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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
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.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
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
Case report
Full Version
The Silent Invader: A Case Report of Pulmonary and Cerebral Nocardiosis by Nocardia cyriacigeorgica in a Renal Transplant Recipient
Correspondence Address :
Dr. Palraj Kennedy Kumar,
Plot No. 35, West Patel Street, Kamarajnagar, Avadi, Chennai-600071, Tamil Nadu, India.
E-mail: kennychennai1973@gmail.com
Nocardia species primarily affect the lungs of immunocompromised individuals. The clinical presentation may mimic pulmonary tuberculosis. Accurate identification and high clinical suspicion are crucial for correct diagnosis and treatment, especially in tuberculosis-endemic regions. A prolonged antibiotic regimen with two or more drugs is needed, and non adherence to the treatment protocol can lead to potentially fatal outcomes. A 37-year-old man with systemic hypertension and chronic kidney disease, who also underwent live-related renal transplantation, presented with fever, cough, and weight loss. No other significant complaints were noted. Physical examination revealed elevated body temperature and bilateral basal crepitations. Baseline investigations showed anaemia, leukopenia and elevated renal parameters. A chest X-ray indicated right lower zone opacity. A provisional diagnosis of pulmonary tuberculosis or mycosis was considered. Video bronchoscopy revealed thick mucoid secretions that were collected for staining, culture, and sensitivity testing. Gram stain and modified Acid-Fast Bacilli (AFB) stain showed microscopic features suggestive of Nocardia species, while the colonies that grew on culture were identified as N. cyriacigeorgica. Treatment was initiated with oral cotrimoxazole and intravenous imipenem. After 14 days, he was discharged with a continuation plan but did not adhere to the regimen. The patient eventually presented again 10 days later with seizures and altered sensorium, leading to a diagnosis of cerebral nocardiosis. Despite treatment, he progressed to septic shock and died. Effective treatment of nocardiosis requires a multidrug regimen, typically consisting of cotrimoxazole, amikacin, or imipenem, tailored to the severity of the infection. Early diagnosis, prompt treatment, and strict adherence to protocols are mandatory for successful treatment, as delays or non compliance can lead to fatal outcomes.
Brain abscess, Immunocompromised, Opportunistic infection
A 37-year-old man presented with a five-day history of high-grade fever, productive cough, and weight loss. He was a known case of systemic hypertension and chronic kidney disease, having received a live-related renal transplant a year ago. For this, he was on immunosuppressive therapy with methylprednisolone and tacrolimus. Physical examination revealed a fever of 101.2°F, and auscultation of the chest revealed bilateral coarse lower zone crepitations. Initial investigations showed microcytic hypochromic anaemia (haemoglobin 6.2 g/dL), leukopenia (1710 cells/cu.mm), and elevated renal parameters (serum creatinine 2.8 mg/dL, BUN 52 mg/dL). A chest X-ray indicated right lower zone opacity (Table/Fig 1).
A provisional diagnosis of pulmonary tuberculosis was considered based on the chest X-ray findings. Video bronchoscopy revealed thick mucoid secretions in the bilateral lower lobes, which were sent for microscopy and culture. Gram stain and 1% modified AFB staining were performed on the bronchial secretions. The Gram stain showed a moderate number of inflammatory cells along with filamentous, branching, gram-positive bacilli, and 1% modified AFB staining confirmed the presence of acid-fast filamentous bacilli (Table/Fig 2), suggestive of Nocardia spp. Routine AFB staining and potassium hydroxide fungal mounts were negative. Culture on blood agar grew chalky white colonies (Table/Fig 3), which produced catalase and hydrolysed urea. These colonies were identified by Matrix Assisted Laser Desorption Ionisation Time-Of-Flight (MALDI ToF-MS) as Nocardia cyriacigeorgica. Susceptibility testing according to the Central Laboratory Standards Institute (CLSI) guidelines (1) showed susceptibility to ceftriaxone, amikacin, cotrimoxazole, linezolid, and imipenem, but resistance to amoxicillin-clavulanic acid (Table/Fig 4).
