Isolated tuberculous orchitis presented as epididymo-orchitis: An unusual presentation of tuberculosis.

Urogenital tuberculosis (UGTB) is almost 8%-15% of the extrapulmonary site of TB of all kinds, and epididymal involvement is rarer, counted only 28% of UGTB. Isolated tuberculous epididymitis (ITE), without the inclusion of prostate or clinical evidence of renal involvement, is an even more rare entity and is challenging to diagnose. However, isolated epididymis TB presented as a huge scrotal abscess with scrotal sack involvement is exceptionally uncommon. The symptoms of such ITE resemble the epididymo-orchitis or malignant tumor, which results in misdiagnosis or delay in diagnosis. A 32-year-young man, sexually inactive, was presented with a rapid, painless scrotal growing. There was no clinical evidence for TB. Clinical examination of the genitalia revealed an enlarged right tactical with intratesticular masses (abuses) and swollen spermatic cord along with inflamed epididymitis. The radiological and laboratory shows no evidence of TB with clear chest X-rays, normal blood, and urine analysis. There were no symptoms of Mycobacterium tuberculosis during the microdot enzyme immunoassay analysis. A repeated magnetic resonance imaging and ultrasonic investigations were performed that revealed findings suggesting a chronic inflammatory process with severe abscess involving the spasmatic cord and scrotal sack, which mislead the diagnosis of epididymo-orchitis. Later, the extensive formation of superficial abscess breaches the scrotal sack. A pathological investigation of excretion and intrascrotal tissues established the diagnosis of ITE. The patient was kept on anti TB treatment medications for 12 months due to delay in diagnosis (12 weeks), continuous discharge, and severe involvement of epididymitis along with a scrotal sack and spermatic cord and had a remarkable recovery. The delayed diagnosis of ITE could lead the severe complication, which could result in surgical intervention or an orchiectomy. The first line of treatment should be the pharmacological approach for cases of epididymis TB, and surgery should be the 2nd option. A surgical procedure should be considered only in cases where the diagnosis is not established or when there is a strong clinical indication such as abscesses, cutaneous fistulas, or extensive involvement of the epididymis and testis.

Invasive aspergillus sinusitis with orbitocranial extension.

CONTEXT: Invasive sinonasal aspergillosis is a silently progressive disease that, left untreated, may invade the adjacent intracranial and intra-orbital compartments incurring serious morbidity. AIM: To evaluate our results of a collaborative surgical management plans for patients with invasive sinonasal aspergillosis with orbitocranial extension. SETTING AND DESIGN: Retrospective study. MATERIALS AND METHODS: Between the years 2000 and 2012, 12 patients with Aspergillus sinusitis with orbitocranial extension were treated at our institution. Preoperative CT and MRI scans were done in all cases and cerebral angiography in two patients with subarachnoid hemorrhage (SAH). Surgical combined transcranial and endonasal approaches to the skull base were considered in all patients. Adjuvant antifungals were administered postoperatively with regular clinical and radiologic follow up. RESULTS: All cases had a long history of headache and nasal obstruction (n = 12). Five presented with unilateral proptosis, one with meningitis, one with epilepsy, two with SAH, and one patient presented with trigeminal neuralgia. Craniotomy alone was chosen for the patients with isolated sphenoiditis (n = 2) while a combined cranial and endonasal approach was elected for the other patients (n = 10). Adjuvant antifungal therapy was used for 3-12 months. Patients were followed up clinically and radiologically for an average 36-month period (range = 12-50 months) with disease eradication achieved in eight patients (67%). Two died as consequence to SAH. Follow up also showed that three patients (25%) had sinunasal recurrence requiring evacuation through an endonasal approach. CONCLUSIONS: Surgical intervention, with adjuvant antifungal therapy, aiming for safe total removal of the fungal burden, whenever feasible, has a major role in the management of invasive sinonasal aspergillosis with orbitocranial extension with minimal morbidity and good outcomes.

Growth Characteristics of Alkhumra Hemorrhagic Fever Virus in Mammalian Cell Lines.

