Normal White Blood Cell Count Research Articles

Arthrocentesis of suspected septic sternoclavicular arthritis: microbial yield and predictors of culture positivity.

Evaluate the microbial yield and factors predicting culture positivity for image-guided arthrocentesis of suspected septic sternoclavicular (SC) arthritis. An electronic health record search identified image-guided SC joint aspirations for suspected septic arthritis. Data was extracted by retrospective chart review including patient demographics, procedure characteristics, pre-procedure lab testing, joint culture results, final SC joint diagnoses and any effect of positive synovial cultures on subsequent antibiotic therapy. Factors associated with positive joint fluid cultures were assessed using a Chi-squared test for categorical predictors and logistic regression for continuous predictors. A total of 31 SC arthrocenteses met inclusion criteria with most (81%) performed using ultrasound guidance. Synovial fluid was successfully aspirated in 19/31 (61%) of cases, and in all other cases lavage fluid was successfully obtained. Synovial cultures were positive in 9/31 (29%) of cases. A final diagnosis of septic arthritis was assigned to 20/31 cases (65%) in which 9/20 (45%) had positive synovial cultures. There was no statistically significant association between synovial culture positivity and risk factors for septic arthritis, positive blood cultures, pre-aspiration antibiotics and whether synovial fluid or lavage fluid was cultured. Serum white blood cell count (WBC) and erythrocyte sedimentation rate (ESR) demonstrated statistically significant positive correlation with positive synovial cultures. Arthrocentesis is effective for microbial speciation in SC septic arthritis, and diagnostic yield may be increased with lavage when encountering a dry tap. Normal serum WBC and ESR values indicate an extremely low likelihood of positive synovial cultures.

TCL1-family negative T-cell prolymphocytic leukemia with rapid progression of extranodal disease despite a normal white blood cell count

Here we describe the case of a 69-year-old man who was found to have moderate thrombocytopenia and severe splenomegaly during a medical checkup at the age of 67. At the first visit, his white blood cell (WBC) count was 7,400/µl with 80% lymphocytes, and bone marrow aspiration showed 24% atypical lymphocytes. Flow cytometry of atypical lymphocytes was positive for mature T-cell markers, and T-cell clonality was revealed by T-cell receptor gene rearrangement. TCL1 was negative on immunohistochemistry. We diagnosed TCL1-family negative T-cell prolymphocytic leukemia (T-PLL) and employed watchful waiting. Thirty months after diagnosis, the patient developed urinary retention and right lower-limb paresis despite a normal WBC count, and an extradural tumor around the thoracic vertebrae and spinal cord compression were detected. The tumor was diagnosed as extranodal involvement of TCL1-family negative T-PLL, but the patient's general condition deteriorated rapidly, and no treatment was possible. T-PLL is a rare disease characterized by leukocytosis, and the WBC count generally increases with disease progression. Although blood counts are recommended for observation, it is important to keep in mind that the disease may worsen even if blood counts do not change.

Association of Overweight and Inflammatory Indicators with Breast Cancer: A Cross-Sectional Study in Chinese Women.

This cross-sectional study aimed to explore the association of overweight and inflammatory indicators with breast cancer risk in Chinese patients. Weight, height, and peripheral blood inflammatory indicators, including white blood cell count (WBC), neutrophil count (NE), lymphocyte count (LY), platelet count (PLT) and the concentration of hypersensitivity C-reactive protein (hsCRP), were collected in 383 patients with benign breast lumps (non-cancer) and 358 patients with malignant breast tumors (cancer) at the First Affiliated Hospital of Soochow University, China, from March 2018 to July 2020. Body mass index (BMI), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and systemic immune-inflammation index (SII) were determined according to the ratio equation. The correlations among overweight, inflammatory indicators, and the proportion of non-cancer or cancer cases were analyzed. BMI is associated with an increased breast cancer risk. Compared with non-cancer patients, the average WBC count, NE count, NLR, and level of hsCRP were significantly higher in cancer patients. The level of hsCRP was closely associated with the size of malignant breast tumors. We conclude that overweight and high levels of hsCRP may serve as putative risk factors for malignant breast tumors in Chinese women.

