Cystic fibrosis (CF) is a multi-system disorder caused by alterations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein, which is mainly involved in the regulation of transmembrane hydroelectrolytic flux in cells that produce mucus, sweat, saliva, tears, and digestive enzymes. Characteristic clinical features of CF include recurrent endobronchial infections, progressive obstructive pulmonary disease, pancreatic insufficiency, and chronic digestive problems. The CFTR protein is also important for the development of the vas deferens; therefore, males with CF are usually infertile.
Khan and Mohammad (1985) performed a review study on patients diagnosed with CF in Bahrain during a 7-year period (1979-1984). A total of eight proven cases of CF (6 females, 2 males) were reviewed; ages ranging from 42 days to 5 months. All these patients fulfilled the classical criteria of CF - chronic pulmonary disease, exocrine pancreatic deficiency, and abnormally high sweat chloride levels. Five of these patients were from consanguineous families. Three patients died by the age of 6-months and five more by 14-months of age. [Khan IM, Mohammad AM. Muscoviscidosis (cystic fibrosis of the pancreas) in Bahrain, Arabian Gulf. Bahrain Med Bull. 1985; 7(1):17-23.]
Al Arrayed and Abdulla (1996) studied the incidence of cystic fibrosis in Bahrain retrospectively by reviewing the records of patients diagnosed for cystic fibrosis (CF) during a 17 years period in one hospital (1978-1994). The survey included a total of 27 patients (25 Bahrainis) with CF. The minimum incidence of CF was found to be 1:7,700. Male: female ratio was 1:1. All patients were diagnosed within the first year of life and 60% were diagnosed by three months of age. The consanguinity rate was high among the parents (80%). About four to six patients (19-22%) had sickle cell trait, one patient had sickle beta thalassemia, and 98% of patients had G6PD deficiency. The mortality rate was 60% as only 11 patients were alive by the time of the study.
Al-Mahroos (1998) performed a study to identify the incidence and evaluate the causes of high mortality among Bahraini children with cystic fibrosis (CF). During an 18 year period, 25 children with a mean age of two months were diagnosed to have CF. The incidence of CF in Bahrain is estimated to be 1:5,800 live births, while the prevalence is 3:100,000 individuals. Although CF in Bahraini children was considered to be phenotypically severe, a dramatic decline in mortality was noticed during the first year of life from 80% (1981-1985) to 50% (1986-1990) then to 9% (1991-1995).
Kerem et al. (1995) reported that the incidence of CF and the frequency of disease-causing mutations varied considerably among Jewish ethnic subgroups. Among non-Ashkenazi Jews, the disease occured at a similar frequency as Jews from Libya (1:2700). It was found to be rare in Jews from Yemen (1:8800), Morocco, (1:15000), and Iraq (1:32000). Kerem et al. (1995) indicated that in each Jewish ethnic group, the disease is caused by a different repertoire of mutations.
Kamal and Nazer (1984) carried out a pilot study to investigate cystic fibrosis (CF) among children in Jordan. Out of 15,314 children, 12 were diagnosed with CF - five suffered from meconium ileus and the other seven children were clinically diagnosed based on recurrent chest problems, failure to thrive, positive family history, and high levels of sweat chloride. Out of the five subjects with meconium ileus, two patients passed away following diagnosis while the other three children passed away during the post-operative phase.
Nazer (1992) conducted a prospective study in Jordan to screen for CF using the BM test for meconim albumin. The study consisted of 7,682 neonates from 10 different hospitals in Jordan; only four neonates presented a positive reaction to BM test strips. The diagnosis was confirmed in three subjects through sweat chloride test employing pilocarpine iontophoresis. The study revealed an incidence of 1 in 2560 live births for CF.
In 2002, Kakish (2002) conducted a retrospective study that included 72 patients with cystic fibrosis and revealed the presence of infantile hypertrophic pyloric stenosis (IHPS) in two of them. The incidence of 2.7% is greater than the 0.3% incidence expected in the general population. Kakish (2002) suggested that the nine fold increase in IHPS in patients with CF could be due to an association between the two disorders and warrants further investigation.
[See also: Kuwait > Kollberg, 1986].
Aluwihare et al. (1981) reported two CF patients (Kuwaiti and Syrian) with meconium ileus. Both patients were reported to have died, one postoperatively and the other at the age of 1 year due to recurrent chest infections.
During the period of 1980 to 1985, Kollberg (1986) reported 17 cases of CF in Kuwait. The cases included eight Kuwaitis, two Syrians, and one Jordanian.
Issa et al. (1988) reported three cystic fibrosis cases devoid of hyponatremia, metabolic alkalosis, and hypochloremia.
Between the period of 1979 to 1989, Farag and Teebi (1989) carried out a questionnaire survey in all Kuwaiti hospitals revealing 40 cases of CF in about 500,000 live births. Of the 40 cases, 26 subjects were found to be Bedouins or had Bedouin ancestors. [Farag TI, Teebi AS. Observations on cystic fibrosis (CF) in Kuwait. Am J Hum Genet. 1989; Suppl.4:A238.]
