Background These Delphi recommendations aimed to establish regional consensus for the effective management of Cytomegalovirus (CMV) reactivation/infection and CMV disease following allogeneic hematopoietic stem cell transplantation (alloHSCT). Method A modified Delphi approach, comprising three rounds of anonymous questionnaires with field experts, was used. The first round included open-ended questions to identify and prioritize key topics, while the subsequent rounds focused on refining responses and reaching a consensus. A predefined consensus threshold of 70% agreement among panelists was used. Results After two rounds, a consensus was reached on 21 key questions related to the diagnosis and management of CMV reactivation and CMV disease post-alloHSCT. The panel identified these areas as priorities for future research or guideline refinement. Conclusion This Delphi study successfully established an expert consensus on pre-emptive therapy and prophylactic treatment for managing CMV reactivation and treatment strategies for CMV disease. The study findings, based on inputs from experts related to clinical practices in the region, can serve as an additional tool for clinical decision-making. Moreover, the panelists highlighted the unmet need for harmonizing diagnostic practices and thresholds among hematology centers in the Gulf region. Clinical trial number Not applicable.

Background/objectives: The outcome of refractory/relapsed systemic Anaplastic Large Cell Lymphoma (R/R-sALCL), especially for anaplastic lymphoma kinase-1 (ALK-1)-negative disease, remains dismal even after autologous hematopoietic stem cell transplantation (AHSCT). The intensification of both salvage and conditioning regimens, without increasing the toxicity, could improve the outcome of AHSCT in R/R-sALCL. Methods: Based on the successful experience of the incorporation of antiD20 monoclonal antibodies in the treatment of B-Cell Lymphomas, we designed a salvage and conditioning regimen incorporating the antiCD30-conjugated antibody (Brentuximab Vedotin, BV) to standard chemotherapy regimens, and we describe herein the clinical course of a patient with AKL-ve, R/R-sALCL, who received salvage regimen BV + DHAP, followed by AHSCT with preparative regimen consisted of BV plus standard BEAM. Results: The novel regimen was well tolerated, and no severe adverse effects were noticed. The engraftment was prompt and successful. The patient remained in complete metabolic remission for almost 12 months post-transplant. Conclusions: The proposed treatment approach, which combines antiCD30-conjugated antibody with standard salvage and conditioning regimens, demonstrated a completely acceptable toxicity with promising efficacy.

BACKGROUND:The significance of patient engagement (PE) is widely acknowledged as a crucial element in fostering positive health outcomes, elevating care quality, and streamlining healthcare systems. Despite its recognized advantages, the level of patient engagement in Arab nations remains suboptimal.METHODS:A high-level assembly was convened in Dubai with 11 distinguished patient advocates from diverse Arab countries. Their collective aim was to dissect the obstacles hindering patient engagement in the Arab world and propose pragmatic strategies to surmount them. First, a series of five open-ended, comprehensive questions were posed and thoroughly deliberated upon. Second, the barriers to patient engagement within the experts' respective communities were debated. A qualitative thematic analysis was conducted and two reports were generated by two independent researchers from the original meeting recordings.RESULTS:This paper highlights the importance of patient engagement in advancing healthcare and categorizes barriers to patient engagement as patient-related, provider-related, or system/government-related. The experts identified the primary gaps in patient engagement and proposed strategies to promote it, with a primary focus on motivating both patients and providers toward shared decision-making.CONCLUSIONS:This paper amalgamates the insights and recommendations distilled from the expert gathering, juxtaposing them within the broader context of existing literature on patient engagement. Offering a comprehensive viewpoint, this article delves into the challenges and opportunities intrinsic to bolstering patient engagement in the Arab world. Moreover, it spotlights invaluable tools often overlooked within Arab countries. The practical insights provided here can serve as a roadmap for administrators and decision-makers, providing guidance to enhance patient engagement on both a national and institutional scale.

