A decade in focus: mixed germ cell tumors with choriocarcinoma components

Introduction

This 10-year registry review aimed to investigate the clinical behaviour and outcomes of mixed germ cell tumours with choriocarcinoma components, a rare and aggressive subtype of testicular cancer, in Saudi Arabia. The study explores the demographic characteristics of affected patients, tumour profiles, and the mortality rate associated with this malignancy.

Methods

Utilizing data from the Saudi Cancer Registry, the authors identified 33 cases of mixed germ cell tumours with choriocarcinoma components among 1001 testicular cancer cases recorded between 2008 and 2017. Demographic information, including age, marital status, region of residency, year of diagnosis, and 10-year survival status, were collected. Tumour factors, such as the basis of diagnosis, origin site, behaviour, grade, extension, and laterality, were also analyzed.

Results

The majority of cases (78.8%) occurred in the young age group (18-45 years), and most tumours (97%) originated in normally descended testes. Grade IV (undifferentiated anaplastic) tumours and distant metastasis were present in 45.5% of patients. All cases exhibited malignant tumour behaviour. The overall mortality rate was 15%, with a mean time from diagnosis to death of 7.72 months (range: 0.5-21.5 months).

Conclusion

Mixed germ cell tumours with choriocarcinoma components are rare and tend to affect younger populations. These tumours demonstrate aggressive clinical behaviour, with a significant proportion presenting with high-grade lesions and metastasis at diagnosis. The observed mortality rate underscores the poor prognosis associated with this malignancy. Our study provides essential insights into the clinical characteristics of this rare tumour subtype in the Saudi Arabian population, emphasizing the need for further research to identify prognostic factors and optimize management strategies for affected patients.

Stress cardiomyopathy as a cardiovascular manifestation of COVID-19

Patients with coronavirus disease 2019 (COVID-19) may present with a broad spectrum of clinical manifestations, affecting several organ systems. Predominant cardiac manifestations include myocardial injury, heart failure, cardiogenic shock, and arrhythmias. Stress (takotsubo) cardiomyopathy, characterized by apical ballooning of the heart leading to acute left ventricular dysfunction, is rarely seen in patients with COVID-19. We present a case of COVID-19-associated stress cardiomyopathy in a female in her sixties.

Persistent Median Artery, Bifid Median Nerve, and Reversed Palmaris Longus Encountered During Cadaveric Dissection: The First Reported Case

The median artery is a transient embryological structure that normally disappears with the development of the radial and ulnar arteries. In rare instances, though, it persists as the persistent median artery (PMA). The superficial and deep palmar arches are formed through the anastomoses of the radial and ulnar arteries, giving hand and digits their main blood supply. This complex network of vessels and their anastomoses are prone to anatomical variations based on how the anastomosis occurs and which arteries contribute to this anastomosis. While it normally forms through the anastomosis of the radial and ulnar arteries, the superficial palmar arch (SPA) may also form differently, as in our case here, where the median artery persisted and branched off the radial artery, anastomosing with the ulnar artery to give rise to the SPA. This may also interfere with the normal compartmental architecture within the hand, possibly contributing to various clinical pathologies like carpal tunnel syndrome (CTS). Notably, in addition to the persistent median artery, our findings revealed a reversed palmaris longus and a bifid median nerve. These two additional variations can potentially exacerbate the risk of CTS. Alone, the coexistence of the PMA and the reversed palmaris longus is deemed a rare anomaly, only reported once in the literature. The addition of a third variation to the existing ones, like the bifid median nerve, is first reported by us and calls for more investigation for a possible genetic mutation. In this case, we report a persistent median artery, reversed palmaris longus muscle, and bifid median nerve in the forearm of a male cadaver found during a routine anatomy teaching session.

Reversed Palmaris Longus: A Rare Anatomical Phenomenon Discovered

The palmaris longus (PL) muscle is considered by many to be a vestigial muscle due to it having little to no functional significance on the upper limb. This, however, made it highly valuable in surgical procedures, especially as a graft in plastic and reconstructive cases. Variations in the muscle's morphology were discussed in the literature, but some are more rare than others. Those variations may have clinical implications on different pathologies such as Guyon's syndrome or Carpal tunnel syndrome based on the nerves and vessels surrounding it, and thus demand a proper understanding of the variation's anatomy. Here, we report a case of one of the rarer variations, a unilaterally reversed palmaris longus muscle in the left forearm of a 55-year-old male cadaver, discovered in a routine teaching session. Throughout the case, we will discuss the normal anatomy, the variation, and the clinical implications this variation may have.

