Repeated Peritonitis in a Peritoneal Dialysis Patient: An Unusual Case of Bacillus licheniformis With Vancomycin Failure Despite Sensitivity.

Bacillus licheniformis (B. licheniformis) is an aerobic, gram-positive, spore-forming rod typically found in soil, decaying organic matter, vegetables, and water, and occasionally part of normal gut flora. This report highlights a case of unusual repeated peritonitis caused by B. licheniformis, with three episodes occurring over six months, all of which were sensitive to vancomycin yet presented an unclear cause for recurrence. Peritonitis represents a significant cause of mortality, hospitalization, and failure of peritoneal dialysis catheters, leading to forced transitions to hemodialysis. The rarity of B. licheniformis as a pathogen in human infections emphasizes the critical need for precise microbial identification and customized therapeutic strategies.

SARS-CoV-2 with Influenza B Coinfection in a Patient with Sickle Cell HbSC Presenting with Painful Crisis: A Case Report.

Sickle cell disease is a hereditary red blood cell disorder characterized by hemolytic anemia, particularly in association with stress. As they grow, most children with sickle cell anemia undergo auto-splenectomy, making them vulnerable to serious infections. Patients with sickle cell disease infected with the SARS-CoV-2 virus are reported to have an increased risk for hospitalization, thrombosis, and other complications compared to non-sickle cell patients. Influenza infection in patients with sickle cell is associated with increased morbidity. Patients with sickle cell HbSC are reported to have a milder form of the disease than HbSS. Coinfection with SARS-CoV-2 and influenza B is rarely reported in patients with hematologic diseases, including sickle cell hemoglobinopathy. We are reporting an unusual case of a patient with sickle cell HbSC with co-infection of SARS-CoV-2 and influenza B with a favorable outcome.

Rasmussen's Aneurysm in Active Pulmonary Tuberculosis: A Case Report.

Hemoptysis is a common presenting symptom of pulmonary tuberculosis (TB). Rasmussen aneurysm can present with severe hemoptysis, which is usually diagnosed using computed tomography (CT) angiography. A false aneurysmal dilatation of the pulmonary artery is known as a Rasmussen aneurysm. It occurs due to a gradual weakening of the arterial wall adjacent to pulmonary cavitation. Computed tomography angiography of the chest is the standard diagnostic technique for Rasmussen aneurysm. An early angiographic or surgical procedure with vascular embolization is recommended following a definitive diagnosis. We present a 29-year-old woman whom the medical commission referred due to a cavitary lesion on a screening chest X-ray. Hospital admission was preferred for the Mycobacterium tuberculosis infection workup, which revealed radiological evidence of the Rasmussen aneurysm. The patient was eventually treated as a case of active tuberculosis on a radiological basis via the decision of the local infectious disease (ID) team. The most common symptoms reported in patients with tuberculosis infection are hemoptysis, cough, low-grade fever, night sweats, and weight loss. Hemoptysis can rarely originate from the Rasmussen aneurysm of the pulmonary artery. However, hemoptysis is the predominant symptom in chronic cavitary tuberculosis with Rasmussen aneurysm. A CT pulmonary angiogram (CTPA) is considered the imaging modality of choice to confirm the diagnosis of Rasmussen aneurysm. Fatal hemoptysis is one of the consequences of a Rasmussen aneurysm if it is massive and not treated promptly. Confirming the diagnosis with proper follow-up is essential to preventing devastating outcomes.

Polycythemia Vera With High Serum Erythropoietin Level: A Case Report and Literature Review.

