Clinical Course Research Articles

Chronic inflammatory demyelinating polyneuropathy following COVID-19 vaccination: a case report and literature review

BackgroundSevere post-vaccination neurological complications are rare. Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is an immune-mediated polyneuropathy affecting the peripheral nerve roots, which is not well described as a post-vaccination side effect. Here, we present a rare complication of vaccination against SARS-CoV-2, reaching a diagnosis of CIDP.Case presentationA 67-year-old diabetic male presented with lower extremity paresthesia and weakness following the third dose of the Sinopharm (BBIBP-CorV) vaccine. Despite initial dismissal as a diabetic complication, symptoms escalated, affecting all extremities. Electromyography study revealed abnormal spontaneous activity with chronic reinnervation changes, which was more significant in the lower extremities. Based on the clinical course, radiographic imaging, and laboratory data, a diagnosis of CIDP with severe axonal demyelinating features was established. Treatment with intravenous immunoglobulin (IVIg), prednisolone, and azathioprine resulted in marked improvement of the upper extremities but limited recovery in distal lower extremity muscles.ConclusionAlthough CIDP is a rare complication following COVID-19 vaccination, it should be considered in the differential diagnosis. Timely diagnosis of vaccine-induced CIDP is challenging, and any delay can adversely affect treatment response in affected patients.

Human herpesvirus 6 as the underestimated causative agent of seizure disorders in febrile children

Introduction and objective: The aim of the study was to analyse the clinical symptoms and laboratory abnormalities of seizure disorders in febrile children infected with pathogens from the Herpesviridae family – human herpesvirus 6 (HHV-6), human cytomegalovirus (HCMV), and Epstein–Barr virus (EBV). Materials and methods: A total of 75 children were included in the study, including 64 patients after a febrile seizure and 11 patients after an epileptic seizure triggered by infection. The control group consisted of 36 children with developmental delay. Routine inflammatory markers were analysed including C-reactive protein (CRP), procalcitonin (PCT), erythrocyte sedimentation rate (ESR), and white blood count (WBC). Pathogens were detected using standard diagnostic methods. Results: Compared to control group, median CRP and PCT were significantly higher in children with all types of febrile seizures, and ESR was significantly higher in children with simple and complex seizures. Most children with WBC below and above the normal range were children with simple febrile seizures plus and those with complex seizures, respectively. HHV-6 was detected in 33% of children. HCMV was found in 5%, and EBV in 4% of children. There was no significant correlation between children with and without primary HHV-6 infection regarding age, gender, febrile seizures type and first-time seizures, nor significant differences in inflammatory markers except for WBC. The difference between the number of children with three-day fever and those without rash was borderline significant (p = 0.06); children with primary HHV-6 infection without rash had more frequent first-time seizures (p = 0.04). Conclusions: The clinical course of seizure disorders and the intensity of the inflammatory reaction in children were mild. HHV-6 was the most common causative agent of fever and seizure disorders.

Extensive deep neck infection associated with acupuncture

Deep neck infections are rare but potentially lethal conditions that require prompt identification and management. They can occur in the peritonsillar, submandibular, parapharyngeal and retropharyngeal spaces. The most affected areas tend to differ by age, with tonsillitis being more common in children and odontogenic in older adults. Predisposing factors to infection can also influence location. Early treatment is paramount as airway compromise, septic shock and extension to adjacent structures can lead to morbidity and mortality. Here we report a case of extensive deep neck infection in an elderly diabetic patient with multiple abscesses involving the paraspinal space and extending anteriorly close to the carotid sheet, yet without airway compromise or hemodynamic instability. After further questioning, the likely mode of infection was identified as acupuncture in the affected region. We present a review of the presentations, differential diagnoses, treatments, and clinical course of adults with deep neck infections to highlight the importance of expeditious diagnosis and treatment.

Competency assessment in pediatric dental practice: A study on recent dental graduates in integrated curriculum.

