Chemokine Levels among Patients with Middle East Respiratory Syndrome Coronavirus Infection

Middle East respiratory syndrome coronavirus (MERS-CoV) is associated with significant morbidity and mortality due to intense pulmonary inflammation. Enhanced chemokine-mediated leukocyte infiltration in lungs has been linked with unfavorable outcomes with respect to the disease. This cross-sectional study assessed the levels of chemokines among 46 MERS-CoV-infected patients (19 asymptomatic and 27 symptomatic) and 52 healthy controls using a customized Luminex human chemokine magnetic multiplex panel. The plasma levels of interferon-inducible protein (IP)-10 (568.5 ± 114.7 vs. 55.19 ± 5.85 pg/mL; p < 0.0001), macrophage inflammatory protein (MIP)-1 alpha (MIP-1A) (30.78 ± 2.81 vs. 18.16 ± 0.91 pg/mL; p < 0.0001), MIP-1B (36.63 ± 4.25 vs. 25.26 ± 1.51 pg/mL; p < 0.003), monocyte chemoattractant protein (MCP)-1 (1267 ± 309.5 vs. 390.0 ± 35.51 pg/mL; p < 0.0002), and monokine-induced gamma interferon (MIG) (28.96 ± 3.93 vs. 16.29 ± 1.69 pg/mL; p < 0.001), interleukin (IL)-8 (147.9 ± 21.57 vs. 84.63 ± 10.62 pg/mL; p < 0.004) were significantly higher in symptomatic patients than healthy controls. Likewise, the levels of IP-10 (247.6 ± 80.09 vs. 55.19 ± 5.85 pg/mL; p < 0.0002) and MCP-1 (650.7 ± 149 pg/mL vs. 390 ± 35.51 pg/mL; p < 0.02) were also significantly higher in asymptomatic patients compared to healthy controls. However, no differences were observed in the plasma levels of MIP-1A, MIP-1B, MIG, and IL-8 between asymptomatic patients and uninfected controls. Conversely, the mean plasma levels of regulated on activation normal T cell expressed and secreted (RANTES) (3039 ± 301.0 vs. 4390 ± 223 pg/mL; p < 0.001) and eotaxin (176.9 ± 30.20 vs. 296.2 ± 28.11 pg/mL; p < 0.01) were significantly lower in symptomatic MERS-CoV-infected patients compared to healthy controls. Likewise, the levels of eotaxin (162.7 ± 21.60 vs. 296.2 ± 28.11 pg/mL; p < 0.01) were also significantly lower in asymptomatic patients. Interestingly, the level of MCP-1 (2139 ± 548.2 vs. 776.5 ± 165.3 pg/mL; p < 0.004) was significantly higher in deceased symptomatic patients compared to recovered symptomatic patients. MCP-1 was the only chemokine associated with a higher risk of mortality. Symptomatic MERS-CoV-infected patients had a significant elevation of plasma chemokines and elevated MCP-1 levels were found to be associated with fatal outcomes.

Diagnostic performances of celiac disease serological tests among Saudi patients

BACKGROUND

: The prevalence of celiac disease (CD) is relatively high in Saudi Arabia, and little is known about the accuracy of serological markers in the local population. This study aimed to assess the diagnostic performance of various serological markers for detecting CD in Saudi children and adults.

METHODS

We conducted a retrospective study of 148 CD patients and 512 controls to assess the diagnostic performances of IgA anti-tissue transglutaminase antibodies (TTG), IgG anti-TTG, IgA anti-deamidated gliadin peptide antibodies (anti-DGP), IgG anti-DGP, and endomysium antibodies (EMA).

RESULTS

: Immunoglobulin A (IgA) anti-TTG was the most sensitive test [98.9% (95% confidence interval (CI) 94.1-99.8%)], while EMA was the most specific [100%, 95%CI 98.6-100%]. By applying the criteria of IgA anti-TTG titers ≥10 × upper limit of normal (ULN) and positive EMA, 57.3% of patients could have avoided intestinal biopsy. IgG anti-DGP test had a sensitivity of 85.9% (95% CI = 77.3-91.5%) and a specificity of 93.5% (95% CI = (90.0-95.9%). Titers of IgA anti-TTG, IgA anti-DGP, and IgG anti-DGP were higher in CD patients with the Marsh 3c class than in those with the Marsh 3b and Marsh 3a classes. IgG anti-TTG and IgA anti-DGP had no additional diagnostic value.

CONCLUSIONS

: IgA anti-TTG and EMA are excellent CD markers in children and adults. The use of IgA anti-TTG titers ≥10 × ULN and positive EMA as criteria for CD diagnosis in children and adults might be a good alternative to intestinal biopsy.

Differential expression of carcinoembryonic antigen-related cell adhesion molecule-5 (CEACAM5) and dipeptidyl peptidase-4 (DPP4) with detection of Middle East respiratory syndrome-coronavirus in peripheral blood

BACKGROUND

Middle East respiratory syndrome-coronavirus (MERS-CoV) utilizes CD26 (dipeptidyl peptidase-4) and CD66e or CEACAM5 (carcinoembryonic antigen-related cell adhesion molecule 5) receptors for cell infection. Peripheral blood mononuclear cells (PBMCs) play a critical role in mounting adaptive immune response against the virus. This study was performed to assess the expression of CD26 and CD66e on PBMCs and their susceptibility to MERS-CoV infection.

METHODS

Surface expression of CD26 and CD66e receptors on PBMCs from MERS-CoV patients (n = 20) and healthy controls (n = 20) was assessed by flow cytometry and the soluble forms were determined by enzyme-linked immunosorbent assay (ELISA). MERS-CoV UpE and Orf1a genes in PBMCs were detected by using Altona diagnostics reverse transcription polymerase chain reaction (RT-PCR) kit.

RESULTS

Mean fluorescent intensity (MFI) of CD66e was significantly higher on CD4 + lymphocytes (462.4 ± 64.35 vs 325.1 ± 19.69; p < 0.05) and CD8 + lymphocytes (533.8 ± 55.32 vs 392.4 ± 37.73; p < 0.04) from patients with MERS-CoV infection compared to the normal controls. No difference in MFI for CD66e was observed on monocytes (381.8 ± 40.34 vs 266.8 ± 20.6; p = 0.3) between the patients and controls. Soluble form of CD66e among MERS-CoV patients was also higher than the normal controls (mean= 338.7 ± 58.75 vs 160.7 ± 29.49 ng/mL; p < 0.01). Surface expression of CD26 on PBMCs and its soluble form were no different between the groups. MERS-CoV was detected by RT-PCR in 16/20 (80%) patients from whole blood, among them 8 patients were tested in PBMCs, 4/8 (50%) patients were positive.

CONCLUSION

Increased expression levels of CD66e (CEACAM5) may contribute to increased susceptibility of PBMCs to MERS-CoV infection and disease progression.

A CD40 variant is associated with systemic bone loss among patients with rheumatoid arthritis

OBJECTIVES

Little is known about genes predisposing to systemic bone loss (SBL) in rheumatoid arthritis (RA). Therefore, we examined the association between SBL and variants of genes playing a critical role in both immune response and bone homeostasis among patients with RA.

METHODS

IRAK-1 rs3027898, IRAK-2 rs3844283, IRAK-2 rs708035, IFIH1 rs1990760, CD40 rs48104850, TNFAIP3 rs2230926, and miR146-a rs2910164 were genotyped in 176 adult RA patients. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (DXA).

RESULTS

Low BMD was observed in 116 (65.9%) patients. Among them, 60 (34.1%) had low femoral neck (FN) Z score, 72 (40.9%) had low total femur (TF) Z score, and 105 (59.6%) had low lumbar spine (LS) Z score. Among all the SNPs assessed, only CD40 rs4810485 was found to be associated with reduced TF Z score with the CD40 rs4810485 T allele protecting against reduced TF Z score (OR = 0.40, 95% CI = 0.23-0.68, p = 0.0005). This association was confirmed in the multivariate logistic regression analysis (OR = 0.31, 95% CI = 0.16-0.59, p = 3.84 × 10^-4). Moreover, median FN BMD was reduced among RA patients with CD40 rs4810485 GG genotype compared to RA patients harbouring CD40 rs4810485 TT and GT genotypes (0.788 ± 0.136 versus 0.826 ± 0.146 g/cm², p = 0.001). IRAK-1 rs3027898, IRAK-2 rs3844283, rs708035, IFIH rs1990760, TNFAIP3 rs2230926, and miR146-a rs2910164 were not found to be associated with SBL.

CONCLUSION

This study for the first time ever demonstrated an association between a CD40 genetic variant and SBL among patients with RA.

KEY POINTS

• CD40 rs4810485 GG genotype is associated with decreased BMD among patients with RA. • CD40 rs4810485 might serve as a genetic marker for SBL in RA. • CD40 genetic variations might be integrated in future development of more effective therapeutic interventions for prevention of SBL in RA.

