Acquired reactive perforating collagenosis: a clinicopathologic study of 15 cases from Saudi Arabia.

BACKGROUND: Perforating dermatoses include a family of disease characterized by transepidermal elimination of collagen. Despite being described many years ago in association with systemic disease, it is still clinically misdiagnosed. OBJECTIVE: A retrospective clinical and pathologic review that will increase clinical and pathologic diagnostic awareness of this entity and explore associated systemic disease. PATIENTS AND METHODS: In this report, we present from Saudi Arabia for the first time details of a series of patients seen at the King Abdulaziz Medical City, WR, Jeddah, Saudi Arabia, during the period 2002-2009. RESULTS: The study revealed 15 histologically confirmed cases of acquired reactive perforating collagenosis (ARPC). Patients were predominantly adult females with a mean age of 54 years. The lesions were pruritic, predominantly multiple, erythematous excoriated papules and umblicated nodules centrally crusted with an average duration of 6 months, involving the extremities with or without the trunk in 12 patients. Associated systemic disease included diabetes mellitus in 12 patients and chronic renal failure on dialysis in 8 patients. The provisional clinical differential diagnosis included perforating collagenosis in only eight patients. CONCLUSION: ARPC is not uncommon in Saudi Arabia. The noduloulcerative lesions involve predominantly the extremities, and diabetes mellitus is the most common associate. It is hoped that this article will increase awareness for recognition of this entity to start appropriate therapy.

Rhinoscleroma: a clinicopathological study from the Gulf region.

INTRODUCTION: Rhinoscleroma is a chronic progressive inflammatory disease of the upper respiratory tract. We report a clinicopathological series from the Gulf region. METHODS: The clinical and pathological features of patients diagnosed with rhinoscleroma at three main hospitals in Saudi Arabia and Bahrain over a 20-year period are presented. Archived glass slides and paraffin blocks from these patients were retrieved from the pathology files for review. Special stains were performed whenever indicated. Biopsy material and clinical data from 25 patients formed the basis of this study. RESULTS: Most of the patients were young females with a median age of 24 years. The nose was involved in all cases with frequent extension to other parts of the upper respiratory tract. The provisional clinical diagnoses included syphilis, midline granuloma and malignancy. The histological differential diagnoses included leprosy, malakoplakia and metastatic renal cell carcinoma. CONCLUSION: Rhinoscleroma is rare in Saudi Arabia and Bahrain. Awareness of possible clinical presentations and early diagnosis will significantly reduce the morbidity caused by this disease.

The pattern of lower gastrointestinal disease in the eastern region of Saudi Arabia: a retrospective analysis of 1590 consecutive patients.

To determine the pattern of lower gastrointestinal disease in the Eastern region of Saudi Arabia we analysed 1907 colorectal biopsies obtained from 1590 consecutive patients (1256 males & 334 females), evaluated during a 13 year period (1983-1996) in a tertiary care teaching hospital. The age range was 6-81 years with a mean of 37 + 15. During the same period 6874 new patients were seen in the Gastroenterology Clinics. Saudi Arabs constituted 970 (61 %) of all patients. The remaining 620 (39%) were non-Saudi, mostly of Arab origin from neighbouring countries. The most common presenting symptom for referral was abdominal pain (1193 patients, 75%) followed by diarrhea (636 patients, 40%). The most frequent histologic diagnosis was a normal mucosa followed by non specific proctocolitis accounting respectively for 37.9% and 37.4% of all cases. These were followed by schistosomiasis, 113 (7.1%), adenocarcinoma, 91 (5.7%) and ulcerative colitis, 91 cases with a relative frequency of 5.7% and a calculated prevalence of 1.3%. Of significance was the encounter of 14 cases of Crohn's disease amounting to 0.9% of all cases with a calculated prevalence of 0.2%. A minority of 83 patients (5.2%) were cases of either a benign polyp, diverticular disease, tuberculosis, ischaemia, lymphoma, pseudomembranous colitis (PMC), eosinophilic gastroenteritis or malacoplakia. These data show that although a "normal mucosa" and "nonspecific proctocolitis" were the dominant diagnoses, significantly, ulcerative colitis and Crohn's disease exist and should be considered in the differential diagnosis of lower GI disease.

Spontaneous tonsillar hemorrhage: an underdiagnosed condition.

