Negative Serological Tests Research Articles

Analyzing clinical characteristics of patients with myasthenia gravis through repetitive nerve stimulation testing

AbstractBackgroundThe diagnosis of Myasthenia gravis (MG) is confirmed by clinical features with the presence of MG‐specific antibodies or the effect of intravenous edrophonium (Tensilon) administration. Diagnosis of MG is difficult in cases with negative serologic and Tensilon testing. Electrophysiological tests can support the diagnosis in such cases. Repetitive nerve stimulation testing (RNST) is one such electrophysiological test, and it is usually performed on several muscles.AimThe probability of RNST‐positivity varies between muscles, so we aimed to elucidate the relationship between muscle‐specific RNST‐positivity and patients’ clinical characteristics.MethodsWe included 46 patients and examined RNST results for the abductor digiti minimi (ADM), trapezius, and frontalis muscles. We classified muscles as RNST‐positive or RNST‐negative and compared RNST‐positive and RNST‐negative muscles for various clinical characteristics.ResultsWe observed RNST‐positivity in 11 out of 40 (27.5%) ADM muscles, 20 out of 35 (57.1%) trapezius muscles, and 14 out of 29 (48.3%) frontalis muscles. The trapezius muscle's RNST‐positivity rate was the highest in the 21 patients who underwent RNST for all 3 muscles and was significantly higher than the ADM's RNST‐positivity rate. RNST‐positivity in any muscle was significantly associated with higher serum antiacetylcholine receptor antibody (AChR‐Ab) titers. Frontalis muscle RNST‐positivity was significantly associated with higher Quantitative Myasthenia Gravis scores.ConclusionWhen diagnosing MG, physicians should recognize that the trapezius has the highest RNST‐positivity rate and that patients with low AChR‐Ab titers may exhibit negative RNST results. Furthermore, patients with frontalis muscle RNST‐positivity may present severe symptoms.

Comparison of multiplex real-time polymerase chain reaction with serological tests and culture for diagnosing human brucellosis

ObjectiveBrucellosis is a zoonotic disease with various clinical presentations and early diagnosis is crucial to avoid severe complications. Due to limitations of conventional diagnostic methods, polymerase chain reaction (PCR) based approaches have gained importance in diagnosis.We aimed to evaluate diagnostic value of multiplex real time-PCR (mRT-PCR) in serum samples collected from brucellosis suspected patients by comparision sensitivity of mRT-PCR with those of conventional diagnostic methods. Material and MethodsA total of 249 serum samples collected from the suspected brucellosis patients admitted to the hospitals in three different provinces were analyzed by serological tests, culture and mRT-PCR. In laboratories of the participating hospital, serum samples were tested for the Brucella specific antibody by commercial serological kits including standart tube agglutination test (STAT), Coombs’ test, and immunocapture test (ICT). Blood culture was performed for 153 of the patients in the participating hospital. All serum samples were analyzed for the presence of Brucella DNA by mRT-PCR. ResultsAccording to laboratory test results, 215 of the 249 suspected cases having comparible clinical data were identified as brucellosis cases. Of the 215 brucellosis cases, 36 were diagnosed as definitive cases, the remaning 179 patients were presumptive cases. Sensitivity of mRT-PCR in the samples that were positive by ICT, STAT, Coombs’ test, and blood culture was 70.2%, 77.3%, 83%, and 97.2%, respectively. By using mRT-PCR, additional 17 suspected patients were diagnosed as presumptive cases. Among the mRT-PCR positive serum samples, Brucella abortus was detected in 3 samples (1.9%), the remaining 156 samples (98.1%) had B. melitensis DNA. ConclusionOur results indicate that mRT-PCR can be considered a useful diagnostic tool in patients who have negative serologic test results, and in detection of Brucella species.

