This review attempts to clarify the concepts of Laboratory Quality Management System (Lab QMS) for a medical testing and diagnostic laboratory in a holistic way and hopes to expand the horizon beyond quality control (QC) and quality assurance. It provides an insight on accreditation bodies and highlights a glimpse of existing laboratory practices but essentially it takes the reader through the journey of accreditation and during the course of reading and understanding this document, prepares the laboratory for the same. Some of the areas which have not been highlighted previously include: requirement for accreditation consultants, laboratory infrastructure and scope, applying for accreditation, document preparation. This section is well supported with practical illustrations and necessary tables and exhaustive details like preparation of a standard operating procedure and a quality manual. Concept of training and privileging of staff has been clarified and a few of the QC exercises have been dealt with in a novel way. Finally, a practical advice for facing an actual third party assessment and caution needed to prevent post-assessment pitfalls has been dealt with.

Subset of faecal E. coli that can enter, colonize urinary tract and cause infection are known as uropathogenic E. coli (UPEC). UPEC strains act as opportunistic intracellular pathogens taking advantage of host susceptibility using a diverse array of virulence factors. Presence of specific virulence associated genes on genomic/pathogenicity islands and involvement of horizontal gene transfer appears to account for evolution and diversity of UPEC. Recent success in large-scale genome sequencing and comparative genomics has helped in unravelling UPEC pathogenomics. Here we review recent findings regarding virulence characteristics of UPEC and mechanisms involved in pathogenesis of urinary tract infection.

Purpose : The hallmark of chronic hepatitis B (CHB) infection is the presence of hepatitis B surface antigen (HBsAg) positivity for at least 6 months. Recently, serum levels of HBsAg have been compared with serum HBV DNA as a surrogate marker to monitor CHB patients. However, data correlating these two markers are scarce. Hence, the present study was done to correlate HBV DNA with HBsAg in CHB patients. Materials and Methods: Consecutive patients of CHB were included. HBV DNA was measured by real-time polymerase chain reaction (PCR). Serum HBsAg was measured by Architect HBsAg. Results: Of the 198 patients enrolled, 166 fulfilled the inclusion criteria (mean age 43 ± 14 years, 87% males) and the median HBV DNA was 1.7 × 10 ³ (range 6.0-1.1 × 10 ⁸ ) IU/ml. Median HBsAg was 8.7 × 10 ³ (range 5.0-3.2 × 10 ⁵) IU/ml. Overall correlation between HBV DNA and HBsAg was weak but significant (Spearman ρ = 0.443, P < 0.01). Correlation in HBe antigen-positive group was better (ρ = 0.402, P < 0.01) in comparison to HBe antigen-negative group (ρ = 0.193 P = 0.05). Good correlation existed in treatment-naïve group (ρ = 0.538, P < 0.01) .Correlation was regardless of normal or raised alanine transaminase (ALT). Eighty (48%) patients had high HBV DNA (≥2000 IU/ml). Correlation in high DNA group was significant (P < 0.01). The best cut-off of HBsAg for diagnosing high DNA is 3.36 ×10 ³ IU/ml. Conclusions: Serum HBsAg correlates with HBV DNA in CHB patients, especially in high serum HBV DNA, HBe antigen-positive and treatment-naïve group. HBsAg levels can be used for predicting high serum HBV DNA levels.

Purpose: Influenza has a major impact on public heath, annually affecting 15-20% of the global population. Information on the activity of influenza virus in Mumbai is limited. The present study was carried out to determine the prevalence of influenza viruses causing acute respiratory infections in children by molecular methods. Objective: To study the prevalence of influenza viruses among the paediatric population in Mumbai by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). Materials and Methods: From July 2007 to July 2009, 100 respiratory samples (nasal and throat swabs) were collected from paediatric patients with acute respiratory symptoms. attending out patients department, and admitted to the paediatric wards of B. J. Wadia Hospital for Children, Mumbai. The samples were collected and processed as per World Health Organization (WHO) guidelines. Viral RNA was extracted and one-step rRT-PCR was performed to detect influenza type A (H1 and H3) and influenza type B virus. Results: Out of 100 samples processed by rRT-PCR, a total of 11 samples (11%) were positive for influenza virus. The typing for influenza A subtypes showed 1% (1) positivity for H1 and 5% (5) positivity for H3 subtypes and 5% (5) samples tested positive for influenza type B virus. Conclusion: It was observed that both influenza type A and B viruses were prevalent in Mumbai during the study period. Such surveillance data are important in the early detection of any antigenic variants that may be helpful in global influenza vaccine preparation and for any pandemic preparedness activity.

