Disseminated Toxoplasmosis in an Allogeneic Hematopoietic Stem Cell Transplant Recipient: A Case Report and Review of the Current Literature

Reactivation infections in hematopoietic stem cell transplants are mitigated by prophylactic regimens. Despite high rates of exposure, morbidity and mortality secondary to toxoplasmosis are limited to subsets of patients such as immunocompromised persons. We describe the first case of disseminated toxoplasmosis in a double umbilical cord blood transplant recipient.

Utility of Whole Blood Real-Time PCR Testing for the Diagnosis of Early Lyme Disease

OBJECTIVES

Whole blood real-time polymerase chain reaction (WB-RTPCR) detection of Borrelia burgdorferi is not currently recommended for diagnosing Lyme disease. This study aims to elucidate the utility of WB-RTPCR as a diagnostic aid for early Lyme disease (ELD), defined as either positive PCR or positive immunoglobulin M with negative immunoglobulin G immunoblot.

METHODS

A retrospective analysis was performed on 33,199 blood specimens evaluated concurrently by WB-RTPCR and antibody-capture serology (ACEIA) methods (group A). Fifty-six pairs of specimens from a separate data set were retrospectively identified and analyzed at initial and follow-up time points to monitor for seroconversion (group B). Also, a separate data set of 2,526 specimens concurrently assessed by molecular and modified two-tiered enzyme-linked immunosorbent assay serology methods was analyzed (group C).

RESULTS

Group A yielded 1,379 specimens consistent with ELD when tested by ACEIA and WB-RTPCR. In total, 131 (9.5% of positive results) were identified by WB-RTPCR, with negative serology. Group C identified 358 samples compatible with ELD, with 31 (8.7% of positive results) identified by RTPCR alone.

CONCLUSIONS

When used concurrently with serologic testing, WB-RTPCR testing increases diagnostic sensitivity in cases of ELD.

A Comparison of Lyme Serological Testing Platforms with a Panel of Clinically Characterized Samples from Various Stages of Lyme Disease

Background

In 2019, the CDC updated serology testing guidelines for Lyme disease diagnosis to include alternative modified two-tiered testing that replaces the western blots of standard testing with an additional ELISA. Antibody-capture serological assays have also been used as an aid for Lyme diagnosis. A panel of clinically characterized samples from the CDC was tested to compare modified two-tiered testing to the standard two-tiered algorithm and an antibody capture immunoassay.

Methods

A CDC panel of 92 samples comprised a range of samples including early Lyme, Lyme neuroborreliosis, Lyme arthritis, infections by other pathogens, and healthy controls. The panel was tested on a standard two-tiered platform by the CDC, the ZEUS Borrelia Test System for modified two-tiered testing, and a lab-developed antibody-capture serological assay. Sensitivity and specificity results from each assay were compared to determine significance.

Results

The antibody-capture assay demonstrated increased sensitivity but decreased specificity compared to the modified and standard two-tiered platforms. There was no statistical difference found between the modified and standard two-tiered platforms.

Conclusions

Improved sensitivity of antibody-capture when testing early Lyme disease samples is offset by decreased specificity, especially with syphilis-positive samples. Modified two-tiered testing is similar to standard two-tiered methods while also being more scalable and simpler to interpret.

A High-Content Screen for C/EBPα Expression Identifies Novel Therapeutic Agents in Dedifferentiated Liposarcoma

PURPOSE

Dedifferentiated liposarcoma (DDLS), one of the most common and aggressive sarcomas, infrequently responds to chemotherapy. DDLS survival and growth depend on underexpression of C/EBPα, a tumor suppressor and transcriptional regulator controlling adipogenesis. We sought to screen and prioritize candidate drugs that increase C/EBPα expression and may therefore serve as differentiation-based therapies for DDLS.

EXPERIMENTAL DESIGN

We screened known bioactive compounds for the ability to restore C/EBPα expression and inhibit proliferation selectively in two DDLS cell lines but not in normal adipose-derived stem cells (ASC). Selected hits' activity was validated, and the mechanism of the most potent, SN-38, was investigated. The in vivo efficacy of irinotecan, the prodrug of SN-38, was evaluated in DDLS xenograft models.

