A Rare Incidence of Hepatocellular Carcinoma With Tumor Thrombus Extending to the Right Heart.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths and the sixth most commonly diagnosed cancer worldwide due to several common risk factors, including hepatitis C virus (HCV), hepatitis B virus (HBV), and other causes of cirrhosis. In HCC, intrahepatic vascular invasion and a tumor thrombus are commonly observed. However, the extrahepatic spread of the tumor thrombus to the heart via the portal vein, hepatic vein, and inferior vena cava (IVC) is rarely reported and is considered a poor prognostic factor. In addition, rarely, there is a risk of cor pulmonale and thromboembolism of the pulmonary vessels. Our patient also presented with this rare complication of HCC. Our patient's clinical presentation was bilateral pedal edema, moderate ascites, and abdominal discomfort with raised jugular venous pressure. These signs and symptoms are related to an impairment of the right heart caused by intracardiac tumor thrombus metastasis, leading to diastolic dysfunction. Based on these findings, echocardiography and abdominal computed tomography (CT) scan were performed with the definitive diagnosis of hepatocellular carcinoma with tumor thrombus metastases in the hepatic vein, inferior vena cava, and right atrium. The management team agreed on a conservative treatment plan based on the advanced stage of the disease and the high risk associated with aggressive treatment modalities. Unfortunately, on day 7 of admission, the patient died from a possible pulmonary embolism that led to cardiopulmonary arrest. This case underscores the importance of screening patients with a high HCC tumor burden with abdominal ultrasound and echocardiography for early detection and timely management.

Extensively drug-resistant typhoid fever; it's not that simple: a case report.

Multi-drug resistant strains of Salmonella typhi (S. typhi) has remained endemic in developing countries for the last two decades. With irrational use of antibiotics, an extensively drug-resistant (XDR) strain of S. typhi, sensitive only to Carbapenems and Azithromycin, has evolved which was first reported in Sindh, Pakistan, in 2018. Most of the cases of XDR S. typhi infection treated with antibiotics improve without any complications. Failure to respond to appropriate antibiotics should raise the suspicion of visceral abscesses. Splenic abscess is a rare complication of S. typhi infection. A patient with splenic abscess due to XDR S. typhi has been reported who responded to prolonged antibiotic treatment. We report the case of a young boy from Peshawar with multiple splenic abscesses due to XDR S. typhi which did not respond to percutaneous aspiration and culture-guided antibiotics for two weeks. Eventually, he had to undergo splenectomy. He has remained afebrile since then.

Predictors of Mortality in Patients With Dengue Fever: Insights From a Comparative Analysis.

Objective To determine the clinical and biochemical predictors of mortality in patients with dengue fever. Methods This was an analytical, cross-sectional study conducted at Hayatabad Medical Complex, Peshawar, Pakistan. The study participants were patients admitted to the hospital for the management of dengue fever. Clinical parameters (age, gender, duration of hospital stay, and the presence of complications) and biochemical parameters [white blood cells count (WBC), platelet count, serum c-reactive protein (CRP) level, serum alanine aminotransferase (ALT) level, and serum creatinine] were recorded. These parameters were compared between the survivors and non-survivors of dengue fever. Results Out of 115 patients, the majority (n=82, 71.3%) were up to 45 years and the mean age was 38.40 ± 18.1 years. Most of the patients (n=105, 91.3%) survived. On univariate logistic regression analysis, age more than 45 years [odds ratio (OR) 0.141, 95% confidence interval (CI) 0.034 - 0.585, p = 0.007), leukocytosis (> 11,000/mcL) (OR 0.187, 95% CI 0.049 - 0.719, p = 0.015), and acute kidney injury (creatinine > 1.5 mg/dL) (OR 0.124, 95% CI 0.029 - 0.531, p = 0.005)] at the time of admission reduced the likelihood to survive. Leukocytosis and acute kidney injury remained significant independent predictors of mortality on multivariate logistic regression analysis. [(OR 0.201, 95% CI 0.042 - 0.960, p = 0.044) and (OR 0.148, 95% CI 0.026 - 0.857, p = 0.033) for survival, respectively]. Gender, duration of inpatient stay, thrombocytopenia (platelets < 30,000/mcL), and acute liver injury (ALT > 200 IU/L) were not associated with mortality from dengue fever. Conclusion Age over 45 years, leukocytosis, and acute kidney injury at presentation increased the likelihood of mortality from dengue fever in this study. Gender, duration of hospital stay, thrombocytopenia, and acute liver injury did not affect the odds of mortality.

