Journal of Laboratory Physicians
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October-December 2017
Volume 9 | Issue 4
Page Nos. 223-345

Online since Monday, September 11, 2017

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ORIGINAL ARTICLES  

The memory lymphocyte immunostimulation assay in immune system disorders: Is useful or useless? p. 223
Maria Vadalà, Carmen Laurino, Beniamino Palmieri
DOI:10.4103/JLP.JLP_137_16  
Aim: The aim of the study was to evaluate the clinical relevance, sensitivity and specificity of in vitro blood test, Memory Lymphocyte ImmunoStimulation Assay (MELISA®), in genetically predisposed patients that suffer by autoimmune/inflammatory syndrome induced by adjuvants, after HPV-vaccination and that could have a high metal hypersensitivity. Materials and Methods: Sixteen girls (aged 12–24 years) that developed long-lasting and invalidating somatoform symptoms occurring within 20 days postvaccination are included in this descriptive study. The hypersensitivity to five metals (aluminum, nickel, mercury, methyl mercury, and thimerosal) was measured by MELISA® test. Results: Seven girls showed negativity to all the five metals tested. The findings showed metal hypersensitivity only in nine patients: Toxicity to aluminum (two girls), reactivity to nickel (seven girls), followed by mercury (seven girls). Conclusion: The MELISA® assay is neither sensitive nor specific in detecting metal hypersensitivity and associated chronic diseases, including autoimmune pathologies.
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Histopathological study with immunohistochemical expression of vascular endothelial growth factor in placentas of hyperglycemic and diabetic women p. 227
Debashish Bhattacharjee, Santosh Kumar Mondal, Pratima Garain, Palash Mandal, Rudra Narayan Ray, Goutam Dey
DOI:10.4103/JLP.JLP_148_16  
Aims and Objectives: Spectrum of hyperglycemia in pregnancy includes gestational diabetes mellitus (GDM), mild hyperglycemia, and overt diabetes. Many authors have worked on morphological changes of the placenta in diabetes, but few studies have correlated histopathological changes with vascular endothelial growth factor (VEGF) immunoexpression. The aim of this study was to detect different histopathological changes in various groups of diabetic placentas and to correlate with VEGF immunoexpression. Materials and Methods: Pregnant women were screened for diabetes. They were subsequently divided into normoglycemic (12 cases), GDM (33 cases), mild hyperglycemic (13 cases), and overt diabetes (18 cases). Placentas collected were subjected to histopathological examination. VEGF expressions were studied by immunohistochemistry. Results: Overt diabetic placenta displayed villous immaturity (44.4%), villous edema (38.9%), chorangiosis (61.1%), fibrinoid substance deposition (38.9%), and Hofbauer cell hyperplasia in 44.4% cases. GDM placentas displayed villous immaturity (45.5%), villous edema (45.5%), chorangiosis (42.4%), and fibrinoid substance deposition in 75.6% cases. Mild hyperglycemic placentas displayed villous immaturity (38.5%), chorangiosis (61.5%), and fibrinoid substance deposition in 61.5% cases. VEGF immunoexpression in GDM placentas was absent in all placental components except syncytiotrophoblast. VEGF expression in overt diabetic placentas was increased in syncytiotrophoblast and capillary endothelium compared to normoglycemic placentas. Mild hyperglycemic placentas expressed similar VEGF expression in all components when compared to normoglycemic controls. However, it displayed weak expression in vessel endothelium. Conclusion: Histopathological changes in diabetic placentas might be a consequence of altered or abnormal VEGF expression in diabetic placentas. Pathogenesis and VEGF expression in GDM placentas are significantly different from overt diabetic placentas.
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Comparative evaluation of galactomannan test with bronchoalveolar lavage and serum for the diagnosis of invasive aspergillosis in patients with hematological malignancies p. 234
Ankit Gupta, Malini R Capoor, Trupti Shende, Bhawna Sharma, Ritin Mohindra, Jagdish Chander Suri, Dipender Kumar Gupta
DOI:10.4103/JLP.JLP_127_16  
Introduction: Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in patients with hematological malignancies. In recent years, testing for values of galactomannan (GM) in serum and bronchoalveolar lavage (BAL) fluid has been investigated as a diagnostic test for IPA for such patients, but global experience and consensus on optical density (OD) cutoffs, especially for BAL galactomannan remains lacking. Methods: We performed a prospective case–control study to determine an optimal BAL GM OD cutoff for IPA in at-risk patients. Cases were subjects with hematological diagnoses who met established revised definitions for proven or probable IPA established by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group (EORTC/MSG, 2008), without the use of BAL GM results. Exclusion criteria included the use of piperacillin/tazobactam and use of antifungals that were active against Aspergillus spp. before bronchoscopy. There were two control groups: patients with hematological diagnoses not meeting definitions for proven or probable IPA and patients with nonhematological diagnoses with no evidence of aspergillosis. Following bronchoscopy and BAL, GM testing was performed using the Platelia Aspergillus seroassay in accordance with the manufacturer's instructions. Results: There were 51 cases and 20 controls. Cases had higher BAL fluid GM OD indices (ODIs) (mean: 1.27 and range: 0.4–3.78) compared with controls (mean: 0.26 and range: 0.09–0.35). Receiver operating characteristic analysis demonstrated an optimum ODI cutoff of 1.0, with high specificity (100%) and sensitivity (87.5%) for diagnosing IPA. Conclusions: Our results support BAL GM testing as a reasonably safe test with higher sensitivity compared to serum GM testing in at-risk patients with hematological diseases. A higher OD cutoff is necessary to avoid overdiagnosis of IPA.
