Negative Serological Tests Research Articles

Atypical fulminant presentation of amebiasis in chronic kidney disease patient on maintenance hemodialysis

Amebiasis is a common cause of dysentery in India and can have an atypical fulminant course with negative serological tests in immunosuppressed individuals such as chronic kidney disease (CKD). We present a patient of CKD on dialysis who presented with features of dysentery with negative blood and serology workup. The diagnosis of amebic colitis was made after colonoscopy and histopathology which revealed amebic trophozoites and her symptoms abated after appropriate therapy. This case report illustrates the need for colonoscopy and histopathology for definite diagnosis of fulminant presentation of amebic colitis in an immunosuppressed individual such as CKD.

THE STRUCTURES OF CEREBROSPINAL FLUID IN DIAGNOSTICS AND TREATMENT EFFICACY ASSESSMENT IN PATIENT WITH NEUROSYPHILIS

Background: In the last years, there has been an increase in cases of latent and late neurosyphilis. Due to the wide implementation of antibiotics, there is a significant reduction in sensitivity of serological and general clinical tests used for diagnosis of this disease. The situations are not uncommon when it is not possible to exclude or confirm the invasion of Treponema pallidum into the nervous system structures. Absence of objective diagnostic criteria for neurosyphilis hints the timely administration of an adequate treatment aimed at prevention of an irreversible derangement of the nervous system and to the patient death. Aim: To search for new diagnostic symptoms of an injury to the brain structures caused by Treponema pallidum in patients with previous syphilis, based on a new technology of assessment of solid phase structures of cerebrospinal fluid. Materials and methods: One hundred and thirty one patient that had been treated for various forms of syphilis were recruited to this study. In addition to generally accepted clinical and laboratory assessments, including various serological methods, all patients underwent clinical and serological assessment of cerebrospinal fluid (CSF). According to the results of this assessment, all patients were categorized into three groups. Group 1 (n=27) consisted of patients with early asymptomatic neurosyphilis, group 2 (n=46), with late meningovascular neurosyphilis, group 3 (n=58), those without diagnosed neurosyphilis but with strong positive serum tests, negative CSF serology and negative VDRL test. An innovative method of marginal dehydration of biological fluids was used. The method is included into the Lithos-system diagnostic technology and allows for evaluation of the structures of CSF systems “lipid – water”, “lipid – protein – water” after their transition from liquid crystal phase into a solid phase. These structures called anisomorphons are seen only at polarized microscopy. The control group comprised 24 patients from in-patient department of neurology and neurosurgery with serous meningitis (n=8), as well as with purulent meningitis and meningoencephalitis (n=16) of bacterial etiology. Results: The morphological sign of a destructive process in central nervous system of neurosyphilis patients was represented by amorphous ovals that were absent in normal CSF. In group 1 patients, the amorphous ovals were found in small numbers within basic anisomorphons – dendrites. In group 2 patients, multiple separated amorphous ovals were detected as spheres, as well as basic anisomorphons – dendrites, fully filled with spheres made of amorphous ovals. Based on these characteristics, in 2 patients from group 3, early asymptomatic neurosyphilis was diagnosed, and in 5 patients, late meningovascular syphilis. At follow-up of 22 patients from group 2, positive trend towards normalization of CSF anisomorphons were seen only after 6 months of additional specific treatment. Conclusion: Assessment of CSF anisomorphon contents in patients with neurosyphilis by means of marginal dehydratation may serve as an additional diagnostic criterion of an early or late phase of neurosyphilis, help decide on the sanitation of the central nervous system and assess the treatment efficacy.

