Genital tuberculosis in Indian infertility patients

OBJECTIVES

To analyze the clinical and laparoscopic features of 40 infertile women with genital tuberculosis.

MATERIALS AND METHODS

This prospective clinical study was carried out at a tertiary care hospital from October 1, 2004, to August 30, 2006, with 150 infertile women in whom there was clinical suspicion of genital tuberculosis. All underwent diagnostic laparoscopy and biopsy for confirmation and other causes of infertility were excluded.

RESULTS

Among the 40 infertile women affected with genital tuberculosis there were cases of primary (n=30) and secondary (n=10) infertility; pelvic pain (n=8); menorrhagia (n=9); oligomenorrhea (n=7); hypomenorrhea (n=8); and primary (n=2) and secondary (n=2) amenorrhea. There were histories of pulmonary (n=9) and abdominal tuberculosis (n=6), ectopic pregnancy (n=4), and antitubercular treatment (n=10) in 10. There were cases of positive Mantoux test results (n=2); endometrial aspiration showing tubercular endometritis (n=10); positive acid-fast bacillus culture results (n=1); and positive polymerase chain reaction results (n=9). Laparoscopic examination revealed abnormally dilated, tortuous, and blocked fallopian tubes (n=13); peritubal and periovarian adhesions (n=18); Fitz Hugh Curtis syndrome (n=15); omental adhesions (n=18); and bowel adhesions (n=15). Hysteroscopy revealed flimsy intrauterine adhesions (n=7). All patients were treated for tuberculosis and 13 were counseled for in-vitro fertilization and embryo transfer or adoption.

CONCLUSION

Genital tuberculosis is common in India and a combination of clinical and laparoscopic diagnoses, along with endometrial histopathologic studies, acid-fast bacillus culture, and polymerase chain reaction assays provides the best available method for the diagnosis of genital tuberculosis in infertile women.

Low molecular weight proteins of outer membrane of Salmonella typhimurium are immunogenic in Salmonella induced reactive arthritis revealed by proteomics

In patients with reactive arthritis (ReA)/undifferentiated spondyloarthropathy (uSpA), synovial fluid mononuclear cells (SFMC) show proliferation to bacterial antigens that trigger ReA, i.e. Chlamydia, Yersinia, Campylobactor, Shigella and Salmonella species. We have shown previously that SFMC proliferate significantly to outer membrane proteins of S typhimurium in Salmonella induced ReA. In the present study we characterized the immunoreactive fractions of outer membrane protein (Omp) of S typhimurium in Salmonella induced ReA. Omp of Salmonella was isolated and fractionated by continuous elution sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) using Prep-Cell into eight Omp fractions based on molecular weight. Twenty-three patients with ReA were screened for the bacterial trigger using the SFMC proliferative response to crude lysates of Y enterocolitica, S flexneri, C jejuni and S typhimurium using thymidine uptake assay. SFMC from patients with salmonella induced ReA were tested against eight fractions. Seven of 23 patients with ReA had S typhimurium-induced ReA. Of these seven patients, five patients SFMC had a significant stimulation index (SI) against < 22, 22-26, 25-35 and 28-40 kDa fractions of Omp. These fractions were analysed by SDS-PAGE and matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry, which revealed 10 proteins. These proteins were 37 kDa OmpA, 33 kDa TsX, 28 kDa putative Omp, 28 kDa Vac J, 39 kDa OmpD, 18 kDa OmpX, 23 kDa OmpW, 43 kDa OmpS1 and 19 kDa peptidoglycan-associated lipoprotein. In conclusion, for the first time we have identified some low molecular weight proteins in the Omps of Salmonella which are T cells immunoreactive in patients with salmonella induced ReA/uSpA.

Chemokine and chemokine receptor analysis reveals elevated interferon-inducible protein-10 (IP)-10/CXCL10 levels and increased number of CCR5+ and CXCR3+ CD4 T cells in synovial fluid of patients with enthesitis-related arthritis (ERA)

