Is hepatitis C virus genotype 4 predominant in Saudi Arabia?

Hepatitis C virus (HCV) genotype 4 is believed to be predominant in the Middle East including Saudi Arabia (SA). We attempted to genotype 80 HCV isolates from different parts of SA by direct sequencing of a variable 222bp fragment from the NS5B region. The phylogenetic analysis of the NS5B sequences was complemented by direct sequence analysis of the conserved 5'-NCR region for HCV type-specific polymorphism. All 80 NS5B sequences separated into 3 clades which comprised 6 type 1b variants, 30 type 4 variants (24 of type 4a and 6 of type 4c or d) and 44 type 3 variants. Apart from two definitive type 3b variants the other 42 type 3 NS5B sequences formed 4 clusters with low similarity to type 3a-f HCV sequences from the database. The precise subtyping of these 42 type 3 variants awaits sequencing of longer HCV RNA stretches. Our results indicate that HCV type 4 may not be the only dominant genotype in SA.

Tuberculous peritonitis in chronic liver disease: Clinical features and response to treatment.

To find out the clinical presentation, laboratory results, and treatment response of tuberculous peritonitis in patients with chronic liver disease, we retrospectively reviewed the medical records of all patients with tuberculous peritonitis diagnosed by laparoscopy at King Khalid University Hospital over a period of seven years. A total of 17 patients (Group 1, consisting of 11 males and six females with a mean age of 539 +/- 17.5 years) had both chronic liver disease and tuberculous peritonitis, while 27 patients (Group 2, consisting of 17 males and 10 females with a mean age of 39.5 +/- 16.3 years) had only tuberculous peritonitis. Tuberculous peritonitis in chronic liver disease had similar clinical and laboratory presentation compared to patients with tuberculous peritonitis but without liver disease. However, Group I were significantly older, had lower ascitic protein content and higher mortality (P values of 0.004, 0.002, and 0.02, respectively). Both groups responded favorably to specific therapy. The overall mortality was recorded as 5.6%. In conclusion, the clinical presentation of tuberculous peritonitis in patients with chronic liver disease is similar to that of patients without liver disease except for ascitic protein, which is lower in the former group of patients. The prognosis is good with specific therapy.

Seasonal variation of culture positive brucellosis at a major teaching hospital.

Brucellosis is one of the main zoonoses in the world. In Saudi Arabia, it was recognized as a major health problem in 1983G and since then many measures have been implemented to control the disease. We conducted a study to determine the yearly incidence and seasonal variation of blood culture positive brucellosis (Brucella cases) diagnosed at King Khalid University Hospital (KKUH) in Riyadh between 1985G and 1991G. The results showed that there was a fivefold decline in the incidence of Brucella cases over the seven years of the study from 8.6 cases/1000 admissions in 1985G to 1.4 cases/1000 admissions in 1991G. The disease showed a prevalence that extended throughout year with the majority of cases occurring during spring, summer and early fall. The possible reasons for the seasonal variation and decreasing incidence of brucellosis noted in this study are discussed.

Laparoscopy in tuberculous peritonitis.

Intra-abdominal tuberculosis remains a significant health hazard in the developing countries. In countries where sophisticated medical facilities are not easily available, laparoscopic examination of intra-abdominal organs is helpful. In this study, 22 patients were found to have peritoneal tuberculosis out of 82 laparoscopic examinations. The major clinical presentation in these patients were abdominal pain, weight loss, fever and ascites. Tuberculin test was not always positive. Direct visualization of the peritoneum and obtaining peritoneal biopsies provide the definitive tissue diagnosis to confirm the clinical diagnosis.

Hepatitis C in chronic renal failure patients.

The occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients in our Nephrology Unit was investigated over a period of 1 year. A total of 71 patients was studied comprising 26 chronic haemodialysis (CHD) patients, 6 acute haemodialysis patients, 4 peritoneal dialysis patients and 35 CRF patients not on dialysis. Patients were screened before and after haemodialysis, and their baseline and postdialysis values of liver enzymes were determined. Eleven (15.5%) of the total 71 patients were HCV antibody positive. Analysis of the individual patient groups showed that 8 (30.7%) of the 26 CHD patients were positive for HCV. Our data showed a statistically significant relationship between seroconversion and duration of dialysis (p < 0.05). A high statistically significant (p < 0.0001) correlation was observed between the HCV antibodies and CRF. The relative risk of hepatitis C was about 22 times greater for those with CRF compared with the normal controls, which makes CRF an important risk factor. A high proportion of the HCV seroconverters had elevated liver enzyme (serum glutamic pyruvic transaminase). The data presented show a positive correlation between HCV seroconversion, CRF, duration on dialysis and elevated serum liver enzymes.

