Case Report: Histoplasmosis in Himachal Pradesh (India): An Emerging Endemic Focus.

We describe four cases of histoplasmosis indigenous to Himachal Pradesh (India) that will be of considerable public health interest. A 48-year-old human immunodeficiency virus (HIV)-negative man with cervical and mediastinal lymphadenopathy, hepatosplenomegaly, adrenal mass, and bone marrow involvement was treated as disseminated tuberculosis without benefit. Progressive disseminated histoplasmosis was diagnosed from the fungus in smears from adrenal mass. Another 37-year-old HIV-positive man was on treatment of suspected pulmonary tuberculosis. He developed numerous erythema nodosum leprosum-like mucocutanous lesions accompanied by fever, generalized lymphadenopathy, and weight loss. Pulmonary histoplasmosis with cutaneous dissemination was diagnosed when skin lesions showed the fungus in smears, histopathology, and mycologic culture. Both were successfully treated with amphotericin B/itraconazole. Third patient, a 46-year-old HIV-negative man, had oropharyngeal lesions, cervical lymphadenopathy, intermittent fever, hepatosplenomegaly, and deteriorating general health. Progressive disseminated oropharyngeal histoplasmosis was diagnosed from the fungus in smears and mycologic cultures from oropharyngeal lesions and cervical lymph node aspirates. He died despite initiating treatment with oral itraconazole. Another 32-year-old man 3 months after roadside trauma developed a large ulcer with exuberant granulation tissue over left thigh without evidence of immunosuppression/systemic involvement. He was treated successfully with surgical excision of ulcer under amphotericin B/itraconazole coverage as primary cutaneous histoplasmosis confirmed pathologically and mycologically. A clinical suspicion remains paramount for early diagnosis of histoplasmosis particularly in a nonendemic area. Most importantly, with such diverse clinical presentation and therapeutic outcome selection of an appropriate and customized treatment schedule is a discretion the treating clinicians need to make.

Primary Cutaneous Histoplasmosis in an Immunocompetent Host from a Nonendemic Area.

A 32-year-old male presented to Dermatology outpatient Department with complaints of a single nonhealing ulcer on his right thigh. This lesion was there for the last 1΍ months. It had begun as a small nodule and increased up to the present size of 3 cm with an oozing and ulcerated surface and thickened everted margins. The systemic investigations were normal which included hemogram, biochemistry, including liver and renal function tests, chest X-ray, ultrasonography of abdomen, computed tomography of the thorax, and abdomen. Skin biopsy revealed multiple rounds to oval spores with surrounding halo intracellularly as well as extracellularly. A diagnosis of deep fungal infection as histoplasmosis was made and confirmed on culture.

Genetic Diversity among Group A Streptococcus Isolated from Throats of Healthy and Symptomatic Children.

BACKGROUND: Group A streptococcus (GAS) is the commonest bacterial cause of pharyngitis. Children in the age group of 5-15 years are most commonly affected. It can also colonize throats of healthy children in this age group. Both cases and carriers can transmit it in the community. METHODS: Throat swab samples were collected from 1849 asymptomatic and 371 symptomatic children. RESULTS: The rate of isolation of GAS was 1.41% among the asymptomatic group and 7.55% among the symptomatic group. Nine different emm types were encountered in the asymptomatic children and 14 among the symptomatic children. CONCLUSION: Throat swab cultures must be used in all cases of pharyngitis. Early and appropriate antibiotic therapy will prevent complications. Asymptomatic throat carriage of GAS in children was low in our study. However, they can still act as reservoirs. Emm typing helps in understanding epidemiology and finding new types.

A Rare Case of Primary Supraclavicular Lymphadenitis due to Cryptococcus Neoformans in an HIV Infected Patient.

Cryptococcosis caused by encapsulated yeast Cryptococcus neoformans most commonly presents as disease of the central nervous system. Cryptococcus is a non-mycelial budding yeast found in soil, pigeon droppings and their nesting places. The three 'classic' virulence factors of cryptococci are: polysaccharide capsule, melanin production and growth at 37°C. Here, we present a rare case of cryptococcosis affecting left supraclavicular lymph node in a Human Immunodeficiency virus (HIV) infected individual. Culture of fine needle aspirate of the lymph node yielded Cryptococcus neoformans which was identified by standard microbiological techniques. Meyer's mucicarmine stain imparted a typical rose burgundy colour to the capsule. Unusual characteristics of the isolate included poorly developed capsule and the presence of yeast in chains resembling pseudo-hyphae. This case highlights the importance of microbiological techniques for diagnosis and prompt treatment of cryptococcosis.