Polycythemia vera (PV) is a primary acquired marrow condition that causes erythrocytosis. It may present with erythromelalgia, pruritus, splenomegaly, and thrombotic events. Secondary causes of polycythemia should be ruled out before labeling a patient as having PV. Serum erythropoietin (EPO) level helps distinguish primary and secondary polycythemia, but it should be aided by further testing such as the JAK-2 gene mutation test. We present a case of a previously healthy 47-year-old female who came to the hospital with a headache and transient left-sided body weakness. She had no similar episodes in the past. Her initial workup showed a high hemoglobin and a high hematocrit level. A plan computed tomography (CT) scan of the head showed evidence of a thalamo-capsular infarct. The serum EPO level was elevated, and a bone marrow biopsy returned positive for JAK-2 mutation indicating the diagnosis of polycythemia vera despite the high EPO level. The World Health Organization (WHO) consensus criteria for diagnosing PV demand the presence of two major criteria and one minor criterion or the presence of the first major criterion and two minor criteria. Decreased EPO is considered a minor WHO criterion for PV diagnosis. A low EPO is also used to discriminate PV from secondary thrombocytosis, as it might be low, as expected, or elevated. Phlebotomy primarily treats PV with low risk with a target hematocrit of less than 45%. PV patients with high risk can benefit from low-dose aspirin. Anticoagulation may be added for patients with thromboembolism. Patients with polycythemia vera can present with a high or low serum EPO level. Further diagnostic tests are usually required to confirm the final diagnosis.

Brucella infection presenting as infective endocarditis complicated by embolic stroke.

Brucellosis (undulant fever) is a zoonotic infection caused by Brucella species. It typically presents with fever, malaise, night sweats, and arthralgia. One of its rare complications is infective endocarditis, which occurs in approximately 1.3% of patients and can be further complicated by embolic stroke. This report describes a rare occurrence of Brucella endocarditis presenting as an embolic stroke. A 34-year-old male presented with sudden left-sided weakness and fever. He reported headaches, fever, and generalized weakness in the preceding week. The patient worked on a farm and hence had animal contact. A neurological exam showed left-sided facial weakness, and power of 0/5 and 1/5 in the left upper and lower extremities, respectively. CT scan of the head revealed a right middle cerebral artery (MCA) territory infarct with penumbra and a right MCA occlusion. He underwent a cerebral artery thrombectomy with successful recanalization. However, he continued to have fever and high inflammatory markers. Echocardiography showed aortic valve vegetation and blood cultures grew Brucella melitensis. A multidisciplinary meeting was held to determine the optimal management, which included a course of rifampicin and doxycycline.

Biphasic Peritoneal Mesothelioma Is a Rare Tumor and a Diagnostic Challenge: A Case Report.

Malignant peritoneal mesothelioma (MPM) is a rare subtype of mesothelioma. There are three main histological subtypes of mesothelioma: epithelioid, sarcomatoid, and biphasic (mixed). Risk factors include asbestos exposure, previous radiation, and some germline mutations. Treatment includes surgical resection of amenable tumors or cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. We present a 34-year-old male who presented with weight loss, night sweats, and pleuritic chest pain and was found to have ascites with peritoneal nodularity on abdominal imaging. He had a history of tuberculosis contact, but no history of asbestos exposure. After a long challenging and interesting diagnostic process, he was subsequently diagnosed with biphasic MPM. The diagnostic challenge stems from not only the rarity of the tumor but also from the absence of risk factors, the unavailability of some special laboratory investigations, in addition to the potentially misleading effect of tuberculosis exposure history, a top differential diagnosis in the case. This is a case report of a really challenging and totally unexpected diagnosis of biphasic peritoneal mesothelioma in a patient with tuberculosis exposure, constitutional symptoms, but no history of asbestos exposure. It highlights the diagnostic process as well as the importance of early diagnosis to improve the overall survival of such malignancies.

DVT as the Initial Presentation of Multiple Myeloma: A Rare Case Report and Literature Review.

Multiple myeloma patients are recognized to have a higher risk of venous thrombosis. The cause of this could be attributed to several risk factors, such as circulating prothrombotic microparticles, disease-specific variables, and alterations in coagulation and fibrinolysis factors. Recent research has revealed that these individuals also experience greater arterial thrombosis, including acute myocardial infarction and stroke. In this case report, we present the clinical profile and management of a 42-year-old patient who presented with signs and symptoms of deep venous thrombosis (DVT) and was diagnosed with multiple myeloma. The aim of this case report is to highlight a rare clinical presentation and diagnostic workup in a patient with multiple myeloma. Additionally, we discuss the possible factors provoking the development of DVT as a first presentation before treatment initiation and their possible mechanisms.