Nanoindentation study of the viscoelastic properties of human triple negative breast cancer tissues: Implications for mechanical biomarkers.

This paper presents the results of a combined experimental and theoretical study of the structure and viscoelastic properties of human non-tumorigenic mammary breast tissues and triple negative breast cancer (TNBC) tissues of different histological grades. A combination of immunofluorescence and confocal microscopy, and atomic force microscopy is used to study the actin cytoskeletal structures of non-tumorigenic and tumorigenic breast tissues (grade I to grade III). A combination of nanoindentation and statistical techniques is then used to measure viscoelastic properties of non-tumorigenic and human TNBC of different histological grades. A Standard Fluid Model/Anti-Zener Model II is also used to characterize the viscoelastic properties of the non-tumorigenic and tumorigenic TNBC tissues of different grades. The implications of the results are discussed for the potential application of nanoindentation and statistical deconvolution techniques to the development of mechanical biomarkers for TNBC detection/cancer diagnosis. STATEMENT OF SIGNIFICANCE: There is increasing interest in the development of mechanical biomarkers for cancer diagnosis. Here, we show that nanoindentation techniques can be used to characterize the viscoelastic properties of normal breast tissue and TNBC tissues of different histological grades. The Standard Fluid Model (Anti-Zener Model II) is used to classify the viscoelastic properties of breast tissues of different TNBC histological grades. Our results suggest that breast tissue and TNBC tissue viscoelastic properties can be used as mechanical biomarkers for the detection of TNBC at different stages.

Do Laboratory Biomarkers Predict Survival In Severe Covid-19? A Cross-Sectional Study.

Background: This study aims to compare lymphocyte count, C-reactive protein (CRP), ferritin, Lactate Dehydrogenase (LDH) and D-dimer among survivors and non-survivors of severe COVID-19. Methods: This retrospective cross-sectional analytical study included 69 patients for whom a record of the biomarkers and survival status was available. Baseline and peak values were selected for serum CRP, ferritin, LDH and D-Dimer. Baseline and trough lymphocyte counts were selected. Data were analyzed using SPSS version 21. Mean and standard deviation were used to compare the biomarkers with paired t-test. p-value <0.05 was taken as significant. Results: The mean age of the study population was 55.5±9.1 years and 50 (72.5%) were male. Among survivors, the increase in CRP level was not significant (from 15.80±9.8 mg/dl to 17.87±8.4 mg/dl, p=0.45) while it was significant in non-survivors (from 16.68±10.90 mg/dl to 20.77±12.69 mg/dl, p=0.04). There was no significant rise in LDH levels in survivors (from 829.59±499 U/L to 1018.6±468 U/L, p=0.20) while it increased significantly in non-survivors (from 816.2±443.08 U/L to 1056.61±480.54 U/L, p=0.003). The decrease in lymphocyte count and increase in D-Dimers in both the groups was significant (p=0.001). There was no significant elevation in ferritin in both the groups (p>0.05). Conclusion: In severe COVID-19 patients, serum CRP and LDH can be used for risk stratification and predicting survival. Lymphopenia, increase in serum ferritin and D-dimers may not predict survival.

Crimean-Congo Hemorrhagic Fever Case Series: a Chronology of Biochemical and Hematological Parameters.

