Atypical Variants Research Articles

SILENT MYOCARDIAL ISCHEMIA IN PATIENTS WITH ACUTE CORONARY SYNDROME AND DIABETES MELLITUS

ST-segment elevation myocardial infarction, stenting of the infarct-related coronary artery, silent (painless) myocardial ischemia, diabetes mellitus, 24-hour electrocardiographic monitoring.
 Introduction. Currently, approximately 422 million people in the world have diabetes mellitus, and over 1.3 million individuals in Ukraine are diagnosed with diabetes mellitus. Diabetic neuropathy is known to contribute to the development of atypical and painless variants of ischemic heart disease in individuals with diabetes. This poses a challenge for timely diagnosis and obscures the course of ischemic heart disease, as the prevalence of silent myocardial ischemia is significantly high in these patients. Therefore, the aim of this study is to investigate the occurrence of myocardial ischemia episodes in patients with ST-elevation myocardial infarction within the first day following stenting of the infarct-related coronary artery. Furthermore, we aimed to demonstrate the painless nature of these episodes in the presence of type 2 diabetes mellitus through a clinical case presentation.
 Materials and methods. 30 patients with ST-segment elevation myocardial infarction were examined, and 24-hour electrocardiographic monitoring was performed during the first day after the infarct-related coronary artery stenting. Results. Episodes of transient myocardial ischemia were registered in 50% of people. We found that the majority of episodes (80%) were painless. In the presence of diabetes mellitus, only episodes of painless myocardial ischemia were noted that is supported by the example of a clinical case. The study highlighted the informativeness of 24-hour electrocardiographic monitoring in identifying episodes of myocardial ischemia, particularly in its painless variant. The results demonstrate that patients with ST-elevation myocardial infarction (STEMI) experience episodes of transient myocardial ischemia within the first day after coronary artery stenting, with a majority of these episodes being painless. Furthermore, in the presence of diabetes mellitus, ischemic episodes tend to be painless. Therefore, 24-hour electrocardiographic monitoring serves as a valuable method for the detection of myocardial ischemia.

The Case Files

The Case Files

P319 MID VENTRICULAR TAKOTSUBO SYNDROME IN A PATIENT WITH COVID 19 PNEUMONIA: A CASE REPORT

Abstract Background Takotsubo Syndrome (TTS) is an acute and transient myocardial disfunction associated with chest pain, electrocardiographic changes and minimal myocardial enzymatic release mimicking acute myocardial infarction but without significant coronary artery disease. Physical or emotional stress play a central role in the pathogenesisof this cardiomyopathy. Several variants have been described including the classic type, reverse Takotsubo, midventricular type and focal type. Mid ventricular Takotsubo is characterized by circumferential mid–ventricular hypokinesia with hypercontractility of base and apex. This atypical variant is one of the most rare form that occurs in 15% of patients with Takotsubo syndrome. We report a Takotsubo case with mid–ventricular pattern in a postmenopausal woman with COVID–19 interstitial pneumonia. Clinical case A 56–year–old female patient was admitted to our intensive cardiac care unit for acute chest pain and dyspnea. In clinical history hypertension, dyslipidemia, anemia and schizophrenia were documented. COVID–19 molecular test was positive. CT scan showed multiple ground–glass opacities bilaterally. Hemodynamic parameters were normal but ECG showed ST–segment elevation and T waves inversion in the lateral precordial leads. Troponin–I was elevated and peaked at 1704 ng/mL. A transthoracic echocardiogram showed ballooning of the midventricular segments with hyperkinesis of the basal and apical segment. Coronary angiography showed normal coronaries. The patient was treated with beta–blockers and intravenous fluid infusion. After 10 days in hospital, echocardiography showed normalization of regional contractility and improvement of ejection fraction. The patient was discharged in good condition. Conclusions Recent studies have reported an increase in TTS incidence during the COVID–19 pandemic. SARS-CoV-2 infection induces physical and psychological stress in patients, which may lead to an increase in the risk of TTS development. The pathophysiology of COVID-19-induced TTS still remains unclear. The mortalityrate of TTS is higher (36.5%) in COVID–19 patients.

Detection of Atypical Salmonella Infantis Phenotypes in Broiler Environmental Samples.

