Moamen AL Zoubi is affiliated to the Advocate Illinois Masonic Medical Center, USA.

Cardiac tamponade is a life threatening condition often requiring urgent or emergent pericardiocentesis and close monitoring in the ICU. We report a 51 year-old spanish speaking female with a history of hypothyroidism who presented with facial swelling, SOB and orthopnea for 3 weeks. She denies joint pain, rash, fever, chills, weight loss. She had travelled to Mexico 6 years ago but did not remember exposure to TB patients. She had not received BCG vaccine as a child. In the ER her vitals were stable. Labs were remarkable for Alk phos 230, AST 63 and ALT 102. Otherwise, unremarkable including normal thyroid function test. ANA comprehensive panel and HIV test were negative. The ECG showed sinus rhythm and low QRS amplitude. Chest X-ray demonstrated bilateral pleural effusion. Echocardiogram showed large pericardial effusion with features consistent with tamponade physiology. Urgent pericardiocentesis was done with 450 ml fluid withdrawn. Thoracentesis was done as well and samples were sent for analysis. The fluids was an exudate.AFB smears and fungal culture came back negative. Repeated Echo showed complete resolution of pericardial effusion. Patient was discharged on colchicine 0.6 mg by mouth twice a day x2 weeks. Two weeks later the patient presented again with dyspnea and found to have cardiac tamponade after performing Echocardiography. Patient was taken to the operating room and a pericardial window was performed. TB quantiferon test found to be positive from the previous admission and she was started empirically on anti-TB medication as recommended by infectious diseases service. The results of pericardial biopsy showed no evidence of TB or sarcoidosis. No granulomas or malignant cells were seen. AFB smear was negative in three consecutive samples and Anti-TB medication were discontinued. Viral serology sent and came back elevated as high as 320:1 for coxsackie B type 4. Repeated Echocardiogram showed no pericardial effusion and patient reported improvement of her symptoms. The patient was discharged on indomethacin 50 mg BID with a cardiology follow up in 2 weeks. To the best of our knowledge, this is the first reported case of cardiac tamponade secondary to group B coxsackieviruses. We encourage considering viral causes as a probable etiology for cardiac tamponade of unknown etiology.

Anamika Gupta has completed her PhD from Banaras Hindu University, India and Postdoctoral studies from National AIDS Research Institute, India. Currently, she is working with Boston University School of Medicine as a Visiting Researcher. She has published 13 papers in peer reviewed journals and 5 manuscripts are in process. She has also published 3 chapters in the books of international repute.

Beijing genotype of Mycobacterium tuberculosis has attracted special attention due to its association with multi drug resistance and rapid transmission. The present study was undertaken to investigate the prevalence of Beijing genotype of M. tuberculosis and their association with drug resistance and clinical characteristics of TB patients. A total of 381 clinical isolates were cultured from more than 4000 TB patients’ sputum samples from 2008 to 2014, of which the genetic profile was determined by using multiplex-PCR and Spoligotyping methods and the drug susceptibility testing to first-line anti-TB drugs was performed by using proportion method and MGIT960. Detection of mutations at rpoB codons (516, 526 and 531), katG codon 315 and embB codon 306 in Beijing and non-Beijing-strains were determined by MAS-PCR and DNA-sequencing. We also characterized a collection of M. tuberculosis isolates to see if Beijing strains had a higher rate of mutations in katG315, rpoB-RRDR region and embB306 gene. Multidrug-resistance was observed to be significantly associated with Beijing strains (p=0.03) and a strong correlation between Beijing strains and specific resistance mutations in katG315, rpoB531 and embB306 gene segments was also found (p=<0.0001, <0.0001 & 0.0014 respectively). These findings will help to understand the transmission and drug resistance related genetic characteristics of the Beijing/W genotype of M. tuberculosis and may provide a scientific basis for the development of new TB diagnostic tool for effective management and control of TB in countries with higher prevalence of Beijing strains.

Mojdeh Habibi Zoham has completed General Medicine from Tehran University of Medical Sciences in 2009. She continued her work with graduation in Pediatrics from Tehran University of Medical Sciences in 2012. After her graduation, she has started working as an Associate Professor of Tehran University of Medical Sciences. She has been working in Pediatric ICU ward of Bahrami Children Hospital for at least 3 years and has 6 published articles in reputed journals.

Basidiobolomycosis is a rare fungal disease caused by Basidiobolus ranarum which is an environmental saprophyte. It is a chronic inflammatory disease that is generally restricted to the subcutaneous tissue and rarely involves gastrointestinal tract. With the intent to spread the awareness of this potentially life threatening and rare infection, we report a 4 years old boy presenting with abdominal pain and fever with eventual diagnosis of gastrointestinal basidiobolomycosis. We discuss the non-specific and confusing of symptoms of this rare infection and treatment options in detail.

