Mild Lymphopenia Research Articles

Anti-IL12p40 autoantibodies in a teenage girl with multiple recurrent abscesses

More frequent among adults, phenocopies may be caused by somatic mutations or anti-cytokine autoantibodies, mimicking the phenotypes of primary immunodeficiencies. A fourteen-year-old girl was referred for a two-year history of weight loss and multiple recurrent abscesses, complicated recurrent pneumonia, pyelonephritis, osteomyelitis, and septic shock, without fever. She had started with nausea, hyporexia, and weight loss, then with abscesses in her hands, knee, ankle, and spleen. She also developed a rib fracture and left thoracic herpes zoster. The patient was cachectic, with normal vital signs, bilateral crackles on chest auscultation, tumefaction of the knee joint, and poorly healed wounds in hands and chest, oozing a yellowish fluid. Chest computed tomography revealed multiple bilateral bronchiectases. Laboratory workup reported chronic anemia, leukocytosis, neutrophilia, mild lymphopenia, thrombocytosis, pan-hypergammaglobulinemia, and elevated acute serum reactants. Lymphocyte subsets were low but present. Mycobacterium tuberculosis was detected via polymerase chain reaction in a bone biopsy specimen from ankle osteomyelitis. Whole-exome sequencing failed to identify a monogenic defect. Interleukin-12 was found markedly elevated in the serum of the patient. Phosphorylation of STAT4, induced by increasing doses of IL-12, was neutralized by patient serum, confirming the presence of anti-IL12 autoantibodies. IL-12 and IL-23 are crucial cytokines in the defense against intracellular microorganisms, the induction of interferon-gamma production by lymphocytes, and other inflammatory functions. Patients who develop neutralizing serum autoantibodies against IL12 manifest late in life with weight loss, multiple recurrent abscesses, poor wound healing, and fistulae. Treatment with anti-CD20 monoclonal antibodies was effective.

Retrospective evaluation of leflunomide as an adjunctive therapy in dogs with non-associative immune-mediated thrombocytopenia: 20 cases (2008-2021).

To describe leflunomide as an adjunctive therapy in the treatment of non-associative immune-mediated thrombocytopenia. A retrospective study of dogs with a diagnosis of non-associative immune-mediated thrombocytopenia treated with leflunomide March 2008 to September 2021 was conducted. Data collected included signalment, clinical signs, physical examination findings and diagnostic testing performed. Medications administered, duration of hospital stay, time to platelet concentration >150×109/L and adverse events during leflunomide therapy were recorded. Relapses within a year of diagnosis were reported. A total of 20 client-owned dogs met inclusion criteria. Nineteen of 20 dogs (95%) achieved a platelet concentration >150×109/L with leflunomide and prednisone combination therapy and four dogs (21.1%) relapsed during treatment or shortly after treatment. Adverse effects included diarrhoea (n=5), mild lymphopenia (n=9) and mild intermittent anaemia (n=1). A single dog developed hepatotoxicity presumed to be secondary to leflunomide therapy that resolved after drug discontinuation. One dog was treated for aspiration pneumonia during treatment. Two dogs were euthanased while receiving leflunomide. Length of hospitalisation, time to platelet recovery, treatment response and relapse rate were comparable with alternative treatment protocols. Most adverse effects did not require leflunomide dose adjustment; however, two dogs died while undergoing leflunomide treatment and there is compelling evidence that one of these dogs experienced fatal infection secondary to immune-suppression. Hepatotoxicity remains a known complication of leflunomide treatment and serial biochemistry testing is recommended.

Frequency of Dimethyl Fumarate-Induced Lymphopenia among Omani Patients with Multiple Sclerosis.

