Epidemiological patterns of cervical human papillomavirus infection among women presenting for cervical cancer screening in North-Eastern Nigeria.

BACKGROUND: Sub-Saharan countries including Nigeria have the highest burden of Human Papillomavirus (HPV) infection in the world. Most studies on HPV surveillance in Nigeria were done in the southern part of the country. Geographical and socio-cultural diversity of Nigeria makes these data unlikely to be universally representative for the entire country. Northern Nigeria especially the North-East carries a higher prevalence of cervical cancer and many of its risk factors. The region may be harbouring a higher prevalence of HPV infection with a possibility of different genotypic distribution. This study was carried out to determine the burden and confirm the predominant HPV genotypes among women presenting for cervical cancer screening at the Federal Teaching Hospital Gombe (FTHG), North-eastern, Nigeria. METHODS: The study was an observational hospital based cross sectional study among women who presented for cervical cancer screening in FTHG. A total of 209 consenting women were tested for cervical HPV infection using PCR. DNA sequencing was carried out on positive samples to determine the prevalent HPV genotypes. RESULTS: The prevalence of cervical HPV infection among the participants with mean age of 39.6 ± 10.4 years was 48.1 %. The five most predominant genotypes were 18, 16, 33, 31 and 35, with prevalence of 44.7 %, 13.2 %, 7.9 %, 5.3 % and 5.3 % respectively. Other genotypes observed were 38, 45, 56, 58, 82 and KC5. Multiple HPV infections were detected among 7.9 % of participants. Risk factors such as level of education (X (2) = 15.897; p = 0.007), age at sexual debut (X (2) = 6.916; p = 0.009), parity (X (2) = 23.767; p = 0.000), number of life time sexual partners (X (2) = 7.805; p = 0.005), age at first pregnancy (X (2) = 10.554; p = 0.005) and history of other malignancies (X (2) = 7.325; p = 0.007) were found to have a statistically significant association with HPV infection. CONCLUSION: This study identified a high burden of HPV infection in Northern Nigeria while also confirming HPV 18 and 16 as the most predominant genotypes. It further justifies the potential benefit of the currently available HPV vaccines in the area. A larger and community based study is however recommended for better representation of the area.

Ecthyma gangrenosum in Saudi Arabia.

We report a diagnosis of ecthyma gangrenosum EG in 4 females of mean age 54.8 range 43-64 years, within 10 months. Severe drug reaction treated with high dose systemic corticosteroids in patient one, acute myelocytic leukemia treated with high dose dexamethasone, and multiple broad-spectrum antibiotics in patient 2 preceded the onset of EG. Patients 3 and 4 had vasculitic purpura and hemodialysis. In addition, patient 3 was receiving multiple broad-spectrum antibiotics plus anti-tuberculosis TB drugs for gastric TB, while patient 4 was on melphalan and high dose systemic corticosteroids. Pseudomonas aeruginosa was isolated from blood culture of the first 3 patients, and skin culture of patient one. Blister aspirate from patient 4 yielded Candida albicans. Factors enhancing skin invasion by pathogenic organisms in our patients were breached skin integrity, therapy with high dose corticosteroids and multiple broad-spectrum antibiotics, hematologic malignancies and chemotherapy with severe neutropenia.

BK virus infection in a renal transplant Saudi child.

BK human polyomavirus BKV causes an asymptomatic primary infection in children, but later, establishes latency mainly in the urinary tract. Virus-host interactions influencing persistence and pathogenicity are not well-understood. We present here a 12-year-old Saudi boy, who had renal transplant in Egypt. Seven months later, he was admitted to our Pediatric Nephrology Unit as a case of renal impairment. He developed BKV infection, diagnosed and successfully managed in our hospital. This case demonstrates the expanding clinical importance of BKV in a post renal transplant patient. This virus can be detected in transitional cells in the urine decoy cells using cytology. Testing for BKV deoxyribonucleic acid in urine and blood is an early detection assay, and can be used as a screening test in the early stages. The early reduction of immunosuppression can improve the prognosis. No specific antiviral treatment has been established yet. This is the first report of detecting BK virus in a Saudi post-transplant child in urine and blood specimens by using polymerase chain reaction.

