Late diagnosis of 5-alpha-reductase type 2 deficiency in an adolescent girl with primary amenorrhoea

Deficiency of the 5-alpha-reductase enzyme has been found to affect male sexual development. We report an 18-year-old patient who was referred to an endocrinology clinic in Jizan, Saudi Arabia, in April 2014 with primary amenorrhoea, virilisation and a lack of secondary sex characteristics. As female external genitalia were present at birth, she had been raised as a female. Magnetic resonance imaging revealed no uterine or ovarian tissue in the pelvis and the presence of a scrotal sac. She was diagnosed with 5-alpha-reductase type 2 deficiency, a 46,XY disorder of sexual development. Typically, affected males have pseudovaginal perineoscrotal hypospadias and ambiguous genitalia at birth. Individuals who have been raised as female manifest characteristics of virilisation at puberty, including deepening of the vocal tone, phallus enlargement, scrotal hyperpigmentation and increased muscle mass

Antimicrobial agent- resistance in Escherichia coli, isolated from patients with diarrhea in Aden

The potency of five types of antimicrobial agents, tested against four Escherichia coli isolates and causing diarrhea in patients, in Aden were evaluated. The production of the beta-lactamase was also evaluated by using direct capillary tubes method. Ofloxacin was the most antimicrobial agent with the highest susceptibility rate and the most active compound among the E. coli isolates [100% susceptible], followed by tetracycline [75% susceptible] and ampicillin [50% susceptible]. The resistance rates to cefpodoxime [100% resistance] and amoxi-clavu. [75% resistance] were high among the isolates in this study. The studied E. coli isolates demonstrated high resistance rates to beta-lactam drugs, including amoxicillin- beta-lactamase inhibitor combination [amoxi-clavu.]. The production of beta-lactamase among the studied E.coli isolates [25%] and, therefore, did not contribute significantly to the resistance of these isolates. The results presented in this study confirm that bacterial resistance continues to be a great problem in Aden

Kinetic study of purified urease enzyme from date-palm seeds

Date seeds of Alhajere variety [from Wadi Hajer - Hadramout] was studied for urease enzyme content. Results showed the occurrence of the urease enzyme, with specific activity 598 unit /mg protein. Urease extracted from Alhajere date seeds was purified by using ammonium sulphate [40-60%] saturation and dialyzed by using 20 mM potassium phosphate buffer at pH 8. The results of urease characterization showed that the optimum pH of the enzyme activity was 8 and also the same value for the optimum pH of the enzyme stability. The optimum temperature of the enzyme activity was 40°C and that for urease stability was [40-50]°C. Kinetic studies showed that Km and Vmax values were 8.4 mmolar and 975 mmole/min respectively, using urea as a substrate

Visceral leishmaniasis complicated by secondary bacterial infections in Iraqi Kala-Azar

Kala-azar is a vector borne parasitic disease endemic in Iraq. This disease is complicated by secondary bacterial infections which may lead to death. The study was carried out to detect the bacterial infections associated with kala-azar and the effective treatment. Collection of blood, urine, stool and ear exudate specimens from 63 proved kala-azar patients. The bacterial isolates from the specimens were subjected to antibiotics sensitivity test. 63 [46.7%] of 135 hospitalized children with visceral leishmaniasis, developing 102 episodes of infections. The sites of these infections were urinary tract 46 [45.1%], lower respiratory tract 37[36.3%], gastrointestinal 10[9.8%] and middle ear 9[8.9%]. Both Gram negative and Gram positive bacteria were isolated. Most of the isolated bacteria belong to the family Enterobacteriaceae. The antibiotics gentamicin, amikacin and co-trimoxazole were the most effective. Bacterial infections were common among hospitalized children with kala-azar. The commonest were Gram negative bacteria of the family Enterobacteriaceae

Prospective surveillance of nosocomial device-associated bacteremia in three adult intensive units in Malaysia

Nosocomial blood stream infection (or nosocomial bacteremia) is a common problem in hospitals worldwide, including Malaysia. A three-year prospective cohort study (October 2003-March 2007) of the incidences, risk factors, and patterns of the microorganisms causing bacteremia was conducted using a validated surveillance form in three intensive care units (ICUs) in Malaysia. Center for Disease Control criteria were used to diagnose bacteremia. Patients were monitored from admission until the end point of study, which was the first detection of bacteremia in the blood in each patient. The frequency of occurrence of bacteremia with clinical symptoms was 10.7% (n = 23). Bacteremia was observed to occur within a mean length of stay of 10 days in ICU. The rate of device-related infection was 10.4% per device utilization days with a device utilization rate of 95.9%/1000 patient days. The total number of patient days was 2309 and the period of device utilization was 2211 days. The common bacteria detected were extended-spectrum beta-lactamases (ESBLs) Klebsiella pneumoniae (n = 6); Pseudomonas aeruginosa (n = 6); Acinetobacter species (n = 5); Methicillin-resistant Staphylococcus aureus (MRSA)(n = 3); and (non- ESBL) Klebsiella pneumoniae (n = 2). Multivariable analysis using Cox Proportional Hazard Model showed that the predictors for developing bacteremia were cancer, MRSA carriage, duration of central venous catheter (CVC) infusion, frequency change of CVC, and the administration of hydrocortisone drugs. These results indicate that a combination of nursing and medical interventions as well as patients' severity of illness could lead to bacteremia in ICU. Strategic implementation of quality assurance measures in ICUs could help to control this problem.

