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Cushing's syndrome is a constellation of features occurring due to high blood cortisol levels. We report a case of a 47-year-old male with a history of recurrent olfactory neuroblastoma (ONB). He presented with bilateral lower limb weakness and anosmia and was found to have Cushing's syndrome due to high adrenocorticotropic hormone (ACTH) levels from an ectopic source, ONB in this case. Serum cortisol and ACTH levels declined after tumor removal.

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Wernicke's encephalopathy (WE) is an acute neuropsychiatric emergency due to thiamine deficiency. This report includes a case of a young pregnant female in her second trimester (17th weeks) complaining of hyperemesis gravidarum, who, due to excessive vomiting, developed severe vitamin B1 deficiency, leading to WE and Korsakoff's psychosis. The typical triad of confusion, ocular signs, and ataxia is fundamental for the diagnosis of WE, yet not all cases present with the entire triad; however, our patient presented with all the symptoms. Replacement of thiamine, which is a crucial vitamin that plays an important role in the integrity of the nervous system, is the first step in the management of WE.

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BACKGROUND: The effect of neuraminidase inhibitor (NAI) treatment on length of stay (LoS) in patients hospitalized with influenza is unclear. METHODS: We conducted a one-stage individual participant data (IPD) meta-analysis exploring the association between NAI treatment and LoS in patients hospitalized with 2009 influenza A(H1N1) virus (A[H1N1]pdm09) infection. Using mixed-effects negative binomial regression and adjusting for the propensity to receive NAI, antibiotic, and corticosteroid treatment, we calculated incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Patients with a LoS of <1 day and those who died while hospitalized were excluded. RESULTS: We analyzed data on 18 309 patients from 70 clinical centers. After adjustment, NAI treatment initiated at hospitalization was associated with a 19% reduction in the LoS among patients with clinically suspected or laboratory-confirmed influenza A(H1N1)pdm09 infection (IRR, 0.81; 95% CI, .78-.85), compared with later or no initiation of NAI treatment. Similar statistically significant associations were seen in all clinical subgroups. NAI treatment (at any time), compared with no NAI treatment, and NAI treatment initiated <2 days after symptom onset, compared with later or no initiation of NAI treatment, showed mixed patterns of association with the LoS. CONCLUSIONS: When patients hospitalized with influenza are treated with NAIs, treatment initiated on admission, regardless of time since symptom onset, is associated with a reduced LoS, compared with later or no initiation of treatment.

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INTRODUCTION: Venous thromboembolism (VTE) during hospitalization is a serious and potentially fatal condition. Despite its effectiveness, evidence-based thromboprophylaxis is still underutilized in many countries including Saudi Arabia. OBJECTIVE OF THE STUDY: Our objectives were to determine how often hospital-acquired VTE patients received appropriate thromboprophylaxis, VTE-associated mortality, and the percentage of patients given anticoagulant therapy and adherence to it after discharged. METHODS: This study was conducted in seven major hospitals in Saudi Arabia. From July 1, 2009, till June 30, 2010, all recorded deep vein thrombosis (DVT) and pulmonary embolism (PE) cases were noted. Only patients with confirmed VTE diagnosis were included in the analysis. RESULTS: A total of 1241 confirmed VTE cases occurred during the 12-month period. Most (58.3%) of them were DVT only, 21.7% were PE, and 20% were both DVT and PE. 21.4% and 78.6% of confirmed VTE occurred in surgical and medical patients, respectively. Only 40.9% of VTE cases received appropriate prophylaxis (63.2% for surgical patients and 34.8% for medical patients; P < 0.001). The mortality rate was 14.3% which represented 1.6% of total hospital deaths. Mortality was 13.5% for surgical patients and 14.5% for medical patients (P > 0.05). Appropriate thromboprophylaxis was associated with 4.11% absolute risk reduction in mortality (95% confidence interval: 0.24%-7.97%). Most (89.4%) of the survived patients received anticoagulation therapy at discharge and 71.7% of them were adherent to it on follow-up. CONCLUSION: Thromboprophylaxis was underutilized in major Saudi hospitals denoting a gap between guideline and practice. This gap was more marked in medical than surgical patients. Hospital-acquired VTE was associated with significant mortality. Efforts to improve thromboprophylaxis utilization are warranted.

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The diagnosis of deep venous thrombosis (DVT) may be challenging due to the inaccuracy of clinical assessment and diversity of diagnostic tests. On one hand, missed diagnosis may result in life-threatening conditions. On the other hand, unnecessary treatment may lead to serious complications. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia (KSA), an expert panel led by the Saudi Association for Venous Thrombo-Embolism (SAVTE; a subsidiary of the Saudi Thoracic Society) with the methodological support of the McMaster University Working Group, produced this clinical practice guideline to assist healthcare providers in evidence-based clinical decision-making for the diagnosis of a suspected first DVT of the lower extremity. Twenty-four questions were identified and corresponding recommendations were made following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. These recommendations included assessing the clinical probability of DVT using Wells criteria before requesting any test and undergoing a sequential diagnostic evaluation, mainly using highly sensitive D-dimer by enzyme-linked immunosorbent assay (ELISA) and compression ultrasound. Although venography is the reference standard test for the diagnosis of DVT, its use was not recommended.

