Diabetes mellitus and obesity among South Asians with ischemic stroke across three countries

BACKGROUND

Diabetes mellitus and central obesity are more common among South Asian populations than among White British people. This study explores the differences in diabetes and obesity in South Asians with stroke living in the United Kingdom, India, and Qatar compared with White British stroke patients.

METHODS

The study included the UK, Indian, and Qatari arms of the ongoing large Bio-Repository of DNA in Stroke (BRAINS) international prospective hospital-based study for South Asian stroke. BRAINS includes 4580 South Asian and White British recruits from UK, Indian, and Qatar sites with first-ever ischemic stroke.

RESULTS

The study population comprises 1751 White British (WB) UK residents, 1165 British South Asians (BSA), 1096 South Asians in India (ISA), and 568 South Asians in Qatar (QSA). ISA, BSA, and QSA South Asians suffered from higher prevalence of diabetes compared with WB by 14.5% (ISA: 95% confidence interval (CI) = 18.6-33.0, p < 0.001), 31.7% (BSA: 95% CI = 35.1-50.2, p < 0.001), and 32.7% (QSA: 95% CI = 28.1-37.3, p < 0.001), respectively. Although WB had the highest prevalence of body mass index (BMI) above 27 kg/m2 compared with South Asian patients (37% vs 21%, p < 0.001), South Asian patients had a higher waist circumference than WB (94.8 cm vs 90.8 cm, p < 0.001). Adjusting for traditional stroke risk factors, ISA, BSA, and QSA continued to display an increased risk of diabetes compared with WB by 3.28 (95% CI: 2.53-4.25, p < 0.001), 3.61 (95% CI: 2.90-4.51, p < 0.001), and 5.24 (95% CI: 3.93-7.00, p < 0.001), respectively.

CONCLUSION

South Asian ischemic stroke patients living in Britain and Qatar have a near 3.5-fold risk of diabetes compared with White British stroke patients. Their body composition may partly help explain that increased risk. These findings have important implications for public health policymakers in nations with large South Asian populations.

Cigarette smoking as a risk factor for ischaemic stroke in young South Asian male migrants to Qatar: The BRAINS study

BACKGROUND

The incidence of stroke in the Middle East is high, given its relatively young population. Smoking is a well-recognized risk factor for ischaemic stroke, and its high regional prevalence may partly account for this increased stroke risk. This research aims to determine whether young male South Asian migrants in Qatar were adversely affected by stroke depending on their smoking status.

METHODS

Data from the ongoing international prospective BRAINS study was analysed. Male South Asian migrants to Qatar with a history of ischaemic stroke were recruited. Multivariate regression analysis was used to estimate the effects of comorbidities, such as BMI, hypertension, diabetes, hypercholesterolemia, alcohol consumption, and ischemic heart disease, on the association of age of stroke onset and smoking status.

RESULTS

We identified 778 (mean age 49.5±10.2) migrant male workers of South Asian descent with ischaemic stroke in Qatar, of which 41.3% of the sample were current smokers. Compared to non-smokers, current smokers suffered a stroke 2.03 years earlier (95%CI: 0.60-3.46, P=0.005). Multivariate regression analysis demonstrated that only current smoking status was associated with an earlier age of stroke onset (β=2.03, SE=0.74, P=0.006).

CONCLUSION

Smoking is associated with at least a two-year earlier onset of ischaemic stroke in male South Asian migrants to the Middle East. Our study has important implications for the public health management of migrants in host countries.

Risk Factors, Clinical Presentation, Diagnosis, and Treatment Outcomes of Portal Vein Thrombosis: A Five-Year Hospital-Based Study From Qatar

Background

There is a lack of robust epidemiological information on portal vein thrombosis (PVT) in Qatar. This study aimed to describe the risk factors, clinical presentation, diagnosis, and treatment outcomes of PVT in patients with and without liver cirrhosis admitted to Hamad General Hospital.

Methods

This retrospective observational study was conducted at Hamad General Hospital, Doha, Qatar. Consecutive patients with PVT between January 1, 2015 and December 31, 2019 were included in this study.