Introduction Crimean-Congo hemorrhagic fever (CCHF) is a widespread tick-borne zoonotic disease. Sporadic outbreaks of CCHF occur in endemic regions, including Pakistan. The clinical spectrum of the illness varies from asymptomatic seroconversion to severe disease which may end in death. The treatment is supportive, including blood and blood products. There is multi-organ involvement in CCHF including acute hepatitis, thrombocytopenia, coagulopathy, acute kidney injury (AKI), and encephalopathy. Hematological and biochemical parameters may identify patients at substantial risk of worse outcomes. Early detection of the disease and forecasting the clinical course may be helpful. This case series aims to evaluate the trends of hematological and biochemical parameters among the survivors and non-survivors of CCHF. Methods All consecutive patients aged 16 years and above admitted to the isolation unit of Hayatabad Medical Complex, Peshawar, Pakistan between 1st July and 30th July 2022 with the diagnosis of CCHF were included in this case series. The diagnosis of CCHF was made by detecting viral ribonucleic acid by a polymerase chain reaction. For all patients, age, gender, address, occupation, clinical presentation, history of contact with animals, and travel history were recorded. All the vitals were taken regularly. The hematological (complete blood count) and biochemical parameters (serum creatinine, alanine aminotransferase (ALT), and C-reactive protein (CRP)) were documented daily. The blood group was determined for all the cases. Results Out of 17 cases, the majority (16 cases, 94.1%) were male and butchers (eight cases, 47.1%) by profession. All cases had significant contact with animals. Four patients (23.5%) died. Three out of the four non-survivors (75%) had ALT < 5 times the upper limit of normal with a static pattern of liver enzymes without much decline in ALT till death. One non-survivor (25%) had marked elevation of ALT at presentation, which had a declining trend till death. Seven out of 13 survivors (53.8%) had moderate to marked elevation in the level of ALT at presentation. The ALT showed a downward trend during the course of illness in all these patients. The remaining survivors (six out of 13, 46.2%) had a mild elevation of ALT and 50% of them showed improvement in the ALT level during hospitalization. All patients had thrombocytopenia at presentation. None of the non-survivors showed a persistent increase in the platelet count, and three cases remained severely thrombocytopenic at the time of death. However, the trend in platelet count among all the survivors was increasing. The CRP level in the majority (three out of four cases, 75%) of the non-survivors remained elevated till death, while all survivors showed a progressive decline in CRP level. A majority (11 out of 17 cases) had blood group B. Half of the non-survivors (two out of four cases) and the majority of the survivors (nine out of 13 cases) had blood group B. AKI was found in all non-survivors, while all the survivors had normal renal function throughout the course. Conclusion A persistently raised ALT and CRP level, a persistently low or decreasing platelet count, and AKI were associated with mortality. Blood group B was the commonest blood group among patients of CCHF, which is not reflective of the blood group distribution of the general population from which this case series has been reported.

Adhesion of LHRH/EphA2 to human Triple Negative Breast Cancer tissues.

The adhesive interactions between molecular recognition units (such as specific peptides and antibodies) and antigens or other receptors on the surfaces of tumors are of great value in the design of targeted nanoparticles and drugs for the detection and treatment of specific cancers. In this paper, we present the results of a combined experimental and theoretical study of the adhesion between Luteinizing Hormone Releasing Hormone (LHRH)/Epherin type A2 (EphA2)-AFM coated tips and LHRH/EphA2 receptors that are overexpressed on the surfaces of human Triple Negative Breast Cancer (TNBC) tissues of different histological grades. Following a histochemical and immuno-histological study of human tissue extracts, the receptor overexpression, and their distributions are characterized using Immunohistochemistry (IHC), Immunofluorescence (IF), and a combination of fluorescence microscopy and confocal microscopy. The adhesion forces between LHRH or EphA2 and human TNBC breast tissues are measured using force microscopy techniques that account for the potential effects of capillary forces due to the presence of water vapor. The corresponding adhesion energies are also determined using adhesion theory. The pull off forces and adhesion energies associated with higher grades of TNBC are shown to be greater than those associated with normal/non-tumorigenic human breast tissues, which were studied as controls. The observed increase in adhesion forces and adhesion energies are also correlated with the increasing incidence of LHRH/EphA2 receptors at higher grades of TNBC. The implications of the results are discussed for the development of targeted nanostructures for the detection and treatment of TNBC.

