Middle East respiratory syndrome coronavirus in pediatrics: a report of seven cases from Saudi Arabia / 医学前沿

Infection with Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in 2012 as an important respiratory disease with high fatality rates of 40%-60%. Despite the increased number of cases over subsequent years, the number of pediatric cases remained low. A review of studies conducted from June 2012 to April 19, 2016 reported 31 pediatric MERS-CoV cases. In this paper, we present the clinical and laboratory features of seven patients with pediatric MERS. Five patients had no underlying medical illnesses, and three patients were asymptomatic. Of the seven cases, four (57%) patients sought medical advice within 1-7 days from the onset of symptoms. The three other patients (43%) were asymptomatic and were in contact with patients with confirmed diagnosis of MERS-CoV. The most common presenting symptoms were fever (57%), cough (14%), shortness of breath (14%), vomiting (28%), and diarrhea (28%). Two (28.6%) patients had platelet counts of < 150 × 10/L, and one patient had an underlying end-stage renal disease. The remaining patients presented with normal blood count, liver function, and urea and creatinine levels. The documented MERS-CoV Ct values were 32-38 for four of the seven cases. Two patients (28.6%) had abnormal chest radiographic findings of bilateral infiltration. One patient (14.3%) required ventilator support, and two patients (28.6%) required oxygen supplementation. All the seven patients were discharged without complications.

Progressive multifocal leukoencephalopathy [PML] in a patient with lymphoma treated with rituximab: a case report and literature review

Progressive multifocal leukoencephalopathy [PML] is a rare demyelinating disease caused by reactivation of a latent JC polyoma virus. The first cases of PML were described 50 years ago in patients with lymphoma. PML typically occurs in immunocompromised individuals, particularly those infected with HIV. We present a 52-year-old male with lymphoma who was treated with R-CHOP [R: Rituximab; C: Cyclophosphamide; H: Doxorubicin; O: Vincristine; P: Prednisone]. After six cycles of therapy, the patients developed tonic-clonic seizure. MRI of the brain showed multiple brain lesions. The pathology of a brain biopsy was diagnostic for PML. We review radiographic and histopathological features of the disease. The literature on PML and its association with immunosuppressant agents is reviewed, and the impact of rituximab and other biological agents in the setting is highlighted

Prevalence of Panton-Valentine leukocidin-positive methicillin-susceptible Staphylococcus aureus infections in a Saudi Arabian hospital

Panton-Valentine leukocidin [PVL] is a two-component toxin associated with the toxicity and virulence of Staphylococcus aureus. The presence of PVL is well documented in community-acquired methicillin-resistant S. aureus [CA-MRSA] and is observed in methicillin-susceptible S. aureus [MSSA] with variable prevalence. We assessed the prevalence of PVL in a sample of 93 MSSA patients in a healthcare facility in Eastern Saudi Arabia using real-time PCR for lukSF-PV genes. The presence or absence of PVL was correlated with age, gender, hospitalization status, infection site and antibiotic resistance. PVL was detected in 28 [30%] patient samples. PVL was associated with a greater likelihood of resistance to trimethoprim-sulfamethoxazole [a resistance of 39.2% of PVL-positive isolates compared to 6.1% of PVL-negative isolates] [p< 0.0007]. These results suggest a significant prevalence of PVL expression in MSSA strains in the study population and call for monitoring of and surveillance programs for PVL status and the selection of appropriate antibiotic treatments

Sterile cyst formation after intrathecal stem cell transplant for Parkinson's disease: a case presentation and literature review

In recent years, fetal or autologous stem cell transplant for the treatment of Parkinson's disease [PD] has been practiced in a few medical organizations. However, the potential complications related to the growth of allograft tissue have not yet been well described apart from case reports. Here, we present a 42-year-old Saudi male who suffered from early onset Parkinson's disease. He sought medical care in China and received autologous intrathecal stem cell transplantation. He did not demonstrate any significant improvement. A few months later, the patient went back to China and underwent fetal cell transplantation into the left hemisphere and a second stem cell transplantation intrathecally. He presented with seizures and had a left frontal brain cyst. The cyst was drained and contained clear fluid. All cultures were negative. He had an uneventful recovery

