Case characteristics among Middle East respiratory syndrome coronavirus outbreak and non-outbreak cases in Saudi Arabia from 2012 to 2015.

OBJECTIVES: As of 1 November 2015, the Saudi Ministry of Health had reported 1273 cases of Middle East respiratory syndrome (MERS); among these cases, which included 9 outbreaks at several hospitals, 717 (56%) patients recovered, 14 (1%) remain hospitalised and 543 (43%) died. This study aimed to determine the epidemiological, demographic and clinical characteristics that distinguished cases of MERS contracted during outbreaks from those contracted sporadically (ie, non-outbreak) between 2012 and 2015 in Saudi Arabia. DESIGN: Data from the Saudi Ministry of Health of confirmed outbreak and non-outbreak cases of MERS coronavirus (CoV) infections from September 2012 through October 2015 were abstracted and analysed. Univariate and descriptive statistical analyses were conducted, and the time between disease onset and confirmation, onset and notification and onset and death were examined. RESULTS: A total of 1250 patients (aged 0-109 years; mean, 50.825 years) were reported infected with MERS-CoV. Approximately two-thirds of all MERS cases were diagnosed in men for outbreak and non-outbreak cases. Healthcare workers comprised 22% of all MERS cases for outbreak and non-outbreak cases. Nosocomial infections comprised one-third of all Saudi MERS cases; however, nosocomial infections occurred more frequently in outbreak than non-outbreak cases (p<0.001). Patients contracting MERS during an outbreak were significantly more likely to die of MERS (p<0.001). CONCLUSIONS: To date, nosocomial infections have fuelled MERS outbreaks. Given that the Kingdom of Saudi Arabia is a worldwide religious travel destination, localised outbreaks may have massive global implications and effective outbreak preventive measures are needed.

Presentation and reasons for HIV-1 testing in Saudi Arabia.

Clinical presentation, CD4+ T lymphocyte count at diagnosis, and reasons for HIV-1 testing reflect the attitudes towards HIV testing and also the ability of the health-care system to diagnose HIV early. In a cross-sectional study from the HIV database in a large HIV-referral centre in Saudi Arabia, all 410 HIV-infected patients were included, 276 men and 134 women. Women were younger at diagnosis (mean age 25.5 compared with 29 years for men, P < 0.04) and had higher CD4+ T lymphocytes (mean 461 for women and 223 for men, P < 0.001). Out of 276 men, 90 (33%) were identified as HIV infected when they presented with AIDS. Fifty-five percent of the infected women were tested for HIV-1 because of contact with an infected person compared with 8% of the infected men, odds ratio (OR) 13.8 (95% confidence interval [CI]: 7.7-24.9). AIDS remains the main presentation for HIV-infected men. Women are diagnosed earlier and younger than men.

Successful therapy of cerebral phaeohyphomycosis due to Ramichloridium mackenziei with the new triazole posaconazole.

Cerebral phaeohyphomycosis caused by Ramichloridium mackenziei is universally fatal. All reported cases with long-term follow-up have indicated 100% mortality despite antifungal therapy and surgical intervention. We describe the case of a 62-year-old patient who underwent renal transplantation and had a cerebral abscess caused by R. mackenziei. The infection progressed despite surgical evacuation and therapy with liposomal amphotericin B, itraconazole, and 5-flucytosine. The patient was subsequently treated with the investigational triazole posaconazole oral suspension, 800 mg/day, in divided doses. Treatment with posaconazole resulted in progressive clinical and radiologic improvement. The patient is alive four years after diagnosis and maintained on posaconazole therapy. This case supports the potential role of this extended-spectrum azole in the treatment of this serious fungal infection of the central nervous system.

Disseminated Mycobacterium simiae infection in patients with AIDS.

OBJECTIVES: To report our experience with disseminated Mycobacterium simiae disease in patients with AIDS, and review other cases reported in the literature. METHODS: We retrospectively reviewed all cases of M. simiae that were isolated from sterile body sites over a 9-year period at the University Health System Hospital at San Antonio, Texas, U.S.A. Data included patient demographics, clinical features, other accompanying opportunistic infections, in vitro susceptibility, therapy and outcome. RESULTS: Ten cases of M. simiae disseminated disease were identified. All of them were inpatients with AIDS. Another nine cases of disseminated infection in AIDS patients were reported in the literature. Advanced AIDS with absolute CD4 counts of less than 50 and an associated AIDS-defining illness characterized all cases. Persistent fever and debilitation without localizing signs were the most common clinical features. Our patients responded poorly to antimycobacterial drugs and died within 6 months of diagnosis. The only reported successful therapy was in patients who responded well to highly active antiretroviral therapy and antimycobacterial regimens containing clarithromycin, ethambutol and ciprofloxacin. CONCLUSIONS: Clinical presentation of M. simiae infection mimics Mycobacterium avium complex, with fever and progressive debilitation, but is less responsive to therapy. Immuno-reconstitution with potent antiretroviral therapy may be the best therapy for such resistant disease.

