scholarly journals Thrombotic events following tocilizumab therapy in critically ill COVID-19 patients: a Façade for prognostic markers

2020 ◽  
Vol 18 (1) ◽  
Author(s):  
Bassam Atallah ◽  
Wasim El Nekidy ◽  
Saad I. Mallah ◽  
Antoine Cherfan ◽  
Laila AbdelWareth ◽  
...  
Keyword(s):  
Inflammatory Markers ◽  
Prognostic Markers ◽  
Thrombotic Event ◽  
Case Series ◽  
Global Scale ◽  
Current Treatment ◽  
Gulf Region ◽  
Treatment Protocols ◽  
Acute Thrombosis ◽  
Prognostic Outcome

Abstract Background Hospitals in the Middle East Gulf region have experienced an influx of COVID-19 patients to their medical wards and intensive care units. The hypercoagulability of these patients has been widely reported on a global scale. However, many of the experimental treatments used to manage the various complications of COVID-19 have not been widely studied in this context. The effect of the current treatment protocols on patients’ diagnostic and prognostic biomarkers may thus impact the validity of the algorithms adopted. Case presentation In this case series, we report four cases of venous thromboembolism and 1 case of arterial thrombotic event, in patients treated with standard or intensified prophylactic doses of unfractionated heparin or low molecular weight heparin at our institution. Tocilizumab has been utilized as an add-on therapy to the standard of care to treat patients with SARS-CoV-2 associated acute respiratory distress syndrome, in order to dampen the hyperinflammatory response. It is imperative to be aware that this drug may be masking the inflammatory markers (e.g. IL6, CRP, fibrinogen, and ferritin), without reducing the risk of thrombotic events in this population, creating instead a façade of an improved prognostic outcome. However, the D-dimer levels remained prognostically reliable in these cases, as they were not affected by the drug and continued to be at the highest level until event occurrence. Conclusions In the setting of tocilizumab therapy, traditional prognostic markers of worsening infection and inflammation, and thus potential risk of acute thrombosis, should be weighed carefully as they may not be reliable for prognosis and may create a façade of an improved prognostic outcome instead. Additionally, the fact that thrombotic events continued to be observed despite decrease in inflammatory markers and the proactive anticoagulative approach adopted, raises more questions about the coagulative mechanisms at play in COVID-19, and the appropriate management strategy.

scholarly journals AB0648 REACTIVE ARTHRITIS IN SYPHILIS MIMICKING RHEUMATOID ARTHRITIS: A CASE REPORT

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1357.1-1357
Author(s):  
S. M. Lao ◽  
J. Patel
Keyword(s):  
Rheumatoid Arthritis ◽  
Reactive Arthritis ◽  
Joint Pain ◽  
Inflammatory Markers ◽  
Morning Stiffness ◽  
Treponema Pallidum ◽  
Case Series ◽  
Penicillin G ◽  
Joint Involvement ◽  
Igg Antibody

