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ABSTRACTS OF PAPERS PRESENTED AT THE 68TH RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY, 12TH JULY 1999, 2.30 PM IN THE SP JAIN CAFETERIA (CONVENOR DR. HL DHAR)

1.MULTIDRUG RESISTANT SALMONELLA TYPHI - IN BOMBAY

Sweta Chomal, Lina Deodhar


Typhoid fever is a world wide problem and widely prevalent in the developing countries. Typhoid fever occurs in two epidemiological types. The first is the endemic or residual typhoid that occurs throughout the year, and the second is the epidemic typhoid, which may occur in endemic or nonendemic areas. The disease is caused by gram negative bacillus, Salmonella typhi (S. typhi) and the infection is acquired by ingestion.

Typhoid fever is known to occur in all age groups, bacteriological diagnosis of typhoid fever consists of the isolation of S. typhi from the patient's blood and/or demonstration of antibodies in the blood. Bacteraemia occurs early in the disease and blood cultures are positive in approximately 90% of cases in the first week of fever while antibodies are produced by the end of the first week.

In last one and half years period, we received 3900 blood cultures. Blood cultures were processed by using BACTEC 9050. Out of a total of 523 positive blood cultures, 120 S. typhi strains were isolated.

Identification of S. typhi was based on the following :

1. Gram's staining.

2. Cultural characteristics on blood and macConkey agar media.

3. Biochemical reactions and

4. Agglutination by using polyvalent salmonella antisera.

Antibiotic sensitivity test was carried out by using standard methods. All S. typhi strains were found sensitive to ciprofloxacin while 77 (64%) strains were resistant to commonly used drugs like chloramphenicol, ampicillin, co-trimoxazole and tetracycline.

Salmonellosis continues to be a serious public health hazard in India. Due to the development of multiple drug resistance and atypical presentation especially in paediatric patients, typhoid fever is becoming increasingly difficult to diagnose. Hence blood culture studies are very useful in such cases.


2. BRAIN ABSCESS DUE TO PSEUDOALLESCHERIA BOYDII (A CASE REPORT)

Priya Miskeen, Lina Deodhar, AL Kirpalani

The common diseases of the central nervous system (CNS) include meningitis and space occupying lesion (SOL) of the brain which is either a granuloma, an abscess or a tumour. Brain abscess is caused by bacteria, fungi or parasites. The commonest microorganisms causing brain abscess include Staphylococcus aureus, Enterobacteriacae, Streptococci, mycobacteria, bacteroides, nocardia and some of the protozoan parasites like Toxoplasma gondii and Entamoeba histolytica. Several fungi like aspergillus, candida, Cryptococcus neoformans, Pseudoallescheria boydii, etc. are also responsible in causing brain abscess.

A male patient, 41 year old, underwent renal transplant in December, 1998. In April 1999, he was admitted in Bombay Hospital for headache and convulsions of few days duration. His MRI showed "changes in left frontal lobe of the brain suggestive of an infective granuloma". An aspirate from this lesion, sent in the month of April, revealed a fungal aetiology of the lesion. A second sample from the brain abscess was sent on 2nd June and this sample confirmed the earlier findings. The fungus was identified as 'Pseudoallescheria boydii'. The patient received amphotericin B and fluconazole but he expired within 7-10 days after the second aspiration was done. P. boydii is listed as an aetiologic agent of mycetoma but can cause infections in immunocompromised hosts. These include :

Meningitis, Keratitis, Arthritis, External otomycosis, Endocarditis and, Brain abscess

Microscopically the fungus is seen in the form of septate hyphae with single celled conidia near the tip. Culture grown on common laboratory media shows white fluffy colony and the reverse of the colony shows a brown colour changing to black.

P boydii is present in soil, manure and polluted water. Route of infection is aspiration of the fungus to the lungs producing pulmonary infection and then leading to dissemination of the fungus to the brain. Rarely this fungus can gain entry through fracture skull or paranasal sinuses.