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Screening of methicillin-resistant Staphylococcus aureus in healthcare workers and students and its susceptibility to mupirocin in a tertiary care teaching hospital in South India p. 239
Jutang Babat Ain Tiewsoh, Meena Dias
DOI:10.4103/0974-2727.214262  
Background: Staphylococcus is the most common pathogen causing infection in hospitals. They also colonize the healthcare workers who serve as reservoir of infection. Emergence of methicillin-resistant Staphylococcus aureus (MRSA) is a burning issue throughout the world contributing to significant morbidity and mortality. Use of mupirocin to eradicate the carrier state is the need of the hour. Objectives: To screen healthcare workers (HCWs) and medical students for MRSA and to know the susceptibility of mupirocin in this group. Materials and Methods: A total of 432 students, nursing staff, doctors and house-keeping staff were screened for MRSA for 4 months. The MRSA and methicillin-resistant coagulase-negative Staphylococcus (MRCoNS) isolates were then tested for mupirocin resistance. Results: Out of 432 samples, 24 (5.55%) were MRSA and 104 (24.07%) were MRCoNS. Only 4.16% (n = 1) showed high-level resistance to mupirocin among the MRSA isolates, while resistance among MRCoNS was higher at 6.7% (n = 7) for low-level resistance and 17.30% (n = 18) for high-level resistance. Conclusion: MRSA colonization of HCWs may serve as a source of infection and mupirocin resistance should be screened for all whether working in Intensive Care Units or not and if detected, alternative treatment should be used which will result in appropriate use of this antibiotic for decolonization.
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Simultaneous determination of arginine, citrulline, and asymmetric dimethylarginine in plasma by reverse-phase high-performance liquid chromatography p. 243
P. V. L. N Srinivasa Rao, Aparna R Bitla
DOI:10.4103/JLP.JLP_70_16  
Background: Arginine, citrulline and asymmetric dimethylarginine (ADMA) are three molecules in the nitric oxide (NO) pathway which provide useful information about vascular endothelial function. ADMA accumulates with patients with chronic kidney disease (CKD) and inhibits NO synthesis. We describe the modification of a previously established method for the measurement of amino acids analysis for simultaneous detection of arginine, citrulline, and ADMA in plasma and to validate its performance in patients with CKD. Materials and Methods: Arginine, citrulline, and ADMA were simultaneously separated by reverse-phase high-performance liquid chromatography by precolumn derivatization with O-phthalaldehyde using the modified method. It was then applied for analysis in thirty patients with CKD and thirty healthy controls so as to cover the entire measuring range, i.e., normal and uremic range. Results: The method showed a good performance in terms of linearity, precision, and recovery. The detection limit of the assay for ADMA was found to be 0.05 μmol/L at a signal-to-noise ratio of 3:1. The average within run coefficient of variation for ADMA using this method was 4.7% in the normal range and 1.9% in the uremic range, while the average between-day precision in the normal and uremic range was 6.5% and 5.2%, respectively. Patients with CKD were found to have higher concentration of ADMA compared to controls. Conclusion: This method can be useful in assessing the baseline cardiovascular risk in an individual as well as in the follow-up of the patients who are receiving L-arginine, and thus, assess the response to treatment by simultaneous measurement of arginine and ADMA.
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Evaluation of different phenotypic tests for detection of metallo-β-lactamases in imipenem-resistant Pseudomonas aeruginosa p. 249
Rohit Sachdeva, Babita Sharma, Rajni Sharma
DOI:10.4103/JLP.JLP_118_16  
Purpose: Pseudomonas aeruginosa causes a wide spectrum of infections including bacteremia, pneumonia, urinary tract infection, etc., Metallo-beta-lactamase (MBL) producing P. aeruginosa is an emerging threat and cause of concern as they have emerged as one of the most feared resistance mechanisms. This study was designed to know the prevalence of MBL production in P. aeruginosa and to evaluate the four phenotypic tests for detection of MBL production in imipenem-resistant clinical isolates of P. aeruginosa. Methods: Totally, 800 isolates of P. aeruginosa isolated from various clinical samples were evaluated for carbapenem resistance and MBL production. All imipenem-resistant strains were tested for carabapenemase production by modified Hodge test. Screening for MBL production was done by double-disc synergy test and combined disc test (CDT). Confirmation of MBL production was done by the E-test (Ab BioDisk, Solna, Sweden). Results: Out of the 800 isolates of P. aeruginosa, 250 isolates were found resistant to imipenem. Based on the results of E-test, 147 (18.37%) isolates of P. aeruginosa were positive for MBL production. The CDT has the highest sensitivity and specificity for the detection of MBL production as compared to other tests. Conclusion: The results of this study are indicative that MBL production is an important mechanism of carbapenem resistance among P. aeruginosa. Use of simple screening test like CDT will be crucial step toward large-scale monitoring of these emerging resistant determinants. Phenotypic test for MBL production has to be standardized, and all the isolates should be routinely screened for MBL production.
