Presence of perineuritis in a case of papular purpuric gloves and socks syndrome associated with mononeuritis multiplex attributable to B19 parvovirus

A previously healthy 16-year-old boy developed papular purpuric gloves and socks syndrome concomitant with mononeuritis multiplex attributable to acute infection with parvovirus B19. A cutaneous biopsy showed lymphocytic lichenoid vasculitis and perineuritis. We discuss the relevance of these pathologic findings, and we suggest a correlation with the patient's neurologic condition. This case illustrates the difficulties in differentiating dysesthesia accompanying cutaneous manifestations of exanthem from neurologic disease on the basis of the clinical appearance alone.     

Gestational diabetes mellitus causes changes in the concentrations of adipocyte fatty acid-binding protein and other adipocytokines in cord blood

OBJECTIVE

To determine the concentrations of adipocyte fatty acid–binding protein (AFABP) and other adipocytokines in maternal and cord serum of pregnant women with gestational diabetes mellitus (GDM) and of control subjects and to relate them to indexes of insulin sensitivity.

RESEARCH DESIGN AND METHODS

In 86 control and 98 GDM pregnant women, venous blood was collected before vaginal delivery and arterial blood from cord immediately after delivery. Serum insulin and adipocytokines were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

GDM women had higher prepregnancy BMI, and data were adjusted for it. Maternal serum insulin, insulin-to-glucose ratio, homeostasis model assessment (HOMA), AFABP, and retinol-binding protein 4 (RBP4) were higher and adiponectin was lower in GDM than in control subjects, whereas serum glucose, insulin, insulin-to-glucose ratio, HOMA, nonesterified fatty acids, and RBP4 were higher and glycerol, AFABP, and adiponectin were lower in cord blood serum of GDM than of control subjects. AFABP and adiponectin in cord serum of control subjects were higher than in maternal serum; in GDM women no difference was found for AFABP in cord versus maternal serum, although adiponectin remained higher in cord. Values of leptin in both groups were lower in cord than in maternal serum, and those of RBP4 were lower in only GDM women.

CONCLUSIONS

It is suggested that fetal tissues are the main source of cord arterial serum AFABP, and in GDM fetuses AFABP values correlate with adiposity markers. A downregulation of adiponectin and upregulation of RBP4 in GDM mothers and their fetuses may be related to their insulin-resistant condition, whereas changes in AFABP do not seem to be related.Pregnancy is associated with substantial changes in maternal metabolism, which provide sufficient energy and nutrients to the fetus. Glucose is the primary source of energy for the fetoplacental tissues but, because the fetus only produces glucose under extreme conditions, it is necessary to ensure its transport through the placenta. In this context, the mother develops a state of insulin resistance during midpregnancy and progressing through the third trimester, which reduces the consumption of glucose by maternal tissues and increases gluconeogenesis enabling a sufficient supply of glucose to the fetus (1). This causes a positive maternal-fetal glucose gradient, which facilitates its placental transfer. However, in a substantial proportion of pregnancies, the insulin-resistant condition is greatly increased and gestational diabetes mellitus (GDM) develops (2); the consequent adverse metabolic state results in complications for the mother, the fetus, and the neonate (3).The mechanisms responsible for the development of GDM are unclear, but mechanisms similar to those in type 2 diabetes have been implicated (4), supporting the notion that the two conditions have similar underlying pathophysiology. Adipose tissue secretes several specific proteins called adipocytokines that modulate the action of insulin in different tissues (5), suggesting that alterations in the expression and secretion of these factors may be linked to GDM and related diseases. Recently, adipocyte fatty acid–binding protein (AFABP), a member of the mammalian intracellular fatty acid–binding protein multigene family (6), was described as a novel adipocytokine. This protein is responsible for intracellular fatty acid trafficking and contributes to the regulation of hormone-sensitive lipase activity (7). Moreover, mice deficient in AFABP are protected from development of hyperinsulinemia, hyperglycemia, and insulin resistance (8,9). Recent studies have shown that AFABP is present in human serum (10), and its levels are associated with insulin resistance and type 2 diabetes (10,11). Therefore, in adults, AFABP concentrations have been considered an independent predictor of diabetes, contributing to the control of systemic insulin sensitivity and of lipid and glucose metabolism. So far there is only one study where the level of AFABP in GDM women at midpregnancy has been determined (12), and no information is available on its levels either during late pregnancy or in cord serum. Thus, the objectives of the current study were to measure the concentrations of AFABP in maternal and cord serum of control and GDM pregnant women and to examine its relationship with glycemia and other related variables.     

