Dengue-chikungunya infection in the tertiary care hospital of northern India: Cross-sectional latent class cluster analysis in viral infection.

Cases of dengue and chikungunya fever are escalating all over India. Both viruses share a common vector, the "Aedes" mosquito. Due to similar clinical symptoms, both the dengue (DENV) and chikungunya (CHIKV) virus can circulate as co-infection. There is very limited data available on dengue-chikungunya co-infection in Uttarakhand, India. The purpose of this study was to determine the seroprevalence of dengue and chikungunya virus infections, as well as their co-infection, in patients presenting with clinical symptoms. Serum samples of clinically suspected patients from the tertiary care hospital of Uttarakhand were collected, and Latent Class Cluster Analysis was performed for clinical profiling. ELISA was performed for DENV and CHIKV. 279 cases were enrolled, out of which 222 (79.5%) came positive for dengue NS1 Ag, 143 (51.2%) for dengue IgM, 98 (35.1%) for IgG followed by 16 (5.7%) of CHIKV IgM, and 4 (1.4%) were NS1 Ag with CHIKV IgM. Among the clinical features, fever (n = 270, 96.8%) was the most common symptom in all suspected dengue and chikungunya cases. Other symptoms like chills (n = 254, 91.0%), arthralgia (n = 241, 86.4%), and headache (n = 240, 86.0%) were present in a significant number. Results showed fewer odds of getting both DENV and CHIKV infection simultaneously, but the risk is still not negligible. This study explores the clinical presentation of the suspected dengue-chikungunya case. The increasing incidence of dengue and chikungunya and their co-infection necessitate the authorities' active surveillance of endemic regions and effective patient care management.

Dengue Burden and Circulation of Dengue-2 Serotype Among Children Along With Clinical Profiling in Uttarakhand, India: A Cross-Sectional Study From 2018 to 2020.

BACKGROUND: The multiple serotypes of the dengue virus (DENV) are always a major public concern for dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). OBJECTIVE: This study aimed to analyse the demographic characteristics and circulating serotypes of dengue among the paediatric age group. METHODOLOGY: One hundred forty-one clinically suspected children were enrolled in the study from 2018 to 2020 in a tertiary care hospital in Uttarakhand, India. Central tendency, frequency, and One-Way ANOVA were measured for continuous and categorical data. The Shapiro-Wilks test was used to calculate the normality assumption. Dengue NS1 Ag, IgM, and IgG antibodies ELISA were performed, and NS1-positive samples were further tested for molecular studies. RESULT: From one hundred forty-one suspected cases, 100 (70.92%) came positive for dengue NS1 antigen, 18 (12.76%), and three (2.12%) came positive for IgM and IgG antibodies respectively. Rest 20 (14.18%) samples came negative for dengue. Fever with chills (97.5%), headache (89%), and arthralgia (82%) were the most common clinical features. Molecular studies showed the dengue serotype-2 (DEN-2) was found in most cases, followed by the dengue-3 serotype (DEN-3). CONCLUSION: This is the preliminary study as the authors' best knowledge which demonstrate the burden of dengue in children with prevalent serotypes for consecutive three years in Uttarakhand. This study identifies that the serotype-2 (DEN-2) of the dengue virus was the primary cause of infection in children at the tertiary care hospital in northern India. These results will help further to understand the nature of the disease so that improved patient care management will imply. Further molecular studies on large sample sizes during the endemic would be helpful to gain knowledge of the actual load of the disease and the genetic characteristics of the virus.

Post-COVID pulmonary fungal infections: An unanticipated predicament or a ticking time bomb? Clinico-microbiological profile of cases encountered during the second wave of COVID-19 pandemic at a teaching hospital in the Himalayas with a brief literature review.

