Haemophagocytic lymphohistiocytosis due to Burkholderia pseudomallei in a primigravida.

Introduction: Melioidosis is caused by Burkholderia pseudomallei, a Gram-negative, saprophytic bacillus, commonly found in soil or contaminated water. As infection with this bacterium produces a wide variety of clinical manifestations the organism is aptly called the 'great mimicker'. Even though it is non-fastidious and an easily cultivable organism, it can be misidentified in automated identification systems. Case report: A 24-year-old primigravida presented with complaints of fever and myalgia of 45 days' duration. She was diagnosed to have haemophagocytic lymphohistiocytosis (HLH) based on clinical and laboratory parameters. Blood and bone marrow culture sent to the microbiology laboratory grew non-fermenting Gram-negative bacilli which were misidentified as Burkholderia cepacia by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) technology. It was subsequently identified as B. pseudomallei by 16S rRNA gene sequencing. The patient was commenced on intensive phase therapy with intravenous ceftazidime for 2 weeks, followed by maintenance therapy with oral trimethoprim and sulfamethoxazole for 3 months. In view of HLH, she was treated with intravenous dexamethasone for 2 weeks which was later switched to oral dexamethasone for a period of 6 weeks. She responded well to the treatment, but had to undergo medical termination of her pregnancy as there was severe intrauterine growth restriction of the fetus. Conclusion: Prognosis of melioidosis is excellent if early diagnosis and appropriate antibiotic treatment is provided. In this era of automation, it is important to determine if the suspected pathogen is listed in the database of the automated identification system.

Disseminated tuberculosis with macrophage activation syndrome in a child with lupus nephritis.

In children with systemic lupus erythematosus on immunosuppressive therapy, infection is a known complication. We present a case of a 12-year-old girl who was previously diagnosed with lupus nephritis but had stopped taking allopathic medications and had been on herbal medicines for a year. She was referred to us with persistent fever and disease activity in spite of restarting immunosuppressive treatment. Results of blood tests and bone marrow aspiration were suggestive of macrophage activation syndrome. Imaging of her chest and abdomen showed features suggestive of miliary tuberculosis (TB) in the lungs and granulomas in the spleen. Mycobacterium tuberculosis was identified in bone marrow cultures, resulting in a diagnosis of disseminated TB. She was successfully treated with intravenous steroids, anti-tuberculous therapy and intravenous immunoglobulin. Mycophenolate mofetil was added after 6 weeks. The patient recovered from TB and her lupus was under control during follow-up.

Salmonella Typhi: a rare cause of parotid abscess.

The incidence of extraintestinal infection caused by Salmonella spp has been increased during the past decade. Here we report a case of a parotid abscess caused by Salmonella enterica subspecies enterica serotype Typhi (S Typhi) in an individual without any significant abnormality of the parotid gland. A 68-year-old man presented to the surgical department with high-grade intermittent fever associated with painful swelling over the right side of the face, extending into the neck. An ultrasound of the neck revealed an abscess of the right parotid gland. S Typhi was isolated from the pus drained from the parotid gland. The patient was treated with intravenous followed by oral cephalosporin for a period of 7 days. This case gives an insight into one of the rarer aetiological agents causing parotid abscess.

Melioidosis presenting as septicaemia and facial nerve palsy.

A 43-year-old farmer presented with acute onset pneumonia, septicaemia and peripheral facial nerve palsy (left side). Burkholderia pseudomallei was isolated from the blood culture of the patient. The patient was successfully treated with intravenous meropenem and oral cotrimoxazole for 2 weeks followed by maintenance therapy with cotrimoxazole. The case is reported to increase awareness among the clinicians and microbiologists regarding melioidosis.

Salmonella typhi Splenic Abscess Following Blunt Abdominal Injury: A Case Report.

Splenic abscess as a complication of enteric fever due to Salmonella typhi is a rare entity. Here, we are presenting a case of splenic abscess caused by Salmonella typhi with a blunt injury to the abdomen as the predisposing factor. The patient underwent total splenectomy due to failure of conservative management. Splenic abscess is a potential life threatening disease if left untreated. In spite of its rarity, Salmonella typhi has to be considered as a possible pathogen causing the disease.

Mycobactericidal activity of various concentrations of bleach.

Treatment of sputum samples using bleach has been proposed to sterilize the sample and increase the sensitivity of smear microscopy, for the diagnosis of tuberculosis (TB). However the concentration and exposure times needed for sterilizing sputum samples are poorly defined. In this study, thirty sputum samples that tested positive for acid fast bacilli by direct smear microscopy at microbiology laboratory were divided into three groups and treated with equal amounts of 5%, 3%, 1% bleach. It was found that 5% and 3% bleach were effective in sterilizing sputum, at a contact time of five minutes, 1% bleach requires a greater contact time for adequate mycobactericidal activity.

Improved detection of Mycobacterium tuberculosis using two independent PCR targets in a tertiary care centre in South India.

INTRODUCTION: Tuberculosis (TB) causes significant morbidity and mortality worldwide as one of the leading infectious diseases. In India, more than 1.8 million new cases occur every year. Rapid and accurate diagnosis of TB would improve patient care and limit its transmission. This study aimed to evaluate a dual target polymerase chain reaction (PCR) diagnostic assay to detect Mycobacterium tuberculosis from pulmonary and extra-pulmonary samples at a tertiary care centre in South India. METHODOLOGY: Samples were collected from patients with a low index of suspicion of TB. Acid-fast smears were performed by Auramine O fluorescent microscopy and PCR was performed by using two site-specific primer pairs targeting IS6110 by nested PCR and TRC4 by conventional PCR. Amplified products for IS6110 and/or TRC4 were indicative of M. tuberculosis. RESULTS: Among 114 (19 pulmonary and 95 extra-pulmonary) samples tested by PCR assay, 12 (11%) were positive for both IS6110 and TRC4, of which 11 (10%) were non-respiratory and one was (1%) respiratory in origin. PCR for TRC4 alone was positive for eight (7%) non-respiratory and two (2%) respiratory samples, while IS6110 alone tested positive for six (5%) non-respiratory samples and one (1%) respiratory sample. Of a total of 29 PCR positive samples, 17 (15 %) were acid-fast smear positive. CONCLUSION: Although the target site of IS6110 is specific for M. tuberculosis, some strains from South India may lack this region. Therefore, the use of an additional target site (TRC4) is required for improved detection of M. tuberculosis.