Background: This study reports a comparative diagnostic potential of three different assay systems used to detect HCV infection in acute and chronic liver diseases. Methods: A total number of 364 patients with various types of liver diseases were analyzed for hepatitis C virus (HCV) core antigen using Enzyme Immuno Assay (EIA), HCV-RNA by RT-PCR and anti-HCV antibodies by third generation EIA system. Simultaneously these patients were also tested for markers of other hepatitis viruses, notably, hepatitis A, B, C, D and E. In some cases, even transfusion transmitted virus (TTV) was tested using TTV-DNA as the marker of TTV infection. Results: Analysis of results demonstrated the presence of hepatitis B, C and E in different proportions of patients belonging to these liver diseases. Hepatitis A and D infections could not be detected in these cases TTV infection was prevalent in different liver diseases in different proportions. Though none of control sera demonstrated hepatitis A-E infection, however, TTV infection was noted in control group also. When we analysed all the sera for HCV infection using these different assay systems, we found HCV core, HCV-RNA and anti-HCV antibodies in 18.3%, 18.3% and 5.83% cases of acute viral hepatitis (AVH), 13.3 %, 13.3% and 46.6% cases of chronic viral hepatitis (CVH), 23.8%, 23.8% and 23.8% cases with cirrhosis of liver and 20%, 17.5% and 10% cases respectively, of fulminant hepatic failure (FHF) patients. Whereas HCV core and HCV-RNA assays were comparable and predominantly positive in acute cases (AVH and FHF), anti-HCV antibodies were detected in high proportions in chronic liver diseases. Cirrhosis patients showed all the markers in equal proportions. This pattern of HCV markers remains unaffected by co-infection of HCV with other hepatitis viral infections. Conclusion: In conclusion, where HCV core and HCV-RNA are best diagnostic markers in acute liver diseases, anti-HCV diagnoses high proportion of HCV cases in chronic liver diseases. This diagnostic pattern is not changed on co-infection of HCV with other viral infections. Keywords: HCV, Core, Hepatitis, PCR, TTV.

Background: Although no definite risk factors have emerged for the different hematological malignancies, a viral cause has been postulated. Several studies have detected SV40 DNA sequences in tumor tissues obtained from non-Hodgkin's lymphoma patients. A link between SV40 and NHL is biologically plausible because SV40 causes hematological malignancies in laboratory rodents. Methods: We investigated 266 Egyptian cases of different hematological malignancies, for the presence of SV40 DNA using multiplex nested PCR technique. These cases consisted of 158 non-Hodgkin's lymphoma (NHL), 54 Hodgkin's disease(HD), 26 acute lymphocytic leukemia (ALL), 13 acute myeloid leukemia (AML), 8 chronic lymphoblastic leukemia (CLL), 7 chronic myeloid leukemia (CML), in addition to 34 subjects of control group. Results: Our results have shown that SV40 DNA sequences were found in 53.8% of non-Hodgkin lymphoma patients, 29.6% of Hodgkin's disease patients, and 40.7% of different types of leukemia cases. Frequency of SV40 DNA sequences was higher in NHL patients compared to the other tumor cases. Also, frequency of SV40 DNA sequences was significantly higher (p<0.05) in NHL patients than in the control group. Regarding the different histological types of non-Hodgkin's lymphoma, SV40 DNA sequences were detected frequently in diffuse large B-cell lymphoma and in follicular lymphoma. Conclusions: The present study suggests that SV40 DNA virus is significantly associated with non-Hodgkin's lymphoma and might have a role in the development of these hematological malignancies. Polyomavirus SV40 may act as a cofactor in the pathogenesis of these tumors and this could lead to new diagnostic, therapeutic, and preventive approaches.

