Retrospective Evaluation of Horses Diagnosed with Neuroborreliosis on Postmortem Examination: 16 Cases (2004-2015)

BACKGROUND

Equine neuroborreliosis (NB), Lyme disease, is difficult to diagnose and has limited description in the literature.

OBJECTIVE

Provide a detailed description of clinical signs, diagnostic, and pathologic findings of horses with NB.

ANIMALS

Sixteen horses with histologically confirmed NB.

METHODS

Retrospective review of medical records at the University of Pennsylvania and via an ACVIM listserv query with inclusion criteria requiring possible exposure to Borrelia burgdorferi and histologic findings consistent with previous reports of NB without evidence of other disease.

RESULTS

Sixteen horses were identified, 12 of which had additional evidence of NB. Clinical signs were variable including muscle atrophy or weight loss (12), cranial nerve deficits (11), ataxia (10), changes in behavior (9), dysphagia (7), fasciculations (6), neck stiffness (6), episodic respiratory distress (5), uveitis (5), fever (2), joint effusion (2), and cardiac arrhythmias (1). Serologic analysis was positive for B. burgdorferi infection in 6/13 cases tested. CSF abnormalities were present in 8/13 cases tested, including xanthochromia (4/13), increased total protein (5/13; median: 91 mg/dL, range: 25-219 mg/dL), and a neutrophilic (6/13) or lymphocytic (2/13) pleocytosis (median: 25 nucleated cells/μL, range: 0-922 nucleated cells/μL). PCR on CSF for B. burgdorferi was negative in the 7 cases that were tested.

CONCLUSION AND CLINICAL IMPORTANCE

Diagnosis of equine NB is challenging due to variable clinical presentation and lack of sensitive and specific diagnostic tests. Negative serology and normal CSF analysis do not exclude the diagnosis of NB.

Acquired factor V inhibitor after exposure to topical human thrombin related to an otorhinolaryngological procedure

Acquired factor V (FV) inhibitors occur rarely and classically develop after exposure to bovine thrombin. The clinical presentation is variable, ranging from asymptomatic with incidental laboratory abnormalities to significant bleeding. With the development of human-derived thrombin agents, bovine thrombin is less frequently used. We report a case of an acquired FV inhibitor that developed in a patient after exposure to human thrombin used as a hemostatic agent during an otorhinolaryngology surgical procedure. Our review of the literature revealed only one prior reported case of FV inhibitor after exposure to human thrombin. Hematologists and surgeons should be aware of this rare, but potentially life-threatening, complication in the postprocedural setting.

Obesity and oral disease - a challenge for dentistry

The prevalence of overweight and obesity is rising in many developed and developing countries and, most worryingly, among children. Within the EU, Scotland has the highest prevalence, more than twice that of the Netherlands, and in England almost a quarter of children now enter primary school either overweight or obese, rising to one in three on leaving at age 11 years. Whilst most epidemiological data is based on body mass index, this is not a reliable indicator of individual adiposity and morbidity risk. The association between excess adiposity and type 2 diabetes is well recognised and the latter carries implications for oral disease and dental treatment. Current research has not established a clear association between excess adiposity and caries prevalence, however, there is evidence for a higher prevalence of chronic periodontal disease in obese populations. There is some evidence that this is not mediated solely by diabetes, but by secretion by adipose tissue of chemical mediators of inflammation, including cytokines and hormones, which could modify the response of the periodontal tissues to the oral environment. Dental professionals must become aware of this growing problem, of the demands that the rising obesity prevalence will place on dental care services and the need for bariatric dental facilities. Together, with service providers, dental professionals must prepare for the challenge ahead.

Toll-like receptor alterations in myelodysplastic syndrome

Recent studies have implicated the innate immunity system in the pathogenesis of myelodysplastic syndromes (MDS). Toll-like receptor (TLR) genes encode key innate immunity signal initiators. We recently identified multiple genes, known to be regulated by TLRs, to be overexpressed in MDS bone marrow (BM) CD34+ cells, and hypothesized that TLR signaling is abnormally activated in MDS. We analyzed a large cohort of MDS cases and identified TLR1, TLR2 and TLR6 to be significantly overexpressed in MDS BM CD34+ cells. Deep sequencing followed by Sanger resequencing of TLR1, TLR2, TLR4 and TLR6 genes uncovered a recurrent genetic variant, TLR2-F217S, in 11% of 149 patients. Functionally, TLR2-F217S results in enhanced activation of downstream signaling including NF-κB activity after TLR2 agonist treatment. In cultured primary BM CD34+ cells of normal donors, TLR2 agonists induced histone demethylase JMJD3 and interleukin-8 gene expression. Inhibition of TLR2 in BM CD34+ cells from patients with lower-risk MDS using short hairpin RNA resulted in increased erythroid colony formation. Finally, RNA expression levels of TLR2 and TLR6, as well as presence of TLR2-F217S, are associated with distinct prognosis and clinical characteristics. These findings indicate that TLR2-centered signaling is deregulated in MDS, and that its targeting may have potential therapeutic benefit in MDS.