Positive Antinucleolar Antibodies on Direct Immunofluorescence of Lesional Skin of a Patient With Limited Systemic Sclerosis

To the Editor: Limited systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs. Circulant anticentromere antibody is usually positive.1 Antinucleolar antibodies are positive less frequently (15%–40%),2 having prognostic significance on the overall course of the patients. We present a case of limited SSc with negative serologic test for extractable nuclear antigens in which direct immunofluorescence revealed positive antinuclear antibodies (ANA) with nucleolar pattern. A 54-year-old man was referred to the dermatology department because of a 5-year history of multiple asymptomatic telangiectasias on the face and neckline. Clinical examination revealed the presence of sclerodactyly and multiple scars of ulcers in the fingertips that appeared when the patient worked in a frigorific chamber. Capillaroscopy showed predominance of areas of angiogenesis and some small avascular areas. The patient complained about mild interphalangeal arthralgias without inflammatory changes. Unspecific gastrointestinal symptoms and dyspnea were also present. High-resolution chest computed tomography showed mild pulmonary fibrosis predominantly in peripheral areas and bases of the lungs. Echocardiography confirmed the clinical suspicion of pulmonary hypertension, and bosentan therapy was initiated. Circulant ANA resulted positive at 1:1280 dilution. The determinations of extractable nuclear antigens, antibodies against parietal cells, against smooth muscle, and against double-stranded DNA were all negative. A skin biopsy of the neckline area with telangiectasia revealed lymphocytic perifolliculitis, with no other alterations. Direct immunofluorescence study (DIF) performed on lesional skin showed the presence of IgG ANA with a nucleolar pattern (Fig. 1).FIGURE 1.: Direct immunofluorescence on a skin biopsy from an area with telangiectasia in the patient's neckline. IgG resulted positive with a nucleolar pattern (×100).Circulating autoantibodies are found in as many as 95% of patients with SSc and carry greater weight in the newly proposed ACR/EULAR classification system. Centromere (CEN) proteins (P), topoisomerase I, and RNA polymerase III autoantibodies closely reflect patterns of organ involvement and disease progression.3 Circulating anti-Th/To type antinucleolar antibodies are detectable mainly by immunoprecipitation, which is not performed routinely in most clinical laboratories. Its positivity is related to limited skin involvement and frequent fibrosis of internal organs (interstitial lung disease, pericarditis, and renal involvement). Frequency of negative circulating antibodies with positive DIF findings is largely unknown because the last is not routinely performed. In the study by Kulthanan et al,4 a subgroup of patients with SSc presented positive DIF findings in 77% of the cases with the dermoepidermal junction and epidermal nuclei as the most common site, and of these patients, 45% presented negative serum ANA. Shibeshi et al5 reported a DIF positivity rate of 25,7% in 63 patients with SSc, with only one case with no circulating autoantibodies at all, and another with positive serum ANA but no characteristic antibodies of SSc. Antinucleolar pattern has been rarely reported in DIF of patients with SSc. Only 6 cases were found in the literature, all of them with high ANA titles. As these cases date from the 1980s, only circulating anti-ribonucleoprotein was performed, resulting positive in one of the patients.6,7 Our patient had ANA in peripheral blood, but more specific antibodies were not detected (antinucleolar, Scl70, or anticentromere). However, a skin biopsy with DIF was allowed to demonstrate the fixation of antibodies with a nucleolar pattern. Nucleolar pattern ANA in DIF of a skin biopsy is an unusual finding. We believe this technique can help to confirm clinical diagnosis and assess prognosis on individual patients.

