Seroprevalence of acute dengue in a Malaysian tertiary medical centre.

OBJECTIVES: The aims of this study were to determine the seroprevalence of acute dengue in Universiti Kebangsaan Malaysia (UKM) Medical Centre and its correlation with selected haematological and biochemical parameters. METHODS: This cross-sectional study was conducted from January to June 2015. A patient was serologically diagnosed with acute dengue if the dengue virus IgG, IgM or NS-1 antigen was reactive. RESULTS: Out of 1,774 patients suspected to have acute dengue, 1,153 were serologically diagnosed with the infection, resulting in a seroprevalence of 64.9%. Dengue-positive patients had a lower mean platelet count (89 × 10(9)/L) compared to the dengue-negative patients (171 × 10(9)/L) (p<0.0001). The mean total white cell count was also lower in the dengue-positive cases (4.7 × 10(9)/L vs. 7.2 × 10(9)/L; p<0.0001). The mean haematocrit was higher in patients with acute dengue (42.5% vs. 40.0%; p<0.0001). Likewise, the serum alanine transaminase level was also higher in patients with acute dengue (108 U/L vs. 54 U/L; p<0.0001). CONCLUSIONS: Dengue is very prevalent in UKM Medical Centre as most patients suspected to have acute dengue had serological evidence of the infection. The platelet count was the single most likely parameter to be abnormal (i.e. low) in patients with acute dengue.

Molecular detection of the New Delhi metallo-ß-lactamase-1 gene in Enterobacteriaceae isolates in a tertiary medical centre.

BACKGROUND: New Delhi metallo-ß-lactamase-1 (NDM-1) is a relatively recent carbapenemase enzyme that inactivates all ß-lactam antibiotics with the exception of aztreonam. This study aims to ascertain the baseline prevalence and antibiotic susceptibility patterns of NDM-1-producing Enterobacteriaceae in a tertiary medical center in Malaysia. METHODS: Over a period of one year, all Enterobacteriaceae isolates from all clinical specimens with reduced susceptibility to at least one carbapenem and resistance to at least one third generation cephalosporin were subjected to antibiotic susceptibility testing by disk diffusion and molecular detection of the NDM-1 gene by single-target PCR followed by gel electrophoresis. RESULTS: A total of 13,098 Enterobacteriaceae isolates were screened and 63 (0.48%) had reduced susceptibility to at least one carbapenem. Of this 63, 18 (29%) were NDM-1-positive. Of this 18, 16 (89.0%) were Klebsiella pneumoniae, one (5.5%) was Escherichia coli and one (5.5%) was Klebsiella ornithinolytica. Reduced susceptibility to at least one aminoglycoside was seen in 17 (94%) of the NDM-1-positive isolates. All 18 (100%) had reduced susceptibility to ertapenem and were resistant to all the second and third generation cephalosporin antibiotics tested. CONCLUSION: The prevalence of NDM-1-producing Enterobacteriaceae among all the Enterobacteriaceae isolates in our institution is low (0.14%) and screening for the NDM-1 gene is best performed using ertapenem-impregnated disks.

Screening for New Delhi metallo-ß-lactamase-1 in Enterobacteriaceae: Is there a role for the modified Hodge test?

OBJECTIVE: The New Delhi metallo-ß-lactamase-1 (NDM-1) enzyme is a plasmid-encoded enzyme that inactivates carbapenem antibiotics. This study aims to ascertain if the modified Hodge test (MHT) has a role in screening for NDM-1 in Enterobacteriaceae with reduced carbapenem susceptibility. METHODS: Over a period of one year, all Enterobacteriaceae isolates from all clinical specimens with reduced susceptibility to at least one carbapenem were subjected to MHT and conventional polymerase chain reaction (PCR) detection of the NDM-1 gene. RESULTS: A total of 13,098 Enterobacteriaceae isolates were screened and 63 (0.48%) had reduced susceptibility to at least one carbapenem. Out of the 63 isolates, 45 (71.4%) were MHT-positive. The NDM-1 gene was detected in 18 of the 63 isolates (28.6%). All 18 PCR-positive isolates were also MHT-positive. Thus, the sensitivity and specificity of the MHT in detecting NDM-1 in Enterobacteriaceae with reduced carbapenem susceptibility are 100% and 40%, respectively. CONCLUSION: The MHT is a useful test to screen for the presence of NDM-1 in Enterobacteriaceae with reduced carbapenem susceptibility. However, due to its rather low specificity, all MHT-positive isolates should be subjected to alternative tests (e.g. PCR) for confirmation, especially if other types of carbapenemases (e.g. KPC) are prevalent.

