Life-Threatening Stridor due to Laryngeal Tuberculosis in the COVID-19 Era: Report of a Case

Laryngeal tuberculosis is the most frequent granulomatous disease of the larynx and it is prone to be diagnosed as cancer. COVID-19 pandemic caused considerable disruption in tuberculosis service provisions both in the primary care and hospital settings. This report describes a rare case of life-threatening stridor in a patient who presented with an ulceroproliferative laryngeal mass later confirmed as laryngeal tuberculosis. Urgent tracheostomy was performed. The patient’s sputum and the computed tomography of the chest revealed a pulmonary, as well as laryngeal tuberculosis. The patient was commenced on a 24 week course of anti-tuberculous treatment which was interrupted because of a mild course of hospital-acquired coronavirus infection. 3 months after initial treatment for tuberculosis, his sputum cultures became negative. Flexible laryngoscopy was performed at our department 4 months after commencement of treatment, demonstrating complete regression of the lesion and symmetrical laryngeal mobility, hence the patient was successfully decannulated and discharged to be followed up to his community hospital. In the time of COVID-19 pandemic, we should never underestimate other severe infectious diseases.

Pencil Beam Scanning (PBS) Intensity-Modulated Proton Therapy (IMPT) Chemoradiotherapy for Anal Canal Cancer—Single Institution Experience

Background: A favourable dose distribution has been described for proton beam therapy (PBT) of anal cancer in dosimetric studies. The relationship between dosimetric parameters in bone marrow and haematologic toxicity, treatment interruptions, and treatment efficacy has also been documented. There are only few references on clinical results of PBT for anal cancer. The primary objective of the retrospective study was to assess the efficacy of pencil beam scanning intensity-modulated proton therapy (PBS IMPT) in the definitive chemoradiotherapy of anal cancer. Secondary objectives were established to identify the risks of acute chronic toxicity risks and to assess colostomy rates. Materials and methods: Patients were treated for biopsy-proven squamous cell cancer (SCC) of the anus at initial or advanced stages. Eligible patients received PBS IMPT at a single institution. Treatment was administered in two volumes: 1—tumour with margins plus involved lymph nodes; 2—regional lymph node groups: perirectal (mesorectal), obturatory, inguinal, internal, external, and common iliac. The total doses of 57.5 GyE and 45 GyE, respectively, were administered in volumes 1 and 2 in 25 fractions, 5 fractions per week, respectively (a simultaneous integrated boost). Concomitant chemotherapy cisplatinum (CDDP) plus 5-FU or CDDP plus capecitabine was administered as per protocol. The treatment effect was assessed using DRE (digital rectal examination) and MRI (magnetic resonance imaging) within the follow-up period. Toxicity was scaled using CTCAE version 4.0 criteria. Results: 39 of 41 patients treated during the period of February 2014–August 2021 were eligible for analysis. All patients completed treatment, 76.9% without interruption. The median treatment time was 35 days (32–35). The median follow-up period was 30 months, 34 patients are alive to-date, 5 patients died prior to the date of analysis, and 2 deaths were unrelated to the primary disease. The 2-year overall survival, relapse-free survival, and colostomy-free survival were 94.2%, 93.8%, and 91.0%, respectively. Complete regression was achieved in 36 patients (92.3%), partial regression was achieved in 2 (5.1%), and immediate progression at end of treatment occurred in 1 patient (2.6%). Salvage resection was indicated for two patients in partial regression and due to severe chronic dermatologic toxicity. The grade 3 and 4 haematological toxicity rates were 7.7% and 5.1%, respectively. The most frequent non-haematological acute toxicities of grade 3–4 observed were dermatitis (23.1%), diarrhoea (7.7%), and dehydration (7.7%). Chronic toxicity emerged predominantly as skin atrophy/ulceration grade 2 (26.5%) and grade 3–4 (5.8%), and radiation proctitis grade 2 (38.2%) and grade 3 (2.9%). Discussion, conclusions: This single-institution study showed the high efficacy of PBS IMPT, achieving a high rate of complete regression. The haematological acute toxicity of grade 3–4 remained low; however, the impact of altered chemotherapy (CDDP instead of mitomycin C) remains unclear. The incidence of other acute toxicities shares similarity with photon therapy investigated in large studies. The acute toxicity completely resolved in all patients, had no lethal outcomes, and never resulted in the necessity for colostomy. By contrast, it was chronic toxicity, skin ulceration, perirectal fistulation, and fibrosis that resulted in salvage surgery and/or the need for a colostomy. A challenging question remains: to what extent can PBT prevent chronic toxicity? Longer follow-up remains necessary.

