Diagnostic Potential of Circulating Biomarkers in Adenosine Deaminase Diagnosed Pleural Tuberculosis Cases.

Pleural tuberculosis accounts for nearly 20% of Extra pulmonary tuberculosis. Adenosine deaminase, commonly used biomarker for the diagnosis, is non specific and there is paucity of literature on its correlation with conventional or newer methods for the diagnosis of extra pulmonary forms of TB. The aim of the study was to assess diagnostic potential of T cell function markers [interferon (IFN-γ), interleukin (IL-2) and IFN-γ/IL-2 ratio]; macrophage activation marker [neopterin]; and oxidative stress markers [protein carbonyl and malondialdehyde (MDA)] in pleural tuberculosis. 26 pleural TB cases diagnosed on the basis of suggestive chest X-ray and raised serum ADA levels and healthy controls were included in the study. Pleural fluid specimens were subjected to Zeihl Neelsen staining and culture on Lowenstein Jensen medium. Serum IFN-γ, IL-2, neopterin and protein carbonyl levels detection were done by ELISA and MDA levels were determined by measuring the thiobarbituric acid reactive substances. Median serum levels of IFN-γ, IL-2, IFN-γ/IL-2 ratio, neopterin, protein carbonyl and MDA were significantly different between cases and controls. Levels of all biomarkers except IL-2 were significantly higher in cases with contact history. Mean levels of ADA and ESR were 46.27 U/L and 46.62 mm/hr in PTB cases. AUC for IFN-γ, IL-2, IFN-γ/IL-2 ratio, neopterin, protein carbonyl and MDA were significantly discriminative for cases and controls. IFN-γ/IL-2 ratio was best discriminatory biomarker with highest area under ROC curve. Though no correlation was seen between ADA and any of the six biomarkers, ESR levels correlated significantly with all biomarkers except IL-2 by spearman's correlation coefficient. Though all the circulating biomarkers under study provide useful supportive evidence for the diagnosis of PTB, further studies involving diverse control groups particularly non-PTB effusion are needed to validate these results.

Neopterin and oxidative stress markers in the diagnosis of extrapulmonary tuberculosis.

BACKGROUND: Extrapulmonary tuberculosis (EPTB) often presents with nonspecific signs and symptoms. Further the paucibacillary nature of extrapulmonary specimens and irregular distribution of bacilli lower the sensitivity of conventional diagnostic methods making EPTB, a diagnostic dilemma. OBJECTIVE: To study neopterin, protein carbonyl and malondialdehyde (MDA) in EPTB. METHODS: Sixty nine clinically confirmed cases with an equal number of age and sex matched healthy controls were enrolled. Ziehl-Neelsen staining for acid fast bacilli and culture on Lowenstein-Jensen medium were performed on all the extrapulmonary specimens. Serum neopterin and protein carbonyl levels were estimated using commercial ELISA kits. Malondialdehyde was determined by measuring thiobarbituric acid reactive substances. RESULTS: Serum neopterin, protein carbonyl and MDA levels were significantly discriminative for cases of EPTB from healthy controls (p < 0.05). Levels of all the three biomarkers under study significantly differed between culture as well as smear positive and negative cases. A positive correlation between neopterin and protein carbonyl was seen among the cases. CONCLUSIONS: So far few studies have integrated combination of validated host biomarkers for active disease in EPTB. Our study suggests the potential diagnostic role of neopterin, protein carbonyl and MDA in EPTB.

Comparative Diagnostic Utility of Neopterin and IFN-γ/IL-2 in Extrapulmonary Tuberculosis.

