Case report: EBV-related eye orbits and sinuses lymphohistiocytic infiltration responsive to rituximab in a patient with X lymphoproliferative syndrome type 1

Background and aims

X lymphoproliferative syndrome type 1 (XLP1) is a rare inborn error of immunity due to mutations of SH2D1A, encoding for slam-associated protein (SAP). The clinical phenotype includes severe mononucleosis, hemophagocytic lymphohistiocytosis (HLH), and B-cell lymphomas.

Methods

We report the case of a child affected with XLP1 who presented with an incomplete HLH, triggered by Epstein-Barr virus (EBV) and treated with rituximab, involving orbits and paranasal sinuses.

Results

The lesion was indistinguishable from lymphoma, complicating diagnosis and treatment. In addition, considering the high incidence of lymphoma in patients with XLP1, histology helped define its nature, driving therapeutic choices.

Conclusion

We described an unusual presentation of incomplete HLH in a patient affected with XLP1: an EBV-driven infiltration of the orbits and paranasal sinuses. This led us to a challenging differential diagnosis of lymphoma-associated hemophagocytic syndrome, which can be frequently observed in patients with XLP1. Considering the extremely poor prognosis of this clinical finding, we sought for a prompt diagnosis and managed to obtain it and to immediately establish the right treatment on the basis of the pathological finding.

A rare case of bilateral conjunctival Kaposi's sarcoma in a HIV-negative patient

PURPOSE

Kaposi's sarcoma (KS) is a rare multi-centric vascular neoplasm, first described by Moritz Kaposi in 1872. It can appear in four different forms: classic, endemic, HIV-related and post-transplant form. We present an uncommon case of seronegative HIV infection patient with skin KS involving conjunctiva of both eyes.

OBSERVATIONS

Firstly, right eye lesions were surgically removed. Subsequently, the patient was administered with systemic chemotherapy (doxorubicin) to treat both skin and left eye lesions. No signs of recurrence were observed at 20 months' follow-up.

CONCLUSIONS

Both eyes involvement in KS is rarely described in scientific literature. Both surgery and chemotherapy could be considered valid treatment options for conjunctival KS.

Primary cutaneous anaplastic large-cell lymphoma of the eyelid: report of two cases and review of the literature

PURPOSE

Two new cases of primary cutaneous CD30+ anaplastic large-cell lymphoma (cALCL) of the eyelid are reported; these are analysed alongside existing cases to identify challenges relating to the diagnosis and management of such rare lesions.

MATERIAL AND METHODS

A review of existing literature on the PubMed database is conducted using the keywords: 'eyelid lymphoid proliferations', 'lymphoma of the eyelid', and 'primary cutaneous CD30+, ALK-anaplastic large-cell lymphoma of the eyelid'. Two new cases of cALCL are reported. Cases where patients present solely with a nodular periocular lesion are analysed for recurrence and survival rate.

RESULTS

Two new patients with a painless ulcerated nodule on the upper eyelid receive a confirmed diagnosis of cALCL after undergoing an excisional biopsy. The first, elderly patient has spontaneous remission; the second patient, with a concomitant chronic infection of hepatitis C virus (HCV), presents a more diffuse disease at the onset and requires radiotherapy. Together with 13 patients a primary cALCL identified from 11 previous studies, this constitutes a cohort of 15 patients. Of these, 10 present with an exclusively nodular lesion of the eyelid and four experience disease recurrence; no deaths from cALCL are reported.

CONCLUSION

Differential diagnosis between primary cALCL and lymphomatoid papulosis is essential and requires careful consideration of clinical and pathologic features. Radiologic staging examination is crucial in order to exclude systemic ALCL, particularly for patients with comorbidity. Though cALCL has the pathological features of a malignant lesion, the prognosis seems favourable for patients; a relatively high percentage even experience spontaneous resolution.

P1296 Effects of contact-to-balloon time on variations of the left ventricle global and regional function during hospitalization of STEMI patients: an echocardiographic study

Background

Ischemic time duration is one of the most important determinants of infarct size in patients with ST-segment elevation myocardial infarction (STEMI). An early reperfusion with percutaneous coronary intervention (PCI) therapy reduces the adverse events and mortality. It also influences the wall motion abnormalities and left ventricular ejection fraction (LVEF), which can be easily detected by a standard transthoracic echocardiogram (TTE).

