Intractable pruritus associated with insulinoma in the absence of multiple endocrine neoplasia: a novel paraneoplastic phenomenon

Anti-amphiphysin antibody-associated paraneoplastic brainstem encephalitis with pruritus and dysphagia as the first symptoms: A case report

RATIONALE

Anti-amphiphysin antibodies are uncommonly detected in paraneoplastic neurologic syndromes (PNS), especially in patients with small cell lung cancer. Here, we report the first case of anti-amphiphysin antibody-associated PNS with pruritus and dysphagia as the first complaints.

PATIENT CONCERNS

The patient was a 58-year-old man who sought medical advice with a chief complaint of dysphagia and the lung occupancy. We found that he had developed progressive pruritus several months ago.

DIAGNOSES

In the outer basal segment of the right lung lower lobe, PET-CT revealed small occupancies with hypermetabolism. Later, the pathology showed small cell lung cancer. And anti-amphiphysin antibodies were detected in serum. Above all, the patient's symptoms improved significantly after antitumor treatment. Even neither of the 2 cranial enhancement MRIs showed any meaningful imaging signs, the above evidence could confirm the diagnosis of PNS.

INTERVENTIONS

The chemotherapy regimen was etoposide 0.1g d1-3+cisplatin 40 mg d1-3 (q3w). Paroxetine 20 mg/day was given to relieve the itching.

OUTCOMES

After the treatment, the Watian water swallowing test dropped from grade 5 to grade 1, the intense itching also became tolerable.

LESSONS

Clinicians should consider diagnoses other than anxiety states or esophageal cancer in a patient with pruritus and dysphagia, such as PNS.

Helicobacter pylori Infection Maybe a Risk Factor for Cardiac Syndrome X

Purpose

Cardiac syndrome X (CSX) is a condition with normal coronary angiography but angina pectoris. Chronic inflammation caused by Helicobacter pylori (H. pylori) infection may play a pathogenic role in CSX. Therefore, we conducted a meta-analysis to explore the relationship between H. pylori infection and risk of CSX.

Methods

A systematic search in the Web of Science, Medline, Embase and Chinese databases (CNKI and Wanfang) was conducted up to October 2021. Articles on the association between H. pylori infection and the risk of CSX were included and were analyzed by R software (version 4.1.0).

Results

Ten case-control studies involving 703 CSX patients and 731 healthy controls were included. H. pylori infection was associated with an increased risk of CSX (OR: 8.29, 95% CI: 4.64–14.82). We also found a significant association in those 25–40 years of age (OR: 1.34, 95% CI: 1.04–1.72), those 40–50 years of age (OR: 11.27, 95% CI: 4.29–29.61), those over 50 years of age (OR: 7.18, 95% CI: 3.59–14.36), those in developing countries [Iran (OR: 12.99, 95% CI: 8.61–19.60) and China (OR: 5.14, 95% CI: 3.09–8.56)]. However, this association was not apparent in a developed country [Italy (OR: 0.93, 95% CI: 0.37–2.33)].

Conclusions

Our study suggested a possible association between H. pylori infection and the risk of CSX. Its pathogenicity is stronger in middle-aged individuals and some developing countries. However, more studies are needed to further investigate whether early eradication of H. pylori can reduce the incidence rate of CSX, especially in middle-aged individuals and some developing countries.

Itch: Epidemiology, clinical presentation, and diagnostic workup

Itch, or pruritus, is the uncomfortable sensation underlying the desire to scratch. Itch is a very common complaint in the general population that can result from dermatologic, systemic (eg, renal, hepatobiliary, endocrine), paraneoplastic, neuropathic, and psychogenic etiologies. Chronic itch is associated with significant sleep disturbances and profoundly reduces overall quality of life. Certain populations, including elderly and African Americans, are at increased risk of experiencing heightened burden of itch. Because of the variable clinical presentation and wide-ranging etiologies, itch presents a challenge for clinicians. The initial evaluation should include a complete blood count, with differential, hepatic, renal, and thyroid function testing along with diabetes screening. Further testing should be guided by history and physical examination findings. There should be a heightened concern for underlying malignancy in individuals older than 60 years of age who have a history of liver disease and diffuse itch less than 12 months of duration. For individuals with chronic pruritus of unknown origin, increased blood eosinophils may serve as a biomarker of T helper cell type 2 polarization and response to immunomodulator therapies. In this first part of a 2-part continuing medical education series, we describe the broader epidemiology and specific conditions associated with itch and the clinical presentation and diagnostic workup for patients with itch.

