Diagnostic Accuracy of a Limited Immuno-panel of Calretinin and Ber-EP4 for Diagnosis of Malignant Effusions.

OBJECTIVE: To differentiate between adenocarcinoma cells and reactive mesothelial cells (RMC) in serous effusions using a limited immuno-panel of Ber-EP4 and Calretinin. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Pathology, Allama Iqbal Medical College, Lahore, in collaboration with the Departments of Surgery, Pulmonology and Oncology, Jinnah Hospital, Lahore, from March 2015 to March 2016. METHODOLOGY: Ninety-seven clinically and radiologically proven cases of peritoneal and pleural effusion and peritoneal wash of patients with suspicion of malignancy were included in the present study. Diagnostic accuracy of a limited immuno-panel of Calretinin and Ber-EP4 for diagnosis of malignant effusions was calculated using histopathology as gold standard. RESULTS: The sensitivity of Ber-EP4 for malignant cases was 98.6%, specificity 100%, positive predictive value (PPV) 100%, negative predictive value (NPV) 96%, and diagnostic accuracy 98.9%. Sensitivity of Calretinin as positive staining for RMC was 79.2%, specificity and positive predictive value (PPV) 100%, negative predictive value (NPV) 93.6%, and diagnostic accuracy 94.8%. CONCLUSION: Limited immuno-panel of Calretinin and Ber-EP4 had a high positive and negative predictive value and is cost-effective in resource limited set-up for identification of adenocarcinoma cells and reactive mesothelial cells in challenging cases of serous effusions.

Field evaluation of a blood based test for active tuberculosis in endemic settings.

Over 9 million new active tuberculosis (TB) cases emerge each year from an enormous pool of 2 billion individuals latently infected with Mycobacterium tuberculosis (M. tb.) worldwide. About 3 million new TB cases per year are unaccounted for, and 1.5 million die. TB, however, is generally curable if diagnosed correctly and in a timely manner. The current diagnostic methods for TB, including state-of-the-art molecular tests, have failed in delivering the capacity needed in endemic countries to curtail this ongoing pandemic. Efficient, cost effective and scalable diagnostic approaches are critically needed. We report a multiplex TB serology panel using microbead suspension array containing a combination of 11 M.tb. antigens that demonstrated overall sensitivity of 91% in serum/plasma samples from TB patients confirmed by culture. Group wise sensitivities for sputum smear positive and negative patients were 95%, and 88%, respectively. Specificity of the test was 96% in untreated COPD patients and 91% in general healthy population. The sensitivity of this test is superior to that of the frontline sputum smear test with a comparable specificity (30-70%, and 93-99%, respectively). The multiplex serology test can be performed with scalability from 1 to 360 patients per day, and is amenable to automation for higher (1000s per day) throughput, thus enabling a scalable clinical work flow model for TB endemic countries. Taken together, the above results suggest that well defined antibody profiles in blood, analyzed by an appropriate technology platform, offer a valuable approach to TB diagnostics in endemic countries.

Diagnosis of paediatric sepsis by automated blood culture system and conventional blood culture.

OBJECTIVE: To evaluate the time required for isolation of aerobic bacterial pathogen from paediatric septicaemia suspects by using BACTEC 9240 blood culture system, and to compare the results with conventional blood culture technique. METHODS: This comparative cross-sectional study was conducted at the Jinnah Hospital, Lahore, Pakistan, from July to December 2013, and comprised blood samples of suspected septicaemia children. The blood samples were inoculated into automated BACTEC 9240 Peds Plus/F resin-based media. At the same time, conventional blood culture bottle was also inoculated for comparison. The time of culture positivity and bacterial spectrum isolated from these samples was evaluated. SPSS 20 was used for data analysis. RESULTS: Of the 100 blood culture samples, 36(36%) were true pathogens on BACTEC 9240, while 24(24%) were positive through the conventional method. The mean age of the participants was 0.65±20 days. Staphylococcus aureus was detected in 12(12%) samples by BACTEC 9240 and in 7(7%) cases by conventional system. BACTEC 9240 significantly reduced time of positivity from 48 hours to 21 hours compared to conventional system. The number of samples detected within 36 and 48 hours was 7(19.4%) by BACTEC 9240 and 17(70.8%) by conventional system (p<0.05). CONCLUSIONS: Diagnosis of paediatric septicaemia through BACTEC 9240 was quicker with high yield and great sensitivity compared to the conventional technique.

