Parsonage-Turner syndrome following chikungunya virus infection:A case report

Rationale: Parsonage-Turner syndrome is a rare syndrome of unknown etiology, affecting mainly the lower motor neurons of the brachial plexus.Chikungunya fever is a mosquito-borne viral disease characterized by acute fever and polyarthritis/polyarthralgia.Patient concerns: A 54-year-old Brazilian male patient who presented with a 2-day history of fever(temperature 38.8 ℃), arthralgia, erythematous rash, diffuse osteomuscular pain and headache, which evolved into left shoulder pain associated with morning stiffness.Diagnosis: Parsonage-Turner syndrome and chikungunya fever.Interventions: Symptomatic treatment(a combination of short-acting dypirone(500 mg every 6 h) and slow-release opioids(tramadol 100 mg every 4 h) and physiotherapy/rehabilitation with improvement.Outcomes: The patient was improved and discharged, remaining with symptomatic treatment and physiotherapy/rehabilitation.Lessons: To the best of our knowledge, there were no reports of Parsonage-Turner syndrome following chikungunya virus infection.Awareness of the possibility of this rare association is important.The present case report highlights the importance of awareness of this association as a new cause of morbidity in patients with chikungunya virus infection.     

Clinical outcomes of hospitalized patients with chikungunya fever: A retrospective analysis

Objective:To describe the prognostic and clinical profile of hospitalized patients with chikungunya virus(CHIKV)infection focusing on renal outcomes.Methods:This is a cross-sectional study including all patients with confirmed chikungunya fever(CHIKF)admitted to 3 different highcomplexity hospitals in Fortaleza,Brazil between January 2016 and June 2017.Data analysis was carried out to evaluate correlation between clinical profile and outcomes.Results:Fifty-five patients were included,with a median age of 77(IQR=21)years,and 23(41.82%)were male.Twenty-five patients(45.45%,25/55)developed acute kidney injury(AKI),and 15(60.00%,15/25)were classified as KDIGO 1,1(4.00%)as KDIGO 2,and 9(36.00%)as KDIGO 3.The overall mortality was 34.54%whilst AKI-related mortality was 64.00%(16/25).Both AKI and encephalitis were associated with higher mortality.Patients who died were significantly older[82(IQR=12)years vs.70(IQR=28.75)years,P<0.001].In the multivariate analysis,abdominal pain was associated with an increased risk of severe AKI(OR=5.33,95%CI=1.11–25.64,P=0.037)and AKI was an independent risk factor of death(OR=12.06,95%CI=2.55–57.15,P=0.002).Recovery of renal function was similar among the different age groups.Conclusions:AKI is present in half of the study population and is an independent risk factor of death.Thus,renal function should be carefully monitored in hospitalized patients with CHIKV infection.     

Differential diagnosis of left-sided abdominal pain:Primary epiploic appendagitis vs colonic diverticulitis

AIM:To investigate the clinical characteristics of left primary epiploic appendagitis and to compare them with those of left colonic diverticulitis.METHODS:We retrospectively reviewed the clinical records and radiologic images of the patients who presented with left-sided acute abdominal pain and had computer tomography(CT) performed at the time of presentation showing radiological signs of left primary epiploic appendagitis(PEA) or left acute colonic diverticulitis(ACD) between January 2001 and December 2011. A total of 53 consecutive patients were enrolled and evaluated. We also compared the clinical characteristics,laboratory findings,treatments,and clinical results of left PEA with those of left ACD.RESULTS:Twenty-eight patients and twenty-five patients were diagnosed with symptomatic left PEA and ACD,respectively. The patients with left PEA had focal abdominal tenderness on the left lower quadrant(82.1%). On CT examination,most(89.3%) of the patients with left PEA were found to have an oval fatty mass with a hyperattenuated ring sign. In cases of left ACD,the patients presented with a more diffuse abdominal tenderness throughout the left side(52.0%vs 14.3%; P = 0.003). The patients with left ACD had fever and rebound tenderness more often than those with left PEA(40.0% vs 7.1%,P = 0.004; 52.0% vs14.3%,P = 0.003,respectively). Laboratory abnormalities such as leukocytosis were also more frequently observed in left ACD(52.0% vs 15.4%,P = 0.006).CONCLUSION:If patients have left-sided localized abdominal pain without associated symptoms or laboratory abnormalities,clinicians should suspect the diagnosis of PEA and consider a CT scan.     

