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  ~ Table of Contents - Current issue
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July-September 2018
Volume 36 | Issue 3
Page Nos. 301-449

Online since Wednesday, November 14, 2018

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EDITORIAL  

Pseudomonas aeruginosa - Difficult to outmanoeuvre Highly accessed article p. 301
Payal K Patel, Twisha S Patel, Keith S Kaye
DOI:10.4103/ijmm.IJMM_18_331  PMID:30429380
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REVIEW ARTICLES Top

An update on antimicrobial resistance and the role of newer antimicrobial agents for Pseudomonas aeruginosa Highly accessed article p. 303
Agila Kumari Pragasam, Balaji Veeraraghavan, E Nalini, Shalini Anandan, Keith S Kaye
DOI:10.4103/ijmm.IJMM_18_334  PMID:30429381
Infections due to Pseudomonas aeruginosa is a major health concern, especially hospital-acquired infections, in critically ill individuals. Antimicrobial resistance (AMR) increases the morbidity and mortality rates associated with pseudomonal infections. In this review, we aim to address two major aspects of P. aeruginosa. The first part of the review will focus on the burden of AMR and its prevailing mechanisms seen in India, while the second part will focus on the challenges and approaches in the management with special emphasis on the role of newer antimicrobial agents.
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Hepatitis E virus infection: An old virus with a new story! p. 317
Ekta Gupta, Pragya Agarwala
DOI:10.4103/ijmm.IJMM_18_149  PMID:30429382
Hepatitis E virus (HEV) infection is an important public health problem. HEV infection has been identified as a major cause of enterically transmitted acute sporadic hepatitis in India especially in adult age group. India is hyperendemic for HEV, with the disease presenting both as outbreaks and as cases of acute sporadic viral hepatitis. Most of these outbreaks can be traced to contamination of drinking water supplies with human fecal matter. The last decade has witnessed tremendous change in our understanding of the virus in its epidemiology, clinical features, diagnostic approaches, treatment options and the need for vaccination. With the identification of culture systems for HEV and development of animal models for its replication, knowledge regarding its replication and pathogenesis has evolved. This review attempts to discuss the nuances in our understanding of this virus, its pathogenesis and diagnosis, especially with reference to the Indian scenario.
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Legionella and Legionnaires' disease: Time to explore in India p. 324
Rama Chaudhry, K Sreenath, Sonu Kumari Agrawal, Arvind Valavane
DOI:10.4103/ijmm.IJMM_18_298  PMID:30429383
Legionella pneumophila was first recognised as a fatal cause of pneumonia more than four decades ago, during the 1976-American Legion convention in Philadelphia, USA. Legionella spp. continue to cause disease outbreaks of public health significance, and at present, Legionnaires' disease (LD) has emerged as an important cause of community and hospital-acquired pneumonia. Parallel to this, the understanding of LD has also increased exponentially. However, the disease is likely to be underreported in many countries because of the dearth of common definitions, diagnostic tests and active surveillance systems. In this review, we outline the basic concepts of Legionella including clinical presentations, epidemiology, laboratory diagnosis and the status of LD in India. This article also summarises the progress of research related to Legionella in this country, identifying the research gaps and discussing priorities to explore this unexplored pathogen in India.
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SPECIAL ARTICLE Top

Newer β-Lactam/β-Lactamase inhibitor for multidrug-resistant gram-negative infections: Challenges, implications and surveillance strategy for India p. 334
Balaji Veeraraghavan, Agila Kumari Pragasam, Yamuna Devi Bakthavatchalam, Shalini Anandan, V Ramasubramanian, Subramanian Swaminathan, Ram Gopalakrishnan, Rajeev Soman, OC Abraham, Vinod C Ohri, Kamini Walia
DOI:10.4103/ijmm.IJMM_18_326  PMID:30429384
Antimicrobial resistance (AMR) is a major public health concern across the globe, and it is increasing at an alarming rate. Multiple classes of antimicrobials have been used for the treatment of infectious diseases. Rise in the AMR limits its use and hence the prerequisite for the newer agents to combat drug resistance. Among the infections caused by Gram-negative organisms, beta-lactams are one of the most commonly used agents. However, the presence of diverse beta-lactamases hinders its use for therapy. To overcome these enzymes, beta-lactamase inhibitors are being discovered. The aim of this document is to address the burden of AMR in India and interventions to fight against this battle. This document addresses and summarises the following: The current scenario of AMR in India (antimicrobial susceptibility, resistance mechanisms and molecular epidemiology of common pathogens); contentious issues in the use of beta-lactam/beta-lactamase inhibitor as an carbapenem sparing agent; role of newer beta-lactam/beta-lactamase inhibitor agents with its appropriateness to Indian scenario and; the Indian Council of Medical Research interventions to combat drug resistance in terms of surveillance and infection control as a national response to AMR. This document evidences the need for improved national surveillance system and country-specific newer agents to fight against the AMR.
