Multiple myeloma of the central nervous system: a clinicopathological review.

Multiple myeloma (MM) is a systemic malignancy of pathologic plasma cells that is treatable with chemotherapeutic agents and irradiation, but rarely curable. The spectrum of neurological complications of MM is diverse; however, involvement of MM in the cerebrospinal fluid and leptomeningeal infiltration is considered rare. There have been many reviews of central nervous system complications in MM but there are none on intracranial and leptomeningeal infiltration of MM. We review this here along with our clinicopathological experience and a summary of our present knowledge of this condition.

Emergence and trends of penicillin non-susceptible Streptococcus pneumoniae in Saudi Arabia and Kuwait - perspective and outstanding issues.

For many years in the past Streptococcus pneumoniae was uniformly susceptible to penicillin until the sudden and unexpected emergence of clinical infections caused by penicillin-resistant S. pneumoniae (PRSP) in 1967. Within the following decade, reports of nosocomial and community outbreaks of infections due to PRSP became widespread all over the world. Recent reports suggest that the incidence of resistance rates is rising in many countries although there are geographical variations in the prevalence and patterns of resistance between countries. The problem of antibiotic resistance is further compounded by the emergence of resistance to many beta-lactam antibiotics. The first report of PRSP in Saudi Arabia was in 1991. Barely a year after, PRSP infection was reported in Kuwait in 1992. Since then, studies from various parts of these countries have recorded prevalence rates ranging from 6.2% in Riyadh to 34% in Jeddah and 20% to 56% in neighboring Kuwait. These suggest considerable variation in the prevalence of PRSP in different cities in the Saudi Kingdom and Kuwait. The mechanism of resistance is due to chromosomally mediated alteration of penicillin-binding proteins (PBPs), which are target sites for beta-lactam antibiotics. It would appear that the spread of PRSP strains in Saudi Arabia is driven by the selective pressure created by excessive use and misuse of antimicrobial agents made possible by the easy availability of these agents, often frequently obtainable over the counter. In Kuwait, irrational and misguided use of antibiotics may be the major driving force favoring the spread of PRSP. The serotypes of strains encountered in Saudi Arabia and Kuwait are almost identical, with serotypes 19, 6, 15, 14 and 23 being the most common; together they constitute about 70% of the isolates circulating in these countries. In general, almost 90% of the serotypes included in the 23-polyvalent vaccine are present in the general population. However, a much lower percentage of these serotypes is found in the conjugated vaccines, which are more relevant to our communities. This paper reviews the emergence and the steady increase in the prevalence of penicillin-resistant pneumococcal strains in Saudi Arabia and Kuwait during the last 10 years. It discusses the trends, mechanisms of resistance and factors associated with the emergence, dissemination, and colonization of resistant organisms and suggests options available to clinicians for management of infections due to PRSP.

In vitro activity of quinolones against S. pneumoniae, H. influenzae and M. catarrhalis in Saudi Arabia.

Susceptibility of 88 clinical Streptococcus pneumoniae isolates, 116 Haemophilus influenzae isolates and 80 Moraxella catarrhalis isolates to 6 fluoroquinolones--ciprofloxacin, ofloxacin, levofloxacin, trovafloxacin, grepafloxacin and gemifloxacin--were determined. Isolates were from patients with invasive disease at 4 hospitals in Saudi Arabia between 1996 and 1998. S. pneumoniae isolates were fully susceptible to trovafloxacin, grepafloxacin and gemifloxacin; susceptibility to ofloxacin and levofloxacin was 97.7% and 98.9% respectively. H. influenzae isolates were susceptible to all agents, except for trovafloxacin (99.1%). M. catarrhalis strains were fully sensitive to all agents except ofloxacin (97.5%). No isolates were resistant to gemifloxacin or grepafloxacin.

Chloroquine-resistant Plasmodium falciparum malaria: report of two locally acquired infections in Saudi Arabia.

We report here two cases of Saudi patients who acquired chloroquine-resistant Plasmodium falciparum locally, without any history of foreign travel, blood transfusion, or drug abuse. Both were satisfactorily treated, the first with quinine and a pyrimethamine-sulfadoxine combination, and the other with quinine and tetracycline. These two cases suggest either the possible establishment of chloroquine-resistant P. falciparum in Saudi Arabia, or the beginning of the spread of resistant strains from countries with established resistance to this country. Diligent notification of cases by attending physicians to the Ministry of Health will help to achieve effective control.