Purpose: Virulence genes play important roles in pathogenesis of infections caused by S. aureus. The aim of this study was to determine the prevalence of PVL, eta and mecA genes in S. aureus isolated from patients in South-Western Nigeria. Materials and Methods: In this study, a total of 116 S. aureus isolates from the clinical specimens submitted to laboratories in tertiary hospitals in the South Western Nigeria were used. Antibiotic susceptibility test was carried out to determine the susceptibility pattern of the isolates using multiple antibiotics disc. Minimum inhibitory concentration (MIC) was also carried out to determine the degree of resistant of the isolates to methicillin. PCR was used to screen for the presence of PVL, eta, and mecAgenes. Results:mecA gene was detected in 48 (41.4%) of 116 strains of S. aureus. The MIC ₅₀ and MIC ₉₀ for mecA negative strains were 1 and 8 μg/ml, respectively while the MIC ₅₀ and MIC ₉₀ for mecA positive were >256 μg/ml. Twenty eight (24.1%) of 116 isolates were PVL gene positive with none of them mecA+. The prevalence of community acquired MRSA (CA-MRSA) was estimated to be 6.9% using molecular techniques. No localization of mecA gene and PVL gene on the genome of the entire S. aureus strains studied. Site of isolation of organism /specimen type was found to be associated with the prevalence of PVL+ and mecA+ S. aureus (P< 0.01). Conclusion: This study concludes that the PVL+ MRSA is rare and the prevalence of CA-MRSA is low in South-Western, Nigeria.

Purpose: The macrolide lincosamide streptogramin B (MLS _B ) family of antibiotics serves as an alternative for the treatment of skin and soft tissue infections caused by methicillin-resistant Staphylococcus aureus (MRSA). However, resistance to clindamycin too has emerged, which is of two types, inducible and constitutive. Therapeutic failure is common with inducible type of clindamycin resistance. This study was done to determine the various clindamycin resistance patterns in MRSA isolates and to compare them with minimal inhibitory concentration (MIC) of clindamycin. Materials and Methods: Fifty MRSA isolates were studied by disc approximation test (D test) to detect inducible iMLS _B resistance and MIC by agar dilution technique. Results: Of the 50 isolates, 34 were sensitive to both clindamycin and erythromycin. 16 isolates showed different sensitivity patterns; nine of these were positive for D zone indicating inducible iMLS _B resistance, five were positive for constitutive MLS _B resistance and two showed possible efflux mechanism for macrolide resistance. Out of the 34 sensitive isolates, 5 showed isolated colonies (subpopulation) inside the clindamycin-sensitive zone. When these sub-populations were tested further, two were constitutive MLS _B phenotypes, two were inducible iMLS _B and one was HD (hazy D zone), which is D ⁺ with growth up to clindamycin disc (which is also considered as constitutive MLS _B phenotype). Seven isolates showed an MIC of ≥4 μg/ml to clindamycin in spite of being susceptible to both erythromycin and clindamycin by Kirby Bauer disc diffusion technique. Out of these seven isolates, five were those which grew as subpopulation inside the clindamycin-sensitive zone. Conclusion: Detection of iMLS _B resistance among MRSA helps to avoid treatment failure with clindamycin. Studying the subpopulation inside the clindamycin-sensitive zone raises the question of existence of hetero-resistance or some other mechanism, which needs further study.

