Showing papers in "Journal of Laboratory Physicians in 2013"

Recurrent challenges for clinicians: emergence of methicillin-resistant Staphylococcus aureus, vancomycin resistance, and current treatment options

Abstract: Gram-positive pathogens mainly, Staphylococcus aureus, Enterococcus and coagulase-negative Staphylococcus, are developing increasing resistance to glycopeptides that pose a problem in treating infections caused by these pathogens. Vancomycin is the treatment of choice in treating methicillin-resistant S. aureus (MRSA). Community-acquired MRSA is associated with infections in patients without recent history of hospital admission and without the classical risk factors for MRSA carriage (including healthcare personnel). MRSA poses new threats and challenges beyond the hospital with the emergence of community-acquired MRSA. Indiscriminate use of vancomycin leads to the emergence and spread of vancomycin resistance in multidrug resistant strains is of growing concern in the recent years. Minimum Inhibitory concentration (MIC) remains an important determinant in choosing the right antibiotics. Infections caused by MRSA strains with vancomycin MIC > 4 μg/mL leads to the vancomycin treatment failure. The Clinical Laboratory Standards Institute had also lowered the cut-off susceptibility and resistance breakpoints for vancomycin. Despite the availability of newer antimicrobial agents (Linezolid, Daptomycin, Tigecycline) for drug-resistant Gram-positive pathogens, clinicians and patients still need options for treatment of MRSA infection. There is a need to reduce the global burden of infections caused by Gram-positive pathogens and its resistant strains (mainly MRSA). Continuous efforts should be made to prevent the spread and the emergence of glycopeptide resistance by early detection of the resistant strains and using the proper infection control measures in the hospital setting.

Fluoroquinolone Therapy in Staphylococcus aureus Infections: Where Do We Stand?

Abstract: Aim: The study aimed to evaluate the utility of various commonly used fluoroquinolones against Staphylococcus aureus isolates. Materials and Methods: A total of 250 isolates of S. aureus were studied from different clinical specimens like blood, pus, wound swabs, sputum, ear swabs, and body fluids between November 2009 and December 2011. All the isolates were tested for their susceptibility to fluoroquinolones and other antimicrobial agents by Kirby-Bauer disc diffusion method using criteria of standard zone of inhibition. Methicillin-resistant S. aureus (MRSA) detection was done by cefoxitin disk diffusion method. The MRSA isolates were tested for minimum inhibitory concentration (MIC) to vancomycin by E-test strips. All the MRSA strains were sent to National Staphylococcal Phage-typing Centre, Maulana Azad Medical College, New Delhi for phage typing. Results: A total of 107 strains of S. aureus (42.8%) were detected as MRSA. Multidrug resistance was observed among the MRSA strains more commonly than among the MSSA stains. Among the fluoroquinolones, maximum resistance in MRSA was seen to ciprofloxacin (92.5%), followed by ofloxacin (80.4%). None of the S. aureus isolates showed resistance to vancomycin and linezolid. The MICs of vancomycin for the MRSA tested ranged from 0.5 to 2 μg/ml. Phage typing pattern of 107 MRSA isolates revealed that 37 (34.6%) MRSA isolates were nontypeable and 70 (65.4%) were typeable. Conclusion: Ciprofloxacin can no longer be used in empirical therapy against MRSA infections. Use of other members of fluoroquinolone should be limited only to those strains that show laboratory confirmation of their susceptibility. Vancomycin remains the drug of choice to treat MRSA infections.

Comparison of Serum Lipid Profiles between Normal Controls and Breast Cancer Patients.

Abstract: Background: Researchers have reported association of plasma/serum lipids and lipoproteins with different cancers. Increase levels of circulating lipids and lipoproteins have been associated with breast cancer risk. Aim: The aim of this study is to compare serum lipid profiles: total-cholesterol (T-CHOL), triglyceride (TG), high density lipoprotein-cholesterol (HDL-C), low density lipoprotein-cholesterol (LDL-C) and very low density lipoprotein-cholesterol (VLDL-C) between breast cancer patients and normal participants. Materials and Methods: A total of 403 women in this study were divided into two groups in the period during May 2006-April 2007. Blood samples were collected from 249 patients with early stage breast cancer and 154 normal controls for serum lipid profiles (T-CHOL, TG, HDL-C, LDL-C and VLDL-C) analysis using Hitachi 717 Autoanalyzer (Roche Diagnostic GmbH, Germany). TG, LDL-C and VLDL-C levels in breast cancer group were significantly increased as compared with normal controls group (P < 0.001), whereas HDL-C and T-CHOL levels were not. Results: The results of this study suggest that increased serum lipid profiles may associate with breast cancer risk in Thai women. Further studies to group important factors including, cancer stages, types of cancer, parity, and menopausal status that may affect to lipid profiles in breast cancer patients along with an investigation of new lipid profiles to clarify most lipid factors that may involve in breast cancer development are needed.