Comparison of the Brucella Standard Agglutination Test with the ELISA IgG and IgM in patients with Brucella bacteremia.

The presumptive diagnosis of Brucellosis is based on a high or rising antibody titer measured by the Brucella Standard Agglutination Test (SAT). This tests does not discriminate between the immunoglobulin classes (IgG and IgM). The purpose of this study was to compare the diagnostic value of SAT with Brucella Enzyme Linked Immunosorbent Assay (ELISA) IgG and IgM tests in patients with Brucella bacteremia. Over a one-year period, we had 68 patients with clinical features suggestive of Brucellosis who had positive blood cultures for Brucella species. Sera were obtained from all of the patients as well as a control group of 70 healthy military personnel who were blood donors and had no symptoms of Brucellosis. Patients and blood donors originated from the same referral population. All the sera were tested by SAT and ELISA. All the 70 controls had a negative SAT. The sensitivity and specificity of the SAT test for the bacteremic patients were 95.6% and 100.0% respectively, while that of the ELISA IgG were 45.6% and 97.1%, and that of the ELISA IgM were 79.1% and 100.0% respectively. The sensitivity and specificity of either IgG or IgM positivity were 94.1% and 97.1% respectively. Assuming that the population prevalence of active Brucellosis in Saudi Arabia (SAT >or=1:320) is 5%, the positive and negative predictive values of SAT were 100% and 99.7% respectively; of ELISA IgG they were 45.2% and 97.1%; and of ELISA IgM they were 100% and 98.9%. When both the ELISA IgG and IgM were combined, the positive and negative predictive values were 63% and 99.6% respectively. In patients with Brucella bactremia, the sensitivity of either ELISA IgM or IgG were lower than SAT, however, combining IgM and IgG had similar sensitivity and specificity to SAT. The positive predictive value of SAT and IgM is satisfactory.

Treatment outcome of tuberculosis among Saudi nationals: role of drug resistance and compliance.

OBJECTIVE: Recent studies have demonstrated a high prevalence of multiresistant Mycobacterium tuberculosis (MDR-TB) in Saudi Arabia. In this study, we assessed the impact of this and other factors on the treatment outcome of tuberculosis among Saudi nationals. METHODS: We studied all patients (147 patients) with a culture-proven diagnosis of tuberculosis seen at the King Khalid National Guard Hospital (KKNGH), Jeddah, Saudi Arabia from June 1993 to June 1999. Treatment outcome was classified as success or failure based on the clinical assessment, improvement or deterioration of chest X-rays, and results of follow-up sputum examination. RESULTS: Of the 147 patients, only 126 completed the follow-up program. Treatment was found to be successful in 102 (81.0%) and unsuccessful in 24 (19.0%) of these 126 patients. However, treatment success is much less (102/147; 69.4%) and failure is much higher (45/147; 30.6%) if the 21 patients who were lost to follow-up are regarded as treatment failures. The prevalence of poor compliance and multiply drug-resistant Mycobacterium tuberculosis were found to be significantly higher among those with treatment failure than among those in whom treatment was successful. There was no significant difference in treatment outcome between the different age groups. However, failure of treatment was observed to be more common (P < 0.001) among males (35 patients; 46.7%) than among females (10 patients; 13.9%). This could be explained mainly by the significantly higher prevalence of non-compliance among males (44%) than among females (15.3%). There were no significant differences in the symptoms, radiologic findings, clinical presentation (pulmonary versus extrapulmonary), social background or drug resistance between genders. CONCLUSION: Successful treatment outcome among Saudi Nationals seen at the KKNGH in 1993-99 was below the rate recommended by the WHO, and failed treatment was associated with poor compliance, male gender and drug-resistant Mycobacterium tuberculosis. These results emphasize the importance of culture and sensitivity tests for Mycobacterium tuberculosis and close supervision of patients taking antituberculosis medications.

Increasing resistance of M. tuberculosis to anti-TB drugs in Saudi Arabia.