Purpose: The present study was undertaken to evaluate the screening antibiotic, confirmatory phenotypic test and agent against PCR as gold standard and to detect the prevalent MBL gene. Materials and Methods: Three hundred and twenty-six Pseudomonas aeruginosa isolates were screened for resistance to Imipenem (IPM), Meropemem (MEM) and Ceftazidime (CAZ) by disc diffusion. Isolates resistant to any of these were considered screen test-positive for MBL and were subjected to Double disc synergy test (DDST) and Disc potentiation test (DPT: Using IPM, MEM and CAZ alone and with EDTA), Minimum inhibitory concentration (MIC) reduction [four-fold or more reduction in MIC of IPM and MEM in presence of chelators: EDTA and 1,10-phenanthroline (EPI/EPM: EDTA-phenanthroline- Imipenem/Meropenem Broth Microdilution method)] and polymerase chain reaction (PCR) for bla_IMP and bla_VIM . Results: Screen test-positives by MEM and CAZ were 19.3% as against 17.8% by IPM. MEMDDST, DPT and EPM confirmed 100% screen-test positives as against 93.7% by CAZ DDST and DPT-2, 76.2% by CAZ DPT-1, 88.9% by IPM DDST, 85.7% by IPM DPT-1 and 92.1% by EPI. IPMand CAZ DDST together confirmed 100% while IPM and CAZ DPT-2 confirmed 96.8%. All 63 screen-test positives showed the presence of bla_VIM . Conclusions: MEM was found to be the best screening and confirmatory agent for MBL detection and bla_VIM was found to be the prevalent MBL gene in this part of the country.

Purpose: The present study screened clinical isolates of Enterococcus faecalis and Enterococcus faecium to determine the prevalence of high-level gentamicin-resistant enterococci and the potential virulence genes among them. Materials and Methods: Clinical enterococcal isolates were obtained from three university teaching hospitals in Northwest Iran. Isolated enterococci were identified phenotypically followed by antibiotic susceptibility testing. Multiplex PCR was performed for the detection of genus, species-specific targets, gentamicin resistance, and potential virulence genes. Results: Of 220 enterococcal isolates, 133 (60.45%) isolates were identified as high-level gentamicin-resistant. Of these isolates, 79 (59.4%) and 54 (40.6%) were E. faecalis and E. faecium, respectively. All high-level gentamicin-resistant strains carried aac(6′)Ie-aph(2″)Ia. Of 220 isolates, 65.9% were positive for gelE, and 55%, 53.6%, 51.8%, and 49.5% of isolates were positive for cpd, asa1, ace, and esp, respectively. Phenotypically detected β-haemolytic strains (19.54%) were found to possess cylL _ls MAB. Conclusion: The study revealed that high-level gentamicin-resistance was related to the presence of aac(6′)Ie-aph(2″)Ia. Isolated enterococci harboured potential virulence determinants, which were more common among E. faecalis than among E. faecium strains.

Purpose: Extrapulmonary tuberculosis (EPTB) is emerging problem in developing and developed countries. The diagnosis of EPTB in its different clinical presentations remains a true challenge. IS6110-based polymerase chain reaction (PCR) is used for rapid identification and positivity rate of the Mycobacterium tuberculosis complex in clinical isolates of different sites of EPTB. The present study was carried out to study the prevalence of M. tuberculosis complex in clinical isolates of EPTB at tertiary care centres in Lucknow. Materials and Methods: Seven hundred fifty-six specimens were collected from the suspected cases of EPTB which were processed for Mycobacteria by Ziehl Neelson (ZN) staining and BACTEC culture. All the specimens were also processed for IS6110-based PCR amplification with primers targeting 123 bp fragment of insertion element IS6110 of the M. tuberculosis complex. Results: Of these 756 specimens, 71(9.3%) were positive for acid fast bacilli (AFB) by ZN staining, 227(30.1%) were positive for mycobacteria by BACTEC culture and IS6110 PCR were positive for M. tuberculosis complex in 165 (20.7%) isolates. We found a significant difference in sensitivities of different tests (P<0.05). Conclusions: This study reveals the positivity of M. tuberculosis complex in clinical isolates of EPTB case in tertiary care hospitals in Northern India. 72.7% of M. tuberculosis complex was confirmed by IS6110-PCR in culture isolates from different sites of EPTB. The high prevalence of the M. tuberculosis complex was seen in lymph node aspirate and synovial fluid. However, utility of PCR may play a potentially significant role in strengthening the diagnosis of EPTB especially targeting IS6110.

