Tropical Doctor

In global health, a discipline with a racist and colonial history, white supremacy, white privilege and racism are still present today. ¹ Although many believe we are witnessing a resurgence of racism in global health, because of a recent rise of extreme right comments and racism in the community and online ^{2, 3}. In reality racism has always been an inherent aspect of global health and its predecessors: tropical health and international health by prioritizing the health issues of the colonizers over those of the native populations. ⁴ As such, we are rather bearing witness to long standing issues that have been persistently overlooked. There is a need for a paradigm shift to enable true authentic leadership that promotes the values of our shared humanity.

Maintaining accurate and complete operation notes is an essential metric of the quality of surgical care. While developed countries have implemented electronic health records to improve documentation, financial constraints prevent this realisation in the Caribbean. Somewhat paradoxically, previous studies in this area have focussed on ‘process’ while neglecting the key role of the surgeon. We conducted a 25-item Knowledge, Attitudes and Practices survey of orthopaedic doctors to identify any culturally unique health-related behaviours. Our results indicate that while most doctors understand the importance of operation notes, many are unaware of international note-keeping recommendations. Legibility was identified as a significant issue by 92% of doctors. A disturbing and previously unreported finding from the study revealed that 72% of surgeons would occasionally write the operation notes, although they were not scrubbed in for the procedure. We suggest that future studies examine this peculiar behaviour in greater detail.

Our study aimed to identify prognostic factors for surgical site infection following long bone fracture intramedullary nailing at a tertiary hospital in a low-resource setting. This was a longitudinal observational study involving 132 participants enrolled over a one-year period with femoral and tibial diaphyseal fractures scheduled for ORIF. Participant median age was 30 years (range: 26 – 42). The prevalence of surgical site infection was 16%. Male sex (AOR=0.26, 95% CI [0.70–0.98]; p = 0.047) was associated with lower odds of surgical site infection while associated non-musculoskeletal injuries were associated with higher odds of developing surgical site infection. Our study confirms a higher surgical site infection rate than normally accepted. However, intramedullary nailing in our setting is justified as it allows an early return to a pre-injury state. These interventions must be carried out in the best possible circumstances. Future studies could explore alternative methods of fracture fixation.

Tubercular empyema thoracis continues to be one of the leading causes of morbidity in low-income countries. Despite antitubercular therapy (ATT) and thoracostomy, empyema drainage is hampered by multiple septations, loculations, debris, and blood clots leading to complications. In a comparative experimental study to estimate the efficacy and safety of intrapleural streptokinase (IPSTK) in tubercular empyema, 30 cases of chronic multiloculated tubercular empyema were compared by radiological improvement by chest radiography, duration and volume of fluid drained, and degree of dyspnoea according to the modified Borg scale, depending on whether streptokinase was used or not. The former scored on all counts; we therefore conclude that intrapleural streptokinase is a safe, efficacious intervention in tubercular empyema. It decreases morbidity and reduces the need for surgery.

Orchidopexy for undescended testis is recommended at a younger age than heretofore; our study aimed to assess delays, and their causes, by retrospective analysis of data from a single tertiary care centre over one year (2015–2016). Almost 80% of children were brought after 1 year of age, mostly because of delayed referral by primary physicians (60%), or missed diagnosis by parents or primary physicians (20%). Misconception about the risk of surgery below 1 year was significant (15%). A timely referral is encouraged.

Enteral alimentation can be administered continuously, cyclically, intermittently, or by a bolus technique. Current literature does not suggest superiority of any one regime. Most studies have used nasogastric feeds, little is known about the outcome of jejunal feeding.

This study compares the efficiency and safety of bolus and continuous jejunostomy feeding. 46 adults undergoing a feeding jejunostomy for nutritional support or as an adjunct to a major upper GI surgery, were randomised to bolus feeding (BF group, n = 24) and continuous feeding (CF group, n = 22). Demographic, anthropometric, and laboratory parameters were measured preoperatively and on post-operative days (POD) 3, 7, 15, and 30. These parameters; as well as nutritional and functional outcomes, and complications at POD 30; were comparable in both groups. Both groups tolerated jejunal feeds well. Bolus feeding is simple, inexpensive, and permits daily physical activities. Hence it may be preferred over continuous jejunostomy feeding for enteral alimentation.