Power doppler ultrasonography guided and random prostate biopsy in prostate cancer diagnosis - a comparative study.

OBJECTIVE: To compare the diagnostic accuracy of power Doppler-guided targeted prostate biopsy and random sextant biopsy in the diagnosis of prostate cancer. METHODS: The prospective study was carried out at the Allama Iqbal Medical College and Jinnah Hospital, Lahore, Pakistan, from January to December, 2012, and comprised clinically suspected cases of carcinoma prostate. Power Doppler-guided biopsies using automatic biopsy gun were obtained from the suspected targeted site. One to three cores per suspected site were obtained. Subsequently random sextant biopsies were performed in the same sitting. Six cores were obtained from 6 random sites using the same gun. Biopsies from both sources were processed for routine haematoxylin and eosin stainstained sections for histopathological examination. RESULTS: Of the 50 patients in the study, 30(60%) were diagnosed with power Doppler-guided biopsy as malignant, whereas random sextant biopsy could pick up 22(44%) cases. For benign prostatic hyperplasia, random sextant biopsy labelled 28(56%)as benign, whereas only 20 (40%) were labelled as benign with power Doppler-guided biopsy. Discrepancy in the results between the two procedures was observed in 14(28%) cases, and of them, 1 1(22%) were labelled as malignant on power Doppler-guided biopsy while histopathology of sextant biopsies labelled these as benign.The sextant biopsies rendered a specificity, sensitivity, negative predictive value, positive predictive value and diagnostic accuracy of 60.71%, 86.36%, 85%, 63.33% and 72% respectively. CONCLUSION: Random sextant biopsy in combination with power Doppler-guided targeted biopsy increases the rate of detection of prostate cancer whereas both procedures in isolation have low sensitivity and specificity for cancer detection.

Concomitant presence of culture-proven active pulmonary tuberculosis in patients with chronic obstructive pulmonary disease - A hospital based study.

OBJECTIVE: To find out the prevalence of concomitant active pulmonary Tuberculosis (TB) in patients of Chronic Obstructive Pulmonary Disease (COPD) using the gold standard liquid and solid culture media for the detection of acid fast bacillus. METHODS: Eighty clinically and radiologically diagnosed cases of COPD of any severity, ≥40 years of age with no previous history of anti-tuberculous therapy were selected from department of Pulmonology, Jinnah Hospital, Lahore. Detailed demographic profile, clinical symptomatology and history of smoking were recorded. Sputum samples of these patients were subjected to ZiehlNeelsen (ZN) stain and culture on Lowenstein-Jensen (L.J) medium and Mycobacterium Growth Indicator Tube (MGIT) for the detection and isolation of Mycobacteriumtuberculosis (MTB). RESULTS: Out of 80 COPD patients, 6 (7.5%) were culture positive for acid fast bacillus consistent with active tuberculous infection. The concomitance was more prevalent in elderly, male, smokers. MGIT was a more sensitive and a rapid technique to detect the presence of mycobacterium as compared to LJ culture media and ZN stain. CONCLUSION: The prevalence of active TB in COPD patients was 7.5%. Detection was improved when liquid culture media was employed for the detection of acid fast bacillus. Regular monitoring and screening of patients with COPD for PTB should be routinely carried out in susceptible cohort to avoid cross spreading of infection and appropriate management.

An outbreak of pyrimethamine toxicity in patients with ischaemic heart disease in Pakistan.

