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INFECTIOUS Recognised and registered with the


Pakistan Medical & Dental Council
DISEASES I NO.PF.11-F-96 (Infectious Diseases) 2560
DJ College of Physicians & Surgeons, Pakistan
JOURNAL of Pakistan
Higher Education Commission, Pakistan
Published by the Infectious Diseases Society of Pakistan Indexed - WHO EMRO
October - December 2010 Volume 19 Issue 04
Infectious Diseases Journal of Pakistan
Official Organ of the Infectious Diseases Society of Pakistan
CONTENTS PAGE #

President Altaf Ahmed GUEST EDITORIAL 224


Consultant Microbiology, The Indus Hospital
Karachi, Pakistan ORIGINAL ARTICLES
Gen. Secretary Ejaz A. Khan General Practitioners’ Knowledge regarding Tuberculosis: A Survey
Department of Pediatrics, from Karachi 226
Shifa International Hospital, Islamabd, Pakistan Fauzia Haji Mohammad, Tabinda Ashfaq, Qudsia Anjum,Yaseen Usman
Treasurer M. Asim Beg Validation of BBL CHROMagar Candida Medium (BD Diagnostics)
Pathology& Microbiology, in Isolating and Differentiating Candida Species in Clinical Specimens 230
Aga Khan University, Karachi, Pakistan
Ashraf Hussain, Aamer Ikram, Muhammad Roshan, Luqman Satti
Editorial Office
Red Cell Distribution Width in the Diagnosis of Iron Deficiency
Editor: Aamer Ikram Anemia and Thalassemia Trait 234
Malik Muhammad Adil, Ayesha Junaid, Iffat Zaman, Zeshan Bin
Editorial Board Ishtiaque
Naseem Salahuddin: Karachi Ejaz Vohra: Karachi Irrational use of Flagyl (Metronidazole) by Practitioners in
Naila B Ansari: Karachi Rumina Hasan: Karachi Outpatient Clinics 237
Shehla Baqi: Karachi Noaman Siddiqui: Abbottabad Tehmina Munir, Munir Lodhi
Nurul Iman: Peshawar Aamir J Khan: Karachi
Ejaz Khan: Islamabad D S Akram: Karachi Treatment of Helicobacter pylori Infection; A Controlled Randomized
Ayesha Khan: Islamabad Comparative Clinical Trial 240
Arshad Mehmood, Khan Usmanghani, Abdul Hannan, E. Mohiuddin,
Overseas Advisers: Muhammad Akram, Muhammad Asif, Muhammad Riaz ur Rehman
Murat Akova: Ankara,Turkey Drug Susceptibility Pattern of Typhoidal Salmonellae to the
Rayhan Hashmey: UAE Conventional Anti-Typhoid Drugs; A Current Perspective 243
Deborah Briggs: U Kansas, USA Anam Imtiaz , Saba Abbasi, Javaid Usman
Peter Chiodini: Royal College Trop Med/Hyg UK
Salman Siddiqui: USA CASE REPORT
Adeel Butt: U of Pittsburgh, USA Central Nervous System ring enhancing lesions in an
Farida Jamal: KL, Malyasia Immunocompromised Child with Status Epilepticus: A Case Report
and Literature Review 246
Business and Circulation Amna Batool, Yawar Najam, Ejaz Ahmed Khan, Ismail A Khatri
Nasir Hanook
Rights: Gelatinous Bone Marrow in AIDS 250
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the editor/publisher and author(s) of IDJ. NEWS & VIEWS 252
Disclaimer: INSTRUCTIONS FOR AUTHORS 254
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Volume 19 Issue 04 Oct-Dec 2010 . 223
GUEST EDITORIAL

Plagiarism in Today’s World


Scientific progress has been provided an essential aid with the introduction of the internet. Literature search, correspondence and
submission of research articles can all be performed at a fast speed. As in any other field, the use of new inventions can be misused
also. This is seen as Plagiarism or intellectual theft, which is an integral component of scientific misconduct. According to the
Merriam – Webster Online Dictionary plagiarism is defined as, “To steal and pass off (the ideas and words of another) as one’s
own, to use (another’s production) without crediting the source, committing literary theft, to present as new and original an idea
or product from an existing source”. In other words plagiarism is an act of fraud. It has two components, stealing followed by
lying1. “Plagiarism has also been stated as one of the most serious crimes in academia”2.

Authors resort to plagiarism for various reasons, the most important being to increase the number of publications in a short time.
As demanded in Pakistan, doctors serving in the government teaching institutions require a fairly large number of research
publications in indexed journals for promotion. Being busy practitioners, these professionals at times resort to easy and unfair
means for writing articles. Secondly, in this part of the world, most authors do not have a good command over English language
and copying verbatim from the net is simple and saves time and energy. At times the author is ignorant about the wrong doing,
which is not an acceptable excuse. An important reason is lack of appropriate training. This is because the senior faculty, universities
and governing bodies that are responsible for providing the correct guidance, lack expertise, time and funding resources to conduct
required training/workshops for the junior doctors.

Another reason commonly encountered is the desire to become eminent. Scientists want to have a large number of publications
to their credit, so that they can be quoted all over the world. Low moral values are the most important factor, an honest individual
would never resort to unfair means. “Ethical writing is a reflection of ethical practice”3.

Whatever the reason, plagiarism is stealing of intellectual property and when detected has to be penalized. It not only brings
disgrace to the author besides losing the published material, promotions may be stopped or even services terminated. Some
institutions may impose a monitory penalty.

Ethics, trust and honesty are the basis of research and publication. Research is essential for the progress of science as the results
obtained should be published for the benefit of others. The American College of Physicians in their Ethics Manual have stated
that, “Dishonesty should not be tolerated - it should be investigated and punished, researchers should be careful, impartial, unbiased
and open to investigation and purpose of scientific research should not be self-promotion, personal publicity and financial gain”4.

Ethics took shape with the Nuremberg Code formed in 1946, The Helsinki Declaration in 1964, and The Belmont Report of 19795.
All these have formed a base for important guidelines on Ethics in Research and have been adopted by the World Association
of Medical Editors (WAME)6, International Committee of Medical Journal Editors (ICMJE)7 and Committee on Publication Ethics
(COPE)8. These guidelines on ethics are followed by most scientific journals.

Despite the guidelines from international authorities which have been adopted by most journals and institutions, the act of
plagiarism is being detected and reported from all over the world. This dishonesty may start from school and continue to the
professional colleges and university. A study on cheating from Croatia which included students in four medical universities,
reported more than 99 percent to have admitted to at least one form of educational dishonesty and 78 percent reported to some
form of cheating. The study concluded that “Academic dishonesty of university students does not begin in higher education;
students come in medical schools ready to cheat”9.

Another questionnaire based study on Plagiarism by Shirazi et al included fourth year medical students and faculty members10.
The results revealed that 19% and 22% of students and faculty knew about referencing material from other sources. Surprisingly,
74% students and 69% faculty had observed that colleagues indulge in plagiarizing and were not reported. The study concluded
that there was a general lack of information regarding plagiarism among medical students and faculty members.

A third cross sectional questionnaire based study conducted by the editorial section of the Journal of Pakistan Medical Association
(JPMA) included all authors who submitted their manuscripts for publication in 2010. This study was planned to score the level
of perception and practices regarding plagiarism. In this study of JPMA, only 22% of the participants could define plagiarism
correctly. The level of perception and practices regarding plagiarism of authors submitting to JPMA was 30% above the 75th
Percentile. The study concluded that the authors submitting to JPMA had inadequate knowledge on plagiarism 11 .

Plagiarism has been reported earlier from Pakistan. “In Pakistan, this problem is not uncommon and many such cases are brought
to the notice of editors of medical journals. Surprisingly, the people involved in this matter are usually from a higher academic
echelon who had published a similar paper of their own in a local prestigious journal, which was earlier, published in an international
journal”12. Preventive strategies regarding plagiarism have been advised by Hashim et al, ”Local literature has advocated using
reference managers to prevent plagiarism” 13.

Detecting plagiarism is not difficult with the availability of the internet and numerous software. Hence, every journal should have
a regular screening system. More than this, there is a dire need to root out plagiarism from our teaching institutions. For this,
awareness has to be created to consider plagiarism a fraudulent act and which can have drastic and damaging consequences if
224 . Infectious Diseases Journal of Pakistan
detected. Faculty members have to acquaint themselves with the rules and teach their students. Workshops and hands-on training
would be an added advantage for the purpose. It is also essential for all institutions, journals and health policy makers to have
definite guidelines on plagiarism which will promote ethical research and publication.

Fatema Jawad
Editor-in-chief
Journal of Pakistan Medical Association
Email: jpma_jpma@hotmail.com

References
1. www.merriam-webster.com/dictionary/plagiarized. Cited 26 December Overlapping Publications. www.rin.ac.uk/policy/committee-publication
2010. ethics-cope-guidel.
2. Pechenik A. A short guide to writing about biology. 4th Edition. New York: 9. Taradi SK, Taradi M, Knezevic T, Dogas Z. Students come to medical
Addison Wesley Longman. 2001; p.10. schools prepared to cheat: a multi-campus investigation. J Med Ethics doi
3. Kolin F C. Successful writing at Work. 6th Edition. Houghton Mifflin. 10.1136/jma.2010.035410.
2002. 10. Shirazi B, Jafarey AM, Moazam F. Plagiarism and the medical fraternity:
4. American College of Physicians Ethics Manual. American College of A study of knowledge and attitudes. J Pak Med Assoc 2010; 60:269-73.
Physicians. Ann Intern Med 2005; 101: 263-74. 11. Jawad F, Ejaz K, Riaz M K, Jafary A, Shirazi B. What is plagiarism and
5. Summary from the Nuremberg Code. Trials of War Criminals before the how much authors know about it? Oral presentation at 5th Regional
Nuremberg Military Tribunals. Under Control Council Law 10, Volume 2, Conference on Medical Journals in the Eastern Mediterranean Region,
Nuremberg, October 1946 - April 1949. Washington DC, US Government Karachi-Pakistan, December 2-5, 2010 Abstract Book, page 71.
Printing Office, 1949; pp. 181-2. 12. Gadit AA. Plagiarism: how serious is this problem in Pakistan? J Pak
6. WAME http://www.wame.org/resources. Med Assoc 2006; 56: 618.
7. www.icjme.org. Uniform Requirements for Manuscripts Submitted to 13. Hashim MJ, Rahim MF, Alam AY. Training in reference management
Biomedical Journals. software - a part of new medical informatics workshops in Pakistan. J Ayub
8. Publishing and Editorial issues related to Publication in Biomedical Journals: Med Coll Abbottabad 2007; 19: 70-1.

Volume 19 Issue 04 Oct-Dec 2010 . 225


ORIGINAL ARTICLE

General Practitioners’ Knowledge regarding Tuberculosis: A Survey from Karachi

Fauzia Haji Mohammad*, Tabinda Ashfaq*, Qudsia Anjum**,Yaseen Usman*

*Department of Family Medicine, Ziauddin University, Karachi


**Al Ahli Hospital, Qatar

Abstract

Objective knowledge and hence reduce the disease burden and development
To assess the knowledge gaps regarding tuberculosis in general of multi drug resistant tuberculosis.
practitioners of Karachi registered for attending the continuous
medical education programme. Key Words
CME, General Physicians, Tuberculosis.
Methods
This was a cross sectional survey targeting General Practitioners Introduction
of Karachi attending the continuous medical education Tuberculosis (TB) is an important cause of morbidity and
programme organized by the College of Family Medicine, mortality in the developing world. One third of the world’s
through non-probability purposive sampling. For analysis, they population, approximately two billion people are infected with
were arbitrarily divided into two groups on the basis of clinical Mycobacterium tuberculosis1. In 2006, 1.7 million people died
experience; group 1 with less than 5 years and group 2 with from tuberculosis worldwide, majority from developing countries
more than 5 years of experience. with more than half of these deaths occurring in Asia. Pakistan,
being a third world country ranks eighth in prevalence of
Results tuberculosis2.
A total of 120 general practitioners (GPs) attended the CME
programme, out of which 109 completed the questionnaire. According to WHO estimated TB burden in 2004, its incidence
71 (65.13%) were males and 38 (34.86%) were females. Mean in Pakistan is 181/100,000 and prevalence is 329/100,000
age of general practitioners was 37.7 ± 9.9 years and mean people3. Tuberculosis has been regarded primarily as a disease
duration of their practice was 10.6 ± 8.7 years. The overall of poverty and overcrowding4. Factors contributing to persistent
knowledge score was found to be slightly higher among general prevalence of this devastating illness in the community include
practitioners in group 1. The most common symptom for inadequate knowledge of health care professionals, lack of
diagnosis of tuberculosis identified by 38% general practitioners diagnostic tools in health care setup, non-availability of anti-
in group 1 was chronic cough, whereas 42% general practitioners tuberculous drugs and poor patient compliance5. WHO declared
in group 2 recognized low grade fever with night sweats. Most tuberculosis as a global emergency in 1993, thus national TB
general practitioners in both groups, 59% versus 46% identified guidelines were launched with a revision in 19986. Although
sputum for acid fast bacillus (AFB) smear as investigation of evidence based guideline is available, yet health care
choice. Only 21% GPs in group 1 versus 37% in group 2 knew professionals lack knowledge for appropriate management of
about the correct duration of therapy for pulmonary tuberculosis, TB. A number of local studies have shown that private
and 12% group 1 versus 15% group 2 general practitioners practitioners are not compliant with the treatment guidelines7,10.
knew about the duration of treatment for extra pulmonary A study done on family physicians in Pakistan targeting
tuberculosis. Drugs for initial phase were correctly identified knowledge regarding Mantoux test, revealed an overall
by 55% general practitioners in group 1 and 54% in group 2. inadequacy in knowledge; only 18.8% family physicians scored
The drugs for continuation phase were correctly identified by >80% correct responses11.
10% general practitioners in group 1 and 20% from group 2.
An international study assessed knowledge of health care
Conclusion professionals and community health workers. Although doctors
The study identified gaps in knowledge regarding tuberculosis and nurses had better mean scores than non-professionals, yet
among general practitioners from Karachi. Their active an overall knowledge gap existed12. A few other international
engagement in educational activities could enhance their studies also revealed lower levels of knowledge regarding the
Corresponding Author: Fauzia Haji Mohammad, symptoms and diagnostic procedures for TB among doctors in
Department of Family Medicine, Ziauddin University, private practice and primary care physicians13,14. The literature
Clifton, Karachi. search in the area has suggested updating knowledge of general
Email: fauziaakhtar@yahoo.com practitioners (GPs) to improve the scenario for early detection