A Rare Case Report of a Vertebral Artery Variant Arising From the Aorta With Its Clinical Significance: An Uncommon Anatomy Unveiled

The vertebrobasilar (VB) system, comprising two vertebral arteries and one basilar artery, is responsible for providing vital vascular supply to the central nervous system structures. Disruption in this network can lead to fatal neurologic outcomes, and variations in the origin of vessels may contribute to unexplained symptoms of clinical relevance. Therefore, an extensive understanding of the VB system's anatomy and its variations is crucial for diagnosing neurological disorders. Here, we report a case of a vertebral artery variant arising from the aortic arch proximal to the left subclavian artery in the cadaver of a 50-year-old male, discovered incidentally during a teaching dissection session. We also discuss the clinical pathophysiology and the relevance of the neurological symptoms in relation to the anomaly.

The Clinical Significance of CD163+ Tumor-Associated Macrophages (TAMs) in Laryngeal Squamous Cell Carcinoma

Background and objective The tumor's microenvironment is currently considered an important indicator of the tumor's prognosis, treatment failure, and recurrence. CD163+ tumor-associated macrophages (TAMs) are a marker of poor prognosis in many types of human cancers. In the present study, the expression of CD163+ TAMs was analyzed in laryngeal squamous cell carcinomas (LSCCs) using immunohistochemistry, and this expression was correlated with the clinical and pathological characteristics of LSCC patients. Materials and methods One commercial human larynx microarray with 80 cases of LSCCs, was used for this study. For comparison with normal laryngeal mucosa, a second microarray carrying normal tissues from all human anatomical sites, including normal laryngeal tissues, was used. Immunohistochemical staining was performed, and the primary antibody was a mouse monoclonal against human CD136. The absence of the primary antibody was used as a negative control. The percentage of positive cells was categorized into five scores: 0 (0%); 1, (1%-10%); 2, (11%-50%); 3, (51%-80%); and 4, (>80%). A case was scored as positive for CD163 with a score >= 1. The χ2 test was used to assess the CD163 expression in LSCC cases (N=80). A statistically significant difference was defined as P 0.05. Results The human larynx microarray containing 80 cases of LSCCs was used for this study. The age of the cancer patients in this array was in the range of 39 to 72, with a median of 53. LSCC grades were distributed as follows: 25 patients were designated as grade I, 43 were designated as grade II, and 6 were designated as grade III. Two tumors' (2/80) cores were missing from the microarray. Six tumors on the microarray did not have a grade designation reported by the manufacturer of the array. The expression of CD163 in normal, benign, unmatched laryngeal tissue was absent. In cancer cases, on the other hand, a significant number of LSCCs had TAMs that were positive for CD163 (87% positive tumors, with an IHC score ranging from 1 to 4, χ2=30.634; p<0.001). The rest of the LSCC cases (10 in total) had negative CD163 expression (score of 0). Conclusion A significant majority of LSCCs were found to have CD163+ TAMs expression using tissue microarrays (TMAs). This expression is positively correlated with the tumor's grade, clinical manifestation, and TNM staging. Morphologic evidence shows that the majority of LSCCs express the highest range of immunohistochemistry (IHC) scores for CD163 protein in the membranes and cytoplasm of their TAMs. This study provides evidence of the clinical significance of CD163+TAMs in LSCCs and proposes further studies to pinpoint the exact role of these cells in LSCC patients.

MINOCA mimic: Type 2 myocardial infarction due to severe aortic stenosis complicated by cardiogenic shock

Acute myocardial infarction without significant obstructive coronary disease presents a challenging clinical entity that requires timely intervention. The term myocardial infarction with nonobstructive coronary arteries (MINOCA) describes a working diagnosis attributed to varying etiologies in patients with a presumed ischemic cardiac condition. Several overlapping etiologies can be classified as type 2 myocardial infarction (MI). The 2019 AHA statement established diagnostic criteria and clarified the associated confusion, aiding in appropriate diagnosis. In this report, we present a case of demand-ischemia MINOCA and cardiogenic shock in a patient with severe aortic stenosis (AS).

Parotid Gland Tuberculosis: A Case Report and Literature Review

Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis that primarily affects the lungs. Although TB can affect many organs, involvement of the head and neck is extremely rare and involvement of the salivary glands is even rarer. Clinical diagnosis is challenging and may be misdiagnosed, as it mimics neoplasms on physical exams and imaging. In this paper, we present a case of parotid tuberculosis in a 28-year-old man who presented with a painful left parotid mass, loss of appetite, fever, and weight loss for six months. Suspicion of infection arose, and treatment began with intravenous antibiotics, followed by oral antibiotics, with no improvement. A biopsy of the patient's left parotid gland was performed, and a diagnosis of parotid TB with jaw osteomyelitis due to Mycobacterium tuberculosis infection was made. The patient was started on isoniazid for one week, followed by isoniazid, ethambutol, and rifampicin for six months. Follow-up after six months showed full resolution of the swelling.

