Tsutsugamushi Disease (Scrub Typhus) Meningoencephalitis in North Eastern India: A Prospective Study

Background:

Scrub typhus is rampant in northern, eastern, and southern India. Central nervous system involvement in the form of meningitis or meningoencephalitis is common in scrub typhus. As specific laboratory methods remain inadequate or inaccessible in developing countries, prompt diagnosis is often difficult.

Aim:

The aim of this study was to characterize neurological complications in scrub typhus from northeastern region of India.

Subjects and Methods:

We did a prospective study of scrub meningoencephalitis at North Eastern Indira Gandhi Regional Institute of Medical Sciences among patients admitted to hospital between October 2009 and November 2011. The diagnosis was made based on the clinical pictures, presence of an eschar, and a positive Weil–Felix test (WFT) with a titer of >1:160 and if required a positive scrub IgM enzyme-linked immunosorbent assay. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits, and magnetic resonance imaging (MRI) brain performed if needed.

Results:

Twenty-three patients of scrub typhus meningitis that were serologically confirmed were included in the study. There were 13 males and 10 females. Fever ≥1 week was the most common manifestation (39.1%). Interestingly, none had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 17 cells/μL, 90%, 86 mg/dL, 0.6605 and 3.6 U/mL, respectively. All patients were treated with doxycycline. There was no mortality in our study.

Conclusions:

Absence of Eschar does not rule out scrub typhus. Clinical features and CSF findings can mimic tuberculous meningitis so misdiagnosis may lead to unwarranted prolonged empirical antituberculous therapy in cases of lymphocytic meningoencephalitis. Delay in treatment can be potentially fatal. WFT still serves as a useful and affordable diagnostic tool for this disease in resource-poor countries.

Immunohistochemical Analysis of P53 and PRB in Esophageal Squamous Cell Carcinoma

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) is one of the fatal cancers with a high incidence rate in Asia. Many genes including p53 and pRb play an important role in its carcinogenesis. Expressions of p53 and pRb proteins have been associated with prognosis of ESCC.

OBJECTIVE

The study was undertaken to analyze the expressions of p53 and pRb with the various clinicopathological characteristics including stage and grade of ESCC.

MATERIALS AND METHODS

We examined 30 biopsy samples of ESCC for p53 and pRb protein expressions using immunohistochemistry. Immunointensity was classified as no immunostaining (-), weakly immunostaining (+), weak immunostaining (++) and strongly positive immunostaining (+++).

RESULTS

Significant association was seen between positive p53 expression and tumor size (p=0.042), invasion to adventitia (p=0.009) and lymph node metastasis (p=0.014), and negative pRb expression was associated with invasion to the adventitia (p=0.015) and lymph node metastasis (p=0.003) There was significant association of p53+/ pRb- (n=11) with tumor invasion to adventitia (p=0.001), lymph node metastasis (p=0.0007) and TNM staging (p=0.042).

CONCLUSION

The study shows that p53 and pRb proteins, individually as well as synergistically, may serve as putative prognostic markers in ESCC.

Subcutaneous dirofilariasis

Subcutaneous Human Dirofilariasis is an uncommon zoonotic infection caused by Dirofilariarepens. The reports of this infection in humans in India are limited, although increasingly being reported worldwide. We report a case of Dirofilariasis with subcutaneous presentation from the state of Meghalaya and to emphasize the importance of considering this entity in the differential diagnosis of patients presenting with subcutaneous nodules.

Granulomatous interstitial nephritis in granulomatosis with polyangiitis mimicking leprosy: A case report

Granulomatous polyangiitis (GPA) is a small vessel vasculitis commonly affecting the upper and lower respiratory tracts and kidneys. About 90% of the cases are associated with ANCA, namely, PR3-ANCA and MPO-ANCA. Herein, we describe a patient of GPA who presented with anasarca, sensory neuropathy, recurrent upper airway congestion, epistaxis, and rapidly progressive glomerulonephritis. Granulomatous interstitial nephritis and necrotizing granulomatous inflammation of the nasal septum were found on biopsy of the kidney and nasal septum, respectively both of which are rare findings. PR3-ANCA and MPO-ANCA were negative. Fulfilling the ACR criteria, this case of GPA proves that biopsy is still the gold standard of diagnosis.

Study of Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency and Genotype Polymorphism of G6PD B and G6PD (A+/A-) in Patients Treated for Plasmodium vivax Malaria in a Tertiary Care Hospital in North East India

Introduction

Glucose-6-phosphate dehydrogenase (G6PD) enzyme deficiency is the most common enzymopathy in humans, and its distribution has been historically described to be closely associated with that of malaria. North East India provides optimal conditions for transmission of malaria and bears a considerable burden of Plasmodium vivax (P. vivax) malaria. Primaquine, a mainstay in the treatment of vivax malaria, may trigger episodes of acute hemolysis in patients with G6PD deficiency. The present study sought to delineate the frequency and genotypes of G6PD deficiency among patients suffering from vivax malaria infections. 

