Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411121EnglishN2019November9HealthcarePhenomenological Study on Lived Experiences of Patients Undergoing Radiation Therapy in a Selected Hospital, Calicut
English0104Sheeja CVEnglish Assuma Beevi TMEnglish Maryelizabeth TidiyaEnglish Theertha P KrishnanEnglishIntroduction: Radiation therapy involve the use of ionizing radiation rays to cure or improve symptoms of cancer by damaging DNA of that cell. Radiation therapy is used for treating different types of cancers effectively. Patients undergoing radiation therapy are having physical & psychological discomfort and cause difficulties in doing their daily living activities. Identifying the experiences of patients will help the health care team to plan the patient care efficiently.
Aim and Objective: The purpose of the study was to explore the lived experience of patients undergoing Radiation therapy to attain a realistic view of difficulties after exposure to Radiation therapy.
Research Design: Descriptive phenomenological research design was selected by the researcher to disclose the lived experience of patients undergoing Radiation therapy.
Method: Semi-structured interviewschedule with a purposive sample of 10 patients undergoing Radiation therapy were conducted. Verbatim transcripts were analyzed by using Descriptive phenomenological Analysis.
Results: Five super-ordinated themes were emerged from the analysis are living with physical discomfort, pain, emotional disturbances, psychosocial difficulties,unable to do daily activities. The sub themes for living with physical discomfort include nausea, vomiting & dyspnea, for emotional disturbances include feeling dejected& unable to cope up with any stress and for psychosocial difficulties are not willing to mingle in social gatherings and feeling bad for taking help from others in doing their day to day activities.
Conclusion: Physical & psychological discomfort of the study participants who are undergoing Radiation therapy were identified through their Lived experience. Sudden changes in their living style caused due to Radiation therapy have increased the physical and psychological impact in their life.
Relevance to clinical practice: It is important to identify physical, emotional and psychosocial issues faced by the patients undergoing Radiation therapy enable the health care team to plan and give individualized care. Exploring the lived experience of patients wouldmake it possible to provide planned nursing care to patients undergoing Radiation therapybased on their needs.
EnglishRadiation Therapy, Living ExperienceIntroduction
Cancer is characterized by development of abnormal cells in the body. These cells have the ability to divide uncontrollably and infiltrate & destroy the body tissues. The treatment for cancer is differed depending on the type, location and stage of cancer. This include surgery, radiation therapy, chemotherapy, hormone therapy and immunotherapy. The diagnosis of Cancer is done along with a thorough physical examination and a complete medical history.
Cancer has the ability to spread throughout body. 90–95% of cancers are occurring from genetic mutations and 5–10% are from inherited genetic reasons. Common environmental factors include tobacco use (25–30%), diet and obesity (30–35%), infections (15–20%), radiation (both ionizing and non-ionizing up to 10%) and the remaining are from stress, lack of physical activity and pollution. 1
The environment contributing to cancer refers not only to air, water, and soil but also to the substances and conditions at home and workplace, including diet, smoking, alcohol, drugs, exposure to chemicals, sunlight, ionizing radiation, electromagnetic fields and infectious agents.2 Lifestyle, economic and behavioral factors are all aspects of the environment that is causing occurrence of cancer.
The prevention strategies used for cancers are maintaining a healthy body weight, not drinking much alcohol, by eating plenty of vegetables, fruits and whole grains, taking vaccination against infectious diseases, not eating much processed and red meat, being away from smoking and avoiding too much sunlight exposure.3,4
The side effects of Radiation therapy are usually causing displeasure. Coping with cancer is a burden for many patients and their caregivers. Patients may undergo physical, psychological and social problems due to the diagnosis of cancer. Nurses are the care providers of health care system who are available for 24 hours with the patient.
Use of advanced technologies in delivering radiation therapy allow it to be a day care treatment and the side effects are comparatively less. By identifying lived experience of patientsundergoing Radiation therapy enable the nurses to plan the care at home which would be provided by their caregivers. Investigator felt that it would be ideal to identify these problems through their lived experience.
Rationale of the study
Radiation therapy is the use of ionizing rays to cure or improve symptoms of cancer. These rays damage DNA of tissue by killing it and sparing normal body tissues through which radiation is passing to destroy the tumor cells. Different shapes of radiation beams are used from multiple exposure angles to intersect at the tumor cells and giving a much larger dose than in the surrounding healthy tissue. Response to the treatment of radiation therapy is varied depends on the type of cancers.It is an integral part for treating cancer. Today, nearly 60% of cancer patients receive target specific radiation therapy. 5
The toxicities associate with radiation therapy are usually mild, reversible and depends upon the treatment area.6 Patients undergoing treatment for cancer needs education, guidance and support regarding the effects and side effects of ionizing rays. By identifying common issues faced during radiation therapy will help to plan the care and make patients more familiar with their day today activities without much difficulties.
Patients undergoing Radiation therapy are experiencingsome side effects and are becoming physically weak. This situation exacerbatesthe symptoms and may not be able to tolerate the side effects of radiation therapy. By identifying the live experience of patient undergoing Radiation therapy will help the nurse to plan the care for their patients. Preferences of patients also can be considered while planning the care. So that the nursing interventions will relieve the symptoms as the care is psychologically accepted by them.
Most of the patients will undergo a drastic change in their physical, psychological and social aspects of life after knowing thediagnosis as cancer. The treatment also causes economic and psychological burden. Teaching certain intervention strategies to the patient and their family members would help them to cope with the diagnosis and treatment of cancers. These strategies are identified through their lived experiences. These experiences are the basics to plan nursing intervention strategies for treating patient undergoing Radiation therapy.
Purpose of the Study
Explore the lived experience of patients undergoing Radiation Therapy to attain a realistic view of difficulties faced during the therapy and complications felt by them after first exposure to the therapy.
Objectives
Explore lived experiences of patients undergoing Radiation Therapy.
Methodology
Qualitative descriptive phenomenological research approach with descriptive phenomenological design to explore the lived experience of patients undergoing Radiation therapy is selected.
Setting
Radiation Therapy Unit Aster MIMS Hospital Kozhikode
Population
All patients undergoing Radiation therapy
Sample and Sample Size
Patients undergoing Radiation therapy and those who meets the inclusion criteria. Qualitative research seeks in-depth understanding of a particular phenomenon, therefore sampling focused on patients undergoing Radiation therapy capable of providing rich data. Sample size was based on the intensity of data collected and continued until data saturation achieved.
Sampling Technique
Purposive Sampling Technique.
Inclusion Criteria
Patients who are
diagnosed with cancer and undergoing radiation therapy
have underwent first dose of radiation therapy
willing to participate in the study.
able to communicate and share their experience
Exclusion criteria
patients who are undergoing chemotherapy
have undergone surgery
not able to communicate and share their experience.
Selection and development of study instruments
Main source of data for Phenomenological studies are in-depth conversations.The tool used were in two parts.
Tool 1-Bio-Socio Demographic Proforma
This consist of structured questions such as age, gender, educational level, occupation, socio-economic Status, monthly income, type of cancer, history of use of any drug
Tool 2- Lead Questions forIn-depth Interview
Tell me about your experience of Radiation therapy.
Are you undergoing any problems during therapy?
If so, what are such experiences?
What are the measures used to reduce such symptoms?
Tell in detail about the issues faced during radiation therapy
Content Validity
Content validity was done by giving Bio-Socio Demographic Proforma and Lead Questions for In-depth Interview to experts in the field of Nursing. Based on their suggestion the tool was modified.The tool was translated to Malayalam and re-translated to English to confirm the accuracy.
Pretesting of Tool
Pre-testing of the tool was done by administering tool to sample to assess feasibility, clarity and to assess any further modification are needed in tool.
Data collection procedure
After ethical clearance from Aster MIMS Ethical Committee, obtained permission from Head of oncology Department. Eligible participants who were willing to participate in the study was given Subject Information Sheet and Informed Consent was obtained from each study participant.Data was collected by maintaining a rapport with the participants and interviewing them. Interview was carried out in Malayalam. Researcher collected data from each participant. Data was audio-recorded, translated and transcribed into verbatim. Data was read line by line for significant statements. Sub-themes and themes generated by going through each statement.