Resurgence of TB has emphasized the need for newer methods of diagnosis. Extrapulmonary tuberculosis (EPTB), being paucibacillary, is a diagnostic dilemma. The aim of the present study was to correlate IFN-γ/IL-2 with neopterin in diagnosis of EPTB. Extrapulmonary specimens from 69 clinically diagnosed cases were stained by Ziehl-Neelsen and cultured on Lowenstein-Jensen medium for Mycobacterium tuberculosis. ELISA was used to assess serum IFN-γ, IL-2 and neopterin levels. Median serum levels of IFN-γ/IL-2 and neopterin were 3.22 and 21.6 nmol/L in clinically diagnosed EPTB cases and 0.52 and 4.20 nmol/L in healthy controls respectively (p < 0.001). Both IFN-γ/IL-2 and neopterin were significantly higher in culture positive (14.64 and 49.8 nmol/L) than culture negative cases (3.01 and 17.5 nmol/L) respectively (p < 0.05). IFN-γ/IL-2 was significantly higher in AFB smear positive cases (8.63) than smear negative cases (3.04) (p = 0.003), whereas no significant difference in neopterin levels was seen (p = 0.307). A positive correlation between IFN-γ/IL-2 and neopterin was seen in EPTB cases (spearman's rho = 0.453, p < 0.001), whereas in healthy controls no such correlation existed (spearman's rho = 0.018, p = 0.884). An urgent need for research in the field of biomarkers exists to utilize them as point of care test in the diagnosis of EPTB.

Convergence of Minds: For Better Patient Outcome in Intensive Care Unit Infections.

BACKGROUND: There is emergence of resistance to the last-line antibiotics such as carbapenems in Intensive Care Units (ICUs), leaving little effective therapeutic options. Since there are no more newer antibiotics in the armamentarium in the near future, it has become imperative that we harness the interdisciplinary knowledge for the best clinical outcome of the patient. AIMS: The aim of the conference was to utilize the synergies between the clinical microbiologists and critical care specialists for better patient care and clinical outcome. MATERIALS AND METHODS: A combined continuing medical education program (CME) under the aegis of the Indian Association of Medical Microbiologists - Delhi Chapter and the Indian Society of Critical Care Medicine, Delhi and national capital region was organized to share their expertise on the various topics covering epidemiology, diagnosis, management, and prevention of hospital-acquired infections in ICUs. RESULTS: It was agreed that synergy between the clinical microbiologists and critical care medicine is required in understanding the scope of laboratory tests, investigative pathway testing, hospital epidemiology, and optimum use of antibiotics. A consensus on the use of rapid diagnostics such as point-of-care tests, matrix-assisted laser desorption ionization-time of flight mass spectrometry, and molecular tests for the early diagnosis of infectious disease was made. It was agreed that stewardship activities along with hospital infection control practices should be further strengthened for better utilization of the antibiotics. Through this CME, we identified the barriers and actionables for appropriate antimicrobial usage in Indian ICUs. CONCLUSIONS: A close coordination between clinical microbiology and critical care medicine opens up avenues to improve antimicrobial prescription practices.

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.

Correlation between the clinico radiological heterogeneity and the immune-inflammatory profiles in pediatric patients with neurocysticercosis from a tertiary referral centre.

INTRODUCTION: Neurocysticercosis (NCC) is the leading cause of epilepsy in developing world. Cysticercal lesions develop in brain depending upon a combination of host immune-inflammatory response, mainly mediated by cytokines produced by cysticercal antigens. AIM AND OBJECTIVES: To correlate between MRI findings and levels of Th1/Th2 cytokines present in sera of children clinically suspected of NCC with generalized or partial seizure. MATERIAL AND METHODS: Fifty children presenting with history of seizures and/or mass effects and/or hydrocephalous, with a diagnosis of NCC based on the clinical and radiological profile were included. Antibody (IgM) for NCC and Th1/Th2 cytokine response (TNF-α, IL-2/and IL-6) detection was done on sera from all the patients following manufacturer's instructions. RESULTS: Out of 50 cases, 10 presented with acute symptoms of NCC with an immunological response of a predominance of pro-inflammatory cytokines (IL-2: 8, TNF-α: 2). High IL-6 was found in 40 children indicating an active lesion with chronic granulomas suggestive of parasitic destruction and persisting presentation with seizures. However, the levels of IL-6 differed with values lower in patients with inactive (calcified lesions) forms of NCC. A significant proportion (43 of 50 cases) had negative serology, probably because of the waning of antibody response months or years after the parasites die. CONCLUSION: Parasite maintains equilibrium with host immune response in early infection, a mild Th1 response is provoked; but later this equilibrium is disturbed toward Th2 response that leads to parasite destruction. Number or stage of the parasites along with immunegenetic aspects may explain the pleomorphic and unpredictable course of NCC.

