Bhanu Mehra

Rapid Tests versus ELISA for Screening of HIV Infection: Our Experience from a Voluntary Counselling and Testing Facility of a Tertiary Care Centre in North India

Early and accurate diagnosis of human immunodeficiency virus (HIV) infection is essential for timely identification of patients needing antiretroviral therapy and for instituting HIV prevention strategies. The primary methodology for HIV testing has shifted from enzyme linked immunosorbent assay (ELISA) to rapid diagnostic tests (RDTs) in recent years, especially in resource limited settings. However, the diagnostic performance of RDTs is a matter of concern. In the present study the performance of an RDT being used as the initial test in serial testing based algorithm for HIV diagnosis was compared with ELISA. Seven hundred and eighty-seven sera, tested at the voluntary counselling and testing facility employing a serial testing algorithm (based on SD Bioline HIV-1/2 3.0 as the first test), were subsequently tested with Microlisa-HIV for anti-HIV antibodies. The first test missed 9 HIV reactive samples and also registered 5 false positives. The sensitivity, specificity, and negative and positive predictive values of the first test were 77.5%, 99.3%, and 98.8% and 86.1%, respectively, taking ELISA as the standard test. Our study highlights that RDTs fare poorly compared to ELISA as screening assays and that reactive results by RDTs need to be confirmed by western blot for a positive serodiagnosis of HIV infection.

Cysticercosis of the temporalis muscle causing temporal headache in a pregnant woman

Cysticercosis is the most common parasitic disease of the human nervous system. With the increasing use of magnetic resonance imaging (MRI) and high-resolution computed tomography (CT) scans, early and correct diagnoses can be made in most cases. A 25-year-old primigravida at 34 weeks of pregnancy was referred from the Antenatal Clinic to the Otorhinolaryngology Clinic at Lok Nayak Hospital, New Delhi, India, following 2 years of right temporal swelling. The woman had been experiencing occasional temporal headaches, which had increased in the past 2–3 months, along with the size of the swelling. Her prenatal records were normal. On initial examination, a single diffuse swelling measuring 4×3 cm was found in the right temporal region. It was nontender, firm, and nonpulsatile. A cranial CT scan revealed an ovoid hypodense cystic lesionmeasuring 11×8 mm in the right temporalis muscle with diffuse perifocal edema (Fig. 1). Cysticercosis was suspected and enzyme-linked immunosorbent assay (ELISA) revealed positive serology for the infection. Magnetic resonance imaging of the brain was performed to rule out neurocysticercosis. The ocular fundus examination was normal. The womanwas prescribed a daily dose of albendazole (15 mg/kg) and dexamethasone (8 mg) for 2 weeks. She underwent normal vaginal delivery and continued to receive albendazole for 2 weeks postpartum. Her symptoms were relieved and did not return at follow-up, which she attended regularly for 2 years. Humans are infected with tapeworm cysts via fecal–oral transmission [1]. Two cases of cysticercosis with isolated temporalis muscle involvement have been reported previously, neither of which involved pregnant women [2,3]. In cases of isolated muscular involvement, serologic tests such as ELISA are useful; the sensitivity of the test ranges from 50% to 87% and the specificity from 63% to 95% [4]. For patients in endemic areas, the typical characteristics of the infection revealed via CT or MRI scan are usually sufficient for establishing a diagnosis of cysticercosis, with no need for histologic or serologic confirmation [2]. The treatment is pharmacologic: medication destroys the cysts and causes massive and rapid release of larval antigens; this can lead to increased pain or generalized anaphylaxis, which may be relieved by corticosteroids [1]. In the present case, the combined effects of a relative immunocompromised state and fluid retention—common factors during pregnancy, especially in the last trimester—may have caused an increase in the size of the swelling and aggravated the symptoms of cysticercosis.

Evaluation of SD BIOLINE Syphilis 3.0 for rapid diagnosis of syphilis: Report from a regional sexually transmitted infection reference laboratory in North India

Background: Serology is considered the mainstay of syphilis diagnosis. The limitations of the traditional serological methods and the advent and availability of novel immunochromatographic assays have led to the widespread application of rapid point-of-care procedures as screening tools for syphilis. However, these tests have not been extensively evaluated. This study was designed to evaluate the performance of a rapid syphilis diagnostic test known as SD BIOLINE Syphilis 3.0 (SD Biostandard Diagnostics Private Limited, Gurgaon, Haryana, India). Materials and Methods: A panel comprising of 50 venereal disease research laboratory reactive and 50 nonreactive sera was tested using SD BIOLINE Syphilis 3.0. The performance of the test was evaluated using IMMUTREP Treponema pallidum hemagglutination assay (TPHA) (OMEGA Diagnostics Limited, Scotland, United Kingdom) as the reference standard and sensitivity, specificity, and negative and positive predictive values were calculated. Results: The sensitivity, specificity, and positive and negative predictive values of SD BIOLINE Syphilis 3.0 were 92.86% (confidence interval of 95%: 80.52–98.50%), 98.28% (90.76-99.96%), 97.50% (86.84–99.94%), and 95.00% (86.08–98.96%), respectively, compared to TPHA as the gold standard. Conclusion: Keeping in view the high sensitivity and specificity of SD BIOLINE Syphilis 3.0, we conclude that the test can be used as a tool for rapid on-site diagnosis of syphilis and as an alternative to TPHA for detection of antibodies to Treponema pallidum.

