Elevated Erythrocyte Sedimentation Rate Research Articles

Child with fever and a rash.

A previously healthy 9-month-old Asian male presented to the emergency department with 3 days of fever and rash. The rash had begun on his buttocks, then spread to his trunk and extremities (Figures 1 and 2). His mother noted his hands and feet appeared red and swollen over the previous 2 days (Figure 3), and that his tongue appeared unusually red with some fine vesicles and cracking of his upper lip (Figure 4). Cervical lymphadenopathy was noted on physical examination. Laboratory results included a serum white blood cell count of 18,400/mm3, an elevated C-reactive protein and erythrocyte sedimentation rate of 71 mg/dL and 63 mm/h respectively, and urinalysis with 58 WBCs/hpf. Kawasaki disease is an acute systemic vasculitis with a predilection for the coronary arteries that most commonly affects children of Asian or Pacific Islander descent that are <5 years old.1-3 Kawasaki disease is a clinical diagnosis based on the presence of fever for 5 days combined with at least 4 of the following features: oral changes including strawberry tongue or erythema and cracking of the lips, bilateral conjunctival injection, a maculopapular or erythema multiforme-like rash, erythema and edema of the hands and feet, and cervical lymphadenopathy.4 As with this case, Kawasaki disease may be diagnosed with fever duration of less than 5 days if other classic clinical findings are present, including an elevated serum white blood cell count, elevated inflammatory markers, and evidence of sterile pyuria.4

SUPERFICIAL CERVICAL LYMPHADENITIS ASSOCIATED WITH STREPTOCOCCUS PHOCAE IN FIVE COMMON BOTTLENOSE DOLPHINS (TURSIOPS TRUNCATUS): A CASE SERIES.

Between 2009 and 2018, five common bottlenose dolphins (Tursiops truncatus) at the US Navy Marine Mammal Program presented with superficial cervical lymphadenitis. Clinical findings included ultrasonographic evidence of cervical lymph node enlargement, severe leukocytosis, elevated erythrocyte sedimentation rates, and reduced serum iron. Three of the dolphins presented with clinicopathologic changes without presence of clinical signs, and the other two cases additionally presented with partial to complete anorexia, lethargy, and refusal to participate in training sessions. Ultrasound-guided fine needle aspiration or biopsy of the affected lymph nodes yielded Streptococcus phocae by PCR in all cases, and the organism was cultured in one of five cases. Animals were treated with a combination of enteral, parenteral, intralesional antimicrobial, or a combination of those therapies and supportive care. Time to resolution of clinical disease ranged between 62 and 188 days. To the authors' knowledge, this is the first report of Streptococcus phocae cervical lymphadenitis in cetaceans. Streptococcus phocae lymphadenitis should be a differential for cervical lymphadenopathy in this species, especially when associated with pronounced systemic inflammation and a history of potential exposure.

Comparison of Short-Term Versus Long-Term Antibiotic Therapy Among Severe Cases of Pneumonia: A Prospective Observational Study Among Children.

Introduction Pneumonia continues to be the leading cause of morbidity and mortality in children younger than five years. The World Health Organization (WHO)recommends intravenous antibiotics for five days for severe pneumonia. However, the optimum duration of parenteral antibiotic therapy for pneumonia is not practicable and feasible in poor and resource-constrained settings like India. Given thecurrent Indian scenario wherein childhood pneumonia is extremely prevalent, we attempted to undertake this study to compare theduration of antibiotic therapy in severe cases of community-acquired pneumonia (CAP). Methods A prospective observational study was carried out on 225 cases of severe and very severe CAP patients at a tertiary care center. The study group included children between two months to five years of age. The participants were subjected to antibiotic therapy (parenteral) plus supportive care. The selection of antibiotics was empirical and according to the WHO acute respiratory infection control program. Hematological parameters including blood hemoglobin, C-reactive protein, erythrocyte sedimentation rate (ESR), and total leukocyte count, and radiological evaluation were performed on all the participants. Cases were followed up for the duration of clinical response. Results Out of the 225 cases, 25 patients did not respond to antibiotics and were categorized as the treatment failure group. Of the remaining 200 cases, 104 (52%) showed clinical response within three days (3.0±0.016), and 96 showed a response in four to seven days (4.4±0.064). The mean duration of antibiotic therapy among short-course versus long-course treatment wasstatistically significant (p<0.0001). The majority of patients developed leukocytosis, neutrophilia, and elevated ESR. Conclusion Short-course parenteral antibiotics therapy was equally effective as long-coursetherapy in severe pneumonia. However, very severe pneumonia patients required a longer course of parenteral antibiotics therapy.Very severe pneumonia was significantly associated with high mortality and treatment failure.

