JEE

VAN

U T

IME

S

Indian Association of Medical Microbiologists– Delhi Chapter www.iammdelhi.com

Editors Poonam Loomba Sonal Saxena Jaswinder Oberoi Renu Gupta Manisha Jain

Volume 2, July 2018

2

Edito ial Tea

D Poo a Sood Loo a

Di e to P ofesso

G B Pa t Hospital Ne Delhi

D So al Sa e a

Di e to P ofesso

Lad Ha di ge Medi al College

Ne Delhi

D Jas i de K O e oi Se io Co sulta t

Si Ga ga Ra Hospital Ne Delhi

D Re u Gupta

Assista t P ofesso

I stitute of Hu a eha iou & Allied S ie es

Delhi

D Ma isha Jai

Assista t P ofesso

VMMC & Safda ja g Hospital Ne Delhi

JEEVANU TIMES

Offi ial pu li atio of I dia Asso iatio of Medi al Mi o iologists-Delhi Chapte

3

JEEVANU TIMES

Offi ial pu li atio of I dia Asso iatio of Medi al Mi o iologists-Delhi Chapte

Ta le of o te ts

Re ie a ti le

Clostridiu diffi ile i fe tio : a e ie of lite atu e

Bha a Sha a

VMMC & Safda ju g Hospital, Ne Delhi.

Pg -

Cli i al Case Repo t

Se e e hae o hagi p eu o o al p eu o ia i a hild: A a e o pli a-tio

Pooja Sha a, Shali i De a Duggal, Re u Gu , Stuti Kaushik, Ta isha Bha a a, Ma oj Ga g, Deepti Jai

D . BSA Hospital, Delhi

Pg -

Aspe gillosis i a patie t o e t a o po eal e a e o ge atio suppo t

Poo i a Se , Ba sidha Ta ai, P ag a P Je a

Ma Supe spe ialit Hospital, Ne Delhi

Pg -

A ase epo t of isdiag osed east a s ess

Pu a i Ba a , Ta u Thuk al, Shi pi Chop a, Sa deep Na a

BLK Supe Spe ialit Hospital, Ne Delhi

Pg -

Mi o iolog updates f o a ou d the o ld

Pg -

Mi o iolog uiz

Pg

4

F o the edito ’s desk

G eeti g a d el o e to the e t editio of Jee a u Ti es. The o je ti e of Jee a u

Ti es is to pu lish up-to-date, high- ualit a d o igi al esea h pape s alo gside ele-

a t a d i sightful e ie s a d to e ou age the ou g i o iologists to pu lish thei

a ti les. As su h, the e slette aspi es to e i a t, e gagi g a d a essi le, a d at

the sa e ti e i fo ati e a d useful. This issue o tai s a e ie a ti le o Clost idi-

u diffi ile i fe tio : a i fe tio hi h is e o i g i easi gl p e ale t ith the is-

use of a ti i o ials. We also ha e a se ies of ase epo ts o a e a u usual p ese ta-

tio s of Aspe gillosis, se e e p eu o o al hae o hagi p eu o ia a d isdiag o-

sis.

A pape s that ou ish to su it, a e u h app e iated a d ill ake a su sta tial

o t i utio to the su ess of this e slette . Best ishes a d tha k ou i ad a e fo

ou o t i utio to the Jee a u Ti es

With est ishes

D Poo a Sood Loo a

Edito

Jee a u ti es

5

Clostridiu diffi ile i fe tio : a e ie of lite atu e

Autho : D . Bha a Sha a

Depa t e t: Depa t e t of Mi o iolog

I stitute: VMMC & Safda ju g Hospital, Ne Delhi.

Co espo di g autho : ha a @g ail. o

Re ie arti le

I trodu tio

Clostridiu diffi ile C. diffi ile is o idel

e og ized as the leadi g ause of oso o ial

dia hea o ld ide ith asso iated su sta tial

o idit a d o talit [ , ]. Re e t data sug-

gest a i ease i oth the i ide e a d se-

e it of C. diffi ile i fe tio CDI [ ]. O e

, , people eed hospital a e a d at least

, people die f o CDI i the U ited States

ea h ea ased o statisti s f o the Ce te s

of Disease Co t ol a d P e e tio [ ]. Clost idi-

u diffi ile C. diffi ile is a G a -positi e,

st i tl a ae o i , spo e-fo i g a te iu that

auses a spe t u of p ese tatio a gi g f o

ild, self-li iti g dia hea, to se ious dia hea,

pseudo e a ous olitis a d life-th eate i g

ful i a t olitis, hi h a esult i death [ ].

It as fi st isolated i f o fe es a d e-

o iu of as pto ati e o i fa ts, a d

as o igi all a ed Ba illus diffi ilis e ause

of its o pholog , a d e ou te ed the diffi ul-

ties i ulti ati g it [ ]. Si e the , it as e-

lie ed to e a o e sal o ga is u til the

late s, he it as e og ized as the etio-

logi age t of pseudo e a ous olitis [ ].

Pathoge esis

I o de fo C. diffi ile to ause disease, se e al

i po ta t o -ditio s ust e et. A pe so

ust ha e o ta t ith the spo es of a to i -

p odu i g st ai of C. diffi ile i o i atio

ith alte atio of the o al olo i i o io-

ta, pe itti g olo iza-tio of the o ga is .

CDI de elops he a patie t i gests the spo es

of a to ige i st ai of C. diffi ile ia pe so al

o ta t o e i o e t. A o g health peo-

ple, C. diffi ile does ot ause p o le s due to

i pa t o e sal o el flo a a d a ti od -

ediated i u it ; ho e e , i the setti g of

a a o al o dis upted olo i u osa,

these spo es olo ize the o el a d su se-

ue tl ge i ate, a d egetati e a te ia

sta t p odu i g t o la ge to i s, a e te oto -

i , T dA, a d a toto i , T dB, hi h a e e -

oded t dA a d t dB, espe ti el [ ]. To i

A, auses i eased i testi al pe ea ilit a d

fluid se etio . To i B, leads to i te se olo i

i fla atio . To i s ou d to e epto s gai

i t a ellula e t odifi atio of Rho p o-

tei s-s all gluta l t a speptidase- i di g

p otei s. These p otei s a e i ol ed i

6

a ti pol e izatio , toskeletal a hite -

tu e, a d ell o e e t. The esulta t effe t

is the loss of i te ellula tight ju tio s lead-

i g to se eta dia hea, a d a i fla ato-

espo se ith e e tual ell death [ ]. The

fa t that a ti ioti s alte the gut i o iota

has ee esta lished si e the s, sho tl

afte st epto i e a e a aila le a d i -

estigato s oted the i pa t of o al ad i -

ist atio of this age t o the a te ia p ese t

i the fe es of i e[ ]. A ti ioti s a e the

ajo isk fa to fo the de elop e t of C.

diffi ile disease e ause of the loss of e dog-

e ous i o iota that allo s C. diffi ile,

he p ese t, to p olife ate a d i ade. Se -

e al i te esti g studies of the gut i o i-

o e usi g ultu e-i depe de t ethods

ha e elu idated the sig ifi a t alte atio s

that fol-lo a ti ioti ad i ist atio [ , ].

Othe i po ta t i ule e fa to s that o -

t i ute to the pathoge esis of C. diffi ile i -

lude adhesi s, fi iae, flagella, a apsule,

a d a pa a stalli e S-la e p otei

i po ta t i ellula adhesio [ - ].

Risk fa tors

The hief isk fa to fo the disease is p io to

e pose a ti i o ials. I the hospital setti g,

the ajo it of CDI ases is asso iated ith

the use of a ti ioti s. Ho e e , up to / of

ases of o u it -a ui ed CDI i a e e t

stud did ot ha e a ti ioti s i the da

p io to the de elop e t of s pto s sug-

gesti g a diffe e t patte of disease et ee

o u it -a ui ed a d oso o ial ases [ ].

The isk of de elopi g disease afte e posu e to

a ti i o ials is highl a ia le a d depe ds o

host fa to s age, diet, i u e s ste fu tio ,

et . , the t pe a d dose of a ti ioti , a d the du-

atio of t eat e t. Although li da i usage

as losel li ked ith the disease histo i all

a d still o stitutes to e a ajo isk fa to ,

o e ases at the p ese t a e att i uted to the -

ap ith β-la ta age ts e ause of thei o -

o use [ ]. Othe isk fa to s i lude ad-

a ed age > ea s , e e t su ge

t a spla t, gast oi testi al p o edu es , p oto

pu p i hi ito s, i u osupp essa t, u de l i g

de ilitati g o ditio s, i fla ato o el dis-

ease, p olo ged hospitalisatio > d , a d a-

sogast i tu e feedi g [ , ].