Dimethyl fumarate (DMF) is known to cause lymphopenia when used to treat patients with multiple sclerosis (MS). However, research on DMF therapy in the Arab world, especially in Oman, is scarce. This study aimed to analyse the prevalence of lymphopenia among Omani patients with MS and their reasons for discontinuing DMF therapy. In this retrospective study, the medical records of Omani patients with MS who were treated using DMF at two tertiary hospitals in Muscat, Oman, from February 2017 to February 2023 were reviewed. Their demographic, clinical and laboratory data were retrieved and analysed. Absolute lymphocyte count values at baseline and at the last follow-up, as well as the reasons for discontinuing DMF therapy, were collected. Descriptive and inferential statistical techniques were used for data analysis. Binary-logistic regression analysis was used to identify the risk factors for DMF-induced lymphopenia. A total of 64 Omani patients with MS were included in this study. The majority of the study participants (n = 40; 63%) were female. All included patients started DMF therapy at the mean age of 33 ± 7.7 years. After administration of DMF, 14 (21.9%) patients developed grades 1-3 of lymphopenia. The DMF therapy was discontinued for 23 (36.0%) patients, mainly in response to adverse events or confirmed pregnancy. Female gender was the only significant predictor of DMF-induced lymphopenia (P = 0.037). Most Omani patients with MS had mild lymphopenia (grades 1-2). Early adverse events and pregnancy were the main reasons provided for discontinuing DMF therapy.

The effect of radioiodine therapy on blood cell count in patients with differentiated thyroid cancer.

This study aimed to investigate the long-term effects of radioiodine treatment (RAI) on blood cell counts in patients with differentiated thyroid cancer (DTC) and to describe the characteristics of patients at high risk for blood cell count abnormalities. The study included patients with DTC who underwent RAI treatment between 2007 and 2017. Patients with regular complete blood counts for at least 5years were included, while those with diseases or treatments that could influence blood count parameters were excluded. Blood cell count abnormalities were defined according to the Common Terminology Criteria for Adverse Events version 5.0, and factors influencing these abnormalities were examined. A total of 225 patients were analyzed. The mean age at diagnosis was 45.8 ± 13.9years, and 76.5% of patients were female. In the first year after RAI, leukocyte, neutrophil, and lymphocyte counts were significantly reduced compared with baseline values. The leukocyte and neutrophil counts returned to baseline values by the third year, while the decrease in lymphocytes continued until the fifth year. Blood cell count abnormalities developed in 16 patients (7.1%) within the first year after RAI. Risk factors for blood cell count abnormalities within the first year after RAI included male sex, older age, T4, N1, and M1 disease, as well as higher RAI doses. In logistic regression analysis, only RAI dose remained independently associated with blood cell count abnormalities. These results suggest an association between RAI dose and blood cell count abnormalities, characterized by mild lymphopenia, and indicate that the risk of mild lymphopenia persists over time. Careful consideration should be given when planning high-dose RAI for patients at a high risk of blood cell count abnormalities, such as males with metastatic disease and of advanced age.

Zoledronic acid-induced severe lymphopenia.

Although anemia, thrombocytopenia, and mild lymphopenia have been reported in the acute phase response after zoledronic acid, severe lymphopenia has not been reported. This article describes a case of severe lymphopenia following a 5 mg zoledronic acid infusion administered to treat osteoporosis. Zoledronic acid is used to treat osteoporosis, hypercalcemia, Paget's disease, and solid malignancies, including multiple myeloma, breast cancer, and prostate cancer. An acute phase response can be seen in 42% of patients after zoledronic acid treatment. Acute phase response may be accompanied by short-term spontaneously recovered anemia, thrombocytopenia, and severe lymphopenia.

Interstitial cystitis in common variable immunodeficiency: Could it be another autoimmune complication? A descriptive report

IntroductionCommon variable immunodeficiency (CVID) is considered the most common Human Inborn Error of Immunity (HIEI) and involves low IgG and susceptibility to infections. ESID 2014 criteria has expanded diagnostic criteria to include autoimmunity and lymphoproliferation. One less common and not well understood noninfectious complication of CVID is interstitial cystitis (IC), which may be caused by immune dysregulation. We hypothesized that patients with both CVID and IC may have reduced switched memory B cells. We conducted this study using data from United States Immunodeficiency Network (USIDNET) and compared results to patients at our institution to see if there were any variables of interest. Results and DiscussionSeventeen of 1446 patient (1.2%) with CVID in the USIDNET database had a diagnosis of possible interstitial cystitis and all were females. Patients in this group had normal average range for IgG (798 mg/dL) with IVIG replacement, along with normal WBC, platelet, IgM and basic T cell enumeration. B cell phenotyping data was available for only one patient, showing normal memory and switched memory B cells. Data from our institution showed similar normal ranges for all the above labs except one female patient who had low memory and switched memory B cell population and had the mildest IC-related disease course. One male patient had normal memory and switched memory B cell population with mild Tcell lymphopenia, however had the worst IC-related clinical outcome. ConclusionWe failed to observe a strong correlation between low switched memory B cells and IC in patients with CVID. IVIG, despite its immunomodulating effects, also appeared to lack any association. While the severity of IC and male gender for one of our patients may be coincidental, it does raise the suspicion that the phenotype of IC in male CVID patients may be different from their female counterparts. IC may be underreported in USIDNET, leading to limited data and prohibiting any clear causative conclusions we may draw this study. Nevertheless, we believe it is important to raise the awareness of this rare disease, so that we can be cognizant of its heterogeneous manifestations and impacts on morbidity and mortality.

