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  ~ Table of Contents - Current issue
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April-June 2018
Volume 36 | Issue 2
Page Nos. 153-297

Online since Tuesday, August 7, 2018

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EDITORIAL  

WHO essential diagnostics list (2018): A revolutionary step in strengthening health laboratories at all levels of healthcare p. 153
Rajesh Bhatia
DOI:10.4103/ijmm.IJMM_18_195  PMID:30084403
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SPECIAL ARTICLE Top

Prevention of healthcare-associated infections in low- and middle-income Countries: The 'bundle approach' Highly accessed article p. 155
Purva Mathur
DOI:10.4103/ijmm.IJMM_18_152  PMID:30084404
Background: Healthcare-associated infections (HCAI/HAIs) are one of the most common adverse events in patient care and account for substantial morbidity and mortality. The high rates of HCAIs in a facility are an indicator of poor quality of healthcare services. According to the World Health Organization, at any time, up to 7% of patients in developed and 10% in developing countries will acquire at least one HAI. These infections also present a significant economic burden at the societal level. However, a large percentage of HAIs are preventable through effective infection prevention and control measures. Objectives: Prevention of these infections also needs to be prioritised in view of the growing antimicrobial resistance in HAIs. The bundle approach to the prevention of HAIs is a relatively new concept that is revolutionising the care of high-risk patients in the Intensive Care Units. This report details the bundle approach for the prevention of HAIs, particularly the device-associated infections, for low- and middle-income countries. Conclusion: With the escalating armamentarium of antimicrobial resistance, healthcare sector has to go back to the very basics of hospital infection control; develop, assess and implement bundles of prevention. These are cost-effective and easily adaptable, to cater to the increasing HCAIs and MDR infections in the LMICs.
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ORIGINAL ARTICLES Top

Profile of respiratory pathogens causing acute respiratory infections in hospitalised children at Rajasthan a 4 year's study p. 163
M Anjaneya Swamy, Bharti Malhotra, PV Janardhan Reddy, Jitendra Tiwari
DOI:10.4103/ijmm.IJMM_18_84  PMID:30084405
Introduction: Various pathogens cause respiratory tract infections in children of <5 years of age causing severe morbidity and mortality. The profile of causative agents varies from place to place. Aims: The objectives of our study were to detect the profile and trends of respiratory pathogens causing acute respiratory tract infection in children using a custom multiplex real-time polymerase chain reaction (RT-PCR) and to develop a diagnostic algorithm. Materials and Methods: A total of 997 children with clinical manifestations of respiratory infections were included in the study. Their nasopharyngeal aspirate and throat swab samples were subjected to nucleic acid extraction followed by multiplex RT-PCR for eighteen viruses and six bacteria. Statistical Analysis Used: Chi-square test was employed to study the P value of different viruses and bacteria. Results: A total of 765 (76.73%) samples were found to be positive for one of the respiratory pathogens. Viruses were detected in 598 (59.98%) and bacteria in 167 (41.85%) samples, respectively. The prevalence of single and co-infections among viruses and bacteria were 77.76% and 22.24%, 81.44% and 18.56% each, respectively. Respiratory syncytial virus (RSV) A/B and Streptococcus pneumoniae were the most predominant pathogens detected in the study and were associated with lower respiratory tract infections. Conclusion: RSV and S. pneumoniae were the most common pathogens detected, higher prevalence was observed in children <1 year of age. Viruses were predominant during winter months. The study helped to prepare diagnostic algorithm which will help in reducing diagnostic costs. However, further studies are required to assess whether viruses are bystander or real pathogens and include larger panel of bacteria and viruses for diagnosis.
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BK virus characterisation among HIV-1-Infected individuals and its association with immunosuppression p. 172
Subha Jagannath, Jaiprasath Sachithanandham, Veena V Ramalingam, John Paul Demosthenes, Asha M Abraham, Anand Zachariah, George M Varghese, Rajesh Kannangai
DOI:10.4103/ijmm.IJMM_18_54  PMID:30084406
Purpose: BK virus (BKV) is an opportunistic pathogen which causes significant morbidity and mortality in individuals who are immunodeficient. We aimed to quantitate and characterise BKV and to correlate with the degree of immunosuppression among human immunodeficiency virus (HIV)-1-infected individuals. Methods: BKV DNA detection was carried out using an in-house quantitative real-time polymerase chain reaction on paired whole-blood and urine samples collected from 187 antiretroviral therapy (ART)-naïve HIV-1-infected individuals and 93 healthy individuals who served as controls. Sequencing was performed for a proportion of high BK viral load (VL) samples to observe non-coding control region (NCCR) rearrangements. Results: BKV positivity in urine was 25.6% among HIV-infected individuals and 10.7% in control individuals (P = 0.03). The BK VL showed a significant negative correlation with CD4+ T-cell counts, a positive correlation with WHO clinical staging and no significant correlation with HIV-1 VL. Of 42 BKVs from urine samples sequenced, two showed rearrangements without clinically severe disease or high VL. Their NCCR and VP1 sequence-based genotyping revealed genotype I. In a small subset of individuals (n = 8) on ART who were being followed up, six individuals showed either decrease or complete clearance of virus with ART. Conclusion: There was a higher frequency of BK viruria in HIV-1-infected individuals than among healthy controls and the positivity correlated with the degree of immunosuppression. There was no association of high VL with NCCR rearrangements in urine.
