Capsule-Deficient Cryptococcal Meningitis: A Diagnostic Conundrum.

Cryptococcosis is a serious systemic mycosis. Its incidence has escalated in the past four decades. Cryptococcus neoformans causes localized or disseminated infection in immunocompromised and immunocompetent patients. The capsulated form is commonly encountered which can be diagnosed on an India ink preparation or antigen detection. However, the noncapsulated forms are very rare and require a high index of suspicion for correct diagnosis. Herein, we present a case of cryptococcal meningitis due to a noncapsulated strain in an apparently immunocompetent patient with no proven immunodeficiencies along with review of world literature. Such cases are a diagnostic challenge for the clinician as well as microbiologist.

Typing of Neisseria gonorrhoeae isolates by phenotypic and genotypic techniques in New Delhi, India.

BACKGROUND: The objective of this study is to investigate gonococcal isolates using phenotypic and genotypic methods. METHODOLOGY: Sixty gonococcal isolates obtained were examined. Strains were divided into 9 resistant phenotypes: Chromosomally mediated penicillin-resistant Neisseria gonorrhoeae (CMRNGP), penicillinase-producing NG (PPNG), chromosomally mediated tetracycline-resistant NG (CMRNGT), TRNG, PPNG and TRNG, CMRNGPT, quinolone resistant NG (QRNG), Azithro R, and decreased susceptibility (DS) to ceftriaxone. These isolates were also subjected to auxotyping and NG-multi-antigen sequence typing (MAST). RESULTS: Of 60 isolates, 32 (53.33%) PPNG and only one was CMRNGP; 16 (26.66%) were CMRNGT, while 18 (30%) were TRNG. Both PPNG and TRNG found in 13 (21.66%) and none were CMRNGPT. QRNG was seen in 93.33%, 5% Azithromycin R, and 6.66% were DS to ceftriaxone. Based on auxotyping, 24 (40%) nonrequiring, 16 (26.66%) were proline requiring, 13 (21.66%) arginine requiring while 7 (11.66%) belonged to others. The most common ST was 6058 (32.5%). The discriminatory indices of antibiogram, auxotyping and NG-MAST were 0.77, 0.72, and 0.95, respectively. CONCLUSIONS: NG-MAST is the method of choice for epidemiological studies.

Nagging Presence of Clostridium difficile Associated Diarrhoea in North India.

INTRODUCTION: Clostridium Difficile Associated Diarrhoea (CDAD) is a significant cause of morbidity in hospitalised patients worldwide. The data on clinical epidemiology of this disease in Indian subcontinent is scarce. AIM: To evaluate the risk factors and clinical course of patients with CDAD. MATERIALS AND METHODS: A cross-sectional study was planned at our tertiary care centre, All India Institute of Medical Sciences, whereby, all patients who had nosocomial diarrhea between 2010 and 2014 were included in the study. Their clinical and laboratory profile were recorded using structured questionnaire and their stool samples were subjected to ELISA for detection of toxins A and B (Premier toxins A and B). Those patients who had toxins A and B in their stool samples were diagnosed as CDAD. The clinical and laboratory profile of CDAD patients were further analysed. RESULTS: A total of 791 patients with nosocomial diarrhea were included in this study. CDAD was diagnosed in a total of 48(6%) patients. The year wise breakdown of the positive patients is as follows: 7/135 (5.2%), 4/156 (2.6%), 5/141 (3.5%), 9/193 (4.7%) and 23/166 (13.8%), respectively. A total of 16/48 (33.3%) of CDAD cases belonged to the age group of 51-60 years. Malignancy (n=15, 31.25%) was the most common underlying pathological condition. All the patients had a history of antibiotic intake. Most common antibiotic used in the patients of CDAD was third generation cephalosporins (n=27, 56.25%). The use of clindamycin, carbapenems and colistin increased in the year 2014. Mean duration of hospital stay was 9.8 days. Diarrhoea was associated with fever in 50% of the patients while abdominal pain was seen in 39.6% of the patients. CONCLUSION: The control of Clostridium difficile infection suffers from the rampant use of higher antibiotics. There is a need for proper implementation of antimicrobial stewardship programmes and better hospital infection control to stop the transmission of this nagging bug.

Detection of Mycoplasma pneumoniae and Legionella pneumophila in Patients Having Community-Acquired Pneumonia: A Multicentric Study from New Delhi, India.

