Rare complications of heart transplant: Autopsy findings.

BACKGROUND: Heart transplantation has evolved as the only treatment option for patients with refractory heart failure. CASE PRESENTATION: We here, report two unusual complications that developed following cardiac transplant to which the recipients succumbed. Post mortem conducted revealed the cause of death as severe antibody mediated rejection in one case and ruptured mycotic aneurysm of ascending aorta in the second recipient. CONCLUSION: Hence, autopsy remains the key procedure that can help establish the cause of death after cardiac transplant. It is also imperative for clinicians to have awareness and high index of suspicion for early detection of the ongoing complications and intervene either surgically or medically to prevent catastrophic events.

Utility of multiplex real-time PCR for diagnosing paediatric acute respiratory tract infection in a tertiary care hospital.

Background: Acute respiratory infections (ARIs) are responsible for considerable morbidity and mortality among children all over the world. Many of the etiologic agents of the infections especially viral go undiagnosed for lack of requisite facility and the cost factors. We have used a commercially available platform for diagnosis of ARIs in children receiving inpatient and outpatient services in a tertiary care centre. Methods: The framework of the study was prospective and observational. In this study, clinical samples of children suffering from ARIs were subjected to real-time multiplex PCR targeting both viral and bacterial pathogens. Results: Of 94 samples received at our centre (49 male and 45 female), the positivity for respiratory pathogens was detected in 50 (53.19%) samples. Clinical symptoms of patients and age distribution have been elaborated in text. A single pathogen (n = 29/50), two pathogens (15/50) and three pathogens (n = 6/50) were detected by multiplex RT-PCR. Of 77 isolates detected, maximum numbers were of human rhinovirus (HRV) (n = 14) (18.18%) Streptococcus pneumoniae (n = 14) (18.18%) followed by Staphylococcus aureus (n = 10) (12.98%). Conclusion: The epidemiology of ARIs considering viral etiologies is poorly understood due to less number of studies especially in Indian subcontinent. The advent of latest advanced molecular methods has made it possible to identify common respiratory pathogens and has contributed to cover the gap in existing knowledge.

An Unusual Clinical Manifestation of Plasmablastic Lymphoma in a Renal Transplant Recipient.

Plasmablastic lymphoma is a rapidly progressive CD20 negative large cell non-Hodgkin lymphoma with poor outcome. It occurs mostly in immunocompromised individuals and has a predilection for extranodal sites. They need to be differentiated from other entities sharing similar morphological features like poorly differentiated carcinoma, Burkitt's lymphoma, Alk positive large B cell lymphoma, Diffuse large B cell lymphoma, and anaplastic myeloma. EBV negativity in recipients, type, intensity, and duration of immunosuppressives used are certain risk factors in development of posttransplant lymphoproliferative disorders. High index of suspicion can help clinch the diagnosis early and prevent catastrophic consequences. Our renal transplant recipient presented with complaints of pain abdomen and malena for which he underwent exploratory laparotomy. Diagnosis was established on histopathology and timely treatment initiated reverted the disease.

Posttransplant lymphoproliferative disorder in renal transplant recipients: Experience from a Tertiary Care Center.

Posttransplant lymphoproliferative disorders (PTLDs) are potentially fatal complications arising after solid organ or hematopoietic stem cell transplant. The most crucial factor in pathogenesis of PTLDs is either a primary infection with Epstein-Barr virus or reactivation of its latent state due to immune dysregulation. This complex pathobiology leads to a myriad of clinical manifestations due to uncontrolled lymphoproliferation that may be reactive, polymorphous or monomorphous. We report our experience at a tertiary center of six cases detected over a span of six years. All our patients were proven as high grade B-cell lymphoma on histopathology, which remains the gold standard for diagnosis. Two cases were of primary central nervous system lymphoma, two had disseminated disease, fifth showed allograft involvement, and last case presented with gastrointestinal obstruction. All the patients were managed with reduction of immunosuppression, chemotherapeutic agents, and rituximab. Five patients responded well with a follow-up period of 3-28 months since the time of treatment initiation and had preserved renal function with no episodes of disease recurrence or allograft rejection.

Device-associated Central Nervous System Infection Caused by Candida parapsilosis.

