Opportunistic Fungal Infections Dr.T.V.Rao MD

Opportunistic Mycosis Opportunistic mycosis a fungal or fungus-like disease occurring in an animal / human’s with a compromised immune system. Opportunistic organisms are normal resident flora that become pathogenic only when the host's immune defenses are altered, as in immunosuppressive therapy, in a chronic disease, such as diabetes mellitus, or during steroid or antibacterial therapy that upsets the balance of bacterial flora in the body. T.V.Rao M.D

Opportunistic mycosis a fungal or fungus-like disease occurring in an animal / human’s with a compromised immune system. Opportunistic organisms are normal resident flora that become pathogenic only when the host's immune defenses are altered, as in immunosuppressive therapy, in a chronic disease, such as diabetes mellitus, or during steroid or antibacterial therapy that upsets the balance of bacterial flora in the body.

T.V.Rao M.D

Common Opportunistic Fungus We find the highest frequency of opportunistic fungal infections come in the following order: 1.Candidiasis 2.Aspergillosis 3.Cryptococcosis

We find the highest frequency of opportunistic fungal infections come in the following order: 1.Candidiasis 2.Aspergillosis 3.Cryptococcosis

Candida as Opportunistic Infection

Candidosis Candidiasis also called as Monoliasis, Can infect Skin, Mucosa, or Internal Organs Called as Yeast Like fungus Currently important cause of opportunistic fungal infection.

Candidiasis also called as Monoliasis,

Can infect Skin, Mucosa, or Internal Organs

Called as Yeast Like fungus

Currently important cause of opportunistic fungal infection.

What are Candida Normal flora Exist in Mouth, Gastrointestinal tract. Vagina, skin in 20 % of normal Individuals. Colonization increases with age,in pregnancy Hospitalization Immunity Depends on T lymphocytes, and effective Immunity Important etiological agent presenting as opportunistic infection in Diabetus and HIV patients

Normal flora

Exist in Mouth, Gastrointestinal tract.

Vagina, skin in 20 % of normal

Individuals.

Colonization increases with age,in pregnancy

Hospitalization

Immunity Depends on T lymphocytes, and effective Immunity

Important etiological agent presenting as opportunistic infection in Diabetus and HIV patients

Morphology and Culturing Ovoid shape or spherical budding cells and produces pseudo mycelium Routine cultures are done on Sabouraud's Glucose agar, Grow predominantly in yeast phase A mixture of yeast cells and pseudo mycelium and true mycelium are seen in Vivo and Nutritionally poor media.

Ovoid shape or spherical budding cells and produces pseudo mycelium

Routine cultures are done on Sabouraud's Glucose agar,

Grow predominantly in yeast phase

A mixture of yeast cells and pseudo mycelium and true mycelium are seen in Vivo and Nutritionally poor media.

Macroscopic and Microscopic appearance of Candida spp

Pseudohypal structures in Candida

Normal Flora to Pathogenic fungi As Candida is present in practically all humans, it has many opportunities to cause endogenous infections in compromised host - so, Candida infections continues to most frequent opportunistic fungal infection.

As Candida is present in practically all humans, it has many opportunities to cause endogenous infections in compromised host - so, Candida infections continues to most frequent opportunistic fungal infection.

Systemic Candidosis Occurs in Patients who carry more yeasts in Mouth, Gastrointestinal system, Predisposed with Individuals with 1 On antibiotic or/and Steroid Therapy 2 Immunosupressed 3 Recipients with organ transplantation 4 Infancy – Old age – Pregnancy On Antibiotic therapy 5 Indisposed with trauma Occluding lesions, 6 Immuno Supression, Major event in AIDS patients 7 Diabetus mellitis. 8 Zink and iron deficiencies

Occurs in Patients who carry more yeasts in Mouth, Gastrointestinal system,

Predisposed with Individuals with

1 On antibiotic or/and Steroid Therapy

2 Immunosupressed

3 Recipients with organ transplantation

4 Infancy – Old age – Pregnancy

On Antibiotic therapy

5 Indisposed with trauma Occluding lesions,

6 Immuno Supression, Major event in AIDS patients

7 Diabetus mellitis.

8 Zink and iron deficiencies

Pathogenesis and Pathology Mucosal infections occur superficially –Discrete white patches on mucosal surface. Can affect tongue Infants and old persons are affected In Immune compromised /AIDS. Oral candidois is commonly seen Vaginal Candidosis causes itching soreness white discharge, White colored lesions, Pregnancy in advanced stage, Majority experience one episode in a life time T.V.Rao MD

Mucosal infections occur superficially –Discrete white patches on mucosal surface.

