AABS 4.2 (2017) by PaGe

eISSN: 2349-6991 pISSN: 2455-0396

Annals of Applied BioSciences An International, Open access, Indexed, Peer-reviewed Journal

April-June. 2017; Vol. 4, Issue 2

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DOI : 10.21276/aabs

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Table of Contents Review Articles Bone Morphogenetic Proteins: An Overview

R35-R37

Original Article Tumour-like lesions of oral cavity: A clinicopathological study of 95 cases

A83-A88

Anamika Sharma, Himani Sharma

Smita Surendra Masamatti, Alka V Gosavi, Kalpana Ranjitsingh Sulhyan

Coronal Incision: An Approach to Facial Fractures Surya Rao Rao Venkata Mahipathy, Alagar Raja Durairaj, Narayanamurthy Sundaramurthy, Shobhan Nandy

A89-A93

Comparison of ELISA & rapid screening tests for the diagnosis of HIV, HBV & HCV among blood donors in blood bank of C.C.M. Medical College Durg Chhatishgarh Prahlad Chandra Agrawal, Shiv Chandraker, Prarabdha Agrawal

A94-A98

The awareness and perception about the Ethical concerns related to the Biobanks among Medical and Dental practitioners- A questionnaire based study Mohammadi Begum Khan, Faizan Ahmed Khan, Veena Vaswani, Uma Kulkarni, Parvathy Ram Mohan

A99-A103

Spectrum of Interface dermatitis : An Observational studyâ&#x20AC;&#x2122; Vishrabdha Rahul Pawar, Vaibhav Pandurang Mane, Renuka Satish Ashtekar

A104-A110

Studies on bio-ethanol production using fermentation by free and immobilized A111-A116 yeast cells P Manasa, Narasimhulu Korrapati, Paramjeet Saroj

Health and health related quality of life of children living with HIV infected parents A117-A121 Priyanka Chauhan, Sunit Pathak, N C Prajapati

Clinicopathological profile of anaemia cases in adults (20-60 years) attending a A122-A128 rural hospital Mangal Motilal Pandure, Deepak Kumar Ghosh

Hepatitis B versus HIV in Blood Donors Ravi Jain, Ashok Yadav

A129-A133

III

Case Reports

A Rare Case Report Of Corynebacterium minutissimum Causing Bacteremia In An Immunocompetent Patient Sunita Gupta, Vibha Bhargava, Rohit Jain, Prateek Goyal, G N Gupta

C13-C15

Lingual Schwannoma: A Case Report Manish Munjal, Archana Arora, Damanpreet Singh, Gopika Talwar, Japsimran Nagpal

C16-C17

Diagnosis of subcutaneous cysticercosis as a cystic mass over chest wall: A case report and review of the literature Tanima Dwivedi, Reshma Davangeri

C18-C20

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Review Article DOI: 10.21276/AABS.1336

Bone Morphogenetic Proteins: An Overview Anamika Sharma* and Himani Sharma Department of Periodontology, Subharti Dental College and Hospital, Meerut India.

ABSTRACT For over years research has been carried out for finding the treatment procedures for the regeneration of a lost or injured part so that form and function of lost structures can be restored. This regenerative field holds the promise of engineering damaged tissues with the help of various growth factors including Bone Morphogenetic Proteins (BMPs), by stimulating the body’s own repair mechanisms. BMPs constitute the largest subgroup of transforming growth factor beta superfamily. Till date over 30 members of this family has been identified. They are dimeric molecules and exhibit their effects using specific cell surface receptors. With the development of the techniques required for the isolation and cloning of these molecules, we are now able to understand their properties. They are powerful inductors of the osteogenic activity and have proliferative effects on various cellular types. This made us to use them in various therapeutic procedures including oral maxillofacial reconstruction, periodontal regeneration, enhancing osseointegration around dental implants and in various endodontic procedures. However, their effect is dosage and carrier dependent. Thus, the aim of this review is to help in understanding the structure, classification, signaling and role of BMPs in regeneration of bone and tissues. Keywords: Bone Morphogenetic Proteins, Regeneration, Growth Factors

Introduction

The advancement in tissue engineering techniques has made it possible to develop various procedures utilizing the biological mediators like bone morphogenetic proteins (BMPs) for the regeneration of bone and tissues lost due to diseases.1,2 BMPs comprises of a group of potent, multi-functional growth factors, belonging to transforming growth factor beta (TGF-β) superfamily, which were discovered by Urist and coworkers3 in 1965. They have been shown to play an important role in regulating the growth, differentiation and apoptosis of various cell types, including osteoblasts, chondroblasts, neural cells, and epithelial cells, depending on the cellular microenvironment and the interaction with other regulatory factors.4,5 Also when implanted into the bone matrix this protein component resulted in series of cellular events leading to mesenchymal cell infilteration, cartilage formation, vascularization, bone formation, and remodeling of the new bone along with proliferation of hematopoietic bone marrow elements.6 Hence, this review is an attempt to summarise the characteristics and various applications of Bone Morphogenetic Proteins.

Classification of BMPs

Till date only 20 different human BMPs have been discovered and classified into subfamilies, but including

activin, inhibin, growth differentiating factors (GDFs) there are nearly 30 members in BMP family.7 BMPs are classified on the basis of their sequence similarities and functions into four subfamilies:-. a. Ist group- BMP2 and BMP4 – (80% homology)highly related molecules, differs mainly in amino terminal region, where BMP2 contains a heparinbinding domain. b. IInd group- BMP3, BMP3B (GDF10) – also called as Osteogenin. c. IIIrd group- BMP5, BMP6, BMP7, BMP8a, BMP8b – (78% homology) d. IVth group- GDF5, GDF6, GDF7-(cartilage-derived morphogenetic protein 1,2,3) However, BMP1 is not considered as a member of TGF-β superfamily, as it lacks the structure conserved in the TGF-β superfamily. In some studies, it has been reported as a procollagen C- proteinase, processing procollagen to collagen.8,9

Structure And Signaling Of BMPs

BMPs are synthesized as precursor proteins having polypeptide chains ranging in size from 369-513 amino acids which are cleaved by pro-protein convertases and serine endoproteases to generate mature and active homodimers and heterodimers.3,10,11 These dimeric molecules, constitutes about 120 amino acids. It comprises of seven conserved cysteine residues.

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Out of these six forms a cysteine knot motif, linked with three intra-molecular disulfide bonds forming a critical core of the BMP monomer.10,12,13 BMP molecules exhibit their activity by binding to two types of specific cell surface receptors: Bone morphogenetic protein receptor, type 1 (BMPR 1) and Bone morphogenetic protein receptor, type 2 (BMPR 2). The BMP signaling cascade is initiated by binding to these cell surface receptors through-3 • •

Canonical pathways Non-Canonical pathways.

Dosage And Carriers of BMP-

The estimated amount of BMP per kilogram pulverized bone is 0.002mg.14 The amount of BMP required to induce bone bridging in osseous defects depends upon- the state of organism in the evolutionary scale, anatomic location of the site of application and the type of defect.15,16 BMP is water soluble, and diffuses very easily in body fluids. For the effectiveness BMPs require a competent carrier in order to be contained.10,15

of new connective tissue attachment and bone in both root submerged and non-submerged environment.13,23 Thus, concluding that BMPs offer promise as an attractive candidate for treating severe periodontal lesions with significant potential for stimulating periodontal regeneration.23

Conclusion

Several studies have highlighted that BMPs provide a framework for the regeneration of the various tissue components of the periodontium and, in addition, may play important physiological roles in repair, regeneration and remodeling. However, despite a great deal of research effort, the ideal treatment modality using BMPs has yet to be established and further basic research is required to elucidate the detailed mechanism of BMP receptor activation and signal transduction to the cell nucleus and the their clinical applications.

References 1.

Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology 11th edition. Elsevier health sciences; 2015

These carriers can be broadly classified into – naturally occurring polymeric substances, inorganic salts, synthetic polymers and composites of synthetic and naturally occurring polymers and titanium. About 15-55% of increased retention was seen when BMPs were combined with gelatin foam or collagen.17

Kao RT, Murakami S, Beirne. The use of biologic mediators and tissue engineering in dentistry. Periodontol. 2000 2009;50:127-53.

Richard NW, Jordan, Zhongliang W, Youlin D, Min Q, Michael P et al. Bone Morphogenetic Protein (BMP) Signaling in Development and Human Diseases. Genes & Diseases. 2014;1(1):87-105.

Regenerative Potential of BMPs-

Kingsley DM. The TGF-b superfamily: New members, new receptors, and New genetic tests of function in different organisms. Genes Dev. 1994;8:133–46.

Wang EA. Bone morphogenetic proteins (BMPs): Therapeutic Potential in healing bony defects. Trends Biotechnol. 1993;11:379‑83.

Reddi AH. Cell biology and biochemistry of endochondral bone Development. Coll Relate Res. 1981;1:209‑26.

Reddi AH. Bone Morphogenetic Proteins: An unconventional approach to isolation of first mammalian morphogens. Cytokine & Growth Factor reviews. 1997;6:11-20.

Karuppanan PS, Elavarasu S, Jayaprakash SG. The application of bone morphogenetic proteins to periodontal and peri-implant tissue regeneration: a literature review. J pharm bioallied sci. 2012;4:427-30.

Sakau T. Bone Morphogenetic Proteins: From Basic Studies To Clinical Approaches. Bone. 1998;22(6):591–603.

Bowers et al, described the first successful use of BMP for periodontal regeneration. BMPs, demonstrates pleotrophic effects on the stimulation of several key events required for tissue regeneration including DNA synthesis, chemotaxis, differentiation, and matrix synthesis.19,20 18

Several tests have been conducted, demonstrating the increased regeneration of alveolar bone, periodontal ligament(PDL) and cementum in bone defects, bone healing, acceleration osteointegration, oral and maxillofacial reconstruction, bone pathology sequel repair, distraction osteogenesis as well as, in endodontic procedures.2,21,22,23,24,25Treatment of endosseous implants with bovine BMP and rhBMP-2 caused the stimulation of agreater amount of bone deposition and bone-to-implant contact, which was more significant after 4 and 12 weeks of healing.26,27,28 The anabolic effect of BMPs on periodontal tissues is through stimulation of osteoblastic differentiation in human PDL cells and by stimulation of alkaline phosphatase activity in periosteal cells thus, enhancing the regeneration

10. Lee MB. Bone morphogenetic proteins: background and implications for oral reconstruction.J ClinPeriodondol. 1997;24:355-365. 11. Kawabata M, Imamura T, Miyazono K. Signal transduction by bone morphogenetic proteins. Cytokine Growth Factor Rev. 1998;9(1):49-6.

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R-37 12. Griffith DL, Keck PC, Sampath TK, Rueger DC, Carlson WD. Three-dimensional structure of recombinant human osteogenic protein 1: structural paradigm for the transforming growth factor beta superfamily. ProcNatlAcadSci U S A. 1996;93:878–883. 13. Ripamonti U, Reddi AH. Periodontal regeneration: potential role of bone morphogenetic proteins .Journal of Periodontal Research. 1994;29(4):225-235. 14. Nelsen SM, Christian JL. Site-specific cleavage of BMP4 by furin, PC6, and PC7.J BiolChem 2009;284(40):27157-66. 15. Setti SR. Bone morphogenetic proteins: basic concepts. Neurosurg Focus. 2002;13(6):1-6. 16. Setti SR. Bone morphogenetic proteins: basic concepts. Neurosurg Focus. 2002;13(6):1-6. 17. Ziyad S, Haidar ZS, Hamdy RC, Tabrizian M. Delivery of recombinant bone morphogenetic proteins for bone regeneration and repair. Part A: Current challenges in BMP delivery. BiotechnolLett. 2009;31:1817–1824. 18. Vukicevic S, Sampath KT, editors. Bone Morphogenetic Proteins.In:Regeneration of Bone and Beyond.Elseveir; 2004. pg45-72. 19. Bowers G, Felton F, Middleton C, Glynn D, Sharp S, Mellonig J, et al. Histologic comparison of regeneration in human intrabony defects when osteogenin is combined with demineralized freeze-dried bone allograft and with purified bovine collagen. J Periodontol. 1991;62:690-702. 20. Sigurdsson TJ, Lee MB, Kubota K, Turek TJ, Wozney JM, Wikesjo U. Periodontal repair in dogs: Recombinant human bone morphogenetic protein-2 significantly enhances periodontal regeneration. Journal of periodontology. 1995;66:J31-I38. 21. Saito A, Saito E, Handa R, Honma Y, Kawanami M. Influence of residual bone on recombinant human bone morphogenetic

AABS; 4(2): 2017 protein- 2-induced periodontal regeneration in experimental periodontitis in dogs. J Periodontol. 2009;80:961-968. 22. Bashutski JD, Wang HL. Biologic agents to promote periodontal regeneration and bone augmentation. Clinical Advances in Periodontics. 2011;1(2):80-87. 23. Díaz-Sánchez RM, Yáñez-Vico RM, Fernández-Olavarría A, Mosquera-Pérez R, Iglesias-Linares A, Torres-Lagares D. Current approaches of bone morphogenetic proteins in dentistry. J Oral Implantol. 2013;41:337-42. 24. Weng D, Poehling S, Pippig S, Bell M, Richter EJ, Zuhr O et al. The effects of recombinant human growth/differentiation factor-5 (rhGDF-5) on bone regeneration around titanium dental implants in barrier membrane-protected defects: a pilot study in the mandible of beagle dogs. Int J Oral Maxillofac Implants. 2009;24:31-7. 25. Giannobile WV, Somerman MJ. Growth and amelogeninlike factors in periodontal wound healing. A systematic review. Ann Periodontol. 2003;8:193-204. 26. Hanisch O, Tatakis DN, Rohrer MD, Wöhrle PS, Wozney JM, Wikesjö UM. Bone formation and osseointegration stimulated by rhBMP-2 following subantral augmentation procedures in nonhuman primates. Int J Oral Maxillofac Implants. 1997;12:785-92. 27. Cochran DL, Schenk R, Buser D, Wozney JM, Jones AA. Recombinant human bone morphogenetic protein-2 stimulation of bone formation around endosseous dental implants. J Periodontol. 1999;70:139-50. 28. Cochran DL, Jones AA, Lilly LC, Fiorellini JP, Howell H. Evaluation of recombinant human bone morphogenetic protein-2 in oral applications including the use of endosseous implants: 3-year results of a pilot study in humans. J Periodontol. 2000;71:1241-57.

*Corresponding author: Dr. Anamika Sharma, Professor & Head, Department of Periodontology, Subharti Dental College & Hospital, Meerut., INDIA Phone: +91 09219600994 Email: prof_anamika@hotmail.com Date of Submission : 09.02.2017 Date of Acceptance : 14.04.2017 Financial or other Competing Interests: None. Date of Publication : 30.04.2017

Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article DOI: 10.21276/AABS.1426

Tumour-like Lesions of Oral Cavity: A Clinicopathological Study of 95 Cases

Smita Surendra. Masamatti1*, Alka Vikas. Gosavi2 and Kalpana Ranjitsingh Sulhyan2 Dept. of Pathology, Sapthagiri Institute Of Medical Sciences And Research Centre Bangalore, Karnataka, India 2 Dept. of Pathology, Government Medical College, Miraj, Maharashtra, India.

ABSTRACT Background: Tumourlike lesions or reactive lesions of the oral cavity are group of fibroconnective tissue lesions that commonly occur in the oral mucosa as a result of injury. Aim: The purpose of this study is to determine the relative prevalence of different histopathological aspects of oral soft tissue tumourlike lesions which were received at Pathology department, Government medical college, Miraj, Maharashtra Methods: A total number of 95 cases of tumourlike lesions were included in the study. Specimens were received at department of pathology, Government medical college, Miraj, Maharashtra over a period of 5 years from August 2008 to July 2013. It was one year retrospective and four years prospective, cross sectional study Result: A total number of 642 oral biopsies and excised specimens were studied, out of which 95cases (14.8%) belonged to tumourlike lesions. Among tumorlike lesions, pyogenic granuloma (47.38%) was the commonest lesion, followed by Mucocele (26.32%). Majority of tumorlike lesions were located on gingiva (38.94%) followed by lower lip (28.42%). Males (57.89%) were more commonly affected than females and the commonest symptom was swelling (100%). Conclusion: The most common tumourlike lesion in our study was pyogenic granuloma. Few very rare and interesting cases like plasma cell granuloma and Nasolabial cyst were also seen. Tumorlike lesions presented mainly as nodule or swelling, which should be differentiated from other benign and sometimes malignant lesions, as the tumourlike lesions have good prognosis when compared to malignant lesions. Hence histopathology remains the mainstay for correct diagnosis and treatment. Keywords: Oral Cavity, Pyogenic Granuloma, Reactive Lesion, Tumourlike Lesion

Introduction

The term â&#x20AC;&#x153;soft tissue tumourâ&#x20AC;? includes a different group of neoplastic and reactive lesions which are derived from supporting mesenchymal or connective tissues of the body. These consist of tumours made up of fibrous tissue, fat, muscle, nerves and blood vessels. [1] In oral cavity, mastication makes it susceptible for different types of trauma and injury, also the presence of teeth and odontogenic tissue is adding more liability for variety of diseases which vary from, simple inflammatory disease to highly malignant tumours. [2] Tumourlike lesions of oral cavity are not included in the WHO classification 2005. However the previous WHO classification 1971 by P.N.Wahi et al included these lesions in their classification. According to this classification, the various tumourlike conditions listed are, Verruca vulgaris, Papilliferous hyperplasia, Mucocele, Nasolabial cyst, Fibrous overgrowth, congenital fibromatosis, Xanthogranuloma, Pyogenic granuloma, Peripheral giant cell granuloma (Giant cell epulis), Traumatic neuroma, Inflammatory pseudotumour (Plasma cell granuloma).[3]

Although these lesions are benign in nature, they do have a tendency towards recurrence with incomplete removal of the lesion or the local irritants involved at the site. The treatment in each case is complete surgical excision, however nowadays different treatment modalities are available which offers better outcomes with less chances of recurrence. [4] The various tumourlike lesions in the present study were pyogenic granuloma, mucocele, plasma cell granuloma, nasolabial cyst, fibrous epulis and giant cell fibroma. The present study reviews the various clinical and histopathological features of all these six types of reactive lesions and establishes the relative prevalence of different tumourlike lesions in relation to age, gender and site in oral cavity.

Materials and Methods

The present study consisted of analysis of tumourlike lesions of oral cavity received in the histopathology section of department of pathology at Government medical college, Miraj, Maharashtra over a period of 5 years that is from August 2008 to July 2013. This was one year

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retrospective and four years prospective study. Patients data were assessed to collect data including, age, gender, affected site clinical presentation, personal habits and clinical diagnosis. The material comprised of oral biopsies and excision specimens. Inclusion criteria 1. Tumorlike lesions of oral cavity. 2. Specimens which were adequate and representative of the lesion. 3. Resected surgical specimens like wide local excision, incisional biopsies, wedge biopsies etc Exclusion criteria 1. Inadequately preserved specimens. 2. Neoplasms arising from nasopharynx and oropharynx 3. Neoplasms of odontogenic origin. 4. Bone tumours of mandible and maxilla.

Result

During the five year interval, 95 tumorlike lesions were recorded from a total oral biopsy of 642 cases. This constituted about 14.79% of total oral biopsies. The age range of the patients was from 8 to 73 years and the mean age was 30 years. Most of the lesions (36.84%) were found in the third decade of life. Males constituted 57.89% of the cases and 42.11% of the lesions were found in females. The most affected anatomic location was Gingiva (38.94%) followed by lower lip (28.42%). Pyogenic granuloma (PG): There were 45 cases of PG, maximum no of cases occurred between second and third decade. Maximum no of PG (48.88%) were located on gingiva, with female preponderance of 64.45%. Grossly the size of PG ranged from 0.3cms to 2.5cms. Histologically all PG showed numerous small and large vascular channels which are engorged with RBCs and lined by flat or plump endothelium. Polymorphs as well as chronic inflammatory cells were also seen. (Figure 1) Mucocele: In the present study, 25 mucocele cases were encountered. The peak incidence was found in 2nd and 3rd decade with slight male preponderance of 52%. Lower

lip was commonest site (48%). Grossly all of them were, dome shaped mucosal swelling ranging from 1 to 2 mm to several centimeters in size. Microscopically they were classifed as 1) Extravasation type & 2) Retention type. Extravastion type showed foci of stromal reaction due to spillage of mucous from a traumatically injured minor salivary gland where as retention cyst shows mucous filled cyst completely lined by cylindrical, cuboidal or flattened cells. (Figure 2) Nasolabial cyst (NLC): One case of NLC was encountered as incidental finding. Patient was 63 year old female who presented with fluctuant, soft, cystic mass on left gingivolabial sulcus measuring about 2x2 cms. Microscopy revealed cyst lined by pseudostratified columnar epithelium. Numerous goblet cells were seen. (Figure 3) Plasma cell granuloma (PCG): One case of PCG was observed in a 58 year old female, presented with polypoidal mass over gingiva. Radiological and serum electrophoresis were normal. Grossly the mass measured 3x2 cms, cut surface showed whitish appearance. Histologically the mass was covered by stratified squamous epithelium & was composed of aggregates of spindle cells separated by thick collagen bundles. Many Russell bodies were noted. (Figure 4) Fibrous epulis (FE): There were 18 cases of FE which showed a peak incidence in 4th decade (55.55%) with slight male preponderance. Gingiva was the most common site (61.11%). On gross examination, all cases presented as nodular lesions. Microscopically the mass was covered by stratified squamous epithelium and composed of proliferating fibroblasts arranged haphhazardly and at places in short bundles. Foci of clacification were also noted in few cases. Giant cell fibroma (GCF): Five cases of GCF were encountered during the study period. Majority of them showed male preponderance (80%) and maximum no of cases occurred in gingiva (60%). Histologically all GCF showed mass covered by stratified squamous epithelium and was composed collagenous stroma with many scattered stellate shaped fibroblast.

Table 1: Broad classification of tumourlike lesions of oral cavity along with genderwise distribution. Sl.no Type of tumourlike lesion Males Females Total no of cases (%) 1 Mucocele (Extravasation and retention type) 13 12 25(26.32%) 2 3 4 5 6 TOTAL

Pyogenic granuloma Plasma cell granuloma Nasolabial cyst Fibrous epulis Giant cell fibroma

16 --10 04 43

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29 01 01 8 01 52

45(47.38%) 01(1.05%) 01(1.05%) 18(18.94%) 05(5.26%) 95(100%)

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AABS; 4(2): 2017

Table 2: Agewise distribution of tumourlike lesions of oral cavity. Age in years

1 2 3

Sl.no

Tumourlike lesions of oral cavity Mucocele

Pyogenic granuloma

Plasma cell granuloma

Nasolabial cyst

1-10

08(8.55%)

11-20

20(21.05%)

21-30

35(36.84%)

31-40

20(21.05%)

41-50

06(6.31%)

51-60

02(2.10%)

61-70

02(2.10%)

>70

01(1.05%)

95(100%)

Total

Fibrous epulis

Giant cell fibroma

Total

Table 3: Distribution of various clinical features of tumourlike lesions of oral cavity. Sl.no

Symptoms

Tumourlike lesions . No ( %)

Swelling/nodular lesion

95(100%)

Pain

55(57%)

Difficulty in chewing

48(50.5%)

Excessive salivation

15(15.7%)

Table 4: Sitewise distribution of tumourlike lesions of oral cavity. Sl.no

Lesions

Buccal mucosa

Mucocele

Pyogenic granuloma

Plasma cell granuloma

Nasolabial cyst

Fibrous epulis

Giant cell fibroma

Total

18(18.94%)

Tongue

Gingiva

Floor of mouth

Lower lip

Total

08(8.42%)

27(28.42%)

95(100%)

05(5.26%) 37(38.94%)

Fig. 1: Pyogenic granuloma showing many capillary sized blood vessels.( H & E, x100).