The patient was treated with oral cotrimoxazole (Sulfamethoxazole 800 mg + Trimethoprim 160 mg) twice daily and intravenous imipenem 500 mg three times daily during the 14 days of hospitalisation. He was also given a single dose of oral linezolid 600 mg on the first day of hospitalisation, which was stopped considering his renal parameters. He received two units of packed red blood cell transfusion for anaemia and was monitored closely for renal function. After 14 days of rigorous treatment, he improved significantly and was discharged with instructions to continue cotrimoxazole and imipenem therapy for two more weeks. However, the patient did not adhere to the antibiotics after discharge.
Ten days after discharge, the patient presented with multiple episodes of seizures and altered sensorium with a Glasgow Coma Scale (GCS) score of 6/15, a high-grade fever, hypotension, and reduced renal output. Magnetic resonance imaging of the brain revealed right frontal and intra-axial lesions with perilesional oedema, suggestive of cerebral abscess (Table/Fig 5). He was diagnosed with cerebral nocardiosis and was treated with a multidrug regimen consisting of tablet cotrimoxazole 160 + 800 mg twice daily, injection imipenem 500 mg three times daily, and injection ceftriaxone 1 g twice daily. Unfortunately, he deteriorated over the subsequent hours. The patient progressed to septic shock. Blood cultures did not grow any organism, and within 48 hours, he succumbed despite resuscitation efforts.
Genus Nocardia comprises aerobic actinomycetes that are gram-positive, filamentous bacilli with a branching and beaded appearance, exhibiting weak acid-fast properties. Nocardia species are ubiquitously found in the environment, and infections are often underdiagnosed (2). Nocardiosis is sporadic in nature, with the pulmonary form being the most common presentation. It clinically and radiologically mimics pulmonary tuberculosis, resulting in an increased likelihood of misdiagnosis (2). Risk factors such as long-term steroid and immunosuppressant usage, as well as Human Immunodeficiency Virus (HIV) infection, can lead to severe forms of Nocardia infection. Currently, there are about 100 identified species of Nocardia, more than 50 of which are clinically significant, with reports published from around the globe (2),(3).
N. cyriacigeorgica was first identified in a patient with chronic bronchitis in 2001 (4) and has since been reported in Canada, Greece, Turkey, Thailand, and India. This organism has been associated with various manifestations, including pulmonary lesions, cellulitis following dental extraction, bacteraemia, brain abscesses, lesions in solid organ recipients, endophthalmitis, and scleral buckle injuries (5),(6),(7). These manifestations are related to infections or iatrogenic immunosuppression. N. cyriacigeorgica commonly disseminates following pulmonary manifestations (8). A comprehensive 11-year retrospective study from Taiwan revealed that the lungs are the most common site of involvement, followed by the skin and soft tissue. Additionally, the study found that one-third of the population died within three months (9).
Pulmonary and disseminated nocardiosis are common in patients with compromised cell-mediated immunity and those receiving immunosuppressive therapy, while cutaneous infections can occur even in immunocompetent individuals. In this patient’s case, the development of opportunistic pulmonary nocardiosis can be attributed to the immunosuppressive therapy involving steroids and a calcineurin inhibitor. Pulmonary nocardiosis typically presents with non specific symptoms that overlap with conditions such as tuberculosis and fungal infections, primarily caused by Aspergillus species, making diagnosis challenging (10). In a country like India, where tuberculosis is endemic, this type of clinical presentation must be carefully addressed, especially in the immunocompromised population.
The microbiological diagnosis of Nocardia poses challenges due to the slow growth of the bacteria from respiratory specimens. In present case, growth on enriched medium was observed only after 72 hours of incubation. Additionally, the growth of Nocardia colonies may be obscured by the normal flora present in respiratory specimens (3). Extended incubation of cultures from respiratory specimens of patients with a clinical suspicion of nocardiosis may be beneficial. Advancements in isolation techniques and laboratory diagnostics have significantly contributed to the increased detection of various Nocardia species. Laboratory identification of Nocardia species was originally based on their ability to utilise specific sugars and decompose substrates. While there are relatively few standardised biochemical tests available, techniques such as 16S rRNA PCR and sequencing, hsp65 sequencing, DNA hybridisation, and MALDI-TOF MS have now established a more accurate classification (11).