Atypical pathogens including Mycoplasma pneumoniae and Legionella pneumophila are increasingly recognized as important causes of community-acquired pneumonia (CAP). Mycoplasma pneumoniae accounts for 20-40% of all CAP and L. pneumophila is responsible for 3-15% of cases. The paucity of data from India in this regard prompted us to conduct this prospective multicentric analysis to detect the prevalence of M. pneumoniae and L. pneumophila in our geographical region. A total of 453 patients with symptoms of pneumonia and 90 controls with no history of lower respiratory tract infections were included in the study. A duplex polymerase chain reaction (PCR) targeting 543 bp region of P1 adhesin gene of M. pneumoniae and 375 bp region of macrophage infectivity potentiator (mip) gene of L. pneumophila was standardized for simultaneous detection of these atypical pathogens. Respiratory secretions, blood, and urine samples were collected from each patient and control and were subjected to duplex PCR, culture and serology for M. pneumoniae and L. pneumophila. Urine samples were subjected for detecting L. pneumophila antigen. Among the 453 patients investigated for M. pneumoniae, 52 (11.4%) were positive for IgM antibodies, 17 were positive by culture, and seven tested positive by PCR (P1 gene). Similarly for L. pneumophila, 50 cases (11%) were serologically positive for IgM antibodies, one was positive by PCR (mip gene) and urine antigen detection. A total of eight samples were positive by duplex PCR for M. pneumoniae P1 gene (N = 7) and L. pneumophila mip gene (N = 1). Of the 90 controls, two samples (2.2%) showed IgM positivity, and 15 (16.7%) showed IgG positivity for M. pneumoniae. For L. pneumophila, three samples (3.3%) tested positive for IgM, and 12 (13.3%) tested positive for IgG antibodies. The study findings indicate the presence of M. pneumoniae and L. pneumophila in our geographical region, and a combination of laboratory approaches including PCR, culture, and serology is required for effective detection of these agents.

Comparative evaluation of galactomannan test with bronchoalveolar lavage and serum for the diagnosis of invasive aspergillosis in patients with hematological malignancies.

INTRODUCTION: Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in patients with hematological malignancies. In recent years, testing for values of galactomannan (GM) in serum and bronchoalveolar lavage (BAL) fluid has been investigated as a diagnostic test for IPA for such patients, but global experience and consensus on optical density (OD) cutoffs, especially for BAL galactomannan remains lacking. METHODS: We performed a prospective case-control study to determine an optimal BAL GM OD cutoff for IPA in at-risk patients. Cases were subjects with hematological diagnoses who met established revised definitions for proven or probable IPA established by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group (EORTC/MSG, 2008), without the use of BAL GM results. Exclusion criteria included the use of piperacillin/tazobactam and use of antifungals that were active against Aspergillus spp. before bronchoscopy. There were two control groups: patients with hematological diagnoses not meeting definitions for proven or probable IPA and patients with nonhematological diagnoses with no evidence of aspergillosis. Following bronchoscopy and BAL, GM testing was performed using the Platelia Aspergillus seroassay in accordance with the manufacturer's instructions. RESULTS: There were 51 cases and 20 controls. Cases had higher BAL fluid GM OD indices (ODIs) (mean: 1.27 and range: 0.4-3.78) compared with controls (mean: 0.26 and range: 0.09-0.35). Receiver operating characteristic analysis demonstrated an optimum ODI cutoff of 1.0, with high specificity (100%) and sensitivity (87.5%) for diagnosing IPA. CONCLUSIONS: Our results support BAL GM testing as a reasonably safe test with higher sensitivity compared to serum GM testing in at-risk patients with hematological diseases. A higher OD cutoff is necessary to avoid overdiagnosis of IPA.

Osteomyelitis due to multiple rare infections in a patient with idiopathic CD4 lymphocytopenia.

A 26-year-old male patient presented with features suggestive of osteomyelitis involving the entire left femur, hip joint and knee joint. Culture from the debrided tissue grew Acinetobacter spp. and he was treated with sensitivity based antibiotics but the symptoms did not resolve. The synovial biopsy showed multinucleated giant cells and acid fast bacilli on Ziehl Neelsen stain. Cartridge based nucleic acid amplification test (GeneXpert) was negative. The Mycobacteria growth indicator tube culture was found to be positive for Mycobacterium abscessus. The patient was started on imipenem, amikacin and macrolide based therapy. There was partial response initially but the patient worsened again. A girdle stone arthroplasty with cemented nail (with tobramycin) insertion after debridement of the infected tissue was done. Potassium hydroxide (KOH) mount from the debridement sample was found to be positive for aseptate hyphae suggestive of mucormycosis. He was treated with liposomal amphotericin B. He was evaluated for immunodeficiency in view of multiple atypical infections and was found to have a low CD4 count. The patient was discharged on amikacin, azithromycin, trimethoprim-sulfamethoxazole and posaconazole. Follow up showed considerable resolution both clinically and radiologically. To our knowledge, this is the first reported case of osteomyelitis with co-infection of Acinetobacter spp., M. abscessus and mucormycetes. We report this case to highlight the possibility of multiple rare infections in patients with immunodeficiency. Also, atypical complicated bone infections, such as Mycobacterium abscessus and mucormycetes might require combined medical and surgical treatment.