Atypical Clinical Forms Research Articles

Concomitant primary and secondary syphilis: a case series from a reference center in Mexico

Primary syphilis is characterized by the presence of a chancre and secondary syphilis by the presence of syphilis. The presence of chancres within secondary syphilis have been reported, however, this form of presentation is rare. Patients with synchronous diagnosis of primary and secondary syphilis were included. They underwent a reverse sequence algorithm for syphilis diagnosis with a rapid syphilis test, if positive, a rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL) tests were performed. A total of 15 patients were included. All were men. In primary syphilis, penile chancre predominated in 13 patients (86.6%), and one (6.7%) was in the tongue. In secondary syphilis syphilitic roseola was the most common type of presentation in 10 patients (66.6%), followed by the palmoplantar plaques in 6 patients (40%) and condyloma lata in 2 patients (13.3%). One patient presented alopecia in a “moth-eaten” pattern and this presentation coexisted with a condyloma lata and the palmoplantar plaques. Other patient presented with syphilitic roseola, palmoplantar plaques and condyloma lata. Clinical presentation as coexistent primary-secondary syphilis will become more frequent. First contact physicians and dermatologists would have to take more in consideration infrequent and atypical clinical forms of this disease.

Immunomorphological insights into clinical variants of bullous pemphigoid in Moscow Region patients

Bullous pemphigoid is an autoimmune blistering dermatosis in which the pathogenesis is primarily characterized by the production of autoantibodies IgG and IgE against hemidesmosomal proteins (BP180 and BP230) and the disruption of T-cell immune response regulation. The classical understanding of the clinical course of bullous pemphigoid has undergone significant transformation in recent years due to the identification of numerous conditions that do not exhibit typical clinical presentations but are diagnosed as bullous pemphigoid based on immunofluorescence’s results. Often, when an atypical clinical form of bullous pemphigoid develops, a specialist physician may not have grounds to include bullous pemphigoid in the differential diagnosis. Consequently, specific diagnostic tests (such as immunomorphological examinations of skin biopsies) that would allow for the verification of this blistering dermatosis are not performed for the patient. Clearly, due to the absence of an accurate diagnosis, patients do not receive the necessary therapy. There is currently no information in the world literature regarding the frequency of atypical forms of bullous pemphigoid. However, it is known that bullous pemphigoid is a relatively common blistering dermatosis in the population of European countries, with a prevalence ranging from 2.4 to 66 cases per million people, depending on the region.

Identification of Factors Associated with Mortality in the Elderly Population with SARS-CoV-2 Infection: Results from a Longitudinal Observational Study from Romania.

The progression of SARS-CoV-2 infection has been linked to a hospitalization rate of 20%. The susceptibility of SARS-CoV-2 infection increases with age, resulting in severe and atypical clinical forms of the disease. The severity of SARS-CoV-2 infection in the elderly population can be attributed to several factors, including the overexpression of angiotensin-converting enzyme 2 (ACE2) receptors, immunosenescence, and alterations in the intestinal microbiota that facilitate the cytokine storm. In light of these observations, we conducted a retrospective analysis based on prospectively collected data between 23 December 2021 and 30 April 2022 (the fourth wave of SARS-CoV-2 infection). We analyzed patients aged over 60 years who were hospitalized in a county hospital in Romania. The primary objective of our study was to assess the risk factors for an unfavorable outcome, while the secondary objective was to assess the clinical and baseline characteristics of the enrolled patients. We included 287 cases with a complete electronic medical record from this available cohort of patients. We aimed to retrospectively evaluate a group of 127 patients that progressed, unfortunately, toward an unfavorable outcome versus 160 patients with a favorable outcome. We used the Combined Ordinal Scale of Severity that combines the WHO ordinal scale and the degrees of inflammation to assess the severity of the patients at the time of the initial assessment. The age group between 70 and 79 years had the highest percentage, accounting for 48.0%-61 patients, of the deceased patients. We noted statistically significant differences between groups related to other cardiovascular diseases, nutritional status, hematological diseases, other neurological/mental or digestive disorders, and other comorbidities. Regarding the nutritional status of the patients, there was a statistically significant unfavorable outcome for all the age groups and the patients with a BMI > 30 kg/m2, p = 0.004. The presence of these factors was associated with an unfavorable outcome. Our results indicate that with the presence of cough, there was a statistically significant favorable outcome in the age group over 80 years, p ≤ 0.049. In terms of the presence of dyspnea in all groups of patients, it was associated with an unfavorable outcome, p ≤ 0.001. In our study, we analyzed laboratory test results to assess the level of inflammation across various WHO categories, focusing on the outcome groups determined by the average values of specific biomarkers. Our findings show that, with the exception of IL-6, all other biomarkers tend to rise progressively with the severity of the disease. Moreover, these biomarkers are significantly higher in patients experiencing adverse outcomes. The differences among severity categories and the outcome group are highly significant (p-values < 0.001). CART algorithm revealed a specific cut-off point for the WHO ordinal scale of 4 to stand out as an important reference value for patients at a high risk of developing critical forms of COVID-19. The high death rate can be attributed to proinflammatory status, hormonal changes, nutritional and vitamin D deficiencies, comorbidities, and atypical clinical pictures.