Background: Despite its long-term history, haematopoietic stem cell transplantation (HSCT) still faces challenges in several countries under development and especially in the private health sector. Objectives, Design and Methods: In this retrospective analysis, we present our experience and the results of 48 adult patients who underwent HSCT (autologous 37, allogeneic 9) at a private-sector hospital in Abu Dhabi, United Arab Emirates (UAE). The main indications were multiple myeloma and acute myeloid leukaemia in the autologous and allogeneic setting, respectively. Results: All patients successfully engrafted, and after a median follow-up of 6 (range: 1-11) months, 42 patients are alive (36 autografted and 6 allografted). The 1-year overall survival rates were 97% and 62% for autografted and allografted patients, respectively, while 4 patients died within 100 days post-transplant from treatment-related causes (1 patient from the autografted group and 3 patients from the allografted group). Conclusion: Our data confirm that HSCT is a feasible, safe, and effective treatment approach, offering high success rates to UAE patients with haematological malignant diseases.

Background Cytomegalovirus (CMV) infection after abdominal organ transplantation is associated with increased morbidity and mortality. The use of valganciclovir for CMV prophylaxis is limited by drug-induced myelosuppression and potential emergence of resistance. Letermovir is approved for primary CMV prophylaxis in CMV seropositive allogeneic hematopoietic cell transplant recipients. However, it is increasingly used off-label for prophylaxis in solid organ transplant (SOT) recipients. Methods Based on pharmacy records, we examined retrospectively the use of letermovir for CMV prophylaxis in abdominal transplant recipients initiated on therapy at our center from January 1, 2018 through October 15, 2020. Data were summarized using descriptive statistics. Results Twelve episodes of letermovir prophylaxis occurred in ten patients. Four patients received primary and 6 patients received secondary prophylaxis during the study period, with 1 patient receiving letermovir secondary prophylaxis on 3 separate occasions. All patients receiving letermovir for primary prophylaxis had successful outcomes. However, letermovir secondary prophylaxis was unsuccessful in 5 of the 8 episodes (62.5%) due to breakthrough CMV DNAemia and/or disease. Only 1 patient discontinued therapy due to adverse effects. Conclusion Although letermovir was generally well tolerated, the high rate of failure when used as secondary prophylaxis was noteworthy. Additional controlled clinical trials assessing the safety and efficacy of letermovir prophylaxis in SOT recipients are warranted.

The safety and immunogenicity of a protein-based tetravalent vaccine SCTV01E that contains spike protein ectodomain (S-ECD) of Alpha, Beta, Delta and Omicron BA.1 are assessed and compared with bivalent protein vaccine SCTV01C (Alpha and Beta variants) and monovalent mRNA vaccine (NCT05323461). The primary endpoints are the geometric mean titers (GMT) of live virus neutralizing antibodies (nAb) to Delta (B.1.617.2) and Omicron BA.1 at day 28 post-injection. The secondary endpoints include the safety, day 180 GMTs against Delta and Omicron BA.1, day 28 GMTs to BA.5, and seroresponse rates of neutralizing antibodies and T cell responses at day 28 post-injection. 450 participants, comprising of 449 males and 1 female, with a median age (range) of 27 (18–62) years, are assigned to receive one booster dose of BNT162b2, 20 µg SCTV01C or 30 µg SCTV01E and completed 4-week follow-up. All SCTV01E related adverse events (AEs) are mild or moderate and no Grade ≥3 AE, serious AE or new safety concerns are identified. Day 28 GMT of live virus neutralizing antibodies and seroresponse against Omicron BA.1 and BA.5 with SCTV01E are significantly higher than those with SCTV01C and BNT162b2. These data indicate an overall neutralization superiority with tetravalent booster immunization in men.

