Coupling of gene regulation and carrier modification manipulates bacterial biofilms as robust living catalysts

The biofilm of an engineered strain is limited by slow growth and low yield, resulting in an unsatisfactory ability to resist external stress and promote catalytic efficiency. Here, biofilms used as robust living catalysts were manipulated through dual functionalized gene regulation and carrier modification strategies. The results showed that gene overexpression regulates the autoinducer-2 activity, extracellular polymeric substance content and colony behavior of Escherichia coli, and the biofilm yield of csgD overexpressed strains increased by 79.35 % compared to that of the wild type strains (p < 0.05). In addition, the hydrophilicity of polyurethane fibres modified with potassium dichromate increased significantly, and biofilm adhesion increased by 105.80 %. Finally, the isoquercitrin yield in the catalytic reaction of the biofilm reinforced by the csgD overexpression strain and the modified carrier was 247.85 % higher than that of the untreated group. Overall, this study has developed engineered strains biofilm with special functions, providing possibilities for catalytic applications.

POS0818 SOUTHEND PRE-TEST PROBABILITY SCORE AND HALO SCORE AS MARKERS FOR DIAGNOSIS AND MONITORING OF GCA: EARLY RESULTS FROM THE PROSPECTIVE HAS-GCA STUDY

Background

Ultrasound (US) is recommended as the first line imaging test in patients with suspected Giant Cell Arteritis (GCA). Traditionally, the US halo sign has been used for diagnosis. We have recently described a composite Halo Score that allows to quantify vascular inflammation on US. Prospective studies on response and disease monitoring are lacking.

Objectives

To prospectively assess the role of US in diagnosing and monitoring GCA patients. We report early baseline and 12-month data on our current recruitment in a study that has suffered disruption from the pandemic.

Methods

HAS GCA (IRAS#264294) is an ongoing, prospective, multicentre study recruiting from referrals of suspected GCA to fast-track clinics. Based on the Southend GCA clinical pre-test probability score (SPTPS)1, patients were stratified in to low, intermediate and high risk categories2. Temporal and axillary US Halo Scores were calculated from the halo thickness and extent in bilateral temporal arteries, parietal and frontal branches (TAHS) and axillary arteries (AAHS). These scores were summed (TAHS x1 plus; AAHS x3) to generate a Total Halo Score (THS)3.

Mann Whitney U test was used to compare baseline features between GCA and controls. Wilcoxon signed rank test was used to evaluate disease features at baseline and at 12 months in GCA patients. Sensitivity (Sn), Specificity (Sp) and ROC curve were calculated, where applicable. P value <0.05 is statistically significant

Results

202 patients (71 GCA, 131 controls) have been recruited thus far: 23 completed 12-month follow up assessment; 6 were lost to follow up (4 died, 2 withdrew consent due to pandemic). Demographics, clinical features, and US results are shown (Table 1).

Table 1.

Baseline features of GCA patients and controls

GCA (n=71)Controls (n=131)P-valueAge, median (IQR)75 (70-81)68 (62-76)0.001Female, n (%)38 (54)89 (68)0.05SPTPS category, n (%) Low risk0 (0)59 (45)<0.001 Intermediate risk16 (23)49 (37)0.04 High risk55 (77)23 (18)<0.001Halo score (HS), median (range) Temporal artery HS12 (0-22)2 (0-17)<0.0001 Axillary artery HS12 (0-21)6 (0-18)<0.0001 Total HS21 (2-40)8 (0-29)<0.0001Clinical features, n (%) Temporal headache53 (75)93 (71)0.62 Scalp tenderness36 (51)40 (31)0.006 Jaw claudication38 (54)9 (7)<0.001 PMR symptoms29 (41)35 (27)0.06 Constitutional symptoms42 (59)29 (22)<0.001 Visual disturbance40 (56)58 (44)0.11 Vision loss21 (30)9 (7)<0.001

AA, axillary artery; GCA, Giant cell arteritis; TA, Temporal artery

Among GCA patients, 50 had cranial, 5 large-vessel and 16 mixed phenotypes. Diseases were diagnosed by US and additional tests such as PET CT.

Jaw claudication (54%) and constitutional symptoms (59%) were the dominant features in GCA patients. Median age was 75 years in GCA (54% females) and 68 years in controls (68% females). GCA and controls were stratified by SPTPS to Low risk (0% vs 45%; Sn-undefined, Sp-98), Intermediate risk (23% vs 37%; Sn-81, Sp-98) and High risk (77% vs 18%; Sn-98, Sp-91). Optimal SPTPS cut-off point was ≥12 (Sn-89, Sp-76).

Median THS was 21 in GCA and 8 in controls. Optimal cut-off Halo Score in diagnosis was TAHS ≥5 (Sn-89, Sp-86), AAHS ≥11 (Sn-55, Sp-75), THS ≥15 (Sn-79%, Sp-86%). Baseline Halo Score and CRP levels showed positive correlation (spearman rank correlation). Among the 23 patients who completed 12-months follow up, median TAHS, AAHS and THS reduced from 12 to 2, 12 to 6 and 21 to 10, respectively (Figure 1).

Conclusion

Along with SPTPS, Halo Score successfully discriminates GCA from non GCA mimics and. HS is effective in showing 12-month response. This score may be a useful marker to monitor GCA disease activity

References

[1]Laskou F et al. Clin Exp Rheumatol. 2019

[2]Sebastian A et al. RMD Open. 2020

[3]Sebastian A et al. BMC Rheumatol. 2020

Disclosure of Interests

Alwin Sebastian: None declared, Alessandro Tomelleri: None declared, Pierluigi Macchioni: None declared, Giulia Klinowski: None declared, Carlo Salvarani: None declared, Abdul Kayani: None declared, Mohammad Tariq: None declared, Diana Prieto-Peña: None declared, Edoardo Conticini: None declared, Muhammad Khurshid: None declared, Sue Inness: None declared, Jo Jackson: None declared, Kornelis van der Geest Speakers bureau: Roche, Grant/research support from: Mandema stipend, Bhaskar Dasgupta: None declared

[Cotton Leaf Curl Multan Betasatellite as a Tool to Study the Localization of Geminiviruses in Plants]