The first study on clinicopathological changes in cats with feline infectious peritonitis with and without retrovirus coinfection.

Feline infectious peritonitis (FIP) is an infectious, immune-mediated, and fatal disease in cats caused by a mutant feline coronavirus (FCoV) infection. Feline immunodeficiency virus (FIV) and feline leukemia virus (FeLV) are two common retroviruses that play a role in reducing feline immune function with opportunistic retrovirus infection being a predisposing factor for the development of FIP. This study aimed to evaluate the clinicopathological parameters of FIP in cats with and without retrovirus coinfection. In total, 62 cats presenting with pleural and/or peritoneal effusion at the Kasetsart University Veterinary Teaching Hospital, Bangkok, Thailand, were selected for the study. Effusion samples were collected and a reverse transcriptase-polymerase chain reaction (RT-PCR) assay was performed on all samples using the 3' untranslated region primer. All FCoV-positive cats were tested for retrovirus infection using a commercial kit (Witness FeLV-FIV [Zoetis]; United States). Clinical signs, hematological, and biochemical parameters of these cats were investigated and grouped. Of the 62 cats with pleural and/or peritoneal effusion, FCoV was detected in 32, of which 21 were highly suspicious for FIP. The cats suspected of FIP were divided into three subgroups following viral detection. A total of 14 had only FCoV infection (Group A), four had FCoV and FeLV infection (Group B), and three had FCoV, FeLV, and FIV infection (Group C). Of the rest, 11 had definitive diagnoses, which included three being FCoV and FeLV-positive (Group D), and eight were retrovirus-negative (Group E). Mild anemia and lymphopenia were found in cats infected with these three viruses. An albumin-to-globulin ratio lower than 0.5 was found in FIP cats with only FCoV infection. Typically, cats with clinical effusion and FIP, with and without retrovirus coinfection, had similar hematological findings. Clinical signs, blood parameters, fluid analysis with cytological assessment, and RT-PCR assays could identify better criteria to diagnose FIP with and without retrovirus coinfection.

Molecular Diagnostic Confirmation and Haemato-Biochemical Changes of Clinical Hepatozoon canis Infection in a Rhipicephalus sanguineus Tick-Infested Dog from Colima, Mexico

Canine hepatozoonosis is a tick-borne disease caused by Hepatozoon canis (James, 1905) and Hepatozoon americanum (Vincent-Johnson, 1997). The disease has been reported infrequently in Mexico. The aim of this report was to describe haemato-biochemical changes and confirm diagnosis by molecular-based methods of clinical infection by H. canis in a dog. A 9-year-old female, boxer dog, Canis familiaris (Linnaeus, 1758), was taken to a veterinary clinic at Colima, Mexico. The dog showed depression and more than 2 weeks of gradual weight loss without decreased appetite. Rhipicephalus sanguineus (Latreille, 1806) ticks were found when the dog was physically examined. Blood samples were collected for smear, hematological, and biochemical analyses, and PCR assays. Hematological analysis revealed an apparently non-regenerative normochromic normocytic moderate anemia, mild thrombocytopenia, left shift without neutrophilia, and mild lymphopenia associated with possible stress. Biochemical analysis showed hyperbilirubinemia, hyperamylasemia, hypoalbuminemia, hyperglobulinemia, increased ALT, and hypocalcemia. Microscopic examination of Diff-Quick-stained blood smears showed capsule-shaped structures consistent with gametocytes of Hepatozoon sp. Clinical history, hematological changes, and molecular assays described in the report confirmed the first case of canine hepatozoonosis caused by H. canis in the Pacific region of Mexico.

Peripheral lymphocyte count defines the clinical phenotypes and prognosis in patients with anti-MDA5-positive dermatomyositis.

