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   Table of Contents - Current issue
April-June 2018
Volume 7 | Issue 2
Page Nos. 109-201

Online since Wednesday, June 13, 2018

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Mycobacterium abscessus complex: Natural history and treatment outcomes at a tertiary adult cystic fibrosis center Highly accessed article p. 109
Emma Tippett, Samantha Ellis, John Wilson, Tom Kotsimbos, Denis Spelman
DOI:10.4103/ijmy.ijmy_55_18  PMID:29900884
Background: Mycobacterium abscessus complex (MAbsC) is a significant management dilemma when taking care of patients with cystic fibrosis (CF). Methods: We undertook a retrospective cohort analysis of all CF patients in whom MAbsC was isolated from 2005 to 2014. The natural history of MAbsC was determined and clinical factors examined in an attempt to predict transient compared to persistent colonization. Results: No correlation was found between recurrent MAbsC isolation and clinical factors such as body mass index, respiratory function, or age. Over two-thirds of our cohort cleared MAbsC colonization with no intervention and no consistent effect on lung function was identified. Four CF patients were initiated on treatment with only one successful outcome. Conclusion: This analysis demonstrates there are no clear predictors of those CF patients who will become persistently colonized with MAbsC and that a significant proportion will spontaneously clear carriage. As treatment success rate is poor, more work is urgently required in improving patient outcomes.
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The effect of human leukocyte Antigens-DRB1 alleles on development of different tuberculosis forms in children p. 117
Anna Starshinova, Irina Dovgalyuk, Andrey Berkos, Yulia Ovchinnikova, Ludmila Bubnova, Piotr Yablonskiy
DOI:10.4103/ijmy.ijmy_41_18  PMID:29900885
Background: Nowadays, there is no doubt that the development of infectious process is determined not only by individual features of a human, but also by features of infection agent. It is commonly known that ability to form an adequate immune response is based on immunogenetic peculiarities of macroorganism. Methods: The immunogenetic study was performed in 228 children from 1 to 15 years old with different manifestations of tuberculosis (TB). Control group was consisted of 446 adult healthy donors-residents of the Northwestern region of Russia. Human leukocyte antigens (HLA)-DRB1* allelic genes were assessed in all individuals. Results: HLA-DRB1 alleles *01, *03, *11, *13, *07, and *15 were observed significantly rare in children with TB in comparison with healthy donors that may indicate their protective role in the development of the disease. It was also noticed that DRB1 *07 and *15 alleles were observed significantly rare in children with lung TB in comparison with other forms of disease that allows to assume a protective function of these alleles for lung TB with no influence on development of generalized TB. This assumption requires further researches. Conclusion: As a result of the study, statistically significant differences in the distribution of HLA-DRB1* alleles in children with TB in comparison with a control group for *01, *03, *11, *13, *07, *15, and *16 alleles were found. It may indicate their protective role in the development of TB. DRB1 *07 and *15 alleles were observed significantly rare in children with single TB than in children with generalized TB and healthy controls.
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Effect of chlorine on Mycobacterium gordonae and Mycobacterium chubuense in planktonic and Biofilm State p. 122
Alejandra Soledad Oriani, Fermín Sierra, Mónica Diana Baldini
DOI:10.4103/ijmy.ijmy_30_18  PMID:29900886
Background: There is evidence that drinking water could be a source of infections with pathogenic nontuberculous mycobacteria (NTM) potentially risky to human health. The aim was to investigate the resistance of two NTM isolated from drinking water, Mycobacterium gordonae and Mycobacterium chubuense, at different concentrations of chlorine (as sodium hypochlorite), used in drinking water sanitation. Methods: The NTM were grown in suspension and in biofilms and were challenged with biocide for 10 and 60 min. Results: To obtain 7-log reduction from the initial population of M. chubuense, in the planktonic state, there were necessary 20 ppm of chorine and 60 min of exposure. The same effect was achieved in M. gordonae with 10 ppm for the same period. The maximum reduction of both NTM in biofilm was 3-log reduction and was achieved using 30 ppm for 60 min. The chlorine susceptibility of cells in biofilms was significantly lower than that of planktonic cells. The results highlight the resistance of both NTM to the concentrations used in routine water sanitation (0.2 ppm according to Argentine Food Code). Differences in chlorine resistance found between the two NTM in planktonic growth decrease when they are grown in biofilm. Conclusion: This suggests that current water disinfection procedures do not always achieve effective control of NTM in the public supply system, with the consequent health risk to susceptible population, and the need to take into account biofilms, because of their deep consequences in the way to analyze the survival of prokaryotic cells in different environments.