Burkholderia cepacia complex (BCC) is nonfermenting, Gram-negative bacteria known to cause high morbidity and mortality. They commonly affect patients with cystic fibrosis (CF) and are often missed in those without, despite being fatal if left untreated. We report a case of cepacia syndrome in a 42-year-old, immunocompetent man without CF who initially presented with sepsis secondary to pneumonia. Multiple isolates from blood, synovial fluid, and wound swabs grew BCC. Treatment options and management strategies remain poorly understood for BCC in general and in cases without CF in specific. We successfully treated the patient using a combination of intravenous and inhalational antibiotics. This case report elaborates on the disease presentation, investigations, and management strategy employed to treat this rare infection.

OBJECTIVES:To compare the yield of early combined use of chest X-ray (CXR) and chest computed tomography (CT) in patients diagnosed with community-acquired pneumonia (CAP) presenting to the emergency department (ED) and assess the impact of chest CT on the initial diagnosis.METHODS:The medical records of 900 patients who presented to the ED and were diagnosed with CAP over a 1-year period were reviewed, and 130 patients who underwent CXR and chest CT within 48 hours were selected. CXR findings were classified as positive, negative, or inconclusive for CAP. Chest CT findings were defined as positive, negative, inconclusive, or positive with add-on to the CXR findings. CT was classified as having no benefit, large benefit, or moderate benefit based on the chest CT and CXR findings.RESULTS:Chest CT results were positive in 90.7% of patients, with 41.5% being newly diagnosed after negative or inconclusive CXR and 21.5% being diagnosed with add-on to the CXR findings. CT had large, moderate, and no benefit over CXR in diagnosing or excluding CAP in 45.3%, 21.5%, and 33.1% of patients, respectively.CONCLUSION:Early chest CT may be used to compliment CXR in the early diagnosis of CAP among patients in the ED.

Tumor necrosis factor (TNF) inhibition has become a widely used biological therapy in patients with underlying autoimmune diseases and its association with increased risk for tuberculosis and other granulomatous diseases has been extensively studied recently.[1] Non- tuberculous mycobacterial infections are also associated with the immune dysfunction caused by the use of immunomodulatory drugs, mainly anti TNF-alpha (α), ranging from localized skin infection to disseminated disease.[2,3] Psoriasis and psoriatic arthritis patients treated with anti-TNF are at higher risk of developing skin non-tuberculous mycobacterial infection due to the disease itself and the combined side effect of the medications used.[4] The following case describes a skin infection with Mycobacterium marinum (M. marinum) associated with the use of golimumab, a fully human monoclonal antibody against TNF-α, in a patient with psoriatic arthritis. A 53-year-old female patient with psoriatic arthritis followed at the rheumatology- dermatology clinic presented for evaluation of a non-resolving indurated plaque over the base of the right fifth digit despite the use of local steroid and systemic treatment for her arthritis. She reported no recent trauma or abrasion, no fever or chills. No other skin lesions were identified back then. Golimumab 50 mg subcutaneous monthly injections were added to standard methotrexate for worsening arthritis and liver function tests secondary to methotrexate. The patient received 2 doses of golimumab 50 mg after which she started noticing the erythematous lesion over her finger, increasing in size and erythema (Figure 1a). Informed consent of the patient was obtained from the patient for this case report. She was referred to the dermatology for skin biopsy and started empirically on a course of amoxicillin for suspected cellulitis. Golimumab was stopped and the patient was kept on methotrexate to avoid flare of her joint disease. Pathology was consistent with granulomatous tuberculoid dermatitis (Figure 1b). Acid fast, Gram, periodic acid-Schiff, and Gomori methenamine- silver stains were non-revealing for organisms or fungi. Non-tuberculous mycobacteria were recovered from the mycobacterial culture one month after initial presentation and were identified later as M. marinum. The patient was then started on clarithromycin and doxycycline with significant improvement after two weeks of treatment. Mycobacterium marinum is an atypical mycobacteria or mycobacteria other than Mycobacterium tuberculosis that is typically associated with fishes and water.[5] Few cases of M. marinum infection were reported in patients treated with anti-TNF-α ranging from localized skin infection to disseminated disease.[2,3] The literature mentions only six cases of psoriasis associated with M. marinum infection and anti-TNF-α was administered in all cases.[4,6-9] This is another rare case of M. marinum sporotrichoid-like skin infection in a patient on anti-TNF-α treatment. To our best knowledge, the present case is the first described in association with golimumab therapy. The exposure to fresh fish as well the immunosuppression predisposed the patient to acquire this infection. Golimumab was stopped and the patient was started on combination clarithromycin and doxycycline with significant improvement after two weeks.

