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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 8 | Issue 3
Page Nos. 211-312

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ORIGINAL ARTICLES  

Spoligotyping with pncA sequencing strategy conferring the transmission of multidrug-resistant tuberculosis in Egypt p. 211
Suzan Ismail, Khaled Al Amry, Galal Aggor, Hoida El Naggar, Salah Selim
DOI:10.4103/ijmy.ijmy_111_19  PMID:31512595
Background: This study explored the genetic diversity of Mycobacterium tuberculosis isolates in Egypt by spoligotyping in combination with pncA gene sequencing, spoNC. Methods: First, isolates were selected from 400 isolates positive for M. tuberculosis that referred to Central Labs Ministry of Health and then were subjected to the study analyses. Results: Twenty one isolates were found to be multidrug resistant (MDR) and 29 isolates were sensitive for isonizide (INH) and rifampicine (RIF) after testing by phenotypic drug susceptibility testing (DST) and Mycobacteria Growth Indicator Tube (MGIT). Spoligotyping yielded 45 patterns belonging to seven families that previously reported in neighboring countries such as Iraq, Syria, Iran, and Turkey. While four isolates were orphans. Conclusion: Application of spoNC on obtained spoligotype patterns enhances to reduce the clustering rate. Bejing family the predominant (34%) were subdivided by pncA sequence into three sensitive DST pncA wild type, three MDR-DST isolates showing cys14Arg mutation in pncA, two sensitive DST isolates with pncA Gly97Asp mutation, and three sensitive DST pncAVal128Gly mutation. The next most common CASI_DELHI family (16%) were subdivided by pncA sequencing into CASI_DELHI (st 381, MDR) including two pncA silent mutation ser65ser (tcc > tct) and CASI_DELHI (st26, sensitive) which included six pncA (wild-type) results, and Latin-American-Mediterranean 6 family (6%) all had PncA Gly97Asp mutation. We concluded that spoNC provides good snap shot for MDR surveillance and its country origin and performs early identification of outbreaks in Egypt.
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A bioinformatics analysis of exosomal microRNAs released following mycobacterial infection p. 218
Shamila D Alipoor, Ian M Adcock, Gert Folkerts, Johan Garssen, Esmaeil Mortaz
DOI:10.4103/ijmy.ijmy_88_19  PMID:31512596
Background: Tuberculosis (TB) still remains a major health threat worldwide. The current TB diagnostics are suboptimal, and there is a high clinical need for identifying novel biomarkers of disease prevalence. Circulating exosomes have been currently attractive as novel biomarkers in a wide range of pathological conditions. Methods: In this study, we performed bioinformatics analysis on the downstream targets of a dysregulated microRNA (miRNA) cluster induced by Bacillus Calmette–Guerin infection of human macrophages to provide greater understanding of their potential roles in disease pathogenesis. Results: Our analysis demonstrated that these dysregulated miRNAs have central roles in the host metabolic and energy pathways. Conclusion: This suggests that the host miRNA network is perturbed by Mycobacterium to re-patterning host metabolism machinery to favor its intracellular survival. The dysregulated miRNAs can be delivered to local and distal cells by exosomes and thereby modulate their function.
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Surveillance and characterization of drug-resistant Mycobacterium tuberculosis isolated in a reference hospital from Argentina during 8 years' period p. 223
Belén Rocío Imperiale, Ángela Beatríz Di Giulio, María Belén Mancino, Martín José Zumárraga, Nora Susana Morcillo
DOI:10.4103/ijmy.ijmy_94_19  PMID:31512597
Background: Argentina is considered a country with a middle tuberculosis (TB) incidence. However, according to the last national epidemiological report released in 2018, since 2013, the trends are steadily increasing. The aims of this study were to determine the drug-resistance (DR), multi-DR and extensively DR (MDR/XDR-TB), and rifampicin resistance (RIF-R) burden as a part of the local TB diagnosis (June 2010–August 2018); to detect the mutations associated to isoniazid (INH) and RIF-R and their geographical distribution; and to analyze the lineage relationship among the genetic patterns of the isolates circulating in the community. Methods: Respiratory and extrapulmonary specimens were processed by Ziehl–Neelsen stain and cultured on specific media. Drug-susceptibility testing of isolates was performed by the MGIT 960 and a colorimetric micro-method. Mutations conferring DR were detected by Genotype and DNA sequencing. Results: The study showed a DR-TB prevalence of approximately 20% of the isolated strains, while M/XDR-TB-and particularly RIF-R-affected more than 5.0% of the total amount of cases. DR geographical distribution revealed isolates carrying mutations in the inhA gene promoter region only constrained to three districts where it was also registered two same family relatives' cases with the infrequent rpoB S522 L/Q mutation. The fact that most DR/MDR-TB isolates were not grouped in genetic clusters suggested that these cases may mostly have occurred due to endogenous reactivation rather than recently transmission. Conclusion: According to the obtained results, it would be convenient, in highly MDR-TB suspected individuals, to confirm phenotypically, the INH and RIF susceptibility detected by molecular tests.