Carriage of Staphylococcus aureus among Hajj pilgrims.

OBJECTIVE: To evaluate the prevalence of methicillin resistant Staphylococcus aureus (MRSA) carriage among a cohort of pilgrims during 2004 Hajj season. METHODS: Pilgrims attending the 2004 Hajj season were recruited and screened for carriage of MRSA. Standard microbiological techniques were used to screen for the presence of MRSA. RESULTS: Out of 411 individuals screened, 85 (20.6%) were positive for Staphylococcus aureus (S. aureus) of which only 6 (1.46 %) were MRSA. Four individuals (4.6%) had the S. aureus organism in both nasal and axillary swabs, while 7 individuals (8%) had the organism in their axillae only. The other 74 individuals (87.1%) had the organism in their nares only. The 6 MRSA isolates were positive for the mecA gene by polymerase chain reaction method. None of the pilgrims examined had any risk factors for community-acquired methicillin resistant S. aureus (CAMRSA). Overall, the prevalence of MRSA in the population of pilgrims examined was found to be low (1.46%) in comparison with most community based studies. CONCLUSION: A low rate of MRSA carriage was noticed among the screened cohort. Physicians treating patients suspected of S. aureus infection during the Hajj pilgrimage should bear in mind the possibility of community acquired - MRSA and should obtain appropriate samples for bacterial cultures and susceptibility testing so that antimicrobial agents could be introduced when necessary at a later stage.

International travel and sexually transmitted diseases.

Despite concerted efforts to control sexually transmitted diseases (STDs) worldwide, they still remain a major public health problem. Out of the 25 organisms known to be transmitted sexually, travelers are at greater risk of acquiring HIV and other STDs in developing countries in view of the high prevalence rates in these countries, particularly after sexual exposure to local commercial sex workers (CSWs). Some of the STDs acquired during international travel are more likely to be resistant to standard antimicrobial regimens for the STDs. HIV, gonorrhoea, syphilis, non-specific urethritis, hepatitis B, hepatitis C, and other STDs are a significant risk for travelers who engage in unprotected sex, especially with overseas CSWs. It is recognized that barrier contraceptives provide considerable protection against STDs, but they are not regarded as 100% protective. Sexual abstinence and sexual monogamy with a 'known' partner carry a much lower risk than the safest of 'safer sex' practices. However, in the event of a sexual exposure to a new partner in the country being visited, prior hepatitis B immunization and the consistent and proper use of a latex condom are strongly advised, followed by proper medical investigations and physical examination on returning home, before sexual activity is resumed.

Evaluation of 2 real-time PCR assays for the investigation of mecA gene in clinical isolates of MRSA in Western Saudi Arabia.

