Fluroquinolone drug resistance among MDR-TB patients increases the risk of unfavourable interim microbiological treatment outcome: An observational study.

OBJECTIVES: Sputum culture conversion at the end of the intensive phase of multidrug-resistant tuberculosis (MDR-TB) treatment is a key predictor for successful treatment outcome. This observational study was undertaken to assess the interim microbiological outcome of a cohort of rifampicin-resistant (RR)-TB patients with variable resistance to second-line drugs. METHODS: During Jan-Apr 2018, we consecutively enrolled 100 RR-TB patients, who underwent phenotypic drug susceptibility testing (DST) to assess baseline resistance to second-line drugs. Following RR-TB diagnosis, these patients were started on MDR-TB treatment. After 6 months of treatment, sputum culture conversion status was determined. Data were analysed to assess the impact of resistance to second-line drugs on culture conversion. RESULTS: DST of 100 RR-TB patients showed a high resistance to fluoroquinolones (FQs; levofloxacin 56%; moxifloxacin 44%) followed by kanamycin (8%) and capreomycin (6%). None of the patients were resistant to the other drugs tested (amikacin, clofazimine and linezolid). At 6-month treatment follow-up, 28 patients had been lost to follow-up and eight had died. Microbiological outcome was obtained from the remaining 64 patients, but successful culture conversion was achieved in only 62.5% of the patients. FQ resistance was found to be a strong predictor (P<0.001) for unfavourable microbiological outcome. CONCLUSION: The rate of FQ resistance in RR/MDR-TB is high and has strong association with unsuccessful interim microbiological outcome of conventional MDR-TB treatment.

Second Line Injectable Drug Resistance and Associated Genetic Mutations in Newly Diagnosed Cases of Multidrug-Resistant Tuberculosis.

Aim: To investigate the phenotypic and genotypic profile of multidrug-resistant (MDR) Mycobacterium tuberculosis (MTB) clinical isolates with reference to second-line injectable drugs (SLIDs). Methods: A total of 110 MTB isolates, recovered consecutively from confirmed MDR-TB patients between March and June 2016, were included in this study. Phenotypic drug susceptibility testing against SLIDs (Kanamycin, Amikacin, and Capreomycin) and Ofloxacin (OFX) was performed using the MGIT 960 system. For genotypic analysis, SLID/(s) resistant (n = 13) and susceptible isolates (n = 26) were subjected to PCR and DNA sequencing for rrs, eis (promoter region), and tlyA loci of MTB. Furthermore, the identified genetic mutations were analyzed with respect to its significance in detecting phenotypic resistance. Result: Among the 110 analyzed isolates, phenotypic resistance to OFX, SLIDs, and to both was 59.1%, 11.8%, and 10.0%, respectively. Out of a total 13 SLID/(s) resistant isolates, 10 had mutations (including two novel mutations) in one or more of the targeted genes. Only one SLID susceptible MTB isolate showed mutation in the targeted region. In SLID resistant isolates, most frequent mutation detected was C-12T under eis promoter region (46.1%). Conclusion: Mutations in rrs, eis, and tly A loci together are important in predicting SLID resistance in MTB isolates. Future molecular epidemiology studies are needed to have more insight into frequency and clinical relevance of novel mutations identified in this study.

Herbal Nephropathy.

This column is supplied by Amita Jain, MD, and Juan Jose Olivero, MD. Dr. Jain completed an internal medicine residency at Houston Methodist Hospital in Houston, Texas, and recently joined a primary care practice in Delaware. She earned a Bachelor of Medicine and Surgery (MBBS) degree, with a distinction in microbiology, from Terna Medical College at the Maharashtra University of Health Sciences in Navi Mumbai, India. Before coming to Houston, Dr. Jain completed residency training in internal medicine and allied subspecialties at the Dr. Babasaheb Ambedkar Memorial Hospital in Byculla, Mumbai. Dr. Olivero is a nephrologist at Houston Methodist Hospital and a member of the hospital's Nephrology Training Program. He obtained his medical degree from the University of San Carlos School of Medicine in Guatemala, Central America, and completed his residency and nephrology fellowship at Baylor College of Medicine in Houston, Texas.

Novel mutations conferring resistance to kanamycin in Mycobacterium tuberculosis clinical isolates from Northern India.

Twenty-nine Kanamycin resistant clinical isolates of Mycobacterium tuberculosis from Northern India were screened to evaluate genetic mutations in rrs gene, eis gene with its promoter, and whiB7 gene along with its 5'UTR. 14 strains (~48.0%) collectively exhibited mutations in rrs, eis or whiB7 target regions. While the highest frequency of mutations was found in rrs gene, eis and whiB7 loci displayed novel mutations. The novel mutations displayed by eis and whiB7 loci were found to be associated specifically with the Kanamycin resistance as none of the twenty nine Kanamycin sensitive strains harbor them. The inclusion of novel mutations of eis and whiB7 loci will be useful in improving the specificity of future diagnostics.

Human parvovirus B19 associated dilated cardiomyopathy.