Abnormal Liver Enzymes Due to H. pylori Infection

Case: We present a case of a 53 year-old female with no past medical history, who presented to gastroenterology clinic for abdominal pain. She was seen in the emergency department on several occasions for abdominal pain, nausea and vomiting. Her labs were notable for abnormal liver enzymes (AST 103, ALT 164, normal alkaline phosphatase and bilirubin). A CT abdomen showed a calcified granuloma within the right hepatic lobe and a distended gallbladder with no definite gallbladder wall thickening. An ultrasound abdomen did not show evidence of cholelithiasis. She continued to have persistent abdominal pain as well as AST and ALT elevations with workup revealing negative serologic testing for HAV, HBV, HCV, autoimmune liver disease, alpha-1 antitrypsin, iron overload and Wilson's disease. A liver biopsy was then done and showed mild chronic portal and lobular inflammation. She also underwent an upper endoscopy with biopsies returning positive for Helicobacter pylori (H. pylori) and pathology showing chronic H. pylori-related gastritis. She received a 2-week course of standard therapy with symptom resolution. Her liver enzymes were evaluated at 8 and 12 weeks following treatment and showed normalization of her AST and ALT levels. Discussion: H. pylori is a gram negative bacterium that has the ability to adhere to the gastric epithelium. It is the most common chronic bacterial infection in humans and is thought to infect approximately 50 percent of the world's population, with higher rates seen in developing countries. The transmission route for H. pylori remains unknown but is thought to occur through the fecal-oral route. H. pylori is typically diagnosed using a urea breath test or stool antigen. Treatment involves the use of a combination of antibiotics and a proton pump inhibitor. Reinfection with H. pylori is uncommon and occurs at an annual rate of 2 percent. Complications of H. pylori infection include gastritis, gastric ulcers, duodenal ulcers and gastric cancers. In a minority of patients, mild elevations in AST and ALT levels are seen, which normalize following eradication of H. pylori. There appears to be a temporal association between the infection and liver enzyme abnormalities, but a direct link is yet to be made. The underlying mechanism of liver injury is unclear but a genetic predisposition may be the differentiating factor between patients. Further studies are required to investigate such association and its clinical significance.

Normal CRP and WBC values in total hip arthroplasty (THA) with signs of loosening. Do we need a joint aspiration?

PurposeOverall Total hip arthroplasty (THA) is a very successful procedure. However, in case of complication dedicated management is required. Two major complications of THA failures are aseptic loosening (AL) and periprosthetic joint infection (PJI). The primary hypothesis of this study was that joint aspirations in patients with signs of loosening after THA are capable to detect PJI in suspected AL with negative serologic testing. MethodsIn this study a total of 108 symptomatic patients with radiographic signs of prosthetic loosening and hip pain in THA were included. Based on a standardized algorithm all patients underwent serological testing followed by joint aspiration preoperatively. Intraoperatively harvested samples were subjected to microbiological testing and served as the gold standard in differential diagnosis. Demographics, as well as the results of serologic and microbiological testing were collected from the medical records. ResultsOf the included patients 85 were finally diagnosed with an AL and 23 with PJI. Within the patients with PJI 13 (56%) patients demonstrated elevated CRP and WBC counts, as well as positive synovial cultures after joint aspiration. In ten patients (44%) diagnosed with PJI neither CRP nor WBC were abnormal. ConclusionThe diagnosis of PJI can be difficult in THA with radiographic signs of loosening. Clinical features including pain, fever, and local sings of infection are uncommon especially a long period after index operation. First-line screening testing relies on serological evaluation of CRP and WBC. However, normal CRP and WBC values cannot rule out a PJI. These cases can be detected by joint aspiration and synovial cultures reliably.

Mortality and Egg Production Patterns in the United States Prior to HP/LPAI H7N9 Detection.

In March 2017, two commercial broiler breeder operations were confirmed with H7N9 highly pathogenic avian influenza (HPAI), and an additional six commercial broiler breeder operations were found positive with an H7N9 low pathogenicity avian influenza virus (LPAIV) or an H7 LPAIV (N type not identified). To better understand conditions leading up to testing positive for AI, egg production and mortality data for the 6 mo before the outbreak were obtained from five case farms (two HPAIV-infected farms and three LPAIV-infected farms) and two control farms. Both HPAI farms experienced a sudden spike in mortality immediately before testing positive. Two LPAI farms experienced drops in egg production along with slight increases in mortality that occurred after a negative serologic test and before a positive PCR test. The third LPAI farm also had a notable drop in egg production with a coinciding increase in mortality before testing positive for AIV (last negative test date not available). Additionally, both HPAI farms and two LPAI farms reported mild respiratory illnesses in the weeks prior to testing positive for AI. Control farms did not experience similar drops in production or increase in mortality. Clinical signs on LPAI farms were mild and easily confused with background health patterns, suggesting the need for improved sensitivity to identify LPAI quickly. Applying a trigger of a 2% drop in egg production along with a mortality of 8 per 10 000 hens in individual barns showed that all case farms would be identified and uninfected farms would be falsely triggered on 1% of days monitored.