OBJECTIVE: In diagnostic microbiology laboratories, Methicillin resistant Staphylococcus aureus (MRSA) is identified by positive coagulase test and positive deoxyribonuclease (DNase) activity followed by demonstration of oxacillin resistance on susceptibility testing on agar plate. This usually takes an approximately 48-72 hours. The purpose of this study is to evaluate 2 real-time polymerase chain reaction (PCR) assays for the presence of mecA gene in a population of MRSA strains circulating in Jeddah, Western Saudi Arabia, in order to determine their usefulness in the speedy diagnosis of MRSA in our clinical setting and their contribution to optimal patient management. METHODS: Ninety MRSA isolates obtained from clinical samples were identified by using conventional methods. They were collected between February 2004 and August 2004, from 2 major hospitals in Jeddah; King Abdul-Aziz University Hospital, Jeddah (50 strains) and King Khalid National Guard Hospital, Jeddah (40 strains). All isolates were confirmed as MRSA using Gram stain, catalase and coagulase activity, confirmatory DNAse activity and Kirby Bauer disc diffusion method with resistance to oxacillin by the agar disc method. The DNA extract was tested by 2 assays. The first was the commercial IVD Roche kit, which detects the mecA gene using the Light Cycler system. The other method employs multiplex PCR which detects As442 fragment and mecA optimized for the Smart Cycler system (Cephied). The length of time taken to perform the assays was recorded. RESULTS: All isolates were positive for Sa442 fragment and the coa gene specific for Staphylococcus aureus (S. aureus). However, 88/90 isolates (97.7%) tested were positive for mecA gene with both systems. The amplification, detection and melting curve analysis took 59.2 minutes for 32 samples on the Light Cycler and 46.7 minutes for 16 samples on the Smart Cycler. CONCLUSION: The 2 methods studied were equally specific and sensitive for the detection of mecA gene in confirmed S. aureus isolates and capable of identifying MRSA much earlier than conventional methods. The detection of 2 targets in the multiplex PCR assay reduces the 2-hour time required for DNase testing and may be used as a primary screening test for the detection of MRSA in clinical samples, such as blood cultures and sterile body fluids.

Abdominal tuberculosis. On-going challenge to gastroenterologists.

OBJECTIVE: The aim of this study is to record the observations and experience on the diagnosis and management of abdominal tuberculosis (TB) and to highlight the difficulties in the diagnosis and management of this condition. METHODS: Two hundred consecutive patients attending the Gastroenterology Department of the King Khalid National Guard Hospital, Jeddah, Kingdom of Saudi Arabia between May 1991 and May 2001, suspected with abdominal TB were investigated. A detailed clinical history and physical examination were obtained. Data of 75 confirmed cases of abdominal TB were analyzed. RESULTS: The most common presenting symptoms were anorexia (84%), abdominal pain (84%) and weight loss (72%). Abdominal tenderness was the most common clinical finding, followed by ascites and abdominal mass (42%). The chest radiograph suggestive of pulmonary TB was diagnosed in 24 patients (32%). Computed tomographic (CT) scanning revealed abnormalities in all 51 patients who underwent the procedure, while positive findings were observed by abdominal ultrasound in 66% of the tested patients. Histopathological examination of patients showed tuberculous granuloma, while acid fast bacilli were seen in 34%. Mycobacterium tuberculosis was identified by microbiological methods in 60% of patients. The most common presenting symptoms were anorexia (84%), abdominal pain (84%) and weight loss (72%). Abdominal tenderness was the most common clinical finding, followed by ascites and abdominal mass (42%). The chest radiograph suggestive of pulmonary TB was diagnosed in 24 patients (32%). Computed tomographic (CT) scanning revealed abnormalities in all 51 patients who underwent the procedure, while positive findings were observed by abdominal ultrasound in 66% of the tested patients. Histopathological examination of patients showed tuberculous granuloma, while acid fast bacilli were seen in 34%. Mycobacterium tuberculosis was identified by microbiological methods in 60% of patients. CONCLUSION: A high index of clinical suspicion is required to make an early diagnosis of abdominal TB. Suspicion should be aroused, particularly in patients having a combination of anorexia, abdominal pain, weight loss and ascites. Diagnosis requires the utilization of a combination of various diagnostic procedures especially abdominal ultrasound, CT scan and endoscopy, which provides a high diagnostic yield in this disease. A normal chest radiograph does not exclude the presence of abdominal TB. A timely use of laparoscopy are often required to prevent surgical intervention.

Leuconostoc bacteremia in a child with short-gut syndrome.

In the last decade Leuconostoc species have been reported with increasing frequency as human pathogens, causing bacteremia, meningitis and peritonitis. We report here a child with short-bowel syndrome who developed bacteremia following multiple surgeries for necrotizing enterocolitis. Leuconostoc species was isolated from the blood cultures. The child was successfully treated with ampicillin and gentamycin. He however remained total parenteral nutrition dependent due to his multiple abnormalities. We call the attention of microbiologists and pediatricians to this emerging pathogen, which is intrinsically resistant to vancomycin and can be misidentified in the microbiology laboratory as Viridans streptococci or Enterococci. Increased awareness by clinicians of this organism is called for, if it is to be recognized and appropriately treated.