Results

We included 363 cases representing 0.05% of all inpatients admitted to our hospital during the study period. Their mean age was 47.79 ± 14.48 years. There were 258 (71.1%) males and 105 (28.9%) females. Abdominal pain was the most common presenting symptom (160 (44.1%)), while splenomegaly was the most common presenting sign (158 (43.5%)). Liver cirrhosis was the most frequent risk factor for PVT (147 (40.5%)), while no risk factors were identified in 49 (13.5%) patients. Anticoagulant therapy was given to 171/207 (82.6%) patients with acute PVT and 19/156 (12.2%) patients with chronic PVT. The options used for anticoagulation treatment were: low molecular weight heparin (LMWH) or unfractionated heparin alone, LMWH/unfractionated heparin followed by warfarin, and direct-acting oral anticoagulants (rivaroxaban). Out of the 262 patients in whom PVT recanalization was assessed, 43.8% of the cases had recanalization after anticoagulation treatment, while 12.6% of them had spontaneous recanalization without such therapy. A comparison between different anticoagulants used in this study showed no significant difference in the effectiveness of the three regimens used. The 30-day mortality was recorded for 71 patients (19.5%). The major risk factors for 30-day mortality were: age over 45 years, male sex, hepatic failure, malignancies, and bilirubin > 34 µmol/L.

Conclusion

PVT is a rare clinical entity in Qatar with liver cirrhosis being the most common risk factor. Early administration of anticoagulation therapy is associated with a significant recanalization, while age > 45 years, male sex, hepatic failure, malignancies, and bilirubin > 34 µmol/L are independent risk factors for 30-day mortality.

Splenic Abscess in Qatar: A Single-Center Experience

BACKGROUND & OBJECTIVES

Splenic abscess (SA) is a rare clinical entity. There is a lack of information on SA in most Arab and Gulf countries, including Qatar. This study describes the demographics, clinical features, microbiologic etiologies, treatments, and outcomes of patients with SA at the largest tertiary medical center in Qatar over the previous six years.

METHODS

This retrospective observational study was conducted at Hamad general hospital. It involved all patients of 18 years old or above who were admitted with the diagnosis of SA for the period between January 1, 2015, and December 31, 2020.

RESULTS

We recruited 25 patients, of which 14 (56%) were males, and 11 (44%) were females. The mean age ( ±  SD) of them was 48.64 ± 19.08 years. The mean illness duration was 22.88 ± 11.88 days. Fever was the most common presenting symptom and was found in 21 (84%) cases, whereas bacteremia was the most predisposing factor found in 15 (60%) patients. The etiology of SA was bacterial in 16 cases (64%), mixed (fungal and bacterial) in one (4%), and tuberculous in one (4%), whereas the etiological agent was unidentified in seven (28%) cases. Intravenous antimicrobial therapy was administered empirically in all patients. However, seven patients (28%) received intravenous antibiotics as the only treatment modality for SA, 15 patients (60%) underwent percutaneous drainage with a pigtail catheter, and two patients underwent splenectomy. The inhospital mortality was three (12%).

CONCLUSIONS

This study showed that SA could be caused by various organisms that should be isolated to guide the choice of antimicrobial agents. An abdominal computed tomography is a good diagnostic modality, whereas computed tomography- and ultrasonography-guided percutaneous drainage were efficient therapeutic options that reduce the need for surgery.

Anemia in Chronic Kidney Disease Patients: An Update

Chronic kidney disease (CKD) is one of the most common disabling diseases globally. The main etiopathology of CKD is attributed to progressive renal fibrosis secondary to recurrent renal insults. Anemia is a known complication in CKD patients, associated with higher hospitalization rates and increased mortality risk. CKD-associated anemia (CKD-AA) is either due to true iron deficiency and/or functional iron deficiency anemia. There is new emerging evidence about the effects of erythropoiesis stimulating agents in the treatment of CKD-AA and their role in reversing and preventing kidney fibrosis in the early stages of CKD. This effect potentially provides new scopes in the prevention and treatment of CKD-AA and in decreasing the progression of CKD and the associated long-term complications. Epidemiology, pathophysiology, and treatments of CKD-AA will be discussed.

