RE: Water pipe (shisha) smoking among male students of medical colleges in the eastern region of Saudi Arabia

94 Ann Saudi Med 31(1) January-February 2011 www.saudiannals.net sium of 5.0 mEq/L, urea of 105 mEq/L, and creatinine of 2.6 mg/ dL. Inflammation markers were high—erythrocyte sedimentation rate (ESR) was 32 m/h, C-reactive protein and procalcitonin levels were 32.5 mg/L and 1.01 ng/mL, respectively. Throat, blood and urine cultures were obtained and empiric antimicrobial treatment with piperacillin and tazobactam was commenced. The blood and urine cultures were negative. Fever persisted under antimicrobial treatment and the culture from the diabetic foot lesion yielded a gram-negative bacillus R ornithinolytica (biotype 77563289). The isolated bacterium was positive for lactose, indole, and ornithine and was identified with the help of Vitek 2 System (bioMérieux, Marcy l’Etoile, France). An antibiogram for R ornithinolytica demonstrated susceptibility only to ertapenem, levofloxacin, and tigecycline. Antimicrobial therapy was switched to tigecycline 100 mg once daily. With this therapy, she became afebrile and the rashes in the legs disappeared; also, her clinical status significantly improved. R ornithinolytica has been isolated from the gut of the fish, termites, and aquatic environments.1 An ability to convert histidine to histamine, leading to fish poisoning had been reported previously.2 This bacterium was first described in 1989 by Sakazaki et al.3 There are only three case reports of human infection by R ornithinolytica in the literature. The first patient was an 82-year-old woman in whom the microorganism caused an enteric fever-like syndrome, and the organism was isolated from blood.1 The second patient was a 97-year-old woman who presented with a giant renal cyst, which caused colic obstruction. The fluid culture isolated from the cyst was positive for R ornithinolytica.4 The third reported case was of R ornithinolytica bacteremia in an infant with visceral heterotaxy.5 Only this case showed marked skin flushing, which was possibly related to a histamine reaction. The present case illustrates for the first time, isolation of R ornithinolytica from a diabetic foot wound in a patient with many comorbidities and an association with a rash. The distinctive feature of our case was R ornithinolytica that was markedly resistant to antimicrobial agents compared with previous reports. R ornithinolytica has been shown to be resistant to ampicillin and other commonly used antibiotics.6 In the abovementioned cases, skin rash possibly due to a histamine reaction was reported in only one case. We speculate that maculopapular rash in the proximity of diabetic wound may also be related to the histamine-producing characteristic of R ornithinolytica. Despite the existence of myriad causes of maculopapular rashes on the legs, the disappearance of the rash after fever ceases with tigecycline treatment may suggest a causal link between the rash and R ornithinolytica.

sium of 5.0 mEq/L, urea of 105 mEq/L, and creatinine of 2.6 mg/ dL. Inflammation markers were high-erythrocyte sedimentation rate (ESR) was 32 m/h, C-reactive protein and procalcitonin levels were 32.5 mg/L and 1.01 ng/mL, respectively.
Throat, blood and urine cultures were obtained and empiric antimicrobial treatment with piperacillin and tazobactam was commenced. The blood and urine cultures were negative. Fever persisted under antimicrobial treatment and the culture from the diabetic foot lesion yielded a gram-negative bacillus R ornithinolytica (biotype 77563289). The isolated bacterium was positive for lactose, indole, and ornithine and was identified with the help of Vitek 2 System (bioMérieux, Marcy l'Etoile, France). An antibiogram for R ornithinolytica demonstrated susceptibility only to ertapenem, levofloxacin, and tigecycline. Antimicrobial therapy was switched to tigecycline 100 mg once daily. With this therapy, she became afebrile and the rashes in the legs disappeared; also, her clinical status significantly improved.
R ornithinolytica has been isolated from the gut of the fish, termites, and aquatic environments. 1 An ability to convert histidine to histamine, leading to fish poisoning had been reported previously. 2 This bacterium was first described in 1989 by Sakazaki et al. 3 There are only three case reports of human infection by R ornithinolytica in the literature. The first patient was an 82-year-old woman in whom the microorganism caused an enteric fever-like syndrome, and the organism was isolated from blood. 1 The second patient was a 97-year-old woman who presented with a giant renal cyst, which caused colic obstruction. The fluid culture isolated from the cyst was positive for R ornithinolytica. 4 The third reported case was of R ornithinolytica bacteremia in an infant with visceral heterotaxy. 5 Only this case showed marked skin flushing, which was possibly related to a histamine reaction.
The present case illustrates for the first time, isolation of R ornithinolytica from a diabetic foot wound in a patient with many comorbidities and an association with a rash. The distinctive feature of our case was R ornithinolytica that was markedly resistant to antimicrobial agents compared with previous reports. R ornithinolytica has been shown to be resistant to ampicillin and other commonly used antibiotics. 6 In the abovementioned cases, skin rash possibly due to a histamine reaction was reported in only one case. We speculate that maculopapular rash in the proximity of diabetic wound may also be related to the histamine-producing characteristic of R ornithinolytica. Despite the existence of myriad causes of maculopapular rashes on the legs, the disappearance of the rash after fever ceases with tigecycline treatment may suggest a causal link between the rash and R ornithinolytica.

