Antimony susceptible Leishmania donovani: evidence from in vitro drug susceptibility of parasites isolated from patients of post-kala-azar dermal leishmaniasis in pre- and post-miltefosine era

Post-kala-azar dermal leishmaniasis (PKDL) patients are a key source of Leishmania donovani parasites, hindering the goal of eliminating visceral leishmaniasis (VL). Monitoring treatment response and parasite susceptibility is essential due to increasing drug resistance. We assessed the drug susceptibility of PKDL isolates (n = 18) from pre-miltefosine (MIL) era (1997-2004) with isolates (n = 16) from the post-miltefosine era (2010-2019) and post-miltefosine treatment relapse isolates (n = 5) towards miltefosine and amphotericin B (AmB) at promastigote stage and towards sodium antimony gluconate (SAG) at amastigote stage. PKDL isolates were examined for mutation in gene-encoding AQP1 transporter, C26882T mutation on chromosome 24, and miltefosine-transporter (MT). PKDL isolates from the post-miltefosine era were significantly more susceptible to SAG than SAG-resistant isolates from the pre-miltefosine era (P = 0.0002). There was no significant difference in the susceptibility of parasites to miltefosine between pre- and post-miltefosine era isolates. The susceptibility of PKDL isolates towards AmB remained unchanged between the pre- and post-miltefosine era. However, the post-miltefosine era isolates had a higher IC50 value towards AmB compared with PKDL relapse isolates. We did not find any association between AQP1 gene sequence variation and susceptibility to SAG, or between miltefosine susceptibility and single nucleotide polymorphisms (SNPs in the MT gene. This study demonstrates that recent isolates of Leishmania have resumed susceptibility to antimonials in vitro. The study also offers significant insights into the intrinsic drug susceptibility of Leishmania parasites over the past two decades, covering the period before the introduction of miltefosine and after its extensive use.

IMPORTANCE

Post-kala-azar dermal leishmaniasis (PKDL) patients, a key source of Leishmania donovani parasites, hinder eliminating visceral-leishmaniasis. Assessment of the susceptibility of PKDL isolates to antimony, miltefosine (MIL), and amphotericin-B indicated that recent isolates remain susceptible to antimony, enabling its use with other drugs for treating PKDL.

Application of CL Detect™ rapid test for diagnosis and liposomal amphotericin B for treatment of cutaneous leishmaniasis: A retrospective analysis from a tertiary care centre in a non-endemic area in India

Background Increasing urbanisation has led to the occurrence of cutaneous leishmaniasis (CL) in new areas, which was otherwise localised to endemic areas. Healthcare workers should be made aware of this entity to ensure clinical suspicion of CL and investigations needed to confirm CL. The article describes patients seen at a tertiary hospital in Delhi. Aims To establish the utility of the CL Detect Rapid test as a diagnostic tool and the efficacy of Liposomal Amphotericin B (LAmB) for the complete cure of CL patients. Methods Data of patients of CL (n = 16) was retrospectively analysed concerning diagnosis and treatment. Diagnosis rested on histopathology, real-time PCR, and CL Detect Rapid Test. Speciation of the parasite was based on the Internal transcribed spacer-I gene. Patients were treated with LAmB (i.v., 5 mg/kg up to three doses, five days apart). Results A positivity of 81.3% (95%CI, 54.4-96) was observed for CL Detect Rapid test in comparison with 100% (95%CI, 79.4-100.0) for real-time PCR and 43.8% (95%CI, 19.8-70.1) for microscopy/histopathological examination. L. tropica was the infective species in all cases. All the patients treated with LAmB responded to treatment, and 9/10 patients demonstrated complete regression of lesions, while one was lost to follow-up. Limitations It is a retrospective study, and the data includes only confirmed cases of CL at a single centre. Conclusion This study highlights the utility of CL Detect as a promising diagnostic tool and the efficacy of LAmB for the complete cure of CL.

Mid-circuit correction of correlated phase errors using an array of spectator qubits

Scaling up invariably error-prone quantum processors is a formidable challenge. Although quantum error correction ultimately promises fault-tolerant operation, the required qubit overhead and error thresholds are daunting. In a complementary proposal, co-located, auxiliary 'spectator' qubits act as in-situ probes of noise, and enable real-time, coherent corrections of data qubit errors. We use an array of cesium spectator qubits to correct correlated phase errors on an array of rubidium data qubits. By combining in-sequence readout, data processing, and feed-forward operations, these correlated errors are suppressed within the execution of the quantum circuit. The protocol is broadly applicable to quantum information platforms, and establishes key tools for scaling neutral-atom quantum processors: mid-circuit readout of atom arrays, real-time processing and feed-forward, and coherent mid-circuit reloading of atomic qubits.

Tuberculids: A Narrative Review

Tuberculids are a group of dermatoses with tuberculoid histology and the absence of tubercle bacilli. They are considered to be hypersensitivity reactions to circulating Mycobacterium tuberculosis (M. tb) or its antigens in individuals with good immunity. The objective of the review is to provide a detailed literature review of all available articles on tuberculids in the past 10 years and provide an update on epidemiology, etiopathogenetic mechanisms, clinical manifestations, and treatment. A search was performed on PubMed using the keywords lichen scrofulosorum, papulonecrotic tuberculid, erythema induratum, and erythema nodosum tuberculosis for all articles, with no restrictions on age, gender, or nationalities. An update on tuberculids, including some new concepts in pathogenesis, atypical presentations, new investigative modalities, and treatments are reviewed.

