Computed Tomography Score an Excellent Marker: Differentiates Eosinophilic and Non-eosinophilic Variants of Chronic Rhinosinusitis with Nasal Polyp.

Eosinophilic and non-eosinophilic subtypes of chronic rhinosinusitis with nasal polyp (CRSwNP) have different clinical profile and management. Currently the 2 subtypes are differentiated based on tissue eosinophilic infiltration, which is identified after surgery by histopathological examination. Hence this study was conducted to compare utility of computed tomography (CT) scans, serum IgE levels, absolute eosinophil count (AEC) and Sino-nasal Outcome Test (SNOT)-20 score for discriminating the 2 subtypes. In this prospective study of 1 year duration, patients suspected of CRSwNP were recruited. Serum IgE levels and AEC estimation were performed by ELISA and standard numerical formula respectively, along with histopathological examination of nasal polyp biopsies. CT score and ratio of CT score for ethmoid sinus and maxillary sinus (E/M ratio) were calculated. Patients were asked to fill SNOT-20 questionnaire. Receiver-operating characteristic (ROC) curve analysis was performed. Out of 52 patients studied, 38 and 14 were no. of eosinophilic and non-eosinophilic CRSwNP cases respectively on the basis of histopathological examination. E/M ratio and overall CT score were found to be highly accurate with area under ROC curve of 0.990 and 0.964 respectively, while rest 3 parameters had low accuracy. Optimal cut-off of CT score and E/M ratio for eosinophilic CRSwNP were 6 and 2.065 respectively. This study demonstrated E/M ratio and total CT score as the most useful surrogate markers for preoperative differentiation of eosinophilic and non-eosinophilic CRSwNP, and hence can be used to predetermine postoperative management before surgery.

Revisiting the Utility of Histopathological Examination of Biopsy: A Necessity in Microbiology.

INTRODUCTION: Culture is the gold standard, while potassium hydroxide mount is simplest technique used for diagnosis of fungal pathogens. Histopathological examination is the only definitive means to identify certain uncultivable fungi. AIM: To analyse role of histopathological examination and potassium hydroxide (KOH) mount for diagnosing fungal infections by correlating them with culture. MATERIALS AND METHODS: In this nine year retrospective study, all biopsy specimens submitted for microbiological examination were included. Histopathological examination of biopsies of cases with positive microbiological findings on either KOH mount or culture was carried out. Any discrepancy between histopathology interpretation and microbiology KOH or culture results, taking culture as the gold standard, were noted. STATISTICAL ANALYSIS: Open Epi software was used for statistical analysis. Comparisons between groups were made by using the chi-square test. A p-value < 0.05 was considered statistically significant. Cohen's Kappa coefficient (κ) was calculated as a measure of agreement between different variables. RESULTS: Concurrent pathology specimen could be obtained in 70 samples positive for fungal elements in either KOH or culture. Thirty-two cases were positive for fungi in culture, of which 16 were correctly identified by histopathological examination. Histopathological examination was strongly associated with culture result. KOH mount was in good agreement with positive culture result for yeast. Eleven culture negative but KOH and histopathology positive cases included seven samples with hyphae suggestive of zygomycosis, and two cases of rhinosporidiosis. Allergic mucin was strongly associated with Aspergillus species. KOH mount and detection of allergic mucin on histopathological examination were found to be excellent complementary tools for diagnosing Aspergillus species. Necrosis was highly specific for fungal growth in culture and had good positive predictive value. CONCLUSION: We advocate using histopathology, culture and KOH examination in an integral manner to avoid potential lapses in patient management.

Sporadic occurrence of cryptococcal meningitis in HIV-seronegative patients: Uncommon etiology?

Cryptococcosis in HIV-seronegative patients is rarely reported from India. This prospective study was conducted to look for cryptococcal meningitis in HIV-seronegative individuals and compare their laboratory features to cryptococcal meningitis in HIV-seropositive patients. Cerebrospinal fluid was collected from 153 suspected cases of meningitis and subjected to India ink preparation, antigen detection, and culture. Nineteen samples tested positive for Cryptococcus neoformans infection. Seventeen and two patients were HIV reactive and nonreactive, respectively. In vitro susceptibility of C. neoformans isolates to fluconazole and amphotericin B was performed using standard broth microdilution method and E-test. Eighteen strains were susceptible to amphotericin B, while fluconazole was reported susceptible in 15 strains. Hence, index of suspicion of C. neoformans infection as possible cause of meningitis must be maintained even in HIV-negative patients. Use of amphotericin B for treating C. neoformans meningitis should be restricted to prevent any increase in resistance.

