Usamah Hadi

Rhinolithiasis: A Forgotten Entity:

OBJECTIVE : To review the clinical presentation of patients with rhinoliths, which are calcareous concretions with an unclear pathogenesis. STUDY DESIGN AND SETTING : Using retrospective chart review we analyzed clinical, radiological, and demographic data as well as our diagnostic work-up and management of 8 patients. RESULTS : Most patients presented with nonspecific nasal complaints; most commonly, purulent rhinorrhea and nasal obstruction. The rhinolith was discovered incidentally in some patients. CONCLUSION : Rhinoliths are rare and can have various clinical presentations. The treatment of choice is surgical removal. SIGNIFICANCE : A high index of suspicion is required for the diagnosis of such a forgotten entity.

Detection of a highly prevalent and potentially virulent strain of Pseudomonas aeruginosa from nosocomial infections in a medical center

BackgroundWe correlated genotypes, virulence factors and antimicrobial susceptibility patterns of nosocomially identified Pseudomonas aeruginosa isolates from clinical specimens to those of environmental isolates encountered in the same units of a medical center. Antibiotic susceptibility testing, RAPD analysis and detection of enzymatic activities of extracellular virulence factors, were done on these isolates.ResultsData showed that most of the clinical and environmental isolates were susceptible to tested antimicrobial agents. RAPD analysis determined the presence of 31 genotypes, with genotype 1 detected in 42% of the clinical isolates and 43% of the environmental isolates. Enzymatic activity testing showed that genotype 1 produced all virulence factors tested for.ConclusionIn conclusion, our data demonstrated the predominant prevalence of a potentially virulent P. aeruginosa genotype, circulating in a number of units of the medical center and emphasize the need to reinforce infection control measures.

The use of TNF-α blockers in Cogan’s syndrome

A 37-year-old woman, previously healthy, who in September 2001 noted sudden onset of erythema in both eyes, followed by vertigo, vomiting, tinnitus in both ears, and hearing loss in the left ear then in the right over 1-week period. Slit lamp examination revealed bilateral interstitial keratitis. Her physical examination was essentially unremarkable except for decreased hearing bilaterally, more so on the right. An audiogram conWrmed the presence of severe bilateral sensorineural hearing loss (SNHL), more so on the right. Brainstem auditory evoked response testing revealed delay of all waves on the left and no waves on the right. A gadolinium enhanced MRI of the brain conWrmed the presence of inXammation around the cochlea bilaterally. Her laboratory tests at that time showed a sedimentation rate of 26 mm/h, with a negative ANA, rheumatoid factor, anti-SSA and anti-SSB, anticardiolipins (IgG, IgM), c-ANCA and p-ANCA, and VDRL. A lumbar puncture was normal. Her chest X-ray, electrocardiogram and echocardiography were also normal. Accordingly, the diagnosis of Cogan’s syndrome was made. Therapy was initiated with topical steroid eye drops and oral prednisone at 1 mg/kg/day. The ocular symptoms improved within few days but after 3 weeks, the patient denied any clinical improvement in her hearing and audiogram conWrmed worsening of the SNHL on the left. After 3 weeks from the diagnosis of Cogan’s syndrome the Wrst dose of inXiximab was initiated at 3 mg/kg for three doses at 0, 2 and 6 weeks. After the Wrst dose of inXiximab, the patient reported decrease in the sensation of aural fullness and vertigo and subjective improvement in hearing, associated with improvement on the audiogram in the left ear. Methotrexate as 12.5 mg/week was added after the second dose of inXiximab. Because the hearing conditions remained stable oral prednisone was reduced gradually. Patient was lost of follow up after the third dose of inXiximab and returned after 2 years. She has stopped her medications since then and found to have subjective and objective deterioration for which she underwent left cochlear implant.

Tuberculous parotitis: A forgotten entity

of the salivary glands can be misdiagnosed in the light of their infrequent occurrence in a general otolaryngologic practice. The differential diagnosis includes inflammatory conditions, immunologic disorders, trauma, cysts, systemic disorders and neoplasms. Preoperative diagnosis is difficult, as the disease can be mistaken for a neoplasm. Fine needle aspiration biopsy, computerized tomographic scan analysis, sialography, and chest radiography can give nonspecific results, especially in the absence of history of pulmonary tuberculosis.1 We report a case of tuberculosis of the parotid gland presenting as a parotid mass. The otolaryngologic manifestations of tuberculosis will be discussed.