Enterococcus avium. An unusual cause of cerebral abscess.

Enterococci are responsible for an increasing number of human infections. They are normally part of the flora of the human gastrointestinal tract, buccal cavity, perineal skin, vagina, urethra and gallbladder, but may occur as pathogens in several sites causing urinary tract infections, intra-abdominal infections, fatal bacteremia, meningitis and endocarditis. Enterococcus avium is a rare cause of infection in humans. Here, we report a 19-year-old Saudi girl diagnosed as a case of astrocytoma grade II arising from the right thalamus. She underwent treatment with radiotherapy followed by 5 chemotherapy sessions. She subsequently developed a cerebral abscess, and we performed mini craniotomy of the left parietal region with drainage of the brain abscess. The pus obtained from the abscess grew Enterococcus avium. We successfully treated her with antibiotics and discharged her home. The rarity of the organism causing cerebral abscess has motivated the documentation of this case and the pathogenesis of Enterococcus avium.

Neisseria meningitidis W-135 carriage during the Hajj season 2003.

During the 2003 Hajj pilgrimage to Mecca, 344 pilgrims of 29 different nationalities were screened by means of a throat swab to detect Neisseria meningitidis carriage. N. meningitidis was isolated from 11 subjects; 2 were serogroup W-135, 1 serogroup B, and 8 were non-groupable. The results indicate a very low colonization rate for N. meningitidis among the tested cohort, with a predominance of non-groupable strains. These results, combined with a review of the published data, warrant a re-evaluation of current recommendations by the Saudi Ministry of Health for the use of ciprofloxacin for Saudi pilgrims departing at the end of the Hajj season. However, vaccination with the meningococcal quadrivalent vaccine, for all pilgrims, should continue to be recommended. The possibility of new strains arising as a cause of future meningococcal outbreaks should be considered, and annual surveillance may give an early warning.

Comparison of helicobacter pylori stool antigen test with CLO test in the diagnosis of helicobacter pylori associated dyspepsia in a Saudi population.

OBJECTIVE: To compare the diagnostic usefulness of Helicobacter pylori (H.pylori) stool antigen test (HpSA) enzyme immunoassay (EIA) with the Campylobacter-like organism (CLO) test in Saudi patients with H.pylori associated dyspepsia. METHODS: Sixty consecutive adult Saudi patients suspected of H.pylori infection with dyspepsia attending the Gastroenterology Unit of the King Khalid National Guard Hospital, Jeddah, were recruited into the study. The study was carried out between 1st January and 30th June 2003. There were 25 males and 35 females. Their ages ranged from 19-72 years. Mean age was 39.6 years. At endoscopy diagnosis was made by taking gastric antrum mucosal biopsy for histology (Giemsa stain) and the CLO test was performed on a biopsy sample. A stool sample from each patient was sent to the Microbiology Department for HpSA EIA test. Helicobacter pylori status was determined by the positivity of the CLO test, the histology, or both. RESULTS: Both tests were positive in 26 specimens and negative in 21 patients. Discordant results were obtained in 13 specimens. Discordant results were resolved using the histology biopsy results. The sensitivity of the HpSA test was 88.6% and specificity 93.5%. The positive predictive value (PPV) of the HpSA test was 93.9%, while the negative predictive value (NPV) was 87.8%. The sensitivity of the CLO test was 87.8%, and specificity 92.5%, while PPV of the CLO test was 93.5% and NPV was 86.2%. CONCLUSION: The HpSA test is a useful and reliable test for the diagnosis of H.pylori infection. It is non-invasive, relatively cheap and convenient for the patient. It can be performed in any laboratory performing the enzyme-linked immunoabsorbent assay test. It is particularly suitable for developing countries where facilities for endoscopy are not readily available.