226 . Infectious Diseases Journal of Pakistan


and treatment of TB. Therefore, this study was aimed to assess
Table 1: Knowledge scores versus years of clinical experience
the knowledge gaps regarding tuberculosis in general practitioners
of Karachi, who were registered for attending the continuous Knowledge Years of clinical experience p value
medical education (CME) programme. scores
< 5 years > 5 years
Material & Methods
n % n %
This was a cross sectional survey targeting the GPs of Karachi
registered for attending the CME programme organized in 13 or more 12 17.66 5 12.2
National Institute of Child Health during May-June 2010. This 0.447
CME programme was organized by the College of Family <13 56 82.4 36 87.8
Medicine for MRCGP (International) exam constituting a few
lectures on TB, in order to update GPs knowledge in the light
of recent guidelines. The data was collected on a pre-tested groups, 59% and 46% (p-value=0.763) identified sputum for
self-administered questionnaire before attending the respiratory AFB smear as the investigation of choice. Regarding duration
module. The questionnaire was distributed simultaneously to of therapy for pulmonary tuberculosis only 21% GPs in group1
all of them after verbal informed consent. A total of 120 GPs knew about the correct duration as compared to 37% GPs in
were surveyed using non-probability purposive sampling method. group 2 (p-value 0.095), whereas 12% in group 1 versus 15%
The sample size was calculated at 95% confidence level and in group 2 GPs knew about the correct duration of treatment
sampling error of 10%, assuming proportion of knowledge for extra pulmonary tuberculosis (p-value 0.931). Drugs for
among GPs to be 28%. initial phase were correctly recognized by 55% GPs in group
1 and 54% GPs in group 2 (p-value 0.206), while the drugs for
All the results were analyzed using SPSS version 11. A continuation phase were correctly marked by 10% GPs with
knowledge score of TB was calculated from 18 MCQs (1 point <5 years experience and 20% with >5years experience (p-value
was given for each correct answer). Frequencies were calculated 0.035).
for categorical variables (gender). Mean and standard deviations
were calculated for age and year of experience. GPs were Regarding the side effects of various anti-TB drugs, 41% GPs
divided in two groups on the basis of years of experience for in group 1 and 39% in group 2 identified peripheral neuropathy
the purposes of analysis, group 1 with less than 5 years and as the side effect of isoniazid, 58% from group 1 and 44% from
group 2 with more than 5 years of clinical experience. Cross group 2 identified orange color body fluid as the side effect of
tabulation was done and chi-square test was applied to compare rifampicin, 59% in group 1 and 44% in group 2 identified vision
the knowledge between two groups of GPs; p-value of <0.05 impairment as the side effect of ethambutol, and 58% from
was considered significant. group 1 and 46% from group 2 identified gout as the side effect
of pyrazinamide.
Results
A total of 109 GPs completed questionnaires which were Discussion
analyzed. Majority of the respondents were males (65.1%) and GPs are considered as a back bone of health care system and
34.9% were females. Mean age of general practitioners was they are the first contact physicians for most of the patients. It
37.7 ± 9.9 years and mean duration of their practice was 10.6 has been observed that majority of GPs lack expertise in
± 8.7 years. There were 68 (62.4%) doctors in group 1 and diagnosing TB, thus leading to increased burden.
41(37.6%) in group 2.
Several studies have shown poor knowledge regarding TB
Table 1 shows the overall knowledge score regarding tuberculosis among GPs probably because in Pakistan after medical
among GPs. It was found that GPs in group 1 had slightly better graduation most doctors practice independently without adequate
knowledge than the doctors in group 2. Only 17.6% GPs in clinical experience and supervised training7, 10. In addition, there
group 1 scored more than 72% as compared to 12.2 % in group 2. is also lack of motivation for up gradation of knowledge through
82.4% and 87.8% doctors in two groups respectively scored CME programmes and workshops. In our study, majority of
below 72%. the respondents were male, the possible reason for this is that
majority of female doctors practice as gynecologist and
Table 2 summarizes the symptoms, diagnosis, and treatment of pediatrician. Few local studies have also assessed knowledge
TB as recognized by the two groups of GPs. The most common of general population about TB, where again there were
symptom for the diagnosis of TB identified by 38% GPs in misconceptions with inadequate knowledge 1 5 - 1 7 .
group 1 was chronic cough, whereas 42% GPs in group 2
recognized low grade fever with night sweats (p-value 0.437) Most common symptom of pulmonary TB is chronic cough,
as the most common presenting complain. Most GPs in the two which was identified by few in the current study; this is consistent

Volume 19 Issue 04 Oct-Dec 2010 . 227


Table 2: Knowledge regarding diagnosis of tuberculosis

Knowledge of General Practitioners <5 years >5years p value


n=68 % n=41 %

Most common symptom of tuberculosis


High grade fever with chills and rigors 6 9 5 12 0.437
Low grade fever with night sweats 25 37 17 42
Chronic cough (> 3 weeks) 26 38 9 22
Weight loss 6 9 5 12
Hemoptysis. 5 7 5 12
Investigation of choice to diagnose pulmonary tuberculosis
Complete blood count and ESR 7 10 5 12 0.763
Chest X-ray 6 9 6 15
Sputum for AFB smear 40 59 19 46
Tuberculin skin test 7 10 5 12
Blood for AFB smear 8 12 6 15
Three negative sputum samples can exclude the diagnosis
Yes 31 46 23 56 0.288
No 37 54 18 44
Duration of therapy for pulmonary tuberculosis
6 months 15 22 6 15 0.095
8 months 14 21 15 36
9 months 33 48 13 32
12 months 6 9 7 17
Duration of therapy for extra pulmonary tuberculosis
6 months 8 12 5 12 0.931
8 months 8 12 6 15
9 months 13 19 9 22
12 months 39 57 21 51
Duration of initial intensive phase and continuation phase
2 months + 7 months 17 25 9 22 0.293
2 months + 6 months 31 45 16 39
3 months + 6 months 14 21 7 17
3 months + 5 months 6 9 9 22
Drugs of initial intensive phase
HRE 19 28 6 15 0.206
HRZE 37 55 22 54
HRSE 5 7 7 17
HRZES 6 10 6 15
Drugs of continuation phase
HR 45 66 17 41 0.035
RE 7 10 11 27
RZ 9 14 5 12
HE 7 10 8 20
H=isoniazid, R=rifampicin, Z=pyrazinamide, E=ethambutol, S=streptomycin

with findings in a study conducted in Oman18. This may lead identified by almost half of GPs in both the groups. These
to delay in the diagnosis of disease with increasing spread of figures were almost similar to another study done in Karachi
disease as well as complications. The gold standard test for the (58.3 %)10. The overall reason for these results is that GPs
diagnosis of pulmonary TB is sputum smear for AFB; correctly consider this test to be unreliable and inconvenient in outpatient

228 . Infectious Diseases Journal of Pakistan


Table 3: Knowledge regarding side effects of antituberculous disease burden and development of multi-drug resistant
tuberculosis.
Knowledge of <5 years >5years p-value
General Practitioners n=68 % n=41 % Refrences
1. Tuberculosis fact sheet [Online] 2008 [cited 2008 December
Side effect of Isoniazid 30]. Available from:
U R L h t t p : / / w w w. w h o . i n t / m e d i a c e n t r e / f a c t s h e e t s / f s 1 0 4 /
1. Vision impairment 6 9 5 12 0.529 en/index.html.
2. Orange colored body fluids 23 34 9 22 2. WHO Report 2008: Global tuberculosis control-surveillance, planning
3. Peripheral neuropathy 28 41 16 39 and financing Geneva: WHO; (WHO/HTM/TB/2008.393).
3. WHO Report 2006.Global tuberculosis control, surveillance,
4. Ototoxicity 6 9 5 12
planning and financing. Geneva: WHO; (WHO/HTM/TB/2006.392).
5. Gout 5 7 6 15 4. S h a b b i r I , M i r z a N , I q b a l R , K h a n S U , Aw a n S R .
Side effect of Rifampicin Clinicoepidemiological profile of one hundred AFB smear
1. Vision impairment 9 13 6 15 0.697 positive cases of pulmonary tuberculosis. Pak J Chest Med
2005; 11:29-33.
2. Orange colored body fluids 39 58 18 44 5. Masroor M, Ahmed I, Qamar R, Imran K, Aurangzeb,Tanveer, Khan MH.
3. Peripheral neuropathy 7 10 5 12 Prevalence and pattern of resistance to anti-tuberculosis drugs in our
4. Ototoxicity 7 10 7 17 community. Pak J Chest Med 2007;13(1):21-30.
6. Tu b e r c u l o s i s : A G l o b a l E m e rg e n c y. [ o n l i n e ] 1 9 9 9 [ c i t e d
5. Gout 6 9 5 12 2010 June 11] Available from: URL http://www.nfid.org/
Side effect of Ethambutol factsheets/tb.shtml.
1. Vision impairment 40 59 18 44 0.521 7. Ahmed M, Fatmi Z, Ahmed J, Ara N. Knowledge, attitude
and practice of private practitioners regarding TB-DOTS in a rural district
2. Orange colored body fluids 9 13 6 15 of Sindh, Pakistan. J Ayub Med Coll 2009; 21:28-31.
3. Peripheral neuropathy 8 12 5 12 8. Hussain A, Mirza Z, Qureshi FA, Hafeez A. Adherence of private
4. Ototoxicity 6 9 7 17 practitioners with the National Tuberculosis Treatment Guidelines in
Pakistan: a survey report. JPMA 2005; 55:17-9.
5. Gout 5 7 5 12 9. Shehzadi R, Irfan M, Zohra T, Khan JA, Hussain SF. Knowledge regarding
Side effect of Pyrazinamide management of tuberculosis among general practitioners in northern areas
1. Vision impairment 7 10 6 15 0.742 of Pakistan. JPMA 2005; 55:174-6.
10. Khan J, Malik A, Hussain H, Ali NK, Akbani F, Hussain SJ, Kazi GN,
2. Orange colored body fluids 6 9 5 12
Hussain SF. Tuberculosis diagnosis and treatment practices of private
3. Peripheral neuropathy 11 16 6 15 physicians in Karachi, Pakistan. East Med Health J 2003; 9:769-75.
4. Ototoxicity 5 7 5 12 11. Ali NS, Jamal K, Khuwaja AK. Family physicians understanding about
5. Gout 39 58 19 46 Mantoux test: A survey from a high endemic country. Asia Pac Fam Med
2010; 9:8. Published online 2010 May 31; DOI: 10.1186/1447-056X-9-8.
setting and also there is poor compliance of patients. 12. Keifer EM, Shao T, Carrasquillo O, Nabeta P, Seas C. Knowledge and
attitudes of tuberculosis management in San Juan de Lurigancho district
Knowledge regarding treatment of pulmonary and extra of Lima, Peru. J Inf Dev Countries 2009; 3:783-8.
pulmonary TB was also found to be deficient in both groups, 13. Dato MI, Imaz MS. Tuberculosis control and the private sector in a low
which is consistent with another study done among Pakistani incidence setting in Argentina. Rev Salud Publica (Boqota) 2009;
GPs7. Our finding of almost 50% GPs giving treatment for more 11:370-82.
than recommended duration is similar to a study from Jamnagar 14. Savicevic AJ. Gaps in tuberculosis knowledge among primary health care
physician in Croatia: epidemiological study. Coll Antropol 2009; 33:481-6.
India 19. This would result in increased side effects, poor 15. Mushtaq MU, Majrooh MA, Ahmad W, Rizwan M, Luqman MQ, Aslam
compliance and increased treatment cost. The response for MJ, Siddiqui AM, Akram J, Shad MA. Knowledge, attitudes and practices
correct drugs for intensive and continuation phase of primary regarding tuberculosis in two districts of Punjab, Pakistan. Int J Tubers
pulmonary TB was less than similar kind of study from Karachi Lung Dis 2010; 14:303-10.
(73.3 %)10. Similarly drugs of initiation and continuation phase 16. Khan JA, Irfan M, Zaki A, Beg M, Hussain SF, Rizvi N. Knowledge,
attitude and misconceptions regarding tuberculosis in Pakistani patients.
were correctly identified by limited number of GPs. The reason JPMA 2006; 56:211-4.
is lack of knowledge and familiarization with TB guidelines by 17. Khan SJ, Anjum Q, Khan NU, Nabi FG. Awareness about common diseases
GPs. Current situation is expected to result in increased number in selected female college students of Karachi. JPMA 2005; 55:195-8.
of multi-drug resistant TB cases. 18. Al-Maniari AA, Al-Rawas OA, Al-Ajmi F, De Costa A, Eriksson B, Diwan
VK. Tuberculosis suspicion and knowledge among private and public
Conclusion general practitioners: Questionnaire based study in Oman. BMC Public
Health 2008; 8:177-183.
The study identified gaps in knowledge regarding TB among 19. S. Yadav, A. Patel, S. V. Unadkat, V. V. Bhanushali. Evaluation of
GPs from Karachi. Their active engagement in educational management of TB patients by General Practitioners of Jamnagar City.
activities could enhance their knowledge and hence reduce the Ind J Com Med 2006; 31:259-60.

Volume 19 Issue 04 Oct-Dec 2010 . 229


ORIGINAL ARTICLE

Validation of BBL CHROMagar Candida Medium (BD Diagnostics) in Isolating and Differentiating
Candida Species in Clinical Specimens

Ashraf Hussain, Aamer Ikram, Muhammad Roshan, Luqman Satti


Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi

Abstract

Objective incidence has risen five fold during this decade and is currently
To determine the diagnostic efficacy of BBL CHROMagar between fourth and sixth most common nosocomial blood
Candida (BD Diagnostics) in isolating and differentiating various isolate in America and Europe2,3. A tilt towards non-albicans
Candida species using API 20 C AUX (BioMerieux) as gold Candida has been reported especially in hematological and
standard. transplant patients4. Moreover fungemia/colonization ratio of
non-albicans Candida has also been found to be more than that
Methods of Candida albicans 5. Identification of different Candida species
One hundred and six isolates of yeasts isolated from various has important therapeutic implication as C. glabrata is less
clinical specimens were studied from March 2007 through sensitive to ketoconazole and fluconazole than other species
September 2007. All suspected Candida colonies were and C. krusei displays innate resistance to fluconazole 6 .
presumptively identified on Gram staining and tested up to
species level by simultaneous inoculation on CHROMagar Presumptive identification of C. albicans is usually done through
Candida medium and API 20 C AUX test strips followed by testing for germ-tube formation7. However, C. tropicalis, C.
recommended incubation. parapsilosis and Cryptococcus gastricum also have resembling
structures8. Therefore it should not be used as a sole criterion
Results for identification of C. albicans. Reference identification
Out of the total, 52.8% were identified as C. albicans. High procedures using biochemical and morphological studies and
sensitivities (98.2%-100%) and specificities (95%-96.8%) were conventional methods of yeast identification mainly consisting
shown by CHROMagar Candida medium for most commonly of assimilation / fermentation characteristics are difficult and
isolated Candida species of C. albicans, C. krusei, C. tropicalis require expertise7. Packaged kit and automated systems are
and C. glabrata. expensive and limited by the size of their database 10 .
Chromogenic agar media like BBL CHROMagar Candida are
Conclusion easy to use and interpret due to formation of distinct color and
CHROMagar Candida medium was easy to use, cost effective morphologies resulting from cleavage of chromogenic substrates
and reliable agar medium for isolation and differentiation of by species specific enzymes10. The rationale of the study is to
most frequently occurring yeast species in the clinical specimens evaluate the diagnostic efficacy of CHROMagar Candida for
and is recommended for use in peripheral labs. identification and differentiation of various yeast species in
clinical samples as it is now direly needed to precisely identify
Key words the pathogen not only at the reference laboratories but also at
API 20C AUX Medium, Candida Infections, CHROMagar the peripheral diagnostic facilities.
Candida medium, non-albicans Candida species.
Material and methods
Introduction This study was conducted at Department of Microbiology,
The incidence of fungal infections is rising with increasing Armed Forces Institute of Pathology, Rawalpindi, from March
number of immunocompromised patients, widespread use of 2007 through September 2007. One hundred and six yeast
broad spectrum antibiotics and invasive procedures1. Candida isolates yielded from various clinical specimens including blood,
species are important cause of local and blood stream infections high vaginal swabs, urine, sputum, stool and tissues sent for
causing significant mortality and morbidity especially in critically culture and sensitivity to the department of microbiology were
ill patients, immunocompromized population and infants. Overall included in the study irrespective of age and gender of patients.
Upon isolation of a yeast colony, 0.5 MacFarland suspension
Corresponding Author: Ashraf Hussain, was prepared in normal saline and 100 uL of the suspension
Pathology Department, Combined Military Hospital, was dispensed on CHROMagar (BD Diagnostics) plate and
Chhor. spread with wire loop. The plates were incubated at 370C for
Email: hussainashraf78@yahoo.com 48 hrs. Identification of Candida species was made according

230 . Infectious Diseases Journal of Pakistan


to the color and morphology of the yeast colonies. Distinct Only four out of these ten yeast species could be identified on
green colored were labeled as Candida albicans, metallic blue CHROMagar Candida medium (Table 2). Distinctive colony
color as Candida tropicalis and pinkish colonies with spreading morphology is depicted in figure 2.
margins and velvety texture were presumptively identified as
Candida krusei (Fig 1). Table 1: Frequency of various yeast species identified on
API 20C AUX (n = 106)

S. No. Yeast Identified Number of Isolates %

1. Candida albicans 56 52.8


2. Cryptococcus laurentii 2 1.9
3. Candida krusei 19 17.9
4. Candida humicola 4 3.8
5. Candida tropicalis 11 10.4
6. Candida glabrata 7 6.6
7. Candida parapsilosis 3 2.8
8. Rhodotorula rubra 1 0.9
9. Trichosporon cutaneum 2 1.9
10. Trichosporon capitatum 1 0.9
Figure 1: Colony color and morphology of four most
commonly isolated Candida species on CHROMagar plate.
Clockwise: Pink velvety: C. krusei, green: C. albicans, Total 106 100
purple: C. glabrata, blue: C. tropicalis
Table 2: Various yeast species identified using CHROMagar
All the yeast isolates were simultaneously inoculated on API 20C
Candida (n = 106)
AUX (BioMerieux, France) test strips in accordance with the
manufacturer’s instructions. Interpretation was done after 48 and
S. No Yeast Identified Frequency Percent
72 hours of incubation. This method was considered as gold
standard in the study and results of CHROMagar Candida medium
were compared. Sensitivity, specificity, positive predictive value 1. Candida albicans 57 53.8
(PPV) and negative predictive value (NPV) were calculated. 2. Candida krusei 23 21.7
3. Candida tropicalis 14 13.2
Results 4. Candida glabrata 12 11.3
A total of 106 specimens yielding growth of various yeasts Total 106 100
were studied. The mean age for these patients was 42 years
(range 1 - 80 years) with greatest number around 30 years of
age. 67% (n = 71) specimens were from female patients. The
most frequent specimen which yielded Candida spp was urine
closely followed by high vaginal swab, 45.3% and 40.6%
respectively. Sputum yielded growth of yeast species in 7.5%
of the specimens. Other specimens containing yeasts with a
lesser frequency included pus and pus swab, blood, throat swab,
stool, catheter tip and tissue.

