Outcomes of Tyrosine Kinase Inhibitors Maintenance Therapy with or without Allogeneic Hematopoietic Stem Cell Transplantation in Philadelphia Chromosome Positive Acute Lymphoblastic Leukemia in First Complete Remission: A Systematic Review and Meta-Analysis

We conducted a systematic review and meta-analysis to compare outcomes of tyrosine kinase inhibitor (TKI) maintenance therapy with or without allogeneic hematopoietic stem cell transplantation (HSCT) in Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) in first remission (CR1). A literature search was performed on PubMed, Cochrane, and Clinical trials.gov. After screening 1720 articles, 12 studies were included. Proportions and odds ratios (OR) with 95% confidence intervals (CI) were computed. I² provides an estimate of the percentage of variability in results across studies that is due to real differences and not due to chance. Of 1039 patients, 635 (61%) had TKI alone and 404 (39%) patients had HSCT followed by TKI. At 3 years, a trend towards poor overall survival (OS; OR 0.67, 95% CI 0.39-1.15, I² = 68%), (disease-free survival; OR 0.58, 95% CI 0.26-1.29, I² = 76%), and higher relapse rate (RR; OR = 2.52, 95% CI = 1.66-3.83, I² = 26%) was seen with TKI alone compared to HSCT-TKI. Although HSCT followed by TKI maintenance in Ph+ ALL has long been considered standard of care, the introduction of potent third-generation TKIs and bispecific T-cell engagers such as Blinatumomab has significantly improved outcomes while sparing the need for HSCT in newly diagnosed patients.

Mitochondrial neurogastrointestinal encephalomyopathy in a Pakistani female: a case report

Background

Mitochondrial neurogastrointestinal encephalopathy is a rare multisystem autosomal recessive disease caused by mutations in the TYMP gene, that encodes for thymidine phosphorylase. Mitochondrial neurogastrointestinal encephalopathy is a progressive degenerative disease characterized by a distinctive tetrad of gastrointestinal dysmotility, peripheral neuropathy, ophthalmoplegia with ptosis, and asymptomatic leukoencephalopathy. It provides a diagnostic dilemma to physicians in regions like Pakistan because of a lack of genetic study availability and associated financial constraints of the population. However, with careful examination and a few basic investigations, mitochondrial neurogastrointestinal encephalopathy can be diagnosed by ruling out most of the close differentials.

Case presentation

We report the case of a 23-year-old Asian female whose chief complaints were epigastric pain, bilious emesis, weight loss for 3 months, and bilateral lower limb weakness for 20 days. All clinical signs and symptoms along with relevant investigations including nerve conduction studies, electromyography, and magnetic resonance imaging of the brain were highly suggestive of mitochondrial neurogastrointestinal encephalopathy syndrome. Because of financial constraints, genetic studies could not be performed. The patient was managed with a multidisciplinary approach involving gastroenterology, physiotherapy, and nutrition departments. Currently, therapeutic options for the disease include allogeneic hematopoietic stem cell transplant and carrier erythrocyte entrapped thymidine phosphorylase; however, these could not be provided to the patient owing to certain limitations.

Conclusions

As misdiagnosis and delayed diagnosis are quite common in this disease, the prime objective of this case report is to increase the basic understanding of this disease, especially its signs and symptoms, and address the limitations regarding the diagnostic investigations and management of patients with mitochondrial neurogastrointestinal encephalopathy.

A Remarkable Case of Acute Motor-Sensory Axonal Polyneuropathy (AMSAN) Variant of Guillain Barré Syndrome, in a Diabetic Patient Infected With COVID-19: A Case Report and Review of the Literature

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease- 2019 (COVID-19), has been a global epidemic in our healthcare system. SARS-CoV-2 primarily affects the respiratory system, but neurological involvement has also been reported, including Guillain–Barré syndrome (GBS) development.

Case Presentation

A 58-year-old male with known co-morbid hypertension and type 2 diabetes mellitus presented to the emergency room with complaints of worsening shortness of breath, dry cough, and fever for the past 10 days. On day 20 of hospitalization, he developed neurological symptoms after being tested positive for COVID-19. A neuroelectrophysiology study was conducted to evaluate neurological symptoms and suggested that the patient suffers from acute motor-sensory axonal polyneuropathy (AMSAN). CSF analysis showed elevated protein levels that confirmed the diagnosis of GBS. He was subsequently treated with oral prednisolone and IVIG, which improved neurological symptoms.