Candidemia and the susceptibility pattern of Candida isolates in blood.

OBJECTIVE: Candida species has become one of the most common blood isolates as well as one of the leading causes of nosocomial bloodstream infections. The purpose of our study was to determine the prevalence of Candida species among our bloodstream infecting organisms and the susceptibility pattern of the Candida isolates to antifungal agents. METHODS: A prospective study was carried out in the Division of Microbiology, King Khalid National Guard Hospital, Jeddah, Kingdom of Saudi Arabia of all positive blood cultures for Candida species. The study took place from 1st January 1998 to March 2002. Identification and susceptibility pattern of isolates were determined by the Candifast technique to amphotericin B, fluconazole, nystatin, Flucytosine, econazole, ketoconazole and miconazole. RESULTS: Over a 2-year period, 17,916 blood cultures were performed in our hospital. There were 2,972 positive cultures, of which 83 (2.8%) patients had Candida species isolated from their bloodstream. Of these, 38 (46%) were Candida albicans (C.albicans). The remaining 45 strains were made up of Candida tropicalis 9 (10.8%); Candida parapsilosis 9 (10.8%); Candida species 9 (10.8%); Candida guilliermondi 6 (7.2%); Candida krusei 5 (6%); Candida glabrata 4 (4.8%); Candida pseudotropicalis 2 (2.4%) and Trichosporon species 1 (1.2%). All Candida species were susceptible to amphotericin B. However, only 18 (47%) out of 38 C.albicans were susceptible to fluconazole, while only 8 (17.7%) of 45 non-C.albicans strains were susceptible to this drug. CONCLUSION: The susceptibility of C.albicans to fluconazole in our hospital using the Candifast method is very low (47%). These results need to be confirmed by carrying out the Etest or the NCCLS M27-A method to confirm the true susceptibilities of Candida strains in our locality.

Meningococcal carriage among local inhabitants during the pilgrimage 2000-2001.

The first international outbreak of Neisseria meningitidis serogroup W135 occurred in 2000, in direct association with the annual Hajj in Saudi Arabia. In anticipation of the following Hajj, we conducted a survey of oropharyngeal carriage rates of N. meningitidis both pre- and post-pilgrimage in the King Khalid National Guard Hospital (KKNGH) employees preparing to attend the Hajj. These KKNGH employees were native to the Mecca-Jeddah area. Pre-Hajj throat cultures were obtained 1 week prior to Hajj, and post-Hajj cultures within 10 days after completing the Hajj pilgrimage. A total of 327 throat culture samples were collected from 218 persons. Overall meningococcal carriage rate was found to be 4.7%. Serogroup W135 accounted for 40% of all recovered pre-Hajj strains of N. meningitidis. Only one post-Hajj sample was positive for N. meningitidis W135. This high rate of colonization with N. meningitidis serogroup W135 indicates this strain predominates amongst the population indigenous to the Mecca-Jeddah area. This 'nidus' of N. meningitidis W135 is a potential reservoir for future outbreaks. More worrying, there is real risk of future W135 endemicity in this vulnerable local population. These preliminary findings warrant larger surveillance studies examining both transmission and carrier rate acquisition of N. meningitidis in the Mecca-Jeddah area. These vital data are needed to curb further epidemic outbreaks during future Hajj pilgrimages.

Sexually transmitted diseases and travel.

Sexually transmitted diseases (STDs) are infections and resulting clinical syndromes caused by more than 25 infectious organisms transmitted through sexual activity. International travellers are at great risk of contracting any of these STDs, including HIV, if they have been sexually exposed to persons with any of these diseases. Population movement has been shown to be a major contributing factor in the global spread of STDs. Increased sexual promiscuity and casual sexual relationships tend to occur during travel abroad to foreign countries. Travellers should be aware that the risk of STDs is high especially in the developing countries and sexual encounter with casual partners or commercial sex workers (CSWs) carries a high risk of infection. Prevention of STDs during travel can be achieved by complete abstinence from sexual exposure or adopting safe sexual practices such as consistently and correctly using a latex condom during sexual contact.

