Case Report: Complete and Fast Recovery From Severe COVID-19 in a Pemphigus Patient Treated With Rituximab

COVID-19 is characterized by a severe pulmonary disease due to severe acute respiratory syndrome (SARS)-CoV-2 infection. For clinicians involved in the management of patients with chronic autoimmune diseases the risk linked to the conditions itself and to drug-induced immunosuppression during the COVID-19 pandemic is a major topic. Pemphigus is a rare autoimmune blistering disease (AIBD) of the skin and mucous membranes caused by autoantibodies to desmosomal components, desmoglein 1 and 3. Among immunosuppressant therapies, rituximab (RTX) is considered a highly effective treatment with a favorable safety profile, but it induces a prolonged B-cell depletion that can lead to higher susceptibility to infections. For this reason, concerns about its use during the pandemic have been raised. We describe a case of a pemphigus patient in which RTX-induced B cell depletion led to the severe inflammatory phase, whereas corticosteroid treatment allowed a favorable outcome.

A proposal for a comprehensive approach to infections across the surgical pathway

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Predominance of Clostridium difficile 027 during a five-year period in Bolzano, Northern Italy

Toxigenic Clostridium difficile is responsible for antibiotic-associated diarrhoea and other diseases. The increasing frequency and severity is attributed to highly-virulent ribotypes such as 027. The aim of the study was to collect epidemiological and molecular data for C. difficile isolates during 2009-2013 in the Central Hospital of Bolzano, Northern Italy. Stool samples from inpatients of the Bolzano Central Hospital were screened for toxins A and B, and C. difficile was cultured and tested for antibiotic susceptibility. PCRs were performed for genes of toxin A, toxin B, binary toxin and ribotyping. During the period 2009-13 from 320 patients (9% of patients tested) at least one stool sample proved positive for C. difficile toxins, and incidences for all hospital inpatients per 10,000 patient days (per 1,000 admissions) varied between 2.2 (1.5) and 4.3 (3.0). Out of 138 isolates (43% of total isolates were studied), 24 different ribotypes were identified. Isolates with ribotype 027 were predominant (38%), followed by 018 (13%) and 607 (10%). Whereas for ribotype 018 a significant decrease was seen during the five-year period, ribotype 027 increased significantly from 0% in 2009 to 64% in 2012, decreasing then to 10% in 2013. Isolates were sensitive to metronidazole and vancomycin, whereas isolates of the three major ribotypes were resistant to moxifloxacin. Our data indicates a significant change in C. difficile incidence rates and ribotype frequencies during the five-year period in the Central Hospital in Bolzano.

Intravascular large B-cell lymphoma associated with silicone breast implant, HLA-DRB1*11:01, and HLA-DQB1*03:01 manifesting as macrophage activation syndrome and with severe neurological symptoms: a case report

BACKGROUND

Silicone implants have been successfully used for breast augmentation and reconstruction in millions of women worldwide. The reaction to the silicone implant is highly variable; it can lead to local inflammatory symptoms, and sometimes to systemic symptoms and disease. Over 80 cases of anaplastic lymphoma kinase-negative anaplastic large cell lymphoma have been reported in patients with silicone breast implants and have been accepted as a new clinical entity. To the best of our knowledge, an intravascular large B-cell lymphoma associated with a silicone breast implant has not been reported previously.

CASE PRESENTATION

A 48-year-old Caucasian woman who presented with high fever was found to have splenomegaly on physical examination. A laboratory diagnosis revealed pancytopenia, hypertriglyceridemia, and hyperferritinemia. She developed signs of altered sensorium, hemiparesis, aphasia, and cauda equina syndrome. On further evaluation, she fulfilled the necessary five out of eight criteria for diagnosis of macrophage activation syndrome/hemophagocytic lymphohistiocytosis. Dexamethasone administration was followed by prompt improvement; however, 3 days later she again manifested high fever, which persisted despite administration of immunoglobulin and cyclosporine A. Her silicone breast implant was considered a possible contributor to her macrophage activation syndrome and was therefore removed. A histological examination of the capsule tissue showed an extensive lymphohistiocytic/giant cell foreign body reaction suggestive of autoimmune/inflammatory syndrome induced by adjuvants. However, the histological examination unexpectedly also revealed an intravascular large B-cell lymphoma.

