Toxic epidermal necrolysis with systemic lupus erythematosus: case report and review of the literature.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are potentially fatal mucocutaneous diseases characterized by extensive necrosis and exfoliation of the epidermis. TEN and SJS are most often caused by various kinds of drugs. Other risk factors for SJS/TEN include pneumonia infection, HIV infection, genetic factors, underlying immune diseases, and tumors. SJS and TEN were first identified in 1922, but at present, a widely recognized view is that SJS and TEN represent phases in the continuous progress of the same disease. SJS/TEN has a very high mortality, but is rare, and cases of SJS/TEN combined with systemic lupus erythematosus (SLE) are even less common. Occasionally, acute cutaneous manifestations of SLE and SJS/TEN can be phenotypically similar, both causing extensive epidermal necrosis. In this paper, we present a recent case of a 32-year-old female SLE patient with a drug-induced (the health product, astaxanthin) TEN/SJS. To provide context to this case, we have reviewed relevant case studies published in English, accessed via PubMed databases. The search covers all published case studies from 1988 to 2019. We collected a total of 30 cases in the literature, and analyzed their characteristics from the aspects of gender, suspicious medication history, and treatment in order to expand clinicians' approach to diagnosis and treatment.

Correlation between the warning symptoms and prognosis of cardiac arrest.

BACKGROUND: A low survival rate in patients with cardiac arrest is associated with failure to recognize the condition in its initial stage. Therefore, recognizing the warning symptoms of cardiac arrest in the early stage may play an important role in survival. AIM: To investigate the warning symptoms of cardiac arrest and to determine the correlation between the symptoms and outcomes. METHODS: We included all adult patients with all-cause cardiac arrest who visited Peking University Third Hospital or Beijing Friendship Hospital between January 2012 and December 2014. Data on population, symptoms, resuscitation parameters, and outcomes were analysed. RESULTS: Of the 1021 patients in the study, 65.9% had symptoms that presented before cardiac arrest, 25.2% achieved restoration of spontaneous circulation (ROSC), and 7.2% survived to discharge. The patients with symptoms had higher rates of an initial shockable rhythm (12.2% vs 7.5%, P = 0.020), ROSC (29.1% vs 17.5%, P = 0.001) and survival (9.2% vs 2.6%, P = 0.001) than patients without symptoms. Compared with the out-of-hospital cardiac arrest (OHCA) without symptoms subgroup, the OHCA with symptoms subgroup had a higher rate of calls before arrest (81.6% vs 0.0%, P < 0.001), health care provider-witnessed arrest (13.0% vs 1.4%, P = 0.001) and bystander cardiopulmonary resuscitation (15.5% vs 4.9%, P = 0.002); a shorter no flow time (11.7% vs 2.8%, P = 0.002); and a higher ROSC rate (23.8% vs 13.2%, P = 0.011). Compared to the in-hospital cardiac arrest (IHCA) without symptoms subgroup, the IHCA with symptoms subgroup had a higher mean age (66.2 ± 15.2 vs 62.5 ± 16.3 years, P = 0.005), ROSC (32.0% vs 20.6%, P = 0.003), and survival rates (10.6% vs 2.5%, P < 0.001). The top five warning symptoms were dyspnea (48.7%), chest pain (18.3%), unconsciousness (15.2%), paralysis (4.3%), and vomiting (4.0%). Chest pain (20.9% vs 12.7%, P = 0.011), cardiac etiology (44.3% vs 1.5%, P < 0.001) and survival (33.9% vs 16.7%, P = 0.001) were more common in males, whereas dyspnea (54.9% vs 45.9%, P = 0.029) and a non-cardiac etiology (53.3% vs 41.7%, P = 0.003) were more common in females. CONCLUSION: Most patients had warning symptoms before cardiac arrest. Dyspnea, chest pain, and unconsciousness were the most common symptoms. Immediately recognizing these symptoms and activating the emergency medical system prevents resuscitation delay and improves the survival rate of OHCA patients in China.

[Clinical study on improving decreased gastrointestinal motility of post-operative esophageal cancer patients by unblocking the interior and purgation method].