Purpose: Paired blood culture (PBC) is uncommon practice in hospitals in India, leading to delayed and inadequate diagnosis. Also contamination remains a critical determinant in hampering the definitive diagnosis. Objectives: To establish the need of PBC over single blood culture (SBC) along with the degree of contamination, this comparative retrospective study was initiated. Materials and Methods : We processed 2553 PBC and 4350 SBC in BacT/ALERT 3D (bioMerieux) between October 2010 and June 2011. The positive cultures were identified in VITEK 2 Compact (bioMerieux). True positivity and contaminants were also analyzed in 486 samples received from catheter and peripheral line. Results : Out of 2553 PBC samples, positivity was seen in 350 (13.70%). In 4350 SBC samples, positivity was seen in 200 samples (4.59%). In PBC true pathogens were 267 (10.45%) and contaminants were 83 (3.25%), whereas in SBC 153 (3.51%) were true positives and contaminants were 47 (1.08%). Most of the blood cultures (99.27 %) grew within 72 h and 95.8% were isolated within 48 h. In 486 PBCs received from catheter/periphery (one each), catheter positivity was found in 85 (true positives were 48, false positives 37). In peripheral samples true positives were 50 and false positives were 8. Conclusion: Significantly higher positive rates were seen in PBCs compared with SBCs. Automated blood culture and identification methods significantly reduced the time required for processing of samples and also facilitated yield of diverse/rare organisms. Blood culture from catheter line had higher false positives than peripheral blood culture. Thus every positive result from a catheter must be correlated with clinical findings and requires further confirmation.

Purpose: Controlling and eliminating lymphatic filariasis will require further research of preventative measures and implementation. Parasite is dependent on glycolysis for ATP production. The glycolytic enzyme glyceraldenyde-3-phosphate dehydrogenase (GAPDH) plays an important role in glycolysis and therefore is either a potential target for anti-parasite drug development or a vaccine candidate. Therefore, we tried to investigate the DNA vaccine-elicited immune responses in BALB/c mice. Materials and Methods: We cloned a gene encoding the glyceraldehyde-3-phosphate dehydrogenase (GAPDH) from periodic Brugia malayi into vector pcDNA3.1. Mice were injected at a dosage of 100 μg recombinant plasmid DNA with CpG intramuscular injection and immunized three times at 2-week intervals. pcDNA3.1 and normal saline were used as control. The tissue of muscles at the 4 weeks after the third injection was collected and target genes were detected using RT-PCR. The humoral responses elicited in mice by inoculation with the recombinant plasmid pcDNA3.1-BmGAPDH were detected using a standard ELISA. Two weeks after the third immunization, stimulation index (SI) was measured using the MTT method and the level of secreted IL-4 and INF-g were detected using ELISA. Results: Specific gene fragment coding GAPDH was amplified and the recombinant plasmid pcDNA3.1-BmGAPDH was constructed. Post-challenge sera from the mice immunized with the DNA vaccine had specific antibody titres of 1:1600 to 1:6400, and the highest titre was observed in the mice that were inoculated by pcDNA3.1-BmGAPDH/CpG at 6 weeks. At 4 weeks after immunization, the spleens of the mice were obviously enlarged. The proliferation of spleen T lymphocytes seen on the MTT assay was higher in the pcDNA3.1-BmGAPDH group than in the control group (P value <0.05). The levels of IL-4 and INF-g in serums from the immunized mice were significantly higher than that of the control (P value <0.05). Conclusions: We conclude that the recombinant eukaryotic plasmid pcDNA3.1-BmGAPDH could elicit humoral and cellular immune responses in mice.

Antimicrobial resistance has been a challenge in all countries. The aim of this study is to ascertain the risk factors that predispose patients to infections with extended spectrum beta lactamase (ESBL)-producing gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA). Patients who were treated in the secondary care hospital due to infections in 2009 and their isolates were evaluated retrospectively. In total, 174 patients and their 189 isolates, which contained 36 ESBL-producing gram-negative bacteria, 112 non-ESBL-producing gram-negative bacteria, and 41 gram-positive bacteria were evaluated retrospectively. Hospitalisation in the previous 3 months, comorbidity, and usage of amoxicillin-clavulanate in the previous 3 months were determined to be the risk factors associated with infections by the ESBL-producing gram-negative bacteria. Hospitalisation was found to be a risk factor for infection with MRSA. Hospitalisation and underlying conditions increase the colonisation with resistant bacteria and resistance rates in the patients, hospitals and communities. An infection control programme should be contemplated not only for hospitals, but also for the greater community.