Prevalence of albicans and non-albicans candiduria in a Malaysian medical centre.

OBJECTIVE: To determine the proportion of albicans and non-albicans candiduria in a hospital setting and to ascertain if fluconazole is still suitable as empirical antifungal therapy based on antifungal susceptibility patterns of Candida species. METHODS: The cross-sectional study was conducted between December 2010 and December 2011 at UKM Medical Centre, Kuala Lumpur, Malaysia and comprised 64 urine samples from patients who were either suspected or confirmed to have urinary tract infections. Yeasts were speciated using ID 32 C and subjected to antifungal susceptibility testing using Sensititre® YeastOne YO8. RESULTS: Candida albicans accounted for 38(59.4%) of the isolates, Candida tropicalis 18(28.1%), Candida glabrata 6(9.4%) and Candida parapsilosis 2(3.1%). Overall, the isolates were susceptible to both amphotericin B (MIC90 1 µg/ml) and to 5-flucytosine (MIC90 0.25 µg/ml), but susceptible-dose dependent towards fluconazole (MIC90 16 µg/ml). Individually, Candida albicans was susceptible to fluconazole (MIC90 2 µg/ml), amphotericin B (MIC90 0.5 µg/ml) and 5-flucytosine (MIC90 0.25 µg/ml). Candida tropicalis was also susceptible to fluconazole (MIC90 4 µg/ml), amphotericin B (MIC90 1 µg/ml) and 5-flucytosine (MIC90 0.125 µg/ml). Candida glabrata was resistant to fluconazole (MIC90 64 µg/ml), but susceptible to amphotericin B (MIC90 1 µg/ml) and 5-flucytosine (MIC90 0.125 µg/ml). Lastly, Candida parapsilosis was resistant to fluconazole (MIC90 256 µg/ml), but susceptible to amphotericin B (MIC90 0.5 µg/ml) and 5-flucytosine (MIC90 0.5 µg/ml). CONCLUSION: The commonest yeast associated with candiduria at the study site was Candida albicans, and fluconazole can still be used for empirical therapy of candiduria.

Paecilomyces lilacinus fungaemia in an AIDS patient: the importance of mycological diagnosis.

Fungaemia due to Paecilomyces lilacinus is generally not considered in AIDS patients because this condition is not categorised as an AIDS-indicator illness. We report a case of a 25-year-old lady who presented to our hospital with Guillain-Barré Syndrome, with the subsequent development of refractory fungaemia, multi-organ failure and disseminated intravascular coagulopathy. Amphotericin B was given as empirical antifungal therapy. HIV screening was reactive and Paecilomyces lilacinus was isolated from her blood. The fungaemia did not resolve after one week of amphotericin B treatment. The addition of itraconazole was also unsuccessful in clearing the fungaemia. Accurate mycological diagnosis is important in the care of AIDS patients with fungaemia because of the risk of treatment failure with empirical therapy.

Rhodotorula mucilaginosa Fungemia in an Infected Biloma Patient Following a Traumatic Liver Injury.

