The diagnosis of hypophosphatasia in children as a multidisciplinary effort: an expert opinion

Hypophosphatasia (HPP) is a rare genetic disorder in which pathogenic variants of the ALPL gene lead to a marked decrease of tissue non-specific alkaline phosphatase (TNSALP) activity. Although HPP is a systemic disorder, its clinical manifestations are more evident on bones, teeth, muscle and central nervous system. The clinical spectrum ranges from severe forms with extreme skeletal deformities, respiratory impairment, seizures, to very mild forms with onset in late adulthood and few clinical signs. The diagnosis can be suspected by measurement of TNSALP activity, but the insufficient awareness among health professionals and the lack of official guidelines are responsible for delayed diagnosis in children with HPP. The purpose of the current document is to provide an expert opinion directed at optimizing the diagnostic pathway of pediatric HPP. From April to December 2022, a multidisciplinary working group of 6 experts including two pediatric endocrinologists, a pediatric neurologist, a pediatric odontologist, a clinical geneticist, and a molecular biologist gathered in a series of periodic meetings to discuss the main issues related to the diagnosis of HPP in children and formalize an Expert Opinion statement. The experts agreed on a diagnostic trail that begins with the recognition of specific clinical signs, leading to biochemical analyses of TNSALP activity and vitamin B6 serum concentration. Very important are the neurological and dental manifestation of the disease that should be thoroughly investigated. The evaluation of TNSALP activity must consider sex and age variability and low activity must be persistent. Repeated blood measurements are thus necessary. The molecular analysis is then mandatory to confirm the diagnosis and for genetic counseling.

The clinical management of children with achondroplasia in Italy: results of clinician and parent/caregiver surveys

PURPOSE

This study aimed to assess the real-world management of achondroplasia in Italy.

METHODS

Two online surveys addressed to (1) parents/caregivers of individuals with achondroplasia and (2) Italian clinicians managing individuals with achondroplasia were conducted to assess real-world perspectives on achondroplasia management. Both surveys collected data on either patient or clinician demographics, details on diagnoses and referrals, disease complications, and views/experiences with limb lengthening surgery.

RESULTS

In total, 42 parents/caregivers and 19 clinicians (from 18 hospitals) completed the surveys. According to parents/caregivers, achondroplasia diagnosis was most commonly made in the third trimester of gestation (55% of respondents), with a genetic test performed to confirm the diagnosis in all but one case. In contrast, the clinicians indicated that, while achondroplasia was typically suspected during the prenatal period (78%), diagnosis was more frequently confirmed postnatally (72%). Parents/caregivers reported that the greatest impact of achondroplasia-related complications occurred in their children between the ages of 2-5 years. The most significant complications were otitis, sleep apnoea, stenosis of the foramen magnum or pressure on the spinal cord, and hearing difficulties. Lengthening surgery had been presented as a treatment option to 92% of responding parents/caregivers, with 76% of clinicians viewing surgery favourably. Typically, clinicians' reasons for suggesting limb lengthening surgery were to improve patient quality of life, increase patient autonomy and self-acceptance, improve trunk-limb disproportion, short stature and walking, and ensure that all possible treatment options had been presented to the parents/caregivers.

CONCLUSION

This survey provides insight into the real-world management of individuals with achondroplasia in Italy.

Temporal and inter-individual changes in the integrated biochemical condition of the gonads of female swordfish (Xiphias gladius) from the Southeastern Pacific Ocean

