Elevated WBC Count Research Articles

Spinal Subdural Abscess Mimicking An Intradural-Extramedullary Tumor- A Rare Case Scenario

Spinal subdural abscesses (SSA) are very rare disease. The etiologies of SSA are hematogenous spread, iatrogenic contamination, and local extension. Elevated WBC counts, ESR, and C-reactive protein are usually found in laboratory tests. But they are not sensitive indicators of SSA, especially chronic abscesses patient tend to have a less specific characteristic. We report the case of a healthy child with subdural abscess referred to our hospital as an intradural– extramedullary (IDEM) tumor

Leukocytosis in Negative Malaria Rapid Diagnostic Test Febrile Illness Among Children Under Five Years in a District Hospital

Background: Definitive tests are not routinely available in Ghanaian district hospitals for diagnosing febrile illnesses among children under five years after excluding malaria with the rapid diagnostic test (RDT). Most of such febrile presentations are likely microbial. If an infection-induced WBC elevation is demonstrated consistently enough in such malaria-RDT negative febrile illnesses, it could become a diagnostic aid. Methods: Retrospective data from the clinical records were obtained for 432 children from 6 months to 5 years of age, who had presented with fever (temperature ≥ 37.5°C). Their respective WBC counts were also documented and statistical analysis of the data carried out. Results: A significant relationship was demonstrated between the malaria-RDT negative status and the patient’s elevated WBC count (P < 0.001). Leukocytosis was absent in 58.6% of RDT-negative febrile children. Patients who tested RDT-negative were twice as likely to have elevated WBC counts (OR = 2.19) than RDT-positive patients. Conclusions: An elevated WBC count has demonstrated a potentially weak relationship with a negative malaria-RDT status among febrile children U-5 in DPH. Standing alone, however, the WBC may not be decisive for the evaluation of U-5 febrile presentations after excluding malaria.

MON-697 Necrotising Fasciitis- Importance of Glycemic Control

Introduction:Necrotising fasciitis is an infection of the deep soft tissues characterised by fulminant tissue destruction, systemic toxicity and high mortality. We report a case where accurate diagnosis, timely surgical intervention and antibiotic therapy along with strict glycemic control resulted in a favourable outcome.Case:A 74 year old woman with a history of type 2 diabetes mellitus, hypertension and end stage renal disease(ESRD) on peritoneal dialysis(PD) presented to the emergency department with the complaint of pain in the right lower quadrant of abdomen, right pelvis and right groin since 4 days which acutely worsened overnight. Of note the patient has Peritoneal catheter for dialysis and was last dialysed last night without any difficulty. Other associated symptoms were chills, nausea. The patient denied fever, skin changes in the affected area.On physical examination, the patient was awake, alert and oriented, in moderate distress. Abdomen was soft, non distended, PD catheter was in place with no surrounding skin erythema or tenderness. Genitourinary examination showed swelling of Mons Pubis with overlying erythema on the right side with extension to the right labia majora, exquisitely tender to palpation, no crepitus, no pustules, no palpable abscesses or visible wounds.Initial labs showed elevated WBC count(36.4K/UL; n<10.5K/UL) and Blood glucose of 361mg/dl(n 70-100mg/dl). CT scan of the abdomen and pelvis showed right anterior pelvic wall subcutaneous infiltration extending inferiorly into the mons pubis and right labial regions suspicious for cellulitis with no abscess. Broad spectrum intravenous antibiotics Meropenem, Vancomycin and Fluconazole were started and patient was taken to the operative room for debridement and approximately 25 cm long and 15 cm wide and 8 cm large abscess originating in the right labia extending up into her right groin was found along with necrotic skin, subcutaneous tissue and fat which was sharply excised. Peritoneal dialysis catheter site looked non infected and was left in place and fluid cultures were sent. Patient was switched to Hemodialysis while awaiting PD catheter fluid cultures. Hospital course was complicated by multiple debridements, severe septic shock requiring upto 4 pressors and intubation. She was started on insulin drip for glycemic control as the blood sugars were constantly ranging 300mg/dl(n 70-100mg/dl). HbA1C was 10.9% (n 5.7-6.4%). After 10days she was extubated and off pressors and was stable to be transferred to subacute rehab facility for diligent wound care for the next few weeks before she could go home.Conclusion:In patients with uncontrolled diabetes mellitus who present with critical illness like necrotising fasciitis, strict glycemic control with insulin drip yield favourable outcomes.