Unusual Observations in Leishmaniasis-An Overview

Leishmaniasis significantly affects the population of the tropics and subtropics. Clinical features and infective species of Leishmania are the primary factors driving the direction of diagnosis. The rise in incidences of atypical presentations present a challenge in patient treatment. Knowledge of unusual/rare presentations can aid in having a broader perspective for including the different aspects during the examination and thus avoid misdiagnosis. A comprehensive literature survey was performed to present the array of atypical presentations confounding clinicians which have been seen in leishmaniasis. Case reports of unusual findings based on the localizations and morphology of lesions and infective species and the predominant geographical sites over almost five decades highlight such presentations in the population. Information regarding the clinical features recorded in the patient and the chosen treatment was extracted to put forward the preferred drug regimen in such cases. This comprehensive review presents various unusual observations seen in visceral leishmaniasis, post-kala-azar dermal leishmaniasis, cutaneous leishmaniasis, and mucocutaneous leishmaniasis. It highlights the need to consider such features in association with differential diagnosis to facilitate proper treatment of the patient.

Optimization with photonic wave-based annealers

Many NP-hard combinatorial optimization (CO) problems can be cast as a quadratic unconstrained binary optimization model, which maps naturally to an Ising model. The final spin configuration in the Ising model can adiabatically arrive at a solution to a Hamiltonian, given a known set of interactions between spins. We enhance two photonic Ising machines (PIMs) and compare their performance against classical (Gurobi) and quantum (D-Wave) solvers. The temporal multiplexed coherent Ising machine (TMCIM) uses the bistable response of an electro-optic modulator to mimic the spin up and down states. We compare TMCIM performance on Max-cut problems. A spatial photonic Ising machine (SPIM) convolves the wavefront of a coherent laser beam with the pixel distribution of a spatial light modulator to adiabatically achieve a minimum energy configuration, and solve a number partitioning problem (NPP). Our computational results on Max-cut indicate that classical solvers are still a better choice, while our NPP results show that SPIM is better as the problem size increases. In both cases, connectivity in Ising hardware is crucial for performance. Our results also highlight the importance of better understanding which CO problems are most likely to benefit from which type of PIM. This article is part of the theme issue 'Quantum annealing and computation: challenges and perspectives'.

A Case-Control Study of Serum and Tissue Catalase among Morphological Variants of Vitiligo

Background

Role of oxidative stress in the pathogenesis of vitiligo.

Aim

Estimation of serum and tissue catalase levels in morphological variants of vitiligo.

Settings and Design

A prospective case-control study was conducted in the outpatient department of Dermatology in Safdarjung hospital.

Materials and Methods

We estimated levels of serum and tissue catalase in 30 vitiligo patients and 30 matched healthy controls.

Statistical Analysis

The data analysis was done in Statistical Package for Social Sciences (SPSS) version 21.0. Normality of data was tested by Kolmogorov-Smirnov test.

Results

Serum and tissue catalase was lower in vitiligo patients than controls. Serum catalase was lowest in vulgaris type, whereas in the acrofacial type had lowest tissue catalase levels.

Conclusion

Vitiligo patients have a generalized oxidative stress functioning at a higher pace as seen with decreased serum and tissue CAT which can well be taken as a marker of active disease and they can be helped with topical pseudoCAT preparations.

Positioning of Low Alcohol or Alcohol-Free Minoxidil Formulation for the Management of Androgenetic Alopecia: Indian Perspective

Topical minoxidil is used for treating different hair disorders. Even though it is an effective therapy, many patients show poor compliance due to the cost, side effects, and duration of treatment. Topical minoxidil is the mainstay treatment for androgenetic alopecia (AGA). Recently, low alcohol or alcohol-free topical minoxidil formulation has proven to be an alternative for patients suffering from AGA, including those with poor compliance with other therapies. Thus, the current article provides the positioning of low alcohol or alcohol-free topical minoxidil to manage AGA in Indian clinical practice.

P265 Phaeohyphomycosis caused by Rhinocladiella similis mimicking Sporotrichosis

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Objective

A case of phaeophyphomycosis caused by Rhinocladiella similis with a clinical picture simulating sporotrichosis is described.

Methods

A 34-year-old male patient, employed in a textile factory presented with multiple subcutaneous nodules on the lateral aspect of the dorsum of the left hand and left forearm. There was a history of mechanical trauma 1 year back. On examination, three to four verrucous ulcerative nodules clustered on the dorsum of the left hand were observed. A preliminary diagnosis of sporotrichosis was made and a punch biopsy was performed from the lesion and subjected to KOH examination, fungal culture, and histopathological examination. ITS sequencing was done to confirm the identity of the isolate.

