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Direct shedding of microbes by patients and health care workers results in contamination of Intensive care unit environment. Intensive care unit acquired infections due to microbial contamination is a major concern because the patient’s immunity is already compromised. To determine the rate of bacterial contamination on environmental surfaces of Intensive care unit and health care workers and to determine the antibiogram of the isolates. Air samples and swabs from healthcare workers, their accessories, surrounding environmental surfaces were collected randomly over a period of 2 months in Adult Intensive care units. Bacterial isolates were identified by standard microbiological techniques. Antibiotic sensitivity testing was performed by Kirby Bauer disc diffusion method and data analyzed by Statistical Product and Service Solutions 22 version software. A total of 208 samples were randomly collected over 2 months, of which 56 samples yielded positive bacterial growth. Of 56 growth, 12 isolates were detected from air sampling method and 44 isolates from swabs. Among 44 isolates identified from swabs, 10 were isolated from healthcare workers, 4 from health care worker’s accessories and 30 from environmental surfaces. Six different bacterial isolates were identified, Coagulase Negative Staphylococcus (24) and Micrococcus (15) were the major isolates followed by Non fermenters (6), Staphylococcus aureus(4), Bacillus species(4) and diphtheroids (3) The antimicrobial sensitivity pattern of these bacterial isolates were sensitive to commonly used antibacterial agents. Study results showed Intensive care unit staff and environmental surfaces as probable sources of bacterial contamination. Study highlights the importance of cleaning and disinfection process and educate the health care workers about the possible sources of infections within Intensive care unit.

Purpose To describe a technique for traumatic cataract management for cases in which part of the anterior capsule has been incarcerated into a healed corneal laceration. Methods This is a single-center retrospective chart review of 3 patients with capsular/corneal incarceration after penetrating injury. Each patient underwent primary globe repair, followed by subsequent cataract surgery with intraocular lens (IOL) and iris prosthesis placement. The main outcome measure was corrected distance visual acuity. Results At a mean of 19-month postoperative follow-up (range 12-26 mo), corrected distance visual acuity ranged from 20/25 to 20/80 and all patients had improved vision compared with before cataract surgery. At the final follow-up, all IOLs and iris prostheses were in stable position and no eyes required corneal transplantation. Conclusions Traumatic cataracts may be complicated by incarceration of the anterior capsule into the cornea. Incorporating the posterior aspect of the cornea into the anterior capsulotomy enables cataract removal and IOL placement in a stable capsular bag complex.

The genetic causes of multiple congenital anomalies are incompletely understood. Here, we report novel heterozygous predicted loss-of-function (LoF) and predicted damaging missense variants in the WW domain binding protein 11 (WBP11) gene in seven unrelated families with a variety of overlapping congenital malformations, including cardiac, vertebral, tracheo-esophageal, renal and limb defects. WBP11 encodes a component of the spliceosome with the ability to activate pre-messenger RNA splicing. We generated a Wbp11 null allele in mouse using CRISPR-Cas9 targeting. Wbp11 homozygous null embryos die prior to E8.5, indicating that Wbp11 is essential for development. Fewer Wbp11 heterozygous null mice are found than expected due to embryonic and postnatal death. Importantly, Wbp11 heterozygous null mice are small and exhibit defects in axial skeleton, kidneys and esophagus, similar to the affected individuals, supporting the role of WBP11 haploinsufficiency in the development of congenital malformations in humans. LoF WBP11 variants should be considered as a possible cause of VACTERL association as well as isolated Klippel-Feil syndrome, renal agenesis or esophageal atresia.

The role of vasoactive chemicals in the pathogenesis of hepatopulmonary syndrome (HPS), a disorder characterized by intrapulmonary vascular dilation (IPVD), is only vaguely elucidated. We aimed to study the association between plasma H2S, nitrate levels, and presence and severity of IPVD and HPS. Consecutive adult patients with cryptogenic cirrhosis were evaluated for IPVD (by contrast echocardiography) and for hypoxemia (by arterial blood gas analysis). Plasma H2S and nitrate levels were measured in these patients. Fifty-eight patients with cryptogenic cirrhosis (male, 45; median age, range, 45, 16–74 years; Child’s class; A, 30; B, 18; C, 10) were enrolled in this study. Thirty-four of the 58 (59%) patients had IPVD and 13 (22%) had HPS (mild, 4; moderate, 5; severe, 2; very severe, 2). Plasma H2S levels were significantly higher in patients with IPVD (19.6, 5.7–83 μmol/L) as compared to patients who had no IPVD (12.3, 0–47 μmol/L; p-value 0.03) with an area under receiver operating characteristic curve of 0.68 (95% CI 0.53–0.84). Plasma H2S levels were higher in patients with IPVD irrespective of liver disease severity. There was a trend for higher plasma nitrate levels in patients with IPVD (47, 15.8–126.4 nmol/mL) as compared to patients who had no IPVD (32.3, 6.9–51.4 nmol/mL; p-value 0.1). Raised plasma H2S and nitrate levels had an additive effect on the presence of IPVD. Neither plasma H2S nor plasma nitrate levels correlated with the degree of hypoxemia. Raised plasma H2S and nitrate levels predict the presence of IPVD in patients with cryptogenic cirrhosis.

Introduction: Bacillus cereus is a gram positive bacilli found commonly in the soil and environment. It is a bacteria rarely associated with endocarditis. Case History: Intravenous drug abuse, presence of valvular defects, pacemakers, immunodeficiency are some of the known risk factors for B.cereus endocarditis. We present here a case series of two patients with B.cereus endocarditis along with a review of the literature. Conclusion: This is the first report of B.cereus endocarditis from India to the best of our knowledge.

