Clinical Diversity of CNS Cryptococcosis.

BACKGROUND: Though cryptococcal meningitis (CM) is recognized as a disease of the immunocompromised, studies have implicated that it also affect immunocompetent patients. METHODOLOGY: This was a cross sectional study conducted in the Department of Medicine of a tertiary teaching institution in North India. All the patients diagnosed with CM on the basis of detection of cryptococcal antigen or the presence of capsulated budding yeast cells on India ink preparation, from April 2009 to March2015 were included in the study. Demographical profile, clinical presentation, predisposing factors, CSFcharacteristics, imaging abnormalities and in patient outcome were noted and analyzed. RESULTS: Among the 40 patients diagnosed with CM, 62.5% of them were males. Patients who were immunocompetent constituted 20%, those with predisposing factors other than HIV were 25% and55% had HIV infection (initial presentation in 59%). Mean age of presentation was 44.75 ± 15.58 years. Mean duration of symptoms in all three groups varied from few days to 4-5 weeks. Clinical presentations included fever (16), headache (14), altered sensorium (16), seizures (5), paraparesis (4), hemiparesis (2), lateral rectus palsy (3), VII nerve palsy (2), bilateral vision loss with ptosis (1) and ataxia (1). Neck stiffness was present in 50% patients of immunocompetent group, 45.45% of HIV patients and none in the 3rd group. Acellular CSF (37.5%) was not unusual. Mean CSF white cell count in HIV patients, in other immunocompromised patients and immunocompetent patients were 100± 158.53, 36.88 ± 92.43 and 32.5 ± 62.05 /mm3 respectively which was predominantly lymphocytic. Mean CSF protein were 136.73 ± 139.82, 62.67 ± 51.11 and 152.29 ± 218.24 g/dl in these groups. Abnormalities detected on imaging included, meningeal enhancement, encephalomalacia, infarct, cerebellitis, hydrocephalus, cord hyper intensities and cervical spine intramedullary lesion. Mortality rate in CM patients was 20%. On mortality analysis, death was mostly attributed to the primary disease. CONCLUSIONS: Clinical presentation of CM in both immunocompetent and immunocompromised patients was similar. Though previous studies noted less inflammation in immunocompromised patients, in this series it was noted that both immunocompromised and immunocompetent patients mounted similar inflammatory response. Since the presentation of CM is variable, all cases of meningitis should be screened for the same.

Impact of vitamin D fortified milk supplementation on vitamin D status of healthy school children aged 10-14 years.

UNLABELLED: Vitamin D deficiency is a major public health problem, needing immediate attention. We studied the effect of vitamin D fortification of milk in school children. Our results show that fortification of milk is safe and effective strategy to deal with widespread vitamin D deficiency. INTRODUCTION: Vitamin D deficiency among school children and adolescents is a well-documented major public health problem, needing immediate attention. To assess the effect of vitamin D fortified milk on serum 25 hydroxy vitamin D [S.25(OH)D] levels, we carried out a prospective double-blind randomized control trial in apparently healthy school children, aged 10-14 years. METHODS: Of 776 subjects recruited out of 796 who consented, 713 (boys-300; girls-413) completed the study. Subjects were randomized into three groups. Group A (n = 237) received 200 ml of unfortified milk per day while group B (n = 243) and group C (n = 233) received 200 ml of milk fortified with 600 IU (15 µg) and 1,000 IU (25 µg) of vitamin D per day for 12 weeks. Serum calcium, phosphate, alkaline phosphatase, S.25(OH)D, and urinary calcium/creatinine ratio were estimated at baseline and after supplementation. RESULTS: Hypovitaminosis D [25(OH)D < 20 ng/ml] was observed in 92.3 % subjects with mean S.25(OH)D level of 11.69 ± 5.36 ng/ml. There was no significant difference in S.25(OH)D levels among the three groups at baseline. The mean percentage change in S.25(OH)D level in groups B (137.97 %) and C (177.29 %.) were significantly greater than group A (-5.25 %). The percentage of subjects having S.25(OH)D levels >20 ng/ml following supplementation were 5.9 % in group A, 69.95 % in group B, and 81.11 % in group C in comparison to 6.32 %, 4.9 % and 12 %, respectively, at baseline. CONCLUSION: Fortification of milk with vitamin D is an effective and safe strategy in improving S.25(OH)D levels in children aged 10-14 years.

