A case of Takotsubo cardiomyopathy after bronchoscopy

Takotsubo Cardiomyopathy (TCM), also known as Broken Heart Syndrome, is an acute stress-induced cardiomyopathy with transient cardiac failure. It is triggered by preceding extreme physical or psychological stress. The etiology remains unclear, however, pathophysiological activation of the adrenergic system causing catecholamine-induced myocardial dysfunction is proposed. Use/ overuse of short acting beta-2-agonist (SABA) is a possible predisposing factor. We report a case of TCM in a 64-year-old female after bronchoscopy with endobronchial ultrasound (EBUS) and transbronchial needle aspiration biopsy (TNAB). The case shows a possible delay from symptom onset to echocardiographic visibility of TCM on and underlines the importance of reviewing a patient’s use of SABA prior to invasive procedures.

The role of magnetic resonance imaging in the diagnosis of brachial plexopathy in a COVID-19 patient

Severe COVID-19 infection can lead to acute respiratory distress syndrome (ARDS) requiring intensive care admission. Mechanically ventilated patients are commonly managed by being positioned in a prone ‘swimmer’s position’. However, this position can lead to a variety of potential complications not related to the illness, including stretching of the brachial plexus resulting in nerve damage. Brachial plexopathy is an important consideration in all patients stepped down from prolonged prone ventilation. This is to prevent possible long-term numbness and weakness in the affected arm which may require intensive physiotherapy. The role of magnetic resonance imaging is particularly useful in visualizing the brachial plexus and providing an accurate diagnosis. Early recognition and prompt imaging is recommended to reduce the incidence and severity of brachial plexopathy, particularly in the wake of a second COVID-19 wave. We report a case of brachial plexopathy in a 54-year-old male following intensive care admission and the relevant MRI protocol and findings which highlight this pathology.

Characteristics of lupus patients admitted to a major rheumatology center in Malaysia

Background: Systemic lupus erythematosus (SLE) admission can cause considerable morbidity, mortality and healthcare utilization. SLE generally develops in younger patients who are in their most productive years. That said, it is pivotal to determine predictors for poor outcomes (disability and mortality) from SLE hospitalization especially among highly developing Asian countries like Malaysia. Methods: Our retrospective cross-sectional study involved adults aged 12 years and above with underlying SLE who were admitted to the medical ward of our hospital between January 2018-December 2018. Results: This study demonstrated that infection and lupus flare are the main causes of hospitalization. Nearly one-fifth (18.9%) of lupus hospitalization had poor outcomes. Multivariate logistic regression analysis revealed that high disease activity (OR=1.15, 95% CI 1.05-1.47, p=0.001) and concurrent flare with infection (OR=1.10, 95% CI 1.02-1.53, p=0.007) at hospitalization were remarkably associated with poor outcome at discharge. Conclusion: Optimization of disease activity and infection control during outpatient’s visits is crucial to improve hospitalization outcome.

Plasma cell myeloma with tumorous liver involvement, presenting as a carcinoma of unknown primary

Background: A hepatic tumor mass by plasma cell myeloma is rare and is reported in 16% of patients with plasma cell myeloma. Unusual morphological variants of plasma cell myeloma in such a localisation may be a diagnostic challenge. Case presentation: A 60-year-old woman with low-back pain had MRT and CT scan results showing osteo-destructive lesions on different sites and a tumor mass in the liver. Her clinical presentation was classified as a carcinoma of unknown primary. Elevated serum-levels of the immunoglobulin heavy chain IgA and the immunoglobulin light chain kappa gave rise for a bone marrow trephine biopsy, revealing infiltration by a plasma cell myeloma with typical morphology (Fig.1A). Though the histological specimen of the liver resembled a clear cell carcinoma, the immunophenotype revealed plasma cell myeloma. Conclusion: In tumours with an extraordinary morphology and not conclusive immunohistochemical results, the use of plasma cell antibodies may lead to the correct diagnosis.

Tongue abscess: a rare condition. A report of two cases and a summary of 66 reported cases

Tongue (lingual) abscess is a rare condition, which, potentially compromise the airway acutely and may lead to death in the misdiagnosed cases. The incidence of such cases has been extensively reduced since the introduction of antibiotics era and most of our current knowledge is based, mainly, on a limited number of case reports. Here, we reviewed the current available data related to tongue abscess using the Pub-Med database and present two new cases which were treated at our institute. In total, 66 cases (43 case reports and 8 case series) were fall within the inclusion criteria and were discussed in the current study. The presenting symptoms included mainly, but not limited, pain and swelling of the tongue. In extreme cases, airway securing by tracheostomy procedure is considered. Most of cases were treated by needle aspiration and/or surgical incision and drainage with excellent outcome. No specific bacterial signature was noticed. To conclude, lingual abscess must be recognized promptly, followed by securing airway and surgical drainage.