CONCLUSIONS

The genetic background of our patient with silicone breast implants might have predisposed her to three rare and difficult to diagnose syndromes/diseases: macrophage activation syndrome/hemophagocytic lymphohistiocytosis, autoimmune/inflammatory syndrome induced by adjuvants, and intravascular large B-cell lymphoma. The simultaneous manifestation of all three syndromes suggests causal interrelationships. Human leukocyte antigen testing in all women who undergo silicon breast implantation could in the future enable us to better evaluate the risk of potential side effects.

Imported visceral leishmaniasis - unexpected bone marrow diagnosis in a patient with fever, pancytopenia, and splenomegaly

Leishmaniasis is spreading from mediterranean countries to the north of Europe. The Alps are not an endemic region and there are only few reports of sporadic cases. We report the case of a 72 year old male who presented after a syncope with fever, cough and a sacral skin rash. Clinical examination revealed splenomegaly, elevated liver enzymes and pancytopenia; differential diagnosis included myeloproliferative or lymphoproliferative disorders, infections and auto-immune conditions that cause enlargement of the spleen and liver diseases, however, all tests were negative. In (18)FDG PET computerized tomography, pathological and diffuse uptake in the spleen was seen, with mild and homogeneous FDG uptake in the bone marrow and normal tracer uptake elsewhere in the body. Bone marrow aspiration revealed the presence of numerous intra- and extracellular Leishmania amastigotes. Travel history indicated that he had been in Sardinia for a 7-day vacation several months ago. The patient promptly responded to treatment with liposomal amphotericin B. Imported visceral leishmaniasis is likely to be seen more frequently in non-endemic regions and fever, pancytopenia and splenomegaly are diagnostic clues, whereas diagnostic confirmation may be done by detection of Leishmania spp. amastigotes in the bone marrow.

Molecular epidemiology of methicillin-resistant Staphylococcus aureus from bacteraemia in northern Italy

BACKGROUND

Vancomycin is frequently used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia; reduced susceptibility to vancomycin is therefore disturbing.

METHODS

molecular epidemiological analysis of 81 MRSA bacteraemia isolates collected during 2002-10 in the province of Bolzano, northern Italy was performed. MICs of a range of antimicrobials were determined by agar microdilution, screening for hGISA was by Macro-Etest and Etest GRD and confirmed by PAP-AUC with vancomycin and teicoplanin. All isolates were characterised by toxin gene profiling, agr, spa, and SCCmec-typing; MLST and PFGE were carried out on representative strains.

RESULTS

The dominant clones identified were ST8-MRSA-IVc (55%) and ST228- and ST111-MRSA-I (25%); most of the latter two lineages (19/20; 95%) were GISA or PAP-AUC confirmed hGISA. One ST8-MRSA-IVc isolate harboured ccrA2B2 together with ccrA4B4. The remainder were diverse genotypically and belonged to MLST clonal complexes 1, 22, 45 and 398.

CONCLUSIONS

Diverse lineages of MRSA were identified as causing bacteraemia in a province in northern Italy. The association of a specific genotype with the hGISA and GISA phenotypes among representatives of the second most common lineage identified is of clinical concern.

Preoperative reduction of spondylolisthesis

The treatment of SL, especially in some cases, is mostly surgical. This lesion can be considered an extremely localised kyphosis (only two vertebrae) or a localized (sub-)luxation: at most hearetically pre-operative reduction should represent the first stage of the treatment, also because reduction makes further surgery easier and enables us to obtain the best results. After a glance at the various surgical techniques that have been used in the past, we describe our method of preoperative reduction in case of severe SL, an improvement of Scaglietti's original technique. According to the parameters taken into consideration, spondylolisthesis (SL) of the 4th and, above all, the 5th lumber vertebrae can be considered, especially in severe cases, as kyphosis or displacement (or even dislocation in the case of ptosis). In SL-kyphosis the antero posterior axes of the contiguous vertebral bodies are no longer parallel but tend to over-impose one to the other anteriorly forming an open posterior angle of varying degrees. It is an extremely short kyphosis (only two vertebrae) but from all points of view, even therapeutic, it reflects the characteristics of all types of vertebral kyphosis. SL-subluxation or SL-luxation (ptosis) is characterized by the respectively partial or total loss of normal alignment between the vertebrae involved. This can be explained by the fact that nearly all those who have dealt with the problem of treating SL, especially of L5, always ask themselves beforehand if it is possible and/or opportune to eliminate or improve the condition before surgery. In other words the question of reduction (pre or intraoperative, partial or total) of more or less severe L5 SL is always considered by all authors, even if their conclusions are often in disagreement.