Hepatoblastoma-An Unusual Presentation: A Case Report

Hepatoblastoma (HB) is the most common primary hepatic malignancy in children and accounts for 43% of the pediatric liver tumors. The usual presentation is the presence of an abdominal mass, vomiting, elevated αfetoprotein levels and thrombocytosis and it occurs in infants and children under 3 years of age. A 6-year-old male child presented to the outpatient department with complaints of mild to moderate grade fever, vomiting and loose stools for 3 days. The child was otherwise active and there was no palpable abdominal mass. USG abdomen and CT scan revealed the presence of an encapsulated solid hepatic tumor suggestive of HB. Complete blood count showed an elevated WBC count, high ESR and high α-fetoprotein levels (958 ng/ml) but no thrombocytosis. A nonanatomical excisional biopsy of the tumor confirmed it to be hepatoblastoma. The unusual features noticed in this case was presentation at a slightly later age (6 years), absence of abdominal mass and absence of thrombocytosis.

Elevated Serum C-reactive Protein (CRP) Level Predicts Increased Post-Implant Mortality in Patients Undergoing HeartMate 3 LVAD Implantation

C-reactive protein (CRP) emerged as a biomarker of inflammation in heart failure patients and associated with increased morbidity and mortality. We hypothesized that higher serum CRP level prior to Heartmate 3 LVAD implantation is associated with increased risk of post-implant adverse events and mortality. 123 patients who underwent Heartmate 3 LVAD implantation at a tertiary care center and had a CRP level measured prior to device implant were included in the analysis. Optimal CRP cut-off was determined used ROC curve and patients were categorized into high vs. low CRP groups accordingly. Study end-points included RVAD use, need for CVVH, in-hospital mortality, and 2-year survival. Mean and median pre-implant CRP levels in HM3 patients were 35.5±43.6 mg/L and 15.0 mg/L respectively. Patients with an elevated pre-implant CRP (≥12 mg/L) were more likely to be in INTERMACS Class I or II (78.4% vs. 46.6%), to have temporary MCS (49.2% vs. 27.5%), and elevated WBC count (9.1 vs. 7.5) compared to those with a pre-implant CRP less than 12 mg/L (all p <0.05). High CRP group had significantly higher RVAD use (32.3% vs. 15.5%, p=0.030), need for CVVHD (13.8% vs. 3.4%), and in-hospital mortality (14.0% vs. 1.8%, p=0.028). Patients with elevated pre-implant CRP had significantly lower survival compared to those with lower pre-implant CRP (74.2% vs. %96.1, log-rank p =0.020) and a trend-towards lower freedom from post-implant stroke (%89.2 vs. %98.3, log-rank p =0.072) at 2-year follow-up (Figure). After adjustment for age, ischemic etiology, creatinine, bilirubin, albumin, and INTERMACS Class, high CRP (≥ 12 mg/L) remained as an independent predictor of survival on LVAD support (HR 3.81 [1.35 - 10.75], p=0.011). Pre-implant CRP is a strong predictor of morbidity and mortality in patients undergoing HM3 implantation. Routine assessment of CRP prior to implant may improve patient selection and outcomes in this population.

1263 Endoscopic Management of a Surgical Clip Found Within the Common Bile Duct Following Remotely Performed Laparoscopic Cholecystectomy

INTRODUCTION: Minimally invasive surgery with surgical clip placement has become the gold standard for management of cholecystitis and biliary colic due to its favorable safety profile and low risk of complications. Though generally safe, surgical clips can serve as a source of complication years after cholecystectomy by migrating into the common bile duct and serving as a nidus for stone formation. To date, very few cases of this have been reported. While uncommon, this complication should be considered in the differential diagnosis for choledocholithiasis and cholangitis. CASE DESCRIPTION/METHODS: Here we present a 35-year-old female with a past medical history of invasive rectal adenocarcinoma who underwent laparoscopic cholecystectomy over ten years ago. She presented to the hospital with a two-week history of RUQ abdominal pain, chills, and nausea. Physical exam showed scleral icterus and RUQ abdominal tenderness. Labs showed elevated WBC count and LFTs in a cholestatic pattern. Patient was started on antibiotics for suspected cholangitis and underwent MRCP which suggested presence of metallic clip within the common bile duct. Subsequent ERCP revealed large stone impacted against the ampulla of Vater. Sphincterotomy and balloon sweep of the common bile duct were performed with extraction of large stone formed around surgical clip, followed by release of copious amount of purulent bile. Following procedure LFTs showed downward trend and symptoms resolved. DISCUSSION: Though the exact incidence and mechanism of surgical clip migration into the common bile duct is unknown, it is thought to be a slow process with the potential for subsequent stone formation years after surgery. Clinical presentation is the same as non-iatrogenic choledocholithiasis. In most reported cases, stone extraction required surgical intervention due to large size. Here we present a case successfully managed with sphincterotomy and balloon extraction over ten years after laparoscopic cholecystectomy. Though rare, the potential for surgical clip within the common bile duct serving as a nidus for stone formation should be considered in post-cholecystectomy patients presenting with symptoms of choledocholithiasis and cholangitis, regardless of how recently surgery was performed. Minimally invasive surgery and the use of surgical clips has become almost ubiquitous; thus clinicians should be aware of this possible complication and options for management.

