WIMJ2016 Complete Issue

WIMJOURNAL, Volume No. 3, Issue No.
1, 2016 pISSN 2349-2910

eISSN 2395-0684
ORIGINAL ARTICLE
Aerobic bacteriology of the subgingival plaque in patients with and without
periodontitis undergoing tooth extraction
Dhotre S. V.1, Jahadirdar V. L.2, Davane M.S.3, Mumbre S.S.4, Nagoba B. S.5
Assistant Professor of Microbiology, Ashwini Rural Medical College Hospital & Research
Centre,Kumbhari, Solapur1, Formerly Dean Govt. Medical College, Miraj2, Assistant Professor
of Microbiology, MIMSR Medical College, Latur3, Professor of PSM, Ashwini Rural Medical
College Hospital & Research Centre, Kumbhari, Solapur.4, Assistant Dean (R&D),MIMSR
Medical College, Latur5.
Abstract: Conclusions: There is a distinctive bacterial

flora in the healthy oral cavity which is
Aim: To report the pattern of distribution of
different from that of the patients with
the aerobic subgingival microflora in patients
periodontitis. However, there is predominance
with and without periodontitis undergoing
of viridans group streptococci in the
tooth extraction and healthy controls.
subgingival plaque of healthy controls and
Methods: The prevalence and the distribution
patients as well, suggesting their contribution
of the aerobic cultivable microflora were
in progression of periodontitis, if oral hygiene
examined in healthy controls, patients
is compromised.
undergoing tooth extractions without
periodontitis and patients undergoing tooth Keywords: Periodontitis, tooth extraction,
extraction with periodontitis. The bacterial
Introduction:
isolates were grown using standard culture
techniques and the isolates were identified The oral cavity is colonized with different
using automated Vitek2 (bioMerieux). types of microorganisms.(1) Oral cavity is the
Results: A total of 370 aerobic isolates, initial part of the gastrointestinal tract; due to
comprised of 32 different species were the regular supply of food it makes an
identified in this study. Majority of the strains environment favourable for the growth of
225 (60.81%) were isolated from patients of microorganisms. The microbiology of the oral
periodontitis as compared to 145 (39.19%) subgingival flora has been the area of intense
patients without periodontitis. investigation for several decades. This focus is
© Walawalkar International Medical Journal 1

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Dhotre S. V
justifiable since bacteria are the etiological committee. This study included 120 subjects,
agents of periodontitis and other oral diseases, divided into three groups:
which remain the primary cause of tooth loss
(Group I) 40 healthy controls
in adults worldwide.
(Group II) 46 patients undergoing single tooth
The largest biomass of oral bacteria in the
extraction without periodontitis.
mouth exists on the teeth, which comprises
dental plaque, can accumulate upto 1011 (Group III) 34 patients undergoing single
organisms per gram wet weight and bacteria tooth extraction with periodontitis.
form the predominant microflora of the dental
All participants provided written informed
plaque.(2) Species of bacteria which are
consent.
normally associated with subgingival plaque
are also associated with periodontopathic Exclusion criteria-
pathogens such as, Porphyromonas gingivalis,
We excluded patients if they had fewer than
Treponema denticola, and Prevotella
10 teeth; an active viral infection, poorly
intermedia in periodontal disease.(3) It is
controlled systemic disease, penicillin allergy,
therefore essential to gain a complete
antimicrobial usage within three months prior
understanding of the bacteria colonising the
dental treatment, temperature greater than
subgingival plaque, which are associated with
100.5°F or facial cellulitis; or were
the periodontopathic pathogens in periodontal
immunocompromised by virtue of disease or
disease process and systemic infections such
medications.
as infective endocarditis. Considering this dual
relationship of the oral microflora in health Inclusion criteria-
and disease, it is vital to understand its
Patients -The study was initiated with patients
composition and define its role in the oral
who were enrolled with our hospital-based
cavity. In the present study an attempt has
dental service who needed to have at least one
been made to find out the bacterial isolates
erupted tooth extracted.
commonly associated with periodontitis.
Materials and methodsThis study was

approved by the institutional ethical

Controls -Controls were healthy subjects who Results

were matched for age and sex and satisfied the
The average age of the 120 adult
same exclusion criteria as the cases.
subjects was 49 years, 8 months ± 3 years, 8
Bacteriological analysis months.
A prospective bacteriological analysis of the Subgingival plaque bacteriology

subgingival plaque was carried out in patients
A total of 69 bacterial strains were isolated
and controls after taking pre-informed and
from subgingival plaque of group I healthy
written consents from the volunteers.
controls comprising of 17 bacterial species
Clinical samples of subgingival plaque were (Table 1). The predominant isolates were
obtained from healthy controls and patients viridans group streptococci 59 (85.51%),
undergoing tooth extraction. Subgingival whereas the other bacterial strains which
plaque samples were collected from the included Kocuria rosea 3 (4.35%), Gemella
gingival area of buccal and lingual tooth morbillorum 2 (2.90%), Kocuria cristinae 2
surfaces using sterile Gracey curettes into (2.90%), coagulase negative staphylococci 1
(7)
sterile ringer’s solution. (1.45) and other bacterial species were less
frequently isolated.
Subgingival plaque specimens were inoculated
onto special media, Tryptone soya blood agar The distribution of aerobic organisms isolated
supplemented with strepto supplement from subgingival plaque samples of patients
(Nalidixic acid 3.750 mg, Nemomycin undergoing tooth extraction without
sulphate 1.060 mg and Polymixin B sulphate periodontitis (group II) and patients
8500 units for 500 ml media) and Mutans undergoing tooth extraction with periodontitis
Sanguis agar (Himedia laboratories, Mumbai). (group III) is shown in Table 2. Out of the 80
Cultures with growth were further subjected to patients of tooth extraction, all the subgingival
standard biochemical identification using plaque samples (yielded positive cultures;
automated Vitek 2 (bioMérieux) system to producing 370 different isolates of which
complete the strain identification. majority were 260 (70.27%) were viridans
streptococci. Isolation of viridans group
streptococci was highest among the Group III

subjects with periodontitis 167 (45.30%), and Group II 52 (14.05%). Overall rate of
when compared to group II subjects without bacterial isolation was higher in Group III
periodontitis 93 (25.13%). However, the rate subjects with periodontitis 225 (60.81%) than
of isolation of other bacteria was almost Group II subjects without periodontitis 145
similar in both groups; Group III 58 (15.67%) (39.18%).
Table No. 1: Distribution of bacterial strains isolated from subgingival plaque of group
A-healthy controls (n=40) on aerobic culture
Sr. No Non-streptococcal species No. (%)

1 Kocuria rosea 3 (4.35)
2 Gemella morbillorum 2 (2.90)
3 Kocuria cristinae 2 (2.90)
4 CONS 1 (1.45)
5 Micrococcus species 1 (1.45)
6 Neisseriae spp 1 (1.45)
Sub- total I 10 (14.49)
Viridans group streptococcal species
7 Steptococcus oralis 12 (17.39)
8 Streptococcus mutans 12 (17.39)
9 Streptococcus mitis 9 (13.04)
10 Granulicatella elegans 6 (8.70)
11 Granulicatella adiacens 4 (5.80)
12 Streptococcus anginosus 4 (5.80)
13 Streptococcus gordonii 3 (4.35)
14 Streptococcus sanguinis 3 (4.35)
15 Streptococcus constellatus 2 (2.90)
16 Streptococcus parasanguinis 2 (2.90)
17 Streptococcus sinensis 2 (2.90)
Sub- total II 59 (85.51)
Total I + II 69 (100)

Table No. 2: Distribution of microorganisms isolated from subgingival plaque of patients

undergoing tooth extraction with and without periodontitis (n=80)
Microorganism isolated Patients without Patients with

periodontitis periodontitis
Group I (n=46) Group II (n=34) Total isolates
Bacterial isolates No. of isolates
Kocuria rosea 8 11 19
Enterococcus spp 5 6 11
Gemella morbillorum 4 7 11
CONS 3 8 11
Corynebacterium spp 4 4 8
Neisseriae spp 5 3 8
Staphylococcus aureus 4 3 7
Kocuria cristinae 3 3 6
Micrococcus species 2 4 6
Bacillus spp 4 1 5
Rothia spp 4 1 5
Eikenella spp 1 3 4
Acinetobacter lwoffi 2 1 3
Escherischia coli 1 1 2
Lactococcus spp 2 0 2
Erysipelothrix rhusiopathiae 0 1 1
Pseudomonas aeruginosa 0 1 1
sub-total 1 52 58 110
Viridans Group Streptococci
Streptococcus mitis 12 38 50
Steptococcus oralis 12 33 45

Streptococcus mutans 14 16 30
Streptococcus anginosus 2 4 6
streptococcus constellatus 2 5 7
Streptococcus sanguinis 18 23 41
Streptococcus parasanguinis 5 7 12
Streptococcus gordonii 1 3 4
Streptococcus hyointestinalis 0 1 1
Streptococcus pluranimalium 0 1 1
Streptococcus sinensis 1 1 2
Streptococcus thoraltensis 0 1 1
Streptococcus tigurinus 0 1 1
Nutritionally variant streptococci
Granulicatella adiacens 9 12 21
Granulicatella elegans 17 21 38
sub-total 2 93 167 260
Total isolates (1+2) 145 225 370
Discussion bacterial species from the subgingival plaques

It has long been known that oral from patients with and without periodontitis
bacteria preferentially colonize different and healthy controls.
surfaces in the oral cavity as a result of It was observed that, a total of 69
specific adhesins on the bacterial surface aerobic isolates from healthy controls and 370
binding to complementary specific receptors aerobic isolates from patients undergoing
(8,9)
on a given oral surface. The purpose of tooth extraction were recovered. Among these
this study was to define the predominant isolates, majority of the strains belonged to
bacterial flora of the healthy oral cavity by viridans group of streptococci 59 (85.51%) in
identifying and comparing the cultivable controls and 260 (70.27%) in patients

undergoing tooth extraction, whereas the other comparatively less, these findings fairly
bacterial strains accounted for 10 (14.49%) in correlate to the fact that poor oral hygiene
controls and 110 (29.73%) in patients results in plaque and calculus accumulation
undergoing tooth extraction (Table 1, 2). around teeth that can lead to inflammation and
The oral cavity can be colonized by a ulceration of the gingival tissues (that is,
wide range of bacteria; more than 700 species gingivitis), which precedes periodontitis and
have been detected.(10) Viridans streptococci eventual tooth loss.(17)
constitute a significant proportion of the flora Conclusion:
around the teeth, especially in the dental There is a distinctive bacterial flora in
biofilm that grows above the gingival crest. the healthy oral cavity which is different from
The supragingival plaque also contains a that of the patients with periodontitis.
higher proportion of viridans streptococci However, there is predominance of viridans
species, whereas deeper periodontal pockets group streptococci in the subgingival plaque
harbour more anaerobic and gram-negative of healthy controls and patients as well,
species. These factors may explain our finding suggesting their contribution in progression of
of high incidence of viridians streptococcal periodontitis, if oral hygiene is compromised.
isolation from the subgingival plaque in the Further studies are necessary to analyze larger
study population. Our findings are in numbers of clinical samples for the levels of
agreement with many earlier studies, which essentially all oral bacteria in well controlled
have also reported predominance of viridians clinical studies; to draw concrete evidences
streptococci in the oral flora, as compared to about the distribution of bacteria in the
other bacterial genera.(11-16) subgingival bacterial community and its role
Our study also shows a significant in periodontal diseases.
relationship between distribution of Conflict of interest: None to declare
subgingival plaque micoflora and poor oral Source of funding: Nil
hygiene and periodontal disease parameters. References
High rate of bacterial isolation 225 (60.81%) 1. Ribet D., Pascale C. How bacterial
was observed in patients with periodontitis, pathogens colonize their hosts and
whereas the rate of bacterial isolation 145 invade deeper tissues. Microbes and
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http://dx.doi.org/10.1016/j.micinf.201 Interdental Sites Using a Low

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Microbiol. Infect. Dis. 1995;22:267- 11. Igarashi T, Yamamoto A, Goto N.
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Heinecke A, Häberlein I, Flemmig TF. C, Medina J, Diz P. Prevalence,
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2007;13:56–62. Donelly JP, Catovski D, Galton DA.
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Address for correspondence:

Dr. B. S. Nagoba
Assistant Dean,
Research & Development,
Maharashtra Institute of Medical Sciences & Research,
Latur-413 531,M.S., INDIA
Email: bsnagoba@gmail.com
Office Telephone: +912382227587
Mobile No. +919423075786

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 pISSN 2349-2910
eISSN 2395-0684
ORIGINAL ARTICLE
Study of acute undifferentiated fever cases and their etiologies in rural

Konkan area of Maharashtra state
Patil S. N1, Korochikar S. P2
Medical Director, B. K.L. Walawalkar Rural Medical College & Hospital, Sawarde1,
Department of Microbiology, B. K.L. Walawalkar Rural Medical College & Hospital, Sawarde2 .
samples received from District hospitals and

Abstract:
Primary health centers from Sindhudurg
Background:
District of Maharashtra state for the duration
Acute undifferentiated fever (AUF) is a
of October 2012 to January 2014. Patients
common cause for which the patients seek
with age ≥5years and with classical symptoms
health care in India. It is region specific and
of febrile illness were included in the study.
has similar clinical presentation, with varied
About 500 blood samples received were
etiologies. Due to this it posses challenge to
investigated for Malaria, Bacterial culture
the diagnosis, treatment and public health.
sensitivity, Leptospira culture, ELISA for
Majority of patients present with nondescript
scrub typhus, Brucella, Dengue and
symptoms. Scrub typhus, Malaria, Enteric
Leptospira and further evaluated for
Fever, Dengue, Leptospirosis, Chikungunya,
commonest region specific AUF etiology.
Spotted fever, Rickettsiosis, Hantavirus, Q
fever, Brucellosis, Influenza and other
Results:
bacterial infections are some of the common
The study included 500 blood samples
etiologies of AUF. The prevalence of local
obtained from patients presenting with
AUF etiologies helps to prioritize differential
classical symptoms of AUF. Samples received
diagnosis and guide the treatment. The study
from males showed highest number of positive
aimed to find out the predominant AUF
cases amounting for 82.47% with majority of
etiologies in the rural Konkan area of
cases (83%) cases in middle age group. The
Maharashtra state in India.
sero-positivity of samples accounted for
42.8%. Brucella was the most common cause
Materials and Methods:
of AUF (28.50%) followed by Leptospira
This prospective observational study was
(27.10%) and Scrub typhus (21.49%).
conducted at a tertiary care hospital on the

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Patil S.N.
Interestingly there were no positive cases of epidemic diseases. Majority of patients show
malaria and only 11.21% samples positive for nondescript symptoms like Fever with chills,
Dengue which are considered as most Headache, Retro-orbital pain, Myalgia,
common AUF etiologies and treated Arthralgia, Rash, Hemorrhagic manifestation
accordingly. and Leucopenia. The reports indicate that
Conclusion: Scrub typhus, Malaria, Enteric Fever, Dengue,
AUF is the most common clinical problem Leptospirosis, Chikungunya, Spotted fever,
worldwide with varied etiologies and non Rickettsiosis, Hantavirus, Q fever, Brucellosis,
descript symptoms. Understanding of Influenza and other bacterial infections like
etiologies, their local prevalence and their UTI, Respiratory Tract infections and
specific features will be helpful in treating diarrheal diseases are some of the common
AUF cases during various outbreaks. etiologies of AUF(2). The prevalence of local
AUF etiologies determines the prioritization
Key words: Acute undifferentiated of differential diagnosis of the clinical
febrileillness, dengue fever, etiology, scrub syndrome (3).
typhus, Konkan. In the developing countries usually acute
febrile illness is considered as either dengue or
Introduction: malaria and the treatment is given
The classical manifestation of an infection or accordingly. Laboratory evaluations for fever
illness is fever. It is the most common clinical in developing countries usually include
complaint observed in variety of patients. microscopy of thick and thin blood smears for
Acute undifferentiated fever (AUF) also malaria. In India, although about 100 million
known as acute febrile illness is a common individuals are investigated for malaria by
cause for which the patients seek health care microscopy every year, as per the official
in India, especially between the month of June estimates only less than 2% of them are slide-
(1)
and September . An acute febrile illness is positive. The annual slide positivity in
characterized by a sudden onset of fever with malaria-endemic countries is estimated to be
chills and often diagnosed on the basis of about 5% (6 million confirmed cases of 128
clinical observations. Acute febrile illness has million individuals investigated in 43
great diversity of etiology and posses countries)(4,5). The estimates show that, about
challenge to the diagnosis, treatment and 30 % to 90% of all patients with AUF are
public health response to the endemic and treated with antimalarial drugs, though only

to 45% of them have laboratory confirmed Patients with age ≥5years and with febrile
malaria(6). There is inadequate understanding illness with symptoms like fever with duration
among the health care providers about proper of 2 to 14 days & oral or axillary temperature
diagnosis and treatment for acute febrile ≥38°c, body ache, rash, abdominal pain,
illness. In rural parts of India the health sector ocular pain and red eyes and who consented
is underdeveloped with inadequate health care for the study were included. The patients who
facilities and resources for proper diagnosis of denied consent and with fever localizing the
disease. Reporting of cases and a treatment source of infection to skin, soft tissue,
seeking is lethargic and there is no health respiratory, gastrointestinal, meningeal or
awareness in the community. Acute febrile genitourinary tract were excluded from study.
illness can lead to fatal conditions if 18 ml of venous blood sample was collected
misdiagnosed or mistreated. aseptically before the administration of the
There is paucity of data regarding AUF antibiotics. The sample was dispensed 2 drops
etiologies in rural Konkan region of in EMJH medium, 8 to 10 ml in BacTec
Maharashtra. This study was aimed to bottle, 6ml in plain Vacutainer and 2 ml in
determine the prevalence of AUF etiologies at EDTA Vacutainer.
a rural tertiary care hospital at Sindhudurg The samples were investigated for Malaria,
District of Maharashtra state. Bacterial culture sensitivity, Leptospira
culture by EMJH method, ELISA for scrub
Materials and Methods: typhus, Brucella, Dengue and Leptospira. The
The study was conducted at BKL Walawalkar observations of investigations were recorded
Hospital; a 500 bedded rural tertiary health for analysis with reference to age, gender,
care center. Samples were obtained from investigations, area and etiologies.
patients treated at Civil hospital and various
Primary Health Centers of Sindhudurg district Results:
viz; District Hospital Sindhudurg, Sub District Total 500 samples were received for the study
Hospital Kankavali, Kudal, Sawantwadi and from October 2012 to January 2014.
Primary health centers from Hirlok, Kasal, Maximum104 (20.8%) samples were received
Kalsuli, Kharepatan, Nandgaon, Varavade, from Sub District Hospital Kankavali
Mangaon and Hivale. The duration of study followed by 87 (17.4%) samples from District
was from October 2012 to January 2014. Hospital Oras respectively.

