Co-infection of Central Nervous System by M. Tuberculosis, Cryptococcus and possibly Naegleria fowleri.

Co-infection due to Mycobacterium tuberculosis, Cryptococcus and Naegleria fowleri has not been reported till now in literature, to the best of our knowledge. Here we report a curious case of co-infection of the central nervous system due to these three pathogens in an apparently immune-competent, HIV negative boy. The 15 year old boy was a diagnosed case of tubercular meningitis and was on anti-tubercular and anti-epileptic treatment. However, two months later he presented again in the emergency department with sudden loss of consciousness. His CSF showed presence of capsulated budding yeast cells (suggestive of Cryptococcus) and flagellated parasites (resembling the flagellated stage of Naegleria fowleri). CSF was also positive for Cryptococcal antigens by Latex Agglutination test. The boy was HIV negative and apparently immuno-competent. He was subsequently put on amphotericin B therapy for six weeks. Repeat microscopy, done towards the end of amphotericin B course, showed clearing of CSF. However, the patient's condition improved only slightly, owing to neurological damage caused by the pathogens as suggested by brain CT and MRI scans. Thus infection caused by the members of three different kingdoms in an apparently immunocompetent boy highlights the importance of thinking beyond the ordinary causative pathogens, and actively searching for rarer etiologies to ensure timely intervention; especially in nonresponsive cases.

Vibrio cholerae O1 serotype Ogawa in a neonate.

In India, cholera is endemic and affects usually the 3 to 5-year-old age group. There have been occasional reports in the neonatal period with Vibrio cholerae O139 Bengal. We report here a case of Vibrio cholerae O1 diarrhea in a 2-day-old, breastfed male, who had been delivered in the hospital and developed severe dehydration.

Aetiology of chronic diarrhoea in tropical children.

AIM: We studied the causes and presentations of chronic diarrhoea in post-weaned children. METHODS: Forty seven children (6 months to 12 years) with diarrhoea of more than 2 weeks duration were recruited and subjected to detailed clinical examination and investigations. RESULTS: Primarily on the basis of history, clinical examination and duodenal biopsy, children could be classified into 5 groups namely tropical enteropathy (46.8%), irritable bowel syndrome (10.6%), giardiasis (14.8%), celiac disease (6.8%) and non specific diarrhoea (21.8%). Children with tropical enteropathy improved with broad spectrum antimicrobial therapy, those with irritable bowel syndrome and non specific chronic diarrhoea with dietary interventions while children with celiac disease required definite withdrawal of gluten from diet.

Risk factors for duodenal ulcer in north India.

OBJECTIVES: The present study was designed to evalutate the association of various risk factors such as smoking, alcohol, NSAIDs, inadequate dietary intake of fibres and consumption of spicy foods with chronic duodenal ulcer using a case-control design and to establish the association of Helicobacter pylori and duodenal ulcer using different diagnostic techniques in Indian subjects. MATERIALS: A total of 16 consecutive patients with endoscopically proven duodenal ulcer (DU) constituted the test group while 160 subjects with non-ulcer dyspepsia (NUD) were recruited as controls. METHODS: All subjects were interviewed based on a standard questionnaire and underwent an upper gastrointestinal endsocopy wherein multiple biopsies were taken for rapid urease test (RUT), histology and culture for detection of H. pylori. The serum samples of all the subjects were tested for the presence of antibodies against H. pylori using ELISA. RESULTS: There were significantly greater number of smokers (80%) and alcoholics (58%) in the male population of DU group as compared to the controls (49% smokers & 15% alcoholics). Similar trend was seen in relation to history of chronic exposure to NSAIDs (29% in DU & 11% in NUD) and inadequate intake of fibre in diet (66% and 39% respectively). The overall prevalence of H. pylori was 82.5% in DU and 50.6% in NUD [p < 0.001]. CONCLUSIONS: In North Indian subjects, alcohol consumption, smoking, inadequate intake of fibre in diet and use of NSAIDs are the risk factors associated with doudenal ulcer disease. Further, infection with H. pylori is strongly associated with DU in the North Indian population.

