'The great imitator': Neurosyphilis and new-onset refractory status epilepticus (NORSE) syndrome.

New-onset refractory status epilepticus (NORSE) is a syndrome of new-onset drug resistant status epilepticus that often has a catastrophic outcome. A 30-year-old man of Somali origin presented with refractory status to a district general hospital. A clinical diagnosis of NORSE syndrome was made, and he was transferred to the regional epilepsy center for immunomodulatory treatment and consideration for cyclophosphamide treatment. After transfer to the regional epilepsy center, his repeat cerebrospinal fluid tested strongly positive for syphilis, indicating a diagnosis of neurosyphilis, and the patient was treated with high-dose intravenous (IV) benzylpenicillin. His status epilepticus abated 24 h later. New-onset refractory status epilepticus syndrome is a diagnosis of exclusion. Before instigation of potentially harmful neuromodulatory therapies, treatable causes such as neurosyphilis should be considered. We advocate the early transfer of refractory status patients to a specialist epilepsy center for both seizure management and cause determination.

Change in meticillin-resistant Staphylococcus aureus clones at a tertiary care hospital in the United Arab Emirates over a 5-year period.

AIMS: Meticillin-resistant Staphylococcus aureus (MRSA) strains isolated in Tawam Hospital, a tertiary care hospital in the United Arab Emirates, were examined in order to understand the reasons for a doubling of its incidence between 2003 and 2008 while maintaining the same infection control measures. METHODS: All consecutive non-duplicate clinically relevant MRSA isolates recovered between January and December 2003 and between May and October 2008 were studied. The antibiotic susceptibility, pulsed field gel electrophoresis, toxin gene, staphylococcal cassette chromosome mec (SCCmec), spa, agr and multilocus sequence types of the strains were tested. RESULTS: In 2003, typical healthcare-associated (HA-MRSA) genotypes (ST239-MRSA-III, ST22-MRSA-IV and ST5-MRSA-II) represented the majority (61.5%) of the isolates. By 2008 this pattern had changed and clonal types considered as community-associated (CA) MRSA comprised 73.1% of the strains with ST80-MRSA-IV, ST5-MRSA-IV and ST1-MRSA with non-typable SCCmec types being the most frequent. However, further epidemiological investigations showed that only one-third of the CA-MRSA infections were actually acquired in the community, indicating that CA-MRSA clones have entered and spread within the hospital. CONCLUSIONS: The emergence of CA-MRSA clones with subsequent entry to and spread within the hospital has contributed to the increasing incidence of MRSA observed in Tawam Hospital and probably also in other hospitals in the UAE.

The molecular epidemiology of Stenotrophomonas maltophilia bacteraemia in a tertiary referral hospital in the United Arab Emirates 2000-2004.

BACKGROUND: Stenotrophomonas maltophilia is recognised as an important cause of nosocomial infection, especially in immunocompromised patients, resulting in significant morbidity and mortality. The treatment of S. maltophilia infection presents a therapeutic challenge. The precise modes of transmission of S. maltophilia in the hospital environment are not known and such knowledge is essential to target interventions to prevent spread. There are few published data on the patterns of nosocomial infection in the United Arab Emirates (UAE). A recent study showed that S. maltophilia is an established cause of bloodstream infection in Tawam Hospital in the UAE. Little is known about its epidemiology in the hospital. METHODS: We describe the clinical characteristics of 25 episodes of S. maltophilia bacteraemia which occurred from 2000-2004. The strains were characterised using pulsed field gel electrophoresis (PFGE). RESULTS: All episodes were hospital-acquired and malignancy and central venous catheters were predisposing factors. Catheter-associated infection comprised 88% infection. Catheter removal was important for the successful management of catheter-associated infection. The results of PFGE suggested that there were as many strains as patients. S. maltophilia strains isolated from the same patient had indistinguishable PFGE profiles. CONCLUSION: PFGE is a valid and reproducible typing method for S. maltophilia. The precise sources and modes of spread of S. maltophilia in the hospital are still not known. Knowledge that person to person transmission was not a major mode of transmission enabled infection control interventions for S. maltophilia to be targeted more effectively.

Brevinin-1BYa: a naturally occurring peptide from frog skin with broad-spectrum antibacterial and antifungal properties.

Brevinin-1BYa (FLPILASLAAKFGPKLFCLVTKKC) is a cationic alpha-helical peptide containing an intramolecular disulphide bridge that is present in skin secretions of the foothill yellow-legged frog Rana boylii. A synthetic replicate of the peptide showed growth inhibitory activity against a range of reference strains of Gram-positive and Gram-negative bacteria, against clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) (minimum inhibitory concentration (MIC)=2.5 microM), and against reference strains and clinical isolates of the opportunistic yeast pathogens Candida albicans, Candida tropicalis, Candida krusei and Candida parapsilosis (MIC

Eradication of Cryptosporidium in four children with acute lymphoblastic leukemia.