Ten different yeast species could be identified using API 20 C


AUX medium (Table 1). Candida albicans was found to be the
most common yeast present in the clinical specimen (52.8%).
This was followed by Candida krusei (17.9%), Candida tropicalis
(10.4%) and Candida glabrata (6.6%). Other less frequently
isolated yeasts included Candida parapsilosis, Candida humicola,
Figure 2: Close view of distinct colony colors and morphology
Cryptococcus laurentii, Trichosporon cutaneum, Trichosporon
of Candida species on CHROMagar Candida
capitatum and Rhodotorula rubra.

Volume 19 Issue 04 Oct-Dec 2010 . 231


The sensitivities, specificities negative and positive predictive tropicalis.
values of the four Candida species identified on CHROMagar
Candida medium are shown in table 3: Although CHROMagar candida was able to support growth of
all 106 yeast isolates, it placed them in one of the four species
Table 3: Sensitivities, Specificities, Negative and Positive of Candida: C. albicans, C. krusei, C. tropicalis or C. glabrata.
predictive values for Candida species on CHROMagar Generally 10% to 14% of the specimens are found to be
Candida Medium containing mixed Candida species, however in our study; we
Yeast Species Sensitivity Specificity PPV NPV were unable to detect any mixed infections. The reason probably
lies in the method of study as the yeast was first isolated on
% % % %
non-differential media like SDA, blood agar and CLED agar
etc, and then isolated colonies were tested for species
Candida albicans 98.2 96 96.5 97.9 identification on these systems. This might have led to failure
Candida krusei 100 95.4 82.6 100 to put to test the apparently similar looking yeast colonies of
Candida tropicalis 100 96.8 78.5 100 different species. Although detection of mixed Candida infection
Candida glabrata 100 94.9 58.3 100 is also considered to be an advantage with the use of
CHROMagar Candida medium, this aspect could not be directly
Discussion determined during the study. However keeping in view the test
With ever increasing number of immunocompromised patients results obtained for major Candida species, it can be said with
in various medical facilities, isolation of various yeast species confidence that mixed infections with Candida albicans, C.
is expected to rise. Candida species is the most common yeast tropicalis and C. krusei can easily be detected while using this
causing mortality and morbidity in such patients. Injudicious medium for isolation of yeast.
empirical use of fluconazole without correctly identifying the
involved species has resulted not only in treatment failure but It can be appreciated from the results that although C. albicans
also in the development of fluconazole resistant Candida still remains the major yeast to be isolated from the clinical
glabrata and Candida krusei sttrains6. specimen, non-albicans Candida species now make a very
substantial component of the total number. Presuming all the
While PCR is extremely helpful in definite identification of isolates as C. albicans without identifying the actual species
infection with various microbes, these nucleic acid amplification can lead to error thus affecting management. In a critical patient,
techniques for Candida are still in the investigatory stage and an undesirable outcome due to such an error of presumption is
not available for routine clinical use 11. The classical Wickerhan completely unacceptable. Similarly, chronic cases may remain
and Burton method utilizes identification through assessment unresponsive to the subsequently used antifungals and their
of assimilation by determining the ability of given yeast isolate misery may prolong.
to grow in a set of defined minimal liquid media supplemented
with different carbohydrates11,12. Though precise, it is laborious In this study, the sensitivity and specificity of CHROMagar
and time consuming and therefore not preferable for routine Candida medium was found to be very high for Candida
use. Auxanographic technique replaced this for use in clinical albicans, C. krusei, C. tropicalis and C. glabrata. This is in
laboratory. This is more simple and rapid method and several accordance with other studies conducted to check these
of its modifications are commercially available such as API parameters for these species by CHROMagar Candida medium13.
20C, API ID 32C, Vitek, MINITEK etc. These generally are Pfaller MA et al, by adhering to the manufecturer’s guidelines
the most frequently employed techniques for the purpose of and published criteria of Odds and Bernaerts14, were able to
identification of the yeasts to the species level. However, most identify correctly 100% of the tested isolates of C. albicans, C.
of the peripheral laboratories don’t have access even to these tropicalis and C. krusei and 90% of the isolates of C. glabrata
biochemical identification techniques in developing countries up to the species level14. These four species constituted around
like ours. The main reason is high cost in addition to technical 87% of the total isolates in that study; however, despite high
expertise required for performing and interpretation of these sensitivity and specificity obtained for C. glabrata, the PPV
tests. Alternative methods are required in routine clinical for this particular species was only 58.3%. This is due to the
laboratories which must be cheap and sufficiently reliable. fact that some of the relatively infrequently isolated species
Sabouraud’s dextrose agar is an excellent medium for primary like C. parapsilosis did give a light purple shade in cream
isolation of yeasts, but it fails to differentiate various species colored colonies, the criteria set for identification of C. glabrata
in clinical specimen5. CHROMagar Candida medium by BD on CHROMagar. The manufacturer doesn’t claim the
Diagnostics is a medium claimed to have high sensitivity and identification of this particular species on this medium, but
specificity for detection of three of the most commonly isolated studies are available in which C. glabrata was successfully
yeast species: Candida albicans, Candida krusei and Candida identified on this agar medium by its light purplish colony14.

232 . Infectious Diseases Journal of Pakistan


In this study, all the isolates of C. glabrata were successfully Clin Infect Dis 2004; 38: 311-20.
identified as such, but several other isolates like C. parapsilosis 4. Schelenz S, Gransden WR. Candidemia in London teaching Hospital:
analysis of 128 cases over a 7 year period. Mycoses 2003; 46:390-6.
were falsely identified as C. glabrata. Interpretation of results
5. Roilides E, Farmaki E, Evdoridou J, Francesconi A, Kasai M, Filioti J.
when dealing with C. glabrata on CHROMagar has been Candida tropicalis in a neonatal intensive care unit: Epidemiologic and
unreliable in several other studies14, 15. Beighton D et al concluded molecular analysis of out break of infection with an uncommon neonatal
that colonies identified as C. glabrata varied in color from pathogen. J Clin Microbiol 2003; 41:735-41.
purple to pale pink that could lead to some degree of confusion 6. Bouchara JP, Declerck P, Cimon B. Planchenault C, De Gentile L, Chabasse
with colonies subsequently identified as C. parapsilosis as D. Routine use of CHROMagar candida medium for presumptive
identification of candida yeast species and detection of mixed fungal
evident in this study as well15. Although, the PPV in this study populations. Clin Microbiol Infect 1996; 2:202-8.
for C. glabrata was rather low, the NPV (100%) still highlights 7. Freydiere AM, Guinet R, Bioron P: Yeast identification in the clinical
its value for this species. This shows that although some of the microbiology laboratory: Phenotypical methods. Med Mycol 2001, 39:9-33.
infrequently isolated Candida species were identified as C. 8. Pfaller MA, Messer SA, Hollis RJ, Jones RN, Doem GV, Brandt ME.
glabrata in this study, none of the C. glabrata present in the Trends in species distribution and susceptibility to flunconazole among
blood stream isolates of candida species in the United States. Diagn
specimens were missed. This has a practical significance, since
Microbiol Infect Dis 1999; 33:217-22.
C. glabrata may be involved in several chronic infections like UTI11. 9. Koehler AP, Chu KC, Houang ETS, Cheng AF. Simple, reliable and cost
effective yeast identification scheme for the clinical laboratory. J Clin
Conclusion Microbiol 1999; 37: 422-6.
CHROMagar Candida medium has been found to be easy to 10. Bauters TG, Nelis HJ. Comparison of chromogenic and fluorogenic
use, cost effective and reliable agar medium for isolation and membrane filtration methods for detection of four Candida species. J Clin
Microbiol 2002; 40: 1838-9.
differentiation of most frequently occurring yeast species from
11. Hazen KC, Howel SA. Candida, Cryptococcus, and other yeasts of medical
the clinical specimen and its usage is recommended for peripheral importance. In: Murray PR, Baron EJ, Landry ML, Jorgensen JH, Pfaller
laboratories. MA, editors. Manual of Clinical Microbiology. Washington, D.C: ASM
Press; 2007.
References 12. Reiss E, Morrisson CJ. Non culture methods for diagnosis of disseminated
1. Moran GP, Sullivan DJ, Coleman DC. Emergence of non-candida albicans candidiasis. Clin Microbiol Rev 1993; 6:311-23.
species as pathogens. In: Calderone RA Candida and Candidiasis. 13. Pfaller MA, Houston A, Coffman S. Application of CHROMagar Candida
Washington DC. Am Soc Microbiol 2003; 37-53. for rapid screening of clinical specimens for Candida albicans, Candida
2. Pfaller MA, Diekema DJ, Jones RN, Sader HS, Fluit AC, Hollis RJ. tropicalis, Candida krusei, and Candida (Turolopsis) glabrata. J Clin
International surveillance of blood stream infections due to candida species: Microbiol 1996; 34: 58-61.
frequency of occurrence and in vitro susceptibilities to fluconazole, 14. Odds FC, Bernaerts R. CHROMagar Candida, a new differential isolation
ravuconazole, and voriconazole of isolates collected from 1997 through medium for presumptive identification of clinically important Candida
1999 in the SENTRY Antimicrobial Surveillance Program. J Clin Microbiol species. J Clin Microbiol 1994; 32:1923-9.
2001; 39:3254-9. 15. Beighton D, Ludford R, Clark DT, Brailsford SR, Pankhurst CL. Use of
3. Marchetti O, Bille J, Fluckiger U, Eggimann P, Ruef C. Epidemiology of CHROMagar Candida medium for isolation of yeasts from dental samples.
candidemia in Swiss tertiary care hospitals: secular trends 1991-2000. J Clin Microbiol 1995; 33: 3025-7.

Volume 19 Issue 04 Oct-Dec 2010 . 233


ORIGINAL ARTICLE

Red Cell Distribution Width in the Diagnosis of Iron Deficiency Anemia and Thalassemia Trait

Malik Muhammad Adil, Ayesha Junaid, Iffat Zaman, Zeshan Bin Ishtiaque

Pathology Department, Shifa International Hospital, Islamabad

Abstract

Objective objective quantitative measurements are desirable. It has been


To evaluate diagnostic importance of Red Cell Distribution suggested that Red Cell Distribution Width (RDW) could fulfill
Width (RDW) in differentiating iron deficiency anemia from this role4. RDW which is an objective measure of the degree of
Thalassemia trait. anisocytosis, has been proposed to be useful in early classification
of anemias because it becomes abnormal earlier in nutritional
Patients and methods deficiency anemia than any of the other red cell parameters,
A total of 100 cases aged 5 months to 50 years of either sex especially in case of iron deficiency anemia 5,6. Bessman and
with diagnosed iron deficiency anemia or thalassemia trait were colleagues have indicated that the use of RDW, made available
compared with respect to their RDW value. by new automated blood cell analyzers, has improved the
distinction between iron deficiency anemia and thalassemia
Results trait5. However, the reliability of using RDW as a sole method
RDW value in iron deficiency anemia was between 36.2% to for diagnosis of anemia is uncertain7.
55.2% (Mean 44.1%). The range of RDW in Thalassemia trait
was 14.7% to 24.9% (Mean 19.8%). The purpose of this study was to determine whether we could
reproduce the accuracy of classification in our population using
Conclusions RDW in patients with iron deficiency anemia and thalassemia
The very high range of RDW in iron deficiency anemia as trait keeping in view the financial constraints in a developing
compared to slight elevation of the value in thalassemia trait in country. If this were so, the time and expense of evaluating iron
our study suggests that RDW value obtained from simple deficiency anemia and thalassemia trait might be reduced.
Complete Blood Counts (CBC) can help in differentiating the
two pathologies. Material and methods
A total of 100 patients (50 with iron deficiency anemia and 50
Key words with thalassemia trait), aged 5 months to 50 years, who reported
Iron deficiency anemia, RDW, Thalassemia trait to Shifa International Hospital, Islamabad, for iron studies and
hemoglobin electrophoresis were included in the study. The
Introduction study was carried out from June 2004 to December 2004.
Iron deficiency anemia is one of the most common nutritional
disorders in the world1. In Pakistan after iron deficiency anemia, Patients with iron deficiency anemia
beta thalassemia trait is the second most common cause of 5 ml venous blood was collected from each of the subject using
hypochromic microcytic anemia2. However, in population where aseptic technique. In order to avoid the problem of diurnal
thalassemia is also prevalent, it is important to distinguish variation in iron level, all blood samples were collected between
between these two common causes of microcytic anemia. For 10 am to 12 noon. The blood was distributed as follows:
the diagnosis of iron deficiency anemia and thalassemia trait, (a) 3 ml of blood was added to K 2 EDTA at a final
estimation of serum iron, TIBC and level of HbA2 are required3. concentration of 2.5mg/ml for blood complete examination
Red blood cell size variation (anisocytosis), along with (b) 1.8 ml was added to plain tube and centrifuged at 1500
poikilocytosis, has been recognized as morphologic hallmarks rpm for 5 minutes to obtain serum. This serum was
of some anemias. Traditionally, microscopists subjectively analyzed for serum iron and TIBC.
assess anisocytosis as either slight, moderate, or marked. This
subjective assessment has limitations, and therefore more Blood complete examination was carried out using SYSMEX-
KX hematology analyzer. Low, normal & high controls prepared
Corresponding Author: Malik Muhammad Adil, commercially were tested before each batch of samples. Quality
Department of Medicine, control was assured by running normal specimen after every
Shifa International Hospital, Islamabad. 19 test samples. Serum iron & TIBC were analyzed using
Email: malikmuhammad.adil@gmail.com ROCHE DIAGNOSTICS reagents on automated clinical
234 . Infectious Diseases Journal of Pakistan
chemistry analyzer HITACHI-911. Commercial controls were with other studies.
run before every batch of samples in order to standardize the
sample results. The quantitative determination of both serum Distribution of iron deficiency anemia by RDW is shown in
iron and TIBC were based upon direct photometric method. figure 1, 44% of cases had RDW in range of 40.1-45%. Figure 2
The following criteria were used: shows distribution of Thalassemia trait by RDW, 86% of cases
Anemia was defined as hemoglobin concentration of less than have RDW in range of 14-20%.
11.5 gm/dl (WHO criteria).
Mean Corpuscular Volume (MCV) <80fl (Normal 90±10 fl) 50
RWD <14.6% (Normal 13.4±1.2%)
Serum iron less than 115ug/dl
TIBC more than 360 ug/dl 44
40

Patients with thalassemia trait


Hemoglobin electrophoresis was done and quantitative HbA2
30

Percentage
levels > 3.5% were taken as thalassemia trait. 30
The proposal was reviewed by internal review board and the
study was approved by the Ethics Committee of Shifa College 20
of Medicine. All data was entered in to Statistical package for
Social Sciences (SPSS version 10.0). The data was re-validated 18
and later analyzed.
10
Results 8
RDW value in 50 patients with iron deficiency anemia and 50
patients with thalassemia trait are depicted in table 1. Mean 0
RDW in patients with iron deficiency anemia was 44.1±4.1 % 35.1-40 40.1-45 45.1-50 50.1-56
(Range 36.2-55.2%). Elevated RDW was found in all 50 cases Iron deficiency anemia (RDW)
none of them were with normal RDW. Mean RDW in patients
with thalassemia trait was 18±1.8 % (Range14.7-24.9 %).
Fig 1: Distribution of iron deficiency anemia by RDW.
Elevated RDW was found in all 50 cases none of them were
with normal RDW. Table 2 shows comparison of our results
100
Table 1: RDW values in different types of anemia.
Anemia No. of RDW % Elevated pvalue
cases RDW 80 86
Mean Range Cases %
Iron
deficiency 50 44.1±4.1 36.2-55.2 50 100 0.001 60
Percentage

Thalassemia
trait 50 18±1.8 14.7-24.9 50 100

40

Table 2: Comparison with different studies.