Determination of Extended-Spectrum β-Lactamases and AmpC Production in Uropathogenic Isolates of Escherichia coli and Susceptibility to Fosfomycin.

Abstract: Background: Urinary tract infection due to Escherichia coli is one of the common problem in clinical practice. Various drug resistance mechanisms are making the bacteria resistant to higher group of drugs making the treatment options very limited. This study was undertaken to detect ESBLs and AmpC production in uropathogenic Escherichia coli isolates and to determine their antimicrobial susceptibility pattern with special reference to fosfomycin. Materials and Methods: A total number of 150 E. coli isolates were studied. ESBL detection was done by double disc synergy and CLSI method. AmpC screening was done using cefoxitin disc and confirmation was done using cefoxitin/cefoxitin-boronic acid discs. In AmpC positive isolates, ESBLs was detected by modifying CLSI method using boronic acid. Antimicrobial susceptibility pattern was determined following CLSI guidelines. Fosfomycin susceptibility was determined by disc diffusion and E-test methods. Results: ESBLs production was seen in 52.6% of isolates and AmpC production was seen in 8% of isolates. All AmpC producers were also found to be ESBLs positive. ESBLs positive isolates were found to be more drug resistant than ESBLs negative isolates. All the strains were found to be fosfomycin sensitive. Conclusions: ESBLs and AmpC producing isolates are becoming prevalent in E. coli isolates from community setting also. Amongst the oral drugs, no in-vitro resistance has been seen for fosfomycin making it a newer choice of drug (although not new) in future. An integrated approach to contain antimicrobial resistance should be actually the goal of present times.

Role of genotype® mycobacterium common mycobacteria/additional species assay for rapid differentiation between Mycobacterium tuberculosis complex and different species of non-tuberculous mycobacteria

Abstract: Background: Mycobacterium tuberculosis complex (MTBC) and non-tuberculous mycobacteria (NTM) may or may not have same clinical presentations, but the treatment regimens are always different. Laboratory differentiation between MTBC and NTM by routine methods are time consuming and cumbersome to perform. We have evaluated the role of GenoType ® Mycobacterium common mycobacteria/additional species (CM/AS) assay for differentiation between MTBC and different species of NTM in clinical isolates from tuberculosis (TB) cases. Materials and Methods: A total of 1080 clinical specimens were collected from January 2010 to June 2012. Diagnosis was performed by Ziehl-Neelsen staining followed by culture in BacT/ALERT 3D system (bioMerieux, France). A total of 219 culture positive clinical isolates (BacT/ALERT ® MP cultures) were selected for differentiation by p-nitrobenzoic acid (PNB) sensitivity test as and BIO-LINE SD Ag MPT64 TB test considering as the gold standard test. Final identification and differentiation between MTBC and different species of NTM were further confirmed by GenoType ® Mycobacterium CM/AS assay (Hain Lifescience, Nehren, Germany). Results: Out of 219 BacT/ALERT ® MP culture positive isolates tested by PNB as 153 MTBC (69.9%) and by GenoType ® Mycobacterium CM/AS assay as 159 (72.6%) MTBC and remaining 60 (27.4%) were considered as NTM species. The GenoType ® Mycobacterium CM/AS assay was proved 99.3% sensitive and 98.3% specific for rapid differentiation of MTBC and NTM. The most common NTM species were; Mycobacterium fortuitum 20 (33.3%) among rapid growing mycobacteria and Mycobacterium intracellulare 11 (18.3%) among slow growing mycobacteria. Conclusion: The GenoType ® Mycobacterium assay makes rapid and accurate identification of NTM species as compared with different phenotypic and molecular diagnostic tool and helps in management of infections caused by different mycobacteria.

Nondiabetic Renal Disease in type 2 Diabetes Mellitus Patients: A Clinicopathological Study.

