Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : DD03 - DD04 Full Version

Palatal Infection by Multidrug Resistant Non Fermenting Gram Negative Bacilli in a COVID-19 Positive Patient Mimicking Black Fungus Infection- A Case Report


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52879.16125
Lino Varghese Koshy, Ambujavalli Balakrishnan, Jaison Jayakaran, Priyadarshini Shanmugam

1. Postgraduate Tutor, Department of Microbiology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India. 2. Assistant Professor, Department of Microbiology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India. 3. Assistant Professor, Department of Microbiology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India. 4. Professor, Department of Microbiology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Priyadarshini Shanmugam,
Professor, Department of Microbiology, Chettinad Hospital and Research Institute, Rajiv Gandhi Salai, Chengalpattu District, Chennai, Tamil Nadu, India.
E-mail: priyadarshini0018@gmail.com

Abstract

As the second wave of Coronavirus Disease-2019 (COVID-19) swept through India, many patients developed serious bacterial secondary infections such as pneumonia, sepsis and fungal infections such as mucormycosis. Among the bacterial infections, the most common organisms associated with secondary bacterial infections were Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia. Here, authors present a rare case of 31-year-old COVID-19 positive male patient with sepsis who developed palatal necrosis due to infection caused by a non fermenting gram negative bacillus resembling the lesions seen in mucormycosis. The necrotic tissue, bronchoalveolar lavage fluid and blood samples were sent for culture. Blood cultures yielded Elizabethkingia meningoseptica and necrotic tissue yielded Stenotrophomonas maltophilia.

Keywords

Opportunistic infections, Stenotrophomonas maltophilia, Zygomycosis

Case Report

A 31-year-old male patient with no known co-morbidities was brought to the emergency room complaining of gradually worsening cough with increased difficulty in breathing for the past three weeks, with no similar complaints among family members. His oxygen saturation was 93% on room air which increased to 97% with nasal oxygen 4 lit/minute. He was haemodynamically stable. He was treated with doxycycline 100 mg twice daily, vitamin C 500 mg once daily, tab zincovit once daily and was admitted to the ward, after being diagnosed as COVID-19 positive by Reverse Transcriptase- Polymerase Chain Reaction (RT-PCR). His Computed Tomography (CT) severity score was 12/25. Four days after admission, the patient gradually worsened and progressed to Acute Respiratory Distress Syndrome (ARDS) for which he was maintained on oxygen support by Non Re-breather Mask (NRM) and Non Invasive Ventilation (NIV) via bilevel positive airway pressure and bain circuit. He was treated with intravenous steroids (dexamethasone), remdesivir and antibiotics (intravenous ceftriaxone 1.5 g twice daily, piperacillin and tazobactam 4.5 g thrice daily for one week) and was transferred to the Intensive Care Unit (ICU) for further management and transferred back to the ward after his condition stabilised.

One week later, the patient developed severe breathlessness and was diagnosed to have a right sided pneumothorax for which an Implantable Cardioverter Defibrillator (ICD) was inserted. Pustular discharge was obtained after the insertion of ICD revealing a pyopneumothorax. On oral examination, a black colored lesion was observed on the hard palate (Table/Fig 1). Tissue scrapings from the lesion, bronchoalveolar lavage and a blood sample were sent to the laboratory for culture and antibiotic sensitivity with suspected mucormycosis (Black Fungus). He was started on meropenem 500 mg thrice daily, colistin 150 mg twice daily and cotrimoxazole 300 mg twice daily for seven days. Ten days postthoracotomy, the bronchopleural fistula closure was done. He was intubated and ventilated and his vitals were stable. CT brain showed no evidence of intracranial haemorrhage. Seven days after maintaining status quo the patient deteriorated and was placed on ionotropic support. However, he succumbed to the illness without any response to treatment.

Consent was obtained from patients’ attenders to publish this case report and to add a photograph of the hard palate.

Laboratory Investigations

The Potassium Hydroxide (KOH) mount showed that there were no fungal growth. The samples were inoculated on the blood agar, chocolate agar, MacConkey agar, nutrient agar (Table/Fig 2), thioglycolate broth and Sabouraud’s Dextrose Agar (SDA). Blood agar and chocolate agar gave a growth of grey white colonies with no lysis. MacConkey agar yielded medium sized translucent colonies which were lactose non fermenting without any pigmentation. A uniform turbidity was observed in the thioglycolate broth.

Gram’s stain from the culture plates showed long and slender Gram negative bacilli (Table/Fig 3), which were oxidase negative, indole negative, Triple Sugar Iron (TSI) alkali slant by alkaline butt, citrate utilisation negative, urease negative, mannitol motility agar non fermenting and non motile and esculin hydrolysis positive. All these pointed towards a possible identity of Stenotrophomonas maltophilia, which was confirmed by Vitek 2 compact, automated ID and Antibiotic Susceptibility Testing (ABST) system. The organism was susceptible to minocycline, levofloxacin and cotrimoxazole. SDA yielded no growth suggesting no fungal involvement.

