Amp C β-lactamases are clinically important cephalosporinases encoded on the chromosomes of many Enterobacteriaceae and a few other organisms, where they mediate resistance to cephalothin, cefazolin, cefoxitin, most penicillins, and β-lactamase inhibitor/β-lactam combinations. The increase in antibiotic resistance among Gram-negative bacteria is a notable example of how bacteria can procure, maintain and express new genetic information that can confer resistance to one or several antibiotics. Detection of organisms producing these enzymes can be difficult, because their presence does not always produce a resistant phenotype on conventional disc diffusion or automated susceptibility testing methods. These enzymes are often associated with potentially fatal laboratory reports of false susceptibility to β-lactams phenotypically. With the world-wide increase in the occurrence, types and rate of dissemination of these enzymes, their early detection is critical. AmpC β-lactamases show tremendous variation in geographic distribution. Thus, their accurate detection and characterization are important from epidemiological, clinical, laboratory, and infection control point of view. This document describes the methods for detection for AmpC β-lactamases, which can be adopted by routine diagnostic laboratories.

Background: There are sporadic reports on detection of extended-spectrum beta-lactamases (ESBL) producers from Karnataka; hence, this is a first multicentric study across Karnataka state to determine the prevalence of ESBL production among clinical isolates of Escherichia coli and Klebsiella pneumoniae. Aims and objectives: To determine the prevalence of ESBL producing clinical isolates of E. coli and K. pneumoniae from five geographically distributed centers across Karnataka, to study the susceptibility of ESBL producing isolates to other beta-lactam and beta-lactam-beta-lactamase inhibitors and to demonstrate transferability of plasmids coding for ESBL phenotype. Materials and Methods: Two hundred isolates of E. coli and K. pneumoniae each were collected from each of the five centers (Bellary, Dharwad, Davangere, Kolar and Mangalore). They were screened for resistance to screening agents (ceftazidime, cefotaxime, ceftriaxone, aztreonam) and positive isolates were confirmed for ESBL production by test described by Clinical and Laboratory Standards Institute . Co-production of ESBL and AmpC beta-lactamase was identified by using amino-phenylboronic acid disk method. Susceptibility of ESBL producers to beta-lactam antibiotics and beta-lactamase inhibitors was performed. Transferability of plasmids was performed by conjugation experiment. Results: Overall prevalence of ESBL production among E. coli and K. pneumoniae across five centers of the state was 57.5%. ESBL production was found to be 61.4% among E. coli and 46.2% among K. pneumoniae. ESBL production was significantly more among E. coli than K. pneumoniae. Significant variations in distribution of ESBL across the state was observed among E. coli isolates, but not among K. pneumoniae isolates. All ESBL producers demonstrated minimum inhibitory concentration levels ≥2 μg/ml towards cefotaxime, ceftazidime and ceftriaxone. Conclusion: Overall prevalence of ESBL production among clinical isolates of E. coli and K. pneumoniae across Karnataka state was high. The prevalence of ESBL production was significantly higher with E. coli than K. pneumoniae isolates. Higher rates of resistance to ceftriaxone and cefotaxime than to ceftazidime suggests the possibility of presence of CTX-M type ESBLs. Of all the beta-lactam/beta-lactamase inhibitor combinations tested, cefepime-tazobactam demonstrated highest in-vitro activity against ESBL producers. There was no statistical difference in the transferability of plasmids among E. coli and K. pneumoniae.

Background: Isolation of Brucella is the gold standard in the laboratory diagnosis of brucellosis. As Brucella is intracellular and the number of circulating bacteria is usually low, removal/dilution of antibacterial substances, concentration of bacteria and optimal culture conditions may enhance the rate of isolation. Aims and Objectives: The objective of the following study was to compare the lysis concentration (LC), clot culture and conventional Castaneda blood culture techniques for the isolation rate and recovery time in the diagnosis of human brucellosis. Materials and Methods: Blood cultures by LC, clot culture and conventional method were performed in 169 patients who had antibody titers ≥160 international units by the serum agglutination test. Results: Overall blood culture positivity was found to be 24.8%, 43.1% and 34.9% by conventional, LC and clot culture techniques in that order. The mean recovery time by LC and clot culture techniques was significantly less than conventional method, resulting in an overall difference of nearly 6 and 4 days respectively. Conclusions: For the isolation of Brucella from blood, LC and clot culture techniques are better than the conventional technique.

