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INDIAN JOURNAL OF MEDICAL MICROBIOLOGY (OfÞcial publication of Indian Association of Medical Microbiologists, Published quarterly in January, April, July and October) Indexed in Index Medicus/MEDLINE/PubMed, ‘Elsevier Science - EMBASE’, ‘IndMED’

EDITORIAL BOARD EDITOR Dr. SAVITRI SHARMA L V Prasad Eye Institute Bhubaneswar - 751 024, India ASSOCIATE EDITOR Dr. Shobha Broor

ASSISTANT EDITOR Dr. V Lakshmi

Professor, Department of Microbiology All India Institute of Medical Sciences New Delhi - 110 029, India

Professor and Head, Dept. of Microbiology Nizam’s Institute of Medical Sciences Punjagutta, Hyderabad - 500 082, India

ASSISTANT EDITOR Dr. P Sugandhi Rao

ASSISTANT EDITOR Dr. Reba Kanungo

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Professor and Head Department of Microbiology, Perunthalaivar Kamaraj Medical College and Research Institute, Kadhirkamam, Puducherry - 605 009, India

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452

Indian Journal of Medical Microbiology

vol. 25, No. 4

INDIAN JOURNAL OF MEDICAL MICROBIOLOGY (Publication of Indian Association of Medical Microbiologists)

ISSN 0255-0857

Volume 25

Number 4

October-December, 2007

CONTENTS Page No.

Guest Editorial The Need for Control of Viral Illnesses in India: A Call for Action C Lahariya, UK Baveja

.......309

Review Article Immunobiology of Human ImmunodeÞciency Virus Infection P Tripathi, S Agrawal

.......311

Special Articles Serum Levels of Bcl-2 and Cellular Oxidative Stress in Patients with Viral Hepatitis HG Osman, OM Gabr, S Lotfy, S Gabr

.......323

Rapid IdentiÞcation of Non-sporing Anaerobes using Nuclear Magnetic Resonance Spectroscopy and an IdentiÞcation Strategy .......330 S Menon, R Bharadwaj, AS Chowdhary, DV Kaundinya, DA Palande

Original Articles Species Distribution and Physiological Characterization of Acinetobacter Genospecies from Healthy Human Skin of Tribal Population in India SP Yavankar, KR Pardesi, BA Chopade Extended-spectrum Beta-lactamases in Ceftazidime-resistant Escherichia coli and Klebsiella pneumoniae Isolates in Turkish Hospitals S Hoşoğlu, S Gündeş, F Kolaylõ, A Karadenizli, K Demirdağ, M Günaydõn, M Altõndis, R Çaylan, H Ucmak Typhoid Myopathy or Typhoid Hepatitis: A Matter of Debate M Mirsadraee, A Shirdel, F Roknee

.......336

.......346

.......351

Correlation Between in Vitro Susceptibility and Treatment Outcome with Azithromycin in Gonorrhoea: A Prospective Study .......354 P Khaki, P Bhalla, A Sharma, V Kumar Comparison of Radiorespirometric Buddemeyer Assay with ATP Assay and Mouse Foot Pad Test in Detecting Viable Mycobacterium leprae from Clinical Samples .......358 VP Agrawal, VP Shetty Detection of Mycoplasma Species in Cell Culture by PCR And RFLP Based Method: Effect of BM-cyclin to Cure Infections V Gopalkrishna, H Verma, NS Kumbhar, RS Tomar, PR Patil

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.......364

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Virulence Factors and Drug Resistance in Escherichia coli Isolated from Extraintestinal Infections .......369 S Sharma, GK Bhat, S Shenoy Antimicrobial Susceptibility Testing of Helicobacter pylori to Selected Agents by Agar Dilution Method in Shiraz-iran J Kohanteb, A Bazargani, M Saberi-Firoozi, A Mobasser Outbreak of Acute Viral Hepatitis due to Hepatitis E virus in Hyderabad P Sarguna, A Rao, KN Sudha Ramana

.......374 .......378

A Comparative Study for the Detection of Mycobacteria by BACTEC MGIT 960, Lowenstein Jensen Media and Direct AFB Smear Examination .......383 S Rishi, P Sinha, B Malhotra, N Pal Cytokine Levels in Patients with Brucellosis and their Relations with the Treatment H Akbulut, I Celik, A Akbulut

.......387

Brief Communications Rapid Detection of Non-enterobacteriaceae Directly from Positive Blood Culture using Fluorescent In Situ Hybridization .......391 EH Wong, G Subramaniam, P Navaratnam, SD Sekaran Latex Particle Agglutination Test as an Adjunct to the Diagnosis of Bacterial Meningitis K Surinder, K Bineeta, M Megha