This study aimed to investigate the relationship between various independent variables, such as cumulative grade point average (CGPA), socio-economic backgrounds, anxiety levels, and the self-rated competency levels, across six domains outlined by the American Dental Education Association (ADEA) of recently graduating dental students during pediatric patient care. This cross-sectional study was conducted at the College of Dentistry, Jouf University, Saudi Arabia. It included 74 participants (37 final-year dental students and 37 dental interns). Multiple logistic regression was employed to analyze the association between various independent variables (including CGPA, grade point average [GPA] in didactic, practical, and clinical courses, socio-economic backgrounds, gender, and self-reported student anxiety) and self-rated ADEA competency in pediatric dental practice within general dentistry (p<0.05). Final-year dental students were 28.5 times more likely to be competent in professionalism (C2) than interns (adjusted odds ratio [AOR]=28.54, p=0.001). In professionalism (C2), males were 91% less likely to be competent than females (AOR=0.09, p=0.001). A high GPA in didactic courses increased the likelihood of competence in health promotion (C4) by 3.4 times compared with an average GPA (AOR=3.41, p=0.071). Regarding the establishment and maintenance of oral health (C6B), final-year dental students were 4.4 times more likely to be competent than interns (AOR=4.41, p=0.013). This study identified key factors affecting clinical competency during pediatric patient care among newly graduating dentists. It highlighted the influence of gender differences, academic performance (GPA), and anxiety levels among graduates as significant predictors.

Solitary fibrous tumour of mesentery: a rare tumour-case report and a comprehensive review of literature

Solitary fibrous tumours (SFTs) represent an infrequent clinical entity distinguished into pleural and extrapleural forms, with morphological resemblance. Literature exists on extrapleural forms of SFTs but few cases originating from small bowel mesentery have been reported. We report here one such case of a 64-year-old male presenting with abdominal pain and mass in the right lower quadrant of abdomen. Radiology suggested a neoplastic etiology arising from the jejunum which was surgically resected. Histopathology confirmed a spindle cell tumour originating from small bowel. Patient had an uneventful clinical course and was discharged after 1 week of surgery. We also reviewed the literature on SFTs arising from mesentery and found that only 24 cases have been reported worldwide in the past 35 years.

Are COVID-19 Polymorphisms in ACE and ACE2 Prognosis Predictors?

Regardless of the containment of the SARS-CoV-2 pandemic, it remains paramount to comprehensively understand its underlying mechanisms to mitigate potential future health and economic impacts, comparable to those experienced throughout the course of the pandemic. The angiotensin-converting enzyme 2 (ACE2) provides anchorage for SARS-CoV-2 binding, thus implicating that ACE and ACE2 might contribute to the variability in infection severity. This study aimed to elucidate predisposing factors influencing the disease course among people infected by SARS-CoV-2, focusing on angiotensin-converting enzyme (ACE) and ACE2 polymorphisms. Notably, despite similar demographics and comorbidities, COVID-19 patients exhibit substantial differences in prognosis. Genetic polymorphisms in ACE and ACE2 have been implicated in disease progression, prompting our investigation into their role in COVID-19 evolution. Using next-generation sequencing (NGS), we analyzed ACE and ACE2 genes in a sample group comprising six subjects infected by SARS-CoV-2. Our findings revealed a correlation between specific polymorphisms and COVID-19 outcomes. Specifically, ACE and ACE2 intronic deletions were observed in all deceased patients, suggesting a potential association with mortality. These results highlight the significance of genetic factors in shaping the clinical course of COVID-19, emphasizing the importance of further research into the impact of genetic variations on COVID-19 severity.

Bacterial Infections in Acute-on-chronic Liver Failure: Epidemiology, Diagnosis, Pathogenesis, and Management.

Acute-on-chronic liver failure (ACLF) is a distinct condition characterized by the abrupt exacerbation of pre-existing chronic liver disease, often leading to multi-organ failures and significant short-term mortalities. Bacterial infection is one of the most frequent triggers for ACLF and a common complication following its onset. The impact of bacterial infections on the clinical course and outcome of ACLF underscores their critical role in the pathogenesis of systemic inflammation and organ failures. In addition, the evolving epidemiology and increasing prevalence of multidrug-resistant bacteria in cirrhosis and ACLF highlight the importance of appropriate empirical antibiotic use, as well as accurate and prompt microbiological diagnosis. This review provided an update on recent advances in the epidemiology, diagnosis, pathogenesis, and management of bacterial infections in ACLF.

