Population wide testing pooling strategy for SARS-CoV-2 detection using saliva.

SARS-CoV-2 pandemic has forced frequent testing of populations. It is necessary to identify the most cost-effective strategies for the detection of COVID-19 outbreaks. Nasopharyngeal samples have been used for SARS-CoV-2 detection but require a healthcare professional to collect the sample and cause discomfort and pain to the individual. Saliva has been suggested as an appropriate fluid for the diagnosis of COVID-19. We have investigated the possibility of using pools of saliva samples to detect SARS-CoV-2 in symptomatic and asymptomatic patients. Two hundred and seventy-nine saliva samples were analyzed through RT-PCR of Envelope, Nucleocapsid and Open Reading Frame 1ab genes. Reproducibility assays showed an almost perfect agreement as well as high sensitivity (96.6%), specificity (96.8%), positive predicted value (96.6%), and negative predicted value (96.8%). The average Cycle Threshold of the genes detected was 29.7. No significant differences (p > 0.05) were detected when comparing the cycle threshold average of two consecutive reactions on the same positive saliva samples. Saliva samples have a higher median viral load (32.6) than in nasopharyngeal samples (28.9), although no significant differences were detected (p > 0.05). Saliva-pool samples allowed effective SARS-CoV-2 screening, with a higher sensibility (96.9%) on 10-sample pools than in 20-sample pools (87.5%). Regardless of pools size specificity was high (99.9%) and an almost perfect agreement was observed. Our strategy was successfully applied in population wide testing of more than 2000 individuals, showing that it is possible to use pooled saliva as diagnostic fluid for SARS-CoV-2 infection.

Rifampicin-Induced Nephrotoxicity in a Tuberculosis Patient: Treatment Dilemma?

Acute kidney injury related to rifampin is usually a clinical diagnosis. We report a case of a man being treated for pulmonary tuberculosis with acute tubulointerstitial nephritis related to rifampicin. LEARNING POINTS: Rifampicin can cause acute kidney injury.Renal impairment may develop weeks after rifampicin administration was started.

Characteristics and management of asymptomatic SARS-CoV-2 infections.

The coronavirus disease 2019 (COVID-19) pandemic has caused and is still causing tremendous morbidity, mortality, and damage to our societies. The disease course of COVID-19 can be unpredictable ranging from asymptomatic infections to multi-organ failure and death. Transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) from an asymptomatic infected individual to others has been observed early in the pandemic. Asymptomatic individuals have been shown to have quantitative SARS-CoV-2 viral loads, there may or may not be radiological and/or laboratory abnormalities. No antiviral therapy has been approved for the treatment of asymptomatic SARS-CoV2- infection. The management of asymptomatic individuals at home requires that the person can be monitored for any signs and symptoms of deterioration and that the requirements for infection prevention and control measures can be fulfilled. It is crucial to properly diagnose and manage asymptomatic COVID-19 cases with effective testing, contact tracing, quarantine, and isolation strategies. Preventing asymptomatic SARS-CoV-2 infections that have a major role in the unhindered transmission of the virus is a milestone to take control of the pandemic. Vaccination has been proven to be the crucial pillar for preventing asymptomatic infections and real-life data will continue to exhibit the effects of community vaccination in breaking the transmission chain of SARS-CoV-2 infections.

Thymoma and Tuberculoma: Unexpected Coexistence.

Mediastinal tumours can be incidental findings on chest x-ray or present with systemic symptoms and/or direct effect of the mediastinal mass. We report the case of a woman with symptomatic thymoma B1 and simultaneous thymus tuberculosis. LEARNING POINTS: The association of tuberculosis (TB) of the thymus and thymoma is extremely rare.The differential diagnosis of a mediastinal mass should include TB, particularly in endemic regions.Mediastinal mass resection or biopsy can be of great value in diagnostic work-up.

Pulmonary mucormycosis: A case report.

Mucormycosis is a rare fungal infection caused by Mucorales order fungi. The rhino-cerebral form of mucormycosis is most commonly seen in patients with diabetes mellitus, whereas, pulmonary mucormycosis is a rare manifestation in patients with haematological malignancy and transplant recipients. We report a case of pulmonary mucormycosis presenting with a late acute onset diabetes on a patient immunosuppressed with a low dose of steroids. We aim to illustrate the need for a high clinical suspicion for the diagnosis of mucormycosis and to report the importance of early and aggressive inhiation of antifungal therapy.

Botulism disguised as parotitis.

