ABSTRACTS OF PAPERS TO BE PRESENTED AT THE 69TH NATIONAL

CONFERENCE ON TUBERCULSIS AND CHEST DISEASES TO BE HELD IN

MUMBAI FROM 5TH TO 7TH FEBRUARY, 2015

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ORAL PRESENTATIONS

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INVESTIGATING THE FACTORS ASSOCIATED WITH MULTI DRUG

RESISTANT-TUBERCULOSIS IN SURAT DISTRICT -A CASE CONTROL STUDY

Yadav Shiv K ,Damor Rahul , Kantharia S L , Patel M Z, Tiwari Mani

Introduction: - The emergence of Multi-Drug Resistant Tuberculosis (MDR-TB) has become a significant public health problem and an obstacle to effective TB control. In India prevalence of Primary MDR-TB is 2.2% (1.9–2.6%) and Secondary MDR-TB is 15% (11–19%). WHO estimates that there were about 450,000 new (incident) MDR-TB cases in the world in 2012.So the factors responsible for Causation and Emergence of MDR-TB need to be assessed.

Aims & Objective:-Investigating the factors associated with Multi Drug Resistant-Tuberculosis.

Methodology:- An Unmatched Case Control Study, Purposively Recruited 68 MDR-TB Patients as Cases and 136 non - MDR-TB Patients as Control (from Rural as well as urban Area of Surat District ) diagnosed by CBNAAT were interviewed for investigating the risk factors.

Observations:-After adjusting for other factors in multivariate analysis, a model prepared (having Nagelkerke R2 -0.563) which showed Low Education level (OR-1.778), HIV-AIDS status( OR-5.913),Skilled work(OR7.249),Unskilled work(OR-0.075) Duration of stay at Present address(OR-4.762) were factors found to be significantly ( P value<0.05 ) associated with MDR-TB.

Conclusion & Recommendation:-Multivariate analysis showed important risk factors for MDR-TB. Smoking, Inadequate DOTs Therapy and Previous history of Tuberculosis have not been detected as risk factors. Detailed Multi-Centric study to identify risk factors in various socio economical groups is recommended..

RETROSPECTIVE ANALYSIS OF MDR-TB PATIENTS REGISTERED UNDER RNTCP IN A PUBLIC SECTOR HOSPITAL OF WESTERN REGION OF INDIA

Tiwari Mani, Roy Arun Kumar, Patel M.Z., Shamaliya Khyati,Yadav Shiv Kumar, Tamakuwala Grinish

Introduction:-MDR-TB is a man-made phenomenon. Poor treatment, poor drugs and poor adherence to DOTS lead to development of MDR-TB. Sputum sample collection as early as possible for DST & rapid initiation of treatment after diagnosis is important to prevent spread & good outcome of the treatment of MDR-TB.

Aims & Objective: Description &Exploration of the delays at various levels of management of MDR-TB.

Methodology:-Operational Research, Secondary Data analysis of 638 cases of MDR-TB Diagnosed by CBNAAT Technology registered for DOTS PLUS Therapy at Pulmonary Medicine Department ,NCH Surat from Aug 2012 to Sept 2014.

Observation: Male to female Patient ratio2:1,more in age group <30 years,HIV Seropositivity-3.6%, Majority 54.4% of patients were resident of SMC followed by 15.4% Surat,11% Navsari,10.5%Valsad & rest were of neighbouring districts & UT.Time gap between Sputum Sample Collection and diagnosis was ≤3 days in 54% patients followed by 4-7 days in 43% patients.Time gap between diagnosis and initiation of treatment was ≤1 week in 37%,1-2 weeks in 38% patients&>2 weeks in 25%patients.

Conclusion& Recommendation: SMC needs active interventions. There is significant delay in diagnosis & treatment initiation. So, meticulous individual case tracking system is likely to shorten the gap and reduce the delays in curing the MDR-TB patients.

HAEMATOLOGICAL PROFILE OF SMEAR POSITIVE NEW PULMONARY TUBERCULOSIS

Anupama Murthy, R.Karthikeyan, Selvi

Background: Tuberculosis is a major public health problem in India. Reversible peripheral blood abnormalities are commonly associated with pulmonary tuberculosis. Insight into the relationship between haematological abnormalities and mycobacterial infection has come from an understanding of the immunology of mycobacterial infection .There is a paucity of literature in the haematological changes associated with tuberculosis, though tuberculosis is a common condition.

Material and Methods: Retrospective observational study was done in Department of Respiratory Medicine at PSG Medical College and Research Centre. One hundred patients of new smear positive Pulmonary Tuberculosis were included. Disseminated tuberculosis and patients receiving ATT were excluded from this study. The various haematological parameters were studied by means of hemogram by automated cell counter and data analysed.

Results: Among 100 patients studied, data analysed, anaemia was seen in 65% of patients. Leucocytosis as a response to infection was observed in 41% patients, thrombocytosis was observed in 31% patients while thrombocytopenia was observed in 2% patients. 95% patients had increased erythrocyte sedimentation rate. 59% patients had a normal leukocyte count

Conclusion: Various haematological abnormalities have been demonstrated in all 100 patients with pulmonary tuberculosis in the present study. Which consistent with reported

literature and reinforce the fact that they can be valuable tools in monitoring Pulmonary Tuberculosis such as anaemia and increased ESR, other findings such as thrombocytosis suggest the need for further studies in this field.

SMOKING

O.A. Sarma

*Warnings *Thank you for not smoking *Tobacco largest killer in 21st century *Screen sans smoke *Poison in the air *World ‘No Tobacco Day’ 31st May *Statutory Warning : Cigarette smoking is injurious to health *Magnitude of the problem *Don’t smoke away your life *Smoking : orgy in parties / get-together events *Smoking & Drinking-Twin Dangers *Smoking lifestyle oriented disorder *Lady NICOTINE *Passive smoking Environmental Tobacco smoke (ETS) *carcinoma larynx *Lungs-Chimney *Art inspired by tobacco – Lancet *Tarred by tobacco use *Smoking-Tobacco and cities *Smoking causes blinding eye disease *Smoking induces cancer *PUC checkups *Cigarette-lighter life extinguisher *Don’t puff away your life *Tobacco industry will resist smoking control measures : Tobacco field cash-crop, income for Government in country *Hook onto hookah *Unmindful of ‘World No-tobacco Day *Deaths due to Tobacco *Tobacco a killer weed *Puff that kills *Smoking : 7 letters sin *There are 1.3 billion smokers worldwide, 70% in developing countries *India World’s 2nd largest tobacco growing Country *Smoking/chewing tobacco product is rapingpharynx, pulmone-Satanic 7 7 7 7 7 7 7 7 Demonic dangers 7 7

REPORT OF INTEGRATION OF TB & HIV CONTROL PROGRAMMES (RNTCP & NACP) AT PRIVATE MEDICAL COLLEGE

K. C. Mohanty, Salil Bendre, Rathna Balakrishnan, Simhadri Naidu

INTRODUCTION:

K. J. Somaiya medical college and research centre was the first private medical college in Maharashtra to start DOTS centre in 1999 and DOTS Plus centre in 2012. Integrated screening for TB & HIV was started in K. J. Somaiya medical college since 2007.

AIMS & OBJECTIVES

To stimulate other private medical colleges t start combined RNTCP and NACP centres

METHOD

An integrated report of patients visiting K. J. Somaiya medical college at the Chest and Tuberculosis department and the ICTC since 2007. All patients diagnosed with TB were referred to the ICTC and all patients who tested positive for HIV were screened for TB.A total of 260 patients were screened out of which 98 patients were diagnosed with HIV-TB co-infection through the ICTC. 19(19.3%) of these patients were found to be sputum positive and were referred to the DOTS centre for TB treatment. 48 patients on DOTS were diagnosed

with HIV, of which 31 (64.5%) were treated with Category I, 4 (8.3%) with Category II and 5 (10.4%) with Categories 4 & 5 respectively. 5 patients (10.4%) expired while on treatment.219 patients with HIV-TB co-infection have been hospitalised from January 2007 till October 2014 out of which 120 (54.7%) were pulmonary cases while the remaining 99 (45.6%) were extra-pulmonary cases, of which 26 patients (11.9%) expired.

CONCLUSION

With our experience we suggest that patients who require ART should be given priority after referral by DOT centres after diagnosis and assessment. All ART centres should be given information regarding DOTS & DOTS Plus.

A SUCCESSFUL EXAMPLE OF PUBLIC-PRIVATE PARTNERSHIP FOR DOTS IMPLEMENTATION

K. C. Mohanty, Salil Bendre, Nikhil Sarangdhar, Seema Ingole

DESIGN:

Retrospective analysis of 14 years data at K. J. Somaiya medical college DOT centre.

SETTING:

A teaching hospital cum medical college with 300 beds in Mumbai, with 30 beds for TB and Chest diseases, which acts as a tertiary referral institute for several specialities. The institute has got RNTCP accredited DOT centre, DMC and is on the final phase of getting accredited I.R.L. for mycobacterial culture & DST

PATINTS AND INTERVENTIONS:

A retrospective study was conducted at K.J. SOMAIYA medical college & hospital taking into consideration the performance of the DOTS centre from March 1999 up to December 2013. Patients were enrolled as per RNTCP norms into treatment categories “Partially observed treatment” was implemented where patients were administered the first dose under supervision and were given medicine packets for next 14 days. Follow-up was done every 15 days when the patient returned with empty sachets. Sputum for AFB and other investigations performed as per programmatic norms.

CONCLUSION:

Sputum conversion was observed in 747 out of 836 patients on CAT I (89.4%), 192 out of 258 patients in CAT II (74.8%). 31 patients have been enrolled so far on DOTS Plus and 11 out of 13 patients whose I.P has been completed have shown sputum conversion at end of I.P. (84.6%) . These conversion rates are better than the national average (88% in CAT I, 71 % in CAT II and 60% in DOTS Plus)

A CASE OF SILICOSIS IN A CHAKKI MILL WORKER

K. C. Mohanty, Salil Bendre, Nikhil Sarangdhar, Suhas Tiple

SUMMARY

We present a case of Silicosis in a forty-four year old male who was treated as Tuberculosis because of its clinico-radiological features. Further clinical correlation with computerised high-resolution chest tomography clinched the diagnosis and played an important role in proper management of the case. We report this case because in many such cases, the diagnosis is likely to be missed and they are likely to be mistakenly treated as Tuberculosis.

INTRODUCTION:

Silicosis is a fibrosing disease of lungs caused by the inhalation, retention and pulmonary reaction to crystalline silica or Silicon dioxide. The link between Silicosis and Tuberculosis has been recognised for nearly a century. The disease usually occurs as the chronic form which presents after a long latent period of exposure, usually up to fifteen - twenty years or more.

CASE REPORT:

In March 2014 a forty-four old male, resident of Mulund, Mumbai presented to the Chest OPD of one of the major municipal hospitals of Mumbai with complaints of chronic cough for eleven months and progressively increasing dyspnoea on exertion (MMRC Grade II) . The cough was non-productive and without expectoration or haemoptysis. There was no postural or seasonal variation. There was no chest pain, fever or weight loss.There was no medical history of any major illness/disease and no family/contact/past history of Tuberculosis. Sleep, Appetite and Bowel/Bladder habits were normal. The patient had no addiction.

He was advised a Chest X-ray film by the consultant at the Chest OPD which revealed Bilateral micro nodular shadows in both lung fields which were present on his previous Chest radiograph dated 18th February and 12th March 2014 taken on consultation for the same complaints. The consultant advised Sputum AFB smear (from a designated microscopy centre) and screening tests for retroviral disease, both of which were negative. He was then given a diagnosis of Smear negative pulmonary tuberculosis (new case) and referred to the nearest DOTS centre for CAT-I DOTS. The patient presented to our OPD for a second opinion on 31st May 2014.

On further questioning , the patient revealed that he works in a chakki (flour mill) and that he has been working for more than thirty-five years (his father too used to work in a chakki and he would often assist his father since a very young age.

Clinical examination revealed grade I clubbing and scattered crackles. Rest of the examination was normal, including pulse oximetry. He was advised complete blood profile, Electrocardiogram, Spirometry and a high-resolution computerised tomography of the chest.Spirometry revealed moderate airflow obstruction with partial bronchodilator reversibility and mildly reduced FVC suggestive of restriction. HRCT Chest revealed patchy consolidation in posterior segment of right upper lobe and apical segment of right lower lobe with adjoining fibrosis and fibro nodular opacities in posterior and superior segments of right

upper lobe, lateral segment of right middle lobe and left upper lobe and apical segment of left lower lobe with minimal pleural thickening, along with calcified left hilar , pre-vascular and pre and para-tracheal nodes with egg-shell calcification. Rest of the investigations were inconclusive. The patient was advised bronchoscopy with biopsy which was declined. 6 minute walk test was performed which was normal.

Based on the above results he was diagnosed as a case of Silicosis and started on treatment with inhaled long acting bronchodilators and corticosteroids (Formoterol and Budesonide) via dry-powder inhaler. He was also recommended pulmonary rehabilitation and vaccination with polyvalent pneumococcal and seasonal influenza vaccines. He responded to treatment in terms of clinical improvement and keeps regular follow-up monthly since the last six months.

TREATMENT OUTCOME OF PULMONARY TUBERCULOSIS PATIENTS TAKING DOTS CATEGORY-2 OF PREVIOUSLY LOST TO FOLLOW UP FOR

TREATMENT

Balbir Malhotra, N C Kajal, Nagaraja C L, Rahul Prabhu

Introduction; The effectiveness of India’s TB control programs depends critically on patient compliance and completion of full course of treatment. Discontinuing treatment prior to completion of treatment, can leave patients infectious for longer time, the emergence of multidrug resistance and consequently spread of infection.

Objectives; To explore the treatment outcome of pulmonary tuberculosis patients taking DOTS category-2 of previously lost to follow for treatment.

Methods:

Case study was conducted in a tertiary health care centre.

Results: Majority of the previously lost to follow up for treatment patients were complete the treatment (76%) successfully without interruption of treatment. Majority of male patients (13.9%) than female patients (0%) (p=0.006), rural patients (14.3%) than the urban patients (0%) (p=0.000), uneducated patients (20.3%) than the formal/primary educated patients (0%) and higher educated patients (0%) (p=0.000) and financially unstable patients (16.9%) than the financially stable patients (0%) and financially dependence on others (0%) (p=0.000) were lost to follow up for treatment. Most of higher educated patients (44.4%) and urban patients (26.7%) were shifted to MDR treatment.

Conclusion: Lost to follow up for treatment can be prevented by educating the patients and repeated retrieval actions from the RNTCP workers and attached medical officers.

STUDY OF PREVALENCE AND CLINICAL PROFILE OF DIABETES AND PRE-DIABETES AMONG 1000 TB PATIENTS DIAGNOSED AT OUR INSTITUTE

A. A. Saibannavar, M. V. Bansode

Introduction: The burden of tuberculosis and diabetes mellitus is significantly high in India. People with diabetes are at high risk (2.5 times more) of developing active tuberculosis. The main purpose of this study is to screen diabetes and pre-diabetes among TB cases. As the risks of treatment failure, deaths and reactivation are high in TB-DM patients; we have also included study of clinical profile of these patients.

Material and Methods: We have done a prospective study over a period of two years. Study size is 1000 TB patients diagnosed at our institute. All willing patients above the age of 12 years are included in our study. We followed WHO criteria with fasting blood glucose level (FGL) for diagnosis of diabetes and pre-diabetes status. TB patients with FGL>110mg/dl are evaluated in details to study their clinical profiles. Outcomes of these patients are noted from TB registers/records.

Results: Out of 1000 TB patients, 212(21.2%) have impaired FGL>110mg/dl. Among them, 80 TB patients have diabetes and 132 TB patients have pre-diabetes status. They have male predominance, low socio economic status and older age group. Pulmonary TB with sputum positive status is most common presentation among these TB patients. Pleural effusion is the most common type of extra pulmonary TB seen in them. Bilateral lung infiltration is commonly seen on XRC. Symptoms are same as that of non diabetes TB patients. Out of 212, 7 patients died before completion of DOTS.

Conclusion: In our study, prevalence rates of diabetes and pre-diabetes among TB patients are 8% and 13.2% respectively. This study reveals that those with TB-DM were more likely to have the infective form of TB. Outcome of these patients on DOTS is significantly good with mortality rate of 3.5%. Screening patients with TB for FGL estimation will help in early detection of DM.

DIRECT OBSERVATION (DO) FOR DRUG-RESISTANT TUBERCULOSIS: DO WE REALLY DO?

Stella Smith, Petros Isaakidis, Mrinalini Das, Sonakshi Jadhav, Jennifer Furin, Zarir

Udwadia, Tony Reid

Background

Direct-observation (DO) is recommended for drug-resistant tuberculosis (DR-TB) patients during their entire treatment duration. However, there is limited published evidence on implementation of direct-observation in field. This study aims to detail whether directly-observed therapy(DOT) was followed by DR-TB patients under DOT-providers in Médecins Sans Frontières(MSF) tuberculosis programme, Mumbai, India.

Methods

This was a cross-sectional, questionnaire-based survey/audit of DR-TB patients on treatment, their DOT-providers and MSF-health-staff involved during June-August 2014. Patients were defined as ‘following DOT’ if DOT provider had seen the patient swallow his/her medications ‘every day’ or ‘most of the days’ on average during treatment. If DOT was not followed(i.e. directly-observed ≤half of the time), barriers to follow DOT were also recorded.

Results

A total of 71 DR-TB patients, 65 DOT-providers and 21 MSF-health-staff were included in the study. About 55% patients were co-infected with HIV and majority (41%) had Pre-XDR TB. Most of the patients (78%) were registered for DOT at nearby clinic. Among all patients, 34% (24/71) followed DOT during treatment. However, DOT providers mentioned 46% (30/65) of patients followed DOT. In contrast, MSF-staff reported none of the patients complied with DOT. Time involved, adverse drug-reactions during treatment and closed-clinic were common barriers to follow DOT. Conclusion

Direct-observation was not followed by two-thirds of the patients in our study. However, they were successfully continuing treatment. We believe alternate strategies and innovative monitoring tools may be adopted by tuberculosis programme, to help similar non-DOT patients in treatment compliance.

TUBERCULOSIS TREATMENT OUTCOMES IN SUBSTANCE-ABUSE PATIENTS

OF NAGALAND, INDIA

Rahul Shenoy, Mrinalini Das, Homa Mansoor, Rey Anicete, Loshan, Imyangluba Ao,

Peter Saranchuk, Petros Isaakidis

Background

The national tuberculosis (TB) programmes have been adopting many strategies to achieve universal coverage of TB treatment among vulnerable population groups. However, substance-abuse TB patients including Intravenous drug users (IDUs) still remain a challenge towards global TB elimination. This study aimed to detail experiences of a Médecins Sans Frontières (MSF) tuberculosis programme attended by substance-abuse patients in Mon district, Nagaland, India.

Methods

This was a retrospective cohort study of substance-abuse patients including IDUs who were initiated drug-susceptible TB treatment at Mon District Hospital, Nagaland, India between April 2012 and December 2013.

Results

A total of 49 substance-abuse tuberculosis patients (23 on Category I treatment, 26 on Category II) with complete outcomes were included in the study. Majority of the patients were males (92%). None of them were HIV co-infected. Most patients (69%) were suffering from pulmonary, smear-positive tuberculosis. Overall, about two-thirds(67%, 33/49) of patients were cured or had completed their treatment. Bivariate analysis showed that previous history of TB was significantly associated with unsuccessful TB treatment outcomes (defined as death, loss-to-follow-up and failure).

Conclusion

Substance-abuse patients including IDUs suffering from TB need special attention in the tuberculosis programmes. Poor treatment outcomes in the study hints the urgent need of a tailored model of care, with focus on treatment-literacy and adherence-counselling adapted to history of substance-abuse and socio-cultural norms. National TB programmes should devise separate TB treatment packages including drug-substitution-therapies and effective monitoring systems to tackle TB burden among substance-abuse patients.

OTOTOXICITY ASSOCIATED WITH USAGE OF INJECTABLE KANAMYCIN IN DRUG RESISTANT TB PATIENT (CAT IV ELIGIBLE)

Roy Arun Kumar, Tiwari Mani ,Patel M Z,Shamaliya Khyati,Vavia Ravi, Yadav Shiv Kumar

B ackground : - MDR TB is associated with long duration of treatment along with severe adverse drug reactions. Among cat IV drugs, injectable Kanamycin is associated with severe ototoxicity. This study was done to explore the ototoxicity associated with Kanamycin during the treatment of cat IV eligible Drug Resistant TB patients.

Methodology: - A Prospective follow up study on 100 confirmed cat IV eligible Drug Resistant TB patients diagnosed by CBNAAT at DR TB centre, Surat. Patients were followed up monthly for a period of 6 months which included PTA of all patients to assess the ototoxicity.

Aims & Objective:- To study the pattern and Time of Onset of Ototoxicity due to Kanamycin in Category IV eligible patients under PMDT programme.

Results:- 55% Patients developed ADRs with Cat IV Drugs, out of which 56.4% were male and 43.6% were female. 37(46 %) of patients had ototoxicity (mild to severe Sensory Neural Hearing loss) due to kanamycin, out of them 67.6% developed ototoxicity within 1 Month,13.5% developed within 1-3 months & 18.9% developed within 3-6 months of Treatment.

Conclusion & Recommendation:- Ototoxicity is associated with Injectable Kanamycin in a significant number of patients, so all the patients should be regularly tested by PTA. Early& prompt intervention should be done with substitution (Reserve Cat IV drugs) to prevent progression to irreversible hearing loss.

SUCCESSFUL ENGAGEMENT OF CHEMISTS (MEDICAL SHOP OWNERS) IN TB CARE AND CONTROL – A SUCCESS STORY

Vikas Panibatla, Eleesha Babu, Sunita Prasad

Context: RNTCP efforts in tackling and eliminating TB should be supported by wide variety of stakeholders in the community. Chemists are integral part of health system and are the firstcontact point for consultation for any sort of illnesses. With an objective to engage Chemistsin TB programme, TB Alert India with funding support from Lilly MDR TB Partnership and UWW is implementing a project in four Tuberculosis Units Telengana state, India since October 2012.

Methodology/Intervention: Chemists were sensitized and trained in identifying, referring TB symptomatic persons to testing and treatment facilities of RNTCP. Trained/enrolled chemists are followed up closely. Linkages are established with local RNTCP staff.