Clinical Course and Pattern of Uveitis in Western Iran

Background: Demographic characteristics apparently play a critical role in the incidence and prevalence of uveitis in different societies. Numerous studies have investigated the demographic-epidemiological factors and clinical patterns of uveitis in Iran; however, no study has been conducted in the west of the country yet. Objectives: To assessed epidemiologic pattern of uveitis in patients residing in the west of Iran. Methods: This study investigated 358 files of uveitis patients referring to the specialized retina-uveitis clinics in a referral hospital in the west of Iran from March 2016 to September 2022. The demographic characteristics, clinical patterns, and complications of uveitis were evaluated in this study. Results: The uveitis patients’ mean age (± SD) at the diagnosis time was 48.14 (± 11.91) years (18 - 72 years), the patients with anterior uveitis had the lowest mean age (45.47 ± 11.54 years), and the patients with panuveitis had the highest mean age (52.90 ± 10.14 years) at the diagnosis time. The prevalence of the disease was equal in both genders; however, posterior uveitis and panuveitis significantly involved males more than females (P &lt; 0.01 and 0.01 respectively). The most common anatomical pattern of involvement belonged to anterior uveitis (34%), followed by panuveitis (23.4%), posterior uveitis (22.9%), and intermediate uveitis (19.5%). The prevalent etiology in anterior, intermediate, and panuveitis were idiopathic and Toxoplasma chorioretinitis was the most common causes in posterior uveitis (34.14%). Moreover, acute clinical course and non-granulomatous pathology were also more prevalent. The most common complications of the disease were cataracts and cystoid macular edema (CME). Also, patients with panuveitis followed by posterior uveitis had the worse visual prognosis. Conclusions: The predominant pattern of involvement in patients referring to the referral center in the west of Iran was in the form of anterior uveitis, acute in terms of clinical course, and non-granulomatous in terms of pathology. This clinical view for evaluation in a referral center differs from the pattern expected to be observed in the general population and even in general ophthalmology centers.

Clinical characteristics of pediatric noninfectious uveitis and risk factors for severe disease: a single-center study.

We aimed to present thedemographic, clinical, laboratory, and treatment data of children with non-infectious uveitis and to evaluate the risk factors for the development of complications and the need for biological treatment. Patients diagnosed with non-infectious uveitis in childhood and followed up for at least 1year were included in the study. Demographic data, including age, gender, age at diagnosis, uveitis in first-degree relatives, and rheumatologic diseases, were obtained retrospectively from medical records. The presence of complications or the need for biologic therapy was considered a composite outcome suggesting severe disease. The study included 123 patients (female: n = 59, 48%). The mean age at diagnosis was 14.89 ± 4.86years. Uveitis was symptomatic in 104 patients (84.6%). Approximately one-quarter of the patients had at least one rheumatic disease (n = 35, 28.5%), the most common being juvenile idiopathic arthritis. Thirty-three patients (26.8%) had anti-nuclear antibody positivity. Biologic agents were needed in 60 patients (48.8%). Complications developed in 14 patients (11.4%). Early age at disease onset (aOR, 0.875; 95% C.I. 0.795-0.965, p = 0.007) and female gender (aOR, 2.99; 95% C.I. 1.439-6.248, p = 0.003) were significantly associated with the need for biologic treatment, while Behçet's disease (BD) was strongly associated with uveitis-related complications (aOR, 14.133; 95% C.I. 2.765-72.231, p = 0.001). We suggest that among pediatric patients with non-infectious uveitis, females, those with an early age of disease onset, and those with BD need to be closely monitored due to a significantly increased risk of severe disease. Key Points • Limited data exist on the clinical course of non-infectious uveitis in children and the associated risk factors for severe disease. • Our study reveals that nearly a quarter of pediatric patients with non-infectious uveitis also have a rheumatic disease. • Among pediatric patients diagnosed with non-infectious uveitis, we observed an increased risk of severe disease in those with an earlier onset age, in female patients, and in those diagnosed with Behçet's disease.

Simplifying venous outflow: Prolonged venous transit as a novel qualitative marker correlating with acute stroke outcomes.