The integrated biochemical condition (IBC) of gonads is closely related to the reproductive success of highly migratory marine species. The IBC of gonads can be influenced not only by size and/or age, but also by environmental conditions. Here, female swordfish, Xiphias gladius, that migrate to temperate regions with a marked seasonality (e.g., the Southeastern Pacific Ocean, SEPO) were compared in relation to the IBCs (lipids, proteins, glucose and, fatty acid profiles) of their gonads; individuals with two body size ranges and distinct degrees of sexual maturity were evaluated, and considered as: small and/or virginal (SV: <170 cm lower jaw fork-length (LJFL), oocyte size (OS) <0.08 mm) vs large and/or maturing females (LM: >190 cm LJFL, OS >0.133 mm). This comparison was conducted in two environmentally contrasting seasons (winter vs spring). Our results showed that the gonadosomatic index (GSI) was significantly higher in LM than SV. Lipid contents varied significantly between seasons and body sizes. The highest lipid concentrations were recorded in the spring in large females. No significant differences were found when comparing the protein and glucose contents of the two evaluated seasons or body size ranges of the studied females. In turn, the fatty acid (FA) profiles of female gonads significantly varied for both seasons and body size ranges. A high content of saturated fatty acids (SFAs), monounsaturated fatty acids (MUFAs) and poly-unsaturated fatty acids (PUFAs) were recorded in female gonads in the spring. The SFAs C16:0 and C18:0, the MUFA C18:1n9, and the essential PUFA C22:6n3 were the main contributors to the observed differences between spring and winter. These results could be used as indicators of the nutritional condition and health status of swordfish individuals. Hence, the IBC of female swordfish gonads have great potential to aid in estimating survival rates and stock abundances of this species. The integration of this information constitutes an asset in fishery management models with an ecosystem approach.

SAPHO—a diagnosis to consider in patients with refractory costochondritis

Background

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a rare, heterogeneous, self-limited disease of unknown etiology. It involves progressive bone and joint damage, and skin and bone lesions may occur at different times in the course of the disease. Skin lesions are characterized by neutrophil dermatosis. Its management is empirical and mainly symptomatic, and nonsteroidal anti-inflammatory drugs are the first-line treatment.

Case presentation

Forty-seven-year-old female presented with a 7-year history of costochondral pain. It had progressive onset, chronical course, with no other associated symptoms, and no other joint involvement. She was treated with intermittent NSAID (nonsteroidal anti-inflammatory drugs), which provided only partial pain relief; there was bilateral tender swelling of the sternoclavicular region, the skin over the sternoclavicular area was slightly erythematous, but there were no other skin lesions, and based on imaging findings, a diagnosis of SAPHO syndrome was established. The patient received an infusion of zoledronic acid with subsequent complete resolution of her chest wall symptoms, and completely improved after 3 days.

Conclusions

This case is considered atypical presentation of SAPHO syndrome, without skin changes, long-term persistence of refractory symptoms, and the diagnosis was established by imaging, with complete resolution after zoledronic acid infusion. SAPHO is a differential diagnosis in patients with chronic costochondritis. Therapeutic failure to NSAID is a key to its diagnostic suspicion. Also, early diagnostic suspicion is associated with better outcomes.

Dysregulation of macrophage PEPD in obesity determines adipose tissue fibro-inflammation and insulin resistance

Resulting from impaired collagen turnover, fibrosis is a hallmark of adipose tissue (AT) dysfunction and obesity-associated insulin resistance (IR). Prolidase, also known as peptidase D (PEPD), plays a vital role in collagen turnover by degrading proline-containing dipeptides but its specific functional relevance in AT is unknown. Here we show that in human and mouse obesity, PEPD expression and activity decrease in AT, and PEPD is released into the systemic circulation, which promotes fibrosis and AT IR. Loss of the enzymatic function of PEPD by genetic ablation or pharmacological inhibition causes AT fibrosis in mice. In addition to its intracellular enzymatic role, secreted extracellular PEPD protein enhances macrophage and adipocyte fibro-inflammatory responses via EGFR signalling, thereby promoting AT fibrosis and IR. We further show that decreased prolidase activity is coupled with increased systemic levels of PEPD that act as a pathogenic trigger of AT fibrosis and IR. Thus, PEPD produced by macrophages might serve as a biomarker of AT fibro-inflammation and could represent a therapeutic target for AT fibrosis and obesity-associated IR and type 2 diabetes.