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Use of culture- and ELISA-based toxin assay for detecting Clostridium Difficile, a neglected pathogen: A single-center study from a tertiary care setting p. 254
Sujata Lall, Gita Nataraj, Preeti Mehta
DOI:10.4103/JLP.JLP_157_16  
Introduction: Clostridium difficile is a Gram-positive spore-bearing anaerobic bacillus increasingly associated with both community- and hospital-acquired colitis and diarrhea. It is the most common identifiable bacterial cause of healthcare-associated diarrhea associated with antibiotic use and one of the most common anaerobic infections. The diagnosis of C. difficile infection includes detection of toxin A/B in stool specimens by direct enzyme immunoassay, culture of pathogen from the stool specimens using a selective agar Cycloserine-Cefoxitin fructose agar (CCFA), tissue culture assay, and detection of glutamate dehydrogenase an enzyme produced by C. difficile. With few reports from India on this disease, the present study was planned to throw more light on the prevalence and utility of laboratory diagnostic methods for C. difficile-associated diarrhea (CDAD). Material and Methods: After taking approval from the Ethics Committee, 150 patients with antibiotic-associated diarrhea were taken as a study group and fifty patients with exposure to antibiotics but who did not develop diarrhea were taken as controls. Stool specimen was processed for both culture on CCFA and toxin detection by IVD Tox A + B ELISA. Results: Only four specimens were culture positive, whereas 13 were ELISA positive. All culture-positive isolates were toxigenic. C. difficile was neither isolated nor its toxin detected in the control group. Culture- and toxin-based assays may not detect all cases of CDAD. Conclusion: Based on the results of the present study, culture does not provide any additional yield over toxin assay. Better diagnostic modalities would be required to prove CDAD.
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Correlations between gingival crevicular blood glucose and capillary blood glucose: A preliminary report p. 260
Siluvai Sibyl, Darshana Bennadi, Nandita Kshetrimayum, Maurya Manjunath
DOI:10.4103/JLP.JLP_141_16  
Introduction: Oral health plays an important role for screening of many systemic diseases. Hence, dentists play an important role in screening for systemic diseases as well. Early diagnosis of any systemic diseases can prevent long-term complications. Diabetic is one of the common chronic diseases. Hence, the study had been undertaken to evaluate whether gingival crevicular blood (GCB) can be used to screen for diabetes during routine oral health checkups. Materials and Methods: This analytical study included thirty participants who visited the Department of Periodontics, who fulfilled inclusion criteria and were willing to participate. Blood samples were collected by finger stick method and periodontal probing. The glucose levels of both the samples were estimated using glucometer and correlated the levels from both the methods. Results: Correlation between capillary finger stick blood glucose and GCB glucose was high (0.97) and was significant at 0.01 level. Conclusion: Blood oozing during routine periodontal examination can be used for diabetes mellitus screening in dental office.
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Changing prevalence and antibiotic drug resistance pattern of pathogens seen in community-acquired pediatric urinary tract infections at a tertiary care hospital of North India p. 264
Vrushali Patwardhan, Dinesh Kumar, Varun Goel, Sarman Singh
DOI:10.4103/JLP.JLP_149_16  
b>Introduction: Timely treatment of urinary tract infection (UTI) with appropriate antibiotic administration is of immense importance in children to reduce the consequences. Aims and Objectives: The aim and objective of this study was to assess the temporal changes in the microbiological profiles and antimicrobial resistance patterns of uropathogens in pediatric community-acquired UTI. Materials and Methods: This is a retrospective analysis of data collected over a Scattered period of 5 years. The baseline data collected were from January to December 2009, and the second period considered for comparison was from January to December 2014. Urine specimens from children (<17 years) suspected of UTI were cultured by a semi-quantitative method on cysteine lactose electrolyte-deficient medium. Antibiotic sensitivity was put up by Kirby–Bauer disc diffusion method as per the Clinical and Laboratory Standard Institute guidelines. Results: In the year 2009, 340 of 2104 (16.15%) urine specimens yielded significant colony count, whereas in 2014, it was 407 of 2212 (18.39%) (P = 0.051). Escherichia coli was the predominant pathogen and was significantly more prevalent in girls than in boys (P < 0.0001) during both periods. There was a significant overall increase in resistance to ampicillin (from 40.29% to 58.72%), amoxyclav (from 26.17% to 40.54%), nitrofurantoin (from 28.82% to 39.06%), and norfloxacin (from 30% to 41.42%). However, the maximum increase in the resistance was noted for co-trimoxazole from 35.58% in 2009 to 63.39% in 2014 (P = 0.0000058). The prevalence of extended-spectrum beta-lactamases (ESBLs) has also significantly increased from 21.7% to 33.16% (P = 0.0045). Conclusion: Although E. coli remains the prime pathogen in pediatric UTI, the prevalence of resistance has dramatically increased over the 5-year study period. Our study highlights the emergence of community-acquired ESBL-producing uropathogens in children proclaiming treatment challenges.
