Background. Libman-Sacks endocarditis (LSE) is a rare cardiovascular manifestation of systemic lupus erythematosus/antiphospholipid syndrome that is described as a sterile verrucous nonbacterial vegetative lesion. These lesions can cause progressive damage to the heart valves leading to valve surgery. The most common valves to be affected are the aortic and mitral valves. Libman-Sacks endocarditis is associated with malignancies, other systemic diseases like systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS). The majority of LSE patients are usually asymptomatic. Case Summary. We describe a 39-year-old male patient who presented with increasing shortness of breath and pulmonary congestion. He was found to have severe mitral valve regurgitation and mitral stenosis. Transesophageal echocardiogram confirmed the diagnosis of Libman-Sacks endocarditis with thickened mitral valve leaflets with symmetrical mass-like structure causing a restriction in the valve function during both cardiac phases later diagnosed with systemic lupus erythematosus by immunology. The patient was started on diuretics, anticoagulants, angiotensin inhibitors, beta-blockers, and hydroxychloroquine. He underwent successful mechanical mitral valve replacement with a 27 mm St. Jude valve. The mitral valve was found to be grossly thickened with friable tissue and complete amalgamation of the leaflets with subvalvular apparatus. The patient suffered some warfarin adverse effects a year later but did well otherwise. Conclusion. This case demonstrates that Libman-Sacks endocarditis can be the first manifestation of systemic lupus erythematosus. Early and prompt diagnosis of LSE can prevent and lessen the many side effects associated with thromboembolism. Additionally, addressing the underlying disease is key to successful treatment.

Objectives: The aims of this study were:1) to assess the awareness of diabetes and its systemic and oral complications among adults with diabetes in Saudi Arabia, 2) to evaluate their behaviors toward maintaining proper oral hygiene and factors associated with adequate oral health knowledge, and 3) to identify what recommendations and improvements are needed in diabetic clinics in KSA. Methods: A validated questionnaire of six parts was distributed online to include all diabetes patients in Saudi Arabia. After applying the criteria, 400 diabetes responses were included. The data was analyzed using SPSS statistical software version 24. Descriptive statistics, univariate and multivariate analysis were used to report the results. Results: Participants’ responses showed that older aged patients with type 2 diabetes and the longer duration of diabetes had higher levels of awareness regarding oral health. However, their knowledge about being at high risk for oral diseases was low compared to their awareness regarding systemic complications. Relatively lower percentages of the participants (55.9%) were aware that diabetes can make teeth and gums worse and that gum disease makes it harder to control blood sugar (24.8%). Almost two thirds of the individuals believed that they should have regular visits to dental clinics, but many barriers were identified for their irregularity or no visits. With regards to the participants’ source of information, 52% learned from health care providers, and 50% from the internet. Conclusions: Our study revealed comparatively better results of awareness than previous studies reported in Saudi Arabia, however not to the desired standard. Therefore, both dentists and all healthcare providers should be encouraged to take the responsibility to promote proper oral hygiene practices among their diabetic patients in order to reduce the risk of having periodontal diseases. Further research is required to identify obstacles preventing those patients from having regular dentist visits. Key words: Diabetes, oral health, periodontal disease, awareness, Saudi Arabia

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Patient: Female, 24-year-old Final Diagnosis: Focal segmental glomerulosclerosis Symptoms: Facia • lower extremity edema Medication: — Clinical Procedure: — Specialty: Nephrology Objective: Unusual or unexpected effect of treatment Background: Primary focal segmental glomerular sclerosis (FSGS) frequently causes recurrence after kidney transplantation, leading to graft loss in half of the patients. Conservative treatment of FSGS is the main acceptable method due to the lack of randomized clinical trials. A few strategies are known to treat FSGS recurrence, such as plasma-pheresis and intravenous immunoglobulin (IVIG), but failure to achieve remission may occur. In addition, some of these treatment strategies are more established in pediatric patients and lack evidence in adult patients. Case Report: We describe the case of a 24-year-old woman who had a kidney transplant due to FSGS and was admitted to the hospital for an evaluation of lower-limb and facial swelling. Her kidney biopsy showed segmental glomerulosclerosis compatible with recurrence of FSGS. Her FSGS relapses were further confirmed by increase in serum creatinine and proteinuria. The patient had several FSGS relapses that were treated by different combinations of plasmapheresis, pulse steroid, mycophenolic acid, tacrolimus, prednisolone, IVIG, and IV rituximab. She did not respond to conventional therapy and was eventually treated successfully using cyclophosphamide and remained in remission afterward. Conclusions: FSGS has a high recurrence rate after kidney transplantation. A few options to achieve remission have been investigated. In this report, we present the case of a young woman with FSGS recurrence after a kidney transplant, achieving remission successfully with cyclophosphamide. Cyclophosphamide can be used a treatment of FSGS recurrence in a transplanted kidney when all other options have been exhausted. Additional research is needed to assess the efficacy and safety profile of cyclophosphamide in such cases.

Background: Catheter-related infection (CRI) is a serious complication among hemodialysis patients, associated with significant morbidity and mortality. This study investigated the incidence, predictors, presentation, and complications of CRI. Methods: This single-center, retrospective, observational study enrolled all eligible chronic hemodialysis patients with tunneled central venous catheters inserted between June 2016 and June 2019. Results: Over 3 years, 63 patients (59% men) with a total of 27,395 catheter days were included of these patients. The median age was 68 years (interquartile range [IQR]: 58,76), and median hemodialysis duration was 62 months (IQR: 16,101). A total of 30 episodes of clinical CRI occurred, resulting in an overall incidence rate of 1.1 per 1,000 catheter days. CRI was significantly associated with baseline anemia (adjusted hazard ratio [AHR]=3.29; 95% confidence interval [CI], 1.42–7.64; P=0.006) and the use of the femoral vein as opposed to internal jugular vein (AHR=3.23; 95% CI, 1.29–8.06; P=0.012). The incidence of catheter-related bacteremia was 0.91 per 1,000 catheter days, and the most commonly isolated organism was Staphylococcus aureus (26%). Recurrent infection developed in 9/27 (33.3%) episodes and was lower among catheter salvage with antibiotic lock and catheter removal compared to catheter salvage alone. Conclusions: Anemia and the use of the femoral instead of the internal jugular vein are associated with a higher incidence of CRI. Catheter-related blood stream infection was associated with increased mortality, recurrence rate, and resource utilization. Along with systemic antibiotics, catheter management such as catheter removal or antibiotic lock use may help reduce the recurrence rate.