Presenting Features of Giant Cell Arteritis with Active Versus Healed Arteritis on Biopsy

ABSTRACT Giant cell arteritis (GCA) is often categorised as ”active” or ”healed” on temporal artery biopsy (TAB). The purpose of this study was to compare the initial clinical presentation of patients with GCA according to active versus healed arteritis on TAB. A retrospective chart review was performed for patients with biopsy-proven GCA (BP-GCA) at a single academic medical institution from a previously reported cohort. The arteritis on TAB was categorised as “active” or “healed” based on the pathological reports. Demographic information, clinical presentation, past medical history, and test results were collected from the date of TAB. These baseline characteristics were entered into the GCA Risk Calculator. Of 85 patients with BP-GCA, 80% had active and 20% had healed disease according to histopathology. A higher percentage of those with active arteritis had ischaemic optic neuropathy (ION) (36% versus 6%, p = .03), elevated erythrocyte sedimentation rates (92% versus 63%, p = .01), elevated C-reactive protein levels (79% versus 46%, p = .049), GCA risk score > 7.5% (99% sensitivity, 100% versus 71%, p < .001), higher mean GCA risk calculator scores (neural network p = .001; logistic regression p = .002). Patients with healed arteritis were less likely to have visual manifestations than the active arteritis group (38% versus 71%, p = .04). Patients with active vasculitis on biopsy had higher rates of ION and elevated inflammatory markers, as well as higher predictive scores from the GCA risk calculator. Further research is needed regarding correlation of biopsy findings and risk of complications or relapses.

Elevated C-Reactive Protein and Erythrocyte Sedimentation Rate Correlates with Depression in Psoriasis: A Chinese Cross-Sectional Study.

Psoriasis patients often suffers from anxiety and depression. Inflammation, anxiety, and depression have been associated with each other, but the relationship has not been examined in subjects with psoriasis. The primary objective was to investigate the relationship between the C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) and depression among patients with psoriasis. In this case-control, cross-sectional study, 239 individuals with psoriasis and 142 with healthy controls (HCs) were recruited. Psychological as well as clinical, and laboratory data were collected. 50.2% of subjects with psoriasis reported depressive symptoms, compared with 26.8% of HCs. 39.7% and 17.6% observed anxiety symptoms in psoriasis patients and HCs. The odds of anxiety (AOR= 3.123; 95% CI = 1.851-5.269) and depression (AOR= 2.698; 95% CI = 1.690-4.306) were higher in psoriasis patients relative to HCs. Furthermore, the elevated CRP (AOR =2.139; 95% CI = 1.249-3.663) and ESR (AOR =1.827; 95% CI = 1.078-3.096) were the risk factors of depression in patients with psoriasis. The threshold for distinguish psoriasis patients in depression was 3.24 (area under the curve [AUC], 0.605; sensitivity, 0.57; specificity, 0.64) for CRP and 26.5 (AUC, 0.632; sensitivity, 0.52; specificity, 0.73) for ESR. A substantial prevalence of anxiety and depression symptoms was observed in Chinese psoriasis subjects, and the odds were much higher in psoriasis patients relative to HCs. The elevated CRP and ESR level was significantly associated with depression in psoriasis patients. Besides, the discrimination capability of CPR and ESR on depression further indicates the extra value of inflammatory biomarkers in the management of psoriasis patients.