Abstract: Background: The prevalence of nondiabetic renal disease (NDRD) among type 2 diabetics varies widely depending on the populations being studied and the selection criteria. Also, for patients found to have NDRD different predicting factors have been identified by different studies. Objectives: To determine: (i) Frequency and spectrum of NDRD in type 2 diabetics with atypical clinical renal disease, in our set up and (ii) common clinical markers that are associated with NDRD in our local population. Materials and Methods: Ninety-three type 2 diabetic patients with atypical clinical renal disease who had undergone renal biopsy to rule out NDRD were recruited. Patients were grouped into Group 1 with isolated NDRD, Group 2 with NDRD superimposed on diabetic nephropathy (DN), and Group 3 with isolated DN; and their clinical and biochemical parameters were statistically analyzed using analysis of variance, Kruskal-Wallis test, and Chi-square tests of statistical significance. Results: 68.8% of the patients had NDRD with or without concurrent DN. Patients with isolated NDRD had shorter duration of diabetes compared to the other groups. Absence of retinopathy and presence of microscopic hematuria and active urinary sediment had positive predictive value of 79.24, 81, and 100%, respectively, for NDRD in type 2 diabetics. Chronic interstitial nephritis was the commonest NDRD and membranous glomerulonephritis was the commonest glomerular NDRD in our setup. Interpretation and Conclusions: The frequency of NDRD in type 2 diabetics with atypical clinical renal disease is high in our setup thereby making the renal biopsy procedure imperative to rule out the same. Shorter duration of diabetes, absence of retinopathy, presence of microscopic hematuria, and active urinary sediment are markers associated with NDRD in type 2 diabetes with clinical renal disease.

Multidrug resistance in bacteria: a serious patient safety challenge for India.

Abstract: Patient safety is an important issue affecting the delivery of health care in developed, transitional and developing countries. With the advancements in patient care, hitherto unknown issues relating to patient safety are emerging. An important problem endangering patient safety is infections acquired in the health care facilities. Health care associated infections (HCAIs) are no longer a local or regional problem. With the dissemination of multi-drug resistant bacteria across the globe, the problem of HCAIs has become even grimmer. The emergence of pan-resistant bacterial strains, compounded by lack of availability of new antimicrobials foretells a grave future for management of infections acquired in hospitals. Therefore, it is important to frame local policies and measures and take affirmative actions for prevention of HCAIs and reduce the burden of multi drug resistance.

Procalcitonin as a predictor of sepsis and outcome in severe trauma patients: a prospective study.

Abstract: Introduction: Despite the advances in medical sciences, the morbidity and mortality due to sepsis in severe trauma patients remains high; hence the need for early and accurate diagnosis. Very few prospective studies are available in a country like India, which tried to analyze the prediction of sepsis using serum procalcitonin (PCT) in such a large scale among trauma patients. This study explores the role of the biomarker PCT in early diagnosis of sepsis and prediction of outcomes in severe trauma cases. Materials and Methods: We studied the patient population prospectively in two different groups. One with acute trauma but no clinical evidence of sepsis and the second group with clinical evidence of sepsis and are followed. Bronchoalveolar lavage, tracheal aspirates, pus, urine, body fluids from sterile body sites, etc., were collected including blood for culture and serum for PCT assays. Such assays were done on samples collected on days 1 and 4 and then compared. Additionally, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels were also tested. Antimicrobial sensitivity tests were carried out for all the isolates from the clinical samples and correlated with the clinically suspected cases of sepsis. Outcomes of the patients were noted. Results: Patients with high initial PCT levels (>2 ng/ml) in severe trauma cases had poor outcomes and risk of developing complications. Its correlation with severe outcomes was better marked as compared with CRP and ESR levels. The difference in PCT levels between days 1 and 4 in group two patients was statistically significant ( P = 0.006) but were not statistically significant for CRP ( P = 0.646) and ESR ( P = 0.935). The study also shows that PCT levels fall in response to appropriate antimicrobial treatment. Conclusion: PCT is a useful biomarker for early and accurate prediction of sepsis in severe trauma patients. If used in adjunct to clinical findings, it proves to be a good biomarker for early diagnosis, treatment and for monitoring response to therapy in confirmed cases of sepsis. It will prove to be a good supportive indicator of sepsis in early stages for the trauma patients in a low resource country like India.

Association of secondary hyperparathyroidism with hemoglobin level in patients with chronic kidney disease.

