Cytomegalovirus Infections in the Atypical Host: A Case Series of Clinical Conundra.

Background Cytomegalovirus (CMV) reactivation may occur as the shedding of the virus from various body sites or could represent an active disease that might be fatal if untreated. Distinguishing between the two states may prove very difficult. The role of the CMV disease in patients with hematological malignancies or transplant patients is more defined than that in other immunocompromised patients where neither anti-CMV prophylaxis is used nor plasma CMV levels are monitored. Here, we try to examine cases with CMV viremia in the latter group of patients in an attempt to make a distinction between CMV infection and disease to determine which patients would benefit from treatment. Methods Elderly patients, patients with rheumatological disorders, and patients with inflammatory bowel disease (IBD) and with clinical suspicion of CMV disease who were referred to the infectious diseases service at Sultan Qaboos University Hospital were examined from 1 January 2018 to 31 January 2023. We added a patient we found in our referral log book from 2012. Clinical, epidemiological, and laboratory data were retrieved from the hospital information system. Plasma CMV levels and CMV body fluid levels including pulmonary samples obtained from bronchoalveolar lavage (BAL) in suspected cases of CMV pneumonitis and gastrointestinal (GI) CMV levels obtained from stool and gastrointestinal tissue biopsies in suspected cases of gastrointestinal CMV disease were collected. COBAS® AmpliPrep/COBAS® TaqMan®assay (Roche Molecular Systems, Inc., Branchburg, NJ) was used to measure CMV copies per milliliter. Results A total of 28 patients were considered to have CMV disease, 12 of whom were elderly (≥60 years) and the rest were young and middle aged (Y/M). The most common comorbidities of the elderly included chronic kidney disease (CKD), hypertension (HTN), and diabetes mellitus (DM). In the Y/M group, seven patients had systemic lupus erythematosus (SLE), one had antineutrophil cytoplasmic antibody (ANCA) associated vasculitis, four patients had IBD, two had IBD plus primary immunodeficiencies (one patient had agammaglobulinemia and one had combined deficiencies), and one patient had combined immunodeficiency. CKD was a common finding in the SLE patients. Diarrhea was the most common CMV presentation occurring in 19 patients (67.9%), being bloody in 10 patients. Four patients had pulmonary presentations, and four had hematological presentations in the form of anemia or pancytopenia. Nineteen patients were given CMV antiviral treatment, and one patient received it during the first episode but not in the second episode. Twenty-eight-day mortality in the treated group was 20% versus 55.5% in the untreated group. The majority of the deaths occurred in the SLE and elderly patients. Thrombocytopenia occurred in 60.7%, 70.6% of whom died signaling a potential predictive role for thrombocytopenia in early empirical CMV antiviral treatment and in prognosis. Conclusion The difficulty in distinguishing CMV infection from CMV disease remains a concern in the elderly and SLE patients. In our small study, there was a survival benefit in early screening for CMV and initiating preemptive CMV antiviral therapy in these two groups even before CMV disease is proven. This urgency was not observed for patients with IBD or primary immunodeficiencies. A major common factor for CMV disease was CKD, whereas thrombocytopenia was an indicator of disease and prognosis.

Characteristics of SLE patients with symptomatic COVID-19: Single centre experience at Sultan Qaboos University Hospital over a 30-month period.

BACKGROUND: COVID-19 pandemic was declared by WHO in March 2020. Severity of disease varied from asymptomatic to fatal infection. Severe disease was found to be associated with hyperinflammation syndrome. Systemic lupus erythematosus (SLE) is treated with various immunosuppressive agents, intensity of which depends on the severity of the disease. We aimed to study the characteristic of SLE patients infected with COVID-19. METHODS: 352 patients with SLE were included in this observational cross-section study conducted over a 30-month period beginning from 24th February 2020 (first COVID cases documented in Oman) until end of July 2022. Data were retrieved from electronic medical records and through questionnaire handed to patients in OPD or filled through phone calls. RESULTS: 40.6% of SLE patients developed COVID-19 infection with mean age of 37 years and maintaining their male to female ratio as in SLE disease. Majority of the patients in both COVID-infected and non-infected groups had SLE disease activity of zero. Sore throat and cough were present in almost all patients. Other common symptoms were myalgia/arthralgia (94%) followed by fever. Significant difference between the groups was in severity of SLE and in lung involvement. No difference was noted between the two groups in other parameters including regarding the frequency of medication. CONCLUSIONS: This is the first study of COVID-19 in SLE patients in the Gulf Council Countries (GCCs). A significant difference between COVID-infected and uninfected groups was seen in the SLE disease activity and whether lung was involved in the SLE patients. We found no impact for DM, HTN, BMI, IHD, lupus nephrites of SLE medication on COVID-19 infection.

Clinical Presentations of Brucellosis Over a Four-Year Period at Sultan Qaboos University Hospital and Armed Forces Hospital, Muscat, Oman.