Comparison Of Collagen-Curcumin Blend (Collaper Rtu)With Intralesional Steroid Injections in Oral Submucous Fibrosis a Randomized, Open-Label Interventional Study.

Introduction: Oral Submucous Fibrosis (OSMF) is a precancerous condition characterized by limited mouth opening, burning sensation, stiffness, and blanching of the oral mucosa induced by areca nut eating. With any of the current therapy regimens, complete regression of the illness has not been accomplished in all patients. Curcumin is a yellow pigment found in curry powder that has antioxidant, anti-inflammatory, and pro-apoptotic properties. As a result, interventional research was conducted to determine the efficacy of Collaper RTu a proprietary collagen-curcumin based product in patients with OSMF.Setting and design: Forty patients with clinically and histologically confirmed Oral Submucous Fibrosis participated in a randomized open label interventional research. Method & materials: For the research, forty patients with clinically and histologically verified Oral Submucous Fibrosis were randomly assigned to one of two groups. The first group was given a weekly intralesional injection of 4 mg Dexamethasone and 1500 I.U Hyaluronidase, whereas the second was given two Collagen-Curcumin pills (Collaper Rtu 60mg Collagen with 100 mg Curcumin) every day for three months. On a weekly basis, the improvement of burning sensation, interincisal distance, and tongue protrusion was assessed.Results: From early to late stages, the burning feeling improved in both groups. Collaper Rtu was found to eliminate the burning feeling. In groups 1 and 2, the mean increase in interincisal distance was 3.13 mm and 1.25 mm, respectively. The interincisal distance improved significantly in both groups by the end of the first month. When compared to group 2, group 1's tongue protrusion recovered faster at the conclusion of the first month. Conclusion: Collaper RTu is useful and effective in lowering the burning feeling in people with early OSMF.

Application of vessel endothelium growth factor inhibitor ranibizumab in complex therapy of retinopathy of prematurity

AIM: To conduct a retrospective study of the application of vessel endothelium growth factor inhibitor ranibizumab in complex therapy of retinopathy of prematurity in Ural State children`s ophthalmological center at State Autonomic Health Institution of the Sverdlovsk Region Multiprofile Clinical Medical Center BONUM in Yekaterinburg. MATERIAL AND METHODS: The study included 17 patients (33 eyes). The gestation age was from 23 to 30 weeks (mean: 26.51.7 weeks), birth weight was from 600 to 1850 g (mean: 867229 g). 8 patients (47%) had APROP, and 9 patients (53%) had ROP stage III, type 1, plus disease. Laser coagulation of the avascular areas of the retina as the start in ROP therapy was performed in three patients with APROP (4 eyes, 12.1%). Intravitreal injection of the anti-VEGF ranibizumab was performed in 17 patients (33 eyes), including patients with previous laser coagulation. The age of the patients at the time of injection was from 7.7 to 15.6 weeks (10.51.9 weeks), PCA from 32.3 to 39.6 weeks (37.01.8 weeks). Patients with stage IVa ROP (5 patients, 6 eyes) underwent 25G or 27G lens sparing vitrectomy. RESULTS: As a result of the complex treatment of ROP, the following results were obtained: complete regression in 13 patients (28 eyes, 84.8%). Partial regression in two patients (2 eyes, 6.1%). ROP progression to stage V in two patients (3 eyes, 9.1%). CONCLUSION: Complex treatment of severe stages of active ROP with laser treatment, IVI injections, ranibizumab, and vitrectomy made it possible to preserve vision in 90.9% of patients.

Thymic Tumours in Children

Thymomas are very rare neoplasms in children and they represent less than 1% of mediastinal tumours in the paediatric population. The aim of our study was to assess the long-term treatment results of children with thymic tumours. A total number of eight children (four boys and four girls) with thymic tumours were identified. Median age at diagnosis was 7 years. In seven of them, thymoma was diagnosed; in one, a thymic carcinoma was diagnosed. In five of them, the WHO type was assessed: in two of them, the B1 type was found; in one, B2 was found; in one, AB was found, and in one, C was found. In all but one, surgery was the first-line treatment, but six patients had only partial resection. One patient started treatment with chemotherapy and four others received chemotherapy after the surgery. Radiotherapy was applied in six patients, with a median total dose of 37.5 Gy. Follow-up ranged from 8.5 to 273.5 months, with a median of 6.1 years. During this time, four patients died: one due to progression of the disease, and in the other three, the reason for death was unknown. In all evaluated patients, complete regression was observed (100% local control). Two-, 5- and 10-year OS and PFS were 85% and 72%, 51% and 54%, 51% and 54%, respectively. Combined treatment could provide satisfactory results in thymoma patients. There is a need for further, larger studies, which could help to establish optimal management strategies.

