Abdullah Balkhair

Cerebro-rhino orbital mucormycosis: An update

Mucormycosis is an uncommon fungal infection which can lead to fulminant necrotizing infection under optimal host condition. Fungi have the ability to invade blood vessels and can affect different parts of the body. The most common, though the most aggressive, form is cerebro-rhino-orbital mucormycosis that occurs in debilitated patients, in conjunction with sinus or para-sinus involvement. Due to increased number of newly diagnosed cases of mucormycosis world-wide resulting from uncontrolled metabolic conditions, this paper intends to widen the readers scope and knowledge about the nature of the disease and its multicomplexity that require a collaborative effort for careful management. Patients who are at risks both at the onset of the disease and during its management have been identified in the paper.

The Struggle Against MERS-CoV (The Novel Coronavirus)

The emergence of novel viruses is arguably viewed as a potential threat to human health. The past decade has seen the emergence of SARS-coronavirus, H5N1 (bird flu) and the H1N1 which caused a global pandemic. Furthermore, the last few months have witnessed the emergence of two novel respiratory viruses: the Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) in June 2012 in Saudi Arabia and the influenza A virus H7N9 in March 2013 in China. The basis for this noticeable increase in the number of novel viruses remains elusive and is uncertain at best. Proposed explanations for this observation include the increased mixing between different animal species and humans, climate changes, intense international travel, expansion of the immune suppressed population, and changes in the virus itself to adapt to other species. MERS-CoV was first isolated from a 60 year old Saudi male who died of severe pneumonia and renal failure in June 2012.1 The second confirmed case was soon reported from a 49 year old Qatari citizen who had travelled to Saudi Arabia prior to his illness.2 He subsequently succumbed to severe pneumonia. Fortunately, the conclusion at that time was that the virus did not exhibit human to human transmission. Since September 2012, the number of cases reported to the World Health Organization (WHO) has sharply increased.3,4 This triggered a global response and raised the fear of a possible recurrence of another version of 2002-2003 SARS outbreak. The first clusters were reported retrospectively from Jordan which occurred in one of the tertiary hospitals in April 2012.5 It involved 13 cases (with 2 laboratory confirmed). Subsequently, multiple clusters were reported from the Eastern part of Saudi Arabia, United Kingdom (UK), France, Tunisia and Italy. Cases have also been reported from United Arab Emirates (UAE) and Germany. All of the European and Tunisian cases had direct or indirect connection with the Arabian Peninsula. These cases all occurred either in a healthcare facility or among close family members. Hence, the conclusion at the present time alludes to the fact that the virus does exhibit potential human to human transmission. However, we still believe that the infectivity of this virus is limited and the transmissibility rate is low based on the high number of close contacts who tested negative for MERS-CoV. However, the sudden increase in the number of cases over the last month3 and the emergence of a number of clusters has clearly demonstarted to the scientific communities that something has happened to the MERS-CoV which has caused it to alter its behavior. According to the WHO, the total laboratory confirmed human infections with MERS-CoV globally is 81 cases with 45 deaths as of 11 July 2013.6 Saudi Arabia is heavily impacted by this virus (64 cases and 38 deaths).3 It is important to note that there has not been a single case of MERS-CoV in Oman to date. All suspected cases in Oman thus far tested negative (personal communication). To date, most infections with MERS-CoV resulted in unusually severe pneumonia and severe acute respiratory illness requiring ventilation and intensive care.7 Many patients developed severe organ dysfunction particularly renal failure. It has also been observed that most severe infections occur among the elderly, immune suppressed individuals and those with co-morbidities. A milder form of the illness is also seen but in a minority of cases. Most affected individuals have been adults with a median age of 56 years. Only two pediatric cases have been reported and the current case fatality rate stands at 58%. The exceptionally high fatality rate (>50%) thus far emanating from MERS-CoV infection coupled with the behavioural uncertainties of this novel virus have understandably caused major public and international concerns. After the emergence of the initial cases in the Arabian Peninsula, there have been extensive international efforts and preparations to halt further spread of this lethal virus incurring substantial costs on the healthcare systems, particularly of neighboring countries. A wide range of animals are considered reservoirs for coronaviruses. Interspecies transmissibility is well recognized in coronaviruses with SARS coronavirus being a prototype for this phenomenon. However, the origin of the MERS-CoV is still unknown, and less so whether it has an animal reservoir. Scientists however, currently believe that bats are the most likely reservoir,8 in addition to a high possibility of an intermediate animal host(s) probably of a domestic nature. Immediate development of diagnostic tests for rapid identification of infected patients is essential. Real-time reverse transcription-polymerase chain reaction (RT-PCR) assays have been developed to detect MERS-CoV in respiratory, blood and stool samples.9 So far, the virus has mainly been detected in lower respiratory samples. There is currently no specific treatment for patients with MERS-CoV infection, no specific antiviral therapy is yet available, and no vaccination is currently on hand. The basis of the current management strategy is mainly supportive with emphasis on good critical and supportive care. In the absence of effective drugs or a vaccine, control of MERS-CoV infection in hospital settings relies heavily on the practice of appropriate infection control precautions including prompt isolation of suspicious cases. Personal protective equipment and good infection control practices are extremely useful to prevent further transmission. This novel virus is largely unknown to the scientific community. Very little is known about its behavior, however, it is generally accepted that it has a wide genetic diversity and thus can mutate, change its virulence and even tissues tropism. The risk MERS-CoV poses on public health is not yet entirely understood, however the continued outbreak of new cases, the ongoing risk of transmission to humans, the recent reports of nosocomial outbreaks with transmission to healthcare personnel,10 and the increasing reports of cases imported outside Saudi Arabia justifiably raise public concern. As is typically the case with any newly discovered virus, today there questions prevail over this seemingly lethal virus. Most pressing questions incline towards its origin, its main risk factors for infection and whether it has an epidemic potential. What is truly reassuring, however, is the swiftness at which the scientific community is learning about this presently mysterious virus. Over the past few weeks, observations allude to the fact that mild respiratory illness might be part of the clinical spectrum, the incubation period might be longer than previously estimated, presentations may not initially include respiratory symptoms and lower respiratory tract is the preferable site for virus proliferation and hence for sampling.4 The fact that our current knowledge on this virus is sparse should not induce unnecessary panic or fear, instead it should promote vigilance and a state of preparedness. Over reaction to the current situation may lead to significant clinical, economic and epidemiological impacts among others.