Expression of VEGF, EGF and HGF in early- and late-stage colorectal cancer

The heterogenous nature of colorectal cancer (CRC) highlights the need for a better understanding of the growth factors that affect tumour growth and cancer progression. The aim of the present study was to evaluate the role of epidermal growth factor (EGF), vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF) in the early (I and II) and late (III and IV) stages of CRC. The serum levels and mRNA expression (n=30) of the aforementioned growth factors were measured and immunohistochemistry (n=20) was performed in patients with CRC. Histological examination revealed comparable distribution of early-stage [I: 8 (26.7%) and II: 7 (23.3%)] and late-stage [III: 8 (26.7%) and IV: 7 (23.3%)] CRC. The mean serum concentrations of VEGF during the early (152.9±14.5 vs. 88.39±3.99 pg/ml; P=0.001) and late (182.7±25.8 vs. 88.39±3.99 pg/ml; P=0.002) stages were significantly higher compared with those in controls. Similarly, the mean serum concentrations of EGF in the early (409.4±7.96 vs. 153.7±13.8 pg/ml; P=0.05) and HGF in the late (90.4±17.4 vs. 56.9±4.97 pg/ml; P=0.05) stages were significantly higher compared with those in controls. The serum concentrations of VEGF, EGF and HGF were comparable between the early and late stages of CRC. Compared to normal tissues, the mRNA expression of both VEGF (P<0.001) and HGF (P<0.01) was upregulated in early-stage and downregulated in late-stage CRC. The expression of EGF remained significantly elevated during both the early and late stages of CRC (P<0.01). Histopathological analyses confirmed increased expression of VEGF in cancerous tissues compared with that in normal tissues. The present study emphasized the need for monitoring the serum levels and tissue expression of growth factors to fully elucidate their role in patients with CRC.

1231 A Full-Cycle Audit Of ‘Safe’ Surgical Handovers in A Tertiary Centre

Aim

1. Assess performance in surgical handovers at Southampton General Hospital (SGH) against RCS ‘Safe Handover’ guidelines Identify any areas for improvement to ensure safe and effective handover of surgical patients

Method

10 evening surgical handovers were anonymously audited In October 2019 against RCS ‘safe handover’ guidelines. The results were subsequently analysed and circulated amongst the surgical department. Handovers were then led consistently by surgical registrars and advanced nurse practitioners (ANPs). A prompt including the RCS handover guidelines was made and distributed to all members of the surgical team and included in departmental inductions. Following this, a further 10 evening handovers were anonymously audited between July and August 2020.

Results

Many aspects of handover performance descriptors described by the RCS in the re-audit improved following the circulation of our prompt including RCS handover guidelines and examples of minimum or good standards of practice for handover. Specifically, handover timeliness, the briefings provided (100% from 70%), the audibility of a single speaker (70% from 30%), the number of educational discussions held during handovers (100% from 50%) and awareness of the on-call overnight consultant (100% from 80%) all vastly improved.

Conclusions

Emphasis on undertaking effective handovers needs to continue as ‘safe' handovers between shifts can protect both patient and doctor safety. This is especially true following the implementation of the European Working Time Directive (EWTD) and a move to full shift working. Handovers are also proposed as opportunities for training which may be helpful especially in an era of reduced hours of surgical training.

In the peripheral blood mononuclear cells (PBMCs) of HCV infected patients the expression of STAT1 and IRF-1 is downregulated while that of caspase-3 upregulated

Several peripheral blood mononuclear cell (PBMC) defects have been linked with hepatitis C virus (HCV) infection, including alterations in cytokine secretion and increased cell death. This study was performed to investigate the expression levels of signal transducer and activator of transcription 1 (STAT1), interferon regulatory factor 1 (IRF-1), and caspase 3 in PBMCs of patients infected with HCV. STAT1, IRF-1, and caspase 3 expression levels were compared in PBMCs from 19 untreated (naïve) HCV+ patients, 8 treated (sustained responder [SR]) HCV patients, and 20 HCV- healthy controls. Moreover, PBMCs from naïve HCV+ patients and SR-HCV patients were also evaluated for HCV RNA expression. The expression levels of STAT-1 and IRF-1 were significantly downregulated in PBMCs from naïve HCV+ patients (P  Keywords: PBMC; hepatitis C virus; STAT1; IRF-1; caspase-3.

The effect of low versus high tidal volume ventilation on inflammatory markers in animal model undergoing lung ventilation: A prospective study

Background and Aims:

Mechanical ventilation (MV) with high tidal volume (Vt.) may induce or aggravate lung injury in critically ill patients. It might also cause an overwhelming systemic inflammation leading to acute lung injury (ALI), diffuse alveolar damage (DAD) and multiple organ failure (MOF) with subsequent high mortality. The objective of this study was to compare the effects of different Vt. on the inflammatory markers of the broncho-alveolar lavage (BAL) fluid and lung biopsy in a group of animal model (Beagle dogs).

Methods:

A two-phased prospective study involving 30 Beagle dogs (15 dogs/phase), each phase divided into three groups (each 5 dogs/group). In the first phase each group received MV with Vt. of 8 (low), 10 (normal, control group), and 12 (high) ml/kg body weight (b.w.) respectively. BAL fluid was obtained at the time of induction of anesthesia immediately following tracheal intubation and one hour later following MV to count the macrophages, neutrophils and lymphocytes. In the second phase of the experiment, in addition to obtaining (BAL) fluid similar to the phase one, mini thoracotomy and lung biopsy obtained from the upper lobe of the right lung at same timings for histopathological examination study. Mann-Whitney-Wilcoxon test was used for statistical analysis of the data obtained.

Results:

BAL fluid analysis showed increase in the counts of macrophages and lymphocytes with Vt. of 12 ml/kg b.w. compared to the control group (10 ml/kg b.w.) (P < 0.05). in the second phase, similar findings obtained. The histopathological study of the lung tissue obtained in the second phase of the study from the group that received a high Vt. of 12 ml/kg b.w. showed significant inflammatory changes with presence of neutrophil infiltration and edema in the bronchial wall compared to the control group (10 ml/kg b.w.) (P < 0.05).

Conclusions:

The use of high Vt. in ventilated animal lung model may increase the risk of inflammation and subsequent damage in healthy lungs, these findings may help physicians to avoid using high Vt. in short-term mechanically ventilated patients in the operating room setting.

Assessment of Th1/Th2 cytokines among patients with Middle East respiratory syndrome coronavirus infection

Middle East respiratory syndrome coronavirus (MERS-CoV) is a member of the beta-coronavirus genus of zoonotic origin that emerged in the Arabian Peninsula and is associated with significant morbidity and mortality. This study was conducted to assess the plasma levels of cytokines to evaluate the Th1/Th2 status among 46 MERS-CoV-infected patients (19 asymptomatic and 27 symptomatic) and 52 normal healthy controls using a customized luminex kit. Comparative analysis of data between MERS-CoV-infected patients and normal healthy controls revealed that although no difference was observed between asymptomatic MERS-CoV patients and controls, the mean plasma levels of interleukin (IL)-10 (44.69 ± 40.04 pg ml-1 versus 14.84 ± 6.96 pg ml-1; P < 0.0001), IL-4 (22.46 ± 8.02 pg ml-1 versus 16.01 ± 9.97 pg ml-1; P < 0.0001), IL-5 (10.78 ± 2.86 pg ml-1 versus 8.06 ± 1.41 pg ml-1; P < 0.0001) and IL-13 (14.51 ± 3.97 pg ml-1 versus 11.53 ± 4.16 pg ml-1; P < 0.003) in MERS-CoV symptomatic patients were significantly higher than the normal controls. The mean plasma levels of interferon (IFN)-γ and IL-12 were no different among the study groups. The cytokine profile among symptomatic MERS-CoV-infected patients was skewed to a Th2 type immune response.

Pattern of antinuclear antibody and antiextractable nuclear antigen antibody test requisitions in Riyadh

Background:

International guidelines for screening of systemic autoimmune rheumatic diseases (SARD) recommend antinuclear antibody (ANA) test as the first level test and antiextractable antigen (anti-ENA) along with anti-double-stranded DNA (anti-dsDNA) as second line tests following a reactive ANA test. This study was performed to assess adherence to international guidelines for investigation of SARD and to compare the requesting pattern of ANA and second level tests between rheumatology and nonrheumatology physicians in Riyadh.

Methodology:

This retrospective cross-sectional study comprising of 300 first time requests for investigation of SARD was performed in the immunology unit at King Khalid University Hospital (KKUH). Data were collected between April and May 2018. Information regarding the requesting physicians’ specialty and the first time requested tests (ANA, anti-dsDNA, and anti-ENA) were extracted from the electronic medical records. Reasons for requisition of tests were also recorded.