Abstract WP116: Clinical And Diagnostic Features On Cerebrospinal Fluid And Vessel Wall MRI Can Differentiate Primary From Secondary CNS Vasculitis

Introduction: Differentiating primary CNS vasculitis (PCNSV) from secondary CNS vasculitis (SCNSV) can be challenging based on brain imaging and cerebrospinal fluid (CSF) profile alone. Little is known about the diagnostic nuances of differentiating these 2 entities with CSF and vessel wall magnetic resonance imaging (VWMRI) as overlapping features may exist. We aimed to look at clinical features, serum &amp; CSF biomarkers, and VWMRI differences between PCNSV &amp; SCNSV. Methods: Patients presenting to our tertiary care center with a diagnosis of PCNSV or SCNSV between January 2015 and January 2021 were extracted from electronic medical record data. We included patients older than 18 years of age with active disease who had CSF studies and VWMRI data available. Demographic, clinical and diagnostic characteristics were reviewed and descriptive statistics were reported for comparison. Results: A total of 42 patients (24 with PCNSV and 18 with SCNSV) met study inclusion criteria. The SCNSV group was older (median age 43 years vs 41.5 years), had a higher proportion of male gender (78% vs 54%) and black race (22% vs 4%) compared to PCNSV. Patients with PCNSV more commonly had headache (63% vs 50%) and seizures (21% vs 11%) but less commonly had encephalopathy (42% vs 50%), focal neurological deficits (79% vs 83%) and constitutional symptoms (17% vs 33%). Patients with PCNSV more likely had positive antinuclear antigen levels (25% vs 11%) and elevated sedimentation rate (33% vs 25%) but less likely had elevated C-reactive protein (25% vs 33%) in blood. Comparison of CSF studies showed that the PSCNV group had a lower median CSF white blood cell count (10 cells/mm3 vs 43.5 cells/mm3 , both lymphocytic), lower median CSF protein count (62 mg/dl vs 82 mg/dl) and lower IgG index (33% vs 56%) in comparison to the SCNSV group. On VWMRI, PCNSV group had less diffuse (40 vs 54%) involvement and more anterior multifocal lesions (40 vs 15%) compared to SCNSV group with more large or medium-vessel involvement (70 vs 54%). Conclusion: Clinical and diagnostic differences with regards to CSF and VWMRI exist between PCNSV and SCNSV that can aid in differentiating these two entities. This can prove useful especially in undiagnosed systemic vasculitides presenting with CNS vasculitis.

Clinical characteristics and quality of life in patients with inflammatory bowel disease-associated anemia in Southeast China.

Clinical characteristics of inflammatory bowel disease (IBD) with anemia have not been fully elucidated. This study aimed to investigate the frequency of, risk factors for, and management of anemia in IBD patients and to evaluate the quality of life (QOL) in IBD patients with anemia. We included two patient cohorts. In cohort 1, clinical data from 697 IBD patients were retrospectively collected. In cohort 2, the Short Form-36 Health Survey (SF-36) and Fatigue Scale-14 (FS-14) questionnaires for IBD patients were completed to evaluate the QOL. Anemia was present in 35.6% of IBD patients [38.2% of Crohn's disease (CD) patients vs. 29.3% of ulcerative colitis (UC) patients, P = 0.025]. Elevated platelet (PLT) count (CD: OR, 1.004; 95% CI, 1.001-1.007; P = 0.007; UC: OR, 1.010; 95% CI, 1.004-1.016; P = 0.001), elevated erythrocyte sedimentation rate (ESR) (CD: OR, 1.024; 95% CI, 1.012-1.036; P < 0.001; UC: OR, 1.025; 95% CI, 1.001-1.051; P = 0.044), and lower albumin levels (CD: OR, 0.801; 95% CI, 0.749-0.857; P < 0.001; UC: OR, 0.789; 95% CI, 0.720-0.864; P < 0.001) were associated with anemia. Among the IBD patients with anemia, only 25.8% received treatment for anemia. IBD patients with anemia had significantly lower SF-36 scores (P = 0.011) and higher FS-14 scores (P = 0.026) than those without anemia. Anemia is common in IBD patients. Elevated PLT count and ESR are risk factors for anemia in IBD patients. Anemia may negatively impact IBD patients' QOL, but few anemia patients receive treatment for anemia.