Cotton leaf curl Multan betasatellite (CLCuMB) is a ubiquitous betasatellite commonly found along with cotton leaf curl disease (CLCuD) associated begomoviruses in the Old World. It has a promiscuous replicative nature and trans-replicated by a diverse range of geminiviruses. CLCuMB encodes a single ORF, βCl, in the complementary direction and has pathogenicity, symptoms determinant, suppressor of post-transcription and transcription gene silencing functions. After substituting the βC1 gene with the target gene, it has been used successfully as a gene delivery vector. In the present study, the βC1 gene of CLCuMB was substituted with the green fluorescent protein (GFP) gene, and the resulting construct utilized as a reporter vector to decipher in planta localization of geminiviruses. The recombinant CLCuMB expressing GFP (CLCuMB-GFP) was co-inoculated to Nicotiana benthamiana plants either with Cotton leaf curl Kokharan virus (CLCuKoV) alone or in a combination with the wild type CLCuMB to investigate the objectives of the study. Results showed that CLCuKoV successfully supported the replication and systemic movement of CLCuMB-GFP either alone or in the presence of wild type CLCuMB. The presence of CLCuMB-GFP was readily detected with PCR and Southern blot hybridization. The modified CLCuMB may serve as a tool useful for in planta localization of geminiviruses.

The antisense 5' end of the V2 gene confers enhanced resistance against the monopartite begomovirus cotton leaf curl Kokhran virus-Burewala strain

Whitefly-transmitted viruses of the genus Begomovirus (the family Geminiviridae) have become a limiting factor for agricultural productivity in many warmer parts of the world. The economies of Pakistan and India have, since the early 1990s, suffered losses due to cotton leaf curl disease (CLCuD). The disease is caused by begomoviruses, the most important of which at this time is cotton leaf curl Kokhran virus strain Burewala (CLCuKoV-Bu), and a disease-specific betasatellite, cotton leaf curl Multan betasatellite (CLCuMuB). Efforts to minimize losses due to CLCuD rely mainly on the use of insecticides to kill the whitefly vector; no resistant cotton varieties are currently commercially available. The study described here has investigated RNA interference technology for its potential to yield resistance against CLCuKoV-Bu and three other begomoviruses; CLCuKoV, tomato leaf curl New Delhi virus (ToLCNDV) and Pedilanthus leaf curl virus (PeLCV). Three fragments of the virion-sense V2 gene of CLCuKoV-Bu were transformed into Nicotiana benthamiana in antisense orientation and transgenic lines expressing virus-specific short RNAs were assessed for their ability to yield resistance. Only CLCuKoV-Bu with the V2 sequence closest to the promoter was resistant. Inoculation of CLCuKoV-Bu with CLCuMuB into transgenic plants did not significantly affect the outcome, although viral DNA was detected in number of plants, suggesting that the betasatellite may impair RNAi resistance. Overall the results indicate that targeting the 5' end of V2 gene using antisense-RNA has the potential to deliver resistance against begomoviruses and that RNAi-based resistance imparts some degree of resistance to heterologous viruses. Keywords: geminivirus; begomovirus; RNAi; resistance; CLCuKoV-Burewala; CLCuMuB.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Outcome of adult patients with acute lymphoblastic leukaemia receiving the MRC UKALL XII protocol: a tertiary care centre experience

INTRODUCTION

Acute lymphoblastic leukaemia (ALL) is a heterogeneous group of lymphoid neoplasm resulting from the proliferation of malignant lymphoid cells. We aimed to study the outcome of adult patients with ALL receiving the Medical Research Council UKALL XII protocol.

METHODS

This was a retrospective study conducted at Aga Khan University Hospital from January 2001 to December 2008. The medical records of all adult patients were reviewed and analysed for clinical, morphological and immunological features at presentation and impact on treatment outcomes. Multivariate analysis and survival studies were performed using Kaplan-Meier statistics.

RESULTS

The total number of patients was 54, with a male to female ratio of 3.4:1 and a median age of 28 years. Common presenting symptoms were fever (n is 49) and bleeding (n is 14). 38 patients had haemoglobin less than 10 gms/dl, 21 had white blood cell (WBC) count of 50 × 10E9/L or more, and 35 had lactate dehyrogenase more than 1,000 IU. Morphologically, FAB-L2 was the commonest subtype, with 38 patients with B-ALL and eight with T-ALL. Multivariate analysis showed that age above 30 years, male gender, WBC count above 50 × 10E9/L and T-ALL subtype were independent risk factors for poor survival. 46 (85 percent) patients achieved complete remission. The median survival was 12.3 months. At the end of five years, 16 patients were alive, two were alive with disease and 14 were in complete remission.

CONCLUSION

Overall survival and relapse rates in our study were comparable to those reported internationally.

Molecular characterization of glucose-6-phosphate dehydrogenase deficiency in Pakistani population

INTRODUCTION

Glucose-6-phosphate dehydrogenase (G6PD; E.C. 1.1.1.49) deficiency is the commonest inborn error of metabolism with more than 140 genetic variants. The incidence of G6PD deficiency is 2-9% in Pakistan, but G6PD variants were never studied comprehensively. We therefore designed this study to describe the frequency of G6PD variants and their associated enzyme activities in Pakistan.

METHODS

Patients diagnosed with G6PD deficiency were enrolled. RFLP-PCR was utilized to identify common mutations previously reported from Asian countries. Where mutational analysis failed, amplification of 9-12 exons with subsequent gene sequencing was performed. G6PD enzyme activity was assessed through the quantitative enzyme assay.

RESULTS

Two hundred and seventy-six G6PD-deficient subjects (237 male and 39 women) were investigated. G6PD Mediterranean (563C-T) was the most common genetic variant (n=216 or 78%). G6PD Chatham (1003A-G) and G6PD Orissa (131C-G) were observed in 14 (5%) and two (0.7%) subjects respectively. A novel mutation 973 G-A with a predicated amino acid change of asp325asn was identified in exon 9. This was named G6PD Karachi after the place of origin of proband. Polymorphism in position 1311C/T was uniformly observed with all variants. Forty-three or 17% of DNA samples remained uncharacterized. Very low levels of G6PD enzyme activity was observed with 563C-T mutation.

CONCLUSION

We concluded that 563C-T was the commonest G6PD variant, while 1003A-G and 131C-G were less-frequent genetic variants of G6PD in Pakistani population. A novel genetic variant 973G-A was also identified. Very low levels of G6PD enzyme activity was seen with G6PD 563C-T. Mutational analysis failed in a significant proportion of samples warranting further work.