Data were collected over a period of one week, using a semi-structured interview guide and conducted in-depth face-to-face interviews. These audio taped data were transcribed by a bilingual transcriber. The translated version of the interview was coded, and the analysis was done manually using Descriptive phenomenological Analysis (Figure: 1).
Result
Present study shows that 60% of study participants were females and 40% were males. 60% were belong to between 40-50- years of age. 70% were not having any job, 60% had primary education, 20% had stomach cancer, 30% had breast cancer and 50% were with head and neck cancer for type of cancer.
Five super-ordinated themes were emergedfrom main data analysis.That is living with physical discomfort, pain,emotional disturbances, psychosocial difficulties and unable to do daily activities. The sub themes for living with physical discomfort include nausea, vomiting & dyspnea, for emotional disturbances includes feeling dejected, unable to cope up with any stress and psychosocial difficulties include not willing to mingle in social gatherings.
Discussion
Present study reveals that patients who are undergoing Radiation therapy experience physical, emotional, and social adjustment problems. Diagnosis of cancer is a major health problem for the patients and their family members. Though technology is advanced and accessibility of treatment is increased, the stigma for the diagnosis of cancer is still present in the society. Study participants are becoming emotionally weak and psychologically disturbed as they expressed their experiences. Economic burden is another major issue for the family members to be focused. Many feels that cost of treatment is more for their reach. Insurance and third-party payments may be able to render help for such patients. Ultimately all of them want to be out of these issues and want to lead a peaceful life.
Similar study explain the phenomenon studied as the meaning of hope was essential during radiotherapy treatment and the results suggest that interpersonal relationships can be a prerequisite to the experience of hope.7 It also help health care professionals maintain a sense of importance of the ‘whole experience’ for those in their care.8 Lived experiences of patients are basics to realize the issues faced during their treatment.
It is important to identify the issues related to physical, emotional and psychosocial difficulties faced by the patients who are undergoing Radiation therapy to plan and give individualized care. Exploring the lived experience of patients will help and enable to provide such care for patients undergoing Radiation therapy. It is found that intrapersonal and interpersonal relationship skills are beneficial for reducing these unpleasant feeling of patients. Interpersonal relationship skills also can be included in the nursing interventions.
Relevance to clinical practice
It is important to identify the issues related to physical, emotional and psychosocial difficulties faced by the patients undergoing Radiation therapy to plan and give individualized care for patients. Exploring the lived experience of patients will help and enable to provide such care for patients undergoing Radiation therapy.
Conclusion
Participants explained the experience of their living after the diagnosis of cancer. The treatment with Radiation therapy has caused certain changes in doing day today activities of life. As a result of difficulties caused to them during Radiation therapy increased physical and psychological impact to their living.
Funding for this research- self funded
Conflict of interest
Authors have no conflict of interest
Acknowledgement
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this article. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed
Englishhttp://ijcrr.com/abstract.php?article_id=2638http://ijcrr.com/article_html.php?did=2638
Kushi LH, Doyle C, McCullough M, Rock CL, Wahnefried W, Bandera EV, et al (2012). American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity, CA Cancer J Clin. 62 (1): 30–67. doi:10.3322/caac.20140. PMID 22237782.
Parkin DM, Boyd L, Walker LC (December 2011), The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010, British Journal of Cancer, 105 Suppl 2: S77–81. doi:10.1038/bjc.2011.489. PMC 3252065. PMID 22158327.
Anand P, Kunnumakkara AB, Sundaram C, Harikumar KB, Tharakan ST, Lai OS, et al (September 2008), Cancer is a preventable disease that requires major lifestyle changes, Pharmaceutical Research. 25 (9): 2097–116. doi:10.1007/s11095-008-9661-9. PMC 2515569. PMID 18626751.
National Cancer Institute (26 February 2018), "Targeted Cancer Therapies". www.cancer.gov. Retrieved 28 March 2018.
Manton K, Akushevich I, Kravchenko J (28 December 2008), Cancer Mortality and Morbidity Patterns in the U.S. Population: An Interdisciplinary Approach. Springer Science & Business Media. ISBN 978-0-387-78193-8.
Islami F, Goding SA, Miller KD, Siegel RL, Fedewa SA, Jacobs EJ, et al (January 2018), Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States, Ca. 68 (1): 31–54. doi:10.3322/caac.21440. PMID 29160902.
Prince, Jim M, Damian C, Stew M, Steve Y, Ian W, et al, tumorradio sensitivity – General Practice Notebook, Archived from the original on 24 September 2015.
Hill R, Healy B, Holloway L, Kuncic Z, Thwaites D, Baldock C (March 2014), Advances in kilovoltage x-ray beam dosimetry, Physics in Medicine and Biology. 59 (6): R183–231.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411121EnglishN2019November9HealthcareA Study of Clinical and CSF Characteristics in Cases of Acute Meningoencephalitis in Immunocompetent Adults in a Tertiary Care Hospital of Eastern India
English0515Md. Hamid AliEnglish Sinjan GhoshEnglish Nandini ChatterjeeEnglish Udas Chandra GhoshEnglishMeningoencephalitis is a very critical illness that is widespread andit remains a major cause of mortality and morbidity with neurological disabilities. It usually presents with varying degrees of symptoms of meningeal inflammation, posing difficulties in diagnosis and treatment. Study was conducted to Evaluate clinical severity and CSF(cerebrospinal fluid) findings at presentation. Encompassing the clinical status, CSF assays, along with revelations of recent trends of infection responsible formeningoencephalitis, this study also shows that early confirmation of clinical suspicion with judgement of severity & CSF study, is of great significance. Prompt diagnosis providesphysicians with an opportunity to prevent undue mortality and morbidity.. Here lies therelevance of this study.
EnglishAcute Meningoencephalitis, Cerebrospinal fluid, MRI of brainIntroduction:
The incidence of acute encephalitis in western countries is 7.4 cases per100,000 population per year. In tropical countries, the incidence is 6.34 per 100,000 per year.[3] Herpes simplex encephalitis has an incidence of 2–4 per million population per year. [4] The common pathogens which are encountered in adult bacterial meningitis are Streptococcus pneumoniae (30-50%), Neisseria meningitidis (10-35%), Staphylococci (5-15%), other Streptococcus species, Haemophilus influenza (1-3%), Gram negative bacilli (1-10%) and Listeria monocytogenes[4]. Prompt recognition, early diagnosis, efficient decision making followed byrapid institution of therapy plays a pivotal role in saving a large salvageable portion of the affected population and thus reducing mortality. Tuberculous meningitis (TBM) remains the most common presentation. In spite of advances in diagnostic technology and effective therapeutic options, it continues to pose significant management challenges. Despite anti-TB chemotherapy, 20-50% of the affected people die and many who survive have significant neurological deficits. The case fatality noted to be associated significantly with delay in diagnosis and treatment. Tuberculous meningitis (TBM) generally occur in course of a sub acute or chronic case but TBM may have an acute presentation. The duration of presenting symptoms may vary from 1 day to 9 months, although several cases may present with symptoms of less than 2 weeks duration. Diagnostic evaluation includes various microbiological, pathologic, molecular, and biochemical investigations & imaging modalities. Imaging helps in early diagnosis and helps in preventing morbidity and mortality.[5]
Aims and objectives of these studies: Evaluation of clinical severity and CSF(cerebrospinal fluid) findings at presentation in Acute Meningoencephalitis.