The incidence of drug resistance in Mycobacterium tuberculosis (MTB) isolated from our hospital between April 1996 and March 1998 was compared with an earlier study (1993-1995). Thirty (29.7%) of 101 MTB isolates were resistant to one or more anti-TB drugs and 21 (20%) of 101 were multi-drug resistant M. tuberculosis (MDR-TB). Resistance was most common to isoniazid (28.7%), followed by streptomycin (22.8%) and rifampicin (20.8%). Resistance to pyrazinamide and ethambutol was 7.9 and 6.9%, respectively. There was a three-fold increase in resistance compared with the earlier study.

HACEK group endocarditis at the Riyadh Armed Forces Hospital.

INTRODUCTION: Fastidious Gram-negative organisms classified as the HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella spp.) are rare causes of infective endocarditis. CASE REPORT: In this series, we report six cases of endocarditis in Saudi patients occurring between 1990 and 1994 in our hospital, caused by two of the organisms in the HACEK group, i.e. Cardiobacterium hominis and Actinobacillus actinomycetemcomitans. The clinical features, predisposing factors and treatment of the patients are briefly described. The microscopic and cultural characteristics of the organisms are described together with the laboratory methods of diagnosis. MAJOR FINDINGS: HACEK endocarditis was frequently associated with prosthetic heart valves or structural heart abnormalities. Dental caries or periodontal disease seems to be a predisposing factor. The prognosis of HACEK endocarditis is very good as clinical and bacteriological cure were achieved with antibiotic therapy in all our cases except one who required mitral valve replacement. Contrary to previous reports we did not find all the organisms sensitive to penicillin and aminoglycosides. However, all our isolates were sensitive to amoxycillin, cefuroxime, ceftriaxone and ciprofloxacin. CONCLUSIONS: Laboratory diagnosis of HACEK group of organisms requires a high index of suspicion and should be suspected in cases of endocarditis in which fastidious Gram-negative coccobacilli are isolated which fail to grow on MacConkey agar. Empiric therapy should be started in suspected cases with second generation cephalosporins or with ciprofloxacin, until antibiotic sensitivity results become available. Antibiotic therapy should be continued for 4-6 weeks. Progress and outcome was very good in the series.

Antibiotic resistance in developing countries.

During the past decade there have been major changes in the susceptibility of bacteria that cause various infections. Resistance to anti-infective agents, including antibiotics, is worldwide, both in developed and developing countries. Almost all bacterial species can develop resistance to anti-infective agents and resistance can readily be transferred among bacteria by transmissible elements (plasmids). Measures to prevent the emergence of resistance must be implemented urgently. A multiplicity of factors drive antibiotic resistance and solutions require the collaboration of governmental agencies, pharmaceutical companies, healthcare providers and consumers. Knowledge of resistance patterns and of the ways by which resistance is overcome is vital to the future of antimicrobial chemotherapy.

Penicillin-resistant and -intermediate Streptococcus pneumoniae in Saudi Arabia.

The antibiotic susceptibility was analyzed of approximately 400 consecutive isolates of S. pneumoniae isolated from different regions of Saudi Arabia. Most of these isolates were from respiratory (sputum, otitis, 53.8%), blood/CSF (26.3%) and ophthalmic (20%) specimens. Overall 6.2% of the isolates were penicillin-resistant (MICs > or =2 microg/ml) and 51.2% were -intermediate (MICs 0.1-1 microg/ml). The resistance rates to cefuroxime, clarithromycin and ceftriaxone were 14.9%, 14.8% and 4.5% respectively. Only 3.5% of S. pneumoniae showed resistance to amoxycillin/clavulanic acid. The MICs of all tested antibiotics increased as did the penicillin MICs. Penicillin resistance was significantly associated with resistance to cefuroxime (p<0.001) but not with the others. These data indicate the presence of penicillin and multiple-resistant pneumococci in Saudi Arabia and that these strains can spread among individuals. A greater awareness with extended indications for microbiological diagnosis, antimicrobial susceptibility testing and restrictive prescription of antibiotics are needed.

Diagnostic value of Brucella ELISA IgG and IgM in bacteremic and non-bacteremic patients with brucellosis.