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Molecular characterisation of virulent gene vacA in Helicobacter pylori clinical isolates from patients with gastroduodenal diseases in Assam, India p. 178
Anisha Sarma, Lahari Saikia, Mituban Gogoi, Kaushal Yadav
DOI:10.4103/ijmm.IJMM_18_67  PMID:30084407
Background: Helicobacter pylori, the gastric bacterium, is widely known to be one of the most genetically diverse group of organisms whose pathogenesis as well as the diversity in infection outcome may be attributed to a variety of virulent genes. Aim: This study aimed to study the molecular profile of H. pylori vacA gene by determining the phylogenetic relatedness and genetic diversity of the strains isolated in this region with those of other geographical regions. Materials and Methods: A total of twenty H. pylori clinical strains were isolated from randomly selected 100 patients suffering from gastroduodenal diseases as well as endoscopically normal patients in a cross-sectional hospital-based setting from January 2016 to May 2017. VacA signal sequence and mid regions of H. pylori were amplified by polymerase chain reaction followed by DNA sequencing and phylogenetic analysis. Results: VacA s1m1 allelic variant was more prevalent in our study, regardless of the clinical outcomes. Phylogenetic analysis of VacA s1 strains revealed clustering of most of the strains. VacA m1 strains clustered with Bangladesh strains which is a country nearest to India. Conclusion: Prevalence of VacA s1m1 strains may account for high risk of transmission of this gastric pathogen and the overall risk of acquiring infection. Phylogenetic analysis results suggests the prevalence of high genetic diversity in our region. Our findings may aid in developing a better understanding of the genetic structure of H. pylori and the pathophysiology of associated diseases, thus facilitating the implementation of various treatment options.
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Trends in antimicrobial resistance patterns of Group A streptococci, molecular basis and implications p. 186
Tintu Abraham, Sujatha Sistla
DOI:10.4103/ijmm.IJMM_18_107  PMID:30084408
Background: Group A streptococcus (GAS) causes a wide variety of diseases ranging from mild skin and soft-tissue infections to severe, life-threatening conditions. A fluctuating trend has been observed in the antibiotic resistance pattern from different parts of the world. The present study was undertaken to determine the prevalence of antibiotic resistance among GAS isolates and the underlying genetic mechanisms. Materials and Methods: Two hundred and six GAS isolates were characterised by antimicrobial susceptibility pattern, macrolide resistance phenotype (double-disc test) and resistance determinants by multiplex polymerase chain reaction. Results: All the isolates were susceptible to penicillin, vancomycin and linezolid. Erythromycin resistance was found in 53% of isolates with inducible macrolide, lincosamide and streptogramin B the predominant phenotype (63%) with ermB the major genetic determinant. Clindamycin resistance was observed in 33% of isolates with all being inducible resistant. Tetracycline resistance was found in 58% of isolates with tetM as the major genetic determinant (97%). Erythromycin and tetracycline co-resistance was found in 39% of tested GAS isolates. Conclusion: The erythromycin and tetracycline resistance in GAS continues to exist at high levels and may be attributed to the over-prescription and use of these antibiotics. Our findings indicate that the use of these antibiotics especially macrolides as empiric therapy in penicillin-allergic patients may not be appropriate.
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Distribution of hepatitis C virus genotypes in Istanbul, Turkey p. 192
Nuran Karabulut, Sema Alacam, Ayfer Yolcu, Mustafa Onel, Ali Agacfidan
DOI:10.4103/ijmm.IJMM_17_381  PMID:30084409
Purpose: The hepatitis C virus (HCV) has seven main genotypes and multiple subtypes. The distribution of HCV genotypes varies across geographical regions worldwide. Updated estimates of HCV genotype distributions have a critical importance for developing strategies to manage or eliminate HCV infection. The aim of this study was to determine the distribution of HCV genotypes in patients with HCV admitted to a university hospital in Istanbul, Turkey. Materials and Methods: A total of 412 HCV RNA positive patients with 46.6% of males and 53.4% of females between January 2013 and September 2016 were included in the study. Genotyping of HCV of the study population was performed by a commercial reverse hybridisation line probe-based assay. Results: Genotype 1 (82.5%) was dominant genotype, followed by genotype 3 (10.7%), genotype 2 (4.6%) and genotype 4 (2.2%). Among patients with genotype 1, subtype 1a, 1b and undetermined subtype were 6.3%, 38.8% and 37.4%, respectively. It was observed that genotype proportion was dependent on gender and age of the patients. Genotype 1 and genotype 2 were more prevalent in females, whereas genotypes 3 and 4 were more prevalent in males. Genotype 1 in the older patients and genotype 3 in the younger patients were more prevalent. Conclusion: The majority of patients with HCV infection had genotype 1 (82.5%), followed by genotype 3, 2 and 4. Monitoring the change in HCV genotype distribution is critical for the development of effective strategies for HCV elimination.
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Identification of Raoultella spp.: Comparison of three methods p. 197
Alicja Sekowska, Agnieszka Mikucka, Eugenia Gospodarek-Komkowska
DOI:10.4103/ijmm.IJMM_17_99  PMID:30084410
Background: Raoultella is a Gram-negative bacteria, which commonly occur in the natural environment such as water, soil and on plants. In recent years, Raoultella spp. gained more interest. There is also an increasing number of publications describing mainly clinical cases involving these bacteria. Identification of Raoultella spp. is difficult due to a phylogenetic relationship with Klebsiella spp. Purpose: Available biochemical tests do not always allow for their identification to species. Thus, the aim of this study was to evaluate selected methods of identification of Raoultella spp. and their differentiation from genus Klebsiella. Materials and Methods: In this evaluation three methods were used such as manual test ID32E (bioMérieux), automatic test VITEK2 Compact (bioMérieux) and matrix-assisted laser desorption ionisation-time of flight mass spectrometry (MALDI-TOF MS) method (Bruker). Results: Good identification of the species was obtained for 81.4% of the strains in the ID32E test, 93.3% in VITEK2 Compact test, and 97.4% in MALDI-TOF MS method, respectively. Conclusion: It was established that MALDI-TOF MS method is reliable in identifying genus Raoultella.