Introduction: This study attempts to generate preliminary data regarding post-COVID pulmonary fungal infections, namely, COVID-19-associated pulmonary aspergillosis (CAPA), COVID-19-associated pulmonary mucormycosis (CAPM), and mixed infections from the Himalayas and compares the micro-radio-clinical profile and outcomes of the affected patients. Materials and Methods: A retrospective data analysis was conducted, where clinical profiles, microbiological and radiological reports, and outcomes of n = 16 patients of post-COVID pulmonary infections were compared. Results: Of n = 16 patients, n = 7 had CAPA (n = 5 Aspergillus fumigatus, n = 1 Aspergillus flavus, and n = 1 Aspergillus niger), n = 5 CAPM (Rhizopus arrhizus), and n = 4 with mixed infections (n = 3 infected with Aspergillus fumigatus and Rhizopus spp. and n = 1 with Aspergillus flavus and Rhizopus arrhizus). Thick-walled cavitary lesions, air-fluid levels, and multiple centrilobular nodules were some of the common radiological findings reported among these patients. Conclusion: The immuno-compromised state following COVID-19 infection and treatment might be responsible for the progression of regular exposure to the dense Himalayan vegetation into an invasive pulmonary fungal infection. Suspecting post-COVID pulmonary fungal infection is necessary for primary care physicians to ensure timely referral to higher centers. Mixed pulmonary fungal infections (coinfection with Aspergillus spp. and Rhizopus spp.) are also emerging as important sequelae of COVID-19.

Evaluation of Direct Examination, Culture, and Histopathology in the Diagnosis of Mucormycosis: Reiterating the Role of KOH Mount for Early Diagnosis.

Introduction Invasive fungal infections have always been a major cause of mortality and morbidity and are especially prevalent in the immunosuppressed groups of patients. Members of the Mucoracea family have an increasing incidence and prevalence. It has always been difficult to diagnose this condition due to various reasons. Materials and Methods This was an observational study carried out jointly by the Department of Microbiology and the Department of Pathology for a duration of one year. All patients who presented in various clinical departments with a high index of clinical suspicion for mucormycosis were included in this study. A total of 186 samples were received from suspected cases of mucormycosis and were all subjected to direct microscopy by potassium hydroxide (KOH), fungal culture, and histopathological examination. Results Mucormycosis was documented in 33 out of 186 cases on direct microscopy, whereas 21 were positive on fungal culture. Histopathological positivity was reduced with only 11 cases showing aseptate hyphae suggestive of mucormycosis. Conclusion As these organisms generally do not grow well on routine culture media and with the histopathological results also being not suggestive clearly of mucormycosis, direct microscopy thus becomes more important and essential in the rapid diagnosis of this deadly condition.

Comparative Assessment of Matrix-assisted Laser Desorption Ionization-time of Flight Mass Spectrometry (MALDI-TOF-MS) and Conventional Methods in the Identification of Clinically Relevant Yeasts.

BACKGROUND: Candida species are generally identified by conventional methods such as germ tube or morphological appearance on cornmeal agar (CMA), biochemical methods using API kits, and molecular biological techniques. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF-MS) has revolutionized the identification of fungi reducing the turnaround time of days to minutes. PURPOSE: To compare the performance of MALDI-TOF MS and conventional methods in the identification of clinically relevant yeasts. MATERIALS AND METHODS: In this study, Candida identifications on CMA are compared with the results obtained on MALDI-TOF MS (Bruker Daltonics, Bremen, Germany). Discrepant results were confirmed by sequencing internal transcribed spacer (ITS) regions of rDNA. RESULTS: A total of 114 clinical Candida species isolated from blood cultures were isolated and identified with conventional methods as well as with the MALDI-TOF-MS system. The agreement between the two test results were analyzed using Inter-rater reliability analysis (Cohen's Kappa) in SPSS Software Version 24 (IBM Corp., Armonk, NY). Overall, there was substantial agreement (Cohen's kappa=0.763) between the two methods. A value between 0.61 and 0.80 is classified under substantial. The most frequently isolated bloodstream Candida species included Candida albicans, C. tropicalis, C. parapsilosis, C.lusitaniae, C. glabrata which were accurately identified by MALDI-TOF-MS. When compared with conventional identification methods, MALDI-TOF-MS results are more reliable and rapid for Candida identification.

