Candida pneumonia in young and immunocompetent lady: A case report and literature review

Background

Candida is a frequent respiratory tract colonizer. True candida pneumonia is rare and seen with predominance in immunosuppressed patients. Our aim is to document a previously unreported case of Candida pneumonia in a young and immunocompetent patient, highlighting, an unusual pathological manifestation of this infection in immunocompetent individuals.

Case summary

We report a previously healthy young lady who remained symptomatic with fever, cough and shortness of breath for three weeks duration despite treatment with extensive antibiotics regimen for community acquired pneumonia. She was eventually treated as a probable, rare case of candida pneumonia. The patient demonstrated a dramatic response to single antifungal treatment both clinically and biochemically within the first 24hrs of treatment. Candida albican was isolated on repetitive cultures form the sputum and bronchoalevolar lavage samples. The patient had negative blood cultures. Her HRCT scan revealed bilateral basal air space opacities with peri bronchovascular distribution and centrilobular nodules with branching pattern suggestive of tree in bud predominantly in lower lobes. Her endobronchial biopsies was mostly unremarkable apart from rare non-necrotizing granuloma.

Conclusion

Candida can rarely cause clinically significant pneumonia in immunocompetent patients and should be considered in the differential diagnosis of granulomatous lung disease.

Lung ultrasound to predict gas-exchange response to prone positioning in COVID-19 patients: A prospective study in pilot and confirmation cohorts

PURPOSE

To examine whether lung ultrasound prior to prone positioning can predict the resulting gas-exchange response.

MATERIALS AND METHODS

This is a prospective observational study on critically-ill COVID-19 patients with a pilot and confirmation cohort. Lung ultrasound examinations were performed before prone positioning and gas-exchange parameters were recorded before and after position change.

RESULTS

A total of 79 patients, 36 in the pilot cohort and 43 in the confirmation cohort, were included. In the pilot cohort, a moderate correlation between pre-turn lung ultrasound score index (LUSI) and change in PaO2/FiO2 after prone positioning was found. These findings were corroborated and extended upon in the confirmation cohort. The confirmation cohort found that anterior LUSI had the strongest correlation with follow-up time-points 1, 6, 12, and 24 h after prone positioning, with strength of correlation gradually increasing up to 24 h. In a multivariate model anterior aeration loss (odds ratio 0.035; 95%CI 0.003-0.319 for anterior LUSI >50%) and higher pre-turn PaCO₂ (odds ratio 0.479 95% CI 0.235-0.979) were negatively predictive of a PaO2/FiO2 increase ≥20 mmHg.

CONCLUSIONS

Anterior LUSI, in addition to other clinical parameters, may be used to aid COVID-19 respiratory strategy and a clinician's decision to prone.

Differential Serum-intestinal Dynamics of Infliximab and Adalimumab in Inflammatory Bowel Disease Patients

BACKGROUND AND AIMS

Therapeutic drug monitoring is used to guide anti-tumour necrosis factor [TNF] therapy. However, the associations between serum drug levels [SDL], TNF-bound, and free anti-TNF in the target tissue are incompletely defined. We aimed to assess the interactions between these parameters in inflammatory bowel disease [IBD] patients.

METHODS: ENZYME-LINKED IMMUNOSORBENT

assays [ELISA assays] were used to detect free drug and TNF-drug complexes in intestinal tissues. Concurrent SDL, anti-drug antibodies [ADA], pharmacotherapy, clinical response, endoscopic appearance, and histological severity were determined. Comparisons between anti-TNFs and paired inflamed/non-inflamed tissue were performed. Variables were correlated and potential interactions detected using multivariate analysis.

RESULTS

A total of 95 biopsies taken from 49 anti-TNF treated IBD patients [26 receiving infliximab and 23 adalimumab] were studied. Free drug levels were higher in inflamed compared with non-inflamed paired specimens. Tissue free-drug and TNF-drug complexes levels were higher in adalimumab-treated patients. In adalimumab-treated patients, SDL were correlated with free drug, but not TNF-drug complex levels, in both inflamed and non-inflamed segments. In infliximab-treated patients, higher SDL were associated with the presence of tissue free drug in both inflamed and non-inflamed segments, whereas TNF-drug complexes were mostly detected in non-inflamed but not in inflamed tissue. In the presence of ADA, neither free drug nor TNF-infliximab complexes were measured in the tissue. Tissue levels did not correlate well with clinical, endoscopic, or histological scores.