Background: Transvaginal ultrasound is used conventionally as initial investigation of patients with abnormal uterine bleeding but saline contrast sonohysterography is a better technique to reliably distinguish focal from diffuse endometrial lesions. This study was performed to compare the ability of transvaginal ultrasonography and saline infusion sonohysterography as initial modality for the diagnosis of endometrial abnormalities in women with abnormal uterine bleeding. Patients and Methods: In a prospective study, 100 women with abnormal uterine bleeding were submitted to sequential examination by transvaginal ultrasound, and sonohysterography. The presence of focal endometrial lesions and the type of lesion (endometrial hyperplasia, polyp, submucous myoma, or malignancy) were noted. Predictive values were calculated by correlating the results with final diagnosis reached by hysteroscopy and endometrial biopsy. Results: The sonohysterography had 92.9% sensitivity and 89.7% specificity compared to 71.4% sensitivity and 67.7% specificity achieved by transvaginal sonography. There was 91% agreement between saline contrast sonohysterography and hysteroscopy as compared to 69% for TVS (p = 0.002). The diagnostic performance of sonohysterography for 3 main endometrial abnormalities (i.e. endometrial hyperplasia, polyps and submucous myoma) was better than transvaginal sonography. The best results were seen in cases of submucous myoma where sensitivity and specificity of sonohysterography reached to 100% as compared to TVS (61.55 and 97.7% respectively). Conclusion: Our results have substantiated that sonohysterography is a better tool than transvaginal sonography for the assessment of endometrial intra-cavity lesions. By providing accurate differentiation between focal and diffuse endometrial lesions, it can help in decision making regarding selection of cases for hysteroscopy and directed biopsy. We recommend that saline contrast sonohysterography should be used as an initial investigation in cases of abnormal uterine bleeding. Keywords: Ultrasound, transvaginal sonography, sonohysterography, hysteroscopy, abnormal uterine bleeding.

Background: Both pro- and anti-inflammatory cytokines are implicated in development and prognosis of leprosy so the genetic regulation of such cytokines could play an important role. Objective:. This study was planned for testing the association of cytokine gene polymorphisms with susceptibility and clinical types of leprosy among Egyptian cases. Subjects: This study included 47 cases (29 men, 18 females, mean age = 46.3 years) with leprosy in addition to 98 healthy unrelated controls (52 males, 46 females, mean age = 44.9 years). Cases were recruited from Leprosy Clinics, Delta region of Egypt. Cases were classified into paucibacillary (PB) (n = 17; 10 males, 7 females; mean age 42.6 years) and multibacillary (MB) (n = 29; 19 males, 10 females; mean age 43.9 years). Methods: For all cases and controls, DNA was extracted and amplified using polymerase chain reaction with sequence specific primers (PCR-SSP) for detection of single nucleotide polymorphisms (SNPs) in the promoter regions of cytokine genes, TNF- - 308 (G/A), IL-10-1082(G/A), IL-6-174(G/C) as well as IL-1RaVNTR in intron 2 of the gene. Results: Compared to controls, all cases have shown increased frequency of homozygous genotypes : IL-10-1082 (GG) (Odds ratio 6.6, P <0.05), homozygous TNF- -308 (GG) (Odds ratio =3.23), and homozygous IL-1Ra (11) (Odds ratio = 3.6, P<0.05) with increased frequency of IL10 G and ILRa 1 alleles (P<0.05). BP subgroup showed increased frequency of homozygous IL- 10-1082 (GG) (Odds ratio = 18.6, P<0.05) with increased frequency of IL10 G allele (P<0.05). On the other hand, MB subgroup showed increased frequency of homozygous TNF- -308 (GG) (Odds ratio = 5.84, P<0.05) and homozygous IL-1Ra (11) (Odds ratio = 4, P<0.05) with increased frequency of IL-1Ra 1 allele (P<0.05). There is predominance for heterozygous IL-6-174 (G/C) polymorphism in all studies patient subgroups as well as controls with no significant difference among them. Conclusion: Genetic polymorphisms related to TNF- -308 and IL-10-1082 and IL-1Ra may be used as genetic markers for susceptibility and clinical outcome of leprosy among Egyptian cases from the Nile Delta. Abbreviations: TNF; tumor necrosis factor, IL; interleukine, IL-1Ra; IL-1 receptor antagonist, PCR; polymerase chain reaction, SNP; single nucleotide polymorphism, VNTR; variable number tandem repeat. Key words: Leprosy, Cytokines, Gene polymorphism, Egypt