MATERIALS AND METHODS:
Patients, who were admitted in between January 2013—August 2014 in the department of General Medicine of NRS Medical College and Hospital from rural and urban catchment area, were included in this study as simple random selection. 50 patients, aged>12years were included in this prospective observational study with Fever and Signs of Meningitis (Nuchal rigidity, vomiting, and headache) or Signs of meningoencephalitis: Meningeal signs with altered sensorium, focal neuro-deficits, and seizures. The following patients with Sepsis, Metabolic Encephalopathy, Dyselectrolytemia, Poisoning, Cerebrovascular Accident, Intracranial SOL, Neurocysticercosis, Enteric Fever with meningism, Vascular Aneurysms producing local compressive effect, Acute disseminated Encephalomyelitis (ADEM) and Cerebral Malaria were excluded from the study. Clinical Characteristics-Glasgow Coma Scale(GCS) Scoring( 3 to 15) as a marker of clinical severity on admission. According to the score calculated on admission, patients divided into three groups-Gr. A(GCS 3-5), Gr. B (GCS 6-9), Gr. C (GCS 10-15). : The macroscopic appearance of the CSF recorded. A routine CSF total and differential count were done by a haemocytometer by standard methods. The CSF samples subjected to a cytospin by using Shandon cytospin MODEL 001/ 002. Gram stained of CSF was done and examined under microscope. ZN staining, Bacterial culture, TB culture (BACTEC) and Cryptococcal staining(India Ink Stain) were also done. Specific viral analysis was done by ELISA according to relevance, availability and feasibility. All CSF samples were cultured on Sheep blood agar, Chocolate agar, MacConkey's agar and Thioglycollate broth for specific diagnosis. Neuroimaging may precede CSF study by lumbar puncture if there is any contraindication to the procedure like history suggestive of presence of Intracranial SOL, Papilloedema, focal neurodeficits, and signs of increased intracranial tension or new onset seizures. We used laboratory methods available in the Hospital and NABL accredited private laboratory. It was a Simple observational study. History taking and Meticulous Clinical Examination & Haemato-Pathological and Biochemical Investigations: including complete blood count, Fasting and Post Prandial Glucose, Blood Urea and Creatinine, Serum Sodium and Potassium, Blood Culture study, HIV 1& 2, HBs Ag and Anti HCV Antibody, Malaria dual antigen, Dengue Ns1 antigen and Dengue specific IgG and IgM, Widal’s Test, Leptospira specific IgM antibody. CSF was analysed for a) Cytology-Cell type and Cell count, b) Biochemistry- Glucose, Protein and Chloride and c) Microbiology-Gram staining, ZN staining, Bacterial culture, TB culture(BACTEC) and Cryptococcal staining(India Ink Stain) d) Specific Viral analysis by CSF ELISA according to relevance, availability and feasibility. Final Diagnosis Based on Set Criteria and Segregation of cases according to etiological groups from CSF and MRI findings. Descriptive statistical methods were used, utilizing the SPSS software for data analysis.
REVIEW OF LITERATURE:
Mortality of acute bacterial meningitis is 25%. Morbidity in the tem of neuro-deficit is also very high. Now are going through the advanced stage of antibiotic era & critical care facility. In spite of that we are facing increased mortality. The prognosis is worse with a delay in management.[6] Increased morbidity and mortality is seen in both high and low-income group &countries.[5] It is very tough job to select patients for timely antibiotic administration in emergency room.[7]
Schutte CM and Van der Meyden CH in their study found good correlation between both the GCS and CSF-protein level at admission and the outcome of patients with meningitis was found. With the GCS value being a better prognostic indicator than high CSF protein levels.[8] Syamal Modi and Amit Kumar Anand in their study found Streptococcus pneumonia was the most common pathogen which was isolated in 120 (60%) culture positive cases. Cell counts showed the predominance of neutrophils in all cases with ABM. In ABM protein is high & sugar is low.[9] Gram staining is one of the cornerstones methods in diagnosing ABM in developing countries.
Mani R, Pradhan S et al in their study conducted in South India (NIMHANS) in 2007 [10] observed that, as compared to Western studies, the relative incidence of meningitis caused by H. influenza, N. meningitides and Listeria is less in South-East Asia. On the contrary, gram negative bacilli such as Klebsiella pneumonia and Pseudomonas aeruginosaare increasingly being recognised as important pathogens of community-acquired as well as nosocomial meningitis especially among the elderly and in patients with chronic debilitating diseases like cirrhosis, diabetes and malignancies.[11]. Steiner, H. Budka et al in their review of diagnosis and management recommendations in Viral encephalitis states that analysis of CSF for protein and glucose contents, cellular analysis and identification of the pathogen by biotechnology method like PCR polymerase chain reaction (PCR) and serology. Hospitalisation is mandatory with ICCU facility [21] . Combinations of meningitis/ encephalitis and myelitis/ radiculitis are associated with Epstein Barr Virus (EBV); myelitis with VZV, CMV, EBV, and HSV-2; and ventriculitis/encephalitis with VZV and CMV. Brainstem encephalitis due to HSV and VZV, and poly myeloradiculitis due to CMV are well documented. Recent large CSF PCR studies have shown that VZV, EBV, and CMV more frequently produce meningitis, encephalitis, or encephalopathy in immunocompetent hosts than was formerly realized.[12]
A study conducted by Rathore SK, Dwibedi B et al during April 2011 to July 2012. Blood and CSF samples of 526 AES cases are investigated by serology and/or PCR. Viral aetiology was identified in 91 (17·2%) cases. Herpes simplex virus (HSV; types I/ II) was most common (16·1%), followed by measles (2·6%), Japanese encephalitis virus (1·5%), dengue virus (0·57%), varicella zoster virus (0·38%) and enteroviruses (0·19%). Simultaneous infection of HSV-I and measles were observed in seven cases. This report provides the first evidence on viral aetiology of acute encephalitis syndrome viruses from eastern India showing dominance of HSV that will be useful in informing the public health system.[13] However, measurement of antibodies in single specimen of serum and CSF lacks sensitivity; they interpreted the positivity (positive for IgM and/or IgG antibody) in relation to other supportive clinical, electroencephalographic and neuro-radiological evidences. CSF-PCR is the diagnostic test of choice, which has sensitivity rate as high as 98-99% and specificity of100%.,[14]. HSE is the only form of sporadic encephalitis which has a specific antiviral therapy i.e. acyclovir.,[15] F. Frantzidou, F. Kamaria et al found in their study that Entero viruses was the most common cause of adult aseptic meningitis and together with HSV-1 the main causes of encephalitis.[16].
RESULTS AND ANALYSIS
GENDER DISTRIBUTION: (Figure 1&Chart 1) All immune-competent patients aged 12yrs or more were selected randomly over a period of 19 months for this observational study as per the clinical inclusion criteria.18 cases (36%) were male and 32 cases (64%) were female. Patients ranging from ages 12 yrs to 77 yrs were selected and divided into age groups. Maximum number of patients (26%) belonged to 12-20 yrs age group.
Groups according to the Glasgow coma Scale: (See Figure 4 & Chart 2)The patients were clinically examined and classified into three groups according to the Glasgow coma scale.15 cases(30%) belonged to group A(GCS 3 to 5), 22 cases(44%)Belonged to Gr. B(GCS 6 to 9) while 13 cases (26%) belonged to Gr. C (GCS 10 to 15) on admission, 30% patients had a very poor clinical condition (GCS 3 to 5) during admission as evident from the GCS category distribution while majority of patients belonged to group B. ( See table2 & Chart 2)
Etiological groups& gender distribution: (See Figure 2& Chart 3) After obtaining the investigation results the cases were segregated into etiological groups and Re classified according to the GCS groups and gender. Majority of cases had a viral aetiology (56%) followed by tuberculous (28%) and bacterial aetiology (16%). Pyogenic meningitis cases had a Male predilection (62.5%) while tuberculous and viral meningitis had female predilection in incidence, 57.14% and 75% respectively.
