The Journal of Infection in Developing Countries <p>A peer-reviewed open access journal, focusing on global health.</p> The Journal of Infection in Developing Countries en-US The Journal of Infection in Developing Countries 1972-2680 <p>Authors who publish with this journal agree to the following terms:</p> <ol type="a"> <li>Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a <a title="Creative Commons Attribution License" href="" target="_new">Creative Commons Attribution License</a> that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.</li> <li>Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.</li> <li>Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See <a title="The Effect of Open Access" href="" target="_new">The Effect of Open Access</a>).</li> </ol> Health care-associated infection surveillance: A prospective study of a tertiary neonatal intensive care unit <p>Introduction: Health care-associated infection (HCAI) is a serious problem of neonatal intensive care units (NICUs) which is related to morbidity, mortality and increased cost of medical care. This study aimed to determine the incidence of HCAI in a tertiary NICU and identify the risk factors.</p> <p>Methodology: This prospective cohort study was conducted between July 1, 2011 and June 30, 2012. All newborns admitted to the NICU except for those who died or were discharged within 48 hours after admission were included. The definitions of Centers for Disease Control and Prevention (CDC) were used to diagnose specific types of infections. The incidence, causative organisms, risk factors and mortality of HCAIs were evaluated.</p> <p>Results: Among 352 newborns, a total of 60 HCAI episodes were evaluated in 37 (10.5%) of the patients over 5,212 patient-days. The overall incidence of HCAI was 17%, and the rate was 11.5/1,000 patient-days. Blood stream infection (BSI) was the most common HCAI (n = 42, 70%). In a multivariable logistic regression analysis, the presence of a central venous catheter/umbilical catheter (CVC/UC), the presence of a urinary catheter, and gestational age (&lt; 32 weeks of gestation) were identified as significant independent risk factors. Gram-negative pathogens were the most common isolates. The overall mortality rate was 4%. The HCAI-related mortality rate was 10.8%.</p> <p>Conclusions: Patient care quality can be improved with surveillance of HCAI. The incidence and rate of HCAI in our NICU were found to be higher than international reports with a direct impact on mortality of preterm infants.</p> Atila Kilic Emel Okulu Bilge Aldemir Kocabas Serdar Alan Ufuk Cakir Duran Yildiz Dilek Kahvecioglu Ilke Mungan Akin Omer Erdeve Saadet Arsan Erdal Ince Begum Atasay ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 181 187 10.3855/jidc.10688 Microbiological safety and hygienic quality of camel meat at abattoir and retail houses in Jigjiga city, Ethiopia <p>Introduction: Camel meat is a relatively new, emerging meat type that may serve as sources of foodborne pathogens to the consumer.</p> <p>Methodology: A cross-sectional study was conducted to determine the microbiological safety and quality of camel meat from an abattoir and retail houses in Jigjiga city, Ethiopia. A total of 140 camel carcass and retail meat samples (70 each) were examined for the presence and load of <em>Staphylococcus aureus</em>, <em>Escherichia coli</em> O157: H7, <em>Listeria monocytogenes</em>, <em>Campylobacter </em>spp., aerobic bacteria, fecal coliforms (FCs), and yeast and molds (Y&amp;Ms). Presumptive isolates were confirmed using biochemical tests.</p> <p>Results: <em>S. aureus</em> and<em> E. coli</em> O157: H7 populations varied widely between carcasses at the abattoir and retail meat samples. <em>S. aureus</em> and <em>E. coli</em> O157:H7 were detected in 12.1 and 4.3% of the samples, respectively. <em>E. coli </em>O157:H7 counts were significantly higher in retail meat (4.21 ± 0.02) compared to the carcasses (3.99 ± 0.00) at the abattoir (P &lt; 0.05). Out of 140 samples analyzed, 5% were positive for <em>Campylobacter </em>spp. The mean fecal coliforms, and yeast and molds counts were significantly higher in retail meat samples (6.17 ± 0.067 and 4.95 ± 0.067 log10 cfug<sup>-1</sup>, respectively). <em>L. monocytogenes</em> (11 cfug<sup>-1</sup>) were detected below the permissible limit (100 cfug<sup>-1</sup>).