Incomplete Kawasaki Disease with Peripheral Facial Nerve Palsy and Lung Nodules: A Case Report and Literature Review

The diagnosis of Kawasaki disease (KD) is challenging and often delayed mainly in case of young infants and in presence of an incomplete disease and atypical features. Facial nerve palsy is one of the rare neurologic symptoms of KD, associated with a higher incidence of coronary arteries lesions and may be an indicator of a more severe disease. Here, we describe a case of lower motor neuron facial nerve palsy complicating KD and perform an extensive literature review to better characterize clinical features and treatment of patients with KD-associated facial nerve palsy. The patient was diagnosed at the sixth day of disease and presented extensive coronary artery lesions. A prompt treatment with intravenous immunoglobulins, aspirin and steroids obtained a good clinical and laboratory response, with resolution of facial nerve palsy and improvement of coronary lesions. The incidence of facial nerve palsy is 0.9–1.3%; it is often unilateral, transient, more frequent on the left and seemingly associated with coronary impairment. Our literature review showed coronary artery involvement in the majority of reported cases (27/35, 77%) of KD with facial nerve palsy. Unexplained facial nerve palsy in young children with a prolonged febrile illness should prompt consideration of echocardiography to exclude KD and start the appropriate treatment.

Immediate and progressive neurological damage after electrical injury: A pediatric case report

BACKGROUND

An electrical injury can cause multiple consequences, especially to the nervous system, both peripheral and central. Such consequences may present immediately as well as later on.

AIMS OF THE STUDY

To report on a case of a 5-year-old boy with focal refractory status epilepticus after an electrical injury.

METHODS

Clinical history, electroencephalography, neuroimaging, and laboratory data of a patient admitted to our emergency department.

RESULTS

A 5-year-old male received an electrical shock by contact with an alternating current source after coming out of the pool. When reaching our emergency department, focal seizures was observed in the same site affected by the electrical insult, with progressive structural changes in the related brain area. In the days after, his neurological conditions dramatically evolved leading to brain death.

CONCLUSIONS

Based on our knowledge, this is the first report on refractory status epilepticus in a child after electrical injury. The possible underlying pathogenetic mechanisms are not yet clear.

Preexisting mild cognitive impairment as a risk factor for COVID-19 infection: A scoping review and case reports

Introduction

SARS-Co-V2 neuroinvasive ability might be the basis for the onset of delirium and neuropsychiatric outcomes.

Objectives

We hypothesized that some infected patients with preexisting cognitive dysfunction may present delirium as unique manifestation of COVID-19 infection or as a prodrome of a new episode consistent with the psychiatric history.

Methods

We conducted a PubMed literature search to verify whether cognitive impairment might predispose to COVID-19. We included three patients with mild cognitive impairment and delirium at admission for SARS-Co-V2 suspected infection. Delirium was diagnosed according to DSM-5 criteria‚ Cognitive Assessment Method and Coma Glasgow Scale.

Results

Literature analysis evidenced patients presenting delirium or delirium-like symptoms as clinical manifestation of COVID-19, plus a cognitive impairment‚ from mild to severe‚ which preexisted or was evidenced during the acute phase or after the infection. Most studies described delirium in patients with a past neurological/psychiatric history. Contrasting data emerged on the potential link between COVID-19 and delirium in patients with cognitive impairment and without a past neuropsychiatric history. Our patients had no history of other medical complications. Our first patient had no psychiatric history‚ the second reported only a depressive episode‚ and the third had story of bipolar disorder. Delirium resolved completely after 2 days in the first patient. The other patients required 4 and 14 days to resolve: delirium appeared as the prodrome of a new psychiatric episode in line with their past history.

Conclusions

Clinicians should acknowledge the possibility that COVID-19 infection may appear as delirium and acute psychiatric sequelae as unique manifestation.

Disclosure

No significant relationships.

Atypical Clinical and Neuroradiological Findings in a Child With Bifacial Weakness With Paresthesias

BACKGROUND

Guillain-Barré syndrome (GBS) is the broad term used to describe a number of related acute autoimmune neuropathies, which together form a continuous spectrum of variable and overlapping syndromes. Bifacial weakness with paresthesias (BFP) is a rare variant of GBS, characterized by isolated facial diplegia in the absence of ophthalmoplegia, ataxia, or limb weakness, and it is usually associated with distal limb paresthesias.