Case report: Diagnosis of hereditary hemorrhagic telangiectasia (Osler Weber Rendu Syndrome) in a 23-year-old male presented with anemia and thrombocytopenia and its response to bevacizumab.

Osler Weber Rendu Syndrome (OWS) is characterized by the development of abnormally dilated blood vessels, which manifest as arteriovenous shunts (pulmonary, gastrointestinal, hepatic, and cerebral) and mucocutaneous telangiectasias (lips, tongue, and fingertips). It is an autosomal dominant disease with a defect in transforming growth factor beta superfamily genes. This defect results in increased angiogenesis and disruption of vessel wall integrity. The disease remains underreported, with occasional history of recurrent epistaxis, iron deficiency anemia, and gastrointestinal bleeding in moderate to severe cases. Diagnosis is based on clinical presentation and confirmed by genetic testing. Various local (nasal saline, air humidification, laser ablation, and electric cauterization for epistaxis and endoscopic Argon Plasma Coagulation-APC for active GI bleeding), surgical, and systemic (tranexamic acid and antiangiogenic agents like bevacizumab and thalidomide) treatment options are used depending upon disease severity. Here, we present a case with recurrent gastrointestinal bleeding refractory to endoscopic APC ablation and thalidomide and severe symptomatic anemia requiring multiple packed red cell transfusions. The patient was ultimately started on bevacizumab, to which he had a good response and has remained in remission for 8 months as of now. This case emphasizes the need to have a low threshold of suspicion to diagnose HHT and start targeted therapy like bevacizumab early on in moderate to severe cases of HHT rather than just relying on temporizing palliative measures like ablation, cauterization, and tranexamic acid.

Diagnosis and treatment of flurbiprofen-induced Stevens-Johnson syndrome: A rare case report.

Our case highlights the occurrence of severe cutaneous adverse reactions with flurbiprofen use and alerts physicians to its odds with safer drugs.

Dengue Fever, Crimean-Congo Hemorrhagic Fever, and COVID-19 Triple Co-infection: Out of the Frying Pan Into the Fire.

In developing countries, infectious diseases are thriving due to poor hygiene, inadequate public health infrastructure, and socio-cultural factors. Generally, infections are due to a single pathogen, but due to the shared risk factors for transmission, co-infections are not uncommon. The severity and outcome of infections are adversely affected by co-infection. Co-infections present as diagnostic and therapeutic enigmas because of the complex interaction between different pathogens involved and distorted host responses. The southeast Asian region, particularly Pakistan, is known for unique combinations of different infections. We present a distinctive case of triple co-infection of dengue virus, Crimean-Congo hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. The index case was a 60-year-old gentleman who presented with fever, cough, shortness of breath, bruises, and hemoptysis. He had thrombocytopenia, deranged liver and renal function, coagulopathy, and infiltrates in both lung fields. Subsequent investigations revealed a positive polymerase chain reaction for ribonucleic acid of dengue virus, Crimean-Congo Hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. He received supportive treatment including antibiotics, blood products, ribavirin, and supplemental oxygen. He developed multi-organ failure and succumbed to the triple co-infection. This case will act as a wake-up call for clinicians, public health authorities, and infectious disease specialists to plan before the volcano of co-infections erupts.

Polymyositis: The Comet Tail After COVID-19.

