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To evaluate clinical performance and diagnostic accuracy of urinary HPV for non-invasive screening of high-grade precancerous and cancerous cervical lesions in a visual inspection under acetic acid (VIA) -positive cohort.The study included 180 women aged 35-65 years, who were VIA positive in a colposcopy clinic. All participants had the initial stream of a random urine sample tested for the presence of high-risk HPV (hrHPV) types 16 and 18 and acetowhite lesions were biopsied per protocol. Concordance analysis was conducted to assess agreement between detection of hrHPV in urine and the presence of premalignant and malignant lesions in cervix on histopathology. Measures of diagnostic accuracy were estimated to evaluate the performance of urinary HPV against histopathology (reference standard).Substantial agreement between urinary HPV detection and histopathology was found (Cohen's κ is 0.696, P ≤ 0.001), with an agreement in 88.9% of the cases and disagreement in 11.1%. The diagnostic performance of urinary HPV in predicting the presence of a high-grade precancerous or cancerous lesion was as follows: sensitivity 67%, specificity 97%, positive predictive value 89%, and negative predictive value 88.8%.HPV DNA detection from urine has good concordance with the histopathology for detection of precancerous and cancerous lesions of the cervix. Further studies on optimization of urine sampling and processing techniques are warranted.

Background Intestinal parasites are a major public health problem in tropical countries. Over 1.5 billion people are infected with soil-transmitted helminths (STH), of which 225 million are in India. Parasitic infections are associated with poor sanitation, lack of safe potable water, and improper hygiene. Materials and Methods The study was undertaken to ascertain the impact of control strategies, namely open-defecation free drive and mass drug administration of single dose albendazole. Stool samples received at AIIMS Bhopal Microbiology laboratory, across all age groups, were studied for protozoan trophozoites/cysts and helminthic ova. Results Out of 4,620 stool samples, 389 (8.41%) were positive either for protozoal or helminthic infections. Protozoan infections were more common than helminthic infections with Giardia duodenalis infection being the most common, 201 (51.67%), followed by Entamoeba histolytica, 174 (44.73%). The helminthic infections constituted 14 (3.5%) of the positive stool samples with Hookworm ova in 6 (1.5%) cases. Conclusion This study proves that strategies, namely “Swachh Bharat Abhiyan” and “National Deworming Day” started in 2014 and 2015 led to significant reduction of intestinal parasite infections in Central India, with a higher reduction of STH compared with protozoan parasite infection being ascribed to the activity spectrum of albendazole.

Objective Microbiological confirmation of tuberculosis (TB) in pediatric cases is challenging due to its paucibacillary nature and difficulty in specimen collection. This study aimed to validate stool as an alternative sample for the diagnosis of pediatric pulmonary TB via Xpert MTB/RIF (Xpert) assay. Materials and Methods This cross-sectional study included 75 pediatric patients up to 10 years of age with signs and symptoms suggestive of TB. From each recruited patient, pulmonary and stool samples were collected in a sterile container. The collected samples were subjected to Ziehl-Neelsen staining, BACTEC MGIT 960 culture (MGIT), Xpert, and in-house multiplex polymerase chain reaction for TB diagnosis. Results About 13.33% (10/75) of the pulmonary samples and, of them, 50% (5/75) of the stool samples were positive by Xpert assay. The sensitivity and specificity of Xpert assay with stool and pulmonary samples were 50 (95% confidence interval [CI]: 18.71–81.29%) and 100% (95% CI: 94.48–100%), respectively. Conclusion The Xpert assay on stool samples showed limited sensitivity and good specificity in the diagnosis of pulmonary TB. Therefore, it can be proposed as an alternative screening sample to diagnose TB in pediatric cases for which getting a respiratory sample is extremely difficult. However, further studies with greater number of samples and multiple baseline variables are required to support our findings. Strategies to optimize stool Xpert assay should be performed to enhance the sensitivity of this method to detect Mycobacterium tuberculosis in children.