The objective of this study was to determine the expression and transferability of tetracycline and erythromycin resistance among 188 MRSA strains from a Malaysian tertiary hospital. The minimum inhibitory concentrations (MICs) for oxacillin, erythromycin, tetracycline and ciprofloxacin ranged from 4 to 512 μg/ml, 0.25 to 256 μg/ml, 0.5 to 256 μg/ml and 0.5 to 512 μg/ml, respectively. Tetracycline-resistant strains showed co-resistance towards ciprofloxacin and erythromycin. There was a significant increase (P<0.05) of high-level tetracycline (≥MIC 256 μg/ml) and erythromycin (≥MIC 128 μg/ml) resistant strains in between the years 2003 and 2008. All erythromycin-resistant strains harboured ermA or ermC gene and all tetracycline-resistant strains harboured tetM or tetK gene. The blaZ was detected in all MRSA strains, whereas ermA, tetM, ermC, tetK and msrA genes were detected in 157 (84%), 92 (49%), 40 (21%), 39 (21%) and 4 (2%) MRSA strains, respectively. The blaZ, tetM, ermC and tetK genes were plasmid-encoded, with ermC gene being easily transmissible. Tn5801-like transposon was present in 78 tetM-positive strains. ermA and tetM genes were the most prevalent erythromycin and tetracycline resistance determinants, respectively, in MRSA strains. The association of resistance genes with mobile genetic elements possibly enhances the spread of resistant traits in MRSA.

Multidrug-resistant tuberculosis (MDR-TB) has rarely been reported from children in India. Their response to therapy is also not known. We present four HIV-negative children with MDR-TB (3 children with extra-pulmonary TB and 1 child with pulmonary TB) who presented in 2003-2005. All the four children were already on antituberculous therapy (ATT) for 3-9 months prior to being detected as MDR-TB. These patients were started on second-line ATT for 18 months. In three patients, there was complete resolution, and one patient with severe bilateral pulmonary TB had the disease localized to one lung after 18 months of therapy.

Microbiological contamination of blood and blood products is a well-recognised transfusion risk. This study was performed in the blood bank of our oncology centre, with an objective to detect bacterial contamination in our blood products using oxygen consumption as a surrogate marker [Pall Enhanced Bacterial Detection System (eBDS)]. Results revealed that the percentages of failed units were 1.16% for random donor platelets (RDP), 0.81% for single donor platelets (SDP) and 2.94% for packed red blood cells (PRBCs), of which one RDP and one SDP grew coagulase-negative staphylococcus, while one PRBC culture grew Gram-positive bacilli.

The development of reduced vancomycin susceptibility in Staphylococcus aureus in many cases appears to be associated with characteristic changes. These changes may have pitfall of identifying S. aureus by automated testing methods like Vitek 32. In this study, we retested 24 heterogeneous vancomycin-intermediate Staphylococcus haemolyticus (h-VISH) collected in 2008-2010 at the Department of Clinical Microbiology by conventional biochemical tests and polymerase chain reaction (PCR). The heterogeneous vancomycin-intermediate S. aureus (hVISA) reversion test and electron microscopic examination were also used. Six isolates of 24 h-VISH possessed nuc, coa, and 16S rRNA genes, and could be reversed into S. aureus. It suggested that biochemical and morphological changes in hVISA and vancomycin-intermediate S. aureus (VISA) should be considered, and the detection of S. aureus, especially reduced vancomycin susceptibility isolates, requires more attention and different techniques.

We considered samples received for culture of mycobacteria using BACTEC MGIT 960 system over a period of 1 year. Tubes flagged positive by MGIT were evaluated for presence of serpentine cording. The cord formation was compared with isolates identified as Mycobacterium tuberculosis complex (MTC) based on p-nitrobenzoic acid (PNB) test. Cords were found in 591 isolates of which 584 (98.8%) were confirmed as MTC. The sensitivity and specificity of cord formation were found to be 99.7% and 89.9%, respectively.

Dengue has become endemic in India with outbreaks occurring almost every year. The seroprevalence and serotypic data of the last 7 years in samples obtained from suspected dengue patients from a tertiary care hospital were analyzed. Out of 7846 serum samples received in the virology laboratory from suspected dengue cases during 2002 to 2008, 2366 (30.15%) were serologically confirmed. Serotyping was done using mRT-PCR. All the four serotypes were detected in 2003, while data in 2004, 2005 and 2006 revealed the the predominance of Den-3. In the year 2007 predominance of Den-2 was observed, whereas in 2008 Den-1 was the most common serotype isolated. Overall, Den-2 and Den-3 were the most predominant serotypes during 2003-2007 but Den-1 replaced these strains in the year 2008. Since the emergence of a new predominant strain can lead to the occurrence of an outbreak, presence of Den-1 in the year 2008 would pose an alarming situation before us. Well-targeted population-based epidemiological studies are urgently required to control dengue menace.