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Multiple docking analysis and In silico absorption, distribution, metabolism, excretion, and toxicity screening of anti-leprosy phytochemicals and dapsone against dihydropteroate synthase of Mycobacterium leprae p. 229
Sumit T Halder, Tehseen M Dhorajiwala, Lalit R Samant,
DOI:10.4103/ijmy.ijmy_123_19  PMID:31512598
Background: Leprosy is a neglected tropical disease affecting millions of people. The current treatment against leprosy includes various antibacterial drugs of which dapsone is known to bind to dihydropteroate synthase of Mycobacterium leprae. Dapsone is an expensive antibacterial drug with many side effects. A natural alternative for dapsone having less to no side effects and cheaper in production is needed. The three-dimensional protein structure of dihydropteroate synthase of M. leprae is not available. Methods: Protein homology modeling of target protein was carried out, and protein structure validation and energy minimization were performed. Phytochemicals mentioned in literature having anti-leprosy properties were studied for absorption, distribution, metabolism, excretion, and toxicity (ADMET) properties and that which passed ADMET filters were further carried for comparative in silico docking analysis along with dapsone. Preliminary docking analysis was carried using AutoDock Vina, and results obtained were validated using AutoDock 4.2.6 and SwissDock. Results: Neobavaisoflavone was predicted to be ten times safer for administration than dapsone. On performing in silico docking, it was found that neobavaisoflavone has better binding affinity than dapsone and forms a stable protein–ligand complex. Residues GLY.50, THR.88, and VAL.107 play an important role as binding site residues. Conclusion: Further, in vitro and in vivo experimental studies are required to confirm anti-leprosy properties of neobavaisoflavone over drug dapsone.
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Expression of mycolic acid in response to stress and association with differential clinical manifestations of tuberculosis p. 237
Naresh Kumar Sharma, Nisha Rathor, Rajesh Sinha, Shraddha Gupta, Gaurav Tyagi, Kushal Garima, Rakesh Pathak, Pooja Singh, Ashima Jain, Mridula Bose, Mandira Varma-Basil
DOI:10.4103/ijmy.ijmy_69_19  PMID:31512599
Background: Extrapulmonary tuberculosis (EPTB), accounting for 10%–20% of all cases of tuberculosis (TB), is known to be determined by host immunity. However, the contribution of bacterial factors to the development of EPTB has not been studied extensively. Mycolic acids are predominant lipids constituting the cell wall of Mycobacterium tuberculosis, and keto-mycolic acid is involved in the synthesis of foamy macrophages that facilitate persistence of mycobacteria. Hence, the present study was performed to gain an insight into variable expression of mycolic acids in clinical isolates of M. tuberculosis under stress. Methods: Pansusceptible clinical isolates of M. tuberculosis from patients with lymph node TB (LNTB) (n = 10) and pulmonary TB (PTB) (n = 10) were subjected to sodium dodecyl sulfate (SDS) stress, and the expression of mycolic acid and its biosynthetic genes was compared. Any bias arising due to the genotype of the clinical isolates was ruled out by performing single-nucleotide polymorphism cluster grouping (SCG), wherein no significant difference was observed between the SCG of LNTB or PTB isolates. Results: The expression of α-mycolic acid during the exposure to SDS was high in 7/10 (70%) LNTB and 6/10 (60%) PTB isolates. Methoxy mycolic acid showed an increased expression in 7/10 (70%) LNTB isolates and 4/10 (40%) PTB isolates. Increased expression of keto-mycolic acid on exposure with SDS was observed in 8/10 (80%) M. tuberculosis LNTB and 3/10 (30%) PTB isolates. Similarly, the mycolic acid synthesis gene, fas, was upregulated more in LNTB isolates than PTB isolates in vitro and ex vivo. SCG 3a was the most common SCG observed in 40% (8/20) of the isolates, followed by SCG 3b in 30% (6/20) of the isolates. There was no significant difference between the SCG of LNTB or PTB isolates. Conclusion: The higher expression of keto-mycolic acid in LNTB as against PTB isolates may indicate better survival in LNTB isolates in the presence of stress.