In numerous countries, strict and targeted measures concerning Salmonella monitoring and control are implemented and high quality of surveillance is ensured by obligatory investigation of samples from the primary production level of animals according to EN/ISO standards. Here, 2 phenotypic characteristics of Salmonella exhibited on compulsory media are crucial, namely, motility demonstrated on modified semisolid Rappaport Vassiliadis agar (MSRV), and production of hydrogen sulfide (H2S) on xylose lysine deoxycholate agar (XLD). In the present study, we describe the detection of Salmonella Infantis variants found in broiler environmental samples with major alterations in their growth characteristics on MSRV, XLD, and brilliant green-phenol red-agar (BPLS). The variants proved to be non-motile on MSRV and displayed non-confirming colony appearances on the previously mentioned selective agars. The growth spectrum comprised pinhead sized yellow colonies with small black centers, but also pinpoint sized colorless colonies, both colony types of regular shape. Our work contributes to highlight the finding of S. Infantis variants which possess more than one phenotypic deviation from the "typical" growth characteristics and by this limit the detection power of the actual obligatory used media. IMPORTANCE Salmonellosis caused by non-typhoidal Salmonella serovars is the second most frequently reported zoonotic disease in humans in the EU. The transmission of these agents is mainly via contaminated food of animal origin. In this context, poultry products are the main source of infection. Therefore, continuous and standardized surveillance of the prevalence of such Salmonella serovars at the primary production level is essential. Our findings show the phenotypic heterogeneity of the serovar Infantis and provide growth characteristics of atypical variants. Such variants pass unnoticed official screening methods, resulting in incorrect identification and being underrepresented in epidemiological surveillance programs.

Decline in Visual and Posterior Cortical Functions in Logopenic Progressive Aphasia (P5-6.001)

<h3>Objective:</h3> To determine how frequently features of posterior cortical atrophy (PCA) occur in patients with logopenic progressive aphasia (LPA) and determine the neuroimaging correlates of these features. <h3>Background:</h3> LPA and PCA are two atypical clinical variants of Alzheimer’s disease. Overlap can be observed clinically between phenotypes, although it is unclear how frequently patients meeting criteria for LPA develop clinical PCA features, and whether these features are associated with neuroanatomical overlap with PCA. <h3>Design/Methods:</h3> Thirty-six LPA patients recruited by the Neurodegenerative Research Group underwent extensive neuropsychological testing, MRI and [¹⁸F] flortaucipir PET. All patients were evaluated for PCA features including simultanagnosia, Gerstmann syndromes, ideomotor apraxia, and visuospatial and visuoperceptual function, with cut-points used to define abnormality. Patients were classified as Pure-LPA (having no PCA feature), LPA+ (impairment on one test) or LPA-PCA (impairment on 2+ tests). Neuroimaging profiles in each of the three LPA groups were compared to 14 matched healthy controls and 14 matched typical PCA patients using multiple regression analysis in SPM12. <h3>Results:</h3> Eleven patients (31%) were classified as pure-LPA, 16 (44%) as LPA+ and 9 (25%) as LPA-PCA. There were no differences in disease duration, naming, or sentence repetition across groups. The LPA+ group showed worse simultanagnosia (29%), ideomotor apraxia and Gerstmann syndrome (34%) compared to Pure-LPA group. The LPA-PCA group showed further worsening in simultanagnosia (89%), and visuospatial and visuoperceptual impairment compared to LPA+ group. All three LPA groups showed greater left temporoparietal volume loss and flortaucipir uptake compared to controls and PCA, with greater flortaucipir uptake occurring in the occipital and frontal lobes in LPA+ and LPA-PCA compared to Pure-LPA. <h3>Conclusions:</h3> Our results demonstrate that LPA patients can develop features of PCA related to spread of tau into occipito-frontal regions, highlighting syndromic and anatomical overlap between atypical variants of AD. <b>Disclosure:</b> Dr. Singh has nothing to disclose. Dr. Graff-Radford has received personal compensation for serving as an employee of Mayo Clinic. Dr. Graff-Radford has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for NINDS/NIH. Dr. Graff-Radford has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Academy of Neurology. The institution of Dr. Graff-Radford has received research support from NIH. Arenn Faye Carlos, MD has nothing to disclose. The institution of Dr. Machulda has received research support from NIH. Christopher Schwarz has received personal compensation for serving as an employee of Mayo Clinic. The institution of Christopher Schwarz has received research support from NIH. Matthew Senjem has received stock or an ownership interest from Align Technology, Inc.. Matthew Senjem has received stock or an ownership interest from Inovio Biomedical Corp.. Matthew Senjem has received stock or an ownership interest from Johnson &amp; Johnson. Matthew Senjem has received stock or an ownership interest from Mesa Laboratories, Inc.. Matthew Senjem has received stock or an ownership interest from Nvidia Inc.. Matthew Senjem has received stock or an ownership interest from LHC Group, Inc.. Matthew Senjem has received stock or an ownership interest from Natus Medical Incorporated. Matthew Senjem has received stock or an ownership interest from Varex Imaging Corporation. Matthew Senjem has received personal compensation in the range of $100,000-$499,999 for serving as a IT Technical Specialist II with Mayo Clinic. The institution of Dr. Jack has received research support from NIH. The institution of Dr. Jack has received research support from Alexander Family Alzheimer’s Disease Research Professorship of the Mayo Clinic. Dr. Lowe has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for AVID Radiopharmaceutical. Dr. Lowe has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Eisai Inc. The institution of Dr. Lowe has received research support from AVID Radiopharmaceuticals. Dr. Josephs has nothing to disclose. Dr. Whitwell has nothing to disclose.