The diagnostic value of Brucella ELISA IgG and IgM has been evaluated in patients with brucellosis. Serum samples and blood cultures were collected from 83 patients with brucellosis. The sera were tested by Brucella ELISA for Brucella IgM and IgG antibodies. All 44 controls were negative for IgG and IgM. Brucella melitensis was isolated from blood cultures of 30/83 (36.1%) patients. Among the 30 bacteremic patients, 24 (80%) had an increased IgM titer of > or = 200. Of the 53 non-bacteremic patients, 41 had IgM titer > or = 200, while 22 had IgG titer of > or = 1,600. The ELISA IgM and IgG tests achieved a specificity and sensitivity of 100% and 96% respectively, while the positive and negative predictive values were 100% and 94% respectively. The Brucella ELISA is a reliable and sensitive test in the diagnosis of brucellosis. The test is rapid, easy to perform and can be automated.

Approach to the control of sexually transmitted diseases in developing countries.

PIP: Despite the high prevalence of sexually transmitted diseases (STDs) in developing countries, the diagnostic facilities in special clinics are not available in many cities. The laboratory facilities, the quality of the statistical reporting system, and the personnel providing this information are briefly described. It is suggested that the main reason for the poor STD services is due to meager financial allocations and lack of well-trained personnel. For the control of STD in developing countries, epidemiological and clinical approaches have been suggested for both urban and rural areas. Specific needs for the future have been outlined especially for improved financial resources to enable diagnostic and treatment facilities to be provided. The present unsatisfactory situation and lack of meaningful data also require immediate improvment.^ieng

Epidemiology of hepatitis E virus in male blood donors in Jeddah, Saudi Arabia.

To our knowledge, only a few epidemiological reports on the prevalence of hepatitis E antibodies in Saudi blood donors have been published. Men of several nationalities, donating blood at King Khalid National Guard Hospital (Jeddah, Saudi Arabia) were selected (n = 593) for this study examining the seroprevalence of hepatitis E virus (HEV) in the local male donor population and testing the relationship of the antibody to HEV (anti-HEV) to donor characteristics using Odds Ratio (OR) and Chi-square statistic. The prevalence of anti-HEV in the group examined was 16.9 per cent (100/593). The seroprevalence for Saudi donors was 14.8 per cent compared with 33.3 per cent for non-Saudis of Middle Eastern origin. Donors who were 40 yr and over had significantly higher seroprevalence than those donors who were 30 yr or younger (OR = 2.5, p = 0.006). There was a significant association between anti-HEV and anti-HCV with donors who were positive to anti-HCV having about 5 times the risk of HEV than those who were anti-HCV negative (p = 0.02). These findings demonstrate the high seroprevalence rate of anti-HEV among male blood donors in Saudi Arabia.

Erratum: Multidrug-resistant tuberculosis.

Full text is available as a scanned copy of the original print version.

Comparative study of Amplicor polymerase chain reaction and ligase chain reaction for direct detection of M.tuberculosis in clinical specimens.

Full text is available as a scanned copy of the original print version.

Sero-epidemiological study of Lymphogranuloma venereum in Western Nigeria.

A sero epidemiological study involving 5009 individuals resident in the two largest cities (Ibadan and Benin) in the Western Region of Nigeria has been carried out, using the LGVCFT to determine the presence of LGV antibodies. These individuals come from various population groups and social classes (i.e. blood donors, antenatal clinic patients, general out-patients, venereal diseases clinic patients and prostitutes). Among the 3638 subjects tested in Ibadan, the seroreactivity rates ranged from 5.3% to 11.5%, while of the 1371 in Benin, the seroreactivity ranged from 7.3% to 18.3%. The seroreactivity rates confirm previous suspicion that there is a considerable reservoir of infection among the female population both in normal women and in prostitutes. While the value of LGVCFT as an epidemiological tool in the estimation of latent or active infection in a community has been substantiated, a puzzling variation in the endemicity of the LGV agent, even within the same region, has been observed. It is suggested that routine testing of blood donors and antenatal women with LGVCFT such as done with serological tests for syphilis should be carried out in tropical countries where LGV is endemic.

Ureaplasma urealyticum (T. mycoplasma) and male infertility in topical countries.

In view of the potential role of ureaplasma urealyticum in reproductive failure, sample of semen from 100 Nigerian males was cultured in oxoid mycoplasma broth. In 39% of the patients, Uraeplasma uraelyticum was cultured. Of those with positive culture, 92.3% were infertile patients. Five subfertile males achieved pregnancy in their partners after eradication of the ureaplasma urealyticum by a course of tetracycline.