Objective: Literature investigating the change in psychological problems of the health care workers (HCWs) throughout the coronavirus disease (COVID-19) pandemic is lacking. We aimed at comparing the psychological problems and attitudes toward work among HCWs over two waves of the COVID-19 pandemic in India. Methods: A survey was conducted involving HCWs (n = 305, first wave, 2020; n = 325, second wave, 2021). Participants’ demographic and professional and psychological characteristics (using attitude toward COVID-19 questionnaire [ATCQ]; Depression, Anxiety, and Stress Scale – 21 Items and impact of event scale – 22) were recorded. The unpaired t-test/chi-squared test was used for comparison. Results: Significant improvements (χ2(1) = 7.3 to 45.6, P < 0.05) in level of depression (42.2% vs 9.6%), anxiety (41.3% vs 16.3%), stress (30.1% vs 6.7%), event-related stress symptoms (31.2% vs 27%), work-related stress (89.8% vs 76.8%), and stigma (25.9% vs 22.8, though marginally significant) were found among the participants of the second wave (vs first wave). However, on subgroup analysis, allied-HCWs (housekeeping staff and security personnel) reported lesser concerns over the domains of the ATCQ vis-a-viz frontline-HCWs (doctors and nurses). Conclusion: This improvement could be attributed to greater awareness about the illness, better coping skills, vaccination, and so forth; however, more research is warranted to investigate these determinants.

Chronic Hepatitis B (CHB) Virus infection is major etiological factor for liver cirrhosis and/ or liver cancer. The viral protein, major contributor in predisposition of chronicity and Hepatocellular Carcinoma (HCC) is Hepatitis B x (HBx) protein. Its dynamic subcellular distribution to an extent determines its multifactorial role. It is a regulatory protein which modulates viral as well as host machinery in favours to HBV persistence. An insight on HBx stabilising factors is critical for therapeutic purpose. The precise role of HBx in the pathogenesis of Chronicity of HBV is not known. Summary: This review comprehensively summarizing different mechanisms and their regulation by HBx protein with respect to chronicity and HCC emphasising viral persistence. Key Messages 1. HBx is a key protein for viral persistence. 2. Dynamic subcellular distribution of HBx determines its function. 3. HBx modulates cellular machinery to favours HBV survival. 4. HBx affects various intermediary mechanisms contributing to disease progression. 5. HBx may be a potent target to prevent the disease progression towards HCC.

Introduction: We prospectively evaluated EUCAST rapid antimicrobial susceptibility testing methodology for susceptibility testing directly from blood culture bottles in comparison to CLSI disk-diffusion method. Methodology: During May-November 2019, positively flagged blood culture bottles showing Gram-negative micro-organisms were simultaneously processed by rapid antimicrobial susceptibility testing and CLSI methodology. Antibiotics tested were cefotaxime, ceftazidime, piperacillin-tazobactam, imipenem, meropenem, gentamicin, tobramycin and trimethoprim-sulphamethoxazole. Results: Overall, 80 isolates identified as Escherichia coli (n = 24, 30%), Klebsiella pneumoniae (n = 15, 18.7%), Pseudomonas aeruginosa (n = 16, 20%) and Acinetobacter baumannii (n = 25, 31.2%) were included. Categorical agreements of rapid antimicrobial susceptibility testing at 4-, 6- and 8-hour reading times were 88.1% (304/345), 90.8% (425/468) and 92.3% (467/506), respectively. Major Error rates were 14% (21/150), 4.9% (10/206) and 4/236 (1.7%), whereas Very Major Error rates were 1.1% (2/177), 1.3% (3/232) and 3.3% (8/243), respectively. Results categorized as “Area of Technical Uncertainty” were significantly lower at 8-hour {10.2% (39/384) vs 5.2% (28/534), 4- vs 8-hour, p = 0.003, Fischer’s exact test}. Conclusions: Except for a slightly higher Very major error rate, rapid antimicrobial susceptibility testing at 8-hour is equivalent to Disk-diffusion method (CLSI-M100) using CLSI-M52 criteria for equivalence: (Categorical agreement ≥ 90%, Very major error ≤ 1.5% and Major error ≤ 3%). Poor Categorical agreements at all reading times were noted for piperacillin-tazobactam, ciprofloxacin and E. coli. Performance of rapid antimicrobial susceptibility testing methodology in resource limited settings brings unique challenge of identifying micro-organisms within 8 hours. We suggest reading and reporting of results at a single time point using rapid antimicrobial susceptibility testing method i.e. at 8-hour.