Can affect tongue

Infants and old persons are affected

In Immune compromised /AIDS. Oral candidois is commonly seen

Vaginal Candidosis causes itching soreness white discharge, White colored lesions,

Pregnancy in advanced stage,

Majority experience one episode in a life time

T.V.Rao MD

Predisposition after Surgery and Therapeutic Approaches Post operative Immuno Supression Use of IV catheters Use of cytotoxinc drugs and cortosteriods Use of Urinary Catheters

Post operative Immuno Supression

Use of IV catheters

Use of cytotoxinc drugs and cortosteriods

Use of Urinary Catheters

Important species of Candida in Human infections C.albicans C.tropicalis C.glabrata C.Krusei

C.albicans

C.tropicalis

C.glabrata

C.Krusei

Prominent Infections with Candida

Oral Thrush produced by Candia albicans

Many cases of AIDS are suspected by observation of Oral Cavity

Laboratory Diagnosis Skin scrapings, Mucosal scrapping, Vaginal secretions Culturing Blood and other body fluids, Observations Microscopic observation after Gram staining. Gram + yeast cells.

Skin scrapings,

Mucosal scrapping,

Vaginal secretions

Culturing Blood and other body fluids,

Observations

Microscopic observation after Gram staining. Gram + yeast cells.

Laboratory Diagnosis Isolation of Candida from various specimens confers diagnosis Serology Molecular Methods

Isolation of Candida from various specimens confers diagnosis

Serology

Molecular Methods

Microscopy Gram staining – A rapid method KoH preparation Methylamine silver staining

Gram staining – A rapid method

KoH preparation

Methylamine silver staining

Culturing Easier to culture on Sabouraud's dextrose agar Culturing in routine Blood culture Media Culturing urine - A semiquative estimations are essential Colony forming units essential in attributing infections T.V.Rao MD

Easier to culture on Sabouraud's dextrose agar

Culturing in routine Blood culture Media

Culturing urine - A semiquative estimations are essential Colony forming units essential in attributing infections

T.V.Rao MD

Easier Identification of species as C.albicans Germ tube test identifies C.albicans from other Candida species. Majority of Diagnostic laboratories depend on this test.

Germ tube test identifies C.albicans from other Candida species.

Majority of Diagnostic laboratories depend on this test.

Emerging Methods for detection of Candida Infections Molecular Methods PCR

Molecular Methods

PCR

Cryptococcosis.

Cryptococcus neoformans A Capsulated yeast – A true yeast.. A sporadic disease in the past. Most common infection in AIDS patients.

A Capsulated yeast – A true yeast..

A sporadic disease in the past.

Most common infection in AIDS patients.

Structure of C.neoformans

Morphology A true yeast Round 4 – 10 microns Surrounded by Mucopolysaccharide capsule. Thick in vivo Negative staining with India Ink and Nigrosin 60% of the infected prove positive by India Ink preparation on examination of CSF KoH preparations in Sputum and other tissues, PAS and Mucicaramine staining helps confirmation.

A true yeast

Round 4 – 10 microns

Surrounded by Mucopolysaccharide capsule.

Thick in vivo

Negative staining with India Ink and Nigrosin

60% of the infected prove positive by India Ink preparation on examination of CSF

KoH preparations in Sputum and other tissues,

PAS and Mucicaramine staining helps confirmation.

As Seen in India Ink preparation

Culturing CSF -Culturing on Sabouraud's agar, and incubated at 37 0 c for upto to 3 weeks Cultures appear as Creamy, white, yellow Brown colored Simple urease test helps in confirming the isolate.

CSF -Culturing on Sabouraud's agar, and incubated at 37 0 c for upto to 3 weeks

Cultures appear as Creamy, white, yellow

Brown colored

Simple urease test helps in confirming the isolate.

Cryptococcus neoformans Serotypes A true yeast 4 serotypes - A,B,C,D A and D - C.neofromans var neoformans B and C - C.neoformans var gatti. Many infections are caused by C.neofromans var neoformans. Found in wild/Domesticated birds. Pigeons carry C.neofromans , Birds do not get infected.