Studies Elevated RDW 20
Iron deficiency
anemia Thalassemia trait
14
Bessman et al 5 97% 4%
0
Flynn et al 7 94% 48%
14-20 20.1-25
Viswanath et al 9 100% 100%
Laso et al 10 100% 100% Thalassemia trait (RDW)
Our study 100% 100% Fig 2: Distribution of thalassemia trait by RDW.

Volume 19 Issue 04 Oct-Dec 2010 . 235


Discussion suggested slight increase in RDW in patients with iron deficiency
The availability of automated blood cell analyzers that provides and moderately elevated RDW in thalassemia trait4. Results of
index of RDW has new approaches to patients with anemia. another study from India are in accordance with our study which showed
While the emergency physician is primarily responsible for the elevated RDW in all cases of iron deficiency anemia 9 .
detection of patients with anemia, the inclusion of the RDW in
the complete blood count has made diagnosing certain anemias Conclusion
easier, especially microcytic8. The measure of elevated RDW We suggest that RDW may be useful in initial differentiation
was used by Bessman to classify microcytic anemias into two between iron deficient and thalassemia trait patients. In iron
categories5. Anemia with normal RDW (microcytic homogenous) deficiency anemia patients, RDW is likely to be moderately to
included heterozygous thalassemia and chronic disease, and markedly elevated, and thalassemia trait patients show slightly
those with elevated RDW (microcytic heterogeneous) included elevated RDW. The cost and time may be saved by following
iron deficiency, S beta thalassemia, hemoglobin H, and RBC a sequence of steps in evaluating microcytic RBC.
fragmentation. In Bessman study, 96% of thalassemia trait cases
were with normal RDW (mean RDW 3.7±1.6%), while 97% References
of iron deficiency anemia cases were with elevated RDW (mean 1. DeMaeyer EM, Dallman P, Gurney JM, Hallberg L, Sood SK, Srikantia
RDW 16.3±1.8%). Thus Bessman et al were able to classify SG. Preventing and controlling iron deficiency anemia through primary
health care: a guide for health administrators and programme managers
96% of anemias due to thalassemia minor and 97% due to iron
1989:5-58 WHO Geneva, Switzerland.
deficiency using RDW 5 while Flynn et al 7 results categorized 2. Akhtar F, Malik HS, Anwar M. Prevalence of beta thalassemia trait in
only 55% of thalassemia cases as microcytic homogeneous patients with hypochromic microcytic anemia. Pak J Pathol 2002;
(normal RDW). In our study RDW was elevated in both cases 13(2): 11-3.
(iron deficiency anemia and thalassemia trait) but there was 3. Weatherall DJ, Clegg JB.Thalassemia syndromes. Oxford 1972; p.113.
4. Roberts GT, El Badawi SB.Red blood cell distribution width index in
great difference between their means i.e. 44.1±4.1% for iron
some hematologic diseases. Am J Clin Pathol 1985; 83(2):222-6.
deficiency and 18±1.8% for thalassemia trait. In iron deficiency 5. Bessman JD, Gilmer PR Jr, Gardner FH. Improved classification of
cases the RDW elevated more than double the normal while in anemias by MCV and RDW. Am J Clin Pathol 1983; 80(3):322-6.
thalassemia trait, increase was in fractions, so in general our 6. Das Gupta A, Hegde C, Mistri R. Red cell distribution width as a measure
study did show that it was very unusual for a patient with iron of severity of iron deficiency in iron deficiency anemia. Indian J Med Res
1994; 100:177-83.
deficiency to have normal RDW. It appears that iron and
7. Flynn MM, Reppun TS, Bhagavan NV. Limitations of red blood cell
hemoglobin studies are still required to confirm the diagnoses distribution width (RDW) in evaluation of microcytosis. Am J Clin Pathol
of iron deficiency and thalassemia in our population. 1986; 85(4): 445-9.
8. Evans TC, Jehle D. The red blood cell distribution width. J Emerg Med
However, cost and time may be saved by following a sequence 1991; 9(1):71-4.
of investigation in evaluating microcytic RBCs. The CBC with 9. Viswanath D, Hegde R, Murthy V, Nagashree S, Shah R. Red cell
distribution width in the diagnosis of iron deficiency anemia. Indian J
differential and RDW provides the first and most important test
Pediatr 2001;68(12):1117-9.
with significant cost savings in our population where affordability 10. Laso FJ, Mateos F, Ramos R, Herrero F, Perez-Arellano JL, Gonzalez
is main problem in diagnosing these two common conditions. Buitrago JM. Amplitude of the distribution of erythrocyte size in the
In one study, the result was interesting in a way that they differential diagnosis of microcytic anemia. Med Clin (Barc) 1990; 94(1):1-4.

236 . Infectious Diseases Journal of Pakistan


ORIGINAL ARTICLE

Irrational Use of Flagyl (Metronidazole) by Practitioners in Outpatient Clinics

Tehmina Munir*, Munir Lodhi**

* Department of Pathology, ** Paediatric Department, Combined Military Hospital, Multan.

Abstract

Objective hospital and being given for the treatment of acute diarrhoea.
To determine the frequency of prescription of flagyl by general Appropriate measures need to be taken and importance of better
practitioners in outpatient clinics in order to limit its use for prescribing habits should be highlighted during clinical meetings
treatment of acute diarrhoea and other GIT symptoms. and discussions.

Study Design Key Words


A descriptive study. Diarrhoea, Metronidazole.

Place and Duration of Study Introduction


Combined Military Hospital, Multan between 1st January and Worldwide acute diarrhoea constitutes a major cause of morbidity
31st May 2010. and mortality, especially in the developing countries1. Most
cases of acute diarrhoea are caused by enteric infections. Food
Methodology and water-borne outbreaks constitute a major portion of
Total number of patients who were given flagyl during study diarrhoeas reported in outpatient setup. Significant morbidity
period was retrieved from the computerized record of the and mortality in the developing world is attributable to diarrhoeal
patients. Clinical diagnosis was not available in most of the diseases2.
cases, so to determine the number of patients with diarrhoea,
patients who were advised oral rehydration salts in addition to Childhood diarrhoea is a major cause of morbidity and mortality
oral flagyl was determined. A questionnaire about the preference and causes 3.3 million deaths worldwide. Rotavirus has been
of the physicians for various antibiotics for the treatment of reported to be the most common cause of severe childhood
acute diarrhoea was developed and distributed among the doctors diarrhoea in developing as well as developed world3. Other
working in the outdoor clinics. organisms isolated in the stools of patients with diarrhoea are
Escherichia coli, Aeromonas spp, Salmonella spp,
Results Campylobacter spp, Entamoeba histolytica, Giardia lamblia,
Over a period of 5 months, 4068 patients were prescribed flagyl Cryptosporidium etc. Among parasites E. histolytica causes
for their ailment. The age range of the patients was between 9 bloody diarrhoea, giardiasis results in chronic diarrhoea and
months to 65 years. Male to female ratio was 3:1. Out of 4068 Cryptosporidium causes diarrhoea in immunocompromised
patients, 1074(26%) were given flagyl along with oral rehydration individuals4. Most cases of acute diarrhoea are self-limiting or
salts indicating that the antimicrobial was being prescribed for viral and last less than a day. Treatment of diarrhoea primarily
acute diarrhoea. Sixteen doctors working in outdoor/ emergency consists of rehydration. Bismuth subsalicylate may reduce
departments responded to the questionnaire; 14 (87.5%) preferred enterotoxin action and if there is no significant febrile or
flagyl, whereas 8 (50%) prescribed oral flagyl for acute as well inflammatory process, low doses of anti-motility agents may
as chronic gastroenteritis. Out of 14 doctors who said that they offer some relief with minimal risk5,6,7. Appropriate antibiotics
prescribed flagyl for acute diarrhoea, 12(75.1%) were highly may be given for infectious bacterial diarrhoeas8. Most of the
qualified medical practitioners and only 2 (12.5%) of them were doctors performing their duties in our outpatient departments
without any postgraduate qualification. are general duty medical officers who have a tendency to over
prescribe medicines and antibiotics.
Conclusion
Our study showed that flagyl was being grossly misused in the
In our setup, metronidazole is being prescribed to patients of
Corresponding Author: Tehmina Munir, any age and sex irrespective of type or cause of diarrhoea. A
Department of Pathology, Combined Military Hospital, study was carried out at CMH Multan, 500-bedded hospital, to
Multan. know about the prescribing habits of the physicians particularly
Email: tehmunir_doc@yahoo.com for patients of diarrhoea in the outdoor clinics in order to limit

Volume 19 Issue 04 Oct-Dec 2010 . 237


the use of the antimicrobial for the treatment of acute diarrhoea antibiotic for acute diarrhoea by 14 doctors was flagyl, whereas
and other gastrointestinal symptoms. 8 prescribed flagyl for acute as well as chronic diarrhoea. Out
of 14 doctors prescribing oral flagyl for acute diarrhea, 12 (75%)
Material & Methods were highly qualified medical practitioners and only 2 (12.5%)
Total number of patients in the hospital, given flagyl were general duty doctors.
(metronidazole) from 1st January to 31st May 2010, was
determined from computerized record of the hospital. As most During 5 months, 801 stool examinations were performed.
of the doctors do not write the diagnosis on the prescription Vegetative form of Giardia intestinalis was detected in 17
forms, an indirect attempt was made through number of patients patients whereas that of E. histolytica was not detected.
given ORS along with flagyl.
Discussion
A questionnaire about the preference of the physicians for The study observed that flagyl was being misused in the hospital,
various antibiotics for the treatment of acute diarrhoea was unnecessarily prescribed for 1074 patients of acute diarrhoea.
developed and distributed among the doctors working in the However the extent of the problem may be much bigger as mild
outdoor clinics. Fresh fecal specimens were collected in clean cases of diarrhoea and patients with other GIT symptoms might
container and examined under the microscope to detect Giardia have been treated with flagyl. Our results also showed that most
lamblia, Entamoeba histolytica and eggs and ova of other of our qualified practitioners also prefer giving flagyl for acute
intestinal parasites. An attempt was made to collect the dysenteric diarrhoea.
and watery specimens and pass them on to laboratory within
15 minutes of collection. Direct and eosin slides were prepared Keeping in view the climatic and the sanitary conditions,
and examined under microscope (10x and 40x). prevalent diarrhoeal diseases constitute a major proportion of
our outpatient workload. A large number of patients were being
E. histolytica was identified by presence of trophozoites having treated with flagyl reserved for GIT infections like amoebiasis,
single nucleus, containing ingested red cells and showing active giardiasis, trichomoniasis, anaerobic infections and Clostridium
directional amoeboid movement. Giardia lamblia was identified difficile associated diarrhoea 9. Metronidazole has also been
by the presence of small pear shaped flagellate with a rapid used with other drugs for eradicating H. pylori in patients with
tumbling and spinning motility in fresh diarrhoeal specimens duodenal ulcer10. Inappropriate use of antimicrobials with
particularly in mucus. Giardia lamblia cysts were looked for specific reference to flagyl has also been seen in other hospitals
in formed specimens. of the country as well. In one of the hospitals in Karachi, 39%
of general practitioners and 32% of pediatricians prescribed
Results anti-amoebics to more than 30% diarrhoeal patients11. The
During five months, 4068 patients were prescribed flagyl. Mean frequent irrational use of flagyl has been reported in other
age was 33 years; range 9 months to 65 years. Male to female developing countries like Bangladesh where in one study 17%
ratio was 3:1; 3099 (76%) males and 969 (24%) females. All of the patients were treated with metronidazole in outdoor clinics
the outdoor patients were prescribed oral flagyl. Table I shows irrespective of the diagnosis12.
patients of various age groups who were given flagyl.
A Dutch researcher studied popularity of drugs particularly
Out of 4068 patients, 1074 (26.4%) were given flagyl along metronidazole in treating diarrhoea in Philipines13. She attributed
with oral rehydration salts, indicating that the antimicrobial was this popularity to high frequency of amoebiasis in that country,
being prescribed for acute diarrhoea. poor diagnostic methods, unreliable laboratories and aggressive
pharmaceutical marketing. Our hospital however had an efficient
Sixteen doctors who were working in outdoor/emergency clinical laboratory and the diagnosis of Giardiasis is rather
departments responded to the questionnaire. The preferred simple requiring minimal cost and time. Lack of laboratory
facilities or the inability of patients to afford microbiological
Table 1: Age distribution of Patients tests were said to be main reason for prescribing antimicrobials
in diarrhoeal cases in Pakistan. However, extremely short
Age Group No. of Patients communication time between doctor and patient was also a
major reason for omitting required laboratory tests 14 .
Below then 10 years 77
10 to 29 1363 Inadequate knowledge might be an important determinant for
30 to 49 2120 unrestricted and irrational use of metronidazole. Whereas
50 to 69 447 knowledge may be necessary for good practice, improving
knowledge may not improve prescribing practices15. In our
Above then 70 61
study even qualified practitioners prescribed flagyl for cases of