We describe two children presenting with acute left ventricular dysfunction. Both cases had evidence of dilated cardiomyopathy, requiring inotropic support and were tested for cardiotropic viruses by conventional or real-time polymerase chain reaction using specific primers for enteroviruses, human parvovirus B19, Adenoviruses, Epstein-Barr virus (EBV), herpes simplex viruses 1 and 2 (HSV), human herpes virus-6 (HHV-6) and cytomegalovirus (CMV). IgG and IgM antibodies against parvovirus B19, EBV, HSV and CMV were also tested by ELISA. One case tested positive for parvovirus B19 infection and recovered completely within 6 months in absence of any specific therapy. The other case tested positive for parvovirus B19 infection in association with hypocalcaemia and was cured following standard heart failure therapy along with calcium and vitamin D supplementation. Sequence analysis of DNA products from both patients revealed genotype 3. To best of our knowledge this is first report of circulating genotype 3 from India.

Effect of green tea extract (catechins) in reducing oxidative stress seen in patients of pulmonary tuberculosis on DOTS Cat I regimen.

BACKGROUND AND AIM: The role played by free radicals in pathogenesis of pulmonary tuberculosis and treatment mediated toxicity is well established. Hence, the present study was undertaken to assess the effect of crude green tea catechin in reducing the oxidative stress seen in patients of AFB positive pulmonary tuberculosis. METHODS: A total of 200 newly diagnosed cases of AFB positive pulmonary tuberculosis, who received CAT I regimen were enrolled consecutively from DOTS center. Out of 200 patients, 100 randomly selected patients received catechin (500 microg) with antitubercular treatment (ATT) (cases) and 100 received starch (500 microg) with ATT (control). Oxidative stress level in blood samples of cases and controls as compared at the time of enrollment and after one and four months of treatment. Oxidative stress was measured in terms of free radicals (lipid peroxidation, nitric oxide), enzymatic antioxidant (catalase, superoxide dismutase, glutathione peroxidase) and non enzymatic antioxidant (total thiol, reduced glutathione) levels. RESULTS: The results showed significant difference in all the parameters among cases and controls. A significant decrease (p< or = 0.001) in LPO level was observed in cases as compare to controls during the follow up while the level of NO was significantly increased (p< or =0.001) in cases as compare to controls. Significant decrease (p< or =0.001) in catalase and GPx level was observed in cases as compare to controls while SOD levels significantly rose (p< or =0.001) in cases as compared to controls. Significant decrease (p< or =0.001) in SH level was observed in cases as compared to controls while the level of GSH was significantly increased (p< or =0.001) . CONCLUSION: These findings suggest that crude catechin extract can play a definite role as adjuvant therapy in management of oxidative stress seen in pulmonary tuberculosis patients. More detailed studies are needed to document use of catechin in reducing the frequency and severity of side effects of treatment.

Protective activity of picroliv on hepatic amoebiasis associated with carbon tetrachloride toxicity.

BACKGROUND AND OBJECTIVE: Picroliv, isolated from the root and rhizome of Picrorhiza kurroa, is known to have significant hepatoprotective activity. Its effects against Entamoeba histolytica induced liver damage are not studied. This study aims to evaluate the hepatoprotective action of picroliv against the hepatotoxic changes induced by carbon tetrachloride (CCl(4)) and E. histolytica infection in three animal models. METHODS: Mastomys, gerbils and albino Druckray rats were used in this study. A total of 30 animals were used for each model and divided into five groups of six animals each. Group I consisted of normal animals. The rest received six doses of CCl(4) intraperitoneally. Group II served as hepatotoxic control. The remaining animals were infected intraperitoneally with E. histolytica trophozoites, of which group III was the hepatotoxic plus amoeba infected control. The remaining animals were divided into two groups, one received hepatoprotective agent picroliv and the other silymarin. All animals were sacrificed seven days post amoeba infection. RESULTS: Increase in the enzyme levels induced by CCl(4) was further elevated after E. histolytica infection. Pinpoint abscesses were found to develop only in gerbils after E. histolytica infection. Picroliv was found to possess hepatoprotective activity against amoebic liver abscess. INTERPRETATION AND CONCLUSION: Significant recovery obtained in serum enzyme levels in all animal models and against amoebic liver abscess in gerbils on treatment with picroliv indicated that picroliv possesses therapeutic activity against E. histolytica induced hepatic damage.

Protective effect of green tea extract against the erythrocytic oxidative stress injury during mycobacterium tuberculosis infection in mice.

The present study has been undertaken to monitor the extent of oxidative stress in mice infected with M tuberculosis and the role of crude green tea extract in repairing the oxidative damage. The mice were divided into three groups of 9 each; normal, infected-untreated and infected-treated. The infected group of animals exhibited significant enhancement of erythrocytic catalase and glutathione peroxidase activities along with elevated levels of erythrocytic total thiols and plasma lipid peroxidation as compared to normal animals. The infected group also exhibited significantly decreased activity of superoxide dismutase and levels of glutathione in erythrocytes. Upon oral administration of green tea extract for seven days the oxidative stress parameters were reverted back to near normal levels as evidenced by a fall in catalase, glutathione peroxidase, total thiol and extent of lipid peroxidation with concomitant increase in the levels of SOD and reduced glutathione in infected animals. The findings thus, portray that there is a high oxidative stress during early stages of tuberculosis and antioxidants such as green tea extract, can play a vital role by reducing stress through adjuvant therapy.