Nasal Allergies in the Middle Eastern Population: Results from the “Allergies in Middle East Survey”:

Background Chronic respiratory diseases such as asthma and allergic rhinitis (AR) are a major public health problem in developing countries including those in the Middle East. However, to date, there is a paucity of information related to physician-diagnosed AR in this region. The Allergies in Middle East Survey was undertaken to help clarify and broaden the understanding of physician-diagnosed AR across Egypt, Iran, Lebanon, Saudi Arabia, and the United Arab Emirates. The survey explores the frequency of physician-diagnosed AR, prevalence and types of associated symptoms, the impact on quality of life (QOL), current treatment practices, and therapy expectations. Methods In total, 7411 households in five countries (Egypt, Lebanon, Saudi Arabia, Iran and the United Arab Emirates) were screened to identify individuals that were ≥4 years old with a physician diagnosis of AR and either symptoms and/or treatment in the past 12 months. A total of 501 respondents from the five countries completed the survey. Standardized questionnaires were used to make comparisons across the regions; however, the data collection procedures were tailored for each country. The sample was probability based to ensure valid statistical inference to the population. Results Ten percent of the Middle East population surveyed had a physician diagnosis of AR, with 65% of respondents stating that their allergies were intermittent in nature. An otolaryngologist or allergist diagnosed the majority of the individuals surveyed. Runny nose, nasal and throat itching, postnasal drip, and nasal congestion or stuffed up nose were the most common and bothersome symptoms of AR. The majority of survey participants (58% of the overall survey population) with AR reported that the condition had an impact on their daily private and professional life. Seventy-two percent of adults reported that their AR symptoms limited their work/school activities and 35% reported that their AR interfered with and caused them to miss work or school within the past 12 months. One factor, in addition to the outward AR symptoms, that could have contributed to these function impairments may have been sleep disturbances. Although a secondary symptom to AR, sleep disturbances (difficulty getting to sleep, waking up during the night or lack of a good nights sleep) were shown in this survey to be extremely troubling in ~15% of AR sufferers. In the past year >90% of patients reported taking a medication of any type for their AR, with nearly a 4:1 ratio of patients taking a prescription medication versus an over-the-counter (OTC) medication in the past 4 weeks. Over 75% of survey respondents reported taking an intranasal corticosteroid (INCS) in the last 4 weeks and the satisfaction rate of INCS medications was similar to that reported for OTC medications. The most common reasons cited for dissatisfaction with INCS medications were inadequate effectiveness, bothersome side effects (e.g., unpleasant taste and retrograde drainage into the pharynx), decreased effectiveness with chronic use, and failure to provide 24-hour relief. Conclusion These data show that AR is common in the Middle East region as elsewhere in the world. Many patients with AR in Middle East region suffer from their symptoms (e.g., runny nose, nasal itching, nasal congestion, postnasal drip, and other symptoms) on all or most days during the times of the year that their allergies are worst. These symptoms have been shown to reduce QOL and performance at work/school to a significant degree. Additionally, the survey data underscore a considerable treatment gap with current therapies for AR and that many AR patients still have not found adequate effectiveness with currently available medications. Thus, through identification of disease impact on the Middle East population and highlighting treatment gaps, clinicians in the Middle East may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.BACKGROUND Chronic respiratory diseases such as asthma and allergic rhinitis (AR) are a major public health problem in developing countries including those in the Middle East. However, to date, there is a paucity of information related to physician-diagnosed AR in this region. The Allergies in Middle East Survey was undertaken to help clarify and broaden the understanding of physician-diagnosed AR across Egypt, Iran, Lebanon, Saudi Arabia, and the United Arab Emirates. The survey explores the frequency of physician-diagnosed AR, prevalence and types of associated symptoms, the impact on quality of life (QOL), current treatment practices, and therapy expectations. METHODS In total, 7411 households in five countries (Egypt, Lebanon, Saudi Arabia, Iran and the United Arab Emirates) were screened to identify individuals that were ≥4 years old with a physician diagnosis of AR and either symptoms and/or treatment in the past 12 months. A total of 501 respondents from the five countries completed the survey. Standardized questionnaires were used to make comparisons across the regions; however, the data collection procedures were tailored for each country. The sample was probability based to ensure valid statistical inference to the population. RESULTS Ten percent of the Middle East population surveyed had a physician diagnosis of AR, with 65% of respondents stating that their allergies were intermittent in nature. An otolaryngologist or allergist diagnosed the majority of the individuals surveyed. Runny nose, nasal and throat itching, postnasal drip, and nasal congestion or stuffed up nose were the most common and bothersome symptoms of AR. The majority of survey participants (58% of the overall survey population) with AR reported that the condition had an impact on their daily private and professional life. Seventy-two percent of adults reported that their AR symptoms limited their work/school activities and 35% reported that their AR interfered with and caused them to miss work or school within the past 12 months. One factor, in addition to the outward AR symptoms, that could have contributed to these function impairments may have been sleep disturbances. Although a secondary symptom to AR, sleep disturbances (difficulty getting to sleep, waking up during the night or lack of a good nights sleep) were shown in this survey to be extremely troubling in ∼15% of AR sufferers. In the past year >90% of patients reported taking a medication of any type for their AR, with nearly a 4:1 ratio of patients taking a prescription medication versus an over-the-counter (OTC) medication in the past 4 weeks. Over 75% of survey respondents reported taking an intranasal corticosteroid (INCS) in the last 4 weeks and the satisfaction rate of INCS medications was similar to that reported for OTC medications. The most common reasons cited for dissatisfaction with INCS medications were inadequate effectiveness, bothersome side effects (e.g., unpleasant taste and retrograde drainage into the pharynx), decreased effectiveness with chronic use, and failure to provide 24-hour relief. CONCLUSION These data show that AR is common in the Middle East region as elsewhere in the world. Many patients with AR in Middle East region suffer from their symptoms (e.g., runny nose, nasal itching, nasal congestion, postnasal drip, and other symptoms) on all or most days during the times of the year that their allergies are worst. These symptoms have been shown to reduce QOL and performance at work/school to a significant degree. Additionally, the survey data underscore a considerable treatment gap with current therapies for AR and that many AR patients still have not found adequate effectiveness with currently available medications. Thus, through identification of disease impact on the Middle East population and highlighting treatment gaps, clinicians in the Middle East may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.