Results:

Of the total requests, 159 (53%) requests included ANA as a single first level test, whereas the rest of the requests (n = 141, 47%) included ANA test in conjunction with second level tests for the investigation of SARD. From the department of rheumatology, 14 (29.8%) initial requests were for ANA test as the only first line investigation that was significantly lower than 145 (57.3%) similar requests from the rest of the departments (P < 0.001).

Conclusion:

ANA and second level tests requests by physicians particularly among rheumatologists lacked compliance to international guidelines. The current study strongly suggests the need for strict compliance to international guidelines for screening of systemic autoimmune disorders among physicians.

Screening for Q fever. A tertiary care hospital-based experience in central Saudi Arabia

OBJECTIVES

To evaluate the presence of Coxiella burnetii  (C. brunetii) infection among patients presenting with fever of unknown origin (FUO).

METHODS

A cross-sectional study of 100 patients (54 men and 46 women; mean age: 34.3 ± 19.2 years) with FUO was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia between March 2015 and June 2016. Phase 1 and phase 2 C. burnetii-specific antibodies in serum samples were detected by enzyme-linked immunosorbent assay.

RESULTS

Coxiella burnetii phase 1 and phase 2 antibodies were detected in 16% of the patients. Phase 2 IgM was present in 2% of the patients, whereas phase 2 IgG antibodies were detected in 11%  of the patients. Coxiella burnetii-specific phase 1 IgG was found in 2% of the patients, and 8% of the patients harbored phase 1 IgA antibodies in their serum.

CONCLUSION

The presence of C. burnetii-specific antibodies in many patients suffering from FUO highlights the importance of Q fever screening among patients presenting with febrile illness.

Association of IL-13 rs20541 and rs1295686 variants with symptomatic asthma in a Saudi Arabian population

OBJECTIVE

Interleukin 13 (IL-13) plays a critical pro-inflammatory role in asthma. Several single nucleotide polymorphisms (SNPs) are associated with asthma susceptibility in specific populations; however, further replicative studies in other ethnic groups are mandatory.

METHODS

The association between IL-13 SNPs rs762534, rs20541, rs1295686, and rs1800925 (risk alleles A, A, T, and A, respectively) and asthma predisposition in a Saudi Arabian cohort was examined via a case-control cross-sectional study.

RESULTS

The frequencies of alleles between asthmatics and control populations were significantly different for rs20541 and rs1295686 SNPs (p < 0.001), whereas the frequencies of genotypes between asthmatics and controls were significantly different only for rs20541. The association of the risk (minor) alleles with asthma was examined using the dominant genetic model. Individuals with at least one copy of the risk alleles A (for rs20541) and T (for rs1295686) had significantly greater odds of being asthmatic (OR = 2.13, 95% CI = 1.39-3.26, p < 0.0001; OR = 1.69, 95% CI = 1.12-2.54, p = 0.008) relative to their most common homozygous genotypes. On the other hand, the minor A alleles for rs762534 and rs1800925 were not significantly associated with asthma risk. Regarding haplotype association analysis, individuals with at least one copy of the minor "risk" allele for both rs20541 and rs1295686 (CATG and CATA, respectively) had greater odds of being asthmatic relative to CGCG haplotype; however, this trend was not statistically significant (p > 0.3).

CONCLUSIONS

IL-13 minor T and A alleles for rs1295686 and rs20541, respectively, were associated with significantly higher risk of asthma in the Saudi Arabian population.

Clinical and therapeutic features of brucellosis: An 11-year study at a tertiary care hospital in Riyadh, Saudi Arabia

To study the varying presentations, risk factors, and treatment outcomes among patients with physician-diagnosed brucellosis. This retrospective analysis evaluated all cases of brucellosis reported at King Khalid University Hospital during 2003-2013. Data were retrieved from patient records and a laboratory information system. Descriptive statistics were generated to summarize the study variables. Fisher's exact test or Pearson's chi-square test was used to compare categorical variables. Out of 163 patients identified with brucellosis, 76.7% of patients were culture positive. Fever was the most frequent symptom (85.9%), followed by arthralgia (46.6%). The most common clinical signs was splenomegaly (12.9%), followed by hepatomegaly (11.0%). Laboratory investigations revealed lymphocytosis and anemia in 66.3% and 55.2% of the patients, respectively. Approximately half of the patients (47.8%) had high erythrocyte sedimentation rates, and 56.4% had neutrophilia. Raw milk consumption and direct contact with animals were reported by 45.4% and 16.0% of patients, respectively. Treatment failure and relapse were observed in 8 (5.7%) cases. All treatment failures and relapses occurred among children <= 10 years of age or adults > 45 years old (11.0% vs. 0%; p = 0.006). Our findings demonstrate that raw milk consumption can be a substantial factor in brucellosis prevention in Saudi Arabia. Laboratory findings, along with the observed pattern in clinical signs and symptoms, can potentially mean underdiagnosis of mild cases. Age was the only factor associated with unfavorable treatment outcomes.

Screening for skin-sensitizing allergens among patients with clinically suspected allergic contact dermatitis

Objectives:

To detect common skin-sensitizing agents among patients experiencing allergic contact dermatitis (ACD).

Methods:

This was a retrospective study of 152 patients with clinically suspected ACD who underwent patch testing in an allergy clinic at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia between January 2012 and February 2015. Of these patients, only 74 (48%) patients reacted to one or more contact allergens. This group of patients included 58 (78.4%) women and 16 (21.6%) men (mean age: 37.8±13.8 years). Patch testing was performed using the thin-layer rapid-use epicutaneous patch test panels.

Results:

Nickel sulfate was the most common sensitizing agent, with 26 (35.1%) patients yielding a positive result; followed by p-phenylenediamine in 17 (22.9%), butyl-tetra-phenol formaldehyde in 12 (16.2%), gold sodium thiosulfate in 10 (13.5%), and thimerosal in 6 (8.1%) patients. Nickel reactivity was significantly higher among women (41.4%) than among men (12.5%) (p<0.0001). Similarly, gold reactivity among women (15.5%) was also higher than among men (6.2%) (p≤0.02).

Conclusion:

The high level of skin sensitization due to nickel, PPD, and gold in patients with ACD emphasizes the need for measures to decrease exposure to these sensitizing agents.

Assessing the Detection of Middle East Respiratory Syndrome Coronavirus IgG in Suspected and Proven Cases of Middle East Respiratory Syndrome Coronavirus Infection

Middle East respiratory syndrome coronavirus (MERS-CoV) causes severe respiratory disease with significant mortality. Two testing methods are currently used for MERS-CoV diagnostics: nucleic acid detection (the gold standard) and serological analysis. In this study, we evaluated the detection of MERS-CoV-IgG in suspected and proven cases of MERS-CoV infection. We enrolled 174 patients: 113 had respiratory symptoms/suspected MERS-CoV infection, 31 had confirmed influenza A or B infection, 23 had a recent confirmed MERS-CoV infection, and 7 had confirmed MERS-CoV infection 1 year before. All underwent MERS-CoV RNA and MERS-CoV-IgG testing. Thirty patients were found to be MERS-CoV RNA positive; however, during serological analysis, only 6 (3.4%) patients were positive for MERS-CoV-IgG, 1 (0.6%) patient was equivocal, and 167 (96%) patients were negative. Among the serological positives, four were recently MERS-CoV RNA positive and two were MERS-CoV RNA negative. No cross-reactivity to influenza A or B was detected. Based on the lack of correlation between nucleic acid and serological analysis, we conclude that MERS-CoV-IgG testing may not be suitable for diagnosing acute infection or estimating its prevalence during an outbreak. In addition, our findings show that MERS-CoV-IgG may not have significant value in determining disease severity or prognosis.

Micro RNA-146a But Not IRAK1 is Associated with Rheumatoid Arthritis in the Tunisian Population

BACKGROUND

Rheumatoid arthritis (RA) is characterized by the production of an array of proinflammatory cytokines through the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signaling pathway. Interleukin-1 receptor (IL-1R) and Toll-like receptors contain a common cytoplasmic motif the Toll/IL-1R (TIR) homology domain. This motif is required for NF-κB activation. IL-1R-associated kinase 1 (IRAK1) is a key adapter molecule recruited during the signaling cascade of the TIR. Its gene expression is regulated by the micro-RNA (miR)-146a.

OBJECTIVE

We investigated the role of IRAK1 single-nucleotide polymorphism (SNP) rs3027898 (IRAK1 rs3027898) and miR-146a SNP rs2910164 (miR-146a rs2910164) in Tunisian patients with RA and their association with C reactive protein (CRP), rheumatoid factor (RF), anticyclic citrullinated peptide (anti-CCP) antibodies, and erosion.

PATIENTS AND METHODS

In a cohort of 172 adult RA patients and 224 matched controls, IRAK1 rs3027898 genotyping was determined by mutagenically separated polymerase chain reaction (MS-PCR) with newly designed primers, and miR-146a rs2910164 genotyping was determined by fragment length polymorphism PCR-restriction (RFLP-PCR).