Postpartum Septic Shock Due to Clostridium Perfringens From Chorioamnionitis: A Rare Case.

Although postpartum infections caused by Clostridium species are relatively rare, they can have severe consequences if not promptly identified and treated. Clostridial uterine infections typically originate as localized chorioamnionitis, stemming from fetal and/or placental tissue infection. The infection may then spread to the uterine wall and endometrial tissues, and in the most severe cases, it may result in sepsis and shock. These infections can cause serious illness and a high mortality rate without proper treatment. We describe the case of a 26-year-old primigravida woman at 39 weeks gestation who presented with active labor. Clostridium perfringens was isolated from her blood culture, which led to an intrapartum fever and postpartum septic shock. The patient was admitted to the intensive care unit and received appropriate management, resulting in a favorable outcome.

Design, synthesis, and unraveling the antibacterial and antibiofilm potential of 2-azidobenzothiazoles: insights from a comprehensive in vitro study.

The present study reports the synthesis of 2-azidobenzothiazoles from substituted 2-aminobenzothiazoles using sodium nitrite and sodium azide under mild conditions. All the synthesized compounds were examined for their antibacterial activity against Gram (+) bacteria, Staphylococcus aureus (ATCC 25923), Enterococcus faecalis (ATCC 51299), Bacillus cereus (ATCC 10876) and Gram (-) bacteria, Escherichia coli (ATCC 10536), Pseudomonas aeruginosa (ATCC 10145), Klebsiella pneumonia (ATCC BAA-2146)and clinical isolates of Gram (+) Methicillin Resistant S. aureus (MRSA) and Multi Drug Resistant E. coli. The Minimum Inhibitory Concentration (MIC) and Minimum Bactericidal Concentration (MBC) values by broth dilution method revealed that compound 2d exhibited significant antibacterial potential against E. faecalis and S. aureus with MIC of 8 µg/mL, while other synthesized compounds had only moderate effects against all the tested species. The compound significantly inhibited the biofilm formation of the bacterial strains below its MIC. The selective cytotoxicity of Compound 2d towards bacterial cells was evidenced on extended exposure of Human Embryonic Kidney-293 cell line to higher concentrations of the compound. Hence, the present study confirmed that compound 2d can be a potential drug candidate for future development as an antibacterial drug.

Isolated Sixth Cranial Nerve Palsy as Initial Presentation of Pituitary Apoplexy: A Case Report.

Pituitary apoplexy is a serious condition, which if left untreated, might lead to irreversible life-long complications. Hence, pituitary apoplexy should always be included in the differential diagnoses of a patient with an isolated sixth cranial nerve (CN) palsy. This report highlights the case of a patient presenting with isolated CN palsy associated with pituitary apoplexy. Although pituitary adenomas are common, they seldom present with isolated abducent nerve palsy without any other CN involvement. The 47-year-old female patient presented with acute right eye pain, diplopia, and a squint. Examination revealed an isolated unilateral sixth CN palsy. Brain MRI showed a sellar and suprasellar mass suggestive of hemorrhagic pituitary apoplexy. The patient was transferred to neurosurgery and underwent transsphenoidal resection of a pituitary macroadenoma. Postoperative follow-up showed clinical improvement. It is, thus, imperative for physicians to have the knowledge to recognize an isolated sixth cranial nerve palsy and its associated causes.

The utility of testing erythropoietin level in polycythemia diagnosis.