Among 500 samples investigated, 336 samples Aztreonam, Cefotaxime/K Clav,

belonged to males and 164 to females Ceftazidime/K Cal, Cefalothin, Nitrofurantoin,
respectively. The age ranged from 12 to 80 Tetracyclin, Trimeth/Sulf. Also 100%
years with mean age of 36.52 +
+15.22 years. susceptibility was observed for 4 antibiotics
Maximum 415 (83%) cases belonged to age viz; Imipenem, Levofloxacin, Meropenem,
group above 50 years including 277 (82.47%) Ticar/K Clav.
cases of Males. Thus the results indicate predominance of
The investigations indicated 214 (42.8%) Brucella, Leptospira and Scrub typhus cases
positive cases with maximum 61 (28.50%) most common in Males as compared to
Brucella positive cases followed
wed by 58 females with maximum cases in age group
(27.10%) of Leptospira and 46 (21.49%) scrub above 50 years.
typhus positive cases by ELISA. Interestingly Figures and Tables:
there were no cases positive for malaria. Fig 1: Prevalence of AUF cases Positive for
The samples from District Hospital Oras various investigations
showed highest 57 (65.4%) positive cases with
Prevalence of Positive Cases
maximum 16 (18.4%) cases of Scrub typhus,
14 (16%) Leptospira ELISA Positive and 13
(14.9%) Brucella Positive cases. Blood Culture
The Bacterial culture indicated 21 (4.2%) Lepto Culture
0% 10% 2%
positive cases including 3 Gram negative Scrub Typhus
27%
21% Brucella
bacilli and 14 Gram positive cocci with
29% Dengue
Staphylococcus as a common isolate 11% Lepto ELISA
accounting
ng for 13 (61.90%) positive cultures. Malaria
The antibiotic sensitivity pattern against 29
antibiotics showed Gram positive cocci
showing 100 % resistance to 12 antibiotics
viz; Amox/KClav, Amphicillin/ Sulbactum, Discussion:
Amphicillin, Cefazolin, Cefepime, The study aimed to determine the common
Cefotaxime, Ceftriaxone,
triaxone, Cefalothin, AUF etiologies prevalent in the rural Konkan
imipenum, Nitrofuranton, Norfloxacin and region.
Oxacillin. The gram negative bacilli show Out of 500 samples investigated, 336 samples
s
100% resistance to 7 antibiotics viz; belonged to males and 164 to females

respectively. The age ranged from 12 to 80

years with mean age of 36.52 +15.22 years. Fig 2: Gender based distribution of positive
Highest 415 (83%) cases belonged to age AUF cases
group above 50 years i.e. middle age group
40
which is the working group at a risk for Males Females 37
exposure to infectious agents. Maximum 277 35

31
(82.47%) cases belong to Males which is 30
30
likely due to increased chances of exposure to 27
No. of Positive cases

pathogens as males predominantly work 25
21
outside. The findings are consistent with other 19
20
studies(7). 16
The study shows predominant AUF etiologies 15
like Brucella (61, 28.50%), Leptospira (58, 10 11

10 8
27.10%) and Scrub typhus (46, 21.49%)
5 3
which are zoonotic diseases most prevalent in
1
00
rainy season and common in farmers and 0
individuals with close contact of cattle or
exposed to contaminated water by the excreta
of infected animals especially rats. Many Investigations
studies indicate Leptospira, Rickettsiae,
Malaria and Dengue as most common
etiologies of AUF. The findings of Leptospira
and Scrub typhus are consistent with other
studies except that of Malaria and Dengue (1).
In current study there were no cases of malaria
associated with AUF while the Dengue
positive samples accounted for only 24
(11.21%) cases. The findings from a study in
Karnataka indicate Scrub typhus as most
common cause of acute fever followed by
Leptospirosis which is consistent with
findings in current study(8).

Table 1: Distribution of Positive AUF cases
Infection Area wise percentage of positive cases n (%) Total
Sawantwadi
Kharepatan
Nandgaon
Varavade
Mangaon
Kankavli
DH Oras
Kalsuli
Hirlok
Hivale
Kudal
Kasal
SDH
SDH
Total 87 104 33 SDH

5 27 20 37 28 62 46 25 26 500
Samples (17.4) (20.8) (6.6) (1) (5.4) (4) (7.4) (5.6) (12.4) (9.2) (5) (5.2) (100)
Blood 3 3 0 0 2 1 3 0 4 1 0 4 21
Culture (3.5) (2.9) (0) (0) (7.4) (5) (8.1) (0) (6.5) (2.2) (0) (15.4) (4.2)
Leptospira 2 1 0 0 0 0 0 0 1 0 0 0 4
Culture (2.3) (0.96) (0) (0) (0) (0) (0) (0) (1.6) (0) (0) (0) (0.8)
Scrub 16 7 3 2 2 1 1 2 7 1 2 2 46
Typhus (18.4) (6.7) (9.1) (40) (7.41) (5) (2.7) (7.1) (11.3) (2.2) (8) (7.7) (9.2)
13 15 7 0 3 3 1 1 6 4 2 6 61
Brucella
(14.9) (14.4) (21.2) (0) (11.1) (15) (2.7) (3.6) (9.7) (8.7) (8) (23.1)(12.2)
9 6 0 0 4 1 1 0 2 0 1 0 24
Dengue
(10.3) (5.8) (0) (0) (14.8) (5) (2.7) (0) (3.2) (0) (4) (0) (4.8)
Lepto 14 6 4 0 0 2 4 1 11 10 3 3 58
ELISA (16.0) (5.8) (12.1) (0) (0) (10) (10.8) (3.6) (17.7) (21.7) (12) (11.5)(11.6)
0 0 0 0 0 0 0 0 0 0 0 0 0
Malaria
(0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)
Area wise
Total 57 38 14 2 11 8 10 4 31 16 8 15 214
Positive (65.4) (36.6) (42.4) (40) (40.7) (40) (27) (14.3) (50) (34.7) (32) (57.7)(42.8)
Cases

With scarce diagnostic facilities and treatment Oras is a coastal city inhabited by the major
options in rural parts of India, majority of population of Sindhudurg district with
clinicians assume that the patient with AUF is tourism, fishing and agriculture as its major
likely to be suffering from malaria or either occupation. The regional prevalence of
dengue and the treatment is given accordingly. pathogens and their chances of exposure to the
A similar study in central India on Non local people influence the disease pattern.
malarial Acute Undifferentiated (NMAUF) The Bacterial culture indicated 21 (4.2%)
cases revealed that about 39.9% patients with positive cases including 3 Gram negative
NMAUF received unnecessary treatment with bacilli and 14 Gram positive cocci with
antimalarial drugs, indicating need for Staphylococcus as a common isolate
awareness and guidelines to improve accounting for 13 (61.90%) positive cultures.
treatment strategies for AUF cases(9). The findings are consistent with other studies
The samples from District Hospital Oras on bacterial etiologies of AUF. Bacterial
showed highest 57 (65.4%) positive cases with infection is one of the known etiologies for
maximum 16 (18.4%) cases of Scrub typhus, AUF with S. aureus and E. coli common
14 (16%) ELISA positive and 13 (14.9%) isolates(10).
Brucella positive cases. Thus the results indicate predominance of
Table 2: Account of Bacterial culture Brucella, Leptospira and Scrub typhus as most
isolates common AUF etiologies especially in Males
Sr. Isolates Count with maximum cases in middle age group
No.
above 50 years.
A Gram Positive Cocci 14
1 Staphylococcus species 13
Conclusion:
2 Micrococcus species 1 Acute febrile illness is the most common
B Gram Negative Bacilli 3 clinical problem worldwide with the diversity
3 Escherichia coli 2 of etiologies and non descript symptoms, it

posses challenge to the diagnosis, treatment
4 Pseudomaonas species 1
and public health. As most commonly AUF is
C Miscellaneous 4
diagnosed on basis of clinical observations
5 Candida 4 due to lack of treatment protocols and
Total 21 diagnostic facilities especially in the rural
parts there is tendency of under treatment of

other cause of AUF. The patients are 5. World Health Organization, 2007. Global
unnecessarily treated with anti bacterial and RBM Online Database. Geneva:
anti malarial drugs and also subjected to WHO.http://www.rbm.who.int/wmr2005/ht
unnecessary investigations adding to the cost m/1-1.htm.
of treatment. Understanding of etiologies, 6. Amexo M, Tolhurst R, Barnish G, Bates I,
their local prevalence and their specific 2004. Malaria misdiagnosis: effects on the
features will be helpful in treating AUF cases poor and vulnerable. Lancet 364: 1896–
during various outbreaks. 1898.
7. MA Andrews, Aleena Elizabeth, Pravinlal
Conflict of interest: None to declare Kuttichira, Clinical Profile of acute
undifferentiated febrile illness in patients
admitted to a teaching hospital in Kerala;
Source of funding: Nil
Health Science 2014;1(3):IS001D
8. Kashikunti MD, Gundikeri SK, Dhananjay
References: M; Acute Undifferentiated febrile illness-
lineal spectrum and outcome from a tertiary
1. Susilawati TN, McBride WJ. Acute
care teaching hospital of north Karnataka;
undifferentiated fever in Asia: a review of
Int J Biol Med Res.2013;4(3):3399-3402
the literature. The Southeast Asian journal
9. Rajnish Joshi, John M. Colford Jr.,
of tropical medicine and public health.
Arthur L. Reingold, and Shriprakash
2014;45(3):719-26.
Kalantri; Nonmalarial Acute
2. Kumar A, Dua V K, Pradipsinh K Rathod
Undifferentiated Fever in a Rural Hospital
:Malaria attributed death rates in India;
in central India: Diagnostic Uncertainty and
Lancet 377 (9770), 991-992, 19 (2011)
Over treatment with Antimalarial Agents;
3. P. Neelu Shree, L. Premkumar; A Pilot
Am, J. Trop. Med. Hyg., 78(3), 2008,
Study of Acute Undifferentiated Fever
pp.393-399
Using Certain Rapid Microbiological And
Virological Tests; Int J Pharm Bio Sci
2015Ot; 6(4): (B) 715-723
4. World Health Organization, 2005. World
Malaria Report 2005. Geneva: WHO and
UNICEF.

10. Amorn Leelarasamee MD, Chanpen febrile illness in Thailand; J Med Assoc
Chupaprawan MD, Etiologies of Acute Thai 2004;87(5):464-72

Dr. Suvarna N. Patil,
Medical Director,
Department of General Medicine,
B.K.L. Walawalkar Rural Medical College& Hospital,
Sawarde - 415 606, Dist – Ratnagiri, M.S., INDIA
Email: drsuvarnanpatil@gmail.com

eISSN 2395-0684
ORIGINAL ARTICLE
Prospective study of emergency presentation of abdominal tuberculosis
Akhilesh R. Mishra1, Dipak D. Thorat2 and V. M. Deshmukh3
Lokmanya Tilak Muncipal Medical College and Hospital, Sion Mumbai
Abstract: details, post operative course and the final

Background: outcome of the disease.
In developing countries like India, where To study the incidence of HIV positivity in
poverty, malnutrition and overcrowding patients with abdominal tuberculosis.
prevail, tuberculosis continues to be one of the Methods and material:
important causes of morbidity, mortality and The study was designed as a prospective
loss of working man hours. Abdominal observational study conducted during a study
tuberculosis (TB) can affect the period between June 2006 and June 2008 in a
gastrointestinal tract, the peritoneum, lymph tertiary care centre in Mumbai. All patients
nodes of the small bowel mesentery or the with a clinical suspicion of abdominal
solid viscera (e.g. liver, spleen, pancreas etc) tuberculosis were included in the study with
Patient of abdominal Koch’s can present as confirmation on histopathological
those with a chronic undulating course and examination. Patient’s written informed valid
those with an acute or subacute abdominal consent was taken after explaining the nature
catastrophe. In emergency the patient may of study.
present with various presentations like Result and conclusion:
stricture causing obstruction or with Age group commonly affected was between
perforation and require a different 21-30 years with male predominance.
management from those routine such cases Amongst the various complications of
Aim and objective: abdominal tuberculosis intestinal obstruction
To study the varied presentation of patients was the most common mainly due to stricture
with Abdominal Tuberculosis as acute and less commonly due to hyperplastic
surgical abdomen presenting in emergency ileocaecal mass. Next common complication
setting to those with a subacute course. observed was free perforation of the intestine
To evaluate the line of management whether which occurs at a site proximal to a tight
operative or conservative, the operative stricture. All patients were subjected to

