Syed Manazir Ali

Role of parenteral testosterone in hypospadias: A study from a teaching hospital in India

Objectives: To evaluate the effect of parenteral testosterone on penile length, preputial skin and side effects in patients with hypospadias. Materials and Methods: 23 patients with hypospadias were included in this study. An oily solution, each ml of which contained testosterone propionate 25 mg, and testosterone enanthate 110 mg, equivalent to 100 mg of testosterone was given deep intramuscularly 4, 3 and 2 weeks before reconstructive surgery at the dose of 2 mg/kg body weight. Increase in penile length, transverse preputial diameter, and diameter at the base of penis were noted. Basal testosterone levels were obtained before the institution of therapy and on the day of operation. In addition, side effect such as development of pubic hair and delay in bone age was noted. Results: Following parenteral testosterone administration, the mean increase in penile length, transverse preputial diameter and diameter at the base of penis was 1.35±0.40 cm (P<0.001), 1.40±0.47 cm (P<0.001), and 0.72±0.47 cm (P<0.001), respectively. Serum testosterone level after injection was well within normal range for that age. Minimal side effects were noted in form of development of fine pubic hair. Conclusion: We conclude that parenteral testosterone can be safely used to improve the surgical outcome of hypospadias repair.

First reported New Delhi metallo-β-lactamase-1-producing Cedecea lapagei

Cedecea lapagei is a Gram-negative, facultative anaerobic, nonspore-forming bacterium belonging to the family Enterobacteriaceae, first isolated by the US Centers for Disease Control and Prevention (CDC) laboratories in 1981. It has been reported as a pathogen in a few cases of bacterial peritonitis, wound infection, chemical burns and pneumonia [1]. New Delhi metallo-β-lactamase-1 (NDM-1) was first reported in 2009 in Klebsiella pneumoniae and Escherichia coli isolated from a patient in Sweden who had received medical care in New Delhi, India [2]. Here we report the presence of a clinically significant NDM-1producing C. lapagei in a 26-day-old female preterm baby admitted to the paediatric intensive care unit (ICU) of a 1300-bed tertiary care hospital in Aligarh, India. The patient was diagnosed with lateonset sepsis, apnoea and hypocalcaemia and was treated with cefotaxime and phenytoin (Epsolin) with no recovery observed after the first week. Amikacin was also added to the treatment along with cefotaxime for another week. The baby started recovering after 14 days. An NDM-1-producing C. lapagei isolate was detected in a blood sample, which to the best of our knowledge is the first report of NDM-1-producing C. lapagei. The identity of the isolated strain (AK68) was confirmed by BD PhoenixTM 100 Automated Microbiology System using panel NMIC/ ID-55 (Gram-negative susceptibility card) followed by 16S rDNA sequencing. Furthermore, antimicrobial susceptibility was determined by the standard disk diffusion method using Mueller– Hinton agar as per Clinical and Laboratory Standards Institute (CLSI) guidelines. The strain was found to be resistant to imipenem, meropenem, aztreonam, ceftazidime, cefotaxime, cefoxitin, cefepime and cefoperazone/sulbactam. Moreover, detection of metallo-βlactamase activity was performed using two imipenem disks (10 μg), one containing 10 μL of 0.1 M anhydrous ethylene diamine tetraacetic acid (EDTA). The disks were placed 25mm apart on Mueller– Hinton agar plates [3]. Minimum inhibitory concentrations (MICs) were determined following CLSI guidelines and the results are given in Table 1. MIC data showed high resistance to β-lactams. PCR amplification of whole DNA from strain AK68 using previously described primers revealed the presence of blaNDM [4]. Following purification, the amplified product was sent for sequencing (SciGenom Labs Pvt. Ltd., Kerala, India). The obtained sequence was identified as blaNDM-1 by sequence analysis using BLAST (http://www.ncbi.nlm.nih .gov). The presence of other markers (blaVIM, blaOXA-1, blaOXA-9, blaCMY, blaSHV, blaCTX-M, blaTEM, blaIMP and blaKPC) was also checked for in association with blaNDM-1. Only blaCTX-M, blaSHV and blaTEM were found in coexistence with blaNDM-1. The genetic environment of blaNDM-1 was analysed for the presence of an insertion sequence (IS) known to be associated with the blaNDM-1 in Enterobacteriaceae [5]. Primers targeting the IS element Aba125 identified a complete ISAba125 upstream of blaNDM-1 in strain AK68. The bleomycin resistance gene bleMBL was not identified downstream of blaNDM-1, which is an unusual feature compared with earlier known species carrying blaNDM-1 [3] and needs to be further characterised. The plasmid incompatibility group was determined by PCRbased replicon typing (PBRT). The strain was found to be untypeable. Conjugal transfer was performed using C. lapagei AK68 as donor and azide-resistant E. coli J53 strain as recipient on selection medium with cefoxitin (10 μg/mL) and sodium azide (100 μg/mL). Conjugation confirmed the plasmid location of blaNDM-1. This is the first case of an NDM-1-producing C. lapagei strain isolated from a neonate admitted to the paediatric ICU of a north Indian hospital. Hence, there is an urgent need to perform a proper surveillance study to control further spread of NDM-1 in evolving new species. Nucleotide sequence accession number: The sequence of blaNDM-1 determined in this strain was submitted to GenBank with the accession no. KX231908. Funding: This study was supported by grants DBT Award BT/ HRD/NBA/34/01/2012, BT/PR8281/BID/7/448/2013 and ICMR grant AMR/5/2011-ECD-1 to AUK. Competing interests: None declared. Ethical approval: Clearance from the institution ethical committee was received for the whole study [no. 151/201517/PDFWM2015-2017-UTT-31140 (SAII)].