Clinical Characteristics of Connective Tissue Disease-Associated Interstitial Lung Disease in 1,044 Chinese Patients

Because the prevalence of connective tissue disease (CTD)-associated interstitial lung disease (ILD; CTD-ILD) in China is unknown, we wanted to analyze the clinical characteristics of this disease in Chinese patients. The medical records of patients who received a diagnosis of ILD and treated in Shanghai Pulmonary Hospital from January 1999 to January 2013 were reviewed. Based on the records, patients who also received a diagnosis of CTD were identified, and their records of follow-up examinations for a minimum of 12months until the end of December 2013 were reviewed. Of the 2,678 patients who received a diagnosis of ILD, 1,798 (67%) were identified as having CTD-ILD; 299 (11.2%) had idiopathic pulmonary fibrosis (IPF). Complete clinical data were available for 1,044 patients with CTD-ILD and 178 with IPF. We found that 332 of the 1,044 patients with CTD-ILD (32%) did not receive an accurate diagnosis at the initial hospital admission, 195 (18.7%) of the 1,044 patientsshowed persistent negative test results for autoantibodies, and 262 (25.1%) of the 1,044 patientshad negative autoantibodies at the initial hospital admission and then became positive at follow-up examinations. Of the 288 patients who had confirmed CTD-ILD, 41 (14%) showed pulmonary symptoms as the initial clinical manifestation (PSIM) and 247 (86%) showed extrapulmonary symptoms as the initial clinical manifestation (EPSIM). For the 756 patients who had undifferentiated CTD-ILD, the proportion of PSIM and EPSIM was 44%and 56%, respectively. For patients who presented with PSIM, 23 who had confirmed CTD-ILD (56%) and 216 who had unconfirmed CTD-ILD (65%) did not receive an accurate diagnosis at the initial visit but were ultimately diagnosed at subsequent follow-up examinations. Patients with CTD-ILD do not receive an accurate diagnosis at the initial hospital admission possibly because of negative serologic test results for autoantibodies and the absence of obvious extrapulmonary symptoms. Thus, patients with ILD should be examined for extrapulmonary symptoms and tested for autoantibodies at follow-up examinations.

What is the best histopathological classification for celiac disease? Does it matter?

What is the best histopathological classification for celiac disease? Does it matter?

Diagnostic parameters of serological ELISA for invasive amoebiasis, using antigens preserved without enzymatic inhibitors

Amoebiasis is the third cause of death due to parasites in the world. Although, numerous serodiagnostic and salivary tests have been developed, the majority of these assays lack sensitivity in endemic zones to detect acute amoebic liver abscess. The two main limiting factors to develop reliable assays are the high levels of anti-amoeba antibodies in populations living in endemic zones, and the proteolysis of amoebic extracts even treated with inhibitors. Our group reported a method to preserve amoebic antigens without using enzymatic inhibitors (IC:MC fraction) that shows stability for years. Here we describe the development of a serologic ELISA to diagnose amoebiasis made with IC: MC antigens, and its validation for clinical use in endemic areas. In our study, we included sera from 66 patients diagnosed with acute amoebic liver abscess and 33 volunteers living in an endemic area for amoebiasis. Our assay was compared with an indirect haemaglutination assay (IHA) an ELISA elaborated with antigens derived from untreated trophozoites. The ELISA made with IC: MC antigens presented more reproducibility compared to other assays. Sera from 95% ALA patients showed a positive value. The ELISA (IC: MC) detected 97% of patients with ALA compared to an 81% using IHA. The parameters of ELISA (vs. IHA) were Sensitivity 98% (81%), Specificity 96% (97%), Positive predictive value 98% (96%), Negative predictive value 96% (73%) and Accuracy 98% (87%). A negative serologic test does not rule out the diagnosis of invasive amoebiasis. The ELISA made with antigens preserved without using enzymatic inhibitors has valuable serodiagnostic value to diagnose acute amoebic liver abscess, even in populations living in endemic zones of amoebiasis carrying antibodies against amoebas. In conclusion, ELISA-IC:MC presented better diagnostic parameters than IHA although a negative serologic test does not rule out acute invasive amoebiasis.

A retrospective comparison of false negative skin test rates in penicillin allergy, using pencilloyl-poly-lysine and minor determinants or Penicillin G, followed by open challenge.