Background: Preliminary reports suggest that during the COVID-19 pandemic, telecounseling could be an effective model of psychological intervention for the frontline healthcare workers (fHCW) with psychological problems. Literature is sparse in this area, particularly from low- and middle-income countries, including India. We aimed to investigate the feasibility and the effectiveness of telecounseling (vs. general education) on the psychological problems of the fHCW over three time-points (baseline vs. end-of-session and at two and four weeks after the intervention). Methods: The study followed a single-blind, active arm versus general education, parallel-group randomized control design, with participant allocation in 1:1. Active healthcare workers (HCWs) with mild- to-severe or clinically concerning scores on any of the sub-scales of Depression, Anxiety and Stress Scale (DASS-21) or Impact of Event Scale-Revised (IES-R; represented by higher scores) were included, while those with known psychiatric illness were excluded. Chi-square and Mann-Whitney U test and linear-mixed effect model (group-, time, and group by time-effect) were used for analysis. Results: There were no baseline group differences (telecounseling group, active arm, n = 9; general education group, control arm, n = 10). A significant time-effect (P = 0.044 to Conclusion: Telecounseling could be a feasible and scalable model of psychological interventions for the fHCW with psychological problems, albeit with some feasibility challenges.

ObjectivesWe implemented a diagnostic stewardship care-bundle (DSB): “Sepsis-48” with the aim of evaluating its impact on changes in duration of key steps in automated blood culture diagnostics (aBCD), compliance to care-bundle and turnaround time (TAT).MethodsIn this prospective study, a care-bundle checklist for automated blood culture bottles (BCBs) received from adult intensive care units (AICUs) was implemented between July 2020-June 2021 (intervention period, P2) and compared with a retrospective, pre-intervention period (P1) between March-June 2020. Microbial identification in positive BCBs with gram-negatives (+nBCBs) was enabled by inoculating conventional biochemical tests directly (dID) and direct antimicrobial susceptibility testing (dAST) was done as per EUCAST RAST standard. Clinical reports were issued only if a RAST reportable gram-negative was identified in dID.ResultsWe observed significant reductions in the Loading time (LT) [63.5 (104.5-24.5) vs 32 (55-14) minutes, P®. Similar improvements were also noted for +nBCBs received from other locations.ConclusionsThe “diagnostic stewardship care-bundle” strategy to improve aBCD was successfully implemented leading to significant reductions in duration of targeted steps. Laboratories should implement “diagnostic stewardship care-bundles” as per their needs to improve microbiological diagnostics.