Neurological complications of giant cell arteritis: A study of 15 cases and a review of the literature

Giant cell arteritis (GCA) is considered a neuro-ophthalmologic emergency. New-onset headache in patients aged 50 years and above with elevated erythrocyte sedimentation rate should prompt evaluation for GCA. Retrospective study of 15 patients presenting with GCA from 1991 to 2008 at the Mohamed V Military hospital at Rabat and Avicenne Military hospital of Marrakech. Fifteen cases were recorded, with female predominance (male to female ratio 2:3) and a mean age of 63 years (range: 55-83 years). All patients (100%) presented with headache. The headache was isolated in 20% of cases and neuro-ophthalmic complications were found in 73% of cases. Biopsy was conclusive for GCA in 67% of cases and all of our patients were placed on steroids with spectacular improvement. New-onset headache in patients aged 50 years and above should prompt evaluation for GCA. Steroids, especially during the acute phase, must be started urgently to avoid irreversible neurological impairment.

Characterizing the Spectrum of Latent Mycobacterium tuberculosis in the Cynomolgus Macaque Model: Clinical, Immunologic, and Imaging Features of Evolution.

Mycobacterium tuberculosis infection outcomes have been described as active tuberculosis or latent infection but a spectrum of outcomes is now recognized. We used a nonhuman primate model, which recapitulates human infection, to characterize the clinical, microbiologic, and radiographic patterns associated with developing latent M. tuberculosis infection. Four patterns were identified. "Controllers" had normal erythrocyte sedimentation rate (ESR) without M. tuberculosis growth in bronchoalveolar lavage or gastric aspirate (BAL/GA). "Early subclinicals" showed transient ESR elevation and/or M. tuberculosis growth on BAL/GA for 60 days postinfection, "mid subclinicals" were positive for 90 days, and "late subclinicals" were positive intermittently, despite the absence of clinical disease. Variability was noted regarding granuloma formation, lung/lymph node metabolic activity, lung/lymph node bacterial burden, gross pathology, and extrapulmonary disease. Like human M. tuberculosis infection, this highlights the heterogeneity associated with the establishment of latent infection, underscoring the need to understand the clinical spectrum and risk factors associated with severe disease.

C-REACTIVE PROTEIN - THE MOST USEFUL REACTANT OF ACUTE PHASE IN RHEUMATOID ARTHRITIS

The aim of the study was to determine the most useful biochemical marker of the acute phasereactants for the evaluation of disease activity in rheumatoid arthritis (RA). Sixty patients with RA were included, 27 of whom were treated with non-steroid anti-inflammatory drugs (NSAIDs) and methotrexate (MTH).The control group consisted of 33 patients treated only with NSAIDs due to irregular control. Inthe first group, disease activity was evaluated at four-week intervals and in the control group at three-week intervals, following the scores of the articular indices, complete blood count (CBC), elevatedsedimentation rate (ESR), and C-reactive protein (CRP) in every patient. In the first group of patients, decreased activity of RA was found in every subsequent control, with a consecutive decrease in the mean values of the scores of the articular indices and statistically significant differences in the four-time intervals.Considering laboratory parameters, there were statistically significant differences in the meanvalues of haemoglobin (Hb), erythrocytes (Er), platelets (Plt), and ESR (p=0.0462, p=0.0076, p= 0.0058,p= 0.0003). The mean values of CRP did not show statistically significant differences, but the number ofpatients who were CRP negative increased (the standard deviation also increased). In the group of patientstreated only with NSAIDs, there were statistically significant differences in the mean values of the scoresof the articular indices, with increases in every subsequent control (in favor ofdisease progression).There were no statistically significant differences considering CBC, ESR, and CRP (in favor of apermanently active disease). CRP is the most useful marker in the prospective evaluation of patients with rheumatoid arthritis.Keywords: rheumatoid arthritis, articular indices, reactants of the acute phase