Prolonged venous transit (PVT), defined as presence of time-to-maximum 10 s within the superior sagittal sinus (SSS) and/or torcula, is a novel, qualitatively assessed computed tomography perfusion surrogate parameter of venous outflow with potential utility in pretreatment acute ischemic stroke imaging for neuroprognostication. We aim to characterize the correlation between PVT and neurological functional outcomes in thrombectomy-treated patients. A prospectively-collected database of large vessel occlusion acute ischemic stroke patients treated with thrombectomy was retrospectively analyzed. Spearman's rank correlation coefficient and point-biserial correlations were performed between PVT status (i.e., no region, either SSS or torcula, or both), 90-day modified Rankin score (mRS), mortality (mRS 6), and poor functional outcome (mRS 4-6 vs 0-3). Of 128 patients, correlation between PVT and 90-day mRS ( = 0.35, p < 0.0001), mortality (r = 0.26, p = 0.002), and poor functional outcome (r = 0.27, p = 0.002) were significant. There is a modest, significant correlation between PVT and severity of neurological functional outcome. Consequently, PVT is an easily-ascertained, qualitative metric that may be useful as an adjunct for anticipating a patient's clinical course. Future analyses will determine the significance of incorporating PVT in clinical decision-making.

Assessment of international MOGAD diagnostic criteria in patients with overlapping MOG-associated disease and multiple sclerosis phenotypes.

The clinical spectrum and diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) has evolved in the setting of an optimized anti-MOG-IgG cell-based assay and expert consensus. The McDonald criteria for MS have been revised multiple times to improve the accuracy and specificity of diagnosis on a framework based on clinical presentation, MRI findings, and CSF results. While the uses of MS and MOGAD diagnostic criteria are helpful for typical cases, such utility for patients with overlapping clinical, laboratorial, and imaging features is unknown, posing diagnostic and management uncertainties. To report a multicenter cohort of patients with overlapping phenotypic features of MOGAD and MS and evaluate the application of new MOGAD diagnostic criteria. A collaborative retrospective cohort study was performed to identify patients with both positive serum anti-MOG-IgG and fulfillment of the MS revised 2017 McDonald criteria. Clinical and radiographic features of patients fulfilling inclusion criteria were reviewed longitudinally, including relapses, repeated MRI, and MOG-IgG testing in detail to allow the panel of expert opinion to assign to each case. The International MOGAD Panel proposed criteria were applied at onset and last follow-up to each case and compared to the expert author diagnosis assignment based on presentation, clinical and imaging features, and response to treatment. Ten of 225 (4%) MOG-IgG seropositive cases met study inclusion criteria [seven of 10 were female; age at initial event: eight adults (mean age 26.8years), two adolescents (mean age 14.5years)]. AQP4-IgG was negative for all. Apart from serum titers of MOG-IgG, distinguishing clinical and radiographic features [i.e., clinical severity of the initial demyelinating event, radiographic features (optic nerve/spine/brain), and presence/absence of lesion normalization on serial scans] led to consensus of three separate classifications differing by degrees of shared features of MOGAD and MS. Patients were classified by expert panel into (1) Classic MOGAD even with MS-like, well-defined brain lesions, when severe events and most T2 lesions normalized (n = 5; MOG-IgG titers 1:100, 1:20, 1:160, 1:40, 1:200); (2) Classic RRMS included cases thought to have likely false positive or clinically irrelevant MOG-IgG, due to mild clinical events and no radiographic normalization of well-defined MS-like lesions (n = 3; MOG titers 1:20, 1:100, 1:40); (3) MOGAD and MS overlapping phenotype was defined by those with a combination of mild and severe clinical events, partial T2 lesion normalization, both well- and ill-defined lesions (n = 2; MOG titers 1:20, 1:100). The application of the International MOGAD Panel criteria categorized five patients (50%) in agreement with expert assignment. One additional patient was classified in agreement to assignment when MOGAD criteria were applied after serial MOG-IgG titers testing. While the International MOGAD Panel diagnostic criteria have helped with accuracy for the diagnosis of this condition, in a group of patients seropositive for MOG-IgG with overlapping clinical and imaging features of RRMS criteria review may lead to increased accuracy. Serial serologies, repeated imaging, close attention to clinical course, and response to therapy are possible variables to consider for further refinement of MOGAD diagnostic criteria.

Immune-related adverse events requiring hospitalization in patients with lung cancer: implications and insights.

