Pelvic pain in Maigne’s syndrome—a multi-segmental approach

Background Maigne’s syndrome is a poorly understood condition that affects the thoracolumbar junction. The symptoms can range from pain in the low back, pelvis, hip, lower abdomen, and groin. These symptoms can have bio-mechanical and neurophysiological attributions due to the complexity of spinal mechanics. Thoraco-lumbar junction (T12-L1) is a transitional zone with a higher degree of mean angular motion and a mean translation motion than T10-T11 and T11-T12. This higher degree of translational and rotation mobility predisposes these segments to a higher degree of stress, making them more prone to biomechanical faults such as dysfunctions and positional faults. These altered static and dynamic mechanics can create a cascade of problems along the biomechanical chain. The co-existence of thoracolumbar junction problems with pelvic pain and dysfunctions strengthens the idea of regional interdependence. Case presentation The patient is a 44-year-old Caucasian male who reported pain in the low back with symptoms radiating to the right hip, iliac region, lower abdomen, and gluteal region. The patient tested positive for Sacroiliac joint dysfunction with both Laslett’s cluster testing and palpatory sacroiliac examination. In addition, the segmental examination showed restriction in thoracolumbar junction with positive skin rolling test and hypomobility in manual segmental testing. Thus, the manual therapy treatment targeted the thoracolumbar junction and sacroiliac joint to address the underlying biomechanical dysfunctions. Conclusions The manual therapy targeting both sacroiliac and thoracolumbar spine can improve pelvic and thoracic spine mobility. In addition, therapeutic exercises can focus on enhancing anterior and posterior chain force generation capacity. This combined approach helped improve functional outcomes with a significant decrease in the Modified Oswestry Disability index and significant improvement on Visual analog scale.

AstraZeneca ChAdOx1-S COVID-19 Vaccine Can Be Safely Administered in Patients with EDTA Allergy

Background: Immediate hypersensitivity reactions to COVID-19 vaccines have been postulated to be linked to their excipients, such as polyethylene glycol (PEG) in Pfizer Comirnaty, or polysorbate 80 and ethylenediaminetetracetic acid (EDTA) in AstraZeneca ChAdOx1-S [recombinant] (Vaxzevria). These excipients are potentially found in a range of other products, including injectable and oral medications as well as intravenous radiocontrast media (RCM) and various cosmetic products.Currently patients with proven excipient allergy may be advised to avoid a COVID-19 vaccine containing that excipient and/or potentially cross-reactive excipients. We present two cases of previously confirmed EDTA anaphylaxis, who had negative Vaxzevria vaccine in-vivo testing and subsequently tolerated the vaccine.Case 1: A patient with history of anaphylaxis to RCM and local anaesthetics (LA) had positive intradermal test (IDT) to EDTA nine years earlier. Skin testing to Vaxzeria vaccine (up to 1:10 IDT), Comirnaty vaccine (up to 1:10 IDT) and EDTA 0.3mg/mL IDT were negative. However, following EDTA 3mg/ml IDT, he developed immediate generalised urticaria without anaphylaxis. Basophil activation testing was negative to disodium EDTA, Vaxzevria and Cominarty vaccines. Given the negative in-vitro and in-vivo testing to Vaxzevria vaccine, he proceeded to Vaxzevria immunisation and tolerated both doses.Case 2: A patient with history of anaphylaxis to RCM had positive skin testing to EDTA and RCM containing EDTA six years earlier. Following referral to COVID19 vaccine clinic, Vaxzevria vaccine (1:10 IDT) and Cominarty vaccine (1:10 IDT) were negative whilst EDTA was positive at 0.3mg/mL IDT. He subsequently tolerated both Vaxzevria vaccinations.Conclusion: Excipient allergy does not necessarily preclude a patient from receiving a vaccine containing that excipient. Allergy testing can help identify excipient-allergic patients who may still tolerate vaccination, which is important in situations where COVID-19 vaccination options are limited.