Admission Total Leukocyte Count as a Predictor of Mortality in Cardiac Intensive Care Unit Patients

BackgroundInflammation is a sequela of cardiovascular critical illness and a risk factor for mortality. ObjectivesThis study aimed to evaluate the association between white blood cell count (WBC) and mortality in a broad population of patients admitted to the cardiac intensive care unit (CICU). MethodsThis retrospective cohort study included patients admitted to the Mayo Clinic CICU between 2007 and 2018. We analyzed WBC as a continuous variable and then categorized WBC as low (<4.0 × 103/mL), normal (≥4.0 to <11.0 × 103/mL), high (≥11.0 to <22.0 × 103/mL), or very high (≥22.0 × 103/mL). The association between WBC and in-hospital mortality was evaluated using multivariable logistic regression and random forest models. ResultsWe included 11,699 patients with a median age of 69.3 years (37.6% females). Median WBC was 9.6 (IQR: 7.4-12.7). Mortality was higher in the low (10.5%), high (12.0%), and very high (33.3%) WBC groups relative to the normal WBC group (5.3%). A rising WBC was incrementally associated with higher in-hospital mortality after adjustment (AICc adjusted OR: 1.03 [95% CI: 1.02-1.04] per 1 × 103 increase in WBC). After adjustment, only the high (AICc adjusted OR: 1.37 [95% CI: 1.15-1.64]) and very high (AICc adjusted OR: 1.99 [1.47-2.71]) WBC groups remained associated with increased risk of in-hospital mortality. ConclusionsLeukocytosis is associated with an increased mortality risk in a diverse cohort of CICU patients. This readily available marker of systemic inflammation may be useful for risk stratification within the increasingly complex CICU patient population.

Initiative to reduce unnecessary routine daily testing of complete blood counts across 11 safety net hospitals.

National societies recommend against performing routine daily laboratory testing without a specific indication. Unnecessary testing can lead to patient harm, such as hospital-acquired anemia. The objective of this study was to reduce repeat complete blood counts (CBCs) after initial testing. This was a quality improvement initiative implemented across 11 safety net hospitals in New York City. A best practice advisory (BPA) was implemented that asked the user to remove a CBC if the last 2 CBCs within 72 hours had normal white blood cell and platelet counts and unchanged hemoglobin levels. The outcome measure was the rate of CBCs per 1000 patient days preintervention (January 8, 2020, to December 22, 2020) to postintervention (December 23, 2020, to December 7, 2021). The process measure was the acceptance rate of the BPA, defined as the number of times the repeat CBC order was removed through the BPA divided by the total number of times the BPA triggered. Across 11 hospitals, repeat CBC testing decreased by 12.3% (73.05 to 64.04 per 1000 patient days, P < .001). Six of the 11 hospitals exhibited statistically significant decreases, ranging from a 10% to 48.9% decrease of repeat CBCs. The overall BPA action rate was 20.0% (24,029 of 119,944 repeat CBCs). This low-effort, electronic health record-based intervention can effectively reduce unnecessary laboratory testing.

A Case Report on Cecal Volvulus: Approach to Management

Cecal volvulus is a rare cause of intestinal obstruction caused by axial twisting of the cecum that occurs in 1–1.5 % of all intestinal obstruction, with an incidence of 2.8–7.1 cases per million annually. Cecal volvulus is potentially life-threatening without prompt surgical intervention. A 57-year-old woman presented with severe abdominal pain and distention. Laboratory examinations revealed normal white blood cell count with neutrophilic predominance. Diagnosis of acute cecal volvulus was made from a “whirl sign” on abdominal computed tomography. An exploratory laparotomy confirmed the diagnosis of cecal volvulus and a segmental ileocolic resection with primary anastomosis was carried out. The patient was discharged improved and returned to her normal activities of daily living. Conclusion: The management of volvulus involves a series of stepwise decisions that must be performed rapidly. Due to the fact that this condition is relatively uncommon makes it more critical for surgeons to maintain a solidified algorithm tailored to the disease process in order to amplify chances of successful outcome. In this case, the diagnosis of acute cecal volvulus was made from a “whirl sign” on abdominal computed tomography. An exploratory laparotomy confirmed the diagnosis of cecal volvulus and a segmental ileocolic resection with primary anastomosis was carried out. The patient was discharged, improved. Key words: Cecal volvulus, ileo-colectomy, whirl sign

Nil Intervention is at Times the Best Intervention

A sudden drop of air-fluid level in the pneumonectomy space in the absence of a bronchopleural fistula and pleural infection is termed benign emptying of the pneumonectomy space (BEPS). We report a 28-year-old female patient who presented to a tertiary care referral centre, in Pondicherry, India in 2020 with multiple episodes of vomiting. Subsequent to a left-sided pneumonectomy due to tuberculosis, she was diagnosed with BEPS. Generally, patients with BEPS are clinically stable, afebrile with no fluid expectoration and have a normal white blood cell count. Bronchoscopy reveals an intact bronchial stump and pleural fluid cultures are often sterile. In terms of management, close monitoring and early detection of a bronchopleural fistula are the key points. BEPS should be a differential diagnosis in case of a drop in the air-fluid level of the post-pneumonectomy space. Awareness of this entity is crucial as it helps prevent unnecessary and morbid surgical interventions. Keywords: Pneumonectomy; Pleura; Hydropneumothorax; Case Report; India.