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Evaluation of Nordmann, Dortet, and Poirel test for the identification of extended spectrum betalactamase production among urinary isolates of Escherichia coli p. 269
R Deepa, Mythry Ravichandran, S Thasneem Banu, R Sharmila
DOI:10.4103/JLP.JLP_154_16  
Context: Current phenotypic techniques for extended spectrum beta lactamase (ESBL) detection can be interpreted after 24 h of incubation only, resulting in a delay in initiating therapy. Nordmann, Dortet, and Poirel (NDP) in 2012 proposed a novel test named ESBL NDP to overcome this limitation. Aims: This study aimed to evaluate the ESBL NDP test for the identification of ESBL among Escherichia coli isolates against the Clinical Laboratory Standards Institute-recommended phenotypic confirmatory method. Settings and Design: This cross-sectional study was conducted over a period of 3 months on a sample size of 100. Subjects and Methods: One hundred nonduplicate clinically significant E. coli urinary isolates positive by initial screening test for ESBL were subjected to the ESBL NDP test and phenotypic confirmatory test. The NDP test was evaluated by determining the sensitivity, specificity, kappa value, and confidence interval (CI) for kappa. Results: The phenotypic confirmatory test and the ESBL NDP test were positive in 82% and 63% of the isolates, respectively. ESBL NDP test had a sensitivity and specificity of 76% and 100%, positive and negative predictive values of 100% and 48%, respectively, kappa value of 0.54 (moderate agreement), and 95% CI for kappa of 0.43–0.66. The time to positivity was 1 h in 93.6% of the isolates. Conclusion: The NDP test showed a good specificity, with time to positivity of 1 h. The low sensitivity could be due to the difference in the phenotypic type of ESBL producer and technical reasons.
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Care bundle approach to reduce device-associated infections in a tertiary care teaching hospital, South India p. 273
Suman Susan Prakash, Deepashree Rajshekar, Anusha Cherian, Apurba Sankar Sastry
DOI:10.4103/JLP.JLP_162_16  
Context: The care bundle approach is a set of evidence-based practices that when performed collectively and reliably have been shown to improve the patient outcome. Aims: To evaluate the impact of the bundle care approach on reducing device-associated infections (DAIs). Settings and Design: The study was conducted at a tertiary care hospital, South India. The study period was from January 2016 to September 2016 which was divided into three phases, each comprising 3 months. Subjects and Methods: During the implementation phase, bundle care forms were implemented in all Intensive Care Units (ICUs) and the ICU staff were given a basic education on the importance of bundle care approach. The DAI rates (ventilator-associated pneumonia [VAP] rates, central line-associated bloodstream infection [CLABSI] rate, and catheter-associated urinary tract infection [CAUTI] rate) were calculated throughout the study period. Statistical Analysis Used: Statistical analysis was performed using SPSS 19 software. Results: During preimplementation phase, the VAP rate, CLABSI rate, and CAUTI rate were 14.79, 4.98, and 4.86 per 1000 device days, respectively. Rates were reduced to 13.03, 3.98, and 3.39 per 1000 device days, respectively, during the implementation phase and further reduced into 11.91, 3.49, and 2.36 per 1000 device days during the postimplementation phase. The month-wise decreasing trend of DAI rates was significant for medical ICUs as compared to surgical and pediatric ICUs. Conclusions: The month-wise decreasing trend of VAP rate, CLABSI rate, and CAUTI rate was noted, which signifies that the use of care bundle approach has a great impact on reducing DAIs
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Identification of genus Acinetobacter: Standardization of in-house PCR and its comparison with conventional phenotypic methods p. 279
Sughosh S Kulkarni, Radhika Madalgi, Ganavalli S Ajantha, Raghavendra D Kulkarni
DOI:10.4103/0974-2727.214263  
Background: Acinetobacter is grouped under nonfermenting Gram-negative bacilli. It is increasingly isolated from pathological samples. The ability of this genus to acquire drug resistance and spread in the hospital settings is posing a grave problem in healthcare. Specific treatment protocols are advocated for Acinetobacter infections. Hence, rapid identification and drug susceptibility profiling are critical in the management of these infections. Aims: To standardize an in-house polymerase chain reaction (PCR) for identification of genus Acinetobacter and to compare PCR with two protocols for its phenotypic identification. Methodology: A total of 96 clinical isolates of Acinetobacter were included in the study. An in-house PCR for genus level identification of Acinetobacter was standardized. All the isolates were phenotypically identified by two protocols. The results of PCR and phenotypic identification protocols were compared. Results: The in-house PCR standardized was highly sensitive and specific for the genus Acinetobacter. There was 100% agreement between the phenotypic and molecular identification of the genus. The preliminary identification tests routinely used in clinical laboratories were also in complete agreement with phenotypic and molecular identification. Conclusion: The in-house PCR for genus level identification is specific and sensitive. However, it may not be essential for routine identification as the preliminary phenotypic identification tests used in the clinical laboratory reliably identify the genus Acinetobacter.