Nosocomial diarrhea.

OBJECTIVE: To study the occurrence of nosocomial diarrhea in pediatric wards and the role of infections in its causation. METHODS: 75 cases conforming to the CDC definition of nosocomial diarrhea were selected for the study. Stool samples were subjected to direct microscopic examination, bacteriological culture and direct antigen detection for Clostridium difficile (C. difficile) and Rota virus. RESULTS: All the cases were sporadic in origin. Rota virus was detected in 16.67% cases and Enteropathogenic Escherichia coli (E.P.E.C.) was detected in 12% cases. Cases in which no pathogen was detected (82.7%) outnumbered those in which a pathogen was identified (17.3%). CONCLUSION: Rota virus and E.P.E.C were the most common etiological agents. C. difficile was detected in one case only. Most of the sporadic cases of nosocomial diarrhea in pediatric patients can be managed on fluids and electrolytes.

Detection of cryptosporidium oocysts in acute diarrheal stools.

Three hundred and fifty stool samples from patients with acute diarrhea and 30 samples from normal healthy controls were examined for the presence of various parasitic and bacterial enteropathogens by conventional techniques. Cryptosporidium oocysts were detected in 15 out of 350 (4.3%) fecal samples. In 10 cases (2.9%) it was identified as a sole pathogen while in 5 cases (1.4%) it was isolated in association with cysts of E. histolytica, Giardia lamblia and with Salmonella typhimurium. Ten out of fifteen cases were in the pediatric age group. None of the 30 control cases had Cryptosporidium oocysts in their stools.

Henoch-Schonlein purpura: the Chandigarh experience.

OBJECTIVE: To determine the clinical profile of children with Henoch-Schonlein purpura (HSP). DESIGN: Hospital based descriptive follow-up study. SUBJECTS: 45 patients attending the Pediatric Rheumatology and Immunology clinic over the last 4 years. RESULTS: The patients were aged between 2.5-12 years with a male to female ratio of 2:1. All cases had palpable purpura. Gastrointestinal involvement was seen in 38 patients, with abdominal pain in 35 (78%) and lower GI bleed in 21 (47%). Large joint arthritis occurred in 60%. Renal involvement was seen in 14 subjects (31%). Major renal involvement occurred in 9 patients, with nephritic syndrome in 6 and nephrotic syndrome in 3 cases. Five patients had minor urinary abnormalities; 6 patients with major renal involvement and crescentic glomerulonephritis were treated with high dose pulse steroid therapy followed by oral prednisolone and azathioprine for 12-18 months. Normalization of urinary abnormalities occurred in these patients over 4-8 months and presently all are normotensive and off antihypertensive drugs. CONCLUSIONS: HSP in children is a common form of vasculitis. Though short term results in HSP nephritis have been good, long term prognosis in those with major renal involvement would remain guarded.

Seroepidemiology of ocular toxoplasmosis-profile of an urban population.

200 uveitis cases and 100 controls were serologically analysed for Toxoplasma antibodies (Ab) using indirect fluorescent antibody test (IFAT-IgG, Igm) and enzyme linked immunosorbent assay (ELISA IgG, IgM). Ophthalmologically cases were segregated into 4 groups anterior uveitis, posterior uveitis, pan uveitis and varied presentation uveitis. Toxoplasma seropositivity of 32% in cases and 4% in controls was established. IHA, IFAT, ELISA detected 20%, 18% and 32% cases as seropositive respectively, IFAT being most specific (100%) and ELISA most sensitive (41.37%). Insignificant change in Ab titre was observed in sequential samples of seropositive cases. Posterior Uveitis cases had the maximum seropositivity (41.7%). Highest seropositivity was in 16-25 years age group with no sex preponderance. Dietary habits and occupational history had no bearing on Toxoplasma infection. Results indicate that serology in mandatory for diagnosing Toxoplasma as a cause of uveitis, 2 or more tests on a single serum sample detecting IgG and Igm Ab are the best indicators of infection.

Study of fungal isolates in patients with chronic diarrhea at a tertiary care hospital in north India.