Extracellular vesicles released by steatotic hepatocytes alter adipocyte metabolism

The composition of extracellular vesicles (EVs) is altered in many pathological conditions, and their molecular content provides essential information on features of parent cells and mechanisms of crosstalk between cells and organs. Metabolic Syndrome (MetS) is a cluster of clinical manifestations including obesity, insulin resistance, dyslipidemia and hypertension that increases the risk of cardiovascular disease and type 2 diabetes mellitus. Here, we investigated the crosstalk between liver and adipocytes by characterizing EVs secreted by primary hepatocytes isolated from Zucker rat model, and studied the effect they have on 3T3-L1 adipocytes. We found that steatotic hepatocytes secrete EVs with significantly reduced exosomal markers in comparison with their lean counterpart. Moreover, proteomic analysis revealed that those EVs reflect the metabolic state of the parent cell in that the majority of proteins upregulated relate to fat metabolism, fatty acid synthesis, glycolysis, and pentose phosphate pathway. In addition, hepatocytes-secreted EVs influenced lipolysis and insulin sensitivity in recipient 3T3-L1 adipocytes. Untargeted metabolomic analysis detected alterations in different adipocyte metabolic pathways in cells treated with hepatic EVs. In summary, our work showed that steatosis has a significant impact in the amount and composition of EVs secreted by hepatocytes. Moreover, our data point to the involvement of hepatic-EVs in the development of pathologies associated with MetS.

Trends in ionizing radiation exposure of healthcare workers in France (2009-2019): the EXPERTS study

Background

Health workers exposed to ionizing radiation (IR) account for +50% of workers exposed to artificial IR in France. Over the last 10 years, the use of IR in medicine has developed due to the introduction of new practices. The EXPERTS study aims to evaluate and characterize the trends in IR exposure of health workers in France between 2009 and 2019.

Methods

The study includes all health workers with at least one dosimetric record in the System for occupational dosimetry registration (SISERI) database for each of the years 2009, 2014, and 2019, in the 6 hospitals included in the study (in Paris & Bordeaux). Individual passive external doses, professional activity, age and gender were collected via SISERI and occupational medicine units. Doses were estimated from badges worn at chest level under the lead apron.

Results

1,999 workers were included. Mean Hp(10) doses significantly decreased between 2009 and 2019 (-0.004 mSv/year; p &lt; 0.05). Workers in Bordeaux hospitals were more exposed than those in Paris in 2009 and 2014, while trend was reversed in 2019 (p &gt; 0.05). Doses in men were significantly higher than women's doses in 2009 and 2014 (p &lt; 0.02), but were similar in 2019 (p = 0.99). Physicians had the highest mean IR doses between 2009 and 2019 (0.14mSv ±1.09), and more specifically surgeons and cardiologists, but their exposure tended to decrease in recent years. Radiological technologists have similar mean doses (0.14mSv ±0.38), relatively stable over the study period - the most exposed in the nuclear medicine unit (0.60mSv ±0.58).

Conclusions

IR exposure of health workers in France decreased significantly between 2009 and 2019, despite an increase in practices using IR - this decrease was partly recorded in orthopaedic surgeons. This may be related to radiation protection rules' application. However, badges may not always be worn properly. This study could be extended to other healthcare centres to study local specificities and to adapt radiation protection policies

Key messages

Despite the increase in medical practices using ionising radiations (IR), the average exposure of health workers to IR has decreased over the 10 last year, mainly in Bordeaux hospitals. Differences in average IR exposure were found by occupation, gender, health care units, and hospitals. Policies should use these results to promote radiation protection rules.