238 . Infectious Diseases Journal of Pakistan


acute diarrhoea. Studies are needed to look in more depth at the Vol 1.13th Ed. McGraw Hill 1994. New York, 213-21.
reasons for this discordance and the extent to which better 5. Chaudhury SAR. Prescribing a rational drug. Bangla J Physiol Pharmacol
1991;7:1.
knowledge may lead to improvement in prescribing practice for 6. Palmar DL, Koster FT, Islam AFMR. A comparison of sucrose and glucose
acute diarrhoea. in oral electrolyte therapy of cholera and other severe diarrhoeas. N Eng
J Med 1997; 297:1107.
Metronidazole is a potential carcinogen and mutagen in rodents. 7. King Ck, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis
Acute toxicity causes gastrointestinal tract symptoms whereas among children- oral rehydration, maintaining nutritional therapy. MMWR
Resource Rep 2003; 52:1-16.
chronic toxicity causes neurological damage16. We should be 8. Thielman NM, Guerrant RL. Acute infectious diarrhoea. N Eng J Med
extremely cautious while prescribing metronidazole in cases 2004; 350(1): 38-47.
where its usage is not warranted. 9. Finegold SM. Metronidazole. In: Mandell, Douglas and Bennett’s Principles
and Practice of infectious diseases. New York: Churchill Livingstone, 2000;
Conclusion 361- 5.
10. Carpintero P, Blanco M, Pajares JM. Ranitidine versus colloidal bismuth
This comparatively smaller scale study showed that metronidazole subcitrate in combination with amoxicillin and Metronidazole for eradicating
is being grossly misused in our hospital. This finding may only Helicobacter pylori in patients with duodenal ulcer. Clin Infect Dis 1997;
be the tip of the iceberg; a larger scale multicentre study may 25:1032-7.
provide the exact extent of inappropriate prescription by the 11. Murakami K, Okimoto T, Kodama M, Sato R, Wtanabe K, Fujitoka T.
general as well as qualified practitioners. Continued medical Evaluation of three different proton pump inhibitors with amoxicillin and
metronidazole in the treatment of Helicobacter pylori infection. J Clin
education is needed to limit its usage in indicated cases only. Gastroentrol 2008; 42(2): 139-42.
12. Nizami SQ, Khan IA, Bhutta ZA. Drug Prescribing Practices of general
practitioners and pediatricians for childhood diarrhoea in Karachi, Pakistan.
References Soc Sci Med 1996; 42(8): 1133-9.
1. King CK, Glass R, Bresee JS, Duggan C. Managing Acute Gastroenteritis 13. Gyon AB, Barman A, Ahmed JU, Ahmed AU, Alam MS. A baseline survey
among Children. Recommendations and Reports- National Center for on use of drugs at the primary health care level in Bangladesh. Bull WHO
Infectious Diseases- Nov 21, 2003/52(RR6); 1-16. 1994; 72(2): 265-71.
2. Sazawal S, Black RE, Bhan MK. Zinc supplementation reduces the incidence 14. Van Staa A. Myth and Metronidazole in Manila. The popularity of drugs
of persistent diarrhoea and dysentery among low socioeconomic children among prescribers and dispensers in the treatment of diarrhoea. Master thesis
in India. J Nutr 1996;126:443-50. in Medicine and cultural Anthropology, University of Amsterdam, 1993.
3. Shah M, Yousaf Zai M, Lakhani NB, Chotani RA, Naushad G. Prevalence 15. Radyowwijati A, Hilbrand H. Determinants of Antimicrobial use in the
and correlates of diarrhoea. Ind J Pediatr 2003; 70(3): 207-11. developing world. Child Health Research Project Special Report 2002;
4. Lawrence S, Friedman Kurt J. Diarrhea and constipation- Isselbacher and 4(1): 1-35.
Brunwald.eds. In: Harrison’s Principles and Practice of Internal Medicine. 16. Metronidazole (Flagyl) facts, e-MedExpert.com 31 Mar 2008.

Volume 19 Issue 04 Oct-Dec 2010 . 239


ORIGINAL ARTICLE

Treatment of Helicobacter pylori Infection; A Controlled Randomized Comparative Clinical Trial

Arshad Mehmood*, Khan Usmanghani*, Abdul Hannan*, E. Mohiuddin*, Muhammad Akram*,


Muhammad Asif**, Muhammad Riaz ur Rehman**

*Department of Clinical Sciences, Faculty of Eastern Medicine, Hamdard University Karachi, Pakistan
**College of Conventional Medicine, Faculty of Eastern Medicine, The Islamia University Bahawalpur

Abstract

Background estimated rates are around 25% 5-6. Infections are usually acquired
Helicobacter pylori induces chronic inflammation of the in early childhood. In developed nations it is currently uncommon
underlying gastric mucosa and is strongly linked to the to find infected children. The percentage of infected people
development of duodenal and gastric carcinoma. increases with age; about 50% infected over the age of 60 years
as compared to around 10% between 18 and 30 years.7-8
Methods
A study was conducted to evaluate the efficacy of Pylorex, a Coded herbal formulation Pylorex contains Curcuma longa,
herbal formulation, for treatment of H. pylori infection as Mallotus philippinensis and Glycyrrhiza glabra. These medicinal
compared to triple allopathic therapy (Omeprazole, Amoxicillin, herbs used in this study were selected on the basis of their
Metronidazole). The therapeutic evaluations of these medicines traditional use in Greek system of medicine, especially for
were conducted on 97 clinically and immunologically diagnosed treatment of H. pylori infection9.
cases of H. pylori infection.
This study was conducted to evaluate the efficacy of Pylorex
Results for treatment of H. pylori infection as compared to triple
H. pylori was eradicated in 16 (32.6%) out of 49 patients by allopathic therapy (Omeprazol, Amoxicillin, Metronidazole)
the use of triple allopathic therapy (Control drugs), and in 9 among the population living in Gadap Town.
(18.7%) out of 48 patients by the use of Pylorex (Test drug).
Materials and methods
Conclusion The therapeutic evaluations of these medicines were conducted
Pylorex possesses a therapeutic value for the treatment of H. on clinically and immunologically diagnosed cases of H. pylori
pylori associated symptoms but the eradication rate is superior infection at Shifa-ul-Mulk Memorial Hospital, for Eastern
in triple allopathic therapy. Medicine, Hamdard University Karachi, from June 2007 to July
2009. All selected patients (n=97) were thoroughly examined.
Introduction Participants who were willing to undergo treatment and to attend
Helicobacter pylori, gram-negative bacterium, is found on the all the follow up visits during the clinical trial were selected.
luminal surface of the gastric epithelium. It contains a
hydrogenase which produces energy by oxidizing molecular The therapeutic evaluation of the drug was made on the basic
(H2) that is produced by intestinal bacteria. It produces catalase, improvement in the subjective signs and symptoms, clinical
urease and oxidase. It is capable of forming biofilms and can observations and laboratory investigations at periodic intervals
convert from spiral to a possibly coccoid form. The coccoid during the course of treatment. Patients were randomly assigned
form can adhere to gastric epithelial cells in vitro1- 4. Half of to receive triple allopathic therapy (Omeprazole 20 mg twice
the world's population is infected by this bacterium. Actual daily 15 minutes before meal, Amoxicillin 500 mg twice daily
infection rates vary; people in under developed countries have and Metronidazole 500 mg twice daily after meal; and 500 mg
much higher infection rates than the developed countries where Pylorex twice daily. The duration of treatment was 15 days with
a window for follow up visit of 15-30 days for periodic
Corresponding Author: Muhammad Akram, assessment.
Department of Basic Medical Sciences,
Faculty of Eastern Medicine, Hamdard University, Primary analysis was based on antigen test that uses enzyme
Madinat-al-Hikmah, Muhammad Bin Qasim Avenue, immunoassay to detect the presence of H. pylori antigen in
Karachi, Pakistan. stool specimens. The samples were tested at Aga Khan
Email: makram0451@hotmail.com Laboratories Karachi. Weekly record of sign and symptoms

240 . Infectious Diseases Journal of Pakistan


was maintained for analyzing the improvement in H. pylori Table 2: Stool antigen after treatment
associated symptoms. Disappearance of abdominal pain, heart
burning, and regurgitation, fullness of stomach, nausea, vomiting, Treatment group Total p-
melena and hematemesis were especially noted. (n) value
After Test Control
treatment (Pylorex) (Triple allopathic
The subjects were randomly divided into two groups; the test therapy)
and the control groups (Table 1). The data was adjusted based
on the number of cases in the light of demographic factor using -tive 09 (18.7%) 16 (32.6%) 25
statistical methods like multinomial logistic regression. P-value Stool +tive 39 (81.3%) 33 (67.4%) 72 0.359
less than 0.05 was considered as statistically significant. antigen
Total 48 49 97
Results
The intent-to-treat population consisted of 97 patients enrolled;
48 were treated with coded herbal formulation Pylorex and 49
with triple allopathic therapy. The mean age of patients prescribed
Pylorex was 27 years and 26.1 years for males and females
respectively. The mean age of patient prescribed triple allopathic
treatment was 26.3 and 28.5 years for males and females
respectively.
in

ng
n

h
rn
tio

ac
Pa

iti

Bu

m
ta

om
al

According to the analysis H. pylori was eradicated in 16 patients

sto
i

rt
in

rg

/v

ea
om

gu

of
ea

H
(32.6%) out of 49 patients by the use of triple allopathic therapy
Re
bd

s
s

es
au
A

ln
(Control drug), and in 9 patients (18.7%) out of 48 patients by N

l
Fu
the use of Pylorex (Table 2). All differences that were equal to Figure 1: Improvement response in symptoms after treatment
or more than the set cut-off values were considered clinically
significant. Results of stool antigens before and after both the
treatments are shown in table 1 and 2. The evaluation of H. than synthetic antibiotics, some patients prefer to use herbal
pylori eradication was significantly high in the control group medicines. Thus healthcare professionals should be aware of
as compared with test group. But there was a significant the available evidence for herbal antibiotics.
difference in H. pylori associated symptoms as observed between
two treated groups at the end of therapy (fig 1). It has been previously reported that Curcuma longa, Mallotus
philippinensis and Glycyrrhiza glabra have anti-H. pylori effects
commonly used for the treatment of this infection10-12. In a recent
Discussion study, anti-H. pylori activity of 50 commonly used Unani
Hundreds of plants worldwide are used in traditional medicine (traditional) medicinal plants from Pakistan, extensively utilized
as treatment for bacterial infections. Some of these have also for the cure of gastrointestinal disorders, were explored as
been subjected to in vitro screening but the efficacy of such natural source compounds against H. pylori13.
herbal medicines has seldom been rigorously tested in controlled
clinical trials. Conventional drugs usually provide effective Curcumin is the substance that gives the spice turmeric its
antibiotic therapy for bacterial infections but there is an increasing yellow color. Dozens of studies have shown that it is chemo-
problem of antibiotic resistance and a continuing need for new preventative, and recently it has been shown to have a strong
solutions. Although natural products are not necessarily safer antibacterial effect against H. pylori. Studies have indicated
that curcumin could be considered as a valuable support in the
treatment of infections14-15.
Table 1: Baseline stool antigen in patients
Treatment group Total In a recent study, researchers found that licorice extract produced
(n) a potent effect against clarithromycin-resistant H. pylori strains.
Baseline Test (Pylorex) Control The authors concluded that licorice extract could form the basis
(Triple allopathic for alternative H. pylori therapeutic agent. Licorice extracts are
therapy)
also effective against H. pylori strains resistant to both amoxicillin
Positive and clarithromycin10 .
stool 48 49 97
antigen Mallotus philippinensis (Kameela) also has activity against
H. Pylori especially against clarithromycin and metronidazole

Volume 19 Issue 04 Oct-Dec 2010 . 241


resistant strains which could be utilized for the development of of Helicobacter pylori in the human stomach. Am J Clin Pathol 1994;102
antimicrobials against H. pylori related disorders 11 . (4): 503–7.
5. Pounder RE, Ng D. The prevalence of Helicobacter pylori infection in
So taking advantage, the coded herbal formulation Pylorex,
different countries. Aliment Pharmacol Ther 1995;9(2): 33–9.
contains the three ingredients Curcuma longa, Mallotus 6. Everhart JE, Kruszon-Moran D, Perez-Perez GI, Tralka TS, McQuillan
philippinensis and Glycyrrhiza glabra for the treatment of G. Seroprevalence and ethnic differences in Helicobacter pylori infection
H. pylori infection. among adults in the United States. J Infect Dis 2000; 181 (4): 1359–63.
7. Malaty HM. Epidemiology of Helicobacter pylori infection. Best
Triple allopathic therapy is commonly used for the treatment Pract Res Clin Gastroenterol 2007;21 (2): 205–14.
of H. pylori infection but it exerts side effects. In order to 8. Mégraud F. H. pylori antibiotic resistance: prevalence, importance, and
advances in testing. Gut 2004;53 (9): 1374–84.
overcome this problem, there is a need to find new medicinal 9. Said HM (1969). Hamdard Pharmacopoeia of Eastern Medicine. Hamdard
agents, which have good efficacy and less adverse effects. The Foundation Karachi;12: 406.
control drugs exhibited side effects like gastrointestinal 10. Krausse R, Bielenberg J, Blaschek W, Ullmann U. In vitro anti-Helicobacter
intolerance nausea and vomiting, whereas Pylorex was well pylori activity of extractum liquiritiae, glycyrrhizin and its metabolites.
tolerated by the treated patients. More detailed studies are J Antimicrob Chemother 2004;54(1):243-6.
needed to evaluate such herbal medicines. 11. Syed Faisal Haider Zaidi, Ikuko Yoshida, Farhana Butt, Muhammed
Aasim Yusuf, Khan Usmanghani, Makoto Kadowaki and Toshiro Sugiyama.
Potent Bactericidal Constituents from Mallotus philippinensis against
Conclusion Clarithromycin and Metronidazole resistant strains of Japanese and
The eradication rate of H. pylori is superior in triple allopathic Pakistani Helicobacter pylori. Biol Pharm Bull 2009; 32:631-6.
therapy as compared to Pylorex, however Pylorex possesses a 12. Warren JR, Marshall BJ. Unidentified curved bacilli on gastric epithelium
therapeutic value for the treatment of associated symptoms. in active chronic gastritis. Lancet 1983;1:1273-5.
13. Vaezi MF, Falk GW, Peek RM. CagA-positive strains of Helicobacter
References pylori may protect against Barrett’s esophagus. Am J Gastroenterol
1. Brown LM . Helicobacter pylori: epidemiology and routes of transmission. 2000;95:2206–11.
Epidemiol Rev 2000;22 (2): 283–97. 14. Mahady GB, Pendland SL, Yun G, Lu ZZ. Turmeric (Curcuma
2. Olson JW, Maier RJ. Molecular hydrogen as an energy source for longa) and curcumin inhibit the growth of Helicobacter pylori, a group
Helicobacter pylori. Science 2002;298 (5599): 1788–90. 1 carcinogen. Anticancer Res 2002.; 22(6):4179-81.
3. Stark RM, Gerwig GJ, Pitman RS (1999). Biofilm formation by 15. Nostro A, Cellini L, Di Bartolomeo S, Di Campli E, Grande R, Cannatelli
Helicobacter pylori. Lett Appl Microbiol 1999;28 (2): 121–6. MA, Marzio L, Alonzo V. Antibacterial effect of plant extracts against
4. Chan WY, Hui PK, Leung KM, Chow J, Kwok F, Ng CS. Coccoid forms Helicobacter pylori. Phytother Res 2005;3:198-202.

H1N1 INFLUENZA ALERT

In recent weeks several young women, mostly peripartum, and a young male have been admitted to three Karachi
hospitals with acute lung injury (ARDS) and suspected or confirmed H1N1 influenza pneumonia. They all required
ventilatory support.

IDSP strongly recommends influenza vaccination, especially in pregnant women, and vigilance for lower respiratory
involvement in all patients with influenza-like illness.
Early diagnosis and treatment with oseltamivir or zanamivir is known to improve outcome.

242 . Infectious Diseases Journal of Pakistan


ORIGINAL ARTICLE

Drug Susceptibility Pattern of Typhoidal Salmonellae to the Conventional Anti-Typhoid Drugs;


A Current Perspective

Anam Imtiaz *, Saba Abbasi*, Javaid Usman**

*Student, Army Medical College, National University of Sciences and Technology (NUST), Rawalpindi, Pakistan.
**Professor and Head of Department of Microbiology, Army Medical College, National University of Sciences and
Technology (NUST), Rawalpindi, Pakistan.

