Posterior reversible encephalopathy syndrome post stem cell transplantation in sickle cell disease: case series and literature review.

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a serious neurological syndrome that may develop following immunosuppressive therapy for stem cell transplantation (SCT). We report 8 patients with sickle cell disease (SCD) who developed PRES, which is likely to be related to immunosuppression. Methods: This is retrospective cohort analysis of the SCD registry at the King Faisal Specialist Hospital and Research Center (KFSHRC) in Riyadh, Saudi Arabia. Inclusion criteria included all adults SCD patients who underwent SCT from 2011 until 2022. We explored all cases of PRES in patients with SCT. PRES was diagnosed with MRI imaging showing reversible vasogenic cerebral edema associated with neurological symptoms including severe headache, seizures, encephalopathy, delirium, and visual disturbances. Results: During ten years follow-up (2011-2022) we found 8 patients with PRES (age range between 14 to 37 years at diagnosis) PRES occurred 8 to 124 days following SCT in 7 cases and one patient developed PRES 8 months prior to SCT. All patients were on immunosuppressive medications, including tacrolimus, cyclosporine, sirolimus and or mycophenolate mofetil. Headache, seizures, visual hallucinations, confusion, and drowsiness were the most common presenting symptoms. MRI showed abnormalities in the occipital, parietal and frontal lobes in most cases. Recovery was complete in all patients and no recurrences were noted. Two patients had graft versus host disease (GVHD). We compared risk factors for PRES among the 8 cases and 136 SCT in SCD patients who did not develop PRES. There was a significant association between PRES and imaging abnormalities, including previous bi-hemispheric infarctions (p = 0.001), and cerebral microbleeds (CBMs). PRES was strongly associated with presence (p = 0.006), size (p = 0.016) and number (p = 0.005) of CMBs. Conclusion: PRES can develop days to weeks following SCT in patients with SCD, and is associated with immunosuppressive therapy, previous bi-hemispheric infarctions and CMB. Prompt recognition and intervention leads to good recovery.

Prevalence of Chronic Kidney Disease in People Living With HIV Following in Dammam Medical Complex, Saudi Arabia.

Backgrounds People living with human immunodeficiency virus (HIV) are at a greater risk of chronic kidney disease (CKD) compared to people not having HIV. Evaluating the prevalence of CKD in people living with HIV in Dammam, Saudi Arabia was the main objective of this study. Methods This cross-sectional study included adult HIV patients who were followed at Dammam Medical Complex. The patients' demographic data, comorbid conditions, and HIV history were reviewed from their electronic medical records. Results A total of 729 patients were counted. The glomerular filtration rate (GFR) of 235 patients could not be estimated. The data for the remaining 494 patients were analyzed. The cohort consisted of 406 male patients (82.19%) and 88 female patients (17.81%). The mean ± standard deviation for the patients' age and HIV duration were 39.08±10.93 years and 4.37±3.15 years, respectively. Ten patients (2.02%) had a GFR of <60 mL/min/1.73 m2. Among 136 patients who had an estimated GFR of ≥60 mL/min/1.73 m2 and were tested by a urine examination, 27 patients (19.85%) had albuminuria. Combining the two figures resulted in an estimated prevalence of CKD in HIV patients of 21.47%. Only one patient (0.02%) was receiving dialysis. Conclusions The prevalence of CKD in people living with HIV in Dammam, Saudi Arabia was higher than the general population. The findings highlight the elevated risk of CKD among people living with HIV and emphasize the importance of regular monitoring and early detection of kidney dysfunction in this population.

Prevalence of the HLA-B*5701 Allele and Abacavir Hypersensitivity in Saudi HIV Patients: A Multicenter Study.

