IgA vasculitis after COVID-19: a case-based review

IgA-associated vasculitis (IgAV) known as Henoch - Schönlein purpura (HSP) disease is an inflammatory disorder of small blood vessels. It's the most common type of systemic vasculitis in children which can be associated with the inflammatory process following infections. IgA vasculitis is a rare and poorly understood systemic vasculitis in adults. Coronavirus disease 2019 (COVID-19) has been associated with HSP in both adults and children. A 58-year-old woman was diagnosed with HSP, fulfilling the clinical criteria: palpable purpura, arthritis, hematuria. The disclosure of the HSP disease was preceded by a infection of the respiratory tract. COVID-19 infection was confirmed via the presence of IgM and IgG antibodies. This case indicates the possible role of SARS-CoV-2 in the development of HSP. The clinical course of IgAV in adults appears to be different from pediatric IgAV, especially due to higher risk of renal complications. Symptoms of the disease quickly resolved with low-dose of steroids.

Enhancing Immune Response in Non-Small-Cell Lung Cancer Patients: Impact of the 13-Valent Pneumococcal Conjugate Vaccine

Background: Non-small-cell lung cancer (NSCLC) is one of the most frequently diagnosed diseases among all types of lung cancer. Infectious diseases contribute to morbidity and mortality by delaying appropriate anti-cancer therapy in patients with NSCLC. Methods: The study aimed to evaluate the effectiveness of vaccination with the 13-valent pneumococcal conjugate vaccine (PCV13) in 288 newly diagnosed NSCLC patients. The analysis of the post-vaccination response was performed after vaccination by assessing the frequency of plasmablasts via flow cytometry and by assessing the concentration of specific anti-pneumococcal antibodies using enzyme-linked immunosorbent assays. Results: The results of the study showed that NSCLC patients responded to the vaccine with an increase in the frequencies of plasmablasts and antibodies but to a lesser extent than healthy controls. The immune system response to PCV13 vaccination was better in patients with lower-stage NSCLC. We found higher antibody levels after vaccination in NSCLC patients who survived 5 years of follow-up. Conclusions: We hope that our research will contribute to increasing patients' and physicians' awareness of the importance of including PCV13 vaccinations in the standard of oncological care, which will extend the survival time of patients and improve their quality of life.

Spontaneous pneumomediastinum as a complication of COVID-19

In December 2019, an atypical form of severe pneumonia emerged in Wuhan in China's Hubei province, which in February 2020 was named COVID-19. The disease may have features of interstitial pneumonia and severe respiratory failure requiring intensive oxygen therapy. Spontaneous pneumomediastinum is a rare pathological condition with air in the mediastinum outside the trachea, oesophagus and bronchi. It is potentially life-threatening complication of both invasive and non-invasive mechanical ventilation. There have been reports that it may complicate the course of interstitial lung disease in the course of COVID-19. The report describes two cases of young patients who spontaneously developed this complication. Immediate diagnose is important in order to applicate adequate procedures.

The Influence of External Breast Prostheses on the Body Postures of Women Who Have Undergone Mastectomies

Most women who have had a mastectomy and have not opted for breast reconstruction choose to use an external breast prosthesis. This study aimed to assess the impacts of external breast prostheses on the body postures of women after unilateral mastectomies. An additional aim was to identify whether postural asymmetry depended on the side of mastectomy. This study involved 52 women after unilateral mastectomy and consisted of two parts: (1) anthropometric measurement and (2) assessment of body posture using the moiré topography method. The posturometric indices showed that the body posture of the subjects in the sagittal plane is characterized by forward trunk inclination and a tendency to excessive kyphosis. There were no significant differences between parameters characterizing body posture with and without external breast prosthesis. The lack of external breast prosthesis had a significant effect only on excessive forward trunk inclination. Significant differences were found in the posturometric parameters in the transverse plane between the groups of patients after left- and right-sided mastectomy. The obtained results did not fully confirm the hypothesis that the external breast prosthesis affects the body posture of women after unilateral mastectomy.