Distribution according to age groups :(See Figure 3&Chart 5)
Majority of pyogenic meningitis cases (37.5%) belonged to 31-40yrs age group while maximum number of tuberculous meningitis cases (35.71%) and viral Meningoencephalitis cases (28.57%) belonged to 12-20 yrs age group. Out of 50 cases 8 cases(16%) were diagnosed as pyogenic meningitis[ 5males(62.5%) and3 females(37.5%)]
Distribution of Patients according to GCS on admission: (See figure 4 & Chart 6) 1case was in gr A(GCS 3 to 5), 5 cases in gr B(GCS 6 to 9) and2 cases were in gr C(GCS 10 to 15). So 12.5% cases presented in a clinically severe state(GCS 3 to 5) during admission.14 cases(28%) were diagnosed as tuberculous meningitis[ 6males(42.86%) and 8 females(57.14%)] 6 cases were in gr A(GCS 3 to 5), 6 cases in gr B(GCS 6 to 9) and 2 cases were in gr C(GCS 10 to 15). 42.86% cases presented in a clinically poor condition(GCS 3 to 5) on admission. (See table 5 & Chart 5)28 cases (56%) were diagnosed as viral meningoencephalitis. [ 7males (25%) and 21females(75%)] 8 cases were in Gr A(GCS 3 to 5), 11 cases in Gr B(GCS 6 to 9)and 9 cases were in Gr. C(GCS 10 to 15)28.57% cases presented in a clinically poor state(GCS 3 to 5) on admission.
Classification according to gcs in different etiological groups :(See Figure 5)
After comparative analysis of three etiological groups and their GCS categories it was found that tuberculous meningitis cases(42.8%) presented in a more severe state followed by cases of viral meningoencephalitis(28.57%) and pyogenic meningitis(12.5%).
CSF Findings
Cytology: Cell Count & Cell Type: (See Figure 5 & Chart 7 & 8)
In cases that were later diagnosed as pyogenic meningitis, the cell counts ranged from 120 to
5900 cells/cumm with a mean count of 950.5± 3748.84 cells/cumm and neutrophil
predominance. In cases with a final diagnosis of tuberculous meningitis, the cell counts ranged from 60 to 460 cells/cumm with a mean count of 225.86±217.22 cells/cumm with a lymphocyte
predominance. In cases categorized as viral meningoencephalitis, the cell counts ranged from 30 to 510cells/cumm with a mean count of 128.607±276.86cells/cumm and a predominantly lymphocytic picture.
Biochemistry & ADA levels: (See Figure 6 & Chart 9)
Pyogenic meningitis cases revealed a mean CSF glucose of 19±18.9mg/dl,mean protein levels of 62.375±48.52mg/dl, mean chloride levels of 112.88±12.48 meq/Lt with mean ADA level of 8.025±24.14. This picture was consistent with hypoglycorrhachias expected in pyogenic meningitis. Tuberculous meningitis cases revealed a mean CSF glucose of 35.79±22.9mg/dl, mean protein levels of 268.86±368.12 mg/dl, mean chloride levels of n112.714±12.54 meq/Lt with mean ADA level of 16.29±16.14 U/L. Protein levels were markedly increased with ADA levels also higher than normal range along with low glucose levels consistent with the diagnosis. Viral meningoencephalitis cases revealed a mean CSF glucose of 60.11±32.28 mg/dl, mean protein levels of 96.96±91.98 mg/dl, mean chloride levels of113.45±14.32 meq/Lt with mean ADA level of 3.76±4.38U/L. The protein levels were higher with normal glucose levels.
CSF Culture, staining and viral PCR:
According to affordability of the patient and availability of appropriate facilities in Eastern India - CSF culture and staining, CSF viral antibody detection by ELISA (when suspected) were sent with the routine samples. Some cases were diagnosed accurately from CSF culture and ELISA that were corroborating with the clinical assumptions and radiological imaging findings.
Pyogenic Meningitis etiologies:- (N=8): (See Figure 7 & Chart 10)
CSF gram staining and culture revealed Streptococcus pneumoniae in 4(50%) cases, Neisseria meningitides in 1(12.5%) case, Staphylococcus aureus in 1(12.5%) case and culture negative in 2(25%) cases. This shows that majority of the culture positive cases were positive for Streptococcus pneumonia followed by equal incidence of Neisseria meningitides and Staphylococcus aureus. 25 % cases that were culture negative had classical symptoms which
resolved with empiric antibiotics.
Tuberculous Meningitis:- (N= 14)
All the cases suspicious of tuberculous etiology were ZN smear negative. CSF culture was negative in 10 cases(71.4%) while culture could not be done in 4 cases(28.6%). Diagnosis had to be established on clinical features, CSF cytology, CSF biochemistry, brain imaging and therapeutic response to anti tubercular drugs.
Viral Meningoencephalitis:- (N=28): (See Figure 8 & Chart 11)
Patients with CSF cytology indicating a viral infection revealed the following viral etiologies in CSF Elisa (IgG). 10 cases(35.72 %) were positive for Herpes simplex, 3 cases(10.72%) were positive for Varicella zoster, 4 cases(14.28%) were positive for Japanese B while 11cases (39.28%) were negative or indeterminate..
DISCUSSION
Pyogenic Meningitis
Acute bacterial meningitis is more common in resource-poor than resource-rich settings. Survival is dependent on rapid diagnosis and early treatment, both of which are difficult to achieve when laboratory support and antibiotics are scarce. Syamal Modi and Amit Kumar Anand in their study Phenotypic Characterization and Antibiogram of CSF Isolates in Acute Bacterial Meningitis done in a tertiary care hospital Patna (India) found that 62.3% patients were males and 37.7% were females. The gender distribution and male preponderance in disease incidence was also marked (62.5 % males and 37.5% females) in our study done in Eastern India. In our study sample size was smaller in comparison to theirs. This male predilection reported in several previous studies. [17] Similar to the study by Marjolein J. Lucas, Matthijs C. Brouwer et al (2014),[18] patients using immunosuppressive drugs and those with asplenia, diabetes mellitus, alcoholism, or infection with immunodeficiency virus were considered immune compromised and excluded from our study. Schutte CM, van der Meyden CH in their study found patients with a Glasgow coma scale (GCS) value of > 12 had a good neurological outcome, while those with a GCS value of ≤ 8 had a poor outcome. They concluded that the GCS value was a better prognostic indicator than high CSF protein levels[8]. In our study we adapted GCS as the criteria for clinical severity. Group A (GCS 3 to 5) was considered as most severe clinical category. Pyogenic meningitis can be accurately and rapidly diagnosed by gram staining. Some studies have reported sensitivities of 60-90% and specificities of >97% of CSF gram staining in the diagnosis of ABM.[6], . In our study: 50% cases were diagnosed as Streptococcus pneumoniae induced meningitis, followed by equal incidence of Neisseria meningitides and Staphylococcus aureus cases (12.5% each) on CSF gram staining and culture 25 percentage cases did not reveal any organism on CSF culture. Negative CSF cultures are estimated to occur in11%–20% of patients with bacterial meningitis.[19],[6] However, the clinical presentation of patients with culture-positive bacterial meningitis and patients with culture-negative bacterial meningitis was reported to be similar. R Mani, S Pradhan et al in their study conducted in South India (NIMHANS), found that streptococcus pneumoniae was the most common etiological agent of community-acquired meningitis in all age groups. This accounting for 238 (61.8%) cases in their study, reflecting a similar trend reported in an earlier study from their institute (1978-1988).[20] Most Indian studies have also reported a high incidence of pneumococcal meningitis[21],[22]. In our study, also Streptococcus pneumonia was the most common organism isolated from CSF culture (50% cases. Analysis of the CSF is essential, and simple techniques can enhance the yield of diagnostic microbiology. Penicillin-resistant and chloramphenicol-resistant bacteria are a considerable threat in resource-poor settings that go undetected if CSF and blood cannot be cultured.
The future rests with the provision of effective conjugate vaccines against S pneumoniae, Haemophilus influenzae, and Neisseria meningitides to children in the poorest regions of the World.