COMPARATIVE ANALYSIS BETWEEN PSEUDOMONAS AERUGINOSA GENOTYPES AND SEVERITY OF SYMPTOMS IN PATIENTS WITH UNILATERAL OR BILATERAL OTITIS EXTERNA

Random amplified polymorphic DNA (RAPD) analysis was done on 32 isolates of Pseudomonas aeruginosa. These isolates were obtained from 22 patients who presented to the emergency room in a major medical center in Beirut, Lebanon, during a 5-month period with the diagnosis of either unilateral or bilateral otitis externa. Patients had yellowish to greenish discharge, moderate to severe external auditory canal swelling, moderate to severe pain, and periauricular cellulitis. None of these patients had intrinsic predisposing factors. An ear swab was obtained from both ears of patients, cultured on trypticase soy agar. P. aeruginosa was identified on the basis of pyocyanine production and API identification kits. RAPD analysis was done by using two primers (10 mer and 21 mer primers) and appropriate PCR conditions on extracted DNA. Our data have shown 23 RAPD patterns (A–W) distributed among the 32 P. aeruginosa isolates. RAPD patterns were reproducible. Twenty of 32 isolates were recovered from 10 patients with bilateral otitis externa. The remaining 12 of 32 isolates were recovered from 12 different patients with unilateral otitis externa. Eleven RAPD patterns (A,B,C,D,E,F,H,I,R,U,V) were associated with severe clinical symptoms, including severe pain, severe external auditory canal swelling, periauricular cellulitis, and a yellowish discharge. The remaining RAPD patterns were not associated with severe infections. This denotes a possible association between certain genotypes and severity of symptoms.