HIV/AIDS Awareness among VCT Clients: A Cross-Sectional Study from Delhi, India

The contribution of India to the global burden of HIV/AIDS is significant. A major barrier that the country has faced in its battle against this disease is the inadequate and inaccurate information about it among the population. The present analysis explores the knowledge about HIV/AIDS among clients attending a voluntary counselling and testing (VCT) facility in India. Two hundred clients attending the VCT facility were assessed in this regard using a structured predesigned questionnaire. Sixty-three (31.5%) of the respondents had never heard of HIV/AIDS. In comparison to males, a significantly higher number of females had not heard about the disease (P < 0.01). Lower levels of education of participants were found to be significantly associated with the response of not having heard of HIV/AIDS (P < 0.01) as was an occupation status of being an unemployed man/housewife (P = 0.002). For the 137 (68.5%) respondents who had heard about HIV/AIDS, television was the source of information in 130 (94.9%) followed by posters in 93 (67.9%) and newspapers in 88 (64.2%). While the knowledge about HIV transmission and prevention was good, the extent of misconceptions was high (61.8%). Our study highlights the strong need to raise the levels of HIV awareness among Indian population.

An Unusual Case of Cystic Fibrosis Associated Pneumocystis jiroveci Pneumonia in an Infant.

Pneumocystis jiroveci pneumonia (PJP) is one of the major infections in patients with impaired immunity. The entity is common in HIV-seropositive individuals but quite very rare in HIV-seronegative individuals especially children. We report here a case of 16-week-old HIV-seronegative infant with chief complaint of chronic cough of one month of evolution. Sweat chloride test for diagnosis of cystic fibrosis was positive. Bronchoalveolar lavage (BAL) fluid was collected and Pseudomonas aeruginosa was isolated on culture. Empirical antibiotic regimen comprising ceftriaxone and azithromycin was initiated that was switched to meropenem as per antimicrobial susceptibility report, but the patient did not improve. Subsequently, an immunofluorescence staining of BAL fluid was performed and P. jiroveci cysts were detected. Following a laboratory confirmation of Pneumocystis pneumonia, cotrimoxazole was added and the clinical condition of the patient significantly improved. This is an unusual case wherein unsuspected PJP occurred and since signs and symptoms of the patient persisted even after the initiation of antimicrobial therapy for Pseudomonas infection and resolved only after treatment for PJP was started, it suggests a causative role of P. jiroveci rather than colonization/contamination.

Evaluation of Baseline CD4+ T Cell Counts and ART Requirement in Newly Diagnosed HIV Seropositive Individuals in a Tertiary Care Hospital of Northern India.

INTRODUCTION Antiretroviral Therapy (ART) has changed the outlook of Human Immune-deficiency Virus (HIV)/Acquired Immuno Deficiency Syndrome (AIDS) patients worldwide. AIM To analyse the trends in baseline CD4+ T cell counts and ART requirements in newly diagnosed HIV seropositive individuals in a Tertiary care hospital of Northern India. MATERIALS AND METHODS Out of 1263 HIV seropositive clients identified from January 2012 to June 2014, the baseline CD4+ T cell counts of only those 470 clients were analysed, who registered at the linked ART centre. RESULTS The mean baseline CD4+ count of the study group was 249.77±216.0cells/mm3 and that of male and female were 300.31±240.47cells/mm3 and 232.38±204.25cells/mm3 respectively. A total of 259 of 334 (77.54%) HIV reactive males, 83 of 130 (63.85%) HIV reactive females and overall 348 of 470 (74.04%) required antiretroviral treatment on enrolment. CONCLUSION In the present study, about three-fourth of newly diagnosed HIV positive Indian patients required initiation of ART at registration. The relatively low baseline CD4+ T cell counts in this population highlights the need for timely baseline CD4+ counts testing of HIV positive patients and the urgency of initiating treatment in HIV reactive individuals in Indian health care settings.