Primary antimicrobial resistance rates and prevalence of Helicobacter pylori infection in the north of Spain. A 13-year retrospective study

ObjectiveHelicobacter pylori resistance to antimicrobial agents is on the rise and it is thus imperative to be aware of local resistance rates. The main objective of the present study was to describe the evolution of primary antimicrobial resistance in H. pylori, analysing its antibiotic susceptibility over a 13-year period in a region of northern Spain, as well as host-related factors.Patients and methodsBetween 2004 and 2016 a total of 3426 patients who met the H. pylori eradication criteria underwent gastroscopy. The gastric biopsies were processed and those testing positive for H. pylori were identified and tested for clarithromycin, metronidazole and levofloxacin susceptibility using E-test.ResultsH. pylori was isolated in 1604 (47%) patients, ranging from 63% (133/212) in 2004 to 39% (137/347) in 2016. Primary resistances to clarithromycin, metronidazole and levofloxacin were on average 19% (278/1116), 40% (572/865) and 17% (137/669), respectively. Clarithromycin resistance was 24% (167/686) in females and 15% (11/753) in males (p = 0.0002); metronidazole resistance was 29% (72/246) in patients over 70 years compared to 42% (499/1190) in younger patients (p = 0.0396); levofloxacin resistance increased with age, being 13% (57/439) in patients ≤55 years, 19% (46/236) for those between 56 and 70, and 26% (34/130) in patients >70 years (p = 0.0087).DiscussionA decline in the prevalence of H. pylori infection was observed over the years, along with relatively high rates of primary resistance to clarithromycin, metronidazole and levofloxacin. Variations in resistance rates were found with sex and age.     

Oral Toxicity of Okadaic Acid in Mice: Study of Lethality,Organ Damage,Distribution and Effects on Detoxifying Gene Expression

In vivo, after administration by gavage to mice and rats, okadaic acid has been reported to produce lesions in liver, small intestine and forestomach. Because several reports differ in the damage detected in different organs, and on okadaic acid distribution after consumption, we determined the toxicity of this compound after oral administration to mice. After 24 hours, histopathological examination showed necrotic foci and lipid vacuoles in the livers of intoxicated animals. By immunohistochemical analysis, we detected this toxin in the liver and kidneys of intoxicated animals. Okadaic acid induces oxidative stress and can be activated in vitro into reactive compounds by the post-mitochondrial S9 fraction, so we studied the okadaic effect on the gene expression of antioxidant and phase II detoxifying enzymes in liver. We observed a downregulation in the expression of these enzymes and a reduction of protein expression of catalase and superoxide dismutase 1 in intoxicated animals.     

An unusual adverse effect of nadroparin injections: Calcinosis cutis

In 1988, Tumiati et al described the first case of calcinosis cutis related to a calcium-containing heparin. Since then, only 18 cases have been reported in the literature; they usually have an altered calcium-phosphate product, an elevated parathyroid hormone (PTH), or both. We report a 33-year-old patient who developed calcinosis cutis at sites of nadroparin injections without any disturbance of calcium-phosphate product, PTH, or vitamin D. The pathogenesis of calcinosis cutis secondary to nadroparin injections remains controversial; Proposed causes included metastatic, dystrophic, iatrogenic, or multifactorial etiologies. This is the first case of multiple nodules of calcinosis cutis without alterations of calcium-phosphate product, PTH, or vitamin D, which supports an iatrogenic mechanism. We also suggest that calcinosis cutis could be more frequent than we thought and is probably an underdiagnosed entity.     

Vascular compromise prior to intestinal manifestations of Crohn's disease in a 14-year-old girl.

Vascular manifestations as extraintestinal symptoms of Crohn's disease are rare and only occasionally reported in children. A 14-year-old girl with vascular compromise prior to intestinal manifestations of Crohn's disease is described. The vascular symptoms were due to segmental narrowing of several major arteries as shown by angiography. This kind of vascular involvement in our patient is different from the pattern described in Crohn's disease and resembles Takayasu's disease. Recently, it has been suggested that Crohn's disease could be mediated by multifocal gastrointestinal infarction due to chronic focal mesenteric arteritis at the level of the muscularis propria of the gut. In Takayasu's disease, a granulomatous inflammation of the vasa vasorum of affected vessels is frequently found. An intramural arteritis, granulomatous in nature, could be the common pathway in both Crohn's and Takayasu's diseases. Until the etiologies of both diseases are uncovered, the interrelation between them will remain subject to speculation.