Healthcare-Associated nontuberculous mycobacterial endocarditis following coronary artery angiography.

Infective endocarditis in a patient with structural heart disease following coronary artery angiography is a rare complication. We report a rare case of Mycobacterium chelonae infective endocarditis following coronary artery angiography in a young male with congenital heart disease. This case illustrates the diagnostic as well as therapeutic challenges we faced when managing this rare infectious entity.

Histoplasmosis in non-endemic North-Western part of India.

PURPOSE OF STUDY: The western and North-Western parts of India are usually considered non-endemic for histoplasmosis. On the contrary, we observe histoplasmosis cases with relatively higher frequency from this region although the awareness and laboratory facility to diagnose the disease are not adequate. Hence, we planned the present retrospective study to compile the cases and to analyse different clinical parameters. MATERIALS AND METHODS: Medical records of the patients diagnosed with histoplasmosis during January 2012-August 2017 at two infectious disease clinics of Ahmedabad were included in this study. RESULTS: During the study, 12 cases of histoplasmosis were diagnosed. The median age of the patients was 53 years; all males except one. The diagnosis of histoplasmosis was confirmed on histopathology for 11 cases, and one patient was diagnosed as probable histoplasmosis. The patients were either from Gujarat or Rajasthan without any travel history to endemic zone of histoplasmosis, except one patient. The majority (67%) of the patients had no apparent immunosuppression. Adrenal enlargement, oral ulcers and lymphadenopathy were common presentations in four patients each. We lost two patients in follow-up, and rest 10 patients responded to either to amphotericin B deoxycholate and/or itraconazole therapy. CONCLUSION: This study highlights that Gujarat and Rajasthan are an endemic region for histoplasmosis, and a systematic study is required to understand epidemiology of the disease. Histoplasmosis should be a differential diagnosis in a patient presenting with adrenal enlargement, lymphadenopathy, oral ulcers and fever of unknown origin in this region.

Clinical Profile and Outcome of Progressive Multifocal Leukoencephalopathy in HIV Infected Indian Patients.

BACKGROUND AND OBJECTIVE: Progressive multifocal leukoencephalopathy (PML) is a fatal demyelinating disease of the Central nervous system (CNS) caused by the human polyoma virus JC (JCV). Human Immunodeficiency Virus (HIV) infection predisposes to PML. Very sparse data is available regarding the effect of Highly Active Anti Retroviral Therapy (HAART) on clinical outcome of PML in Indian settings. This study was carried out to look into clinical profile, survival and neurological outcome of HIV infected PML patients in HAART era. METHODS: We looked in our cohort of HIV-1-infected individuals retrospectively. Diagnosis of PML was done on basis of clinical and radiological abnormalities highly suggestive of the condition, with or without confirmation of JCV DNA in the cerebrospinal fluid (CSF) by polymerase chain reaction (PCR). RESULTS: Out of 892 HIV infected patients, 31 met the criteria for the diagnosis of PML. The median CD4+ cell count was 73 cells/µL (Interquartile range (IQR), 43-160 cells/µL) at the presentation of PML. Median duration of PML symptoms were 30 days (IQR, 15-60 days) before diagnosis of PML could be made. The median survival was 538 days. In those patients who survived more than one year, the median survival time was 1095 days (95% confidence interval (CI), 1090.35 -1099.64 days). Those who survived more than one year (n=13), Neurologic function were categorized as cure or improvement in 8, same status in 3 or progression in 2 patients. CONCLUSIONS: In the pre-HAART era, PML patients had very poor prognosis with median survival of 4-6 months after diagnosis. Till date HAART is the only way for reversal of immune system in HIV infected patients and its prompt institution is the most effective therapeutic approach in increasing survival in this group. In this study, 46.4% patients survived after 1 year on HAART. Amongst them, 69% patients completed 3 years. There is strong need of research for the development of pharmacotherapy against JC virus to increase the survival.

A Prospective, Multicentre, Open-Label Single-Arm Exploratory Study to Evaluate Efficacy and Safety of Saroglitazar on Hypertriglyceridemia in HIV Associated Lipodystrophy.

OBJECTIVE: This study was designed to explore the efficacy and safety of saroglitazar 4 mg on hypertriglyceridemia in patients with HIV associated lipodystrophy. METHODS: During this 12-week prospective, multi-centric, open-label, single arm exploratory study, 50 patients were enrolled to receive saroglitazar 4 mg orally once daily in the morning before breakfast. The primary efficacy endpoint was the percent change in triglyceride (TG) levels from baseline to Week 6 and Week 12. The secondary efficacy endpoints were assessment of low-density-lipoprotein (LDL), very-low-density-lipoprotein (VLDL), high-density-lipoprotein (HDL), non-HDL cholesterol, total cholesterol, apo-lipoprotein (Apo) A1, Apo B, and C-peptide and fasting insulin for HOMA beta and HOMA IR. Safety assessment was performed during the study. RESULTS: Saroglitazar 4 mg significantly decreased the serum TG levels from baseline at Week 6 (percent change: -40.98; 95% CI: -50.82, -31.15) and Week 12 (percent change -45.11; 95% CI: -52.37, -37.86). Reduction in VLDL cholesterol (percent change: -46.33; 95% CI: -52.89, -39.76) and total cholesterol (percent change: 7.37; 95% CI: 1.96, 12.78) was observed at week 12 from baseline. Saroglitazar increased HDL cholesterol (percent change: 34.56, 95% CI: 22.22, 46.90), Apo A1 (percent change: 33.16; 95% CI: 18.69, 47.63) and Apo B (percent change: 10.55, 95% CI: 2.86, 18.25) levels at week 12 from baseline. Saroglitazar treatment led to increase in the C-peptide (percent change: 59.42, 95% CI: 48.78, 70.06), fasting insulin levels (percent change: 47.10; 95% CI: 38.63, 55.57), HOMA of beta cell function for C-peptide (percent change: 71.67; 95% CI: 39.09, 104.26) and HOMA of insulin resistance for C-peptide (percent change: 58.29, 95% CI: 46.74, 69.83) at week 12 from baseline. Saroglitazar treatment was safe and well tolerated in this study. CONCLUSION: Overall, the observed changes in lipid profile after 12 weeks of saroglitazar treatment were in the direction of improvement in patients with HIV associated lipodystrophy. TRIAL REGISTRATION: Clinical Trial Registry of India Phase II/CTRI/2010/091/000107.

First Crimean-Congo hemorrhagic fever outbreak in India.

Crimean-Congo hemorrhagic fever (CCHF) has not been reportedly previously from India. Initial clinical features of dengue fever and CCHF are similar and it is very difficult to differentiate and diagnose CCHF. Common clinical features of CCHF include; high grade fever with chills, headache, body ache, myalgia, vomiting, abdominal pain, weakness and bleeding from multiple sites. Laboratory investigations showed cytopenia, raised prothrombin time (PT) and activated partial thromboplastin time (aPTT), raised creatinine phosphokinase (CPK) and lactic dehydrogenase (LDH) as well as altered liver and renal functions. Patients with above symptoms can rapidly progress to bleeding from multiple sites and death compared to dengue fever. It is crucial to recognize CCHF at early stage to institute ribavirin treatment and also to prevent nosocomial spread of disease to health care workers. We are describing first four cases of recent CCHF outbreak in Ahmedabad.