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Pulmonary functions' assessment in post-tuberculosis cases by spirometry: Obstructive pattern is predominant and needs cautious evaluation in all treated cases irrespective of symptoms p. 128
Shital Patil, Rajesh Patil, Anil Jadhav
DOI:10.4103/ijmy.ijmy_56_18  PMID:29900887
Background: Approximately 30%–40% patients suffer with lung function issues in spite of successful treatment outcome; and these problems are less documented routinely. Methods: Prospective multicentric study conducted during July 2013–June 2017, to find pulmonary function assessment in posttuberculosis (TB) cases irrespective of their symptoms, included 500 cases in symptomatic and asymptomatic group and subjected to inclusion and exclusion criteria. All cases were subjected to spirometry analysis. Statistical analysis was done using Chi-square test. Results: In spirometry assessment of symptomatic post-TB cases, obstructive pattern was predominant type documented in 42% cases. In spirometry assessment of asymptomatic post-TB cases, obstructive pattern is documented in 32%, mixed pattern in 14%, and normal spirometry is documented in 46% cases. In spirometry assessment in symptomatic and asymptomatic cases, obstructive pattern is documented in 210 cases and 160 cases, respectively (P < 0.00001). Abnormal lung function is documented in 70% and 54% in symptomatic and asymptomatic post-TB cases, respectively (P < 0.00001). Conclusions: Lung function impairment is known to occur after pulmonary TB irrespective of duration of treatment and outcome of disease. Obstructive lung disease is the predominant lung function impairment in symptomatic cases. Significant number of asymptomatic cases are also having obstructive pattern of lung function in spirometry analysis.
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Antimicrobial effect of dimethyl sulfoxide and N, N-Dimethylformamide on Mycobacterium abscessus: Implications for antimicrobial susceptibility testing p. 134
Zara I Kirkwood, Beverley Cherie Millar, Damian G Downey, John E Moore
DOI:10.4103/ijmy.ijmy_35_18  PMID:29900888
Background: The emergence of antimicrobial resistance globally has initiated the discovery of novel antibiotics and other antimicrobial substances. Many of these novel compounds may be found in phytochemicals, where these novel compounds are extremely difficult to redissolve for antimicrobial susceptibility testing, following extraction. The aim of this study was to examine the potential antimicrobial effects of the common solvents, dimethyl sulfoxide (DMSO) and N, N-dimethylformamide (DMF), which are commonly employed as solvents of novel antimicrobial substances, with the nontuberculous Mycobacterium and Mycobacterium abscessus. Methods: M. abscessus clinical isolates (n = 17 isolates) were examined for the antimicrobial effects of DMSO and DMF. McFarland 0.5 standards of each isolate were prepared individually on Columbia Blood agar onto which DMSO and DMF were added (10 μl) in the range neat (undiluted) – 10,000-fold (10−4) dilution and incubated. Zones of inhibition were recorded in mm. Results: DMSO and DMF had an inhibitory effect on M. abscessus (n = 17 clinical isolates). This inhibitory effect was avoided by diluting DMSO 10-fold and DMF 10,000-fold. Conclusion: Such data are important when employing these common solvents with molecules which are difficult to dissolve into solution, including conventional antibiotics, as well as novel antimicrobial agents, particularly in antimicrobial susceptibility studies. Investigators should therefore be aware of this inhibition and avoid working with these solvents at high concentration to avoid bacterial growth inhibition. The use of appropriate experimental controls is highly recommended in such circumstances to avoid the reporting of false-positive antimicrobial effects.