Thirty-four cases of esophageal perforation: the experience of a district general hospital in the UK

Esophageal perforation is uncommon and traditionally has a high rate of morbidity and mortality. Our aim was to perform a 13-year retrospective review of the cases managed in our district general hospital. Thirty-four cases of esophageal perforation diagnosed between 1995 and 2008 were retrospectively analyzed. There were 20 males and 14 females with a median age of 64 (range 23-86) years. The etiology of the perforations were Boerhaave's syndrome (n= 19), therapeutic endoscopy (n= 9), diagnostic endoscopy (n= 2), gastric lavage injury (n= 1), foreign body (n= 1), blunt chest trauma (n= 1), and spontaneous tumor perforation (n= 1). Only 11 cases (32%) had evidence of surgical emphysema upon examination. In 50% of cases, another clinical diagnosis was initially suspected. Twenty-four were treated surgically and 10 cases managed non-operatively. Surgical treatment included thoracotomy with primary repair (n= 9), T-tube drainage (n= 7), emergency esophagectomy (n= 1), or intra-operative stent insertion (n= 1). Four cases had primary repair and fundal wrap via abdominal approach without thoracotomy. Two patients were treated with washout and drainage only. Eight patients died overall (in-hospital mortality 23.5%). Esophageal perforations are often initially misdiagnosed and the majority do not have surgical emphysema. There are a wide variety of methods to manage esophageal perforation. Management tailored to the location and size of perforation, degree of contamination, and underlying cause appears to result in a reasonable prognosis.

Chronic phase chronic myeloid leukemia: response of imatinib mesylate and significance of Sokal score, age and disease duration in predicting the hematological and cytogenetic response

OBJECTIVE

To evaluate the response of imatinib mesylate in chronic phase of chronic myeloid leukemia and to observe the significance of Sokal score and various factors which predict the response.

METHODS

This was a descriptive, prospective study conducted from May 2001 to September 2006. One hundred and thirty six patients with diagnosis of chronic myeloid leukemia in chronic phase were analyzed. Hematologic and cytogenetic responses were assessed according to defined criteria.

RESULTS

The median age at time of diagnosis was 33 years (range, 12-65 years). Among them 86 were males, 50 were females. At the end of study response was analyzed overall and according to Sokal score. At median follow-up of 18 months, 122 patients were evaluable for cytogenetic response. Complete hematologic response was seen 86% while complete and major cytogenetic response was observed in 34.4% and 49.2% cases respectively. Analysis of variables like younger age, disease duration at time of starting imatinib failed to show any significant influence on response to imatinib mesylate, however, response was found to be higher in patients who had low Sokal score at the time of presentation.

CONCLUSION

Imatinib mesylate has substantial activity in chronic phase of CML. Low Sokal score at time of presentation predict the higher hematologic as well as cytogenetic response in patients with chronic phase.

Cardiac disease in beta-thalassaemia major: Is it reversible?

INTRODUCTION

The aim of this study was to evaluate the spectrum of cardiac involvement and its outcome in beta-thalassaemia major.

METHODS

There were 75 patients with a mean age of 13.8 (+/- 5.5) years, of whom 33 were male and 42 were female. Clinical history, examination and laboratory investigations were assessed. Electrocardiograms, chest radiographs and echocardiograms were reviewed.

RESULTS

44 patients had cardiac involvement in the form of left ventricular systolic dysfunction in 17, diastolic dysfunction in 22, pericardial effusion in 12 and pulmonary hypertension in 12 patients. With intense chelation therapy and cardiac medications, the condition of 13 of 17 patients with systolic dysfunction, and four of 22 with diastolic dysfunction, improved.

CONCLUSION

Cardiac disease is a common complication of siderotic disease in thalassaemia major and it can be prevented with regular chelation. This study has shown improved systolic function after regular chelation therapy.

Flow cytometric and demographic analysis of t cell acute lymphoblastic leukemia in Pakistani population

BACKGROUND

This study was carried out to analyze the proportion of T cell acute lymphoblastic leukemia (TALL) among all acute lymphoblastic leukemia (ALL) in Pakistani population and its correlation with the demographic features. Accuracy of cell surface markers used in flow cytometric analysis of the leukemic cells was also determined.

METHODS

Data of 209 consecutive cases of acute lymphoblastic leukemia (ALL) presenting between July 1995 and July 2003 was analyzed. Flow cytometry was performed on all ALL cases using the standard protocols. TALL markers included CD3, CD5 and CD7.

RESULTS

Proportion of TALL among known ALL Pakistani patients was 17.22%. Mean age of the TALL patients was 17.2 years. Proportion of TALL was higher in adults than in children (21.95% vs. 14.17%). Overall in this study there were more male patients affected by TALL (25/36 or 69.40%) than females (11/36 or 30.60%). The female to male ratio among TALL patients was 1:2.27. However, the proportion (%) of TALL in females was higher than males (18.96% vs. 15.82 %) i, e, 1.2:1. CD7 was found to be the most sensitive among both adults & children. It was positive in 94.4% of the TALL cases.

CONCLUSION

Proportion of TALL among ALL in Pakistan is similar to that reported in this region, indicating a candidate association with geographical location and socioeconomic status. The reactivity of markers with TALL. cells was similar to what we expected based upon literature. However, due to some aberrant and cross reactivity displayed by each marker, we strongly recommend a panel approach including B and myeloid markers to ensure a correct diagnosis of TALL.

Frequency of hereditary thrombophilia: an AKUH experience

OBJECTIVE

To determine the frequency of various causes of hereditary thrombophilia at a referral laboratory and the age and gender distribution.

METHODS

This is a descriptive study incorporating a retrospective analysis of requests for thrombophilia screening sent to Clinical laboratory, Aga Khan University Hospital from November 1995 to May 2002. Patients were screened for hereditary causes of thrombophilia including Protein C, Protein S, antithrombin III, Factor V Leiden and homocysteine. Frequency of each disorder; and age and sex distribution was determined.

RESULTS

All the patients suspected clinically for thrombophilia were screened. Of the 2825 patients, 70 were diagnosed to have inheritance as a cause of thrombophilia with a frequency of 2.3% for protein C deficiency, 1.4% for protein S deficiency, 1.5% for antithrombin III deficiency, 14.2% for factor V leiden mutation and 2.0% for homocystenemia.

CONCLUSION

All the causes of hereditary thrombophilia can be diagnosed by relatively simple laboratory methods, however because of the low frequency of these disorders the screening of general population is not indicated in the absence of clinical symptoms. More prospective studies are required to define the occurrence of these disorders and other causes of thrombosis.