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Seroprevalence of transfusion transmitted infections in healthy blood donors: A 5-year Tertiary Care Hospital experience p. 283
Sushama A Chandekar, Gaythri P Amonkar, Heena M Desai, Nitin Valvi, Gururaj V Puranik
DOI:10.4103/0974-2727.214246  
Introduction: Transfusion transmitted infections (TTIs) can cause threat to bloody safety as blood transfusion is an important mode of transmission of TTI to the recipient, hence, to prevent transmission of these diseases, screening tests on blood bags is an important step for blood safety. Aim: This study was undertaken with the aim of determining the seroprevalence of TTI in healthy blood donors in a tertiary care blood bank. Materials and Methods: A retrospective study was carried out over a period of 5 years from January 2007 to December 2011. Serum samples were screened for hepatitis B surface antigen (HBsAg), antibodies to human immunodeficiency virus (HIV) Type 1 and 2, hepatitis c virus (HCV) and syphilis using enzyme-linked immunosorbent assays with the third generation kits and venereal disease research laboratory test, respectively. Results: A total of 76,653 healthy donors were included out of which majority of donors were male (91.79%). The overall seroprevalence of HIV, HBsAg, HCV, and syphilis were 0.26%, 1.30%, 0.25%, and 0.28%, respectively. Conclusion: Methods to ensure a safety blood supply should be encouraged. For that, screening with a better selection of donors and use of sensitive screening tests including nucleic acid testing technology should be implemented.
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Clinical manifestations of nocardiosis: Study of risk factors and outcomes in a tertiary care hospital p. 288
Teena Wadhwa, Usha Baveja, Navin Kumar, Deepak Govil, Sharmila Sengupta
DOI:10.4103/JLP.JLP_111_16  
Purpose: The aim of this study is to evaluate the predisposing risk factors, clinical presentations, laboratory parameters, and treatments taken and outcomes in patients of nocardiosis in the span of 5 years in a tertiary care hospital. Materials and Methods: The patients whose specimens showed Nocardia like organism in Gram-staining, Kinyoun staining and characteristic colonies in culture were included in the retrospective analysis study. Retrospective analysis of associated risk factors, clinical presentations, and radiological findings was performed. Results: Of the thirteen patients, 11 (76.9%) had immunosuppressive pathologies including solid organ transplantation, autoimmune disease, use of steroids, and immunosuppressive drugs as important risk factors. Four types of clinical manifestations were observed, pulmonary (46.1%), cutaneous (23.07%), cerebral (15.3%), and bacteremia (15.3%). The most common presentation was pulmonary with steroid therapy as a significant risk factor. Consolidation and pleural effusion were the common radiological findings in these cases. In eight of the nine patients anti-nocrdial drugs were given. Cotrimoxazole as monotherapy was given in four cases (44.44%), cotrimoxazole in combination with meropenem in two cases (22.22%); minocycline and linezolid were given in one case each. The overall mortality was 36.36% and was seen in patients with pulmonary nocardiosis. Conclusions: The study indicates that Nocardial infections are re-emerging on account of an increase in numbers of immunocompromised patients due to increased organ transplants, autoimmune diseases, malignancies, and use of immunosuppressive drugs and steroids. The diagnosis is often missed/not suspected and delayed because of the clinical resemblance to many other infections. Nocardial infection should be suspected and assessed particularly in immunocompromised patients not responding to treatment/improving clinically.
