Makassed General Hospital

Hematopoietic cell transplantation (HCT) carries a high infection risk, especially pre-engraftment. Fluoroquinolone (FQ) prophylaxis is common, but rising FQ-resistant Enterobacterales (FQRE) rates may limit its effectiveness. This study evaluated febrile neutropenia, bacteremia, and mortality in HCT patients based on FQ prophylaxis and FQRE colonization. A retrospective analysis of HCT recipients at a tertiary center in Lebanon (2017–2022) was performed. Patients receiving FQ prophylaxis during neutropenia were compared with those who did not. FQRE colonization was monitored through weekly perianal swabs post-transplant. Of 156 HCT recipients (mean age 54 years; 61% males), 73.1% received FQ prophylaxis, and 39% had FQRE colonization. Febrile neutropenia occurred in 86%, more frequently in non-prophylaxis and FQRE-colonized patients, though prophylaxis delayed its onset within 10 days post-transplant. Bacteremia affected 39.1% of 64 eligible patients, with lower rates in the prophylaxis group (35.7% vs. 62.5%, p = 0.02). Escherichia coli and coagulase-negative staphylococci predominated. All-cause mortality was 3.8%, with pneumonia and Clostridioides difficile infections in 5.1% and 3.2%, respectively; prophylaxis showed non-significant reductions in these outcomes. FQ prophylaxis reduced febrile neutropenia and bacteremia in HCT recipients, including those colonized with FQRE. Larger studies are needed to confirm its effects on multiple outcomes. Not applicable.

Introduction:Chylothorax, a rare cause of pleural effusion, is the result of chyle leakage into the pleural space from the thoracic duct, with causes divided between traumatic and non-traumatic, with malignant and surgical trauma causes being the most

BackgroundCor triatriatum sinister is a rare congenital heart disease that can mimic left atrial obstructive lesions. Symptoms vary based on the severity of obstruction.Case SummaryWe report a case of a 14-year-old girl with severe exercise intolerance. Echocardiography and computed tomography scan revealed a fibromuscular membrane causing left atrial obstruction and an anomalous venous drainage with a persistent left superior vena cava to the coronary sinus. Surgical intervention is definitive, typically via sternotomy.DiscussionGiven the complexity and lack of expertise in minimal invasive thoracotomy for such lesions, we used 3-dimensional (3D) heart printing for virtual surgical planning. This approach facilitated a safe and precise repair. To our knowledge, this is the first reported case using 3D printing to enable a minimally invasive thoracotomy for cor triatriatum sinister correction.Take-Home MessagesMinimally invasive approaches should not be dismissed for complex congenital heart defects. Multimodal imaging can enhance surgical feasibility.

We aimed to evaluate the impact of COVID-19 on breast cancer care in terms of the stage at presentation, treatment delays, and follow-up in a tertiary care center in Lebanon. This retrospective study compared patients with breast cancer who presented to a tertiary care center in Lebanon before (September 2019-December 2019) and during (September 2020-December 2020) the COVID-19 pandemic. We extracted data from the electronic medical records of patients with breast cancer who had their initial presentation, were under treatment, or were on follow-up during our period of interest. Of the 333 patients, 186 visited the hospital in the pre-COVID-19 period and 147 during the pandemic, showing almost a 12% reduction in the number of patients during the COVID-19 pandemic. In the pre-COVID period, more patients were presented for screening (52%); however, more symptomatic patients were presented during the pandemic (51.4%). Almost 54% had an advanced stage at presentation during the pandemic compared with 48% before the pandemic but with no statistical significance (P = .50). Significantly fewer patients came for chemotherapy in the COVID-19 period (38.1%) compared with the pre-COVID-19 period (52.2%). Fewer patients underwent surgery during the pandemic, although the difference was not statistically significant. Multivariate analysis showed that the COVID-19 pandemic was not associated with having an advanced stage at presentation (P = .24). The management of breast cancer was not substantially affected by the COVID-19 pandemic in a sample of Lebanese patients. However, 4 months might not be sufficient to draw a solid conclusion.

Emerging in the 1800s under the label "fat in the liver" and later gaining prominence in the 1980 as non-alcoholic fatty liver disease (NAFLD), the disease predominantly attributed to metabolic dysfunction presents a formidable health issue marked by substantial morbidity and mortality. It was 2020 when a change of one letter "NAFLD" to metabolic dysfunction-associated fatty liver disease "MAFLD" linked with the change in the definition and diagnostic criteria began a new controversy around the globe. Metabolic dysfunction-associated fatty liver disease (MAFLD) criteria represent a substantial departure from previous diagnostic measures of NAFLD, and provide the first set of positive criteria for diagnosis of the disease in adults and children that emphasise the key attribute of metabolic dysfunction in the pathogenesis, and acknowledges that the disease is a continuum across the life span. In 2023, an adapted version of the diagnostic criteria of MAFLD was proposed to define a slightly modified term; metabolic dysfunction-associated steatotic liver disease (MASLD). The MASLD criteria did not provide any conceptual advantage, and emerging evidence suggests that it actually performs worse than the MAFLD criteria. This raises the intriguing question of why MASLD was unable to take advantage of being second? In this review, we will explore the possible reasons for this unique case and highlight the current evidence supporting the use of MAFLD instead of MASLD in defining metabolic dysfunction-associated fatty liver diseases.

