Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Diabetes: A Case Report

We present a case of a 42-year-old female living with poorly controlled diabetes who presented with a nine-month evolution of ataxic gait, reduced motor and sensitive function of lower and upper limbs, and postural anesthesia of fingers, feet, and toes. Deep tendon reflexes were abolished in the lower limbs and markedly diminished in the upper limbs. Cerebrospinal fluid (CSF) analysis showed a high protein level, and both imaging and serologic studies were normal. Although she had a previous electrophysiologic study showing distal symmetric polyneuropathy (DSPN) with an axonal lesion, nerve conduction studies were repeated, and a diagnosis of chronic inflammatory demyelinating polyneuroradiculopathy (CIDP) was made. According to the state of the art, intravenous immunoglobulin (IVIg) was started. The patient’s Inflammatory Neuropathy Cause and Treatment (INCAT) score and Medical Research Council (MRC) Sum Score both improved after two cycles. Unfortunately, symptoms quickly recurred, and corticosteroids were introduced to try to delay symptom recurrence, although it worsened diabetes control. Later, IVIg was stopped due to nephrotic syndrome, and immunosuppression was initiated. CIDP is a potentially treatable disease, but the diagnosis must be made as soon as possible to start therapy and reduce sequelae. Neuropathy in patients living with diabetes is common, but patients must be monitored closely to enable a correct diagnosis and adequate treatment.

Pulmonary Mucormycosis in a Poorly Controlled Diabetic Patient

Mucormycosis is a severe fungal infection that occurs mainly in immunocompromised patients. It is characterized by several syndromes with rhino-orbito-cerebral and pulmonary involvement.

We report the case of a 49-year-old patient admitted for diabetic ketoacidosis and Influenza B pneumonia nonresponsive to treatment, which was later diagnosed with pulmonary mucormycosis. After correct diagnosis and appropriate treatment with isavuconazole, the patient had a favorable evolution, which reinforces the importance of an accurate diagnosis.

Renal Impairment, C. difficile Recurrence, and the Differential Effect of Bezlotoxumab: A Post Hoc Analysis of Pooled Data From 2 Randomized Clinical Trials

Background

Renal impairment is not a consistently cited risk factor for recurrent Clostridioides difficile infection (rCDI). We examined the association between renal impairment and rCDI and the effect of bezlotoxumab, an anti–toxin B monoclonal antibody, in reducing rCDI in participants with renal impairment.

Methods

We pooled data from 2 randomized, double-blind, placebo-controlled, multicenter, phase 3 clinical trials conducted in participants receiving bezlotoxumab or placebo infusion during oral antibacterial drug treatment for CDI. We assessed the association between renal impairment and rCDI in placebo-treated participants and evaluated the effect of bezlotoxumab vs placebo in reducing rCDI among participants with renal impairment, defined as an estimated glomerular filtration rate <90 mL/min.

Results

The proportion of placebo-treated participants experiencing rCDI within 12 weeks was higher in those with renal impairment (n = 919) vs those without renal impairment (n = 612; 36.6% and 27.7%, respectively; difference, 8.9%; 95% CI, 1.3% to 16.3%). Renal impairment was significantly associated with a higher rate of recurrence in placebo-treated participants lacking commonly recognized risk factors for rCDI (renal impairment as only risk factor, 28.8%; vs normal renal function and no risk factors, 12.5%; difference, 16.3%; 95% CI, 3.4% to 28.8%). Among all participants with renal impairment, the rate of rCDI was 19.5% among bezlotoxumab-treated vs 36.6% among placebo-treated participants (difference, –17.1%; 95% CI, –23.4% to –10.6%).

Conclusions

This post hoc analysis adds to the literature suggesting an association of renal impairment as an independent risk factor for rCDI and provides preliminary evidence that patients with renal impairment who suffer with CDI may benefit from adjunctive treatment with bezlotoxumab.

Bone Marrow Langerhans Cell Histiocytosis in Association with Kasabach-Merritt Syndrome: The Difficulty of a Differential Diagnosis

Langerhans cell histiocytosis is a rare haematological disorder with variable clinical findings and a high mortality rate. On the other hand, Kasabach-Merritt syndrome is of rare onset at adult age, requiring the simultaneous presentation of vascular lesion, thrombocytopenia, and consumptive coagulopathy. We present the first reported case of both diseases in a single patient and highlight the difficulties of diagnostic. A 69-year-old woman with immune thrombocytopenic purpura underwent surgery for the removal of giant skin haemangiomas. During post-operative care, intravascular disseminated coagulopathy developed. After weeks of corticosteroids and immunosuppressive therapy with no clinical improvement, pulmonary tuberculosis was diagnosed and appropriate treatment initiated. Despite all the efforts, the patient's clinical condition kept worsening and she eventually died. An autopsy revealed bone marrow Langerhans cell histiocytosis. In this case, the patient's autoimmune background together with tuberculosis and intravascular disseminated coagulopathy masked the presentation and made the diagnosis of a rapidly progressive fatal disease very difficult.

Pituitary Apoplexy May Be Mistaken for Temporal Arteritis

Pituitary apoplexy is a rare endocrine emergency, characterized by a sudden increase in pituitary gland volume secondary to acute ischaemic infarction or haemorrhage of the pituitary gland, usually in the presence of a pituitary adenoma. We present the case of a 79-year-old man admitted for new-onset, bi-temporal and severe headache, associated with photophobia and vomiting, whose additional study revealed pituitary apoplexy. This case highlights the need for high clinical suspicion of this rare entity in order to reduce the associated mortality.

