Leptospirosis in pregnancy: A lesson in subtlety.

INTRODUCTION: Leptospirosis is a zoonotic disease caused by spirochaete of the genus Leptospira. Human infection occurs after exposure to water or soil contaminated by urine from an infected animal. Most patients manifest as self-limited systemic illness. However 10% of patients manifest as severe disease associated with high fatality. The disease affects mostly men, cases involving pregnant women are uncommon. We presented a case of leptospirosis in a pregnant woman leading to mortality of both mother and foetus. CASE REPORT: A 28-year-old woman at 18 weeks of gestation, had shortness of breath and collapsed. She was brought unconscious to the emergency department and died shortly after arrival. A week prior to this, she had presented to the same hospital with pain on both thighs. Examination of the patient and ultrasound of the foetus revealed normal findings. Post mortem examination revealed hepatosplenomegaly and congested lungs; no jaundice, meningeal inflammation or cardiac abnormalities was evident. Histopathology examination of the lungs revealed pulmonary haemorrhages and oedema. Multiple infarcts were seen in the spleen and the kidneys showed foci of acute tubular necrosis. Laboratory investigations revealed Leptospira IgM antibody and PCR for leptospira were positive. This case illustrates the subtleness of clinical presentation of leptospirosis. The diagnosis was obscure even at post-mortem and was only suspected following histopathological examination, leading to further investigations. CONCLUSION: Leptospirosis may have a subtle presentation and a high index of suspicion for this infection is required for early identification of the disease.

Conventional versus molecular detection of Chlamydia trachomatis and Neisseria gonorrhoeae among males in a sexually transmitted infections clinic.

BACKGROUND: Chlamydia trachomatis and Neisseria gonorrhoeae are important bacterial pathogens of sexually transmitted infections (STIs) worldwide. This study sought to compare the analytical sensitivity and specificity of conventional methods against a rapid molecular method in detecting STIs caused by these bacteria. METHODS: Ninety five first-time male attendees of the Genito-urinary Medicine Clinic in Hospital Kuala Lumpur were included in this cross-sectional study. The detection of C. trachomatis was achieved through direct fluorescence antibody (DFA) staining of urethral swabs and real-time polymerase chain reaction testing (Xpert® CT/NG assay) on urine specimens. N. gonorrhoeae was detected through Gram staining and culture of urethral swabs and Xpert® CT/ NG assay on urine specimens. RESULTS: From the Xpert® CT/NG results, 11 (11.6%) attendees had chlamydia, 23 (24.2%) had gonorrhoea and 8 (8.4%) had both STIs. The sensitivity and specificity of DFA in detecting chlamydia compared to Xpert® CT/NG were 5.3% (95% CI: 0-28) and 94.7% (95% CI: 86-98), respectively. For gonorrhoea, the sensitivity and specificity of Gram staining were 90.3% (95% CI: 73-98) and 95.3% (86-99), respectively, whereas the sensitivity and specificity of culture compared to Xpert® CT/NG were 32.2% (95% CI: 17-51) and 100% (95% CI: 93-100), respectively. CONCLUSION: Although Gram-stained urethral swab smears are sensitive enough to be retained as a screening tool for gonorrhoea, culture as well as DFA lack sensitivity and are poorly suited to screen for gonorrhoea and chlamydia, respectively. However, owing to their high specificity, conventional detection methods are still suitable as confirmatory tests for gonorrhoea and chlamydia.

A sudden paediatric death due to hand, foot and mouth disease: the importance of vigilance.

BACKGROUND: Hand, foot and mouth disease (HFMD) is caused by enteroviruses such as Coxsackie virus A16 (CVA16) and Enterovirus 71 (EV71). The diagnostic hallmarks are oral ulcers and maculo-papular or vesicular rash on the hands and feet. Severe form of this disease can lead to death due to neurological and cardiopulmonary complications. This case report aims to describe a fatal case of HFMD with minimal oral and skin manifestations. CASE REPORT: A four-year-old girl was brought to a hospital after suddenly becoming unresponsive at home. She had a history of fever and lethargy for three days prior to her demise. The patient, and f ive other children in her neighbourhood had been diagnosed to have HFMD at a local health clinic; the other children had recovered without complications. RESULTS: Autopsy revealed a few punctate, sub-epidermal vesicles measuring 1 to 2 mm on the palm of her right hand and sole of the right foot, visible only with a magnifying glass. Internal examination revealed prominent nodularity at the oro- and hypopharynxes. The lungs were markedly congested and oedematous. Histopathology of the lung showed marked oedema and haemorrhage with mild pneumonic changes. Oedema with increase in macroglia and astrocytic proliferation were seen in the cerebral tissue, but no lymphocytic infiltration was evident. Enterovirus EV71 was detected by polymerase chain reaction in samples from the lung, cerebrospinal fluid and serum. The cause of death was given as HFMD complicated by pneumonia. CONCLUSION: Fatal HFMD may have minimal signs. A complete history, careful physical examination and relevant investigations lead to a diagnosis at post mortem examination. Awareness of the subtle signs and rapid deterioration associated with a fatal case of HFMD is a challenge to clinicians who encounter these cases.