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Mishra A.R.
operative intervention with local resection and mesentery or the solid viscera (e.g. liver,
anastomosis being the most preferred surgery spleen, pancreas etc)
performed. Terminal ileum and ileocaecal The gastrointestinal tract is involved in
region was the most common site involved. 66-75% of patients with abdominal
The incidence of HIV positivity was 11 per tuberculosis; the terminal ileum and the
cent. The incidence of mortality was 11 per ileocaecal region are the most common sites,
cent. Sepsis was the main cause of mortality in followed by the jejunum and colon. Multiple
all the cases. Duration of stay ranged from 2 sites are common, and most patients with
to 60 days. A prolonged stay was seen in gastrointestinal lesions also have peritoneum
patients who developed post operative and lymph node involvement; multiple lesions
complications. often occur.
Keywords: Primary lesions are often due to
Intestinal, Tuberculosis, Emergency ingestion of milk from infected cattle. Because
Introduction: of the common practice of boiling milk before
Tuberculosis is one of the major drinking, in India, the incidence of primary
public health problems in developing intestinal tuberculosis was less. But over the
countries of the world in the present era. It has past decade, the incidence of abdominal
made its impact felt through ages. No other tuberculosis presenting with complications has
disease has so much social, economical and been observed to have increased.
health significance. Intestinal tuberculosis is known to be
In advanced countries, the incidence an extremely chronic disease process causing
of tuberculosis had started to recede in the past chronic obstruction so that symptoms are
century with the advent of excellent never significant. Hence, patients often
chemotherapeutic agents but is making its neglect their symptoms or are misdiagnosed.
presence felt again with the upsurge of HIV- The chronic obstruction eventually culminates
AIDS pandemic. In developing countries like in a variety of complications.
India, where poverty, malnutrition and The advent and upsurge of HIV and AIDS in
overcrowding prevail, tuberculosis continues the past two decades has contributed a great
to be one of the important causes of morbidity, deal in providing a more fulminant course to
mortality and loss of working man hours. the disease. The increasing incidence of multi
Abdominal tuberculosis (TB) can drug resistant tuberculosis has further
affect the gastrointestinal tract, the amplified the problem. This has also resulted
peritoneum, lymph nodes of the small bowel in putting a tremendous strain on health

resources of our country which aims to INCLUSION CRITERIA:

provide treatment free of cost to the All cases of acute abdomen who
community. Since the treatment of presented in casualty suspected abdominal
tuberculosis runs a long and protracted course, tuberculosis between age group of 13 to 60 yrs
compliance of patients and a timely follow up irrespective of gender
remains a formidable challenge. All these EXCLUSION CRITERIA:
have resulted in significantly increased Histopathology negative for tuberculosis and
morbidity of the disease in modern era. patint with Genito-urinary tuberculosis
In emergency the patient may present Study design:
with various presentations like stricture A Prospective study
causing obstruction or with perforation and Detailed history of the patient was recorded
require a different management from those with emphasis on following points:
routine such cases 1. Duration of abdominal symptoms and their
The following is a study of serial 45 cases of nature.
abdominal tuberculosis which were admitted 2. Past, present or family history of
and treated in surgical wards of a general tuberculosis.
tertiary care hospital attached to a medical 3. History of ingestion of anti tubercular
college in Mumbai. therapy: category, duration.
4. History of low grade fever.
Materials and methods: 5. History of loss of weight and appetite.
The study was designed as a * Patients were subjected to a thorough
prospective observational study conducted physical examination taking into account the
during a study period between June 2006 and following parameters:
June 2008 at Lokmanya Tilak Muncipal I) General Examination:-
Medical and hospital Sion Mumbai. All a) Built
patients with a clinical suspicion of abdominal b) Nutritional status
tuberculosis were included in the study with c) Pallor
confirmation on histopathological d) Pulse
examination. Patient’s written informed valid e) Blood pressure
consent was taken after explaining the nature II) Per Abdomen examination:-
of study. a) Signs of peritionitis: rebound
tenderness, guarding, rigidity, distension
b) Visible peristalsis

c) Palpable lump complications of anti tubercular therapy, if

d) Ascitis any.
• Haematological and Biochemical All the above data was recorded in a
investigations were done with special specified case record proforma given at the
attention to haemoglobin and serum end and analysed at the end of study period.
albumin levels.
• HIV ELISA was done for all patients Discussion:
after appropriate pre test counselling. The incidence of intestinal
• X-ray chest was done routinely for all tuberculosis is highest among young adults in
patients to detect any active or old the third decade of life, according to Banerjee
healed lesion of pulmonary and Chuttani which corroborates with this
tuberculosis. study in which the incidence between age of
• X-ray Abdomen in standing position 21-30 years has found to be 46 %

was also done for each patient and the The mean age in this series was found
following points were noted to be 29 years. Haddad(58) et al found the
a) Presence of fluid levels and their average age of presentation of patients of
number abdominal tuberculosis to be around 26 years
b) Distended loops amongst Indians whereas it was 46 years for
c) Gas under diaphragm rest of the world. According to them it may be
d) Presence of colonic gas shadow due to high prevalence and earlier recognition
Special investigation like USG and CT were of the disease in the Indian subcontinent.
done in selected patients who presented with A higher incidence is seen in male
diagnostic dilemma. patients with a male: female ratio of 1.77:1.
Operative details were recorded which Various studies by several authors, Anand(11),
included intra operative findings and the type Banerjee, have quoted a female predominance
of procedure performed. with a male to female ratio of 1.3:12 and 1:9
Post operative complications, if any which is not conformity with this study. This
were also noted. discrepancy may be due to the fact that
Patients were examined at regular patients with tuberculosis of genital tract who
intervals after surgery to assess their general present to gynaecologists have not been a part
condition, nutritional status, to watch for of the study.

In this series the commonest the patients which compared well with the
complaint which brought the patient to the findings of Anand11 (1956) 100%, Bhansali(7)
hospital was abdominal pain seen in 98 % of (1968) 100% and Prakash8 (1978) 96.77%.
Symptomatology
97.78% 97.78%
100.00% 86.67%
80.00% 62.22%
60.00% No
37.78%
40.00% Yes
13.33%
20.00% 2.22% 2.22%
0.00%
Abdominal Pain Vomitting Distension Lump
A rather rare finding in this series has been the Hypoalbuminemia i.e, serum
se albumin
presence of right iliac fossa lump with a <3.5 g% was present in 78 % cases.
incidence of only 4 %. Anand(11) and Hypoalbuminemia was a prominent feature in
Prakash10 have described a 64 % incidence of patients who developed post operative
right iliac fossa lump. complications.
The commonest site of involvement is In our study x-ray
ray features suggestive
terminal ileum as seen in 68 % of cases. This of pulmonary tuberculosis either healed or
has been supported by studies of Tandon10, active were seen only
ly in 16 % of cases.
Bhansali7, Prakash10, possibly because of Evidence of pulmonary tuberculosis on x-ray
x
physiologic stasis and abundance of lymph
lymphoid chest included pulmonary infiltration, hilar
tissue in this region. lymphadenopathy, cavitatory lesions and
Anaemia ( haemoglobin <10 %) was miliary mottling.
seen in 22 % patients which was low in Sharma(13) 44
et al studied 70 cases of
comparison to study conducted by Sharma13 et abdominal tuberculosis and found evidence of
al where all his cases were reported to have active
ive or healed lesions on chest X-ray
X in 22
anaemia. (46%). X-rays
rays were more likely to be positive
in patients with acute complications (80%).

In Prakash's8, 10 series of 300 patients, none Agrawal(1964) also quote a lower percentage.
had active pulmonary tuberculosis but 39 per Thus, according to literature obstruction is the
cent had evidence of healed tuberculosis. most common complication followed by
Tandon27 et al found chest X-ray to be positive perforation. The present study corroborates
in only 25 per cent of their patients. Hence, this fact.
about 75 per cent cases do not have evidence Mesenteric lymphadenopathy was
of concomitant pulmonary disease. seen in 20 % of patients. Certain rare
Rendel and Richard stated that plain complications like enlarged lymph node at
X-ray abdomen in an erect posture gives a root of mesentry causing duodenal obstruction
good clue to the level of intestinal obstruction. and formation of gastropancreatic fistula
Fluid and gas accumulates in the bowel above secondary to pancreatic tuberculosis were also
the site of obstruction and are trapped in a seen in this series.
number of bowel loops. In erect posture gas The type of surgery performed was
settles on top of fluid giving a ‘step ladder dependent on intra operative findings. Local
pattern’. resection of stricturous segment followed by
Number of fluid levels, their location, primary anastomosis was the most common
presence of gas in the ascending colon, surgery done in 50 % patients. Cases where
mucosal pattern of the intestine above the perforation was situated close to ileocaecal
fluid level gives an idea about the site of junction, a more extensive resection in the
obstruction. This was seen in 28 % patients. form of quartercolectomy was required.
46 % patients had evidence of free gas under Stricuroplasty is a well documented
diaphragm. modality in various studies {Katariya et al
26
Acute presentation of the disease (1977), Eggleston (1983)} . However,in
accounted for 72 % of cases. The incidence of present series most of patients were subjected
obstruction is 64 % followed by perforation in to resection anastomosis as they were tight
44 % of patients. strictures. Stricturoplasty was done only in 2
Anand11(1956), Ohri and % patients.
Agrawal(1964) reported the incidence of
obstruction ranging from 12.5% to 60
%.Bhansali7 quotes an incidence of 30%.
The incidence of perforation quoted by
Bhansali7 (1968) is about 22%.
Banerjee(1950),Ahmad (1962), Ohri and

PROCEDURE PERFORMED
33.33%
35.00% 28.89%
30.00%
25.00%
20.00% 15.56%
15.00%
10.00% 6.67%
2.22%2.22% 2.22%2.22%2.22%2.22%2.22%
5.00%
0.00%
Surgery
bout 14% of patients were subjected

About 14%
% patients had superficial infection and
to diagnostic laparoscopy with either lymph complete wound dehiscence was seen in 6 %
node or peritoneal tubercle biopsy. patients which in corroboration with a study
A positive histopathological report conducted by Khan et al in which the
was obtained in 100 % patients. incidence of wound infection has been
Wound infection was a common reported as 24 %.
complication seen in 20 % cases of which
Post Operative Complications
15.56% 6.67%
8.89% 2.22% BURSTABDOMEN
4.44%
LEAK
62.22% LEAK,MALABSORPTION
NIL
SEPTICEMIA
WOUNDINFECTION

Anastomotic leak with resultant faecal fistula reported by Bhansali 7(1978) was 24 % and
was seen in 10 % patients. Eggleston and Madhu was 18 %.26 since the
A high incidence of malabsorption was mortality was low it was not possible to apply
seen in studies conducted by Tandon32 et al ( methods of statistical significance to analyse
ranging from 40 % to 75 %) and Pimparkar factors causing mortality.
and Dhonde2.The present study does not A new dimension has been added to
confirm to this observation where the the problem of tuberculosis due to the
incidence of malabsorption is very low i.e 2 emergence of HIV infection. In the present
%. series 5 (10 %) cases tested positive for HIV
3
Pimparkar and Donde studied 40 by ELISA technique. In a study from Mumbai
patients with malabsorption and divided then conducted by P M Rathi, Amrapurkar3 et al
into those with and without bowel stricture. the seroprevalance was found to be 16.6 % in
They performed glucose and lactose tolerance patient with abdominal tuberculosis.
tests, d-xylose test, faecal fat and schillings
test for B12 malabsorption and found them to References:
be abnormal in 28, 22, 57, 60 and 63 per cent 1. Peda Veerraju H. Abdominal tuberculosis.
respectively in patients with stricture In: Satya Sri S, editor. Textbook of pulmonary
compared to 0, 0, 8, 25 and 30 per cent and extrapulmonary tuberculosis. 3rd ed. New
respectively without strictures. Delhi: Interprint; 1998 p. 250-2.
Tandon10, 28
et al also reported biochemical 2. Pimparkar BD. Abdominal tuberculosis. J
evidence of malabsorption in 75 per cent of Assoc Physicians India 1977; 25 : 801-11.
patients with intestinal obstruction and in 40 3. Rathi PM, Amarapurakar DN, Parikh SS,
per cent of those without it. The cause of Joshi J, Koppikar GV, Amarapurkar AD, et al.
malabsorption in intestinal tuberculosis is Impact of human immunodeficiency virus
postulated to be bacterial overgrowth in a infection on abdominal tuberculosis in western
stagnant loop, bile salt deconjugation, India. J Clin Gastroenterol 1997: 24 : 43-8.
diminished absorptive surface due to 4. Paustian FF. Tuberculosis of the intestine.
ulceration, and involvement of lymphatics and In: Bockus HL. editor. Gastroenterology,
lymph nodes. vol.11, 2nd ed. Philadelphia : W.U. Saunders
The present study has comparatively Co.; 1964 p. 31 1.
lower mortality of 10 % of which 4 % were 5. Wig KL, Chitkara NK, Gupta SP. Kishore
during the immediate post operative period K. Manchanda RL. Ilcoceacal tuberculosis
due to fulminant septicaemia. Mortality with particular reference to isolation of

Mycobacterium tuberculosis. Am Rev Respir 11. Anand BS. Distinguishing Crohns disease
Dis 1961; 84 : 169-78. from intestinal tuberculosis. Natl Med J India
6. Vij JC, Malhotra V, Choudhary V, Jain NK. 1989; 2 : 170-5.
Prasaed G, Choudhary A, et al. A 12. Kapoor VK. Abdominal tuberculosis.
clinicopathological study of abdominal Postgrad Med J 1998; 74 : 459-6.
tuberculosis. Indian J Tuberc 1992; 39 : 213- 13. Shah P, Ramakanlan R. Role of vasculitis
20. in the natural history of abdominal
7. Bhansali SK. Abdominal tuberculosis. tuberculosis - evaluation by mesenteric
Experiences with 300 cases. Am J angiography. Indian J Gastroenterol 1991; 10 :
Gastroenterol 1977; 67 : 324-37. 127-30.
8. Prakash A. Ulcero-constrictive tuberculosis 14. Bhargava DK. Shriniwas, ChopraP,
of the bowel. Int Surg 1978; 63 : 23-9. Nijhawan S. Dasarathy S, Kushvvaha AK.
9. Hoon JR, Dockerty MB. Peberton J. Peritoneal tuberculosis: laparoscopic patterns
ileocaecal tuberculosis including a comparison and its diagnostic accuracy. Am J
of this disease with non-specific regional Gastroenterol 1992; 87 : 109-12.
cnlcrocolitis and noncascous tuberculatcd 15. Sharma AK. Agarwal LD. Sharma CS.
entcrocolitis. Int Abstr Snrg 1950: 91 : 417- Sarin YK. Abdominal tuberculosis in children
40. : experience over a decade. Indian Peadiatr
10. Tandon HD, Prakash A. Pathology of 1993; 30 : 1149-53.
intestinal tuberculosis and its distinction from
Crohn's disease. Gut 1972; 13 : 260-9.

Dr. Dipak D Thorat,
Department of General Surgery,
Lokmanya Tilak Muncipal Medical College and Hospital,
Sion, Mumbai, India
Email: deepakdthorat@gmail.com

eISSN 2395-0684
ORIGINAL ARTICLE
Haematological profile of adult sickle cell disease patients in North

Maharashtra
A. J. Jadhav1*, S. M. Vaidya2, V. R. Bhagwat3, A. R. Ranade4, M. Vasaikar5
Assistant Professor1, Associate Professor4,5, Professor2,3,

Department of Physiology1,2,4, Department of Biochemistry3, Department of Pathology5,
1,3,4,5
Shree Bhausaheb Hire Government Medical College, Dhule-424001 (Maharashtra) India,
2
Bharati Vidyapeeth Medical College, Pune- 411043 (Maharashtra) India.
Abstract: Volume 27.18 ± 5.35% in the male and female

SCD patients when compared with the carriers
Background:
and normal subjects. Mean Corpuscular
Sickle cell anaemia is a major genetic disease
Volume 93.91 ± 6.9 was found to be higher
in India that presents major challenges to our
whereas Mean Corpuscular Haemoglobin
health care systems.
Concentration 28.71 ± 2.19 values were less
Aim and Objective: The aim of this study
(P<0.05) in the patients than the carriers and
was to evaluate the haematological profile of
controls. Mean Corpuscular Haemoglobin
Sickle Cell Disease (SCD) patients in the
26.91 ± 2.07 levels of the patients were not
steady state from tribal population of North
statistically significant when compared with
Maharashtra.
carriers and normal subjects.
Material & methods: Thirty six sickle cell
Conclusion: Our results show, moderate to
disease patients in steady state, 43 sickle cell
severe anemia and high foetal haemoglobin
carriers and 43 normal healthy volunteers with
levels in the adult SCD patients. Sickle cell
age group18-40 years were recruited for the
carriers and the normal control subjects
study. Subjects having history of vaso-
showed mild to moderate anaemia. The
occlussive crisis, blood transfusion and serious
occurrence of anaemia in these patients
illness within last three months were excluded
suggests that there is strong need to monitor
from the study.
these patients, to prevent triggering factors of
Results: We found low levels of haemoglobin
vaso-occlussive crisis. The data so obtained
7.86 ± 1.93gm/dl, Red Blood Cell count 2.93
would help in the management, prevention
± 0.73 milli/cmm, as well as the Packed Cell