Chemokines and chemokine receptors play a major role in homing of cells to the site of inflammation. Enthesitis-related arthritis (ERA) is a chronic inflammatory arthritis and no data are available on chemokines and their receptors in ERA. Blood (20) and synovial fluid (SF) (11) was collected from patients with ERA, and peripheral blood (PB) was collected from 12 patients with polyarticular juvenile idiopathic arthritis (JIA), nine patients with systemic onset and 18 healthy controls. Chemokines [interleukin (IL)-10/CXCL10, thymus and activation-regulated chemokine (TARC)/CCL17 and regulated upon activation normal T cell expressed and secreted (RANTES)/CCL5] were measured in serum and SF. Chemokine receptor expression was measured by flow cytometry. There was no difference in blood CD4(+) T cells bearing CCR5, CCR4 and CXCR3 in ERA and healthy controls. In paired samples the median frequency of CCR5(+) CD4(+) T cells was higher in SF compared to PB (15.8 versus 3.9%, P < 0.005), as was the frequency of CXCR3(+) T cells (21.61% versus 12.46%, P < 0.05). Median serum interferon-inducible protein-10 (IP-10)/CXCL10 levels were higher in patients with ERA compared to controls (139 versus 93 pg/ml; P < 0.05). Further median SF IP-10/CXCL10 levels were higher than the serum levels (2300 pg/ml versus 139 pg/ml; P < 0.01). Serum levels of RANTES/CCL5 were higher in patients (150 ng/ml) compared to control (99 ng/ml; P < 0.01). The SF levels were significantly lower compared to serum (P < 0.05). TARC/CCL17 levels in SF were lower than serum. There is increased homing of CCR5 and CXCR3(+) CD4 cells to the SF. Increased SF levels of IP-10/CXCL10 may be responsible for this migration in patients with ERA.

Osteonecrosis of the medial tibial plateau: a case report

Medial tibial plateau osteonecrosis is a disease that lacks distinguishing signs and symptoms, especially in the early stage, and requires clinicians to exercise a high degree of suspicion to prevent disease progression. We present a case of spontaneous osteonecrosis of the medial tibial plateau in a 59-year-old woman. Within 5 months of the onset of symptoms, the entire medial tibial plateau collapsed down into the metaphyseal region, causing severe varus deformity, instability, and inability to walk without crutches and a hinged knee brace. Initial symptoms of medial joint line pain and generalised swelling of the knee were attributed to early degenerative changes. Subsequent radiographs were misinterpreted as simple medial compartment arthritis. Due to severe bone loss and significant lateral collateral ligament attenuation, a total joint arthroplasty was required, using a stemmed tibial component with medial metal block and bone graft augmentation. The speed of bone collapse and the extension into the metaphysis, requiring complex joint arthroplasty, makes this case unique.

Arthritis as presenting manifestation of pure neuritic leprosy--a rheumatologist's dilemma

OBJECTIVES

Leprosy classically presents with cutaneous and neurological manifestations. In diagnosed cases of leprosy, rheumatological involvement varies from 1% to 70%. A primary articular presentation without cutaneous manifestations is not yet known. Herein, we present our experience of five cases of leprosy that presented with predominant articular involvement in the absence of cutaneous manifestations.

METHODS

The study was conducted in the Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences located in the state of Uttar Pradesh, one of the nine endemic states in India. Case records of patients with a definite diagnosis of leprosy were screened for the presenting manifestations, pattern of articular involvement, tenosynovitis, neurological signs and symptoms. Reports of nerve conduction study (NCS), nerve and synovial biopsy and other diagnostic tests were retrieved from laboratory records. Available radiographs were examined for evidence of juxta-articular osteopenia and erosions.

RESULTS

Case records of 11,740 patients were screened, of which 28 had a diagnosis of leprosy. Twenty patients had presented with rheumatological complaints primarily. Five of the patients who presented with inflammatory arthritis with/without tenosynovitis (n = 4) and tenosynovitis alone (n = 1) had pure neuritic leprosy. All of these patients had thickened peripheral nerves and abnormal NCS. Sural nerve biopsy confirmed the diagnosis of leprosy in all these cases.

CONCLUSION

A combination of tenosynovitis and thickened nerves in association with symmetric polyarthritis should raise a suspicion of leprosy even in the absence of cutaneous features.

Levonorgestrel-releasing intrauterine system vs. transcervical endometrial resection for dysfunctional uterine bleeding

OBJECTIVE

To compare the acceptability, efficacy, adverse effects, and user satisfaction of a levonorgestrel intrauterine system (LNG-IUS) and transcervical resection of the endometrium (TCRE) for the treatment of dysfunctional uterine bleeding.

METHOD

Of 50 women with a pictoral blood loss assessment chart (PBAC) score of 100 or greater, 25 had a LNG-IUS inserted (Mirena; Schering, Berlin, Germany) and 25 underwent TCRE. Procedure-related complications, PBAC score, hemoglobin levels, adverse effects, and rates of acceptability and satisfaction were recorded at 3-month intervals for a period of 12 months.

RESULTS

At the end of 1 year there were a 97% and a 94% reduction in menstrual blood loss in the LNG-IUS and TCRE groups, respectively, and hemoglobin concentration had increased by 5.5% in the LNG-IUS group and 5.2% in the TCRE group. Adverse effects were similar in both groups except for systemic effects, which were seen only in the LNG-IUS group. Satisfaction rates were about 80% in the 2 groups.

CONCLUSION

Both treatments were found to be equally effective but LNG-IUS placement requires less operator skill and entails no operative hazards, and the device provides effective contraception.

