AB1075 KNEE ARTHRITIS BY PARACOCCIDIOIDES BRASILIENSIS IN A LONG-STANDING RHEUMATOID ARTHRITIS PATIENT

Background

Arthritis by Paracoccidioides brasiliensis is a remarkably unusual etiology of infectious joint disease. While osseous lesions can be present in systemic disease, intra-articular-restricted disease without typical lung or lymph node involvement is mostly anecdotal1,2.

Objectives

We hereby describe a case of this fungal arthritis in a patient with rheumatoid arthritis (RA) without significant immunosuppression.

Methods

Patient records review. Written informed consent was obtained.

Results

A 65-year-old female Brazilian patient with a 35-year history of seropositive RA complained of a painful knee edema for the last three weeks. Skin surrounding the joint was erythematous, warm, and tender to the touch, which initially raised the suspicion of cellulitis. She had already received a 10-day course of amoxicillin-clavulanate, with no improvement. C-reactive protein was 17.8 mg/L, rest of blood chemistry panel was within reference range. Point-of-care ultrasound revealed joint effusion, and a diagnostic arthrocentesis was performed. Synovial fluid was slightly turbid, with 10,100 cells per mm3, of which 80% were lymphocytes. Cultures for bacteria and mycobacteria yielded negative results, but culture for fungi detected growth of P. brasiliensis. The patient had been solely on prednisone 5 mg once daily for the last year, given that, due to covid-19 pandemics, she lost regular follow-up and abandoned treatment with immunosuppressants. Aside from mild RA-related interstitial lung disease, she had no other comorbidity. She denied local trauma to the knee, which made hematogenous dissemination of the fungi the most probable source. Comprehensive work-up to search for organic involvement of paracoccidioidomycosis, including chest computed tomography and transthoracic echocardiogram, did not evidence any visceral compromise. Voriconazole 200mg t.i.d. was started, with good response. Three months after the beginning of the azole, tofacitinib was started for moderate RA disease activity, which also responded satisfactorily. Repeat arthrocentesis and synovial biopsy were performed eight months after the start of antifungal treatment, the former being normal (770 cells per mm3, negative cultures), and the later only demonstrating non-specific chronic synovitis with fibrosis.

Conclusion

We reported an exceedingly rare presentation of P. brasiliensis infection with exclusive joint involvement.

References

[1]Silvestre MTA, Ferreira MS, Borges AS, et al. Monoartrite de joelho como manifestação isolada de paracoccidiodomicose. Rev. Soc. Bras. Med. Trop. 1997 Oct, 30(5): 393-5. doi: 10.1590/S0037-86821997000500008

[2]Bonilla-Abadía F, Vélez JD, Zárate-Correa LC, et al. Overinfection by Paracoccidioides brasiliensis in Gouty Crystal Arthritis. Case Rep Med. 2012;2012:128103. doi:10.1155/2012/128103

Disclosure of Interests

None declared

Assessing air pollution in European cities to support a citizen centered approach to air quality management

European cities have made significant progress over the last decades towards clean air. Despite this progress, several cities are still facing acute air pollution episodes, with various urban areas frequently exceeding air quality levels allowed by the European legal standards and WHO guidelines. In this paper, six European cities/ regions (Bristol, UK; Amsterdam, NL; Sosnowiec, PL; Ljubljana, SI; Aveiro, PT; Liguria, IT) are studied in terms of air quality, namely particulate matter, nitrogen dioxide and ozone. The concentrations trends from 2008 to 2017 in the different typology of monitoring stations are addressed, together with the knowledge of daily, weekly and seasonal pollution patterns to better understand the city specific profiles and to characterize pollutant dynamics and variations in multiple locations. Additionally, an analysis of the duration and severity of air pollution episodes is also discussed, followed by an analysis of the fulfillment of the legislated limit values. Each of our 6 case study locations face different air pollution problems, but all these case studies have made some progress in reducing ambient concentrations. In Bristol, there have been strong downward trends in many air pollutants, but the levels of NO₂ remain persistently high and of concern. In recent years, decreasing concentration levels point to some success of Amsterdam air quality policies. PM₁₀ exceedances are a seasonal pollution problem in Ljubljana, Sosnowiec and Aveiro region (even if with different levels of severity). While, exceedances of NO₂ and O₃ concentrations are still problematic in Liguria region. The main findings of this paper are particular relevant to define and compare future citizen-led strategies and policy initiatives that may be implemented to improve and fulfill the EU legislation and the WHO guidelines.