Cli i al features

The i u atio pe iod et ee spo e i gestio

a d the o set of the disease has ot ee dete -

i ed. Ho e e , ost patie ts de elop dia hea

du i g o sho tl afte taki g a ti ioti s, o up to

- eeks afte its dis o ti uatio [ , ]. CDI

has a ide spe t u a ge of li i al p ese ta-

tio s f o ild, self-li iti g dia hea, to se ious

dia hea, pseudo e a ous olitis a d life-

th eate i g ful i a t olitis, hi h a esult i

death. Wate dia hea is the a di al s pto

of CDI[ ]; it a ies f o ild, ode ate to se-

e e. Patie ts ith olitis ith o ithout pseu-

do e a ous olitis usuall p ese t ith ate-

7

dia hea up to - ti es dail , a -

do i al a pi g a d pai , fe e , a o e ia

a d ausea [ ]. The li i al p ese tatio of

CDI a ges f o as pto ati a iage, to

ild o ode ate dia hea, to ful i a t oli-

tis [ , ]. Th ee o o e ate , o lood

stools pe -h pe iod is the hall a k of

s pto ati ill ess [ ]. Mild disease is

ha a te ized dia hea i the a se e of

sig s a d s pto s of olitis he eas od-

e ate disease is ha a te ized ode ate

dia hea ith olitis a ifested fe e , a -

do i al a ps a d dis o fo t, usuall i

the lo e uad a ts [ ]. Se e e disease is

ha a te ized hite lood ell ou t of

> , ells/μL, se u al u i < g/dL,

a d/o a se u eati i e le el ≥ . ti es

the p e o id le el [ ].

The li i al featu es of CDI/ful i a t olitis

i lude fe e , dia hea leadi g to h po ole-

ia, se e e lo e uad a t o diffuse a -

do i al pai , a do i al diste tio , se e e

la ti a idosis, h poal u i e ia, a d sig ifi-

a t leuko tosis , hite lood ells/

μL o highe [ ]. Ful i a t olitis a lead

to o el pe fo atio a d to i ega olo .

Othe o pli atio s of C. diffi ile i lude

ele t ol te i ala e, e al failu e f o se-

e e deh d atio , s ste i i fla ato e-

spo se s d o es a d sepsis [ ].

La orator ethods for Clostridiu

diffi ile dete tio :

The diag osis of CDI is ased o the li i al fea-

tu es, o fi atio of the p ese e of eithe to -

i A alo e o to i s A a d B togethe i the stool,

a d so eti es e dos op to e if pseudo e -

a ous olitis. CDI should e suspe ted i a

hospitalized patie t ho de elops dia hea o

a pe so i the o u it ho de elops dia -

hea afte a ou se of a ti ioti s o i asso iatio

ith i u osupp essi e the ap . CDI should o -

l e i estigated i patie ts ith dia hea. Diag-

osti tests a aila le i lude e z e i u oas-

sa s EIA fo to i s, EIA fo C. diffi ile gluta ate

deh d oge ase GDH a d u lei a id a plifi a-

tio tests NAATs, o Pol e ase hai ea tio

PCR fo C. diffi ile to i ge es. Othe diag osti

tests i lude to ige i ultu es, o ell ultu e

eut alizatio assa s CCNA [ ]. O e st ateg

to i p o e se siti it is th ough a t o-step

ethod that uses EIA dete tio of GDH as a i i-

tial s ee . A tige -positi e spe i e s fo GDH

a d egati e fo to i s if tested a e fu the

assessed usi g a NAAT o CCNA. To ige i ul-

tu e is o side ed the gold sta da d; ho e e its

use li ited i the li i al setti g gi e the du a-

tio of ti e fo ultu e esults to e o e a aila-

le. NAATs e.g. PCR a e highl spe ifi > % ,

a d highl se siti it apid tests fo C. diffi ile

dete tio . This diag osti test affo ds a ui k a d

effi ie t a of dete ti g CDI [ ]

8

Ma age e t of CDI

T eat e t of C. diffi ile i fe tio i ol es

stoppi g s ste i a ti ioti s if possi le p o-

ide app op iate suppo ti e a e ith h d a-

tio a d ele t ol te epla e e t as eeded.

Studies ha e i di ated highe u e ates a d

de eased elapse i patie ts i ho a ti i-

oti s e e dis o ti ued [ , ]. Met o ida-

zole a d a o i a e the p i ipal d ugs

used to t eat C. diffi ile i fe tio . Patie ts

ith ild o ode ate dia hea a e ge e all

t eated ith et o idazole g TID fo

to da s, as studies ha e i di ated si i-

la u e ates ith eithe et o idazole o

a o i . Patie ts ith se e e dia hea

a e t eated ith a o i to g

QID fo - da s, as patie ts ith o pli-

ated C. diffi ile had a u e ate of % ith

et o idazole o pa ed to % ith a o-

i . Re u e e ates e e also highe

ith et o idazole. Adju t the ap is ith

a o i e e a g i l sali e

a d /o i t a e ous et o idazole. Su ge

ith total ole to is i di ated i se e e

olitis ith sig ifi a t to e i s pto s[ ].

Othe a ti ioti s that a e o side ed as

alte ati e the ap fo CDI i the u usual

e e ts e.g. alle g o i tole a e to oth

fi st- li e age ts i lude fida o i i , a it a-

i , tei opla i , fusidi a id a d itazo a-

ide, ifa i i a d ifa pi . Most of the a -

ti e o pa ato studies fou d o statisti all

sig ifi a t diffe e e i effi a et ee a o-

i a d these age ts fo i itial the ap of CDI

e ept tei opla i a d fida o i i . The e o -

e ded dose is g e e hou s fo

da s. Tei opla i appea s to e ette tha a -

o i fo a te iologi u e a d has o de li e

supe io effe ti e ess i te s of s pto ati

u e, hile fida o i i appea s supe io to a -

o i i te s of lo e e u e e ates a d

glo al li i al u e ates i.e., li i al u e ates

o i ed ith e u e e ates . No e a ti i-

o ial the apies su h as i t a e ous i u o-

glo uli , spe ifi o o lo al a ti odies the ap ,

to i - i di g age ts e.g., holest a i e,

tole a e , p o ioti s [e.g., Sa ha o es ou-

la dii S. oula dii ] a d fae al the ap ha e ee

studied fo use as sta d-alo e t eat e ts o i

o i atio ith sta da d the ap fo CDI. Su -

gi al i te e tio ole to is i di ated i pa-

tie ts ith to i ega olo ho a e ot e-

spo di g to edi al t eat e t, i patie ts ith

o goi g se e e sepsis despite a ti ioti t eat-

e t, a d/o he olo i pe fo atio is li i al-

l suspe ted [ , ].

Recurrent CDI

Between 20% and 35% of patients with CDI will fail initial antibiotic treatment and, of these, 40–60% will have a second recurrence. The majority of recurrences are due to relapses of CDI with the original strain rather than re-infection with a dif-ferent strain . Resistance to vancomycin or metro-nidazole is not considered a factor in recurrent CDI, but such antibiotics may contribute to con-tinued intestinal dysbiota. Recurrent infection is

9

o ti ued i testi al d s iota. Re u e t i -

fe tio is o e o o i olde patie ts

> ea s , fe ales, Cau asia patie ts,

those ith u e t a ti ioti use, o o i-

ta t use of p oto pu p i hi ito s a d o e

se e e i itial disease. The p ese e of o o -

idities, a ti- eoplasti he othe ap , i ad-

e uate IgG a ti od espo se to To i A

afte i itial episode, i fla ato o el dis-

ease, o ga t a spla tatio , h o i kid e

disease, h poga aglo uli ae ia, i u o-

defi ie a d e posu e to a i fa t a ie

o i fe ted adult ha e also ee e og ized

as isk fa to s . The o t i utio of p oto

pu p i hi ito s PPIs to CDI e ai s u -

lea . C. diffi ile spo es a e esista t to gas-

t i a id, ut egetati e fo s a e sus epti-

le. I o u it -a ui ed CDI patie ts, PPI

e posu e as o se ed i % of patie ts

ith CDI, ith o e posu e to a ti ioti s .

The e ha e ee epo ts of i eased CDI isk

ith PPIs; ho e e , othe studies ha e e-

po ted o i ease i isk follo i g adjust-

e t fo o-e iste t o ditio s [ – ]. P o-

ioti s a a t th ough a u e of e ha-

is s. These i lude te po a olo izatio ,

p odu tio of a te i idal a ids a d peptides,

a d o petitio ith C. diffi ile fo ut ie ts

a d epithelial adhesio . La to a illi ha e

ee sho to supp ess g o th of C. diffi ile

i ha ste s [ ].

