- Email: [email protected]
Snippets
current medicine research and practice 5 (2015) 290–292
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/cmrp
Snippets Tulsi Chugh * National Emeritus Professor of Microbiology, National Academy of Medical Sciences (NAMS), Ansari Nagar, Mahatma Gandhi Marg, Delhi, India
article info Article history: Received 13 November 2015 Accepted 18 November 2015 Available online 7 December 2015
1. Mycobacterial disease in patients with rheumatoid arthritis Rheumatoid arthritis (RA) is a major cause of disability and the risk of acquiring or dying of an infectious disease is higher because of disease-related immune dysfunction or immunosuppression caused by therapeutic agents. There is an increased risk of mycobacterial diseases in those receiving anti-TNFa therapies. Population based study in Europe has shown the risk of development of TB 4-folds higher and a similar study in Taiwan, the risk was 2.28 folds higher in RA patients.1 Furthermore, the risk for nontuberculous mycobacteria (NTM) disease was 6.24 folds higher in RA patients than controls and the risk of death among RA patients with NTM disease was 3.06folds higher than that for RA patients without NTM disease. A recent-similar study from Canada showed a 2.07-fold higher risk for NTM disease in RA patients and a 1.81-fold increased risk for death among RA patient with NTM disease. Increasing evidence shows that the risk for mycobacterial diseases among RA patients is essentially attributable to the use of immunosuppressive therapies. There is thus a clear need for close monitoring of RA patients for any evidence of tuberculosis or NTM disease, especially those who have a concurrent condition (diabetes mellitus) or ≥65 years of age.
1. Liao T-L, Lin C-H, Shen G-H, et al. Risk for mycobacterial disease among patients with rheumatoid arthritis, Taiwan, 2001–2011. Emerg Infect Dis. 2015;21(8):1387–1395.
2.
Hepatitis E virus infection
Hepatitis E virus (HEV) is transmitted by contaminated water, undercooked meat, blood transfusion or solid organ transplant. HEV infection is usually self-limited and occurs world-wide but more in South Asia. It causes acute hepatitis, less often chronic hepatitis and rarely cirrhosis in immunocompromised patients. HEV infection with chronic hepatitis in patients with haematologic malignancies and stem cell transplantation and solid organ transplant (SOT) has been reported. Treatment with oral ribavirin can lead to a rapid clearance of HEV and thus prevents chronic hepatitis. Patients with elevated liver enzymes should be screened for HEV infection and a 3-month course of oral ribavirin administered to prevent chronic hepatitis. It enables the continuation of cytotoxic treatment of underlying malignancy.1 A multicentric study shows that ribavirin monotherapy for a 3-month period is an appropriate therapy for HEV positive SOT patients.2
* Tel.: +91 9818575933. E-mail address: [email protected] http://dx.doi.org/10.1016/j.cmrp.2015.11.011 2352-0817/# 2015 Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd on behalf of Sir Ganga Ram Hospital.
current medicine research and practice 5 (2015) 290–292
1. Kamar N, Izopet J, Tripon S, et al. Ribavirin for chronic hepatitis E virus infection in transplant recipients. N Engl J Med. 2014;370(12):1111–1120. 2. Tavitian S, Peron JM, Huguet F, et al. Ribavirin for chronic hepatitis prevention among patients with hematologic malignancies. Emerg Infect Dis. 2015;21(8):1466–1469.
1. Lee CH, Lee MC, Shu CC, et al. Risk factors for pulmonary tuberculosis in patients with chronic obstructive airway disease in Taiwan: a nationwide cohort study. BMC Infect Dis. 2013;13:194.
5. 3. Free-living amoebae in water resources of intensive care units in tertiary care hospitals in India1 Free living amoebae (FLA) are known to cause primary amoebic meningoencephalitis and granulomatous amoebic encephalitis. In addition, these amoebae may also serve as hosts for many pathogens (ECHO virus, adenovirus, Coxsackie i.e. virus, Legionella spp., atypical mycobacteria, Pseudomonas spp. and others). These cause infections in various immunocompromised patients. FLA have been isolated from sea water, soil, dialysis units, contact lenses, and human nares and throat. The mode of transmission is inhalation or inoculation through skin lesions. FLA have been reported in samples collected from immunodeficiency wards in Iran (52.9%) and 42.9% of water samples from the hydraulic systems of dental units and haemodialysis units in Egypt. In a study conducted in PGIMER, in Chandigarh, water samples and swabs from tap mouths were collected in various units of the hospital. Four tap water samples (8%) and 10 swab samples (20%) grew trophozoites and cysts of FLA. These were confirmed by PCR and sequencing. It is important to investigate and take necessary control measures in various institutions to protect patients at risks. 1. Khurana S, Biswal M, Kaur H, et al. Free living amoebae in water sources of critical units in a tertiary care hospital in India. Indian J Med Microbiol. 2015;33(3):343–348.