BackgroundA history of penicillin allergy in patients is common, but only 10–15 % are truly allergic. While the gold standard for diagnosing penicillin allergy is challenge, it is not recommended that this be done without first carrying out diagnostic skin testing. This is carried out with the major determinant benzylpenicilloyl (PPL) and the minor determinant mixture (MDM), consisting of penilloate, penicilloate and Penicillin G. However, since availability of the MDM is limited, Penicillin G alone has been used.MethodsA retrospective chart review was carried out on patients tested for penicillin allergy in the Clinical Immunology and Allergy Clinic at the Health Sciences Centre, Winnipeg, Canada between 2005 and 2013. A total of 521 patients charts were reviewed, of whom 240 had skin testing, ImmunoCap® for IgE to Penicillin G and V and had oral challenges with penicillin, amoxicillin or cloxacillin.Results17/240 (7.5 %) were skin test positive, 8 to PPL, 4 to MDM and 5 to Penicillin G. One was also positive on ImmunoCap® testing. Three patients had negative skin tests but weakly positive ImmunoCap®. 222 patients with negative skin tests and serological tests were challenged. Of these, 12 patients reacted to challenge. Three of the challenges were equivocal. Of the nine patients with definite positive challenges, three were tested with Penicillin G and six with MDM. Therefore the false negative rates for testing were 2.3 % with PPL and Penicillin G and 6.97 % for PPL and MDM. The difference was not significant (p = 0.0856).ConclusionsIn this group of patients with a history of penicillin allergy tested with the major determinant of benzyl penicillin and either MDM or Penicillin G, there was no difference in the rate of false negative testing, based on oral penicillin challenges. Therefore, Penicillin G can be safely used as an alternative to MDM in diagnosing penicillin allergy.

Course of Chronic Trypanosoma cruzi Infection after Treatment Based on Parasitological and Serological Tests: A Systematic Review of Follow-Up Studies.

BackgroundChagas disease is caused by the flagellate protozoan Trypanosoma cruzi (T. cruzi). It is endemic in Latin American countries outside the Caribbean. The current criterion for cure in the chronic phase of the disease is the negativization of at least two serological tests such as enzyme-linked immunosorbent assay (ELISA), indirect immunofluorescence assay (IIF) and indirect hemagglutination assay (IHA). The serological evolution of treated subjects with chronic T. cruzi infection is variable. Treatment failure is indicated by a positive parasitological and/or molecular test (persistence of parasitemia).ObjectivesTo summarize the pattern of response to treatment of parasitological, molecular and serological tests performed during the follow-up of subjects with chronic T. cruzi infection.MethodsElectronic searches in relevant databases and screening of citations of potentially eligible articles were accomplished. Organizations focusing on neglected infectious diseases were asked for help in identifying relevant studies.Included studies were randomized controlled trials (RCTs), quasi-RCTs, and cohort studies involving adults and children with chronic infection who received trypanocidal treatment (benznidazole or nifurtimox) and were followed over time. The assessment of risk of bias was performed separately for each study design. The Cochrane Collaboration’s tool and the guidelines developed by Hayden et al. were used. Two reviewers extracted all data independently. A third review author was consulted in case of discordant opinion.Additional analyses were defined in ad-hoc basis. Scatter plots for percentage of positive parasitological and molecular tests and for negative serological tests were developed by using the lowess curve technique. Heterogeneity was measured by I2.The protocol was registered in PROSPERO, an international prospective register of systematic review protocols (Registration Number CRD42012002162).ResultsOut of 2,136 citations screened, 54 studies (six RCTs and 48 cohort studies) were included. The smoothed curves for positive xenodiagnosis and positive polymerase chain reaction (PCR) were characterized by a sharp decrease at twelve month posttreatment. Afterwards, they reached 10–20% and 40% for xenodiagnosis and PCR, respectively. The smoothed curves for negative conventional serological tests increased up to 10% after 48 months of treatment. In the long-term, the rate of negativization was between 20% and 45%.The main sources of bias identified across cohort studies were the lack of control for confounding and attrition bias. In general, RCTs were judged as low risk of bias in all domains. The level of heterogeneity across included studies was moderate to high.Additional analysis were incomplete because of the limited availability of data. In this regard, the country of origin of study participants might affect the results of parasitological and molecular tests, while the level of risk of bias might affect serological outcomes. Subgroup analysis suggested that seronegativization occurs earlier in children compared to adults.ConclusionsWe acknowledge that there is a dynamic pattern of response based on parasitological, molecular and serological tests in subjects chronically infected with T. cruzi after treatment. Our findings suggest a trypanocidal effect in the long-term follow-up.Further research is needed to explore potential sources of heterogeneity and to conduct reliable subgroup analysis.