</p> <p>Conclusions: This study indicated that the further the process progress, the greater the risk of contamination to the product. Therefore, good hygienic practices at the abattoir and retail houses and strict slaughtering process should be prompted to enhance the overall safety and quality of camel meat.</p> Henok Ayalew Tegegne Amare Berhanu Yitbarek Getachew Biresaw Serda Dagmar Nölkes Sissay Tilahun Berhanu Sibhat ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 188 194 10.3855/jidc.9686 Presence of virulence factors and antibiotic resistance among Escherichia coli strains isolated from human pit sludge <p>Introduction: In Bangladesh, human sludge from dry pit latrines is commonly applied directly to agricultural lands as manure. This study was conducted to investigate the presence of antibiotic resistance, virulence factors and plasmid contents of <em>E. coli</em> strains isolated from sludge samples.</p> <p>Methodology: <em>E. coli</em> were isolated from human feces from closed pit latrines and identified by culture method. Antibiotic susceptibility patterns of the isolates were determined by Standard Kirby-Bauer disk diffusion method. Pathogenic genes and antibiotic resistance genes of ESBL producing isolates were determined by PCR assay.</p> <p>Results: Of the 34 samples tested, 76.5% contained <em>E. coli</em>. Of 72 <em>E. coli</em> isolates, 76.4% were resistant to at least one of the 12 antibiotics tested and 47.2% isolates were resistant to three or four classes of antibiotics. Around 18% isolates were extended spectrum β- lactamase producing and of them 6 were positive for <em>bla</em><sub>TEM</sub> specific gene, 4 for <em>bla</em><sub>CTX-M</sub> gene, 1 for <em>bla</em><sub>OXA</sub> gene and 2 for both <em>bla</em><sub>TEM</sub> and <em>bla</em><sub>CTX-M</sub> genes. Moreover, among 72 isolates, 4.2% carried virulence genes of enterotoxigenic <em>E. coli</em>; two isolates were positive for <em>st</em> and one was positive for both <em>st</em> and <em>lt</em> genes. In addition, 59.7% of the isolates contained plasmids (range 1.4 to 140 MDa) of which 19.5% isolates contained a single plasmid and 40.2% contained multiple plasmids.</p> <p>Conclusions: The presence of pathogenic, drug resistant <em>E. coli</em> in human sludge necessitates a regular surveillance before using as a biofertilizer.</p> Zahid Hayat Mahmud Farozaan Fatima Shirazi Muhammad Riadul Haque Hossainey Mohammad Imtiazul Islam Mir Alvee Ahmed Tanvir Noor Nafiz Khan Mohammad Imran Jinath Sultana Md Shafiqul Islam Mohammad Aminul Islam Md Sirajul Islam ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 195 203 10.3855/jidc.10768 Epidemiology and costs of severe acute respiratory infection and influenza hospitalizations in adults with diabetes in India <p>Introduction: The incidence of diabetes mellitus is increasing rapidly in India. In addition to well-known complications, diabetes increases the risk for hospitalization and death from severe acute respiratory infection (SARI) and influenza. Here we examined the impact of SARI and influenza in Indian adults with diabetes.</p> <p>Methodology: This was a single-center, active surveillance study conducted in Jammu and Kashmir State, India, during the 2015–2016 and 2016–2017 influenza seasons. Adults hospitalized for SARI and receiving at least one diabetes medication were included. Demographics, health care use, and direct costs were collected from medical records and interviews of patients or caregivers. Indirect costs were estimated based on lost earnings and WHO-CHOICE estimates for hospital costs.</p> <p>Results: The study included 192 patients with type 2 diabetes. Median age was 66 years, median body mass index was 26.6 kg/m<sup>2</sup>, and most patients had comorbidities, especially hypertension and cardiovascular disease (83.9%). Only 32.2% regularly monitored blood glucose or hemoglobin A1C, and median values at admission indicated poor glycemic control for most. Influenza was detected in 8.9% of cases. The median hospital stay for SARI was 8 days, and 22 patients (11.4%) died. Median total costs associated with hospitalization were US$710 (interquartile range, $539–$1067) for SARI patients and US$716 ($556–$1078) for influenza patients, mostly (~75%) from indirect costs.