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ORIGINAL ARTICLES Top

Dominance of international high-risk clones in carbapenemase-producing Pseudomonas aeruginosa: Multicentric molecular epidemiology report from India p. 344
Agila Kumari Pragasam, Balaji Veeraraghavan, Shalini Anandan, Vignesh Narasiman, Sujatha Sistla, Arti Kapil, Purva Mathur, Pallab Ray, Chand Wattal, Sanjay Bhattacharya, Vijayashri Deotale, K Subramani, JV Peter, TD Hariharan, I Ramya, S Iniyan, Kamini Walia, VC Ohri
DOI:10.4103/ijmm.IJMM_18_294  PMID:30429385
Background: Pseudomonas aeruginosa is one of the most common opportunistic pathogens that cause severe infections in humans. The burden of carbapenem resistance is particularly high and is on the rise. Very little information is available on the molecular mechanisms and its clonal types of carbapenem-resistant P. aeruginosa seen in Indian hospitals. This study was undertaken to monitor the β-lactamase profile and to investigate the genetic relatedness of the carbapenemase-producing (CP) P. aeruginosa collected across different hospitals from India. Materials and Methods: A total of 507 non-duplicate, carbapenem-resistant P. aeruginosa isolated from various clinical specimens collected during 2014–2017 across seven Indian hospitals were included. Conventional multiplex polymerase chain reaction for the genes encoding beta-lactamases such as extended-spectrum beta-lactamase (ESBL) and carbapenemase were screened. A subset of isolates (n = 133) of CP P. aeruginosa were genotyped by multilocus sequence typing (MLST) scheme. Results: Of the total 507 isolates, 15%, 40% and 20% were positive for genes encoding ESBLs, carbapenemases and ESBLs + carbapenemases, respectively, whilst 25% were negative for the β-lactamases screened. Amongst the ESBL genes, blaVEB is the most predominant, followed by blaPER and blaTEM, whilst blaVIM and blaNDM were the most predominant carbapenemases seen. However, regional differences were noted in the β-lactamases profile across the study sites. Genotyping by MLST revealed 54 different sequence types (STs). The most common are ST357, ST235, ST233 and ST244. Six clonal complexes were found (CC357, CC235, CC244, CC1047, CC664 and CC308). About 24% of total STs are of novel types and these were found to emerge from the high-risk clones. Conclusion: This is the first large study from India to report the baseline data on the molecular resistance mechanisms and its association with genetic relatedness of CP P. aeruginosa circulating in Indian hospitals. blaVIM- and blaNDM-producing P. aeruginosa is the most prevalent carbapenemase seen in India. Majority of the isolates belongs to the high-risk international clones ST235, ST357 and ST664 which is a concern.
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Hepatitis C virus infection in a tertiary care hospital in Mumbai, India: Identification of a mixed and novel genotype p. 352
Priya Madan Yabaji, Aruna Shankarkumar, Akash Shukla, Shobna Bhatia
DOI:10.4103/ijmm.IJMM_18_221  PMID:30429386
Purpose: Hepatitis C virus (HCV) is a leading cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma (HCC). HCV being a ribonucleic acid virus has considerable sequence variability. Assessment of viral load and genotype is necessary for designing treatment strategies and monitoring for viral resistance among HCV-infected cases. HCC is the most common form of liver cancer, often occurring in people with chronic hepatitis B or C. We undertook this study to observe genotype distribution of the virus in HCV patients from Mumbai. Materials and Methods: Between January 2017 and December 2017, the study was conducted on 120 chronic hepatitis outpatients from a tertiary care hospital, Mumbai, after obtaining ethics approval. All these diagnosed cases of HCV were subjected to molecular diagnosis in a research institute, Mumbai, by real-time polymerase chain reaction-based techniques. Results: Males were more preponderant than females with HCV infection, and the highest number of HCV-infected cases was observed in the age group of 41–50 years. Genotype 3 (n = 70; 58.3%) accounted for the highest number of cases followed by genotypes 1b (n = 29; 24.2%) and then 1a (n = 14; 11.7%). Mixed genotypes 1b + 3 and individual genotype 4 were found in two cases each (1.7%). A total of three samples (2.5%) were found with untypeable genotype. Conclusion: The major HCV genotype observed was 3 which is difficult to treat with direct-acting antivirals, owing to the more rapid progression of liver disease, increased rates of steatosis (non-alcoholic fatty liver disease), a higher risk for cancer (HCC). We believe this study is the first one to address the prevalence of mixed genotypes and untypeable genotype from India.