CASE DESCRIPTION

An 8-year-old boy was brought to our attention; because 5 days before coming to the hospital, he noticed he could no longer smile. Bilateral facial droop and inability to close both eyes were evident along with slight paresthesias at the hands and feet and gait disturbances. He progressively developed hypophonia, dysarthria, dysphagia associated with dysmetria, and limb ataxia. Nerve conduction studies showed a demyelinating polyneuropathy. Brain and spine magnetic resonance imaging (MRI) revealed contrast enhancement of both facial nerves and cauda equina nerve roots along with a hyperintense signal of the periaqueductal gray matter, superior cerebellar peduncles, and pontine tegmentum. Because BFP is not typically associated with other cranial neuropathies or ataxia, these clinical features along with peculiar MRI findings supported the diagnosis of "BFP plus." Finally, it can be speculated that this case configures a rare overlap between BFP and the other GBS variants, such as Bickerstaff encephalitis.

CONCLUSIONS

This atypical case underlines the potential role of MRI in contributing to refining the nosological classification of GBS spectrum and optimizing individual treatment, especially in children where unusual manifestations are not infrequent and neurological examination is more challenging.

Diagnostic issues faced by a rare disease healthcare network during Covid-19 outbreak: data from the Campania Rare Disease Registry

Background

The aims of this study were: to investigate the capacity of the rare disease healthcare network in Campania to diagnose patients with rare diseases during the outbreak of Covid-19; and to shed light on problematic diagnoses during this period.

Methods

To describe the impact of the Covid-19 pandemic on the diagnosis of patients with rare diseases, a retrospective analysis of the Campania Region Rare Disease Registry was performed. A tailored questionnaire was sent to rare disease experts to investigate major issues during the emergency period.

Results

Prevalence of new diagnoses of rare disease in March and April 2020 was significantly lower than in 2019 (117 versus 317, P < 0.001 and 37 versus 349, P < 0.001, respectively) and 2018 (117 versus 389, P < 0.001 and 37 versus 282, P < 0.001, respectively). Eighty-two among 98 rare disease experts completed the questionnaire. Diagnostic success (95%), access to diagnosis (80%) and follow-up (72%), lack of Personal Protective Equipment (60%), lack of Covid-19 guidelines (50%) and the need for home therapy (78%) were the most important issues raised during Covid-19 outbreak.

Conclusions

This study describes the effects of the Covid-19 outbreak on the diagnosis of rare disease in a single Italian region and investigates potential issues of diagnosis and management during this period.

Abstract PD5-11: Not presented

This abstract was not presented at the symposium.

Abstract OT2-01-05: TRINITI-1: Ribociclib + everolimus (EVE) + exemestane (EXE) triplet combination in men or postmenopausal women with HR+, HER2– advanced breast cancer (ABC) following progression on a cyclin-dependent kinase (CDK) 4/6 inhibitor

Background: There is extensive crosstalk between the cyclin D–CDK4/6–inhibitor of CDK4–retinoblastoma and phosphatidylinositol 3-kinase (PI3K)/mammalian target of rapamycin (mTOR) pathways at the G1/S cell-cycle checkpoint. Both pathways are frequently dysregulated in hormone receptor-positive (HR+) breast cancer and have been associated with endocrine therapy (ET) resistance. CDK4/6 and PI3K/mTOR inhibitors have demonstrated clinical activity in combination with ET. Although CDK4/6 inhibitors combined with ET significantly improve progression-free survival (PFS) in ABC, disease progression eventually occurs, highlighting the need for effective treatment options following doublet therapy. Ribociclib (LEE011; CDK4/6 inhibitor; 3-weeks-on/1-week-off) + EVE (mTOR inhibitor) + EXE triplet therapy has shown preliminary clinical activity in heavily pretreated HR+, human epidermal growth factor receptor 2-negative (HER2–) ABC including patients (pts) with prior exposure to CDK4/6 inhibitors, suggesting this combination may restore sensitivity to CDK4/6 inhibitor-based therapy.