Occurrence of blaNDM Variants Among Enterobacteriaceae From a Neonatal Intensive Care Unit in a Northern India Hospital

Carbapenem-resistance among enterobacteriaceae has become a global health concern. The objective of this study was to understand NDM producing enterobacteriaceae and their genetic basis of resistance, spreading in neonatal intensive care unit. Carbapenem resistant NDM producing enterobacteriaceae isolates were recovered from rectal swab and blood sample of infants admitted in NICU. These were determined by using Carba-NP test. All isolates were identified using BD PhoenixTM−100 and MICs were determined by broth microdilution method. The blaNDM and associated resistant markers were checked by PCR followed by sequencing. Moreover, ERIC-PCR and genetic environment of blaNDM gene were also performed for the analysis of clonal relationship and genetic surrounding of the strains. We characterized 44 isolates with blaNDM variants in Escherichia coli (45.5%), Klebsiella pneumoniae (40.9%), Citrobacter freundii (4.5%), Citrobacter braakii (2.3%), Klebsiella oxytoca (2.3%), Enterobacter cloacae (2.3%), Enterobacter aerogenes (2.2%) from NICU, showing resistance against all antibiotics except colistin and polymixin B. ISAba125 and bleomycin gene were found surrounding all blaNDM variants, besides class I integron on plasmid. (ERIC)-PCR data revealed non-clonal relatedness among most of the isolates. The transfer of resistant markers was confirmed by conjugation experiment. The PCR-based replicon typing was carried out using DNA of transconjugants. These isolates carried NDM-1 (20.45%), NDM-4 (36.36%), NDM-5 (38.64%), NDM-7 (4.55%), along with OXA, CMY, and SHV variants on conjugative plasmid of IncFIA, IncFIC, IncF, IncK, IncFIB, IncB/O, IncHI1, IncP, IncY, IncFIIA, IncI1, and IncN types. An increased number of carbapenem-resistant NDM producing enterobacteriaceae isolates recovered from NICU which is alarming signal for health workers and policy makers. Hence, it is utmost important to think about infection control measures.

Prevalence of pulmonary arterial hypertension on echocardiography in newborns with maternal risk factors

Persistent Pulmonary Hypertension of Newborn (PPHN), considered an extreme form of PAH, can be defined as a failure of normal fall in pulmonary vascular resistance (PVR) at or shortly after birth, leading to shunting of unoxygenated blood into the systemic circulation across foramen ovale or ductusarteriosus.1 PPHN physiology mimics the fetal circulation in which PVR exceeds SVR and right to left hemodynamic shunting occurs through foramen ovale and/or ductus Arteriosus.1

A case of bilateral tension pneumothorax—life saving intervention going wrong!

About 1% of newborns may develop spontaneous pneumothorax shortly after birth. However, neonatal tension pneumothorax is a rare occurrence with only few incidences reported in literature. If prolonged resuscitation of a neonate is failing, underlying tension pneumothorax may be suspected and managed early to improve survival. Here, we present a report of a newborn baby who developed a bilateral tension pneumothorax and extensive surgical emphysema after being delivered by caesarean section for fetal distress.

Newborn with meroanencephaly: Surviving all odds

Neural tube defects are a group of congenital anomalies of brain development that carry a significant risk of morbidity and mortality. Anencephaly is a serious form of this defect with a very poor prognosis. It can present in three forms – meroanencephaly, holoanencephaly, and craniorachischisis. Meroanencephaly is considered to be the classic form of anencephaly. It manifests as a lack of cranial vault bones and exposed dorsal neural tissue resulting from defective neural tube closure in the very early period of gestation. Antenatally, the diagnosis may be suggested by ultrasound examination and by elevated maternal alpha-fetoprotein level. Here, we describe a case of meroanencephaly who was discharged from the hospital in fair condition despite the life-threatening anomaly.