Results

The skin punch biopsy from the lesion on the dorsum of the hand showed marked hyperkeratosis, papillomatosis, parakeratosis, acanthosis, and irregular elongation of rete ridges. No fungal structures and neutrophils were seen. On examination with 40% Potassium hydroxide round yeast-like cells were seen. An initial diagnosis of sporotrichosis was established. After 5 days, white to grayish colonies with aerial hyphae were observed on Sabouraud's dextrose agar which eventually turned greenish black on further incubation. Lactophenol cotton blue (LPCB) mount of the slide culture showed thin, hyaline, septate hyphae with oval conidia arranged in a bottle brush pattern around erect conidiophores and also directly arising from the hyphae. The pathogen was confirmed by ITS sequencing as R. similis. Patient was started on itraconazole 200 mg twice daily for 12 weeks. The patient is on regular follow-up and has shown gradual regression of the lesions indicating response to therapy.

Conclusion

Rhinocladiella similis infections have been reported chiefly from Brazil causing chromoblastomycosis. There have been no reports of infections due to this pathogen from the Indian subcontinent. This report presents the first case of R. similis as an agent of phaeohyphomycosis and calls for the need of a thorough evaluation of these cases so as to manage cases appropriately. It also underlines the need to study and redefine the ecological niche of this pathogen as well as its clinical spectrum.

P036 Epidemiology and antifungal susceptibility profile of infections caused by Fusarium species

 

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM

Aim

This study was performed to evaluate the clinical, epidemiological, and antifungal susceptibility profile of Fusarium species from clinical cases.

Methods

This study was conducted over a period of 14 years in a tertiary hospital in North India, 84 clinical isolates of Fusarium species isolated from various clinical samples like corneal scrapings, nail, tissue, and blood. The isolates were characterized phenotypically, and antifungal susceptibility testing was performed by broth microdilution method as per document CLSI M38-A3.

Results

On phenotypic identification, 69.04% were Fusarium solani sensu stricto, followed by Fusarium oxysporum (22.61%), Fusarium dimerum (8.33%) and Fusarium incarnatum (1.19%). The infection spectrum of Fusarium spp. was onychomycosis (54.76%), keratomycosis (19.04%), fusariosis (15.47%), white grain mycetoma (3.57%), burn wound infection (3.57%), hyalohyphomycosis (3.57%). In all 92.85% isolates were susceptible to amphotericin B (0.125-1 μg/ml). For voriconazole, 70.23% strains had MIC ranging between 0.5-1 μg/ml, while 29.76% had MIC >4 μg/ml. High MICs were found to itraconazole (>16 μg/ml), caspofungin (>16 μg/ml) and fluconazole (>64 μg/ml).

Conclusion

Fusarium solani is the most common species isolated. Fusarium spp. causes a broad spectrum of infections in humans including superficial, locally invasive, and disseminated infections. The clinical form of Fusarium species infections depends largely on the immune status of the host and the portal of entry of pathogen. Antifungal susceptibility testing is recommended owing to the variable susceptibility pattern of Fusarium spp. Large-scale studies are required to know the exact epidemiological, clinical factors, and antifungal susceptibility patterns of Fusarium infections.

Erythrasma – A red herring in the ongoing epidemic of tinea

We describe the presentation of five adults with erythrasma, misdiagnosed as tinea and prescribed antifungal treatment which resulted in incomplete clearance. The lesions were restricted to axillary and/or inguinal folds. They were dry, brown macules with fine scaling. Except for one with moderate pruritus, they were asymptomatic. No fungal elements could be demonstrated in any of the patients in 10% KOH preparation. Gram stain revealed short gram-positive rods in varying proportions. All the patients showed a pink fluorescence on Wood’s lamp examination. After treatment with topical clindamycin singly or in combination with oral azithromycin, there was complete clearance of the lesions leaving normal-appearing skin in three and residual hyperpigmentation in one. The overdiagnosis of tinea in the ongoing epidemic of dermatophytosis is a potential concern. Wood’s lamp examination is very useful to confirm or exclude erythrasma.

Drug-resistance and its impact on cutaneous tuberculosis

Drug resistance in tuberculosis is a universal health problem, with India and China having the highest number of multidrug resistant tuberculosis (MDR-TB) cases globally. As cutaneous tuberculosis (CTB) accounts for 1.5% of all extrapulmonary tuberculosis, drug resistance in CTB remains less discussed and understood. The sensitivity and specificity of the routine diagnostic workup for CTB are low compared to pulmonary tuberculosis. Therefore, identifying drug resistance becomes challenging and needs a high index of suspicion. Molecular techniques such as polymerase chain reaction (PCR), line probe assays, DNA microarray, and sequencing help us to identify tubercular bacilli and drug resistance early. Prompt initiation of effective therapy reduces disease-related morbidity and mortality and makes the patient non-contagious. Lately, World Health Organization (WHO) has recommended using “all oral longer MDR TB regimen” for pulmonary and extrapulmonary drug-resistant TB instead of a painful older regimen requiring long term therapy with injectables. This review focuses on the drug resistance in CTB, various methods and newer techniques to diagnose them and recent updates on treatment guidelines.