Purpose

Aim of our study was to assess the immediate effects of an early percutaneous revascularization in STEMI patients on variations of the left ventricle (LV) global and regional function.

Methods

The study population consists of 141 consecutive patients with STEMI undergoing PCI from January to June 2018. The population was divided into two groups basing on first medical contact-to-balloon time (C2B), respectively ≤90 minutes and >90 minutes. Cardiac biomarkers were obtained uniformly. A standard TTE was performed in all patients, at moment of in-hospital admission and at the time of discharge, recording the LV wall motion abnormalities and LVEF, using the wall motion score index (WMSI) and modified Simpson’s rule, respectively. Finally, we performed a sub-analysis in the group of patients who showed an improvement of the LVEF ≥10% at discharge.

Results

In both groups at baseline, patients suffered from a moderately reduced LVEF (41 ± 8.3% in ≤90 min group vs 40.97 ± 8.91% in >90 min group, p = ns). A WMSI >1 was recorded uniformly: 1.78 ± 0.39 in patients with C2B ≤90 min and 1.81 ± 0.40 in patients with C2B >90 min, without significant differences between the two groups. At the time of discharge, a significant improvement of LVEF (from 41 ± 8% to 44 ± 9%, p = 0.013) and WMSI (from 1.78 ± 0.39 to 1.64 ± 0.38, p = 0.036) exclusively emerged in the ≤90 min group. Furthermore, we identified 37 patients who experienced, at the time of discharge, an improvement of the LVEF ≥10% compared to baseline values. In these patients the C2B time resulted significantly shorter, when compared with patients with LVEF improvement <10%: 42 min (IQR 18.5-77.5) vs. 104 (IQR 48-176), p < 0.0001. Additionally, these patients had lower significant levels of cardiac biomarkers. A significant improvement in WMSI was also observed in the ≥10% group (1,69 ± 0,41 vs 1,49 ± 0,41, p= 0.039).

Conclusion

Our study shows the immediate effects of an early revascularization. In particular, the duration of C2B time influences the recovery of ventricular function, in terms of ejection fraction and parietal kinetics. A standard TTE is a low cost and easily available examination, which may provide immediate results without impacting significantly on health costs.

P299 Acute effects of Levosimendan on myocardial function in patients with severe mitral regurgitation and left ventricular dysfunction undergoing MitraClip repair

Background

MitraClip system has developed as a valid therapeutic option in patients affected by moderate to severe and severe mitral regurgitation, low left ventricular ejection fraction (LVEF) and high surgical risk. Often, after the procedure occurs afterload mismatch, an acute and transient worsening of LVEF. Inotropic drugs can improve hemodynamic values at the prize of severe side effects. Levosimendan increases myocardial contractility without an elevation of intracellular calcium concentration, tachyarrhythmia and cardiomyocytes necrosis.

Purpose

Aim of our study was to assess the acute Levosimendan effects on LVEF of patients who underwent MitraClip procedure

Methods

Among 160 patients who underwent MitraClip procedure in our institute, 99 patients, with LVEF ≤35%, were included in the study. Transthoracic echocardiogram was performed in all patients, at moment of hospital admission and at discharge; transesophageal echocardiogram was performed during the procedure. We recorded the LVEF by modified Simpson’s rule. Periprocedural hemodynamic parameters were also recorded. 59 patients received Levosimendan during and early after the procedure (L-group) and 40 patients did not (no-L-group). Levosimendan perfusion was started at 0.01 μg/kg/min 1 h before the procedure without a loading dose, and maintained for 12h, according to hemodynamics.

Results

In the overall population, patients suffered from a severe reduction of LVEF (29.5 ± 5.3%) and high systolic pulmonary arterial pressure (sPAP) (51 ± 14.2 mmHg), without significant difference between the two groups. Acute procedural success was achieved in 98% of the study population, with 2 procedural failures in no-L-group (p = 0.16). During the procedure we observed a significant improvement of LVEF compared to baseline values only in L-group (from 29.6 ± 5.7% to 32.1 ± 7.6%, p = 0.046); in no-L-group the LVEF improved from 29.4 ± 5% to 30.2 ± 4.9% (p = 0.47); at discharge the LVEF was 31.3 ± 4.9% and 30.8 ± 5.7%, in L-group and no-L-group, respectively (p = ns compared to baseline and procedure). At discharge the sPAP significantly reduced in the overall population to 46.3 ± 12.7 mmHg (p 0.015): from 50.8 ± 12.3 mmHg vs 48.7 ± 11.9 in L-group (p = 0.35); from 51.2 ± 16 to 44.3 ± 13.2 mmHg (p = 0.04) in no-L-group. In-hospital mortality was 1.7% in L-group (1 patient die) and 0% in no-L-group. No relevant arrhythmias were reported in any patient during the hospital recovery.