老挝基孔肯雅热流行特征研究进展

基孔肯雅热(Chikungunya fever, CHIKF)是经携带基孔肯雅病毒(Chikungunya virus, CHIKV)的白纹伊蚊或埃及伊蚊叮咬人类,出现以发热、关节痛、关节炎、皮疹为主要临床表现的急性病毒性传染病,广泛流行于热带与亚热带地区。以往老挝主要采用CHIKV血清学抗体检测方法发现老挝存在基孔肯雅热低度流行,2012年采用病原学检测方法(CHIKV RT-PCR)首次在老挝南部占巴塞省(Champasak)证实了CHIKV在老挝的分布。近年来通过CHIKV的调查、监测及其相关研究,基本弄清了老挝基孔肯雅热流行特征,本文综述了老挝基孔肯雅热流行特征研究进展。     

Outcome of surgical treatment of intestinal perforation in typhoid fever

AIM:To represent our clinical experience in the treatment of intestinal perforation arising from typhoid fever.METHODS:The records of 22 surgically-treated patients with typhoid intestinal perforation were evaluated retrospectively.RESULTS:There were 18 males and 4 females,mean age 37 years(range,8-64 years).Presenting symptoms were fever,abdominal pain,diarrhea or constipation.Sixteen cases were subjected to segmental resection and end-to-end anastomosis,while 3 cases received 2-layered primary repair foll...     

All ileo-cecal ulcers are not Crohn's:Changing perspectives of symptomatic ileocecal ulcers

AIM To investigated clinical,endoscopic and histopathological parameters of the patients presenting with ileocecal ulcers on colonoscopy.METHODS Consecutive symptomatic patients undergoing colonoscopy,and diagnosed to have ulcerations in the ileocecal(I/C) region,were enrolled.Biopsy was obtained and theirclinical presentation and outcome were recorded.RESULTS Out of 1632 colonoscopies,104 patients had ulcerations in the I/C region and were included in the study.Their median age was 44.5 years and 59% were males.The predominant presentation was lower GI bleed(55,53%),pain abdomen ± diarrhea(36,35%),fever(32,31%),and diarrhea alone(9,9%).On colonoscopy,terminal ileum was entered in 96(92%) cases.The distribution of ulcers was as follows:Ileum alone 40%(38/96),cecum alone 33%(32/96),and both ileum plus cecum 27%(26/96).The ulcers were multiple in 98% and in 34% there were additional ulcers elsewhere in colon.Based on clinical presentation and investigations,the etiology of ulcers was classified into infective causes(43%) and noninfective causes(57%).Fourteen patients(13%) were diagnosed to have Crohn's disease(CD).CONCLUSION Non-specific ileocecal ulcers are most common ulcers seen in ileo-cecal region.And if all infections are clubbed together then infection is the most common( 40%) cause of ulcerations of the I/C region.Cecal involvement and fever are important clues to infective cause.On the contrary CD account for only 13% cases as a cause of ileo-cecalulcers.So all symptomatic patients with I/C ulcers on colonoscopy are not Crohn's.     

Giardiasis in patients with dyspeptic symptoms

AIM: To investigate the prevalence of giardiasis in patients with dyspeptic symptoms. METHODS: Clinical records of consecutive patients who attended Gastroenterology Department at Aga Khan University Hospital from January 2000 to June 2003 and had esophagogastroduodenoscopy (EGD) with duodenal biopsies and international classification of diseases 9th revision with clinical modifications (ICD-9-CM) coded with giardiasis were studied. RESULTS: Two hundred and twenty patients fulfilled the above criteria. There were 44% (96/220) patients who were giardiasis positive, 72% (69/96) of them were males and 28% (27/96) of them were females. There were 65% (81/124) males and 35% (43/124) females who were giardiasis negative. The mean age of patients with giardiasis was 28±17 years, while that of giardiasis negative patients was 40±18 years (P<0.001). In patients with giardiasis, abdominal pain was present in 71% (68/96) of patients (P = 0.02) and diarrhea in 29% (28/96) (P = 0.005); duodenitis in 25% (24/96) on EGD (P = 0.006) and in 68% (65/96) on histopathology (P = 0.002). CONCLUSION: Giardiasis occurs significantly in young people with abdominal pain, while endoscopic duodenitis is seen in only 25% of giardiasis positive cases, which supports routine duodenal biopsy.     