Conclusion

Ever since the emergence of COVID-19, GBS has surfaced as to its potentially dangerous outcome. Healthcare professionals should be mindful of GBS and should rule it out in anyone having sensory symptoms or weakness during or after a COVID-19 infection. Its early detection and treatment can result in improved clinical outcomes.

A Case Report on Neuroleptic Malignant Syndrome (NMS): How to Approach an Early Diagnosis

Neuroleptic malignant syndrome (NMS) is a life-threatening neurological emergency that has been observed to occur in some patients following the administration of anti-dopaminergic agents or the rapid withdrawal of dopaminergic medications.

In this report, the authors present a case of a 51-year-old male patient with a known history of cocaine abuse, who was given quetiapine during his hospitalization. This precipitated an episode of NMS that eventually concluded uneventfully due to quick diagnosis and management. Prompt recognition of the condition is required to reduce significant morbidity and mortality. Ultimately, maintaining vigilance for the clinical features of NMS is crucial for timely diagnosis and intervention.

A Misdiagnosed Case of Schizoaffective Disorder With Bipolar Manifestations

Bipolar and schizoaffective disorders are both psychiatric illnesses that share common traits, but also significant differences. Due to the close overlap in symptoms, obtaining the correct diagnosis can be difficult. The management of these patients often poses a challenge to clinicians.

Five years ago, our patient was misdiagnosed with bipolar disorder with psychotic features. It was later discovered that she was suffering from schizoaffective disorder, bipolar type. The schizoaffective disorder involves symptoms of both schizophrenia and mood disorder.

Navigating a Curious Case of Unilateral Keratouveitis in Pakistan

Keratouveitis is a rare but potentially dangerous condition of the eye that requires prompt management otherwise it may result in severe visual impairment. We report a challenging case of unilateral keratouveitis.

A 40-year-old man presented with right eye erythema, epiphora, decreased vision, and severe pain from one month after failure to antibiotics treatment. Slit-lamp examination showed circumcorneal injection of conjunctiva, a central corneal ulcer, hypopyon and cells in the anterior chamber (AC). The culture and sensitivity of ocular tissue showed no growth of organisms. Intravitreal antibiotics (vancomycin and ceftazidime) along with anterior chamber tap led to resolution of the inflammation. The corneal ulcer was markedly reduced and vision was improved.

This case emphasizes two important points. First, how to approach a case of keratouveitis of uncertain etiology, in a less resourceful situation. Second, how to treat unilateral keratouveitis with intravitreal antibiotics and anterior chamber/vitreous tap. 

COVID-19 and the male susceptibility: the role of ACE2, TMPRSS2 and the androgen receptor

COVID-19 is the pandemic that hit the world starting December 2019. Recent studies and international statistics have shown an increased prevalence, morbidity as well as mortality of this disease in male patients compared to female patients. The aim of this brief communication is to describe the pathophysiology of this sex-discrepancy, based on the infectivity mechanism of the coronavirus including the Angiotensin-Converting Enzyme 2 (ACE2), the Type II transmembrane Serine Protease (TMPRSS2), and the androgen receptor. This could help understand the susceptibility of urological patients, especially those receiving androgen deprivation therapy for prostate cancer, and testosterone replacement therapy.

The role of asymptomatic screening in the detection of recurrent ovarian cancer

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The pelvic exam was a useful tool in the detection of ovarian recurrence.

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CA-125 use was not associated with better survival or rate of secondary cytoreductive surgery.

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Providers should carefully consider modalities for asymptomatic ovarian recurrence monitoring.

Objective

To investigate the utility of asymptomatic screening, including CA-125, imaging, and pelvic exam, in the diagnosis and management of recurrent ovarian cancer.

Methods

Women with ovarian cancer whose cancer recurred after remission were categorized by first method that their provider suspected disease recurrence: CA-125, imaging, symptoms, or physical exam. Differences in clinicopathologic, primary treatment characteristics, and outcomes data including secondary cytoreductive surgery (SCS) outcome and overall survival (OS) were collected.

Results

102 patients were identified at our institution from 2003 to 2015. 20 recurrences were detected by symptoms, while 62 recurrences were diagnosed first by asymptomatic rise in CA-125, 5 by pelvic exam, and 15 by imaging in the absence of known exam abnormality or rise in CA-125.

Mean time to recurrence was 18.9 months, and median survival was 45.8 months. These did not vary by recurrence detection method (all p > 0.4). Patients whose disease was detected by CA-125 were less likely to undergo SCS than those detected by other means (21.7% vs. 35.0%, p = 0.007). In addition to the 5 patients whose recurrence was detected primarily by pelvic exam, an additional 10 (total n = 15) patients had an abnormal pelvic exam at time of diagnosis of recurrence.