Validation and Application of Skin RT-QuIC to Patients in China with Probable CJD

The definite diagnosis of human sporadic Creutzfeldt–Jakob disease (sCJD) largely depends on postmortem neuropathology and PrPSc detection in the brain. The development of real-time quaking-induced conversion (RT-QuIC) of cerebrospinal fluid (CSF) samples makes it possible for premortem diagnosis for sCJD. To test the diagnostic potential of RT-QuIC of skin specimens for probable sCJD, we collected the paired skin and CSF samples from 51 recruited living patients referred to the Chinese CJD surveillance center, including 34 probable sCJD, 14 non-CJD, and 3 genetic prion disease (gPrD). The samples were subjected to RT-QuIC assays using recombinant hamster PrP protein rHaPrP90-231 as the substrate. Using skin RT-QuIC assay, 91.2% (31/34) probable sCJD patients, and 1 T188K genetic CJD (gCJD) cases showed positive prion-seeding activity, while 85.7% (12/14) non-CJD patients were negative. CSF RT-QuIC positive seeding activity was only observed in 14 probable sCJD patients. Analysis of the reactivity of 38 positive skin RT-QuIC tests revealed that the positive rates in the preparations of 10−2, 10−3 and 10−4 diluted skin samples were 88.6% (39/44), 63.6% (28/44), and 25.0% (11/44), respectively. Eleven probable sCJD patients donated two skin specimens collected at different sites simultaneously. Although 95.5% (21/22) skin RT-QuIC elicited positive reaction, the reactivity varied. Our preliminary data indicate high sensitivity and specificity of skin RT-QuIC in prion detection for Chinese probable sCJD and highlight that skin prion-seeding activity is a reliable biomarker for premortem diagnosis of human prion disease.

MECHANICAL VENTILATION FOR INTERSTITIAL LUNG DISEASE BY SYSTEMIC SCLEROSIS WITH CREST SYNDROME. PRESENTATION OF A CLINICAL CASE

INTRODUCTION. Interstitial lung disease (ILD) with acute respiratory failure needs ventilatory support poorly documented. One of the interstitial diseases known is the Systemic sclerosis, its advanced stages develop CREST syndrome. Faverio P, et al. (2016) suggested do not close the door to these patients and open the correct protocol, criticizing the little value that the scientic community concede to invasive mechanical ventilation (IMV). CASE REPORT. 85-year-old male is internalized in critical care unit by pneumonia, the complementary evaluation shows a systemic sclerosis disease with CREST syndrome and it is conrmed by elevation of anti-centromere antibody and positive skin biopsy. Tomography highlights pneumonic consolidation plus interstitial lung involvement and echocardiography reveals pulmonary hypertension. The management is done with IMV, keeping the goal of driving pressure less than 15 as lung protection, recovering respiratory function in 3 weeks. Discussion. The evidence is too insufcient to establish the best decision on IMV to the management of ILD.

Reactivation of Q fever: case report of osteoarticular infection developing at the site of a soft tissue injury

Coxiella burnetii , the causative agent of Q fever, is known to cause acute and persistent infection, but reactivation of infection is rarely reported. This case demonstrates reactivation of a distant, untreated Q fever infection after a relatively innocuous soft tissue injury in an adjacent joint without pre-existing pathology. A 52-year-old male abbatoir worker sustained an adductor muscle tear in a workplace injury. He was unable to walk thereafter, and developed a chronic, progressive, destructive septic arthritis of the adjacent hip with surrounding osteomyelitis of the femur and acetabulum. He had evidence of prior Q fever infection, with a positive skin test and serology 15 years beforehand. He was diagnosed with chronic osteoarticular Q fever on the basis of markedly elevated phase I antibodies, and symptomatic and serological response to prolonged antibiotic treatment with doxycycline and hydroxychloroquine. He required a two-stage hip arthroplasty. This case illustrates reactivation of latent C. burnetii infection at the site of a soft tissue injury. Clinicians need to be aware of this possibility in patients with previous Q fever infection, and in the setting of undiagnosed osteoarticular pathology following soft tissue injury.