Gallbladder perforation still continues to perplex surgeons; 25 such patients diagnosed either pre- or intra-operatively and managed at our institute over the last 10 years period were analysed. Only eight were diagnosed pre-operatively, while a large majority (17) had a wrong initial working diagnosis. Symptoms and signs were variable. No blood investigation was specific. A computed tomography scan was generally better than ultrasound in detecting the perforation. All our cases were managed operatively with no mortality and a mean duration of hospital stay of 6.8 days. Most perforations were extra-hepatic (84%) and those of Niemeier’s type I (52.2%). Because of its varied clinical presentation, gallbladder perforation is often an intra-operative diagnosis, but early intervention carries a good outcome.

Fournier’s gangrene (FG), a necrotizing fasciitis of the genital and perineal region, is a serious and debilitating multi-infective pathological condition. More commonly seen in adults, its occurrence in neonates is uncommon. We share our experience with neonatal FG (NFG), highlighting potential factors which may predispose neonates to it.

Ours is a five year retrospective review of cases of NFG in our service. Data obtained included health facility of birth, mode of delivery, symptoms and duration, investigation results, treatment and outcome. Sixteen neonates were included, comprising 13 males (M:F  =  4.3:1). Fourteen were delivered outside our centre; breech vaginal delivery, hot water massaging and application of native concoctions were common. All were treated with antibiotics and wound debridement, but five (37.5%) died.NFG is not that rare in our service. Early recognition is imperative to reduce mortality. Neonates delivered by breech vaginally may be particularly at risk.

Our study looks at the effects of burnout and stress levels of nurses, behaviour regarding medical waste, and other effective risk factors on the first time and recurrent diagnosis of nosocomial infection (NI) in neonatal intensive care units in Hargeisa, Somaliland. This multicentric follow-up study was conducted and repeated measurements were taken from 72 neonates and 45 nurses working in three hospitals for a period of five months. Nurses with high burnout levels had 3.7 times higher risk of neonates under their care being diagnosed with an NI (odds ratio: 3.743; 95% CI: 1.498–9.356). By controlling other variables, the stress level of nurses increased the incidence rate of neonates being diagnosed more than once with NI by 3.2 times. Statistically, the direction of causal association was from the high burnout among nurses to the diagnosis of NI, and high stress was associated with the recurrent diagnosis of infections in neonates.

In a rural block in North East India, community health workers (CHW) empowered with a mobile phone-based application screened a total of 2,686 participants for Oral Potentially Malignant Lesions (OPMLs), and an oral medicine specialist recommended treatment remotely. Independent risk factors were determined using independent multiple logistic regression models. Nearly 700 (26%) participants were identified with OPMLs. The sensitivity, specificity, positive predictive values, negative predictive values and accuracy of the CHW was 70.3, 88.4, 66.8, 89.9% and 83.7% respectively. Male gender, married status, smokeless tobacco, paan, areca-nut and alcohol consumption were independent predictors of OPMLs, the burden of which in North East India can be attributed to the high consumption of tobacco and non-tobacco products. Such programmes, with the recommendations from remote specialists, will facilitate early detection in remote settings.

Our study aimed at determining clinical factors associated with prolonged hospitalisation and death among children admitted with blackwater fever (BWF). We analysed 920 eligible records for the period January – December 2018 from Mbale and Soroti Regional Referral Hospitals in Eastern Uganda. The median hospitalisation was 3 (IQR: 2–5 days) days. Prolonged hospitalisation was in 251/920 (27.3%). Clinical features independently associated with prolonged hospitalisation included abdominal tenderness, body pain and mild fever. 29/920 (3.2%) died, of these 20 (69.0%) within 48 h of admission. Features of severity associated with mortality were noisy or interrupted breathing, tachypnoea, chest pain, convulsions, delayed capillary refill time (≥3 s), severe pallor, high fever (>38.5°C), altered level of consciousness, prostration and acidotic breathing.

This study retrospectively analysed the emergence of multidrug-resistant Salmonella enterica in a level IV hospital in Lima, Peru. A total of 64 S. enterica from January 2009 to June 2010 (Period 1, 24 isolates) and January 2012 to December 2014 (Period 2, 40 isolates) were included. Some 25 were from non-hospitalized and 39 from hospitalized patients. Antimicrobial susceptibility to 15 antimicrobial agents was established by automated methods. Most of the isolates were from blood (46.9%), urine (21.9%) and faeces (14.1%). There was a reduction in blood isolates in Period 2, while all the faecal isolates were from this period. In Period 1, only 3/24 (12.5%) isolates showed antibiotic resistance, whereas 25/39 isolates (64.1%) from Period 2 were antibiotic-resistant, with multidrug-resistant and extensively drug-resistant rates of 17.9% and 20.5%, respectively. Multidrug-resistant/extensively drug-resistant Salmonella isolates were introduced in the hospital in 2013, with Salmonella recovered from faeces from non-hospitalized patients suggested an increase in community-acquired multidrug-resistant/extensively drug-resistant Salmonella infections.