Pertussis worldwide. Vaccinating children and adults

Pertussis (whooping cough) is an important cause of morbidity and mortality in infants world-wide, and continues to be a public health concern despite high vaccination coverage. The disease, caused by bacterium Bordetella pertussis, is present in all countries. Before vaccines became widely available in the 1950s, pertussis was one of the most common childhood diseases worldwide. According to WHO, estimation of deaths was 4 millions/year in 1950 and 100 000/year in 2015. But morbidity remains important with a high circulation of the bacterium determining atypical clinical forms after whole cell or acellular vaccines use. This is due mainly to the absence of booster doses in adolescents and adults. Major progress are generalisation of PCR and vaccination of mother during pregnancy. A resurgence of pertussis is observed after generalisation of acellular vaccines use. In China the progression of allele ptxPl was found in all areas following the use of acellular vaccine. This allele, rare before acellullar vaccine, is linked to a macrolide resistance, and reaches more than 30% of strains isolated in hospitalised children.These evolutions must be evaluated in clinical forms and genotyping of all strains, in all areas.

From dengue outbreaks to endemicity: Reunion Island, France, 2018 to 2021.

BackgroundAfter 40 years of limited viral circulation, Reunion Island has since 2018 experienced recurrent dengue outbreaks of increasing intensity and severity.AimWe aimed to report on the epidemiology and characteristics of dengue in Reunion Island between 2018 and 2021.MethodsBetween 2018 and August 2021, we systematically collected data on dengue cases via an automated transmission system between the health authorities and the medical laboratories. We set up additional surveillance systems for dengue-related activity in primary care, in emergency departments and in inpatient departments.ResultsUntil 2020, despite numerous cases, outbreaks had a limited public health impact because of few severe cases, low lethality and no heavy burden for the health care system. In 2021, however, the number of severe cases increased (from 0.4% of all cases in 2018 to 0.8% in 2021), as did the number of paediatric cases (from 8% in 2018 to 15% in 2021) and atypical clinical forms of dengue (108 cases of post-dengue maculopathy). Of note, haemorrhagic forms were rare and multi-organ failure was the most frequent severity throughout the study period. In parallel, the dominant serotype switched from DENV2 to DENV1 in 2020 and DENV1 became the only serotype detected in 2021.ConclusionThese findings indicate that dengue is becoming endemic in Reunion Island. Since comorbidities associated with severity of dengue are common in the population, health authorities should carefully consider the impact of dengue when addressing public health policies.

