Acceptability of traditional healers as directly observed treatment providers in tuberculosis control in a tribal area of Andhra Pradesh, India.

SETTING: Vizianagaram district of Andhra Pradesh, India, where 9% of the population is tribal. OBJECTIVE: To 1) examine traditional healers' (THs) diagnostic and treatment practices for tuberculosis (TB); 2) understand health-seeking behaviour for TB amongst tribal groups; 3) evaluate the acceptability of THs to public health workers; and 4) assess how THs can collaborate with the TB Programme. METHODS: In-depth interviews with 120 THs, 37 exit interviews and four focus group discussions with TB patients; interviews with eight non-governmental organisations (NGOs) and 38 public health staff. RESULTS: There were 18 THs per 1000 population. Of the 120 THs interviewed, 15 (13%) claimed to be TB specialists. Of the 72 healers aware of TB, 65 (90%) considered prolonged cough an important symptom and 53 (74%) believed that TB could be cured with allopathic drugs. THs felt collaboration was possible by directly observed treatment (DOT) providers (49, 68%), referring symptomatic individuals (54, 75%) and offering treatment for side effects (18, 25%). CONCLUSION: Involvement of THs in the TB Control Programme may improve services as they are a major health service provider in tribal areas and are acceptable as DOT providers to patients, public health providers and NGO workers.

Pulmonary manifestations in brucellosis: a report on seven cases from Bikaner (north-west India).

OBJECTIVES: Pulmonary manifestations of Brucellosis are rare. We came across seven patients with predominant symptomatology of pulmonary involvement amongst 98 patients of active brucellosis seen in last four years. MATERIAL AND METHODS: The study is related to patients of brucellosis whose principal presenting features were related to respiratory symptom (cough, expectoration, pain in chest and breathlessness) along with fever and other constitutional symptoms. It included seven patients amongst 98 patients of active brucellosis seen during June 1996 to Feb. 2000 at PBM Hospital Bikaner. Diagnosis was confirmed by demonstration of the raised brucella agglutination titre of 1:320 or more in the serum. All patients were treated with rifampicin 900 mg daily and doxycyclin 100 mg twice daily for six week. The treatment was extended for another four weeks in two patients because of persistence of skiagram abnormalities. RESULT: Three patients had abnormality in skiagram chest in the form of pleural effusion, multiple paranchymal opacities and pneumonia. The skiagram chest was normal in remaining four patients. The response of treatment started with 10-15 days and all the patients became symptom-free at the end of six weeks except one patient. Skiagram chest at this time was normal in patients of pleural effusion but there was persistence of haziness and few opacities in other two patients. Follow up skiagram chest at the end of six months and twelve months was normal in all patients except calcified opacity in one patient. There was no evidence of relapse in any patient at the end of one year follow up. Liver function tests remained within normal range and no drug toxicity was observed. CONCLUSION: Pulmonary manifestations of brucellosis are rare. Treatment with rifampicin and doxycylin showed marked clinical and radiological improvement. All patients were completely disease-free at the end of one year follow up.

Scorpion envenomation causing hemiparesis.

We report a case of scorpion sting who presented with right hemiparesis and deranged level of consciousness. Prolonged BT/CT, decreased platelet counts, prolongation of PT and APTT with positive fibrinogen degradation products (FDP) D-dimer and CT scan findings of multiple cerebral haemorrhagic infarct indicating the presence of disseminated intravascular coagulation (DIC) as a cause of hemiparesis. Patient was managed with fresh blood transfusion and conventional treatment with favourable outcome.

The role of rifampicin in the management of cutaneous leishmaniasis.