.......395

Helminthic Infestation in Children of Kupwara District: A Prospective Study SA Wani, F Ahmad, SA Zargar, BA Fomda, Z Ahmad, P Ahmad

.......398

Clinical and Mycological ProÞle of Cryptococcosis in a Tertiary Care Hospital MR Capoor, D Nair, M Deb, B Gupta, P Aggarwal

.......401

Candida spp. other than Candida albicans: A Major Cause of Fungaemia in a Tertiary Care Centre .......405 S Shivaprakasha, K Radhakrishnan, PMS Karim

Case Reports Enterobacter sakazakii in Infants: Novel Phenomenon in India P Ray, A Das, V Gautam, N Jain, A Narang, M Sharma

.......408

Ocular Toxocariasis in a Child: A Case Report from Kashmir, North India BA Fomda, Z Ahmad, NN Khan, S Tanveer, SA Wani

.......411

Cutaneous Actinomycosis: A Rare Case SC Metgud, H Sumati, P Sheetal

.......413

Fatal Haemophagocytic Syndrome and Hepatitis Associated with Visceral Leishmaniasis P Mathur, JC Samantaray, P Samanta

.......416

A Rare Case of Mucormycosis of Median Sternotomy Wound Caused by Rhizopus arrhizus R Chawla, S Sehgal, S Ravindra Kumar, B Mishra

.......419

Mycobacterium fortuitum Keratitis C Sanghvi

.......422

Correspondence Prevention of Parent-to-Child Transmission of HIV: An Experience in Rural Population N Nagdeo, VR Thombare www.ijmm.org

.......425

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Combining Vital Staining with Fast Plaque: TB Assay D Rawat, MR Capoor, A Hasan, D Nair, M Deb, P Aggarwal

.......426

Disseminated Histoplasmosis PK Maiti, MS Mathews

.......427

Authors’ Reply RS Bharadwaj

.......428

Microwave Disinfection of Gauze Contaminated with Bacteria and Fungi VH Cardoso, DL Gonçalves, E Angioletto, F Dal-Pizzol, EL Streck

.......428

Endoscope Reprocessing: Stand up and Take Notice! A Das, P Ray, M Sharma

.......429

Prevalence of Toxoplasma gondii Infection amongst Pregnant Women in Assam, India BJ Borkakoty, AK Borthakur, M Gohain

.......431

Evaluation of Glucose-Methylene-Blue-Mueller-Hinton Agar for E-Test Minimum Inhibitory Concentration Determination in Candida spp. MR Capoor, D Rawat, D Nair, M Deb, P Aggarwal

.......432

Resurgence of Diphtheria in the Vaccination Era N Khan, J Shastri, U Aigal, B Doctor

.......434

A Report of Pseudomonas aeruginosa Antibiotic Resistance from a Multicenter Study in Iran MA Boroumand, P Esfahanifard, S Saadat, M Sheihkvatan, S Hekmatyazdi, M Saremi, L Nazemi

.......435

Trends of Antibiotic Resistance in Salmonella enterica Serovar Typhi Isolated from Hospitalized Patients from 1997 to 2004 in Lagos, Nigeria KO Akinyemi, AO Coker

.......436

Book Review Hospital-Acquired Infections: Power Strategies for Clinical Practice Reba Kanungo

.......438

Title Index, 2007 Author Index, 2007 Scientific Reviewers, 2007

.......440 .......442 .......446

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October-December 2007 Microbiology, (2007) 25(4): 419-21 Indian Journal of Medical

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Case Report

A RARE CASE OF MUCORMYCOSIS OF MEDIAN STERNOTOMY WOUND CAUSED BY RHIZOPUS ARRHIZUS *R Chawla, S Sehgal, S Ravindra Kumar, B Mishra

Abstract We describe a case of mucormycosis of median sternotomy wound caused by Rhizopus arrhizus. The patient, a known diabetic and a case of coronary artery disease underwent coronary artery bypass surgery. In the postoperative period, patient developed infection of the median sternotomy wound, from which R. arrhizus was isolated on culture. Patient succumbed in spite of being treated with surgical debridement and amphotericin B. To the best of our knowledge, this is the Þrst reported case of mucormycosis of median sternotomy wound from India. Key words: Median sternotomy wound, mucormycosis, Rhizopus arrhizus