APOE ɛ4 Influences Within and Between Network Functional Connectivity in Atypical Alzheimer Disease (P11-6.006)

<h3>Objective:</h3> To assess functional connectivity in posterior cortical atrophy (PCA) and logopenic progressive aphasia (LPA) and evaluate how within and between-network functional connectivity differs based on the apolipoprotein E (<i>APOE)</i> ɛ4 status. <h3>Background:</h3> <i>APOE</i> ɛ4 influences atrophy and tau deposition in patients with atypical Alzheimer’s disease (AD), with <i>APOE</i> ɛ4 carriers having greater predisposition to medial temporal involvement. This raises questions on whether the <i>APOE</i> genotype would influence memory network connectivity, a network mainly comprised of medial temporal structures. <h3>Design/Methods:</h3> One-hundred forty amyloid-positive PCA (n=58) and LPA (n=82) patients were recruited by the Neurodegenerative Research Group and underwent structural and resting state functional MRI. Spatially preprocessed data were analyzed to explore the default mode network (DMN), salience, language, visual and memory networks, using a region of interest approach in Conn toolbox. Bayesian hierarchical linear models (BHLM) adjusted for age and sex, assessed the influence of APOE ɛ4 on within and between-network connectivity. <h3>Results:</h3> We found reduced within-network connectivity in the memory and language networks in LPA, with an increase in salience network connectivity in PCA, in <i>APOE</i> ɛ4 carriers compared to non-carriers. <i>APOE</i> ɛ4 did not influence memory within-network connectivity in PCA. Between-network analysis showed evidence of reduced connectivity from the DMN in both groups, with reduced DMN-to-salience and DMN-to-language network connectivity in PCA <i>APOE</i> ɛ4 carriers, and reduced DMN-to-visual network connectivity in LPA <i>APOE</i> ɛ4 carriers. In addition, we found reduced connectivity from the visual-to-language and visual-to-salience networks in <i>APOE</i> ɛ4 carriers compared to non-carriers in both PCA and LPA. Both network-level and voxel-level findings concurred with the BHLM findings, specifically showing reductions in the within-network connectivity for the memory network in LPA <i>APOE</i> ɛ4 carriers. <h3>Conclusions:</h3> The <i>APOE</i> genotype influences brain connectivity, both within and between-networks, in atypical AD variants. However, there was evidence that the modulatory effects of <i>APOE</i> differ across phenotype. <b>Disclosure:</b> Dr. Singh has nothing to disclose. Mr. Martin has nothing to disclose. Dr. Graff-Radford has received personal compensation for serving as an employee of Mayo Clinic. Dr. Graff-Radford has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for NINDS/NIH. Dr. Graff-Radford has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Academy of Neurology. The institution of Dr. Graff-Radford has received research support from NIH. The institution of Dr. Machulda has received research support from NIH. Minerva Carrasquillo has nothing to disclose. The institution of Dr. Taner has received research support from NIH. Dr. Josephs has nothing to disclose. Dr. Whitwell has nothing to disclose.

Radiolabelled folate micellar carriers as proposed diagnostic aid for CNS tumors by nasal route.