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Fig. 2: a) Gross picture of Mucocele of lower lip, cystic swelling. b) Low power showing cyst lined by granulation tissue. Cavity shows mucin associated with foamy histiocytes. Inset shows foamy histiocytes (H & E, x100).

Fig. 3: Nasolabial cyst- Cyst wall lined by pseudostratified columnar epithelium. Inset shows presence of goblet cells in the lining. (H & E,x100).

Fig. 4: a) Gross picture of PCG showing solid greywhite cut surface. b) Microscopy showing sheets of plasma cells separated by thick collagen bands. (H & E, x100). Inset shows Russell bodies, x400).

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Discussion

The present study findings cannot be exactly compared with other similar studies as there are only few studies reporting the prevalence of oral mucosal lesions around the world and also the difference is attributed to the given geographic area. The study aims to report the prevalence of histopathology of various tumorlike lesions along with its clinical correlation, received at Government medical college, Miraj, Maharashtra. The final outcome of the study shows that the soft hemorrhagic lesions were more common than the fibrous lesions. Pyogenic granuloma was the most common tumourlike lesion. All the six tumourlike lesions in our study are discussed in detail and are compared with other studies. Pyogenic granuloma (PG): PG is a relatively common entity first described by Poncet and Dor in 1897 as “Human botryomycosis”. Hartzell introduced the term ‘Pyogenic granuloma’ (PG) and some authors used the term ‘Lobular capillary hemangioma’ (LCH). [5] It accounts for about 1.5 to 2 % of all oral lesions. [6] In 2001, M. Umut Akyol et al reviewed 835 cases in the literature and showed that the prevalent age for the development of pyogenic granuloma appears between 11 and 40 years, and also the most common site was gingiva (75%) and less frequently at other sites like tongue. Our findings correlate with this study. [5] Mucoceles are mucous cysts related to obstruction or trauma of the minor salivary glands. [7] They typically appear as dome shaped mucosal swellings that range from 1 to 2 mm to several centimeters in size. It is often seen in young individuals, the lower lip being the classic location. [8] Oliveira et al studied 112 cases of mucocele and found that extravasation cyst was the most commonly found (92.45%) however mucous retention cysts were also observed (7.54%). It was most prevalent in the second decade of life (45%) and predominant location was lower lip (52.25%). [7] These all findings correlated with our findings. Plasma cell granuloma (Inflammatory pseudotumour): Inflammatory pseudotumour (IPT) is a tumourlike lesion. Other synonyms used for this lesion are Plasma cell granuloma, histiocytoma, Xanthomatous granuloma, inflammatory myofibroblastic tumour and spindle cell pseudotumour. The exact incidence of IPT in oral cavity is unclear. [9]Clinicallly and radiographically it may be misinterpreted as a malignant neoplasm. It tends to affect children and young adults. The cheek and mandible are the sites of predilection in oral cavity. [10]But in our study, one case of PCG (1.05%) was seen, which presented as a gingival swelling. Kim et al suggested that interleukin-6 Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

AABS; 4(2): 2017 (IL-6) and phospholipase C-1 may induce heavy plasma cell infiltration in cyclosporine induced gingival overgrowth. [11] Our patient did not give any history of intake of medicines. Nasolabial cyst: Nasolabial cyst is a rare non odontogenic tumour arising from maxillofacial soft tissues. They represent about 0.7% of all cysts in the maxillofacial region and 2.5% of all non odontogenic cysts. [12]This condition was first described by Zuckerkandl in 1882. The various synonyms for nasolabial cyst include Nasoalveolar cyst, Klestadt cyst, Fissural cyst, Non odontogenic cyst, soft tissue cyst. Clinically these cysts are seen in the extraosseous region of the nasolabial fold, projecting over upper lip. It is more common in middle aged females (4:1), usually asymptomatic and unilateral. [13]Lopez Rios et al noticed extensive apocrine change in the lining epithelium. [14] Tiago RS et al observed that most of the patients belonged to age group of above 30 years with a female preponderance and cysts were unilateral in 85% of the cases, which correlates with our study. [15] Giant cell fibroma (GCF): Giant cell fibroma is a fibrous hyperplastic lesion of oral cavity and has a distinctive clinicopathology unlike traumatic fibroma. GCF is a relatively rare tumourlike lesion that could be diagnosed only on histopathological examination. It was named so due to its characteristically large, stellate shaped, mononuclear and multinucleated giant cells. Sabrinath et al reported that the mean age was 39 years, gingiva being the commonest location and showed slight male preponderance which correlates with our findings. [16] Fibrous epulis: Fibrous epulis is considered to be one of the most common benign growths occuring on gingiva. The lesion is usually located in the premolar area between ages of 21 to 40 years. H.A. Ajagbe observed that the lesions were more common in females than males’ correlates with our findings. And also in his study, centres of ossification and calcification were noted, which were not seen in our cases. [17] Buchner et al reported most of the cases to occur in the 3rd, 4th and 5th decade of life whereas Kfir Y et al found the majority of cases in the 2nd, 3rd and 4th decade, which correlates with our findings. [18, 19] The various results obtained in this study overall confirm with those of other researchers, though slight differences were observed in age and gender distribution. It is helpful to know the various histopathological types and clinical presentation of tumourlike lesions of oral cavity in order to develop a clinical impression of such lesions during practice. And also the data will help the clinicians and pathologists to be aware of possible occurrence of such rare lesions. e-ISSN: 2349-6991; p-ISSN: 2455-0396

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Conclusion

Tumourlike lesions usually present as swelling or nodule which may mimic benign or malignant lesions clinically and pose a diagnostic problem to the clinicians and pathologists. So all oral lesions should be diagnosed early and subjected for histopathological examination for the correct diagnosis as tumourlike lesions have got good prognosis and doesnot recurr unlike the malignant lesions.

Reference 1.

Shahsavari F, Khourkiaee SS, Moridani SG. Epidemiologic study of benign soft tissue tumors of oral cavity in an Iranian population. Journal of dentomaxillofacial radiology, pathology and surgery. 2012;1(1):10-14.

Hassawi BA, Ali E, Subhe N. Tumors and tumor like lesions of the oral cavity. A study of 303 cases. Tikrit medical journal.2010:16(1):177-83.

P.N.Wahi. Histological typing of oral and oropharyngeal tumours. Issue 4 of international histological classification of tumours. World health organisation. 1971.

Kasyap B, Reddy S, Nalini P. Reactive lesions of oral cavity: A survey of 100 cases in Eluru, West Godavari district. Contemporary clinical dentistry. 2012; 3(3): 294-97.

Akyol MU, Yalciner EG, Dogan AI. Pyogenic granuloma (lobular capillary hemangioma) of the tongue. Int J Pediatr Otorhinolaryngol.2001; 58: 239-41.

Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J oral sci. 2006 Dec; 48(4): 167-75.

Oliveira DT, Consolaro A, Freitas FJ. Histopathological spectrum of 112 cases of mucocele. Braz Dent J. 1993; 4(1):29-36.

Ackerman L.V. and Rosai. J Oral cavity and oral pharynx. A textbook of surgical pathology. 9th ed. Mosby St Louis: 1996.p-247.

Shek AW, Wu PC, Samman N. Inflammatory pseudotumour of the mouth and maxilla. J clin pathol. 1996; 49(2): 164-7.

10. Coffin CM, Fletcher JA, Fletcher C.D.M. , Unni KK, Mertens F(Ed): World health organisation classification of tumours. Pathology and genetics of tumours of soft tissue and bone. IARC Press: Lyon; 2002.p91-3. 11. Kim SS, Eom D, Huh J, Sung I, Choi I, Sung HR et al. Plasma cell granulomas in cyclosporine induced gingival growth; A report of two cases with immunohistochemal positivity of interleukin-6 and phospholipase C-g. J Korean med sci. 2002; 17: 704-7. 12. Pereira Filho VA, Silva AC, Moraes M, Moreira RW,Villalba H. Nasolabial cyst: Case report. Braz Dent J. 2002; 13(3):212-4. 13. Nasolabial cyst by Dr T. Balasubramanian [internet][Cited on 2014 Oct 20] Available at: http://www.drtbalu.co.in/naso cyst.html. 14. Lopez-Rios F, Lassaletta- Atienza L, Domingo- Carrasco C, Martinez- Tello FJ. Nasolabial cyst: report of a case with extensive apocrine change. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997 Oct; 84(4); 404-6. 15. Tiago RS, Maia MS, Nacimento GM, Correa JP, Salgado DC. Nasolabial cyst: diagnostic and therapeutical aspects. Rev Bras Otorhinolaringol. 2008; 74(1):39-43. 16. Sabrinath B, Sivaramakrishnan M, Sivapathasundharam B. Giant cell fibroma: A clinicopathological study. J oral maxillofac Pathol. 2012; 16(3): 359-62. 17. Ajagbe HA, Daramola JO. Fibrous epulis: Experience in clinical presentation and treatment of 39 cases. 18. Buchner A, Calderon S, Ramon Y. Localized hyperplastic lesions of the Gingiva: a clinicopathological study of 302 lesions. J Periodontol. 1997 Feb; 48(2):101-04. 19. Kfir Y, Buchner A, Hansen LS. Reactive lesions of the Gingiva. A clinicopathological study of 741 cases. J Periodontol. 1980 Nov; 51(11):655-61.

*Corresponding author: Dr Smita Surendra. Masamatti, DQ 14, Sapthagiri Hospital, Chikkasandra, Bangalore, 560090, India Phone: +91 9741147555 Email: smitamas@yahoo.co.in Date of Submission : 22.03.2017 Date of Acceptance : 06.04.2017 Date of Publication : 10.04.2017

Financial or other Competing Interests: None.

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Original Article DOI: 10.21276/AABS.1430

Coronal Incision: An Approach to Facial Fractures Surya Rao Rao Venkata Mahipathy1*, Alagar Raja Durairaj1, Narayanamurthy Sundaramurthy1 and Shobhan Nandy2 1

Dept. of Plastic & Reconstructive Surgery, Saveetha Medical College & Hospital, Tamilnadu, India 2 Dept. of Oral & Maxillofacial Surgery, Saveetha Dental College & Hospital, Tamilnadu, India

ABSTRACT Background: The coronal incision with its various modifications provides the most versatile approach to various areas in the craniomaxillofacial region coupled with excellent exposure. The aesthetic advantage of a hidden scar in the hairline, accounts for its continued popularity. In maxillofacial it can be used for fractures in the frontal bone, nasal bone and extensive fractures involving zygomatic arch and complex Methods: In this clinical and observational study, we operated 5 patients with complex cranio-maxillofacial injuries involving frontal bone, zygomatic arch and zygomatic complex, nasal bone and supra-orbital region. All the five cases were trauma cases between ages of 20 to 60 years with no facial nerve injury per-operatively. These cases for followed for post-operative complications namely sensory and motor nerve deficits, haematoma, wound dehiscence and ptosis Result: Two patients each had sensory and motor nerve deficits and one patient had minimal wound dehiscence, all settled conservatively Conclusion: The incision provides excellent access, has reduced complications and produces an acceptable scar. This incision is advised in treating complex cranio-facial trauma, tumors and le-fort esthetic surgeries. Keywords: Coronal, Aesthetic, Facial Fractures, Versatile

Introduction

The coronal incision with its various modifications provides the most versatile approach to various areas in the craniomaxillofacial region coupled with excellent exposure. The aesthetic advantage of a hidden scar in the hairline, accounts for its continued popularity. In maxillofacial it can be used for fractures in the frontal bone, nasal bone and extensive fractures involving zygomatic arch and complex. [1] Severe cranio-maxillofacial injuries especially those involving the mid-face, are difficult to approach, this technique provides optimum exposure of the fracture sites, allowing for accurate anatomic reduction and fixation of the fractured segments and good cosmetic results in the incision site. [2] This procedure has been used extensively by neurosurgery to gain access to the region of interest. In 1973, Henderson and Jacksondescribed the good access afforded by this flap for Le Fort II osteotomies. It gives excellent exposure to the upper and middle third of facial skeleton. [3] Various indications for the coronal approach include severe cranio-maxillofacial trauma, craniofacial deformities, craniotomy procedures, osteotomies of upper and middle one third of face, harvesting of bone and fascial grafts when indicated, for improved access to condylar regions, and also for forehead rejuvenation. This procedure has

proved to provide adequate exposure even as low as the mandibular condyles without extensive complications. [4]

Materials and Methods

In this clinical and observational study, we operated 5 patients with complex cranio-maxillofacial injuries involving frontal bone, zygomatic arch and zygomatic complex, nasal bone and supra-orbital region. All the five cases were trauma cases between ages of 20 to 60 years with no facial nerve injury per-operatively. The positioning of anesthetic tubing for intubation should be in such a manner as to provide optimal access to entire head, face and oral cavity. Out of the 5 cases, three cases went for oral intubation as they did not have any occlusal discrepancies and for the other two we required submental intubation. A local anesthetic with adrenaline was infiltrated along the planned Lazy S incision line to facilitate dissection and minimize blood loss.The incision was marked 2 to 3 cm posterior to the hairline extending into the pre-auricular incision. Allis forceps were used to clamp the scalp to achieve hemostasis. The incision was given parallel to hair follicles through the skin, galea, ending superior to the loose areolar plane leaving the periosteum intact. The dissection was carried supra-periosteally and the flap was gradually turned forwards until 5 cm above the supra-orbital ridges.

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Then the periosteumis incised on the skull and extended over the temporalis fascia. Following that,the dissection is sub-periosteal on the skull and under the temporalis fascia on the temporal region exposing and being superficial to the temporalis muscle. It is important to incise the temporalis fascia just below and along itâ&#x20AC;&#x2122;s attachment to the superficial temporal line. From this point onwards the periosteum and the temporalis fascia is included in the main flap. This step is crucial to prevent facial nerve palsy. This flap is extended down wherethe supra-orbital neuro-vascular bundle was then identified and released from its foramen by removing a small wedge of bone above. This facilitates further retraction of the flap and minimizes paresthesia of forehead. Following complete release of the neuro-vascular bundles, the flap was further dissected infero-medially to expose the entire nasal, ethmoidal and orbital regions. Laterally when the superior border of the zygomatic arch is felt, a subperiosteal incision is made involving the superficial part of the temporalis fascia attachment to the zygomatic arch, exposing the arch and reflecting the entire flap inferiorly. Following that the fractured segments were fixed using appropriate techniques. A drain was then secured which prevented hematoma and the scalp was closed in layers using 3-0 polyglactin and 2-0 nylon. Pressure bandage

was maintained for 72 hours. Following that the drain was removed and on the fifth post-operative day the patients were clinically examined for the complications. Parameters involved motor nerve deficits, sensory nerve deficits, hematoma, wound dehiscence and ptosis.

Results

Sensory nerve deficits: 2 out of 5 patients had sensory nerve deficits in the supra orbital and supra trochlear region, but recovered within 2 week post-operatively. They regained complete sensation. Motor nerve deficits: 1 patient developed frontalis muscle weakness unilaterally, he recovered partially when clinically examined on the 4th follow up week. Another patient developed unilateral frontalis muscle weakness and did not recover even after 4 weeks. So in total 2 patients had this complication. Hematoma: The drain served well, no patient had this complication. Wound dehiscence: 1 patient had this complication which required secondary suturing. Ptosis: No patient was had ptosis.

Fig. 2: Exposure of Fractured Zygomatic Arch.

Fig. 1: Temporalis Fascia Elevation.

Fig. 3: Fractured Segments Fixed with Miniplates.

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Fig. 4: Fixed Fronto-Zygomatic Region.Â

Discussion

The coronal approach traditionally used by the neurosurgeons to gain access to the neurocranium has in the 21st century has gained popularity in the realm of craniomaxillofacial surgery for exposure of the craniofacial skeleton including the orbit and nasal bones. Since the coronal flap provides access to the frontal, temporal and zygomatic regions, the reconstruction of orbit, zygoma, frontal and nasoorbitoethmoid (NOE) regions is accomplished without the need for any facial incisions. [1] Although condylar fractures of the mandible may be treated by closed reduction and appropriate physiotherapy, open reduction and internal fixation is indicated in specific circumstances. In a study 25 cases of a previously unreported method of exposure of condylar fractures using an extended bicoronal approach combined with myotomy of the masseter muscle. Acceptable reduction and fixation was achieved in all cases with an early return to function. The incidence of complications was low, with three mild temporary facial palsies which had resolved by the sixth postoperative week and one hematoma beneath the bicoronal scalp flap. A cosmetically acceptable scar was produced in all cases. The excellent surgical exposure and protection of the facial nerve, combined with cosmetically acceptable scars, commend the use of this technique. [4] Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

AABS; 4(2): 2017

Fig. 5: Flap raised with temporalis fascia and periosteum, Reconstruction of Right Orbital Rim and Frontal bone with Titanium Mesh and Miniplates.

Rejuvenation surgery of the upper one-third of the face can be accomplished by a number of well-known techniques and approaches. This study was a retrospective blinded comparison of pre- and postoperative photographs of patients who underwent forehead lifts. A total of 140 patients having undergone forehead lift procedures and with 12-month postoperative photographic documentation were included in the study. Of these 121 patients had coronal forehead lifts and 19 had endoscopic-assisted forehead lifts. Results revealed that at 1 year follow-up both methods achieved brow elevation without a significant difference in the approach. [5] Thirty-one cases of comminuted or multiple fractures of the zygomaticomaxillary complex were treated with open reduction and rigid fixation by a coronal approach and analyzed for indications and postoperative complications. Twenty three patients had a hemi coronal approach and eight had a bicoronal approach. Among the early complications noted were one case of hemorrhage, no infections, and two patients experienced paresthesia/ anesthesia in the supra orbital region, two patients in the temporal/parietal region, six patients experienced facial nerve weakness related to nerve retraction and moderate surgical edema was observed in e-ISSN: 2349-6991; p-ISSN: 2455-0396

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three patients. Late complications included two cases of alopecia/baldness along the incision, one case of persistent paresthesia in the operative area. As far as the esthetics in relation to the incision was concerned, all patients were extremely satisfied. [6] A retrospective study was conducted on 69 out of 83 patients regarding the indications and complications of scalp incisions for treating zygomatic complex fractures, the other 14 patients were treated by local incisions and approaches. In the early postoperative period, 5 patients suffered from hemorrhage, 2 had infections, 24 patients reported immediate postoperative anesthesia and paraesthesia affecting the supraorbital region. Six had symptoms and signs of facial nerve injury: difficulty with wrinkling the forehead or to closing the eyes. After a follow-up of 3-5 years, 6 cases suffered from a scar wider than 0.5 cm, paraesthesia in 2 cases (parietal region and temporal region), depression of the temporal fossa in 2 and 1 patient had (persistent) palsy of the temporal branch of the facial nerve.On one hand, coronal incisions offer advantages such as: extensive exposure to ensure exact anatomical reduction. On the other hand, this incision has disadvantages such as obvious scars, long operating time, infections, hemorrhage, paraesthesia in the operative region, palsy of the facial nerve and depression of the temporal fossa. Therefore, the indications for coronal incisions should be strictly applied, and this incision should not be over used. [7] The coronal flap has recently become a preferred approach for the otolaryngologist-head and neck surgeon requiring access to the craniofacial skeleton and orbit. The variety of cases in which it has proven indispensable include craniofacial reconstruction, facial trauma, and tumor resection. This method of exposure has become particularly useful with increased indications for rigid internal fixation and primary bone grafting in the management of complex facial fractures. Our experience is reviewed in terms of indications for and benefits of the coronal approach, with a detailed description of the technique emphasizing anatomic planes and neurovascular structures. Careful attention to the latter should allow prevention of potential complications. [8] The coronal incision has been modified so that if it needs to be extended to improve exposure, the extension will be behind the ear and therefore less noticeable. The incision has been used in 25 adults and 30 children with no complications. Its cosmetic appearance is superior to the preauricular coronal incision, and it is preferred

especially by young people in whom the scar tends to widen with time. [9] The coronal scalp incision often leaves a noticeable scar causing the hair to part away from it, especially when wet. Changing the straight-line to a zigzag incision, called the stealth incision, eliminates this obvious deformity. [10] The use of bicoronal incisions has been sufficiently described in neurosurgery and craniofacial surgery including osteotomies and injuries. This approach provides excellent surgical access for nasal reconstruction with a very low rate of morbidity. A series of 11 patients, together with three case reports, illustrates the advantages and possible complications of this type of incision. [11]

Conclusion

The incision provides excellent access, has reduced complications and produces an acceptable scar. This incision is advised in treating complex cranio-facial trauma, tumors and le-fort esthetic surgeries. Though complications are rare, but when happens it causes significant morbidity. Thus this should only be indicated only in extensive facial trauma, pathologies and complicated cranio-facial procedures.

References 1.

Rajmohan, Susmitha, David Tauro, Bhupesh Bagulkar, and Anuj Vyas. 2015. “Coronal/Hemicoronal Approach – A Gateway to Craniomaxillofacial Region.” Journal of Clinical and Diagnostic Research : JCDR 9 (8): PC01-PC05. doi:10.7860/JCDR/2015/14797.6296.

Abubaker, A. O., G. Sotereanos, and G. T. Patterson. 1990. “Use of the Coronal Surgical Incision for Reconstruction of Severe Craniomaxillofacial Injuries.” Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons 48 (6): 579–86.

Shepherd, D. E., R. P. Ward-Booth, and K. F. Moos. 1985. “The Morbidity of Bicoronal Flaps in Maxillofacial Surgery.” The British Journal of Oral & Maxillofacial Surgery 23 (1): 1–8.

Dunaway, D. J., and J. A. Trott. 1996. “Open Reduction and Internal Fixation of Condylar Fractures via an Extended Bicoronal Approach with a Masseteric Myotomy.” British Journal of Plastic Surgery 49 (2): 79–84.

5. Dayan, S. H., S. W. Perkins, A. J. Vartanian, and I. M. Wiesman. 2001. “The Forehead Lift: Endoscopic versus Coronal Approaches.” Aesthetic Plastic Surgery 25 (1): 35–39. 6. Zhuang, Q.-W., X. P. Zhang, X. Wang, J. Zhang, Z.-P. Li, Y.-M. Si, and J. Meng. 2015. “Coronal Approach to Zygomaticomaxillary Complex Fractures.” European Review for Medical and Pharmacological Sciences 19 (5): 703–11.

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Zhang, Qing-Bin, Yao-Jun Dong, Zu-Bing Li, and Ji-Hong Zhao. 2006. “Coronal Incision for Treating Zygomatic Complex Fractures.” Journal of Cranio-Maxillo-Facial Surgery: Official Publication of the European Association for Cranio-Maxillo-Facial Surgery 34 (3): 182–85. doi:10.1016/j.jcms.2005.09.004.

Polley, J. W., and M. Cohen. 1992. “The Retroauricular Coronal Incision.” Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 26 (1): 79–81.

Frodel, J. L., and L. J. Marentette. 1993. “The Coronal Approach. Anatomic and Technical Considerations and Morbidity.” Archives of Otolaryngology--Head & Neck Surgery 119 (2): 201–207; discussion 140.

11. Atlan, G., P. Jammet, C. F. Schmitt-Bernard, L. Dupoirieux, and F. Souyris. 1994. “Bicoronal Incision for Nasal Bone Grafting.” International Journal of Oral and Maxillofacial Surgery 23 (1): 2–5.