Abstract: Purpose: Secondary hyperparathyroidism (SHPT) is one of the less recognized reasons of anemia in chronic kidney disease (CKD). In this study, we evaluated the role of SHPT as a cause of anemia and correlation of intact parathyroid hormone (iPTH) and hemoglobin (Hb) level in hemodialysis (HD) patients. Methods: This cross-sectional study was carried out in 63 individuals admitted in HD unit of the institute. Serum samples were collected and urea, creatinine, Hb, ferritin and iPTH levels were measured. Statistical analysis was carried out using the SPSS software (IBM, NY, USA). Results: Mean ± standard deviation for serum urea, creatinine, Hb, ferritin and intact PTH were 177 ± 15.52, 15.16 ± 2.28 mg/dl, 7.03 ± 2.26 g/dl, 654.7 ± 563.4 ng/ml, 539.18 ± 493.59 pg/ml respectively. A reverse correlation was found between intact PTH and Hb level. Conclusions: A variety of postulated pathophysiological mechanisms linking SHPT and anemia in CKD are discussed. An efficient control of parathyroid hormone hypersecretion may be required to achieve a better management of anemia in HD patients.

Evaluation of serum zinc status and glycated hemoglobin of type 2 diabetes mellitus patients in a tertiary care hospital of Assam

Abstract: The present study was undertaken to find out any correlation between serum zinc concentration and HbA1C% in patients with type 2 diabetes mellitus (DM). The study was carried out on 50 newly diagnosed patients of type 2 diabetes and controls in the Department of Biochemistry, Assam Medical College and Hospital, Dibrugarh. Analyses of blood glucose (fasting and postprandial), glycated hemoglobin (HbA1c), serum zinc, urea, and creatinine concentrations were performed by standard methods. Concentrations of fasting and postprandial blood glucose were significantly higher in the diabetic group than controls (P < 0.001) and the mean HbA1c% was also higher in cases (8.32% ±1.58%). The mean serum zinc concentration in cases was found to be significantly lower than controls (79.85 ± 13.4 vs. 109.74 ± 9.72 μg/dL) and P < 0.001 with correlation coefficient r = -0.804. Present study revealed an inverse relationship between HbA1C% and serum zinc concentration in patients with type 2 DM, substantiated by regression analysis.

Promoting affordable and quality tuberculosis testing in India.

Abstract: The Revised National Tuberculosis Control Programme (RNTCP) has made good progress by providing basic TB diagnosis and treatment free of cost to all patients in the public sector. Recently, the RNTCP announced “universal access to quality TB diagnosis and treatment for all TB patients in the community” as its new goal for the next 5‐year plan.[2] This is a worthy goal, but any plan to reach all TB patients in India will need to include India’s dominant private sector.

Urinary Tract Infection due to Paenibacillus alvei in a Chronic Kidney Disease: A Rare Case Report.

Abstract: Paenibacilli, the Gram positive, aerobic spore bearing bacilli are found normally in the environment Though these organisms were not known to cause human disease, until recently; few species of this genus have been reported to cause infections in humans We report here, a case of urinary tract infection in a 60-year-old chronic kidney disease patient due to this rare bacterium The patient presented with complains of fever, dysuria, and flank pain Routine and microscopic examination of urine revealed no abnormality except plenty of pus cells and albumin (1+) Bacterial culture showed significant bacteruria and the isolated bacteria was identified to be Paenibacillus alvei based on standard biochemical reactions

Association of hematological profile of human immunodeficiency virus-positive patients with clinicoimmunologic stages of the disease

Abstract: Aim: This work was carried out to study the hematologic profile of human immunodeficiency virus (HIV)-positive patients and its association with the clinicoimmunologic stage of the disease. Materials and Methods: A total of 187 patients with HIV, whether symptomatic or asymptomatic, diagnosed by enzyme-linked immunosorbent assay (ELISA) method according to the National AIDS Control Organization (NACO) guidelines were included in this study. Patients in the study population were divided into two groups: (1) Group A (antiretroviral therapy (ART) included patients receiving ART [ART-Y]) and (2) Group B included treatment naοve patients (ART-N). The patients were tested for hemoglobin (Hb), total red blood cells (RBC) count, RBC indices, reticulocyte count, packed cell volume (PCV), total lymphocyte counts(TLC), differential leukocyte counts (DLC), platelet count, and erythrocyte sedimentation rate (ESR). Cut-off values were determined as Hb Results: (1) Anemia (predominantly normocytic normochromic) was prevalent in 40.1%, with slightly higher prevalence in those not receiving ART. It occurred with high frequency in patients with immunological (42.05%) and clinical acquired immunodeficiency disease syndrome (AIDS) (70.58%) compared with those who had an asymptomatic HIV infection with CD4 > 200/μl (28.57%). Patients on zidovudine ( AZT) therapy had 34.6% anemia with increased mean corpuscular volume (MCV). (2) Thrombocytopenia was seen in 3.74% patients (higher percentage in untreated patients). (3) Leucopenia was observed in 5.88% in ART-Y (Group A) and 8.14% in ART-N (Group B) patients. (4) Pancytopenia was found in 1.6% patients.