Painless Left Scrotal Mass: A Rare Case of Paratesticular Angiofibroma

Angiofibromas, also known as angiomyofibroblastoma-like tumors or AMF-like tumors, refer to a collection of rare, benign yet highly cellular tumors of the vulva, scrotum, perineum, or inguinal region. In this paper, we present a 34-year-old Saudi man who presented with findings of a testicular tumor on physical examination and imaging and tested negative for all the markers associated with testicular tumors.

Using Donor-Derived Cell-Free DNA for Assessment of Myocardial Injury in Heart Transplant Recipients After SARS-CoV2 Infection

Purpose

A link between SARS-CoV2 infection and myocardial injury has been described. Our center utilizes non-invasive surveillance with gene expression profiling and donor-derived cell-free DNA (dd-cfDNA) in heart transplant (HTx) patients who are either stable or in whom invasive surveillance is contraindicated. We evaluated whether HTx recipients diagnosed with SARS-CoV2 infection demonstrated evidence of myocardial allograft injury using dd-cfDNA.

Methods

HTx recipients were included if they had dd-cfDNA testing (AlloSure; CareDx Inc., Brisbane, CA) within 60 days of their initial SARS-CoV2 diagnosis. Data on hospitalization, therapy, and clinical outcomes was captured. Dd-cfDNA results at the assay limit of detection (LOD, <0.12%) were set equal to the LOD.

Results

Between 3/2020 and 6/2021, we identified 12 HTx recipients with SARS-CoV2 and dd-cfDNA results within the specified time period; median age was 55 (IQR 28 - 64.5) with infection occurring 506.5 days (IQR 176 - 803.5) after transplant. Mean dd-cfDNA was 0.13 ± 0.03%, assessed 26 (IQR 20 - 35) days after infection. Prior results, available for 9 patients and obtained a median of 33 (IQR 27 - 59) days prior to infection, did not differ from post-infection values (0.13 ± 0.02%, p = 0.66). Following diagnosis, 8 (67%) patients were hospitalized; 5 had mycophenolate held, 2 received steroids, 2 received convalescent plasma, 4 received remdesivir, and 1 received monoclonal Ab therapy. At a median follow-up time of 304 (IQR 212.5 - 331) days after diagnosis, all twelve patients were alive with good allograft function (mean ejection fraction 59 ± 4.8%); interval clinically-relevant immunologic outcomes included one episode of rejection (pAMR1) and three (25%) findings of de novo donor-specific antibodies (dnDSA).

Conclusion

In this single-center pilot study assessing myocardial injury among HTx recipients within 2 months of SARS-CoV2 infection, the majority of patients had low dd-cfDNA results (<0.15%) and demonstrated good intermediate-term (6-12 months) graft function. While limited by sample size and protocol-based inclusion criteria, our findings suggest that sustained myocardial injury in HTx recipients after SARS-CoV2 infection may not be common. The impact of SARS-CoV2 infection on immunologic outcomes including rejection and dnDSA in this population merit further study.

A Case of Cytomegalovirus Colitis in an Immunocompetent COVID-19 Patient

Cytomegalovirus (CMV) is a double-stranded DNA virus that belongs to the herpesvirus family. In the immunocompetent host, CMV infection is usually mild and goes unnoticed. Patients become prone to CMV infection as a result of immunosuppressive drugs or disorders that weaken cellular immunity. In severe COVID-19 infection, the patient experiences a drop in his T lymphocytes and becomes prone to opportunistic infections such as CMV colitis. In this paper, we presented a rare case of CMV colitis in a 54-year-old female with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) polymerase chain reaction. The patient was admitted to the intensive care unit and intubated due to the severity of her presentation. The patient received high-dose dexamethasone followed by a tapering dose of prednisolone. Fifteen days post-admission, the patient started to have melena with a drop in her hemoglobin. Sigmoidoscopy revealed ulcerated lesions that extended 5 cm proximally, and multiple biopsies confirmed the diagnosis of CMV colitis. The patient was started on ganciclovir 5 mg/kg intravenously for 21 days. The patient's symptoms improved to the point where she no longer complained of melena, and her hemoglobin level normalized. The patient was discharged home in stable condition, to be followed later in the outpatient clinic.

Acquired Hemophilia A Post-COVID-19 Vaccination: A Case Report and Review

Acquired hemophilia A (AHA) is an inhibitory coagulopathy that represents a rare variant of hemorrhagic syndromes. We present a case of idiopathic AHA in a 75-year-old male patient with a cutaneous hematoma that could be attributed to a recent COVID-19 vaccination. The aim of this report is to raise awareness of a possible association between AHA and COVID-19 vaccination and to review similar reported cases and management plans to prevent the development of possible morbidity and debilitating complications. This case illustrates an exceptionally rare side effect of the COVID-19 vaccination. The advantages of obtaining the COVID-19 vaccine outweigh the risks.