A true yeast

4 serotypes - A,B,C,D

A and D - C.neofromans var neoformans

B and C - C.neoformans var gatti.

Many infections are caused by

C.neofromans var neoformans.

Found in wild/Domesticated birds.

Pigeons carry C.neofromans ,

Birds do not get infected.

Pigeons and Red river gum tress harbors the Cryptococcus in nature

Life cycle of C.neofromans

Pathogenesis Enters through lungs - inhalation of Basidiospores of C neoformans Enters deep into lungs, Men acquires more infections, and women less infected. Self limiting in most cases, Pulmonary infections can occur. Present as discrete nodules - Cryptococcoma. T.V.Rao MD

Enters through lungs - inhalation of Basidiospores of C neoformans

Enters deep into lungs, Men acquires more infections, and women less infected.

Self limiting in most cases,

Pulmonary infections can occur.

Present as discrete nodules - Cryptococcoma.

T.V.Rao MD

Pathogenesis Can infect normal humans Abnormalities of T lymphocyte function aggravates, the clinical manifestations. In AIDS 3- 20% develop Cryptococcosis. Present with Chronic meningitis , Meningo encephalitis Manifest with – head ache low grade fever, Visual abnormalities ,Coma – fatal Treatment reduces the morbidity and cure in non immuno supressed expected.

Can infect normal humans

Abnormalities of T lymphocyte function aggravates, the clinical manifestations.

In AIDS 3- 20% develop Cryptococcosis.

Present with Chronic meningitis , Meningo encephalitis

Manifest with – head ache low grade fever,

Visual abnormalities ,Coma – fatal

Treatment reduces the morbidity and cure in non immuno supressed expected.

Pathogenesis Can manifest with involvement of ,Skin, mucosa,organs,Bones,and as Disseminated form. Can mimic like Tuberculosis ,

Can manifest with involvement of ,Skin,

mucosa,organs,Bones,and as Disseminated form.

Can mimic like Tuberculosis ,

Laboratory Diagnosis . CSF Microscopic observation under India Ink preparation Direct microscopy - Gram staining Cultures on Sabouraud dextrose agar, Serological tests for detection of Capsular antigen CSF findings mimic like Tuberculosis IN CSF - latex test for detection of Antigen Blood cultures, ELISA

CSF Microscopic observation under India Ink preparation

Direct microscopy - Gram staining

Cultures on Sabouraud dextrose agar,

Serological tests for detection of Capsular antigen

CSF findings mimic like Tuberculosis

IN CSF - latex test for detection of Antigen

Blood cultures,

ELISA

Treatment Immune competent - Fuconazole,Itraconazole Immune Deficient – Amphotericin B Flu cytosine AIDS patients are not totally cured , Relapses are frequent with fatal outcome . Rapid resistance with Fluconazole. Avoid contact with Birds

Immune competent - Fuconazole,Itraconazole

Immune Deficient – Amphotericin B

Flu cytosine

AIDS patients are not totally cured , Relapses are frequent with fatal outcome .

Rapid resistance with Fluconazole.

Avoid contact with Birds

ASPERGILLOSIS

Aspergillosis In nature > 100 species of Aspergillosis exist, Few are important as human pathogens 1 A.fumigatus 2 A.niger 3 A.flavus 4 A.terreus 5 A.nidulans

In nature > 100 species of Aspergillosis exist, Few are important as human pathogens

1 A.fumigatus

2 A.niger

3 A.flavus

4 A.terreus

5 A.nidulans

Fungal spores enters through respiratory tract

Morphology Cultured as Mycelial fungus Separate hyphae with distinctive sporing structures Spore bearing hyphae – Conidiophores terminates in a swollen cell vesicle surrounded by one or two rows of cell ( Streigmata ) from which chains of asexual conidia are produced

Cultured as Mycelial fungus

Separate hyphae with distinctive sporing structures

Spore bearing hyphae – Conidiophores terminates in a swollen cell vesicle surrounded by one or two rows of cell ( Streigmata ) from which chains of asexual conidia are produced

Pathogenesis - varied clinical presentations Allergic Aspergillosis – Atopic individuals, with elevated IgE levels 10-20% of Asthmatics react to A.fumigatus Allergic alveoitis follows particularly heavy and repeated exposure to larger number of spores Maltsters Lung – causes allergic alveolitis, who handle barley on which A.claveus has sporulated during malting process T.V.Rao MD

