Multiple myeloma of the central nervous system: a clinicopathological review.

Multiple myeloma (MM) is a systemic malignancy of pathologic plasma cells that is treatable with chemotherapeutic agents and irradiation, but rarely curable. The spectrum of neurological complications of MM is diverse; however, involvement of MM in the cerebrospinal fluid and leptomeningeal infiltration is considered rare. There have been many reviews of central nervous system complications in MM but there are none on intracranial and leptomeningeal infiltration of MM. We review this here along with our clinicopathological experience and a summary of our present knowledge of this condition.

Multiple myeloma of the central nervous system: a clinicopathological review

Multiple myeloma [MM] is a systemic malignancy of pathologic plasma cells that is treatable with chemotherapeutic agents and irradiation, but rarely curable. The spectrum of neurological complications of MM is diverse; however, involvement of MM in the cerebrospinal fluid and leptomeningeal infiltration is considered rare. There have been many reviews of central nervous system complications in MM but there are none on intracranial and leptomeningeal infiltration of MM. We review this here along with our clinicopathological experience and a summary of our present knowledge of this condition

The presence of atypical mycobacteria in the mouthwashes of normal subjects: role of tap water and oral hygiene.

BACKGROUND: The nontuberculous mycobacteria (NTM) have been found in different environmental sources. They tend to colonize different body surfaces and secretions. The purpose of this study is to evaluate the presence of NTM in the oral cavity of healthy individuals and its relationship to tap water or oral hygiene. MATERIALS AND METHODS: One hundred sixty-seven healthy subjects were recruited. Three consecutive early morning mouthwashes using tap water were performed and examined for the presence of Mycobacterium tuberculosis (MTB) and NTM. In addition we obtained mouthwashes from 30 control healthy individuals with good oral hygiene using sterile water and examined these for the presence of MTB and NTM. RESULTS: NTM was isolated from the mouthwash of 44 (26.3%) subjects that used tap water. On the other hand, NTM was isolated from the mouthwash of 10 (33%) subjects that used sterile water. Age, gender, social class oral hygiene and the regular use of toothbrush made no statistically significant differences in the isolation rate of NTM. CONCLUSION: The rate of isolation of NTM from mouthwash is high in normal subjects. It is independent of oral hygiene, the use of tap water or teeth brushing. Smear-positive sputum could be NTM rather than M. tuberculosis. Tuberculosis polymerase chain reaction or culture confirmation is essential in developing countries to avoid the unnecessary use of antituberculosis therapy when the clinical suspicion is very low.

Emergence and trends of penicillin non-susceptible Streptococcus pneumoniae in Saudi Arabia and Kuwait - perspective and outstanding issues.

For many years in the past Streptococcus pneumoniae was uniformly susceptible to penicillin until the sudden and unexpected emergence of clinical infections caused by penicillin-resistant S. pneumoniae (PRSP) in 1967. Within the following decade, reports of nosocomial and community outbreaks of infections due to PRSP became widespread all over the world. Recent reports suggest that the incidence of resistance rates is rising in many countries although there are geographical variations in the prevalence and patterns of resistance between countries. The problem of antibiotic resistance is further compounded by the emergence of resistance to many beta-lactam antibiotics. The first report of PRSP in Saudi Arabia was in 1991. Barely a year after, PRSP infection was reported in Kuwait in 1992. Since then, studies from various parts of these countries have recorded prevalence rates ranging from 6.2% in Riyadh to 34% in Jeddah and 20% to 56% in neighboring Kuwait. These suggest considerable variation in the prevalence of PRSP in different cities in the Saudi Kingdom and Kuwait. The mechanism of resistance is due to chromosomally mediated alteration of penicillin-binding proteins (PBPs), which are target sites for beta-lactam antibiotics. It would appear that the spread of PRSP strains in Saudi Arabia is driven by the selective pressure created by excessive use and misuse of antimicrobial agents made possible by the easy availability of these agents, often frequently obtainable over the counter. In Kuwait, irrational and misguided use of antibiotics may be the major driving force favoring the spread of PRSP. The serotypes of strains encountered in Saudi Arabia and Kuwait are almost identical, with serotypes 19, 6, 15, 14 and 23 being the most common; together they constitute about 70% of the isolates circulating in these countries. In general, almost 90% of the serotypes included in the 23-polyvalent vaccine are present in the general population. However, a much lower percentage of these serotypes is found in the conjugated vaccines, which are more relevant to our communities. This paper reviews the emergence and the steady increase in the prevalence of penicillin-resistant pneumococcal strains in Saudi Arabia and Kuwait during the last 10 years. It discusses the trends, mechanisms of resistance and factors associated with the emergence, dissemination, and colonization of resistant organisms and suggests options available to clinicians for management of infections due to PRSP.