Dengue fever--an emerging viral fever in Ludhiana, North India.

The present study was undertaken to determine the seroprevalence of dengue fever and dengue haemorrhagic fever (DHF) in patients attending medical clinics or admitted in ICU with febrile signs and symptoms of heamorrhages. 168 (39.4%) out of 426 samples were tested positive for IgM antibodies. Of the 168 positive cases 159 were detected during the months of October and November 2005. Early detection of DHF/DSS can go a long way in managing these patients and to reduce morbidity and mortality specially in DHF and DSS cases.

Comparison of rapid colorimetric method with conventional method in the isolation of Mycobacterium tuberculosis.

The aim of the study was to evaluate two methods (colorimetric and conventional) for isolation of Mycobacterium tuberculosis. A total of 500 clinical specimens were processed by modified Petroff's method and then inoculated into MB/BacT-240 system bottles and on LJ medium slopes. The specimens included 242 sputum, 95 gastric aspirates, 47 pleural fluids, 45 CSF, 32 urine, 18 pus, 11 bronchoalveolar lavage, 3 tissue, 2 stool, 2 lymphnode specimens, 2 synovial fluid and 1 bronchial wash specimens. The isolation rate was 16.4% by the colorimetric method and 2.2% by the conventional method. The mean detection time was 16 days and 26 days respectively. Among 36 direct smear positive samples, 63.9%(23/36) and 30%(11/36) were positive by colorimetric and conventional methods respectively. Out of 464 direct smear negative samples 12.9%(60/464) and 0.6%(3/464) were positive by colorimetric and conventional methods respectively. Therefore, colorimetric method enables rapid detection leading to early diagnosis and drug susceptibility testing.

Acute liver failure.

Acute liver failure in children is associated with a high mortality. Most cases in our setup are due to water borne hepatotropic viruses HAV and HEV. The clinician must be aware of the earliest and the subtle signs of acute liver failure to identify cases early enough and institute supportive therapy. Focus of therapy has to be on prevention, early recognition and appropriate management of complications. Despite good intensive care, about 40-60% children with liver failure die. As and when liver transplantation becomes available in India, it would be an attractive option.

Epidemiology of hepatitis E and A in Ludhiana.

AIM: To study the epidemiology of hepatitis E and A in Ludhiana. METHODS: A retrospective analysis of laboratory data of the year 2001 was done, to study the epidemiology of hepatitis E and A in Ludhiana in relation to prevalence, age, sex, area of residence and seasonal variation. RESULTS: Prevalence of HEV was 13.9%. Infection with it occurred through out the year with no preponderance of cases following the monsoons. Young male adults between 20-40 years of age were predominantly affected. Prevalence of HAV was 5.5% affecting mainly children below 14 years of age. Population of urban areas around "Gandha Naliash" (a large open sewer) was at high risk as there was clustering of HEV & HAV cases around that area.

Prevalence of neuroendocrine dysfunction in patients recovering from traumatic brain injury.

Although hypopituitarism is a known complication of head injury, it may be underrecognized due to its subtle clinical manifestations. The nonspecific symptoms may be masked by and may contribute to the physical and psychological sequelae of brain trauma. This study examines the prevalence of neuroendocrine abnormalities in patients rehabilitating from traumatic brain injury. Seventy adults (mean age, 31.5 +/- 1.1 yr; range, 18--58; 46 men and 24 women) with traumatic brain injury an average of 49 +/- 8 months before the study (median, 13 months) underwent a series of standard endocrine tests, including serum levels of TSH, free T(4), insulin-like growth factor I, PRL, testosterone (males), and cosyntropin stimulation. Abnormal results of these tests were followed by dynamic tests of gonadotropin, TSH, and GH secretion. Glucagon stimulation testing in 48 subjects revealed GH deficiency (peak, <3 microg/L) in 14.6%. Free T(4) (n = 6; 8.6%), TSH (n = 7; 10%), or both (n = 2; 2.9%) were low in 21.7%, whereas 87% had both TSH and free T(4) below the midnormal level. Basal morning cortisol was below normal in 45.7% of subjects, whereas cosyntropin-stimulated levels were insufficient (peak, <500 nmol/L) in 7.1%. Hypogonadism and hyperprolactinemia were uncommon. In summary, pituitary hormone deficiencies were identified in a substantial proportion of patients with previous brain injury. GH deficiency, found in 15% by glucagon stimulation testing, may compound the physical and psychological complications of traumatic brain injury and interfere with rehabilitation.