We investigated an outbreak of darkening of skin, bleeding from multiple sites, leucopenia and thrombocytopenia in ischaemic heart disease patients. Case patients were defined as patients who had received medicines from the pharmacy of Punjab Institute of Cardiology between 1 December 2011 and 12 January 2012 and who developed any one of the following: darkening of skin, bleeding from any site, thrombocytopenia and leucopenia. Clinical and drug-related data were abstracted. All 664 case patients had received iso-sorbide-mono-nitrate contaminated with about 50 mg of pyrimethamine, and 151 (23%) died. The median age of 117 patients admitted at Jinnah Hospital Lahore was 57 years (range, 37-100) and 92 (79%) were male. The median time from intake of medicine to presentation was 37 days (range 13-72). Symptoms and signs included bleeding (in 95% of the patients), skin hyperpigmentation (in 61%), diarrhoea (in 53%) and abdominal pain (in 48%). At presentation, the median white cell count was 2.3 × 10(9) /L (range, 0.1 × 10(9) -16.0 × 10(9) ), the median hemoglobin concentration was 109 g/L (range 58-169) and the median platelet count was 18 × 10(9) /L (range, 0 × 10(9) -318 × 10(9) ). Bone marrow examination revealed trileneage dysplasia and severe megaloblastosis. The predictors of mortality included presentation prior to 15 January 2012, age more than 57 years, hypotension and leukocyte count less than 1.5 × 10(9) /L. None of the patients who died received Calcium folinate because all deaths occurred prior to contaminant identification. We describe an outbreak of pyrimethamine toxicity in ischaemic heart disease patients receiving medicines from a single pharmacy due to accidental contamination of iso-sorbide mono-nitrate tablets at industrial level. Late recognition of illness resulted in high mortality.

Deaths due to dengue fever at a tertiary care hospital in Lahore, Pakistan.

OBJECTIVE: We conducted this study to review deaths due to dengue fever (DF) during a large outbreak of DF in Lahore, Pakistan. METHODS: We reviewed deaths due to DF at Jinnah Hospital Lahore between August and November 2011. Clinical and laboratory data were abstracted. The 2011 World Health Organization Regional Office for South-East Asia (WHO SEARO) guidelines were used to classify the disease. RESULTS: Out of 128,634 probable DF patients who visited the outpatient department, 2313 patients were hospitalized; 1699 (73.3%) were male. RT-PCR was positive in 92 of 114 hospitalized patients (DENV-2 in 91 patients and DENV-3 in 1 patient). Sixty dengue-related deaths were reported; 41 (68.3%) were male. The mean age (± standard deviation) was 44 (± 20.5) y. The diagnosis at the time of presentation was DF in 5 (8.3%), dengue haemorrhagic fever without shock in 16 (26.6%), dengue shock syndrome in 20 (33%), and expanded dengue syndrome in 19 (31.7%) patients. Expanded dengue syndrome included encephalopathy in 12 (20%) patients, intracerebral bleed in 3 (5%), multiorgan failure in 3 (5%), and Guillain-Barré syndrome in 1 (1.6%). Twenty-nine (48.3%) patients had at least 1 comorbidity. CONCLUSION: Dengue shock syndrome and expanded dengue syndrome were the most common causes of death.

Clinicopathological study of Papanicolaou (Pap) smears for diagnosing of cervical infections.

Cervical infections are not uncommon in our population especially in young and sexually active women. One thousand samples of married women, aged between 20 and 70 years, were studied by conventional Papanicolaou smears. These samples were examined in the Department of Pathology, King Edward Medical University, Lahore from January 2007 to June 2009. Only cases without (pre)neoplastic cytology were included. Six types of infections were diagnosed cytologically. The overall frequency of normal, inadequate, neoplastic, and infective smears was 50%, 1.8%, 10.2%, and 38.3%, respectively. Most of the patients (67%) were in the reproductive age group with mean age 34.7 ± 2.6 years. The commonest clinical sign seen in 354/383 (92%) cases and symptom in (349/383; 91%) cases were vaginal discharge and pruritis vulvae. Among the infective smears, 290 cases (75.7%), the cytologic diagnosis was nonspecific inflammation. Most of these 290 smears contained clue cells (indicating Gardnerella infection) and a lack of lactobacilli. Such smears are predominant in patients suffering from bacterial vaginosis (BV). Twenty-eight smears (7.3%) were positive for Trichomonas vaginalis, 27 cases (7%) were smears with koilocytic change pathognomonic of human papilloma virus infection. Twenty-five smears (6.5%) were positive for fungal infection. Seven cases (1.8%) were diagnosed as herpes simplex virus infection. Finally, there were six cases (1.5%) with atrophic vaginitis. We conclude that the cervical smear is well suited for diagnosing cervical infections. It is clear that Gardnerella, known to be associated with bacterial vaginosis, is a major problem in our Pakistani population.

