Period Of Clinical Improvement Research Articles

Paradoxical tuberculous reaction to anti-tnfα discontinuation: a complex case of miliary tuberculosis and macrophagic activation syndrome with hepatic manifestations

Tuberculosis reactivation during anti-TNF-alpha therapy paradoxically worsened following reconstitution of pathogen-specific immune responses after cessation of TNFα antagonist treatment and initiation of anti-bacillary therapy. We report the case of a 46-year-old woman who was prescribed a tumor necrosis factor blocker (anti-TNF) for a relapse of Behçet's disease. The patient developed pulmonary miliary tuberculosis following the reactivation of latent tuberculosis, despite a normal pre-therapeutic work-up. Discontinuation of anti-TNF and initiation of anti-bacillary drugs triggered a paradoxical tubercular reaction (PTR). The diagnosis of paradoxical reaction to anti-tuberculosis drugs was evoked by the clinical and biological deterioration and the appearance of miliary cerebral tuberculosis and cerebral venous thrombosis after a period of clinical improvement. Although this phenomenon has been documented, it represents a major challenge for clinicians. The peculiarity of this case lies in its association with a macrophagic activation syndrome (MAS) with hepatic involvement, retained on clinical-biological and histological criteria. The overlap between MAS and PTR makes it difficult to diagnose these two entities with certainty. The patient responded favorably to moderate-dose systemic corticosteroid therapy with progressive degression, and the reintroduction of anti-tuberculosis drugs.This work aims to highlight the importance of close monitoring of TB patients on anti-TNFα therapy for early diagnosis and management of complications to improve the prognosis of these complex patients.

Conundrum of re-positive COVID-19 cases: A systematic review of case reports and case series

BackgroundThe systematic review was conducted to summarize and synthesize evidence from all available case series and case reports published on re-positive COVID-19 cases. MethodsThe systematic review was registered with Prospero (CRD42020210446). PRISMA guidelines were followed for conducting the systematic review. Inclusion criteria for studies included case reports and case series which have documented cases of positive reverse transcriptase polymerase chain reaction (RT-PCR) after a period of clinical improvement or a negative RT-PCR report. Reviews, opinions, and animal studies were excluded. Methodological quality was assessed using the modified Murad scale. ResultsA total of 30 case reports/case series were included in the study, wherein a total of 219 cases were included. In re-positive cases, the age range varied from 10 months to 91 years. The pooled proportion of positive cases after follow-up using random-effects was 12% (95% confidence interval [CI]: 09%–15%). Among the re-positives, a total of 57 cases (26%) had comorbidities. A total of 51 (23.3%) and 17 (7.8%) re-positive cases had been treated with antivirals and corticosteroids, respectively. Only a few studies have confirmed the presence of antibodies after the first episode. Studies that included contact tracing of re-positives did not find any positive cases among close contacts of re-positive cases. ConclusionThe systemic review found that reinfection is a possibility within 123 days of a negative RT-PCR test in a small number of cases of COVID-19. This has wider ramifications in framing clinical, preventive, and public health policy guidelines.

098 A case of delayed post-hypoxic leukoencephalopathy complicating drug overdose

IntroductionDelayed post-hypoxic leukoencephalopathy (DPHL) is a syndrome characterised by neurological deterioration following a period of recovery after an initial hypoxic event with striking white-matter change on magnetic resonance imaging. We present a case characterised by insidious onset and a fluctuating course of cognitive and neuropsychiatric symptoms.MethodsSingle case report.ResultsA 61 year old lady, with a background history of previously well managed bipolar affective disorder, was found unresponsive following an intentional overdose of temazepam and tramadol. She was hypotensive, hypoxic and required ventilatory and inotropic support. Following extubation, the patient had residual left-sided weakness and MRI confirmed a right frontal watershed infarction. A three week period of clinical improvement was followed by marked deterioration firstly with fluctuating mood and other neuropsychiatric symptoms which progressed to severe impairment of cognition and alertness. There was generalised slowing on the EEG and the CSF was unremarkable. Repeat neuroimaging undertaken on day 41 of the admission, revealed new symmetric and confluent cerebral white matter changes with high signal on the Diffusion Weighted Images (DWI) and Fluid Attenuated Inversion Recovery (FLAIR) images. The patient was managed with supportive care and sustained a clinically significant recovery (MOCA 26/30), despite ongoing cognitive impairments including working memory and deficits in social cognition including mood instability and disinhibition. Repeat neuroimaging 3 months after initial presentation revealed partial resolution of the white matter changes.ConclusionA diagnosis of DPHL should be considered in patients with variable mood and cognition following initial improvement after a hypoxic event.