Giant haematoma of the posterior compartment of thigh in a patient with coronavirus disease 19 pneumonia and pulmonary embolism - Case Report

Introduction. During the Coronavirus-19 (Covid-19) pandemic, a significant increase in the frequency of complications in the form of venous thrombosis was observed. However, there is also the other side of the coin - an increase in the tendency to bleeding in the course of COVID19. Case Report. We present the case of a patient hospitalised in the COVID-19 Isolation Ward due to severe pneumonia in the course of SARS-CoV2 infection. She developed respiratory failure requiring a non-invasive mechanical ventilation. In addition, pulmonary embolism was diagnosed, the treatment with low molecule heparin was initiated. Soon, the patient developed a huge haematoma of the posterior compartment of the thigh causing deformation and dysfunction of the limb and resulting with acute haemorrhagic anaemia. Conclusion. Our article is a contribution to the discussion on the need to pay attention to the possibility of haemorrhagic complications in the course of anticoagulant treatment due to venous thrombosis in COVID-19 patients.

Humulus lupus extract rich in xanthohumol improves the clinical course in critically ill COVID-19 patients

BACKGROUND

The systemic inflammatory response following severe COVID-19 is associated with poor outcomes. Several anti-inflammatory medications have been studied in COVID-19 patients. Xanthohumol (Xn), a natural extract from hop cones, possesses strong anti-inflammatory and antioxidative properties. The aim of this study was to analyze the effect of Xn on the inflammatory response and the clinical outcome of COVID-19 patients.

METHODS

Adult patients treated for acute respiratory failure (PaO₂/FiO₂ less than 150) were studied. Patients were randomized into two groups: Xn - patients receiving adjuvant treatment with Xn at a daily dose of 4.5 mg/kg body weight for 7 days, and C - controls. Observations were performed at four time points: immediately after admission to the ICU and on the 3rd, 5th, and 7th days of treatment. The inflammatory response was assessed based on the plasma IL-6 concentration, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP) and D-dimer levels. The mortality rate was determined 28 days after admission to the ICU.

RESULTS

Seventy-two patients were eligible for the study, and 50 were included in the final analysis. The mortality rate was significantly lower and the clinical course was shorter in the Xn group than in the control group (20% vs. 48%, p < 0.05, and 9 ± 3 days vs. 22 ± 8 days, p < 0.001). Treatment with Xn decreased the plasma IL-6 concentration (p < 0.01), D-dimer levels (p < 0.05) and NLR (p < 0.01) more significantly than standard treatment alone.

CONCLUSION

Adjuvant therapy with Xn appears to be a promising anti-inflammatory treatment in COVID-19 patients.

Reliability and Repeatability of a Postural Control Test for Preterm Infants

BACKGROUND

the current study aims to evaluate the reliability and repeatability of a new PT based on Center of Pressure (CoP) movement analysis in a repeated measures design.

METHODS

the examination consisted of two parts: (1) the videotaping of General Movements (GMs) and GMs assessment (GMA) and (2) Posturometric Tests (PT) in supine and prone positions. PTs were performed twice (by two investigators) in the supine and prone positions using a force plate. Based on the GMA results, infants were stratified into two groups: (1) infants with normal FMs (indicating normal future motor outcomes) (n = 18) and (2) infants with abnormal FMs (indicating later neurological dysfunction) (n = 19).

RESULTS

the comparative analysis between the groups of infants with normal FMs and abnormal FMs in PT in supine showed significant differences for all parameters that described spontaneous CoP displacement. The reliability analysis determined that all ICCs of the outcomes presented at least a moderate level of reliability. The ICCs were higher for outcomes of PT performed in the supine position than in the prone position. The ICCs were higher for outcomes of PT performed in infants with abnormal vs. normal FMs.

CONCLUSIONS

although the current study yielded promising results, further longitudinal research in preterm infants should identify whether altered postural control parameters prognose future motor outcomes.