Hammad A is affiliated to the National Ribat University, Sudan.

Background: Humans infected with schistosoma parasite demonstrate substantial immune responses against both adult worms and eggs. This response can be studied in different age group in both males and females in exposed and infected population. The study aimed to determine the humoral immune responses of Sudanese residents in an endemic area of Schistosoma haematobium. Methods: Syringe filtration techniques were used to detect Schistosoma haematobium eggs. To rule out Schistosoma mansoni and other helminths infection, Kato Katz technique for the examination of stool was used. One hundred twenty eight individuals were included in the study. Twenty one subjects who were Schistosoma haematobium negative participated in the study as a control group. Different ELISA techniques were used to detect different anti-Schistosoma haematobium antibodies. Results: The mean infection intensity was 61.92 eggs per 10 ml urine. Peak infections were found among the age group of 3-13 year. 53.1% had light infection and 46.9% had heavy infection. High levels of anti-soluble egg antigen (SEA) IgE was detected in infected individuals in the age group range (13-23 years) while low levels were observed in individual of ˃23 year of age. The highest anti- (SEA) IgA level was detected in old patients. The highest anti-SEA IgM levels were found in children aged 3-13 year. Females produced high levels of anti-SEA IgE, IgM and IgG, while males produced high levels of IgA. Conclusion: These results showed high production of IgE which may protect the host until development of other immune responses and may also protect the host from re-infection.

Musa H A is affiliated to the National Ribat University, Sudan.

Background: Schistosome-specific acquired immunity capable of reducing levels of infection or re-infection develops slowly. The nature of these protective immune responses suggesting that anti-helminths immune responses fall into a Th1 (pro-inflammatory) and Th2 (anti-inflammatory). Objective: The aim of this study was the detection and quantification of pro-inflammatory cytokines in both sera and urine of patients with urinary schistosomiasis. Methodology: One hundred and thirty sera and urine were collected from patients with urinary schistosomiasis in two villages south Elduiem (Sudan). The disease was confirmed by finding Schistosoma haematobium eggs in urine using syringe filtration techniques. To rule out Schistosoma mansoni and other helminths infection Kato Katz technique for stool examination was used. Sera and urine of seventy subjects who were Schistosoma haematobium negative included in the study as controls. Samples were examined for IFNγ and IL-2, cytokines level using ELISA techniques. Results: The prevalence of Schistosoma haematobium infection in the study population showed that the peak of infection was in childhood (3-13 years) followed by a sharp decline in infection intensity. Males infected more than females 62% and 38% respectively. Measurements of parasite specific cytokine responses showed high levels of both cytokine productions before treatment then after treatment. There are significant differences in cytokine production in infected groups and control one. Females produce high levels of IFNγ and IL-2 than males. Aged people produce high levels of both cytokine than young people. There are a positive association between the production of cytokine and intensity of the infection. Conclusion: The conclusion drawn from the study is that pro-inflammatory cytokines were produced in large amount before treatment with significant difference between males and females.

Nurul Azmawati Mohamed has completed her Bachelor of Medicine and Surgery in 2002 from University of Sheffield, United Kingdom and Masters of Pathology (Medical Microbiology) in 2012 from National University of Malaysia. She is a Clinical Microbiologist and Senior Medical Lecturer at Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia. Her interest is in bacteriology, particularly on antibiotic resistant organisms. She has published 10 articles in journals and presented in conferences locally and internationally.

Background: Taking honey with citrus juice (lemon/lime/calamansi) to soothe sore throat has been practiced in many parts of the world for decades. Various combinations of honey with different types of citrus juice (lime, lemon and calamansi to name a few) have been traditionally used by the Egyptians, Assyrians, Greeks, Romans, Chinese, Indians and Malays for the treatment of sore throat. The amount of honey and citrus juice used also varies from different cultures and places. Objective: To systematically review the antibacterial effect of honey and citrus juice on Streptococcus pyogenes. Methodology: Using the keywords honey, manuka, tualang, citrus, lime and Streptococcus pyogenes, we systematically searched EBSCOhost, Ovid, Scopus and WEB OF SCIENCE databases for reports of studies investigating the antibacterial effect of honey and citrus juice on Streptococcus pyogenes. Results: A total of 415 abstracts were initially identified. 26 abstracts were finally chosen and reviewed by looking at the title, abstracts and full paper using pre-determined inclusion and exclusion criteria in relation to honey (n=22) and citrus (n=4). None of the articles studied the effect of both honey and citrus juice on the organism. Majority of the studies showed that both honey and citrus have significant antimicrobial effect on Streptococcus pyogenes. Conclusions: There is no available data on the combined effect of honey and citrus on Streptococcus pyogenes. This knowledge gap offers an opportunity to investigate those effects with the purpose to support traditional practice with scientific evidences.

