Eosinophilic Granulomatosis with Polyangiitis Relapse after COVID-19 Vaccination: A Case Report

Background: We here describe the case of a 71-year-old Caucasian woman previously diagnosed with Eosinophilic Granulomatosis with Polyangiitis (EGPA) that had been treated with Mepolizumab, an anti-IL5 monoclonal antibody, since 2019 with a good clinical response. Methods: She had a mild COVID-19 in December 2020 and she tested negative for SARS-CoV-2 infection in only late January 2021. In April 2021 she received the first dose of mRNA BNT162b2 vaccine. Ten days later she developed myalgia, dyspnea and numbness of the limbs due to a relapse of EGPA that occurred during Mepolizumab treatment.

The Subcutaneous Injection of Organophosphate: A Case Report

Organophosphate (OP) poisoning is prevalent in developing countries. Toxicity occurs by voluntary injection, inhalation, and absorption. Self-injection is rare. The current case report describes a 61-y/o male with subcutaneous self-injected one cc OP poisoning presenting with delayed drowsiness, nausea, and vomiting. He was treated and presented a good clinical response to treatment with pralidoxime and had a successful recovery. Diagnosis of OP compound toxicity by the parenteral route is a challenge. By observing patients, the dose, and the time between poisoning until the time to start treatment, we can conclude different presentations and outcomes of OP poisoning.

Small molecule tyrosine kinase inhibitors modulated blood immune cell counts in patients with oncogene-driven NSCLC

Background Lack of biomarkers and in vitro models has contributed to inadequate understanding of the mechanisms underlying the inferior clinical response to immune checkpoint inhibitors (ICIs) in patients with oncogene-driven non-small cell lung cancer (NSCLC). Methods The effect of small molecule tyrosine kinase inhibitors (TKIs) on peripheral blood mononuclear cells (PBMCs) in 34 patients with oncogene-driven NSCLC (cohort A) was compared with those from 35 NSCLC patients without oncogene-driven mutations received ICI (cohort B) or from 22 treatment-naïve NSCLC patients (cohort C). Data for each blood biomarker were summarized by mean and standard deviation and compared by Wilcoxon rank sum tests or Kruskal-Wallis tests with significance at 2-sided p value < 0.05. Co-culture of PBMCs and pleural effusion-derived tumor cells from individual patients with oncogene-driven NSCLC was used to determine the in vitro cytotoxicity of TKI and ICI. Results Except for low CD3% in cohort A, there were no significant differences in other 12 blood biomarkers among the 3 cohorts at baseline. TKI treatment in cohort A was associated with significant increase in CD3% and decrease in total and absolute neutrophils (p < 0.05). In cohort B, patients with good clinical response to ICI treatment (N = 18) had significant increases in absolute lymphocyte counts (ALCs), CD4 and/or CD8 cell counts. Conversely, those patients with poor clinical response to ICI (N = 17) had significant decreases in these cell counts. Of the 27 patients with pre- and post-treatment blood samples in cohort A, 11 had poor clinical response to TKIs and decreased lymphocyte counts. Of the remaining 16 patients who had good clinical response to TKI therapy, 10 (62.5%) patients had decreased, and 6 (37.5%) patients had increased lymphocyte counts. Multicolor immunophenotyping of PBMCs revealed ICI treatment activated additional immune cell types that need further validation. We confirmed that TKI treatment could either antagonize or enhance the effect of ICIs in the co-culture assay using patient’s tumor cells and PBMCs. Conclusions To the best of our knowledge, this is the first study showing that TKIs can have various effects on blood immune cells, which may affect their response to ICIs. Further validation of the blood biomarker and in vitro assay is warranted.

Eales Disease Debut in Childhood

Introduction: Eales disease is considered a peripheral retinal vascular disease characterized by inflammation (vasculitis), ischemia, vascular occlusion, and neovascularization. Its etiology is not yet defined, it generally affects young men in the second decade of life. Case: Male patient, 10 years old of age with a red eye with blurred right eye vision of 1 month of evolution that worsened 4 days before coming to the service, accompanied by photophobia and eye pain. Discussion: Eales disease affect to more often young males, whose main characteristic peripheral phlebitis which can cause retinal ischemia and neovascularization. Although its etiopathogenesis is unknown. Some cases in the literature that relate it to a type IV hypersensitivity reaction to M. tuberculosis’s antigens The treatment of choice was systemic and topical corticosteroids, with a very good clinical response and periodic follow-up of the patient, with warning signs.

Lenvatinib in Anaplastic Thyroid Carcinoma (ATC) in a Tertiary Caner Hospital- a Single Institute Experience

Anaplastic Thyroid Carcinoma (ATC) is an aggressive rare form of caner with limited treatment options and short survival. In view of initial case reports have shown some good clinical response with lenvatinib, we used the same in our institute. We are presenting a retrospective series of 4 cases between 2018-2021. It showed very promising results with 75% showing clinically meaningful regression of tumor. Hypertension is the most common side effect, which should be aggressively managed. We feel that, lenvatinib remains a safe and effective option to explore in patients with refractory anaplastic thyroid carcinoma.

