Letters type G9, which was earlier considered uncommon worldwide, accounted for 23.7% of cases and was the third most prevalent one. Along with G genotypes, they reported the presence of P[4], P[6] and P[8] genotypes. Das et al 5 reported G1 as the most prevalent type, as observed by us. They found G1 P[8] accounting for 20% followed by G2 P[4] at 15% and G[4] P[8] at 6% of the typeable strains. Even though primers for the most prevalent types were included in their study, 24% of strains remained untypeable. We conclude that, along with the four common types G1-G4, other types of rotavirus are present in this region. Knowledge of the prevalence of genotypes would help in better epidemiological surveillance and formulation of better vaccines. Anita Chakravarti, Rajni Kumaria, Arpita Chakravarti Department of Microbiology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi 110 002 References 1.
2.
3.
4.
5.
Jain V, Das BK, Bhan MK, Glass RI, Gentsch JR, The Indian Strain Surveillance Collaborating Laboratories. Great diversity of group A rotavirus strains and high prevalence of mixed rotavirus infections in India. J Clin Microbiol 2001;39:3524-9. Chakravarti A, Broor S, Natarajan R, Setty VS, Mittal SK. Epidemiological and clinical characteristics of acute diarrhoea in children due to human rotavirus. J Trop Paediatr 1992;38:1-2. Tam JS, Kum WWS, Lam B, Yeung CY, Ng MH. Molecular epidemiology of human rotavirus infection in children in Hong Kong. J Clin Microbiol 1986;23:660-4. Gouvea V, Glass RI, Woods P, Taniguchi K, Clark HF, Forrester B, et al. Polymerase chain reaction amplification and typing of rotavirus nucleic acid from stool specimens. J Clin Microbiol 1990;28:276-82. Das S, Sen A, Uma G, Varghese V, Chaudhuri S, Bhattacharya SK, et al. Genomic diversity of Group A rotavirus strains infecting humans in eastern India. J Clin Microbiol 2002;40:146-9.
Correspondence to: Dr Anita Chakravarti, Professor of Microbiology, H. No. D-79, South Park Apartments, Kalkaji, New Delhi 110 019. E-mail:
[email protected]
Acute viral hepatitis in third trimester of pregnancy Abortions, intra-uterine deaths and pre-term labor have been reported to be more frequent in pregnant women with acute viral hepatitis (AVH). 1,2 Vertical transmission of hepatitis E virus (HEV) from mother
to child is also known. 3,4 We studied the etiological spectrum of AVH among pregnant women and the obstetric outcome in such women. Between April 2001 and May 2004, we recruited 71 consecutive pregnant women in the third trimester who had AVH. Diagnosis of AVH was based on clinical history and at least 5-fold serum ALT elevation. Patients with fulminant hepatic failure were excluded. Apart from liver function profile, serological tests, including anti-HAV IgM (MHAV Ab EIA; Murex Diagnostics, England), HBsAg (Eliscaan Microelisa; Ranbaxy, Delhi), anti-HBc IgM (MHBc EIA; Murex), anti-HCV antibodies (Innotest HCV EIA Ab III; Innogenetics NV, Belgium), anti-HEV IgM (Genelabs Diagnostics, Singapore) and HEV RNA (in-house reverse transcription-polymerase chain reaction), were done. HEV infection was diagnosed if anti-HEV IgM or HEV RNA or both tested positive. Patients were treated conservatively and followed up till delivery. Cord blood, collected at the time of delivery, was also tested for the above serological markers; for 22 infants during the latter part of the study, infant blood was tested instead of cord blood, since reports became available suggesting that the latter may be contaminated with maternal blood. The mean (SD) age of the study subjects was 24.2 (4.9) years and gestational period was 34.2 (2.1) weeks. The frequency of serological markers of infection with various viral agents was as follows: HAV 1 (1.4%), HBV 4 (5.6%), HCV none, HEV 24 (33.8%); 38 (53.5%) patients lacked all the markers. In addition, four patients had infection with multiple agents; this included HAV+HBV in 1 patient (1.4%), HBV+HEV in 2 (2.8%), and HCV+HEV in 1 (1.4%). Overall, 27 (38%) of our pregnant patients had HEV infection; this was similar to data from previous Indian studies (40%-57%). 5,6 Fifty-eight women were followed up till delivery. None had evidence of coagulopathy. In 12, hepatitis had recovered by the time of delivery and they delivered at term. Thirty patients (51.7%) had preterm labor (before 37 weeks of gestation). Fiftyfive women had vaginal delivery and 3 had uneventful caesarean section for obstetric indications. There was no maternal mortality. Four babies (6.9%) were still-born, including an anencephalic child born to a mother with HEV infection. Cord or infant blood had evidence of HEV infection in 8 infants born to mothers with HEV infection. One of 4 infants born to an HBV-infected mother had HBV infection; no infant had HAV infection.