RESULTS

The IRAK1 rs3027898 A allele was detected in 67% of RA patients and 70% of controls indicating that it is not associated with RA in codominant, dominant, or recessive models even after stratification by age and gender. The miR-146a rs2910164 G allele was detected in 76% of RA patients and 68% of controls, thus the C allele confers some protection based on a dominant model [CC+GC (odds ratio (95% confidence interval) = 0.6 (0.3-0.9), p = 0.03)]. No association with CRP, RF, anti-CCP, or erosion was found for either SNPs.

CONCLUSION

The IRAK1 rs3027898 was not associated with RA, whereas C allele of miR-146a rs2910164 was found to be protective. Functional studies are required to investigate the exact role of miR-146a rs2910164 during RA.

Increased Spontaneous Programmed Cell Death Is Associated with Impaired Cytokine Secretion in Peripheral Blood Mononuclear Cells from Hepatitis C Virus-Positive Patients

Peripheral blood mononuclear cells (PBMCs) play a critical role in clearing hepatitis C virus (HCV). PBMC defects have been linked with HCV infection; however, the underlying mechanisms remain obscure. We hypothesized that PBMCs of HCV-infected patients are more susceptible to programmed cell death (PCD), and are therefore unable to clear HCV. We compared spontaneous PBMC PCD and cytokine [interleukin (IL)-1, -6, -8, -10, and -12] secretion between untreated (naive) HCV⁺ and treated [sustained responder (SR)] patients with HCV, and HCV^- healthy controls. Spontaneous PBMC PCD was assessed by annexin-V fluorescein isothiocyanate/propidium iodide staining, and cytokine levels were measured by cytometric bead array. Differences between groups were analyzed through paired and nonpaired t tests and Mann-Whitney U test. The rate of spontaneous PCD was higher in PBMCs of naive HCV⁺ patients (p < 0.0001) and SR-HCV patients (p < 0.002) than in HCV^- controls. Significantly low levels of IL-8, -6, and -10 were detected in the supernatant of cell cultures of PBMCs from naive HCV⁺ (p < 0.05) and SR-HCV (p < 0.05) patients relative to HCV^- controls. There was no difference between the naive HCV⁺ and SR-HCV groups in terms of PBMC PCD rate or cytokine levels. The present findings indicate that HCV infection is associated with increased PBMC susceptibility to PCD and decreased production of IL-8, -6, and -10.

Assessment of antigen presenting cell infiltration in lung tissues of patients with bronchiectasis

BACKGROUND

Bronchiectasis is a chronic disease characterized by permanent dilatation of the conducting airways accompanied by sustained inflammation.

AIMS

To assess whether chronic inflammation of lungs in bronchiectasis is associated with alterations in the numbers of infiltrating antigen presenting cell (APC).

SETTING AND DESIGN

Lobectomy specimens from 12 nonsmoker, nonasthmatic patients with acquired (noncongenital) bronchiectasis and six control patients were included in the study. Histopathology slides were reviewed, and immunohistochemical markers for dendritic cells (DCs) macrophages and Langerhans cells have been applied and analyzed.

MATERIALS AND METHODS

Tissue specimens were stained by immunohistochemistry using markers for DCs (CD83 and CD23), macrophages (CD68 and CD163), and Langerhans cells (CD1A and S-100 protein). The mean cell counts of stained cells in five high power microscopic fields were recorded.

STATISTICAL ANALYSIS USED

Descriptive statistics, mean, standard deviation, median, and interquartile range were used. A nonparametric Mann-Whitney U-test was used to compare cell counts between bronchiectasis and control patients. P <0.05 was considered significant.

RESULTS

The mean age of patients with bronchiectasis and controls was 36.7 ± 16.6 and 31.8 ± 22.6 years, respectively. The predominant cell type among the patients was macrophage (median 50.5) followed by DCs (median 44.85), histiocytes (median 32), and Langerhans cells (median 5%). Compared to the controls a significantly higher number of macrophages (P = 0.01), DCs (P = 0.001), and Langerhans cells (P = 0.014) were present.

CONCLUSION

Chronic inflammatory response in acquired (noncongenital) bronchiectasis is most probably mediated by increased infiltration of APCs in lung tissues.

Neonatal brucellosis: A case report

Although brucellosis is not uncommon in Saudi Arabia, neonatal brucellosis has been infrequently reported. In this case of neonatal brucellosis, Brucella abortus was isolated by blood culture from both the mother and the neonate. Serology was positive only in the mother.

Identification of IgE- binding pollen protein from Cannabis sativa in pollen-hypersensitive patients from north Pakistan

Cannabis sativa (C.sativa) is well-known for its medicinal, industrial and recreational use. However, allergies in relation to Cannabis sativa (C.sativa) are rarely reported. C. sativa is one of the common weeds found in Pakistan and its pollen grains are common in spring and fall season. Although categorized as an aeroallergen, there are limited number of reports regarding allergenic potential in C. sativa. Therefore, the current study is aimed at exploring the IgE- binding potential among the C. sativa pollen in local pollen allergic patients. Initial screening of C. sativa sensitized individuals was carried out by dot blot from the sera of pollen allergic patients. Proteins from the pollen grains were extracted and resolved on 10% gel. Eight bands were visible on gel however only one protein fragment i.e. of 14KDa size was found to bind to IgE as analyzed through protein gel blot analysis. Strong IgE affinity of a 14 kDa protein fragment from C. sativa pollen extract suggests its allergenic potential. Further study is required to find the exact nature of this protein fragment.

Prevalence of IgG-mediated food intolerance among patients with allergic symptoms

BACKGROUND

Food intolerance mediated by food specific IgG antibodies has been implicated in a variety of disorders.

OBJECTIVES

To assess the prevalence of food specific IgG antibodies among patients clinically presenting with allergic symptoms lacking laboratory evidence of allergy.

DESIGN

Descriptive retrospective cross-sectional study.

SETTING

King Khalid University Hospital, Riyadh between 2010-2015.

PATIENTS AND METHODS

Patients were screened for food specific IgG antibodies. All symptomatic patients lacking laboratory evidence of allergy who underwent food specific IgG testing during the study duration were included.

MAIN OUTCOME MEASURE(S)

Levels of IgG antibodies in patients with unidentified allergic symptoms.

RESULTS

We selected 71 patients with allergic symptoms lacking laboratory evidence of allergy. There were 49 female and 22 male patients mean age 38.8 (16.0) years. The majority (85.7%) had urticaria. The most frequently occurring food specific IgG antibodies were against cola nut in 80.3% of patients followed by yeast in 78.9%, wheat in 77.5%, red kidney bean in 71.8%, pea in 63.4%, corn in 62% and egg white in 62% of the patients. Compared with male patients, females harbored significantly higher food specific IgG antibodies for frequently occurring food materials, particularly against wheat (74% vs 25.5%; P < .0001), corn (77.3% vs 22.7%; P < .0001) and cola nut (71.9% vs 28.1%; P < .001). Patients aged less than 40 years had higher levels of food specific IgG against gliadin (P < .003), egg white (P < .03) and barley (P < .05) compared with older patients.

CONCLUSION

The detection of a variety of food specific IgG antibodies among patients with allergic symptoms indicates a possible link to food intolerance allergy. Females are prone to develop food intolerance more than males.

LIMITATIONS

Difficulty of comparison of results with previous studies because of lack of data. Follow-up studies could not be performed to assess the effects of elimination from the diet due to limited time allocated for this study.

Assessment of pro-inflammatory cytokines in sera of patients with hepatitis C virus infection before and after anti-viral therapy

Introduction: A number of cytokines have been implicated in hepatitis C virus (HCV)-related liver disease. This study aimed to assess the serum levels of pro-inflammatory cytokines in patients with HCV infection before (naïve) and after successful treatment (sustained responders) with Pegylated interferon and ribavirin. Methodology: The present study included 19 naïve HCV patients and 8 sustained responders. Additionally, 20 healthy individuals were included as a control group. The serum levels of the pro-inflammatory cytokines interleukin-8 (IL-8), IL-6, IL-10, IL-1β, and IL-12p70 were measured using flow cytometry. Results: The serum IL-8 levels were significantly higher in the naïve group (21.5±10.7 pg/mL; p = 0.02) than in the control group (14.1±1.7 pg/mL) and the sustained responder group (10.4±6.2 pg/mL; p = 0.002). The serum IL-6 levels were significantly higher in the naïve group (7.3±2.06 pg/mL; p = 0.02) than in the control group (5.9±1.01 pg/mL) whereas IL-6 in sustained responder group (6.4±1.5 pg/mL) was no different than naïve HCV patients or the controls. The serum IL-10 levels were significantly higher in the naïve group (4.42±0.64 pg/mL) than in the control group (3.6±0.34 pg/mL; p =0.0002) and not the sustained responder group (4.1±0.86 pg/mL). Moreover, the serum IL-12p70 levels were higher in the sustained responder group (3.43±0.84 pg/mL; p =0.05) than in the control group (2.76±0.83 pg/mL). There were no differences in the serum IL-1β levels among the groups. Conclusion: Successful anti-viral therapy against HCV was associated with significant reductions in the serum IL-8 levels and skewing of the pretreatment Th2 dominant immune response to the Th1 response.