The inhibitory effect of micafungin on biofilm formation by Pseudomonas aeruginosa

This study assesses the potential effect of micafungin, an antifungal agent known to inhibit 1,3-β-D-glucan synthesis in Candida albicans, on biofilm formation of selected Pseudomonas aeruginosa isolates by decreasing the synthesis of extracellular matrix β-D-glucan forming units. The effect of an optimal therapeutic dose of 10 mg ml−1 micafungin on the production of biofilm was monitored in vitro using a microtiter plate assay. Phenotypic reduction in the formation of biofilm was significant (based on average optical density; p < 0.05) in most of the isolates. Moreover, the relative gene expression of biofilm encoding genes for alginate and pellicles (algC and pelC, respectively), and the cell wall 1,3-β-D-glucan encoding gene (ndvB) was evaluated using quantitative reverse transcription PCR. For all the genes tested, the levels of mRNA transcription were also decreased significantly (p < 0.05) in micafungin-treated samples cf. their untreated counterparts. In conclusion, this study presents micafungin as a potential agent for disrupting the structure of a biofilm of P. aeruginosa allowing the possible exposure and treatment of core-planktonic cells.

Circulating immune complexes and complement C3 and C4 levels in a selected group of patients with rhinitis in Lebanon

BackgroundA number of reports indicate that circulating immune complexes (CIC) and activation of the complement system contribute to the pathogenesis of Type I allergy. The aim of this study was to investigate the status of CIC in 113 patients with rhinitis in Lebanon and determine complement components C3 and C4 serum levels in the CIC-positive patients. Serum specific IgE antibodies were previously detected and reported in 74 of the 113 patients.MethodsCIC were detected by polyethylene glycol precipitation and serum C3 and C4 levels quantified by radial immunodiffusion.ResultsCIC was positive in 20 of the specific IgE-positive and 13 of the specific IgE-negative patients. C3 and C4 levels were within the normal range in all the 33 CIC-positive patients.ConclusionsThe antibody class that constitutes the complexes does not seem to be IgG or IgM. Moreover, complement activation does not seem to be involved in the allergic reaction since both C3 and C4 levels were normal in all patients. The role of these complexes, if any, in the pathogenesis of rhinitis is yet to be determined.

Arteriovenous Malformation of the Parotid Gland: Case Report and Review of the Literature

In adults, an arteriovenous malformation is a rare presentation of a parotid mass with only a few cases reported in the literature. The clinical picture and behavior may be quite misleading. Careful examination with a high index of suspicion may reveal certain characteristic symptoms, signs and radiologic findings. A rare case of arteriovenous malformation of the parotid gland is presented with a brief review of the diagnostic workup and treatment of such lesions.

PCR-Based Detection, Restriction Endonuclease Analysis, and Transcription of tonB in Haemophilus influenzae and Haemophilus parainfluenzae Isolates Obtained from Children Undergoing Tonsillectomy and Adenoidectomy

ABSTRACT We developed and evaluated a PCR-based-restriction endonuclease analysis method to detect and analyze the tonBgene of Haemophilus influenzae and Haemophilus parainfluenzae from pediatric patients undergoing tonsillectomy and adenoidectomy. Multiple sites from the same patient, including the surface of adenoids and tonsils, as well as the core of tonsils, were cultured on chocolate agar and identified using standard procedures and the API NH Kit. A total of 55 H. influenzae isolates were recovered from different sites of 20 patients, and 32 H. parainfluenzae isolates were recovered from various sites of 12 patients. DNA was extracted from American Type Culture Collection strains and test isolates by the PureGene kit. Two primers, G1 (21-mer) and G2 (23-mer), were designed by us to amplify by PCR the tonB gene that consists of an 813-bp fragment. A nested PCR using primers T1 (23-mer) and T2 (24-mer) that flank an internal sequence to the gene of the order of 257 bp and restriction endonuclease digestion using XhoI and BglII were done to detect whether heterogeneity within the gene exists between the two species. Reverse transcription-PCR (RT-PCR) was finally done to detect transcription of the gene in both species. Our data have shown that the tonB gene was detected in both species. It is known to encode a virulent protein, TonB, in H. influenzae; however, demonstration of its presence in H. parainfluenzae is novel. Nested-PCR and restriction endonuclease analysis have shown that the tonB gene is apparently structurally the same in both species, with possible differences that may exist in certainH. parainfluenzae isolates. RT-PCR done on selected numbers of H. influenzae and H. parainfluenzae have shown that the tonB gene was transcribed in both species. This shows that the TonB protein, if expressed, may play a different role in the virulence in H. parainfluenzae since it is not needed for heme or heme complexes uptake as with H. influenzae.