Undifferentiated liver embryonal sarcoma in adults: A report of four cases and literature review

AIM: To evaluate the undifferentiated embryonal sarcoma of liver (UESL) in adults in order to improve its diagnosis and treatment. METHODS: Four primary and one recurrent cases of UESL were clinicopathologically evaluated and immunohistochemically investigated with a panel of antibodies using the EnVision+ system. Relevant literature about UESL in adults was reviewed. RESULTS: Three males and one female were enrolled in this study. Their chief complaints were abdominal pain, weight loss, or fever. Laborator...     

Tuberculosis of pancreas and peripancreatic lymph nodes in immunocompetent patients： experience from China

AIM: To determine the clinical, radiographic and laboratory characteristics, diagnostic methods, and therapeutic variables in immunocompetent patients with tuberculosis (TB) of the pancreas and peripancreatic lymph nodes. METHODS: The records of 16 patients (6 male, 10 female;mean age 37 years, range 18-56years) with tuberculosis of the pancreas and peripancreatic lymph nodes from 1983 to 2001 in the Southwest Hospital were analyzed retrospectively.In addition, 58 similar cases published in Chinese literature were reviewed and summarized. We reviewed the clinical,radiographic and laboratory findings, diagnostic methods,therapeutic approaches, and outcome in the patients. Criteria for the diagnosis of pancreatic tuberculosis were the presence of granuloma in histological sections or the presence of Mycobacterium tuberculosis DNA by polymerase chain reaction (PCR). RESULTS: Predominant symptoms consisted of abdominal nodule and pain (75 ％), anorexia/weight loss (69 ％),malaise/weakness (64 ％), fever and night sweats (50 ％),back pain (38 ％) and jaundice (31％). Swelling of the head of the pancreas with heterogeneous attenuation echo was detected with ultrasound in 75 ％ (12/16). CT scan showed pancreatic mass with heterogeneous hypodensity focus in all patients, with calcification in 56 ％ (9/16) patients, and peripancreatic nodules in 38 ％ (6/16)patients. Anemia and lymphocytopenia were seen in 50 ％(8/16) patients, and pancytopenia occurred in 13 ％ (2/16) patients. Hypertransaminasemia, elevated alkaline phosphatase (AP) and GGT were seen in 56 ％ (9/16)patients. The erythrocyte sedimentation rate (ESR) was elevated in 69 ％ (11/16) cases. Granulomas were found in 75 ％ (12/16) cases, and in 38 ％ (6/16) cases caseous necrosis tissue was found. Laparotomy was performed in 75 ％ (12/16) cases, and ultrasound-guided fine needle aspiration (FNA) was done in 63 ％ (10 of 16). The most commonly used combinations of medications were isoniazid/rifampin/streptomycin (63 ％, n=10) and isoniazid/rifampin pyrazinamide/streptomycin or ethambutol (38 ％, n=6). The duration of treatment lasted for half or one year and treatment was successful in all cases. The characteristics of 58 cases from Chinese literature were also summarized. CONCLUSION: Tuberculosis of the pancreas and peripancreatic lymph nodes should be considered as a diagnostic possibility in patients presenting with a pancreatic mass, and diagnosis without laparotomy is possible if only doctors are aware of its clinical features and investigate it with appropriate modalities. Pancreatic tuberculosis can be effectively cured by antituberculous drugs.     

