Cardiovascular collapse and McConnell's sign as early manifestations of leucostasis

A man in his late 70s with chronic myelomonocytic leukaemia presented for evaluation of acute leukaemic transformation and initiation of cytoreductive therapy after being found to have asymptomatic hyperleucocytosis. Within 24 hours, the patient developed vasopressor-refractory shock, severe lactic acidosis and multiorgan failure. Serial echocardiographic assessments revealed interval enlargement of the right ventricle with development of the McConnell's sign, and abdominal CT showed diffuse bowel wall thickening, likely due to ischaemia. CT angiography excluded pulmonary embolism or occlusion of intra-abdominal arteries. Despite aggressive care, the patient died from cardiovascular collapse within 8 hours of the onset of hypotension. An autopsy revealed extensive infiltration of early myeloid cells in pulmonary, myocardial, hepatic and intestinal microvasculature. This case illustrates different mechanisms by which leucostasis causes acute cardiovascular collapse and stresses the emergent nature of this diagnosis.

Skin biopsy in the diagnosis of intravascular lymphoma: A retrospective diagnostic accuracy study

BACKGROUND

The yield of skin biopsies in the evaluation of intravascular lymphoma (IVL) is largely unknown in Western patients. Most data supporting this test come from Asian populations, in which both prevalence and disease presentation seem to differ.

OBJECTIVE

To determine the yield and diagnostic properties of skin biopsy in the evaluation of IVL.

METHODS

We reviewed skin biopsy pathology reports of 50 patients being evaluated for IVL to calculate the diagnostic yield of this test. An additional 6 patients, who underwent skin biopsies after the diagnosis of IVL was made by other means, were included to calculate the sensitivity and specificity of our index test.

RESULTS

Skin biopsy samples were positive for 5 of the 50 patients being investigated for IVL. Sensitivity was 50% and specificity was 100%.

LIMITATIONS

Only pathology reports containing IVL as an indication for the biopsy were retrieved. This might have excluded patients in whom the disease was considered but was not deemed likely enough to be listed as the indication for the test, inflating our estimative of skin biopsy yield.

CONCLUSION

A relatively high diagnostic yield was found in the evaluation of IVL among patients with a diverse presentation in a Western hospital.

Personalized Prediction of Hospital Mortality in COVID-19-Positive Patients

Objective

To develop predictive models for in-hospital mortality and length of stay (LOS) for coronavirus disease 2019 (COVID-19)–positive patients.

Patients and Methods

We performed a multicenter retrospective cohort study of hospitalized COVID-19–positive patients. A total of 764 patients admitted to 14 different hospitals within the Cleveland Clinic from March 9, 2020, to May 20, 2020, who had reverse transcriptase-polymerase chain reaction–proven coronavirus infection were included. We used LightGBM, a machine learning algorithm, to predict in-hospital mortality at different time points (after 7, 14, and 30 days of hospitalization) and in-hospital LOS. Our final cohort was composed of 764 patients admitted to 14 different hospitals within our system.

Results

The median LOS was 5 (range, 1-44) days for patients admitted to the regular nursing floor and 10 (range, 1-38) days for patients admitted to the intensive care unit. Patients who died during hospitalization were older, initially admitted to the intensive care unit, and more likely to be white and have worse organ dysfunction compared with patients who survived their hospitalization. Using the 10 most important variables only, the final model’s area under the receiver operating characteristics curve was 0.86 for 7-day, 0.88 for 14-day, and 0.85 for 30-day mortality in the validation cohort.

Conclusion

We developed a decision tool that can provide explainable and patient-specific prediction of in-hospital mortality and LOS for COVID-19–positive patients. The model can aid health care systems in bed allocation and distribution of vital resources.

Factors associated with the development of Congenital Zika Syndrome: a case-control study

BACKGROUND

We aim to investigate possible maternal- and pregnancy-related factors associated with the development of Congenital Zika Syndrome (CZS) in children of mothers with probable gestational infection.

METHODS

This case-control study, we recruited mother-infant pairs between May 2015 and October 2017 in a pediatric infectious disease clinic in Rio de Janeiro. Inclusion criteria required either that the mother reported Zika infection symptoms during pregnancy or that the infant presented with clinical or imaging features of the CZS. Exclusion criteria included detection of an alternative cause for the patient's presentation or negative polymerase chain reaction assays for Zika in all specimens tested within 12 days from the beginning of maternal symptoms. Infants with CZS (CDC definition) were selected as cases and infants without CZS, but with probable maternal Zika virus infection during pregnancy, were selected as controls. Maternal and pregnancy-related informations were collected and their relationship to the presence of congenital anomalies due to CZS was assessed by Fisher exact or Mann-Whitney test.

RESULTS

Out of the 42 included neonates, 24 (57.1%) were diagnosed with CZS (cases). The mean maternal age at the birth was 21 years old. The early occurrence of maternal symptoms during pregnancy was the only variable associated with CZS (odds ratio = 0.87, 95% CI: 0.78-0.97). Case's mothers presented symptoms until the 25th week of gestational age (GA), while control's mothers presented until 36th weeks of GA. Income; illicit drug, alcohol, or tobacco use during pregnancy; other infections during pregnancy (including previous dengue infection) were not associated with CZS.

CONCLUSIONS

Our study corroborates the hypothesis that Zika virus infection earlier in pregnancy is a risk factor to the occurrence of congenital anomalies in their fetuses.

Primary lymphoplasmacytoma of the conjunctiva

We report the case of an 80-year-old patient with isolated lymphoplasmacytoma of the conjunctiva. Only five other such cases have been previously reported in the literature. In all six patients, the disease remained limited and no sign of systemic disease could be found after prolonged follow-up. As isolated plasmacytoma of the conjunctiva seems to be benign, treatment of such tumours should be conservative.

Chemical burns of the eye with special reference to alkali burns

Alkali burns of the eye are more severe than acid burns because of the rapid penetration through the cornea and anterior chamber, combining with cell membrane lipids, thereby resulting in disruption of the cells and stromal mucopolysaccharides with concomitant tissue softening. Effective emergency measures must be instituted immediately followed by careful clinical evaluation in order to recognize and treat problems as they arise. We present our experience with 27 patients who sustained corneal lime burns, two of which are discussed in detail. The problem of chemical burns of the eye is reviewed with special emphasis on alkali burns.