Results/Discussion: Around 274 trained Chemists are actively participating in the project.From Feb ’13 to Sept ’14 Chemists have referred 1580 TB symptomatic persons for testing.Around 92% (1448/1580) referred have reached for testing indicating good quality ofcounselling. Near about 11% (162/ 1448 tested) are diagnosed with TB. Near about 78%(14/18) TB patients taking DOTS from Chemists are declared cured. Treatment adherencemonitoring is good. Around four people are still taking treatment. On an average Chemistshave contributed 5% of the total cases tested at Tuberculosis Units.

Conclusion: Chemists can refer TB symptomatics and can be a good DOTS provider. Theirengagement will enable early TB detection and prevent TB patient from getting intoun-necessary treatment shopping.

PERFORMANCE, RESPONSE AND OUTCOME OF TREATMENT UNDERRNTCP IN A DISTRICT NAGPUR RURAL, MAHARASHTRA

Amol Khadse, M. Chahande, Anand Zade, Sheshrao Devgade

Objectives: To evaluate the Revised National Tuberculosis Control Programme (RNTCP) through assessment of performance, response and outcome of treatment of patients.

Study Design: Cross-sectional observational study.

Material and Methods: In Nagpur district, Maharashtra, cases registered in the year (1 January to 30 Dec 2013) were selected for the study. Data were collected by review of records from all peripheral health units with a pre-designed and pre-tested schedule.

Results: Sputum-positive among chest symptomatics was 1615. Overall 1934 were new cases and among them 1606 were pulmonary, 1201 were sputum-positive among new pulmonary cases detected. Sputum conversion rate of new sputum-positive cases at 2 or 3 months was 93.50%. Cure rate for new sputum-positive pulmonary TB cases was 87.75 % and out of all smear-positive cases was 1201. Default among new smear-positive cases was 1%.

Conclusion: Sputum conversion rate after intensive phase of treatment, defaulter rate and cure rate among new sputum-positive cases which were in comparison to RNTCP norms have been reflected in the study.

CAUSES AND THEIR IMPACT ON OUTCOME OF MDR-TB: ANALYSIS OF CATEGORY IV RNTCP

Neha Agrawal, Amitabh Das Shukla, Rajneesh Kumar Srivastava

OBJECTIVE

The present retrospective study was undertaken with objective to determine the causes of MDR Pulmonary Tuberculosis and their impact on outcome in patients treated by Category IV, RNTCP from 24th March, 2013 to 24th March, 2014 at Drug Resistant Tuberculosis (DR-TB) Centre at MLN Medical College, Allahabad, Uttar Pradesh.

METHODOLOGY

All patients enrolled in the study period were classified into two groups as positive outcome, (sputum culture conversion at the end of six months of treatment) and negative outcome, (no sputum culture conversion at the end of six months of treatment/death). History of anti tuberculosis treatment prior to registration in Category IV was analysed, and patients of both groups were classified into either failure, relapse or default subsets. Patients with HIV positivity, pregnancy, diabetes, or hypothyroidism were excluded from this study. Both groups were compared to find statistically significant difference in causes of MDR TB.

FINDINGS

Total patients enrolled were 209, out of which, 63 were excluded and remaining were classified into two groups as positive (n=108) and negative (n=38) outcomes. Most common cause of MDR-TB was default from treatment (47.9%). Patients of default and relapse subsets had significantly higher possibility of positive outcome (p=0.01 and 0.000244 respectively), while failure subset had equal possibility of positive or negative outcome (p=0.552). Hence we conclude that prevention of default could decrease emergence of MDR-TB, and relapse/default has greater chances of cure than failure subsets.

PROFILE OF OSTEOARTICULAR TUBERCULOSIS IN CHILDREN

Ira Shah, Samruddhi Dani, Rujuta Mehta, Abhay Nene.

Aim: To determine prevalence and clinical profile of osteoarticular tuberculosis (TB) in children. Methods: Cross-sectional analysis from 2007-2013. All patients diagnosed with bone TB, spinal TB or TB abscesses were included in the study.

Results: Out of 1318 children with TB, 39(2.96%) had osteoarticular TB, of which 16(42%) had osteomyelitis, 8(20.5%) had spinal involvement, 7(17.9%) had TB synovitis, 2(5.1%) had psoas abscess and 6(15.4%) had paravertebral, gluteal and axillary abscesses. The mean age of presentation was 7.1±3.5 years (range 2-14 years). Of the 33 cases in which a culture was done, 25(64%) showed a positive culture. Drug sensitivity tests were done in 21 patients of which 10(47.6%) tested were drug resistant, of which 4(36.4%) were multidrug resistant (MDR), 2(18.2%) were extensively drug resistant (XDR), 3were partial XDR (27.3%) and 1 was poly-resistant (9.1%). Nine (23.1%) patients had TB in the past with atreatment duration of 8.3±5.3 months. Contact with a TB patient had occurred in 10(25.6%) cases. Associated pulmonary TB were seen in 6(15.39%) and TB meningitis were seen in 1(2.6%) patients.

Surgical intervention was needed in 11(28.2%) patients of which 5(45.5%) underwent curettage, drainage was done in 1(9.1%), arthrotomy in 4(36.4%) and spinal surgery in 1(9.1%) patient. In 19(70.4%) out of 27 cases tested, the ESR was found to be elevated. Elevated ESR was more commonly seen in spinal TB as compared to osteoarticular TB

(Odds ratio =4.46). Conclusion: Drug resistant osteoarticular TB is an emerging problem in children. Elevated ESR is more commonly seen in spinal TB.

OVERDIAGNOSIS OF TUBERCULOSIS AND ROLE OF TUBERCULIN TEST

Ira Shah, Shefali Parikh, Pradnya Paikrao

This is a retrospective analysis of children who were referred to our tuberculosis (TB) clinic from March 2010 to Feb 2011 but were not started on ATT and none of them subsequently developed TB. Interpretation of tuberculin test as a means of diagnosis was analysed.

Results: 34 (11.2%) children were overly diagnosed as TB. Seventeen out of 28 referred children were tuberculin positive and 8 were tuberculin negative. Also, 12 of tuberculin positive children had a reading of ≥15mm, yet none of them developed active disease. Although 2 TU is the recommended standard dose for tuberculin testing in India, in our study no child had received 2 TU, 23.5% of tuberculin positive patients had received a 5 TU dose and 35.3% a 10 TU dose.

Conclusion: Most children with over-diagnosis of TB receive TT with more than 2TU units. The size of tuberculin reaction needs to be interpreted carefully.

BEST PRACTICES IN MANAGING MDR- TB AT CHEST CLINIC MOTI NAGARA DOCTOR – PATIENT RENDEZVOUS

A.K. VASISHT

INTRODUCTION

Drug resistance TB is a major concern for TB control programmes world wide. Not following Basic DOTS leads to development of MDR-TB apart from the risk factors and presence of HIV. As the drugs are toxic and duration of treatment long, development of ADR in patients taking treatment for MDR-TB leads to treatment interruption, failure, development of resistance and increased mortality.

METHODS

Chest Clinic Moti Nagar caters to a population of approximately 13 lakhs . Members of community belonging to all walks of life from slum dwellers to those in the low and middle income groups are being provided TB related services. At present 124 patients are taking treatment for MDR-TB and 9 patients for XDR- TB. Long duration of treatment necessitates frequent monitoring in respect to treatment adherence and identifying development of any ADR. To improve treatment outcomes, various innovative practices are

being adopted during the course of treatment. Utilizing the services of cured MDR- TB patients in promoting treatment adherence is proving fruitful.

RESULTS

These novel initiatives connect with the patients and their relatives and impart awareness about MDR-TB and its treatment. Majority of problems and myths about the disease are solved as patients open up and ask many questions about their illness, clear their doubts and thereby helping in removing any stigma.

CONCLUSIONS

Services of counsellors in promoting awareness about MDR-TB, motivating patients to complete treatment and deal with any ADR apart from explaining the hazards of substance use must be obtained. Monthly counselling sessions at DOT centre/patient’s home with his family members should form part of MDR -TB management package. Knowledge sharing by doctors and DP in implementing PMDT guidelines along with sense of ownership amongst them will go a long way in controlling this deadly scourge.

SOCIO-DEMOGRAPHIC PROFILE OF DR TB

K. Anupama Murthy

Introduction

Tuberculosis is leading cause of death from curable infectious disease. MDR TB is considered serious and life threatening illness in recent years. With prevalence of 13- 18 % in retreatment cases and 3 % in new cases. RNTCP has framed guidelines under PMDT to treat such patients under CAT – IV DOTS (DOTS PLUS).

Methodology

Retrospective, observational study was done from PMDT records in department of Respiratory Medicine at PSG IMSR, Coimbatore, over two year period during October 2012 to October 2014.

Correlation with urban and rural profile was also done. Prevalence of MDR tuberculosis cases in new and retreatment cases was analyzed.

Results

Amongst 202 patients who underwent drug susceptibility test from six DMCs, 77% were males and 70.8% were from urban areas. The diagnostic methods employed were LPA for 113 (55.9%) subjects and CB NAAT for 89 (44.1%) subjects. Diagnostic methods did not detect TB in 57 (25.2%) subjects. LPA better detected TB than CB NAAT adjusted odds ratio 4.40 (95% CI, 1.952 – 9.93 P < 0.0001). Among 151 subjects in whom TB was detected rifampicin resistance was found in 22 (14.56%). Subjects from rural area had higher risk for drug resistance independent of gender, method used and previous ATT use (adjusted odd ratio 04.066 (95% CI 1.38 – 11.94) P = 0.011).

Conclusion

In our study prevalence of multidrug resistant’s tuberculosis is at par with national average. However in rural population higher prevalence of drug resistant tuberculosis after adjustment to confounding factors were noted.

TUBERCULOSIS AND DISABILITY-ADJUSTED LIFE YEARS (DALYs) LOST IN MUMBAI

Mangesh Jagdhane

The objectives of the study are to understand the pattern of TB morbidity and mortality in Mumbai, to measure the burden of tuberculosis by using the indicator of DALY.

This study is based on secondary data from many sources as there is no single comprehensive data source which provides all thee required information on age specific deaths due to tuberculosis. Hence the author used the sources to fulfil objectives of the study: Mumbai District TB Control Society (MDTCS), office of City TB Officer, data of TB mortality from March 2012 to March 2013. The limitation of the study is that this study is limited to Mumbai metropolitan only.

The limitation of the study is that this study is limited to Mumbai metropolitan only. In the calculation of disability adjusted life years (DALYs) overall 2516.53 years of life got lost due to the tuberculosis in the population of Mumbai. Among these, total 324.48 DALYs were lost in age group of 0-15 year’s population, in this population, male children lost 255.96 DALYs while female children lost 68.67 DALYs. Among the adult population in Mumbai, the total DALY lost was 1869 years and in this age group, males lost 1828.49 DALYs and females lost 42.12 DALYs. Among the elderly population they lost total 322.81 DALYs and among these 313.69 DALYs lost by male population and 9.12 DALYs lost by females respectively.

COMMUNITY BASED SCREENING FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE AMONG ELDERLY IN AN URBAN AREA OF SOUTH

INDIA

Ramesh Chand Chauhan, Anil Jacob Purty, Murugan Natesan, Zile Singh

Background and Objectives: Under-diagnosis of chronic obstructive pulmonary disease (COPD) is common as this disease is often not recognised and diagnosed until it is moderately advanced. This study was an attempt to find the burden of COPD among elderly urban population.

Material and methods: This community based observational study was conducted among 1037 elderly people in urban areas of Puducherry in India. Participants were recruited using multistage random sampling technique. IPAG questionnaire [Cut off Score – 17 (Positive predictive value: 92%)] was administered among all study subjects. We compared

quantitative parameters between COPD and non-COPD subjects using the student t-test and chi-square test was applied for qualitative variables.

Results: Among 1,037 subjects, 435 (41.9%) were male and the proportion of smokers among them was 16.5%. A positive IPAG questionnaire for COPD (≥17 points) was obtained in 342 (33.1%) subjects. Based on the responses by the probable COPD subjects, 69 (22.2%) had no cough, 215 (62.9%) reported sputum production in the absence of a cold, 186 (54.4%) cough up phlegm (sputum) in the morning, 162 (47.4%) had frequent or occasional wheezing and 113 (33 %) reported to have or had any allergies. Age and body weight found to be associated with positive IPAG questionnaire. Probable COPD was significantly higher among smokers (52.9%) as compared to non-smokers (31.7%) (P value <0.01).

Conclusions: Proportion of subjects with possible COPD was high in community. IPAG questionnaire was an easy to administered tool for screening of COPD and little expertise is sufficient for its administration.

OPERATION ASHA USING EDETECTION TECHNOLOGY APPLICATION FOR IMPROVED RESULTS IN ACTIVE CASE FINDINGS AND CONTACT TRACING

Shelly Batra, Sandeep Ahuja, Valeria Lauria

Objective: There are 1.8 million new cases of TB in India each year. Open cases of TB infect 10-15 others annually. Close contacts of patients are likely to contract TB. An urgent need is to scale up detection of these hidden patients. The eDetection App enables providers to methodologically screen at-risk individuals, thus effectively curbing an exponential spread of TB.

Intervention: The eDetection App runs on Android-enabled tablets. It was piloted on 4 tablets in two cities in India, Gwalior and Jaipur. During the 12 months pilot, providers visited families of existing patients, factories where patients work and also went door-to-door. They used the App to educate the community on symptoms of TB, ask them to answer a basic questionnaire, and subsequently facilitate sputum testing and diagnosis of symptomatics.

Results: Over twelve months, approximately 1900 contacts of existing TB patients were screened using the Detection system. Data analysis showed that out of this number, 103 have been found to test positive for TB and have been subsequently enrolled in the RNTCP program. Prevalence of TB in those cities is 216/100,000population. With eDetection we have found that 5.4 % of all screened by the App used by the community health workers had TB, which means our detection far exceeds the estimated prevalence. Using the App must be the gold standard to improve case detection both by active case finding and contact tracing.]

EFFECT OF A STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING PULMONARY REHABILITATION AMONG PATIENTS WITH

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

K.Venugopal, Praveen, Antony

The present study was aimed to investigate the “Effect of a structured teaching programme on knowledge regarding pulmonary rehabilitation among patients with Chronic

Obstructive Pulmonary Disease.” The objectives of the study were to assess the knowledge regarding pulmonary rehabilitation among patients with chronic obstructive pulmonary disease, to evaluate the effect of a structured teaching programme on knowledge regarding pulmonary rehabilitation among patients with Chronic Obstructive Pulmonary Disease and to find out the association between knowledge regarding pulmonary rehabilitation among patients with Chronic Obstructive Pulmonary Disease and selected demographic variables. This study is based on Betty Neuman’s system model. Sixty patients with Chronic Obstructive Pulmonary Disease aged above 20 years admitted in the medical ward of General Hospital, Alappuzha were selected by using non-probability convenient sampling. The tool used for the study was a structured questionnaire to assess the knowledge of patients with Chronic Obstructive Pulmonary Disease regarding pulmonary rehabilitation were done following this a structured teaching programme was administered. After 14 days, again structured questionnaire regarding pulmonary rehabilitation was distributed and assessed the level of knowledge of patients with Chronic Obstructive Pulmonary Disease. The collected data were analyzed with inferential and descriptive statistics. The findings reveal that there is a significant improvement in the level of knowledge of patients with Chronic Obstructive Pulmonary Disease regarding pulmonary rehabilitation (p < 0.01 level). The variables such as age and duration of illness have significant association with knowledge level of patients with Chronic Obstructive Pulmonary Disease. Structured teaching programme was effective in improving the level of knowledge among patients with Chronic Obstructive Pulmonary Disease regarding pulmonary rehabilitation.

RIFAMPICIN EXPOSURE IS LOWER IN HIV-INFECTED TB PATIENTS RECEIVING INTERMITTENT THAN DAILY ANTI-TB TREATMENT

A K Hemanth Kumar, G Narendran, S Ramesh Kumar, Geetha Ramachandran, L Sekar, K Raja, Soumya Swaminathan

Objectives: We compared the pharmacokinetics of rifampicin (RMP) during daily and intermittent (thrice-weekly) anti-tuberculosis treatment (ATT) in HIV-infected TB patients in south India to evaluate the difference caused by schedule of drug administration.

Methodology: A sub-population of 41 HIV-infected TB patients enrolled in a prospective, randomised controlled clinical trial, formed the study population. The study was undertaken during the intensive phase of ATT and serial blood samples at pre-dosing and at different time points, after directly observed drug administration, were collected. Plasma RMP concentrations were determined by High Performance Liquid Chromatography and certain pharmacokinetic parameters were calculated.

Results: Patients treated with the thrice-weekly regimen had significantly lower plasma Cmax

and AUC0-24 and higher oral clearance of RMP than those treated with the daily regimen. The proportion of patients with sub-therapeutic RMP Cmax (< 8.0µg/ml) was 100% in the thrice weekly and 85% in the daily arm (non-significant).

Discussion & Conclusion: The majority of patients had “sub-therapeutic” RMP peak concentrations, with mean levels being even lower in the intermittent arm. As treatment progresses, this could manifest as delayed smear conversion leading to treatment failure or relapse and possibly acquisition of drug resistance. Hence maintaining optimal drug levels is important to ensure that treatment is adequate. All patients are being systematically followed

up to determine outcome data, in order to ascertain the influence of lower drug levels on treatment outcome.

KNOWLEDGE OF PRIVATE PRACTITIONERS OF BANGALORE CITY REGARDING DIAGNOSIS, TREATMENT OF PULMONARY TB AND

COMPLIANCE WITH CASE NOTIFICATION

Joydev Gupta, N. Nagendra, V.K. Chadha

In a recent study in PPM project in Hyderabad, 80% of presumptive pulmonary TB (PTB) were X-rayed without sputum examination. In another study, 5% of private practitioners (PPs) in Mumbai had knowledge of appropriate treatment regimen. Bangalore city has a large private health care sector and large number of patients from surrounding states and districts also seek health care in the city. Therefore, a study is taken up in Bangalore city to find out the proportions of allopathic qualified PPs having adequate knowledge regarding diagnosis and treatment of a new case of pulmonary TB and complying with case notification.

A series of CMEs for PPs were held by NTI, Bangalore during September to November 2014 on Standards of TB care in India. Prior to technical deliberations, the willing participants were asked to fill up a semi-structured questionnaire.

Definitions of adequate knowledge and practice, and proportions of PPs possessing the same are as under:

Definition Proportion(N = 47)

Diagnosis Persistent cough for ≥2 weeksSputum examination X-ray based diagnosis after no response to a course of broad spectrum antibiotics

6%

Treatment At least 2 months of INH, Rifampicin, Ethambutol, Pyrazinamide and four months of HR/HRE, in accepted doses

66%

Ensuring treatment adherence

Direct Observation of Treatment (DOT) 65%

Monitoring treatment response

Follow up sputum examination 60%

Adverse reactions Awareness of at least four of - Nausea and vomiting / skin rash/ Tingling or numbness in hands & feet/ Joint pains / Impaired vision / impaired hearing / dizziness / Jaundice

79%

TB case notification Notified any TB case in last two years 31%

About 15% prescribed fluroquinolones as first choice of antibiotic for patients presenting with cough for 1 week and 85% prescribed other antibiotics.

The findings will help to formulate appropriate strategies for imparting knowledge regarding diagnosis, treatment and TB case notification among PPs.

COST ANALYSIS OF DIAGNOSTIC ALGORITHMS FOR PULMONARY TUBERCULOSIS USING GENEXPERT IN DIFFERENT COMBINATIONS WITH

SPUTUM MICROSCOPY AND X-RAY

V.K. Chadha

A cost analysis study was undertaken to estimate cost per case of Pulmonary TB (PTB) diagnosed under the Revised National TB Control Programme (RNTCP) in Karnataka using GeneXpert as a standalone test or in various combinations with sputum smear microscopy and chest X-ray. The following diagnostic strategies were considered for this purpose:-Strategy A: Direct GeneXpert for all Presumptive PTB patients (GX)Strategy B: Smear examination, followed by Gene pert in patients smear negative on two

sputum specimen (SM – GX)Strategy C: Smear examination followed by X-ray among smear negative patients and –

GeneXpert in those having any abnormal pulmonary shadow on X-ray (SM – CXR- GX)

Strategy D: Direct screening by X-ray followed by GeneXpert in those having any abnormal pulmonary shadow on X-ray (CXR – GX)

The annual costing was undertaken for Designated Microscopy Centres (DMCs), District and State level Laboratory costs, costs of X-ray, salaries and costs incurred by patients and one attendant for each patient towards transport and loss of wages.

For costing at DMC level, we included capital costs for building and equipments converted into annual costs and their maintenance, consumables, salaries for hiring 20% of LTs besides cost of transporting 20% specimen from PHCs to DMCs.

For district level, cost of one DMC for Quality Assurance (QA), salary of one Lab Attendant and 5 Senior Tuberculosis Laboratory Supervisor (STLS) and annual cost of training LTs were included.

For State level, cost of salary of one microbiologist and two LTs, annual cost of training STLSs and supervisory visits were included.

All costs were as per with RNTCP norms.

X-ray cost was considered at a consolidated rate of Rs.150 per x-ray.

Costs incurred by patients and attendants towards conveyance and wage loss calculated from numbers of visits required to complete the particular algorithm and the follow-up sputum examination.

The total cost was divided by the potential yield of cases to obtain the cost per case diagnosed.

The cost to programme per case diagnosed was estimated to be the lowest with SM – CXR- GX strategy at about Rs.6000 and more than Rs. 9000 by each of the other strategies.

The cost including the expenditure incurred by patients per case was about Rs.12,000 by SM – CXR- GX, Rs. 13000 by direct GeneXpert and between Rs.15000 – Rs. 18000 with other two strategies.

Conclusion:

Considering the initial financial constraints, it would be desirable to implement SM – CXR- GX strategy in the initial phase of the roll out of GeneXpert for diagnosis of PTB. In the long run, shifting to direct GeneXpert would reduce the patient-cost and also help in early detection of resistance to Rifampicin.

CONCOMITANT PULMONARY TUBERCULOSIS AND LEPROMATOUS LEPROSY WITH TYPE 2 LEPRA REACTION IN A SINGLE INDIVIDUAL: A CASE

REPORT

Srikant Agarwal, Gopal Purohit, K.C Agarwal, Sunil Vyas

Introduction-Both tuberculosis and leprosy are chronic granulomatous disease caused by Mycobacterium tuberculosis and Mycobacterium leprae, respectively. The infrequent occurrence of these two diseases in a single individual is explained by their transmission dynamics that is the higher reproductive rate of tubercular bacilli than the lepra bacilli and the degree of cross immunity they offer in an individual.

Background-The concomitant occurrence of both tuberculosis and leprosy in a single individual are not an uncommon clinical condition but is reported infrequently in literature.