Antimicrobial susceptibility and resistance patterns vary among Nocardia species. N. brasiliensis, N. abscessus, and N. farcinica are intrinsically resistant to imipenem, while N. cyriacigeorgica is resistant to ciprofloxacin and clarithromycin. Therefore, species identification through conventional biochemical tests, automated identification methods, or sequencing is essential for choosing an effective antibiotic therapy (1),(2). While sulfonamides were the preferred antimicrobials earlier, the current treatment protocol usually consists of cotrimoxazole in combination with ceftriaxone, amikacin, or imipenem (10). N. cyriacigeorgica is usually susceptible to cephalosporins, imipenem, amikacin, linezolid, and cotrimoxazole but resistant to penicillin, amoxicillin-clavulanic acid, clarithromycin, and ciprofloxacin (1). Cotrimoxazole is the cornerstone of treatment for various clinical forms of nocardiosis, as most species are susceptible to this drug. Literature states that the outcome after antibiotic treatment for nocardiosis is excellent with combination therapy involving multiple drugs. The duration of treatment is crucial to prevent relapse of infection. As Nocardia replicates slowly and may remain as cryptic intracellular organisms, these often tend to relapse (2). Hence, extended antimicrobial therapy lasting from a few weeks to several months is necessary. The treatment duration for pulmonary or systemic infections varies from two weeks to up to six months, and may even extend up to 12 months in cases of cerebral nocardiosis (2),(3). Clinical improvement can be assessed after two weeks of treatment initiation, and surgical intervention is indicated in appropriate cases. Successful clinical outcomes with no relapses have been reported in several cases of N. cyriacigeorgica infections when patients were treated with a strict combination regimen over an extended duration (Table/Fig 6) (3),(5),(6),(7),(12),(13). However, careful monitoring of antibiotic-related toxicity is advised.
Poor prognosis is observed either during a delay in diagnosis or when treatment is deferred or not adhered to. The outcome depends largely on the extent of the infection and patient factors (2),(3). According to a report from the USA, mortality rates for nocardiosis can reach up to 25% for pulmonary manifestations and up to 100% in cases involving the central nervous system (14). An Indian report stated a mortality rate of 31.25% for pulmonary and dermal nocardiosis, with a 100% mortality rate in cerebral nocardiosis (15). Previously published reports on varied presentations of N. cyriacigeorgica from India have shown good recovery with almost no relapses, thanks to the prompt identification of the causative organism, an effective antibiotic regimen, and meticulous follow-up of the patient (Table/Fig 6). Reports published from India over the last decade have mostly indicated that patients have completely recovered after adhering to treatment (Table/Fig 6). In present case, the unfavourable outcome may be attributed to the patient’s non adherence to treatment and existing co-morbid conditions, which heightened the risk of dissemination within days. Accurate identification, prompt initiation, and maintenance of appropriate treatment will greatly reduce Nocardia-related mortality.
Nocardia species are particularly significant in cases associated with immunosuppression due to their non specific presentation, which mimics tuberculosis. Therefore, accurate identification is essential in regions where tuberculosis is endemic. Advances in laboratory diagnostics, such as MALDI-TOF MS and gene sequencing, have aided in the precise identification and classification of these species. Antimicrobial treatment for any form of nocardiosis necessitates a multidrug regimen, usually including cotrimoxazole and imipenem, for an adequate duration based on the severity of the infection. Successful outcomes depend on early diagnosis, prompt initiation, and strict adherence to treatment protocols, as delays or non adherence can result in poor prognosis.
DOI: 10.7860/JCDR/2024/75214.20285
Date of Submission: Sep 01, 2024
Date of Peer Review: Sep 27, 2024
Date of Acceptance: Oct 19, 2024
Date of Publishing: Nov 01, 2024
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: Sep 07, 2024
• Manual Googling: Sep 30, 2024
• iThenticate Software: Oct 18, 2024 (5%)
ETYMOLOGY: Author Origin
EMENDATIONS: 5
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
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- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com