Association of vitamin B12 deficiency with metformin use in patients with type 2 diabetes treated in the largest tertiary care hospital in Qatar

BACKGROUND

Data on the effect of metformin on serum vitamin B12 (VitB12) level in patients with type 2 diabetes mellitus (T2DM) in Qatar are limited; therefore, we aimed to assess the prevalence of VitB12 deficiency and its related factors among patients with tbl2DM treated with metformin at Hamad General Hospital in Doha, Qatar, from January 1, 2017, to December 31, 2017.

METHODS

This cross-sectional analytical study involved patients with tbl2DM aged ≥ 18 years who used metformin for at least 3 months. The serum VitB12 was quantified on a chemiluminescent enzyme immunoassay analyzer using Cobas e 801 module, Roche, and VitB12 deficiency was defined as serum VitB12 level of ≤ 145 pmol/L. All data were obtained from the patients' electronic medical records.

RESULTS

The study recruited 3124 eligible patients with tbl2DM. The overall prevalence of metformin-associated VitB12 deficiency was 30.7% [95% confidence of interval, 0.290-0.323]. A significant difference exists in the median VitB12 levels between the VitB12-normal and VitB12-deficient groups [129 vs. 286; p < 0.001]. Compared with the VitB12-normal group, the VitB12-deficient group had higher mean body mass index (BMI) (p < 0.001) and consumed higher doses of metformin (p = 0.001). They also more often used sulfonylurea (p = 0.004), dipeptidyl peptidase-4 inhibitor (p < 0.001), thiazolidinediones (p < 0.001), glucagon-like peptide 1 [GLP-1] receptor agonists (p < 0.001), alpha-glucosidase inhibitor (p < 0.001), and H2 blocker/proton pump inhibitors [PPI] (p < 0.001) than the VitB12-normal group. Moreover, the VitB12-normal group consumed more calcium supplements (p < 0.001) than the VitB12-deficient group. In the multivariate analysis, independent risk factors for metformin-associated VitB12 deficiency in patients with tbl2DM include high daily dose of metformin >2000 mg, male gender, high BMI, smoking, sulfonylurea, dipeptidyl peptidase-4 inhibitor, H2 blockers/PPI, low fasting blood glucose, and low hemoglobin.

CONCLUSION

This study showed a high prevalence of VitB12 deficiency in patients with tbl2DM taking metformin and a significant negative correlation between the daily dose of metformin and serum VitB12 level. Therefore, regular screening for serum VitB12 is necessary in patients with tbl2DM on metformin treatment, especially those who have the abovementioned risk factors.

Coronavirus Disease-19-associated Acute Pancreatitis: Report of Three Cases and Review of Case Reports

BACKGROUND: Reports on coronavirus disease 2019 (COVID-19) associated with acute pancreatitis continue to emerge. In this series, we present three cases of acute pancreatitis associated with COVID-19 with no obvious etiology. CASE REPORTS: The first case was a 47-year-old man who presented with severe abdominal periumbilical pain, preceded by fever and dry cough. Based on a positive COVID-19 polymerase chain reaction (PCR) test and elevated serum amylase and lipase >3 times the upper normal limit, the diagnosis of COVID-19 and acute pancreatitis were established. The next case was a 57-year-old man with confirmed COVID-19 who developed severe epigastric pain radiating to the back and was associated with nausea and vomiting. His serum amylase and lipase were elevated >3 times the upper normal limit confirming the diagnosis of acute pancreatitis. The third case was a 31-year-old man who presented to the emergency department with a few hours of severe epigastric pain radiating to the back associated with nausea and vomiting. Two days before his presentation, he had a runny nose and fever. A combination of serum amylase and lipase elevation, >3 times the upper normal limits, and a positive COVID-19 PCR test were obtained concurrently, confirming the diagnosis of COVID-19 associated acute pancreatitis. All patients were admitted to the Mesaieed Hospital COVID-19 facility and received treatment for COVID-19 according to our local guidelines, while acute pancreatitis was treated conservatively. All three patients were discharged in good condition. CONCLUSION: This case series suggests a possible correlation between COVID-19 and acute pancreatitis.