Etiological spectrum of infectious keratitis in the era of MALDI-TOF-MS at a tertiary care hospital.

BACKGROUND: Infectious Keratitis (Ik) Is A Potential Vision-Threatening Ocular Infection Caused By A Variety Of Microorganisms. AIM: To Explore Risk Factors And Etiological Agents Associated With Ik. DESIGN: A Prospective Cross-Sectional Study In Which Corneal Scrapings From 120 Suspected Cases Were Evaluated At A Tertiary Health Care Institute From January To December 2019. METHODS: Scrapings Were Subjected To Direct Microscopy, Culture, And Identification By Both Conventional Methods And Maldi-Tof-Ms. The Patient's Demographic Data And Predisposing Factors, If Any Were Recorded. RESULTS: The Mean Age Of Patients Was 48.9 Years And Predisposing Factors Were Documented In 46% (55/120) Of Cases. Overall, Infective Etiology Could Be Established In 51% (N = 61/120) Of Cases. Fungal Growth In 26% (N = 31/120) Of Cases And Bacterial Growth In 22% (N = 27/120) Of Cases Was Obtained. Growth Of More Than One Species Of Fungi Or Growth Of Bacteria Along With Fungus Were Observed In 2% (N = 3/120) Of Cases. Of All The Fungal Isolates Obtained (N = 34), The Most Common Isolate Was Fusarium (18/34) Followed By Aspergillus (8/34), Curvularia (4/34), Pseudallescheria Boydii (3/34), And Geotrichum (1/34). Among The Gram-Positive Bacterial Isolates (N = 16), Staphyloccus Species (15/16) Were Isolated In Maximum Number Followed By Streptococcus Pneumoniae (1/16). Among The Gram-Negative Isolates (N = 13), Pseudomonas Species (8/13) Were Isolated In Maximum Number Of Cases, Followed By Acinetobacter (3/13), Klebsiella Pneumoniae (1/13), And Escherichia Coli (1/13). CONCLUSION: For Initiating Appropriate Empirical Therapy, The Knowledge Of The Epidemiological Pattern Of Infectious Keratitis Of A Particular Geographical Region Is Crucial.

Candida tropicalis in the tropics: A rare fungal cause of perinephric abscess.

Perinephric and renal abscess are very rare entities with insidious presentation and pose a great diagnostic challenge, common etiology being bacterial. Only less than 30 cases of fungal etiology have been reported in literature. Herein, we report first case of fungal perinephric abscess caused by Candida tropicalis in a young diabetic female who presented with right flank pain and vomiting. Diagnosis made by CT imaging and culture of USG guided aspiration of perinephric abscess revealed growth of Candida tropicalis. Candida tropicalis perinephric abscess requires a very high index of suspicion for diagnosis. Associated high morbidity and mortality rates are likely due to misdiagnosis, therefore fungal perinephric and renal abscess must be kept as differential diagnosis in cases of fever with abdominal pain. Prompt diagnosis and early treatment are important for better outcome. Imaging and microbiological investigations are required for diagnosis, and drainage is indicated for successful therapy.

Cryptococcosis in non-human immunodeficiency virus-infected patients: A clinical dilemma and diagnostic enigma.

Cryptococcosis is a fungal disease with worldwide distribution and wide array of clinical manifestations, caused by encapsulated basidiomycetous yeasts called Cryptococcus spp. It has traditionally been considered an opportunistic infection known to occur in immunocompromised hosts, particularly those who are infected with human immunodeficiency virus. However, this infection has also been reported in phenotypically 'normal' or otherwise clinically non-immunocompromised patients. The seemingly mysterious nature of this potentially fatal illness has always kept clinicians and diagnosticians in a dilemma. This case series reiterates this perspective.

Angio-invasive Cerebral Aspergillosis Resulting in Hemispheric Infarct in an Immunocompetent Man.