Glioma refers to the most atypical variant of the malignant central nervous system tumors posturing massive challenge to the research fraternity owing to the flimsy improvement in the patient survival rate over the past years. The aim of the proposed work was developing a diagnostic aid for brain tumors, which could be administered via the non-invasive intranasal route. Since overexpression of folate receptors in the central nervous system tumors is 500 times more than the normal healthy cells, we aimed at fabricating a radiolabeled folate encapsulated micellar delivery system to be given via the nasal route. Folate conjugated bifunctional chelating agent was synthesized, radiolabeled with 99mTc, and encapsulated in a micellar carrier. The fabricated micelles were further evaluated for in vivo nasal toxicity in rats and the same were found safe for intranasal administration. The fabricated micelles owing to their nano size, mucoadhesive nature, and enhanced permeation were observed to have a higher uptake into the brain (around 16% in 4 h) than as compared to the radiolabeled conjugated folate solution when studied for in vivo biodistribution in mice. Single-photon emission computerized tomography imaging performed in higher animals upon intranasal administration of the micellar formulation revealed enhanced uptake of the micelles into the animal brain. It is believed that the aforementioned formulation can be of a great diagnostic value in the detection of not only brain tumors but also other folate expressing cancers such as cervical, breast, and lungs as the system is fast, non-toxic, accurate, non-invasive, and simple.

Bowen's Disease: Literature Review

The paper presents the results of the bibliographic research materials on Bowen's disease over the past 15 years. The aetiopathogenesis of the disease is not yet fully understood; however, most experts designate the following trigger factors: prolonged use of drugs that suppress the immune response, human papillomavirus, light skin type, and excessive exposure to sunlight, ionizing radiation, arsenic intake. Clinical manifestations of Bowen's disease take anular, verrucous, pigmented, and acral forms. Atypical variants of the disease include “giant” Bowen's disease, and cases of localization of lesions on the face. The paper describes the clinical symptoms of each clinical form of Bowen's disease, diagnostic methods, and various treatment methods used in foreign and domestic practice. Comparative results of research on the treatment methods of Bowen's disease include such methods as surgical removal, Mohs micrographic surgery, photodynamic therapy, curettage, cryotherapy, laser ablation, radiation therapy as well as conservative treatment methods. The latter include topical application of external remedies (fluorouracil, imiquimod, diclofenac), as they can be quite effective in certain cases. The advantages of photodynamic therapy are indicated both in terms of high efficiency and in the safety spectrum of treatment of Bowen's disease.

A Rare Case of Asymmetric Progressive Supra Nuclear Palsy Diagnosed In vivo with Magnetic Resonance/Positron Emission Tomography.

PSP and CBD are usually multi system sporadic disorders characterized by tau inclusions in neurons and glia. The clinical and neuroimaging features are different .However in some cases overlapping of features are noted. Here we present a case of a 65 years old female patient, presenting a 3 years history of insidious onset of asymmetric right upper and lower limb dystonia, followed by slowness, falls and injuries to the back, Parkinsonism, urinary incontinence and cognitive dysfunction and upward gaze palsy. MRI findings were suggestive of moderate cerebral and cerebellar atrophy with prominent ventricular system, reduced antero-posterior midline midbrain diameter, at the level of superior colliculus on axial imaging (morning glory sign was positive) on the left side. PET showed asymmetric hypo metabolism noted in the left superior and middle frontal gyrus, superior temporal and mid temporal gyrus in addition to striatum and thalamus, as well as midbrain, pons and right cerebellar hemisphere. Overall MR/PET was suggestive of unilateral PSP (left) and it corroborated with clinical history of unilateral dystonia and supranuclear gaze palsy. Based on MRI the differential considered was also CBD, but PET showed metabolic activity in the motor cortex. Additionally based on the hummingbird sign and morning glory sign a rare diagnosis of unilateral PSP could be made which also corroborated with the clinical picture.The case report emphasizes the utility of PETMRI simultaneously in situations like these to pick atypical variants or cases with overlapping pathology to reach a diagnosis with in vivo imaging methods.

