Lumbosacral pain in a patient with psoriatic arthritis: when the rheumatic disease is innocent.

Lumbar pain is a very common symptom that derives from benign musculoskeletal conditions, rheumatic inflammatory diseases, neoplasms, and referred and/or nociplastic pain. A 70-year-old man with psoriatic arthritis presented with early-onset lumbosacral pain without evident red flags. Symptomatic treatment was unhelpful. Radiographic imaging showed subtle signs of a disease that could easily be missed. Magnetic resonance imaging revealed a massive prostatic malignancy with bone (sacral and iliopubic) metastasis. Awareness must be given not to disregard every lumbar pain as part of the preexisting rheumatic inflammatory disease (spondyloarthropathy in this case) or a common muscle/ligament/articular disarrangement. Persistence of pain, albeit not inflam-matory nor sharp in nature, despite adequate treatment might be just as important as an acute red flag and requires proper follow-up.

An outbreak of respiratory syncytial virus infection in hematopoietic stem cell transplantation outpatients: good outcome without specific antiviral treatment.

BACKGROUND: Respiratory syncytial virus (RSV) is a common cause of seasonal respiratory viral infection in hematopoietic stem cell transplantations (HSCT) patients. The efficacy of treatment, however, remains controversial. We describe an outbreak of 31 cases of RSV that occurred in an HSCT outpatient care unit in the fall season from March through May 2010, with a good outcome without any specific antiviral treatment. METHODS: During these 3 months, 222 nasal wash samples were tested and, of these, 31 outpatients were positive for RSV. In 2009, 99 samples had been tested and only 10 outpatients were positive for RSV in the same period. RESULTS: Seven (22.5%) patients had severe neutropenia (<500 cells/µL); severe lymphopenia (<200 cells/µL) was present in 13 (41.9%) patients, and 14 (45%) had received intravenous broad-spectrum antibiotics. Hospitalization was necessary only for 8 patients (25.8%); 20 had lower respiratory tract infection (64.5%). Only 1 patient died as a result of proven invasive aspergillosis. CONCLUSION: This report suggests that HSCT outpatients with no risk factors may not always require specific treatment for RSV.

Validation of the North America expert consensus statement on reporting CT findings for COVID-19 in individuals with lung cancer.

The aim of our study was to validate the use of the standardized Radiological Society of North America (RSNA) reporting system in individuals with known lung cancer who presented to the emergency department with suspected COVID-19. We included patients aged 18 years or older from the Cancer Institute of the State of São Paulo (ICESP) with a confirmed diagnosis of lung cancer, admitted to the emergency department and undergoing chest computed tomography (CT) for suspicion of COVID-19. Comparison between SARS-CoV2 RT-PCR across RSNA categories was performed in all patients and further stratified by diagnosis of lung cancer progression. Among 58 individuals included in the analysis (65±9 years, 43% men), 20 had positive RT-PCR. Less than a half (43%) had no new lung findings in the CT. Positive RT-PCR was present in 75% of those with typical findings according to RSNA and in only 9% when these findings were classified as atypical or negative (P<0.001). Diagnostic accuracy was even higher when stratified by the presence or absence of progressive disease (PD). Extent of pulmonary inflammatory changes was strongly associated with higher mortality, reaching a lethality of 83% in patients with >25% of lung involvement and 100% when there was >50% of lung involvement. The lung involvement score was also highly predictive of prognosis in this population as was reported for non-lung cancer individuals. Collectively, our results demonstrated that diagnostic and prognostic values of chest CT findings in COVID-19 are robust to the presence of lung abnormalities related to lung cancer.

Clinical presentation and in-hospital prognosis of lung cancer patients presenting with suspected and confirmed COVID-19.