Itching as the onset of pain (part 2)

Itching of the skin is a particularly unpleasant subjective sensation that causes the need to scratch. Physiological itching occurs in response to environmental irritants (friction, insect crawling, temperature changes, etc.) and disappears after elimination of the cause. Pathological itching is caused by changes in the skin or throughout the body and causes a strong need to get rid of itching by combing or any other method. Itching is a common symptom of local (dermatological) or general (systemic) disease. It can be limited (localized) or diffuse (generalized).One of the causes of itching is often noted endocrine diseases and metabolic disorders: hyper- and hypofunction of the thyroid gland, diabetes mellitus and hyperparathyroidism. In thyroid hyperfunction, generalized (inconstant and little-pronounced) itching of the skin is observed in the clinical picture only in 10 % of patients. It is accepted that itching of the skin in thyrotoxicosis syndrome is due to increased activity of kinin in combination with an increase in major metabolism and an increase in body and skin temperature (123).Itching caused by impaired bile secretion is characteristic of many diseases of the liver: primary biliary cirrhosis, sclerosing cholangitis, viral hepatitis caused by cholestasis medications and other causes of obstructive jaundice. It is in these cases that prurigo is usually generalized, but in some typical cases it is more pronounced on the feet and palms. With this pathology, itching is caused by obstruction of the biliary tract, however, and to this day, no close correlation has been found between serum bilirubin and the severity of itching.If it was previously thought that itching in pathology of the peripheral or central nervous system, such as multiple sclerosis, neuropathy, compression or irritation of nerves (e.g., paraesthetic dorsalgia, brachioradial itching) is also a significant symptom, then modern studies prove that in more cases, itching is not characteristic of most pathologies of the nervous system, so after a detailed anamnesis, examination and initial research, the patient should be referred to a related specialist, except in cases of about obvious postherpetic neuropathy, painless paresthesia, or brachioradial itching, which can often be guided in the provision of primary care.Instead, there are some psychological conditions and a number of psychiatric illnesses (obsessive-compulsive disorders, depression, and parasite illusions) that are most commonly diagnosed with the exclusion method. Neurotic squabbles are scattered on the body of the excorii, covered with scales that may occur in any area of the body that the patient may reach, but are often limited by limbs.

Pruritus in Systemic Diseases: A Review of Etiological Factors and New Treatment Modalities

Pruritus is the most frequently described symptom in dermatology and can significantly impair the patient's quality of life. In 10–50% of adults with persistent pruritus, it can be an important dermatologic clue for the presence of a significant underlying systemic disease such as renal insufficiency, cholestasis, hematologic disorder, or malignancy (Etter and Myers, 2002; Zirwas and Seraly, 2001). This review describes the presence of pruritus in different systemic diseases. It is quite important to discover the cause of pruritus for providing relief for the patients experiencing substantial morbidity caused by this condition.

Chronic pruritus: a paraneoplastic sign

Chronic itch could be a presenting sign of malignancy. Pruritus of lymphoma is the common prototype of paraneoplastic itch and can precede other clinical signs by weeks and months. Paraneoplastic pruritus has also been associated with solid tumors and is an important clinical symptom in paraneoplastic skin diseases such as erythroderma, Grovers disease, malignant acanthosis nigricans, generalized granuloma annulare, Bazex syndrome, and dermatomyositis. In any case with high index of suspicion a thorough work-up is required. This review highlights the association between itch and malignancy and presents new findings related to pathophysiological mechanisms and the treatment of itch associated with malignancy. Combinative therapies reducing itch sensitization and transmission using selective serotonin and neuroepinephrine reuptake inhibitors, Kappa opioids, and neuroleptics are of prime importance in reducing this bothersome symptom.

Cutaneous paraneoplastic syndromes: uncommon presentations

Paraneoplastic syndromes are a group of clinical manifestations associated with a malignancy, but not directly related to the primary tumor itself or to its metastases. Characteristically, they follow a course parallel to the tumor, resolve with successful treatment of the primary tumor, and tend to recur with its relapse or the onset of metastases. The mechanism by which they occur is not well understood, but may be related to the production of bioactive substances by or in response to the tumor, such as polypeptide hormones, hormone-like peptides, antibodies or immune complexes, cytokines, or growth factors.