We present a case of kala-azar infection that recurred in a patient after completion of the standard treatment course of miltefosine, amphotericin B-deoxycholate (short course), and amphotericin B lipid formulations. The patient was cured after continuous amphotericin B-deoxycholate administration for 4 weeks. This is a unique case of relapse following the use of three important drugs. Although amphotericin B-deoxycholate is a second line drug in Nepal, it has shown a satisfactory clinical response with continuous treatment for 4 weeks. Therefore, an extended course of amphotericin B-deoxycholate may be beneficial in patients with resistance to the standard short course and other anti-leishmania drugs.

The aetiology of fungal sinusitis is diverse and changing. Aspergillus species has been the most common cause for fungal sinusitis, especially in dry and hot regions like India. Trichosporon species as a cause for fungal sinusitis has been very rarely reported the world over. Here, we report a rare case of allergic fungal sinusitis caused by Trichosporon inkin in a 28-year-old immunocompetent woman. Bilateral nasal obstruction, nasal discharge and loss of smell were her presenting complaints. Diagnostic nasal endoscopy showed bilateral multiple polyps. Functional endoscopic sinus surgery was performed and many polyps were removed. Based on mycological and histopathological studies, the pathogen was identified as T. inkin.

We describe a case of catheter-related bloodstream infection, in a patient with colon cancer, caused by a methicillin-sensitive Staphylococcus aureus strain, nontypeable by pulsed field gel electrophoresis of SmaI macrorestriction fragment analysis, belonging to ST398. The patient recovered after daptomycin therapy. This is the first report that documents the emergence of ST398 in Greece.

Human intestinal capillariasis is caused by Capillaria philippinensis. This disease is endemic in Philippines and Thailand. To the best of our knowledge, we report the third case of human intestinal capillariasis from India and the first case from Andhra Pradesh, which is a non-endemic area. A 40-year-old female presented with diarrhoea, vomiting, decreased urinary output, ascitis, pedal oedema, hypoalbuminemia, and electrolyte imbalance. Microscopic examination of stool sample revealed the presence of ova, larvae, and adult worms of C. philippinensis. Patient recovered from the disease after taking albendazole 400 mg daily for 1 month along with supportive treatment.

John Cunningham virus infection is an important cause of progressive multifocal leucoencephalopathy (PML) in the context of advanced human immunodeficiency virus infection. Limited data are available regarding the true incidence of PML as a presenting manifestation of HIV. We report one such case and also highlight the effective use of polymerase chain reaction in confirming its diagnosis.

Vancomycin-resistant enterococci rarely cause meningitis and present a therapeutic challenge. Antimicrobial susceptibility testing was done for strains of Enterococcus species isolated from CSF samples of patients with meningitis by phenotypic methods. Multiplex polymerase chain reaction was performed to determine the genetic basis of vancomycin resistance of such isolates. We report here two cases of enterococcal meningitis caused by vancomycin-resistant Enterococcus species. One of the isolates was identified as Enterococcus faecalis and the other as Enterococcus gallinarum. We also report the simultaneous presence of vanC1 and vanA resistance genes in the strain of E. gallinarum. To the best of our knowledge, this is the first report of vanA resistance gene in an isolate of E. gallinarum from the Indian subcontinent. This is also the first Indian report of vancomycin-resistant Enterococcus causing meningitis.

We report a case of a 30-year-old immunocompetent man with disseminated cryptococcosis who was initially treated with antitubercular therapy due to clinical and radiological diagnosis of vertebro-cerebral tuberculosis. The diagnosis of Cryptococcus infection was made due to incidental isolation of this fungus from blood culture with negative cerebrospinal fluid culture results. Though disseminated cryptococcosis with central nervous system, skeletal, and skin involvement is an uncommon manifestation of Cryptococcus neoformans infection, a high clinical suspicion and early initiation of therapy is needed to recognise and treat such patients efficiently.