OBJECTIVE: The purpose of this study was to review the clinical profile of patients diagnosed with spontaneous tonsillar hemorrhage (STH). METHOD: We conducted a retrospective review of all cases presenting with tonsillar hemorrhage at KFHU between February 1992 and January 1997. RESULTS: Spontaneous tonsillar hemorrhage was diagnosed in four patients, two children and two adults, all females. Spontaneous tonsillar hemorrhage was associated with an acute febrile illness in the children. A bleeding ulcer was suspicious of malignancy in one adult, and no underlying cause was found in the other. All had tonsillectomy and histologically proven sepsis. CONCLUSIONS: Spontaneous tonsillar hemorrhage is an uncommon emergency complication of tonsillar sepsis. Awareness of the condition by practising otolaryngologists will reduce unwarranted prolonged invasive investigations. Tonsillectomy is the definitive mode of treatment.

Primary localized cutaneous amyloidosis: a clinicopathologic study from Saudi Arabia.

BACKGROUND: Primary localized cutaneous amyloidosis (PLCA) refers to deposition of amyloid in apparently previously normal skin with no evidence of deposits in internal organs. Certain ethnic groups are particularly predisposed. The objective of this study was to investigate the occurrence of PLCA in a hospital-based set-up and to review the clinico-pathologic findings of histologically confirmed cases. METHODS: Methods included a retrospective evaluation of the records and paraffin sections of skin biopsies of all patients, diagnosed clinically as cutaneous amyloidosis in a tertiary care teaching hospital during the period 1987-95. RESULTS: Twenty-one out of 42 suspected cases were histologically confirmed as PLCA; the total number of biopsied patients during the whole period was 920. Eleven were cases of lichen amyloidosis (LA) and 10 were of macular amyloidosis (MA). All were adults, and women dominated in MA. The mean duration of symptoms was shorter for the latter subtype. Histologically epidermal changes were the main differentiating feature between LA and MA. CONCLUSIONS: PLCA is a rare chronic progressive skin disorder affecting adults, with a prevalence of 0.15 among patients attending the dermatology clinic in a tertiary care teaching hospital in Saudi Arabia. There were few differences in demographic profile or histochemical characteristics between LA and MA. Meticulous histologic examination of sections and even sequential biopsies may be needed to confirm the diagnosis in clinically suspected cases.

Chronic idiopathic ulcerative colitis in Saudi Arabia: A clinicopathological study of 76 cases.

In this report we present our experience with 76 cases of chronic idiopathic ulcerative colitis (IUC) out of 1279 consecutive colorectal biopsies (6.0%), seen during an 11-year period (1983-1994), in a tertiary care teaching hospital. During the same period, 12 (0.8%) patients with Crohn's disease were seen. Of the 76 patients with IUC, forty-nine were male and 27 were female, with an age range of six to 88 years, a mean of 38 +/- 16 and a median of 36 years. Forty-nine patients were Saudi Nationals (27M, 22F), 21 were non-Saudi Arabs and six were Asians. In most patients, the onset of IUC was at 20 to 49 years (70%). The disease duratio at diagnosis ranged from one month to five years, with a median of 12 months. The follow-up period ranged form 13 months to 11 years, with a median of three years. Diarrhea, hematochesia and abdominal pain were the dominant symptoms. The disease grade was generally of mild to moderate severity (55 patients, 72%) and was of low stage (distal involvement in 69 patients, 91%). The rarity of skin manifestations and of development of colonic cancer is to be noted in spite of the relatively short period of follow-up. Our findings compare with experience from the region, confirming the mild course of the disease as contrasted to Western experience. These findings will be discussed.

Chronic hepatitis--an update on terminology.

This is a review on the updated terminology of chronic hepatitis, a topic that has gained much popularity in the current literature of gastroenterology. The aim of this review is to familiarize readers with its use and to discourage the old terminology. The new terminology of chronic hepatitis takes into consideration etiology, severity (grade) and degree of chronicity measured by fibrosis (stage). The use of the new terminology would standardize our diagnosis with the aim of standardizing therapeutic modalities for the purpose of reproducibility of results.

Crohn's disease in Saudi Arabia: a clinicopathological study of 12 cases.