RE: Water pipe (shisha) smoking among male students of medical colleges in the eastern region of Saudi Arabia
To the Editor: We have critically read the brief report by Dr. Taha et al 1 and offer some comments that might be useful to the readers of this journal. Evidently, shisha smoking is a major public health problem and this socializing but highly dangerous toxic behavior has spread worldwide to include the African and Asian continents, Australia, Europe, and North America. Therefore, water pipe smoking is no more confined to the Arabic and or Eastern world. Secondly, use of the water pipe is potentially hazardous and by all yardsticks more dangerous than cigarette smoking. In addition, second hand smoke from the water pipe is thought to be more dangerous than that from cigarette smoke, although opposing evidence has also been reported. 2 Shisha smoking is reported to contribute to a variety of diseases including cardiovascular, respiratory, addiction, and cancer. The lingering misbelief among the general public that water pipe smoking is less dangerous than cigarette smoking is no longer tenable. 3 Thirdly, a critique of relevant literature on tobacco use goes hand in hand with the saying that everything in excess is very bad. An epidemiological study is needed to assess mild to moderate use of water pipe and tobacco use in the general population. There is currently converging evidence that water pipe smoking is generally more common among young adolescents, including girls, at a global level. This is a very dangerous epidemiological trend in the young, who already have other compounding lifestyle problems that might result in disastrous consequences.
Unfortunately, this study recruited only male medical students and hence lost an opportunity to explore simultaneously the water pipe smoking behavior of female medical students. This is a major caveat because a comparative study involving both genders might have substantiated or refuted already emerging findings; one of them is that water pipe smoking is more common among females. Another limitation of this study is that the authors designed a new questionnaire rather than using one of the most relevant standardized questionnaires developed jointly by international health organizations, including the World Health Organization, the Canadian Public Health Association and the US Centers for Disease Control and Prevention. In doing so, the authors fell short of assessing the specific and relative social and cultural beliefs of male versus female students in Saudi Arabia, as medical students in medical colleges often hail from different regions. Furthermore, this study did not add anything major or new to the existing literature on shisha smoking. However, one finding and related explanation is noteworthy: mothers of water pipe smokers had an advanced education compared with mothers of those of nonsmokers. According to this study this result was speculatively attributed to two factors including shisha smoking as a prestige behavior and an indication of a modern standard of living. However, the commentators feel that these explanations might not be true because mothers were not asked about the explanations underlying the linkage between their higher education and shisha smoking. This finding needs further study. There might be more plausible explanations: shisha smoking in modern times is merely a continuation of a very old traditional behavior of the Eastern world and it may not be a prestigious behavior at all; rather it may reflect low status. A study that recruits a larger sample representative of all Saudi medical colleges might truly shed light on this finding and a more detailed explanation must be included in the measurement tools. 4 Finally, shisha smoking is a global health problem of the young population and needs effective preventive strategies across the world, including health warning labels on water pipe tobacco products and related accessories. 5 Shisha smoking is a rapidly re-emerging epidemic, especially among the young population and hence is a research priority. In addition, there are some grey areas, especially epidemiological perspectives and long-term effects of water pipe smoking, including cancer development, that need the special attention of researchers worldwide.