THE NEW INCREASE IN THE RATE OF CONTAMINATION AND DEATHS RESULTING FROM SPOTTED FEVER IN BRAZIL

Rocky Mountain spotted fever is an infectious, acute febrile disease of variable severity. It can range from mild and atypical clinical forms to severe forms, with a high lethality rate. Rocky Mountain spotted fever is caused by a bacterium of the genus Rickettsia, transmitted by tick bites. In Brazil, two species of rickettsiae are associated with clinical conditions of Spotted Fever. Rickettsia rickettsii, which leads to Brazilian Spotted Fever (BSF), considered a serious disease, registered in the north of the state of Paraná and in the states of the Southeast Region. Rickettsia parkeri, which has been recorded in environments of the Atlantic Forest (Rio Grande do Sul, Santa Catarina, Bahia and Ceará), producing less severe clinical conditions.The objective of this article wasto describe through a literature review, Rocky Mountain spotted fever in Brazil, forms of transmission, treatment, mortality and clinical manifestations.In Brazil, the main vectors are ticks of the genus Amblyomma, such as A. sculptum (= A. cajennense) known as the star tick, A. aureolatum and A. ovale. However, potentially, any species of tick can harbor the bacteria that cause Rocky Mountain Spotted Fever, such as the dog tick.

Morphological features of skin changes in the undetermined clinical picture of psoriasis and atopic dermatitis in children

Absrtact Introduction The literature describes atypical clinical forms of psoriasis and atopic dermatitis in children that combine features of both diseases. In such cases, dermatologists resort to biopsy of plaque skin elements in the complex diagnosis. However, the histological picture in these biopsy specimens is uncertain and does not allow to make an unequivocal judgment about the correspondence of changes to one or another disease. The purpose of work was to compare pathomorphological changes in biopsy specimens of plaque skin elements in children with undetermined clinical picture of the disease with changes in typical forms of psoriasis and atopic dermatitis. Materials and methods A morphometric study of 10 plaque skin biopsy specimens from children (mean age 9.2±1.11 years) with an indeterminate clinical picture of the disease was performed. The obtained data were compared with two control groups of adult patients with typical clinical pictures of psoriasis (n=20; mean age 34.35±3.58 years) and atopic dermatitis (n=10; mean age 41.33±7.35 years). Results A comparative morphometric analysis of skin biopsy specimens revealed the fewest differences between the analyzed parameters of the squamous epithelium of the patients in the study group and the group with psoriasis. In all three groups, the main mass of the inflammatory infiltrate in the dermis was composed of lymphocytes and macrophages whose numerical density differed in psoriasis and atopic dermatitis at different levels of the dermis, while in the study group it had intermediate values. The number of neutrophils and eosinophils in the study group had minimal values. Discussion Morphological changes in the epidermis of the study group were closest to those in psoriasis, while the cellular composition of the inflammatory infiltrate of the dermis did not correspond to any of the control groups and had either intermediate values (in terms of lymphocytes and macrophages) or minimal values (in terms of eosinophils and neutrophils).

CHANGES IN SERUM SOMATOSTATIN AND GASTRIN LEVELS IN PATIENTS AFTER CHOLECYSTECTOMY AND GASTROESOPHAGEAL REFLUX DISEASE.

The aim: To study of changes in the level of serum gastrin (GN) and somatostatin (SST) in patients with GERD after ChECT and determined their characteristics from clinical forms of GERD. Materials and methods: 64 patients with different clinical forms of GERD were examined. The patients with GERD were divide into 2 clinical groups. Group 1 included 34 patients with GERD after ChECT, among them there were 14 males (41.2 %) and 20 females (58.8 %), with the average age of 40.2 ± 3.2 years. Group 2 consisted of 30 patients with GERD without ChECT. Among them there were 18 males (60.0 %) and 12 females (40.0%), with the average age of 38.9 ± 4.7 years. All patients were tested for serum SST and GN level by enzyme-linked immunosorbent assay (ELISA). Results: In all patients with GERD of both group there was a significant increase in the level of serum SST. At the same time, a more higher indicators have been established in 2 Group of patients (increase up to 0.702 ± 0.029 pg / ml - p <0.01). Noteworthy is the change in the level of SST in the serum in both groups of the examined patients depending on the clinical form of GERD, with the maximum increase in patients with atypical manifestation of GERD. The analysis of the level of GN in blood serum indicates its decrease in the examined patients. In this case, the most pronounced changes were found in patients with extraesophageal clinical signs of GERD. Conclusions: 1. In patients after ChECT gastroesophageal reflux disease often has atypical symptoms (mostly cardiac and bronchopulmonary forms in 45.0% and 25.0 % of examend patients). 2. There was detected an increase in the level of blood SST of patients with GERD while there was observed a decrease in the GN indicator in the serum, especially in its atypical forms. 3. Duodenogastric reflux is often diagnosed during endoscopic examination of patients with GERD after cholecystectomy. At the same time, its severity correlates with the level of SST in blood serum (r=0.76; p<0.01 in the typical form and r= 0.72; p<0.05 in the atypical clinical form of GERD).