To explore the role of peripheral lymphocyte count in phenotyping and prognosis prediction in dermatomyositis (DM) patients with anti-MDA5 antibodies. In total, 1669 patients with idiopathic inflammatory myopathy (IIM) were retrospectively enrolled. Clinical characteristics and prognosis of patients with anti-MDA5+ DM were analyzed in association with peripheral lymphocyte counts and clusters determined by unsupervised machine learning. The peripheral lymphocyte count was significantly lower in the anti-MDA5+ DM group (N=421) than in the other IIM serotype groups. The anti-MDA5+ DM patients were divided into three groups; the severe lymphopenia group had skin ulcers and rapidly progressive interstitial lung disease (RP-ILD); patients with a normal lymphocyte count had a younger age of onset, more frequent arthritis, and normal serum ferritin levels, whereas mild lymphopenia group showed a moderate increase of serum ferritin and intermediate incidence of RP-ILD. Survival analysis revealed that the 3- and 6-month mortality rates were significantly higher in the severe lymphopenia group (29.0% and 42.1%, respectively) than in the mild lymphopenia group and normal lymphocyte count group (p value <0.001). Consistently, unsupervised machine learning identified three similar groups; the arthritis cluster shows the highest lymphocyte counts and best prognosis; the RP-ILD cluster presents the lowest peripheral lymphocyte, high incidence of RP-ILD, and poor prognosis; the typical DM rash cluster had a moderate peripheral lymphocyte count and an intermediate prognosis. Lymphopenia is a unique manifestation of anti-MDA5+ DM. Peripheral lymphocyte count can define clinical phenotypes and predict prognosis in anti-MDA5+ DM.

RECURRENT FUNGAL INFECTIONS FROM BIRTH TO ADULTHOOD: UNKNOWN DIAGNOSIS UNTIL GENETIC TESTING FOR STAT-1 VARIANTS

<h3>Introduction</h3> Signal transducer and activator of transcription 1 (STAT-1) is a transcription factor that plays key roles in cell viability and pathogen responses. Mutations in STAT-1 result in differing degrees of susceptibility to viral, fungal and bacterial infections, vascular alterations, failure to thrive, and autoimmunity. We report a case of STAT-1 variant presenting with a life-long history of recurrent fungal infections where the diagnosis required genetic testing. <h3>Case Description</h3> A 33-year-old man presented for an evaluation of recurrent fungal infections. He experienced oral thrush, tinea pedis, tinea corporis, and onychomycosis since infancy. He was hospitalized twice for Candida esophagitis requiring IV antifungals. He required treatments with oral antifungals every few months, as he was refractory to topical treatments. He had no bacterial or viral infections, and otherwise unremarkable past medical history. He had thorough workups through multiple specialists with no diagnosis made as his immunologic laboratory studies were normal. However, his 4-year-old son was diagnosed with chronic mucocutaneous candidiasis (CMCC) and had genetic testing showing a STAT-1 variant (c.1159A>G (p.Thr387Ala)). The patient then underwent genetic testing which revealed the same pathogenic STAT-1 variant. Further evaluation showed normal T-cell mitogen studies, total IgG/A/M/E, IgG subclass levels, and vaccine responses. Flow cytometry showed mild B-cell lymphopenia and normal T/NK cells. <h3>Discussion</h3> Patients with pathogenic STAT-1 variants can present with variable infection histories and normal immunologic testing. This case highlights the importance of genetic testing for patients presenting with CMCC regardless of normal immunologic testing to identify a specific diagnosis and defects associated with CMCC.