Allergic Aspergillosis – Atopic individuals, with elevated IgE levels

10-20% of Asthmatics react to A.fumigatus

Allergic alveoitis follows particularly heavy and repeated exposure to larger number of spores

Maltsters Lung – causes allergic alveolitis, who handle barley on which A.claveus has sporulated during malting process

T.V.Rao MD

Pathogenesis Aspergilloma – A fungal ball, fungus colonize Preexisting (Tuberculosis ) cavities in the lung and form compact ball of Mycelium which is later surrounded by dense fibrous wall presents with cough, sputum production Haemoptysis occurs due to invasion of blood vessels

Aspergilloma – A fungal ball, fungus colonize Preexisting (Tuberculosis ) cavities in the lung and form compact ball of Mycelium which is later surrounded by dense fibrous wall presents with cough, sputum production

Haemoptysis occurs due to invasion of blood vessels

Pathogenesis Invasive Aspergillosis occurs in immunocompromised with underlying disease Neutropenia Most common predisposing factor A.fumigatus is the most common infecting species In Bone marrow recipients leads to high mortality Lung sole site in 70 % of patients Fungus invades blood vessels, causes thrombosis septic emboli Can spread to Kidney and heart.

Invasive Aspergillosis

occurs in immunocompromised with underlying disease

Neutropenia Most common predisposing factor

A.fumigatus is the most common infecting species

In Bone marrow recipients leads to high mortality

Lung sole site in 70 % of patients

Fungus invades blood vessels, causes thrombosis septic emboli

Can spread to Kidney and heart.

Pathogenesis Endocarditis A rare complication Open heart surgeries are risk factors Poor prognosis Paranasal granulomas Caused by A.flavus,A,fumigtus may invade paranasal sinuses spread to bone to orbit of the eye, and Brain T.V.Rao MD

Endocarditis A rare complication

Open heart surgeries are risk factors

Poor prognosis

Paranasal granulomas

Caused by A.flavus,A,fumigtus

may invade paranasal sinuses spread to bone to orbit of the eye, and Brain

T.V.Rao MD

Zygomycosis

Zygomycosis Also called as Mucor Mycosis or Phycomycosis Saprophytic mould fungi Major Causative agents Rhizopus, Mucor, Absidia. Patents may manifest with Rhinocerbral Zygomycosis T.V.Rao MD

Also called as Mucor Mycosis or Phycomycosis

Saprophytic mould fungi

Major Causative agents Rhizopus,

Mucor,

Absidia.

Patents may manifest with Rhinocerbral Zygomycosis

T.V.Rao MD

Morphology Majority are with Broad aseptate mycelium with many number of asexual spores inside a sporangium which develops at the end of the aerial hyphae

Majority are with Broad aseptate mycelium with many number of asexual spores inside a sporangium which develops at the end of the aerial hyphae

Mucor Microscopy Non septate hyphae Having branched sporangiophores with sporangium at terminal ends T.V.Rao MD

Microscopy

Non septate hyphae

Having branched sporangiophores

with sporangium at terminal ends

T.V.Rao MD

Rhizopus Microscopy Shows non septate hyphae Sporangiophores in groups they are above the Rhizoids

Microscopy

Shows non septate hyphae

Sporangiophores in groups

they are above the Rhizoids

Important Clinical Manifestations Rhino cerebral Zygomycosis associate with Diabetus mellitus, leukemia, or lymphomas Causes extensive Cellulitis, and tissue destruction. T.V.Rao MD

Rhino cerebral Zygomycosis associate with Diabetus mellitus, leukemia, or lymphomas

Causes extensive Cellulitis, and tissue destruction.

T.V.Rao MD

Mucormycosis Cellulitis causes extensive tissue destruction. Spread from Nasal mucosa to turbinate bone,paranasal sinuses ,orbit, and Brain Rapdily fatal if untreated

Cellulitis causes extensive tissue destruction.

