Three different presentation of same pathophysiology

We report three male patients of younger age group presented with acute vein thrombosis of different sites, right lower limb, cortical venous sinuses thrombosis with cerebral vascular accident and third case is mesenteric vein thrombosis. All patients were Vegetarian, had low level of cobalamin with marked hyper homocysteinemia with normal serum and red cell folic acid. The low Cobalamin level was not suspected secondary to pernicious anemia, based on the fact that there was no evidence of atrophic gastritis and an absence of antiparietal cell antibodies. There were no evident of immobilization, recent surgery, malignancy, antiphospholipid antibody, myeloproliferative disorder, and hormone replacement therapy. No deficiencies in protein C, protein S, or antithrombin III, normal factor V Leiden, no prothrombin gene mutation 20210A and no clone for paroxysmal nocturnal hemoglobin-urea were detected, no cause was found for the thrombosis apart from their secondary hyperhomocysteinemia.

Diagnostic value of pleural fluid interferon-gamma and adenosine deaminase in patients with pleural tuberculosis in Qatar

Objective

To investigate the diagnostic utility of interferon-gamma (IFN-γ) and adenosine deaminase (ADA) in tuberculous pleural effusions by determining the best cutoff levels of these two markers for pleural tuberculosis, in the context of the local epidemiological settings in Qatar.

Methods

We prospectively studied IFN-γ and ADA levels in the pleural fluid of patients presenting to Hamad General Hospital between June 1, 2009 and May 31, 2010.

Results

We studied 103 patients with pleural effusions, 72 (69.9%) with pleural tuberculosis, and 31 (30.1%) with nontuberculous etiologies. The mean IFN-γ concentration for the group with tuberculous effusions was significantly higher than that in the group with nontuberculous effusions (1.98 ± 81 vs 0.26 ± 10 pg/mL [P < 0.0001]). The mean ADA activity for the tuberculous effusions group was significantly higher than that in group with nontuberculous effusions (41.30 ± 20.09 vs 14.93 ± 14.87 U/L [P < 0.0001]). By analysis of receiver operating characteristic (ROC) curves, the best cutoff values for IFN-γ and ADA were 0.5 pg/mL and 16.65 U/L, respectively. The results for IFN-γ vs ADA were: for sensitivity, 100% vs 86%, respectively; for specificity, 100% vs 74%, respectively; for positive predictive value, 100% vs 88.5%, respectively; and for negative predictive value, 100% vs 69.7%, respectively.

Conclusion

IFN-γ and ADA could be used as valuable parameters for the differentiation of tuberculous from nontuberculous effusion, and IFN-γ was more sensitive and specific for tuberculous effusion than ADA.

Humoral hypercalcemic crisis in a pregnant woman with uterine leiomyoma

We report a case of parathyroid hormone-related protein-mediated hypercalcemic crisis in a 36-year-old pregnant woman, who was admitted to women hospital with recurrent vomiting and epigastric pain. She was diagnosed with uterine fibroid since the first month of her pregnancy, but the pregnancy had been uneventful. Serum calcium was 4.8 mmol/l, while parathyroid hormone was low. Hypercalcemia was attributed to humoral hypercalcemia associated with uterine fibroid as other causes of hypercalcemia were excluded.

Epidemiological features of Clostridium difficile infection among inpatients at Hamad General Hospital in the state of Qatar, 2006-2009