A Strange Occurrence of Hematohidrosis: A Case Report From Saudi Arabia

Hematohidrosis is a rare disorder of blood excretion from the eccrine sweat gland not associated with an injury or trauma. Although several hypotheses exist to explain such a condition, the etiology of hematohidrosis remains unknown. Psychological stress is strongly linked to the condition, yet patients may present completely healthy with no identifiable etiology. The diagnosis of hematohidrosis can be difficult and requires the exclusion of bleeding disorders, vasculitis, and other disorders. Here, we present a case of hematohidrosis in a 20-year-old female who had almost weekly bloody tears, as well as gum bleeding, ear bleeding, and epistaxis for the past four months. During hospitalization, the patient was thoroughly investigated for an etiology, but no identifiable cause was found. The patient was diagnosed with hematohidrosis and treated with propranolol. Her condition had improved significantly on follow-up.

Fruitful Pregnancy Outcome in a Case of Eisenmenger Syndrome With Severe Pulmonary Hypertension: A Rare Case Report

Eisenmenger syndrome (ES) is considered an absolute contraindication for pregnancy. ES is characterized by a congenital heart abnormality that results in a significant anatomical shunt. Hemodynamic forces generate a left-right shunt, leading to severe pulmonary arterial hypertension (PAH). Eventually, the shunt will become a right-to-left shunt due to increased pulmonary vascular resistance, leading to significant hypoxemia and cyanosis. Pregnant women with ES experience volume overload as a result of the syndrome and the physiological response of pregnancy. The decrease in systemic vascular resistance that occurs during pregnancy also increases the right-to-left shunt, resulting in left ventricular failure. Due to the significant risk to both the mother and the fetus, women are advised to terminate their pregnancy during the first trimester. However, with all the odds, very few cases show positive neonatal and maternal outcomes. Appropriate management of ES includes a multidisciplinary team assembled to monitor and manage the patient carefully and thoroughly. In this paper, we present a case of ES secondary to an atrial septal defect with severe PAH in a 32-year-old woman who underwent a cesarean section at 33 weeks of gestation. She delivered a healthy baby girl. On the seventh postoperative day, she was discharged with no complications.

Unusual Lower Lip Swelling: A Rare Case of Lip Schwannoma

Schwannoma (neurilemmoma) is a benign neoplasm that arises from the nerve sheath's Schwann cells. Between 25% and 40% of all schwannomas are discovered in the soft tissues of the head and neck area, but they are infrequently detected in the oral cavity, with the lips being the most unusual site of involvement. Peripheral nerves in the intraoral cavity originate only 1% of schwannomas despite the fact that lips and oral cavity are heavily innervated anatomical areas. Schwannomas are more common in people between the third and fifth decades of life, and there is no predilection based on gender or race. Here, we report a case of lip schwannomas in a 22-year-old female. The lesion was affecting her lower lip and growing steadily for the past two years. The mass measured 1.5 x 1 cm, involving the lower lip with surface telangiectasia. The patient underwent surgical removal of the lower lip mass, and the mass was sent for histopathological correlation that showed completely excised encapsulated schwannoma with free margins. The patient did not have any postoperative complications and was discharged home on the same day. The patient was followed up in the outpatient clinics, and she made full recovery and was pleased with the outcome.

Acute Transverse Myelitis Following COVID-19 Infection: A Rare Case From Saudi Arabia

Respiratory viral illnesses can lead to a wide variety of neurological complications. However, only a few cases of acute transverse myelitis (ATM) following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported in the literature. Here, we report a case of ATM following SARS-CoV-2 infection in a 57-year-old male patient. The patient presented to the emergency room with lower abdominal pain, urinary retention, bilateral lower limbs weakness, and allodynia for the last four days. One week earlier, he had experienced fever, cough, and shortness of breath. On physical examination, he was vitally stable with sensory loss from the nipples down to the lower limbs bilaterally. His nasopharyngeal polymerase chain reaction for SARS-CoV-2 was positive. MRI of the spine showed an abnormal cord signal extending from the level of the D2 vertebra down to the conus medullaris. The main differential diagnosis was transverse myelitis, and the patient was started on pulse steroids for seven days. After the therapy, the condition of the patient improved with the restoration of power and sensory sensation in his lower limbs. A new MRI of the whole spine one month later showed normal morphology and signal intensity without any abnormal enhancement. The patient was discharged home with almost complete resolution of his symptoms for later follow-up in the clinic.