Background:Reactive arthritis is a form of spondyloarthritis with aseptic joint involvement occurring after a gastrointestinal or urogenital infection. Most commonly associated with Chlamydia trachomatis, Salmonella, Shigella, Campylobacter, and Yersinia. Syphilis is an infection caused by the spirochete Treponema pallidum and is not usually associated with reactive arthritis. Syphilis is a great imitator of other diseases due to its broad presentation including painless chancre, constitutional symptoms, adenopathy, rash, synovitis, neurological and ocular findings.Objectives:To discuss a patient who presented with symptoms of rheumatoid arthritis (RA) but was later diagnosed with syphilis.Methods:31 year old male, former tobacco smoker, referred to Rheumatology for sudden onset joint pains, elevated anti-cyclic citrullinated peptide (anti-CCP), and elevated inflammatory markers. He reported pain in bilateral wrists, fingers, and right elbow for 6 weeks. Associated with 45 minutes of morning stiffness and new onset lower back pain without stiffness. He denied trauma, fever, chills, skin rash, dysuria, or diarrhea. Initiated trial naproxen 500mg twice a day only to have minimal relief. Patient is sexually active with men and was recently diagnosed with oropharyngeal gonorrhea treated with azithromycin 4 months prior. All other STI screening including syphilis, gonorrhea, HIV were negative at that time. Patient is on emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis. He denied family history of immune mediated conditions. Exam was significant for mild synovitis of both wrists and bilateral 2nd metacarpophalangeal joints. Initial labs revealed weakly positive anti-CCP 21 (normal <20), sedimentation rate 64 (normal ESR 0-15 mm/hr), C-reactive protein 24 (normal CRP 0-10 mg/L), and negative RF, ANA, HLA B27. During a short trial of prednisone taper, there was temporary improvement in symptoms, however synovitis recurred upon completion. Hydroxychloroquine (HCQ) 200mg twice a day was started for possible RA and he was referred to Ophthalmology for baseline retinopathy screening. Incidentally, he developed right sided blurry vision 2 weeks after initiation of HCQ. He was diagnosed with panuveitis of the right eye with inflammation of the optic nerve head and prednisone 40mg daily was initiated for presumed ocular manifestation of RA. However, further workup of panuveitis revealed reactive Treponema pallidum antibody and RPR quantity 1:32. Prednisone was immediately discontinued and he was referred to the emergency department for possible neurosyphilis.Results:Lumbar puncture showed cerebral spinal fluid with 260 red blood cells, 1 white blood cell, 27mg/dL protein, 60mg/dL glucose, non reactive VDRL, reactive pallidum IgG antibody, and negative cultures. Meningitis and encephalitis panels were negative. Patient completed a 14 day course of IV penicillin G with complete remission of joint pain, visual symptoms, and normalization of anti-CCP, ESR, and CRP.Conclusion:This case highlights how syphilis may mimic signs and symptoms of RA including symmetrical small joint pain, morning stiffness, elevated inflammatory markers, and positive anti-CCP. Anti-CCP is >96% specific for RA but was a false positive in this patient. There have only been few reported cases noting positive anti-CCP with reactive arthritis. This is a rare case of reactive arthritis secondary to syphilis with resolution of symptoms upon treating the syphilis.References:[1]Carter JD. Treating reactive arthritis: insights for the clinician. Ther Adv Musculoskelet Dis. 2010 Feb;2(1):45-54.[2]Cohen SE, Klausner JD, Engelman J, Philip S. Syphilis in the modern era: an update for physicians. Infect Dis Clin North Am. 2013 Dec;27(4):705-22.[3]Singh Sangha M, Wright ML, Ciurtin C. Strongly positive anti-CCP antibodies in patients with sacroiliitis or reactive arthritis post-E. coli infection: A mini case-series based review. Int J Rheum Dis. 2018 Jan;21(1):315-321.Disclosure of Interests:None declared.

Scurvy Masquerading as Juvenile Idiopathic Arthritis or Vasculitis with Elevated Inflammatory Markers: A Case Series

2020 ◽  
Vol 218 ◽  
pp. 234-237.e2 ◽  
Author(s):  
Alexandra Perkins ◽  
Clay Sontheimer ◽  
Jeffrey P. Otjen ◽  
Susan Shenoi
Keyword(s):  
Juvenile Idiopathic Arthritis ◽  
Inflammatory Markers ◽  
Case Series

What's the Buzz? The Neuroscience and the Treatment of Tinnitus

2021 ◽  
Author(s):  
Amanda Henton ◽  
Thanos Tzounopoulos
Keyword(s):  
United States ◽  
The United States ◽  
Global Scale ◽  
Current Treatment ◽  
Public Health Issue ◽  
Current State ◽  
Acquired Hearing Loss ◽  
Neurophysiological Mechanisms ◽  
Necessary And Sufficient