In vitro activity of quinolones against S. pneumoniae, H. influenzae and M. catarrhalis in Saudi Arabia.

Susceptibility of 88 clinical Streptococcus pneumoniae isolates, 116 Haemophilus influenzae isolates and 80 Moraxella catarrhalis isolates to 6 fluoroquinolones--ciprofloxacin, ofloxacin, levofloxacin, trovafloxacin, grepafloxacin and gemifloxacin--were determined. Isolates were from patients with invasive disease at 4 hospitals in Saudi Arabia between 1996 and 1998. S. pneumoniae isolates were fully susceptible to trovafloxacin, grepafloxacin and gemifloxacin; susceptibility to ofloxacin and levofloxacin was 97.7% and 98.9% respectively. H. influenzae isolates were susceptible to all agents, except for trovafloxacin (99.1%). M. catarrhalis strains were fully sensitive to all agents except ofloxacin (97.5%). No isolates were resistant to gemifloxacin or grepafloxacin.

In vitro activity of quinolones against S. pneumoniae, H. influenzae and M. catarrhalis in Saudi Arabia

Susceptibility of 88 clinical Streptococcus pneumoniae isolates, 116 Haemophilus influenzae isolates and 80 Moraxella catarrhalis isolates to 6 fluoroquinolones--ciprofloxacin, ofloxacin, levofloxacin, trovafloxacin, grepafloxacin and gemifloxacin--were determined. Isolates were from patients with invasive disease at 4 hospitals in Saudi Arabia between 1996 and 1998. S. pneumoniae isolates were fully susceptible to trovafloxacin, grepafloxacin and gemifloxacin; susceptibility to ofloxacin and levofloxacin was 97.7% and 98.9% respectively. H. influenzae isolates were susceptible to all agents, except for trovafloxacin [99.1%]. M. catarrhalis strains were fully sensitive to all agents except ofloxacin [97.5%]. No isolates were resistant to gemifloxacin or grepafloxacin

Treatment outcome of tuberculosis among Saudi nationals: role of drug resistance and compliance.

OBJECTIVE: Recent studies have demonstrated a high prevalence of multiresistant Mycobacterium tuberculosis (MDR-TB) in Saudi Arabia. In this study, we assessed the impact of this and other factors on the treatment outcome of tuberculosis among Saudi nationals. METHODS: We studied all patients (147 patients) with a culture-proven diagnosis of tuberculosis seen at the King Khalid National Guard Hospital (KKNGH), Jeddah, Saudi Arabia from June 1993 to June 1999. Treatment outcome was classified as success or failure based on the clinical assessment, improvement or deterioration of chest X-rays, and results of follow-up sputum examination. RESULTS: Of the 147 patients, only 126 completed the follow-up program. Treatment was found to be successful in 102 (81.0%) and unsuccessful in 24 (19.0%) of these 126 patients. However, treatment success is much less (102/147; 69.4%) and failure is much higher (45/147; 30.6%) if the 21 patients who were lost to follow-up are regarded as treatment failures. The prevalence of poor compliance and multiply drug-resistant Mycobacterium tuberculosis were found to be significantly higher among those with treatment failure than among those in whom treatment was successful. There was no significant difference in treatment outcome between the different age groups. However, failure of treatment was observed to be more common (P < 0.001) among males (35 patients; 46.7%) than among females (10 patients; 13.9%). This could be explained mainly by the significantly higher prevalence of non-compliance among males (44%) than among females (15.3%). There were no significant differences in the symptoms, radiologic findings, clinical presentation (pulmonary versus extrapulmonary), social background or drug resistance between genders. CONCLUSION: Successful treatment outcome among Saudi Nationals seen at the KKNGH in 1993-99 was below the rate recommended by the WHO, and failed treatment was associated with poor compliance, male gender and drug-resistant Mycobacterium tuberculosis. These results emphasize the importance of culture and sensitivity tests for Mycobacterium tuberculosis and close supervision of patients taking antituberculosis medications.

Comparison of the Brucella Standard Agglutination Test with the ELISA IgG and IgM in patients with Brucella bacteremia.