Pre e tio

P e e tio of CDI is halle gi g health au-

tho ities. Ho e e , p e e ti e easu es a e tak-

e su h as i ple e tatio of i fe tio - o t ol

easu es o ta t isolatio a d follo i g good

ha d - ashi g e e o e . I additio , the

o e sto e to o t olli g this i fe tio is the

o t ol of a ti i o ial p es i i g. A ultidis i-

pli a a ti ioti a age e t p og a to e-

st i t the i app op iate use of a ti ioti s a

lead to a sig ifi a t de ease i oso o ial i fe -

tio s aused C. diffi ile[ ]

Refe e es

. Pee AF, Dello ES, Lu d J, et al. Bu de of

gast oi testi al disease i the U ited States:

Gastroe terolog ; : - ;e

. Wiega d PN, Nath a i D, Wil o MH, Ste-

phe s J, Shel a a A, Haide S. Cli i al a d

e o o i u de of Clostridiu diffi ile i fe -

tio i Eu ope: a s ste ati e ie of

health a e-fa ilit -a ui ed i fe tio . J Hosp

I fe t ; : - .

. M Do ald LC, O i gs M, Je iga DB. Clos-

tridiu diffi ile i fe tio i patie ts dis-

ha ged f o US sho t-sta Hospitals, -

. E erg I fe t Dis ; : - .

. Ce te s fo Disease Co t ol a d P e e tio .

A ti ioti esista e th eats i the U ited

States; . A aila le at: http://

. d .go / d ug esista e/pdf/a -th eats-

- .pdf. A essed De e e ,

. Kutt PK, Woods CW, Se a AC, Be oit SR,

Naggie S, F ede i k J, et al. Risk fa to s fo

a d esti ated i ide e of o u it

10

asso iated Clost idiu diffi ile i fe tio ,

No th Ca oli a, USA. E e g I fe t Dis

; : - .

. Hall IC, O’ Toole E. I testi al flo a i e -

o i fa ts ith a des iptio of a e

pathoge i a ae o e, Ba illus diffi ilis.

A J Dis Child ; : - .

. Ba tlett JG Cli i al p a ti e. A ti ioti -

asso iated dia hea. N E gl J Med ;

: - .

. Rup ik M, Dupu B, Fai eathe NF,

Ge di g DN, Joh so S, Just I, et al. Re-

ised o e latu e of Clost idiu

diffi ile to i s a d asso iated ge es. J

Med Mi o iol ; : - .

. Su X, Sa idge T, Fe g H. The e te oto i-

it of Clostridiu diffi ile to i s. To i s

Basel ; : - .

. B itto RA, You g VB. . I te a tio

et ee the i testi al i o- iota a d

host i Clost idiu diffi ile olo izatio

esista e. T e ds Mi o iol. : – .

. Jako sso HE, Je e g C, A de sso AF,

Sjolu d-Ka lsso M, Ja s-so JK, E g-

st a d L. . Sho t-te a ti ioti

t eat e t has diffe i g lo g-te i -

pa ts o the hu a th oat a d gut i o-

io e. PLoS O e :e . doi: . /

jou al.po e. .

. Dethlefse L, Huse S, Sogi ML, Rel a

DA. . The pe asi e effe ts of a a -

ti ioti o the hu a gut i o iota, as

e ealed deep S RNA se ue i g.

PLoS Biol. :e . doi: . /jou al.p io

. Se aihia M, W e BW, Mulla P, Fai eath-

e NF, Mi to N, Sta le R, Tho so NR,

Ro e ts AP, Ce de o-Ta aga AM, Wa g H,

Holde MT, W ight A, Chu he C, Quail MA,

Bake S, Baso N, B ooks K, Chilli g o th T,

C o i A, Da is P, Do d L, F ase A, Felt ell

T, Ha e Z, Hol o d S, Jagels K, Moule S,

Mu gall K, P i e C, Ra i- o its h E, Sha p S,

Si o ds M, Ste e s K, U i L, Whithead

S, Dupu B, Douga G, Ba ell B, Pa khill J.

. The ultid ug- esista t hu a patho-

ge Clost idiu diffi ile has a highl o ile,

o-sai ge o e. Nat. Ge et. : – .

. Chilli g o th T, C o i A, Da is P, Do d L,

F ase A, Felt ell T, Ha e Z, Hol o d S, Ja-

gels K, Moule S, Mu gall K, P i e C, Ra i-

o its h E, Sha p S, Si o ds M, Ste e s K,

U i L, Whithead S, Dupu B, Douga G,

Ba ell B, Pa khill J. . The ultid ug-

esista t hu a pathoge Clost idiu

diffi ile has a highl o ile, o-sai ge o e.

Nat. Ge et. : – .

. P uitt RN, La DB. . To a d a st u tu al

u de sta di g of Clos-t idiu diffi ile to i s

A a d B. F o t. Cell. I fe t. Mi o iol. : .

doi: . /f i . . .

. Ake lu d T, S e u gsso B, Lage g e A, Bu -

a LG. Co elatio of disease se e it ith

fe al to i le els i patie ts ith Clost idiu

diffi ile-asso iated dia hea a d dist i utio

of PCR i ot pes a d to i ields i it o of

o espo di g isolates. J Cli Mi o iol ;

11

: - .

. Ba tlett JG. Cli i al p a ti e. A ti ioti -

asso iated dia hea. N E gl J Med ;

: - .

. Su o ie D, Ku u jia AG, W d MA,

Ci og a CE. Past, p ese t, a d futu e

the apies fo Clost idiu diffi ile-

asso iated disease.A Pha a othe

; : - .

. S h oede MS. Clost idiu diffi ile-

asso iated dia hea. A Fa Ph si ia

; : - .

. M Fa la d LV, Su a i z CM, Sta WE.

Risk fa to s fo Clost idiu diffi ile a -

iage a d C. diffi ile-asso iated dia hea

i a oho t of hospitalized patie ts. J I -

fe t Dis ; : - .

. Kell CP, Pothoulakis C, LaMo t JT. Clos-

t idiu diffi ile olitis. N E gl J Med ;

: - .

. Kell CP, Pothoulakis C, LaMo t JT. Clos-

t idiu diffi ile olitis. N E gl J Med ;

: - .

. A a d A, Bashe B, Mi T, Glatt AE. Epide-

iolog , li i al a ifestatio s, a d out-

o e of Clost idiu diffi ile-asso iated

dia hea. A J Gast oe te ol ; :

- .

. Ba tlett JG. Cli i al p a ti e. A ti ioti -

asso iated dia hea. N E gl J Med

; : - .

. Kell CP, LaMo t JT. Clostridiu diffi ile-

o e diffi ult tha e e . N E gl J Med

; : - .

. Bu ha C-AD, Ca oll KC. Diag osis of Clos-

tridiu diffi ile i fe tio : a o goi g o u -

d u fo li i ia s a d fo li i al la o ato-

ies. Cli Mi ro iol Rev ; : - .

. Ko a TM. Diag osis a d a age e t of

Clostridiu diffi ile i fe tio . Se i Respir

Crit Care Med ; : - .

. Su a i z CM, B a dt LJ, Bi io DG, et al.

Guideli es fo diag osis, t eat e t, a d p e-

e tio of Clostridiu diffi ile i fe tio s. A

J Gastroe terol ; : - .

. Bulusu M, Na a a S, Shetle K, T iada-

filopoulos G. Leuko tosis as a ha i ge a d

su ogate a ke of Clostridiu diffi ile i fe -

tio i hospitalized patie ts ith dia hea.

A J Gastroe terol ; : - .

. Kufel i ka AM, Ki TJ. Effe ti e utilizatio of

e ol i g ethods fo the la o ato diag osis

of Clostridiu diffi ile i fe tio . Cli I fe t Dis

; : - .

. Mu ad YM, Pe ez J, Nokh eh R, et al. I pa t

of pol e ase hai ea tio testi g o Clos-

tridiu diffi ile i fe tio ates i a a ute

health a e fa ilit . A J I fe t Co trol

; : -

. Gould CV, M Do ald LC Be h-to-

edside e ie : Clost idiu diffi ile olitis.

C it Ca e : .

33. Mulla e KM, Mille MA, Weiss K, Le t ek A,

Gola Y, et al. Effi a of fida o i i

e sus a o i as the ap fo Clost idiu

12

diffi ile i fe tio i i di iduals taki g o -

o ita t a ti ioti s fo othe o u e t

i fe tio s. Cli I fe t Dis : - .

. Za FA, Bakka aga i SR, Moo thi KM, Da-

is MB A o pa iso of a o -

i a d et o idazole fo the t eat e t

of Clost idiu diffi ile asso iated dia -

hea, st atified disease se e it . Cli

I fe t Dis : - .

. Nelso RL, Kelse P, Lee a H, Mea do

N, Patel H, Paul K, et al. A ti ioti t eat-

e t fo Clost idiu diffi ile-asso iated

dia hea i adults. Co h a e Data ase

S st Re ; doi: . / .

CD .pu .

. Che g AC , F e guso JK, Ri ha ds MJ,

Ro so JM, Gil e t GL, M G ego A, et al.

Aust alasia so iet fo i fe tious diseas-

es guideli es fo the diag osis a d t eat-

e t of Clost idiu diffi ile i fe tio .