Paediatric Septic Arthritis of the Hip: Epidemiology, Diagnosis, and Treatment

Background: Septic arthritis of the hip is an orthopaedic emergency which requires prompt diagnosis and treatment. If treated late or inadequately, it can have devastating consequences for the development of the hip joint. Infection is most commonly caused by Staphylococcus aureus which spreads via the blood stream or from an adjacent area of osteomyelitis. Diagnosing and managing this condition continue to be challenging and poor outcomes may occur. Neonates may present with sepsis and failure to thrive. There may be no fever. The hip is held in flexed, abducted and externally rotated position. The limb is held still and any passive movement causes pain. Older children typically present with a limp or refusal to walk. Children typically have elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Needle aspiration is the most specific diagnostic test. Prompt surgical drainage and postoperative antibiotic therapy until signs of infection resolve are necessary to prevent late sequelae. Objectives: The present review aims to discuss the published evidence related to the diagnosis of septic arthritis of the hip based on history, physical examination, laboratory tests, imaging studies and arthrocentesis, and management including antibiotic treatment and surgical joint debridement. Conclusion: With prompt diagnosis and appropriate treatment, outcomes are generally good, with only few long-term sequelae. Delay in diagnosis and treatment may result in growth disturbances and joint destruction.

Clinical and Laboratory Profile of Patients with Newly Diagnosed Juvenile Idiopathic Arthritis: An Observational Study from a Tertiary Care Centre, Karnataka, India

Introduction: Juvenile Idiopathic Arthritis (JIA) is the most common rheumatic condition of childhood. It represents a heterogeneous group of childhood arthritis. Aim: To study the clinical profile and laboratory characteristics of all newly diagnosed JIA patients. Materials and Methods: This hospital-based prospective observational study was conducted in the Department of Paediatric Rheumatology in Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India between December 2017 to April 2019. All children who fulfilled International League of Associations for Rheumatology (ILAR) criteria for the diagnosis of JIA were enrolled in the study, and their clinical and laboratory parameters were evaluated. The analysis between matchedpairs data like the comparison between age of onset and age of presentation in males and females were done by paired t-test. Results: Fifty one children were included in the study with M:F of 1:1.12. Mean age at onset was 8.71±4.02 years and median duration of disease was 13 months (2-96 months). The most common subgroup was polyarticular JIA 18 (35.3%) followed by Systemic Onset Juvenile Idiopathic Arthritis (SOJIA) 14 (27.5%), enthesitis-related arthritis 13 (25.5%) and oligoarticular JIA 4 (7.8%). Knee (94%) was the most common joint involved followed by the ankle (70.5%). Fever was the most common extra-articular feature present in 73% of cases. Hepatomegaly, splenomegaly and lymphadenopathy was present in 33.3%, 9.8% and 21.6% children, respectively. Anaemia, leukocytosis, thrombocytosis and elevated Erythrocyte Sedimentation Rate (ESR) were more common in SOJIA. Macrophage Activation Syndrome (MAS) was diagnosed in 2 cases of SOJIA (14.3%) with no mortality. Conclusion: Polyarticular JIA was the common subtype in the study, followed by SOJIA. Most common joint involved was knee, followed by ankle and fever is the most common extraarticular manifestation.