Immune checkpoint inhibitors (ICI) are associated with a distinct spectrum of toxicities. Data on irAE hospitalization rates and clinical course of patients with thoracic malignancies are lacking. Patients with advanced thoracic malignancy treated with ICI (2/2016 to 6/2021) were retrospectively identified. Demographic and clinical data of confirmed irAE hospitalizations were extracted from the medical record and a descriptive analysis was performed. From February 2016 to June 2021, 1312 patients with thoracic malignancy received ICI (monotherapy, combination with 2nd ICI or other agents) with 102 patients (7.7%) hospitalized for irAEs. Treatment intent was first-line therapy in most patients (N = 50, 49%) with 9% (n = 9) receiving adjuvant ICI (N = 9). Sixty patients (59%) received ICI alone, 32% (N = 33) chemo plus immunotherapy, and 7% (N = 7) dual ICI. The median age on admission was 68 years. The median time between ICI initiation and admission was 64 days (1-935 days). Pneumonitis (32.3%; 33/102) was the most frequent indication for admission followed by gastroenterocolitis (19.6%; 20/102), hepatitis (12.7%; 13/102), myo/pericarditis (9.8%; 10/102), and endocrinopathies (9.8%; 10/102). Multi-organ toxicity occurred in 36% (N = 37) of patients. Overall, 85.2% (87/102) of patients received systemic corticosteroids and 17.6% (18/102) required additional lines of immunosuppression. The median length of hospitalization stay was 7 days (2-28 days) with a 25.5% (n = 26) readmission rate within 60 days and an 11.8% (n = 12) in house mortality rate. Severe irAE requiring inpatient admission, although infrequent, results in considerable morbidity, mortality, and healthcare utilization. Pneumonitis was the most common irAE requiring inpatient management in our patient population with a significant risk of mortality despite the use of guideline-directed systemic immunosuppression. This study highlights the continued need for collaborative efforts amongst medical specialties for improving the diagnostic and therapeutic management of patients with irAEs.

Determination of endometrial cancer molecular subtypes using a whole exome-sequencing based single-method approach

AimEndometrial cancer (EC) is heterogeneous with respect to epidemiology, clinical course, histopathology and tumor biology. Recently, The Cancer Genome Atlas (TCGA) network has identified four molecular subtypes with distinct clinical courses by an integrated multi-omics approach. These subtypes are of critical importance in the clinical management of EC. However, determination of TCGA molecular subtypes requires a complex methodological approach that is resource intensive and difficult to implement in diagnostic routine procedures. In this context, Talhouk et al. reported the precise determination of modified subtypes based on molecular surrogates obtained by a two-method approach comprising immunohistochemistry and DNA-sequence analysis (Proactive Molecular Risk Classifier for Endometrial Cancer; ProMisE). In this study, we aimed to identify EC molecular subtypes in analogy to TCGA and ProMisE applying an innovative whole exome-sequencing (WES) based single-method approach.MethodsWES was performed in a cohort comprising N = 114 EC patients. WES data were analyzed using the oncology treatment decision support software MH Guide (Molecular Health, Heidelberg, Germany) and EC molecular subtypes in analogy to TCGA and ProMisE were determined. Results from both classifications were compared regarding their prognostic values using overall survival and progression-free survival analyses.ResultsApplying a single-method WES-approach, EC molecular subtypes analogue to TCGA and ProMisE were identified in the study cohort. The surrogate marker-analogue classification precisely identified high-risk and low-risk EC, whereas the TCGA-analogue classification failed to obtain significant prognostic values in this regard.ConclusionOur data demonstrate that determination of EC molecular subtypes analogue to TCGA and ProMisE is feasible by using a single-method WES approach. Within our EC cohort, prognostic implications were only reliably provided by applying the surrogate marker-analogue approach. Designation of molecular subtypes in EC will be increasingly important in routine clinical practice. Thus, the single-method WES approach provides an important simple tool to tailor therapeutic decisions in EC.

Hyperekplexia: A Single-Center Experience.

Hyperekplexia is a rare neurogenetic disorder that is classically characterized by an exaggerated startle response to sudden unexpected stimuli. This study aimed to determine clinical and genetic characteristics of our patients with hyperekplexia. The age of onset and diagnosis, familial and perinatal history, clinical course, complications, metabolic screening tests, magnetic resonance imaging (MRI), medications, neuropsychometric evaluations, and gene mutations of patients diagnosed with hyperekplexia were reviewed retrospectively. All hyperekplexia patients had displayed neonatal excessive startle response and muscle stiffness, which we accepted as the major form of the disorder. Sixteen patients had mutations in genes associated with hyperekplexia. The ages at clinical diagnosis and genetic confirmation ranged from newborn to 16 years old and from 2.5 to 19 years, respectively. Nine patients (56.25%) were initially misdiagnosed with epilepsy. Seven patients (43.75%) carried a diagnosis of intellectual disability, defined here as a total IQ <80. Delayed gross motor development was detected in 4 patients (25%), and speech delay was reported in 3 (18.75%). Mutations in GLRA1 (NM_000171.4) and SLC6A5 (NM_004211.5) were identified in 13 (81.25%) and 3 patients (18.75%), respectively. Fifteen of the 16 patients (93.75%) showed autosomal recessive inheritance. Only 1 patient (6.25%) showed autosomal dominant inheritance. Although hyperekplexia is a potentially treatable disease, it can be complicated by delayed speech and/or motor acquisition and also by intellectual disability. This study shows that hyperekplexia is not always a benign condition and that all patients diagnosed with hyperekplexia should be evaluated for neuropsychiatric status and provided with genetic testing.