OBJECTIVES: Brucellosis is a highly contagious zoonotic disease which can have serious health implications for affected humans and livestock. This study aimed to evaluate the clinical presentation, geographical distribution and risk factors of brucellosis cases admitted over a four-year period to two hospitals in Muscat, Oman. METHODS: This observational study was conducted from January 2015 to December 2018 at the Sultan Qaboos University Hospital and Armed Forces Hospital in Muscat. All patients with probable or definitive diagnoses of brucellosis according to the diagnostic criteria of the World Health Organization were included. Relevant data were gathered from the patients' medical records, including results from standard agglutination tests, Brucella enzyme-linked immunosorbent assays, bacterial blood or tissue/aspirate cultures and Brucella polymerase chain reaction tests. RESULTS: A total of 64 patients were diagnosed with brucellosis over the study period. The median age was 31.5 years and 73.4% were male. The majority (95.2%) presented with fever, followed by weight loss (51%), transaminitis (48.4%), peripheral arthritis/arthralgia (15.9%) and back pain (spondylodiscitis/sacroiliitis; 23.4%). Overall, 75.5% reported having consumed raw dairy products, while only 25.9% gave a positive history of animal contact. CONCLUSION: Patients with brucellosis presented with a wide range of clinical features, the most predominant of which was fever. The majority of patients were residents of or had recently visited Salalah and had consumed raw dairy products. These findings highlight the need for healthcare practitioners to maintain a high index of suspicion for this diagnosis. Moreover, further regulatory measures are necessary to oversee the sale of raw/unpasteurised dairy products.

Mycoplasma pneumoniae Pneumonia with Worsening Pleural Effusion Despite Treatment with Appropriate Antimicrobials: Case report.

Mycoplasma pneumoniae is a common cause of community-acquired pneumonia. As M. pneumoniae pneumonia is usually a mild and self-limiting disease, complications such as pleural effusion occur only rarely. We report a 22-year-old woman who presented to the Emergency Medicine Department of the Sultan Qaboos University Hospital, Muscat, Oman, in 2017 with an eight-day history of fever associated with coughing, chills and rigors. She was diagnosed with M. pneumoniae pneumonia, but subsequently developed pleural effusion which worsened despite treatment with appropriate antimicrobials. The pleural effusion required drainage, which revealed that it was of the more severe exudative type. Following drainage, the patient improved dramatically. She was discharged and advised to continue taking antibiotics.

Methemoglobinemia in an elderly patient with glucose-6-phosphate dehydrogenase deficiency: a case report.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked genetic disorder characterized by low levels of the G6PD enzyme. It is present worldwide but with more prevalence in the Middle East and the Mediterranean areas. We report a case of severe hemolysis due to G6PD deficiency manifesting as methemoglobinemia in a 70 year old Omani male never known to have any previous hemolytic episodes or previously diagnosed of G6PD deficiency.

Infective Endocarditis of the Aortic Valve caused by Pseudomonas aeruginosa and Treated Medically in a Patient on Haemodialysis.

Infective endocarditis (IE) in patients on dialysis is a serious infection with a high mortality rate. It is usually caused by Gram positive bacteria with Gram negative organisms being relatively rare as a cause. Recommended treatment usually involves surgical valve replacement and the extended use of antibiotics. Successful treatment with antibiotics alone is rare. We report a case of IE caused by Pseudomonas aeruginosa in a patient on dialysis treated solely with antibiotics.

Diagnostic Value of Electrocardiographic T Wave Inversion in Lead aVL in Diagnosing Coronary Artery Disease in Patients with Chronic Stable Angina.

OBJECTIVES: The clinical value of T wave inversion in lead aVL in diagnosing coronary artery disease (CAD) remains unclear. This study aims to investigate the correlation between aVL T wave inversion and CAD in patients with chronic stable angina. METHODS: Electrocardiograms (ECGs) of 257 consecutive patients undergoing coronary angiography were analyzed. All patients had chronic stable angina. All patients with secondary T wave inversion had been excluded (66 patients). The remaining 191 patients constituted the study population. Detailed ECG interpretation and coronary angiographic findings were conducted by experienced cardiologists. RESULTS: T wave inversion in aVL was identified in 89 ECGs (46.8%) with definite ischemic Q-ST-T changes in different leads in 97 ECGs (50.8%). Stand alone aVL T wave inversion was found in 27 ECGs (14.1%) while ischemic changes in other leads with normal aVL were identified in 36 ECGs (18.8%). The incidence of CAD was 86.3%. Single, two- and multi-vessel CAD were found in 38.8%, 28.5% and 32.7% of cases respectively. The prevalence of left main, left anterior descending, left circumflex and right coronary arteries were 4.7%, 61.2%, 29.3% and 44.5%, respectively. T wave inversion in aVL was found to be the only ECG variable significantly predicting mid segment left anterior descending artery (LAD) lesions (Odds Ratio 2.93, 95% Confidence Interval 1.59-5.37, p=0.001). CONCLUSION: This study provides new information relating to T wave inversion in lead aVL to mid segment LAD lesions. Implication of this simple finding may help in bedside diagnosis of CAD typically mid LAD lesions. However, further studies are needed to corroborate this finding.