[An unusual etiology of acute pancreatitis]

A 54-year-old woman consulted the emergency department for abdominal pain, vomiting and fever for 5 days. A biochemical assessment was performed and showed a lipasemia higher than 5 times normal range (264 UI/L). Hyperlipasemia is in favor of acute pancreatitis. On obtaining further history, the patient reported the SARS-CoV-2 infection two weeks ago with a laboratory investigations done the same day as the positive PCR showed a normal lipasemia. The imaging findings were suggestive of early acute pancreatitis. Acute pancreatitis secondary to SARS-CoV-2 infection is suspected.

Response to growth hormone therapy in ring chromosome 15: Review and evidence from a new case on possible beneficial effect in neurodevelopment

Type 1 Insulin-like Growth Factor Receptor(IGF1R) plays a fundamental role in normal growth and development. Its disruption is usually characterized by severe intrauterine and postnatal growth retardation, microcephaly and neurodevelopmental delay.The efficacy of recombinant human growth hormone treatment remains a challenge for children with IGF1 resistance and pathogenic mutations of IGF1R, with limited data in patients carrying the most severe form of IGF1R defect, the ring chromosome 15.

SUBJECT AND METHOD

We tested a high dose of rhGH in a new patient with ring chromosome 15, as confirmed by karyotype and CGH array. We performed a systematic review, and all published r(15) syndrome cases treated by growth hormone(GH) up to April 2023 were searched, and their response to GH therapy was recorded and summarized.

RESULTS

Twelve patients with ring chromosome 15 received GH therapy according to a literature review. We expand the spectrum by the 13th case treated by GH, and we report an impressive improvement in intellectual performance and progressive catch-up growth after 5 and 20 months of follow-up. By introducing our new case in the analysis, the sex ratio was 3:10, and GH therapy was started at the age of 5.5 (3/9.4) (years) for an age of diagnosis of 4.75 (1.3/9.5) (years). The height before GH therapy was -5.1(-5.9/-4.1) SDS. The median duration of treatment was 1.7(0.9/2) (years), with a median height gain of 1(0.3/1.8) SDS and an improvement in growth velocity of 4.1(2.8/5.3) (cm/year).

CONCLUSION

GH seems to be effective for r(15) syndrome patients with short stature.

[Fatal nutrient deficiencies after gastric bypass]

INTRODUCTION

Bariatric surgery is a very effective treatment for obesity. After gastric bypass, micronutrient deficiencies frequently occur which can have dramatic consequences.

CASE REPORT

We report the case of a 55-year-old woman who was admitted for psychomotor retardation, bilateral leg pitting edema and psoriasis-like rash that had been ongoing for 3 months. Pancytopenia, encephalopathy and heart failure rapidly occurred leading to multiorgan dysfunction syndrome and death. We retrospectively identified severe selenium deficiency with possible secondary cardiomyopathy, niacin deficiency resulting in pellagrous encephalopathy with skin lesions and gelatinous transformation of bone marrow.

CONCLUSION

Micronutrient deficiency should systematically be assessed when new symptoms occur in a patient with a history of bariatric surgery. Selenium deficiency should be considered in the presence of any heart failure in this context.

Lipid and oxidative profile in hemodialysis patients: Clinical follow-up for three years

BACKGROUND

The major cause of death for hemodialysis (HD) patients was cardiovascular morbidity; it was closely related to oxidative stress (OS).

AIM

Firstly, to evaluate lipid peroxidation biomarkers on HD patients through measuring malondialdehyde (MDA) and conjugated dienes (CD), and secondly, to follow these parameters after three years undergoing HD.

METHODS

One hundred patients with end stage renal diseases receiving regular hemodialysis and 100 healthy volunteers were included in this study. Routine chemical data, lipid profile and levels of MDA and CD were measured.

RESULTS

The plasmatic and erythrocyte MDA levels were significantly increased in the HD patients compared to healthy subjects (p <0.001). However, an increased level on erythrocyte CD was only observed between the two study groups (p<0.001). After 3 years, a significant increased level of lipid peroxidation biomarkers was observed.

CONCLUSION

The disturbance in lipid peroxidation state in HD patients was observed. At three years follow-up, oxidative stress is more pronounced with a significant increase in MDA and CD.

Differential time to positivity of central and peripheral blood cultures is inaccurate for the diagnosis of Staphylococcus aureus long-term catheter-related sepsis

OBJECTIVES

Differential time to positivity of cultures of blood drawn simultaneously from central venous catheter and peripheral sites is widely used to diagnose catheter-related bloodstream infections without removing the catheter. However, the accuracy of this technique for some pathogens, such as Staphylococcus aureus, is debated in routine practice.