Discussion

Recurrence detection method was not associated with differing rates of survival or optimal SCS, however those patients detected by CA-125 were less likely to undergo SCS. The pelvic exam was a useful tool for detecting a significant proportion of recurrences.

Seroprevalence of peste des petits ruminants and bluetongue in goat population of Meghalaya, India

Aim:

This study aimed to determine the seroprevalence of peste des petits ruminants (PPR) and bluetongue (BT) in goats’ population in the state of Meghalaya of Northeast India.

Materials and Methods:

The serosurveillance study was done from the random sampling (n=598) of blood collected from five districts (Ri-Bhoi, East Khasi Hills, West Khasi Hills, Jaintia Hills and West Garo Hills) of Meghalaya. The presence of antibodies against PPR and BT in the samples was detected by indirect enzyme-linked immunosorbent assay (ELISA) method for PPR and competitive ELISA for BT.

Results:

The results showed the overall seropositivity of PPR and BT at 7.19% and 60.20%, respectively. West Garo Hills recorded the highest seroprevalence of both PPR (9.81%) and BT (68%) and 3.6% of the samples tested positive for both PPR and BT.

Conclusion:

The random survey results indicating the presence of PPR and BT have specific implication in epidemiological perspectives since it highlights the prevalence under natural situations, where the subclinical, inapparent, or non-lethal or recovery of infection was suspected in unvaccinated animals. It also warrants further studies to suggest appropriate control measures to prevent the spread of infection.

Detection of classical swine fever virus E2 gene in cattle serum samples from cattle herds of Meghalaya

The present study focused on the detection and genetic characterisation of 5' untranslated region (5'UTR) and E2 gene of classical swine fever virus (CSFV, family Flaviviridae, genus Pestivirus) from bovine population of the northeastern region of India. A total of 134 cattle serum samples were collected from organised cattle farms and were screened for CSFV antigen with a commercial antigen capture enzyme linked immunosorbent assay (Ag-ELISA) and reverse transcription-polymerase chain reaction (RT-PCR). A total of 10 samples were positive for CSFV antigen by ELISA, while all of them were positive in PCR for 5'UTR region. Full length E2 region of CSFV were successfully amplified from two positive samples and used for subsequent phylogenetic analysis and determination of protein 3D structure which showed similarity with reported CSFV isolate from Assam of sub-genogroup 2.1, with minor variations in protein structure.

Solvent Effect on the Electronic Polarizability of Benzonitrile

In this study, the static and dynamic electronic polarizability of benzonitrile is reported. This property was determined using refraction index measurements of neat benzonitrile and CCl4, THF, C6H12 and CH3CN diluted solutions. The real refractive index of pure benzonitrile was obtained by refractometry, FTIR transmission spectroscopy and Kramers-Kr¨onig transform. These results indicate that the vibrational contribution to the visible refraction is very small, and the electronic polarizabilities calculated with these values agree with reported values. In binary mixtures, the polarizability of benzonitrile was obtained with the refractometric method proposed by Singer and Garito at five frequencies to obtain the dispersion curve. The local field effects were tested within the Onsager and Lorentz local field approach. The static properties in each solvent was obtained by extrapolation of the Cauchy-type dispersion curve to zero frequency, which gave a monotonic increased as a function of the squared frequency. The polarizabilities obtained in this work agree well with theoretical and experimental data, reported by other authors. The static and dynamic electronic polarizability of benzonitrile was found to be little affected by the dielectric nature of the solvent, and the electric deformability is similar to that of the benzene molecule. The effect of the replacement of the C-H group by N in 4-cyano-pyridine and benzonitrile molecules is discussed.

Influence of residual disease and extreme drug resistance assays on outcome in patients with epithelial ovarian cancer