Anaphylaxis following rivaroxaban ingestion: report of an extremely rare case

We reported an anaphylactic reaction following ingestion of rivaroxaban in a 48-years-old male, who was recently discharged from the hospital as a case of deep vein thrombosis. At home, the patient developed a diffuse itchy skin rash, shortness of breath, and vomiting 30 minutes after rivaroxaban ingestion. Emergency Medical Service found that the patient had severe dyspnea, low blood pressure, and decreased blood oxygen saturation. The patient was given oxygen, intramuscular epinephrine, intravenous hydrocortisone, diphenhydramine, salbutamol nebulizer, and was immediately transferred to the emergency department of Hamad General Hospital. Subcutaneous enoxaparin was initiated, while hydrocortisone and salbutamol nebulizer continued. On the next day, his vital signs had stabilized, and intravenous hydrocortisone was switched to prednisolone tablets, and salbutamol nebulizer was switched to budesonide/salmeterol inhaler, whereas enoxaparin was overlapped with warfarin. After achieving the target international normalized ratio (INR), enoxaparin was discontinued and the patient was discharged with significant clinical and laboratory improvement.

Frequency of Acute Kidney Injury in Patient Receiving Piperacillin - Tazobactam: A Hospital-based Study from Qatar

BACKGROUND

several studies have been reported piperacillin-tazobactam (TAZ / PIPC)-associated AKI with various frequencies. The aim of this study was to determine the frequency of TAZ/PIPC- associated AKI among our patients and to identify the risk factors for this clinical entity.

METHODS

this retrospective cross-sectional study was conducted at Hamad General Hospital; it involved adult patients who were admitted from January 2017 to December 2017.

RESULTS

we involved 917 patients, of whom 635 (69.25%) were males and 282 (30.75%) were females. The mean age of the patients was 52 (SD 19) years, and 98 (10.7%) patients were diagnosed with AKI. The patients with AKI were significantly older than without AKI [59.71 (SD 19.79) versus 51.06 (SD 18.67); P <0.001]. After TAZ/PIPC initiation, the mean creatinine level in the AKI group was higher than the mean creatinine level in the non-AKI group, [158.91 (SD 81.93) versus 66.78 (SD 21.42); P<001]. The mean time of onset of AKI after PIPC/TAZ initiation was 4.46 (SD 3.20) (1-12 days). AKI was significantly associated with low mean serum albumin (P<0.001), high mean fasting blood glucose (P<0.001), coronary artery diseases (P<0.001), heart failure (P<0.001), liver diseases (P=0.047), diabetes mellitus (P=0.021) and hypertension (P<0.001). The in-hospital mortality was significantly higher in the AKI group [38.78% versus 5.13% in the non-AKI group; P<0.001], and only advanced age and heart failure were found as independent risk factors for TAZ/PIPC-associated AKI.

CONCLUSION

TAZ/PIPC was significantly associated with AKI. Advanced age and heart failure were identified as independent risk factors for TAZ/PIPC-associated AKI.

Enterococcal meningitis/ventriculitis in Qatar-Experience with eight patients

Background & objectives: Enterococcal meningitis/ventriculitis (EMV) is a relatively rare condition that usually affects patients with underlying diseases. This study was designed to describe the clinical profile, laboratory parameters, treatment, and outcomes of EMV in patients admitted to Hamad General Hospital, Qatar.

Methods and material: This retrospective hospital-based study described the patients with EMV from 2009 to 2013.

Results: Eight patients were recruited for the study. Their median age was 42 years (21.50–53.75 years). Six patients (75%) were males, and two (25%) were females. Fever was the most common presenting symptom being present in seven (87.5%) cases. Six patients (75%) had nosocomial EMV, and all acquired the infection after placement of an external ventricular drain (EVD). The isolated species include seven (87.5%) E. faecalis and one (12.5%) E. gallinarum, and all of them were sensitive to ampicillin and vancomycin. In all patients with nosocomial EMV, the infected EVDs were removed, and the eight patients received empirical antibiotics that were modified upon receipt of culture results. All patients were cured, and no mortality was reported.