Lubani et al. (1991) reported two siblings suffering from CF and gastritis associated with Helicobacter pylori, folate deficiency megaloblastic anemia, intellectual disability, and other minor abnormalities. The subjects were born to second cousin Bedouin parents in Kuwait. Lubani et al. (1991) proposed the possibility of a new autosomal recessive cystic fibrosis-like syndrome.
Three Bedouin siblings suffering from CF were reported by Farag et al. (1994) at Al-Jahra Hospital in Kuwait. The three sibs were born to phenotypically normal first cousin Bedouin parents. PCR amplification was employed to examine six CF mutations (delta F508, delta I507, G542X, S549N, G551D, R553X), but none of the six mutations were detected in this Bedouin family. [Farag TI, Samilchuck E, AbulHasan S, Al-Awadi SA, Kandil H, Mady SA, El-Ghanem M. Cystic fibrosis in Kuwait and neighbouring populations. J Kuwait Med Assoc. 1994; 24(2):176-9.]
[See also: Qatar > Abdul Wahab et al., 2000; Wahab et al., 2004b].
Salem and Idresh (1962) reported the first case of CF in an Arab child from Lebanon. [Salem M, Idresh H. Cystic fibrosis in the Middle East. J Med Liban. 1962; 15:61-74.]
[See: Iraq > Kerem et al., 1995].
Rajab et al. (2005) undertook a study to estimate the prevalence of commonly diagnosed autosomal recessive diseases in Oman from 1993 to 2002. The study revealed that cystic fibrosis was diagnosed in 32 patients, with an observed incidence of 1 in 15,000 births.
[See also: Qatar > Abdul Wahab et al., 2000].
Abdul Wahab et al. (1998) reviewed 35 cases (17 Qatari nationals) of bronchiectasis diagnosed in Qatar during a 12-year period. Four of these patients were recognized as probably having CF as the underlying cause for brochiectasis. Apart form the common symptom of cough, all four of these patients showed clubbing and a failure to thrive.
Abdul Wahab et al. (2000) undertook a study to describe 45 CF patients belonging to 32 families, diagnosed over a 12-year period at the Hamad Medical Corporation in Qatar. The study included patients from Qatar (31 patients), Saudi Arabia (four patients), Kuwait (one patient), UAE (one patient), Oman (one patient), and Yemen (one patient). All 31 Qatari cases belonged to the same Bedouin tribe. The study also included non-Arabic-Asian families from Pakistan (four patients) and Iran (two patients). Parental consanguinity was observed in 44 cases (98%) and a family history of CF in 27 cases (60%). By reviewing the medical records of these patients, Abdul Wahab et al. (2000) found that the majority of cases presented early in life with respiratory symptoms that included cough, repeated chest infections and a bronchiolitis-like picture. Laboratory findings revealed that 17 (38%) patients of the same Bedouin tribe had metabolic alkalosis and/or hypo-electrolytemia, prompting Abdul Wahab et al. (2000) to suggest that metabolic alkalosis might be a relatively common manifestation of CF during infancy in arid climates.
[See also: Syria > Wahab et al., 2002; Egypt > Wahab et al., 2004a].
In 1986, Kollberg reported a male patient suffering from CF; he was the second child of consanguineous Saudi Arabian parents.
Although CF had been thought to be very rare in Arabs, Nazer et al. (1989) documented CF in 13 children from Saudi Arabia. Duration of symptoms prior to diagnosis varied from 1 month-5 years (mean 23 months). The main clinical manifestations of the children were abdominal distention, failure to thrive, steatorrhea, hepatomegaly, rectal prolapse and recurrent respiratory infections, often with Pseudomonas aeruginosa.
Al Umran et al. (1989) reported three cases of CF in three indigenous Saudi families. Among the three reported cases, two patients were born to first cousin parents.The third patient was a female born by Cesarean section due to fetal intestinal obstruction, which was diagnosed through ultrasound.
During the period of 1980 to 1987, Mathew et al. (1991) reported 10 Saudi Arabian children who were suspected of having CF. Out of these 10 children, five were confirmed of having CF with hypoelectrolytemia and metabolic alkalosis on initial presentation.
Al Arrayed and Abdulla (1996) described a Saudi patient in a retrospective study carried out to calculate the incidence of cystic fibrosis in Bahrain. [See: Bahrain > Al Arrayed and Abdulla, 1996]
Banjar and Mogarri (1998) reported the demographic and clinical data of 84 Saudi patients (49 males and 35 females) with CF who were admitted to a referral center in Saudi Arabia during a 12 year period. Following diagnosis, ten patients died due to respiratory failure and four were lost to follow-up, but were later confirmed to be dead. Of the remaining 70 patients, approximately 80-90% of them presented with cough, wheezing, repeated chest infection, failure to thrive, or diarrhea (a sign of pancreatic insufficiency). Meconium ileus was found in 4% of the patients. Consanguinity was noticed in 78%, whereas family history of CF was recorded in 52% of the subjects. Pseudomonas aeruginosa was found in more than 50% of the subjects. [Banjar H, Mogarri I. Demographic and clinical data of cystic fibrosis patients in a tertiary care centre in Saudi Arabia. Emirates Med J. 1998; 16(3):166-9.]