Tinnitus is a pervasive public health issue that affects approximately 15% of the United States population. Similar estimates have also been shown on a global scale, with similar prevalence found in Europe, Asia, and Africa. The severity of tinnitus is heterogeneous, ranging from mildly bothersome to extremely disruptive. In the United States, approximately 10-20% of individuals who experience tinnitus report symptoms that severely reduce their quality of life. Due to the huge personal and societal burden, in the last twenty years a concerted effort on basic and clinical research has significantly advanced our understanding and treatment of this disorder. Yet, neither full understanding, nor cure exists. We know that tinnitus is the persistent involuntary phantom percept of internally-generated non-verbal noises and tones, which in most cases is initiated, by acquired hearing loss and maintained only when this loss is coupled with distinct neuronal changes in auditory and extra-auditory brain networks. Yet, the exact mechanisms and patterns of neural activity that are necessary and sufficient for the perceptual generation and maintenance of tinnitus remain incompletely understood. Combinations of animal model and human research will be essential in filling these gaps. Nevertheless, the existing progress in investigating the neurophysiological mechanisms has improved current treatment and highlighted novel targets for drug development and clinical trials. The aim of this review is to thoroughly discuss the current state of human and animal tinnitus research, outline current challenges, and highlight new and exciting research opportunities.

scholarly journals Primary Gastric Melanoma – Is an Aggressive Strategy Worthwhile?

2021 ◽  
Author(s):  
Rivi Haiat Factor ◽  
Danny Hazan ◽  
Jacob Frand ◽  
Ronen Brenner ◽  
Hananya Vaknine ◽  
...  
Keyword(s):  
Case Series ◽  
Sun Exposure ◽  
Surgical Oncology ◽  
Treatment Protocols ◽  
Pathologic Evaluation ◽  
Ocular Lesions ◽  
Pet Ct ◽  
Rare Malignancy ◽  
Main Component ◽  
Specific Symptoms

Abstract Background: Primary gastric melanoma (PGM) is a rare malignancy. Unlike skin melanoma which carries a definitive correlation to sun exposure, the pathogenesis of gastric melanoma is not well defined. It appears in the older age with median of 70 years and has no known risk factors. The diagnosis may be challenging due to non-specific symptoms, and endoscopy with tissue biopsy along with detailed physical examination ruling out skin and ocular lesions, and PET-CT, are the tools for establishing diagnosis. The prognosis for PGM is poor mainly due to late diagnosis. No detailed staging algorithm nor treatment protocols for PGM exists. Methods: A case series of all patients with PGM that were evaluated and managed by our surgical oncology service between 2011 and 2016. Data regarding diagnosis, imaging, pathologic evaluation and treatment protocols were collected and analyzed. Results: During study acquisition period, 3 cases with the diagnoses of PGM were identified. One patient was treated with aggressive surgery upfront, one patient was treated with more conservative surgical approach with delay from diagnosis to surgery, and one patient was not eligible for surgery due to age, medical and general condition. In 5 years of follow-up only the patient that had aggressive surgery survived. Conclusion: PGM carry very bad prognosis. We believe that aggressive surgery should be considered as the main component of the therapy plan without delay, for better clinical outcome and survival.

A case series of cerebral venous thrombosis as the first manifestation of homocystinuria

2021 ◽  
pp. 239698732110594
Author(s):  
Antonio Ochoa-Ferraro ◽  
Subadra Wanninayake ◽  
Charlotte Dawson ◽  
Adam Gerrard ◽  
Mary Anne Preece ◽  
...  
Keyword(s):  
Venous Thrombosis ◽  
Effective Treatment ◽  
Cerebral Venous Thrombosis ◽  
Thrombotic Event ◽  
Case Series ◽  
Autosomal Recessive Disorder ◽  
Retrospective Case ◽  
Tertiary Referral Centre ◽  
Physician Awareness ◽  
The Mean

Background Cerebral venous thrombosis (CVT) is an important cause of stroke particularly in younger patients and potentially fatal if diagnosis is delayed. The presentation of symptoms is highly variable and consequently the diagnosis and underlying cause is often delayed or overlooked. Homocystinuria, a rare autosomal recessive disorder is an identified risk factor for CVT. Purpose A timely diagnosis and treatment of the underlying cause of CVT could result in improved outcome and prevent further events. This case series describes the clinical course of six adults presented with unprovoked CVT, in whom the diagnosis of underlying homocystinuria was delayed with adverse consequences. We aim to highlight the importance of recognising homocystinuria as an underlying cause of CVT and offer a practical approach to the diagnosis and management. Methods This is a retrospective case series of a cohort of 30 consecutive patients seen in a UK tertiary referral centre. Result Six out of 30 patients presented with CVT prior to homocystinuria diagnosis. The mean and range of age at the time of the first CVT episode was 22.6 (range 11–31) years. The mean ±SD age at diagnosis of homocystinuria as the underlying cause was 26 ± 4.2 years. The time between first CVT and diagnosis of homocystinuria ranged from 1.6 to 11 years resulting in a delay to introduction of effective treatment and, in some cases, a further large vessels thrombotic event. Conclusion Physician awareness of homocystinuria as an underlying cause for an unprovoked CVT will facilitate timely introduction of effective treatment to prevent a further event.

