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Immune checkpoint inhibitors (ICIs)—anti-programmed death-1 (PD-1) and their ligands (PD-L1 and PD-L2) have become widely used in the treatment of several malignancies. Many immune-related adverse events (irAEs) have been linked to these agents. Nonetheless, tuberculosis (TB) reactivation during their use is increasingly recognized and reported. Herein, we present a 58-year-old lady with advanced non-small cell lung cancer (NSCLC) ALK-negative, EGFR wild, and PD-L1 immune histochemistry (IHC) strongly positive in 95% of tumor cells, on ongoing treatment with Pembrolizumab as a first-line monotherapy. Our patient presented with 1-week history of productive cough and high-grade fever. Further workup yielded the diagnosis of pulmonary tuberculosis after her Pembrolizumab sixth cycle with positive AFB smear and TB PCR from BAL (rifampin resistance not detected), with negative HIV status. Hence, immunotherapy was held, and patient was commenced on anti-TB regimen. History revealed contact with active TB patient over the past decade, without previous documentation of latent TB or previous TB infection. Her sputum AFB smear remained persistently positive 4 weeks through anti-TB regimen course. Later, the patient was discharged after her sputum was cleared from AFB (two negative sets). In light of pembrolizumab mechanism of action as an immune checkpoint inhibitor, we suspected its implication on reactivating latent TB which was observed in our patient demonstrating features of pulmonary tuberculosis. She was not re-challenged with Pembrolizumab following TB diagnosis.

ObjectiveTo compare the patient profile and outcomes in Qatar during the first and second waves of the COVID-19 pandemic.SettingA retrospective observational study was conducted comparing the demographic, clinical and laboratory characteristics of patients with COVID-19 infection admitted to a secondary care hospital, during the first and second waves of the pandemic.Participants1039 patients from the first wave and 991 from the second wave who had pneumonia on chest X-ray and had a confirmed SARS-CoV-2 infection by a real-time PCR test of a nasopharyngeal swab were included. Patients with a normal chest X-ray and those who had a negative PCR test despite a positive COVID-19 antigen test were excluded.OutcomeLength of stay, need for mechanical ventilation, final disposition and mortality were the key outcomes studiedResultsInfluenza like symptoms (18.5% in the first wave vs 36.1% in the second wave, p 0.001), cough (79.2% vs 87%, p<0.001) and dyspnoea (27.5% vs 38% p<0.001) were more common in the second wave. Second wave patients had significantly higher respiratory rate, lower peripheral oxygen saturation, needed more supplemental oxygen and had higher incidence of pulmonary embolism. More patients received hydroxychloroquine and antibiotics during the first wave and more received steroids, antivirals and interleukin-1 antagonist during the second wave. The second wave had a shorter length of stay (14.58±7.75 vs 12.61±6.16, p<0.001) and more patients were discharged home (22% vs 10%, p<0.001).ConclusionsPatients who presented during the second wave of COVID-19 pandemic appeared to be more ill clinically and based on their laboratory parameters. They required shorter hospitalisation and were more likely to be discharged home. This could represent greater expertise in handling such patients that was acquired during the first wave as well as use of more appropriate and combination therapies during the second wave.

Indapamide is one of the most effective and well-known anti-hypertensive medications. Electrolyte disturbances have been classically recognized as a typical side effect profile of indapamide. The most common electrolyte imbalance described with indapamide was hypokalemia; however, hyponatremia is being increasingly reported. In this case, we report a unique form of severe electrolytes derangement (hyponatremia, hypokalemia, hypophosphatemia, and hypocalcemia), which was complicated by seizures, rhabdomyolysis, and acute kidney injury that occurred within only 10 days of indapamide initiation. The patient was admitted to the medical intensive care unit for prompt electrolyte replacement and close monitoring. With the discontinuation of indapamide and the prompt replacement of the deficient electrolytes, the patient's condition has improved dramatically, and he was discharged in a good state of health. Electrolyte disturbances are expected to be seen with indapamide usage, and it might be associated with severe consequences like arrhythmias and seizures. This case report would raise awareness and add to the importance of closely following patients after prescribing indapamide.