Purpose To report 2 cases with late postoperative Candida albicans interface keratitis and endophthalmitis after Descemet stripping automated endothelial keratoplasty (DSAEK) with corneal grafts originating from a single donor with a history of presumed pulmonary candidiasis. Methods Two patients underwent uncomplicated DSAEK by 2 corneal surgeons at different surgery centers but with tissue from the same donor and were referred to the Bascom Palmer Eye Institute with multifocal infiltrates at the graft-host cornea interface 6 to 8 weeks later, and anterior chamber cultures that were positive for the same genetic strain of C. albicans. Immediate explantation of DSAEK lenticules and daily intracameral and instrastromal voriconazole and amphotericin injections failed to control the infection. Thus, both patients underwent therapeutic penetrating keratoplasty with intraocular lens explantation, pars plana vitrectomy, and serial postoperative intraocular antifungal injection. Results Both patients are doing well at 2 years postoperatively with best-corrected vision of 20/20 and 20/30+ with rigid gas permeable lenses. One patient required repeat optical penetrating keratoplasty and glaucoma tube implantation 1 year after the original surgery. Literature review reveals that donor lenticule explantation and intraocular antifungals are often inadequate to control fungal interface keratitis, and a therapeutic graft is commonly needed. Conclusions Interface fungal keratitis and endophthalmitis due to infected donor corneal tissue is difficult to treat, and both recipients of grafts originating from the same donor are at risk of developing this challenging condition.

Background/purpose Typhoid and paratyphoid fever continue to be important causes of illness and death in parts of Asia, being associated with poor sanitation and consumption of unsafe food and water. Antimicrobial resistance has emerged to traditional first-line drugs, namely, the fluoroquinolones, as well as to third-generation cephalosporins, posing challenges to treatment. Azithromycin has proven to be an effective alternative for treatment of uncomplicated typhoid fever. The purpose of this study was to determine the antimicrobial susceptibility, clinical outcome and serotype distribution pattern of clinical isolates belonging to Salmonella enterica subspecies enterica. Methodology All clinical isolates of S. enterica obtained from blood, sterile body fluids, as well as stool and urine samples at Amrita Institute of Medical Sciences and Research Centre, Kerala, India, between August 2011 and July 2013 were included in the study and processed based on standard microbiology protocols. Results A total of 118 isolates of Salmonella were obtained during the study period. Out of these, 79 were of S. Typhi (66.95%), followed by isolates of S. Paratyphi A (22; 18.64%) and S. Typhimurium 12 (10.17%). Five isolates could not be identified further. There was 100% susceptibility to ceftriaxone in all S. enterica subspecies. Ciprofloxacin susceptibility was 32.91% for S. Typhi and 40.90% for S. Paratyphi A as determined by the disk diffusion method. The susceptibility profile of S. Typhi isolates to different antimicrobials was as follows: chloramphenicol (94.93%), ampicillin (77.21%), cotrimoxazole (75.94%) and azithromycin (78.48%). For S. Typhi, the minimum inhibitory concentration (MIC) of ciprofloxacin required to inhibit the growth of 50% of organisms was 0.5 μg/mL (intermediate) and MIC required to inhibit the growth of 90% of organisms was 1 μg/mL (resistant). S. Typhimurium was 100% susceptible to cotrimoxazole, ampicillin, ceftriaxone, chloramphenicol, ofloxacin and azithromycin. Susceptibility to ciprofloxacin was 66.66%. Patients from whom S. Typhimurium was isolated had comorbidities with documented risk. Of the 118 patients, 3 expired. Two had typhoid fever and were in sepsis at admission. One had S. Typhimurium and was suffering from multiple myeloma. Conclusion S. Typhi was the predominant isolate. All isolates were susceptible to ceftriaxone. Chloramphenicol susceptibility was >90%. No multidrug-resistant Salmonella strains were isolated. Susceptibility to ciprofloxacin for S. Typhi was 33%. Recovery rate was 97%.

Soil Transmitted Helmenthiasis (STH) is a major public health problem in the developing countries. Trichuriasis is one of the common prevalent parasitic infestations in the tropical and sub-tropical countries across the globe incuding India. However, there has been a steady decline of STH in the last five years where there has been success of albendazole with Mass Drug Administration (MDA) in National Filariasis Control Program and Kerala state has been one of them. We report a case of whipworm infection that was incidentally diagnosed by colonoscopy where repeated stool microscopy was uncontributory. The worm can be overlooked, particularly if colon preparation is not good.

PURPOSE: To evaluate whether high-resolution optical coherence tomography (HR-OCT) can detect histologic tumor margins of ocular surface squamous neoplasia (OSSN). METHODS: Eight eyes of 8 patients with OSSN undergoing excision were studied prospectively. Immediately before surgery, the tumor was imaged using a commercially available HR-OCT (Bioptigen/Leica Microsystems, Buffalo Grove, IL) to identify the conjunctival margins of the neoplastic lesion. The tumor borders of the lesion determined by HR-OCT were mapped in relation to an anatomical reference point and transferred intraoperatively. The tumor was excised with 4 mm margins from the visible edge of the lesion with a “no-touch” technique. The specimens were sent for pathological analysis and the histologic tumor margin was compared to the HR-OCT predicted tumor border. RESULTS: Mean age of the 8 patients were 67±9.9 years. Seven (87.5%) were male, 7(87.5%) were white and ethnically, 3 (37.5%) were Hispanic. All eight tumors were bulbar and in the exposure zone. Seven tumors were limbal. Corneal extension was present in 5(62.5%). Mean tumor area was 17.5±11.1 mm(2). Clinically, two (25%) of the tumors were leukoplakic, 1(12.5%) papillomatous, and 3(37.5%) gelatinous. A conjunctival tumor margin identified with the HR-OCT coincided with the pathologically confirmed margin mark in all eyes. CONCLUSIONS: HR-OCT has the potential to predict histologic tumor margins in OSSN. Optical identification of tumor margins could potentially decrease the incidence of residual positive margins, and minimize healthy tissue removal. Advances in HR-OCT technology and integration into a microscope for ‘real-time” imaging are needed to further improve this technique.