Frequency and molecular epidemiology of Panton-Valentine leukocidin gene in Staphylococcus aureus colonising HIV-infected patients.

BACKGROUND: HIV-infected patients pose a high risk of contracting skin and soft tissue infections caused by Staphylococcus aureus. Those who are colonized with methicillin-resistant S. aureus (MRSA) that carry Panton-Valentine leukocidin (PVL) are predisposed to severe infections that could lead to necrotic skin infections. However the association of S. aureus specifically methicillin sensitive S. aureus carrying PVL gene in HIV patients has not been widely reported. Here, we study the prevalence and the molecular epidemiology of PVL-producing S. aureus in HIV-infected patients. METHODS: Swabs from four body sites of 129 HIV-infected patients were cultured for S. aureus and identified by standard microbiological procedures. The isolates were subjected to antimicrobial susceptibility testing by disk diffusion against penicillin, erythromycin, clindamycin, and cotrimoxazole. PCR was used to detect the PVL gene and genetic relationship between the isolates was determined by using pulse field gel electrophoresis. RESULTS: A total of 51 isolates of S. aureus were obtained from 40 (31%) of the patients. The majority (43.1%) of the isolates were obtained from the anterior nares. Thirteen (25.5%) of all the isolates were resistant to more than one category of antibiotics, with one isolate identified as MRSA. Thirty-eight (74.5%) isolates (including the MRSA isolate) carried PVL gene where the majority (44.7%) of these isolates were from the anterior nares. A dendogram revealed that the isolates were genetically diverse with 37 distinct pulsotypes clustered in 11 groups. CONCLUSION: S. aureus obtained from multiple sites of the HIV patients were genetically diverse without any clonality observed.

Graphite foils as potential skin and epithelium dosimeters at therapeutic photon energies.

This work builds upon a prior study, examining the dosimetric utility of pencil lead and thin graphitic sheets, focusing upon the measurement of skin doses within the mammographic regime. In recognizing the near soft-tissue equivalence of graphite and the earlier-observed favourable thermoluminescence yield of thin sheets of graphite, this has led to present study of 50 µm thick graphite for parameters typical of external beam fractionated radiotherapy and skin dose evaluations. The graphite layers were annealed and then stacked to form an assembly of 0.5 mm nominal thickness. Using a 6 MV photon beam and delivering doses from 2- to 60 Gy, irradiations were conducted, the assembly first forming a superficial layer to a solid water phantom and subsequently underlying a 1.5 cm bolus, seeking to circumvent the build-up to electronic equilibrium for skin treatments. Investigations were made of several dosimetric properties arising from the thermoluminescence yield of the 50 µm thick graphite slabs, in particular proportionality and sensitivity to dose. The results show excellent sensitivity within the dose range of interest, the thermoluminescence response varying with increasing depth through the stacked graphite layers, obtaining a coefficient of determination of 90%. Acknowledging there to be considerable challenge in accurately matching skin thickness with dose, the graphite sheets have nevertheless shown considerable promise as dosimeters of skin, sensitive in determination of dose from the surface of the graphite through to sub-dermal depth thicknesses.

Exploring the thermoluminescence characteristics of smartphone screen safety glasses for retrospective dosimetry applications.