OBJECTIVE: To observe the clinical effect of unblocking the interior and purgation method on improving decreased gastrointestinal motility of post-operative esophageal cancer patients, and to study its mechanisms. METHODS: 60 patients with post-operative esophageal cancer were randomly assigned to two groups, the treatment group and the control group, 30 in each group. Routine therapies were given to the two groups. Chinese drugs with unblocking the interior and purgation action was infused by enteral nutrition tube to patients in the treatment group, while normal saline was infused to those in the control group. The first flatus time, the first defecation time, the bowel tones recovery time after operation, and the total amount of the gastric juice draining between the first day and the third day after operation of all patients were recorded. Plasma motilin (MTL) and vasoactive intestinal peptide (VIP) contents were detected before operation and the fourth day after operation. RESULTS: The first flatus time, the first defecation time, the bowel tones recovery time after operation, and the total amount of the gastric juice draining were less in the treatment group than in the control group, showing statistical difference (P<0.05, P<0.01). The post-operative MTL contents were higher and VIP contents lower in the treatment group than in the control group, showing statistical difference (P<0.05, P<0.01). There was no significant difference in plasmal MTL and VIP contents of the treatment group between before and after treatment (P>0.05). But there was significant difference in plasmal MTL and VIP contents of the control group between before and after treatment (P<0.01). CONCLUSION: Unblocking the interior and purgation method could significantly promote the gastrointestinal motility recovery of post-operative esophageal cancer patients, showing good clinical effect.

Cardiac arrhythmias and cardiac arrest related to mushroom poisoning: A case report.

BACKGROUND: Mushroom exposure is a global health issue. The manifestations of mushroom poisoning (MP) may vary. Some species have been reported as rhabdomyolytic, hallucinogenic, or gastrointestinal poisons. Critical or even fatal MPs are mostly attributable to Amanita phalloides, with the development of severe liver or renal failure. Myocardial injury and even cases mimicking ST-segment elevation myocardial infarction (STEMI) have been previously reported, while cardiac arrhythmia or cardiac arrest is not commonly seen. CASE SUMMARY: We report a 68-year-old woman with MP who suffered from delirium, seizure, long QT syndrome on electrocardiogram (ECG), severe cardiac arrhythmias of multiple origins, and cardiac arrest. She was intubated and put on blood perfusion. Her kidney and liver functions were intact; creatine kinase-MB was mildly elevated, and then fell within normal range during her hospital stay. We sent the mushrooms she left for translation elongation factor subunit 1α, ribosomal RNA gene sequence, and internal transcribed spacer sequence analyses. There were four kinds of mushrooms identified, two of which were found to be toxic. CONCLUSION: This is the first time that we found cardiac toxicity caused by Panaeolus subbalteatus and Conocybe lactea, which were believed to be toxic to the liver, kidney, and brain. We suggest that intensive monitoring and ECG follow-up are essential to diagnose prolonged QT interval and different forms of tachycardia in MP patients, even without the development of severe liver or renal failure. The mechanisms need to be further investigated and clarified based on animal experiments and molecular signal pathways.

[Effects of early treatment with metoprolol on myocardial inflammatory cytokine expression and heart function in rats with acute myocardial infarction].

OBJECTIVE: The aim of study was to explore the effects of early beta-adrenergic blockade-metoprolol treatment on myocardial inflammatory cytokine expression and heart function in rats after acute myocardial infarction (AMI). METHODS: The therapeutic effects of metoprolol on myocardial inflammation and heart function up to 4 weeks (according to the protocol of CCS-2) were studied by the rat model of AMI. Myocardial inflammation was examined by taking account of the number of lymphocytes infiltrated in the myocardium and analyzing the myocardial cytokine production including the pro-inflammatory cytokines: interleukin (IL)-1beta, 6 and tumor necrosis factor (TNF)-alpha and the anti-inflammatory cytokine: IL-10. Echocardiography was used to evaluate heart function. RESULTS: The levels of TNF-alpha, IL-1beta, IL-6 and IL-10 in AMI group were markedly elevated compared to sham rats (P < 0.01) and the cytokines principally excreted by cardiac myocytes. After 4 weeks therapy, metoprolol reduced the production of TNF-alpha and IL-1beta and increased IL-10 levels (P < 0.05) in cardiac myocytes, but had no effect on the number of lymphocytes infiltrated in myocardium. Echocardiography showed that metoprolol markedly improved left heart function (P < 0.05). CONCLUSION: Early metoprolol treatment can improve heart function and myocardial inflammatory cytokine expression after AMI. One immunopharmacologic mechanism underlying the beneficial effects of beta-adrenergic blockade may involve the attenuation of pro-inflammatory cytokines and the increase of anti-inflammatory cytokine levels in cardiac myocytes.