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Jadhav A.J.
and control programme for SCD patients at prevalence of sickle cell disease is very high,
the primary health care centers in India. amongst the Scheduled Tribes (ST) mainly in
Bhill and Pawara tribal groups of North
Keywords: Sickle cell Haemoglobin,
Maharashtra regions. It is also found in the
Anaemia, Haematological values
population belongs to Scheduled Castes (SC)
Introduction: (11)
and Other Backward Classes (OBC) .
Sickle Cell Disease (SCD) is a major Despite the high prevalence of SCD in the
genetic disease in India that presents major tribal population of North Maharashtra, very
(1)
challenges to our health care systems . SCD few studies were carried out in adult SCD
is particularly common among the people patients. Since these groups are living in
whose ancestors come from sub-Saharan geographically remote hilly areas, existing
Africa, India, Saudi Arabia and Mediterranean health facilities are inadequate and hence
(2-4)
countries . SCD is an autosomal recessive remain backward in all aspect of life including
hemoglobinopathy, caused by the substitution health and education. These tribal people are
th
of valine for glutamic acid at the 6 position under the influence of superstitions, especially
of the β-(beta) polypeptide chain of towards health problems. There is need to find
hemoglobin. Under the deoxygenated most suitable and practically feasible
conditions, Sickle Cell Haemoglobin (HbS) is parameters that could predict disease severity
polymerized, leading to the formation of long and aid in therapy. Since anaemia is a
fibres inside the Red Blood Cells (RBC). The dominant feature of SCD, the purpose of this
RBCs containing HbS will distort into study is to evaluate haematological profile for
elongated sickle shapes. These sickled and early prediction of sickle cell crisis.
rigid RBCs have shortened lifespan and
Material and Methods:
undergo intravascular and
The present study was carried out in
extravascularhemolysis. Furthermore, sickled
Shri Bhausaheb Hire Govt. Medical College,
RBCs can adhere to the vascular endothelium,
Dhule and District Hospital Nandurbar. Most
ultimately blocking the normal blood flow
of the patients in this study were from the
through the vasculature (5-6).
tribal population of North Maharashtra
In Maharashtra sickle cell gene is
(Dhule, Nandurbar and Jalgaon district). The
widely spread in all districts of Vidarbha
study was approved by local ethical
region, North Maharashtra (Satpuda ranges)
committee. The written informed consent
and some part of Marathwada region (7-10). The
from all participants was obtained prior to the analyzer. Haemoglobin (Hb), Red Blood Cell
study. A total of 122 subjects in the age group count (RBC), Pack Cell Volume (PCV), Mean
18-40 participated in the study, which Corpuscular Volume (MCV), Mean
included 36 diagnosed sickle cell disease Corpuscular Haemoglobin (MCH) and Mean
patients (SS), 43 sickle cell carriers (AS) and Corpuscular Haemoglobin Concentration
43 healthy (AA) controls. The SS patients and (MCHC).
AS carriers were confirmed by HPLC Statistical analysis:
analysis. The control subjects were without Student ‘t’ test (unpaired) was used for
any haemoglobinopathies and were matched statistical comparison of the means. Results
for age, sex and socio-economic aspects. were expressed as Mean ± SD with
Inclusion Criteria: significance level at 0.05.
Patients included in this study were in their Result:
steady state, no history of crises in the last 3 Various haematological parameters in
months, and without any symptoms related to male and female patients / subjects are shown
SCD or other diseases which could affect the in the table-1. Hb concentrations, RBC counts
hematological findings; and PCV were lower in SCD patients in both
Exclusion criteria: History of blood the sexes. The MCV was comparatively high
transfusion in the last 3 months, previous in female SCD patients as compared to males.
history of surgery, or were suffering from any MCH and MCHC were found to be low in
other diseases and the patients those were not both male and female patients. HbF
willing to participate in the study. concentration was found to be higher in
Collection of blood: female SCD patients than male SCD patients.
Under all aseptic precautions, 2-3 ml However, the difference was not statistically
of blood was drawn from ante-cubital vein by significant.
clean vein-puncture with a sterile plastic In sickle cell carriers and normal
syringe and blood sample was collected in an healthy subjects, Hb concentration, RBC
EDTA (anticoagulant) tube. Quantification of count and PCV were lower in both the sexes
Foetal Haemoglobin (HbF) was done on Bio- however, in females it was found to be
Rad variant system using High Performance significantly lower (P<0.05) as compared to
Liquid Chromatography (HPLC). male counterparts.
Following haematological parameters Hb concentration, RBC count and
were measured on BC-5000 auto haematology PCV was significantly low (P<0.05) in SCD
patients as compared to sickle cell carriers, and the normal healthy controls. We found
and the normal controls (Table-2). However, low Hb concentration, RBC count and PCV in
the MCV was significantly high (P<0.05) and sickle cell patients as well as carriers as
MCHC was significantly low (P<0.05) in SCD compared to the normal control subjects of
patients as compared to sickle cell carriers, both the sexes.
Table 1: Gender Related Values of Haematological Parameters of Sickle Cell Patients (SS),
Sickle Cell Carriers (AS) and Control Subjects (AA)
Phenotype SS AS AA
Gender Male Female Male Female Male Female
n 17 19 23 20 22 21
*
Hb (gms/dl) 8.34 ± 1.91 7.58 ± 1.84 11.91 ± 1.45 10.06 ± 1.96 12.60 ± 1.31 10.81 ± 1.42
RBC (mill/mm3) 3.11 ± 0.79 2.77 ± 0.63 4.54 ± 0.46 *3.9 ± 0.59 4.90 ± 0.56 4.07 ± 0.65
PCV (%) 27.53 ± 4.83 26.17± 5.27 36.58± 2.63 *31.69 ± 3.63 39.74 ± 2.06 33.90 ± 3.46
MCV µm3 90.44 ± 8.39 94.97 ± 4.75 81.06 ± 6.8 82.00 ± 7.4 81.91 ± 8.38 84.20 ± 8.17
MCH (pg/dl) 27.06 ± 1.94 27.35 ± 2.24 26.29 ± 2.53 25.81 ± 3.24 25.81 ± 1.96 26.75 ± 2.35
MCHC (g/dl) 30.06 ± 2.24 28.81 ± 2.11 32.55 ± 3.13 31.56 ± 3.72 31.68 ± 2.34 31.86 ± 2.07
HbF(%) 18.04 ± 6.89 19.34 ± 6.49 0.85 ± 0.36 1.75 ± 1.32 - -
The figures are Mean ± SD; Hb = Haemoglobin in gram/dL; RBC = Red Blood Cell count in
millions/cubic milimeter; PCV = Packed cell volume; MCV = Mean corpuscular volume in cubic
micrometer; MCH =Mean corpuscular haemoglobin in picogram/dL; MCHC = Mean corpuscular
haemoglobin concentration in gram/dL; HbF = Foetal haemoglobin in percentage of total Hb.

Table 2: Comparative Haematological Parameters in Sickle Cell Patients (SS), Sickle Cell
Carriers (AS) and Control Subjects (AA)
Parameters SS AS P value AA P value
(n=36) (n=43) (SS vs AS) (n=43 ) (SS vs AA)
Hb (g/dl) 7.86 ± 1.93 11.05 ± 1.94 P<0.05 11.23 ± 1.59 P<0.05
RBC (mill/mm3) 2.93 ± 0.73 4.24 ± 0.62 P < 0.05 4.27 ± 0.72 P < 0.05
(mill/mm3)
PCV (%) 27.18 ± 5.35 34.31 ± 3.97 P < 0.05 34.72 ± 3.93 P < 0.05
MCV (µm3) 93.91 ± 6.19 81.50 ± 7.11 P < 0.05 82.25 ± 8.14 P < 0.05
MCH (pg/dl) 26.91 ± 2.07 26.07 ± 2.89 P=0.39 26.47 ± 2.34 P=1.99
MCHC (g/dl) 28.71 ± 2.19 32.09 ± 3.45 P < 0.05 32.28 ± 2.18 P < 0.05
HbF (%) 18.73 ± 6.72 0.85 ± 0.36 P < 0.05 -- P < 0.05
±6.7666633366
The figures are Mean ± SD; *P<0.05. Hb = Haemoglobin in gram/dL; RBC = Red Blood Cell
count in millions/cubic milimeter; PCV = Packed cell volume; MCV = Mean corpuscular volume
in cubic micrometer; MCH =Mean corpuscular haemoglobin in picogram/dL; MCHC = Mean
corpuscular haemoglobin concentration in gram/dL; HbF = Foetal haemoglobin in percentage
of total H.
Discussion: We found lower levels of

The sickle cell disease patients haemoglobin, RBC count and PCV in the
experience enormous clinical complications male and the female patients of sickle cell
than the sickle cell carriers, who generally disease. Although the hemoglobin
lead a normal life. The present study is a concentration, RBC counts and PCV was
systematic and honest attempt to report the low in female SCD patients as compared to
hematological profile of sickle cell disease male SCD patients, it was statistically not
patients, sickle cell carriers and the normal significant (P = 0.42). Increased
healthy subjects from the tribal population of erythropoesis due to androgens in males, and
North Maharashtra. blood loss in females during menstruation

may be responsible for higher levels of In SCD patients mean HbF level
hemoglobin and erythrocyte count in males. (18.73%) was higher in both the sexes and
The results obtained in this study were was comparable to few earlier Indian studies
(13)
comparable with previous Indian studies of however, some Indian studies reported
(12-13) (21)
Khan et al and Shrikhande et al . low levels of HbF . As the quality of life
Increased rate of hemolysis during is dependent on the symptoms and the
oxygenation and deoxygenation process impact of an illness on an individual, timely
associated with recurrent infections in sickle and appropriate treatment is very much
cell anemic patients could account for these necessary for the patients with SCD because
decreased values. There could also a blunted life-threatening complications are known to
response to erythropoietin secretion in sickle develop rapidly. Anemia, hepato-
cell anemia. The rate of its increased splenomegaly and vaso-occlusive crisis in
secretion may not be proportional to the the form of bone and joint pains and
degree of anemia. This may be due to right infections are such complications reported to
shifted hemoglobin dissociation curve seen be very common in SCD patients.
in sickle cell disease (14-15). Haplotype studies suggest that sickle
The mean MCV was high in both the sexes cell anaemia (SCA) in Indians is linked to
of SCD patients, whereas MCHC values the Arab-Indian haplotype having high
were low in our study which was levels of HbF. This has a mild clinical
(7,16-17)
comparable to other studies . No presentation which goes unnoticed,
gender related difference was seen in MCV, sometimes throughout the life. HbF is a
MCH and MCHC values. In the SCD blessing in disguise; actually it retards the
patients, vitamin B12 and folic acid are pathogenic polymerization of sickled
maintained in a critically balanced state. erythrocytes when it is present. SCD in
Increased demand in erythropoesis due to association with higher HbF (>10%) levels
chronic hemolysis or pregnancy in females tends to have less anaemia and milder
(22-24)
causes deficiency state and leads to clinical manifestations . However, the
macrocytosis (18). Low MCV values reported phenotype of SCD varies significantly
in some studies may be due to confounding among different population groups of India
factors such as co-existing iron deficiency and there is limited regional data. Therefore,
anemia and other unknown factors such as it is rather difficult to say that higher levels
α-thalassemia which is frequent and often of HbF in SCD will protect patients from
associated to SCD (19-20). the severity of the

complications. The severity of SCD varies frequent complaints of fatigue, generalised

greatly between individuals, since not all weakness, breathlessness, joint pain,
(9-10)
patients have identical pleiotropic genes repeated abortions etc in sickle cell
(secondary effectors genes). Some carriers carriers. The present results on the
may have mutated genes that can either hematological profile most probably appears
(5)
ameliorate or exacerbate the phenotype . due to lack of balanced nutritional dietary
Therefore, in view of these contradictory intake or due to poverty and/or blood loss in
reports, and the present observations in the females during menstruation or repeated
patients, it is rather difficult to comment abortions could be other possible reasons
conclusively on the role of HbF and SCD responsible for low haemoglobin
complications. Further research in this area concentration, RBC count and PCV in sickle
and direction in future may give clearer cell carrier females.
picture. Conclusion:
The present study shows low levels The results of this study shows
of haemoglobin, RBC count, PCV and moderate to severe anemia and high foetal
altered blood indices in the carriers than the haemoglobin levels in the adult SCD
normal healthy controls. This indicates that patients. Sickle cell carriers and the normal
carriers were having mild to moderate control subjects showed mild to moderate
anaemia even in the asymptomatic state. anaemia. Regular health check-ups and
This latent state in the carriers could monitoring of haematological profile may
precipitate complications in specific help to guide the clinician to prevent vaso-
situations. Surprisingly, the control group occlusive crisis and further complications.
females in the present study also showed The data so obtained would help in the
mild to moderate anemia. It appears that due management, prevention and control
to poverty, the overall nutritional status of programme for SCD patients at the primary
the subjects is below average. There is need health centers in India. Further, large cohort
to provide balanced diet with additional studies are needed to determine the
supplements of vitamins to remain association between clinical complications
physically fit in geographically adverse hilly of the disease and changes in the
areas. hematological parameters along with foetal
According to several studies, quality haemoglobin levels in the adult SCD
of life for sickle cell carriers is relatively patients.
normal without significant health problems Conflict of interest: None to declare
(21, 25)
. However, few other studies reported Source of funding: Nil

References 10. Kate SL, Langejwar DP.

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Dr. Anita J. Jadhav.
Assistant Professor of Physiology,
Shree Bhausaheb Hire Government Medical College,
Dhule-424001, Maharashtra, India.
Email: anitanarad@gmail.com

eISSN 2395-0684
ORIGINAL ARTICLE
An institution-based cervical PAP smear study, correlation with clinical

findings & histopathology in the Konkan region of Maharashtra state,
India
Bhushan M. Warpe1, Shweta Joshi-Warpe2, Sarvesha S. Sawant3

Assistant Professor, Department of Pathology, B.K.L.Walawalkar Rural Medical College and
Hospital, Sawarde, District-Ratnagiri, Maharashtra, India1,2, Technician, Department of
Pathology, B.K.L.Walawalkar Rural Medical College and Hospital, Sawarde, District-Ratnagiri,
Maharashtra, India3
Abstract: 2015 to 31st July 2016, were prospectively

studied and classified according to revised
Background:
Bethesda terminology, 2014. Also cyto-
Cervical carcinoma is a common radiological and clinico-cytological, cyto-
cause of death in India. It is presented by histological correlation was studied.
spectrum of precancerous lesions, called Results:
cervical intra-epithelial neoplasia (CIN).
Due to increasing awareness among masses
Cervical cytological screening is designed to
inculcated by social workers, most of the
detect over 90% of cytological
patients for PAP smear cytology came for
abnormalities. It has been established that
routine screening to rule out cervical lesions
cervical cancers can be diagnosed at the pre-
followed by clinical finding of per-vaginal
invasive stage with adequate, repetitive
discharge. The 350 screened patients were in
cytological screening. Keeping in view of
the third and fourth decades of life. 99/350
the importance of cervical PAP
cases were subjected to USG study, with
abnormalities & by classifying them by
maximum number of cases (34 cases)
Bethesda terminology; correlation with
showing normal study, followed by cases
clinical findings & histopathological
with ovarian cysts and fatty liver disease.
findings was done.
Negative for intra-epithelial lesion (NILM)
Methods: without any denotable organism was the pre-
dominant cytological finding of PAP smear
All cervical Pap smears reported in
study followed by cases of NILM with
Department of Pathology from 1st August
bacterial vaginosis (30 cases) with two

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Warpe B.M.
malignancies. Intra-epithelial lesions (IELs) successful cancer screening techniques in

were noted in 16.86%. ASCUS comprised medicine.(2,3)
12.29%, ASC-H comprised 1.14%, L-SIL
PAP smear screening has been
comprised 1.71%, H-SIL comprised 1.43%,
widely embraced by physicians and women
Atrophic cervical smears comprised 5.14%,
alike, and is considered a critical part of the
Squamous cell carcinoma comprised 0.29%
routine health care of women. However in
cases. ASC/L-SIL ratio was 7.8 and
the developing world without the complex
inadequacy rate for PAP smear study was
resources required to process and read Pap
7.43%. Cytology-histopathology correlation
specimens, screening remains a challenge.(4)
was possible in 62 cases.
Among women with cervical cancer in the
Conclusion: U.S., at least 60% did not have appropriate
Pap surveillance prior to their diagnoses.(5) It
Classification of cervical PAP smear
is also a common women cancer in Indian
cytology based on Bethesda terminology
population. There is still no national
revealed it is a useful cost effective,
program on cervical pathology, detection,
screening tool for cervical lesions.
prevention and treatment.
Correlation of PAP smear cytology with
‘gold standard’ histological reports reveal In the decades since the initial
excellent diagnostic parameters, implying development of the Pap smear, our
the greater efficacy of cervical PAP smears. understanding of the pathophysiology of
cervical cancer has evolved considerably.
Keywords: PAP-smear, NILM, ASC-US,
The occurrence of premalignant cervical
ASC-H, L-SIL, H-SIL
lesions, now referred to as cervical dysplasia
Introduction: (CIN), was recognized as early at the
1940s.(6) During the 1970s and 1980s, the
The Papanicolou screen (“PAP smear”)
human Papilloma virus (HPV) was identified
was introduced to the world by Dr. George
within cervical lesions.(7,8) As early as 1976,
Papanicolaou for the identification of
Dr. Harald zur Hausen and colleagues
cervical lesions/cancers. Since becoming
postulated a role for the HPV in cervical
widely known after his publication in 1941
oncogenesis, and his subsequent work
and wide acceptance in clinical practice in
isolating oncogenic HPV strains and
the 1950s; it is currently the most commonly
elucidating the oncogenic process earned
performed cancer screening test world-
him the Nobel Prize in Medicine in 2008.(9-
wide.(1) This has been one of the most
11).