Spread from Nasal mucosa to turbinate bone,paranasal sinuses ,orbit, and Brain

Rapdily fatal if untreated

Other Manifestations Severe immuno compromised may manifest as primary cutaneous lesions Rarely infects Burns patients But lesions can be less severe than Brain lesions

Severe immuno compromised may manifest as primary cutaneous lesions

Rarely infects Burns patients

But lesions can be less severe than Brain lesions

Laboratory Diagnosis Histopathology more reliable than culturing A certain Diagnosis needs Biopsy Nasal discharges Sputum, rarely contain many fungal elements

Histopathology more reliable than culturing

A certain Diagnosis needs Biopsy

Nasal discharges Sputum, rarely contain many fungal elements

Histological sections Contain non septate hyphae in thromboses vessels or sinuses surrounded by leukocytes or giant cells T.V.Rao MD

Contain non septate hyphae in thromboses vessels or sinuses surrounded by leukocytes or giant cells

T.V.Rao MD

Microscopy In Koh preparation shows broad aseptate branching mycelium, and distorted hyphae But staining with Methenamine silver is more sensitive. Staining with PAS not helpful

In Koh preparation shows broad aseptate branching mycelium, and distorted hyphae

But staining with Methenamine silver is more sensitive.

Staining with PAS not helpful

Culturing Always depend on clinical history and presentation for certain diagnosis Cultured on Sabouraud's dextrose agar. T.V.Rao MD

Always depend on clinical history and presentation for certain diagnosis

Cultured on Sabouraud's dextrose agar.

T.V.Rao MD

Pathology and Pathogenesis Spread from nasal mucosa Spread to turbinate bones Para nasal sinuses , orbit, brain Associated with uncontrolled diabetes mellitus In leukemia patients , Lymphoma patients, Leads to fatal outcome, Improved with Anti fungal treatment. Spread to lungs disseminated infection,.

Spread from nasal mucosa

Spread to turbinate bones Para nasal sinuses , orbit, brain

Associated with uncontrolled diabetes mellitus

In leukemia patients , Lymphoma patients,

Leads to fatal outcome,

Improved with Anti fungal treatment.

Spread to lungs disseminated infection,.

Treatment Early Diagnosis highly essential for effective cure High doses of I V Amphotericin B Surgical interventions Control of Diabetus a basic requirement for better clinical outcome

Early Diagnosis highly essential for effective cure

High doses of I V Amphotericin B

Surgical interventions

Control of Diabetus a basic requirement for better clinical outcome

PNEUMOCYSTOSIS Identified as most Important opportunistic fungal infection in the Era of AIDS

Pneumocystosis Pneumocystis jiroveci – causes pneumonia in immunocompromised In the past considered as Protozoan Now Molecular biologic studies prove as Fungus Related to Ascomycetes Many Animals harbor in lungs in Rats, Ferrets, Rabbits, Causes the diseases in human if immunocompromised

Pneumocystis jiroveci – causes pneumonia in immunocompromised

In the past considered as Protozoan

Now Molecular biologic studies prove as Fungus Related to Ascomycetes

Many Animals harbor in lungs in Rats, Ferrets, Rabbits,

Causes the diseases in human if immunocompromised

Species Pneumocystis carnii found in rats Pneumocystis jiroveci in human species

Pneumocystis carnii found in rats

Pneumocystis jiroveci in human species

Predisposing factors Corticosteroid therapy Transplant recipients Antineoplastic therapy Transplant recipients When retroviral treatment is not started,a major cause of death in AIDS patients . Infections of the other organs is on raise, Spleen,Lymphnodes, Bone marrow,

Corticosteroid therapy

Transplant recipients

Antineoplastic therapy

Transplant recipients

When retroviral treatment is not started,a major cause of death in AIDS patients .

Infections of the other organs is on raise, Spleen,Lymphnodes, Bone marrow,

Morphology Spherical, Elliptical 4- 6 microns, contains 4 to 8 nuclei Stained with Silver stain, toludine blue, Calcoflour white Trophozites present in a tight mass P.Jiroveci is an extracellular pathogen T.V.Rao MD

Spherical, Elliptical

4- 6 microns, contains 4 to 8 nuclei

Stained with

Silver stain, toludine blue, Calcoflour white

Trophozites present in a tight mass

P.Jiroveci is an extracellular pathogen

T.V.Rao MD

Life cycle of P.Jiroveci

Pathogenesis P.Jiroveci is extracellular pathogen, In AIDS patients – infiltration of alveolar spaces with plasma cell leads to interstitial plasma cell pneumonias Plasma cells are absent in AIDS related Pneumocystis pneumonia Blockade of oxygen exchange interface, results in Cyanosis