Conclusions: EMV is a recognized complication related to the introduction of EVD, whereas community-acquired enterococcal meningitis was reported among children who had no established risk factors or immunosuppression. Because of its nonspecific clinical presentation, treating physicians should have a high suspicion index.

Tuberculous Adenitis with Concurrent Hodgkin Lymphoma: A Case Report

The concomitant occurrence of tuberculous adenitis and Hodgkin lymphoma is rare, posing a diagnostic dilemma since both have similar symptoms, such as lymphadenopathy, weight loss, fever, and night sweats. We reported such a case in a 15-year-old girl who presented with fever and neck swelling and was found to have lymphadenopathy. A biopsy of the right supraclavicular lymph node showed Reed-Sternberg cells and stained positive for acid-fast bacilli and tuberculosis culture. The patient was diagnosed with tuberculous adenitis with concurrent Hodgkin lymphoma in the same lymph node. She was started on anti-tubercular medications and chemotherapy and showed clinical improvement. This case highlights the need for suspicion in order to identify these two disorders in the same patient, since missing one of them is possible and may lead to fatal complications.

Role of Fiberoptic Bronchoscopy in the Rapid Diagnosis of Sputum Smear-negative Disseminated Tuberculosis with Pulmonary Miliary Infiltrates

Objectives

We sought to evaluate the role of bronchoscopy-related procedures such as bronchoalveolar lavage (BAL), bronchial wash (BW), bronchial brush (B brush), transbronchial biopsy (TBB), and post-bronchoscopy sputum (PBS), alone or in combination, in the rapid diagnosis of negative sputum smear disseminated tuberculosis (TB).

Methods

We performed a secondary post hoc analysis of data collected from our previous study entitled "Disseminated tuberculosis among adult patients admitted to Hamad General Hospital, Qatar: A five-year hospital-based study" with a modified objective.

Results

We identified 27 patients. BAL fluid was positive for acid-fast bacilli (AFB) smear in 7/27 (25.9%) patients and were culture-positive for Myobacterium tuberculosis in 17/27 (63.0%) cases, while BW collections were smear-positive in 9/27 (33.3%) cases and culture-positive for M. tuberculosis in 18/27 (66.7%) cases. TBB showed caseating granulomas in 10/16 (62.5%) cases and one case of non-caseating granuloma (6.3%). PBS was positive for AFB in 4/8 (50.0%) patients. The combination of these procedures enabled us to diagnose disseminated TB rapidly in 22 (81.5%) cases.

Conclusions

Bronchoscopy proved to be an effective method for the rapid diagnosis of disseminated TB in patients in whom sputum smear microscopy was negative.

Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-Based Study

BACKGROUND

The main purpose of this study was to describe the demographic and clinical features of cryptic disseminated TB; it was also aimed to shed light on diagnostic test, procedure results, organ involvement, and outcomes of cryptic disseminated TB in patients with confirmed disseminated TB.

MATERIALS AND METHODS

We performed a secondary post hoc analysis of collected data from our previous study entitled "Disseminated Tuberculosis among Adult Patients Admitted to Hamad General Hospital, Qatar: A Five-Year Hospital-Based Study" with modified objectives. This study included patients admitted from January 1, 2006 to December 31, 2010.

RESULTS

Twenty-three patients were recruited with non-miliary patterns on chest x-ray. Their mean age was 34.4±12.6 years and 15 (65.6%) were males. The mean duration of illness was 46.13±48.4 days and the most common presenting symptom was fever in 20 patients (87%), while 3 (13%) patients had underlying medical conditions with diabetes mellitus 2 (8.7%), being the most common. Bronchoalveolar lavage (BAL) and bronchial wash (BW) fluids were Acid-fast bacilli (AFB) positive in 1/4 (25%) of the cases and culture-positive for Mycobacterium tuberculosis (M. tuberculosis) in 4/4 (100%) of all the cases. Two patients (8.7%) had positive sputum smear, while 18 (78.3%) patients had positive culture for M. tuberculosis. All except one patient completed their treatment in Qatar. One patient died one month after the start of antituberculous treatment.

