Antinuclear antibody titration and pattern are helpful in the diagnosis of systemic autoimmune rheumatic diseases.

INTRODUCTION: Anti-nuclear antibody (ANA) testing is among the most common immunological test requested in the diagnostic immunology laboratory. The main purpose of this test is to screen for the underlying systemic autoimmune rheumatic diseases (SARDs). The gold standard laboratory method for ANA detection is by the indirect immunofluorescence (IIF) assay. In most laboratories, positive ANA-IIF is reported in terms of titration and pattern. OBJECTIVE: This study was conducted with the aim of determining the correlation between ANA-IIF titration and pattern for the diagnosis of SARDs. MATERIALS AND METHODS: A retrospective study was conducted whereby the positive ANA-IIF samples from 1st July 2018 until 31st December 2019 and 1st January 2021 until 31st March 2021 were included in this study. The duplicate samples were excluded. ANA-IIF titration and pattern were recorded for all patients. The demographic, clinical, and final diagnosis data were retrieved from each patient's clinical note. RESULTS: A total of 179 patients were included for analysis. The majority of the patients were female (79.9%) and from Malay ethnicity (66.5%). Sixty-five patients (36.3%) had ANA-IIF positive at 1:80 titration followed by 45 patients (25.1%) positive at titration of equal or more than 1:160. Speckled was the predominant pattern visualised in 90 patients (50.3%) followed by homogeneous in 76 patients (42.5%). Forty-five patients (25.1%) were finally diagnosed with SARDs with 41 of them diagnosed as SLE. ANA titration was significantly associated with the final diagnosis of SARDs at all titres (p<0.001) but the best cut-off was noted at a titre of equal or more than 1:320 with the sensitivity and specificity of 86.7% and 77.6% respectively. The homogeneous pattern was also significantly associated with SARDs (p=0.04). The final diagnosis of SARDs were significantly higher in female (p=0.03) and their age was significantly younger (p<0.001). CONCLUSION: ANA-IIF titration of equal or more than 1:320 can be used as the best titration for differentiating between SARDs and non-SARDs in a positive ANA sample. Patients with homogeneous pattern were more likely to be diagnosed with SARDs than other ANA-IIF patterns.

Antifungal susceptibility profile and biofilm-producing capability of Candida tropicalis isolates in a tertiary medical centre.

BACKGROUND: Candida tropicalis is a globally distributed yeast that has been popping up in the medical literature lately, albeit for unenviable reasons. C. tropicalis is associated with substantial morbidity, mortality as well as drug resistance. The aims of this study were to ascertain the antifungal susceptibility profile and the biofilm-producing capability of this notorious yeast in our centre. METHODS: C. tropicalis isolates from sterile specimens were collected over a 12-month period. Conclusive identification was achieved biochemically with the ID 32 C kit. Susceptibility to nine antifungal agents was carried out using the colourimetric broth microdilution kit Sensititre YeastOne YO10. Biofilm-producing capability was evaluated by quantifying biomass formation spectrophotometrically following staining with crystal violet. RESULTS: Twenty-four non-repetitive isolates of C. tropicalis were collected. The resistance rates to the triazole agents were 29.2% for fluconazole, 16.7% for itraconazole, 20.8% for voriconazole and 8.3% for posaconazole-the pan-azole resistance rate was identical to that of posaconazole. No resistance was recorded for amphotericin B, flucysosine or any of the echinocandins tested. A total of 16/24 (66.7%) isolates were categorized as high biomass producers and 8/24 (33.3%) were moderate biomass producers. None of our isolates were low biomass producers. CONCLUSION: The C. tropicalis isolates from our centre were resistant only to triazole agents, with the highest resistance rate being recorded for fluconazole and the lowest for posaconazole. While this is not by itself alarming, the fact that our isolates were prolific biofilm producers means that even azole-susceptible isolates can be paradoxically refractory to antifungal therapy.

Non-bacteremia liver abscess caused by Burkholderia pseudomallei from a tertiary teaching hospital in Malaysia: a case report and literature review.

Melioidosis is endemic in Southeast Asia, including Malaysia. Liver abscess is not uncommon in melioidosis, but it is usually associated with bacteremia. We presented a case of a 55-year-old gentleman with underlying end-stage renal failure who presented with non-specific abdominal pain for three months. Initial blood investigations showed leukocytosis and increased C-reactive protein. Computed tomography (CT) of the abdomen revealed multiple hypodense lesions in the liver and spleen. The culture of the liver specimen obtained through the ultrasound-guided isolated Burkholderia pseudomallei. He was given an adjusted dose of intravenous ceftazidime due to underlying renal failure. Melioidosis serology also returned positive for IgM with titer >1:1280. His blood cultures were reported negative three times. Despite on antibiotics for five weeks, there was no significant improvement of the liver abscesses was observed. He was unfortunately infected with the SARS-CoV-2 virus during his admission and passed away due to severe COVID-19 pneumonia.