Viral Meningoencephalitis
Herpes simplex virus type 1 (HSV-1) is the most common cause of sporadic encephalitis (Davison et al., 2003; Mailles et al., 2007). In some recent reports from Scandinavia and central Europe, however, varicella zoster has been identified as the most common viral agent responsible for encephalitis (Cizman & Jazbec, 1993; Studahl et al., 1998; Koskiniemi et al., 2001).[23] A study named - Viral aetiology and clinico-epidemiological features of acute encephalitis syndrome in eastern India conducted by Rathore SK, Dwibedi B et al during April 2011 to July 2012.[13] Blood and CSF samples of 526 AES cases were investigated by serology and/or PCR. Viral aetiology was identified in91 (17·2%) cases. Herpes simplex virus (HSV; types I or II) was most common (16·1%). Simultaneous infection of HSV I and measles was observed in seven cases. This report provides the first evidence on viral aetiology of Acute encephalitis syndrome viruses from eastern India showing dominance of HSV that will be useful in informing the public health system. In our study there were majority of HSV cases. In CSF Elisa (IgG). 10 cases (35.72%) were positive for Herpes simplex, 3 cases (10.72%) were positive for Varicella zoster, 4 cases(14.28%) were positive for Japanese B while 11 cases(39.28%) were negative or indeterminate. So there is a similarity and etiological preponderance of HSV in both western and eastern India.
Panagariya A, Jain RS et al[24] in a study conducted in North West India with Herpes simplex encephalitis cases included patients admitted with provisional diagnosis of an encephalitic illness over a period of 30 months. Special investigations included CSF analysis, EEG, CT scan and MRI. Herpes simplex virus (HSV) antibody estimation in CSF and blood was done simultaneously using ELISA. 28 patients showed electroencephalographic, serologic and/or neuro radiological evidence of herpes simplex encephalitis. Exact incidence of this disease (HSE) is the most difficult to estimate, because only few patients with common cause of fatal sporadic acute encephalitis with severe disease report to hospital whereas mild and self limiting cases usually go unrecognised. In India, HSE appears to be under diagnosed; probably due to lack of awareness and diagnostic facilities.CSF polymerase chain reaction (PCR) and immuno-cytochemistry could not be done in their study because of non-availability. CSF PCR is not always available in laboratories in eastern part of India, due to which it could not be done in our study. Moreover affordability was also a point of concern in case of patients attending our hospital. Japanese encephalitis (JE) is the leading cause of encephalitis in Southeast Asia, where 30,000–50,000 cases are recorded annually (Tsai, 1997).[25] The World Health Organisation estimated nearly 14,000 deaths due to JE in the year 2002. Of these, 8,500 occurred in Southeast Asia, 3,000 in the western Pacific region and about 2,000 in the eastern Mediterranean region.
The incidence of neurologic complications associated with varicella is estimated to be 1–3 per 10,000 cases [26]. The central nervous system (CNS) manifestations that occur most frequently with varicella are cerebellar ataxia and encephalitis [26]. The most serious CNS complication of varicella, has an incidence of 1–2 episodes per 10,000varicella cases, with the highest incidence in adults and infants.[27] The CSF findings are usually abnormal with elevated opening pressure, a mild-to-moderate lymphocytic pleocytosis (usually 12 yrs) fulfilling the inclusion criteria were randomly selected over a period of 19 months. A male preponderance was marked in Pyogenic meningitis cases while a female preponderance was noted in tuberculous meningitis and viral meningo encephalitis cases.
An increased propensity of disease occurrence was seen in age groups 31-40 yrs in pyogenic meningitis and younger age groups (12- 30 yrs) were more affected in tuberculous and viral meningoencephalitis. Individual patients were assessed by clinical status on admission and divided into three GCS group. 15 cases(30%) belonged to group A(GCS 3 to 5), 22 cases(44%) belonged to gr B(GCS 6 to 9) while 13 cases( 26%) belonged to gr C( GCS 10 to 15) on admission. 18cases(36%) were male and 32 cases(64%) were female. Patient’s ages ranging from 12 yrs to77 yrs were selected and divided into age groups. CSF study and MRI brain was done and etiologically the cases were reclassified. Out of 50 cases 8 cases(16%) were diagnosed as pyogenic meningitis [ 5 males (62.5%) and 3 females(37.5%)], 14cases (28%) were diagnosed as tuberculous meningitis [6males (42.86%) and 8 females (57.14%)] and 28 cases(56%) were diagnosed as viral meningoencephalitis [7males (25%) and 21females (75%)].CSF study revealed neutrophilic picture with hypoglycorrhachia in bacterial meningitis with CSF culture studies revealing Streptococcus pneumoniae as the most commonly isolated pathogen(50% cases). Tuberculous meningitis revealed CSF lymphocytic pleocytosis with significantly increased protein and ADA levels. CSF ZN staining in all cases were negative, CSF culture for tuberculosis was negative in 71.4% cases and could not be done in 28.6% cases although the diagnosis was established on other parameters and imaging evidence.
The CSF samples of viral meningoencephalitis revealed lymphocytic picture and increased protein with majority of cases being positive for Herpes simplex antibody (in CSF by ELISA method) in 35.72%. 14.28% cases were positive for Japanese B antibody. 10.72% cases were diagnosed as Varicella zoster cases. Serological confirmation of diagnosis was not possible in other cases due to non-availability of the specific test (Viral PCR) or a negative serology in 39.28%.
CONCLUSION
In this Eastern India based study viral etiologies were more frequently detected (56%) followed by tubercular(28%) and pyogenic(16%) causes of disease. There was an overall female preponderance (64%) with maximum number of patients belonging to younger age groups. Male predilection in pyogenic meningitis (62.5%) and a female predilection (57.14%) in tuberculous meningitis was noted, which was similar to several other studies done in other parts of the world. Most of the tuberculous meningitis cases (42.8%) were clinically more severe according to the GCS category during admission followed by viral meningoencephalitis (28.57%) and pyogenic meningitis (12.5%).CSF cytology revealed neutrophillic picture in pyogenic and lymphocyticpleocytosis in tuberculous and viral meningoencephalitis. CSF biochemistry revealed hypoglycorrhachia in pyogenic and tuberculous meningitis and high protein levels in viral and grossly high protein content in tuberculous meningitis cases. ADA levels were also high in tuberculous meningitis.CSF gram staining, culture and serology results showed Streptococcus
pneumoniae as the most common pathogen causing pyogenic meningitis(50%) and Herpes simplex as most common viral pathogen (35.72%) causing meningoencephalitis. This is a potential area of research and rightfully demands attention in the near future. India being a resource poor nation, improvisation of the specific diagnostic modalities and implementation with regard to affordability should be prioritised. Especially in this part of the world, there is a dearth of multicentric prospective studies on meningoencephalitis. More studies should be conducted based on correlation of clinical aspects with brain imaging; prognostication and taking into account the long term outcomes.
Limitations of the study
Sample size is small (N= 50). This study was done over a certain catchment area, hence not a multicentric study. As the study was done in a tertiary care hospital, the mean values may not properly reflect the actual population mean. Due to small sample size and wide range of variation in the values of the CSF parameters, in certain cases the standard deviation exceeded the mean values.CSF PCR could not be done due to non-availability during that period. Empiric therapy had to be started in most of the cases prior to confirmation of diagnosis, for the sake of the patients. Some of the patients who fulfilled the inclusion criteria, had to be excluded due to economic constraints.
Conflict of interest- Authors did not have any conflict of interest.
Corresponding author: Dr. Sinjan Ghosh. Department of Neurology, Nil Ratan Sircar Medical College and Hospital,Kolktata 14, West Bengal, India
Englishhttp://ijcrr.com/abstract.php?article_id=2639http://ijcrr.com/article_html.php?did=2639
Bandaru NR, Ibrahim MK, Nuri MS, Suliman MB. Etiology and occurrence of acute bacterial meningitis in children in Benghazi, Libyan Arab Jamahiriya. East Mediterr Health J. 1998; 4:50-7
Bloch KC, Glaser C. Diagnostic approaches for patients with suspected encephalitis. Curr Infect Dis Rep. 2007; 9(4):315-22.