Increased expression of HLA DR2 in acquired aplastic anemia and its impact on response to immunosuppressive therapy

OBJECTIVE

To study the frequency of HLA DR2 status of patients with aplastic anemia and their response to immunosuppressive therapy at a tertiary care hospital.

METHODS

Thirty eight consecutive patients of acquired aplastic anemia were evaluated with respect to demographic features, severity of HLA DR2 status and response outcome to immunosuppressive therapy.

RESULTS

The mean age of the patients was 24.6 years + 16.4 with a male to female ratio of 2.8:1. Positivity of HLA DR2 was markedly high in acquired aplastic anemia patients. Twenty four (65%) out of 38 patients as compared to 45 (15%) of 300 healthy controls (p<0.0001) were positive for HLA DR2. Response to immunosuppressive therapy, which included antilymphocyte globulin, cyclosporin and methylprednisolone, was available in sixteen HLA DR2 positive patients and was found satisfactory in 12/16 (75%) patients.

CONCLUSION

HLA DR2 was significantly higher in patients with acquired aplastic anemia and favourable response to immunosuppressive therapy was also associated with HLA DR2 positivity.

Pulmonary infiltrates during chemotherapy-induced febrile neutropenia: incidence, patterns and outcomes

OBJECTIVE

To analyze the incidence, etiologies, radiographic patterns, and clinical outcomes of adult leukemics with prolonged febrile neutropenia and pneumonia.

METHODS

A retrospective study was conducted at a tertiary care hospital. The medical records of adult patients with acute myeloid leukemia diagnosed between January 1989 and June 2000 and undergoing induction chemotherapy were included. Only the patients who presented with a pulmonary infiltrate, secondary leukemia (e.g., transformed chronic myeloid leukemia underlying myelodysplastic syndrome, or disease following alkylating agent therapy) were included and those developing infiltrates following consolidation chemotherapy were excluded.

RESULTS

A total of 124 patients were admitted to the hospital with a diagnosis of AML during the study period. Thirty-one patients were excluded; 93 patients received induction chemotherapy and were included in the study analysis. The median age was 36 years (15 - 70 years); 58 males and 35 females. Sixty two percent patients received Cytosine Arabinoside (Ara-C), 17% received Etoposide, 11% received Ara-C and Mitoxantrone, and 6% received All-trans-retinoic Acid. The mean onset and duration of neutropenia were 5 and 15 days, respectively. Pulmonary infiltrates were identified during 45% of neutropenic episodes. A presumptive causative organism was isolated from 50% of patients with an infiltrate: Gram-positive bacteria were most common (47%) followed by Gram-negative bacilli (33%) and fungi (20%). Survival data were available for 88 patients; median disease free survival for the entire cohort was 7 months. Male sex (p=0.015), onset of neutropenia (p=0.02) and bilateral distribution of an infiltrate (p=0.03) were statistically significant predictors of early mortality. For patients with and without pneumonia, the median disease-free interval and overall survival were 2.5 and 4.6 months and 9 and 13 months (p=0.038 and p=0.095) respectively.

CONCLUSION

Neutropenia occurred at a mean of 5.0 after initiation of induction chemotherapy. The majority of patients had bilateral pulmonary infiltrates. Male sex, onset of neutropenia and bilateral distribution of an infiltrate were found to be statistically significant predictors of early mortality.

Polycythemia vera and idiopathic erythrocytosis: comparison of clinical and laboratory parameters

OBJECTIVE

To evaluate the various clinical and laboratory parameters of Polycythemia vera and idiopathic erythrocytosis in order to differentiate between two entities at the Aga Khan University Hospital.

METHODS

Twenty six patients of polycythemia vera and 34 patients of idiopathic erythrocytosis were analyzed with respect to clinical features and laboratory findings.

RESULTS

Patients with idiopathic erythrocytosis were males with a mean age of 41 years and no splenomegaly. Patients with polycythemia were older males and females with splenomegaly, red cell count of mor than 6.5 million/cmm, haematocrit 55%, leucocytosis, thrombocytosis and low erythropoietin level.

CONCLUSION

Based on the above-mentioned findings, we suggest that polycythemia vera and idiopathic erythrocytosis are separate entities and the diagnosis of these can be made on the basis of clinical and laboratory parameters.

Prevalence of hepatitis C virus in lymphoproliferative disorders

OBJECTIVE

To study the prevalence of hepatitis C virus in lymphoproliferative disorders.

METHODS

A case control prospective study was performed on 143 patients with lymphoproliferative disorders and 29 patients with non-hematological malignancies were taken as controls. All the patients in both groups were analyzed for various risk factors for infection with hepatitis C virus and were tested for the presence of hepatitis C virus antibody (anti HCV), cryoglobulins and rheumatoid factor antibody. Hepatitis C viremia was documented by detection of HCV RNA by polymerase chain reaction.

RESULTS

There was no significant difference for risk factors for hepatitis C virus infection in both the groups except for the increase in number of surgical procedures being carried out in the control group. There was no significant difference in the presence of rheumatoid factor antibody in both the groups and cryoglobulins were not positive in any individual. Five percent patients with lymphoproliferative disorders and 3.4% with non-hematological malignancies were positive for anti HCV. HCV RNA was detected in 29.2% cases and 31.0% in controls.

CONCLUSION

There was no association between hepatitis C virus infection and lymphoproliferative disorder in our population. However, further studies are required from this region to establish any causal relationship between hepatitis C virus infection and lymphoproliferative disorder.

Hematologic and cytogenetic findings in eleven chronic myelogenous leukemia patients treated with imatinib mesylate at a tertiary care hospital

OBJECTIVE

To evaluate the response of Imatinib mesylate in patients with myeloid leukemia in chronic accelerated and blast phase.

PATIENTS AND METHODS

Eleven patients with established diagnosis of chronic myeloid leukemia were treated with Imatinib mesylate. Adverse events were documented with regular follow ups. Hematological and cytogenetic responses were assessed according to established criteria. Patients with zero percent Philadelphia positive metaphases were labeled as complete cytogenetic response while patients with 1% to 35% Philadelphia positive metaphases were termed as partial responders.

RESULTS

Of 11 cases there were 7 males and 4 females with a mean age of 39.5 years and median age 51 years (range 21-69). Male to female ratio was 7:4. Median follow-up was 34 weeks (range 8-78). Four patients were in blast crisis, 1 in accelerated phase and remaining six patients were in chronic phase. All patients achieved hematological response. Cytogenetic response was present in six patients, 3 were responders and the remaining were non responders. Two patients achieved complete cytogenetic response and one patient had partial cytogenetic response. Both patients with complete cytogenetic response relapsed in twelve weeks time.