The recognition of anti-nuclear antibody's dense fine speckled pattern and the detection of anti-DFS70 antibodies in the laboratory practice: Its prevalence and clinical significance.

Anti-nuclear antibody test (ANA) is the test commonly requested for the working diagnosis of systemic autoimmune rheumatic diseases (SARDs) particularly in ANA-associated rheumatic diseases (AARDs) such as SLE, systemic sclerosis, Sjogren syndrome, mixed connective tissue diseases, and dermatomyositis. Dense fine speckled (DFS) pattern is an ANA fluorescence pattern that is commonly encountered in laboratories. This pattern is largely detected among the healthy population and in non-SARDs patients. Although this pattern is still can be observed among SARDs patients, the low prevalence of monospecific or isolated anti-DFS70 antibodies makes it useful for ruling out AARDs diagnosis. Thus, the inclusion of anti-DFS70 antibodies is perhaps logical for the exclusion of SARDs/AARDs. This review provides evidence of the prevalence of anti-DFS70 antibodies in different populations including healthy individuals, patients with SARDs and non- SARDs. The algorithm that includes the detection of anti-DFS70 antibodies during ANA screening is also suggested.

Bullous cellulitis as an extraordinary manifestation of a Vibrio cholerae O1 Ogawa infection.

Vibrio cholerae is a gram-negative bacterium synonymous with its namesake disease, cholera. Thus, gastrointestinal symptoms are the norm and V. cholerae is very rarely associated with skin and soft tissue infections. We describe a case of a 63-year-old Chinese woman with multiple medical comorbidities on corticosteroid therapy who developed fever and a painful swelling on her left leg after being pricked by a branch while gardening. There was no abdominal pain, vomiting or diarrhea. A diagnosis of bullous cellulitis was made clinically, and blood was sent for bacteriological culture. A beta-hemolytic commashaped gram-negative bacillus was isolated from the blood. It was also oxidase-positive and produced an acid/alkaline (A/K) reaction on triple sugar iron agar. It was identified biochemically as Vibrio cholerae. After additional testing, it was found to be of the O1 serogroup and Ogawa serotype. The infection resolved following a 10-day course of high-dose co-trimoxazole therapy.

Salmonella enteritidis abdominal aorta mycotic aneurysm presented with acute cholestatic jaundice: A case report and literature review.

Mycotic aneurysm is one of the extra-intestinal manifestations of Salmonella Enteritidis infection. The diagnosis of this condition is challenging owed to its variation in clinical presentations. We presented a case of a 54-year-old man with underlying diabetes mellitus and chronic smokers presented with acute right flank pain and fever associated with mild jaundice. The initial laboratory investigations suggested features of obstructive jaundice and urinary tract infection. The contrast enhancing computed tomography of the abdomen revealed the presence of saccular mycotic aneurysm located at the infrarenal abdominal aorta. The blood culture grew Salmonella Enteritidis which was susceptible to ceftriaxone, trimethoprim-sulfamethoxazole, ciprofloxacin, ampicillin, and amoxicillin-clavulanic acid. Intravenous ceftriaxone was initiated, and he underwent open surgery and artery repair at day 8 of admission. He responded well to the treatment given and subsequently discharged home after completed three weeks of intravenous ceftriaxone.

Effect of dietary supplementation of Spirulina platensis powder on performance, some serum biochemistry, digestive enzymes, microbial content, antioxidant parameters and immune responses of growing Japanese quail.

This study was performed to examine the influences of Spirulina platensis powder (SPP) on growth performance, physiological status, blood biochemistry, and intestinal microbial population in quail. 240-10-days old Japanese quail chicks were distributed into five groups. Each group had four replicate pens with 12 birds each. The first group received a basal diet (control group). Groups from two to five received the basal diet with SPP at levels of 1.5, 3.0, 4.5, and 6.0% as dietary ingredients, respectively. Results clarified significantly higher live body weight and body weight gain (p < 0.001) with significant enhancements (p < 0.001) in feed conversion values for groups that received SPP levels, especially 4.5% compared with the control and other groups. Birds fed on a diet containing SPP had significantly higher amylase, trypsin and lipase levels (p < 0.001) than the control. Intestinal Lactobacillus sp. was significantly increased, and Escherichia coli and Salamonella populations were significantly decreased by dietary SPP levels (p < 0.001). Liver function, total lipid profile, antioxidant parameters and immune response were significantly affected by SPP levels compared with the control (p < 0.001). In conclusion, the inclusion of SPP until 4.5% in quail diets could improve the growth performance, intestinal microbial population and serum biochemical constituents of growing quail.