The Utility of Screening for Coccidioidomycosis in Recipients of Inhibitors of Tumor Necrosis Factor α.

Tumor necrosis factor α inhibitors (TNFi) are commonly used to treat immune-mediated disorders, but they are associated with an increased risk of mycobacterial and fungal infections. We compared the outcomes of TNFi recipients screened for asymptomatic coccidioidomycosis with those of unscreened patients to compare the development of symptomatic coccidioidomycosis and to describe its outcomes for patients with abnormal coccidioidal screenings. We searched electronic health records from 4 September 2010 through 26 September 2016 for all patients receiving a TNFi for dermatologic, rheumatologic, or gastroenterologic diagnoses, then categorized patients by whether or not they had undergone coccidioidal serologic testing for screening or diagnostic purposes. A total of 2793 patients had a TNFi prescribed. Of those, 1951 met the inclusion criteria: 1025/1951 (52.5%) never had coccidioidal screening; 925/1951 (47.4%) had serologic screening either before beginning TNFi therapy or annually, or both after beginning a TNFi. Symptomatic coccidioidomycosis developed in 35/1025 (3.4%) unscreened patients. Of those screened, 861/925 (93.1%) had negative serologic tests, of which 11/861 (1.3%) subsequently developed symptomatic coccidioidomycosis; 36/925 (3.9%) had coccidioidomycosis at screening (7, probable infection; 11, possible infection; 18, asymptomatic seropositive result); and 17 had only positive findings for immunoglobulin M antibodies and did not meet the definition for coccidioidomycosis. The unscreened cohort was more likely to have symptomatic coccidioidomycosis than the screened cohort (35/1025 vs 11/861, P < .01). Screening for asymptomatic coccidioidomycosis within a Coccidioides-endemic area allowed for identifying and managing asymptomatic coccidioidomycosis before patients began TNFi therapy. Less symptomatic infection developed in the screened than the unscreened cohort.

Operative Recognition of Syphilis of the Aorta

Aortic syphilis has not disappeared. Few patients with aortic syphilis are diagnosed pre-operatively or after histologic examination of the resected aortas. The gross features of the wall of the syphilitic aortic aneurysm, however, are unique allowing diagnosis of this entity on the operating table. Thirty patients aged 33 to 84years (mean 66) (18 women) had a syphilitic aneurysm involving the tubular portion of ascending aorta resected at Baylor University Medical Center at Dallas from 2009 through 2017. That syphilis was the cause of the aneurysm was not appreciated either preoperatively or at operation. Syphilis produces characteristic changes in the aorta: it is thicker than normal due to fibrous thickening of the intima and adventitia, the intimal surface is 100% abnormal, and the sinus portion of the aorta is uninvolved. The process begins at or just distal to the sinotubular junction. Histologic findings are specific. A negative serologic test for syphilis does not rule out the presence of syphilis of the aorta. The key to identifying at operation syphilis of the aorta is to note that its entire intimal surface is abnormal, that one or more saccular aneurysms may arise from the fusiform aneurysm, that the aneurysmal wall isthicker than normal, and that the wall of the sinus portion of the aorta is spared. Identificationof the syphilitic cause appears to be important because antibiotic therapy is recommended to prevent or retard the development of neurological syphilis, particularly in the younger patients.

Evaluation of the General Organization of Veterinary Services control program of animal brucellosis in Egypt: An outbreak investigation of brucellosis in buffalo.