CONCLUSIONS

SDL correlated with tissue free drug levels; however, different dynamics were observed for TNF-drug complex levels. Infliximab and adalimumab tissue drug dynamics differ. Better understanding of these interactions may allow future therapeutic optimisation.

The Association between GDP and non-communicable disease mortality in the WHO European Region

Background

The WHO Europe Region consists of 53 countries, each of which has differences in mortality from cardiovascular (CVD), neurological, and chronic respiratory diseases. Such diverse metrics result from political, social, and economic events that have influenced the health performance of each European sub-region. From a public health perspective, an updated analysis of such metrics is required for policymakers and health system organisations to improve the overall population health outcomes.

Methods

This study utilised data between 1990-2017 from the Global Burden of Disease study 2017 to explore the association between GDP and NCD mortality in Western, Central, and Eastern Europe and Central Asia. The mortality data was already stratified by age and sex, and a fixed effected regression analysis was run to observe associations between both variables using STATA. Data completeness was 80-100% for GDP and 100% for mortality across the European region. The final results were reported as a rate per 100,000, with confidence intervals. The rate changes were calculated using an equation from the GBD.

Results

The most significant decrease per 100,000 of the population across all three NCDs as GDP increased was in Central Asia and Eastern Europe among both sexes. For every 1000 unit increase in GDP, we expect -12.13 [-13.60, -10.66] and -14.49 [-16.89, -12.29] less deaths in CVD in females and males per 100,000 of population, respectively. Western Europe had the lowest decrease per 100,000 of the population, as with every 1000 unit increase in GDP, we expect -2.42 [-2.59, -2.25] and -4.09 [-4.33, -3.84] fewer deaths in CVD in females and males, respectively.

Conclusions

The overall differential rate of mortality from the three NCDs is decreasing across all regions. However, there is a large disparity between the sexes. Males have a higher mortality rate across CVD and chronic respiratory diseases, whilst neurological disorders were highest among females.

Key messages

This study’s analysis has added to existing knowledge on chronic health patterns in the WHO European region. Governments in Eastern Europe and Central Asia should introduce health policies targeting unhealthy consumption of alcohol, smoking and diets, as seen in Western Europe.

Are all vaccines safe for the pregnant traveller? A systematic review and meta-analysis

Pregnant travellers and their offspring are vulnerable to severe outcomes following a wide range of infections. Vaccine-preventable diseases can have a particularly severe course in pregnant women, but little is known about the safety of travel vaccines in pregnant women. We performed a systematic review of all published literature concerning the safety of vaccines frequently given to travellers such as yellow fever, MMR (mumps, measles and rubella), influenza, Tdap (tetanus, diphtheria and pertussis), meningococcus, hepatitis A and B, rabies, polio, typhoid fever, tick-borne encephalitis and Japanese encephalitis vaccines. We included case series, cohort studies and randomized controlled trials (RCTs). For the meta-analysis, we included only RCTs that compared the administration of a vaccine to placebo or to no vaccine. Outcome measures included severe systemic adverse events, maternal outcomes related to the course of pregnancy, neonatal outcomes and local adverse events. We calculated the risk ratio and its 95% confidence interval as the summary measure. The safety of influenza vaccine is supported by high-quality evidence. For Tdap vaccine, no evidence of any harm was found in the meta-analysis of RCTs. A slight increase in chorioamnionitis rate was reported in 3 out of 12 observational studies. However, this small possible risk is far outweighed by a much larger benefit in terms of infant morbidity and mortality. Meningococcal vaccines are probably safe during pregnancy, as supported by RCTs comparing meningococcal vaccines to other vaccines. Data from observational studies support the safety of hepatitis A, hepatitis B and rabies vaccines, as well as that of the live attenuated yellow fever vaccine. We found little or no data about the safety of polio, typhoid, Japanese encephalitis, tick-borne encephalitis and MMR vaccines during pregnancy.

Selection criteria for resuscitation and survivability rates for neonates at the limit of viability

AIM

To evaluate outcomes of a cohort of infants born at 23 weeks' gestational age after introducing a new selection score for resuscitation in the delivery room (DR).