Effect of dietary supplementation of Jerusalem Artichoke extract on performance, blood biochemistry, antioxidant parameters, and immune response of growing Japanese quail.

This study aimed to examine the impact of the Jerusalem Artichoke extract (JAEx) as a feed additive on the performance, blood biochemistry, antioxidant indices, immunity, and intestinal microbiota in growing Japanese quails. In total, 270 birds were randomly divided into three groups, with six replicates of 15 birds each. The first group was fed a control diet without JAEx. The second and third groups received the control diet plus 200 and 400 ppm JAEx, respectively. The groups fed the diet containing 200 and 400 ppm JAEx had the best body weight, body weight gain and feed conversion ratio, and faster growth rate with the best performance index, compared with the control group (p < 0.05). The control quails had a lower feed intake than the JAEx-treated quails. The groups fed JAEx 200 and 400 ppm had the lowest lipid profile, blood glucose, liver enzymes, Salmonella and Escherichia coli population and the highest antioxidant indices, immune responses and Lactobacilli population number compared to the control group (p < 0.05). In conclusion, the addition of JAEx at 400 ppm followed by 200 ppm improved the productive performance, antioxidant capacity, blood biochemical and immunological indices, and intestinal microbiota in growing Japanese quails.

Non-bacteremia liver abscess caused by Burkholderia pseudomallei from a tertiary teaching hospital in Malaysia: a case report and literature review

@#Melioidosis is endemic in Southeast Asia, including Malaysia. Liver abscess is not uncommon in melioidosis, but it is usually associated with bacteremia. We presented a case of a 55-year-old gentleman with underlying end-stage renal failure who presented with non-specific abdominal pain for three months. Initial blood investigations showed leukocytosis and increased C-reactive protein. Computed tomography (CT) of the abdomen revealed multiple hypodense lesions in the liver and spleen. The culture of the liver specimen obtained through the ultrasound-guided isolated Burkholderia pseudomallei. He was given an adjusted dose of intravenous ceftazidime due to underlying renal failure. Melioidosis serology also returned positive for IgM with titer >1:1280. His blood cultures were reported negative three times. Despite on antibiotics for five weeks, there was no significant improvement of the liver abscesses was observed. He was unfortunately infected with the SARS-CoV-2 virus during his admission and passed away due to severe COVID-19 pneumonia.

Bullous cellulitis as an extraordinary manifestation of a Vibrio cholerae O1 Ogawa infection

@#Vibrio cholerae is a gram-negative bacterium synonymous with its namesake disease, cholera. Thus, gastrointestinal symptoms are the norm and V. cholerae is very rarely associated with skin and soft tissue infections. We describe a case of a 63-year-old Chinese woman with multiple medical comorbidities on corticosteroid therapy who developed fever and a painful swelling on her left leg after being pricked by a branch while gardening. There was no abdominal pain, vomiting or diarrhea. A diagnosis of bullous cellulitis was made clinically, and blood was sent for bacteriological culture. A beta-hemolytic commashaped gram-negative bacillus was isolated from the blood. It was also oxidase-positive and produced an acid/alkaline (A/K) reaction on triple sugar iron agar. It was identified biochemically as Vibrio cholerae. After additional testing, it was found to be of the O1 serogroup and Ogawa serotype. The infection resolved following a 10-day course of high-dose co-trimoxazole therapy.

Salmonella enteritidis abdominal aorta mycotic aneurysm presented with acute cholestatic jaundice: A case report and literature review

@#Mycotic aneurysm is one of the extra-intestinal manifestations of Salmonella Enteritidis infection. The diagnosis of this condition is challenging owed to its variation in clinical presentations. We presented a case of a 54-year-old man with underlying diabetes mellitus and chronic smokers presented with acute right flank pain and fever associated with mild jaundice. The initial laboratory investigations suggested features of obstructive jaundice and urinary tract infection. The contrast enhancing computed tomography of the abdomen revealed the presence of saccular mycotic aneurysm located at the infrarenal abdominal aorta. The blood culture grew Salmonella Enteritidis which was susceptible to ceftriaxone, trimethoprim-sulfamethoxazole, ciprofloxacin, ampicillin, and amoxicillin-clavulanic acid. Intravenous ceftriaxone was initiated, and he underwent open surgery and artery repair at day 8 of admission. He responded well to the treatment given and subsequently discharged home after completed three weeks of intravenous ceftriaxone.