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Evaluation of the tuberculosis control program in South West Cameroon: Factors affecting treatment outcomes p. 137
Kareen A Atekem, Nicoline Fri Tanih, Roland Ndip Ndip, Lucy Mande Ndip
DOI:10.4103/ijmy.ijmy_20_18  PMID:29900889
Background: Tuberculosis (TB) has been ranked as one of the leading causes of death worldwide. In Cameroon, the National Tuberculosis Control Program aims to fight TB through the implementation of international directives (Directly Observed Treatment Short course [DOTS]). TB control program must reach global targets for detection (70%) and treatment success (85%) as stated by the United Nations Millennium Development Goals (MDGs). Implementing DOTS in Cameroon has not met the MDGs of 85% success rate. This study aimed at identifying factors affecting treatment success. Methods: A cross-sectional retrospective study was used to collect data from 895 TB registers from January 2011 to December 2012. Out of the seven treatment centers in Fako Division, three were randomly selected following stratification into government, not-for-profit and for-profit structures. Descriptive statistics were used to obtain frequencies. Binomial logistics regression was used to obtain significant values for the various factors. Multinomial logistics was used on significant factors. Results: Of the 895 registered TB patient records obtained, 416 (46.5%) patient were female and 479 (53.5%) patient were male. Characterizing TB patients, 510 (57.0%) were smear-positive pulmonary TB, 225 (25.1%) were smear-negative pulmonary TB, and 160 (17.9%) were extrapulmonary TB patients. Comparing treatment success rate (TSR) across the three centers, Baptist Hospital Mutengene had the highest value 94.97 (38%), followed by Regional Hospital Buea 83.74 (33%), and Central Clinic Tiko the least 73.13 (29%). Conclusion: Patient registration year, treatment center, TB classification, and HIV status were identified to significantly affect TSR, hence, effectiveness of the TB program.
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Latent tuberculosis infection among patients with coronary artery stenosis: A case–Control study p. 143
Ahmad Farooq Alsayed Hasanain, Khalid M El-Maghraby, Ali A H. Zayed, Amany M A. Nafee, Sherif M Abdel-Aal, Sally M Bakkar
DOI:10.4103/ijmy.ijmy_34_18  PMID:29900890
Background: The activation of the cell-mediated immune responses by Mycobacterium tuberculosis can promote atherogenesis. Aims: The aim of this study is to determine the frequency of latent tuberculosis infection (LTBI) among patients with coronary artery stenosis (CAS) and to explore the association between LTBI and development of CAS. We conducted a case–control study which included 183 patients′ who underwent percutaneous coronary angiography (121 patients with CAS and 62 patients without as a control group). Methods: For all the study population, clinical evaluation, tuberculin skin test (TST), imaging studies (including chest radiography and echocardiography), laboratory investigations, and electrocardiography were carried out. Only for the patients with positive TST, QuantiFERON-TB Gold test was performed. Predictors of CAS were identified using univariate analyses (Yates' corrected Chi-square test or Fischer's exact test) followed by multivariate analysis (binary logistic regression). Results: Among 29.5% of the study population, LTBI was detected, and among patients with CAS, 56.2% of patients had advanced CAS. After multivariate analysis, it was found that metabolic syndrome (MS) (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.5–22.6, P = 0.022) and LTBI (OR 2.5, 95% CI 1.2–17.3, P = 0.018) were the predictors of CAS among the study population, while only diabetes mellitus (DM) (OR 1.9, 95% CI 1.1–11.7, P = 0.031) was the predictor of advanced CAS. Conclusion: LTBI is associated with the development of CAS. In addition, MS is associated with CAS, while its related disorder, DM, is associated with advanced CAS.