The aim of this retrospective study was to evaluate the epidemiology, clinical course and outcome of Clostridium difficile infection among inpatients at Hamad General Hospital in Qatar, from 2006 to 2009. During this period, 123 patients were diagnosed with C. difficile infection and the overall incidence was 1.6/10,000 patient days. The mean age (±SD) of patients was 50.9 ± 21.2 years. The most frequent underlying disease was hypertension 51/123 (41.5%) and 133 prescriptions of antimicrobials were ordered for 105/123 (86.1%) patients prior to C. difficile infection with piperacillin-tazobactam being the most frequently prescribed antimicrobial 39/131 (29.7%). Nosocomial infection was found in 101/123 (82.0%) of cases, and the most common clinical feature was watery diarrhoea 119/123 (96.7%). Antimicrobials were discontinued in 53/105 (50.5%) cases and 118/123 (95.9%) of them received metronidazole as the initial treatment. The mean treatment duration (±SD) was 9.08 ± 5.6 days. Fifteen (12.7%) patients failed the first course of antimicrobial therapy, of which four were treated with oral vancomycin, and eleven patients received both drugs. Recurrence of infection was observed in 12/118 (10.2%) patients and 30-day mortality was 38/123 (30.9%). Several clinical variables were associated with increased 30-day mortality on univariate analysis. Only occurrence of disease among Qataris, prolonged hospitalisation, positive stool occult blood test, high white blood cells and septic shock were found to be independent predictors of mortality by multivariate logistic regression analysis. In conclusion, C. difficile infection was a recognise cause of morbidity and mortality in our hospital with low and stable incidence. It involved predominantly patients younger than 65 years with underlying illness and metronidazole and vancomycin were effective in resolving symptoms in the majority of our patients.

Evaluation of the use of piperacillin/tazobactam (Tazocin) at Hamad General Hospital, Qatar: are there unjustified prescriptions?

Objectives

The aim of this study was to evaluate the appropriateness of piperacillin/tazobactam (Tazocin^®; Pfizer, New York, NY) usage in our hospital.

Subjects and methods

This retrospective study was designed to involve all patients admitted to Hamad General Hospital and prescribed piperacillin/tazobactam as an empiric therapy from January 1 to March 31, 2008. The medical records of such patients were retrospectively reviewed and studied.

Results

During this period, 610 prescriptions were ordered for 596 patients. The main indication for initiation of Tazocin was sepsis (207/610; 34%). The overall rate of appropriateness of empirical therapy was 348/610 (57%). Most of the inappropriate prescriptions were in cases of aspiration pneumonia and abdominal infections, with inappropriate prescriptions found mostly in surgical wards (86%) and the surgical intensive care unit (66.7%). Septic work-up results showed positive cultures in 57% (345/610) of cases. There were 198/254 prescriptions (78%) where antibiotics were changed according to the sensitivity data to narrow-spectrum antimicrobials. In 56/254 (22%) cases, pathogens were susceptible to narrow-spectrum antibiotics even though piperacillin/tazobactam was continued.

Conclusion

Our study showed that there was an injudicious use of piperacillin/tazobactam at our hospital, evidenced by the significant number of inappropriate empiric prescriptions and inappropriate drug modifications, based on the results of microbial cultures and antibiograms.

Peritoneal tuberculosis in Qatar: a five-year hospital-based study from 2005 to 2009

There is limited information about peritoneal tuberculosis in Qatar. This retrospective study aimed to review our experience with peritoneal tuberculosis in patients admitted to Hamad general hospital over a period of 5 years, from 2005 to 2009, with emphasis on presentation, investigation, diagnosis and therapeutic outcome. Fifty-four patients with peritoneal tuberculosis identified during the study period were included. The mean age of them was 31.85 years and 96.3% (52/54) of them were non-Qataris with male predominance. The main symptoms and signs at the time of presentation were abdominal pain and ascites respectively. Underlying diseases were described in 24% (13/54) and history of contact with tuberculous cases was present in 31.5% (17/54) of patients. Tuberculin test was positive in 66.7% (36/54). The ascitic fluid smear showed acid fast bacilli in 2% (1/53), and culture was positive in 39.6% (21/53) of cases. Laparoscopically obtained peritoneal biopsy showed caseating granulomas in 93% (40/43) and mycobacteria were identified by acid fast staining and culture in 58.5% (24/41) and 98% (40/41) of the tested specimens respectively. Most of the patients (84%; 37/44) who had completed their therapy in Qatar improved with antituberculosis therapy, and only one patient died. In conclusion, the clinical features and the imaging findings of the disease were non-specific. A high index of suspicion is essential for early diagnosis. Culture of ascitic fluid delayed the diagnosis in clinically suspected cases, whereas laparoscopically guided peritoneal biopsy provided rapid and correct diagnosis. A Six-month course with antituberculous therapy was effective and improved the outcome.