Botulism is an acute toxin-mediated neuroparalytic syndrome caused by some Clostridium species. It typically presents itself as an acute symmetric descending paralysis of cranial and peripheral nerves, which can potentially evolve to respiratory failure and death. We report a case of botulism diagnosed in a patient presenting with a parotitis probably due to xerostomia, even though he had already sought medical assistance for blurred vision and dysphagia. The neurological symptoms resolved without administration of antitoxin and botulism diagnosis was confirmed with identification of both toxins B and F in patient's serum. We aim to illustrate the need for a high clinical suspicion for the diagnosis of botulism and to report an atypical case of botulism with the production of toxins B and F, the latter being of rare occurrence.

The UriCath study: characterization of the use of indwelling urinary catheters among hospitalized older patients in the Internal Medicine Departments of Portugal.

PURPOSE: Approximately 25% of older inpatients have an indwelling urinary catheter (IUC), 45-54% unnecessarily. This study aims to describe the prevalence, indications, and complications of IUC use in Portuguese older inpatients. METHODS: Multicentric, cross-sectional, observational study conducted in Portuguese internal medicine wards (UriCath). RESULTS: Of a total of 3135 inpatients from 39 hospitals, we included 628 patients with 65 years old or more using an IUC, mean age 82.0 ± 7.5. Prevalence of IUC use was 20.0%. The average Barthel Index was 44.0 ± 37.3 and Charlson comorbidity Index was 7.0 ± 2.8. The main reasons for IUC use were: urinary output monitoring (47.5%), urinary retention (22.5%), and pressure ulcers (11.0%). The IUC removal was attempted in 9.1% and 24.7% developed a complication. CONCLUSION: IUC use among older inpatients is prevalent and often inappropriate. Clinical awareness and development guidelines for restricted use of IUC are essential to reduce morbimortality and healthcare costs.

Ocular Melanoma Presenting as Masquerade Syndrome.

A masquerade syndrome is an ophthalmological entity where a neoplasm mimics an inflammatory condition. Ocular melanoma (chiefly uveal) may present with symptoms suggestive of intraocular inflammation such as endogenous endophthalmitis. Ocular melanoma is most commonly found in middle-aged and older caucasian patients. One-third of all uveal melanoma cases present asymptomatically. Early diagnosis facilitates treatment before ocular melanoma reaches metastatic stage IV. Current therapy options for stage IV patients are palliative care and clinical trial participation. LEARNING POINTS: Masquerade syndrome and intraocular haemorrhage can hide a neoplastic aetiology.A biopsy should be carried out for correct diagnosis if intraocular haemorrhage is present and a neoplastic pathology is suspected.A multidisciplinary approach should be adopted to enhance the quality of life of patients with metastatic ocular melanoma.

Olmesartan-Associated Enteropathy: An Unexpected Cause of Chronic Diarrhoea.

Olmesartan-associated enteropathy is a rare cause of severe enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhoea. It may be difficult to recognise because of its clinical and histologic similarities to other clinical entities. The authors present the case of a 72-year-old woman with a 6-month clinical history of non-bloody diarrhoea and weight loss. Discontinuation of olmesartan resulted in clinical and histologic recovery, and therefore, physicians need to be aware of olmesartan-associated enteropathy in order to avoid unnecessary testing. Although rare, it is considered an emerging and underdiagnosed enteropathy. LEARNING POINTS: Olmesartan-associated enteropathy is characterised by chronic diarrhoea (often severe) and weight loss that is unresponsive to a gluten-free diet.When a patient presents with unexplained chronic diarrhoea, a detailed medication review is needed. If duodenal biopsies reveal villous atrophy and coeliac disease is excluded, drug-induced enteropathy is likely.Clinical response and histologic improvement are expected after olmesartan is withdrawn.

Eosinophilic fasciitis: an atypical presentation of a rare disease.

Eosinophilic fasciitis, or Shulman's disease, is a rare disease of unknown etiology. It is characterized by peripheral eosinophilia, hypergammaglobulinemia, and high erythrocyte sedimentation rate. The diagnosis is confirmed by a deep biopsy of the skin. The first line of treatment is corticotherapy. We present a rare case of eosinophilic fasciitis in a 27-year-old woman with an atypical presentation with symmetrical peripheral edema and a Groove sign. The patient responded well to treatment with corticosteroids at high doses and, in this context, was associated with hydroxychloroquine and azathioprine. After two and a half years, peripheral eosinophilia had increased, and more of her skin had hardened. At that time, the therapy was modified to include corticoids, methotrexate, and penicillamine. It is of great importance to publicize these cases that allow us to gather experience and better treat our patients.

Easy resolution of severe obstructive kidney injury.

Chronic constipation is a common diagnosis with a high prevalence in the elderly. Constipation affects the quality of life of sick individuals, bringing several clinical complications.