128 Indian Journal of Gastroenterology 2005 Vol 24 May - June
Letters Khuroo et al 3 observed vertical transmission of HEV in 5 of 8 infants born to HEV-infected pregnant women. In a study from the UAE, HEV RNA in cord or infant blood was observed in all 26 babies born to HEV RNA-positive mothers. 4 In our previous study, vertical transmission was observed in onethird of cases. 7 Neonatal HEV infection is associated with complications like anicteric hepatitis, hypothermia, hypoglycemia and neonatal deaths. 3,4 We conclude that HEV is a common cause of acute hepatitis in pregnant women and can be transmitted vertically. Mona Dahiya, Ashok Kumar, P Kar,* R K Gupta, Ajay Kumar** Departments of Obstetrics and Gynecology, *Medicine and **Pediatrics, Maulana Azad Medical College, New Delhi References 1. 2.
3. 4.
5. 6.
7.
Mirghani OA, Aeed OK, Basama FM. Viral hepatitis in pregnancy. East Afr Med J 1992;69:445-9. Desilva HJ, Jayawardena J, Pethiyagoda AV, Sirisena JL. Viral hepatitis complicating pregnancy – 5-year hospitalbased retrospective study. Ceylon Med J 1993;38:15-7. Khuroo MS, Kamilli S, Jameel S. Vertical transmission of hepatitis E virus. Lancet 1995;315:1025-6. Kumar RM, Uduman S, Rana S, Kochiyil JK, Thomas L. Seroprevalence and mother to infant transmission of hepatitis E virus among pregnant women in United Arab Emirates. Eur J Gynaecol Reprod Biol 2001;10:9-15. Jaiswal SPB, Jain AK, Naik G, Soni N, Chitnis DS. Viral hepatitis during pregnancy. Intl J Gynecol Obstet 2001;72:103-8. Singh S, Mohanty A, Joshi YK, Dwivedi SN, Deka D. Outcome of hepatitis E virus infection in Indian pregnant women admitted to a tertiary care hospital. Indian J Med Res 2001;113:35-9. Kumar A, Beniwal M, Kar P, Sharma JB, Murthy NS. Hepatitis E in pregnancy. Intl J Gynaecol Obstet 2004;85:240-4.
Correspondence to: Dr Ashok Kumar, 13-B, DDA Flats, Ber Sarai, New Delhi 110 016. E-mail:
[email protected]
Is sentinel node mapping useful in colorectal carcinoma? There is substantial evidence that adjuvant systemic chemotherapy improves survival in patients with Duke C colorectal cancers.1 Accurate identification of lymph nodes involved by metastases is thereby of vital importance as it facilitates decision-making with regard to adjuvant systemic therapy. Understaging of colorectal cancer specimens is common when using standard surgical and pathological techniques. 2 Sentinel lymph node biopsy, although accepted in breast malignancies and melanomas, has not caught on in colorectal
carcinoma. Unlike in carcinoma of breast and melanoma, the role of sentinel node biopsy in colorectal cancer is not to decide on the extent of lymphadenectomy but to increase the histological yield of positive lymph nodes following standard radical resection. Nine patients operated on for curable colorectal cancer from February 2004 to July 2004 were studied. The cancers were documented by colonoscopic biopsy and staged by contrast helical CT scan of the abdomen. Patients with liver metastasis, ascites or peritoneal deposits were excluded from the study. Under general anesthesia, 0.5 mL to 1 mL of Lymphazurin ® dye was injected into the subserosa of the tumor. Two patients underwent laparoscopic colonic resection and seven underwent open surgery. Resection was performed in the standard radical fashion. All specimens were sent for routine hematoxylin-eosin staining examination. All lymph nodes were retrieved from the specimen. Blue-stained nodes seen during pathologic examination were considered as sentinel nodes and the rest were defined as nonsentinel nodes. We followed the ADASP recommendations for processing of lymph node specimens.3 No special techniques such as immunohistochemistry or polymerase chain reaction (PCR) were used. A total of 127 nodes were removed from the specimens (median 14 per case). Six of 9 patients had successful sentinel node mapping by the pathologist, two of which were obvious during surgery owing to the bluish hue of the nodes. In two of these six cases, sentinel nodes demonstrated tumor deposits whilst the nonsentinel nodes were histologically normal. In the remaining 4 cases, sentinel and nonsentinel nodes were negative for tumor deposits. The diameter of the sentinel nodes ranged from 0.3 cm to 1 cm (mean [SD] 0.6 [0.2] cm) whilst the nonsentinel nodes ranged from 0.2 cm to 2.5 cm (1.2 [0.6] cm) (two-tailed p=0.001; MannWhitney U test). Theoretically, sentinel lymph nodes, the first draining nodes, are most likely to harbor metastasis. If these nodes are small they are liable to be missed by the pathologist. Sentinel lymph node mapping will help in drawing attention to these nodes. In this study, the sentinel nodes were significantly smaller than nonsentinel nodes. It is consequently likely that they might have been overlooked at routine processing, although we do not have evidence for this. This becomes more relevant where facilities for immunohistochemistry and PCR technology are not accessible. Detection of malignant involvement of lymph
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