Methods

Blood specimens from 80 individuals diagnosed with vivax malaria underwent enzyme assay for G6PD deficiency. Samples with deficient phenotype underwent isolation of DNA using a genomic DNA isolation kit (Qiagen India Pvt. Ltd., New Delhi, India). The genomic DNA underwent amplification, serial denaturation, annealing, extension, final extension followed by digestion with restriction endonucleases Nla III and Fok I. The digested products were subjected to horizontal agarose electrophoresis for the separation of digested fragments. Samples without nucleotide 376 adenine→guanine (A→G) mutation were classified as G6PD B. Those with the mutation were further classified into G6PD A(+) and G6PD A(-) based on the presence of Nla III site.

Results

Twenty-seven out of 80 individuals (33.75%) with P. vivax malaria were found to have G6PD deficiency, of which a majority (n=24) had G6PD B genotype. Three individuals had Asparagine→Aspartic Acid mutation at position 376 (A→G), of which G6PD A(+) and G6PD A(-) were present in two and one cases, respectively.

Conclusion

G6PD deficiency was noted in about a third of patients with vivax malaria. Since primaquine therapy is contraindicated in this group of patients, there is a rationale for looking into screening patients with vivax malaria from the region prior to primaquine therapy. Further large scale studies may substantiate this and help in better genotypic and geographic characterization of G6PD deficiency in the region. 

Amanita Nephrotoxic Syndrome: Presumptive First Case Report on the Indian Subcontinent

Mushroom poisoning is a rare cause of acute kidney injury. Here, we present a case with presumed Amanita nephrotoxic syndrome, a first of its kind from the Indian subcontinent.

Insulin:Glucagon Bipolar Axis in Obesity With a Glimpse Into Its Association With Insulin Resistance in Different Glucose Tolerance States

BACKGROUND

Dysregulation of insulin and glucagon secretion alters the normal insulin:glucagon ratio (IGR) in type 2 diabetes mellitus, obesity, and metabolic syndrome. This study explores the scope of construing the role of these two diametrically opposing hormones on the glucose level not just in obesity but in different glucose tolerance states by looking at the hormone levels and at the insulin glucagon bipolar axis itself.

MATERIALS AND METHODS

This is an analytical cross-sectional study of 60 healthy adults consisting of an equal number of adults who are lean and adults who are obese. It was conducted at North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), located in Shillong City, Meghalaya, India. Fasting glucose, insulin, glucagon, and lipids were estimated. Postprandial estimation of glucose was done two hours after oral administration of 75 grams of glucose solution.

RESULT

The study demonstrated a state of hyperinsulinemia and hyperglucagonemia prevailing in obesity and all sub-categories of the group of persons who are obese. The study showed a higher fasting IGR in the group consisting of adults who were obese (with a mean of 4.11) when compared with the group of adults who are lean (with a mean of 2.24). Fasting IGR was seen to increase with increasing levels of insulin resistance and increasing impairment in glucose tolerance. IGR showed a positive correlation with the homeostatic model assessment for insulin resistance (HOMA-IR) in the impaired fasting glucose (IFG) category and strongly in the impaired glucose tolerance (IGT) category.

CONCLUSION

Hyperglucagonemia in the group of adult persons who are obese indicates a decreased sensitivity of alpha cells to insulin failing insulin to adequately suppress the secretion of glucagon. The study also demonstrated a positive correlation between IGR and HOMA-IR in obesity and all glucose tolerance states of the group of adults who are obese. It is telltale that the sturdier the insulin resistance, the higher the IGR.

Purple Urine Bag Syndrome

The purple urine bag syndrome (PUBS) i.e. purple discolouration of urine, is an uncommon and alarming condition in patients with long term urinary catheterisation. Though the condition is benign, it should draw immediate attention to the possibility of an underlying urinary tract infection. The postulated hypothesis for this unusual event is probably a chemical reaction involving tryptophan from food in the gut. We report a case with this unusual and interesting phenomenon in a 65 year old female.

COVID-19 Vaccination Status Among Healthcare Workers and Its Effect on Disease Manifestations: A Study From Northeast India

Background and objective

Since being declared a global pandemic, coronavirus disease 2019 (COVID-19) has led to millions of cases and deaths worldwide. Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to wreak havoc on individuals, healthcare systems, and economies, the intensive vaccination strategies adopted by several countries have significantly slowed the progress and the severity of the disease. In this study, we aimed to determine the COVID-19 vaccination status among healthcare workers (HCWs) and examine the effects of vaccination on disease manifestations.