</p> <p>Conclusions: Adults with diabetes in India hospitalized with SARI or influenza are generally older, in poor health, and suffer from poor glycemic control. The costs for their hospitalization and care are substantial.</p> Parvaiz A Koul Amit Bhavsar Hyder Mir Mark Simmerman Hemant Khanna ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 204 211 10.3855/jidc.10903 Surgical site infection incidence and risk factors in thoracic surgical procedures: A 12-year prospective cohort study <p>Introduction: Surgical site infections (SSI) continue to be a major problem for thoracic surgery patients. We aimed to determine incidence rate (IR) and risk factors for SSI in patients with thoracic surgical procedures.</p> <p>Methodology: During 12 years of hospital surveillance of patients with thoracic surgical procedures, we prospectively identified SSI. Patients with SSI were compared with patients without SSI.</p> <p>Results: We operated 3,370 patients and 205 (6.1%) developed SSI postoperatively. We detected 190 SSI among open thoracic surgical procedures (IR 7.1%) and 15 SSI after video-assisted thoracic surgery (IR 2.1%). Five independent risk factors for SSI were identified: wound contamination (p = 0.013; relative risk (RR) 2.496; 95%, confidence interval (CI): 1.208-5.156), American Society of Anesthesiologist (ASA) score (p = 0.012; RR: 1.795; 95% CI: 1.136-2.834), duration of drainage (p &lt; 0.001; RR: 1.117; 95% CI: 1.085-1.150), age (p = 0.036; RR: 1.018; 95% CI: 1.001-1.035) and duration of operation (p &lt; 0.001; RR:1.005; 95% CI:1.002-1.008).</p> <p>Conclusion: The results are valuable in documenting risk factors for SSI in patients undergoing thoracic surgery. The knowledge and prevention of controllable risk factors is necessary in order to reduce the incidence of SSI.</p> Vlado S Cvijanovic Aleksandar S Ristanović Nebojsa T Maric Natasa V Vesovic Vanja V Kostovski Ljubinko V Djenic Dejan V Stojkovic Aleksandar S Nikolic Dragan M Djordevic Vesna D Suljagic ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 212 218 10.3855/jidc.11240 Pitfalls in diagnosis and management of suspected urinary tract infection in an urban tropical primary care setting <p>Introduction: Diagnosis and management of urinary tract infection (UTI) are complex, and do not always follow guidelines. The aim of this study was to determine adherence to the 2014 Malaysian Ministry of Health guidelines for managing suspected UTI in a Malaysian primary care setting.</p> <p>Methodology: We retrospectively reviewed computerized medical records of adults with suspected UTI between July-December 2016. Excluded were consultations misclassified by the search engine, duplicated records of the same patient, consultations for follow-up of suspected UTI, patients who were pregnant, catheterised, or who had a renal transplant. Records were reviewed by two primary care physicians and a clinical microbiologist.</p> <p>Results: From 852 records, 366 consultations were a fresh episode of possible UTI. Most subjects were female (78.2%) with median age of 61.5 years. The major co-morbidities were hypertension (37.1%), prostatic enlargement in males (35.5%) and impaired renal function (31.1%). Symptoms were reported in 349 (95.4%) consultations. Antibiotics were prescribed in 307 (83.9%) consultations, which was appropriate in 227/307 (73.9%), where the subject had at least one symptom, and leucocytes were raised in urine full examination and microscopic examination (UFEME). In 73 (23.8%) consultations antibiotics were prescribed inappropriately, as the subjects were asymptomatic (14,4.6%), urine was clear (17,5.5%), or UFEME did not show raised leucocytes (42,13.7%). In 7 (2.3%) consultations appropriateness of antibiotics could not be determined as UFEME was not available.</p> <p>Conclusion: Several pitfalls contributed to suboptimal adherence to guidelines for diagnosis and management of suspected UTI. This illustrates the complexity of managing suspected UTI in older subjects with multiple co-morbidities.</p> Alison A Jackson Pauline Siew Mei Lai Aqtab Mazhar Alias Nadia Atiya Siti Nurkamilla Ramdzan Tun Firzara Abdul Malik Fadzilah Hanum Mohd Mydin Haireen Abd Hadi Sajaratulnisah Othman ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 219 226 10.3855/jidc.11089 Impact of PCV7 vaccination on nasopharyngeal carriage and antimicrobial resistance among children in Turkey <p>Introduction: We aimed to evaluate the effects of 7-valent pneumococcal conjugate vaccine on nasopharyngeal carriage of <em>Streptococcus pneumoniae </em>and antibiotic resistance in children in a well-child clinic in a tertiary children’s hospital in Turkey.