Acute Tubular Necrosis as a Complication of Collagenous Colitis

Introduction: Microscopic colitis is a subdiagnosed cause of chronic diarrhea, especially among the elderly, although it can occur in patients of any age. This case evidences the potential seriousness of the pathology, in particular, the development of acute tubular necrosis which could be prevented by an early diagnosis. Case Report: An 80-year-old man, previously healthy, with a history of watery diarrhea, anorexia occasional abdominal cramps and weight loss (9 kg), in the last 5 months. He was submitted to a colonoscopy 1 month before, which did not showed endoscopic lesions, and treated with loperamide, but without improvement. There was no history of joint pains or swelling, fever or use of non-steroidal antiinflammatory drugs. He recurred to the emergency department due to worsening diarrhea, asthenia and dizziness. On the physical exam he was pale and dehydrated. Laboratory tests showed iron deficiency anemia, acute tubular necrosis (creatinine of 12.8mg/dL, eGFR of 4ml/min (1.73m2) and hypokalemia (K+ 2.4mEq/L). Urinary tract infection and obstruction were excluded and he was admitted on an intensive care unit. Stool cultures were negative, including specific tests forbacteria or parasites. The presence of celiac disease was excluded with normal duodenal biopsies and negative serologic testing. An ileocolonoscopy was performed, revealing a mucosa with normal appearance. Biopsies of the right and left colon were taken and the histopathological exam was consistent with the diagnosis of collagenous colitis. He presented progressive improvement of the renal impairment, with fluids and correction of the hydroelectrolytic disorders, without the need of haemodialysis. The patient was treated with oral budesonide with resolution of diarrhea. Budesonide was stopped after 1 year of treatment. Eighteen months after the diagnosis, he is currently being followed in outpatient clinic, asymptomatic, but complaining of occasional constipation.

Acquiring hepatitis C in prison: the social organisation of injecting risk.

AimThe potential for transmission of hepatitis C virus (HCV) in prison settings is well established and directly associated with sharing of injecting and tattooing equipment, as well as physical violence. This study is one of the first to examine the circumstances surrounding the acquisition of HCV in the prison setting via inmates’ own accounts.MethodThis is a sub-study of a cohort of prison inmates in New South Wales, Australia. Cohort participants were inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. Cohort participants were monitored every 3 to 6 months for HCV antibodies and viraemia and via behavioural risk practices questionnaire. Participants with a documented HCV seroconversion were eligible to participate in in-depth interviews with a research nurse known to them.ResultsParticipants included six inmates (four men, two women) with documented within-prison HCV seroconversion. Participants reported few changes to their injecting practices or circumstances that they attributed to HCV acquisition. Participants believed that they were sharing syringes with others who were HCV negative and trusted that others would have declared their HCV status if positive. Some participants described cleaning equipment with water, but not with disinfectant. In a departure from usual routine, one participant suggested that he may have acquired HCV as a result of using a syringe pre-loaded with drugs that was given to him in return for lending a syringe to another inmate. Participants described regret at acquiring HCV and noted a number of pre- and post-release plans that this diagnosis impacted upon.ConclusionsAcquiring hepatitis C was not a neutral experience of participants but generated significant emotional reactions for some. Decisions to share injecting equipment were influenced by participants’ assumptions of the HCV status of their injecting partners. The social organisation of injecting, in trusted networks, is a challenge for HCV prevention programs and requires additional research.

Clinical features of idiopathic inflammatory polymyopathy in the Hungarian Vizsla.