Seasonal dynamics of biochemical composition and fatty acids of swordfish (Xiphias gladius) in the Southeast Pacific Ocean off the coast of Chile

In the Southeast Pacific Ocean, Xiphias gladius migrates through the Chilean coastal zone for feeding. Here, it forages for different prey items from autumn to spring, acquiring a great variety of energy and nutritional reserves. We evaluated seasonal variations in the biochemical reserves (i.e., contents of lipids, proteins, and glucose), total energy content and fatty acid profile of specimens captured during the austral autumn, winter, and spring. Our results show that higher amounts of lipids were found in the winter and spring, while protein and glucose were higher in the autumn. Thus, the energy content showed significant differences, with higher levels in winter and spring. Furthermore, the fatty acid profile was more diverse in the spring than the autumn and winter and was characterized by higher amounts of polyunsaturated fatty acids. These findings suggest that temporal changes in the biochemical reserves, total energy content and fatty acid profile support the idea of a "trophic migration" (i.e., the feeding period) established by the dynamics of fishery fleets. The high amounts of lipids and diverse fatty acid profile found in the spring could indicate the end of the trophic migration during this season. Thus, X. gladius may reach an optimum nutritional condition in the spring and make energetic adjustments to carry out its reproductive migration during the austral summer. Therefore, this species seems to meet the high energy demands of the reproductive season by foraging for a wide range of prey items from autumn to spring and storing an increased amount of lipids at the end of the feeding period. Overall, our data provides crucial baseline knowledge for future research on the ecophysiology of X. gladius, as well as for the management and conservation of this fishery resource under an ecosystem approach.

The age again in the eye of the COVID-19 storm: evidence-based decision making

BACKGROUND

One hundred fifty million contagions, more than 3 million deaths and little more than 1 year of COVID-19 have changed our lives and our health management systems forever. Ageing is known to be one of the significant determinants for COVID-19 severity. Two main reasons underlie this: immunosenescence and age correlation with main COVID-19 comorbidities such as hypertension or dyslipidaemia. This study has two aims. The first is to obtain cut-off points for laboratory parameters that can help us in clinical decision-making. The second one is to analyse the effect of pandemic lockdown on epidemiological, clinical, and laboratory parameters concerning the severity of the COVID-19. For these purposes, 257 of SARSCoV2 inpatients during pandemic confinement were included in this study. Moreover, 584 case records from a previously analysed series, were compared with the present study data.

RESULTS

Concerning the characteristics of lockdown series, mild cases accounted for 14.4, 54.1% were moderate and 31.5%, severe. There were 32.5% of home contagions, 26.3% community transmissions, 22.5% nursing home contagions, and 8.8% corresponding to frontline worker contagions regarding epidemiological features. Age > 60 and male sex are hereby confirmed as severity determinants. Equally, higher severity was significantly associated with higher IL6, CRP, ferritin, LDH, and leukocyte counts, and a lower percentage of lymphocyte, CD4 and CD8 count. Comparing this cohort with a previous 584-cases series, mild cases were less than those analysed in the first moment of the pandemic and dyslipidaemia became more frequent than before. IL-6, CRP and LDH values above 69 pg/mL, 97 mg/L and 328 U/L respectively, as well as a CD4 T-cell count below 535 cells/μL, were the best cut-offs predicting severity since these parameters offered reliable areas under the curve.

CONCLUSION

Age and sex together with selected laboratory parameters on admission can help us predict COVID-19 severity and, therefore, make clinical and resource management decisions. Demographic features associated with lockdown might affect the homogeneity of the data and the robustness of the results.

Monte Carlo study of patient and medical staff radiation exposures during interventional cardiology

The aim of this study is to assess the radiation exposure of the patient and the medical staff during interventional cardiology procedures. Realistic exposure scenarios were developed using the adult reference anthropomorphic phantoms adopted by the International Commission on Radiological Protection (ICRP110_Male and ICRP110_Female), and the radiation transport code Geant4 (version 10.3). The calculated equivalent and effective doses were normalised by the simulated Kerma-Area Product (KAP), resulting in two conversion coefficients H_T/KAP and E/KAP. To properly evaluate the risk of exposure, several dose-dependent parameters have been investigated, namely: radiological parameters (tube kilovoltage peak (kVp), type of projection, field size (FOV)), and operator positions. Four projections (AP,PA,LAO25° and RAO25°) were simulated for three X-ray energy spectra (80,100 and 120 kVp) with four different values of FOV (15×15 cm²,20×20 cm²,25×25 cm² and 30×30 cm²). The results showed that the conversion coefficients values increase with increasing tube voltage as well as the FOV size. Recommended projection during the interventional cardiology procedures, whenever possible, should be the PA projection rather than AP projection. The most critical projection for the patient and the main operator is the RAO25° projection and the LAO25° projection respectively. The comparison of our results with the literature data showed good agreement allowing their use in the dosimetric characterization of interventional cardiology procedures.