METHODS

This was a retrospective charts review study using data from the maternal and newborn registry funded by the Qatar National Research Fund. Parents were consulted prenatally and their wishes were honored. The plan of resuscitation was based on the new selection score. The seven components of the score were four antenatal and three immediate postnatal in the DR. Each component received a score of zero, one, or two according to its presence, uncertainty or absence, respectively. Only a score of≥7 would receive active resuscitation unless specified otherwise during prenatal consultation.

RESULTS

The study reviewed 60 infants that were delivered over a two year period. The DR death rate was 23 of 60 (38%). Thirty-seven infants (61%) were admitted to the NICU. The score was applied only on 37 infants where all score criteria were reported in their files. Twenty infants had score <7; of them 13 (65%) died in the DR and 7 were admitted to NICU of whom two (29%) survived to discharge. Seventeen babies with scores≥7 admitted to NICU of whom nine (51%) survived to discharge. The survival rate to discharge was 13 of 37(35%). A satisfaction survey included 33 neonatal physicians; 32 neonatologists stated the score was easy to comprehend, 26 voted for easy to implement, and 30 voted for ethical relief and moral comfort.

CONCLUSIONS

Using a resuscitation score of seven was associated with improved survival until the discharge of those infants resuscitated. NICU physicians described the score as functional and convenient.

Standard pre-travel consultation versus shorter consultation combined with smartphone support: a randomized controlled trial

Immediate and long-term recalls of a pre-travel consultation are suboptimal. We aimed to assess the role of online consultation for travellers. We randomized travellers into two study groups. In the intervention arm, each traveller was given a short pre-travel consultation of 8-12 minutes, combined with the option of smartphone support before and during the trip. In the control arm, each traveller was given a standard length pre-travel consultation of 18-22 minutes. Endpoints included knowledge about potential risks, travellers' satisfaction, time allocated to each traveller and clinical events. We enrolled 75 patients in the intervention group and 74 patients in the control group. Online consultation was used 33 times, by 24 travellers, both before and during the trip. Important health hazards that were addressed included animal and insect bites (8), treatment of diarrhea (4), malaria prophylaxis (2) and altitude sickness prophylaxis (5). Other consultations consisted mainly of reassurances of worried travellers and provision of data. Knowledge about travel-related risks was higher in the control group before travelling (8.86 ± 1.12 vs 8.34 ± 1.32, P = 0.014), and there was a trend towards higher levels of knowledge also during the trip (8.29 ± 1.35 vs 7.89 ± 1.39, P = 0.06). Travellers' satisfaction before and during the trip was similar in both groups: median 10 (10, 10) in both groups before traveling (P = 0.51) and median 9 (8, 10) in both groups during the trip (P = 0.71). In the intervention group, time allocated to each traveller was <12 minutes. There were no differences in the number of clinical events (P > 0.2 for all comparisons). Online WhatsApp support addressed several important travel-related hazards but, when combined with a shortened pre-travel consultation, was associated with a lower level of knowledge about health risks. Therefore, such smartphone support should augment, rather than replace, pre-travel consultation.

Vitamin D and cardiometabolic disorders: a review of current evidence, genetic determinants and pathomechanisms

Vitamin D deficiency has been implicated in the pathophysiology of cardiometabolic disorders including obesity, type 2 diabetes mellitus, cardiovascular diseases and polycystic ovary syndrome. Despite a large number of experimental and observational studies supporting a role for vitamin D in these pathologies, randomized controlled trials have reported little to no effect of vitamin D supplementation in the prevention or treatment of these disorders, although some results remain ambiguous. Polymorphisms in genes related to vitamin D metabolism, particularly in the vitamin D receptor and binding protein and the metabolizing enzyme 1-α-hydroxylase, have emerged as potential contributors to these divergent results. It is now becoming increasingly recognized that the effects and potential benefits of vitamin D supplementation may vary by several factors including vitamin D deficiency status, ethnicity and/or the presence of genetic variants, which affect individual responses to supplementation. However, these factors have seldom been explored in the available literature. Future trials should consider inter-individual differences and, in particular, should aim to clarify whether certain subgroups of individuals may benefit from vitamin D supplementation in the context of cardiometabolic health.

