Elevated Serological Markers Research Articles

Aggressive Presentation and Rapid Progression of Osteonecrosis of the Femoral Head After COVID-19

BackgroundWe aim to report the consecutive patients diagnosed with osteonecrosis of femoral head (ONFH) following recovery from COVID-19 disease and elucidate the unique features of ONFH associated with COVID-19.MethodsConsecutive 22 patients (39 hips) recovered from COVID-19 and presented with ONFH from November 2020 to October 2021 were included. All the patients received corticosteroids as a supportive treatment during COVID-19. Patients were classified into two types based on the type of presentation, namely classic ONFH and rapidly destructive coxarthrosis (RDC) depending on radiographs, MRI, inflammatory markers and hip aspiration findings. Harris hip score was used to evaluate the functional outcome before and after treatment.ResultsThe mean time to diagnose of ONFH from the onset of hip symptoms was 39.3 days (range 10–90 days). The average duration of onset of hip symptoms after COVID 19 infection was 7.5 months (range 3 – 11 months). The average cumulative dose of methylprednisolone equivalent was 811 mg (range 200–2100 mg) and the average duration of steroid intake was 2.8 weeks. There was significant elevation in the inflammatory markers in RDC group compared to classic ONFH (p < 0.05). The Harris hip score improved from 63.6 ± 23.2 at presentation to 82.6 ± 9.6 after treatment (p < 0.05). Three patients had features of RDC. Among the three patients with RDC, two patients had rapid progression of ONFH and underwent total hip arthroplasty (THA). The third patient is awaiting a THA.ConclusionONFH after COVID-19 can have a varied presentation. While the most common presentation is like classical ONFH, some patients can have an acute and aggressive presentation with rapid destruction. They have features like elevated serological markers and extensive periarticular bone and soft tissue edema. A low cumulative dose of steroids in our patients suggests that the COVID-19-associated vasculitis may play a role in the pathogenesis of ONFH.

Rare Case of Acute Pancreatitis With Normal Lipase Level

Introduction: Acute pancreatitis can be diagnosed with one of the following criteria: clinical symptoms of pancreatitis, radiological findings and/or elevated serological markers for pancreatitis. However, there is very limited literature on acute pancreatitis with normal lipase level. Case description: 64 yo female with h/o hypertension and chronic back pain, presented with acute onset severe non-radiating epigastric pain, nausea and vomiting. She was not a smoker but drinks 4-5 glasses of hard liquor once every week. Significant examination findings: BP 153/100 mmHg, HR irregularly irregular, severe epigastric tenderness with no guarding or rigidity. Significant lab results included: lipase 30 U/L, calcium level 9.9 mg/dl, WBC count 17500 thou/uL, glucose 132 mg/dl, total bilirubin 1.7 mg/dl, direct bilirubin 0.5 mg/dl, normal transaminases. The liver function test normalized on day 2. CT abdomen and pelvis with IV contrast: acute edematous pancreatitis with extensive atherosclerotic plaques with 30% narrowing in the proximal SMA and no gall stones. IgG-713 mg/dl, IgG4- 45.9 mg/dl (normal). On admission in the ED, she was also found to be in atrial fibrillation with RVR (175/min) and further tests for causes of atrial fibrillation revealed elevated free T4 level- 3.44 and suppressed TSH- 0.01- primary hyperthyroidism. She had no symptoms of hyperthyroidism except for minimal weight loss. She was improved with conservative management and was discharged. Discussion: There are very few cases of acute pancreatitis with normal lipase level in literature. Lipase level has 55-100% sensitivity and 94-100% negative predictive value in the diagnosis of acute pancreatitis. Whereas contrast enhanced CT scan has 92% sensitivity and 100% specificity in diagnosing pancreatitis. Autoimmune pancreatitis should be a consideration in patients with normal lipase level and checking IgG4 level can be of value. When negative in such patients like our patient, clinical and imaging findings can suffice the diagnosis of acute pancreatitis.Figure 1

Beidseitiges, rezidivierendes Verschwommensehen mit Farbringen um Lichtquellen und Kopfschmerzen

A 21-year-old male presented with headache and blurred vision associated with halos around sources of light. The visual acuity was slightly reduced and the intraocular pressure in the left eye was elevated to 44mmHg and in the right eye to 49mmHg. Slit lamp examination of the anterior segment revealed bilateral cells and a Tyndall phenomenon 2 +, several cell clumps adherent to the corneal endothelium, known as mutton-fat keratic precipitates and a circumscribed inflammatory infiltration of the right iris. The posterior segment of both eyes was normal. The cause of the presumed clinical diagnosis secondary open angle glaucoma due to anterior granulomatous uveitis was sarcoidosis, confirmed by elevated serological markers of angiotensin-converting enzyme (ACE), soluble interleukin-2 receptor (sIL-2R) and by pulmonary hilar lymphadenopathy. The local and systemic corticosteroid therapy was successful and also normalized the intraocular pressure.