Mitochondria-Mediated (MAVS) Innate Immune Signaling Drives Inflammation-Induced Bone Marrow Failure

Bone marrow failure syndromes (BMFS) are life threatening diseases, characterized by impaired fitness of hematopoietic stem cells (HSC) and ineffective hematopoiesis causing the absence of one or more hematopoietic lineages in the peripheral blood. Substantial clinical data indicate that hyperactivity of inflammatory cytokines, including TNFα, IL-6, and transforming growth factor-β (TGFβ), directly contribute to BMF. Inflammatory challenges result in irreversible HSC functional decline, including decreased repopulation potential and myeloid-bias differentiation. We recently showed that the combination of inflammatory challenges, including polyinosinc:polycytidilic acid (pIC - a double stranded RNA [dsRNA]) plus high TGFβ causes chronic pancytopenia, anemia, expanded hematopoietic stem and progenitor cell pools, and enhanced bone marrow dysplasia, mimicking a myelodysplastic syndrome (MDS) that developed 3-4 months after pIC challenge (Javier et.al. Haematologica 2022). However, the mechanisms behind this association and/or causality are still ill-defined. Here, we show that mitochondrial antiviral signaling (MAVS) protein can mediate the negative effect of pIC and TGFβ on HSC functions and BMF/ MDS development. Differential gene expression analyses in HSCs suggested that pIC plus TGFβ altered expression of nuclear-encoded mitochondrial genes. Mitochondria serve as platform for the activation of MAVS and downstream innate immune signaling in response to dsRNA. We thus examined the role of mitochondria and MAVS in pIC plus TGFβ-induced BMF/MDS. We show that overexpression TGFβ and pIC together cause alterations in mitochondrial proteins and membrane potential as well as enhanced caspase1 activity, but not the necroptotic signals p-RIP1 and p-RIP3, in HSCs. pIC exposure caused an increase in MAVS expression, and a redistribution into large aggregates that localize onto mitochondria in HSCs, indicative of MAVS activation (two days after pIC exposure in vivo). The MAVS aggregates resolved into smaller and dispersed clusters by 3 months after pIC exposure in control mice. In contrast, in HSCs from TGFβ overexpressing mice, MAVS aggregates persisted 3 months after pIC exposure. To determine the impact of augmented MAVS in dsRNA+TGFβ-driven BMF, we used MAVS deficient mice crossed with TGFβ overexpressing mice. We found that absence of MAVS protein restored normal white blood cell count, including neutrophils and lymphocytes, restored normal red blood cell but not platelet counts in TGFβ overexpressing mice after pIC challenge, compared to controls. Remarkably, MAVS deficiency partially rescued the dysplastic features of bone marrow myeloid cells in TGFβ overexpressing mice after pIC challenge. MAVS-deficiency also reduced the increased caspase1 activity and lowers mitochondria membrane potential in HSCs of these mice. In serial competitive transplant studies, MAVS-deficiency conferred HSC repopulation advantage. These findings suggest that pIC+TGFβ overexpression mediated BMF/MDS phenotype depends on chronic activation of MAVS. Because MAVS aggregation depends on mitochondrial fusion, we used genetic loss of the mitochondrial fission regulator Drp1. Drp1-deficiency caused severe mitochondrial aggregation in HSCs; this was associated with sustained MAVS aggregation. In response to pIC, Drp1-deficient mice exhibited increased caspase-1 activity, increased mitochondrial membrane potential and increase in HSC numbers 6 months after pIC challenges. Drp1 loss resulted in anemia and mild pancytopenia. Interestingly, Drp1-deficient bone marrow myeloid progenitors exhibited severe dysplastic features after pIC challenged. These findings suggest that chronic mitochondrial and MAVS aggregation are sufficient to drive BMF/MDS phenotype. Finally, we investigated the levels of epigenetic markers (acetyl H3K27 and methyl H3 Lys4) in HSCs after pIC stress. H4K4me3 levels were decreased in HSCs long-term after pIC challenges [6 months], this was further decreased in Drp1-deficient HSCs. In conclusion, these findings indicate that non-genetic factors contribute to the onset of BMF/MDS. Mitochondria and MAVS protein together mediate an innate immune mechanism that drives BMF/MDS. This study opens the possibility to target mitochondria-related proteins as a therapeutic strategy to restore ineffective hematopoiesis due to chronic inflammation.