The presumptive diagnosis of Brucellosis is based on a high or rising antibody titer measured by the Brucella Standard Agglutination Test (SAT). This tests does not discriminate between the immunoglobulin classes (IgG and IgM). The purpose of this study was to compare the diagnostic value of SAT with Brucella Enzyme Linked Immunosorbent Assay (ELISA) IgG and IgM tests in patients with Brucella bacteremia. Over a one-year period, we had 68 patients with clinical features suggestive of Brucellosis who had positive blood cultures for Brucella species. Sera were obtained from all of the patients as well as a control group of 70 healthy military personnel who were blood donors and had no symptoms of Brucellosis. Patients and blood donors originated from the same referral population. All the sera were tested by SAT and ELISA. All the 70 controls had a negative SAT. The sensitivity and specificity of the SAT test for the bacteremic patients were 95.6% and 100.0% respectively, while that of the ELISA IgG were 45.6% and 97.1%, and that of the ELISA IgM were 79.1% and 100.0% respectively. The sensitivity and specificity of either IgG or IgM positivity were 94.1% and 97.1% respectively. Assuming that the population prevalence of active Brucellosis in Saudi Arabia (SAT >or=1:320) is 5%, the positive and negative predictive values of SAT were 100% and 99.7% respectively; of ELISA IgG they were 45.2% and 97.1%; and of ELISA IgM they were 100% and 98.9%. When both the ELISA IgG and IgM were combined, the positive and negative predictive values were 63% and 99.6% respectively. In patients with Brucella bactremia, the sensitivity of either ELISA IgM or IgG were lower than SAT, however, combining IgM and IgG had similar sensitivity and specificity to SAT. The positive predictive value of SAT and IgM is satisfactory.

Antibiotic resistance in developing countries.

During the past decade there have been major changes in the susceptibility of bacteria that cause various infections. Resistance to anti-infective agents, including antibiotics, is worldwide, both in developed and developing countries. Almost all bacterial species can develop resistance to anti-infective agents and resistance can readily be transferred among bacteria by transmissible elements (plasmids). Measures to prevent the emergence of resistance must be implemented urgently. A multiplicity of factors drive antibiotic resistance and solutions require the collaboration of governmental agencies, pharmaceutical companies, healthcare providers and consumers. Knowledge of resistance patterns and of the ways by which resistance is overcome is vital to the future of antimicrobial chemotherapy.

Diagnostic value of Brucella ELISA IgG and IgM in bacteremic and non-bacteremic patients with brucellosis.

The diagnostic value of Brucella ELISA IgG and IgM has been evaluated in patients with brucellosis. Serum samples and blood cultures were collected from 83 patients with brucellosis. The sera were tested by Brucella ELISA for Brucella IgM and IgG antibodies. All 44 controls were negative for IgG and IgM. Brucella melitensis was isolated from blood cultures of 30/83 (36.1%) patients. Among the 30 bacteremic patients, 24 (80%) had an increased IgM titer of > or = 200. Of the 53 non-bacteremic patients, 41 had IgM titer > or = 200, while 22 had IgG titer of > or = 1,600. The ELISA IgM and IgG tests achieved a specificity and sensitivity of 100% and 96% respectively, while the positive and negative predictive values were 100% and 94% respectively. The Brucella ELISA is a reliable and sensitive test in the diagnosis of brucellosis. The test is rapid, easy to perform and can be automated.

Tract microflora in Saudi patients with cholelithiasis.

OBJECTIVES: To identify the microflora in the gallbladder of patients undergoing laparoscopic cholecystectomy for gallstones, and the antibiotic susceptibility pattern of the isolates, as well as the usefulness of Gram staining of bile at the time of operation. METHODS: Bile samples were obtained from 112 patients undergoing elective laparoscopic cholecystectomy for gallstones and inoculated directly into aerobic and anaerobic blood culture bottles in the operating theatre. Samples were also collected in sterile universal containers for Gram staining of a centrifuged deposit. Isolates were identified and their in-vitro susceptibilities determined by Kirby Bauer technique. RESULTS: Of 112 bile samples examined, 28 (25%) were culture positive, four of which contained more than one organism. The most common organisms isolated were Escherichia coli 9 (28.1%), Enterococcus faecalis 5 (15.6%) and Pseudomonas aeruginosa 3 (9.4%). In one sample we found Aeromonas hydrophilia and Enterobacter cloacae. No anaerobes were detected but Candida albicans was isolated in one case. In 19 bile samples (67.8%) organisms were identified on Gram stain. Positive bile cultures were found statistically significant (P < 0.05) in patients over the age of 50 (13/32), in patients who developed post-operative fever (6/12) and patients who developed leucocytosis (5/6). CONCLUSION: Age over 50 years was the only significant pre-operative factor associated with positive bile cultures (P < 0.05). In view of the microflora of the gallbladder and the susceptibility pattern of our isolates we would suggest that antibiotic prophylaxis recommended for laparoscopic cholecystectomy for gallstones needs to be reviewed and the role of bacteribilia in the surgical management of cholelithiasis requires further study.