CONCLUSION

Imatinib mesylate is a drug with curative potential and can be used as a first line drug in the management of CML, however at present the cure rate is unknown.

Use of intravenous anti-D in patients with refractory and relapsed immune thrombocytopenic purpura

OBJECTIVE

To determine the response to i.v. anti-D and its comparison with splenectomy as second line therapy in refractory and relapsed cases of ITP, in the Aga Khan University Hospital, Karachi.

METHODS

A total of 23 patients with chronic ITP were treated with either anti-D or splenectomy as second line treatment. The patients were assessed for time to achieve a response to second line treatment, duration of response and adverse events.

RESULTS

There were 12 patients in the anti-D group and 11 in the splenectomy group. The mean platelet count at presentation was 9,000/cumm. The mean age was 8.9 years and 13.0 years and the male to female ratio was 1:1 and 1:1.2 in anti-D and splenectomy group respectively. 54.5% of the patient in the anti-D group responded compared to 81.8% in the splenectomy group. Median time to achieve a response was 7 days in the anti-D group and 1 day in the splenectomy group. Mean time to relapse was 87.8 days in the anti-D group and 55.4 days in the splenectomy group. No adverse events were recorded for any of the infusions of anti-D and none of the patients had more than 0.5 gm/dl fall in the hemoglobin level following anti-D infusion.

CONCLUSION

It was thus concluded that Anti-D is a relatively safe, convenient and effective therapy for chronic ITP and can be used as a splenectomy sparing agent when treatment is clinically indicated.

Outcome of adult acute lymphoblastic leukemia: a single center experience

OBJECTIVE

To study the outcomes of adult patients with acute lymphoblastic leukemia.

SETTING

Tertiary care hospital.

STUDY DESIGN

Retrospective analysis.

METHODS

Fifty eight adult patients (age >14 years) diagnosed as cases of acute lymphoblastic leukemia were studied with respect to their clinical, morphological and immunopathological features at presentation and their relationship with treatment outcomes.

RESULTS

Forty five (77.5%) of the patients belonged to younger age group with male preponderance. The median age was 20 years and mean age was 25.1 years. Male to female ratio was 3:1. Common presenting signs were lymphadenopathy (17.2%), hepatomegaly (32.7%) and splenomegaly (62%). Laboratory features at presentation revealed: hemoglobin > or = 10 gm/dl in 18 (31%), WBC >50 x 10E9 / L in 18 (31%), LDH more than 1000 IU/L in 44 (75.8%) of patients. Morphology revealed that FAB L1 was seen in 21(37.2%) and L2 in 62 (32.7%). Immunophenotyping showed that 26 (61.9%) were early pre-B ALL, 6 (14.2%) were pre-B ALL and T-ALL were 10 (23.8%). Univariate analysis showed age more than 30 years, male gender, total leucocyte count >50 x 10(9)/L and hemoglobin more than 10 gm/dl to be risk factors for poor outcome. Multivariate analysis revealed age more than 30 years, male sex and total leucocyte count > 50 x 10(9)/L are independent risk factors for poor survival. Patients were treated according to the MRCUKX and XII adult protocols. Thirteen (22.4%) patients died during induction therapy secondary to sepsis and progressive disease whereas 42 (72.4%) patients achieved complete remission. Median survival was 18.6 months and 42% patients were alive at 5-years.

CONCLUSION

Overall survival and disease free survival were comparable to those reported in literature. However, age more than 30 years, male gender and total leucocyte count >50 x 10(9)/L had an adverse impact on overall survival.

Chromosomal abnormalities as a cause of recurrent abortions: a hospital experience

OBJECTIVE

To analyze the chromosomal abnormalities in couples with history of recurrent abortions.

DESIGN

Retrospective study.

SETTING

Cytogenetic section, Department of Pathology at the Aga Khan University Hospital, Karachi, Pakistan.

PATIENTS

Three hundred couples with history of recurrent abortions.

MAIN OUTCOME MEASURE

Structural chromosomal abnormalities in carrier couples.

RESULTS

G-banded chromosomes were analyzed from both partners of 300 couples who had had two or more spontaneous abortions. Sixteen (5.3%) couples showed a chromosomal aberration in one of the partners. Seven translocations, 5 inversions, 2 deletions and 2 sex chromosomal abnormalities were identified. There was an increase in structural aberations, which was not significantly different from that reported worldwide.

CONCLUSION

Chromosomal analysis is advocated as a primary tool in the evaluation of couples with repetitive fetal wastage.

Long-term outcomes of acute myeloid leukemia in adults in Pakistan

OBJECTIVE

To describe the long-term outcomes of Acute Myeloid Leukemia (AML) and to study clinicopathological features at presentation, morphological subtypes and remission rates.

METHODS

Demographic information, response to therapy and survival of patients (>14 years of age) admitted between January 1988 to August 1996 with acute myeloid leukaemia was retrieved and analysed.

RESULTS

Seventy-four patients were admitted with a diagnosis of AML during the study period. There were 43 males and 31 females. Age ranged between 15 and 70 years with a mean age of 38 years. The most common presenting feature was fever (67.5%) and the morphological subtype according to French-American-British Group (FAB) criteria was M4. Fifty-five patients received treatment and were evaluable for response and outcomes. Thirty-six (65.4%) patients had complete remission. Sixteen (29.1%) died during the first 28 days after starting induction chemotherapy. The median survival was 11 months. Six (11%) patients (4 females, 2 males) are surviving beyond 4 years (long-term survivors).

CONCLUSION

Our study suggests that the long-term outcomes of adults with AML are comparable to what has been reported in the literature for patients who do not receive bone marrow transplants.

Acute myeloid leukemia in children in Pakistan: an audit

OBJECTIVE

To see the clinical features and treatment of children with Acute Myeloid Leukemia (AML) in Pakistan.

SETTING

Tertiary referral at a specialist Hematology/Oncology center.

METHODS

Retrospective, chart-based review of children (less than 14 years) admitted to the hospital with a diagnosis of AML between January 1987 and August 1997.

RESULTS

A total of 23 patients were admitted. There were 18 males and 5 females. The mean age was 8 +/- 5 years. M3 was the commonest morphological subtype (43%). Twenty-two percent of the patients presented with hyperleucocytosis (TLC > 100 x 10(9)/L) and 95% with an elevated LDH (> 548 IU/L). Pneumonia at presentation was seen in 29%. Of 23 patients 14 were evaluable for responses. Six patients died early (43%); 3 before starting the chemotherapy and 3 during the induction chemotherapy, 8/11 (73%) patients entered remission. The median survival was 9 months.