Khan F, Rizvi M, Fatima N, Shukla I, Malik A, Khatoon R. Bacterial meningitis in North India: Trends over a period of eight years. Neurology Asia. 2011;16(1):47–56.
Rozenberg, F; Deback C; Agut H (June 2011). "Herpes simplex encephalitis: from virus to therapy". Infectious Disorders Drug Targets 11 (3): 235–250
D C Hughes, A Raghavan, S R Mordekar, P D Griffiths, D J A Connolly.Role of imaging in the diagnosis of acute bacterial meningitis and its complications.Postgrad Med J .2010;86:478-485.
Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med. 1993;328:21–28.
BeggN Cartwright, KAV , Cohen J., Kaczmarski, EB . Innes, JA. Leen, CLS et al .Consensus statement on diagnosis, investigation, treatment and prevention of acute bacterial meningitis in immunocompetent adults. Journal of Infection [J. Infect.]. 1999; 39: 1-15
Schutte CM, van der Meyden CH.A prospective study of Glasgow Coma Scale (GCS), age, CSF-neutrophil count, and CSF-protein and glucose levels as prognostic indicators in 100 adult patients with meningitis.J Infect. 1998;37(2):112-5.
Syamal Modi, Amit Kumar Anand. Phenotypic Characterization and Antibiogram of CSF Isolates in Acute Bacterial Meningitis. J Clin Diagn Res. 2013; 7(12): 2704–2708.
Mani R, Pradhan S, Nagarathna S, Wasiulla R, Chandramuki A. Bacteriological profile of community acquired acute bacterial meningitis: A ten-year retrospective study in a tertiary neurocare centre in South India. Indian J Med Microbiol 2007;25:108-14
Tang LM, Chen ST, Hsu WC, Lyu RK. Acute bacterial meningitis in adults: A hospital-based epidemiological study. QJM 1999; 92 :719-25.
Domingues R.B., Fink M.C.D., Tsanaclis A.M.C., de Castro C.C., Cerri C.C., Mayo M.S., et al.Diagnosis of herpes simplex encephalitis by magnetic resonance imaging and polymerase chain reaction assay of cerebrospinal fluid. J NeurolSci. 1998;157:148-153
Rathore SK, Dwibedi B, Kar SK, Dixit S, Sabat J, Panda M. Viral aetiology and clinico-epidemiological features of acute encephalitis syndrome in eastern India. Epidemiol Infect. 2014; 24:1-8
Satishchandra P, Ravi V, Shankar SK : Herpes simplex encephalitis : Clinicopathological and virological appraisal. Progress in Clinical Neuro Sciences1996; 11 : 167-186
Coren ME, Buchdahl RM et al : Imaging and laboratory investigation in herpes simplex encephalitis. J NeurolNeurosurg Psychiatry1999; 67 : 243-245
Frantzidou, F., Kamaria, F., Dumaidi, K., Skoura, L., Antoniadis, A. and Papa, A. (2008), Aseptic meningitis and encephalitis because of herpesviruses and enteroviruses in an immunocompetent adult population. European J Neurol, 15: 995–997
Pfister HW, Feiden W, Einhaupl KM. Spectrum of complications during bacterial meningitis in adults: results of a prospective clinical study. Arch Neurol. 1993;50:575–81.
Marjolein J. Lucas, Matthijs C. Brouwer, ,Arie van der Ende and Diederik van de Beek. Outcome in patients with bacterial meningitis presenting with a minimal Glasgow Coma Scale score.Neurol Neuroimmunol.2014;1: 1 e9
Pfister HW, Feiden W, Einhaupl KM. Spectrum of complications during bacterial meningitis in adults: results of a prospective clinical study. Arch Neurol. 1993;50:575–81.
Chandramukhi A. Neuromicrobiology. In: Neurosciences in India: Retrospect and Prospect . The Neurological Society of India, Trivandrum and CSIR: New Delhi; 1989. p. 361-95
Kabra SK, Praveen Kumar, Verma IC, Mukherjee D, Chowdhary BH, Sengupta S, et al . Bacterial meningitis in India: An IJP survey. Indian J Pediatr 1991; 58 :505-11.
Chinchankar N, Mane M, Bhave S, Bapat S, Bavdekar A, Pandit A, et al . Diagnosis and outcome of acute bacterial meningitis in early childhood. Indian Pediatr 2002; 39 :914-21.
Misra, U. K., Tan, C. T. and Kalita, J. Viral encephalitis and epilepsy.Epilepsia 2008; 49: 13–18
Panagariya A, Jain R S, Gupta S, Garg A, Sureka R K, Mathur V. Herpes simplex encephalitis in North West India. Neurol India 2001;49:360
Tsai TF, Chang GJ, Yu XY. Japanese encephalitis vaccine. In: Plotkins SA, Orenstein WA, editors. Vaccines. Philadelphia: W.B. Saunders; 1999. p. 684-710.
Applebaum E, Rachelson MH, Dolgopol VB. Varicella encephalitis. Am J Med 1953;15:223-30.
Choo PW, Donahue JG, Manson JE, Plott R. The epidemiology of varicella and its complications. J Infect Dis 1995;172:706-12.
Misra UK, Kalita J, Syam UK, Dhole TN. Neurological manifestations of dengue virus infection. J Neurol Sci. 2006;244:117–22.
Lee KY, Cho WH, Kim SH, Kim HD, Kim IO. Acute encephalitis associated with measles: MRI features. Neuroradiology.2003; 45: 100–106.
I. Steiner, H. Budka, A. Chaudhuri, M. Koskiniemi, K. Sainio, O. Salonen et al. Viral encephalitis: a review of diagnostic methods and guidelines for management. European Journal of Neurology2005; 12: 331–343
Sutlas PN, Unal A, Forta H, Senol S, Kirbas D. Tuberculous meningitis in adults: Review of 61 cases. Infection. 2003;31:387–391.
Lammie GA, Hewlett RH, Schoeman JF, Donald PR. Tuberculous cerebrovascular disease: A Review. J Infect. 2009;59:156–166
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411121EnglishN2019November9Life SciencesFungal Infections and Aflatoxin Contamination in Maize Grains Collected from West Showa and East Wallega Zones, Ethiopia
English1622Solomon YilmaEnglish Kassahun SadessaEnglish Denberu KebedeEnglishMycotoxin affects the world’s food crops and creates a large economical loss in the developed and developing countries. Aflatoxins are a group of mycotoxins that mainly produced by Aspergillus species viz., A. flavus, and A. parasiticus. An aflatoxins contamination of maize grains has exhibiting a serious threat to human and animal health over the past two decades. Toprotect the safety of food commodities, regular monitoring and diagnosis of the presence and amount of non-permissible levels of aflatoxins in food is necessary to take appropriate management measures. Maize grain samples were collected from Ilu Galan and Bako districts of West Shoa and Gobu Sayo district of East Wollega zones of Oromiya; from different grain storage types. About 500 gr of maize grains were sampled from each sampling spot. PDA media was used for isolation of associated maize grains sample associated fungi. Sun-culturing and purification of the associated fungi were done and preserved using agar slant technique. The associated fungal mycoflora were characterized based on morphological and growth sporulation properties. Enzyme Linked Immuno Sorbent Assay (ELISA) diagnostic kit were used for identification and quantification of aflatoxins. Aspergillus, Fusarium Penicillium and Trichoderma species were identified and characterized. Aflatoxin B1 was identified and quantified from zero to 381.6μg/kg. About 34.4% of the samples were positive to aflatoxin B1 compared to Food and Drug Administration (20μg/kg) and European Union (4μg/kg), respectively. The management of mycotoxigenic fungi, improvement of storage methods, development of resistant maize varieties and awareness creations could be possible solutions
EnglishMaize grain, Storage methods, Fungi, Identification, Detection, Quantification and AflatoxinB1Mycotoxins are toxic secondary metabolites produced by certain fungi viz., Aspergillus, Fusarium, Alternaria and Penicillium spp. in agricultural products that are susceptible to mold infestations (Morenoaet al., 2009). Now a day mycotoxin effectis attracting the worldwide attention because of the significant economic losses associated with their impact on human health, animal productivity and trade (Wagacha and Muthomi, 2008). These toxins are highly toxic and carcinogenic to animals and humans which lead to hepatotoxicity, teratogenicity, immunotoxicity and even death (Wen et al., 2004).Children below five years remain most vulnerable, with exposure damaging their immunity and causing stunted growth (www.aatf-africa.org). Mycotoxins contaminate and reduce crops quality through discolorations and reduction of nutritional values (Waliyaret al., 2008). Regulations on mycotoxins have been set and strictly enforced by most agricultural commodities importing countries, thus affecting international trade(FAO, 1988). In some developing countries where agricultural commodities account for about 50 percent of the total national exports, the economic importance of mycotoxins is considerable. FAO (2014) has estimated that about 25% of agricultural crops worldwide contaminated by mycotoxins. Similarly, the Center for Disease Control (CDC) has estimated that more than 4.5 billion people in the developing world are exposed to aflatoxins (CDC, 2004). The total allowable level of aflatoxin (µg/kg) in human food in different countries were reported i.e., Australia, china, European union, India, Kenya, Taiwan and USA is 15, 20, 4-15, 30, 20, 50, and20, respectively (FAO, 2004). The estimated crop lost due to aflatoxin is $225 million per year, out of the $932 million crop lost in each year in the USA (Betran and Isakeit, 2003).