To determine the accuracy of direct microbial identification (dID) and antimicrobial susceptibility testing by EUCAST rapid antimicrobial susceptibility testing (rAST) methodology from positively flagged blood culture bottles (BCBs) as well as reduction in turnaround time (TAT) compared to standard methodology.It was a hospital based, prospective cohort study conducted over a period of 21 months from March 2020 to November 2021 in which positively flagged blood culture bottles were simultaneously processed by dID ​+ ​rAST and by VITEK®-2 Compact system or Kirby-Bauer disk diffusion method. TAT was calculated as the time (hours) taken from receipt of sample in bacteriology laboratory to release of clinical reports with complete identification and susceptibility testing results in both methods.Of 301 dID ​+ ​rAST performed in study, 125 (41.5%) BCBs were identified as having one of the 8 reportable micro-organisms by EUCAST rAST standard. Amongst VITEK concordant BCBs with gram-negatives, mean reduction in TAT by dID ​+ ​rAST methodology was 23 ​± ​1.4 ​h. Amongst VITEK concordant gram-negatives, Categorical Agreement (CA) rates for any drug-bug combination were 94.4%, 94.5% and 93.6% and Very Major Error (VME) rates were 3.1%, 3.4% and 3.9% at 4-, 6- and 8-h reading time, respectively.EUCAST rAST methodology can generate susceptibility testing reports a day earlier if incorporated into the laboratory workflow. For resource-limited settings, implementing EUCAST rAST approach can be used effectively in early reporting, which can reduce antimicrobial use and improve patient outcomes by promoting timely escalation or de-escalation of empirical antibiotic therapy.

Objectives Surgical-site infections (SSIs) can complicate virtually any surgical procedure. While SSI can result from numerous causes, contamination of the surgical field can also contribute to it. Intraoperative bacterial contamination during clean orthopaedic procedures can be detected using perioperative cultures. We hypothesized that perioperative cultures could be used to predict possibility of development of SSI in patients undergoing clean orthopaedic surgeries. Materials and Methods We conducted a prospective cohort study at a tertiary care hospital over a 2-year period. Intraoperative surgical wound lavage fluid and closed suction drain tip obtained in the postoperative period were sent for aerobic culture. All patients were followed up to look for the development of SSI for a period of at least 30 days for those undergoing nonimplant surgery, and 90 days for those with implant surgery. Statistical Analysis Means with standard deviation of the continuous data were calculated. Fisher's exact test and chi-square test were used for the analysis of the categorical variables. Relative risk and odds ratio were calculated to evaluate the association of the parameters under study with SSI. Results A total of 384 patients satisfying the inclusion and exclusion criteria were included. Perioperative cultures detected surgical wound contamination in 39 patients (10.1%). Forty-five patients (11.7%) developed SSI during the follow-up period. Skin commensals constituted 59% of perioperative contaminants and accounted for 20% of the SSIs. The relative risk of developing SSI with perioperative contamination was 0.41 (95% confidence interval: 0.09–1.63). Conclusion Intraoperative surgical-site contaminants could be detected using perioperative cultures. However, these contaminants did not lead to SSI. Timely treatment of perioperative contamination with appropriate antibiotics and local wound care probably helped in the reduction of SSI.

Aeromonas salmonicida is a well-known pathogen in salmonid fishes. It was believed to be non-pathogenic to humans because of inability to grow at 37°C. Here we present a case of a woman in her 20s who was diagnosed with abdominal tuberculosis 6 months previously but had not been compliant with the treatment. She presented with occasional febrile episodes, whitish vaginal discharge, burning micturition, anal ulcer, whitish discharge from mouth and recent onset breathlessness. Patient tested serologically positive for HIV-1, and A. salmonicida was isolated from urine sample. Patient was treated with antituberculosis therapy, antiretroviral therapy and antimicrobials. She showed marked improvement over the next few weeks. This case highlights the importance of recognition of rare organisms, especially in immunocompromised patients. The identification and subsequent treatment of such pathogens have improved since the advent of automated identification systems.

Background: The objectives of our study were to study the stethoscope cleaning practices of medical personnel and to assess the microbial load on stethoscopes and efficacy of cleaning stethoscopes with alcohol-based disinfectant. Methodology: A questionnaire-based cross-sectional study was conducted among medical personnel at a tertiary care hospital in India to assess their knowledge and cleaning practices regarding stethoscope disinfection. Samples from the stethoscopes were collected before and after cleaning with alcohol-based disinfectant. Results: Out of 62 participants, 53.22% individuals had never cleaned their stethoscope. All the initial swab samples showed bacterial growth. There was mixed growth in the samples taken from 35 stethoscope bells and 31 diaphragms. Bacteria included coagulase negative staphylococci, bacillus species, diptheroids, S. aureus, Acinetobacter and Klebsiella pneumoniae. After cleaning with an alcohol-based disinfectant, there was a significant decrease in the average number of bacterial colony-forming units. Conclusions: Regular cleaning practices should be followed to prevent growth and transmission of potentially pathogenic organisms.

