Rapidly advancing invasive endomyocardial aspergillosis.

The exposure to Aspergillus organisms/spores is likely common, but disease caused by tissue invasion with these fungi is uncommon and occurs primarily in the setting of immunosuppression. We report a case of rapidly advancing invasive endomyocardial aspergillosis secondary to prolonged usage of multiple broad-spectrum antibiotics in a nonimmunocompromised host. A 36-year-old cotton textile worker presented to our institution with a 3-month history of weight loss and fatigue. He reported receiving prolonged use of multiple broad-spectrum antibiotic treatment. The echocardiogram demonstrated multiple endomyocardial vegetations and a mass in the left atrium. Myocardial biopsy specimen revealed an invasive endomyocardial aspergillosis. The patient was investigated for immune deficiency including HIV, and this workup was negative. Treatment was started with amphotericin B and heparin for presumed left atrial thrombus. The patient died because of a rupture of mycotic aneurysm that resulted in cerebral hemorrhage. This case illustrates the risk of an invasive fungal infection in a nonimmunocompromised host who is a prolonged user of antibiotics in the setting of environmental exposure of opportunistic invasive fungal infections.     

Calciphylaxis: A condition mimicking necrotizing vasculitis

Summary A patient with end stage renal disease developed ischaemic skin necrosis and digital gangrene. He had diffuse arterial calcification associated with hyperparathyroidism secondary to renal failure. The patient received inappropriate cyclophosphamide therapy as he had been misdiagnosed as having an inflammatory vasculitis. This clinical picture, previously named calciphylaxis should come into the differential diagnosis of systemic vasculitis in a uraemic patient with hyperparathyroidism.     

Acute Abdominal Aorta Embolism Caused by Rupture of a Cardiac Hydatid Cyst

We report a case of an abdominal aortic embolism due to rupture of a cardiac hydatid cyst. This report emphasizes the diagnostic, preventative, and treatment options for hydatid cyst embolism of abdominal aorta. Echocardiography should be routinely performed in all patients with hydatid disease for possible involvement of the heart. This enables early diagnosis and treatment of cardiac echinococcus before life-threatening complications occur.     

Isolated Ruptured Inter‐Atrial Septal Cystic Echinococcosis during Pregnancy

Herein, we present a case of asymptomatic isolated cardiac cystic echinococcosis localized entirely to the inter‐atrial septum in a pregnant woman. The patient underwent successful surgery. Cardiac cystic echinococcosis is rarely seen in pregnancy. A high index of suspicion is necessary for the diagnosis of a cardiac cyst hydatid. The treatment of cardiac cyst hydatid is surgical and should not be delayed during pregnancy. Early surgery might prevent septic embolization and cardiac life‐threatening complications and save the lives of both mother and baby as in the present case.     

Recurrent Left Ventricular Apical Ballooning Syndrome in a Patient with Pheochromocytoma

Transient left ventricular apical ballooning syndrome is characterized by reversible left ventricular wall motion abnormalities, chest pain or dyspnea, ST-segment elevation, and mild elevation of cardiac enzyme levels in the absence of obstructive coronary artery disease. The pathophysiology of the syndrome is still unknown. The probable mechanism is supposed to be a catecholamine discharge. We report the case of a 66-year-old woman with recently diagnosed pheochromocytoma who presented with chest pain and ST-segment elevation. Coronary angiography revealed normal coronaries and apical dyskinesia at ventriculography. A similar episode of chest pain occurred 4 years ago with same angiographic findings and reversible inferobasal akinesia. In-hospital course was uneventful and the patient was discharged from the hospital 4 days later with treatment of aspirin 1 × 100 mg, metoprolol 1 × 50 mg, lisinopril 1 × 10 mg, and atorvastatin 1 × 20 mg. At 2 years follow-up after the event, the patient remained asymptomatic.     