Rhodotorula mucilaginosa fungemia is rare and highly resistant to antifungal therapy. We herein report a case involving a 31-year-old male admitted after a high-velocity road traffic accident. He sustained a grade IV liver injury with right hepatic vein thrombosis, which necessitated an urgent laparotomy. Post-operatively, repeated imaging of the abdomen revealed the presence of a biloma. Percutaneous subdiaphragmatic drainage was carried out but appeared ineffective, prompting a second surgery for an urgent hemi-hepatectomy. The patient was then nursed in the intensive care unit (ICU); however, during his stay in the ICU, he became more sepsis, which was evident by worsening ventilatory support and a rise in septic parameters from the biochemistry parameters. Despite intravenous piperacillin-tazobactam and fluconazole, his septic parameters did not improve and a full septic workup was conducted and was found to be positive for Rhodotorula mucilaginosa from the blood cultures. After discussion with the infectious disease physicians and clinical microbiologists, it was decided to initiate a course of intravenous meropenem and amphotericin B based on minimum inhibitory concentration (MIC) values, considering the patient's extended ICU stay and catheter use. Eventually, after successfully weaning off mechanical ventilation, the patient was discharged from ICU care. This case underscores the necessity of individualized approaches, combining timely imaging, appropriate drainage techniques, and tailored treatments to optimize outcomes for such intricate post-traumatic complications.

Successful Treatment of Sternal Osteomyelitis and Mediastinitis Caused by Rhizopus Following Cardiac Surgery.

Sternal osteomyelitis and mediastinitis are rare yet severe complications post-cardiac surgery, often associated with significant morbidity and mortality. Fungal etiologies, particularly those caused by Rhizopus spp., are infrequent but can lead to aggressive infections. Here, we present the case of a 68-year-old male who developed sternal osteomyelitis and mediastinitis caused by Rhizopus spp. two weeks following coronary artery bypass grafting surgery. Debridement and pectoralis flap reconstruction were performed following clinical identification and confirmation with microbiological examinations and a CT scan. Prompt recognition, aggressive surgical intervention, and targeted antifungal therapy were crucial for successful management. This case underscores the importance of considering fungal pathogens, such as Rhizopus, in the differential diagnosis of post-cardiac surgery infections, as well as aggressive treatment to improve outcomes for affected patients.

Isolation of an obscure fungus, Parengyodontium album, from the blood of a severely neutropenic patient: The first reported case from Malaysia.

Parengyodontium album is a very rarely encountered opportunistic fungal pathogen. A severely neutropenic 11-year-old boy with acute T-cell lymphoblastic leukemia/lymphoma was febrile and lethargic during his admission for elective chemotherapy. No cutaneous lesion or obvious source of infection was noted, and clinical examination was otherwise unremarkable. A blood specimen was sent for culture and fungal elements were visualized. Amphotericin B was administered empirically while awaiting fungal identification. Morphologically, a hyaline mould with thin septate hyphae plus smooth-walled conidiophores and conidiogenous cells arranged in whorls of up to four was cultured. Internal transcribed spacer region sequencing identified the fungus conclusively as P. album. Repeat blood culture was also positive for the same fungus. Following a two-week course of amphotericin B, fungemia clearance was attained.

Exophiala dermatitidis, 'the real black fungus' fungemia in a patient with COVID-19.

The second wave of the COVID-19 pandemic in India had brought with it a surge of 'black fungus' co-infection, which is a misnomer for mucormycosis. The present case illustrates the 'real black fungus' infection in a 50-year old male patient with COVID-19 pneumonia, who otherwise had no significant previous medical history. He was admitted on day 8 of COVID-19 illness and was intubated due to persistently low oxygen saturation. Blood cultures were positive for flask-shaped dematiaceous budding yeasts with pseudohyphae formation, which grew as brown-black fuzzy colonies on Sabouraud dextrose agar. The isolate was identified as Exophiala dermatitidis based on phenotypic characterization. Despite antifungal therapy with amphotericin B and itraconazole, the patient deteriorated rapidly and succumbed to acute respiratory distress syndrome and multiorgan failure. A review of reported cases of Exophiala dermatitidis fungemia over the last 5-years is discussed.

A Spuriously Negative Cryptococcal Antigen Assay Result in Disseminated Cryptococcosis: the Deception of the Postzone Phenomenon.