CONTEXT: Diarrheagenic Escherichia coli (DEC) is the leading cause of infectious diarrhea in developing countries. On the basis of virulence and phenotypic characteristics, the DEC is categorized into multiple pathotypes. Each pathotype has different pathogenesis and geographical distribution. Thus, the proper management of disease relies on rapid and accurate identification of DEC pathotypes. AIMS: The aim of the study was to determine the prevalence of DEC pathotypes in India. MATERIALS AND METHODS: A cross-sectional study was carried out between January 2008 and December 2012 at Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Center, Belgaum (Karnataka), India. A total of 300 stool samples were collected from diarrhea patients with age >3 months. The DEC was identified by both conventional and molecular methods. RESULTS: Of 300 samples, E. coli were detected in 198 (66%) and 170 (56.6%) samples by culture and polymerase chain reaction, respectively. Among DEC (n = 198) isolates, eae gene (59.5%) was the most prevalent followed by stx (27.7%), east (27.2%), elt (12.6%), est (10.6%), ipaH (5.5%), and eagg (1.5%) genes. On the basis of virulence genes, enteropathogenic E. coli (33.8%) was the most common pathotype followed by Shiga toxin-producing E. coli (STEC, 23.2%), enterotoxigenic E. coli (ETEC, 13.6%), enteroinvasive E. coli (5.5%), enteroaggregative heat-stable enterotoxin 1-harboring E. coli (EAST1EC, 4.5%), STEC/ETEC (3.5%), STEC/enteroaggregative E. coli (STEC/EAEC, 1.0%), and EAEC (0.05%). CONCLUSIONS: The hybrid DEC is potentially more virulent than basic pathotypes. The pathotyping should be included in clinical settings for the proper management of DEC-associated diarrhea.

Context: The conventional diagnostic tools for dermatophytoses suffer from several limitations including low sensitivity, specificity, and long turn-around-time. Aims: The present study was, therefore, performed to evaluate the performance of a polymerase chain reaction (PCR)-based method for the diagnosis of this condition. Settings and Design: The study was conducted in the Dermatology outpatient department of a tertiary care teaching hospital in central India over a period of 3 months from July to September 2015. Materials and Methods: Forty participants, including 25 cases and 15 controls, were recruited in this observational study. Direct microscopy and fungal culture were performed from skin scrapings and nail clippings collected from the participants. PCR was also performed to amplify the chitin synthase 1 and internal transcribed spacer 2 genes from DNA samples extracted from the same clinical materials, using the method reported by Brillowska-Dabrowska et al. The diagnostic performance of fungal culture and PCR was compared using OpenEpi software. Results: We observed a significant male predominance among patients with dermatophytoses. The sensitivity of fungal culture and dermatophyte PCR to diagnose dermatophytoses was 24% and 48%, respectively, whereas the specificity of the two assays was 100% and 93.3%, respectively. The likelihood ratio of a positive PCR assay was 7.2 and the negative likelihood ratio was 0.5. PCR assay also delivered a significant shortening of the time-to-diagnosis, with the mean turn-around-time being 8 hours and 14 days for PCR and culture, respectively. Conclusion: This study, thus, highlights the potential merits of the dermatophyte PCR assay in achieving a rapid diagnosis of dermatophytoses and underscores its utility as a complementary test to improve the sensitivity of the conventional diagnostic tools for this condition, as well as to reliably differentiate this condition from other similar skin conditions.