</p> <p>Methodology: We collected nasopharyngeal (NP) specimens from 557 two-month-old babies before vaccination. After the study population had received PCV7, NP samples were obtained from 135 babies. Antimicrobial susceptibility testing and serotyping were performed.</p> <p>Results: <em>S. pneumoniae</em> colonized in 48 (8.6%) of the 557 two-month-old babies before vaccination. The follow-up cohort consisted of 135 subjects. The prevalence of PCV7 strain decreased from 33.3% to 19.3% after vaccination. However, non-PCV7 types increased from 66.6% to 80.6% (p = 0.02). Of PCV7 serotypes, 19F was the most frequent serotype before and after vaccination. There was an increase in 6A and 15 of non-PCV7 serotypes after vaccination. Penicillin non-susceptible increased from 56.3% to 80.6% after vaccination (p =0.03). Serotypes 14, 18C, 9V and 6B, which were identified before vaccination, never colonized afterwards. Number of siblings and having sibling with older age of five were determined to be significant effective factors for SP colonization presence after vaccination and antibiotic use was negatively associated with pneumococcal carriage but associated with penicillin non-susceptibility.</p> <p>Conclusions: Nasopharyngeal carriage rate of <em>S. pneumoniae</em> dropped after PCV7 vaccination, and replacement by NVT pneumococci were also observed. Risk factors for nasopharyngeal carriage included household crowding and having a sibling age five years or older. Penicillin non-susceptibility increased in both VT and NVT strains.</p> Basak Kaya Gursoy Ufuk Beyazova Melahat Melek Oguz Filiz Demirel Secil Ozkan Nedim Sultan Selin Nar Otgun ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 227 232 10.3855/jidc.10833 Dengue in the campus community of an overseas American university: A cross-sectional study <p>Introduction: After a large outbreak of dengue virus (DENV) serotype-3 in Saint Kitts and Nevis (SKN) in 2008, we performed a cross-sectional study to determine the prevalence of anti-DENV immunoglobulin G (IgG) antibodies in expatriate and local persons affiliated with an American veterinary school there.</p> <p>Methodology: This campus community comprised mostly expatriate students and faculty and Kittitian administrative staff. In 2009, a stratified random sample of students, faculty and staff was invited to complete an electronic survey to assess risk factors for DENV and provide blood for testing for anti-DENV IgG antibodies by an enzyme-linked immunosorbent assay. IgG-positive specimens were also tested by a 90% plaque reduction neutralization test (PRNT<sub>90</sub>) to determine immunoreactivity to DENV (1-4) serotypes and West Nile virus. Risk factors for anti-DENV IgG seropositivity were determined using simple and adjusted logistic regression.</p> <p>Results: Of the 118 participants, the overall prevalence of DENV IgG antibodies was 44.1% (95% confidence interval [CI]: 35.1-53.0%), ranging from 30.1% in students, 100.0% in staff and 57.9% in faculty (<em>p</em> &lt; 0.001). Duration of residence in St. Kitts was the only variable significantly associated with seropositivity on multiple logistic regression (adjusted odds ratio [95% CI]: 1.21 [1.07-1.37]). The serotype of DENV was determined in 11 persons: DENV-1 (n = 4), DENV-2 (n = 3), and DENV-3 (n = 4).</p> <p>Conclusions: Expatriate students and faculty moving to St. Kitts from non-endemic areas were at high risk of DENV infection. There is a need for increased emphasis on pre-travel mosquito-borne virus prevention education for persons moving to St. Kitts to study and work.</p> Hamish Mohammed Mary H Hayden Elise Lee Luis M Santiago Rosina C Krecek Floyd Revan Elizabeth Hunsperger ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 233 239 10.3855/jidc.10701 In vitro anti-Trichomonas vaginalis activity of Haplophyllum myrtifolium <p>Introduction: In the classic treatment of <em>Trichomonas vaginalis</em> infection, although metronidazole has been used since the 1960s, there has been an increase in MTZ-resistant <em>T. vaginalis</em> strains and failure in the treatment of trichomoniasis causes serious concerns. Therefore, the present study aimed to investigate the <em>in vitro</em> antitrichomonal activities of extracts (ethanol and total alkaloid) and pure compounds (chrysosplenetin, dictamnine, gamma-Fagarine, skimmianine) of <em>H. myrtifolium</em> against <em>T. vaginalis</em>.