Thirty-Day Outcomes After Open Revascularization for Acute Mesenteric Ischemia From the American College of Surgeons National Surgical Quality Improvement Program

Open revascularization for acute mesenteric ischemia (AMI) is associated with high perioperative morbidity and mortality; however, results from contemporary studies are varied. Therefore, we evaluated 30-day mortality after open revascularization for AMI and identified preoperative factors associated with mortality. We performed a retrospective cohort study of patients in the American College of Surgeons National Surgical Quality Improvement Program database undergoing open mesenteric revascularization for AMI from 2005 to 2017. The primary outcome was 30-day mortality. We used multivariable logistic regression to identify preoperative factors independently associated with 30-day mortality. The study cohort included 918 patients; their median age was 70years (interquartile range: 59-80years), 62% were female, and 90% were white. Thirty-day mortality after open revascularization for AMI was 32%, specifically 35% after embolectomy, 31% after thromboendarterectomy, and 28% after mesenteric bypass. Mortality was higher in patients requiring concomitant bowel resection (38% vs. 29%, respectively, P<0.01). The preoperative factor most strongly associated with 30-day mortality was disseminated cancer (odds ratio = 8.8, 95% confidence interval = 2.4-32, P=0.001). Other factors independently associated with mortality were renal dysfunction, preoperative intubation, preoperative blood transfusion, diabetes, elevated preoperative international normalized ratio, elevated preoperative white blood cell count, and increasing age. In this retrospective cohort study using a real-world, nationwide cohort, open revascularization for AMI was associated with high mortality, with nearly one-third of patients dying within 30 days of their operation. The factors identified to be independently associated with 30-day mortality, particularly disseminated cancer, preoperative renal dysfunction, and elevated preoperative WBC count, are an important tool for preoperative risk stratification.

Inhalation of sodium hydrosulfide (NaHS) alleviates NO2-induced pulmonary function and hematological impairment in rats

BackgroundInhalation of NO2 leads to a progressive airflow limitation and the development of emphysema-like lesions. We report on the efficacy of hydrogen sulfide (NaHS) for alleviating NO2-induced pulmonary impairment. MethodsSprague Dawley rats were exposed to 20 ppm NO2 for 6 h over six consecutive days for 75 days. At day 75, rats who had developed NO2-induced emphysema were then divided into sodium hydrosulfide (NaHS) administrated group, placebo (NaCl) group and spontaneous recovery group for about one month (days 76–105); Pulmonary function (PF) and hematological and biochemical indices were measured at days 14, 45, 75, and 105. ResultsNO2 exposure for 75 days was associated with a significant decrease in FEV100/FVC%, an increased in functional residual capacity (FRC), and histologic evidence of emphysema, moreover; NO2 exposure led to elevated triglyceride (TG), red blood cell (RBC), hemoglobin (HGB), and hematocrit (HCT) levels. Impaired rats treated with NaHS showed no further deterioration in PF compared to rats exposed to ambient air and elevated WBC, granulocyte and lymphocyte counts and HDL-C levels to rats given NaCl. ConclusionsNO2 exposure causes emphysema and a decline in PF in rats. NaHS could alleviate the PF decline as possible indicated by an elevation of HDL-C levels and leukocyte. NaHS has therapeutic potential for emphysema caused by air pollutant NO2.