Clinical Manifestations of Benign Paroxysmal Positional Vertigo of the Horizontal Semicircular Canal: Pathophysiology of Atypical Manifestations

The presence of a direction changing positional nystagmus (DCPN) in a patient with vertigo is the characteristic sign to diagnose a benign paroxysmal positional vertigo of the horizontal semicircular canal (HSC-BPPV). If a persistent DCPN is observed when positional tests are performed, a light or heavy cupula phenomenon must be suspected. In order to differentiate between these clinical phenomena, a null plane test should be considered for diagnosis. On the other hand, when a paralytic or irritative fixed direction nystagmus is found, then a complete or incomplete jamming within the HSC may be involved. In this particular situation a head shaking nystagmus test may be clarifying. When persitent DCPN or paralytic-irritative nystagmus are found in positional testing, ENT clinicians must keep alert to search for atypical clinical forms of HSC-BPPV.

New possibilities of systemic therapy of plaque psoriasis with the IL23p19 inhibitor risankizumab

Introduction. There is a trend towards rising incidence of psoriasis and increase in the degree of incidence of severe, atypical and treatment-resistant clinical forms of psoriasis in the Russian Federation. In this regard, cases of early disability of patients and deterioration of their quality of life are recorded, which determines the medical and social significance of this disease. In the last few years, a much deeper understanding of the pathogenesis of psoriasis has been gained. This is especially true of the role of T-helper 17 cells, the role of the IL-23 cytokine in the development of the disease, which has resulted in the development of new classes of biological drugs, which creation introduced significant changes in the treatment of psoriasis that has become more effective, safer and convenient for patients. More new biologics undergo clinical trials and receive approvals with each passing year. Among them is risankizumab, interleukin-23 inhibitor, which is a safe and effective drug for the treatment of moderate to severe plaque psoriasis and psoriatic arthritis in adult patients. Interleukin-23 inhibitors are not required to be administered as often as interleukin-17 inhibitors and may have a more favourable safety profile without an increased risk of candidiasis or inflammatory bowel disease. Overall, these highly effective drugs contribute to the improvement of the long-term efficacy of psoriasis therapy due to relief of skin lesions and joint symptoms, as well as to the enhancement of patients’ quality of life and lengthening of remissions.Purpose. To analyse key information about risankizumab using the results of clinical trials published in the current scientific literature.Materials and methods. This analysis used literature sources from the international medical databases: PubMed, Cochrane Library, MEDLINE.Results. Presently, a number of phase III registrational trials of risankizumab in 2,109 patients with plaque psoriasis have been published: UltIMMa-1, UltIMMa-2, IMMvent and IMMhance, as well as an additional side by side comparative study of risankizumab with secukinumab (IMMerge) in 327 patients with plaque psoriasis. The results of these studies were used as the grounds for approval of risankizumab for the treatment of patients with moderate to severe plaque psoriasis and psoriatic arthritis by the Russian Ministry of Health on September 14, 2020. There have also been several reports of interim results of the open-label enhanced LIMMitless study, which included patients from pivotal studies. Our records show that the percentage of patients receiving risankizumab for 3 years (172 weeks) and maintaining PASI 90 and PASI 100 was 88 and 63%, respectively, and the percentage of those maintaining sPGA 0/1 was 88%.Conclusion. The analysed data showed that risankizumab is one of the most effective target drugs for the treatment of psoriasis and psoriatic arthritis, it has a favourable safety profile and a more convenient dosage regimen as compared with other genetically engineered biologic drugs (GEBD) (the recommended dose of Skyrizi is 150 mg (two 75 mg injections) administered by subcutaneous injection at week 0, week 4, and every 12 weeks thereafter).