Introduction Human immunodeficiency virus (HIV) incidence and prevalence are increasing in Saudi Arabia, with a total prevalence of 12,000 in 2020. Treatment of HIV patients includes multiple regimens that may involve abacavir (ABC), which is a potent drug for treating HIV and can be used as a single or combined pill. Unfortunately, its use was limited by the known associated hypersensitivity reaction (HSR). A worldwide literature review over the past decades reported that the incidence of ABC-related HSR is 5-8%. Methods The study was a cross-sectional multicentric study involving five governmental hospitals in Saudi Arabia and included all HIV patients who were following in these centers. Results Out of 3082 patients, 1293 were tested for HLA-B*5701. The prevalence for ABC-HSR is 1.59%, with variability among the five hospitals, with the highest in King Fahad Hospital in Hafuf (KFH-H) at 4.00% and the lowest in Dammam Medical Complex (DMC) at 0.49%. In previous studies, HLA-B*5701 associated with ABC-HSR varied among different ethnic groups. Our study showed that two patients developed ABC-HSR clinically while they were both negative for HLA-B*5701. Conclusion The fact that patients with negative genetic testing are still at risk of developing ABC-HSR makes continuing screening for HLA-B*5701 status essential, as the consequences of missing such a life-threatening HSR could be detrimental.

Diagnostic accuracy of large and medium vessel occlusions in acute stroke imaging by neurology residents and stroke fellows: A comparison of CT angiography alone and CT angiography with CT perfusion.

INTRODUCTION: Neurology senior residents and stroke fellows are first to clinically assess and interpret imaging studies of patients presenting to the emergency department with acute stroke. The aim of this study was to compare the diagnostic accuracy of brain CT angiography (CTA) with and without CT perfusion (CTP) between neurology senior residents and stroke fellows. METHODS: In this neuroimaging study, nine practitioners (four senior neurology residents (SNRs) and five stroke fellows (SFs)) clinically assessed and interpreted the imaging data of 50 cases (15 normal images, 21 large vessel occlusions (LVOs) and 14 medium vessel occlusions (MeVOs) in two sessions, 1 week apart in comparison to final diagnosis of experienced neuroradiologist and experienced stroke neurologist consensus. Interrater agreement of CTA alone and CTA with CTP was quantified using kappa statistics, sensitivity, specificity and overall accuracy. RESULTS: Overall, arterial occlusions were correctly identified in 221/315 (70.1%) with CTA alone and in 266/315 (84.4%) with CTA and CTP (p < 0.001). The sensitivity of overall arterial occlusions detection with CTA alone was 94.2% (95% CI: 90.8%-96.6%) while with addition of CTP was 98% (95% CI: 95.6%-99.3%), The specificity of CTA alone was 74.7% (95% CI: 67.2%-81.3%) which increased with CTP to 84.4% (95% CI: 77.7%-89.8%). The likelihood of correct identification with CTA alone was 156/189 (82.54%) for LVOs and 65/126 (51.59%) for MeVOs. This increased to 169/189 (89.42%; p = 0.054) for LVOs and 97/126 (76.98%; p < 0.001) for MeVOs when the CTA images with CTP were viewed. There was good overall interrater agreement between readers when using CTA alone (k 0.71, 95% CI, 0.62-0.80) and almost perfect (k 0.85, 95% CI, 0.76-0.94) when CTP was added to the image for interpretation. CTA and CTP had a significantly lower median interquartile range (IQR) interpretation time than CTA alone (114 [IQR, 103-120] s vs 156 [IQR, 133-160] s, p < 0.001). DISCUSSION: In cerebral arterial occlusions, the rate of LVO and MeVOs detections increases when adding CTP to CTA. The accuracy and time for diagnosing arterial occlusion can be significantly improved if CTP is added to CTA. As MeVOs are commonly missed by front-line neurology senior residents or stroke fellows, cases with significant deficits and no apparent arterial occlusions need to be reviewed with neuroradiological expertise.

Unveiling Monkeypox: A Rare Case of Sexual Transmission in Saudi Arabia.

This case report describes the presentation, management, and clinical course of monkeypox in a 30-year-old female with multiple sexual partners admitted to Dammam Medical Complex, a major hospital in eastern Saudi Arabia. The patient presented with a rash on her inner thighs and vagina, accompanied by subjective fever and itching. A biopsy confirmed the diagnosis of monkeypox. Despite the absence of complications, the patient was isolated and received conservative therapy under the care of the infectious disease team. This case report highlights the effectiveness of conservative therapy in managing monkeypox, testing another possibility of sexually transmitted disease, and emphasizes the role of the infectious disease team in providing comprehensive care to patients with infectious diseases.