Functional evaluation in total hip replacement patients

An evaluation of total hip replacement patients requires objective criteria that allow for the measurement of any changes in the biomechanics of the prosthesis and the effects of these changes on clinical findings. An evaluation of loading and joint movement during walking in these patients has been dealt with by many authors. In this study 15 patients who had undergone total hip replacement for coxarthrosis primary or secondary to congenital dysplasia were examined by kinematic and kinetic gait analysis, clinical evaluation, and radiographic evaluation of the position of the neocenter of prosthetic joint rotation. The patients with prostheses in congenital dysplasia presented with a pattern of walking that was significantly modified. In agreement with what is reported in the literature proximal positioning had less influence on gait parameters as compared to lateral dislocation. Furthermore, changes in positioning observed did not seem to have negative effects on joint loading, measured indirectly by the calculation of joint moments.

Autotransfusion with intra- and postoperative blood recovery in prosthetic hip surgery. A study conducted on 1368 cementless prostheses

With regard to increasing reservations as to homologous transfusions and the objective risks that they involve, since 1984 we have been using an autotransfusion technique in total hip arthroplasty constituting blood predeposit for hemodilution, and intra- and postoperative blood recovery. When this method was used postoperative complications were not very significant even when patients were high-risk (cardiopathic); furthermore, the use of homologous transfusions was required in 2.2% of the patients in 1994 as compared to 90% in 1985. The use of our orthopaedic protocol allows for rapid recovery of movement in the patient thus reducing time bed-ridden and related risks (DVT and/or PTE); the transfusion protocol allows for a return to normal of hemodynamic conditions a few days after surgery. Finally, the reduced incidence of complications caused by homologous transfusions (hepatitis, AIDS...) constitutes a financial saving for the government.

Reimplantation or explantation in the treatment of septic prosthetic loosening

Indications for the surgical treatment of septic loosening of hip arthroplasty vary depending on different parameters. Explantation is indicated when patients are elderly, in generally poor condition, when there are veterate infections, particularly if these were caused by gram negative bacteria, and when there is severe skeletal injury. Reimplantation is instead indicated in patients whose general conditions are good, and who are young and motivated.

Infection therapy in cementless T.H.A

Reimplantation (when possible) represents today the method of choice when dealing with and attempting to resolve cases of deep infection in total hip arthroplasty. In recent years we have, however, had the chance to treat some cases of infection in cementless arthroplasty (without loosening) by conservative treatment: surgical debridement and specific antibiotic therapy (2 cases), or medical therapy alone (1 case), both associated with immobilization in a plaster cast for 2-3 weeks. The long-term results proved to be quite encouraging: none of the 3 patients treated conservatively showed (after 5-6 years) clinical-radiographic signs of recurrence of the infection.

The surgical treatment of spondylolisthesis

The authors report the results obtained in 244 patients submitted to anterior interbody fusion. The method involves preoperative reduction in plaster (when necessary) and anterior surgical stabilization, facilitated by improvement in the anatomical and biomechanical conditions obtained with reduction. This method obtained excellent results in 85% of the cases, with fusion and absence of symptoms, and good results in 10% of the cases, with occasional symptoms and/or fibrous. Results were unsatisfactory in 5% of the cases because of residual radiculopathy (4 cases), non-union of the fusion (3 cases), retrograde ejaculation (2 cases), loosening of the graft (1 case) or unthreading of a screw (1 case). It is our opinion that anterior interbody fusion is the best surgical method for the stabilization of Meyerding grades III, IV and V spondylolisthesis. Posterolateral fusion is used to treat some cases with slippage equal to less than 25% (grade I) and cases where more than one level is involved.

