Neeraj Nischal

Index-TB guidelines: Guidelines on extrapulmonary tuberculosis for India.

Extrapulmonary tuberculosis (EPTB) is frequently a diagnostic and therapeutic challenge. It is a common opportunistic infection in people living with HIV/AIDS and other immunocompromised states such as diabetes mellitus and malnutrition. There is a paucity of data from clinical trials in EPTB and most of the information regarding diagnosis and management is extrapolated from pulmonary TB. Further, there are no formal national or international guidelines on EPTB. To address these concerns, Indian EPTB guidelines were developed under the auspices of Central TB Division and Directorate of Health Services, Ministry of Health and Family Welfare, Government of India. The objective was to provide guidance on uniform, evidence-informed practices for suspecting, diagnosing and managing EPTB at all levels of healthcare delivery. The guidelines describe agreed principles relevant to 10 key areas of EPTB which are complementary to the existing country standards of TB care and technical operational guidelines for pulmonary TB. These guidelines provide recommendations on three priority areas for EPTB: (i) use of Xpert MTB/RIF in diagnosis, (ii) use of adjunct corticosteroids in treatment, and (iii) duration of treatment. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, which were evidence based, and due consideration was given to various healthcare settings across India. Further, for those forms of EPTB in which evidence regarding best practice was lacking, clinical practice points were developed by consensus on accumulated knowledge and experience of specialists who participated in the working groups. This would also reflect the needs of healthcare providers and develop a platform for future research.

Atypical cases of filariasis from a non-endemic area

Filariasis can present in many different ways and pose significant dilemma to the clinician. We report four atypical cases of filariasis which presented as abdominal mass, cervical lymph node enlargement, fever in pregnancy and nosocomial febrile illness respectively. All the four cases were treated successfully with oral antifilarial agents. It is essential to be aware of such atypical presentations of filariasis so that prompt therapy can be initiated.

Osteomyelitis due to multiple rare infections in a patient with idiopathic CD4 lymphocytopenia

A 26-year-old male patient presented with features suggestive of osteomyelitis involving the entire left femur, hip joint and knee joint. Culture from the debrided tissue grew Acinetobacter spp. and he was treated with sensitivity based antibiotics but the symptoms did not resolve. The synovial biopsy showed multinucleated giant cells and acid fast bacilli on Ziehl Neelsen stain. Cartridge based nucleic acid amplification test (GeneXpert) was negative. The Mycobacteria growth indicator tube culture was found to be positive for Mycobacterium abscessus. The patient was started on imipenem, amikacin and macrolide based therapy. There was partial response initially but the patient worsened again. A girdle stone arthroplasty with cemented nail (with tobramycin) insertion after debridement of the infected tissue was done. Potassium hydroxide (KOH) mount from the debridement sample was found to be positive for aseptate hyphae suggestive of mucormycosis. He was treated with liposomal amphotericin B. He was evaluated for immunodeficiency in view of multiple atypical infections and was found to have a low CD4 count. The patient was discharged on amikacin, azithromycin, trimethoprim-sulfamethoxazole and posaconazole. Follow up showed considerable resolution both clinically and radiologically. To our knowledge, this is the first reported case of osteomyelitis with co-infection of Acinetobacter spp., M. abscessus and mucormycetes. We report this case to highlight the possibility of multiple rare infections in patients with immunodeficiency. Also, atypical complicated bone infections, such as Mycobacterium abscessus and mucormycetes might require combined medical and surgical treatment.

Bilateral optic neuritis following Mycoplasma pneumoniae infection

Dear Editor, We read with interest, the article on bilateral optic neuritis following Mycoplasma pneumoniae infection by Chiang and Huang.[1] Management of the case by authors was solely based on the hypothesis that optic neuritis developed secondary to an immune reaction. After going through the literature, we would like to highlight few important facts regarding the role of M. pneumoniae in cases with neurological damage. Extrapulmonary manifestations of M. pneumoniae infection especially nervous system involvement have been widely reported in the literature. Neurological injury falls into two patterns: Direct invasion by organism and secondary to an immune response. Cases when neurological involvement has been attributed to an immune complex mediated reaction, the duration of prodromal respiratory symptoms has usually been >7 days.[2] An auto-immune response causes neurological damage secondary to cytokine production, autoimmunity, and vascular occlusion. In a large case series published by Bitnun et al. the authors claim that in patients with neurological involvement they could detect M. pneumoniae antigen by polymerase chain reaction in cerebrospinal fluid/throat of patients who had at least 5–7 days of respiratory prodromal symptoms.[3] They proposed that respiratory infection can have a cytotoxic effect on respiratory epithelium, and this can facilitate blood stream invasion by M. pneumoniae. In the current case, coexistence of respiratory symptoms and visual symptoms along with raised Mycoplasma immunoglobulin (Ig) M titres (+, >75 BU/mL) raises the possibility of acute M. pneumoniae infection for the treatment of which intravenous Ig should be administered under a 2 week macrolide cover.[4] Although the response to Ig suggests an immune mechanism is involved along with acute infection, administration of high dose steroids can cause transient leucopenia which can suppress micro-organism. Holistic approach in such a case requires management of systemic status along with visual complaints. A chest X-ray at the time of presentation and a repeat serology to look for change in IgM and IgG levels would have supplemented the management. We agree with authors that in cases of optic neuritis in children with respiratory symptoms M. pneumoniae should not be overlooked as a probable cause and should be investigated for.