CONCLUSION

The pediatric patients with acute myeloid leukemia present with advanced disease. There is a high early death rate (within 28 days of diagnosis). The long-term outcome was inferior to that reported in the literature.

Cancer patterns in Karachi division (1998-1999)

OBJECTIVE

A minimal cancer incidence data for Karachi, the largest city of Pakistan, is being presented here, for the years 1998-1999. The city has a population of 9,802,134; males 5,261,712 (52.6%) and females 4,540,422 (47.4%); census 1998.

METHODOLOGY

A predominantly mixed (passive and active) registration system has evolved in Karachi, the data sources being the hospitals within the Karachi Division. The reported/retrieved cancer data sets at the Karachi Cancer Registry are checked, coded, computerised in an analytical format and analysed.

RESULTS

The incident cancer cases registered in Karachi, during the 2-year period, 1st January 1998 to 31st December 1999 were analysed. The age-standardised incidence rate (ASR) of cancer, all sites was 132.4/100,000 for the males. Cancer of the lung 10.8%; ASR 17.3 was the most frequently recorded malignancy, followed by oral cavity 10.5%; ASR 13.2 and larynx 5.0%; ASR 7.4. The age-standardised incidence rate (ASR) of cancer, all sites was 133.0/100,000 in the females. Cancer of the breast, 32.0%; ASR 40.7 was the most frequently recorded malignancy, followed by oral cavity 8.1%; ASR 11.7 and gall bladder 3.6%; ASR 5.5.

CONCLUSION

The present data has been calculated with an estimated 15-20% probable under ascertainment. Tobacco-associated cancers in Karachi were responsible for 38.3% of the tumours diagnosed amongst the males. Two principal cancers, breast and oral cavity were responsible for 40.1% of the cancers in females. A rare finding was the high incidence of gall bladder cancer in the females. At present it is difficult to determine whether this indicates a genuine high risk or a selection bias. A continuous process of cancer registration to study the trends in the incidence and an adequate cancer control program are possible and essential for Pakistan and can be based on the pattern being practiced in Karachi.

Lack of benefit of granulocyte macrophage or granulocyte colony stimulating factor in patients with febrile neutropenia

OBJECTIVES

To compare the clinical benefits of granulocyte-colony stimulating factor (G-CSF) or granulocyte macrophage-colony stimulating factor (GM-CSF) plus standard supportive care to supportive care alone among cancer patients with febrile neutropenia.

METHODS

Clinical data were collected retrospectively from 148 consecutive cancer patients with neutropenia and fever. Patients had hematologic (i.e., acute leukemias or lymphoproliferative disorders) or non-hematologic malignancies (i.e., solid tumors including carcinoma of breast, lung, or colon). Clinical variables analyzed included: age and sex; underlying malignancies; chemotherapy regimens; symptoms at time of presentation; duration of fever prior to study enrollment; days from chemotherapy until administration of GM-CSF or G-CSF; number of previous neutropenic episodes; duration of fever and day of defervescence; absolute neutrophil count on day of defervescence; duration of neutropenia; number and types of antibiotics used; day amphotericin B begun; number of culture-documented infective episodes involving bloodstream, lung, pleura, urinary tract, gastrointestinal tract, intravenous cannulae, or skin; types of antimicrobial isolates; cost of cytokine therapy; length of hospital stay and clinical outcome.

RESULTS

The use of myeloid growth factors increased the number of circulating peripheral white blood cells, but no significant effect was noted in terms of duration of neutropenia or fever, number of culture-proven infections (except pneumonia; p < 0.04), length of hospital stay, or survival.

CONCLUSION

In areas with limited health care resources, expensive treatment with GM-CSF or G-CSF should be reserved for patients with complicated febrile neutropenia where the expected risk of infection is high and the duration of neutropenia is prolonged, or those with documented infections that are refractory to antibiotic treatment.

Epidemiological features of aplastic anaemia in Pakistan

OBJECTIVE

To complete the data on the demographic features of patients diagnosed to have aplastic anemia at a single institution over a 7.5 years period.

METHODS

Demographic information was retrieved from the patients medical records retrospectively as well as prospectively of those patients who presented with features of aplastic anaemia. Their diagnosis was confirmed by performing a complete blood count and bone marrow trephine.

RESULTS

One hundred and forty four patients were diagnosed to have aplastic anemia; there were 106 males and 38 females. Their ages ranged from 2 to 75 years, with a median of 17 years, 112 (77.7%) patients were below the age of 30 years. Severe aplastic anemia (SAA) was seen in 74 (51.4%), very severe (VSAA) in 24 (16.7%) and non-severe aplastic anemia (NSAA) in 46 (31.9%) patients. No obvious cause could be established for 74.3%. Thirteen patients admitted using drugs known to cause AA and one was a radiographer (9%). Out of 44 patients tested, 7 (15.9%) were found to have either hepatitis B virus markers or antibody to hepatitis C at the time of diagnosis of AA. However it was difficult to establish a cause and effect relationship with either drugs or viruses.

CONCLUSION

Aplastic anaemia is found to occur mostly in young males. The most common type was idiopathic severe aplastic anaemia.

Low-level lead exposure and blood lead levels in children: a cross-sectional survey

The authors studied 53 girls (44.5%) and 66 (55.5%) boys in Karachi, Pakistan, to determine their blood lead levels. The association between blood lead levels/water lead levels and the possible risk factors and symptoms associated with lead toxicity was explored. The mean lead level for the entire group was 7.9 microg/dl (standard deviation = 4.5 microg/dl). Thirty (25.2%) of the children had lead levels that exceeded 10 microg/dl; 12 (10.0%) of these had lead levels that exceeded 15 microg/dl. Thirteen (20.9%) of the children under the age of 6 yr (n = 62) had lead levels greater than 10 microg/dl, and 6 (9.6%) had levels in excess of 15 microg/dl. The authors found no association (p > .05) between high lead levels in water and blood lead levels in children. Mean blood lead levels were highest in the group of children exposed to various risk factors for lead absorption (e.g., exposure to paint, remodeling, and renovation; use of lead utensils; pica). There was a significant association between a history of exposure to paint/renovation activities and a history of pica. High blood lead levels in the children in Karachi stress the urgency for actions that control lead pollution. Screening programs should be instituted by the state. Individuals must become aware of lead's toxicity, and they must avoid substances that contain lead.