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Survival model analysis of tuberculosis treatment among patients with human immunodeficiency virus coinfection p. 244
Adeboye Azeez, Ruffin Mutambayi, Akinwumi Odeyemi, James Ndege
DOI:10.4103/ijmy.ijmy_101_19  PMID:31512600
Background: Tuberculosis (TB) with human immunodeficiency virus (HIV) coinfection is the highest clinical epidemiology and public health issue. Despite many programs established to tackle the epidemic, TB target controls have not been reached. One of the many factors attributed to the failure in TB treatment is HIV coinfection. The aim of this study is to assess the survival rate of HIV infection among TB patients and the risk factors of death among the TB patients with HIV coinfection during the retro of directly observed treatment, short-course (DOTS) program. Methods: This study is a retrospective cohort conducted to compare the survivorship between TB/HIV patients for 8 months DOTS. Death among TB patients was considered as failures and those defaulted or survived were censored. The Cox proportional-hazards regression and log-linear model were used to establish the hazard ratio (HR) of death for each variable at baseline and estimate the risk factors effect among TB patients. Results: The findings revealed that 50% of death from TB/HIV patients were from HIV coinfection (advanced HR = 2.01, 95% confidence interval = 1.13–3.17). The risk of death was significantly higher in HIV-positive TB patients (P = 0.000) during the extension care phase. TB/HIV-positive patients on antiretroviral therapy have decreased survival rate (log-rank test = 14.88, df = 2, P = 0.0001). The probability of TB patients surviving is significantly decreased in HIV positive with some factors such as age, weight, smoking, and alcohol found significant. Conclusion: The probability of survival in HIV-positive TB patients was significantly lower during the TB treatment. Weight loss, age, alcohol, smoking, and pregnancy were showed to affect the survival probability of TB/HIV patients' coinfection significantly.
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An In silico approach to identify potential inhibitors against multiple drug targets of Mycobacterium tuberculosis p. 252
Satish Kumar, Parameswar Sahu, Lingaraja Jena
DOI:10.4103/ijmy.ijmy_109_19  PMID:31512601
Background: The increasing incidence of multidrug-resistant cases of tuberculosis (TB) and difficulty in treating these cases requires an urgent need to find an effective anti-TB drug. There are many phytochemicals with reported antibacterial and antitubercular activities. Instead of targeting only a single target of Mycobacterium tuberculosis (MTB), this study aims to identify phytochemicals targeting multiple drug targets of MTB through subtractive genomic/proteomic approach followed by in silico screening of phytochemicals with reported anti-TB activity. Methods: Of 614 essential genes of MTB reported in database of essential genes, 15 gene products were selected using different bioinformatic resources and tools such as PANTHER, Venny, NCBI, and BLAST. Results: Virtual screening analysis of these selected drug targets against identified 148 phytochemicals revealed that amentoflavone, carpaine, 13'bromo-tiliacorinine, and 2'nortiliacorinine, able to inhibit more than one target of MTB. Conclusion: These selected compounds may be proposed as potential inhibitors of MTB and need to be tested in TB culture studies in vitro to assess their anti-TB activity.
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Soluble urokinase-type plasminogen activator receptor as a biomarker of treatment response in childhood tuberculosis p. 262
Ery Olivianto, Sri Sudarwati, Heda Melinda Nataprawira
DOI:10.4103/ijmy.ijmy_52_19  PMID:31512602
Background: Childhood tuberculosis (TB) is a major health problem worldwide, especially in developing countries. In 2015, there are estimated 950,000 cases of childhood TB. Since most TB in children is paucibacillary, this gives rise not only to problem in diagnosing but also in monitoring the response to anti-TB treatment as well. Soluble urokinase-type plasminogen activator receptor (suPAR), a glycosylphosphatidylinositol-linked membrane protein of various cells of immune system, is one of the potential biomarkers to be used in the management of TB. The objective of this study is to study the decrease of serum suPAR level after anti-TB treatment in children with TB and its association with patient characteristics. Methods: We conducted a prospective study on children suspected of having TB due to a history of contact with active TB case and symptoms such as coughing, fever, and enlarged lymph nodes. The diagnosis of TB is established by history, physical examination including anthropometric examination. Tuberculin skin test using PPD RT-23 and interferon-gamma releasing assay with Quantiferon TB-Gold Plus was performed. Chest X-rays were read by two independent radiologists. Microbiological examination was performed using microscopic examination and Xpert MTB/RIF. The level of suPAR before and after anti-TB treatment was examined with the Elisa method. Results: There was no significant difference of serum suPAR levels before and after anti-TB treatment (mean 0.71 [standard deviation 0.585] ng/mL; P = 0.072). There was no association between ages (P = 0.112), nutritional status (P = 0.228), diagnosis of pulmonary or extrapulmonary TB (P = 0.956), and radiological feature (P = 0.810) with serum suPAR levels decrease. Conclusion: There is no suPAR serum level decrease 2 months after treatment with anti-TB and there is no association with age, nutritional status, pulmonary or extrapulmonary TB diagnosis, and radiological feature.