10. Munro, I. R., and J. A. Fearon. 1994. “The Coronal Incision Revisited.” Plastic and Reconstructive Surgery 93 (1): 185–87.

*Corresponding author: Dr. Surya Rao R.V.M., Associate Professor, Dept. of Plastic & Reconstructive Surgery, Saveetha Medical College & Hospital, Thandalam, Kanchipuram Dist. 602105, Tamilnadu, India Phone: +91 9444152963 Email: surya_3@hotmail.com Date of Submission : 22.03.2017 Date of Acceptance : 06.04.2017 Date of Publication : 10.04.2017 Financial or other Competing Interests: None.

Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article DOI: 10.21276/AABS.1450

Comparison of ELISA & Rapid Screening Tests for the Diagnosis of HIV, HBV & HCV Among Blood Donors in Blood Bank of C.C.M. Medical College Durg Chhatishgarh Prahlad Chandra Agrawal1, Shiv Kumar Chandraker1 and Prarabdha Agrawal2 Dept. of Pathology, Chandulal Chandrakar Memorial Medical College, Durg Chhatishgarh, India 2 Pandit Jawaharlal Nehru Medical College, Raipur, India

ABSTRACT Background: HIV,HBV,& HCV is preventable transmitted disease, can accurately & correctly analyse by Elisa ,a superior method than rapid screening of blood units & its components. Aim: To see the positive results shown by Elisa method is positive by rapid or not. By this the superiority of method can be decided for screening of blood units in blood bank. Method: Out of 3650 blood units a sample of 50 elisa reactives were retested by Rapid method & results are analysed & compared. Only the higher Optical density gives positive result by rapid. Lower Optical density were not detected by rapid method, carry the risk of transmission to recipient. Result: The result of Elisa is not parallel to rapid test. Many samples reactive by Elisa were not detected positive by rapid due to low OD. Conclusion: Study shown that Rapid testing of samples for HIV, HBV& HCV are inferior to Elisa, Which is a gold standard for screening of blood donors in blood banks. Keywords: Transmitted transfusion Diseases, Hepatitis C virus, Prevalence, Blood Units

Introduction

Blood transfusion services is a life saving vital part of modern health care system(1) worldwide TTIs still remain a major public health problem in many developing countries, mainly due to resourced facility, lack of staff. (2) Blood transmitted infections involves pathogenic viruses are most prominent in transfusion medicine. (3) Screening of blood donors/blood units is done in almost every blood bank facility for viral marker like HIV,HBV & HCV before the blood units/components are transfused to prevent TTIs. With every units of blood there is 1% chance of TTIs. Inspite the marked improvement in safety of blood donations, viruses, bacterias remain the most transmitted infection passed on from donor to recipient through transfusion.(4) The greatest risk are donations given in infectious window period (WP),which is the time between the development of infectious viraemia & reactivity by routine serological or nucleic acid technology(NAT)donor screening test. (5) Blood donors occasionally carry an infectious agent without having any sign & symptom.(6) Blood transfusion services possess threat to future recipient

through blood product. Several screening test/assay have been developed to overcome such threat.These technique are immunochromatographic assay,Enzyme linked immunoabsorbent (Elisa) & Nucleic acid test(NAT),Polymerase chain reaction(PCR). Important issue of blood safety is to identify the infectious donors & to prevent its onward transmission by that safeguarding the recipients. Two strategy is important for its success,one is adaptation of national transfusion policy for selection of donors aims mainly to exclude donors with high risk of infection like HIV,HBV & HCV, second is the application of method with high specificity & sensitivity,so as to identify the true positive & true negative individual/ blood units.(7) Screening of blood donors are serious issue, if it is not done properly, it leads to serious consequences on blood service. False positive results can leads to larger number of blood donors being deferred, while false negative testing may jeopardize blood safety.(8) Transfusion of infected blood to individual is a crime. (9) To avoid this strict haemvigilance & quality control system is necessary for all the blood centres. Mostly

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immunochromatographic rapid test or Elisa test kits are used in blood centre for viral markers. The primary objective of present study is to retest the sample of Elisa method with Rapid immunochromatographic technique, & see the sensitivity difference among them.

Material & Method

Present study is carried out in the Blood Bank of C.C.M.Medical college Durg C.G. among the 3650 Blood donors attending between 1 april 2016 to 31 march 2017 for the period of one year. The collected blood units were tested for viral markers HIV,HBV & HCV by Enzyme linked immunoabrbent immunoassay & immunochromatographic Rapid technique. In our study many reactive sample by Elisa not detected positive by rapid method.

Results

Figure 1 shows out of 3650 blood units tested for viral markers 50 samples detected Reactive by Elisa. When we retested the Reactive samples with rapid method, there is remarkable difference in sensitivity(Table 1 & figure 2). Figure 3 & Table 1 shows out of 50 Reactive samples 10 samples were positive for HIV (0.27%),36 for HBV(0.96%) & 4 Samples (0.10%) for HCV infection. From Figure 4 By rapid method of 10 cases of HIV reactive by Elisa only 6 cases shows positive (60%) result, remaining 4 cases (40%) were lower optical density not detected positive. In case of HBV out of 36 cases, only 28 cases (77.7%) positive by rapid method, & 8 cases(22.2%) not detected positive. For HCV out of 4 cases, 2 cases Positive (50%) & 2 cases (50%) negative by rapid screening.

Table 1 OD OF HIV. Optical density

Result

Serial No.

Cut of value

Positive Control

Test

Elisa

Rapid

0.1404

1.6976

1.9885

0.1325

2.4706

0.2400

0.1325

2.4706

0.17

0.1325

2.4706

0.22

0.1325

2.4706

1.90

0.1585

1.1762

0.53

0.1707

1.2222

0.17

0.1707

1.2222

0.36

0.1745

1.307

0.53

0.1358

2.329

2.63

OD OF HBV Serial No.

Cut of value

Optical Density

Result

Positive Control

Test

Elisa

Rapid

0.2068

3.467

3.500

0.2068

3.467

1.27

0.2026

2.6320

0.94

0.2239

2.9599

0.95

0.1761

3.1917

3.20

0.2041

2.7519

3.20

0.1957

3.4574

2.85

0.1996

3.2748

2.96

0.1904

3.4442

0.21

0.1928

3.2641

3.55

0.1928

3.2641

0.31

0.1928

3.2641

0.20

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Serial No.

Cut of value

Optical Density

Result

Positive Control

Test

Elisa

Rapid

0.2355

3.0186

3.47

0.2355

3.0186

0.76

0.2162

2.9471

0.22

0.1849

3.1171

4.32

0.1796

3.3759

3.88

0.1796

3.3759

3.33

0.1849

3.4998

4.35

0.1953

3.4777

3.26

0.1953

3.4777

3.79

0.2063

2.9479

0.28

0.1926

3.3030

3.18

0.1751

3.3333

2.28

0.1888

3.2020

2.19

0.1966

3.2111

0.20

0.2084

2.9719

0.21

OD OF HCV Optical Density

Result

Serial No.

Cut of value

Positive Control

Test

Elisa

Rapid

0.3519

2.5767

1.45

0.3128

2.4831

0.32

0.3253

2.4055

1.07

0.3263

2.4744

0.43

Fig. 1

Fig. 2

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Fig. 3

Fig. 4

Discussion

Prevalence of HCV in India studies ranges between 0.41.09%. Studies done in Pakistan (18 19) & Bangladesh (20) reported HCV prevalence range 0.07-4.9% & 0.134.3% . Overall seroprevalance of HCV in our blood bank was 0.10%( Table 1 & Figure 3)

TTIs are the common serious problem of blood transfusion. In developed countries very low rate of transmission of TTIs has been achieved by avoiding unnecessary transfusion, using only regular voluntary donors, systematic screening of donors for infections by high sensitive assay method like Elisa & availability of NAT.(10) Glynn et al reported that introduction of NAT in blood donors decreased the risk of HCV & HIV significantly.(11) If these interventions are applied uniformly the risk of TTIs remains low. Recently blood banks in India are trying these interventions for improved safety, but NAT not available in most parts of India including Chhattisgarh because of unaffordibility of the test.(12) Seroprevalance of TTIs in his study was 50/3650(1.37%), this comparable to other studies by Teoks et al (1.49%)(13), saghir et al (2.35%)(14) Abdullah & Ali et al (3%)(15) The NACO has reported the overall prevalence of HIV of 0.36%(2006 estimate) in India. In our study almost similar value is found. Seroprevalance of HIV in Indian studies reported to range between 0.2-1% (16 17) overall seroprevalance of HIV in our study was 0.27%,(Table 1 & Figure 3) which is similar to other studies in India.

When we compare the result of Elisa with rapid test, a dramatic outcome is achieved. For HIV(Table 1 & Figure 3) out of 10 cases 6 cases shown reactive by Elisa have high optical density above 0.53, as compare to 4 cases in which OD was 0.24 (cov was 0.13-0.17). so marginal rise in OD is not detected by rapid method. This shows lower sensitivity of rapid test as compare to Elisa . In cases of HBV(Table 1& Figure 3) 36 cases reported reactive by elisa, only 28 cases have optical density above 0.76 to 2.85( cov 0.17-0.23),given positive result (77.7%) as compare to 8 cases (22.2%) have optical density up to 0.76 (ranges 0.20-0.76) not detected positive. For HCV(Table 1 & Figure 3) out of 4 cases 50% shown positive & 50% shown negative by rapid technique. Optical density above 1.07 given reactive whereas optical density below 0.43 detected negative by rapid test.

Conclusion

WHO placed India in the intermediate zone for HBV. The seroprevalance of HBV in our study was 0.96%.(Table 1 & Figure 3) In India it ranges between 0.86-4% (18 19). Seroprevalance of Pakistan (20) & Bangladesh is reported as (range 1.55-8.4%) & (range 1.5-2.96%)

This study showed remarkable sensitivity difference between both the method. For HIV 40%( 4 cases out of 10), HBV 22.2%(8 cases out of 36) & for HCV 50%(2 out of 4 cases) were not detected by Rapid method(Table 1 & Figure 4). This lower sensitivity method is unsuitable & is inferior in quality testing of infectious markers in blood donors in blood bank as screening. So the Rapid method are not recommended in transfusion centre for screening of donors.

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Transfusion medicine. Technical manual, 2 nd ed. WHO; 2003. p. 151.

Aach RD, Szmuness W, Mosley JW, Hollinger FB, Kahn RA, Stevens CE, et al. Serum alanine aminotransferase of donors in relation to the risk of non-A,non-B hepatitis in recipients: the transfusion-transmitted viruses study. N Engl J Med. 1981; 304(17):989-94. PubMed | Google Scholar

Niederhauser C, Schneider P, Fopp M, Ruefer A, Levy G. Incidence of viral markers and evaluation of the estimated risk in the Swiss blood donor population from 1996 to 2003. Euro Surveill. 2005; 10(2):14-6. PubMed | Google Scholar

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Busch MP, Glynn SA, Stramer SL, Strong DM, Caglioti S, Wright DJ, et al. A new strategy for estimating risks of transfusion-transmitted viral infections based on rates of detection of recently infected donors. Transfusion. 2005;45(2):254-64. PubMed | Google Scholar

McClelland DBL. Handbook of transfusion medicine : blood transfusion services of the United Kingdom. 2nd ed ed London: HMSO.1996. Google Scholar

Basavaraju SV, Mwangi J, Nyamongo J, Zeh C, Kimani D, Shiraishi RW, et al. Reduced risk of transfusion-transmitted HIV in Kenya through centrally co-ordinated blood centres, stringent donor selection and effective p24 antigenHIV antibody screening. Vox Sang. 2010; 99(3):2129. PubMed | Google Scholar

Rahman M, Khan SA, Lodhi Y. Unconfirmed reactive screening tests and their impact on donor management. Pak J Med Sci. 2008; 24(4):517-19. PubMed | Google Scholar Torane VP, Shastri JS. Comparison of ELISA and rapid screening tests for the diagnosis of HIV, Hepatitis B and Hepatitis C among healthy blood donors in a tertiary care hospital in Mumbai. Indian J Med Microbiol. 2008; 26(3):284-5. PubMed | Google Scholar

10. Lathamani K., Bhaktha G, Nayak S.,Kotigadde S. Prevalence of HIV, HCV,HBV and Syphilis in Blood donors among the Dakshina Kannada District, India Int.J.Curr.Microbiol.App. Sci (2013) 2(10):249-252

11. Glynn SA, Kleinman SH, Wright DJ, Bush MP. For the NHLBI retrovirus epidemiology donor study: International application of incidence rate/ window period model. Transfusion 2002; 42: 966-72 12. Shah N, Shah J.M. , Jhaveri P, Patel K, Shah C.K., Shah N.R. Sero prevalence of HBV, HCV, HIV and syphilis among blood donors at a tertiary Care Teaching Hospital in Western India GUJARAT MEDICAL JOURNAL ,2013 ; 68: 35 39 13. Sharma RR, Cheema R, Vajpayee M, Rao U, Kumar S, Marwaha N, et al. Prevalance of markers of transfusion transmissible diseases in voluntary and replacement blood donors. The national medical journal of India 2004; 171: 19 -21. 14. Paramjit K, Basu S. Transfusion transmitted infections: Existing and emerging pathogens. Journal of post graduate medicine 2005;51:146–51. 15. World health organization South-East Asia Regional Office. Prevention of hepatitis B in India-an overview. Available from: whqlibdoc.who.int/searo/2002/SEA_Hepat .-5.pdf, accessed on June 10, 2014 16. Chandrasekaran S, Palaniappan N, Krishnan V, Mohan G, Chandrasekaran N. Relative prevalence of hepatitis B viral markers and hepatitis C virus antibodies (Anti HCV) in Madurai, South India Indian journal of medical sciences 2000;547:270-73 17. Khan MA, Rehaman A, Ashraf M, Ali A, Detta A. Prevalance of HPV, HCV and HIV in blood donors at Liaquatpur. Professional med j 2006;13:23-26. 18. Khan Z, Raziq F, Aslam N. Prevalance of HIV in blood doors in NWFP. J Postgradmed inst 2002;16:187-89. 19. Saha SK, Banik RK, Saha MR, Habibullah MM, Mahtab MA. Prevalance of transfusion transmitted infectio in healthy blood donors in sir Salimullah medical college Dhaka, Bangladesh. Euroasianjournals of hepatogastroenterology,2011;1:68-70. 20. Saha SK, Banik RK, Saha MR, Habibullah MM, Mahtab MA. Prevalance of transfusion transmitted infectio in healthy blood donors in sir Salimullah medical college Dhaka, Bangladesh. Euroasian journals of hepato-gastroenterology, 2011;1:68-70.

*Corresponding author: Dr Prahlad Chandra Agrawal, Dept. of Pathology, Chandulal Chandrakar Memorial Medical College, Durg Chhatishgarh, India Phone: +91 9425212528 Email: drpcagrawal206@gmail.com Date of Submission : 30.03.2017 Date of Acceptance : 08.04.2017 Financial or other Competing Interests: None. Date of Publication : 11.04.2017

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Original Article DOI: 10.21276/AABS.1400

The Awareness and Perception About The Ethical Concerns Related to The Biobanks Among Medical and Dental Practitioners: A Questionnaire Based Study Mohammadi Begum Khan1*, Faizan Ahmed Khan1, Veena Vaswani2, Uma Kulkarni3 and Parvathy Ram Mohan1 Department Of Orthodontics, Yenepoya University, Deralakatte, Mangalore, India 2 Dept. Of Forensic Medicine, Yenepoya University, Deralkatte, Mangalore, India 3 Department Of Ophthalmology, Yenepoya University, Manglaore, India

ABSTRACT Background: The term “Biobank” has been used in different ways but one way is to define it as “an organized collection of human biological material and associated information stored for one or more research purposes”. By definition, “Biobank” is a long-term storage and conservation facility for biological specimens, to support future scientific investigation. The aim of this study is to assess the awareness and perception of Biobanks, their existence, aims and objectives and the ethical concerns related to them, among the clinicians pertaining to both medical and dental specialties. Methods: A questionnaire comprising of 31 questions of which few are purely awareness and rest are perception based is framed. The questions which were framed for the questionnaire, have few of them given direct responses as YES, NO, DON’T KNOW and the remaining of them have been graded into LIKERT’S SCALE, ranging from 1 to 5. Statistical analysis: After obtaining the response, the answers were plotted in MS-Excel sheet and analysed statistically for the Percentages, Frequencies, Chi-square and degree of Association (p>0.05= No Association) between the two fraternities responses by using SPSS 22.0 version software. The p value was set at 0.05 Result: There was found a level of association between both the groups for certain sensitive questions relating to privacy of information and ownership claims. Conclusion: It can be concluded that the willingness to participate in sample donation, motivation for sample donation are in agreement with each other, which is worth being further investigated. Keywords: Biobanks, Awareness, Ethical Issues, Informed Consent, Clinical Practitioners

Introduction

The term “Biobank” has been used in different ways but one way is to define it as “an organized collection of human biological material and associated information stored for one or more research purposes”. Collections of plant, animal, microbe, and other nonhuman materials may also be described as Biobanks but in some discussions the term is reserved for human specimens only.1 By definition, “Biobank” is a long-term storage and conservation facility for biological specimens, to support future scientific investigation.2 Biobanks consist of two different parts: 1) The biologic material that is collected, processed, and long-time stored. 2) The database, including information about demographic and clinical data for each sample. Thus the scientific research has escalated its performance since the inception of these Biobanks which are heavily supported by government as the research results are highly beneficial to the society. In recent years there has been a great

ramification in the practices and policymaking of these Biobanks as there is been an increasing diversity in the set of research purposes and types as well as source of research samples.3 For instance, Biobanks could comprise the collections of human bodily substances of all kinds, such as cells, tissues, blood, or DNA. They range in capacity from small collections of samples to large-scale national repositories. The collected samples could be populationbased or disease-specific, originating from diverse profile of individuals, eg, minors or adult persons. Biobanks are considered to be the storehouse of many biological samples which might range from being just anonymous to belonging to specific personal information. Also, the Biobanks might operate for various purposes such as diagnostic, therapeutic, or research.4 Key Organizations Associated with Biobanks: Some examples of organizations which participated in creating written guidelines about biobanking are the following:5 •

World Medical Association, Council for International

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Organizations of Medical Sciences, Council of Europe, Human Genome Organisation, World Health Organization, and UNESCO.

History of Biobank Governance: In 1998 the Icelandic Parliament passed the act on Health Sector Database which allowed for the creation of a national Biobank in that country. In 1999 the United States National Bioethics Advisory Commission issued a report containing policy recommendations about handling human biological specimens.6 In 2005 the United States National Cancer Institute founded the Office of Biorepositories and biospecimen Research so that it could have a division to establish a common database and standard operating procedures for its partner organizations with biospecimen collections. In 2006 the Council of the European Union adopted a policy on human biological specimens which was novel for discussing issues unique to Biobanks.6 The aim of this study is to assess the awareness and perception of Biobanks, their existence, aims and objectives and the ethical concerns related to them, among the clinicians pertaining to both medical and dental specialties.

Objectives of the study

 To assess the level of awareness among the clinicians of both medical and dental field about the existence and goals of Biobanks  To assess their perception variations about the different issues related to Biobanks like their areas of interests, aims and objectives  To assess their perception variations about the ethical issues which are being faced by these Biobanks and the ownership claims chaos involved with them.

Materials and Methods:

A questionnaire comprising of 31 questions of which few are purely awareness and rest are perception based is framed and analyzed by the subject experts and also approved by the Ethical society of YENEPOYA UNIVERSITY. The questions which were framed for the questionnaire, have few of them given direct responses as YES, NO, DON’T KNOW and the remaining of them have been graded into LIKERT’S SCALE, wherein a range of 1 to 5 numbers have been given which have the interpretation as : Strongly agree (1), Agree (2), Don’t know (3), Disagree (4), and Strongly disagree (5). The sample size was decided to be 50 for each medical and dental specialties comprising to a total of 100 sample size which was decided to be appropriate to judge the level of

awareness and variations in perceptions. The questionnaire was distributed among the registered medical and dental practitioners preferably practicing in and around the Mangalore city located in the southern part of Karnataka, India, After obtaining the informed consent. Statistical Analysis: After obtaining the response, the answers were plotted in MS-Excel sheet and analysed statistically for the Percentages, Frequencies, Chi-square and degree of Association (p>0.05= No Association) between the two fraternities responses by using SPSS 22.0 version software. The p value was set at 0.05. (QUESTIONNAIRE IS ATTACHED) The sensitivity of the awareness and perception was assessed by taking Four questions from the questionnaire pertaining to awareness  About the type of volunteers to be encrolled in the Biobanks,  Information sharing by the Biobanks( confidentiality issues) ,  Ownership claims faced by them  Their willingness to participate and the type of sample donation they prefer.

(The level of Association among the responses was assessed using Chi-square test.)

[The Selected Questions Were: Q.no.1: Do you think, a Biobank for its efficient progress and better scientific research results should look to recruit the following types of volunteers. Please rate them according to your perception. Q.no.2: Do you think the information about your donated tissue samples research results by the Biobank should be shared? If yes, with whom? Kindly show your degree of consent for the following choices given. Q.no.3: Please rate the following, for the Ownership claim (Intellectual property) about the research results of the specimen that you have donated to a Biobank. Q.no.4: If you are interested to donate your specimen which one do you prefer?]

Result

Results Obtained Using The Sensitive Questions Pertaining to Knowledge and Perception: The discussion about their perception level shows that both the groups have equally consented in majority for Likert scale 2 (agree) for types of participants (Volunteers) to be recruited for the Biobank to work efficiently for its genuine research results. When asked about the sharing of information about their research data, most of them in both the groups have consented in majority to be limited it to only themselves and there was strong disagreement to be shared with

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family members and relatives as well as disagreement was shown for publishing the data by both the groups. There was also found a level of ASSOCIATION between both the groups when their perception was assessed about the sharing of the research data with the researcher and the same Biobank. When the Ownership issues were assessed, both the groups have consented for sharing of the data with the donor only in majority followed by donor and Biobank

was the perception for medical practitioners but it was donor and researcher by the dental practitioners. When their willingness to participate and donate different parts was assessed, most of the dental practitioners have agreed for blood only and disagreed for all the organs donation, whereas most of medical practitioners have agreed for blood only and strongly disagreed for ova/ sperm followed by all the organs donation.

Table 1: Response chart for Q.no: 15. Q. NO.15 (1) (2) (3) (4)

Medical practitioners (Response in Likerts scale) 2 (38%) 2 (38%) 2 (38%) 2 (38%)

Dental practitioners (Response in Likerts scale) 2 (50%) 1 (36%) 1(42%) 2 (36%)

Level of Association No No No No

Table 2: Response chart for Q.no: 22.