PF531 TRANSFORMING ACTIVITIES OF THE NUP98-KMT2A FUSION GENE ASSOCIATED WITH MYELODYSPLASIA AND ACUTE MYELOID LEUKEMIA

Background: Inv (11)(p15q23) found in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) was previously shown to lead to the expression of a fusion consisting of the N-terminal part of nucleoporin 98 (NUP98) and almost the entire open reading frame (ORF) of the lysine methyltransferase 2A (KMT2A, aka MLL1). Aims: To address the role of the NUP98-KMT2A fusion as a potential leukemogenic oncogene. Methods: To overcome the limitations related to the large size of the fusion ORF, we generated DOX-inducible transgenic iNUP98-KMT2A mice. We studied the effects of iNUP98-KMT2A expression in hematopoietic cells ex vivo in clonogenic assays; and in vivo by assessing blood counts, histology, and immunophenotyping as well as by competitive repopulation assays. In addition, we established primary mouse embryonic fibroblast (MEF) cultures to address the effects of iNUP98-KMT2A on cell cycle progression and cellular senescence. Results: In contrast to other KMT2A fusion such as MLL-AF9, induction of iNUP98-KMT2A did not alter differentiation but impaired growth of bone marrow (BM)-derived cells in vitro. Induction of iNUP98-KMT2A in vivo resulted in signs of disease after a highly variable latency of 13–106 weeks (median latency = 80 weeks, n = 22). Some symptomatic mice presented with increased white blood counts with morphological signs of dysplasia, reduced red blood cells, and increased apoptosis in the BM with signs of extramedullary hematopoiesis. In addition, we observed a 3-fold expansion of Lin−Sca-1+c-Kit+ (LSK) hematopoietic stem and progenitor cells (HSPC) in the BM of these mice. BM cells from symptomatic iNUP98-KMT2A mice had a competitive advantage in reconstitution assays. About 20% (5/22) of the mice on DOX presented with transplantable AML with elevated WBC counts and leukemic blasts in the peripheral blood with infiltration of multiple organs. Expression of iNUP98-KMT2A was associated with aberrant cell cycle progression in LSK cells from primary-induced mice. Similarly, iNUP98-KMT2A expression affected cell cycle progression and abrogated cellular senescence in MEF associated with aberrant expression of Sirt1, Tert, Rbl2, Twist1, Vim, and Prkcd that was also observed in BM cells. Notably, similar to patients with NUP98-KMT2A, and in contrast to other KMT2A fusions, primary AML cells from diseased iNUP98-KMT2A mice expressed very low levels of the Hox-A-B-C gene cluster. In addition, iNUP98-KMT2A leukemic blasts were resistant to the effects of pharmacological targeting of Menin/KMT2A interface or BET-family proteins. Summary/Conclusion: Our work shows that the NUP98-KMT2A fusion has oncogenic potential in mice leading to an MDS-like disease or AML. In contrast to other KMT2A fusions, NUP98-KMT2A does not primarily block differentiation and provide aberrant self-renewal potential, but alters cell cycle progression leading to dysplasia and impairs cellular senescence.

Haplo-HSCT Is Superior to Chemotherapy for Standard Risk ALL in CR1—Results of Prospective Multicenter Trial (NCT02042690)

Background In the present prospective multicenter trial (NCT02042690), we investigated whether haplo-HSCT has a favorable impact on survival as post remission treatment for standard risk acute lymphoblastic leukemia (ALL) patients in the first complete remission (CR1) by comparing with chemotherapy alone. Methods £°Inclusion criteria of ALL:(1) age 18 to 39 years; (2) without high-risk features, which consisted of elevated WBC count(>30 *109/L for B cell lineage or >100 *109/L for T cell lineage), or high-risk cytogenetic abnormalities, determined according to the National Comprehensive Cancer Network 2013 guidelines; and (3) achieving CR after 1 to 2 cycles of induction. Subjects without a suitable HLA matched sibling (MSD) or HLA-matched unrelated donor (iÝ8/10 URD) after 2 cycles of consolidation (Hyper-CVAD B/A*1) were eligible for haplo-HSCT or further chemotherapy (Hyper-CVAD B/A*3). Landmark analysis (4 months after CR1) was used when comparing the outcomes of patients receiving haplo-HSCT vs. chemotherapy. A propensity score (PS) was calculated using multivariable logistic regression for each individual. The hazard ratios (HRs) for Leukemia-free survival (LFS), overall survival (OS), cumulative incidence of relapse(CIR), and nonrelapse mortality(NRM) were adjusted with PS. Results Newly diagnosed standard risk ALL patients meeting inclusion criteria (n=112) were consecutively enrolled at 5 centers including Peking University Peoplei¯s Hospital, Peking Union Hospital, Wuhan Union Hospital, First Hospital of Soochow University and General Hospital of PLA and between July 2014 and June 2017, with median follow-up 24.6 months. Patients were excluded in final analysis: 1) early relapse (n=6) within 4 months after CR1; 2) MSD-HSCT (n=16) or URD-HSCT (n=1). The remaining patients (n=89) either received haplo-HSCT (n=49) or chemotherapy (n=40). The 2-year LFS (70.5 [54.2-81.9]% vs 41.4[25.9-56.2]%, p=0.0073) and 2-year OS (81.3 [65.5-91.4]% vs 51.2[33.8-66.1]%, p=0.0073) of the Haplo-HSCT group was significantly higher than the chemotherapy group. In the multivariate analysis with propensity score adjustment, postremission treatment (haplo-HSCT vs chemotherapy) was an independent risk factor affecting the LFS (HR 0.388, 95% CI 0.172-0.873, P=0.022), OS (HR 0.346, 95% CI 0.156-0.140-0.853, P=0.003) and CIR(HR 0.247, 95% CI 0.098-0.624, P=0.003); Positive minimal residual disease after the first consolidation was an independent risk factor for LFS (HR 2.162, 95% CI 0.973-4.803, P=0.027) and CIR (HR 3.667, 95% CI 1.445-9.302, P=0.006). Diagnosis (T vs B) was an independent risk factor for OS(HR2.267, 95% CI 1.493-3.442, P=0.021). Conclusions Our results suggest that Haplo-HSCT is superior to chemotherapy alone as post-remission treatment for in adult patients (age 18-39) with standard risk ALL in CR1.