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Prothrombotic state in HIV: A study on protein C, protein S, homocysteine and correlation with CD4 counts p. 201
Swati Khare, Rashmi Kushwaha, Ashutosh Kumar, Vimala Venkatesh, Himanshu D Reddy, Mili Jain, Mohd Yusuf, Uma Shankar Singh
DOI:10.4103/ijmm.IJMM_15_414  PMID:30084411
Introduction: Human immunodeficiency virus (HIV) may result in variable haematological manifestations. Thrombotic events are more common among HIV-infected persons than the general population, possibly due to the increased inflammatory/hypercoagulable state and presence of concurrent comorbidities. Aims and Objectives: (1) Screen for coagulation abnormalities in HIV-infected patients. (2) Detect certain prothrombotic factors such as deficiency of protein C and protein S and elevation of homocysteine as possible precursors of coagulation defects in HIV patients. (3) Correlation of coagulation abnormalities with CD4 counts. Methods: A pilot study of 1-year duration conducted in the Department of Pathology in collaboration with ART centre, KGMU Lucknow. All diagnosed HIV-seropositive patients (n = 30) who were not taking Vitamin K, antithrombotic and antiplatelet drugs including aspirin, oral contraceptives and not having known protein C/S deficiency were included in the present study as cases. Apart from this, 30 age- and sex-matched healthy individuals were also included in the present study. Assessment of the bleeding time, prothrombin time and activated partial thromboplastin time, complete blood count was done. Protein C and S were measured by calorimetric assay. Serum homocysteine was measured by the semi-automated method. CD4 count was done by flow cytometry. Results: The findings of the present study suggest a relationship between HIV, its complications and thrombosis. The HIV-seropositive patients have reduced levels of haemoglobin, CD4 counts, platelet counts, mean platelet volume, protein C and S activity as compared to the healthy individuals. Thrombophilic abnormality in the form of hyperhomocysteinaemia is more frequent in HIV-infected patients. All these parameters have a definite correlation with CD4 count.
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Polymorphisms in cytotoxic T-lymphocyte associated antigen 4 gene does not affect scytotoxic T-lymphocyte associated antigen 4 levels in human papillomavirus-infected women with or without cervical cancer p. 207
Priyanka Wagh, Priyanka Kulkarni, Shilpa Kerkar, Himangi Warke, Hemangi Chaudhari, Kedar Deodhar, Bharat Rekhi, Hemant Tongaonkar, Jayanti Mania-Pramanik
DOI:10.4103/ijmm.IJMM_17_220  PMID:30084412
Background: Cervical cancer (CaCx) is the second most common cancer in Indian women. Cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) + 49 AA polymorphism is known to be associated with CaCx. Current attempt is to use immunotherapy for the treatment of metastatic melanoma and metastatic castration-resistant prostate cancer, i.e., blocking of CTLA-4 using a fully human monoclonal CTLA-4 antibody to disrupt its inhibitory signal. This allows the CTLs to destroy the cancer cells. There is no information available on the soluble level of CTLA-4 on which the immunotherapy is targeted. This is specifically in Indian population including cases with CaCx. Objective: The aim of this study is to evaluate the levels of soluble CTLA-4 (sCTLA-4) in human papillomavirus (HPV)-infected women with or without CaCx and their association with the polymorphism at CTLA-4 + 49 A/G and CTLA-4 −318 C/T genotypes. Materials and Methods: This is an exploratory case–control study involving two groups of HPV-infected women, the cases were with invasive CaCx and the control group was women with the healthy cervix. sCTLA-4 levels were measured using ELISA in 92 CaCx cases and 57 HPV-positive women with the healthy cervix. Results: Both cases and controls have similar sCTLA-4 levels. Comparison of CTLA-4 + 49A/G and −318 C/T genotypes with sCTLA-4 levels among cases and control also did not show any statistically significant difference. Conclusion: The present study suggests sCTLA-4 levels are not affected by a polymorphism at + 49 A>G CTLA-4. Hence, levels of CTLA-4 are similar in both CaCx cases and control group.
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Rapid detection of ethambutol-resistant Mycobacterium tuberculosis in clinical specimens by real-time polymerase chain reaction hybridisation probe method p. 211
DS Chauhan, R Sharma, D Parashar, R Das, P Sharma, AV Singh, PK Singh, K Katoch, VM Katoch
DOI:10.4103/ijmm.IJMM_14_304  PMID:30084413
Background: Early diagnosis of drug resistance (DR) to ethambutol (EMB) in tuberculosis (TB) remains a challenge. Simple and reliable method (s) are needed for rapid detection of DR Mycobacterium tuberculosis (MTB) in clinical specimens. Objectives: The aim of this study was to design fluorescence resonance energy transfer hybridisation probe-based real-time polymerase chain reaction (PCR) method for the early detection of EMB-resistant MTB direct from clinical sputa. Materials and Methods: Primers and probes were designed against 306 codon of embB gene which is commonly associated with EMB resistance. A comparative study was done between Lowenstein–Jenson (L–J) proportion and hybridisation probe-based real-time PCR method for susceptibility testing. DNA sequencing was used in nine representative isolates to validate the efficiency of real-time PCR method to detect emb306 mutation of MTB. Results: A total of 52 clinical sputum samples and corresponding culture isolates (from category II pulmonary TB cases) were included in this study. Out of 52 MTB isolates, 32 and 20 were resistant and susceptible to EMB, respectively, as determined by L–J proportion method. Real-time PCR showed 95% specificity, 75% sensitivity and 82.69% accuracy when compared with L–J proportion method. A 100% of concordance was observed by validating the real-time PCR results with DNA sequencing. Conclusions: Our real-time PCR hybridisation probe method promises for rapid detection of EMB-resistant MTB directly from clinical specimens. However, future studies and modifications of method by incorporating other potential loci along with targeted mutation (emb306) are still required to increase the sensitivity of method.