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The problem of resistance in Mycobacterium tuberculosis may be underestimated in Africa p. 148
Simeon I B. Cadmus, Olutayo I Falodun, Oba E Fagade, Robert Murphy, Babafemi Taiwo, Dick Van Soolingen
DOI:10.4103/ijmy.ijmy_29_18  PMID:29900891
Background: The true burden of tuberculosis (TB) and particularly multidrug-resistant (MDR) TB in Sub-Saharan Africa has remained underestimated. Methods: We investigated drug susceptibility profile and genetic diversity of Mycobacterium tuberculosis isolates collected from confirmed tuberculosis patients in Ibadan, southwestern Nigeria. Results: We confirmed that from 74 randomly selected Mycobacterium tuberculosis isolates available for drug susceptibility testing in Ibadan, in 2011, 13.5% of them were MDR-TB. Conclusions: This figure is obviously above the national and World Health Organization figures.
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Clinical pilot study: Clarithromycin efficacy in multibacillary leprosy therapy p. 152
Hendra Gunawan, Muljaningsih Sasmojo, Helena Eka Putri, Erda Avriyanti, Reti Hindritiani, Oki Suwarsa
DOI:10.4103/ijmy.ijmy_58_18  PMID:29900892
Background: Rifampicin is one of the important components in the multidrug therapy (MDT)-World Health Organization regimen for leprosy. Clarithromycin is one of the alternative therapies of rifampicin. Methods: This clinical pilot study was to compare the efficacy of 2,000 mg clarithromycin to 600 mg rifampicin in combination with dapsone and clofazimine for 3 months in multibacillary (MB) leprosy patients. They were divided into an MDT-MB regimen group that consists of rifampicin-dapsone-clofazimine and clarithromycin-dapsone-clofazimine (CDC) regimen group, each group consisted of seven patients. Results: The morphological index (MI) was reduced insignificantly after 3 months therapy in MDT-MB group (P = 0.248). While in the CDC group, the MI decrement showed a significant result (P = 0.004). The comparison of MI reduction in MDT-MB and CDC groups showed an insignificant difference (P = 0.130). Skin discoloration was occurred in both groups, whereas mild-nausea was presented in the CDC group, in addition, red-colored urine was developed in the MDT-MB group. Conclusion: We concluded that 2,000 mg clarithromycin is as effective as 600 mg rifampicin in combination with dapsone and clofazimine regimen in MB leprosy patients. Hence, clarithromycin can be considered as an alternative therapy for leprosy patients who resistance and/or allergy to rifampicin.
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Mycobacterium tuberculosis Strains H37ra and H37rv have equivalent minimum inhibitory concentrations to most antituberculosis drugs p. 156
Marc Tobias Heinrichs, Robert Justin May, Fabian Heider, Tobias Reimers, Sherwin Kenneth B. Sy, Charles Arthur Peloquin, Hartmut Derendorf
DOI:10.4103/ijmy.ijmy_33_18  PMID:29900893
Background: Mycobacterium tuberculosis (Mtb) strains H37Ra and H37Rv are commonly used to study new and re-evaluate old antituberculous agents with respect to their pharmacodynamic effects in vitro. The differences in membrane proteins and, in particular, differences in carrier proteins between Mtb H37Ra and Mtb H37Rv may have an impact on antibiotic potency. The question of whether H37Ra can be used as a reliable surrogate for H37Rv and clinical strains has not been addressed sufficiently. The purpose of this study is to provide a full comparison of susceptibility data of the most common antituberculosis (TB) agents against both Mtb strains. Methods: In addition to a literature review, in vitro checkerboard susceptibility study was conducted comparing the in vitro minimum inhibitory concentration (MIC) of 16 common antituberculous drugs against H37Ra and H37Rv. Heifets–Sanchez TB agar drug susceptibility plates were utilized. Results: Half of the antibiotics demonstrated similar growth inhibition against both strains, while slightly differing MIC values were found for 7 of 16 drugs. With the exception of rifampicin, no marked difference in MIC against H37Ra and H37Rv was observed. Conclusion: While neither the attenuated (H37Ra) nor the virulent strain (H37Rv) is a clinical strain, both strains predicted MICs of clinical isolates equally well, when comparing the current in vitro results to clinical susceptibility data in the literature. H37Ra comes with the benefits of lower experimental costs and less administrative barriers including the requirement of a biosafety Level III environment.