Conclusion

In MitraClip patients with severe reduction of LVEF, Levosimendan has proven to improve hemodynamic outcome, increasing myocardial contractility during and early after procedure.

P1362 Echocardiographic findings and BNP levels in patients with valve-in-valve implantation in small failed mitroflow aortic prosthesis

BACKGROUND

Early structural valve deterioration (SVD) frequently occurs in Mitroflow aortic bioprosthesis, especially for small sizes (19-mm and 21-mm), and it is associated with reduced overall survival. Treatment by percutaneous valve-in-valve (ViV) implantation is considered a challenging procedure. This is mainly due to an elevated risk of coronary ostia obstruction and high residual post-procedural mean gradients (mG), particularly when severe pre-existing patient-prosthesis mismatch (PPM) is present.

PURPOSE

Aim of our study was to assess the feasibility of transfemoral ViV in small Mitroflow aortic valves using supra-annular self-expanding valves, named CoreValve and Evolut R and Acurate neo and report the midterm clinical results by comparing serum natriuretic peptide type B levels (BNP) before the procedure and at a mean follow-up of 2 years.

METHODS

This is an observational study including 11 patients with stenotic-type SVD of small Mitroflow aortic valves, considered at high/prohibitive risk for surgical reoperation, who underwent ViV implantation between July 2012 and March 2018. We performed echocardiographic assessment of valve hemodynamics (according to VARC-2 definitions) before and after the procedure and during the follow-up. We used the BNP ratio (the ratio between measured serum BNP/NT-proBNP level and maximal normal level) to compare BNP results before the procedure and at follow-up. All-cause mortality during the hospitalization and follow-up was also reported.

RESULTS

The Mitroflow size was 19-mm in 4 patients and 21-mm in 7 patients. Pre-existing severe PPM was present in 4 patients and moderate PPM in 7. CoreValve 26 was implanted in 2 patients, EvolutR 23 in 5 and Acurate neo S in 4 patients. We reported no coronary obstruction, deaths or other major events during the hospitalization. At a mean follow-up of 2 years one patient died. The baseline aortic mG of 56 ± 19 mmHg has significantly reduced after the procedure to 16,6 ± 8 mmHg (p < 0.0001) and follow-up 29,6 ± 16 mmHg (p = 0.008). A post-procedural mG≥20, but <40 mmHg, was observed in 3 patients. BNP ratio at baseline was 14,6 ± 12; only one patient had a BNP ratio <3. At follow-up (n = 7 patients), BNP ratio was significantly lowered to 1,5 ± 1,08 (p = 0.01) with only one patient with a BNP ratio >3. Patients with mPG ≥20 mmHg did not show differences in terms of mortality and reduction of serum BNP levels.

CONCLUSIONS

In our experience the ViV procedure on small degenerated aortic Mitroflow bioprosthesis appears to be technically feasible and provides good midterm clinical results with a net reduction in serum BNP levels, although an increase in mG was observed. Even though a post-procedural mG ≥20 mmHg is considered indicative of suboptimal aortic valve hemodynamics (according to VARC-2 criteria), its correlation with worse outcomes remains unclear and deserves further investigations.

P748 Three-year echocardiographic outcomes in MitraClip patients with chronic kidney disease

Background

Chronic kidney disease (CKD) has been shown to impact negatively the prognosis of patients with heart failure, coronary artery or valvular heart disease and emerged as predictor of poor outcomes in mitraclip population.

Purpose

Aim of our study was to evaluate three-year echocardiographic outcomes in CKD patients with severe mitral regurgitation (MR) treated with mitraclip.

Methods

This in an observational study including patients treated with mitraclip in our institution, who completed three years of follow up. Patients population was divided into two groups according to basal creatinine clearance (CrCl): group A, including patients with normal/mild decline of renal function (CrCl > 60 ml/min) and group B, including patients with CKD (CrCl < 60 ml/min). Demographic and procedural characteristics were compared, as well as echocardiographic data, including grade of MR, left ventricular ejection fraction (LVEF), mean transmitral gradient and systolic pulmonary artery pressure (sPAP). Kaplan-Meier survival curves were obtained.

