Further characterization of clinical and laboratory features occurring in VEXAS syndrome in a large-scale analysis of multicenter case-series of 116 French patients

BACKGROUND

A new autoinflammatory syndrome related to somatic mutations of UBA1 was recently described and called VEXAS syndrome.

OBJECTIVE

To describe clinical characteristics, laboratory findings and outcomes of VEXAS syndrome.

DESIGN

Case-series.

SETTING

Patients referred to a French multicenter registry between November 2020 and May 2021.

PATIENTS

116 patients with VEXAS syndrome.

MEASUREMENTS

Frequency and median of parameters and vital status, from diagnosis to the end of the follow-up.

RESULTS

Main clinical features were skin lesions (83.5%), non-infectious fever (63.6%), weight loss (62%), lung involvement (49.6%), ocular symptoms (38.8%), relapsing chondritis (36.4%), venous thrombosis (34.7%), lymph nodes (33.9%), and arthralgia (27.3%). Hematological disease was present in 58 cases (50%), considered as myelodysplastic syndrome (MDS, n= 58) and monoclonal gammapathy of unknown significance (n=12).UBA1 mutations included p.M41T (44.8%), p.M41V (30.2%), p.M41L (18.1%), and splice mutations (6.9%). After a median follow-up of 3.0 years, 18 patients died (15.5%), from infectious origin (n=9) and MDS progression (n=3). Unsupervised analysis identified 3 clusters: cluster 1 (47%) with mild-to-moderate disease; cluster 2 (16%) with underlying MDS and higher mortality rates; cluster 3 (37%) with constitutional manifestations, higher C-reactive protein levels and less frequent chondritis. Five-year probability of survival was 84.2% in cluster 1, 50.5 % in cluster 2, and 89.6% in cluster 3. UBA1 p.Met41Leu mutation was associated with a better prognosis.

CONCLUSION

VEXAS syndrome displays a large spectrum of organ manifestations and shows different clinical and prognostic profiles. It also raises a potential impact of the identified UBA1 mutation.

[Expectation of patients and caregivers about patient education for immune thrombocytopenia]

INTRODUCTION

Immune thrombocytopenia (ITP) durably affects quality of life in patients. Patient education aims at improving their self-care and psychosocial skills, allowing them be more autonomous, to prevent avoidable complications, and to maintain or improve quality of life. The aim of this study was to assess patients' and caregivers' expectations regarding patient education in ITP.

METHOD

ITP Patients and caregivers were asked about topics that should be addressed in a patient education program through a digital anonymous survey. Their responses were analyzed both qualitatively and quantitatively. A double-blind keyword attribution of the answers was carried out by two physicians and then faced until consensus was found.

RESULTS

Thirty-eight ITP patients were included: 68% were less than 50 years old and 84% had chronic ITP. On the other hand, twenty-five caregivers were included. Caregivers raised more topics related to the cognitive domain than patients. The psychoaffective and motivational topics tended to be more represented in patients' responses. Only 53% of topics were mentioned by both patients and caregivers.

CONCLUSION

These discrepancies emphasize the differences between patients and caregivers' expectations regarding a patient education program in ITP, and thus the relevance of patient-caregiver co-construction of such programs.

[Bilateral adrenal hemorrhage under apixaban in primary antiphospholipid syndrome]

INTRODUCTION

Adrenal hemorrhage is a classical but rare complication of antiphospholipid syndrome, revealing diagnosis in one third of the cases. Anti-vitamin K therapy is the standard treatment but direct oral anticoagulants are discussed as an alternative. In the latest recommendations, it is advised not to use direct oral anticoagulants in the setting of antiphospholipid syndrome.

CASE REPORT

We present a case of bilateral adrenal hemorrhage revealing primary antiphospholipid syndrome with triple positive antibody profile, in a 47-year-old man treated by apixaban for previous venous thromboembolism.

CONCLUSION

To our knowledge, it is the first case of adrenal hemorrhage occurring during apixaban treatment in a patient with antiphospholipid syndrome. This case illustrates the inefficacy of direct oral anticoagulants to prevent thrombotic events in antiphospholipid syndrome, in accordance with the latest recommendations.

[Gaucher Disease type 1 mimicking immune thrombocytopenia: Role of hyperferritinemia and hypergammaglobulinemia in the initial evaluation of an isolated thrombopenia]

INTRODUCTION

Gaucher disease type 1 is a rare genetic disease. It can cause thrombocytopenia. Current guidelines do not support bone marrow examination in front of isolated thrombocytopenia if no evidence suggests malignant hemopathy. This strategy aiming at sparing unnecessary investigations makes such rare diseases more difficult to diagnose.

CASE REPORT

A 31-year-old woman was diagnosed with immune thrombocytopenia according to current guidelines. She presented later with mild splenomegaly. Bone marrow aspirate smears showed Gaucher cells. Gaucher disease was then confirmed. Looking backward, initial biological clues (hyperferritinemia, hypergammaglobulinemia) should have enabled to consider the diagnosis.

CONCLUSION

Gaucher disease type 1 can be responsible for apparently isolated thrombocytopenia. The disease must be looked for if the thrombocytopenia is associated with unexplained hypergammaglobulinemia or hyperferritinemia. Diagnosing immune thrombocytopenia without bone marrow sample requires to systematically pay attention to any clinical or biological abnormality, not to ignore rare differential diagnoses.

Landscape and climatic characteristics associated with human alveolar echinococcosis in France, 1982 to 2007

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Epidemiological investigation of a human leptospirosis case reported in a suburban area near Marseille

Leptospirosis has been re-emerging in both developed and developing countries, including in Europe, where the phenomenon has notably been associated with urban transmission. In this work, we describe an epidemiological investigation that demonstrated a case of human infection due to peri-urban transmission of Leptospira interrogans serovar icterohaemorrhagiae in southeastern France.