Background and Aim:Brucellosis is a major constraint to livestock production in Egypt as well as many developing countries worldwide. Bovine brucellosis is an economically important disease with reproductive failure as a principal manifestation resulting in abortion, premature birth and decreased milk production in females, and orchitis and epididymitis in males. In spite of the efforts of Egyptian veterinary services to overcome brucellosis, the disease is still prevalent in both animals and humans and represents one of the most important public health hazards in Egypt. The aim of the present work was to investigate the efficacy of the control program implemented by the General Organization of Veterinary Services in Brucella infected buffalo farm on serological, molecular, cultural, and histopathological basis. Brucella melitensis biovar 3 was recovered from 6 buffalo-cows.Materials and Methods:Blood samples were collected from a total of 750 non-vaccinated lactating buffalo-cows. These animals were proved positive for Brucella by the Egyptian brucellosis national program. Sera were tested using buffered acidified plate antigen test and rose Bengal test as screening tests and complement fixation test as a confirmatory test. Positive animals were separated for slaughtering under the supervision of the Egyptian veterinary authorities. Remaining animals were tested every 3 weeks with slaughtering of positive cases and this continued until the remaining animals revealed three successive negative serological tests. Different lymph nodes (prescapular, prefemoral, mediastinal, retropharyngeal, and supramammary) were collected from 11 Brucella seropositive buffalo-cows slaughtered after being confirmed serologically as Brucella infected cases. Samples were collected and processed for bacterial isolation and nucleic acid detection using polymerase chain reaction (PCR). Parts of these specimens were fixed in 10% neutral buffered formalin for 48 h then processed by paraffin embedding technique.Results:“Test and slaughter” policy was applied on Brucella infected dairy buffalo farm. The program continued for 6 months with slaughtering of positive cases until the herd was proved Brucella free. B. melitensis biovar 3 could be recovered from six buffalo-cows. Universal PCR confirmed Brucella on genus level and Bruce-ladder multiplex, PCR confirmed the presence of B. melitensis on the species level. Histopathological examination of Brucella-infected lymph nodes revealed massive rarified and depleted lymphoid areas of both sub-capsular and deep cortical lymphoid follicles, macrophage cells granulomatous reaction, as well as fat, infiltrates, and chronic vasculitis. The chronic nature of Brucella lesions has been confirmed in this study as indicated by the chronic vasculitis and collagen deposition.Conclusion:Freedom status from brucellosis in this study required 6 months which are considered long time allowing the spread of infection to other localities especially under unhygienic conditions, husbandry system favoring mixed populations of different ages, sex, aborted and pregnant, and lack of controlled movement of animals. Therefore, effective control of animal brucellosis requires surveillance to identify infected animal herds, elimination of the reservoirs, and vaccination of young heifers. B. melitensis biovar 3 is the cause of the Brucella outbreak in buffalo which still remains the prevalent type of Brucella in Egypt. The disease runs a chronic course allowing further spread of infection.

Rheumatologic complications in a cohort of 227 patients with common variable immunodeficiency.

Common variable immunodeficiency (CVID) is the most prevalent symptomatic type of human primary immunodeficiency diseases (PID). Clinically, CVID is characterized by increased susceptibility to infections and a wide variety of autoimmune and rheumatologic disorders. All patients with CVID registered in Iranian PID Registry (IPIDR) were enrolled in this retrospective cohort study. We investigated the frequency of rheumatologic diseases and its association with immunological and clinical phenotypes in patients with CVID. A total of 227 patients with CVID were enrolled in this study. The prevalence of rheumatologic disorders was 10.1% with a higher frequency in women than men. Most common rheumatologic manifestations were juvenile idiopathic arthritis (JIA) and adult rheumatoid arthritis (RA) followed by juvenile spondyloarthritis (JSpA) and undifferentiated inflammatory arthritis (UIA). Septic arthritis in patients with CVID with a history of RA and JIA was higher than patients without rheumatologic complication. Patients with CVID with a history of autoimmunity (both rheumatologic and non-rheumatologic autoimmunity) had lower regulatory T cells counts in comparison with patients without autoimmune disorders. There was an association between defect in specific antibody responses and negative serologic test results in patients with rheumatologic manifestations. JIA, RA, JSpA and UIA are the most frequent rheumatologic disorders in patients with CVID. Due to antibody deficiency, serologic tests may be negative in these patients. Therefore, these conditions pose significant diagnostic and therapeutic challenges for immunologists and rheumatologists in charge of the care for these patients.

Prediction of extended high viremia among newly HIV-1-infected persons in sub-Saharan Africa.