Med J Aust ; : -

. Asla S, Ha ill RJ, Mushe DM. T eat-

e t of Clost idiu diffi ile- asso iated

disease: old the apies a d e st ategies.

La et I fe t Dis ; : – .

. Co el OA, Mille MA, Louie TJ et al. T eat-

e t of fi st e u e e of Clost idiu

diffi ile i fe tio : fida o i i e sus a o-

i . Cli I fe t Dis ; Suppl :S –

.

. Kell CP, LaMo t JT. Clost idiu diffi ile—

o e diffi ult tha e e . N E gl J Med

; : – . Lo I, Mol i e DC, Lea

BA et al. T eat e t ith o o lo al a ti od-

ies agai st Clost idiu diffi ile to i s. N E gl J

Med ; : –

. M Fa la d LV, El e GW, Su a i z CM.

B eaki g the le: t eat e t st ategies fo

ases of e u e t Clost idiu diffi ile

disease. A J Gast oe te ol ; : –

.

. M Fa la d LV, Su a i z CM, G ee e g RN et

al. A a do ized pla e o- o t olled t ial of

Sa ha o es oula dii i o i atio ith

sta da d a ti ioti s fo Clost idiu diffi ile

disease. JAMA ; : – .

. Naa e P, Mikelsaa M. I te a tio s et ee

La to a illi a d a ti ioti -asso iated dia -

hea. Ad Appl Mi o iol ; : – .

. S h oede MS. Clost idiu diffi ile-asso iated

dia hea. A Fa Ph si ia ; : -

Ou fa ou ite u pe sti ke :

"Suppo t a te ia; it is the o l ultu e e ha e left."

Did ou hea a out the fa ous i o iologist ho isited diffe e t ou t ies a d spoke la guages?

He as a a of a ultu es

13

I trodu tio

Co u it a ui ed p eu o ia CAP i i-

de e is illio ases pe ea of hi h

% ases e ui e hospitalizatio . Mo talit

ate is et ee - %, hi h a ise upto

% i i te si e a e u it ICU .[ ] Hae o -

hagi p eu o ia HP is defi ed as p eu o-

ia o pli ated pul o a hae o hage

hi h a fu the lead to hae o hagi

pleu al effusio . Most o o i fe tious

auses of HP i lude Pa to -Vale ti e Leu-

ko idi p odu i g Staph lo o us aureus,

Strepto o us p oge es, Ste otropho o as

altophilia, Chala dia p eu o iae, i flu-

e za i uses et . Ra e auses i lude pul o-

a a th a , p eu o i plague, alle gi

o ho-pul o a aspe gillosis ABPA ,

P eu o stis jirove ii p eu o ia, leptospi-

osis, u ellosis, Va i ella Zoste , a d Pa ai -

flue za i uses, et .[ ] No -i fe tious auses

i ludet au a, hae o hagi diathesis, pul-

o a th o oe oli diseases, pleu o-

pul o a alig a , sple i i ju , et .[ ]

Strepto o us p eu o iae is a leadi g ause of

CAP ith asso iated pa ap eu o i effusio s i

o e tha % of ases. [ ] Se e it depe ds up-

o age, asso iated o- o idities, i u e status

et . He e e dis uss a a e ase of hae o hagi

p eu o o al p eu o ia ith effusio i a -

ea -old hild. O lite atu e sea h th ough i te -

et, e did ot fi d a si gle ase of hae o hag-

i pleu al effusio due to p eu o o us.

Case Report

A - ea -old ale hild as ad itted to paediat-

i e e ge depa t e t ith histo of ough

a d fe e fo da s, fast eathi g a d de-

eased o al a epta e fo da s. The e as o

histo of p e ious hospitalizatio o i u iza-

tio ith p eu o o al a i e. The e as o

othe sig ifi a t past histo .

O ge e al ph si al e a i atio , patie t

as si k, asal fla i g as p ese t, lood p es-

su e / Hg, hea t ate eats/ i ,

te pe atu e °F, espi ato ate RR / i ,

o ge satu atio %. O hest e a i atio ,

Se e e hae o hagi p eu o o al p eu o ia i a hild: A a e o pli atio

Autho s: Pooja Sha a , Shali i De a Duggal , Re u Gu , Stuti Kaushik , Ta isha Bha a a ,

Ma oj Ga g , Deepti Jai ;

Depa t e t: Depa t e t of Mi o iolog Depa t e t of Paediat i s

I stitute: D . BSA Hospital, Se to , Rohi i, Delhi-

Co espo di g autho : shali iduggal @ ediff ail. o

Case report

14

the e e e de eased hest o e e ts ith

sto dull ote o pe ussio a d a se t

eath sou ds i ight lu g o aus ultatio .

Rest of the s ste i e a i atio as o -

al. Total leu o te ou t TLC as /µl,

platelet ou t /µl, hae oglo i . g/

dL. I itial ed side hest X- a sho ed ight

sided pleu al effusio . Pleu al tap as do e

o sa e da of ad issio , hi h tu ed out

to e hae o hagi . I te oastal hest tu e

ICD as i se ted. As pe the A e i a tho-

a i so iet guideli es, si e the patie t

sho ed th ee i o ite ia fo se e e CAP

i eased RR, th o o tope ia, ulti lo a

i filt ates patie t as kept u de i te si e

a dio espi ato o ito i g.[ ]

Patie t as i ediatel t eated e -

pi i all ith i t a e ous eft ia o e g,

hou l a d a o i g, hou l .

Pleu al fluid as se t fo g a stai a d ul-

tu e. A possi ilit of de gue hae o hagi

fe e DHF as also o side ed a d o e u it of

f esh f oze plas a as t a sfused. Ult aso og-

aph of hest o da of hospital sta sho ed

ight sided septal olle tio i lu g a d ultiple

ai fo i ith asal o solidatio . High esolutio

o puted to og aph featu es e e o siste t

ith ult aso og aph suggesti e of hae otho-

a . Pat h a eas of o solidatio e e also see

i left uppe a d lo e lo e, though left osto-

ph e i a gle as lea . Multiple e la ged

p e as ula g oup of l ph odes e e also

see .

G a stai of pleu al aspi ate e ealed

a pus ells a d g a positi e diplo o i, sug-

gesti e of p eu o o al i fe tio . Ziehl Neelse

stai fo a id fast a illi as egati e. Cultu e

g e S. p eu o iae. A ti ioti sus epti ilit

testi g AST Ki Baue ethod sho ed se -

siti it to pe i illi o a illi , a o illi -

la ula i a id, hlo a phe i ol, ip oflo a i ,

eft ia o e, le oflo a i , li ezolid a d pipe a il-

15

Isolate as esista t to li da i , o-

t i o azole a d e th o i . Follo i g the

AST epo t, le oflo a i g/kg/da as

added to the i itial egi e o da th ee.

De gue se olog , lood ultu e e e ega-

ti e, & sputu ultu e as u e a ka le.

Cli i al ourse duri g hospital sta

Du i g fi st si da s of sta , TLC a d te pe a-

tu e i eased to /µL a d °F e-

spe ti el , etu i g to o al da eight.

Platelet ou t a d RR e a e o al the

si th da . Hae o hagi fluid kept o de-

easi g o e da s a d ICD as e o ed o

da of ad issio . Patie t’s dist ess also

kept o de easi g o e ti e, ith O satu a-

tio ai tai ed at - %. He sta ted a -

epti g o al feeds, as dis ha ged o da

afte gi i g fi st dose of p eu o o al a -

i e a d as ad ised to follo up. Follo up

isit at o e o th sho ed esolutio ith

o plete e o e .

Dis ussio

This ase highlights the a e p ese tatio of

ost o o a te ia asso iated ith CAP.

The p ese tatio as o siste t ith se e e

p eu o ia ut hae o hagi tap poi ted

to a ds diffe e tial diag osis of DHF i ie

of u e t de gue out eak, hae o hagi

pleu al effusio , fe e a d th o o tope-

ia. O e g a positi e diplo o i e e see

o g a stai a d fu the S. p eu o iae

g e o pleu al fluid ultu e, a ti ioti s e e

fu the atio alized. This isolate sho ed e-

sista e to a olides a d li osa ides ut sus-

epti ilit to β la ta s a d flu o uoi oles FQ .

He e a o i atio of a β la ta a d FQ as

gi e as pe ATS guideli es fo i patie t, ICU

t eat e t. [ ]

I asi e p eu o o al disease is defi ed

as a i fe tio o fi ed S. p eu o iae iso-

latio f o ste ile sites e.g. e e ospi al fluid,

pleu al fluid a d lood.[ ] Mo talit ate a ies

f o - % i i asi e disease ut a go upto

% i se e e ases.[ ] I i asi e disease, se -

o da o pli atio s su h as a th itis, e i gi-

tis, e do a ditis a d o a ditis a o u .