Moyamoya syndrome in a known case of pulmonary tuberculosis

We report an unusual association of pulmonary tuberculosis with moyamoya syndrome in a 30-year-old Filipino female who was admitted to our hospital with a 1-week history of fever and cough. Chest X-ray showed widespread bilateral consolidation with cavity, whereas sputum was positive for acid fast bacilli (AFB). Two weeks after starting antituberculous treatment, the patient developed two episodes of loss of consciousness, which were unwitnessed. Urgent brain computed tomography (CT) showed multiple infarctions, suggesting vasculitis. The electroencephalogram showed epileptic discharges. Magnetic resonance angiography showed a picture consistent with moyamoya disease. Brain CT angiography was performed and it showed the same pictures. The patient was diagnosed with pulmonary tuberculosis-associated moyamoya syndrome. On the following days, she was discharged on antituberculous medications, antiepileptic and oral hypoglycemic treatment. After 1 year, the patient was seen in the clinic, she was well and seizure-free.

Neurocysticercosis in Qatari patients: case reports

Neurocysticercosis is the most common parasitic infection of the central nervous system. It is a major cause of seizures in developing countries, especially in the Indian subcontinent and most of Asia, Latin America and Africa. It is increasing in prevalence in Muslim countries, especially in the Gulf region reflecting the demographics of these countries which rely heavily on labourers from highly endemic areas. Infections among Muslims in non-endemic regions are increasing. We describe one prospective case report of a Qatari male who presented with seizures and was found to have neurocysticercosis, and three retrospective cases of this infection among Qatari Muslims, who were admitted to a tertiary care hospital over the past 10 years.

Rifampicin-isoniazid induced fatal fulminant hepatitis during treatment of latent tuberculosis: A case report and literature review

A 42-year-old Indian man received 450 mg rifampicin (RIF) and 150 mg isoniazid (INH) daily after being diagnosed of a latent tuberculosis infection. Baseline serum aminotransferase and total bilirubin levels were within normal limits. On day 31 of treatment, the patient experienced epigastric discomfort and general malaise and one week later he developed nausea and episodic vomiting. The patient missed his first scheduled clinic appointment and he continued taking RIF-INH despite his symptoms. He visited the tuberculosis clinic on day 47 of treatment where he was found to be jaundiced and his liver enzymes were elevated. RIF-INH was stopped and the patient was admitted to our hospital as a case of RIF-INH induced hepatitis. On the 7th day of hospitalization, the patient developed consciousness disturbance with flapping tremor and high ammonia level. The patient was diagnosed with fulminant hepatic failure and transferred immediately to the medical intensive care unit, where he died 4 days later.

Fungal peritonitis in patients undergoing continuous ambulatory peritoneal dialysis in Qatar

Introduction: This study was conducted at Hamad General Hospital to determine the incidence of fungal peritonitis and to describe its clinical and microbiological findings in patients undergoing continuous ambulatory peritoneal dialysis in Qatar. Methodology: The medical records of these patients between 1 January 2005 and 31 December 2008 were retrospectively reviewed and the collected data were analysed. Results: During the study period, 141 episodes of peritonitis were observed among 294 patients. In 14 of these episodes (9.9%), fungal peritonitis was reported in 14 patients with a rate of 0.05 episodes per patient year, while the bacterial peritonitis rate was 0.63 per patient year. Thirteen (93%) patients had one or more previous episodes of bacterial peritonitis that was treated with multiple broad-spectrum antibiotics, 11 (85%) had received broad-spectrum antibiotics within the preceding month, 12 (92%) within three months, and 8 (62%) within six months. Candida species were the only fungal species isolated from the dialysate with predominance of non-albicans Candida species (especially Candida parapsilosis). Therapeutic approach was immediate catheter removal, followed by systemic antifungal therapy and temporary haemodialysis. Nine patients (64.3%) were continued on haemodialysis, whereas five patients (35.7%) died. Conclusions: Prior antibiotic use was an important risk factor predisposing patients to the development of fungal peritonitis. Early detection of fungal peritonitis would lead to early institution of appropriate therapy and prevention of complications.