Many studies across the world showed that the maize grains highly contaminated with aflatoxins that mostly caused by Aspergillus flavus and Aspergillus parasiticus(Patten, 1981; Munkvold, 2003). Aflatoxins can produced by fungal action during production, harvest, transportation, storage and food processing (CAST, 2003; Murphy et al., 2006). According to Befekadu and Berhanu (2000) the maize crop is the third most important crop in Ethiopia after wheat and teff which accounts for the largest share in total crop production. The maximum quantities of maize produced are stored under poor storage conditions. The traditional storage of maize in Ethiopia made up of mud, bamboo strips, and pits (Chauhan et al., 2016). Storage of maize grains under poor storage methods enhances the growth of fungi and promotes the production of mycotoxins (Chauhanet al.,2008).Despite the fact that maize is a crucial food to Ethiopia and it’s vulnerable to aflatoxin risk due to different geographical and climatic conditions and poor handling (Alemu et al,2008). There are limited reports on the relationship between fungal infections and aflatoxins contamination in maize crop in Ethiopia.
Materials and Methods
Description of the study areas and sample collections
The maize grain samples were collected from West Showa and East Wallega Zones of Oromia regional state which is located at about 250km to the West of Addis Ababa along the main road to Asossa. Ilu Gelan and Bako Tibe districts from West Shoa Zone; Gobu Sayo district from East Wallega Zone were selected for this studies based on their maize production potential and available storage systems. These areas annual rainfall and temperature range from 800 – 1000 mm and 15°C – 29°C, respectively. A total of 90 maize grain samples were collected; about 30 samples were collected from each district i.e., Ilu Gelan, Bako Tibe and Gobu Sayo. Maize grains were sampled from six traditional grain storage types. The samples were collected from different storage positions across different storage types. About 500gm maize grains were sampled from each sampling spot from the top, middle and bottom of each type of storage. The samples were temporary stored in the paper bag and transported to Ambo plant protection research center laboratory within 72 hour for fungal Microflora and Aflatoxins analysis.
Mycotoxigenic fungi isolation, characterization and identification
Agar plate method was used to determine the number and kind of fungi present. About 48 undamaged kernels of each sample was taken by a spatula directly into sterilized flasks and surface sterilized with 2% hypochlorite solution for 3 minutes and then rinsed in sterile distilled water. Potato dextrose agar (PDA) medium containing 100μg chloramphenicol per ml was used. About 8seeds per plate were cultured to isolate and detect the associated fungi. The plates were incubated at 25oC and the presence of A. flavus and other common fungi were observed after one week. The suspected mycotoxigenic fungi colonies were further purified individually by sub culturing on PDA plate and then on PDA slant. Isolated fungi were then identified according to Raper and Fennel (1965), Nelson et al. (1983), Rechard (1996), and Klich (2002) based on colony characteristics and morphology under light microscope.
Detection, identification and quantification of Aflatoxin B1
Specific ELISA kit was used for the detection, identification and quantifications aflatoxin B1. The samples preparation, extraction and purification were done according to the instruction given by the company (RIDASCREEN®Aflatoxin B1, Germany). ELISA reader was employed for the quantification of aflatoxin B1. Finally, detected and quantified aflatoxin B1 was used for analysis across each samples, grain and storage types.
Statistical Analysis
Statistical analysis on aflatoxin B1 concentration and standardized curve of determination was performed using mini tab version 20 and all the graph and percentage was done by excel.
Results
Assessment and identification of fungal microflora
The assessment of associated and identified fungi spps. were provided below in the Fig. 1. A total of nine species of fungi were isolated and identified as Aspergillus flavus, Aspergillus parasiticus, Fussarium verticilliodes, Penecillium notatum, Penecillium verrucosum, Fussarium proliferatum,Fussarium gramminearum, Aspergilus niger, and Trichoderma Spp. The most common fungi isolated from the maize grains were Aspergillus flavus (25.7%) and Aspergillus parasiticus (18.9%) from the total of ninety maize grain samples.
Occurrences of mycotoxigenic fungi in different maize storage types
Mycotoxigenic fungal occurrence were assessed in all maize samples collected from the six of storage types; namely open above ground(OAG), sack in open air(SOA), sack in house(SH), open sorghum stalk (OSS), improved gottera(IG), and in house ground (IHG) storages (Table1). Accordingly, the highest occurrence of mycotoxigenic fungi were seen in OAG storage typewhich has been accounted about 44(29.7%) followed by SOA 27(18.2%) and few mycotoxigenic fungal 5(3.4%) was isolated from IG. Aspergillus species; A. flavus, A. parsiticus and Fussarium species; F. gramminearum, F. verticilliodes were the most prevalent mycotoxigenic fungi in OAG and SOA storage types.
Aflatoxins detection and identification in maize grain samples
Aflatoxins B1 has been identified from the maize samples detected in laboratory using Enzyme Linked Immuno Assay (ELISA). The results of ELISA has reveal that the mean31 (34.4%) of 90 maize grain sample were above and shown toxicity higher than those recommended by Food and Drug Administration (2004) and European Union (2018)standards which states that maximum permissible level of afaltoxin B1 in maize should be 20µg/kg and 4µg/kg, respectively. Higher aflatoxin B1 concentration (73.3%) was observed in maize grains sampled from Gobu Sayo district followed byIlu Gelan(20%)(Table 2). The determination of aflatoxinB1 concentration was done by developing a curve from the supplied aflatoxin B1standard which has ranged from 0-4.5ppb (Fig. 2).
Aflatoxin B1 concentration across storage and grain types
The level of aflatoxin B1 concentration is presented in Table 3. It was observed that the level of aflatoxin B1 in sample 2,14, 57,71,74,75,78,82 and 83 was detected and measured between 3.9-381.6 ppb and its corresponding storage type were open above ground, open sorghum stalk and sack in house. It is also observed that the aflatoxin B1 level was varied with the maize grain storage types. Open above ground, open sorghum stalk and sack in house storage types were exposed to rain and high temperature which has been created conducive environment for mycotoxigenic fungi growth and development.
Notice: OAG; open above ground, OSS; open sorghum stock, SH; sack in house, SOA; sack in open air, IG; improved gottera, IGH, in house ground storage
The highest concentration of aflatoxinB1was detected and quantified in LIMU variety (8.9 ppb) followed by BH660 (4.0ppb) and BH540 (1.6ppb). Out of the total 90 sample about 34.4 % (31 samples) were possessed more than 0.05ppb concentration of aflatoxins B1 while 65.6 % (59 samples) have had the aflatoxin B1 level less than 0.05 ppb. Whereas, results of ELISA has demonstrated that 0.2 ppb as a mean aflatoxin B1 concentration for all 90 maize grain samples tested(Table 4).