T eati g ph si ia should ha e high diag osti

suspi io of the . [ , ] Ou patie t as ought i

a e si k o ditio ith hae o hagi p eu o-

o al p eu o ia a d had asso iated a poo

p og osti fa to s like ou g age, ICU ad issio

a d high RR. Ti el edi al a d su gi al i te -

e tio s i the paediat i e e ge depa t e t

itself follo ed defi ite i o iologi al diag o-

sis helped the patie t su i e.

Refere es

. P asad P a d Bhat S. Cli i o i o iologi al

stud of o u it -a ui ed p eu o ia.

Lu g I dia. ; : – .

. A aila le f o : https:// adiopaedia.o g/

a ti les/hae o hagi -p eu o ia. [Last a -

essed o Ju e ].

. Ma ko iak PA, Sellie P , Mo suez JJ, Fadel E,

16

E a s J,Vitte o D. A U usual Cause of

He o hagi Left Pleu al Effusio . Cli i al

I fe tious Diseases. 2006; : – .

https://doi.o g/ . / . A ail

a le f o : https: e edi

i e. eds ape. o /a ti le/ -

o e ie .

. I fe tious Diseases So iet of A e i a/

A e i a Tho a i So iet Co se sus

Guideli es o the

. Ma age e t of Co u it -A ui ed

P eu o ia i Adults Cli i al I fe tious

Diseases ; :S – .

. Ce te s fo Disease Co t ol a d P e e -

tio , I asi e p eu o o al disease

IPD Strepto o us p eu o iae

ase defi itio , . A aila le f o :

https:// . d .go / dss/ o ditio s/

i asi e-p eu o o al-disease/ ase-

defi itio / /.[Last a essed o Ju e

].

. Li WS, Baudoui SV, Geo ge RC et al. B itish

Tho a i So iet guideli es fo the a age-

e t of o u it a ui ed p eu o ia i

adults: update . Tho a . ; ,iii –

iii .

. Rou A, Ca al a tiM, Ma os M et al. I pa t

of al ohol a use i the etiolog a d se e it

of o u it -a ui ed p eu o ia, Chest.

; : – .

. B o AO, Ma B, Gao G et al. St epto o -

us p eu o iae t a slo ates i to the o-

a diu a d fo s u i ue i olesio s that

dis upt a dia fu tio . PLoS Pathoge s.

: :e .

A oss

. I e to of Hot ai o e : Ko h

. JC Pol o a i us auses: PML

. Rapid ethod fo TB diag osis: CBNAAT

. Cell all defi ie t fo : P otoplast

. Ce i al a e ell li e: HeLa

. Spo e stai i g ethod: Fulto

. Disease aused U eaplas a: NGU

. Mediu fo Ca p lo a te : Ski o

. Zoo oti disease ith hepato e al i -ol e e t: Weil

. Cells see i agi osis: Clue

. West Af i a he o hagi fe e : lassa

Do

. Ve to o e age t asso iated ith Mi-o ephal : Zika

. Pig e t see i P e otella: he i

. Beta La ta a ti e agai st MRSA: eft-ip ole

. Test fo p eu o o us: Opto hi

. Rea tio o stai i g A th a a illi f o lood fil s:M Fa dea

. Adoles e t a i atio i di ated fo : HPV

. Risus Sa do i us is see i : Teta us

. L ti a ea o a te ial ultu e phage:Pla ue

. T epo e a a ateu is etiologi al

Answers to Microbiology quiz published in Jeevanu Times January

17

Case report

Aspergillosis i a patie t o e tra orporeal e ra e o ge atio support

Autho s: D Poo i a Se , D Ba sidha Ta ai, D , P ag a P Je a

Depa t e t: Depa t e t of Mi o iolog

I stitute: Ma Supe spe ialit Hospital, Saket, Ne Delhi

Co espo di g autho : Ba sidha .Ta ai@ a health a e. o

I trodu tio

E t a o po eal e a e o ge atio

ECMO fo i te si e a e patie ts ith se-

e e a dia o e e si le pul o a failu e

has e o e o e o o o e the last fe

ea s[ ].Co pli atio s esulti g f o ECMO

fu the i ease the o talit i this g oup of

patie ts, hi h is al ead high due to se e it

of u de l i g ill ess [ ]. Patie ts o ECMO

a e ofte e ei i g oad-spe t u a ti i-

oti s; the ha e ultiple e t poi ts fo

pathoge s a d thei i u e s ste is i -

pai ed lood i uit i te a tio . These fa -

to s a e thought to p edispose the to fu -

gal i fe tio s spe iall Ca dida spp. a d As-

pergillus spp [ ]. We he e des i e a ase

he e ECMO as used as a pa t of the a -

age e t of a patie t of ILD ith ARDS A ute

espi ato dist ess s d o e a d the pa-

tie t de eloped i asi e pul o a aspe gil-

losis.

Case: A ea old ale k o ase of h pe -

te sio , Dia etes ellitus t pe II, h poth oidis

a d i te stitial lu g disease as ad itted i

so e othe hospital o / / ith o -

plai ts of fe e a d eathless ess. Fu the i -

estigatio o fi ed ILD ith supe added es-

pi ato i fe tio . Patie t as ot o a t eat-

e t fo ILD i spite of ei g; it as diag osed i

Jul . He as gi e a ti ioti s, ste oids a d

othe suppo ti e a age e t. I et ee pa-

tie t as little i p o ed ho e e agai de el-

oped eathless ess, shifted to ICU, put o BIPAP

suppo t a d IV a ti ioti s. I spite of all the

effo ts the eathless ess as pe siste t a d pa-

tie t as shifted to ou hospital o / / .

Afte ad issio to ou hospital the la pa a e-

te s e e as follo s He oglo i - . g ./dl,

Platelet ou t as . lakhs/ µl, total leu o te

ou t as , /µl , se u C eati i e . g/

dl , INR . . Se u C eati i e as i easi g

a d u i e output as de easi g g aduall , Pa-

tient was in persistent hypoxia even on 100% FiO2 and was going into metabolic and respirato-

18

-to a idosis so he as put o ECMO sup-

po t. Be ause of poo li i al p og essio a d

pe siste t espi ato i suffi ie BAL sa -

ples e e se t fo i o iologi al i estiga-

tio s. Both BAL a d se u sa ple e e se t

fo gala to a a GM assa . I fu gal i-

os op KOH ou t septate fu gal h phae

ith a ute a gle a hi g e e see . Asper-

gillus flavus as also isolated f o BAL ul-

tu e late o .

Chest X a sho ed ilate al opa ities ,

oth se u a d BAL gala to a a as pos-

iti e so o i o azole g BD IV a d Cas-

pofu gi g IV as sta ted alo g ith

othe suppo ti e a age e t. F o th da

of ad issio ili u i sta ted to ise apid-

l .Ult asou d i agi g of uppe a do e

e ealed ild to ode ate as ites a d i t a-

hepati holestasis se o da to s ste i

ill ess. The e as pe siste t ise of ili u i

so o i o azole as stopped a d liposo al

a phote i i B g/kg alo g ith a idula-

fu gi g IV e e sta ted. I spite of that

ge e al o ditio of patie t e ai ed iti-

al, he as i espi ato failu e, dist i uti e

sho k ith h pe ili u i e ia.

Total se u ili u i as still . g/dl

o th da of ad issio othe pa a ete s

e e also o ti ui g to e de a ged a d

o se ed fu the . Blood ultu e as fou d

to e positi e fo E tero a ter loa ae , a ti-

ioti olisti MU IV as added to t eat-

e t. No the patie t as a ase of I asi e

Aspe gillosis, E tero a ter lood st ea i fe -

tio , espi ato failu e o ECMO, dist i uti e

sho k, eta oli a idosis, a do i al diste sio ,

h pe ili u i e ia. Patie t ulti atel su -

u ed to death o th da of ad issio .

Dis ussio :

Aspe gillus is a u i uitous e i o e tal h ali e

ould. T pi all , i asi e aspe gillosis IA affe ts

patie ts ith i he ited i u e defi ie ies, ad-

a ed HIV i fe tio , p olo ged eut ope ia a d

alloge ei he atopoieti ste ell t a spla ta-

tio HSCT [ ]. Aspe gillosis is also a e e gi g

oppo tu isti i fe tio i iti all ill patie ts i

the ICU, pa ti ula l i patie ts ith COPD o se-

e e li e disease [ ]. F o the last fe de ades

the use of ECMO fo the a age e t of life

th eate i g pul o a o a dia failu e has i -

eased. P olo ged ECMO use has ee ide ti-

fied as a isk fa to fo ECMO- elated oso o ial

i fe tio [ , ]. Patie ts a e at isk of oso o ial

i fe tio hilst o ECMO as the ha e ultiple

po tals of e t [ , ].

We he e epo ted a ase of i asi e aspe gil-

losis i a patie t follo i g ECMO t eat e t.