Infectious agents have been implicated in the pathogenesis of autoimmune disorders for decades. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is no exception. This became evident as the pandemic evolved. Once considered a respiratory pathogen only, SARS-CoV-2 is now linked to a variety of autoimmune rheumatic disorders such as rheumatoid arthritis, systemic lupus erythematosus, reactive arthritis, spondyloarthropathies, vasculitis, and inflammatory myopathy. Although the exact cause for muscle injury in the setting of coronavirus disease 2019 (COVID-19) is not established, autoimmune inflammatory damage is the most accepted mechanism. Moreover, SARS-CoV-2 can cause direct muscle damage and indirectly through a cytokine storm. Inflammatory polymyositis in relation to COVID-19 has seldom been reported in developing countries. Here, we report a unique case of inflammatory polymyositis in a 52-year-old lady. The patient presented with muscle weakness, generalized body aches, and fatigue occurring four months after recovering from mild COVID-19. She had muscle weakness of Medical Research Council (MRC) grade 3/5 involving the shoulders and pelvic girdle with elevated muscle enzymes. Electromyography revealed an active irritable myopathic process consistent with inflammatory polymyositis. She underwent magnetic resonance imaging-guided muscle biopsy from the right thigh which revealed findings consistent with inflammatory myopathy. She was offered prednisolone and azathioprine. After four weeks of treatment, she had a remarkable improvement in her muscle strength to MRC grade 5/5.

Acute Kidney Injury Following Posaconazole for Mucormycosis: SARS-CoV-2 as a Back-Seat Driver.

Viruses have been implicated in the causation of several systemic illnesses, either directly or by immune modulation. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not an exception. Due to altered immune regulation, it is often associated with novel clinical manifestations and complications which have not been reported before. SARS-CoV-2 induces a pro-inflammatory state which makes the patient vulnerable to developing a variety of previously unreported adverse reactions to medications. Coronavirus disease 2019 (COVID-19) and its treatment have provided a fertile ground for various opportunistic infections including mucormycosis. The standard treatment for mucormycosis is surgical debridement and liposomal amphotericin B. Triazole antifungals such as posaconazole and isavuconazonium are the second-line agents for those intolerant to first-line therapy. Posaconazole is safer than amphotericin B as far as renal adverse effects are concerned. We report the case of a 60-year-old lady with type 2 diabetes mellitus, hypertension, ischemic heart disease, and osteoarthritis. She had severe COVID-19 requiring non-invasive ventilation four months ago. She presented with right rhino-orbital swelling, diplopia, and serosanguinous discharge from the right nostril. She had right third, sixth, and seventh cranial nerve palsies. Magnetic resonance imaging revealed right maxillary, ethmoid, and frontal sinusitis. Biopsy from the right nostril confirmed mucormycosis. Having normal renal and liver functions, she was started on oral posaconazole as she had an allergic reaction to a test dose of 1 mg amphotericin B (non-liposomal) in 20 mL of 5% dextrose water infused over 30 minutes. On day five, she developed acute kidney injury requiring renal replacement therapy. Her posaconazole was stopped. As she was not improving with conservative treatment, an ultrasound-guided, percutaneous renal biopsy was performed from the left kidney. The renal biopsy revealed thrombotic microangiopathy. She was started on liposomal amphotericin B as decided by the multidisciplinary team. Her renal function improved, and she continued on liposomal amphotericin B. We conclude that thrombotic microangiopathy, in this case, was likely due to posaconazole. This is a novel adverse effect presumably of posaconazole. This case report will alert physicians to be vigilant of the renal adverse effects of posaconazole in patients who have had COVID-19. Patients who develop renal injury while on posaconazole should undergo an early renal biopsy to ascertain the exact histopathology.

Diagnosis of Primary Hepatic Lymphoma in a 55-Year-Old Male Patient Presented With Pain in the Right Hypochondrium: A Very Rare Case.