Dysbalance of cytokines in schizophrenia and strategies for restoration of immune functions

We discuss the cumulative effect of different cytokines in veterans with schizophrenia. Previously we reported that the chemoattractant G-CSF, MCP, MDC and GRO, which activates human macrophages, monocytes, neutrophils and basophils that these factors were significantly increased compared to control subjects and also that levels NF-γ and IL-17 and Il-2 were significantly decreased as compared to controls. Based on these results we hypothesize that the immune system with schizophrenia is trying to restore the balance of their immune system by reducing the amounts of pro-inflammatory cytokines and increasing the amounts of anti-inflammatory and regulating cytokines. We decided to use an unorthodox approach by clustering the cytokines in four groups according to their predominant functions and analyzing the effect of cumulative amounts of cytokines in each group. This hypothetical approach provided theoretical explanation about the changes of cytokines in patients with schizophrenia. We suggest an individualized approach for treatment of psychosis in patients with schizophrenia by augmenting psychotropic medications with the help of monoclonal antibodies which block the excessive amounts of specific proinflammatory cytokines.

Mucormycosis in a liver allograft after liver transplantation for secondary biliary cirrhosis due to bile duct injury

Introduction: Mucormycosis refers to a group of opportunistic mycoses that occur generally in immunocompromised patients and are caused by Mucorales, ubiquitous filamentous fungi with broad, thin-walled, sparsely septate, ribbon-like hyphae. Case report: A 57-year-old man with a history of secondary biliary cirrhosis due to inadvertent bile duct injury during cholecystectomy. He was referred to our center and underwent LT on June 2018. Due to severe coagulopathy he underwent exploratory laparotomy and abdominal packing for 48 hours. He recovered with good liver function and LFT´s with a tendency towards normalization. On post op day 8 the patient presented an episode of fever and a CT scan was performed showing a large zone of hypoperfusion with bubbles of gas in the liver dome. A percutaneous biopsy was taken for cultures. Preliminary results reported a filamentous fungus and liposomal amphotericin b was initiated with the suspicion of mucormycosis. The patient remained afebrile and asymptomatic. After 5 days of treatment a new image was performed, and progression of the lesion was noticed, due to these findings the patient was taken to the OR for surgical debridement. Involvement of the liver dome and diaphragm was noticed and a non-anatomic hepatectomy was performed. After surgery the patient required increasing amounts of vasopressors. Despite all the support he progressed to multiple organic failure and finally expired. The product of hepatectomy confirmed the diagnosis of mucormycosis (Rhizopus sp). Discussion: Despite all the efforts the patients’ clinical condition deteriorated after surgery showing the high mortality rate in liver transplant recipients that has been reported of 50 to 100%.

Factors predicting relapse in dermatomyositis

Dermatomyositis (DM) is a rare autoimmune disease characterized by classic cutaneous manifestations and proximal muscle inflammation. Clinical symptoms are improved in many patients on treatments, but some experiences relapse. No consensus exists regarding the definition of a DM relapse. In practice, a relapse is diagnosed when the symptoms recur or worsen after first improving under treatment. Published data on both prevalence and risk factors of relapse in DM is limited. The aim of this study was to evaluate the frequency of relapse in DM and identify factors predicting relapse in patients with non-paraneoplastic DM.

Re-infusion of high output effluent from a loop jejunostomy into its distal limb through a subcutaneously implanted catheter in a patient with co-existing acute purulent peritonitis and acute small bowel obstruction: A case report

Diverting jejunostomy is almost always a last ditch effort in a situation of abdominal catastrophe. Although it is life-saving, it may adversely affect the patient’s metabolic status and renal function. Consequentially an emergency jejunostomy should be a temporary measure and should be closed as early as possible. We present a unique case where the creation of а temporary loop jejunostomy was indicated. To prevent acute renal failure, we re-infused the stoma effluent into its distal limb through a Foley catheter. The latter was implanted subcutaneously which allowed us to re-feed the stoma without disturbing the appliance seal. The patient recovered on oral intake without the use of total parenteral nutrition.