Abstract

Introduction Introduction
Typhoid fever is an important public health issue in developing Typhoid is one of the major health problems of the developing
countries like Pakistan due to overcrowding and poor sanitary world where it is responsible for serious morbidity1. Moreover,
conditions. Moreover, development of antibiotic resistance has the widespread acquisition of plasmid mediated resistance
added to the problems. against the conventional anti-typhoid drugs has added to the
problem2.
Objectives
To study the current trends of typhoidal salmonellae susceptibility The resistance to chloramphenicol emerged in 1970s and the
to the conventional anti-typhoid drugs. multidrug resistant strains came to notice in the late 1980s and
early 1990s 3. In Pakistan, the first multi-drug resistant S. typhi
Material & Methods was isolated in 1987 and by the end of 1990s isolation rates
A descriptive cross-sectional study was carried out at the reached epidemic proportions leaving fluoroquinolones and the
Microbiology Department of Army Medical College (National 3rd generation cephalosporins as the only treatment options 4, 5.
University of Sciences and Technology), Rawalpindi from Injudicious use of these drugs has lead to the emergence of
January 2006 to December 2009. All the isolates were dealt resistance against quinolones as well 6-9.
with standard microbiological procedures. The antimicrobial
sensitivity against the conventional anti-typhoid drugs was In recent years, there have been increasing reports of reversal
determined using Kirby-Bauer disc diffusion method as per the towards sensitivity to the conventional anti-typhoid drugs from
guidelines of Clinical and Laboratory Standards Institute. various parts of the world10,11. Such observations prompted us
to conduct a study at our institute to determine the trend of
Results susceptibility of typhoidal Salmonellae against the conventional
Out of 240 typhoidal Salmonellae isolated, 111 were Salmonella drugs and help local therapeutic recommendations.
typhi and 129 were Salmonella paratyphi A. An increase in the
percentage of multi-drug resistant isolates of typhoidal Methods
Salmonellae was found. This study was carried out on typhoidal Salmonellae isolated
from blood during January 2006 to December 2009 at the
Conclusion Department of Microbiology of Army Medical College, National
The susceptibility of typhoidal Salmonellae to the conventional University of Sciences and Technology (NUST), Rawalpindi.
anti-typhoid drugs has not improved.
The blood culture samples were received from the wards of
Key words
Military Hospital (MH), Rawalpindi; 1100-bedded tertiary care
Antibiotic Sensitivity, Anti-typhoid Drugs, Typhoid, Typhoidal
hospital. Five mL of venous blood was collected aseptically
Salmonellae.
using a disposable syringe and added to 50mL of sterile Brain
Heart Infusion broth (BHI) (Merck) from adults and 3mL blood
Corresponding Author: Anam Imtiaz, in 30mL BHI from children. The top of the culture bottle was
Army Medical College, National University of Sciences and cleaned with iodine immediately before the addition of blood.
Technology (NUST), The subcultures were done on MacConkey’s agar (Oxoid,
Rawalpindi, Pakistan. Basingstoke, UK) at 24 hr, 48 hr, and 5th and 7th days. Cultures
E-mail: anam_ib@hotmail.com showing no growth till seven days were considered as negative.

Volume 19 Issue 04 Oct-Dec 2010 . 243


The isolates were identified on the basis of morphology and Table 2: Resistance (%) pattern of Salmonella paratyphi A
biochemical tests using API 20E (Biomerieux, France) and were (n=129) to conventional drugs
confirmed as Salmonella typhi or Salmonella paratyphi A by
serological tests using standard antisera (Bio-Rad). 2006 2007 2008 2009
Antibiotic / Year (%) (%) (%) (%)
Antimicrobial susceptibility testing was done by using (n = 39) (n=30) (n=31) (n=29
chloramphenicol (30µg disk), ampicillin (10 µg disk) and
cotrimoxazole (1.25/23.75 µg disk) (Oxoid, UK) on Chloramphenicol 5.1 16.7 16.1 27.6
Mueller–Hinton agar (Oxoid, UK) by the Kirby–Bauer disk Ampicillin 7.7 20 12.9 24.1
diffusion method according to the guidelines of Clinical and Cotrimoxazole 12.8 20 12.9 20.7
Laboratory Standards Institute (CLSI 2006)12. The plates were
incubated at 37ºC for 24 hours. Escherichia coli ATCC 25922 The resistance to the conventional anti-typhoid drugs increased
and Salmonella Typhi AMCOL (local strain) were used as over the four years (2006 to 2009) for Salmonella typhi. Even
controls. The data was analyzed using SPSS 17.0. though a definite increase in the percentage of isolates sensitive
to the conventional drugs occurred in 2007 for Salmonella
Results
paratyphi A, the percentage of resistant isolates rose subsequently.
During the study period, a total of 240 typhoidal Salmonellae
were isolated; out of which 111 were Salmonella typhi and 129
Discussion
were Salmonella paratyphi A.
Significant variation is found in the resistance patterns of
The mean age of the subjects was 33.7 years (range 1 to 90 typhoidal Salmonellae in different regions of Pakistan. An
years) with a male to female ratio of 17:1. There was an increase interesting trend seen in our study was a decrease in the isolation
in the isolation rates of S. paratyphi A as compared to S. typhi frequency of typhoidal Salmonellae in the 4 years (from 81 in
from 2007-2009 (Fig 1). 2006 to 41 in 2009). The decreased isolation rates may be due
to the practice of self medication and empiric antibiotic treatment
The antimicrobial resistance pattern of Salmonella typhi in cases suspected of typhoid.
and Salmonella paratyphi A to the conventional anti-typhoid
drugs is shown in Table 1 and 2 respectively. Moreover, it was observed that the isolation rates of S. paratyphi
A exceeded that of S. typhi in 2008 and increased in the
subsequent years. This is concurrent to the reports by Anjum
et al and Butt et al, of increasing incidence of enteric fever
caused by S. paratyphi A in 2002 13,14.

For Salmonella paratyphi A, the percentage of resistant isolates


increased from 2006 to 2007. This percentage decreased in
2008 and a sudden surge was seen in the year 2009. The
development of resistance by the bacteria is related to exposure
to drugs. With time, the conventional anti-typhoid drugs were
out of use for the treatment of typhoid fever and a reversal
towards sensitivity was expected. However, 2009 witnessed a
rise in the frequency of resistant isolates of both S. typhi and
Figure 1 : Frequency of Salmonella typhi and Salmonella S. paratyphi A. Hassan et al have reported a steady increase in
paratyphi A from 2006-2009.
resistance to cotrimoxazole, ampicillin and chloramphenicol
for S. typhi while a fall in resistance for S. paratyphi A 15.
Table 1: Resistance (%) pattern of Salmonella typhi
(n= 111) to conventional drugs In contrast, another regional study has reported an increase in
the sensitivity of the typhoidal Salmonellae to chloramphenicol 16.
2006 2007 2008 2009 However, similar to our study, resistance to ampicillin and
Antibiotic / Year (%) (%) (%) (%)
(n = 42) (n=29) (n=28) (n=12) cotrimoxazole was reported to be increasing.

Chloramphenicol 40.5 51.7 57.1 66.7 In a study conducted in United States in 2009, only 13% of the
Ampicillin 42.9 51.7 46.4 75 2016 isolates studied were found to be resistant to ampicillin,
chloramphenicol and cotrimoxazole, which is in sharp contrast
Cotrimoxazole 45.2 51.7 57.1 66.7
to our results 17.

244 . Infectious Diseases Journal of Pakistan


Conclusion basis of resistance and clinical response to treatment. Clin
The susceptibility of typhoidal Salmonellae to the conventional Infect Dis 1997; 25:1404-10.
9. Nkemngu NJ, Asonganyi ED, Njunda AL. Treatment failure
anti typhoid drugs has not improved enough to justify their in a typhoid patient infected with nalidixic acid resistant
empirical use. We would like to recommend a judicious use of S. enterica serovar Typhi with reduced susceptibility to
second line drugs for the treatment of typhoid so that resistance ciprofloxacin: a case report from Cameroon. BMC Infect
could be contained. Dis 2005; 549.
10. Krishnan P, Stalin M, Balasubramanian S. Changing trends
in antimicrobial resistance of Salmonella enterica serovar
References Typhi and Salmonella enterica serovar Paratyphi A in Chennai. Ind J
1. Ochiai RL, Acosta CJ, Danovaro-Holliday MC, Baiqing
Pathol Microbiol 2009; 52: 505-8.
D, Bhattacharya SK, Agtini MD. A study of typhoid fever
11. Dutta S, Sur D, Manna B, Bhattacharya SK, Deen JL, Clemens JD.
in five Asian Countries: disease burden and implication for
Rollback of Salmonella enterica serotype Typhi resistance to
controls. Bull World Health Organ 2008; 86(4): 260-8.
chloramphenicol and other antimicrobials in Kolkata, India. Antimicrob
2. Shanahan PM, Jesudason MV, Thomson CJ, Amyes SG.
Agent Chemother 2005; 49:1662-3.
Molecular analysis of and identification of antibiotic resistance genes in
12. Wikler AM, Hindler JF, Patel JB, Bush K, et al. Performance
clinical isolates of Salmonella typhi from India. J Clin Microbiol 1998;
standards for antimicrobial disk susceptibility tests; approved
36(6):1595-600.
standard-tenth edition; 10th ed. Pennsylvania: CLSI document M02-A10; 2009.
3. Rowe B, Ward LR, Threlfall EJ. Multidrug-Resistant Salmonella typhi:
13. Anjum P, Qureshi AH, Parvez MH, Zahoor Ul Haq M,
A Worldwide Epidemic. Clin Infect Dis 1997; 24(1): 180-1.
Hamid M. Increasing prevalence of multidrug resistant
4. Usman J, Karamat K.A, Butt T. Alarming state of emerging
Salmonella enterica serotype Paratyphi A in patients with
resistance in Salmonella Typhi to conventional antityphoid
enteric fever. Pak J Med Res 2004; 43(2):56-9.
drugs in the Kharian region. JCPSP 1996; 6 (1): 30-2.
14. Butt T, Ahmad RN, Salman M, Kazmi SY. Changing trends
5. Thaver D, Zaidi AK, Critchley J, Azmatullah A, Madni
in drug resistance among typhoid Salmonellae in Rawalpindi,
SA, Bhutta ZA. A comparison of fluoroquinolones versus
Pakistan. East Mediterr Health J 2005; 11: 1038-44.
other antibiotics for treating enteric fever: meta-analysis.
BMJ 2009; 338:1865. 15. Hasan R, Zafar A, Abbas Z, Mahraj V, Malik F, Zaidi A.
6. Dimitrov T, Udo EE, Albaksami O, Kilani AA, Shehab Antibiotic resistance among Salmonella enterica serovars Typhi and
EM. Ciprofloxacin treatment failure in a case of typhoid Paratyphi A in Pakistan (2001-2006). JIDC 2008;2(4): 289-94.
fever caused by Salmonella enterica serotype Paratyphi A 16. Aggarwal A, Vij AS, Oberoi A. A three-year retrospective
with reduced susceptibility to ciprofloxacin. J Med Microbiol study on the prevalence, drug susceptibility pattern, and
2007; 56(2): 277-9 phage types of Salmonella enterica subspecies Typhi and
7. Threlfall EJ, Ward LR. Ward. Decreased susceptibility to Paratyphi in Christian Medical College and Hospital, Ludhiana, Punjab.
Ciprofloxacin in Salmonella enterica serotype Typhi, United J Indian Academy C Med 2007; 8(1):32-5.
Kingdom. Emerg Infect Dis 2001; 7(4): 762-3. 17. Lynch MF, Blanton EM, Bulens S, Polyak C, Vojdani J,
8. Wain J, Hoa NT, Chinh NT, Vinh H, Everett MJ, Diep TS, Stevenson J, Medalla F, Barzilay E, Joyce K, Barrett T,
Day NP, Solomon T, White NJ, Piddock LJ, Parry CM. Mintz ED. Typhoid Fever in the United States, 1999-2006.
Quinolone-resistant Salmonella typhi in Vietnam: molecular JAMA 2009 26; 302(8): 898-9.

Volume 19 Issue 04 Oct-Dec 2010 . 245


CASE REPORT

Central Nervous System ring enhancing lesions in an Immunocompromised Child with Status
Epilepticus: A Case Report and Literature Review

Amna Batool*, Yawar Najam*, Ejaz Ahmed Khan*, Ismail A Khatri**

*Department of Pediatrics and **Neurology, Shifa International Hospital, Islamabad.

Abstract otitis media, and skin infections and was treated for pulmonary
In some developing countries like Pakistan the incidence of tuberculosis two years ago. His previous immune workup for
Human Immunodeficiency Virus infection in children is unknown recurrent infections had revealed IgG level of greater than 25
and probably underreported . Children usually get HIV infection g/L on two occasions. There was no known history of previous
through vertical transmission and have progressively impaired transfusions or exposures to animals or birds. He was living in
cellular and humoral immunity. Children can have variable Pakistan with his grandparents since age of ten months and his
presentation from being asymptomatic to severe symptoms with parents were in South Africa. His father, a businessman, was
any organ involvement. Central nervous system involvement of Pakistani origin and his mother was of African origin. No
is commonly seen in children with HIV infection and has a poor illnesses were reported in his parents except that his mother
prognosis. Encephalopathy, seizures, status epilepticus, spastic was being treated for tuberculosis for last two years in South
weakness of extremities, microcephaly, developmental delay Africa.
or regression, can be the presenting CNS features. We present
case of a HIV child with status epilepticus history of recurrent On examination, he was a sick looking, frail child. His heart
infections and had ring enhancing brain lesions. rate was 100/minute, respiratory rate 20/minute, blood pressure
100/60 mmHg and he was afebrile. His weight and height were
Key words: Brain Lesions, Encephalopathy, HIV Infection, at the 5th percentile. Neurological examination showed Glasgow
Status Epilepticus Coma Scale of 4/15 and no signs of meningeal irritation. He
was having generalized tonic clonic seizures on presentation.
Introduction He had no lymphadenopathy and had only mild hepatomegaly.
Global burden of HIV infection in children is substantial because The skin showed multiple hyperpigmented macules, few scabbed
of increasing number of infected women1-4. In Pakistan much lesions along with few round blisters and erythematous lesions
lower number of cases are reported5-8. Vertical transmission is on face, upper trunk and lower extremities (Fig 1). Rest of the
the most common route of acquiring infection in children. systemic examination was unremarkable. His seizures were
controlled using intravenous midazolam and phenytoin.
HIV infected children can have a diverse presentation with
involvement of any system of the body. CNS involvement is The initial laboratory investigations showed white blood cell
quite common in children. Seizure or status epilepticus can be count of 12,800/µL, hemoglobin 13 g/dL (polymorphs 86%,
the presenting feature with or without CNS lesions with diverse
etiology. CNS involvement is associated with a poor prognosis.
We will review here CNS involvement in a case of pediatric
HIV infection focusing on mass lesions.