CASE- A 36 year old male who was a known case of lepromatous leprosy(proven by skin biopsy) on multibacillary leprosy drugs since 18 months presented with complaints of cough with expectoration and Fever since 20 days. General examination shows erythematous nodules over legs and forearm. Chest X-ray s/o- Bilateral lower zone infiltrates, CECT s/o-multiple centrilobular & peribronchial nodules which coalesce to form fluffy consolidation s/o infective pathology with endobronchial spread, Sputum AFB was negative, BAL fluid smear was positive on ZN staining and LPA of BAL fluid detected MTB (sensitive for R & H).Patient was started on cat 1 DOTS.

Conclusions: Rifampicin is a bactericidal drug and constitutes important drug in the treatment regimen of both leprosy and tuberculosis. So the latter must be screened out in each patient of leprosy to avoid acquired drug resistance to rifampicin due to single drug therapy.

ONE YEAR TREATMENT RESPONSE OF CATEGORY IV REGIMEN IN WESTERN RAJASTHAN UNDER RNTCP

Sunil Kasotia, K C Agarwal, Gopal Purohit, Isha Garg

AIMS AND OBJECTIVES- MDR-TB is an emerging global threat to clinicians for both diagnosis and management. Study was done to know the bacteriological and radiological response, adverse drug reactions ,death and default rate during one year of treatment.

METHODS- Prospective case series study on 200 patients enrolled under RNTCP category IV regimen. Bacteriological follow up done for one year as per RNTCP schedule. Chest radiographs done at baseline, 6 months and at 12 months.

RESULTS – 146(73%) patients showed culture conversion at different time intervals within a mean duration of 3.47 months. Amongst these 146 patients , 26 reverted, 7 died and 7 defaulted subsequently. 106 (53%) patients showed favourable bacteriological response while poor treatment response(15) and reversion(26) was noted among 41 patients.

147 chest radiographs were available for comparison out of which 106 (72%) showed positive radiological response and also showed favourable bacteriological response and this was statistically significant(p<0.001).

494 adverse events observed among 161 (80.5%) patients leading to withdrawal of offending agent in 72 (36%) patients ,commonly nausea and vomiting (59.5%), arthralgia (28%), sleep disturbance(24%), headache(20%), vestibular toxicity(15.5%), hearing loss(12%),skin rash(9.5%) etc.

CONCLUSION- Priority should be given to prevent the development and amplification of drug resistance by strengthening the existing DOTS programme. Timely diagnosis and aggressive management of adverse reactions along with education and proper counselling of patients including family members should be done at each and every level of health care system.

TO STUDY THE PREVALENCE, RISK FACTORS AND CLINICAL PROFILE OF ASTHMA-COPD OVERLAP SYNDROME (ACOS)

Ravinder Malik, Stani Ajay, Arti Shah, Parth Shah

Background: ACOS is recognized by the coexistence of increased variability of airflow in a patient with incompletely reversible airway obstruction. Patients typically have inflammatory features that resemble COPD, with increased airway neutrophilia, as well as features of airway wall re-modelling. The risk factors for these events are mixed, such that increasing age, bronchial hyper-responsiveness, tobacco smoke exposure, asthma and lower respiratory infections/ exacerbations. Objectives: To study the prevalence, risk factors and clinical profile of ACOS.

Methods: This is a prospective, descriptive and analytic study. Total consecutive 50 patients with Obstructive Airway Disease (OAD) taken for study from Department of Respiratory Medicine, Smt. B. K. Shah Medical Institute & Research Centre, Piparia, Vadodara, Gujarat. Detail clinical history and physical examinations done followed by Chest X-ray, ECG, Spirometry and Complete blood count. Diagnosis of ACOS considered according to GINA guideline 2014.

Results: ACOS has high prevalence in populations with Obstructive Airways Diseases.

Conclusion: Asthma and COPD are common in the general population, and they coexist in a substantial proportion of subjects. The ACOS represents an important clinical phenotype that deserves more medical attention and further research.

RAPID SPS IDENTIFICATION OF NON TUBERCULOUS MYCOBACTERIA BY MOLECULAR GENETIC ASSAY FROM CULTURE

Chitra.C.Iravatham , C.E.Prasad, M.Vijaykumar , D.Mallikarjuna , P.N.S.Reddy

Setting: Clinical Lab and Chest clinics in Private sector.

Introduction: Differential diagnosis of non healing abscess to be M.tuberculosis (Mtb) or Non tuberculous mycobacteria (NTM) has always been a catch 22 situation for the clinicians. Suspected NTM isolates had to be sent to referral lab for species identification either by HPLC or Conventional biochemical method which are both time consuming and laborious. Advent of molecular diagnostic modalities has contributed a great deal towards early diagnosis.

Objective:- To evaluate DNA strip technology for sps identification of NTM from culture slope.

Material and Methods: Patients presenting with non healing abscess, not responding to ATT were referred for investigation of NTM ( n-13). Samples included Non healing sub cutaneous abscess ( sequlae to laparoscopic procedure) (n-9) ; Sputum ( n- 1 ); BAL ( n-1); Breast abscess (n-1) ; lymph node tissue ( n-1) ;All patients were HIV negative. Male female ratio 5:8; Mean age male 48.5 ;female- 38.7.

Samples screened for AFB by Z.N. and fluorescent stain, Line probe assay( LIPA) direct from clinical sample to rule out Mtb complex and check HR resistance; AFB culture by conventional L J and MGIT system. Antibiogram by MIC method for ATT (SHER) and microdilution method for aminoglycosides,quinolones ,linezolid , clarithromycin and cotrimaxazole.

Species identification from culture positive slope by DNA strip assay using Genotype mycobacterium CM kit ( Hains ) and also by conventional biochemical method.

Results: All samples positive for AFB. AFB culture positive within two weeks. Sps identified by DNA strip molecular assay were-M.fortuitum/M.mageritense (n-9) ; (post laparoscopic procedure) ; M.abscessus/M.immunogenum (n-2) ( breast abscess and sputum); M.chelonae/M.immunogenum (n-1 ) BAL ; M.scrofulaceum (n-1 ) tissue cx lymph node. Turnaround time < 8 hours.

Antibiogram profile: Resistant to first line ATT ; M.fortuitum sps and M.scrofulaceum were sensitive to amino glycosides, Quinolones,linolizid and Cotrimaxazole. M chelonae sps showed resistant to quinolone. Conventional identification method confirmed the rapid growers. and HPLC confirmed M.scrofulaceum.

Conclusion; Early diagnosis and intervention will have a positive impact on treatment outcome Limitation : Assay can be performed from culture positive slopes and not directly from clinical samples.

RETROSPECTIVE STUDY OF PATTERN OF AGE AND SEX DISTRIBUTION IN NEW SMEAR POSITIVE CASES IN TUBERCULOSIS UNIT, GGH , VIJAYAWADA

N.Kumar Varma

IntroductionTuberculosis caused by Mycobacterium tuberculosis, primarily affects lungs and cause pulmonary tuberculosis. The problem of tuberculosis is enormous and causes a major health problem in India.

Aims and objectives:To study the incidence of smear positivity in different age groups.To study gender preponderance in smear positive individuals.

Methodology:

All Patients of newly diagnosed smear positive patients were taken from year Jan’2012- dec’2013 in Tuberculosis Unit ,GGH, Vijayawada .They were statistically analysed and patterns are described.

Results: Most of them are males between age group 20 to 40 years.

Discussion:

Most of the cases in our study group are males. And they are in age group of 20 to 40 years.

TUBERCULOSIS AND DIABETES

Tanay Joshi, Ravi Dosi, Satish Motiwale, Kapil Jangid

Introduction: TB is a major public health problem mainly in low and middle socioeconomic countries, where the number of people with diabetes is also rising rapidly. The growing prevalence of diabetes poses a challenge for TB control as uncontrolled diabetes leads to a greater risk of developing TB.

Aims and Objectives:

A prospective study for evaluation of presentation, disease progression and treatment response of tuberculosis with type 2 diabetes mellitus subjects.

Material and methods:

The study was done on 58 subjects in Dept. of TB and Chest diseases SAIMS over the past one year.

We enrolled 58 patients for our study of which 30 were fresh cases of tuberculosis along with newly diagnosed diabetes. The remaining 28 cases were known diabetics and out of them, 10 were newly diagnosed tubercular cases while 18 had past history of tuberculosis.

HbA1c and Sputum AFB c/s for first line anti-tubercular drugs was done for all the patients. AFB c/s was done in LJ media.

Observation:

Group one of 30 subjects having fresh tubercular and newly diagnosed diabetics were mainly in the age group of 40-50 years. 60% patients had history of alcohol addiction and 84% of them had tobacco addiction. Contact history was present in 10 cases. No patient was found to have drug resistance against any first line anti tubercular drugs. HbA1c was below 7 in all the 30 subjects.

Whereas, group second of 28 patients belonged mainly to the older age group of 50-60 years. HbA1c was above 7 for all these patients. Out of these patients, the newly found tubercular 10 subjects presented with bilateral extensive disease. They did not had any strong contact history , 40% of them were alcoholic and 35% presented with history of chronic tobacco addiction. Culture reports of these patients showed no drug resistance against any of the first line anti-tubercular drugs.

The remaining 18 cases who were old tubercular and diabetics also had bilateral extensive disease. These patients had poor drug compliance for the anti-tubercular drugs. 50% of these patients were oxygen dependant. From the culture reports single drug resistance was found in 4 cases against isoniazid. This group of patients had poor prognosis; 14 patients had to be admitted in ICU and 8 of them died.

CONCLUSION:

~ Patients with HbA1c > 7 presented with bilateral extensive disease irrespective of past history of tuberculosis.

~ Poor drug compliance was found in patients having alcohol and tobacco addiction and those who were on long term treatment for diabetes.

~ Drug resistance to anti tubercular drugs was found in patients having uncontrolled diabetes mellitus with old history of tuberculosis.

CLONING AND EXPRESSION OF ANTIGENIC PROTEINS OF PATHOGENIC ORGANISMS: SPECIAL FOCUS ON MYCOBACTERIAL FAMILY

Utpal Roy , Gautam Krishnan, Sam C Joy, B Natesh, Siddharth T,Rohit Shivkumar

The development of new vaccines and diagnostics against Mycobacterium tuberculosis is a top priority in view of the variable efficacy of BCG vaccine and the immune-compromised status of many subjects and the latent infection. We focus on two main

proteins Superoxide dismutase A(SODA) and alpha crystalline(ACR) of M.tb explore their importance as potential vaccine and diagnostic candidates. SOD A is an important regulator of the Reactive oxygen response in case of M.tb helping it avoid being killed within the macrophage whereas ACR is involved in the heat shock response helping it to survive the latent phase.

The genes were PCR amplified from genomic DNA of H37Rv and cloned into pet21A with sticky end approach . High efficiency competent cells were prepared to facilitate cloning .The clone of SODA was tested for production of soluble active protein.Optimisation of expression conditions like temperature, time of induction ,optical density of induction with IPTG(Iso-propyl-thio-galactopyranoside) was carried out to achieve this. Further constructs will be carried out with tags to facilitate purification. The clone of SODA was sequenced and found to be in correct orientation in pET21A..An algorithm has been created using Neural Network tool in MATLAB to predict possibility of obtaining a clone and serves as a useful guide to direct cloning efforts .

THE PUBLIC PRIVATE MIX MODEL FOR TUBERCULOSIS CONTROL IN A RURAL AREA OF WARDHA DISTRICT

Abhay M Gaidhane, Quazi Syed Zahiruddin, Shilpa Gaidhane, Yatin Dholakia

Background: India has a large private health sector which is preferred by almost two third of tuberculosis patients. Involvement of private providers in RNTCP may enhance the case detection and prevent delay in diagnosis. PPM models from major cities in India have documented increase in case detection rate and are cost effective for that particular area.

Objectives: To see the effectiveness of innovative PPM model for RNTCP implemented in rural area of Wardha district with regards to identification and referrals of chest symptomatic for diagnosis, contribution of PPs in case detection and treatment completion . Methodology: The project was implemented in 2 block of Wardha District of Maharashtra, India. Phase one of the project was focused on mapping of RNTCP services, private providers, sensitization of private providers through one to one meeting and establishing the referral system. All enrolled PPs were trained in RNTCP for one day and were provided guidelines, protocol and referral forms. Phase 2 focused on actual implementation of services. RA visit all PPs once in a fortnight in their specified geographic area to collect the data regarding the number of suspects referred by them and to give the feedback of the previous referral. Project coordinator convene a monthly meeting of SW/RA, STS and STLS to discuss progress, identify gaps and possible solutions. RA will be give the monthly report to PPM coordinator and PPM coordinator will prepare the monthly technical report. In addition to this the various awareness activities including the world TB day was organized in the community. Analysis of Phase 3 of the project was focused on evaluation with focus on the scalability and sustainability of the project in the other part of rural area, which is currently underway. Mixed Methods were used for evaluation phase. Therefore the findings of the phase one and phase 2 are presented here.

Findings: 144 PPs participated in the project and 98% of the PPS were visited by RAs as per the schedule in the third year. Overall 1199 Tuberculosis suspects were referred to DMC by

PPs and of these, 876 (73%) reached the DMC. The number of TB suspects referred by PPs was increased from first year to third year and the main reason periodic visit by RA and prompt feedback about their referral. Out of total patients referred by PP 3.4% were diagnosed as tuberculosis and overall PPS contributed PP contributes to 14.8% of the total cases registered under RNTCP in the project year over three years. It was also observed that most of the PPS were not willing to become the DOTS providers.

Conclusion: The three years of the project implementation shows that PPs may play the active role in early case detection. However, they required the repeated motivation and prompt feedback about their referral. This will prevent the delay in delay in the diagnosis and initiation of treatment and will increase the confident of PPs and community in RNTCP.

IMPACT OF INTEGRATED ACSM STRATEGIES ON TB KNOWLEDGE ANDAWARENESS LEVELS IN TRIBAL DOMINANT DISTRICTS OF JHARKHAND

Prashant Kulkarni, K.T. Arasu, Zoe Abrahamson , Wendy Darby, AbhayKudale

Objectives

To assess the impact of NGO initiated integrated ACSM intervention strategies on TB knowledge and awareness levels.

Methodology

A baseline study was conducted in 2012 in selected blocks of East and West Singhbhum districts of Jharkhand to understand TB knowledge, awareness levels and identify locally suitable ACSM intervention strategies. Based on the findings of the baseline integrated ACSM strategies were implemented which consisted of sensitization of grass root workers and community network, Dakua (tribal communicator), tribal folk media, community radio, mobile phone text message service. After 2 years of intervention an impact assessment study was conducted. The sample size considered for analysis was 811. The scores for knowledge and awareness indicators were calculated for baseline and midterm assessment and compared using paired t-test.

Results

The average knowledge score increased from 3.39± 2.25 to 4.55 ±2.15 (p<0.0001) and meanawareness score increased from 1.73± 0.84 to 2.14 ±0.83 (p<0.0001) whereas the knowledge awareness overlap score increased from 1.43 ±0.8 to 1.92± 0.69(p<0.0001). The result showed statistically significant change across knowledge indicators such as symptoms, mode of transmission; awareness indicators - free diagnostic facility of TB at government health facilities, heard about DOTS and overlapping indicators- curable nature of TB and diagnostic tests for TB. Friends, villagers, health and NGO workers were the predominantly reported sources of information for TB. The findings are inconsonance with the programme case notification rate.

Conclusion

The locally congruent intervention strategies integrated using locally available resources showed positive impact.

PUBLIC-PRIVATE PARTNERSHIPS FOR TUBERCULOSIS CONTROL IN INDIA: WHAT LESSONS CAN BE DRAWN FOR STRENGTHENING HEALTH SYSTEMS

TOWARDS UNIVERSAL HEALTH COVERAGE?

Solomon Salve, Kabir Sheikh, John Porter

Introduction: Public-Private Partnerships (PPP) are increasingly utilized as a public health strategy to strengthening health systems in achieving Universal Health Coverage (UHC). The TB control strategy in India encourages public sector to actively partner with private practitioners (PPs) to improve the quality of front line service delivery. However, ensuring effective and sustainable involvement of private practitioners (PPs) still constitutes a major challenge. This paper provides crucial lessons for UHC by focusing on constrains and challenges PPs face in implementing PPP-TB.

Methods: The study was carried out between Nov. 2010 and Dec. 2011 in a district of a southern Indian State and utilised qualitative methodologies, combining observations, informal interactions and in-depth interviews with 21 PPs of different medical systems. Result: PPs perceived themselves to be crucial healthcare providers, with different roles within the PPP TB policy. Despite, PPs felt neglected and undervalued in the actual implementation of PPP-TB policy. The entire process of involving a PP in the TB programme was considered to be government driven. Their professional skills and the potential of diverse medical systems they followed remained unrecognised at the policy level, weakening their bond with the policy and programme. As a result, although PPs felt responsible towards TB patients, they found it difficult to perceive themselves as a ‘partner to the TB programme’.

Conclusion: Any strategy employed towards achieving UHC in India, however evidenced based, may fail if concerns of PPs are neglected. The abilities of PPs, and potential of different medical systems need to be recognised and supported with appropriate strategies for ensuring their long-term involvement in the programme.

ANTIMYCOBACTERIAL SUSCEPTIBILITY TESTING OF ISONIAZID WITH NARBORNENE AS NANO CARRIER

Kalai Selvi

Introduction

Recent development in the synthesis of newer TB drugs to reduce side effects and promote the action on lesion site is increasing to develop new anti TB drugs with less toxicity, very effective, long time circulation in blood. The use of nano particles in drug delivery has received a lot of attention in the field of newer antimycobacterial drug development. Additionally, the importance of targeted drug delivery in medicine, polymeric nanoparticles is e cient, tissue specific, and nontoxic in nature.ffi

Norbornene is a bridged cyclic hydrocarbon. Narbornene- it acts as an carrier, nano sized and it carries the anti TB drugs, it has an hydrazone linker which will release the drug

under acidic pH. Narbornene attached with polyethylene glycol, provides biocompatibility and prolonged circulation of the drug in blood.

Aim & Objective of the study: Standardization of Narbornene based nano TB drugs on H37Rv Mycobacterium tuberculosis strain by antimycobacterial susceptibility testing by Absolute Concentration Method.

Material & Methods: The drug was procured from Indian Insitute of Science Education and Research (IISER) Kolkata where the drug was synthesized .the antimycobacterial susceptibility testing was done in Department of Microbiology, SRM Medical College Kattankulathur. Drug susceptibility testing was performed by absolute concentration method (NIRT, Manual), where the drug was made into 0.025, 0.05, 0.1, 0.2, 1.0, 5.0 concentrations and incorporated in the solid medium Lowenstein Jensen medium, after sterility checking Mycobacterium tuberculosis was inoculated and then incubated at 37o C for 28 days to identify the minimum inhibitory concentration.

Results and discussion: The minimum inhibitory concentration of the nano drug was higher in the range of 2µg/ml when compared to the conventional drug Isoniazid. Further standardization has to be done by extending the concentration to identify the better minimum inhibitory concentration of the Nano drug.

PATIENT’S PERCEPTIONS ABOUT THE IMPLEMENTATION OF REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME

S.K. Verma

Introduction: Revised National Tuberculosis Control Programme (RNTCP) was launched by the Government of India in 1993. A variety of factors such as, adherence, compliance and patient satisfaction are important but usually under studied indicators of effective programme implementation. The present study has attempted to analyze the perceptions of patients regarding the implementation of RNTCP.

Material and Methods: All patients attending the OPD and IPD of Department of Pulmonary Medicine and under treatment with DOTS both from the Department of Pulmonary Medicine and elsewhere, between March 2014 and July 2014, from the state of Uttar Pradesh were included in the study. The study design was cross-sectional in nature using a predesigned and tested questionnaire.

Results: Out of 200 patients studied, 74.5% patients were not aware about the disease they were suffering from. 80% patients said that they were not talked in detail about their disease. 64.79% patients said that their doctor was the source of knowledge regarding DOTS prior to treatment. Despite an average distance of 4.75 km between their home and DOTS centre, 90.5% patients said that they did not have any problem in travelling to the DOTS centre for medications. 91.5% patients felt the DOT provider to be supportive and 93.5% patients said that the behaviour of DOT provider was satisfactory.

Conclusion: 64% patients said that they were completely satisfied with the treatment under DOTS, 28.5% were partially satisfied and 7.5% were not satisfied with the treatment.

EFFECT OF NON COMPLIANCE TO DIRECTLY OBSERVED TREATMENT SHORT COURSE ON TB TREATMENT AMONG HIV-TB CO-INFECTED

ADULTS IN BANGALORE MUNICIPALITY AREA

Arun Mohan MV, Ranganath TS, Amitkumar Rao

Background: TB and HIV are known to act in deadly synergy and TB is an important cause of mortality in people living with HIV. Non-compliance to Directly observed treatmentshort course (DOTS) in any TB patient leads to treatment failure for the individual and increased prevalence of drug resistance. Compliance to either of the therapies i.e., ART or DOTS individually itself is a challenge, for a HIV-TB co-infected this task becomes herculean. Hence, this study was designed to determine non-compliance to DOTS and its effect on outcome among HIV-TB co-infected patients; and also to determine factors influencing non-compliance to DOTS among these patients.

Methodology: A longitudinal observational study was done among all HIV-TB co-infected patients (160 patients) who registered during the study period(November 2010 -October 2012),at 5 randomly selected Tuberculosis Units of Revised national tuberculosis control programme in Bangalore Municipality area, following their informed consent. Data was collected by personal interview using a pre-tested, semi-structured questionnaire, once in intensive phase(IP) and subsequently at 2 month intervals until treatment completion.

Results: The number of missed DOTS doses had a significant (p>0.05) association with DOTS outcome. The probability of an unsuccessful outcome increased with an increase in the number of doses missed and this was significant at more than 5 missed doses of IP and of Continuation Phase individually or more than 7 doses totally during the course. Most common reason for missing doses was travel outstation (23%) followed by adverse effects due to simultaneous consumption of ART.

Conclusion: Since, an HIV-TB co-infected individual has limited doses that can be safely missed, a stronger mechanism to identify & prevent non-compliance, such as that followed in ART by NACO, is warranted.

BACTERIA CONTAMINATING SPUTUM IN COPD PATIENT

Sangeeta Mahale, Kirti Jain, Bharti Jain, Padmakar Tripathi, Nagmi Aliya

Aims: To study the bacterial infection of various respiratory problems in population of attending the Department Of Tuberculosis & Respiratory Diseases, Kasturba Hospital BHEL Bhopal,MP .