P.Jiroveci is extracellular pathogen,

In AIDS patients – infiltration of alveolar spaces with plasma cell leads to interstitial plasma cell pneumonias

Plasma cells are absent in AIDS related Pneumocystis pneumonia

Blockade of oxygen exchange interface, results in Cyanosis

Diagnosis Ideal specimens 1 Bronchoalveloar lavage 2 Lung biopsy 3 Induced sputum Stains preferred 1.Giemsa 2 Toludine blue 3 Methenamine silver 4 Calcofluor white X ray of Chest supports the Diagnosis T.V.Rao MD

Ideal specimens

1 Bronchoalveloar lavage

2 Lung biopsy

3 Induced sputum

Stains preferred

1.Giemsa

2 Toludine blue

3 Methenamine silver

4 Calcofluor white

X ray of Chest supports the Diagnosis

T.V.Rao MD

Diagnosis Culturing yet not possible Direct Fluorescent method with Monoclonals a rapid and emerging method Serology – For epidemiological purpose only to establish prevalence of Infection.

Culturing yet not possible

Direct Fluorescent method with Monoclonals a rapid and emerging method

Serology – For epidemiological purpose only to establish prevalence of Infection.

Immunity - Pneumoctistis In the absence of immuno Supression P.Jiroveci does not cause disease . Cell Mediated immunity plays a dominant role in resitance to Infection. Infection not seen until CD4 counts drop to <400/microliters .

In the absence of immuno Supression P.Jiroveci does not cause disease .

Cell Mediated immunity plays a dominant role in resitance to Infection.

Infection not seen until CD4 counts drop to

<400/microliters .

Treatment Acute cases are treated with Trimethoprim-Sulphamehoxazole Pentamidine, Isothionate are very effective compounds

Acute cases are treated with Trimethoprim-Sulphamehoxazole

Pentamidine, Isothionate are very effective compounds

Prophylaxis Treating with TMP-SMZ Aerolized Pentamidine is effective and locally reaches higher concentration in the lungs.

Treating with TMP-SMZ

Aerolized Pentamidine is effective and locally reaches higher concentration in the lungs.

Pencillium marneffi Causes serious disseminated infection, Papular skin lesions in AIDS Common in South east Asia

Morphology A dimorphic fungi Mould at 25 0 c Yeast at 37 0 c Intracellular yeast like appearance as in Histoplasmosis The fungi are associated with Bamboo rat

A dimorphic fungi

Mould at 25 0 c

Yeast at 37 0 c

Intracellular yeast like appearance as in Histoplasmosis

The fungi are associated with Bamboo rat

Typical microscopic appearance of P.marneffi

Dimorphic chaterization of Pencillum marneffi

Pathology and Pathogenesis Inhalation of Conidia Primary site of infection RES Present with Chills, Fever Malaise Hepato splenomegaly Probably AIDS defining infection T.V.Rao MD

Inhalation of Conidia

Primary site of infection RES

Present with Chills, Fever Malaise Hepato splenomegaly

Probably AIDS defining infection

T.V.Rao MD

Laboratory Diagnosis Microscopy Tissues, skin Lymph node bone marrow Use of special stains Culturing on Sabouraud dextrose agar Immunoblot methods PCR T.V.Rao MD

Microscopy

Tissues, skin Lymph node bone marrow

Use of special stains

Culturing on Sabouraud dextrose agar

Immunoblot methods

PCR

T.V.Rao MD

Treatment Some times Amphotericin B may be considered. Major Antifungal treatments are speculative

Some times Amphotericin B may be considered.

Major Antifungal treatments are speculative

Other Opportunistic Mycoses

Other Opportunistic Fungus Advances in Medicine have resulted in increase in fungal infections Devastating systemic infections have been caused by species of 1. Fusarium 2 Paecilomyces 3 Bipolaris 4 Curvilaria 5 Alternaria

Advances in Medicine have resulted in increase in fungal infections

Devastating systemic infections have been caused by species of

1. Fusarium

2 Paecilomyces

3 Bipolaris

4 Curvilaria

5 Alternaria

Created as Educative Material for Graduate Medical Students Dr.T.V.Rao MD Email [email_address]