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Jain HK, Das A, Dixit S, Kaur H, Pati S, Ranjit M, Dutta A, Bal M. Development and implementation of a strategy for early diagnosis and management of scrub typhus: an emerging public health threat. Front Public Health 2024; 12:1347183. [PMID: 38660358 PMCID: PMC11039949 DOI: 10.3389/fpubh.2024.1347183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
Scrub typhus, caused by Orientia tsutsugamushi, is a re-emerging zoonotic disease in the tropics with considerable morbidity and mortality rates. This disease, which is mostly prevalent in rural areas, remains underdiagnosed and underreported because of the low index of suspicion and non-specific clinical presentation. Limited access to healthcare, diagnostics, and treatment in rural settings further makes it challenging to distinguish it from other febrile illnesses. While easily treatable, improper treatment leads to severe forms of the disease and even death. As there is no existing public health program to address scrub typhus in India, there is an urgent need to design a program and test its effectiveness for control and management of the disease. With this backdrop, this implementation research protocol has been developed for a trial in few of the endemic "pockets" of Odisha, an eastern Indian state that can be scalable to other endemic areas of the country, if found effective. The main goal of the proposed project is to include scrub typhus as a differential diagnosis of fever cases in every tier of the public health system, starting from the community level to the health system, for the early diagnosis among suspected cases and to ensure that individuals receive complete treatment. The current study aimed to describe the protocol of the proposed Scrub Typhus Control Program (STCP) in detail so that it can receive valuable views from peers which can further strengthen the attempt.
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Affiliation(s)
- Hitesh Kumar Jain
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Arundhuti Das
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Sujata Dixit
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Harpreet Kaur
- Department of Epidemiology and Communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | - Sanghamitra Pati
- Department of Public Health, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Manoranjan Ranjit
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Ambarish Dutta
- Department of Epidemiology, Public Health Foundation of India, Indian Institute of Public Health, Bhubaneswar, India
| | - Madhusmita Bal
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
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Chauhan R, Ahmad S, Goyal C, Tewatia P. Hepatopathy in Scrub Typhus: Clinical Presentation, Association With Morbidity and Impact on Outcome. Cureus 2024; 16:e52316. [PMID: 38357080 PMCID: PMC10866566 DOI: 10.7759/cureus.52316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Acute liver injury accompanies tropical fevers like scrub typhus. This study was undertaken to evaluate liver injury in scrub typhus and its association with the disease severity. METHODS This was a single-centre prospective, observational study on in-patients of scrub typhus from north India. All patients were categorized on basis of elevation of transaminases as having normal or abnormal liver function. Those with hepatopathy were sub-categorized as having mild, moderate, severe or very severe liver injury. RESULTS Liver dysfunction was present in 76/109 of the patients and was significantly associated with eschar, clinically discernible hepatomegaly and splenomegaly. Shock, renal and respiratory insufficiency, need for intensive care and oxygen supplementation were also significantly associated with hepatopathy. Duration of hospitalization and mortality were comparable in patients with/without liver injury; however delayed defervescence (6.2+3.8 vs. 4.5+2.5 days; p=0.025) was observed with hepatopathy. Icterus (p=0.001), hepatomegaly (p=0.015), thrombocytopenia (p<0.001) and raised erythrocyte sedimentation rate (ESR) (p=0.003) were significantly observed with increasing grade of liver injury. Conclusion: Liver dysfunction and its increased severity in scrub typhus did not translate into increased morbidity and/or poor outcomes.