Electrocardiogram, Echocardiogram and NT-proBNP in Screening for Thromboembolism Pulmonary Hypertension in Patients after Pulmonary Embolism

Background: The annual mortality of patients with untreated chronic thromboembolism pulmonary hypertension (CTEPH) is approximately 50% unless a timely diagnosis is followed by adequate treatment. In pulmonary embolism (PE) survivors with functional limitation, the diagnostic work-up starts with echocardiography. It is followed by lung scintigraphy and right heart catheterization. However, noninvasive tests providing diagnostic clues to CTEPH, or ascertaining this diagnosis as very unlikely, would be extremely useful since the majority of post PE functional limitations are caused by deconditioning. Methods: Patients after acute PE underwent a structured clinical evaluation with electrocardiogram, routine laboratory tests including NT-proBNP and echocardiography. The aim of this study was to verify whether the parameters from echocardiographic or perhaps electrocardiographic examination and NT-proBNP concentration best determine the risk of CTEPH. Results: Out of the total number of patients (n = 261, male n = 123) after PE who were included in the study, in the group of 155 patients (59.4%) with reported functional impairment, 13 patients (8.4%) had CTEPH and 7 PE survivors had chronic thromboembolic pulmonary disease (CTEPD) (4.5%). Echo parameters differed significantly between CTEPH/CTEPD cases and other symptomatic PE survivors. Patients with CTEPH/CTEPD also had higher levels of NT-proBNP (p = 0.022) but concentration of NT-proBNP above 125 pg/mL did not differentiate patients with CTEPH/CTEPD (p > 0.05). Additionally, the proportion of patients with right bundle brunch block registered in ECG was higher in the CTEPH/CTED group (23.5% vs. 5.8%, p = 0.034) but there were no differences between the other ECG characteristics of right ventricle overload. Conclusions: Screening for CTEPH/CTEPD should be performed in patients with reduced exercise tolerance compared to the pre PE period. It is not effective in asymptomatic PE survivors. Patients with CTEPH/CTED predominantly had abnormalities indicating chronic thromboembolism in the echocardiographic assessment. NT-proBNP and electrocardiographic characteristics of right ventricle overload proved to be insufficient in predicting CTEPH/CTEPD development.

Timber-colonizing gram-negative bacteria as potential causative agents of respiratory diseases in woodworkers

Occurrence

Gram-negative bacteria occur commonly in the inner tissues of stored coniferous and deciduous timber, showing a marked variation in numbers. The greatest maximal numbers are found in the sapwood of coniferous timber. The common constituents of the Gram-negative biota are potentially pathogenic species of Enterobacteriaceae family of the genera Rahnella, Pantoea, Enterobacter, and Klebsiella. The air of wood-processing facilities is polluted with the wood-borne Gram-negative bacteria and produced by them endotoxin, as demonstrated worldwide by numerous studies.

Effects

There are three potential pathways of the pathogenic impact of wood-borne Gram-negative bacteria on exposed woodworkers: allergic, immunotoxic, and infectious. Allergic impact has been underestimated for a long time with relation to Gram-negative bacteria. Hopefully, the recent demonstration of the first documented case of hypersensitivity pneumonitis (HP) in woodworkers caused by Pantoea agglomerans which developed in extremely large quantities in birch sapwood, would speed up finding of new wood-related cases of HP caused by Gram-negative bacteria. The second pathway is associated with endotoxin, exerting strong immunotoxic (excessively immunostimulative) action. It has been demonstrated that endotoxin is released into wood dust in the form of nano-sized microvesicles, by peeling off the outer membrane of bacteria. Endotoxin microvesicles are easily inhaled by humans together with dust because of small dimensions and aerodynamic shape. Afterwards, they cause a nonspecific activation of lung macrophages, which release numerous inflammatory mediators causing an inflammatory lung reaction, chest tightness, fever, gas exchange disorders, and bronchospasm, without radiographic changes. The resulting disease is known as “Organic Dust Toxic Syndrome” or “toxic pneumonitis.” The potential third pathway of pathogenic impact is infection. The suspected species is Klebsiella pneumoniae that may occur commonly in wood dust; however, until now this pathway has not been confirmed.

Conclusion

Summarizing, Gram-negative bacteria-inhabiting timber should be considered, besides filamentous fungi and actinobacteria, as important risk factors of occupational disease in woodworkers that could be either HP with allergenic background or toxic pneumonitis elicited by endotoxin.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-021-01829-1.

