Strongyloidiasis: challenges in diagnosis and management in non-endemic Kuwait.

Among immunocompromised individuals, hyper-infection with Strongyloides stercoralis may occur and lead to fatal strongyloidiasis. To clinicians and laboratory diagnosticians in non-endemic countries such as Kuwait, this severe infection poses a particular problem. The clinical histories and signs and symptoms of four Kuwaiti cases of S. stercoralis hyper-infection were reviewed. Each of the four was found not only to have lived in an area where S. stercoralis was endemic but also to have been treated with immunosuppressive steroids (for medical problems unrelated to the nematode infection). When they presented with undiagnosed hyper-infections their clinical features were confusing. Three of the cases, all with low eosinophil counts, died but the other, who was treated with thiabendazole, survived. In the light of these observations, healthy medical examinees who had recently moved from endemic zones were checked for asymptomatic S. stercoralis infection, both by stool examination and ELISA-based serology. Of 381 stool samples investigated over a 3-month period, 183 (48%) were found positive for helminths, 7% for S. stercoralis. Of 198 individuals from endemic zones who were screened after another medical examination, 71 (35.8%) were found positive for intestinal helminth parasites, including one (1.45%) infected with S. stercoralis. Although ELISA appear reliable in making a presumptive diagnosis of strongylodiasis, the results of such assays are not very specific and are best interpreted in conjunction with the patient's clinical status. The concurrent administration of anthelminthics to patients prescribed steroids who, because they live or have lived in an area where S. stercoralis is endemic, are at risk of infection with the nematode, should be considered.

Echinococcosis of the rib with epidural extension: a rare cause of paraplegia.

Skeletal echinococcosis is a relatively rare entity and that of the rib is exceptional. Less than 50 cases of costal echinococcosis have been reported in the literature so far. Accurate pre-operative diagnosis aids in appropriate management and helps to eradicate the disease. This also prevents the dissemination of parasite and further complications. We report a case of echinococcosis of the rib with epidural extension in a young adult who presented with paraparesis and back pain. His laboratory investigations were within normal limits. Plain radiographs of the dorsal spine, CT scan of thorax and MRI of dorsal spine were performed. The imaging features were suggestive of echinococcosis involving the rib with epidural extension. The cyst was completely resected. Histopathology of the resected specimen confirmed the diagnosis of echinococcosis.

Female genital tuberculosis: hysterosalpingographic appearances.

Genital tuberculosis is an important cause of infertility in developing countries and hysterosalpingography (HSG) is the initial procedure performed for the evaluation. Reviewing 37 cases of female genital tuberculosis, we encountered various appearances on HSG. Of 579 HSGs performed over a period of 4 years, 492 (85%) were performed as part of infertility work up. Genital tuberculosis was found in 6.3% of all the patients who underwent HSGs and 7.5% of all patients investigated for infertility. The various features of proven tuberculosis cases are illustrated in this pictorial review. We briefly discuss the pathology and these appearances along with radiopathological correlation.

Imaging features and guided drainage in emphysematous pyelonephritis: a study of 11 cases.

AIM: The purpose of the present study is to evaluate the role of image-guided drainage in emphysematous pyelonephritis (EPN). MATERIALS AND METHODS: We reviewed 11 patients with EPN treated either by ultrasonography (three patients) or computed tomography (CT)-guided drainage (eight patients). There were eight male and three female patients in our study with ages ranging from 24 to 75 years, mean 56.3 years. All the patients underwent plain radiography, ultrasonography and plain CT of the abdomen. Contrast-enhanced CT was performed in seven patients. RESULTS: Seven of 11 patients, were successfully treated with per cutaneous drainage. One patient died within 24 h (case 2), due to septicaemia. Three patients subsequently required nephrectomy. Replacement of the drainage catheter was required in one patient. The catheter was kept in situ, for an average of 17 days. The catheter drained pus and gas in all patients. The quantity of pus ranged from 300 to 2000 cm(3). All 10 patients improved symptomatically within 24 h of drainage, with improved urine output and serum creatinine levels within 48 h. CONCLUSION: CT-guided drainage of EPN has established itself as a safe, quick and life-saving palliative treatment of choice as opposed to conventional emergency nephrectomy. Excluding the patient who died, the success rate of our study was 70%.