Risk factors among HIV positive/AIDS patients: a prospective study at a tertiary care referral centre.

BACKGROUND: HIV/AIDS is a global problem, South Asia and Africa bearing the maximum burden. The incidence is reported to be rising in Pakistan. It is important to document the prevalence of various risk factors in our population so that appropriate measures could be taken for preventing emergence of new cases. Objectives were to identify the possible etiological factors/high risk behaviour in cases diagnosed as HIV/AIDS presenting at a tertiary care referral centre. METHODS: Prospective observational case series carried out over a one year period at HIV/AIDS referral centre at Allama Iqbal Medical College Lahore. Five hundred patients were included who were positive for HIV on screening devices and then confirmed by ELISA. All these patients were referrals from Punjab AIDS control programme (PACP). A detailed history was taken on a pre-designed Performa specially targeted to identify the known risk factors for HIV infection. RESULTS: Five hundred HIV positive subjects diagnosed by screening device and confirmed on ELISA were included in the present study. Three hundred and fourteen (63%) were males and 186 (37%) were females. Mean age was 35 +/- 12 years. Most prevalent risk factor among these patients was sexual transmission followed by intravenous drug abuse, injections from substandard health facilities, and transmission from infected spouse. CONCLUSION: HIV/AIDS is a preventable disease if the risk factors are avoided. Community awareness for unsafe homo and heterosexual practices and discouraging visits to non qualified health practitioners should be the top priority by PACP apart from controlling the IDUs menace.

Posttransplantation lymphoproliferative disorder with skin involvement.

Posttransplantation lymphoproliferative disorders (PTLD) are lymphoid proliferations or lymphomas that develop as a result of immunosuppression in recipients of solid organs and bone marrow allografts. The disorder is seen in 1-2% of renal transplant recipients with a variable time period of presentation and is usually seen within the first year following transplantation. We report a case of B-cell lymphoma (PTLD WHO class-3) presenting with skin involvement in a patient of renal transplantation, 8 years after receiving the transplant.

Comparison of diagnostic efficacy of rapid diagnostic devices for dengue virus infection--a piolt study.

BACKGROUND: To compare the diagnostic efficacy of commercially available rapid diagnostic test devices for Dengue serology. To find out the sensitivity and specificity of rapid diagnostic devices with Elisa results as the Gold standard. METHODS: During the dengue virus epidemic in Lahore a pilot study was conducted in order to evaluate the diagnostic efficacy of two most frequently used immunochromatographic rapid test devices in public sector hospitals. The results of both the kits were compared to each other. Sensitivity and specificity was calculated against results of ELISA as the reference gold standard. RESULTS: Results of kit-A revealed a very high false negative rate when compared to ELISA where actual prevalence rate shown by ELISA was 96.0% compared to prevalence rate of 44.0% with rapid diagnostic test device kit-A. Similarly the results of rapid test device Kit-B showed high false negative results for dengue virus prevalence. Actual prevalence rate of dengue fever shown by ELISA was 96.0% where as it turned out to be 50% with the kit-B rapid test device. Comparison of Results of two kits revealed no significant difference of test positivity rates. CONCLUSION: Rapid test devices based on immunochromatographic method supplied in the public sector hospitals are not reliable diagnostic tools for screening for dengue virus infection Health authorities need to review their strategy for supply of more reliable tools during epidemics in order to avoid false negative results.