Melioidosis in India and Bangladesh: A review of case reports

Objective: To conduct an epidemiological and clinical review of published case reports of melioidosis from India and Bangladesh. Methods: Data from published case reports were abstracted and summarized. We further compared the clinical epidemiology of the melioidosis cases in India with case series from highly endemic areas in Northern Australia and Southeast Asia to elucidate any differences in presentations and risk factors between the regions.Results: We identified a total of 99 cases published between 1953 and June 2016, originating from India(n=85) or Bangladesh(n=14). Cases were predominantly male and ranged in age from 1 month to 90 years. Diabetes mellitus was the most common risk factor reported(58%). About 28% of the cases had history of exposure via high-risk occupations or exposure to contaminated water. The overall case fatality rate(CFR) was 26%. Factors influencing mortality included the occurrence of septic shock(CFR, 80%), environmental exposure(CFR,39%), primary presentation of pneumonia(CFR, 38%), misdiagnosed and/or mistreated cases(CFR, 33%) or the presence of a risk factor(CFR, 29%). Because of the small number of cases in Bangladesh, pattern of clinical epidemiology is limited to India. Soft tissue abscess(37%)was the most common clinical presentation reported from India followed by pneumonia(24%)and osteomyelitis/septic arthritis(18%). Neurological melioidosis(n=10, 12%) presented as pyemic lesions of the brain or meninges. A few cases of prostatic abscess(n=4) in men and parotid abscess(n=4) were also noted. The above patterns were consistent with case series from Southeast Asia and Northern Australia for the most part, in terms of risk factors associated with infection and factors influencing mortality. Differences included clinical presentation of pneumonia which was notably lower than that reported in Southeast Asia and Northern Australia; a higher proportion of neurological and parotid abscess presentation; and a lower CFR compared to that reported in case series in Southeast Asia. About 39% of the cases were misdiagnosed and/or mistreated, suggesting underreporting and under estimation of the true disease burden. Conclusions: The concentration of melioidosis cases in southern and eastern states in India and in Bangladesh, which share climatic conditions and rice farming activities with known endemic areas in Southeast Asia, suggests an endemicity of melioidosis in this region. Thus, increased awareness among healthcare personnel, particularly among clinicians and nurses practicing in rural areas, and improved surveillance through case registries is essential to guide early diagnosis and prompt treatment.     

Right‐Sided Endomyocardial Fibrosis with a Right Atrial Thrombus: Three‐Dimensional Transthoracic Echocardiographic Evaluation

Endomyocardial fibrosis is a form of restrictive cardiomyopathy mainly affecting poor children and young adults in geographically restricted areas of Latin America, Africa, and Southeast Asia. The pathophysiological hallmark of the disease is focal or diffuse endocardial thickening involving mainly the inflow, the apices, and the subvalvular region leading to valvular regurgitation, diastolic dysfunction and obliteration of the ventricular apex. Advanced right‐sided disease has slow flow of blood through chambers with propensity of thrombus formation especially in the right atria. Although two‐dimensional transthoracic echocardiography remains the cornerstone for the diagnosis of this disease, the case presented here shows how three‐dimensional transthoracic echocardiography can add substantial information regarding the region of involvement of the right ventricle as well as the various characteristics of the right atrial thrombus.     

Conjunctival melanoma in a child: A clinicopathological report

We report a case of a 16 years old Asian Indian boy who presented with a large brownish lesion measuring 20 × 12 mm on the temporal conjunctive in his right eye. Anterior segment optical coherence topography revealed cystic spaces without scleral involvement. The patient underwent conjunctival excisional biopsy using “no touch” technique with double freeze-thaw cryotherapy to underside of the adjacent conjunctival margins. Excision involved 4 mm of the surrounding apparently normal conjunctiva. Absolute alcohol epitheliectomy was done at the limbus and surrounding 2 mm of cornea to devitalize residual atypical melanocytes if any. Histopathology confirmed diagnosis of conjunctival melanoma. We started the patient on topical mitomycin C 0.04% with one weekly on and off cycles postoperatively. No recurrence was noted after nine months follow up.     

A clinical and microbiological study of puerperal sepsis in a tertiary care hospital in India

Objective: This prospective study was carried out to evaluate the clinical profile and bacterial isolates among women with puerperal sepsis in a tertiary hospital in North India.

Materials and methods: Women with puerperal sepsis (n?=?45) admitted from January 2015 to April 2016 were followed prospectively. Cultures were obtained from cervix, blood, urine, and pyoperitoneum. Initial antibiotics were cefotaxime or piperacillin with tazobactam plus amikacin plus clindamycin or metronidazole and were changed according to sensitivity.

Results: Out of 7887 deliveries during this period, 45 (0.2%) women had puerperal sepsis. 16 (35.5%) delivered in the present hospital, 25 (55.5%) at another health care facility, and 4 (8.9%) at home. Delivery was by cesarean section (CS) in 24/45 (53.3%) and vaginal in 21/45 (46.6%). Grade 1 sepsis occurred in 21, grade 2 in two, and grade 3 in 22 women. Majority (29/45 or 64.5%) had no risk factor for puerperal sepsis. There were two (4.4%) deaths and 13/45 (28.8%) had near-miss morbidity. Pathogenic bacteria were isolated in 33/45 (73.3%) in cervical swab (69%), blood, urine, or pus culture with no significant difference in the bacterial yield or species isolated between cotton or polyester swabs (p?>?.05). Escherichia coli were the commonest isolate and was sensitive to amikacin in all. Five had stillbirths and 4/40 neonates developed sepsis but recovered.

Conclusions: Escherichia coli was the commonest pathogen and was uniformly sensitive to amikacin, which may be included among the initial antibiotics to treat puerperal sepsis in India.     

Predicting Post Renal Biopsy Complications

At our institution, kidney biopsies are performed by an interventional nephrologist with standardized guidelines using real‐time ultrasound. We hypothesized that patient factors could predict post biopsy complications. We did a retrospective review of 100 patients who underwent renal biopsy. Prebiopsy data obtained included demographics, blood pressure, laboratory studies, and kidney size. Biopsy procedure information was also recorded. Complications and post biopsy imaging was noted. A minor complication was defined as one not requiring intervention while a major complication required interventions like readmission or blood transfusion. The average age was 47 years, 41 were men, 51 were black, 30 had diabetes, 42 were obese, and 81 had hypertension. Twenty‐six patients had a complication; 14 minor and 12 major including 1 nephrectomy. Factors predictive of a complication were thrombocytopenia (p = 0.002) and inpatient status (p = 0.04). Drop in hemoglobin at 6 hours was moderately sensitive and specific for a bleeding complication with an ROC of 0.723. Thrombocytopenia and inpatient status are risk factors for complications after renal biopsy. Serum creatinine, obesity, blood pressure, kidney size, needle size, and number of passes were not predictive of a major complication in our study.