Successful Treatment of Infective Endocarditis With Oral Antibiotics: A Case Report.

Infective endocarditis (IE) is a serious and potentially life-threatening infection of the heart valves. It is commonly treated with prolonged courses of intravenous antibiotics, and in some cases, surgical intervention may also be necessary. While the use of oral antibiotics in the treatment of IE is generally limited, there are select cases where they may be considered as an alternative treatment option. Here, we report a case of staphylococcal right-sided IE successfully treated with oral antibiotics (linezolid and rifampicin). Our case highlights the potential for oral antibiotics to be used as step-down therapy for select patients with IE.

Paxlovid for Treating COVID-19 Patients: A Case-Control Study From Two Hospitals in the Eastern Province of Saudi Arabia.

Background Coronavirus disease 2019 (COVID-19) is an infectious disease that shortly progressed into an unprecedented pandemic spreading all over the world and causing millions of deaths. Many new COVID-19-specific therapies were suggested for the treatment of the patients at increased risk of progression to severe disease, especially those who were unvaccinated and those with a likely inadequate vaccine response. One of the preferred therapies in this setting is Paxlovid, a combination of the oral protease inhibitors nirmatrelvir and ritonavir. Paxlovid was authorized by the Saudi Ministry of Health for the treatment of mild to moderate COVID-19. This study aimed to report the effects of Paxlovid on the mortality of the COVID-19 patients at Dammam Medical Complex (DMC) and Qatif Complex Hospital (QCH), two hospitals in the Eastern Provence of Saudi Arabia, and compare the results with the international data. Methods The study was a retrospective study that included all the COVID-19 patients who were treated with Paxlovid at DMC and QCH between January and December 2022. Those patients were compared with control COVID-19 patients who did not receive Paxlovid. The patients were included irrespective of their COVID-19 vaccination status. All the patients were managed according to the Saudi Ministry of Health guidelines. They were followed up through the infectious disease virtual clinics and were monitored for ICU admissions and death of any cause for three months following their COVID-19 infections. Results A total of 92 COVID-19 patients were included. The patients consisted of 47 male and 45 female patients (51.09% and 48.91%, respectively). The mean ± standard deviation for the patients' age was 55.58±19.25 years. Twenty-eight patients were given Paxlovid (30.43%). Eighteen patients (19.57%) died. The use of Paxlovid was associated with lower ICU admissions (0.0% vs. 18.75%, P value <0.05) and with lower deaths (3.57% vs 26.56%, P value <0.05) but the Paxlovid group included less immunocompromised patients (7.14% vs. 60.94%, P value <0.001), cancer patients (0.0% vs. 42.19%, P value <0.001), and chronic kidney disease patients (7.14% vs. 29.69%, P value <0.05) than the control group. Conclusion This study suggests that Paxlovid is highly effective in reducing the risk of severe COVID-19 or mortality. However, larger studies with better qualities are needed for a full assessment of the role of Paxlovid in COVID-19 management in Saudi Arabia.

A Surge in Malaria Cases in the Eastern Health Region of Saudi Arabia During the COVID-19 Pandemic.