The effect of maize grain storage types on the growth of mycotoxigenic fungi which in turn favor the production of aflatoxin B1were analyzed from the data of mycological results. There were six types of maize grain storage were observed during sample collection (Fig. 3). The occurrences of aflatoxin B1in different storage types were recognized different in concentrations. Accordingly, the highest aflatoxin B1 concentration were recorded in open ground (18.03 ppb) and the lowest aflatoxin B1 concentration were observed in maize grain stored in improved gottera (0.16ppb) as stated in Table 5.
Figure 3: open above ground(A), improved gottera(B), sack in house(C), sack in open air(D), Open sorghum stalk (E), in house ground(F)
Discussions
Several fungal species have been isolated from the maize grain sampled from three districts. Mycotoxigenic fungi were isolated and identified from the maize grain samples as well as the associated aflatoxin B1 was detected and quantified. Aspergillus spp. were the most predominant mycotoxigenic fungi with 50.7% frequency of occurrence followed by Fussarium spp. with 26.4%, and Penicillium spp with 22.3%.Trichoderma species was also isolated in trace amount(1.07%). Similar studies were done in Gedeo zone by Chauhan et al. (2016)and in Kewot Provence by Geremew Tassew et al. (2016). The higher frequency of fungal infection specifically Aspergillus spp. was due to poor storage types and longtime storage greater than two yearsas similarly reported by Habtamu et al.(2001).The maize grain aflatoxigenic fungi contamination started from the fields before harvest and continued across storage, consumptions and marketing which is similarly reported by Bhat et al. (1997) and Gao et al. (2007)in different maize growing countries like Ethiopia Kenya, Somalia, Uganda and Sudan. The prevalence of maize grain aflatoxin B1 contamination has reached 34.4% and higher aflatoxin B1 concentration 22 (73.3%) were observed in Gobu Sayo province followed by Ilu Gelan6 (20%).About 3.3 %and 7.7% maize samples had aflatoxinB1 higher than those recommended by Food and Drug Administration (FDA; 20µg/kg) and European Union (EU; 4µg/kg) regulatory levels respectively. The observed aflatoxin B1 concentration was very low compared to the reports of Chauhan et al. (2016) that has stated mean aflatoxins concentration for a two year stored maize grain samples53 ppb with 100% contamination in aflatoxin. The highest aflatoxin B1 concentration were recorded in open ground (18.03 ppb) this could be due to the exposure of the grain to favorable temperature and rain which in turn facilitate the growth of aflatoxigenic fungi, and the lowest aflatoxin B1 concentration were observed in grain stared in improved gottera(0.16ppb).Generally, there should be the management of mycotoxigenic fungi starting from the field, harvesting, transport, and storage through the development of mycotoxins resistant maize varieties, improvement of grains storage types and awareness creations.
Conclusions
The fungi isolated in the present study were from the different genera that are common in maize grain. A. flavus was the predominant one while other toxin-producing species such as Aspergillus parasiticus, Fussarium verticiloide and Penecillium notatum occurred at relatively at the higher levels. The aflatoxin B1 concentration in the majority of the sample are below the recommended level however, in few of the sample its level is much higher than the EU standard. The level of aflatoxinB1 concentration is higher in maize grain stored in open ground field.
Acknowledgement
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=2640http://ijcrr.com/article_html.php?did=2640
Alemu, T., Birhanu, G., Azerefgne, F., & Skinnes, H. (2008). Evidence for mycotoxin contamination of maize in Southern Ethiopia: The need for further Aflatoxins – Biochemistry and Molecular Biology 384 multidisciplinary research. Cereal Research Communications, Vol. 36, pp. 337- 339,0133-3720
Befekadu Degefe and Berhanu Nega (2000). Annual report on the Ethiopian economy, The Ethiopian Economic Association, Addis Ababa, available online https://www.eeaecon.org › node
Betran, F.J., and Isakeit, T., 2003. Aflatoxin Accumulation in Maize hybrids of different maturities. Agronomy Journal96, 565-570.
Bhat RV, Sherry PH, Amruth RP, Sudershan RV (1997) A food borne disease outbreak due to the consumption of mouldy sorghum and maize containing fumonisis mycotoxins. J Toxicol 35:249–255
ChauhanNitin M., Alemayehu P. Washe and Tesfaye Minota (2016).Fungal infection and aflatoxin contamination in maize collected from Gedeo zone, Ethiopia 7:53, pp 2-8
CDC (2004). Health Studies - Understanding Chemical and Radiation Exposureshttps://www.cdc.gov › nceh › hsb › chemicals › aflatoxin53(34);790-793.
European Communities (2006). Setting Maximum Levels of Contaminants in Certain Foodstuffs. Official Journal of the European Union L364, 5-24.
FDA (2018). Guidance & Regulation (Food and Dietary Supplements) available online (www.fda.gov/Food/GuidanceRegulation/).
FAO. 1988. FAO Trade Yearbook, 1987, 41: 380. Rome
FAO (2004). Worldwide regulations for mycotoxins in food and feed .available online www.fao.org nkvold GP. Cultural and genetic approaches to managing mycotoxins in maize. Ann Rev Phytopathol. 2003;41:99–116.
Gao J, Liu Z, Yu J (2007). Identification of Aspergillus section flaviin maize in northeastern China. Mycopathologia 11:91–95
Habtamu Fuffa, Kelbessa Urga and Funu,(2001). Survey of Aflatoxin Contamination in Ethiopia Ethiop J Health Sci Vol. 11, No.1 pp:17-25
Klich, M.A. (2002). Identification of Common Aspergillus Species. Central bureau of Shimmel cultures. Utrecht. Netherlands. p.116
Morenoa, E.C., Garciab, G.T., Onoc, M.A., Vizonid, E., Kawamurae, O., Hirookaf, E.Y. and Onoa, S.Y.E., 2009. Co-occurrence of mycotoxins in corn samples from the Northern Region of Paran? State, Brazil. doi: 10.1016/j.foodchem.2009.02.037.
Monkvold GP. (2003). Cultural and genetic approaches to managing mycotoxins in maize. Ann Rev Phytopathol. 2003;41:99–116.
Nelson PE, Toussoun TA, Marasas WFO(1983). Fusarium Species: An Illustrated Manual for Identification. Pennsylvania State University Press; University Park, Pennsylvania, USA: 1983.
Patten R.C., 1981. Aflatoxins and disease. Am J Trop Med Hyg 30:422–425.
Raper KB, Fennell DI (1965). The genus Aspergillus available online cabdirect.org
Richard A. Humber(1996). Fungi Identification Manual of Techniques in Insect Pathology, New York USA ISBN 0--12-432555-6
Wagacha, J.M. and Muthomi, J.W., 2008. Mycotoxin problem in Africa: Current Status, implications to food safety and health and possible management strategies. International Journal of Food Microbiology124, 1-12.
Geremew T, Gezmu TB, Woldegiorgis AZ, Gemede HF (2016) Study on Aspergillus Species and Aflatoxin Levels in Sorghum (Sorghum bicolor L.) Stored for Different Period and Storage System in Kewet Districts, Northern Shewa, Ethiopia. J Food SciNutr 2: 010.
Waliyar F, Ravinder Reddy Ch, Alur AS, Reddy SV, Reddy BVS, Reddy AR and Gowda CLL. 2008. Management of Grain Mold and Mycotoxins in Sorghum. Patancheru 502 324, Andhra Pradesh, India: International Crops Research Institute for the Semi-Arid Tropics. 32pp
Wen, Y., Hatabayashi, H., Arai, H., Kitamoto, H. and Yabe, K., 2004. Function of the cypX and moxY genes in aflatoxin biosynthesis in Aspergillus parasiticus. Applied and Environmental Microbiology 6: 3192-3198.