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Lamivudine plus tenofovir versus lamivudine plus adefovir for the treatment of hepatitis B virus in HIV-coinfected patients, starting antiretroviral therapy p. 217
Jayeeta Sarkar, Debraj Saha, Bhaswati Bandyopadhyay, Bibhuti Saha, Runu Chakravarty, Subhasish Kamal Guha
DOI:10.4103/ijmm.IJMM_17_37  PMID:30084414
Background: Combination of tenofovir disoproxil fumarate (TDF), lamivudine (3TC) and efavirenz (EFV) is preferred in the treatment of HIV/hepatitis B virus (HBV) coinfection. We postulated that a HBV active nucleoside reverse transcriptase (RT) inhibitor/nucleotide RT inhibitor backbone of adefovir dipivoxil (ADV) +3TC would be as effective as TDF +3TC for the Indian population. Objective: ADV + 3TC could be an alternative option for these HIV/HBV coinfected individuals, preserving the dually active TDF + 3TC as second-line nucleoside backbone following failure of the first-line ART. Materials and Methods: This randomised control trial (CTRI/2012/03/002471) was carried out at the ART Centre of Calcutta School of Tropical Medicine, India. Seventy-eight (39 on each arm) treatment-naïve HIV/HBV coinfected patients were randomised to receive either the combination of lamivudine + tenofovir + EFV or lamivudine + adefovir + zidovudine + EFV and followed up for 120 weeks. Results: Median age of the study participants was 36 years (21–62), majority were male (61/78; 78.2%) and heterosexually (39/78; 50%) infected. Baseline characteristics were identical in both arms. There was no statistically significant difference in median aspartate aminotransferase (37 vs. 29.5 U/L), alanine aminotransferase (ALT) (36 vs. 34.5 U/L), ALT normalisation rate (80 vs. 70%), AST to platelet ratio index (0.45 vs. 0.33), CD4 count (508 vs. 427 cells/mm3), HBV DNA suppression (81.8 vs. 70%), hepatitis B e antigen loss (9 vs. 5%), hepatitis B surface antigen seroclearance rate (6.06 vs. 18.75%) and death (3 vs. 3) at 120 weeks between TDF (n = 33) and ADV (n = 32), respectively. Conclusions: Adefovir plus lamivudine is an effective alternative of tenofovir plus lamivudine in long-term HBV treatment outcome in HIV/HBV coinfected patients.
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The effectiveness of sofosbuvir and daclatasvir in the treatment of hepatitis C in thalassaemia major patients and their effect on haematological factors p. 224
Farhad Zamani, Hossein Ajdarkosh, Fahimeh Safarnezhad-Tameshkel, Azita Azarkeivan, Hossein Keyvani, Farshad Naserifar, Jamshid Vafaeimanesh
DOI:10.4103/ijmm.IJMM_18_90  PMID:30084415
Context: Patients with thalassaemia are at risk of infections such as hepatitis C virus (HCV) due to their repeated blood transfusions; meanwhile, the treatment of thalassaemia patients who had developed HCV infection is a controversial issue. Aims: Although the effectiveness of direct-acting antivirals on HCV infection has been confirmed, their side-effects as well as effects on haematological factors due to the resultant need for blood transfusion remain to be further understood. Materials and Methods: In this study, 61 patients with major beta thalassaemia and HCV infection, and who had a history of interferon treatment failure were examined. The patients underwent a 24-week treatment with sofosbuvir (SOF) and daclatasvir (DAC). Sustained virological response 12 was used to assess response to treatment. At the end of the study, the need for blood transfusion and serum ferritin was evaluated. Results: About 98.4% of the patients responded to the treatment, and only one patient with genotype 1b did not respond positively. No significant complications necessitating treatment cessation were observed, and all the patients tolerated the treatment well. The level of liver enzymes showed a significant reduction 12 weeks after the treatment. The need for blood transfusions in patients before treatment was averagely 1.595 ± 0.65 bag per month, in which 1.593 ± 0.64 bags were received after treatment (P = 0.9). This regimen did not affect the amount of anaemia in patients and did not differentiate the need for blood transfusions. The rate of haemoglobin before treatment was 9.5 ± 1.42 g/dl, which reached 9.6 ± 1.6 g/dl after treatment (P = 0.54). Ferritin levels decreased significantly (from 1948.08 ± 1539.54 to 1315.73 ± 1207.67 ng/ml) (P = 0.001) in the patients after the treatment. Conclusion: Combination of SOF and DAC is an effective and tolerable treatment regimen without affect on the amount of anaemia in patients and did not differentiate the need for blood transfusions.