BRUCELLA INFECTION FOLLOWING TOTAL JOINT ARTHROPLASTY

Brucellosis is a common zoonotic infection that carries a high economic burden in China especially in Xinjiang. Purpose of the message:To discuss the treatment of brucella infection following total joint arthroplasty and find out its curative effect. Methods. We analyzed 8 patients with who infected joint brucella after received arthroplasty in our department from March 2009 to March 2019, whose ages were from 55 to 79 years old (average age was 65.6 ± 1 years). The following parameters were measured in the pre- and post-operation periods: HSS and Harris score, range of knee motion (ROM), VAS, erythrocyte sedimentation rate (ESR) and C-reactive Protein (CRP). From x-ray to find out post-operate curative effect of revision operation. Results. All cases had pain and elevated ESR. Deep vein thrombosis (DVT) and nerve damage were not found in these cases. There were no sinuses on the skin have be found. All patients received total joint arthroplasty and infected with brucella post operation receive revision operation at last. All cases were followed-up for 6-30 months; the average follow-up period was14 ± 0.5 months. Post operation we took an HSS and Harris score and X-rays to find out its curative effect after revision operation. There were also no patients with aseptic loosening or fracture of prosthesis during or post- revision operation, no recurrence had been found. The average ROM of knee was improved to 90 ± 3°. Conclusions. Recent clinical results indicate that systemic antibrucellosis chemotherapy and surgery technical is effective to treat the patients following. Revision operation can significantly improve the function of the joint and relieve pain.

Left ventricular strain in patients with Takayasu arteritis with preserved ejection fraction: an analysis using cardiac magnetic resonance imaging feature tracking

The alteration of myocardial strain in patients with Takayasu arteritis (TAK) remains unclear. This study aimed to evaluate left ventricular (LV) stain in patients with TAK and preserved left ventricular ejection fraction (pLVEF) using cardiac magnetic resonance imaging feature tracking (CMR-FT) to analyze risk factors for impaired LV strain and to compare the baseline difference of LV strain between patients with reduced and nonreduced LVEF at 6-month follow-up. In all, 51 patients with TAK and 30 healthy controls were prospectively enrolled. All participants underwent multiple short- and long-axis cine scans with true fast imaging with steady-state precession sequence. In this observational study, LV global and regional longitudinal, circumferential, and radial strain and their strain rates were analyzed with FT on cine images. The relationship between LV strain and clinical data was explored. The baseline LV strain between patients with TAK and reduced and nonreduced LVEF was compared using transthoracic echocardiography (TTE) at the 6-month follow-up. Patients with TAK with pLVEF showed a decline in baseline global longitudinal peak strain (GLS) [TAK (-13.35%±3.11%) vs. controls (-14.77%±1.74%), P=0.021] and circumferential peak strain (GCS) [TAK (-21.46%±2.66%) vs. controls (-22.75%±2.57%), P=0.027] in comparison with normal controls. The longitudinal peak strain (LPS) in the apical (P=0.003) and midventricular regions (P=0.027) and the circumferential peak strain (CPS) in the basal (P=0.021) and midventricular regions (P=0.008) also decreased in patients with TAK. Patients with pulmonary hypertension (PH) or myocardial late gadolinium enhancement (LGE) showed a greater reduction in strain compared with those without PH or LGE. GLS showed a negative association with erythrocyte sedimentation rate (ESR), while GCS showed a positive association with disease duration. In the 30 patients who were followed up, the baseline global and apical circumferential diastolic peak strain rates (DPSR) in patients with reduced LVEF were higher than those in patients without reduced LVEF. In patients with TAK and pLVEF, CMR-FT indicated that both global and segmental myocardial strain decreased. PH, male gender, long disease duration, elevated ESR, and myocardial LGE were associated with declined LV strain. Baseline increased circumferential DPSR may be associated with the decline in LVEF during follow-up.