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BACKGROUND: Neuraminidase inhibitors were widely used during the 2009-10 influenza A H1N1 pandemic, but evidence for their effectiveness in reducing mortality is uncertain. We did a meta-analysis of individual participant data to investigate the association between use of neuraminidase inhibitors and mortality in patients admitted to hospital with pandemic influenza A H1N1pdm09 virus infection. METHODS: We assembled data for patients (all ages) admitted to hospital worldwide with laboratory confirmed or clinically diagnosed pandemic influenza A H1N1pdm09 virus infection. We identified potential data contributors from an earlier systematic review of reported studies addressing the same research question. In our systematic review, eligible studies were done between March 1, 2009 (Mexico), or April 1, 2009 (rest of the world), until the WHO declaration of the end of the pandemic (Aug 10, 2010); however, we continued to receive data up to March 14, 2011, from ongoing studies. We did a meta-analysis of individual participant data to assess the association between neuraminidase inhibitor treatment and mortality (primary outcome), adjusting for both treatment propensity and potential confounders, using generalised linear mixed modelling. We assessed the association with time to treatment using time-dependent Cox regression shared frailty modelling. FINDINGS: We included data for 29,234 patients from 78 studies of patients admitted to hospital between Jan 2, 2009, and March 14, 2011. Compared with no treatment, neuraminidase inhibitor treatment (irrespective of timing) was associated with a reduction in mortality risk (adjusted odds ratio [OR] 0·81; 95% CI 0·70-0·93; p=0·0024). Compared with later treatment, early treatment (within 2 days of symptom onset) was associated with a reduction in mortality risk (adjusted OR 0·48; 95% CI 0·41-0·56; p<0·0001). Early treatment versus no treatment was also associated with a reduction in mortality (adjusted OR 0·50; 95% CI 0·37-0·67; p<0·0001). These associations with reduced mortality risk were less pronounced and not significant in children. There was an increase in the mortality hazard rate with each day's delay in initiation of treatment up to day 5 as compared with treatment initiated within 2 days of symptom onset (adjusted hazard ratio [HR 1·23] [95% CI 1·18-1·28]; p<0·0001 for the increasing HR with each day's delay). INTERPRETATION: We advocate early instigation of neuraminidase inhibitor treatment in adults admitted to hospital with suspected or proven influenza infection. FUNDING: F Hoffmann-La Roche.

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INTRODUCTION: Gastrointestinal basidiobolomycosis (GIB) is an emerging fungal infection with a few cases reported worldwide. It is caused by Basidiobolus ranarum, which does not usually invade blood vessels and rarely disseminates. CASE PRESENTATION: We present a rare case of GIB with hepatic dissemination in a 12-year-old Yemeni boy living in southwestern Saudi Arabia. The initial provisional diagnosis was intestinal lymphoma, and a right hemicolectomy was carried out, but histopathological assessment ruled out lymphoma and suggested intestinal tuberculosis. Two weeks after starting antituberculous medications, the patient was referred to our hospital because of fever and right upper abdominal discomfort. There was leukocytosis with marked eosinophilia, and a liver biopsy showed evidence of B. ranarum infection. A second opinion by histopathological examination of resected tissues diagnosed colonic basidiobolomycosis. The patient was treated successfully with itraconazole. CONCLUSION: GIB is an emerging disease in southwestern Saudi Arabia and should be considered in a patient with an abdominal mass and eosinophilia coming from this region. Persistent elevation of leukocytes and eosinophils after surgical resection of the affected tissue could be used as a predictor of fungal dissemination. Further research is needed for a better understanding of GIB.

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OBJECTIVE: To assess the epidemiologic and clinical manifestations of the first wave of H1N1 influenza A patients. METHODS: This study is a retrospective chart review of all patients admitted in King Saud Medical Complex, Riyadh, Kingdom of Saudi Arabia, from 22nd May to 31st August 2009, with a proven diagnosis of H1N1 influenza A. Only patients with a positive nasopharyngeal swab were included, and excluded when the swab was negative. Charts were then analyzed for epidemiological and clinical data. RESULTS: A total of 153 patients with proven H1N1 infection were admitted, with a predominance of male patients (108 [71%]). Most patients were Saudis (111 [73%]), with 83 males (75%), and 28 females (25%). The mean age was 25 years (standard deviation; 9.45 years), and median age was 24 years. The most common symptoms in order of frequency were; fever (143 patients), cough (126 patients), sore throat (70 patients), headache (18 patients), shortness of breath (17 patients), myalgia (11 patients), diarrhea (9 patients), and vomiting (7 patients). Average duration of symptoms before admission was 3.55 days, and the average time of hospitalization was 4.8 days. Full recovery was obtained in 150 patients. Death occurred in 3 patients. CONCLUSION: True to its designation as a pandemic, H1N1 influenza A, has reached Saudi Arabia and poses a risk to the young population without immunity, and those with co-morbid disease, particularly of the lungs (bronchial asthma), and the pregnant. Despite its virulence in infecting people, deaths are far less than anticipated for such a novel virus. Social distancing can be recommended. However, further observation has to continue to substantiate these tentative preliminary findings.