Trace element deficiency or excess is implicated in the development or progression in some cancers. Here we report the elevated levels of copper and low level of zinc in the plasma of esophageal cancer patients in Kashmir India- a high incidence area. The average level of copper was significantly higher for patients than for controls (p<0.0001) with a mean concentration of 169 μg/dl and 149 μg/dl for patients and controls, respectively. In contrast, the average level of zinc in patients was significantly lower than in controls (p<0.0001) with a mean concentration of 86.8 μg/dl and 96.1 μg/dl for patients and controls, respectively. No significant difference in copper and zinc levels was observed for different age groups in controls or patients. For controls, the level of copper was not significantly different in males and females (median: 155 μg/dl for males and 144 μg/dl for females, p=0.10), but we observed a higher level of zinc in females (median: 90.5 μg/dl for males and 101 μg/dl for females, p=0.03). Copper or zinc concentrations were not significantly associated with gender, tumor site, green tea with salt (nun chai) consumption, smoking habits or snuff in cases. Patients with poorly differentiated tumors had a higher copper concentration than those with moderately or well-differentiated tumors (p<0.0001). No association was found between copper concentration and TP53 mutation status but patients with TP53 mutant tumor had lower zinc levels than those with no mutation. Our results point towards a role of the trace element imbalance in the esophageal tumorigenesis in high risk Kashmiri population exposed to a range of nitroso compounds or their precursors. Further prospective cohort studies are warranted to determine whether change in the plasma zinc and copper homeostasis may represent an independent risk factor for this malignancy as well as possible target for preventive intervention. Abbreviations: ESCC-esophgeal squamous cell carcinoma,TE-trace elements, PCR- polymerase chain reaction Key words: Esophgeal squamous cell carcinoma, Trace elements, copper excess, Zinc deficiency, TP53 mutations, Kashmir

Background: Breast cancer continues to be a major cause of morbidity and mortality throughout the world. The behavior of breast cancer varies widely. Several parameters have been investigated to predict the prognosis in breast cancer. But still there is no single parameter that can predict prognosis in an individual patient. Among the novel prognostic markers is E-cadherin; a calcium-dependent epithelial cell adhesion molecule. Its loss has been associated with metastases, thereby providing evidence for its role as an invasion suppressor. The objective of the present study was to assess the prognostic value of E-cadherin expression in breast cancer cases, and its correlations with the other studied prognostic parameters. Methods: The study comprised 54 breast cancer patients admitted at King Fahd Specialist Hospital, Qassim during the period 2001-2006. The median tumor size was 3cms. Fifty cases (92.6%) had invasive ductal carcinoma, four cases had lobular carcinomas, and most were grade II (82%), stage II (48%), and the majority of cases had positive axillary lymph nodes (70.3%). Representative sections from formalin-fixed paraffin embedded tissue blocks were taken from the 54 cases of breast cancer, and were stained for E-cadherin expression by immunohistochemical technique (monoclonal E-cadherin (NCL-E-cad), Novocastra). All the lobular carcinoma cases were negative for membranous expression of E-cadherin while 72% of invasive ductal carcinomas were positive for the marker. Results: A significant correlation was found between strong E-cadherin expression and node negative cases. Node negative cases were found to be an independent predictor of strong E-cadherin expression while node positive cases predicted negative expression of E-cadherin (P = 0 .026). Also loss of E-cadherin was noted in advanced stages of breast cancer supporting the view that loss of E-cadherin expression is a marker of aggressiveness. However, there was no correlation between the Ecadherin and other prognostic parameters as tumor size, tumor grade, ER, PR, and HER-2 expression. Conclusion A significant correlation was found between strong E-cadherin expression and node negative cases. Key Words: breast cancer, E-cadherin, immunohistochemistry, immunostaining, prognostic factors.

Objective: To design and test an in-expensive air-inflated balloon that is easy to sterilize and use for the control of atonic post partum hemorrhage (APPH). Outcome measures: Primary outcome measure: Maternal Mortality (MM). Secondary outcome measures: Surgical maternal morbidities, amount and doses of drugs, blood transfusion units used for resuscitation, general condition of women on admission and outcome on discharge, the resuscitation time and time for regaining normal uterine tone; hospital stay and ICU admission. Technical outcomes: Incidence of Balloon rupture, allergic manifestations, and pyrexia. Methods: Randomized clinical trail / cross over study Two hundred and forty women with diagnosis of atonic PPH complicating vaginal deliveries were randomly assigned to be managed either by ecbolics and uterine massage as recommended by the WHO; or by WHO protocol plus El-Menia air inflated balloon. Results: No maternal mortality in either group. The maternal morbidities in the form of surgical intervention (uterine and ovarian artery ligation, uterine compression suture, internal iliac artery ligation and abdominal hysterectomy) were observed in five women in controls and none in the studied women. Blood transfusion units, ecobolic drugs, resuscitation time, regaining uterine tone time, hospital stay and ICU admission were significantly less in studied women than controls. Out of the 19 failures to arrest APPH in the controls; 14 cases responded to secondary application of El-Menia balloon, and only five cases required surgical intervention. Conclusion : El-Menia balloon is an inexpensive, easy to apply, effective in controlling APPH with minimal side effects. It is targeted for use on a large scale in developing countries to reduce the maternal mortality and morbidity caused by APPH. Key words: atonic pph, el-menia balloon