The discoveries of premalignant cervical 2014. Also cyto –histological, cyto-

lesions and the role of HPV in cervical radiological and clinico-cytological
dysplasias and cancers have also enabled correlation was studied.
physicians to gradually refine the use of Pap
smear screening. As a result, the number of Inclusion criteria:
women who need Pap smears, and the 1. Patients of varied age group with
abnormal cervical PAP smears/ abnormal
frequency at which they are recommended,
cervical biopsy with gynecological
has changed significantly over the last
several years.(9-11) complaints.
2. Symptomatic cases with normal cervix

Computer-Assisted interpretation of
cervical cytology, HPV genetic testing are having abnormality either in Pap smear or in
cervical biopsy.
the new diagnostic ways of reporting
cervical pathology especially in the Control population:
developed world. HPV vaccination drive has a. Clinically asymptomatic cases with
reduced worldwide morbidity and mortality normal cervix for routine screening.
(12-14)
due to cervical lesions. b. Suspicious cervix with normal PAP smear
or cervical biopsy reported.
Cervical cytology reporting has attained
uniformity worldwide due to Bathesda Results:
classification,2014 of cervical PAP smears.
(12-14)
Maximum patients in our study were
Faster diagnostics yields faster
in the third decade of life followed by
therapies. So treatment is initiated faster
patients in the fourth decade of life.
with help of Pap smears. We study a year
old analysis of cervical PAP smear study in Maximum patients in our study had
Konkan belt of Maharashtra state, India abnormal vaginal discharge (total 82 cases).
where our tertiary care is set-up. 64 cases came for routine cervical PAP
screening. This was followed by cases with
Material and Methods:
uterine prolapse (54 cases).
With approval of Ethics Committee

Out of 99 cases subjected to USG
and consent of patients, all cervical Pap
study, maximum number of cases (34 cases)
smears reported in department of pathology
had normal study. This was followed by
from 1st August 2015 to 31st July 2016, were
cases with simple ovarian cysts and fatty
prospectively studied and classified
liver. Maximum number of cases was of
according to revised Bethesda terminology,
NILM in our study (245 cases).
Maximum NILM cases without any Cytology-histopathology

histopathology correlation
denoted infective pathology (150 cases). was possible in 62 cases. On correlation,
This was followed by cases of NILM with sensitivity was 96.49%, specificity was 80%,
bacterial vaginosis (30 cases). Overall, positive predictive value (PPV) was 98.21%,
maximum of PAP smears had NILM negative predictive value (NPV) was
diagnosis (75.14 % cases) on cervical PAP 66.67%, and Diagnostic accuracy was 80%
80%.
smears. Intra-epithelial
epithelial lesions (IELs) –
Discussion:
16.86%. Atrophic cervical smears
mears comprised
5.14% cases. Inadequacy rate for PAP smear Age-wise distribution:
study was 7.43%.
In our study, most of the patients
Among IELs, ASCUS comprised were in parity 2 (58%). Rathod SB, et al
12.29% of overall cases, ASC-H
ASC comprised (2015)15 had 28.4% cases in parity 3 and
1.14%, L-SIL
SIL comprised 1.71%, H-SIL
H 21.2% cases in parity 4. In our one year
comprised 1.43%, Squamous cell carcinoma study, 350 cervical PAP smears were
comprised 0.29% cases. ASC/L
ASC/L-SIL ratio screened.
was 7.8.
Graph 1: Age-wise
wise distribution of our 350 cervical PAP smear cases
140
120
100
80
60
NO.Of
40 CASES
20
0
0 to 11 to 21 to 31 to 41 to 51 to 61 to 71 to 81 to 91
10 20 30 40 50 60 70 80 90 to100
Graph 1 show that maximum patients in our study were in the third decade of life followed by
patients in the fourth decade of life.

Table 1 shows the age-wise distribution of two comparative studies:
Rathod GB,et al (2015)15 Our study
31-40 years - 34.57%
41-50 years 42.4% 30%
51-60 years 21.2% 10%
Patient’s complaints: Cusco’s speculum is inserted to visualize

and fix the cervix with patient in dorsal
Maximum patients in our study had
position and proper illumination. After
abnormal vaginal discharge (23.43% cases).
cervical inspection, Ayre’s spatula is
18.29% cases came for routine cervical PAP
inserted. It is inserted in a way that long end
screening due to PAP smear screening
goes into cervical canal while smaller end of
camps at our set-up owing to increased mass
spatula rests on the ectocervix. Spatula is
awareness by social workers. This was
then rotated through 360 degrees
followed by cases with uterine prolapse
maintaining contact with ectocervix. Do not
(15.43% cases).
use too much force to avoid hemorrhagic
USG abdomen and pelvis was done artifact on smeared slides. The sample
in 99 out of 350 cases. It revealed normal should be ‘evenly’ spread and fixed
study in majority (37.37% cases), fatty liver immediately with cytofix spray fixative or
associated with pregnancy (14.14% cases), 95% ethanol. Both sides of spatula should be
simple ovarian cysts (11.11% cases), and smeared.
uterine fibroids (9.9% cases).
For endocervical sampling, use
(
Cervical PAP smear: Technical aspect : endocervical brush. Its cytobrush bristles
10-14)
Sampling must not be done during should be visible in the endocervical canal.
menses. Avoid vaginal contraceptives, Rotate the brush through 180 degrees.
vaginal medications for atleast 48 hours Sample is rolled on slide, smeared and fixed
prior to taking the smears. Sexual abstinence as earlier quoted. If spray fixative is used,
should be about 24 hours. Post-partum spray should be kept at 10 inches distance
smears should be taken only after 6-8 weeks from the smeared slides to avoid cellular
of delivery. destruction by propellant in the spray. Smear
should form a monolayer for proper

penetration of cell surface by fixative. inflammation are excluded from the

estimate.(12-14)
PAP smear-Sample adequacy:
Endometrial cells in exodus pattern are
An adequate cost-effective
commonly seen after 40 years of age in
conventional cervical PAP smear should have
cervical smears due to exfoliation. Nuclear
minimum of approximately 8000-12000 well-
features are important to know about the
visualized, well-preserved squamous epithelial
atypical features of these glandular cells.
cells. This applies to squamous cells while
endocervical cells and cells obscured The inadequacy in PAP smear
‘completely’ with hemorrhage and reporting is chiefly because of sampling error,
improper fixation, non co-operative patients.
Table 2 shows the comparison of inadequacy rate in PAP smear study:
Study by Inadequacy rate
Rathore SB, et al (2013)16 7.4%
Kalyani R, et al (2016)17 17.8%
Our study 7.4%
Transformation zone (TZ) component:
Under the influence of estrogen, the cervical TZ to carcinogens, HPV begins the
original squamo-columnar junction moves process of intra-epithelial neoplasia.(10)
onto the portio. The exposure of delicate
Negative for intra-epithelial lesion or
columnar cells to vaginal environment creates
malignancy (NILM):
squamous metaplasia. An adequate TZ
component requires minimum of ten well- According to Bathesda 2001/2014
preserved endocervical/squmous metaplastic classification of cervical cytology, there is a
(12-14)
cells, singly or in clusters, having either category called NILM. It includes non-
honeycombing pattern of endocervical cells or specific inflammatory pathology and
spidery cytoplasm of squamous metaplastic infections due to organisms like trichomonas
cells. The TZ component in our study was vaginalis (TV), Candida, bacterial vaginosis
seen in 70.3% of our cases. Exposure of (BV), actinomycosis and HSV viral infection.

Bacterial vaginosis produces Clue cells, associated with NILM include post-
Trichomonas vaginalis are pear-shaped menopausal atrophic smears, post-
organisms that prodice Cannol-ball squamous hysterectomy glandular cells, reactive changes
lesions, Candida produces Shish-kebab associated with intra-uterine device,
appearance while actinomyces bacteria inflammation, radiation. In our study, out of
produces Cotton-ball squamous lesions on 75.14% NILM cases, 5.14% cases were post-
cytology. Other non-neoplastic findings menopausal atrophic smears.
Table 3 shows comparative estimation of NILM cases by different studies:
Studies Percent of NILM cases
Saha R, et al (2005)18 51.16%
Rathore SB, et al (2013)16 86%
Selhi PK, et al (2013)19 96.08%
Laxmi PV, et al (2016)20 67%
Kalyani R, et al (2016)17 96.92%
Our study 75.14%
After excluding the atrophic smears, the following table 4, shows the distribution of the NILM
smears:
Selhi PK, et al (2005)19 Our study
NILM with non-specific inflammation 90.9% 61.2%
NILM with Candida infection 2.8% 0.8%
NILM with trichomonas vaginalis (TV) 0.6% 7.35%
NILM with HSV 0.1% -
NILM with bacterial vaginosis (BV) - 12.24%
NILM with mixed infection: (TV+BV) - 5.3%
Other mixed infections - 3.67%
Increased lactobacilli - 3.23%

NILM with specific infective etiology can vary from place to place. Most common infection was
trichomonas parasitic infestation followed by bacterial vaginosis in our study. It was Candida
infection by the above compared study.
Intra-epithelial lesions (IELs): It includes squamous and glandular cell abnormalities in PAP smear
study.(12) Table 5 shows the comparative data on IELs by different studies:
Studies Percent of IELs in study
Mehmetoglu HC, et al (2010)21 1.2%
Bal MS, et al (2012)22 5%
Kalyani R, et al (2016)17 3.08%
Selhi PK, et al (2013)19 2.04%
Our study 16.86%
Atypical squamous cells (ASC): High-grade squamous intra-epithelial lesion

(ASC-H).(12-14)
Among IELs comes a category called
Atypical squamous cells (ASC) which refers According to Bathesda, ‘ASC-US’
to cytological changes suggestive of term is preferred because 10-20% of these
Squamous intra-epithelial lesions (SIL), which cases are proven to have CIN2/CIN3 on
are quantitatively / qualitatively insufficient confirmatory cervical biopsy while the rest are
for a definitive definition. ASC have cells with proven to be cervical inflammatory pathology
squamous differentiation, high N:C ratio, (cervicitis). ASC-US on cytology generally
minimal nuclear hyperchromasia, chromatin corresponds to diagnosis of Low-grade
smudging, multi-nucleation at places.(12-14) squamous intra-epithelial lesion (L-SIL) or
SIL of indeterminate grade on cervical
ASC is divided into two by Bathesda
biopsy.(12-14)
classification: Atypical squamous cells of
undetermined significance (ASC-US) and
Atypical squamous cells, cannot differentiate

Table 6 shows the comparative data on ASC-US lesions by different studies:
Studies Percent of ‘ASC-US’ cases in study from overall

PAP smear cases studied
Saha R, et al (2010)18 2.33%
Bal MS, et al (2012)22 0.3%
Kalyani R, et al (2016)17 1.46%
Selhi PK, et al (2013)19 1.6%
Rathore SB, et al (2013)16 4%
Our study 12.29%
ASC-US category was high in our study as per ASC-H category includes small
above table. Biopsy was possible in 18% of squames with high N:C ratio. These cells have
those cases. Biopsy revealed all these cases as the size of squmous metaplastic cells. They
chronic cervicitis without dysplasia / cervical are also called atypical (immature) metaplastic
intra-epithelial neoplasia (CIN). lesions.(12)
Table 7 shows the comparative data on ASC-H lesions by different studies:
Studies Percent of ‘ASC-H’ cases in study from overall

Kalyani R, et al (2016)17 0.32%
Our study 1.14%
On biopsy, the two ASC-H categorized cases in our study revealed: one case as CIN3 and
other as Squamous cell carcinoma (SCC).
Low grade squamous intraepithelial lesions cytopathic effect or koilocytosis. Alternatively

(L-SIL): Among IELs, comes the other the cytoplasm is keratinized. Peri-nuclear
category L-SIL, on cytology. These squames halos that are seen in the absence of nuclear
have three times the size of normal abnormalities are not diagnosed as ‘L-SIL’.
intermediate squamous cell nuclei, irregular
nuclear membranes, coarse chromatin, HPV

Table 8 shows the comparative data on ‘L-SIL’ lesions by different studies:
Studies Percent of ‘L-SIL’ cases in study from overall

Bal MS, et al (2012)22 2.7%
Kalyani R, et al (2016)17 0.24%
Laxmi PV, et al (2013)20 7.5%
Our study 1.71%
The L-SIL cases in our study were confirmed as CIN1 on cervical biopsy.
High-grade squamous intra-epithelial lesion ratio, irregular nuclear membranes, over-

(H-SIL): IELs with less mature cells than crowded clusters with central whirling and
those found in L-SIL category of cervical flattening at the cluster edges.(12)
cytology. They have markedly raised N:C
Table 9 shows the comparative data on ‘H-SIL’ lesions by different studies:
Studies Percent of ‘H-SIL’ cases in study from overall

Bal MS, et al (2012)22 0.7%
Kalyani R, et al (2016)17 0.41%
Laxmi PV, et al (2013)20 6%
Our study 1.43%
The H-SIL cases in our study were confirmed as CIN3 and Squamous cell carcinoma on cervical
biopsy.
Squamous cell carcinoma (SCC) : The former are mostly isolated singly
dispersed cells on cytology with irregular
SCC can be keratinizing or non-
chromatin pattern, hyperkeratosis,
keratinizing lesions.
pleomorphic parakeratosis and pathognomonic
tumor diathesis.
The non-keratinizing type SCC on size than H-SIL, but have irregular chromatin
cytology are single/syncytial aggregates of pattern, clinging tumor diathesis, pleomorphic
dysplastic squamous cells that are smaller in cell types.(12-14)
Table 10 shows the comparative data on ‘SCC’ lesions by different studies:
Studies Percent of ‘SCC’ cases in study from overall

Bal MS, et al (2012)22 1.3%
Kalyani R, et al (2016)17 0.41%
Selhi PK, et al (2013)19 0.16%
Our study 0.29%
Out of two cases reported as SCC on cytology, cytology report must be confirmed on ‘gold
one was confirmed as large-cell keratinizing standard’ biopsy report, if needed. Out of 350
SCC on cervical biopsy while the other was cases, cervical biopsy was advised on 62
reported as CIN-3 on biopsy. Any cases. The maximum cases (45.2%) were
reported as chronic non-specific cervicitis.
Table 11 shows following histopathology (gold standard test) correlation with cytology
Histopathology Total Cytological Diagnosis

Diagnosis HPR
No. NILM ASCU ASC- L-SIL H-SIL Atrop Cance AG
of Unsatisfact S H hic r C-
cases ory N
OS
Infections 50 1 38 7 1 - - 2 - -
Carcinoma 2 - - - - - 1 - 1 -
Dysplasia 5 - 1 - - 1 1 - 1 1
Other Benign 5 2 3 - - - - - - -
Pathology
Total 62
*AGC-NOS: Atypical endocervical glandular cells:not otherwise specified

Table 12 shows Cytology vs Histopathology chart of 62 cases for calculating diagnostic

parameters
Histo
T.P. F.P.
55 1 56
Cyto
F.N T.N
6
2 4
Total 62
57 5
Diagnostic parameters on correlation:

1) Sensitivity = TP/TP + FN X 100 = X 100 = 96.49%

2) Specificity = TN/F.P + T.N X 100 = X 100 = = 80%

3) Positive predictive value: PPV=TP/T.P+FP X 100 = = 98.21 %

4) Negative predictive value: NPV = TN/FN.TN X 100 = = 66.67%

5) Diagnostic accuracy = TN/TN + FP X 100 = = 80 %

Correlation of PAP smear cytology with Conclusion:

‘gold standard’ histological reports reveal
Premalignant and malignant lesions of
excellent diagnostic parameters, implying
cervix are common and can be diagnosed
the greater efficacy of cervical PAP
early by conventional Pap smears. Use
smears.(16,23)
Bathesda system, 2014 for cytological
reporting of cervical PAP smears for
uniformity of reporting process. Conventional

Pap smears are required not only for the [2] Ries L, Eisner MP, Kosary CL, et al.
diagnosis and management of the malignant SEER Cancer Statistics Review, 1975–2002.
lesions but it is also helpful in identifying the Bethesda,
infectious etiologies and treatment in
MD: National Cancer Institute, 2004.
developing countries. They need to be
correlated with histopathology for further [3] Jemal A, Siegel R, Ward E et al. Cancer
management. Most of the screened patients in statistics, 2006. CA Cancer J Clin
our study were in the third and fourth decades 2006;56:106–130.
of life. Classification of cervical PAP smear
[4] U.S. Department of Health and Human
cytology based on Bethesda terminology
Services.Healthy People 2010. Washington,
revealed it is a useful cost effective, screening
DC:U.S. Government Printing Office, 2000.
tool for cervical lesions. Negative for intra-
epithelial lesion (NILM) was mostly the pre- [5] Sawaya GF, Grimes DA. New
dominant cytological finding of PAP smear technologies in cervical cytology screening: a
study. Pap smear significantly correlates with word of caution, Obstetrics & Gynecology
cervical histology as per this study. 94(2), August 1999, p 307–310.
Acknowledgement: [6] Pund ER, Nieburgs H, Nettles JB, et al.