Diagnostic Dilemma of Cutaneous Tuberculosis: Opening of the Pandora's Box

ABSTRACT

Tuberculosis in all forms, that is, pulmonary (PTB) or extrapulmonary (EPTB), is a universal health problem. Cutaneous tuberculosis (CTb) remains one of the least studied and often under-reported variants of EPTB because of its wide and protean clinical presentation. The diagnosis of CTb remains challenging because of lack of sensitive and specific investigations for its diagnosis. The sensitivity of some of the traditional tests is low because of low concentration of mycobacteria in paucibacillary lesions. Besides it is difficult to distinguish between M. tuberculosis (MTb) and other mycobacterial species in skin biopsies morphologically. Molecular methods may target either MTb DNA or RNA, and serve as promising tools in the diagnosis of various forms of CTb, with high sensitivity and rapidity. This review is focused on diagnostic challenges of CTb and to discuss various methods and newer technologies for diagnosing CTb. This will help the dermatologists and dermatopathologists to elucidate and accurately diagnose CTb from other infectious granulomatous dermatitis for appropriate timely treatment of the patient.

TP1.2.3Oncological Outcomes of Organ Preservation Strategies - Local Excision Procedures and ‘Watchful Waiting’ In Management of Low Rectal Cancers – A Systematic Review And Meta-Analysis

Objective

To evaluate local recurrence, metastases, and survival outcomes of `wait and watch’ (WW) strategy and local excision (LE) of tumours, in comparison to the present standard practice of total mesorectal excision (TME) for locally advanced rectal cancers.

Data Sources

MEDLINE, EMBASE, PubMed databases, and sources of Grey literature.

Study Selection

Randomised and non-randomised prospective studies, retrospective studies with propensity-score-matched analyses.

Data Extraction and Synthesis

These were carried out independently by two reviewers. A random-effects methodology was used for meta-analyses. Data was presented keeping with the 27-item PRISMA checklist.

Main Outcomes

The primary outcomes of interest were local recurrence, distant metastases, disease-free-survival and overall-survival, which were assessed in comparison to those associated with radical surgeries (TME).

Results

7 of the 16 studies in the systematic review were included for the quantitative synthesis and meta-analysis. Local recurrence rates were comparable amongst patients in WW group and LE group to those undergoing TME. [Risk ratio (RR) 3.07/1.41; 95% Confidence Interval (CI) 0.86-10.95/0.66-3.01; P = 0.08/P=0.89 respectively]. Rates of distant metastases in the WW group and LE group were comparable to those undergoing TME [RR = 0.71/0.94; 95% CI 0.22-2.30/0.55-1.61; P = 0.56/ P = 0.83 respectively]. The median 3-year disease-free survival among patients undergoing WW, LE procedure, and TME were 88%, 80%, and 78.2% respectively; and the median 3-year overall survival among the three groups were 96%, 93%, and 89.5% respectively.

Conclusions and Relevance

Organ-preservation strategies appear to be a viable treatment option in the management of rectal-cancers. Further research is warranted to provide stronger levels of evidence on organ-preservation strategies.

TP1.2.6Functional Outcomes of Organ Preservation Strategies - Local Excision Procedures and 'Watchful-Waiting' In Management of Low Rectal Cancers - A Systematic Review

Objective

To evaluate functional outcomes and quality of life (QOL) associated with `wait-and-watch’ (WW) strategy and local-excision (LE) of rectal tumours after neo-adjuvant therapy, in comparison to the standard practice of total-mesorectal-excision (TME) for locally-advanced-rectal-cancers.

Data Sources

Medline, EMBASE, PubMed databases, and sources of Grey literature.

Study Selection

Randomised and non-randomised prospective studies, and retrospective studies with propensity-score-matched analyses analysing outcomes of WW and LE procedures for rectal cancer.

Data Extraction and Synthesis

Risk of bias assessments and data extraction were carried out independently by two reviewers. A narrative synthesis of data was presented keeping with the 27-item PRISMA checklist.

Main Outcomes

The outcomes of interest were those of faecal-incontinence (FI), bowel and rectal-evacuatory function, sexual-function, stoma-free-survival, and quality-of-life scores, which were assessed in comparison to those associated with radical surgeries.

Results

7 studies reported functional outcomes. Faecal-incontinence, bowel, and rectal-evacuatory-function assessed by various scoring systems were found to be least affected among patients on WW strategy, followed by those undergoing local excision and most in patients undergoing TME. These reflected on the quality of life assessments (FIQOL and FACT-C questionnaires). Sexual dysfunction was not higher among patients who underwent LE compared to TME. Advantage of stoma-free-survival with organ preservation strategies was realised for up to 2 years after treatment.

Conclusions

Organ-preservation strategies appear to have a favourable functional outcome compared to the gold standard of TME for up to 2 years after the commencement of treatment. Further research is warranted to provide stronger levels of evidence regarding the same.