Evaluation and comparison of immunchromatography and immunofluorescent techniques in diagnosis and epidemiological studies in Iraqi Kala-Azar

Infantile kala-azar is an endemic protozoal disease prevalent among children in Iraq. A rapid diagnostic laboratory tests are required for immediate treatment. A prospective study was conducted in two pediatric hospitals in Baghdad during the period from Oct. 2005 to Sept. 2006 to evaluate the efficiency of immunochromatography strip test [IC] with rK39 antigen compared to indirect fluorescent antibody test [IFAT] for serodiagriosis of visceral leishmaniasis [VL] to investigate its use for epidemiological studies in Iraqi kala-azar. The study included 54 proved cases for Leishmania donovani [L.D.] bodies in bone marrow, 108 clinically diagnosed cases, 38 with diseases other than VL [tuberculosis, acute amoebic dysentery, urinary schistosomiasis, brucellosis, toxoplasmosis and malaria] and 24 healthy controls. In addition of 3000 patients presented with fever, anaemia and hepatosplenomegaly. The highest sensitivity of the sera was obtained by IC [92.6%] and by IFAT [96. 3%], and the highest specificity by IC [100%] and by IFAT [86.8%]. In the epidemiological study with rK39 strip test 66.1% positive reactions were obtained in patients with fever, anaemia and hepatosplenomegaly. IC strip test with rK39 antigen was more easy to perform but less sensitive than IFAT and the former was more specific than the latter

Tuberculous aortitis

Tuberculous aortitis [TA] is a rare entity that is invariably indicative of disseminated tuberculosis. TA is associated with aneurysm formation in about half of cases. Another possible complication is perforation of adjacent structures [1-7]. Both abdominal and thoracic aorta are involved with equal frequency.[7-9] Fatal outcomes are frequently reported even after antituberculosis chemotherapy and surgical intervention. We present a case of tuberculous aortic aneurysm [TBAA] that underwent surgical resection and graft replacement in the bed of the infected aorta. Following an apparently successful chemotherapy, the patient died suddenly. We postulate that reactivation of the un-eradicated bacilli precipitated graft failure. Similar cases in the literature are reviewed. We propose lifelong suppressive therapy with antituberculosis agents to prevent such a catastrophic event

Induction of clindamycin resistance in erythromycin-resistant, clindamycin susceptible and methicillin-resistant clinical Staphylococcal isolates

To demonstrate the in vitro ability of erythromycin to induce clindamycin in erythromycin resistant and clindamycin susceptible clinical isolates of Staphylococci. We studied 291 clinical isolates of erythromycin-resistant [ER-R] clindamycin-susceptible Staphylococci [CL-S] at Almana General Hospitals, Al-Khobar, Dammam, Saudi Arabia during the period from June 2004 to May 2005. The isolates included 70 Staphylococcus aureus, 81 Methicillin Resistant Staphylococcus aureus [MRSA] and 140 coagulase-negative Staphylococci [CNS]. We examined these isolates for inducible clindamycin resistance [ICR] by erythromycin induction test using double disc susceptibility test [D-test]. Strains producing ICR show flattening of the clindamycin disc zone adjacent to the erythromycin disc. Of the 291 ER Staphylococci studied, 82 [28%] demonstrated constitutive clindamycin resistance [2 [2.9%] S. aureus, 43 [53%] MRSA and 37 [26%] CNS]. Inducible clindamycin resistance was demonstrated in 113 [38.8%] of Staphylococcal isolates, including 84 [28.9%] from adult patients and 29 [10%] from pediatric patients. The incidence of ICR was 49 [70%] for S. aureus, 35 [43%] for MRSA and 29 [20.7]% for CNS. Overall, 96 [33%] of the isolates remained susceptible to clindamycin and were negative for clindamycin induction [19 [27%] S. aureus, 3 [3.7%] MRSA and 74 [52.8%] CNS]. We conclude that a significant number of ER-R CL-S staphylococcal isolates studied were positive for ICR. These isolates should be reported as clindamycin resistant. Given the high rate of inducible resistance to clindamycin in the staphylococcal isolates, we recommend that microbiology laboratories perform erythromycin induction test on all ER-R CL-S staphylococcal isolates prior to reporting clindamycin susceptibility