The role of a conjunctival biopsy in the diagnosis of eosinophilic granulomatosis with polyangiitis with ocular involvement

A 33-year-old Asian man presented with redness, swelling, and blurring of vision in both eyes for 1 month associated with headache and pain. The patient had a history of allergic rhinitis with a progressive hearing loss for 3 months, followed by bell's palsy. Given his elevated serum cytoplasmic anti-neutrophil cytoplasmic antibody (C-ANCA) and erythrocyte sedimentation rate (ESR) levels as well as computed tomography head, orbit, and peripheral nervous system that showed marked bilateral mastoiditis with opacification of the right middle ear canal and enlargement of the bilateral lacrimal gland, the suspicion of small vessel vasculitis with ocular and ear involvement was high. Because there was no significant lung or kidney involvement, a conjunctival biopsy was attempted, which revealed small capillaries surrounded by eosinophils and plasma cells. Because there are no validated diagnostic tests for eosinophilic granulomatosis with polyangiitis (EGPA), a conjunctival biopsy can be valuable and minimally invasive in the early diagnosis and treatment of small vessel vasculitis.

Granulomatose com poliangiíte na infância: experiência de um centro de referência terciário no Ceará (BR)

Granulomatosis with polyangiitis (GPA) is an ANCA-associated necrotizing granulomatous vasculitis. It is rare in the pediatric population and predominantly affects small and medium-sizes blood vessels; it preferentially involves the kidneys and the upper and lower respiratory tract. This retrospective case series looked into the medical charts of children and adolescents aged up to 18 years diagnosed with the condition based on the EULAR/PReS criteria in the period ranging from 2014 to 2019. It describes clinical characteristics, laboratory findings and treatment options, along with the progress of GPA in children. In our series, GPA predominantly affected females (80%) and the median age at diagnosis was 11.1 years. The classic clinical triad comprising granulomatous inflammation, pauci-immune necrotizing glomerulonephritis, and upper and lower respiratory tract involvement, was highly prevalent, and delays in diagnosis occurred particularly in individuals with mild kidney or lung involvement. Laboratory findings included elevated erythrocyte sedimentation rate, anemia, and hematuria; alterations included sinus disease, pulmonary infiltrates, nodules, and cavitation seen on CT scans of the head and chest, all of which are key diagnostic elements. All patients were treated with glucocorticoids and cyclophosphamide. Morbidity remained significant and unchanged throughout the course of the disease. Clinical and laboratory findings and prescribed treatments were consistent with the literature. Given its severity, this disease requires early recognition, aggressive initial treatment, and long-term patient follow-up.

Amalric triangular sign: Combined central retinal artery and posterior ciliary artery occlusion presenting with macular edema

A 55-year-old female patient presented with no light perception and features suggestive of central retinal artery occlusion (CRAO) and posterior ciliary artery occlusion. Multimodal imaging analysis revealed retinal thickening, cherry-red spot, pallid optic disc with choroidal infarction (Amalric sign), and macular edema. Carotid Doppler disclosed 70% stenosis of the right common carotid artery. Systemic investigations showed elevated erythrocyte sedimentation rate, total cholesterol, and low-density lipoprotein level. The Amalric triangular sign with CRAO may present with macular edema. Prompt cardiac and carotid evaluation with appropriate management should be done.