SCH 56592, amphotericin B, or itraconazole therapy of experimental murine cerebral phaeohyphomycosis due to Ramichloridium obovoideum ("Ramichloridium mackenziei").

Ramichloridium obovoideum ("Ramichloridium makenziei") is a rare cause of lethal cerebral phaeohyphomycosis. It has been, so far, geographically restricted to the Middle East. BALB/c mice were inoculated with two strains of R. obovoideum intracranially. Therapy with amphotericin B, itraconazole, or the investigational triazole SCH 56592 was conducted for 10 days. Half the mice were monitored for survival and half were killed for determination of the fungal load in brain tissue. Recipients of SCH 56592 had significantly prolonged survival and lower brain fungal burden, and this result was found for mice infected with both of the fungal strains tested. Itraconazole reduced the brain fungal load in mice infected with one strain but not the other, while amphotericin B had no effect on brain fungal concentrations. This study indicates a possible role of SCH 56592 in the treatment of the serious cerebral phaeohyphomycosis due to R. obovoideum.

Efficacy of the triazole SCH 56592 against Leishmania amazonensis and Leishmania donovani in experimental murine cutaneous and visceral leishmaniases.

Current therapy for leishmaniasis is unsatisfactory. Efficacious and safe oral therapy would be ideal. We examined the efficacy of SCH 56592, an investigational triazole antifungal agent, against cutaneous infection with Leishmania amazonensis and visceral infection with Leishmania donovani in BALB/c mice. Mice were infected in the ear pinna and tail with L. amazonensis promastigotes and were treated with oral SCH 56592 or intraperitoneal amphotericin B for 21 days. At doses of 60 and 30 mg/kg/day, SCH 56592 was highly efficacious in treating cutaneous disease, and at a dose of 60 mg/kg/day, it was superior to amphotericin B at a dose of 1 mg/kg/day. The means of tail lesion sizes were 0.32 +/- 0.12, 0.11 +/- 0.06, 0.17 +/- 0.07, and 0.19 +/- 0.08 mm for controls, SCH 56592 at 60 and 30 mg/kg/day, and amphotericin B recipients, respectively (P = 0.0003, 0.005, and 0.01, respectively). Parasite burden in draining lymph nodes confirmed these efficacy findings. In visceral leishmaniasis due to L. donovani infection, mice treated with SCH 56592 showed a 0.5- to 1-log-unit reduction in parasite burdens in the liver and the spleen compared to untreated mice. Amphotericin B at 1 mg/kg/day was superior to SCH 56592 in the treatment of visceral infection, with a 2-log-unit reduction in parasite burdens in both the liver and spleen. These studies indicate very good activity of SCH 56592 against cutaneous leishmaniasis due to L. amazonensis infection and, to a lesser degree, against visceral leishmaniasis due to L. donovani infection in susceptible BALB/c mice.

Efficacies of KY62 against Leishmania amazonensis and Leishmania donovani in experimental murine cutaneous leishmaniasis and visceral leishmaniasis.

Current therapy for leishmaniasis is unsatisfactory because parenteral antimonial salts and pentamidine are associated with significant toxicity and failure rates. We examined the efficacy of KY62, a new, water-soluble, polyene antifungal, against cutaneous infection with Leishmania amazonensis and against visceral infection with Leishmania donovani in susceptible BALB/c mice. Mice were infected with L. amazonensis promastigotes in the ear pinna and in the tail and were treated with KY62 or amphotericin B. The cutaneous lesions showed a remarkable response to therapy with KY62 at a dose of 30 mg per kg of body weight per day. At this dose, the efficacy of KY62 was equivalent to or better than that of amphotericin B at 1 to 5 mg/kg/day. Mice infected intravenously with 10(7) L. donovani promastigotes and treated with KY62 showed a 4-log reduction in the parasite burden in the liver and spleen compared to untreated mice. These studies indicate potent activity of KY62 against experimental cutaneous leishmaniasis caused by L. amazoniensis and against experimental visceral leishmaniasis caused by L. donovani.

Breast abscess caused by Brucella melitensis.

Cutaneous and soft tissue lesions are uncommon manifestations of brucellosis. Though breast involvement in animal brucellosis is not uncommon, involvement of the breast in human brucellosis is extremely rare. We report a case of breast abscess in a 39-year-old female caused by Brucella melitensis. Treatment with combination of trimethoprim/sulphamethoxazole (TMP/ SMX; cotrimoxazole) and doxycycline for 3 months resulted in clinical cure.