Interleukin-1 receptor antagonist gene polymorphism in patients with rheumatoid arthritis in India

BACKGROUND & OBJECTIVES

Interleukin-1 receptor antagonist (IL-1Ra) is a naturally occurring anti-inflammatory molecule that blocks action of IL-1. Polymorphism in IL-1Ra gene intron 2 results in differences in production of IL-1Ra. These polymorphisms are reportedly associated with autoimmune disease susceptibility in different studies. However, such data are lacking from India. We undertook this study to examine the IL-1Ra polymorphism as a susceptibility marker in patients with rheumatoid arthritis (RA).

METHODS

DNA samples from 107 patients with RA and 111 healthy controls were used to study genotypes of the IL-1RA gene by PCR. Allelic frequencies and carriage rates were calculated and compared in both the groups.

RESULTS

Among the 107 patients with RA, 93 were females and 75 per cent were seropositive for rheumatoid factor. The frequencies of IL-1RA alleles in controls were as follows: Allele 1 (IL- 1RN*1) was 83.33 per cent, IL-1RA allele 2 (IL-1RN*2) was 16.21 per cent and allele 3 (0.46%). In RA patients the allele frequencies were 84.11 per cent for IL-1RN*1, 14.95 per cent for IL- 1RN*2, 0.47 per cent each for IL-1RN*3 and IL-1RN*4. There was no difference in frequency of different alleles between the two groups. However, homozygosity for allele 2 was more frequent in controls (9.91%) as compared to patients (4.67%).

INTERPRETATION & CONCLUSION

Our findings indicated that IL-1RA polymorphism was not a susceptibility marker in RA nor did it show any association with seropositivity, Sjögren's syndrome or subcutaneous nodules. Further studies with large sample need to be done to confirm these findings.

MCTD: is it rare in India?

Mixed connective tissue disease (MCTD) has been rarely reported from India. Thus, we did a retrospective analysis of cases of MCTD seen at our hospital during the last 13 years. We found 16 cases among 441 patients with connective tissue disease. All the 16 patients (15 females) of MCTD fulfilled classification criteria by Kasukawa and at least one of the other two (Sharp's and Alarcon-Sergovia). Raynaud's phenomenon, sclerodactyly, puffy fingers, esophageal hypomotility, and pulmonary disease were the most common manifestations. At a median follow-up of 12 months (1-172), 12 patients developed features of limited scleroderma and three patients had pulmonary hypertension.

Is the enthesitis-related arthritis subtype of juvenile idiopathic arthritis a form of chronic reactive arthritis?

OBJECTIVE

Enteric organisms are known to trigger reactive arthritis. The enthesitis-related arthritis (ERA) form of juvenile idiopathic arthritis (JIA) clinically resembles reactive arthritis. Therefore, we looked for a role of enteric bacteria in ERA.

METHODS

Synovial fluid (SF) was obtained from 26 patients with ERA and 10 patients with rheumatoid arthritis (RA). Blood specimens were also obtained from patients with ERA and from 10 normal individuals. Lymphocyte proliferation assays were done on whole blood and SF mononuclear cells using as antigens crude lysates of the enteric bacteria Salmonella typhimurium, Yersinia enterocolitica, Shigella flexneri and Campylobacter jejuni. Crude lysate of Escherichia coli was used as a control antigen. HLA-B27 typing was done using the polymerase chain reaction. Homing of gut-specific T cells (CD103+) to the synovial compartment was studied using tri-colour flow cytometry. The antigen-specific cytokine profile was determined by flow cytometry.

RESULTS

Antigen-specific lymphoproliferative responses were observed in 14 of 26 patients. Among these patients, 12 showed a response in SF (four each to S. typhimurium and C. jejuni, and in two each to S. flexneri and Y. enterocolitica), and two patients in blood (S. typhimurium in both). None of the healthy controls showed a response in the blood. Lymphoproliferative responses in SF were more frequent in patients with JIA (12/26) than in controls with RA (1/10, P < 0.05). Patients with an antigen-specific response had a higher ratio of SF/blood CD103+ T cells compared with those with no antigen-specific response (P < 0.01). Antigen-specific as well as mitogen-stimulated cytokine production showed a Th1 bias.

CONCLUSION

Enteric bacteria may have a role in exacerbation of disease in patients with ERA. The immune response in patients with ERA is Th1-dominant.

Fatal pulmonary oedema following laparoscopic chromopertubation

The body of a 30-year-old woman was received for autopsy. The available medical case records mentioned that she had been married for the past 3 years and had had primary infertility. She had undergone a diagnostic-cum-operative laparoscopy under general anaesthesia in a private nursing home. On laparoscopy, the internal genital organs were normal except for a fimbrial cyst on each side. Chromopertubation was done using methylene blue dye along with diagnostic dilatation and curettage. The patient was extubated and shifted to the recovery room. About 15 minutes later she developed cyanosis and became unconscious. She died despite sustained efforts at resuscitation.