In India, the world's second most populous state, an increasing proportion of its population are elderly. Older people invariably face special psychiatric challenges. In a community-based cross-sectional study, depression was found to be present in almost a third of the elderly; furthermore, low family income, poor literacy and uncertain employment status were found to be significant associations.

There has been a surge in the incidence and severity of sexual assaults globally with the insurgence of COVID-19 owing to lockdown restrictions. Ekiti Sexual Assault Referral Centre, Ado-Ekiti also known as Moremi Clinic was established in June 2020 as a multisectoral response centre to this surge. Seventy-four survivors accessed medical services from June 2020 to May 2021. Adolescents made up 54.1% while the median age was 14.5 years. Only seven survivors were seen within 24 h of the event and around a quarter had follow-up visits. A quarter of survivors reported repeat episodes of sexual assault. Complications documented were sexually transmitted infections (13.5%), depression (4.1%) and posttraumatic stress disorder (5.4%). There was a failure of contraception in 4.5% of survivors who had taken emergency contraceptive pills. For improvements in quality of care, strategies to ensure early presentation and encourage follow-up visits must be introduced.

We aimed to determine the outcome of bacteriologically confirmed drug-resistant (DR) tuberculosis (TB) in 174 children. We found that DR-TB infected children have nonetheless a high treatment completion rate with a low incidence of fatality and treatment failure. Reversible adverse drug reactions are common during therapy.

Tuberculosis is a state of immunosupression which exposes the patients to further opportunistic pathogens like fungus. Methods: 102 newly diagnosed sputum positive pulmonary tuberculosis cases were enrolled. Significant fungal isolates were seen in 31/102 (30.4%) patients. Aspergillus spp. were isolated in 13/31(41.9%) of the positive fungal cultures while Candida spp. were isolated in 15/31 (48.4%). Low body mass index, duration of symptoms, haemoptysis, severity of radiological features and IgG Aspergillus antibodies were independent risk factors for positive fungal culture. Significant proportion of patients with PTB have fungal colonisation of their airways which can lead to poor clinical outcomes. Few easily ascertained clinical parameters can help the clinician to determine patients who are at a higher risk of fungal colonisation.

Whilst nausea affects around 80% of pregnant women, hyperemesis gravidarum, an extreme form of the same, affects only 0.5% to 3%, but may lead to severe nutritional deficiency. Wernicke’s encephalopathy is an acute neuropsychiatric disorder which occurs due to thiamine deficiency and needs emergency treatment to prevent neurological morbidity and mortality. Wernicke’s encephalopathy is characterised by a clinical triad of oculomotor abnormalities, cerebellar dysfunction and altered mental state. Korsakoff’s psychosis is a chronic condition and consequence of Wernicke’s encephalopathy, resulting from its delayed treatment. Wernicke’s encephalopathy is a well-known complication of chronic alcohol abuse. Not many are aware of its association with hyperemesis gravidarum. Although it is a rare complication, if not diagnosed and treated promptly, it may result in permanent and irreversible neurological sequelae. The objective of our retrospective observational study was to analyse the clinical profile and outcome (short and long term) in a rare yet preventable complication of pregnancy.

When the COVID-19 pandemic unfolded in March 2020, surgical care was impacted globally. The developing nations in the Caribbean were unprepared with fragile, resource poor healthcare systems. A series of rapid policy changes in response to the pandemic radically changed surgical care and prevented the usual oversight in the operating theatre. Attending surgeons responded utilising readily available technology for distance mentoring. Using this model, postgraduate surgical residents were able to complete 96% of trauma laparotomies safely without major complications.

There is still no organised national screening programme for colorectal cancer in Jamaica. We sought to evaluate the detection of colorectal cancer precursor lesions in patients who underwent opportunistic screening over three years. Patients with colorectal polyps were selected for further study. In 431 procedures, there were 84 (19.5%) patients with colorectal polyps identified at screening colonoscopy, which gave a 19.5% sensitivity to identify patients with polyps at risk of developing colorectal cancer, 9.5% being <50 years of age. At the time of examination, 16.7% had already developed invasive adenocarcinoma. We conclude that it is time for policy makers to develop a national colorectal cancer screening programme to diagnose patients early and improve their therapeutic outcomes.