Eosinophilic Gastroenteritis: An Unusual Disease of Gastrointestinal Tract

Eosinophilic gastroenteritis (EGE) is a rare gastrointestinal disease characterized by generalized abdominal pain, nausea, vomiting, diarrhea, gastrointestinal bleeding and weight loss. The etiology and pathogenesis are not well understood and mostly based on case reports. Clinical presentation may vary depending on sites and depth of involvement of the gastrointestinal tract. The diagnosis is usually confirmed by histology that shows eosinophilic infiltration and the absence of secondary cause of eosinophilia.The authors present a case report of a 47-year-old woman that was diagnosed with dyslipidemia, obesity and allergic rhinitis. She had no significant family history. She was admitted in internal medicine department with 2 weeks of abdominal pain, nausea, vomiting, diarrhea and weight loss (&gt; 10%). Further study revealed increased eosinophil count, normocytic anemia, elevated erythrocyte sedimentation rate and normal Ig E levels. Digestive endoscopic study was performed, and multiple biopsy specimens showed moderate eosinophilic infiltration in stomach and duodenal mucosa.The patient was started on prednisolone, with clinical improvement. Follow-up go the patient twenty years after the beginning of this treatment showed stabilization of clinical symptoms and laboratory tests.So, eosinophilic gastroenteritis is characterized by three criteria - presence of gastrointestinal symptoms, histologic evidence of eosinophilic infiltration and exclusion of other causes of tissue eosinophilia. The treatment is based on the severity of symptoms. Corticosteroids are the mainstay of therapy, so the usual dose of prednisolone/prednisone is 20-40 mg daily for two weeks with tapering thereafter. In the literature, the use of montelukast and biologic agents have been reported.

Extrapulmonary Tuberculosis: Clinical and Diagnostic Features and Risk Factors for Early Mortality

Objective: The aim of this study is to evaluate patients with EPTB in terms of demographics, anatomic localization, diagnosis and risk factors on early mortality. Materials and methods: The data of 217 inpatients who were followed up with EPTB, between January 2010 and December 2020, were evaluated retrospectively. Patients were followed-up during hospital admission and early mortality was considered. Risk factors on mortality were identified in multivariate analysis using logistic regression model. Results: The median age was 54 (IQR: 37-67) and the rate of male patients was 43.3%. 76 (35%) patients had at least one comorbidity. The most common underlying conditions were diabetes mellitus and immunosuppressive treatment. The most common forms of EPTB were lymph node, bone and CNS. Microbiological findings (ARB and/or TB-culture and/or M. tuberculosis PCR) were positive in 75 patients and histopathological findings (necrotising granuloma with/without pathological caseification) were supportive for diagnosis in 68.2%. The overall mortality rate was 8.5%. In the multivariate analysis, factors independently associated with increased risk of death included advanced age, elevated sedimentation rate above 50mmHg, miliary TB and CNS TB. Conclusion: In conclusion, EPTB is an important health problem in developing countries with significant mortality in specific forms. The most common forms of EPTB are lymph node, bone and CNS TB. The most common underlying conditions are diabetes and immunosuppressive therapy although most patients do not have any underlying diseases. The diagnosis is forcing and a substantial proportion of patients have negative microbiological findings. The diagnosis are based on pathological, radiological and/or clinical findings in patients without definitive microbiological diagnosis. Advanced age, high sedimentation rate and severe forms such as CNS and miliary TB are associated with early mortality.

Secondary hypothyroidism following the Resolution of Graves’ Disease: A Case Report

This is the case report of a 39-year-old lady who presented with clinical and laboratory features of secondary hypothyroidism two years after achieving clinical and biochemical resolution of Graves' disease and cessation of anti-thyroid medications. The thyroid function tests at presentation revealed: Serum T3 1.33ng/ml (normal range 0.8-1.7ng/ml), Serum T4 2.92 (normal range 4.5-12.0µg/dl), and TSH 0.2mIU/l (normal range 0.5-5.0mIU/l). Thyroid-related autoantibodies could not be assayed in the patient due to financial constraints. However, pointers to the possible autoimmune nature of secondary hypothyroidism include the recurrence of exophthalmos, dating of symptoms back to puerperium, relative lymphocytosis, and moderately elevated erythrocyte sedimentation rate (ESR). The patient was subsequently placed on levothyroxine and low-dose steroids, and the patient achieved clinical and biochemical euthyroidism in the sixth, ninth, and twelfth months of follow-up. This report is to demonstrate the development of secondary hypothyroidism following Graves' disease, and it also serves to highlight the judicious use of clinical acumen in the face of limited laboratory support to diagnose and treat endocrine disorders in resource-poor settings.