Acute Back Pain: A Survey of Primary Health Care Physicians' Awareness and Knowledge of "Red Flag" Signs

Background:

The failure to detect “red flag” signs in patients presenting with acute low back pain can adversely affect the outcome of management. This can seriously affect the quality of life and productivity of the patient.

Objective:

The present questionnaire-based study was performed to assess the knowledge and awareness of red flag signs among primary health care physicians managing patients with acute back pain in Riyadh, Saudi Arabia.

Materials and Methods:

The study sample size was comprised of 80 subjects. The level of knowledge was assessed by means of a new structured self-administered questionnaire. The design of this questionnaire was based on the Agency for Health Care Research and Policy (AHCRP) guidelines for detection of red flag signs. Physicians were asked about red flag signs that indicate the presence of tumor, infection, spinal fracture, or cauda equina syndrome.

Results:

Sixty-eight (85% of total) physicians were aware of red flag signs. Of the 68 physicians who were aware of the red flag signs, 58 (72%) were aware of neurological deficit, 36 (45% of total) were aware of extremes of age (<10 years and >50 years), and 33 (41% of total) were aware of and routinely inquired about the history of spinal trauma, whereas only 24 (30% of total) were aware of and inquired about constitutional symptoms in their patients with acute back pain.

Conclusion:

Although low back pain is extremely common, knowledge and awareness of red flag signs of primary health care physicians managing patients with acute back pain in Riyadh appear to be inadequate. This indicates a lack of adherence to the international guidelines. Specific educational programs should target these deficiencies and increase awareness.

Rapid detection of circulating fibrocytes by flowcytometry in idiopathic pulmonary fibrosis

BACKGROUND:

Current protocols for detection of circulating fibrocytes (CFs) in peripheral blood described in various pulmonary and nonpulmonary disorders involve complex and time consuming, non standardized techniques.

OBJECTIVE:

Testing a method to rapidly detect and quantify CFs using whole blood lysis flow cytometry-based assay in patients with idiopathic pulmonary fibrosis (IPF) and healthy controls.

METHODS:

One milliliter of venous blood sample in ethylenediaminetetraacetic acid (EDTA) from 33 IPF patients and 35 healthy control subjects was collected. Using whole blood lysis method peripheral blood leukocytes were labeled with monoclonal antibodies for cell surface (CD34 and CD45) and intracellular markers (collagen-1) for flow cytometric analysis. CFs were defined as CD45⁺ cells coexpressing collagen-I and CD34 molecules.

RESULTS:

In 29 (87.8%) IPF patients and 10 (28.5%) control subjects, a well-defined highly granular CD45⁺ cell population was detected in dot plots generated by side scatter properties of CD45⁺ cells. These CD45⁺ cells were identified as CFs on the basis of coexpression of collagen-I and CD34; none of the other cell types in the peripheral blood were labeled with these monoclonal antibodies. In IPF patients the percentage of CFs was significantly higher compared to healthy controls (median (range): 1.37% (0.52-5.65) and 1.04% (0.1-1.84), respectively; P = 0.03).

CONCLUSIONS:

Whole blood lysis method combined with fluorescence-activated cell sorting (FACS) allows detecting a well-defined homogeneous population of CFs. This method is simple, reproducible, and provides an accurate and rapid estimation of CFs.

ESBL-producing Escherichia coli and Klebsiella pneumoniae at a tertiary care hospital in Saudi Arabia

INTRODUCTION

The increasing frequency and antibiotic resistance among extended-spectrum β-lactamases (ESBLs)-producing bacteria are posing a serious threat. This study sought to investigate the frequency and antibiotic susceptibility of ESBL-producing E. coli and K. pneumoniae at a tertiary care hospital.

METHODOLOGY

Data were collected from samples sent to the microbiology laboratory between 2006 and 2010 at King Khalid University Hospital, Riyadh. ESBLs were confirmed using Etest strips of cefotaxime/cefotaxime + clavulanic acid, ceftazidime/ceftazidime + clavulanic acid, and cefepime/cefepime + clavulanate.

RESULTS

Out of 17,105 samples, 1,076 (6.3%) ESBL-producing isolates of E. coli (808) and K. pneumoniae (268) were confirmed. Among these, 680 (63.2%) isolates were found in urine samples, followed by 287 (26.7%) in superficial swabs, deep wounds swabs, tissues and sterile body fluids, 71 (6.6%) in respiratory, and 38 (3.5%) in blood samples. The overall frequency rates of ESBL E. coli and K. pneumoniae were 6.6% and 5.5%, respectively. The frequency of ESBL-producing E. coli and K. pneumoniae increased significantly during the study period. E. coli resistance against cotrimoxazole was 71.1%, followed by ciprofloxacin (68.2%) and gentamicin (47%). Similarly, 62.7% of K. pneumoniae isolates were resistant to gentamicin, 59.5% to cotrimoxazole, and 49.8% to ciprofloxacin. There was no statistically significant change in antimicrobial resistance over the study period.

CONCLUSIONS

Although the frequency rates of ESBL-producing E. coli and K. pneumoniae increased, no change in the anti-microbial susceptibility was observed over the study period.

Screening for hen's egg and chicken meat specific IgE antibodies in Saudi patients with allergic disorders

BACKGROUND

Allergy to hen's egg and meat contributes significantly to the manifestations of food allergy all over the world.

OBJECTIVES

This study was performed to assess the presence of hen's egg and meat specific IgE antibodies among patients investigated for various allergic disorders.

METHODS

This is a retrospective study performed at King Khalid University Hosptial, Riyadh. Data from 421 patients with allergic disorders screened for food specific IgE antibodies between January 2009 and March 2011 were analyzed. Sixty (14.25%) patients including 42 males and 18 females with the mean age (sd) of 7.5 (7.4) years were found to have specific IgE antibodies against hen's egg and chicken meat. There were 56 (93.3%) children and 4 (6.7%) adult patients. Specific IgE antibodies were measured by radioallergosorbent test (RAST) using Pharmacia ImmunoCAP 250 analyzer.

RESULTS

Atopic dermatitis was the most common (55%) clinical condition. Out of the total 60 patients harboring hen's egg and chicken meat specific IgE antibodies high levels of egg white, yolk and chicken meat specific IgEs were detected in 58 (96.6%), 37 (61.6%) and 6 (10%) patients respectively. Both the egg white and yolk antibodies coexisted in 35 (58.3%) patients.

CONCLUSION

Sensitization against hen's egg was higher compared to the chicken meat. Egg white sensitization higher than the egg yolk particularly in Saudi children with food related allergic disorders.

Immunological evaluation of β-thalassemia major patients receiving oral iron chelator deferasirox

OBJECTIVE

To determine the immune abnormalities and occurrence of infections in transfusion-dependent β-thalassemia major patients receiving oral iron chelator deferasirox (DFX).

STUDY DESIGN

An observational study.

PLACE AND DURATION OF STUDY

Hematology Clinics, King Khalid University Hospital, Riyadh, Saudi Arabia, from July to December 2010.

METHODOLOGY

Seventeen patients with β-thalassemia major (12 females, median age 26 years) receiving deferasirox (DFX) for a median duration of 27 months were observed for any infections and had their immune status determined. Immune parameters studied included serum immunoglobulins and IgG subclasses, serum complement (C3 and C4) and anti-nuclear antibody (ANA) level, total B and T-lymphocytes, CD4+ and CD8+ counts, CD4+/CD8+ ratio, and natural killer (NK) cells. Immunological parameters of the patients were compared with age, gender, serum ferritin level and splenectomy status. Lymphocyte subsets were also compared with age and gender matched normal controls.

RESULTS

A considerable reduction in serum ferritin was achieved by DFX from a median level of 2528 to 1875 μmol/l. Serum IgG levels were increased in 7 patients. Low C4 levels were found in 9 patients. Total B and T-lymphocytes were increased in 14 patients each, while CD4+, CD8+ and NK cells were increased in 13, 12 and 11 patients respectively. Absolute counts for all lymphocyte subsets were significantly higher compared to the normal controls (p ² 0.05 for all parameters). Raised levels of IgG were associated with older age, female gender, splenectomized status and higher serum ferritin levels but this did not reach statistical significance except for the higher ferritin levels (p=0.044). Increased tendency to infections was not observed.

CONCLUSION

Patients with β-thalassemia major receiving DFX exhibited significant immune abnormalities. Changes observed have been described previously, but could be related to DFX. The immune abnormalities were not associated with increased tendency to infections.