Blood cultures from the patient yielded Elizabethkingia meningoseptica which was susceptible to cotrimoxazole and pus from the pyothorax yielded Pseudomonas aeruginosa which was susceptible to aminoglycosides, fluoroquinolones, monobactam and carbapenems.

Discussion

COVID-19 is ongoing pandemic with its manifestations and complications showing to be multifaceted. Non fermenting gram negative bacilli are an important group of pathogens causing hospital acquired infections. They can cause a wide range of infections including surgical site infections, ventilator associated pneumonia, catheter associated infections which can lead to sepsis and death if not controlled. These group of pathogens shows a wide range of antibiotic resistance which contributes to their virulence (1). Secondary infections caused by non fermenting gram negative bacilli are seen in COVID-19 patients with prolonged hospital stay. The common non fermenters associated with these infections are Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia (2). Index case was of a COVID-19 positive patient who developed palatal lesion caused by non fermenting gram negative bacilli, resembling mucormycosis.

There have been reports of secondary infection with Stenotrophomonas maltophilia following COVID-19 infection in India which is an opportunistic pathogen (2),(3). Stenotrophomonas maltophilia is a non fermenting gram negative rod. In addition, Stenotrophomonas colonisation has been associated with lung damage (4). Long term ICU stay, NIV, catheter related infections. Stenotrophomonas maltophilia can cause a spectrum of infections but the majority of the cases involve pneumonia and bacteremia (5). Incidence of Stenotrophomonas infection increases with the severity of COVID-19 pneumonia (5).

Although the pathogen in the reported case is not considered to be very virulent, the organism is an opportunistic pathogen with a mortality rate of 43% in infected individuals (6). Some studies reported a mortality of greater than 50% when associated with bacteremia (7),(8). Another cause of concern with this organism is that it is intrinsically resistant to β-lactam and aminoglycoside antibiotics (9). Stenotrophomonas species is reportedly resistant to antipseudomonal antibiotics and administration of these antibiotics can enhance the growth of Stenotrophomonas.

Conclusion

COVID-19 is associated with a wide array of secondary infections, both bacterial and fungal, especially in patients requiring prolonged hospitalisation. Therefore, a high index of suspicion is necessary while looking for infections with opportunistic infections such as Stenotrophomonas maltophilia which is associated with significantly higher mortality. Also, caution should be taken during administration of antipseudomonal antibiotics as these might enhance the growth of Stenotrophomonas maltophilia. Antibiotics targeting this organism also should be considered in patients with severe COVID-19 pneumonia and patients with central venous catheters.

References

1.
Malini A, Deepa EK, Gokul BN, Prasad SR. Nonfermenting gram-negative bacilli infections in a tertiary care hospital in Kolar, Karnataka. Journal of Laboratory Physicians. 2009;1(02):062-66. [crossref] [PubMed]
2.
Vijay S, Bansal N, Rao BK, Veeraraghavan B, Rodrigues C, Wattal C, et al. Secondary infections in hospitalised COVID-19 patients: Indian experience. infection and drug resistance. 2021;14:1893. [crossref] [PubMed]
3.
Bilgic A, Sudhalkar A, Gonzalez-Cortes JH, de Ribot FM, Yogi R, Kodjikian L, et al. Endogenous endophthalmitis in the setting of COVID-19 infection: A case series. Retina. 2021;41(8):1709-14. [crossref] [PubMed]
4.
Pek Z, Cabanilla MG, Ahmed S. Treatment refractory Stenotrophomonas maltophilia bacteraemia and pneumonia in a COVID-19-positive patient. BMJ Case Reports CP. 2021;14(6):e242670. [crossref] [PubMed]
5.
Karpati F, Malmborg AS, Alfredsson H, Hjelte L, Strandvik B. Bacterial colonisation with Xanthomonas maltophilia-A retrospective study in a cystic fibrosis patient population. Infection. 1994;22(4):258-63. [crossref] [PubMed]
6.
Robin T, Janda JM. Pseudo-, Xantho-, Stenotrophomonas maltophilia: An emerging pathogen in search of a genus. Clinical Microbiology Newsletter. 1996;18(2):09-13. [crossref]
7.
Wang WS, Liu CP, Lee CM, Huang FY. Stenotrophomonas maltophilia bacteremia in adults: four years' experience in a medical center in northern Taiwan. Journal of Microbiology, Immunology, and Infection. 2004;37(6):359-65.
8.
Jang TN, Wang FD, Wang LS, Liu CY, Liu IM. Xanthomonas maltophilia bacteremia: An analysis of 32 cases. Journal of the Formosan Medical Association. 1992;91(12):1170-76.
9.
Pankuch GA, Jacobs MR, Rittenhouse SF, Appelbaum PC. Susceptibilities of 123 strains of Xanthomonas maltophilia to eight beta-lactams (including beta-lactam-beta-lactamase inhibitor combinations) and ciprofloxacin tested by five methods. Antimicrobial Agents and Chemotherapy. 1994;38(10):2317-22. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/52879.16125

Date of Submission: Oct 15, 2021
Date of Peer Review: Nov 24, 2021
Date of Acceptance: Jan 01, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 17, 2021
• Manual Googling: Dec 29, 2021
• iThenticate Software: Feb 24, 2022 (2%)

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