Evidence-based recommendations for the management of ankylosing spondylitis: systematic literature search of the 3E Initiative in Rheumatology involving a broad panel of experts and practising rheumatologists

Objective. Recommendations and/or guidelines represent a popularway of integrating evidence-based medicine into clinical practice.The 3E Initiatives is a multi-national effort to develop recommendationsfor the management of rheumatic diseases, which involves a largenumber of experts combined with practising rheumatologists addressingspecific questions relevant to clinical practice. Methods. Ten countries participated in three rounds of discussionsand votes concerning the management of AS. A set of nine questionswas formulated in the domains of diagnosis, monitoring and treatment,after a Delphi procedure. A literature search in MedLine wasconducted. Predefined outcome parameters for the domains ofdiagnosis, monitoring and treatment were assessed. The evidenceto support each proposition was evaluated and scored. Afterdiscussion and votes, the final recommendations were presentedusing brief statements by each national group, following whichthe final international recommendations were formulated. Results. A total of 2699 papers were found and 467 were selectedfor analysis. Twelve key recommendations were developed: threein the domain of diagnosis addressing general diagnostic considerations,early AS diagnosis and general practitioners’ referralrecommendations; three concerning monitoring of AS disease activity,severity and prognosis; six concerning pharmacological treatment(except biologics): non-steroidal anti-inflammatory drugs/COX-IIinhibitors, bisphosphonates and treatment of enthesitis. Thecompiled agreement among experts ranged from 72% to 93%. Conclusion. Recommendations for the management of AS were developedusing an evidence-based approach followed by expert/physicianconsensus with high level of agreement. Involvement of a largerand more representative group of rheumatologists may improvetheir dissemination and implementation in daily clinical practice. KEY WORDS: Ankylosing spondylitis, Systemic literature search, Recommendations, Non-steroidal anti-inflammatory drugs, COX-II inhibitors, Monitoring, Diagnosis, Treatment     

Thalidomide has both anti-inflammatory and regulatory effects in Behcet's disease

Thalidomide is shown to be an effective treatment for mucocutaneous symptoms of Behcet's disease (BD). In this study, the effects of thalidomide on peripheral blood mononuclear cells were investigated ex vivo. In an open prospective study, ten patients were given 200 mg/day thalidomide for 12 weeks and cluster of differentiation 4 (CD4), CD8, CD11a, CD11b, CD16, CD18, CD28, CD44, CD45RO, CD45RA, CD56, CD120a and γδ+ T cells were analysed with flow cytometry at 0, 3, 7, 30 and 90 days. Two patients were excluded from the analysis for attacks of uveitis within the first 2 weeks. At day 7, tumour necrosis factor-α (TNF-α) receptor+ (CD120a; 12% vs 5%), CD8/CD11b+ (12% vs 6%) and CD16/CD56+ (16% vs 9%) cells decreased in BD patients compared to day 0. On the other hand, CD4+CD45RO+ T cells (24% vs 34%) at day 30 and γδ+ T cells (11% vs 21%) at day 90 increased after treatment. These results suggest that thalidomide tends to decrease TNF-α receptor levels, CD8/CD11b+ T cells and natural killer cells in early treatment and increases CD4+CD45RO+ memory T and γδ+ T cells later in BD.     

Short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction

Purpose

This study aims to analyse the short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction surgery.

Methods

Clinical outcomes of 19 patients who had partial medial meniscectomy and anterior cruciate ligament reconstruction during the same surgery (Group 1) were compared with the outcomes of 25 patients who had also reconstruction but did not have any meniscal lesion (Group 2). Median follow-up time was 29 months (range 12–67 months) in Group 1 and 27 months (range 12–70 months) in Group 2. Feeling of apprehension in sports activities, International Knee Documentation Committee (IKDC) score, KT-2000 Arthrometer^® measurements and post-operative time to return to sports activity were the criteria for data analysis.

Results

Eight patients (42 %) in Group 1 and 5 patients (20 %) in Group 2 stated feeling of apprehension in sports activities. IKDC score improved to A in 11 patients (58 %) from Group 1, and 18 patients (72 %) from Group 2. Mean anterior translation according to KT-2000 arthrometer measurements was 5.2 ± 1.3 mm in Group 1, and 4.6 ± 1.3 mm in Group 2. Post-operative time to return to sports activity was 8.5 ± 3.0 months in Group 1, and 6.5 ± 2.2 months in Group 2.

Conclusion

Partial meniscectomy for irreparable medial meniscal tears, applied during the same surgery with anterior cruciate ligament reconstruction, negatively affects the clinical outcomes in the short-term follow-up. This study may be a reference for long-term clinical trials and also future investigations of new methods in the treatment of similar cases.

Level of evidence

IV.