Rapid Multiplex Loop-Mediated Isothermal Amplification (m-LAMP) Assay for Differential Diagnosis of Leprosy and Post-Kala-Azar Dermal Leishmaniasis

Leprosy and post-kala-azar dermal leishmaniasis (PKDL) are co-endemic neglected tropical diseases often misdiagnosed because of close resemblance in their clinical manifestations. The test that aids in differential diagnosis of leprosy and PKDL would be useful in endemic areas. Here, we report development of a multiplex loop-mediated isothermal amplification (m-LAMP) assay for differential detection of Mycobacterium leprae and Leishmania donovani using a real-time fluorometer. The m-LAMP assay was rapid with a mean amplification time of 15 minutes, and analytical sensitivity of 1 fg for L. donovani and 100 fg for M. leprae. The distinct mean Tm values for M. leprae and L. donovani allowed differentiation of the two organisms in the m-LAMP assay. Diagnostic sensitivity of the assay was evaluated by using confirmed cases of leprosy (n = 40) and PKDL (n = 40) (tissue and slit aspirate samples). All the leprosy and PKDL samples used in this study were positive by organism-specific QPCR and loop-mediated isothermal amplification assays. The diagnostic sensitivity of the m-LAMP assay was 100% (95% CI: 91.2-100.0%) for detecting PKDL and 95% for leprosy (95% CI: 83.1-99.4%). Our m-LAMP assay was successfully used to detect both M. leprae and L. donovani in a patient coinfected with leprosy and macular PKDL. The m-LAMP assay is rapid, accurate, and applicable for differential diagnosis of leprosy versus PKDL, especially in endemic areas.

Real-Time Fluorimetry Loop-Mediated Isothermal Amplification for Diagnosis of Leishmaniasis and as a Tool for Assessment of Cure for Post-Kala-Azar Dermal Leishmaniasis

Despite the dwindling number of visceral leishmaniasis (VL) cases in India, there is an urgent need for early and unequivocal diagnostics for controlling and preventing the reemergence of VL. Post-kala-azar dermal leishmaniasis (PKDL), a dermal sequela of VL, serves as a reservoir of the parasite. Diagnosis of PKDL, especially the macular variant, is challenging and poses impediment toward attainment of VL elimination. In this study, a real-time fluorimetry loop-mediated isothermal amplification (RealAmp) assay has been established for the detection of different clinical manifestations of leishmaniasis. The study included 150 leishmaniasis patients (25 VL, 25 cutaneous leishmaniasis [CL], and 100-PKDL) along with 120 controls. The assay demonstrated sensitivity of 100% (95% CI: 86.68-100) for diagnosis of VL and PKDL (95% CI: 79.61-100) and 96% (95% CI: 86.68-100) for CL with 100% specificity. Moreover, considering the cardinal role of PKDL, diagnosis using minimally invasive slit aspirate was explored, which demonstrated remarkable sensitivity of 96% (95% CI: 87.64-98.47). As a test of cure for PKDL, RealAmp successfully detected parasite in two of posttreatment cases who later reported relapse on follow-up. Also, direct sample lysis using slit aspirate was attempted in a small group that yielded sensitivity of 89% (95% CI: 67.20-96.90). RealAmp depicted excellent diagnostic accuracy in the diagnosis of leishmaniasis in concordance with the established SYBR Green I-based visual loop-mediated isothermal amplification (LAMP) and the reference comparator real-time PCR. The study endorsed the employment of LAMP either as visual-LAMP or RealAmp for an accurate and expeditious diagnosis of PKDL and as a tool for assessment of cure.

Development of a novel loop-mediated isothermal amplification assay for rapid detection of Mycobacterium leprae in clinical samples

BACKGROUND

Sensitive and definitive diagnostic tests are required for timely treatment of leprosy and to control its transmission.

AIM

In the present study, we report the development of loop-mediated isothermal amplification assay using six primers targeting the RLEP gene sequence uniquely present in Mycobacterium leprae.

METHODS

Tissue punch samples (n = 50) and slit aspirates (n = 50) from confirmed cases of leprosy (M. leprae positive by quantitative polymerase chain reaction), reporting at the Department of Dermatology, Safdarjung Hospital, New Delhi, were analyzed using newly developed closed tube loop-mediated isothermal amplification assay. The sensitivity and specificity; positive predictive value, negative predictive value and accuracy were calculated using MedCalc statistical software.

RESULTS

The loop-mediated isothermal amplification assay specifically amplified M. leprae genomic DNA with an analytical sensitivity of 100 fg. About 47 Out of the 50 quantitative polymerase chain reactions confirmed M. leprae positive tissue samples, 47 were positive by loop-mediated isothermal amplification assay (sensitivity 94%; 95% confidence interval 83.5%-98.8%) while only 31/50 were positive by histopathology (sensitivity 62%; 95% confidence interval 47.2%-75.4%) . Using slit aspirate samples of these 50 patients, 42 were positive by both quantitative polymerase chain reaction and loop-mediated isothermal amplification assay (sensitivity 84%; 95% confidence interval 70.9%-92.8%) while only 23/50 (sensitivity 46%; 95% confidence interval 31.8%-60.7%) were positive by microscopy.

LIMITATIONS

In the present study, the leprosy patient cohort was not uniform, as it comprised a lower number of paucibacillary cases (22%) compared to multibacillary (78%) cases.

CONCLUSION

Loop-mediated isothermal amplification assay established here provides a rapid and accurate diagnostic test for leprosy in terms of sensitivity and specificity. The assay is simple to perform in comparison with other molecular techniques (polymerase chain reaction/quantitative polymerase chain reaction) and has potential for field applicability.