Cytokine gene polymorphisms of TNFα, IL-6, IL-10, TGFβ and IFNγ in the Saudi population

Studies have demonstrated associations between cytokine gene polymorphisms and ethnicity. In the present work the authors examine polymorphisms in the genes encoding interleukin-6 (IL-6), IL-10, interferon-gamma (IFNgamma), tumour necrosis factor-alpha (TNFalpha) and transforming growth factor-beta (TGFbeta1) using the polymerase chain reaction sequence-specific primer (PCR-SSP) method in 150 healthy unrelated Saudis, and results compared with those from other studied populations. The genotype distributions were consistent with the Hardy-Weinberg equilibrium, and the genotype frequencies observed among Saudis showed both similarity and difference to other populations. The most notable difference was in the distribution of IL-6, where the Saudi population showed a lower CG genotype frequency compared with White American (22% vs. 39.2%, P = 0.004), Italian (22% vs. 50%, P < 0.0001) and Brazilian (22% vs. 40.8%, P < 0.0001) populations. The study population also showed a higher frequency of the IL-6 GG genotype compared with White Americans (72% vs. 45.1%, P < 0.0001), Italians (72% vs. 41%, P < 0.0001) and Brazilians (72% vs. 49.3%, P < 0.0001). These results may have significant clinical relevance to the understanding of prevalent diseases in Saudi Arabia.

Q fever: a neglected zoonosis in Saudi Arabia

BACKGROUND AND OBJECTIVES

Infection due to Coxiella burnetii (C burnetii), the causative agent of Q fever is rarely sought for in clinical practice. This study was performed to detect C burnetii infection in patients with pyrexia of undetermined cause (PUC).

DESIGN AND SETTINGS

This is a prospective study conducted at King Khalid University Hospital, Riyadh be.tween March 2011 and January 2013.

PATIENTS AND METHODS

A total of 3 mL venous blood was collected from 51 patients with PUC at King Khalid University Hospital, Riyadh. This group of patients included 30 males and 21 females (mean age 33.9 [21.3] years) with the history of febrile illness ranging between 4 and 8 weeks. A control group of 50 healthy individuals comprising 39 males and 11 females (mean age 27 [9] years) was also included in the study. Detection of phase II C burnetii-specific IgG antibodies was performed by immunofluorescence assay, and a titer of > 1:64 was considered positive.

RESULTS

Phase II C burnetii-specific IgG antibodies were detected in 18 (35.2%) patients out of the total 51 tested. Two (4%) individuals out of 50 in the control group tested positive for anti-C burnetii IgG antibodies. The proportion of positive results among the patients was significantly higher than the controls (P < .0002, 95% CI, 15.09-46.25). The antibody titer range was between 1:128 and 1:1024 where 6 patients had titers of 1:256, 5 had 1:512, 4 had 1024, and 3 had 1:128.

CONCLUSION

The evidence of C burnetii infection in a sizable number of patients emphasizes the need for inclusion of serologic investigations for Q fever in patients with PUC.

Garlic and onion sensitization among Saudi patients screened for food allergy: a hospital based study

BACKGROUND

Detection of specific IgE antibodies against food materials indicates allergic sensitization. Some very widely consumed foods materials such as garlic and onion have rarely been investigated for their allergenic potential.

OBJECTIVES

To assess the presence of garlic and onion specific IgE antibodies in patients investigated for food allergy.

METHODS

Radioallergosorbent test (RAST) results of 108 patients with clinical suspicion of food allergy who were specifically screened for garlic and onion specific IgE antibodies along with other food allergens were analyzed retrospectively at King Khalid University Hospital between January 2008 and April 2009. This group of patients included 73 males and 35 females with mean age 27+13.2 years. Estimation of garlic and onion specific IgE antibodies was performed by radioallergosorbent test (RAST) using Pharmacia ImmunoCAP 250 analyzer.

RESULTS

Out of the 108 patients 15 (13.8%) had garlic and onion specific IgE antibodies in their sera. Garlic specific IgE antibodies with the RAST scores between one to four were present in 14 and onion specific IgE were detected in 13 patients. For garlic specific IgEs majority of patients (08) had RAST score of one (0.35-0.69 kU/L) and for onion specific IgE antibodies seven patients had RAST score of two (0.70-3.49 kU/L). Among these patients 12 (80%) were found to have coexisting specific IgE antibodies against garlic and onion.

CONCLUSION

The presence of garlic and onion specific IgE antibodies in a sizeable number of patients indicate sensitization and allergenic potential of these food materials.

Cytokine gene polymorphisms and serum cytokine levels in patients with idiopathic pulmonary fibrosis

Background

Studies have demonstrated associations between cytokine gene polymorphisms and the risk of idiopathic pulmonary fibrosis (IPF). We therefore examined polymorphisms in the genes encoding interleukin (IL)-6, IL-10, interferon gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), and transforming growth factor-beta 1 (TGF-β₁), and compared the serum levels of these cytokines in IPF patients and healthy controls. Furthermore, we examined the association of the studied genotypes and serum cytokine levels with physiological parameters and the extent of parenchymal involvement determined by high-resolution computed tomography (HRCT).

Methods

Sixty patients with IPF and 150 healthy controls were included. Cytokine genotyping was performed using the polymerase chain reaction sequence specific primer (PCR-SSP) method. In a subset of patients and controls, serum cytokine levels were determined by enzyme-linked immunosorbent assay.

Results

There was no difference between IPF patients and controls in the genotype and allele distributions of polymorphisms in TNF-α, IFN-γ, IL-6, IL-10, and TGF-β₁ (all p > 0.05). The TNF-α (−308) GG, IL-6 (−174) GG and CG, and IL-10 (−1082, -819, -592) ACC ATA genotypes were significantly associated with HRCT scores (all p < 0.05). IL-10 (−1082, -819, -592) ACC haplotype was associated with the diffusion capacity of the lung for carbon monoxide, and ATA haplotype was associated with the partial pressure of oxygen (PaO₂) (all p < 0.05). The TGF-β₁ (codons 10 and 25) TC GG, TC GC, CC GG and CC GC genotypes were significantly associated with the PaO₂ and HRCT scores (p < 0.05). The TGF-β₁ (codons 10 and 25) CC GG genotype (5 patients) was significantly associated with higher PaO₂ value and less parenchymal involvement (i.e., a lower total extent score) compared to the other TGF-β₁ genotypes (81.5 ± 11.8 mm Hg vs. 67.4 ± 11.1 mm Hg, p = 0.009 and 5.60 ± 1.3 vs. 8.51 ± 2.9, p = 0.037, respectively). Significant differences were noted between patients (n = 38) and controls (n = 36) in the serum levels of IL-6 and IL-10 (both, p < 0.0001), but not in the levels of TNF-α and TGF-β₁ (both, p > 0.05).

Conclusion

The studied genotypes and alleles do not predispose to the development of IPF but appear to play an important role in disease severity. Our results suggest that the TGF-β₁ (codons 10 and 25) CC GG genotype could be a useful genetic marker for identifying a subset of IPF patients with a favorable prognosis; however, validation in a larger sample is required.

Pattern of patch test reactivity among patients with clinical diagnosis of contact dermatitis: a hospital-based study

BACKGROUND AND OBJECTIVES

Contact allergy is associated with a significant morbidity all over the world. This study was performed to investigate the pattern of sensitization by contact allergens in the local population.

DESIGN AND SETTING

Retrospective study to investigate patch test reactivity among patients with clinical diagnosis of contact dermatitis who were referred to the allergy clinic at the King Khalid University Hospital, Riyadh, between April 2008 and March 2010.

PATIENTS AND METHODS

Of the 196 patients referred to the allergy clinic over the 2-year period, 91 (46.4%) patients reacted to one or more patch test allergens, and these patients were included in this study. The study group included 82 (91.1%) of Saudi nationality and 9 (8.9%) patients of other nationalities. The patch test was performed using the T.R.U.E TEST, containing 24 allergens/allergen mixes.

RESULTS

Of the 91 cases who reacted positively to one or more allergens, 67 (73.6%) were females with a mean age of 37 (8.3 years) and 24 (26.4%) were males with a mean age of 34 (11.6 years). Thirty-three (36.2%) patients reacted to nickel sulfate, 14 (15.3%) to p-phenylenediamine, 13 (14.2%) to p-tert-butylphenol-formaldehyde resin, 13 (14.2%) to thimerosal, and 9 (9.8%) to colophony. Reactivity against the rest of the allergens was not remarkable. A significantly higher percentage of females reacted to nickel sulfate (84.8% vs 15.2% in males;P=.0001), p-tert-butylphenol-formaldehyde resin (92.3% vs 7.7%; P=.0001), and thimerosal (76.9% vs 23.1%;P=.03).

CONCLUSIONS

Patch test reactivity to nickel sulfate was high. The pattern of contact allergy observed in this study indicates the need for large-scale investigations to identify local allergens responsible for contact allergy and for formulation of policies directed towards avoidance of exposure.