METHODS

In a 320-bed reference cancer centre, the charts of patients with at least one blood culture positive for S. aureus among paired blood cultures drawn over a six-year period were studied retrospectively. Microbiological data were extracted from the prospectively compiled database of the microbiology unit. Data concerning the 149 patients included were reviewed retrospectively by independent physicians blinded to the absolute and differential times to positivity, in order to establish or refute the diagnosis of catheter-related sepsis. Due to missing data, 48 charts were excluded, so 101 cases were actually analysed. The diagnosis was established in 62 cases, refuted in 15 cases and inconclusive in the remaining 24 cases.

RESULTS

For the 64 patients with both central and peripheral positive blood cultures, the differential positivity time was significantly greater for patients with catheter-related bloodstream infections due to S. aureus (P<0.02). However, because of the high number of false-negative cases, the classic cut-off limit of 120 min showed 100% specificity but only 42% sensitivity for the diagnosis of catheter-related bloodstream infection due to S. aureus.

CONCLUSIONS

These results strongly suggest that despite its high specificity, the differential time to positivity may not be reliable to rule out catheter-related bloodstream infection due to S. aureus.

Increased serum concentrations of Nɛ-carboxymethyllysine are related to the presence and the severity of rheumatoid arthritis

Background There are limited data regarding the contribution of advanced glycation end products in the presence of rheumatoid arthritis. We investigated whether serum N^ɛ-carboxymethyllysine and pentosidine were related to the presence and the severity of rheumatoid arthritis. Methods Eighty patients with rheumatoid arthritis and 30 control subjects were included in a cross-sectional study. The severity of rheumatoid arthritis was assessed using the disease activity score for 28 joints. Serum N^ɛ-carboxymethyllysine and pentosidine were measured by enzyme-linked immunosorbent assay. Results Serum N^ɛ-carboxymethyllysine and pentosidine concentrations were significantly higher in patients with rheumatoid arthritis vs. control subjects ( P < 0.001). Serum N^ɛ-carboxymethyllysine and pentosidine concentrations were significantly higher in rheumatoid arthritis patients with high disease activity vs. rheumatoid arthritis patients with moderate disease activity ( P < 0.001, P = 0.019, respectively). A multiple logistic regression analysis demonstrated that N^ɛ-carboxymethyllysine was independently associated with the presence of rheumatoid arthritis (OR = 1.21, 95% CI: 1.05-1.39, P = 0.006). Furthermore, in a multivariate stepwise regression analysis, N^ɛ-carboxymethyllysine was independently correlated with disease activity score for 28 joints (standardized β = 0.43, P = 0.001). Conclusion Serum N^ɛ-carboxymethyllysine and pentosidine were increased during rheumatoid arthritis, and N^ɛ-carboxymethyllysine was independently associated with the presence and the severity of rheumatoid arthritis.

Pentosidine as a biomarker for microvascular complications in type 2 diabetic patients

Serum soluble receptor for advanced glycation end product (sRAGE) may reflect the activity of the advanced glycation end product (AGE)-receptor for advanced glycation end product (RAGE) axis, which has been proposed as a potential mechanism linking hyperglycaemia to vascular complications in diabetes. We have investigated whether serum AGEs, sRAGE and pentosidine levels were increased and correlated with microvascular complications in type 2 diabetes mellitus (DM). We included 30 healthy control subjects, and 200 diabetic patients were divided into two subgroups: 100 patients with diabetic retinopathy and 100 patients with diabetic nephropathy. AGEs, sRAGE and pentosidine were measured in serum by enzyme-linked immunosorbent assay (ELISA). Serum AGEs, sRAGE and pentosidine levels were significantly increased in diabetic patients with retinopathy and in diabetic patients with nephropathy compared to control subjects (p < 0.001). Serum AGEs, sRAGE and pentosidine levels are positively associated with microvascular complications in type 2 DM. Multiple regression analysis reveals serum pentosidine as an independent determinant of the presence of diabetic retinopathy (p = 0.004) and the presence of hypertension (p = 0.018) and hyperlipidaemia (p = 0.036). Pentosidine levels may be a biomarker for microvascular complications in type 2 diabetic patients.

Diagnostic strategy for oncology patients with acute respiratory failure

Acute respiratory failure (ARF) is frequent and often fatal in patients with a malignancy. However, there is not one type of "oncology patient", and it's high time that both clinical management and further studies consider specific populations rather than the heterogeneous and artificial group of "cancer patients". This individual-based approach will allow a relevant use of the numerous non invasive diagnostic tools developed during the past years: high resolution tomodensitometry, echocardiography, urine or serum antigen assays, polymerase chain reaction, serum biomarkers etc. These non invasive tools have reduced but not weakened the value of fiberoptic bronchoscopy and bronchoalveolar lavage: some subsets of patients may always benefit from this technique, particularly when new protective strategies such as non invasive mechanical ventilation and target-controlled infusion of sedative drugs are used. The present review focuses on the personalised approach required in "oncology patients" with ARF, based on first identifying the pattern of immunodeficiency, then listing the most probable hypotheses in the light of clinical and radiological findings in order to, finally, select the most accurate diagnostic tools.

