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Talwar A, Rajeev A, Rachapudi S, Khan S, Singh V, Talwar A. Spontaneous pneumomediastinum: A comprehensive review of diagnosis and management. Intractable Rare Dis Res 2024; 13:138-147. [PMID: 39220281 PMCID: PMC11350202 DOI: 10.5582/irdr.2024.01020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/09/2024] [Accepted: 07/25/2024] [Indexed: 09/04/2024] Open
Abstract
Pneumomediastinum is a rare condition defined by the presence of air in the mediastinum. In the absence of traumatic injury, iatrogenic injury, or clear etiology, it is called spontaneous pneumomediastinum (SPM). Spontaneous pneumomediastinum most commonly occurs in younger individuals and has a self-limiting course with a good outcome. The purpose of the present manuscript is to systematically review the existing literature on SPM evaluation and management for updated clinical understanding of this condition. A literature search was conducted of publications about SPM on MEDLINE/PubMed and Google Scholar by identifying all the articles with key search terms "pneumomediastinum" and "spontaneous pneumomediastinum". Inclusion criteria were case series published in English between 1980 and 2023. In total, 24 case series were selected and reviewed to determine presenting symptoms, clinical signs and predisposing factors associated with spontaneous pneumomediastinum. Most patients were male; the average age at diagnosis was 26.3 years. The most common presenting symptoms were chest pain and dyspnea. The most common exam finding was subcutaneous emphysema, in 35.4% of patients. Only 5.9% had the classic Hamman's sign. Risk factors include history of asthma, history of smoking, and recent physical activity. This manuscript presents an extensive review of relevant literature highlighting the diagnosis and essential management of spontaneous pneumomediastinum.
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Affiliation(s)
- Ankoor Talwar
- Department of General Surgery, MedStar Georgetown University Hospital-Washington Hospital Center, Washington, DC, USA
| | - Athira Rajeev
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
| | - Shasank Rachapudi
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
| | - Sara Khan
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
| | - Vijay Singh
- Department of Cardiovascular and Thoracic Surgery, Northwell Health, Bayshore, NY, USA
| | - Arunabh Talwar
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
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Wei BM, Fox LP, Kaffenberger BH, Korman AM, Micheletti RG, Mostaghimi A, Noe MH, Rosenbach M, Shinkai K, Kwah JH, Phillips EJ, Bolognia JL, Damsky W, Nelson CA. Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part I. Epidemiology, pathogenesis, clinicopathological features, and prognosis. J Am Acad Dermatol 2024; 90:885-908. [PMID: 37516359 DOI: 10.1016/j.jaad.2023.02.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/11/2023] [Accepted: 02/26/2023] [Indexed: 07/31/2023]
Abstract
Drug-induced hypersensitivity syndrome (DiHS), also known as drug reaction with eosinophilia and systemic symptoms (DRESS), is a severe cutaneous adverse reaction (SCAR) characterized by an exanthem, fever, and hematologic and visceral organ involvement. Anticonvulsants, antibiotics, and allopurinol are the most common triggers. The pathogenesis involves a complex interplay between drugs, viruses, and the immune system primarily mediated by T-cells. DiHS/DRESS typically presents with a morbilliform eruption 2-6 weeks after drug exposure, and is associated with significant morbidity, mortality, and risk of relapse. Long-term sequelae primarily relate to organ dysfunction and autoimmune diseases. Part I of this continuing medical education activity on DiHS/DRESS provides an update on epidemiology, novel insights into pathogenesis, and a description of clinicopathological features and prognosis.