Four children on chemotherapy for acute lymphoblastic leukemia presented with severe diarrhea and dehydration. Cryptosporidium was identified in the stools using modified Ziehl-Neelsen stain. Two of them received paromomycin and responded well. One was started on paromomycin for 10 days and although there was clinical improvement, his stools examination continued to be positive for Cryptosporidium. He then received azithromycin for 10 days. He responded well and his stools became negative for Cryptosporidium. The fourth patient received azithromycin from the start and responded well. Cryptosporidium should be considered in all immunocompromised children with severe or prolonged diarrhea, and since it is not seen in a routine ova and parasite examination, the laboratory should be notified for diagnostic confirmation using modified Ziehl-Neelsen stain. Immunocompromised children with Cryptosporidium diarrhea may benefit from paromomycin or azithromycin therapy.

Recombinant human interleukin 11 and bacterial infection in patients with [correction of] haematological malignant disease undergoing chemotherapy: a double-blind placebo-controlled randomised trial.

BACKGROUND: Bacteraemia in patients with haematological malignant disease causes substantial morbidity. Recombinant human interleukin 11 (rhIL-11) prevents gastrointestinal epithelial disintegrity and has immunomodulatory actions. Our aim was to ascertain whether or not treatment with rhIL-11 can prevent gut-associated infections. METHODS: We did a double-blind placebo-controlled randomised trial, to which we enrolled 40 patients with haematological malignant disease who were undergoing chemotherapy. Patients received either rhIL-11 50 microg/kg (n=20) or placebo (n=20) daily by subcutaneous injection from the day before the start of chemotherapy until resolution of neutropenia or for 21 days, whichever was longer. Our primary outcome measure was a reduction in bacteraemia. Analysis was by intention to treat. FINDINGS: Significantly fewer patients who received rhIL-11 rather than placebo developed bacteraemia, particularly of gastrointestinal origin: the proportion of patients with at least one positive blood culture was 0.65 and 0.25, respectively (p=0.02). The numbers of patients (placebo vs rhIL-11) for each number of distinct isolates were: no organism isolated seven versus 15, one organism nine versus four, two organisms two versus one, three organisms one versus none, and four organisms one versus none (p=0.01), suggesting a lower bacterial load in the rhIL-11 than in the placebo group. Time to first bacteraemic event was longer in patients who received rhIL-11 (p=0.03) than in those who received placebo. INTERPRETATION: rhIL-11 reduces the frequency and load of bacteraemia in patients with haematological malignant disease undergoing chemotherapy, possibly by gastrointestinal cytoprotective or immunological mechanisms [corrected].

Epidemiology, presentation, management and outcome of candidemia in a tertiary care teaching hospital in the United Arab Emirates, 1995-2001.

Sixty episodes of candidemia among hospitalized patients in the United Arab Emirates (0.77/1000 discharges) in 1995-2001 were identified through case retrieval. All patients had malignancy (65%) or serious non-malignant disease (35%). Candida albicans accounted for 45% of isolates. Non-C. albicans Candida species occurred more frequently than C. albicans in adults (67%), hematologic-malignancy patients (58%), and cases of breakthrough candidemia (83%) and were prevalent overall in 2000-2001 (67-73%). C. tropicalis was identified in 15% of cases, C. glabrata in 5%, C. parapsilosis in 5%, C. inconspicua in 2%, C. famata in 2% and C. lusitaniae in 1%. Delayed diagnosis or treatment was common, as was Karnofsky scale < or = 40%, septic shock, and inadequate dosage or duration of antifungal drug therapy. Crude mortality was 50%, and mortality attributable to candidemia was 30%. Univariate analysis indicated patients were more likely to die (odds ratio for death [95% CI]) if they had been stationed in the intensive care unit (ICU) (4.76 [1.31-17.2]), had a Karnofsky scale < or = 40% (38.76 [4.66-322.47]), or suffered septic shock (9.88 [2.9-33.65]). They were more likely to survive in cases with concomitant bacteremia (0.25 [0.07-0.91]), adequate antifungal dose (0.28 [0.08-0.94]), and removal of central lines (0.26 [0.07-0.95]). The high association of bacteremia with candidemia (70% of cases) is unusual. The apparent survival benefit experienced by patients who had bacteremia (odds ratio for survival on multivariate analysis = 2.40 [0.28-20.17], P < 0.03) is novel.