Post Arthrotomy Prevotella bivia Septic Arthritis and Secondary Osteomyelitis

Prevotella is a common gram-negative anaerobic rod that is frequently associated with female genitourinary tract infections, pelvic inflammatory disease, aspiration pneumonia, lung abscess and pleural empyema. Osteomyelitis in association with septic arthritis is rare with only a handful of cases reported worldwide. In this case study, we report a patient who presented with a clinical picture of septic arthritis complicated by the presence of a sinus tract at the site of a previous arthroscopic surgery. Initial sinus pus cultures demonstrated Streptococcus agalactiae , which were confirmed with intra-operative joint fluid cultures. After a brief period of clinical improvement following arthrotomy, a sudden clinical deterioration prompted re-cultures demonstrating heavy growth of Provetella bivia . Repeat MRI demonstrated new signs of osseous involvement. The patient was managed with a redo arthrotomy, extensive debridement of osteomyelitic tissue, washout and an extended antibiotic therapy regimen. This association is first of its kind in Saudi Arabia. J Microbiol Infect Dis 2019; 9(2):100-103.

Effect of Low Dose Azithromycin Towards The Long Period of Clinical Improvement, Level of IL-8 And Sputum Neutrophil of Pneumonia Patients

Backgrounds: Pneumonia is an acute inflammation of the lung parenchyma caused by microorganisms. Inflammation is an immune response that occurs when bacterial infection. The immune response that occurs will induce alveolar macrophages secrete IL-8 which mediates the movement of neutrophils into the alveolar to release reactive oxygen species (ROS) and protease. Low-dose azithromycin has anti-inflammatory effects that are used on a chronic inflammatory disease of the lung, so its use in pneumonia interesting to do. This study aimed to determine the effect of low-dose azithromycin towards the long period of clinical improvement, level of IL-8 and sputum neutrophil of pneumonia patients.
 Methode: This research is an experimental study with pretest and post-test design. Subjects were patients with pneumonia who were treated at the Hospital Dr. Moewardi Surakarta in July - August 2016. Samples were taken by consecutive sampling as many as 30 patients. treatment group (n = 15) received additional therapy of azithromycin 250 mg / day and the control group (n = 15) received additional placebo. 
 Result: Supplementation of low-dose azithromycin was significantly reduced levels of IL-8 (reduction = -90.31 ± 89.30; P=0.002) and sputum neutrophil (reduction = -35.73 ± 25.25; P=0.0001) in pneumonia patients. There is a statistically significant difference (P=0.0001) of the long period of clinical improvement between treatment groups (3.87 + 0.64 days) and control (5,60+ 0.91 days). 
 Conclusion: Supplementation 250 mg/day of azithromycin during hospitalization led to decreased levels of IL-8 serum, sputum neutrophil, and affect the long period of clinical improvement in pneumonia patients. (J Respir Indo 2018; 38(1): 39-47)

Bilateral obstetric brachial plexus injury: A case report

Our case report describes a bilateral obstetric brachial plexus injury in a 14-year-old boy. In the first years of his life, treatment was conservative. After a period of clinical improvement, spontaneous regeneration had stopped. At age two years and three months, neurotmesis with root avulsion was diagnosed, which was the grounds for microsurgery. Unilateral revision and external neurolysis were performed. Currently, we observed dysfunction of the upper limbs associated with paresis primarily of the shoulder flexors, abductors, external rotators, elbow flexors and abnormal posture as well.

Aneurisma de la arteria pulmonar en Enfermedad de Behçet

Behçet disease is a systemic disease with diverse clinical symptoms which vary according to the organs and systems involved. Typically, patients have oral and genital ulcers and episodic ocular involvement with periods of clinical improvement. We report an 18-year-old mole presenting with chest pain and hemoptysis and a history of ulcers in the oral cavity and scrotum. A chest CAT scan showed a mass located adjacent to the heart that a pulmonary arteriography defined as a left pulmonary artery aneurism. The patient was operated, excising left inferior pulmonary lobe. Due to skin and ocular involvement, the patient complied with criteria for Behçet disease. Immunosuppressive treatment with prednisone and azathioprine was started and the patient was discharged from the hospital.

Nocturnal Oxyhemoglobin Desaturation in COPD Patients with Arterial Oxygen Tensions Above 60 mm Hg

We studied 152 COPD patients with a daytime PaO2 greater than or equal to 60 mm Hg using formal polysomnography (EEG, airflow, respiratory muscle movement, ear oximeter) to detect the presence of nocturnal, nonapneic, oxyhemoglobin desaturation. Nine subjects were disqualified by the unexpected discovery of sleep apnea, as were another eight because they could not sleep in the laboratory setting. Of the remaining 135 subjects, 37 (27 percent) desaturated below a baseline sleep saturation of 90 percent for five minutes or more, reaching a nadir saturation of at least 85 percent. Anthropomorphic, pulmonary function, and historic factors comparing desaturators and nondesaturators failed to separate the groups. Awake PaO2 at rest in the desaturators was significantly lower than in the nondesaturators. The PaCO2 was higher in the desaturators. Reversibility of the desaturation phenomenon was demonstrated in three patients during subsequent polysomnographic studies following periods of clinical improvement. Continuous oxyhemoglobin monitoring during sleep remains the only reliable tool for detecting nocturnal desaturation.