In clinical settings, standard dosimeters might miss radiation mishaps. Retrospective dosimeters could help to track personnel (such as patients and other staff who don't wear dosimeters) exceeding safe limits and assess long-term exposure trends. This study has investigated key thermoluminescence (TL) dosimetric characteristics, including the glow curve structure, dose-response, energy dependence, sensitivity and fading of various safety glasses that are used as screen protectors of smartphones subjected to photon irradiation. Among the studied glasses, the HD Anti-Peep safety glass for iPhone has been found to exhibit a linear dose-response with a regression coefficient of 99% within the dose range of 2-10 Gy. Moreover, all the safety glasses showed independence with respect to photon energy of 6 MV and 10 MV. The TL glow curves of the samples showed a broad glow peak between 125 °C and 325 °C at 10 Gy. The TL kinetic parameters of the safety glasses were also studied by analyzing the glow curves using the peak shape and initial rise method. The geometric factor (µg) is found to be within the range of 0.43-0.53, which indicates the suitability of applying Chen's general-order formula to calculate the kinetic parameters such as activation energy, frequency factor and trap lifetime. The activation energy (E) and frequency factor (s) are found in the range of 0.31-0.54 eV and 4.55 × 103 to 2.12 × 106 s-1 respectively obtained via the peak shape method. The relatively long trap lifetime and observed thermoluminescence features indicate that the HD Anti-Peep safety glass offers a better option to estimate dose retrospectively to ensure the safety of human health.

Carbon rich media for luminescence-based surface dosimetry and study of associated surface defects.

The present study continues research into the utilisation of carbonaceous media for medical radiation dosimetry, focusing on the effects of surface area-to-volume ratio and carbon content on structural interaction alterations and dosimetric properties in sheet- and bead-type graphitic materials (with the respective carbon content of ∼98 wt% and ∼90 wt%). Using 60Co gamma-rays and doses from 0.5 Gy to 20 Gy, the study has been made of the response of commercially available graphite in the form of 0.1 mm, 0.2 mm, 0.3 mm and 0.5 mm thick sheets, also of activated carbon beads. Confocal Raman and photoluminescence spectroscopy have been employed, examining radiation-induced structural interaction alterations. Dose-dependent variation in the Raman intensity ratio ID/IG relates to the varying dominance of defect generation and dose-driven defect annealing. Of the various thickness graphite sheets, the 0.1 mm thick medium possesses the greatest surface area-to-volume ratio. Perhaps unsurprisingly, it also exhibits the greatest thermoluminescence (TL) yield compared to that of the other carbonaceous sheet foils used herein. Moreover, the second greatest mass-normalised TL yield has been observed to be that of the porous beads, reflected in the greater defect density (ID/IG > 2) when compared to the other media, due in part to their inherent feature of large internal surface area. Considering the challenge posed in matching skin thickness with skin dose, the near tissue equivalent graphite sheets show particular promise as a skin dosimeter, sensitive as a function of depth.

Thermoluminescent characterization and defect studies of graphite-rich media under high dose neutron exposure.

Thermoluminescence (TL) materials have a broad variety of uses in various fields, such as clinical research, individual dosimetry, and environmental dosimetry, amongst others. However, the use of individual neutron dosimetry has been developing more aggressively lately. In this regard, present study establishes a relationship between the neutron dosage and the optical property changes of graphite-rich materials caused by high doses of neutron radiation. This has been done with the intention of developing a novel, graphite-based radiation dosimeter. Herein, the TL yield of commercially graphite-rich materials (i.e. graphite sheet, 2B and HB grade pencils) irradiated by neutron radiation with doses ranging from 250 Gy to 1500 Gy has been investigated. The samples were bombarded with thermal neutrons as well as a negligible amount of gamma rays, from the nuclear reactor TRIGA-II installed at the Bangladesh Atomic Energy Commission. The shape of the glow curves was observed to be independent of the given dosage, with the predominant TL dosimetric peak maintained within the region of 163 °C-168 °C for each sample. By studying the glow curves of the irradiated samples, some of the most well theoretical models and techniques were used to compute the kinetic parameters such as the order of kinetics (b), activation energy (E) or trap depth, frequency factor (s) or escape probability, and trap lifetime (τ). All of the samples were found to have a good linear response over the whole dosage range, with 2B grade of polymer pencil lead graphite (PPLGs) demonstrating a higher level of sensitivity than both HB grade and graphite sheet (GS) samples. Additionally, the level of sensitivity shown by each of them is highest at the lowest dosage that was given, and it decreases as the dose increases. Importantly, the phenomenon of dose-dependent structural modifications and internal annealing of defects has been observed by assessing the area of deconvoluted micro-Raman spectra of graphite-rich materials in high-frequency areas. This trend is consistent with the cyclical pattern reported in the intensity ratio of defect and graphite modes in previously investigated carbon-rich media. Such recurrent occurrences suggest the idea of employing Raman microspectroscopy as a radiation damage study tool for carbonaceous materials. The excellent responses of the key TL properties of the 2B grade pencil demonstrate its usefulness as a passive radiation dosimeter. As a consequence, the findings suggest that graphite-rich materials have the potential to be useful as a low-cost passive radiation dosimeter, with applications in radiotherapy and manufacturing.