Zygomycosis is a progressive infection caused by one of the phycomycetes. These are large, thin-walled and nonseptate fungi. Zygomycetes consist of two orders Mucorales and Entomophthorales, which contain genera and species of medical importance. Fungi of the order mucorales are distributed into six families (Mucoraceae, Cunninghamellaceae, Saksenaea, Thamnidiaceae, Syncephalastraceae and Mortierellaceae) and cause mucormycosis. Species belonging to the family Mucoraceae are more commonly isolated from patients with mucormycosis than of any other family. Among the family Mucoraceae, Rhizopus arrhizus (Rhizopus oryzae) is by far the most common cause of infection.1 Fungi of the order Mucorales are ubiquitous organisms often found in decaying vegetation. Based on clinical presentation and site of infection, mucormycosis can be divided into six clinical categories: (i) rhinocerebral, (ii) pulmonary, (iii) cutaneous, (iv) gastrointestinal, (v) disseminated and (iv) miscellaneous.2 These categories of invasive mucormycosis tend to be associated with metabolic acidosis, hyperglycaemia, corticosteroid therapy, immunosuppressive therapy for organ transplantation, neutropoenia and desferoxamine therapy.1 We report here a case of mucormycosis of median sternotomy wound. Case Report A 48-year-old male patient, resident of New Delhi, presented in the Cardiology outpatient department of G.B. Pant Hospital, New Delhi, with complaints of recurrent chest pain and dyspnoea on exertion for the past two months. Patient admitted to smoking on an average 10 cigarettes a day for the past 25 years and also consumed alcohol regularly for the same duration. Patient was a known case of type 2 diabetes mellitus *Corresponding author (email: ) Departments of Microbiology (RC, SS, BM), Pathology (SRK), G.B. Pant Hospital, New Delhi - 110 002, India Received: 22-03-07 Accepted: 26-05-07

and had been on insulin therapy for the past 14 years due to poor glycaemic control on oral hypoglycaemic agents. On echocardiography, ejection fraction was found to be 25-30%. Patient was taken up for coronary angiography and was found to have triple vessel disease with 90, 100 and 100% blockage in left anterior descending, circumßex and right coronary artery, respectively. In view of the persisting symptoms, the patient was taken up for coronary artery bypass graft through median sternotomy. The patient was on broad-spectrum antibiotic prophylaxis during the postoperative period. In spite of being on insulin therapy during the postoperative period, patient’s blood sugar level was high; however, there was no ketoacidosis. On the seventh post-operative day, oedema and induration were noted at the incision site. Over the next three days there was spread of induration, blistering of skin and a gaping of the median sternotomy wound. A ßuffy cottony growth was observed on the surface of the wound. The excised skin along with the underlying tissue was sent for bacteriological culture, fungal culture and histopathological examination. Ten percent potassium hydroxide (KOH) and lactophenol cotton blue (LPCB) mount of the specimen showed the presence of broad, hyaline, aseptate hyphae. On Gram stain, no bacteria were seen. For bacterial culture, specimen was inoculated on 5% sheep blood agar, MacConkey’s agar and glucose broth and incubated at 37 °C. For fungal culture, Sabouraud dextrose agar (SDA) with and without cycloheximide was inoculated in triplicate, one set was incubated at 25 °C, while the second and the third set were incubated at 37 and 46 °C, respectively. Microscopic characterization of the fungal isolate was carried out by preparing LPCB mount from the growth and by microslide culture technique. A rapid, white, ßuffy growth was observed after 24 h on blood agar and on the surface of glucose broth. Similar growth was seen after 48 h on SDA without cycloheximide, incubated at 25 and 37 °C. However, no growth occurred on the above mentioned medium when incubated at 46 °C. The colonies were initially white but on continued incubation became grey in colour (Fig. 1).

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Figure 1: Growth of Rhizopus arrhizus on SDA without cycloheximide. White ßuffy growth is seen towards the bottom of the tube with grey coloured growth at the top

Figure 3: Lactophenol cotton blue (LPCB) mount of growth of Rhizopus arrhizus on SDA without cycloheximide. Aseptate hyaline hyphax is seen along with numerous angular, ellipsoidal sporangiospores (×400)

Figure 2: Lactophenol cotton blue (LPCB) mount of growth of Rhizopus arrhizus on SDA without cycloheximide. Two sporangiophores are seen arising from the stolon directly above rhizoidal tufts (×50)

Figure 4: Periodic acid-Schiff staining of the tissue section showing broad, aseptate and irregularly branching hyphae. Inset: Similar Þndings on Gomori’s methenamine-silver staining (×400)

Wide, hyaline, aseptate hyphae were seen. Sporangiophores, approximately 1500 µm long and 18 µm wide, smooth-walled, non-septate, were seen originating singly or in groups from stolons directly above the rhizoidal tufts. Rhizoids were brown and branched. Sporangiophores were unbranched, terminating in round, greyish black sporangia measuring 100-200 µm in diameter. The columella and apophysis together were globose and upto 130 µm in height. Collapsed columella resembling umbrella were seen. Greyish-green coloured sporangiospores (3-8 µm in length) were produced in abundance and were angular, subspherical to ellipsoidal with ridges on the surface (Figs. 2, 3). The fungal isolate was identiÞed phenotypically as Rhizopus arrhizus by comparing the abovementioned characteristics with standard descriptions given by Ribes et al.1

showed broad, aseptate, ribbon-like hyphae with irregular branching along with necrotic tissue.