Preinvasive carcinoma of the cervix uteri:
We are thankful to Dr. Suvarna N.
seven cases in which it was detected by
Patil, Medical Director for sanction of project
examination of routine endocervical smears.
at the College ethical committee. Last but not
Arch Pathol Lab Med 1947; 44: 571–577.
the least; we are thankful to the numerous
patients involved in this study. [7] Meisels A, Fortin R, Roy M.
Condylomatous lesions of the cervix. II.
Conflict of interest: None to declare Cytologic, colposcopic and histopathologic

study. Acta Cytol 1977; 21:379–390.
Source of funding: Nil
References: [8] Beckmann AM, Myerson D, Daling JR, et
al. Detection and localization of human
[1] Papanicolaou GN, Traut HF. The
papillomavirus DNA in human genital
diagnostic value of vaginal smears in
condylomas by in situ hybridization with
carcinoma of the uterus. Am J Obstet
Gynecol. 1941;42:193-206.
biotinylated probes. J Med Virol 1985; [15] Rathore SB, Dr. Atal R. Study of
16:265–273. Cervical Pap Smears in a Tertiary Hospital.
International Journal of Science and
[9] zur Hausen H. Condylomata acuminata
Research (IJSR) 2013;4(3):2074-8.
and human genital cancer. Cancer Res. 36,
530, 1976. [16] Rathod GB, Singla D. Histopathological
V/S cytological findings in cervical lesions
[10] Dürst M, Gissmann L, Ikenberg H, zur
(Bethesda system) - A comparative study.
Hausen H. A papillomavirus DNA from a
IAIM 2015; 2(8):16-9.
cervical carcinoma and its prevalence in
cancer biopsy samples from different [17] Kalyani R, Sharief N, Shariff S. A study
geographic regions. Proc. Nat. Acad. Sci. U.S. of PAP smear in Tertiary Hospital in South
80, 3812-3815, 1983. India. J Cancer Biol Res. 2016; 4(3):1084.
[18] Saha R, Thapa M. Correlation of cervical
[11] Boshart M, Gissmann L, Ikenberg H,
cytology with cervical histology studied in
Kleinheinz A, Scheurlen W, zur Hausen H. A
oncology clinic of Kathmandu Medical
new type of papillomavirus DNA, its presence
College Teaching Hospital. US National
in genital cancer and in cell lines derived from
Library of medicine, national institute of
genital cancer. EMBO J. 3, 1151-1157, 1984.
health. Kathmandu Univ Med J (KUMJ).
[12] Solomon D, Nayar R (eds): The Bethesda 2005 Jul-Sep; 3(3):222-4.
System for Reporting Cervical Cytology:
[19] Selhi PK, Singh A, Kaur H, Sood N.
Definitions, Criteria, and Explanatory Notes,
Trends in cervical cytology of conventional
ed 2. New York, Springer, 2004.
Papanicolaou smears according to revised
[13] Nayar R, Wilbur DC (eds): The Bethesda Bethesda System: A Study of 638 Cases.
System for Reporting Cervical Cytology: IJRRMS Jan-March 2014; 4(1):21-5.
Definitions, Criteria, and Explanatory Notes,
[20] Laxmi PV, Sree Gouri SR. Study and
ed 3. New York, Springer, 2015.
Analysis of Two Hundred Cervical PAP
[14] Solomon D: Foreword; in Nayar R, Smears in Our Hospital at Sri Padmavathi
Wilbur DC (eds): The Bethesda System for Medical College for women, SVIMS, Tirupati.
Reporting Cervical Cytology: Definitions, International Journal of Contemporary
Criteria, and Explanatory Notes, ed 3. New Medical Research. 2016;3(9):2789-93.
York, Springer 2015.
[21] Mehmetoglu HC, Ganime S, Ozacakir A, in Papanicolaou smears. J Cytol. 2012 Jan-
Bilgel N. Pap smear screening in the primary Mar; 29(1):47-9.
health care setting: A study from Turkey. N
[23] Patel MM, Pandya AN, Modi J. Cervical
Am J Med Sci. 2010 Oct; 2(10): 467472.
PAP smear study and its utility in cancer
[22] Bal MS, Goyal R, Suri AK, and Mohi screening, to specify the strategy for cervical
MK. Detection of abnormal cervical cytology cancer control. National Journal of
Community Medicine 2011; 2(1):51-4.
Author for Correspondence:
Dr. Bhushan M. Warpe,

B.K.L.Walawalkar Rural Medical College and Hospital, Sawarde,
District-Ratnagiri, Maharashtra, India,
Email: bhushan.warpe@gmail.com

eISSN 2395-0684
CASE REPORT
Skull metastasis of follicular thyroid carcinoma: a rare case report

Shital Khedkar1, Ashish Pokharkar2, Sandip Sathe3, Bhushan Warpe4, Shweta Joshi5
Assistant Professor, Department of ENT, BKL Walawalkar Rural Medical College & Hospital,
Sawarde1, Specialist Registrar, Tata Memorial Hospital, Mumbai2, Senior Resident Department
of ENT, , BKL Walawalkar Rural Medical College & Hospital3, Assistant Professor, Department
of Pathology, BKL Walawalkar Rural Medical College & Hospital4, Assistant Professor,
Department of Pathology. BKL Walawalkar Rural Medical College & Hospital, Sawarde5
Abstract: Introduction:
Follicular thyroid carcinoma is a malignant Follicular carcinoma is the second most
epithelial tumor arising in both eutopic thyroid common thyroid malignancy. Generally very
gland and/or heterotopic thyroid tissue. slow growing in nature. Distant spread may
Follicular cancer accounts for 5-15% of all occur to bones, lungs, brain, skin and
thyroid cancers in iodine sufficient areas i.e. is sometimes kidneys and adrenal glands.
the second commonest form of differentiated According to literature, the reported incidence
thyroid malignancy. It spreads via of distant metastasis is between 10% and 25%,
haematogenous routes. So it spreads to lungs but it is very uncommon for the disease to
and bones. In thyroid cancer only 2.5 % cases present with distant metastasis at initial
(1)
shows skull metastases. Here, presenting a 61 presentation itself . From available data,
year old female with a swelling in the skull around 2.5% to 5% of cases of thyroid cancers
(2)
left frontotemporal region for 4 years duration may spread to the skull .Skull bone
with proptosis. She also had thyroid swelling metastasis is common in prostate, lung, breast
of 20 years duration which is asymptomatic. carcinomas, but very rare for thyroid
Cytological confirmation was done to carcinoma. Metastasis in thyroid cancer occurs
diagnose follicular carcinoma with skull bone in long standing cases generally 15-20 years
metastasis. After total thyroidectomy external duration. Here we present a case who has
beam radiotherapy was given to skull presented with skull swelling along with long
metastases in view of threatened vision. standing neck swelling.
Radioiodine therapy was given afterwards. Case report:
Keywords: follicular thyroid carcinoma, The patient, a 60 years old female
Metastasis, proptosis presented to the out-patient department with
WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Shital Khedkar
complaints of swelling in the left side swellings elsewhere in the body. There were
of head of 4 years duration. The patient no other comorbidities associated with this.
complained that the swelling has gradually On examination, the patient was found
grown in size but not causing pain or any to have large, well circumscribed swelling in
other distressing symptom. There is significant the left frontotemporal region of skull, of
proptosis of left eye is seen due to swelling. about 6.5 x 7.5 cm size and with smooth
Also she complained of diminution of vision surface (Figure 1).The swelling was found to
of left eye. be hard, immobile and fixed to underlying
bone. There was no appreciable pulsations or
cough impulse over the swelling.
Figure 1: left frontotemporal skull

metastasis with proptosis of left eye
On detailed history, she revealed that
Figure 2: Right neck swelling of thyroid
she was having a swelling in the neck for origin
about 20 years. Since she did not have any On examination of neck 5 x 6.5 cm
symptom associated with the swelling, she did size well rounded mass of right thyroid gland
not undergo any evaluation for the same and is seen, it was hard in consistency and with
was not under any medication for the same. restricted mobility(Figure 2). Left thyroid was
Also, there was no history of any recent looking normal. There was no sign of any
increase in the size of the neck swelling. Apart retrosternal extension. There were no palpable
from these, the patient had no symptoms regional lymph nodes. The trachea was
suggestive of pressure on neck structures, no central. There were no features of carotid
features of toxicity and no features of any compression. All the other systems including

the respiratory and central nervous systems

were found to be normal.
The patient underwent thyroid
function test which revealed normal values
and euthyroid status. CT scan of brain showed
heterogeneous mass arising from left temporal
bone which was compressing and displacing
left orbital contents with stretching of optic Figure 4:CT scan of neck showing right
nerve (Figure 3). CT scan of neck revealed thyroid enlargement with heterogeneous
right lobe thyroid heterogeneous swelling with appearance.
peripheral enhancement suggestive of thyroid
malignancy (Figure 4). There were no
detectable lymph nodes in the neck. A Fine
Needle Aspiration Cytology (FNAC) of the
nodule showed diagnosis of Follicular
neoplasm.FNAC of skull lesion suggested
follicular carcinoma cells. CT thorax and other
routine investigations were all within normal Figure 5: Section from cystic nodule of
limits. Based on these findings, the patient right thyroid lobe showing capsular
was diagnosed as Follicular thyroid carcinoma invasion (arrow) and underneath tumor
with skull metastases and proptosis. cells in repetitive follicular pattern (H&E,
X 40).
Figure 5: Section from cystic tumor of

isthmic nodule showing tumor cells in
Figure 3: CT Scan of skull metastasis repetitive follicular pattern (H&E, X 400).

After complete preoperative profile Haematogenous spread is however much more

and ophthalmic checkup, patient was taken for common in FTC with almost 20% of patients
total thyroidectomy. Intra-operatively the having distant haematogenous metastasis at
gland was found to have multiple nodules on the time of presentation. Although lungs and
right side with left side looking normal. Total bones are commonly involved sites by
thyroidectomy with bilateral level II to IV and metastasis, the brain, skin, liver, adrenal gland
central compartment neck dissection was and even mediastinum may also be involved
done. Post-operative histopathology confirmed by thyroid cancers(6). There are reported cases
diagnosis of follicular carcinoma (figure 5, 6) of metastases from follicular carcinoma to the
(7)
Post-operative period was uneventful. kidneys and even the choroid of the eye .
Postoperatively patient received 30Gy (10#) Among bones, skull is a rare site for
external beam radiotherapy for skull metastasis.
metastasis. After completion of EBRT patient The largest case series of skull
was refereed for radioactive iodine therapy. metastases from all types of thyroid cancers
Discussion: consists of 12 cases reported by Nagamine et
(2)
Follicular thyroid cancer (FTC) is al . In this series, mean time from the
second most common thyroid cancer around diagnosis of thyroid tumor until discovery of
10% of all thyroid cancers. Generally bone skull metastasis was 23.3 years. Skull
metastasis of thyroid tumors are multiple with metastases from thyroid cancers are usually
ribs, sternum and vertebrae a common sites (3). soft, hemispheric tumors resting on the skull.
Skull is a rare site of metastasis with occipital These tumors are usually highly vascular, with
region as commonest one. Follicular thyroid evident osteolytic changes in the skull. The
carcinoma occurs in much older age group commonest mode of presentation of skull
than papillary i.e. in the 40 to 60 years of age metastases from follicular cancer is as
(4)
group . This carcinoma is generally seen in pulsatile skull swellings. Very rarely, there
elderly females, with longstanding non-toxic can be features of cranial nerve dysfunction,
multi-nodular goiter (50.2%), solitary thyroid focal brain symptoms or symptoms due to
nodule (44.2%) and rarely in patients with increased intracranial pressure. Rarely do they
(5)
endemic goiter. This type of neoplasm is cause proptosis with loss of vision as in our
probably induced by chronically elevated case. These lesions are osteolytic on skull X-
Thyroid-Stimulating Hormone (TSH) levels. ray and CT scan and highly vascular on
Follicular cancers are slow growing tumors. angiographic assessment (8).
One of the significant problems in The prognosis of FTC is not as

skull metastases is the bone defect which may extremely favorable as papillary, but much
require bone resection and cranioplasty. Most better than anaplastic thyroid cancer or other
of these tumors are highly vascular, and there cancers in the body. Prognosis commonly
is potential for significant morbidity and depends on the presence and extent of distant
mortality associated with surgical resection. metastatic disease. In locally limited disease,
As per general recommendations, histo- 90% ten year survival can be expected,
pathologic tissue diagnosis should always be whereas with distant disease that value drops
attempted, followed by total thyroidectomy, to below 50%. In summary, metastasis from
radioiodine ablation, or external beam differentiated thyroid malignancy should
radiation, and chronic thyroid stimulating always be suspected in patients who present
hormone suppression. However, experts with suspicious skull metastases. After
recommend that surgical resection of the confirmation such patients should undergo
metastatic lesion should only be performed in thyroidectomy and radio-iodine ablation or
carefully selected cases because of the external irradiation for the metastases as they
(9)
associated morbidity . can have a good prognosis.
We have managed proptosis in this Conclusion:
case with EBRT in view of threatened vision It is rare presentation of follicular
due to involvement of optic nerve.EBRT can carcinoma of thyroid showing skull metastasis
give good palliation in cases where metastases and specifically in frontotemporal region
is diffuse, inoperable and involving important causing proptosis. So in differential diagnosis
structure like optic nerve. Surgical debulking of skull metastasis one must keep in mind
is also an option in case of sudden diminution about follicular thyroid carcinoma.
of vision. The effectiveness of Iodine-131 (I- References:
131) in bone metastases treatment is 1. Shahaar, shah jp, loree tr. Differentiated
suboptimal. Even in patients who have bone thyroid cancer presenting initially with distant
metastases that avidly take up I-131, only a metastasis. Am j surg. 1997;174:474-6.
very small proportion is able to achieve 2. Nagamine y, suzuki j, katakura r, yoshimoto
complete response following I-131 therapy. t, matoba n, takaya k. Skull metastasis of
Bone metastases associated with radiographic thyroid carcinoma. Study of 12 cases. J
changes are particularly known not to respond neurosurg. 1985;63:526-31.
well to I-131 therapy.(10)
3. Zettinig g, fuegerbj, passler c, kaserer k, indian perspective. 1st ed. Mumbai, india:
pirich c, dudezak r, et al. Long term follow-up quest publications; 1998: 443-450.
of patients with bone metastases from 6. Schlumberger m, tubiana m, de vathaire f,
differentiated thyroid carcinoma-surgery or hill c, gardet p, travaglijp, et al. Long term
conventional therapy? Clinendocrinol results of treatment of 283 patients with lung
(oxf) 2002;56:377–82. and bone metastases from differentiated
4. Shah s, muzaffar s, soomroi, hasan s. thyroid carcinoma. J clinendocrinolmetab.
Morphological pattern and frequency of 1986;63:960
thyroid tumours. J pak med assoc. 7. Guignier b, naoun o, subilia a, schneegans
1999;49:131-3. o. Choroidal metastasis from follicular thyroid
5. Rao rs, parikhhk. Prognostic factors in well- carcinoma: a rare case. J frophtalmol. 2011
differentiated carcinoma of thyroid. In: shah may;34(5):329.e1-5.
dh, samuel am, raors, eds. Thyroid cancer - an
8. Prodam f, pagano l, belcastro s, golisano g, 10. Mydlarzwk, wu j, aygun n, olivi a, careyjp,
busti a, samà m, et al. Pituitary metastases westrawh, et al. Management considerations
from follicular thyroid carcinoma. Thyroid. for differentiated thyroid carcinoma presenting
2010 jul;20(7):82330. as a metastasis to the skull base. Laryngoscop.
9. Akdemiri, erol fs, akpolat n, ozveren mf, 2007 jul;117(7):114652.
akfirat m, yahsi s. Skull metastasis from
thyroid follicular carcinoma with difficult
diagnosis of the primary lesion. Neurol med
chir (tokyo). 2005;45:205-8.