We sought to compare the clinical presentation and prognosis of patients with lung cancer and confirmed COVID-19 infection to those with negative RT-PCR SARS-CoV-2 results. We included patients with confirmed lung cancer and suspected COVID-19 who presented to the emergency department. The primary outcome was in-hospital mortality and secondary outcomes included admission to intensive care unit (ICU) or mechanical ventilation. We analyzed the characteristics according to RT-PCR results and primary outcome. We constructed a logistic regression for each RT-PCR result group to find potential predictors of the primary outcome. Among 110 individuals with confirmed lung cancer (65±9 years, 51% male), 38 patients had positive RT-PCR and 72 patients had negative RT-PCR. There was no difference between groups for any clinical characteristic or comorbidities though individuals with confirmed COVID-19 had higher functionality in the ECOG scale. Leucocytes and lymphocytes were lower in individuals with positive tests. The primary outcome occurred in 58 (53%) individuals, 37 (34%) were admitted to the ICU, and 29 (26%) required mechanical ventilation. Although mortality was similar between the two groups, individuals with confirmed COVID-19 were significantly more likely to be admitted to the ICU or receive mechanical ventilation. Only lower lymphocytes and higher CRP were significantly associated with higher mortality. The clinical presentation of COVID-19 in lung cancer is not sufficient to identify higher or lower probability groups among symptomatic individuals, the overall mortality is high irrespective of RT-PCR results, and lymphopenia on admission was associated with the diagnosis and prognosis for COVID-19.

Validation of the North America expert consensus statement on reporting CT findings for COVID-19 in individuals with lung cancer

The aim of our study was to validate the use of the standardized Radiological Society of North America (RSNA) reporting system in individuals with known lung cancer who presented to the emergency department with suspected COVID-19. We included patients aged 18 years or older from the Cancer Institute of the State of São Paulo (ICESP) with a confirmed diagnosis of lung cancer, admitted to the emergency department and undergoing chest computed tomography (CT) for suspicion of COVID-19. Comparison between SARS-CoV2 RT-PCR across RSNA categories was performed in all patients and further stratified by diagnosis of lung cancer progression. Among 58 individuals included in the analysis (65±9 years, 43% men), 20 had positive RT-PCR. Less than a half (43%) had no new lung findings in the CT. Positive RT-PCR was present in 75% of those with typical findings according to RSNA and in only 9% when these findings were classified as atypical or negative (P<0.001). Diagnostic accuracy was even higher when stratified by the presence or absence of progressive disease (PD). Extent of pulmonary inflammatory changes was strongly associated with higher mortality, reaching a lethality of 83% in patients with >25% of lung involvement and 100% when there was >50% of lung involvement. The lung involvement score was also highly predictive of prognosis in this population as was reported for non-lung cancer individuals. Collectively, our results demonstrated that diagnostic and prognostic values of chest CT findings in COVID-19 are robust to the presence of lung abnormalities related to lung cancer.

Clinical presentation and in-hospital prognosis of lung cancer patients presenting with suspected and confirmed COVID-19

We sought to compare the clinical presentation and prognosis of patients with lung cancer and confirmed COVID-19 infection to those with negative RT-PCR SARS-CoV-2 results. We included patients with confirmed lung cancer and suspected COVID-19 who presented to the emergency department. The primary outcome was in-hospital mortality and secondary outcomes included admission to intensive care unit (ICU) or mechanical ventilation. We analyzed the characteristics according to RT-PCR results and primary outcome. We constructed a logistic regression for each RT-PCR result group to find potential predictors of the primary outcome. Among 110 individuals with confirmed lung cancer (65±9 years, 51% male), 38 patients had positive RT-PCR and 72 patients had negative RT-PCR. There was no difference between groups for any clinical characteristic or comorbidities though individuals with confirmed COVID-19 had higher functionality in the ECOG scale. Leucocytes and lymphocytes were lower in individuals with positive tests. The primary outcome occurred in 58 (53%) individuals, 37 (34%) were admitted to the ICU, and 29 (26%) required mechanical ventilation. Although mortality was similar between the two groups, individuals with confirmed COVID-19 were significantly more likely to be admitted to the ICU or receive mechanical ventilation. Only lower lymphocytes and higher CRP were significantly associated with higher mortality. The clinical presentation of COVID-19 in lung cancer is not sufficient to identify higher or lower probability groups among symptomatic individuals, the overall mortality is high irrespective of RT-PCR results, and lymphopenia on admission was associated with the diagnosis and prognosis for COVID-19.

Recurrent Focal myositis: a rare inflammatory myopathy.

Focal myositis is an acute and localized muscle inflammation of unknown aetiology. The clinical diagnosis is often difficult to obtain, since it can be confused with infections, vascular thrombosis or muscle tumours such as sarcomas. This leads to a significant delay in the diagnosis, resulting in the administration of inappropriate and potentially harmful treatments.  We report here a case of recurrent focal myositis in a woman where the diagnosis was only obtained after 6 years, despite multiple hospital admissions. This case reinforces the importance of clinical knowledge and experience to tackle challenging medical scenarios.

Posterior reversible encephalopathy syndrome: the importance of its recognition in patients with systemic lupus erythematosus.

The posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological entity characterized by the association of clinical neurological signs (headache, confusion, vision changes, vomiting and seizures) and the typical changes in magnetic resonance imaging of the brain. Its pathogenesis is still poorly defined but seems to imply a vascular and endothelial dysfunction. It occurs more frequently in patients with hypertensive encephalopathy, eclampsia, renal failure and has also been associated with the use of immunosuppressive drugs. The authors present a case of PRES in a young woman with systemic lupus erythematosus with active and severe manifestations of the disease.

Clinical and pathological presentation of squamous metaplasia of the rete ovarii in a Zebu cow / Apresentação clínica e patológica de um caso de metaplasia escamosa da rete ovariana em vaca Zebu

Squamous metaplasia of rete ovarii is characterized by replacement of the normal cuboidal epithelium of rete ovarii by a keratinized stratified scamous epithelium, leading to accumulation of keratinized material within the tubules and cystic dilatation of rete ovarii. The present study decribes a case of scamous metaplasia of rete ovarii in a 10 year old Zebu cow, including clinical, surgical, ultrasonographic, histopathological and hormonal findings. At first ultrasound examination the cow had lightly asymmetric ovaries with follicles presenting echogenicity similar to luteinized follicular cysts. After transvaginal follicular aspiration creamy yellowish sanguineous-purulent content was recovered. After unilateral ovariectomy the ovary was sectioned and brownish viscous material drained from cystic cavity. Histopathology confirmed the diagnosid of squamous metaplasia of the rete ovarii. Progesterone concentrations assessed by chemiluminescent enzyme immunoassay within different time periods after ovariectomy showed that pathology did not compromise normal luteal ovarian activity in a contralateral reminiscent ovary.

A metaplasia escamosa de rete ovarii é caracterizada pela substituição do epitélio cúbico normal da rete ovarii por um epitélio escamoso estratificado queratinizado, levando ao acúmulo de material queratinizado dentro dos túbulos e à dilatação cística da rete ovarii. O presente estudo descreve um caso de metaplasia escamosa de rete ovarii em uma vaca Zebu de aproximadamente 10 anos, incluindo aspectos clínico, cirúrgico, ultrassonográfico, histopatológico e dos achados hormonais. Ao primeiro exame ultrassonográfico, a vaca tinha ovários levemente assimétricos e com folículos apresentando ecogenicidade semelhante à dos cistos foliculares luteinizados. Após a aspiração folicular por via transvaginal, foi recuperado conteúdo sanguinopurulento amarelado e de aspecto cremoso. Após a ovariectomia unilateral, o ovário foi seccionado, permitindo a drenagem de material de aspecto viscoso amarronzado da cavidade cística. A histopatologia confirmou o diagnóstico de metaplasia escamosa da rete ovarii. As concentrações de progesterona avaliadas por quimioluminescência, em diferentes períodos de tempo após a ovariectomina unilateral, mostrou que a patologia não comprometeu a atividade ovariana normal do ovário contralateral remanescente.

The involvement of hexokinases in trehalose synthesis.

Yeast cells harboring a MAL2-8c gene accumulate trehalose during the transition phase of growth on glucose due to the presence of the ADPG-dependent trehalose 6-phosphate synthase. Under these conditions, glucokinase appeared not to provide G-6-P for trehalose synthesis and the two hexokinases seemed to act synergistically. After incubation in d-xylose, trehalose levels in these cells dropped almost in 90%, confirming the involvement of both hexokinases in the accumulation of this carbohydrate. Nevertheless, G-6-P levels appeared to be similar in all strains. Some explanations for this paradox are discussed. In stationary phase, neither of the three isoenzymes were involved in trehalose synthesis. Possibly, gluconeogenesis provides the substrate for trehalose synthesis at that stage.