Empirical model for estimating dengue incidence using temperature, rainfall, and relative humidity: a 19-year retrospective analysis in East Delhi.

OBJECTIVES: Aedes mosquitoes are responsible for transmitting the dengue virus. The mosquito lifecycle is known to be influenced by temperature, rainfall, and relative humidity. This retrospective study was planned to investigate whether climatic factors could be used to predict the occurrence of dengue in East Delhi. METHODS: The number of monthly dengue cases reported over 19 years was obtained from the laboratory records of our institution. Monthly data of rainfall, temperature, and humidity collected from a local weather station were correlated with the number of monthly reported dengue cases. One-way analysis of variance was used to analyse whether the climatic parameters differed significantly among seasons. Four models were developed using negative binomial generalized linear model analysis. Monthly rainfall, temperature, humidity, were used as independent variables, and the number of dengue cases reported monthly was used as the dependent variable. The first model considered data from the same month, while the other three models involved incorporating data with a lag phase of 1, 2, and 3 months, respectively. RESULTS: The greatest number of cases was reported during the post-monsoon period each year. Temperature, rainfall, and humidity varied significantly across the pre-monsoon, monsoon, and post-monsoon periods. The best correlation between these three climatic factors and dengue occurrence was at a time lag of 2 months. CONCLUSIONS: This study found that temperature, rainfall, and relative humidity significantly affected dengue occurrence in East Delhi. This weather-based dengue empirical model can forecast potential outbreaks 2-month in advance, providing an early warning system for intensifying dengue control measures.

Comparison of multiplex RT-PCR and real-time HybProbe assay for serotyping of dengue virus using reference strains and clinical samples from India.

BACKGROUND: Dengue virus serotyping is crucial from clinical management and epidemiological point of view. AIMS: To compare efficacy of two molecular detection and typing methods, namely, multiplex reverse transcription polymerase chain reaction (RT-PCR) and real-time Hybprobe assay using a panel of known dilution of four reference Dengue virus strains and a panel of sera collected from clinically suspected dengue patients. SETTINGS: This study was conducted at a tertiary-care teaching hospital in Delhi, India. MATERIALS AND METHODS: Dengue serotype specific virus strains were used as prototypes for serotyping assays. Viral load was quantified by quantitative real time reverse transcription polymerase chain reaction (qRT-PCR). Acute phase serum samples were collected from 79 patients with clinically suspected Dengue fever on their first day of presentation during September-October 2012. Viral RNA from serum and cell culture supernatant was extracted. Reverse transcription was carried out. Quantitative detection of DENV RNA from reference strain culture supernatants and each of the 79 patient samples by real-time PCR was performed using light cycler Taqman master mix kit. Serotyping was done by multiplex RT-PCR assay and Hybprobe assay. RESULTS: The multiplex RT-PCR assay, though found to be 100% specific, couldn't serotype either patient or reference strains with viral load less than 1000 RNA copies/ml. The Hybprobe assay was found to have 100% specificity and had a lower limit of serotype detection of merely 3.54 RNA copies/ml. CONCLUSIONS: HybProbe assay has an important role especially in situations where serotyping is to be performed in clinical samples with low viral load.

Anti-cysticercus antibody detection in saliva as a potential diagnostic tool for neurocysticercosis.

OBJECTIVES: This study was planned to determine the usefulness of anti-cysticercus IgG antibody detection in saliva for neurocysticercosis (NCC) diagnosis, along with serum C-reactive protein (CRP) level to serve as a surrogate marker. MATERIALS AND METHODS: In this prospective study of 14 months duration, blood and saliva samples were collected from 40 patients suspected to be suffering from NCC and were subjected to anti-cysticercus IgG antibody detection by ELISA. Serum CRP levels were estimated as acute-phase reactant by high sensitivity CRP ELISA. RESULTS: Anti-cysticercus IgG was detected in serum and saliva of 34 and 30 patients, respectively. Cases positive for salivary antibody were positive for serum antibody and their serum CRP level was higher than normal. Cases negative for salivary antibody had low serum CRP levels. Anti-cysticercus IgG detection in saliva was 88.24% sensitive, 100% specific, and had a positive predictive value of 100% and negative predictive value of 60%. Positive salivary anti-cysticercus IgG and high serum CRP level showed a significant association. Difference between CRP levels of patients positive for anti-cysticercus antibody in both serum and saliva, and patients positive for antibody in serum but not saliva was highly significant. CONCLUSIONS: Saliva, being painless and noninvasive, can be used as alternative to serum for NCC diagnosis.

Chikungunya: a reemerging infection spreading during 2010 dengue fever outbreak in National Capital Region of India.