Materials and methods

This cross-sectional study was conducted at a teaching hospital in Northeast India from April 2021 to September 2021, during the second phase of the COVID-19 pandemic. HCWs employed in the hospital who were laboratory-confirmed cases of COVID-19 based on semiquantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) or cartridge-based nucleic acid amplification test (CBNAAT) on oropharyngeal samples were included in the study. Data analysis was performed using Microsoft Excel (Microsoft Office Professional Plus 2019, Microsoft Corp., Redmond, WA)

Results

A total of 178 HCWs reported positive for COVID-19 infection during the study period. Of these, 42 (23.59%) were males and 136 were females (76.40%). Among them, 86 (48.32%) HCWs were fully vaccinated, 58 (32.58%) were partially vaccinated, and 34 (19.10%) were not vaccinated. Most of the HCWs experienced mild disease (145, 81.46%), and only four (2.24%) reported moderate to severe disease. Compared with unvaccinated HCWs, individuals who have had either one or two doses of vaccines were less likely to have moderate to severe disease or seek treatment at the hospital. On symptoms analysis, shortness of breath was found to be more common in unvaccinated individuals than in vaccinated patients, and anosmia and loss of taste were more common in vaccinated than in unvaccinated individuals. No deaths were reported among the participants included in this study.

Conclusions

Following the first and second waves of the COVID-19 pandemic, a substantial proportion of HCWs were infected with SARS-CoV-2, likely as a result of the acquisition of the virus in the community during the early phase of local spread. Fully vaccinated individuals with COVID-19 were more likely to be completely asymptomatic or only mildly symptomatic compared to unvaccinated HCWs.

A clinico-serological study of neurocysticercosis in patients with ring enhancing lesions in CT scan of brain

AIMS OF THE STUDY

To study the clinical profile of neurocysticercosis and the utility of serological test using enzyme linked immunosorbent assay (ELISA) in patients with ring enhancing lesions in CT scan of brain.

METHODS

A total of 51 patients presenting between April 2003 to March 2004 to the Assam Medical College and Hospital, Dibrugarh, with ring enhancing lesions in CT scan of brain suggestive of neurocysticercosis were included in the study. Serum samples for ELISA test were taken from all patients and controlled sera were taken from 20 patients admitted in the ward, who did not have clinical evidence of cysticercosis and whose CT scan of brain were either normal or revealed lesion other than cerebral cysticercosis.

RESULTS

The maximum incidence of neurocysticercosis was found in the age group between 21 and 30 years (43.41%). Seizures were the commonest clinical presentation (100%). Eleven patients (21.56%) had ring enhancing lesions with central scolex. Fourty patients (78.44%) showed only ring enhancing lesions. ELISA test for definitive neurocysticercosis showed a sensitivity of 82.60% and specificity of 100%, while patients with CT scan features of neurocysticercosis had a sensitivity of 78.43% with ELISA.

CONCLUSION

ELISA for cysticercosis showed a sensitivity of 82.60% and specificity of 100%. The study also shows that therapeutic effectiveness with albendazole is quite satisfactory. As the study population is small in number which was conducted in a span of one year, an evaluation with a larger number of patients will definitely throw more light on the subject.

Two Case Reports of Ochrobactrum anthropi Bacteremia in a Tertiary Care Hospital in Northeast India

Ochrobactrum anthropi is a non-fermenting, Gram-negative bacillus and an emerging opportunistic pathogen. We have isolated this organism from the blood cultures of two patients, a 53-year-old immunocompetent male presenting with an episode of mild fever post craniotomy and an 85-year-old male with chronic obstructive pulmonary disease (COPD) and urinary retention on an indwelling catheter. The organism was identified using VITEK 2 (bioMérieux, France). Both the isolates were resistant to most of the β-lactams, including cephalosporins, and sensitive to quinolones, aminoglycosides, and carbapenems.

Tuberculosis of the bone marrow with secondary hemophagocytic lympho-histiocytosis presenting as obstructive jaundice: A clinician's challenge for the ages

Tuberculosis. a disease of great public concern, is spread through inhalation of micro-droplets from an infected person. Despite lungs being the primary site, there may be multisystemic involvement, very rarely involving bone marrow, a dreaded manifestation of disseminated tuberculosis, associated with high mortality and morbidity. We report a case of tuberculosis of bone marrow with concomitant secondary hemophagocytic lympho-histiocytosis, bringing into light the importance of clinical suspicion and evaluation of bone marrow being a primary site of involvement in patients of disseminated tuberculosis.