Human leucocyte antigens: their association with end-stage renal disease in Saudi patients awaiting transplantation

Most patients with chronic renal failure develop end-stage renal disease (ESRD) that requires renal transplantation. This study investigates the possible associations between human leucocyte antigen (HLA) Class I and Class II molecules with ESRD. Genotyping data (HLA) obtained between 2005 and 2009 on 235 unrelated Saudi patients (147 males, 88 females; mean age: 58 +/- 7 years) with ESRD awaiting renal transplantation were assessed retrospectively at the King Khalid University Hospital. Data were compared with the results on 60 normal, healthy, unrelated Saudi individuals (37 males and 23 females; mean age: 51 +/- 5 years). HLA Class I and Class II antigens were detected by lymphocytotoxicity and a polymerase chain reaction (PCR) method using DNA sequence-specific primers. Although present in small numbers, HLA Cw2 was found in significantly fewer patients (n = 11; 4.68%) compared to normal subjects (n = 9; 15%) and was found to confer protection against ESRD (P = 0.005; relative risk [RR]: 3.594, 95% confidence interval [CI]: 1.415-9.126). Among the HLA Class II antigens, HLA DQB1*03(8) was detected more frequently in the patient group (n = 65; 27.6%) than in the normal controls (n = 9; 15%) and was positively associated with risk of ESRD (P = 0.04; RR: 0.462, 95% CI: 0.215-0.991). No significant differences were observed between the two groups in respect of HLA-A2, HLA-B50(21), HLA-B51(5) and HLA-Cw7 (HLA Class I), and HLA-DRB1*04, HLA-DRB1*07 and HLA-DQB1*02 (HLA Class II). Occurrence of the most frequent HLA alleles was no different between the ESRD group and the controls. The protective role of HLA-Cw2 and the marginal susceptibility associated with HLA-DQBI*03(8) for ESRD requires further investigation.

Modifications influencing Widal test reactivity in a novel microplate assay

Reliability of the Widal tube agglutination test has been the subject of many controversies over the years. This study was performed to assess the effect of certain modifications on the performance of Widal test in a novel microplate assay. Sera from 37 patients (21 males; 16 females) (mean age 28 +/- 7 years) were tested in the Immunology Unit at King Khalid University Hospital, Riyadh. Among them were 26 patients with suspected typhoid fever and 11 had bacteriologically confirmed diagnosis of Salmonella infection. The modifications included either the use of 0.5% bovine serum albumin (BSA), absorption of sera with sheep red blood cells (SRBC) or heat inactivation of sera. Compared with Widal tube agglutination test, microplate assay with SRBC absorption of the sera from patients with suspected typhoid fever was not only associated with enhancement of detection titers for both H (p < or = 0.001) and O (p < or = 0.005) Salmonella agglutinins but also the percentage of reactivity. The presence of BSA augmented detection titers for Salmonella H agglutinins (p < or = 0.02) only. Heat inactivation of sera however was found to be associated with reduction in the detectable titers for both H (p < or = 0.03) and O (p < or = 0.01) agglutinins. Increased titers of Salmonella agglutinins were also evident in 11 patients with confirmed diagnosis of Salmonella infection. The novel microplate agglutination assay using the SRBC absorption was associated with enhancement in Widal test reactivity and appears to be a useful alternative for the diagnosis of Salmonella infection.

Salmonella isolates’ serotypes and susceptibility to commonly used drugs at a tertiary care hospital in Riyadh, Saudi Arabia

Introduction: Resistance of Salmonella to therapeutic agents currently being used for treatment of Salmonella infections is emerging as a global problem. This study aimed to assess the prevalence of Salmonella serotypes and their susceptibility patterns to commonly used drugs for treatment of Salmonella infections including quinolones. Correlation between nalidixic acid susceptibility of these isolates and their ciprofloxacin minimum inhibitory concentrations was also sought. Methodology; Salmonella isolates (n=213) were collected between January 2007 and May 2009 at King Khalid University Hospital in Riyadh, Saudi Arabia. The isolates were serotyped and their susceptibilities to commonly used first-line anti-Salmonella drugs (ampicillin, ceftriaxone, trimethoprim/sulfamethoxazole, nalidixic acid and ciprofloxacin) were determined using the automated Microscan system, the Kirby-Bauer disk diffusion method, and E-test. Results: The most frequently detected serotype was D1 (37%) followed by the serotypes, B (24%) and C1 (11%). Non-typable Salmonella isolates detected using available conventional Salmonella anti-sera were (11%). Overall resistance rates to nalidixic acid, ampicillin, trimethoprim/sulfamethoxazole and ceftriaxone were 99/213 (46%), 43/213 (20%), 34/213 (16%) and 7/213 (3%), respectively. Of the total isolates, 117 (55%) had a ciprofloxacin MIC of < 0.125 µg/ml and among these 105 (90%) were susceptible to nalidixic acid. The remaining 96 (45%) isolates had a ciprofloxacin MIC of ≥ 0.125 µg/ml and among them, 83 (86.5%) were resistant to nalidixic acid. Conclusions: The majority of Salmonella isolates in this study were non-typhi serotypes. Significantly higher proportions of Salmonellae were resistant to nalidixic acid and ciprofloxacin and a vast majority of nalidixic acid resistant organisms exhibited decreased susceptibility to ciprofloxacin.

Detection of Salmonella typhi agglutinins in sera of patients with other febrile illnesses and healthy individuals

BACKGROUND AND PURPOSE

Widal test is frequently applied for the detection of Salmonella agglutinins to diagnose Salmonella enterica serotype Typhi infection. There are however a number of controversies challenging the diagnostic utility of this test. This study was performed to determine the prevalence of Salmonella agglutinins in patients with other febrile illnesses and healthy blood donors.

MATERIALS AND METHODS

Sera from 50 healthy blood donors were compared for the presence of Salmonella agglutinins in various groups of patients with other febrile illnesses using Widal test in the division of Serology and Immunology at King Khalid University Hospital, Riyadh. The patient groups of other febrile illnesses included infections with Beta-hemolytic streptococcus (n = 50), Brucella (n = 46), Helicobacter pylori (n = 24), Treponema pallidum (n = 30), Toxoplasma (n = 44), and other parasites (n = 20).

RESULTS

Majority of the patients and normal individuals were tested positive for Widal test at dilution of less than 1 : 40 both for the O (62.5%) and H (64.6%) antigen. A decreasing trend in Widal reactivity was observed with increasing dilutions of the serum samples. At 1 : 160 titer, which is generally considered as a cut off point for positive Widal test, 6.4 and 11% individuals had positive Widal test for O and H Salmonella antigens, respectively.

CONCLUSION

Detection of a significant number of positive Widal tests in conditions where it is expected to be nonreactive appears to be a serious problem in making a correct diagnosis of typhoid fever, thus challenging the diagnostic utility of the Widal test.

Antenatal screening for syphilis at a tertiary care hospital in Riyadh

BACKGROUND

Routine serologic screening for syphilis is recommended for all pregnant women in Saudi Arabia. This study examined the results of routine antenatal syphilis screening at a tertiary care hospital in Riyadh.

PATIENTS AND METHODS

The results of rapid plasma reagin (RPR) tests were compiled for in 3270 pregnant women tested between October 2002 and March 2003 at King Khalid University Hospital. Any RPR reactivity observed in neat or diluted serum was considered positive and confirmed by a Treponema pallidum hemagglutination (TPHA) test.

RESULTS

Syphilis screening constituted 87% of RPR tests requested for all reasons during the study period. The majority of women (73%) were screened between 15 to 22 weeks of gestation. Of the 3270 women tested only one was found to have syphilis, a prevalence rate of 0.03%.

CONCLUSION

The prevalence of syphilis is extremely low in the antenatal care population at King Khalid University Hospital in Riyadh. This calls for a nation-wide survey to assess the need for continuation of antenatal syphilis screening with regards to its potential benefits and cost effectiveness in the Kingdom of Saudi Arabia.

Serial evaluation of percentage of activated T-lymphocytes in peripheral blood of human immunodeficiency virus infected individuals as a prognostic marker

OBJECTIVE

Immune activation often associated with human immunodeficiency virus (HIV) infection is characterized by increasing number of peripheral blood T-lymphocytes expressing HLA-DR molecule. This study was performed to investigate the changes in the percentage of activated lymphocytes in the peripheral blood of HIV infected patients on antiretroviral therapy.

METHODS

Routine flow cytometry data for peripheral blood lymphocyte subsets were analyzed in 11 HIV infected hemophilia patients (mean age 27 +/- 7) at approximately 6 monthly intervals from 1996 to 2002 in the Division of Immunology, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. The number of data sets for each individual was variable, ranging between 5-13. Percentages of each lymphocyte subset were extracted and correlations were sort by using linear regression analysis.