Purpose of review Pseudomonas aeruginosa is one of the most feared nosocomial pathogens. Treatment of P. aeruginosa infections is challenging because of the limited choices of antibiotics and the emergent resistance of the pathogen. The present review aims at addressing the management of P. aeruginosa infections and highlighting the novel antibiotics that show a future promising role. Recent findings Novel fluoroquinolones have been recently introduced and show favorable activity. New combinations of β-lactams/β-lactamase inhibitors have been studied in various indications of infections because of P. aeruginosa . Cefiderocol, a new cephalosporin, shows very promising results against P. aeruginosa . Currently, combination therapy is only recommended in limited scenarios. Extended-infusion of β-lactams exhibit clinical benefit. Bacteriophage therapy is a growing field of interest and may have an impactful effect on the treatment of resistant P. aeruginosa . Summary Factors that guide clinical decisions for empiric and directed P. aeruginosa therapy include the epidemiology, the patient's risk factors, the site of infection, and the available treatment options. Conventional antipseudomonal antibiotics have been used successfully for a long time, but the increase in worldwide resistance necessitates the need for newer agents. Antimicrobial stewardship is essential to preserve the new drugs and prevent future development of resistance.

Question: A 48-year-old man with HIV infection (PCR undetectable CD4 483) who used cocaine and was a heavy user of alcohol presented with jaundice, fever, and acute onset left upper-quadrant abdominal pain. The pain was exacerbated by breathing. He had associated intermittent fevers and weight loss starting 3 weeks before presentation. He denied chest pain, nausea, vomiting, or a change in bowel habits. Home medications included dolutegravir, emtricitabine, tenofovir disoproxil fumurate, and recent intake of tamoxifen, clomifene, and chorionic gonadotropin to counteract the effects of anabolic steroids that were used 4 months before presentation. On examination, his temperature was 39°C, he was jaundiced, and he had icteric sclera. The abdomen was soft and nondistended with minimal left upper quadrant tenderness. Blood work showed a white blood cell count of 7800/μL, hemoglobin of 12.2 g/dL, platelets of 378,000/μL, alanine aminotransferase 236 IU/L (upper limit of normal [ULN], 65 IU/L), aspartate aminotransferase 166 IU/L (ULN, 50 IU/L), total bilirubin 3.4 mg/dL (ULN, 1.2 mg/dL), direct bilirubin 2.6 mg/dL (ULN, 0.3 mg/dL), alkaline phosphatase 1064 IU/L (ULN, 120 IU/L), γ-glutamyl transferase (GGT) of 655 (ULN, 50 IU/L), protein of 73 g/L, and albumin of 34 g/L. Lipase, lactate dehydrogenase, and international normalized ratio were normal. Blood smear was unrevealing. A contrasted computed tomography scan showed multiple subcentimetric mesenteric and multiple retroperitoneal lymph nodes, the largest of which was 1.3 cm in the aortocaval area. All medications were discontinued. Hepatitis A, B, and C serologies were negative, including hepatitis B and C PCR. Epstein-Barr virus IgM was negative and cytomegalovirus IgM was equivocal. During this hospitalization, his cholestatic liver enzymes continued to rise, reaching a maximum value of total bilirubin of 7.8 mg/dL, direct bilirubin of 6.5 mg/dL, and 3 days later, alkaline phosphatase of 1637 IU/L and GGT of 1171 IU/L. Alanine aminotransferase and aspartate aminotransferase slowly down trended during the hospitalization. Magnetic resonance cholangiopancreatography showed an edematous enlarged liver with minimal peripheral intrahepatic dilatation without an obstructing mass or extrahepatic biliary ductal dilatation (Figure A). Comprehensive autoimmune hepatic serology, iron studies, ceruloplasmin, and alpha-1 antitrypsin labs were negative. The patient remained febrile, so a positron