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Affiliation(s)
- Rishabh Chauhan
- Internal Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, IND
| | - Sohaib Ahmad
- Internal Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, IND
| | - Chandan Goyal
- Internal Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, IND
| | - Pavit Tewatia
- Internal Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, IND
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Kumaraswamy J, Govindasamy P, Nagarajan LS, Gunasekaran K, Abhilash KPP, Prakash JAJ. Genotyping of Orientia tsutsugamushi circulating in and around Vellore (South India) using TSA 56 gene. Indian J Med Microbiol 2024; 47:100483. [PMID: 37890413 DOI: 10.1016/j.ijmmb.2023.100483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/05/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE The immunodominant TSA 56 gene of Orientia tsutsugamushi, (scrub typhus agent) has four variable regions (VD-I to VD-IV) making it useful for genotyping. This study was undertaken to determine Orientia tsutsugamushi genotypes circulating in and around Vellore using complete and partial TSA 56 gene. METHODS Of the 162 patients positive by 47 kDa qPCR, on 21 samples PCR to amplify the complete TSA 56 gene (≈1605 bp: Long protocol) and the partial gene sequence using the Horinouchi (≈650bp) and the Furuya (≈480 bp) protocol was performed. Sanger and Nanopore sequencing was performed to obtain sequence data for assigning genotype. For 13 amplicons partial and complete gene data was obtained. RESULTS Phylogenetic analysis of the complete gene (Long protocol) which includes VD-I to VD-IV region and partial gene (Horinouchi) which amplifies the VD-I to VD-III regions showed identical genotypes. Twelve belonged to TA763 genotype and one belongs to Karp genotype. The Furuya sequence (in silico) correctly identified the Karp genotype and 10 of the TA763 genotypes. Two TA763 genotypes (identified by complete and 650 bp partial gene analysis) were misidentified by Furuya sequence analysis as Karp genotype. CONCLUSIONS Analysis of the 13 complete 56 kDa gene sequences suggests that TA763 is the commonest genotype in Vellore. Sanger sequencing of the 650 bp fragment gives similar results. However, these results need to be validated by larger prospective multi-centric studies.
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Affiliation(s)
- Janaki Kumaraswamy
- Department of Clinical Microbiology, Christian Medical College, Vellore, 632004, Tamil Nadu, India.
| | - Punitha Govindasamy
- Department of Clinical Microbiology, Christian Medical College, Vellore, 632004, Tamil Nadu, India.
| | - Lakshmi Surya Nagarajan
- Department of Clinical Microbiology, Christian Medical College, Vellore, 632004, Tamil Nadu, India.
| | - Karthik Gunasekaran
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.
| | - K P P Abhilash
- Emergency Medicine, Christian Medical College, Vellore, 632004, Tamil Nadu, India.
| | - John Antony Jude Prakash
- Department of Clinical Microbiology, Christian Medical College, Vellore, 632004, Tamil Nadu, India.
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Chunduru K, A R M, Poornima S, Hande H M, M M, Varghese GM, Devaki R, Saravu K. Clinical, laboratory, and molecular epidemiology of Orientia tsutsugamushi infection from Southwestern India. PLoS One 2023; 18:e0289126. [PMID: 37490497 PMCID: PMC10368267 DOI: 10.1371/journal.pone.0289126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
Scrub typhus is a vector borne disease which in a proportion of patients causes multiorgan involvement and death if untreated. Infecting genotype and virulence factors play a role in severity of infection and outcome. The current prospective cohort study was undertaken to elucidate the severity of illness in scrub typhus patients and to identify the circulating genotypes in Karnataka, India. A total of 214 patients of either gender from 9 districts of Karnataka and one patient each from Andhra Pradesh and Kerala, India were enrolled in the study. With a predefined severity criterion, 132 patients were segregated to the severe group. Multi organ involvement was seen in 59 (44.69%) patients. Phylogenetic analysis revealed JG-v like (48.97%), Karp-like (26.53%), JG-like (22.44%), and Kato-like (2.04%) strains in Karnataka. Patients infected with Orientia tsutsugamushi Karp-like strains had respiratory involvement (69.2%), cardiovascular involvement (46.2%) and thrombocytopenia (23.1%) and required higher hospital resource utilization.
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Affiliation(s)
- Kiran Chunduru
- Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Manoj A R
- Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Subhadra Poornima
- Department of Genetics and Molecular Medicine, Kamineni Life Sciences, Hyderabad, Telangana, India
| | - Manjunatha Hande H
- Department of Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Mridula M
- Department of Microbiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ramakrishna Devaki
- Department of Biochemistry, Kamineni Academy of Medical Sciences and Research Centre, LB Nagar, Hyderabad, Telangana, India
| | - Kavitha Saravu
- Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Multiple Orientia clusters and Th1-skewed chemokine profile: a cross-sectional study in patients with scrub typhus from Nepal. Int J Infect Dis 2023; 128:78-87. [PMID: 36566774 DOI: 10.1016/j.ijid.2022.12.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/13/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Scrub typhus is an emerging infectious disease in Asia caused by Orientia tsutsugamushi (Ot). From Nepal, only scant data on the genetic epidemiology of this agent is available, and determinants of immunoregulation are poorly understood. METHODS Patients (n = 238) referred to the National Public Health Laboratory (Kathmandu, Nepal) from all over Nepal for suspected scrub typhus were enrolled upon positive immunoglobulin (Ig)M testing between July and October 2015. From Ot 16S and 47 kD polymerase chain reaction (PCR)-positive samples, the variable domain I of the 56 kD gene was sequenced and phylogenetically analyzed. T helper (Th) cell-associated cytokines (n = 13) and chemokines (n = 12) were quantified by multiplex bead arrays. RESULTS In 93/238 (39.1%) IgM-positive samples, Ot DNA was detected by quantitative PCR. Phylogenetic analysis of 56 kD sequences revealed seven distinct clusters, six of them with high homologies to strains detected in other countries. The Th1-related cytokines interferon-γ and C-X-C motif chemokine ligand 10 were strongly upregulated and correlated with bacteremia, while levels of Th2-associated chemokines were reduced. Bacteremia also correlated with concentrations of interleukin (IL)-6 and IL-10 but not tumor necrosis factor-α. CONCLUSION We identified a considerable genetic heterogeneity of human-pathogenic Ot strains circulating in Nepal. Acute Nepalese scrub typhus patients showed strong Th1 but impaired Th2 responses, especially on the chemokine level.
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A Case Report. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Prakash R, Negi SS, Bhargava A, Sharma K, Jagzape T, Wasnik P. Evaluation of an in-house PCR for diagnosing scrub typhus along with a preliminary study of genotypic characterization of Orientia tsutshugamushi circulating in Chhattisgarh: A prospective clinico-microbiological study. Indian J Med Microbiol 2022; 40:510-515. [PMID: 36050139 DOI: 10.1016/j.ijmmb.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/28/2022] [Accepted: 08/03/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE Scrub typhus, caused by Orientia tsutsugamushi (O. tsutsugamushi) present nonspecific clinical features during manifestation of acute undifferentiated febrile illness (AUFI) to render its early diagnosis difficult. Accordingly, this study was undertaken to assess an in-house groEL PCR versus IgM ELISA for the diagnosis of scrub typhus and to genotypically characterise the randomly selected scrub typhus positive cases. METHODS Blood samples, collected from two hundred twenty one (221) AUFI cases were subjected to groEL PCR and IgM ELISA for diagnosis of scrub typhus. Eleven randomly selected PCR positive cases were processed for DNA sequencing to determine the genetic diversity of O. tsutsugamushi in Chhattisgarh. RESULTS Scrub typhus prevalence of 35.2% were detected among AUFI cases using both in-house groEL PCR and IgM ELISA. PCR alone showed sensitivity, specificity, positive and negative predictive values of 66.6% (CI: 55.08-76.94), 100% (CI: 90 to 100),100% (CI: 93.15 to 100) and 57.37% (CI: 44.05 to 69.96) while for IgM ELISA, these parameters were 62.8% (CI: 51.13-73.50), 100% (CI: 90 to 100), 100% (CI: 92.75 to 100) and 54.68% (CI: 41.75 to 67.18) respectively. PCR and ELISA could detect scrub typhus in 37.2% and 33.3% cases, when tested alone. groEL PCR detected the O. tsutsugamushi throughout the course of infection. Phylogenetic analysis depicted 5 of 11 positive cases belonged to Kuroki, Japan strain of O. tsutsugamushi, followed by Gilliam and Karp strain in 4 and 2 cases respectively. CONCLUSION Scrub typhus should be considered in differential diagnosis of AUFI. groEL PCR may aid on to IgM ELISA test for optimum laboratory diagnosis of scrub typhus by its implementation especially in seronegative cases. Predominance of Kuroki-like strain followed by Gillian and Karp strains of O. tsutsugamushi in Chhattisgarh confirm variable geographical distribution of O. tsutsugamushi and provide the baseline epidemiological data which will eventually be used to help the researchers for developing better diagnostic tests and vaccine covering the predominant genotypes.