Primary hepatic lymphoma (PHL) is a rare subtype of diffuse large B-cell lymphoma (DLBCL). A 55-year-old male patient presented to us with jaundice and right upper quadrant pain. Investigations showed elevated alkaline phosphatase, lactate dehydrogenase, total bilirubin, normal alanine transaminase, and negative viral profile. Sonographic and computed tomographic scans show hepatosplenomegaly with hypodense lesion in liver associated with lymph nodes enlargement in the region of porta hepatis celiac axis, mediastinal and axillary lymphadenopathy. On immunohistochemistry, cells were positive for cluster of differentiation (CD)-19, CD-20, CD-21, c-myelocytomatosis oncogene (c-MYC), B-cell lymphoma 2 (Bcl-2), multiple myeloma oncogene-1 (MUM-1), same as B cell markers so it is diagnosed as PHL. DLBCL especially PHL shall be considered among the differentials of space-occupying lesions of liver. Early diagnosis of primary hepatic lymphoma is not a difficult task if excisional lymph node biopsy is taken following detection on ultrasound or CT scan which will lead to improved treatment, improvement in survival, and cost-effectiveness with good prognostic outcomes.

Extensively Drug-Resistant Salmonella typhi Infection: From Pill to Scalpel.

Water-borne infections like typhoid fever are common in the developing world. The emergence of extensively drug-resistant Salmonella typhi (XDR S. typhi) is of great concern for both local and global public health. Fever, diarrhea, and abdominal pain are the commonest manifestations of typhoid fever. Abdominal pain may be due to ileal and colonic inflammation/ulceration and mesenteric lymphadenitis. Sometimes, abdominal pain in typhoid is due to ileal perforation leading to peritonitis, and acute appendicitis which needs urgent surgical intervention. Delayed surgical intervention can result in morbidity and sometimes even death. We report a case of XDR S. typhi infection in a 17-year-old female who presented with fever and abdominal pain. During the course of the hospital stay, while she was on appropriate antibiotics, her abdominal pain worsened due to acute appendicitis. She underwent an appendectomy and had an uneventful recovery. This is the first case, to our knowledge, of acute appendicitis caused by XDR S. typhi. Although appropriate antibiotics are the mainstay of treatment for typhoid fever, physicians should be mindful that surgical consultation may be necessary in certain cases.

COVID-19 Associated Illnesses From Alveoli to Glomeruli: A Case Report.

Hypoxemic respiratory failure is the most frequent complication of severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) infection. Coronavirus disease-19 (COVID-19) is no longer considered a standalone respiratory infection. It can involve other organs, including kidneys by direct invasion or indirectly through immune activation, cytokine storm, microthrombi and hemodynamic instability. Multiorgan involvement carries a worse prognosis in COVID-19. Tubulopathy is the most frequently reported renal pathology, followed by glomerulopathies. Among the glomerulopathies, immunoglobulin A (IgA) nephropathy is less often reported. Differentiating tubulopathy from glomerulopathy is important from the management and prognostic point of view. Laboratory investigations, including urine microscopy, cannot predict glomerulopathy as a cause of renal involvement. Therefore, it is important to proceed with renal biopsy early to make a definite diagnosis. We report a case of a 33-year-old male who presented three weeks after recovery from COVID-19 with proteinuric acute kidney injury. Subsequent renal biopsy revealed IgA nephropathy.

A Patient With Fever, Loose Motions and Jaundice: Hickam's Dictum or Occam's Razor.

