Undiagnosed tuberculosis associated with hemophagocytic lymphohistiocytosis due to improper use of corticosteroid

INTRODUCTION

Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening hematologic disease segregated into familial (primary) and acquired (secondary) subtypes. Hyperinflammation and HLH occur when the immune system fails to clear activated macrophages and histiocytes. Infections, malignancies, and rheumatologic disorders are the major triggers leading to HLH. Miliary tuberculosis is a serious disease with a lymphohematogenous spread of Mycobacterium tuberculosis, which is known to be one of the causative agents of HLH. Miliary tuberculosis and HLH have atypical presentations which are similar to routine diseases. Hence, physicians may face challenges to diagnose and treat these complications.

CASE REPORT

We report the case of a 60-year-old man with a history of prolonged fever, shortness of breath, jaundice, altered mental status, undiagnosed lower back pain, and overuse of parenteral betamethasone. Miliary tuberculosis was diagnosed by diffuse, vague random micronodules in both lungs and positive acid-fast bacilli in bronchoalveolar lavage and bone marrow aspiration and biopsy. Moreover, compatible presentation and pancytopenia, hypertriglyceridemia, high serum level of ferritin and fibrinogen-derived products, and evidence of hemophagocytosis on bone marrow aspirate led to the diagnosis of HLH. Unfortunately, despite nearly two months of an anti-tuberculosis regimen (standard and salvage) and eight doses of etoposide, he eventually passed away after clinical improvement.

CONCLUSIONS

Irrational and indiscriminate use of glucocorticoids can be a devastating cause of the spread of tuberculosis and its rare complications, such as HLH.

A case of pituitary gland abscess associated with granulomatous hypophysitis

BACKGROUND

Granulomatous hypophysitis is a rare disease that presents with chronic inflammation of the pituitary gland. In this study, we reported a case of granulomatous hypophysitis associated with a pituitary abscess.

CASE PRESENTATION

A 39-year-old woman presented with a 2-year history of infertility. For the past six months, she has suffered from amenorrhea, decreased libido, headaches, and vertigo. She was referred to our hospital with a suspected diagnosis of nonfunctioning pituitary adenoma based on her presentation and brain MRI findings. She underwent trans-sphenoidal surgery (TSS). Direct observation during surgery revealed drainage of malodor pus and pituitary gland abscess. The histopathological evaluation also showed granulomatous hypophysitis and neutrophilic microabscess formation. The patient was initially treated with high doses of ceftriaxone (2 g twice daily) and metronidazole (500 mg (mg) four times per day). Also, the patient received cortisol replacement therapy after the operation. After obtaining the antibiogram and culture results, the treatment regimen was continued for 4 weeks postoperatively, followed by amoxicillin-clavulanate (500/125 mg three times daily) for a total duration of 12 weeks.

CONCLUSION

The patient recovered uneventfully and the postoperative MRI was normal without any remnant lesions.

Garcin syndrome in a case of acquired immunodeficiency syndrome

In this study, we report a parapharyngeal diffuse large B-cell lymphoma in a human immunodeficiency virus (HIV) infected patient which had caused the patient to suffer from Garcin syndrome.

Evaluation of the epidemiologic, clinical, radiologic, and treatment methods of patients with subacute and chronic meningitis

Background

Meningitis is known as a meningeal inflammation accompanied by pleocytosis in the cerebrospinal fluid (CSF), and can be classified into acute, subacute, and chronic meningitis based on symptoms duration of ≤ 5 days, ≥ 5 days and ≥ 4 weeks, respectively. Subacute and chronic meningitis are caused mainly by indolent infectious agents and noninfectious causes such as autoimmune, and neoplastic. In this study, we investigated the characteristics, diagnosis, and treatment of subacute and chronic meningitis.

Methods

We extracted the medical records of patients with chronic and subacute meningitis who were referred to three tertiary centers from Jun 2011 to Jun 2021. Initially, 2050 cases of meningitis were screened, and then 79 patients were included in the study.

Results

Headache (87.3%), nausea and vomiting (74.7%), fever (56.4%), and visual impairments (55.7%) were the most prevalent symptoms. The most common signs were nuchal rigidity (45.3%), altered mental status (26.9%), and papillary edema (37.5%). Brain computed tomography (CT) was normal in 68.6% of the patients while 22.9% of the cases had hydrocephalus. Brain magnetic resonance imaging (MRI) was normal in 60.0% of the patients. The most common abnormal MRI findings were leptomeningeal enhancement (16.0%) and hydrocephalus (16.0%). We had a 44.3% definite diagnosis with bacterial (n:25, 31.6%) and neoplastic (n:8, 10.1%) being the most prevalent etiologies. Mycobacterium tuberculosis (60%) and Brucella spp. (12%) were the most prevalent bacterial pathogens.

Conclusions

The most common etiologies include infectious, neoplastic, and immunologic. Due to insidious presentation and uncommon etiologies, establishing a proper diagnosis, and providing timely targeted treatment for patients with subacute and chronic meningitis remains a challenge for clinicians.

