Culture-negative subacute bacterial endocarditis masquerades as granulomatosis with polyangiitis (Wegener’s granulomatosis) involving both the kidney and lung

Background

Subacute bacterial endocarditis (SBE) occasionally exhibits positive cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA) of the anti-proteinase-3 (PR-3) type. Clinically, it mimics ANCA-associated vasculitis, such as Wegener's disease with glomerulonephritis. Lung abscesses are the most common manifestation of lung involvement. We herein report a case of culture-negative SBE strongly c-ANCA/PR3-positive accompanied by pulmonary involvement and glomerulonephritis. In this case, we took biopsies of both the lung and kidney, although renal biopsy is usually preferred over lung biopsy. The lung biopsy showed severe alveolar capillaritis, suggesting vasculitis consistent with polyangiitis. The renal biopsy revealed glomerulonephritis with a membranoproliferative pattern. To our knowledge, this is the first such reported case.

Case presentation

A 68-year-old Chinese male patient presented to our hospital with a fever, cough, chest pain, and recurrent peripheral edema. He had a past medical history significant for treated schistosomiasis 20 years previously. Physical examination revealed palpable purpura, mild hypertension, hepatosplenomegaly, and a holosystolic cardiac murmur (Levine 2/6). Echocardiography showed tricuspid valve vegetations with moderate to severe regurgitation. Serum c-ANCA/PR3 and cryoglobulin were strongly positive. Renal biopsy results indicated membranoproliferative glomerulonephritis with several crescents. Chest CT revealed multiple intraparenchymal and subpleural nodules, and lung biopsy showed polyangiitis. The patient’s ANCA titers, glomerulonephritis, and pulmonary injury all resolved after antibiotic therapy.

Conclusion

SBE may present with positive c-ANCA/PR3, multiple pulmonary nodules, pulmonary polyangiitis, and glomerulonephritis clinically mimicking granulomatosis with polyangiitis (Wegener's granulomatosis).

     

Clinical, radiological and endocrinological findings in a case of McCune-Albright syndrome

The McCune-Albright syndrome was described as a syndrome of polyostotic fibrous dysplasia, café au lait skin pigmentation, and autonomous endocrine hyperfunction in 1937. We report a 17-year girl with early menarche and accelerated growth for the past three years. The endocrinological examination showed slight rise of growth hormone with other hormones in normal range. The CT showed an expansive bony lesion over the left parietal area. The bone mass was excised with bone cement cranioplasty performed for the defect. Histology confirmed it was fibrous dysplasia. Although uncommon, this syndrome must be kept in mind in cases with bony abnormalities and extensive endocrinological workup done and treatment given for best results.     

Impact of Mental Health Training on Village Health Workers Regarding Clinical Depression in Rural India

Village health worker (VHW) programs are known to be effective means of promoting health of communities. Comprehensive rural health project in India recently trained VHWs to identify, refer, and help people with mental health issues. This study evaluated knowledge, attitude, and behavior of VHWs regarding depression. Cluster sampling was used including all 36 VHWs trained in mental health. Among these, 24 were available and willing to participate in the study. Five FGDs were conducted among 24 VHWs, and the results were analyzed qualitatively. Four out of five groups were able to diagnose the presented case correctly as depression. VHWs were able to identify many symptoms and to suggest management options for depression. They showed supportive and empathetic attitudes towards depressed patients. VHWs are likely to be useful at identifying and assisting people with depression in the communities with lack of adequate resources provided they receive ongoing training and supervision.     

Oxiracetam and Zinc Ameliorates Autism-Like Symptoms in Propionic Acid Model of Rats

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder characterized by restrictive behaviour, deficit in social skills and interaction. The multifactorial etiology, complex pathophysiology and different combination of symptoms (unusual speech patterns, frequent repetition of phrases) make it difficult to treat. Thus, present study aimed to find the protective effects of oxiracetam alone and in combination with zinc on brain behavioral, biochemical, pro-inflammatory cytokines and neurotransmitters level. Rats were administered with propionic acid (250 mg/kg p.o.) for 3 days and immediately on next day treatment were given with oxiracetam (25, 50 mg/kg i.p), zinc (4 mg/kg) as well as oxiracetam (25 mg/kg i.p) in combination with zinc (4 mg/kg p.o). Behavioral parameters were performed from 22th to 28th day. On 29th day, all the animals were sacrificed by cervical dislocation and the brain was preserved for biochemical (LPO, GSH, nitrite, mitochondrial complex I, IV and cAMP), neuroinflammatory (TNF-α, IL-1β, IL-6) and neurotransmitters (5-HT, GABA, glutamate and acetylcholine) analysis. The propionic acid administration showed memory impairment, restrictive behavior, increased proinflammatory cytokines level, biochemical and neurotransmitters alteration. However, treatment with oxiracetam alone and in combination with zinc significantly attenuated behavioral, biochemical, inflammatory cytokines and restored neurotransmitters level. The finding of present study demonstrated that oxiracetam alone and in combination with zinc afforded superior anti-autistic effect through antioxidant, anti-inflammatory and anti-excitotoxic mechanisms and could serve as attractive strategy in managing autism.     

Development of a Shared Decision Making Model in a Community Mental Health Center

Shared Decision Making (SDM) is an essential component of recovery oriented treatment for clients with severe and persistent mental illnesses. SDM has been found to be effective in improving outcome of treatment of non-psychiatric ailments, and studies of SDM in community mental health settings are limited. We designed and implemented a low tech SDM program in a non-academic community mental health center and evaluated the outcome on decisional certainty and satisfaction with services. The results suggest that SDM can be effectively integrated with evidence based psychiatric rehabilitation practices utilizing already existing resources.     

Novel GPR43 Agonists Exert an Anti-Inflammatory Effect in a Colitis Model

GPR43 (also known as FFAR2), a metabolite-sensing G-protein-coupled receptor stimulated by short-chain fatty acid (SCFA) ligands is involved in innate immunity and metabolism. GPR43 couples with Gα_i/o and Gα_q/11 heterotrimeric proteins and is capable of decreasing cyclic AMP and inducing Ca²⁺ flux. The GPR43 receptor has additionally been shown to bind β-arrestin 2 and inhibit inflammatory pathways, such as NF-κB. However, GPR43 shares the same ligands as GPR41, including acetate, propionate, and butyrate, and determination of its precise functions in association with endogenous ligands, such as SCFAs alone, therefore remains a considerable challenge. In this study, we generated novel synthetic agonists that display allosteric modulatory effects on GPR43 and downregulate NF-κB activity. In particular, the potency of compound 187 was significantly superior to that of pre-existing compounds in vitro. However, in the colitis model in vivo, compound 110 induced more potent attenuation of inflammation. These novel allosteric agonists of GPR43 clearly display anti-inflammatory potential, supporting their clinical utility as therapeutic drugs.     

Bronchopleural fistula and bilateral pneumothorax in a patient with COVID‐19

COVID‐19 pneumonia causes several complications that include pneumothorax, hydropneumothorax, empyema, and rarely leads to bronchopleural fistula (BPF). BPF is a communication between the pleural space and the bronchial tree. We report a case of 24 years man with pneumothorax, hydropneumothorax, and BPF that appeared after COVID‐19 infection.