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.

Background: Global, regional and national estimates clearly place diarrhoeal diseases as a major, albeit to an extant neglected public health problem. Deaths of children aged

In view of paucity of information on serotype distribution of Dengue virus (DENV) in Central India, we undertook a cross-sectional study to identify clinical and virological characteristics of DENV serotypes that circulated in this region during the 2016 outbreak. Suspected cases were screened by ELISA for NS1 antigen and anti-DENV IgM antibodies. Serologically confirmed cases were subjected to RT-PCR based detection and serotyping. The RT-PCR results were confirmed by nucleotide sequencing. Genome-wide association was undertaken with DENV sequences from ViPR database and the immune evasion potential of infecting serotypes was ascertained by computing antigenic variability in B cell and Cytotoxic T cell (CTL) epitopes of all DENV proteins. The immunological basis of more prolonged viremia in DENV2-infected patients was also addressed through sequencing of NS2a gene and comparing the CTL activity in NS2a sequences identified among patients with ≤5 days and >5 days of illness. Among 166 serologically confirmed Dengue patients, 75 were positive for DENV RNA. Serotyping revealed predominance of DENV-1 and DENV-2, followed by DENV-3. Co-infection with multiple serotypes was observed in 15.5% of cases. In ~40% cases, DENV RNA was detectable beyond 5 days, among whom majority were DENV-2 infected (p = .044). Highest prevalence of antigenic variability was observed in B cell and CTL epitopes of DENV-2. The potential association between prolonged viremia and higher ability for immune evasion in DENV-2 patients was further corroborated with the observation of poorer HLA-I binding affinity in CTL epitopes observed in NS2a sequences retrieved from patients with >5 days of illness, compared to those with ≤5 days. This is the first report from central India revealing circulation of all DENV serotypes and high prevalence of co-infection with multiple serotypes. We also observed prolonged viremia upon DENV-2 infection, which could be potentially associated with its superior immune evasion potential.

Introduction: Outbreaks due to non-O157:H7 Shiga toxin producing Escherichia coli (STEC) resulting in Haemolytic Uraemic Syndrome (HUS) have garnered much attention because of associated mortality transcending across continents and also because diarrhoea due to E.coli itself is rare in developed countries. The actual incidence of non-O157:H7 STEC in sporadic acute diarrhoea is not fully elucidated, both in developing as well as in developed countries. Due to larger extent of faecal-oral transmission in developing countries it is prudent to look for non-O157: H7 STEC in such epidemiological settings because of very high potential to spread across larger geographical regions and cause life threatening illness. Aim: To determine the extent of acute diarrhoea caused by Shiga toxin producing E. coli and measure their genotypic diversity. Materials and Methods: The study was designed as a cross-sectional study and conducted between 2009-2011 in department of Microbiology at JN Medical College Belgaum (Karnataka) and Regional Medical Research Center, Belgaum (RMRC-ICMR). Stool samples from 300 sporadic cases of acute diarrhoea were processed by microscopy, culture, for the identification of diarrhoeagenic pathogens viz. Vibrio cholera, Shigella spp., Salmonella spp. and protozoan parasites. PCR was performed for the detection of eae and stx genes in E. coli isolates. Their relatedness was determined by Random Amplification of Polymorphic DNA (RAPD). Results: PCR detected stx along with eae in 23.2% culture isolates of E.coli isolated from diarrhoea samples. Only three isolates were identified as STEC by serology as O59, O60 and O69 serotypes. Eleven clones were detected by RAPD fingerprinting in the 46 STEC isolates. Conclusion: Non-O157:H7 STEC are prevalent in this region and laboratories shall look beyond O157:H7 serotype of E.coli. These isolates have potential of causing outbreaks transcending borders. Hence they shall be reported and efforts be made to identify their sources and prevent spread.