Cryptococcus is a basidiomycetous yeast responsible for considerable HIV-related morbidity and mortality. A cachectic 26-year-old HIV-positive man with a CD4 count of 103 cells/µl presented with fever, breathlessness, and bilateral lower limb weakness. A brain computed tomography scan could not elucidate the neurological deficit. His blood was sent for culture and serum cryptococcal antigen detection, with the latter testing as negative. By the fourth day of admission, the patient's condition had deteriorated drastically. A lumbar puncture was performed, and like his serum sample, the cerebrospinal fluid also tested negative for cryptococcal antigens. By this time, Cryptococcus neoformans was isolated from the admission blood culture. The laboratory diluted both the serum and cerebrospinal fluid specimens to retest for cryptococcal antigens, and finally, an antigen titer of ≥1:2560 was recorded.

A Preliminary Study on Coagulation Parameters and Sterility of Thawed Refrozen Fresh Frozen Plasma.

Thawed fresh frozen plasma (FFP) if not used within 6 h, may have to be discarded due to the risk of contamination and uncertainty about its quality. The main objective of this study was to evaluate the levels of coagulation Factor II (FII), Factor VIII (FVIII), fibrinogen and bacterial growth in thawed refrozen FFP. Thirty FFP samples were collected from healthy donors. FFP were thawed in water bath at 37 °C for 20-25 min. Approximately 10 mL of plasma from each FFP unit was tested for FII, FVIII, fibrinogen and sterility. The thawed FFP units were then kept at 4 °C for 6 h before being refrozen and stored at - 20 °C. Two weeks later, the refrozen FFP were thawed again and representative samples were analysed as before. There was a significant decline in the mean FVIII level, from 155.77% to 85.6% at second thaw. The mean FII level increased significantly from 74.9% to 82%, whereas the mean fibrinogen level fell from 3.34g/L to 3.28 g/L, but the decline was not statistically significant. There was no bacterial contamination in all samples at both time points. Refrozen plasma may be considered as an alternative to the storage of thawed unused FFP provided they are kept in a controlled environment to reduce wastage. These thawed refrozen FFP can be used later in bleeding cases like other FFP as the levels of FVIII are still within the standard haematology range (0.5-2 IU/mL) and above the minimal level of 30% coagulation factors required for adequate haemostasis.

The Pitfall of Utilizing a Commercial Biochemical Yeast Identification Kit to Detect Candida auris.

Candida auris is an emerging pathogenic yeast responsible for nosocomial infections with high mortality, on a global scale. A 65-year-old woman with hypovolemic shock and severe metabolic acidosis was intubated and admitted to the intensive care unit (ICU). Shortly after admission, she developed ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii, which necessitated treatment with high-dose ampicillin-sulbactam. Two weeks later, a yeast was cultured from her blood. It formed pale pink colonies on CHROMagar Candida medium and produced predominantly oval budding yeast cells with the occasional rudimentary pseudohyphae on cornmeal agar. ID 32 C identified the yeast as Candida sake However, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and sequencing of the D1/D2 region of the 28S rRNA gene identified the yeast as C. auris.

Presence of anti-mitochondrial antibodies and elevated serum immunoglobulin G levels: is this primary biliary cirrhosis-autoimmune hepatitis overlap syndrome?

Primary biliary cirrhosis in combination with autoimmune hepatitis has been termed "overlap syndrome", but its diagnosis is challenging. We report a case of a 43-year-old lady who presented with a six-month history of jaundice and pruritus. She subsequently developed gum bleeds. Laboratory investigations revealed hypochromic microcytic anemia, abnormal coagulation profiles, elevated serum alanine transferase and alkaline phosphatase levels, and raised serum IgG and IgM levels. Her serum was also positive for anti-nuclear and anti-mitochondrial antibodies. The findings from her abdominal CT scan were suggestive of early liver cirrhosis and the histopathological examination results of her liver biopsy were consistent with primary biliary cirrhosis. The patient was treated with ursodeoxycholic acid and her liver function test parameters normalized after six months.