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Affiliation(s)
- Brian M Wei
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | | | - Abraham M Korman
- Department of Dermatology, The Ohio State University, Columbus, Ohio
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arash Mostaghimi
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Megan H Noe
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, California
| | - Jason H Kwah
- Department of Medicine, Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jean L Bolognia
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut; Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Hama N, Abe R, Gibson A, Phillips EJ. Drug-Induced Hypersensitivity Syndrome (DIHS)/Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS): Clinical Features and Pathogenesis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1155-1167.e5. [PMID: 35176506 PMCID: PMC9201940 DOI: 10.1016/j.jaip.2022.02.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 05/16/2023]
Abstract
Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is one example of a severe delayed T-cell-mediated adverse drug reaction. DIHS/DRESS presents with fever, widespread rash and facial edema, organ involvement, and hematological abnormalities, including eosinophilia and atypical lymphocytosis. DIHS/DRESS is associated with relapse 2 to 4 weeks after acute symptoms, often coinciding with reactivation of prevalent chronic persistent human herpesviruses such as human herpesvirus 6, EBV, and cytomegalovirus. The mortality of DIHS/DRESS is up to 10% and often related to unrecognized myocarditis and cytomegalovirus complications, with longer-term consequences that contribute to morbidity including autoimmune diseases such as thyroiditis. It is essential that all potential drug causes, including all new drugs introduced within the 8 weeks preceding onset of DIHS/DRESS symptoms, are identified. All potential drug culprits, as well as drugs that are closely related structurally to the culprit drug, should be avoided in the future. Systemic corticosteroids have remained the mainstay for the treatment of DIHS/DRESS with internal organ involvement. Steroid-sparing agents, such as cyclosporine, mycophenolate mofetil, and monthly intravenous immune globulin, have been successfully used for treatment, and careful follow-up for cytomegalovirus reactivation is recommended. Strong associations between HLA class I alleles and DIHS/DRESS predisposition include HLA-B∗13:01 and dapsone, HLA-B∗58:01 and allopurinol, and HLA-B∗32:01 and vancomycin. These have opened a pathway for prevention, risk stratification, and earlier diagnosis. Single-cell sequencing and other studies of immunopathogenesis promise to identify targeted treatment approaches.
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Affiliation(s)
- Natsumi Hama
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Andrew Gibson
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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Biju R, Davis S, Sanal G. Quetiapine-induced drug rash with eosinophilia and systemic symptom syndrome. JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/jmedsci.jmedsci_82_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kim GY, Anderson KR, Davis DM, Hand JL, Tollefson MM. Drug reaction with eosinophilia and systemic symptoms (DRESS) in the pediatric population: A systematic review of the literature. J Am Acad Dermatol 2020; 83:1323-1330. [DOI: 10.1016/j.jaad.2020.03.081] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 03/11/2020] [Accepted: 03/25/2020] [Indexed: 12/17/2022]
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Shiohara T, Mizukawa Y. Drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS): An update in 2019. Allergol Int 2019; 68:301-308. [PMID: 31000444 DOI: 10.1016/j.alit.2019.03.006] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Indexed: 12/14/2022] Open
Abstract
The aim of this review was to provide an updated overview of drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS). Several new insights have been made, particularly with regards to the diagnosis, pathogenesis and care of some important complications and sequelae. The indication of herpesvirus reactivations in diagnosis in the assessment of disease severity is now better specified. Nevertheless, because fatal complications and autoimmune sequelae have been under-recognized, there is a clear need to identify effective parameters for assessing disease severity and predicting prognosis of the disease in the early phase. In this regard, we have established a scoring system that can be used to monitor severity, predict prognosis and stratify the risk of developing severe complications including fatal cytomegalovirus (CMV) disease. Regulatory T cells are likely to be central to the mechanism and would represent potential targets for therapeutic approaches that can ameliorate inflammatory responses occurring at the acute phase while preventing the subsequent development of harmful outcomes, such as CMV disease and autoimmune diseases.
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Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms severity score: A useful tool for assessing disease severity and predicting fatal cytomegalovirus disease. J Am Acad Dermatol 2019; 80:670-678.e2. [DOI: 10.1016/j.jaad.2018.08.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 08/26/2018] [Accepted: 08/30/2018] [Indexed: 12/16/2022]
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Acute Respiratory Distress Syndrome and Lamotrigine: A Case Report. PSYCHOSOMATICS 2017; 58:313-316. [PMID: 28222856 DOI: 10.1016/j.psym.2016.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 12/14/2016] [Accepted: 12/14/2016] [Indexed: 11/23/2022]
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Oliveira AM, Carvalho R, Martins A, Reis J. Acute Hepatitis in the DRESS Syndrome. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:304-308. [PMID: 28868484 PMCID: PMC5580171 DOI: 10.1016/j.jpge.2016.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/06/2016] [Indexed: 11/16/2022]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, idiosyncratic reaction characterized by diffuse maculopapular rash, facial edema, lymphadenopathy, fever, eosinophilia and/or other leukocyte abnormalities, and involvement of internal organs as liver, kidney, heart and lung. Diagnosing this entity is specifically complicated due to the multiplicity of organs involved. DRESS syndrome must be recognized promptly and the causative drug withdrawn in order to improve patient outcomes. Indeed, it is a potentially life-threatening condition, with a reported mortality between 5 and 20%. We describe a case of a 22-year old woman admitted to our hospital with acute diffuse, pruritic rash associated with crampy abdominal pain, vomiting, diarrhea and fever three weeks after starting sulfasalazine therapy. Initially, laboratory parameters revealed normal white blood cell count and normal liver enzymes, but during hospitalization, eosinophilia developed and liver enzymes, including transaminases and cholestatic parameters, dramatically increased. The diagnostic of DRESS syndrome was made and sulfasalazine was withdrawn and as there were signs of disease severity, systemic corticotherapy was initiated, with gradually improvement of the rash and symptoms resolution. The patient was discharged home after thirty days of hospitalization.