Outcomes of ST-Elevation Myocardial Infarction due to spontaneous coronary artery dissection: a nationwide cohort sample

Background

Spontaneous coronary artery dissection (SCAD) is a common, non-atherosclerotic cause of myocardial infarction (MI). While conservative therapy is preferred in most cases, its role among those presenting as ST-elevation myocardial infarction (STEMI) remains undefined.

Purpose

We aimed to explore outcomes of SCAD causing STEMI, stratifying cases by involved coronary artery and revascularization status.

Methods

We used the Nationwide Readmission Database (2015–2018) to identify patients hospitalized with STEMI by using ICD-10-Clinical modification codes, and then stratified them into SCAD or no-SCAD groups. Each group was further subdivided by involved coronary artery (i.e., left main, left anterior descending, left circumflex, or right coronary artery), and if revascularization (i.e., percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)) was performed. We excluded patients &gt;55 years old or with iatrogenic dissection. The age restriction allows us to compare a similarly aged group of patients. The primary outcome was in-hospital mortality. Cardiogenic shock, acute kidney injury, mechanical complications, length of stay, and 30-day readmission for all-cause, heart failure or MI were secondary outcomes.

Results

Of the 17,556 patients with STEMI identified, 338 (1.9%) had SCAD. Patients with SCAD were younger (median age (IQR) 46.0 (33–90) vs 49.0 (41–57); p&lt;0.001) and more likely to be female (67% vs 21.6%, p&lt;0.001). They were less likely to have PCI (55.3% vs. 80.7%; p&lt;0.001), more likely to undergo CABG (4.7% vs 1.3%; p&lt;0.001), with left main and left anterior descending coronary arteries more often affected (2.4% vs 1.1%, and 53.3% vs 48.6%; p for both =0.05, respectively). In-hospital mortality did not differ between groups (3.6% vs 3.3, p=0.81). Revascularization was associated with lower in-hospital mortality among no-SCAD patients (2.6% vs 7.0%, p&lt;0.001), but not among SCAD patients (4.0% vs 3.1%, p=0.76) even when stratified by involved coronary artery. Revascularization among SCAD patients was associated with lower 30-day readmission rates for MI (0.0% vs 2.8%, p=0.05). SCAD patients were less likely to have acute kidney injury (6.5% vs 11.2%, p=0.01), but had a longer length of stay (median (IQR) 3.0 (1.0–6.0) vs 2.0 (1.0–4.0), p&lt;0.001). Both groups had similar rates of cardiogenic shock (11.8% vs 10.6%, p=0.56), mechanical complications (0.6% vs 0.3%, p=0.22), and 30-day readmission rates for all-cause, and heart failure.

Conclusion

In-hospital mortality did not differ between patients with STEMI due to SCAD or no-SCAD. Although revascularization was not associated with lower in-hospital mortality among SCAD patients (regardless of involved coronary artery), their 30-day readmission rate for MI was lower suggesting further studies are warranted to explore patient subsets of SCAD that may benefit from revascularization.

Funding Acknowledgement

Type of funding sources: None.

A Challenging Case of Persisting Hypokalemia Secondary to Gitelman Syndrome

There are several causes of hypokalemia, including transcellular shift, renal loss, gastrointestinal loss, and decreased oral intake. Sometimes it is challenging to know the source of the problem; however, with detailed history, physical examination, and appropriate laboratory investigations, the physician should be able to narrow down the differentials diagnosis to reach the right one. One of the rare causes of hypokalemia is Gitelman syndrome, which is a salt-losing tubulopathy that manifests as renal potassium wasting, metabolic alkalosis, hypokalemia, hypomagnesemia, hypocalciuria, and hyperreninemic hyperaldosteronism. This disorder is inherited in an autosomal recessive pattern with an incidence of 25 instances per million population. We report a challenging case of persistent hypokalemia in a 30-year-old woman who presented with a history of palpitation, bilateral upper and lower limbs numbness, nausea, diarrhea, and generalized fatigue for three days. After history and physical examination, the patient was diagnosed with an episode of enteritis, and laboratory workups revealed low potassium and magnesium levels, and it was thought that these electrolyte abnormalities were secondary to gastrointestinal loss. Therefore, the patient was mainly treated supportively along with potassium and magnesium replacement. However, after one week of replacement, the patient still had low potassium and magnesium levels in spite of being diarrhea-free, so renal loss was suspected. Urine electrolytes revealed high renal potassium loss with low-normal blood pressure, arterial blood gases revealed metabolic alkalosis with a pH of 7.49 and bicarbonate level of 29 mEq/L. Repeated urine chemistry was done to check for chloride level and turned out to be high, and 24-hour urinary excretion of calcium was very low. Therefore, the patient was diagnosed with Gitelman syndrome and was managed with potassium and magnesium replacements intravenously, and was encouraged to consume a diet rich in these electrolytes. After complete resolutions of the symptoms and correction of potassium and magnesium levels, the patient was discharged home in stable condition.