RESULTS

Of 3,119 compounds, screen criteria were met by 19. Validation experiments confirmed the DDLS selectivity of deguelin, emetine, and SN-38 and showed that they induce apoptosis in DDLS cells. SN-38 had the lowest IC₅₀ (approximately 10 nmol/L), and its pro-apoptotic effects were countered by knockdown of CEBPA but not of TP53. Irinotecan significantly inhibited tumor growth at well-tolerated doses, induced nuclear expression of C/EBPα, and inhibited HIF1α expression in DDLS patient-derived and cancer cell line xenograft models. In contrast, doxorubicin, the most common treatment for nonresectable DDLS, reduced tumor growth by 30% to 50% at a dose that caused weight loss.

CONCLUSIONS

This high-content screen revealed potential treatments for DDLS. These include irinotecan, which induces apoptosis of DDLS cells in a C/EBPα-dependent, p53-independent manner, and should be clinically evaluated in patients with advanced DDLS.

P5349Platelet/lymphocyte ratio as an inflammatory marker and predictor of short-term neurological outcomes in survivors after cardiac arrest

Background

Platelet/lymphocyte ratio (PLR), an inflammatory marker associated with poor outcomes in different clinical situations, may play a role in the proinflammatory state triggered during hypoxic-ischemic brain injury secondary to cardiac arrest.

Purpose

To study PLR dynamics and its relationship with neurologic outcomes in survivors after CA treated with target-temperature-management (TTM).

Methods

Observational retrospective study from a prospective database of survivors of in-hospital and out-of-hospital CA admitted to our Acute Cardiac Care Unit between August 2006 to December 2018. All patients received TTM according to our local protocol.

Results

A total of 466 patients were included. Mean age was 62.7±14.4 years and 102 (21.9%) were women. Baseline characteristics are shown in Table 1. 430 (92.2%) of CA were witnessed, 312 (67.0%) had ventricular fibrillation as initial cardiac rhythm. Among them, 236 (51.1%) survived until hospital discharge and 208 (45.1%) presented favorable neurological outcomes (a score 1 or 2 on cerebral performance category (CPC)). The mean value of PLR at admission and during targeted temperature was 100.4±5.2 and 224.5±7.3 respectively (mean difference 123.1±7.1, p<0.0001). This increase in PLR was significantly higher among patients with worse neurological outcomes (CPC 3–5, mean DPLR 138.2±5.5) at 3 months compared with survivors with CPC 1–2 (mean DPLR 108.2±6.3, p=0.0348 for paired comparison between both groups).

Table 1 Hypertension, n (%) 235 (54.9) Diabetes, n (%) 113 (26.4) Dyslipidaemia, n (%) 171 (40.0) Smocking habit, n (%) 208 (48.5) Time to ROSC mean ± SD, min 26.6±18.6 Mean arterial pressure at HA mean±DS, mmHg 81.3±22.1 pH at HA mean ± SD 7.18±0.16 Lactic at HA mean ± SD 6.37±4.42 ROSC: return of spontaneus circulation; HA: hospital admission.

Conclusion

Our findings reflect the impact of inflammation in neurological outcomes after OHCA treated with TTM. Major increases of PLR constitute a novel marker of poor prognosis during early assessment of OHCA patients.

Parathyroid Hormone as a Predictor of Post-Thyroidectomy Hipocalcemia: A Prospective Evaluation of 100 Patients

INTRODUCTION

Hypocalcemia is a frequent complication after total thyroidectomy and the main reason for prolonged hospitalization of these patients.

MATERIAL AND METHODS

We studied prospectively 112 patients who underwent total or completation thyroidectomy between June 2012 and November 2013. Twelve patients with preoperative changes in parathyroid function were excluded. Parathyroid hormone and calcium levels were determined pre-operatively, immediately after surgery, on 1st day and on 14th day after surgery.