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Diagnostic accuracy of Xpert MTB/RIF assay in extrapulmonary tuberculosis p. 357
Sheetal Bankar, Reena Set, Disha Sharma, Daksha Shah, Jayanthi Shastri
DOI:10.4103/ijmm.IJMM_18_173  PMID:30429387
Introduction: The WHO endorsed Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay, has been evaluated for pulmonary TB in a number of studies but very few have investigated it for extrapulmonary specimens. The present study evaluates the performance of Xpert MTB/RIF assay in the diagnosis of extrapulmonary TB (EPTB). Aim and Objectives: The aim of the study is to determine sensitivity and specificity of Xpert MTB/RIF assay for diagnosis of EPTB and RIF resistance in comparison to culture on Lowenstein–Jensen (LJ) medium and proportion method (PM), respectively. Materials and Methods: A total of 738 specimens from clinically suspected cases of EPTB were subjected to Ziehl–Neelsen staining, Xpert MTB/RIF assay and culture on LJ medium. PM was done on MTB isolates. Results: The sensitivity, specificity of Xpert MTB/RIF assay for diagnosis of EPTB were 84.91% (95% confidence interval [CI] 72.41%–93.25%) and 86.72% (95% CI 83.94%–89.17%) and for RIF resistance detection were 60.00% (95% CI 32.29%–83.66%) and 94.74% (95% CI 73.97%–99.87%), respectively. Among culture-positive cases, the sensitivity of Xpert MTB/RIF assay was 94.12% in smear positive and 80.56% in smear-negative cases. Xpert MTB/RIF showed maximum sensitivity of MTB detection from lymph node specimens (100% [95% CI 54.07%–100.00%]) and other body fluids (100% [95% CI 15.81%–100.00%]). Conclusion: The present study establishes Xpert MTB/RIF assay as a promising tool in the rapid diagnosis of EPTB and detection of RIF resistance.
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Changing virulence factors among vaginal non-albicans Candida species p. 364
Krishnapriya Kalaiarasan, Rakesh Singh, Latha Chaturvedula
DOI:10.4103/ijmm.IJMM_18_94  PMID:30429388
Background: Vulvovaginal candidiasis (VVC) is caused by overgrowth of Candida species in the female lower genital tract and most commonly caused by Candida albicans. The production of various virulence factors may attribute to their pathogenicity. Hence, this study was aimed to determine the production of various virulence factors of Candida spp. causing VVC. Materials and Methods: A total of 51 Candida spp. were isolated prospectively from 50 patients among 211 clinically suspected cases of VVC. The haemolytic activity, biofilm production, proteinase activity, phospholipase activity and esterase activity were detected by standard methods. Statistical analysis was performed using OpenEpi version 3.01. Results: Haemolytic activity was observed in 42 Candida isolates (82.4%), biofilm activity in 21 Candida isolates (41.2%), proteinase and esterase activity in 19 Candida isolates (37.3%) each and phospholipase activity in 15 Candida isolates (29.4%). Phospholipase activity was observed in all of the C. albicans strains, whereas all strains of Candida krusei were able to produce biofilm. All strains of Candida parapsilosis and 87% strains of Candida glabrata were haemolytic. Five of the eight C. glabrata strains were found to produce strong proteinase (Prz score ≤0.63). About 30.4% strains of C. glabrata and 20% strains of C. krusei were found to be positive for esterase activity. This is one of the few studies which revealed esterase activity among C. glabrata and C. krusei strains. Conclusions: This study highlighted that there is a change in the virulence factors among the non-albicans Candida species, especially C. glabrata strains which were haemolytic and produce strong proteinase activity and esterase activity. It may be one of the explanation of the most common causative agent of VVC in our study. Multicentric studies from this area might be required to get a more generalised conclusion.
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Rapid detection of the commonly encountered carbapenemases (New Delhi metallo-β-lactamase, OXA-48/181) directly from various clinical samples using multiplex real-time polymerase chain reaction assay p. 369
Mubin Kazi, Rukhsar Khot, Anjali Shetty, Camilla Rodrigues
DOI:10.4103/ijmm.IJMM_18_324  PMID:30429389
Background: Resistance due to New Delhi metallo-β-lactamase (NDM) and OXA-48/181 continues to emerge as a threat which is associated with nosocomial outbreaks and is a serious healthcare concern. Phenotypic detection being laborious and time-consuming requires rapid detection of NDM and OXA-48/181, which is achieved through real-time polymerase chain reaction (RT-PCR). Materials and Methods: In this study, RT-PCR assay was developed to simultaneously detect NDM and OXA-48/181. The assay was validated on 102 non-duplicate, phenotypically characterised clinical samples. Results: The assay showed a sensitivity and specificity of 97% and 100% for the detection of carbapenemases in comparison to conventional PCR. The in-house developed multiplex RT-PCR would help to rule-in the presence of NDM and OXA-48/181. Conclusions: Rapid detection of these carbapenemases would be assist in better patient management, in terms of accurate antimicrobial treatment, help in cohorting infected from uninfected patient to prevent spread.