Changes in mean esophageal pressure during early recovery in mechanically-ventilated neonates--evidence for airway-closure and gas-trapping?

We studied transmission of a constant mean airway pressure through the lungs to the pleural space in nine mechanically-ventilated neonates with low-compliance lung disease. Infants were studied for 3.1 +/- 1.6 hr during a period of clinical improvement, but at a time when lung compliance was still markedly reduced. Two of our infants were studied during recovery from fluid overload, while seven infants with hyaline membrane disease were studied at a stage of disease during which maximal diuresis has been found to occur. During the study period, mean esophageal pressure decreased in all infants from 5.6 +/- 1.3 to 4.2 +/- 1.8 cm H2O (P less than 0.001) while total compliance increased slightly.

Correlation between plasma chlorpromazine and its metabolites and clinical ratings in patients with acute relapse of schizophrenic and paranoid psychosis.

Nine patients diagnosed as having acute schizophrenic psychosis were treated with chlorpromazine. Their clinical response to drug treatment was measured by the use of a clinical rating scale developed from the Present State Examination, and a nurses rating scale. Plasma levels of chlorpromazine (CPZ), 7-hydroxychlorpromazine (7OHCPZ), monodesmethylchlorpromazine (NOR1CPZ) and chlorpromazine sulphoxide (SOCPZ), were monitored during the period of hospital treatment. Correlations were made between the increase in plasma levels of drug or metabolites and improvement in the different PSE scores. These showed that the most significant correlations occurred when symptoms with high diagnostic significance for schizophrenia (Group 1) and symptoms rating perceptual disorders (P) were correlated with plasma 7OHCPZ levels in plasma samples taken before the first morning dose of CPZ. The ration of 7OHCPZ to CPZ in these samples increased significantly as clinical ratings improved, this correlation being most highly significant against the Group 1 and P scores. The ratio of 7OHPCZ to SOCPZ increased significantly only in the case of Group 1 and P scores. This indicates a preferential shift of CPZ metabolism towards the formation of the active 7OHCPZ during the period of clinical improvement.

Transfer factor therapy in patients with cancer.

The objective of this study was to utilize transfer factor to stimulate cell-mediated immunity to specific tumor antigens in cancer patients. Thirty-five selected patients with advanced recurrent cancer, who were not suitable for further conventional therapy, were treated with transfer factor. Transfer factor was prepared from cohabitants of the patients and administered at 2-week intervals. This immunotherapeutic approach produced a clinical effect in 13 patients in terms of regression of tumor (1), arrest of metastatic disease (14), or pain relief (14). Conversion of dermal reactivity to specific tumor antigens was observed during periods of clinical improvement. Despite continued immunotherapy, the duration of clinical improvement was short (2 weeks to 12 months). Seven of the 11 patients not responding to therapy exhibited serum blocking of lymphocyte responsiveness. In 11 patients there is insufficient data to evaluate the clinical effectiveness of this therapy. The results suggest that transfer factor can stimulate specific cell-mediated immunity in cancer patients and produce a clinical effect on tumor under certain circumstances.

THROMBOPENIA IN ACUTE DISSEMINATED LUPUS ERYTHEMATOSUS

Instances of the extremely acute, frequently fatal exanthematic type of lupus erythematosus are seen so infrequently by one observer that I feel justified in reporting my hematologic finding in three such cases. This consisted of marked thrombopenia. In case 1 the thrombocytes varied in number somewhat in proportion to the clinical condition of the patient. During periods of clinical improvement the thrombocytes increased, only to decrease again when the patient became worse. In the two fatal cases the thrombocytes reached a low point before death. REPORT OF CASES Case 1.— Mrs. M. E., aged 28, first noted violaceous macules and papules on her finger-tips in 1929. Since that time they had appeared and disappeared intermittently. On June 1, 1932, her face was sunburned. The burn failed to disappear and gradually spread, involving the whole face and neck. Since the onset of this acute phase she had suffered from arthritic pains.

Effect of Hypertonic Solutions on Cerebrospinal Fluid Pressure with Special Reference to Secondary Rise and Toxicity.

The effect of hypertonic solution on the spinal fluid pressure is of vital importance from a clinical standpoint, since Weed and McKibben1 show that the cerebrospinal fluid volume could be reduced by intravenous injection of hypertonic solution. Cushing and Foley2 and Foley and Putnam3 applied this observation to clinical cases of increased intracranial pressure and it was immediately recognized of importance in the treating of head injuries. However, Browder4 among others pointed out from clinical observations: first, the toxicity of NaCl solution, and second, the occasional deaths that occur after a short period of clinical improvement after intravenous administration of hypertonic solution in cases of head injuries with symptoms of increased intracranial pressure.Our experiments were carried out on a series of 10 dogs and one man. We used various concentrations of NaCl and of glucose. The results were uniform. First, it was demonstrated that hypertonic saline has a definitely toxic effect, which in con...