Background Primary colonic epithelial defects leading to inflammatory responses are considered central to the development of ulcerative colitis (UC). However, a systematic analysis of various colonic subcompartments in the pathogenesis of UC before inflammation remains elusive. Here, we explored changes in colonic subcompartments and their associated niche signals in patient mucosal biopsies and in an animal model of colitis. Methods Analysis of mucosal biopsies obtained from uninvolved and involved regions of patients with UC and Crohn's disease was performed and compared with normal subjects. Temporal analysis of colonic subcompartments was performed in mice administered with 5% dextran sodium sulphate. Phenotypic enumeration of the crypt subcompartment was complemented with flow cytometric analysis. Members of Notch and Wnt signaling pathways were analyzed by molecular, biochemical, and colocalization studies. Results Phenotypic enumeration of colonocytes' subcompartments from patients revealed significant alterations of the lower crypt, enriched in stem cell and progenitors, independent of inflammation. These changes, unique to UC, were confirmed by immunohistochemistry and molecular analysis. In parallel, a defect in proliferation and Muc2 synthesis was observed. Animal data before inflammation recapitulated human studies. Mechanistic studies revealed that changes in signaling through Wnt primarily affected colonic stem cells, whereas Notch affected progenitor function. Conclusions Our results thus provide new insights into the development of inflammation and relapse in UC and suggest that the stem cell niche in the colon may influence pathogenesis of the disease.

Introduction: Urine antimicrobial activity is a seldom analysed laboratory test which greatly impacts the quantification of urine specimens. Presence of antimicrobial activity in the urine reduces the bacterial load in these specimens. Hence, the chances of erroneously reporting insignificant bacteriuria can be reduced on analysis of the antimicrobial activity in urine. Aim: The aim of the study was to measure the antimicrobial activity of urine samples obtained from patients in a tertiary care hospital. Materials and Methods: A total of 100 urine specimens were collected from the study group. Tests like wet mount, Gram staining and culture were performed. Antimicrobial susceptibility testing was done on the bacteria isolated from each specimen. The urine specimens were reported as significant bacteriuria (>105 Colony Forming Unit (CFU)/ml) and insignificant bacteriuria (

BACKGROUND: Coliforms and other bacterial indicators are known to be present in Community water samples causing faecal pollution of water. There is also a growing body of evidence demonstrating that the aquatic environmental microbes are drug resistant. OBJECTIVE: The objective of this study was to evaluate the microbial quality of the water from tap, well and pond in urban households of Kochi, Kerala state. MATERIALS AND METHODS: A total of 100 water samples (46 from well water, 45 from tap water and 9 from lakes and ponds) were analysed by the multiple fermentation tube method to determine the presumptive coliform count or the most probable number (MPN) of coliforms, and the isolates were identified using standard procedures, followed by susceptibility testing. RESULTS: Eighty samples were positive for growth (76 grew coliforms, four samples grew non-pathogens). A total of 105 coliform isolates were grown in culture. The MPN numbers were noted to be >100 for over 50% of all the samples (n = 56), thus making the water unsatisfactory for drinking purposes. The highest number of organism isolated was Klebsiella pneumonia (n = 55), followed by Enterobacter spp (n = 34) and Escherichia coli (n = 16). Well water had the highest proportion of all three of these organisms. Up to 26%–40% resistance was seen to amoxicillin–clavulanic acid and 5.4%–5.8% of resistance was noted to third-generation cephalosporins, while two isolates were extended-spectrum beta-lactamase-producing Enterobacteriaceae (CTX-M and TEM types). CONCLUSION: The city municipal water authorities need to adopt more aggressive treatment/disinfection practices to combat high coliform contamination. The bacteriological quality of well water at the source needs to be monitored. Meanwhile, continued adequate home purification is suggested for drinking water. The city water does not pose a threat of antibiotic resistance for now. Environmental sampling should be given equal priority as clinical sampling in the coming days.

Alterations in liver vascular tone play an important role in chronic liver disease. The hepatic stellate cell (HSC) and mediators such as nitric oxide (NO) and hydrogen sulfide (H2S) have been implicated in regulation of vascular tone and intra-hepatic pressure. Though these have been studied in chronic liver damage, changes in response to acute liver injury induced by hepatotoxins such as dimethyl nitrosamine are not well understood. Liver injury was induced in mice by a single intra-peritoneal injection of dimethylnitrosamine (DMN), following which animals were sacrificed at 24, 48 and 72 h. Changes in vascular mediators such as NO and H2S as well as stellate cell activation was then examined. It was found that a single low dose of DMN in mice is sufficient to induce activation of hepatic stellate cells within 24 h, accompanied by oxidative stress, compromised metabolism of H2S and decreased levels of the von Willebrand factor (vWF) cleaving protease; a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), which functions in intravascular thrombosis. A suppression of hepatic NO levels is also initiated at this time point, which progresses further and is sustained up to 72 h, at which point the HSC activation is still present. Compromised levels of ADAMTS13 and H2S metabolism however, begin to recover by 48 h and are almost similar to control by 72 h. In conclusion, these data suggest that even moderate acute insults in the liver can have far reaching consequences on a number of mediators of vascular flow in the liver.