First study on detection of cryptic resistance to linezolid among clinical isolates of methicillin resistant Staphylococcus aureus from India.

PURPOSE: Linezolid is an oral antibiotic which is widely used for serious infections caused by Methicillin Resistant Staphylococcus aureus (MRSA). With emergence of vancomycin MIC creep among clinical strains of MRSA, it is essential to know the possible emergence of subclinical resistance against linezolid as well. With this background, we aimed to detect evident (phenotypic) and cryptic (hidden or genotypic) linezolid resistance among MRSA isolates. METHODS: 250 clinical isolates of MRSA were collected and their susceptibility patterns were determined. Every third MRSA isolate was subjected to PCR for domain V of the 23S rRNA for the mutation hotspot in the 746bp segment which harbors the classical mutation for linezolid resistance. Restriction Fragment Length Polymorphism was done to confirm presence of the G2576U mutation. RESULTS: Six isolates (2.4%) were phenotypically resistant to linezolid. Among these six LRSA isolates, 5 demonstrated the G2576U mutation by PCR - RFLP. Cryptic resistance to Linezolid was identified in two isolates among linezolid susceptible isolates. CONCLUSIONS: In the present study, hidden resistance to linezolid was observed in linezolid susceptible clinical isolates. Emergence of resistance against over-the-counter drugs like linezolid is major challenge. Identification of cryptic resistance among patients implies impending resistance to linezolid. Judicious use of antimicrobials, application of strict infection control practices and prescription audit needs to be made mandatory to preserve such drugs.

Effect of Helicobacter pylori eradication therapy in iron deficiency anaemia of pregnancy - a pilot study.

BACKGROUND & OBJECTIVES: Despite routine iron supplementation and promotion of diet modification, iron deficiency anaemia (IDA) remains widely prevalent in our antenatal population. Recent studies in pediatric population have highlighted the role of Helicobacter pylori infection in IDA. This study was undertaken to study the effect of eradication therapy in H. pylori infected pregnant women with IDA. METHODS: Randomized placebo-controlled double blind clinical trial was done on 40 antenatal women between 14-30 wk gestation, with mild to moderate IDA and having H. pylori infection, as detected by stool antigen test. These women were randomly divided into group I (n=20): H. pylori treatment group (amoxicillin, clarithromycin, omeprazole for 2 wk) and group II (n=20): placebo group. Both groups received therapeutic doses of iron and folic acid. Outcome measures were improvement in haematological parameters and serum iron profile after 6 wk of oral iron therapy. RESULTS: The prevalence of iron deficiency in pregnant women with mild to moderate anaemia was 39.8 per cent (95% CI 35.7, 44.3); and 62.5 per cent (95% CI 52, 73) of these pregnant women with IDA were infected with H. pylori. After 6 wk of therapeutic oral iron and folic acid supplementation, the rise in haemoglobin, packed cell volume, serum iron and percentage transferrin saturation was significantly (P<0.05) higher in the group given H. pylori eradication therapy as compared to the placebo group. INTERPRETATION & CONCLUSIONS: Our results showed a high occurrence of H. pylori infection in pregnant women with IDA. Eradication therapy resulted in significantly better response to oral iron supplementation among H. pylori infected pregnant women with IDA.

T helper 1 to T helper 2 shift in cytokine expression: an autoregulatory process in superantigen-associated psoriasis progression?