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Nine year trends of dengue virus infection in Mumbai, Western India p. 296
Jayanthi Shastri, Manita Williamson, Nilima Vaidya, Sachee Agrawal, Om Shrivastav
DOI:10.4103/JLP.JLP_169_16  
Introduction: Dengue virus (DENV) causes a wide range of diseases in humans, from acute febrile illness Dengue fever (DF) to life-threatening Dengue hemorrhagic fever (DHF) or Dengue shock syndrome (DSS). Factors believed to be responsible for spread of Dengue virus infection include explosive population growth, unplanned urban overpopulation with inadequate public health systems, poor standing water and vector control, climate changes and increased international recreational, business, military travel to endemic areas. All of these factors must be addressed to control the spread of Dengue and other mosquito-borne infections. The detection of Dengue virus RNA by reverse transcriptase PCR (RT-PCR) in human serum or plasma samples is highly indicative of acute Dengue fever. Moreover, the method is able to identify the Dengue virus serotype by demonstrating defined sequence homologies in the viral genomic RNA. Methods and Results: During the nine year period of this study analysis, 6767 strongly suspected cases were tested by RT-PCR. 1685 (24.9%) were Dengue PCR positive and confirmed as Dengue cases. Observations on the seasonality were based on the nine year's data as the intensity of sampling was at its maximum during monsoon season. Dengue typing was done on 100 positive samples after storage of Dengue RNA at – 80°C. Dengue serotypes were detected in 69 samples of which Dengue 2 was most predominant. 576 samples were processed for NS1 antigen and PCR simultaneously. 19/576 were positive (3.3 %) for NS1 as well as by PCR . 23/576 samples were negative for NS1 antigen, but were positive by RT-PCR. The remaining 534 samples which were negative for NS1 antigen were also negative by Dengue RT-PCR. Conclusion: In this study we sought to standardize rapid, sensitive, and specific fluorogenic probe-based RT-PCR assay to screen and serotype a representative range of Dengue viruses that are found in and around Mumbai. Qualitative Dengue virus TaqMan assays could have tremendous utility for the epidemiological investigation of Dengue illness and especially for the study of the viremic response with candidate live-attenuated dengue virus vaccines.
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Simple, rapid, and cost-effective modified Carba NP test for carbapenemase detection among Gram-negative bacteria p. 303
Shoorashetty Manohara Rudresh, Giriyapur Siddappa Ravi, Lakshminarayanappa Sunitha, Sadiya Noor Hajira, Ellappan Kalaiarasan, Belgode Narasimha Harish
DOI:10.4103/JLP.JLP_138_16  
Purpose: Detection of carbapenemases among Gram-negative bacteria (GNB) is important for both clinicians and infection control practitioners. The Clinical and Laboratory Standards Institute recommends Carba NP (CNP) as confirmatory test for carbapenemase production. The reagents required for CNP test are costly and hence the test cannot be performed on a routine basis. The present study evaluates modifications of CNP test for rapid detection of carbapenemases among GNB. Materials and Methods: The GNB were screened for carbapenemase production using CNP, CarbAcineto NP (CANP), and modified CNP (mCNP) test. A multiplex polymerase chain reaction (PCR) was performed on all the carbapenem-resistant bacteria for carbapenemase genes. The results of three phenotypic tests were compared with PCR. Results: A total of 765 gram negative bacteria were screened for carbapenem resistance. Carbapenem resistance was found in 144 GNB. The metallo-β-lactamases were most common carbapenemases followed by OXA-48-like enzymes. The CANP test was most sensitive (80.6%) for carbapenemases detection. The mCNP test was 62.1% sensitive for detection of carbapenemases. The mCNP, CNP, and CANP tests were equally sensitive (95%) for detection of NDM enzymes among Enterobacteriaceae. The mCNP test had poor sensitivity for detection of OXA-48-like enzymes. Conclusion: The mCNP test was rapid, cost-effective, and easily adoptable on routine basis. The early detection of carbapenemases using mCNP test will help in preventing the spread of multidrug-resistant organisms in the hospital settings.
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Spectrum of meningioma with special reference to prognostic utility of ER,PR and Ki67 expression p. 308
Madhumita Mukhopadhyay, Chhanda Das, Madhu Kumari, Ankita Sen, Bedabrata Mukhopadhyay, Biswanath Mukhopadhyay
DOI:10.4103/JLP.JLP_158_16  
Background: Meningiomas are the most common primary central nervous system neoplasms originating from the arachnoid cap cells and constitute between 13% and 26% of all intracranial tumors. Aims and Objectives: The aim of the study was to analyze the age-, sex-, and site-wise distribution of different histological patterns of meningiomas seen in our center and to assess the status of estrogen receptor (ER), progesterone receptor (PR), and proliferation marker Ki-67 in various grades of meningioma. Materials and Methods: A prospective study was done in 90 cases. Patients presented with symptoms of headache and seizure and underwent subsequent excision surgery at Neurosurgery Department were taken. We have studied histological typing and grading of the tumors, and immunohistochemical staining was done for ER, PR, and Ki-67. Statistical Analysis: Two-group comparison was done using Mann–Whitney U-test and Fisher's exact test. Comparison of Ki-67 expression between Grade 1 and Grade 2 meningiomas was determined using Mann–Whitney U-test. Comparison of ER and PR status between different histological grades was done by Fisher's exact test. Two-tailed P < 0.001 was considered statistically significant. Results: According to histological type, meningothelial meningioma is most common (38.8%) followed by transitional (22.2%). PR positivity is seen in 96.34% of Grade 1 tumors, and all Grade 2 tumors were PR negative (Fisher's exact test P < 0.001). About 3.66% of Grade 1 and all Grade 2 tumors were positive for ER (Fisher's exact test two-tailed P < 0.001). Mean Ki-67 labeling index (LI) was 2.57 ± 1.674 among Grade I tumors, 7.11 ± 1.084 in Grade II meningiomas. Conclusions: Most of Grade 1 meningiomas show PRs positivity and lack of ERs positivity. Meningiomas with higher proliferation index and negative PR are very likely to be Grade II or Grade III. Evaluation of ER, PR status, and Ki-67 labeling index (LI) with histological evaluation helps us in providing information about the biologic behavior of meningiomas.