PROFOUND LYMPHOPENIA AND HYPOGAMMAGLOBULINEMIA ASSOCIATED WITH ROTAVIRUS VACCINATION

<h3>Introduction</h3> Rotavirus is the most common cause of severe infectious gastroenteritis in infants. The live vaccine, while effective in immunocompetent patients, has been associated with life-threatening infection in infants with Severe Combined Immunodeficiency (SCID). We present a case of lymphopenia and hypogammaglobulinemia following rotavirus vaccination in a previously immunocompetent patient. <h3>Case Description</h3> A 3-month-old, ex-full-term Latinx female, presented with worsening diarrhea beginning one-week post rotavirus vaccination. She was meeting age-appropriate milestones, had a negative newborn screen (NBS), including SCID screen, and no pertinent family history. She was admitted for un-resolving diarrhea, electrolyte abnormalities, lymphopenia and hypogammaglobulinemia. Stool rotavirus PCR was positive 8 weeks after vaccination. Total IgG and IgM were low. The presence of a thymus was confirmed on ultrasound. EGD and flexible sigmoidoscopy were grossly normal. She received palivizumab, IVIG, and bactrim and fluconazole prophylaxis. Diarrhea resolved one week after hospitalization. Repeat NBS at 4 months of age demonstrated TRECs of 28/ul. Absolute CD45RA and CD45RO were low. ADA and PNP enzyme, whole exome genome sequencing, chromosomal microarray, and plasma amino acid profile were normal. At 8 months of age, she had mild B-cell lymphopenia with decreased absolute counts and normal percentage. Her leukopenia, neutropenia, and T-cell lymphopenia resolved. <h3>Discussion</h3> The temporal relationship of vaccine administration with onset of clinical findings, the persistently positive stool rotavirus PCR, and the absence of other clear etiology suggests rotavirus vaccine as the inciting factor for this patient's presentation. This case highlights a potentially rare subset of immunocompetent patients who could contract rotavirus infection from the rotavirus vaccine.

Study on the Immunity Interventions A Deterrent Effect Against Pathogens

The year 2020 is exceptional year in human history and normal activities have almost stopped. That indicates human life will face greater consequences of Pandemics (COVID-19) in future. Few decades back man was not highly dependent on science and technology as today and has become ease oriented that pushing us toward non-healthy lifestyle. Economic challenges, social pressures, and health issues are some of things that might negatively affect our immune system. The cytokine storm was decreased by a large dosage of vitamin C, which also lowered chances of ICU admission and moderate or mild lymphopenia recovery in people who slept well by enhancing immunity mechanisms. Weak immune system is a big threat and life can be miserable if we failed to improve, revive and replenish our immune system. Healthy and active life style can increase immunity which will give us hope to fight with these types of catastrophic conditions.

The humoral response to SARS-COV-2 vaccines in MS patients: A case series exploring the impact of DMT, lymphocyte count, immunoglobulins, and vaccine type

Background & ObjectivesCertain disease modifying therapies may negatively impact the humoral response to SARS-CoV-2 vaccines. Many MS related clinical, demographic, and immunological characteristics can also affect vaccine response but those have not been fully explored. This study aimed to investigate potential correlations between clinical, demographic, and immunological variables in MS patients to post-vaccination spike protein antibody positivity rates and levels. MethodsPatients with MS and related neuroimmunological disorders who requested verification of the immune response to the SARS-COV-2 vaccine were tested for the spike protein antibody from January to October 2021. We performed an exploratory analysis to compare patients with positive versus negative spike protein antibody. ResultsFifty patients (mean age 53 ±12, 78% females) were included. There were 29 patients with positive post-vaccination spike protein antibody (58%) and 21 with negative antibody (42%). Patients with negative antibody were more likely to have been on B-cell therapy (86% vs 31%, P=.001) while positive patients were more likely to have been on a fumarate (31% vs 4.8%, P=.03). Thirty percent of positive patients on fumarate therapy had mild lymphopenia. No differences existed between groups in gender, age, race, disease phenotype, vaccine brand, and lymphocyte counts. Among patients on B-cell therapy, 33% had a positive spike protein antibody. There was an association between detectable CD19 cells at time of vaccination and positive humoral response to vaccination (P=0.049). There was no relationship between subgroups in terms of vaccine timing relative to B-cell therapy dose. Hypogammaglobulinemia was not associated with seroconversion rates, however it was associated with decreased quantitative spike protein antibody levels (p=0.045). DiscussionB-cell therapy is associated with a negative humoral response to SARS-COV-2 vaccines. Patients on B-cell depleting therapy with detectable CD19 counts at the time of vaccination were associated with a positive humoral response. There was no relationship between hypogammaglobinemia and seroconversion rate, however it was associated with decreased spike protein antibody levels. The fumarates are associated with positive humoral response even in the presence of mild lymphopenia.