Glaucoma may develop or worsen after ocular surface transplantation and often requires surgical management for adequate intraocular pressure control. Traditional glaucoma filtering procedures in patients with prior ocular surface transplant may be problematic for several reasons, which include mechanical disruption of the pre-existing graft, epithelial and stem cell toxicity induced by antifibrotic agents, and increased risk of future corneal transplantation failure. We describe the implantation of a glaucoma drainage implant via a limbal-based conjunctival incision with tube placement in the ciliary sulcus in three eyes of two patients with prior ocular surface transplantation. At a follow-up interval of 3-7 months, all three eyes have excellent postoperative control of intraocular pressure, stable vision, and healthy ocular surface grafts.

With the introduction of highly sensitive hepatitis B surface antigen immunoassay, transfusion associated HBV infection have reduced drastically but they still tend to occur due to blood donors with occult hepatitis B infection (OBI) and window period (WP) infection. Sera from, 24338 healthy voluntary blood donors were screened for HBsAg, HIV and HCV antibody using Vitros Enhanced Chemiluminescent Immunoassay. The median age of the donor population was 30 (range 18–54) with male preponderance (98%). All serologically negative samples were screened by nucleic acid testing (NAT) for viral DNA and RNA. NAT-positive samples were subjected to discriminatory NAT for HBV, HCV, and HIV and all samples positive for HBV DNA were tested for anti-HBc, anti-HBs, HBeAg. Viral load was determined using artus HBV RG PCR Kit. Of the 24,338 donors screened, 99.81% (24292/24338) were HBsAg negative of which NAT was positive for HBV DNA in 0.0205% (5/24292) donors. Four NAT positive donors had viral load of

PURPOSE To describe a method of surgical management for cases of localized epithelial downgrowth (EDG). METHODS Single-center retrospective chart review of patients with histologically confirmed localized EDG of stratified squamous epithelium. Each patient underwent a partial lamellar sclerokeratouvectomy encompassing the area of suspected EDG. The main outcome measure was recurrence of EDG. RESULTS At a mean of 51 months of postoperative follow-up (range: 31-86), no patient had evidence of recurrent EDG. One eye developed worsening of preexisting glaucoma. All 3 eyes developed localized corneal edema, but only 1 required corneal transplantation. CONCLUSIONS EDG is a potentially devastating complication of intraocular surgery or penetrating injury. In cases of localized involvement of the anterior chamber structures, definitive management of EDG can be achieved via resection of the involved scleral, corneal, and uveal tissue. A lamellar approach minimizes tissue loss and maintains a structurally sound, pressurized globe.

The primary aim of this study was to assess the usefulness of plasma hydrogen sulphide (H2S) level at admission as a predictor of severity of acute pancreatitis. The secondary aims were to examine whether the level of H2S after 48 h correlated with severity and whether level of H2S correlated with pulmonary, renal or infectious complications. Plasma hydrogen sulphide was measured within 24 h of admission and 48 h later, in patients with acute pancreatitis. Patients were classified as having mild or severe pancreatitis, and H2S levels in the two groups were compared. A total of 55 patients had H2S estimation carried out within 24 h of admission. H2S levels were similar in patients with mild (mean 31.8 ± 18.8, range 7.1 to 81.4 µmol/L) and severe pancreatitis (mean 28.2 ± 21.6, range 6.1 to 74.4 µmol/L; p = 0.339). There was no difference found between the groups after 48 h (mild n = 28, mean 26.8 ± 19.4 µmol/L, and severe n = 20, mean 34.6 ± 21.0 µmol/L; p = 0.127). There was also no difference in the levels between patients with or without lung injury, kidney injury or sepsis. Performing H2S estimation to predict severity in acute pancreatitis is not beneficial.

Article history: Objective: To determine the risk factors associated with mortality in Acinetobacter calcoaceticus- baumannii (Acb) complex blood stream infection. Methods: This was an observational study conducted in tertiary care hospital of South India. All patients with blood culture positive for Acb complex from January 2008 to December 2009 were included and a standardized abstraction form was used to abstract data. P value was calculated by Chi square test. Univariate analysis was done by using 2x2 tables and the variables with P value of

Acute fatty liver of pregnancy (AFLP), characterized by hepatic microvesicular steatosis, is a sudden catastrophic illness occurring almost exclusively in the third trimester of pregnancy. Defective fatty acid oxidation in the fetus has been shown to be associated with this disease. Since the placenta has the same genetic makeup as the fetus and as AFLP patients generally recover following delivery, we hypothesized that the placenta might be involved in pathogenesis of this disease. In an animal model of hepatic microvesicular steatosis (using sodium valproate), we found that microvesicular steatosis results in mitochondrial structural alterations and oxidative stress in subcellular organelles of the liver. In placentas from patients with AFLP, we observed placental mitochondrial dysfunction and oxidative stress in subcellular organelles. In addition, defective placental fatty acid oxidation results in accumulation of toxic mediators such as arachidonic acid. Escape of these mediators into the maternal circulation might affect the maternal liver resulting in microvesicular steatosis.

BACKGROUND: Ventriculoperitoneal shunt insertions are one of the important neurosurgical procedures done to enhance the neurological functions and improve the survival of patients with hydrocephalus. However, shunt infections are associated with an increased risk of morbidity and the mortality of 30%–40%. The study objective was to evaluate the clinical features, aetiology, resistance pattern and outcome of patients with cerebrospinal fluid (CSF) shunt infections over a 10-year period (2001–2010) amongst the microbiologically-proven cases. METHODOLOGY: Retrospective chart review was carried out to evaluate the age, sex and aetiology of hydrocephalus, biochemical parameters, clinical features and outcome of the culture-positive cases. RESULTS: Out of the 184 post-procedure and initial ( CONCLUSION: CONS continues to be a challenge to neurosurgeons in the treatment of shunt infections. Adequate prophylactic antibiotics based on the local susceptibility pattern should be administered besides strengthening the infection control protocols of the hospital. Surveillance of healthcare-associated infections may well extend to shunt infections at the locations where insertions are carried out.