Is Scrub Typhus a Cause of Febrile Illness Among Paediatric Population of Delhi

Sir, Scrub typhus is a febrile illness caused by Orientia tsutsugamushi and transmitted through the bite of larval forms of trombiculid mites [1]. The signs and symptoms of the disease are relatively nonspecific and in areas like Delhi where outbreaks have not been reported so far, low index of suspicion makes the diagnosis of this infection difficult. Furthermore, there is a paucity of information regarding the role of scrub typhus as a cause of fever in paediatric population. In the present study, l00 paediatric patients, 1-12years of age and presenting with febrile illness to the paediatric outpatient department or ward of a tertiary care health centre from February 2013 to March 2014 were included. Common causes of fever (malaria, dengue, enteric fever) were ruled out by history, clinical examination and appropriate laboratory investigations. In 30 patients who remained febrile and no definitive etiological diagnosis could be made, blood samples (5 ml) were collected and the serum separated and preserved at -70°C till further analysis. These samples were tested for antibodies to O. tsutsugamushi employing the immunochromatographic test (ICT), SD Bioline Tsutsugamushi Assay (Standard Diagnostics, Yongin, Korea) that employs the 56-kDa major surface protein antigens from representative O. tsutsugamushi including Gilliam, Karp, and Kato strains and detects IgG, IgM, and IgA antibodies to O. tsutsugamushi. The test was performed as per manufacturers instructions and any positive samples further tested by an IgM ELISA (InBiOS International Inc. USA) to diagnose current infection. Among these 30 cases, ICT was positive in three (10%) samples. Further analysis of the reactive samples by IgM ELISA revealed all three samples to be IgM positive. Outbreaks of scrub typhus have been reported from various parts of India in the recent past [2,3]. Thus, there is a strong possibility of presence of this disease in this region also. All three serologically confirmed cases in the present study were residents of Delhi with no history of recent travel to a scrub typhus endemic region, a strong evidence in favour of existence of the disease in the city. The 10% prevalence of scrub typhus reported in our study is in contrast to another report from Delhi where the prevalence of scrub typhus was reported to be quiet low [4]. A study conducted in paediatric population of Sri Lanka, a region endemic for scrub typhus, has reported a prevalence of 33.33% [5]. Scrub typhus is grossly under-diagnosed due to its non-specific clinical presentation, low index of suspicion among clinicians and lack of diagnostic facilities. Since antimicrobials effective for scrub typhus are usually not included in empirical therapy for febrile illnesses, early diagnosis is imperative to reduce the mortality and complications associated with the disease. Our study highlights the existence of scrub typhus in Delhi, a region non-endemic for this infection and the need to consider it as a possible cause of paediatric febrile illnesses. To the best of our knowledge this is the first study undertaken to estimate seroprevalence of scrub typhus in paediatric population of Delhi.

An Audit of VDRL Testing from an STI Clinic in India: Analysing the Present Scenario with Focus on Estimating and Optimizing the Turnaround Time

BACKGROUND Timeliness of reporting is of utmost importance to limit the spread of syphilis. The present analysis was undertaken to evaluate the turnaround time of syphilis testing (mainly Venereal disease research laboratory /VDRL test) in a sexually transmitted infections (STI) clinic in India; to find out the possible reasons for delay; to describe the trends of clinical indications for syphilis testing from an STI clinic; to assess the frequency of a positive syphilis serology among STI clinic attendees; and to analyse the follow-up rates of VDRL report collection. MATERIALS AND METHODS Two hundred consecutive VDRL requests received at the serology laboratory of a tertiary care health facility from the STI clinic of the linked hospital were prospectively analysed to evaluate the above parameters. RESULTS For the 200 requests audited, the mean absolute turnaround time of VDRL test was 7.46±2.81 days. The mean duration of the pre-laboratory, laboratory and post laboratory phases was 0, 4.69±2.13 and 2.77±2.51 days respectively. The interval from specimen receipt to performance of tests (mean duration=4.25±1.96 days) was the major reason for long VDRL turnaround time. The common indications for syphilis testing in STI clinic attendees were lower abdominal pain (33%), vaginal discharge (26.5%) and genital ulcer disease (9%); and the follow-up rate for report collection was 71%. CONCLUSION Our study highlights the strong need to shift to alternative testing methods, mainly rapid point of care procedures for serodiagnosis of syphilis in order to circumvent the problems of long turnaround time and low patient follow-up rates.

A study of HIV-concordant and -discordant couples attending voluntary counselling and testing services at a tertiary care center in North India

A large number of Indian couples are exposed to the risk of heterosexual human immunodeficiency virus (HIV) transmission. The present records-based study was undertaken at the voluntary counselling and testing facility of a tertiary care hospital in New Delhi, India to determine HIV prevalence among Indian couples; to assess the magnitude of seroconcordance and discordance among HIV-affected couples; and to compare the concordant and discordant partnerships for sociodemographic determinants and cluster of differentiation 4 (CD4) counts. Of the 1309 couples included in the study, 249 (19%) were HIV-affected, and of them 113 (45.4%) were concordantly and 136 (54.6%) discordantly affected by HIV. Males were the HIV-infected partners in 72% of the serodiscordant partnerships analyzed. Seroconcordance was significantly associated with the occupation status of being a housewife (P = 0.009). The contribution of discordant partnerships to the burden of HIV/acquired immune deficiency syndrome (AIDS) is significant, warranting novel couple-targeted counselling strategies and preventive measures, including safe sexual behavior and possibly preexposure HIV prophylaxis of the uninfected partner.