Peripheral lymphocyte subset alteration in patients with COVID-19 having differential clinical manifestations

Background & objectives: The COVID-19 disease profile in Indian patients has been found to be different from the Western world. Changes in lymphocyte compartment have been correlated with disease course, illness severity and clinical outcome. This study was aimed to assess the peripheral lymphocyte phenotype and subset distribution in patients with COVID-19 disease from India with differential clinical manifestations. Methods: Percentages of peripheral lymphocyte subsets were measured by flow cytometry in hospitalized asymptomatic (n=53), mild symptomatic (n=36), moderate and severe (n=30) patients with SARS-CoV-2 infection, recovered individuals (n=40) and uninfected controls (n=56) from Pune, Maharashtra, India. Results: Percentages of CD4+Th cells were significantly high in asymptomatic, mild symptomatic, moderate and severe patients and recovered individuals compared to controls. Percentages of Th memory (CD3+CD4+CD45RO+), Tc memory (CD3+CD8+CD45RO+) and B memory (CD19+CD27+) cells were significantly higher in the recovered group compared to both asymptomatic, mild symptomatic patient and uninfected control groups. NK cell (CD56+CD3-) percentages were comparable among moderate +severe patient and uninfected control groups. Interpretation & conclusions: The observed lower CD4+Th cells in moderate+severe group requiring oxygen support compared to asymptomatic+mild symptomatic group not requiring oxygen support could be indicative of poor prognosis. Higher Th memory, Tc memory and B memory cells in the recovered group compared to mild symptomatic patient groups might be markers of recovery from mild infection; however, it remains to be established if the persistence of any of these cells could be considered as a correlate of protection.

A rare case of disseminated penicilliosis - first of its kind from North India

Penicilliosis is a rare opportunistic fungal infection caused by Talaromyces marneffei, especially in the HIV-infected patients. The untreated disease is highly fatal. The infection is endemic in Southeast Asia and Northeast India. The present case is the first case of disseminated penicilliosis from North India and Delhi in a 31-year-old male, recently diagnosed with HIV. This case highlights the importance of considering an unusual organism as the cause of disseminated disease in the nonendemic area.

Fermentation, isolation, purification and characterization of an antitubercular antibiotic from Streptomyces luridus MTCC 4402.

Tuberculosis, caused by Mycobacterium tuberculosis, continues to be a serious public health problem around the world, and it urges the need for development of new antitubercular drugs. An antibiotic producing strain, Streptomyces luridus (MTCC 4402) was earlier isolated from soil by our group. In this work, the phylogenic status was established by 16S rRNA gene sequence analysis. The strain was found to be active against clinically resistant strains. The culture was grown in shake flasks in a medium containing cornsteep liquor, glucose, CaCO3, soyabean meal and starch. Antibiotic production reached maximum at the end of 72 h. and fermentation profile was obtained. The active compound was extracted into ethyl acetate and was subjected to activity guided purification by column chromatography using silica gel, TLC and HPLC methods. The pure compound eluted at 16.7 min. by gradient elution was subjected to 1H, 13C NMR and mass spectral analyses. The acquired data was compared with that of natural products’ data base and found to be a known antibiotic, spiramycin. The purified compound was studied for mutagenic, cytotoxicity, antitubercular activities. It was non mutagenic at the concentration of 1000 mg/mL, non cytotoxic and active as antitubercular agent at a concentration of 64 mg/mL and was comparable to rifampicin.

Tinea corporis due to Trichophyton violaceum: A report of two cases.

Dermatophytes are Fungi which infect keratinized tissues, that is, skin epidermis, hair and nails. Trichophyton violaceum is an anthropophilic, cosmopolitan dermatophyte. It primarily causes tinea capitis and less commonly tinea corporis and tinea unguium. We present a report of two cases of tinea corporis due to T. violaceum in children. Infections due to T. violaceum are important because of its transmissibility within families and community and its potential to spread and establish in new geographical areas.

Envelope specific T cell responses & cytokine profiles in chikungunya patients hospitalized with different clinical presentations.