Nurul Azira Binti Mohd Shah has completed her degree in Bachelor of Medicine and Bachelor of Surgery (MBBS) from University of Malaya, Malaysia. She was also awarded Master of Pathology (MPath) in Clinical Microbiology from Universiti Sains Malaysia. She is a Clinical Microbiologist and Medical Lecturer in Universiti Teknologi MARA, Malaysia.

Background: Amoebiasis is a parasitic disease caused by Entamoeba histolytica that causes death in developing country. The gold standard treatment for amoebiasis is metronidazole. However, the emergence of resistant against metronidazole has been increasingly reported. Thus, it is important to search for other alternative control measure which is safe and effective. Medium chain triglyceride (MCT), an active compound in natural products is widely available as a nutrient supplement and has been shown to have anti-protozoal properties. Objective: Therefore the objective of this study is to investigate the potential effect of medium chain triglycerides (MCT) against amoebic infections. Methods: The trophozoites of Entamoeba histolytica HM1: IMSS strain were axenically cultivated in TYI-S-33 medium in culture flasks and incubated anaerobically by using Anaerocult A (Merck). The anti-amoebic effect was determined by measuring the minimum inhibitory concentration (MIC) of E. histolytica against MCT active compounds which include lauric acid, capric acid, caprylic acid and caproic acid were based on scoring of trophozoites growth using the standard method. Results: Lauric acid and capric acid exhibited anti-amoebic effect with minimum inhibitory concentration (MIC) of 400 μg per ml and 800 μg per ml respectively. Conclusion: In conclusion, MCTs was active against E. histolytica in vitro and should be considered as a probable anti-amoebic compound in amoebiasis.

Veeraraghavan Meyyur Aravamudan is senior resident in advanced internal medicine at National University Hospital, Singapore.

A 46 year old Malay male with past surgical history of mastoidectomy in 2007 for cholesteatoma was admitted with sudden onset of headache, altered level of consciousness and lethargy for 1 day. Associated symptoms included multiple episodes of non-projectile vomiting and photophobia. He denied blurring of vision, otalgia and otorrhea. Physical examination revealed a lethargic looking male patient with a GCS of 3. His temperature was 38.5 oC. Neck rigidity was present on movement in all directions. Cranial nerve and fundoscopic examination was unremarkable. He had skew deviation of eyes to right. Rest of the neurological examination did not reveal any motor deficits. He was started on empirical intravenous ceftriaxone, vancomycin, acyclovir and ampicillin for clinically suspected meningitis while awaiting lumbar puncture results. Computerized tomography (CT) of brain was normal. Cerebrospinal fluid (CSF) obtained from lumbar puncture showed cell count of 900 units per mm3 with 80% lymphocytes and 20% neutrophils, protein of 0.92 gram per liter and glucose was 1.7 mmol per liter. Gram stain did not reveal any organism and cultures were negative. Polymerase chain reaction (PCR) for neurotropic viruses i.e., HSV, measles, mumps and enterovirus were negative. Cerebrospinal fluid acid fast bacillus (AFB) smear was negative. Computerized tomography (CT) temporal bone with contrast showed right middle ear and mastoid cholesteatoma with surrounding infected granulation tissue which extended into the inner ear and intracranially. He was subsequently referred to ENT and underwent right modified radical mastoidectomy. He made a good clinical recovery. Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. Because of their erosive and expansile properties they can destroy the ossicles and can potentially spread into the base of the skull into the brain causing meningitis. Even though the incidence of cholesteatoma causing meningitis is rare, these are still potential life threatening complications. Cholesteatoma is still considered a surgical disease requiring either the complete removal of its squamous lined matrix or its exteriorization for continued aural toilet and ventilation. In the pre-antibiotic era, the mortality rate from intracranial complications following the otologic diseases was approximately 75%. In the post-antibiotic era, mortality was around 34%. Meningitis is the most common intracranial complication. There are three dissemination passages for the occurrence of otogenic meningitis which are hematogenous, congenital dehiscence (such as Hyrtl’s fissures) or preformed (osseous erosion). Every patient with suspicion of complication needs to be followed up by several medical specialties and must be submitted to full physical exam and computerized tomography with contrast. The treatment must be aggressive with early initiation of intravenous antibiotic and early drainage of the infectious focus in order to reduce the morbidity and mortality rate. Early recognition and computerized tomography of temporal bone were important in diagnosis of meningitis secondary to cholesteatoma and prompt referral to ENT surgeon for early surgery should be considered to avoid long-term complications.