BackgroundA retrospective study of the clinicopathological features of presumed and confirmed cases of idiopathic inflammatory polymyopathy in the Hungarian Vizsla dog and guidelines for breeding.Results369 medical records were reviewed (1992–2013) and 77 Hungarian Vizslas were identified with a case history consistent with idiopathic inflammatory polymyopathy. Inclusion criteria were: group 1 (confirmed diagnosis); histopathology and clinical findings compatible with an inflammatory polymyopathy and group 2 (probable diagnosis); clinical findings compatible with a polymyopathy including dysphagia, sialorrhea, temporal muscle atrophy, elevated serum creatine kinase (CK) activity, and sufficient clinical history to suggest that other neuromuscular disorders could be ruled out. Some group 2 dogs had muscle biopsy, which suggested muscle disease but did not reveal an inflammatory process. The mean age of onset was 2.4 years; male dogs were slightly overrepresented. Common presenting signs were dysphagia, sialorrhea, masticatory muscle atrophy, and regurgitation. Common muscle histopathological findings included degenerative and regenerative changes, with multifocal mononuclear cell infiltration with lymphoplasmacytic myositis of variable severity. A positive response to immunosuppressive treatment supported an immune-mediated aetiology. The mean age at death and survival time were 6.4 and 3.9 years, respectively. Recurrence of clinical signs and aspiration pneumonia were common reasons for euthanasia.ConclusionsDiagnosis of Vizsla idiopathic inflammatory polymyopathy can be challenging due to lack of specific tests, however the presence of dysphagia, regurgitation and masticatory muscle atrophy in this breed with negative serological tests for masticatory muscle myositis and myasthenia gravis, along with muscle biopsies suggesting an inflammatory process, support the diagnosis. However, there is an urgent need for a more specific diagnostic test. The average of inbreeding coefficient (CoI) of 16.3% suggests an increased expression of a Dog Leukocyte Antigen Class II haplotype, leading to an increased disease risk. The prognosis remains guarded, as treatment can only manage the disease. Recurrence of clinical signs and perceived poor quality of life are the most common reasons for humane euthanasia.Electronic supplementary materialThe online version of this article (doi:10.1186/s12917-015-0408-7) contains supplementary material, which is available to authorized users.

Peripheral Thrombosis and Necrosis after Minimally Invasive Redo Mitral Valve Replacement due to Unknown Etiology: Difficult Diagnosis of Heparin Induced Thrombocytopenia.

We report on a 75-year-old male with acute onset of peripheral thrombosis causing necrosis of the fingers, elbow, and toes associated with thrombocytopenia after minimally invasive redo mitral valve replacement. Both warfarin and dalteparin were commenced on postoperative day 1 and his INR reached 2.1 on postoperative day 4. On postoperative day 5, the patient developed peripheral thrombosis which progressed to necrosis on postoperative day 6. Platelet counts decreased significantly on the same day. His clinical features were compatible with heparin induced thrombocytopenia (HIT). However, serology testing was negative and the diagnosis was never confirmed. The patient was treated for HIT and platelet count improved eventually. Although no clear consensus exists, we believe this case illustrates why therapy for HIT should be initiated when clinical features strongly suggest HIT despite a negative serology test, unless an alternate diagnosis can be found.

T-Cell/Histiocyte-Rich Large B-Cell Lymphoma Masquerading as Autoimmune Hepatitis with Clinical Features of Hemophagocytic Lymphohistiocytosis

We report the case of a 20-year-old male who presented with acute hepatitis resembling autoimmune hepatitis, but subsequently found to be T-Cell Rich/Histiocyte Rich Large B-Cell Lymphoma. Our patient was mistakenly diagnosed with autoimmune hepatitis based on liver histology demonstrating a pronounced lobular and portal infiltrate comprised predominately of polyclonal T cells, in the setting of negative serologic testing. This conclusion was reinforced by a compelling biochemical response to standard immunosuppressive therapy. The correct diagnosis of T/HRBCL subsequently was established by bone marrow biopsy (and confirmed by lymph node biopsy) when the patient presented with clinical features of HLH. In conclusion, our case elucidates a unique clinical spectrum of T/HRBCL. This patient initially presented with acute hepatitis, before mistakenly being diagnosed with autoimmune hepatitis and finally exhibited clinical features of HLH, which led to the diagnosis of T/HRBCL. It is critical to consider lymphoma in the differential for acute hepatopathy and clinical features of HLH.

