Hemophagocytic Lymphohistiocytosis mimics many common conditions: case series and review of literature

Introduction. Hemophagocytic lymphohistiocytosis (HLH), a rare but potentially fatal disease, is characterized by excessive immune activation and cytokine release which stimulates bone marrow macrophages to engulf hematopoietic cells. HLH could be secondary to infections: viral, fungal, and bacterial; malignancies and autoimmune diseases. The diagnosis of HLH is usually delayed due to the presence of non-specific symptoms at presentation. This delay contributes to increased mortality. Cases and review. We present the case of 4 patients who presented with subjective fevers and extreme fatigue. Patients all had systemic inflammatory response syndrome (SIRS). All patients were initially managed as in sepsis from an underlying infection. All unfortunately progressed to multiple organs dysfunction and died. The underlying causes for HLH in the patients were considered to be: HIV/AIDS, T cell lymphoma, histoplasmosis and juvenile rheumatoid arthritis. We have also included a brief review of the literature on HLH highlighting the treatment and outcomes of patients in case series; and the many conditions which can trigger HLH. Conclusion. Patients with HLH usually share various non-specific symptoms, such as fever and malaise, with patients across a wide spectrum of conditions: from bacterial sepsis to malignancies. Since early suspicion and diagnosis is critical to prompt therapy and improved mortality, including HLH as a possible cause of fever particularly in patients with prolonged fever of unknown origin and cytopenias will be crucial.

Acceptability, feasibility and costs of universal offer of rapid point of care testing for HIV in an acute admissions unit: results of the RAPID project

OBJECTIVES

UK guidance recommends that acute medical admissions are offered an HIV test. Our aim was to determine whether a dedicated staff member using a multimedia tool, a model found effective in the USA, is an acceptable, feasible, and cost-effective model when translated to a UK setting.

METHODS

Over 4 months in 2010, a health advisor (HA) approached 19-65-year-olds at a central London acute medical admissions unit and offered a rapid HIV point of care test (POCT) with the aid of an educational video. Feasibility and acceptability were assessed through surveys and uptake rates. Costs per case of HIV infection identified were established.

RESULTS

Of the 606 eligible people admitted during the pilot, 324 (53.5%) could not be approached or were individuals for whom testing was deemed inappropriate. In total, 23.0% of eligible admissions had an HIV POCT. Of the patients who watched the video and had not recently been tested for HIV, 93.6% (131 of 140) agreed to an HIV test; four further patients had an HIV test but did not watch the video. Three tests (2.2%; three of 135) were reactive and all were confirmed HIV positive on laboratory testing. HIV testing in this setting was felt to be appropriate by 97.5% of individuals. The cost per patient was £21, and the cost per case of HIV identified was £1083.

CONCLUSIONS

Universal POCT HIV testing in an acute medical setting, facilitated by an educational video and dedicated staff, appears acceptable, feasible, effective, and low cost. These findings support the recommendation of HIV testing for all medical admissions in high-prevalence settings, although with this model a significant proportion remained untested.

Rehabilitation of patients with extended facial and craniofacial resection

Surgery of benign and malignant disease of the nose and sinuses can result in disfigurement and disability. Many patients have speech, mastication, and swallowing problems, anosmia, and pain. If the orbit is retained, visual loss, dystopia, diplopia, and epiphora can occur. This study reviews the senior author's experience with 34 patients over the last 18 years. Group and case analyses demonstrate that in patients with cancer, the eye can be preserved if one anatomical boundary is retained beyond a negative frozen section margin. Dystopia can be prevented by reconstruction of the floor with skin and fascial grafts or flaps. Epiphora can be reduced by repair of the medial canthus and dacryocystorhinostomy. Evidence is presented for prosthetic management of speech and swallowing and restoration of cheek contour. Case examples are used to illustrate the surgical techniques.

The effect of swallowing bolus and head position on eustachian tube function via sonotubometry

Eustachian tube function was evaluated by sonotubometry in otologically normal young adults. The purpose of the research was to determine if the incidence or duration of eustachian tube opening would be altered with changes in swallowing bolus volume or changes in head rotation. The subject performed multiple swallows of 10 cc water bolus and dry swallows (saliva), with the head in the straight-forward, turned right, and turned left positions. Both ears were evaluated. The average incidence and duration of eustachian tube opening for all swallows was 74% (398 msec). No significant differences were found with any combination of bolus type or head position, suggesting that neither liquid bolus volume nor head rotation need be controlled when sonotubometry is performed.

The E3 protein of bovine coronavirus is a receptor-destroying enzyme with acetylesterase activity

In addition to members of the Orthomyxoviridae and Paramyxoviridae, several coronaviruses have been shown to possess receptor-destroying activities. Purified bovine coronavirus (BCV) preparations have an esterase activity which inactivates O-acetylsialic acid-containing receptors on erythrocytes. Diisopropyl fluorophosphate (DFP) completely inhibits this receptor-destroying activity of BCV, suggesting that the viral enzyme is a serine esterase. Treatment of purified BCV with [3H]DFP and subsequent sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the proteins revealed that the E3 protein was specifically phosphorylated. This finding suggests that the esterase/receptor-destroying activity of BCV is associated with the E3 protein. Furthermore, treatment of BCV with DFP dramatically reduced its infectivity in a plaque assay. It is assumed that the esterase activity of BCV is required in an early step of virus replication, possibly during virus entry or uncoating.

The effect of dried mussel extract on an induced polyarthritis in rats

A polyarthritis was induced in a number of rats by the intradermal injection of a modified Freund's adjuvant into the right foot pad. Powered extract of New Zealand mussel fed to the rats did not have any beneficial effect on either the development or the severity of the arthritis.