The e a e th ee ajo t pes of o hopul o-

a Aspe gillus i fe tio s: i asi e aspe gillosis,

h o i aspe gillosis, a d alle gi aspe gillosis.

Aspe gillosis i fe tio a also a ifest as si us

disease i i u o o p o ised hosts. If left u -

t eated, i asi e aspe gillosis a ha e o talit

app oa hi g %. I ases of suspe ted i asi e

aspe gillosis, a e te si e diag osti o kup is

19

is e essa , ut t eat e t should e i itiat-

ed as ea l as possi le to edu e o idit

a d o talit . Despite a tifu gal the ap al-

so o talit a ges f o - % i fe as-

es [ , ].

I a othe ise i u o o pete t pe -

so , Aspergillus o idia a e i haled a d take

up phago tes i the lu gs. The o idia

ge i ate i to h phae at od te pe atu e.

I i u o o pete t hosts, phago tes se-

ete ediato s hi h a ti ate eut ophils.

Neut ophils kill the i asi e h phae, a d the

Aspergillus i fe tio is kept at a . If a of

these e ha is s a e i pai ed i a i u -

o o p o ised patie t, the i fe tio a e

allo ed to sp ead.

A st o g li i al suspi io to ide tif pa-

tie ts at isk fo i asi e aspe gillosis is the

fi st step i e aluati g fo aspe gillosis. The

fu gal i os op of the sputu should e

do e fi st to ide tif a patie t ith i asi e

aspe gillosis sho s a gula di hoto ousl

a hi g septate h phae i IA . I o al

hosts the e e p ese e of Aspergillus does

ot e essa il i di ate a ute i fe tio , ho -

e e , i the i u o o p o ised host, fi d-

i g the fu gus should p o pt the li i ia to

t eat as a a ute i fe tio . The ultu e of

the Aspergillus spe ies i the sputu o

o hoal eola la age ith the ide tifi a-

tio of h phae, hi h is the gold sta da d,

ill o fi that the i fe tio is

f o Aspergillus a d ot a othe ould o

fu gus. Tissue iops of a aspe gillo a a e

helpful to o fi the diag osis a d e lude oth-

e o ditio s that a ause lu g asses.

Se u io a ke s su h as gala to a a

assa s a e helpful; it a also e easu ed i

sa ple f o a o hoal eola la age. Test

should e used as a s ee i g tool fo the ea l

dete tio of IA. Si gle o o se uti e positi e as-

sa s se u ith high OD i de a se e as a

i o iologi al ite io fo p o a le IA. Gala -

to a a f o BAL fluid - de o st ated e el-

le t se siti it i hae atolog a d o -

hae atolog patie ts ,solid o ga t a spla t e-

ipie ts, i te si e a e u it patie ts, patie ts

ith auto-i u e diso de s, AIDS patie ts, used

as a o fi ato diag osti assa i patie ts

ith u e plai ed adiologi al featu es. It’s ot

suita le fo the ea l dete tio of IA ho e e

BAL GM assa s et e e o e ded to assess

the out o e of a tifu gal the apies.

Chest adiog aphs a sho pa e h al

opa ities of pul o a aspe gillo a fu gus

all . CT i agi g of the lu gs ill sho ha a te -

isti odules ith su ou di g atte uatio halo

sig , aspe gillo a fu gal all i a p e-e isti g

lu g a it , a itatio s, o fi osis. Blood ul-

tu es i su h ases a e of li ited alue, ofte ot

positi e e e i disse i ated i fe tio . The p es-

e e of , - eta D-glu a s i se u sig ifies

the p ese e of fu gal i asio ut is ot spe ifi

fo Aspe gillus spe ies. PCR- ased diag osis ha e

ot ee sta da dized a d e ai i estigatio -

al.

20

Ou patie t as i espi ato dist ess &

o ECMO. Chest a as sho i g ilate al

opa ities i oth lo e lo es, oth se u

a d BAL gala to a a e e positi e, fu -

gus i os op KOH as positi e fo a ute

a gle a hed fu gal h phae. A o di g to

EORTC/MSG Eu opea o ga izatio fo e-

sea h a d t eat e t of a e /M osis

stud g oup ; it as fulfilli g the ite ia of

P o a le I asi e Aspe gillosis so o i o a-

zole as sta ted i ediatel fo the patie t.

Vo i o azole is fo ulated as sulfo ut l-

ethe lode t i solutio fo IV ad i ist a-

tio a d lode t i ole ule is e all

lea ed so a u ulatio of the ehi le o u s

i i di iduals ith e al i suffi ie [ ].

This d ug is hepati all eta olized, ith

o l % of the d ug appea i g u ha ged i

the u i e. Si e i ou patie t oth se u

eati i e a d se u ili u i sta ted to ise,

o eo e li i al p og essio as e poo

so o i o azole as kept o hold, a phote i-

i B alo g ith a idulafu gi as sta ted.

U fo tu atel patie t also de eloped g a

egati e sepsis, as o i t a e ous olisti

fo the sa e ut e pi ed o th da of ad-

issio . Cause of death as att i uted to

i asi e aspe gillosis, ARDS , g a egati e

sepsis o ILD ith ulti o ga failu e.

Co lusio : Patie ts u de goi g ECMO a e at

i eased isk of i fe tio s o pa ed to oth-

e patie ts i ICU. Cli i ia s should o side

i fe tio ith fu gus i patie t ot espo d-

i g to a ti ioti s. ECMO patie ts ith IPA did ot

al a s ha e lassi u de l i g isk fa to s[ ]. Di-

ag osi g IPA i ICU patie ts a e diffi ult ut a

li i al algo ith to diag ose IPA i su h patie ts

a e useful thoughts should ot e gi e fo

usi g o i atio a tifu gal the ap . Cli i ia s

should also o ito o i o azole le el i the se-

u to guide dosi g a d to a oid a tifu gal i -

te a tio a d side effe ts.

Refere es

. Mosie JM, Kelse M, Raz Y,Gu e so KJ,

Me e R,H pes CD. E t a o po eal e -

a e o ge atio ECMO fo iti all ill

adults i the e e ge depa t e t: histo ,

u e t appli atio s, a d futu e di e tio s.

C it a e ; :

. Pa ell BJ, Ku a P, Raju BC, Joh so EM,

Fa do TC, Ol e WJ. I asi e pul o a as-

pe gillosis post e t a o po eal e a e

o ge atio suppo t a d lite atu e. Med -

ol ase ep ; : -

. Ca a as YA, Yusuff H, Po te R. Fu gal i fe -

tio s i adult patie ts o e t a o po eal life

suppo t. C it Ca e. Ap ; :

. A eele AM, Bulpa P, Misset B, Messe a

W,Ca doso T, Pai a JA.Epide iolog of i a-

si e aspe gillosis i iti all ill patie ts: li i-

al p ese tatio , u de l i g o ditio s, a d

out o es C it Ca e ; :

21

. Au o C, Che g AC, Pi he D, Leo g T,

Meg i G, Coope DJ et al. I fe tio s a

ui ed adults ho e ei e e t a o po-

eal e a e o ge atio : isk fa to s

a d out o e. I fe t Co t ol Hosp Epi-

de iol ; : – .

. Hsu MS, Chiu KM, Hua g YT, Kao KL, Chu

SH, Liao CH. Risk fa to s fo oso o ial

i fe tio du i g e t a o po eal e -

a e o ge atio .J Hosp I fe t ;

: – .

. Ma as o SF, Lukas G, M Do ald M,

M Milla J, Ihle B .Re ie of ECMO e t a

o po eal e a e o ge atio sup-

po t i iti all ill adult patie ts. Hea t

Lu g Ci ; : – .

. Ale izakos M, Fa akiotis D, M lo akis E. Up-

dated p a ti e guideli es fo the diag osis

a d a age e t of aspe gillosis: halle ges

a d oppo tu ities. J Tho a Dis. De ;

: - .

. Segal BH. Aspe gillosis. N. E gl. J. Med.

Ap ; : - .

. Kise TH, Fish DN, A uila te CL, Ro e

JE, We pe MF, Ma La e R E aluatio of sul-

fo ut lethe -β- lode t i SBECD a u u-

latio a d o i o azole pha a oki eti s i

iti all ill patie ts u de goi g o ti uous

e al epla e e t the ap . C it Ca e.

Fe ; : .

22

I trodu tio

B east i fla atio i o e of ep odu -

ti e age g oup is see o e o o l i la -

tati g as o pa ed to o -la tati g o e .

A ute i fla atio of east a e att i ut-

ed to the i eased a ti it of the east tis-

sue i espo se to fe ale ho o es. I fe -

ti e auses of east a s ess i lude Staph -

lo o us aureus ith the p edo i a t patho-

ge i pli ated i oth the g oups. Whilst,

Kle siella p eu o iae, Peptostrepto o us

ag us, Strepto o us group B, E tero a ter

loa ae, Methi illi resista t staph lo o us

aureus MRSA a d M o a teriu tu er u-

losis e e espo si le fo east a s esses

o l i o la tati g o e .

B east a s ess due to Sal o ella i fe tio is

a e, though fe ases ha e ee epo ted

f o I dia. - Sal o ella i fe tio s a e a a-

jo pu li health p o le i I dia a d a e

t a s itted o all o ta i ated food a d

ate . I t a ellula su i al st ategies afte

phago tosis help these a te ia to disse i ate

th oughout the od a d lo alize i the eti ulo-

e dothelial s ste . Sal o ellosis a li i all

a ifest as e te i fe e , food poiso i g septi-

ae ia ith o ithout lo al suppu ati e lesio .

It has ee i pli ated i e do a ditis, osteo e-

litis, is a iage, , e i gitis, a s ess fo -

atio i li e , pa eas, gall ladde a d

splee .

He e e p ese t a ase of east a s ess due to

Sal o ella ithout a k o p edisposi g fa -

to s.

Case Report

A ea s old ou g lad p ese ted ith a pai -

ful lu p i ight east. She had fe e o a d off

fo - da s ith episodes of dia hoea

a ou d the sa e ti e hi h as self esol i g.

This patie t as a k o ase of h poth oidis

ith a past histo of t o fi st t i este a o -

tio s. She had a ea s old ale hild ho as

ot east-fed. He last p eg a as u e-

A ase epo t of isdiag osed east a s ess

Autho s: D Pu a i Ba a , D Ta u Thuk al , D Shi pi Chop a , D Sa deep Na a

Depa t e t: Depa t e t of Cli i al Mi o iolog a d Depa t e t of Respi ato Medi i e,

I stitute: BLK Supe Spe ialit Hospital, Ne Delhi.

Co espo di g autho : pu a i. a a @g ail. o

Case report

23

ful e ept fo the histo of gestatio al dia-

etes. She also de ied a histo of gall

sto es.

The patie t had take edi al opi io f o a

lo al p a titio e a d as put o a ti-

i fla ato edi atio alo g ith a o i-

illi - la ula i a id as a e pi i al a ti i-

oti . The eafte a ult asou d as pe fo ed

that e ealed a ell defi ed o al h po e hoi

lesio of . i uppe i e uad a t. A

ildl e la ged ode ith thi ke ed o te

as see i the ight a illa. C tolog of the

east lesio e ealed g a ulo atous asti-

tis. Based o the fi di gs of i agi g esults

she as e pi i all sta ted o a titu e ula

the ap ATT .

No , the patie t p ese ted seeki g a se o d

opi io to us. O lo al e a i atio , the a ea

as a ith ild te de ess i the uppe

i e uad a t of ight east. A s all o ile

lu p ould e eli ited o adhe e t to the

ski . The patie t as afe ile ith a pulse

ate of pe i ute. No othe a o alit

as dete ted o s ste i e a i atio .

The a s ess as d ai ed ult asou d guid-

ed aspi atio a d sa ple as o tai ed fo

i o iologi al e aluatio to ule out a

i fe ti e patholog . Stai i g fo a id fast a-

illi, Ge e pe t a d M o a te iu ultu e

e e egati e. Di e t G a ’s stai sho ed

ple t of leu o tes ut o a te ia e e

see . Blood, u i e a d stool ultu es e e o

o t i uto a d Widal test as o ea ti e.

Ae o i ultu e of the a s ess g e Sal o ella

Parat phi A hi h as esista t to Nalidi i a id

ith i te ediate sus epti ilit to ip oflo a i .

It as sus epti le to A pi illi , azith o i ,

efi i e, eft ia o e, hlo a phe i ol a d o-

t i o azole. The patie t as put o i t a e ous

eft ia o e g a hou l fo da s. The e-

afte , she as put o o al efi i e g t i e

dail fo a othe da s. The e as a sig ifi a t

espo se to t eat e t. The lu p su sided a d

patie t e o e ed o pletel .

Dis ussio

Sal o ella T phi a d Parat phi A a e espo si le

fo o idit a d o talit espe iall i de elop-

i g ou t ies. The li i al spe t u of sal o el-

losis is a ied a d a p ese t i the fo of gas-

t o-i testi al i fe tio , a te ae ia, fo al dis-

ease o a lead to a a ie state. E t a-

i testi al fo al a ifestatio s a e a ied a d

depe d o fa to s like e t e es of age, i u e-

supp essio , i t a- e ous d ug a use, p e ious

t au a et .

B east a s ess as a a ifestatio of Sal o ella

i fe tio is a a e o ditio . Repo ts of Sal o el-

la Pa at phi A h o i east a s ess i I dia

ha e ee epo ted f o M so e a d Pu e. I

the a se e of a sig ifi a t past histo of

24

fe e , gast o-i testi al i fe tio othe tha

t o self li iti g episodes of dia hoea o

t au a, the sou e of i fe tio i the p ese t

ase still e ai s dou tful. Although lood,

stool a d u i e sa ples o tai ed f o the

patie t did ot ield Sal o ella, the p o a-

ilit of the patie t ei g a a ie a ot e

uled out. I a o la tati g fe ale, seedi g

of Sal o ella i the east tissue th ough a

a ie state, although u likel , is the o l

p o a ilit o side ed the autho s.

To su a ize, this ase highlights the fa t

that Sal o ella a p ese t ith at pi al

li i al pi tu es a d ust e o side ed as a

diffe e tial diag osis i su h situatio s.

The use of ATT is a pa t i ou ou t . As

see i this ase, ithout a o lusi e e i-

de e, the patie t as sta ted o ATT. Thus

it is i pe ati e to state that li i al judge-

e t alo g ith a o ust i o iologi al

suppo t is helpful to li h the diag osis a d

i stitute app op iate t eat e t.

Refe e es:

. A delHadi MSA, Bukha ie HA. B east i -

fe tio s i o -la tati g o e . J Fa il

Co u it Med Sep-De ; :

- .

. Ja aku a K, Appala aju B, Go i da VK.

A at pi al p ese tatio of Sal o ella

T phi- a ase epo t. I dia J Med Mi o iol

; : - .

. Siddesh G, Su a a MN. A ase of east a -

s ess due to Sal o ella Pa at phi A. I t J

Health Allied S i ; : - .

. Ghadage DP, Wa khade AB, Mali RJ, Bho e

AV. Re u e t east a s ess due to Sal o-

ella Pa at phi A: a u usual ase. I t J Res

Med S i Aug; : - .

. Lesse CF, Mille SI. Sal o ellosis. I : B au -

ald E, Fau i AS, Kaspe DL, Hause SL, Lo go

DL, Ja eso JL, edito s. Ha iso ’s p i iples

of i te al edi i e. th ed. Ne Yo k NY :

M G a Hill; . p. - .

. Kau R, Ba a P. A ase of Sal o ella t phi

i fe tio leadi g to is a iage. J La Ph si-

ia s Ja -Ju ; : - .

. Je a PP, Duggal SD, Ku a A, Bha a a T, Sha -

a A, Gu R. Isolatio of Sal o ella t phi

f o agi al s a i a ase of septi a o -

tio . I dia J Med Mi o iol Ap -Ju ;

: - .

. Va ai a A, Sa as athi K, Te dolka U, De A,

Shah S, Mathu M. Sal o ella e te itidis

e i gitis- A ase epo t. I dia J Med Mi-

o iol ; : - .

. A a M, A a PK. Pa eati a s ess aused

S. T phi. I dia J Med Mi o iol ;

: - .

. Si ha S, Sha a DC, Mi i B, Gupta V, Chatto-

padh a TK. Sple i a s ess- ase epo t a d

e ie of lite atu e. T op Gast oe te ol

Jul-Sept; : - .

25

Microbiology Updates from around the world….

Mi ro iolog Update :

WHO re o e ds t phoid o jugate a i e i e de i setti gs

The Wo ld Health O ga izatio WHO e o -e ds i ple e tatio of atio al t phoid a -

i atio p og a s as pa t of oade o t ol effo ts i setti gs he e t phoid is e de i . I Ma h , the WHO i di ated a p efe e e fo t phoid o jugate a i e TCV o e othe t phoid a i es a d e o e ded TCV ad i -ist atio fo hild e si o ths o olde , ith at h-up a i atio a paig s fo hild e up

to ea s old.

Co pa ed ith othe t phoid a i es, TCV has g eate a d lo ge lasti g i u oge i it a d has esta lished safet i i fa ts a d ou g hil-d e . A TCV li e sed i I dia a d Nepal is u de -goi g li e su e i othe e de i ou t ies; TCV is ot a aila le i the U ited States o Eu ope.