Psoriasis is an inflammatory skin disorder characterized by increased activation of CD4(+) T lymphocytes, and systemic and local overexpression of pro-inflammatory cytokines such as interleukin 2 (IL-2), gamma interferon (IFN-gamma), IL-6 and tumour necrosis factor alpha, indicating that immunopathogenesis of the disease is T helper 1 (Th1) mediated. Several studies suggest a pivotal role of bacterial superantigens in the initiation and/or exacerbation of this illness. This study was conducted to assess the systemic Th1/Th2 imbalance in Indian psoriasis patients presenting with variable duration of disease by studying systemic superantigen-stimulated peripheral blood mononuclear cell (PBMC) cytokine expression. PBMCs were isolated and stimulated in vitro with superantigens (streptococcal pyrogenic exotoxin A and staphylococcal enterotoxin B), and the cytokines released (IFN-gamma for a Th1 response, and IL-4 and IL-10 for a Th2 response) were assayed. In contrast to controls, psoriasis patients in the early course of disease were characterized by significantly increased expression of the pro-inflammatory cytokine IFN-gamma, whilst a shift towards IL-10 secretion (Th2 response) was observed in those presenting with increased duration of disease. These observations suggest a possible shift from a Th1 to a Th2 cytokine response with superantigen-associated progression for the duration of psoriasis, perhaps as an adaptive process by the immune system in an attempt to downregulate abnormal inflammatory Th1 immune responses.

Development, optimization, standardization, and validation of a simple in-house agar gradient method to determine minimum inhibitory concentration of vancomycin for Staphylococcus aureus.

BACKGROUND: The Clinical and Laboratory Standards Institute recommends reporting minimum inhibitory concentration (MIC) values of vancomycin for Staphylococcus aureus. Commercial MIC strips are expensive, and the traditional broth microdilution method is cumbersome. With this background, we attempted to develop and standardize an in-house agar gradient method to determine MIC values of vancomycin for S. aureus. OBJECTIVES: To develop and validate an in-house vancomycin MIC strip, based on simple agar gradient method for S. aureus as per bioassay development guidelines. MATERIALS AND METHODS: Filter paper gradient strips were made in house and impregnated with varying concentrations of vancomycin to create an antibiotic gradient. During standardization, MICs of ninety clinical strains of S. aureus and ATCC 29213 were tested by the broth microdilution and commercial strip followed by the in-house strip. During the validation stage, MICs of ninety different clinical strains of S. aureus and ATCC 29213 were determined by the in-house strip followed by MIC detection by broth microdilution and commercial strips. A reading of more than ± 1log2 dilution compared with broth microdilution was considered as an outlier. RESULTS: During the initial stage, there were 7/90 outliers in the clinical strains, and no outliers were seen with the ATCC 29213 control strain. Corrective action included increasing precaution during the antibiotic impregnation on the strip. During validation stage, only 4/90 outliers were observed in the clinical strains. The commercial strips had 29/90 among clinical and 15/30 outliers in the control strain during the prevalidation phase. Despite maintaining cold chain during the validation phase, the outliers for commercial strip were 18/90 and 4/30 for clinical and control strains, respectively. CONCLUSION: Reporting vancomycin MIC for S. aureus may be attempted using the in-house method after validating it with a gold standard broth microdilution method and quality control as per protocol.

Trend of antibiotic resistance of Vibrio cholerae strains from East Delhi.

BACKGROUND & OBJECTIVE: Epidemics of cholera caused by toxigenic Vibrio cholerae O1 and O139 (Bengal strain) represent a major public health problem in most developing countries. In view of the reported shift in epidemiology and pattern of antibiotic resistance in this was study carried out to assess the development of resistance to essential drugs like fluoroquinolones during treatment of cholera and cholera like cases in Delhi. METHODS: Faecal specimens collected from 1184 patients with cholera and cholera like illness between 2001-2006 admitted to Guru Teg Bahadur hospital, East Delhi were subjected to culture isolation. Antimicrobial susceptibility testing of V. cholerae isolates was done by disc diffusion method. RESULTS: Of the 1184 faecal samples examined, 670 (56.6%) were positive for V. cholera from 2001- 2006. V. cholerae El Tor Ogawa (54.6%) was more common than serotype Inaba (32.5%). During 2004-2006 V. cholerae Inaba emerged as the predominant serotype. Resistance to nalidixic acid, furazolidone and co-trimoxazole was constantly high (100%). Multiple antibiotic resistance (MAR) V. cholerae O1 Inaba isolates exhibited increased resistance to ciprofloxacin with MIC >4 microg/ml, but largely all remained susceptible to other antibiotics like, gentamicin, tetracycline and chloramphenicol. INTERPRETATION & CONCLUSION: V. cholerae have a permanent existence in the environment and during the quiescent period, their survival in water bodies allows dissipation of resistance patterns to different serotypes or strains of V. cholerae O1 and therefore there is need for constant observation.