Failed back syndromes: opinions and personal experiences

The authors consider poor results in lumbar disc surgery to be commonly caused by the following conditions: 1) recurrence of the hernia; 2) postoperative instability; 3) scarring entrapment of the spinal nerve roots; 4) coexisting local or general pathology; 5) arachnoiditis; 6) psychological causes and those where insurance is involved. In particular patients with insurance-related motivations or those affected with depressive syndromes are frequently observed among those submitted to lumbar surgery. The only indications for surgery include recurrence of disc herniation and postoperative instability. In any of the other situations further surgery often results in worsening of the patient's conditions, or it at any rate does not guarantee improvement in the conditions of the patients.

Surgical treatment of unresolved Osgood-Schlatter lesion

The Osgood-Schlatter lesion is considered a traction apophysitis. Treatment is generally conservative, and only rarely does a surgical treatment become necessary for the persistence of pain and swelling over the tibial tubercle. The most widely used procedure consists of the excision of all intratendinous ossicles with or without removal of the prominent tibial tubercle. In 15 cases treated in this manner compared with 11 cases treated with various procedures before 1975, the results were clearly better with the former. There was only one fair and no poor results. Removal of all loose intratendinous ossicles associated with prominent tibial tubercles is the procedure of choice, both from the functional and the cosmetic point of view.

Avulsion fractures of the scapula: report of eight cases

Fractures of the scapula from indirect trauma represent 0.01% of all skeletal fractures treated in our Institute. They are avulsion fractures that result from the violent pulling of the muscles, the ligaments, or both on their bony insertion. In our series of eight cases any possible direct trauma to the scapula was carefully excluded. In all patients treatment did not represent a particular problem and it was always conservative. Clinical results were always good, with excellent recovery of shoulder function except in one case with a circumflex nerve lesion leaving a deltoid muscle deficit.

Knee arthroplasty rating

A number of rating systems used to evaluate the results of total knee arthroplasty exist. Many of these systems are based on different concepts, and might be expected to give divergent results. To see if this was so, the authors examined a consecutive series of 235 posterior stabilized knee arthroplasties recording the results according to five rating systems: HSS (The Hospital for Special Surgery), Brigham, Freeman, BOA (British Orthopaedic Association), and the VENN diagram. In spite of their apparent differences, all point systems and the BOA gave almost identical results, while the VENN diagram proved to be the most stringent. The authors suggest that any of the current point systems may be used to "score" arthroplasties, but the results should also be rated with the VENN diagram in order to see the quality of the arthroplasty and a comparison between the different series.

Large cell lymphoma of bone. A report of three cases of B-cell origin

Clinicopathological and immunohistological features of three cases of large cell lymphoma of bone are reported. On histological grounds, all the cases were diagnosed as histiocytic lymphomas (Rappaport) or primary centroblastic lymphomas, polymorphic subtype (Kiel). On immunophenotyping, malignant cells strongly reacted with the anti-leucocyte antibodies PD7/26 and ROS-220C, thereby indicating their lymphomatous nature, and expressed the B-cell antigens CD19 and CD22. Further studies are warranted to determine whether the B-cell phenotype observed in our cases is typical of the majority of primary large cell lymphomas of bone. Immunohistological analysis with monoclonal antibodies is expected to be of great value not only in defining the immunological phenotype of this rare pathological entity, but also in differentiating it from other neoplasms that involve the skeleton, either primarily or secondarily.

Clinical evaluation of 104 hip resection arthroplasties after removal of a total hip prosthesis

Functional results of resection arthroplasty are currently considered poor. In 104 hip prosthesis removals after either septic or aseptic loosening, pain, walking, joint motility, life style, and patient's opinion were evaluated. A satisfactory result was recorded in 72% of cases. Prognosis is poorer in patients who are young, have septic loosening, and have poor residual mobility. Resection arthroplasty should be considered a salvage procedure in cases of septic loosening and/or bone stock deficiency after a failed total hip arthroplasty.

Tibial osteotomy in the treatment of genu recurvatum in the adult

The authors analyse the results of 23 cases of high tibial osteotomy for genu recurvatum in adults performed at the Rizzoli Orthopaedic Institute from 1968 to 1983. The osteotomy is at the supratuberosity level. After detaching the patella tendon an anterior bone wedge is inserted and the tendon reinserted at a higher level. This operation has produced better results than other surgical techniques. It is indicated in the osseous type of recurvatum or in the combined type in which the osseous component is predominant. In the combined type with a capsulo-ligamentous prevalence, the poor results obtained with osteotomy alone indicate the need for combining the operation with a plastic reconstruction of the posterior capsulo-ligamentous structures.