(1) (2) (3) (4)

Medical practitioners (Response in Likerts scale) 1(56%) 2(40%) 5(36%) 2(40%)

Dental practitioners (Response in Likerts scale) 1(72%) 2(34%) 5(38%) 1(38%)

(5)

5(40%)

5 (40%)

(6) (7) (8) (9) (10)

5(40%) 5(30%) 5(32%) 5(48%) 5(54%)

5 (36%) 2 (26%) 2 (26%) 5(34%) 5(48%)

Yes Yes No No No

Medical practitioners (Response in Likerts scale) 1(38%) 2&3(30%) 3(34%) 2&3(32%)

Dental practitioners (Response in Likerts scale) 1(40%) 3(32%) 5(32%) 1&3(26%)

(5)

2(34%)

2 (30%)

(6)

2&3(34%)

1(30%)

Medical practitioners (Response in Likerts scale) 1(50%) 5(28%) 5&3 (28%) 59(32%) 5(36%) 5(34%) 5(36%) 5(42.9%)

Dental practitioners (Response in Likerts scale) 1(40%) 5(40%) 5(38%) 5 (44%) 5(42%) 5(42%) 5(44%) 5(42%)

Q. NO.22

Level of Association No No No Yes

Table 3: Response chart for Q.no: 25. Q. NO.25 (1) (2) (3) (4)

Level of Association No No No No

Table 4: Response chart for Q.no: 29. Q. NO.29 (1) (2) (3) (4) (5) (6) (7) (8)

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Level of Association No No No No No No No No

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Discussion

Our results illustrated a general public agreement to participate in Biobanking and emphasize the need to establish awareness campaigns to promote public involvement in biomedical research, which correlate with increased level of participation in biobanking.7 Speaking about the consent issues in Biobanking, Hoeyer K. 20128 has reported that Biobanks usually collect sample and data for multiple future research and it is not feasible to obtain specific consent for any single research. It has been discussed that one-off consent or a broad consent for various research purposes may not suffice ethical and legal requirements. Speaking about the children and incompetent adults participation in biobanking , Hens K et al. in 20099 stated that the majority of Biobanks do not involve children because of special ethical problems and concerns that are not easily addressable, and also because the increased sensitivity of the public and the media toward this segment of the population sometimes makes it an unnecessary risk that many Biobanks are not willing to take. However, this could lead medical research on children to lag behind the research on adults. From the ethical point of view, in that way children will eventually suffer relatively more than adults. So, nearly all authors support the idea of involving children in Biobanks, but they also agree that the risk for them should be actively minimized. When perception was assessed about the sharing of research data, the level of perception was found to be in accordance to what has been reported in other cultures where a high level of concern about protection of privacy was measured. i.e, limiting to oneself and not disclosing to others.10-14 These findings were in agreement with the study done by Kaufman DJ 2009 and Hansson MG in 201115,16 which stated that the fundamental concern about privacy is usually also the main concern of the participants when they are deciding whether to donate their samples to Biobanks. Their study showed that up to 90% of people were concerned about their privacy Thus, concluded that consequences of breaking privacy could substantially affect publicâ&#x20AC;&#x2122;s willingness to participate and substantially delay the research. Therefore, Biobanks must always guarantee a maximal level of protection of participants. Another study by Cambon-Thomsen A. in 2011 17 reported about the privacy and identifiability of the samples and stated that there is a widespread concern that insurance companies and employers could access personal information. They usually have great interest in personal information and Biobanks must guarantee adequate protection of personal data. Further, results of research can also harm not only individuals, but the whole groups could feel stigmatized

because of their genetic predisposition or other relevant information. Biobanks that perform research on a specific ethnic or other group of people must consider this and be very careful when publishing the results. The level of awareness about the Biobanks and its working protocols as well as the ethical concerns were found to be closely matching between these groups. It was also found that the willingness to participate and organ donation was also nearly the same. Speaking about the public awareness about the Biobanks, Rothstein MA 2005 in 18 focused about the commercialization aspect in Biobanking and stated that although Biobanks have a primary focus on research and improving medical knowledge, this will not necessarily prevent private companies from trying to use Biobank data for their own interest. In general, commertialization raises several ethical issues, such as preventing exploitation, ensuring fairness to study participants, and balancing costs and benefits. Some articles showed that commercialization, in general, tended to decrease public trust in Biobanks, although it did not completely diminish it. However the Owner- ship claiming was found to be differing in the groups where dental practitioners have agreed it to shared it between donor and researcher whereas medical practitioners have agreed to be shared among donor and the Biobanks. This finding in general is found to be ambiguous as Chalmers D. in 201119 has discussed about the ownership claims issues in the Biobanking sector and presented the ethical and legal issues that are encountered in this regard in the Biobanking. What happens when a participant donates a part of body to a Biobank? Could Biobanks become owners of the sample or does it remain in the ownership of the participants? Chalmers, has recently explored this issue in great depth and concluded that the legal position on ownership remained unsettled. Other authors take the position that complete anonymization would practically make biological materials ownerless, but that in all other instances the donors maintain ownership and should be able to withdraw both their consent and their biological material donated to the Biobank. Another study by Nwabueze, Remigius Nnamdi in 200720 reported about an important aspect of Biobanking wherein the debate is about the ownership of the samples. As of 2007, Iceland had three different laws on ownership of the physical samples and the information they contain. Icelandic law holds that the Icelandic government has custodial rights of the physical samples themselves while the donors retain ownership rights. In contrast, Tonga and Estonia give ownership of Biobank samples to the government, but their laws include strong protections of donor rights. Our study however, revealed that the percentage is maximum for ownership claiming between the donor and the researcher. This suggests that the researcher has the value of trust more

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Conclusion

This questionnaire based survey has given information about comprehension and motivation of both medical and dental practitioners towards Biobanking and its aims, objectives, research obligations as well as the ethical issues about consent, sharing of research information, willingness to participate in sample donation, motivation for sample donation and ownership claims , which is worth being further investigated. As the level of understanding of aims and methods of a specific research project seems to vary in relation to modalities of approaching research, most of the participants are seemingly motivated by a “pragmatic”or a “selfless attitude” to contribute to research. This study also suggests that people may have a “responsibility or an obligation” to participate in research are not new, especially where risks are considered low for participants; even if the “dilemma or quandary” between respect of autonomy and respect of solidarity cannot be completely overcoming, a balance can still be continuously pursued.

Acknowledgements

All The Authors And Yenepoya University

AABS; 4(2): 2017 6.

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Greely, H. T. “The Uneasy Ethical and Legal Underpinnings of Large-Scale Genomic Biobanks”. Annual Review of Genomics and Human Genetics. 2007; 8: 343–364.

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Artene S A, Ciurea ME, Purcaru S O, Tache DE. Biobanking in a Constantly Developing Medical World ; The ScientificWorld Journal 2013.

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Hewitt, R. E. “Biobanking: The foundation of personalized medicine”. Current Opinion in Oncology. 2011; 23 (1): 112–119.

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Fullerton, S. M.; Anderson, N. R.; Guzauskas, G.; Freeman, D.; Fryer-Edwards, K. “Meeting the Governance Challenges of Next-Generation Biorepository Research”. Science Translational Medicine. 2010; 2: (15) Cambon-Thomsen, A.; Rial-Sebbag, E.; Knoppers, B. M. “Trends in ethical and legal frameworks for the use of human biobanks”. European Respiratory Journal. 2007; 30 (2): 373–382.

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Haga, S.; Beskow, L. “Ethical, Legal, and Social Implications of Biobanks for Genetics Research”. Genetic Dissection of Complex Traits. Advances in Genetics. 2008; 60: 505–544 Gaskell G, Gottweis H, Starkbaum J et al: Publics and biobanks: Pan-European diversity and the challenge of responsible innovation. Eur J Hum Genet 2013; 21: 14–20. Hoeyer K. Trading in Cold Blood? Trust in Biobanking 2012; 21-41. Hens K, Nys H, Cassiman JJ, Dierickx K. Genetic research on stored tissue samples from minors: a systematic review of the ethical literature. Am J Med Genet A. 2009;149A: 2346-58. Tupasela A, Sihvo S, Snell K, Jallinoja P, Aro AR, Hemminki E: Attitudes towards biomedical use of tissue sample collections, consent, and biobanks among Finns. Scand J Public Health 2010; 38: 46–5 Beskow LM, Dean E: Informed consent for biorepositories: assessing prospective participants’ understanding and opinions. Cancer Epidemiol Biomarkers Prev 2008; 17: 1440–1451. Ahmad M, Al Gamal E, Othman A, Nasrallah E: Knowledge, attitudes and practices towards cancer prevention and care in Jordan. Report 2011. Asai A, Ohnishi M, Nishigaki E, Sekimoto M, Fukuhara S, Fukui T: Attitudes of the Japanese public and doctors towards use of archived information and samples without informed consent: preliminary findings based on focus group interviews. BMC Med Ethics 2002; 3: 21-27. Willison DJ, Keshavjee K, Nair K, Goldsmith C, Holbrook AM: Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness investigators. Patients’ consent preferences for research uses of information in electronic medical records: interview and survey data. BMJ 2003; 326: 31. Hansson MG. The need to downregulate: A minimal ethical framework for Biobank research. Methods Mol Biol. 2011;675:39-59. Kaufman DJ, Murphy-Bollinger J, Scott J, Hudson KL. Public opinion about the importance of privacy in Biobank research. Am J Hum Genet. 2009;85:643-54. Cambon-Thomsen A. The social and ethical issues of postgenomic human Biobanks. Nat Rev Genet.2004;5:866-73 Rothstein MA. Expanding the ethical analysis of Biobanks. J Law Med Ethics. 2005;33:89-101. Chalmers D. Genetic research and Biobanks. Methods Mol Biol. 2011; 675:1-37. Nwabueze, Remigius Nnamdi . Biotechnology and the Challenge of Property: Property Rights in Dead Bodies. Aldershot, England: Ashgate Press 2007; 169– 170.

*Corresponding author: Dr. Mohammadi Begum Khan, Fellow (Cleft Orthodontics), Department Of Orthodontics, Yenepoya University, Deralakatte, India 575018. Phone: +91 7338502550 Email: sabiakareem127@gmail.com Date of Submission : 09.03.2017 Date of Acceptance : 05.04.2017 Financial or other Competing Interests: None. Date of Publication : 15.04.2017

Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article DOI: 10.21276/AABS.1460

Spectrum of Interface Dermatitis : An Observational Study Vishrabdha Rahul Pawar1, Vaibhav Pandurang Mane1* and Renuka Satish Ashtekar2 Department of Pathology , Bharati Vidyapeeth Deemed University Medical College And Hospital, Sangli. India Department of Dermatology and Skin VD , Bharati Vidyapeeth Deemed University Medical College And Hospital , Sangli, India 1

ABSTRACT Background: Major role of a dermatopathologists is to try to make specific diagnosis of inflammatory skin diseases. IFD means inflammatory infiltrate that abuts or obscures the dermo-epidermal junction in askin biopsy.This type of reaction is also seen in skin disorders associated with systemic illness like LE and skin changes of potentially fatal disorders such as Graft versus host disease, S-J syndrome and toxic epidermal necrolysis. Aims & Objectives: 1)To study the histopathology of interface dermatitis.(2)To study the common types of skin manifestations in interface dermatitis.(3)To determine other histological features associated with interface dermatitis.4)To identify the clinical concordance of various types of interface dermatitis. Material & Methods: Present study is a retrospective , Hospital based study. Ethical consideration was taken. Study duration was Jan 2012 to Dec 2015. Results: In the present study, a total of 121 cases of IFD were studied, the majority of which [65] presented as papulosquamous [ papules and plaques ] lesions. Of theses 121 cases, the most common type of IFD was LP and its variants (53.71 %).The next common was LDE (8.26 %) followed by PL(7.4% ). The least common was LN (0.8 % ) and dermatomyositis (1.6 %). Female preponderance was noted in case of IFD [ 59.9 % ]. The percentage of clinical concordance was good in cases of LP & its variants (90.77 %), DLE ( 83.33%) and in Dermatomyositis. Conclusion: A good clinicopathologic correlation is absolutely essential for the final diagnosis of IFD. Keywords: Interface, Dermatitis, Lichen

Introduction

LTR or IFD is one of the common clinical and histological presentation in Dermatology and Pathology. IFD refers to the finding of an inflammatory infiltrate that abuts or obscures the dermo-epidermal junction in a skin biopsy [1] Interface reactions are so named because they are cell mediated immunologic reactions where the basal keratinocytes that reside above the dermo-epidermal junction are the target.[2] One of the challenging aspects of being a dermatopathologists is to try to make specific diagnosis of inflammatory skin diseases. Now the microscopic findings of many inflammatory skin diseases and the most expert dermatopathologists are able to handle discrepancies between clinical and histopathological findings. This has changed the negative feelings of clinical dermatologists regarding the utility of biopsy in diagnosis of inflammatory conditions.[3] Lichen Planus is the prototype of the term “Lichenoid’which refers to papular lesion of certain skin disorders.[4]. This type of reaction can also be seen in skin disorders associated with systemic illness like LE and skin changes of potentially fatal disorders such as Graft versus host disease, S-J syndrome and toxic epidermal necrolysis [5]

Components of the infiltrate in IFD are i.

Basal layer of epidermis having tall columnar cells perpendicular to basement membrane. ii. Dermo-epidermal junction. iii. The papillary dermis in contact with basement membrane. iv. The adventitial dermis around the adnexal structures. Le Boit PE has classified ID into 5 types : i. ii. iii. iv. v.

Acute cytotoxic type IFD with premature terminal differentiation IFD with irregular epidermal hyperplasia IFD with psoriasiform hyperplasia. IFD with epidermal atrophy.

Aims and Objectives • • •

To study the histopathology of interface dermatitis To study the common types of skin manifestations in interface dermatitis. To determine other histological features associated with interface dermatitis.

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To identify the clinical concordance of various types of interface dermatitis.

Material & Methods

Present study is a retrospective study, done in a tertiary care hospital. Ethical consideration was taken. Study duration was Jan 2012 to Dec 2015. The skin biopsy samples received in department of Pathology in this period were studied. We retrieved 402 cases of skin biopsies received in this period , of which 121 showed the findings of IFD. Inclusion Criteria: The skin biopsies showing the dermoepidermal inflammatory infiltrate. Exclusion Criteria: All the skin biopsies showing the histopathological findings other than dermoepidermal inflammatory infiltrate. Limitations: The sample size is less. Direct access to the patient to note down the demographic findings was not possibleThe demographic findings were collected from the history and clinical findings noted on the requisition forms procured from the record section. Ethical consideration was taken.The studied data was analyzed by relevant statistical method. Limitation of this retrospective study was the small sample size and that there was no direct access to the patients, so we had to rely on the clinical details given in the requisition forms.

Results

In the present study, a total of 121 cases of IFD were studied, the majority of which [65 ] presented as papulosquamous [ papules and plaques ] lesions (53.71 % ).

AABS; 4(2): 2017 Of theses 121 cases, the most common type of IFD was LP and its variants (53.71 %) .The next common was LDE (8.26 %) followed by PL (7.4 % ). The least common was LN (0.8 %) and dermatomyositis (1.6 %). IFD affects any age group. In the present study the majority cases were in the 4 th decade (41- 50 yrs) (28.92 %) followed by 31 -40 yr age group [19.83 %] and 51 â&#x20AC;&#x201C; 60 yr [18.18 %]. Female preponderance was noted in case of IFD [59.9 %]. In all the cases of IFD studied the female preponderance was seen with majority cases of LP and its variants. Clinical concordance was seen in 100[82.64%] cases and discordance in 21[17.36%] cases. The percentage of clinical concordance was good in cases of LP & its variants [90.77 % ], DLE [ 83.33% ] and in Dermatomyositis, we had only one case, [100 % ] due to characteristic clinical presentation.

Discussion

We have tabulated the results sequentially according to the frequency of cases that we have studied and we are following the histopathological classification of Le Boit. In this the epidermal changes are taken as classifying IFD into five groups[2]. In most of the cases the diagnosis was consistent and easy to observe, but in few cases clinical correlation was necessary. In group I- Acute Cytotoxic type- Basal cell vacuolization with lymphocytic infiltrate in the lower epidermis with scattered necrotic keratinocytes at various levels in the epidermis is the characteristic finding. EM is the prototype of this category. Other conditions described with this

Table 1: The types of skin manifestations in ID.

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Table 2: Types of Interface dermatitis.

Table 3: Age distribution of lesion.

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Table 4: Gender wise distribution of IFD.

Table 5: Clinical concordance in IFD.

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Table 6: Frequency of different types of IFD as per Le Boit groups. Type of ID I

Clinical condition

No. of cases

4.1

LDE

8.26

53.69

DLE

4.9

LDE

8.26

III

Hypertrophic LP

4.9

2.47

PLEVA

7.4

Atrophic LP

3.2

SLE

4.13

1.6

change are S-J syndrome, FDE, Acute Graft Versus Host reaction, PLEVA, TEN [2]. Vacuolar change is often an integral part of the basal cell damage in the lichenoid reaction. As a consequence of basal cell damage, there is variable melanin incontinence resulting from interference with melanin transfer from melanocytes to keratinocytes, which is associated with drug induced or solar induced lichenoid lesions.[7] In the present study we had 73(60 %) of 121 cases showing spongiosis and 25( 20.6 % ) cases showed evidence of civatte bodies. Of these 05 cases were of EM (4.1%), 09 cases (7.4%) of PLEVA and 10 cases (8.26%) cases of LDE. Sushma Desai et al[8] studied 120 cases and found (6.6 % )cases of EM. Suja Ajoy Kumar et al[9] studied 71 cases and found (5.6 %) EM. Erythema Multiforme-It is a clinical pathologic condition with a wide variety of underlying causes. The clinical finding has a targetoid morphology with a peripheral rim of erythema and a central zone of pallor. Some lesions manifest a dusky or violaceous appearance with no true central clearing. Blisters may be observed. As the pathogenetic basis of erythema multiforme is one of cellular cy-toxicity, the sites of predilection are those where anti-genic processing is maximal, which includes the palms and soles, but lesions may occur elsewhere and may become widespread.[1] In our study we studied 05 cases of EM with 80% clinical concordance. One case was missed clinically due to lack of classic clinical appearance. In 03 cases the blister formation was noted. Histopathologically 03 cases showed subepidermal bulla (Fig 2), dense lymphocytic tagging at the dermo-epidermal junction. Basket weave pattern of orthokeratosis and the characteristic basilar vacuolopathy is seen.(Fig 3).The melanin incontinence could be due to irritation. Civatte bodies are seen. (Figure 4)

Lichenoid Drug Eruptions- The lesion closely appears like LP clinically, there may be eczematization & pronounced hyperpigmentation. LDE usually differs from LP by presence of focal parakeratosis and mild basal vacuolar change, few plasma cells & eosinophils. There is more melanin incontinence than in LP. The infiltrate is often less and less band like than in LP itself.[7] . A few inflammatory cells may extend around vessels in the mid and lower dermis. Sometimes the histology mimics LP, few eosinophils in the infiltrate may be the only clue diagnosis. Pleva: Although both PLEVA and pityriasis lichenoides chronica (PLC) are considered to be variants of the same disease, namely, Mucha Haberman disease. The histological findings are different.[6] In our study we noted cases of PLEVA. (Fig 5) shows Hyperplastic epidermis and dense dermal infiltrate which is becoming Lichenoid. Also perivascular lymphocytic infiltration is noted. The upper dermis shows many extravasated RBCs. In Group II - IFD with Premature Terminal Differentiation: Early development of a thick granular layer and compact stratum corneum which resembles acral skin and usually associated with dense lichenoid infiltrate of lymphocytes. LP is a prototype of this. Other conditions in which this pattern may be seen are DLE, LDE, GVHD, and Dermatomyositis, albeit with paucity of dermal infiltrate. In the present study we had (69.4 % ) cases with hyperkeratosis and (66.9%)cases of lymphocytic band like infiltrate in the dermis. We had 53.69 % cases of LP, (4.9 %) of DLE, (8.26 %) of LDE and (1.6 %) of dermatomyositis. Suja Ajoy Kumar had 57.7% cases of LP, 15.4% cases of DLE and 1.4% cases of Dermatomyositis. Lichen Planus- It is an idiopathic disorder.It affects skin and mucous membrane and is characterized by small, flat topped papules clinically and a band like mononuclear cell

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A-109 infiltrate histologically. The individual papules often have a polygonal shape, a violaceous to gray- red hue and a thin, retractile scale. Mucous membrane lesions have a lacy, white appearance.[2] In our study we found 53.69% cases of LP of which 4.9% were of Hypertrophic and 3.2% of atrophic variant. There was 90.77% clinical concordance in cases of LP. Histologically the epidermis was broad and acanthotic with saw-toothed pattern of rete pegs(Fig 6). Focal wedge shaped hypergranulosis is noted. The stratum corneum is moderately thick. The dense Lichenoid infiltrate of lymphocytes is seen occupying the widened papillary dermis. And is admixed with melanophages. Colloid bodies that represent anucleated remnants of apoptotic basal keratinocytes are seen. DLE- We studied cases of DLE with 83.33 % clinical concordance.(Fig 7) It shows Hyperkeratotic, acanthotic epidermis. Focal hypergranulosis is noted. Dense superficial and deep dermal lymphocytic infiltrate admixed with melanophages is noted. Perivascular infiltrate is shown in (Fig 8) In Group III are Cases with Changes of Irregular Epidermal Hyperplasia. In this there is marked irregular epidermal hyperplasia as seen in Hypertrophic lichen planus, verrucous DLE and some long standing cases of LDE In the present study we had 53.69 % cases of LP ,4.9 % cases of DLE and 8.26 % cases of LDE with 7/121 cases of hypertrophic LP. Sushma Desai et al had (4.1% ) of hypertrophic LP. Suja Ajoy Kumar had single case of HTLP. Hypertrophic LP We had (49%) of hypertrophic lichen planus. (Fig 9). It shows irregular hyperplasia of mainly follicular infundibular epithelium with focal hypergranulosis and a markedly thickened compact horny layer. The hyperplastic follicular infundibula show lichenoid infiltrates at their bases and sides with small subepidermal clefts..The interfollicular papillary dermis shows markedly thickened vertically oriented bundles of collagen, evidence of repeated rubbing of the lesion. In Group IV-are cases of ID with psorisiform hyperplasia. Some of the conditions in this group are diseases which show interface changes as a secondary pathological feature and are therefore not classified as primary ID. True ID which show this pattern are LS and Lichenoid variant of persistent pigmented purpuric dermatitis. Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

AABS; 4(2): 2017 In present study we had 50.41% cases with psoriariform hyperplasia . We found 2.47 % cases of LS. Lichen Striatus: It is a combination of several patterns of inflammation, which may not be seen in individual lesions. Although classified as a primary interface dermatitis, it often shows psoriasiform hyperplasia of the epidermis with foci of mild to moderate spongiosis with few scattered individually necrotic keratinocytes in the spinous layers. Mounds of parakeratosis are often seen in the thickened stratum corneum. The interface changes in well-developed lesions may be minimal and a diagnosis of psoriasiform or spongiotic dermatitis may be given. Presence of a fairly dense peri-eccrine and periadnexal infiltrate of lymphocytes is the characteristic finding. Sometimes, this finding alone may serve to differentiate lichen striatus from other eczematous dermatoses.[1,5,6] In our study the LS showed(Fig 10) epidermis with psorisiform hyperplasia, dense infiltrate involving both superficial and deep dermis which obscures the basal layer of epidermis., spongiosis and the infiltrate involving the periadnexal and structures. Grp IV-includes Cases of ID with Epidermal Atrophy: This represents the late atrophic phase of several dermatoses like atrophic LP ,LE and dermatomyositis ,acrodermatitis, chronic atrophicans ,Lichen sclerosis et atrophicus, counter of old lesions of porokeratosis and poikiloderma due to various causes . In the present study we had 2.47%) cases of epidermal atrophy . We found 3.30% cases of atrophic LP , 4.13 % cases of SLE and 1.6 % cases of dermotomyositis. Sushma Desai et al found 2.5% cases of atrophic LP. Hegade et al[10] noted ( 5.6 % ) cases of atrophic LP in their studies. Atrophic LP: Atrophic lesion may resemble parakeratosis clinically. Typical papules of LD are usually present at the margins A rare form of atrophic LP is composed of annular lesions. On histopathology: Epidermis is thin and there is loss of normal rete ridges pattern. The infiltrate is usually less dense than in typical LP.(7) Lupus Erythematosus (LE) It is an autoimmune disorder affecting skin, hematopoietic, and lymphoreticular organs, joints, kidney, lung, serosa, and cardiovascular structures in concert or in isolation. Lupus erythematosus is subdivided clinically into systemic (SLE), subacute cutaneous (SCLE), and discoid (DLE) forms, each with its own characteristic skin findings. Lesions of SLE, for example, show a pauciinflammatoryinterface dermatitis with subtle basal layer vacuolopathy and no basement membrane zone thickening, keratotic follicular plugging, or acanthosis [1] e-ISSN: 2349-6991; p-ISSN: 2455-0396

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Dermatomyositis: Dermatomyositis combines an inflammatory myopathy with characteristic skin lesions: the often-subtle heliotrope rash, the Gottron papule, a violaceous or hypopigmented papule over the joints of the fingers, erythema of the upper back (the ‘‘shawl sign’’), extensive erythema of the extensor surfaces of the arms, scaly alopecia, and cuticular overgrowth with periungual telangiectasias. Skin lesions of dermatomyositis manifest an atrophying cell-poor lymphocytic interface dermatitis accompanied by dermal mucinosis and vascular alterations that vary according to the age of the lesion biopsied and the presence or absence of myopathy: in patients with myopathic dermatomyositis, a characteristic injury pattern comprising a variably cell- poor, often thrombogenic lymphocytic vasculopathy mainly affecting the dermal papillae capillaries is seen.[1,3]

PLC : Pityriasis Lichenoid Chronica LSEA:Lichen sclerosiset atrophicus GVHD : Graft Versus Host disease LS : Lichen Striatus DM : Dermatomyositis PLEVA : Pityriasis Lichenoides et varioliform TEN: Toxic Epidermal Necrolysis

Reference 1.