Background: Schistosomiasis is one of the neglected tropical diseases caused by a trematode, Schistosoma spp, and affects many systems in the body including the gastrointestinal tract. Schistosomiasis of the appendix is a well-recognized disease and presents as a chronic granulomatous inflammation. This study aims to document the frequency and pattern of distribution of schistosomal appendicitis in our environment. Materials and Methods: This is a retrospective histopathological review of schistosomiasis of the appendix in the Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria - Nigeria, between January 1, 1991 to December 31, 2012. Results: Within the study period, there were 1,464 appendectomy specimens histologically examined in the Pathology Laboratory. Thirty of these, representing 2.1%, were diagnosed as schistosomiasis of the appendix. The male:female ratio was 6.5:1 and peak age incidence was in the 20-29 years age group. Abdominal pains, vomiting and fever were seen in 23 (76.7%) and altered bowel motion in seven (23.3%) patients. Conclusion: This study showed that schistosomiasis of the appendix is not rare and that its presentation is similar to other forms of appendicitis. There is a need to focus on the prevention of schistosomiasis in order to reduce morbidity among these economically viable age groups.

Purpose: Bloodstream infections (BSIs) are one of the major life-threatening infections in hospitals. They are responsible for prolonged hospital stays, high healthcare costs, and significant mortality. The epidemiology of BSIs varies between hospitals necessitating analysis of local trends. Few studies are available on trauma patients, who are predisposed due to the presence of multiple invasive devices. Materials and Methods: A prospective surveillance of all BSIs was done at a level 1 trauma center from April, 2011 to March, 2012. All patients admitted to the different trauma intensive care units (ICUs) were monitored daily by attending physicians for subsequent development of nosocomial BSI. An episode of BSI was identified when patients presented with one or more of the following signs/symptoms, that is, fever, hypothermia, chills, or hypotension and at least one or more blood culture samples demonstrated growth of pathogenic bacteria. BSIs were further divided into primary and secondary BSIs as per the definitions of Center for Disease Control and Prevention. All patients developing nosocomial BSIs were followed till their final outcome. Results: A total of 296 episodes of nosocomial BSIs were observed in 240 patients. A source of BSI was identified in 155 (52%) episodes. Ventilator-associated pneumonia was the most common source of secondary BSI. The most common organism was Acinetobacter sp. (21.5%). Candida sp. accounted for 12% of all blood stream organisms. A high prevalence of antimicrobial resistance was observed in Gram-negative and-positive pathogens. Conclusions: Trauma patients had a high prevalence of BSIs. Since secondary bacteremia was more common, a targeted approach to prevention of individual infections would help in reducing the burden of BSIs.

Introduction: Vulvovaginal candidiasis is one of the most common infections seen in women. Materials and Methods: A total of 300 symptomatic women were studied. High vaginal swabs collected from each patient were processed by Gram stain, culture on Sabourauds dextrose agar and CHROM agar plates. Isolates were identified and speciated using conventional methods and by the color of the colonies on the CHROM agar. Antifungal susceptibility was performed by disc diffusion method for fluconazole (25 μg) and voriconazole (1 μg) discs as per Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: Vulvovaginal candidiasis was found in 53 (17.7%) of cases. Gram stain was positive in 22 (41.41%) of culture positives. Speciation of isolates by conventional and CHROM agar methods showed similar results. C. albicans 35 (66.0%) was the most common species isolated followed by C. tropicalis 14 (26.4%), C. krusei 2 (3.8%), C. parapsilosis and C. glabrata in 1 (1.9%) case each. Sensitivity to fluconazole was found in 91.4% of C. albicans, 57.1% of C. tropicalis and 50.0% of C. krusei. Sensitivity to voriconazole was seen in 91.4% of C. albicans, 85.7% of C. tropicalis and 50.0% of C. krusei. C. parapsilosis and C. glabrata were found sensitive only to voriconazole. Conclusion: CHROM agar has the advantage of being rapid, simple and cost effective method as compared to conventional methods in speciation of Candida. Routine susceptibility testing of Candida isolates help in selecting the most appropriate antifungal agent for vulvovaginal candidiasis.