Clinical characteristics, outcomes, and risk factors of SARS-CoV-2 breakthrough infections among 572 fully vaccinated (BBIBP-CorV) hospitalized patients

BackgroundBreakthrough infections have been widely reported in vaccinated individuals. However, the clinical characteristics, outcomes, and risk factors of SARS-CoV-2 breakthrough infections among fully vaccinated (BBIBP-CorV) hospitalized patients have not yet been fully elucidated. MethodsIn the single-center cohort study conducted at Xiangya Hospital of Central South University, we enrolled the hospitalized COVID-19 patients who had received full (2 doses) vaccination with the BBIBP-CorV vaccine between December 5, 2022, and January 31, 2023. We collected and analyzed information related to clinical characteristics, laboratory results, treatments, outcomes and prognostic data. Univariate and multivariable Cox regression were performed to assess the impact of clinical characteristics and laboratory results on the composite outcome (including the initiation of endotracheal intubation, non-invasive respiratory support, intensive care unit admission, and all-cause death). ResultsA total of 572 COVID-19 hospitalized patients with fully vaccinated (BBIBP-CorV) were included. The median age of the patients was 66 years (IQR 53, 74). The most common symptoms included fever (347 [60.7 %]), dry cough (401 [70.1 %]), and expectoration (333 [58.2 %]). Among those with pre-existing chronic comorbidities, 44.2 % had hypertension and 20.5 % had diabetes. Laboratory tests revealed that the majority of patients (425/549 [77.4 %]) had normal white blood cell counts. Composite outcome occurred in 11.9 % of patients, with 96.7 % of patients discharged and 3.3 % of patients died. Multivariate Cox regression analyses suggested that the NLR >4 (adjusted HR, 5.50 [95%CI: 1.56–19.47]; P = 0.008), D-dimer >0.5 mg/ml (adjusted HR, 2.17 [95%CI: 1.03–4.59]; P = 0.042) and procalcitonin >0.1 ng/ml (adjusted HR, 3.22 [95%CI: 1.38–7.52]; P = 0.007) were independently associated with the composite outcome. ConclusionBreakthrough infection after being fully vaccinated (BBIBP-CorV) is more likely to occur in older patients and patients with pre-existing chronic comorbidities. NLR >4, D-dimer >0.5 mg/ml and procalcitonin >0.1 ng/ml were independent risk factors for composite outcome.

Association between the Clinical, Laboratory and Ultrasound Characteristics and the Etiology of Peripheral Lymphadenopathy in Children.

Peripheral lymphadenopathy affects most children at least once in a lifetime and represents a major reason for concern. Therefore, we aimed to identify the most common causes of peripheral lymphadenopathy in hospitalized children and to determine the clinical, laboratory and ultrasound characteristics that enable fast, easy and accurate etiological diagnosis. We performed a cross-sectional study including 139 children who were hospitalized because of peripheral lymphadenopathy. Ultrasound of lymph nodes was performed in 113 (81.3%) patients. Lymphadenopathy was generalized in nine (6.5%) patients. Malignant etiology was established in only three (2.2%) patients. Bacterial lymphadenitis, infectious mononucleosis (IM) and cat scratch disease (CSD) were diagnosed in 66 (47.5%), 31 (22.3%) and 29 (20.9%) patients, respectively. Bacterial lymphadenitis was significantly associated with neutrophilia (p < 0.01), and increased C-reactive protein levels (p < 0.01). IM was associated with pharyngitis (p < 0.01), leukocytosis without neutrophilia (p = 0.03) and increased blood liver enzyme levels (p < 0.01). CSD was associated with recent contact with a cat (p < 0.01), absence of a fever (p < 0.01) and normal white blood cell count (p < 0.01). Thorough history and clinical examination in combination with a few basic laboratory tests enable fast and accurate differentiation between the most common etiologies of lymphadenopathy in children to avoid unnecessary procedures and hospitalizations.

Enterovirus Central Nervous System Infection in Infancy, the Value of Routine Testing.