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Hepatitis C virus and its genotypes in chronic liver disease patients from Meghalaya, Northeast India p. 376
Bhupen Barman, Kaustubh Bora, Kryshanlang G Lynrah, W Valarie Lyngdoh, Mohammad Jamil
DOI:10.4103/ijmm.IJMM_17_371  PMID:30429390
Background and Objectives: Hepatitis C virus (HCV) is an important cause of chronic liver disease (CLD). Although Northeast India is believed to be a HCV hotspot, the proportion of HCV infection and the distribution of HCV genotypes in CLD cases from the region are not known. The objectives of the study were to determine the proportion of HCV infection in newly diagnosed CLD patients from Meghalaya, Northeast India, and further investigate the HCV genotype distribution in those patients. Materials and Methods: The aetiology of CLD was evaluated in 196 newly diagnosed patients, recruited consecutively over a period of 1 year in a medical college hospital from Meghalaya. Those positive for HCV infection were genotyped, and the mode of transmission of the virus was investigated. Results: A considerable proportion (43 patients, 21.9%) of CLD patients were positive for HCV (95% confidence interval [CI]: 16.7%–28.2%). Other leading causes of CLD were alcohol (36.32%) and hepatitis B virus infection (39.3%). Genotype 3 was the most prevalent (48.7%, 95% CI: 33.9%–63.8%), followed by genotype 6 (30.8%, 95% CI: 18.6%–46.6%) and genotype 1 (20.5%, 95% CI: 10.8%–35.5%). The frequency of genotype 6 was remarkably higher than in the other regions of India. Injecting drug use appeared to be the most common mode (28 patients) of acquiring HCV. This was true irrespective of the genotype. Conclusions: The presence of HCV in newly diagnosed CLD cases from Meghalaya was considerable. The genotype distribution of HCV was distinct from the other regions of India.
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Incidence, epidemiology and control of Clostridium difficile infection in a tertiary care private hospital in India p. 381
Tanu Singhal, Sweta Shah, Reshma Tejam, Pooja Thakkar
DOI:10.4103/ijmm.IJMM_18_340  PMID:30429391
Purpose: Clostridium difficile infection (CDI) is a serious healthcare-associated infection (HAI) now being increasingly reported from hospitals across India. However, there is a paucity of data on the incidence of and impact of control measures on CDI in India. Materials and Methods: This is a retrospective study conducted at a tertiary care hospital in Mumbai from January 2016 to December 2017. All patients with healthcare-onset diarrhoea were tested for C. difficile by glutamate dehydrogenase (GDH)/toxin assay or nucleic acid amplification test (NAAT). CDI was defined as either GDH and toxin positive or NAAT positive. The incidence of CDI was calculated per 1000 patient days. Demographic features of patients with CDI including age, sex, duration of hospitalisation before onset of CDI, antibiotic use and treatment administered were summarised. Results: A total of 67 patients had CDI in the study period with a mean incidence of 0.2/1000 patient days. A halving of the CDI incidence was seen after intensification of the CDI prevention bundle. The mean age of affected patients was 64 years and CDI occurred at a median duration of 2 weeks after hospitalisation. Eighty-seven per cent of the patients were on antibiotics at the time of diagnosis of CDI. The crude mortality rate was 22%. Conclusions: CDI is an emerging HAI in India. All hospitals need to set up policies for surveillance, testing, treatment and prevention of CDI based on recent international guidelines and local infrastructure/logistics.
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Evaluation of an in-house LipL32 polymerase chain reaction for diagnosis of leptospirosis and its correlation with various serological diagnostic techniques p. 385
Linda Rose Jose, Sumana Neelambike Mahadeviah, V Balamurugan, K Ramachandra Kini
DOI:10.4103/ijmm.IJMM_17_355  PMID:30429392
Background: Leptospirosis is a zoonotic disease of ubiquitous distribution. During rainy seasons, in spring and summer and also during harvest times, the risk of leptospirosis increases as there are chances of frequent contact with infected rat population which is common in Karnataka as farming is a main source of income to the people here. There is a paucity of data regarding the prevalent serovars from Karnataka. This study was undertaken as an attempt to compare a battery of tools such as immunochromatographic test (ICT), microscopic agglutination test (MAT), immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) and in-house polymerase chain reaction (PCR) to detect leptospirosis. Settings and Design: This study using consecutive sampling technique was conducted in a tertiary care centre, Mysore, Karnataka. Subjects and Methods: Samples from 783 suspected cases of leptospirosis in and around Mysore between April 2013 and April 2016 were processed. Samples from 783 patients suspected of leptospirosis were subjected to ICT, IgM ELISA, MAT and in-house PCR. Statistical Analysis Used: The statistical analysis was carried out using SPSS software version. Results: Among 783 samples tested, only 14 (1.7%) were positive by ICT, 341 (44%) were positive by IgM ELISA, 368 (47%) were positive by MAT and 393 (50.2%) were positive by in-house PCR. Conclusions: Mysore can be considered endemic for leptospirosis. The in-house PCR based on LipL32 gene proved to be useful in the early diagnosis of leptospirosis.