Progressive multifocal leukoencephalopathy in a patient with mediastinal teratoma: a case report

BackgroundProgressive multifocal leukoencephalopathy (PML) is a rare demyelinating lytic brain infection caused by the John Cunningham virus (JCV). JCV manifests primarily in patients with innate immunodeficiency or taking immunomodulatory medications. In this case study, we report a PML patient with comorbid mediastinal teratoma and mild lymphopenia.Case presentationA 73-year-old female presented with a 3-month history of progressive hemiplegia, hemianopsia, and cognitive impairment. She was diagnosed as PML by cerebrospinal fluid metagenomics sequencing and brain biopsy. Extensive immunological tests did not reveal an apparent immunodeficiency, but further work-up revealed that the PML was most likely the first presentation of mediastinal teratoma and the mild lymphopenia. Mirtazapine and immunoglobulin were started, the patient’s condition was relatively stable and approved to be discharged from hospital. But unfortunately, she died of the lung infection 10 months after first presentation.ConclusionsThis case confirms that mediastinal teratoma may induce the lymphopenia and trigger PML, delayed or incorrect diagnosis may worsen the course of the disease and result in poor prognosis.

Nasal Transmissible Venereal Tumor (TVT) with Bone Metastasis in a Dog

Background: Transmissible venereal tumor (TVT) is a highly contagious round cell neoplasm that affects dogs, and it is usually transmitted through coitus. The tumor is mainly located in the genital area; however, the neoplasm can also be extragenital, affecting the nose, mouth, and eyes, as well as the skin and superficial lymph nodes. Cytological examination is the most commonly used method for definitive diagnosis due to its low cost and fast execution. Chemotherapy, radiotherapy, surgical resection, and other procedures such as cryosurgery are the possible treatment options. The objective of this report was to describe a case of extragenital TVT with nasal primary site and metastasis in the bone tissue in a dog treated at a private veterinary hospital in the city of Belém, Pará, Brazil.Case: A 6-year-old male domiciliary Labrador Retriever dog, weighing 24.2 kg, received oncologic treatment in a private veterinary hospital in the city of Belém, Pará, Brazil. The animal had a history of neoplastic disease, and he had undergone TVT resection associated with chemotherapy treatment more than 3 years ago. The clinical examination revealed a volume increase in the periorbital region, left lateral ocular displacement, left nostril excessive epistaxis, recurrent sneezing, cough, and pain signs, and tumor metastasis was suspected. Complementary exams of oncological cytology, computed tomography (CT), hemogram, and serum biochemistry were requested for diagnosis and staging of the condition, and supportive therapy was prescribed. The cytological report showed a dense population of neoplastic round cells with characteristics of TVT. CT indicated the presence of a heterogeneous hypodense mass with irregular contours and partially defined limits, with slight uptake of the intravenously injected contrast medium that obliterated the nasal cavity, maxillary recess, nasopharyngeal meatus, frontal sinus, and sphenoid sinus on the left side. The hematological analysis revealed mild anemia, neutrophilia, and lymphopenia, while the biochemical analysis only showed hypocalcemia. The prescribed therapy was amoxicillin + potassium clavulanate, omega-3, firocoxib, tranexamic acid, and finally chemotherapy with lomustine. Since the patient did not return for follow-up, the outcome could not be determined.Discussion: The patient described in this report was a domiciliary dog who did not live with other pets, but had access to the community environment and contact with other animals. The animal’s history, clinical signs, and cytological and imaging findings were consistent with those of TVT. In extragenital presentations of TVT, the inguinal and sublumbar lymph nodes, lungs, and abdominal organs are most commonly affected. Furthermore, bone involvement is rare, as this has not been commonly described in the literature as compared to the other sites of metastases. An abrasive brush was used for the cytological sample collection, because it provides slides with richer cells as compared to the imprint samples. CT is an important tool for the diagnosis of neoformations in the skeleton, and this method demonstrated high efficiency in identifying the bone involvement and the degree of the invasion and lesion in this case. The therapeutic agents used in this case were different from the usual, since the patient was given lomustine (40 mg/capsule, orally) in the metronomic chemotherapy. This drug has been previously used as an alternative in a canine TVT case resistant to vincristine.Keywords: neoplasm, extragenital, computed tomography, TVT.Título: Tumor Venéreo Transmissível (TVT) nasal com metástase óssea em um cãoDescritores: neoplasia, extragenital, tomografia computadorizada, TVT.