OBJECTIVES: Polycythemia vera (PV) is classically thought to be associated with low erythropoietin (EPO) levels. Here, we present a review of the utility of using EPO levels in diagnosing polycythemia. METHODS: We conducted a systematic literature review of the Medline data through Pubmed and Google Scholar. We included the articles which described confirmed PV associated with elevated EPO level. Our search strategy included the following terms in Pubmed (((polycythemia vera[MeSH Terms]) OR (jak2 protein tyrosine kinase[MeSH Terms])) OR (Myeloproliferative Disorders[MeSH Terms])) AND (Erythropoietin[MeSH Terms]), and 'polycythemia vera with erythropoietin' in Google Scholar. RESULTS: Our research yielded four cases of PV with elevated EPO levels. The most common symptom was a headache. Thrombotic phenomena happened in a single case in the form of Budd-Chiari syndrome. The mean Hb level was 20.2 gm/dl, and the EPO level was 213 mlU/mL. DISCUSSION: Although PV is usually associated with low EPO levels, high levels do not exclude this diagnosis. Workup should include testing for JAK2 mutation and bone marrow biopsy in the presence of suggestive signs and symptoms. Novel biomarkers are also being proposed to aid in the diagnosis. CONCLUSION: Although elevated EPO levels suggest secondary causes of polycythemia, cases where elevated EPO levels were associated with an underlying PV are reported in the literature, and we have summarized a review of them. Workup for polycythemia should include JAK2 mutation testing if signs and symptoms suggest PV even if EPO is elevated.

A Challenging Case of Adult-Onset Still's Disease Complicated by Macrophage Activation Syndrome With Multiorgan Failure.

Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disease that involves the excessive production of proinflammatory cytokines. Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune-mediated disorder that can be primary or secondary to malignancy, infections, and autoimmune diseases. We present an interesting case of a young female with adult-onset Still's disease that commenced during pregnancy. Whole-body fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scan showed diffuse uptake in the spleen and bone marrow with widespread lymphadenopathy. During the delayed diagnostic process to exclude lymphoproliferative malignancy, she developed severe HLH/macrophage activation syndrome (MAS) with multiorgan failure. In this case report, we described the challenges faced during the diagnosis of AOSD. We also highlighted the importance of using clinical criteria to aid in the early diagnosis and management of AOSD patients and the role of FDG-PET/CT scans in patients with AOSD. Additionally, we discussed the management aspects for patients with macrophage activation syndrome.

Cerebral Neuroschistosomiasis Presenting as a Brain Mass.

Neuroschistosomiasis is a rare manifestation of schistosomal infections presenting with cerebral and spinal cord involvement. We reported a case of a 31-year-old woman who presented with a history of headache, dizziness, and nausea. Brain MRI with contrast showed features suggestive of brain lesion with edema, and a serology test for Schistosoma was positive. She was diagnosed with neuroschistosomiasis and treated with intravenous steroids followed by praziquantel resulting in a significant regression of the brain mass. Cerebral neuroschistosomiasis is a rare complication of Schistosoma infection, and clinicians should consider it among the differential diagnosis of unexplained brain lesions.

Physical Activity Among Medical Students at the University of Khartoum, Sudan, 2022: Knowledge, Practice, and Barriers.

Introduction Physical inactivity is a highly prevalent modifiable risk factor for many diseases, including cardiovascular and cerebrovascular diseases, the leading causes of death. Many health institutes have issued and adopted guidelines and recommendations on physical activity. This study aims to study the knowledge, practice, and barriers of medical students enrolled at the University of Khartoum, Sudan, regarding physical activity. It aimed to assess the students' knowledge about physical activity, to determine the levels of physical activity and compare it with the WHO recommended levels and data from other countries, to compare the activity and sedentary levels between males and females, and to take a look on the barriers to physical activity. Methods An observational, descriptive, cross-sectional study was conducted at the Faculty of Medicine, University of Khartoum in December 2022. A total of 336 students were included using systematic random sampling. Data were collected using an online questionnaire that included the Global Physical Activity Questionnaire (GPAQ). Levels of physical activity were described and compared between males and females. Results Around 40.5% of the students achieved the recommended level of physical activity. The mean level of vigorous-intensity physical activity was 50.9 minutes/week (SD= 125.7), the mean level of moderate-intensity physical activity was 156.5 minutes/week (SD= 316.1), the mean level of total physical activity was 207 minutes/week (SD= 356). Between males and females, there was a significant mean difference in the level of vigorous-intensity physical activity and total physical activity. The mean level of sedentary behavior was 7.61 hours/day (SD= 4.62) with no significant difference between males and females (p=0.127). Students showed good knowledge about the cardiovascular and mental benefits of physical activity but not about its protective benefits against cancer. Only 19.4% knew the WHO-recommended levels of physical activity. The most common major barriers toward physical activity reported by the students were lack of time (43.8%), and lack of suitable facilities (31.3%) among others. Conclusion More than half (59.5%) of the students were insufficiently active. Levels of physical activity were significantly associated with the participants' sex but not their knowledge of the recommended levels of physical activity. Males showed higher levels of physical activity. Lack of time was the most common barrier to exercise. More knowledge and education about physical activity should be provided as well as suitable facilities.