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String test: A new tool for tuberculosis diagnosis and drug-resistance detection in children p. 162
Belén Rocío Imperiale, Cecilia Nieves, Belén Mancino, Myriam Sanjurjo, Silvina Tártara, Ángela Beatríz Di Giulio, Juan Carlos Palomino, Nora Susana Morcillo, Anandi Martin
DOI:10.4103/ijmy.ijmy_54_18  PMID:29900894
Background: There is a critical need to improve the diagnostic accuracy of tuberculosis (TB) in children. Several techniques have been developed to improve the quality of sputum samples; however, these procedures are very unpleasant and invasive and require hospitalization and trained personnel. This study aims to explore the potential use of a new and noninvasive tool, “string test,” for TB diagnosis in children and in adults not able to render sputum samples and at risk of developing multidrug-resistant TB (MDR-TB). Methods: Children with clinical suspicion of TB attending the pediatric consultation at the Cetrangolo or Cordero Hospitals and adults suspected of MDR-TB and unable to produce sputum attending the Infectious Disease Unit of Cetrangolo Hospital were included in this study. Subjects and Methods: The “string test” is a string that is swallowed by the patients and exposed to gastrointestinal secretions that were late analyzed for TB diagnosis and drug-resistance detection by GenoType MTBDRplus. MedCalc software was used to perform statistical analysis. Results: This technique could be applied on 62.1% of selected children. About 11 (30.6%) children were diagnosed as TB cases, 8 (22.2%) from gastric aspirate and using the “string test.” Six out of 19 adults were also diagnosed. Genotype directly on the string specimen detected two MDR-TB in adults and two isoniazid-resistant cases before obtaining the isolate. Conclusion: This test was safe, cheap, and easily implemented without requiring hospitalization. This research could represent a significant step forward to diagnose and rapidly detect drug-resistant TB in children.
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Drug-Resistant tuberculosis in Ethiopia: Characteristics of cases in a referral hospital and the implications p. 167
Yoseph Worku, Tewodros Getinet, Shikur Mohammed, Zhenhua Yang
DOI:10.4103/ijmy.ijmy_48_18  PMID:29900895
Background: Tuberculosis (TB) programs should design intervention strategies based on the sound knowledge of the existing local epidemiology and sociodemographic characteristics of drug-resistant-TB (DR-TB) cases. The aim of the study was to characterize the pulmonary multidrug-resistant (MDR) and rifampicin-resistant (RR) TB cases enrolled in a referral hospital at Addis Ababa, Ethiopia, called All Africa Leprosy, Tuberculosis, Rehabilitation and Training (ALERT) Hospital. Methods: We conducted a descriptive study based on retrospective review of medical records of 340 pulmonary MDR/RR-TB cases enrolled in ALERT Hospital from November 2011 to December 2016. To characterize the cases, we described the distribution of demographic and clinical characteristics. To compare the distribution of demographic and clinical characteristics between male and female cases, we used Pearson's Chi-squared test. Results: Males accounted for 52.9% of the 340 cases. Nine out of ten cases were in the age group of 15–44 years. Sputum acid-fast bacilli smear-positive and human immunodeficiency virus-coinfected cases constituted 63.7% and 18.1% of cases, respectively. The proportion of new cases increased through the years from nil in 2011 to 21.4% in 2016. Adult males above 24 years constituted more than three quarters (77.2%) of the total male cases, while adult females in this age group constituted 56.9%. The age distribution between male and female cases showed significant differences (P < 0.001). Conclusion: There is age disparity between male and female cases with high impact of MDR/RR-TB on productive adult male population. The transmission potential for DR-TB is also high in the community.