Tofersen decreases neurofilament levels supporting the pathogenesis of the SOD1 p.D91A variant in amyotrophic lateral sclerosis patients

BackgroundSince the antisense oligonucleotide tofersen has recently become available for the treatment of amyotrophic lateral sclerosis (ALS) caused by mutations in SOD1, determining the causality of the over 230 SOD1 variants has become even more important. The most common SOD1 variant worldwide is p.D91A (c.272A > C), whose causality for ALS is contested when in a heterozygous state. The reason is the high allele frequency of SOD1D91A in Europe, exceeding 1% in Finno-Scandinavia.MethodsWe present the clinical disease course and serum neurofilament light chain (NfL) results of treating 11 patients either homo- or heterozygous for the SOD1D91A allele for up to 16 months with tofersen.ResultsTofersen decreases serum neurofilament levels (sNFL), which are associated with the ALS progression rate, in the 6 ALS patients homozygous for SOD1D91A. We observe significantly lower sNfL levels in the 5 patients heterozygous for SOD1D91A. The results indicate that both mono- and bi-allelic SOD1D91A are causally relevant targets, with a possibly reduced effect size of SOD1D91Ahet.ConclusionsThe finding is relevant for decision making regarding tofersen treatment, patient counseling and inclusion of SOD1D91A patients in drug trials. As far as we are aware, the approach is conceptually new since it provides evidence for the causality of an ALS variant based on a biomarker response to gene-specific treatment.

Challenges of Teaching EHR-Based Documentation in an Obstetrical Clinical Course While Fostering Positive Student Experiences.

Perinatal documentation is challenging and complex requiring multiple documentation modalities. By customizing an academic EHR to parallel documentation in perinatal units, pre-licensure nursing students will learn and experience documentation standards and practice on the academic EHR. Student feedback and experiences will be recorded utilizing student surveys.

The High Burden of Asymptomatic Kidney Diseases in Individuals with HIV: A Prospective Study from a Tertiary Care Center in India

Background HIV infection is associated with a significant kidney disease burden. This study is aimed to screen for kidney disease in all HIV patients on highly active anti retroviral therapy (HAART), study clinico-histological correlation, and assess the impact of early diagnosis on the clinical course. Materials and Methods It was a prospective, longitudinal study done in a tertiary care hospital. Adult HIV-infected patients, on HAART for at least 3 months, were screened for kidney disease. Kidney biopsy was done if indicated. Patients were treated as per standard guidelines. Results were analyzed at 3 months. Results Among 1600 patients, 966 were compliant with HAART and were tested. Two hundred and sixty-two patients completed the study duration. Out of these 262 patients 78.2% were receiving tenofovir-based ART regimen. Around 31.2% were hypertensive and 19.8% were diabetic. The mean eGFR was 57.5 ± 24 mL/min/1.73 m2. Around 19.8% had asymptomatic urine abnormalities, 40.1% had proteinuria, and 27.1% had AKI. Acute nephritic syndrome was seen in 16.4%, rapidly progressive renal failure (RPRF) in 13.3%, and CKD in 10.6% patients. Out of 74 patients who underwent biopsy, histology showed chronic tubulointerstitial nephritis in 16 (21.6%), acute tubulointerstitial nephritis in 11 (14.8%), diabetic nephropathy in 10 (13.5%), and thrombotic microangiopathy in 7 patients (9.4%). Higher viral load levels, diabetes mellitus, and age above 60 years were associated with kidney disease. Conclusion Asymptomatic HIV infection has a significant burden of kidney disease. Kidney biopsy is crucial for correct diagnosis and management. The absence of HIV associated nephropathy in proteinuric HIV patients is notable in this study.