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Expanded diagnostic approach to hepatitis E virus detection in patients with acute-on-chronic liver failure: A pilot study p. 391
Runal John Steve, Fletcher John Gnanadurai, Raghavendran Anantharam, Visalakshi Jeyaseelan, Uday George Zachariah, Ashish Goel, Eapen Eapen Chundamannil, Priya Abraham
DOI:10.4103/ijmm.IJMM_18_35  PMID:30429393
Introduction: Acute decompensation of pre-existing chronic liver disease (CLD), known as acute-on-chronic liver failure (ACLF), is associated with high mortality. Hepatitis E virus (HEV) as a potential cause was studied. Objectives: The objectives of this study are to evaluate the role of HEV in ACLF patients using an IgM anti-HEV antibody enzyme-linked immunosorbent assay (ELISA), HEV antigen ELISA, and a quantitative HEV polymerase chain reaction (PCR). Materials and Methods: In this prospective cross-sectional study, blood samples were collected from 50 ACLF (cases) as defined by the standard guidelines (APASL, 2014) and 50 patients with stable CLD (controls) from January 2015 to August 2016, after obtaining informed consent. Two IgM ELISAs (MP Diagnostics HEV IgM ELISA 3.0, Singapore and Wantai HEV IgM ELISA, Beijing, China) were compared using plasma from cases and controls. In addition, an HEV antigen detection by ELISA (Wantai, Beijing, China) and a real-time PCR for quantification of HEV RNA in plasma and stool were employed. Results: Ethanol was the leading cause of acute insult in ACLF (54%) cases. HEV infection accounted for 20% of cases. Ten ACLF patients (20%) had 1–3 markers of HEV versus two (4%) among controls (P = 0.0138). Among ACLF cases, one had HEV viraemia (403 IU/ml), faecal shedding (2790 IU/ml) and detectable HEV antigenaemia. Agreement between the two anti-HEV IgM ELISAs was 0.638 (kappa value). Conclusion: This study shows that alcohol is a major contributing factor for both underlying CLD and ACLF while HEV is the most common infectious cause for ACLF, suggesting a need for a vaccination in such patients, whenever made available.
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Evaluation of immune response to hepatitis B vaccine in healthcare workers at a tertiary care hospital p. 397
Praveena Basireddy, Surekha Avileli, Nagajyothi Beldono, Swarna Latha Gundela
DOI:10.4103/ijmm.IJMM_17_431  PMID:30429394
Purpose: Healthcare workers (HCWs) are at high risk of acquiring hepatitis B virus (HBV) infection through occupational exposure which is preventable through hepatitis B vaccination. In the current study, the response to HBV surface antigen (HBsAg) vaccine was assessed in a selected group of HCWs by testing for antibodies against HBsAg (anti-HBs). Methods: Blood samples were collected in all HCWs, who have received the complete schedule of hepatitis B vaccination and anti-HBs levels, were assessed quantitatively in sera using ELISA. Results: The age range of the study participants was 20–55 years. The mean months after the last dose of vaccination were 60.36. Among the 85 participants, 96.5% (n = 82) have protective immunity to hepatitis B. The anti-Hbs response was similar in both male and female (P > 0.05). There was a decline in immune response as the age was increasing (P < 0.05). The results of the study found a significant decline in the immune response with time (P < 0.05). The anti-Hbs response was declined with smoking habit (P < 0.05) and with increasing body mass index (P < 0.05). Conclusion: Post-HBsAg vaccination immunity to hepatitis B was 96.5% in HCW and was similar to that of global rates. Increasing age, time period, smoking habit, and overweight were associated with decreased immunity. Many studies are needed in developing newer HBV vaccines with very high immunogenicity. Giving highly immunogenic vaccine to HCWs will ensure safety at work by reducing nosocomial transmission which is very much desired in a resource-limited country.
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Microbiological and chest X-ray studies on influenza B virus-associated pneumonia p. 401
Xiaoyun Wang, Yan Tian
DOI:10.4103/ijmm.IJMM_18_66  PMID:30429395
Introduction: The signs and symptoms of influenza B are commonly ignored. Therefore, very few clinical reports are available. This study is an attempt to evaluate the clinical features and characteristics of influenza B virus-associated pneumonia patients. Objective: The aim of this study is to investigate the microbiological and characteristics of influenza B virus-associated pneumonia patients. Methodology: Patients with <16 years old with a clinical diagnosis of influenza B virus infection and who had chest radiography within 2 days were enrolled. A total of 49 patients were categorised as the pneumonia group by clinical symptoms and chest X-ray (CXR) findings, whereas 107 patients were categorised as the non-pneumonia group based on the laboratory data and normal CXR findings. Results: The study observed that the age of the patients in the pneumonia group was significantly younger than the non-pneumonia group. The white blood cell (WBC) count of the pneumonia group was also higher. However, the haemoglobin (Hgb) level was lower in the pneumonia group. The C-reactive protein (CRP) level of the pneumonia group was also significantly high. The CXR findings revealed that 28.57% of patients had alveolar consolidation, 32.65% had interstitial infiltration and 40.82% had ground glass opacity. Conclusions: High clinical suspicion is required to detect pneumonia in influenza B virus patients. Based on the CXR findings, the study also suggests that patients with pleural effusion and positive bacterial culture need more attention for the severity of clinical outcome. Moreover, critical care should be given to paediatric patients having higher WBC count, higher CRP level and lower Hgb. These parameters would be helpful to differentiate primary pneumonia from non-pneumonic influenza.