291
Epstein–Barr virus and gastric cancer
Gastric carcinoma is the second leading cause of cancer to deaths in the world. Ninety five percent of all malignant tumours in the stomach are adenocarcinoma. The role of Helicobacter pylori (H. pylori) as a cause of gastric cancer and mucosa-associated lymphoid tissue (MALT) has been well established. Epstein–Barr virus (EBV) is known to be associated with 10% of gastric adenocarcinoma. Epstein–Barr virus can be demonstrated in the cancer cell by in situ hybridisation, monoclonality of EBV-DNA and elevated antibodies. In a prospective case control study of 100 patients in Vellore, India, 6% had EBV infection in adenocarcinoma.1 In a meta-analysis of pooled data of 5081 cases from 15 international populations, 9% of gastric cancers had EBV.2 There is an evidence in the current literature that EBVassociated gastric adenocarcinoma is slightly more common in males, younger age, have a preferential location in the body and fundus of the stomach and less lymph node involvement. There is also an evidence in the literature that EBV-associated gastric carcinomas have a more favourable prognosis. 1. Rymbai ML, Ramalingam VV, Samarasan I, et al. Frequency of Epstein–Barr virus infection as detected by messenger RNA for EBNA 1 in histologically proven gastric adenocarcinoma in patients presenting to a tertiary care center in South India. Indian J Med Microbiol. 2015;33(3):369–373. 2. Camargo MC, Murphy G, Koriyama C, et al. Determinants of Epstein–Barr virus-positive gastric cancer: an international pooled analysis. Br J Cancer. 2011;105(1):38–43.
6. Occupational exposure of healthcare workers to blood and body fluids 4. Tuberculosis and chronic obstructive pulmonary disease (COPD) An association between tuberculosis (TB) and chronic obstructive pulmonary disease (COPD) and asthma and active TB disease has been reported, due to smoking and corticosteroid use.1 Inhaled corticosteroid (ICS) and long-acting b-agonists (LABA) are the recommended treatment. ICS therapy is known to predispose to pneumonias including TB independent of the use of oral corticosteroids. The COPD group had a significant risk of developing TB than a control group (2.9% vs 1.2%, p < 0.001) in a large study of 23,594 COPD cases and 47,188 controls in Taiwan. The common comorbidities in COPD patients were malignancy, diabetes mellitus and auto-immune diseases, and often had a low income as compared to control subjects. The patients with higher doses of oral corticosteroids and oral LABA were more likely to develop active pulmonary TB.
Healthcare workers (HCWs) are exposed to blood and body fluids from percutaneous injury (needle stick, sharp injuries), mucocutaneous injury (splashes into eyes) or contact with damaged skin. HCWs are thus exposed to human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Worldwide, 3 million HCWs are exposed to these blood-borne viruses; 70,000 get HBV infections, 15,000 HCV and 500 HIV infections each year. The epidemiology, attitude, prevalence rates of accidents practices and knowledge in India are not documented. The occupational risk of HBV can be decreased by vaccination. Transmission of these blood-borne viruses from infected HCWs to patients has also been reported. A search of English literature during 1972–2002, 50 outbreaks have been reported in which 48 HBV infected HCWs (39 surgeons – orthopaedics, cardiothoracic surgery and obstetrics and gynaecology) transmitted the infection to 500 persons. Transmission of HBV infection from an infected orthopaedic
292
current medicine research and practice 5 (2015) 290–292
surgeon in USA to 2 patients has been documented recently. Patients visiting a dental clinic in Oklahoma, USA has also tested positive in 2013 (57 HCV, 3 HBV and 1 HIV) due to use of rusty instruments and old needles. With regard to HBV, there is a consensus to exclude HCWs who test positive for hepatitis B virus e antigen (HBeAg) or HBV DNA, from performing exposure-prone procedures. American Academy of Orthopaedic Surgery (June 2012) has also laid down guidelines for prevention of transmission of blood-borne viruses HCWs to patients in clinical practice. India has 1.5 million HIV positive, 12 million HCV positive and more than 20 million HBV positive population. There is an urgent need for implementation of policies for prevention
of transmission of such infections in healthcare institutions from patients to HCWs or vice versa. 1. Markovic-Denic L, Maksimovic N, Marusic V, Vucicevic J, Ostric I, Djuric D. Occupational exposure to blood and body fluids among health-care workers in Serbia. Med Princ Pract. 2015;24:36–41. 2. Enfield KB, Sharapov U, Hall KK, et al. Transmission of hepatitis B virus from an orthopedic surgeon with a high viral load. Clin Infect Dis. 2013;56(2):218–224. 3. Puro V, Scognamiglio P, Ippolito G. [HIV, HBV, or HCV transmission from infected healthcare workers to patients]. Med Lav. 2003;94(6):556–568.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/cmrp
