Khalil M. Charafeddine

Ongoing Epidemic of Cutaneous Leishmaniasis among Syrian Refugees, Lebanon

In September 2012, a cutaneous leishmaniasis outbreak began among Syrian refugees in Lebanon. For 948 patients in whom leishmaniasis was not confirmed, we obtained samples for microscopic confirmation and molecular speciation. We identified Leishmania tropica in 85% and L. major in 15% of patients. After 3 months of megulamine antimonite therapy, patients initial cure rate was 82%.

Comparison of neutrophil volume distribution width to C-reactive protein and procalcitonin as a proposed new marker of acute infection

Abstract Background: The aim of this study was to assess the use of neutrophil distribution width (NDW) and to compare it to C-reactive protein (CRP) and procalcitonin (PCT), in the detection of early sepsis in the intensive care unit. Methods: Subjects (N = 166) were divided into 4 groups: healthy, acute inflammatory non-infectious (AINI), localized infection, and systemic infection, according to clinical history and cultures. NDW, CRP, and PCT were compared among the different groups using multivariate analysis of variance (MANOVA). Diagnostic efficacy was assessed using receiver operating characteristic curves and areas under the curves (AUC). Results: The lowest meanNDW was found in the healthy group (n = 41), followed by the AINI (n = 20), localized infection (n = 55), and systemic infection (n = 50) groups. AUCNDW was 0.877 for infected (localized + systemic) vs non-infected (healthy + AINI) groups, and 0.965 for systemic infection vs non-infected groups. A cut-off of 21.9 resulted in 90% sensitivity, 92% specificity, 90% positive predictive value, and 92% negative predictive value (AUCNDW = 0.965, 95% confidence interval 0.935–0.995). According to MANOVA, only NDW was able to differentiate an acute inflammatory process from early infection in postoperative patients, but not healthy from AINI subjects. Conclusions: NDW had the highest diagnostic accuracy and is available with the complete blood count with differential (CBC). It may be a promising parameter to aid in the diagnosis of acute infection in adults, provided the possibility of haematological disorders is first ruled out.

Extended use of serum free light chain as a biomarker in lymphoproliferative disorders: a comprehensive review.

Serum free light chain (sFLC) assays were shown to improve detection, management, and prognostication in plasma cell disorders. Recently, sFLC assays improved detection of M proteins when combined with standard methods of protein electrophoresis/immunofixation in patients with non-Hodgkin lymphoma/chronic lymphocytic leukemia (NHL/CLL). Incidence of abnormal sFLC ratio (sFLCr) varied from 0% to 36% and 29.7% to 59% in NHL and CLL, respectively. Increased sFLC levels or abnormal sFLCr predict shorter overall survival in early-stage CLL. Furthermore, abnormal sFLCr correlated with advanced disease stage and poorer outcome. In diffuse large B-cell lymphomas, increased sFLC was demonstrated as an independent, adverse prognostic factor for overall/event-free survival. Moreover, abnormal sFLCr can be a diagnostic tool in central nervous system lymphomas. Finally, the quantitative FLC assay has the potential to become a new, easily measured biomarker for predicting prognosis and enhanced detection in NHL/CLL. It may be used serially at follow-up evaluations to provide clues to relapse.

Transfusion-related Plasmodium ovale malaria complicated by acute respiratory distress syndrome (ARDS) in a non-endemic country

46year old female presented with a one week history of high grade fever, chills, cough, and severe nausea. The patient had been admitted a month earlier with severe lower gastrointestinal bleeding from hemorrhoids necessitating transfusion of 7 units of packed red blood cells. Initial work-up was unremarkable. Because of persistent symptoms, the patient was admitted 2 days later. Malaria smear was positive. Due to the severity of her symptoms, she was managed as falciparum malaria and was started on intravenous quinine and oral doxycycline. On the second day of treatment the patient developed respiratory failure, requiring intubation and ventilatory support with new bilateral pulmonary infiltrates. Antimalarial treatment was continued for a total of 7 days followed by primaquine for 14 days once the blood smear results revealed Plasmodium ovale infection. The patient remained intubated in the intensive care unit (ICU) for 16 days, and was later extubated successfully with a clear chest x-ray after a total of one month hospitalization. To our knowledge, this is the first case of acute respiratory distress syndrome (ARDS) secondary to blood transfusion related P. ovale malaria infection in a non-endemic country.