BACKGROUND: Cerebral aspergillosis usually affects immunocompromised hosts and may rarely occur in immunocompetent individuals. Due to its angio-invasive nature, Aspergillus may cause various vascular complications, particularly mycotic aneurysms and infarcts. CASE PRESENTATION: A 22-year-old immunocompetent male with diagnosed case of sino-cerebral aspergillosis was taking voriconazole for two months. His headache worsened and repeat imaging showed an increase in the size of the lesion. The patient was managed with right frontal craniotomy and surgical debridement, and voriconazole was continued. After ten days of uneventful post-operative course, the patient developed left-sided hemispheric infarct. The patient is doing well at nine months' follow-up, and he is off voriconazole for three months after the follow-up imaging showed complete resolution of disease. CONCLUSION: Treatment of choice for cerebral aspergillosis is voriconazole. Surgical debridement may be a useful adjunct in patients not responding to voriconazole alone.

Baseline assessment of hand hygiene knowledge perception: An observational study at a newly set up teaching hospital.

BACKGROUND: Hand hygiene plays a crucial role in preventing health-care-associated infections (HCAIs) by reducing the spread of antimicrobial resistance. But, its compliance with optimal practices usually remains low at most of our health-care settings. AIM: This study focused on one of the primordial, basic and low-cost practice of infection control. MATERIALS AND METHODS: A cross-sectional observational study was conducted among medical faculty, senior residents, postgraduates, nursing faculty, ward sisters/matron, and staff nurses at All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand. Data were collected on a pretested structured questionnaire distributed among the participants, which consisted of questions to assess the knowledge and perception toward hand hygiene. RESULTS: A total of 171 health-care workers (HCWs) were assessed in this study. Overall response rate observed was 87.8% ± 11.6%. Majority of the participants were staff nurses. Approximately 55% of them had received formal hand hygiene training in the last 3 years. Overall correct knowledge seen among participants was 66.4% ± 27.5%. It was observed that in situations requiring hand hygiene, it was performed in approximately 70%-80% of the times. Alcohol-based hand rub was not available at every point of care, whereas single-use towel was not present at every sink. When monitored whether the HCW started hand hygiene activity or not, compliance was seen in only 32% of the total. CONCLUSION: It is now essential for developing countries to formulate the policies for implementation of basic infection control practices. As we are facing an era of multidrug-resistant pathogens that are rapidly increasing globally, and paucity of availability of new antimicrobials, it is been essential to look at the role of basic infection control practices at health-care settings and implement them at priority level.

Candida auris emergence in the Himalayan foothills: First case report from Uttarakhand, India.

BACKGROUND AND PURPOSE: Candida auris is a rapidly emerging fungus, which is considered globally a cause of concern for public health. This report describes the first case of C. auris fungemia from a tertiary care hospital in the hilly state of Uttarakhand in India. CASE REPORT: The patient was a 37-year-old female who underwent a Whipple procedure for the carcinoma of the head of the pancreas. She developed fever 12 days after the operation while recovering from surgery in the hospital. Blood culture yielded C. auris which was identified by the matrix-assisted laser desorption/ionization-time of flight mass spectrometry (Bruker Daltonics, Germany). The patient was successfully treated with caspofungin. CONCLUSION: In conclusion, C. auris is potentially multidrug resistant, resulting in nosocomial outbreaks and sporadic infections which can be potentially prevented when identified early by implementing contact precautions.

Curvularia lunata causing orbital cellulitis in a diabetic patient: An old fungus in a new territory.

BACKGROUND AND PURPOSE: Rhinocerebral mycosis is a rapidly invasive infection in diabetic patients with an unfavorable course. Herein, we report a rare case of orbital cellulitis caused by Curvularia lunata following fungal rhinosinusitis in a diabetic male patient. CASE REPORT: A 35-year-old male with uncontrolled diabetes presented to the emergency department of our center with high-grade fever accompanied by chills and rigors, severe diffuse headache, and projectile vomiting with swelling and loss of vision in the right eye. The tissue sample from surgical debridement showed pigmented hyphae; in addition, Curvularia lunata was isolated in culture. Imaging was indicative of orbital extension. Therefore, the patient was diagnosed with fungal rhinosinusitis with orbital cellulitis. The patient was subjected to extensive surgical debridement, along with antifungals. Rhinosinusitis resolved; however, the loss of vision was irreversible. CONCLUSION: Orbital cellulitis is a very rare but life-threatening complication of fungal rhinosinusitis. Very few cases of orbital cellulitis following fungal rhinosinusitis have been reported in the literature. Early and prompt diagnosis can save the life of a patient.