Background : Breast cancer is by far the most frequent cancer of women. However the preventive measures for such problem are probably less than expected. The objectives of this study are to assess breast cancer knowledge and attitudes and factors associated with the practice of breast self examination (BSE) among female teachers of Saudi Arabia. Patients and Methods: We conducted a cross-sectional survey of teachers working in female schools in Buraidah, Saudi Arabia using a self-administered questionnaire to investigate participants' knowledge about the risk factors of breast cancer, their attitudes and screening behaviors. A sample of 376 female teachers was randomly selected. Participants lived in urban areas, and had an average age of 34.7 ±5.4 years. Results: More than half of the women showed a limited knowledge level. Among participants, the most frequently reported risk factors were non-breast feeding and the use of female sex hormones. The printed media was the most common source of knowledge. Logistic regression analysis revealed that high income was the most significant predictor of better knowledge level. Knowing a non-relative case with breast cancer and having a high knowledge level were identified as the significant predictors for practicing BSE. Conclusions: The study points to the insufficient knowledge of female teachers about breast cancer and identified the negative influence of low knowledge on the practice of BSE. Accordingly, relevant educational programs to improve the knowledge level of women regarding breast cancer are needed. Key words: breast cancer, Saudi Arabia, knowledge, screening, self examination of breast

The polycystic ovary syndrome (PCOS), one of the most common causes of infertility due to anovulation, affects 4-7% of women). Etiology of PCOS remains largely unknown, familial aggregation of cases suggests genetic susceptibility to the disorder. Though genes involved remain unknown, recent evidence points to a gene of the insulin receptor .Genes implicated in ovarian follicular development may also play a role. A fundamental aspect of the syndrome seems to be a defect in insulin metabolism. There is consistent evidence that increase of body weight may favour a more severe hyperandrogenism. Treatment of PCOS has been mostly symptomatic. Only recently has the use of insulinomimetic or insulin sensitizing agents provided an option to treat the presumed underlying cause of this disorder, which is insulin resistance. Metformin appears to improve risk factors for cardiovascular disease in diabetic and non-diabetic patients, indicating that its use could be associated with a reduction in coronary heart disease in patients with PCOS. The use of metformin in hyperinsulinemic women with PCOS improved the lipid profile, including decreases in total cholesterol, low density lipoprotein cholesterol, and triglyceride concentration.

Minimally Invasive Surgery is the most important revolution in surgical technique since the early 1900s. Its development was facilitated by the introduction of miniaturized video cameras with good image reproduction. The marvels of electronic and information technology have strengthened the biochemical and molecular power of diagnosis and the surgical and medical management of gynecology, transforming the very practice of medical science into a reality that could barely be envisaged two decades ago. We now enter the age of Robotics, Telesurgery, and Therapeutic Cloning. This dynamic process of reform continues to deliver practitioners with information, ideas and tools that spell answers to some of the most pressing dilemmas in clinical management. New technology will provide us with better opportunities of vision of the operative field, such as 3-D Endoscopy. Other promising technologies such as incorporation of ultrasonography, magnetic resonance imaging, laser-based technology or assisted optical coherence tomography will not only enhance better visualization of the surgical field, but also discriminate the pathologic tissue from the normal one, enabling the surgeon to excise the pathologic tissue accurately. Pain mapping and photodiagnosis offer a new direction in the diagnosis of microscopic endometriosis. Better detection of the disease results in higher chances of success following treatment.