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Detection of anti-hepatitis C virus and hepatitis C virus RNA in dried blood spot specimens using Whatman No. 1 filter paper p. 230
Ritapa Ghosh, Naba Kumar Hazarika
DOI:10.4103/ijmm.IJMM_17_238  PMID:30084416
Purpose: Dried blood spot (DBS) specimen simplifies blood collection, processing, storage and shipment and may reduce the cost of testing for hepatitis C virus (HCV) infection. We wanted to see if DBS using a cheap filter paper is reliable alternative to serum for detection of anti-HCV and HCV RNA. Materials and Methods: At a tertiary care hospital in Northeast India, we collected 91 paired DBS and serum specimens from patients at risk of HCV infection from July 2014 to June 2015. DBS was collected on Whatman No. 1 filter paper. After processing, the specimens were subjected to anti-HCV detection by a third-generation Enzyme-Linked Immunosorbent Assay (ELISA). The reactive DBS and serum specimens were further subjected to HCV RNA detection by polymerase chain reaction. The results were analysed in paired screen-positive study design. Results: Anti-HCV was detected in 9 (9.9%) DBS specimens and 10 (10.9%) serum specimens. There was statistically significant (P < 0.0001) correlation between the optical density values of DBS and serum specimens (Pearson r = 0.9181, 95% confidence interval: 0.8781–0.9453). HCV RNA was detected in 5/9 (55.6%) reactive DBS and 9/10 (90.0%) reactive serum specimens. There was no correlation between HCV RNA levels in the DBS and the serum specimens. The relative sensitivity rate and the relative false-positive rate of DBS anti-HCV ELISA were 0.89 and 1.00, respectively. Conclusions: DBS using Whatman No. 1 filter paper is quite reliable as serum for detection of anti-HCV. It can be useful in effective surveillance. However, it is not suitable for confirmation of chronic HCV infection.
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Co-circulation of four dengue serotypes at South Eastern Andhra Pradesh, India: A prospective study p. 236
Rishi Gowtham Racherla, Madhavi Latha Pamireddy, Alladi Mohan, Nagaraja Mudhigeti, Padmalatha Anjaneyulu Mahalakshmi, Umapathi Nallapireddy, Usha Kalawat
DOI:10.4103/ijmm.IJMM_18_109  PMID:30084417
Background: Dengue is one of the most important mosquito-borne viral diseases in the world. The emergence and spread of four dengue viruses (DENVs) (serotypes) represent a global pandemic. The four distinct serotypes are, namely, DENV-1, DENV-2, DENV-3 and DENV-4. Very few dengue serotyping studies have been reported from Andhra Pradesh. In this context, the present study focuses on the circulating serotypes of dengue in South-Eastern Andhra Pradesh. Methodology: Study was done at Sri Venkateswara Institute of Medical Sciences, a teaching hospital in Tirupati, Andhra Pradesh. Acute phase dengue serum samples were collected and tested for NS1 antigen and anti-human IgM antibodies by enzyme-linked immunosorbent assay (ELISA). NS1-positive samples were further serotyped by reverse transcriptase real-time polymerase chain reaction (rRT-PCR). Results: A total of 398 serum samples were received from clinically suspected dengue fever cases. Of these, 150 (37.7%) samples were positive for NS1 and/or IgM ELISA. The 96 NS1 antigen-positive samples were further processed for serotyping, of which 36 were negative by rRT-PCR. DENV-2 (41%) was the predominant serotype, followed by DENV-4 (37%), DENV-3 (12%) and DENV-1 (10%) in descending order. Conclusion: This study reports the all four dengue serotypes' co-circulation. This is the first report from South Eastern Andhra Pradesh. Amongst four, DENV-2 was predominant followed by DENV-4. The information of predominant serotypes can guide in forecasting dengue outbreaks and improving control measures of vectors thus may be helpful in the prevention of outbreaks.
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Performance of an in-house real-time PCR assay for detecting Cytomegalovirus infection among transplant patients from a tertiary care centre p. 241
Santhosh Kumar Duraisamy, Shoba Mammen, Sasi Kumar Reddy Lakshminarayan, Susan Verghese, Mahesh Moorthy, Biju George, Rajesh Kannangai, Santosh Varghese, Alok Srivastava, Asha Mary Abraham
DOI:10.4103/ijmm.IJMM_18_126  PMID:30084418
Background: Quantitative Cytomegalovirus (CMV) polymerase chain reactions are increasingly being used for monitoring CMV DNAemia in haematopoietic stem cell transplants and solid organ transplants. Objective: In this study, a commercial CMV viral load assay was compared with an in-house viral load assay. Materials and Methods: A total of 176 whole-blood samples were tested for CMV DNAemia using both assays. Results: Our evaluation showed a difference of 1 log10copies/ml between the two assay systems in determining CMV viral loads in the clinical samples. Conclusion: The in-house viral load assay had a better correlation with clinical findings compared to the commercial assay. Quality assessment of these assays was done by the United Kingdom National External Quality Assessment Scheme (UKNEQAS), an external proficiency testing programme, and by the National Institute for Biological Standard and Control (NIBSC) standard. For UKNEQAS and NIBSC standards, the bias between the assays was 0.73 log10and 0.85 log10, respectively. This difference is well within the acceptable range already reported in the literature.