Nonspecific interstitial pneumonia: clinical associations and outcomes.

BackgroundStudies have shown that nonspecific interstitial pneumonitis (NSIP), even when initially diagnosed as an idiopathic form of the disease, might be associated with an autoimmune background that later reveals itself as an organ-specific or a systemic autoimmune disease.MethodsNSIP patients were divided into three groups. The NSIP patients who met the criteria for having a systemic autoimmune disease (SAD) were defined as the systemic autoimmune disease-associated NSIP (SAD-NSIP) group. The NSIP patients who did not meet the criteria for a systemic autoimmune disease were defined as an antibody-positive group (i-NSIP-Ab + group) if their sera were positive for autoantibodies. The NSIP patients with negative serologic tests for auto-antibodies were defined as the antibody-negative group (i-NSIP-Ab- group). The clinical characteristics were analyzed and compared among the three groups.ResultsNinety-seven NSIP patients were included. The mean age of the study population was 48 ± 11 years. The mean follow-up time was 54 ± 34 months. At the time of the surgical lung biopsies, 23/97 (23.7%) of the patients were classified as SAD-NSIP; 30/97 (30.9%) were in the i-NSIP-Ab + group; and 44/97 (45.4%) were in the i-NSIP-Ab- group. At the end of the follow-up period, three cases were diagnosed with polymyositis (one case from the i-NSIP-Ab + group, two cases from the i-NSIP-Ab- group), one with scleroderma (from the i-NSIP-Ab + group, scl-70 positive and skin biopsy) and another one with microscopic polyarteritis (from the i-NSIP-AB-group, p-ANCA and MPO positive, renal biopsy). Three cases in the i-NSIP-Ab- group were later found to be positive for autoantibodies. Due to these changes in classification, at the end of the follow-up period, the SAD-NSIP group consisted of 28/97 patients (28.9%), the i-NSIP-Ab + group of 31/97 (32.0%) and the i-NSIP-Ab- group of 38/97(39.1%). There were no significant differences in clinical manifestations, radiographic findings or pulmonary function tests among the three groups at the time of surgical lung biopsy or after reclassification after the follow-up period. SAD was an independent risk factor for the survival of the patients with NSIP after follow-up.ConclusionFollow-up is recommended because idiopathic NSIP may be the first manifestation of a systemic autoimmune disease.

Щодо діагностики нейросифілісу в інфекційному стаціонарі

Наведений клінічний випадок нейросифілісу, який був діагностований у інфекційному стаціонарі. Клінічна симптоматика пізнього нейросифілісу має неспецифічний характер, проте особливістю перебігу є відсутність гарячки та інтоксикації, білково-клітинна дисоціація в лікворі. Критерієм ефективності терапії є нормалізація показників спинномозкової рідини при негативних специфічних серологічних реакціях (мiкропреципiтацiї, iмунофлюоресценцiї). У лікуванні нейросифілісу використовують високодозову безперервну антибіотикотерапію під контролем аналізу спинномозкової рідини.