Histopathology of Post Kala-azar Dermal Leishmaniasis

The various lesions seen in the clinical presentation of post kala-azar dermal leishmaniasis (PKDL) are reflected in the histopathology of the type of lesion biopsied. The cells that form the dermal infiltrate include lymphocytes, histiocytes, and plasma cells in varying proportions. The infiltrate, which is mild and confined to the superficial dermis in macular lesion becomes denser with the increasing severity of the lesion. Leishman–Donovan bodies (LDB) in general are rarely demonstrable in macules and somewhat infrequently in the rest, though at times they may be numerous; mucosal lesions offer a greater chance of visualizing LDB than biopsies from the skin. A characteristic histomorphology in nodules is prominent follicular plugging with a dense plasma cell-rich lymphohistiocytic dermal infiltrate that shows an abrupt cut-off in the lower dermis, an appearance highly suggestive of PKDL even in the absence of LDB. Russell bodies within plasma cells, vascular changes, and xanthoma-like hue have been seen in plaques from chronic PKDL. The histopathologic picture in some may also mimic that seen in tuberculoid and lepromatous leprosy, and other granulomatous dermatoses. In contrast to Indian PKDL, epithelioid cell granulomas with giant cells are more common in African PKDL, and vascular changes are rare though neuritis showing LDB has been described.

Bis(benzo-15-crown-5-κ5 O)barium tetrakis(isothiocyanato-κN)cobaltate(II)

The title compound, [Ba(C14H20O5)2][Co(NCS)4], is formed by discrete anions and cations. The molecular packing is controlled by weak C—H...π interactions.

How genetic variation was analyzed in phenytoin-induced gingival enlargement using single-nucleotide polymorphism of candidate gene CYP2C9?

Background:

Phenytoin-induced gingival overgrowth is an adverse drug reaction affecting few individuals, on phenytoin therapy for its antiepileptic effect. Analysis of genetic variation of CYP2C9*2 gene was done to identify the action of metabolic enzyme cytochrome P 450 on this drug. The main background of this publication is a quick review about one of the molecular techniques used to identify the single-nucleotide polymorphism (SNP) using polymerase chain reaction coupled with restriction fragment length polymorphism (PCR-RFLP).

Materials and Methods:

Deoxyribonucleic acid (DNA) was extracted from 5 ml of venous blood withdrawn from the individual, who had gingival overgrowth following phenytoin therapy. DNA was isolated, using the phenol-chloroform method. Isolated DNA was used for SNP analysis of CYP2C9*2 presentation. The basic procedure used for SNP analysis in our case was PCR-RFLP.

Results:

Genetic variation of CYP2C9*2 in our case was homomutant.

Conclusion:

The etiology of phenytoin-induced gingival overgrowth is always an enigma, but it is now becoming clearer that a multifactorial role may be involved in the cause. One of the factors analyzed was polymorphism of CYP2C9*2 gene and it was found to be homomutant in our case. Adverse drug reaction can be minimized, by either reducing the drug dosage or drug substitution. However, larger scale genome-wide study has to be carried out to confirm one of the etiopathogenesis as mutation of the CYP2C9 gene, in phenytoin-induced gingival overgrowth.

"Central giant cell granuloma" - An update

There are multiple lesions in the jawbones with a common histological character of the presence of osteoclast-like giant cells under one category - giant cell lesions. The central giant cell granuloma (CGCG) is the most common of all and is found to be more prevalent in the Indian population. The pathogenicity still remains an enigma and needs to be differentiated from other look-alike lesions in order to have proper treatment planning. Furthermore, CGCG specifically needs to be differentiated from central giant cell tumor to avoid mutilating surgeries. This article is an attempt to give an outline of the CGCG with updating of the latest information on the perception of this lesion.

Cutaneous tuberculosis of the pinna

BACKGROUND

Cutaneous tuberculosis (CTB) rarely involves the ear as the primary site, but while diagnosing and treating ear infections, it should be considered a differential diagnosis in a tropical country such as India. The present study reports the incidence and clinical presentation of auricular tuberculosis (TB) in a tertiary care hospital in New Delhi.

METHODS

A retrospective, observational study was conducted from 2005 to 2019 whereby all cases of CTB confirmed by biopsy were retrieved from the database. The demographic details, clinical details, Mantoux results, and photographs were extracted and studied. The data were entered into MS Excel and analyzed.

RESULTS

In a retrospective analysis of 886 cases of CTB over a period of 15 years, we found 20 cases (2.26%) of ear involvement (1 case with bilateral involvement). The median age of the patients with ear involvement was 29 years with 42.11% men and 57.89% women. Morphological variants seen over pinna were predominantly classic plaque type (31.58%) and nodular (31.58%), with few ulcerative (21.05%) and tumoral forms (15.79%). CTB of the pinna showed predominant involvement of either helix or ear lobule (7 cases each). All cases were strongly positive to tuberculin and showed response to the empirical antitubercular treatment.

CONCLUSION

CTB can exclusively affect the pinna in varied presentations. The ear lobules and the helix are the usual sites of affection. It is rare for both ears to be affected with CTB, unlike bacilliferous leprosy. Regression following institution of antitubercular treatment is a reasonable way to confirm CTB.