Meckle’s diverticulum, the commonest congenital anomaly of the gastrointestinal tract, can become the leading point of intestinal intussusception. However, the precise pre-operative diagnosis can be difficult. We report here a case of a 15-year old boy with acute abdomen in whom intussuscepted Meckle’s diverticulum was diagnosed pre-operatively by CT scan. We conclude that CT scan is a safe, non-invasive tool to diagnose this condition before surgery and can improve outcome, especially in the acute abdomen with doubtful diagnosis. Keywords: Meckle’s diverticulum, intussusception, Computed Tomography

Proclination and extrusion of upper central incisors are considered as the main manifestations of pathological migration. They are the most common chief complaint of adult patients nowadays. With adequate orthodontic-periodontal teamwork it is possible to reestablish a healthy and well-functioning dentition with good occlusion, sufficient masticatory function, and satisfactory esthetics that will improve the psychological status of the patient after correcting the elongation and the migration of the anterior teeth.This report present a case with pathological migration of upper right central incisor treated orthodontically with a combination of intrusion, extrusion and retraction movement. This mechanics improve the bone topography, improve esthetics and also helps the patient to achieve good home oral hygiene care. Key words: pathological migration, orthodontic intrusion, orthodontic extrusion, adult orthodontic

Objective: We report an extremely rare case of pneumocephalus after cochlear implantation. Method: Case report and a review of the world literature on pneumocephalus after cochlear implantation. Results: We present a case of uneventful cochlear implantation in a patient with nasal polyposis. Post-operative nose blowing resulted in subcutaneous emphysema pneumocephale presenting five weeks post surgery. This resolved on conservative therapy, and the patient went on to use her implant successfully. Conclusion: To our knowledge this is the first report in the world literature of delayed onset as well as asymptomatic pneumocephalus after cochlear implantation Key words: Cochlear implant and pneumocephalus

The well known habit of children to place objects in mouth frequently leads to impaction of foreign body in tracheobronchial tree. It is one of the leading causes of accidental home deaths in children under 6 years. (1) The major issue involves the accurate diagnosis, speedy and safe retrieval of the foreign body. The accurate diagnosis may elude even the sophisticated physician because often the initial choking incidents are not witnessed and the delayed symptoms may mimic other common conditions, such as asthma, pneumonia, or upper respiratory tract infections. (1-3) The most common foreign bodies aspirated are food products - peanuts, beans and seeds. (1,4) Beans and seeds absorb water over time and with subsequent swelling rapidly change from partial to complete bronchial obstruction. Some organic foreign bodies cause surrounding tissue reaction, and this may result in a condition known as arachidic bronchitis. (3)