Resistance to aspirin and clopidogrel therapy

Introduction:  Despite increasing evidence on the roles of aspirin and clopidogrel in decreasing morbidity and mortality from cardiovascular disease, resistance to therapy remains an emerging clinical entity. The aim of this review was to revisit current knowledge of the mechanisms, laboratory evaluation, clinical impact and management of resistance to aspirin and clopidogrel therapy.

Study of KIR genes in Lebanese patients with tuberculosis

A total of 103 Lebanese tuberculosis (TB) cases and 38 controls without TB were studied for the killer cell immunoglobulin-like receptors (KIR) genotypic profile using polymerase chain reaction sequence-specific primers. Patients and controls were assigned to the AA, AB or BB genotypes based on their A or B haplotype genetic make-up, and KIR gene frequencies were compared. We found an increase in the KIR A haplotype in TB patients compared to controls, and only KIR 2DL3 was found to be significantly more prevalent among TB patients. This confirms the findings of another unique international study performed in the Mexican population showing a greater repertoire of inhibitory KIR genes among TB patients than controls.

Vitamin D receptor genotypes and response to zoledronic acid therapy in thalassemia-induced osteoporosis.

Dear Editor, We have previously reported the results of the efficacy and safety of zoledronic acid treatment in thalassemia-induced osteoporosis [1]. Zoledronic acid was administered at a dose of 4 mg intravenously to 18 patients with betathalassemia and osteoporosis. We have shown that this treatment was efficacious in improving the bone mineral density (BMD) and in reducing bone resorption in treated patients. In this study, we assessed the polymorphisms BsmI, ApaI, and TaqI of vitamin D receptor (VDR) gene in the treated patients. We then assessed whether these VDR gene polymorphisms influenced the response to zoledronic acid treatment. We analyzed patients’ DNA previously extracted from whole blood samples and stored in the Department of Pathology and Laboratory Medicine at our medical center. After DNA amplification using specific primers targeting a 740-bp original VDR gene, restriction enzymes digestion was performed at 37°C for BsmI and ApaI and 65°C for TaqI. Visualization of digested products was done on 1.2% (BsmI) and 2% (ApaI and TaqI) agarose gel electrophoresis. The results are interpreted as follows: For TaqI, the presence of two fragments at 495 and 245 bp corresponds to TT genotype; the presence of three fragments at 290, 245, and 205 bp corresponds to tt genotype; and the presence of four fragments at 495, 290, 245, and 205 bp corresponds to Tt genotype. For ApaI, the presence of a single fragment at 700 bp corresponds to AA genotype; the presence of two fragments at 490 and 210 bp corresponds to aa genotype; and the presence of three fragments at 700, 490, and 210 bp corresponds to Aa genotype. For BsmI, the presence of a single fragment at 800 bp corresponds to BB genotype; the presence of two fragments at 650 and 150 bp corresponds to bb genotype; and the presence of three fragments at 800, 650, and 150 bp corresponds to Bb genotype. In our previous study, 18 thalassemic patients with osteoporosis defined as z score <−2.5 were given zoledronic acid 4 mg intravenously every 3 months over a period of 12 months. BMD was measured at the lumbar spine, femoral neck, and hip at baseline, 6, and 12 months [1]. Kruskal–Wallis test was conducted to test for correlations between BMD responses and VDR genotypes. Differences were considered statistically significant when p value was less than 0.05. The analyses were performed using SPSS software version 15.0 (SPSS, IL, USA). The frequency distribution of the VDR genotypes was as follows: 27.8% BB, 50% Bb, 22.2% Bb, 5.6% AA, 61.1% Aa, 33.3% Aa, 22.2% TT, 50% Tt, and 27.8% tt. The mean percentage change in BMD at 1 year (from baseline to end of study at 12 months) at the different sites was calculated and Ann Hematol (2008) 87:947–948 DOI 10.1007/s00277-008-0497-5

The immune microenvironment in cutaneous leishmaniasis.