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Leprosy in Northwest Louisiana: A case series p. 173
Andrew Stevenson Joel Chandranesan, Pradeep Kumar Mada, Frances Ramos-Herberth, David Walsworth, Robert Penn, Ronald Washburn
DOI:10.4103/ijmy.ijmy_21_18  PMID:29900896
Hansen's disease, commonly known as leprosy, is a chronic mycobacterial infection caused by Mycobacterium leprae. Although generally uncommon in the United States, it is endemic in the Southern United States. We diagnosed and managed five leprosy patients from Northwest Louisiana, each presenting a distinct set of challenges. A retrospective study was performed to collect demographic, clinical, and laboratory data from our cases. The information was analyzed with a specific focus on associated factors, diagnosis, and management. The mean age at diagnosis was 67.6 years (range 56–83 years), and the average delay in diagnosis was 8.4 months (range 1–20 months). All five patients presented with nonhealing rashes, and three initially sought help from primary care providers. Only two patients developed subjective numbness. Leprosy was not suspected before skin biopsy in three cases, while noninfectious diagnoses were considered, including mycosis fungoides, erythema multiforme, vasculitis, and amyloidosis. In the other two cases, leprosy was in the initial differential diagnosis. Ultimately, the diagnosis of leprosy was established in all five individuals based on clinical presentation, routine histopathology, and tissue acid-fast staining. This case series highlights the importance of leprosy, especially in the Southern United States where its incidence is increasing.
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Bronchial wash culture is less valuable in patients suspected to have nontuberculous mycobacteria lung disease for bilateral bronchiectasis with nodules p. 178
Keisuke Watanabe, Masaharu Shinkai, Masahiro Shinoda, Takeshi Kaneko
DOI:10.4103/ijmy.ijmy_38_18  PMID:29900897
Backgrounds: Bronchiectasis (BE) with nodules on chest computed tomography (CT) is one of the radiological findings of nontuberculous mycobacteria (NTM) lung disease. However, the NTM lung disease is not diagnosed in some patients who undergo bronchoscopy, though their radiological findings show BE with nodules. We need the indicator to distinguish the patients who would not be given the diagnosis of NTM lung disease with bronchoscopy. Methods: We retrospectively reviewed the records of the patients who underwent bronchoscopy from January 2010 to July 2013 at our hospital because sputum test had not yielded the diagnosis of NTM lung disease or the patients had been unable to produce sputum, though their chest CT had shown BE with nodules. Results: A total of 36 patients were included in this study, and acid-fast bacterium (AFB) culture of bronchial wash was positive in 17 patients. More patients with negative culture in bronchial wash had AFB-negative culture with purulent sputum before bronchoscopy (37% vs. 0%, P = 0.008) and bilateral BE with nodules on chest CT (89% vs. 41%, P = 0.007). Multivariate analysis showed that bilateral BE with nodules on chest CT was the risk factor for the negative culture of AFB with bronchial wash (odds ratio: 0.149; 95% confidence interval: 0.024–0.913, P = 0.040). Conclusion: Patients with bilateral BE with nodules on chest CT have less possibility to have positive AFB culture from bronchial wash when sputum test was not diagnostic.