Healthcare associated infections [HAI] perspectives

Healthcare associated infections [HAI] are among the major complications of modern medical therapy. The most important HAIs are those related to invasive devices: central line-associated bloodstream infections [CLABSI], catheter-associated urinary tract infections [CAUTI], ventilator-associated pneumonia [VAP] as well as surgical site infections [SSI]. HAIs are associated with significant mortality, morbidities and increasing healthcare cost. The cited case-fatality rate ranges from 2.3% to 14.4% depending on the type of infection. In this mini-review, we shed light on these aspects as well as drivers to decrease HAIs

Middle east respiratory syndrome-coronavirus infection: an overview

Middle East Respiratory Syndrome-coronavirus [MERS-CoV] was reported from a number of countries in the Middle East and Europe with a reported high mortality rate. MERS-CoV was initially isolated from a patient from Bisha, Saudi Arabia. A recent outbreak of MERS-CoV infection was described in a healthcare facility. Although, the recent publications on this topic had shed light on the epidemiology of the disease, many questions remain to be answered

Middle East respiratory syndrome novel corona [MERS-CoV] infection. Epidemiology and outcome update

Middle East respiratory syndrome coronavirus MERS-CoV is a newly emerging respiratory virus with a high case fatality rate among identified cases. The virus is thought to cause a severe disease in patients with underlying Co-morbidities. The identification of asymptomatic patients and mild cases among family and healthcare worker contacts of confirmed cases indicates a wider spectrum of clinical manifestation of the disease. The majority of patients presented with fever [98%], fever with cough [83%], and shortness of breath [72%]. Radiographic manifestations range from unilateral infiltrate [43%], to increased bronchovascular markings [17%], and diffuse reticulonodular pattern [4%]. Our understanding of the epidemiology and clinical presentation of the disease is increasing overtime. It is still not known what the source of the virus is and what the best treatment modality should be

Nocardia abscessus brain abscess in an immunocompetent host

Nocardia brain abscesses typically occur in immunocompromised patients. Most cases of nocardiosis are caused by the Nocardia asteroides complex and Nocardia brasiliensis. Here, we present a patient with a Nocardia abscessus brain abscess. The diagnosis was confirmed by DNA sequencing, and the organism was susceptible to linezolid, clarithromycin, ceftriaxone, imipenem, tobramycin, amikacin, minocycline and sulfamethoxazole. The patient was successfully treated medically in combination with surgical excision

Changes in the pattern of hospital intravenous antimicrobial use in Saudi Arabia, 2006-2008

Hospitals should measure antimicrobial use based on the WHO's recommended metric, the defined daily dose [DDD]. There is no data on antimicrobial usage based on DDD in Saudi Arabia. Thus, this study evaluates the trend in antimicrobial consumption based on this concept. Observational study in a general hospital in Saudi Arabia from 2006-2008. We analyzed the use of intravenous systemic antibacterial agents [group 101 of the Anatomical Therapeutic Chemical [ATC] classification and the classes of this group] that were administered to hospitalized patients by revieweing the data obtained from the pharmacy records. Antimicrobial consumption was calculated as the number DDD per 100 bed-days. Of the total parenteral antibiotics, ciprofloxacin was the most common used intravenous antibiotic [67.6%], followed by ceftriaxone [6%], cefazolin [5%], and imipenem-enzyme inhibitor [4.3%]. The DDD per 100 patients-days usage of intravenous antimicrobial agents was as follows: J01MA02 ciprofloxacin [parenteral] 82.643, J01DD04 ceftriaxone 7.447, J01DB02 cefazolin 6.166, J01DH51 imipenem-enzyme inhibitor 5.234, J01MA 12 levofloxacin 3.188, and J01XA01 vancomycin 2.97. intravenous ciprofloxacin usage increased from 3.55 to 82.643 DDDD/100 patient days. The study showed that the most commonly used intravenous systemic antimicrobial agents was ciprofloxacin. Thus, strategies are needed to specifically target these agents for prescribing improvement