Chemotherapy induced histopathological changes in retinoblastoma, assessment of high risk predictive factors & its correlation with comorbid conditions

Background & Objectives: Retinoblastoma is a malignant intraocular tumor and its treatment requires a multidisciplinary approach. Chemotherapy is an important modality in treatment of retinoblastoma. The purpose of this study was to assess the histopathological changes in retinoblastomas treated with chemotherapy along with correlation of comorbid conditions with high risk histopathological factors (HRF). Methods: All post-chemotherapy enucleated eye specimens received in the pathology department between 2017 to 2021 were included in the study. Slides were retrieved and reviewed for chemotherapeutic effects, tumor regression, and for assessment of HRF. Patient demographic data, information regarding chemotherapy and co-morbid conditions were retrieved through the hospital database. Chi-square was used to analyze the relation between comorbid conditions and HRF. Results: Chemotherapeutic effects were seen in all eyes with varying degrees of responses. Necrosis, calcification, and gliosis were the most common findings. The majority of eyes showed tumor occupying less than 50% of the eye whereas complete regression was noted in one eye only. Retinal detachment, glaucoma, and buphthalmos were the most common comorbid conditions at the time of diagnosis. Patients with glaucoma were more likely to have ciliary body invasion. Kaplan Meier analysis showed that patients with more than two HRF had decreased survival rates in comparison to those with one or no HRF. Conclusion: Histopathological evaluation of chemotherapy-treated eyes shows varying degrees of response to chemotherapy. Post enucleation histopathological evaluation of the globe plays an important role in assessing disease activity and guiding further treatment to prevent metastasis. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5786 How to cite this:Yaqoob N, Mansoor S, Zia N, Aftab K, Kaleem B, Jamal S. Chemotherapy induced histopathological changes in retinoblastoma, assessment of high risk predictive factors & its correlation with comorbid conditions. Pak J Med Sci. 2022;38(2):362-368. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5786 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Hordeum murinum aspiration revealed by a pneumopleurocutaneous fistula in a 15-month-old infant

Background Hordeum murinum is a specie of grass rarely reported among the aspirated foreign body. It has high tissue penetration power and may cause lung damages. Case presentation We report the case of a 15-month-old girl who choke while playing in the grass without any evident cause. This episode was immediately followed by vomiting and coughing with traces of blood. While she was fine during the following week, she relapsed at day (D) 7 with fever. At D10, she was finally hospitalized for signs of respiratory distress. The chest CT-scan revealed a voluminous right sub pleural empyema with an aerial component, responsible for the collapse of the right lower lobe, and complicated by a pneumopleurocutaneous fistula to the right paravertebral muscles. Intravenous antibiotics were prescribed, but no invasive procedure was performed. At D18, the spikelet of a false barley spontaneously externalized through the fistula. Evolution was favorable thereafter with disappearance of the fever and progressive decrease of the biological inflammatory syndrome. The follow-up at 4 months was reassuring, with normal clinical evaluation, and complete regression of the empyema on the chest X-rays. Conclusions Hordeum murinum is a rare type of foreign body, and the aspiration often goes unnoticed. In these peculiar cases, CT-scans can be as informative as bronchoscopies, and the evolution is usually favorable after fistulization.