OBJECTIVE: The aim of this study was to evaluate the rate of isolation and antifungal susceptibility profile of various opportunistic yeasts in faeces of patients with chronic diarrhea. PATIENTS: The study included 120 patients who received the consultation and treatment for the complaints of chronic diarrhea for a period of more than 15 days. MATERIALS AND METHODS: The microscopy of samples of stool was followed by the culture on Sabourauds-dextrose agar. Isolate were tried for their sensitivity to fluconazole, flucytosine, amphotericin B and voriconazole. RESULTS: The significant growth of fungal organism was seen in 32 (26.7%) stool specimen. These fungal isolates include five (15.6%) of C. albicans, 14 (43.8%) of C. tropicalis, five (15.6%) of C. krusei, two (6.3%) of C. famata, two (6.3%) of C. parapsilosis isolates and one isolate each of C. lusitaniae, C. guilliermondii, Stephanoascus ciferri and Trichosporon asahii (3.1% each). Most of the yeast isolates (65.6%) were found to be sensitive to all four antifungal agents i.e., fluconazole, flucytosine, amphotericin B and voriconazole. The highest resistance was seen against fluconazole in 10 (31.3%) isolates followed by flucytosine in eight (25%) isolates. No resistance to voriconazole was observed in any of the isolates. The resistance to the antifungal agents was higher among the other species of Candida compared to C. albicans. CONCLUSION: The study could establish the relation between the opportunistic yeasts and chronic diarrhea and gives information on the antifungal sensitivity profile of the isolated yeasts.

Thyroid diseases as a sequelae following treatment of head and neck cancer.

AIMS: To evaluate the radiation-induced sequelae on thyroid gland and influence of concomitant chemotherapy. MATERIALS AND METHODS: This prospective study was carried out on 53 patients of head and neck carcinoma in the age group of 30-75 years (55.9 years). Patients were treated with external beam radiotherapy (52.8%) or concurrent chemo-radiotherapy with 5-flourouracil and cisplatinum (47.1%). The target volume included the thyroid gland, which received an average dose of 60 Gy in 30 fractions. Thyroid function tests were done at the start of radiotherapy. Follow up thyroid function tests were done on completion of radiotherapy treatment, at 3 months, at 6 months after treatment, and then every 6 months. Follow up ranges from 3-51 months (median: 27 months). RESULTS: Subclinical hypothyroidism was seen in 4 (7.5%) of the 53 patients. In three patients, the incidence was seen after a gap of 12 months and in one patient after a gap of 35 months. Of the four patients, three were of age ≤41 years and 1 was of age 66 years. In younger age group (30-39 years) patients, TSH shows statistically significant (P < 0.05) increase in TSH values. No significant difference was observed in radiation and chemo-radiation treatment groups (P > 0.10). CONCLUSIONS: Subclinical hypothyroidism is an important sequelae seen in the treated patients of head and neck when thyroid is in the radiation field. The patients with age less than 45 years are more prone to develop hypothyroidism. Chemotherapy has not affected the incidence of hypothyroidism significantly. Also, the dose of radiation has not shown any statistically significant difference.

Co-infection of Central Nervous System by M. Tuberculosis, Cryptococcus and possibly Naegleria fowleri

Co-infection due to Mycobacterium tuberculosis, Cryptococcus and Naegleria fowleri has not been reported till now in literature, to the best of our knowledge. Here we report a curious case of co-infection of the central nervous system due to these three pathogens in an apparently immune-competent, HIV negative boy. The 15 year old boy was a diagnosed case of tubercular meningitis and was on anti-tubercular and anti-epileptic treatment. However, two months later he presented again in the emergency department with sudden loss of consciousness. His CSF showed presence of capsulated budding yeast cells (suggestive of Cryptococcus) and flagellated parasites (resembling the flagellated stage of Naegleria fowleri). CSF was also positive for Cryptococcal antigens by Latex Agglutination test. The boy was HIV negative and apparently immuno-competent. He was subsequently put on amphotericin B therapy for six weeks. Repeat microscopy, done towards the end of amphotericin B course, showed clearing of CSF. However, the patient’s condition improved only slightly, owing to neurological damage caused by the pathogens as suggested by brain CT and MRI scans. Thus infection caused by the members of three different kingdoms in an apparently immunocompetent boy highlights the importance of thinking beyond the ordinary causative pathogens, and actively searching for rarer etiologies to ensure timely intervention; especially in nonresponsive cases.