Human nonpolio enterovirus (EV) is a major cause of infection in neonates and infants; however, the clinical presentation and cerebrospinal fluid findings vary significantly. Infection caused by EV in patients under 1 year of age can present with a broad clinical spectrum, from fever to severe systemic and/or neurological disease. Retrospective cohort analysis of infants with EV central nervous system (CNS) infection presenting to a tertiary center between January 2017 and December 2022. We recorded patient demographics, parent-reported symptoms at presentation, and blood and cerebrospinal fluid (CSF) testing at presentation. Seventy-eight patients were included in the final study. Forty-one percent of infants with an EV CNS infection had a normal CSF white blood cell count. Clinical presentation was similar in infants with and without CSF pleocytosis. Median C-reactive protein was higher in cases of EV CNS infection without pleocytosis. EV CNS infection commonly presents without CSF pleocytosis. Testing for EV should be considered in febrile infants with no source regardless of CSF parameters.

Validation of JRS atypical pneumonia score in patients with community-acquired Chlamydia psittaci pneumonia

IntroductionThe Japanese Respiratory Society (JRS) atypical pneumonia score is a useful tool for the rapid presumptive diagnosis of atypical pneumonia. We investigated the clinical features of community-acquired pneumonia (CAP) due to Chlamydia psittaci and validated the JRS atypical pneumonia score in patients with C. psittaci CAP. MethodsThis study was conducted at 30 institutions and assessed a total of 72 sporadic cases with C. psittaci CAP, 412 cases with Mycoplasma pneumoniae CAP, and 576 cases with Streptococcus pneumoniae CAP. ResultsSixty-two of 72 patients with C. psittaci CAP had a history of avian exposure. Among the six parameters of the JRS score, matching rates of four parameters were significantly lower in the C. psittaci CAP than the M. pneumoniae CAP in the following parameters: age <60 years, no or minor comorbid illness, stubborn or paroxysmal cough, and absence of chest adventitious sounds. The sensitivity of the diagnosis of atypical pneumonia in patients with C. psittaci CAP was significantly lower than the M. pneumoniae CAP (65.3% and 87.4%, p < 0.0001). When the diagnostic sensitivity was analyzed for different ages, the diagnostic sensitivities for the C. psittaci CAP were 90.5% for non-elderly patients and 30.0% for elderly patients. ConclusionsThe JRS atypical pneumonia score is a useful tool for distinguishing between C. psittaci CAP and bacterial CAP in patients aged <60 years, but not in patients aged ≥60 years. A history of avian exposure in middle-aged patients with normal white blood cell count may be suggestive of C. psittaci pneumonia.

Paenibacillus thiaminolyticus sepsis and meningoencephalitis in a 37-day old preterm infant

Introduction: The Paenibacillus genus consists of saprophytic organisms that are commonly associated with soil, water, plants, feces, and diseased insect larvae. Human infection is rare. This disease typically occurs in immunocompromised hosts, adults with a history of intravenous drug use, and hosts with prosthetic medical devices. There are a limited number of case reports describing Paenibacillus infections in neonates. This is the second published instance of pediatric meningoencephalitis caused by Paenibacillus thiaminolyticus in a preterm infant with intrauterine drug exposure. Case Report: A 37-day-old male infant with a history of prematurity of 33 weeks completed gestation presented to the Emergency Department for acute onset poor feeding, poor color, and unresponsiveness at home. Examination revealed cyanosis, apnea, and hypotonia. Vital signs were significant for hypotension and hypothermia. Initial labs revealed a metabolic acidosis, elevated C-reactive protein, normal complete white blood cell count, and a negative viral respiratory pathogen panel. Aerobic blood culture and cerebrospinal fluid (CSF) culture were positive for P. thiaminolyticus within 24 hours. Cranial ultrasound and magnetic resonance imaging revealed changes concerning for liquefactive meningoencephalitis. The infant was admitted to the neonatal intensive care unit (NICU) and ultimately discharged home on a “do not resuscitate/do not intubate” status and later died at 11 months of age. Conclusion: Paenibacillus species are common environmental organisms but can cause devastating disease in neonates. This is the second reported case of a preterm infant with P. thiaminolyticus infection and inutero drug exposure (IUDE), supporting that prematurity and IUDE may be risk factors for severe disease.

Elevated preoperative serum interleukin-6 level is predictive for worse postoperative outcome after soft tissue sarcoma surgery