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Affiliation(s)
- Rishika Prakash
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Raipur, India
| | - Sanjay Singh Negi
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Raipur, India.
| | - Anudita Bhargava
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Raipur, India
| | - Kuldeep Sharma
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Raipur, India
| | - Tushar Jagzape
- Department of Paediatrics, All India Institute of Medical Sciences (AIIMS), Raipur, India
| | - Preetam Wasnik
- Department of General Medicine, All India Institute of Medical Sciences (AIIMS), Raipur, India
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Nanaware N, Desai D, Banerjee A, Zaman K, Mittal M, Mittal M, Kulkarni S. Genotypic Characterization of Orientia tsutsugamushi Isolated From Acute Encephalitis Syndrome and Acute Febrile Illness Cases in the Gorakhpur Area, Uttar Pradesh, India. Front Microbiol 2022; 13:910757. [PMID: 35865917 PMCID: PMC9294505 DOI: 10.3389/fmicb.2022.910757] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/23/2022] [Indexed: 01/09/2023] Open
Abstract
Scrub typhus infections caused by Orientiatsutsugamushi (OT), continue to remain underdiagnosed globally, due to the lack of distinctive symptoms. The elusive nature of the Acute Encephalitis Syndrome (AES) outbreak in Gorakhpur, Uttar Pradesh that claimed numerous pediatric lives was the driving force of this study which involved serological diagnosis (IgM-ELISA), isolation of OT in cell culture, confirmation by PCR, and characterization by Sanger sequencing. In total, 12 out of 36 patients were seropositive, of which 4 were positive by PCR. Upon enrichment in cell culture, additional 3 patients (including two seronegative) were detected positive by PCR. In total, three of these 7 patients were found to be infected with two strains of OT. Taken together, this study for the first time reports the occurrence of dual infections in addition to three circulating OT genotypes (Gilliam, Kato, and Karp-like) and highlights the significance of enriching OT in cell culture systems for efficient molecular detection.
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Affiliation(s)
- Nikita Nanaware
- Indian Council of Medical Research (ICMR)–National AIDS Research Institute, Pune, India
| | - Dipen Desai
- Indian Council of Medical Research (ICMR)–National AIDS Research Institute, Pune, India
| | - Anwesha Banerjee
- Indian Council of Medical Research (ICMR)–National AIDS Research Institute, Pune, India
| | - Kamran Zaman
- Indian Council of Medical Research (ICMR)–Regional Medical Research Centre, Gorakhpur, India
| | - Mahim Mittal
- Baba Raghav Das (B.R.D.) Medical College, Gorakhpur, India
| | - Mahima Mittal
- Baba Raghav Das (B.R.D.) Medical College, Gorakhpur, India
| | - Smita Kulkarni
- Indian Council of Medical Research (ICMR)–National AIDS Research Institute, Pune, India,*Correspondence: Smita Kulkarni, ;
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Prakash JAJ, Kamarasu K, Samuel PP, Govindarajan R, Govindasamy P, Johnson LA, Ramalingam P, Nirmalson J, Seran KC. Detection of Orientia tsutsugamushi in Novel Trombiculid Mite Species in Northern Tamil Nadu, India: Use of Targeting the Multicopy traD Gene. JOURNAL OF MEDICAL ENTOMOLOGY 2022; 59:693-699. [PMID: 34850037 DOI: 10.1093/jme/tjab180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Indexed: 06/13/2023]
Abstract
Detection of Orientia tsutsugamushi DNA in a trombiculid mite chigger species suggests that it might be a potential vector of scrub typhus in an endemic area. Over a period of 20 mo, 85 rats were trapped, 57 had chiggers that were identified by standard morphometric techniques. The chigger pools were assessed by performing PCR assays targeting fragments of the single-copy genes 56 kDa type-specific antigen gene (TSA56) by nested PCR and the 47 kDa (htrA) quantitative real-time PCR (qPCR). The novel traD SYBR green assay that detects a multicopy gene was also performed. In total, 27 chigger pools were positive by traD qPCR, of which only 7 were positive by 47 kDa qPCR and in 3 of these, 56 kDa gene was amplified by nested PCR. Orientia tsutsugamushi-specific DNA was detected in Ascoschoengastia spp., Schoengastiella ligula, Leptotrombidium rajasthanense, Leptotrombidium deliense, and Leptotrombidium jayawickremei chigger pools. Therefore, they could be potential vectors of scrub typhus in Southern India. The three 56 kDa sequences belonged to TA716 genotype and Kato genogroup. Further studies are needed to confirm these chigger species as scrub typhus vectors in Northern Tamil Nadu.