In this report we present our experience with 12 cases of Crohn's disease out of 1279 consecutive colorectal biopsies (0.9%), seen during an l 1 years period (1983-1994) in a tertiary care teaching hospital. During the period 76 cases (6%) of Ulcerative Colitis (UC) were seen. Of the 12 patients with Crohn's disease, seven were males and five were females, all Saudi nationals aged 16-39 with a median of 23 years, relatively younger than those with UC seen during the same period. Recurrent colicky abdominal pain was the striking presenting symptoms in all patients, commonly associated with weight loss. The disease involved both small and large bowel in eight patients (67%) and the colon alone in one patient. Granulomas were seen in seven patients (58%). Surgery was offered for two patients and most of the remaining patients were symptomatic on follow up.

Pattern of pleural effusion in Eastern Province of Saudi Arabia: a prospective study.

In order to establish the clinical pattern and aetiology of pleural effusion in adults in the eastern province of Saudi Arabia, all patients aged 18 years and above presenting with clinical and radiological evidence of pleural effusion, between 1st December 1987 and 30th November 1991, at three participating hospitals, were prospectively studied. Of the 201 (145 male, and 56 female) patients recruited, 102 (51%) were Saudis; their mean age was 43.4 +/- 17.8 years. Pleural effusion was more common on the right side (56%) than the left (32%). In rank order, the most common diagnoses were tuberculosis (37%), neoplasm (18%), parapneumonia (14%), and congestive cardiac failure (14%). There were a variety of other causes. The aetiology was indeterminate in only 3 (1.5%) patients. Patients with tuberculosis (75 patients) were relatively young (mean age 33.4 years) and 50 (67%) of them were expatriates, mainly from the Indian subcontinent and Yemen. Of the diagnostic procedures, the most useful were histological examination and culture of pleural biopsy. The contribution of culture and cytology of pleural fluid to diagnosis was rather small. It is concluded that the clinical pattern and aetiology of pleural effusion observed in this study are similar to those of the developing countries, although they seem to have been influenced by the large migrant labour force in the country.

Tuberculous pleural effusion in the eastern province of Saudi Arabia.

The incidence and clinical pattern of tuberculous pleural effusion (TPE) and the contribution of individual laboratory procedures in the diagnosis of TPE were assessed in a five year prospective study. Two hundred and fifty-three patients presenting in three participating hospitals with pleural effusion (PE) were assessed clinically and had various laboratory investigations. Eighty-nine (35.2%) of them, including 73 (82%) men and 31 (34.8%) Saudis had TPE. Their mean age +/- SD was 33.4 +/- 11.2 years. Main symptoms in rank order were cough (80%), fever (75%), shortness of breath (64%), chest pain (61%), anorexia and weight loss (47%). PPD was positive in 82 (92%) patients. Positive culture or histological evidence of tuberculosis (TB) was observed in pleural biopsy (68.5%), pleural fluid (10%) and sputum (2%). Pleural fluid microscopy was positive in only one patient, chest radiological features of TB in 3 (3.4%). Six months anti-TB therapy resulted in complete recovery in 86 patients. It is concluded that in this community TPE constitutes over a third of all the causes of PE. The relatively young age of patients reflects the age structure of the indigenous population as well as immigrant workers. PPD, histology and culture of pleural biopsy were the most useful diagnostic tools while pleural fluid and sputum microscopy were unhelpful. The 6-months anti-TB therapy was excellent.

Pattern of chronic liver disease in the eastern province of Saudi Arabia. A hospital-based clinicopathological study.

During the period 1982-1990, 544 patients with clinical evidence of liver disease were admitted to King Fahd University Hospital, Al-Khobar, Saudi Arabia. Besides routine laboratory and sonographic investigations, all were subjected to either a needle liver biopsy, laparoscopy or a laparotomy. The tissue diagnoses were as follows: liver cirrhosis 17.3%, periportal fibrosis 14.3%, metastatic cancer 12.9%, primary hepatoma (hepatocellular carcinoma: HCC) 12.1%, hepatic granuloma 11.2%, chronic active hepatitis 7.7%, chronic persistent hepatitis 2.2%, fatty liver 7.2%, hydatid liver disease 4.6% and others 2.8%. In 7.7% the histology was normal. These results will be discussed and compared with results reported in local and international literature.

Pediatric liver disease in the eastern province of Saudi Arabia: A clinicopathological study.