Chikungunya fever is an important reemerging arbovirus illness, which is transmitted by the same vector as of dengue virus. Many cases of concurrent infections with multiple dengue virus serotypes have been reported in many countries. Also, concurrent infection with Chikungunya virus and dengue virus has been reported in the past in Delhi. Therefore, this study was done to detect Chikungunya IgM antibodies in suspected dengue fever patients. In this study, 1666 serum samples suspected of dengue fever and collected during the outbreak period (August 2010-December 2010) were tested for dengue IgM antibodies, of which 736 tested negative. Of the 736 dengue IgM negative sera, 666 were tested for Chikungunya IgM antibodies. The demographic profile and essential laboratory investigations were recorded. Chikungunya IgM was detected in 9.91 % of the patients. During the post-monsoon period though dengue dominated in numbers, the number of Chikungunya fever cases increased gradually followed by an abrupt decrease with the onset of winter. The Chikungunya IgM positive patients were suffering from fever of more than 5 days duration and had thrombocytopenia. Due to similarity in clinical features and vector transmitting dengue and Chikungunya virus, continuous surveillance of both dengue fever and Chikungunya fever is desirable for better management and epidemiological assessment.

Application of a stool antigen test to evaluate the burden of Helicobacter pylori infection in dyspepsia patients.

Helicobacter pylori (HP) is causally associated with peptic ulcer disease and gastric carcinoma. Determination of the prevalence of HP infection in dyspepsia patients' in particular geographical area is imperative for the appropriate management of dyspepsia. HP antigen detection in stool is a noninvasive diagnostic test of HP infection. This prospective study was conducted to find out the prevalence of HP infection based on stool antigen testing in dyspeptic patients who had also undergone upper gastrointestinal (GI) endoscopy. This study highlights the high prevalence of HP infection in dyspeptic Indian patients, particularly males, and emphasizes the growing importance of the bacterium causing infection among children. We also found HP stool antigen testing to be superior to upper GI endoscopy for detecting HP infection. Hence, we recommend initial testing for HP stool antigen in dyspeptic patients before initiating treatment and before carrying out any invasive procedure such as endoscopy.

Erratum to: Chikungunya: a reemerging infection spreading during 2010 dengue fever outbreak in National Capital Region of India.

[This corrects the article DOI: 10.1007/s13337-016-0314-z.].

Frequency of nucleotide sequence variations in the internal ribosome entry site region of hepatitis C virus RNA isolated from responding and non-responding patients with hepatitis C virus genotype 3 infection.

Located within 5' untranslated region of HCV RNA is internal ribosome entry site (IRES) which directs cap-independent translation of viral polyprotein. Mutations in IRES sequence have been shown to cause changes in efficiency of protein translation in vitro in few instances. No study has been done to investigate association between frequency of nucleotide sequence variations in IRES region of HCV-3 RNA and response to pegylated interferon-α plus ribavirin therapy. Hence, this study was planned to analyze relationship between frequency of nucleotide sequence variations of HCV-3 IRES region and response to therapy. Twenty-seven HCV-3 patients were studied, of whom 19 responded to therapy and 8 did not. Alanine aminotransferase and aspartate aminotransferase levels were significantly lower in responders compared to non-responders. HCV RNA detection and genotyping was performed by nested-PCR and RFLP respectively. Viral load quantification in pre and post therapy samples was done by real time PCR. The viral load was significantly lower in the patients after treatment as compared to before treatment. HCV IRES region from pre-treatment sera of 27 HCV-3 infected patients was amplified by nested PCR and sequenced. Secondary structure of IRES region of HCV-3 was predicted using the M fold Web Server. Mutational analysis revealed hot spot of mutations in HCV-3 IRES region from 40-80 and 210-280 nucleotides. Though more mutations were found in non-responders as compared to responders, this difference was statistically insignificant. Therefore, in addition to IRES region of HCV-3, some other host and viral factors may contribute to therapy outcome.

A case of extended spectrum beta-lactamase producing Salmonella enterica serotype paratyphi A from India.

Enteric fever caused by Salmonella enterica is a systemic infection with high rates of morbidity and mortality. Increasing antibiotic resistance in S. enterica has led to shift in the choice of antibiotics used against this organism from chloramphenicol and ampicillin to trimethoprim-sulfamethoxazole, fluoroquinolones, and extended-spectrum cephalosporins. Resistance to cephalosporins, due to the production of extended-spectrum beta-lactamases (ESBLs), is the cause of serious concern worldwide. So far, these enzymes have been detected in many species of the family Enterobacteriaceae including different serotypes of S. enterica. To the best of our knowledge, however, ESBL production in Salmonella Paratyphi A has not yet been reported from India. We present here a case of ESBL producing Salmonella Paratyphi A from India. This is a worrisome finding with grave clinical implications, since the dissemination of this resistance trait would further limit the therapeutic options available for the treatment of enteric fever.