Material & Methods: The patients are advised to do sputum AFB we have taken their sputum for culture. Sputum culture is done on nutrient plate. Identification of microorganism is done according to Ziehl - Neelsen stain, Gram stain, Cultural character and Biochemical test.

Result: Study shows that out of 50 patients there are 36 male and 14 female. Following data are collected from Sputum AFB & Culture patient. 1 Smear AFB Positive 6

2 Follow up TB patient 173 Follow up smear AFB Positive 14 Growth on Nutrient Agar 265 Follow up TB patient growth on Nutrient Agar 56 Identify Gram’s Positive organism on Nutrient Agar 157 Identify Gram’s Negative organism Nutrient Agar 98 Contaminated growth 29 Cocci 2010 Bacilli 1011 Catales Positive 812 Gram’s Positive Cocci 913 Gram’s Negative Cocci 614 Gram’s Negative Bacilli 315 Gram’s Positive Bacilli 6

Conclusion: The study shows that more male patient came to the lab. 60% of the sputum samples have bacterial contamination. 12% of Follow up TB patient‘s sample have bacterial contamination. The infection of cocci is more than of bacilli. Gram Positive bacteria spread more infection as compare to Gram Negative.

CHEST WALL MASS DUE TO TUBERCULOSIS: CASE REPORT OF 3 CASESBharath Kathi

BACK GROUND: Chest wall mass is a rare manifestation of tuberculosis now a days. We report three cases admitted in our ward with tuberculosis with persistent chest wall mass.

PATIENTS & METHODS : Case1 : A 35 year old male patient presented with low grade fever , cough with expectoration , right sided chest wall mass and progressive worsening of dyspnea . Cough impulse was appreciated on the swelling. Lung exam revealed decreased breath sounds on the right side with succusion splash. Chest X ray showed right hydropneumothorax & CT chest demonstrated tracking of fluid & air into subcutaneous plane suggestive of hydro pnuemo (empyema) neccisitans. Sputum was positive for AFB. ICD tube was inserted & ATT was started.

Case 2: A 30 year old male patient presented with cough, nocturnal fevers, night sweats, and a cutaneous left chest wall mass. Bilateral air entry was felt with crepitations on left side. Chest x ray showed left sided cavities with air fluid levels and CT chest showed pleural thickening with hypodense collection with air left side anterior chest wall. Patient ‘s sputum and collection from the mass was AFB positive. A possibility of caverno pleuro cutaneous tract in healing stage was considered & patient was started on ATT.

Case 3. A 55 year old male patient present with chest pain, fever ,cough& SOB. Examination reveals a 5cmx3cm swelling over sternum. Chest xray revealed left sided pleural effusion and FNAC of swelling was suggestive of cold abscess. CT chest revealed dense collection anterior to sternum& left side costochondral junction suggestive of tuberculous osteomyelitis.

CONCLUSION: Tuberculosis must be on the differential diagnosis for the presentation of a persistent painless chest wall mass with out signs of inflammation especially in patients from

endemic regions. The present case report describes three such cases where tuberculosis was the cause for chest wall mass and three cases responded well with anti tubercular therapy.

ROLE OF THE CHEST X-RAY IN THE DIAGNOSIS OF INTRA-THORACIC CHILDHOOD TUBERCULOSIS

Syed Hissar, Ruvandhi Nathavitharana, Banu Rekha, V Chandrasekaran, NS Gomathi, D Baskaran, Soumya Swaminathan

BACKGROUND AND AIMS: Children with TB frequently misdiagnosed and both commonly under and over-diagnosed. In absence of bacteriologic confirmation, chest radiograph plays important role in diagnosis of tuberculosis(TB). We evaluated the role of chest X-ray in the initial diagnostic work up. PATIENTS AND METHODS:Children<15 years with clinical signs and symptoms suggestive of TB not responding to antibiotics were enrolled. Children underwent chest-Xray,sputum or gastric lavage forsmear and culture. The X-rays were reviewed by two independent radiologists in blinded manner. Further a panel, consisting of paediatric pulmonologist, pulmonologist and physician, reviewed any abnormal X-rays and classified as–Abnormal-suggestive of TB, Abnormal and normal.

RESULTS: 630 children were enrolled and given an initial treatment decision. 7/630(1.1%) patients had positive smears, and25/630(4%)cultures returned positiveand of these, 4, 8 and 13 had X-rays abnormal- suggestive of TB, abnormal and normal respectively. Of 630 X-rays assessed, 97(15%) were read as abnormal and 396(63%) as normalby both readers. There was discordance in 137(22%) X-rays and kappa was Κ=0.44 indicating moderate level(0.41-0.6) of inter-reader agreement.123patients with abnormal x-rays determined by panel.49(40%)were started on anti-tuberculosis therapy(ATT), of these 12(25%) were based on bacteriologic confirmation and 37(75%) were based on radiologic and clinical evaluation.

CONCLUSION: The role of chest X-ray childhood TB diagnosis is unclear given the range of abnormalities and lack of specificity. Further research is warranted in determining the expansion of imaging modalities and to devise a comprehensive diagnostic strategy along with other tests for diagnosis.

TREATMENT INTERRUPTIONS DURING INTENSIVE PHASE AMONG NEW SMEAR POSITIVE TB PATIENTS TAKING TREATMENT UNDER DOTS IN

BENGALURU CITY DURING 2010-11 AND ITS ASSOCIATION WITH OUTCOME: A RETROSPECTIVE RECORD BASED ANALYSIS

S.K.Tripathy

Objective: To analyse the frequency of treatment interruption and its association with outcome in new smear positive TB patients taking treatment under various DOT providers in Bengaluru city from 4th QR 2010 to 3rd QR 2011.

Method: Retrospective record based cohort study of routinely recorded data collected from treatment card of new smear positive TB patients registered in 9 T.U. of Bengaluru city from 1st Oct 2010 to 30th Sept 2011 with validation of data by cross checking with TB register and DOT provider register maintained at DMC.

Result: Total of 1,864 new smear positive TB patient’s treatment cards were evaluated during the period and among them 329(18%) patients had treatment interruption for one or more days during intensive phase. Of the 329 new smear positive TB patients 90(27%) were taking treatment under the supervision of community DOT provider and rest 239(73%) under the supervision of Institutional DOT provider. The frequency of treatment interruption was found to be significantly lower (P<0.05) in patients taking treatment under the supervision of community DOT provider than taking under Institutional DOT provider. Favourable treatment outcome was found in 273(83%) of the patients who had treatment interruptions in intensive phase.

Conclusion: Retrieval activity by community DOT provider to bring back the new smear positive TB patients who interrupts treatment during intensive phase is better than Institutional DOT provider and hence community DOT should be encouraged.

HIV AND DIABETES AMONG DRUG RESISTANT TB (DRTB) PATIENTS IN NAGPUR, INDIA

Rajesh Deshmukh,B O Tayade,Dhande D J,K B Tumane

Background: India is second highest HIV/TB burden country in world and has high prevalence of Diabetes. People living with HIV and Diabetes(DM) have higher risk of progressing to active TB. There is paucity of data from India on the HIV and Diabetes co-morbidities among the Drug resistant TB (DRTB) patients hence we carried out a study to know the proportion of HIV and Diabetes comorbidities among DRTB patients in Nagpur.Methods: Patients who were receiving treatment at the DRTB centre were screened for HIV and DM as a routine pre-treatment evaluation for initiating DRTB treatment between Jan 2013- Jan14.Total 110 DRTB patients were screened for HIV and DM and admitted for treatment at DRTB centre. Demographic, laboratory and clinical information was extracted from medical records and distributions of co-morbidities were analysed.

Results: Among the total 110 DRTB patients 80(73%) were male and 30(27%) were females. Majority 85(77%)were from rural and tribal areas and 25(23%) were from urban area. Among the total patients 56(51%) were in 15-34 years age group .Among the 110 patients 10(9%) were found to be HIV infected and 7(6%) were diagnosed as having Diabetes.9(8%) patients died while on treatment.

Conclusions and recommendations: Co-morbidities like HIV and DMamong DRTB patients create challenges for successful adherence to drug resistant TB treatment and lead to poor outcomes of treatment .Early diagnosis of HIV and DM among DR TB patients and early linkages with the existing Anti-retroviral therapy and Diabetic care under the National program is critical for treatment success and reducing mortality among DRTB patients.

OUTCOME OF DOTS

P. V. Potdar , M. M. Nayak , H. S. Thakker

INTRODUCTION

Record keeping and re-assessment is the 5th pillar of Directly Observed Treatment Short course (DOTS). Direct observation is considered as the most important component of DOTS Programme. Overall efficacy of the programme can be assessed only by proper record keeping. DOTS implemented by a devoted gives excellent short and long term outcome across all socio-economic strata. We present results of an attempt to trace these patients to know the quality of record keeping and possibly outcome of patients treated with DOTS over 3 years.

OBJECTIVES

To assess the treatment outcome of dots and record keeping of the TB health visitor in a semi urban area of Navi Mumbai.

METHODOLOGY

The outcome was assessed via contact numbers which were provided to the TB health visitor and those who did not give contact numbers were traced by TB health visitor by home visits.

A study of 342 patients were carried out who had suffered from pulmonary as well as extra-pulmonary tuberculosis over a span of 3 years from 2010 to 2012.

FINDINGS

77.33% of the patients were not traceable.

2 in 2010 and 1 in 2012 pulmonary tuberculosis patients denied any history of treatment taken shown to have registered under DOTS (who could be traced).

2 patients who had history of pulmonary tuberculosis in 2010 have turned MDR – TB and are on Cat. IV regimen (who could be traced).

SENSITIVITY AND SPECIFICITY OF BERLIN QUESTIONNAIRE INSENSITIVITY AND SPECIFICITY OF BERLIN QUESTIONNAIRE IN DETECTION OF OBSTRUCTIVE SLEEP APNEADETECTION OF OBSTRUCTIVE SLEEP APNEA

Kamaljeet Singh , Arti Shah, Stani Francis Ajay, Parth ShahKamaljeet Singh , Arti Shah, Stani Francis Ajay, Parth Shah

IntroductionIntroduction: -: - Sleep apnea is a sleep disorder characterized by intermittent, complete and Sleep apnea is a sleep disorder characterized by intermittent, complete and partial airway collapse, resulting into frequent episodes of apnea and hypopnea. Suchpartial airway collapse, resulting into frequent episodes of apnea and hypopnea. Such breathing pause can cause acute adverse effects, such as oxyhemoglobin desaturation,breathing pause can cause acute adverse effects, such as oxyhemoglobin desaturation, fluctuation in blood pressure and heart rate, increased sympathetic activity, cortical arousalfluctuation in blood pressure and heart rate, increased sympathetic activity, cortical arousal and sleep fragmentation.and sleep fragmentation.

In India, the prevalence of OSA is estimated to be 13.7%. In a resource limited settingIn India, the prevalence of OSA is estimated to be 13.7%. In a resource limited setting like India, there is a paucity of health care facilities further limiting the evaluation of OSAlike India, there is a paucity of health care facilities further limiting the evaluation of OSA patients. Berlin questionnaire serves as a primary evaluation and screening tool for predictionpatients. Berlin questionnaire serves as a primary evaluation and screening tool for prediction of OSA. of OSA. The questionnaire consists 3 categories related to risk of having sleep apnea.The questionnaire consists 3 categories related to risk of having sleep apnea.

Aim of the studyAim of the study: - : - ToTo compare compare the usefulness of Berlin questionnaire for diagnosis of the usefulness of Berlin questionnaire for diagnosis of obstructive sleep apnea.obstructive sleep apnea.

Method:Method: Observational cross sectional study comparing Berlin questionnaire for Observational cross sectional study comparing Berlin questionnaire for obstructiveobstructive sleep apnea. sleep apnea. The patients were recruited after taking informed consent. Out of total no ofThe patients were recruited after taking informed consent. Out of total no of patients attending respiratory medicine opd 115 were satisfying inclusion criteria or this studypatients attending respiratory medicine opd 115 were satisfying inclusion criteria or this study and were subjected to Berlin questionnaire. All the patients subjected to overnightand were subjected to Berlin questionnaire. All the patients subjected to overnight polysomnography which was used as gold standard method for evaluating obstructive sleeppolysomnography which was used as gold standard method for evaluating obstructive sleep apnea. The analysis was carried out for the sensitivity and specificity and the usefulness ofapnea. The analysis was carried out for the sensitivity and specificity and the usefulness of Berlin questionnaire was evaluated. Berlin questionnaire was evaluated.

Study type: Study type: ObservationalObservational cross sectional study.cross sectional study.

SiteSite: S.B.K.S. M.I. & R.C, Piparia, Vadodara, Gujarat. (Tertiary rural care centre) : S.B.K.S. M.I. & R.C, Piparia, Vadodara, Gujarat. (Tertiary rural care centre) Results:Results: A total of 115 individuals included in study, which included 95 males (82.6%) and A total of 115 individuals included in study, which included 95 males (82.6%) and 20 females (17.4%). Higher proportions of males may be due to difference in health seeking20 females (17.4%). Higher proportions of males may be due to difference in health seeking behavior in two sexes.behavior in two sexes.

Among 115 patients included in the study, 31 were found to be Berlin questionnaire negative,Among 115 patients included in the study, 31 were found to be Berlin questionnaire negative, while 84 were positive.while 84 were positive.

In the positive group, the AHI was found to be 10 normal, 12 mild, 29 moderate as well 58In the positive group, the AHI was found to be 10 normal, 12 mild, 29 moderate as well 58 severe.severe.

DiscussionDiscussion: Analysis suggests that Sensitivity of Berlin questionnaire for mild and severe: Analysis suggests that Sensitivity of Berlin questionnaire for mild and severe AHI is very high and overall sensitivity is also high. This suggests that Berlin questionnaireAHI is very high and overall sensitivity is also high. This suggests that Berlin questionnaire can be utilized as a predictive tool for the evaluation of sleep apnea before the actualcan be utilized as a predictive tool for the evaluation of sleep apnea before the actual polysomnography testing. polysomnography testing.

ConclusionConclusion: : The Berlin questionnaire appears to be a valid instrument for ruling outThe Berlin questionnaire appears to be a valid instrument for ruling out obstructive sleep apnea and can be used in countries with limited resources, like India inobstructive sleep apnea and can be used in countries with limited resources, like India in predicting the obstructive sleep apnea.predicting the obstructive sleep apnea.

CAN SELF HELP GROUPS BE THE LINK FOR ACSM EFFORTS? BASELINE

FINDINGS FROM VIRUDHUNAGAR DISTRICT OF TAMIL NADU

Saju Joseph, David Jones, Mercy Annapoorni, Clare Shaw and Sheela Rangan

Introduction: Between 2009 and 2012, Blossom Trust a community-based NGO, implemented the Campaign for Education, Prevention and Treatment of TB (CEPT)in Virudhunagar District, Tamil Nadu. Under this project 2,798 community-based volunteers including 1679 Self Help Group (SHG) members were recruited and trained. Before implementing Phase II of this project, a baseline survey was undertaken in May 2014to assess the knowledge and awareness of SHG members and identify their needs to function as volunteers.

Methods and Findings: The survey was conducted among 100 SHG members randomly selected from block level lists of SHG groups from 11 blocks of Virudhunagar. Respondents were interviewed after taking informed consent.

Almost all respondents (98%) reported they had heard of TB. Cough as a cardinal symptom was reported by 89%. More than two-thirds (68%)knew how TB is transmitted and 81% percent mentioned sputum examination as a diagnostic test for TB. Almost all the respondents (97%) knew that TB treatment is provided free of cost at government health facilities. Eighty-one percent reported they would be supportive towards a fellow SHG member with TB. More than half (52%)reported they needed further training in TB.

Conclusion: These findings suggest that given the high levels of knowledge and awareness among SHG members, empowering them further and involving them in community-based TBACSM efforts can be impactful. Community volunteers linked to ASCM interventions can help identify and meet specific needs of patients, raise TB awareness among the general population and reduce the stigma associated with TB.

PLEURAL EFFUSIONS IN 6 MONTHS PERIOD IN GOVERNMENT GENERAL HOSPITAL, VIJAYAWADA -- A CROSS SECTIONAL STUDY

M.LaxmikanthAim of the study

To study the aetiology of pleural effusion.

Methodology

All Patients of Pleural Effusion are taken from May 2014 to Oct’2014, Department of Pulmonary medicine, GGH, Vijayawada .They were analysed by cross sectional study.

Results

There were 18 patients with pleural effusion, Of them 3 were transudate, 15 were exudative nature. Of the 15, 9 were due to TB (4 were TB and HIV co-infection and 5 were only due to TB),2 were due to Pancreatic disease and 1 was malignant effusion. Rest of the two were due to subpleural rupture of lung abscess.

Discussion Pleural effusion (PE) is a common problem in pulmonary medicine practice. In cases with transudative PE, the diagnosis is usually made without any difficulties but exudative PE requires careful differential diagnosis that includes tuberculosis (TB) and metastatic cancers, which are often found to be the cause in a large number of patients.

Conclusion

Most of the effusions in the study are right sided. Most common cause of pleural effusion in our study is TB. As India is TB endemic country, and with emergence of TB and HIV co-infection, the occurrence of Pleural effusion can be explained by the fact that there could be a subpleural rupture of TB foci.

UTILITY OF NON INVASIVE VENTILATION (NIV) IN TYPE II RESPIRATORY FAILURE

Bharath Kathi

INTRODUCTION : The term non-invasive ventilation (NIV) refers to the application of artificial ventilation without an endotracheal tube. By avoiding endotracheal route NIV prevents complications associated with invasive ventilation and facilitate the discontinuance of ongoing ventilatory dependence and treat chronic respiratory failure in numerous diseases. AIMS & OBJECTIVES :To study the role, outcome of Non invasive positive pressure ventilation in patients with Type II Respiratory Failure and compare the clinical and physiological parameters before and after the application of NIPPV in the study population.

MATERIAL & METHODS: The study was conducted among 40 patients with Type II Respiratory failure. Once eligibility was verified, patients were included in the study. Parameters that were recorded include dyspnoea quantitated by modified Borg dyspnoea score, respiratory rate (RR), heart rate (HR), arterial blood gas analysis(ABG). All patients were administered NIPPV using the BiPAP with oro nasal mask. RESULTS & DISCUSSION : In our study cohort, the most common clinical diagnosis included COPD exacerbation, 90% (36/40) with or without associated co-morbidities.The Borg dyspnoea score improved from 5 at baseline to 1.4 ± 0.07 at discharge .(p <0.0001) .The mean respiratory rate dropped from 34.8 ± 4.4 before NIV to 13.82 ± 1.96 (p <0.0001) at discharge.. The mean pH changed from 7.29± 0.02 at baseline to 7.4 ±0.03 at discharge(p <0.0001), mean PaCO2 and PaO2 which changed from, 67.3 ± 5.61, 54.6 ± 8.85 at baseline to 50.02 ± 4.08 ,75.1 ± 9.71 at the time of discharge respectively(p<0.0001 for both parameters). Respiratory rate at baseline was significantly higher in the patients who failed to respond to NIV and there was a significant improvement in the clinical and blood gas parameters within the 1st hr of NIV in the successful group whereas no such improvement was observed in the failure group. In the present study, NIPPV was successful in 34 patients (85%) and 6 patients (15%) failed to respond and required intubation.

BIO-ENHANCERS & ATT

Akshay Parikh

Piperine is a highly purified and standardised extract obtained from Piper nigrum and Piper longum.

Piperine is the first and only scientifically studied bio-enhancer. Piperine is known to increase bio-availability of different drugs, including that of rifampicin. Apart from increasing bio-availability of the co-administered drug, piperine also has hepato-protective, anti-inflammatory,immuno-modulatory and anti-oxidant actions. In addition, a recent study has also demonstrated that piperine increases the bactericidal action of rifampicin. The bio-enhancing action of piperine is through its inhibitory action on Cytochrome P 450 and P-Glycoproteins.

Pharmacokinetic studies have shown that when 200mg of rifampicin is co-administered with 10mg of piperine, it provides serum rifampicin levels which are equal to those obtained with 450mg of rifampicin.

Piperine has no action on bio-availability of INH, Pyrazinamide or Ethambutol.

Approximately 30% of patients develop nausea, vomiting, diarrhea and abdominal discomfort with rifampicin and around 28% of patients develop hepatitis when rifampicin is co-administered with INH and pyrazinamide. These adverse effects associated with use of rifampicin may lead to premature discontinuation of therapy. This non-adherence to treatment leads to increased risk of treatment failure, relapse and development of acquired drug-resistance

Around 25-30% of patients fail to achieve therapeutic serum rifampicin levels with 450 mg dose of rifampicin. This leads to slow sputum conversion or sputum non-conversion, resulting in prolonged duration of treatment. Rifampicin-induced auto-induction and overexpression of P-Glycoproteins is responsible for decreased bio-availablity and sub-therapeutic serum rifampicin levels.

To overcome these short comings of conventional rifampicin, a novel formulation of rifampicin ( Risorine) was jointly developed by Indian Institute of Integrative Medicine, Jammu, India and Cadila Pharmaceuticals Ltd, Ahmedabad, India.

This novel formulation contains 10mg of piperine.

“Risorine” has undergone all the necessary pre-clinical and clinical studies required to prove its efficacy and safety. Risorine was approved by the DCGI ( Indian Drug Regulatory Authority) in 2009.

Currently following two formulations of “Risorine” are marketed in India:

1. Risorine capsules:

Each capsule contains 200mg Rifampicin + 10mg Piperine + 300mg INH

2. Risorine Kit:

Each Risorine kit contains:

One capsule of Risorine( 200mg Rifampicin +10mg Piperine+300mg INH) + Two tablets of Pyrazinamide 750mg each + One tablet of Ethambutol 800mg

Risorine Kit is meant for intensive phase of treatment. The patient has to consume one kit daily for first two-three months of treatment.

Risorine capsule is indicated in maintenance phase of treatment. The patient is required to consume one capsule of Risorine daily for 4-5 months.

A comparative clinical trial has shown that there is no difference in the sputum-conversion rate or clinical cure rate in patients treated with either standard regimen of 450mg rifampicin or Risorine regimen.

Phase IV studies have shown that Risorine therapy is associated with improved gastro-intestinal tolerance and reduced risk of hepato-toxicity. This helps in improving patient compliance and reduces the risk of treatment failure and chances of relapse.

Benefits of Risorine therapy:

- Risorine therapy is as effective as conventional 450mg rifampicin regimen- Risorine therapy has better gastro-intestinal tolerance than conventional

450mg rifampicin regimen.- Risorine therapy is associated with reduced risk of hepato-toxicity.- Risorine therapy is particularly beneficial for patients with compromised liver

functions. Risorine is preferred in elderly patients, alcoholics, patients with malnutrition and in patients who have suffered from hepatitis B or C in the past.