Observational cross-sectional study of 5279 bronchoscopy results for the practical effectiveness of various biopsy techniques in the diagnosis of lung diseases with particular emphasis on lung cancer

INTRODUCTION

Bronchoscopy is the main method in the diagnosis of various lung diseases. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the most modern bronchoscopic technique useful in diagnosis and staging of lung cancer (LC).

OBJECTIVE

The aim of the study was to assess the yield of bronchoscopy in patients with suspected various respiratory diseases including LC. In particular, we examined the efficiency of different biopsy techniques in the diagnosis of LC in correlation with its localisation and pathomorphological type.

PATIENTS AND METHODS

The results of pathomorphological examinations from 5279 bronchoscopies performed in 2016-2018 were analysed. The material was collected with EBUS-TBNA, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endobronchial forceps biopsy. Clinical and demographic factors were analysed using the Fisher χ² test.

RESULTS

5279 patients were diagnosed due to various respiratory symptoms. LC was confirmed in 36.42% of patients. 40.81% of patients had no definitive pathomorphological diagnosis. Among patients with LC, the most frequent diagnosis was non-small cell LC: squamous cell lung cancer (SCC)-32.07% and adenocarcinoma (AC)-30.61%, then small cell LC-25.83% and not otherwise specified non-small cell lung cancer (NSCLC-NOS)-11.49%. Diagnosis of SCC was obtained significantly more often (χ²=43.143, p<0.000001) by forceps biopsy (41.09%) than by EBUS-TBNA/EUS-FNA (26.62%). On the contrary, diagnosis of AC or NSCLC-NOS was significantly more often (χ²=20.394, p<0.000007, and χ²=3.902, p<0.05, respectively) observed in EBUS-TBNA/EUS-FNA (34.31% and 12.6%) than in endobronchial biopsies (24.52% and 9.64%).

CONCLUSIONS

The use of bronchoscopy in the diagnosis of various lung diseases is vital but also has many limitations. Effectiveness of EBUS-TBNA and endobronchial forceps biopsy in the diagnosis of lung cancer is strongly affected by tumour localisation and type of cancer.

Impact of copy number variant and single nucleotide polymorphism of the programmed death-ligand 1 gene, programmed death-ligand 1 protein expression and therapy regimens on overall survival in a large group of Caucasian patients with non-small cell lung carcinoma

Anti-programmed death-1 or anti-programmed death-ligand 1 (PD-L1) blockade may be ineffective in some patients with non-small cell lung cancer (NSCLC) with high percentage of tumor cells with PD-L1 expression. In addition, immunotherapy may provide great benefits in patients without PD-L1 expression. The present study assessed PD-L1 protein expression by immunohistochemistry, copy number variation (CNV) of PD-L1 and two single nucleotide polymorphisms (SNPs), rs822335 and rs822336, in the promoter of PD-L1 by quantitative PCR in 673 patients with NSCLC. Overall survival time of patients with NSCLC depending on the assessed predictive factors (PD-L1 CNV or SNP) and the treatment methods (immunotherapy in first/second line of treatment or chemotherapy) was analyzed. The present study revealed significantly higher PD-L1 copies number in patients with ≥10% and ≥50% of tumor cells with PD-L1 expression compared to patients with lower percentage of PD-L1-positive tumor cells (P=0.02 and P=0.0002, respectively). There was a significant positive correlation (R=0.2; P=0.01) between number of PD-L1 copies and percentage of tumor cells with PD-L1 protein expression. Percentage of tumor cells with PD-L1 expression was lower in patients with TT genotype of the rs822335 polymorphism compared to those with CC genotype (P=0.03). The present study observed significantly higher risk of death in patients treated with chemotherapy compared to those treated with immunotherapy (P<0.0001; hazard ratio=2.4768; 95% confidence interval, 2.0120–3.0490). The present study demonstrated a close relationship between PD-L1 copies number, genotype of rs822335 PD-L1 polymorphism and PD-L1 protein expression on tumor cells. However, the impact of CNV and SNPs of PD-L1 on overall survival of patients with NSCLC requires further investigation.

Thiram - Toxic inhalational lung injury

INTRODUCTION

Thiram, a fungicides, is widely used on seeds and as foliar agent on turf, vegetables and fruit. It is also used in the rubber industry as a vulcanization accelerator. When absorbed through the respiratory system, it is rapidly metabolised to dimethylthiocarbamate and carbon disulphide, causing noxious effects. A brief review is presented of the literature, centering on the interesting case of a 45-year-old woman admitted to the hospital suffering from acute respiratory failure.