Flow cytometric analysis of childhood leukemias

OBJECTIVE

To collect demographic data for childhood (less than 15 years) leukemias in Karachi, describe the accuracy of the cell surface markers routinely used in the flow cytometric analysis of leukemic cells and arrive at an ideal panel of antibodies for analyzing leukemic samples.

MATERIALS AND METHODS

Data from 62 consecutive cases of childhood leukemias referred to the Department of Pathology, Aga Khan University Hospital, (AKUH) between January 1995 and December 1998 was analyzed using Epi Info Version 6. Flow cytometry on all samples was performed using standard protocols.

RESULTS

The mean age of patients was 8.2 years and 49 (79%) were males. Fifty (81%) had acute lymphoblastic leukemias of which 50% were CD10 positive and 24% CD10 negative Pre-B cell leukemias. Among all Pre B cell All 98% were positive for CD19, 96% for CD22, 89% for HLA-DR and 67% for CD10. Of the 10 AML cases, 100% were positive for CD33, 90% for CD13, 80% for CD19 and 70% for HLA-DR.

CONCLUSION

The mean age in this study population was significantly higher and percentage of CD10 positive Pre-B All is lower than that in the West. Both these factors might be responsible for the poorer prognosis of these patients. It is not possible to specify a minimum or maximum panel of antibodies that should be used for phenotyping all cases of childhood leukemias. A certain degree or redundancy is essential in any panel of antibodies used for flow cytometry of leukemias.

Prevalence of hepatitis G virus in Pakistani children with transfusion dependent beta- thalassemia major

We ought to obtain data on the prevalence of the newly discovered tranfusion transmittable hepatitis G virus in polytransfused b- thalassemia major children. Each individual had received multiple blood transfusions, from 12 to 36 per year. No documentation of prior hepatic infection was available. Serum samples were collected prospectively from the randomly selected subjects and were analyzed for HGV RNA by polymerase chain reaction using primer specific for two different regions of the HGV genome. Among the 100 individuals examined 21 were positive for HGV RNA. Four patients had evidence of dual infection, both HGV RNA and HCV RNA were isolated from their sera. While in one sample presence of both HGV RNA and HBV DNA was established. Only one child was positive for hepatitis E antibodies. The sera of 10 children were reactive for hepatitis B surface antigen whereas 35 individuals were positive for hepatitis C virus antibody. The ALT levels were variable in HGV infected children. Four out of 16 (25%) showed peak ALT levels of 218 IU/I, 8/16 (50%) children demonstrated slightly elevated ALT levels whereas 25% individuals showed normal ALT levels. Alkaline Phosphatase levels were elevated in 90% of the children and 20% patients of this series also had higher GGT levels. The observed AP levels were not statistically different among HGV, HGV/HCV or HGV/HBV groups. Even though the ALT levels were deranged in the children with HGV alone but none of the children had demonstrated symptoms of liver disease, their direct and total bilirubin levels were normal and no complain of jaundice was recorded. In conclusion, our findings suggested that like other blood borne hepatic viruses, HGV is also prevalent in the high risk group of multiple transfused patients in Pakistan but our results support the absence of any causal relationship between HGV and hepatitis.

Results of faculty evaluation at the Aga Khan University, Karachi, Pakistan

OBJECTIVE

The aim of the retrospective correlational analysis was to identify the attributes valued most by students for assessing the overall effectiveness of a teacher.

METHODS

Responses of the students to the two versions of evaluation questionnaires, each attempting to assess 4 and 8 characteristics respectively on a scale of 1-5 were included in the analysis. The third and fourth year students, at the end of each course/module completed a total of 2110 evaluation forms, which were studied.

RESULTS

The over all effectiveness of the teacher showed statistically significant correlation of .914 and .895 with ability to communicate ideas effectively and clarity and organisation of the lectures. Whereas the knowledge of subject and the successful use of teaching aids showed a correlation of .658 and .637 with a statistical significance of P < .01.

CONCLUSION

Students need a basic outline of what they have to learn and guidance to plan their studies.

The spectrum of bacterial infections in febrile neutropenic patients: effect on empiric antibiotic therapy

The aim of this retrospective analysis was to look at the spectrum of bacterial isolates and their resistance patterns to the commonly used antibiotics in the setting of febrile neutropenia. A total of 127 bacteria were isolated from patients with acute leukemias, lymphoproliferative disorders, aplastic anaemia and various solid tumours. Fifty-four percent organisms were gram negative; while the rest were gram positive. E. coli, pseudomonas aeruginosa, staphylococcus aureus, enterococcus and streptococci were the commonly isolated organisms. Forty-eight percent organisms were isolated from blood, 16% from urine, 13% from wounds and superficial abscesses and 11% from respiratory tract. E. coli exhibited a great degree of resistance to the commonly used antibiotics, such as pipericillin (70%), ofloxacin (50%) and aztreonam (50%). Pseudomonas and klebsiella also showed varying degree of resistance against the antibiotics. Staphylococcus aureus and staphylococcus epidermidis were almost universally resistant to penicillin and showed a variable degree of resistance to other antibiotics too. Compared to the previous reports, the pattern of bacterial isolates and their resistance to antibiotics has changed over the past years. Aminoglycosides and third generation cephalosporins seem to be the choice of antibiotics for the upfront management of febrile neutropenic patients.

HIV antibody seroprevalence and associated risk factors in sex workers, drug users, and prisoners in Sindh, Pakistan

OBJECTIVE

To determine prevalence of HIV infection and risk behaviors in commercial sex workers (CSWs), drug users, and prisoners in Sindh, Pakistan.

METHODS

A medical clinic was established in a "red-light" district of Karachi. Eighty-one CSWs who registered at the clinic between November 1993 and June 1994 were provided HIV counseling and testing and administered a risk factor questionnaire. Next, 316 male drug users were tested for HIV-1 antibody from April to July 1994. Finally, a voluntary serosurvey of HIV-1 and HIV-2 and risk behaviors of 3525 prisoners in Sindh was conducted between July 1994 and December 1994. Abbott Recombinant HIV third-generation enzyme-linked immunosorbent assay (ELISA) and confirmatory testing with Western blot analysis were used in all three groups.