Adaptation of WHO Definitions of Clinical Forms of Chikungunya Virus Infection for the Elderly.

The WHO defined three clinical forms for chikungunya virus infection (CHIKV, namely, acute, atypical, and severe cases) and a chronic form. These definitions seemed inappropriate for the elderly. So, we propose an adapted definition for elderly people. A cross-sectional analysis was performed including patients aged ≥ 65 years, who attended the emergency department with a positive biological diagnosis of CHIKV in 2014. A total of 267 elderly patients (80 ± 8 years) were included. When using the 2015 WHO definitions, 114 patients could not be classified (42.7%) in any of the category, of whom 43 (37.7%) reported absence of fever, 85 (74.6%) reported absence of joint pain, and 14 (12.3%) reported absence of both fever and joint pain. After adaptation of the WHO definitions, the 114 unclassifiable patients were reclassified as follows: eight as typical cases, 50 as atypical cases, 42 as severe cases, and 14 remained unclassifiable. The atypical clinical form was the most common form. The 2015 WHO definitions of the clinical forms at the acute phase of CHIKV are ill suited to the elderly. The adapted definition we propose here appears to be more appropriate and could help improved management of older patients with CHIKV.

Beyond Giant Cell Arteritis and Takayasu's Arteritis: Secondary Large Vessel Vasculitis and Vasculitis Mimickers.

To provide an overview of mimickers of large vessel vasculitis (LVV), by the main presenting manifestation, i.e., systemic, vascular, and cranial manifestations. The main differential diagnoses in patients with giant cell arteritis (GCA) and Takayasu arteritis (TAK) presenting with systemic manifestations (i.e., fever, anorexia, weight loss, night sweats, arthralgia/myalgia, and/or increased inflammatory indexes) are neoplastic, infectious, or other inflammatory conditions. In patients with vascular manifestations (such as peripheral ischemia, vascular stenoses, or aneurysms), atherosclerosis and non-inflammatory vascular diseases should be excluded. In those presenting with predominant cranial symptoms (i.e., temporal headache, jaw claudication, scalp tenderness, transient or permanent vision loss), other causes of headache, cerebrovascular accidents, optic neuropathy, and neuromuscular syndromes need to be considered. The diagnosis of LVV maybe challenging, especially when patients present with atypical or incomplete clinical forms. In these cases, a multidisciplinary approach is strongly recommended.

Encefalitis aguda en pacientes COVID-19: primer reporte de casos en Perú.

En el contexto de la pandemia de COVID-19, se han descrito formas clínicas atípicas, en las que predominan síntomas extrar-respiratorios; entre ellos han sido reportados casos de manifestaciones neurológicas concurrentes. En base a la identificación de coronavirus en el sistema nervioso central en el brote SARS-CoV del 2002, se ha planteado un potencial neurotropismo del SARS-CoV-2. En la literatura mundial se han descrito escasos pacientes con encefalitis aguda asociada a SARS-CoV-2. En este reporte les presentamos dos casos de pacientes peruanos con encefalitis aguda concurrente a COVID-19, revisamos la literatura y discutimos los posibles mecanismos de neurotropismo y neuro-invasión.

Th17 lymphocytes in atypical cutaneous leishmaniasis caused by Leishmania (L.) infantum chagasi in Central America

Skin lesions in nonulcerated cutaneous leishmaniasis (NUCL) caused by Leishmania (L.) infantum chagasi are characterized by a mononuclear inflammatory infiltrate in the dermis, which is composed mainly of lymphocytes, followed by macrophages, few plasma cells and epithelioid granulomas with mild tissue parasitism. Previous studies have shown that the main population of lymphocytes present in the dermal infiltrate is CD8+ T cells, followed by CD4+ T cells, which are correlated with IFN-γ+ cells. To improve the knowledge of cellular immune responses in NUCL, skin biopsies were submitted to immunohistochemistry using anti-ROR-γt, anti-IL-17, anti-IL-6, anti-TGF-β, and anti-IL-23 antibodies to characterize the involvement of Th17 cells in the skin lesions of patients affected by NUCL. ROR-γt+ , IL-17+ , IL-6+ , TGF-β+ and IL-23+ cells were observed in the dermal inflammatory infiltrate of NUCL skin lesions. A positive correlation between CD4+ T-lymphocytes and ROR-γt+ and IL-17+ cells suggests that some of the CD4+ T-lymphocytes in NUCL could be Th17 lymphocytes. Moreover, a positive correlation between ROR-γt+ cells and TGF-β+ , IL-6+ , IL-17+ and IL-23+ cells could indicate the role of these cytokines in the differentiation and maintenance of Th17 lymphocytes. Our findings improve knowledge of the pathogenesis of this rare and atypical clinical form of leishmaniasis.

