Epstein-Barr futile myocarditis requiring urgent orthotopic heart transplantation.

We present the case of a 37-year-old man who was diagnosed with an Epstein-Barr futile myocarditis. The diagnosis was made in the Accident and Emergency Department, with the input of portable echocardiography. The patient subsequently underwent an urgent orthotopic heart transplantation and he has now completely recovered.

Antimicrobial activity of tigecycline against nosocomial pathogens in Pakistan: a multicenter study.

OBJECTIVE: To measure the in-vitro activity of various antibiotics including tigecycline against Gram negative and positive nosocomial aerobic isolates. METHODS: A total of 430 clinical isolates of both Gram positive (143) and negative (287) aerobic bacteria were used from 3 centres during the year 2006 and 2007. Minimum inhibitory concentration (MIC) was determined using broth micro dilution panels. Antibiotic resistance was interpreted using CLSI guidelines. RESULTS: Most of the isolates were resistant to more than one drug. Resistance to tigecycline was not found. Tigecycline (1 microg/ml) had low MIC against organisms tested. CONCLUSION: This data indicates that tigecycline, a new drug in its class, has broad-spectrum in-vitro activity against both Gram negative and positive nosocomial isolates. Therefore, it may be a suitable drug to be used for the treatment of highly resistant nosocomial infections.

Low-level quinolone-resistance in multi-drug resistant typhoid.

OBJECTIVE: To find out the frequency of low-level quinolone-resistance in Multi-Drug Resistant (MDR) typhoid using nalidixic acid screening disc. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Armed Forces Institute of Pathology, Rawalpindi, from January 2005 to December 2005. MATERIALS AND METHODS: Blood was obtained from suspected cases of typhoid fever and cultured in to BacT/ALERT. The positive blood cultures bottles were subcultured. The isolates were identified by colony morphology and biochemical tests using API-20E galleries. Susceptibility testing of isolates was done by modified Kirby-Bauer disc diffusion method on Muellar Hinton Agar. For the isolates, which were resistant to nalidixic acid by disc diffusion method, Minimal Inhibitory Concentrations (MICs) of ciprofloxacin and nalidixic acid were determined by using the E-test strips. Disc diffusion susceptibility tests and MICs were interpreted according to the guidelines provided by National Committee for Control Laboratory Standard (NCCLS). RESULTS: A total of 21(65.5%) out of 32 isolates of Salmonellae were nalidixic acid-resistant by disk diffusion method. All the nalidixic acid-resistant isolates by disc diffusion method were confirmed by MICs for both ciprofloxacin and nalidixic acid. All the nalidixic acid-resistant isolates had a ciprofloxacin MIC of 0.25-1microg/ml (reduced susceptibility) and nalidixic acid MICs > or = 32 microg (resistant). Out of all Salmonella isolates, 24 (75%) were found to be MDR, and all were S. typhi. CONCLUSION: Low-level quinolone-resistance in typhoid was high in this small series. Screening for nalidixic acid resistance with a 30 microg nalidixic acid disk is a reliable and cost-effective method to detect low-level fluoroquinolone resistance, especially in the developing countries.

Post-transplant infections: single center experience from the developing world.

OBJECTIVE: To describe our experience of post-transplant infections in allogeneic stem cell transplants at the Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan. METHODS: From July 2001 to September 2006, patients with malignant and non-malignant hematological disorders having human leukocyte antigen (HLA)-matched sibling donors were selected for transplant. Pre-transplant infection surveillance was carried out, and strict prophylaxis against infection was observed. After admission to the hospital, patients were kept in protective isolation rooms, equipped with a HEPA filter positive-pressure laminar airflow ventilation system. Bone marrow and/or peripheral blood stem cells were used as the stem cell source. Cyclosporin and prednisolone were used as prophylaxis against graft-versus-host disease (GVHD). The engraftment was monitored with cytogenetic/molecular analysis and change of blood group. Survival was calculated from the date of transplant to death or last follow-up. RESULTS: One hundred and fifty-four patients received allogeneic stem cell transplants from HLA-matched siblings for various hematological disorders at the Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan between July 2001 and September 2006. Indications for transplant included aplastic anemia (n=66), beta-thalassemia major (n=40), chronic myeloid leukemia (n=33), acute leukemia (n=8), and miscellaneous disorders (n=7). One hundred and twenty patients were male and 34 were female. The median age of the patient cohort was 14 years (range 1 1/4-54 years). One hundred and thirty-six patients and 135 donors were cytomegalovirus (CMV) IgG-positive. One hundred and forty patients (90.9%) developed febrile episodes in different phases of post-transplant recovery. Infective organisms were isolated in 150 microbiological culture specimens out of 651 specimens from different sites of infections (23.0% culture positivity). Post-transplant infections were confirmed in 120 patients (77.9%) on the basis of clinical assessment and microbiological, virological, and histopathological examination. Mortality related to infections was 13.0%. Fatal infections included CMV disease (100% mortality, 6/6), disseminated aspergillosis (66.7% mortality, 4/6), pseudomonas septicemia (42.9% mortality, 9/21), and tuberculosis (25% mortality, 1/4). CONCLUSIONS: More than 90% of our patients developed febrile episodes with relatively low culture yield. The majority of infections were treated effectively, however CMV, aspergillosis, and pseudomonas infections remained problematic with high mortality.