Infectious diseases like malaria, typhoid, leptospirosis, and dengue fever are the leading causes of morbidity and mortality in developing countries like Pakistan. Although rare, it is possible to have coinfection with organisms that are endemic in a region, causing diagnostic and therapeutic dilemmas. Leptospirosis is caused by Gram-negative spirochetes. Leptospira are widely distributed and are transmitted by contamination of water and food by the urine of infected animals like rodents. Leptospirosis is characterized by fever, body aches, abdominal pain, and hepatic and renal involvement. Laboratory abnormalities include cytopenia, elevated bilirubin, alanine aminotransferase, and abnormal renal function tests. Typhoid fever is caused by Salmonella typhi (S. typhi), which is transmitted by fecal contamination of drinking water and food items. The clinical manifestations of typhoid fever include fever, abdominal pain, and diarrhea. Laboratory abnormalities include cytopenia and mildly deranged liver function tests. A strain of S. typhi resistant to all antibiotics except azithromycin and carbapenems was isolated in 2016 in Pakistan. Most of the clinical manifestations and laboratory abnormalities of leptospirosis and typhoid fever overlap. There have been case reports of coinfection of S. typhi and Leptospira, but there is no report of coinfection of extensively drug-resistant (XDR) S. typhi and Leptospira. We present a case of a 20-year-old man with fever, loose motions, and jaundice from Peshawar, Pakistan who had coinfection of Leptospira and XDR S. typhi. The attending physicians should adopt Hickam's dictum instead of Occam's razor approach.

The Effect of Tocilizumab on Inflammatory Markers in Survivors and Non-survivors of Severe COVID-19.

OBJECTIVE: To determine the effects of tocilizumab (TCZ) on inflammatory markers, laboratory indices; and short-term outcome in patients with severe COVID-19. STUDY DESIGN: Cross-sectional analytical study. Place and Duration of the Study: Hayatabad Medical Complex, Peshawar, Pakistan from 10th June till 31st August 2020. METHODOLOGY: Fifty-four patients with severe COVID-19 fulfilled the inclusion criteria and were included. All patients had received TCZ (4 mg/kg) in addition to standard treatment. Serum C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer levels, full blood count, and liver function tests (LFTs) were checked before and 24 hours after receiving TCZ. Short-term outcome, defined as survival at day 28, was determined from hospital record/telephonic contact. Paired t-test was employed to assess the statistical significance of mean differences between the pre- and post-TCZ variables, considering a p-value of <0.05 as significant. RESULTS: Overall, the mean pre- and post-TCZ CRP was 18.7 ± 10.7 and 10.2 ± 8.6 mg/dl (p <0.001). It was 18.0 ± 10.3 and 10.3 ± 8.8 mg/dl (p=0.003) in survivors; and 19.4 ± 11.4 and 10.2 ± 8.7 mg/dl (p=0.005) in non-survivors, respectively. Overall, mean D-dimer level decreased from 12.5 ± 23 to 10.3 ± 12.2 µg/ml following TCZ (p=0.643); it decreased from 15.8 ± 29.8 to 11.4 ± 10.6 µg/ml (p=0.612) in survivors; and 9.0 ± 12.8 to 9.2 ± 14.1 µg/ml (p=0.961) in non-survivors, respectively. There were no significant differences in the pre- and post-TCZ LDH levels overall and between the groups. The 28-day mortality was 46.3%. CONCLUSION: Tocilizumab results in a significant reduction in CRP, while mean change in LDH and D-dimers was not substantial. The mean change in inflammatory markers did not predict survival. Key Words: Tocilizumab, COVID-19, Biomarkers, Outcome, Mortality.

Histopathologic spectrum of childhood tumours in a Tertiary Hospital: a ten-year review.

BACKGROUND: There has been a growing public health burden of childhood tumours in low and middle income countries (LMICs) as the trend in epidemiological transition continues to vary. OBJECTIVE: The objective of this report is to determine the spectrum of childhood tumours at a tertiary hospital in Nigeria. METHODS: A retrospective review of the histopathology register over the period January 2006 to December 2015. RESULTS: The total paediatric tumour cases was 248, including 143 (57.7%) females and 105 (42.3%) males, aged 0 - 12 years (mean 6.1 years ± 3.97 SD). The age group 2 - 5 year cohort had the highest prevalence of tumour. The predominant tumour based on tissue of origin was epithelial neoplasms 88 (35.5%), vascular neoplasms 56 (22.6%), neural neoplasm 42 (16.9%), mesenchymal neoplasm 37 (14.9%), germ cell neoplasm 13 (5.2%) and haematopoietic neoplasms 12 (4.8%). Majority of the tumours were benign, 148 (59.7%) and malignant 100 (40.3%). The most predominant benign tumour was haemangioma 33 (13.3%) and predominant malignant tumour was lymphoma 22 (8.9%). CONCLUSION: Benign tumours remain the commonest neoplasm of children in this hospital-based data. Development and implementation of a tumour registry would provide a more comprehensive information.