Olmesartan-Associated Sprue-Like Enteropathy

Introduction: We present a case of olmesartan-associated sprue-like enteropathy presenting with chronic diarrhea. Although this has been previously reported, it is critical to raise awareness of this rare side effect. A 67-year-old female with history of asthma, insulin-dependent diabetes, remote Clostridium difficile colitis, and hypertension presented with 1 month of severe, watery diarrhea accompanied by abdominal bloating and distention. Initial work-up was notable for mild hypokalemia with normal liver panel, lipase, and complete blood count. Infectious stool studies including fecal leukocytes, Clostridium difficile toxin PCR, rotavirus ELISA, bacterial cultures, as well as giardia and cryptosporidium antigen testing all returned negative. Fecal fat staining returned abnormal. Tissue transglutaminase IgA antibody testing was negative for celiac disease. Colonoscopy to the distal ileum was normal, finding 2 tubular adenomas, normal colonic mucosa, and biopsies negative for microscopic colitis. Her diarrhea persisted, and GI was reconsulted. A review of her medicines revealed she had been taking olmesartan for 2 years. Olmesartan-associated sprue was suspected, and EGD revealed duodenal mucosal changes consistent with sprue-like enteropathy with moderate villous blunting, mild active inflammation, and increased intraepithelial lymphocytes (IELs) by CD3 immunohistochemical staining. Improvement in diarrhea was seen after 1 week of discontinuation of olmesartan, and complete resolution was observed at 1 month. Olmesartan is 1 of several angiotensin II receptor antagonists available for the treatment of hypertension. In 2012, Rubio-Tapia et al identified 22 patients treated with olmesartan who developed clinical features of chronic diarrhea, weight loss, and sprue-like enteropathy, evidenced by villous atrophy and mucosal inflammation on intestinal biopsy. All cases demonstrated negative serologic testing for celiac disease by IgA tissue transglutaminase, and a majority had failed prior therapy with gluten-free diet. Notably, all 22 patients experienced resolution of symptoms with withdrawal of olmesartan and discontinuation of gluten-free diet. The mean duration of exposure to olmesartan was 3.1 years, suggesting a potential drug-induced cell-mediated damage rather than a type I hypersensitivy reaction. Our case report matches prior descriptions of olmesartan-associated sprue-like enteropathy. Though rare, clinicians should be aware of the association between olmesartan and sprue-like illness.

Chronic ulcerating genital herpes simplex virus infection: A diagnosis mislead by HIV infection

We report a case of chronic herpes simplex in a 27 year old lady presenting with a history of persistent verrucous ulcer in the natal cleft of nine months duration. The patient was diagnosed and treated initially as a case of Tuberculosis Verrucosa Cutis (TVC) based on the chronicity of the ulcer, negative HIV serological tests and histopathological findings. The diagnosis had to be revised as the lesion was increasing in size and the patient was not responding to treatment even after completing antituberculous treatment for six months. Repeat histopathological examination and immunohistochemistry showed DNA of herpes simplex. Based on this finding a repeat HIV serology was sent which was positive. The ulcer healed after a course of acyclovir. The case is being reported to highlight the importance of considering chronic herpes simplex infection in a case of chronic genital ulcer. In addition this case reminds us the nature of HIV infection to mislead the diagnosis by altering the natural course of the disease process.

Diagnostic Challenges in Celiac Disease

1. The most important challenge in diagnosis of celiac disease is not-performing the diagnostic tests in suspected persons. Because of multi-organ damage and multiple manifestations of disease, diagnosis of celiac disease may be delayed. It seems general physicians should be aware about uncommon presentations of disease and indications of celiac tests. 2. The second most important challenge is in patients with suspected disease but negative serologic tests. In these cases evaluating of HLA can be useful. 3. The third challenge is in cases with positive serologic tests but negative histopathological findings. There may be false positive serologic response or consumption of gluten before testing. We recommend introduction of gluten for at least 3 mo and re- endoscopy and if diagnosis is equivocal HLA-typing for DQ8 and DQ2 should be done. 4. The forth challenge is about performing endoscopy. Based on guideline from ESPGHAN if there are typical clinical manifestations of celiac disease, Anti-TTG more than ten times UPN, positive Anti-EMA and HLA DQ2, performing endoscopy may not be necessary, but many physicians don’t agree with this idea. 5. In people who are genetically predisposed to celiac disease antibody levels may be fluctuating thus endoscopy with biopsy should be done in these patients. 6. In children lower than 2years, Anti- TTG and Anti –EMA have low sensitivity. we recommend Anti-TTG and Anti-DGP in these patients. 7. Resolution of symptoms after gluten free diet is not necessarily a feature of celiac disease. This condition may be seen in patients with IBS or non-celiac gluten sensitivity.