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Comparing the profile of respiratory fungal pathogens amongst immunocompetent and immunocompromised hosts, their susceptibility pattern and correlation of various opportunistic respiratory fungal infections and their progression in relation to the CD4+T-cell counts p. 408
Asma Husein Roohani, Nazish Fatima, Mohammad Shameem, Haris Manzoor Khan, Parvez Anwar Khan, Anees Akhtar
DOI:10.4103/ijmm.IJMM_18_258  PMID:30429396
Introduction: Invasive fungal infections are increasingly common in the nosocomial setting. Materials and Methods: The patients were divided into two groups immunocompetent and immunocompromised that is, patients with significant neutropenia <500 neutrophils/μl for longer than 10 days. microscopy, culture, identification of isolates were done and some specilised tests on serum and BAL for antigen detection were performed. Results: Majority of the patients were young adult males in this study. A higher prevalence of 26.7% was seen in immunocompromised patients. Amongst yeasts, Candida albicans was the predominant species followed by the National AIDS Control that is, Candida glabrata, Candida dubliniensis, Candida parapsilosis and Candida tropicalis in the same order. Amongst moulds, Aspergillus fumigatus was the most common species followed by Aspergillus flavus and Aspergillus niger. Mucor and Penicillium marneffei were seen in a lower prevalence. By Broth microdilution method, isolates of Candida spp. were most sensitive to caspofungin, amphotericin B, ketoconazole and fluconazole in the same order. Isolates of Aspergillus spp. were most sensitive to caspofungin, amphotericin B and itraconazole in the same order. By disc diffusion method, resistance to fluconazole was observed in 6.9% isolates of C. albicans. 50% of C. dubliniensis and 20% of C. glabrata showed resistance to fluconazole. A total mortality of 27.7% was observed during this study. This was distributed as 24.1%, 26.7%, 50%, 50%, 100% and 0% among by patients of candidiasis, aspergillosis, cryptococcosis, pneumocystosis, mucormycosis and penicilliosis. Fifteen per cent were lost to follow-up. Conclusion: Patterns of invasive fungal infections are changing in many ways. In the midst of these evolving trends, IFI of the respiratory tractcontinue to remain important causes of morbidity and mortality. Diagnostic tools can be adequately used only if the treating physician is aware of the propensity of patients to acquire a fungal infection. Thus, continuous awareness and education is crucial for successful management of patients. Judicious use of antifungal medications as prophylactic measures must be employed, particularly in the critically ill and patients of HIV.
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Changes in hepatitis C virus genotype distribution in chronic hepatitis C infection patients p. 416
Mehmet Burak Selek, Orhan Baylan, Ergenekon Karagöz, Mustafa Özyurt
DOI:10.4103/ijmm.IJMM_18_10  PMID:30429397
Purpose: Identification of hepatitis C virus (HCV) genotypes is very important in the selection of antiviral treatment, dose adjustment of antiviral agents, determining the treatment duration and following-up of treatment response. We aimed to determine the distribution pattern of HCV genotypes in chronic hepatitis C infection (CHC) patients. Materials and Methods: We have included 106 CHC patients who were positive in the anti-HCV and HCV-RNA tests performed in our hospital during the 16-month period. Anti-HCV assays were performed on device using a chemiluminescent microparticle immunoassay, while HCV-RNA tests and HCV genotyping assays were performed by real-time polymerase chain reaction. Results: Of the 106 cases; genotype 1b was detected in 67.0%, genotype 3 was detected in 16.0%, genotype 1a was detected in 14.2% and genotype 2 was detected in 2.8% patients. Genotypes 4, 5 and 6 were not detected in our study group. There were no statistically significant differences between the gender and age groups according to the HCV genotype distribution. The genotype 3 detection rate (16%) was the highest rate among the studies compared with the other studies in our country. Conclusions: Events that cause social changes such as war and immigration and intense commercial and touristic activities affect and alter the HCV genotype distribution in HCV-infected patients. For this reason, further multicentre studies are required reflecting all the regions in order to determine the genotype distribution in HCV-infected patients at regular intervals.