PIP: Findings in a study of 100 Nigerian males supported the contention that ureaplasma urealyticum may have an inhibitory influence on fertility. When semen samples from 20 normal males, 17 males with sperm counts of 20-39 million/ml, and 63 males with sperm concentrations less than 20 million/ml were cultured in an oxoid mycoplasma broth, ureaplasma urealyticum was cultured in 39 of the samples. 36 of these 39 positive cultures were from males with sperm counts of less than 20 million/ml. Those patients with positive cultures and their wives were treated with tetracycline and within 6 months of treatment, conception occurred in the wives of 5 of the males with sperm concentrations of 20-35 million/ml. Apparently there is a tendency for the ureaplasma urealyticum to attach to sperm cells, and this may have an inhibitory effect on fertilization. Since positive cultures were obtained from 3 of the fertile males, it is possible that ureaplasma urealyticum is pathogenic for some individuals but not for others. This study does not prove that there is a cause and effect relationship between ureaplasma urealyticum and infertility; however, in view of the high infertility rates in many parts of Africa, tetracycline or doxycycline therapy is routinely recommended for males with ureaplasma urealyticum in their ejaculate and for their wives. Included is the formula for the oxoid mycoplasma broth and a table showing the number and distribution of positive and negative cultures by sperm concentration.

Infective factors of male infertility among Nigerians.

Seminal fluid from 782 Nigerian males with complaints of infertility were examined with respect to infective agents and indices such as sperm count, motility and the presence of a significant number of pus cells. Various infective agents were recovered from 54 (7%) of the patients, while in 25% of the remaining patients, a significant number of pus cells was present, with associated abnormal seminal fluid indices. Our findings indicate that seminal fluids constitute an important medium for the spread of various infective agents, and that genital infections by these infective agents, sexually and non-sexually transmitted, may be responsible for a good percentage of infertility cases in Nigerian males.

Susceptibility of penicillinase-producing Neisseria gonorrhoeae in Ibadan to cefoxitin.

The minimum inhibitory concentration (MIC) of fourteen strains of penicillinase-producing Neisseria gonorrhoeae (PPNG) isolated in Ibadan to cefoxitin has been determined and compared with that of other antibiotics, viz. penicillin, ampicillin, thiamphenicol, spectinomycin, erythromycin and oxytetracycline. All the strains show high-level resistance to penicillin and ampicillin and the MIC of cefoxitin ranged from 0.5 to 16.0 micrograms/ml, with 71% of the strains having an MIC of 1.0 microgram/ml or less. The data suggest that cefoxitin may be a useful alternative to spectinomycin in the treatment of uncomplicated gonococcal infections, due to either PPNG or non-PPNG strains. However, further experiments and in vitro studies are indicated.

Pattern of reactive serological tests for syphilis in different population groups attending the University College Hospital Ibadan (1976-1985).

A review of the reactive serological tests for syphilis was carried out. An overall seroreactivity of 5.1% was obtained over the 10-year period reviewed. A subtle but steady rise in the incidence of syphilitic infections was noted, from 7 to 10 new cases per 1000 population between 1970 and 1975. The predictive characteristics obtained from the screening tests show that the tests are reliable diagnostic tests when the results are carefully interpreted, and the medical personnel can be alerted of the prevalence of syphilitic infections.

PIP: Serological tests for syphilis conducted at the University College Hospital, Ibadan, Nigeria, from 1976-1985 were compared to results from 1970-1975, showing a clear increase in prevalence. The departments participating were the antenatal care, special treatment (venereal disease), outpatient, wards, and blood bank. For most of the decade, sera and verified with the TPHA (Treponema pallidum hemagglutination test) test, although data were also available from the 1st half of the period from initial screening with the RPR (Rapid Plasma Reagin) test. The overall positive rates were 5.1% with the VDRL, 7.7% with the TPHA test, and 2.8% with the RPR test. The lowest rate of reactive sera by the VDRL was the antenatal clinic, with 2.3%, and the highest were the outside-hospital clinics, with 7.6%. Using the TPHA test as a reference, the sensitivity of the VDRL was 54.7%, and its specificity was 94.7%. Considering a positive titer of 1:4 as reactive, 0.995% of the VDRL tests were positive, giving a syphilis incidence of 10/1000. This is an increase of 3 cases/1000 above the rate found in the previous decade. The results are plausible considering the rapid increase in new cases of other STDs (sexually transmitted diseases).