Dr. Shital Khedkar
Assistant Professor,
Department of ENT,
BKL Walawalkar Rural Medical College & Hospital,
Sawarde, Dist – Ratnagiri – 415 606.Maharshtra, India
Email:drskhedkar09@gmail.com

eISSN 2395-0684
CASE REPORT
A case of idiopathic hypoparathyroidism with Systemic Lupus Erythematosus
Nillawar AN1, Mitul Chhatriwala2. #
Associate Professor, Department of Biochemistry,S.B.K.S.Medical Institute & Research
Centre, Vadodara, Gujarat1, Assistant Professor, Department of Biochemistry,
Pramukhswami Medical College, Karamsad, Gujarat2
# Both the authors contributed equally
Abstract: repeated pericardial effusion. On admission,

Hypoparathyroidism is a rare disease. radiological findings on MRI (plain &
The main cause of hypoparathyroidism is contrast) were multiple lacunar infarcts in
postsurgical hypoparathyroidism. However, basal ganglia on both side and calcification in
cases of hypoparathyroidism in patients caudate nucleus, putamen, pulviener, internal
suffering from SLE exist although it is capsule. Laboratory findings were total serum
uncommon. We present the case of a woman calcium – 4.5mg/dl, PTH – 2.02pg/ml, ionized
suffering both from systemic lupus calcium – 0.67mg/dL, 25-hydroxy vitamin-D
erythematosus and hypoparathyroidism. This – 70ng/ml. Hypercaliuria present. ANA;
reported association of hypoparathyroidism positive, Anti-ds DNA antibodies positive. All
with lupus expands the spectrum of endocrine other laboratory findings are within normal
disorders seen in this disease. We suggest that limit. This association of hypoparathyroidism
there may be a common underlying with SLE is a rare association.
pathophysiological process linking these
diseases. Keywords: Hypoparathyroidism, SLE,
Hypercalciuria, CaSR, Basal ganglion
Case report: calcification, Hypothyroidism
We present a case of 50-year-old
female resident of Madhya Pradesh, India who Introduction:
had chief complaint of seizures and Hypoparathyroidism is rare disease. Broadly
generalised weakness. She is a known case speaking, causes of hypoparathyroidism can
hypothyroidism and systemic lupus be classified as PTH- deficient and PTH-
erythematous for 15 years. Past history of sufficient (Psuedo hypoparathyroidism type

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Nillawar A.N.
1 and type 2). Causes of PTH-deficient Case Report:

Hypoparathyroidism include post thyroid
50-year-old female, presents with
surgery, infiltration of parathyroid glands,
complaints of cough with yellow
neck radiation which impairs either PTH
expectoration for 15 days. She has pedal
synthesis or secretion.(1)This can be caused
oedema and generalised weakness and
by autoantibodies to parathyroid gland and
arthralgia on and off for 15 years. She has
related molecules.(2)Laboratory values of
seizure disorder for 15 years and is treated
intact PTH, Serum Ionized calcium, 25 (OH)
with anti-seizure treatment. Additionally she
D levels, Serum Phosphate, Glomerular
has documented severe hypocalcaemia for
filtration rate (GFR), serum Magnesium and
10 years (Range of hypocalcaemia is in
evaluation for relative hypercalciuria help to
between Total calcium=4 to 5 mg %). On
dissect out causes of Hypocalcaemia.
examination, patient does not have any sign
Screening for autoimmune polyglandular
suggestive of neuromuscular irritability. Her
syndrome helps to understand syndromal
laboratory values from recent encounter are
presentation of hypocalcaemia.(3)Here we
presented in Table:
report a case of PTH deficient
hypoparathyroidism associated with
hypothyroidism and SLE.
Haematological parameters:
Test Value Remark

Hb 11.6 Gm% Slightly anaemic
MCV, MCH, MCHC, 97fl/31.8/32/10220/3.2 lakhs Within Normal Limit
TLC, DLC, Platelets
ESR 76mm/hr Raised

Serum Chemistry:
Test Value Normal range Comment
Sr. ALT 24 IU/L 4-10 IU/L
Sr. AST 20 IU/L 4-14 IU/L
Sr. ALP 90 IU/L 40-120 IU/L
Sr. Total Protein: 8gm% 7.0-7.5 mg/dl
Sr. Albumin 4.1gm% 3.5-5 mg/dl
Sr. Urea 21 mg/dl 15-40 mg/L
Sr. Creatinine 1.1mg/dl 0.9-1.1 mg/L
Sr. Na 138 mEq/L 136-145 mEq/L
Serum K 4.0 mEq/L 3.5-5.5 mEq/L
Serum Cl 102 meq/L 95-105 mEq/L
Serum Total Calcium 4.7 mg/dl 9-11 mg/dl
Serum Ionized 0.67 mg/dl 4.5-5.5 mg/dl Severe Hypocalcaemia
Calcium
Serum Phosphorus 4.8 mg/dl 3.5-5.5 mg/dl
Vit D (OH,25) 70 ng/ml 20-100 ng/ml Sufficient status
Serum Mg 1.9 mg/L 1.8-2.0 mg/dl Rules out Hypomagnesaemia
Serum PTH 2.02 pg/ml 10-65pg/ml
Serum TSH 10.4 µIU/L 0.4-4.0 µIU/L Diagnostic of
Hypothyroidism
*Urinary Calcium 384 mg/24 hr 250-300 mg/24 hr Relative Hypercalciuria
Urinary Ca/Cr 0.2 Less than 0.14 Indicates Hypercalciuria
eGFR 120 ml/min/1.73m2 110-120 ml/min Rules Out Kidney failure
Sr ANA Level Positive in 1:160 titre Sensitive for SLE, These
much high titres s/o SLE
Anti ds-DNA Ab Positive Highly specific for SLE
*Hypercalciuria is defined as urinary excretion of more than 250 mg of calcium per day in women or
more than 275-300 mg of calcium per day in men while on a regular unrestricted diet

MRI brain (plain & contrast) showed multiple paracellular reabsorption of Ca and Mg ions
lacunar infarct in basal ganglia bilaterally, resulting in hypocalcaemia and
calcification in caudate nucleus, putamen, hypomagnesemia.(5,4)
pulvinar, internal capsule (Figure y). On Chest
Antibodies to CASR are shown to be
X-ray, pleural and pericardial effusion is
responsible for hypoparathyroidism in
seen.(4,5)
autoimmune polyendocrine syndrome type 1
Family history and pedigree analysis was in one reported study.(7)Usually APS type 1
inconclusive in this patient. presents in childhood to adolescence.
Addison’s disease and type 1 diabetes are the
Discussion:
associates in this syndrome.
This patient has hypoparathyroidism
Acquired hypoparathyroidism patients
with deficient parathormone. There was no
have antibodies reactive exclusive to CaSR as
history of removal of parathyroid or surgical
observed by the experiment done by Yangxin
manipulation of thyroid which rules out
Li and et al which showed the presence of
inadvertent damage to parathyroid glands. In
such antibodies. In this study, 8 female
cases without such iatrogenic removal, age of
Patients were having associate
presentation and accompanying illness can
(3)
hypothyroidism.(8)
suggest the diagnosis. Early age of
presentation is associated with some genetic Prevalence of hypothyroidism and
diseases like DiGeorge syndrome or HDR presence of anti-thyroid antibodies (Anti-TPO,
syndrome, a group of hypoparathyroidism anti-thyroglobulin) is quite high in SLE.(9,10)
associated with hypomagnesemia. In familial
isolated hypoparathyroidism, there is
activating mutation of CaSR. CaSR is
expressed extracellularly on parathyroid gland
and renal distal tubules. Free ionized calcium
is the direct first messenger for these
receptors.(6) Activating mutations of CaSR
results in suppressed secretion of PTH. This
results in hypercalciuria as activation in
kidney tubular cells result in suppression of

Known causes of Hypoparathyroidism due to Impaired PTH:
Known Syndrome or Onset Presentation and Mechanism

diagnosis association with
H/o Surgical removal of Hypocalcaemia Damage to
thyroid or parathyroid/ persistent after 6 parathyroid glands
radiation/cancer months of surgery
metastasis/hemochromatosis
DiGeorge syndrome Early onset, facial Branchial arch
dysmorphology, dysmorphogenesis
cardiac anomalies
HDR syndrome Early Onset Renal disease,
sensorineural
deafness
Familial Hypoparathroidism Neonatal/Infantile Associated with Genetic diseases
with Hypomagnesemia presentation hypomagnesemia. with Activating
Some are associated CaSR mutations/
with Bartter’s defective
syndrome Parathormone
Family history. secretion
Can be autosomal
recessive or
dominant
Autoimmune polyendocrine Late onset/ Addison’s disease. Mutations in
Neoplasis(APN) type 1 Or Post partum. Type 1 Diabetes autoimmune
Hypothyroidism, regulator region.
Waxing and waning Few cases are seen
of disease. with autoantibodies
against CaSR
Acquired Late Onset In one of the study
Hypoparathyroidism strongly associated Antibodies against
withhypothyroidism CaSR receptors
and female gender
In this patient, SLE is diagnosed by criterion Seizure disorder and positive anti ds-DNA
laid down by American College of and ANA. (11) She has hypothyroidism and
Rheumatology as patient has evidence of hypoparathyroidism. She is a severe and
pericardial effusion, arthralgia, history of long-standing case of hypocalcaemia with

symmetrical basal ganglion calcification and assay of anti CaSR antibody or mutation
long history of seizure disorder (MRI testing for the same.
Images attached). Similar pattern of
Presence of hypoparathyroid
calcification has been reported (2,11,15–17)
(12-14)
dysfunction in SLE is very rare
previously. Despite severe deficiency
though evidence of anti CaSR antibodies in
of ionized calcium, patient did not show any
SLE is not found in literature. We suggest
signs of neuromuscular irritability or any
that there may be a common underlying
ECG changes. She has signs of cardiac
pathophysiological process linking these
failure in terms of pedal oedema and signs
diseases which could be genetic or even
of pericardial effusion. (Most likely disease
autoimmunity.
process of SLE). She has laboratory
evidence of hypothyroidism in terms of So this is a case of late onset, female of SLE
raised TSH. In spite of very low calcium, with hypothyroidism and PTH-deficient-
kidneys are excreting large amount of hypoparathyroidism with severe
calcium suggest activation of CaSR hypocalcaemia and hypercalciuria and
receptors. (See table). We did not perform normomagnesemia.

References
1. Fong J, Khan A. Hypocalcemia: the calcium-sensing receptor a familial

updates in diagnosis and management for syndrome of hypocalcemia with
primary care. Can Fam physician Médecin hypercalciuria due to mutations in the
Fam Can. 2012;58(2):158-162. calcium-sensing receptor.
doi:10.1136/bmj.333.7563.334. 1115;335(15).
http://www.nejm.org/doi/pdf/10.1056/
2. Mohanasundaram K, Shankar H,
NEJM199610103351505. Accessed
Tamilselvam TN, Rajeswari S.
June 25, 2017.
Hypoparathyroidism – A rare
endocrinological abnormality in 6. Kos CH, Karaplis AC, Peng J-B, et al.
systemic lupus erythematosus. Indian J The calcium-sensing receptor is
Rheumatol. 2014;9(2):96-97. required for normal calcium
doi:10.1016/j.injr.2014.01.004. homeostasis independent of parathyroid
hormone. J Clin Invest. 2003;111(7).
3. Fukumoto S, Namba N, Ozono K, et al.
doi:10.1172/JCI200317416.
Causes and differential diagnosis of
hypocalcemia--recommendation 7. Gavalas NG, Kemp EH, Krohn KJE,
proposed by expert panel supported by Brown EM, Watson PF, Weetman AP.
ministry of health, labour and welfare, The Calcium-Sensing Receptor Is a
Japan. Endocr J. 2008;55(5):787-794. Target of Autoantibodies in Patients
doi:10.1507/endocrj.K08E-076. with Autoimmune Polyendocrine
Syndrome Type 1. J Clin Endocrinol
4. Pollak MR, Brown EM, Estep HL, et
Metab. 2007;92(6):2107-2114.
al. Autosomal dominant hypocalcaemia
doi:10.1210/jc.2006-2466.
caused by a Ca2+-sensing receptor
gene mutation. Nat Genet. 8. Li Y, Song YH, Rais N, et al.
1994;8(3):303-307. Autoantibodies to the extracellular
doi:10.1038/ng1194-303. domain of the calcium sensing receptor
in patients with acquired
5. Imon P Earce SH, Atherine Illiamson
hypoparathyroidism. J Clin Invest.
CW, Lga Ifor OK, et al. Hypocalcemia
1996;97(4):910-914.
with hypercalciuria due to mutations in
doi:10.1172/JCI11851 9. Rasaei
N, Shams M, Kamali-Sarvestani E, Assoc Physicians India.

Nazarinia MA. The Prevalence of 2005;53(NOV.):948.
Thyroid Dysfunction in Patients With
14. Fulop M, Zeifer B. Case report:
Systemic Lupus Erythematosus. Iran
extensive brain calcification in
Red Crescent Med J.
hypoparathyroidism. Am J Med Sci.
2015;17(12):e17298.
1991;302(5):292-295.
doi:10.5812/ircmj.17298.
http://www.ncbi.nlm.nih.gov/pubmed/1
10. Pyne D, Isenberg DA. Autoimmune 750448. Accessed June 25, 2017.
thyroid disease in systemic lupus
15. Nashi E, Banerjee D, Crelinsten G.
erythematosus. Ann Rheum Dis.
Hypoparathyroidism in systemic lupus
2002;61(1):70-72.
erythematosus. Lupus. 2005;14(2):164-
http://www.ncbi.nlm.nih.gov/pubmed/1
165. doi:10.1191/0961203305lu2042cr.
1779764. Accessed June 25, 2017.
16. Attout H, Guez S, Durand J, Dubois F,
11. Petri M, Orbai A-M, Alarcón GS, et al.
Rughoobur A, S?ri?s C.
Derivation and validation of the
Hypoparathyroidism in systemic lupus
Systemic Lupus International
erythematosus. Jt Bone Spine.
Collaborating Clinics classification
2007;74(3):282-284.
criteria for systemic lupus
doi:10.1016/j.jbspin.2006.06.008.
erythematosus. Arthritis Rheum.
2012;64(8):2677-2686. 17. Jiang L, Dai X, Liu J, Ma L, Yu F.
doi:10.1002/art.34473. Hypoparathyroidism in a patient with
systemic lupus erythematosus coexisted
12. Full Text A Case Report of Basal
with ankylosing spondylitis: A case
Ganglia Calcification - A Rare Finding
report and review of literature. Jt Bone
of Hypoparathyroidism.
Spine. 2010;77(6):608-610.
13. Deepak S, Jayakumar B, Shanavas. doi:10.1016/j.jbspin.2010.02.012.
Extensive intracranial calcification. J

Author for Correspondence:

Dr.Nillawar AN.
Associate Professor,
Department of Biochemistry, S.B.K.S.Medical Institute & Research Centre,
Vadodara, Gujarat, India
Email:nilawaranup@gmail.com

eISSN 2395-0684
CASE REPORT
Psychosomatic chest pain in a 10-year-old girl
Sanyogita Nadkarni,
Leicester Frith Hospital, Groby Road, Leicester LE3 9QF, United Kingdom
Background: on and off with no other related symptoms

Psychosomatic symptoms are very such as dyspnoea, palpitations, headache or
common in children. Most of the times they tremors. All the investigations including ECG
are ignored or managed superficially. were reported to be normal. She was absent
However, if diagnosed correctly and given the from school for one month.
right treatment children can free of any In her past history, she had no
underlying anxiety disorder or a psychiatric developmental delay and was otherwise well
disorder. adjusted in her academic performance. In her
family history, both the parents were reported
Keywords: to have anxious personality. Her mother had
Psychosomatic symptoms, Chest pain, psoriasis and she was reported to be
Children, Somatisation disorder submissive and avoiding any conflictual
situations. Her father had irritable nature and
Case report: reported to have similar symptoms as that of
A 10-year-old girl from a stable family the daughter in his school days.
background was referred for a psychiatric Both the parents shared an affectionate
opinion. She presented with chest pain of bond with the child. The mother reported
unknown origin. She had two episodes, first spending good amount of time with her
episode lasting three days just before her daughter. The parenting style was however,
annual exams and second episode lasting for authoritarian tending towards more
15 days. Whereas the first episode did not punishment and strict discipline.
have significant physical precipitating factor, In her psychometric testing, she appeared to
the second episode was precipitated by have above average IQ. A psychiatric
cycling. In addition, she had newly started her diagnosis of anxiety disorder and somatisation
school and had reported mild problems with disorder based on DSM 5 criteria was made
teachers and classmates. The symptoms were using the child behavior checklist (CBCL).

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Nadkarni S.S
The girl was then treated with psychological counselling as this will aid in
cognitive behavior therapy, using additional building better coping strategies.
inputs from play therapy. Parents were taught References:
the correct communication techniques and the 1. Salvador Minuchin , Lester Baker , Bernice
mother was referred for anxiety management L. Rosman et.al. A Conceptual Model of
as part of family therapy.(1) The girl responded Psychosomatic Illness in Children: Family
to treatment and she resumed school very Organization and Family Therapy; Arch Gen
soon. Psychiatry. 1975;32(8):1031-1038.
Conclusions: 2. JW Greene, LS Walker; psychosomatic
This shows that anxiety disorders can problems and stress in adolescence; Pediatric
be exhibited in the form of psychosomatic Clinics of North America, 1997 – Elsevier.
(2)
symptoms and hence psychosomatic 3. JD Lipsitz, C Masia, H Apfel, Z Marans, et
symptoms in children need further exploration al ;Noncardiac chest pain and
(3).
for a comprehensive treatment It is felt that psychopathology in children and adolescents;
most of the children will benefit from Journal of Psychosomatic Research, May
2005 – Elsevier.