Salivary IL-8 as a putative predictive biomarker of radiotherapy response in head and neck cancer patients

Objectives Ionizing radiation increases the expression of a number of salivary proteins involved in immunoregulatory networks related to infection, injury, inflammation, and cancer. Our main objective was to analyze whether there are significant differences in salivary cytokines before and after radiotherapy and whether any of them are associated to better outcomes after radiotherapy serving as a potential predictive biomarker of response to the treatment. Materials and methods We analyzed a panel of eight salivary markers (IL-4, IL-6, IL-8, and IL-10; MCP-1; TNF-α; VEGF; and EGF) in a group of HNC patients (N = 30), before and after irradiation treatment pre- and post-RT. We also compared these results with a group of healthy controls (N = 37). In both groups, we used stimulated saliva and we performed immunoassays based on multi-analyte profiling technology (Luminex xMAP). Results In our group of 30 HNC patients, 24 of them showed a good clinical response after radiotherapy treatment while 6 cases did not respond to radiotherapy. The data revealed a post-treatment increase in multiple cytokines in the stimulated saliva of HNC patients; the increases in IL-8 and MCP-1 were statistically significant (p ≤ 0.001 and p ≤ 0.0001, respectively). Analysis of receiver operating characteristic curves indicated the strong potential of IL-8 as a predictive biomarker of RT good outcomes (area under the curve = 0.84; p = 0.018). Conclusions After analyzing the panel of salivary cytokines, IL-8 showed the best association to the response to radiotherapy; in this sense, low IL-8 levels in the saliva of HNC patients before receiving irradiation therapy are associated with positive RT outcomes. Clinical relevance Salivary IL-8 expression in HNC patients undergoing RT may serve as a potential predictive biomarker of response to the treatment.

Primary mammary actinomycosis challenged with penicillin allergy

Actinomycosis is a subacute-to-chronic bacterial infection caused by gram-positive, filamentous, non-acid-fast, facultative anaerobic bacteria. It is a normal commensal bacterium found in the oral cavity and the lower reproductive tract of women. We present a case of primary actinomycosis of the breast. A postmenopausal woman, complicated by penicillin allergy, presented with a left breast lump clinically simulating malignancy. The first line of treatment for actinomycosis is penicillin. Due to a penicillin allergy, the patient was initially treated with doxycycline. However, doxycycline was discontinued due to tremors, and was replaced by clindamycin. The patient had a good clinical response with resolution of the abscess.

Immunotherapy for Recurrent orthostatic cerebral hypo-perfusion syndrome in recurrent COVID-19 infection

Orthostatic hypotension, often interpreted as a drop in blood pressure as a person moves from lying or sitting to standing, has a direct impact on the brain. It results in a decrease in brain perfusion pressure and in many cases causes symptoms of transient cerebral hypo perfusion. This report treats a case of recurrent orthostatic hypotension in a field of recurrent Covid-19 infection, with a good clinical response to early immunotherapy. Signs of lung infection retroceded until complete disappearance under treatment with chloroquine sulfate and azythromycin. However, due to persistent signs of dysautonomy and paresthesias, we had subjected the patient to intravenous immunoglobulin immunotherapy with a good therapeutic response until the patient's complete recovery 150 days after the start of treatment. The prognosis remains unknown at this time, as we do not yet have data from large-scale studies on this subject.

Posterieur reversibel encefalopathiesyndroom in het postpartum

A late postpartum complication The posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome characterized by acute neurological symptoms such as headaches, visual symptoms, altered consciousness and epileptic seizures in combination with subcortical vascular edema. One of the possible causes of PRES is pre-eclampsia. Observational studies show that some women with new-onset hypertension in the postpartum have an imbalance in pro- and anti-angiogenic factors, as in women with antepartum pre-eclampsia. Based on this case report, this potentially dangerous clinical entity is described. The 38-year-old primiparous patient presented 17 days after childbirth with a headache and severe hypertension. The diagnosis of PRES was made via an MRI. There was a good clinical response among chlorthalidone, bisoprolol and amlodipine. Sequential MRI images showed reversibility of the lesions. Regular blood pressure monitoring in women who recently gave birth, is important. New-onset hypertension is an alarm sign for pre-eclampsia in this patient group. Brain imaging is strongly recommended in case of the concomitant presence of risk factors of a headache. Early diagnosis of PRES and rapid treatment are necessary to prevent permanent neurological damage and mortality.

Case Report: THSD7A-Positive Membranous Nephropathy Caused by Tislelizumab in a Lung Cancer Patient

Immune checkpoint inhibitors (ICIs) became the standard treatment for many different kinds of cancers and can result in a variety of immune-related adverse events (irAEs). IrAEs of kidney are uncommon and consists of different pathology types. Among the different types, membranous nephropathy (MN) is rare and have not been well-described. Since MN can also be associated with malignancies, differential diagnosis in patients receiving ICIs who develop MN can be very difficult. We present the case of a 74-year-old man with metastatic non-small cell lung cancer who developed MN after ICIs therapy. The patient tested positive for thrombospondin type-1 domain-containing 7A antibodies (THSD7A) when diagnosed with MN. Supplementary examinations revealed the predisposing antigen in the primary tumor and present of the antibody after immunotherapy, which corresponded to the patient’s clinical course of nephropathy. Treatment consisting of systemic glucocorticoids and rituximab resulted in a good clinical response, and the THSD7A antibodies were no longer detected. In this case, we first discuss the potential mechanism of immunotherapy related MN, in which the activation of humoral immunity may play an important role.