How important is the 'quality' of the cytotoxic T lymphocyte (CTL) response in protection against HIV infection?

Cytotoxic T lymphocyte (CTL) responses have been associated with protection from HIV-1 infection in people with a high degree of exposure to HIV and who show no serological evidence of HIV infection (HEPS, highly exposed persistently seronegative). However, it remains unclear how protective CTL responses could apparently develop in a minority of people, whilst the great majority of HIV-infected people make strong CTL responses yet progress to AIDS and death. In this paper we review the data which supports the hypothesis that the quality of the T-cell response, rather than its magnitude, may be an important factor that merits further investigation.

[Meningomyeloradiculitis caused by Schistosoma mansoni. Research protocol and report of 21 cases]

Twenty one cases of schistosomal meningomyeloradiculopathy due to Schistosoma mansoni are reported. This result was attained after a 4- year research period based on a "Clinical and Laboratory Investigation Protocol" applied on 212 patients in Itabuna, a city of Southeast region of Bahia state in the Northeast of Brazil. This region is a non endemic one for schistosomiasis. The Protocol consisted in leading to investigation every patient that presented a clinical triad characterized by: lumbar pain, paresthesias in the inferior limbs, miction difficulties. Diagnostic criteria were based on clinical neurologic signs, presence of Schistosoma mansoni eggs on feces or rectum biopsy, positive immunofluorescence reaction for schistosomiasis in the cerebrospinal fluid (CSF), the inflammatory CSF characteristics, and an exhaustive research for differential diagnosis. The diagnosis has been essentially based on clinical and laboratory data, not having for any of the cases an histopathological study. The treatment was performed the earliest as possible, and corticosteroids associated to oxaminiquine were used for all cases. The patients were studied as to sex, age, profession, city of origin, initial symptoms, laboratory tests related to schistosomiasis, the onset type of neurologic clinical symptoms and several CSF aspects. Treatment beginning was related with time of disease. Clinical evolution and sequelae were analysed. Abdominal contractions were observed in 10 cases several hours before the clinical picture had been clearly presented. Clinical diagnosis is justified since it is performed under severe clinical and laboratory evidences, as well as an accurate search for differential diagnosis. The authors think that the schistosomal meningomyeloradiculopathy is a well defined nosological entity by its neurological picture, as also from the pathological point of view. Finally, the authors suggest to neurological services of the country the planning and application of similar or even more detailed Protocol in order to obtain an early diagnosis and treatment for the disease, preventing so irreversible damages and sequelae very harmful for the patients in their social life.

Choroidal thickness changes in systemic lupus erythematosus patients

Purpose

To compare choroidal thickness (CT) between patients with systemic lupus erythematosus (SLE) without ophthalmologic manifestations and a control group. To study the effects in CT of disease duration, activity index, medication and systemic comorbidities.

Methods

Cross-sectional study where spectral-domain optical coherence tomography with enhanced depth imaging was used to measure CT in 13 locations, subfoveally and at 500-µm intervals along a horizontal and a vertical section from the fovea. Linear regression models were used.

Results

Sixty-eight SLE patients and fifty healthy controls were enrolled. CT multivariable analysis revealed lower values in SLE patients (12.93-26.73 µm thinner) in all locations, except the inferior quadrants (6.48-10.44 µm thicker); however, none of these results reached statistical significance. Contrary to the control group, the normal topographic variation in CT between macular quadrants and from the center to the periphery was not observed in the SLE group. Multivariable analysis in the SLE group alone revealed a significant negative association with anticoagulants (50.10-56.09 µm thinner) and lupus nephritis (40.79-58.63 µm thinner). Contrary to controls, the CT of SLE patients did not respond to changes in mean arterial pressure.

Conclusion

CT in SLE appears to be thinner, particularly in the subset of patients with nephritis and taking anticoagulants, suggesting more advanced systemic vascular disease. Choroidal responses to hemodynamic changes may also be altered in SLE.