Case report
A six-year-old boy presented with generalized tonic-clonic
seizures and loss of consciousness for 5 hours. He received
blood transfusion prior to referral from a local hospital where
he had presented with lethargy, generalized weakness and
anemia. Over the past few years, the child had multiple severe
bacterial infections including recurrent pneumonias, suppurative

Corresponding Author: Amna Batool, Figure 1: Patient’s skin showing multiple hyperpigmented
Chief Resident, Department of Pediatrics, macules, few scabbed lesions along with few round blisters
Shifa International Hospital, Sector H-8/4, Islamabad. and erythematous lesions
Email: dramnabatool@yahoo.com

246 . Infectious Diseases Journal of Pakistan


lymphocytes 12%, monocytes 2%), total protein 8.8 g/dL, rates of 5-10%, 10-20% and 10-20% respectively3-5. The exact
sodium 118 mEq/L, potassium 3.7 mEq/L, chloride 87 mEq/L, burden of HIV in Pakistan is not known. The USAIDS/WHO
bicarbonate 21 mEq/L, glucose 100 mg/dL, creatinine 0.14 and National AIDS Control Program (NACP 2007) estimates
mg/dL and calcium 8.5 mg/dL. Serum immunoglobulin levels that there are 84,000 cases of HIV with 3000-4000 needing
showed IgA 1.7 g/L, IgG 19.6 g/L, IgM 0.74 g/L. Liver function treatment1. Pakistan officially has 3073 HIV cases including
tests and cerebrospinal fluid analysis were normal. EEG showed 332 AIDS cases reported by September 20051. Most reported
moderate to severe generalized encephalopathy. Chest X-ray cases are in the age group of 20-44 years, while males outnumber
showed bilateral infiltrates and right upper lobe females by a ratio of 7:1. However, high risk groups exist within
collapse/consolidation. Serum HIV ELISA test was positive the Pakistani population that maintains a 10-20 fold higher
which was confirmed by the Western Blot assay. Further prevalence of HIV6, 7. The HIV sero-prevalence of 0.2-11.5%
evaluation showed negative Rapid Plasma Reagin, toxoplasma has been reported among various high risk groups in Pakistan8.
IgG and IgM, cytomegalovirus IgM but a positive Under reporting is mainly due to the inadequacy of surveillance
cytomegalovirus IgG. His CD4+ count was 7 cells/µL. and testing systems, social stigmata attached to the disease as
well as the lack of awareness among health practitioners and
Recurrent infections, hypergammaglobulinemia, a very low the general population.
CD4+ count and a positive HIV antibody led to a diagnosis of
AIDS encephalopathy with syndrome of inappropriate Once the HIV virus enters in human body it destroys CD4+
antidiuretic hormone (SIADH) secretion. He was managed with lymphocytes thus weakening the immune system and making
intravenous fluids, broad-spectrum antibiotics, anticonvulsants HIV-infected children vulnerable both to pathogenic and
and mechanical ventilation. Axial flair images on MRI brain opportunistic microorganisms. So a normal childhood illness
showed bilateral juxtacortical high signal lesions right >left in will present as a severe, recurrent or persistent infection.
frontal and temporo-occipital areas (Fig 2). The multiple Progression of HIV in children depends on age, time of
enhancing CNS lesions suggested opportunistic infection. Triple acquisition, CD4+ count and viral load. This process may take
antiretroviral therapy (zidovudine, lamivudine and nevirapine) several months to years, during which the child may remain
and high dose co-trimoxazole/trimethoprim was commenced asymptomatic.
immediately. Unfortunately before further diagnostic work-up
could be done for the CNS lesions, the child’s condition worsened The definitive diagnosis of HIV requires laboratory confirmatory
and he died 3 days after initiation of antiretroviral therapy. testing. The HIV antibody test is commonly used as a screening
Discussion test and must be re-confirmed by other tests. Some of the tests
used for laboratory diagnosis for HIV in children include:
antibody tests like HIV IgG antibody tests, rapid tests; virologic
tests like HIV PCR, HIV culture; and P24 antigen assay9-12.

Primary CNS infection by HIV is quite common as it is a


neurotropic virus. CNS involvement occurs in majority of HIV
infected children13-16. CNS involvement is atleast 3 times more
common in children than in adults14. Risk factors for involvement
of CNS in HIV infected children include: age <2 years, severity
of HIV related systemic features and the degree of depression
of helper T cells. CNS involvement is mediated mainly by the
direct cytotoxic effect of the virus as well as through the infected
Figure 2: Axial flair images on MRI brain showing bilateral monocytes and macrophages. Over production of various
juxtacortical high signal lesions (right >left) in frontal and cytokines including tumor necrosis factor leads to neurological
temporo-occipital areas. manifestations observed.

Globally the number of children (<15 years) living with HIV The neurological manifestations of HIV infection include:
was estimated to be more than 2,000,000 in 2007, new infections progressive encephalopathy, static encephalopathy, seizures,
>350,000, and 270,000 deaths; more than 90% occurring in strokes, HIV myopathy and myelopathy, peripheral neuropathy,
Sub-Saharan Africa1,2. Importantly, global estimates of HIV in developmental delay or regression, psychiatric manifestations
children continues to steadily increase as compared to adults. and sleep problems.

It is estimated that 90% children acquire the infection during Our patient presented with status epilepticus, encephalopathy
pregnancy period, delivery or breastfeeding with transmission and CNS enhancing lesions, which probably implied severe

Volume 19 Issue 04 Oct-Dec 2010 . 247


HIV CNS involvement with a secondary opportunistic infection. features24. These lesions appear isodense or hyperdense on CT
scan and T1 weighted MRI images, whereas they are hypodense
HIV encephalopathy (HIVE) is the commonest CNS on T2 weighted MRI images24, 25.
manifestation of HIV infection in children with 50-90% having
clinical or radiologic evidence of encephalopathy at some stage14, 15. Proton magnetic resonance ( 1 H-MR) spectroscopy and
Presentation is early and approximately 10% children with fluorodeoxyglucose positron emission tomography (FDG-PET)
HIVE present within their first year of life15. Patients can have are recently used modalities for differentiating focal CNS lesions,
developmental delay, microcephaly, pyramidal tract signs and in particular lymphoma, from infections such as toxoplasmosis.
spasticity. Risk factors for development of HIVE include high Both techniques are more sensitive and specific than MRI
viral load (>5 log10 copies/mL) and lower CD8+ T-lymphocyte alone26. Tuberculomas, tubercular abscesses, syphilitic abscesses,
percentage (<20% CD8+ T-lymphocytes), presence of nocardia abscesses, cryptococcal abscess and cerebrovascular
hepatomegaly, splenomegaly, or lymphadenopathy in the first accidents (CVA) with accompanying edema are some other
3 months of life17. More than 50% patients die within 3 years causes of intracranial mass lesions that present with seizures
of diagnosis with median survival of about 11 months from the Our child had multiple ring enhancing lesions which could be
time of diagnosis15. of infectious origin such as toxoplasmosis, tuberculosis or
fungal. Definitive diagnosis could not be made as the child died
Neuro-imaging in HIVE shows white matter disease and cerebral within few days of presentation.
atrophy. White matter lesions are typically seen within the
periventricular white matter. On MRI, these lesions appear as An HIV infected child who has CNS involvement with ring
low signal on T1 weighted sequences and high signal on T2 enhancing lesions requires emergent care. Management of
weighted sequences18-20. White matter disease may be associated children with neurological involvement needs to be
with basal ganglia or white matter calcification. There may be comprehensive; intensive care with ventilatory support, close
finding of a necrotizing encephalopathy with an associated monitoring of fluids and electrolytes, anticonvulsants and broad-
cardiomyopathy 18 . It is associated with poor prognosis. spectrum antibiotics should be instituted. Further specific therapy
such as antiviral, antituberculous and antiparasitic drugs must
Seizures are frequently observed as CNS manifestations21, 22. be given with additional supporting evidence with low threshold.
Status epilepticus is also observed quite often and seen in some Antiretroviral therapy must be given accordingly as soon as
8-18% HIV infected children21. It may be caused by direct possible for optimal outcome.
HIVE, cerebral mass lesions, focal neurological lesions,
meningitis, and encephalitis. Electrolyte abnormalities, metabolic Conclusion
disturbances like hyponatremia, hypomagnesaemia and renal HIV should be considered in a child with history of repeated
failure all lead to increased risk of status epilepticus. It is infections presenting with status epilepticus or encephalopathy and
associated with poor outcome. Our patient presented with status unexplained MRI abnormalities. Prognosis is generally poor.
epilepticus, persistent severe hyponatremia and CNS lesions.
Generally about 50% of the neurological disorders in HIV Reference
infected children are due to cerebral mass lesions. These mass 1. UNAIDS. 2008 Report on the global AIDS epidemic. Joint United Nations
lesions can be of three types i.e. opportunistic infection, CNS Programme on HIV/AIDS. Available at:
neoplasm and cerebrovascular disease. Opportunistic infections h t t p : / / w w w. u n a i d s . o r g / e n / K n o w l e d g e C e n t r e / H I V D a t a /
include toxoplasmosis, cryptococcosis and cytomegalovirus GlobalReport/2008/2008_Global_report.asp.
2. Amy Sarah Ginsburg, Anna Miller, Catherine M. Wilfert. Diagnosis of
infection22. The most common is toxoplasmosis, it is seen in up Pediatric Human Immunodeficiency Virus infection in resource
to 50% of patients in Europe and Africa20. Up to 40% of patients constrained settings. Pediatric Infect Dis J 2006; 25: 1057–64.
with cerebral toxoplasmosis present with seizures. CT scan 3. Piwoz EG, Ross JS. Use of Population-Specific Infant Mortality
brain and anti-toxoplasma antibody titer are useful diagnostic Rates to Inform Policy Decisions Regarding HIV and Infant Feeding. J
aids. CT scan brain shows ring-enhancing lesions that improve Nutrition 2005; 135: 1113–9.
4. De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J,
on treatment as confirmed by repeat scans. Early and prompt
Hoff E, Alnwick D, Rogers M, Shaffer N. Prevention of mother-to
treatment with sulfadiazine and pyrimethamine is associated -child HIV transmission in resource-poor countries: translating research
with rapid recovery. into policy and practice. JAMA 2000; 283: 1175–82.
5. Hamzullah Khan, Balqis Afridi, Tahniat Ishaq. HIV/AIDS transmission
The second most common etiology of cerebral mass lesion is from mother to child with special attention toward transmission through
primary CNS lymphoma though generally intracranial neoplasms breast-feeding. Rawal Med J 2007; 32(1): 79–81.
6. Alia Zaidi, Waheeduz Zaman Tariq, Kashan Abidi Haider, Liaqat Ali,
in HIV infected children are rare23. This mostly presents with
Abdus Sattar, Farah Faqeer, Saeedur Rehman. Seroprevalence of hepatitis
seizures and neuroimaging is diagnostic. Involvement of corpus B, C and HIV in healthy blood donors in Northwest of Pakistan. Pak J
callosum, exclusive white matter involvement, periventricular Pathol 2004; 15 (1): 11-6.
location and subependymal spread are common distinguishing 7. Yasmin Bhugri. HIV/AIDS in Pakistan. JPMA 2006; 56 (1): 3-4.

248 . Infectious Diseases Journal of Pakistan


8. Members of the HIV seroprevalence study group of Pakistan. HIV 17. Gurbindo D, Resino S, Sanchez-Ramon S, Leon JA, Munoz-Fernandez
Seroprevalence in Pakistan. AIDS 1996; 10(8): 926–7. MA. Correlation of viral load and CD8 T-lymphocytes with development
9. Ng KP, Saw TL, Baki A, Kamarudin R. Evaluation of three commercial of neurological manifestations in vertically HIV-l-infected infants. A
rapid tests for detecting antibodies to human immunodeficiency virus. prospective longitudinal study. Neuropediatr 1999; 30: 197-204.
Med J Malay 2003;58(3):454-60. 18. Haller JO, Cohen HL. Paediatric HIV infection: an imaging update.
10. Hoguin A. Evaluation of three rapid tests for detection of antibodies to Pediatr Radiol 1994;24:224–30.
HIV-1 non-B subtypes. J Virol Methods 2004; 115(1):105-7. 19. Jeanes AC, Owens CM. Imaging of HIV disease in children. Br J Radiol
11. World Health Organization: HIV assays: operational characteristics (phase 2002 14:8-23.
1). 2002; Report 13. 20. Report of the quality standards subcommittee of the American Academy
12. Wilkinson D, Wilkinson N, Lombard C, Martin D, Smith A, Floyd K, of Neurology. Evaluation and management of intracranial mass lesions
Pallard R. On-site HIV testing in resource-poor settings: is one rapid test in AIDS. Neurology 1998; 50:21-6.
enough? AIDS 1997:11(3);377-81. 21. Holtzman DM, Kaku DA, So YT. New-onset seizures associated with
13. Grubman S, Oleske J. HIV infection in infants, children, and adolescents. human immunodeficiency virus infection: causation and clinical features
In: AIDS and Other Manifestations of HIV Infection. Ed. Wormser GP. in 100 cases. Am J Med 1989; 87:173–7.
3rd edn. Philadelphia, Lippincott-Raven Publishers, 1998; pp 349 - 71. 22. Van Paesschen W, Bodian C, Maker H. Metabolic abnormalities and new
14. Tardieu M, Le Chenadec J, Persoz A, Meyer L, Blanche S, Mayaux MJ. onset seizures in human immunodeficiency virus-seropositive patients.
HIV-1-related encephalopathy in infants compared with children and Epilepsia 1995; 36(2):146–150.
adults. French Pediatric HIV Infection Study and the SEROCO Group. 23. Owens CM, Allan R, Thomas K, Evans J, Stevens J. The radiological
Neurology 2000; 54: 1089-95. spectrum of vertically-acquired HIV infection. Br J Radiol 1996;69:777–82.
15. Angelini L, Zibordi F, Triulzi F, Cinque P, Giudici B, Pinzani R, et al. 24. Provenzale JM, Jinkins JR. Brain and spine imaging findings in AIDS
Age dependant neurologic manifestations of HIV infection in children. patients. Radiol Clin North Am 1997;35(5):1127–66.
Neurol Sci 2000; 21:135–42. 25. Lee SH, Rao KCVG, Zimmerman RA. Primary tumours in adults. In:
16. Vardhaman S. Udgirkar, Milind S. Tullu, Sandeep B. Bavdekar,Vijayalaxmi Cranial MRI and CT. 3 rd edn. McGraw-Hill, 1992: 295–380.
B. Shaharao, Jaishree R. Kamat, Priya R. Hira. Neurological manifestations 26. Safriel YI, Haller JO, Lefton DR, Obedian R. Imaging of the brain in the
of HIV infection. Ind Pediatr 2003; 40:230-4. HIV-positive child. Pediatr Radiol 2000; 30:725–32.

Volume 19 Issue 04 Oct-Dec 2010 . 249


CASE REPORT

Gelatinous Bone Marrow in AIDS

Salman Saleem*, Mehreen Ali Khan**, Ayesha Hafeez**, Aamer Ikram**, Usman Rathore**

*Department of Medicine, Combined Military Hospital, Gujranwala


**Department of Pathology, Combined Military Hospital, Quetta

Abstract growth of Acinetobacter baumannii and he was put on antibiotics


Bone Marrow aspiration is done in patients of AIDS to assess according to the sensitivity report. However, his fever did not
peripheral dysplasias/pancytopenia and to diagnose bacterial/ settle even after appropriate antimicrobial therapy for two weeks.
fungal infections. Gelatinous transformation of bone marrow
is relatively uncommon in HIV infection but if seen in a Bone marrow aspiration was done from posterior superior iliac
pancytopenic patient it may be an indication of HIV infection. spine. The aspirated marrow was jelly like in appearance and
difficult to spread over slides. After Giemsa and Leishman’s
We report a case of pyrexia of unknown origin whose blood staining, the marrow was reported to be hypocellular with fat
picture revealed pancytopenia. Bone marrow aspiration revealed spaces and gelatinous transformation. The patient refused to
a gelatinous bone marrow. Based on this finding, anti-HIV have trephine biopsy due to his severe pain. Review of literature
antibodies tested by enzyme linked immunosorbant assay turned revealed that gelatinous transformation of marrow had been
out to be positive. identified in different disorders including AIDS. Patient was
reinvestigated and anti-HIV antibodies were positive by ELISA.
Keywords The diagnosis was confirmed by Western Blot assay. Patient
Acquired Immunodeficiency Syndrome, Gelatinous Bone was advised further treatment (HAART) but he preferred to go
Marrow, Pancytopenia. abroad for further consultation and also he didn’t want to disclose
his ailment to his family.
Introduction
Gelatinous bone marrow transformation is a rare disorder of Discussion
unknown pathogenesis having fat cells atrophy, focal loss of Infection with HIV, a retrovirus of lentivirus subgroup, is a
haemopoietic tissue and deposition of extracellular gelatinous frequent cause of immune deficiency giving rise to a wide range
material. Different diseases are characterized by gelatinous of symptoms, opportunistic infections and malignancies1. The
bone marrow transformation and AIDS is among major causes virus is transmitted by blood, body fluids, semen and breast
for this change. milk. The majority of infections occur during heterosexual
intercourse.
Case Report
A 45-years-old male presented to Department of Medicine, The disease still remains checked in our country due to social
Combined Military Hospital Gujranwala with history of fever and religious obligations. Infection from blood and blood
and bone pains for three months. The fever was low grade and products is possible as screening practices are not strictly adopted
intermittent in nature. He was having severe bone pains especially in most parts of the country. The official figure was 3073 HIV
limbs. He consulted many doctors in the city but remained infected cases in 2005. Around 84,000 cases of HIV were
undiagnosed. He had been working in UAE in past. On estimated in Pakistan in 2007, according to the UNAIDS and
examination, he was febrile and underweight but he denied any National AIDS Control Program.2 These figures still remain
weight change during last six months. No unusual low because of under-diagnosed to undiagnosed cases due to
lymphadenopathy was noticed. On investigations, his blood non-availability of expertise or diagnostic modalities.
complete picture revealed pancytopenia (TLC 3.4x 109 /L; Hb
6.4g/dL; Platelet 48x109/L; Reticulocytes 0.2%). Repeated slides In our country AIDS is a social taboo and patients don’t give
for malarial parasite were negative. His LDH and alkaline history suggestive of AIDS. This patient had multiple
phosphatase were raised. Serum bilirubin, ALT, urea, creatinine, consultations and investigations for fever but anti-HIV antibodies
electrolytes were within normal limits. No abnormality was were not considered previously.
detected on X-rays chest. Meanwhile his blood culture revealed
Gelatinous bone marrow transformation shows loss of
Corresponding Author: Mehreen Ali Khan,
Department of Pathology, haemopoietic cells, atrophy of fat cells and deposition of
Combined Military Hospital, Quetta. gelatinous substance extracellularly3,4. Gelatinous bone marrow
Email: mehreen35@hotmail.com is not a specific disease but presence of gelatinous marrow