Seroprevalence of anti Vi antibodies and immunogenicity of Typhim Vi vaccine in children.

This prospective study was carried out on 250 children between 6 months to 5 years of age to determine seroprevalence of anti Vi antibodies and to measure seroresponse and percent seroconversion to TyphimVi polysaccharide vaccine in children 2-5 years of age. Fifty children each were enrolled between 6 to 12 months of age (Group A), between 1- 2 years of age(Group B), between 2-3 years of age (Group C), between 3-4 years of age (Group D) and between 4-5 years of age (Group E). Anti-Vi antibody baseline titres were determined in all children. Children in Groups C to E were vaccinated with Typhim Vi vaccine. Baseline and postvaccination antibody titres were determined by ELISA. Test sera which had antibody levels >1 microg/ml were scored as seropositive. Of 250 children, 3 had base line anti-Vi antibodies >1 microg/ml. Following immunization overall seroconversion rate was 77.5% with 65.3%, 78.2% and 88% children showing seroconversion in Groups C, D and E respectively. Seroconversion was significantly more in Group E children compared to Group C (p=0.0148). There were no significant adverse reactions following vaccination. The study highlights very low prevalence of baseline anti Vi antibodies in children between 6 months and less than 5 years of age and shows high immunogenicity and safety of Typhim Vi polysaccharide vaccine in children 2-5 years of age.

Anti-HBs Titers Following Pentavalent Immunization (DTwP-HBV-Hib) in Term Normal Weight vs Low Birthweight Infants.

OBJECTIVE: To compare anti-HBs titers between term low birth weight (1800-2499 g) infants and normal birthweight infants, 6 weeks after last dose of primary immunization with pentavalent vaccine, and to study adverse events following immunization (AEFI) with pentavalent vaccine. DESIGN: Cohort study. SETTING: Tertiary-care hospital predominantly catering to urban poor population of East Delhi. PARTICIPANTS: 265 low birthweight (1800-2499 g) and 265 normal birthweight (2500-4000 g) infants. Monovalent Hepatitis B vaccine was administered within 24 hours of birth followed by three primary doses of pentavalent vaccine at 6, 10 and 14 weeks. Anti-HBs titers were estimated after 6 weeks of third dose of pentavalent vaccine. Adverse events following immunization (AEFI) month were observed for a month after each dose of pentavalent vaccine. MAIN OUTCOME MEASURES: Anti HBs antibody titers after 6 weeks of primary immunization, and AEFI. RESULTS: 443 (83.5%) infants (225 low birthweight and 218 normal birthweight infants) completed the follow-up. Seroprotection against hepatitis B virus was achieved in both groups after pentavalent vaccine administration. Anti HBs GMTs in low birthweight infants (194.8 mIU/mL) and normal birthweight infants (204.2 mIU/mL) were comparable (P = 0.17). No serious adverse events were observed in either group. CONCLUSIONS: Three primary doses of pentavalent vaccine administered along with zero dose of Hepatitis B vaccine at birth provide good seroprotection. The vaccine appears to be safe in both low birth weight and normal birthweight infants born at term.

A pilot study on the effects of curd (dahi) & leaf protein concentrate in children with protein energy malnutrition (PEM).

BACKGROUND & OBJECTIVE: In protein-energy malnutrition (PEM) there is a significant impairment of immunity, both cell-mediated and humoral, which may be reversed with nutritional rehabilitation. With the use of probiotics like curd (dahi) and micronutrient-rich leaf protein concentrate (LPC), this immune recovery may be hastened. This study was conducted to assess the impact of supplementation of curd and LPC on nutritional status, and immunity as assessed by anthropometry, haemoglobin, ferritin levels, T- cell subpopulation and C-reactive protein (CRP), in children suffering from PEM. METHODS: Eighty moderate to severely malnourished children (1-5 yr) were randomized to receive either curd or LPC in addition to WHO recommended two-step diet over 15 days. Nutritional, immunological and haematological parameters were measured before and after supplementation and compared within the groups. RESULTS: The change in weight, haemoglobin level and CD4:CD8 T-cell subpopulation was significant in both the groups after supplementation. Response of CRP was blunted in PEM. Serum ferritin decreased significantly after supplementation in both groups. INTERPRETATION & CONCLUSION: Curd and LPC when added to diet of malnourished children, may have therapeutic value by accelerating immune recovery. More studies need to be done on a larger sample to confirm these findings.