Clinical and laboratory observation on immunoglobulin replacement therapy switching from an intravenous to a subcutaneous route in a Malaysian X-linked agammaglobulinemia patient.

We report a clinical and laboratory observation in a boy with X-linked agammaglobulinemia (XLA) who underwent an immunoglobulin replacement therapy (IRT) via the subcutaneous route (IGSC) seven years after his IRT via intravenous route (IGIV). He was free of invasive infections when on IGIV but not the troublesome coughs a week before the next infusion. A switch to a subcutaneous route resulted in significant improvement of symptoms with good weight gain. When on 2-weekly IGSC cycle, adjusting dose for weight resulted in an IgG trough level of > 600 mg/dl.

Brain abscess caused by Salmonella Enteritidis following craniotomy for meningioma: A case report and literature review.

Salmonella intracranial infection is infrequently encountered in clinical practice. However, with prompt intervention and appropriate antimicrobial therapy, the outcome is usually favourable. A 56-year-old gentleman who worked as an organic fertilizer production supervisor underwent tumour resection for meningioma located at the left frontal temporoparietal region. The surgical procedure went smoothly, and he has prescribed dexamethasone thereafter. He was discharged well. However, a few days after that he developed a fever associated with pus discharged from the surgical wound. A computed tomography (CT) scan of the brain was performed and it revealed an abscess located at the left frontal temporoparietal subdural and subgaleal regions with adjacent cerebritis. Another craniotomy was done to drain the abscess. The bacterial culture of the pus specimen grew Salmonella Enteritidis. The bacterium was susceptible to ciprofloxacin, ceftriaxone, and amoxicillin-clavulanic acid. Clinical improvement was evident after surgical intervention with an additional 6 weeks of ceftriaxone therapy.

Adult-onset nasopharyngeal diphtheria: an uncommon but rapidly progressive and potentially fatal infection.

Nasopharyngeal diphtheria is an acute infectious upper respiratory tract disease caused by toxigenic strains of Corynebacterium diphtheriae. We report a case of a young adult who presented to us with a short history of fever, sore throat, hoarseness of voice and neck swelling. He claimed to have received all his childhood vaccinations and had no known medical illnesses. During laryngoscopy, a white slough (or membrane) was seen at the base of his tongue. The epiglottis was also bulky and the arytenoids were swollen bilaterally. The membrane was sent to the microbiology laboratory for culture. A diagnosis of nasopharyngeal diphtheria was made clinically and the patient was treated with an antitoxin together with erythromycin, while awaiting the culture result. Nevertheless, the patient's condition deteriorated swiftly and although the laboratory eventually confirmed an infection by toxin-producing C. diphtheriae, the patient had already succumbed to the infection.

Typhoid fever presenting as acute psychosis in a young adult: case report and literature review of typhoid psychosis.

The rarity of acute psychosis in typhoid fever can result in delayed and misdiagnosis of the condition. We report a case of a 20-year-old man who presented with fever and acute psychotic symptoms. This was associated with headache, dizziness, and body weakness. There were no other significant symptoms. Neurological examination revealed reduced muscle tone of bilateral lower limbs but otherwise unremarkable. The computed tomography (CT) scan of his brain showed no abnormality. Blood specimens for microbiological culture grew Salmonella Typhi. This isolate was susceptible to chloramphenicol, ampicillin, ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole. He was treated with intravenous ceftriaxone for one week and responded well. He was discharged with oral ciprofloxacin for another week. The repeated blood and stool for bacterial culture yielded no growth of Salmonella Typhi.

Typhoid fever presenting as acute psychosis in a young adult: case report and literature review of typhoid psychosis

@#The rarity of acute psychosis in typhoid fever can result in delayed and misdiagnosis of the condition. We report a case of a 20-year-old man who presented with fever and acute psychotic symptoms. This was associated with headache, dizziness, and body weakness. There were no other significant symptoms. Neurological examination revealed reduced muscle tone of bilateral lower limbs but otherwise unremarkable. The computed tomography (CT) scan of his brain showed no abnormality. Blood specimens for microbiological culture grew Salmonella Typhi. This isolate was susceptible to chloramphenicol, ampicillin, ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole. He was treated with intravenous ceftriaxone for one week and responded well. He was discharged with oral ciprofloxacin for another week. The repeated blood and stool for bacterial culture yielded no growth of Salmonella Typhi.