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Background: Extreme drug resistance (EDR) assays have been used as tools in identifying those agents that are least likely to be of clinical benefit in the treatment of epithelial ovarian cancer (EOC). We sought to examine the effect of obtaining EDR assays on the outcome of patients with EOC in the primary and recurrent setting. Methods: We conducted a retrospective review of demographic, pathologic, EDR assay and outcome data from 377 patients with EOC who had an assay sent at the time of their diagnosis or at recurrence. Univariate followed by multivariate analyses using Cox proportional hazards method were performed to identify and estimate the impact of independent prognostic factors on time to progression (TTP), overall survival (OS) and survival after recurrence (RS). Results: Increasing age was associated with a worse OS and RS (HR = 1.34; 95% CI, 1.14–1.58 and HR = 1.14; 95% CI, 1.00–1.31, for each decade increase in age respectively). Compared with patients with microscopic residual disease, patients who were left with 0.1 to 1.0 cm and >1.0 cm residual disease had an increased risk of recurrence (HR=1.94; 95% CI, 1.33 to 2.84 and HR=3.61; 95% CI; 2.07 to 6.39, respectively) and death (HR = 1.59; 95% CI, 1.03 to 2.45; and HR = 2.14; 95% CI, 1.09 to 4.20, respectively). For patients who recurred, those who did not undergo secondary cytoreductive surgery and patients who were left with >1.0 cm residual had an increased risk of death compared to patients with microscopic residual (HR = 2.13; 95% CI, 1.28 to 3.54; and HR = 2.84; 95% CI, 1.71 to 4.71, respectively). EDR assay results for single agents or combinations did not independently predict patient outcomes. Conclusions: The amount of residual disease continues to be an important prognostic factor, especially when all macroscopic disease is removed both in the primary and recurrent setting. Increasing age is also an independent predictor of OS and RS. EDR assay results do not independently predict or alter the outcomes of patients with EOC who are treated with the current standard of care including optimal cytoreductive surgery followed by platinum and taxane combination chemotherapy in either the primary or recurrent setting.

No significant financial relationships to disclose.

Determinants of outcome in elderly patients with positive sentinel lymph nodes

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Background: Older women are less likely to receive standard of care treatment for breast cancer. This undertreatment may be linked to the perception that elderly patients (pts) may not tolerate or derive benefit from treatment that is often viewed as “too toxic.” Methods: From July 1997 to July 2003, 1,470 pts with invasive cancer with positive sentinel lymph nodes (PSLN) by intraoperative frozen section or final pathologic exam by hematoxylin-eosin and/or immunohistochemistry (IHC). We examined sociodemographic, pathologic, and therapeutic variables that affected the outcome of elderly pts ≥70 years old. A comorbidity score was assigned using Adult Comorbidity Evaluation-27 system. Chi-square, Fisher's exact Wilcoxon tests, and multivariate logistic regression analysis were used. Results: The median age was 53 years (range 21–89) and median tumor size 1.6 cm (range 0.1–11). 1,265 (86.1%) pts were <70 years old and 205 (13.9%) pts were ≥70 years old. 183 (12.5%) pts had IHC only PSLN, 1,021 (69.5%) had 1–3 PSLN, and 266 (18%) ≥4 PSLN. Breast conservation therapy (BCT) was performed in 59.7% of pts. Elderly pts were more likely to have moderate to severe comorbidities (46% vs. 11%, p < 0.0001) and BCT (67% vs. 59%, p = 0.026), compared to pts <70 years old. Elderly pts were less likely to undergo completion ALND (73% vs. 89%, p < 0.0001), adjuvant chemotherapy (43% vs. 90%, p < 0.0001) and radiotherapy following BCT (82% vs. 90%) compared to pts <70 years old. The 5-year disease-free survival (DFS) was not significantly different for elderly pts compared to non-elderly pts (87.7% vs. 91.9%, p = 0.21), on the other hand the 5-year overall survival was significantly worse for elderly pts (80.4% vs. 93.2%, p < 0.0001), a difference that was mainly due to a significantly higher 5-year cumulative incidence of death due to other causes (13.2% vs. 1.9%, p < 0.0001). On multivariate analysis, ER or PR positive status, IHC only PSLN and T1 tumors were the only factors independently associated with improved odds of 5-year DFS. Conclusions: Tumor rather than patient factors were the primary determinants of breast cancer outcomes in our cohort of node positive breast cancer pts. Elderly breast cancer pts with an estimated life expectancy beyond 5 years should receive the same standard of care therapy as their younger counterparts.

No significant financial relationships to disclose.