We describe a low-cost simulation model for teaching core needle biopsy to surgical trainees in Low- and Middle-income countries (LMICs). Pre-session and post-session surveys showed that correct core sampling (ability to hit the beetroot) after training was 91.4% compared to 75.7% before demonstration and improved adequacy (68.5% before v. 85.7% after). This low-cost model using locally available products is designed to simulate a palpable breast lump and can easily be incorporated into surgical training in LMICs, where a palpable breast lump is the commonest presentation of breast cancer.

We present three unusual cases of atypical scrotal lesions in children. The first was a firm left scrotal mass with the testis indistinguishable. The second with apparently a large hydrocoele, which was a cyst, and the third with multiple nodular lesions, pushing the left testis into the right hemiscrotum. These turned out to be a pigmented neuroectodermal tumour, a lymphatic malformation and neurofibromas respectively. Paediatric surgeons should be aware of such surgical surprises.

As possession of a mobile phone becomes ubiquitous in the general population, its hazards, especially for vision, should be better known and understood. Although blast injuries are common in war, gas cooking and with firecrackers, mobile phone blasts, popularly known as BOMBILE (Blast of Mobile Battery in the Living Eye), are becoming more and more frequent. We present three cases phone battery explosion diagnosed with ocular surface burn. Although none had severe injuries and vision was salvageable and no visual or cosmetic impairment resulted, this may not always be so. Public education, producer liability, and better technological solutions are urgently required to lessen the risks.

Maxillary osteomyelitis is a rare event. With emergence of bisphosphonates, the incidence of jaw osteomyelitis has increased. We report five uncommon cases, with a comprehensive review of etiology and pathology. The correlation between osteonecrosis and osteomyelitis is discussed.

Cutaneous leishmaniasis is spreading in Ethiopia and outbreaks have been recorded at new foci. In the Ankesha-Guagsa district, from September 24 to 28, 2020, 39 suspected cases were screened, and amastigote stages were identified in lesion samples of 34 (87.2%) cases.

Spirochaetes comprise a heterogenous group of gram negative, motile, spiral shaped bacteria. Some of these pathogens are known to cause numerous human diseases such as Lyme disease, relapsing fever, syphilis and leptospirosis. However, intestinal spirochetosis is a rare condition. Patients frequently present with long-term complaints of loose stools, abdominal pain and weight loss and rectal bleeding. Hence to establish a diagnosis an endoscopy with biopsy is required. In this article, we describe four such cases, having different ages and socio- economic background, successfully treated with a short course of metronidazole.

Since 2017, the Global Anaesthesia Surgery and Obstetric Collaboration (GASOC) has been hosting journal clubs to promote critical appraisal of global surgery publications. The COVID-19 pandemic has prompted a transition to an online-only journal club format. Attendees have rated the online GASOC journal clubs highly in terms of relevance for their learning and development, and the ability to engage with discussions. This transition has allowed more trainees in low- and middle-income countries (LMICs) to register for journal clubs, but barriers have continued to restrict their participation. Feedback submitted by participants has allowed GASOC to identify and address these barriers in order to promote bidirectional partnerships between high-income country and LMIC trainees.

Atractaspis bibronii are highly specialised snakes found across Southern Africa. Adapted for subterranean hunting of prey, snakes of the genus Atractaspis demonstrate a unique biting mechanism, with an ability to deliver venom via a single fang, protruded over an almost closed mouth in a side-to-side striking pattern. It is not possible to handle these snakes safely. Atractaspididae can be mistaken for medically insignificant snakes and often occur in remote areas that may lead to delayed or reduced presentation to suitable care facilities. We here report a case of an A. bibronii envenomation in remote Southern Africa to the right ring finger from a single fang with significant complication. Medical, and subsequently, surgical management of a progression from discolouration at the bite site, to spreading oedema, blistering, local necrosis and secondary infection required amputation of the digit.

We present a case highlighting bottlenecks on the care chain for a victim of an open traumatic brain injury. Risks of severe complications, infectious in particular, escalate with every hour.

COVID-19 can manifest with signs and symptoms related to many different systems. Therefore, in the examination of almost every patient, COVID-19 infection is excluded first This may cause other diseases to be missed, as almost occurred in the case of a 15-year old boy with brucellosis and a splenic abscess. Public and health care personnel fear of COVID-19 may cause more harm than the virus itself.