BackgroundThe pro-inflammatory cytokine interleukin-6 (IL-6) plays a role in cancer development and progression, but research into the predictive value of IL-6 on postoperative outcome in soft tissue sarcoma (STS) is scarce. The purpose of this study is to investigate the predictive value of serum IL-6 level for the achievement of assumed (post)operative outcome after STS surgery, the so-called textbook outcome. MethodsPreoperative IL-6 serum levels were collected in all patients with a STS at first presentation between February 2020 and November 2021. Textbook outcome was defined as a R0 resection, no complications, no blood transfusions, no reoperation within the postoperative period, no prolonged hospital stay, no hospital readmission within 90-days, and no mortality within 90-days. Factors associated with textbook outcome were determined by multivariable analysis. ResultsAmong 118 patients with primary, non-metastatic STS, 35.6% achieved a textbook outcome. Univariate analysis showed that smaller tumor size (p = 0.026), lower tumor grade (p = 0.006), normal hemoglobin (Hb, p = 0.044), normal white blood cell (WBC) count (p = 0.018), normal C-reactive protein (CRP) serum level (p = 0.002) and normal IL-6 serum level (p = 1.5 × 10−5) were associated with achieving textbook outcome after surgery. Multivariable analysis showed that elevated IL-6 serum level (p = 0.012) was significantly associated with not achieving a textbook outcome. ConclusionsIncreased IL-6 serum level is predictive for not achieving a textbook outcome after surgery for primary, non-metastatic STS.

PO-05-150 A CASE OF QUINIDINE RESPONSIVE PURKINJE-MEDIATED POLYMORPHIC VENTRICULAR TACHYCARDIA

Polymorphic ventricular tachycardia (PMVT) has several different etiologies including ischemic ventricular fibrillation (VF), VF in coronary artery disease without active ischemia, idiopathic VF, and Torsades De Pointes (TdP). To review a case of quinidine responsive Purkinje mediated PMVT and the importance of considering alternative formulations of quinidine. N/A A 74-year-old female with no cardiac history presented with an inferior STEMI. An echocardiogram showed LV ejection fraction of 25% with multiple regional wall motion abnormalities. Left heart catheterization revealed multivessel disease for which she underwent CABG x 2 (LIMA to LAD, SVG to PDA) with intraoperative course complicated by VT requiring lidocaine drip. Ventricular arrhythmias initially seemed responsive to lidocaine; however, 4 days after CABG the patient was noted to have increased ectopic burden on telemetry and ultimately developed PMVT that required defibrillation (Fig 1A, 1B). Repeat catheterization revealed patent stents. Telemetry and ECGs were typical for Purkinje-mediated PMVT, so the patient was started on quinidine sulfate IR 400 mg every 8 hours with successful lidocaine wean and improvement in ectopic burden, with cessation of PMVT. Unfortunately, approximately 9 days after quinidine sulfate initiation the patient was noted to have rising LFTs with a normal abdominal ultrasound, platelet count, and white blood cell count, prompting discontinuation of quinidine. Without quinidine she had recurrence of PVCs that triggered bouts of PMVT (Fig 1C). PVC ablation was considered, targeting short-coupled PVCs in the border zone of scar that could be triggers for the patient’s PMVT. However, it was felt that the patient was too tenuous for ablation. Ultimately, she was trialed on quinidine gluconate ER formulation. This was started as once daily dosing and titrated up to 12-hour dosing with suppression of PVCs/PMVT and no further LFT derangements. The patient ultimately underwent ICD implant for secondary prevention and was discharged home. Purkinje mediated PMVT can occur in patients with coronary artery disease without acute ischemia. We describe a case of quinidine mediated hepatitis that was overcome by switching formulation from quinidine sulfate IR to quinidine gluconate ER. It is essential that hospitals, particularly arrhythmia referral centers, keep quinidine supplies in stock because this medication can be lifesaving during arrhythmic storms.

The positive association between white blood cell count and metabolic syndrome is independent of insulin resistance among a Chinese population: a cross-sectional study.

The association between white blood cells (WBCs) and metabolic syndrome (MS) has been consistently reported in previous studies using regional samples. However, it remains unclear whether this relationship has urban-rural differences and is independent of insulin resistance using a large-scale representative sample. Additionally, accurate risk prediction in patients with MS is crucial for developing targeted interventions to enhance the quality of life and prognosis of patients. The aims of this study were (1) to examine the cross-sectional association between WBCs and MS among the national population and analyze the urban-rural difference and whether insulin resistance plays a moderator effect in this association and (2) to describe the performance to predict MS using machine learning (ML) models. A cross-sectional study was performed using 7,014 data from the China Health and Nutrition Survey (CHNS). WBCs were analyzed using an automatic hematology analyzer and MS was defined according to the criteria of the American Heart Association scientific statements of 2009. Variables on sociodemographic characteristics (sex, age, and residence), clinical laboratory (BMI and HOMA-IR), and lifestyle characteristics (smoking and drinking status) were used to construct ML models to predict MS [logistic regression (LR) and multilayer perceptron (MLP) neural network]. We found that 21.1% of participants (1,479/7,014) were classified as having MS. In multivariate logistic regression (including insulin resistance), the result revealed a significant positive association between WBCs and MS. The odds ratios (95% CI) for MS with increasing WBC level were 1.00 (reference), 1.65 (1.18, 2.31), and 2.18 (1.36, 3.50) (p for trend: 0.001). For two ML algorithms, two models showed adequate calibration and good discrimination, but the MLP showed better performance (AUC-ROC = 0.862 and 0.867). With the aim of confirming the association between WBCs and MS, this cross-sectional study is the first to show that maintaining normal WBC count levels is helpful to prevent the development of MS, and this association is independent of insulin resistance. The results also showed that the MPL algorithm represented a more prominent predictive performance to predict MS.