Incidental Finding of Nocardia: A Case Series from a Tertiary Care Centre in Uttarakhand.

Nocardiosis is a rare bacterial infection that may lead to a severe disease. These infections are rare among normal population and are showing an increasing trend worldwide attributable to the increase in the immunosuppressed population. Most of these patients present with nonspecific clinical features such as fever, productive cough, and exertional dyspnoea as seen in our series of patients which makes it difficult to be diagnosed. Pulmonary nocardiosis is rarely clinically suspected and often diagnosed very late in the course of disease resulting in high mortality. A similar observation was made in one of our cases where the patient was being treated on the lines of pneumonia, and in the end she was diagnosed with pulmonary nocardiosis. In view of the limited literature available, we report here a case series of pulmonary nocardiosis in immunosuppressed patients diagnosed incidentally by fungal KOH mount. The most common conditions causing immunosuppression were type II DM, COPD, and pulmonary tuberculosis.

A rare case of fatal cerebral phaeohyphomycosis caused by Cladophialophora bantiana in an immunocompetent individual in India.

BACKGROUND AND PURPOSE: Herein, we describe a rare case of fatal cerebral phaeohyphomycosis by Cladophialophora bantiana in an immunocompetent individual without any underlying risk factors. CASE REPORT: A 55-year-old female presented with a short history of fever for 1 month, as well as headache, sudden onset of right-sided upper and lower limb weakness, and loss of speech for 10 days. Contrast-enhanced magnetic resonance imaging scan revealed large, peripherally enhancing, well-defined, cystic, space- occupying, axial lesion in the left parietal lobe with a mass effect. The patient was subjected to craniotomy, and the drained pus revealed pigmented septate hyphae in potassium hydroxide mount examination, which was identified as Cladophialophora bantiana. The patient was started on amphotericin B and voriconazole. However, she developed acute respiratory infection leading to multi-organ failure and death on day 27 post-operation. CONCLUSION: In the absence of comparative trials owing to the rarity of the disease, the radical resection of lesion, drainage of pus, and prolonged targeted antifungal therapy with close postoperative radiological surveillance are the therapeutic measures of choice for patients with brain abscess caused by phaeoid fungi.

Cryptococcal meningitis: An under-reported disease from the hills of Uttarakhand: A hospital-based cross-sectional study.

BACKGROUND: Cryptococcal meningitis is a fatal opportunistic neuroinfection and an AIDS defining illness. It can also occur in non-HIV patients who are immunodefecient due to chronic glucocorticoid use, organ transplantation, malignancy and sarcodiosis. MATERIALS AND METHODS: A cross-sectional study was conducted in a tertiary care hospital from July to December 2018. CSF samples of 364 patients were received by Microbiology laboratory during this period for the purpose of aerobic bacterial, fungal and TB culture, respectively. All samples were subjected to examination by direct wet mount, Gram stain and India ink preparation. Ziehl Neelsen staining, solid culture for Mycobacterium tuberculosis on Lowenstein Jensen medium and Gene Xpert was also performed on all CSF samples. These samples were further subjected to fungal culture on Sabouraud's dextrose agar. Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF-MS) was used for identifying all bacterial (except M. tuberculosis) and fungal isolates. RESULTS: Out of 364 CSF samples received, 288 were sterile after 48 hours of aerobic incubation. Bacterial isolates, M. tuberculosis and Cryptococcus spp. were obtained in culture from 51, 21 and 4 samples, respectively. The prevalence of cryptococcal meningitis in our study was 1.09% (4/364). Cryptococcus neoformans var grubii was the most common isolate (2/4; 50%) followed by Cryptococcus neoformans var neoformans (1/4; 25%) and Cryptococcus neoformans var gattii (1/4; 25%), respectively. CONCLUSION: Cryptococcal meningitis is a rapidly fatal condition which requires a high index of suspicion and calls for a collective effort from family physicians and diagnosticians alike. This disease is under-reported from Uttarakhand and therefore calls for further research from this region.