Trial design and objectives: TRINITI-1 (NCT02732119) is a US-based, phase I/II, single arm, open-label study of ribociclib (continuous daily dosing) + EVE (2.5 mg/day) + EXE (25 mg/day) in men and postmenopausal women with HR+, HER2– ABC refractory to ≥1 line of ET. Phase I dose escalation consists of 2 ribociclib dose-level cohorts (250 and 300 mg/day), followed by a Simon Two-Stage phase II trial in pts with disease progression on prior CDK4/6 inhibitor-based therapy. No more than 3 lines of therapy for ABC, including ≤1 prior chemotherapy regimen, are permitted. Previous EXE treatment of &gt;28 days for metastatic disease, prior mTOR inhibitors, and progression on &gt;1 CDK4/6 inhibitor are prohibited. All pts in phase II must have progressed on a CDK4/6 inhibitor as the last regimen before study entry. Additional eligibility criteria include measurable disease or lytic/mixed bone lesions and Eastern Cooperative Oncology Group performance status of ≤1. Exclusion criteria include visceral crisis, unstable CNS metastases, and clinically significant heart disease. Phase I primary objective: maximum tolerated dose and/or recommended phase II dose of the triplet combination. Phase II primary objective: clinical benefit rate (CBR) at 24 weeks (0.1 significance level, 80% power to test CBR ≤15% against CBR ≥30%) with centrally-assessed PFS as a key secondary objective. Other secondary objectives include preliminary antitumor activity (phase I), safety and pharmacokinetics (phase I/II), and overall response rate, overall survival, and duration of overall response (phase II). Tumor assessments (RECIST v1.1) will be performed every 8 weeks for the first 12 months, and every 12 weeks thereafter until disease progression. Exploratory analyses include biomarkers potentially predictive of response and mechanisms of resistance.

Target accrual: Approximately 52 pts at ∼30 sites; 3–6 pts per cohort in phase I, an initial 19 in phase II with another 20 enrolled upon demonstration of clinical benefit in ≥4 pts.

Citation Format: Bardia A, Hurvitz S, Yardley DA, Zelnak A, DeMichele A, Clark AS, Warsi G, Small T, Tucci C, Moulder S. TRINITI-1: Ribociclib + everolimus (EVE) + exemestane (EXE) triplet combination in men or postmenopausal women with HR+, HER2– advanced breast cancer (ABC) following progression on a cyclin-dependent kinase (CDK) 4/6 inhibitor [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-05.

Open partial nephrectomy with no clamping of the pedicule: a good surgical option in treatment of renal cancer

AIM

The aim of the present work was to describe authors' surgical experience using the partial nephrectomy technique without intraoperatory pedicle clamping for masses even up to 4 cm of size.

METHODS

The study enrolled 96 patients with an average age of 59.7 years, who underwent partial nephrectomy without pedicle clamping. The average dimensions of the masses treated were 3.7x3x3.8. In preoperative and in postoperative time creatinine, hemoglobine, hematocrit and platelets were monitored. The follow-up was of 1-3-6 months. At the third month postoperatively a renal US scan was performed, together with a control CT scan and at the sixth month of follow-up the patients underwent also a control Tc99/DMSA renal scintigraphy in back, front, oblique and right posterior oblique left rear projections.

RESULTS

Surgery and anesthesia time have been respectively of 1 h 51 min e 2 h 30 min. In the postoperative time the average values were: creatinine 1.46 ng/mL (±0.45), hemoglobin: 11.25 g/dL (±1.6), hematocrit: 36.4 % (±3), platelets: 205 x 103 (±45 x 103). At follow-up at 1-3-6 months the average values were: creatinine 1.16 ng/dL (±0.66), hemoglobin 14.13 g/dL (±0.13), hematocrit 42.43% (±1.03), platelets 204 x 103 U/L (±1.66 x103). After six months the renal function demonstrated intraparenchymal homogeneous distribution of the drug in all the patients, with a 7% of difference of relative uptake by the operated kidney than the healthy controlateral one.

CONCLUSION

The partial nephrectomy without intraoperative pedicle clamping can be a good therapeutic option for the treatment of kidney cancer for masses even up to 4 cm of size. The follow-up should be longer to assess oncological results.

Early Clinical Experience with Different Mesh in Correction of High-Degree Cystocele

Background

Cystocele is connected to an ingravescent relaxation of uretrovesical support system. During surgical correction of this disease, a mesh has been introduced to strengthen weak tissue. The aim of the study was to compare different material aspects and various devices.

Methods

From June 2002 to December 2008, 80 patients underwent surgical correction for high-degree cystocele. None of the patients had stress-incontinence. All the patients were studied with cistography and urodynamic test. Three different kinds of mesh were employed, such as: Goretex (26 pt.), Prolene (27 pt.), Bovine Pericardium (27 pt.). During surgery the mesh have been modelled if necessary and fixed by detached sutures.

Results

By comparing the devices: in Goretex group there were excellent results about anatomical correction, in the follow-up too (6 months), good continence and an improving of quality of life; in Prolene group no post-surgery complication, 3 pts. referred urge incontinence resolved in about 3 months. After 6 months a subset of patients reported sensation of foreign vulvar body and moderate dyspareunia; in Bovine Pericardium group we had an intra-operatory difficulty, for its softness a high risk to tear the net itself. No post-surgery complications. No urinary symptoms. After 3 months 5 of the patients referred a sensation of foreign vulvar body and dyspareunia. After 6 months, 4 patients still have the same sensation.