INVOLVING EDU CLOWNS IN INFORMATION, EDUCATION AND COMMUNICATION ACTIVITIES TO PROMOTE HIV AND TB CO-INFECTION AWARENESS AMONG PEOPLE LIVING WITH HIV AND AIDS ABOUT CARE

AND SUPPORT DURING TREATMENT

Mercy Annapoorani, Indira Devi

Background Paneer HIV positive women network trust is a group of women working for women PLHIV members at 11 blocks of Virudunagar District in Tamil Nadu. The main objectives are to provide basic information about HIV and co infection, identify and coordinate all the women, improving psych-socio, physical-economic conditions, addressing the problems of discrimination among HIV infected people, creating awareness among women on STI/HIV/AIDS/TB.

Aim To access the knowledge about co-infection, care and support during their treatment

adherence and impact created by Edu- Clowns.

Methodology

We have conducted 33 “Edu Clowns” activities during women PLHA meeting, in that 825 members have been participated during the period of January 2014 –November 2014. We have selected 150 members to know about their learning through Edu Clown activities by randomly. The major topics covered during the activity are nutritional support, treatment period for TB, Do’s and Dont’s, psychological and physical support for co infected patients. We used interview schedule for collecting the details and it was analyzed in IBM SPSS version 20.

Results

92.9% of them have increased knowledge about nutritional support, 98.9% recalled about the treatment period and ways of drug intake, 85.7% of them know about do’s and

don’ts during treatment, 87.5% of them know about the psychological support and 91.5% of physical support has to rendered to the co infected patients. In overall 91.3% of them women have learned about co-infection through Edu- Clown activities.

Innovation method of Programme:

The Edu clowns with their strange but attractive costume successfully lure in a large number of the gathering which is floating in nature. The TB & HIV messages shared by the Edu Clowns have created a substantial impact on the audience which has motivated them to avail testing and treatment facilities at government hospitals and Blossom as well.

Conclusion

Involving Edu-clowns as community theatre campaign for ACSM activities, Co infection, TB creates long term impact on people which motivates them to discuss, share TB and co-infection messages and avail TB treatment facilities with mainstream institutions. Edu-clowns prove to be an effective way to reach out to large audience and floating population.

LEGITIMACY OF NON- TUBERULOUS MYCOBACTERIUM IN A TB ENDEMIC REGION - A HOSPITAL BASED STUDY

AjoyVerma , Lokender Kumar, M M.Puri, Gopi A, Gavishkumar, Jyoti Arora ,V P Myneedu, Rohit Sarin

Introduction:

The isolation of non- tuberculous mycobacteria (NTM) from clinical specimens is becoming common in mycobacteriology laboratories. GloballGy, the NTM’ s are perceived as a contaminant only. Concomitantly NTMs are observed to be another major causative agent of pulmonary and extra-pulmonary diseases in immune-competent patients. It calls for a different line of diagnosis. To complement the paradox on role of NTM its isolation, identification and diagnosis, a study was carried out in in symptomatic patients attending OPD of NITRD N New Delhi.

Material & Methods:

The study was conducted on the patients whose first sputum culture report was positive for NTM in the microbiology laboratory. At the time of enrolment, second sputum sample was collected along with patient’s clinical data and radiological finding. The results of 2 sputum culture along with clinical & radiological features were recorded and co-related. During the study, tracing of the patients was done mainly through 3 different methods (i) Patients were traced during the report collection in microbiology laboratory by clinical microbiologist, (ii) Patients were traced through Laboratory records registration number, address and/or phone number. Cultures were done in MGIT 960 automated bacterial culture system and identification was done through routine biochemical character.

Results :

As per protocol, during the 12 months of study period, 2285 sputum samples were processed for liquid culture using MGIT-960 system(BD)for isolation of NTM. 77 (3.36%) patients showed their 1st sputum was positive for NTM. Culture od 2ndsputum sample of 77 patients showed positive growth in 36/2285(1.5%) specimen and 41/2285 (1.79%) were negative for NTM. The 36 positive patients were analyzed further in this study .The age distribution of 36 patients showed that 61% NTM were isolated from patient’s age group 20-45 years. Male : female ratio was 2:1. The common symptoms were cough (36), fever (28), hemoptysis (24), , weight loss (23) , sputum production (10), and loss of appetite (24). Lung was involved in all 36 patients. Bilateral lung was involved in 20 patients and unilateral lung was involved in 16 patients. In X-ray cavity in lung was seen in 31/36 patients. Results showed that 11 different species of NTM were identified. The species identified were M.kansasii(11), M.chelonae(06),M.terrae complex (05), M.avium complex (05), M.fortuitum(02), M.haemophilum(1), M.gastri(1), M.xenopi(1), M.intracellularae(1), M.abscessus(1), and M.vaccae(1).

Conclusion

It is imperative on the part of microbiologist to carry out identification tests on all culture isolates before DST is done as 50 % of the laboratory isolates were positive for NTM in repeat samples. Any of the standard tests for M. Tb complexes turn out to be negative;microbiologist shall look for NTM’s. For this purpose a checklist to be developed to avoid delay in diagnosis of NTM related diseases.

EARLY DETECTION OF MULTI DRUG RESISTANT TUBERCULOSIS BY

SIMPLE CULTURE METHODS

G.Divya, Karthika Jayakumar, Aarya.V.Sankar, M.Krithika

Background: Drug resistance tuberculosis (TB) remains as an alarming concern worldwide. Early detection of MDR-TB with economical methods in the low income country is the urgent need of the hour.

Design: Descriptive cross sectional hospital based study.Objective: 1) To detect the MDR TB isolates among the pulmonary tuberculosis patients (PTB). 2) To assess the rapidity and ease of the NRA, REMA and TLA for the detection of MDR TB and to evaluate the turnaround time for positivity compared to the gold standard method.

Material and Methods: A total of 75 sputum specimens from patients suspected with PTB were included in the study. They were cultured on both LJ and Middle brook 7H11 agar. Among which 50 growth culture were subjected for drug susceptibility testing with three rapid culture methods.

Results: Out of 75 sputum specimens, 67% were from male patients and 33% were from female patient. Maximum number of patients belongs to age group 41-60 yrs. Among these 50 (66.6%) grew on culture medium. Culture isolates subjected for drug susceptibility testing by NRA, REMA and TLA were found to be 100% susceptible to all four anti-TB drugs.

Conclusion: Rapid, cheap, accurate non conventional methods may serve as an alternative method for DST when more sophisticated equipments are not available in low resource settings.

PROFILE OF PROVIDERS APPROACHED BY TB PATIENTS FROM FIRST ONSET OF TB SYMPTOMS TILL FIRST INITIATION OF ATT, MUMBAI AND

PATNA

Akshaya Patil, Nerges Mistry, Sheela Rangan, Yatin Dholakia, Shimoni Shah, Eunice

Lobo

Background and Methods: The private sector plays a significant role in the care of TB patients both in Mumbai and Patna. In order to understand the profile and behaviour of providers approached by pulmonary TB patients, an active survey was conducted in Mumbai and Patna between May-August 2014. A Semi-structured interview schedule was used to conduct in-depth interviews of these patients.

Results: Eighty-three and 64 self-reported TB patients were interviewed in Mumbai and Patna. 70% patients in Mumbai first approached private practitioners after the onset of TB symptoms, in Patna 69% and 25% approached private practitioners and chemists respectively. In both the cities 60% of the first providers who were approached advised tests. Out of these 50% and 38% advised CXR and sputum examinations in Mumbai,while 81% and 21% advised CXR and sputum examination in Patna.66% and 23% providers in Mumbai and Patna advised sputum examination. In Mumbai55% providers who made the TB diagnosis were from the private sector but 64% of the providers who initiated treatment were from the public sector. About 50% and 4% of diagnosing providers, 60% and 7% of providers who first initiated treatment were allopath’s and non-allopaths respectively. In Patna 90% providers who first diagnosed and initiated treatment were from the private sector and reportedly allopaths.

Conclusion: The role of chemists in Patna and the Public sector and non-allopaths in Mumbai is crucial in achieving early and accurate diagnosis and treatment of TB patients. Use of bacteriological tests for TB detection needs to be scaled up especially in Patna for accurate diagnosis.

SPUTUM BACTERIOLOGICAL PROFILE AND ANTIBIOGRAM IN EXACERBATIONS OF BRONCHIECTASIS

Aslam N K , Manoj D K , Achuthan V , Rajani M , Rajeev R , Shafeek K

Objectives of Study

1) To identify Bacterial Flora in Sputum during exacerbations of Bronchiectasis2) To assess the antibiotic sensitivity pattern of isolated organisms.

Methodology

A Cross-sectional observational study was done at Academy of Medical Sciences, Pariyaram ,Kerala from January 2013 to December 2013. Sputum samples from 52 patients

with exacerbation of bronchiectasis were subjected to bacterial culture and antibiotic sensitivity.

Main Findings

Out of fifty two patients 28(54%) were males and 24(46%) were females. Twenty seven patients (51.9%) were smokers and 25 (48.1%) were non-smokers. The Mean age of the study population was 58.44.This study yielded pathogenic bacterial growth in 76.9 % . Gram negative organisms were predominant (87.5%) Three commonest organisms identified were Pseudomonas aeruginosa in 30.8% cases, Klebsiella in 21.2% cases and Acinetobacter in 9.6 % cases. Commonest gram positive bacteria were Streptococcus Pneumoniae (60%). Modified Ziehl-Neelsen stain for acid fast bacilli was negative in all cases. Pseudomonas aeruginosa was 100% sensitive to Imipenem (p value <0.05) and ciprofloxacin (p value <0.05).Sensitivity of pseudomonas aeruginosa to Piperacillin-tazobactam was 85.7% (p value <0.05). The sensitivity to commonly used antipseudomonal cephalosporin ceftazidime was only 42.8% (p value = 0.0265).Mean hospital stay duration was 8.06 days.60% cases of Acinetobacter group (p value <0.05) died during the hospital stay.

EFFECT OF HATHA YOGASANAS ON THE LUNG FUNCTIONS IN HEALTHY VOLUNTEERS

R.Chellaa, Soumya M.S, Inbaraj, Ravinayar

Objective:

To assess the effect of Yogasanas on upper airway resistances in normal individuals using Rhinomanometer and lower airway resistances using Spirometer. To establish a normative data, so that future studies on the effect of yoga on diseases of the airway can be validated.

Methodology:This is a prospective case series of 25 healthy volunteers between the ages of 18 to 50. The nasal anatomy and upper airway resistance were measured using a rhinomanometer. The lung function parameter FEV1/FVC% was measured using a spirometer. The volunteers practiced yogasanas for 3 months. The tests were done before and after 3 months of yoga practice. The quality of life of the volunteers was assessed using a SF-12 questionnaire before and after 3months of practice.

Results:

The average value for the average nasal airway resistance was found to be 0.12 Pa/cm3/s before doing yoga and it was 0.13 Pa/cm3/s after doing yoga. The average (FEV1/FVC %) before doing yoga was 99% and after doing yoga was 95.64%.

Discussion:

Results show that there is an improvement in the nasal airway resistance before and after the practice. The FEV1/FVC% slightly differs before and after the practice but still it falls under the normal range this might be due to compliance and climatic changes, the SF-12 questionnaire of the candidates shows better quality of life.

PATIENT PATHWAYS TO TB CARE, MUMBAI SLUMS

Akshaya Patil, Nerges Mistry, Sheela Rangan, Yatin Dholakia, Shimoni Shah, Eunice

Lobo

Background: Early and accurate diagnosis is critical to reduce the chain of transmission of Tuberculosis (TB).The main objective of the study was to determine the various delays that occur from the onset of TB symptoms till first TB diagnosis and first initiation of anti-TB therapy among pulmonary TB patients.

Methods: A community based active survey was conducted in 15 high TB burden wards in Mumbai to identify self-reported TB patients. 83 consenting patients were interviewed by an in-depth semi-structured and pre-tested interview schedule. Means were calculated to determine the patient, diagnostic, treatment and total delay.

Results: The mean patient, diagnostic and treatment delay were 24 days (range: 0-191), 7 days (range: 0-240) and 5 days (range: 0-58) respectively. The mean total pathway time was 66 days (range: 0-339). Fifty-four patients had either one or more delays. 22% of the patients had patient delay of more than a month while 42% had diagnostic delays beyond 3 weeks.26% retreatment patients had delayed seeking help by more than one month as compared to 18% of new cases. 32% retreatment patients compared to 53% new cases had diagnostic delays of more than 3 weeks.

Conclusion: The high number of patients with overall delays, more number of patients with patient delays in the retreatment group and longer diagnostic duration among new TB patients indicate a need for intensive efforts to improve both patient knowledge/awareness and provider behaviour.

HOST GENETICS AND TUBERCULOSIS

Aravindan.P.P

Background and Objective:

Tuberculosis (TB), the leading causes of morbidity and mortality by a single infectious agent, Mycobacterium tuberculosis; is still a major health problem in the world. According to the annual report on global control of TB from WHO, about 9.4 million incident cases and 14 million prevalent cases occurred in 2009. Approximately 1.7 million people died of TB, including 0.38 million deaths among the HIV Positive people and most cases were in the South East Asia, Africa and Western Pacific regions. (35%, 30% and 20% respectively).

It is well known that host genetic susceptibility, together with bacterial strains and environmental factors play an important role in determining TB predisposition and drug response. Only about 10% of the infected individuals develop the clinical disease while most infected people carry the bacteria without overt symptoms. To date, many studies have shown evidence of association between host genetic polymorphisms and TB Susceptibility, including CCL2/MCP-1, NRAMP 1 /SLC 11 A1, IRG MI, IL 8, TLR and NOD 2 genes.

Most of these genes participate in immune response and their polymorphism can alter immunity and lead to genetic susceptibility to TB. Based on the conclusions of several studies it is possible to state beyond doubt that tuberculosis is a genetically primed and determined infectious disease caused by Mycobacterium tuberculosis and genetic polymorphism is the basic mechanism to initiate the progression from infection to disease.

Material and Methods:

This is a special article compiled with reference to various case control studies, meta analysis and other research work on different genes and tuberculosis. The genes selected and number of studies from different countries and ethnic groups for this article are shown below This is a special article compiled with reference to various case control studies, meta analysis and other research work on different genes and tuberculosis. The genes selected for the study are :NRAMP 1 (SLC 11 A1), VDR , LMP/TAP , CCL2/MCP -1 , IRGM 1, IL 1, IL 8, IL 10, IL12, TLR , NOD 2 , HLA, MBL, MHC, TNF, P2 X7, EREG, SP110And INTERFERON GAMA.

Results:

Genetic Polymorphisms in different genes showed variable levels of significance in relation to tuberculosis. (P-values 0.001 to 0.05) All these were proved by the researchers using appropriate statistical methods and tools. Data was collected from published research studies and are acknowledged in the reference.

Conclusions:

Based on different research work across the world, there is sufficient evidence to prove that tuberculosis is a genetically primed and determined infectious disease caused by Mycobacterium tuberculosis and the genetic polymorphism is the mechanism which leads to progression from infection to tuberculosis disease. Hence the hypothesis, algorithms and the theory are developed with my name. Hence for provoking thoughts and encouraging more research in the field of genetics and tuberculosis I formulated Aravindan’s hypothesis, Algorithms and Theory. Genetic susceptibility to tuberculosis has been substantiated based on the extensive literature review and research findings well narrated. Also, based on those findings I have formulated “Aravindan’s Theory of genetic polymorphism and tuberculosis”. According to this theory, tuberculosis is an infectious disease caused by M tuberculosis, primed and determined by genetic polymorphism.

A COMPARISON OF CLINICAL, LABORATORY & RADIOLOGICAL IMAGING

IN ASSESSING PREVALENCE OF PULMONARY TUBERCULOSIS AMONG

ADULTS IN RURAL KANCHEEPURAM

Sunilkumar Jada, Karthika Jayakumar, Sundara murthy, Sri Vidhya

Background: Tuberculosis (TB) is one of the most ancient diseases of mankind. Tuberculosis remains a global public health problem. India has a major share of the global incidence of tuberculosis (TB) including MDR-TB and TB related mortality. The prevalence of TB disease is an important epidemiologic index to measure the burden in a community. Objective: To estimate the prevalence of pulmonary tuberculosis among adults in rural Kanchipuram and to compare clinical, laboratory and radiological imaging in assessing prevalence. Study design: Type of study: cross-sectional study. Methodology: We collected samples from individual family clusters randomly, having cough for more than two weeks. All the symptomatic and anti-TB treatment (ATT) subjects are subjected for X-ray chest. Sputum samples are collected early morning in a sterile container for diagnosis, Acid fast staining and culture in Middle brook 7H10 are done. Results: Total study subjects were 1510, 126 were having the symptoms of pulmonary tuberculosis. 34 were Positive for pulmonary tuberculosis. Middlebrook 7H10 agar media, the positive percentage being 31 (2.05%), and 20 were radiological positive. Among the 919 of males screened 25 (1.65%) were positive, compared to females 591 of them 9 (0.59%) were positive. Conclusion: The prevalence of our study reveals that TB is still a major problem. Rapid detection by the culture media we have used will ensure early institution of ATT & early recovery. This will reduce the morbidity & mortality of the patients. As the study shows low prevalence rate it can be further reduced to zero prevalence.

AIR BORNE INFECTION CONTROL - BACTERIAL AND FUNGAL YIELDS OF AIR SAMPLES IN HOSPITAL ENVIRONMENT

M.Anitha, Karthika Jayakumar, T.Valliammai, S.Sushmitha

Background: Hospitals and other healthcare facilities are complex environment that requires ventilation for comfort of the patients and control of hazardous pathogens. Airborne transmission occurs when pathogenic microorganisms are transferred from an infected to a susceptible individual via the air.

Objective: To detect the air borne bacteria in open plate technique.

Design: Descriptive design

Methods: A study on indoor air microbiological contamination in hospital wards were investigated and analysed in the period June-September 2014. Air samples were taken pre and post disinfection with 2% sodium hypochlorite.

Results: The results obtained by air investigation conducted in Shri Sathya Sai Medical College and Research Institute. The predominant bacteria isolated from collected air samples were: Staphylococcus aureus, Streptococcus pyogenes, E.coli , Proteus mirabilis, Proteus vulgaris, Pseudomona aeruginosa, Klebsiella pneumoniae,Acinetobacterbaumannii,Citrobacterkoseri and Tubercle bacilli.

According to IMA classes: pre disinfection, had ‘C’ grade and colony counts 32 CFU.m-3(26-50 CFU.dm-2.h-1) the performance was fair and for post disinfection with 2% Sodium hypochlorite the outcome was ‘A’ grade and colony counts 4 CFU.m-3 (0-5 CFU.dm-2.h-1) the performance was very good.

Our study is the first in vitro analysis with the involvement of open bottle technique for Mycobacterium tuberculosis growth in LJ media.

Conclusion: From our study, it has been showed that the hospital air is dispersed with bacteria especially the most potent MDR Tuberculous bacilli.To make it healthy, safe for the diseased patients, disinfection is a must in the given scenario,2% sodium hypochlorite was the ideal disinfectant and even TB bacilli was also reduced to zero.

SCREENING OF DIABETES MELLITUS PATIENTS FOR ACTIVE PULMONARY TUBERCULOSIS

Krishnappa.M

Background

Despite the control strategy tuberculosis remains the major problem in many countries. Low-to-middle income countries, like India have highest burden of tuberculosis and are experiencing the fastest increase in diabetes prevalence. If these two overlap, the tuberculosis programmes are adversely affected.

Worldwide 70% of diabetics live in TB endemic countries. In 22 countries with highest burden of TB, the prevalence of diabetes mellitus in general population ranges from 2-9%. People with a weak immune system, chronic diseases such as diabetes are at a higher risk of progressing from latent to active TB.

Objective

Screening of diabetes mellitus patients attending our tertiary care hospital for active pulmonary tuberculosis and it’s prevalence in diabetics.

Study Design

Cross sectional study from June 2014 to September 2014, at Shree Sathya Sai Medical College and Research Institute, Ammapettai.

Material and Methods

Two laboratory technicians were trained to identify the diabetes mellitus patients attending our hospital using International Case Definition for diabetes. Suspected pulmonary tuberculosis patients were recognised by symptom based enquiry. Two sputum samples, one early morning and the other spot were collected, obtaining the consent. Of the 1409 cases of diabetes mellitus patients who were identified, 32 chest symptomatics were subjected to

sputum smear examination for Acid Fast Bacilli, by Ziehl-Neelsen staining using Light Microscope under oil Immersion lens. The results recorded.

Results and Conclusion

1409 Diabetes mellitus patients were recognised including both in-patients and out patients during the study period. Based on symptoms, 32 were screened for active pulmonary tuberculosis by Z-N staining. 5 patients found to have AFB in the sputum sample, the grade being 1+ to 3+. Prevalence of active pulmonary tuberculosis is 6.7 times higher than the prevalence in general population. Diabetes mellitus appears to have a definite role as an important risk factor for developing pulmonary tuberculosis.

TRUSTWORTHY MYCOBACTERIAL SPECIES IDENTIFICATION BY POLYMERASE CHAIN REACTION –RESTRICTION ENZYME ANALYSIS

(PRA) OF HSP65 GENE IN A REFERENCE LABORATORY

Ajoy Verma

Background: Non tuberculous mycobacterium are now often causing pulmonary and extra pulmonary disease in immune-competent patients and has become a growing threat worldover. Species identification of NTM determines the line of treatment and management of the disease. Routine diagnostic methods smear microscopy and culture, fail to identify nontuberculous mycobacterium.

Objective: To identify the mycobacterial species by using simple and robust technique by amplifying Hsp 65 gene using polymerase chain reaction followed restriction enzyme digestion of amplified product and analysis of results.

Design: Initially culture positive growth was confirmed through capilia and biochemical tests. The confirmed non-tuberculous mycobacterial isolates were subjected for species identification by polymerase chain reaction – restriction enzyme analysis. In this method the extracted DNA were amplified by using Hsp-65 target gene followed by restriction enzyme digestion with endonuclease enzyme BstE11 and Hae111 restriction enzyme. Results were compared with the standard pattern to identify the species.

Results: In the PRA test, initial amplification was seen with all 45 mycobacterial strains which produced 439bp of amplification band. Out of 45 NTMs, 42 were identified to species level when digested with BstE 11 and Hae111 restriction enzyme and 03 isolates were not identified to species level. In PRA test, all together 12 types of NTMs were identified, whereas in biochemical test 8 categories were acknowledged. Common species identified were Mycobacterium chaelonae (18) among the 26 rapid growing NTM and Mycobacterium avium complexes (8) amongst the 16 slowly growing NTMs. PRA and biochemical identification showed 93% (42/45) concordant results.

