Cutaneous Cryptococcosis Manifested as a Large Cystic Mass: A Rare Manifestation of Cryptococcus Infection

Cryptococcus infection is an invasive fungal infection common in immunocompromised hosts, especially in organ transplant recipients and in patients with HIV. Its presentation varies from localized skin lesions to systemic disseminated infection involving the lungs and the central nervous system (CNS). We present the case of a 50-year-old woman with diabetes mellitus type 2 (DM-2), end-stage renal disease (ESRD) status post deceased donor kidney transplantation seven and a half years ago who presented with a low-grade fever, cough, nausea, vomiting, and a large cystic mass on the right foot. A CT scan of the chest showed a 14 mm cavitary lesion in the middle lobe of the right lung. Serum and cerebrospinal fluid cryptococcal antigens were detected. MRI of the right foot showed a large multilocular lobulated septated cystic mass. Histopathology showed cryptococcus; the diagnosis was made as disseminated cryptococcus infection. She was treated with antifungal therapy successfully. A large cutaneous cystic mass is a rare cutaneous presentation of cryptococcus infection; clinicians should keep it in the differential diagnosis, especially in transplant recipient patients.

A Case of Acute Encephalitis in COVID-19 Patient: A Rare Complication

Coronavirus disease 19 (COVID-19) is a respiratory disease, has a variable presentation, and neurological involvement in COVID-19 is not widely reported. We report a rare case of acute encephalitis in a COVID-19 patient presented with fever, dry cough, and dyspnea. She had a fever, tachypnea, and tachycardia. On auscultation, she had scattered wheezing in both lung fiends. Chest X-ray revealed small infiltrates in the lower lobe of both lungs. A nasopharyngeal swab for the COVID-19 polymerase chain reaction was positive. Later on, she developed sudden onset confusion accompanied by restlessness and visual hallucinations. Neurological examination revealed an altered level of consciousness, slight trembling of the limbs, psychomotor restlessness, and poor speech with no signs of meningeal irritation. Magnetic resonance imaging of the brain revealed diffuse hyperintense signals. A possible diagnosis of acute encephalitis was made due to concurrent COVID-19 infection and lack of other findings suggesting a diagnosis other than COVID-19. She was treated with azithromycin, tocilizumab, and methylprednisolone. Her condition started improving gradually.

Comparison of Iron Profile in Patients With and Without Coronary Heart Disease

Introduction Atherosclerosis is considered a major cause of coronary artery disease (CAD). Pathogenesis of atherosclerosis involves the oxidation of low-density lipoprotein (LDL) within the lysosomes of macrophages. Ferritin and iron have pro-oxidant properties, and ferritin is an independent positive determinant of oxidized LDL level. In this study, we will determine the association between ferritin and serum iron levels and CAD. Methods This case-control study was conducted in the cardiology unit of a tertiary care hospital in Pakistan from December 2020 to April 2021. After taking informed consent, 400 patients with a confirmed diagnosis of CAD were enrolled. Another set of 400 patients without a history of CAD were included in the control group. A blood sample of 5 ml was drawn and sent to the laboratory to test for ferritin, serum iron, and total iron-binding capacity (TIBC). Ferritin, serum iron, and iron-binding capacity were compared between the case and control groups.  Results Serum ferritin was significantly higher in patients with CAD compared to patients without CAD (921.21 ± 201.21 ug/L vs. 101.21 ± 92.21 ug/L; p-value: <0.0001). Serum TIBC was significantly lower in patients with CAD compared to patients without CAD (302.12 ± 101.75 umol/L vs. 362.12 ± 82.16 umol/L). Conclusion Patients with raised levels of ferritin should consult a physician to manage their ferritin levels since they are at a greater risk of CAD. Treatment ranges from lifestyle changes to pharmacological therapy, thus reducing the overall risk and normalizing the ferritin levels.

Association Between Diabetic Retinopathy and Carotid Intima-Media Thickness

Introduction

Patients with diabetes having advanced stage of diabetic retinopathy (DR) may predict future risk of coronary artery disease. To predict cardiovascular outcomes carotid intima-media thickness (CIMT) is utilized in diabetic patients. The aim of our study was the evaluation of the relationship between retinopathy and CIMT as two valuable non-invasive methods for early detection of micro- and macrovascular complication of diabetes.

Methods

This comparative cross-sectional study was conducted in the internal medicine ward of tertiary care hospital in Pakistan from November 2020 to January 2021. Three hundred patients with type 2 diabetes mellitus and 300 control subjects were enrolled in the study after taking informed consent. Ophthalmological examination was done to screen patients for DR. CIMT was evaluated by a Doppler ultrasound for both carotid arteries.

Results

Carotid artery intimal thickness was more in patients with retinopathy compared to patients without retinopathy in both right (0.77 ± 0.16 vs. 0.66 ± 0.12; p-value: <0.0001) and left carotid artery (0.77 ± 0.15 vs. 0.65 ± 0.11; p-value: <0.0001).