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Nalidixic acid-resistant Salmonella typhi NARST infections increase minimal inhibitory concentrations of fluoroquinolones, due to chromosomal mutations in the gene encoding DNA gyrase, and can lead to a delayed treatment response. This in turn alters the course of the disease allowing for a protracted period of illness and the occurrence of complications. In this case report, we present a patient from the Indian sub-continent, who was diagnosed with NARST complicated by sub-intestinal obstruction, her diagnosis, treatment, and subsequent recovery.

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Chronic granulomatous disease CGD is a condition of inability to deal with bacterial and fungal infections, due to defective respiratory burst in neutrophils leading to recurrent cutaneous and visceral infections. Usually a disease of childhood, but patients nowadays survive to adulthood, and diagnosis might be difficult if not considered. We describe a 20-year-old female with previously undiagnosed CGD, presenting with recurrent cutaneous and hepatic abscesses.

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Congenitally corrected transposition of the great arteries CCTGA is a rare congenital disease first described by Von Rokitansky in 1875. Transposition of the great arteries comprises 2.6 - 7.8% of all cases of congenital heart disease, and if uncorrected, is commonly fatal in the first year of life. Patients with corrected transposition of the great arteries without associated defects may remain undiagnosed until adult life. Symptoms occur rarely before the fourth and fifth decades, when rhythm disturbance, left atrioventricular valve regurgitation, and moderately impaired systemic ventricular function cause congestive cardiac failure. We report here a case of drug overdose with ischemic symptoms, and CCTGA without associated anomalies in a 40-year-old male.

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The spinal cord can be involved in a variety of disease processes. These can be congenital or acquired. An acute onset of symptoms usually allows a defined set of causes to be considered including trauma, ruptured vascular anomalies, demyelination, and myelitis. Intramedullary cavernous hemangioma of the spinal cord is a congenital or acquired vascular malformation, and one of the rare causes of hematomyelia. We present such a case, and discuss the symptoms, diagnosis, and suggested best treatment options based on a review of present day literature.

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Staphylococcus aureus is the most common cause of endocarditis in intravenous drug users. The organism gains access by intravenous injection or from the direct invasion of skin at injection sites. Known for its aggressiveness, the right sided endocarditis that ensues can lead to complications such as pulmonary abscesses and even death. We report the unusual case of an intravenous drug abuser, who following the occurrence of extensive pulmonary abscesses, developed bilateral pneumothoraces within a few days.

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Neurosyphilis is the infection of the central nervous system with treponema pallidum species, and true to its reputation as the old mimic, can present with a multitude of clinical scenarios, one of which is stroke in the young. Rare in developed countries, except for an at-risk population of drug abusers and HIV infected patients; it is still common in the rest of the world. We describe the case of a young Indian male, his presentation, diagnosis and treatment, and remarkable recovery on aqueous penicillin G therapy following his presentation with a stroke.

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Hospitalized patients are in danger of deep venous thrombosis either due to a genetic tendency, immobilization or the underlying medical condition. Paradoxically heparin, the substance used to prevent this complication, can lead to thrombo-embolic phenomena, which can be life threatening. We report a case of heparin-induced thrombocytopenia, which caused a massive pulmonary embolism, and its management by administering a thrombolytic agent in a situation where bleeding seems inevitable.

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Dilated cardiomyopathy and the resultant left ventricular dysfunction are risk factors for thrombus formation in the heart, reflecting the intimate relationship between structure and function in this vital organ. Once formed, depending on size, location, and mobility, left ventricular thrombi have the tendency to embolize, sometimes with dire consequences. Proper management of these thrombi is still controversial. We present a case of an unusual large thrombus, which resolved with anticoagulation therapy alone, giving hope that more invasive intervention can safely be circumvented.

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Candida albicans CA is an opportunistic fungus, which lives in close association with its human host. Immuno-competence is the barrier to its tendency to invade. Normal skin, commensal bacteria and neutrophils are the first hurdles and once broken down by indwelling catheters, antibiotics or ablative chemotherapies, dissemination can occur with grave consequences. We describe a young patient with apparent full immune competence, who suffered from disseminated CA infection, her presentation, diagnosis and therapy with amphotericin B deoxycholate, which lead to her complete recovery and return to a productive life.

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