Crowson AN, Magro CM, Mihm MC Jr. Interface Dermatitis. Arch Pathol Lab Med 2008 Apr; 132 (4) : 652-66.

Le Boit PE. Interface Dermatitis. How specific are its histopathologic features? Arch Dermatol 1993; 129:1324-28

Virendra Sehgal, G Srivastava et al. Lichenoid tissue reaction/Interface dermatitis: Recognition, classification, etiology & clinicopathological overtones. Indian Journal of Dermatology ,venerology and Leprology 2011; Vol 77: Issue 4:418-430.

Tilly JJ, Drolat BA, Esterley NB et al. Lichenoid eruptions in Children. J Am Acad Dermato;2004;51:606-24.

Rajiv Joshi. SYMPOSIUM DERMATOPATHOLOGY. Indian Journal of Dermatology, Venereology & Leprology 2013;79:3: 349-59.

Philip Le boit. Dermatitis involving dermo-epidermal junction. In:Maize JC. Burgdorf WH, Hurt MA, Le Boit PE, Metcalf JS, Smith T et al, editors. Cutaneous Pathology. Philadelphia: Churchill Livingstone:1998.pg 87-145.

Weedon D. The Lichenoid Reaction Pattern. In: Weedon D, editor. Skin Pathology. 2 nd ed. New York: Churchill Livingstone; 2002. p. 31-74.

Sushama Desai, Anuya Badwe, Balkrishna Nikam et al. Histopathological study of Interface dermatitis with its clinical correlation. International journal of healthcare & Biomedical research, Volume: 2, Issue: 3 , April 2014 , Pages 24-32

Suja Ajoy Kumar, G Nandakumar. A study of Interface Dermatitis with clinical correlation. Journal of Evolution Of Medical and Dental Sciences 2015 ; Vol . 4, Issue 42, May 25; Page: 7344-7351

In our study we had 02 cases of dermatomyositis with 100% clinical concordance. The case of DM that we studied shows atrophic epidermis with cell poor lymphocytic IFD accompanied by mucinosis. (Fig.11)

Conclusion

A clinicopathologic correlation is absolutely essential for the final diagnosis of IFD. Presence of an interface lichenoid inflammatory reaction should not be the only criterion for the diagnosis of LP or any of its variants

Acknowledgement

The authors are thankful to the Department of Dermatology, Technicial Staff , BVDUMC & H, Sangli, for their help and cooperation

Abbreviations used

IFD : Interface dermatitis DE junction : Dermo epidermal junction LP : Lichen Planus ALP : Atrophic Lichen Planus HLP : Hypertrophic Lichen Planus EM : Erythema Multiforme LE :Lupus Erythematosus LDE : Lichenoid Drug Eruptions

10. Vijaya Kumar Hegde , Urmila N Khadilkar , A clinicopathological study of interface dermatitis. IOSR Journal of Dental and Medical Sciences (IOSR- JDMS) .2014. Volume 13, Issue 4 Ver. IV. (Apr. 2014), PP 105-107

*Corresponding author: Dr. Vaibhav Mane, Flat No. 1 Shri Ramshailya Aparrtment , Neminathnagar, Sangli 416415. INDIA Phone: +91 9422041490 Email: vaishnavilab1060@gmail.com Date of Submission : 05.04.2017 Date of Acceptance : 18.04.2017 Date of Publication : 21.04.2017

Financial or other Competing Interests: None.

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Original Article DOI: 10.21276/AABS.1508

Studies on Bio-ethanol Production Using Fermentation by Free and Immobilized Yeast Cells Manasa P, Narasimhulu Korrapati* and Paramjeet Saroj Department of Biotechnology, National Institute of Technology Warangal, Telangana, India.

ABSTRACT Background: Production of bioethanol from yeast cells is very important to meet the energy crisis and this work mainly concentrated on bioethanol production by free and immobilized yeast cells. Methods: Batch fermentation with free and immobilized yeast cells was done and compared. Result: The maximum concentration of ethanol was reached around 48 h which was 30.02 gL-1 and 28.78 gL-1 for S.cerevisiae and Bakerâ&#x20AC;&#x2122;s yeast respectively. The maximum ethanol concentrations for each sets were 30.5 gL-1, 27.6 gL-1, and 28.2 gL-1 for subsequent sets of immobilized S.cerevisiae and 28.2 gL-1, 27.6 gL-1, and 26.98 gL-1for subsequent sets of immobilized bakerâ&#x20AC;&#x2122;s yeast Conclusion: As the total time for immobilized cells experiments was 3 sets of 56 h each or 168 h, it shows the stability of cells and longer functional period. However, as the ethanol concentration was stagnant after 8h, one must reduce the time period of set readings to 4h or 6h. However, the maximum ethanol concentration was observed after 48h from the inoculation of the culture in all the cases which shows a promising time period to be targeted industrially. In conclusion, the immobilized cells have significant advantage over free cells using sodium alginate as the immobilizing agent. More research focused on the size, cell density and industrial scale studies using packed bed or tubular reactor must be done to analyze it better. Keywords: Immobilized Cells, Fermentation, Recyclability, Alginate, Bioethanol, Glucose.

Introduction

Industrial revolution lead to use of machines and fuel. In recent years, the energy demand of any country is used to evaluate the development index. Presently, the major source fuel is fossils. The depletion of fossil fuels at an alarming rate is one of the major problems. Whereas being limited, fossil fuel are not environment friendly. To meet the ever increasing demand of energy while keeping in mind the environmental pollution, other sources, including solar and bioenergy such as, biomass, biogas and biofuel are being explored. In liquid fuels, ethanol, is identified as one of the best alternative. Useful as an environmental friendly additive for gasoline, ethanol is also easily produced by fermentation. Further, containing 35% oxygen, no particulate pollution and higher fuel combustion is obtained by ethanol. Being referred to as alternative oil and renewable energy source, studies on production of ethanol are important [1,2,3,4,5,6]. Ethanol production is mainly done using microbes which ferment sugars. The sugars include hexoses such as glucose, mannose, xylose and galactose. Saccharomyces cerevisiae, a yeast is one of the easiest available and widely studied microbe. It is a highly effective bioethanol producing organism by fermentation of hexose sugars, especially glucose. With an ability of grow in relatively

low pH, the chances of contamination are also reduced. Further, high tolerance to ethanol concentration other inhibitory compounds adds on to its ability of being an ideal bioethanol producer [7]. S. cerevisiae mainly utilizes glucose as the course of carbon and metabolizes the same for the production of bioethanol. In this study, we used only native strains. Being a native strain, it is unable to metabolize xylose and only glucose fermentation was analyzed [8, 9]. Free cells are referred to as the broth culture. A major limitation of using free cells for fermentation is the lack of re-usability. A different approach of immobilizing cells have been reported widely. Immobilizing is done either using agar, or other polymers. A few of the main advantages of using immobilized cells are higher density of cells for every volume of the reaction mixture, easily separable from the reaction mixture hence increasing the chances of reusability, inhibition of cell loss during downstream and other flow operations, early achievement of exponential phase, high conversion rate of substrate, not affected by inhibitory molecules, more yield in lesser duration, better control over biomass growth [10]. A number of studies have reported the advantage of using immobilized cells for fermentation. With higher production as compared to free cells, the immobilized cells provide an economical

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alternative to free cells technique. With promising results in industrial applications, many different methods for immobilizing have been reported. [11, 12, 13]. The technique of using alginate to obtain immobilized cell’s beads is economical, easy to obtain, and can be easily carried out at room temperature and mild conditions [14]. In this study, we used the method of immobilizing using alginate to obtain beads of desired cells and compared the ethanol fermentation of free cells with that of immobilized beads. Further, we also established the recyclability of alginate beads observing the fermentation for three sets.

Materials and Methods

Microorganisms: Baker’s Yeast and Saccharomyces cerevisiae were used as microorganisms. Chemicals: Glucose, Potassium dichromate, calcium chlorite, sodium alginate, sulfuric acid, Ethanol were used in the experimental work. Biological Media: Yeast peptone broth and yeast fermentation broth were prepared and used in the work. Glassware: Erlenmeyer flasks, Test tubes, Measuring cylinder, petri dish, funnel were used. Other Equipments: Syringe filter, syringe (2mm), filter paper, falcon tubes, UV Spectrophotometer, cuvettes, Shaking Incubator, LAF, Eppendorf tubes, Centrifuge, Micropipettes were used. Mother Culture: Obtained by streaking on YPD Agar plate Growing Medium: The yeast cells were grown in a sterile solution (121°C, 15 min.) containing 20 gL-1 glucose, 20 gL-1 peptone, and 10 gL-1 yeast extract, pH 5. After 24 h. at 25-30°C, the mixture was centrifuged (8000 rpm, 10 min.) and suspended in sterile water (0.10 L). Fermentation Medium with Glucose: A sterile solution (121°C, 20 min.) was prepared with 180 gL-1 glucose, Yeast Nitrogenous Base 1.7 gL-1, ammonium sulfate 5 gL1 , and 2.5 gL-1 yeast. Sodium Alginate Beads for Immobilization: For the immobilization in beads, 4% (w/v) sodium alginate was dissolved in 0.10 L water and added to a 0.10 L suspension of S. cerevisiae in a falcon. The solution was mildly shaken. A CaCl2 solution with a final concentration of 1.3% (w/v) was prepared in a separate beaker. The mixture containing the cells and the sodium alginate was added dropwise to 0.150 L of the CaCl2 solution using a 0.05 L syringe. The beads were hardened in this solution overnight at 4°C. After hardening in the CaCl2 solution, the

beads were rinsed with sterile water to be used thereafter in the fermentation experiments. The beads obtained had a diameter approximately between 3 to 5 mm. Batch Fermentation Experiments Using Free Cells: An experiment using free cells for the fermentation was carried out using the overnight grown yeast cells. The overnight grown cells were suspended in 100mL yeast fermentation media and allowed for fermentation. The fermentation was carried out at 25-30°C at 120rpm. Samples were collected for every 8 h. to calculate the ethanol concentration. Batch Fermentation Experiments using the Immobilized Cells Approximately 25g of calcium alginate beads was added to a 100 mL Erlenmeyer flask containing 50 mL of the fermentation medium with glucose in the yeast fermentation media. All steps prior to fermentation were carried out under LAF. The flasks were placed in an orbital shaker for 25-30°C and 100 rpm. Samples were collected every 8 h. During the fermentation period. After 56 h, the beads were filtered and rinsed with sterile water and added to a fresh yeast fermentation medium. The procedure was repeated two times for the successive fermentation cycles and reading were observed and tabulated. Analytical Methods: Ethanol concentration was determined using Di-chromate method as described by Seo et al. [15]. TBP [tri-n-butyl phosphate] was used to extract ethanol in an aqueous solution; 1.5ml of TBP, and 1.5ml of an ethanol standard solution or sample were mixed in a test tube and then vortexed vigorously 20 min. After phase separation, 1ml of the solvent phase (upper layer) was transferred to a 2ml Eppendorf tube. The dichromate reagent (equal volume=1ml) was then added, and then vortexed vigorously for 20 min. After phase separation, 750µl of the dichromate reagent-containing lower phase was used to measure the OD at 595 nm.

Results and Discussion

Batch Fermentation with Free Cells: Batch fermentation was carried out for Baker’s yeast and S.cerevisiae with 180 gL-1 of glucose in triplicates with 100ml each. The concentration of ethanol was observed after 24h of growth. The fermentation was observed for 160 h. For every 8h, 1.5ml of media was collected and analyzed for ethanol concentration and tabulated as Table 1 and Table 2. As shown in the Fig 1 and Fig 2, the maximum concentration of ethanol was reached around 48 h which was 30.02 gL-1 and 28.78 gL-1 for S.cerevisiae and Baker’s yeast respectively. Further, as the graph shows, the concentration of ethanol was roughly constant after 48 h only varying with the lower range of 3.9 gL-1 and 1.8 gL-1 for S.cerevisiae and Baker’s yeast respectively. The results are comparable to studies

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A-113 [15]. The graph also shows the production of ethanol is constant which suggest that the maximum concentration is reached at the end of the exponential phase itself. The constant region may highlight the stationary phase. The results suggested to focus on the first half of the time period or roughly 40-50 h for obtaining the maximum concentration of ethanol on industrial scale. Batch Fermentation with Immobilized Cells: The immobilized cells were obtained using sodium alginate beads which had a diameter of 3-5mm. Each fermentation media had a glucose concentration of 180 gL-1. Three sequential fermentation cycles were carried out to observe the recyclability of the immobilized cells. Each fermentation set was observed for 56 h. For every 8h, 1.5ml of media was collected and analyzed for ethanol concentration and tabulated as Table 3 and Table 4. The maximum ethanol concentrations for each sets were 30.5 gL-1, 27.6 gL-1, and 28.2 gL-1 for subsequent sets of

AABS; 4(2): 2017 immobilized S.cerevisiae and 28.2 gL-1, 27.6 gL-1, and 26.98 gL-1for subsequent sets of immobilized bakerâ&#x20AC;&#x2122;s yeast as shown in Fig 3 and Fig 4. This maximum ethanol concentration was slightly different when compared to free cells which may be due to diffusional barriers, however, interestingly the difference was not significant. This may lead to inhibition of nutrients to some cells especially at the center of the beads leading to inefficient fermentation. However, this drawback can be removed by reduced sixe of beads which increases the surface area for effective contact with the media. The concentration of ethanol in the fermentation media changed marginally during the observed time of exposure to alginate beads. This suggests that in each fermentation set, the immobilized yeast cells were in their stationary phase. Further, the concentration declined after each set of use suggesting loss of efficiency in subsequent steps.

Table 1: Ethanol concentration values for S.cerevisiae Ethanol Concentration(gL-1) 0 20.61795 25.55345 26.48444 30.02154 28.1654 27.9582 27.20162 27.95662 28.65 27.30988 27.4526 27.62651 26.92016 26.12548 27.9995 27.36401 27.1365 27.92963

Time(h) 0 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136 144 152 160

Table 2: Ethanol concentration values for Bakerâ&#x20AC;&#x2122;s yeast Ethanol Concentration (gL-1) 0 22.11907984 23.7822 25.698 28.77852954 28.00012 27.86969 27.97789806 27.30987821

Time(h) 0 24 32 40 48 56 64 72 80

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Table 3: Ethanol concentration for immobilized alginate beads of S.cerevisiae Ethanol Concentration (gL-1) Set 1 Set 2 0 0 0 8 25.69 24.6365 16 26.54 25.9586 24 27.6 26.6969 32 30.5214 27.3621 40 28.635 27.64 48 28.0125 27.145 56 27.5214 25.0315 Table 4: Ethanol concentration for immobilized alginate beads of Bakerâ&#x20AC;&#x2122;s Yeast Ethanol Concentration (gL-1) Set 1 Set 2 0 0 0 8 25.66 25.3114 16 25.648 24.9895 24 26.482 26.324 32 27.99519 27.6352 40 28.2152 24.6528 48 27.86969 26.512 56 27.01301 25.874

Fig. 1: Ethanol concentration for S.cerevisiae free cells.

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Time(h) 88 96 104 112 120 128 136 144 152 160 Time (h)

Set 3

0 24.722 25.845 23.151 28.201 25.015 26.908 25.652 Time (h) Set 3 0 25.215 23.013 26.01 26.98 23.625 25.1 24.685

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Fig. 2: Ethanol concentration for Bakerâ&#x20AC;&#x2122;s Yeast free cells.

Fig. 3: Fermentation cycles for immobilized alginate beads of S.cerevisiae.

Fig. 4: Fermentation cycles for immobilized alginate beads of Bakerâ&#x20AC;&#x2122;s Yeast

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Conclusion

Immobilizing the cells in sodium alginate beads provide several advantages. Such as easy separation, recyclability, control on biomass being used, total duration and most importantly, much lower cost. Moreover, as observed in our experiments, no significant difference can be established between free and immobilized cells. It can be said that even though diffusional barriers might exist, proper agitation, bead size and cell concentration can lead to similar ethanol production from both free and immobilized cells. A major challenge tackled with immobilization is removal of contamination as all experiments were done in sterile conditions. As the total time for immobilized cells experiments was 3 sets of 56 h each or 168 h, it shows the stability of cells and longer functional period. However, as the ethanol concentration was stagnant after 8h, one must reduce the time period of set readings to 4h or 6h. However, the maximum ethanol concentration was observed after 48h from the inoculation of the culture in all the cases which shows a promising time period to be targeted industrially. In conclusion, the immobilized cells have significant advantage over free cells using sodium alginate as the immobilizing agent. More research focused on the size, cell density and industrial scale studies using packed bed or tubular reactor must be done to analyze it better.

Acknowledgements

The authors thankful to the Director, National Institute of Technology, warangal for supporting to conduct this research.

C, L., F, W., & F, O.-Y. (2009). Ethanol fermentation in a magnetically fluidized bed reactor with immobilized Saccharomyces cerevisiae in magnetic particles. Bioresource Technol, 100:878–882.

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PY, W., C, S., & H, S. (1980). Fermentation of a pentose by yeasts. Biochem Biophys Res Commun, 94:248–254.

10. R, W., A, F., PJS, M., JAR, R., E, T., & K, A. (2001). Continuous fermentation of sugar cane syrup using immobilized yeast cells. J Biosci Bioeng, 91:48–52. 11. Y, L., & S, T. (2006). Ethanol fermentation from biomass resources: Current state and prospects. Appl Microbiol Biot, 69:627–642. 12. DS, I., DP, T., SN, C., AS, M., & CR, R. (1983). Ethanol production by S. cerevisiae immobilized in hollow-fiber membrane bioreactors. Appl Environ Microb, 46:264–278. 13. W, Y., X, W., J, Z., B, S., YY, Z., & C, M. (2011). Bacterial cellulose membrane – A new support carrier for yeast immobilization for ethanol fermentation. Process Biochem, 46:2054–2058.

References

14. Z, Z., G, L., & Y, L. (2010). Immobilization of Saccharomyces cerevisiae alcohol dehydrogenase on hybrid alginate-chitosan beads. Int J Biol Macromol, 47:21–26.

15. Seo, H.-B., Kim, H.-J., Lee, O.-K., Ha, J.-H., Lee, H.-Y., & Jung, K.-H. (2009 ). Measurement of ethanol concentration using solvent extraction and dichromate oxidation and its application to bioethanol production process. J Ind Microbiol Biotechnol , 36:285–292.

FW, B., WA, A., & M, M.-Y. (2008). Ethanol fermentation technologies from sugar and starch feedstocks. Biotechnol Adv, 26:89–105. Y, L., & S, T. (2006). Ethanol fermentation from biomass resources: Current state and prospects. Appl Microbiol Biot, 69:627–642.

*Corresponding author: Dr. Narasimhulu Korrapati, Department of Biotechnology, National Institute of Technology Warangal, Telangana-506004, India, Phone: +91 9985470286 Email: simha7762006@gmail.com Date of Submission : 05.05.2017 Date of Acceptance : 14.06.2017 Financial or other Competing Interests: None. Date of Publication : 05.07.2017

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Original Article DOI: 10.21276/AABS.1532

Health and Health Related Quality of Life of Children Living with HIV Infected Parents Priyanka Chauhan1, Sunit Pathak2* and N C Prajapati3 1 Dept of Pediatrics, KGMU, Lucknow, India FH Medical College, Tundla, Firozabad, India 3 GMC, Badaun, UP, India

ABSTRACT Objective: To study the health and health related quality of life of children living with HIV infected parents using Pediatric Quality of Life Inventory (PedsQL) â&#x201E;˘ 4.0 Generic Core Scales. Methods: The study was conducted from January 2013 to October 2014 at S. N. Medical College, Agra , ART centre and pediatrics OPD. The Pedsql generic core version 4.0 was administered to 300 children in the age group of 8-18 years living with HIV infected parents and 300 controls who visited the pediatric OPD for minor ailments. Results: In this study it was found that children living with HIV infected parents had lower mean weight(26.89 vs 30.76 kg), height(1.09 vs 1.35metres) and body mass index (15.73 vs 17.16) compared with controls. The percentage of children not attending the school for more than six months was also significantly higher in the study group ( 32% vs 15% in controls. Their Pedsql scores were lower in emotional, social and school domains as compared with the controls. Conclusion: These findings are along expected lines, it is vital to establish a baseline of socioeconomic and physical parameters of such children in Indian context. This knowledge is vital to plan a meaningful policy intervention and to measure its efficacy. These findings can guide in the development of future interventions that promote care and support of children living in HIV/AIDS affected families. we feel more such studies are required in future to realise the big picture. Keywords: HIV, Peds QL,HRQOL, Social and School Domain

Introduction

HIV in children is a major health problem which is increasingly becoming prominent cause of childhood morbidity and mortality in India.The total number of people living with HIV in India is estimated at 2.4 million in 2009 with 4.4% children less than 15 years of age (NACO) (1). A search of the literature has shown that there has been very limited research on the HRQOL of children living with HIV infected parents in India. The information gathered on children living with HIV infected parents, including children orphaned by AIDS, would be of benefit to all the health team members, and family members involved in taking care of these young children and would assist in determining the resource allocation that is necessary in terms of social, emotional and school support that would optimise the quality of life of these children. In addition, the specific domains assessed using the modified version of PedsQL 4.0 Generic Core Scales may highlight specific aspects of quality of life in children. The aim of this study was to study the health and health related quality of life of children living with HIV positive parents through Pedsql 4.0.