Necrotising fasciitis is a dreaded aggressive soft tissue infection that can cause extensive tissue necrosis. It may arise in the breast where its diagnosis may not readily be evoked.

Brucella is the most common zoonosis in the world and is also included among the neglected endemic zoonoses by the World Health Organization. Its clinical presentation is often vague and it is not frequently suspected. A thorough history of social-economic status and animal exposure is often missed. We present a case of abdominal cocoon in a young patient residing at a dairy farm who tested positive for Brucella serology. Timely diagnosis and management prevented the progression of this debilitating condition to intestinal obstruction.

Trans-abdominal penetration by foreign bodies causing bowel injury is uncommon. We present a case of injury to the caecum caused by deliberate trans-abdominal placement of hand sewing needles. The patient was managed successfully by urgent laparotomy with right hemicolectomy and primary anastomosis.

Parameatal urethral cyst (PUC) is a comparatively unusual pathology in children. Since its first report, approximately 100 cases have been reported in the literature, mostly in the Japanese population. We report such a case in a 9-year old boy who presented with urine stream distortion, successfully managed by complete excision of the cyst, with total removal of the epithelium, which is the treatment of choice to prevent recurrence.

Lung herniation, where the lung and its visceral and parietal components protrude outwards from a defect in the chest wall, is not common. It is most commonly secondary to blunt or penetrating trauma. The diagnosis is difficult, as the presentation differs according to aetiology. Ultrasound or CT scanning help in diagnosis and treatment planning. We present a 70-year-old female patient with lung herniation following a cow's kick on the thorax.

Post-malaria neurological syndrome(PMNS) is a rare heterogenous syndrome heralded by the appearance of new neurological or psychiatric manifestations emerging in the post-infectious phase after clearance of malaria parasitaemia. Most cases of PMNS have been described in adults. Only seven cases have been reported in children. We describe two further cases of possible PMNS who presented with prominent psychiatric manifestations evolving into generalized encephalopathy after complete recovery from malaria. Both patients were treated with antivirals and antibiotics without clinical improvement. One patient received pulse corticosteroids and had a remarkable and rapid clinical improvement. The other recovered without specific treatment.

Hepatitis B virus infection is a global problem and causes several liver diseases including acute and chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Though uncommon, some immune mediated extra-hepatic manifestations may develop during the infection. Exudative ascites during HBV infection is one such.

Two cases of visceral leishmaniasis are presented; one patient was from an endemic region and visceral leishmaniasis was suspected clinically, while the other was from a non-endemic region and it was not suspected clinically. Bone marrow examination was negative in both cases and both showed different morphological pictures in the liver biopsies. These are discussed. Importance of travel history is also highlighted even if it is in distant past.

Lumbar spinal or epidural anaesthesia has a lower complication rate compared to general anaesthesia. An occasional patient may develop spinal cord injury during the procedure and develop neurological complications. We report an interesting case of paraparesis due to dorsal spinal cord involvement and syrinx formation following spinal anaesthesia for abdominal surgery.

Primary hyperparathyroidism is not so uncommon a disease. In high-income countries, with the introduction of routine biochemical testing in 1980s, it is diagnosed early, and the majority are seen as asymptomatic disease. However, in India, a severe symptomatic form is still seen, and many times patients are undiagnosed, thus continuing to suffer debilitating disease. Here, we report such a patient who was being treated as having bony metastases from an unknown primary source, when in fact he had osteitis fibrosa cystica due to primary hyperparathyroidism and was cured after surgery.

Chickenpox is a highly contagious disease caused by varicella zoster virus. Fever and papulovesicular rash are hallmarks of this disease. These manifestations are self-liming and complete recovery is seen in most cases. We report two cases of chickenpox infection where the rare and atypical manifestations of acute respiratory distress syndrome with pleural effusion were seen.

Parasitic infections are the leading cause of hypereosinophilia in the paediatric population in tropical countries. We report an unusual case of Toxocara infection in an eight-year-old boy who presented with intermittent fever, hypereosinophilia complicated by massive pericardial effusion and a mycotic aneurysm. This child received treatment with four weeks of albendazole and steroids.

Opsoclonus myoclonus syndrome secondary to scrub typhus infection is a rare clinical entity. Hence, it is important to know its clinical manifestations and complications, so that it can be properly managed. We report a 28-year-old female whose initial manifestation was only fever, which subsided in four days. Two days later, she developed opsoclonus myoclonus syndrome. This was managed with doxycycline and clonazepam, but as it persisted, intravenous immunoglobulin was added. She showed excellent response to treatment.