Etiology of pleural effusion among adults in the state of Qatar: a l-year hospital-based study

There have been no systematic studies of diseases causing pleural effusion in Qatar. This prospective, hospital-based study involved all adult patients (> 15 years) with pleural effusions who were admitted to referral hospitals over a 1-year period. A total of 200 cases of pleural effusion were identified (152 males and 48 females); mean age 45.1 (SD 18.5) years. A majority of patients (73.5%) were non-Qataris, mostly from the Asian subcontinent. The most frequent cause of pleural effusions was tuberculosis (32.5%), followed by pneumonia (19%), cancer (15.5%) and cardiac failure (13%). The most frequent cause of malignant effusion was bronchogenic carcinoma (38.7%), whereas Gram-positive organisms were the most frequent isolates from empyema fluid (62.5%). Histological examination and culture of pleural biopsy were the most useful diagnostic workup for tuberculosis effusions, whereas repeated cytological examination of pleural fluid and pleural biopsy were most useful for malignant effusions.

Enterococcus gallinarum meningitis: a case report and literature review

We report a case of Enterococcus gallinarum meningitis in a 53-year-old female who was admitted to our hospital with a fever, headache, and consciousness disturbance one week after a life-saving craniotomy operation. There was obvious neck stiffness; lumber puncture was performed and cerebrospinal fluid parameters were consistent with bacterial meningitis. The patient was given ceftriaxone and vancomycin for bacterial meningitis. Cerebrospinal fluid culture yielded an isolate which was identified as Enterococcus gallinarum. The isolate was sensitive to ampicillin, ampicillin/clavulanate, linezolid, moxifloxacin and teicoplanin, but it showed intermediate sensitivity to vancomycin and quinoprism- dalfopristin. Intravenous linezolid, 600 mg every 12 hours, was started. Three days after starting treatment, the patient became afebrile; a repeat lumber puncture two week later showed no white blood cells in cerebrospinal fluid and no bacterial growth. Treatment with linezolid was continued for a total therapy duration of three weeks, after which the patient was discharged in a good condition. 

Epidemiology of bacteraemia in Hamad general hospital, Qatar: a one year hospital-based study

We conducted a one-year observational study from July 2007 to June 2008 to describe the epidemiology of bacteraemia at Hamad general hospital. During this period, a total of 452 episodes of bacteraemia occurred, which corresponds to a rate of 19/1000 hospital admissions. Most patients 58.8% (266/452) had community acquired bacteraemia, and primary bacteraemia accounted for 62.2% (281/452) of the cases. The most common source of bacteraemia was intravenous catheterization in 19.2% (87/452) but no source was identified in 42.9% (194/452) of the episodes. Gram-negative organisms were isolated in 63.1% (285/452) episodes with Escherichia coli being the most frequent 21.5% (97/452). Multidrug resistance was observed in 33.3% (7/21) of all Pseudomonas aeruginosa isolates, 50% (6/12) of Acinetobacter isolates and 28.6% (6/21) of Enterobacter isolates, whereas all ESBL producing Klebsiella spp. and E. coli were multiresistant. The percentages of oxacillin resistant coagulase negative Staphylococci isolates and methicillin-resistant Staphylococcus aureus isolates were 81.8% (27/33) and 13.2% (7/53) respectively. In hospital mortality was 22.5% (102/452), and inadequate treatment and septic shock were found to be independent predictors of mortality. Therefore, bloodstream infection surveillance is crucial to produce meaningful guidelines for prevention (e.g., catheter-related) and empirical treatment of bacteraemia in Qatar.