Cutaneous leishmaniasis is an infection that has spread to non‐endemic regions, stimulating recent interest for the enhanced understanding of this disease. Downregulation of the CD1a receptor on Langerhans cells has been described in various cutaneous infections.

Diagnosis of cutaneous leishmaniasis: why punch when you can scrape?

Cutaneous leishmaniasis (CL) has been introduced to the Leishmania under-endemic Lebanese population in an uncontrolled manner as a result of recent large-scale displacement of refugees from endemic Syria. Accordingly, a quick and reliable method to diagnose CL is essential. Matched punch biopsies and air-dried scrapings on 72 patients were obtained. Scrapings were collected in two forms: thick drop (N = 33) or thin smear (N = 39). Clinical information was recorded. Sections of punch biopsies and scrapings were stained and examined microscopically. Polymerase chain reaction (PCR) was performed on both scraping forms and biopsies. The diagnostic sensitivity of the tests performed revealed that microscopy in conjunction with PCR on punch biopsies was the most sensitive test (93%) overall. However, taken individually, microscopy and PCR yielded the highest sensitivities when performed on drop scrapings (63% and 85%, respectively), and not smear scrapings (38% and 56%, respectively) as compared with the punch biopsies (44% and 83%, respectively). Microscopic concordance for punch biopsies and drop scrapings was present in 25 of 33 cases. Concordance was predicted only by the high/low parasitic index (PI: 3.1 ± 1.7 and 0.4 ± 0.5, respectively; P < 0.05). Herein, we optimized a novel rapid method for reliable diagnosis of CL based on drop scrapings with good agreement with the gold standard punch biopsy technique.

Correlation of methylenetetrahydrofolate reductase polymorphisms with homocysteine metabolism in healthy Lebanese adults

Hyperhomocysteinemia is associated with several vascular and teratogenic conditions. Determinants of total homocysteine concentrations include genetic and nutritional factors. This study assesses the relation between homocysteine concentrations and MTHFR gene polymorphisms at two common alleles (C677T (rs1801133) and A1298C (rs1801131)) as well as other predictors of homocysteine (folate, vitamin B(12), body mass index (BMI), age, and gender) in a group of healthy Lebanese: 109 males and 124 females aged 17-55years. We used serum for the determination of homocysteine, folate and vitamin B(12) levels and blood drawn in EDTA tubes for molecular analysis of MTHFR polymorphisms. Hyperhomocysteinemia was present in 59/233 (25.3%) of the subjects, with male/female ratio of 1.95. Multivariable regression analysis showed that homocysteine levels were negatively related to folate and vitamin B(12) and positively related to male gender and C677T homozygosity; but not A1298C polymorphism, BMI or age. The prevalence of wild, heterozygous, and homozygous C677T genotypes was 45.0%, 43.3% and 11.6%, respectively; with a carrier frequency of 54.9% and allelic frequency of 33.3%. The A1298C genotypic prevalence was 39.5%, 30.9%, and 29.6% respectively; with a carrier frequency of 60.5% and allelic frequency of 45.1%. C677T/A1289C compound heterozygosity was present in 47/233 (20.2%) of volunteers. In this first pilot study, gender, folate, vitamin B(12) and C677T mutational status could explain around 32% of homocysteine variations. Future larger studies are recommended to investigate other predictors of homocysteine variation and combine them with markers explored in this and other studies, in order to evaluate their impact on vascular and/or congenital diseases.