Epidemiology of multi-drug resistant organisms in a teaching hospital in oman: a one-year hospital-based study.

Background. Antimicrobial resistance is increasingly recognized as a global challenge. A few studies have emerged on epidemiology of multidrug resistant organisms in tertiary care settings in the Arabian Gulf. Aim. To describe the epidemiology of multi-drug resistant organisms (MDRO) at Sultan Qaboos University Hospital, a tertiary hospital in Oman. Methods. A retrospective review of MDRO records has been conducted throughout the period from January 2012 till December 2012. Organisms were identified and tested by an automated identification and susceptibility system, and the antibiotic susceptibility testing was confirmed by the disk diffusion method. Results. Out of the total of 29,245 admissions, there have been 315 patients registered as MDRO patients giving an overall prevalence rate of 10.8 (95% CI 9.3, 12.4) MDRO cases per 1000 admissions. In addition, the prevalence rate of MDRO isolates was 11.2 (95% CI 9.7, 12.9) per 1000 admissions. Overall, increasing trends in prevalence rates of MDRO patients and MDRO isolates were observed throughout the study period. Conclusion. Antimicrobial resistance is an emerging challenge in Oman. Continuous monitoring of antimicrobial susceptibility and strict adherence to infection prevention guidelines are essential to prevent proliferation of MDRO. Along such quest, stringent antibiotic prescription guidelines are needed in the country.

Extrapontine myelinolysis as presenting manifestation of adrenal failure: A case report

BACKGROUND Hyponatremia is a fairly common metabolic disorder. Hyponatremic myelinolysis is a relatively rare, life threatening complication with poorly understood pathophysiology, varied clinical manifestations and uncertain treatment. This case report highlights the range of clinical and imaging phenomena associated with hyponatremic myelinolysis. METHODS Case report. RESULT A middle aged lady presented with an acute delirious state, hypotension and severe hyponatremia on a background of skin hyper-pigmentation and weight loss. Her clinical course evolved to an akinetic-rigid state and later to parkinsonism. Extensive investigations for recognizing a primary neurologic disorder, including brain MRI and CSF analysis were normal, though she had disseminated miliary tuberculosis involving multiple organs. Brain MRI changes characteristic of extrapontine myelinolysis appeared two weeks after the onset of symptoms. The patient recovered completely over several weeks. CONCLUSION This case of hyponatremic extrapontine myelinolysis occurred as the presenting manifestation of adrenal failure secondary to disseminated tuberculosis. Extraponine myelinolysis is difficult to diagnose in the context of delayed brain MRI changes and can have a favorable outcome with modern management.

A child with human parvovirus B19 infection induced aplastic anemia and acute hepatitis: effectiveness of immunosuppressive therapy.