Neoadjuvant chemoradiotherapy followed by radical vulvectomy for adenoid cystic carcinoma of Bartholin's gland: a case report and review of the literature

Adenoid cystic carcinoma (ACC) of Bartholin's gland is a rare variant and around 90 cases have been reported. Herein, the authors re port a locally advanced ACC of Bartholin's gland that was treated with neoadjuvant chemotherapy followed by right radical hemi-vulvectomy and reconstruction with a gracilis musculocutanous flap. There was no evidence of recurrence after three years of follow up.

Vitamin D and cardiometabolic risk factors and diseases

Obesity, type 2 diabetes, and cardiovascular disease (CVD) are the most common preventable causes of morbidity and mortality worldwide. Insulin resistance, which is a shared feature in these conditions, is also strongly linked to the development of polycystic ovary syndrome (PCOS), which is the most common endocrine disease in women of reproductive age and a major cause of infertility. Vitamin D deficiency has reached epidemic proportions worldwide, primarily due to the shift to sedentary, indoor lifestyles and sun avoidance behaviours to protect against skin cancer. In recent years, vitamin D deficiency has been implicated in the aetiology of type 2 diabetes, PCOS and CVD, and has been shown to be associated with their risk factors including obesity, insulin resistance, hypertension, as well as chronic low-grade inflammation. Treating vitamin D deficiency may offer a feasible and cost-effective means of reducing cardiometabolic risk factors at a population level in order to prevent the development of type 2 diabetes and CVD. However, not all intervention studies show that vitamin D supplementation alleviates these risk factors. Importantly, there is significant heterogeneity in existing studies with regards to doses and drug regimens used, populations studied (i.e. vitamin D deficient or sufficient), and the lengths of supplementation, and only few studies have directly examined the effect of vitamin D on insulin secretion and resistance with the use of clamp methods. Therefore, there is a need for well-designed large scale trials to clarify the role of vitamin D supplementation in the prevention of type 2 diabetes, PCOS, and CVD.

The Effect of Silane Treated Hybrid Filler on the Mechanical and Thermal Performance of Carboxylated Nitrile Butadiene Rubber (XNBR) Composites

Carboxylated Nitrile Butadiene Rubber (XNBR) was reinforced with untreated and silane treated hybrid filler. The hybrid filler was composed of organic layered nanosilicates (NLS) and agro polymer based olive husk powder (OHP). The fabricated composites were inspected with regard to their mechanical and thermal properties. It was found that the silane treated hybrid filler was able to improve the tensile strength at break and the tensile modulus as compared to the control. The overall degree of interaction between the matrix and both the untreated and treated hybrid filler was improved. This was evidenced by the increased degree of curing which is the torque difference (τmax–τmin) derived from the moving die rheometer (MDR) and the decreased swelling index data. Dynamic mechanical analysis (DMA) revealed that the apparent was the highest in case of the silane treated hybrid filler. The thermogravimetric analysis (TGA) revealed that the thermal stability of the composites improved with the incorporation of the hybrid filler. The attenuated total reflectance (ATR-IR) revealed that dipole-dipole interactions between the various reactive functional groups namely the carboxylic of the XNBR, the hydroxyl group of the agro-polymer and the silanol of the silane agent occurred during the fabrication stage of the composites. Scanning electron microscopy (SEM) showed that the fracture surface of the samples differ after the incorporation of the treated hybrid filler.

Sociodemographic characteristics associated with blindness in a Nile Delta governorate of Egypt

BACKGROUND

Globally, blindness is associated with old age and being female. Other sociodemographic and socioeconomic status characteristics associated with blindness have included educational attainment, and occupation. These factors reflect exposure to specific risk factors for blinding eye diseases and utilisation of preventive and curative services by specific sectors of the population.

METHODS

A population based survey of blindness and trachoma was conducted in Menofiya governorate in Egypt. 3322 adults 50 years of age and over were sampled from throughout the governorate (population 2.7 million). Visual acuity and clinical conditions were recorded and interviews with respondents were conducted.

RESULTS

Overall, blindness (<6/60 presenting vision in the better eye) was recorded in 13% of the study population. Besides age and sex, other factors associated with blindness (logistic regression) were marital status and poor sanitation in the household.

CONCLUSION

Socioeconomic status does not appear to be a significant factor associated with blindness in adults in this setting. Instead, sociocultural factors, in particular, characteristics associated with gender sensitive decision making within households, are likely to be more important considerations in understanding blindness in these communities. Successfully combating blindness in the Nile Delta of Egypt will require gender sensitive efforts aimed at timely and effective utilisation of eye care services.

