Background: Scrub typhus is an acute febrile illness widely prevalent in the 'tsutsugamushi triangle' region of the world. Clinical features include fever, myalgia, headache, rash, and a pathognomonic eschar. An eschar is formed by the bite of chigger mite that inoculates the causative agent of Scrub typhus Orientia tsutsugamushi. The aim of this study is to determine the most common sites of eschars over the bodies of patients with Scrub typhus. Materials and Methods: In a retrospective analysis, we examined a total of 418 patients who presented to Christian Medical College, Vellore between 2009 and 2012 with an acute febrile illness and an eschar on clinical examination and confirmed to have scrub typhus with a positive Scrub typhus IgM ELISA test. We studied the distribution of eschars over the bodies of 418 patients with Scrub typhus. Results: There was a significant difference in the distribution of eschars between males and females with a preponderance of the chest and abdomen (42.3%) among females and the axilla, groin and genitalia (55.8%) in males. Some unusual sites of an eschar were the cheek, ear lobe and dorsum of the feet. Conclusion: The eschar is the most useful diagnostic clue in patients with acute febrile illness in areas endemic for Scrub typhus and therefore should be thoroughly examined for its presence especially over the covered areas such as the groin, genitalia, infra-mammary area and axilla.

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The treatment of the emerging multidrug resistant (MDR) gram-negative organisms is a challenge. The development of newer antibiotics has recently slowed down. This has led to the re-emergence of the 'old forgotten' antibiotic "Colistin", whose use had almost stopped (after 1970's) due to the high incidence of nephrotoxicity and neurotoxicity. Colistin (polymyxin E) is a polypeptide antibiotic belonging to polymyxin group of antibiotics with activity mainly against the gram-negative organisms. Use of colistin has been increasing in the recent past and newer studies have shown lesser toxicity and good efficacy. Colistin acts on the bacterial cell membrane resulting in increased cell permeability and cell lysis. Colistin can be administered orally, topically, by inhalational route, intramuscularly, intrathecally, and also intravenously. Parenteral Colistin (in the form of colistimethate sodium) has been used to treat ventilator-associated pneumonia (VAP) and bacteremia caused by MDR bacteria such as Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. Inhaled Colistin is used for treating pneumonia/VAP due to MDR gram-negative organisms and also used prophylactically in patients with cystic fibrosis. This manuscript is a brief review of Colistin and its clinical applications in the pediatric population.

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Background: The occurrence of candidemia is on a rise worldwide. Non-albicans Candida species have emerged as major causes of candidemia in many countries. Added to it is the problem of antifungal resistance in Candida isolates. Objectives: To find out the prevalence of candidemia in our intensive care unit (ICU) setup along with the antifungal susceptibility pattern of Candida isolates and various risk factors associated with candidemia. Materials and Methods: All Candida isolates from blood stream infections of ICU patients were included in the 1 year study period (November 2008-October 2009). The isolates were speciated using various phenotypic tests. Antifungal susceptibility testing was done by disk diffusion methods according to Clinical and Laboratory Standards Institute guidelines and also using CANDIFAST. Various risk factors associated with the development of candidemia were looked into. Results: A total of 39 Candida isolates were isolated during the study period of 1 year (prevalence of 0.65%). Candida tropicalis (74.35%) was the most common isolate followed by Candida albicans, Candida parapsilosis, Candida krusei and Candida glabrata. All the 39 Candida isolates (100%) were sensitive to amphotericin B while 12 isolates (30.8%) were resistant to fluconazole. The risk factors commonly associated with candidemia patients were long term antibiotic therapy (64.1%), use of central venous catheters (56.4%), urinary catheters (53.9%), steroid therapy (35.9%) and diabetes mellitus (33.3%). Conclusion: Candidemia is emerging as a significant problem in hospitalized patients, especially in ICU setups. Non-albicans Candida species are the major cause of candidemia as found in our study and few other studies in India. Multicentric studies involving many hospitals are required to know the true prevalence of candidemia and the status of antifungal drug resistance among Candida isolates in our country.

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Objectives: This study reviewed previous studies to explore the global patterns of seasonal variation in gastrointestinal diseases. Study Design and Methods: A series of systematic literature reviews were undertaken to identify studies reporting seasonal and monthly data on clinical onset or relapse of gastrointestinal diseases (Acute pancreatitis, inflammatory bowel disease, Peptic ulcer diseases (PUD), gastroesophageal reflux disease, colon cancer and colonic diverticulitis). Thirty-two primary studies (published 1970-2012) from 17 countries were identified. Results: Upon review of the evidence, it appears that the seasonal peaks of PUD are most prominent in colder months while the peak of incidence rate of Crohn diseases in most of the countries subjects were found during the spring and summer seasons. Seasonal trend in the onset of acute pancreatitis exhibits a summer peak in some countries. There were no clearly seasonal peaks noted for the ulcerative colitis. Conclusions: Future experimental and observational studies should consider how the environmental factors (infection, cold, air pollution etc.) or other triggers (dietary habit, alcohol consumption) promotes or hinders such diseases.