A clinical, dermoscopic, histopathological and immunohistochemical study of melasma and facial pigmentary demarcation lines in the skin of color

Melasma and facial pigmentary demarcation lines (FPDL) are common causes of patterned facial pigmentation that may mimic each other. There is a paucity of studies investigating these two conditions. The objective of this study was to make a detailed comparative analysis of these disorders. A clinical, dermoscopic, histopathological and immunohistochemical analysis of lesional and perilesional skin was conducted in 20 patients each of melasma and FDPL. The most common morphological patterns were centrofacial in melasma and W-shaped pattern in FPDL. Dermoscopy in melasma revealed similar patterns in lesional and perilesional skin, whereas FPDL did not. Histopathology of melasma revealed increased melanin in the suprabasal and basal layers (100%), melanophages in the upper dermis and solar elastosis (65%) in contrast to FPDL, wherein increased basilar melanin (75%) and dermal melanophages were the key findings. Expression of vascular endothelial growth factor and stem cell factor was slightly increased in lesional melasma skin, but not in FPDL. The study was limited by its small sample size and immunohistochemistry carried out in a few patients. Melasma and FPDL, although similar in presentation, are distinct entities. Dermoscopy, histology and immunohistochemistry reveal subtle differences.

Assessing the Efficacy and Safety of Liposomal Amphotericin B and Miltefosine in Combination for Treatment of Post Kala-Azar Dermal Leishmaniasis

BACKGROUND

No satisfactory canonical treatment is available for post-kala-azar dermal leishmaniasis (PKDL), clinical sequela of visceral leishmaniasis. Confined treatment options and substantial increase in relapse rate after miltefosine (MIL) treatment warrant the need to adapt resilient combination therapies. In this study, we assessed the safety and efficacy of combination therapy using liposomal amphotericin B (LAmB) and MIL for treating PKDL.

METHODS

Thirty-two PKDL patients, confirmed by microscopy or quantitative polymerase chain reaction (qPCR), were included in the study. An equal number of cases (n = 16) were put on MIL monotherapy (100 mg/day for 90 days) or MIL and LAmB combination for 45 days (3 injections of LAmB, 5 mg/kg body weight, and 100 mg/day MIL). Parasite load in slit aspirate was monitored using qPCR.

RESULTS

Patients treated with combination therapy demonstrated a rapid decline in parasite load and achieved 100% cure, with no reports of relapse. Those treated with MIL monotherapy attained clinical cure with a gradual decrease in parasite load; however, 25% relapsed within 18 months of follow-up.

CONCLUSIONS

Liposomal amphotericin B and MIL combination for treating PKDL is efficacious and safe, with high tolerability. Furthermore, this study established the utility of minimally invasive slit aspirate method for monitoring of parasite load and assessment of cure in PKDL.

Elevated IL-6R on CD4+ T cells promotes IL-6 driven Th17 cell responses in patients with T1R leprosy reactions

Th17 cells play vital role during pathogenesis of leprosy reactions. Previously, we have reported that IL-23 is involved in Th17 cells differentiation. Subsequently, our group also showed that IL-6 induces Th17 cell differentiation along with TGF-β in leprosy reactions. Here, we next asked the question that whether IL-6 or IL-23 induced Th17 cells are different in nature? In this study, Type 1 Reactions (T1R) showed significantly (p < 0.001) higher percentage of IL-17A producing CD4⁺IL6R⁺ T cells as compared to non-reaction (NR) patients. Furthermore, recombinant IL-6, IL-23 and TGF-β promoted IL-17A secretion by CD4⁺IL6R⁺ T cells. Subsequently, IL-6R and IL-23R blocking experiments showed significantly (p < 0.002) down regulated IL-17A in T1R reaction as compared to NR leprosy patients. The present study for the first time establishes that pathogenic Th17 cells produce IL-17 in an IL-6 dependent manner in leprosy T1R reactions. Thus, present approaches that specifically target Th17 cells and/or the cytokines that promote their development, such as IL-6, TGF-β and IL-23A may provide more focused treatment strategies for the management of Mycobacterium leprae and its reactions.

A comparative study of topical tacrolimus and topical triamcinolone acetonide in nodular scabies

The aim of this study was to compare the efficacy and safety of 0.1% triamcinolone acetonide and 0.03% tacrolimus ointment for the treatment of nodular lesions of scabies. In this double-blind randomized controlled trial, 50 Indian men with postscabeitic persistent nodular lesions (labelled to have nodular scabies (NS)/postscabies prurigo (PSP)) over the external genitalia, were enrolled. They were randomized into two groups to receive either a mid-potency topical corticosteroid (TCS); triamcinolone acetonide 0.1% ointment twice daily, or topical calcineurin inhibitor (CNI); tacrolimus ointment 0.03% twice daily over the nodular lesions for 2 weeks. All patients were followed up on three visits: 1, 2, and 6 weeks, for assessment. Efficacy was evaluated by 5-point range investigator-assessed VAS, and a 4-point severity of pruritus scale (SPS) score. The mean VAS score was higher in triamcinolone group compared to tacrolimus group at both follow-ups, although statistically significant only at 2nd week visit. The fall in mean SPS at both follow-ups was also higher in the steroid group, but the difference was not statistically significant. While, the overall tolerance to either ointment was excellent, mild hypopigmentation, and epidermal atrophy were detected on dermoscopic evaluation of the treated areas at the 2nd week visit in a small subset of patients in the triamcinolone group. The frequency of relapse of lesions and/or pruritus after four weeks of the 2-week therapy was high in both the groups (higher in tarolimus group). Conclusively, although both treatment options provided safe and satisfactory short term improvement, the results from this study suggest an overall higher efficacy of a mid-potency TCS like triamcinolone 0.1% over topical CNI like tacrolimus 0.03%, in the short-term treatment of nodular lesions of NS/PSP. Topical CNIs may be considered for maintenance of effect, if prolonged therapy is warranted.