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Affiliation(s)
- Ana Maria Oliveira
- Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
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Saha M, Gorai S, Madhab V. Oxcarbazepine-induced drug rash with eosinophilia and systemic symptoms syndrome presenting as exfoliative dermatitis. J Pharmacol Pharmacother 2016; 7:142-5. [PMID: 27651712 PMCID: PMC5020775 DOI: 10.4103/0976-500x.189681] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a type of severe adverse cutaneous drug reaction characterized by fever, skin eruption, hematological abnormalities, and internal organ involvement. Although anticonvulsant drugs are mainly implicated in DRESS, newer anticonvulsants such as oxcarbazepine-induced definite cases of DRESS syndrome are rare and oxcarbazepine-induced DRESS syndrome presenting as exfoliative dermatitis is even rarer. We report a case of a 35-year-old male who developed DRESS syndrome presenting as exfoliative dermatitis after taking oxcarbazepine for 3 weeks.
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Affiliation(s)
- Mahimanjan Saha
- Department of Dermatology, Silchar Medical College, Silchar, Assam, India
| | - Surajit Gorai
- Department of Dermatology, Burdwan Medical College, Burdwan, West Bengal, India
| | - Vaswatee Madhab
- Department of Dermatology, Silchar Medical College, Silchar, Assam, India
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Tortajada-Girbés M, Moreno-Prat M, Ainsa-Laguna D, Mas S. Spontaneous pneumomediastinum and subcutaneous emphysema as a complication of asthma in children: case report and literature review. Ther Adv Respir Dis 2016; 10:402-9. [PMID: 27585598 PMCID: PMC5933618 DOI: 10.1177/1753465816657478] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Spontaneous pneumomediastinum (SPM) is an uncommon disorder. It is rarely
reported in paediatric patients and may be accompanied by subcutaneous
emphysema. It is usually benign and self-limiting, with only supportive
therapy being needed, but severe cases may require invasive measures. Asthma
exacerbations have classically been described as a cause of SPM. However,
detailed descriptions in asthmatic children are scarce. We aimed at
improving the current understanding of the features of SPM and subcutaneous
emphysema, and outcomes, by means of a case report and a systematic
review. Methods: For the systematic review a literature search was performed in PubMed to
identify reported cases of SPM in asthmatic children. Results: The case a 10-year-old asthmatic girl with SPM is reported. The patient
received an inhaled corticosteroid and long-acting beta2 agonist, in
addition to sublingual immunotherapy (SLIT) with eventual control of asthma
symptoms. Review: A total of 114 published cases were found since 1995, most
of them in teenagers; no sex differences were observed. Clinical
presentation was associated with an asthma exacerbation in a number of
cases. Other presenting features were chest pain, dyspnoea, cough, and
particularly acute swelling of the face, neck, and upper chest. Subcutaneous
emphysema was present in most patients. Overall, three cases of pneumothorax
and two cases of pneumorrhachis were reported. Therapy was mainly based on
supportive care, rest, oxygen therapy, analgesics, steroids, and
bronchodilators. All patients recovered spontaneously, in spite of a small
initial increase in SPM in a few cases. Conclusions: Early identification of patients at risk of SPM would avoid the high number
of under-diagnosed cases. Patients should be treated not only with
supportive therapy but also with measures to achieve control of the
underlying cause (such as poorly controlled asthma).
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Affiliation(s)
- Miguel Tortajada-Girbés
- Department of Pediatrics, Dr. Peset University Hospital, Valencia, Spain; Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Av. Gaspar, Aguilar, 90. 46017 Valencia, Spain
| | - Miriam Moreno-Prat
- Luis Oliag Health Centre Valencia, Departament of Valencia Dr. Peset, Valencia, Spain
| | - David Ainsa-Laguna
- Department of Pediatrics, Dr. Peset University Hospital, Valencia, Spain
| | - Silvia Mas
- Universitat Pompeu Fabra, Barcelona, Spain
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Dar WR, Sofi N, Latief M, Dar IA, Kasana BA. Levetiracetam Induced Drug Reaction with Eosinophilia and Systemic Symptom Syndrome. Indian J Dermatol 2016; 61:235. [PMID: 27057042 PMCID: PMC4817467 DOI: 10.4103/0019-5154.177777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptom syndrome (DRESS) is a hypersensitivity drug reaction, most frequently associated with antiepileptic drugs, characterized by skin rash, fever, pharyngitis, lymphadenopathy, and visceral organ involvement, typically presenting within 8 weeks of initiation of therapy. Management involves prompt withdrawal of the offending drug and use of systemic corticosteroids. We here present a rare case of DRESS secondary to levetiracetam. Only few case reports of DRESS secondary to levetiracetam have been published so far.