Ultrasound detects subclinical joint inflammation in the hands and wrists of patients with systemic lupus erythematosus without musculoskeletal symptoms

Objectives

To assess the prevalence and severity of ultrasonographic abnormalities of the hand and wrist of asymptomatic patients with systemic lupus erythematosus (SLE) and compare these findings with those from patients with SLE with musculoskeletal signs or symptoms and healthy controls.

Methods

We conducted a prospective cross-sectional study that evaluated bilaterally, with grey-scale and power Doppler (PD) ultrasound (US), the dorsal hand (2nd to 5th metacarpophalangeal and 2nd to 5th proximal interphalangeal joints) and wrist (radiocarpal, ulnocarpal and intercarpal joints) of 30 asymptomatic patients with SLE, 6 symptomatic patients with SLE and 10 controls. Synovial hypertrophy (SH) and intra-articular PD signal were scored using semiquantitative grading scales (0–3). Individual scores were graded as normal (SH≤1 and PD=0) or abnormal (SH≥2 or PD≥1). Global indexes for SH and PD were also calculated. US findings were correlated with clinical and laboratory data and disease activity indexes.

Results

US detected SH (score ≥1) in 77% asymptomatic patients with SLE, mostly graded as minimal (score 1: 63%). 23% of the asymptomatic patients with SLE showed abnormal US PD findings (SH≥2 or PD≥1). SH was present in all symptomatic patients with SLE, mostly graded as moderate (grade 2: 67%), and with associated PD signal (83%). SH (score 1) was identified in 50% of controls, however, none presented abnormal US PD findings. SH index in the asymptomatic SLE group was higher than in the control group (2.0 (0–5) vs 0.5 (0–2), median (range), p=0.01) and lower than in the symptomatic SLE group (7.0 (4–23), median (range), p<0.001). No significant correlation was demonstrated between US PD findings and clinical or laboratory variables and disease activity indexes.

Conclusion

A small subgroup of asymptomatic patients with SLE may present subclinical joint inflammation. Global US scores and PD signal may be important in disease evaluation and therapeutic monitoring.

The role of ophthalmic imaging in central nervous system degeneration in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disorder that can involve any organ system. Central nervous system involvement can be a severe life threatening complication, ultimately resulting in severe neurodegenerative changes. Magnetic resonance imaging suggests that neurodegeneration, which may have deleterious effects on brain function, may occur early in SLE and experimental models suggest that neuroprotection may be feasible and beneficial. The retina is an extension of the brain. Recent ophthalmic imaging technologies are capable of identifying early changes in retinal and choroidal morphology and circulation that may reflect CNS degeneration. However, their utility in monitoring CNS involvement in SLE has been poorly studied as these have only been performed in small cohorts, in a cross-sectional design, non-quantitatively and without correlation to disease activity. The authors aim to review the current understanding of neurodegeneration associated with SLE, with particular focus on the visual pathway. We describe the neuropathology of the visual system in SLE and the evidence for retinal and choroidal neurodegenerative and microvascular changes using optical coherence tomography technology. We aim to describe the potential role of optical imaging modalities in NPSLE diagnosis and their likely impact on the study of neuronal function.

Ocular involvement in systemic lupus erythematosus patients: a paradigm shift based on the experience of a tertiary referral center

Objective

To evaluate ocular involvement in a cohort of systemic lupus erythematosus (SLE) patients of a tertiary referral center and to compare the results with the existing literature.

Methods

Patients underwent a complete ophthalmological evaluation, including visual acuity, slit-lamp examination, fluorescein staining, Schirmer-I test, Goldmann applanation tonometry, fundoscopy, 10-2 automated threshold visual fields, fundus autofluorescence and spectral-domain optical coherence tomography to screen for hydroxychloroquine (HCQ) macular toxicity.

Results

A total of 161 patients (16 men and 145 women) were enrolled in this study. The mean age was 47.6 years and the mean disease duration was 11.5 years. Fifty patients (31.1%) had at least one ocular manifestation of SLE. The most frequent manifestation was dry eye syndrome (12.4%), immediately followed by cataracts (11.2%) and HCQ macular toxicity (11.2%). Among patients with HCQ maculopathy, two presented with an atypical spectral-domain optical coherence tomography pattern. Five patients (3.1%) presented with glaucoma, two patients (1.2%) presented with SLE retinopathy while only one presented with lupus choroidopathy (0.6%).