We assessed the efficacy of rifampicin in the treatment of cutaneous leishmaniasis (oriental sore) using a double-blind placebo-controlled study. We studied 46 patients with cutaneous leishmaniasis, of whom 23 received rifampicin (group A) and another 23 received placebo (group B) for a period of 4 weeks. Each patient was assessed clinically for size of lesion, type of lesion, duration of lesion, number of lesions, and distribution of lesions, initially, and at the end of 1 week, 2 weeks and 4 weeks. Biochemical tests including enzyme studies were done to detect any toxic effects of the drug. Group A patients received rifampicin 1200 mg/day in two divided doses and group B patients received two doses of an identical placebo capsule. Seventeen (73.9%) of the 23 patients receiving rifampicin had complete healing. Two (8.6%) had partial healing and four (17.3%) showed no response, whereas out of 23 patients receiving placebo one patient (4.3%) showed complete healing, eight (34.7%) patients showed partial healing and 14 (60. 98%) patients showed no healing or exacerbation of lesion. The difference was statistically significant in favour of response to rifampicin. This dose of rifampicin was well-tolerated and no side-effects were seen in any patient. In cases of cutaneous leishmaniasis where injectable treatment is not feasible or not acceptable, as in cases of multiple lesions, rifampicin is a better alternative oral treatment. It is simple to administer, cheap, more effective and less toxic than other available oral drugs, and well-tolerated by patients.

Meningoencephalitis in brucellosis.

Human brucellosis, more specifically neurobrucellosis, is a less commonly reported disease in India; although, animal brucellosis and seroprevalence in specific areas is well reported. We are reporting 4 cases of neurobrucellosis presenting as meningoencephalitis. Diagnosis was confirmed by serological test and agglutination titre was > 1:320 in all the patients. All these patients had close contact with animals and history of raw milk ingestion was present in 3 cases. The aim of presenting these cases is to create awareness among physicians while treating meningitis in persons, engaged in occupations related to brucellosis or having a history of ingestion of raw milk or milk product.

Clinical profile of neurobrucellosis--a report on 12 cases from Bikaner (north-west India).

OBJECTIVE: To study the spectrum of neurobrucellosis in a prospective study at Bikaner which is supposed to be uncommon in India. METHOD: This study was done on admitted patients of brucellosis from June 1996 to June 1999 in whom the diagnosis was done by history of exposure to animals, fever and arthralgia and demonstration of brucella antibody titres in serum 1:160. CSF examination was done in all the patients. All cases were treated by combination of doxycycline 100 mg twice daily, rifampicin 900 mg daily for 6-8 weeks and injection streptomycin 0.75 to 1 gm i.m. per day for initial 14 days. Detailed neurological examination and antibody titres of serum and CSF again measured at the end of treatment. RESULTS: Twelve out of 92 patients revealed evidence of neurobrucellosis in which four cases were of meningoencephalitis, two cases of myelitis leading to spastic paraparesis, five cases of polyradiculoneuropathy and one case of polyneuroradiculomyeloencephalopathy. The treatment regimen used was associated with a high cure rate and significant reduction in antibody titres in serum and CSF. CONCLUSION: Neurobrucellosis is an uncommon but serious manifestation affecting central and peripheral nervous system. The clinical profile of the disease mimicks closely to commonly seen neurological infective diseases like tubercular meningitis, viral encephalitis, aseptic meningitis, cerebral malaria and viral encephalopathy. Serum and CSF testing for brucella antibody titre is an important test for the diagnosis. Blood culture is not an ideal test for neurobrucellosis because of low yield and longer time required for the diagnosis. High degree of suspicion is prudent for the diagnosis. High degree of cure rate can be achieved by treatment with present regimen in a disease which is otherwise having high mortality and morbidity.

Poor diagnostic accuracy and applicability of Siriraj stroke score, Allen score and their combination in differentiating acute haemorrhagic and thrombotic stroke.