Presence of sandflies infected with Leishmania infantum and Massilia virus in the Marseille urban area

Leishmaniasis is considered a rural disease in Europe. However, circumstantial evidence has indicated urban transmission of leishmaniasis and phleboviruses in the urban area of Marseille, France. To investigate this urban transmission, sandflies were trapped in 33 locations in the urban area (horse farms, public gardens and a residential area). Sandflies were always captured: 87.8% were Phlebotomus perniciosus, a vector of Leishmania infantum and Toscana and Massilia viruses. RT-PCR and cell culture inoculation identified the Massilia virus in 2/99 pools of sandflies, and PCR identified Leishmania in 5/99. No dual infection was observed, but both pathogens were detected in samples from the same trapping site.

Long-term ocular outcome in congenital toxoplasmosis: a prospective cohort of treated children

OBJECTIVES

Congenital toxoplasmosis remains a public health problem throughout the world. Long-term longitudinal studies are still needed to argument controversial screening and treatment strategies and to enable to accurately counsel parents.

METHODS

We conducted a prospective cohort study over 16 years in Marseilles, France. Seronegative pregnant women underwent monthly serological testing. Children were treated antenatally with rovamycine as soon as maternal infection was detected and with pyrimethamine and sulfadoxine in case of positive Toxoplasma PCR on amniotic fluid. Postnatal treatment with pyrimethamine and sulfadoxine was systematically prescribed for one year and possibly continued at the physician discretion.

RESULTS

127 children were included. 24 children (18.9%) presented ocular lesions causing visual impairment in eight cases. Eleven children (8.7%) presented with ocular lesions at birth, mostly macular. Sixteen children (12.6%) developed ocular lesions during follow-up, mostly peripheral. The first ocular lesion could occur as late as 12 years after birth. No significant risk factor of chorioretinitis was identified including gestational age at infection, type of antenatal treatment and shorter postnatal treatment.

CONCLUSIONS

These results confirm the overall good prognosis of congenital toxoplasmosis in Europe but highlight though a low risk of late ocular manifestation. Chorioretinitis affected 18.9% of children suffering from congenital toxoplasmosis despite antenatal and neonatal screening associated with early treatment. Long-standing follow-up is needed because first lesion can occur as late as 12 years after birth. Late lesions were less often macular but nevertheless caused sometimes visual impairment.

Optimization of Toxoplasma gondii DNA extraction from amniotic fluid using NucliSENS easyMAG and comparison with QIAamp DNA minikit

Antenatal diagnosis of congenital toxoplasmosis relies on PCR in amniotic fluid. Because parasitic load is often low, DNA extraction must be optimized. Manual methods remain widespread although automated methods appear more effective. This study aimed at optimizing an automated method and at comparing it with a widespread manual method: QIAamp DNA minikit. To optimize NucliSens easyMAG, we evaluated the addition of proteinase K pre-treatment and the increase of the amount of silica particles used for the extraction. The optimized method was then compared to QIAamp DNA minikit on samples containing less than 25 tachyzoites/ml. NucliSens easyMAG DNA yield was improved after proteinase K pre-treatment (p < 0.01), but not with a higher silica particle input. The optimized method yielded more positive PCRs than the manual method, especially for samples containing 5 tachyzoites/ml or less (71% vs 26%, p < 10(-4)). The DNA amount in samples found positive by PCR was higher after optimized automated extraction than after manual extraction (p < 10(-4)). Proteinase K pre-treatment should be added to extract DNA from amniotic fluid using NucliSens easyMAG. Using this optimized automated method rather than manual methods would improve the sensitivity of Toxoplasma PCR and simplify the daily workflow.

[Permanent deafness following typhoid fever: case report from Dakar, Senegal]

Severe infections due to Salmonella typhi and Salmonella paratyphi are still common in sub-Saharan Africa where many patients are empirically treated for malaria. In addition to the usual clinical signs and complications of typhoid fever, clinicians practicing in high incidence areas must be aware of less common manifestations. The purpose of this report is to describe a case involving an 18-year-old boy who presented with quinine-resistant febrile coma. The final diagnosis was typhoid fever. After recovery the patient presented complete deafness. Discussion raises the question of whether deafness was secondary to typhoid fever or to drug therapy.

[The poster, an intelligent choice for scientific communication]

The dissemination of knowledge is a fundamental duty in any discipline, and nurses are increasingly required to communicate the results of their clinical or theoretical accomplishments. In recent years, thanks to computerization and other technological advances, poster sessions have become a preferred instrument for communicating scientific information to a large audience. After presenting the advantages of this type of communication, the authors-two nurses and a programmer analyst-deal with the essentials of creating a poster, from choosing a type of poster, its content and its visual design to planning the necessary human and material resources. They then describe the delivery of a poster session and stress the importance of evaluating the experience. Their technical advice on such matters as the choice of materials, colours and illustrations will be a valuable resource for those who are considering a poster session as a vehicle for scientific communication.

Perforation jéjunale par embolie de cholestérol: à propos d'un cas traité chirurgicalement

A case of ischaemic jejunal perforation which could be attributed to mesenteric cholesterol emboli is reported. The jejunal pathology had been preceded by other, more classical sites of systemic cholesterol embolization that occurred immediately after arterial catheterization in this male patient with aneurysm of the abdominal aorta. Emergency segmental resection of the jejunum was performed with satisfactory immediate results. Histological examination of the operative specimen confirmed that the perforation was caused by cholesterol emboli. Cholesterol embolization of the intestine may have various clinical consequences which are reviewed by the authors.