RESULTS

Of the 100 patients enrolled, 60 have developed hypocalcaemia (60%) but only 14 patients had symptomatic hypocalcaemia. It mostly occurs 24 hours after surgery (76.7%). It was permanent in 3 patients and temporary in the others. In the 60 patients with hypocalcaemia, it has been found hypoparathyroidism in 19 patients immediately after surgery, in 14 patients on 1st day but only 3 had hypoparathyroidism (patients with permanent hypocalcaemia). Comparing the group of patients with and without hypocalcaemia we found a decrease of parathyroid hormone in both (immediately after surgery and on 1st day) but was more important in the hypocalcaemia group (p = 0.004 and p < 0.001). The decrease of PTH levels was more pronounced in the hypocalcaemia group, with significance on the first day (22.29% vs 50.29%, p < 0.001). The best predictor of hypocalcaemia identified was the decrease of parathyroid hormone levels > 19.4% determined on the 1st day (sensitivity = 82%; specificity = 63%).

DISCUSSION

In our study there was a high incidence of hypocalcemia (60%), expressed predominantly 24 hours after surgery and conditioned, in these patients, a longer hospital stay. However, only 3 patients (3%) had permanent hypocalcemia. We still found a match in the oscillation of serum calcium levels and parathyroid hormone which identified the decrease in parathyroid hormone on the first day after surgery as a reliable predictor of hypocalcemia.

CONCLUSION

Decrease of parathyroid hormone levels > 19.4% determined on 1st day is a good predictor of hypocalcemia after total / completation thyroidectomy, allowing to identify patients at higher risk of hypocalcemia, medicate them prophylactically and get early and safe discharges.

COGENT (COlorectal cancer GENeTics): an international consortium to study the role of polymorphic variation on the risk of colorectal cancer

It is now recognised that a part of the inherited risk of colorectal cancer (CRC) can be explained by the co-inheritance of low-penetrance genetic variants. The accumulated experience to date in identifying these variants has served to highlight difficulties in conducting statistically and methodologically rigorous studies and follow-up analyses. The COGENT (COlorectal cancer GENeTics) consortium includes 20 research groups in Europe, Australia, the Americas, China and Japan. The overarching goal of COGENT is to identify and characterise low-penetrance susceptibility variants for CRC through association-based analyses. In this study, we review the rationale for identifying low-penetrance variants for CRC and our proposed strategy for establishing COGENT.

[Recurrent hypercortisolism after removal of an ACTH secretor pituitary adenoma associated with an adrenal macronodule]

A 29 years old patient was sent to our Outpatient Clinic of Endocrinology presenting clinic of hypercortisolism. Laboratorial study: High urinary free cortisol (UFC); serum cortisol - 25 microg/dl (8 am) (5-25) and 20 microg/dL (11pm); ACTH - 20 pg/mL (9-52) (8 am) and 14 pg/mL (11 pm); serum cortisol after dexamethasone suppression test: 14,9 mg/dL; CRH test: elevation of ACTH; Pituitary MRI: microadenoma; abdominal CT: nodule on the left adrenal. During inferior petrosal sinus sampling with CRH stimulation, ACTH reached 368 pg/mL on the right and 136 pg/mL on the left side. The patient was submitted to transsphenoidal surgery. After surgery, hypertension and physical stigmata improved. In 2006, a relapse of Cushing syndrome was suspected due to worsening of hypertension and increase of weight. A slight increase of UFC, undetectable ACTH and serum cortisol after dexamethasone suppression test equal to 16 microg/dL were found. On abdominal CT, the adrenal nodule kept the same characteristics. In December 2006, the patient was submitted to left adrenalectomy. After surgery, blood pressure normalized, UFC and serum cortisol were reduced, needing substitutive therapy. Progressive tapering of hydrocortisone doses lead to discontinuation in March 2007. He is clinically well, without any treatment. This is an unusual case, in which after surgical cure of Cushing disease, secretory autonomy of a coexisting adrenal nodule occurred. This clinical case is relevant, pointing out the complexity of hypercortisolism cases and the need of long follow-up.

Influenza A/pandemic 2009/H1N1 in the setting of allogeneic hematopoietic cell transplantation: a potentially catastrophic problem in a vulnerable population

We describe Influenza A/pandemic 2009/H1N1 in two allogeneic hematopoietic cell transplantation recipients. The main presentation in both cases consisted of flu-like symptoms manifesting as, fever, arthralgias and myalgias. The virus was isolated in one case from a throat swab and in another case following a bronchoalveolar lavage. Both patients received oseltamivir at a dose of 75 mg orally twice day. The dose of oseltamivir was increased to 150 mg twice per day due to the lack of improvement or progression of symptoms. In one case, clinical symptoms resolved without sequelae. In the second case, pulmonary symptomatology continued to deteriorate, despite aggressive polymicrobial treatment, requiring mechanical ventilation and ultimately the patient died from respiratory failure. These cases highlight the potentially serious effect of the ongoing Influenza A/pandemic 2009/H1N1 pandemic in this very vulnerable population and the urgent need to establish emergency preparedness strategies by oncology and bone marrow transplantation staff to face this serious healthcare challenge.