OBJECTIVE: To evaluate the relevance of bed side clinical diagnostic scoring systems--Siriraj stroke score (SSS), Allen score and their combined use for differentiating acute haemorrhagic and thrombotic stroke. MATERIAL AND METHODS: The study was conducted on 240 admitted patients of stroke over a period of two years. SSS was calculated immediately and Allen score, 24 hours after admission. CT scan was done immediately and 48 hours after admission if required. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic gain were calculated for both the scores. Comparability between the scores and CT scan finding was determined with the help of kappa statistic programme. Receiver operating characteristic curves (ROC) were plotted to assess the diagnostic accuracy of both scores over a range of cut-off points. RESULTS: One hundred and thirty four patients (55.83%) had infarction and 106 patients (44.17%) had haemorrhage. SSS was applicable in 66.25% patients (159 out of 240) while Allen score was applicable in only 61.25% patients (147 our of 240). The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic gain for SSS were 73%, 85%, 85%, 71% and 30% for infarction and 85%, 73%, 71%, 85% and 27% for haemorrhage respectively, whereas the corresponding figures for Allen score were 91%, 60%, 77%, 82% and 18% for infarction and 60%, 91%, 82%, 77% and 41% for haemorrhage respectively. There was overall moderate comparability between SSS and Allen score for diagnosing supratentorial stroke (k = 0.396). The comparability of these scores in terms of certain results was worse (k = 0.143). However when the results that were within the diagnostic range with both the scores were considered, the agreement in diagnosing infarction and haemorrhage was almost perfect (k = 0.874). While considering CT scan finding as gold standard for differentiation of infarction and haemorrhage, the overall accuracy of SSS and Allen score was seventy eight percent. CONCLUSION: (a) Applicability of SSS only in 66.25% patients and wrong diagnosis in 22.01% patients does not reflect its usefulness because adequate management of stroke requires a gold standard diagnosis which is only possible by immediate CT scan. (b) Allen score is not useful because it can be assessed only after 24 hours of onset of stroke. This deprives the management to all thrombotic patients in speculated time window of modern management.

Successful management of hypokalaemia related conduction disturbances in acute aluminium phosphide poisoning.

A case of acute aluminium phosphide poisoning is described, who presented in shock secondary to electrolyte related cardiac rhythm disturbance and the judicious correction of the same could save his life without any consequence.

Heterologous expression of correctly assembled methylamine dehydrogenase in Rhodobacter sphaeroides.

The biosynthesis of methylamine dehydrogenase (MADH) from Paracoccus denitrificans requires four genes in addition to those that encode the two structural protein subunits, mauB and mauA. The accessory gene products appear to be required for proper export of the protein to the periplasm, synthesis of the tryptophan tryptophylquinone (TTQ) prosthetic group, and formation of several structural disulfide bonds. To accomplish the heterologous expression of correctly assembled MADH, eight genes from the methylamine utilization gene cluster of P. denitrificans, mauFBEDACJG, were placed under the regulatory control of the coxII promoter of Rhodobacter sphaeroides and introduced into R. sphaeroides by using a broad-host-range vector. The heterologous expression of MADH was constitutive with respect to carbon source, whereas the native mau promoter allows induction only when cells are grown in the presence of methylamine as a sole carbon source and is repressed by other carbon sources. The recombinant MADH was localized exclusively in the periplasm, and its physical, spectroscopic, kinetic and redox properties were indistinguishable from those of the enzyme isolated from P. denitrificans. These results indicate that mauM and mauN are not required for MADH or TTQ biosynthesis and that mauFBEDACJG are sufficient for TTQ biosynthesis, since R. sphaeroides cannot synthesize TTQ. A similar construct introduced into Escherichia coli did not produce detectable MADH activity or accumulation of the mauB and mauA gene products but did lead to synthesizes of amicyanin, the mauC gene product. This finding suggests that active recombinant MADH is not expressed in E. coli because one of the accessory gene products is not functionally expressed. This study illustrates the potential utility of R. sphaeroides and the coxII promoter for heterologous expression of complex enzymes such as MADH which cannot be expressed in E. coli. These results also provide the foundation for future studies on the molecular mechanisms of MADH and TTQ biosynthesis, as well as a system for performing site-directed mutagenesis of the MADH gene and other mau genes.