Human parvovirus B19 (HPV B19) infections are usually asymptomatic or benign and self-limiting. In immunocompromised patients and patients with chronic hemolytic anemia, it can lead to transient red cell aplasia. Few reports in the literature have implicated HPV B19 as the possible cause of acute hepatitis and severe aplastic anemia in immunocompetent patients. Here, the authors report a previously healthy 6-year-old girl with acute hepatitis and severe aplastic anemia associated with HPV B19 infection diagnosed by serology (ELISA). Other common causes of these manifestations were ruled out. The clinical manifestations subsequently improved significantly with the use of immunosuppressive therapy confirming an autoimmune mechanism.

Treatment of vancomycin-intermediate Staphylococcus aureus (VISA) endocarditis with linezolid

We report a case of infective endocarditis due to vancomycin-intermediate Staphylococcus aureus (VISA). This was treated with a combination of intravenous linezolid and fusidic acid. Cure was achieved without surgical intervention.

Spectrum of AIDS Defining Opportunistic Infections in a Series of 77 Hospitalised HIV-infected Omani Patients

OBJECTIVES Most of the morbidity and mortality in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) result from opportunistic infections (OIs). Although the spectrum of OIs in HIV infected patients from developing countries has been reported, there is a paucity of data on the natural history, pattern of disease, and survival of hospitalised patients with HIV/AIDS, particularly in Arab countries. The aim of this study was to study retrospectively the spectrum and frequency of various OIs in a cohort of hospitalised HIV-infected Omani patients. METHODS Included in the study were 77 HIV-infected Omani patients admitted to a tertiary care teaching hospital in Muscat, Oman, between January 1999 and December 2008. They were diagnosed on their first admission and hence were not on highly active antiretroviral therapy (HAART) at presentation. The frequency of various clinical and laboratory findings and individual OIs were analysed. RESULTS In total, 45 patients (58%) had one or more AIDS-defining OIs. Pneumocystis jiroveci pneumonia (PCP) was commonest (25%), followed by cryptococcal meningitis (22%), cytomegalovirus (CMV), retinitis (17%), disseminated tuberculosis (15%), and cerebral toxoplasmosis (12.5%). Only one patient with Mycobacterium avium-intracellulare (MAI) was identified and one patient had disseminated visceral leishmaniasis. The majority of patients (77%) had CD4+ counts <200 cells/μL. Ten patients (22%) died during hospital stays, with five deaths (50%) being caused by disseminated CMV infection. CONCLUSION A wide spectrum of OIs is seen in hospitalised HIV-infected patients in Oman. P. jiroveci pneumonia and cryptococcal meningitis were the commonest OIs, while disseminated CMV was the commonest cause of death. We hope these results will advance the knowledge of specialists treating HIV in Oman and the Gulf region.

Complicated subacute bacterial endocarditis in a patient with ventricular septal defect.

Infective endocarditis (IE) is an uncommon but life-threatening infection. Despite advances in management, it still causes high morbidity and mortality. We report the case of an 8-year-old girl who presented with a prolonged fever of 2.5 months duration and a history of a small perimembranous ventricular septal defect. She was diagnosed with subacute bacterial endocarditis secondary to Streptococcus mutans. The patient developed a septic pulmonary embolism; however, with the use of appropriate antimicrobial therapy, she made an uneventful recovery. Clinicians should have a high index of suspicion for IE as the possible cause of a prolonged fever, especially in the presence of congenital heart disease (CHD). Currently, IE prophylaxis is not indicated for unrepaired acyanotic CHD. Nevertheless, with the new changes in the guidelines, more prospective studies are needed to investigate the incidence of IE in such lesions, before long-term conclusions can be drawn.

Severe Pulmonary Involvement in Leptospirosis : Alternate antibiotics and systemic steroids

Pulmonary complications in leptospirosis, though common, are often unrecognized in a non-endemic area. We report here a patient with leptospirosis and severe pulmonary involvement who was treated with meropenem (1 g every 8 hours), moxifloxacin (400 mg once daily), and high doses of corticosteroids. Systemic steroids were continued for 3 months because of persistent pulmonary lesions.

Nocardia brain abscess.

A 61-year-old man, with a 3-year history of intravenous drug abuse, diabetes mellitus and hypertension, presented with a 2-week history of progressive left hemiplegia. At admission, he was emaciated, febrile and his Glasgow coma scale score was 14/15. He demonstrated a left upper motor neuron facial weakness, grade 0/5 power in his left arm and leg and a left extensor plantar response. He tested negative for human immunodeficiency virus type 1 and 2 antigen/antibody and infective endocarditis. Hepatitis C virus genotype 3 was detected in his blood sample with a viral RNA load of 12,28,267 IU/ml by polymerase chain reaction. Cerebral magnetic resonance imaging (MRI) disclosed a ring-enhancing lesion in the right frontoparietal area (Figure 1A). The differential diagnoses of a ring-enhancing cerebral lesion include r adiation necrosis, i nflammatory demyelination, n eurocysticercosis, g lioma, l …