Inappropriate Prescribing to Elderly Patients in an Internal Medicine Ward

INTRODUCTION

Polypharmacy is often observed in elderly patients and is associated with an increased risk of adverse drug reactions, side effects and interactions. Clinicians should be alert to inappropriate drug prescribing and reduce polypharmacy.

MATERIAL AND METHODS

Observational, longitudinal, retrospective and descriptive study in an internal medicine ward in a Portuguese hospital. Polypharmacy was defined as the use of five or more different medicines. The purpose of this study was to describe the prevalence of polypharmacy and inappropriate prescribing at admission and discharge in an internal medicine ward, according to deprescribing.org guidelines/algorithms. A total of 838 consecutive patients were admitted between January and July 2017. All patients were aged under 65 years old, and those who died before discharge were excluded. Patients' medications were reviewed from a medical database at hospital admission and discharge. We examined whether patients were taking anticoagulants, proton pump inhibitors, benzodiazepines, antipsychotics and/or antihyperglycemic medication.

RESULTS

A total of 483 patients were included, mean age was 79.2 ± 8.0 years, and 42% of patients were male. Median number of medications at admission and discharge was six. Polypharmacy was present in more than 70% of admitted patients. Proton pump inhibitors were the most common inappropriate prescription at discharge (17.2%).

DISCUSSION

This study demonstrated a low use of inappropriate medicine (11.2% - 17.2%) in older people discharged from hospital, when compared to other studies.

CONCLUSION

Our study shows that polypharmacy is present in more than 70% of elderly admitted patients. Nevertheless, the drug inappropriateness rate was not significantly affected by polypharmacy at both admission and discharge, being overall lower than published data.

Bezlotoxumab (BEZ) for Prevention of Clostridium Difficile Infection (CDI) Recurrence (rCDI): Outcomes in Patients with Substantial Renal Impairment (SRI)

Background

CDI in patients with SRI is harder to treat and is associated with higher recurrence. MODIFY I/II found that BEZ, a monoclonal antibody against C. difficile toxin B, is superior to placebo (PBO) at preventing rCDI in patients receiving standard of care antibiotics (SoC). This post hoc analysis assessed efficacy of BEZ in patients with SRI in the MODIFY studies.

Methods

MODIFY I/II mITT populations were pooled to estimate initial clinical cure (ICC), rCDI, and mortality through 12 weeks. Estimated glomerular filtration rate (eGFR) was calculated with the Modified Diet in Renal Disease (MDRD) method. SRI was defined as eGFR <60 mL/minute/1.73 m². ICC was defined as SOC ≤16 days and no diarrhea on the 2 days after SoC end. rCDI was defined as diarrhea and toxigenic C. difficile in stool. Mortality within 90 days after randomization was summarized.

Results

Of the included 1554 patients, 1101 had no SRI (≥90: n = 612; 60 to < 90: n = 489); 430 had SRI (30 to <60: n = 290; 15 to <30: n = 71; <15: n = 69); 23 had unknown eGFR. 87% of SRI patients had ≥1 risk factor for rCDI. Relative to patients without SRI, more patients with SRI were ≥65 years (69% vs. 44%), immunocompromised (25 vs. 20%), had ribotype 027 (25% vs. 17%), and used concomitant antibiotics during SoC (41% vs. 31%) or after SoC (36% vs. 28%). SRI patients had more severe CDI (21% vs. 14%), lower CDI cure (78.4% vs. 80.1%), higher rCDI (31.6% vs. 27.8%), and death (11.6% vs. 5.3%) In the SRI cohort, more BEZ vs. PBO patients were inpatients (81% vs. 72%), ≥65 years (72% vs. 65%), immunocompromised (28 vs. 22%), and used systemic antibiotics after SoC ended (40% vs. 32%). The rate of ICC was similar between treatment groups and the rCDI rate was significantly less the BEZ vs. PBO group (Table).

Conclusion

SRI was associated with worse CDI outcomes. BEZ given with SoC significantly reduced rCDI in patients with SRI and could benefit this hard to treat population.

Disclosures

Y. Golan, Merck & Co., Inc.: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Research support and Speaker honorarium; Pfizer: Scientific Advisor, Speaker honorarium; Allergab: Grant Investigator and Scientific Advisor, Research grant and Speaker honorarium; The Medicines Company: Scientific Advisor, Speaker honorarium; Seres Pharmaceuticals: Scientific Advisor, Speaker honorarium; H. L. DuPont, BioK International, Salix: Consultant, Consulting fee; University Rebiotix, Seres, Takeda: Grant Investigator, Grant recipient; F. Aldomiro, BMS & ViiV: Scientific Advisor, Consulting fee; MSD, Viiv, Astellas & Pfizer: Participated in Clinical Trials, Research support; E. H. Jensen, Merck & Co., Inc.: Employee, may own stock/hold stock options in Company; M. E. Hanson, Merck & Co. Inc.: Employee, may own stock/hold stock options in the Company; M. B. Dorr, Merck & Co., Inc.: Employee and Shareholder, may own stock/hold stock options in the Company

[Gastric carcinoid associated with pernicious anemia]

A clinical case of a patient with pernicious anaemia and a carcinoid tumor of the gastric fundus is described. In the context of the case the relationship between pernicious anaemia, achlorhydria, atrophic gastritis and gastric carcinoid is discussed. The gastric neuroendocrine tumours and their structural and functional characteristics were reviewed in an attempt to clarify the nomenclature and the diagnostic and therapeutic approach in these situations.