TNFAIP3 mutation causing haploinsufficiency of A20 with a hemophagocytic lymphohistiocytosis phenotype: a report of two cases

BACKGROUND

A20 haploinsufficiency (HA20) is a newly introduced autosomal dominant autoinflammatory disorder, also known as Behcet's-like disease. Some of the most common symptoms of the disease are recurrent oral, genital, and/or gastrointestinal (GI) ulcers, episodic fever, musculoskeletal symptoms, cutaneous lesions, and recurrent infections. Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition of multi-organ failure due to excessive immune activation. HLH has been reported in a few HA20 patients. Herein, we report two children with the primary presentation of HLH, with a mutation in TNFAIP3, in favor of HA20.

CASE PRESENTATIONS

Our first patient was a 4-month-old boy who presented with fever, irritability, pallor, and hepatosplenomegaly. Pancytopenia, elevated ferritin, and decreased fibrinogen levels were found in laboratory evaluation. He was diagnosed with HLH and was treated with methylprednisolone and cyclosporine. Two years later, whole exome sequencing (WES) indicated a mutation in TNFAIP3 at NM_001270507: exon3: c.C386T, p.T129M, consistent with A20 haploinsufficiency. Etanercept, a TNF inhibitor, was prescribed, but the parents were reluctant to initiate the therapy. The patient passed away with the clinical picture of cerebral hemorrhage. The second patient was a 3-month-old boy who presented with a fever and hepatosplenomegaly. Laboratory evaluation found pancytopenia, hyperferritinemia, hypoalbuminemia, hypertriglyceridemia, and hypofibrinogenemia. With the establishment of the HLH diagnosis, he was treated with etoposide, dexamethasone, and cyclosporine, and recovered. WES results revealed a heterozygous de novo variant of TNFAIP3 (c. T824C in exon 6, 6q23.3) that leads to a proline to leucine amino acid change (p. L275P). He was treated with etanercept and has been symptom-free afterward.

CONCLUSIONS

This report is a hypothesis for developing of the HLH phenotype in the presence of TNFAIP3 mutation. Our results provide a new perspective on the role of TNFAIP3 mutation in HLH phenotypes, but more extensive studies are required to confirm these preliminary results.

Online Assessment for Pathology Residents during the COVID-19 Pandemic: Report of an Experience

BACKGROUND & OBJECTIVE

The world is facing COVID-19 pandemic, and medical education system and consequently the evaluation of students at different levels have been overshadowed. Residency students are among those affected. In the present study, we aim to share our experiences regarding holding exams for pathology residents before and during the pandemic.

METHODS

This cross-sectional study was carried out in Tehran University of Medical Sciences. The online exam, which consisted of 30 multiple-choice questions, was designed and held in April 2020 to evaluate pathology residents. To assess the quality of the exam, indices such as the number of questions, highest and lowest scores, the average score, the standard deviation, the variance, Cronbach's alpha reliability coefficient, standard error of measurement, discrimination index, difficulty index, number/percentage of questions on three difficulty levels of easy, normal, hard were reviewed and analyzed.

RESULTS AND DISCUSSION

The average score of the participants in the January exam which was held in the university's exam center was 16.23 (±5.03), while the average score in the online exam which was held after the onset of the pandemic was 20.86 (±5.18). The average discrimination indices in the first and second exams were 0.36 and 0.38, respectively, and the average difficulty indices in the first and second exams were 0.54 and 0.70, respectively. We found the administration of this online examination would be a positive experience. By sharing it, we hope to pave the way for similar ventures in the other departments.

NQO1 C609T Polymorphism is Associated with Coronary Artery Disease in a Gender-Dependent Manner

Findings on the association of NQO1 C609T polymorphism in the NQO1 gene and cardiovascular disease susceptibility are controversial. The objective of the current study was to examine the relationship between this polymorphism and the presence and severity of angiographically determined coronary artery disease (CAD). One-hundred and forty-five patients with newly diagnosed angiographically documented CAD (≥50 % luminal stenosis of any coronary vessel) as case group were compared to 139 controls (subjects with no luminal stenosis at coronary arteries). The presence of C609T polymorphism was analyzed using polymerase chain reaction-based restriction fragment length polymorphism. Among total population, those with combined CT/TT (T allele carrier) genotype showed a trend toward lower odds of CAD compared to those with CC (wild type) genotype, but it did not reach a statistically significant level (p = 0.061). When data were analyzed separately for men or women, CT + TT group as compared to CC genotype was associated with decreased odds of CAD in women (adjusted OR 0.4, 95 % CI 0.2-0.9; p = 0.043), but not in men (adjusted OR 0.8, 95 % CI 0.3-1.9; p = 0.612). The C609T polymorphism within NQO1 is independently associated with CAD in women, but no association was observed in whole study population or in men.

Effect of opium on glucose metabolism and lipid profiles in rats with streptozotocin-induced diabetes

BACKGROUND

This experimental study was performed to determine the impact of opium use on serum lipid profile and glucose metabolism in rats with streptozotocin-induced diabetes.

MATERIAL AND METHODS

To determine the effect of opium, 20 male rats were divided into control (n = 10) and opium-treated (n = 10) groups. After diabetes induction, the animals were investigated for daily glucose measurements for 35 days. Serum lipid profile and haemoglobin A1c (HbA(1c)) were assayed at the baseline (before induction of diabetes) and at 35-day follow-up.

RESULTS

The glycaemia levels in the rats treated with opium were similar to the levels measured in the control rats (544.8 +/- 62.2 mg/dl v. 524.6 +/- 50.0 mg/dl, P = 0.434). In addition, there was no difference between the opium-treated rats and control rats in HbA(1c) (6.5 +/- 0.5% v. 6.6 +/- 0.2%, P = 0.714). Compared to the control rats, the serum total cholesterol, high density lipoprotein (HDL), triglyceride and lipoprotein (a) in the test animals were similar.

CONCLUSION

Opium use has no significant effect on glucose metabolism and serum lipid profile in rats with induced diabetes.

Floating thrombus in the aortic arch as an origin of simultaneous peripheral emboli

Few cases of a floating thrombus in a normal aorta have been reported without other underlying reasons for the thrombus formation and its systemic embolic complications. We report a case in which a floating thrombus in the proximal aortic arch was detected after echocardiography and computed tomography angiography as an origin of upper extremities and ophthalmic embolism.