Conclusion

We hypothesize that Goretex mesh is an excellent device for its operator manageability, good anatomical results, and good tolerability. Further investigation is warranted to determine the effect of each of these techniques.

Viral RNA in nerve tissues of patients with hepatitis C infection and peripheral neuropathy

To assess the presence of viral ribonucleic acid (RNA) in nerve tissues of 15 patients with hepatitis C virus (HCV) infection and peripheral neuropathy with (11) or without (4) mixed cryoglobulinemia, nested reverse transcription-polymerase chain reaction (RT-PCR) was performed. Amplification of HCV-RNA was successful in 7 patients with and 3 without mixed cryoglobulinemia. This study demonstrates that the nested RT-PCR technique is a sensitive method to detect viral RNA in nerve tissue, and offers further evidence that in patients with HCV infection peripheral neuropathy can occur in the absence of mixed cryoglobulinemia.

[Urologic complications of diverticulosis of the colon]

In this paper the complications of colonic diverticulosis are reported, on the basis of two clinical cases personally observed. In the first case, a 68 year-old man, the typical symptomatology with pneumaturia, cloudy urine and watery diarrhea suggested a uro-colonic fistula, therefore a fistula between sigma and bladder, caused by a perforate diverticulum, has been diagnosed by means of cystography and barium enema. In the second case, a 64 year-old woman, the irritative symptomatology, hematuria and endoscopic picture suggested a vesical neoplasia. An accurate examination with abdominal TAC and barium enema, showed a perforate diverticulum between uterus and bladder, without affecting the bladder lumen. The surgical treatment required, in both cases, a left hemicolectomy, a minimal bladder resection in the first case, and a greater one in the second case. During the discussion, the main etiopathogenetic causes of uro-colonic fistulae together with the variants in the onset symptomatology, have been stressed.

Prostatic carcinosarcoma

A unique case of carcinosarcoma of the prostate in a 66-year old man is presented. The patient underwent a total prostatectomy under the diagnosis of prostatic carcinoma. Despite adjuvant radiotherapy, the patient died about 3 months after the operation. The surgically resected primary tumor was composed of two histologically distinct elements, an adenocarcinoma and sarcoma with various mesodermal components. These elements were intimately intermingled and transitional forms were often noted. The sarcomatous portion contained areas of chondromatous differentiation. The pathogenesis of this complex neoplasm is discussed.

[Ventricular arrhythmia in hypertrophic cardiomyopathy. When and how to treat]

Patients with apical hypertrophy have a natural favourable history. Non Specific Ventricular Tachycardia (NSVT) at ambulatory monitoring is more favourable if it is not associated with consciousness disorders. A high rate of NSVT episodes at Holter or the association with syncope can lead to a less favourable prognosis and therefore require pharmacological or electric treatment. The role of ET (electrophysiological test) has not yet been clearly described and is in progress. Recent studies of molecular genetics help to identify high-risk patients. Sustained monomorphic VT is not frequent but when it occurs it should be treated with BT. Patients with a light risk of VT should be treated with pharmacological therapy (white amiodarone and/or sotalol) and preferably with implantable defibrillator (ID) if VT cannot be eliminated. ID should be implanted also in the few patients surviving heart attack to avoid the risk of relapses.

[Heart failure in the elderly. Therapeutic strategies]

The different types of cardiac heart failures are examined: chronic failure deriving from systolic dysfunction, diastolic dysfunction failure, refractory heart failure, acute failure. Heart failure in the elderly is not always associated with impaired ventricular contractility with decreased EF and ventricular enlargement, but frequently with diastolic dysfunction of the left ventricle (LV). The echocardiographic examination is very useful to evaluate the type of ventricular dysfunction. Since the aortic baroceptor system is less sensible, diuretics and drugs decreasing after-load must be use carefully because of orthostatic hypotension and deterioration of kidney function. The elderly are most sensible to the action of digitalis because of the pharmacokinetic changes of the drug due to age. Although the current therapy of heart failure can relieve symptoms and prolong life, prognosis is always serious. The most effective therapy is prevention as it aims at the control and, if possible, at the regression of left ventricular dysfunction in the asymptomatic or slightly symptomatic stage.

[Rupture of the upper urinary tract during renal colic. Two cases]

The rupture of the upper urinary tract is an uncommon event. The authors describe 2 cases during renal colic and they write, particularly, about the diagnostic and therapeutic aspects of this pathology.

[A case of adrenal neoplasm]

Pheocromocytoma is a rare adrenal tumor. Generally its size is reduced and it is one of the causes of arterial hypertension. The authors present a case of giant pheocromocytoma, without arterial hypertension, and particularly they write about the used diagnostic and therapeutic management.