CONCLUSION

Cryptic disseminated TB should be suspected when a patient from TB-endemic countries develops unexplained fever and cough despite normal or non-miliary pattern chest radiograph. Moreover, respiratory specimen cultures should be obtained from these patients, regardless of the symptoms presented and the initial site of the involved organ.

Epidemiological and Clinical Features of Salmonella Typhi Infection Among Adult Patients in Qatar: A Hospital-based Study

Objectives

We sought to describe the epidemiological and clinical features of typhoid fever in Qatar.

Methods

We conducted a retrospective study of adult patients treated for typhoid fever at Hamad General Hospital and Alkhor Hospital between 2005 and 2012.

Results

The mean age of the 354 patients enrolled in the study was 28.4±9.3 years; 296 (83.6%) were males. There were 42, 48, 39, 44, 46, 47, 52, and 36 cases of adults with typhoid fever in 2005, 2006, 2007, 2008, 2009, 2010, 2011, and 2012, respectively. Overall, 343 (96.9%) patients had a history of travel to endemic areas. Among them, 93.0% acquired typhoid fever in the Indian subcontinent. Fever was observed in all cases, and the other predominant symptoms were abdominal pain (38.1%), diarrhea (35.6%), and headache (33.1%). Salmonella typhi, showed high resistance to ciprofloxacin (n = 163; 46.0%), and low resistance to ceftriaxone (n = 2; 0.6%). Four patients developed intestinal perforation, which was surgically repaired in two cases. Two patients (0.6%) died.

Conclusions

Typhoid fever was frequent among immigrants to endemic areas. Travelers returning from endemic areas with suspected typhoid fever should be treated empirically with third-generation cephalosporin after obtaining appropriate cultures. Moreover, preventive measurements such as education on food and water hygiene, and effective vaccination of travelers should be practiced widely among travelers to endemic areas to reduce morbidity and mortality.

Incidence and epidemiological features of acute pancreatitis among adult inhabitants in Qatar

BACKGROUND/AIMS

Acute pancreatitis (AP) is one of the most common gastrointestinal causes of hospital admission in Qatar. The aim of the present study was to investigate the epidemiological features and demographic characteristics of patients with AP and to estimate the annual incidence rates of this disease among adult inhabitants in Qatar.

MATERIALS AND METHODS

This retrospective study was conducted using the data collected by reviewing records of patients with AP admitted to the medical and surgical wards of Hamad GeneralHospital and Alkhor Hospital, Qatar from January 2007 to December 2012. Diagnosis of AP was based on abdominal pain suggestive of AP, serum lipase and/or amylase at least three times the upper limit of normal, and/or characteristic findings of AP on abdominal ultrasound or computed tomography.

RESULTS

A total of 382 AP events were reported in 334 patients. There were 250 (75%) males and 84 (25%) females. The mean age (±SD) of the patients was 56.8±18.7 years. Gallstone disease (40.6%) was the highest cause of AP, followed by alcohol consumption (28.5%) and idiopathic AP (20.7%). The mean annual incidence rate of AP was 5 per 100,000 adult inhabitants in Qatar from January 2007 to December 2012. The incidence rate among men was higher than that among women. Mortality rate was low (0.3%), and there were complications in 112 (29.3%) patients.

CONCLUSION

The annual incidence rate of AP is relatively low in Qatar and tends to behave similar to many European countries in etiology, which can be explained by population structure. Gallstone and alcohol consumption are the main causes, and idiopathic AP is responsible for more cases than expected.

Nosocomial Pseudomonas putida Meningitis: A Case Report and Literature Review

We report a case of Pseudomonas putida meningitis in a 26-year-old Nepalese man who was admitted to Hamad General Hospital with epidermoid cyst for drainage. Ommaya reservoir was placed into the cyst for drainage and externalventricular drainage (EVD) was performed. After four days, the patient was transferred to the ward in stable condition. His weakness resolved partially and headache severity decreased. After three days, the patient developed fever and headache severity increased with deterioration of consciousness level. Cerebrospinal fluid (CSF) through EVD showed 2 200 leucocytes/µL, protein level of 295 mg/dL, and glucose level of < 1.8 mg/dL. Meropenem was started on the patient. Aspirate from Ommaya reservoir and CSF showed gram-negative rods and cultures yielded P. putida sensitive to cefepime, gentamycin, ciprofloxacin, and amikacin, but resistant to meropenem and piperacillin-tazobactam. EVD was replaced and the patient received cefepime and ciprofloxacin for 21 days after which he improved and was discharged with right sided residual weakness.