Increasing resistance of M. tuberculosis to anti-TB drugs in Saudi Arabia.

The incidence of drug resistance in Mycobacterium tuberculosis (MTB) isolated from our hospital between April 1996 and March 1998 was compared with an earlier study (1993-1995). Thirty (29.7%) of 101 MTB isolates were resistant to one or more anti-TB drugs and 21 (20%) of 101 were multi-drug resistant M. tuberculosis (MDR-TB). Resistance was most common to isoniazid (28.7%), followed by streptomycin (22.8%) and rifampicin (20.8%). Resistance to pyrazinamide and ethambutol was 7.9 and 6.9%, respectively. There was a three-fold increase in resistance compared with the earlier study.

Penicillin-resistant and -intermediate Streptococcus pneumoniae in Saudi Arabia.

The antibiotic susceptibility was analyzed of approximately 400 consecutive isolates of S. pneumoniae isolated from different regions of Saudi Arabia. Most of these isolates were from respiratory (sputum, otitis, 53.8%), blood/CSF (26.3%) and ophthalmic (20%) specimens. Overall 6.2% of the isolates were penicillin-resistant (MICs > or =2 microg/ml) and 51.2% were -intermediate (MICs 0.1-1 microg/ml). The resistance rates to cefuroxime, clarithromycin and ceftriaxone were 14.9%, 14.8% and 4.5% respectively. Only 3.5% of S. pneumoniae showed resistance to amoxycillin/clavulanic acid. The MICs of all tested antibiotics increased as did the penicillin MICs. Penicillin resistance was significantly associated with resistance to cefuroxime (p<0.001) but not with the others. These data indicate the presence of penicillin and multiple-resistant pneumococci in Saudi Arabia and that these strains can spread among individuals. A greater awareness with extended indications for microbiological diagnosis, antimicrobial susceptibility testing and restrictive prescription of antibiotics are needed.

Hepatitis C virus genotyping by polymerase chain reaction and DNA enzyme immunoassay among Saudi patients in the Western Province, Saudi Arabia.

BACKGROUND: The distribution of hepatitis C virus (HCV) genotypes in the Western Province of Saudi Arabia is unknown. The purpose of our study was to determine the prevalent HCV genotypes among HCV seropositive Saudi patients in the Western Province, and to study the relationship between types/subtypes, clinical status and liver histology. PATIENTS AND METHODS: Serum samples were collected from 140 consecutive patients attending the Hepatology Clinic with varying grades of liver diseases, high alanine transferase (ALT) for >6 months, positive HCV, qualitative PCR, and who had had liver biopsy. HCV genotyping was determined on patients who had tested positive by both HCV enzyme immunoassay (EIA) and recombinant immunoblot assay (RIBA). RESULTS: Of the 140 patients, 97 (69.2%) had genotype 4, 18 (12.8%) had genotype 1a, and 16 (11.4%) had genotype 1b. Genotypes 2b and 5 were found in two patients (1.4%) each, while 5 patients (3.6%) had mixed infections with genotypes 4 and 5. Of the 97 patients infected with genotype 4, 84 (86.6%) had chronic active hepatitis (CAH), two (2.1%) had CAH with active cirrhosis, 9 (9.3%) had cirrhosis and two (2.1%) had normal liver histology (NLH). CONCLUSION: The most prevalent HCV genotype in the Western Province of Saudi Arabia was genotype 4 (69.2%). Genotype 1b was encountered in 16 (11.4%) patients. For the first time, genotype 5 was identified in the Western Province of Saudi Arabia. Genotypes 1b and 4 were associated with different histological grades of liver disease.

Comparative study of Amplicor polymerase chain reaction and ligase chain reaction for direct detection of M.tuberculosis in clinical specimens.

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Erratum: Multidrug-resistant tuberculosis.

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