Background Malaria transmission was stopped on most of the vast area of the Kingdom of Saudi Arabia. However, the pandemic of coronavirus disease (COVID-19) has negatively affected the efforts to control malaria. For instance, COVID-19 was reported to induce a relapse of malaria that is caused by Plasmodium vivax. Furthermore, physicians' attention toward COVID-19 can only result in neglect and delayed diagnosis of complicated malaria cases. These factors, among others, might have contributed to an increase of malaria cases in Dammam, Saudi Arabia. Thus, this study was conducted to examine the effects of COVID-19 on malarial cases. Methods The medical records of all patients who were treated at Dammam Medical Complex for malaria between July 1, 2018, and June 30, 2022, were reviewed. Malaria cases were compared between the pre-COVID-19 period (between July 1, 2018, and June 30, 2020) and the COVID-19 period (between July 1, 2020, and June 30, 2022). Results A total of 92 malaria cases occurred in the total study period. There were 60 cases of malaria in the COVID-19 period as opposed to only 32 cases in the pre-COVID-19 period. All the cases were imported from the endemic Saudi southern areas or from outside the country. Eighty-two patients (89.1%) were males. Most of them were Sundaneses (39 patients, 42.4%), Saudis (21 patients, 22.8%), and tribal peoples (14 patients, 15.2%). Fifty-four patients (58.7%) were infected with Plasmodium falciparum. Seventeen patients (18.5%) were infected with Plasmodium vivax. Another 17 patients (18.5%) had a mixed infection with both Plasmodium falciparum and Plasmodium vivax. A trend toward more infected stateless tribal patients was observed in the COVID-19 period compared to the pre-COVID-19 period (21.7% vs 3.1%). A similar trend was noticed for mixed malarial infections with both Plasmodium falciparum and Plasmodium vivax (29.8% vs 0%) with a P value of less than 0.01. Conclusion Malaria cases were almost doubled during the COVID-19 pandemic as compared to the pre-pandemic era signifying the negative effects of the pandemic on malaria epidemiology. The cases increased for a variety of causes that include alternation of health-seeking behaviors, changes in healthcare structures and regulations, and the interruption of malaria preventive services. Future research is needed to study the long-term effects of the changes imposed by the COVID-19 pandemic and to mitigate the effects of any future pandemic on malaria control. As two patients from our cohort were diagnosed with malaria based on blood smears, although they had negative rapid detection tests (RDTs), we recommend testing all the patients who are suspected to have malaria with both RDTs and peripheral blood smears.

Castleman's Disease With Tongue Lesions in an HIV-Positive Patient From Saudi Arabia.

Castleman's disease (CD) is a rare lymphoproliferative disorder that presents with heterogeneous clinical manifestations. We present a case report of a 34-year-old male patient co-infected with CD and HIV, who exhibited tongue lesions along with systemic symptoms. Prompt diagnosis and appropriate management, including antiretroviral therapy (ART) and targeted treatment for CD, resulted in significant clinical improvement. This case highlights the challenges faced in managing CD with tongue involvement in the setting of HIV infection and emphasizes the importance of comprehensive management strategies.

A comparison of three thromboprophylaxis regimens in critically ill COVID-19 patients: An analysis of real-world data.

Introduction: Thrombotic complications of coronavirus disease 2019 (COVID-19) have received considerable attention. Although numerous conflicting findings have compared escalated thromboprophylaxis doses with a standard dose to prevent thrombosis, there is a paucity of literature comparing clinical outcomes in three different anticoagulation dosing regimens. Thus, we investigated the effectiveness and safety profiles of standard, intermediate, and high-anti-coagulation dosing strategies in COVID-19 critically ill patients. Methodology: This retrospective multicenter cohort study of intensive care unit (ICU) patients from the period of April 2020 to August 2021 in four Saudi Arabian centers. Inclusion criteria were age ≥ 18 years, diagnosis with severe or critical COVID-19 infection, and receiving prophylactic anticoagulant dose within 24-48 h of ICU admission. The primary endpoint was a composite of thrombotic events, with mortality rate and minor or major bleeding serving as secondary endpoints. We applied survival analyses with a matching weights procedure to control for confounding variables in the three arms. Results: A total of 811 patient records were reviewed, with 551 (standard-dose = 192, intermediate-dose = 180, and high-dose = 179) included in the analysis. After using weights matching, we found that the standard-dose group was not associated with an increase in the composite thrombotic events endpoint when compared to the intermediate-dose group {19.8 vs. 25%; adjusted hazard ratio (aHR) =1.46, [95% confidence of interval (CI), 0.94-2.26]} or when compared to high-dose group [19.8 vs. 24%; aHR = 1.22 (95% CI, 0.88-1.72)]. Also, there were no statistically significant differences in overall in-hospital mortality between the standard-dose and the intermediate-dose group [51 vs. 53.4%; aHR = 1.4 (95% CI, 0.88-2.33)] or standard-dose and high-dose group [51 vs. 61.1%; aHR = 1.3 (95% CI, 0.83-2.20)]. Moreover, the risk of major bleeding was comparable in all three groups [standard vs. intermediate: 4.8 vs. 2.8%; aHR = 0.8 (95% CI, 0.23-2.74); standard vs. high: 4.8 vs. 9%; aHR = 2.1 (95% CI, 0.79-5.80)]. However, intermediate-dose and high-dose were both associated with an increase in minor bleeding incidence with aHR = 2.9 (95% CI, 1.26-6.80) and aHR = 3.9 (95% CI, 1.73-8.76), respectively. Conclusion: Among COVID-19 patients admitted to the ICU, the three dosing regimens did not significantly affect the composite of thrombotic events and mortality. Compared with the standard-dose regimen, intermediate and high-dosing thromboprophylaxis were associated with a higher risk of minor but not major bleeding. Thus, these data recommend a standard dose as the preferred regimen.