Conclusion: PRA is a easy and sturdy technique for identification of NTM in a routine laboratory. It is fast, cheap and accurate for identification of potentially pathogenic NTM.

CONCEPT REPORT ON PRESENTATION OF LABORATORY DIAGNOSIS OF TUBERCULOSIS

Shaheen

1. Tuberculosis : Magnitude of the problem with Statistics both worldwide and India 2. Lab Diagnosis of Tuberculosis : Problems faced in Pulmonary and extra pulmonary

disease 3. Characteristics of the organisms : Mycobacterium tuberculosis is a slow growing

organism with fastidious requirements4. Afb smears : Advantages and Disadvantages5. AFB culture : Methodology and Equipment used – MGIT BACTEC 6. Sensitivity : Need to do sensitivity with Definition of MDR and XDR TB and

statistics of Indian scenario 7. Line probe assay : Utility and Advantages8. Genexpert Tb test : Utility and Advantages9. Concluding Slide Summarizing all tests

COMPARATIVE EVALUATION OF A MULTIPLE- ANTIGEN (GLCB, HSPX, MPT51, AG 85B AND PSTS1) BASED DIAGNOSTIC PROTOCOL VERSUS

POLYMERASE CHAIN REACTION ASSAYS (QRT-PCR AND GEL-BASED DUPLEX PCR) FOR RAPID AND EFFICIENT DIAGNOSIS OF CHILDHOOD

TUBERCULOUS MENINGITIS

Abhishek MittalBackground

Tuberculosis is a global public health hazard. Tuberculosis Meningitis (TBM) is the most severe form of extra-pulmonary tuberculosis. Prompt diagnosis is crucial for successful TBM management; the case fatality rate for untreated TBM is almost 100%. PCR and ELISA based assays for detecting antigens are fast and reliable but have not yet been amalgamated into routine diagnostics .Thus, there is a need for improving TB diagnostics by development of cost-effective tools.

Methodology

132 CSF samples collected from pediatric wards were included in the study. A pediatric adaptation of Ahuja’s criteria was used as gold standard to classify subjects as TBM and Non-TBM. An ELISA-based assay was performed for detection of mycobacterial antigens and its efficacy was compared with quantitative real-time PCR and gel-based duplex PCR. Standard curve was generated for antigen detection and Receiver-Operating Characteristic (ROC) curves to establish cut offs that distinguished between TBM and non-TBM samples.

Results

GlcB and HspX ELISA had highest sensitivities of 95% and 93% respectively with specificities of 96% and 97%. qRT-PCR was the best performing assay with sensitivity and specificity of 97% and 99% respectively. Gel-based duplex PCR had a diagnostic accuracy of 84% vs. 98% for qRT-PCR assay.

Conclusion

The diagnosis of pediatric TBM is a problem both by conventional microbiological methods and radiological techniques. Present study concludes that in addition to qRT -PCR, GlcB and HspX can serve as potentially useful markers for rapid, inexpensive diagnosis of TBM. Since no commercial test is licensed for diagnosis of TBM, present study provides a better insight into development of rapid tests for better TBM diagnosis.

POSTER PRESENTATIONS

A CLINICO-MICROBIOLOGICAL STUDY OF TUBERCULOSIS IN

IMMUNOCOMPETENT AND IMMUNOCOMPROMISED PATIENTS

Nayan S. , Brahme Dipankar Pal, Sudeshna Mallik

Objectives:

To observe

a) The clinical spectrum of tuberculosis among immunocompromised (IC) and non-immunocompromised (Non-IC) patients.

b) AFB positivity in different specimens.

c) Isoniazid and rifampicin resistance in sputum positive samples by Line Probe Assay(LPA).

Methodology:

25 IC and 25 Non-IC patients with tuberculosis who attended OPD or admitted at School of Tropical Medicine and Chest Medicine, MCH,Kolkata from July’13 to June’14 are selected excluding those with co-morbidities.

Result:

Fever(90%) is the commonest symptom in both the groups. Lymphadenopathy(LN) (44%) is commoner in IC & cough(68%) in non-IC patients. Principal presentation of EPTB is pleural

effusion and cervical lymphadenopathy in non-IC and IC respectively. Disseminated tuberculosis(DTB) is commoner in immunocompromised.Most common form of DTB in IC is LN plus abdominal(42.86%) whereas in non-IC it is PTB plus abdominal(33.32%).20% of IC and 24% of non-IC patients are sputum smear positive.Pleural effusion(40%) is the commonest chest x-ray finding in non-IC patients. In smear positive cases, consolidation and patchy infiltrates are commonly seen in non-IC and IC patients respectively. Hepatosplenomegaly,ascites & retroperitoneal lymph node is commoner in IC(16%) as compared to non-IC(4%) patients and it is mainly seen with CD4<200 in IC.Pleural effusion is found with CD4-200-350/μl.AFB positivity in cervical LN FNAC is commoner in immunocompromised. Overall FNAC positivity for AFB is more in those with CD4 count <200.82% of sputum positive cases are sensitive to rifampicin and isoniazid in LPA.Resistance to rifampicin and isoniazid is 20% in IC and 17% in non-IC patients.

CAPREOMYCIN INDUCED ELECTROLYTE IMBALANCE IN 13-YEAR OLD FEMALE UNDER CAT-V REGIMEN FOR EXTENSIVE DRUG RESISTANT

PULMONARY TUBERCULOSIS

Tiwari Mani,Vaviya Ravi,Bamaniya Bhaskar, Shamaliya Khyati, Patel M. Z

Introduction

CAT-Vregimen under RNTCP has many drugs having grave side effects, Capreomycincauses ATN leading to multiple electrolyte imbalance, more commonly seen in old age,pre-existing renal dysfunction and concomitant use of nephrotoxic drugs. This is a case report of a patient of XDR-TB on second line ATT presenting with hypomagnesemia,hypocalcemia,hypokalemia and hypophosphatemia.

Case Presentation:

A 13-year-old female with XDR-TB presented in our institute with tingling and numbness of limbs and perioral region.

On examination, patient had carpo-pedal spasm and tachycardia. She was on CAT-V regimen for 60 days. Patient’s therapy comprised Capreomycin (0.75 gm/day-6days a week), Moxifloxacin, High dose Isoniazid,Clofazamine,Linezolid,Amoxiclav,Pyridoxine(<45 kg weight band)according to the PMDT guidelines.Capreomycin was stopped promptly as per the guidelines.ECG was S/O Sinus Tachycardia and 2-D Echo was normal.

Serology was S/Ohypomagnesemia,hypocalcemia,hypokalemia and hypophosphatemia.CBC,LFT,RFT,USG(whole abdomen),Thyroid profile and Parathormone were normal.

Patient didn’t have any co-morbid condition. Endocrinologist was consulted and patient was prescribed steroids. Steroidtherapy was tapered over 21 days. Electrolyte correction was initially done by parenteral route followed by oral route. Patient responded to the treatment and turned asymptomatic within 1 month.

Conclusion

Nephrotoxicity is the most serious toxic effect of long term Capreomycin therapy. Proper patient counselling about side-effects, Pre-treatment and periodicrenal evaluation during CAT-V Regimen will help in early detection and prompt management.If nephrotoxicity occurs then dose limitation or discontinuation is recommended.

POLLUTION AND PULMONES

O.A.Sarma

Historical ; 1952 ‘London Fog’, 1984 ‘Bhopal Gas Tragedy’ *Indoor air pollution ‘the rule of 1000’ *Major classes of Air Pollutants *Toxic air pollutants *CO and its health effects *Symptoms based on blood carboxy –Hbg levels *Effects of Co2 concentration *Lead and its health effects : unleaded petrol use *Oxides of Nitrogen (Nox) and its health effects *Ozone and its health effects. Ozone may cause permanent lung damage *Benzene exposure and its health effects (short-term ; long-term) *Polycyclic Aromatic Hydrocarbons (PAHs) and their health effects *SO2 *Respirable Particulate Matter (PM10) *Diesel exhaust particles and its health effects; use of compressed natural gas (CNG) *Ambient Air quality standards (National) *Your ecological foot print *Beware of slow poisoning from auto-pollution : growth of vehicular population in Hyderabad city *Solution for pollution. Quotation *The Earth is our Mother. Whatever befalls the earth, befalls the children of the Earth… the Earth does not belong to us, we belong to the Earth…

- Chief Seattle 1855

COMPARISON BETWEEN MOLECULAR LINE PROBE ASSAY AND

CONVENTIONAL DRUG SUSCEPTIBILITY TESTFOR DETECTION OF MULTI-

DRUG RESISTANT TUBERCULOSIS (MDR-TB)

S. Saini, H.Vashistha,A.Choudhary, V. Ahmad, M. Hanif, K.K. Chopra

Objective of the Study: Newly developed molecular technique based drug susceptibility testing methods for detection of MDR-TB have advantages over conventional phenotypic methods in terms of reduced turnaround time. In the present study we attempted to compare the performance of Line Probe Assay (LPA) with that of conventional solid culture &drug susceptibility test (C&DST) on Lowenstein-Jensen (LJ) medium.

Methodology of Investigation: A total of one thousand and twenty four (N=1024) MDR suspectsunder RNTCP PMDT criteria referred to New Delhi Tuberculosis Centre Centre from February to April 2014 were enrolled in the study. Of them, 568 sputum specimens found acid-fast bacilli positive by Fluorescent Microscopy were processed for LPA (GenoTypeMTBDRplus, Hain Lifescience).Solid C&DST was processed on LJ medium using proportion method. The statistical analysis of data was performed using descriptive parameters.

Results: Of 479 valid LPA tests, 337 (70.4%) were found sensitive and 141 (29.6%) resistant to both or either of two drugs. MDR / rifampicin monoresistance pattern was observed among 18.2% (87/479) specimens. All141 resistant and 19 sensitive specimens were processed for LJ C&DST. Out of total 160 specimens, an overall concordance of 98.3% (N=157)was

observed between LPA and solid C&DST. The concordance level between LPA and LJ C&DST was: LPA sensitive specimens(100%, N=19/19), MDR-TB (98.4%, N=61/62), rifampicin monoresistance(96%, N=24/25), Isonioazid monoresistance (92.6%, N=50/54) results. Diagnostic sensitivity of LPA to detect MDR/ rifampicin mono-resistance was found 100% and specificity >98%.

Conclusion: LPA test results had a good concordance with conventional DST with an additional advantage of a shorter turnaround time. This test can also be useful for systematic surveillance of INH mono-resistance in countries with high isoniazid resistance.

ASSESS THE DIAGNOSTIC EFFICACY OF NEWER TOOLS FOR DIAGNOSIS OF PAEDIATRIC TUBERCULOSIS

H. Vashistha, V. Ahmad, S. Saini, M. Hanif, K.K. Chopra

Introduction

Children account for a major proportion of the global tuberculosis disease burden, especially in endemic areas. However, the accurate diagnosis of childhood tuberculosis remains a major challenge The World Health Organisation has estimated that there are 1 million cases of tuberculosis in children every year. Seventy-five percentage of these cases occur in the 22 high TB burden countries. TB in children is rarely confirmed due to the lack of effective diagnostic tools; only 10 to 15% of paediatric TB is smear positive due to paucibacillary samples and the difficulty of obtaining high-quality specimens from children. By challanges of above problem, our objectives are as follows:

Aims and Objectives:

1. Diagnosis of Paediatric Tuberculosis by fluorescent microscopy and fluorescent based liquid culture methods.

2. To check the specificity and sensitivity between the Induced sputum and Gastric aspirate for better diagnosis of paediatric tuberculosis.

Material and Methods

The present study was carried out at New Delhi Tuberculosis Centre, New Delhi. A total of 150 clinically suspected paediatric pulmonary tuberculosis were considered for the present study. Direct smear fluorescent microscopy and MGIT rapid culture was performed in both clinical sample typesi.e Induced sputum and Gastric aspirate.

Results and Conclusions

Our experimental results revealed with newer technic i.e liquid culture (MGIT 960) increased the sensitivity 18% than smear microscopy. Sensitivity for choosing type of samples i.e Induced sputum and Gastric aspirate for diagnosis of paediatric is major concern. Our results revealed Induced sputum has increased sensitivity 33% than 22% of the gastric aspirates .Specificity remains no change 99% in both cases. Selection of Induced sputum of the child patient may useful sample for diagnosis of paediatric tuberculosis.

CASE REPORT: A RARE CASE OF RIGHT SIDED PLEURAL EFFUSION WIH POLYCYSTIC LIVER DISEASE

Monika Keena

Isolated Polycystic liver disease is an autosomal dominant disease with genetical and clinical heterogeneity. Apart from liver cysts, it exhibits few extra-hepatic manifestations . It is asymptomatic in 95% of cases but in 5% of cases it causes symptoms related to local mass effect of polycystic liver .

We are presenting a case of 45 year female , came with complaints of exertional breathlessness and right sided chest pain and pain abdomen since 6 months. Physical examination showed a lump in right hypochondrium. Chest xray showed right sided pleural effusion. Fluid picture was exudative with lymphocytic in nature and haemorrhagic . Pleural effusion reoccurred despite repeated aspirations. All the causes of pleural effusion were ruled out.USG abdomen showed multiple cysts in the liver and later it was confirmed as polycystic liver disease by CECT Abdomen. After considering the etiology as liver cyst, we aspirated liver cyst percutaneously following that resolution of pleural effusion occurred and patient was lost to follow-up.

` Discussion:- Polycystic liver disease is an asymptomatic condition and treatment is not warranted. The mechanical effects of a large polycystic liver and subsequent disruption of subdiaphragmatic capillaries resulted in persistent exudative pleural effusion, thus surgical debulking of hepatic cyst is required in managing these effusions.

Conclusion:- Recurrent pleural effusion is one of the indications of surgical intervention for Polycystic liver disease.

XDR TUBERCULOSIS – THAT TOO EXTRA PULMONARY – A CASE REPORT

Loreen Gujral

XDR TB is usually encountered in Pulmonary tuberculosis. Here is an interesting XDR Extra Pulmonary (EP) TB.A 57 year old male presented with bilateral joint pain and followed by weight loss in 2011. He had various investigations including MRI twice and received non-specific treatment and also Anti TB Treatment(ATT) twice during these three years. These ATT regimens were not as specified by WHO or Revised National Tuberculosis Control Programme (RNTCP) India. Three years later one of the private laboratory identified drug resistant TB. Finally he was referred to renowned government TB hospital where XDR EP TB was confirmed by culture and PCR and started on XDR TB treatment regimen. XDR TB treatment recommended by RNTCP India is being delivered through the Margaret Leprosy & TB Hospital (authorised by government system).The person has improved tremendously after initiation of treatment .

He had been suffering since last 4 years and spent nearly INR.50,000 which is substantial for a middle class family in Indian standards. This could have been avoided if awareness among medical practitioners was improved to consider diagnosing or suspecting common tropical diseases first and by streamlining referral system.

A CASE OF PULMONARY TUBERCULOSIS MIMICKING AS LUNG CARCINOMA

Abhishek Faye, Amitesh Gupta, Rupaksingla

Introduction

We present a case of pulmonary tuberculosis which was mimicking lung carcinoma clinically, radiologically and even after doing bronchoscopy. Finally we had to resort to open lung biopsy diagnosed it as a case of pulmonary tuberculosis.

Case report

A 35-year-old male patient came to NITRD with complaints of Chest pain and fever for 6 months, Shortness of breath since 3 months. The patient was a chronic smoker. Patient took ATT based on x-rayin 1996 for pulmonary tuberculosis and improved. On chest x-ray a right posteriorly located paratracheal opacity was visualised and CECT chest was suggestive of consolidation in right upper lobe suggestive of infective aetiology/malignancy. The Patient wasn’t improving. Sputum smear for AFB and by conc. were negative multiple times. FOB done and br. brush was suggestive of malignancy. Finally open lung biopsy was done which showed necrotising granulomas on histopathology suggesting TB. Incidentally on doing sp. AFB by conc. this time the smear was 1+ for AFB two times. The patients sputum LPA report showed it to be M.Tb and drug sensitive TB. The patient was put on retreatment regimen for TB with first line drugs.

Discussion

In India with such a high burden of tuberculosis some cases still pose a challenge to the clinician for diagnosis of TB. Lung cancer which carries such a high mortality and is common among smokers need to be ruled out before putting the patient on ATT in a case mimicking both at a tertiary care hospital.

HIV AND LUNG CANCER

Rajat Chhabra, KB Gupta, Vipul Kumar

Lung cancer is the most prevalent non-AIDS-defining malignancy in the HAART era. Smoking plays a significant role in the development of HIV-associated lung cancer, but the cancer risk is 2–4 times greater in HIV-infected persons than in the general population, even after adjusting for smoking intensity and duration. It is also important to remember that lung cancer is very rare in people with HIV. Lung cancer is typically diagnosed a decade or more earlier among HIV-infected persons (mean age, 46 years) compared to those without HIV infection. Adenocarcinoma is the commonest histological subtype, and the majority of patients are diagnosed with locally advanced or metastatic carcinoma.  Squamous cell cancer is the second commonest histological type in HIV-lung cancer patients.

A 60 yr old smoker and HIV positive patient (duration not known, pt not on ART) presented with chest pain and breathlessness for 20 days. CXR PA revealed mass lesion in

left upper side of the chest. CECT thx revealed mass lesion in left upper lung with pleural, pulmonary, and distant metastasis.

USG guided FNAC of the lesion confirmed the diagnosis of SQUAMOUS CELL CARCINOMA OF LUNG. This case highlights the fact that lung cancer although rare in HIV patients, is associated more and more frequently with the advent of ART. Such patients have metastatic disease at the time of presentation and carries poor prognosis.

PTB & DVT

Rajat Chhabra, KB Gupta, Vipul Kumar

Deep vein thrombosis (DVT) is clinically observed and can be confirmed with laboratory methods in 3-4% of patients with pulmonary tuberculosis (PTB). But the real incidence may be closer to 10%, because most of the patients are thought to be clinically inapparent. The lack of awareness regarding the association is possibly responsible for the condition not being recognized and hence screening and treatment strategies have not been standardized.

A 22 year old female TB patient was admitted with painful swelling of right lower limb. On examination the leg was tender &signs of DVT were present. Color Doppler Ultrasonography of left limb showed echogenic thrombus in lumen of right, common femoral, superficial femoral up to adductor canal. CT Angiogram chest showed no evidence of pulmonary embolism. Patient was treated with subcutaneous low molecular weight heparin with an overlap of warfarin for 10 days. Repeat Color Doppler ultrasonography done after 2 weeks of treatment of antithrombotics showed resolution of thrombus.

The thrombogenic potential of TB is not well known but can have serious consequences. Priming of vascular endothelium occurs as a result of interaction between mycobacterial products and the host monocyte–macrophage system. It is also postulated that these changes result in hypercoagulable state predisposing to DVT. Prognosis of the DVT in PTB was found to be good if ATT and LMWH were started simultaneously and earlier. We emphasize on early detection of deep vein thrombosis, early start of prophylactic low molecular weight heparin in severe pulmonary tuberculosis.

SCALP METASTASES--AN UNUSUAL PRESENTATION OF NON-SMALL CELL LUNG CANCER PROGNOSIS OF CUTANEOUS METASTASES

Sunil Nagar, KB Gupta, Vipul Kumar

We report a case of a non smoker 38year old man of metastatic lung cancer presenting as scalp metastases who presented to us with SOB, dry cough, haemoptysis and chest pain. He was only symptomatic since last 1month. Patient had an nodular growth on the scalp in the right occipital region, and one on right chest wall. Immunohistochemistry and radiological investigations helped in making the diagnosis .Chest x-ray lesion brought a suspicion of malignancy even on examination of this patient typical SVC syndrome picture

was seen for which palliative radiotherapy was given. Diagnosis was made via Fibroptic bronchoscopy done with visualization of growth in right main bronchus which was highly vascular because of which only FNAC was taken report suggestive of non small cell poorly differentiated carcinoma possibly adenocarcinoma. FNAC from scalp growth suggestive of deposit from adenocarcinoma. Skin metastasis occurs when cancerous cells break away from the primary tumor and make their way to the skin through the blood circulation or lymphatic system. Patient was later referred to radiotherapy depts. for further management. Adenocarcinoma is most common and most heterogeneous lung cancers that originate from peripheral lung tissue. Adenocarcinoma is not responsive to radiation therapy as in a small cell carcinoma but is rather treated surgically. The case also reflects improvement in cancer care and outcomes in recent times.

ESTIMATION OF THE INCIDENCE OF PRIMARY MDR-TB IN THE POPULATION OF A SEMI URBAN AREA IN NAVI MUMBAI

Vipul Goyal

OBJECTIVE

Primary drug resistance is defined as drug resistance in a patient who has not received any anti-tubercular treatment in the past.

Incidence of primary drug resistant TB in literature. The median prevalence of MDR-TB in new cases of tuberculosis was 1.1 per cent.

Incidence in India to be less than 5 per cent

AIM of our study was to estimate the incidence of primary MDR-TB in the population in a semi urban area in navi Mumbai

METHODOLOGY

A retrospective analysis was conducted on patients diagnosed as tbin the DOTS CENTER inpanvel, navimumbai. The study period extended from june 2012 – December 2014 ,data was collected by interrogating the patients and review of the treatment cards of patients under DOTS the patients were managed strictly under RNTCP protocol as regards tests for drug sensitivity tests as well as treatment categorization

DST was done at RNTCP recognized center by lipa and CB-NAAT

FINDINGS

Out of 64 drug resistant TB patients, 26 were primary MDR

DISCUSSION

Under reporting and inadequate notification combined with restricted recommendations for

use of DST lead to underestimation of the number of DR-TB in developing countries

CONCLUSION

Our results suggest very high incidence of primary MDR in RNTCP setup.

A STUDY ON KNOWLEDGE AND AWARENESS ABOUT TUBERCULOSIS IN SENIOR SCHOOL CHILDREN OF BANGALORE RURAL REGION

Vanaja K, Lokesh R, Reshma Banu, Chethan Kumar, Navyashree, Chaitra S, Rajani T, Susheela Rani, Ramya, Shekar HS

Background: Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (M. Tuberculosis), which most commonly affects the lungs. Pharmacists have a valuable public health role in promoting community awareness of tuberculosis, particularly in reducing the stigma and discrimination often associated with the disease, creating awareness at a community level could play a vital role in control & prevention of TB.