Front loading sputum microscopy - an alternative approach for diagnosis of pulmonary tuberculosis.

INTRODUCTION: Until newer, rapid, economical tools are introduced for diagnosis of Pulmonary Tuberculosis in resource limited settings, optimization of sputum smear examination for increasing case detection remains of utmost priority. The aim of the study was to detect presumptive TB patients using Front Loading sputum microscopy and compare it with Standard method. METHODS: Three sputum specimens (Spot 1- on spot at the time of first visit, Spot 2- one hour after Spot 1 and early morning-next day early morning sample) from 552 TB suspect cases were collected. Zeihl Neelsen staining (spot 1, spot 2 and early morning respectively) and microscopy by Front Loading (spot 1, spot 2) and Standard method (spot 1, early morning) of sputum microscopy were done. RESULTS: Culture on LJ media being the gold standard, the sensitivity and specificity of the Front Loading and the Standard method of sputum microscopy were 68.65%, 94.43% and 70.14%, 93.6% respectively. The difference between two methods was not statistically significant. 91.1% patients gave preference for same day sampling process. CONCLUSION: The sensitivity and specificity of sputum microscopy using an early morning sample followed by another sputum one hour later from the same day appears not to be inferior to using two early morning samples on subsequent days. The Front Loading sputum microscopy can be implemented in DOTS clinic on the day of first visit of patients to health care center to increase compliance of patients with diagnostic procedure and decrease drop-outs.

Changing trends in antimicrobial susceptibility pattern of bacterial isolates in a burn unit.

INTRODUCTION: Emerging antimicrobial resistance in nosocomial bacterial isolates, limits the available treatment options for burn wound infections, among them multi-drug resistant Gram negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) are major contributors to the increase in morbidity and mortality rates. MATERIAL AND METHODS: A retrospective cross-sectional study was done in the Department of Microbiology, University College of Medical Sciences & Guru Teg Bahadur Hospital, Delhi. A total of 818 wound samples from patients admitted in the burn wards and Intensive Care Units (ICUs) examined between 2010-2014 (5 years period). Pseudomonas aeruginosa was found as the most common isolate (37%) followed by Klebsiella pneumoniae (15%) and Acinetobacter baumanii (12%) among Gram negative organisms while S. aureus (12%) remained the major isolates among Gram positive organisms. A significant decrease in incidence of Gram positive organisms was observed in comparison with previous study. However, resistance to ceftazidime and aminoglycosides were increased significantly in Gram negative organisms. Multi-drug resistant P. aeruginosa (MDR PA) accounted for 15.2%, multi-drug resistant A. baumanii (MDR AB) was prevalent in 13.8% and MRSA in 77.4% of burn wound infections. DISCUSSION AND CONCLUSION: Emerging bacterial drug resistance has both clinical and financial implications for the therapy of infected burn patients. Spectrum of bacterial drug resistance in an institution is important for epidemiological as well as clinical purposes. Rising frequency of MDR strains in burn patients is alarming for clinicians as it downgrades the treatment efficacy.

Clinical and serological characteristics of nail psoriasis in Indian patients: A cross-sectional study.