An imported case of P. falciparum malaria presenting as black water fever with acute renal failure

This is a report of a case of blackwater fever in a 28-year-old Nigerian man who was admitted to hospital with fever, jaundice and passing dark urine. Abdominal examination revealed splenomegaly and an examination of the peripheral smear of the patient showed the ring form of the trophozoites of Plasmodium falciparum (P. falciparum). Serum creatinine was 200micromol/L. Treatment with quinine and doxycycline was started and intravenous fluids were administered with close monitoring of the urine output and serum electrolytes. Due to the alarming amount of fluid accumulation and his exacerbated azotaemia the decision was made to haemodialyse the patient; the patient required five haemodialysis sessions during his stay in the hospital. He was discharged on the sixteenth day after admission with a serum creatinine level of 160micromol/L.

Rhabdomyolysis: a review of the literature

Rhabdomyolysis is a potentially life-threatening syndrome that can develop from a variety of causes; the classic findings of muscular aches, weakness and tea-coloured urine are non-specific and may not always be present. The diagnosis therefore rests upon the presence of a high level of suspicion of any abnormal laboratory values in the mind of the treating physician. An elevated plasma creatine kinase (CK) level is the most sensitive laboratory finding pertaining to muscle injury; whereas hyperkalaemia, acute renal failure and compartment syndrome represent the major life-threatening complications. The management of the condition includes prompt and aggressive fluid resuscitation, elimination of the causative agents and treatment and prevention of any complications that may ensue. The objective of this review is to describe the aetiological spectrum and pathophysiology of rhabdomyolysis, the clinical and biological consequences of this syndrome and to provide an appraisal of the current data available in order to facilitate the prevention, early diagnosis and prompt management of this condition.

Mycoplasma pneumoniae associated with severe autoimmune hemolytic anemia: case report and literature review

We report a case of severe hemolytic anemia following Mycoplasma pneumoniae infection in a 29-year-old male patient who was treated with azithromycin. Direct Coombs' test was strongly positive and the cold agglutinin titer was high, with anti-I specificity. Antimycoplasma antibody titer by complement fixation was high 1:10,240. The patient was discharged after 12 days of hospitalization in good health. He remains clinically well with no recurrence of jaundice.

Rosuvastatin induced rhabdomyolysis in a low risk patient: a case report and review of the literature

We report a case of rosuvastatin induced rhabdomyolysis in a low risk patient, who presented with five-day history of generalized muscle pain, weakness and easy fatigability associated with passing dark urine. Initial investigations showed creatinine 140micromol/L, creatine kinase (CK) 4566 U/L and serum myoglobin 2694 ng/ml with a significant increase in urine myoglobin. Although there were no obvious risk factors, the patient was diagnosed with rosuvastatin induced rhabdomyolysis. The drug was stopped on the first day of admission and the patient was initiated on intravenous fluid with cautious monitoring of serum electrolytes. On the following days the level of creatine kinase and serum myoglobin returned toward normal and consequently he was discharged without statins but on dietary therapy. On follow-up evaluation, the patient was symptom free his serum creatinine was 106micromol/L, whereas his LDL cholesterol was 2.1mmol/L. The rosuvastatin induced rhabdomyolysis is discussed and the danger of its use in low risk patients is emphasized.

Clinical pattern of tuberculous adenitis in Qatar: experience with 35 patients

A prospective observational study was conducted to describe the clinical presentation, diagnostic yield of fine-needle aspiration (FNA) cytology and lymph node biopsy and the outcome of tuberculous (TB) adenitis in patients admitted to Hamad General Hospital, Qatar, between 1 January and 31 December 2006. TB adenitis that was predominantly cervical was confirmed in 35 patients (28M, 7F) with a mean age of 29.4+/-9 y. Of the 35 cases, caseating granulomata were confirmed by FNA in 20, by lymph node biopsy following negative FNA in 9, and by biopsy alone in 6. Mycobacterium tuberculosis was cultured from FNA alone in 24 cases, in 9 cases from biopsies after negative FNA and in 6 cases from biopsies alone. The tuberculin test (PPD) was positive in all patients with TB adenitis (100%), while an HIV test was negative in all. The sensitivity of FNA cytology alone was 69% but when combined with a skin test it was 85%. It can be concluded that FNA cytology has an important role in the evaluation of TB adenitis, as a non-invasive alternative to excisional biopsy. After 12 months from the start of a 6-month course of combined antituberculous treatment, 32 patients were cured whereas 3 patients had left the country before completing therapy.