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Is pulmonary tuberculosis in pregnant women a problem in Ghana? Observations and lessons from the national tuberculosis prevalence project p. 267
Nana Yaa Awua-Boateng, Aliyu Mohammed, Leslie Mawuli Aglanu, Godfred Acheampong, John Humphrey Amuasi, Frank Adae Bonsu, Richard Odame Phillips, Ellis Owusu-Dabo
DOI:10.4103/ijmy.ijmy_112_19  PMID:31512603
Background: Despite appropriate prevention and control measures, tuberculosis (TB) remains a significant contributor to maternal morbidity and mortality. Diagnosis of the disease in pregnancy is usually challenging, as the symptoms may be attributed to the pregnancy. Little is known about the true burden of the disease and its associated risk factors among pregnant women. This study sought to assess the prevalence of TB among pregnant women and associated sociodemographic characteristics in Ghana. Methods: The study used nationally representative data gathered from the national TB project in 2013. A total of 1747 pregnant women were sampled from 56 randomly selected diagnostic health centers across the ten regions of Ghana. TB was confirmed with Ziehl–Neelsen staining technique using morning sputum samples from pregnant women who reported coughing for more than 2 weeks. We assessed how the observed TB prevalence differed by some sociodemographic characteristics and other factors. We further examined the regional spatial distribution of pregnant women with TB in the country. Results: Up to 11.2% of the pregnant women had a history of cough during pregnancy. Eighteen (1.1%) cases of TB were confirmed among the pregnant women during the 2-year period, with the Eastern region of the country recording the highest (n = 13, 72%), followed by Volta region ( n = 2, 11.1%). No cases were recorded in five regions. The geographical region of residence was the only determinant of TB in pregnancy significantly associated with TB (P = 0.001). Conclusion: Although the burden of TB was found to be low, appropriate control measures have to be put in place to detect the disease during the early stages of pregnancy to safeguard the health of the expectant mother and the unborn child.
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A multilocus sequence typing scheme for Mycobacterium abscessus complex (MAB-multilocus sequence typing) using whole-genome sequencing data p. 273
Michelle Wuzinski, Aneta K Bak, Aaron Petkau, Walter H B. Demczuk, Hafid Soualhine, Meenu Kaushal Sharma
DOI:10.4103/ijmy.ijmy_106_19  PMID:31512604
Background:Mycobacterium abscessus is a rapid growing nontuberculous mycobacteria (NTM) and a clinically significant pathogen capable of causing variable infections in humans that are difficult to treat and may require months of therapy/surgical interventions. Like other NTMs, M. abscessus can be associated with outbreaks leading to complex investigations and treatment of affected cases. Typing schemes for bacterial pathogens provide numerous applications; including identifying chain of transmission and tracking genomic evolution, are lacking or limited for many NTMs including M. abscessus. Methods: We extended the existing scheme from PubMLST using whole-genome data for M. abscessus by extracting data for 15 genetic regions within the M. abscessus genome. A total of 168 whole genomes and 11 gene sequences were used to build this scheme (MAB-multilocus sequence typing [MLST]). Results: All seven genes from the PubMLST scheme, namely argH, cya, gnd, murC, pta, purH, and rpoB, were expanded by 10, 14, 13, 10, 13, 10, and 9 alleles, respectively. Another eight novel genes were added including hsp 65, erm(41), arr, rrs, rrl, gyrA, gyrB, and recA with 16, 16, 25, 7, 32, 35, 29, and 15 alleles, respectively, with 85 unique sequence types identified among all isolates. Conclusion: MAB-MLST can provide identification of M. abscessus complex to the subspecies level based on three genes and can provide antimicrobial resistance susceptibility prediction based on results from seven genes. MAB-MLST generated a total of 85 STs, resulting in subtyping of 90 additional isolates that could not be genotyped using PubMLST and yielding results comparable to whole-genome sequencing (WGS). Implementation of a Galaxy-based data analysis tool, MAB-MLST, that simplifies the WGS data and yet maintains a high discriminatory index that can aid in deciphering an outbreak has vast applicability for routine diagnostics.