Imaging the Lung in ARDS: A Primer.

Despite periodic changes in the clinical definition of ARDS, imaging of the lung remains a central component of its diagnostic identification. Several imaging modalities are available to the clinician to establish a diagnosis of the syndrome, monitor its clinical course, or assess the impact of treatment and management strategies. Each imaging modality provides unique insight into ARDS from structural and/or functional perspectives. This review will highlight several methods for lung imaging in ARDS, emphasizing basic operational and physical principles for the respiratory therapist. Advantages and disadvantages of each modality will be discussed in the context of their utility for clinical management and decision-making.

A common secretomic signature across epithelial cancers metastatic to the pleura supports IL-6 axis therapeutic targeting.

Many cancers metastasize to the pleura, resulting in effusions that cause dyspnea and discomfort. Regardless of the tissue of origin, pleural malignancies are aggressive and uniformly fatal, with no treatment shown to prolong life. The pleural mesothelial monolayer is joined by tight junctions forming a contained bioreactor-like space, concentrating cytokines and chemokines secreted by the mesothelium, tumor, and infiltrating immune cells. This space represents a unique environment that profoundly influences tumor and immune cell behavior. Defining the pleural secretome is an important step in the rational development localized intrapleural immunotherapy. We measured cytokine/chemokine content of 252 malignant pleural effusion (MPE) samples across multiple cancers using a 40-analyte panel and Luminex multiplexing technology. Eleven analytes were consistently present in concentrations ≥ 10.0 pM: CXCL10/IP10 (geometric mean = 672.3 pM), CCL2/MCP1 (562.9 pM), sIL-6Rα (403.1 pM), IL-6 (137.6 pM), CXCL1/GRO (80.3 pM), TGFβ1 (76.8 pM), CCL22/MDC (54.8 pM), CXCL8/IL-8 (29.2 pM), CCL11/Eotaxin (12.6 pM), IL-10 (11.3 pM), and G-CSF (11.0 pM). All are capable of mediating chemotaxis, promotion of epithelial to mesenchymal transition, or immunosuppression, and many of are reportedly downstream of a pro-inflammatory cytokine cascade mediated by cytokine IL-6 and its soluble receptor. The data indicate high concentrations of several cytokines and chemokines across epithelial cancers metastatic to the pleura and support the contention that the pleural environment is the major factor responsible for the clinical course of MPE across cancer types. A sIL-6Rα to IL-6 molar ratio of 2.7 ensures that virtually all epithelial, immune and vascular endothelial cells in the pleural environment are affected by IL-6 signaling. The central role likely played by IL-6 in the pathogenesis of MPE argues in favor of a therapeutic approach targeting the IL-6/IL-6R axis.

Huge, Invasive, and Destructive Abiotrophia Defectiva Endocarditis of the Aortic Valve and the Aortic Wall. A Case Report of an Emergency but Successful Ross-Konno Operation in a Child

Abstract Background Abiotrophia defectiva forms Gram-positive cocci, part of normal oropharyngeal and gastrointestinal flora and is rarely involved in endocarditis in children population. Its special nutritional requirements and subacute clinical course, may delay diagnosis and proper treatment, leading to life-threatening consequences. Case summary We report a rare case of huge and destructive Abiotrophia Defectiva infective endocarditis of the aortic valve and the aortic wall in a 3-years-old child, in follow-up after surgical valvuloplasty for congenital aortic stenosis. The child presented at our department with signs of left side hemiplegia. Transthoracic echocardiography showed severe aortic regurgitation due to large vegetation extending to the aortic wall up to the aortic arch. Blood cultures resulted positive for A. Defectiva. Initially treated conservatively with antibiotic therapy, but 10 days after admission, sudden clinical deterioration, required intubation and an emergency Ross-Konno operation. Despite the critical conditions and highly risky surgery, the child recovered well and was discharged home 5 weeks after the operation. Discussion A. Defectiva IE is rare in children. Since 1995, only sixteen cases of A. Defectiva IE have been reported in children, including our case. This pathogen has a higher rate of complications when affecting children rather than adult population. Our case demonstrates that conservative strategy with antibiotics is rarely resolutive in case of IE caused by A. Defectiva. Whenever one or more indications for surgery are present, surgical intervention should be always taken into consideration, even if clinical conditions are prohibitive and surgery is at very high risk.