RESULTS

Proportion of activated T-lymphocytes in the peripheral blood was initially high. Over a period of 2-5 years the percentage of T-lymphocytes, expressing HLA-DR molecule was found to have decreased significantly (P < or =0.0001) in all the patients most probably as a result of antiretroviral therapy. There was no statistically significant change in the proportion of any other lymphocyte subtype studied. The reduction in the percentage of HLA-DR+ T-lymphocyte population inversely correlated with CD4/CD8 ratios in 8 and for the CD4+ lymphocyte proportions with 5 out of 11 patients, whereas positive correlation for CD8+ lymphocyte proportions was noted in 4 patients.

CONCLUSION

These findings confirm immune activation in HIV infection with the increasing percentage of HLA-DR+ T-lymphocytes in the peripheral blood. Declining activated T-lymphocyte proportion in the peripheral blood and its inverse correlation with CD4/CD8 ratio may be more sensitive in detection of changes in CD4+ and CD8+ lymphocyte populations in HIV infection serving as a prognostic marker.

Increased prevalence of asthma in Saudi Arabia

BACKGROUND

Bronchial asthma is among the most common chronic illnesses of childhood. A number of reports in the recent past suggest that the prevalence of asthma is increasing globally.

OBJECTIVE

To investigate the changing prevalence of asthma in the Kingdom of Saudi Arabia.

SUBJECTS AND METHODS

Two populations of schoolchildren between the ages of 8 and 16 years were studied using an internationally designed protocol in 1986 and 1995. The questionnaire used in these studies was very similar to the one used in the International Study of Allergy and Asthma in Childhood. A total of 2,123 school-children in 1986 (Jeddah and Riyadh) and 1,008 schoolchildren in 1995 (Hail and Gizan) were enrolled in the surveys. These cross-sectional studies of randomly selected schoolchildren were statistically analyzed using ANOVA and a Z test.

RESULTS

The comparison of data between Riyadh versus Hail (inland desert dry environment) and Jeddah versus Gizan (coastal humid environment) revealed that the prevalence of asthma in the similar populations increased significantly from 8% in 1986 to 23% in 1995 (P < .0001). Likewise, the prevalence of allergic rhinitis also increased from 20% to 25% (P < .003) since 1986. However, no significant change in the prevalence of eczema (from 12% to 13%) was noted between 1986 and 1995.

CONCLUSIONS

The study indicates that there was a significant increase in the prevalence of bronchial asthma and, to a lesser extent, in the prevalence of allergic rhinitis in the Kingdom of Saudi Arabia during this 9-year period. The study also revealed increased exposure to environmental factors such as tobacco smoke and indoor animals in Saudi houses. It seems that the continuing changes in contemporary life may well have contributed to the increased prevalence of asthma in the country.

Circulating adhesion molecules in sarcoidosis

Sarcoidosis is a disease of unknown etiology characterized by non-caseating granulomata together with a number of systemic abnormalities. We have recently shown these include increased expression of the integrins CD11/CD18 on peripheral blood leucocytes. Here we have measured serum levels of the adhesion molecules intercellular adhesion molecule-1 (ICAM-1), E-selectin and vascular cell adhesion molecule-1 (VCAM-1) in 23 patients and 14 normal controls using antigen capture sandwich ELISAs. Median circulating E-selectin levels in the patients were nearly three times those of the controls (P < 0.0001, Mann-Whitney U-test), whilst ICAM-1 but not VCAM-1 levels were only slightly elevated. These results show that endothelial cell activation and shedding of E-selectin into the circulation are additional features of the pathology of sarcoidosis.

A new method for measuring clustering in suspension between accessory cells and T lymphocytes

Specifying the molecular basis and clinical significance of cluster formation between antigen-presenting cells and T lymphocytes will be important in many areas of immunology. In this paper we describe a novel and reproducible technique for measuring cluster formation in suspension between purified human blood monocytes and purified autologous T lymphocytes, and its application to determining the effects of recall antigens and mitogen. Blood monocytes and T lymphocytes from eight normal subjects were separately prelabelled with two different carbocyanine dyes prior to co-culture in suspension with or without antigen (PPD, SKSD) or mitogen (PHA). At 24 h the co-cultures were examined for cluster formation by ultraviolet microscopy and flow cytometry. Control experiments showed that the carbocyanine dyes were non-toxic in vitro, that cell labelling was stable for culture periods up to 120 h, and that the two dyes did not leak from cell to cell. By this technique we measured the proportion of monocytes clustering one or more T lymphocytes in the presence and absence of recall antigen or PHA. There was a close correlation between visual and flow cytometric measurement of monocyte: T lymphocyte clustering (p < 0.001) as well as a close relationship between the ability of the two recall antigens to increase the extent of clustering above baseline (p < 0.001). Antigen-increased cluster formation did not correlate with baseline clustering, unlike PHA-increased clustering, which was related to baseline levels (p = 0.02), suggesting the operation of distinct mechanisms. The method is applicable to measuring cell-cell associations in suspension during extended periods of culture, as well as for the study of agents which might modify intercellular adhesion processes.

Increased CD11/CD18 expression on peripheral blood leucocytes of patients with sarcoidosis

Sarcoidosis is a multisystem disease of unknown etiology characterized by non-caseating granulomata, formed mainly from macrophages surrounded by lymphocytes and plasma cells. Using a novel method for the preparation of blood leucocytes for flow cytometry, we report increased expression of LeuCAMs (CD11/CD18) on peripheral blood leucocytes of 11 Caucasian and 10 Afro-Caribbean patients with sarcoidosis compared with age-, sex- and race-matched controls. Whilst the percentages of the cells expressing CD11/CD18 were no different, the density, expressed as mean fluorescence intensity (MFI), was greater for all leucocytes in sarcoids than in normal individuals. The expression of intercellular adhesion molecule-1 (ICAM-1), a ligand for LFA-1 which is expressed on all leucocytes, was not significantly different from normal, whereas HLA-DR was expressed more intensely on sarcoid monocytes (P less than 0.01) and blood lymphocytes (P less than 0.005) than control cells. Our findings are consistent with leucocyte activation although we were unable to confirm reports of elevated tumour necrosis factor-alpha (TNF-alpha) in the patients' plasma using an ELISA. Increased expression of adhesion molecules on peripheral blood leucocytes may play a role in the cellular extravasation, aggregation, and granuloma formation seen in sarcoidosis.

Alveolar macrophage accessory cell function in bronchial asthma

The capacity of peripheral blood monocytes and alveolar macrophages (AM) obtained by bronchoalveolar lavage (BAL) to present recall antigens, namely, tuberculin purified protein derivative (PPD) or streptokinase-streptodornase (SKSD), to highly purified autologous T-cells has been studied in 11 asthmatic and 11 healthy, nonatopic normal subjects. In the asthmatic group, AM accessory cell function was variable, and most subjects were unable to present either recall antigen as effectively as blood monocytes, although one asthmatic subject demonstrated larger proliferative responses than blood monocytes for both antigens. AM accessory cell activity was not antigen-specific, and there was a correlation between accessory cell efficacy for the two antigens (r = 0.92; confidence interval, 0.53 to 0.98). Furthermore, a correlation existed between the percentage lymphocyte count in the BAL fluid and the ratio of macrophage to monocyte antigen-presenting capability for both PPD (r = 0.92; 95% confidence interval, 0.83 to 0.99) and SKSD (r = 0.90; 95% confidence interval, 0.45 to 0.98). In the normal subjects, AM were also unable to act effectively as accessory cells for the presentation of PPD and SKSD in the majority of subjects. No correlation existed between the percentage lymphocytes in BAL fluid and the ratio of AM to monocyte accessory cell function. These results suggest an association between AM accessory function and the presence of BAL lymphocytes in bronchial asthma.

A method of preparing blood leucocytes for flow cytometry which prevents upregulation of leucocyte integrins

LeuCAM (CD11/CD18) cell-surface antigens are easily upregulated on cell manipulation ex vivo. A procedure for preparing leucocytes, in which human blood is immediately treated ex vivo with buffered formaldehyde and then the erythrocytes and platelets are removed by lysis and differential centrifugation, has been successfully applied to the analysis of LeuCAM antigen expression by flow cytometry. We show that the increased expression of monocyte CD11/CD18, which occurs when mononuclear leucocytes are separated by a standard Lymphoprep density gradient separation, can be avoided if cells are fixed immediately. Following this fixation polymorphs are unable to upregulate CD11/CD18 in response to fMLP stimulation in vitro. The technique produces lymphocyte, polymorph and monocyte populations that can be clearly defined on the basis of forward scatter and side scatter, and preserves the expression of various surface antigens; the percentages of gated lymphocytes expressing CD3, CD4, and CD8 were similar to those obtained using a commercial fixing and lysis solution. The processing does not render cells permeable to antibodies, as evidenced by our failure to stain cells with antibodies to intracellular antigens. We believed the method to be useful for measuring CD11/CD18 expression on blood leucocytes from normal or pathological specimens and to have application to the measurement of other cells surface antigens which may also be upregulated by the separation procedures.