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Positive outcome of pulmonary tuberculosis associated with extraordinary extensive extrapulmonary tuberculosis in an immunocompetent adult p. 183
Jitendra Singh, Anju Dinkar
DOI:10.4103/ijmy.ijmy_61_18  PMID:29900898
Tuberculosis (TB) is known to cause a wide variety of complications and atypical presentations. It usually presents with typical symptoms. Here, we present the unusual case of pulmonary TB with the involvement of lungs, brain, liver, spleen, vertebra, skin, left cervical lymph nodes, bone marrow, and heart. It is unique with this case of disseminated TB presenting in squall and decimating manner involving many different organs simultaneously in an immunocompetent patient who was treated successfully with antitubercular treatment. According to literature review, this is the first case report of this type especially from an endemic country like India.
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“Fleeting pulmonary infiltrates in allergic bronchopulmonary aspergillosis” Misdiagnosed as tuberculosis p. 186
Shital Patil, Rajesh Patil
DOI:10.4103/ijmy.ijmy_57_18  PMID:29900899
Allergic bronchopulmonary aspergillosis (ABPA) is underdiagnosed and underevaluated routinely because of clinical and radiological overlap with tuberculosis (TB), especially in tropical setting with high TB burden countries like India. ABPA is the best-recognized manifestation of Aspergillus-associated hypersensitivity to Aspergillus antigens in patients with long-standing atopic asthma. ABPA with varied clinical presentation has been reported to occur in 20% of asthmatic patients admitted to hospitals and in 5% of all rhinitis cases. In this case report, we documented middle age male with known asthma case for many years with constitutional symptoms such as cough, fever, and shortness of breath diagnosed as TB and received anti-TB treatment for 4 weeks. Finally, we confirmed as a case of ABPA and documented complete clinical and radiological response to medical treatment with antifungals and systemic corticosteroids.
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Erythema nodosum leprosum presenting as sweet's syndrome-like reaction in a borderline lepromatous leprosy patient p. 191
Nyoman Suryawati, Herman Saputra
DOI:10.4103/ijmy.ijmy_49_18  PMID:29900900
Erythema nodosum leprosum (ENL) is characterized by tender erythematous nodules, accompanied by fever, malaise, arthralgia, and systemic complications. Atypical clinical manifestations have been reported such as pustular, bullous, ulceration; livedo reticularis; erythema multiforme-like reaction; and Sweet's syndrome (SS)-like presentation. We reported a case of ENL reaction presenting as SS-like reaction in a borderline lepromatous leprosy patient.
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Acute scrotum: Hansen's disease versus filariasis p. 195
Deepak Vashisht, Bhavni Oberoi, Ruby Venugopal, Sukriti Baveja
DOI:10.4103/ijmy.ijmy_60_18  PMID:29900901
Hansen's disease is caused by Mycobacterium leprae. The disease is known to involve the visceral organs including the testis apart from the skin and nerves in the lepromatous pole of leprosy due to widespread hematogenous dissemination of lepra bacilli. Furthermore, there can be testicular pain during the type 2 reaction in Hansen's disease. Filariasis is a disease caused by the parasitic nematode, Wuchereria bancrofti. This infection most commonly results in lymphedema and secondary vaginal hydrocele with an associated epididymo-orchitis. Acute epididymo-orchitis is either seen in the acute phase or as a part of secondary bacterial infections. The particular interest of this paper is to report the case of Hansen's disease who presented with testicular pain and posed a diagnostic dilemma when his pain did not respond to the standard mode of treatment and an alternate rare diagnosis was sought. This case report also emphasizes the need of reconsideration of diagnosis when the patient is not responding to standard therapy.
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Peritoneal tuberculosis or carcinomatosis: A diagnostic conundrum p. 198
Pankaj Gupta, Surinder Rana, Parimal Agarwal
DOI:10.4103/ijmy.ijmy_62_18  PMID:29900902
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Pneumoperitoneum in treated abdominal tuberculosis: Not always paradoxical worsening p. 200
Harshal S Mandavdhare, Ujjwal Gorsi, Pankaj Gupta, Vishal Sharma
DOI:10.4103/ijmy.ijmy_59_18  PMID:29900903
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