MRSA prevalence in a teaching hospital in Western Saudi Arabia.

OBJECTIVE: To determine the prevalence of Methicillin Resistant Staphylococcus aureus (MRSA) colonization in our institution. METHODS: A 5-day period prevalence study of all adult and pediatric patients. Excluded areas were the adult intensive care unit (screened on admission and weekly thereafter), the outpatient hemodialysis population (screened monthly), and newborns. Our facility is a referral/teaching hospital for the National Guard population and their dependants in Western Saudi Arabia. A total of 240 patients were screened. Nasal sampling was carried out and isolation/identification of MRSA was performed using standard microbiological methods. RESULTS: The total number of patients sampled was 240 and of those 10 (4%) were colonized. The 10 positives were found in 4 patient care areas; adult male medicine 5, adult male oncology 3, adult female medicine one, adult high dependency unit one. These patients care areas had 69 patients (42 males and 27 females). Ten (14%) were colonized by MRSA; 9 males (21%) and one female (3%). Statistical analysis Chi Square for discontinuous variables, "F" test for continuous variables found that one), male gender (p=0.04), 2) the presence of a long term invasive device (p=0.04), 3), length of stay (p=0.004) were predictive of MRSA colonization. CONCLUSION: The overall prevalence of MRSA colonization in our hospital was low, however a sub-segment of the population identified as male, having long term invasive devices, and hospitalized more than 2 weeks, were frequently colonized. Any strategy, in our hospital, to control the spread of MRSA should include the testing of this population.

Enterococcus faecalis endocarditis.

The increasing usage of cephalosporins, to which the enterococci are resistant, has resulted in the rising number of enterococcal infections worldwide. Enterococci are a normal part of the flora of the human gastrointestinal tract, buccal cavity, perineal skin, vagina, urethra and gallbladder, but may occur as pathogens in a number of sites causing urinary tract infections, intra-abdominal infections, fatal bacteremia, meningitis and endocarditis. A Saudi male who developed enterococcal endocarditis with vegetations on both aortic and mitral valves required mitral and aortic valve replacement. The attention of physicians is drawn to the increasing frequency of enterococcus as a cause of nosocomial infections, the risk factors, and antibiotic resistance pattern including resistance to vancomycin as well as its potential for virulence.

Hepatitis C virus genotypes in Saudi Arabia.

Hepatitis C virus genotypes have been associated with specific geographical areas and in many cases with specific mode of transmission. In developed countries, genotype determination has formed a part of the management of patients with hepatitis C virus seropositivity and liver diseases due to hepatitis C virus. The epidemiology of hepatitis C virus has been shown to be changing rapidly in many countries due to population movement and different life-styles; hence the distribution of the genotypes is being monitored closely in many countries. In the Kingdom of Saudi Arabia, there are only a handful of publications recording the hepatitis C virus genotypes in various population groups. These studies have been carried out mainly in Riyadh (Central province) and Jeddah (Western province). There are no studies emanating from the Eastern or Northern provinces. According to these studies, the most prevalent genotype in the Western Province and probably in the whole Kingdom of Saudi Arabia was genotype 4, followed by genotypes 1a and 1b. Genotypes 1, 2a,/2b, 3 and 6 are very rare in the Kingdom of Saudi Arabia. Genotype 5 was identified exclusively in the Western province and nowhere else. Genotypes 1b and 4 were associated with different histological grades of liver disease. Mixed infections with more than one genotype were observed in some studies. More detailed epidemiological studies of hepatitis C virus infections are needed in the Kingdom of Saudi Arabia to gain more insight into a possible type/subtype-specific pathogenesis of hepatitis C virus in the different regions of the Kingdom of Saudi Arabia as well as the distribution of the genotypes in the various localities.

Mumps virus encephalitis can mimic herpes simplex encephalitis.

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