Conclusions

Compared with previous studies, we conclude there has been a significant reduction in disease-related ocular complications, particularly those associated with poor systemic disease control. On the other hand, drug and age-related complications are assuming a prominent role in the ophthalmic care of these patients.

A combined variation of Palmaris longus and Flexor digitorum superficialis: Case report and review of literature

The muscles of the anterior compartment of the forearm often exhibit anatomic variations. During dissection of the upper right limb of a preserved cadaver, morphological variations in the Palmaris longus and Flexor digitorum superficialis muscles were found. The Palmaris longus muscular fibers converged to a tendon that passed beneath the Flexor retinaculum, and inserted at the base of the middle phalanx of the fourth digit, replacing the tendon of Flexor digitorum superficialis. The Flexor digitorum superficialis was divided into two muscular heads: a digastric medial head giving tendons to the second and fifth digits, and a lateral head giving one tendon to the third digit. All these tendons were inserted in the respective digits by two bundles between which were located the tendon of the Flexor digitorum profundus muscle. Variations of flexor muscles must be documented because of their clinical significance and their potential use of these muscles in orthopaedic and reconstructive surgery.

Retinal and choroidal thickness changes in systemic lupus erythematosus patients: a longitudinal study

BACKGROUND/OBJECTIVES

To prospectively evaluate changes in peripapillary retinal nerve fibre layer (pRNFL), in all macular layers and in choroidal thickness (CT) in a cohort of systemic lupus erythematosus (SLE) patients without ophthalmologic manifestations. To associate those changes with ophthalmic characteristics, disease activity state, medication and systemic comorbidities.

SUBJECTS/METHODS

Prospective cohort study of 68 previously diagnosed SLE patients. In two study visits (V1 and V2) at least 12 months apart, patients underwent a complete ophthalmologic examination including spectral domain-optical coherence tomography (SD-OCT) and an autoimmune disease specialist assessment. Automatic retinal segmentation was performed. pRNFL was determined globally and in the six peripapillary sectors and each macular layer thickness was determined in the nine early treatment diabetic retinopathy study (ETDRS) subfields. CT was manually measured at 13 locations in the posterior pole. Only one eye per patient was randomly selected for inclusion. Generalised linear mixed effects models were employed.

RESULTS

Sixty-five patients completed the study. The median follow-up time was twelve months. At V2, pRNFL was significantly thinner globally (p = 0.006) and in the temporal inferior sector (p = 0.017). Patients under chronic medication with anticoagulants or antihypertensives had significantly thinner pRNFL in some locations. No significant changes were observed in macular layers or choroidal thickness between study visits.

CONCLUSIONS

SLE patients presented early SD-OCT signs of neurodegeneration, evidenced by a progressive reduction in pRNFL thickness. Regardless of study visit, baseline chronic medication with anticoagulants or antihypertensives was associated with lower pRNFL thickness, accounting for a deleterious effect of cardiovascular risk factors.

Successful treatment of systemic lupus erythematosus with subcutaneous immunoglobulin

The therapeutic efficacy of high-dose intravenous immunoglobulin in systemic lupus erythematosus (SLE) patients is well established. However, side effects might limit its use and lead to the consideration of therapeutic alternatives, such as the subcutaneous formulation of immunoglobulin, which has been used in some patients with other autoimmune diseases. We report a case of SLE refractory to classical therapies. High-dose intravenous immunoglobulin was effective, but gave rise to significant side effects. The patient was successfully treated with subcutaneous human immunoglobulin, achieving and maintaining clinical and laboratory remission. A lower immunoglobulin dose was needed and no side effects were observed, compared to the intravenous administration. Subcutaneous immunoglobulin could be a better-tolerated and cost-saving therapeutic option for select SLE patients.

[Medical education and health promotion in a day nursery institution]

PURPOSE

The authors present a community work experience in a 410 children Catholic day nursery institution.