Snippets Tulsi Chugh * National Emeritus Professor of Microbiology, National Academy of Medical Sciences (NAMS), Ansari Nagar, Mahatma Gandhi Marg, Delhi, India
article info Article history: Received 13 November 2015 Accepted 18 November 2015 Available online 7 December 2015
1. Mycobacterial disease in patients with rheumatoid arthritis Rheumatoid arthritis (RA) is a major cause of disability and the risk of acquiring or dying of an infectious disease is higher because of disease-related immune dysfunction or immunosuppression caused by therapeutic agents. There is an increased risk of mycobacterial diseases in those receiving anti-TNFa therapies. Population based study in Europe has shown the risk of development of TB 4-folds higher and a similar study in Taiwan, the risk was 2.28 folds higher in RA patients.1 Furthermore, the risk for nontuberculous mycobacteria (NTM) disease was 6.24 folds higher in RA patients than controls and the risk of death among RA patients with NTM disease was 3.06folds higher than that for RA patients without NTM disease. A recent-similar study from Canada showed a 2.07-fold higher risk for NTM disease in RA patients and a 1.81-fold increased risk for death among RA patient with NTM disease. Increasing evidence shows that the risk for mycobacterial diseases among RA patients is essentially attributable to the use of immunosuppressive therapies. There is thus a clear need for close monitoring of RA patients for any evidence of tuberculosis or NTM disease, especially those who have a concurrent condition (diabetes mellitus) or ≥65 years of age.
1. Liao T-L, Lin C-H, Shen G-H, et al. Risk for mycobacterial disease among patients with rheumatoid arthritis, Taiwan, 2001–2011. Emerg Infect Dis. 2015;21(8):1387–1395.
2.
Hepatitis E virus infection
Hepatitis E virus (HEV) is transmitted by contaminated water, undercooked meat, blood transfusion or solid organ transplant. HEV infection is usually self-limited and occurs world-wide but more in South Asia. It causes acute hepatitis, less often chronic hepatitis and rarely cirrhosis in immunocompromised patients. HEV infection with chronic hepatitis in patients with haematologic malignancies and stem cell transplantation and solid organ transplant (SOT) has been reported. Treatment with oral ribavirin can lead to a rapid clearance of HEV and thus prevents chronic hepatitis. Patients with elevated liver enzymes should be screened for HEV infection and a 3-month course of oral ribavirin administered to prevent chronic hepatitis. It enables the continuation of cytotoxic treatment of underlying malignancy.1 A multicentric study shows that ribavirin monotherapy for a 3-month period is an appropriate therapy for HEV positive SOT patients.2
* Tel.: +91 9818575933. E-mail address: [email protected] http://dx.doi.org/10.1016/j.cmrp.2015.11.011 2352-0817/# 2015 Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd on behalf of Sir Ganga Ram Hospital.
current medicine research and practice 5 (2015) 290–292
1. Kamar N, Izopet J, Tripon S, et al. Ribavirin for chronic hepatitis E virus infection in transplant recipients. N Engl J Med. 2014;370(12):1111–1120. 2. Tavitian S, Peron JM, Huguet F, et al. Ribavirin for chronic hepatitis prevention among patients with hematologic malignancies. Emerg Infect Dis. 2015;21(8):1466–1469.
1. Lee CH, Lee MC, Shu CC, et al. Risk factors for pulmonary tuberculosis in patients with chronic obstructive airway disease in Taiwan: a nationwide cohort study. BMC Infect Dis. 2013;13:194.
5. 3. Free-living amoebae in water resources of intensive care units in tertiary care hospitals in India1 Free living amoebae (FLA) are known to cause primary amoebic meningoencephalitis and granulomatous amoebic encephalitis. In addition, these amoebae may also serve as hosts for many pathogens (ECHO virus, adenovirus, Coxsackie i.e. virus, Legionella spp., atypical mycobacteria, Pseudomonas spp. and others). These cause infections in various immunocompromised patients. FLA have been isolated from sea water, soil, dialysis units, contact lenses, and human nares and throat. The mode of transmission is inhalation or inoculation through skin lesions. FLA have been reported in samples collected from immunodeficiency wards in Iran (52.9%) and 42.9% of water samples from the hydraulic systems of dental units and haemodialysis units in Egypt. In a study conducted in PGIMER, in Chandigarh, water samples and swabs from tap mouths were collected in various units of the hospital. Four tap water samples (8%) and 10 swab samples (20%) grew trophozoites and cysts of FLA. These were confirmed by PCR and sequencing. It is important to investigate and take necessary control measures in various institutions to protect patients at risks. 1. Khurana S, Biswal M, Kaur H, et al. Free living amoebae in water sources of critical units in a tertiary care hospital in India. Indian J Med Microbiol. 2015;33(3):343–348.
