Methotrexate in erythema nodosum leprosum: Pitfalls to avoid

We read with interest the short report by Rani et al. entitled “An uncommon variant of erythema nodosum leprosum responding well to methotrexate: Report of two cases.” The article describes two cases of erythema nodosum leprosum (ENL) with ‘atypical features’ and good response to low dose methotrexate. The authors address a few concerns regarding methotrexate in ENL, emphasizing the rational usage of this agent.

Solid Thyroid Follicular Nodules With Longitudinal Nuclear Grooves: Clinicopathologic, Immunohistochemical, and Molecular Genetic Study of 18 Cases

Context.— Follicular thyroid nodules can be a source of diagnostic difficulties, particularly when they display atypical features commonly associated with malignancy, such as nuclear grooves. Objective.— To differentiate lesions with atypical features from similar-appearing benign and malignant lesions. Design.— Eighteen cases of atypical follicular thyroid nodules characterized by a solid growth pattern and prominent longitudinal nuclear grooves were studied and examined for clinicopathologic characteristics. Results.— The lesions occurred in 16 women and 2 men aged 36 to 88 years and measured from 0.2 to 1.5 cm. The tumors were well circumscribed and noninvasive, and histologically characterized by a predominantly solid growth pattern with rare scattered follicles or a combination of solid growth pattern with minor follicular areas. A striking feature seen in all cases was the occurrence of longitudinal nuclear grooves. Immunohistochemical stains showed negativity for cytokeratin 19 (CK19) and HBME-1 in 8 cases; in the other 10, there was focal positivity for HBME-1 in 4 cases and diffuse positivity in 6. All cases were negative for galectin-3 and for CK19, with the exception of 1 case, which was CK19+/HBME-1−. Next-generation sequencing of 16 cases with a 161-gene panel detected 14 single nucleotide variants in 12 cases, predominantly NRAS and HRAS mutations. Clinical follow-up ranging from 18 to 72 months (median, 43.7 months) did not disclose any evidence of recurrence or metastases. Conclusions.— We interpret these lesions as low-grade, indolent follicular proliferations that need to be distinguished from papillary thyroid carcinoma, follicular adenoma, and noninvasive follicular thyroid neoplasms with papillary-like nuclear features.

Clinical profile and outcome of dengue patients with atypical features in the pediatric age group in a tertiary care center of East India

Background: Dengue is one of the most widespread arthropod borne diseases worldwide with an annual incidence of 50–100 million cases per year. The recent resurgence of dengue in the pediatric population has created concern among pediatricians, especially due to increased incidence of atypical features, leading to delayed diagnosis and increased mortality. There are few studies regarding this due to under reporting of the cases. Aims and Objectives: This study aims to study the clinical profile and outcome of dengue patients between the age groups of 1 month and 12 years with special emphasis on patients with atypical features. Dengue patients with atypical presentation are easily misdiagnosed by physicians, especially in the pediatric age group which increases the morbidity and mortality. Materials and Methods: This was a retrospective observational study conducted from May 2018 to September 2019 in the Department of Pediatrics, CNMCH. All pediatric patients who were dengue IgM or dengue NS1 positive were included in the study and their course of stay was followed through hospital records. The data were statistically analyzed through SPSS 16.0 software. Results: Sixty-two dengue patients were included in the study. Thirty-two patients presented as mild febrile illness, classical dengue fever (DF), dengue hemorrhagic fever, or shock syndrome without atypical manifestations. Atypical manifestations were found in 30 patients (48.38%) of our study. Eleven (17.7%) patients had splenomegaly, 5 (8.1%) patients had hepatitis, 3 (4.8%) patients had diarrhea, 2 (3.2%) patients had acalculous cholecystitis, 1 (1.6%) patient had hepatitis with acalculous cholecystitis, 1 (1.6%) patient had hepatitis with diarrhea, 1 (1.6%) patient had myocarditis, 1 (1.6%) patient had paroxysmal supraventricular tachycardia, 1 (1.6%) patient had acute pancreatitis, 1 (1.6%) patient had acute kidney injury, 1 (1.6%) patient had ARDS, 1 (1.6%) patient had encephalitis, and 1 (1.6%) patient had myositis. Need of intensive care facility was more in patients with atypical manifestations due to mis or late diagnosis which prolonged course of stay. Conclusion: Atypical manifestations of DF are more common than reported. Lack of awareness among physicians, especially in primary health center, leads to delayed diagnosis and increased mortality and morbidity.