This prospective study analyzes the clinical features and histopathological findings in liver biopsies of pediatric patients presenting to the hospital with liver disease during a 10 year period. Only those patients in whom liver biopsy was performed for a tissue diagnosis were included. Fifty patients were investigated, all below the age of 12 years, of whom 36 were male and 14 female. Thirty-two were of neonatal-infantile group, 11 had a diagnosis of neonatal giant cell he hepatitis of infections origin and an intact biliary tree. Two had septic shock and one had leishmaniasis. The remaining 18 patients of the neonatal-infantile group constituted five case of glycogen storage disease, six of infantile obstructive cholangiopathy (biliary atreasia), four of fatty change and one each of congenital hepatic fibrosis, neuroblastoma and nonspecific reactive hepatitis. The eighteen older children had the following diagnoses: thalassemia in five, sickle cell disease in four, two each of Reye syndrome and hepatoblastoma. The remaining were one each of glycogen storage disease, Rotor syndrome, cirrhosis, fatty change and non-Hodgkin lymphoma (NHL). These findings are presented and discussed.

Non-steroidal anti-inflammatory drug-induced gastropathy: a comparative endoscopic and histopathological evaluation of the effects of tenoxicam and diclofenac.

A 4-week double-blind study compared the potential for 20 mg/day tenoxicam or 100 mg/day diclofenac sodium to induce gastropathy in 36 patients with joint disease and assessed the influence of gastric colonization by Helicobacter pylori. Endoscopic assessment at the end of 4 weeks indicated that the mucosa was normal in 79% of tenoxicam-treated patients and 59% of diclofenac-treated patients. Only 5% of patients in the tenoxicam group developed severe gastroduodenitis (> 11 haemorrhages or erosions) compared with 18% in the diclofenac group. Histological evaluation indicated that 58% and 47%, respectively, of tenoxicam-treated and diclofenac-treated patients retained normal mucosa after treatment. Diclofenac treatment was discontinued in two patients, due to a duodenal ulcer or severe erosive gastritis. Overall, 5/14 patients with moderate to severe colonization with Helicobacter pylori developed severe chronic active gastritis or ulceration, compared with the 1/22 patients in whom colonization was either absent or mild (P = 0.02). Tenoxicam and diclofenac did not show major differences in terms of gastrointestinal safety, although the trends favoured tenoxicam. The presence of severe colonization of the gastric mucosa with Helicobacter pylori appears to be an important factor for development of severe gastritis or ulceration.

Abdominal tuberculosis in Saudi Arabia: a clinicopathological study of 65 cases.

The clinical and pathological features of 65 patients with abdominal tuberculosis obtained during a 7-yr period were analyzed and the diagnostic procedures critically evaluated. The diagnosis was histologically confirmed in 59 patients. In two more patients, the diagnosis was based solely on a positive ascitic fluid culture for tubercle bacilli. The remaining four patients responded dramatically to anti-tuberculous chemotherapy given on suspected laparoscopic findings in cases in which no biopsy was taken. Laparoscopy was found to be safer and superior to laparatomy and is recommended as an initial investigation in the diagnostic work-up of patients in whom tuberculous peritonitis is suspected. Furthermore, the finding of granulomatous inflammation in peritoneal biopsy is a justification for immediate therapy in such patients. This is particularly valid in endemic areas if one considers the risks of delaying treatment of these patients.

Tendon sheath tumours: a pathological study of the relationship between giant cell tumour and fibroma of tendon sheath.

Thirty-nine soft tissue lesions occurring on the distal aspect of the limbs have been selected because of histological features consistent with those recognized for giant cell tumour of tendon sheath or fibroma of tendon sheath. In spite of the frequent occurrence of such lesions at the stated sites, they were rarely correctly diagnosed pre-operatively. Using a scoring system to grade specified histological features, a blind evaluation to re-classify these 39 lesions was undertaken. This resulted in 29 cases of giant cell tumour of tendon sheath, six fibromas of tendon sheath and four 'transitional stage' lesions. Despite the heterogeneous morphology of these categories, there were no significant differences in the clinical features of affected patients. The existence of a 'transitional stage' lesion, combined with the homogeneous clinical picture of all categories, supports the concept that fibroma of tendon sheath is the end and sclerosing stage of giant cell tumour of tendon sheath, probably consequent on progressive vascular impairment. There is a need for pathologists to recognize the transitional stage lesions so as to avoid their inclusion with other diagnostic entities. For this group the name 'giant cell tumour of tendon sheath--transitional stage lesion' is suggested.