Depression of phagocytic activity of the immune system following traditional cautery in experimental animals.

Traditional cautery, which is practiced widely in Saudi Arabia and some other countries, has not been exposed to detailed scientific investigation. In an attempt to elucidate some of its physiological aspects, we assessed the effect of cautery on a normal animal's nonspecific immune system. Male Wistar rats and guinea pigs were cauterized to simulate traditional cautery in size and percentage of cauterized area. Using radioactive sulfur colloid uptake and clearance, the effect of cautery on the mononuclear phagocyte system was evaluated in rats. The respiratory burst in peripheral polymorphonuclear leukocytes (PMNs) after cautery was measured in the guinea pigs using the chemiluminescence technique. The results showed marked reduction in the intravascular clearance of the colloid with prolonged clearance time following cautery. In addition, the liver uptake of the colloid was reduced in cauterized animals compared with control animals and the white cell count was also significantly reduced. The study showed marked inhibition of phagocytic function in guinea pigs in both whole blood and isolated PMNs. These results indicate that traditional cautery reduces the physiological function of the phagocyctic system in normal experimental animals. The influence of traditional cautery on infected animals deserved further investigation.

An outbreak of acute hepatitis A infection in rural Saudi Arabia.

In areas of hyperendemicity of hepatitis A virus (HAV) infection, acquisition of immunity occurs relatively early in life. In such populations epidemic outbreaks are rare. A recent HAV infection outbreak occurred in the Al-Dahnah district in Saudi Arabia. In thirty day period, 23 children and adolescents were diagnosed by clinical examination. 19 of these were positive for IgM anti-HAV. Concomitant acute infections with the Epstein Bar Virus (EBV) was documented in 4 of these patients. A limited epidemiological survey suggested that the source of infection might have been a contamination of one of the tankers which delivered water supplies to the various houses. In a transitional period of development the rapid improvement in socio economic status and standards of living may increase the susceptible pool. Therefore a greater surveillance is needed to identify and contain such possible outbreaks.

Hepatitis B virus vs schistosomiasis and hepatocellular carcinoma in Saudi Arabia.

Fifty patients with histopathological diagnosis of hepatocellular carcinoma were studied with special reference to infection with hepatitis B virus and schistosomal infestation. The possible correlation of these two risk factors and liver malignancy is discussed.

Gastrointestinal manifestations of brucellosis in Saudi Arabian patients.

Gastrointestinal manifestations of brucellosis in 340 Saudi Arabian patients are reported. Sixty seven per cent of patients presented with gastrointestinal disturbances. The most frequent symptoms were anorexia (40%), abdominal pain (16%), vomiting (11%), and diarrhoea (6%). Hepatomegaly (32%), splenomegaly (29%) and abdominal tenderness (15%) were major abnormalities on physical examination. In endemic areas for brucellosis, gastrointestinal disturbances in the presence of fever of obscure etiology, should raise the possibility of brucellosis.

Experimental treatment of Brucella melitensis infection in sheep with oxytetracycline alone or combined with streptomycin.

The efficacy of oxytetracycline (OTC) alone or combined with streptomycin in the treatment of 118 Najdi ewes believed to have been naturally infected with Brucella melitensis, was evaluated by culture of selected tissues and organs at slaughter. Groups of sheep were given 250, 500 or 1,000 mg of OTC intraperitoneally (i/p) daily for six weeks and in the respective groups at necropsy 52, 69 and 100% of sheep were found to be Brucella-free. Treatment with 250 mg OTC (daily for six weeks i/p) combined with 1,000 mg streptomycin (daily for three weeks intramuscularly) increased the percentage of Brucella-free sheep to 82%. When a group of sheep were each inoculated i/p with 1,000 mg of long-acting OTC every three days over a period of six weeks, 75% of them were Brucella-free at necropsy. B. melitensis was isolated from all (24) non-treated (control) sheep. The results showed that long-term treatment with a high dose of OTC alone had succeeded in eliminating B. melitensis from a group of 16 naturally infected sheep.

Laboratory-acquired brucellosis.

Brucellosis is endemic in Saudi Arabia and hospital laboratories are handling increasing numbers of specimens for diagnosis. We report four cases of laboratory-acquired brucellosis.

Neurological syndromes of brucellosis.