Willingness of health care workers of various nationalities to accept H1N1 [2009] pandemic influenza A vaccination

Media attention on 2009 H1N1 vaccination has been negative. Information on the willingness of health care workers [HCWs] to accept vaccination against the 2009 pandemic influenza is sparse. Thus, we undertook this study to investigate the attitude of HCWs toward this vaccine and possible factors associated with vaccine acceptance. Cross-sectional observational study of HCWs conducted at Saudi Aramco Medical Services Organization [SAMSO] in February 2009.A self-administered questionnaire was distributed to 250 individuals and 161 [64.4%] were completed. Of the total respondents, 66 [41%] were Arab, 55 [34.2%] were Asian/Far East, and 40 [24.8%] were of other nationalities. A total of 65 [40.4%] responses were from physicians and nurses, and 96 [59.6%] were from other HCWs. Of all the responders, 152 [94.4%] were aware of the H1N1 influenza situation, and 135 [83.9%] stated they had received enough information about the current situation. Of all the respondents, 59 [36.6%] stated that they received the seasonal influenza vaccination in 2008-2009, and 50 [31.1%] expressed their willingness to take the 2009 H1N1 vaccine. A total of 24 [14.9%] stated that the vaccine contains thiomersal, 21 [13%] stated that the vaccine contains adjuvants, 19 [11.8%] stated it contains squalene, 17 [10.6%] thought the vaccine causes infertility, and 29 [18%] thought the vaccine causes Guillain-Barre syndrome. In a multivariate analysis, the following factors were noted to be important in choosing to be vaccinated: being Asian, not being a doctor or a nurse, and previous acceptance of the seasonal influenza vaccine [P

analysis of pathological findings for cervical lymph node biopsies in eastern Saudi Arabia

Lymphadenopathy is a common medical problem. A lymph node biopsy may be necessary for definitive diagnosis in selected cases. The study group included a retrospective, hospital-based series of patients who had a cervical lymph node biopsy at the Saudi Aramco Medical Services organization between 1997 and 2008. During the study period, there were a total of 452 cervical lymph node biopsies. Biopsies were performed on 122 [27%] children 60 years. The most common histopathological diagnosis was reactive disease [52.2%, n = 236], which was followed by granulomatous disease [15.5%, n = 70]. We detected carcinoma in 14.6% of the patients [n = 66], Hodgkin's lymphoma in 8.8% [n = 40] and non-Hodgkin's disease in 8.8% [n = 40]. Malignancy was more common in adults than children [19.5% vs. 1.6%, respectively and reactive disease was more common in children than adults [65.3% vs. 47.3%, respectively]. Metastatic disease was more likely in the older age group [17.7% vs. 0%], Hodgkin's disease was found in 12.5% of the adolescents, and non-Hodgkin's disease was present in 10.3% of the adults and elderly. The most common histopathological findings for cervical lymph node biopsies in eastern Saudi Arabia were reactive disease and granulomatous disease

Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia

Peripherally inserted central venous catheters [PICCs] are alternatives to short-term central venous catheters and provide intravenous access in the acute hospital setting. In this study, we describe the rate of PICC-associated bloodstream infections [BSI]. Prospective cohort study using data on PICC lines reviewed from January to December 2009. The infection control team was responsible for prospective BSI case findings. The infection rate was calculated per 1000 device-days. During the study period, 92 PICC lines were inserted with a total of 3336 device-days of prospective surveillance. The most frequent reasons for the insertion of the PICC lines were chemotherapy [n=19, 20.7%], intravenous antimicrobial therapy [n=34, 37%], and for patients in the medical intensive care unit [ICU] [n=16, 17.4%]. The overall BSI rate was 4.5/1000 PICC days. The PICC line-associated BSI rates for a specific indication were as follows: chemotherapy 6.6/1000 device-days, intravenous antimicrobial therapy 1.2/1000 device-days, medical ICU 7.3/1000 device-days, surgical ICU 4.6/1000 device-days, and total parental nutrition patients 2.4/1000 device-days [P<.001]. The rates were not adjusted for patient severity of illness. Our data suggest that underlying conditions and indications for the PICC line use may play an important role in the development of BSI

Sarcoidosis in the eastern region of Saudi Arabia

To review a general hospital's experience with sarcoidosis and the clinical pattern of the disease among Saudis. A retrospective file review was carried out on all patients with a proven diagnosis of sarcoidosis in a general hospital in Eastern Saudi Arabia over a period of 11 years [1998-2008]. Sixty-nine patients, of whom 33 cases were included in the analyses, were diagnosed to have sarcoidosis during the study period. There were 18 females and 15 males. The mean age was 44.5 years [SD 17]. The most common presentations were cough [48%], dyspnea [21%], joint pain [18%], splenomegaly [12%], hepatomegaly [9%], and lymphadenopathy [5%]. The biochemical analysis showed elevated calcium levels in 6% and elevated angiotensin converting enzyme [ACE] in 14 [46.7%]. The tuberculin skin test was negative in all tested patients [n = 29] except one patient. The patients were classified using the modified Scadding classification system. None of the patients was in stage 0, 39.4% were in stage 1, 45% were in stage 2 and 15% were in stage 3.. The diagnosis in all patients was proven histologically. The outcome was favorable in most patients [85%], and in 6% of the patients, the course was chronic and progressive, although 66% received active treatment. Sarcoidosis does occur in native Saudis. The clinical presentation of these patients was similar to the western pattern of disease with some differences such as relative lack of cardiac, eye, parotid, and central nervous system involvement. The rarity of cardiac and central nervous system involvement was comparable with other Middle Eastern studies. Sarcoidosis, though rare in our community, should still be considered in the differential diagnosis of patients with the typical presentation after excluding tuberculosis

Cerebral phaeohyphomycosis due to rhinocladiella mackenziei [formerly ramichloridium mackenziei]: case presentation and literature review

Rhinocladiella mackenziei [formerly Ramichloridium mackenziei], a causative agent of cerebral phaeohyphomycosis, is extremely rare and it is geographically limited to the Middle East. The organism has a predilection to cause brain infections and results in a grave prognosis with a high mortality rate. The current patient was admitted to a long term care facility with chronic respiratory failure and dependence on a mechanical ventilator. She later developed left sided weakness and a CT-scan of the brain revealed multiple variable sized hypodense, well-defined lesions with ring enhancement. A stereotactic needle aspiration of the largest lesion showed fungal hyphae. The final culture grew R. mackenzie. The patient was initially started on liposomal amphotericin B, then voriconazole and caspofungin intravenously as posaconazole was not available. The patient failed to respond to antifungal therapy and finally she died 34 days after the start of the treatment. R. mackenziei is a highly virulent agent, and should be considered in the differential diagnosis of central nervous system disease in patients from the Middle East

Improving adherence to venous thromboembolism prophylaxis using multiple interventions