Effects of Cycloleucine in the Nucleus Accumbens Septi on the Elevated plus Maze Test in Rats

INTRODUCTION

In recent years, an important number of studies have emphasized the psychopharmacological actions of cycloleucine (1-aminocyclopentanecarboxylic acid) acting on the NR1 subunit (glycine allosteric site) of NMDA (N-methyl-D-aspartic acid) receptor. We studied the effects of its injection in an anxiety test.

METHODS

The elevated plus maze test was used. Male rats bilaterally cannulated into the nucleus accumbens septi (NAS) were employed. Rats were divided into 5 groups that received either 1 µL injections of saline or cycloleucine (0.5, 1, 2, or 4 µg) 15 min before testing.

RESULTS

Time spent in the open arm was significantly increased by cycloleucine treatment with all doses (1 and 2 µg, p < 0.05; 0.5 and 4 µg, p < 0.01), like number of extreme arrivals (0.5 and 1 µg, p < 0.05; 2 µg, p < 0.01; and 4 µg, p < 0.001). Open arm entries were increased by the highest dose only (4 µg, p < 0.01).

DISCUSSION/CONCLUSION

Present results show no difference between all doses in the time spent in the open arm, suggesting an indirect, noncompetitive action of the drug. The increase in extreme arrivals and open arm entries suggests a dose influence in these parameters. We conclude that cycloleucine influence on the NMDA receptors within NAS leads to anxiolytic-like effects and behavioral disinhibition, which once more confirms the involvement of NAS in anxiety processing.

COVID-19: age, Interleukin-6, C-reactive protein, and lymphocytes as key clues from a multicentre retrospective study

Background

The SARS-CoV-2 infection has widely spread to become the greatest public health challenge to date, the COVID-19 pandemic. Different fatality rates among countries are probably due to non-standardized records being carried out by local health authorities. The Spanish case-fatality rate is 11.22%, far higher than those reported in Asia or by other European countries. A multicentre retrospective study of demographic, clinical, laboratory and immunological features of 584 Spanish COVID-19 hospitalized patients and their outcomes was performed. The use of renin-angiotensin system blockers was also analysed as a risk factor.

Results

In this study, 27.4% of cases presented a mild course, 42.1% a moderate one and for 30.5% of cases, the course was severe. Ages ranged from 18 to 98 (average 63). Almost 60 % (59.8%) of patients were male. Interleukin 6 was higher as severity increased. On the other hand, CD8 lymphocyte count was significantly lower as severity grew and subpopulations CD4, CD8, CD19, and NK showed concordant lowering trends. Severity-related natural killer percent descents were evidenced just within aged cases. A significant severity-related decrease of CD4 lymphocytes was found in males. The use of angiotensin-converting enzyme inhibitors was associated with a better prognosis. The angiotensin II receptor blocker use was associated with a more severe course.

Conclusions

Age and age-related comorbidities, such as dyslipidaemia, hypertension or diabetes, determined more frequent severe forms of the disease in this study than in previous literature cohorts. Our cases are older than those so far reported and the clinical course of the disease is found to be impaired by age. Immunosenescence might be therefore a suitable explanation for the hampering of immune system effectors. The adaptive immunity would become exhausted and a strong but ineffective and almost deleterious innate response would account for COVID-19 severity. Angiotensin-converting enzyme inhibitors used by hypertensive patients have a protective effect in regards to COVID-19 severity in our series. Conversely, patients on angiotensin II receptor blockers showed a severer disease.