Elevated serum levels of AGEs, sRAGE, and pentosidine in Tunisian patients with severity of diabetic retinopathy

OBJECTIVES

The advanced glycation end products (AGEs)-receptor for AGE (RAGE) axis activity are implicated in diabetic vascular complications. We measured serum AGE, sRAGE and pentosidine levels in Tunisian patients with diabetic retinopathy (DR) and examined whether these biomarkers are related to the severity of DR.

DESIGN AND METHODS

We included 30 healthy control subjects and 100 diabetic patients were divided into 2 subgroups: 40 patients with nonproliferative diabetic retinopathy (NPDR), and 60 patients with proliferative diabetic retinopathy (PRD). AGEs, sRAGE and pentosidine were measured in serum by ELISA.

RESULTS

Serum levels of AGEs, sRAGE and pentosidine were significantly increased in patients with diabetes mellitus compared to nondiabetic controls (P<.01, P<.001, P<.001 respectively). In diabetic patients, serum AGEs, sRAGE and pentosidine levels were significantly higher in patients who had PDR than in those with NPDR (P=.001, P=.01, P=.005 respectively). Furthermore, in stepwise multivariate regression analysis, the levels of pentosidine and duration of diabetes were independently associated with severity of DR.

CONCLUSION

Serum AGEs, sRAGE, and pentosidine levels are related with the presence of DR. Duration of diabetes and pentosidine were independently correlated with the severity of DR.

[Characteristics of encrustation of ureteric stents in patients with urinary stones]

INTRODUCTION

The goal of this prospective study was to characterize ureteral stents encrustation in stone formers.

MATERIAL AND METHODS

We report the results of a study based on 658 double-J stents (412 men and 246 women) collected from patients with in situ urinary calculi. The mean age was 48.2+/-16.0 years without differences between genders. Ureteral stent encrustation was analysed by infrared spectroscopy. Results are expressed according to the main component.

RESULTS

The mean indwelling time was 73.5+/-73.2 days. The main component in stent encrustations was calcium oxalate (43.8%), essentially the monohydrate form (27.1%), followed by proteins (27.4%), calcium phosphates (16.4% with 8.4% brushite), and uric acid (5.2%). Struvite, detected on 49 stents, was the main component in 2.4% of cases. Significant differences according to gender and age were found: calcium oxalate monohydrate, which represented 24.5% in 20 to 29 years old men class increased to 37.0% in 50 to 59 years class and then decreased in older patients. Calcium oxalate dihydrate increased with age up to 70 years in women while it felt dramatically in man beyond 50 years old. Brushite was more abundant in young men (20.4% in patients aged 20-29 years) and was decreasing beyond this age while it remained in stable proportion for all age classes in women. Increasing prevalence of uric acid encrustations with age was observed, especially in men beyond the age of 70 years. Mineral encrustations increased with the indwelling time, the part of mineral being preponderant after 15 days: 7,3% of the stents had become massively encrusted within 113 days mean period. The comparison between biomaterials showed that silicone stents were significantly less encrusted than polyurethane stents.

CONCLUSION

Stent encrustation constitutes a serious complication of ureteral stent use in stone formers. Lithogenic factors should be considered for the prevention of stent encrustation in these patients.

[2,8-dihydroxyadenine nephrolithiasis: from diagnosis to therapy]

Adenine phosphoribosyltransferase (APRT, EC 2.4.2.7) deficiency is an enzymopathy of purine metabolism, which is inherited as an autosomal recessive trait. APRT is a salvage enzyme that normally catalyzes the conversion of adenine to adenosine monophosphate. APRT deficiency results in adenine accumulation with oxidation by xanthine dehydrogenase (XDH; EC 1.1.1.204) to 2,8-dihydroxyadenine (2,8-DHA) then excreted in urine. This compound is extremely insoluble and its crystallization can lead to stone formation and renal failure. The diagnosis of the disease is based on stone analysis by infrared spectroscopy or microscopic examination of urine, which may reveal typical 2,8-DHA crystals. The enzyme activity measurements in erythrocyte lysates will identify both homozygotes and heterozygotes for APRT deficiency. Molecular approach can identify mutations which are responsible of this inherited disease. Two types of deficit are commonly distinguished, depending on the level of residual APRT activity: type I, mainly observed in Caucasian subjects, in whom the enzyme activity is undetectable in homozygous patients and type II, found in Japanese patients who are able to form APRT but the enzyme activity is strikingly reduced because a low affinity for phosphoribosylpyrophosphate. The crystallization of 2,8-DHA and subsequent renal damages may be prevented with allopurinol therapy, a xanthine oxidase inhibitor. The role of the laboratory is crucial to detect APRT deficiency and to assess the efficacy of therapy, the objective being to avoid 2,8-DHA crystal formation.