Study of Laboratory Parameters in COVID-19 Patients at a Tertiary Care Teaching Hospital in Uttar Pradesh

Introduction: COVID-19 infection has been affecting vast population all over the world since 2019. It is very important to make optimum use of routine laboratory parameters in evaluating severity of COVID-19 disease. This will help the clinicians to improve allocation of technical human resources to patients who require it the most. During the path of the COVID-19 disease, inflammatory indices such as lactate dehydrogenase (LDH), C-reactive protein (CRP), interleukin-6 (IL-6), biomarkers like serum procalcitonin (PCT), and ferritin and indices of coagulation profile like D-Dimer, PT levels, and hematological parameters like total leukocyte count, platelets carry prognostic value. The objective of the study is to estimate the utility of various laboratory Biochemical and Hematological parameters in COVID-19 disease. Materials and Methods: The present study is a retrospective cross-sectional observational study conducted in tertiary care rural teaching hospital. The study was conducted from September 1, 2020, to January 31, 2021. The study was carried out on the patients who were hospitalized in Isolation Ward and COVID ICU in our L3 COVID hospital. All patients with positive SARS-CoV-2 nucleic acid test results were included in the study. A sample size of 310 patients was taken. The basic demographic details were collected from the admission records. The confirmatory test for SARS-CoV-2 was done using the WHO-approved kits based on real-time reverse transcription polymerase chain reaction for which suspected cases underwent nasopharyngeal/oropharyngeal swab testing. The levels of CRP, IL-6, PCT, ferritin LDH, D-dimer, complete blood counts, PT were based on standardized methods obtained using various biochemical and hematological laboratory analyzers. Data of investigation reports were gathered from electronic patient record system. Statistical analysis was performed using the Statistical Package for the Social Sciences for Windows (version 25.0). Results: Our study clearly shows that levels of IL-6, D Dimer, PT, and LDH are quite significantly raised in majority of patients while PCT and ferritin being somewhat nonspecific show an increase but not to that significant numbers. The hematological parameters show levels which indicate mild anemia, leukocytosis, neutrophilia, lymphopenia, and thrombocytopenia in patients infected with COVID-19 disease. Conclusion: COVID-19 is an unexplored, new entity with a sudden worldwide onset. The medical fraternity is yet to conquer and analyse this novel virus.

Child Neurology: Recurrent Brainstem Strokes and Aphthous Ulcers in a Child With Mutations in the ADA2 Gene.

An 18-year-old woman with a history of episodic diplopia, oral ulcers, joint pain, rash, and fatigue presented to the emergency department with acute onset of diplopia. At 9 years of age, she had an episode of diplopia, with MRI of the brain showing a small T2-hyperintense, nonenhancing area of restricted diffusion in the right midbrain (Figure, A). An extensive laboratory workup, including hypercoagulability screening, rheumatologic evaluation, infectious studies, and CSF analysis, was notable for mild lymphopenia, neutropenia, and von Willebrand Factor antigen at the upper limit of normal. Echocardiogram did not show structural deficits. She subsequently presented at 11 years of age with a second episode of diplopia. Laboratory results were again notable for lymphopenia and neutropenia. Brain MRI revealed a new left paramedian pontine area of restricted diffusion (Figure, B). Diplopia self-resolved over the course of 1 to 2 months with each event.

Mucocutaneous nasal histoplasmosis in an immunocompetent dog

BackgroundHistoplasma (H.) capsulatum is a dimorphic fungus, and infection is typically via inhalation of microconidia. After conversion to the yeast phase within the lung, the organism is subsequently disseminated to other tissues by macrophages. Nasal histoplasmosis appears to be a rare condition in dogs.Case presentationWe report the clinical case of a 4.5-year-old male neutered Cocker spaniel/Poodle mix, 7.7 kg, body condition score 6/9, that presented with a 3-month history of sneezing and left-sided mucoid nasal discharge. The history also included a mild swelling (transient) of the right carpus with a lameness (grade II-III/IV), coinciding with the onset of sneezing and nasal discharge. The dog lived primarily indoors in the Texas Gulf Coast area. On physical examination, the dog was febrile, and the left nostril was swollen, ulcerative, deformed, and hypopigmented. Mandibular lymph nodes were firm and mildly enlarged bilaterally. Mild lymphopenia, thrombocytopenia, and hyperglobulinemia were noted. Thoracic radiographs were unremarkable. Computed tomography and rhinoscopy revealed swelling of the rostral portion of the left and right nasal passages. Cytology and histology of biopsies of the affected nasal tissue showed pyogranulomatous inflammation and yeast organisms consistent with H. capsulatum. Weak antigenuria was detected on the MVista H. capsulatum antigen test. Treatment with oral itraconazole led to a resolution of the nasal signs and normalization of the appearance of the nostril over 13 weeks, and neither antigenuria nor antigenemia was detected on several recheck examinations. The dog remained in good general and physical condition and showed no signs of disease recurrence more than 6 years after the last examination.ConclusionWe report a rare case of nasal mucocutaneous histoplasmosis in an immunocompetent dog, with an excellent clinical response to oral itraconazole. This case documents that histoplasmosis in dogs can affect primarily the nasal cavity, which responds rapidly to triazole antifungal therapy and has a good prognosis. A similar case has only been reported in human medicine in a young adult.