250 . Infectious Diseases Journal of Pakistan


indicates that patient is having severe generalized illness. AIDS change in the marrow must be tested for anti-HIV antibodies
and few other diseases are associated with gelatinous bone to establish early diagnosis and prompt treatment.
marrow transformation like malignancies, alcoholism,
malabsorption and anorexia nervosa. References
1. The White Cells 2: Lymphocytes and their benign disorders. In: Hoffbrandt
AV, Pettit JE, Moss PAH, editors. Essential Hematology. 4th ed. Italy:
Gelatinous bone marrow in seropositive cases of HIV has been Black Well Science; 2000: p 139.
studied previously4-6. Mehta et al reported that 29% of the 2. UNAIDS. 2008 Report on the global AIDS epidemic. Joint United Nations
patients with AIDS had gelatinous marrow. Delactretaz observed Programme on HIV/AIDS. Available at:
38% of HIV infected patients had gelatinous bone marrow6. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/
2008/2008_Global_report.asp
3. Bohm J. Gelatinous transformation of the bone marrow, the spectrum of
The most common symptoms of bone marrow necrosis include underlying disease. Am J Surg Pathol 2000;24(1) 56-65.
bone pains (78%), fever (68%), anemia (91%), thrombocytopenia 4. Mehta K, Gascon P, Robby S. The gelatinous bone marrow (serous
(73%), leucopenia (45%), raised LDH (51%) and raised alkaline atrophy) in patient with acquired immunodeficiency syndrome. Evidence
of excess sulfates glycosaminoglycan. Arch Pathol Lab Med 1992; 116(5)
phosphatase (40%)7. Our patient had severe bone pains with
504-8.
pancytopenic picture and raised LDH and alkaline phosphatase. 5. Marche C, Tabbara W, Michon C, Ckair B, Bncaire F Metthiessen L Bone
However, diagnosis was pointed towards AIDS only after the marrow findings in HIV infection a pathological study. Prog AIDS Pathol
bone marrow findings. 1990;2:51-60.
6. Delacretaz F, Perey L, Schnidt PM, Chave JP, Costa J. Histopathology
of bone marrow in human immunodeficiency virus infection. Virchows
Conclusion Arch Pathol Anat Histopathol 1987; 411(6):543-51.
Gelatinous bone marrow transformation is an important feature 7. Janssens AM, Offner FC, Van Hove WZ. Bone marrow necrosis. Cancer
of HIV infection. Sera of all the patients having gelatinous 2000;88(8): 1769-80.

Volume 19 Issue 04 Oct-Dec 2010 . 251


NEWS & VIEWS

“Update on Infectious Diseases for the Practicing Clinician” Emergency Room Conference (ERCON)
October 18th to 23rd 2010 October 30, 2010: Islamabad

IDSP conducted a course “Update on Infectious Diseases for Emergency Room Conference (ERCON) was arranged by
Practicing Clinician”, in Karachi. Dr Farheen Ali was Convenor Organization of ER Physicians. Members of IDSP participated
and Dr Fatima Noman Co-Convenor. This is a brief report in the conference. Dr. A. Salam Khan, Convenor of the ERCON
regarding the feedback that we received from the participants introduced and welcomed participants.
and the issues we came across during the course.
Dr. Naseem Salahuddin explained why she believed that rabies
Feedback from participants was an “orphan disease” in Pakistan. Rabies is a common but
1. Overall the course was very much appreciated. Most fatal disease that has never been given its due importance by
participants agreed that the knowledge they gained was the health authorities and no attempt has ever been focused on
valuable in daily practice. its preventive aspect. The obsolete nerve tissue vaccine continues
2. Most requested and stressed that IDSP must continue such to be produced and distributed to Government run centers and
courses and make it an annual event. results in rabies deaths. Dr Seemin Jamali, Director of Emergency
3. There was a request to include and emphasize emerging Services at JPMC, Karachi, spoke on prevention and treatment
infections. of animal bites. Despite JPMC being a Federal Government
4. There were suggestions to include: institute, it has for over a decade obtained modern tissue culture
a. Nosocomial infections vaccine rather than the NIH provided sheep brain vaccine. Thai
b. TB in pediatric patients Red Cross intradermal regimen is both economical and effective
c. HIV in rabies prophylaxis.
d. Bedside/hands-on session for certain topics
5. There were requests to distribute “Antibiotic Guidelines”. Dr Mehmood Javed, ID Consultant at Shifa International Hospital
6. The participants appreciated the handouts given; CDs presented a concise lecture on Viral Hemorrhagic Fever and
were requested by a few. Influenza, and emphasized their preventive aspects.
7. Most were comfortable with afternoon timings. Dr Altaf Ahmad, President IDSP and Director of Lab Services
8. The evaluation sheet was not properly understood by at The Indus Hospital, Karachi, expounded on the importance
many. (We should make it simpler in future and in place of Biosafety and Biosecurity measures as being essential
of 1-5 ranking give actual levels “Unsatisfactory to procedures in the laboratory for protection of personnel as well
Excellent”). as for the environment and community.

Our Feedback and Suggestions


The course should definitely be an annual event, as it provides “8th Annual Conference on Infectious Disease” on 11-12th
the opportunity to update and educate the practicing physician March 2011
regarding common and emerging clinical problems. However,
the scope should be broadened to include post-graduate residents The IDSP is organizing the 8th Annual Conference on Infectious
and fellows as well. It should probably be held around the same Disease on 11-12th March 2011 at Hotel Margalla, in Islamabad.
time each year, so as to be a marked calendar event for clinicians. We cordially invite you to participate in the event with your
colleagues, trainees and students. We welcome all physicians,
We did, however, come across a few issues while putting together surgeons, trainee doctors, nurses and technicians, as they are
this course. We should make a more concerted effort to get an essential part of management and prevention of infectious
handouts prior to the lectures so that participants have them on diseases. Ministry of Health and related National Programmes
time. CDs although cost-effective may not be feasible because
such TB, Malaria and HIV; National Institute of Health; UNICEF;
of the concern that lectures may be re-used without permission.
and WHO would also be participating.
We felt that there was a need for more secretarial help and
The theme of the conference is “THE AGE OF SUPERBUGS:
support. Correspondence and reminders should have been
generated timely. FACTS AND SOLUTIONS” with special emphasis on

Overall the program was well received. We should be able to - Antibiotic resistance
make this a yearly event. - Viral Hemorrhagic fevers
- Disaster related infections
Dr. Farheen Ali - MDR Tuberculosis
- HIV/AIDS threats

252 . Infectious Diseases Journal of Pakistan


- Zoonosis IDJ over Internet
- Nosocomial infections
- Infections in immunocompromised hosts Sincere efforts are being made to ensure easy availability of
- Biosafety in our Labs IDJ over internet in collaboration with Asianet.
- Rational use of antibiotics
Hopefully the requirements would be completed in the near
For further information please contact: future.
Dr. Altaf Ahmed Dr. Ejaz A. Khan
President IDSP General Secretary IDSP Editor IDJ
altafvirus@yahoo.com ejazkhan99@hotmail.com

Volume 19 Issue 04 Oct-Dec 2010 . 253


INSTRUCTIONS FOR AUTHORS

Instructions for Authors in the abstract.

Scope Key Words


The Infectious Diseases Society of Pakistan sponsors the Four to five standard key words must be provided.
Infectious Disease Journal of Pakistan (IDJP). The Journal
Introduction
accepts Original Articles, Review Articles, Brief Reports, Case
The section must clearly state the background and importance
Reports, Short Communications, Letter to the Editor and Notes
of the research along with objectives.
and News in the fields of Microbiology, Infectious Diseases;
with laboratory, clinical or epidemiological aspects.
Materials and Methods
Mention the place and duration of study. design of study and
Criteria for publication
details of interventions used must be clearly described. Provide
All articles are peer reviewed by the IDSP panel of reviewers.
details of subject selection (patients or experimental animals).
Authors may also submit the names and contact information of
Details must be sufficient to allow other workers to reproduce
two persons who potentially could serve as unbiased and expert
the results. Identify precisely all drugs and chemicals used,
reviewers for their manuscript, but IDSP reserves the right of
including generic name(s) and route(s) of administration.
final selection.
Results
Submission of the Manuscript Present results in logical sequences in the text, tables and
Manuscripts must be formatted according to submission illustrations. Articles can have a maximum of five illustrations
guidelines given below, which are in accordance with the (in a combination of figures and tables) per article.
“Uniform Requirements for Manuscripts Submitted to
Biomedical Journals” (originally published in N Engl J Med Discussion
1997; 336:309-15). Emphasize important aspects of the study and compare with
other studies. Do not repeat the details from the results section.
Please submit the manuscript and all enclosures to: The Editor, Discuss the implications of the findings and their limitations.
Infectious Diseases Journal of Pakistan, Department of Pathology, Link the conclusions with the goals of the study but avoid
Combined Military Hospital, Quetta, Pakistan. Electronic copy unqualified statements and conclusion not completely supported
of the manuscript must also be sent to maahin1@yahoo.com. by your data.
All manuscripts submitted to IDJP must be accompanied by an
authorship declaration stating that ‘The authors confirm that Acknowledgments
the manuscript, the title of which is given, is original and has Acknowledge any sources of support, in the form of grants,
not been submitted elsewhere. Each author acknowledges that equipment or technical assistance.
he/she has contributed in a substantial way to the work described
in the manuscript and its preparation’. Review Articles
Authoritative and state of the art review articles on topical issues
Manuscript Categories are also published, with a word limit of 2000. These should be
comprehensive and fully referenced. Articles should contain
Original Articles Abstract, main mext divided into sections, Conclusions and
Articles should report original work in the fields of microbiology References.
and infectious diseases.
Brief Reports
Short clinical and laboratory observations are included as Brief
Title page
Reports. The text should contain no more than 1000 words, 2
This should list title of the article, full names of each author
illustrations or tables and up to 10 references.
with highest academic degree(s), institutional addresses and
email addresses of all authors. Corresponding author should Case Reports
also be indicated with his/her name, address, telephone, fax Instructive cases with a message are published as case reports.
number and e-mail address. A short running title of not more Routine syndromes or rare entities without unusual or new
than 40 characters (including letters and spaces) be placed at features are invariably rejected. The text should contain no more
the foot end of the title page. than 1000 words and 2 illustrations or tables. The authorship
should not exceed 4 persons.
Abstract
Abstract should not exceed 200 words and must be structured Letter to the Editor
in to separate sections. Avoid abbreviations or citing references These may relate to material published in the IDJP, topic of

254 . Infectious Diseases Journal of Pakistan


interest pertaining to infections diseases, and/or unusual clinical Illustrations
observations. A letter should not be more than 300 words, one Illustrations should be numbered and given suitable legends.
figure and 3-5 references. If possible, figures should be submitted in electronic format as
either a TIFF (tagged image file format) or JPEG format.
News and Views Minimum resolution for scanned artwork is:
Pertinent news and updates in infectious diseases from around Black & White Illustration
the world (approximately 200 words). Line, e.g. graphs: 600 dpi
Halftone, e.g. photographs: 300 dpi
Notices Coloured illustrations: 400dpi (images should be split
Announcements of conferences, symposia or meetings may be CMYK)
sent for publication at least 12 weeks in advance of the meeting
date. Details of programs should not be included. Ethical Guidelines
The research project must be reviewed by Ethical Committee
References of the institute. All clinical research articles/studies involving
Number references in the order in which they are first cited in human subjects submitted to the IDJP must adhere to ethical
the text. Label references in text, tables and legends by Arabic guidelines of their institutions and have informed consent from
numerals (in superscript). References cited only in tables or in their patients. All scientific research that uses animals in their
legends to figures should be numbered in accordance with a study protocols must include a statement on the ethical treatment
sequence established by the first identification of the particular of animals during the study.
table or illustration.
Financial support: All authors must disclose any financial
Write all authors, complete title, journal name (standard support they have received during the course of the study.
abbreviation in italics), year, volume, issue, page numbers
according to “Uniform Requirements of Manuscripts Conflict of Interest: If there is any conflict of interest then this
submitted to Biomedical Journals”, as cited in N Engl J Med must be disclosed by the author(s) at the end of the article.
1997; 336:309-15.
Plagiarism
Tables and Figures Make sure that your article is not copied or reproduced.
Data reported either in a table or in a figure should be illustrative Plagiarism in research is a crime and the matter will be taken
of information reported in the text, but should not be redundant seriously.
with the text. Table should be numbered consecutively in Arabic
numerals. Tables and Figures legends should be self-explanatory Instructions updated - December 2010.
with adequate headings and footnotes. Editor IDJ

Volume 19 Issue 04 Oct-Dec 2010 . 255


MEMBERSHIP APPLICATION FORM
E S S O CI
AS E

TY
IO U S DIS

O F PA KI
P

INFECTIOUS DISEASES SOCIETY OF PAKISTAN


S
D
I

CT

S
E TA
IN F N
No.

Name

Mailing Address

Institute/ Organization

Department & Division

Field of Interest

Designation PMDC No.

Phone No. Resdence Office

Cell E-mail
Degree/ Diploma:
MBBS MD MSc Biological Scinec BSc Nursing
MRCP MCPS FRCS FCPS
MRCPath Ph. D M. Phil Pharma. D
DCH Diplomate American Board of
Other
Application for member as
Full Member (Annual/ Life) Overseas Member Associate Member
Rs.500 for 1 yr, Rs.3000/- for life US$.100/- for Life Rs.500 for 1 yr, Rs.3000/- for life

Signature Date
For Office Use Only
Approved/ Not Approved

Membership No: Reference No:


Comments:
Signature General Secretary:

FULL MEMBERSHIP:
Should be at least medical graduates registered with PMDC and having postgraduate qualification in any field.
Full member may be
1. Life: with payment of Rs.3000/- 2. Annual: with 1 year fee of Rs.500/-

ASSOCIATE MEMBERSHIP:
Ph. D, Master degree & M. Phill in biological sciences, BSc in Nursing & allied medical science with 1 yearly fee of Rs.500/-

PRIVILEGES OF MEMBERSHIP:

FULL MEMBER:
All the members shall have the right to:
1. Participate in all activities of the society.
2. Receive all publication including quarterly ID Journal free of cost.
3. Vote according to constitution of the society.

ASSOCIATE MEMBERS:
All the members shall have the right to:
1. Participate in programs of the society.
2. Receive all publication including quarterly ID Journal free of cost.
Please send your Application form by hand or by mail only.
Membership fee will only be received in cash/ cross cheque/ pay order or bank draft made out to Infectious Disease Society of Pakistan.
Mailing Address and Contact Nos:
Infectious Diseases Society of Pakistan
A-53, Block-2, Gulshan-e-Iqbal, Karachi. Ph: 0333-3977011
E-mail: idsp123@yahoo.com

256 . Infectious Diseases Journal of Pakistan

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