Validation of the diagnostic criteria for segmental vitiligo

Background

Segmental vitiligo has a different clinical course and prognosis as compared to nonsegmental vitiligo, which necessitates its correct diagnosis. It may be difficult to distinguish segmental vitiligo from the limited or focal types of nonsegmental vitiligo.

Objective

To validate the previously proposed diagnostic criteria for segmental vitiligo.

Methods

This was a cross-sectional validation study involving patients with limited vitiligo. The diagnostic criteria were used to classify vitiligo lesions as segmental or nonsegmental, and was compared with the experts' diagnosis, which was considered as the "gold standard".

Results

The study included 200 patients with 225 vitiligo lesions. As per the diagnostic criteria, 146 vitiligo lesions were classified as segmental and 79 as nonsegmental. The experts classified 147 vitiligo lesions as segmental and 39 as nonsegmental, while the diagnosis either was labeled "unsure" or could not be agreed upon for 39 lesions. As compared with the experts' opinions ("for sure" cases, n = 186), the sensitivity and specificity of the diagnostic criteria was 91.8% (95% confidence interval [CI]: 86.2%-95.7%) and 100% (95% CI: 91%-100%), respectively. The positive predictive value was 100% (95% CI: 97.3-100%), while the negative predictive value was 76.5% (95% CI: 62.5%-87.2%). There was a 93.5% agreement between the clinical criteria and experts' opinions (k = 0.83, P < 0.001).

Limitation

The diagnostic criteria were compared with the experts' opinion in the absence of an established diagnostic "gold standard".

Conclusions

The proposed diagnostic criteria for segmental vitiligo performed well, and can be used in clinical practice, as well as in research settings.

The Association of Metabolic Syndrome and Psoriasis: A Systematic Review and Meta-Analysis of Observational Study

Background:

Metabolic syndrome worsens complications in psoriasis patients by predisposing them to cardiovascular diseases. Psoriasis has been widely associated with metabolic syndrome; however, it has still not been proven owing to a limited number of studies and some of those reporting conflicting results.

Objective:

Psoriasis has reportedly been associated with metabolic syndrome; however, it has yet not been established beyond doubt owing to conflicting literature. The present meta-analysis of observational studies aims to evaluate the prevalence of metabolic syndrome in psoriasis patients and establish an inferring point that psoriasis patients are certainly susceptible to metabolic syndrome. The study will benefit clinicians to assess and monitor psoriasis patients for several associated comorbid conditions and in its treatment.

Methods:

A systematic web search for ‘Psoriasis’, ‘Metabolic Syndrome’, ‘Hypertension’, ‘Plasma Glucose’, ‘Dyslipidaemia’, ‘Waist Circumference’ was performed, collecting all original observational studies on humans up to April 30, 2018. Depending on the inclusion and exclusion criteria, articles were screened for eligibility. Due to the presence of significant heterogeneity, the Odds Ratio (OR) was calculated using a random-effect model with Der-Simonian and Laird method. The statistical heterogeneity was determined using I2 statistics. Comprehensive Meta-Analysis Software, Version 3 was used to perform all the analysis.

Results:

Sixty-three studies encompassing 15,939 psoriasis patients and 103,984 controls were included in this meta-analysis. Among them, 30.29 % of psoriasis patients were reported with metabolic syndrome in comparison to 21.70 % of subjects in the control group. The present study clearly indicates an increased prevalence of metabolic syndrome among psoriasis patients (OR: 2.077 [95% CI, 1.84 - 2.34]).

Conclusions:

The findings support the fact that psoriasis patients have a higher incidence of metabolic syndrome. Our study also recommends that psoriasis patients should be regularly monitored for metabolic syndrome complications and its associated risk factors such as hypertension, raised triglyceride, lowered HDL Cholesterol, increased fasting plasma glucose, and waist circumference.

Clinicopathological Concordance in 2216 Cases of Skin Biopsy over One Year: An Indian Experience

Introduction

To determine the spectrum of diseases and the level of clinicopathological concordance in skin biopsies received over a period of one year.

Methods

A total of 2216 skin biopsy cases received over a period of one year at a tertiary care center were retrospectively analyzed. The cases were further divided into further categories in levels of concordance based on the agreement between the clinical and histopathological diagnosis rendered.

Results

Of the cases, 61.01% showed clinicopathological concordance. Cases with a descriptive pathological diagnosis, not matching the clinical diagnosis, constituted 31.54%, whereas 4.02% of cases had a definitive pathological diagnosis, which was discordant with the clinical differentials; 3.29% biopsies were inadequate.

Conclusion

This study highlights the clinicopathological concordance in all the biopsies received from dermatology. It emphasizes the importance of skin biopsies in arriving at the diagnosis. However, it is a tool that must be used judiciously. Skin biopsies are also pivotal in flagging malignancies that may mimic benign lesions.