Meningitis is a common and life-threatening infection of the central nervous system (CNS) in infants with long-term and disabling sequelae like hydrocephalus. Hydrocephalus is treated by diverting cerebrospinal fluid (CSF) either to another body cavity (via CSF shunt) or externally (via CSF drain) which are prone to infection. Though rare, Candida parapsilosis (C. parapsilosis) is a known pathogen in device-associated CNS infections and has been reported in both, infants and adults. A six-month-old male infant was brought to the hospital with disproportionate head enlargement of three months duration. Magnetic resonance imaging (MRI) was suggestive of gross asymmetrical hydrocephalus. An external ventricular drain (EVD) was placed, and vancomycin and meropenem were started. Four weeks later, he developed a fever with a blocked EVD. Repeat MRI revealed gross asymmetric dilatation of left lateral ventricle along with pneumocephalus in the right periventricular region. A right temporoparietal craniotomy with drainage of a multiloculated abscess was done along with the removal of right EVD and placement of left EVD. CSF showed pan-susceptible C. parapsilosis and fluconazole was started. Despite treatment, CSF continued to grow C. parapsilosis through day 10. The EVD was removed, and an Ommaya reservoir along with the ventricular catheter was placed for better interventricular antibiotic administration. After day 13 CSF became sterile. Ommaya reservoir was removed, fluconazole was continued for three weeks, and a ventriculoperitoneal shunt was placed five weeks later. The device-associated CNS infections are insidious with nonspecific manifestations making diagnosis difficult. C. parapsilosis has been increasing in prevalence, especially in immunocompromised hosts, infants, and in patients with indwelling catheters. Amphotericin B or fluconazole is the usual treatment with excellent outcomes and no mortality. This case underscores the need for suspicion of C. parapsilosis as a cause of device-associated CNS infections.

Blood culture isolates and antibiogram of Salmonella: Experience of a tertiary care hospital.

BACKGROUND: Enteric fevers contribute majorly to the burden of morbidity from infectious diseases in the developing world. Due to growing antibiotic resistance seen in their management, Salmonella and its various species are required to be periodically tested for sensitivity and resistance patterns, to guide the clinical management at the local level. This will also enable planning of antibiotic recycling wherever feasible. METHODS: A retrospective study of the results of blood culture isolates covering a period of 27 months was done at a tertiary care hospital. Blood samples were directly inoculated in Bactalert culture bottles and sub culture was done on Mac Conkey and Salmonella-Shigella Agar. Non-lactose fermenting colonies were processed for identification, antibiotic sensitivity and MIC value. Slide agglutination test using specific antisera was also done to confirm the serotype. Antimicrobial susceptibility was done in accordance with CLSI standards. RESULTS: 8413 blood samples were processed and 1027 (12.20%) were assessed as 'culture positive'. Salmonella were isolated in 46 samples of which 38 (83%) were Salmonella typhi and a single isolate was Salmonella paratyphi B. S.typhi showed maximum sensitivity to imipenem (100%) (MIC <0.25 µg/ml) followed by ciprofloxacin (76.8%) (MIC >1 µg/ml) and nalidixic acid (50%) (MIC ≥ 32 µg/ml). S. paratyphi B showed 100% sensitivity to all the common antibiotics. Four samples (8%) were classified as multi drug resistant (MDR). CONCLUSION: Our study has shown improved sensitivity to ceftriaxone and cotrimoxazole. A high degree of susceptibility to ampicillin among both S. typhi and S.paratyphi A is encouraging. However, low susceptibility to nalidixic acid and ciprofloxacin is a cause for concern. There is a need for further clinical studies to evaluate the response to chloramphenicol in MDR cases and to formulate uniform laboratory guidelines to test antibiotic sensitivity of S. typhi isolates.

Klebsiella oxytoca: An emerging pathogen?

Klebsiella oxytoca is emerging as an important bacterial isolate causing hospital-acquired infection in adults and having multiple drug resistance to commonly used antibiotics. We analysed our data to observe the current pattern of drug resistance among K. oxytoca isolated from various samples during the period from January 2012 to March 2014 at a tertiary care hospital. A total of 17,335 samples were processed at the hospital laboratory during this period. Klebsiella was isolated from 654 of these clinical samples. Out of these Klebsiella species, 631 (96.48%) were K. pneumoniae and 23 (3.52%) were K. oxytoca. All the K. oxytoca isolates were sensitive to colistin and tigecyclin. However, these isolates showed 58% resistance to imipenem and meropenem. The resistance to gentamicin, amikacin and ceftriaxone was higher at 72%. Resistance to ciprofloxacin and aztreonam was less (58%). All the samples were from patients admitted to ICUs of a tertiary care centre. The data from our study show an increasing burden of infection caused by this bacterium, which is now gaining access to ICUs. It is recommended that Hospital Infection Control Committees must keep a close watch on the antibiotic pattern of K. oxytoca for better patient care.

Drug sensitivity pattern of various Staphylococcus species isolated at a tertiary care hospital.