RESULTS

Computer tomography in angiographic option (angio-CT) showed an extensive, irregular area of ground glass in both upper lobes and apical segments of the lower lobes of the lungs. A significant enlargement of both atria was also described. There was no improvement after cardiac treatment and patient was transferred to the pulmonary department where she was succesfully treated with systemic glucocortycosteroids. The patient remains under the supervision of the pulmonary out-patient department.

Acute hypersensitivity pneumonitis in woodworkers caused by inhalation of birch dust contaminated with Pantoea agglomerans and Microbacterium barkeri

CASE DESCRIPTION

Five workers (2 males and 3 females) employed in a furniture factory located in eastern Poland developed hypersensitivity pneumonitis (HP) after the pine wood used for furniture production was replaced by birch wood. All of them reported onset of respiratory and general symptoms (cough, shortness of breath, general malaise) after inhalation exposure to birch dust, showed crackles at auscultation, ground-glass attenuations in HRCT examination, and lymphocytosis in the BAL examination. The diagnosis of acute HP was set in 4 persons and the diagnosis of subacute HP in one.

IDENTIFICATION OF SPECIFIC ALLERGEN

Samples of birch wood associated with evoking disease symptoms were subjected to microbiological analysis with the conventional and molecular methods. Two bacterial isolates were found to occur in large quantities (of the order 10⁸ CFU/g) in examined samples: Gram-negative bacterium of the species Pantoea agglomerans and a non-filamentous Gram-positive actinobacterium of the species Microbacterium barkeri. In the test for inhibition of leukocyte migration, 4 out of 5 examined patients showed a positive reaction in the presence of P. agglomerans and 2 in the presence of M. barkeri. Only one person showed the presence of precipitins to P. agglomerans and none to M. barkeri. In the inhalation challenge, which is the most relevant allergological test in the HP diagnostics, all patients reacted positively to P. agglomerans and only one to M. barkeri. The results indicate that P. agglomerans developing in birch wood was the main agent causing HP in the workers exposed to the inhalation of dust from this wood, while the etiologic role of M. barkeri is probably secondary.

CONCLUSION

The results demonstrate that apart from fungi and filamentous actinobacteria, regarded until recently as causative agents of HP in woodworkers, Gram-negative bacteria and non-filamentous actinobacteria may also elicit disease symptoms in the workers processing wood infected with large amounts of these microorganisms. The results obtained also seem to indicate that cellular-mediated reactions are more significant for causing disease symptoms compared to those that are precipitin-mediated.

[Hypersensitivity pneumonitis and idiopathic pulmonary fibrosis - case report]

Hypersensitivity pneumonitis (HP), called extrinsic allergic alveolitis, is a syndrome characterized by diffuse inflammation of lung parenchyma and airways in response to the inhalation of antigens to witch the patient has been previously sensitized. The clinical presentation of HP have been categorized as acute, subacute and chronic. The patient with chronic HP may lack a history of acute episodes and usually reports the insidious onset of cough, dyspnoea, fatigue, and weight los. Idiopathic pulmonary fibrosis (IPF) is a type of lung disease that results in scarring (fibrosis) of the lungs for an unknown reason. Symptoms of IPF are the same as in chronic hypersensitivity pneumonitis and differentiation may be difficult. We present a case of patient with chronic HP, in whom the course of the end stage of the disease mimic acute exacerbations idiopathic pulmonary fibrosis.