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Intestinal cryptosporidiosis in renal transplant recipients: Prevalence, species detection and comparative evaluation of SSU rRNA and Cryptosporidium oocyst wall protein genes p. 247
Ujjala Ghoshal, Prabhat Ranjan, Asmita Dey, Uday Chand Ghoshal
DOI:10.4103/ijmm.IJMM_18_179  PMID:30084419
Context: Cryptosporidiosis is intestinal opportunistic infection commonly occurring in immunocompromised patients including renal transplant (RT) recipients receiving continuous immunosuppressive therapy. Knowledge about species of Cryptosporidium-infecting RT recipients is necessary to know about mode of its transmission (anthroponotic or zoonotic). Various genes such as small subunit rRNA (SSU rRNA) and Cryptosporidium oocyst wall protein (COWP) genes may help in species identification though their sensitivity and specificity are highly variable. Subjects and Methods: A total of 993 and 575 stool samples were examined for Cryptosporidium by microscopy from 358 RT recipients and 200 healthy controls, respectively. Stool samples of RT recipients and healthy controls were subjected to polymerase chain reaction (PCR) followed by restriction fragment length polymorphism (RFLP) for species identification. Results: Cryptosporidium was more commonly detected amongst RT recipients than healthy controls (30/358, 8.4% vs. 0/200, respectively; P < 0.001). The infection was more common amongst patients with diarrhoea than those without (26/162, 16.1% vs. 4/145, 2.8%; P < 0.001). Cryptosporidium parvum was identified in 10/30 (33.3%) and Cryptosporidium hominis in 20/30 (66.7%) samples. SSU gene PCR-RFLP proved to be more sensitive (100%) than COWP (90%); however, specificity of both was same (100%). Conclusions: Cryptosporidiosis is common amongst RT recipients, particularly those with diarrhoea. C. hominis is the most common species in the studied population. SSU rRNA PCR was more sensitive molecular method for the differentiation of Cryptosporidium species.
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Assessment of microbiological status after successful completion of intermittent revised national tuberculosis control programme directly observed treatment, short course regimen for microbiologically confirmed pulmonary tuberculosis cases: While new daily regimen going to be implemented in India p. 251
Roumi Ghosh, Sudipta Roy, Md. Khalid Rashid
DOI:10.4103/ijmm.IJMM_18_65  PMID:30084420
Purpose: The Revised National Tuberculosis Control Programme (RNTCP) is now introducing daily fixed-dose regimen instead of Directly Observed Treatment, Short Course (DOTS) regimen for treatment of drug-sensitive tuberculosis (TB) in India. It would be beneficial to understand the drawbacks, barriers and advantages of the existing system for better implementation of new policy. Our study was aimed to evaluate the current microbiological status of new microbiologically confirmed pulmonary TB patients who have successfully completed intermittent DOTS regimen within last 2 years and also to find the economic barriers faced by beneficiaries to avail DOTS treatment. Materials and Methods: We included patients who had completed CAT 1 DOTS regimen within the last 2 years. The patients were interviewed. Sputum sample was collected for microscopy and cartridge-based nucleic acid amplification test. Results: All patients were adhered to intermittent DOTS therapy, and sputum conversion rate was 83%. Minor gastrointestinal side effects were experienced by 60% of cases and 87% consumed drugs under supervision. On microbiological examination, 10% of the study population was found to be positive for TB and they all were rifampicin sensitive. Those who had completed treatment within 1 year with no clinical symptoms re-appeared after treatment. Conclusion: Till date, RNTCP does not follow up the patients for any period of time after successful completion of treatment. Through the present study, we could find relapse cases in 10% of the previously treated non-symptomatic patients. These unnoticed relapse cases have potential to spread TB and increase disease burden of country. Thus, we can conclude that RNTCP has to follow up the patients after successful treatment to determine whether they relapse. It is needed for the success of programme and control of the disease in the country.
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Molecular investigation of staphylococcal cassette chromosome mec types and genotypic relations of methicillin-resistant staphylococci isolated from before and after hospital exposed students p. 257
Bora Ekinci, Tuba Gokdogan Edgunlu, Gulcin Bayramoglu, Gulsen Ulucam Atay
DOI:10.4103/ijmm.IJMM_17_256  PMID:30084421
Background: Reservoir of methicillin resistance genes called staphylococcal cassette chromosome mec (SCCmec), plasmids and genomic characterisations of isolates have been widely investigated in epidemiologic research. However, the extent to which these organisms are transported by patients or hospital staff is not entirely clear. Aim: This study aims to investigate the molecular relatedness and plasmid profiles of MR staphylococci isolated from nursing students before and after hospital training, to find out the possible source. Materials and Methods: This study examined 39 methicillin-resistant (MR) staphylococci and 2 inducible clindamycin-resistant, methicillin-susceptible Staphylococcus aureus. Specimens were collected before and after 4 months of hospital training from the hands and nares of 75 nursing students. A polymerase chain reaction technique was used to confirm the existence of mecA gene and identify SCCmec types; total DNA was digested by SmaI endonuclease restriction to monitorise clonal relatedness by pulsed-field gel electrophoresis (PFGE); plasmid profiles were monitorised on agarose gel. Results: All 39 isolates tested positive for mecA; SCCmec type III was observed most frequently. Interestingly, in one isolate of Staphylococcus epidermidis, four different types of SCCmec elements were observed. There were 23 different types of plasmids, whose sizes ranged from 1.4 to 46.0 kb. After PFGE dendogram analysis, two strains were classified as indistinguishable; six were closely related. Most of the isolates obtained after hospital training showed clonal similarity and seven had multiple SCCmec elements require further investigation for the possible mechanism. Conclusion: Most of the isolates obtained after hospital training showed clonal similarity and seven had multiple SCCmec elements require further investigation for the possible mechanism.