In hospital, deep vein thrombosis [DVT] increases the morbidity and mortality in patients with acute medical illness. DVT prophylaxis is well known to be effective in preventing venous thromoembolism [VTE]. However, its use remains suboptimal. The objective of this study was to evaluate the impact of quality improvement project on adherence with VTE prophylaxis guidelines and on the incidence of hospital-acquired VTEs in medical patients. The study was conducted at Saudi Aramco Medical Services Organization from June 2008 to August 2009. Quality improvement strategies included education of physicians, the development of a protocol, and weekly monitoring of compliance with the recommendations for VTE prophylaxis as included in the multidisciplinary rounds. A feedback was provided whenever a deviation from the protocol occurs. During the study period, a total of 560 general internal medicine patients met the criteria for VTE prophylaxis. Of those, 513 [91%] patients actually received the recommended VTE prophylaxis. The weekly compliance rate in the initial stage of the intervention was 63% [14 of 22] and increased to an overall rate of 100% [39 of 39] [P=0.002]. Hospital-acquired DVT rate was 0.8 per 1000 discharges in the preintervention period and 0.5 per 1000 discharges in the postintervention period, P=0.51. However, there was a significant increase in the time-free period of the VTE and we had 11 months with no single DVT. In this study, the use of multiple interventions increased VTE prophylaxis compliance rate

Pandemic influenza A [2009 H1N1] in hospitalized patients in a Saudi Arabian hospital: Epidemiology and clinical comparison with H1N1-negative patients

The World Health Organization [WHO] declared that pandemic influenza A [H1N1] was a public health emergency of international concern in April 2009. Herein, we describe the characteristics of patients in a Saudi Arabian hospital with and without H1N1 infection. We reviewed the records of patients admitted with influenza-like illness and compared confirmed pandemic H1N1 cases to the H1N1-negative patients admitted to the hospital. Infections due to the novel H1N1 virus were confirmed using real-time reverse transcriptase polymerase chain reaction [rRT-PCR]. During the study period, a total of 165 patients were admitted with influenza-like illness and underwent rRT-PCR testing. Of these patients, 47 [28.4%] had confirmed novel H1N1 virus infection. Thus, the hospitalization incidence rate was 13.4 cases per 100,000 persons. The remaining patients had negative H1N1 rRT-PCR test results. The mean age +/- SD of the H1N1-positive patients was 30.3 +/- 28.5 years compared with 25.3 +/- 23 years for the H1N1-negative group [P=0.28]. Severe obesity was observed in 6.7% and 8.5% of H1N1-positive and H1N1-negative patients, respectively [P=0.74]. The clinical picture was similar between the two groups, except for the higher prevalence of nausea [25.5% vs. 11%] and diarrhea [21.3% vs. 7.6%] in the H1N1-positive group than in the H1N1-negative group [P=0.03] The mortality rate was low in both groups. The clinical presentation and outcome are insufficient to differentiate between influenza-like illness [ILI] caused by H1N1 and that cause by other pathogens. In general, both groups had mild disease in this cohort of patients in Saudi Arabia

Hydrogen sulfide exposure in an adult male

Hydrogen sulfide [H[2]S] is responsible for many incidents of occupational toxic exposure, especially in the petroleum industry. The clinical effects of H[2]S depend on its concentration and the duration of exposure. H[2]S is immediately fatal when concentrations are over 500-1000 parts per million [ppm] but exposure to lower concentrations, such as 10-500 ppm, can cause various respiratory symptoms that range from rhinitis to acute respiratory failure. H[2]S may also affect multiple organs, causing temporary or permanent derangements in the nervous, cardiovascular, renal, hepatic, and hematological systems. We present a case of occupational exposure to H[2]S leading to multi-organ involvement, acute respiratory failure, organizing pneumonia, and shock resembling acute sepsis. The patient also developed mild obstructive and restrictive pulmonary disease and peripheral neuropathy

Improvement in vancomycin utilization in adults in a Saudi Arabian medical center using the hospital infection control practices advisory committee guidelines and simple educational activity