ObjectivePrompt identification of newly HIV-infected persons, particularly those who are most at risk of extended high viremia (EHV), allows important clinical and transmission prevention benefits. We sought to determine whether EHV could be predicted during early HIV infection (EHI) from clinical, demographic, and laboratory indicators in a large HIV-1 incidence study in Africa.DesignAdults acquiring HIV-1 infection were enrolled in an EHI study assessing acute retroviral syndrome (ARS) symptoms and viral dynamics.MethodsEstimated date of infection (EDI) was based on a positive plasma viral load or p24 antigen test prior to seroconversion, or the mid-point between negative and positive serological tests. EHV was defined as mean untreated viral load ≥5 log10 copies/ml 130–330 days post-EDI. We used logistic regression to develop risk score algorithms for predicting EHV based on sex, age, number of ARS symptoms, and CD4 and viral load at diagnosis.ResultsModels based on the full set of five predictors had excellent performance both in the full population (c-statistic = 0.80) and when confined to persons with each of three HIV-1 subtypes (c-statistic = 0.80–0.83 within subtypes A, C, and D). Reduced models containing only 2–4 predictors performed similarly. In a risk score algorithm based on the final full-population model, predictor scores were one for male sex and enrollment CD4<350 cells/mm3, and two for having enrollment viral load >4.9 log10 copies/ml. With a risk score cut-point of two, this algorithm was 85% sensitive (95% CI: 76%-91%) and 61% specific (55%-68%) in predicting EHV.ConclusionsSimple risk score algorithms can reliably identify persons with EHI in sub-Saharan Africa who are likely to sustain high viral loads if treatment is delayed. These algorithms may be useful for prioritizing intensified efforts around care linkage and retention, treatment initiation, adherence support, and partner services to optimize clinical and prevention outcomes.

Nivolumab induced remitting seronegative symmetrical synovitis with pitting edema in a patient with melanoma: a case report

BackgroundNovel immune checkpoint inhibitors have been often utilized for different types of malignancies as salvage therapy with varying success. One obstacle to immune checkpoint inhibitor use is the higher incidence of immune-mediated side effects that can prompt discontinuation of therapy. Remitting seronegative symmetrical synovitis with pitting edema has been described with immune checkpoint inhibitors only once previously. We report a case of a patient who developed remitting seronegative symmetrical synovitis with pitting edema related to immune checkpoint inhibitor therapy and stress that these symptoms can be managed without cessation of immune checkpoint inhibitor therapy.Case presentationWe present a 70-year-old white man who presented with 4 months of progressive inflammatory arthritis with pitting edema. He had been started on nivolumab therapy for his metastatic melanoma with excellent response prior to symptom onset. The symptoms started in his knees and subsequently involved both hands and feet. On evaluation, he was wheelchair bound and completely dependent for all activities of daily living. Evaluation revealed negative serological testing and plain film imaging. Ultrasound demonstrated diffuse flexor tenosynovitis and soft tissue swelling, and a diagnosis of remitting seronegative symmetrical synovitis with pitting edema was made. He was treated with orally administered corticosteroids (0.5 mg/kg per day) which improved his symptoms significantly and allowed him to regain prior independent functioning. His corticosteroids were tapered (0.15 mg/kg per day) but not discontinued and his nivolumab treatment was not interrupted. In follow up he continued to have stable control of his melanoma as well as his remitting seronegative symmetrical synovitis with pitting edema.ConclusionsIn conclusion we present the first case of nivolumab-induced remitting seronegative symmetrical synovitis with pitting edema that is controlled by maintenance low-dose orally administered corticosteroids allowing for continuation of nivolumab therapy. Clinicians who encounter mild-to-moderate immune checkpoint inhibitor immune-mediated adverse effects can consider maintaining immune checkpoint inhibitor therapy with concomitant low-dose corticosteroids rather than abrupt cessation of the immune checkpoint inhibitor.

Real Time Polymerase Chain Reaction for Hepatitis B Screening in Donor Corneas in the Central Eye Bank of Iran.