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MtFtsX a predicted membrane domain of ABC transporter complex MtFtsEX of Mycobacterium tuberculosis interacts with the cell division protein MtFtsZ p. 281
Mushtaq Ahmad Mir, Ramanujam Srinivasan, Parthasarathi Ajitkumar
DOI:10.4103/ijmy.ijmy_98_19  PMID:31512605
Background: Bacterial cytokinesis is orchestrated by a complex of dozen of proteins called 'divisome' at the mid-cell site. FtsZ, the eukaryotic tubulin homolog, localizes to the mid-cell site where it polymerizes and forms a cytokinetic Z-ring. The Z-ring acts as a docking platform for other proteins to localize. In model organisms, Escherichia coli and Bacillus subtilis, FtsZ is known to interact with several proteins. The role of few of these interactions is known, while of others is yet to be studied. In Mycobacterium tuberculosis, the cell division and its regulation are poorly studied. Although, most of the divisome proteins are conserved in M. tuberculosis, surprisingly the homologues of the protein factors required for membrane association of Z-ring and its stabilization are absent. In E. coli FtsE and FtsX, the constituent ATPase and membrane domains of the ABC transporter complex, localize to the Z-ring immediately after Z-ring stabilizing proteins, ZipA and FtsA. Therefore, investigation of the interaction between MtFtsX and MtFtsZ is demanding. Methods: Bacterial two-hybrid system was used to identify the interaction between MtFtsE and MtFtsZ. This interaction was further confirmed by biochemical methods of Ni2+-NTA agarose pull-down and coimmunoprecipitation. Results and Conclusion: Here, we demonstrated that MtFtsX interacts with MtFtsZ in vivo and ex-vivo. Further, we showed that self-interacting MtFtsX interacts with MtFtsE. However, we did not find any interaction between MtFtsE and MtFtsZ. These results suggest that the membrane domain MtFtsX of the ABC transporter complex 'MtFtsEX' might be the membrane-tethering and stabilizing factor for Z-ring in M. tuberculosis.
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Competitive fitness of Mycobacterium tuberculosis in vitro p. 287
Ousmane Kodio, Antieme Combo Georges Togo, Yeya dit Sadio Sarro, Bintou Fane, Fatimata Diallo, Amadou Somboro, Boureima Degoga, Mahamadou Kone, Gagni Coulibaly, Mohamed Tolofoudje, Sidy Bane, Moumine Sanogo, Bourahima Kone, Nadie Coulibaly, Djeneba Dabitao, Bocar Baya, Mamoudou Maiga, Flabou Bougoudogo, Fasse Samake, Sounkalo Dao, Seydou Doumbia, Souleymane Diallo, Bassirou Diarra
DOI:10.4103/ijmy.ijmy_97_19  PMID:31512606
Background: While, bacteria resistance mutations can affect competitive fitness, given our multidrug-resistant (MDR) prevalence, we conducted this study to determine the impact of MDR on the competitive fitness of Mycobacterium tuberculosis (MTB) complex MDR strains. We conducted a cross-sectional study at the University Clinical Research Center (UCRC) from January to December 2017. New TB patients over aged of 18 were recruited at University teaching hospital and health reference centers of Bamako in USTTB Ethical committee approved protocols. Methods: MDR and drug-susceptible (wild-type [WT]) MTB strains (T1 and Beijing) and MTB H37Rv were competed on solid media in UCRC's Tuberculosis Laboratory. Competitive and individual cultures were incubated for 14 days at 37°C with 7% CO2. Number of generation, generation time, and relative competitive fitness (W) of the strains were calculated. Data were analyzed with Epi-Info 7.1.5.2 software (CDC). P value was considered significant when it was <0.05. Scientific calculator (CS-82TL) was used for competitive fitness parameters calculations. Results: We performed 24 competitive cultures and 10 individual cultures. In individual cultures, strains' generation number was for Beijing (WT: 4.60 and mutant MR: 4.40), T1 (WT: 2.69 and MR: 2.37), and H37Rv: 2.91. Generation number of WT strains was less than those of MDR strains in both individual and competitive culture. Relative competitive fitness was below 1 (W<1) in 83.3%. Conclusion: MDR strains were less competitive than WT strains in 83.3% of cases. Resistant mutation impacts bacteria fitness.