Prevalance of pregnancy associated asymptomatic bacteriuria: a study done in a tertiary care hospital.

OBJECTIVES: A prospective study was conducted in the Department of microbiology (IGMC) and the Department of obstetrics & gynecology (KNH), Shimla, and Himachal Pradesh over a period of 1 year from May 2005 to April 2006 on 463 asymptomatic pregnant females with a period of gestation (POG) 28 weeks or less. The aim was to find out the prevalence of pregnancy associated bacteriuria and bacterial causes responsible for this entity. METHODS: The pregnant women were taught to collect the urine sample by aseptic technique which was then subjected to semi quantitative culture method. RESULTS: Significant bacteriuria was present in 7.34% cases. About 78% samples were found to be sterile. Insignificant count and growth of contaminants was positive in 1 and 13% samples, respectively. The most common etiological agent came out to be E. coli followed by other gram positive and gram negative organisms. CONCLUSION: Asymptomatic bacteriuria is a common occurrence which should be diagnosed and treated in early pregnancy keeping in view its adverse effects on pregnancy.

Vidi, vini, vinci: External ophthalmomyiasis infection that occurred, and was diagnosed and treated in a single day: A rare case report.

Ophthalmomyiasis is an infestation of eye with larvae or maggots of certain flies. Oestrus ovis (sheep nasal botfly) belonging to family Oestridae is the most common cause of human myiasis. We describe here an acute presentation of a case of external ophthalmomyiasis, i.e., infestation of conjunctiva due to first instar larvae of Oestrus ovis. In this case report the occurrence, diagnosis and treatment all took place in the setting of a single day. Prompt treatment by removal of larvae mechanically followed by instillation of antibiotic and steroid eye drops helped to prevent serious complications. The taxonomic identification of fly is also important as some fly species are capable of penetrating deeper tissues of eyes, which is sight threatening.

Localized cutaneous leishmaniasis due to Leishmania donovani and Leishmania tropica: preliminary findings of the study of 161 new cases from a new endemic focus in himachal pradesh, India.

Localized cutaneous leishmaniasis (LCL) in India is due mostly to Leishmania tropica. It is mainly endemic in the deserts of Rajasthan. Recently, Himachal Pradesh has been identified as a new endemic focus for the disease. In the last few years, the number of new cases has been increasing almost to epidemic proportions. This report presents the preliminary findings of clinico-epidemiologic and investigative results of 161 new localized cases of LCL seen between May 2001 and December 2003. The study populaton was composed of 80 males and 81 females between 10 months and 75 years of age. All were indigenous to the sub-alpine valley along the Satluj River in the mountainous region of the Kinnaur District (altitude = 700-2,900 meters). Most patients were seen from April to September and had 1-8 lesions (duration = 1-6 months) that involved mainly the face. Tissue smears were positive for amastigotes in 37% and histopathology showed non-caseating epitheloid cell granuloma in 77% of the cases. Analysis by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) of the ribosomal gene region of 10 biopsy specimens showed amplicons indistinguishable from L. donovani in eight cases and L. tropica in two cases. Leishmania was cultured on modified Nicole-Novy-McNeal (NNN) medium containing RPMI 1640 medium and heat-inactivated fetal bovine serum from 13 of 38 biopsy samples. Three of these isolated strains were identified as L. donovani while a fourth was L. tropica by PCR-RFLP of the ribosomal internal transcribed spacer region. One strain had a gp63 sequence identical to that of east African strains. Another strain had a unique gp63 sequence that has not been found in L. donovani complex strains. Sand flies trapped in the cattle sheds of a few patients were identified as Phlebotomus longiductus (Parrot 1928). Treatment with intralesional sodium stibogluconate was effective in all patients without any major side effects. One patient developed lupoid leishmaniasis that responded to higher dose of sodium stibogluconate. Though rarely reported as a cause of LCL, L. donovani seems to be the predominant pathogen in this new focus of cutaneous leishmaniasis. Phlebotomus longiductus is a possible vector, albeit based on circumstantial evidence.