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High prevalence of clindamycin resistance in Staphylococcus aureus blood culture isolates in São Paulo, Brazil p. 314
Felipe S Lupinacci, Daniel Bussius, Felipe Acquesta, Gustavo Fam, Raphael Rossi, Alessandra Navarini, Marcelo J Mimica
DOI:10.4103/JLP.JLP_161_16  
Background: Clindamycin has become an important antimicrobial option for the treatment of Staphylococcus aureus. However, little is known about the current patterns of clindamycin-susceptibility in S. aureus invasive isolates, both in our country and in other developing countries in the world. Aims: The aim of this study was to determine the prevalence of constitutive and inducible clindamycin resistance in methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) blood culture isolates in São Paulo, Brazil. Materials and Methods: From July 2011 to June 2012, all S. aureus isolates from blood cultures collected at our hospital were included in the study. Antimicrobial susceptibility testing was performed according to recommendations of the Clinical and Laboratory Standards Institute. Results: Total prevalence of clindamycin resistance was 68%, including 7.2% with inducible resistance. In MRSA resistance rate was 90.8% whereas in MSSA the rate was 32.7%. Conclusions: Our high prevalence of clindamycin resistance highlights the importance of performing D-test in a routine base, as well of maintaining continued surveillance for the prevalence of clindamycin resistance.
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Antimicrobial resistance profile of Methicillin-resistant Staphylococcus aureus colonizing the anterior nares of health-care workers and outpatients attending the remotely located tertiary care hospital of North India p. 317
Seema Singh, Rubina Malhotra, Pragati Grover, Renu Bansal, Shipra Galhotra, Rupinderjit Kaur, Neerja Jindal
DOI:10.4103/JLP.JLP_8_17  
Introduction: Resistance to antimicrobial agents is a major concern worldwide and is exemplified by the global spread of the Methicillin resistant Staphylococcus aureus (MRSA). Health care workers (HCWs) and asymptomatically colonized patients are important sources of nosocomial MRSA infections. Aims and Objectives: To determine the prevalence of MRSA colonisation, two hundred HCWs and 200 consecutive outpatients attending our tertiary care hospital were studied. Material and Methods: Two sterile pre-moistened cotton tipped swabs were used to collect specimens from their anterior nares. These were inoculated immediately on Blood agar with oxacillin, Mannitol salt agar with oxacillin and CHROM agar. Resistance to cefoxitin was confirmed by PCR by demonstration of mecA gene. Antibiotic susceptibility was determined by Kirby Bauer's disc diffusion method and MIC of vancomycin by using broth dilution and Vitek-2 Compact system. Results: The nasal carriage of MRSA among HCWs was found to be 7.5% and in outpatients 3%. All strains of MRSA from HCWs and outpatients grew on three selective media and mecA gene amplified in all of them. All the isolated strains of MRSA showed high degree of resistance to co-trimoxazole (93.3%), ciprofloxacin (80%) and erythromycin (66.66%). However, there was 100% susceptiability to vancomycin, teicoplanin, linezolid and Rifampicin. Conclusion: Although a direct casual relationship could not be established, it could be assumed that the transmission from colonised health care worker is responsible atleast in part for MRSA infection among patients. Therefore emphasis should be laid on strict implementation of standard infection control practices which would help in minimizing the carriage and transmission of MRSA in the hospital.
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CASE REPORTS Top

Metastasis of renal cell carcinoma to urinary bladder: A rare case report with review of literature p. 322
Saha Arpita, Jain Manoj, Saha Kaushik, Srivastava Anish
DOI:10.4103/JLP.JLP_108_16  
Metachronous metastatic renal cell carcinoma (RCC) to bladder is rare incidence. We report a case of RCC with metachronous metastasis to the urinary bladder occurring 2 years postradical nephrectomy. In a follow-up for the past 1 year, the patient is doing well. To the best of our knowledge, this case is the second case of bladder metastasis from RCC in the Indian literature. We reviewed literature and discuss the histopathological features of bladder metastasis of RCC.