Bonding CAD/CAM materials with current adhesive systems: An overview.

Objective: Overview of the updated literature on the classification of adhesives systems and CAD/CAM materials with clinical guidelines to condition various surfaces for bonding to the tooth structure. Data sources: Searches were conducted in MEDLINE, EMBASE, PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar using specific keywords. Results: 240 papers were revised, 150 articles were excluded, and 90 were eligible for the review. Most studies concluded the essentiality of bonding E-max, zirconia, and hybrid materials to enhance fracture toughness and fatigue resistance. The success of ceramic bonding depends on the microstructure and surface treatment of the materials. The proper treatment of the intaglio starts with using alumina oxide or hydrofluoric acid. This initial treatment could be followed by monobond salinization, which improves the chemical adhesion. Zirconia-based ceramics have grown lately and become the most prescribed for posterior and anterior teeth. Zirconia can be bonded to the tooth structure using the APC concept and 10 MDP promoting primers. Three hundred adhesive resin systems are currently available in the market, and each is different in chemical composition and clinical bonding strength. Of the three hundred systems, the total-etch system remains the gold standard, especially on the enamel surface. The self-etch adhesive system is favorable on dentin due to lowering the postoperative sensitivity. A new generation of dentin adhesives, called universal or multi-mode adhesives. This system has become popular and can be used either as etch-and-rinse or self-etch adhesives. Conclusion: The chemistry of adhesive systems has changed across generations. The variation of dental tissue is the decisive factor in selecting adhesive systems, resin cement, and ceramic materials. Moreover, a reliable bonding strength necessitates a perfect surface treatment and bonding promoter for tooth and CAD/CAM materials.

An Unusual Case of EBV-Negative Primary CNS Lymphoma of Natural Killer/T-Cell Lineage.

Extranodal NK/T-cell lymphoma (ENKTL) is a well-defined cytotoxic lymphoma strongly associated with Epstein-Barr virus (EBV) infection, commonly affecting the nasopharynx and upper aerodigestive tract. Primary central nervous system (CNS) involvement is rare, and only 17 cases were previously reported in the literature. Here, we report the case of a 44-year-old male admitted with a 3-month history of personality changes and progressive right leg weakness. Brain magnetic resonance imaging studies (MRIs) revealed multiple rim-enhancing brain lesions bilaterally. An extensive clinical and laboratory workup was unrevealing, and 2 brain biopsies were initially considered inconclusive. Pertinently, no systemic lymphoproliferative disorder was identified. The patient initially experienced remarkable clinical improvement with dexamethasone, pulse methylprednisolone, and rituximab therapy. However, he eventually had rapid clinical deterioration, was found to have increased brain lesions, and died nearly 6 months after the initial presentation. During this time, the second brain biopsy was found to show involvement by T-cell lymphoma of NK-cell lineage, which was EBV negative. No post-mortem examination was done to identify any systemic lymphoma. This case serves to expand the spectrum of lymphomas involving the CNS.

Effectiveness and safety of favipiravir compared to supportive care in moderately to critically ill COVID-19 patients: a retrospective study with propensity score matching sensitivity analysis.