</p> <p>Methodology: <em>H. myrtifolium</em> was collected from the town of Honaz in Denizli, located in the Aegean region of Turkey, and preparation of extracts and isolation and structure elucidation of pure compounds were performed. Later, different concentrations of extracts and pure compounds were incubated with <em>T. vaginalis</em> trophozoites isolated from Turkey, which are known to be sensitive to metronidazole.</p> <p>Results: It was found that ethanol extract caused a more effective lysis on <em>T. vaginalis</em> trophozoites compared with total alkaloid extract (P &lt; 0.05). No compounds except for furoquinoline alkaloid skimmianine prepared above 37.5 µg/mL were found to have any inhibitory effect on <em>T. vaginalis</em> trophozoites.</p> <p>Conclusion: The ethanol extract of <em>H. myrtifolium</em> and skimmianine can be considered as potential candidates for antitrichomonal drug development.</p> Aysegul A Gokmen Hüseyin Can Hüsniye Kayalar Bayram Pektaş Selçuk Kaya ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 240 244 10.3855/jidc.10854 In-vitro activity of tigecycline and comparator agents against common pathogens: Indian experience <p>Introduction: Tigecycline Evaluation and Surveillance Trail (TEST) study is an on-going global surveillance. The study was performed to determine the susceptibility of common pathogens to tigecycline and comparator antibiotics by broth microdilution (BMD) at two tertiary care centres in India from 2015 to 2017.</p> <p>Methodology: Total of 989 isolates collected from various clinical specimens between January 2015 and September 2017 from two centres in India were included. BMD was performed to determine the minimum inhibitory concentration (MIC) for tigecycline and comparator antibiotics.</p> <p>Results: Among Gram-negative bacteria, susceptibility to tigecycline was lowest among <em>Klebsiella </em>spp. being 84% while others such as <em>E. coli</em>, <em>Enterobacter</em> spp., <em>Serratia</em> spp. and <em>H. influenzae</em> showed susceptibility of 98%, 95%, 98% and 100% respectively. Overall, 99 isolates among <em>Enterobacteriaceae </em>(<em>E. coli, Klebsiella spp</em>. and <em>Enterobacter</em> spp.) were ESBL producers, susceptible to tigecycline. Among the 101 meropenem resistant <em>Enterobacteriaceae</em>, 85 were susceptible to tigecycline (84%). Among the Gram-positive bacteria, <em>S. aureus</em> and <em>Enterococcus</em> spp. were 99% and 98% susceptible to tigecycline respectively. Among 68 MRSA isolates in the study, 66 (97%) were susceptible to tigecycline. Seven vancomycin resistant <em>E. faecalis</em> were isolated and all were susceptible to tigecycline.</p> <p>Conclusion: Tigecycline has retained activity over both Gram-positive and Gram-negative organisms with MIC values comparable to global reports. About 98% of the MDR Gram-positive and Gram-negative bacteria in the study are susceptible to tigecycline. With increased incidence of extensively drug resistant organisms, tigecycline is a potential reserve drug.</p> Balaji Veeraraghavan Aruna Poojary Chaitra Shankar Anurag Kumar Bari Seema Kukreja Bhuvaneswari Thukkaram Ramya Gajaraj Neethimohan Yamuna Devi Bakhtavachalam Shweta Kamat ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 245 250 10.3855/jidc.10376 Effect of aminophylline on the pharmacokinetics of amikacin in Sprague-Dawley rats <p>Introduction: In most resource-poor settings, amikacin is normally co-administered with aminophylline among preterm newborns with infection and apnea of prematurity. There is the likelihood of an interaction between concurrently administered amikacin that is excreted almost solely via kidneys, and aminophylline, which is known to increase filtration fraction. The aim of this study was to evaluate the effect of aminophylline on the pharmacokinetics of amikacin using an animal model.