Material & Methods

The present cross-sectional study was conducted in Department of Paediatrics and ART Centre, SN Medical College, Agra (U.P) from January 2013 to October 2014. Children of age 8 to 18 years of HIV infected parents, attending OPD of ART Centre at SN Medical College Agra during the study period were enrolled in the study group. Child suffering with HIV infection, children suffering with cognitive or communicative disabilities or psychotic disorders and children of parents diagnosed for HIV infection of less than 6months duration at the time of enrolment and children with no parent alive were excluded from the study. Age and sex matched children in the age group of 8-18 yrs of HIV/AIDS negative/not tested parent/s, attending Pediatrics OPD for minor illnesses were included in the control group. Guardian/parents of the child in presence of the child were briefed about the objectives of the study and written consent was obtained. At the time of enrolment in the study a detailed profile of the child was recorded

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on a predesigned, pretested semi structured performa (enclosure). A complete physical examination of each child was done and parameters recorded. Ethical clearance was taken from institutional review board. Paediatric Quality Of Life Generic Core Scale Version 4.0(PedsQL 4.0) (2) in Hindi language was used in all children of the study group for which permission was sought from Dr James W.Varni, who owns the copyrights of PedsQL. PedsQL 4.0 measures the health dimensions (called domains) of physical, emotional, social and school functioning of the child through various questions (called items). It has 8 items for physical functioning domain and 5 items each for emotional, social and school functioning domains (total 23 items). Two methods for administration of the instrument were self-administration and proxy administration. Children ≤12 years opted for proxy method and children >12years, for self administration method. Each item in different domain was assessed and scored by two methods Likert scoring and Reverse scoring. Likert score ranges from 0-4 (0 is never, 1 is almost never, 2 is sometimes, 3 is frequently and 4 is almost always). In reverse scoring the Likert score of each item in the domain was transformed on a scale of 0-100 in a reverse manner where 0 is 100, 1 is 75, 2 is 50, 3 is 25 and 4 is 0. By reverse scoring the HRQOL was plotted on a score of 0-100 where reverse score ‘0’means severely affected and ‘100’ means near normal. The total score in each domain was calculated separately and it denotes the QOL related to that domain ie Physical, Social, Emotional and School. HRQOL for psychosocial functioning was obtained by combining the scores of social, emotional and school functioning domains. A total score for all the domains was

calculated by summing up the scores of all the domains and it denotes overall HRQOL.

Result

Fom January 2013 to October 2014, 556 HIV infected parents with at least one child rin the age group of 8-18 years and fulfilling the inclusion criteria visited the ART centre for consultation. 513 such parents were contacted and were pursued to take part in the study and bring their children on the next visit. Only 300 parents and their eligible children turned up during the study period and were enrolled in the study. Table-1 shows the demographic profile of children and caregivers in the study and the control group. In the present study it was observed that reverse scores ranged from 0-100 and the mean total reverse score was 77.16. Among individual domains children scored best in their physical scores (87.07) but were less in emotional domain (72.53), social domain (79.65) and school domain (69.40).The psychosocial score by reverse scoring was 73.86. (Table-2) The association of Pedsql scores with multiple independent variables was performed. Lower pedsql scores were recorded in older age group, children not attending school, living in nuclear families, with single parent alive, and lower socioeconomic status. (Table-3) For the categorical variables (gender, hiv status etc.) the data was analysed as frequency and percentage and chisquare test was applied for comparisons. For continuous variables (weight, height, reverse scores) mean and standard deviations were calculated and comparison was done using unpaired student-t-test. Spss20 was used to calculate the results. P-values less than 0.05 were considered significant.

Table-1: Demographic profile of children and caregivers in study and control group: Profile

Control group (n=300)

Study group (n= 300)

Children Age group+ Gender+ Schooling+ status Weight (kilogram)

≤12 years

171 (57%)

162 (54%)

> 12years

129 (43%)

138 (46%)

Male

181 (60%)

165 (55%)

Female

119 (40%)

135 (45%)

Attending school

256 (85%)

204 (68%)

Not attending school

44 (15%)

96 (32%)

30.76±8.593

26.89±7.009

Height (metres)*

1.35±0.480

1.09±0.288

BMI*

17.16±3.357

15.73±2.320

Relationship with caregiver+ Parents Grandparents Other relatives

290 (96.7%) 7 (2.3%) 3 (1%)

249 (83%) 34 (11.3%) 17 (5.7%)

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Control group (n=300)

Study group (n= 300)

Children HIV status of Father+ Positive Negative Unknown

214 38 48

300

HIV status of Mother+ Positive Negative Unknown

171 93 36

300

Lively status of parents+ Both alive Only Mother alive Only Father alive

290 7 3

218 48 36

Variables in the Study group Parents’ HIV status+ Disclosed to child Not disclosed

114 186

Disclosed to relatives Not disclosed to relatives

177 123

Mode of administration of HRQOL+ Self-administered Proxy administered

120 180

+ values are given as frequency and (percentage) * values are given as mean± standard deviation

Table 2: Likert Scores and Reverse scores of the Pedsql Generic core scale version 4.0 in the study group. Domain

Likert score

Reverse score

Physical(n=300)

2.073

87.07

Emotional(n=300)

2.731

72.53

Social(n=300)

2.534

79.65

School(n=204)

2.833

69.40

Psychosocial(n=204)

2.699

73.86

Total (n=204)

2.543

77.16

Table 3: Variables affecting Pedsql scores in the Study group: Variable Age

Gender

Type of family

Physical score Emotional score ≤ 12 years > 12 years Male Female Nuclear Joint

Lively status of parents

Both alive Single alive

Social score

School score

Total score

86.37(±14.18) 87.41(±11.48) P value 0.550

78.43(±17.69) 65.44(17.86) Pvalue <0.001

80.01(±14.44) 79.22(±13.86) P value 0.780

73.13(±21.89) 79.48(±17.34) P value 0.071

63.89(±17.05) 74.13(±15.13) P value 0.203

89.64(±12.16) 83.86(±13.41) P value 0.027

74.36(±17.32) 70.23(±20.54) P value 0.280

81.00(±14.16) 77.95(±14.03) P value 0.288

70.66(±20.41) 67.76(±20.98) P value 0.570

78.91(±16.01) 74.95(±17.24) P value 0.310

85.59(±14.06) 88.03(±11.47) P value 0.380

69.23(±20.02) 74.67(±17.87) P value 0.130

74.23(±14.58) 83.17(±12.72) P value 0.003

65.19(±20.31) 72.25(±20.47) P value 0.250

73.56(±15.01) 79.53(±13.45) P value 0.273

88.52(±11.22) 87.64(±6.499) P value 0.740

77.73(±16.76) 66.36(±20.01) P value 0.010

84.92(±11.98) 70.45(±10.22) Pvalue <0.001

72.76(±20.03) 65.56(±18.45) P value 0.340

80.98(±15.24) 72.50(±13.80) P value 0.301

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Variable

Physical score Emotional score

Disclosure of parents’ HIV status

Not Disclosed

Socioeconomic status

Lower

Schooling* status

BMI of child

Disclosed

Middle Not Attending school Attending school ≥ - 2SD < - 2SD

Social score

School score

Total score

86.05(±11.79) 87.79(±13.82) P value 0.51

85.49(±12.03) 63.36(±17.38) Pvalue <0.001

83.05(±14.40) 77.24(±13.51) P value 0.043

77.14(±19.22) 63.85(±19.88) P value 0.008

82.93(±14.36) 73.06(±16.14) P value 0.062

85.58(±13.84) 91.04(±9.48) P value 0.060

71.39(±18.90) 75.56(±18.67) P value 0.320

77.29(±14.38) 85.93(±11.35) P value 0.006

65.78(±21.55) 76.82(±16.37) P value 0.038

75.01(±17.17) 82.34(±13.97) P value 0.020

84.58(±13.14) 89.46(±8.40) P value 0.070

62.34(±20.90) 73.65(±15.67) P value 0.032

74.30(±15.28) 82.83(±12.33) P value 0.005

Not calculated

not calculated

87.64(±12.15) 85.86(±13.40) P value 0.132

73.34(±18.32) 69.22(±22.54) P value 0.280

81.00(±14.15) 77.95(±14.03) P value 0.288

71.65(±19.40) 68.71(±19.90) P value 0.570

78.40(±16.01) 75.43(±17.24) P value 0.243

* As 96/300 children were not attending school, the school score and total score could not be calculated

Discussion

In our study we found that children living with HIV infected parents had lower mean weight, height and body mass index compared with controls. The percentage of children not attending the school for more than six months was also significantly higher in the study group. Their Pedsql scores were lower in emotional, social and school domains. School score was the most affected domain followed by emotional domain. The physical domain was the least affected. The HRQOL was significantly affected by age of child, survival status of parents, type of family the child lives in, socioeconomic status of family, schooling, disclosure of parents’ HIV status. 32% children in the study group were not attending the school, for duration of more than 6 months, at the time of study. Regarding reasons for dropouts, poor economic condition and social stigmas associated with their parents HIV status were the major issues. In the studies by Tao Xu et al (3) and Sengendo and Nambi et al (4) in Uganda, the percentage of dropouts from school was 18% and 45% respectively

are alive. This difference is statistically significant in the emotional and social domains only. Our findings showed that disclosure of parental HIV/AIDS status to the child affected the HRQOL of their children in the emotional, social and school domains (table 3) similar to that reported by Tao Xu et al (3) and Rotheram-Borus et al (6). We found that children living in nuclear families reported lower HRQOL scores than those living in joint families. The difference of scores was statistically significant in social domain (p value=0.003) (Table-3). Children living in such families may also be deprived of family affection and care necessary for their well-being, increasing their risk to develop psychological and behavioural problems as also observed by Fang et al (7); Wild et al (8).

In our study 19% of children had their BMI below 2 Standard deviation (Underweight) (Table 1). It is slightly more than reported by Chinqing Lin et al (5).

The observations in the study show that the HRQOL of children not attending school was lower in physical, social and emotional domains (statistically significant difference in emotional and social domains, p values 0.032, 0.005 respectively). As suggested by the studies conducted by Nyamukapa et al (9) and colleagues in Zimbabwe, being out of school contributed to the greater psychological distress of AIDS affected children, because these children would lose a safe place for learning skills, sharing grief and developing peer networks.

On comparing the HRQOL scores with respect to age the scores were significantly lower in the emotional domain in children greater than 12 years (Table-3). It could be due to children of the older age being able to understand the disease and social stigmas associated with HIV from which their parents were suffering. Other reason could be that children in the older age group had opted for self administration method for response and are their best judges regarding their emotions. The HRQOL scores were better in all domains in children whose both parents

The present study had some limitations that should be acknowledged. Being a cross-sectional study, we were unable to test whether there are changes in children’s HRQOL over time. Moreover the response to the questionnaire was obtained differently for children greater than 12 years (self-administered) and less than 12 years (proxy administered). Despite the limitations, the findings are still applicable and can guide in the development of future interventions that promote care and support of children living in HIV/AIDS affected families.

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References 1.

National Annual Report 2013-14.National Aids Control Organisation Ministry Of Health And Family Welfare. Webpage www.naco.gov.in

Varni, J. Seid, M. Rode, C., 1999. The PedsQL: Measurement Model for the Pediatric Quality of Life Inventory. Medical Care, 37(2):pp. 126-139.

3. Xu, T. Wu, Z. Rou, K. Duan, S. Wang, H., 2010. Quality of Life of children living with HIV/AIDS-affected families in rural areas in Yunnan, Acahina. AIDS Care, 22(3):pp.390-396. 4.

Sengendo, J. & Nambi, J. 1997. The psychological effect of orphanhood: a study of orphans in Raika district. Health Transit. Rev., 7(Suppl.): 105–124

AABS; 4(2): 2017 5.

Rotheram-Borus MJ, Draimin BH, Reid HM, Murphy DA. The impact of illness disclosure and custody plans on adolescents whose parents live with AIDS. AIDS. 1997;11:1159–1164

Chinqing Lin, Li Li, Alan Semaan , 2008 Children’s body mass index and nutrition intake in HIV/AIDS.Vulnerable Child Youth Stud, 3(1): 16–23.

Fang X, Li X, Stanton B, Yan Hong Y, Zhang L, Zhao G, Lin D. Parental HIV/AIDS and psychosocial adjustment among rural Chinese children. Journal of Pediatric Psychology. 2009; 34(10):1053–1062. [PubMed: 19208701]

Wild J. The psychological adjustment of children orphaned by AIDS. Southern African Journal of Child and Adolescent Mental Health. 2002; 13:3–22

*Corresponding author: Dr Sunit Pathak, 238A New Agra, Byepass Road, Agra, India- 282005 Phone: +91 8979834496 Email: drsunitpathak@gmail.com

Financial or other Competing Interests: None.

Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

Date of Submission : 01.06.2017 Date of Acceptance : 12.06.2017 Date of Publication : 05.07.2017

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article DOI: 10.21276/AABS.1555

Clinicopathological Profile of Anaemia Cases in Adults (20-60 years) Attending a Rural Hospital Mangal Motilal Pandure* and Deepak Kumar Ghosh Dept of Pathology, Pravara Institue of Medical Sciences. Deemed University.

ABSTRACT Background: Anemia is a worldwide problem with highest incidence in developing countries. India has the highest prevalence of nutritional anemia predominantly in women and children. Methods: An observational and analytical study was carried out for period of 12 months. We studied 261 adult patient for typing the anemia. We perform the hematology parameter by automated hematologyanalyzer,For confirmation PBS and bone marrow examination, serological test like serum iron profile , vit B12 and folic acid levels in blood is done Result: Total 261 cases of anemia included in the study. Microcytic hypochromic anemia were63.2 %of cases, macrocytic anemia cases were 36.77% of cases. Large number of iron deficiency anemia’s were seen in female with reproductive age group and megaloblastic anemia seen with age 50-60 years of age in both sex. Conclusion: For the diagnosis of nutritional anemia haemogram by automated hematology parameter, PBS, serum iron profile , serum vit B12 and folic acid is required Keywords: Iron Deficiency Anemia, Megaloblastic Anemia, Nonmegaloblastic Macrocytic Anemia, Nutritional Anemia.

Introduction

In 1992, World Health Organization(WHO) global estimates of anemia prevalence averaged 56%, with range of 35-75% depending on geographic location. Prevalence of anemia seen in south Asia, among highest in world. In India recent data from national family health survey 1998/1999 stated that woman with reproductive age have higher prevalence rate concentration and impaired capacity to transport oxygen.[1] It has multiple factor such as genetic- haemoglobinopathies, infectious- malaria, intestinal helminthes and nutritional- which includes iron deficiency as well as deficiency of vitamins such as folate vitamin A, B12 and minerals like cupper. [2] The evaluation of cause of anemia includes complete blood count, peripheral smear, and reticulocyte count and serum iron indices. [3] As per WHO classification, majority of subject 41.3% suffered from moderate anemia, while 18.4and 0.4 suffer from mild and severe anemia. In the study of NeelamDeshpande et al 70% of anemic subject had low MCV with high RDW suggestive of iron deficiency.[4]Uma Khandri and Archana Sharma stated that megaloblastic anemia was diagnosed from complete blood count, red cell indices, blood film examination and assay of two vitamins. Marrow examination was not essential for diagnosis. Cobalamine deficiency was responsible

for megaloblastic anemia in majority of patient (65%), combined (folate and cobalamine) seen in 12% and pure folate deficiency in 6% cases. [5] Hence the present study was carried out to find out commonest type of anemia in the rural population.

Materials and Methods

This is prospective study comprised of adult from outpatientand indoor department of a tertiary care in teaching hospital in Maharashtra, India. The period of study was from January 2015 to December 2015. Total261 patients with anemia’s were selected for study with informed consent.

Selection Criteria for cases

Inclusion criteria(cases included in study) • Male and female patient in the age group 20 to 60 years. • Patient with HB value 10gm/dl or less. Exclusion criteria ;( cases excluded from study) • Pregnant and lactating women due to physiological anemia • Patient who were on treatment / therapy for any reason Haemogram were performed by automated hematologyanalyzersysmex XN 1000. This instrument performed hematology analysis according to

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hydrodynamic focusing, flow cytometry method and SLS hemoglobin method.

cell identified as reticulocyte. Advised them to perform hemoglobin electrophoresis.

Microcytic hypochromic anemia and macrocytic anemia were included in the study. Cases are classified in to microcytic and macrocytic anemia on the basis of MCV. Microcytic anemia is identified when MCV is <80fl, macrocytic anemia is identified when MCV exceeds 100fl, increased RDW in both and confirmed by Peripheral Blood Smear (PBS). PBS examinations were performed, we observed for anisopikilocytes, microcytes and macrocytes.[6]

Result

Total number of cases in study: 261 Table 2 Distribution of cases according to age groups in microcytic hypochromic anemia: Large number of iron deficiency anemia seen in female with age group of 20-29 years, followed by age group of 30-39 years, in reproductive age group there is no specific group affected in other type of anemiaâ&#x20AC;&#x2122;s.

Additional 5ml blood sample collected for special investigation for S. ferritin, S iron, TIBC, % saturation for confirmation of microcytic anemia and S vit B12 and S folic acid estimation in macrocytic anemia.

Table3 Distribution of cases according to age group in macrocytic anemia In nonmegaloblastic macrocytic anemia, cases with increased reticulocyte were ask to investigate for hemolyticanemia.

Values done by automated hematologyanalyzer correlated withPBS findings, S. iron profile value, Vit B12 and folic acid levels. In cases of Hb deficiency syndrome cases with normal RDW and increased reticulocyte count, reticulocyte count was performed manually using supravital stain with methylene blue- showed dark blue granules in the

Table 4 Clinical features of microcytic hypochromic anemia: Table 5 Clinical features -Macrocytic anemia:

Table 1: Age and sex distribution of anaemia in study; Serial number

Age group in years

Male

Female

1 2 3 4 Total

20-29 30-39 40-49 50-60

22(8.42%) 18(6.89%) 24(9.19%) 32(12.26%) 96(36.78%)

73(27.96%) 40(15.32%) 18(6.89%) 34(13.02%) 165(63.21%)

Table 2: Distribution of cases according to age groups in microcytic hypochromic anaemia: Age group in years 20-29 30-39 40-49 50-60 Total

Total number of cases with microcytic hypochromic anaemia Male Female 11 65 10 32 05 11 10 21 36 129 (13.79%) (49.42%)

Iron deficiency anaemia Male Female 04 54 03 26 02 04 02 10 11 94 (4.21%) (36.01%)

Anaemia of chronic disease Male Female 05 7 04 4 03 4 05 7 17 22 (6.51%) (8.42%)

Haemoglobin deficiency Male Female 02 4 03 2 00 3 03 4 08 13 (3.06%) (4.98%)

Table3: Distribution of cases according to age group in macrocytic anaemia : Age group in years 20-29 30-39 40-49 50-60

Total number macrocytic anaemia Male Female 11 08 08 08 19 07 22 13 60 36 (23.98%) (13.78%)

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Megaloblasticanaemia Male 07 04 14 17 42 (16.09%)

Female 06 07 07 10 30 (11.49%)

Nonmegaloblastic macrocytic anaemia Male Female 04 02 04 01 05 00 05 03 18 06 (6.89%) (2.29%)

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Table 4: Clinical features of microcytic hypochromic anaemia Sr no

Symptoms

Number of cases

Signs

Number of cases

Fatigue, palpitation, weakness

Pale conjunctiva, pale tongue and pallar

Menstrual bleeding

Angular stomatitis

Urinary tract infection

Chronic renal disease

Gastrointestinal bleeding, fresh blood in stool

Lower respiratory tract infection

Chronic respiratory infection

Haemorrhoids, GI malignancy, maleana

Post-menopausal bleeding

Growth endometrium/cervix

Joint pain

Rheumatoid arthritis

Dyspnea on exertion

DUB

Table 5: Clinical History-Macrocytic anaemia. Sr no

Symptoms

Number of cases

Signs

Number of cases

Lethargy

Glossits

Tingling and numbness

Pallar

Abdominal pain

Angularcheilosis

Fever

Sleenomegaly

Weightloss, loss of appetite

Hepatomegaly

Alcoholism

Neural manifestation-Myopathy

Pure vegetarian

Ecterus

History of haemolyticanaemia

Graph 1: Distribution of cases of anemia in the study: Total= 261.

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Graph 2: Distribution of cases according to type of anemia.

Graph 3: Distribution of cases of Microcytic hypochromic anaemia: Total; 165.

Graph4: Distribution of cases with Macrocytic anaemia:Total;96.

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Discussion

In women of childbearing age, the anemia prevalence is 30.2%. Overall468.4 million women of childbearing age are anemic. The highest prevalence is found in Africa (47.5%) and in South-East Asia (35.7%). It is 17.8% in America, 14% in the United Arab Emirates; and from a low of 11% in Egypt to over 40% in the Syrian Arab Republic. Iron deficiency anemia was considered as important contribution of anemia in global burden of anemia in WHO report 2002. [7] National Family Health survey in 2005-2006 showed, the prevalence of anemia was 55% in female aged 1549 years and 24% in male aged15-49 years. According to World Health Organization, there are two billion people with anemia in the world and half of anemia due to iron deficiency. [8] In developing countries prevalence of nutritional anemia is 40%, among the various nutritional anemia iron deficiency anemia is most commonIt is the most common nutritional disorder worldwide and accounts for approximately onehalf of anemia cases. [4, 9]In our study male was 36.78% and female was 63.21%. Iron deficiency anemia was 40.22%,more commonly seen in female with reproductive age group. Patient with iron deficiency anaemia has history of decreased work or exercise tolerance, shortness of breath, palpitation. (6)In the etiologies for iron deficiency anemia Terri D et al and Mathew W Short et al stated that itinclude blood loss like menorrhagia, epistaxis, melena, hematuria, and hematemesis.In developing countries decreased intake is primary cause of iron deficiencyanemia.. Other causes of anemia include chronic blood loss from gastrointestinal tract, gynecological disorder and genitourinary blood loss. Gastrointestinal bleeding can be acute or chronic. Patient present with maroon coloured stool or blood in stool. Bleeding may be associated with NSAID or aspirinIngynecological disorder postmenopausal women with excessive menstruation seen. [3,9] In present study in microcytic hypochromic anemia patient present with symptoms like fatigue, palpitation, menstrual bleeding, few of them present with joint pain, Gastrointestinal bleeding, dyspnoea on exertion which is similler to finding of Terri D et al[3] and Mathew W Short et al[9] According to Mathew W Short et al diagnosis of iron deficiencyanemia requires laboratory confirmed evidence of anemia as well as evidence of low iron stores. Values consistent with iron deficiency include a low serum iron level, low transferrin saturation and high total iron binding

capacity. Serum ferritin is particularly valuable in anemic patient because level below 12ug/L is diagnostic of iron deficiency anemia[9,10,11] In our study, 40.22%cases were with iron deficiency anaemia, 36.01% arefemale and04.21% aremale, showed a decreased parameter below the normal range like serum iron, ferritin, transferrin saturation and increased TIBC above the normal level, similarfinding with Mathew W Short et al.[9] Other causes of microcytosis include chronic inflammatory state, lead poisoning and thalassemia and sideroblastic anemia. [9]Hemoglobin level less than 9 gm/dl in patient with microcytic anemia and normal iron studies suggest Hb H disease, B thalassemia major or intermedia. An increased RDW may be particularly helpful in distinguish between iron deficiency and thalassemia minor. A bone marrow aspirate for iron stain remains gold standard for iron deficiency anemia in difficult cases. [12]We performed Prussian blue stain for iron store in cases wherever it is possible in Iron deficiency anemia and showed decreased grading. Ferritin is acute phage reactant protein, serum levels tend to be elevated in inflammatory condition.[12,13,14,15] Ferritin is elevated in inflammation, autoimmune disorder, chronic infection and liver disease. Elevated levels of ferritin well established in stillâ&#x20AC;&#x2122;s disease, multiple sclerosis and rheumatoid arthritis. Ferritin also plays an important role in host immune response is evident from its increased concentration.[13] In anemia of chronic inflammation ferritin levels rises moderately achieving mean level such as 300400ug/L Ferritin criteria used for recognition of coexisting iron deficiency anemia in patient who have chronic inflammation.In the study of Sheetal Patel et al observed massive hyperferritinemia in adult onset stills desease.[14] In our study 14.93% of cases showed increased ferritin above 100ng/ml,8.42% are female and 6.51% are male. Casesinclude various inflammatory conditions like respiratory disease, chronic urinary disease, rheumatoid arthritis and 2 cases of heart diseases Megaloblastic anemia is more common in vegetarian than nonvegetarian. Folic acid deficiency more commonly seen in elder, children, pregnant women and haemolyticanaemia. Clinical feature of megaloblasticanaemia are anorexia, irritability, fatigue, palpitation. Commonest physical finding was pallor, fever, generalized weakness, splenomegaly, hepatomegaly and hypopigmentation. Common neurological manifestation of vit B12 deficiency includes parasthesia, weakness, gait abnormalities and behavior changes. [16,17,18] In the present study most of