Accuracy in Celiac Disease Diagnostics by Controlling the Small‐bowel Biopsy Process

In a Swedish celiac disease screening study (Exploring the Iceberg of Celiacs in Sweden), we systematically reviewed the clinical diagnostic procedures with the aim to evaluate the diagnostic accuracy and to take advantage of lessons learned for improving diagnostic routines. A school-based celiac disease screening study involving 5 Swedish centers, with 10,041 invited 12-year-olds with 7567 consenting participation. All 192 children with elevated serological markers were recommended to undergo small-bowel biopsy, performed and evaluated according to local clinical routines. All of the mucosal specimens were reevaluated by 1 and, when needed, 2 expert pathologists to reach diagnostic consensus. Small-bowel biopsies were performed in 184 children: 130 by endoscopy and 54 by suction capsule. Endoscopic biopsies were inconclusive in 0.6%, compared with 7.4% of biopsies by suction capsule. A patchy enteropathy was found in 9.1%. Reevaluation by the expert pathologist resulted in 6 additional cases with celiac disease and 1 cleared. Sixteen children with normal or inconclusive biopsies, 4 after endoscopy, and 12 after suction capsule were endoscopically rebiopsied, resulting in another 8 cases. The celiac disease prevalence of 30 of 1000 (95% confidence interval 26-34) was not statistically different from that previously reported. The present review revealed the importance of controlling each step of the diagnostic procedure. Several cases would have been missed by relying only on local routines. To improve the quality of childhood celiac disease diagnostics, we recommend multiple endoscopic biopsies from both proximal and distal duodenum and standardized evaluation by a pathologist with good knowledge of celiac disease.

Letter to the editor

Letter to the editor We would like to applaud the authors of the article "The worldwide epidemiology of acute rheumatic fever (ARF) and rheumatic heart disease (RHD)"¹ for highlighting this important disease which continues needlessly to kill people living in poverty while being largely ignored by the developed world.² We would however like to address some key issues.The authors state that: the evidence of serologic infection is based on one of "a pharyngeal swab culture positive for GABHS, positive rapid GABHS antigen test or rising serologic antibody titers". Very few countries in highly affected regions of the world utilize routine rapid antigen or microbiological testing due to the cost involved. Furthermore, the delay involved in repeat serological testing before a diagnosis can be made, will result in missed diagnoses and tragic consequences. We recommend therefore that elevated serological markers of previous GABHS infection, together with major and minor criteria, are sufficient for a diagnosis of ARF.

Structure-Modifying Capacity of Anti-Tumour Necrosis Factor-?? Therapy in Ankylosing Spondylitis

Spondylarthropathies (SpA) present mainly with spondylitis, pauciarticular peripheral arthritis and enthesopathy. Ankylosing spondylitis (AS) is the prototype disease in this concept. Other entities include reactive arthritis, arthritis in patients with inflammatory bowel disease, some forms of psoriatic arthritis and undifferentiated SpA. NSAIDs are the classical cornerstone of medical therapy in patients with SpA. The effect of these drugs on disease progression, more specifically the ankylosis, is uncertain. Sulfasalazine can be combined with NSAIDs, particularly if peripheral arthritis symptoms persist. However, this combination therapy is not effective for the spondylitis symptoms. Indeed, AS is one of the rheumatic diseases for which no real disease-modifying antirheumatic treatment is available. Challenges in chronic autoimmune arthritis have changed dramatically, especially since biotechnological compounds became available. These compounds allow for a specific intervention in the immune cascade underlying the disease. Tumour necrosis factor (TNF)-alpha antagonists (monoclonal antibodies such as infliximab, or soluble receptors such as etanercept) are the first representative drugs in this category. Open-label studies have shown the efficacy of these new targeted drugs, which has been confirmed by controlled studies, at least in the short term. Improvements in several clinical parameters, function, quality of life, biological parameters, histopathological synovial characteristics and magnetic resonance imaging, have all been observed. As a result of these favourable results, anti-TNFalpha therapy has been approved for the treatment of AS and should be considered for patients with severe axial symptoms and elevated serological markers of inflammatory activity who have responded inadequately to conventional nonsteroidal therapy. There is evidence that this new therapeutic approach has a disease- and even structure-modifying effect in SpA. In this context, structure modification should not only be seen as inhibition of bone and cartilage destruction but more broadly as modulation of tissue histology. Some questions remain unanswered, such as the long-term efficacy and safety of anti-TNFalpha therapy, the extent of structural benefit and the cost effectiveness. However, despite these concerns, anti-TNFalpha therapy represents a major therapeutic advancement in the treatment of AS.

Germ cell tumors in children: Gonadal and extragonadal

Sixty-three pediatric patients with germ cell tumors are presented with details of symptoms, histological findings, staging, serological markers, treatment, and response to therapy. The primary sites were: ovarian 32, testicular 17, presacral 7, mediastinal 3, intraabdominal 2, vaginal 1, and right inguinal canal 1. These patients were treated with T2 (sequential use of dactinomycin, doxorubicin, vincristine, and cyclophosphamide, with or without radiation), T6 (combination chemotherapy with cyclophosphamide, bleomycin, dactinomycin, doxorubicin, methotrexate, vincristine), or VAB treatment protocols (velban, dactinomycin, bleomycin, cisplatin). The cure rate for stage I ovarian and testicular germ cell tumors was 100%; for stage III, all primary sites, 82% and for stage IV, all primary sites, 75%. Histology was prognostic in ovarian tumors of the immature malignant teratoma type; the neural type immature teratoma, grades II and III, had the worst prognosis. Initial debulking surgery in combination with chemotherapy and radiation plays an important role in germ cell tumors. Stages II, III, and IV germ cell tumors require aggressive treatment with surgery, radiation, and chemotherapy. For stage I patients, with primary ovarian malignant tumor, cure with surgery alone can be achieved in 50% of the cases and in testicular tumors in about 70% of the patients. For those with stage I and elevated serological markers, it is feasible to follow these markers and give no treatment until there is evidence of persistent elevation or a rise in titers after an initial fall. In those without elevated serological markers, one should take into consideration the size of the tumor and the histological type before taking the "wait and see" approach. These stage I tumors are highly curable when they first present but, if allowed to recur, chemotherapy may not offer the patient such a favorable response and cure rate.