Thyrotoxic periodic paralysis admitted to the medical department in Qatar

OBJECTIVES

In this study we describe the clinical presentation and electrolyte disturbances of thyrotoxic periodic paralysis (TPP) in patients admitted to the Department of Medicine at Hamad General Hospital.

METHODS

Retrospective descriptive study involving patients admitted to the medical department of Hamad General Hospital with paralysis and hyperthyroidism.

RESULTS

Eighteen patients with TPP were identified over a three-year period (2004-2007). Their mean age was 32.4 +/- 8.52 years (range 21 to 48 years); all were males. Eleven patients were from the Philippines, five were from Nepal, one was Indian and one was from Sri Lanka. Fourteen patients (77.8%) had the attack in the summer while the remaining four in winter. Nine had a history of severe exertion, five had ingested a heavy carbohydrate meal, two had a sore throat, one had ingested alcoholic and one was without a precipitating cause. Fifteen patients had no previous history of hyperthyroidism. Later on, all patients proved to have hyperthyroidism. All patients were hypokalaemic, while seven patients had hypophosphataemia and three had hypomagnesaemia. Urinary potassium was <20 mmol/l in all patients. Fifteen patients had ECG changes. All patients had proximal myopathy. Twelve patients had signs of hyperthyroidism in the form of goitre, warm sweaty palms, tachycardia, and tremor. Nine patients had attacks of paralysis before diagnosis. After discharge, ten patients had recurrences within one to seven months.

CONCLUSION

The causes of hypokalaemia and lower-extremity paralysis are numerous; TPP should be taken into consideration in the differential diagnosis of all acute episodes of motor paralysis, especially in young Asian male patients.

Rhino-orbital zygomycosis secondary to Rhizopus oryzae in a renal transplant recipient successfully treated with liposomal amphotericin B

Rhino-orbital zygomycosis is usually an aggressive, fulminant and, at times, fatal disease that requires urgent medical and surgical treatment. We report a case of rhino-orbital zygomycosis caused by Rhizopus oryzae that developed in a 41-year-old male renal transplant recipient. He was diagnosed in the early post transplant period after anti-rejection therapy. The infection was successfully managed with liposomal amphotericin B and functional endoscopic sinus surgery.

Stroke in Qatar: a first prospective hospital-based study of acute stroke

BACKGROUND

Stroke is a major cause of morbidity and mortality in Qatar.

OBJECTIVES

The aim of our study was to determine types of strokes, the associated risk factors, clinical presentation, outcome, and time to hospital admission among Qatari and non-Qatari patients as well as young and nonyoung patients.

METHODS

We conducted a hospital-based prospective observational study including all patients admitted to Hamad Medical Corporation with first-ever stroke from September 15, 2004, to September 14, 2005. A stroke was defined according to World Health Organization criteria.

RESULTS

Stroke was confirmed in 270 patients of whom 217 (80.4%) had ischemic stroke and 53 (19.6%) had hemorrhagic stroke. Male patients predominated in all types of stroke. The main risk factors for stroke were hypertension and diabetes, whereas lacunar infarct was the most common subtype of ischemic stroke. Risk factor profiles were similar between Qatari and non-Qatari patients except for hypercholesterolemia, which was observed with a higher frequency in Qatari compared with non-Qatari patients with ischemic stroke. There were significant differences between the young and nonyoung patients with ischemic stroke with respect to risk factors, ejection fraction, ventricular wall-motion abnormalities, time to hospital admission, and outcome. Most patients arrived at the hospital more than 3 hours from stroke onset because of unawareness of stroke symptoms. The overall in-hospital mortality was 9.3%.

CONCLUSIONS

Hypertension and diabetes mellitus were the main risk factors for stroke in Qatar, whereas lacunar infarct was the most common subtype. Significant differences between the young and nonyoung patients were observed with respect to risk factors, ejection fraction, ventricular wall-motion abnormalities, time to hospital admission, and outcome.