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BRIEF COMMUNICATIONS Top

Use of eschar for the molecular diagnosis and genotypic characterisation of Orientia tsutsugamushi causing scrub typhus p. 422
Manisha Biswal, Kamran Zaman, Vikas Suri, Harshith Rao, Abhay Kumar, Gaurav Kapur, Navneet Sharma, Ashish Bhalla, M Jayashree
DOI:10.4103/ijmm.IJMM_18_8  PMID:30429398
Scrub typhus caused by Orientia tsutsugamushi presents as an acute febrile illness with a varied presentation from mild illness to fatal disease in the absence of appropriate antibiotic treatment. Performing polymerase chain reaction (PCR) on eschar sample acts a rapid diagnostic tool in the early stage of scrub typhus when blood is negative. A total of eight patients from whom both whole blood and eschar samples were collected and tested by nested PCR targeting 56 kDa trichostatin A (TSA) gene to detect O. tsutsugamushi DNA. All (100%) eschar samples and three whole blood samples tested positive. Genetic analysis of the 56 kDa TSA gene sequences showed that the majority were related to Karp reference strains, while one clustered with Kawasaki strain. When present, eschar should be favoured as a diagnostic sample over whole blood in the early phase of infection.
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The prevalence of occult hepatitis B infection among the blood donors in a tertiary care hospital, Puducherry p. 426
KP Athira, K Vanathy, Rajendra Kulkarni, Rahul Dhodapkar
DOI:10.4103/ijmm.IJMM_18_32  PMID:30429399
Occult hepatitis B infection (OBI) is a cause of concern while screening the blood donors to prevent transfusion-related transmission of infection. This study was conducted to assess the prevalence of OBI using total anti-HBc by ELISA and DNA detection by real time polymerase chain reaction (PCR). The samples included were negative for HBs Ag by ELISA. Out of 1102 samples tested, 156 were positive for total anti-hepatitis B core antigen and 52/156 by real-time PCR. Overall, the prevalence was found to be 4.71% (52/1102). The results indicate that nucleic acid-based testing should be an essential part of screening procedure to prevent missing of OBI.
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Serotyping of dengue viruses circulating during 2014–2015 in Assam, India p. 429
Muksedur Rahman, Ajanta Sharma, Saurav Patgiri, Ezaz Hussain, Amrit Kumar Borah, Lahari Saikia
DOI:10.4103/ijmm.IJMM_17_121  PMID:30429400
Dengue has become endemic in India with outbreaks caused by all the four serotypes occurring almost every year. Dengue cases have been increasing alarmingly in Assam also. This study aimed to identify the dengue serotypes circulating in Assam. Clinically suspected dengue fever cases were included in the study. Viral RNA was extracted using QIAamp Viral RNA Mini Kit (Qiagen). Nested reverse transcriptase polymerase chain reaction was done for serotyping. The frequency of dengue was 25.23% with a peak during the period from September (22.56%) to October (26.22%). Two serotypes were detected, DEN-1 (72.7%) and DEN-2 (12.1%) and dual infection in 15.1%.
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Clinical and laboratory characteristics of patients with toxocariasis encountered at a tertiary care centre in North India p. 432
Jutang Babat Ain Tiewsoh, Sumeeta Khurana, Abhishek Mewara, Rakesh Sehgal, Ankita Singh
DOI:10.4103/ijmm.IJMM_18_259  PMID:30429401
Toxocariasis is a neglected soil-transmitted helminthic infection caused by either Toxocara canis or Toxocara cati where humans get infected by accidental ingestion of embryonated eggs, and the definitive hosts are dogs and cats. This study aims to analyse the clinical and laboratory characteristics of Toxocara-infected patients and assessment of response to standard treatment with review of literature. The clinical details of patients with Toxocara serology positive for IgG antibodies by ELISA in 5 years (2013–2017) were retrospectively analysed. A total of 29 patients with clinical features and serology suggestive of Toxocara infection were evaluated. A complete history of 14 patients was available for the analysis. Majority (13/14; 96.5%) of cases were children <15 years, males (79%) and belonged to lower socioeconomic status (64.3%). The most common clinical presentation was fever (78.5%) with respiratory symptoms (57%) followed by gastrointestinal features (35.7%). All the patients had eosinophilia (range 8.3%–85%) and raised total IgE levels. Toxocariasis is more common in children, and the true prevalence may be underestimated. In endemic areas, Toxocara workup should be considered in patients with eosinophilia presenting with respiratory and gastrointestinal features.