Staphylococcal blood stream infections: epidemiology, resistance pattern and outcome at a level 1 Indian trauma care center.

Abstract: Purpose: Blood stream infection (BSI)/bacteremia is a potentially life threatening infection and are associated with a high crude mortality. Coagulase negative Staphylococcus (CONS) and Staphylococcus aureus are the most commonly isolated gram positive bacteria from blood culture samples. While S. aureus is a known pathogen causing BSIs, CONS are considered to be common contaminants of blood culture. Of late many studies have challenged this traditional viewpoint. The aim of this study was to determine the epidemiology and significance of Staphylococcus aureus and CONS bacteremia, their resistance patterns and associated mortality in critically ill trauma patients admitted to a level 1 trauma center. Materials and Methods: The study was conducted from January 2009 to June 2011. All patients from whose blood samples yielded a S. aureus or CONS on culture were included in this study. A detailed history was obtained and follow-up of the patients was done. The isolates of Staphylococci were identified to species level. Antibiotic susceptibility was performed by the disc diffusion method and VITEK-2 system. Results: During this 30 month period, total of 10,509 blood samples were received from 2,938 patients. A total of 1,961 samples taken from 905 patients were positive for one or more pathogens. S. aureus/ CONS were isolated from 469 samples from 374 patients. Crude mortality amongst the patients having Staphylococcal BSI was 25% (94/374). Conclusion: Staphylococcal blood stream infections are a leading cause of morbidity and mortality.

Detection of Different β-Lactamases and their Co-existence by Using Various Discs Combination Methods in Clinical Isolates of Enterobacteriaceae and Pseudomonas spp.

Abstract: Background: Resistance to broad spectrum beta-lactams mediated by extended spectrum β - lactamase (ESBL), AmpC, and metallobetalactamase (MBLs) enzymes are an increasing problem worldwide. The study was aimed to detect occurrence rate and to evaluate different substrates and inhibitors by disc combination method for detecting varying degree of β-lactamase enzymes and their co-production. Materials and Methods: A disc panel containing imipenem (IMP), IMP/EDTA, ceftazidime (CA), ceftazidime-tazobactum (CAT), CAT/cloxacillin (CLOX), ceftazidime-clavulanic acid (CAC), CAC/CLOX, cefoxitin (CN), and CN/CLOX in a single plate was used to detect presence of ESBLs, AmpC, and MBLs and/or their co-existence in 184 consecutive, nonrepetitive, clinical isolates of Enterobacteriace ( n = 96) and Pseudomonas spp. ( n = 88) from pus samples of hospitalized patients, resistant to 3 rd generation cephalosporins. Results: Out of a total of 96 clinical isolates of Enterobacteriaceae , 18.7, 20.8, and 27% were pure ESBL, AmpC, and MBL producers, respectively. ESBL and AmpC were co-produced by 25% isolates. Among 88 Pseudomonas spp. 38.6, 13, and 6% were pure MBL, ESBL, and AmpC producers, respectively. ESBL/AmpC and MBL/AmpC co-production was seen in 20% and 18% isolates, respectively. Among ESBL and AmpC co-producers, CA/CAC/CLOX disc combination (DC) missed 7 of the 24 ESBL producers in Enterobacteriace and 4 of the 18 ESBL in Pseudomonas spp., which were detected by CA/CAT/CLOX DC. No mechanism was detected among 8.3% Enterobacteriaceae and 2.3% Pseudomonas isolates. Conclusion: Diagnostic problems posed by co-existence of different classes of β - lactamases in a single isolate could be solved by disc combination method by using simple panel of discs containing CA, CAT, CAT/CLOX, IMP, and IMP/EDTA.