Objectives: To determine whether educational intervention would affect the level of TB awareness among students of selected schools and pre-university colleges in Bangalore rural region.

Methodology: The present study was conducted among the students of 8 th, 9th, 10th and pre-university college (PUC) in Bangalore rural jurisdiction (n= 2635). A validated questionnaire designed in English and Kannada language, containing 20 questions with multiple choice answers was used. A 30-minute visual health education was given on TB in English, followed by general pictorial presentation. Data collected as pre-test and post-test was evaluated using the knowledge mean scores.

Results: A significant impact on the knowledge about TB was observed with knowledge mean scores improvement from 8.76±2.58 to 15±2.08. Comparison of pre-education and post-education revealed that mean score data (±SD) improved from 7.56 ± 2.61 to 12.78 ± 2.39 (8 th standard); 8.26 ± 2.64 to 14.95 ± 2.02 (9th standard); 9.05 ± 2.52 to 15.24 ± 1.95 (10th standard) and 10.19 ± 2.59 to 16.89 ± 1.61 (PUC).

Conclusion: Increase in the mean knowledge scores from before education to after education scores indicated that empowerment of students could guide the community on various aspects of tuberculosis.

PERFORMANCE EVALUATION OF GENOTYPE MTBDRPLUS ASSAY FOR RAPID DIAGNOSIS OF NONTUBERCULOUSMYCOBACTERIA IN SMEAR

POSITIVE SPUTUM SPECIMENS

V. Ahmad, M. Hanif, S. Saini, H. Vashistha, Z. Siddiq, K.K. Chopra

Objective of the Study: The incidence of detection of nontuberculous mycobacteria (NTM) has increased worldwide not only in HIV-positive patients, but also in HIV-negative patients. The aim of this study was to assess, the effectiveness of Genotype MTBDRplus line probe assay (LPA)for rapid detection of NTM and, differentiation of Mycobacterium tuberculosis complex (MTBC) from NTM in acid-fast bacilli (AFB) positive sputum specimens.

Methodology of Investigation: The present study was carried out among MDR suspects at IRL, New Delhi TB Centre, Delhi. The sputum specimens found AFB positive were subjected for LPA. The Sputum specimens showing absence of TUB band (i.e. absence of MTBC) on LPA strips were processed for liquid culture on MGIT960 (Becton Dickinson). The culture positive isolates showing absence of MPT64 antigen on rapid card Immuno-chromatographic lateral flow assay (SD Bioline) were considered as NTM.

Results: Of total 1047 MDR suspects, 568 sputum specimens found AFB positive were processed for LPA. Of 568 sputum specimens analysed, 538 (94.7%) were identified as MTBC and 30 (5.3%) were as NTM through LPA. A total of 78 specimens, 48 indicated as MTBC and 30 as NTM were processed for liquid culture. Of 78specimen, 89.6% (n=43/48) showing MTBC and 86.7% (n=26/30) as NTM turned out to be liquid culture positive, and subjected for SD Bioline rapid card assay. The Sensitivity, Specificity, Positive Predictive value and Negative Predictive value of LPA for detection of NTM was found to be 100%.

Conclusion: Genotype MTBDRplus line probe assay showed rapid, highly sensitive and specific results for the identification of NTM among AFB positive sputum specimens.The clinical and economic benefit of saving time can facilitate for accelerating management of TB patients.

NON HODGKINS LYMPHOMA PRESENTING AS A CHEST WALL MASS

Abhijit Ahuja, Lavina Mirchandani, Aparna Iyer, Abhay Uppe, Girija Nair, Jayalakshmi Tk

Background

Only 5% of Non-Hodgkin’s Lymphoma present in Anterior Mediastinum.Most commonly seen are large, irregular, anterior & superior mediastinal massAssociated with large pleural effusions, pericardial effusions, pulmonary parenchymal changes.

Prevalence of anterior mediastinal mass is more in adults (65%) as compared to children (28%).

Case report

A 47 year old Male, Farmer ,addicted to Tobacco chewing ½ packet/ day for 40 years , without any co-morbidities came in OPD with complains of tender swelling over chest wall, breathlessness, chest pain, cough & low grade fever since 2 months. Local examination of the swelling revealed the size being 5x2x1cm, shape was irregular, tender, mobile, skin over the mass was tense & not warm on touch. Respiratory system examination revealed reduced breath sounds, left infrascapularly. Chest Xray showed left sided CP angle blunting with homogenous opacity in the left lower lobe, silhouetting with left heart border & diaphragm. High Resolution Computed Tomography showed a large lobulated heterogeneously enhancing lesion in the anterior mediastinum – prevascular compartment extending to superior mediastinum. USG guided biopsy revealed Non Hodgkins Lymphoma.

Conclusion

This case is a rare presentation of Non Hodgkins Lymphoma presenting as a chest wall mass.

BILATERAL EXTENSIVE PULMONARY TUBERCULOSIS IN A THREE MONTH OLD INFANT

Ravindra Kumar Singh, Alok Chandra, Tariq Mahmood, Brijendra Kumar Chaudhary

Introduction

Progressive primary pulmonary tuberculosis is rare in infancy and may often be confused with pyogenic pneumonia or congenital anomalies. However it may be an important cause of morbidity and mortality in highly endemic countries like India.

Case Report

A 3 month old female child presented to our OPD with fever, cough and respiratory distress for past 1 month. Initially she was diagnosed as a case of pneumonia at a private hospital and treated for the same with antibiotics for 15 days, but showed no improvement. She was delivered in a hospital and was vaccinated for BCG at her birth. There was no history of contact with tuberculosis. Her chest X-ray PA view was done which revealed bilateral extensive infiltrates. This aroused the suspicion of Pulmonary tuberculosis and her morning gastric content was aspirated through a paediatric Ryle’s tube and sent for Ziehl Neelsen staining for Acid Fast Bacilli. Tubercle bacilli were identified by Ziehl Neelsen staining. CSF analysis and USG abdomen were within normal limits. A diagnosis of progressive primary pulmonary tuberculosis was made and she was started on anti-tubercular treatment to which she responded dramatically and repeat AFB stain of gastric lavage was negative.

Conclusion

A diagnosis of Pulmonary TB should be suspected in infants with non-resolving pneumonia, even in BCG vaccinated infants and without any history of contact or extra-pulmonary involvement.

MARFENOID FEATURES WITH RECURRENT SPONTANEOUS PNEUMOTHORAX

Aamir Nadeem

Background

Marfenoid features with recurrent spontaneous pneumothorax present with sputum positive tuberculosis.

PATIENT & METHODS:  26 year male presented with c/o cough with expectoration..

Breathlessness on exertion since 5 months, fever since 5 days.

Patient was a smoker and an alcoholic.

H/o koch contact present, grandmother had tb. xray s/o left side pneumothorex.

ICD was inserted. Patient also came with sputum positive, so ATT was started under cat 1. ICD was removed after period of one month. Again after 1 month patient developed  right-sided tension.

Pneumothorax, ICD was inserted and discharged with icd in situ. Then after 5 days, patient came with increased breathlessness cxr s/o increased pneumothorex, hence a new ICD was inserted. HRCT report showed extensive paraseptal panacinar emphysematous changes,air fluid level in few bronchi. a loculated 8*7*3 size air fluid level along lateral aspect of left lower lobe.

Perfusion scan showed patchy tracer concentration.

 Reports were s/o marfenoid features but no definite findings confirmed Marfans syndrome or homocystineurea.

Marfan syndrome evaluation

Skeletal system: scoliosis present

                          skull increase skull length

                          enlarge frontal sinus

                          high arch palate

cvs   mvp present

pulmonary  spontaneous pneumothorax.

skin strech marks.

in/v/o recurrent pneumothorax and large right sided bullae onco ref taken. They advise b/l bullectomy with b/l pleurodesis.

Conclusion

Patient with Marfenoid features can also present with recurrent pneumothorax.

STOCHASTIC MODEL TO PREDICT THE SURVIVAL OF HIV AND TB

PATIENTS THROUGH SOCIO-BEHAVIORAL STUDIES

Vinoth Raman

There are studies related to HIV models and TB models separately in the field of stochastic model. Very few researches have been done jointly with HIV and TB. An attempt is made here using stochastic model to find the threshold level of the patient, who has been infected by HIV and TB. In shock model approach with renewal process and survival time the threshold has been detected to check the Expected threshold time for survival of the patient. HIV and TB are the two modes of transmission which have been studied through three parameter generalized Rayleigh distribution. Many research with different family of distribution had been studied earlier. The three parameter generalized Rayleigh distribution which is the family of exponential distribution also fits in with the shock model approach. The model also shows that once the patient is infected the threshold level decreases, which suggest the models goodness of fit. The model has proved the fact that once the patient is immuno-compromised, the threshold level of life expectancy of the individual decreases gradually. Further research is needed to confirm the outcomes of this model in real life situation.

TOBACCO USE AND ITS IMPACT ON PULMONARY HEALTH AMONG ELDERLY POPULATION IN RURAL AREAS OF MUZAFFARNAGAR-A

CROSS SECTIONAL STUDY

Jai Vir Singh, Sanjeev Davey, Santosh Kumar Raghav , Khursheed Muzammil, Rama

Shankar

Background: The tobacco use is significant in Indian rural population. Out of which elderly people in rural area are at special risk due to ageing and other factors. The Impact of tobacco use on elderly health therefore needs to be studied in depth in rural context. Objective:To study the patterns of tobacco use and its consequent impact on pulmonary health of the elderly. Design & Methodology: A community based cross sectional study was done (April 1st to September 30th

2014) in the field practice area of rural health and training centre (RHTC) of Muzaffarnagar Medical College, Muzaffarnagar. A stratified random cluster sampling was used in which each village was used as a cluster and all population between age of 60-80 years in each village were interviewed by semi-structured schedule. The data was analyzed by software Epi-info version 7.1.3.3. Results and Conclusion: The prevalence of tobacco usage among elderly was 56.7%, in which smoking was the dominant way (65.2%) in the from of Bidi(56.7%). Tobacco usage was significantly associated not only with age; sex and caste (p<0.05 each) but occupational and socio-economic status(p<0.01 each) also, however literacy was most significant factor(p<0.0001)among all. The Tobacco usage in smoking form was highly significantly associated with the presence of COPD (p<0.0001) and overall tobacco usage was also associated significantly with presence of hypertension(p<0.0001),elucidating a significant impact on their pulmonary health. The rural elderly people need health education messages regarding curtailing the use of tobacco for their better health status from elderly health clinics.

A COMPARATIVE MICROSCOPIC & CULTURAL TUBERCULOSIS DIAGNOSTIC STUDY IN RURAL CHENNAI

Karthika Jayakumar

Background: Care of patients with tuberculosis starts with a quality assured medical treatment. This has several facets like clinical, radiological & laboratory techniques. The laboratory techniques need to be reliable, rapid, cost effective & reproducible not only for the patients but also for the clinicians, as it will lay down the base for early initiation of suitable treatment & reduce the mortality & morbidity of the diseased person. Objective: To ensure reliable, early detection and cost effective diagnostic technique by comparing two microscopic and cultures. Design: Case control study, with comparative microscopy & cultural techniques. Methodology: 75 willing Patients with their consent were selected from the Departments of Medicine &TBCD.25 HCW were taken as controls. The sputum collected were processed for two different staining, microscopic & culture techniques. These procedures were done as per standard protocol. The stained smear were screened & interpreted as per RNTCP guidelines. RESULTS: Liquid media exhibited growth as early as 10th day, while LJ media had the growth only on the V week. The liquid media half the rate of the solid media.LED microscopic examination was more sensitive than ZN stain .CONCLUSION: One of the biggest obstacles to the correct diagnosis & efficient management of tuberculosis is the absence of rapid reporting of the bacilli in the given clinical specimen, overcome by the liquid media used in our study.

A PILOT STUDY ON THE APPLICATION OF NUCLEIC ACID BASED AMPLIFICATION TECHNIQUES IN DETECTION OF BIOMARKERS

ASSOCIATED WITH LATENT TUBERCULOSIS

Bagyalakshmi R, Abarna V, Therese KL, Arthi .E, Anitharaj M.

Purpose: To develop Polymerase chain reactions targeting the sigF and acr gene and gene coding for interferon gamma for evaluating its use as a biomarker in detection of latent tuberculosis.

Material and Methods: PCRs for sig F, acr and interferon gamma genes were optimized at an annealing temperature of 68 °C, 65° C and 60° C respectively. Five peripheral blood specimens were collected and processed for detection of biomarkers of latent tuberculosis.Results : PCR targeting sigF gene yielded 420 bp product, acr gene yielded 214 bp product and interferon gamma gene yielded 356 bp product. Among the three target genes, sigF and acr gene were not detected in all the five specimens. Interfeon gamma gene was detected only in two specimens.

Conclusion : PCR for IFN gamma gene was well optimized. Further testing of the target genes is needed to validate its use as biomarker in detection of latent tuberculosis.

PROSPECTIVE & RETROSPECTIVE STUDY OF EPIDEMIOLOGICAL FACTORS OF TB IN

&

AROUND B. G NAGARA

B.P. Satish Kumar

BACKGROUND: TB is among today’s most serious global health concern with approximately 2 billion latent or active infections, and between one & two million annual deaths worldwide.

OBJECTIVES: To assess the epidemiological factor of tuberculosis, and to measure the prevalence of TB in adult population.

DESIGN: Prospective and retrospective study each of six months.

METHODOLOGY: The study was conducted for 1 year after taking ethical approval. The study was conducted from November 2013 to October 2014. The retrospective data were collected from DOTS centre of Adichunchanagiri Hospital & Research centre where as prospective data were taken from patient’s case sheets that were diagnosed with TB. Patients with multiple complications along with TB except HIV were excluded in this study.

RESULTS: The study population of 135 included 86 (63.70%) males and 49(36.30%) females. Male & female ratio was 1.76:1. There were three major population groups: 11(8.148%) were pediatrics, 89(65.925%) were adults & 35(25.925%) were geriatrics. Among 135 total cases 113(83.70%) were new, 12(8.88%) were relapse & 10(7.40%) were categorized as other TB cases where as 72(53.33%) were PTB & 63(46.67%) were EPTB. Among 72 PTB cases, sputum test was positive on 49(68.05%) patients where 23(31.95%) were diagnosed by X- ray.

CONCLUSION: In order to reduce the incidence of the disease, India should take an account to fight against TB as well as should promote the awareness program regarding the transmission and risk factors of TB.

TELEMEDICINE BASED APPROACH FOR THE TREATMENT AND MONITORING OF TUBERCULOSIS INFECTED PATIENTS AMONG INDIAN

POPULATION

Selvaa Kumar C , Pritam Kumar Panda

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, which urgently needs close monitoring system apart from treatment. Objective: Here we propose a telemedicine based software solution for monitoring for those who are directly associated with the infected patients like physicians, pathology labs and pharmacies (P3

group). Methodology: This P3 group also takes Non-Governmental organizations into its fold through a telecommunication network who will be assisted in identifying, isolating, treating and monitoring the infectious disease using IT (Information Technology) based solutions. Idea/hypothesis: This mode of treatment will bring in uniformity among physicians and to follow the National code of conduct during drug prescription with correct dosage followed by continuous monitoring among rural and urban population. Conclusion: This IT based design will certainly be helpful in strengthening the public private partnership universally to treat this contagious disease.

SHORTCOMINGS IN NON-DOTS PRESCRIPTION

AP Kansal, Varinder Singh Bamrah, Sudesh Kumari, Kamaldeep Mahi, Nancy Garg, Hardik Jain

Introduction- Tuberculosis is the most common infectious disease in India. Under RNTCP guidelines Pulmonary Koch’s is mainly diagnosed by sputum examination.

Aim- To study the profile of patients put on Non-DOTS.

Material and methods- This is a cross-sectional study done on patients already taking Non-DOTS treatment for tuberculosis who presented to Chest and T.B Hospital, Patiala, for second diagnosis because of no improvement. Detailed history and clinical examination was done and patients were investigated according to RNTCP guidelines.

Result- Of the 45 patients studied, 31(68.8%) were given Non-DOTS on chest X-ray basis, 6(13.3%) on sputum positive basis, 3(6.6%) on the basis of MRI spine, 1(2.2%) on the basis of CSF examination, 1(2.2%) on the basis of serology, 1(2.2%) on the basis of biopsy of skin ulcer, 1(2.2%) on the basis of BMFT, 1(2.2%) on the basis of FNAC cervical lymph node. Of the 45 patients, 27(60%) were found to have tuberculosis (pulmonary and extra-pulmonary), 8(17.77%) were diagnosed as ABPA, 7(15.55%) diagnosed as Ca lung, 3(6.6%) diagnosed as pneumonia. Out of the 45 patients who were on Non-DOTS, 8(17.8%) were receiving low dose of anti tubercular drugs as per their weight and 5(11%) were on potential drugs for MDR-TB.

Conclusion- A bacteriological diagnosis of tuberculosis should be attempted in every suspected case of pulmonary tuberculosis. Anti-tubercular drugs should be prescribed in correct doses as per RNTCP guidelines. Second line anti tubercular drugs should be avoided in new cases of tuberculosis to prevent development of resistance to these drugs.

TUBERCULAR MASTITIS: A CASE REPORT

AP Kansal, Hardik Jain, Shiyas Mohammed, Prabhleen kaur, Anand Kumar Bansal

Introduction: Tuberculosis is the most widespread human infection in the world. It can involve any organ and mimic other illnesses. Tubercular mastitis is a rare presentation of tuberculosis and accounts for 3-4% of breast lesions in India. We present the case of a patient with tuberculosis in both breasts at different times.

Case Report: A 46 year old lady was referred to our hospital with thick purulent yellowish discharge from the right nipple, which was not associated with fever or pain in the breast. It started 1 month ago, with a breast lump for which lumpectomy was done in a private hospital, but the discharge persisted, for which the patient was referred. She was diabetic, hypertensive and a known case of HCV infection. She had a previous history of lump in the left breast 2 years ago, associated with purulent discharge for which lumpectomy was done and Category I anti-tubercular treatment was given for 7 months based on the cytology report.

Local examination revealed retraction of both nipples, but failed to reveal any lump or tenderness in either breast. Thick purulent discharge could be expressed from the right nipple.

Chest X ray and mammography failed to reveal any significant abnormality. The pus from the right breast was sent for microscopic examination. On cytology, it revealed neutrophils and many lymphocytes at the background of necrosis. On ZN staining, the pus was positive for acid fast bacilli (AFB), thus establishing the diagnosis of tubercular mastitis. Pus culture revealed the growth of staphylococcus aureus, sensitive to azithromycin, amoxicillin and ceftriaxone.

The patient was put on Category II anti-tubercular treatment and other antibiotics, to which she responded well, and was discharged subsequently.Discussion: Tubercular mastitis is a rare extra-pulmonary manifestation of tuberculosis. The most common clinical presentation is that of a solitary, ill defined hard lump situated in the central or the upper outer quadrant, which makes it indistinguishable from Ca breast. Another form of presentation in recent years is tuberculous breast abscess, which is more prevalent in endemic areas of tuberculosis. The gold standard for diagnosis of tubercular mastitis is ZN staining or bacteriological culture of the breast tissue. However, AFB are isolated in only 12% of the patients (this case being one of them). An excision biopsy is strongly recommended to rule out other diagnoses like sarcoidosis, fungal infections and malignancy.

Conclusion: In a TB endemic country like India, a high index of clinical suspicion of tubercular mastitis should be kept in mind, for every woman in the reproductive age group, presenting with a breast lump or nipple discharge.

ROLE OF BRONCHOSCOPY IN THE DIAGNOSIS OF PULMONARY TUBERCULOSIS IN SPUTUM SMEAR NEGATIVE PATIENTS

Vishal Chopra, Ashrafjit Chahal, Hardik Jain, Don Gregory, Prabhleen Kaur, AP Kansal

Background: Tuberculosis (TB) is a major public health problem. Around 30% of cases of pulmonary TB are sputum smear negative. Bronchoscopy can be a useful adjunctive technique to diagnose TB in such cases.

Objective: To assess the role of flexible fiberoptic bronchoscopy in the diagnosis of pulmonary TB in sputum smear negative patients.

Material and methods: A retrospective study of 114 patients, who presented to Dept. of Chest and Tuberculosis, GMC Patiala, was conducted during the period 2013-2014. All the patients underwent a sputum smear examination which was negative for acid fast bacilli (AFB), and remained negative even after sputum induction, done 15 days later as per guidelines of the Revised National Tuberculosis Control Programme (RNTCP). The patients were subjected to fiberoptic bronchoscopy (FOB) after taking informed consent, following which bronchoalveolar lavage (BAL) specimen and post FOB sputum were collected and sent for microscopic examination. No post procedure complications were reported.

Results: Out of the 114 smear negative patients, BAL specimens and post FOB sputum samples of 28 (24.56%) were found to be positive for AFB by Ziehl Neelsen staining technique. Of these, 6 (5.26%) were positive on post FOB sputum examination alone, 4 (3.50%) were positive on BAL specimen examination alone, while 18 (15.79%) were positive with both these samples. All the 28 patients were given anti tubercular treatment as per RNTCP guidelines, to which they responded well.

Conclusion: The results of the study strongly suggest that bronchoscopy is a useful diagnostic technique and should be performed in all smear negative patients, wherever possible and available, to avoid delay in diagnosing the disease and initiating treatment, thus effectively reducing its transmission to the community.

PULMONARY AND EXTRAPULMONARY MANIFESTATIONS IN HIV SEROPOSITIVE PATIENTS PRESENTING IN A TERTIARY CARE CENTRE

AP Kansal, Anand Kumar Bansal, Don Gregory, Kiran N, Varinder Singh Bamrah

The clinical profile of HIV disease in India includes a wide range of conditions like tuberculosis, pneumocystis carinii pneumonia, mycobacterium avium complex, fungal infections and viral and bacterial pneumonia. Tuberculosis is the most common opportunistic infection in Indian patients with HIV. This study is therefore aimed at evaluating pulmonary as well as extrapulmonary manifestations amongst HIV sero-positive patients.

Aim

To study the clinical profile of HIV sero-positive patients.

Material and Methods

The present study was conducted in HIV sero-positive patients who were admitted in Chest and T.B Hospital, Patiala over a period of 1 year. Demographic profile of the patients was recorded along with detailed clinical history, examination, investigations and evaluated for various pulmonary as well as extra-pulmonary manifestations. Risk factors for HIV infection and mode of transmission were also noted.