Onyinye Jane Onyemaechi is a 5th year medical student at First Moscow State Medical University I.M Sechenov, Russia. She is a member of Build Africa Capacity and also she is the president of Association of Nigerian Scholarship students in Russia. In 2011, she was awarded scholarship for her astounding academic excellence to study medicine in Russia. Her interest in tropical medicine grew with her increasing desire to help eradicate malaria. She has been a part of research programs, one of which resulted in the abstract “Evaluating the prevalence of drug resistance in intermittent preventive treatment for malaria during pregnancy”. She understands how to successfully fight for malaria eradication and collective efforts are vital and hopes made people to get inspired to make contributions towards achieving malaria eradication.

Background & Objective: Due to the poor patient compliance with prophylaxis and increasing resistance of parasite strains to chloroquine, administration of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine/pyrimethamine is now recommended for all pregnant women living in areas with stable malaria transmission. However, resistance to sulfadoxine/pyrimethamine is on the increase which risks the drug being compromised. Thus, an urgent need exists to assess alternative drug regimens for IPTp. Design & Method: Numerous molecular epidemiologic studies showed that resistance to pyrimethamine is associated with the acquisition of mutations in Plasmodium spp. dihydrofolatereductase (dhfr) genes while resistance to sulfadoxine is associated with 3 mutations in dihydropteroate synthase (dhps gene). Each mutation leads to a decrease in sensitivity to pyrimethamine (dhfr gene) and sulfadoxine (dhps gene). Results: On a systematic review, results indicated that 2 doses of IPTp with sulfadoxine/pyrimethamine retained activity to reduce placental malaria and low birth weight amongst pregnant that visited the clinic. About >60% of the pregnant women that visited the clinic benefited with 2 doses of IPTp in the proportional reduction of peripheral parasitaemia at delivery compared with that at enrolment while the rate of resistance was at <39% and the proportion of placental infection was reduced by 75% compared with the efficacy of chloroquine prophylaxis administered the previous year. Conclusion: An alternative approach involves systematic detection of placental infection at delivery by using blood smear, rapid diagnostic test or PCR with placental blood. Conversely, placental infection prevalence may change with time because of changes in sulfadoxine/pyrimethamine efficacy (likely to decrease) and quality of IPTp implementation (likely to increase). Such an approach would also provide baseline data to assess efficacy of all preventive measures against pregnancy-associated malaria, including IPTp and use of insecticide-impregnated bed nets and will enable assessment of these effects in a specific population.

Leticia Gely has completed her MD from University of Puerto Rico, School of Medicine. She has completed Pediatric Residency at the University of Puerto Rico in the year 2013 and is a Board Certified Pediatrician. She is currently a 2nd year Fellow in the Neonatal-Perinatal Medicine Program at the University of Puerto Rico. She is a Member of National Academic Associations.

Zika virus (ZV) is a mosquito-borne Flavivirus primarily transmitted by Aedes aegypti mosquitoes found in tropical regions. ZV infection may occur by vertical transmission to the fetus or by intrapartum transmission from a viremic mother to the newborn, and may have severe implications to the newborn health including microcephaly. The World Health Organization and the Centers for Disease Control and Prevention (CDC) activated their respective emergency operations centers to better coordinate response to the ZV outbreak. The Neonatology Section, University of Puerto Rico provides services in a Level 3 Neonatal Intensive Care Unit. A protocol was design based on the CDC and the Puerto Rico Health Department guidelines. The specific aim is to identify, evaluate and treat appropriately all fetus/newborns with possible intrauterine ZV exposure. The protocol included a quality improvement strategy with process mapping for all deliveries with documented prenatal ZV exposure. All interventions will follow the standard evaluations and procedures based on the infant’s needs as recommended by the American Academy of Pediatrics and the CDC recommendations. Review of the process map with local managers and frontline health professionals revealed multiple areas which require improvement, such as including new questions of events occurring during prenatal period and accessibility to prenatal laboratory and fetal ultrasounds for appropriate identification of cases and avoid adding steps that do not add value to the process, will dramatically increase the cost of interventions in a time of decreased funding and may interfere with the standard newborn care and the promotion of breastfeeding practices.