Preceding group A streptococcus skin and throat infections are individually associated with acute rheumatic fever: evidence from New Zealand

IntroductionAcute rheumatic fever (ARF) is usually considered a consequence of group A streptococcus (GAS) pharyngitis, with GAS skin infections not considered a major trigger. The aim was to quantify the risk of ARF following a GAS-positive skin or throat swab.MethodsThis retrospective analysis used pre-existing administrative data. Throat and skin swab data (1 866 981 swabs) from the Auckland region, New Zealand and antibiotic dispensing data were used (2010–2017). Incident ARF cases were identified using hospitalisation data (2010–2018). The risk ratio (RR) of ARF following swab collection was estimated across selected features and timeframes. Antibiotic dispensing data were linked to investigate whether this altered ARF risk following GAS detection.ResultsARF risk increased following GAS detection in a throat or skin swab. Māori and Pacific Peoples had the highest ARF risk 8–90 days following a GAS-positive throat or skin swab, compared with a GAS-negative swab. During this period, the RR for Māori and Pacific Peoples following a GAS-positive throat swab was 4.8 (95% CI 3.6 to 6.4) and following a GAS-positive skin swab, the RR was 5.1 (95% CI 1.8 to 15.0). Antibiotic dispensing was not associated with a reduction in ARF risk following GAS detection in a throat swab (antibiotics not dispensed (RR: 4.1, 95% CI 2.7 to 6.2), antibiotics dispensed (RR: 4.3, 95% CI 2.5 to 7.4) or in a skin swab (antibiotics not dispensed (RR: 3.5, 95% CI 0.9 to 13.9), antibiotics dispensed (RR: 2.0, 95% CI 0.3 to 12.1).ConclusionsA GAS-positive throat or skin swab is strongly associated with subsequent ARF, particularly for Māori and Pacific Peoples. This study provides the first population-level evidence that GAS skin infection can trigger ARF.

Case Study - Candida auris in Skilled Nursing Facility

Candida Auris (C. auris), is a multidrug-resistant organism, first described in Japan 2009, and now a serious, emerging global health threat1. C. auris pathogen can potentiate morbidity and mortality, i.e. lifelong contact precaution isolation, intravenous antifungal treatment, hospitalization and mortality rate of 30-60%1. Los Angeles County (LAC) developed 15 new cases in May 2020, and 73 cases in July 2020, amidst COVID-19 pandemic2. A 88 year old Black female had a positive skin test for C. auris by LAC Department of Public Health (DPH) during skilled nursing facility (SNF) admission for hip fracture in September 2020. Patient’s risk factors for C. auris included: age, kidney transplantation (1998) immunosuppression on tacrolimus, fungal infection on fluconazole, drug-drug interaction between tacrolimus-fluconazole including nephrotoxicity and neurotoxicity, malnutrition, bedbound, Stage 4 sacrococcyx pressure ulcer, osteomyelitis on broad-spectrum antibiotics, chronic indwelling catheter, and healthcare setting. Our multimorbid and frail patient remained asymptomatic with C. auris under an interdisciplinary team approach, including geriatricians, infectious disease, pharmacists, SNF team and local DPH. Our patient’s psychosocial isolation and family distress with local DPH guidelines for COVID-19 SNF visitation restrictions were compounded by multifaceted coordination of patient-centered care between SNF team and specialists via telehealth. Further research in the prevention, detection, and management of C. auris is warranted to protect our vulnerable SNF residents. 1. Centers for Disease Control and Prevention. (2020). Tracking Candida auris. https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html 2. Los Angeles County Health Alert Network. (2020). CDPH Health Advisory: Resurgence of Candida auris in Healthcare Facilities in the Setting of COVID-19. http://publichealth.lacounty.gov/eprp/lahan/alerts/CAHANCauris082020.pdf