Throughout its four billion years of life, earth has witnessed changes in environment (natural resources), human activity, demographic and health transitions. Life expectancy over last 55 years improved more than during the entire previous span of human history primarily due to decline in mortality, income growth, improvements in medical technology (immunization, discovery of newer antibiotics, microsurgery, medical imaging), improvements in public health (clean water, sanitation), progressive healthcare policies, pharmaceutical innovation, healthier lifestyles and scientific knowledge. For centuries, communicable diseases were the main causes of death around the world. Concurrently we are also facing triple burden of disease. We are living under three shadows - one of infectious diseases, the new and growing shadow of non-communicable chronic diseases and, injury primarily due to motor vehicle accidents. Heart diseases, cancer, diabetes, mental illnesses became a real burden for health systems. By the dawn of the third millennium, non communicable diseases are sweeping the entire globe. By 2020 it is predicted that Lifestyle Diseases will be causing seven out of every ten deaths in developing countries. More people smoke today than at any other time in human history. One person dies every ten seconds due to smoking-related diseases. Tobacco is the biggest killer, much bigger in dimension than all other forms of pollution. Worldwide, 1.3 billion people currently smoke cigarettes or other products. In 2020 the global burden is expected to exceed nine million deaths annually. Of everyone alive today, an estimated 500 million people will eventually be killed by tobacco. Up to 80% of cases of coronary heart disease, and up to 90% of cases of Types 2 Diabetes, could potentially be avoided through changing lifestyle factors. About 75 percent of cancer cases are tied in some way to how we live our lives. One-third of cancers could be avoided by eating healthily, maintaining normal weight, and exercising throughout life. As lifestyles reflect both individual choice and the norms and values of community, promotion of health lifestyles should be directed to both the individuals and the community. Each year 10.5 million child deaths are preventable in the sense that these children would not have died if they had been born in rich countries. Twenty-first century is known as the century of knowledge. There is much hope that in the near future we will have more DNA vaccines, better drugs that draw on advances in genetic engineering, ingenious new ways of targeting and destroying pathogens inside the body, a range of new pharmaceuticals as well as new gene and cell therapies to repair damage, to optimize health and to minimize future disease risk. Greater understanding of the human genome will direct the development of medicines to help treat and prevent diseases over the next hundred years. The human genome consists of approximately 3 billion nucleotides of DNA sequence, most of which have now been identified in their linear arrangement on chromosomes. The genome contains several million individual DNA-sequence variants (or alleles), defined as differences in sequence at identical sites on homologous chromosomes. Technological developments now permit high-throughput testing of the several hundred thousand individual sequence variants necessary to provide adequate coverage of all the DNA blocks in humans to ensure that if a variant associated with disease is present, it will be found. Coupling the genotypic data with epidemiologic data that include many covariates, one is theoretically able to identify genes or gene environment interactions that predispose to both normal trait variation and disease processes. The genome sequence continues to teach us about new forms of genetic variation; in the past few years, for example, copy-number variation has begun to be recognized as a contributor to human disease. Copy-number variants can change the gene dose and thus cause comparatively subtle changes at the level of gene expression; they may influence susceptibility to complex traits. X Editorial There are now many large-scale efforts to uncover genetic effects and gene-environment interactions relevant to disease. The downstream functions of such common genetic variants will be potential targets for lifestyle or medical interventions. There is a strong need for more epidemiologic studies so that these new approaches can be exploited. Advances in genetics will allow treatments to target the genes or specific proteins that cause disease. Gene therapies are being developed that aim to replace faulty genes and so reverse the effects of inherited disorders such as cystic fibrosis. The use of stem cells for the treatment of myocardial disorders is gathering pace. Breakthroughs in DNA technology have helped developing highly sensitive and specific diagnostic tests. The use of superconducting quantum interface devices (squids) will make it possible to diagnose heart, brain, auditory and visual problems. A nano diagnostic molecular detection tool is being created by researchers to detect and analyze molecules in the blood and other fluids using nano and micro cantilevers (smaller than the surface of a fly's eye) a promise to revolutionize the diagnosis of diseases such as cancer and opens up new applications in sectors as diverse as environmental protection, chemical analysis and food safety. Development of vaccine will see breakthrough in diseases like cancer and AIDS. Hopefully we will sometimes report new victories over disease. Turning point in history can be identified with certainty only with the benefit of hindsight. The signs are, nevertheless, that the International Journal of Health Sciences (IJHS), a Qassim University Scientific Publication, launches at a key moment in the history of mankind's struggle against diseases (lifestyle, infectious, injury, etc.) affecting millions of people globally. The aim of IJHS is to publish scholarly articles, interesting and informative reviews on any topic connected with health (medical, dental and pharmacy) sciences. Health is more than a medical issue. There is a great opportunity to capture the shining heights of partnership to build a healthy world for tomorrow. Let us rise to the responsibilities of the new world - a brave new world that is united against the disease - a world that we can pass on to our progeny with the knowledge that we rose to the responsibilities of this new age. Medical Journals have a great responsibility to channel the enthusiasm, activity, and expertise of various global health players into a cohesive and compelling public health agenda that brings visible and measurable benefits to humanity. At Qassim University, every day offers opportunities, challenges and growth. IJHS will continue to take full advantage of every technological innovation that will allow us to communicate new work to world. We are dedicated to delivering what medical community has come to rely on and expect. We shall share a human stake in the development of global health. References Amin Tabish, Abdullah Alghasham. Images of Health. Palestinian Medical Journal. 2006; 2(2):108-l1l. Amin Tabish. Knowledge-based Healthcare: Need for Global Health Policy. JK Practitioner. Editorial. 2006; 13(3). Kaare Christensen, and Jeffrey C. Murray. What Genome-wide Association Studies Can Do for Medicine. March 15,2007; Volume 356(11):1094-1097· United Nations Development Programme (1993). Human Development Report. Oxford University Press. United Nations Development Programme (2005). Human Development Report. Oxford University Press.

Tuberculosis has always been an eminent disease for its varied presentation. (1) Patient presenting with constrictive Pericarditis and S/S of cardiac tamponade is quite common in places where it is still a major chronic infective disease.(2) but patient presenting with resistant atrial arrhythmia with other non-specific S/S may be overlooked (3,4,5) following case is an example: