Diffuse Large B-Cell Lymphoma During Third-Trimester Pregnancy and Lactation.

BACKGROUND: Diffuse large B-cell lymphoma is the most common type of non-Hodgkin's lymphoma affecting pregnancy. These tumors may be aggressive and rapidly growing in pregnancy. Management is based on the balance of risks and benefits to both the pregnant patient and the fetus. CASE: We present a case of diffuse large B-cell lymphoma diagnosed in the third trimester of pregnancy. The patient underwent labor induction at 34 weeks of gestation, started a standard chemotherapy protocol postpartum, and breastfed following a timed lactation protocol. CONCLUSION: Management of lymphoma during pregnancy highlights the need to consider all aspects of proposed oncologic and obstetric care as well as neonatal risks. Considerations highlighted in this case include staging methods, administration of antenatal steroids, timing of delivery, and lactation during chemotherapy.

Epidemiology of Upper Extremity Soccer Injuries Among High School- and College-Aged Players in the United States: An Analysis of the 1999-2016 NEISS Database.

BACKGROUND:: Although lower extremity injuries are more common than upper extremity injuries in high school- and college-aged soccer players, upper extremity injuries may be equally severe. The epidemiology of upper extremity injuries is poorly characterized in this population. HYPOTHESIS:: Upper extremity injuries are an important contributor to soccer-related morbidity among high school- and college-aged players. STUDY DESIGN:: Descriptive epidemiology study. LEVEL OF EVIDENCE:: Level 3. METHODS:: The National Electronic Injury Surveillance System (NEISS) is a nationally representative sample of 100 hospital emergency departments (EDs). Each record contains demographic and injury information. Records from 1999 to 2016 were analyzed, including patients between the ages of 14 and 23 years with a soccer-related injury sustained at school or during an athletic event. RESULTS:: A total of 1,299,008 high school- or college-aged patients presented to the ED for a soccer-related injury from 1999 to 2016, of which 20.4% were in the upper extremity. Patients were predominantly male (58.0%) and high school-aged (81.4%). Males constituted a greater proportion of upper extremity injuries when compared with other injury locations (63.5% male for upper extremity). Upper extremity injuries were more likely to be fractures (43.7% vs 13.9%) and dislocations (7.1% vs 3.4%) and less likely to be strains/sprains (27.8% vs 56.6%). Males suffered more shoulder dislocations (81.8% males among patients with shoulder dislocation vs 57.8% among those with other injuries), finger dislocations (72.0% vs 58.0%), upper arm fractures (74.9% vs 57.6%), and forearm fractures (68.3% vs 57.3%). CONCLUSION:: Upper extremity injuries are frequent in high school- and college-aged soccer players presenting to the ED. Efforts to reduce soccer-related injuries should include strategies targeting the upper extremity, perhaps reducing the incidence of high-energy falls. CLINICAL RELEVANCE:: Efforts to reduce soccer-related injuries should include strategies targeting upper extremity injuries, particularly among males and college-aged players.

Antibody-mediated protection against SHIV challenge includes systemic clearance of distal virus.

HIV-1-specific broadly neutralizing antibodies (bNAbs) can protect rhesus monkeys against simian-human immunodeficiency virus (SHIV) challenge. However, the site of antibody interception of virus and the mechanism of antibody-mediated protection remain unclear. We administered a fully protective dose of the bNAb PGT121 to rhesus monkeys and challenged them intravaginally with SHIV-SF162P3. In PGT121-treated animals, we detected low levels of viral RNA and viral DNA in distal tissues for seven days following challenge. Viral RNA-positive tissues showed transcriptomic changes indicative of innate immune activation, and cells from these tissues initiated infection after adoptive transfer into naïve hosts. These data demonstrate that bNAb-mediated protection against a mucosal virus challenge can involve clearance of infectious virus in distal tissues.

Protective efficacy of multiple vaccine platforms against Zika virus challenge in rhesus monkeys.

Zika virus (ZIKV) is responsible for a major ongoing epidemic in the Americas and has been causally associated with fetal microcephaly. The development of a safe and effective ZIKV vaccine is therefore an urgent global health priority. Here we demonstrate that three different vaccine platforms protect against ZIKV challenge in rhesus monkeys. A purified inactivated virus vaccine induced ZIKV-specific neutralizing antibodies and completely protected monkeys against ZIKV strains from both Brazil and Puerto Rico. Purified immunoglobulin from vaccinated monkeys also conferred passive protection in adoptive transfer studies. A plasmid DNA vaccine and a single-shot recombinant rhesus adenovirus serotype 52 vector vaccine, both expressing ZIKV premembrane and envelope, also elicited neutralizing antibodies and completely protected monkeys against ZIKV challenge. These data support the rapid clinical development of ZIKV vaccines for humans.

Vaccine protection against Zika virus from Brazil.

Zika virus (ZIKV) is a flavivirus that is responsible for the current epidemic in Brazil and the Americas. ZIKV has been causally associated with fetal microcephaly, intrauterine growth restriction, and other birth defects in both humans and mice. The rapid development of a safe and effective ZIKV vaccine is a global health priority, but very little is currently known about ZIKV immunology and mechanisms of immune protection. Here we show that a single immunization with a plasmid DNA vaccine or a purified inactivated virus vaccine provides complete protection in susceptible mice against challenge with a strain of ZIKV involved in the outbreak in northeast Brazil. This ZIKV strain has recently been shown to cross the placenta and to induce fetal microcephaly and other congenital malformations in mice. We produced DNA vaccines expressing ZIKV pre-membrane and envelope (prM-Env), as well as a series of deletion mutants. The prM-Env DNA vaccine, but not the deletion mutants, afforded complete protection against ZIKV, as measured by absence of detectable viraemia following challenge, and protective efficacy correlated with Env-specific antibody titers. Adoptive transfer of purified IgG from vaccinated mice conferred passive protection, and depletion of CD4 and CD8 T lymphocytes in vaccinated mice did not abrogate this protection. These data demonstrate that protection against ZIKV challenge can be achieved by single-shot subunit and inactivated virus vaccines in mice and that Env-specific antibody titers represent key immunologic correlates of protection. Our findings suggest that the development of a ZIKV vaccine for humans is likely to be achievable.

Clinical and economic impact of antimicrobial stewardship interventions with the FilmArray blood culture identification panel.

The purpose of this study was to evaluate the impact of the FilmArray Blood Culture Identification (BCID) Panel on the management of patients with blood cultures growing gram positive cocci and Candida. We retrospectively compared clinical and economic outcomes between patients during the BCID testing period and a matched historical control group before BCID testing was introduced. A total of 84 BCID patients were matched to 252 historical controls. BCID identification of coagulase negative staphylococci contaminants resulted in shorter post-culture length of stay (P < 0.008) and saved roughly $30,000 per 100 patients tested. The BCID led to shorter duration of empirical vancomycin for patients with contaminated blood cultures (P = 0.005) and methicillin-susceptible Staphylococcus aureus bacteremia (P < 0.001). Patients with vancomycin-resistant enterococcal bacteremia received active therapy earlier than historical controls (P = 0.047). The BCID, coupled with antimicrobial stewardship intervention, was a cost effective tool to improve patient care.

Mucocutaneous manifestations of helminth infections: Nematodes.

In the 21st century, despite increased globalization through international travel for business, medical volunteerism, pleasure, and immigration/refugees into the United States, there is little published in the dermatology literature regarding the cutaneous manifestations of helminth infections. Approximately 17% of travelers seek medical care because of cutaneous disorders, many related to infectious etiologies. This review will focus on the cutaneous manifestations of helminth infections and is divided into 2 parts: part I focuses on nematode infections, and part II focuses on trematode and cestode infections. This review highlights the clinical manifestations, transmission, diagnosis, and treatment of helminth infections. Nematodes are roundworms that cause diseases with cutaneous manifestations, such as cutaneous larval migrans, onchocerciasis, filariasis, gnathostomiasis, loiasis, dracunculiasis, strongyloidiasis, ascariasis, streptocerciasis, dirofilariasis, and trichinosis. Tremadotes, also known as flukes, cause schistosomiasis, paragonimiasis, and fascioliasis. Cestodes (tapeworms) are flat, hermaphroditic parasites that cause diseases such as sparganosis, cysticercosis, and echinococcus.

Mucocutaneous manifestations of helminth infections: Trematodes and cestodes.

In the 21st century, despite increased international travel for vacation, work, and medical missions and immigration into the United States, there is little published in the dermatology literature regarding the cutaneous manifestations of helminth infections. It has been estimated that 20% to 70% of international travelers suffer from some travel-related health problem. Approximately 17% of travelers seek medical care because of cutaneous disorders, many related to infectious etiologies. This review will focus on cutaneous diseases caused by helminth infections. Part I of the review focused on nematode infections; part II will focus on trematode and cestode infections. Nematodes are roundworms that cause diseases with cutaneous manifestations, such as cutaneous larval migrans, onchocerciasis, filariasis, gnathostomiasis, loiasis, dracunculiasis, strongyloidiasis, ascariasis, streptocerciasis, dirofilariasis, and trichinosis. Tremadotes, also known as flukes, cause schistosomiasis, paragonimiasis, and fascioliasis. Cestodes (tapeworms) are flat, hermaphroditic parasites that cause diseases such as sparganosis, cysticercosis, and echinococcus.

Successful management of infected thoracoabdominal graft and aortobronchial fistula using a hybrid approach.

We present the case of a 72-year-old patient who underwent successful management of a thoracoabdominal aortic graft infection. The patient was diagnosed with infected distal anastomotic pseudoaneurysm and aortobronchial fistula after type I thoracoabdominal aortic aneurysm repair. The infection was caused by the enteric gram-negative bacterium Proteus mirabilis. The high-risk patient was successfully treated with visceral debranching, infrarenal aortic reconstruction, and stent graft coverage of the pseudoaneurysm. The success of this case suggests that endovascular treatment of thoracoabdominal aortic graft infections may be a viable option in some high-risk patients.

Manifestaciones cutáneas de pacientes en hemodiálisis crónica intermitente (HDCI) en 3 centros de Lima Metropolitana / Cutaneous manifestations of patients who are in intermittent chronic hemodialysis (ICHD) in 3 centers of metropolitan Lima

Objetivo: Describir la frecuencia y características de las manifestaciones cutáneas de pacientes en HDCI y su asociación con variables demográficas, clínicas, de laboratorios e impacto en calidad de vida. Material y métodos: Estudio descriptivo y transversal. Se revisaron las historias clínicas, se realizó un examen físico dermatológico y aplicó la encuesta SF36. Resultados: Todos tuvieron al menos una manifestación cutánea atribuida a enfermedad renal crónica (ERC) y/o HDCI. Los cambios más frecuentes fueron: alteraciones en la pigmentación (100%), alteraciones ungueales (85%), prurito y xerosis (ambos 68%). En alteraciones ungueales: onicolisis (23%), uñas mitad y mitad (16%) y estrías longitudinales (15%). En cambios en cabello: cabello fino, opaco y quebradizo (20%) y alopecia difusa (18%). El prurito y la xerosis fueron más frecuentes en diabéticos y pacientes de edad promedio mayor. Las alteraciones ungueales estuvieron asociadas a diabetes y el cambio más frecuente fue onicolisis. La calidad de vida mental fue menor en pacientes con prurito. Conclusión. Todos los pacientes en HDCI tienen al menos una manifestación cutánea. El prurito y la xerosis fueron el síntoma y el signo más importantes, relacionados uno con el otro, diabetes y edad. Además el prurito se asoció a reducción en la calidad de vida mental.

Objective: To describe the frequency and characteristics of the cutaneous manifestations of HDCI patients and its association with demographic, clinical, laboratory and impact on quality of life. Methods: Descriptive and transversal. We reviewed the medical records, physical examination was performed and applied dermatological SF36 survey. Results: all had at least one cutaneous manifestation attributed to chronic kidney disease (CKD) and/or HDCI. The most frequent changes were alterations in pigmentation (100%), nail changes (85%), pruritus and xerosis (both 68%). Changes in nails: onycholysis (23%), half and half nail (16%), longitudinal grooves (15%). Changes in hair: fine hair, dull and brittle (20%), alopecia (18%). Xerosis and pruritus were more frequent in diabetic patients, and average age older. The nail changes were associated with diabetes and onycholysis was the most frequent change. The quality of mental life was lower in patients with pruritus. Conclusion: All patients in HDCI have at least one skin manifestation. Pruritus and xerosis were the most important symptom and sign, related to each other diabetes and age. Besides pruritus associated with reduced quality of mental life.

Enfermedad del suero / Serum sickness

La enfermedad del suero es una enfermedad alérgica rara que se produce por la administración de material antigénico exógeno. Históricamente causada por suero heterólogo; corresponde a una reacción de hipersensibilidad tipo III mediada por depósitos de complejos inmunes circulantes en los pequeños vasos sanguíneos, la cual induce la activación del complemento y subsecuente inflamación. Las características clínicas son fiebre, erupción cutánea, artralgias y linfadenopatías, pudiendo llegar a producir glomerulonefritis o compromiso de otro órgano. Presentamos el caso de un paciente que desarrolló enfermedad del suero posterior a la administración de suero antiofídico.

Serum sickness is a rare allergic disease, produced by the administration of exogenous antigenic material. Historically caused by heterologous serum, it corresponds to a type III hypersensitivity reaction mediated by deposits of circulating immune complexes in small blood vessels, which induces complement activation and subsequent inflammation. Clinical features are fever, rash, arthralgia and lymphadenopathy; this pathology may lead to glomerulonephritis or other organ involvement. We report a patient who developed serum sickness after antivenom administration.

Leishmaniasis cutánea zosteriforme: reporte de un caso / Zosteriform cutaneous leishmaniasis: report of a case

La leishmaniasis cutánea es una enfermedad por protozoarios muy común en nuestro país, causada por diferentes especies de Leishmania. La presentación clínica tipo nódulo y pápula es la más común, aunque también se reportan variantes clínicas poco frecuentes. Las lesiones inusuales se atribuyen a alteraciones en la respuesta del huésped y a la cepa del parásito involucrado. Se reporta el caso de un paciente quien presentó compromiso en la región frontal, unilateral, con histopatología confirmatoria de leishmaniasis cutánea; lo cual ha sido descrito en la literatura como leishmaniasis cutánea variedad zosteriforme y es una forma poco frecuente de presentación.

Cutaneous leishmaniasis is a common protozoal disease very common in our country, caused by several species of Leishmania. The usual clinical presentations are the nodular and papular types, but rare variants have also been reported. Unusual lesions are attributed to alterations in host response and to an atypical strain of parasites involved. We report the case of a patient with unilateral compromise of the forehead with confirmatory histopathology of cutaneous leishmaniasis, which has been described in the literature as zosteriform type cutaneous leishmaniasis and is a rare form of presentation.

Sarcoidosis: síndrome de Lõfgren / Sarcoidosis: LõfgrenÆs syndrome

La sarcoidosis es una enfermedad sistémica, inmunológica y de etiología desconocida, caracterizada por la presencia de granulomas no caseificantes. Todos los tejidos pueden verse afectados, pero el órgano que se daña con más frecuencia es el pulmón, seguido de los ganglios linfáticos, piel, ojos, aparato locomotor y sistema nervioso. Habitualmente tiene un curso agudo o subagudo que suele remitir, pero puede ser crónico, progresivo y dejar graves secuelas. El diagnóstico se basa en la combinación de datos clínicos, radiológicos e histológicos, junto con la exclusión de otras afecciones granulomatosas. El síndrome de Lõfgren es una presentación aguda de sarcoidosis, caracterizada por la presencia de artritis, artralgia, eritema nodoso y linfadenopatías. Se presenta el caso de una paciente joven con clínica compatible con síndrome de Lõfgren.

Sarcoidosis is a systemic and immunologic disease of unknown etiology, characterized by the presence of noncaseating granulomas. Any tissue can be affected, but the lung is the most frequently compromised organ, followed by lymph nodes, skin, eyes, musculoskeletal and nervous system. Usually it has an acute or subacute course that heals itself, but it may also have a chronic and progressive course, causing serious consequences. Diagnosis is based on the combination of clinical, radiological and histological studies, along with the exclusion of other granulomatosus diseases. LõfgrenÆs syndrome is an acute presentation of sarcoidosis, characterized by the presence of arthritis, arthralgia, erythema nodosum and lymphadenopathy.

Queratoacantomas múltiples: un reto diagnóstico y terapéutico / Multiple keratoacanthoma: a diagnostic and therapeutic challenge

El queratoacantoma (QA) es una neoplasia cutánea que por lo usual remite espontáneamente. Muchos queratoacantomas son solitarios pero también se conocen las formas múltiples: del tipo Ferguson Smith, QA eruptivos, QA múltiples persistentes, QA en el síndrome de Muir-Torre y QA centrifugum marginatum, entre otros. Se reporta el caso de una estudiante mujer de 20 años, sin antecedentes patológicos de importancia, que presentó lesiones nodulares de base eritematosa y centro costroso en ambas piernas, de tres meses de evolución. Dada la clínica e histopatología compatible se realizó el diagnóstico de queratoacantomas múltiples recibiendo diferentes tratamientos sin éxito, para finalmente responder a acitretin en una dosis de 0.5mg/kg/día, con involución de las lesiones después de cuatro semanas.

Keratoacanthoma (KA) is a cutaneous neoplasm that usually heals spontaneously. Most KA lesions are unique, but there can also occur as multiple lesions: Ferguson Smith type KA, eruptive KA, multiple persistent KA, KA in Muir-Torre syndrome, and KA centrifugum marginatum, among others. We report the case of a 20 year-old female student, with no significant previous medical history, who presented nodular lesions with erythematous base and crusted center in both legs, for the past three months. Given both the clinical and histological evidence, a diagnosis of multiple keratoacanthomas was made. The patient received different treatments without success until acitretin was administered at a dose of 0.5mg/kg/day, with involution of lesions after four weeks.

Leishmaniasis cutánea difusa transformada por corticoides / Cutaneous leishmaniasis diffuse transformed by corticoids

Las leishmaniasis cutáneas son un grupo de enfermedades parasitarias con gran polimorfismo clínico, producidas por protozoarios del género Leishmania; los cuales son transmitidos al hombre por la picadura de un mosquito (Lutzomia). El Perú sigue siendo una zona endémica, por lo que se presenta el caso de un paciente cuya enfermedad tuvo una evolución prolongada, con cuadro clínico atípico, el cual fue modificado por el uso de corticoides. El caso constituyó un reto diagnóstico, que requirió del estudio histopatológico de las lesiones, donde se observaron múltiples macrófagos vacuolados conteniendo amastigotes de Leishmania. El paciente recibió tratamiento con anfotericin B con remisión del cuadro.

Cutaneous leishmaniasis is a parasitic disease with great clinical polymorphism, caused by protozoa of the genus Leishmania, which is transmitted to humans through the bite of mosquito (Lutzomia). Peru remains an endemic area, and for that reason we present the case of a patient whose disease had a prolonged course, with atypical clinical picture sintomatology, which was modified by the use of corticosteroids. The case was a diagnostic challenge, requiring the histopathology study of the lesions, which showed multiple vacuolated macrophages containing amastigots of Leishmania. The patient was treated with amphotericin B with remission of the lesions.