To evaluate vancomycin utilization according to the adapted criteria of the Centers for Disease Control and Prevention [CDC] with a report of the effect of education program on the utilization. We evaluated the utilization of vancomycin over a 3-month period pre- and post-intervention using educational activity. In the pre-intervention period, of the 74 adult patients vancomycin was prescribed for specific treatment in 66% [n = 49], empirical therapy in 26% [n = 19] and as a prophylaxis in 8% [n = 6]. Vancomycin utilization was considered appropriate based on the CDC recommendations in 48 [65%] patients. Forty-seven [64%] patients received an appropriate dose regimen based on weight, age and creatinine clearance. Only 31% [n = 23] of patients had both peak and trough levels taken around the third dose. In the post-intervention period, vancomycin was used as specific therapy in 41% [n = 14] and empirically in 59% [n = 20]. Compliance with guidelines for empirical use of vancomycin improved from 21% in the pre-intervention phase to 85% after the intervention [P = .0001]. In addition, compliance with vancomycin use in specific therapy was 100% compared to 82%. Compliance rate with vancomycin trough level monitoring increased from 35% in the pre-intervention period to 67.7% in the post-intervention period [P = 0.0002]. In conclusion, in addition to the utilization of CDC based criteria for vancomycin, we had shown that patient's chart review by a clinical pharmacists with a feed back to the physicians when guidelines were not met coupled with and educational efforts are effective methods to decrease inappropriate vancomycin usage

24-year study of the epidemiology of human brucellosis in a health-care system in Eastern Saudi Arabia

The aim of the study was to examine the epidemiology of human brucellosis in a helath-care system in Eastern Saudi Arabia. All cases of human brucellosis from 1983 to 2007 were analyzed. In the study period, there were 913 patients with brucellosis in the Saudi Aramco health-care system. There were 608 males and 305 females with a male to female ratio of [2:1]. The annual incidence rate per 100,000 populations increased from 13 to 70 in 1983 and 1987, respectively, then decreased to 9 in 2006. The age of the patients ranged from 1 to 83 years with a mean age of 35.8 +/- 17.9 years and a median of 36 years. Of the total patients, 195 [21%] and 155 [17%] cases occurred in those between 20-30 and 31-40 years of age, respectively. Children [/= 1:2560 in 10%. The higher brucella titers were associated with higher rate of positive cultures [P value = 0.0002]. There was a decrease in the incidence of brucellosis over the study period. The highest incidence was in patients 40-49 years of age. Continued surveillance and efforts are needed to further decrease the cases of brucellosis

Prevalence and antimicrobial resistance of health care associated bloodstream infections at a general hospital in Saudi Arabia

To determine the trend of health care associated blood stream infection [HA-BSI] at Saudi Aramco Medical Services Organization. This prospective survey was conducted during the year 2002-2006. Definitions of HA-BSI infections were based on the Centers for Disease Control and Prevention categories. There were a total of 1103 distinct episodes of HA-BSI with annual average rates of 8.5 per 1000 discharges and 18 per 10,000 patient-days. Of all episodes, 38% were primary, 47% were central line-associated bloodstream infection [CLABSI], and the remaining 15% were secondary bacteremias. The hospital wide BSI rate per 1000 discharges increased from 7.8 to 11.9 [p<0.001]. Secondary bacteremia remained relatively stable over the study period at 3/10.000 patient-days [p=0.41]. Primary BSI increased from 6.9 to 10.6 per 10.000 patient-days [p<0.001]. Hospital wide CLABSI increased from 3.2 to 6 per 1000 discharges [p<0.001] and from 7 to 11.8 per 10,000 patient-days [p=0.039]. Coagulase negative staphylococcus was the leading pathogen [23.7%] followed by Staphylococcus aureus [11.1%] and Escherichia coli [11.1%]. Of all episodes, candida caused 5%, Klebsiella pneumoniae [9%] and Pseudomonas aeruginosa [7.3%]. The rate of secondary BSI remained relatively stable over the study period. However, primary BSI and CLABSI increased over time. Coagulase negative staphylococcus, Staphylococcus aureus, and Escherichia coli were the most frequent microorganisms