How important are maritime emissions for the air quality: At European and national scale

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Safety and Efficacy of a Dapivirine Vaginal Ring for HIV Prevention in Women

BACKGROUND

The incidence of human immunodeficiency virus (HIV) infection remains high among women in sub-Saharan Africa. We evaluated the safety and efficacy of extended use of a vaginal ring containing dapivirine for the prevention of HIV infection in 1959 healthy, sexually active women, 18 to 45 years of age, from seven communities in South Africa and Uganda.

METHODS

In this randomized, double-blind, placebo-controlled, phase 3 trial, we randomly assigned participants in a 2:1 ratio to receive vaginal rings containing either 25 mg of dapivirine or placebo. Participants inserted the rings themselves every 4 weeks for up to 24 months. The primary efficacy end point was the rate of HIV type 1 (HIV-1) seroconversion.

RESULTS

A total of 77 participants in the dapivirine group underwent HIV-1 seroconversion during 1888 person-years of follow-up (4.1 seroconversions per 100 person-years), as compared with 56 in the placebo group who underwent HIV-1 seroconversion during 917 person-years of follow-up (6.1 seroconversions per 100 person-years). The incidence of HIV-1 infection was 31% lower in the dapivirine group than in the placebo group (hazard ratio, 0.69; 95% confidence interval [CI], 0.49 to 0.99; P=0.04). There was no significant difference in efficacy of the dapivirine ring among women older than 21 years of age (hazard ratio for infection, 0.63; 95% CI, 0.41 to 0.97) and those 21 years of age or younger (hazard ratio, 0.85; 95% CI, 0.45 to 1.60; P=0.43 for treatment-by-age interaction). Among participants with HIV-1 infection, nonnucleoside reverse-transcriptase inhibitor resistance mutations were detected in 14 of 77 participants in the dapivirine group (18.2%) and in 9 of 56 (16.1%) in the placebo group. Serious adverse events occurred more often in the dapivirine group (in 38 participants [2.9%]) than in the placebo group (in 6 [0.9%]). However, no clear pattern was identified.

CONCLUSIONS

Among women in sub-Saharan Africa, the dapivirine ring was not associated with any safety concerns and was associated with a rate of acquisition of HIV-1 infection that was lower than the rate with placebo. (Funded by the International Partnership for Microbicides; ClinicalTrials.gov number, NCT01539226 .).

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There has been strong evidence in recent years that oxygen free radicals may play an important role in the pathophysiology of schizophrenia and bipolar disorder. More recent evidence of altered antioxidant defenses in major mental illnesses has been accumulating. Much of the focus on antioxidant defense mechanism has been on the key scavenging antioxidant enzymes: Superoxide dismutase (SOD), Catalase (CAT) and Glutathione peroxidase (GSH-Px). Of these, SOD activity has been the most frequently examined.

The imbalance between antioxidant and oxidant mechanisms increases what is called oxidative stress, when the oxygen free species react and could damage lipids, proteins, carbohydrates and DNA. Lipids are the main compound of cellular membrane and the oxygen free radicals reaction to them is called lipid peroxidation. Several plasma lipid peroxides, like MDA, are measured by Thiobarbituric acid reactive substances (TBARS). Increased levels of TBARS have been reported in the plasma of drug-free and medicated bipolar disorder and schizophrenic patients. It is hypothesized that psychotic symptoms seen in both disorders might be a consequence of peroxidative injury to membrane phospholipids. Moreover, neuronal functioning is affected by this injury either by changes in membrane fluidity or by alterations in membrane receptors, which can cause neurotransmitter uptake and release impairment and even cell death.

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Three thousand four hundred and four adults were randomly examined and 38 cases of extensor digitorum brevis manus were identified. This short, anomalous muscle located on the dorsum of the hand occurred in 1.1% of the people examined and 19 of the 38 cases required surgery because of pain precluding work. This report reviews the literature and describes the clinical picture of the 38 cases.

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Compression of nerves of the hand by hyperplasia of pacinian corpuscles is a rare occurrence. Six cases with previous history of trauma in the hand in four of them have been reported in the literature. We present two cases of nerve compression of the two varieties reported, both with previous histories of trauma. In these two cases, surgical excision of the tumor determined the disappearance of clinical symptoms.

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