Results

Of the 102 cases diagnosed, 74 (72.5%) were males and 28 (27.5%) were females. The age of cases ranged from 18-82 years. Among 102 cases, 82 (80.5%) were married, 18 (17.6%) were unmarried and 2 (1.9%) were divorced. Heterosexual sex was the most common route of transmission in 78 (76.47%) cases, while 14 (13.72%) were intravenous drug abusers, 9 (8.82%) were found to have history of blood transfusion and 1 was found to be homosexual. Of the 102 cases, 45 (44.11%) were diagnsed as pulmonary tuberculosis, 15 (14.70%) as tubercular pleural effusion, 4 (3.92%) as military tuberculosis, 2 (1.96%) as tubercular empyema. Extra-pulmonary tuberculosis was present in 7 cases (6.86%). Out of these, 3 cases were diagnosed as tubercular lymphadenopathy, 2 cases as abdominal tuberculosis and 2 cases as tuberculoma. 7 cases (6.86%) were diagnosed as pyogenic pneumonia , 13 (12.74%) were upper respiratory tract infections, 6 (5.88%) were post tubercular fibrosis, one case each of pneumocystis carinii pneumonia (PCP), interstitial lung disease, COPD and Herpes zoster.

Conclusion

The above results show that tuberculosis is still the most common opportunistic infection in HIV seropositive patients. Also the incidence of pneumocystis carnii pneumonia has substantially decreased in recent times. Therefore, It is imperative that physicians treating

HIV-infected patients should aggressively identify those with M. Tuberculosis in order to reduce the associated co-morbidity resulting from the pairing of the infections. Creating grass root level awareness coupled with aggressive case finding in suspected high-risk population may be key in prevention and early detection of the dual infections.

STUDY OF AWARENESS ABOUT RESISTANT TUBERCULOSIS AMONG MEDICAL PROFESSIONALS

N.Snigdha, N.Sandeep Krishna

Aim- The basic aim of this study was to assess the existing basic knowledge of medical doctors of various levels of training about the definitions of the resistance patterns in tuberculosis.

Methodology-

Two hundred medical doctors were included in this survey from Siddhartha medical college,Vijayawada. A simple questionnaire was designed and presented to the medical doctors to respond by spontaneous answers to the questions in the questionnaire. The participants were asked to define Multi Drug Resistant Tuberculosis (MDR TB) and Extensively Drug Resistant Tuberculosis (XDR TB) . The participants were required to respond spontaneously by completing the questionnaire on presentation without waiting time, delayed participation or peer discussion.

Results-

Two hundred participants were included in this study. One hundred and forty(70%) participants completed the questionnaire while remaining sixty (30%) participants did not answer the questions completely. Out of 140 responders fifty(35.7%) responders possessed a post graduate degree while remaining ninety (64.3%) responders were post graduate trainees and general medical officers.

Out of total 140 responders sixty (42.8%) could define Multi Drug ResistantTuberculosis (MDR) correctly while eighty (57.2%) could not define MDR TBcorrectly. Subset analysis revealed that out of ninety responders without post graduate qualification, only 36 (40%) could give a correct response. Out of 50 post graduate responders, 24 (48%) gave correct responses.

Out of the total 140 responders, Thirty six(25.7%) responders could define XDR correctly while one hundred and four (74.3%) responses were incorrect. Subset analysis of responses revealed that eight (8.8%) correct responses were recorded in the group without PG Qualification while twenty eight(56%) correct responses were recorded in the PG qualified group of 38.

Discussion- Tuberculosis is the most common cause of death in adults due to single infectious agent. In this era of drug resistance available knowledge is incomplete and not well

disseminated among the medical professionals. The study suggests that there are major gaps in the knowledge of doctors involved in patient care about resistance

Conclusion-

The study suggests that there are major gaps in the knowledge of doctors involved in patient care about resistance and its patterns of tuberculosis to available anti-tuberculous drugs.

TO ASSESS THE KNOWLEDGE AND AWARENESS ABOUT TB AMONG COLLEGE STUDENTS

Ravinandan A P

BACKGROUND: Tuberculosis (TB) is one of the leading causes of mortality in India- almost killing -two persons every three minutes, nearly 1,000 every day. This mortality and morbidity rate can be minimized by creating awareness and improving the knowledge. So, this study was taken up by to assess the college student’s knowledge and awareness about TB. This will help us to minimize and eradicate TB in India.

OBJECTIVE: To assess the knowledge and awareness (KA) about TB among college students.

METHODOLOGY: A prospective and questionnaire based study conducted in a various colleges in Davangere city. A 2 pages data collection form was prepared and it contains informed consent form (ICF) and ten KA questionnaires.

RESULTS AND DISCUSSION: Among 1058 students approached, 462 were male and 596 were female. Mean age was found to be 21 years and mode 17 years. About 1020 (96.4) know TB means tuberculosis. Majority of the students accepted that TB is a curable disease 740 (69.94%). Only 522 (49.33%) students are know that TB caused by Bacteria and 820 (77.5%) were accepted that caused by Mycobacterium tuberculosis. More than 50% of were [581(54.92%)] not know complete symptoms of TB, 212 (20.03%) are thought that it is not preventable and 626 (59.16%) were aware that it is a spreadable disease. Many [458 (43.28%)] of the students opined that, TB patient requires a special care, education and treatment. Still, 329 (31.09%) not aware that TB can be preventable by vaccination and 385 (36.38%) are not know Indian government is providing a free treatment to TB patients. CONCLUSION: Majority of students have very poor knowledge and awareness about TB. Incorporation of TB related topics in education curriculum, creating awareness regularly will be enabling to limit and / or spread of TB in India.

COMPARISON OF IGRA (INTERFERON GAMMA RELEASE ASSAY), QUANTIFERON TB GOLD TEST AND TUBERCULIN SKIN TEST FOR THE

EVALUATION OF YOUNG CHILDERNS AT HIGH RISK FOR TUBERCULOSIS

Dinesh Kaliyamoorthi

BACKGROUND:

Children have become an important epidemiology of tuberculosis as a main marker of recent disease transmission and also an reservoir for the future. Analysis of childhood tuberculosis is becoming a concern due to the increase in number of childhood tuberculosis in developing countries.

OBJECTIVE:The role of interferon gamma release assay in the immunological diagnosis of childhood tuberculosis is under debate. In the present study we have compared interferon gamma release assay and tuberculosis skin test in the diagnosis

DESIGN:

This study was conducted in Shri Sathya Sai Medical College and Research Institute, the samples where collected from children attending OP and IP in the Department of Paediatric and the sample was processed in the Central Microbiological Laboratory.

METHODOLOGY:

After obtaining the blood from the children the blood will be immediately transported to the CENTRAL MICROBIOLOGY LABORATORY and the sample will be centrifuged to separate the serum. The serum is then used to do IGRA quantiferon gold test by ELISA technique.To the same children after cleaning the arm with antiseptic solutions, Tuberculin Purified Protein Derivative (Mantoux) Tubersol 250 U.S. units will be given.

RESULT:

IGAR positive for 10 patients, TST positive for 7 patients, 8 were positive for both., 8 patients were negative for both.

CONCLUSION:

There was a higher positive rate for IGAR test when compared to TST test, but we cannot say that negative IGAR may not exclude tuberculosis. Therefore a combined IGAR and TST test increases the diagnostic sensitivity.

RESISTANCE OF MYCOBACTERIUM TUBERCULOSIS TO FIRST AND SECOND LINE ANTI TUBERCULOSIS DRUGS AMONG MDR SUSPECTS

KK. Chopra, M. Hanif, S. Saini, H. Vashistha, Z. Siddiq, V. Ahmad

Background of the study: MDR TB cases threaten the effectiveness of chemotherapy for both treatment and control of TB and require the use of second-line drugs that are more expensive, toxic, and less effective than first-line anti-TB drugs. The Green Light Committee has observed increasing drug resistance in MDR TB cases in resource-limited countries, leading to the emergence of extensively drug-resistant TB (XDR-TB).This study was aimed

to determine the proportion and resistance pattern of Mycobacterium tuberculosis isolates among MDR-TB suspects.

Methodology of the Study: A total of Eight Hundred and Seventy Seven (N=877) MDR-TB suspects under RNTCP PMDT criteria referred to New Delhi Tuberculosis Centre from April to June, 2014 were enrolled in the study and tested as per PMDT guidelines under RNTCP. The specimens found resistant to rifampicin and isoniazid (MDR-TB) or rifampicin mono-resistant were processed for Liquid culture on MGIT960 and second-line drug susceptibility testing (DST) for ofloxacin and kanamycin.

Results: Of the 877 patients, MDR or rifampicin mono-resistance was observed in 135 (56.1%) of the patients under the study and all 135 specimens were processed for MGIT culture. Out of 135, 75.6% specimens turned out to be culture positive. XDR-TB and kanamycin mono-resistance was observed in equal proportion (1.96%) in the study population. However, a high proportion of M tuberculosis strains with Ofloxacin monoresistance were observed in the study.

Conclusion: Though, XDR-TB was observed in less proportion of study population, this raises an alarm regarding optimal use of second line anti-TB drugs. DST services should be made available and accessible to all MDR-TB suspects in the country.

HUMAN RIGHTS - TB DISEASE – CREATING AWARENESS

P.S. Sarma

Tuberculosis is an infectious disease killing 2 persons every 3 minutes. As on date 8.8. million people are getting infected with TB every year globally. Govt of India has taken a very wise step in making TB a NOTIFIABLE DISEASE nearly 2 years back and taking all steps to provide suitable Investigative and treatment facilities to those needed. Private sector is also involved in a big way.

Regarding Human rights in relation to TB, WHO has initiated the item of UNIVERSAL ACCESS as early as Oct 2010 and instructed all member countries to provide access to diagnostic facilities and Treatment facilities to the needy.

One cannot dismiss an employee on the grounds that he has TB, and a pregnant mother has every right to continue her Pregnancy and deliver the Baby even though she has TB disease . But the question still remains is : HOW MANY ARE AWARE of their RIGHTS REG TB?.

Lot of persuasion and motivation is need for educating our people more so the illiterate section of the community. The factor of STIGMA in the educated, problems of transport and availability of services nearby; availability of Trained Staff are all factors effecting . Role of NGOs and Private Health Sector and Media & Press is very important in creating awareness and also providing information and services to the community not only reg TB but also reg all other Health matters.

Mention may be made of IMA GFATM RNTCP PPM Programme - since 2007.. We have enough success stories where our doctors educated public, given them services freely and creating awareness.

We have an NGO by name SMLS Trust which is creating awareness in Agency areas of my home District East Godavari since 2010 reg TB and our periodic visits to the area created awareness.

DEMOGRAPHIC AND SOCIO-ECONOMIC RISK FACTORS AMONG DIABETIC

AND NON-DIABETIC TUBERCULOSIS PATIENTS UNDER DOT IN SOUTH

DELHI, INDIA

K.U. Khayyam, A.N Siddiqui, Nahida , D Vohora, M Sharma, R.Sarin

Background: The incidence of both these two diseases (TB & Diabetes) is exacerbated by socioeconomic factors and few studies in developing countries had shown the high TB prevalence in low socioeconomic settings as compared to the higher one. In the same way diabetes is also associated with socioeconomic factors and more prevalence is reported in deprived areas.Objectives: Diabetes is a well-known risk factor for tuberculosis (TB) and present study aims to evaluate the demographic and socio-economic risk factors associated with Tuberculosis and compare these factors among diabetic and non-diabetic Tuberculosis patients. Study design: Prospective cohort study. Material and Methods: Study had been conducted on three DMCs (Designated microscopic centers) on patients receiving Directly Observed Treatment, Short Course (DOTS) regimen for the management of tuberculosis from January 2014 to October 2014 at National Institute of Tuberculosis and Respiratory diseases (NITRD), New Delhi, India. After obtaining proper written informed consent, all participants were interviewed using a pretested questionnaire which contains identification and general information, demographic data, environmental data, workplace, economic factors, literacy levels, socio economic status, socio-physiological status, family history of tuberculosis and about known risk factors. All the participants were screened for blood glucose level under fasting condition using standardized glucometer (Accu check, active). Statistical Analysis: The collected data was analysed by using odd ratio test with SPSS version 22.0 to draw significant statistical inferences. Results: A total of 316 patients were enrolled for study. Out of those a total of 50 (15.8%) patients were diagnosed with diabetes mellitus (DM). Prevalence of diabetes in PTB patients was 36 (19.5%), in EPTB patients was 13 (10.1%). We have found a significant (p-value<0.05) difference in the distribution of age groups, Body mass index (BMI) and Literacy levels between patients with TB without diabetes and TB with diabetes. Significantly more patients of TB with DM group experiences negative emotional problems (OR; 0.373 95% C.I. 0.187-0.745) and unable to participate in social activities (OR; 0.491 95% C.I 0.263-0.918) compared to TB without DM group. Conclusion: Many socio economic and demographic risk factors are positively associated with patients of TB with DM. Assessment of these factors in patients and their families are important in order to improve treatment outcomes.

GEOGRAPHICAL AND DEMOGRAPHIC PROFILE OF TUBERCULOSIS IN PEDIATRIC POPULATION IN WESTERN INDIA

Ira Shah, Drishti Tolani

Aim: Pediatric Tuberculosis (TB) is endemic in Mumbai, India. However, geographical distribution and demographic pattern of children affected with TB is not known. This study aims to determine a geographical and demographic profile of children with TB.

Methods: Children from 0-15 years suffering from TB that were referred to our Pediatric TB Clinic located in central Mumbai from 2010 to 2011 were included in the study. Records of all the patients were reviewed and the age, gender, type of tuberculosis, drug resistant (DR) TB, community of patient and the region of residence were recorded. The association of age, gender, type of tuberculosis and drug resistance with area of residence was analyzed.

Results: Total 242 children were included in the study. Mean age of presentation was 5 ±3.8 years. Male: female ratio was 1.1:1. Total 230 (95%) patients were from Mumbai whereas 10 (4.1%) patients were from out of Mumbai. We were unable to record the residence of 2 patients. Of the 230 patients from Mumbai, 63 patients (26%) were from the Central Mumbai, 93 patients (38.4%) were from Central suburbs, 18 (7.4%) were from the South Mumbai and 57 (23.6%) from Western suburbs of Mumbai. The association between the area of residence and type of tuberculosis (pulmonary TB, p=0.1349; abdominal TB, p=0.063; bone TB, p=0.871; latent TB, p=0.0783; disseminated TB, p=0.9; adenopathy, p=0.6576; neuro TB, p=0.2564; serositis, p=0.170), gender (p=0.7139), drug resistance (p=0.5182) and age (p=0.2403) was not statistically significant. Overall 195 (80.6%) patients were Hindus and the remaining 47(19.4%) patients were Muslims. Similarly the association between the community (Hindu and Muslim) and type of tuberculosis (pulmonary TB, p=0.7518; abdominal TB, p=0.2146; bone TB, p=1.0; latent TB, p=0.2217; disseminated TB, p=1.0; adenopathy, p=0.3403; neuro TB, p=0.8157; serositis, p=1.0), gender (p=0.2121), drug resistance (p=0.3625) and age (p=0.8721) was also not statistically significant.

Conclusion: TB at our centre was predominantly seen in children from Central Mumbai which may be due to central location of our hospital. However, type of TB and DR-TB were seen equally in children from all parts of the city and was not located to any specific region.

RARE PRESENTATION OF PULMONARY TUBERCULOSIS AS A CASE OF CRYPTOGENIC ORGANISING PNEUMONIA

K Anupama Murthy, R Karthikeyan , Arun Thomas

INTRODUCTION:

Pulmonary tuberculosis is a great mimicker with varied atypical presentations, which are commonly seen in clinical practice. Cryptogenic Organising Pneumonia is one of the atypical rare presentations and only a few case records have been reported.

CASE: A 48/M, diabetic, smoker, textile mill worker presented with productive cough,

breathlessness and significant weight loss during last 4 months. He was evaluated by a General Physician and based on clinical and radiological picture, was started on empirical ATT.

On presentation to our department he had already completed 3 months of ATT, without much clinical improvement. Lab reports showed neutrophilic leucocytosis, elevated ESR, two samples of sputum were negative. Due to persistence of symptoms despite ATT further work up for alternative diagnosis was sought. HRCT showed thick walled cavity in right upper lobe with an air fluid level.USG guided FNAC/Biopsy done and FNAC was inconclusive. Biopsy reports showed features of COP.

In hospital patient was treated with ATT and was discharged on ATT and symptomatic measures. Further follow up after 1 month showed clinical improvement with weight gain of 3 Kgs and with radiological resolution and regression of the right upper lobe cavity. Patient was continued on ATT and completed 8 months of ATT.

CONCLUSION:

This clinical scenario proves the atypical presentation of pulmonary tuberculosis as COP. Improvement with ATT both clinically and radiological justified the need for starting empirical ATT as in our case and with no further active management for COP.

SOCIO POLITICAL AND ADMINISTRATIVE INTERVENTIONS AND ROLE OF

COMMUNITY PARTICIPATION IN TB CONTROL PROGRAMME IN

KASARAGOD DISTRICT- AN UPDATE

K. Raviprasada, Sunil Kumar.P.P

Introduction:

From 2010 onwards, Kasaragod District TB Centre is involving Panchayath Raj Institutions (PRI), Private Hospitals, line department nongovernmental organizations (NGO) and other community based organization (CBO) in the TB Control programme. The aim was to reach the TB patients in their locality and to address the issues relating to TB suspect examination and to meet other social welfare needs of TB patients. Several socio political and administrative interventions were introduced to increase the wellbeing and medication adherence. This paper discusses the influence of socio political and administrative interventions in TB control programme and involvement of PRIs, NGOs and CBOs on RNTCP programme and community action.

Methodology:

The follow up schedule as per RNTCP norms. The health staff visited the patient’s residence periodically. The outcomes were weight gain and wellbeing, dependency, educational wellbeing of family members and Job continuity. Eight socio political and administrative interventions were introduced in collaboration with PRIs, NGOs and CBOs. They were;For patient support:

1. Nutrition Support programme for TB and MDR TB patients (Kaithangu and Karunya) in collaboration with Kasaragod district panchayath and through private funding.

2. Financial support under Plan Fund and 3. TB pension.

Sensitization Programme for public:1. Formation of Pressure Group for default retrieval and to reduce stigma and

discrimination2. Sensitization Programme for Administrative staff of private hospital3. Training programme for SC/ST promoters4. Sensitization Programme for religious Leaders5. Akshaya Vidhyalayam (TB awareness programme for School students)6. Sanjeevini Centers (RNTCP Rural Information Centre)

Results:

The suspects examined per lakh/year are 257 in 2014. The case detection rate is 64% in 2014. While comparing with 2010, the cure rate is increased from 79 to 88% and decrease in death rate from 6 to 3%. 90.6% (29/32) MDR TB patients were benefited under kaithangu project, whereas 86% of TB patients under Karunya project. 80% of Patients got financial support and TB pension from government.

Discussion:

Implementation of socio-political intervention in Kasaragod district proved to be beneficial for TB and MDRTB patients. It is evident that active participation of PRIs, NGOs and CBOs on RNTCP Programme enhanced the outcomes. Further work is needed to explore factors leading to treatment adherence and to improve the community participation in National health programmes.

MYCOBACTERIUM CHELONAE CAUSING PULMONARY INFECTION – A RARE CASE REPORT

K. Anupama Murthy, R. Karthikeyan, B. Nithilavalli, C. Siddhuraj

M.chelonae a rapidly growing mycobacterium is a member of Runyon group 4 of mycobacteria which are commonly isolated from water and soil. It is a well known cause of soft tissue infections like injection abscess and wound infection. These organisms can also cause generalized disease in immune-compromized host. Pulmonary disease due to RGM is predominantly due to M. abscesses (80%), M. fortuitum (15%), M. chelonae rarely affect the lung and very few case reports are published globally. M. chelonae is characterized by a high degree of in vitro resistance to ATT and attempts at eradicating the organism through chemotherapy have been largely unsuccessful.

We present a 64 year old immune-competent female who is a case of treated pulmonary tuberculosis 3 times in past 14 years (DOTS & Non dots). She presented with cough, sputum and fever for 2 months of duration. Chest X ray, CT chest suggestive of nodular lesions and areas of consolidation in bilateral lower lobes. Sputum smear for AFB showed 1+, Liquid culture showed presence of MOTT – RGM. Species identification was suggestive of M. chelonae in both liquid culture and DNA extraction method. Confirmation of MOTT was done as per ATS guidelines and initiated on treatment according to DST. Patient has now completed 3 months of chemotherapy and showing clinical improvement.

ADVERSE EFFECTS OF AMINOGLYCOSIDES IN CHILDREN WITH DRUG RESISTANT TUBERCULOSIS

Ira Shah, Anmol Goyal

Aim: To determine tolerance of aminoglycosides in children with drug resistant (DR) tuberculosis (TB).

Setting: Retrospective analysis at a Pediatric TB clinic of a tertiary referral children’s hospital over a period of 6 years from 2007 to January 2013.

Methods: Children less than 15 years of age who were diagnosed to have DR-TB who had received aminoglycosides were included in the study. Factors associated with ototoxicity and nephrotoxicity of aminoglycosides in various age groups of both sexes were analyzed.

Results: Sixty-seven out of 84(79.8%) patients with DR-TB received aminoglycoside. Hearing loss was seen in 21(31.3%) patients and the mean duration of treatment after which they developed hearing loss is 5.92.9 months. Among 60(89.6%) who received amikacin, the mean duration of receiving amikacin was 5.82.8 months of which 20 (33.3%) developed hearing loss. Those who developed hearing loss had received amikacin for 72.1 months. Kanamycin was given in 7(10.5%) patients with mean duration of 52.3 months and only 1(14.3%) developed hearing loss after 8 months of therapy. One patient (1.5%) received capreomycin for a duration of 5 months with no hearing loss. Ten (47.6%) children had sensorineural hearing loss while 6 (28.6%) had conductive hearing loss and 5 (23.8%) had mixed hearing loss. High frequency hearing loss was seen in 10 (47.6%) patients, while only 2 (9.523%) had low frequency involvement. No one developed symptomatic hearing loss. Bilateral ear involvement was seen in 16 (76.2%) patients, while right ear was involved in 3 (14.3%) and left ear in 2 (9.5%) patients. Nephrotoxicity was seen in 10 (14.9%) patients which developed after a mean duration of 9 4 months.

Conclusion: Hearing loss especially in high frequency is seen in over 30% of children with DR-TB on aminoglycoside therapy after a mean duration of 5.9 months and nephrotoxicity is seen in 10% of patients. No particular aminoglycoside is associated with oto- or nephrotoxicity. Aminoglycosides can be used in children with DR-TB for a prolonged period of time, however monitoring for adverse effects is essential to prevent clinically irreversible damage.