P. boydii rarely affects the CNS and only 21 cases of brain lesion have been reported in the world literature. This fungal infection of the brain carries a high mortality.

Antifungal therapy for 'P. boydii-brain abscess' is complicated by the fact that many strains are resistant to amphotericin B. The current drug of choice is miconazole, though ketoconazole is also recommended.


3.PREVALENT HEPATITIS 'C' VIRUS GENOTYPE IN A GROUP OF CHRONICALLY INFECTED PATIENTS

MJ Dhorda, SR Kankonkar, AL Kirpalani, DN Amarapurkar


To genotype hepatitis 'C' virus (HCV) in chronically infected patients. HCV RNA positive, non alcohol, non HBsAg related cases of chronic hepatitis patients were selected. These included patients with chronic renal failure (CRF) and other patients with a known history of multiple blood transfusions. Genotyping was performed in three steps-extraction of HCV RNA from serum sample and amplification of the well conserved five non-coding region (NCR), sequencing of the PCR product and thence, phylogenetic analysis to determine the genotype.

Preliminary results suggest that HCV genotype one is more common as compared to the other genotypes.


4.AN UNUSUAL KIDNEY TUMOUR

Anita Shah

A 65 year old man presented with a history of pain in the left flank accompanied by persisten haematuria. He had been operated 10 years ago for renal calculus (PCNL). Physical examination revealed tenderness in the left hypochondrium and a bimanually palpable hard mass in the left flank. The clinical impression was Xanthogranulomatous pyelonephritis. Left nephrectomy was performed. The patient died in the post operative period. the enlarged kidney weighed 340 gms and measured 11 x 8 x 5 cm. The external surface was markedly pale,smooth and mildly bosselated. Cut surface displayed a mildly dilated pelvi-calyceal system lined by haemorrhagic material. The surrounding parentchyma was pale, yellow-white with small islands of identifiable medulla in between. The hilar blood vessels were unremarkable and no enlarged lymph nodes were present. histopathology report showed small cell malignant tumor. The differential diagnosis includes carcinoma, malignant lymphoma. Immunohistochemistry profile: Cytokeratin 8+++, Epithelial membrane antigen+++. Leucocyte common antigen: negative. Final diagnosis was adenocarcinoma (high grade) left kidney.

5. CARCINOSARCOMA OF URINARY BLADDER : A RARE TUMOUR

Bharati Dora, Girish Muzumdar, Anita Shah, AR Chitale

A 50 year old female came with the history of low back ache, haematuria and burning micturition. She was a K/C/O ureterocoele. Cystoscopy showed a necrotic fungating mass filling the ureterocoele cavity. CT scan showed obstruction of distal part of right ureter by a tumour. Also there was extensive pelvic retroperitoneal and portal lymphadenopathy and multiple hepatic nodes S/o tumour metastasis. A trans urethral bladder tumour resection (TUBTR) was carried out.

Microscopically, the tumour showed sheets of epithelial cells (keratinized and non keratinized) and islands of chondrosarcomatous differentiation. The cartilage cells showed positivity for 5100 and vimentin while epithelial cells were positive for pan keratin. Thus the diagnosis was established as carcinosarcoma.

Carcinosarcoma of the urinary bladder is a rare malignant tumour, composed of mesenchymal and epithelial elements. It occurs predominantly in elderly males and is often in an advanced stage of presentation and rapidly becomes lethal. Gross haematuria, dysuria and urinary tract infections are the main presenting symptoms cytoscopically, the tumours appear as sessile, pedunculated or polypoid. Microscopically, the tumours consist of a varied mixture of transitional cell carcinoma/squamous cell carcinoma/adenocarcinoma with chondrosarcoma, osteosarcoma, rhabdomyosarcoma and undifferentiated spindle cell components. Diagnosis is confirmed by immunohistochemistry. These tumours are best managed by radical surgery with or without adjuvant therapy. However, the prognosis is very poor, 70% death rate with in 2 years.


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