RESULTS

None of 81 CSWs tested for HIV-1 antibody were positive. None of 316 drug users tested positive for HIV-1 antibody. Of 3441 male prisoners, 1 was HIV-1 infected, and of 84 female prisoners, 1 was HIV-1 infected. No prisoner was positive for HIV-2 antibody.

DISCUSSION

The prevalence of HIV in CSWs, drug users, and prisoners in Sindh is low at present. Intervention programs implemented at this stage can make an impact in HIV prevention.

Role of serum angiotensin converting enzyme in sarcoidosis

This study was conducted to determine the role of Serum Angiotensin Converting Enzyme (SACE) as a marker in the differential diagnosis of pulmonary diseases and prognosis of sarcoidosis. A retrospective analysis of 113 medical records of patients at The Aga Khan University Hospital, with laboratory investigation for SACE was performed. Among 113 patients, 51 cases were found to have sarcoidosis, 44 of them had SACE levels greater than 52 IU/L (mean ACE 104.44). SACE levels were also found elevated in other clinical conditions like tuberculosis (mean 58.64 IU/L), but the enzyme level were less (p 0.04) than those found in sarcoidosis (mean (92.97 IU/L). SACE activity was found to be considerably lower in other chronic lung diseases such as, fibrosing alveolitis (mean 43.98 IU/L), interstitial lung disease (mean 42.11 IU/L) and chronic obstructive lung disease (mean 40.85 IU/L). Twenty patients of sarcoidosis, who received steroid treatment subsequently showed a decline in the SACE levels. SACE is a useful marker in differential diagnosis as 37.2% cases of sarcoidosis compared to only 9.09% of tuberculosis had SACE levels greater than 100 IU/L. In addition, our data also suggest that serum ACE is useful for the diagnosis as well as monitoring prognosis in sarcoidosis.

Classification and immunophenotyping of acute leukemias: a prospective study

Over a period of 3-1/2 years, 86 cases of acute leukemia were analyzed by immunohistochemical (IHC) means on ficoll separated cytospin preparations of peripheral blood and/or bone marrow samples. Antibodies included in the panel were specific against Tdt, HLA-DR, CD19/CD20/CD22, CALLA (CD10), CD2, CD11C as well as against Ig heavy chains. Of 86 cases analyzed, 48 cases were of ALL, (25 of common pre-B ALL, 15 of pre-B/NULL and 8 of T ALL phenotype), twenty-four (24) out of 86 cases were of non-lymphoblastic (AML/AMML) type. In six cases, there was suggestion of a mixed lineage, while in 8 cases there was inconclusive diagnosis. Mean age was lower in common ALL sub-set of ALL as compared to pre-B/NULL group (i.e., 8 vs 12 years), while in non-lymphoblastic group it was 36 years. T cell phenotype was invariably seen in young adults, who usually presented with a mediastinal mass.

Epidemiology of blood-borne viruses: a study of healthy blood donors in Southern Pakistan

There are only a few published reports regarding the prevalence of hepatitis B virus, hepatitis C virus and human immunodeficiency virus in Pakistani blood donors. The true extent of the prevalence of these viral infections in healthy adults in unclear. We examined blood donors attending the Aga Khan University Hospital and blood donation camps in the cities of Karachi and Hyderabad, Pakistan for the presence of hepatitis B surface antigen (HBsAg), antibodies to hepatitis C virus (anti-HCV) and human immunodeficiency virus (anti-HIV). Relationship of anti HCV to the surrogate marker alanine aminotransferase (ALT) was also examined. Prevalence of HBsAg was found to be 2.28% (1,173/51,257), anti HCV was 1.18%(198/16,705) and that of anti HIV to be 0.02% (10/51,257). Higher rate of prevalence of HBsAg and anti HCV was observed in the younger age group of 21 to 30 years. Male to female ratio for HBsAg was 2.5:1 and for anti HCV 1:1. Seropositivity for HBsAg was significantly greater than anti HCV (p < 0.0001). No clear relationship was found between high ALT (>55 U/l) and anti HCV positivity. Further examination of seropositive samples for HIV revealed only one donor to be positive by Western blot also. Prevalence of hepatitis B and C in the adult blood donor population in Southern Pakistan is higher than western countries but is similar to regional countries. This study also suggested that high ALT is not a useful surrogate marker for hepatitis C virus. Prevalence of HIV in this donor population is very low and is comparable to the western countries.

Lipids and membranes in the organic matrix of urinary calcific crystals and stones

The ultrastructure of the organic matrix of demineralized urinary stones was examined by standard transmission and scanning electron microscopy as well as after malachite green-glutaraldehyde fixation. Crystal ghosts of both calcium oxalate and calcium phosphate were made of amorphous material and were dispersed in a matrix containing amorphous, fibrillar, and membranous substances. Malachite green positive material was seen to be associated with the ghosts, as well as with the membranous and fibrillar components of the organic matrix. Calcium oxalate and calcium-phosphate crystals, induced in human urine in vitro were also found to be associated with an organic matrix containing lipids and proteins. It is suggested that the intimate association between crystals and lipids is a result of the involvement of cellular membranes in the nucleation of these crystals.

Pulmonary tuberculosis in a BCG vaccinated area: relationship of disease severity with immunological and hematological parameters and drug resistance patterns

Clinical hematological and immunological parameters were studied in a group of 145 pulmonary patients with active tuberculosis, from a defined area of Karachi (Kharadar) belonging to the lower socioeconomic strata. Although clinical symptomatology could not differentiate the extent of lung involvement, a majority (69.6%) of the patients were diagnosed radiologically as having moderately advanced pulmonary disease. The peak number of patients were in their second decade of life. No differences were observed in the extent of disease based on age or gender. All hematological parameters for the group were in the normal ranges except for low levels of hemoglobin (9.58 +/- 1.55 SD; normal range 12-14 mg/dl) and a high ESR (90 +/- 31 SD; normal range 0-13 mm/hour). A negative correlation of PPD skin test induration (r = 0.21, p = 0.02), and a positive correlation of total white blood cell (r = 0.20; p = 0.015) was observed with the amount of lung tissue involved. The resistance amongst the strains for the four first line anti-tuberculosis agents was found to be: isoniazid = 27.4%; ethambutol = 14.5%; rifampicin = 11.29% and streptomycin = 12.9%. Multi-drug resistance to the most commonly prescribed combination (rifampicin and ethambutol) was 8.06%. Drug resistance patterns to individual drugs were comparable with resistance patterns observed in strains from greater Karachi at The Aga Khan Hospital during the same period. Such studies should provide improved rationale for patients diagnosis and treatment.