Choline deficiency induced by Mycoplasma fermentans enhances apoptosis of rat astrocytes

A choline uptake system accumulating free choline in an energy-dependent process is described in Mycoplasma fermentans. The uptake system has a K(m) of 2.2x10(-5) M and a V(max) of 0.15 nmol 10 min(-1) mg(-1) cell protein and the choline incorporated could be recovered in the soluble fraction as free choline, phosphorylcholine and CDP-choline. Choline accumulation by M. fermentans resulted in a marked choline depletion of the growth medium. The choline depletion of an astrocyte cell culture induced by M. fermentans was associated with the apoptotic death of the cells. Apoptosis was not obtained with heat-inactivated mycoplasmas and could be reversed by the addition of free choline to the growth medium.

RANTES promotes growth and survival of human first-trimester forebrain astrocytes

We have examined the role of alpha and beta chemokines in the promotion of the ontogenetic development of the brain. RANTES was expressed preferentially in human fetal astrocytes in an age-dependent manner. Astrocytes from 5-week-old brains showed high proliferation and reduced survival, whereas 10-week-old astrocytes exhibited opposite effects. These effects were suppressed by anti-RANTES or anti-RANTES receptor antibodies and were enhanced by recombinant RANTES. RANTES induced tyrosine phosphorylation of several cellular proteins and nuclear translocation of STAT-1 in astrocytes. Interferon-gamma (IFN-gamma) was required for RANTES effects because RANTES induced IFN-gamma and only 10-week-old astrocytes expressed the IFN-gamma receptor. Blocking of IFN-gamma with antibody reversed the effects of RANTES, indicating that cytokine/chemokine networks are critically involved in brain development.

Human first trimester forebrain cells express genes for inflammatory and anti-inflammatory cytokines

Using in situ hybridization and immunohistochemistry the induction of potential cytokines [interleukin 1beta (IL-1beta), IL-4, IL-6, IL-10, tumour necrosis factor alpha (TNF-alpha), interferon gamma (IFN-gamma) and transforming growth factor beta (TGF-beta)] in human embryonic forebrain cells at weeks 5, 7 and 10 of gestation was studied. The aims were to investigate the capacity of these cells to express cytokines, to determine the kinetics of induction and to display the type of cytokine expressing cells in the developing brain. Constitutive cytokine gene expression was recorded from week 5, augmented by about 50% at week 7 and by more than 100% at week 19 (except TGF-beta at week 10). Among other cytokines, IL-1beta exhibited the highest expression at week 10. TGF-beta showed maximum expression at week 7 and declined at week 10. Combined techniques revealed that glial cells are a major source of cytokines. The study show and present for the first time the kinetics of spontaneous cytokine expression in human embryonic forebrain cells. The increased mRNA expressions with age suggest an important role for cytokines in promotion of brain development. The capacity of inducing these cytokines may, however, be implicated in the immunopathogenesis of several brain diseases. The distinctive TGF-beta profile suggests a further role for TGF-beta on modulation of cytokine responses during development.

Tyrosine kinases are required for IFN-gamma-induced growth of human embryonic forebrain astrocytes

The cytokine IFN-gamma was shown to regulate growth and differentiation of human embryonic forebrain astrocytes. This work investigated a signalling pathway used by IFN-gamma during the process of growth regulation of human fetal astrocytes obtained from first trimester embryos. IFN-gamma induced significantly higher cell survival compared to that of unexposed cultures, and this survival could be suppressed by incubation with the tyrosine protein kinase (TPK) specific inhibitor tyrphostin A47 at the non-toxic concentration of 10(-6) M. The signal transducer and activator of transcription (STAT)-1 was translocated into the nucleus upon IFN-gamma stimulation, which was also blocked by incubation with A47. Our data demonstrate that TPKs are actively involved in growth regulation of the developing brain astrocytes induced by IFN-gamma.