Subcutaneous facial mycosis in a child due to Madurella mycetomatis.

Mycetoma is a chronic, granulomatous, subcutaneous, inflammatory disease caused by true fungi (eumycetoma) or filamentous bacteria (actinomycetoma). Eumycetoma usually affects adult males involving limbs and other exposed body parts. Children represent the least commonly encountered age group with this disease. A case of subcutaneous facial mycosis due to Madurella mycetomatis in a three year old child was diagnosed at the Microbiology department Armed Forces Institute of Pathology Rawalpindi, which to our knowledge is the first case reported of its kind. Early diagnosis and timely medical therapy lead to favourable outcome without any surgical intervention.

Peripheral blood-based polymerase chain reaction in diagnosis of pulmonary tuberculosis.

BACKGROUND: The rapid diagnosis of infectious diseases, particularly those that represent a public health problem, like tuberculosis, is a challenging problem. By using nucleic acid amplification techniques like PCR, one may be able to diagnose, the disease on the day of arrival of specimen in the laboratory. For diagnosis of tuberculosis by direct methods like PCR, specimens from site of infection are required. In certain cases it is difficult to get the specimens from site of infection and in such situations; some researchers have tried to detect the DNA of Mycobacterium tuberculosis complex from blood of these patients. The purposive of this study is to determine the diagnostic efficacy of peripheral blood-based polymerase chain reaction for diagnosis of pulmonary tuberculosis. METHODS: This was a simple descriptive study, carried out in Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi from Jan 2004 to Dec 2004. Sputum and blood samples were collected from 96 suspected patients of pulmonary tuberculosis. Sputum samples processed for ZN staining and AFB culture (gold standard) and blood samples processed for PCR. RESULTS: Out of 96 cases, 60 (62.5%) were culture positive. PCR was positive in 14 (14.5%). AFB smear positive were 34 (35.4%). The overall sensitivity and specificity of the PCR assay was 20% and 94.4% respectively and the positive and negative predictive values were 85.71% and 41.46% respectively. The overall efficiency of the test was 47.91%. CONCLUSION: Due to low sensitivity; a negative PCR assay does not rule the disease. However, this test may be helpful in cases where specimens from the site of infection are not available.

Pneumocystis carinii and Trichosporon beigelii pneumonia following allogeneic haemopoeitic stem cell transplantation.

Pneumocystis Carinii and Trichosporon beigelii are opportunistic infections in immunocompromised patients. We report a case of a young lady who underwent haemopoeitic stem cell transplantation for relapsed acute lymphoblastic leukemia. This 25 years old female developed fever, dry cough and rapidly progressive dyspnoea during post transplant neutropenia and was found to be suffering from Pneumocystis carinii pneumonia. She was successfully treated with Co-trimoxazole. The patient again presented with similar symptoms on day 55 post transplant. This time Trichosporon beigelii was isolated from bronchoalveolar lavage and she responded to prompt antifungal therapy. Other complications encountered during the subsequent course were extensive subcutaneous emphysema and spontaneous pneumothorax that required chest intubation and brief hospitalization. The patient is presently nine months post transplant and is asymptomatic.

CTX-M ESBL enzyme in Escherichia coli from urology patients in Rawalpindi, Pakistan.