Toxic Epidermal Necrolysis Post COVID-19 Vaccination - First Reported Case

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of acute, delayed-type hypersensitivity reactions that affect the skin and the mucous membranes. Medications are the culprit cause of these disorders in addition to infections and in very rare instances vaccinations. We report a case of TEN in a 49-year-old woman with no previous medical history. The disorder developed one week after receiving the first dose of COVID-19 vaccine with no other identifiable causes. The patient received two doses of tumor necrosis factor-alpha inhibitor (etanercept) and she stopped developing new lesions after two days of the initial dose; complete healing was observed after 22 days and no side effects were observed in our patient. This case demonstrates an extremely rare complication to the COVID-19 vaccine. The benefits of receiving the COVID-19 outweigh the potential risk.

Molecular characterization and risk factors for carbapenem-resistant Gram-negative bacilli colonization in children: emergence of NDM-producing Acinetobacter baumannii in a newborn intensive care unit in Turkey

BACKGROUND

Multidrug-resistant Gram-negative bacilli are responsible for more than 50% of healthcare-associated infections. Colonization dynamics, characteristics, and risk factor data for CR-GNB are scarce in children.

AIM

To examine the molecular characteristics of, and risk factors for nosocomial colonization with, carbapenem-resistant Gram-negative bacilli (CR-GNB) in hospitalized paediatric patients in a tertiary university hospital's paediatric units in Turkey.

METHODS

A prospective case-control study was performed at a university hospital in Istanbul, Turkey.

FINDINGS

A total of 1840 rectal swab specimens were collected from all 762 hospitalized children between March 2013 and October 2013. Among them, 176 (23%) patients were colonized with CR-GNB. Of these, 72 (9%) patients were colonized with carbapenem-resistant Enterobacteriaceae, 138 (18%) with CR-non-fermenter Gram-negative bacilli (CR-NF) and 34 (4%) with both. The median CR-GNB colonization time was 10 days (range: 1-116). The median duration of rectal colonization with CR-GNB was 8 days (range: 1-160). NDM (31%) was the second most frequent carbapenemase identified in Acinetobacter baumannii isolates, and has not previously been detected in Turkey. All of the 17 patients colonized with NDM-producing A. baumannii were newborns in the neonatal intensive care unit. Independent risk factors for CR-GNB colonization were: age <1 year, nasogastric tube placement, presence of underlying chronic diseases, ampicillin usage, surgical intervention, and carbapenem use.

CONCLUSION

This is the first description of NDM in A. baumannii in newborn units in Turkey. Carbapenem usage is a common independent risk factor for both CRE and CR-NF colonization, which underscores the importance of antibiotic stewardship programmes.

Delayed presentation of a large congenital laryngeal cleft in an adult

Laryngeal clefts are rare congenital malformations of the posterior laryngotracheal wall that lead to an abnormal communication between the airway and pharyngo-oesophageal tract. The condition is almost universally identified during infancy with minor laryngeal clefts very rarely diagnosed in adulthood. We present our tertiary centre's experience of a large laryngeal cleft presenting at an advanced age, with the aim of increasing awareness of this correctible cause of respiratory distress and aspiration in adults.

Role of matrix metalloproteinases and tissue inhibitor of matrix metalloproteinases-1 in Crimean-Congo hemorrhagic fever disease

AIM

Crimean-Congo hemorrhagic fever is a potentially fatal viral disease in humans caused by CCHF virus. We aimed to demonstrate change in serum levels of matrix metallopeinase/tissue matrix metalloproteinase inhibitor (MMP/TIMP) associated with CCHF.

PATIENTS AND METHODS

Blood specimens were collected in acute and convalescence periods from the patients presented to Cumhuriyet University Hospital, Department of Emergency and Infection Diseases with presumed as CCHF between May 2010 and September 2010. Forty-one age and gender matched healthy individuals had not any viral, bacterial, acute or chronic disease were enrolled as the controls. Blood specimens were centrifuged at 4000 rpm for 5 min with in "Hettich universal 32" centrifuge. Serum samples obtained were kept at -80°C. All the specimens were brought to room temperature during the study and MMP-1, 2, 7, 9, 10 and TIMP-1 tests were studied at one time using "RayBiotech" brand kit in "Grifols" brand "Triturus" model ELISA device. Acute, convalescence and control groups were compared in terms of the serum levels of MMP-1, 2, 7, 9, 10 and TIMP-1.

RESULTS

There was a statistically significant increase in serum levels of MMP-1, 7, 9, 10 and TIMP-1 in the convalescence period (p < 0.05) compared to the controls, while the increase in levels of MMP-2 was not statistically significant (p > 0.05). In acute period of CCHF, mean TIMP-1 levels of severe patients was significantly lower than that of the non-severe patients (207913 ± 31051 versus 231300 ± 13267, respectively, p = 0.023).