The Effect of Tocilizumab on Inflammatory Markers in Survivors and Non-survivors of Severe COVID-19.

OBJECTIVE: To determine the effects of tocilizumab (TCZ) on inflammatory markers, laboratory indices; and short-term outcome in patients with severe COVID-19. STUDY DESIGN: Cross-sectional analytical study. Place and Duration of the Study: Hayatabad Medical Complex, Peshawar, Pakistan from 10th June till 31st August 2020. METHODOLOGY: Fifty-four patients with severe COVID-19 fulfilled the inclusion criteria and were included. All patients had received TCZ (4 mg/kg) in addition to standard treatment. Serum C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer levels, full blood count, and liver function tests (LFTs) were checked before and 24 hours after receiving TCZ. Short-term outcome, defined as survival at day 28, was determined from hospital record/telephonic contact. Paired t-test was employed to assess the statistical significance of mean differences between the pre- and post-TCZ variables, considering a p-value of <0.05 as significant. RESULTS: Overall, the mean pre- and post-TCZ CRP was 18.7 ± 10.7 and 10.2 ± 8.6 mg/dl (p <0.001). It was 18.0 ± 10.3 and 10.3 ± 8.8 mg/dl (p=0.003) in survivors; and 19.4 ± 11.4 and 10.2 ± 8.7 mg/dl (p=0.005) in non-survivors, respectively. Overall, mean D-dimer level decreased from 12.5 ± 23 to 10.3 ± 12.2 µg/ml following TCZ (p=0.643); it decreased from 15.8 ± 29.8 to 11.4 ± 10.6 µg/ml (p=0.612) in survivors; and 9.0 ± 12.8 to 9.2 ± 14.1 µg/ml (p=0.961) in non-survivors, respectively. There were no significant differences in the pre- and post-TCZ LDH levels overall and between the groups. The 28-day mortality was 46.3%. CONCLUSION: Tocilizumab results in a significant reduction in CRP, while mean change in LDH and D-dimers was not substantial. The mean change in inflammatory markers did not predict survival. Key Words: Tocilizumab, COVID-19, Biomarkers, Outcome, Mortality.

ABO / Rh-D Blood types and susceptibility to Corona Virus Disease-19 in Peshawar, Pakistan.

OBJECTIVES: To determine the association between ABO/Rh-D blood types and susceptibility to SARS-CoV-2 infection in Pakistan. METHODS: In this cross-sectional study, 1935 confirmed cases of COVID-19 were included using consecutive sampling. Age and gender-matched sample of 1935 blood donors was used as a comparison group. Chi-square test and binary logistic regression were used for inferential statistics. RESULTS: Significantly higher proportion of blood type-B was observed in COVID-19 group (35.9% vs 31.9%, p=0.009). Blood type-AB was found more frequently (14.2% vs 11.8%, p=0.03) in the comparison group. The Rh-D Positive blood types were 93.3% in COVID-19 group and 94.9% in comparison group (p=0.03). The odds of blood type-B, AB and Rh-D positive to test positive for SARS-CoV-2 were 1.195 (95% CI 1.04 - 1.36, p=0.009), 0.80 (95% CI 0.66 - 0.97, p=0.03) and 0.75 (95% CI 0.57- 0.98, p = 0.03), respectively. Blood types A and O did not have significant association with SARS-CoV-2 PCR result (p = 0.22 and 0.88, respectively). CONCLUSIONS: There is significant association between blood types B & AB and susceptibility to COVID-19. There is no association between blood types A and O with COVID-19. Rh- D positive blood types are less susceptible to COVID-19.