Endothelin-1-mediated retinal artery vasospasm and the rabbit electroretinogram.

Electroretinogram (ERG) changes invariably accompany the selective interruption of the retinal circulation that occurs in human central retinal artery occlusion. Since arteriolar ligation or ocular hypertension in the rabbit eye is occasionally used to model human central retinal artery occlusion, we conducted the present study to determine whether selective interruption of the retinal circulation of the rabbit eye alters retinal function as measured by the ERG. The vasoconstrictor, endothelin-1, was injected into the vitreous of rabbits' eyes to induce complete vasospasm and selective interruption of the retinal circulation. This procedure was compared to vascular ligation of the ophthalmic and ciliary arteries in which both the retinal and choroidal circulations were interrupted. A total of 8 rabbits was studied. Circulation was monitored angiographically in half of the eyes, and retinal function was monitored by the ERG in the remaining eyes. Endothelin-1 obliterated retinal arteriolar blood flow without affecting choroidal blood flow for at least 1 hr. Although ERG a-wave amplitude showed a small decline over 2 hr, b-wave and oscillatory potential amplitudes (measures of inner retinal function) showed no loss over this period. In contrast, ligation of the ophthalmic and ciliary arteries produced complete obliteration of both retinal arteriolar and choroidal blood flow and complete loss of the ERG after 2 min. Endothelin-1 induces acute, selective interruption of retinal arteriolar blood flow which has no significant physiologic effect on inner retinal function of the rabbit as monitored by the ERG. The avascular rabbit retina appears to be a poor choice for modeling human retinal artery occlusion.

Evaluation of rapid kits for detection of HIV, HBsAg and HCV infections.

Diagnostic kits (J. Mitra Co. Ltd) for rapid detection of HIV, HBsAg & HCV were evaluated against respective enzyme immunoassay (Ortho Diagnostics). All rapid kits were 100% specific for HIV, HBsAg & HCV. Sensitivity for HIV, HCV & HBsAg was 80%, 87.5% & 93.4% respectively.

Retinal artery occlusion in rabbit eyes using human atheroma.

Previous animal models of central retinal artery occlusion using glass or latex embolic material may not simulate human disease. We have developed a rabbit model using human atherosclerotic material, which may be useful in developing embolus specific treatments, including thrombolysis or laser photodisruption. Fresh human atherosclerotic plaque was harvested from atherosclerotic human aorta by mechanical removal and suspension in normal saline. The suspension was agitated vigorously to produce small particles, which were separated into various sizes by filtration through mesh filters with specific pore sizes. The common carotid artery of the anesthetized rabbit was isolated by neck dissection and cannulated using a modified Seldinger technique. Suspensions of human atherosclerotic plaque were injected into the common carotid artery via this cannula. All animals were examined by slit lamp and fluorescein angiography before and after retinal artery occlusion. This model reliably produced retinal artery occlusion using human atherosclerotic plaque. Plaque particles less than 105 microns reliably produced branch retinal artery occlusion, while larger plaque particles less than 149 microns reliably produced central retinal artery occlusion. Sublingual nitroglycerin, at 0.1 mg/kg, intravenous verapamil, from 0.2 mg/kg to 2 mg/kg, and intracarotid urokinase given acutely in standard doses failed to cause reperfusion. This model will be very useful in the study and treatment of retinal vascular disorders as it may more closely simulate human disease over previous models using artificial embolic materials. Embolic specific treatment stategies, such as thrombolysis and laser photodisruption, may be further developed with this model.