Results

The study population consists of 107 patients (mean age 71 ± 9 years, 69% male): 57 belonging to group A and 50 to group B. Patients of group B had higher values of LogEuroScore (22 ± 10 vs.15 ± 9 p = 0,0002), systemic hypertension (92% vs. 74%, p = 0,026), complicated diabetes (46% vs. 24% p = 0,034) and NYHA IV before the procedure (24% vs 9 %, p = 0,059). Additionally, patients of group B had lower baseline LVEF (35 ± 11 vs. 41 ± 13; p = 0,012). Procedural success was similar between the two groups without significant difference in degree of MR reduction after mitraclip implantation. Echocardiographic follow-up showed that in group B, the LVEF did not improve after the treatment (more than 50% had LVEF < 35% at 1,2 and 3 years) while in the group A it improved significantly (LVEF < 35% from 47,6% at discharge to 29%, 32% and 31% at 1, 2 and 3 years, respectively). In comparison to group A, in group B a progressive increase in residual MR grade was observed (moderate-to-severe MR from 2% at discharge to 14%, 15%, and 27% at 1, 2 and 3 years, respectively) as well as in the mean transmitral gradient (from 3,90 ±1,6 mmHg after the mitraclip implantation to 5,28 ± 1,7; 5,73 ± 1,75; 6,06 ±1,75 at 1, 2 and 3 years, respectively) and sPAP (from 47 ± 12 mmHg at discharge to 49 ± 21; 51 ± 20; 48 ± 22 at 1, 2 and 3 years, respectively). Kaplan Meier estimate of survival free from in-hospital readmission was 77% in group A and 61% in group B (Log-Rank 4.563, p = 0,033) and survival free from cardiovascular death was 95% and 81,5%, in group A and B, respectively (Log-Rank 4.806, p = 0,028).

Conclusion

Our results suggest that CKD patients have poorer outcomes after mitraclip implantation with worsening of some echocardiographic parameters, particularly for residual MR degree, mean transmitral gradient and sPAP, without improvement in LVEF at one, two and three years of follow-up.

95 A rare case of Lactobacillus Plantarum prosthetic valve endocarditis

INTRODUCTION

Lactobacillus species are rare human pathogens but have been implicated in a variety of infections, including bacteremia and endocarditis, with Lactobacillus casei and Lactobacillus rhamnosus among the most frequently isolated species. Endocarditis due to Lactobacillus represents <0.5% of all cases of endocarditis and are associated with structural heart diseases, recent surgery, extended antibiotic and probiotic use and immuno-deficiency. We report a case of Lactobacillus plantarumendocarditis in a patient with biological aortic prosthetic valve.

CASE REPORT

Our patient is a 48 year-old male with a past medical history of surgical aortic replacement with a biological prosthetic valve in 2013. He reports the onset of symptoms 4 months before with worsening asthenia. The patient presented to a cardiologist after 3 months from symptoms beginning. A transesophageal echocardiogram (TEE) described marked fibro-plastic thickening of the cusps with two elongated vegetations (12 mm and 7 mm) causing a moderate-to-severe aortic steno-regurgitation. A few days later he came to our emergency department. On admission, the patient was afebrile, eupnoeic on room air. The cardiac examination revealed a regular rate and rhythm with a grade 4 of 6 holosystolic murmur loudest at the aortic and pulmonary focus. Three sets of blood cultures were drawn on admission. Hence, he was transferred to the Infectious Diseases Department where he started antibiotic therapy with Ceftriaxone and Gentamicin. A 18F-FDG PET-CT total body showed tracer accumulation close to the prosthetic aortic valve. Few days later Lactobacillus Plantarum was isolated from blood cultures and, according to the antibiogram results, therapy was adjusted using G Penicillin, Vancomicyn and Gentamicin. The TEE, performed during the hospitalization, showed one mobile vegetation, reduced in size (5 mm), adherent to the anterior aortic cusp, which prolapsed in the left ventricular outflow tract and commissural fusion, causing severe steno-regurgitation (Gmax 84 mmHg, Gmed 54 mmHg). During hospitalization the serial blood cultures resulted negative. Serial TEEs were also performed (3rdand 6thweek), showing a gradual reduction of the cusps thickening and disappearance of commissural fusion (Figure). In the last TEE no vegetations were described, and the transaortic mean gradient was reduced (Gmed 38 mmHg), persisting severe regurgitation. Hence the patient was discharged with oral antibiotic therapy (amoxicillin and clavulanic acid) and indication to redo aortic valve surgery. Written informed consent was obtained.