Factors Predicting Positive Culture in CT-Guided Bone Biopsy Performed for Suspected Osteomyelitis.

The goal of this study was to identify clinical factors and radiographic characteristics associated with positive culture results from bone biopsy in cases of suspected osteomyelitis. A total of 997 CT-guided bone biopsies were reviewed. We reviewed the images and medical records of 29 cases of suspected osteomyelitis to determine if any of the following factors affected culture results: age, sex, history of diabetes, collection of fluid aspirate at the time of biopsy, recent antibiotic therapy, elevated WBC count, and mean attenuation. Of the 29 CT-guided bone biopsies, 21% yielded positive culture results. We found no significant difference in age, sex, history of diabetes, collection of fluid aspirate at the time of biopsy, recent antibiotic therapy, or elevated WBC count between positive culture and negative culture cases. We did, however, find a significant difference in the mean CT attenuation values of the sampled bone between the two groups: 72.0 ± 41.5 HU (95% CI, 28.4-115.6 HU) among the positive culture group compared with 227.5 ± 198.8 HU (95% CI, 141.4-313.6 HU) among the negative culture group (p = 0.03). The rate of positive culture from image-guided core biopsy of suspected osteomyelitis is low. In this study, lower CT attenuation values were associated with a significantly higher rate of positive culture. An attenuation value of 150 HU may serve as a threshold above which biopsy would be expected to have lower utility for obtaining specific microbial culture data.

Paraneoplastic Leukemoid Reaction in a Case of Carcinoma Gall Bladder: A Rare Scenario

Paraneoplastic Leukemoid reaction may be defined as elevated WBC counts in association of solid malignancy when other causes like infection and hematological malignancies have been ruled out. The exact mechanism has not been fully elucidated. It is likely that various cytokines produced irregularly by the tumor cells, including granulocyte colony-stimulating factor (G-CSF), may underlie the pathogenesis. We here describe a case report of 68-year-old man with locally advanced gall bladder presenting with extremely elevated WBC count. Infection, leukemia, bone marrow involvement were ruled out. Patient underwent surgery and after resection counts normalized. Patient had recurrence few months later which was accompanied by raised TLC. There are many studies associating this rare phenomenon with lung urothelial melanomas and other malignancies but not with gall bladder cancer making this extremely rare occurrence. Therapeutic strategies for the neoplasm, like surgical excision, chemotherapy, and radiotherapy, frequently result in a decrease in the white blood cell count. Nevertheless, in such patients, the leukemoid reactions have been reported to correlate with an aggressive clinical course, lower survival time, occurring shortly before death.

Study the Inflammatory Biomarkers of Acute Coronary Syndrome Patients in Wasit Province

This prospective study was performed in the coronary care unit at AL-Zahraa teaching hospital in Wasit Governorate during the period from January 2018 to June 2018. This study explained the role of inflammatory biomarkers in proper diagnosis, risk stratification and prognostic evaluation of patients with acute coronary syndrome (ACS). A total of 100 patients with ACS, 77 men aged 25–90 years and 23 women aged 45–85 years. They were divided into three age groups. The first group was ˂45years old, the second group was 45–60 years old and the third group was ˃60 years. The risk factors for ACS include gender, age, HT, diabetes, smoking, and dyslipidemia through a questionnaire. Our study revealed that male to female ratio was 3: 1 and demonstrate that male gender and HT were most prevalent risk factor for ACS. Regarding white blood cells and the rate of Erythrocyte sedimentation rate, the results showed a significant increase in white blood cells, neutrophils and the rate of red blood cell deposition at P≤0.05. The results of our study showed a significant increase in the markers of the acute phase protein, which showed a significant increase in the value of fibrinogen and C-reactive protein(CRP) at P≤0.05. Regarding biomarker of myocardial ischemia, there was a significant increase in troponin and creatinine kinase at P≤0.05. There was high 30 day mortality among patients with high level of inflammatory biomarker (fibrinogen and CRP), biomarkers of myocardial ischemia(troponin and CK-MB) and those with markedly elevated WBC count.