Acinetobacter Infections among Adult Patients in Qatar: A 2-Year Hospital-Based Study

This retrospective study was conducted at Hamad General Hospital, Qatar, to describe the demographic data, clinical features underlying diseases, antimicrobial susceptibility, and outcome of A. baumannii infection. It involved all adult patients 15 years of age or older who were managed at Hamad General Hospital for A. baumannii infection from January 1, 2012, to December 31, 2013. We identified a total of 239 patients with A. baumannii infection, of which 182 (76.2%) were males. The mean age was 49.10 ± 19.57 years. The majority of the episodes (25.1%) occurred in elderly patients (≥65 years) and the most commonly identified site of A. baumannii infection was the respiratory tract, 117 (48.9%). Most episodes of infection, 231 (96.7%), were hospital-acquired and high rate of nosocomial infections occurred in the medical intensive care unit, 66 (28.6%). All patients had underlying medical conditions. Maximum resistance was seen to cefotaxime, 147 (58.3%), and minimum resistance was seen to colistin, 2 (1.4%). Of the 239 isolates, 102 (42.7%) were susceptible and 137 (57.3%) were multidrug-resistant. The in-hospital mortality in our study was 31%. Male gender, multidrug resistance, and septic shock were found to be independent mortality predictors.

Adult Klebsiella pneumoniae meningitis in Qatar: clinical pattern of ten cases

OBJECTIVE

To describe the clinical presentation, underlying diseases, antimicrobial susceptibility, treatment and outcome of Klebsiella pneumoniae meningitis patients.

METHODS

This retrospective study involved all patients with 15 years of age or older who admitted to Hamad General Hospital with culture proven Klebsiella pneumoniae meningitis from January 1, 2007 to December 31, 2012.

RESULTS

A total of ten cases were identified (nine males and one female). Their mean age was (43.3±12.8) years. Eight patients (80%) had nosocomial meningitis with neurosurgery being the most frequent associated condition. Fever and altered consciousness were the most frequent symptom. Cerebrospinal fluid showed elevated protein and glucose levels. Gram stain showed Gram-negative rods in 50% of cases, while positive cerebrospinal fluid culture results were found in all patients. Multidrug resistance was observed in two cases, and all patients had received appropriate empirical and definitive antibiotic treatments. The mean duration of intravenous antimicrobial treatment was (19.3±7.0) d and all patients with external ventricular drains underwent removal of the device, while in-hospital mortality was 50%.

CONCLUSIONS

The number of cases was too small to come up with therapeutic and prognostic conclusions. Further large-scale prospective study is needed.

Epidemiology, Clinical Features and Outcome of Liver Abscess: A single Reference Center Experience in Qatar

OBJECTIVE

To describe the etiology, clinical presentation, management and outcome of liver abscess in adult patients admitted at Hamad general hospital, Qatar.

METHODS

A cross sectional study was conducted to involve all adult patients who sequentially encountered episodes of liver abscess during the period from January 1, 2009, to December 31, 2010. Blood cultures were drawn from all patients in the first 24 hours after admission. In addition, all patients had stool examinations and indirect Hemagglutination test for Entameba histolytica. Aspiration of abscess was done under CT guidance and aspirated pus was sent for gram stain and culture.