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Bioassay and molecular study for detection of insecticide resistance dengue causing mosquito vectors p. 435
Monika Soni, Chandrakanta Bhattacharya, Jitendra Sharma, Prafulla Dutta
DOI:10.4103/ijmm.IJMM_18_120  PMID:30429402
Nowadays, dengue infection creates a major problem across the country. The vector species carrying dengue infection has progressively started to developed resistance against most of the currently used insecticides. Hence, a study was carried out in dengue-endemic areas of Assam and Arunachal Pradesh to find the current situation of insecticide susceptibility status of dengue vectors. Based on the previous history of dengue incidence, Aedes mosquitoes were collected from Dibrugarh, Kamrup, Sivasagar, Tezpur and Tinsukia districts in Assam and Pasighat district in Arunachal Pradesh to test the insecticide resistance status through bioassay and molecular methods. The WHO standard bioassay test kits were used to detect insecticide susceptibility status among dengue vectors. In molecular study, allele-specific polymerase chain reaction (PCR) method was done for the detection of mutations in paratype voltage-gated sodium channel gene of Aedes aegypti and Aedes albopictus mosquitoes. In bioassay method, 100% A. aegypti mosquitoes were found to be resistant towards dichlorodiphenyltrichloroethane (DDT), 8% towards pyrethroid and 4% towards malathion. Similarly, 92% A. albopictus mosquitoes have shown resistance competency towards DDT, 12% towards pyrethroid and 8% towards malathion. In allele-specific PCR methods, V1016G heterozygous mutations were detected from the field collected A. aegypti and A. albopictus mosquitoes of Tinsukia, Dibrugarh and Sivasagar district. Similarly, F1534C heterozygous mutations were observed from A. aegypti mosquitoes of Tezpur, Tinsukia and Sivasagar district and A. albopictus mosquitoes of Tinsukia, Dibrugarh and Sivasagar district. From the study, it was concluded that the Aedes mosquitoes have progressively started to developed resistance towards commonly used insecticides.
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CASE REPORTS Top

Fatal Cryptococcus gattii meningitis with negative cryptococcal antigen test in a HIV-non-infected patient p. 439
Vandana Kalwaje Eshwara, Rahul Garg, G Siddaramappa Chandrashekhar, Tushar Shaw, Chiranjay Mukhopadhyay
DOI:10.4103/ijmm.IJMM_18_164  PMID:30429403
Cryptococcus gattii predominantly causes central nervous system and pulmonary infection in both immunocompromised and immunocompetent patients with substantial morbidity. We report a case of rapidly fatal meningitis by C. gattii in an HIV–non-infected man with CD4 lymphopenia who tested negative for cryptococcal antigen. This case may serve as an alert to its wider occurrence and less explored risk factors.
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Herpes simplex virus type 2 and cytomegalovirus perigenital ulcer in an HIV infected woman p. 441
Jyoti Rawre, Mamta Rai, Divya Namdeo, Rojaleen Das, Neena Khanna, Lalit Dar, Benu Dhawan
DOI:10.4103/ijmm.IJMM_18_203  PMID:30429404
We report a case of mucocutaneous Herpes Simplex Virus (HSV)-2 and Cytomegalovirus (CMV) infection in a 39-year-old female with acquired immunodeficiency syndrome, who presented with a perigenital ulcer. The patient was receiving antiretroviral treatment (ART) for 3 months before presentation. Scraping from the perigenital ulcer was positive for HSV-2 and Treponema pallidum using polymerase chain reactions (PCR). The extent and duration of the lesions led us to consider the possibility of coinfection with CMV. The patient also tested positive for CMV by PCR. On subsequent follow-up after 8 weeks, the genital lesions had healed completely. This is possibly ascribable to the ART, which led to significant immune reconstitution.
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Fatal aspergillosis of the renal vasculature in a combined liver-kidney transplant recipient p. 444
Vasant Nagvekar, Chandrasekar H Pranatharthi, Ram Gopalakrishnan, Ramamurthy Anand, Vidya Devarajan, Mandayam Thirunarayan, Anil Tarigopula
DOI:10.4103/ijmm.IJMM_18_165  PMID:30429405
Invasive aspergillosis remains a problem in solid organs and haematopoietic stem cell transplants. We report a case of 12-year-old female with primary hyperoxaluria with regular haemodialysis for the end-stage renal disease. She underwent a combined liver and renal transplantation which got infected by aspergillosis. In this case study, it is speculated that the most likely source of Aspergillus was contaminated preservative solution (perfusate), resulting in infection within the donor kidney and subsequent systemic infection in the recipient. This case study calls for critical analysis and needs for the routine culture of the preservative solution before transplantation, to detect any fungal contamination and manage it prophylactically.
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Cutaneous botryomycosis of the foot: A case report and review of literature p. 447
Kevin John, Karthik Gunasekaran, Thomas Alex Kodiatte, Ramya Iyyadurai
DOI:10.4103/ijmm.IJMM_18_347  PMID:30429406
Botryomycosis is a chronic bacterial infection that manifests clinically as tumours or plaques that are often ulcerated and have discharging sinuses draining small white-coloured granules. Therefore, they closely mimic mycetoma or other fungal infections. It is most commonly caused by Staphylococcus aureus. It can present as cutaneous or visceral disease. The cutaneous form can invade deep tissue leading to extensive destruction and disfigurement. A 31-year-old female presented with progressive swelling of her right foot over a period of 8 years. She had a disfigured right foot with multiple sinuses discharging pus. X-ray and magnetic resonance imaging of the foot showed invasion and destruction of the deep layers of the foot including the bone. Deep biopsy from the foot showed an abscess cavity with Gram-positive cocci within and bacterial culture grew S. aureus establishing the diagnosis of botryomycosis. Botryomycosis is a rare presentation of a common pathogen and needs to be considered while evaluating a chronic invasive subcutaneous infection.
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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