Background: Data on the effect of metformin on serum vitamin B12 (VitB12) level in patients with type 2 diabetes mellitus (T2DM) in Qatar are limited; therefore, we aimed to assess the prevalence of VitB12 deficiency and its related factors among patients with T2DM treated with metformin at Hamad General Hospital in Doha, Qatar, from January 1, 2017, to December 31, 2017. Methods: This cross-sectional analytical study involved patients with T2DM aged ≥ 18 years who used metformin for at least 3 months. The serum VitB12 was quantified on a chemiluminescent enzyme immunoassay analyzer using Cobas e 801 module, Roche, and VitB12 deficiency was defined as serum VitB12 level of ≤ 145 pmol/L. All data were obtained from the patients’ electronic medical records. Results: The study recruited 3124 eligible patients with T2DM. The overall prevalence of metformin-associated VitB12 deficiency was 30.7% [95% confidence of interval, 0.290–0.323]. A significant difference exists in the median VitB12 levels between the VitB12-normal and VitB12-deficient groups [129 vs. 286; p < 0.001]. Compared with the VitB12-normal group, the VitB12-deficient group had higher mean body mass index (BMI) (p < 0.001) and consumed higher doses of metformin (p = 0.001). They also more often used sulfonylurea (p = 0.004), dipeptidyl peptidase-4 inhibitor (p < 0.001), thiazolidinediones (p < 0.001), glucagon-like peptide 1 [GLP-1] receptor agonists (p < 0.001), alpha-glucosidase inhibitor (p < 0.001), and H2 blocker/proton pump inhibitors [PPI] (p < 0.001) than the VitB12-normal group. Moreover, the VitB12-normal group consumed more calcium supplements (p < 0.001) than the VitB12-deficient group. In the multivariate analysis, independent risk factors for metformin-associated VitB12 deficiency in patients with T2DM include high daily dose of metformin >2000 mg, male gender, high BMI, smoking, sulfonylurea, dipeptidyl peptidase-4 inhibitor, H2 blockers/PPI, low fasting blood glucose, and low hemoglobin. Conclusion: This study showed a high prevalence of VitB12 deficiency in patients with T2DM taking metformin and a significant negative correlation between the daily dose of metformin and serum VitB12 level. Therefore, regular screening for serum VitB12 is necessary in patients with T2DM on metformin treatment, especially those who have the abovementioned risk factors.

Coronavirus disease 2019 , which initially emerged in Wuhan, China, has rapidly swept around the world, causing grave morbidity and mortality. It manifests with several symptoms, on a spectrum from asymptomatic to severe illness and death. Many typical imaging features of this disease are described, such as bilateral multi-lobar ground-glass opacities (GGO) or consolidations with a predominantly peripheral distribution. COVID-19-associated bronchiectasis is an atypical finding, and it is not a commonly described sequel of the disease. Here, we present a previously healthy middle-aged man who developed progressive bronchiectasis evident on serial chest CT scans with superimposed bacterial infection following COVID-19 pneumonia. The patient's complicated hospital course of superimposed bacterial infection in the setting of presumed bronchiectasis secondary to COVID-19 is alleged to have contributed to his prolonged hospital stay, with difficulty in weaning off mechanical ventilation. Clinicians should have high suspicion and awareness of such a debilitating complication, as further follow-up and management might be warranted.