Purpose:The aim of this study was to report the results of the use of real-time polymerase chain reaction (PCR) for the diagnosis of hepatitis B virus (HBV) infection in cornea donors at the Central Eye Bank of Iran.Methods:Between 2014 and 2016, all cornea donors that had negative screening serologic results for hepatitis B (HB) surface antigen, HB surface antibody (Ab), hepatitis C virus Ab, human immune deficiency virus Ab, human T-cell leukemia virus Ab, and syphilis, and positive serology for HB core Ab were subjected to real-time PCR with a detection limit of 400 IU/mL to identify HBV DNA. Positive results for HBV DNA were considered occult HBV infections in these donors.Results:Over the 3-year period, 122 out of 10448 cornea donors had negative screening serologic tests outside of HB core Ab. Of which, 90 cases were subjected to real-time PCR. Occult HBV was detected in 11 cases (12.2%), resulting in the rejection of the corresponding corneas. The remaining 79 cases (87.8%) had negative results for HBV DNA and the corresponding corneas were used for transplantation.Conclusion:Implementation of PCR for the detection of occult HBV in cornea donors is necessary to not only increase the security level of cornea donation but also minimize the rejection rate of donors that have isolated HB core Ab reactivity.

Syphilitic hepatitis

A 40-year-old woman with no relevant medical history presented with jaundice with an aspartate aminotransferase (AST) concentration of 172 U/L, an alanine aminotransferase (ALT) concentration of 230 U/L, a total bilirubin concentration of 6·0 mg/dL, a direct bilirubin concentration of 3·6 mg/dL, and an alkaline phosphatase (ALP) concentration of 412 U/L. Full viral hepatitis serological tests and anti-smooth muscle antibodies were negative but anti-nuclear antibodies were positive at 1:640 with a normal IgG concentration. Magnetic resonance cholangiopancreatography showed a normal appearing liver with four prominent retroperitoneal lymph nodes. Laboratory tests on follow-up 6 weeks later showed an AST concentration of 144 U/L, an ALT concentration of 222 U/L, a total bilirubin concentration of 15·0 mg/dL, a direct bilirubin concentration of 9·1 mg/dL, and an ALP concentration of 866 U/L with a positive antimitochondrial antibody (AMA) at 1:320. Percutaneous liver biopsy showed organising microabscesses, mild mixed portal inflammation with bile duct damage, endotheliitis of portal veins, and mild lobular mixed inflammation (figure A, B). After biopsy, she developed a hyperpigmented papulosquamous rash affecting bilateral palms and forearms (figure C). Serum rapid plasma reagin titre was 1:32768 with a positive serum test for syphilis IgG and a negative HIV serological test. She was treated with a 2-week course of continuous intravenous benzylpenicillin 24 million units per day, with resolution of liver chemistries 1 month later. Although Warthin-Starry stain of her liver biopsy was negative for spirochaetes, the Centers for Diseases Control and Prevention reported positive Treponema spp immunohistochemistry confirming syphilitic hepatitis.

The advantages of serological tests of blood and tears for the diagnosis and the follow up of corneal rickettsiosis

PurposeSerological tests were rarely performed in the first intention in the diagnosis of corneal rickettsiosis in patients from an endemic area. The purpose is to elucidate the advantages of serological tests for rickettsiosis in the atypical cases of corneal infectionsMethodsCase series study included 03 patients. immunofluorescent‐antibody tests were performed to detect rickettsiosis in the blood and in the tearsResults2 patients with atypical disciform keratitis, 1 patient with panuveitis with corneal involvement. Rickettsiosis was suspected because of skin palpebral lesions in 2 patients and in chronic uveitis in the 3rd patients. Serological tests were positive in the blood and in the tears. Treatment with tetracyclin was effective in the three cases without use of corticotherapy. In the follow up, good evolution of corneal signs and negative serological tests were noted.ConclusionsRickettsiosis should be considered in the etiology of atypical cases of corneal infection and serological blood and tear testing should be performed firstly in patients from an endemic area.

Laparoscopic Treatment of Primary Hydatid Cyst of Omentum

Omental hydatid cysts usually secondarily exist after the spontaneous, traumatic, or iatrogenic perforation of primary abdominal hydatid cysts. An isolated omental hydatid cyst in the absence of other organ involvement is very rare. Here, we present a 49-year-old male with a primary omental hydatid cyst. He was living in an urban area, but he spent his childhood in rural areas and worked with livestock. The differential diagnosis was not easy because of the negative serological test. Laparoscopic exploration revealed the diagnosis of hydatid cyst and it was removed by laparoscopy without spillage of the cyst contents. After the total excision, no albendazole treatment was prescribed. Isolated omental hydatid cysts should be in the differential diagnosis of the peritoneal cysts and its laparoscopic total excision is a feasible treatment.