Eosinophilic fasciitis: an atypical presentation of a rare disease

SUMMARY Eosinophilic fasciitis, or Shulman's disease, is a rare disease of unknown etiology. It is characterized by peripheral eosinophilia, hypergammaglobulinemia, and high erythrocyte sedimentation rate. The diagnosis is confirmed by a deep biopsy of the skin. The first line of treatment is corticotherapy. We present a rare case of eosinophilic fasciitis in a 27-year-old woman with an atypical presentation with symmetrical peripheral edema and a Groove sign. The patient responded well to treatment with corticosteroids at high doses and, in this context, was associated with hydroxychloroquine and azathioprine. After two and a half years, peripheral eosinophilia had increased, and more of her skin had hardened. At that time, the therapy was modified to include corticoids, methotrexate, and penicillamine. It is of great importance to publicize these cases that allow us to gather experience and better treat our patients.

RESUMO A fasciite eosinofílica ou doença de Shulman é uma doença rara de etiologia desconhecida. É caracterizada por eosinofilia periférica, hipergamaglobulinemia e velocidade de sedimentação eritrocitária elevada. O diagnóstico é confirmado por biópsia profunda da pele. O tratamento de primeira linha é a corticoterapia. Apresentamos um caso raro de fasciite eosinofílica numa mulher de 27 anos com uma apresentação atípica com edema periférico simétrico e sinal de Groove. A paciente respondeu bem ao tratamento com corticoides, mas em doses elevadas, e, nesse contexto, associou-se hidroxicloroquina e azatioprina. Ao fim de dois anos e meio verificou-se aumento de eosinofilia e novamente pele mais endurecida. Nessa altura alterou-se a terapêutica para corticoides, metrotexato e penicilamina. É de grande importância a divulgação desses casos que nos permitem reunir experiência e assim melhor tratar os nossos doentes.

Easy resolution of severe obstructive kidney injury

SUMMARY Chronic constipation is a common diagnosis with a high prevalence in the elderly. Constipation affects the quality of life of sick individuals, bringing several clinical complications.

RESUMO A obstipação crônica é um diagnóstico com alta prevalência comum em idosos. A constipação afeta a qualidade de vida das pessoas doentes, carregando muitas complicações clínicas.

Terlipressin-related Ischaemic Necrosis of the Skin: A Rare Complication.

Terlipressin is used for the treatment of bleeding oesophageal varices and hepatorenal syndrome in patients with cirrhosis. Adverse effects are usually minimal. However, potentially serious side effects such as skin necrosis involving the extremities, scrotum, trunk and abdominal skin can rarely occur. Our patient had greater skin involvement than other described cases. We present the case of a patient with extensive skin necrosis, unrelated to the infusion site, in the lower and upper limbs, scrotum and abdomen after the use of terlipressin. Skin necrosis secondary to terlipressin is a rare complication and early identification is essential so the drug can be immediately suspended. LEARNING POINTS: Skin necrosis secondary to terlipressin is a rare complication.Early identification is essential so the drug can be immediately suspended.Death is not directly related to the skin necrosis but to the secondary complications of advanced liver disease.

Variability of MMP/TIMP and TGF-ß1 Receptors throughout the Clinical Progression of Chronic Venous Disease.

Chronic venous disease (CVeD) is a prevalent condition with a significant socioeconomic burden, yet the pathophysiology is only just beginning to be understood. Previous studies concerning the dysregulation of matrix metalloproteinases (MMPs) and their inhibitors (tissue inhibitors of metalloproteinases (TIMPs)) within the varicose vein wall are inconsistent and disregard clinical progression. Moreover, it is highly plausible that MMP and TIMP expression/activity is affected by transforming growth factor (TGF)-ß1 and its signaling receptors (TGFßRs) expression/activity in the vein wall. A case-control study was undertaken to analyze genetic and immunohistochemical differences between healthy (n = 13) and CVeD (early stages: n = 19; advanced stages: n = 12) great saphenous vein samples. Samples were grouped based on anatomic harvest site and subjected to quantitative polymerase chain reaction for MMP1, MMP2, MMP8, MMP9, MMP12, MMP13, TIMP1, TIMP2, TIMP3, TIMP4, TGFßR1, TGFßR2, and TGFßR3 gene expression analysis, and then to immunohistochemistry for immunolocalization of MMP2, TIMP2, and TGFßR2. Decreased gene expression of MMP12, TIMP2, TIMP3, TIMP4, and TGFßR2 was found in varicose veins when compared to controls. Regarding CVeD clinical progression, two facts arose: results across anatomical regions were uneven; decreased gene expression of MMP9 and TGFßR3 and increased gene expression of MMP2 and TIMP3 were found in advanced clinical stages. Most immunohistochemistry results for tunica intima were coherent with qPCR results. In conclusion, decreased expression of TGFßRs might suggest a reduction in TGF-ß1 participation in the MMP/TIMP imbalance throughout CVeD progression. Further studies about molecular events in the varicose vein wall are required and should take into consideration the venous anatomical region and CVeD clinical progression.