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Antibiotic resistance in Helicobacter pylori: A mutational analysis from a tertiary care hospital in Kashmir, India p. 265
Fayaz Ahmad Wani, Gulnaz Bashir, Mushtaq Ahmad Khan, Showkat Ali Zargar, Zubaida Rasool, Qurteeba Qadri
DOI:10.4103/ijmm.IJMM_18_19  PMID:30084422
Background: Helicobacter pylori infection is recognised as type 1 carcinogen by the International Agency of Research on Cancer. Previous studies in our hospital have revealed high prevalence of H. pylori in our population with a high recurrence rate after completion of treatment. This prompted us to undertake this study. Aim: This study aimed to determine common gene mutations leading to resistance to clarithromycin, metronidazole, tetracycline and quinolones in H. pylori in patients attending our hospital. Settings and Design: This is a cross-sectional hospital-based study. The study was approved by the Institutional Ethics Committee. Materials and Methods: This study was conducted on 196 adult dyspeptic patients with an indication for upper gastrointestinal endoscopy. Gastric biopsies collected from them were subjected to histopathological examination, rapid urease test (RUT) and culture. Of the 196 patients, 95 met the inclusion criteria. Drug susceptibility testing (DST) by various polymerase chain reaction-based methods was done for 47 RUT-positive biopsies and 13 H. pylori isolates. Results: Maximum resistance was seen to metronidazole (81.66%) followed by clarithromycin (45%) and quinolones (3.33%). No high-level resistance was seen to tetracycline. In clarithromycin-resistant cases, A2142G mutation was more prevalent than A2143G mutation. Multidrug resistance (resistance to metronidazole and clarithromycin) was seen in 41.66% of patients. Conclusions: Tetracycline and quinolones could be the antibiotics of choice in the eradication of H. pylori in this region, while recurrence of the infection with H. pylori could be expected among patients receiving either metronidazole or clarithromycin, for eradication therapy. DST should be done on a routine basis utilising both phenotypic and genotypic methods to prevent further emergence of resistance in this region.
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Identification of prevalent dengue serotypes by reverse transcriptase polymerase chain reaction and correlation with severity of dengue as per the recent World Health Organization classification (2009) p. 273
Tanmay K Mehta, Parul D Shah
DOI:10.4103/ijmm.IJMM_17_427  PMID:30084423
Context: A definite link between distinct dengue serotypes and severe clinical manifestations has not been established yet. The WHO classification (2009) of dengue is more competent in diagnosing severe cases compared to traditional (1997) classification. Aims: This study aimed to identify prevalent dengue serotypes and to correlate the severity of dengue with the dengue virus (DENV) serotypes in target population as per the recent WHO classification (2009). Settings and Design: A retrospective comparative observational study was conducted from 1st January 2015 to 31st December 2015. Subjects and Methods: We tested 242 dengue NS-1 antigen ELISA-positive cases for serotyping by dengue reverse transcriptase-polymerase chain reaction (RT-PCR). Severity of each dengue case confirmed by RT-PCR was determined as per the recent WHO classification (2009). Results: On the basis of RT-PCR, dengue infection was confirmed in 135 (55.78%) patients. DEN-3 was the most common serotype found in 71 (52.6%) patients, followed by DEN-2 serotype with 44 (32.6%) patients. Nearly 2.22% cases of DEN-2 and 2.96% cases of DEN-3 serotype were having dengue with warning signs. Severe dengue was found in 2.22% cases of DEN-2 and 5.18% cases of DEN-3 serotypes. Thrombocytopenia, haemorrhagic manifestations and atypical presentations were found most commonly in DEN-3 followed by DEN-2 serotype. Coinfection with more than one serotype was observed in our study, with the most common coinfection pattern being DEN-2 and DEN-3 serotypes. Conclusions: DENV-3 and DENV-2 serotypes are prevalent in the region and are associated with a more serious clinical profile than other serotypes.
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CASE REPORTS Top

Intraventricular haemorrhage as the first manifestation of congenital Cytomegalovirus infection p. 279
Malgorzata Sobolewska-Pilarczyk, Katarzyna Pawlak-Osinska, Sylwia Drewa, Beata Smok, Małgorzata Pawlowska
DOI:10.4103/ijmm.IJMM_18_11  PMID:30084424
Congenital Cytomegalovirus infection (CCMV) is the most common intrauterine infection. Early diagnosis of CCMV is hindered by three factors: There is no screening programme for CMV infection in pregnant women; a high percentage of infections in neonates are asymptomatic; the clinical signs of CCMV infection are uncharacteristic. The aim of this article is to analyse the clinical picture and course of CCMV treatment in a 3-week-old newborn, analyse adverse events in 14-week-long antiviral therapy and also assess intraventricular bleeding as an early indicator for the diagnosis of CCMV.
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Twenty-one episodes of peritonitis in a continuous ambulatory peritoneal dialysis patient: What is the root cause? p. 282
Victorine B Nzana, Anusha Rohit, Deepu George, Madhusudan Vijayan, Milly Mathew, Sundar Sankaran, Palaniappan Nagarajan, Georgi Abraham
DOI:10.4103/ijmm.IJMM_18_225  PMID:30084425
A 51-year-old female, with non-alcoholic liver cirrhosis, portal hypertension, type 2 diabetes mellitus, autosomal dominant polycystic kidney disease with a clipped cerebral aneurysm and chronic kidney disease stage 5 was on continuous ambulatory peritoneal dialysis (CAPD) for 6.5 years elsewhere. She came for opinion on continuation of CAPD as she had 21 episodes of peritonitis in 76 months. Her blood pressure was 80/50 mmHg. She was on haemodialysis with a temporary central access for 2 weeks. She had no abdominal tenderness, and exit site looked normal. Fluid was negative for Mycobacterium tuberculosis. Laparoscopically, we replaced the catheter with a new swan-neck Tenckhoff double-cuff catheter through a different exit site in the same sitting. Catheter-tip biofilm culture isolated Enterococcus casseliflavus. Peritoneal sampling biopsy showed evidence of fibrosis. She has adequate ultrafiltration and is currently on automated peritoneal dialysis for 5 months.