Natural history of untreated idiopathic scoliosis after skeletal maturity

A total of 187 random cases of untreated idiopathic scoliosis, seen from a minimum of 15 to a maximum of 47 years after the end of growth, were reviewed. All curves increased after skeletal maturity (average progression: 0.4 degrees per year). Thoracic curves tend to progress more than lumbar, lumbar more than thoracolumbar, and thoracolumbar more than double major curves. Pain was present in 114 cases (61%) and appeared more frequently in women, after pregnancies, and with fatigue. Cardiopulmonary symptoms were present in 42 patients (22%), especially those with thoracic and thoracolumbar curves greater than 40 degrees. Psychologic disturbances were found in 35 cases (19%), mostly female patients with thoracic curves greater than 40 degrees. The cosmetic appearance of these patients at long-term follow-up was better compared with that at the end of growth, even though the curves progressed. Patients with decompensation of the trunk at the end of growth seemed to improve with time. In an unselected group of patients with severe curves a mortality rate of 17% was found, twice as much as in the Italian general population.

Total knee arthroplasty in Charcot and Charcot-like joints

Nine total knee arthroplasties were performed in seven patients with the diagnosis of neuropathic arthropathy. The patients were divided into two groups, classical Charcot and Charcot-like. The histopathological findings in all of the knees, however, were essentially the same. These included hyperplastic synovium with bone and/or cartilage detritus, severe disorganization of the articular cartilage with invasion by a fibrous pannus, and hemosiderin deposits in synovial macrophages. Chronic inflammatory synovitis was noted in all cases. The results of total knee arthroplasty an average of three years after surgery (range, two to 4.25 years) were excellent in eight knees in six patients and good in one knee. Neuropathic knees can be treated by total joint arthroplasty if severe bone loss is corrected by either bone grafting or a custom-augmented prosthesis and if ligamentous balancing is adequately secured.

Total knee arthroplasty without patellar resurfacing

Twenty-seven knees treated between 1974 and 1980 had a total condylar type knee arthroplasty without patellar resurfacing; the average follow-up period was 5.2 years. Compared with a previously reported group of 100 consecutive total condylar arthroplasties, the overall results in this series were very similar. However, there was a significant difference in stair-climbing ability, and one-third of the patients could not use the operated knee for this activity. In most knees the patella could be resurfaced. A working hypothesis assumes that the patellar button can be omitted in patients with relatively normal patellar cartilage, or relatively young, active, or obese patients who are considered a high risk for patellar bone fractures.

Successive bilateral total knee replacement

We studied the results of 304 posterior stabilized condylar knee arthroplasties, performed over a two and a half-year period, to compare unilateral, bilateral one-stage, and bilateral staged arthroplasty. The minimum length of clinical follow-up was two years. Using The Hospital for Special Surgery rating system, we found the clinical results to be identical for all three groups. The medical complications were similar in each group except that there was a higher incidence of thromboembolism and pulmonary embolism, as seen venographically, in the patients with staged procedures. We concluded that one-stage bilateral knee arthroplasty is preferable in a patient who requires replacement for severely arthritic knees.

Total knee arthroplasty

The standard prosthesis for most arthritic conditions is a tricompartmental type. Patellar resurfacing should be done in most cases. The question of cruciate preservation or substitution is unresolved, and both types give equivalent clinical results. No advantage has been shown for left or right components. Correction of deformity occurs by soft-tissue release and ligament balancing, rather than by bone resection. Most primary replacements can be performed in this manner, but alignment is critical to the function and survival of a functioning arthroplasty. Most failures can be attributed to incorrect ligament balance or incorrect alignment. Cement fixation of the components has proved effective, and there is no immediate need for alternative methods such as bone ingrowth; new methods will have to prove themselves against the standard already established for cemented prostheses. Patellar complications such as fatigue fracture of the patellar bone now constitute the majority of problems following total knee arthroplasty.