To determine the etiologic diagnosis of infectious corneal ulcers at Tilganga Institute of Ophthalmology, a tertiary teaching hospital in Kathmandu Nepal, from 2006-2009.This study involved a review of all microbiology records at Tilganga Institute of Ophthalmology from August 2006 through July 2009. Microbiologic records from the corneal scrapings of all patients suspected of having infectious corneal ulcers were included.Corneal scrapings were obtained from 468 patients. The average patient age was 52 years, and 55% of the affected cases were males. Microorganisms were grown from 185 of the corneal scrapings (40%). Pure bacterial cultures were obtained from 72 patients (39%), and pure fungal cultures were obtained from 113 patients (61%). Gram stain was 75% sensitive (95% confidence interval, 0.632-0.841) in identifying bacterial infection, whereas KOH prep was 80.5% sensitive (95% confidence interval, 0.718-0.871) in identifying fungal organisms. Of 72 bacterial isolates, 50 isolates (69%) were Streptococcus pneumoniae, the most common organism isolated in this study. Of 113 fungal isolates, 40 of isolates (35%) were identified as Aspergillus sp.Fungal organisms (61%) are the most common cause of infectious keratitis in this patient population. Of all organisms, S. pneumoniae was the most common organism identified. Smear microscopy is reliable in rapidly determining the etiology of the corneal infection and can be used to help guide initial therapy in this setting.

Objective: To evaluate the antidiabetic and enzymatic antioxidant effects of ethanolic extracts of leaf and fruit of Trichosanthes dioica and leaf of Clitoria ternatea in streptozotocin (STZ)-induced diabetic rats. Methods: Male adult albino rats of Wistar strain equally divided into 11 groups of six rats each were assigned into non-diabetic and diabetic groups. Diabetes was induced in experimental animals by single dose intraperitoneal administration of STZ at a dose of 60 mg/kg body weight. Group I and II which served as non-diabetic and diabetic controls, respectively, received placebo treatment. The diabetic test Groups III to X were treated with either individual and combined ethanolic extracts of plant materials T. dioica and C. ternatea (200 and 400 mg/kg bw) and Group XI was treated with glibenclamide (600 μg/kg bw) for 28 days consecutively. After completion of experimental duration, the animals were sacrificed and collected serum, liver, and kidney were used for the evaluating therapeutic effects on the STZ-induced diabetic rats. Results: The ethanolic extracts of T. dioica (leaf and fruit) and C. ternatea (leaf) and glibenclamide significantly reduced the levels of lipid peroxidation (LPO) and significantly increased the activities of enzymatic antioxidant markers superoxide dismutase, catalase, and glutathione peroxidase in serum, liver, and kidney of diabetic rats. Conclusions: From the present study, it can be concluded that the combined extract of T. dioica fruit and C. ternatea leaf was found to be more effective in treating diabetes and increased activities of enzymatic antioxidants in diabetic-treated rats substantiate that the investigated drugs do extend a clear protective action against LPO in STZ-induced diabetic rats.

Purpose Describe the presentation and management of superior limbic keratoconjunctivitis (SLK)-like inflammation and secondary limbal stem cell dysfunction in the setting of ocular chronic graft-versus-host disease (cGVHD). Methods Retrospective observational case series in a multicenter clinical practice. Participants were 13 patients (26 eyes) with ocular cGVHD and SLK-like inflammation presenting to the University of Illinois at Chicago and BostonSight® between January 1, 2009 and July 1, 2013. Main outcome measures 1) Reversal or worsening of SLK, and 2) development of limbal stem cell dysfunction. Results All eyes showed evidence of SLK-like inflammation and superior limbal stem cell dysfunction manifested by conjunctival injection and superior conjunctival and corneal staining. In addition to aggressive lubrication, management strategies for SLK included topical steroids (20/26), punctal occlusion (18/26), topical cyclosporine (24/26), autologous serum tears (12/26), therapeutic soft contact lens (13/26 eyes) and scleral lenses (4/26 eyes). SLK and limbal stem cell dysfunction were reversed in 23/26 eyes. Three eyes of two patients with long-standing disease demonstrated frank limbal stem cell deficiency (LSCD) and corneal pannus, with one patient requiring multiple reconstructive surgical procedures. Conclusions SLK-like inflammation is an under-recognized condition in patients with severe dry eyes secondary to ocular cGVHD. Untreated SLK can potentially lead to permanent LSCD over time. Early recognition and management of SLK in ocular cGVHD can improve vision, reverse signs, and may prevent these long-term consequences.

Objectives: To determine the minimum inhibitory concentration of ciprofloxacin among 50 blood stream isolates of Salmonella enterica. Material and Methods: A total of 50 consecutive isolates of Salmonella enterica were tested for susceptibility to antimicrobials using the Kirby Bauer disk diffusion method. Minimum inhibitory concentrations were determined using Hi-Comb strips. All results were interpreted according to the CLSI guidelines. Results: Of the 50 isolates 70%were Salmonella Typhi, 4% Salmonella paratyphi A, 2% Salmonella paratyphi B and the remaining 10% were identified only as Salmonella species. Using the CLSI 2011 breakpoints for disc diffusion, 86% (43/50) were resistant to nalidixic acid(NA), 22% (11/50) to ciprofloxacin, 12% to azithromycin, 6% to cotrimoxazole, 4% to ampicillin and 1% to chloramphenicol. The MIC50 and MIC90 of ciprofloxacin for S.Typhi were 0.181 μg/mL and 5.06 μg/mL respectively. While the same for S. paratyphi A was 0.212μg/mL and 0.228μg/mL respectively. None of the isolates were multi drug resistant and all were susceptible to ceftriaxone. Using the CLSI 2012 revised ciprofloxacin breakpoints for disc diffusion (>31mm) & MIC (

Though pericardial disease is common in patients with renal disease, purulent pericarditis is very rare. We report a fatal case of purulent pericarditis and sepsis due to methicillin-resistant Staphylococcus aureus in a 78-year-old male with systemic hypertension and renal disease along with the molecular characterization of its resistant mechanism.