Increased expression of basic fibroblast growth factor in skin of patients with systemic sclerosis

Increased collagen deposition is a hallmark of systemic sclerosis (SSc). Several fibrogenic cytokines play a role in this sclerosis. The role of basic fibroblast growth factor (bFGF), the most potent fibrogenic cytokine, is poorly understood in SSc. Skin biopsies from forearm of 13 patients with SSc and 3 normal individuals were analyzed by immunohistochemistry using avidin biotin-system to amplify the signal. In addition serum levels of bFGF were also measured in 30 patients including these 13 and 23 healthy controls. Thirteen patients with SSc were all females and had a median age of 26.5 years, median disease duration of 2.25 years. Of these thirteen, seven had diffuse and six had limited disease. The skin biopsies from patients showed increased expression of bFGF in the basal layer of epidermis, dermis (periappendageal, perivascular, matrix tissue) as compared to normal tissues. The expression of bFGF did not correlate with duration of disease or skin score. In contrast, only low levels of bFGF were detectable in 4/30 sera from SSc patients as compared to 3/23 from healthy controls (p = ns). Overexpression of bFGF in skin of patients with SSc along with normal serum levels suggests that bFGF probably acts in an autocrine or paracrine manner in fibrogenesis.

Health promotion behaviors of Gujurati Asian Indian immigrants in the United States

The purpose of this paper was to examine the health promotion behaviors of Asian Indians, one of the fastest-growing immigrant groups in the United States. The sample consisted of 261 respondents randomly selected from the Charotar Patidar Samaj, a national Gujarati Association membership directory. Health promotion behaviors were obtained using the Health Promotion Lifestyle Profile II. Respondents demonstrated lower scores in physical activity and nutrition and higher scores in the areas of interpersonal skills and spiritual growth domain of the health promotion behaviors. Physical inactivity was the highest among adults of 25-50 years of age. A significant difference existed between males and females in the domain of health responsibility. Females were more responsible for their health and reported medical problems to a physician more often than their male counterparts. They also educated themselves about health promotion behaviors through reading and watching TV programs. Study results support previous research findings and make an important contribution to understanding the Asian Indian's health-promoting lifestyle behaviors.

Bone marrow abnormalities in HIV disease

Bone marrow abnormalities are frequently observed in HIV infected individuals at all stages of the disease. The most common abnormal finding is dysplasia affecting one or more cell lines. Erythroid dysplasia is the most common type of dysplasia and is recognized in over 50% of HIV infected patients, abnormal granulocytic and megakaryocytic development is encountered in one-third of patients. Plasma cells are strikingly increased in bone marrow of HIV infected patients. It may represent a physiological response to antigenic stimulation by viruses, other infective agents or secondary to dysregulated B-cell proliferation due to HIV. Herein we present a review discussing the various bone marrow abnormalities associated with the HIV disease.

Study of bone marrow abnormalities in patients with HIV disease

AIM

Present work was carried out to study the bone marrow abnormalities in patients with HIV/AIDS and to find their association with peripheral hematological abnormalities.

METHODS

Seventy four patients of HIV/AIDS were included in the study. The patients had anemia, leucopenia, thrombocytopenia or pyrexia of unknown origin (PUO) as indications for bone marrow examination. A complete blood count, relevant biochemical investigations, HIV RNA load and CD4 positive lymphocyte counts were done, besides a thorough history and clinical examination. HIV positive patients were classified as those having AIDS and those without AIDS according to NACO criteria.

RESULTS

Majority of patients (72.9%) had AIDS. Bone marrow was normocellular in 78.95% of non-AIDS and 74.55% of AIDS, hypocellular in 5.26% of non-AIDS and 7.27% of AIDS, hypercellular in 15.79% of non-AIDS and 18.18 % of AIDS patients. Myelodysplasia was present in 21.05% of non AIDS and 36.46% of AIDS and the most common series affected was granulocytic (15.79% of total in non-AIDS and 30.9% in AIDS). Dysplasia was statistically significantly associated with lower CD4 count (p = 0.031) and anemia (p = 0.013). Myelodysplasia was apparent even before patients developed anemia (16.67%). Increased plasma cells in bone marrow were observed in 57.89% of non-AIDS and 65.45% of AIDS, whereas decreased lymphoid cells were seen in 36.84% of non AIDS and 60.00% of AIDS patients.

CONCLUSIONS

Myelodysplasia is found in 32.43% of cases of HIV/AIDS and is more common in AIDS than in non AIDS patients. Granulocytic series is most commonly associated with evidence of dysplasia. Myelodysplasia is more common in patients with CD4 count < 200/microl and in patients with anemia. 54.05% of patients had decreased lymphoid cells in bone marrow and it was more commonly seen in AIDS than in non AIDS.