Scar Formation and Tuberculin Conversion Following BCG

Objective: To determine frequency of scar formation and positive tuberculin conversion test following BCG vaccine administered within 0-28 days of life in children in 6 months to 6 years of age presenting at outpatient department of Fauji Foundation Hospital Lahore. Study Design: Descriptive case series. Place and Duration of Study: Outdoor Department of Pediatrics, Fauji Foundation Hospital, Lahore from 1st July 2020 to 30th December 2020. Methodology: Ninety seven children were included. Base line demographic information of patients (age, gender, weight on weight machine) was recorded. 0.5 ml BCG was administered in right arm. Tuberculin skin test was assessed as per operational definition. After 48 to 72 hours, scar formation was assessed after 1 month. Data regarding scar formation and positive tuberculin conversion test was recorded. Results: The mean age was 3.20±1.46 years, 39 (40.21%) were male whereas 58 (59.79%) were females. The scar formation following BCG vaccine administered within 0-28 days of life in children in 6 months to 6 years of age was 59 (60.82%) and positive tuberculin conversion test following BCG vaccine administered within 0-28 days of life in children in 6 months to 6 years was recorded in 47 (48.45%). Conclusion: Most babies have developed a post-vaccination scar. The combination of the BCG scar and the positive skin testing tuberculin was very important. The development of BCG scars had no effect on age or sex. Greater trials are advised in order to detect the true extent of the problem and to evaluate regularly the BCG vaccination programs. Keywords: Infants, Tuberculosis, BCG vaccination, Scar formation, Positive tuberculin conversion test

Comparative Assessment of Platinum Salts and Taxane Group Hypersensitivity Reactions, The Role of Skin Tests in Diagnosis?

Purpose We aimed to investigate the role of skin tests (ST) in the diagnosis of hypersensitivity reactions (HSRs) with platinum salts (PS) and taxane (TX) groups drugs and their reliability in patient management. Materials and Method Patients' data who developed immediate HSR with PS and TX were recorded and ST was performed. The gradual challenge was applied to all patients with ST negative and grade 1–2 with the suspect drug. Results In total, the data of 104 patients (74 with PS, 30 with TX) who developed HSR against PS and TX were shared. The gradual challenge was applied to 72 ST negative and grade 1–2 patients (46 PS group, 26 TX group). The gradual challenge was negative in 39 patients in the PS group and 23 patients in the Tx group. The negative predictive value (NPV) for PS was 83% and NPV for TX was 88%. We found significantly higher skin test positivity in patients with PS and TX and grade 3 HSR ( p = 0.007, p = 0.001). A significant correlation was found between skin test positivity and early onset of symptoms ( p = 0.001 for PS, p = 0.015 for TX). In terms of symptoms witnessed in HSR, we observed the itching, urticaria, hypotension, syncope, and abdominal pain symptoms significantly more in the group with a positive skin test ( p < 0.024, p < 0.001, p < 0.001, p < 0.002, and p < 0.025, respectively). Conclusions We found very high NPV values for PS and TX. We found that the gradual challenge applied to patients with negative skin tests is reliable if Grade 3 HSR is not observed and with this approach, unnecessary desensitization processes and/or drug alterations can be avoided.

Characterization of allergic inflammation in chronic uterine cervicitis

Female genital tract chronic inflammation is common in clinics; the pathogenesis is not fully understood yet. House dust mite (HDM) involves the pathogenesis of many chronic diseases in human. This study aims to identify HDM-specific allergic response in the cervix of patients with cervical inflammation. Patients (n=80) with chronic cervicitis (CC) and non-CC control (NC) subjects (n=80) were recruited into this study. Vaginal lavage fluids (VLF) were collected from CC patients and NC subjects. Cellular components and fluid part of VLF were separated by centrifugation, and analyzed by flow cytometry and enzyme-linked immunosorbent assay. We found that a portion (52 out of 80) of CC patients responded to HDM, manifesting positive skin prick test, and HDM-specific IgE and IgG was detected in the VLF (designated CCp patients). VLF of CCp patients showed a Th2 dominant profile. HDM-specific Th2 cells were detected in VLF in CCp patients. Exposure to HDM in the culture induced proinflammatory cytokine release from CCp VLF CD4 + T cells. Exposure to CCp VLF CD4 + T cell-conditioned medium induced de novo Th2 response. Direct exposure to HDM induced allergic response in the cervix of CCp patients. In summary, a portion of CC patients respond to HDM challenge in the cervix. Exposure to HDM induces an allergy-like response in the cervix of CCp patients.