The present study highlights six cases of pneumococcusuria during the time period of May 2008 to May 2010. All the patients had a co-existing predisposing factor with the isolation of Streptococcus pneumoniae in urine. Five of the six patients having signs and symptoms of urinary tract infections (UTI) were treated and cured of the same. It becomes essential to consider pneumococcal UTI in the presence of clinical signs and symptoms associated with urinary tract abnormalities like hydronephrosis and renal stones. S. pneumoniae may be regarded as an emerging pathogen in UTI. Precise microbiological diagnosis must correlate with the clinical signs and symptoms for the administration of appropriate antibiotic therapy.

We describe a case of bacteraemia caused by Weissella confusa in a 48-year-old male who was operated on for adenocarcinoma of the gastro-oesophageal junction and maintained on total parenteral nutrition. Blood cultures were positive for a vancomycin-resistant streptococcus-like organism which was identified as W. confusa by 16S rRNA gene sequencing.

A 35-year-old man presented with a gradually worsening left-sided loin pain and high-grade fever 10 days in duration. He gave a history of left flank injury due to a road traffic accident 4 months previously, accompanied by pain and transient mild hematuria that was managed conservatively without further evaluation. Computed tomo- graphic scan revealed undisplaced fracture of the left 10th rib with a large perinephric hematoma/abscess causing significant compression and displacement of the left kidney. The collection was evacuated by open drainage, and its culture yielded a hydrogen sulfide (H2S)Yproducing variant of Salmonella paratyphi A resistant to nalidixic acid. Blood and urine cultures were sterile. Drainage with culture-specific antibiotics (ceftriaxone followed by cefixime) was curative. Primary perinephric abscess due to S. paratyphi A without any evidence of systemic involve- ment is rare and classically S. paratyphi A is H2S-negative. We hereby report a case of H2S-positive S. paratyphi A causing primary perinephric abscess of posttraumatic hematoma.

Prior to keratoprosthesis implantation, evaluation of anterior segment anatomy is of vital importance to ensure adequate space for the implant. In many cases, corneal opacity prevents direct examination of the anterior segment. In these cases, ancillary imaging studies such as anterior segment optical coherence tomography (OCT) or ultrasound biomicroscopy (UBM) are required for thorough evaluation. Important variables in anterior chamber anatomy include anterior chamber depth, phakic status, presence of synechial angle closure or iris-cornea touch, and location of any hardware such as a glaucoma drainage implant (GDI). These factors aid in the selection of a keratoprosthesis model and can indicate the necessity for additional procedures such as intraocular lens removal or GDI repositioning. Special considerations must be made in pediatric keratoprosthesis given the naturally shallow anterior chamber and in the presence of anterior segment malformations.

Infections caused by Nocardia farcinica are potentially lethal because of the organism's tendency to disseminate and resist antibiotics. Central nervous system involvement has been documented in 30% of infections caused N. farcinica.Case report and review of the literature.A case of primary brain abscess caused by N. farcinica, identified by 16SrRNA sequencing, is presented, and 39 cases reported previously in the literature are reviewed. Our patient underwent a neuronavigation-guided right frontal craniotomy and was treated with trimethoprim/sulfamethoxazole and amoxicillin-clavulanic acid for 12 mo. He showed marginal improvement in his prior left hemiparesis at the last review 14 months later.Cases of N. farcinica infections are being reported increasingly because of recent changes in taxonomy and diagnostic methodology. This change in epidemiology has implications for therapy because of the organism's pathogenicity and natural resistance to multiple antimicrobial agents, including third-generation cephalosporins. Any delay in starting appropriate antibiotic therapy can have adverse consequences.

Chromoblastomycosis is a chronic subcutaneous mycosis commonly caused by Fonsecaea, Phialophora, and Cladophialophora spp. Out of these, Fonsecaea pedrosoi is the most common etiological agent, implicated in 70%–90% of the cases reported worldwide. The histopathological diagnosis of chromoblastomycosis is based on visualization of medlar or sclerotic bodies in the tissue. These sclerotic bodies divide by planar division. Rarely, budding is seen in these sclerotic bodies. As this entity can be confused with phaeohyphomycosis, it is important to be aware of such a presentation also. We report two cases of chromoblastomycosis that showed budding sclerotic bodies.

Systemic endemic mycoses, such as blastomycosis, are rare in Asia and have been reported as health risks among travelers who visit or reside in an endemic area. Adrenal involvement is rarely seen in blastomycosis and has never been reported from Asia. We report the first case of blastomycosis with bilateral involvement of the adrenals in a diabetic patient residing in the state of Arunachal Pradesh, India.

Intracranial infections, especially subdural empyema, due to salmonella are rare. Subdural empyema caused by Salmonella paratyphi A has been documented only once earlier in the literature. Hence, we report a case of subdural empyema and osteomyelitis of cranial vault due to S. paratyphi A. A 42- year-old male presented with headache and purulent discharge from right parietal burr hole wound site. Patient gave a history of head injury two years ago. He underwent burr hole evacuation of chronic subdural haematoma, excision of outer membrane and right parietal craniectomy. The cultures grew S. paratyphi A. Recovery was uneventful following surgical intervention and antibiotic therapy.