Atypical presentations of non-familial anterior megalophthalmos: a rare disease

Anterior megalophthalmos usually presents early in life with megalocornea, deep anterior chamber, raised intraocular pressure, glaucomatous optic nerve damage and iridodonesis/stromal thinning with positive family history. We report atypical features and presentations in two patients (four eyes) with non-familial megalophthalmos. While the first patient, a male, presented at 51 years of age with megalocornea, cataract, phacodonesis, normal pupillary dilatation/normal iris and advanced glaucoma, the second patient presented with iridodonesis with stromal thinning, aphakia and advanced glaucoma. The family history was negative in both patients. The vitreous index was unusually high, >70% in all four eyes, owing to aphakia in the second patient and possible late presentation/variant phenotype in the first patient. Thus, atypical features such as greater vitreous length, absent iris involvement and late-onset adult presentation are common in non-familial anterior megalophthalmos. Clinical surprises due to varied phenotypes should be kept in mind in such cases.

Spinomedullary Weston Hurst Syndrome After COVID-19 and Influenza Co-Infection: A Case Report

The neurological complications of coronavirus disease 2019 (SARS-CoV-2, COVID-19) have so far included a range of para- and post-infectious neuroinflammatory syndromes inclusive of all components of the neuraxis and peripheral neuromuscular system. In comparison to the para-infectious manifestations of anosmia, ageusia, encephalopathy, and encephalitis, cases of post-infectious ADEM have rarely been reported and have most commonly affected the supratentorial component with or without spinal cord involvement. In this report, we describe a case of isolated involvement of the cervicothoracic spinal cord and medulla, occurring in association with microhemorrhages and hemosiderin deposition in the medulla, that presented fulminantly and required aggressive immunotherapy to control the inflammatory attack. We compare and contrast this case against prior reports of acute hemorrhagic leukoencephalitis (Weston Hurst syndrome) and review the atypical features of neuroinflammation reported to occur following COVID-19 infection.

116 An Assessment of Current Practice for Suspected Paediatric Testicular Torsion

Aim British Paediatric surgery guidelines (2019) state ‘immediate surgery should be performed if testicular torsion is suspected’. However, imaging ‘may be considered for a small number of children under the guidance of a senior clinician in late presenters or in those with atypical features. This study reviewed current practice in our hospital. Method Boys aged 16 and under in 2017-2019 who underwent scrotal exploration for suspected testicular torsion were reviewed. Outcomes assessed were number having ultrasound prior to theatre, pathological findings, number who had an orchidectomy, and post-op complications. Additionally, all testicular ultrasounds in those aged under 16 were screened to establish how many were requested for possible or missed torsion. Results 46 patients underwent surgical exploration of which 18 had a confirmed torsion. Six patients had imaging prior to surgery, of which five suggested torsions and four of these were confirmed in theatre. 202 boys under 16 had a testicular ultrasound; 26 of these were for late presentation or those with atypical features of torsion. Three underwent scrotal exploration two of whom had reports suggestive of torsion which was confirmed on exploration. Conclusions Most testicular torsions occur around the age of puberty with no torsion identified in patients under 10. Ultrasound is a useful tool for identification of vascularity or alternative pathology in late or atypical presentations of torsion; but does not replace clinical judgement. Imaging may have prevented unnecessary exploration in 23 cases, although negative imaging did not always preclude exploration.

Early CT features of COVID-19 pneumonia, association with patients’ age and duration of presenting complaint

Background Coronavirus disease (COVID-19) is a respiratory syndrome with a variable degree of severity. Imaging is a vital component of disease monitoring and follow-up in coronavirus pulmonary syndromes. The study of temporal changes of CT findings of COVID-19 pneumonia can help in better understanding of disease pathogenesis and prediction of disease prognosis. In this study, we aim to determine the typical and atypical CT imaging features of COVID-19 and discuss the association of typical CT imaging features with the duration of the presenting complaint and patients’ age. Results The lesions showed unilateral distribution in 20% of cases and bilateral distribution in 80% of cases. The lesions involved the lower lung lobes in 30% of cases and showed diffuse involvement in 58.2% of cases. The lesions showed peripheral distribution in 74.5% of cases. The most common pattern was multifocal ground glass opacity found in 72.7% of cases. Atypical features like cavitation and pleural effusion can occur early in the disease course. There was significant association between increased number of the lesions, bilaterality, diffuse pattern of lung involvement and older age group (≥ 50 years old) and increased duration of presenting complaint (≥ 4 days). There was significant association between crazy-paving pattern and increased duration of presenting complaint. No significant association could be detected between any CT pattern and increased patient age. Conclusion The most common CT feature of COVID-19 was multifocal ground glass opacity. Atypical features like cavitation and pleural effusion can occur early in the course of the disease. Our cases showed more extensive lesions with bilateral and diffuse patterns of distribution in the older age group and with increased duration of presenting complaint. There was a significant association between crazy-paving pattern and increased duration of presenting complaint. No significant association could be detected between any CT pattern and increased patient age.

An uncommon variant of erythema nodosum leprosum responding well to methotrexate: Report of two cases

Reactions in leprosy are acute inflammatory episodes that can be classified as type I or type II. Recognition and timely management of these patients is critical to avoid permanent disability. We present two cases of erythema nodosum leprosum, presenting with recurrent atypical features, responding well to a low dose of methotrexate.