CONCLUSIONS

High serum levels of MMP and TIMP in CCHF disease were found to decrease as progressed to convalescence from the acute period. It is thought MMP and TIMP plays a significant role in pathogenesis of CCHF.

Molecular analysis of East Anatolian traditional plum and cherry accessions using SSR markers

We conducted SSR analyses of 59 accessions, including 29 traditional plum (Prunus domestica), 24 sweet cherry (Prunus avium), and 1 sour cherry (Prunus cerasus) selected from East Anatolian gene sources and 3 plum and 2 cherry reference accessions for molecular characterization and investigation of genetic relationships. Eight SSR loci [1 developed from the apricot (UDAp-404), 4 from the peach (UDP96-010, UDP96-001, UDP96-019, Pchgms1) and 3 from the cherry (UCD-CH13, UCD-CH17, UCD-CH31) genome] for plum accessions and 9 SSR loci [5 developed from the cherry (PS12A02, UCD-CH13, UCD-CH17, UCD-CH31, UCD-CH21), 3 from the peach (Pchgms1, UDP96-001, UDP96-005) and 1 from the plum (CPSCT010) genome] for cherry accessions were used for genetic identification. A total of 66 and 65 alleles were obtained in the genetic analyses of 31 plum and 28 cherry accessions, respectively. The number of alleles revealed by SSR analysis ranged from 4 to 14 alleles per locus, with a mean value of 8.25 in plum accessions, and from 5 to 10 alleles per locus with a mean value of 7.2 in cherry accessions. Only one case of synonym was identified among the cherry accessions, while no case of synonym was observed among the plum accessions. Genomic SSR markers used in discrimination of plum and cherry accessions showed high cross-species transferability in the Prunus genus. Because of their appreciable polymorphism and cross species transferability, the SSR markers that we evaluated in this study will be useful for studies involving fingerprinting of cherry and plum cultivars.

Churg-strauss syndrome without respiratory symptoms in a child

Churg-Strauss Syndrome (CSS) is rare in children. It consists of a small- and medium-sized vessel vasculitis, with skin and peripheral nerve involvement. It is characterized by eosinophilia, extravascular necrotizing granuloma, and eosinophilic infiltration of multiple organs particularly the lungs, but may also involve the gastrointestinal tract, the heart, and the kidneys. The condition is usually associated with a preceding history of asthma or allergic sinusitis. It has rarely been reported in children, where most of the cases had pre-existing asthma, allergic rhinitis, or atopic disease. We report a 10-year-old Arab girl proven to have CSS, with no history of asthma or allergic rhinitis, who presented with tender cutaneous nodules of lower extremities, foot drop, and peripheral eosinophilia, without any clinical respiratory symptoms or signs.

Simple sequence repeat-based assessment of genetic relationships among Prunus rootstocks

Ten SSR loci, previously developed for Prunus, were analyzed to examine genetic relationships among 23 rootstock candidates for sweet and sour cherries, of the species P. avium, P. cerasus, P. mahaleb, and P. angustifolia. Five genotypes of P. laurocerasus, not used as rootstock, were included in the molecular analysis. The number of alleles per locus ranged from 8 to 12, with a mean of 9, while the number of microsatellite genotypes varied from 8 to 17, indicating that the SSRs were highly informative. The degree of heterozygosity (0.61) was high. Clustering analysis resulted in two main clusters. The first cluster was divided into two subclusters; the first subcluster consisted of P. avium and P. cerasus, and the second subcluster consisted of P. laurocerasus. The second cluster was divided into two subclusters. The first subcluster consisted of P. mahaleb genotypes and the second consisted of P. angustifolia genotypes. The reference rootstocks also clustered with their associated botanical species. Unweighted pair-group method with arithmetic mean analysis demonstrated that P. laurocerasus genotypes had less genetic variation and that P. avium genotypes were more closely related to P. cerasus. The SSR-based phylogeny was generally consistent with Prunus taxonomy information, suggesting the applicability of SSR analysis for genotyping and phylogenetic studies in the genus Prunus.