</p> <p>Methodology: Twelve male Sprague-Dawley rats (7 – 8 weeks old) were put into 2 equal groups. The test group received amikacin (10 mg/kg/day) with aminophylline (5 mg/kg/day) via the intraperitoneal route, and the control group received only amikacin (10 mg/kg/day) via the same route. On Day 4, after daily administration of drugs, tail vein blood samples were collected at different time points. Serum samples at each time point for each group were pooled and analyzed by fluorescence polarization immunoassay. Non-compartment pharmacokinetic analysis was used to estimate pharmacokinetic parameters. Area under the concentration-time curves (AUCs) were extrapolated from time 0 to infinity (AUC<sub>0→∞</sub>). Elimination rate constant (K<sub>e</sub>) and elimination half-life (t<sub>1/2e</sub>) were also estimated.</p> <p>Results: Pharmacokinetic parameters of the control group (amikacin only) <em>vis-a-vis</em> the test group were as follows: C<sub>max</sub>; 42.4 μmol/L <em>vs</em> 19.0 μmol/L, AUC<sub>0→∞</sub>; 84.9 μmol/L/h <em>vs</em> 41.4 μmol/L/h<sub>, </sub>K<sub>e</sub>; 0.12 hours<sup>-1 </sup><em>vs</em> 0.24 hours<sup>-1</sup>, and t<sub>1/2</sub>; 5.87 hours <em>vs</em> 2.88 hours, respectively.</p> <p>Conclusion: This study suggests possible interaction between aminophylline and amikacin. However, further studies need to be conducted in humans to ascertain this finding.</p> Seth Kwabena Amponsah Kwabena Frimpong-Manso Opuni Kwabena Aboagye Antwi Victor Pouzuing Kunkpeh ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 251 254 10.3855/jidc.10514 Booster immunity – diagnosis of chronic hepatitis B viral infection <p>Introduction: Diagnosis of chronic hepatitis B virus (HBV) infection particularly its occult form requires monitoring and repeat serological and molecular studies. The aim of the study was to investigate the possible relation between the case of a family outbreak of hepatitis A and the finding that a member of this family was diagnosed with chronic hepatitis B.</p> <p>Methodology: A mother and her two sons, one previously diagnosed with chronic HBV infection, were hospitalized due to suspected acute hepatitis. Serological markers for hepatitis A, hepatitis B and hepatitis C were assessed. Additionally, HBV DNA was tested with a sensitive PCR. Hepatitis B vaccine was administered to the mother to differentiate resolved from occult HBV infection.</p> <p>Results: A family outbreak of hepatitis A was confirmed, alongside a focus of chronic HBV infection. The serological profile for two brothers was HBsAg(+), anti-HBcIgM(-), anti-HBc(+), HBcAg(-)/anti-HBe(+). The mother was negative for all HBV markers except anti-HBc. HBV DNA was detected at a level of 461 IU/mL in the elder brother, 3647 IU/mL in the younger brother and was negative in the mother on two occasions. Her anti-HBc alone, having two sons with chronic HBV infection, and her lack of antibody response to hepatitis B vaccine despite being negative for HBV DNA, led to the diagnosis of probable occult HBV infection.</p> <p>Conclusion: Our results confirmed that a vaccination approach could facilitate diagnosis of chronic HBV infection in the presence of isolated anti-HBc. If it were not for a family outbreak of hepatitis A, this unexpected family HBV focus would not have been revealed.</p> Radka T Komitova Ani K Kevorkyan Maria V Atanasova Aneta V Ivanova Elica Golkocheva-Markova ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 255 260 10.3855/jidc.9929 Pulmonary and testicular tuberculosis in one patient caused by Mycobacterium tuberculosis with different genotypes <p>Extrapulmonary tuberculosis (EPTB) accounted for 14% of 6.4 million cases of TB that were reported to WHO in 2017, and genitourinary TB (GUTB) is the second most common type of EPTB. The most common site of GUTB is the kidneys and testicular TB is relatively rare. The case of one patient with pulmonary and testicular TB caused separately by two different genotypes of <em>Mycobacterium tuberculosis</em> (<em>Mtb</em>) is further rare. Here, we present an unusual case of TB in which pulmonary TB (PTB) and testicular TB were caused by <em>Mtb</em> isolates with two different genotypes in a 91-year-old male patient from Zunyi, Guizhou Province of China. A better understanding of the mechanism by which a small number of tubercle bacilli are spread from the primary site of PTB to more distant parts/organs of the body, and what factors determine the potential EPTB site will provide us with new ways to prevent and control EPTB infections.</p> Yuanbo Lan Ling Chen Hong Zhang ##submission.copyrightStatement## 2019-03-31 2019-03-31 13 03 261 264 10.3855/jidc.11063