Sir, Acute fatty liver of pregnancy (AFLP) is a rare pregnancyrelated liver disorder manifesting in late pregnancy with acute liver failure [1], while the hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is a microangiopathy affecting the liver and other organs in late pregnancy [2]. Long-chain 3-hydroxyacyl-coenzyme-A dehydrogenase (LCHAD) deficiency in the fetus has been associated with these hepatic disorders of the mother during pregnancy [3]. The commonest mutation is G1528C in exon 15 of the mitochondrial trifunctional protein (MTP) α subunit, which leads to a substitution of a glutamine for glutamate, which selectively decreases LCHAD activity [4]. Though the occurrence of the G1528C mutation has been studied in Western populations [4, 5], where it is common, the information on this from other populations is scarce. We studied the presence of the G1528C mutation in three patients with AFLP (all fulfilled “Swansea” criteria for diagnosis, none had liver biopsy, two had coexistent HELLP, and one had coexistent pre-eclampsia and partial HELLP) [6] and one patient with HELLP syndrome (coexistent preeclampsia). All patients (age: 23; 19–28 years, median; range) presented in third trimester (36; 32–38 weeks of gestation). Three were primigravida while one patient had a previous uneventful pregnancy. All patients were eventually discharged in stable condition, and the immediate fetal outcome was favorable in all. The placenta is known to carry out mitochondrial β oxidation, and its genetic make up is identical to the fetus [7], and hence, we used placental DNA for our genetic analysis by polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) analysis. This study was approved by the Institutional Review Board, and consent was obtained from the patient for the study. As required by the criteria, all patients had an unyielding make up for the etiology of acute liver disease, including serology tests for acute viral hepatitis A, B, and E. Controls were placenta from normal deliveries of equal gestational age. The blood was drained, and the placental tissue was rinsed thrice with saline and stored at −80 °C. Baseline laboratory parameters in the four patients analyzed are summarized in Table 1. DNAwas isolated from 100 mg placenta and amplified using forward (5′-CCCTTGCCAGGTGATTGGC-3′) and reverse (5′-GTATAGAAGCCAGGTCCATCCTGCCAAG-3 ′) primers [8]. The PCR products were purified, digested with Pst1, and separated by agarose gel electrophoresis to identify the G1528C mutation. Purified PCR products were bidirectionally sequenced using the BigDye Terminator V3.1 kit in a 3130 genetic analyzer (Applied Biosystems, Carlsbad, USA) and analyzed using NovoSNP software (http://www.molgen. ua.ac.be/bioinfo/novosnp/). PCR was used to amplify the whole of exon 15 of the α subunit, which codes for LCHAD activity of the MTP (Fig. 1a, first lane on left). All healthy controls as well as AFLP and HELLP patients showed two characteristic fragments after Pst1 digestion (465 and 175 bp), indicating an absence of the G1528C mutation [8]. V. Raghupathy :K. R. Thangaraj :K. A. Balasubramanian : A. Ramachandran (*) The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore 632 004, India e-mail: anup@cmcvellore.ac.in

Diving into lakes and ponds is a common activity of rural children. We present two cases of penetrating orbital injuries from plant matter sustained in this manner. Such injuries pose a particular challenge because wooden foreign bodies are often missed during orbital exploration, and current imaging modalities cannot reliably identify retained organic material. When a patient presents with orbital penetration after a high-risk mechanism of injury, such as freshwater diving, the clinician must maintain a very high index of suspicion for retained wooden foreign body.

The authors report a rare case of renal cell carcinoma (RCC) metastasis to the paranasal sinuses. The authors review RCC and its potential for sinonasal metastasis and discuss the variable presentation and need for clinical suspicion for early diagnosis and treatment. A 74-year-old man presented with numbness of the left side of the face, reduced visual acuity and ptosis 12 years after nephrectomy for RCC. Imaging studies showed a lesion in the left pterygopalatine fossa and the histological features supported the diagnosis of metastatic RCC. RCC metastasis to the paranasal sinuses is very rare and can present with various symptoms depending on the affected organ. These symptoms occasionally are the initial manifestation of renal RCC and it is very important to recognise them so that the patient receives the appropriate therapy to improve survival.

Intraocular gnathostomiasis is a rare parasitic infection caused by the third-stage larvae of spiruroid nematode Gnanthostoma spp. seen mostly in tropical and subtropical regions. It is a food-borne zoonosis caused by ingestion of raw or undercooked freshwater fish, amphibians, reptiles, birds, and mammals, all of which are known to harbor advanced third-stage larvae of Gnanthostoma spp. To date, 74 cases of intraocular gnathostomiasis have been reported from 12 different countries. Only four countries have reported more than 10 cases each, and India shares the rare distinction of being one of them, with 14 cases. Surprisingly, not a single case of cutaneous gnanthostomiasis has ever been reported from India. We present one such case of intraocular gnathostomiasis in a 41-year-old male who presented with an actively motile worm attached to the iris, and we review the pertinent literature of all such cases reported from India.

Coryneform bacteria belonging to the genus Brevibacterium have emerged as opportunistic pathogens. Of the nine known species of Brevibacterium isolated from human clinical samples, Brevibacterium casei is the most frequently reported species from clinical specimens. We report the first case of B. casei brain abscess in an immunocompetent patient successfully treated by surgery and antimicrobial therapy.

Salmonellosis is a common infection in systemic lupus erythematosus patients. The present study reports on two such cases of Salmonella typhimurium septic arthritis among the 102 patients seen during a four-year period.

Pneumonia due to non-typhoidal Salmonella is a rarely reported entity. A fatal case of Salmonella pneumonia is reported here where Salmonella Typhimurium was isolated from the endotracheal aspirate and blood culture.