Adverse effects of pesticides residues on biochemical markers in pakistani tobacco farmers

Tobacco is an important cash crop of Pakistan and tremendous amount of irrational pesticides are being used to control insect growth. The frequency of plasma pesticide residues above acceptable daily intake (ADI) and its correlation with biochemical markers for assessment of adverse health effects in the tobacco farmers at district Sawabi, Pakistan was determined. Total 109 adult males consisting of 55 tobacco farmers exposed to pesticides and 54 controls were included. Pesticides residues in blood were analyzed on HPLC and GC-NPD. Plasma butyrylcholinesterase (BChE) was analyzed by Ellman's method. Biochemical markers including serum calcium, phosphorus, urea, creatinine, bilirubin and liver enzymes were measured on Selectra-E auto analyzer. The tobacco farmers had multiple pesticides residues above ADI in their blood consisting of 35 (63%) methomyl; 31 (56%) thiodicarb; 34(62%) cypermethrin; 27 (49%) Imidacloprid; 18 (32%) Methamidophos and 15 (27%) endosulfan. BChE activity was significantly decreased in the pesticides exposed farmers as compared to controls (P<0.001). Plasma biochemical markers including ALT, AST, CK, LDH and phosphate were significantly raised in the pesticides exposed farmers as compared to control group (P<0.001). Total pesticides residues revealed a significant positive correlation with AST (r=0.42), LDH(r= 0.47), ALT (r=0.20) and phosphorus (r=0.51). Excessive exposure to pesticide caused cytotoxic changes in the hepatic and renal biochemical markers which were positively correlated with pesticide residue. Hence these biomarkers might be used in addition to BChE activity for monitoring of adverse effects of pesticides on the health of farm workers.

[DRESS syndrome related to Hexaquine (quinine and thiamine)]

BACKGROUND

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS syndrome) is a severe drug eruption defined as an association of a drug reaction, mostly cutaneous, laboratory abnormalities with the presence of hypereosinophilia and/or atypical lymphocytes, and involvement of one or more organs. We report a case of DRESS syndrome associated with quinine or thiamine (which in France are combined in Hexaquine with serious hepatitis and renal failure and associated viral reactivation of Human Herpes Virus 6 (HHV6).

OBSERVATION

A twenty-three year-old woman was hospitalized for asthenia, fever, erythroderma, facial edema and painful cervical lymph nodes. Laboratory results showed inflammatory syndrome, hypogammaglobulinemia and the presence of activated atypical lymphocytes. Broad screening for infectious serology showed HHV6 reactivation with marked increase in specific IgG levels within two weeks and detection of circulating DNA in blood by PCR (polymerase chain reaction). Two severe complications subsequently appeared: cytolytic hepatitis and interstitial nephritis. The outcome was favorable with oral corticosteroid therapy. Repeated history-taking did not initially identify any causal agent, but several weeks later, the patient remembered taking Hexaquine (quinine and thiamine) for essential muscular cramps daily for 27 days before the onset of symptoms. The patient had taken no other medication during the previous weeks. One year later, at the end of an enteroviral infection, a skin rash similar to the first episode was seen but in isolation on this occasion, suggesting minor reactivation of DRESS syndrome.

DISCUSSION

To our knowledge, ours is the first reported case of DRESS syndrome associated with this drug. Because of the difficulty of identifying the causative drug, even though taken alone, our case once again illustrates the importance of spending adequate time on history taking. Although the physiopathology of DRESS syndrome has not yet been fully elucidated, it is nevertheless probable that it is a multi-factor phenomenon (involving medication and viruses among others).

Mycophenolic acid plasma trough level: correlation with clinical outcome

OBJECTIVES

Assess the relationship between clinical diagnosis, state of immunosuppression, mycophenolic acid (MPA) plasma trough levels (MPACmin), and mycophenolate mofetil (MMF) dosage in renal transplant recipients.

MATERIALS AND METHODS

MPACmin were determined in 30 kidney transplant patients, of whom 7 exhibited biopsy-proven acute rejection. The remaining 23 had normal graft function. Graft outcome, defined by clinical diagnosis and serum creatinine level, was compared according to MPACmin, MMF dosage, and total lymphocyte count (LC).

RESULTS

Patients with acute rejection had similar MPACmin (2.4 +/- 1.7 microg/mL), MMF dosages (1.7 +/- 0.5 g), and LCs (0.001165 +/- 0.0040 x 10(9)/L) when compared with normal patients (2.2 +/- 0.7 microg/mL, 1.7 +/- 0.4 g and 0.001160 +/- 0.00527 x 10(9)/L) respectively. Rejection rates were comparable irrespective of MPACmin)ranges and higher in those receiving the 1-g dose (30%) when compared with those receiving 1.5-g and 2-g doses (12.5% and 11.7%). No relationship was observed between MPACmin and MMF doses, and neither parameter correlated with LC.

CONCLUSIONS

These results suggest that MPACmin is a poor correlate of clinical outcome and state of immunosuppression. Although the usually recommended dosage of MMF (2 g) may be associated with acute rejection, low-dose MMF (1 g) seems to constitute a higher risk.