METHODS

Through non-structured interview and play, clinical-epidemiological observation and a survey of the health needs of three months to six years old children were made.

RESULTS

Four relevant themes were identified for the population: hygiene, oral health, ocular health and substance abuse in some family members. In order to deal with these matters, an interactive educational program was organized which included acting activities, films, competitions and laboratory activities with artificial anatomic shapes.

CONCLUSION

These activities give the medical student the opportunity to get acquainted with the not very well known social reality and be committed to the public health.

Catatonia in Anti-N-Methyl-D-Aspartate (NMDA) Receptor Encephalitis Misdiagnosed as Schizophrenia

Anti-N-Mmethyl-D-aspartate receptor encephalitis is an autoimmune disease of the central nervous system with prominent neurologic and psychiatric features. Symptoms appear progressively and sometimes with an exclusively psychiatric initial presentation. The patient's evaluation should be meticulous, and we should use all the diagnostic tests required for the exclusion of entities that can mimic this disease. We report the diagnostic investigation of a case of anti-N-methyl-D-aspartate receptor encephalitis in a patient with a previous diagnosis of schizophrenia with poor response to antipsychotics. The aim of this case report is to highlight the importance of close surveillance for neuropsychiatric symptoms, especially catatonia, and to recognize autoimmune encephalitis in the differential diagnosis of psychotic disorders with neurological symptoms and resistance or intolerance to antipsychotics. A prompt diagnosis will contribute to a faster onset of therapy and an overall improvement in prognosis.

Eosinophilic enteritis: a rare cause of diarrhoea

We report a case of a healthy young man presenting with 1-week history of diarrhoea, acute abdominal pain and weight loss. Laboratory investigation showed very high peripheral eosinophils levels. After exclusion of the other causes of eosinophilia, a histological bowel sample analysis revealed marked eosinophilic infiltration of a small bowel mucosal layer which confirmed the suspicion of eosinophilic enteritis. Unlike most of the described cases, this patient did not require any specific treatment. Eosinophilic gastroenteritis is a rare and heterogeneous disease that is probably underdiagnosed in clinical practice because it requires a high degree of suspicion and an endoscopic biopsy for definite diagnosis.

Catatonic schizophrenia vs anti-NMDA receptor encephalitis – A video case report

Introduction

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a treatable autoimmune disease of the CNS with prominent neuropsychiatric features that primarily affects young adults and children.

Objective

To present the diagnosis course of a case of anti-NMDAR encephalitis in a patient with previous diagnosis of Schizophrenia.

Methods

Analysis of the patient's clinical records and of a PubMed database review, using “anti-NMDAR encephalitis” as keywords.

Results

We report a single case of a 33-year-old man diagnosed with Paranoid Schizophrenia in 2009 that after 1 year of treatment abandoned follow-up. Six years later, the patient presented to the psychiatric emergency department with persistent headaches, abnormal behavior and loss of motor skill. He was admitted to the psychiatric ward with a presumptive diagnosis of “Catatonic Schizophrenia” and began to manifest fluctuating catatonic symptoms (captured in video). Neuroleptics and benzodiazepines were tried without success. There was a clinical deterioration with autonomic dysfunction, breathing instability and seizures. Complementary exams revealed: EEG with slow base activity; brain MRI with right temporal pole and right frontobasal lesions compatible with head trauma; CSF with pleocytosis; and positive anti-NMDAR antibodies. Occult neoplasm was excluded. Treatment with high-dose steroids, intravenous immunoglobulins, followed by cyclophosphamide resulted in relevant clinical improvement.

Conclusions

As early detection of antibodies may allow for earlier treatment of anti-NMDAR encephalitis, which is associated with better outcomes, we believe the present case underscores the importance of clinicians maintaining vigilance for neuropsychiatric symptoms that have not adequately responded to therapy.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

AB1213 DIFFERENT IMMUNOSUPPRESSIVE REGIMENS WITH NO EFFECT ON INFLUENZA-LIKE ILLNESS

Background:

Autoimmune disease (AID) has been associated with increased risk of influenza and influenza-like illness (ILI) and its worse clinical outcomes complications.