Effect of glycemic control and hypertension on Serum basic amino acids in type II diabetes mellitus

Abnormal insulin secretion has been considered the main cause of changes in carbohydrate lipid and protein metabolism in diabetes mellitus [DM] with increased muscle proteolysis and amino acid mobilization to study the effect of glycemic control and hypertension, on three basic amino acids arginine [Arg.] lysine [Lys] and histidine [His] in type II DM. Fifty five patients with type II diabetes mellitus [DM] were included in the study. They were 39 nortnotensive and 16 hypertensives with different grades of glycemic control as revealed by the level of glycated Hb [HbAk]. Thirty eight were with poor control; HbAlc > 8.5%, [27 normotensives and II hypertensives] while 17 were with acceptable range of control, HbAlc 6.8 - 8.5% [12 normotensives and 5 hypertensives]. Forty non diabetic subjects [28 normotensives and 12 hypertensives] were also included in the study as a control group. Glycatcd Hb [HbAk] was measured by affinity resin column chromatography and serum amino acid analysis was done by reversed high performance liquid chromatography. The results show that type II DM had caused a significant reduction in serum Arg [a precursor of nitric oxide which has an important role in the reduction of diabetic complications] with a significant elevation in serum Lys.while no change in serum His could be seen. Hypertension, on the other hand, has caused a significant elevation in serum His in both diabetics and non diabetics. Serum Arg was not changed while a significant elevation in serum Lys. was found in the non diabetic hypertensive subjects which disappeared in the diabetic hypertensive patients. No effect of the glycemic control on the concentration of any of the three amino acids could be detected in the diabetics of the present study. The possible suggestions and explanations for these events are mentioned

Human immunodeficiency virus in Saudi Arabia

The human immunodeficiency virus HIV type 1 has evolved as one of the most important global infectious pathogens. Although the virus had initially emerged among certain high risk groups in developed countries, it quickly gained momentum in developing countries threatening most population groups. The first case of acquired immunodeficiency syndrome from the Kingdom of Saudi Arabia was diagnosed in 1984. Twenty years later, by the end of 2003, 1509 patients have been reported to have acquired HIV 1. The majority of the early infected patients have acquired HIV 1 from blood product transfusion. Subsequently, the most prevalent mode of transmission became heterosexual. In this review, the distribution of HIV infected persons, prevalence data, and future outlook are presented. Communities considered conservative are not immune from a sexually transmissible virus that has infected 60,000,000 people globally

Primary hyperaldosteronism treated by radiofrequency ablation

This is a report of a 57-year-old Jordanian man who had uncontrolled hypertension and hypokalemia. He was diagnosed to have primary hyperaldosteronism with left adrenal adenoma. Traditionally, surgical resection of the adrenal gland whether by laparotomy or laparoscopic procedures would have been considered at this point. However, the treating team elected radiofrequency ablation of the left adrenal in view of the fact that this facility and the expertise was available in the hospital; in addition, this procedure required a shorter duration of hospitalization, was less expensive, and was less invasive. Subsequently, the patients blood pressure improved to 120/75mm Hg and his anti-hypertensive medications were reduced. Serum aldosterone and computed tomography scan of adrenals improved. We are reporting this case as it is the first time such modalities in the treatment of adrenal adenoma was used

Prevalence of extended spectrum beta lactamase among multidrug resistant gram-negative isolates from a general hospital in Saudi Arabia

To determine the prevalence of extended spectrum b-lactamase [ESBL] among multidrug resistant isolates of enterobacteriaceae and non-fermenting gram-negative bacilli. This study was carried out at the Almana General Hospital, Eastern Province, Kingdom of Saudi Arabia, during the period March 2002 through to June 2003. Multidrug resistant gram-negative isolates from patients admitted to the surgical, medical, pediatric, long-term care and intensive care units were studied for the presence of the ESBL enzyme. A total of 3231 gram-negative organisms were studied for the presence of multidrug resistance and ESBLs. Of these, 197 [6%] isolates were multidrug resistant [MDR], and 156 [4.8%] were positive for ESBL. Seventy nine percent of the MDR strains were positive for ESBL. The most frequent isolates were Escherichia coli [1116] and Klebsiella pneumoniae [687] and ESBL was detected in 72 [6.5%] and 37 [5.4%] of these isolates. The MDR strains that produced ESBL were most commonly isolated from surgical care patients with diabetic fascitis [83%] and patients with indwelling Foley's catheter [79%]. Extended spectrm b-lactamase producing strains showed the highest susceptibility to imipenem and meropenem [86%]. The non-b-lactam antibiotics with greatest activity against these ESBL strains in vitro were ciprofloxacin [72%], amikacin [70%], tobramycin [67%] and gentamicin [56%]. The majority [79%] of the MDR enterobacteriaceae and non-fermenting gram-negative bacilli tested over 15-months were positive for ESBL. Imipenem, meropenem, ciprofloxacin and amikacin showed the highest activity against these ESBL-producing organisms. Due to the growing problem of infection with ESBL-producing bacteria, which are frequently resistant to many classes of antibiotics resulting in difficult-to-treat infections, clinicians need to be familiar with the clinical significance of these enzymes and potential strategies for dealing with them