A Case Series on Intraoral Blue Nevi with a Literature Review-Based Clinico-Pathologic Comparison of Intraoral Blue Nevi with Other Oral Melanocytic Nevi

Nevi are pigmented lesions of bluish-black colour that may occasionally occur in the oral cavity. Out of several oral melanocytic nevi (OMN), blue nevi are significant as some variants are diagnostically challenging due to histopathological overlap with malignant melanoma. The aim of the present report was to present the clinico-pathologic characteristics of 8 new cases of intraoral common blue nevi and 22 OMN. A literature review-based comparison of the clinico-pathological characteristics of intraoral blue nevi with intramucosal nevi is presented. Analysis of the clinico-pathologic characteristics of eight common blue nevi revealed that they are generally small lesions of less than 1 cm in size and are of bluish-black colouration. These lesions were commonly identified in adults (88%), with a female predilection. The hard palate was the most common site of occurrence. These findings could be collaborated with the findings observed in the literature review. It was also revealed that a common blue nevus was the second most common lesion among all OMN. The intraoral common blue nevi included in the present series did not show recurrences or undergo malignant transformation after being followed up for up to 15 years. Unlike a common blue nevus, the literature reveals that a cellular blue nevus or its atypical variant is more diagnostically challenging, while a diagnosis of an epithelioid blue nevus should be followed up with investigations to exclude Carney complex. In conclusion, this case series and literature review reveal that OMN, including intraoral common blue nevi, are small indolent lesions with extremely low malignant transformation potential. A significantly smaller size, well-defined margins and lack of variegations in colour are all features that could be used as clues to differentiate intraoral common blue nevi from mucosal malignant melanoma. However, the diagnosis needs to be confirmed with histopathology.

Concomitant Bullous and Crusted Scabies A Rare Presentation

Scabies is a highly contagious skin condition caused by an infestation of the mite Sarcoptes scabiei. The mites burrow into the upper layers of the skin and lay their eggs, causing intense itching and characteristic linear burrows. There are several atypical clinical variants of scabies, including bullous, crusted, hidden, incognito, nodular, and scalp scabies. Bullous scabies is an uncommon variant, characterized by the formation of large, fluid-filled blisters (bullae) on the skin. Crusted scabies, also known as Norwegian scabies, is a severe and highly contagious form of scabies characterized by thick, crusted lesions on the skin. In this case report, we present a rare case of a 69-year-old man with concomitant bullous and crusted scabies. The patient was treated with a whole-body application of benzyl benzoate lotion and two doses (12mg) of oral ivermectin, two weeks apart, and the skin lesions disappeared 20 days later. This case highlights the importance of considering scabies as a differential diagnosis in patients presenting with bullous lesions and the need for careful examination and investigation to distinguish between bullous scabies and bullous pemphigoid.

HIV-1 Non-Group M Strains and ART

To eliminate HIV infection, there are several elements to take into account to limit transmission and break viral replication, such as epidemiological, preventive or therapeutic management. The UNAIDS goals of screening, treatment and efficacy should allow for this elimination if properly followed. For some infections, the difficulty is linked to the strong genetic divergence of the viruses, which can impact the virological and therapeutic management of patients. To completely eliminate HIV by 2030, we must therefore also be able to act on these atypical variants (HIV-1 non-group M) which are distinct from the group M pandemic viruses. While this diversity has had an impact on the efficacy of antiretroviral treatment in the past, recent data show that there is real hope of eliminating these forms, while maintaining vigilance and constant surveillance, so as not to allow more divergent and resistant forms to emerge. The aim of this work is therefore to share an update on the current knowledge on epidemiology, diagnosis and antiretroviral agent efficacy of HIV-1 non-M variants.

Challenging Patterns of Atypical Dermatofibromas and Promising Diagnostic Tools for Differential Diagnosis of Malignant Lesions.

Dermatofibroma (DF) or fibrous histiocytoma is one of the most frequent benign cutaneous soft-tissue lesions, characterized by a post-inflammatory tissue reaction associated with fibrosis of the dermis. Clinically DFs have a polymorphous clinical aspect from the solitary, firm, single nodules to multiple papules with a relatively smooth surface. However, multiple atypical clinicopathological variants of DFs have been reported and, therefore, clinical recognition may become challenging, leading to a more burdensome identification and sometimes to misdiagnosis. Dermoscopy is considered an important tool in DFs diagnosis, as it improves diagnostic accuracy for clinically amelanotic nodules. Although typical dermoscopic patterns are most frequently seen in clinical practice, there have also been some atypical variants described, mimicking some underlying recurrent and sometimes harmful skin afflictions. Usually, no treatment is required, although an appropriate work-up may be necessary in specific cases, such as in the presence of atypical variants or a history of recent changes. This narrative review's aim is to summarize current evidence regarding clinical presentation, positive and differential diagnosis of atypical dermatofibromas and also to raise awareness about the importance of specific characteristics of atypical variants to better differentiate them from malignant conditions.