Eleven patients with brucellosis presented with neurological features closely simulating transient ischaemic attacks, cerebral infarction, acute confusional state, motor neuron disease, progressive multisystem degeneration, polyradiculoneuropathy, neuralgic amyotrophy, sciatica and cauda equina syndrome. Most patients improved quickly after adequate antibiotic treatment but chronic cases responded poorly. These protean neurological manifestations of brucellosis indicate that the underlying pathological mechanisms are diverse.

Unusual presentation of culture positive brucellosis.

We have reviewed the clinical presentation of 100 consecutive culture positive cases of brucellosis which came under our care during the last two years. Of these, six had atypical presentations and but for the routine practice of sending blood for brucella culture, the diagnosis would have been missed. The unusual presentations included a 19 year old boy presenting as an acute abdomen ending in laparotomy, a 52 year old man presenting with a psoas abscess, a 29 year old woman presenting with a transient perinephric mass, a 75 year old man with an acute flare up of his osteoarthritis, a 65 year old diabetic man presenting in an insulin-resistant diabetic state and a 35 year old man presenting with a cauda equina syndrome.

The chest radiograph in brucellosis.

A retrospective study of chest radiographs in patients with brucellosis was undertaken at King Khalid University Hospital, Riyadh. The commonest presenting symptoms were fever, back and joint pains, excessive sweating, headache, and cough. Different chest radiographic abnormalities were detected, including soft miliary mottling, parenchymal nodules, consolidation, chronic diffuse changes, hilar or paratracheal lymphadenopathy and pneumothorax. Soft miliary mottling and pneumothorax have not been described before. The high incidence of lung abnormalities is most probably due to the chronicity of the disease in the present series.

Upper gastrointestinal endoscopy in Saudi Arabia: analysis of 6386 procedures.

Fibreoptic endoscopy is now established in the investigation of upper gastrointestinal disease. We report our findings in a large series of endoscopic procedures (6386) mostly in Middle Eastern Arabs, and compare the results obtained in Western patients. We find fibreoptic endoscopy to be feasible, safe, acceptable and effective.

A genetic marker for rheumatic heart disease.

The frequency of antigen types (A, B, C, and DR) in an unselected group of 25 patients with chronic rheumatic heart disease and an unselected group of 15 patients with acute rheumatic fever was compared with that in a group of 100 healthy volunteers. All patients and controls were Arabs of Saudi origin. Only the frequency of HLA-DR4 was significantly different in the controls and the patient groups--controls 12%, chronic rheumatic heart disease 72%, acute rheumatic fever 53%, both patient groups together 65% (relative risk 13.6 with 95% confidence interval 10.5-16.7). Eighty three per cent of 12 patients with mitral stenosis and 70% of seven with aortic incompetence had HLA-DR4 antigen. In 17 non-Saudi Arab patients who had acute rheumatic fever or chronic rheumatic heart disease, the frequency of HLA-DR4 was identical (65%) to that in Saudi patients. These findings may have implications for the pathogenesis of rheumatic fever and rheumatic heart disease.

Brucella meningitis.

Infection with Brucella melitensis is endemic in Saudi Arabia but involvement of the central nervous system (CNS) is rare. We report on three patients with acute brucella meningitis, all of whom had a history of exposure to a possible source of infection. Diagnosis was confirmed by isolation of Brucella species from blood cultures. Examination of cerebrospinal fluid revealed lymphocytic pleocytosis with a high concentration of protein and low concentration of glucose. The patients were treated by combinations of co-trimoxazole, doxycycline or rifampicin. All responded well without recurrences. A combination of two of the three drugs was effective in treating brucellosis of the CNS when given for a period of 6-8 weeks.

Spinal brucellosis.

The findings in 44 patients with back pain and brucellosis are described. Radiological changes tended to occur in older patients with a longer duration of disease. The younger patients more often experienced an acute arthritis with sacroiliitis resembling a reactive disease. Bone scanning was more sensitive than radiographs, particularly in detecting acute sacroiliitis and hip involvement. The lumbar spine was the most frequently involved site although no part of the spine was spared. Extensive destruction of a vertebral body with little involvement of the adjacent vertebrae, lower lumbar spondylolysis and spondylolisthesis, and discitis with calcification were striking radiological findings hitherto undescribed in brucellosis. Computerized axial tomography (CAT) scanning revealed vertebral-arch destruction in three cases of spondylolisthesis. Circumferential sclerosis of the vertebral bodies was another CAT-scan finding.