emission tomography computed tomography scan was done and it showed active and enlarged (2.8-cm) portocaval and porta hepatis lymph nodes. Bone marrow biopsy showed no lymphoproliferative disorder, but there was a small poorly formed granuloma (Figure B, between the arrows). What other testing would you obtain to evaluate this patient's fever and abnormal liver enzymes? Look on page 1575 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Although extremely rare, we checked a Venereal Disease Research Laboratory PCR, the results of which came back positive. A Treponema pallidum hemagglutination assay also returned positive with titers 1:5120 (ULN, <1:80), confirming the diagnosis of syphilis. During his hospitalization, the patient developed a syphilitic skin rash on his back, chest, palms, feet, and soles (Figure C). The patient was started on penicillin G, 4 million units intravenously every 4 hours. The fever broke 36 hours after antibiotic initiation and 48 hours later, his bilirubin started to down trend, followed by the alkaline phosphatase and GGT 3 days later. His rash completely disappeared 5 days after antibiotic initiation. He received a total of 2 weeks of penicillin G intravenously at 24 million units a day and his liver enzymes normalized 7 weeks later. Syphilitic hepatitis is extremely rare and occurs in 0.2% of patients with secondary syphilis.1Lee M. Wang C. Dorer R. et al.A great masquerader: acute syphilitic hepatitis.Dig Dis Sci. 2013; 58: 923-925Crossref PubMed Scopus (7) Google Scholar There are few cases of syphilitic hepatitis in HIV carriers reported in the literature. Of the described cases, only 2 patients had an undetectable viral load.2Mullick C.J. Liappis A.P. Benator D.A. et al.Syphilitic hepatitis in HIV-infected patients: a report of 7 cases and review of the literature.Clin Infect Dis. 2004; 39: e100-e105Crossref PubMed Scopus (81) Google Scholar, 3German M.N. Matkowskyj K.A. Hoffman R.J. et al.A case of syphilitic hepatitis in an HIV-infected patient.Hum Pathol. 2018; 79: 184-187Crossref PubMed Scopus (6) Google Scholar The clinical presentation of syphilitic hepatitis includes jaundice, pruritis, nausea, and vomiting, in addition to generalized symptoms of fatigue, malaise, and weight loss. Biochemically, alkaline phosphatase and GGT are predominantly elevated with mild elevation in the transaminases. Few cases describe an elevation in the bilirubin. Diagnosis is made based on Treponemal testing and/or evaluation of tissue for spirochetes on liver biopsy. The majority of cases used penicillin G with excellent response. Doxycycline was also used in one case and ceftriaxone was used in another. In our case, the patient had several other possible reasons for his liver enzyme elevation, including drug-induced liver injury, cocaine, and alcohol use, which could have contributed to his disturbed liver enzymes. The steady improvement in his cholestatic liver enzymes, fever, and rash, shortly after the initiation of penicillin G indicates that syphilis was the cause of his hepatitis. Given the improvement in his symptoms and biochemical markers, we refrained from obtaining a liver biopsy.

Infection with Brucella spp. is endemic to the Middle East and the eastern Mediterranean basin. Brucellosis can mimic infectious and non-infectious febrile illnesses and therefore it can pose a diagnostic challenge. A wide range of deep-seated infections have been ascribed to brucellosis including breast abscesses and infections of prosthetic endovascular devices. The latter are usually rare but difficult to treat short of excision of the infected device. Here, we present the case of a middle-aged Lebanese woman who presented with simultaneous breast abscesses and a pacemaker infection due to brucellosis. To our knowledge, a similar manifestation has not been reported in the literature.

The spelling of the name "Ali Bazarbachi" was incorrect.