A myocardial diverticulum is a rare congenital anomaly characterized by pouch-like protrusions within the myocardial wall, which can potentially lead to various cardiac complications. This case report describes a unique presentation of a left ventricular diverticulum (LVD) with an associated apical thrombus, highlighting the diagnostic and management challenges posed by this condition. A 58-year-old man presented to the emergency department with left arm weakness, wrist drop, and chest pain, initially raising concerns for a stroke. Diagnostic evaluations, including echocardiography and magnetic resonance imaging (MRI), revealed a small focal outpouching at the left ventricular apex, consistent with a congenital LVD containing a thrombus. This diagnosis was supported by the patient's historical imaging dating back to 2007, which had similarly identified this outpouching. The patient was managed with anticoagulation therapy, transitioning from heparin to warfarin, alongside standard cardiac care. This case underscores the importance of considering myocardial diverticulum in the differential diagnosis of patients presenting with cardiac symptoms that might initially suggest more common conditions, such as stroke. It also highlights the essential role of echocardiography and MRI in diagnosing and managing myocardial diverticula.

Colonization with multidrug-resistant Escherichia coli strains causes a substantial health burden in hospitalized patients. We performed a longitudinal genomics study to investigate the colonization of resistant E. coli strains in critically ill patients and to identify evolutionary changes and strain replacement events within patients. Patients were admitted to the intensive care unit and hematology wards at a major hospital in Lebanon. Perianal swabs were collected from participants on admission and during hospitalization, which were screened for extended-spectrum beta-lactamases and carbapenem-resistant Enterobacterales. We performed whole-genome sequencing and analysis on E. coli strains isolated from patients at multiple time points. The E. coli isolates were genetically diverse, with 11 sequence types (STs) identified among 22 isolates sequenced. Five patients were colonized by E. coli sequence type 131 (ST131)-encoding CTX-M-27, an emerging clone not previously observed in clinical samples from Lebanon. Among the eight patients whose resident E. coli strains were tracked over time, five harbored the same E. coli strain with relatively few mutations over the 5 to 10 days of hospitalization. The other three patients were colonized by different E. coli strains over time. Our study provides evidence of strain diversity within patients during their hospitalization. While strains varied in their antimicrobial resistance profiles, the number of resistance genes did not increase over time. We also show that ST131-encoding CTX-M-27, which appears to be emerging as a globally important multidrug-resistant E. coli strain, is also prevalent among critical care patients and deserves further monitoring.IMPORTANCEUnderstanding the evolution of bacteria over time in hospitalized patients is of utmost significance in the field of infectious diseases. While numerous studies have surveyed genetic diversity and resistance mechanisms in nosocomial infections, time series of within-patient dynamics are rare, and high-income countries are over-represented, leaving low- and middle-income countries understudied. Our study aims to bridge these research gaps by conducting a longitudinal survey of critically ill patients in Lebanon. This allowed us to track Escherichia coli evolution and strain replacements within individual patients over extended periods. Through whole-genome sequencing, we found extensive strain diversity, including the first evidence of the emerging E. coli sequence type 131 clone encoding the CTX-M-27 beta-lactamase in a clinical sample from Lebanon, as well as likely strain replacement events during hospitalization.

BackgroundTakotsubo cardiomyopathy (TC) is a transient cardiac syndrome that manifests with symptoms resembling acute myocardial infarction (MI). It is characterized by temporary wall-motion abnormalities predominantly affecting the apical and mid-portions of the left ventricle, despite the absence of significant obstructive coronary disease. TC poses diagnostic challenges due to its resemblance to ST-segment elevation myocardial infarction.Our study aimed to determine the prevalence of TC and identify the factors associated with its occurrence in patients presenting with acute MI in Palestine.ResultsA retrospective analysis was conducted on a cohort of patients diagnosed with TC at Al-Makassed hospital. Women accounted for 90.7% of TC cases (95% CI 88.2–93.2%). The mean age of affected individuals ranged from 62 to 76 years. The most common presenting symptoms were chest pain (83.4%, 95% CI 80.0–86.7%) and dyspnea (20.4%, 95% CI 16.3–24.5%), often following an emotionally or physically stressful event. Electrocardiography (ECG) on admission indicated ST-segment elevations in 71.1% of cases (95% CI 67.2–75.1%), accompanied by mild elevations of Troponins in 85.0% of cases (95% CI 80.8–89.1%). Despite the initial severity, left ventricular ejection fraction (LVEF) improved from 20–49.9 to 59–76% within a mean time of 7–37 days. The in-hospital mortality rate was 1.7% (95% CI 0.5–2.8%), with complete recovery observed in 95.9% of cases (95% CI 93.8–98.1%) and rare recurrence. The underlying etiology is believed to involve exaggerated sympathetic stimulation.ConclusionsTC should be considered as a significant differential diagnosis in acute coronary syndrome (ACS) cases, particularly among postmenopausal women with a preceding stressful event. Our study provides insights into the prevalence and characteristics of TC in the Palestinian population. While stress has been recognized as a potential trigger for TC, further research is needed to explore if there are specific associations between occupation and other unique stressors in the Palestinian context and the prevalence of TC. The study’s results can raise awareness among healthcare professionals in Palestine about the prevalence and characteristics of TC in their patient population.

Vasoplegic syndrome is a type of distributive shock characterized by mean arterial pressure of less than 65 mmHg, with normal to high cardiac output and often refractory to fluid resuscitation, high doses of intravenous vasopressors, and inotropes. It is usually observed after cardiac and solid organ transplantation surgeries. Here, we report a 56-year-old female patient who presented with a profound vasoplegia manifesting as lethargy and confusion in the setting of amlodipine toxicity. This case of severe vasoplegia was refractory to all conditional lines of medical management reported in the literature.The mainstay treatment modalities for vasoplegia includevolume resuscitation,catecholamines, vasopressin, angiotensin II, and possibly methylene blue in unresponsive cases. Our patient was given hydroxocobalamin in favor of methylene blue, given the history of serotonin reuptake inhibitors use, which would have caused a life-threatening serotonin syndrome. Hydroxycobolamine resulted in a dramatic clinical recovery, suggesting its potentially significant role in refractory vasoplegia.