In 2003, Banjar (2003b) reported a 10-year-old male patient with type III Ehlers-Danlos syndrome (EDS) and CF. The patient had a history of recurrent chest infection and was diagnosed with cystic fibrosis due to elevated sweat chloride tests (96 and 114 mmol/L). Pulmonary function tests revealed severe obstructive lung disease and air-trapping. He had pectus carinatum, severed clubbing, hypermobility of all joints, and elastic skin. His mother and two paternal aunts reportedly had hypermobile joints. The patient died from respiratory failure. Since EDS caused the abnormal elasticity of the lung, the patient suffered from a progressive course of cystic fibrosis. [Banjar H. Simultaneous occurrence of cystic fibrosis and Ehlers-Danlos Syndrome. Emirates Med J. 2003b; 21(1):105.]
The same year, Banjar et al. (2003c) studied the factors that contributed to mortality related to cystic fibrosis in the Saudi population by analysing the records of patients who registered with CF at the only referral centre in the country. A total of 183 patients (51% males) were diagnosed with CF between 1985 and 2003. At the time of study, 81% of these patients were alive. About 65% of these patients were found to be in the mild to moderate malnutrition stage for their weight/height. The weight/height, albumin levels, high HCT, low MCHC, low MCV, and development of Pseudomonas resistance to antibiotics were found to be the most significant factors contributing to progressive lung disease. The study showed that mortality from CF is largely dependent on early diagnosis, proper management, and nutritional rehabilitation. In addition, early development of multi-drug resistant Pseudomonas also played a large part in the mortality. Banjar (2003c) suggested an intermittent gentamicin nebulization treatment instead of a continuous regimen for management of the disease.
In 2004, Banjar (2004a) reviewed the comorbidity of CF with other disorders for a period of 10 years. CF patients in the study group presented with SCD, IDDM, CAH, and Ehler's Danlos syndrome. The study included 190 patients consisting of 99 males and 91 females, with a mean age of diagnosis of 2.88 +/- 3.5 years, a period of follow-up of 3 +/- 3 years, and a mean survival of 11 years. Consanguinity was reported in 88% of cases. At the time of the study, out of 190 CF cases, 26 patients had passed away. The same year, Banjar (2004b) reviewed the details of all patients referred to a CF clinic in Saudi Arabia between 1994 and 1998 to study the detailed microbiological data. A total of 96 CF patients (52% male, mean age: 2.9 years) were diagnosed in this time period. The most common bacteria found in the first culture were Pseudomonas aeruginosa (44%), Haemophilus influenza (17%), Staphylococcus aureus (15%), Streptococcus pneumonia (6%), MRSA (4%), Branhamella catarrhalis (6%), and RSV (1%). In the second positive follow-up culture, the Branhamella culture doubled to 13%, while MRSA rose to 6%. The shortest lifespan was observed in patients who had P. aeruginosa and were resistant to gentamicin. [Banjar HH. Microbiological data of cystic fibrosis patients in a tertiary care center in Saudi Arabia. Kuwait Med J. 2004b; 36(3):177-81.]
Al Arrayed and Abdulla (1996) described a Syrian patient in a retrospective study carried out to calculate the incidence of cystic fibrosis in Bahrain. [See: Bahrain > Al Arrayed and Abdulla, 1996]
Al-Mahroos (1998) described a Bahraini patient of Syrian origin with cystic fibrosis. [See also: Bahrain > Al-Mahroos, 1998].
[See also: Kuwait > Aluwihare et al., 1981; Kollberg, 1986].
Benson et al. (1987) were the first to report cystic fibrosis (CF) in a UAE national. The patient was born to first cousin Emirati parents of Baluch descent. Diarrhea was reported in the patient at an early age, while persistent coughing was noted at six months with no response to antibiotic treatment. Chest X-rays revealed hyperinflated lungs and sweat chloride test performed twice showed elevated concentrations. Following Pancreatin treatment, diarrhea improved markedly. [Benson PF, Fahmy NA, Vaswani K, Semrin A. Cystic fibrosis in the United Arab Emirates - a case report. Emirates Med J. 1987; 5:156-7.]
Dawson and Frossard (1994) described the clinical features of cystic fibrosis (CF) in eight Emirati children (six females and two males) based on patient history, laboratory findings, clinical features, and sweat chloride test results. The patients belonged to six sibships and all of them had strikingly elevated sweat chloride concentrations and pancreatic insufficiency. [Dawson KP, Frossard P. Cystic fibrosis in the United Arab Emirates: I - Clinical presentation. Emirates Med J. 1994; 12:245-7.]
One year later, in a follow-up study Dawson and Frossard (1995) reported three more children with CF. Dawson and Frossard (1995) indicated that the disease is more prevalent and present in the severe, multisystem form in the UAE.
[See: Iraq > Kerem et al., 1995; Qatar > Abdul Wahab et al., 2000].