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A 37-year-old woman with a vesico-cutaneous hip fistula was admitted to our department. The bladder fistula had formed after repeated hip infections. The fistula was completely resected and the bladder was repaired using a tension-free closure and indwelling catheter for 2 weeks. Vesico-cutaneous fistulae are very rare, and their causes can be complex.

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Background: The emergence of extensively drug-resistant tuberculosis (XDR-TB) is a major concern in the India. The burden of XDR-TB is increasing due to inadequate monitoring, lack of proper diagnosis, and treatment. The GenoType ^® Mycobacterium tuberculosis drug resistance second line (MTBDRsl) assay is a novel line probe assay used for the rapid detection of mutational patterns conferring resistance to XDR-TB. Aim: The aim of this study was to study the rapid detection of drug resistance and mutational patterns of the XDR-TB by a novel GenoType ^® MTBDRsl assay. Materials and Methods: We evaluated 98 multidrug-resistant (MDR) M. tuberculosis isolates for second line drugs susceptibility testing by 1% proportion method (BacT/ALERT 3D system) and GenoType ^® MTBDRsl assay for rapid detection of conferring drug resistance to XDR-TB. Results: A total of seven (17.4%) were identified as XDR-TB by using standard phenotypic method. The concordance between phenotypic and GenoType ^® MTBDRsl assay was 91.7-100% for different antibiotics. The sensitivity and specificity of the MTBDRsl assay were 100% and 100% for aminoglycosides; 100% and 100% for fluoroquinolones; 91.7% and 100% for ethambutol. The most frequent mutations and patterns were gyrA MUT1 (A90V) in seven (41.2%) and gyrA + WT1-3 + MUT1 in four (23.5%); rrs MUT1 (A1401G) in 11 (64.7%), and rrs WT1-2 + MUT1 in eight (47.1%); and embB MUT1B (M306V) in 11 (64.7%) strains. Conclusions: These data suggest that the GenoType ^® MTBDRsl assay is rapid, novel test for detection of resistance to second line anti-tubercular drugs. This assay provides additional information about the frequency and mutational patterns responsible for XDR-TB resistance.

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Tuberculosis (TB) is responsible for 1.4 million deaths annually. Wide-spread misuse of anti-tubercular drugs over three decades has resulted in emergence of drug resistant TB including multidrug-resistant TB and extensively drug-resistant TB globally. Accurate and rapid diagnosis of drug-resistant TB is one of the paramount importance for instituting appropriate clinical management and infection control measures. The present article provides an overview of the various diagnostic options available for drug resistant TB, by searching PubMed for recent articles. Rapid phenotypic tests still requires days to weeks to obtain final results, requiring biosafety and quality control measures. For newly developed molecular methods, infrastructure, training and quality assurance should be followed. Successful control of drug resistant TB globally will depend upon strengthening TB control programs, wider access to rapid diagnosis and provision of effective treatment. Therefore, political and fund provider commitment is essential to curb the spread of drug resistant TB.

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The thyroid storm is a medical emergency characterized by decompensation of one or more organ systems. Associated cardiac involvement carries poor prognosis. Early recognition and appropriate management of life-threatening thyrotoxicosis is vital to prevent the high morbidity and mortality that may accompany this disorder. We report a young lady presenting with thyroid storm presenting as acute heart failure with biventricular and bilateral internal jugular venous thrombi. In addition, she also had thyrotoxicosis-induced transient protein-S deficiency which recovered following remission.

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Background and Objective: Multidrug resistant tuberculosis (MDR-TB) is caused by infection due to Mycobacterium tuberculosis which is resistant to both isoniazid (INH) and rifampicin (RIF). It is caused by selection of resistant mutant strains due to inadequate treatment and poor compliance. MDR-TB is a major public health problem as the treatment is complicated, cure rates are well below those for drug susceptible tuberculosis and patient remains infectious for months despite receiving the best available therapy. The drug susceptibility pattern of M. tuberculosis is essential for proper control of MDR-TB in every health care setting, hence the study was initiated with the aim of studying the prevalence of MDR-TB in patients attending a tertiary care hospital in east Delhi. Materials and Methods: Five hundred and forty-three pulmonary and extrapulmonary samples from suspected cases of tuberculosis received in the mycobacteriology laboratory from November 2009 through October 2010 were investigated for M. tuberculosis. All the samples were subjected to direct microscopic examination for demonstration of acid fast bacilli followed by culture on Lowenstein-Jensen (LJ) medium to isolate M. tuberculosis. Identification was done by conventional biochemical methods. Drug susceptibility of isolated M. tuberculosis strains was done by conventional 1% proportion method followed by sequencing of RIF resistant isolates to detect mutations to confirm resistance. Results and Conclusions: M. tuberculosis was isolated from 75 out of 543 suspected cases of pulmonary/extrapulmonary TB. Three of the total 75 M. tuberculosis isolates (4%) showed resistance to any one of the first line drugs. Prevalence of MDR-TB was 1.3%. The sequencing of single MDR strain showed mutations at codons 516, 517, and 518. Amplification of rpoB and sequential analysis of the amplicon is a better way of detection of mutation and the evidence of new mutation in this study indicate that mutations continue to arise, probably due to the ability of M. tuberculosis to adapt to drug exposure.

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A patient started on 8 mg lornoxicam twice daily for pain in the hips developed acute-onset scalp hair loss. History and clinical examination revealed no evident abnormalities. Temporal association of the onset of hair loss with the use of lornoxicam, inability to explain hair loss by alternate causes, possibility of hair loss with lornoxicam and resolution on dechallenge placed this reaction as a probable adverse reaction to lornoxicam.

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Primary tracheobronchial amyloidosis (PTBA) is a localized form of amyloidosis. The clinical signs of this condition are non-specific and diagnosis before bronchoscopic examination with multiple biopsies is uncommon. We present three cases of PTBA and compare findings between the thoracic imaging and fiberoptic bronchoscopy. Radiographic findings often had uncharacteristic features. The relatively specific coronal section CT preceded findings in transverse sections, and showed an irregular mucosal surface with diffuse prominent nodes and/or calcification of the tracheobronchus, which we called the "wavy path sign". In conclusion, coronal CT scan can provide ample clues for the early diagnosis of PTBA.

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Ventriculoperitoneal (VP) shunt is one of the most commonly performed procedures in neurosurgery, but it is also the procedure, which is most prone to complications. Spread of cerebrospinal fluid (CSF) into the brain parenchyma is a rare complication of VP shunt and can take the form of CSF edema or a porencephalic cyst. We describe a case of a 1½-year-old child who presented to us with seizures. Computed tomography scan revealed pericatheter porencephalic cyst. Surgical exploration revealed a disconnected VP shunt system. Patient was neurologically observed after shunt extraction. He was seizure free and radiological follow-up showed resolution of cyst. Ours is the first case to document the presence of pericatheter cyst following complete disconnection of shunt system. Though shunt revision is the accepted treatment modality, careful neurological observation can be done after shunt removal especially in asymptomatic cases with compensated hydrocephalus.

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Background: Insight is an important factor associated with non compliance and poor outcome. Poor level of insight has been described as a characteristic in patients with acute bipolar disorder with more unawareness in social consequences with increasing severity in manic episode. Aim: Main aim of study was to see the baseline and longitudinal relationship between dimensions of insight with improvement in psychopathology. Setting and Design: Forty four patients diagnosed with mania, were selected from an inpatient setting at Institute of Mental Health and Hospital, Agra with mean age of 31.07(±9.00) years. They were assessed at base line and were followed up weekly or psychopathology and insight. Materials and Methods: The Young's mania rating scale for psychopathology and insight was assessed on three dimensions of SUMD. Results: Twenty five patients eventually completed the study. There was a positive correlation with global insight and with psychopathology consistent in longitudinal follow-up (P<0.05), but not correlating for awareness for achieved effect of medication and social consequences. Linear regression showed a positive relationship at the first and second week of assessment of SUMD and YMRS scores (P=0.001; 0.019). Conclusion: Improvement in insight is graded in a manic episode as compared to psychopathology. There is slower improvement in awareness of social consequences of mental disorder. It means that improvement in psychopathology may not necessarily indicate remission and need further supervision to improve insight and hence monitoring.

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We report two cases, one male (33 years) and a female (14 years), that developed Post-Kala-azar Dermal Leishmaniasis (PKDL) after successful treatment for visceral leishmaniasis (VL) or Kala-azar with AmBisome, the lipid complex of Amphotericin B. Both cases presented with hypo-pigmented macular lesions all over the body. The patients responded well to AmBisome after treatment with three courses. This first ever case report from India indicates that possibly there is no effective drug for VL until date, which can prevent post-treatment development of PKDL.

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