The Campaign to End Fistula: what have we learned? Findings of facility and community needs assessments

OBJECTIVE

To present a summary of the findings of the fistula needs assessments that have been conducted through the Campaign to End Fistula in 25 countries in Africa and Asia to expand knowledge on the issue related to causes and impact, country capacity to manage the problem and clinical and programmatic gaps.

METHOD

The methodology of the assessments was qualitative and quantitative, and included focus group discussions; in-depth interviews/narratives; key informant interviews; and review of medical records, with slight variations by country.

RESULTS

Analysis of 20 of these assessments provides insight into the capacities, gaps, and perspectives specific to each country regarding fistula prevention and treatment and the social reintegration of treated women.

CONCLUSION

Needs assessment findings have been key tools to spark action and guide the implementation of national programs to eliminate obstetric fistulas throughout Africa and Asia.

Advanced cutaneous squamous cell carcinoma of the trunk and extremity: analysis of prognostic factors

BACKGROUND

Patients with squamous cell carcinoma (SCC) of the skin may exhibit locally advanced or metastatic disease and present a challenging management problem.

METHODS

A retrospective review of 40 patients with advanced SCC of the trunk or extremity managed at Roswell Park Cancer Institute from 1982 through 1992 was performed to identify clinical and pathologic factors that influenced outcome.

RESULTS

There were 27 males and 13 females with a median age of 61 years. Median follow-up was 24 months. Surgical resection to control the primary tumor was often extensive. Amputation was required in nine patients, hemipelvectomy in three patients, and hemicorporectomy in one patient. Median survival was 28 months, and 5-year survival was 43%. Univariate analysis identified stage (P = 0.04), size (P = 0.0001), type of surgical procedure (P = 0.009), and margins of resection (P = 0.005) as having prognostic significance. On multivariate analysis, stage (P = 0.04) and size (P = 0.02) were found to be significant.

CONCLUSIONS

Optimum treatment for advanced SCC of the trunk and extremity involves surgical resection with uninvolved margins. The role of elective node dissection remains undefined. Investigation is needed to define the role of neoadjuvant therapy that may improve functional and cosmetic results.

Rhinoentomophthoromycosis. Report of two cases

Two cases of rhinoentomophthoromycosis are presented. This rare disease can produce progressive deformity of the nose and facial structures. A review of the clinical symptoms along with its diagnosis and treatment is described.

Crossbreeding effects on reproductive traits in two strains of duck (Anas platyrhynchos): brown Tsaiya and Pekin

1. The reproductive performances of 211 domestic duck females (Anas platyrhynchos) from the pure breeds Brown Tsaiya (Ts) and Pekin (Pk) and their two reciprocal crossbreds were analysed. 2. Differences in the 4 genotypes, additive direct and maternal crossbreeding effects and heterosis were estimated on the following traits: age at first egg, egg production to the ages of 30, 35, 40 and 52 weeks of age, egg weight at 30 weeks of age, and (egg) fertility by artificial insemination with Muscovy drakes' pooled semen. 3. Egg production up to 52 weeks of age was higher in Ts than in Pk (respectively 214 +/- 7 and 150 +/- 8 eggs), but not statistically different from that of the reciprocal crossbreds. The ratio of settable eggs to total eggs was nearly 90%, without any difference between genotypes. 4. Average egg weight at the age of 30 weeks was 75 +/- 0.9 g for Pk, which was higher than the corresponding values for Ts (62 +/- 0.8 g), but not significantly different from the crossbreds. 5. An effect of genotype was found on egg fertility: the Pk strain exhibited the lowest value, 71.3 +/- 3.1% compared with 75.9 +/- 2.1% for Ts, 80.6 +/- 2.6% for Ts x Pk and 74.6 +/- 1.9% for Pk x Ts. 6. Crossbreeding genetic variables showed favourable direct genetic effects for egg production and (egg) fertility in Ts, while Pk had favourable direct genetic effects on egg weight. The Pk genotype had a favourable maternal effect on fertility. Direct heterosis was 34% and 10% for egg production up to 30 and 52 weeks of age respectively, 8.8% for egg weight and 5.4% for (egg) fertility. 7. Crossing Ts with Pk seems profitable for the production of mule ducklings.