INTRODUCTION: Favipiravir is a repurposed drug to treat coronavirus 2019 (COVID-19). Due to a lack of available real-world data, we assessed its effectiveness and safety in moderately to critically ill COVID-19 patients. METHODS: This retrospective study was conducted in two public/specialty hospitals in Saudi Arabia. We included patients ≥18 years) admitted April-August 2020 with confirmed SARS-CoV-2 diagnosed by real-time polymerase chain reaction (RT-PCR) from nasopharyngeal swab. Patients received either favipiravir (1800 mg or 1600 mg twice daily loading dose, followed by 800 mg or 600 mg twice daily) or supportive-care treatment. Patients were excluded if they were outside the study period, classified as having a mild form of the disease per WHO criteria, or had an incomplete patient file. Kaplan-Meier (KM) models were used to estimate median time to discharge. Discharge ratios, progression to mechanical ventilation, and mortality outcomes were estimated across the severity spectrum using Cox proportional-hazards models. As a sensitivity analysis, we performed propensity score-matching (PSM) analysis. RESULTS: Overall, median time to discharge was 10 days (95%CI = 9-10) in the favipiravir arm versus 15 days (95%CI = 14-16) in the supportive-care arm. The accelerated discharge benefit was seen across the COVID-19 spectrum of severity. The adjusted discharge ratio was 1.96 (95%CI = 1.56-2.46). Progression to mechanical ventilation was slower with favipiravir (HRadj = 0.10, 95%CI = 0.04-0.29). There was no significant effect on mortality (HRadj = 1.56, 95%CI = 0.73-3.36). There was a statistically non-significant trend toward worse outcomes in the critical category (HRadj = 2.80, 95%CI = 0.99-7.89). Age was an independent risk factor for mortality in mechanically ventilated patients. PSM analyses confirmed these findings. CONCLUSION: Favipiravir was associated with clinical benefits, including accelerated discharge rate and less progression to mechanical ventilation; however, no overall mortality benefits were seen across the severity spectrum.

Prevalence of Dyslipidemia in Patients With Type 2 Diabetes Mellitus: A Cross-Sectional Study.

INTRODUCTION:  Diabetes mellitus (DM), a chronic metabolic noncommunicable disease (NCD), has assumed epidemic proportions worldwide. Type 2 diabetes (T2D) is defined as chronic high blood glucose levels due to the deficiency of insulin or resistance to it. Dyslipidemia is one of the major causes of cardiovascular diseases in patients with T2D. It is characterized by elevated plasma triglyceride (TG), low high-density lipoprotein (HDL) cholesterol, and high low-density lipoprotein (LDL) cholesterol, which is mostly present in patients with DM. METHODS:  We conducted a retrospective cross-sectional study at the King Faisal University (KFU) Health Center in the eastern region of Saudi Arabia. The data of patients from October 2014 to February 2021 were collected. We collected the patients' data from the KFU Health Center after obtaining approval from the KFU polyclinic administration. Prior ethical approval was taken from the Institutional Review Board of Ethics and Research Committee in the College of Medicine, KFU (approval number, 2020-10-62). We collected patients' data, including their gender, age, nationality, and blood analysis (lipids profile - TGs, HDL, LDL, and hemoglobin A1c [HbA1c] levels). RESULT:  This study included 191 patients with T2D, 137 (71.7%) were from Saudi Arabia, and 54 (28.3%) were from other countries. Patients' age ranged from 21 to 100 years, with a mean age of 56.2 ± 11.8 years. There were 107 (56%) females. Cholesterol levels ranged from 102 to 300 mg/dl with a mean value of 187.3 mg/dl. CONCLUSION: In the current study, we assessed the association between HbA1c levels and lipid profiles in patients with T2D at the KFU Health Center in the eastern region of the Kingdom of Saudi Arabia. Our results on the adjusted relationship of HbA1c with lipid profile through regression model have demonstrated that HDL alone had significant adjusted relation with HbA1c if other factors are kept constant. We suggest focusing on TC and HDL levels in T2D health management in future studies.