Hepatic cat scratch disease is rarely reported in liver transplant recipients and has never been reported with discrete liver lesions in the graft. A 52-year-old woman was transplanted for hepatitis C cirrhosis and hepatocellular carcinoma. Her posttransplant course was uneventful. She presented 2.7 years after transplantation with fever of unknown origin and went on to develop multiple and diffuse discrete liver lesions. Despite an extensive work-up including percutaneous and laparoscopic biopsies, a subsegmental resection that included one of these masses was required to make the diagnosis of Bartonella henselae infection. Serologic tests were equivocal. Histology was consistent with cat scratch disease of the liver, and polymerase chain reaction (PCR) testing of the resected tissue confirmed the diagnosis. Response to doxycycline was rapid. Fevers resolved within 7 days. Repeat abdominal CT scan showed reduction of the liver masses. Cat scratch disease should be considered in postliver transplant patients presenting with fever and liver lesions, especially if close contact with cats has occurred. Diagnosis by PCR testing of involved tissue is preferred when serologies are equivocal due to immunosuppression.

A51-year-old male, who had undergone laparoscopic deroofing of a simple renal cyst on the left side two years ago, presented with left flank pain of one month’s duration near the port site, along with low-grade fever. There was no abdominal distension or mass, nor alteration in bladder or bowel habits. He was not a diabetic nor had he any other important medical history. Physical examination revealed a temperature of 100.4 F, soft abdomen with severe tenderness over the left iliac fossa, and unremarkable left flank and costovertebral angle. The white blood cell count was 19,000/mcL, and the serum creatinine concentration was 1.52 mg/dL. A magnetic resonance imaging scan of the abdomen revealed a collection with enhancing septations in the left posterior pararenal space, extending into the psoas and quadratus lumborum muscles and adhering to the posterolateral abdominal wall. There was left perirenal stranding (Fig. 1) and a small left renal upper polar cortical cyst (Fig. 2). Blood and urine culture studies yielded no growth. Empiric antibiotic therapy was of no benefit and the patient returned with a pointing abscess about to rupture. The collection was incised and drained after ruling out any urine leak from the left upper urinary tract by retrograde urography, and a closed suction drain was left in the abscess cavity. The pus sample sent for culture yielded growth of nonfermenting gram-negative bacilli, identified by VITEK 2 compact system (bioMerieux, Inc., St Louis, MO) as Achromobacter xylosoxidans with a 99% probability and an ‘‘excellent identification’’ confidence level. The isolate was susceptible to piperacillin, levofloxacin, co-trimoxazole, ceftazidime, cefoperazone-sulbactam, and meropenem, but resistant to aminoglycosides and tetracycline using Clinical and Laboratory Standards Institute (CLSI) break points for nonEnterobacteriaceae. The drain was removed on the fifth post-operative day and the patient was discharged on oral levofloxacin and cotrimoxazole. Three days after discharge, the patient returned in sepsis with similar complaints and pus draining from the incision. On retaking the history, it was determined that the patient had stopped taking the antibiotics after discharge. On examination, his temperature was 101.6 F and he had tenderness of the left flank. Abdominal ultrasonogram showed minimal residual collection at the abscess site. A second incision and drainage was performed immediately under cover of intravenous cefoperazone-sulbactam. A small amount of purulent material was drained and the abscess wall was debrided. The benign-looking small cortical cyst towards the upper pole was left undisturbed on both occasions. After 1 wk of intravenous antibiotic and supportive therapy, the patient was discharged in good health on oral co-trimoxazole and levofloxacin for 2 wks. On clinic follow-ups at 1 mo and 3 mos, there was no evidence of any continuing infection or any local symptom or abnormal findings on imaging studies other than the unchanged cortical cyst. Achromobacter xylosoxidans is a non-fermenting gramnegative, motile oxidase-positive bacillus belonging to the Alcaligenaceae family [1]. It is characterized by the ability to utilize xylose and glucose oxidatively. Identification using traditional phenotypic test often is unreliable and A. xylosoxidans can be mistaken for non-aeruginosa strains of Pseudomonas or for strains of Burkholderia cepacia complex. Achromobacter xylosoxidans is an opportunistic pathogen capable of causing nosocomial and community-acquired infections, with the source being either endogenous or from a contaminated aquatic hospital environment [2]. It frequently has been iso

Introduction: the genera Abiotrophia and Granulicatella spp. (previously known as nutritionally variant Streptococcus) are infrequently isolated from clinical specimens. Literature quotes that they account for about 5–6% of the infective endocarditis and bacteremia, and lesser in central nervous system infections (post instrumentation) and others. the objective of the study was to assess the clinical significance and outcome of the patients with laboratory isolations of Granulicatella adiacens. case series: We reviewed the clinical records from 2011–12 noting down the demographic details, identifiable risk factors, management of patients in whom Granulicatella adiacens was isolated. seven cases of Granulicatella adiacens were reported in which five were children (

Primary pigment dispersion syndrome (PPDS) is a bilateral condition that occurs in anatomically predisposed individuals. PPDS may evolve into pigmentary glaucoma, but it is difficult to predict which patients will progress. Secondary pigment dispersion is more often unilateral and acquired as a result of surgery, trauma, or intraocular tumor, but can likewise lead to pigmentary glaucoma. We report two cases of patients with bilateral PPDS who developed secondary pigment dispersion and pigmentary glaucoma in one eye. Patients with PPDS who acquire a secondary mechanism of pigment dispersion may be at an increased risk of progression to pigmentary glaucoma, presumably due to an increased burden of liberated pigment. In addition to regular surveillance for progression to glaucoma from PPDS, secondary causes of pigmentary dispersion in these eyes should be considered when patients present with grossly asymmetric findings. When secondary pigment dispersion is identified in eyes with PPDS, we recommend prompt intervention to alleviate the cause of secondary pigment dispersion and/or aggressive control of intraocular pressure to limit glaucomatous damage.