A Case of Fingolimod-associated Cryptococcal Meningitis

BACKGROUND

Leukopenia, a rare adverse effect of Fingolimod therapy, paves the way for opportunistic infections. In this study, we reported rare fingolimod associated cryptococcal meningitis.

CASE PRESENTATION

A 39-year-old woman with RRMS was referred to the emergency department. The patient's major complaints were headache, fever, weakness, and progressive loss of consciousness within the last two days prior to the referral. The patient had a history of hospitalization due to RRMS [two times]. In the second hospitalization, interferon Beta-1a was replaced with Fingolimod. Using polymerase chain reaction, Cryptococcus neoformans was detected in CSF. Liposomal amphotericin B and fluconazole [800 mg per day] were started. Six weeks later, the patient was discharged without any major complaints.

CONCLUSION

Albeit fingolimod associated cryptococcal meningitis is a rare event, Fingolimod therapy in patients with MS should be performed cautiously. Regular follow-ups may give rise to a timely diagnosis of probable fingolimod associated cryptococcal meningitis. Fingolimod therapy can lead to lymphocytopenia and various infections. We, therefore, suggest that intermittent blood lymphocyte counts as well as monitoring of clinical manifestations among MS patients treated with Fingolimod to avoid additional neurological and physical disabilities in these patients.

Efficacy of Hemoperfusion in Severe and Critical Cases of COVID-19

INTRODUCTION

Uncontrolled overproduction of inflammatory mediators is predominantly observed in patients with severe COVID-19. The excessive immune response gives rise to multiple organ dysfunction. Implementing extracorporeal therapies may be useful in omitting inflammatory mediators and supporting different organ systems. We aimed to investigate the effectiveness of hemoperfusion in combination with standard therapy in critically ill COVID-19 patients.

METHOD

We conducted a single-center, matched control retrospective study on patients with confirmed SARS-CoV-2 infection. Patients were treated with hemoperfusion in combination with standard therapy (hemoperfusion group) or standard treatment (matched group). Hemoperfusion or hemoperfusion and continuous renal replacement therapies were initiated in the hemoperfusion group. The patients in the matched group were matched one by one with the hemoperfusion group for age, sex, oxygen saturation (SPO2) at the admission, and the frequency of using invasive mechanical ventilation during hospitalization. Two types of hemoperfusion cartridges used in this study were Jafron© (HA330) and CytoSorb® 300.

RESULT

A total of 128 COVID-19-confirmed patients were enrolled in this study; 73 patients were allotted to the matched group and 55 patients received hemoperfusion. The median SPO2 at the admission day in the control and hemoperfusion groups was 80% and 75%, respectively (p value = 0.113). The mortality rate was significantly lower in the hemoperfusion group compared to the matched group (67.3% vs. 89%; p value = 0.002). The median length of ICU stay was statistically different in studied groups (median, 12 days for hemoperfusion group vs. 8 days for the matched group; p < 0.001). The median final SPO2 was statistically higher in the hemoperfusion group than in the matched group, and the median PaCO2 was lower.

CONCLUSION

Among critically ill COVID-19 patients, based on our study, the use of hemoperfusion may reduce the mortality rate and improve SPO2 and PaCO2.

Umifenovir in hospitalized moderate to severe COVID-19 patients: A randomized clinical trial

INTRODUCTION

The effectiveness of umifenovir against COVID-19 is controversial; therefore, clinical trials are crucial to evaluate its efficacy.

METHODS

The study was conducted as a single-center, randomized, open-label clinical trial. Eligible moderate-severe hospitalized patients with confirmed SARS-Cov-2 infection were randomly segregated into intervention and control groups. The intervention group were treated with lopinavir/ritonavir (400 mg/100 mg bid for 10-14 days) + hydroxychloroquine (400 mg single dose) + interferon-β1a (Subcutaneous injections of 44 µg (12,000 IU) on days 1, 3, 5) + umifenovir (200 mg trice daily for 10 days), and the control group received lopinavir/ritonavir (same dose) + hydroxychloroquine (same dose) + interferon-β1a (same dose).

RESULTS

Of 1180 patients with positive RT-PCRs and positive chest CT scans, 101 patients were finally included in the trial; 50 were assigned to receive IFNβ1a + hydroxychloroquine + lopinavir/ritonavir group and 51 were managed to treat with IFNβ1a + hydroxychloroquine + lopinavir/ritonavir + umifenovir. Since all patients received the intended treatment as scheduled, the analysis just included as the ITT population. Time to clinical improvement (TTCI) did not hold a statistically significant difference between intervention and control groups (median, 9 days for intervention group versus 7 days for the control group; P: 0.22). Besides, Hazard Ratio for TTCI in the Cox regression model was 0.75 (95% CI: 0.45-1.23, P:0.25) which also confirmed that there was no statistically significant difference between the treatment group and the control group. The mortality was not statistically significant between the two groups (38% in controls vs 33.3% treatment group).

CONCLUSIONS

Our findings shed new lights on the facts that additional umifenovir has not been found to be effective in shortening the duration of SARS-CoV-2 in severe patients and improving the prognosis in non-ICU patients and mortality.