Induction of beta-family chemokines mRNA in human embryonic astrocytes by inflammatory cytokines and measles virus protein

The cellular infiltration found during CNS inflammation consists of monocytes and activated T cells, suggesting the presence of cell-specific chemotactic signals during inflammatory responses. Astrocyte chemokine expression might contribute to site-specific leukocyte infiltration within the CNS. To investigate the factors that regulate astrocyte chemokine expression, we examined the ability of human fetal astrocytes to induce beta-family chemokine mRNA. Astrocyte-derived monocyte chemoattractant protein-1 (MCP-1), RANTES, macrophage inflammatory protein-1alpha (MIP-1alpha), and MIP-1beta mRNA were easily induced by lipopolysaccharide and/or the proinflammatory cytokines (IFN-gamma and/or TNF-alpha), respectively. Addition of both IFN-gamma and TNF-alpha together did not lead to an additive effect but resulted in the inhibition of MCP-1 and MIP-1beta mRNA expression, indicating that interaction between chemokines and cytokines may play a key role in regulating the local immune response of resident and infiltrating cells at the site of lesion. Interestingly, ultraviolet light-inactivated measles virus, but not cytomegalovirus, strongly induced expression of MCP-1, RANTES, MIP-1alpha, and MIP-1beta mRNA in human embryonic astrocytes, especially MCP-1 and MIP-1beta. An association occurs between the beta-family chemokine expression in astrocytes and inflammatory factors/virus, suggesting a possible role for beta-family chemokines in the pathogenesis of CNS inflammatory disease.

Interactions between human embryonic forebrain cells and the cytokines interferon-gamma and interleukin-4

In the present study we investigated the capacity of human first trimester forebrain cells at different gestational ages to produce IFN-gamma and IL-4. We also studied the effects of IFN-gamma on their proliferation, survival and expression of MHC antigens. IFN-gamma but not IL-4 was spontaneously produced after 24 h cultures. Furthermore, IFN-gamma exhibited anti-proliferative effects and induced MHC expression on these cells. However, the IFN-gamma exposed cultures showed significantly higher cell survival compared to un-exposed cultures. Co-culture with IL-4 blocked the IFN-gamma production and reversed its anti-proliferative effects. These interactions suggest important roles for cytokines in the survival, proliferation and differentiation of human embryonic and fetal forebrain cells.

Tinea versicolor: histologic and ultrastructural investigation of pigmentary changes

A comparative histopathologic study is made between the hypopigmented and hyperpigmented skin lesions of pityriasis versicolor and normal skin areas utilizing histochemical stains and electron microscopy. There were no differences found between the population of Dopa-positive melanocytes within the hypopigmented and hyperpigmented lesions and the normal skin areas. The total epidermal pigmentation was diminished in hypopigmented lesions. The keratin layer was found to be significantly thicker in hyperpigmented lesions and contained more organisms. In hypopigmented lesions, melanocytes contained fewer and smaller melanosomes and exhibited signs of degenerative cellular changes.

Tinea versicolor: ultrastructural studies on hypopigmented and hyperpigmented skin

Punch biopsy specimens from 4 patients with confirmed diagnosis of tinea versicolor were investigated. Hypopigmented, hyperpigmented and uninvolved sites from the same subject were compared in relation to ultrastructural alterations as a result of infection with Malassezia furfur, by light, scanning, and transmission electron microscopy. Hyperpigmented skin had thicker stratum corneum than hypopigmented but both were thicker than the uninvolved skin. A large number of tonofilaments were noticed in hyperpigmented sites in stratum granulosum. In hypopigmented skin the melanosomes were individually dispersed and fewer in number than the uninvolved skin. In hyperpigmented skin, the melanosomes were sequestered in most cells suggesting difficulty in the transfer of melanosome granules to keratinocytes. In both cases of pigmentation the most readily affected parts of the cells were cytoplasmic organelles with a latent effect on the nucleus and nucleolus. We postulate that either stage of pigmentation (hyperpigmentation or hypopigmentation) is a intermediary in nature as a result of M. furfur invasion.

Incidence of dermatophytosis in Kuwait

Dermatophytosis in Kuwait was found to be associated with poor, over-crowded socioeconomic localities. This infection occurred in all age groups, but patients below 10 years of age were most susceptible. Tinea capitis was observed in 71.1% of 135 patients with dermatophytosis, with a higher incidence (48.2%) in males than in females. Microsporum canis caused 60.7% of all cases of dermatophytosis and 76% of tinea capitis. A high rate of failure to culture from microscopically positive specimens was observed in tinea cruris and onychomycosis.