Cushing’s Syndrome Presenting as Nonconvulsive Status Epilepticus: A Case Report and Literature Review (P9-1.011)

<h3>Objective:</h3> NA <h3>Background:</h3> Cushing’s Syndrome (CS) may present with neuropsychiatric manifestations that can mimic autoimmune encephalitis, potentially delaying diagnosis and treatment. We present a case of CS presenting with personality changes and status epilepticus and performed a literature review describing neurological manifestations of CS. <h3>Design/Methods:</h3> A male in his 50s presented with episodic word-finding difficulties, inappropriate smiling, fatigue, cognitive decline and one episode of generalized tonic clonic seizure on levetiracetam from an outside hospital. Workup revealed thrombocytopenia, hypokalemia, hypertension, normal MRI brain and sella. Continuous electroencephalogram revealed nonconvulsive status epilepticus. Lumbar puncture demonstrated elevated protein with normal white blood cell count. He was started on high-dose IV methylprednisolone followed by IVIg for presumed autoimmune encephalitis. Autoimmune encephalitis antibodies including anti-NMDA receptor were negative. CT PET scan showed bilateral adrenal enlargement, which in the context of hypokalemia, hyperglycemia, hypertension, and thrombocytopenia was concerning for severe Cushing’s Syndrome. Methylprednisolone and anti-seizure medications were stopped. Inferior petrosal sinus sampling and cerebral angiogram were unremarkable. The diagnosis was supported by elevated random and urine cortisol levels and managed with etomidate and ketoconazole. He underwent bilateral open adrenalectomy following which he was started on oral glucocorticoids. Repeat EEG showed no ictal activity and the patient remained seizure-free. <h3>Results:</h3> Literature review utilizing PubMed identified 17 articles describing CS presenting with neuropsychiatric symptoms. The most common symptoms cited were cognitive decline (23%), psychosis (18%) and seizure (6%). Additional isolated cases cited posterior reversible encephalopathy syndrome, hypogeusia and hyposmia. Most patients had significant improvement or full recovery once CS was treated. <h3>Conclusions:</h3> Cushing’s Syndrome can present with neuropsychiatric symptoms and status epilepticus. It can be an emergency requiring prompt endocrine and surgical evaluation. Serum cortisol levels should be checked in patients presenting with acute personality changes and seizures. <b>Disclosure:</b> Dr. Cameron has nothing to disclose. Dr. Venegas has nothing to disclose. Dr. Fahad has nothing to disclose. Dr. Mathew has nothing to disclose.

First Report of Immunoglobulin G4-related Hepatic Inflammatory Pseudotumor in Transplanted Liver.