Clinical and endoscopic features of gastroesophageal reflux disease in patients with obesity

Clinical and endoscopic results of a study at 94 patients with gastroesophageal reflux disease (GERD) and obesity, as well as 85 patients with GERD are presented. A high incidence of atypical clinical manifestations of GERD on the background of obesity (an extraesophageal form of the disease) was revealed. An endoscopic study has mainly established reflux esophagitis of grades B and C (LA) in patients with obesity and a high percentage of cases (up to 59.5%) of duodenogastric reflux with a combination of GERD and obesity, especially in patients with atypical clinical form of reflux disease.

ACUTE APPENDICITIS: HISTORY AND CURRENT STATE OF THE MEDICAL CARE

Introduction. The problem of diagnostics and treatment of an acute appendicitis, despite of comprehensive study of this issue, remains extremely actual that is caused by a high incidence of appendicitis, considerable number of various complications of this disease in the pre - and postoperative period. The objective of this study is to assess the current state and dynamics of indicators on acute surgical pathology of abdominal organs in St. Petersburg, scientific justification of the main trends in the development of surgical science and practice. Material and methods.Materials on monitoring of acute surgical pathology of abdominal organs in St. Petersburg are presented to one of 7 nosological forms in the article, – an acute appendicitis. Historical-analytical, standard- legal and statistical methods were used. Results. A decrease in the proportion of patients with acute appendicitis in the structure of 7 nosological forms of acute surgical pathology of the abdominal organs, united in the concept of «acute abdomen» (by 64.18 %: from 91.93 % in 1953 to 27.75 % in 2016); a decrease in the number of operated patients by 67.9 %; an increase in operational activity to 98.28 % in 2016; an increase in the proportion of patients with hospitalization for less than 24 hours from 58.13 % (1932-1946) to 66.74 % (1953-2016); the rate of late hospitalization (later than 24 hours) remains almost stable for the entire period of observation (more than 60 years), and in recent years has even a slight increase (+8.21%). There is a decrease in postoperative mortality in acute appendicitis in 350 times (from 21.00% in 1910 to 0.06% in 2016).Conclusion. The work demonstrates the success of healthcare in the field of emergency surgery, which are due to many factors to improve organizational approaches related to the development of diagnosis and treatment of acute appendicitis, including – description of characteristic symptoms, introduction of laboratory diagnostics, study of atypical and complicated clinical forms, peculiarities of the disease course in children and elderly people, definition of the terms of surgical intervention, introduction into clinical practice and improvement of instrumental methods of diagnostics and endosurgical methods of appendectomy, etc.

Regional multimodal relationships between tau, hypometabolism, atrophy, and fractional anisotropy in atypical Alzheimer's disease.