BACKGROUND: Alkhumra hemorrhagic fever virus (AHFV) is a flavivirus that was discovered in 1995 in Saudi Arabia. Clinical manifestations of AHFV infection include hemorrhagic fever, hepatitis, and encephalitis with a reported mortality rate as high as 25%. There are no published data on the growth characteristics of AHFV in mammalian cell lines. The objective of this study was to examine the ability of AHFV to grow and propagate in four of the commonly used mammalian cell culture lines and to determine the virus growth curve characteristics in each. MATERIALS AND METHODS: Human epidermoid carcinoma (HEp-2), LLC-MK2, Madin-Darby canine kidney (MDCK), and Vero cell lines were inoculated with AHFV. The virus production by each cell line was determined by growth curve studies. Mean titers were calculated and expressed as median tissue culture infective dose per mL (TCID50/mL). RESULTS: AHFV grew and propagated to variable titers in the employed cell lines. The highest mean titers were observed in the LLC-MK2, followed by the MDCK, Vero, and HEP-2, in descending order. CONCLUSIONS: The growth curve studies showed that AHFV can propagate in the four types of cell lines to variable titers. LLC-MK2 cells are superior to MDCK, Vero, and HEP-2 for propagation of AHFV.

Epidemiology and clinical consequences of occupational exposure to blood and other body fluids in a university hospital in Saudi Arabia.

OBJECTIVES: To describe the epidemiological characteristics, clinical impact, and adequacy of post-exposure management of occupational exposure to blood and body fluids (BBFs).  METHODS: Retrospective chart review of individuals reporting exposure to BBFs from 2007 to 2013 at King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia.  RESULTS: The total number of exposures reported was 326 exposures, of which 302 (92.6%) exposures were percutaneous, 21 (6.5%), mucocutaneous, and 3 (0.9%), bites. Nursing staff/students had the highest rate of exposure (149, or 45.6%), followed by physicians (57, or 17.5%). Surgeons were found to have a significantly higher risk for sharp injuries compared with other physicians (26.3%, or 15 exposures, p less than 0.005). Most (216, or 72.5%) percutaneous injuries were caused by hollow-bore needles. Majority of exposures (124, or 42.6%) occurred after using the needle/sharp item and before disposal. Two-thirds (219, or 67%) of exposed individuals were immune to hepatitis B at the time of exposure. With appropriate post-exposure management, none of exposed individuals seroconverted to HIV, hepatitis B or C virus infections.  CONCLUSION: Occupational exposure to BBFs remains a concern among healthcare workers. Educational programs targeting high-risk groups entailing reinforcement of prevention and adherence to post-exposure management guidelines are needed.

Risk Factors for Primary Middle East Respiratory Syndrome Coronavirus Illness in Humans, Saudi Arabia, 2014.

Risk factors for primary Middle East respiratory syndrome coronavirus (MERS-CoV) illness in humans are incompletely understood. We identified all primary MERS-CoV cases reported in Saudi Arabia during March-November 2014 by excluding those with history of exposure to other cases of MERS-CoV or acute respiratory illness of unknown cause or exposure to healthcare settings within 14 days before illness onset. Using a case-control design, we assessed differences in underlying medical conditions and environmental exposures among primary case-patients and 2-4 controls matched by age, sex, and neighborhood. Using multivariable analysis, we found that direct exposure to dromedary camels during the 2 weeks before illness onset, as well as diabetes mellitus, heart disease, and smoking, were each independently associated with MERS-CoV illness. Further investigation is needed to better understand animal-to-human transmission of MERS-CoV.

Complete genome sequencing and genetic characterization of Alkhumra hemorrhagic fever virus isolated from Najran, Saudi Arabia.

BACKGROUND: Alkhumra hemorrhagic fever virus (AHFV) is a newly described flavivirus first isolated in 1994-1995 from the Alkhumra district south of Jeddah, Saudi Arabia. Subsequently, the virus was also isolated from Makkah (2001-2003) and Najran (2008-2009), Saudi Arabia. METHODS: The full-length genome of an AHFV strain isolated from patients in Najran (referred to as AHFV/997/NJ/09/SA) was PCR amplified and sequenced, and compared with the sequences of 18 other AHFV strains previously isolated from Jeddah and Makkah, dengue virus (DENV), Kyasanur forest disease virus (KFDV), Langat virus, Omsk hemorrhagic fever virus (OHFV), and tick-borne encephalitis virus (TBEV). RESULTS: The RNA of the AHFV/997/NJ/09/SA strain was found to have 10,546 nucleotides encoding for a single 3,416-amino acid polyprotein, whereas the previously reported AHFV strains were composed of 10,685-10,749 nucleotides. The AHFV/997/NJ/09/SA strain showed about 99% homology with the previously reported AHFV strains. The KFDV, Langat virus, TBEV, and OHFV isolates formed a separate cluster with a variable homology. The most important variations were observed in the core protein and NS4a gene sequences of two AHFV isolates. CONCLUSION: The variation in the number of nucleotides and phylogenetic analysis with the other AHFV isolates could have resulted from recombination of circulating virus strains.