Background & objectives: Since the 2006 massive outbreaks, chikungunya (CHIK) is a major public health concern in India. The aim of this study was to assess envelope specific immune responses in patients with chikungunya infection. Methods: This study included 46 hospitalized patients with chikungunya virus infection (encephalitis, n=22, other systemic involvement, OSI, n=12, classical, n=12) and six controls from Ahmedabad city, Gujarat, India. T cell responses and the levels of Th1, pro/ anti-inflammatory cytokines against the CHIK virus envelope antigens were assessed by lymphocyte proliferation assay and by cytometric bead array in flow cytometry, respectively. Results: Lymphoproliferative response was uniform among the patients. Comparisons of cytokines revealed significantly higher levels of interleukin (IL)-4 and IL-5 in encephalitis, OSI and classical patients versus controls. The levels of tumour necrosis factor (TNF)-α were higher in classical patients categories compared to the controls. Interferon (IFN)-γ levels were lower in encephalitis patients versus control. Interpretation & conclusions: Our findings showed recognition of T cell epitopes on the envelope region of chikungunya virus by all patient categories. Lower level of IFN-γ may be associated with the severity of disease in these patients.

Fever of Unknown Origin (FUO) in HIV Infection in the Era of Antiretroviral Treatment (ART) in India: Development of a Simple Diagnostic Algorithm.

Objective: Fever of unknown origin (FUO) is a challenging problem among people living with HIV (PLHIV). With increasing access to Anti-retroviral treatment (ART), the spectrum of causes of FUO has evolved in the developed world. This study evaluated the etiology of FUO among PLHIV in the era of ART in India. Methodology: This prospective study was conducted at a tertiary-care institution in New Delhi, India. Sixty four PLHIV with a diagnosis of FUO were assessed by detailed clinical evaluation and immunological assessment. Specific investigations to identify the etiology of fever: microbiological and radiological investigations, bone marrow and histopathological examination of biopsies were performed. A simple diagnostic algorithm for FUO was developed based on the findings. Results: Sixty five episodes of FUO were studied. Seventy percent of subjects were men, 76% were <40 years of age, and 39% were receiving ART. The mean CD4 count was 156.57±178.43 cells/mm3 (5 to 1144 cells /mm3) and 23% patients had CD4 counts <50 cells/mm3. The mean duration of fever was 11.26±8.54 weeks. Infections were the most common cause for FUO, with Tuberculosis the most common (61.54%), particularly disseminated tuberculosis (41.54%). Cryptococcal meningitis (7.69%), bacterial pneumonia (4.62%), pyogenic abscesses (4.62%), Pneumocystis jirovecii pneumonia (PCP) (3.08%), visceral leishmaniasis (3.08%) were other infections observed. Non-infectious etiologies including lymphoma (4.62%) and progressive multifocal leucoencephalopathy (PMLE) (3.08%) were also seen. The etiology remained undiagnosed in 6.15% episodes. Importantly, two or more concurrent etiologies of fever were seen in 60% of patients. Conclusion: Infections especially Tuberculosis remain the most common cause of FUO in PLHIV even in the era of ART in developing countries like India. Multiple concurrent infections and a rising trend to non-infectious causes are being observed. A simple diagnostic algorithm will help diagnose majority of FUO even at the peripheral centers.

Detoxification of Abrus precatorius L seeds by Ayurvedic Shodhana process and anti‑inflammatory potential of the detoxified extract.

Background: Abrus precatorius seeds traditionally used for the treatment of sciatica and alopecia contains the toxic protein, abrin, a Type II Ribosome Inactivating Protein. Ayurveda recommends the use of Abrus seeds after the Shodhana process (detoxification). Objective: The current study was aimed at performing the Shodhana process, swedana (boiling) of Abrus precatorius seeds using water as a medium and to evaluate the anti‑inflammatory potential of seed extract post detoxification. Materials and Methods: Non‑detoxified and detoxified extracts were prepared and subsequently subjected to various in vitro and in vivo assays. In hemagglutination assay, the non‑detoxified extract shows higher agglutination of RBCs than detoxified extract indicating riddance of toxic hemagglutinating proteins by Shodhana. This was confirmed by the SDSPAGE analysis of detoxified extract revealing the absence of abrin band in detoxified extract when compared to non‑detoxified extract. Results: The cytotoxicity assay in HeLa cell line expresses a higher reduction in growth percentage of the cells with non‑detoxified extract as compared to detoxified extract indicating successful detoxification. Brine shrimp lethality test indicated the reduction in toxicity index of detoxified extract as compared to non‑detoxified extract. Further, the whole body apoptosis assay in zebrafish revealed that percentage of viable cells were greater for detoxified extract than non‑detoxified extract. The anti‑inflammatory studies using carrageenan induced paw edema model in rats was carried out on the extracts with doses of 100 mg/kg and 200 mg/kg, per oral, where the detoxified extract exhibited significant inhibition of rat paw edema at both the doses comparable to that of Diclofenac sodium. Conclusion: Absence of toxicity and the retention of the anti‑inflammatory activity of detoxified Abrus seed extract confirmed that the Swedana process is effective in carrying out the detoxification without affecting its therapeutic potential.