OBJECTIVE: To detect CTX-M phenotype utilizing disc diffusion and MIC testing in Escherichia coli isolated from a tertiary care urology setting. METHODS: Fifty single, non duplicate ESBL producing isolates from a tertiary care urology hospital were evaluated for the presence of CTX-M phenotype. Initially all the urinary isolates were tested for ESBL production. The isolates were identified by using API 20E galleries and screened for ESBL production by combination disc methods. Representative 4 ESBL isolates were sent to Antibiotic Resistance Monitoring and Reference Laboratory (ARMRL), Health Protection Agency, Colindale, London, UK where those were further subjected to MIC testing by agar dilution and E-test strips. RESULTS: A total of 4 ESBL producing E. coli isolates were characterized to be CTX-M on phenotypic characterization. The overall yield of CTX-M phenotypes was 75%. CONCLUSION: The emergence of CTX-M from Pakistan is alarming; however, further studies are required to study the epidemiology and genetic characterization of CTX-M types of ESBLs.

Fungal keratitis due to fusarium solani.

A young man presented with swelling, congestion and lacrimation of right eye for one week. On examination, he had corneal ulcer. Corneal scrapings on lactophenol cotton blue stain revealed fungal hyphae. Culture on Sabouraud agar yielded Fusarium solani after 48 hours. Patient was treated with ketoconazole and miconazole and responded well.

Role of Malassezia yeast (Pityrosporum) in seborrhoeic dermatitis (SD).

OBJECTIVE: The objective of this study was to find out the prevalence of Pityrosporum species in the patients with seborrheic dermatitis (SD) and compare the colonization rate with normal healthy individuals. DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Dermatology Department, Military Hospital and Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi from 01 March 1996 to 28 February 1997. MATERIALS AND METHODS: Fifty patients with clinically diagnosed seborrheic dermatitis were included in this study. Fifty normal healthy individual with matched age and gender were included as control subjects. Three samples from each effected sites were taken from 2 cm2 area. Identical sites in control subjects were also sampled. These samples were examined under the microscope after treating with 10% potassium hydroxide and staining with parker blue black ink for the presence of Pityrosporum yeast cells. The specimen were also inoculated in special lipid enriched media, incubated at 37 degrees C for 4-6 days. RESULTS: Out of 50 patients, Pityrosporum yeast cells were seen microscopically in 37 (74%), and the cultures were positive in 43 (86%). Among the normal individuals yeast cells were seen microscopically in 23 (46%) and the cultures were positive in 22 (44%). CONCLUSION: The colonization rate of Pityrosporum species was higher in the seborrheic dermatitis patients. It might be playing a causative role in the aetiology of this disease.

Characterization of multidrug-resistant typhoid outbreaks in Kenya.

We characterized by antibiotic susceptibility, plasmid analysis, incompatibility grouping, and pulsed-field gel electrophoresis (PFGE) of XbaI- and SpeI-digested DNA 102 Salmonella enterica serovar Typhi (serovar Typhi) isolated from recent outbreaks of typhoid in three different parts of Kenya. Only 13.7% were fully susceptible, whereas another 82.4% were resistant to each of the five commonly available drugs: ampicillin, chloramphenicol, and tetracycline (MICs of >256 microg/ml); streptomycin (MIC, >1,024 microg/ml); and cotrimoxazole (MIC of >32 microg/ml). Resistance to these antibiotics was encoded on a 110-kb self-transferable plasmid of IncHI1 incompatibility group. The MICs of nalidixic acid (MIC, 8 to 16 micro g/ml) and ciprofloxacin (MIC of 0.25 to 0.38 micro g/ml) for 41.7% of the 102 serovar Typhi isolates were 5- and 10-fold higher, respectively, than for sensitive strains. Amplification by PCR and sequencing of the genes coding for gyrase (gyrA and gyrB) and topoisomerase IV (parE and parC) within the quinolone resistance-determining region revealed that the increase in the MICs of the quinolones had not resulted from any significant mutation. Analysis of genomic DNA from both antimicrobial agent-sensitive and multidrug-resistant serovar Typhi by PFGE identified two distinct subtypes that were in circulation in the three different parts of Kenya. As the prevalence of multidrug-resistant serovar Typhi increases, newer, more expensive, and less readily available antimicrobial agents will be required for the treatment of typhoid in Kenya.