Isolated plexiform neurofibroma of the tongue

Abstract: Neurofibromas (NF) are benign tumors of neural origin, of which roughly 90% appear as solitary lesions. They are classified into cutaneous, subcutaneous, and plexiform subtypes. Plexiform neurofibromas are the least common variant and usually are pathognomonic for NF I. Here, we present a very rare case of isolated plexiform neurofibroma with a painless enlarging mass of the tongue of an 11-year-old girl. This rare benign tumor has the potential for malignant transformation, and the diagnosis was difficult owing to the patient's age and to the insidious clinical presentation. The present case is a diffuse isolated plexiform neurofibroma of the tongue that was not associated with neurofibromatosis that was treated with intraoral surgery.

Comparison of various culture methods for isolation of Group B Streptococcus from intrapartum vaginal colonization

Abstract: Aims: Group B Streptococcus (GBS) is one of the most common causes of neonatal sepsis throughout the world. Reports of vaginal colonization of GBS in India are few and variable. A study was conducted on pregnant women in a tertiary care hospital to compare various methods for isolation of GBS, to study the prevalence of GBS in pregnant women in third trimester, and to determine risk factors for GBS colonization. Settings and Design: Observational descriptive study. Materials and Methods: High vaginal swabs from 150 pregnant women in their third trimester were used to compare three methods for isolation of GBS viz. direct culture on 5% Sheep Blood agar, direct culture on selective Columbia Blood Agar and culture in LIM enrichment broth with subsequent culture on 5% Sheep Blood agar. A history of associated risk factors was also taken. Statistical Analysis Used: Statistical analysis was performed by Chi-square test. Results: Isolation was best from LIM enrichment broth with subsequent culture on 5% Sheep Blood Agar. Prevalence of GBS colonization by using culture method was 12.67%. Most frequently associated risk factor was intrapartum fever (42.11%). Conclusions: Standard Culture Method using LIM enrichment should be adopted as standard practice for isolation of GBS from vaginal swabs.

Limb body wall complex: a rare anomaly.

Abstract: We present autopsy findings of a case of limb body wall complex (LBWC). The fetus had encephalocele, genitourinary agenesis, skeletal anomalies and body wall defects. The rare finding in our case is the occurrence of both cranial and urogenital anomalies. The presence of complex anomalies in this fetus, supports embryonal dysplasia theory of pathogenesis for LBWC.

Effect of urogenital cleaning with paper soap on bacterial contamination rate while collecting midstream urine specimens.

Abstract: Context: Urinary tract infection (UTI) is one of the major health problems. Urine culture is considered as a gold standard method for the diagnosis of UTI. But, improper sample collection can lead to contamination with normal urogenital flora. Use of any portable disinfectant that can reduce contamination rate would be the significant help in urine culture interpretation. Aims: To observe the effect of urogenital cleaning with paper soap on bacterial contamination rate while collecting specimens. Materials and Methods: A cross-sectional comparative study was done in 600 patients aged 15-45 years, equally divided into three groups. The first group was given sterile container and instructed to collect midstream clean catch urine (MSU) after urogenital cleaning with provided piece of paper soap. The second group was given sterile container and strictly instructed to collect the MSU sample after urogenital cleansing by tap water only. The third group was given the sterile container and asked for midstream urine. Collected specimens were inoculated in CLED media, incubated aerobically for overnight at 37°C. Reporting of culture was done according to the guideline of American Society of Microbiology. Results: The contamination rate in the three groups were 6.0%, 13.0%, and 27.5%, respectively (P value Conclusions: Contamination rate was significantly lower in group who provided urine specimen after urogenital cleaning with paper soap. Thus, cleaning the urogenital area may reduce the need of the repeat sample to rule out actual contamination and prevent from the unnecessary antibiotic treatment.

A rare case of primary lymphoma of the caecum presenting as intussusception.

Abstract: Mucosa associated lymphoid tissue (MALT) lymphomas are rare neoplasms. They are most common in the stomach followed by small intestine and colon. The symptoms are nonspecific and generally do not present with intussusception. Here we report a rare clinical entity in which a 35-year-old female presented to the emergency with severe abdominal pain which was sudden in onset. History revealed that she had been having vague mild abdominal pain for 2 years. Ultrasonography showed ileocolic intussusception with hypoechoic lesion of 54 × 46 mm seen at the lead point. Emergency laparotomy with the right hemi-colectomy was done. The specimen was sent for histopathological examination which revealed a diagnosis of MALT lymphoma. Awareness of the varied clinical presentation helps in formulating the appropriate therapeutic strategy.