Background: The culture has always been the gold standard test for diagnosis of human brucellosis but the conventional Brucella diagnostic tests viz. serology and culture are often beset with poor specificity & sensitivity respectively. The culture positivity rates for Brucella vary from 92% for bone marrow to 10% for non-blood samples and also dependent on the type of sample. The primary immune-determinant for Brucella species is the cell wall surface lipopolysaccharide, which is antigenically similar to other gramnegative rods. Hence, Brucella serological tests cross react with Escherichia coli 0116 and 0157, Salmonella urbana, Yersinia enterocolitica 0:9, Vibrio cholerae, Xanthomonas maltophilia and Afipia clevellandensis infections, which are common in developing countries also having higher incidence of brucellosis. Aim: The aim of the study was evaluation of conventional serological techniques and PCR for diagnosis of human brucellosis in and around north Karnataka which is endemic for brucellosis and patients often present with elevated base line antibody titers and confounding clinical manifestations. Materials and Methods: Blood/serum samples of 400 patients suffering from acute undifferentiated fever (AUF) were subjected to culture, Brucella slide agglutination test (SAT), standard tube agglutination test (STAT coupled with 2 ME) and PCR. Results: Of the 400 AUF patients, anti-Brucella antibodies were detected by SAT and STAT in serum of 35 and 34 patients respectively. IS711 gene for Brucella was identified in 32 patients by PCR. Twenty samples yielded Brucella in culture on biphasic medium with average incubation period of 9 days. All patients having titer of ≥ 160IU / ml in STAT were found positive by PCR also. Conclusion: Brucella STAT corroborated well with PCR results in all those cases where antibodies were present at least one dilution above cut-off value of 80 IU/ml. We probably need to raise cut-off titers to ≥160 IU/ml because of endemic region. The SAT was upheld as very good quick, easy to perform and economical screening test for human brucellosis. SAT as rapid screening test and STAT as more definitive test can be very well adopted by laboratories working in resource scarce settings for diagnosis of human brucellosis in absence of PCR even for population with normally elevated antibodies levels due to residing in Brucella endemic areas.

One of the complications of brucellosis is infective endocarditis, which carries a high mortality rate if undiagnosed or misdiagnosed. We report a case of Brucella infective endocarditis, which was diagnosed serologically and by polymerase chain reaction. After Brucella specific treatment, patient showed dramatic improvement clinically, as evident by echocardiogram findings and other investigations.

A male patient of 32 years was referred for surgical drainage and orchidectomy of the right testis following a cycling injury. A Venereal Disease Research Laboratory (VDRL) test was requested by the surgery department to rule out secondary syphilis. Although serum samples gave a negative result in the VDRL test, qualitative screening was performed for Brucella antibodies, as per hospital policy, since brucellosis is endemic in this region. Following a positive reaction, a quantitative standard tube agglutination test was carried out yielding titres that were exceptionally high (STAT = 40 960 IU ml(-1); 2-ME = 1 : 5120). This finding correlated with the patient's history which included a number of predisposing factors for contracting brucellosis including exposure to cattle, consumption of raw milk and assisting in the parturition of cattle. Consequently, surgery was postponed and treatment was changed from injections of ceftriaxone to the WHO regimen for the treatment of brucellosis: 1 g streptomycin once daily, administered intra-muscularly, plus 100 mg doxycycline twice daily, taken orally. Following 3 days of this treatment, the testicular swelling reduced considerably and orchidectomy was not required. Indeed, after a week, swelling was completely resolved and the patient was discharged. To our knowledge, this is the first case of such high titres in a patient as a result of epididymo-orchitis without the typical clinical presentation of fever and joint pain that is normally associated with brucellosis.

Human brucellosis, a zoonotic disease, is endemic in the Belgaum district, Karnataka, India. A male patient presented with a generalized itchy rash. Blood was sent for venereal disease research laboratory testing. Screening was carried out for Brucella antibodies following hospital policy and diagnosis was confirmed by PCR.