Objectives:

We aimed to assess the influence and difference of several immunosuppressive (IS) treatments in the incidence of ILI, including glucocorticoids (GC), classic DMARDs and biologic DMARDs.

Methods:

We conducted a cross-sectional study in two autoimmune clinics. Patients were invited to answer a survey reporting ILI symptoms between October 2017 and March 2018. ILI definition was considered according to the European Center for Disease Control. Data regarding current IS, diagnostic, disease activity, comorbidities, and vaccination coverage were collected from electronic registry. Patients with history of cancer, HIV, IGIV treatment, or lack of information were excluded. Univariate and multivariate logistic regression analysis were used to access predictors of ILI.

Results:

We included 109 patients, with mean age 51 years and 81% female gender. The majority of patients had autoimmune arthropathy (n=54) or a connective tissue disease (n=44). Active disease was present in in 39% of patients. IS treatment was: GC 31%, classic DMARD 44%, biologic DMARD 28%. Vaccine coverage was 51%. Overall 41% reported ILI. We did not find any association between studied variables and ILI, including univariate and multivariate analysis. Univariate odds ratio calculation for IS treatment were: GC [OR 1,68 IC 0,7-3,8], classic DMARD [OR 1,03 IC 0,5-2,2], and biologic DMARD [OR 0,86 IC 0,4-2,0]. Comorbidity of pulmonary disease (n=8) may contribute to higher risk to ILI [OR 2,76 IC 0,8-10,0].

Conclusion:

There was no difference in risk of ILI within different IS treatment regimens, although GC may increase the risk. The study is limited by the subjectivity of the ILI survey and the small size of the sample. The stratification of influenza risk will help in designing better vaccine coverage strategies in this population.

References:

[1]Nakafero G, Grainge MJ, Myles PR, Mallen CD, Zhang W, Doherty M, Nguyen-Van-Tam JS, Abhishek A. Predictors and temporal trend of flu vaccination in auto-immune rheumatic diseases in the UK: a nationwide prospective cohort study. Rheumatology (Oxford). 2018 Oct 1;57(10):1726-1734.

[2]Danza A, Ruiz-Irastorza G. Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies. Lupus. 2013 Oct;22(12):1286-94.

[3]McLean-Tooke A, Aldridge C, Waugh S, Spickett GP, Kay L. Methotrexate, rheumatoid arthritis and infection risk: what is the evidence? Rheumatology (Oxford). 2009 Aug;48(8):867-71.

[4]Lacaille D, Guh DP, Abrahamowicz M, Anis AH, Esdaile JM. Use of non biologic disease-modifying antirheumatic drugs and risk of infection in patients with rheumatoid arthritis. Arthritis Rheum. 2008 Aug 15;59(8):1074-81.

[5]Bernatsky S, Hudson M, Suissa S. Anti-rheumatic drug use and risk of serious infections in rheumatoid arthritis. Rheumatology (Oxford). 2007 Jul;46(7):1157-60.

[6]Doran MF, Crowson CS, Pond GR, O’Fallon WM, Gabriel SE. Predictors of infection in rheumatoid arthritis. Arthritis Rheum. 2002 Sep;46(9):2294-300.

[7]Fessler BJ. Infectious diseases in systemic lupus erythematosus: risk factors, management and prophylaxis. Best Pract Res Clin Rheumatol. 2002 Apr;16(2):281-91. Review.

[8]Singh JA, Wells GA, Christensen R, Tanjong Ghogomu E, Maxwell L, Macdonald JK, Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD008794.

Acknowledgments:

None.