基孔肯雅病毒实验诊断进展

基孔肯雅病毒属于披膜病毒科甲病毒属,主要通过携带病毒的蚊媒叮咬感染人类引起基孔肯雅热,表现为自限性发热、皮疹、肌痛、关节痛,其中关节疼痛可延续数月至数年,甚至导致关节畸形。由于基孔肯雅病毒与登革病毒、寨卡病毒等虫媒病毒具有相同的传播媒介,且急性期临床症状相似,但治疗原则与疾病结局完全不同,因此,实验室的确切诊断是基孔肯雅热防治的关键。本文就近几年基孔肯雅病毒在实验室诊断方面的进展作一综述。     

Clinico-epidemiological profile of cases of fever with arthritis (Chikugunya) attending Urban Health Centre, Solapur

This communication describes the findings of a hospital and community survey conducted in the UHC catchment area of solapur city to find out clinico-epidemiological profile of cases of chikungunya fever during mid 2006. A total of 208 cases who attended UHC and 962 community members were studied. 20-44 was the mostly affected age-group and Females outnumber male hospital attendees. Major presenting features were fever, joint pain, bodyache, headache, nausea. In majority of patients, joint pain lasted for two months and subsided by 6th month. Of 21 samples tested, 19 showed IgM positivity for chikungunya.     

Clinical features of chikungunya infection in Sri Lanka

Objective

To investigate the clinical features of chikungunya fever (CHIKF) outbreak in Sri Lanka in 2006 and to estimate the relative risk for CHIKF for various demographic factors.

Methods

A total of 885 individuals belonging to 200 families were studied individually for surveillance of this disease, symptoms, contraction order within the family and means of treatments. Relative risks for CHIKF for demographic characters such as gender, age and educational levels were estimated. The associations of symptoms with age and gender were also studied.

Results

The estimated surveillance of CHIKF in the studied population was 89.2%. The duration of suffering due to this disease was 50.9 d (95% CI, 47.3, 53.9 d) with fever for 3.9 d (95% CI, 3.7, 4.1 d). 93% of the CHIKF patients felt at least one type of joint pain and 8% felt joint swellings. Rash was observed in 15.1% of the patients. Buccal bleeding and mouth ulcer were observed in 1.5% and 9.3% respectively. About 22.7% of the CHIKF patients had vomiting. Female had 1.48 folder higher relative risk for CHIKF infection. The duration suffered due to CHIKF, duration of fever and contraction order within family were highly associated with age (P<0.000). Female patients had more than one folder higher relative risks for the symptoms such as rash, vomiting, buccal bleeding and mouth ulcer (P<0.000).

Conclusions

The surveillance of CHIKF in Sri Lanka was a severe outbreak which infected much on female and caused more suffering on aged population. The symptoms such as rash, bleeding from mucosa, mouth ulcer and vomiting were highly associated with gender. The reasons for these observations need to be further explored.     

Field evaluation of clinical features during chikungunya outbreak in Mayotte, 2005–2006

Background To record and assess the clinical features of chikungunya fever (CHIKF), with a view to enable diagnosis based on clinical criteria rather than costly laboratory procedures in field conditions. Methods As part of a cross‐sectional serologic survey conducted in Mayotte after a massive chikungunya outbreak in 2006, we collected data on clinical features of chikungunya infection and assessed the performance and accuracy of clinical case definition criteria combining different symptoms. Results Of 1154 participants included, 440 (38.1%) had chikungunya‐specific IgM or IgG antibodies by enzyme‐linked immunosorbent assay (ELISA). Of symptomatic participants, 318 (72.3%) had confirmed chikungunya, the dominant symptoms reported were incapacitating polyarthralgia (98.7%), myalgia (93.1%), backache (86%), fever of abrupt onset (85%) and headache (81.4%). There was a strong linear association between symptomatic infection and age (χ² for trend = 9.85, P < 0.001). Only 52% of persons with presumptive chikungunya sought medical advice, principally at public primary health care facilities. The association of fever and polyarthralgia had a sensitivity of 84% (95% CI: 79–87) and a specificity of 89% (95% CI: 86–91). This association allowed to classify correctly 87% (95% CI: 85–89) of individuals with serologically confirmed chikungunya. Conclusions Our results suggest that the pair fever and incapacitating polyarthralgia is an accurate and reliable tool for identifying presumptive CHIKF cases in the field. These criteria provide a useful evidence base to support operational syndromic surveillance in laboratory‐confirmed chikungunya epidemic settings.     