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BRIEF COMMUNICATIONS Top

Alarming resistance of Neisseria gonorrhoeae in a tertiary care hospital of North India p. 285
Mohit Sharma, Meher Rizvi, Richa Gupta, Mohd Azam, Haris M Khan, Anjum Parvez, Indu Shukla
DOI:10.4103/ijmm.IJMM_18_123  PMID:30084426
Background: This study attempted to elucidate the spectrum of sexually transmitted infections in a tertiary care centre in North India and to assess the antimicrobial resistance in Neisseria gonorrhoeae. Materials and Methods: Antimicrobial resistance pattern of N. gonorrhoeae was determined by the standard techniques. Genotypic detection of gyrA, parC and blaTEM genes was also carried out. The results of gyrA gene by polymerase chain reaction were confirmed by DNA sequencing. Results: N. gonorrhoea was identified in 10 (4.98%) patients, and antimicrobial sensitivity was performed in seven patients. All the seven patients tested were quinolone-resistant N. gonorrhoeae (QRNG), 5/7 were penicillinase-producing N. gonorrhoeae, 1/7 was chromosomally mediated penicillin-resistant N. gonorrhoeae and 3/7 were tetracycline-resistant N. gonorrhoeae. Minimal inhibitory concentration (MIC) by E-test was performed in five strains, and we observed that MIC90 for ciprofloxacin was ≥4 μg/ml, for penicillin was ≥6 μg/ml and for tetracycline was 12 μg/ml, which clearly brackets them as resistant isolates. The presence of TEM gene was confirmed genotypically in six out of seven cases. In all seven cases, gyrA and parC were observed, thus confirming their QRNG status. Conclusion: Alarming increase in the resistance to commonly used antimicrobials for gonorrhoea in our study, especially of fluoroquinolones, is a clarion call for the urgent need for prudence in prescribing them. Observing the rampant resistance exhibited by N. gonorrhoeae, it is clear that the day is not far when it will acquire a superbug status and become intractable to treatment by the available antibiotics.
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Clinical spectrum, susceptibility profile, treatment and outcome of culture-confirmed brucellosis from South India p. 289
Selvin Sundar Raj Mani, Karthik Gunasekaran, Ramya Iyyadurai, John Antony Jude Prakash, Balaji Veeraraghavan, Ajay Kumar Mishra, Kirti Sabnis, Punitha John Victor, Sherry Martin, Vignesh Kumar Chandiraseharan, Samuel George Hansdak, George M Varghese
DOI:10.4103/ijmm.IJMM_18_236  PMID:30084427
Brucellosis, a common zoonosis, is under reported in India despite its endemicity and increased exposure to livestock among the population. This study was conducted to determine the clinical manifestations, antibiotic susceptibility pattern, treatment and outcome of culture confirmed brucellosis. Adult patients with culture confirmed brucellosis who presented to a large teaching hospital in South India between 2009 and 2015 were included. A diagnosis of brucellosis was confirmed on automated culture. Clinical profile, laboratory parameters, drug susceptibility, treatment and outcome were documented by reviewing the medical records. The cohort comprised of 22 patients with mean ± SD age of 42 ± 13 years. Twenty one (95.5%) was male. Thirteen (59%) patients were from rural area and risk of acquisition of brucellosis including occupational exposure or consumption of unpasteurized milk was evident in 16 (72.7%) patients. The mean duration of symptoms before presentation was 54.5 ± 52 days. The commonest clinical presentation was prolonged fever without a definite focus in 18 patients (82%), whereas 2 (9%) patients had osteoarticular involvement and one patient (4.5%) each had genital involvement and endocarditis. Eighteen patients (82%) with uncomplicated brucellosis were treated with aminoglycoside and doxycycline for 6 weeks. There was no relapse or mortality at 18 ± 9 months of follow up. Brucellosis in this cohort had acute or subacute presentation with prolonged fever and bacteremia. High index of clinical suspicion based on significant epidemiological history along with automated blood culture improves the efficiency of diagnosis. Cure with lack of relapse among these cases suggests a combination therapy with doxycycline and aminoglycoside is highly effective for the treatment.
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CORRESPONDENCE Top

Oral administration of Klebsiella pneumoniae-specific bacteriophage eradicates the bacteria in albino mice p. 293
Ashutosh Chaturvedi, Gopal Nath
DOI:10.4103/ijmm.IJMM_18_154  PMID:30084428
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High prevalence of varicella seronegativity in nurses at a tertiary care private hospital in Mumbai, India p. 294
Sweta Shah, Tanu Singhal, Reshma Naik, Pooja Thakkar
DOI:10.4103/ijmm.IJMM_18_3  PMID:30084429
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The continuing scourge of congenital syphilis in the face of declining seropositivity: A challenge to control efforts p. 295
Srujana Mohanty, Tapas Som, Ashok Kumar Praharaj
DOI:10.4103/ijmm.IJMM_18_127  PMID:30084430
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2004 - Indian Journal of Medical Microbiology
Published by Wolters Kluwer - Medknow

Online since April 2001, new site since 1st August '04