Seronegative brucellosis of the spine: A case of psoas abscess secondary to brucellar spondylitis.

Brucellosis is an infectious disease that affects many organ systems. Osteoarticular involvement, especially spondylitis, is the most common complication of brucellosis, but psoas abscess is very rare. Serological tests at diagnosis of the disease are very valuable and most widely used. Herein, we report a case of psoas abscess secondary to brucellar spondylitis. In this case, interestingly, the serological test results were negative, and the diagnosis could be made by abscess culture. In patients, particularly those who live in areas endemic for brucellosis, as in our case, it should be kept in mind that a negative serological test result should not exclude the diagnosis of brucellosis.

Human Brucellosis in Febrile Patients Seeking Treatment at Remote Hospitals, Northeastern Kenya, 2014-2015.

During 2014–2015, patients in northeastern Kenya were assessed for brucellosis and characteristics that might help clinicians identify brucellosis. Among 146 confirmed brucellosis patients, 29 (20%) had negative serologic tests. No clinical feature was a good indicator of infection, which was associated with animal contact and drinking raw milk.

The Prison Economy of Needles and Syringes: What Opportunities Exist for Blood Borne Virus Risk Reduction When Prices Are so High?

AimA formal Needle and Syringe Program (NSP) is not provided in Australian prisons. Injecting equipment circulates in prisons as part of an informal and illegal economy. This paper examined how this economy generates blood-borne virus (BBV) risk and risk mitigation opportunities for inmates.MethodThe HITS-p cohort recruited New South Wales inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. For this study, qualitative interviews were conducted with 30 participants enrolled in HITS-p. Participants included 10 women and were incarcerated in 12 prisons.ResultsA needle/syringe was nominated as being typically priced in the ‘inside’ prison economy at $100-$150, with a range of $50-$350. Purchase or hire of equipment was paid for in cash (including transactions that occurred outside prison) and in exchange for drugs and other commodities. A range of other resources was required to enable successful needle/syringe economies, especially relationships with visitors and other prisoners, and violence to ensure payment of debts. Strategies to mitigate BBV risk included retaining one needle/syringe for personal use while hiring out others, keeping drug use (and ownership of equipment) “quiet”, stealing used equipment from the prison health clinic, and manufacture of syringes from other items available in the prison.ConclusionsThe provision of prison NSP would disrupt the inside economies built around contraband needles/syringes, as well as minimise BBV risk. However, any model of prison NSP should be interrogated for any unanticipated markets that could be generated as a result of its regulatory practices.

Primary hepatic Epstein–Barr virus-associated CD30-positive peripheral T-cell lymphoma of cytotoxic phenotype

Primary hepatic peripheral T-cell lymphoma (PTCL) is exceedingly rare. We encountered such a case in a 58-year-old Hispanic female with a history of chronic sinusitis and hypothyroidism who presented with 4weeks of fever and weight loss. Laboratory studies showed altered liver function and mild pancytopenia. Hepatitis and HIV infection were excluded by negative serological tests. A computed tomography (CT) scan showed innumerable small low-density lesions throughout the liver without splenomegaly or lymphadenopathy. CT-guided liver core biopsy showed scattered small lymphoid aggregates located mainly in the portal tracts and periportal regions. Within the lymphoid aggregates, scattered large pleomorphic lymphoma cells were seen, admixed with smaller lymphoid cells and histiocytes. By immunohistochemistry, the lymphoma cells expressed CD2, CD3, CD8, CD30, CD43, CD45, granzyme B, TIA-1, and negative for CD4, CD5, CD7, CD56, βF1, ALK-1, and B-cell markers. In situ hybridization for Epstein–Barr virus-encoded RNA (EBER) was positive in some lymphoma cells. To our knowledge, this is the first reported case of primary hepatic Epstein–Barr virus-associated PTCL with CD30 expression.