Conclusion

In our study, there was a correlation between DR and CIMT. Screening for DR, which may be a potential early marker for complications, may help detect patients at risk of various macro and microvascular complications.

Role of Cod Liver Oil in Reducing Elevated Lipid Parameters

Introduction

The health benefits of cod oil, which includes omega-3 fatty acids, have been of considerable interest to medicine due to its promising results. Studies have shown successful therapeutic effects of a high dietary intake of omega-3 fatty acids by reducing the synthesis of very-low-density lipoprotein, with subsequent low levels of serum triglycerides. 

Methods

This single-blind placebo-controlled two-arm interventional study was conducted in the internal medicine unit of a tertiary care hospital from October 2020 to April 2021. 600 treatment naïve patients with elevated cholesterol levels and/or elevated low-density lipoprotein (LDL) were enrolled in the study and randomized into two groups. The study group received 415 mg cod liver oil daily as a capsule in a bottle, in addition to 10 mg rosuvastatin. On the other hand, the control group received 10 mg rosuvastatin with placebo capsules in an identical bottle. Participants were followed up on day 30.

Results

There was relatively more significant reductions in the total cholesterol (152.22 ± 29.75 mg/dL vs. 171.65 ± 31.21 mg/dL; p-value: <0.0001) and LDL (72.41 ± 27.52 mg/dL vs. 79.15 ± 29.12 mg/dL; p-value: <0.0001) in the intervention group compared to the placebo group after day 30. There was a significant reduction in all lipid values in both groups at day 30 as compared to day 0.

Conclusion

Our study indicates that cod liver oil in addition to rosuvastatin reduces cholesterol more compared to rosuvastatin alone. However, in all cases, lifestyle changes should be the first modification adopted by the patients. Further large-scale trials are needed to examine the role of cod liver oil in reducing lipid values.

Epstein-Barr-positive classical Hodgkin lymphoma-associated haemophagocytic lymphohistocytiosis: a rare case

Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition, which is usually triggered by autoimmune disorders, viral infections and malignancy, like lymphomas. We present a 60-year-old Hispanic woman with a medical history of hypertension and systemic lupus erythematosus presenting with fever, generalised weakness and shortness of breath for 3 weeks. She was hypotensive on presentation, and a CT scan of abdomen/chest showed multiple irregular hepatic and splenic hypodense lesions. A liver biopsy revealed Classical Hodgkin lymphoma (cHL) with positive Epstein-Barr virus (EBV) staining that was later confirmed with high serum EBV DNA levels. Incidentally, a liver biopsy disclosed haemophagocytosis in some cells. HLH-associated cHL is an uncommon condition that can cause severe systemic symptoms acting as the perfect mimic of septic shock, deviating the clinical eye toward treating with antibiotics and not addressing in a timely manner the real aetiology of the patient's condition.

The Jerusalem Balsam: from the Franciscan Monastery in the old city of Jerusalem to Martindale 33

The Jerusalem Balsam, a remedy based on an ethanolic extract of a herbal mixture, was formulated in 1719 in the pharmacy of the Saint Savior monastery in the old city of Jerusalem. Having gained fame, the Jerusalem Balsam was replicated and prepared in Europe. One can still find variations of the formula in current pharmacopoeias (B.P., 1998. The Stationary Office, London, p. 1510; Sweetman, S.C., Blake, P.S., McGlashan, J.M., Parsons, A.V., 2002. Martindale: The Extra Pharmacopeia, 33rd ed. Pharmaceutical Press, London, p. 1101). We report here, five different formulas, all referred to as "The Jerusalem Balsam". Three of those formulas were translated and two of these translations are presented in the text. A third one is available as Supplementary data online. As the formulas originate from different historical periods, the Jerusalem Balsam may be a good case study of the development of pharmaceutical formulations over a 250 years period. One of the formulas, found in a manuscript form in the archive of the monastery, contains four plants: olibanum (Boswellia spp.), myrrh (Commiphora spp.), aloe (Aloe sp.) and mastic (Pistacia lentiscus L.). We conducted pharmacological assays on this four-plant formula. It showed anti-inflammatory, as well as anti-oxidative, and anti-septic properties.

Ethnopharmacological survey of traditional drugs sold in Israel at the end of the 20th century

This report deals with the results of a study of present day uses of traditional medicinal materials in Israel. The survey covered selected markets in medicinal materials, belonging to various religious and ethnic communities, and also included questioning of the sellers and buyers about the healing characteristics of the various materials. The survey yielded information on many and varied medicinal materials, of which 310 are identified according to the following classifications, 264 species of plants (85.1%); 20 species of animals (6.5%); 19 kinds of minerals (6.5%); and seven materials of other or mixed origin (2.3%). Analysis of the data showed that a significant proportion of the materials were of local origin (51.5%) and some were imported from other countries. These data demonstrate that there is still a flourishing and well developed trade in these materials - a trade which is the remnant of a rich and ancient medical culture, which is disappearing from the modern world.