Bisalbuminemia: A rarely encountered protein anomaly

Abstract: 1. Warren JW. Clinical presentations and epidemiology of urinary tract infection. In: Mobley HL, Warren JW, editors. Urinary tract infections‐molecular pathogenesis and clinical management. Washington DC: American Society for Microbiology Press; 1996. p. 3‐27. 2. Douglas CW, Heath J, Hampton KK, Preston FE. Identity of viridans streptococci isolated from cases of infective endocarditis. J Med Microbiol 1993;39:179‐82. 3. Westling K, Ljungman P, Thalme A, Julander I. Streptococcus viridans septicaemia: A comparison study in patients admitted to the departments of infectious diseases and haematology in a university hospital. Scand J Infect Dis 2002;34:316‐9. 4. Chou YS, Horng CT, Huang HS, Hu SC, Chen JT, Tsai ML. Reactive arthritis following Streptococcus viridians urinary tract infection. Ocul Immunol Inflamm 2010;18:52‐3.

Axillary schwannoma with extensive cystic degeneration.

Abstract: Schwannoma affect mainly head, neck, and flexor aspect of the limbs. Neurogenic tumors arising from the brachial plexus are rare and axillary schwannoma is extremely uncommon. Cystic degeneration is common in longstanding cases and which when aspirated may yield only macrophages or lymphocytes leading to false diagnosis of the case in spite of strong clinical suspicion. We report one such rare case of a solitary axillary schwannoma with extensive cystic degeneration, which was misdiagnosed on fine needle aspiration cytology and subsequently confirmed by the histopathological examination and immunohistochemistry.

Effect of Different Anticoagulants on HbA1C Estimation and its Stability.

Abstract: Sir, Glycated hemoglobin/HbA1c is always considered as a stable indicator of glycaemia for the preceding three months.[1] Its potential utility in diabetic care was first reported in 1985 WHO report, and by 2010 all the major expert committee and association across the globe including the ADA has recommended HbA1c for the diagnosis of Type 2 DM, besides its role in prognosis.[2] So, the importance of HbA1c estimation in diabetes has increased manifold in recent years.

Streptococcus mitis: An Unusual Causative Agent for Urinary Tract Infection.

Abstract: Sir, Urinary tract infection (UTI) is one of the frequent bacterial infection observed in clinical practice and is usually caused by members of the Enterobacteriaceae family, in particular Escherichia coli and Gram‐positive cocci such as Enterococcus spp. and Staphylococcus spp.[1] But we encountered a case of UTI caused by an unusual pathogen‐Streptococcus mitis, a member of the viridans group Streptococci (VGS). A 55‐year‐old diabetic female attended the gynaecology outpatient department of our hospital with recurrent burning micturition, low grade fever, and lower abdominal pain since one month. For this she had been empirically treated with ciprofloxacin but with no improvement. On examination, she had an urethrocele causing difficulty in emptying her bladder leading to cystitis. She was diabetic, human immunodeficiency virus (HIV) sero‐negative and her hematological and biochemical parameters were within normal limits except for a neutrophilic leukocytosis. Microscopic examination of her urine samples for two consecutive days revealed plenty of pus cells and traces of albumin while aerobic culture of both the samples showed significant bacterial growth (colony count > 105 CFU/ml) on CLED agar. Isolated organisms were Gram‐positive cocci mostly in chains, catalase negative, bile esculin negative even after 48 hours, showed no growth on nutrient agar and were nonhemolytic on 5% sheep blood agar. This bacterium was further identified as S. mitis by VITEK‐2 system with GP‐67card. The isolate was susceptible to amoxicillin– clavulanic acid, ceftriaxone, gentamicin, and vancomycin but resistant to ampicillin, azithromycin, ciprofloxacin, and ofloxacin. The sensitivity was cross checked by Hicomb MIC strips before handing out the susceptibility results. The patient was successfully treated with amoxicillin– clavulanic acid for one week along with physiotherapy. Although the VGS is a known commensal organism in the human mucosa of the oral cavity, upper respiratory tract, female genital tract, and gastrointestinal tract; it has been documented to be a frequent cause of endocarditis, meningitis, pneumonia, and bacteremia particularly in patients with immunosuppressive conditions.[2,3] There are occasional reports of genito‐urinary infection by VGS, but UTI by S. mitis is unusual.[4] In our case, risk factors for this infection were diabetes and the urethrocele. The patient was asymptomatic after proper antibiotic treatment along with control of blood sugar. Though 16S rRNA gene sequencing is the surest method for identification of Figure 5: The results for adult diabetic samples

Bartholin's Gland Abscesses Caused by Streptococcus pneumoniae in a Primigravida.