Cardiac Abnormalities in HIV Infected Children Presenting to a Tertiary Level Teaching Hospital at New Delhi.

Aims: The aim of our study was to study the prevalence of various cardiac abnormalities in HIV positive children. Study Design: Cross sectional observational study. Place of Study: Antiretroviral treatment clinic of Maulana Azad Medical College and associated Lok Nayak Hospital and Department of Cardiology at G.B.Pant Hospital ,New Delhi . Duration of study : March 2009 to Mar 2010. Methodology: Sixty perinatally acquired, HIV-positive children asymptomatic for cardiac disease in age group of 0-12 years were evaluated for cardiac abnormalities by echocardiography. All children were classified according to the WHO clinical staging for HIV-positive children and also divided into immunologic category as per the age-specific CD4-T lymphocyte count. Results: Sixteen (26.6%) children had evidence of cardiac abnormalities on echocardiography. Twelve (20%) patients in WHO stage III and IV had significant abnormal echocardiographic findings. The major echocardiographic findings seen were left ventricular dilatation in 4 (6.7%) and left ventricular diastolic dysfunction in 3 (5%) children. Conclusions: A baseline echocardiographic study should be done in all patients with symptomatic HIV infection at first contact. Serial echocardiographies should be done to determine the evolution of cardiac disease in HIV infected children. Echocardiographic abnormalities are present even in HIV- infected children who are asymptomatic for cardiac dysfunction.

Rapid validated HPTLC method for estimation of piperine and piperlongumine in root of Piper longum extract and its commercial formulation

Piperine and piperlongumine, alkaloids having diverse biological activities, commonly occur in roots of Piper longum L., Piperaceae, which have high commercial, economical and medicinal value. In present study, rapid, validated HPTLC method has been established for the determination of piperine and piperlongumine in methanolic root extract and its commercial formulation 'Mahasudarshan churna®' using ICH guidelines. The use of Accelerated Solvent Extraction (ASE) as an alternative to conventional techniques has been explored. The methanol extracts of root, its formulation and both standard solutions were applied on silica gel F254 HPTLC plates. The plates were developed in Twin chamber using mobile phase toluene: ethyl acetate (6:4, v/v) and scanned at 342 and 325 nm (λmax of piperine and piperlongumine, respectively) using Camag TLC scanner 3 with CATS 4 software. A linear relationship was obtained between response (peak area) and amount of piperine and piperlongumine in the range of 20-100 and 30-150 ng/spot, respectively; the correlation coefficient was 0.9957 and 0.9941 respectively. Sharp, symmetrical and well resolved peaks of piperine and piperlongumine spots resolved at Rf 0.51 and 0.74, respectively from other components of the sample extracts. The HPTLC method showed good linearity, recovery and high precision of both markers. Extraction of plant using ASE and rapid HPTLC method provides a new and powerful approach to estimate piperine and piperlongumine as phytomarkers in the extract as well as its commercial formulations for routine quality control.

Fungal infections as a contributing cause of death: An autopsy study.

Context: With the continuing rise in the number of immunocompromised patients, the incidence of invasive mycoses has increased. Various studies have reported the trends of fungal infections in autopsies. Because of limitations in antemortem clinical diagnosis owing to lack of sensitive diagnostic tools, information regarding frequency and pathogenesis of fungal infections is largely dependent on autopsy studies. Aim: To study the prevalence of fungal infections at autopsy spanning a period of 20 years and to document recent trends, prevalence of various fungi over decades along with underlying predisposing factors and pathological findings. Settings and Design: Retrospective study. Materials and Methods:All autopsies between 1988 and 2007 were reviewed and all cases showing fungal infections were analyzed. The clinical details and demographic data were retrieved from medical records. Representative sections from all organs were stained with hematoxylin and eosin stain and special stains including Gomori's silver methenamine (GMS) and per-iodic acid Schiff (PAS). Culture details were noted, wherever available. Results: A total of 401 autopsies were performed during the study period. Fungal infections were identified in 35 (8.7%) of these cases. Leukemia was the commonest risk factor. The commonest pathogen in the present study was Aspergillus sp. The commonest single organ involved was brain (n = 18). Culture positivity was seen in 23.8% cases. Conclusion: The study highlights various predisposing factors and organisms in autopsy series. Existing diagnostic modalities are not sensitive to ensure antemortem diagnosis of fungal infections.

Morphologic evaluation of renal function using semi-quantitative method in primary nonproliferative glomerular diseases.