Modified Giemsa staining for rapid diagnosis of malaria infection.

OBJECTIVES: To develop and evaluate a rapid method for the diagnosis of malaria infection by microscopy of stained blood films. SUBJECTS AND METHODS: Blood specimens were collected from randomly selected confirmed malaria cases (n = 75) and suspected malaria cases (n = 175). The microscopy was done on each set of blood films stained by modified and the standard Giemsa staining methods. RESULTS: All the 75 previously diagnosed malaria cases were confirmed by the microscopy of blood films stained by both methods. Forty-nine (28%) of the 175 cases suspected for malaria infection showed malarial parasites on microscopy of blood films stained by both methods. However, due to homogeneous staining and clearer background of the blood films it was possible to determine the parasite species in 65% of the cases on microscopy of the thick films stained with the modified method compared to only 20% with the standard method. Further, the turnaround time for reporting the microscopy test result was 15-20 and 45-50 min with modified and standard staining methods, respectively. CONCLUSION: Our data showed that performance of the modified staining method in detecting malarial parasites was comparable to that of the standard staining method. Moreover, the modified staining method was rapid, easy to use, and reliable.

Diagnosis of abdominal hydatid cyst disease: the role of ultrasound and ultrasound-guided fine needle aspiration cytology.

OBJECTIVE: To retrospectively analyze the role of ultrasound (US) imaging and US-guided fine needle aspiration cytology in the diagnosis and management of abdominal hydatid cyst disease (HCD). SUBJECTS AND METHODS: The medical records of 55 diagnosed cases of HCD seen between January 1986 and December 2000 at Mubarak Al-Kabeer Hospital and Al-Amiri Hospital in Kuwait were reviewed for demographic and clinical data, including radiology and serology. The US findings of the patients were classified into four types as follows: type I: single or multiple well-defined cysts, with or without detached or collapsed wall and with or without echogenic contents; type II: single or multiple cysts with peripheral cysts, with or without echogenic contents; type III: solid or semisolid lesions, and type IV: cysts with calcified walls. RESULTS: The overall accuracy of US in the diagnosis of HCD was 80% (44/55 cases). US examination was suggestive of HCD type I, 16/19 (84%), type II, 21/23 (91%), type III, 3/8 (38%), and type IV, 4/5 (80%). For the 11 remaining undiagnosed cases, US was useful for localizing the lesions for US-guided fine needle aspiration cytology. It established the diagnosis in all the 11 cases, without precipitating complications. CONCLUSION: US alone was valuable for diagnosing and localizing HCD in the abdomen except for solid-type lesions. US-guided fine needle aspiration cytology was useful in localizing and establishing the diagnosis of HCD in the cases where US alone was ineffective.

Drug-resistant Plasmodium falciparum infection in immigrants and non-immune travellers.

OBJECTIVE: To detect the incidence of drug-resistant Plasmodium falciparum malaria infection in immigrants and travellers in non-endemic Kuwait. METHODS: Over a period of 3 years, July 1995 to September 1998, 1352 malaria patients were enrolled in the study. Of these, 1293 were immigrants from countries where malaria is endemic and 59 were non-immune travellers with a recent history of travel to these countries. The in vitro drug sensitivity was determined in 892 patients. RESULTS: In all, 892 of 1352 (66.0%) P. falciparum isolates were successfully cultured in vitro for drug sensitivity and 419 (47.0%) isolates showed in vitro resistance to chloroquine or mefloquine. Fifty-six (13.4%) isolates were resistant to both drugs. Chloroquine resistance was observed in > 70% of the isolates from Africa and India followed by Pakistan (39.9%) and Bangladesh (35.9%). The resistance to mefloquine ranged from 26.2% in isolates from Sri Lanka to 47.5% in isolates from African countries. CONCLUSION: The study highlights the important trend in drug resistance in P. falciparum malaria in immigrants from south-east Asian and African countries.