Alzheimer's disease (AD) can present with atypical clinical forms where the prominent domain of deficit is not memory, that is, atypical AD. Atypical AD patients show cortical atrophy on MRI, hypometabolism on [18 F]fluorodeoxyglucose (FDG) PET, tau uptake on [18 F]AV-1451 PET, and white matter tract degeneration on diffusion tensor imaging (DTI). How these disease processes relate to each other locally and distantly remains unclear. We aimed to examine multimodal neuroimaging relationships in individuals with atypical AD, using univariate and multivariate techniques at region- and voxel-level. Forty atypical AD patients underwent MRI, FDG-PET, tau-PET, beta-amyloid PET, and DTI. Patients were all beta-amyloid positive. Partial Pearson's correlations were performed between tau and FDG standardized uptake value ratios, gray matter MRI-volumes and white matter tract fractional anisotropy. Sparse canonical correlation analysis was applied to identify multivariate relationships between the same quantities. Voxel-level associations across modalities were also assessed. Tau showed strong local negative correlations with FDG metabolism in the occipital and frontal lobes. Tau in frontal and parietal regions was negatively associated with temporoparietal gray matter MRI-volume. Fractional anisotropy in a set of posterior white matter tracts, including the splenium of the corpus callosum, cingulum, and posterior thalamic radiation, was negatively correlated with parietal and occipital tau, atrophy and, predominantly, with hypometabolism. These results support the view that tau is the driving force behind neurodegeneration in atypical AD, and that a breakdown in structural connectivity is related to cortical neurodegeneration, particularly hypometabolism.

Perforated cholecystitis. Classification and atypical clinical forms

To obtain new data for diagnosis and treatment of patients with perforated cholecystitis. It was analyzed the variants of original classification of perforated cholecystitis by Fedorov S.P. - Neimeier O.W. (1934). Moreover, we have assessed treatment of 292 patients with gallbladder perforation (own material of Faculty Surgery Clinic). According to continuous 20-year follow-up perforated cholecystitis was observed in 2.9% of patients with various forms of gallbladder inflammation (n=292 out of 10 215). The frequency of atypical clinical forms of gallbladder perforation including multiple and combined perforation, perforation with acute intestinal obstruction and intraabdominal bleeding was 10% (n=29 of 292). Overall mortality in atypical clinical forms related to whole cohort with perforated cholecystitis was 2% (n=6 of 292). Atypical clinical forms of gallbladder perforation require specific treatment strategy due to the need for emergency surgical interventions. At the same time, the possibilities of video-assisted surgery are somewhat limited compared with other forms of gallbladder inflammation and can be used only in a third of patients.

Increased Frequency of MEFV Genes in Patients with Epigastric Pain Syndrome.

Atypical clinical forms of familial Mediterranean fever (FMF) can be misdiagnosed as therapy-resistant epigastric pain syndrome (EPS) for they share many of the same clinical features, such as abdominal pain. Thus, we aimed to determined the frequency of FMF in patients who were followed with a diagnosis of therapy-resistant EPS. Seventy-five patients with therapy-resistant EPS and 20 controls were involved in the study. To detect the FMF in patients with therapy-resistant EPS, Tel-Hashomer criteria, family history of FMF were researched and recorded. We performed performed MEFV gene analysis on all patients. Forty-three patients with EPS (57.3%) had MEFV gene mutations and the carrier rate was 30.0%. The most common MEFV gene alteration was R202Q (55.8%), followed by E148Q (16.2%), R761H (16.2%), V726A (9.3%), M680I (9.3%) and M694V (4.6%). Rarely seen mutations in the Turkish population were also identified: K695R (2.3%), L110P (2.3%) and G304R (2.3%). Eight patients with EPS were diagnosed with FMF and started on colchicine therapy. Three patients with compound heterozygosities for three mutations, two patients with compound heterozygosities for two mutations (K695R/ V726A and R202Q/ R761H), one patient with homozygous R202Q, one patient with heterozygous R202Q mutation and one patient with non- R202Q heterozygous mutation (G304R/–) had clinical FMF symptoms and were started on colchicine therapy. Patients who have therapy-resistant EPS should also be questioned about FMF, especially in high risk populations.

Neurological manifestations of dengue in Central Brazil.

The incidence of dengue has increased throughout the 2000s with a consequent global increase in atypical clinical forms. This study reports a series of cases of neurological dengue out of 498 confirmed cases of laboratory dengue in Goiânia, Brazil. Cases were confirmed based on viral RNA detection via polymerase chain reaction or IgM antibody capture. Neurological symptoms occurred in 5.6% of cases, including paresthesia (3.8%), encephalitis (2%), encephalopathy (1%), seizure (0.8%), meningoencephalitis (0.4%), and paresis (0.4%). DENV-3 was the predominant circulating serotype (93%). We reported dengue cases with neurological manifestations in endemic area.