BACKGROUND: Staphylococcus aureus and other Staphylococcus species are important pathogenic organisms and are responsible for various hospital infections. These are the predominant organisms found in pus and blood culture isolates. Infections arising due to these bacterial isolates are difficult to treat because of developing multidrug resistance. METHODS: Over a 1-year period at a tertiary care hospital laboratory, 524 Staphylococci species were isolated from pus, blood and urine samples and species-level identification was done. RESULTS: S. aureus formed the predominant species (70.8%) followed by coagulase-negative Staphylococcus (CoNS) (29.20%). S. aureus (91%) was the main isolate from pus samples; however, CoNS was isolated in equally higher proportion in blood culture (63.58%). Among the CoNS, Staphylococcus hemolyticus was the main isolate (9.3%). ß-Lactamase production, alteration of PBP and MLSB resistance were seen in variable degrees in different species. CONCLUSION: CoNS group of Staphylococci is becoming an important cause of infection at tertiary care centres. The increased multidrug resistance among various Staphylococcus species is a cause of great concern and requires adequate measures to prevent the spread of these microorganisms in the hospital and the community.

Seroprevalence of TORCH infections in antenatal and HIV positive patient populations.

BACKGROUND: The TORCH (Toxoplasma gondii, Rubella, Cytomegalovirus (CMV) and the Herpes Simplex Virus) cause range of diseases in pregnant women and HIV patients and lead to adverse fetal outcomes when not treated on time, in HIV positive can cause life threating infections. There is inadequate data available of these infections in India. METHODS: A retrospective study was undertaken to determine the seroprevalence of the TORCH infections in antenatal and HIV/AIDS patients at a tertiary care centre. The laboratory data pertaining to the period Jan 2012-May 2014 was analyzed. The study population involved 162 antenatal cases and 729 HIV/AIDS patients under review at an ART centre. Laboratory testing was done for the presence of IgM and IgG antibodies against the TORCH infections by ELISA method. RESULTS: Among the antenatal cases, 30 (18.52%) samples were found to be seropositive for Toxoplasma IgM, CMV IgM antibodies were found in 47 (29.01%) samples, HSV IgM antibodies were found in 12 (7.40%) samples, Rubella IgM antibodies were found in 13 (8.02%) samples, indicating recent infection. Among the HIV/AIDS cases, indicative of recent or current infection, 160 (21.94%) samples were positive for Toxoplasma IgM, CMV IgM was found in 99 (13.58%), HSV IgM antibodies were found in 98 (13.44%) and Rubella IgM in 47 (6.44%). CONCLUSIONS: The study showed a high seroprevalence of the infections caused by the TORCH complex amongst pregnant women and HIV/AIDS patients despite improved hygiene conditions and health awareness. Maximum seroprevalence for CMV was observed followed by Rubella and HSV infection.

Highly successful and low-cost desensitization regime for sensitized living donor renal transplant recipients.

10-30% of dialysis population awaiting renal transplantation is sensitized. Present desensitization protocols use intravenous immune globulins, rituximab, and plasmapheresis in various combinations; however, these regimens are unaffordable by many in developing countries. We tried desensitization with mycophenolate mofetil and plasmapheresis. Methods. Patients with high PRA titre (> or =50%) or positive crossmatch (>10%) were treated with MMF for a month before proposed transplant and were given five sittings of plasmapheresis. Results. 11 of 12 patients had normalization of PRA/crossmatch with this regimen and were successfully transplanted. One patient lost the graft due to graft vein thrombosis, and two patients died within three months after transplant due to septicemia and pulmonary embolism, respectively, with a functioning graft. No patient, including the two who died, developed clinical rejection over a mean follow-up of 10 months (range 1-16 months). Mean serum creatinine at last follow up was 1.1 mg/dL (range 0.9-1.3 mg/dL). Conclusions. Though the number of patients studied is small, we feel that highly sensitized patients awaiting living donor renal transplant should be tried on this simple and cost-effective regime before transplant. The more aggressive and expensive approaches incorporating IVIg and rituximab should be used only if this relatively low-cost regime is unsuccessful.

PREVALENCE OF ANTIBODIES TO HEPATITIS C VIRUS IN HOSPITALIZED POPULATION SUBSETS.

Prevalence of antibodies to hepatitis C virus (anti-HCV antibody) was ascertained in different subsets of hospitalized patients. Anti-HCV antibody testing was done using a third generation test The anti-HCV positivity in the sera of 308 tuberculosis patients, who had been given streptomycin, was 12.3 per cent It was 7.1 percent among 84 cardiac patients undergoing invasive cardiac procedures, 15.6 per cent in 77 patients on haemodialysis and 41.2 per cent patients with surgical jaundice. It is surmised that hospitalization, particularly parenteral therapy and invasive procedures during hospitalization, puts patients at higher risk of contracting HCV infecticn.