rhodotorula sp. infection in corneal interface following lamellar keratoplasty--a case report.

PURPOSE: To report an unusual organism causing infection following lamellar keratoplasty. METHOD: Case report. RESULT: Both gram stain smear and culture from the interlamellar bed revealed Rhodotorula sp., a red yeast as a causative agent. CONCLUSION: Rhodotorula sp. can cause corneal lamellar graft infection.

Topical pefloxacin in bacterial keratitis.

PROBLEM: To evaluate the clinical efficacy and safety of topical pefloxacin 0.3% drops as the sole antibiotic used to treat culture positive bacterial corneal ulcers. METHODS: Forty two consecutive Gram's smear-positive cases of bacterial corneal ulcers were enrolled for this prospective open labelled clinical trial. All patients underwent a complete clinical and microbiological work up and were put on topical 0.3% pefloxacin drops with supportive cycloplegic, vitamins and antiglaucoma therapy. Of 42 cases, 4 cases of mycotic keratitis and 6 culture negative cases were excluded from the study. RESULTS: Positive microbiologic cultures were obtained in 84.2% (32 of 38) cases. Staphylococcus aureus (14/32; 43.7%) and coagulase negative Staphylococci (12/32; 37.5%) were the two most common organisms isolated. Resolution of the corneal ulcer was achieved in 31 out of 32 cases (96.9%) with a mean duration of 9.3+/-5.3 days (range 3-21 days). Best corrected visual acuity of 20/200 or better was achieved in 65.6% of cases at 4 weeks post resolution. Corneal deposits were observed in one case which disappeared 8 days following discontinuation of therapy. CONCLUSIONS: Topical pefloxacin is effective as a single antibiotic agent for the treatment of bacterial keratitis.

Mycotic keratitis in children: epidemiologic and microbiologic evaluation.

PURPOSE: To evaluate the demographic features, clinical profile, and laboratory diagnosis in cases of mycotic keratitis in children. METHODS: We retrospectively analyzed 211 cases of mycotic keratitis in children younger than 16 years over a 5-year period in a tertiary eye center. Culture-proven cases of fungal keratitis were reviewed. RESULTS: Trauma was the most common predisposing factor (55.3%), followed by associated systemic illness (11.2%), previous ocular surgery (9.8%), and others. Corneal injury contaminated with vegetable matter was responsible for 60.5% of traumatic cases. Aspergillus species were the most frequent isolates (39.5%). Others included Fusarium (10.7%), Alternaria (10.2%), Curvularia (7.4%), and Penicillium (7%). A seasonal variation in the incidence of mycotic keratitis revealed a peak incidence in the months of September and October. One hundred sixty-two children (76.7%) cooperated for examination and scraping under topical anesthesia with or without sedation. General anesthesia for scraping was required in 49 (23%) of 211 children for corneal scraping. Gram stains of corneal scraping were positive for hyphal elements in 54.5% of cases, and potassium hydroxide wet-mount preparation was positive in 90.2% of cases. CONCLUSIONS: This study highlights important risk factors and organisms responsible for mycotic keratitis in children.