FGF23-related hypophosphatemia in patients with low bone mineral density and fragility fractures: challenges in diagnosis and management

PURPOSE

Hypophosphatemia (HP) can be observed in patients evaluated for skeletal fragility. We investigated prevalence of HP among outpatients referred for low bone density or fragility fractures, HP-associated clinical and biochemical features and outcomes of recommended diagnostic algorithm in our cohort.

METHODS

Chronic HP (phosphate ≤ 2.7 mg/dL over 6 months or longer) was retrospectively investigated among 2319 patients. In renal wasting-related HP, intact FGF23 was assessed; non-suppressed FGF23 prompted the performance of ⁶⁸Ga-DOTATOC PET/CT in the suspicion of tumor-induced steomalacia (TIO).

RESULTS

Renal wasting-related HP (median 2.2, range 1.6-2.6 mg/dL) was observed in 19 patients (0.82%). FGF23 levels were suppressed in two patients diagnosed with renal tubular disease, increased in one and within normal range in most patients. X-linked hypophosphatemic rickets was diagnosed in one woman. In the remaining 16 patients, highly prevalent fragility fractures (50%) and severely reduced bone mineral density were detected, though diagnostic criteria for osteomalacia were not fulfilled. ⁶⁸Ga-PET was performed in nine patients and was positive in four. While intact FGF23 levels alone failed to differentiate PET's outcomes (positive: FGF23 median 70.5 pg/mL; negative: 52 pg/mL, P = 0.462), the coexistence of multiple biochemical and radiologic alterations performed better in prediction of PET's positivity.

CONCLUSION

Mild, apparently unexplained HP is observed in 0.82% of patients with low bone density or fragility fractures. In asymptomatic patients with isolated mild hypophosphatemia, the probability of finding an underlying tumor disease is very low, and utility of extensive and expensive diagnostic workup should be carefully considered in this setting.

"Block-and-replace" treatment in Graves' disease: experience in a cohort of pediatric patients

PURPOSE

The "block-and-replace" (BR) method involves the use of a high dose of antithyroid drugs (ATD) with levothyroxine (L-T4). Its use in the management of Graves' disease (GD) is still debated mainly because the frequency of side effects of ATD is dose dependent. We retrospectively studied the effect of medium dose of ATD with L-T4 versus monotherapy with ATD in pediatric patients with unstable GD.

METHODS

28 pediatric patients with GD with unstable response to ATD were treated with L-T4 and medium dose of ATD. We compared the rate of euthyroidism, hypothyroidism and hyperthyroidism episodes observed during treatment with methimazole alone with those observed during the BR approach. We evaluated the occurrence of side effects and the rate of remission in patients treated with ATD + L-T4 therapy and the efficacy of combination therapy to postpone a definitive treatment (radioiodine and thyroidectomy).

RESULTS

Patients showed a better control of thyroid function during the BR therapy, presenting fewer episodes of hyperthyroidism and hypothyroidism. No serious side effects during the BR approach were observed. Only one patient went into remission with the ATD + L-T4 therapy. Fifteen patients required a definitive therapy (4 radioiodine, 11 thyroidectomy). The use of BR method has delayed radioiodine treatment for 4.9 years and surgery for 2.9 years.

CONCLUSIONS

The BR method does not increase the remission rates. It may be useful to combine L-T4 with a medium dose of methimazole when GD is difficult to manage with methimazole alone. It may represent a therapeutic option to postpone definitive treatments to a suitable age.

X-linked hypophosphatemic rickets: an Italian experts' opinion survey

Background

X-linked hypophosphatemic rickets (XLH) is the first cause of inherited hypophosphatemia and is caused by mutation in the PHEX gene, resulting in excessive expression of the phosphaturic factor FGF23. Symptoms are mainly related to rickets in children and osteomalacia in adults and cause several complications that can be highly invalidating. Due to its rarity, XLH is poorly known and diagnosis is frequently delayed. Conventional treatment is based on oral phosphate salts supplementation and activated vitamin D analogs, which however, cannot cure the disease in most cases.