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Chromobacterium violaceum- induced sepsis and multiorgan dysfunction, resembling melioidosis in an elderly diabetic patient: A case report with review of literature p. 325
Sagar Khadanga, Tadepalli Karuna, Dharmendra Dugar, Shakti Prasad Satapathy
DOI:10.4103/JLP.JLP_21_17  
An elderly diabetic farmer presented with chronic nonhealing ulcer over the left foot, multiple liver abscesses, and right-sided pleural effusion. The patient developed septicemia and multiorgan failure. The pus grew pigment producing Chromobacterium violaceum. He was treated successfully with ciprofloxacin for a total duration of 15 days. This case is reported for its rare clinical presentation and resemblance with melioidosis. Of the 200 C. violaceum cases reported across the globe, this is the 14th case from India and the oldest in the literature.
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Hypertriglyceridemia-induced acute pancreatitis with diabetic ketoacidosis: A rare presentation of type 1 diabetes mellitus p. 329
Prabhat Kumar, Abhishek Sakwariya, Amit Ranjan Sultania, Renu Dabas
DOI:10.4103/JLP.JLP_53_17  
Diabetic ketoacidosis (DKA) is a frequently encountered complication of diabetes mellitus. DKA is an insulin deficit state and results in moderate to severe hypertriglyceridemia (HTG). HTG is the third leading cause of acute pancreatitis (AP) and often goes unnoticed. The triad of DKA, HTG, and AP is rarely seen, and literature on the same is sparse. We report a case of AP which was due to DKA-induced secondary HTG in an adult with previously undiagnosed type 1 diabetes. His HbA1c was significantly raised, and C-peptide level was low, confirming chronic hyperglycemia. He was treated successfully with insulin infusion, intravenous crystalloid, and analgesics.
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Rare presentation of mixed autoimmune hemolytic anemia in children: Report of 2 cases p. 332
Preeti Rai, Geetika Sharma, Deeksha Singh, Jyoti Garg
DOI:10.4103/JLP.JLP_95_17  
Immune hemolytic anemia is characterized by clinical and laboratory features of hemolytic anemia with direct antiglobulin test (DAT) positivity. It could be autoimmune hemolytic anemia (AIHA), alloimmune, or drug-induced hemolysis based on the antigenic stimulus. Furthermore, based on thermal amplitude of autoantibody, AIHA is classified as warm (65%), cold (30%), and mixed (5%) type. Mixed AIHA is extremely rare in children and must be differentiated from warm AIHA with clinically insignificant cold agglutinins and cold hemagglutinin disease as their treatment is different. It may present as blood group discrepancy or cross-match incompatibility leading to delay in arranging suitable blood unit for transfusion. Therefore, a thorough immunohematology workup including monospecific DAT, indirect antiglobulin test at 4°C and 37°C, determination of thermal amplitude and titer is essential. We hereby present two pediatric cases of mixed AIHA presenting as ABO forward and reverse blood group discrepancy and cross-match incompatibility.
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Chronic osteomyelitis by Aeromonas hydrophila: A silent cause of concern p. 337
Sonu Agrawal, Deepankar Srigyan, Hira L Nag, Arti Kapil, Benu Dhawan
DOI:10.4103/JLP.JLP_45_17  
Aeromonas is a Gram-negative bacillus, widely found in aquatic environment. Osteoarticular pathology caused by Aeromonas hydrophila is rarely encountered. To the best of our knowledge, this is the first case of chronic osteomyelitis by A. hydrophila reported from India. We report a case of chronic osteomyelitis of the lower limb due to A. hydrophila, which occurred as a delayed complication following open reduction and internal fixation. Prompt medical and surgical intervention supplemented by a comprehensive microbiological workup aided in pathogen identification and specific antimicrobial administration resulting in the successful outcome of our patient. This case illustrates the utility of multidisciplinary management approach involving microbiologists and orthopedicians in investigating and appropriately managing such cases.
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Triad of infective endocarditis, splenic abscess, and septicemia caused by Brucella melitensis p. 340
Shashank Purwar, Sharada C Metgud, Shankar G Karadesai, Mahantesh B Nagamoti, Arathi Darshan, Shreshtha Tiwari
DOI:10.4103/JLP.JLP_12_17  
A 40-year-old farmer from the district of North Karnataka who had received treatment for high fever of 8 days duration was admitted with fever, dyspnea, and poor general condition. Ultrasonography and echocardiogram revealed multiple splenic abscesses, vegetation on atrioventricular valve, aortic regurgitation (Grade I–II), and mitral valve regurgitation (Grade II–III), respectively. Brucella melitensis was detected in blood culture, and high titers of IgM and IgG anti-Brucella antibodies were observed in Brucella specific serological tests. The patient developed fulminant septicemia and succumbed due to multi-organ failure.
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LETTERS TO THE EDITOR Top

Estimated glomerular filtration rate and urine albumin-to-creatinine ratio are renal markers associated with risks of cardiovascular diseases p. 343
Pradeep Sharma
DOI:10.4103/JLP.JLP_52_17  
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Utility of hepatitis C virus RNA as the screening test for diagnosing hepatitis C virus infection in hemodialysis patients p. 345
Supriya Mahajan, Suman Lata Nayak, Ekta Gupta
DOI:10.4103/JLP.JLP_99_17  
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