Pyoderma gangrenosum associated with acne conglobata

We report a 16-year-old male in whom pyoderma gangrenosum appeared in conjunction with acne conglobata. The patient also developed a seronegative spondyloarthropathy that was the main presenting complaint. There was no evidence of inflammatory bowel disease. Treatment with isotretinoin was successful. Both acne and pyoderma lesions healed and the articular symptoms improved. The present case, together with other reports in the literature show that acne conglobata must be included in the list of possible associations of pyoderma gangrenosum. We also comment on acne arthritis, a relatively frequent phenomenon, although still not generally known, in acne conglobata.

Thick cutaneous melanoma of the trunk and extremities: an institutional review

The objective of this study was to review our experience with thick cutaneous melanoma of the trunk and extremities and to identify subgroups of long-term survivors. Ninety-one patients admitted between the years 1977 and 1987, with cutaneous melanoma of the trunk or extremities, Breslow thickness > or = 4.0 mm, or a Clark's level V lesion form the basis of this review. Node positive clinical stage II patients had a 5-year survival rate of 32%. Five-year survival for node positive clinical stage III patients was 0% (P < 0.0001). Node negative clinical stage II patients, and those found to be histologically node positive, had no survival difference, P = 0.88. Sixty per cent of node negative patients with an extremity primary survived 5 years, while patients with a node positive truncal primary had a survival of 14%, P = 0.005. In conclusion, most patients present with local-regional disease. Patients with node negative extremity lesions have the best chance for cure.

Metastasectomy in malignant melanoma

BACKGROUND

Resection of distant metastases in melanoma is occasionally helpful. The extent of applicability of this treatment, the benefit derived, and the prognostic parameters aiding in the selection of the patients need to be defined further.

METHODS

The cases of one hundred fourteen patients with resected distant metastases were reviewed and subjected to multivariate analysis.

RESULTS

The median survival after metastasectomy was 19 months and the estimated 5-year survival rate was 22%. The 5-year survival rate was 33% for those with distant subcutaneous metastases, 22% for those with distant lymph node metastases, and 14% for those with pulmonary metastases (p = 0.12). Twenty patients (18%) are disease free at a median follow-up of 106 months. Significant prognostic parameters were the thickness of the primary melanoma (p = 0.05), the number of metastatic lesions (p = 0.03), and the prior disease-free interval (p = 0.05).

CONCLUSIONS

Resection of distant metastases is applicable in about one fourth of patients with disseminated melanoma. With adherence to certain selection criteria the resulting 5-year survival rate is appreciable and higher than that after other, currently available treatments.

Electroclinical signs of benign neonatal familial convulsions

Benign neonatal familial convulsions comprise a distinct epileptic syndrome with an autosomal mode of transmission. The electroclinical signs of seizures in this syndrome are not yet well defined. In 3 children from two families presenting with benign neonatal familial convulsions, 14 seizures were recorded during electroencephalographic (EEG)-video sessions. All seizures occurred during sleep, after a short arousal reaction. Seizures started with bilateral, symmetrical flattening of the EEG for 5 to 19 seconds; simultaneously there was apnea and tonic motor activity. The EEG flattening was followed by a long (1-2-minute) bilateral discharge of spikes and sharp waves; simultaneously, there were vocalizations, chewing, and focal or generalized clonic activity. The prominence of EEG and motor abnormalities varied between the left and the right from one seizure to the next in any given child. The seizures stopped without EEG or clinical postictal depression. These electroclinical observations suggest that the convulsions of benign neonatal familial convulsions are a form of generalized tonic-clonic seizure whose expression may be asymmetrical, probably because of the immaturity of the corpus callosum or other structures ensuring seizure synchronization.

