Host Immunity and Francisella tularensis: A Review of Tularemia in Immunocompromised Patients

Tularemia, caused by the bacterium Francisella tularensis, is an infrequent zoonotic infection, well known in immunocompetent (but poorly described in immunocompromised) patients. Although there is no clear literature data about the specific characteristics of this disease in immunocompromised patients, clinical reports seem to describe a different presentation of tularemia in these patients. Moreover, atypical clinical presentations added to the fastidiousness of pathogen identification seem to be responsible for a delayed diagnosis, leading to a” loss of chance” for immunocompromised patients. In this article, we first provide an overview of the host immune responses to Francisella infections and discuss how immunosuppressive therapies or diseases can lead to a higher susceptibility to tularemia. Then, we describe the particular clinical patterns of tularemia in immunocompromised patients from the literature. We also provide hints of an alternative diagnostic strategy regarding these patients. In conclusion, tularemia should be considered in immunocompromised patients presenting pulmonary symptoms or unexplained fever. Molecular techniques on pathological tissues might improve diagnosis with faster results.

Prevalence of HIV Infection and Resistance Mutations in Patients Hospitalized for Febrile Illness in Indonesia

ABSTRACT. HIV prevalence in Indonesia is increasing, and only 64% of infected individuals know their status. In a prospective cohort of 1,453 hospitalized patients with unexplained fever, 46 (3.2%) had HIV, including 15 (1.1%) patients without a prior HIV diagnosis. Among 31 subjects previously known to have HIV, 21 (68%) had been receiving combination antiretroviral therapy (cART) at the time of enrollment. Of 39 HIV cases with HIV RNA levels ≥ 100 copies/mL, sequencing for genotype analysis and resistance testing was successful in 30 (77%) subjects. The most common HIV subtypes were AE (90%) and B (10%). Five (16.7%) subjects had resistance mutations to nucleoside and non-nucleoside reverse transcriptase inhibitors, and all of them were on cART. No evidence of transmitted drug resistance was found in newly diagnosed individuals. Hospital-based screening may be an efficient method to expand HIV testing and identify a significant number of new cases. Access to care, close monitoring, expansion of anti-retroviral options, and ensuring availability of CD4 determinations, viral load testing, and genotyping are crucial to control of the epidemic in Indonesia.

Autoinflammatory syndromes in neurology: when our first line of defence misbehaves

Autoinflammatory syndromes result in a defective innate immune system. They are characterised by unexplained fever and systemic inflammation involving the skin, muscle, joints, serosa and eyes, along with elevated acute phase reactants. Autoinflammatory syndromes are increasingly recognised as a cause of neurological disease with a diverse range of manifestations. Corticosteroids, colchicine and targeted therapies are effective if started early, and hence the importance of recognising these syndromes. Here, we review the neurological features of specific autoinflammatory syndromes and our approach (as adult neurologists) to their diagnosis.

Fever as a Side Effect after Electroconvulsive Therapy

<b><i>Background:</i></b> Electroconvulsive therapy (ECT) is the most important and safe nonpharmacological treatment for psychiatric disorders. Some patients experience unexplained fever after ECT, but only a few studies have reported on this. <b><i>Method:</i></b> We investigated fever after ECT by retrospectively reviewing the medical records of patients. Patients treated at the ECT unit of the Department of Psychiatry at Asan Medical Center, Seoul, South Korea, between 30 June 2004 and 30 June 2019, were included. Differences in variables were compared between groups with or without fever after ECT sessions. <b><i>Result:</i></b> There were 28 patients (8.8%) in the fever group. Forty-three ECT sessions (1.5%) resulted in fever after treatment. The female-to-male ratio was higher in the fever group than in the control group, and the mean number of total ECT sessions was also higher in the fever group than in the control group, but there were no other differences between the 2 groups. <b><i>Conclusion:</i></b> Comparing fever and control sessions, fever sessions relatively preceded control sessions and had a longer seizure duration. Postictal delirium occurred more often in the fever sessions than in control sessions. Fever sessions had a higher white blood cell count and lower concomitant quetiapine dosage than control sessions. Because 8.8% of patients who received ECT experienced fever after treatment more than once, fever after ECT is considered to be a common side effect.