Non-pigmented strain of serratia marcescens: an unusual pathogen causing pulmonary infection in a patient with malignancy.

Serratia marcescens is a member of the family Enterobacteriaceae. It has emerged in recent years as an opportunistic pathogen of nosocomial infections. Some biotypes of Serratia marcescens produce the non-diffusible red pigment prodigiosin. Though both pigmented and non-pigmented biotypes may be pathogenic for humans, the non-pigmented biotypes are more virulent due to cytotoxin production and presence of plasmids mediating antibiotic resistance. However in India only one study done 31 years back has reported on infections caused by non-pigmented strains of Serratia marcescens. We present a case of a patient with squamous cell carcinoma of the left retromolar trigone, soft palate and buccal mucosa, who developed pulmonary infection with non-pigmented strain of Serratia marcescens. According to the available literature, this is the second report on infection with non-pigmented strain of Serratia marcescens from India. It is imperative to accurately detect the non-pigmented biotypes due to their tendency to cause serious and difficult to treat infections.

Gender differences in outcomes of low birth weight and preterm neonates: the male disadvantage.

Various studies conducted worldwide have shown that male neonates have higher rates of mortality and morbidity in the perinatal period compared with females. However, there has been only one study from India on this subject. Therefore, this study was conducted to establish the difference in mortality between males and females among neonates born with two established risk factors of septicaemia--low birth weight (<2.5 kg) and preterm birth (<37 weeks). One hundred and fifty consecutive neonates which were either preterm or had low birth weight were recruited after obtaining informed consent from the parents. Blood culture was done, and the bacterial isolates were identified by standard protocol. Statistically significant association was found between male gender and mortality among culture-positive neonates. Therefore, results of the present study indicate that preterm or low birth weight male neonates have higher likelihood of mortality compared with their female counterparts in the Indian scenario.

Comments on 'Current emerging situation of dengue in India': with regard to the clinical and laboratory characteristics of paediatric dengue in India.

Dengue is a major public health problem in India. We evaluated clinical and laboratory characteristics of 700 suspected dengue patients below the age of 12 years. Serum samples of the patients were analysed for dengue NS1 antigen and IgM antibody by ELISA, and were correlated with clinical and haematological parameters. The positivity percentage of the serological tests showed an inverse relationship with age. Positive NS1 antigen and IgM antibody results were significantly associated with patients aged less than 3 years and more than 3 years, respectively. Maximum association with features of haemodynamic instability was seen in infants. The haemorrhagic manifestations of thrombocytopaenia, leucopaenia and anaemia were associated more with older age groups. This study provides evidence for age-related differences in clinical and laboratory features of paediatric dengue in an Indian setting.

Pulmonary Infection Caused by Achromobacter xylosoxidans in a Patient with Carcinoma of Epiglottis: A Rare Case.

Achromobacter xylosoxidans is an aerobic, motile, oxidase and catalase positive, non-fermenting, gram negative bacillus. It is an opportunistic pathogen which is responsible for various nosocomial and community-acquired infections. However, there are only very few reports of pulmonary infections caused by this bacterium in cancer patients. We are presenting a case of a patient with carcinoma of epiglottis, who developed pulmonary infection caused by Achromobacter xylosoxidans. According to the available literature, this is the first case of pulmonary infection caused by Achromobacter xylosoxidans, which was detected in a cancer patient in India. Since Achromobacter xylosoxidans demonstrates resistance to many classes of antimicrobials, vigilant and efficient microbiological work-ups and surveillances are needed, to diagnose infections caused by this rare pathogen in clinical settings.

Multidrug-resistant Staphylococcus hominis subsp. novobiosepticus causing septicemia in patients with malignancy.

A new subspecies of Staphylococcus hominis described by Kloos et al. in 1998 and named S. hominis subsp. novobiosepticus (SHN) has been implicated in nosocomial outbreaks. Multidrug resistance, including resistance to novobiocin and oxacillin, is a particularly important feature of SHN. In our institute, we encountered 13 cases of S. hominis subsp. hominis in cancer patients with septicemia, of which seven were methicillin resistant. The isolates were identified by VITEK ® 2 compact automated system, using GP REF 21342 identification card and antimicrobial susceptibility testing card P-628. The biochemical reactions and antibiotic susceptibility pattern of the seven methicillin-resistant isolates were re-analyzed and patient details were re-checked to finally identify them as SHN. The increasing number of cases reporting isolation of SHN from biological specimens point to potential virulence and clinical importance of this bacterium.