Whole saliva physico-biochemical changes and quality of life in head and neck cancer patients following conventional radiation therapy: a prospective longitudinal study.

BACKGROUND: We investigated the physico-biochemical changes in saliva and its relation to quality of life (QOL) in head and neck cancer patients following conventional radiation therapy (RT). MATERIALS AND METHODS: 53 consecutive head and neck cancer patients underwent conventional RT using telecobalt photons. We analyzed objective sialometry and sialochemical parameters of salivary gland function and a physician reported Oral Assessment Protocol to assess the patients' QOL during (baseline, 3 and 6 weeks) and post RT (3 and 6 months). Statistical analysis was done using SPSS software (version 15.0; SPSS, Inc., Chicago, IL, USA). RESULTS: Stimulated salivary flow rates had shown a consistent decline during and in post-RT analysis (P < 0.001). A significant correlation was seen between mean salivary flow rates at 6 months post-RT and mean salivary electrolytes and amylase levels during the same period (P < 0.001). Mean global QOL scores had significantly worsened during RT and were still significantly poorer at 6 months than initial pre-RT levels (P < 0.001). Further, significant correlation was established between salivary pH values with global QOL scores at 6 months (P = 0.05). CONCLUSIONS: Radiation-induced hyposalivation invariably persists and correlates with poor global QOL scores seen during and following conventional RT. Post RT, there is a trend for biochemical reversal toward pre-irradiation levels suggesting a subsiding inflammation or a probable functional recovery.

Is soluble transferrin receptor a good marker of iron deficiency anemia in chronic kidney disease patients?

Anemia in patients with chronic renal failure is multifactorial with an absolute or functional iron deficiency present in 60-80% of patients. In this study, 102 patients of stage 5 chronic kidney disease (CKD) were enrolled. Thirty six age- and sex-matched anemic patients without any known renal disease were taken as controls. Their sTfR levels were measured with anemia profile.(Fe, TIBC, Ferritin, TSAT). The patients were followed up twice, at four weeks and six months. There was a significant statistical difference in the mean sTfR levels in patients when compared to controls (P < 0.01).The mean level of sTfR in CKD patients was 3.23 +/- 2.07 mg/l while in controls this was 5.16 +/- 3.64 mg/l. sTfR had no statistically significant correlation with the levels of hemoglobin, iron, ferritin, TIBC and TSAT. We conclude that owing to complexity of iron metabolism in CKD, sTfR can not be used as a reliable marker of iron deficiency anemia.

A case of poly-parasitism involving a trematode and four different nematodes in a migrant from Bihar.

Reported is a case of seven-year-old, migrant from Bihar state, infested with Fasciolopsis buski Strongyloides stercoralis Ascaris lumbricoides, Trichuris trichiura and Ankylostoma duodenale in feces. Patient responded to treatment with piperazine, thiabendazole and albendazole, the importance of considering multiple and non-endemicparasite infestations in migrant of poor socio-economic background is emphasized.

Urogenital myiasis due to Chrysomyia bezziana.

Genitourinary myiasis, associated with ulcerating lesions and poor hygiene of the local site, has been infrequently reported. We report a case of 45 year-old urinary incontinent female suffering from carcinoma cervix, who presented with genitourinary myiasis. The larva was identified as of Chrysomyia bezziana Villeneuve (C. bezziana).

Rare case of Metagonimus yokogawai.

Intestinal Heterophyid infections are almost unknown in India with only one documented case report. We report a case of six year old child with diarrhoea without any other associated gastrointestinal symptoms. Examination of the faeces revealed eggs of Metagonimus yokogawai. However, the patient left against medical advice and was lost to follow up. The case is being reported because of its rarity.