A Rare Cause of Severe Hypoglycaemia

A 67-year old woman presented with an unwitnessed fall and decreased oral intake. She had a learning disability, hypertension, epilepsy, asthma, chronic iron deficiency anaemia, mild lymphopenia, osteoporosis and treated uterine cancer. After clinical review, she was treated for Hospital-acquired pneumonia (following a recent hospital admission) with possible aspiration. She was noted to have hyponatraemia secondary to dehydration. She was commenced on intravenous Levofloxacin and Metronidazole along with supportive care, based on antibiotic guidance due to her known allergy to penicillin.On day 3 of admission, she was found unresponsive with a capillary blood glucose of 0.6 mmol/L, which improved with 10% glucose infusion. The low blood glucose was attributed to poor oral intake. However, her serial blood sugar results demonstrated persistent hypoglycaemia for 72h needing further intravenous glucose infusions. A medication review was undertaken and Levofloxacin was discontinued. After 24hrs of discontinuation, the hypoglycaemic episode resolved. A short synacthen test showed a normal cortisol response. There were no further episodes of hypoglycaemia. Conclusion As her persistent hypoglycaemia resolved on discontinuation of Levofloxacin, a diagnosis of fluoroquinolone induced hypoglycaemia was reported to MHRA. Fluoroquinolones are thought to induce hypoglycaemia by increasing the insulin release via blockade of adenosine triphosphate-sensitive K+channels in the β cells of the pancreas. This effect may not be clinically evident in all patients because of physiologic mechanisms that regulate blood glucose levels. Health professionals should be aware of the potential risk of severe hypoglycaemia with the use of Fluoroquinolones which are a first or second-line treatment for common infective processes. Fluoroquinolones should be stopped immediately and switch to a non-Fluoroquinolones antibiotic if possible. In elderly patients with compromised oral intake or in those with other comorbidities, regular blood glucose monitoring should be carried out to avoid life-threatening hypoglycaemic episodes.

ROLE OF HEMATOLOGICAL PARAMETERS IN COVID-19 PATIENT IN INDEX MEDICAL COLLEGE, INDORE

AIM: Study to evulate the pattern of the hematolofical parameters of covid-19 patients along with their clinical course in the Indian scenario.&#x0D; Material&amp; method: A prospective study of 100 patients with laboratory-confirmed covid-19 admitted to index medical college indore from April to june were enrolled for the study. Patients were divided into asymptomatic (mild) patients, and symptomatic (moderate).&#x0D; The demographic date, the clinical status of the patients during admission, and follow up and hematological finding were recorded. The semples for complete blood count and peripheral smears for microscopy examination were collected on the day of admission .the sample were tested for complete blood count on 5-part hematology analyzer, and values were recorded. peripheral smears were stained by gimsa stains, and findings were noted.&#x0D; Results: All the paediatric cases under study were stable and asymptomatic, with only supportive treatment. Adults patients included in the study were given supportive treatment, and only one case showed clinical deteriotion over a period of 90 day of admission.&#x0D; Conclusion: The study of 100 covid-19 cases of Indian population shows that majority of the patients are younger, have asymptomatic to mild clinical presentation, and a higher incidence in the female population. The majority of pediatric cases have mild symptomology with a stable clinical corse. Baseline CBC finding of all the cases show. mild neutrophilia, mild lymphopenia, eosinophilia, mild monocytosis, and a normal to mild thromobocytopenia. a significance statistical trend of increase in CBC PARAMETER, NLR, was noted in follow up cases with persistent symptoms, however, a larger follow up cohort is needed to arrive at a statistical significances.&#x0D; Keywords: hematological, covid-19 &amp; neutrophilia.