[Large inguino-scrotal bladder herniation]

The authors describe a case of voluminous inguinoscrotal bladder erniation. They write about the subjet with the help of the literature and above all they show the possible dangers of a vesical underestimated injury.

Dietary beta carotene and lung cancer risk in U.S. nonsmokers

BACKGROUND

Approximately 15% of all lung cancer deaths in the United States (about 22,350 deaths annually) may not be directly attributable to active cigarette smoking. Consumption of beta carotene, which is derived almost exclusively from intake of fruits and vegetables, has been associated with a reduced risk of lung cancer in smokers. However, studies examining this association in nonsmokers, particularly nonsmoking men, are limited.

PURPOSE

The purpose of this study was to examine whether dietary factors including beta carotene and retinol are associated with a reduced risk for lung cancer in nonsmoking men and women.

METHODS

A population-based, matched case-control study of lung cancer in nonsmokers was conducted in New York State from 1982 to 1985. Dietary interviews were completed for 413 individually matched case-control pairs of subjects. To determine whether the relationship between dietary intake from specific food groups and lung cancer differed by type of interview, smoking history, sex, age, or histologic type, we examined data on the case-control pairs from each subgroup separately. The intake of beta carotene and retinol was calculated as the weighted sum of the monthly frequencies of consumption of food items containing these nutrients, where the weights correspond to the nutrient content of a typical portion of the food items.

RESULTS

Consumption of greens (P for trend < .01), fresh fruits (P for trend < .01), and cheese (P for trend < .05) was associated with a significant dose-dependent reduction in risk for lung cancer, whereas consumption of whole milk (P for trend < .01) was associated with a significant dose-dependent increase in risk. Use of vitamin E supplements was also protective (odds ratio = 0.55; 95% confidence interval [CI] = 0.35-0.85). Increased consumption of the following food groups was associated with a reduction in risk among females: vegetables (P for trend < .025), raw fruits and vegetables (P for trend < .005), and dairy products (P for trend < .025). In males, increased consumption of raw fruits and vegetables was associated with a reduced risk for lung cancer (P for trend < .005). Dietary beta carotene (OR = 0.70; 95% CI = 0.50-0.99), but not retinol (OR = 0.98; 95% CI = 0.82-1.17), was significantly associated with risk reduction.

CONCLUSIONS

This is the largest study to date of dietary factors and lung cancer in nonsmokers; results suggest that dietary beta carotene, raw fruits and vegetables, and vitamin E supplements reduce the risk of lung cancer in nonsmoking men and women.

Lung cancer and exposure to tobacco smoke in the household

BACKGROUND

The relation between passive smoking and lung cancer is of great public health importance. Some previous studies have suggested that exposure to environmental tobacco smoke in the household can cause lung cancer, but others have found no effect. Smoking by the spouse has been the most commonly used measure of this exposure.

METHODS

In order to determine whether lung cancer is associated with exposure to tobacco smoke within the household, we conducted a population-based case--control study of 191 patients with histologically confirmed primary lung cancer who had never smoked and an equal number of persons without lung cancer who had never smoked. Lifetime residential histories including information on exposure to environmental tobacco smoke were compiled and analyzed. Exposure was measured in terms of "smoker-years," determined by multiplying the number of years in each residence by the number of smokers in the household.

RESULTS

Household exposure to 25 or more smoker-years during childhood and adolescence doubled the risk of lung cancer (odds ratio, 2.07; 95 percent confidence interval, 1.16 to 3.68). Approximately 15 percent of the control subjects who had never smoked reported this level of exposure. Household exposure of less than 25 smoker-years during childhood and adolescence did not increase the risk of lung cancer. Exposure to a spouse's smoking, which constituted less than one third of total household exposure on average, was not associated with an increase in risk.

CONCLUSIONS

The possibility of recall bias and other methodologic problems may influence the results of case-control studies of environmental tobacco smoke. Nonetheless, our findings regarding exposure during early life suggest that approximately 17 percent of lung cancers among nonsmokers can be attributed to high levels of exposure to cigarette smoke during childhood and adolescence.

[Role of the markers PAP-PSA in the diagnosis of cancer of the prostate]

The Authors report their personal experience relating to diagnostic screening for prostatic carcinoma using serum assays for specific markers of this tumour: prostatic acid phosphatase (PAP) and prostatic specific antigen (PSA). They underline the importance of high serum values of these substances, especially in tumors in an advanced state, and point out that these markers can play a role both in the diagnosis and in the follow-up of prostatic carcinoma.