Context: Fibrosis is universally accepted as a poor prognostic finding in renal pathology. Semi-quantitative assessment is widely used for prognostication in pathology. Aims: We propose a semi-quantitative method to prognosticate primary nonproliferative glomerular diseases. Settings and Design: A semi-quantitative method based on Banff schema, 97 classification has been modified to suit the requirements. Glomerular, tubulointerstitial, and vascular compartments were scored independently, and the scores were totaled to obtain total scores. Materials and Methods: Seventy-six renal biopsies were assessed by semi-quantitative scores and the individual compartmental and total scores were correlated with serum creatinine levels. Follow-up was available in 24 cases. Statistical Analysis: Pearson correlation coefficient, two-tailed t test, to determine the P value. Results: P values were significant for the total scores as well as individual compartments. There is a linear correlation between the scores and serum creatinine levels. A total score of ≥5 was significant. Conclusions: The semi-quantitative scoring system based on modified Banff schema, 1997 is useful in prognosticating renal biopsies in primary nonproliferative glomerular diseases.

Association of hypoadiponectinemia with non-alcoholic fatty liver disease in urban south Indians - (CURES - 81).

Background & objective: Association between adiponectin and non-alcoholic fatty liver disease (NAFLD) has been reported in west. Studies in Indian population are lacking. This study was undertaken to assess the association of hypoadiponectinemia with NAFLD in Asian Indians. Method: In this cross-sectional study, subjects were randomly selected from Phase 5 of the Chennai Urban Rural Epidemiology Study (CURES), an epidemiological study based on a representative population of Chennai in south India. One hundred twenty one subjects without NAFLD and 72 subjects with NAFLD were selected. NAFLD was diagnosed by ultrasonography. Serum adiponectin levels were measured using radioimmunoassay. Insulin resistance was calculated using Homeostasis Assessment model (HOMA-IR). Results: Serum adiponectin values were significantly lower in subjects with NAFLD compared to those without [5.6 μg/ml (95% Confidence Interval (CI) 5.0 - 6.3 μg/ml] vs 7.4 μg/ml (95% CI: 6.7 - 8.1 μg/ml, P<0.01). Adiponectin levels decreased with increasing severity of NAFLD. Subjects with moderate to severe steatosis had significantly lower adiponectin levels (5.1μg/ml, 95% CI: 4.1- 6.4 μg/ml) compared to subjects with mild steatosis (5.9 μg/ml, 95% CI: 5.0 - 6.9 μg/ml; P<0.001) and subjects without NAFLD (7.3 μg/ml, 95% CI: 6.6 - 8.0 μg/ml; P<0.01). Multiple logistic regression analysis revealed adiponectin to be negatively associated with NAFLD [Odds Ratio (OR): 0.865, 95% Confidence Interval (CI): 0.792- 0.944, P=0.001]. This remained statistically significant even after adjusting for confounding factors age, gender, body mass index, insulin resistance, waist circumference, total cholesterol, triglycerides and glucose intolerance (OR: 0.873, 95% CI: 0.793 - 0.961; P=0.005). Interpretation & conclusion: NAFLD is associated with lower serum adiponectin levels independent of conventional cardiovascular risk factors in Asian Indians known to have high prevalence of diabetes and coronary artery disease.

Narrow band imaging cholangioscopy in hilar cholangiocarcinoma.

Per oral cholangioscopy has been developed as a diagnostic modality for evaluation of bile duct lesions. Per oral cholangioscope with narrow band imaging (NBI) system can provide good quality images of bile duct lesions. There is limited data on per oral cholangioscopy using NBI in biliary tract diseases. We report our experience of NBI cholangioscopy in hilar strictures.

Diarrheagenic E. coli in hospitalized patients: Special reference to Shiga-like toxin producing Escherichia coli.