Calcaneal Osteomyelitis: Current Treatment Concepts

2019 ◽  
Vol 19 (3) ◽  
pp. 230-235 ◽  
Author(s):  
Michael J. McCann ◽  
Ashleigh Wells
Keyword(s):  
Prognostic Factors ◽  
Literature Review ◽  
Medical Management ◽  
Current Treatment ◽  
Proper Treatment ◽  
Treatment Protocols ◽  
Clinical Diagnostic ◽  
Treatment Concepts

Calcaneal osteomyelitis can be a debilitating disease if proper treatment protocols are not initiated. This literature review details the epidemiology, clinical, diagnostic, and prognostic factors, and medical management in those who developed this disease.

Management of challenging radioiodine treatment protocols: a case series and review of the literature

2020 ◽  
pp. jnmt.120.255307
Author(s):  
Joseph Waller ◽  
Courtney A. Lawhn-Heath ◽  
Cathleen Edmonds ◽  
Chloee Wendorf ◽  
Brandon Holmes ◽  
...  
Keyword(s):  
Case Series ◽  
Radioiodine Treatment ◽  
Review Of The Literature ◽  
Treatment Protocols

Immigration Brings New Pathology with No Standardized Treatment Protocol

2018 ◽  
Vol 108 (6) ◽  
pp. 517-522
Author(s):  
Tara L. Harrington ◽  
Denten Eldredge ◽  
Erica K. Benson
Keyword(s):  
Opportunistic Infections ◽  
Treatment Options ◽  
Treatment Protocol ◽  
Current Treatment ◽  
Foot And Ankle ◽  
Treatment Protocols ◽  
Clinical Presentations ◽  
Standardized Treatment ◽  
Madura Foot ◽  
Antimicrobial Interventions

Madura foot is an uncommon invasive soft-tissue infection that foot and ankle specialists encounter. We present two rare cases of Phialemonium and Phaeoacremonium fungi infections of the foot diagnosed in northern California to inform physicians on the presentation and current treatment options for this unique pathology. The two cases presented outline the clinical presentations, diagnostic data, and surgical and antimicrobial interventions. There is a concentration on the antimicrobial options depending on which of the over 20 species is encountered. The pertinent literature and supporting data are reviewed to create an outline for discussion of treatment protocols when faced with these emerging opportunistic infections.

Active phytoconstituents for diabetes management: A review

2018 ◽  
Vol 15 (3) ◽  
Author(s):  
Rajnish Gupta
Keyword(s):  
Diabetes Management ◽  
Sedentary Lifestyle ◽  
Cost Effective ◽  
Arterial Disease ◽  
Current Treatment ◽  
Chronic Complications ◽  
Treatment Protocols ◽  
Artery Disease ◽  
Peripheral Arterial ◽  
Antidiabetic Plants

AbstractDiabetes is a metabolic syndrome increasing rapidly due to occupational stress, lack of physical activity, sedentary lifestyle and increasing occurrence of obesity, associated with rapidly growing urbanization and industrialization. Due to erroneous carbohydrate metabolism, diabetics are more prone to chronic complications like nephropathy, neuropathy, retinopathy, coronary artery disease and peripheral arterial disease resulting in tissue damage. Current treatment protocols to these problems produce more serious adverse effects and are costly too. Medicinal plants provide an alternative of safe, reliable and cost-effective pharmacological source to all these ailments. This review provides the compiled data of isolated active phytoconstituents of 22 potent antidiabetic plants with their plant-part used, which might be useful for drug development.

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