Multisystem inflammatory syndrome in children during the COVID-19 pandemic in Turkey: first report from the Eastern Mediterranean

Objective

We aimed to describe the typical clinical and laboratory features and treatment of children diagnosed with multisystem inflammatory syndrome in children (MIS-C) and to understand the differences as compared to severe/critical pediatric cases with COVID-19 in an eastern Mediterranean country.

Methods

Children (aged <18 years) who diagnosed with MIS-C and severe/critical pediatric cases with COVID-19 and were admitted to hospital between March 26 and November 3, 2020 were enrolled in the study.

Results

A total of 52 patients, 22 patients diagnosed with COVID-19 with severe/critical disease course and 30 patients diagnosed with MIS-C, were included in the study. Although severe COVID-19 cases and cases with MIS-C share many clinical and laboratory features, MIS-C cases had longer fever duration and higher rate of the existence of rash, conjunctival injection, peripheral edema, abdominal pain, altered mental status, and myalgia than in severe cases (p<0.001 for each). Of all, 53.3% of MIS-C cases had the evidence of myocardial involvement as compared to severe cases (27.2%). Additionally, C-reactive protein (CRP) and white blood cell (WBC) are the independent predictors for the diagnosis of MIS-C, particularly in the existence of conjunctival injection and rash. Corticosteroids, intravenous immunoglobulin (IVIG), and biologic immunomodulatory treatments were mainly used in MIS-C cases rather than cases with severe disease course. There were only three deaths among 52 patients, one of whom had Burkitt lymphoma and the two cases with severe COVID-19 of late referral.

Conclusion

Differences between clinical presentations, acute phase responses, organ involvements, and management strategies indicate that MIS-C might be a distinct immunopathogenic disease as compared to pediatric COVID-19. Conjunctival injection and higher CRP and low WBC count are reliable diagnostic parameters for MIS-C cases.

68 例登革热患者的临床诊治特点分析

目的 探讨登革热的临床病程及诊治特点,为登革热的临床诊治提供一定的参考依据。方法 对2013 年8 月~2013 年11 月期间我科收住的68 例登革热患者从临床表现特点、实验室检查、治疗过程及治疗效果、预后等方面进行分析总结。结果 临床主要表现为发热、皮疹、肌肉关节痛、血白细胞下降等。治疗以对症支持的综合治疗为主,预后较好,本组临床治愈67 例,1 例重型登革热表现为持续高热、消化道大出血死亡。结论 对于持续高热伴有皮疹、肌肉关节痛、血白细胞下降等的患者应注意排查诊断登革热,登革病毒抗体阳性有助于确诊本病。治疗以对症支持、预防并发症为主,预后良好。     

基孔肯雅病毒小鼠感染模型研究进展

基孔肯雅病毒(Chikungunya virus, CHIKV)感染引发的基孔肯雅热是一种主要经伊蚊叮咬而传播的虫媒传染病,近些年已在100多个国家流行或暴发,成为严重威胁全球公共卫生安全的虫媒病毒性传染病。CHIKV感染后可以引起急性发热、皮疹、肌肉疼痛以及慢性关节炎、腱鞘炎等临床症状,严重者可发生病毒性脑炎。小鼠模型作为CHIKV最常用的动物感染模型,在病毒感染机理、宿主抗感染免疫机制以及相关疫苗或药物研发等方面应用广泛。本文拟就国内外关于基孔肯雅病毒小鼠感染模型的最新研究进展作一综述。     

Pre-engraftment syndrome after unrelated donor umbilical cord blood transplantation in patients with hematologic malignancies