Safety, efficacy and biological predictors of response to sequential azacitidine and lenalidomide for elderly patients with acute myeloid leukemia

Acute myeloid leukemia (AML) is a disease of the elderly. Poor outcomes with standard therapies necessitate novel approaches. Outpatient regimens sufficiently potent and well tolerated to induce remissions and enable continuation therapy may be beneficial. In this phase-1 study, we determined the maximum tolerated dose (MTD) and the efficacy for sequential azacitidine and lenalidomide as remission induction and continuation therapy in elderly, previously untreated patients. We investigated the impact on global DNA methylation and bone marrow cytokines, and sought biological predictors of response. Eighteen patients were enrolled. The MTD was not reached. Median follow-up was 8.2 months (10.3 months for survivors). Common adverse events included fatigue, injection site reactions, constipation, nausea, pruritus and febrile neutropenia. Ten patients responded (56%), and the rate of complete remissions (CRs) or CRs with incomplete recovery of blood counts for evaluable patients was 44% (7/16). The median response duration was 6.2 months. DNA demethylation and changes in bone marrow cytokines were observed; responders had a unique cytokine profile and a trend towards lower methylation levels. Sequential azacitidine and lenalidomide was well tolerated with encouraging clinical and biological activity in previously untreated elderly AML patients. This trial is registered at ClinicalTrials.gov (NCT00890929).

Introducing new vaccines in the poorest countries: what did we learn from the GAVI experience with financial sustainability?

This paper reviews the experience of the Global Alliance for Vaccines and Immunization (GAVI) in introducing hepatitis B and Haemophilus influenzae type b vaccines in the poorest countries, and explores how financing for immunization has changed since GAVI Fund resources were made available during its first wave of support between 2000 and 2006. The analysis of Financial Sustainability Plans in 50 countries allowed for some of the original funding assumptions of the GAVI approach to be tested against the realities in a wide set of countries, and to highlight implications for future immunization efforts. While the initial GAVI experience with financial sustainability has proved successful through the development of plans, and many countries have been able to both introduce new vaccines and mobilize additional financing for immunization, for future GAVI supported vaccine introduction, some country co-financing of these will be needed upfront for the approach to be more sustainable.

Splenic Rupture: An Unusual Complication of Colonoscopy

Splenic injury is a known, albeit rare, complication of diagnostic and therapeutic colonoscopy. Within a 6-month period, we observed two colonoscopic splenic injuries. We report these two cases of splenic injury who presented differently after colonoscopy: one presented as frank hemorrhagic shock, and the other as a subacute splenic hemorrhage with symptomatic anemia. The first patient presented with hemorrhagic shock several hours after a diagnostic colonoscopy and required an emergency splenectomy. The second patient presented with symptomatic anemia several days after a diagnostic colonoscopy and was treated by angiographic embolization. Clinical presentation and discussion of the mechanisms of injury, available treatment options, and strategies for preventing colonoscopic splenic injuries are presented. Awareness of this complication is paramount in early recognition and management of this potentially life-threatening injury.

Splenic rupture: an unusual complication of colonoscopy

Splenic injury is a known, albeit rare, complication of diagnostic and therapeutic colonoscopy. Within a 6-month period, we observed two colonoscopic splenic injuries. We report these two cases of splenic injury who presented differently after colonoscopy: one presented as frank hemorrhagic shock, and the other as a subacute splenic hemorrhage with symptomatic anemia. The first patient presented with hemorrhagic shock several hours after a diagnostic colonoscopy and required an emergency splenectomy. The second patient presented with symptomatic anemia several days after a diagnostic colonoscopy and was treated by angiographic embolization. Clinical presentation and discussion of the mechanisms of injury, available treatment options, and strategies for preventing colonoscopic splenic injuries are presented. Awareness of this complication is paramount in early recognition and management of this potentially life-threatening injury.