An unusual case of biliary atresia.

Intrahepatic biliary cysts are rarely seen in the patients with biliary atresia. We describe a ten-month-old child with biliary atresia in whom the abdominal imaging studies (ultrasonography, computed tomographic scan and magnetic resonance cholangiopancreatography) revealed multiple intrahepatic biliary cysts ('bile lakes'). The child also had intrapulmonary shunting of blood due to pulmonary arteriovenous fistulae, which were demonstrated on contrast-enhanced echocardiography. Both these findings, 'bile lakes' and pulmonary arteriovenous fistulae occur rarely in biliary atresia.

Invasive amebiasis: challenges in diagnosis in a non-endemic country (Kuwait).

Invasive zymodemes of the enteric protozoan Entamoeba histolytica infect the large intestine and cause extra-intestinal lesions such as amebic liver abscess (ALA). The clinical manifestations of ALA are protean, particularly in patients presenting in a non-endemic, desert country such as Kuwait, and diagnosis becomes problematic. In this study, we present cases of ALA to illustrate the clinical and diagnostic challenges. For serodiagnosis of ALA, we compared the sensitivity and specificity of the indirect hemagglutination assay (IHA) with the ImmunoTab assay and an enzyme-linked immunosorbent assay (ELISA) for this geographic region. We tested sera of 110 patients with ALA, 1,224 patients suspected of having invasive amebic infection, and 50 Europeans with no travel history to an amebic-endemic area. The IHA was simple, rapid, easy to perform, and reliable (sensitivity = 99%, specificity > 95%). The performance of the IHA in detecting ALA in suspected cases was significantly better than that of the ELISA and the ImmunoTab test. Compared with the IHA, both the ELISA and ImmunoTab assay detected relatively higher numbers of false-positive cases (4.7% and 3.6%, respectively). With the availability of ultrasound and computed tomography scans, the serology correlates excellently with the clinical presentation. In chronic cases where fibrosis may be present around the abscess, the IHA has limitations, as in the follow-up of treated patients. Pitfalls in diagnosis are highlighted by discussing the differential diagnosis of ALA from bacterial hepatic abscesses and infected hydatid cysts. Most importantly, the IHA in such cases was invariably at a titer that is considered not significant.

Fetus in fetu. Rare cause of a lump in an adult's abdomen.

Fetus in fetu is a rare entity. The patient usually presents in childhood. A case in which the patient presented in adulthood, with a lump in the abdomen, is reported. Computed tomography findings were diagnostic of this condition and a prospective diagnosis could be made. Computed tomography also helped to differentiate it from mature teratoma.

Diagnosis of imported malaria by Plasmodium lactate dehydrogenase (pLDH) and histidine-rich protein 2 (PfHRP-2)-based immunocapture assays.

This study was conducted to evaluate the performance of two rapid non-microscopic assays: Plasmodium lactate dehydrogenase (pLDH) assay (OptiMAL) and Plasmodium falciparum histidine-rich protein 2 (PfHRP-2) assay (ICT Malaria). The assays were used to detect malaria infection in 515 immigrants living in Kuwait. The performance of both assays was compared to that of microscopy of Giemsa-stained thick blood films and to each other. Of the 515 patients tested, 163 were positive for malaria parasites by microscopy of thick blood film. Of these, 87 were infected with Plasmodium vivax parasites, 63 with P. falciparum, 1 with Plasmodium malariae, and 12 had mixed infections of P. falciparum and P. vivax. The PfHRP-2 assay detected 53 P. falciparum infections and, as expected, failed to detect all but one case of P. vivax. Three cases of mixed infections were also not detected by this assay. The pLDH assay detected 56 P. falciparum cases and 77 P. vivax infections but failed to detect 4 cases of mixed infections. Compared to microscopy, the performance of both the assays to diagnose P. falciparum infection was comparable. The sensitivity for the PfHRP-2 assay was 82% with a specificity of 99.0% and for the pLDH assay the sensitivity was 89% with a specificity of 99.5%. The PfHRP-2 assay detected 4 false positive cases, 2 of which were also detected by the pLDH assay. These patients reported treatment with chloroquine in the last 2-5 weeks. Though the immunocapture diagnostic assays may be helpful in certain situations, microscopy of thick blood film is still the method of choice in diagnosing imported malaria.