[Cystinuria: from diagnosis to follow-up]

Cystinuria is an autosomal recessive disorder characterized by an impaired transport of cystine and dibasic aminoacids, lysine, arginine and ornithine in the proximal renal tubule and in the epithelial cells of the gastrointestinal tract. Recurrent cystine nephrolithiasis is the main clinical feature. Mutations in SLC3A1 and/or SLC7A9 genes, which are encoding respectively the rBAT and the b(0,+)AT proteins of the amino acid transport system, are responsible of this disorder thus inducing a high dibasic amino acid excretion. Diagnostic is based on stone analysis by infrared spectroscopy or microscopic examination of urine which may reveal typical cystine crystals. Quantitative cystine excretion, which may be assessed by aminoacid chromatography, is higher in cystinic patients. Molecular approach can identify mutations which are responsible of this pathology. Medical treatment is mainly based on hydratation and urine alkalinisation, with the addition of thiol derivative only in refractory cases. Follow-up based on pH and specific gravity determination in urine samples and cystine crystal volume measurement are used to optimally monitor the medical treatment of cystinuric patients. Even with medical management, long-term outcome is poor due to insufficient efficacy and low patient compliance. Many patients suffer from renal insufficiency as a result of recurrent stone formation and repeated surgical procedures.

[Mucopolysaccharidosis IVA (Morquio A syndrome): clinical, biological and therapeutic aspects]

Mucopolysaccharidosis IVA (MPS IVA; Morquio A disease) is an autosomal recessive lysosomal storage disorder caused by a genetic deficiency of the N-acetylgalactosamine-6-sulfate sulfatase (GALNS; E.C.3.1.6.4). GALNS is required to degrade keratan sulfate (KS) and chondroitine-6-sulfate (C6S). The accumulation of undegraded substrates in lysosomes of the affected tissues leads to a systemic bone dysplasia. Total urine glycosaminoglycans (GAG) in patients with MPS IVA are close to the normal range so it is difficult to distinguish this disease based on urine GAG excretion. Another potential disease marker could be KS levels in urine and plasma. Although the enzymatic diagnosis of affected patients with MPS IVA can be made, the detection of obligate heterozygotes by enzymatic measurement is less reliable because of a marked overlap of GALNS in fibroblasts or leucocytes from affected phenotype and normal controls. The genetic heterozygoty of MPS IVA has been facilitated by the isolation and characterization of the full lengh cDNA encoding human GALNS. Conventional therapy is symptomatic and limited to palliative procedures, which have virtually no impact upon mortality. To date, there is still no general consensus about the effectiveness of bone marrow transplantation. In the future, gene therapy could represent a great therapeutic improvement.

[Clinical, biologic and molecular characteristics of two Tunisian MPS IV A patients]

Mucopolysaccharidosis type IV A (MPS IV A) is an autosomal recessive disorder resulting from the deficient activity of the lysosomal enzyme, N-acetylgalactosamine-6-sulfate sulfatase (GALNS) and the progressive lysosomal accumulation of keratane sulfate. Clinically, the MPS IV A differs from the other MPS by the localisation of the keratane sulfate in skelet and in eyes associated to the conservation of a normal intelligence. To date, the characterization and purification of the GALNS gene made a research for pathogenic mutations in patients with MPS IV A easier. These mutations are responsible of severe, intermediate or mild phenotype. The aim for this work was the research of clinical, biologic and molecular characteristics of two Tunisian MPS IV A patients who were offsprings of consanguineous mating. Enzymatic and urinary diagnostics suggested a MPS IV A phenotype. A novel homozygous mutation IVS1+1G-A was identified by direct sequencing in the GALNS gene of the two patients. Identification of GALNS mutations provide genotype/phenotype correlations and permit the precision of anomalies responsible of Morquio A phenotype in concerned families.

[Myelodysplastic syndrome / acute myeloid leukemia with t(8; 21) and bundle of Auer rods in neutrophils: an unusual hemopathy]

We report the case of a 8-year-old girl diagnosed with myelodysplastic syndrome. This case was morphologically characterized by the presence of bundle of Auer rods in the neutrophils. The evolution of the disease was marked by a quick transformation in a acute myeloid leukaemia with t(8;21) refractory to treatment. We reviewed the literature for clinical, biological and therapeutic features of this rare childhood hemopathy.