Disclosure of Interests:

None declared

The role of microsurgical flaps in primary burn reconstruction

Despite the wide and growing use of microsurgery, its application in primary burn reconstruction is not very frequent as it faces a number of additional challenges in this setting. A retrospective analysis of the clinical records of all patients submitted to microvascular free tissue transfer for primary burn reconstruction over an 8-year period (from January 2009 to December 2016) was performed. An evaluation of the indications, timing, principles of flap selection, complications and outcomes of free tissue transfer in primary burn reconstruction was made. Fourteen patients required 18 microsurgical flaps for acute soft tissue reconstruction (1.1% of all patients admitted). 64.3% of the patients were male. The mean age was 59.64 years, and mean TBSA was 10.5%. The majority of the injuries were caused by flames (71.4%), followed by electrical contact (21.4%). The primary indication for microsurgical reconstruction was tissue deficit with exposure of tendons, nerves, vessels, bone and/or joints after debridement. The procedure was more often performed in the early period after injury (between the 5th and 22nd day). The most frequently used flaps were the Latissimus dorsi and the anterolateral thigh flap. Major complications included 2 total flap failures (11.1%) and a partial flap failure that required reconstruction with another free flap. Microsurgical free flaps have a valuable role in primary burn reconstruction. Despite the reported higher complication rate in this specific clinical scenario, their use may reduce the total number of surgeries needed to achieve wound closure.

The REWRITE Study - REal-WoRld effectIveness of TrifluridinE/tipiracil in Patients with Previously Treated Metastatic Colorectal Cancer

AIMS

In the pivotal RECOURSE trial, trifluridine/tipiracil improved survival outcomes in refractory metastatic colorectal cancer (mCRC), while demonstrating an acceptable toxicity profile. Routine clinical practice evidence is important to support the ongoing value of recently approved medicines. Our objective was to assess the utilisation patterns and real-world effectiveness of trifluridine/tipiracil in previously treated mCRC patients.

MATERIALS AND METHODS

This was a retrospective observational study including consecutive patients who started trifluridine/tipiracil between 1 April 2018 and 30 September 2019 in the medical oncology departments of three major public hospitals in Portugal. The primary outcome measure was overall survival. Associations between overall survival and patient and tumour characteristics were assessed using multivariate Cox regression analyses.

RESULTS

In total, 111 patients were included in the study, with a mean age of 64 years. From these, 45.9% received two prior lines of treatment, 47.8% had three or more previous lines of treatment and 83.6% had Eastern Cooperative Oncology Group (ECOG) performance status 0-1 at baseline. The median duration of trifluridine/tipiracil treatment was 3.7 cycles (95% confidence interval 3.4-4.1). Most patients (80.4%) remained on their planned dose throughout the trifluridine/tipiracil treatment period, fulfilling 100% relative dose intensity. The median overall survival in the total study cohort was 7.9 months (95% confidence interval 6.4-9.8) and the median progression-free survival was 3.4 months (95% confidence interval 3.2-3.9). The median overall survival was significantly higher in patients with a normal serum lactate dehydrogenase (LDH) level (median overall survival 11.2 months for [135, 205] IU/l LDH [95% confidence interval 8.2-NR] and 13.6 months for [205, 251] IU/l LDH [95% confidence interval 8.2-NR]) and in better fitted (ECOG = 0-1) patients (median overall survival 8.0 months; 95% confidence interval 6.7-10.0). The median time to worsening performance status was 6.2 months (95% confidence interval 5.0-8.0). Treatment discontinuation due to adverse events was low (3.1%).

CONCLUSION

Our study confirms the effectiveness of trifluridine/tipiracil in real-life mCRC patients. Overall survival and progression-free survival outcomes are consistent with the efficacy profile reported in the earlier randomised RECOURSE clinical trial. Like other real-world studies, we found no additional safety concerns in the use of trifluridine/tipiracil.

Multimodality imaging in connective tissue disease-related interstitial lung disease

Interstitial lung disease is a well-recognised manifestation and a major cause of morbidity and mortality in patients with connective tissue diseases. Interstitial lung disease may arise in the context of an established connective tissue disease or be the initial manifestation of an otherwise occult autoimmune disorder. Early detection and characterisation are paramount for adequate patient management and require a multidisciplinary approach, in which imaging plays a vital role. Computed tomography is currently the imaging method of choice; however, other imaging techniques have recently been investigated, namely ultrasound, magnetic resonance imaging, and positron-emission tomography, with promising results. The aim of this review is to describe the imaging findings of connective tissue disease-related interstitial lung disease and explain the role of each imaging technique in diagnosis and disease characterisation.