Validation of a simple universal IELISA for the diagnosis of human brucellosis

The definitive diagnosis of brucellosis requires isolation of the agent, although negative isolation does not rule out the infection. In contrast, serological testing is more sensitive and, therefore, preferred in clinical practice. The majority of reported cases around the world were caused by Brucella melitensis, B. abortus, B. suis and B. canis. The first three species contain O-polysaccharide (OPS) on the cell surface, but B. canis contains no measurable OPS on the rough lipopolysaccharide (R-LPS). A universal indirect enzyme immunoassay for the detection of serum antibody to smooth and rough Brucella spp. in both normal (u-IELISA®) and rapid forms (R-u-IELISA®) has been developed, and, therefore, the potential use of this method was assessed in comparison to cELISA, conventional tests, IELISA and RSAT on a total of 478 sera. The 77 sera from blood donors with no clinical or epidemiological evidence of brucellosis and negative serological tests showed a specificity of 100 % for both u-IELISA® and R-u-IELISA®, with a cut-off value of %P 24 and %P 18, respectively. Sera from 49 culture-positive cases (16 B. suis, 15 B. abortus, 12 B. melitensis and 6 B. canis) yielded a sensitivity of 98 % for u-IELISA® and 95.9 % for R-u-IELISA®. In general, u-IELISA® showed good correlation with cELISA and IELISA for the detection of antibodies to smooth and rough Brucella strains, as well as for monitoring patients during treatment, but R-u-IELISA® seems to need additional optimisation. u-IELISA® is simple to perform and could be a suitable test for field laboratories and hospitals lacking skilled personnel.

Idiopathic CD4 T-Lymphocytopenia In A Patient With Disseminated Tuberculosis

A 26-year-old male patient with a negative serological testing for human immunodeficiency virus, pulmonary tuberculosis with significant T-lymphocytopenia, multifocal skeletal involvements including the vertebrae and wrist, and in addition, right gluteal and bilateral iliopsoas abscesses.

Atypical Presentation of Juvenile Rheumatoid Arthritis in a Patient with Monosomy 1p36

Monosomy 1p36 is a congenital genetic disorder characterized by moderate to severe global developmental and growth delay, hearing and vision impairment, hypotonia, seizures, and distinct facial features. We present the first published description of a patient with monosomy 1p36 with an atypical arthropathy, a feature also not currently described either standalone entity or as part of the monosomy 1p36 syndrome. The patient described is a 11-year-old male who was referred to the pediatric rheumatology clinic for morning stiffness, pain, swelling, and remarkable redness in his all proximal interphalangeal joints (PIP), right wrist and in his right hip with reduced range of motion. The patient had no family history of autoimmune diseases or inflammatory arthritis, tick bites, injuries or recent flu like illness. He resided on a farm in rural Missouri. Upon evaluation the patient was found to have inflammation and swelling in all the PIPs, right wrist as well as pain and limitations in internal rotation of right hip joint. The joints were significantly erythematous and angry looking. Further laboratory evaluations revealed the patient had normal white cell counts (WBC), normal ESR and C-reactive Protein, negative Rheumatoid Factor, was negative for HLAB27 gene and negative serologic tests for streptococcal antigens, mycoplasma and parvovirus. The Contrast MRI scan of his joints showed soft tissue swelling with no synovial enhancement or bone marrow edema. The patient was started on Meloxicam, with no response for 12 weeks. He then received triamcinolone acetonide intra articular injections in his all the PIP joints, and wrist joints with good response. Unfortunately within a month’s time his mid foot and interphalangial joints of several toes were inflamed. He was started on oral methotrexate immunosuppression to which he responded well and currently in remission on tapering doses of methotrexate. This report details a steroid-responsive atypical arthropathy found in association with monosomy 1p36. This arthropathy may be an atypical variant of juvenile rheumatoid arthritis in a patient with chromosomal anomaly, or perhaps an arthropathy associated with monosomy 1p36,an entity which is yet to be recognized. This arthropathy responded to therapy with immunosuppressant agents.