Objective

Due to the low prevalence of XLH, an experts’ opinion survey was conducted across Italian centers to collect data on XLH and on its management.

Methods

A questionnaire was developed by a group of experts to collect data on XLH epidemiology, diagnosis and treatment in Italy.

Results

Data from 10 Italian centers (nine of which pediatric) on 175 patients, followed between 1998 and 2017, were included in the survey. Most patients were followed since childhood and 63 children became adults during the investigated period. The diagnosis was made before the age of 1 and between 1 and 5 years in 11 and 50% of cases, respectively. Clinically apparent bone deformities were present in 95% of patients. These were ranked moderate/severe in 75% of subjects and caused growth stunting in 67% of patients. Other frequent complications included bone pain (40%), dental abscesses (33%), and dental malpositions (53%). Treatment protocols varied substantially among centers. Nephrocalcinosis was observed in 34% of patients. Tertiary hyperparathyroidism developed in 6% of patients.

Conclusions

XLH remains a severe condition with significant morbidities.

Drug reaction with eosinophilia and systemic symptoms (DRESS) and multiple organ dysfunction syndrome (MODS): one more reason for a new effective treatment against leishmaniasis

INTRODUCTION

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug-induced reaction associated with eosinophilia and systemic manifestations. Anticonvulsants, sulfonamides, and antivirals are the most related and described drugs in DRESS syndrome.

METHODS AND CASE

We present a case of severe multiple organ dysfunction syndrome (MODS) with the risk of death associated with DRESS syndrome due to antileishmanial pentavalent antimonial drug and its simultaneous toxicity. Consequently, a comprehensive review of the main clinical problems and comparative discussion of both clinical conditions was made.

DISCUSSION

The overlap of DRESS syndrome and antileishmanial pentavalent antimonial drug toxicity can be life-threatening. Both conditions represent a true clinical, diagnostic, and therapeutic challenge. We exposed specific clinical and laboratory results with rare occurrence.

CONCLUSION

Any physician and dermatologists should keep in mind the broad spectrum of clinical manifestations and laboratory findings associated with the use of pentavalent antimonial drugs. The clinical suspicion, an early diagnosis, and aggressive treatment are essential to prevent complications and death.

Impact of Beads and Drops on a Repellent Solid Surface: A Unified Description

We investigate freely expanding sheets formed by ultrasoft gel beads, and liquid and viscoelastic drops, produced by the impact of the bead or drop on a silicon wafer covered with a thin layer of liquid nitrogen that suppresses viscous dissipation thanks to an inverse Leidenfrost effect. Our experiments show a unified behavior for the impact dynamics that holds for solids, liquids, and viscoelastic fluids and that we rationalize by properly taking into account elastocapillary effects. In this framework, the classical impact dynamics of solids and liquids, as far as viscous dissipation is negligible, appears as the asymptotic limits of a universal theoretical description. A novel material-dependent characteristic velocity that includes both capillary and bulk elasticity emerges from this unified description of the physics of impact.

Relapsing polychondritis, an underestimated dermatological urgency: case report and literature review

BACKGROUND

Relapsing polychondritis is an autoimmune multisystemic disease with primary chondral involvement. Its high mortality and morbidity make it a real clinical challenge.

CASE DESCRIPTION

A 32-year-old woman with a history of relapsing polychondritis, refractory to multiple treatments, with multisystem compromise, imminent risk of death due to severe tracheobronchial damage and difficult ventilatory support, and successful treatment with infliximab.

DISCUSSION AND EVALUATION

Several treatments have been described in the literature, such as nonsteroidal anti-inflammatory drugs, corticosteroids, dapsone, azathioprine, cyclosporine, cyclophosphamide, and methotrexate. However, the cases refractory to conventional therapy may lead to chronicity, irreversibility, and death. As a result, a third-line therapy could improve the prognosis of these patients.

CONCLUSIONS

Biological therapy is a good option for disease control and quality of life improvement. In addition, the physician should consider these treatments to avoid the chronicity and risk of death of these patients.