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Affiliation(s)
- Waseem Raja Dar
- Department of Internal Medicine, Shere Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Najeebullah Sofi
- Department of Medicine, Shere Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Muzamil Latief
- Department of Medicine, Shere Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Imtiyaz Ahmad Dar
- Department of Medicine, Shere Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Basharat Ahmad Kasana
- Department of Medicine, Shere Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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DRESS syndrome associated with type 2 diabetes in a child. Cent Eur J Immunol 2016; 40:493-6. [PMID: 26862317 PMCID: PMC4737734 DOI: 10.5114/ceji.2015.54606] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 08/12/2015] [Indexed: 12/19/2022] Open
Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon, life-threatening drug reaction. The basic findings are skin rash, multiorgan involvement, and eosinophilia. Most of the aromatic anticonvulsants, such as phenytoin, phenobarbital and carbamazepine can induce DRESS. Herein we report a 14-year-old patient with DRESS syndrome related to carbamazepine use. The patient presented with signs of involvement of the skin, lungs, liver, and microscopic hematuria. Carbamazepine treatment was discontinued; antihistamines and steroids were started. Hyperglycemia, commencing on the first dose of the steroid given, persisted even after the discontinuation of steroids and improvement of other signs. There were no signs of pancreatitis or type 1 diabetes clinically in laboratory tests. Her blood glucose levels were regulated at first with insulin and later with metformin. Within 1 year of follow-up, still regulated with oral antidiabetics, she has been diagnosed with type 2 diabetes. Formerly, long-term sequelae related to “drug rash with eosinophilia and systemic symptoms syndrome” such as hepatic and renal failure, type 1 diabetes mellitus, Grave's disease, autoimmune hemolytic anemia, and lupus have also been reported. However, up to date, no cases with type 2 diabetes have been reported as long-term sequelae. To our knowledge, this is the first case in the literature presenting with type 2 diabetes as long-term sequelae.
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Abstract
DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms), also known as hypersensitivity syndrome (HSS), is a severe and potentially life-threatening drug reaction. The worldwide rate of mortality is about 10 %, its incidence is increasing. Drugs that most frequently induce DRESS are aromatic anticonvulsive drugs (carbamazepine, lamotrigine, phenobarbital), and more recently new retroviral therapies. The pathogenesis of DRESS is not yet fully understood, but is certainly multifactorial involving a combination of immune reactions, ethnic predisposition, genetically determined enzyme deficiencies and reactivation of herpes viruses (HHV-6, HHV-7, EBV, CMV). Because of the involvement of the skin and internal organs, the clinical picture can be very variable. No specific clinical, histologic or laboratory parameter is available, so the diagnosis has to rely on the clinical appearance. The long latency period between start of drug intake and the initial manifestation of DRESS and the successive onset of skin and organ involvement complicates the early diagnosis. Although or even because DRESS represents a diagnostic challenge, detailed knowledge about this disease is of utmost importance to enable early therapeutic actions.
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Abstract
DRESS syndrome (Drug rash with eosinophilia and systemic symptoms) is a severe drug-induced hypersensitivity syndrome characterized by diffuse skin rash, fever, eosinophilia, atypical lymphocytes and organ involvement. We report a case of drug reaction with eosinophilia and systemic symptoms (DRESS) to sulphasalazine. A 54-year-old woman developed a widespread papulovesicular rash after treatment with sulphasalazine (1000 mg daily). She was successfully treated with systemic corticosteroids.
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Affiliation(s)
- K. Pałgan
- Department of Allergology, Clinical Immunology and Internal Diseases, Nicolaus Copernicus University in Toruń, Collegium Medicum of L. Rydygier in Bydgoszcz, Poland
| | - Z. Bartuzi
- Department of Allergology, Clinical Immunology and Internal Diseases, Nicolaus Copernicus University in Toruń, Collegium Medicum of L. Rydygier in Bydgoszcz, Poland
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