BACKGROUND: Nail involvement in psoriasis is common with a lifetime incidence of 80-90%. It may reflect severity of cutaneous involvement and predict joint disease. Yet it remains, poorly studied and evaluated especially in Indian psoriatic patients. AIM: The present study was undertaken to evaluate clinical and serological profile of nail involvement in psoriasis and to assess quality of life impairment associated with nail involvement in Indian patients. METHODS: Consecutive patients with nail psoriasis were assessed for severity of cutaneous disease (psoriasis area severity index score) and nail disease (nail psoriasis severity index score). The impairment in quality of life attributable to nail disease was scored with nail psoriasis quality of life 10 score. All patients were also assessed for joint disease and tested for inflammatory and serological markers as erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and anti-cyclic citrullinated peptide antibodies. RESULTS: In our cohort of 38 patients with nail psoriasis, 9 had concomitant psoriatic arthritis. The mean psoriasis area severity index was 14.4 ± 9.6 (range = 0.4-34). The most commonly recorded psoriatic nail changes were pitting (97.4%), onycholysis (94.7%) and subungual hyperkeratosis (89.5%). The mean nail psoriasis severity index score was 83.2 ± 40.1 (range = 5-156) and mean nail psoriasis quality of life 10 was 1.1 ± 0.4. Erythrocyte sedimentation rate and C-reactive protein were raised in 22/38 (57.9%) and 15/38 (39.5%) patients, respectively; rheumatoid factor was positive in 5/38 (13.2%) and anti-cyclic citrullinated peptide antibody was raised in 4/38 (10.5%) patients. LIMITATIONS: Small sample size and lack of a control group. CONCLUSIONS: In Indian patients with nail psoriasis, severity of nail involvement was found to be poorly correlated with the extent of cutaneous disease. In addition the impact of nail disease on patient's quality of life was found to be minimal. This suggests the need for a quality of life questionnaire suited to the Indian population. Serological markers were raised overall in the study patients and more so in the patients with concomitant arthritis.

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.

Safety and immunogenicity of Bio Pox™, a live varicella vaccine (Oka strain) in Indian children: A comparative multicentric, randomized phase II/III clinical trial.

Varicella or chickenpox is a highly contagious disease with a high secondary attack rate. Almost 30% of Indian adolescents lack protective antibodies against varicella, emphasizing the need of routine varicella immunization. The Oka VZV is a well-established, safe and efficacious vaccine strain that is highly immunogenic and produces lifelong protective immunity. The present multicentric, open label, randomized, controlled Phase II/III study, compared the Bio Pox™ (indigenous investigational vaccine) with a licensed vaccine, Varivax™ [a][a] Please note that this article refers to the product named VARIVAX as manufactured by Changchun Keygen Biological Products Ltd., China and marketed in India by VHB Life Sciences Limited, Mumbai, and not the product VARIVAX® owned by Merck Sharp & Dohme Corp., Rahway, New Jersey, USA. Merck Sharp & Dohme Corp. have asked us to make clear that the product manufactured by Changchun Keygen Biological Products Ltd. is unrelated to and is not sponsored, endorsed or otherwise authorised by Merck Sharp & Dohme Corp. , for its safety and immunogenicity profile in 252 healthy subjects in the age group of 1-12 y (cohort I: 6-12 years, II:1-6 years) in 3 tertiary medical institutions. Antibodies were measured by VZV Glycoprotein Enzyme Linked Immunoassay (IgG ELISA) kit. Seroconversion percentage in children having pre-vaccination anti VZV IgG titer <10 mIU/mL (< 5 gp ELISA units/mL) were 80% for Bio Pox™ and 77% for Varivax™ (p = 0.692). The seroconversion rate in the group receiving Bio Pox™ was non-inferior to the group that received Varivax™. There were mild local reactions for both the vaccines; none of the patient had fever or required hospitalization or medication. The Bio Pox™ was found to be safe and immunogenic in children against VZV infection.

Disseminated tuberculosis in a newborn infant.

Tuberculosis (TB) remaining as one of the deadliest communicable diseases. Congenital infection by vertical transmission is rare but high neonatal mortality (up to 60%) and morbidity warrant early and accurate diagnosis of newborns suffering from TB. Intrauterine infection of tuberculosis is most commonly caused by haematogenous spread from the mother causing placental seedling. The organisms reach the fetus via the umbilical vein and the primary focus is often in the fetal liver in hematgenous spread. Another route of infection is by direct ingestion or aspiration of infected amniotic fluid if the placental caseous lesion ruptures directly into the amniotic cavity. Transplacental infection occurs late in pregnancy and aspiration from amniotic fluid occurs in the perinatal period. We report here one case of disseminated tuberculosis in a new born infant.