Evaluation of TH1/TH2 Lymphocyte Balance and Lypopolysaccharide Receptor Expression in Asthma Patients

Introduction: An increase in the number of asthma patients which has recently been observed depends on their place of residence and their occupation. This suggests that both external factors and genetic predispositions affect the development of the disease. The contact with bacterial lypopolysaccharide (LPS) may suppress the development of asthma among rural inhabitants. The mechanism of LPS effect most probably consists in the activation of macrophages and granulocytes by TLR4 and CD14 receptors for the production of cytokines, which affect Th1/Th2 balance. The objective of the study was the evaluation of CD14 and TLR4 expression on mononuclear cells and the analysis of Th1/Th2 balance in peripheral blood among asthma patients. Material and Methods: The study group covered 22 patients with bronchial asthma (mean age 45 ± 15), and was conducted by the method of flow cytometry with the use of fluorochrome-labelled monoclonal antibodies. CD14 and TLR expression was assessed in peripheral blood monocytes. Th1/Th2 balance was determined by the measurement of intracellular IL-2, IFN-γ, IL-4 and IL-10 expression in T-helper cells after culture with the stimulation of cytokine production. Results: A negative correlation was noted between TLR4 expression and the percentage of Th2 lymphocytes, while a positive correlation was observed between expression of TLR4 and percentage of Th1 cells. No relationship was found between CD14 expression on monocytes and the percentage of Th1 and Th2 lymphocytes. Conclusions: An increased percentage of lymphocytes with TLR4 expression is associated with the change in Th1/Th2 balance in favour of Th1 lymphocytes in asthma patients.

[Evaluation of Th1/Th2 lymphocyte balance and lipopolysaccharide receptor expression in asthma patients]

INTRODUCTION

An increase in the number of asthma patients which has recently been observed depends on their place of residence and their occupation. This suggests that both external factors and genetic predispositions affect the development of the disease. The contact with bacterial lypopolysaccharide (LPS) may suppress the development of asthma among rural inhabitants. The mechanism of LPS effect most probably consists in the activation of macrophages and granulocytes by TLR4 and CD14 receptors for the production of cytokines, which affect Th1/Th2 balance. The objective of the study was the evaluation of CD14 and TLR4 expression on mononuclear cells and the analysis of Th1/Th2 balance in peripheral blood among asthma patients.

MATERIAL AND METHODS

The study group covered 22 patients with bronchial asthma (mean age 45 +/- 15), and was conducted by the method of flow cytometry with the use of fluorochrome-labelled monoclonal antibodies. CD14 and TLR expression was assessed in peripheral blood monocytes. Th1/Th2 balance was determined by the measurement of intracellular IL-2, IFN-gamma, IL-4 and IL-10 expression in T-helper cells after culture with the stimulation of cytokine production.

RESULTS

A negative correlation was noted between TLR4 expression and the percentage of Th2 lymphocytes, while a positive correlation was observed between expression of TLR4 and percentage of Th1 cells. No relationship was found between CD14 expression on monocytes and the percentage of Th1 and Th2 lymphocytes.

CONCLUSIONS

An increased percentage of lymphocytes with TLR4 expression is associated with the change in Th1/Th2 balance in favour of Th1 lymphocytes in asthma patients.

Difficulties in the diagnosis of rare immunological diseases manifesting with cystic lung disease and spontaneous pneumothorax: case reports

Pulmonary lymphangioleiomyomatosis (LAM) is a rare disease of an unknown cause affecting women of reproductive age and characterised by smooth muscle proliferation along lung lymphatic channels. Pneumothorax develops in up to 80% of patients with LAM and may be the presenting manifestation of the disease. Pneumothorax also precedes or complicates the clinical course of 25% of patients with Langerhans'-cell histiocytosis (LCH, histiocytosis X) pathologically characterised by involved tissue infiltration with large numbers of unusual Langerhans' cells, often organised as granulomas. A 41-year-old female patient was treated twice by simple tube drainage due to left pneumothorax in 1996. She was then diagnosed with chronic obstructive lung disease demonstrating with dyspnea, cough and wheeze. Abnormalities found in the high-resolution computed tomography (HRCT) scanning were characteristic of LAM with thin-walled parenchymal cysts distributed homogeneously in both lungs and with thickening of interlobular septa. A 38-year-old man was hospitalised due to chronic lung failure in the course of LCH characterised by small, poorly limited nodular lesions and thin-walled cysts revealed in HRCT scans. For two years of observation, he has suffered five episodes of right pneumothorax. When diagnosing pneumothorax in the middle-age patients, the possible cause of the disease is LAM or LCH. The use of HRCT scanning may enable good determination of the nature and distribution of parenchymal abnormalities found in the diseases.