Purpose: This study was conducted to study the prevalence of diarrheagenic Escherichia coli (DEC) in dysentery cases with special reference to Shiga-like toxin producing Escherichia coli (STEC). Methods : During a two-year period, 1066 stool samples were collected from hospitalized patients with diarrhea and dysentery. After taking detailed clinical history and observing the gross and microscopic findings of the stool samples, they were cultured on MacConkey and Sorbitol MacConkey agars and E.coli isolates were identified by standard biochemical tests. Results: Of the 100 E.coli strains isolated in pure culture and sent for sero typing to Central Research Institute (CRI), Kasauli, 43% were found to be DEC, giving an isolation rate of 4.03%. Results of sero typing showed 37.21% STEC which were more common in children. Abdominal pain and stool with mucus flakes were statistically significant parameters (p less than 0.01) in patients with dysentery due to E.coli strains. Though E.coli O157 was not encountered, it was seen that 25% of STEC did not ferment sorbitol. The DEC strains showed maximum in vitro sensitivity to amikacin (83.72%) and all strains were resistant to nalidixic acid. Antibiotics along with ORS and intravenous fluids had to be given in 68.42% patients. As complications, about 16.67% of children developed hemolytic uremic syndrome (HUS),and 10.53% of patients developed acute renal failure. No mortality was reported. Conclusion: Though Enterohemorrhagic E.coli (EHEC) O157:H7 was not encountered in this study, STEC caused by E.coli non O157 was reported. STEC is also known to cause hemorrhagic colitis (HC) and HUS. In this study HUS was reported in 16.67% children. Therefore, proper isolation and identification of STEC is essential in a tertiary care centre, to initiate prompt management and reduce morbidity and mortality in children.

Association of HLA alleles with hepatitis C infection in Maharashtra, western India.

Background & objectives: Host genetic diversity is believed to contribute to the spectrum of clinical outcomes in hepatitis C virus (HCV) infection. The present study aimed at finding out the frequencies of HLA class I and class II alleles of HCV infected individuals from western India. Methods: Forty three clinically characterized anti-HCV positive patients from Maharashtra were studied for HLA A, B, C, DRB1 and DQB1 alleles by PCR- sequence specific primer (SSP) typing method and compared with 67 and 113 ethnically matched, anti-HCV negative healthy controls from western India. Results: Our analysis revealed an association of HLA alleles HLA A*03 (OR= 16.69, EF, 0.44, P=7.9E-12), A*32 (OR= 1474, EF 0.21, P=1.8E-9), HLA B*15 (OR=14.11, EF 0.39, P=2.18E-10), B*55 (OR= 12.09, EF 0.07, P=0.005), Cw*16 (OR= 7.45, EF 0.12, P=0.001), Cw*18 (OR= 402, EF 0.05, P=0.003), DRB1*03 (OR= 4.01, EF 0.08, P=0.01) and DQB1*03 (OR= 3.02, EF 0.22, P=0.001), with HCV infection. HLA II locus haplotype DRB1*11-DQB1*03 (HF=17.64, OR=5.16, P=0.0001) was significantly increased among HCV infected individuals. Interpretation & conclusions: Our data suggest that among the western Indian population, certain HLA alleles or associated haplotype influence HCV infection as a host genetic factor.

Cystic ductal adenocarcinoma of pancreas: an unusual variant.

Cystic lesions of the pancreas are usually pseudocysts (90%); only 10% of them are cystic tumors. These cystic tumors constitute less than 10% of all pancreatic neoplasms, making them an extremely uncommon type of pancreatic malignancy. What is more important is that these tumors are very easily misdiagnosed as pseudocysts because their characteristics are very similar to those of the benign pseudocysts. This gains importance as the cystic tumors have a high cure rate and good prognosis if diagnosed and treated on time. Of all the cystic tumors, the most common are the benign serous cystadenomas, mucinous cystic tumors, intraductal papillary mucinous neoplasms etc. Ductal adenocarcinoma of pancreas presenting in cystic form is an uncommon type of cystic tumor, making it extremely rare among all pancreatic malignancies (solid or cystic). We present the following case report. The review of literature concerning the diagnosis and management has also been discussed.

Capsule endoscopy in obscure gastrointestinal bleeding--an Indian experience.

BACKGROUND: Obscure gastrointestinal bleeding (OGIB) is a common indication for capsule endoscopy (CE). Reports on diagnostic yield of CE in this situation show a wide variation. We evaluated the diagnostic yield and clinical impact of CE in patients with OGIB. METHODS: We reviewed the medical records of patients with OGIB who underwent CE at our institution between June 2002 and October 2005. RESULTS: 154 patients (mean age 47 [SD 17] years; 117 men), including 74 with overt OGIB and 80 with occult OGIB, underwent CE. CE yielded positive findings in 57 of 74 patients (77%) with overt OGIB and 22 of 80 (27%) of those with occult OGIB (p < 0.0001); the overall positive diagnostic yield was 52%. NSAID-induced lesions (15%), angiodysplasias (14%) and aphthous ulcers (12%) were the most frequent findings. CE helped in planning further management in 79% of patients with overt OGIB and 26% of those with occult OGIB. CONCLUSION: CE is a useful diagnostic technique in patients with OGIB, especially those with overt OGIB.