Chronic granulomatous disease with recurrent hepatic abscesses in an adult.

Chronic granulomatous disease CGD is a condition of inability to deal with bacterial and fungal infections, due to defective respiratory burst in neutrophils leading to recurrent cutaneous and visceral infections. Usually a disease of childhood, but patients nowadays survive to adulthood, and diagnosis might be difficult if not considered. We describe a 20-year-old female with previously undiagnosed CGD, presenting with recurrent cutaneous and hepatic abscesses.

Causes of hospitalization of pilgrims in the Hajj season of the Islamic year 1423 (2003).

BACKGROUND: Approximately 2 to 3 million pilgrims perform Hajj every year. Planning for health care requires knowledge of the pattern of diseases, complications, and outcome of pilgrims who require hospitalization during the Hajj period. METHODS: In a cross-sectional study we compiled data on all patients admitted to 1487 beds in four hospitals in Mena (793 beds) and three hospitals in Arafat (694 beds) from the seventh to the thirteenth day of the Hajj season of the Islamic year 1423, corresponding to 8 to 14 February 2003. RESULTS: Of 808 patients hospitalized, most (79%) were older than 40 years. There was no sex preponderance. A total of 575 (71.2%) patients were admitted to medical wards, 105 (13.0%) to surgical wards, and 76 (9.4%) to intensive care units. Most patients (84.8%) had one acute medical problem. Pneumonia (19.7%), ischemic heart disease (12.3%), and trauma (9.4%) were the most common admitting diagnoses. More than one third (39%) had co-morbid conditions. A total of 644 (79.7%) patients were discharged from the hospital in stable condition to continue therapy in their residential camps, 140 (17.3%) were transferred to other hospitals in Makkah for specialized services or further care, 19 (2.3%) were discharged against medical advice, and 5 (0.7%) patients died. CONCLUSION: This study provided information on the most common causes of hospitalization, pattern of diseases, and required medical services for pilgrims in Hajj. It is hoped that this data will be of help to health sector planners and officials to provide optimal and cost-effective health care services to pilgrims in Hajj.

Handwashing and gloving practice among health care workers in medical and surgical wards in a tertiary care centre in Riyadh, Saudi Arabia.

We evaluated the adherence to handwashing and gloving practice among health care workers (HCWs) in 5 medical and 5 surgical wards of a 1250-bed hospital in Riyadh. Nurses, consultants, residents, interns, and medical students attending these wards were each unobtrusively observed for handwashing and gloving practice. Each HCW was observed only once for all handwashing and gloving opportunities during a single patient encounter. 312 handwashing opportunities for 230 HCWs were observed. The study population comprised 110 nurses, 76 residents, 23 medical students, 11 interns, and 10 consultants. Female subjects constituted 56.1% of the population. The ratio of handwashing sinks to beds was 1:6-7. The overall frequency of handwashing was 6.7% before patient contact and 23.7% after patient contact. Adherence to handwashing was 70.0% among medical students, 69.2% among interns, 18.8% among nurses, 12.5% among residents, and 9.1% among consultants. The duration of handwashing was suboptimal for all HCWs (average of 4.7 s). Adherence to wearing gloves for performing procedures was on average 75.5%. Poor adherence to handwashing is a worldwide problem. Strategies to improve hand hygiene practice should be multifaceted and should include increasing the availability and accessibility of handwashing sinks and alcohol-based hand rubs.

The natural history of hepatitis C virus infection.

Chronic hepatitis C virus (HCV) infection is a major health problem worldwide. The natural history of HCV infection is not fully understood. For years, there has been an overestimation of the rate of chronicity in acute HCV. Similar high rates of progression to cirrhosis in chronic HCV were reported. The source of confusion stems from the fact that most acute HCV infections are asymptomatic and never come to medical attention. The consequence of this is that most early studies of natural history reflect the more severe end of the spectrum of the disease. Recent studies reported 43-45% rate of chronicity as opposed to the old rates of 77-85%. Also, the rate of progression to cirrhosis and hepatocellular carcinoma was found to be much lower than previously reported. Multiple factors contribute to the chronicity and progression to cirrhosis, the most important being male gender, age, alcohol intake, and the degree of liver fibrosis on initial biopsy. At least 38% of patients with HCV will manifest symptoms of at least one extrahepatic complication. The most important extrahepatic manifestation is mixed cryoglobulinemia. Other extrahepatic manifestations and their response to antiviral therapy are discussed.