Clinical and Genomic Characteristics in De Novo Blastoid/Pleomorphic (dnMCL) and Transformed Blastoid/Pleomorphic (t-MCL) Mantle Cell Lymphoma (MCL) in the Ibrutinib Era: Comprehensive Analysis of 168 Patients

Clinical and Genomic Characteristics in De Novo Blastoid/Pleomorphic (dnMCL) and Transformed Blastoid/Pleomorphic (t-MCL) Mantle Cell Lymphoma (MCL) in the Ibrutinib Era: Comprehensive Analysis of 168 Patients

Atypical Chronic Myeloid Leukemia

Introduction: Atypical chronic myeloid leukemia (aCML), BCR-ABL1 negative is a rare myelodysplastic syndromes (MDS)/myeloproliferative neoplasm (MPN) for which no current standard of care exists. We present one of the rare presentations of aCML in an elderly patient.Case: A 76 year old male presented to the Hematology clinic for consultation after discharge from local hospital for elevated WBC count. Past medical history was significant for COPD, acid reflux, peripheral arterial disease and hypertension. Physical exam was unremarkable. Initial labs were significant for leukocytosis of 30 k/cu mm, anemia with Hb 10 gm/dl, thrombocytosis 695,000 with neutrophilia of ANC 25,200. Peripheral blood was negative for JAK2 V617F and BCR-ABL. Peripheral blood flow cytometry showed granulocytic left shift with 1.5% myeloblasts. Bone marrow biopsy suggestive of hypercellular marrow (100%) with myeloid predominance, atypical megakaryocytes, increased ring sideroblasts (49% of NRBC), increased blasts (5%) and dysgranulopoeisis over all suggestive of Myelodyplastic Syndrome/Chronic Myeloproliferative Disorder (MDS/MPD). Cytogenetics were positive for U2AF1 positive, CSF3R T6181, CSF3R Q776 pathognomonicof atypical CML and negative for BCR-ABL, FLT3. He was considered transplant ineligible. He was started on Azacitadine and is currently receiving 2nd cycle therapy. He is also receiving darbepoeitin periodically to avoid frequent transfusions. He is currently transfusion independent.Discussion: Increased WBC count (e.g., cutoffs of >40×109/L or 50×109/L), increased percentage of peripheral blood myeloid precursors, female sex, and older age are adverse prognostic factors for overall survival or leukemia-free survival in aCML. aCML cases lack in Philadelphia chromosome. Overall 50-65% of patients show cytogenetic abnormalities. The most frequent is +8 (25%). Other changes such as -7 and del(12p) have also been recurrently observed. Patients with aCML have an estimated median survival between 14 and 30 months. aCML tends to exhibit a more aggressive clinical course than other MDS/MPN subtypes. DisclosuresNo relevant conflicts of interest to declare.

Inflammation as a predictor of disease course in posttraumatic stress disorder and depression: A prospective analysis from the Mind Your Heart Study

BackgroundPrior research has focused largely on the pro-inflammatory states of PTSD and depression, with few studies evaluating the direction of inflammation’s association with these disorders. To clarify whether inflammation plays a role in the development of PTSD or depression, we assessed the predictive value of inflammatory biomarkers on the courses of these conditions in a cohort of Veterans. MethodsThis research was part of the Mind Your Heart Study, a prospective cohort study designed to examine PTSD-related health outcomes. Between 2008 and 2010, 746 San Francisco area Veterans Administration patients were enrolled. At baseline, inflammatory biomarkers were measured from fasting morning venous blood draws, and cortisol and catecholamine levels were measured from 24-hour urine samples. PTSD was diagnosed using the PTSD Checklist at baseline and annual follow-up. Depression was evaluated using the 9-item Patient Health Questionnaire at baseline and follow-up. Ordinal logistic regression models were used to assess the predictive value of baseline biomarker levels on clinically relevant courses of PTSD and depression categorized and ordered as none, resolved, developed, and chronic. ResultsAfter adjustment for age and sex, elevated levels of white blood cell count (OR = 1.27(1.10–1.47), p = 0.001), C-reactive protein (OR = 1.20(1.04–1.39), p = 0.02), fibrinogen (OR = 1.19(1.03–1.38), p = 0.02), and ESR (OR = 1.17(1.00–1.36, p = 0.05), and decreased levels of urine cortisol (OR = 0.84(0.71–0.99), p = 0.04) were significant predictors of poorer courses of PTSD. Elevated levels of WBC count (OR = 1.31(1.14–1.50), p < 0.001), CRP (OR = 1.24(1.07–1.43), p = 0.003), fibrinogen (OR = 1.26(1.09–1.46), p = 0.002), and catecholamines (OR = 1.17(1.01–1.36), p = 0.04) were significant predictors of poorer courses of depression. After additionally controlling for physical activity, elevated WBC count (p = 0.002) and decreased levels of urine cortisol (p = 0.05) remained significant predictors of PTSD course, and elevated WBC count (p = 0.001), CRP (p = 0.03), and fibrinogen (p = 0.02) remained significant predictors of depression course. After adjusting for all significant variables, elevated WBC count (p = 0.02) was a significant predictor of a poorer course of PTSD, and elevated WBC count (p = 0.04) and platelet count (p = 0.03) were significant predictors of a poorer course of depression. ConclusionsIncreased levels of several inflammatory biomarkers were associated with significantly increased odds of clinically worse courses of PTSD and depression. Inflammation may be a target for prevention and treatment of these mental health disorders.