Neurological side-effects of linezolid manifesting as a posterior reversible leuco-encephalopathy syndrome (PRES) is rare. Early identification of this offending drug might reverse this catastrophic event. We report a 45-year-old female, who was diagnosed as a case of disseminated tuberculosis and was treated with antitubercular drugs (ATT), but later developed ATT-induced hepatitis. She was then put on modified ATT (moxifloxacin, terizidone, and linezolid). In the next two days she developed an altered sensorium. Brain imaging was suggestive of PRES. Linezolid was withdrawn, following which she showed an excellent clinical and radiological recovery.

Chikungunya is a tropical viral disease and can present in the new born with perinatal transmission. Presentation usually mimics sepsis and high index of suspicion is needed for diagnosis specially at times of outbreak. Characteristic skin rash and perioral blotchy hyperpigmentation can point to diagnosis along with laboratory confirmation with RTPCR.

Congenital syphilis occurs due to trans-placental transmission of Treponema pallidum or rarely, intrapartum contact with infectious lesions. Even though preventable, congenital syphilis occurs sporadically in India, owing to lack of antenatal screening as well as the lack of awareness among clinicians about the burden of syphilis in the community. Since a significant overlap of clinical manifestations exists with many systemic diseases, awareness among clinicians is crucial for an early diagnosis. Renomegaly, nephrotic syndrome and nephritis can all be the signs of renal involvement in congenital syphilis, which can provide clues of the diagnosis. Direct invasion by spirochetes, hypersensitivity reactions and immune complex deposition in glomeruli contribute to the pathogenesis. We report a case of congenital syphilis characterised by delayed diagnosis with renal as well as cutaneous manifestations from missed maternal syphilis during the antenatal period and owing to the lack of antenatal screening.

Acute fatty liver of pregnancy (AFLP) and acute pancreatitis are peculiar complications of pregnancy. When acute pancreatitis occurs co-incidentally with acute fatty liver of pregnancy, mortality is high. Here, we report a case of a 22-year-old lady in her 36th week of gestation, who presented with pre-eclampsia, acute fatty liver of pregnancy and acute pancreatitis. She fulfilled six Swansea criteria for diagnosis of AFLP, and the diagnosis of acute pancreatitis was based on clinical suspicion, elevated pancreatic enzymes and the sonographic appearance of a swollen pancreatic head.

Primary varicella infection has typical cutaneous lesions which aid in clinical diagnosis. Infants with transplacental transfer of varicella antibody can have varied cutaneous lesions. We report a 4-month-old infant with primary varicella meningoencephalitis without cutaneous lesions whose mother had no history of varicella during antenatal or post-natal period. Diagnosis was made possible by CSF DNA PCR. Infants with encephalitis pose diagnostic challenge to clinicians in resource limited settings. Varicella encephalitis is one such aetiology for which definitive therapy with Acyclovir is available. CSF PCR is the definitive and cost-effective test for the diagnosis varicella encephalitis. In children with meningoencephalitis it is prudent to add Acyclovir empirically pending CSF viral PCR results.

We present a 36-year-old immuno-compromised male with non-resolving pneumonia, who developed a broncho-pleuro-cutaneous fistula following a thoracoscopic biopsy, which was successfully managed with an ultrasound-guided blood patch placed over the bronchial defect. We discuss the mechanism by which this is presumed to close a fistula, thus justifying it as a cost effective and minimally invasive modality of treatment.

Ralstonia mannitolilytica, an emerging opportunistic pathogen is rarely isolated in neonatal units. We have elaborated our experience of managing its recent septic outbreak affecting four neonates in our intensive care unit over a span of five days. Three of the four had extremely low birth weight and had secondary clinical deterioration in the form of recurrent apnoea requiring intubation. All had thrombocytopenia. Their median age at clinical deterioration was 8 (4–12) days. The organism was multidrug resistant, but uniformly sensitive to flouroquinolones and co-trimoxazole, on which all recovered. Environmental samples were negative for the organism. There were no further positive cases. Early recognition and appropriate choice of drug will aid in fast recovery.

We read with interest the short report by Rani et al. entitled “An uncommon variant of erythema nodosum leprosum responding well to methotrexate: Report of two cases.” The article describes two cases of erythema nodosum leprosum (ENL) with ‘atypical features’ and good response to low dose methotrexate. The authors address a few concerns regarding methotrexate in ENL, emphasizing the rational usage of this agent.