474 A case of Takotsubo cardiomyopathy in SARS-CoV-2 infection

Cardiovascular complications are a frequent occurrence in SARS-CoV-2 infection. Takotsubo cardiomyopathy (also known as stress cardiomyopathy) is a possible cause of transient ST segment elevation (1–3% of total cases) and is characterized by a reversible left ventricular dysfunction with coronary arteries free from critical stenosis. The predominant echocardiographic pattern of this cardiomyopathy is an akinesia of the mid-apical myocardial segments (‘apical ballooning’), with preserved kinetics of the basal segments. The incidence of Takotsubo cardiomyopathy showed a marked increase during the COVID-19 pandemic. The data showed that three factors mainly contribute to the onset of cardiomyopathy in patients with COVID-19: cytokine storm, adrenergic hyperactivation and microvascular dysfunction. A 79-year-old woman was hospitalized in the Pneumology department of our hospital for acute hypoxemic respiratory failure due to bilateral interstitial pneumonia SARS-CoV-2 related. In remote medical history: in 2010 diagnosis of breast cancer, treated with quadrantectomy, adjuvant chemo- and radiotherapy, with negative follow-up for disease recovery, systemic arterial hypertension, hypercholesterolaemia and from 2016 syndrome of reduced mobility as a result of a previous ischaemic stroke. Non-invasive mechanical ventilation with c-PAP was started in the ward and, for the detection of anterolateral electrocardiographic anomalies (diffuse symmetrical negative T waves. Figure) and an increase in myocardionecrosis markers (troponin I peak: 5.4 ng/ml), in the absence of chest pain or equivalent, echocardiographic evaluation was performed, which revealed an akinesia of the mid-apical segments of the left ventricle with preserved kinetics of the basal segments and severely depressed global systolic function (ejection fraction: 30%). BNP (18.100 pg/ml), interleukin-6 (339 pg/ml), and CRP (136 mg/l) were elevated on blood chemistry tests. In the suspicion of Takotsubo cardiomyopathy (InterTAK Score: 67, probability: 79.8%), cardioprotective therapy with ACE inhibitor, beta-blocker, diuretics, low molecular weight heparin, double antiaggregation, and statin was started, deferring coronary angiography to improve clinical conditions. In the following days, due to the respiratory and haemodynamic worsening, the patient was transferred to an intensive setting, where she was intubated and treated with levosimendan and noradrenaline. In the intensive care unit, serial echocardiograms (over 30 days) showed a progressive improvement, up to normalization, of the global systolic function (ejection fraction at the last checkup: 55%), with complete regression of the kinetic anomalies, confirming the diagnostic hypothesis of stress cardiomyopathy. For a pulmonary mycotic superinfection (positive bronchoaspirate for Candida albicans and Candida krusei), complicated by iatrogenic pneumothorax, in the following days the patient died.

Innate Immunity Stimulation During COVID-19 Pandemic: Challenge

AIM: We report an open spontaneous anecdotical retrospective survey of Corynebacterium parvum administration to 4000 fragile immune-depressed and multimorbid patients treated with a killed C. parvum strain to enhance the innate immunity integrating the adaptative immune response for a long standing antinfectious resistance. METHODS: 4000 patients (1900 men and 2100 women) with mild, moderate or chronic disease, appealing to our Second Opinion Medical Consultation Network, signed an informed consent and were injected subcutaneously with C.parvum. The treatment was followed up at 6 months after therapy, filling the short form of the medical outcome health survey questionnaire (SF-36), directly by the patients or its parents and monitoring the health regularly via telemedicine (Skype, WhatsApp, mail, etc) or physician’s visit.RESULTS: The main efficacy endpoints, as assessed by the SF-36 questionnaire, are significant improvements in the mental and physical role functioning score (p< 0.02), in general health, in social role functioning (p < 0.02), vitality (p < 0.03), and a significant reduction in bodily pain (p< 0.03). There was a quick (48-72 hours) symptoms improvement and/or complete regression of the herpetic eruptions observed in 1000 affected patients and of herpetic neuralgia (reduced in 80% of cases), also full recovery or frequency reduction (30%) of recurrent cystitis and prostatitis in 120 affected patients, and last, but not least, a life quality improvement in 100 oncologic patients of overall 200 cases. A significant increase in the lymphocyte count (p<0.01), mainly Helper and Killer lymphocytes, was noted after 6 months by Parvulan injection vs. the baseline.The asymptomatic SARS-CoV-2 patients, incidentally, enrolled in our survey, were tested at sixth months for antibodies against SARS-CoV-2 and 14 patients occurred high level of SARS-CoV-2 antibodies. The incubating Covid infections in the Parvulan injected patients even if rail and multi-morbid recovered in a short term (48-96 hours) and with benign clinical course, usually no need of further drugs administration except for the variants, which lasted on average one week and required some antipyretics, and low dose steroid for a few days.CONCLUSIONS: Our results confirm that C.parvum is quite safe and effective to support immune-compromised patients when epidemic or pandemic events rise the life risk and any kind of infections and complications rate.Further double-blind placebo evidence-based studies are urgently required, and our numerically substantial not sponsored spontaneous observation aims exclusively to promote further evidence based double blind institutional studies.