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patient with macrocytic anemia presented with lethargy, tingling numbness, loss of appetite, loss of weight, pain in abdomen, fever and alcoholism

In this study there are 9.18% cases with macrocytosis, in this case showed normal vit B12 and decreased or normal folic acid level

For laboratory diagnosis of megaloblastic anemia complete blood picture with PBS showed macrocytosis, hypersegmented neutrophil, raised MCV and RDW, assay of two vitamins (vit B12 and folic acid) and bone marrow aspiration required for definitive diagnosis.[16,17,18]

Conclusion

The severity of megaloblastic marocytosis is directly proportional to the severity of the anaemia and early megaloblastosis may manifest only mild change. Six lobed neutrophil may be absent and increased in four lobed and five lobed neutrophil may be evident or presence of one seven loabed neutrophil or two six lobed neutrophil or three five lobed neutrophil strongly suggest megaloblastic anemia. [12] Anisocytosis and poikilocytosis is higher in megaloblastic anemia. [16,19] We observed anisopoikilocytosis in most of cases in present study. In our study27% cases showed megaloblastic anemia On PBS showed macrocytes, macrovalocyte, occasional or one-two hypersegmented neutrophil or hypersegmented neutrophil not be seen in few cases, increased MCV, between 110-131fl, on haematology automated analyzer and presence of megaloblast in bone marrow aspiration. The finding of MCV of more than 100cu microns quite helpful due to limited differential diagnosis. An MCV of more than 120cu microns almost always indicate megaloblastic anemia. If there is any doubt as to cause of macrocytic anemia, a bone marrow aspirate and biopsy should be done, in classic megaloblastic anemia one will see increased cellularity in the biopsy specimen. The aspirate will show erythroid hyperplasia, delayed nuclear maturation relative to haemoglobinization of the cytoplasm seen best in basophilic, polychrmatophilic and orthochromatophilic erythroblast.[12]One author stated only minority of patient with MCV level above 100fl are deficient in vitB12 or folate. [,20] Moreover serum cobalamine levels may not be indicative of actual deficiency. Cobalamine levels may be falsely high in patient with megaloblastosis due to nitrous oxide,transcobalamine II deficiency.Vitamin B12 level may be significantly lower imMegaloblastic anemia[21] Only minority of patient with MCV level above 100fl are deficient with vitamin B12 or folate.[20]Patient with nonmegaloblastic macrocytic anemia haveMCV less than 120cu microns. Alcohol ingestion is commonest cause of mild macrocytosis. Other causes of macrocytosis are liver diseases, severe hypothyroidism and chemotherapy induced [12] Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

Result of this study demonstrates large number of iron deficiency anaemia cases seen in female with reproductive age group. In megaloblasticanaemia more number of cases are seen in age group between 50-60 years in both sex. For the diagnosis of microcytic hypochromic anemia haemogram by automated hematologyanalyzer, PBS examinationserum iron profile is necessary for correct diagnosis and for macrocytic anemia haemogram,PBS examination, bone Marrow aspiration cytology and assay of two vitamins like B12 and folic acid and reticulocyte are needed for diagnosis. Serum iron profile, vit B12, folic acid and bone marrow aspiration should be done in addition of PBS examination for correct diagnosis and treatment of nutritional anemia.

Reference 1.

M.E.Bentley and P.L. Griffith. The burden of anemia among women in India. European Journal of Clinical Nutrition. 2003; 57:52-60. Erin McLean, Mary Cogswell, Ines Egli, Daniel Wojdyla and Bruno de Benoist. Worldwide prevalence of anaemia. Public Health Nutrition. 2009 Apr;12(4):444-54. Terri D. Johnson-Wimbley. Diagnosis and manegment of iron deficiency anemia in 21st century. TherapAdv Gastrointestinol.2011; May 4 (3): 177-184. Neelam S Deshpande, Devkinandan Karva, Sharad Angerkhedker, Shishir Deshpande. Prevalence of anemia in adolesant girl and its co-relation with demographic factors. International Journal of Medicine and Public Health. 2013;3(4):235-239. Uma Khanduri, Archna Sharma. Megaloblasticanaemia: Prevalence and causative factors. The National Medical Journal of India.2007;20(4):172-175. Robert T Means, Jr. BertiGlader. Anaemia Genaral Consideration. John Foester, George M Rodger and Frixos Paraskevas. Wintrobes Clinical Haematology. Volume I. Twelth Edition. Philedelphia; LIPPINCOTT WILLIUMS and WIKINS, a WOLKER KLUER bisiness. Page 779-807.

7. Fatin Al-Sayes, MamdoohGari, SafaaQusti ,NadiahBagatian and Adel Abuzenadah. Prevalence of iron deficiency and iron deficiency anemia among females at university stage. Journal of Medical Laboratory and Diagnosis. 2011; vol 2(1):5-11. 8.

Gerardo Alvarez- Uria, Praveen K. Naik, Manoranjan Midde, Pradeep S Yalla and Raghavkalyan Pakam .Prevalace and severity of anaemia Stratified by Age Gender in Rural India. Anemia; 2014. dx.doi.org/10.115/2014/176182.

Matthew W. Short and Jason E. Domagalski. Iron Deficiency Anaemia. Evaluation and Management. Am Fam Physician 2013;87(2):98-104.

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10. Gangather T, Shrikanth P and Suneetha Y. Predictive value of iron store markers in anemia of chronic kidney disease. Journal of Chemical and Pharmaceutical Research. 2010;(3):400-410.

16. Salama Haq, Nasir Eqbal, Fatima Fayyaz and Tahira Tasneem. Serum B12 and folate levels in patient with megaloblastic change in bone marrow. Biomedica. 2012; vol 28:35-41.

11. Berry S Skikne, Carol H Flowers and jams D cook. Serum Transferrin receptor:A Quantitative Measure of Tissue Iron Deficiency. Blood. 1990;7(9):1870-1876.

17. Robert C Langan and Kimberly J Zawistoski. Update on vit B12 Deficiency. Am Fam Physician 2011; 83(12):1425-1430.

12. Ralph O. Wallerstein, Jr, MD,San Francisco. Laboratory evaluation of anemia, West J Med 1987;146:443-451.

18. M Ramani, D Ranganath, O.H. RadhikaKrishna, K geetha, M Kiteeka, Puja Deshmukh. Clinicopathological Review of Megaloblastic Anemia in Children-A 7 year paediatric Hospital Experience. Journal of evolution of Medical and Dental Sciences. 2013; 2(19):4136-4142.

13. Kamala Vanarsa, YujinYe,Jie Han ChunXie,Chandra Mohan and Tianfu Wu. Inflammation associated anemia and ferritin as disease marker in SLE. Arthritis Research and Therapy 2012;14:R182 doi:10.1186/ar4012 14. Sheetal Patel, SeyedMonemian, Avesha Khalid and Harvey Dosik. Iron Deficiency anaemia in Adult Onset Stillâ&#x20AC;&#x2122;s Disease With a Serum Ferritin of 26,387ug/L. Anemia .2011: 184748. Published online May 12, 2011.doi 10.115/2011/184748. 15. Matthis Lorenz, Josef Kletzmayr, Agnes nPerschl, Alexander furrer, Walter H Horl and Gere Sunder- Plassmann. Anaemia and Iron Dficienciesamoung Long Term Renal Transplant Recipiant.JournalOf the American Society of Nephrology 2002 vol 13 (3) Page 794-797.

19. Jeevan Sekhar and Sally P. Stabler. Life threating megaloblastic pancytopenia with normal mean cell volume: case series.. Eur J Inteern Med 2007; 18 (7): 548-550 20. John Lindenbaum. Status of laboratory testing in the diagnosis of Megaloblastic anemia. Blood 1983;64 (4): 624-627. 21. M Premkumar, N Gupta, T Singh and T Velpandian. Cobalamin and Folic Acid Status in Relation to the Etiopathgenesis of Pancytopenia in Adult at a tertiary Care centre in North India. Anemia.2012; http//dx.doi. org/10.11/2012/707402

*Corresponding author: Dr Mangal Pandure, Dept of Pathology, Pravara Institue of Medical Sciences. Deemed University. Email: mangal.garute11@gmail .com Date of Submission : 18.06.2017 Date of Acceptance : 25.06.2016 Date of Publication : 05.07.2017

Financial or other Competing Interests: None.

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Original Article DOI: 10.21276/AABS.1557

Hepatitis B versus HIV in Blood Donors Ravi Jain and Ashok Yadav* Dept. of Pathology, MGM Medical College, Indore , India

ABSTRACT Introduction: Transmission of infectious diseases through donated blood is of concern to blood safety as transfusion forms an integral part of medical and surgical therapy. Blood transfusion carries the risk of transfusion-transmissible infections, including HIV, hepatitis, syphilis, malaria and infrequently toxoplasmosis. Aims & Objectives: To find out the seroprevalence of hepatitis B virus and HIV virus in blood donors , to determine the incidence of transfusion related disease in blood donors, to find the incidence of spectrum of diseases in blood bank donation, to find the age & sex distribution of the cases studied. Material & Methods: The present study was undertaken in the Department of Pathology MGM Medical College Indore. This is a retrospective study that was conducted, during the period 2008 –2015. The screening for HIV & HBS Ag was done by ELISA. Results: Out of total 137689 blood donations, majority of donors are voluntary donors 83.02 % as compared to replacement donors 17.05 %. Seroprevalence of HBV and HIV are 1.64 % and 0.13 % respectively. Seroprevalence is higher in the age group 26-35 year for HBV-0.93 % & HIV-0.065 %. Over all Seroprevalence in the years 2008-15 is 1.89 %. Seroprevalence is higher in voluntary donors 1.33 % as compared to replacement/relative 0.55 % donors. Conclusion: voluntary blood donation should be encouraged for prevention of transfusion-transmissible diseases. The time and cost involved in screening donated blood can be reduced by an effective donor education and selection program that promotes self-exclusion by donors at risk of transfusion-transmissible infections. Keywords: Hepatitis B, HIV, Seroprevalence, Transfusion Transmitted Diseases, Voluntary Donors, Replacement Donors

Introduction

Transmission of infectious diseases through donated blood is of concern to blood safety as transfusion forms an integral part of medical and surgical therapy. Blood transfusion carries the risk of transfusion-transmissible infections, including HIV, hepatitis, syphilis, malaria and infrequently toxoplasmosis, Brucellosis and some viral infections like CMV, EBV and herpes. With every unit of blood, there is 1% chance of transfusionassociated problems including transfusion-transmitted diseases.Among all infections HIV and hepatitis are the most dreadful. The first case of transfusion-associated AIDS was described in an infant given transfusion for erythroblastosisfoetalis.Thereafter, many cases were reported all over the world in which transfusion of blood and its products was the only risk factor.The improved screening and testing of blood donors has significantly reduced transfusion-transmitted diseases in most developed countries. This has not been so in developing nations. Poor health education and lack of awareness result in the reservoir of infections in the population.

Material and Methods

The present study is being undertaken in the Department of Pathology MGM Medical College Indore. This is a retrospective study that will be conducted, during the period 2008 –2015. 1. To find out the seroprevalence of hepatitis B virus and HIV in blood donors. 2. To determine the incidence of transfusion related disease in blood donors. 3. To find the incidence of spectrum of diseases in blood bank donation. 4. To find the age distribution of the cases studied. 5. To find the sex distribution of the cases studied. Tests are routinely done on every blood unit to exclude HIV, HBV, HCV, syphilis and malaria. Donors were selected by the standard criteria for donor fitness. The screening for HIV was done by ELISA using kits. HBS Ag was detected by ELISA. ABO and Rhesus (Rh) blood groups were determined using blood grouping antisera: anti-A, anti-B, anti-AB, and

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anti-D. Selection of cases for the study included the donors of MYH Blood Bank.

Results

The present study was conducted in the Department of Pathology MGM Medical College Indore and M. Y. Hospital blood bank. This is a retrospective study that was

conducted, during the period 2008 â&#x20AC;&#x201C;2015. In the present study, 137689 blood donors are observed in the year 200815 in the M. Y. Blood Bank. The data collected from donor register record book, donors form, master record book, HIV, & HBV positive bag number records. The results and observations studies are presented below:

Graph 1: Number of blood units collected during the year 2008-15. Out of total 137689 blood donations, majority of donors are voluntary donors 83.02 % as compared to replacement/relative donors 17.05 %

Graph 2: Number of male and female donors during the year 2008-15.Out of total 137689 blood donations, majority of donors are male donors 95.59 % as compared to female donors 4.40%.

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Graph 3: Seropositive donors for HBV and HIV in 2008-15 Seroprevalence of HBV and HIV are 1.64 % and 0.13 % respectively.

Graph 4: Age wise distribution of HBV in the year 2008-15. Seroprevalence is higher in the age group 26-35 yearÂ

Graph 5 : Age wise distribution of seroprevalence of HIV in the year 2008-15.

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Graph 6: Overall age distribution of seroprevalence of HBV and HIV in 2008-2015. HBV & HIV are more prevalent in age group 26-35 years

Discussion

Voluntary or Replacement/Relative Donor -In our study, out of total 137689 blood donations, majority of donors are voluntary donors 83.02 % as compared to replacement/ relative donors 17.05 % (Graph 1) Similarly majority of donors are voluntary in another study out of 19135 blood donors, 11165 (58%) were voluntary and 7970 (42%) were replacement donors by Nagarekha Kulkarni8 Associate Professor, Department of Pathology, Vijayanagara Institute of Medical Sciences, Bellary - 583104, Karnataka, India. Male or Female Donors: In our study, out of total 137689 blood donations, majority of donors are male donors 95.59 % as compared to female donors 4.40 % (Graph 2) . Similarly another study is comparable for majority of donors are male 96.22 % by Dimple Arora and Bharti Arora et al9in Haryana. In the another study, the percentage of male patients was 73% (860/1178) as compared with 27% (318/1178) for female patients by Manisha Jain et al10, conducted in New Delhi.

15 (Graph 3). Seroprevalence of HIV is low as compared to another study 0.3% in total donors by Dimple Arora and Bharti Aroraet al9conducted in Haryana. In another study, the seroprevalence of antibodies to HIV in hospital population was 0.35% by SmitaSood and ShirishMalvankar et al11conducted in Rajasthan. This is in accordance with the 2006 estimates of NACO (National AIDS Control Organization), NIHWF (National Institute of Health and Family Welfare), and NMS (National Medical Statistics) which suggest that the national adult HIV prevalence in India is 0.36%. Our seroprevalence of HIV is very low as compared with another study, the overall seroprevalence of HIV was 2.21% by Marius Bolni Nagalo and Mahamoudou Sanou et al13 conducted in Koudougou. Seroprevalence of HIV is low as in another study seroprevalence of HIV was 0.91% Nagarekha Kulkarni8 in Karnataka. In our study seroprevalence is low as compared to overall seroprevalence of HIV (3.8%) by Belay Tessema and Gizachew Yismaw et al14 conducted in University of Gondar, Ethiopia .

Seroprevalence of HBV: In our study, the seroprevalence of HBV is 1.64 % in total blood donations in the year 2008-15 (Graph 3). Seroprevalence of HBV is comparable to another study with seroprevalence of HBS Ag was 1.7 % by Dimple Arora and Bharti Arora et al9conducted in Haryana. The seroprevalence of hepatitis B surface antigen was 0.87% noted in hospital-based population by SmitaSood and ShirishMalvankar et al11 conducted in Rajasthan.In another study conducted among donors of interior Sindh (Pakistan) by Mujeeb et al12, the seroprevalence of HBV was 6.2% .

Age Wise Distribution: In our study, Seroprevalence is higher in the age group 26-35 year for HBV (0.93 %) & HIV (0.065 %) (Graph 4,5 & 6 ). The seroprevalence of HBV was significantly higher donors in the group aged 20-29 years old than in the group 30-40 years old by Marius Bolni Nagalo and Mahamoudou Sanou et al13 conducted in Koudougou. The highest seroprevalence for anti-HIV was found in the age group 31-40 years by SmitaSood and ShirishMalvankar et al11conducted in Rajasthan.

Seroprevalence of HIV: In our study, the seroprevalence of HIV is 0.13 % in total blood donations in the year 2008-

The present study was conducted in the Department of Pathology MGM Medical College Indore and M. Y.

Conclusion

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A-133 Hospital blood bank. This is a retrospective study that was conducted, during the period 2008 –2015. Tests are routinely done on every blood unit to exclude HIV, HBV and HCV. Donors were selected by the standard criteria for donor fitness. The data collected from donor register record book, donors form, master record book, HIV, HBV and HCV positive beg number records. Out of total 137689 blood donations, majority of donors are voluntary donors 83.02 % as compared to replacement/relative donors 17.05 %.Seroprevalence of HBV and HIV are 1.64 % and 0.13 % respectively. Seroprevalence of HBV is higher than HIV. Seroprevalence is higher in the age group 26-35 year for HBV-0.93 % & HIV-0.065 %. Over all Seroprevalence of transfusion transmitted disease in all donations in the year 2008-15 is 1.89 %. Seroprevalence of transfusion transmitted disease is higher in voluntary donors 1.33 % as compared to replacement/relative 0.55 % donors. HBV and HIV are the most prevalent transfusion-transmissible diseases among blood donors in Indore. Screening and better selection of donors are necessary to improve blood safety in the regional blood transfusion centre of M. Y. Hospital. Therefore, it is concluded that voluntary blood donation should be encouraged for prevention of transfusion-transmissible diseases. The time and cost involved in screening donated blood can be reduced by an effective donor education and selection program that promotes self-exclusion by donors at risk of transfusion-transmissible infections.

Acknowledgements

We are Highly grateful to Dr C.V.Kulkarni, Prof.& Head, Dept. of Pathology for providing us the opportunity & full support.

AABS; 4(2): 2017 4.

Haedicke, J.; Brown, C.; Naghavi, H. (Aug 2009). “The brain-specific factor FEZ1 is a determinant of neuronal susceptibility to HIV-1 infection”. Proceedings of the National Academy of Sciences 106 (33): 14040–14045.

Arauz-Ruiz P, Norder H, Robertson BH, Magnius LO (August 2002). “Genotype H: a new Amerindian genotype of hepatitis B virus revealed in Central America”. J. Gen. Virol. 83 (Pt 8): 2059–73.

Coffin CS, et al. “Hepatitis B virus (HBV) quasispecies in hepatic and extrahepatic viral reservoirs in liver transplant recipients on prophylactic therapy”. Liver Transpl 17 (8): 955–62

Schwartz O, Maréchal V, Le Gall S, Lemonnier F, Heard JM (March 1996). “Endocytosis of major histocompatibility complex class I molecules is induced by the HIV-1 Nef protein”. Nat. Med. 2 (3): 338–42.

Kulkarni N. Analysis of the seroprevalence of HIV, HBsAg, HCV and syphilitic infections detected in the pretranfusion blood: A short report. International Journal of Blood Transfusion and Immunohematology 2012;2:1-3.

Dimple Arora, Bharti Arora, Anshul Khetarpal “Seroprevalence of HIV, HBV, HCV and syphilis in blood donors in Southern Haryana” Year 2010 Vol: 53(2)Page308-309

10. Manisha Jain, Anita Chakravarti, VikasVerma, PreenaBhalla”Seroprevalence of hepatitis viruses in patients infected with the human immunodeficiency virus” Year : 2009 Vol: 52( 1)Page : 17-19 11. SmitaSood and ShirishMalvankar “Seroprevalence of Hepatitis B Surface Antigen, Antibodies to the Hepatitis C Virus, and Human Immunodeficiency Virus in a HospitalBased Population in Jaipur, Rajasthan”Year : 2010 , Vol : 35 (1)Page : 165-169

References 1.

Tang, J. and Kaslow, R. A. (2003). “The impact of host genetics on HIV infection and disease progression in the era of highly active antiretroviral therapy”. AIDS 17 (Suppl 4): S51–S60.

12. Mujeeb SA, Pearce MS. Temporal trends in hepatitis B and C infection in family blood donors from interior Sindh, Pakistan. BMC Infectious Diseases. 2008;8:43. doi:10.1186/1471-2334-8-43.

Arthos J, et al (2008). “HIV-1 envelope protein binds to and signals through integrin alpha(4)beta(7), the gut mucosal homing receptor for peripheral T cells”. Nature Immunol. In Press (3): 301–9.

13. Nagalo MB, Sanou M, Bisseye C, et al. Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses and syphilis among blood donors in Koudougou (Burkina Faso) in 2009. Blood Transfusion. 2011;9(4):419-424. doi:10.2450/2011.0112-10.

Various (2008) (PDF). HIV Sequence Compendium 2008 Introduction. Retrieved 2009-03-31.

14. Belay Tessema et al “Seroprevalence of HIV, HBV, HCV and syphilis infections among blood donors at Gondar University Teaching Hospital, Northwest Ethiopia: declining trends over a period of five years” BMC Infectious Diseases201010:111 DOI: 10.1186/1471-2334-10-111

*Corresponding author: Dr Ashok Yadav, Yadav Clinic, New Panchsheel Colony, Musakhedi, Indore (M.P )452001, India Phone: +91 9893273236 Email: drashokmyh@gmail.com, ravijainpatho@gmail.com

Financial or other Competing Interests: None.

Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

Date of Submission : 18.06.2017 Date of Acceptance : 26.06.2017 Date of Publication : 05.07.2017

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Case Report DOI: 10.21276/AABS.1318

A Rare Case Report of Corynebacterium minutissimum Causing Bacteremia In An Immunocompetent Patient Sunita Gupta1*, Vibha Bhargava1, Rohit Jain1, Prateek Goyal2 and GN Gupta1 Department of Pathology and Blood Transfusion, Santokba Durlabhji Memorial Hospital & Medical Research Institute, Jaipur, India 2 Department of Orthopedics, Santokba Durlabhji Memorial Hospital & Medical Research Institute, Jaipur, India

ABSTRACT Non-diphtherial Corynebacteria (NDC), which are also referred to as Diphtheroids are a widely diverse collection of bacteria. Corynebacterium species are normal flora of skin and mucous membrane . Up to now, the pathogenic potential of coryneform bacteria has been underestimated. In recent years, Coryneforms have emerged as important opportunistic pathogens in immunocompromised patients. Majority of the Corynebacterium minutissimum isolates are from erythrasma. Since its discovery in 1961 Corynebacterium minutissimum is rarely implicated in bacteremia . Though routinely considered as contaminants there are reports which establish NDM as a pathogen so it should not be discarded as contaminants in general. Hereby we report a case of bacteremia due to Corynebacterium minutissimum due to polytrauma by road accident. Keywords: Non-diphtherial Corynebacteria, Corynebacterium Minutissimum, Blood Culture, Bacteremia

Introduction

Non diptherial Corynebacterium species largely remains a neglected group with the traditional consideration of these organisms as contaminants.[1] It is a gram-positive, nonspore forming, aerobic or facultatively anaerobic bacillus. [2] They are found as colonizers of the skin and other tissues and in the environment.[3]Although frequently considered as contaminants, these organisms have been associated with invasive disease, particularly in immunocompromised patients.[1]The importance of these isolates in clinical settings is still undetermined, as evidenced by the lack of comprehensive data with a large number of isolates. Although some cases of C. minutissimum infection have been reported, it has rarely been a causative agent of invasive extracutaneous infection.[3] Reports on this group of organisms from India are sparse, except for a few case report concerning a particular species.[1]

Case Report

We report a case of a young patient with Corynebacterium minutissimum bacteremia after polytrauma. Our patient was a 23 years old male who had a history of polytrauma due to road traffic accident one and a half months back. The Patient was brought to our hospital after first aid was given in a government hospital where fractured bones were splinted, catheter and central lines inserted. Patient had multiple bone fractures, Degloving injury and open wound over lumbosacral area with visible bony surface. Nailing was done in our hospital and slab was applied. Debridement and muscle repair was done over exposed

bone at the lumbosacral area. Split skin graft [SSG] was also done and patient was discharged. Post discharge the patient complained of intermittent and high grade fever and was readmitted. On readmission CRP was 6.8 mg/dL. Hemoglobin was 10.6 gm/dL, Total Leucocyte Count was 7800/mm3, Neutrophils were 83.9%, and platelet 201×103 /microlitre Blood culture samples were sent from both hands which turned out to be positive within 48 hours. The specimen was cultured on 5% sheep blood agar plates at 35°C overnight. The growth on Sheep blood agar were smooth, moist grayish white, non hemolytic colonies. [Figure 1] There was no growth on Mac conkey agar. Gram stain done on colonies obtained from Blood agar showed Gram positive bacilli .[Figure 2] The bacteria were non–spore-forming, nonmotile and catalase-positive diphtheroid. Since similar type of colonies were seen on both hands blood culture samples and considering polytrauma history of the patient, It was considered pathogenic and Identification was confirmed using the Vitek 2 C System Anaerobic ANC card (BioMérieux, Durham, NC, USA) which confirmed it as C. minutissimum. Sensitivity was done by Disc diffusion method and it was found to be sensitive to Linezolid, Vancomycin, Teicoplanin, Tigecycline, Imipenam and resistant to Eryhromycin, Clindamycin, Penicillin, Cephalosporin , Quinolones . To reconfirm repeat blood culture samples were sent from both hands which also yielded the same bacteria viz Corynebacterium minutissimum with same sensitivity

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pattern. Patient was initially on Meropenam and Clindamycin at time of admission. Antibiotics were changed to Tigecycline and Vancomycin after blood culture reports. Patient was also diagnosed with Acute Respiratory distress Syndrome and Infective endocarditis due to which the patient was intubated and mechanically ventilated . Colistin and Imipenam were also added.

and Granular cast while urine culture was sterile. Another blood culture was sent after 5 days of starting of antibiotics which turned out to be negative.

Serum electrolytes, Urea and Creatinine were normal. Routine urine showed 8-10RBC /hpf and 10-15 WBCs /hpf

Patient was afebrile after 10 days of starting antibiotics. As a result the central line was removed and the patient was put off the Ventilator . Patient again developed fever after 2-3 days. Blood cultures were sterile at that time. Patient was referred to AIIMS where valve replacement was done and the patient is healthy now.

Fig. 1: The growth on Sheep blood agar were smooth, moist grayish white, non hemolytic colonies.

Fig. 2: Gram stain done on colonies obtained from Blood agar showed Gram positive bacilli

Discussion

be an intact epithelial barrier. Isolate identified in our case was sensitive to vancomycin, linezolid , tigecycline , teicoplanin which correlates to various studies in which all the isolates were uniformly susceptible to vancomycin, linezolid, and tigecycline . . [1], [5]

Corynebacterium species have long been classified as skin contaminants, or “colonizers.” Not surprisingly, Clinicians often disregard blood cultures that yield these organisms 2 . It is clearly stated that the recognition of infections caused by coryneform bacteria is highly dependent on the laboratory personnel’s ability to identify these species. [4] Due to the fact that almost all of them form part of a commensal flora at one or the other site in the body , absolute judgment is needed to find out its clinical significance.[1] Isolation from normally sterile sites of human body and repeated isolation of these bacteria from various clinical samples confirm their role in infection.[6] The increasing size of the immunocompromised population and the more common use of intravascular access devices have likely contributed to this phenomenon..[2] In our case severe skin damage from trauma might have allowed C. minutissimum to cross what would normally

Our isolate was resistant to Eryhromycin, Clindamycin, Penicillin, Cephalosporin , Quinolones which correlates to studies where majority of the isolates were resistant to penicillin, beta lactam, erythromycin, clindamycin.[1] ,[5] Due to lack of established CLSI guidelines for disc diffusion method for this group of organisms following approaches were adopted [1] a) BSAC [British Society for antimicrobial guidelines ] followed for Penicillin, Vancomycin, Ciprofloxacin b) For other antibiotics, the CLSI guidelines applicable for Staphylococci aureus with S.aureus sp ATCC 25923 control strains were used.

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Only few studies globally have characterized the human clinical isolates of NDC and their antimicrobial susceptibility patterns.[6]

Shin JY, Lee WK, Seo YH, Park YS. Postoperative Abdominal Infection Caused by Corynebacterium minutissimum. Infect Chemother 2014;46:261–3.

Conclusion

Funke G, Graevenitz AV, Clarridge III JE, Bernara KA. Clinical Microbiology of coryneform bacteria. Clin Microbiol Rev 1997;10:125-59.

It is now imperative that clinical microbiologists and clinicians understand the potential role of NDC in human infections and not consider all NDC as mere contaminants in laboratory

References 1.

Reddy BS, Chaudhury A, Kalawat U, Jayaprada R, Reddy GSK, Ramana BV. Isolation, speciation, and antibiogram of clinically relevant non-diphtherial Corynebacteria (Diphtheroids). Indian J Med Microbiol 2012;30:52-7. Granok A, Benjamin P, Garrett L. Corynebacterium minutissimum Bacteremia in an Immunocompetent Host with Cellulitis. Clin infect dis 2002;35:e40–2.

5. Rit K, Chakravorty B, Pal N, Saha R. Non diphtherial corynebacterium species isolation and their susceptibility profile from various clinical samples in a tertiary care hospital of eastern India. J Sci 2015;5:699-703. 6. Ramana K V, Vikram G, PadmaWali P, Anand K, Rao M, Rao S D, et al. Non Diphtheritic Corynebacteria (NDC) and Their Clinical Significance: Clinical Microbiologist’s Perspective. Am J Epidemiol and Infect Dis 2014;2:83-7.

*Corresponding author: Dr Sunita Gupta, 12 Hathroi market, Above corporation bank ATM, Ajmer road, Jaipur,302001, India Phone: +91 9413342882 Email: drsunita_gupta@hotmail.com

Financial or other Competing Interests: None.

Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

Date of Submission : 06.02.2017 Date of Acceptance : 12.04.2017 Date of Publication : 21.04.2017

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Case Report DOI: 10.21276/AABS.1457

Lingual Schwannoma: A Case Report Manish Munjal1, Archana Arora1*, Damanpreet Singh1, Gopika Talwar1 and Japsimran Nagpal2 Deptt of ENTHNS, Dayanand Medical college and Hospital, Ludhiana, Punjab, India 2 Dayanand Medical college and Hospital, Ludhiana, Punjab, India

ABSTRACT Schwannomas are benign nerve sheath tumors uncommonly seen in the oral cavity. The etiology is largely unknown and there is no sex predilection and can occur in a vast age group. Magnetic Resonance Imaging is the investigation of choice and transoral resection allows for removal of this tumor in a vast majority of cases. Malignant transformation in these tumors is exceedingly rare. Reported here is a 2x2 cm schwannoma on the lateral border of the tongue , in a 19 yr old male for the last 8 months. Complete transoral excision with primary closure was carried out. Histopathological examination of the surgical specimen revealed features of schwannoma. Keywords: Schwannoma, Neurilemmoma, Antoni A and B

Introduction

A schwannoma, or neurilemmoma, is a slow growing benign tumor of unknown etiology that arises from the Schwann cells of the neural sheath of the peripheral, cranial or autonomic nerves. There is no gender preference and occurs most commonly between the ages of 20 and 50 years. [1] Approximately 25–45% of the Extracranial schwannomas occur in the head and neck region, with only 1% located in the mouth. The parapharyngeal space is the most common site in the head and neck region whereas when present intraorally, the tongue is the most commonly involved. [2, 3]

Case report

A 19-year old male patient presented with an 8 month old swelling at the posterior part of left side of tongue. He described that the mass was small at onset and gradually became large in size. There was mild uneasiness on swallowing though not associated with any local pain nor any referred otalgia.

video assisted rigid 70 degree endoscopic technique with cold instruments .a 1mm border of clinically uninvolved surrounding tissue was resected. The postoperative course was uneventful. The mobility of the tongue was within normal range. Histopathological examination of the surgical specimen showed a well circumscribed 2.5X2X1cm tumor composed of hypercellular and hypocellular areas with no mitosis or nuclear atypia. The overlying epithelium and deep resected margins were free of tumor. These features were suggestive of benign schwannoma. [Fig 2] The patient has been followed up for last 2 years and there has been no evidence of recurrence so far.

Intraoral 70 degree rigid telescopy revealed a firm, circumscribed globular, non tender, pinkish mass 2 x 2 cm in diameter with no bleeding point or puncta, on the of the posterior part of the left side of tongue. No lymph nodes were palpable and the head and neck examination revealed no other lesions. Contrast Enhanced Magnetic Resonance Imaging of the neck revealed a well defined polypoidal lesion which was isointense on T1w and hyperintense on T2w; arising from the myelohyoid muscle and causing mild oropharyngeal compromise. [Fig 1] The patient’s medical history was unremarkable. Surgical complete intraoral excision was carried out using the

Fig. 1: Well demarcated hyper-intense lesion.

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AABS; 4(2): 2017 route. Nowadays, the CO2 laser has also been used for such excision. A complete resection ensures no recurrence. [3] Histologically all of these tumors are encapsulated. Inside the capsule, two main regions are identified; Antoni A and Antoni B. Antoni A regions consist of closely packed spindle-shaped Schwann cells arranged in rows around an eosinophilic area surrounded by a palisade of spindle cells. Free amorphous substance between these rows form the Verocay bodies which are oval or linear in shape. Antoni B regions are composed of fewer and loosely arranged Schwann cells that lack the organoid Verocay bodies. Immunohistochemical markers, S-100 and Leu 7, support the diagnosis further. Differential diagnosis includes neurofibromas, leiomyomas, rhabdomyomas, hemangiomas, lymphangiomas, lipomas, pyogenic granulomas, etc. [3,5]

Fig. 2: Section showing Antoni A & B areas, suggestive of Schwannoma.

Discussion

Schwannomas were first described by Verocay in 1908. [5] Schwannoma is a variable sized, slow-growing benign tumor of the nerve sheath originating from the Schwann cells and presenting usually as a solitary, well circumscribed, firm and painless lesion. It manifests as an insidiously growing mass of long duration, producing few symptoms. [2,3] Schwannoma of the tongue mostly presents on the lingual surface without any gender preference. A schwannoma on the base of tongue is usually larger at presentation than one on the tongue itself, since it is asymptomatic initially. Complete resection is achievable and recurrence is uncommon [4]. The imaging modality of choice for schwannomas of the tongue is Magnetic Resonance Imaging (MRI) as it gives an accurate measurement and localization in relation to nearby structures. On MR, these tumors appear smooth, well demarcated, and not invading the surrounding musculature and are isointense to muscle on T1-weighted images and homogenously hyperintense on T2-weighted images. Surgical excision is the treatment of choice with the transoral route being the most commonly employed. Other approaches like submandibular and suprahyoid pharyngotomy were used for base of tongue schwannomas that were deemed difficult to approach by the transoral

Conclusion

Lingual schwannomas are benign slow growing tumors that are usually asymptomatic. These lesions are amenable to complete surgical excision via transoral route and have a low recurrence rate and very less chances of malignant transformation. MRI and Histopathological examination is diagnostic. The 70 degree video assisted endoscopic technique is excellent for surgical intervention and follow up examinations. Due ethical consent was taken from the participants of the study

References 1.

2. 3.

4. 5.

Lingual Schwannoma Involving the Posterior Lateral Border Of The Tongue In A Young Individual: Case Report. Pereira L J, Patrícia P. Journal of Clinical Pediatric Dentistry. September 2008, Vol. 33, No. 1, pp. 59-62 A rare case of schwannoma of the tongue. Grabowski L. Otolaryngologia Polska. Volume 62, Issue 2, 2008, Pages 191–4 Schwannoma of the tongue: two case reports and review of the literature. Cohen M, Wang M.B. European Archives of Oto-Rhino-Laryngology. November 2009, Volume 266, Issue 11, pp 1823–9 Schwannoma (neurilemmoma) of the tongue. Hwang C. Acta Oto-Laryngologica Vol. 126 , Iss. 8,2006 Pages 861-5. A Schwannoma of the Soft Palate in a Child: Histological and Immunohistochemical Features and Surgical Method. Rahpeyma A ,Jafarian A.Iranian Journal of Otorhinolaryngology No.2, Vol.24, Serial No.67, Spring-2012,95-9

*Corresponding author: Dr Archana Arora, 159-C rishi nagar, Ludhiana-141001. Punjab, India Phone: +91 9888780218 Email: Drarchana.ent@gmail.com

Financial or other Competing Interests: None.

Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

Date of Submission : 02.04.2017 Date of Acceptance : 15.04.2017 Date of Publication : 21.04.2017

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Case Report DOI: 10.21276/AABS.1471

Diagnosis of Subcutaneous Cysticercosis as a Cystic Mass Over Chest wall: A Case Report and Review of The Literature Tanima Dwivedi1* and Reshma Davangeri2 Department of Emergency Laboratory, Institute of Human Behaviour & Allied Sciences, Delhi, India 2 Department of Pathology, KLE University’s Jawaharlal Nehru Medical College, Belagavi, India

ABSTRACT Cysticercosis is the common tropical disease. It is usually present as a neurocysticercosis or intramuscular lesion, rarely may it present in subcutaneous tissue in the adult age group. Prevalence of asymptomatic subcutaneous nodules in India is 12.9-38%. Subcutaneous nodule is usually occur as a part of the disseminated cysticercosis or as an isolated features. Here, we report a 45 year old male presenting with cyst over right chest wall but otherwise asymptomatic. A clinical diagnosis of epidermal cyst was made. Surgical excision was performed. Diagnosis of cutaneous cysticercosis was made by biopsy of subcutaneous nodule and patient was started on treatment. Keywords: Subcutaneous Cysticercosis, cystic mass, chest wall

Introduction

Subcutaneous Cysticercosis is a tissue infection caused by Cysticercus cellulose, a larval form of the tape worm Taenia solium. .[1] Humans acquire cysticercosis through fecal-oral contamination with T. solium eggs from tape worm carriers. Cysticercosis can occur anywhere in the human body, but it is more common in the brain and skeletal muscles and uncommonly in subcutaneous tissues. It presents as asymptomatic subcutaneous nodules with prevalence of 12.9-38% in India.[1] We here present a case of isolated subcutaneous cysticercosis without involvement of any other site.

Case Report

A 45 years male from Karnataka presented with an asymptomatic cyst over the right chest wall since 4 months. Patient was otherwise healthy without any systemic sign and symptoms. He was a farmer by occupation and lives in a lower middle income group. He consumed mixed diet. Physical examination revealed one subcutaneous nodule over right chest wall just below the nipple in the mid clavicle wall. This nodule was well defined, non tender, firm, mobile with a smooth surface and measure 2 × 2cms. Other system examinations were unremarkable. A clinical differential diagnosis of epidermal cyst was given. A complete blood count revealed hemoglobin- 13 g/dl, red blood cells - 6.5 million/cc, , white blood cells - 7500/cc, neutrophils - 65%, lymphocytes - 30%, eosinophils - 3%, monocytes - 2%, platelet count – 2 lakh/cc, peripheral Smear: normocytic, normochromic blood picture . Serum biochemistry was also normal (fasting blood glucose-

98mg/dl, blood urea - 28 mg%, serum creatinine – 0.8 mg/dl, serum sodium -137 mmol/L, serum potassium-4.2 mmol/L, serum calcium- 1.1 mmol/L).Stool examination was negative for ova & cyst and complete urine examination was within normal limits. Chest X-ray and ultrasonography abdomen were normal. The lesion was surgically excised under general anesthesia and sent for histopathological examination. Specimen was received in Department of Pathology. On gross examination, it was a single, cystic, gray white lesion measuring 2 × 1.8 × 0.5 cms. Cut surface contain clear watery fluid and showed a gray white cystic cavity. (Figure 1) On microscopic examination, the excised tissue showed a cystic cavity containing a larval form of Taenia solium showing cuticular layer, prominent sucker and translucent hooklets. Structure of cysticercosis cellulosae typical has duct-like invagination lined by homogeneous bilayered eosinophilic membrane. Cyst wall and outer fibrous tissue was thrown in multiple papillary projections. (Figure 2a, 2b and 2c) Patient was advised other investigation to rule out involvement of other organs by the disease. CT scan brain and Fundus examination was done which confirmed absence of disease in the respective sites. Patients was started on Albendazole 200 mg TDS for 30 days. Six month follow up showed no recurrence.

Discussion

Campbell and Thomson in 1912 , reported the first case of cysticercosis involving the skin in India. 1 Cysticercosis is a global problem mainly in the developing countries. It

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Fig. 1: Cut surface showed a cystic lesion containing clear watery fluid. It was a uniloculated, thin-walled cyst.

Fig. 2a: Structure of larval form of Taenia solium, Cysticercus cellulose, showing cuticular layer, prominent sucker and translucent hooklets. (H&E at 10X ).

Fig. 2b: Duct-like invagination lined by bilayered eosinophilic membrane (H&E at 10X ).

Fig. 2c: Photograph showing caudal end of larva lined by acellular, homogeneous eosinophilic membrane (H&E, 40X)

has been eradicated from most of developed countries but it’s still in Central and South America, South Asia, India and China. 50 million people in world are infected with the taeniasis/cysticercosis complex and 50,000 die from cysticercosis annually. Most infected individuals are aged between 20–50 years. 2

to be more prevalent in the North India especially Bihar, Uttar Pradesh and Punjab because of high consumption of pork and low standard of living. State of Kerala has only few cases of cysticercosis probably due to the high level of education and standards of hygiene. In Jammu and Kashmir, as a Muslim majority State due to prohibition of pork consumption by religion results in low incidence of cysticercosis.3

In India, because of disparities within the country in geography, ethnicity, religious rituals, income, standards of living, food habits, personal hygiene and level of education, which influence the disease burden and also lack of systematic population-based studies, disease is under reported. Consumption of pork is generally restricted to the lower socio-economic strata. Cysticercosis appears Annals of Applied Bio-Sciences, Vol. 4; Issue 2: 2017

Taenia solium has a complex two-host life cycle. Infection is acquired by ingestion of eggs through contaminated food, water or by autoinoculation. Incubation period varies from months to years. In cysticercosis, humans are only definitive hosts and pigs are the intermediate host. Both e-ISSN: 2349-6991; p-ISSN: 2455-0396

Case Report

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humans and pigs can act as intermediate hosts and harbour the larvae or cysticerci. Human’s harbour the adult pork tapeworms in the small intestine and are the only source of cysticercosis for pigs as well as for the other humans. Infective eggs are detached from the adult tapeworm and are passed in the feces. As a result of improper fecal disposal, pigs consume the infected feces. Taenia solium eggs matures into oncospheres and metacestodes and lodge in the striated muscles and other tissues of pigs. These metacestodes evolve into larvaes (cysticerci). When human consume improper cooked infected pork, larvae evaginate and adhere to the intestinal mucosa. Cysticerci invade the intestine mucosa and enter the blood stream. Once they enter the blood stream of humans, they can lodge in any organ in the body such as the skeletal muscles, central nervous system, eye and subcutaneous tissue. 4

Diagnosis of soft tissue lesions requires identification of the Cysticercus cellulose, a larval form of the tape worm Taenia solium in the tissue by histopathological examination. Nigam JS et al reported a case of cysticercus cellulose on a 27-year-old female patient presented with a swelling on the right arm, by fine need aspiration cytology (FNAC).They reported that aspiration of clear fluid in palpable subcutaneous or intramuscular nodule is a strong clue for the diagnosis of cysticercosis.5

Cysticercosis can occur anywhere in the human body, but it has predilection for the tissue like nervous tissue, eyes, skeletal muscles and subcutaneous tissues. Brain is the most common location accounting for 60–90% of all cases. 1 Other site includes tongue, buccal mucosa etc. Involvement of the nervous tissue may cause severe morbidity but involvement of the subcutaneous tissue mainly causes cosmetic problems. Involvement of subcutaneous tissues often manifests as palpable subcutaneous nodules. Neurocysticercosis usually present as recurrent episodes of seizure, headache, focal neurological deficits, chronic meningitis, psychological disturbances, dementia, etc. Orbital cysticercosis may present as proptosis, diplopia and even loss of vision. Cysticercosis of the muscles may cause severe ache, pseudohypertrophy. 2

Cysticercosis of brain and skeletal muscle are relatively common than it’s subcutaneous location. Therefore, it should be considered as differential diagnosis of subcutaneous swelling in the adult age group. Detail medical examination of all proven cases should be carried out , to rule out presence of parasite in any other site. Cysticercosis is considered as a “biological marker” for the social and economic development. Since, cysticercosis is a preventable and eradicable disease, appropriate measures like mass awareness, health education, better medical facilities, identification & mass treatment of T. solium carriers and restriction on sale of contaminated pork may help to reduce the disease burden in the endemic areas.

A similar case of cysticercosis was reported by Siddewari et

al. Patient complaint of seizures with two subcutaneous nodules one over left elbow and other over lateral aspect of left thumb. On Magnetic resonance imaging brain, it was suggestive of neurocysticerosis and biopsy of skin confirmed the diagnosis of subcutaneous cysticercosis.1 Rajan A et al did a study on soft tissue cysticercosis. They reported only 2 cases of subcutaneous cysticercosis out of 21cases which occurred in soft tissue. They reported order of frequency of subcutaneous nodule is on upper arm, abdominal wall, chest wall, eyes, and neck. 3

The treatment of cysticercosis depends on symptoms of the patients and accessibility of lesion. For symptomatic patients drugs like Praziquantel and/or Albendazole are effective. Treatment of choice in solitary accessible lesion is surgical excision.3

Conclusion

Reference 1.

Siddeswari R, Manohar S, Sudarsi cysticercosis. J Acad Med Sci 2012;2:132-4.

B.Cutaneous

S Gole, G Gole, V Satyanarayana, A Deshpande, S Tati. Cysticercosis At Rare Sites: Our Experience At A Rural Medical College In Andhra Pradesh, India. The Internet Journal of Parasitic Diseases. 2012; 5(1).

Agrawal R. Soft tissue cysticercosis study of 21 cases. J Clin Diagn Res. 2012; 6:1669-71.

Del Brutto OH. Neurocysticercosis: a review. Sci World J. 2012;2012:159821

Nigam JS, Sharma A. Fine needle aspiration cytology of cysticercosis. J Clin Diagn Res. 2013;7:3123–3123.

*Corresponding author: Dr. Tanima Dwivedi, Senior Resident, Department of Pathology, Institute of Human Behaviour & Allied Sciences, Delhi-95, India Phone: +91 0124-4259965 Email: tanimadwivedi@gmail.com Date of Submission : 21.04.2017 Date of Acceptance : 21.05.2017 Financial or other Competing Interests: None. Date of Publication : 28.05.2017

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