Extrapulmonary tuberculosis, clinical presentation and outcome

To identify patterns, features, and outcome of extrapulmonary tuberculosis in a tertiary care setting. A retrospective case-series was carried out of all cases diagnosed and treated as extrapulmonary tuberculosis during 1991 through to 2000 at King Faisal Specialist Hospital and Research Centre [KFSH and RC], Riyadh, Kingdom of Saudi Arabia. Demographic, clinical, laboratory, and outcome data were abstracted from medical records. Over a 10-year period, 394 cases of extrapulmonary tuberculosis were diagnosed and treated at KFSH and RC. Isolated extrapulmonary tuberculosis was identified in 339 [86%] patients, 55 cases [14%] had both pulmonary and extrapulmonary tuberculosis. Mean age was 45-years, and 188 patients [47%] had co-morbidities, most commonly diabetes mellitus in 14.2% of patients. Laboratory confirmation of extrapulmonary tuberculosis was available on 386 patients. The most frequent site involvement was lymphadenopathy in 41% of the time. Chest x-ray was normal in 75% of patients. Among 298 patients with follow up data, 10 [3.4%] had documented relapse and 50 [16%] died. Death was related to tuberculosis in 24 [48%] patients. A high level of clinical suspicion is essential for early diagnosis and treatment of extrapulmonary tuberculosis to reduce the significant morbidity and mortality

Polytetrafluoroethylene use for above-knee femoropopliteal bypass in critical limb ischemia

The question of the best material for above-knee femoropopliteal bypass [polytetrafluoroethylene [PTFE] versus vein] continues to be controversial. The aim of this study was to evaluate our results of using PTFE in above knee femoropopliteal bypass and to determine the predictors which affect graft patency. A retrospective analysis of all above knee femoropopliteal graft surgery [PTFE] carried out for limb salvage between September 1997 and October 2001 at the King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. All records were reviewed for risk factors, presentations, management and complications. In a 4 year period, 52 above-knee femoropopliteal bypass grafts were performed in 49 patients. Polytetrafluoroethylene 8 mm grafts were used in all bypasses. Preoperative risk factors were diabetes 41 [80%]; ischemic heart disease 17 [33%]; and smoking 23 [44%]. There was no operative mortality. Primary cumulative graft patency was 94% at first year, 62% at second year, 42% at third year, and 35% at fifth year. Twenty-two grafts have been occluded with re-emergence of critical ischemia in 18 patients, treated by amputation [5] and secondary reconstruction [13], of which 2 limbs required amputation later. Limb salvage was 87%. Female gender and non patent tibial vessels were the only predictors which affected graft patency. Our results were not comparable in terms of long primary patency as those reported with autogenous vein, but comparable regarding limb salvage, early patency and ease of use. Preservation of the saphenous vein for use later encouraged us towards primary use of PTFE for above-knee femoropopliteal bypass

Mycobacterium tuberculosis susceptibility in Saudi Arabia

To present the available susceptibility data of Mycobacterium tuberculosis [M. tuberculosis] isolates from the Kingdom of Saudi Arabia [KSA] published in peer-reviewed journals. In a meta-analysis, studies published between 1966 and 2001 were included. Publication sites include Medline-indexed and non-indexed. Numbers of grown and resistant isolates were tabulated for first-line anti-tuberculosis agents. Twelve studies met the pre-set criteria. Data on 6,316 isolates between 1979 and 2000 were available. Resistance to at least one agent of the first-line anti-tuberculosis agents was 18.4%. Monoresistance to a single first-line agent was found in 10.9%, while polyresistance was noted in 7.6%. Multidrug-resistant M. tuberculosis was noted in 5.7% of all isolates. Resistance to isoniazid was most common noted in 11% of isolates. Resistance rates to other agents were: rifampin 9.7%, streptomycin 9.1%, pyrazinamide 3.1%, and ethambutol 2.5%. The overall resistance rate to at least one agent was not statistically different in isolates grown between 1979-1991 [18.5%] and 1989-2000 [18.3%]. There were large regional variations and higher resistance rates in the Western and Southern regions. Mycobacterium tuberculosis resistance rates to first-line antituberculosis agents and multidrug-resistant M. tuberculosis are high in KSA. A survey and monitoring program for drug-resistant tuberculosis will determine resistance rates at the community level