RESULTS

In total, 67 patients were admitted with liver abscess; 56 patients with pyogenic liver abscess and 11 with amebic liver abscess. There were 61 (91%) males and six (9%) females and their mean age was 47.4 ± 18.5 years. Fever, abdominal pain and vomiting were the commonest presenting features. Of the 56 pyogenic liver abscess patients, four discharged against medical advice and seven refused all invasive procedures and were treated with antibiotics for six weeks. The remaining 44 (79%) patients were treated with antibiotics and one or more invasive procedures, while one patient was treated surgically. The commonest organism isolated was Klebseilla pneumonia found in 21 patients (38%). The mean duration of hospitalization was 13.6 ± 8.1 days; the mean duration of antibiotic therapy was 34.7 ± 40.6 days, and one patient died. In contrast, all amebic liver abscess patients underwent ultrasound guided aspiration and showed good response to metronidazole treatment. Their mean duration of hospitalization was 7.7 ± 4.1 days, mean duration of therapy was 11.8 ± 2.1 days, and all patients were cured.

CONCLUSION

Pyogenic liver abscess was more common than amebic liver abscess with Klebseilla pneumonia being the commonest organism. With good medical measures and early drainage of liver abscess, surgical intervention was unnecessary in almost all the cases.

Ischaemic hepatitis precipitated by recurrent episodes of atrial fibrillation

We report a case of ischaemic hepatitis associated with recurrent fast atrial fibrillation (AF) episodes in a 59-year-old male who presented with shortness of breath, nausea and vomiting. The patient had a history of ischaemic cardiomyopathy. An emergency electrocardiogram showed fast AF with a ventricular rate of 190 min(-1). The aspartate aminotransferase (AST) level was 2222Ul(-1), alanine aminotransferase (ALT) was 1255Ul(-1), lactate dehydrogenase (LDH) was 1842Ul(-1) and serum creatinine was 150 μmoll(-1). An ultrasound of the abdomen showed an enlarged liver with hypoechoic lesions. The patient received digoxin. In the next few days, while liver enzymes and serum creatinine started to return to normal levels, the patient had two attacks of fast AF, each associated with elevated liver enzymes and a concomitant rise in serum creatinine. The patient was transferred to the intensive care unit to improve control of his AF, after which his liver enzymes and renal function gradually returned to normal.

Nosocomial Escherichia coli meningitis in adults: Report of four cases and literature review

We report four cases of nosocomial E. coli meningitis, in male patients with accidental and neurosurgical trauma. The interval between accidents/neurosurgical procedures and the onset of meningitis was 2-15 days (mean 6.25 days). The most consistent clinical features were fever and deterioration of consciousness level. Emergence of extended spectrum beta lactamase E. coli strains had been observed in two (50%) of our cases and the mean duration of antimicrobial treatment was 16.5 days (range: 6-24 days). Two of the four patients (50%) died in the hospital.

Rhabdomyolysis. The role of diagnostic and prognostic factors

Rhabdomyolysis, literally meaning the breakdown of muscle tissue, is a common syndrome with many causes, acquired ones such as exertion, trauma, infections, temperature extremes, drugs, toxins, electrolyte and endocrine abnormalities, and congenital ones such as myopathies and connective tissue disorders. All results in a common pathophysiologic pathway which ends with the dispersing of muscle tissue content into the circulation. Rhabdomyolysis has characteristic clinical, laboratory and radiologic features, but does require a high index of suspicion so that the diagnosis would not be missed. The sensitivity and specificity of the various characteristics, as well as clinical guidelines, are discussed in this paper. The syndrome may present with several complications, e.g. arrhythmias, electrolyte abnormalities, acute renal injury, acidosis, volume depletion, compartment syndrome and disseminated intravascular coagulation. The prognosis is highly variable and depends on the underlying etiologies and complications, but is in general considered as good. The milestone of treatment is vigorous fluid resuscitation. Treatment options, in practice and in research, are discussed in the following pages.

Encephalopathy secondary to isoniazid in patients on hemodialysis

We report isoniazid (INH)-induced encephalopathy in two male patients on hemodialysis. One of them had tuberculous adenitis, and the other had pulmonary tuberculosis. Both were given rifampicin, INH, pyrazinamide, and ethambutol with pyridoxine 40 mg/day. Two patients developed disturbances in consciousness. After excluding other causes, INH-induced encephalopathy was suspected so the drug was stopped and dose of pyridoxine increased. Both patients retained their consciousness within 1 week and were discharged.

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.