TRIAL REGISTRATION

The trial was confirmed by the Ethics in Medical Research Committee of the Shahid Beheshti University of Medical Sciences. signed informed consents were obtained from all the participants or their legally authorized representatives. This trial has been registered as ClinicalTrials.gov, NCT04350684.

Evaluation of 25-hydroxy Vitamin D and 1,25-dihydroxy Vitamin D Levels in Maintenance Hemodialysis Patients

INTRODUCTION

Dysregulated vitamin D metabolism is one of the most important issues in chronic kidney disease- mineral and bone disorder (CKD-MBD). Patients with end-stage kidney disease (ESKD) receive large amounts of calcitriol, i.e., 1,25 -dihydroxy vitamin D [1-25(OH)2D], for suppression of parathyroid hormone (PTH). The aim of this study was to evaluate the 1-25(OH)2D status in maintenance hemodialysis patients and its correlation with 25(OH) D level and calcitriol consumption and to determine whether the usual practice of administrating large amounts of calcitriol for suppression of PTH may lead to toxic serum levels.

METHODS

One hundred and fifty-six maintenance hemodialysis patients were enrolled. Demographic data, comorbid conditions and history of medication use (cumulative and current doses) were retrieved from Hemodialysis Data Processor Software previously designed for our center. Predialysis serum samples were measured for serum levels of 25(OH)D and 1-25(OH)2D accompanying by markers of mineral bone metabolism and inflammation.

RESULTS

Of 156 patients, 66% were male and the mean age was 56.5 ± 16.3 years. There was no significant correlation between serum level of 25(OH)D and 1,25(OH)2D (r = 0.12, P > .05). Only current ingestion of vitamin D was correlated with both 25(OH) D (r = 0.324, P < .001) and 1,25(OH)2D serum levels (r = 0.334, P < .001). There was no significant relationship between current or cumulative calcitriol consumption and 1,25(OH)2D serum level. 1,25(OH)2D/25(OH)D ratio which, represents the degree of vitamin D hydroxylation efficiency was 0.9 pg/ng (expected value in no CKD > 2.2 pg/ng).

CONCLUSION

Calcitriol consumption was not correlated with increased serum 1,25(OH)2D level and the practice of hyperparathyroidism treatment with calcitriol may be safely continued, though we are not yet aware of the 1,25(OH)2D status at the cellular levels.

Blood Pressure Measurement and Left Ventricular Mass Index in Hemodialysis Patients: Comparison of Several Methods

INTRODUCTION

Systemic arterial hypertension is prevalent in end-stage renal disease and is closely associated with left ventricular hypertrophy (LVH). Blood pressure (BP) behavior is unique in this population, and it is not clear which BP measurement should be used for treatment guidance. We aimed to evaluate the association of several methods of BP measurement with left ventricular mass index (LVMI) as hypertensive end-organ damage.

MATERIALS AND METHODS

Patients on maintenance hemodialysis, 3 or 4 times per week for at least 3 months, were enrolled. We compared the diagnostic value of 6 different methods of BP measurement, including predialysis, postdialysis, interdialysis, and standard BP measurements as well as ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring, based on LVMI as the gold standard.

RESULTS

Twenty patients, including 9 women and 11 men were enrolled. Ten patients (50%) had LVH and the others had normal LVMI (LVMI > 100 g/m2 for women and > 131 100 g/m2 for men). Only predialysis and postdialysis systolic BP values were significantly associated with LVMI (P = .02 and P = .02, respectively).

CONCLUSIONS

Predialysis and postdialysis systolic BP values maybe reliable for detecting hypertension in hemodialysis patients, although according to previous data, the importance of self and ambulatory BP monitoring could not be overlooked.

Yellow Nail Syndrome: Report of a Case Successfully Treated with Octreotide

Yellow nail syndrome (YNS) is an uncommon condition characterized by a triad of yellow nail coloration, lymphedema and respiratory tract involvement. This syndrome typically affects middle-aged persons. Although several etiologies have been described, to date; the exact etiology remains unclear. Different treatment plans have been suggested, but all data available emphasize the fact that treatment is mainly symptomatic and the underlying disease is not targeted. The most reported treatment protocol is chemical pleurodesis combined with alpha-tocopherol (vitamin E). Hereby, we describe a case of YNS in a 34 year-old woman with the onset of symptoms in childhood. The symptoms improved dramatically after treatment with octreotide.

Renal Lymphangiectasia: A Curious Cause of Pleural Effusion

Renal lymphangiectasia is a disorder of the lymphatic system of the kidneys, which can be congenital or acquired. Although the exact etiology remains unknown, an obstructive process resulting from several causes, including infection, inflammation or malignant infiltration, has been suggested to be responsible for the acquired form. This disorder may be associated with several pathologies. We report a case of a 24-year-old man with renal lymphangiectasia presenting with polycythemia, ascites and pleural effusion associated with hepatitis C virus (HCV) infection in an intravenous (IV) drug user. Our case is the first in the literature that shows an association between HCV infection and IV drug use.