Immunoglobulin (Ig)G4–related hepatic inflammatory pseudotumor (IgG4-HIPT) is a rare subset of IgG4-related disease characterized by IgG4-positive plasma cell infiltration and fibrosis.1 Only 28 cases have been reported, all occurring in native livers.1-3 We report herein the first case of IgG4-HIPT developing in a transplanted liver. All ethical approval and consent procedures were approved by the Medical Ethical Committee of Icahn School of Medicine at Mount Sinai. According to the institutional guidelines, the patient’s signed privacy consent is not necessary for a single case report with deidentified patient-specific information. Our patient, who is a 62-y-old women who underwent liver transplantation for primary biliary cholangitis 14 y prior, presented with bacteremia. Laboratory tests showed normal white blood cell count, elevated gamma-glutamyl transferase 101 U/L (normal, 8–35), normal alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and bilirubin. Blood culture was positive for methicillin-resistant Staphylococcus aureus and Klebsiella oxytoca. Serological tests for hepatitis A, B, C, and E; cytomegalovirus; and Epstein-Barr virus were negative. Serum total IgG 1654 mg/dL (normal, 586–1602) and IgG4 171 mg/dL (normal, 2–96) were elevated. Computed tomography (Figure 1A) and magnetic resonance imaging (Figure 1C–E) of the abdomen revealed a 6-cm infiltrative mass in segment 8 of the liver. A biopsy of the lesion demonstrated parenchymal collapse replaced with fibrosis and sheets of plasma cells (Figure 1F). Immunohistochemical stains showed up to 150 IgG4-positive plasma cells per high power field and an IgG4:IgG ratio of 60% (Figure 1G and H). There was no evidence of malignancy, recurrent primary biliary cholangitis, acute cellular rejection, or chronic rejection, and a diagnosis of IgG4-HIPT was rendered. Given the patient’s bacteremia, she was started on intravenous daptomycin and ertapenem. Prednisone was deferred because she was asymptomatic from the lesion. The patient was restarted on mycophenolate mofetil 1 mo postdischarge. Repeat computed tomography of the abdomen 7 mo later demonstrated the decreased size of the lesion to 2.3 cm (Figure 1B).FIGURE 1.: Radiology features (A–E). A, Contrast-enhanced computed tomography images demonstrate an infiltrative enhancing mass in segment 8 measuring 6 cm (arrow). B, Follow-up postcontrast computed tomography after 7 mo demonstrates the decreased conspicuity and size of the lesion (measuring 2.3 cm, arrow). Contrast-enhanced MRI obtained during the (C) arterial, (D) portal venous, and (E) delayed venous phases demonstrates an ill-defined lobulated infiltrative progressively enhancing mass (arrow). Microscopic and immunohistochemical features (F–H). F, The inflammatory cells consist predominantly of lymphocytes and plasma cells (arrow) (hematoxylin and eosin stain ×200). The inflammatory cells demonstrated diffuse reactivity for (G) cluster of differentiation 138 and (H) immunoglobulin G4. MRI, magnetic resonance imaging.IgG4-related disease is generally described as an autoimmune disease because the oligoclonal expansions of both activated B cells and cytotoxic CD4+ T cells were considered central to the process.4 In our case, the IgG4-HIPT developed in a liver allograft in a patient on immunosuppression (tacrolimus target trough level 2–6 ng/dL, mycophenolate mofetil 500 mg twice daily). It may seem counterintuitive that an autoimmune process may develop in such a setting. On the other hand, infections such as Escherichia coli and Klebsiella may also incite an IgG4-predominant inflammatory response.3 In our case, the patient developed bacteremia with methicillin-resistant Staphylococcus aureus and Klebsiella at the time the liver mass was noted. Bacterial translocation from the gut to the portal circulation may have provoked an intrahepatic inflammatory response. This theory was further supported by partial or complete treatment response observed in the current and prior reported cases2 upon administration of antibiotics. Diagnosing IgG4-HIPT is challenging because of its rarity and overlapping clinical and radiological features with malignancy. Because IgG4-HIPT is clinically benign, the recognition of this entity is important to avoid unnecessary treatment.

Shared Experiences

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Significance of Platelets and its Indices in Patients with Dengue Fever

Background: Dengue is a viral infection affecting different parts of the world, particularly the under developed countries including Pakistan. Changes in hematological parameters are frequently observed in dengue viral infection out of which the changes in the structure of platelets and their levels are a predominant factor in dengue viral infection. In view of the foresaid, this study was conducted to find the platelet levels and indices in confirmed cases suffering from dengue fever. Methods: This descriptive cross-sectional study was conducted in Peshawar in a duration of five months from September to December 2022. A total of five hundred patients were screened for dengue viral infection. Blood samples were collected from all suspected dengue infected patients and processed for complete blood count (CBC). Percentage and mean standard deviation were calculated and data were expressed in tables and graphs. Results: Among total suspected patients, one hundred fifty patients were found positive in which highest number of patients were male (65.3%) than female patients (34.7%). The minimum hemoglobin, white blood cells, and platelets were 6.9 g/dl, 2400 g/dl, and 43000 g/dl respectively. Low level of hemoglobin was found in 9.4% patients, 25.3% patients had below normal white blood cell count, and 30.4% patients were observed with less than normal platelet count. Few patients were noted with lower mean platelets volume and plateletcrit than normal. Conclusion: The study showed a significant impact of dengue viral infection on complete blood count. The hemoglobin, WBC, platelets, and platelet indices were potentially affected with dengue viral infection. It is necessary to design a strategy for early diagnosis of dengue infected patients for timely treatment, which can together save patients from severe impact of dengue viral infection such as dengue shock syndrome which could be fatal. Keywords: Dengue viral infection, Hematological parameters, Platelets, Mean Platelets Volume, Plateletcrit, Platelet distributive width.