Adult-onset nasopharyngeal diphtheria: an uncommon but rapidly progressive and potentially fatal infection

@#Nasopharyngeal diphtheria is an acute infectious upper respiratory tract disease caused by toxigenic strains of Corynebacterium diphtheriae. We report a case of a young adult who presented to us with a short history of fever, sore throat, hoarseness of voice and neck swelling. He claimed to have received all his childhood vaccinations and had no known medical illnesses. During laryngoscopy, a white slough (or membrane) was seen at the base of his tongue. The epiglottis was also bulky and the arytenoids were swollen bilaterally. The membrane was sent to the microbiology laboratory for culture. A diagnosis of nasopharyngeal diphtheria was made clinically and the patient was treated with an antitoxin together with erythromycin, while awaiting the culture result. Nevertheless, the patient’s condition deteriorated swiftly and although the laboratory eventually confirmed an infection by toxin-producing C. diphtheriae, the patient had already succumbed to the infection.

The reliability of a rapid molecular detection method in determining the prevalence of rifampicin-resistant Mycobacterium tuberculosis in an urban district health facility in Malaysia.

INTRODUCTION: Rifampicin is a key first-line antimycobacterial agent employed for the treatment of pulmonary tuberculosis (PTB). This study sought to obtain prevalence data on rifampicin-resistant Mycobacterium tuberculosis among smear-positive PTB patients in the Klang District of Malaysia. MATERIALS AND METHODS: A total of 103 patients from the Chest Clinic of Hospital Tengku Ampuan Rahimah with sputum smears positive for acid-fast bacilli were included in this cross-sectional study. All sputa were tested using Xpert MTB/RIF to confirm the presence of M. tuberculosis complex and detect rifampicin resistance. Sputa were also sent to a respiratory medicine institute for mycobacterial culture. Positive cultures were then submitted to a reference laboratory, where isolates identified as M. tuberculosis complex underwent drug susceptibility testing (DST). RESULTS: A total of 58 (56.3%) patients were newly diagnosed and 45 (43.7%) patients were previously treated. Xpert MTB/RIF was able to detect rifampicin resistance with a sensitivity and specificity of 87.5% and 98.9%, respectively. Assuming that a single resistant result from Xpert MTB/RIF or any DST method was sufficient to denote resistance, a total of 8/103 patients had rifampicinresistant M. tuberculosis. All eight patients were previously treated for PTB (p<0.05). The overall prevalence of rifampicin resistance among smear-positive PTB patients was 7.8%, although it was 17.8% among the previously treated ones. CONCLUSION: The local prevalence of rifampicin-resistant M. tuberculosis was particularly high among previously treated patients. Xpert MTB/RIF can be employed in urban district health facilities not only to diagnose PTB in smear-positive patients, but also to detect rifampicin resistance with good sensitivity and specificity.

Trichosporon Asahii fungaemia in an immunocompetent polytrauma patient who received multiple antibiotics.

Trichosporon asahii is a yeast-like fungus that is emerging as an important cause of invasive infections in tertiary medical centres. A 58-year-old Chinese man with no known medical illnesses presented with liver lacerations and multiple fractures following an alleged 12-foot fall at a construction site. The gravity of his injuries and poor haemodynamic status necessitated an intensive care unit (ICU) admission, during which several febrile episodes were detected and multiple antibiotics were administered. After being in the ICU for at least two weeks, a urease-positive yeast was isolated from the patient's blood. The yeast formed dry, fuzzy and wrinkled white colonies on Sabouraud dextrose agar following prolonged incubation, and produced blastoconidia, true hyphae, pseudohyphae and arthroconidia on slide culture. It was identified biochemically by the ID 32 C kit as T. asahii. The yeast had elevated minimal inhibitory concentration (MIC) values to fluconazole, amphotericin B, flucytosine and all echinocandins tested. In view of this, the patient was treated with voriconazole and was successfully transferred to the general medical ward.

A fatal case of primary melioidotic prostatic abscess: the peril of poor drug compliance.

Primary prostatic melioidosis is a rare presentation of melioidosis even in melioidosis endemic areas. We report a case of a 58-year-old man with underlying diabetes mellitus who presented with a 5-day history of high-grade fever associated with lower urinary tract symptoms. Suprapubic tenderness and tender prostatomegaly were noted on examination. An abdominal computed tomography (CT) scan confirmed the presence of a prostatic abscess. Both blood and prostatic pus cultures grew Burkholderia pseudomallei. He was initially started on intravenous ceftazidime, followed by an escalation to intravenous meropenem. He was discharged home with oral amoxicillin-clavulanate and doxycycline after completing 12 days of meropenem. Unfortunately, his compliance to oral antibiotic therapy was poor, and he succumbed to the disease.