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CASE REPORTS Top

Sporotrichoid presentation of lupus vulgaris mimicking mycetoma p. 292
Soumil Khare, Namrata Chhabra, Satyaki Ganguly, Neel Prabha
DOI:10.4103/ijmy.ijmy_113_19  PMID:31512607
Most common form of cutaneous tuberculosis (TB) is lupus vulgaris (LV). Atypical presentation of LV is rare and may lead to delay in diagnosis and hence increase in morbidity. Here, we report a case of sporotrichoid form of LV in a 38 year old male who presented as cutaneous lesions mimicking mycetoma. High index of clinical suspicion and relevant investigations play a vital role in confirmation of diagnosis wherever atypical form of cutaneous TB is suspected.
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A case report of disseminated Mycobacterium colombiense infection in an HIV patient p. 295
Eduarda Pena, Diana Machado, Miguel Viveiros, Sofia Jordão
DOI:10.4103/ijmy.ijmy_100_19  PMID:31512608
Mycobacterium colombiense is a newly recognized member of the Mycobacterium avium complex, and only a few cases of infections caused by this pathogen have been reported. We present an imported case of disseminated disease caused by M. colombiense in an HIV patient in early February 2017.
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Perils with Pirfenidone and “the tuberculosis link” p. 298
Madhav H Hande, K Vishak Acharya, A Shreenivasa, Kashinath Nayak, S Arun
DOI:10.4103/ijmy.ijmy_96_19  PMID:31512609
We report a case of idiopathic pulmonary fibrosis (IPF) treated with pirfenidone who developed tuberculosis (TB) and later had exfoliative dermatitis secondary to an interaction between pirfenidone and rifampicin. This case report highlights the possible risk of developing TB in patients diagnosed with IPF and on antifibrotic therapy like pirfenidone. Furthermore, this case report documents a previously unreported adverse reaction due to the interaction of rifampicin with pirfenidone.
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A case report of tuberculous empyema: A tricky disease p. 302
Muhammad Tufail
DOI:10.4103/ijmy.ijmy_110_19  PMID:31512610
Extrapulmonary tuberculosis (TB) can rarely be transmitted to others. The disease mostly affects adults and immunocompromised individuals. A 26-year-old male presented with weight loss and occasional chest pain with a deep breath, but he was otherwise normal. The patient had a history of severe dry coughs, night sweats, fever, confusion, and dizziness for >3 weeks. The patient was initially misdiagnosed with an allergic cough and was treated with anti-allergic medications. Due to small and sticky effusion, the thoracentesis procedure failed, and the patient was referred to a thoracic surgeon for an open decortication. Pleural biopsy (PB) was negative for acid-fast bacilli, but the report showed necrotizing granulomatous inflammation. The patient was started on anti-TB treatment according to the WHO guidelines. The patient gained about 6% of the body weight at the end of the intensive phase and about 15% of the body weight at the end of the continuation phase. His chest pain subsided. Chest radiography showed improvement. The patient recovered, and no relapse occurred. This study recommends that a patient with dry coughs, night sweat, and fever for >3 weeks should be followed up with a chest X-ray for at least the next 3 months.
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Multidrug resistance as a cause of steroid-nonresponsive downgrading type I reaction in Hansen's disease p. 305
Surabhi Sinha, Kabir Sardana, Diksha Agrawal, Purnima Malhotra, Mallika Lavania, Madhvi Ahuja
DOI:10.4103/ijmy.ijmy_121_19  PMID:31512611
While Type 1 reaction in Hansen's disease is commonly encountered, the triggers and reasons for its persistence are not well understood even though the immunological milieu and cytokine interplay have been studied. Herein, we present a case of Type 1 downgrading reaction in which multidrug resistance was the probable cause of steroid-nonresponsiveness and which responded promptly on starting alternate antileprosy treatment.
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LETTERS TO EDITOR Top

Biopsy or bio-spy? The role of fine-needle aspiration cytology in pancreatic tuberculosis p. 309
Graziana Gallo, Stefania Caramaschi, Alessandro Mangogna, Tiziana Salviato
DOI:10.4103/ijmy.ijmy_103_19  PMID:31512612
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Interference of pulse oximeter reading in an undiagnosed case of Hansen's disease p. 311
Anitabh Sukhadeve, Nikahat Jahan, Deepak Dwivedi
DOI:10.4103/ijmy.ijmy_118_19  PMID:31512613
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