Introduction: The majority of physicians' medical judgments are based on clinical information supported by laboratory reports . The availability of a reference interval for different lab values facilitates the process of interpretation . Complete blood count (CBC), testing is one of the most frequently performed hematology test in any clinical setting. Analysis of CBC by hematology analyzers is an indispensable means in the evaluation of many acute and chronic disorders including traumatic, infectious, immunological, and hematological diseases. Establishment of a normal reference interval is essential for accurate clarification of the disease diagnosis as well as for follow up. CBC techniques have improved significantly, and the accurate automated methods have now substituted manual methods. In addition, various novel blood cell parameters have been developed alongside to aid in diagnosis and management of several blood disorders . However significant differences exist in the reference intervals based on age, gender, ethnicity, genetic differences, environmental factors, and geographical location.. Dietary habits and occupational exposures are factors that have been shown to affect reference interval . Therefore, there is a requirement for each country to establish its own reference intervals. Country-specific reference intervals for CBC of adult peripheral blood have been established in many countries around the world; however, there have been no specific comprehensive studies in Arab population in Qatar based on age, gender, geographic location and ABO blood groups. To the best of our knowledge, this is the first study in Qatar that investigated CBC reference intervals in relation to age, gender, and blood grouping which can now be used as a reference when evaluating patient samples in Qatar. Methods: Venous blood specimens were collected from 720 healthy randomly selected individuals aged 18 to 69 years from 2018 to 2019 and analyzed by Sysmex NX-10 and NX -20 automated hematology analyzers. Results were statistically analyzed and compared by gender, age, and ABO blood group. Arab adults were divided into African Arabs (Egypt, Libya, Tunisia, Morocco) and Asian Arabs (Syria, Lebanon, Jordon, Palestine, Qatar). The lower and upper reference limits of the hematology reference intervals were established at the -2 SD and +2SD respectively. Results: Reference intervals were calculated for all the hematology parameters which included red blood cell, white blood cell and differential count, and platelet parameters. Arab males had significantly higher Hb, Hct, RDW, ANC, lymphocytes and monocyte counts compared to adult females. Asian-Arab males had significantly higher Hb concentration and higher WBC, lymphocytes and eosinophil counts compared to African- Arab males. Asian Arab young males had significantly higher Hb level and lymphocyte count and lower monocytes counts compared old males. African Arab young males had significantly higher lymphocyte and lower monocytes counts compared to old males. Asian- Arab young females had higher WBC, ANC counts compared to old Asian Arab females. No statistical difference in the studied hematological parameters was detected among the three groups with different ABO subgroups Conclusions: Data from this study established specific reference intervals which could be considered for general use in the Arab world. The differences in hematology reference intervals in respect to age, sex and geographical location highlights the necessity to establish reference intervals for venous blood parameters among the healthy population in each country or at least in each region. Disclosures No relevant conflicts of interest to declare.

Hematologic reference intervals vary with gender, age, ethnicity, and geographic area. Therefore, local or national laboratory reference ranges are essential to enhance the accuracy when diagnosing health conditions. Still, no comprehensive list of reference ranges tailored to the Arab population living in Qatar. Accordingly, this study aims at establishing a hematology reference guide for Arabs in Qatar.This is a retrospective study where 750 healthy volunteers (18–69 years) from 2015 to 2019 were included, analyzed by an automated hematology analyzer. Arab adults were divided into African (Egypt, Libya, Tunisia, Morocco) and Asian (Syria, Lebanon, Jordon, Palestine, Qatar). The Cell-Dyn and Sysmex were used for measuring hematological parameters.The mean +/- 2SD were established for all the study groups. Arab males had significantly higher Hb, Hct, red cell distribution width, absolute neutrophil count, lymphocytes, and monocyte counts than females. Asian-Arab males had significantly higher Hb concentration and higher WBC, lymphocytes, and eosinophils than African Arabs. Asian-Arab young (>18: < 40 years) males had significantly higher Hb and lymphocytes and lower monocytes than older males (>40 years). African-Arab young males had significantly higher lymphocytes and lower monocytes than older males. Asian-Arab young females had higher WBC and absolute neutrophil count than older Asian Arabs.The findings of this study will help in establishing specific reference intervals in the Arab world. The differences in hematology reference intervals considering age, gender, and geographical location highlight the importance of establishing blood reference intervals in each country considering the ethnic diversity of each country.