Alzheimer's disease phenotypes show different sleep architecture.

Sleep-wake disturbances are a prominent feature of Alzheimer's disease (AD). Atypical (non-amnestic) AD syndromes have different patterns of cortical vulnerability to AD. We hypothesized that atypical AD also shows differential vulnerability in subcortical nuclei that will manifest as different patterns of sleep dysfunction. Overnight electroencephalography monitoring was performed on 48 subjects, including 15 amnestic, 19 atypical AD, and 14 controls. AD was defined based on neuropathological or biomarker confirmation. We compared sleep architecture by visual scoring and spectral power analysis in each group. Overall, AD cases showed increased sleep fragmentation and N1 sleep compared to controls. Compared to atypical AD groups, typical AD showed worse N3 sleep dysfunction and relatively preserved rapid eye movement (REM) sleep. Results suggest differing effects of amnestic and atypical AD variants on slow wave versus REM sleep, respectively, corroborating the hypothesis of differential selective vulnerability patterns of the subcortical nuclei within variants. Optimal symptomatic treatment for sleep dysfunction in clinical phenotypes may differ. Alzheimer's disease (AD) variants show distinct patterns of sleep impairment. Amnestic/typical AD has worse N3 slow wave sleep (SWS) impairment compared to atypical AD. Atypical AD shows more rapid eye movement deficits than typical AD. Selective vulnerability patterns in subcortical areas may underlie sleep differences. Relatively preserved SWS may explain better memory scores in atypical versus typical AD.

Rare forms of dementia-Atypical variants of Alzheimer's dementia

In Germany, around 1.8million people currently suffer from dementia and the numbers are increasing. The main cause of dementia is Alzheimer's disease. This is classically manifested in the form of an amnestic syndrome but also encompasses various atypical variants, especially in younger patients and in the clinical routine are not always easy to recognize. These are described in this narrative review with case studies. Posterior cortical atrophy (PCA) presents with visual disorders, in the logopenic variants of primary progressive aphasia (lvPPA) impaired word retrieval is the main symptom, in the frontal variant of Alzheimer's disease behavioral disorders are prominent and in corticobasal syndrome (CBS) an akinetic rigid Parkinson's syndrome with alien limb phenomenon. As the clinical presentation of these atypical variants shows an overlap with other dementia disorders, the differential diagnosis is often challenging. In this context amyloid biomarkers can provide valuable services.

Atypical Melissococcus plutonius strains: their characteristics, virulence, epidemiology, and mysteries.

Melissococcus plutonius is a Gram-positive lanceolate coccus that is the causative agent of European foulbrood, an important bacterial disease of honey bee brood. Although this bacterium was originally described in the early 20th century, a culture method for this bacterium was not established until more than 40 years after its discovery due to its fastidious characteristics, including the requirement for high potassium and anaerobic/microaerophilic conditions. These characteristics were considered to be common to the majority of M. plutonius strains isolated worldwide, and M. plutonius was also thought to be genetically homologous or clonal for years. However, non-fastidious variants of this species (designated as atypical M. plutonius) were very recently identified in Japan. Although the morphology of these unusual strains was similar to that of traditionally well-known M. plutonius strains, atypical strains were genetically very different from most of the M. plutonius strains previously isolated and were highly virulent to individual bee larva. These atypical variants were initially considered to be unique to Japan, but were subsequently found worldwide; however, the frequency of isolation varied from country to country. The background of the discovery of atypical M. plutonius in Japan and current knowledge on atypical strains, including their biochemical and culture characteristics, virulence, detection methods, and global distribution, are described in this review. Remaining mysteries related to atypical M. plutonius and directions for future research are also discussed.

Pestivirus A Bovine viral diarrhea virus type 1 species genotypes circulating in China and Turkey.