Context: The appropriate collection and preservation of soft tissues from putrefied unidentifiable human corpse for the purpose of identification using DNA profiling technique is critically important especially in developing countries like India having different levels of health-care set ups with largely varying facilities and varying climatic conditions. Aims: The present study was carried out, mainly focusing on quality and quantity of extracted DNA from the soft tissues of putrefied unidentifiable human corpse stored upto 4 weeks at 4°C and at −80°C for DNA analysis. Materials and Methods: The present study was conducted on 16 different putrefied unidentifiable human corpses after getting approval from institutional ethical committee. Around 2 g of four different tissues (brain, kidney, heart and muscle) were collected and preserved for one month followed by DNA extraction using the organic method, the quality and quantity of high molecular weight-DNA was estimated using the spectrophotometer and gel electrophoresis. Further, the amplification polymerase chain reaction (PCR) was also performed (AmpFLSTR ^® Indentifiler™ PCR Amplification kit for multiple loci, of Applied Biosystems, Lab India) and was checked using continuous PAGE. Results: The yield of DNA was significantly higher at −80°C for all the four tissues collected and was best for brain followed by heart, kidney and worst for muscles in all cases. Conclusions: It is suggested that the brain tissue preserved at −80°C is the best among soft issues for DNA extraction. Refrigeration or deep freezing facility should be available at all the centers.

Background: There is an alarming rate of morbidity and mortality observed in the trauma victims who suffer spinal cord injuries (SCI). Such patients are admitted immediately and stay for longer periods of time and thus are at risk of acquiring nosocomial infections. Aims: The aim of this study is to analyze the primary cause of mortality in SCI patients. Design: Retrospective study. Materials and Methods: We conducted a retrospective 4 year analysis of the postmortem data of 341 patients who died after sustaining SCI at a tertiary care apex trauma center of India. Epidemiological data of patients including the type of trauma, duration of hospital stay, cause of death and microbiological data were recorded. Results: On autopsy, out of 341 patients, the main cause of death in the SCI patients was ascertained to be infection/septicemia in 180 (52.7%) patients, the rest 161 (47.2%) died due to severe primary injury. Respiratory tract infections (36.4%) were predominant followed by urinary tract infections (32.2%), blood stream infections (22.2%), wound infections (7.1%) and meningitis reported in only 5 (2.1%) cases. Acinetobacter sp (40%) was the predominant organism isolated, followed by Pseudomonas sp (16.3%), Klebsiella sp (15.1%), Candida sp (7.8%), Escherichia coli (6.9%), Staphylococcus aureus (6.9%), Proteus sp (3.3%), Enterobacter sp and Burkholderia sp (two cases each) and Stenotrophomonas sp (one case). A high level of multidrug resistance was observed. Conclusions: Hospital acquired infections (HAI) are leading cause of loss of young lives in trauma patients; hence efforts should be made to prevent HAIs.

Thyroid tuberculosis is a rare disease even in countries where tuberculosis is endemic. Clinically tuberculosis is not often suspected in cases of thyroid nodule or swelling. We report a case of 11 years female child who presented with a thyroid swelling. Fine-needle aspiration cytology revealed caseating epithelioid granulomas and acid fast bacilli. Patient improved with antitubercular drugs. Tuberculosis may be considered as differential diagnosis of thyroid swelling.

Reactive histiocytic proliferations are extremely rare in paratesticular structures. Nodular histiocytic proliferations have been described in mesothelial-lined locations and only at few nonmesothelial sites. Diffuse histiocytic proliferations are described only in the pelvic peritoneum. We report the first case of diffuse histiocytic proliferation in the hydrocele sac of a 45-year-old man. Predominant histiocytes showed clear cytoplasm and signet ring-like change. Mucicarmin stain did not demonstrate mucin in the cytoplasm. Immunohistochemistry (IHC) staining showed nonspecific staining of these cells with carcinoembryonic antigen and negative staining with epithelial membrane antigen, pan-Cytokeratin, calretinin, cytokeratin 7, 20 and prostate-specific antigen. Strong diffuse cytoplasmic positivity for CD68 defined the mononuclear phagocyte nature of these cells. Diffuse histiocytic proliferations can occur in the hydrocele sac. Histochemical and IHC stainings are critical for accurate diagnosis and to avoid unnecessary surgery.