Severe Urine Retention and Deep Vein Thrombosis: A Case Report and Review of the Literature on an Unusual Association.

Acute urine retention is the most common urologic emergency, and it usually presents with abdominal pain and an inability to pass urine. The distended bladder in urine retention can be enormously large, raising the intra-abdominal pressure and compressing the iliac veins draining the lower limbs and pelvis. Many cases have been reported to have deep vein thrombosis (DVT)-like features with urine retention that resolves with bladder decompression. In rare cases, urine retention can lead to DVT, particularly in young patients. We report a case of a young female patient with a huge distended bladder who devolved extensive venous thrombosis bilaterally. The report sheds light on this unusual complication of acute urine retention and reviews the existing literature on the topic.

The Quality of Discharge Summaries at Al-Shaab Hospital, Sudan, in 2022: The First Cycle of a Clinical Audit.

Background The discharge summary is a vital component of the modern health system. It is defined as a synopsis of information regarding events occurring during the inpatient care of a patient, to allow for a safe, quick, and effective patient-centered discharge process. It contains important information about the patient's hospital stay, including the reason for admission, treatment received, and follow-up needed. Low-quality discharge summaries pose a great risk to patient healthcare since the most frequent reason for error in clinical settings is poor communication. In the United Kingdom, the Professional Record Standards Body (PRSB) has adopted the Academy of Medical Royal Colleges (AoMRC) "Standards for the Clinical Structure and Content of Patient Records" and produced a standard discharge summary form. This study aimed to assess the quality of discharge summaries at Al-Shaab Hospital in Sudan in terms of information, filling adequacy, and adherence to international guidelines and evaluate the discharge interviews. Methods A cross-sectional institution-based study was conducted in the period of September to December 2022 at Al-Shaab Teaching Hospital in Khartoum, Sudan. Systematic random sampling was used to select the study participants from the discharged patients. A total of 70 patients were met in their wards over a period of two months, and the contents of their discharge cards were compared to items on an online checklist based on the Professional Record Standards Body (PRSB) and the Academy of Medical Royal Colleges (AoMRC) standard discharge summary. The patients were also interviewed to assess their knowledge regarding their discharge information. Results The hospital's discharge summary form contained only four headings: date, patient name, age, and ID number. The assessed cards were found to be missing valuable information, including date of admission (missing in 83%), filling doctor's name (missing in 71%), and medication changes (missing in 70%). Only half of the summaries were clearly readable. The majority of patients had poor knowledge regarding their medication side effects (89%) and how to act in an emergency (86%), while knowledge of medication doses and follow-up details was good in 80% and 66%, respectively. Conclusion The patients are discharged with inadequately filled discharge forms. This may be due to the poor design of the form, so a newly designed form will be proposed, based on international standards. The discharge interview is also in need of improvement, to make sure patients are fully aware of their condition.

Impact of Clinical Pharmacist Interventions on Economic Outcomes in a Cardiology Setting in Qatar.

We sought to investigate the economic impact of preventing adverse events in a cardiology setting in Qatar as an effect of the clinical pharmacist as an intervention. This is a retrospective study of interventions by clinical pharmacists within an adult cardiology setting in a public healthcare setting (i.e Hamad Medical Corporation). The study included interventions that took place in March 2018, July 15, 2018 to August 15, 2018, and January 2019. The economic impact was measured via calculating the total benefit, defined as the sum of the cost savings and the cost avoidance. Sensitivity analyses were adopted to confirm the robustness of the results. The pharmacist intervened in 262 patients, resulting in 845 interventions, with appropriate therapy (58.6%) and dosing/administration (30.2%) being the most frequent categories of reported interventions. Cost savings and cost avoidance resulted in QAR-11,536 (USD-3169) and QAR1,607,484 (USD 441,616), respectively, yielding a total benefit of QAR1,595,948 (USD 438,447) per 3 months and QAR6,383,792 (USD 1,753,789) per a year.