Cryptosporidiosis in Kuwaiti children: seasonality and endemicity.

OBJECTIVE: To detect the incidence of cryptosporidial infection in children presenting with gastrointestinal symptoms at the local hospital in Kuwait. METHODS: Over a period of 3 years, September 1995 to August 1997, a single fecal sample from 3549 children was analyzed by modified saframin-methylene blue (SM-B) staining and a direct immunofluorescence test for the presence of Cryptosporidium oocysts. RESULTS: Cryptosporidium oocysts were detected in 51 (10%) children with diarrhea. Prevalence was highest (73%) in children > 2 years of age compared with children < 2 years of age. The maximum number of cases, 38 of 51 (75%), was seen during the months January to April, indicating a marked seasonal variation. Polyparasitism was common in children with diarrhea; however, 43 of the 51 (84%) children with cryptosporidiosis had cryptosporidium infection only. Blastocystis hominis and Endolimax nana were the most common parasites detected (38% and 15%, respectively). Forty-seven of the 51 (90%) children with cryptosporidiosis were Kuwaiti and gave no history of travel abroad, suggesting that the infection was acquired indigenously. Sociodemographic information on children with cryptosporidiosis suggests three possible modes of transmission of infection: drinking contaminated water stored in overhead water tanks, person to person, or contact with infected animals. CONCLUSION: In this study, we observed water-borne transmission of cryptosporidium infection in children with diarrhea. The infection is seasonal and endemic.

Pelvic abscess from enterobius vermicularis. Report of a case with cytologic detection of eggs and worms.

BACKGROUND: Enterobius vermicularis is known to produce perianal and ischioanal abscesses and invade the peritoneal cavity via the female reproductive system, causing pelvic peritonitis. However, there are only rare case reports on the cytodiagnosis of these parasitic lesions. CASE: A 28-year-old woman was admitted with a tender left iliac fossa mass and greenish vaginal discharge. Ultrasonogram and computed tomography scan confirmed the presence of a mass lesion suggestive of a tuboovarian abscess. Cytologic examination of the pus obtained during left salpingo-oophorectomy revealed the presence of ova of E vermicularis and fragments of the adult worm in an inflammatory exudate consisting predominantly of neutrophils, eosinophils and occasional epithelioid cell granulomas. Paraffin sections of the tuboovarian mass showed necrotizing epithelioid cell granulomas, but neither ova nor any worm section was identified. Although the possibility of tuberculosis was considered histologically, Ziehl-Neelsen (Z-N) stain for acid-fast bacilli was negative. Z-N staining of the smear and mycobacterial culture of the pus also did not yield positive results. CONCLUSION: E vermicularis may cause tuboovarian abscess with necrotizing epithelioid granulomas mimicking tuberculosis. Cytologic examination of the pus is helpful in the diagnosis.

Leishmaniasis diagnosed by liver biopsy: management of two atypical cases.

Two patients presenting with pyrexia of unknown origin were diagnosed as having visceral leishmaniasis based on the presence of Leishmania donovani bodies in liver tissue. Of particular interest is that these two case reports suggest that in patients with pyrexia of unknown origin, a liver biopsy for L. donovani bodies should be considered even when several months have passed since leaving an endemic area, when splenomegaly is absent, when bone marrow examination and serology are not diagnostic, and even when abnormal coagulation necessitates a transjugular liver biopsy.