Genetic characterization of pea (Pisum sativum) germplasm from Turkey using morphological and SSR markers

The need for the conservation of plant genetic resources has been widely accepted. Germplasm characterization and evaluation yield information for more efficient utilization of these valuable resources. The aim of the present study was to characterize the pea germplasm conserved at the Aegean Agricultural Research Institute of Turkey using morphological and simple sequence repeat (SSR)-based molecular approaches. Genetic characterization of 30 pea genotypes collected from different regions of Turkey and 10 commercial pea cultivars was performed using the criteria of the International Union for the Protection of New Varieties of Plants (UPOV) (TG 7/9 Pisum sativum), and with 10 SSR markers. We originally tested 15 SSR markers; 10 of these markers were selected on the basis of high polymorphism information content in the molecular assays. Sixty-one alleles were detected at the 10 loci. The number of alleles per SSR locus ranged from 3 (PVSBE2) to 12 (AB53), with a mean of 6.1 alleles. The most informative loci were AB53 (12 alleles), AA355 (9 alleles), AD270 (8 alleles), A9 (7 alleles), AD61 (7 alleles), and AB25 (6 alleles). The UPGMA dendrogram defined by SSR markers revealed genetic relatedness of the pea genotypes. These findings can be used to guide future breeding studies and germplasm management of these pea genotypes.

SSR-based molecular analysis of economically important Turkish apricot cultivars

Turkey is not only the main apricot (Prunus armeniaca) producer and exporter in the world, but it also has a wide variety of apricot germplasms, owing to its close proximity to the centers of apricot origin. However, there is little or no genetic information on many apricot cultivars that are extensively cultivated in Turkey. We examined the genetic relatedness of 25 Turkish and four exotic apricot cultivars using SSR (simple sequence repeat) markers that were either previously developed for apricot, or for peach (P. persica), a close relative of apricot. Allele diversity (with an average allele number of 6.37) at the SSR loci and the heterozygosity rates (with an average Ho value of 0.648) of these cultivars were found to be higher than in previous studies that used the same loci for apricot. This fact might be attributed to the analysis of different numbers of accessions in the different studies. No correlations were found between the genetic relatedness and the geographical distributions of these cultivars. The data reported here will assist in the prevention of confusions in the apricot propagation and breeding in Turkey. The findings can also be directly compared with other studies that used the same SSR markers on apricot.

Genetic characterization of green bean (Phaseolus vulgaris) genotypes from eastern Turkey

Green bean genotypes collected from eastern Turkey were characterized using simple sequence repeat (SSR) markers and morphological traits. Among 12 SSR markers, 10 produced successful amplifications and revealed DNA polymorphisms that were subsequently used to assess genetic relatedness of the genotypes. Based on the number of alleles generated and the probability of identity values, the most informative SSR loci were PVGLND5, PVMEIG, PV-ag001, and PV-ag004. Probably, due to the inbreeding nature of beans, the heterozygosity observed within genotypes was low at most of the SSR loci. The UPGMA dendrogram constructed based on the SSR data yielded two major clusters. The overall genetic distance was around 98%, among the genotypes. This information can be used to help select Turkish green bean lines.

Pattern of varicella and associated complications in children in Unite Arab Emirates: 5-year descriptive study

The objective of this study was to characterize the epidemiology of varicella and varicella-associated complications in Al-Ain, United Arab Emirates (UAE) during 2000-04. The annual number of reported cases varied from 373 to 790 per 100 000 population. Most (89%) occurred in children < 15 years old. Of 187 children requiring hospital admission, 50.3% had febrile illness due to secondary bacterial infection and 17.6% had neurological complications. The overall mortality rate among hospitalized children was 1.1%, all due to invasive group A Streptococcus. Varicella and associated complications in previously healthy children is becoming an important clinical and public health problem in the UAE.

Evaluation of cut-off values of interferon-gamma-based assays in the diagnosis of M. tuberculosis infection

SETTING

A chest disease centre in Istanbul, Turkey.

OBJECTIVE

The diagnostic accuracy of interferon-gamma-based assays for Mycobacterium tuberculosis infection may be improved by using lower cut-off values for the tuberculin skin testing (TST), QuantiFERON-TB Gold (QFT) and T-SPOT.TB (T-SPOT) assays.

DESIGN

Three assays, TST, QFT and T-SPOT, were evaluated for their diagnostic performance with respect to different cut-off values. This evaluation was carried out in a comparative study involving 100 patients with untreated culture-confirmed cavitary pulmonary tuberculosis (TB) and 47 healthy subjects.

RESULTS

The sensitivities of the assays were: TST 70%, QFT 78% and T-SPOT 83.5%, while their specificities were TST 35%, QFT 89.4% and T-SPOT 84.8%. Both QFT and T-SPOT were significantly more specific than TST (both P < 0.001), but were similiar to each other (P = 0.5). Receiver operating characteristic analysis revealed that a cut-off value of 0.818 IU/ml for QFT maximises specificity without significant loss of test sensitivity. Using lower cut-off values for T-SPOT and TST, however, also increased the sensitivity of the assay but resulted in a significant decrease in specificity.

CONCLUSION

Lower cut-off values for TST, QFT and T-SPOT increased the sensitivity of each assay, but only with a lower cut-off value for QFT could specificity be maintained.