Necrotizing soft tissue infections (NSTI) can be rapidly progressive and polymicrobial in etiology. Establishing the element of necrotizing infection poses a clinical challenge. A 64-year-old diabetic patient presented to our hospital with a gangrenous patch on anterior abdominal wall, which progressed to an extensive necrotizing lesion within 1 week. Successive laboratory risk indicator for necrotizing softtissue infections (LRINEC) scores confirmed the necrotizing element. Cultures yielded Enterococci, Acinetobacter species and Apophysomyces elegans and the latter being considered as an emerging agent of Zygomycosis in immunocompromised hosts. Patient was managed with antibiotics, antifungal treatment and surgical debridement despite which he succumbed to the infection. NSTI's require an early and aggressive management and LRINEC score can be applied to establish the element of necrotizing pathology. Isolation of multiple organisms becomes confusing to establish the etiological role. Apophysomyces elegans, which was isolated in our patient is being increasingly reported in cases of necrotizing infections and may be responsible for high morbidity and mortality. This scoring has been proposed as an adjunct tool to Microbiological diagnosis when NSTI's need to be diagnosed early and managed promptly to decrease mortality and morbidity, which however may not come in handy in an immunocompromised host with polymicrobial aggressive infection.

Multilocular cystic renal cell carcinoma (MCRCC) represents a rare variant of clear cell renal cell carcinoma (RCC). MCRCC has been recognized as a separate subtype of RCC in the 2004 World Health Organization (WHO) classification of adult renal tumors. MCRCC is diagnosed on the basis of strict histological criteria according to 2004 WHO classification. The chief differentials diagnosis to be considered include cystic nephroma, cystic clear cell carcinoma, clear cell papillary renal cell carcinoma and tubulocystic carcinoma. Only few cases of MCRCC are reported in literature. This case is being highlighted for its rarity and so as to avoid a misdiagnosis as conventional RCC.

Angioleiomyoma is a benign tumor of vascular smooth muscle origin. Although many factors have been implicated in its pathogenesis, presence of lipometaplasia suggests its hamartomatous nature. This tumor presents as a painful nodular mass in extremities. Thus angioleiomyoma should be considered as a differential diagnosis of any solitary painful mass of forearm. Herein we report a case of 37-years-old female presenting with a slow growing mass in the right forearm. Histopathological and immunohistochemical examination confirmed the diagnosis of angioleiomyoma.

Intentional subcutaneous injection of mercury by mentally healthy children is rare. Usually, it is seen as a part of suicidal attempt in severely depressed patients or by athletes to enhance their performance. We report a case of a 15-year-old child, inspired by a movie, who deliberately self-injected mercury subcutaneously into his forearm that led to the formation of a non-healing ulcer. Histopathology of the biopsy confirmed the diagnosis. A surgical procedure was thereby performed to treat the ulcer and reduce the blood and urinary levels of mercury. However, the patient did not develop clinical signs of chronic poisoning, proving that subcutaneous mercury injection has a low risk of systemic toxicity, and that histopathology plays an important role in diagnosis.

In humans, infection with Hymenolepis diminuta is usually uncommon but has been reported from various areas of the world. Parasitization rates ranging between 0.001% and 5.5% have been reported according to different surveys. We report a rare case of H. diminuta infection in a 10-year-old female from the rural area of Kendrapada district of Odisha. The patient came to our pediatrics outpatient department with the chief complain of intermittent abdominal pain, anal pruritus and nocturnal restlessness. She responded well to praziquantel therapy.

Epidermoid cyst and dermoid cysts are developmental pathologies thought to derive from aberrant ectodermal tissue. They are uncommon in the head and neck region. Rarely, they can be found in the oral cavity and buccal mucosa. However, epidermoid cyst is extremely uncommon in the upper lip and is rarely reported. In this study, we report an uncommon case of epidermoid cyst occurring in the upper lip diagnosed by fine-needle aspiration cytology (FNAC). We present this case because of its extremely rare site of presentation and also to highlight the role of FNAC to in the pre-operative diagnosis of this benign lesion.