Haematoxylin and eosin; periodic acid-Schiff; and Gomori’s methenamine-silver staining (Fig. 4) of the tissue

In a review of 929 cases of zygomycosis by Roden et al, cutaneous zygomycosis was found to be the

Two blood specimens were collected from the patient for fungal and bacteriological culture; however, both were found to be sterile. Based on the above Þndings, a diagnosis of mucormycosis of median sternotomy wound was made and the patient was treated with wound debridement and intravenous liposomal amphotericin B. However, patient’s condition continued to deteriorate and on the thirteenth postoperative day, patient developed hypotension and congestive cardiac failure, which did not respond to inotropic support and died due to cardiac arrest. Discussion

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October-December 2007

Chawla et al - Mucormycosis of Sternotomy Wound

third most common (19%) form after sinus (39%) and pulmonary (24%) zygomycosis.3 Primary mucormycosis of the skin and wounds has been associated with burns, traumatic disruption of skin, persistent maceration of skin and with use of contaminated elasticized surgical bandages.2 Cutaneous mucormycosis can be invasive locally and penetrate from the cutaneous and subcutaneous tissues into the adjacent fat, muscle, fascia and even bone. Secondary vascular invasion may lead to haematogenously disseminated infection of the deep organs. However, isolated cutaneous mucormycosis has a favourable prognosis and a low mortality if aggressive surgical debridement is done promptly. Though elasticized surgical bandage was not used, our patient was a known diabetic and this could have been an important risk factor for development of mucormycosis of the median sternotomy wound. Similar to our case, Abter et al. reported mucormycosis of the median sternotomy wound in a diabetic patient who had undergone coronary artery bypass surgery and mitral valve replacement.4 Their case had a rapid downhill course and died due to invasive sternal mucormycosis inspite of extensive surgical debridement and amphotericin B therapy. Our patient also had a rapid deterioration and was lost. However, in absence of autopsy (declined by family) we could not determine whether the patient died due to invasive spread of sternal wound mucormycosis to the deeper tissues and involvement of the graft leading to graft failure. In a retrospective analysis of cases of cardiac mucormycosis, Virmani et al. reviewed four cases of cardiac mucormycosis occurring after cardiac surgery. The surgical procedures included valve replacement, coronary artery bypass graft and repair of coarctation of aorta.5 Chaudhry et al. reported a case of prosthetic mitral valve mucormycosis caused by Mucor spp. after mitral valve replacement in New Delhi.6 To the best

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of our knowledge, this is the Þrst case of mucormycosis of median sternotomy wound being reported from India. As no effective chemoprophylactic regimen is available for the prevention of mucormycosis, preventive strategies include limiting the sources of contamination in the environment of patients at risk and careful monitoring of diabetic patients. Finally, prompt diagnosis and aggressive treatment of a potentially fatal condition like mucormycosis can only be achieved with heightened awareness and better cooperation between clinicians, microbiologists and pathologists. References 1.

Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human disease. Clin Microbiol Rev 2000;13:236-301.

2.

Spellberg B, Edwards J Jr, Ibrahim A. Novel perspectives on mucormycosis: Pathophysiology, presentation and management. Clin Microbiol Rev 2005;18:556-69.

3.

Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Clin Infect Dis 2005;41:634-53.

4.

Abter EI, Lutwick SM, Chapnick EK, Chittivelu S, Lutwick LI, Sabado M, et al. Mucormycosis of a median sternotomy wound. Cardiovasc Surg 1994;2:474-7.

5.

Virmani R, Connor DH, McAllister HA. Cardiac mucormycosis: A report of Þve patients and review of 14 previously reported cases. Am J Clin Pathol 1982;78:42-7.

6.

Chaudhry R, Venugopal P, Chopra P. Prosthetic mitral valve mucormycosis caused by Mucor species. Int J Cardiol 1987; 17:333-5.

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Source of Support: Nil, Conßict of Interest: None declared.