Treatment of unknown primary melanoma

Sixty-four patients with unknown primary melanoma were identified among 1045 new patients with melanoma (6%) seen during an 11-year period. Their mean age was 44.5 years (median age, 42.7 years). Of these, 39 (59%) were men, and 25 (38%) were women. In 34, only one site was involved. Common single sites were the axilla (29%), groin (24%), and neck (32%). Most of the melanomas (88%) were melanotic. Patients with localized melanoma surgically treated (n = 34) had a median survival of 53 months, and a 5-year survival rate of 45%. The respective rates for disseminated melanoma were 7 months and 10% (P = 0.00001). Localized, unknown primary melanoma should be treated with radical excision because a substantial proportion of patients so treated survive 5 years.

Dandy-Walker malformation: analysis of 38 cases

Thirty-eight cases of Dandy-Walker malformation (DWM) are presented. A female predominance of 3:1 was found. Thirty-two cases (84%) were diagnosed within the 1st year of life. Of these, 17 cases (44.7%) were diagnosed at birth. Ten (26%) were delivered by cesarean section. Thirteen infants (34%) had a birth weight below 3000 g. Several associated malformations were observed, the most frequent being capillary angioma (6 cases); cardiac malformations, ophthalmic anomalies, agenesis of the corpus callosum, malformed limbs, and occipital meningocele were also seen. These observations indicate that DWM represents a disorder of the midline central nervous system indicative of marked genetic and etiologic heterogeneity with the possibility of showing clinical and pathological alterations intra- and extracranially. Macrocephaly was the most frequent physical finding, appearing in 31 cases (82%). Seventeen (44.7%) patients died, 11 before 6 months of age, 3 between 6 and 12 months, and 3 after 1 year. Postmortem studies were performed in 13 patients. Three cases have been lost to follow-up. Mental retardation (IQ below 70) was found in 11 cases (58% of survivors), low intellect (IQ between 70 and 85) in 4, and only 2 patients showed normal intellectual development (IQ more than 85). The high incidence of malformations having several genetic and environmental origins, as well as the high early mortality of patients with DWM, indicate the complexity of this syndrome, which involves the midline developmental field structures. It is not an isolated malformation of the posterior fossa in most cases.

Prognosis for seizure control in infantile spasms preceded by other seizures

Thirteen to 43% of patients with infantile spasms (IS) have other types of seizures, which are considered a feature of an unfavourable prognosis and, to some extent, as a contra-indication for steroid treatment. The present series comprised 43 patients treated with steroids, who suffered from other types of seizures prior to IS. The first seizures resulted from 2 different conditions, correlated to a different outcome of epilepsy. In 27 patients with prenatal encephalopathy, the first seizures were the first manifestation of the epilepsy and IS responded poorly to steroids. In the other 16 patients, the first seizures were occasional, due to acute brain damage, and the following IS responded favourably to steroid therapy. Rational therapeutic indications should take in account the etiology of seizures that precedes IS, and steroids should be administered when IS are due to acute peri- or postnatal acute brain damage.

Ileal conduits for recurrent unresectable colorectal adenocarcinoma

In a retrospective 4 year study, 19 patients with unresectable recurrent pelvic tumor secondary to colorectal adenocarcinoma underwent urinary diversion. An ileal conduit was performed for palliative purposes at the time of exploration. None of the 19 patients had evidence of distant metastases. Survival after the ileal conduit ranged from 2 to 26 months (median 13 months). This survival rate did not vary significantly according to sex or whether hydronephrosis resolved after urinary diversion. Postoperative complications developed in three patients. Two of these complications were ureterointestinal anastomotic leaks and the third was development of an enterocutaneous fistula. The quality of life was rated as good by 75 percent of the patients and fair by 18 percent, with all patients relieved of painful obstructive uropathy. Eighteen of 19 patients were able to resume useful and productive lives.

Metastasis to the parotid gland from colorectal adenocarcinoma

This manuscript presents only the fifth reported case in the literature of colorectal carcinoma with metastasis to the parotid gland. A 66-year-old white woman, referred to Roswell Park Memorial Institute, presented with a left parotid mass and a past history of undergoing right hemicolectomy for an adenocarcinoma of the ascending colon with synchronous liver metastases. The clinical presentation and treatment of the patient are discussed with a review of the literature.