Abstract: Bartholin gland cysts and abscesses are common problems in females during their reproductive time. Majority of Bartholin's gland abscesses described are of polymicrobial nature, but not necessarily involves opportunistic microbes that colonize the perineal region. In this report, we describe a case of Bartholin's abscess caused by Streptococcus pneumoniae in a 25-year-old non-diabetic primigravida.

Primary Intestinal Hodgkin's Lymphoma: An Uncommon Presentation.

Abstract: Primary intestinal lymphoma is a rare lymphoproliferative neoplasm of the small intestine. The primary nature is established on the basis of lack of evidence of lymphoma on chest X-ray, computerized tomographic scan, peripheral blood or bone marrow puncture. Tumor involvement is limited to the gastrointestinal tract, the criteria for inclusion are that the symptoms related to the small intestine are predominant or the only symptoms at the time of laparotomy. Hodgkin's lymphoma (HL) primarily in the small intestine is a rare entity and an uncommon presentation of the disease. Ileum is the more common site of infliction than the jejunum because of its abundant lymphoid follicles. Here, we present a case of primary intestinal HL, in a 30-year-old male.

Evidence based solving approach in diagnosis of primary hyperparathyroidism with oral manifestations: Report of three unusual cases

Abstract: Primary hyperparathyroidism is a common condition that affects 0.3% of the general population in which excessive production of PTH is there. With changing trends it is diagnosed early and asymptomatically with the improvements in routine biochemical tests and radiological procedures. The late bony complications of the disease have therefore started to decline rapidly. The mandible is the predominantly affected site in the maxillofacial area. Maxillary involvement is rare. Here, we reported series of three cases of 30-40-year-old women with osteolytic lesions and bone resorption in maxilla or mandible. Two of presented cases demonstrated evidence of lesions in both mandible and maxilla which is a very rare event. A thorough diagnostic work-up emphasizing on biochemical and radiographic investigations were discussed. We highlighted the role of endocrinologist, oral and maxillofacial surgeons, general practitioner dentists, and radiologists in diagnosing and managing such patients.

Cold agglutinin disease with erythrophagocytosis by neutrophils occurring during recovery phase of chickenpox.

Abstract: on protein evolution and on the molecular structure and characteristics of the albumin molecule. Acquired bisalbuminemia could point to an underlying disease process, such as pancreatic pseudocysts, providing a clinician with another clue towards a possible diagnosis. Studying albumin variants can be of great interest and might be helpful in estimating the geographic distribution of these variants which is again important from anthropology point of view.

Iatrogenic Infection of Clostridium welchii Following Intramuscular Injection of Sodium Diclofenac.

Abstract: Injection site abscess is an iatrogenic infection. Intramuscular (IM) injection is a common route to administer medication. Microorganisms known to cause injection site abscess are Staphylococcus aureus, Pseudomonas, Klebsiella, Escherichia coli commonly, Atypical mycobacteria, Clostridium species rarely. Gas gangrene is a necrotic infection of soft tissue with high mortality, often necessitating amputation in order to control the infection. Here, presenting a case of gas gangrene in a 19-year-old healthy male, who developed a life-threatening infection after IM injection of sodium diclofenac. Prompt clinical diagnosis, laboratory support, and timely surgical intervention saved the patient's life.

In silico Analysis of TCR Vβ7 of Two Patients with Type 1 Diabetes Mellitus.

Abstract: Objective: To compare the sequences and crystal structures of variable region of beta chain 7 (Vβ7) of T cell receptor (TCR) of two patients with type 1 diabetes mellitus (T1DM). Patients and Methods: The skewness of TCR Vβ7 of two T1DM patients were detected with real-time florescence quantitative polymerase chain reaction (FQ-PCR) and deoxyribonucleic acid (DNA) melting curve analysis technique followed by being sequenced, the crystal structures of them were simulated according to CPH models 2.0 Server, IMGT database, and RasMol 2 software. Results: The whole sequences of TCR Vβ7 of T1DM patient-1 were CASRTAGQYEQYFGPGTR, that of patient-2 were CASRTAGQYEQFFGPGTR; the only difference between them lied on the 12 th amino acid. The crystal structures of Vβ7 of the two patients simulated with backbone model were rather similar, while that with sphere model were obviously different. Conclusion: Although the TCR Vβ7 of the T1DM patients share the similar gene sequences, their crystal structures simulated with sphere model are different, and the mechanism needs further study.