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Affiliation(s)
- John Antony Jude Prakash
- Department of Clinical Microbiology, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu 632004, India
| | - Kannan Kamarasu
- Institute of Vector Control and Zoonoses, 150 Titan Jewellery Road, SIPCOT Phase I, Hosur Tamil Nadu 635126, India
| | - P Philip Samuel
- ICMR-Vector Control Research Centre Field Station, 4, Sarojini St, Chinna Chokikulam, Madurai Tamil Nadu 625002, India
| | - Renu Govindarajan
- ICMR-Vector Control Research Centre Field Station, 4, Sarojini St, Chinna Chokikulam, Madurai Tamil Nadu 625002, India
| | - Punitha Govindasamy
- Department of Clinical Microbiology, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu 632004, India
| | - Liji Anna Johnson
- Department of Clinical Microbiology, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu 632004, India
| | - P Ramalingam
- Institute of Vector Control and Zoonoses, 150 Titan Jewellery Road, SIPCOT Phase I, Hosur Tamil Nadu 635126, India
| | - J Nirmalson
- Institute of Vector Control and Zoonoses, 150 Titan Jewellery Road, SIPCOT Phase I, Hosur Tamil Nadu 635126, India
| | - K C Seran
- Department of Community Medicine, Madras Medical College, Near Park Town Station, Chennai, Tamil Nadu 600003, India
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Chunchanur SK, Venugopal SJ, Ambica R, Dakshayani B. Phylogenetic diversity of Orientia tsutsugamushi isolates in patients with scrub typhus in Bengaluru, India. Indian J Med Microbiol 2019; 37:438-441. [PMID: 32003348 DOI: 10.4103/ijmm.ijmm_19_267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Scrub typhus has re-emerged as an important cause of acute febrile illness in India. There is a dearth of information on strain diversity of Orientia tsutsugamushi from Karnataka, India, hence the present study sought to address this issue. One hundred clinically suspected cases of scrub typhus/rickettsiosis (as per the DHR-ICMR guidelines) were included. Nested-polymerase chain reaction (PCR) for 56-kDa gene and phylogenetic analysis was performed. PCR was positive in 22 cases and phylogenetic analysis showed the presence of different strains, with predominance of clustering (57%) with Gilliam-type for the first time in Karnataka. Knowledge of genetic diversity has implications in development of diagnostics and vaccine.
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Affiliation(s)
- Sneha K Chunchanur
- Department of Microbiology, Bangalore Medical College and Research Institute, Victoria Hospital, Bengaluru, Karnataka, India
| | - Shwetha J Venugopal
- Department of Microbiology, Bangalore Medical College and Research Institute, Victoria Hospital, Bengaluru, Karnataka, India
| | - R Ambica
- Department of Microbiology, Bangalore Medical College and Research Institute, Victoria Hospital, Bengaluru, Karnataka, India
| | - B Dakshayani
- Department of Paediatrics, Bangalore Medical College and Research Institute, Victoria Hospital, Bengaluru, Karnataka, India
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