Molecular identification of Fusarium species complex isolated from clinical samples and its antifungal susceptibility patterns.

BACKGROUND AND PURPOSE: More than 300 Fusarium species are grouped into approximately 23 species complexes out of which around 70 are involved in human infections. The nomenclature of these species has undergone considerable changes in recent years. These species cause localized infections in individuals while inducing systemic infections mainly in immunocompromised patients. The present study was conducted to identify Fusarium species in clinical isolates by molecular methods and determine their in vitro minimum inhibitory concentration (MIC) patterns to address the lack of data in this domain in Northern India. MATERIALS AND METHODS: For the purpose of the study, Fusarium isolates obtained from various clinical samples were sent to the Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands, for molecular identification. The MIC testing was performed using the microbroth dilution method as per the Clinical and Laboratory Standards Institute reference method (M38-A2). RESULTS: Fusarium was isolated from 33 patients (i.e., 1, 1, 2, 14, and 15 cases with endophthalmitis, sinusitis, pulmonary involvement, onychomycosis, and keratitis, respectively). These 33 isolates belonged to three species complexes, namely F. solani species complex (FSSC; n=13), F. fujikuroi species complex (FFSC; n=13), and F. incarnatum equiseti species complex (FIESC; n=7). The species identified within FSSC, FFSC, and FIESC included F. keratoplasticum (n=6)/F. falciforme (n=6)/F. solani (n=1), F. proliferatum (n=7)/F. sacchari (n=5)/F. anthophilum (n=1), and F. incarnatum SC species (n=6)/F. equiseti SC species (n=1), respectively. The MIC results showed that all isolates had a lower MIC against amphotericin B than against the other antifungal agents.

Disseminated cryptococcosis and hepatitis C virus infection: A fatal co-infection.

BACKGROUND AND PURPOSE: We report a case of disseminated cryptococcosis in a treatment-naïve patient, incidentally diagnosed with hepatitis C virus (HCV) infection and renal parenchymal disease. The patient succumbed to death given the very late diagnosis of the disease. CASE REPORT: A 54-year-old male presented with the chief complaints of abdominal pain, chest pain, and phlegmy cough for a month. There was a past history of decreased urine output, lower limb swelling, and fever lasting for 15-20 days. After a general physical examination, the differential diagnosis of hepatitis C-related liver disease with hepatic encephalopathy, disseminated tuberculosis, and septic shock was made. Radiological examination revealed renal parenchymal disease on ultrasound abdomen and opacity with reticulonodular opacity in the bilateral lung zones. In laboratory investigations, serum reactive sample was tested for anti-HCV antibodies. In addition, Cryptococcus var grubii was identified in blood culture using the matrix-assisted laser desorption ionization-time of flight mass spectrometry (Bruker Daltonics, Germany). The patient succumbed to death before the initiation of any specific antifungal therapy. CONCLUSION: Cryptococcosis-HCV co-infection is a fatal condition with a fulminant course that might be difficult to treat.

Eosinophilia in Advanced HIV Infection with Hyperinfection Syndrome: A Case Report.

Strongyloides stercoralis is a soil-transmitted helminth that occurs almost worldwide, yet estimates about its prevalence are not well documented. The spectrum of clinical manifestations of strongyloidiasis is wide, ranging from asymptomatic disease to hyperinfection or dissemination of larvae involving multiple organ systems. Immunosuppression can increase the risk of hyperinfection syndrome in patients with strongyloidiasis. Strongyloidiasis continues to remain a neglected tropical disease, the diagnosis of which is often overlooked by clinicians and diagnosticians alike. The paucity of published literature from India further accentuates this problem. We hereby present a case report with the aim of elucidating this relatively underreported infection.