Chronic Lymphocytic Leukemia Manifesting as Colon Polyps

Chronic lymphocytic leukemia (CLL) is a chronic lymphoproliferative disorder and the most common leukemia in the U.S. representing 30% of all leukemias. CLL is a disease of the elderly; mean age of 70 at diagnosis and often asymptomatic. Lymphadenopathy, splenomegaly, and hepatomegaly are common findings. CLL cells can infiltrate any organ but gastrointestinal mucosal involvement is rare. A 54 y/o African-American male presented for screening colonoscopy. Initially diagnosed with CLL in 2014 with bulky lymphadenopathy, night sweats, and weight loss. Lymph node biopsy confirmed the diagnosis showing Trisomy 12, ZAP 70 positive, and CD 38 positive. Initial treatment consisted of Bendamustine and Rituximab. Prior to colonoscopy the patient had stable lymphadenopathy but denied B symptoms and recent labs were within normal limits including LDH and CBC. Colonoscopy was poor prep and from the proximal ascending colon to distal descending colon were multiple small polyps measuring 3-4 mm in size with an appearance similar to either hyperplastic polyps versus lymphoid follicular hyperplasia. In total there were greater than 40 polyps seen. Due to these findings random polypectomies were performed. Histologic examination showed atypical submucosal lymphoid cells. Immunohistochemical staining showed diffusely positive CD5, CD20, CD79a and BCL2 staining. CD10, BCL6, and Cyclin D1 were negative; consistent with a diagnosis of CD5+ low grade lymphoma. The patient was referred to the oncology department for evaluation. The patient was noted to have no B symptoms. He did have an elevated WBC count at 19,000 with increased lymphocytes but with normal hemoglobin and platelet count. The patient's LDH was mildly elevated and subsequently he underwent PET-CT scan which showed some mildly hypermetabolic bilateral axillary lymph nodes but otherwise normal. Recommendation was routine monitoring given lack of cytopenias, B symptoms, or evidence of transformation. Diagnosis of CLL is based on strict criteria including absolute B lymphocyte count >5,000/micoL [5 x 109/L] with mature-appearing small lymphocytes with clonality. Treatment of CLL is based on disease activity judged by B symptoms, progressive increase in lymphadenopathy, pain, or the presence of symptomatic cytopenias, hemolytic anemia, progressive disease, or repeated infections. Gastroenterologists need to keep CLL on the differential when performing endoscopy on patients who have diffuse polyposis.

Chinese guidelines for the diagnosis and treatment of hand, foot and mouth disease (2018 edition).

Hand, foot, and mouth disease (HFMD) is a common infectious disease in childhood caused by an enterovirus (EV), and which is principally seen in children under 5 years of age. To promote diagnostic awareness and effective treatments, to further standardize and strengthen the clinical management and to reduce the mortality of HFMD, the guidelines for diagnosis and treatment have been developed. National Health Commission of China assembled an expert committee for a revision of the guidelines. The committee included 33 members who are specialized in diagnosis and treatment of HFMD. Early recognition of severe cases is utmost important in diagnosis and treatment of patients with HFMD. The key to diagnosis and treatment of severe cases lies in the timely and accurate recognition of stages 2 and 3 of HFMD, in order to stop progression to stage 4. Clinicians should particularly pay attention to those EV-A71 cases in children aged less than 3years, and those with disease duration less than 3days. The following indicators should alert the clinician of possible deterioration and impending critical disease: (1) persistent hyperthermia; (2) involvement of nervous system; (3) worsening respiratory rate and rhythm; (4) circulatory dysfunction; (5) elevated peripheral WBC count; (6) elevated blood glucose and (7) elevated blood lactic acid. For treatment, most mild cases can be treated as outpatients. Patients should be isolated to avoid cross-infection. Intense treatment modalities should be given for those severe cases. The guidelines can provide systematic guidance on the diagnosis and management of HFMD.