CONCLUSIONS

L. plantarum is a rare form of endocarditis. In our patient it caused fibro-plastic thickening of the bioprosthesis cusps and commissural fusion, determining severe steno-regurgitation. It also responded to targeted antibiotic therapy with improvement in cusp mobility but persistence of severe regurgitation.

Abstract 95 Figure

Intravenous injection of bortezomib, melphalan and dexamethasone in refractory and relapsed multiple myeloma

BACKGROUND

A combination of bortezomib (1.3 mg/m(2)), melphalan (5 mg/m(2)), and dexamethasone (40 mg) (BMD), with all three drugs given as a contemporary intravenous administration, was retrospectively evaluated.

PATIENTS AND METHODS

Fifty previously treated (median 2 previous lines) patients with myeloma (33 relapsed and 17 refractory) were assessed. The first 19 patients were treated with a twice-a-week (days 1, 4, 8, 11, 'base' schedule) administration while, in the remaining 31 patients, the three drugs were administered once a week (days 1, 8, 15, 22, 'weekly' schedule).

RESULTS

Side-effects were predictable and manageable, with prominent haematological toxicity, and a better toxic profile in 'weekly' schedule (36% versus 66% in 'base' schedule). The overall response rate was 62%. After median follow-up of 24.5 months (range 2.7-50 months), the median progression-free survival (PFS) was 21.6 with no difference between the two schedules and the median overall survival (OS) was 33.8 months. Independently from the adopted schedule, we found that also in a cohort of relapsed/refractory patients achieving at least partial remission improved PFS (35.2 versus 9 months) and OS (unreached median versus 18 months).

CONCLUSION

Taken together, our observations suggest that BMD is an effective regimen in advanced myeloma patients with acceptable toxicity.

Risk factors for orbital exenteration in periocular Basal cell carcinoma

PURPOSE

To present the proportion of patients with periocular basal cell carcinoma (BCC) who underwent orbital exenteration and to evaluate the significance of the following risk factors: initial tumor site, pathologic features, and initial treatment.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Charts of all patients with BCC referred to Orbital Unit of the University of Naples "Federico II" between 1984 and 2003 were reviewed. Charts were reviewed for patient demographics, previous treatments, tumor site, clinical presentation, duration of symptoms, and histologic subtype. The main outcomes were recurrence rate, tumor-related deaths, orbital infiltration, and rate of exenteration.

RESULTS

Data (including follow-up) were available for 506 patients. Twenty-eight patients (5.5%) underwent orbital exenteration. For 8 patients (28.5%), orbital exenteration was the first procedure performed. In the exenterated group, the most common tumor site was the medial cantus, whereas in the overall group, it was the lower eyelid (P = .001). The proportion of patients initially treated without margin control was significantly higher in patients undergoing exenteration (P = .0001). Pathologic examination revealed a higher incidence of infiltrative subtype in the exenterated group (P = .00019).

CONCLUSIONS

The need for exenteration for BCC may be significantly higher when the lesion involves a medial canthal location, initial management does not include margin-controlled excision, or pathologic analysis reveals an infiltrative subtype. Margin-controlled excision for periocular BCC and close follow-up after excision for medial canthal BCC may be indicated.

Multidisciplinary treatment of primary orbital rhabdomyosarcoma. A single-institution experience

Orbital rhabdomyosarcoma accounts for one-fourth of the primary tumors in the head and neck region. Modern treatment modalities have led to a 2-year survival rate of about 90% in these patients. However, new therapeutic trials are designed to reduce complications and salvage more than 90% of orbital cases. Between 1979 and 1990, 12 children affected by primary orbital rhabdomyosarcoma have been diagnosed and treated at the University of Naples. Ten of them have been uniformly treated by biopsy, followed by immediate radiation and combined chemotherapy. All 12 patients are alive and free of detectable disease, from a minimum of 7 months to a maximum of 123 months after diagnosis. In all children, ocular structures have been spared and the complications observed until now have been few. The above results suggest that the association of immediate radiation therapy and chemotherapy might represent an optimal tool for treatment of orbital rhabdomyosarcoma.