Pestivirus A Bovine viral diarrhea virus type 1 (BVDV-1) is a heterogeneous species within the genus, affecting cattle and other ruminants, with economic impact on livestock production. The study aimed to update the taxonomy of the Pestivirus A, BVDV-1 species and to verify the clustering of the strains reported as genotype 1v, originating from different countries. Recently deposited strains from China, Turkey, and Iran have been evaluated by the palindromic nucleotide substitutions (PNS) genotyping method. Based on secondary structure analysis of the 5'-UTR sequences, strains reported as 1v from China were clustered as sub genotype 1.7.3 (1o). Genotype 1.19 (1w) was restricted to China and genotype 1.21 (1v) was present only in Turkey and Iran. The application of the PNS method clarified the taxonomical status of strains, revealing the homonymy of genetically different clusters. Furthermore, these observations indicated geographic segregation in the Pestivirus A species, and confirmed the occurrence of new atypical genetic variants, with potential implications on control and prophylaxis.

Hydroxycut Induced Atypical Takotsubo Cardiomyopathy: A Case Report

Hydroxycut, an herbal supplement used for weight loss, is known to be associated with multiple side effects with cardiac dysrhythmias being amongst the rarer events. In this case, we report a 69-year-old female presenting after her first dose of Hydroxycut Max supplement resulting in an atypical variant of Takotsubo cardiomyopathy. She presented with symptoms concerning acute coronary syndrome and rapid hemodynamic compromise. Her coronary angiogram showed no obstructive coronary artery disease. The left ventriculogram and transesophageal echocardiogram were suggestive of mid ventricular Takotsubo cardiomyopathy. We further discuss, with the aid of current literature, how caffeine and robusta coffee bean extract, two ingredients in Hydroxycut products can lead to increased sympathetic tone of the myocardium and decreased myocardial perfusion potentially triggering her cardiomyopathy. This will be the first reported case of Hydroxycut induced Takotsubo cardiomyopathy in literature.

ST domed Elevation – an Atypical Variant of Early Repolarization in the White Athlete after the COVID-19 Pandemic. A Case Report.

Background: Interpreting the electrocardiography (ECG) recording in young athletes is challenging for the sports doctor. Changes in intraventricular conduction and early ventricular repolarization observed during sports training are not always confirmed in the literature. We test healthy people and look for irregularities in their ECG records. The study aims to draw attention to ST-Elevation (STE) as a variant of the White Athlete's heart norm, with a frequency lower than an inverted T wave (TWI), but also as an effect of early repolarization of the ventricles in young athletes. Is it physiology? Case report: 14-year-old football player, examined for five years at a sports clinic, cardiology checked every year. Changes like symptomatic adult ECGs with STE and myocardial necrosis were suspected during our observation. Echocardiography, stress test good. A simple response to exercise is to adapt the athlete's heart by ischemia, preconditioning for the heart muscle, and a reversible remodelling that disappears after the sports period. We focus on changes in ECG, which are observed in athletes under 14 years of age, while most of the ECG classifications in an athlete were described above 16 years of age. Conclusion: the variant observed in our White Athlete is an example of several similar repolarization changes in ECG not yet classified as physiological or resulting from intensive training.

Significance of anti-desmocollin autoantibodies in pemphigus.

The major autoantigens for pemphigus are desmogleins (Dsgs), cell-cell adhesive structure proteins, one of the desmosomal cadherins. Recent progress in molecular biology has revealed that IgG autoantibodies of classical pemphigus react with Dsg1 or Dsg3. Desmocollins (Dscs) also belong to the cadherin supergene family that provides structure to the desmosomes and play an important role in cell-to-cell adhesion. In addition to the presence of four desmosomal Dsg isoforms, i.e. Dsg1-4, Dsc1, 2 and 3, all of which are derived from different genes, Dsc1 has been previously identified as the target antigen of IgA autoantibodies in the subcorneal pustular dermatosis (SPD)-type of intercellular IgA dermatosis. In addition to the IgA anti-Dsc1 autoantiboides, the presence of IgG anti-Dsc autoantibodies is described in patients of some autoimmune bullous diseases. In particular, the current pemphigus detecting autoantibodies to Dscs has shown a tendency in atypical variants of pemphigus. Therefore, autoantibodies against Dscs alone may cause detachment of cell-cell adhesion in the epidermis in some pemphigus. However, except for the findings of a few in vitro and in vivo studies, there is currently no clear evidence for the pathogenicity of anti-Dsc autoantibodies in pemphigus, whereas significance of anti-Dsg autoantibodies is well established. This article describes the structure and function of the Dscs, and explores the evidence regarding the pathogenic role of anti-Dsc autoantibodies in pemphigus.