Pre-engraftment syndrome (PES) after umbilical cord blood transplantation (CBT) remains poorly characterized, and the prognosis and appropriate management are unclear. Therefore, we retrospectively analyzed the incidence, risk factors, manifestations, and clinical outcomes of PES in CBT recipients, who had been treated for hematologic malignancies at our transplantation center. PES was defined as unexplained fever higher than 38.3°C that is not associated with documented infection and unresponsive to antimicrobial manipulations and/or unexplained erythematous skin rash occurring prior to neutrophil engraftment. A total of 81 patients (median 18 yr, range 3-48) received either myeloablative (n=72) or non-myeloablative (n=9) conditioning. Neutrophil engraftment was achieved in 69 of the 81 cases [86.2%, 95% confidence interval (CI)=78.9-94.1%], and the median time to more than 0.5 × 10(9) /L ANC was 19 d (range, 12-39). Fifty-one patients (63.0%) developed PES at a median of 7d (range 3-15) post-transplant: 46 patients had both rash and unexplained fever; one patient had unexplained fever alone; and four patients had rash only. Forty-seven patients (92.2%) received IV methylprednisolone (MP) at a median dose of 1 mg/kg (range 0.4-3). All patients treated with MP responded as evidenced by fever resolution combined with resolution of rash. All patients with PES had high serum levels of C-reactive protein (CRP), which were significantly reduced after effective steroid treatment. Univariate analysis identified myeloablative conditioning and younger age as significant risk factors for developing PES. Cumulative incidence of grade II-IV acute graft-versus-host disease (aGVHD) in the PES+ and PES- groups was 51.5% (95% CI=38.0-70.0%) and 17.0% (95% CI=6.9-41.7%), respectively. In a multivariate analysis, we found significantly increased risk of grade II-IV aGVHD among PES patients (P=0.041). However, PES was not associated with sustained donor engraftment, the day to neutrophil recovery, chronic graft-versus-host disease, transplant-related mortality at day 180, and overall survival. Despite of the inherent limitations of this small retrospective study, PES seemed to be common after CBT and associated with high incidence of aGVHD.     

Methotrexate and hydroxychloroquine combination therapy in chronic chikungunya arthritis: a 16 week study

ObjectiveTo study the clinical profile of patients of chronic chikungunya arthritis presenting to a rheumatology OPD in the Western part of India and to judge the treatment response to the disease modifying drugs (methotrexate and hydroxychloroquine) used to treat them.Materials and methodsThe diagnosis of chronic chikungunya arthritis was based on clinical criteria only. All patients giving a history of fever with arthritis starting during the epidemic of chikungunya in the Western part of India (August–September 2006) and having had the arthritis for > 3 months since then were included in the study. Baseline clinical characteristics were calculated. Most patients received methotrexate (15 to 20 mg weekly) and hydroxychloroquine for their chronic arthritis and their ACR 20, 50 and 70 responses and EULAR remission and EULAR good response based on DAS 28 ESR were calculated.ResultsA total of 305 patients presented to the OPD till March 2008. Mean age of the patients was 49 years. Female to male ratio was 2.8:1 (223:82). The other mean baseline values were: patients global 6 (0 to 10, 0 best), physician's global 5.8 (0 to 10, 0 best), HAQ score 1.6 (0 to 3), swollen joint count 8.8 (28 joint count), tender joint count 14 (28 joint count), ESR 52 mm first hour (Westergren). About one-third of the patients had parasthesias in the carpal tunnel distribution. Rheumatoid factor was positive in 76 out of 256 when it was done (29.7%) and anti-CCP was positive in 6/73 when it was done. Data needed for judging treatment response was available in 149 patients at a mean follow up of 16 weeks period and they received combination of methotrexate and hydroxychloroquine. ACR 20 was achieved in 73/149 (48.9%), ACR 50 in 28/149 (18.8%) and ACR 70 in 6/149 (4%). Only one of the patients achieved EULAR remission (DAS 28 ESR < 2.6) and four others achieved EULAR good response (DAS 28 ESR < 3.2) at the end of 16 weeks. None of the patients had any adverse effect to the DMARDs used.ConclusionChronic chikungunya arthritis is a significant cause of morbidity in this part of the world. In this analysis most patients were middle aged and female to male ratio was 3:1. About one-third of the patients reported carpal tunnel symptoms. About half of the patients who received the combination of methotrexate and hydroxychloroquine achieved an ACR 20 response at 16 weeks.