Studies of defect states and kinetic parameters of car windscreen for thermoluminescence retrospective dosimetry.

In case of any natural disasters or technical failures of nuclear facilities, the surrounding media including human beings may receive unexpected radiation exposures. In such a situation, there is no viable way to know how much radiation dose is received by human beings. Realizing that motorized vehicles are parked at fixed but increasing distances within the nuclear installation and industrial environment, this study investigates the kinetic parameters of readily available car windscreens which form the basis to be employed in post-accident dose reconstruction or for retrospective dosimetry. To understand the luminescence features of this crystalline media, a convenient thermoluminescence (TL) technique has been employed. Several well-defined theoretical models and methods were employed to calculate the kinetic parameters including the order of kinetics (b), activation energy (E) or trap depth, frequency factor (s) or escape probability and trap lifetime (τ), by analyzing the glow curves of the irradiated samples. The analysed trapping parameters indicate that the Toyota (E = 0.75-1.31 eV, s = 3.0E+6 - 3.7E+9 (s-1), τ = 6.9E+5 - 1.3E+14 s) and Honda (E = 0.95-1.68 eV, s = 2.1E+10 - 4.1E+13 (s-1), τ = 2.2E+9 - 3.1E+20 s) windscreen offer promising features for conventional TL dosimetry applications, while the obtained longer lifetime (τ = 6.8E+10 - 8.6E+29 s) or higher activation energy (E = 1.23-2.15 eV) for Proton brand windscreen indicates better stability or slow fading of the material, thus suitable for retrospective TL dosimetry. In addition, by assessing the area of deconvoluted micro-Raman spectra of windshield glasses in high-frequency regions, it has been observed the phenomenon of dose-dependent structural alterations and internal annealing of defects. This pattern is also consistent with those cyclical pattern observed in the intensity ratio of defect and graphite modes in the studies of carbon-rich media. Such common phenomena indicate the possibility of using the Raman microspectroscopy as a probe of radiation damage in silica-based media.

The potential of decorative building materials (marble) for retrospective thermoluminescence dosimetry.

Among the various types of decorative materials used in Bangladeshi dwellings, the marble/marble stone is one of the most common ones that used largely for enhancing the beauty and/or aristocracy of the dwelling environment. In this study, the most commonly used, six types of marble stones, have been analyzed for retrospective accident dosimetry. With the interest of characterizing several key thermoluminescence properties to examine their potentiality for dosimetry, annealing - irradiation - readout steps have been done chronologically which comprises the analysis of glow curves, relative sensitivity, dose dependence, repeatability and fading. Considering the various TL parameters, marble 'Carrara' imported from Italy present relatively better capability for reconstruction of radiation dose in the dose range of 10-50 Gy. From fading result, it is clear that for reconstruction of absorbed dose up to four weeks of post exposure, the marble 'Carrara' is found to be the most reliable media among the studied marble types. The Zeff values for the various marble samples are found to be in the range of 13.65-19.12, comparing favorably in replace of TLD-200 (Zeff = 16.3) which can be used for low-level environmental radiation dosimetry. Present work constitutes the first study to investigate the potentials of marble stone for reconstruction of absorbed dose in the range of 10-50 Gy dose.

Assessment of Radiation and Heavy Metals Risk due to the Dietary Intake of Marine Fishes (Rastrelliger kanagurta) from the Straits of Malacca.

The environment of the Straits of Malacca receives pollution as a result of various industrial and anthropogenic sources, making systematic studies crucial in determining the prevailing water quality. Present study concerns concentrations of natural radionuclides and heavy metals in marine fish (Rastrelliger kanagurta) collected from the Straits of Malacca, since aquatic stock form an important source of the daily diet of the surrounding populace. Assessment was made of the concentrations of key indicator radionuclides (226Ra, 232Th, 40K) and heavy metals (As, Mn, Fe, Cr, Ni, Zn, Cu, Co, Sr, Al, Hg and Pb) together with various radiation indices linked to the consumption of seafish. The annual effective dose for all detected radionuclides for all study locations has been found to be within UNSCEAR acceptable limits as has the associated life-time cancer risk. The overall contamination of the sampled fish from heavy metals was also found to be within limits of tolerance.