Refe e e: Wo ld Health O ga izatio . T phoid a i es: WHO positio pape . Ma h . http://apps. ho.i t/i is/ itst ea /ha dle/ / /WER .pdf

Mi ro iolog Update :

La ge out eak of liste iosis i South Af i a

Liste iosis is a food o e a te ial ill ess that auses i asi e i fe tio s, p i a il i i di iduals ith a p edisposi g fa to , su h as p eg a o i -u osupp essio . The la gest liste iosis out eak

dete ted to date ega i South Af i a i Ja ua , ith o e tha la o ato - o fi ed as-

es epo ted as of id-Ma h .

The likel sou e of the out eak, a ead -to-eat p o essed eat p odu t alled polo , as ide ti-fied th ough hole ge o e se ue i g. Re alls

e e su se ue tl issued i South Af i a a d othe Af i a ou t ies to hi h the p odu t as dist i uted

Refe e e:

Liste iosis – South Af i a A aila le at http://. ho.i t/ s /do / - a h- -liste iosis-

south-af i a/e /

Mi ro iolog Update :

O al fe al i o iota t a spla tatio fo e u e t C. diffi ile i fe tio Fe al i o iota t a spla tatio FMT deli e ed ia olo os op is esou e-i te si e a d i asi e. I a

o i fe io it t ial, patie ts ith e u e t Clost idiu diffi ile i fe tio CDI e e a do l as-sig ed to FMT ad i iste ed ia o al apsules o olo os op . At eeks, pe e t i oth g oups

e e f ee of CDI e u e e. Fe al i o ial di e sit ates i eased a d e e ai tai ed fo up to eeks follo i g FMT i oth

g oups. While o al apsules appea to e a ia le deli e ethod fo FMT, thei li i al a aila ilit is li ited, a d thei ost-effe ti e ess is still to e dete i ed.

Refe e e: Kao D, Roa h B, Sil a M, et al. Effe t of O al Capsule- s Colo os op -Deli e ed Fe alMi o iota T a spla tatio o Re u e t Clost idiu diffi ile I fe tio : A Ra do ized Cli i al T ial. JAMA ;

:

26

Microbiology Updates from around the world….

Mi ro iolog Update :

ART i itiatio o da of HIV diag osis i e-sou e-li ited setti gs

The Wo ld Health O ga izatio WHO e o -e ds i itiatio of a ti et o i al the ap ART ithi the fi st se e da s of a HIV diag osis.

I itiatio of a ti et o i al the ap ART ea l i the ou se of HIV i fe tio athe tha aiti g fo CD ell de li e edu es se e e AIDS a d

o -AIDS ill esses.

Se e al t ials i esou e-li ited setti gs ha e de o st ated the e efit of ART at p og essi e-l highe CD ell ou ts. , , Ne e theless, the opti al st ateg fo i ple e tatio e ai s u e tai .

I a t ial i Lesotho, ART i itiatio at ho e o the da of diag osis i p o ed su se ue t li k-age to a e e sus pe e t a d i ologi supp essio e sus pe e t o pa ed

ith outi e health fa ilit efe al fo ART i iti-atio .

Ho e e , those ates e e still u a epta l lo , a d a t ial patie ts e pe ie ed

t eat e t i te uptio , putti g the at isk fo d ug- esista t HIV. Fu the stud is a a ted to ide tif su essful

app oa hes, hi h a diffe lo atio , pa-tie t populatio , a d ART egi e utilized.

Refe e es: . A a i e G, Se itala FC, Na uso a J, et al.

Effe ts of a ulti o po e t i te e tio to st ea li e i itiatio of a ti et o i al the ap i Af i a: a stepped- edge luste - a do ised t ial. La et HIV ; :e .

. Rose S, Maske M, Fo MP, et al. I itiati g A -ti et o i al The ap fo HIV at a Patie t's Fi st Cli i Visit: The RapIT Ra do ized Co t olled T ial. PLoS Med ; :e .

. La ha dt ND, Ri ge a I, Lejo e TI, et al. Effe t of Offe i g Sa e-Da ART s Usual Health Fa ilit Refe al Du i g Ho e-Based HIV Testi g o Li kage to Ca e a d Vi al Supp essio A o g Adults With HIV i Lesotho: The CASCADE Ra -do ized Cli i al T ial. JAMA ; : .

. Walke AS, P e de gast AJ, Mug e i P, et al. Mo talit i the ea follo i g a ti et o i al the ap i itiatio i HIV-i fe ted adults a d hil-d e i Uga da a d Zi a e. Cli I fe t Dis

; : .

Mi ro iolog Update :

Nipah i us out eak i I dia

I Ma , a out eak of Nipah i us as epo ted i I dia's Ke ala state, a d at least people died. Most ases o u ed i fa il e e s o health a e o ke s a i g fo i fe ted patie ts, ho had high fe e , o iti g, a d eathi g diffi ulties. T a s issio a e at-to-hu a th ough di e t o -ta t o a i te ediate a i al host o hu a -to-hu a . The e is o esta lished t eat e t fo Nipah

i us; thus, edu atio a d app op iate i fe tio o t ol p e autio s e ai ke to p e e ti g sp ead of i fe tio

Refe e e: Chatte jee P. Nipah i us out eak i I dia. La et ; : .

27

Microbiology Updates from around the world….

Mi ro iolog Update :

Me ope e - a o a ta i o pli ated u i-a t a t i fe tio

Me ope e - a o a ta is a o el a ti ioti o i atio of a a ape e ith a oad-

spe t u eta-la ta ase i hi ito that pote tl i hi its e tai a ape e ases.

Va o a ta is a o el oad-spe t u eta-

la ta ase i hi ito that pote tl i hi its lass A a ape e ases i ludi g K. p eu o iae-a ape e ases [KPC] . It is ot a ti e agai st lass B o D a ape e ases ie, etallo- eta-

la ta ases a d OXA-t pe e z es . The additio of a o a ta to e ope e

edu es the MICs to e ope e a o g lass A a ape e ase-p odu i g E te o a te ia eae to ild-t pe MIC le els.

Me ope e - a o a ta as o pa a le to pipe a illi -tazo a ta i a t ial of patie ts

ith o pli ated u i a t a t i fe tio a d it is ei g e aluated i patie ts ith a te e ia,

hospital-a ui ed p eu o ia, a d o pli ated i t aa do i al i fe tio s. The ai ole of this age t is fo t eat e t of KPC-p odu i g E te o-

a e ia eae ut it does ot e ha e the li i al a ti it of e ope e agai st a ape e -

esista t P. ae ugi osa o A i eto a te spp. Data e aluati g out o es ith su h o ga is s a e li ited ut e e gi g.

Refe e e: 1. Lo o ska a O, Su D, Ru io-Apa i io D, et al.

Va o a ta : Spe t u of Beta-La ta ase I hi-itio a d I pa t of Resista e Me ha is s o

A ti it i E te o a te ia eae. A ti i o Age ts Che othe ; .

. Casta hei a M, Hu a d MD, Me des RE, Fla RK. Me ope e -Va o a ta Tested agai st

Co te po a G a -Negati e Isolates Colle ted Wo ld ide du i g , I ludi g Ca ape e -

Resista t, KPC-P odu i g, Multid ug-Resista t, a d E te si el D ug-Resista t E te o a te i a eae. A ti i o Age ts Che othe ; .

Mi ro iolog Update :

Mo e e ide e fo o t o e sial theo that He pes i uses pla ole i Alzhei e 's disease

The uest to u de sta d hat auses Alzhei-e 's disease -- a d to t eat it -- is o pli ated the disease's lo g, slo p og essio a d the

diffi ult of olle ti g ai tissue sa ples. But i a la ge-s ale a al sis pu lished Ju e , i the jou al Neu o , esea he s at the I ah S hool of Medi i e at Mou t Si ai use data f o th ee diffe e t ai a ks to suggest that hu a he pes i uses a e o e a u da t i the

ai s of Alzhei e 's patie ts a d a pla a ole i egulato ge eti et o ks that a e e-

lie ed to lead to the disease. Also, esea he s at the I stitute of Hu a Be-

ha iou a d Allied S ie es ide tified eight a -didate ge es elated to o idati e st ess/i fla atio as pote tial AD isk a ke s ith pote tial i ol e e t i i al pathoge esis. These o ks suppo ts the o t o e sial h poth-esis that i uses a e i ol ed i Alzhei e 's dis-ease a d offe s pote tial e paths fo t eat-

e t. Refe e e: Be Readhead, Jea -Via e Hau e-Mi a de, et al.

Multis ale A al sis of I depe de t Alzhei e ’s Co-ho ts Fi ds Dis uptio of Mole ula , Ge eti , a d Cli i al Net o ks Hu a He pes i us. Neu o ,

; DOI: . /j. eu o . . .

Tal a Pu eet, Gupta Re u, etal. Elu idati g ole of o idati e st ess a d i fla ato a ke s i Alzhei-

e ’s disease usi g s ste s iolog app oa h. Doi: . / X

28

Microbiology Crossword 02

Clues

Answers: Next Jeevanu times

29

OFFICIAL PUBLICATION OF IAMM DC