291
Epstein–Barr virus and gastric cancer
Gastric carcinoma is the second leading cause of cancer to deaths in the world. Ninety five percent of all malignant tumours in the stomach are adenocarcinoma. The role of Helicobacter pylori (H. pylori) as a cause of gastric cancer and mucosa-associated lymphoid tissue (MALT) has been well established. Epstein–Barr virus (EBV) is known to be associated with 10% of gastric adenocarcinoma. Epstein–Barr virus can be demonstrated in the cancer cell by in situ hybridisation, monoclonality of EBV-DNA and elevated antibodies. In a prospective case control study of 100 patients in Vellore, India, 6% had EBV infection in adenocarcinoma.1 In a meta-analysis of pooled data of 5081 cases from 15 international populations, 9% of gastric cancers had EBV.2 There is an evidence in the current literature that EBVassociated gastric adenocarcinoma is slightly more common in males, younger age, have a preferential location in the body and fundus of the stomach and less lymph node involvement. There is also an evidence in the literature that EBV-associated gastric carcinomas have a more favourable prognosis. 1. Rymbai ML, Ramalingam VV, Samarasan I, et al. Frequency of Epstein–Barr virus infection as detected by messenger RNA for EBNA 1 in histologically proven gastric adenocarcinoma in patients presenting to a tertiary care center in South India. Indian J Med Microbiol. 2015;33(3):369–373. 2. Camargo MC, Murphy G, Koriyama C, et al. Determinants of Epstein–Barr virus-positive gastric cancer: an international pooled analysis. Br J Cancer. 2011;105(1):38–43.
6. Occupational exposure of healthcare workers to blood and body fluids 4. Tuberculosis and chronic obstructive pulmonary disease (COPD) An association between tuberculosis (TB) and chronic obstructive pulmonary disease (COPD) and asthma and active TB disease has been reported, due to smoking and corticosteroid use.1 Inhaled corticosteroid (ICS) and long-acting b-agonists (LABA) are the recommended treatment. ICS therapy is known to predispose to pneumonias including TB independent of the use of oral corticosteroids. The COPD group had a significant risk of developing TB than a control group (2.9% vs 1.2%, p < 0.001) in a large study of 23,594 COPD cases and 47,188 controls in Taiwan. The common comorbidities in COPD patients were malignancy, diabetes mellitus and auto-immune diseases, and often had a low income as compared to control subjects. The patients with higher doses of oral corticosteroids and oral LABA were more likely to develop active pulmonary TB.
Healthcare workers (HCWs) are exposed to blood and body fluids from percutaneous injury (needle stick, sharp injuries), mucocutaneous injury (splashes into eyes) or contact with damaged skin. HCWs are thus exposed to human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Worldwide, 3 million HCWs are exposed to these blood-borne viruses; 70,000 get HBV infections, 15,000 HCV and 500 HIV infections each year. The epidemiology, attitude, prevalence rates of accidents practices and knowledge in India are not documented. The occupational risk of HBV can be decreased by vaccination. Transmission of these blood-borne viruses from infected HCWs to patients has also been reported. A search of English literature during 1972–2002, 50 outbreaks have been reported in which 48 HBV infected HCWs (39 surgeons – orthopaedics, cardiothoracic surgery and obstetrics and gynaecology) transmitted the infection to 500 persons. Transmission of HBV infection from an infected orthopaedic
292
current medicine research and practice 5 (2015) 290–292
surgeon in USA to 2 patients has been documented recently. Patients visiting a dental clinic in Oklahoma, USA has also tested positive in 2013 (57 HCV, 3 HBV and 1 HIV) due to use of rusty instruments and old needles. With regard to HBV, there is a consensus to exclude HCWs who test positive for hepatitis B virus e antigen (HBeAg) or HBV DNA, from performing exposure-prone procedures. American Academy of Orthopaedic Surgery (June 2012) has also laid down guidelines for prevention of transmission of blood-borne viruses HCWs to patients in clinical practice. India has 1.5 million HIV positive, 12 million HCV positive and more than 20 million HBV positive population. There is an urgent need for implementation of policies for prevention
of transmission of such infections in healthcare institutions from patients to HCWs or vice versa. 1. Markovic-Denic L, Maksimovic N, Marusic V, Vucicevic J, Ostric I, Djuric D. Occupational exposure to blood and body fluids among health-care workers in Serbia. Med Princ Pract. 2015;24:36–41. 2. Enfield KB, Sharapov U, Hall KK, et al. Transmission of hepatitis B virus from an orthopedic surgeon with a high viral load. Clin Infect Dis. 2013;56(2):218–224. 3. Puro V, Scognamiglio P, Ippolito G. [HIV, HBV, or HCV transmission from infected healthcare workers to patients]. Med Lav. 2003;94(6):556–568.