Economic impact of clinical pharmacist interventions in a general tertiary hospital in Qatar.

BACKGROUND: With an increasingly strained health system budgets, healthcare services need to continually demonstrate evidence of economic benefits. This study sought to evaluate the economic impact of interventions initiated by clinical pharmacists in an adult general tertiary hospital. METHODS: A retrospective review of clinical pharmacist interventions was carried out throughout follow-up durations in March 2018, July/August 2018, and January 2019 in Hamad General Hospital (HGH) at Hamad Medical Corporation (HMC) in Qatar. The study included clinical pharmacy interventions data of patients admitted to the internal medicine, critical care, and emergency wards. Included interventions were documented by clinical pharmacists or clinical pharmacy specialists, and approved by physicians. Interventions by non-clinical pharmacists or with missing data were excluded. Adopting the perspective of HMC, we calculated the total economic benefit, which is the sum of the cost savings and the cost avoidance associated with the interventions. Cost savings was defined as the reduced cost of therapy associated with therapy changes minus the cost of intervention and cost avoidance was the cost avoided by eliminating the occurrence of adverse drug events (ADEs). Sensitivity analyses were performed to assess the robustness of results against uncertainties. RESULTS: A total of 852 interventions, based on 340 patients, were included. The analysis projected an annual total benefit of QAR 2,267,036 (USD 621,106) based on a negative cost-savings of QAR-175,139 (USD-47,983) and a positive cost avoidance of QAR741,898 (USD203,260) over the 3-month follow-up period. The uncertainty analysis demonstrated the robustness of outcomes, including a 100% probability of positive economic benefit. CONCLUSIONS: The clinical pharmacist intervention was associated with an increased cost of resource use, which was overtaken by the cost avoidance generated. The pharmacy intervention, therefore, is an overall economically beneficial practice in HGH, reducing ADEs with considerable consequential positive economic savings.

Splenic Infarctions in Polycythaemia Vera are Not Always a Catastrophe.

Splenic infarction can occur as an infrequent thrombotic manifestation in polycythaemia vera (PV) and is usually catastrophic. We describe the case of a middle-aged woman who was diagnosed with PV 3 months before she presented to the emergency department with acute limb ischaemia. A splenic infarction detected on diagnostic imaging during her hospital stay was treated conservatively with modification of her hydroxyurea dose along with pain management, without the need for surgery. LEARNING POINTS: Multiple splenic infarctions are an uncommon presentation in polycythaemia vera.Patients can present with vague abdominal pain, so a high index of suspicion is necessary and diagnosis is usually radiological.Splenic infarction in polycythaemia patients can be treated successfully with hydroxyurea and pain management with aspirin.

Malaria causing post-infectious cerebellitis, a case report and literature review.

Background: Malaria is a common parasitic infection with a wide range of clinical presentations. Thus, it should be suspected for any symptomatic patient with a recent travel history to a malaria-endemic area. Case presentation: In this case report, we will present a previously healthy 28-year-old patient who developed cerebellar signs that were attributed to infectious etiology later on proven to be a malaria-related complication that responded well to anti-malarial medications. Discussion: The classical presentation of malaria with attacks of fever is noticed only in around 60% of the patients. The development of immunity, the increasing resistance to anti-malarial drugs, and the indiscriminate use of anti-malarial drugs have led to malaria presenting unusual characteristics. Cerebellar ataxia, extrapyramidal signs, and various psychiatric manifestations have been described as early presentations of cerebral malaria or as a part of the post-malaria neurological syndrome. Other neurological syndromes like peripheral neuropathies, movement disorders, myelopathies, and stroke-like syndrome have also been described. Conclusion: Malaria should be included as a differential diagnosis in a patient presenting with cerebellar signs as its devastating if left untreated. However, it responds well to anti-malarial regimens if started early during the course.