Dr. Sanyogita Nadkarni,
Mansion House, Leicester Frith Hospital
Groby Road
Leicester LE3 9QF
United Kingdom
Email: sanyogitanadkarni@gmail.com

eISSN 2395-0684
REVIEW
Reverse transcriptase and protease inhibitor resistant mutations in art

treatment naïve and treated HIV-1 infected children in India
A Short Review
Dinesh Bure,
Department of Biochemistry, All India Institute of Medical Sciences, New Delhi
Abstract: Keywords:
Introduction of first line and second Drug Resistance, Mutations, Reverse
line antiretroviral therapy has dramatically transcriptase, and Protease.
improved the quality of life and survival of the
HIV-1 infected individuals. Extension of this Introduction:
therapy in children has similar effect. According to UNAIDS Global AIDS
However the emergence of drug selected Update 2016(1) around 36.7 million people (all
resistance has hampered the response to the ages) are living with HIV, out of which 2.1
therapy. A database of prevalence of drug million are new HIV infections. An estimated
resistance mutations in the Indian children 1.8 million Children are infected with HIV
both ART naïve and treated will help in worldwide. National AIDS Control
deciding the appropriate regimen for the Organisation (NACO) reports that around
individual patient as well as formulating the 21.17 lakh people are infected with HIV in
policies regarding the composition of drugs India. Out of these 6.54% are children (<15
included in the fixed dose combinations and years)(2).
its periodic review by analysis of the Children can have an infection with
information that is made available from time HIV via mother to child transmission, infected
to time. This will enable us to utilize our blood and blood products and through sexual
limited resources in most prudent way. assault. Most of the paediatric HIV infections
are due to mother to child transmission. The
infection can be transmitted from mother to
her child during pregnancy, labour, delivery or

WIMJOURNAL, Volume No. 3, Issue No. 1, 2016 Bure D.G.
breastfeeding. Most commonly it occurs HIV-1 Reverse Transcriptase Mutations:

during peripartum period(3). The study conducted by Soundararajan
Introduction of Antiretroviral Therapy et al.(8) in 48 drug naïve south Indian children
(ART) has dramatically increased survival and showed no significant drug resistant mutation
quality of life of a patient having HIV(4). ART in reverse transcriptase gene. However more
has been effective in both reducing viral load than half of the sequences had important
as well as in increasing the CD4 counts of amino acid substitutions in codons 35, 36, 39,
HIV infected individual. However the long 48, 60, 121,135, 162, 173,177, 200, 207, 211,
term response to ART is hampered by the 214, and 245. In about 30% of sequences
emergence of drug resistant mutations in the Threonine was substituted by Glutamic Acid
(5)
viral genome . The viral genome replication at position 39 and 45% sequences had
by viral reverse transcriptase enzyme is highly Aspartic acid in position 39.
error prone leading to genetic diversity of the An analysis of genotyping of 12
viral pool. Individual treated with ART puts virological failure ART treated Children in St.
selection pressure on virus with the emergence Johns, Bangalore reveal that 11 out of 12 had
of drug resistant strains over a period of time. clinically relevant drug associated mutation in
Children can acquire drug resistant strain from the reverse transcriptase gene(9). The most
mother via vertical transmission(6). Single dose frequent Nucleoside Reverse Transcriptase
Nevirapine used for prevention of mother to Inhibitor (NRTI) mutation was M184V
child transmission has also been demonstrated associated with resistance to Lamivudine,
to be responsible for Non Nucleoside Reverse Abacavir and Emtricitabine. Other common
Transcriptase Inhibitor (NNRTI) drug NRTI mutations were M41L and T214Y/F/I.
mutations(7). Both these mutations confer intermediate level
As ART is being given to more and cross resistance to Tenofovir. K103N/R,
more individuals and with the emergence of Y181C and G190A were the most frequent
drug resistant mutations for the first line NNRTI mutations with associated resistance
therapy it is imperative to have knowledge of to Nevirapine, Efavirine and intermediate to
prevalence of mutations a population harbours high cross resistance to Etravirine.
so that the treatment can be customized A clinical brief by Shah et al.(10)
accordingly. reported two cases of ART treated children in
B.J Wadia Hospital, showing both TAMS-1
(M41L, T215Y/F, L210W) and
TAMS-2 (D67N) mutations. These mutations single dose Nevirapine and 46.15% of
are cross resistant to all NRTI’s and are children had high level of NNRTI resistant
selected for by Stavudine or Zidovudine. mutation after 2 months of single dose
A study conducted in Pune, India Nevirapine prophylaxis(7). Although this study
reported drug resistant mutation for NNRTI failed to find K103N mutation, one of the
in 7.4% ART naïve children(11). They identify common NNRTI mutation, presence of low to
A98G and K103N mutation in the two high level resistant mutation even after single
separate sequences. A98G mutation confers dose of Nevirapine is highly significant.
low level resistance to NNRTI’s and K103N As it is a common observation that the
confer high level resistance to Efavirine and resistance to Nevirapine develops after single
Nevirapine. dose or after interruption of therapy, Sehgal et
A genotyping analysis of ART naïve al. investigated the K103N mutation which
and treated children in AIIMS, New Delhi confer resistance to Nevirapine in 25 children
reveal that drug resistant RT mutation was in which 6 were ART naïve and rest 19 were
present in 30% of ART naïve and 36% of on Nevirapine containing fixed dose
(12)
ART treated children respectively . RT combination therapy. K103N mutation was
mutations conferring resistance to NRTI drugs found in 56% of children including two drug
were identified at positions naïve individuals(14).
65,67,74,77,151,184,215,219. Mutations in The presence of Reverse Transcriptase
the RT gene that confer resistance to NNRTI mutations in ART naïve children should raise
drugs were detected at amino acid positions a general concern. This necessitates the
101, 106, 179, 190, and 227. One ART naïve genotyping of individual case before starting
patient had both K101E and G190A mutations ART therapy. Same is applicable in a patient
which confer high level resistance to where change in therapy regimen or individual
Nevirapine and Efavirine. drug is being considered.
NNRTI mutations after administration
of single dose Nevirapine in both mother and HIV-1 Protease Mutations:
child has been reported previously(13). In India With the introduction of 1st line ART,
a feasibility study conducted at National AIDS over a period of time treatment failure appears
Research Institute (NARI), Pune had observed in score of individuals. Who are then shifted
that 10.5% of children had low levels mutation to 2nd line ART containing protease inhibitors.
for NNRTI after 48 hours of administration of Baseline drug resistant mutation
profile of protease inhibitors is largely reduced susceptibility to each of the Protease

unknown in the population. Resistant strain Inhibitors except Saquinavir and Atazanavir.
may also be vertically transmitted from The same patient also had minor mutations
mother to child if mother is receiving protease M46G and G48E. Other minor mutations
based regimen. Due to recent introduction of observed were L10I and T74S in one
2nd line ART very few studies have been individual each.
conducted to look for protease inhibitor A study conducted at AFMC, Pune
resistant mutations. involving 27 ART naïve children observe no
Soundararajan et al. found no major major mutations in the protease gene. But 3
mutation in the protease gene of 48 ART naïve individual had single minor mutations namely
(8)
children . However they observe that more L10I, A71T and T74S(11). L10I is an accessory
than half of the sequences had polymorphism mutation, which either reduce Protease
at position 12,19,41,89 and 93. Frequent Inhibitor susceptibility or increase the
substitutions were seen at positions 15, 36, 63 replication of viruses containing Protease
and 69. Inhibitor resistance mutations. A71T is a
Shet et al. after doing genotyping of common accessory polymorphic mutation
80 children on first line of ART couldn’t find that increase replication and/or reduce
any protease resistant mutation in any of the Protease Inhibitor susceptibility in viruses.
sample although they had detected significant Another accessory mutation found was T74S
mutations for reverse transcriptase gene(9). which is polymorphic in non B-subtype
Protease inhibitors selected major viruses.
mutations has been observed by Toor et al. in Shah et al. have reported two cases of first line
a study conducted at PGIMER, Chandigarh. treatment failure children having both major
Both major and minor mutations were seen in and minor mutations for the protease
patients with first line ART treatment inhibitors(10). The first case had major
failure(15). One patient had L33F and I47T mutations at position 46 and 54 and minor
major mutation. L33F is selected by each of mutations at positions 10,20,36,63. The
the Protease Inhibitors except Atazanavir, genotyping points towards the high resistance
Indinavir and Saquinavir. In combination with to Nevirapine with possible resistance to
other Protease Inhibitor resistant mutations Amprenavir. The second patient had major
L33F reduce the susceptibility to each of the mutation D30N and minor mutations at
Protease Inhibitors. I74V It associated with position
13,17,19,20,35,36,37,41,45,57,63,64, 69,74 children of subtype B harbouring

and 93 conferring high resistance to polymorphism at different positions for
Nevirapine possible resistance to Ritonavir protease gene(15). Kumar et al. in their study
boosted Atazanavir (ATV/r). had two protease isolate align with subtype A1
The AIIMS, New Delhi study detected five and one RT isolate align with subtype A1(11).
children having single minor mutation for the However the significant observation of
protease gene in codon 10, 76 and 84(12). Out subtype diversity came from study at AIIMS,
of these five 2 children were on first line drugs New Delhi. The authors found that 30% of
and rest were ART naïve. The minor Reverse Transcriptase sequences are
mutations were L10I/V, L76T and I84R/T. clustering with subtype B and 36% of protease
L10I/V are associated with resistance to most gene sequences are aligning with subtype
Protease Inhibitors when present with other B(12). they also had one ART naïve individual
mutations. L76T and I84T are highly unusual whose sequence align with subtype A. All
mutations at these positions. these observations point towards the
emergence of HIV-1 subtype diversity in
With the introduction of second line Indian paediatric population.
therapy containing protease inhibitors for first
line treatment failure children(16), it is Circulating Recombinant Forms (CRF’s):
advisable to check for the Protease Inhibitor Till date no study has been able to
selected mutations before starting the detect circulating recombinant form of HIV in
treatment. Indian paediatric population.
HIV-1 Subtypes: Future:

Subtype C is the most common As more number of first line treatment failure
subtype in India in adults as well as in patients are emerging, genotyping of
paediatric age group(17). Most of the individual patient helps in customizing
genotyping studies done in India in paediatric therapy for that individual and avoiding the
age group reveals HIV-1 subtype C. However drugs mutations against which are already
other subtypes have also started emerging in present. The importance of population data of
Indian paediatric population. Toor et al. drug resistant mutations cannot be more
reported two first line treatment failure emphasized. It will help in formulating the
combination of drugs to be included in the continued evolution of drug resistance in an

regimen and also fixing the recommended HIV-1-infected infant. J. Infect. Dis. 183,
dosage. To be enable to do this more drug 1688–1693 (2001).
resistance mutation studies needed to be
7. Kurle, S. N. et al. Emergence of
conducted and more classes of drugs required
NNRTI drug resistance mutations after single-
to be included in the research investigation.
dose nevirapine exposure in HIV type 1
subtype C-infected infants in India. AIDS Res.
References:
Hum. Retroviruses 23, 682–685 (2007).
1. UNAIDS Global AIDS Update.
http://www.unaids.org/sites/default/files/medi 8. Soundararajan, L. et al.
a_asset/global-AIDS-update-2016_en.pdf. Characterization of HIV-1 isolates from
antiretroviral drug-naive children in southern
2. NACO HIV Estimation India 2015.
India. AIDS Res. Hum. Retroviruses 23, 1119–
http://www.naco.gov.in/sites/default/files/Indi
1126 (2007).
a HIV Estimations 2015.pdf.
9. Shet, A., Neogi, U., Sahoo, P. N. & De
3. Kourtis, A. P., Lee, F. K., Abrams, E.
Costa, A. Effectiveness of first-line
J., Jamieson, D. J. & Bulterys, M. Mother-to-
antiretroviral therapy and acquired drug
child transmission of HIV-1: timing and
resistance among HIV-1-infected children in
implications for prevention. Lancet Infect. Dis.
India. Pediatr. Infect. Dis. J. 32, e227-229
6, 726–732 (2006).
(2013).
4. Oguntibeju, O. O. Quality of life of
10. Shah, I. & Parikh, S. HIV genotype
people living with HIV and AIDS and
resistance testing in antiretroviral (ART)
antiretroviral therapy. HIVAIDS Auckl. NZ 4,
exposed Indian children--a need of the hour.
117–124 (2012).
Indian J. Pediatr. 80, 340–342 (2013).
5. Tang, M. W. & Shafer, R. W. HIV-1
11. Kumar, M. et al. Prevalence of drug
Antiretroviral Resistance. Drugs 72, e1–e25
resistance in human immunodeficiency virus
(2012).
type 1-infected treatment-naive children in
6. Johnson, V. A. et al. Vertical Pune, India. AIDS Res. Hum. Retroviruses 30,
transmission of multidrug-resistant human 294–298 (2014).
immunodeficiency virus type 1 (HIV-1) and

12. Bure, D. et al. Mutations in the reverse transcriptase and protease genes of human
immunodeficiency virus-1 from antiretroviral protease sequences from ART naive and first-
naïve and treated pediatric patients. Viruses 7, line treatment failures in North India using
590–603 (2015). genotypic and docking analysis. Antiviral Res.
92, 213–218 (2011).
13. Eshleman, S. H. et al. Selection and
fading of resistance mutations in women and 16. National Guidelines on Second-line
infants receiving nevirapine to prevent HIV-1 and Alternative First-line ART For Adults and
vertical transmission (HIVNET 012). AIDS Adolescents May 2013.
Lond. Engl. 15, 1951–1957 (2001). http://naco.gov.in/sites/default/files/National
Guidelines on Second-line and Alternative
14. Sehgal, S., Pasricha, N. & Singh, S.
First-line ART For Adults and Adolescents
High rate of mutation K103N causing
May 2013_0.pdf.
resistance to nevirapine in Indian children
with acquired immunodeficiency syndrome. 17. Lakhashe, S., Thakar, M., Godbole, S.,
Indian J. Med. Microbiol. 26, 372–374 (2008). Tripathy, S. & Paranjape, R. HIV infection in
India: epidemiology, molecular epidemiology
15. Toor, J. S. et al. Prediction of drug-
and pathogenesis. J. Biosci. 33, 515–525
resistance in HIV-1 subtype C based on
(2008).
Address for Correspondence:

Dr. Dinesh Bure,
Department of Biochemistry, All India Institute of Medical Sciences, New Delhi
Email ID: dinesh2141986@gmail.com

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WIMJOURNAL, Volume No. 3, Issue No.

1, 2016 pISSN 2349-2910

Abstract: Conclusions: There is a distinctive bacterial

© Walawalkar International Medical Journal 1

Materials and methodsThis study was

© Walawalkar International Medical Journal 2

Controls -Controls were healthy subjects who Results

A prospective bacteriological analysis of the Subgingival plaque bacteriology

supplemented with strepto supplement from subgingival plaque samples of patients

(Nalidixic acid 3.750 mg, Nemomycin undergoing tooth extraction without

standard biochemical identification using plaque samples (yielded positive cultures;

automated Vitek 2 (bioMérieux) system to producing 370 different isolates of which

© Walawalkar International Medical Journal 3

Sr. No Non-streptococcal species No. (%)

© Walawalkar International Medical Journal 4

Table No. 2: Distribution of microorganisms isolated from subgingival plaque of patients

Microorganism isolated Patients without Patients with

© Walawalkar International Medical Journal 5

Nutritionally variant streptococci

sub-total 2 93 167 260

Total isolates (1+2) 145 225 370

Discussion bacterial species from the subgingival plaques

© Walawalkar International Medical Journal 6

© Walawalkar International Medical Journal 7

http://dx.doi.org/10.1016/j.micinf.201 Interdental Sites Using a Low

© Walawalkar International Medical Journal 8

Address for correspondence:

© Walawalkar International Medical Journal 9

Study of acute undifferentiated fever cases and their etiologies in rural

samples received from District hospitals and

© Walawalkar International Medical Journal 10

© Walawalkar International Medical Journal 11

© Walawalkar International Medical Journal 12

Among 500 samples investigated, 336 samples Aztreonam, Cefotaxime/K Clav,

© Walawalkar International Medical Journal 13

respectively. The age ranged from 12 to 80

exposure to infectious agents. Maximum 277 35

No. of Positive cases

like Brucella (61, 28.50%), Leptospira (58, 10 11

© Walawalkar International Medical Journal 14

Table 1: Distribution of Positive AUF cases

Infection Area wise percentage of positive cases n (%) Total

Total 87 104 33 SDH

© Walawalkar International Medical Journal 15

3 Escherichia coli 2 of etiologies and non descript symptoms, it

© Walawalkar International Medical Journal 16

© Walawalkar International Medical Journal 17

Address for correspondence:

© Walawalkar International Medical Journal 18

Abstract: details, post operative course and the final

© Walawalkar International Medical Journal 19

© Walawalkar International Medical Journal 20

resources of our country which aims to INCLUSION CRITERIA:

© Walawalkar International Medical Journal 21

c) Palpable lump complications of anti tubercular therapy, if

• X-ray Abdomen in standing position 21-30 years has found to be 46 %

following points were noted to be 29 years. Haddad(58) et al found the

a) Presence of fluid levels and their average age of presentation of patients of

number abdominal tuberculosis to be around 26 years

b) Distended loops amongst Indians whereas it was 46 years for

c) Gas under diaphragm rest of the world. According to them it may be

diagnostic dilemma. patients with a male: female ratio of 1.77:1.

of procedure performed. with a male to female ratio of 1.3:12 and 1:9