Case Report: Unexplained Fever and Chest Pain in a 5-Year-Old

Pericarditis is a rare, but severe cause of chest pain in children that can easily be overlooked during routine diagnostics. Fibrinous pericarditis was recognized in a 5-year old patient who presented with fever and chest pain. Despite thorough diagnostics, no evident etiological factor was found. Furthermore, the disease was unresponsive to broad-spectrum antibiotics and NSAIDs, however oral prednisone was found to cause rapid improvement in the patients' condition. It was presumed that the patient's condition was caused by a blunt trauma to the chest experienced 3 days prior to the onset of symptoms. In an 8-month follow-up the patient remains in good overall condition and no recurrences were observed.

A case of macrophage activation syndrome in a patient with anti-synthetase syndrome

ABSTRACT Anti-synthetase syndrome (ASS) is an autoimmune disease characterized by autoantibodies against an aminoacyl transfer RNA synthetase with clinical features including interstitial lung disease, non-erosive arthritis, myositis, Raynaud’s phenomenon, unexplained fever and/or mechanic’s hands. Macrophage activation syndrome (MAS) is a potentially fatal hyper- inflammatory syndrome that can occur as a complication of systemic rheumatic diseases. However, the association of MAS and ASS has rarely been reported in the literature. Here, we report this association in a patient with overlap ASS and anti-CCP positive rheumatoid arthritis. First line management with steroids was complicated by diabetic ketoacidosis, hence requiring use of anti-IL1 therapy (anakinra) for disease control.

The Missed symptoms of behjet’s disease

Objectives: Behçet's disease is a systemic chronic proinflammatory vascular disease .this study wants to describe more details of patients with Behçet’s disease in iraq. Methods: Any patient with suspected or diagnosed Behçet’s disease attending centre of dermatology/behjet unit , 2017- 2018. A total 47 patients ,Full history and examination were taken. Percentage of complains were calculated. Results: 37 were females and 10 were males , Age of patients ranged from (11-63) years.Pethargy test was negative in 13 patients , positive in 15 ,21 had negative family history and 9 had positive . They complain from Malaise , oral ulcer, genital ulcer, unexplained fever ,20 symptoms began from childhood ,decreased hearing,eye complain, dysphagia , dyspnea ,headache , memory problems, depression , muscle contraction, peripheral paresthesia , joint complains, sleep disturbances and renal problems. Conclusion: describes new symptoms can help in diagnosis of behjet’s disease .

Somatic Mutations and the Risk of Undifferentiated Autoinflammatory Disease in MDS: An Under-Recognized but Prognostically Important Complication

Objectives: We theorized that myelodysplastic syndrome (MDS) with somatic mutations and karyotype abnormalities are associated with autoinflammation, and that the presence of autoinflammatory disease affected prognosis in MDS.Methods: One hundred thirty-four MDS patients were assessed for the prevalence of autoinflammatory complications and its link with karyotypes and somatic mutation status. Autoinflammatory complications were described either as well-defined autoinflammatory diseases (AD) or undifferentiated “autoinflammatory disease” (UAD) (defined as CRP over 10.0 mg/L on five consecutive occasions, taken at separate times and not explained by infection). Several patient characteristics including demographic, clinical, laboratory, cytogenetics charts, and outcomes, were compared between different groups.Results: Sixty-two (46.3%) patients had an autoinflammatory complication manifesting as arthralgia (43.5% vs. 23.6%, p = 0.0146), arthritis (30.6% vs. 15.3%, p = 0.0340), skin rash (27.4% vs. 12.5%, p = 0.0301), pleuritis (14.5% vs. 4.2%, p = 0.0371) and unexplained fever (27.4% vs. 0%, p &lt; 0.0001). AD were found in 7.4% of MDS patients (with polymyalgia rheumatic being the most frequently one). Classical autoimmune diseases were found only in 4 MDS patients (3.0%). Transcription factor pathway mutations (RUNX1, BCOR, WTI, TP53) (OR 2.20 [95%CI 1.02–4.75], p = 0.0451) and abnormal karyotypes (OR 2.76 [95%CI 1.22–6.26], p = 0.0153) were associated with autoinflammatory complications. Acute leukaemic transformation was more frequent in MDS patients with autoinflammatory features than those without (27.4% vs. 9.7%, p = 0.0080).Conclusions: Autoinflammatory complications are common in MDS. Somatic mutations of transcription factor pathways and abnormal karyotypes are associated with greater risk of autoinflammatory complications, which are themselves linked to malignant transformation and a worse prognosis.