A RARE CASE OF PARANEOPLASTIC NEUROLOGICAL SYNDROME ASSOCIATED WITH ADENOCARCINOMA OF THE LUNG

SESSION TITLE: Lung Cancer 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Paraneoplastic neurologic syndromes (PNS) are rare but clinically important complications of malignancy. These syndromes occur in approximately 0.01% of cancer patients, although more frequently in those with lung cancer, specifically small cell carcinoma. The neurologic syndromes are extensive and may present as encephalomyelitis, cerebellar cortical degeneration, peripheral neuropathy, neuopsoclonus-myoclonus, and retinopathy[1]. CASE PRESENTATION: A 76-year old woman with a recent diagnosis of well differentiated adenocarcinoma, mixed acinar and micropapillary, KRAS p.Gly12Val tumor marker positive, type lung cancer, presented with shortness of breath and altered mental status. According to family she was becoming progressively confused for the prior six weeks, displaying “hyper-somnolence” and speaking “with her eyes closed”. Neurological exam was significant for lethargy, confusion, and incoherent speech. Admission labs showed elevated WBC count 15.7; lactate 0.8. Chest X-ray showed patchy opacities bilaterally, and mild pulmonary congestion. CT scan of her brain was negative for acute pathology. Brain MRI was negative for metastatic disease. Empiric treatment for pneumonia was initiated based on x-ray findings. During her hospital stay, patient remained minimally communicative and unable to follow commands. VEEG was unremarkable. CSF analysis showed 5 WBC, no RBC, with 48% lymphocytes, and 48% monocytes. CSF cytology was negative for malignant cells. Elevated protein was measured at 81 mg/dL. CSF PCR was negative for VZV, HSV, and West Nile Virus. Paraneoplastic encephalitis was suspected due to lack of alternative etiologies for the patient’s symptoms. Treatment with IVIG and high-dose solumedrol was initiated. Ultimately, the paraneoplastic antibody panel resulted with type I anti-neuronal nuclear antibody (ANNA-1) titer of 1:512, Anti-Hu AB titer of 1:32, and anti-recoverin titer of 1:1. DISCUSSION: Paraneoplastic neurologic syndromes are rare clinical syndromes, resulting from the remote effect of a tumor on the nervous system, associated 95% of the time with small cell lung cancer [2]. Our patient’s manifestation of PNS with lung adenocarcinoma is extremely rare. Due to the very low incidence of non-small cell lung cancer associated with PNS, her diagnosis of lung adenocarcinoma was not believed to be contributory to her change in mental status. However, discovery of well characterized onconeural proteins such anti-Hu antibodies in the CSF, made a diagnosis of a PNS highly likely. CONCLUSIONS: Our case demonstrates that lung adenocarcinoma can play a role in the development of paraneoplastic neurologic syndrome and should be considered in the setting of a patient with altered mental status without other cause. Reference #1: Miyamoto, K., et al., A case of paraneoplastic syndrome accompanied by two types of cancer. J Neurol Neurosurg Psychiatry, 2002. 72(3): p. 408-9. Reference #2: Kanaji, N., et al., Paraneoplastic syndromes associated with lung cancer. World J Clin Oncol, 2014. 5(3): p. 197-223. DISCLOSURES: No relevant relationships by Scott Ferrara, source=Web Response No relevant relationships by eman rashed, source=Web Response No relevant relationships by Peter Rattner, source=Web Response No relevant relationships by Michael Silverberg, source=Web Response

Clinical, Bacteriological and Radiological study of severe pneumonia in age group of 2 months to 5 years

Background: Acute respiratory infections (ARI) are one of the commonest causes of death in children in developing countries. The future health of children depends on preventing, diagnosing, treating and limiting Acute Lower Respiratory Tract Infection. The use of these clinical signs in the early detection and treatment of children with pneumonia by primary health care workers forms the basis for the case management strategy formulated by the World Health Organization (WHO) to control mortality and morbidity. Objectives: to study clinical, bacteriological and radiological features of severe pneumonia and to correlate clinical findings with radiological and bacteriological findings. Materials and Method: A prospective observational study among children between 2 months to 5 years of age. A detailed analysis of symptoms and signs such as fever, cough, rapid breathing, refusal of feeds, wheezing, respiratory rate, presence of fever and other signs of cyanosis, etc were noted. Investigations like Hemoglobin, Total WBC count, Differential WBC count, ESR, blood culture Chest X-ray and if require CT scan were done in all patients. Significance for the statistical tests was predetermined at a probability value of 0.05 or less. (p&lt;0.05) Results: over a period of one and half year total 150 cases were included in the study, nearly all patients were presented with cough, tachypnea, fever, chest retractions and other signs. Positive radiological finding were seen in 80.66% of cases.Among bacterial pneumonia, defined radiologicaly; 63.15% had elevated WBC counts; 88.42% had neutrophilia, 67.27% had elevated ESR. Case fatality rate was 6.3% (9 cases). Conclusion: clinical diagnosis by WHO ARI criteria are very sensitive and still can be applied to hospitalized children. Chest X-ray is valuable aid in the diagnosis of pneumonia in children