[The significance of Th1/Th2 function imbalance in patients with post-infarction cardiac insufficiency].

OBJECTIVE: To study the significance of Th1/Th2 function imbalance in patients with post-infarction cardiac insufficiency. METHODS: Forty-three MI (myocardial infarction) patients were divided into 2 groups one month after the onset according to the New York Heart Association (NYHA) classification system: group MI 1 (I, II) 25 patients and group MI 2 (III, IV) 18 patients. At the same time, the heart function was evaluated by two-dimensional echocardiography. Peripheral blood mononuclear cells (PBMCs) were collected from these patients. Cytokine-producing CD4 + T cells were quantified by 3-color flow cytometry after being stimulated with phorbol myristate acetate (PMA) and ionomycin. After being stimulated with PHA, the levels of IFN-gamma and IL-4 in culture supernatants were measured by ELISA. RESULTS: The frequencies of IFN-gamma-producing T cells were found to be significantly higher in group MI 2 (16.8%) than that in group MI 1 (13.1%). There was no significant difference on the frequencies of IL-4-producing peripheral T cells between the two groups. The IFN-gamma level and the ratios of IFN-gamma/IL-4 in group MI 2 were significantly higher than those in group MI 1, while there was no significant difference in IL-4 levels between the two groups. CONCLUSIONS: The Th-cell function was associated with heart function in post MI patients. The up-regulation of Th1 cell function was consistent with poor heart function, suggesting that Th1/Th2 cell function imbalance may participate in ventricular remodelling after MI.

[Acupoint catgut embedding for perimenopausal syndrome: a clinical controlled trial].

OBJECTIVE: To compare the clinical efficacy differences between acupoint catgut embedding and Kuntai capsule for perimenopausal syndrome, so as to provide an effective treatment method for perimenopausal syndrome. METHODS: Thirty-three cases in the embedding group were treated with acupoint catgut embedding at back-shu points and front-mu points of liver, spleen and kidney combined with syndrome differentiation and disease differentiation, ten days per times; the Kuntai group was treated with oral administration of Kuntai capsule, 4 capsules each time, three times per day. The Kupperman index (KI) was observed in the two groups before treatment after 10 days, 30 days and 60 days of treatment, respectively; the efficacy was evaluated according to the ratio of KI. RESULTS: After the treatment, as treatment proceeded, the score of KI and ratio of KI were gradually reduced in two groups; the score of KI and ratio of KI in the embedding group after 10 days of treatment was lower than those in the Kuntai group (both P<0.05); after 10 days of treatment, the total effective rate was 36.4% (12/33) in the embedding group, which was superior to 3.0% (1/33) in the Kuntai group (P<0.05); however, after 30 days and 60 days of treatment, the differences of each index between two groups were not statistically significant (all P>0.05). CONCLUSION: Both the acupoint catgut embedding and Kuntai capsule could reduce the score of KI and improve clinical symptoms, and the acupoint catgut embedding has certain advantage on the early stage of treatment.

Pulmonary embolism in adolescents.

BACKGROUND: Pulmonary embolism (PE) is rare and seldom considered in adolescent patients; however it occurs with a greater frequency than is generally recognized, and it is a potentially fatal condition. The aim of the current study was to understand its epidemiology, clinical features and the cause of delay of its diagnosis in adolescents. METHODS: A retrospective analysis of nine adolescents with acute PE admitted to the Peking University Third Hospital over the past 16-year period was performed. The epidemiology, clinical features and risk factors of the adolescents were described and compared with those of adults and elderly patients. The time to diagnosis and misdiagnosed diseases were analyzed. Pretest probability of PE was assessed retrospectively by the Wells score and revised Geneva score. RESULTS: The incidence of PE was 43.6 per 100 000 hospitalized adolescents in our hospital. The incidence of PE in adolescents was much lower than that in adults and PE is diagnosed in about 1/50 of elderly people. The clinical features in adolescents were similar to those in adults. But fever and chest pain were more common in adolescents (P < 0.05). The major risk factors included surgery, systemic lupus erythematosus (SLE), thrombocytopenia, long-term oral glucocorticoids and trauma. The mean diagnostic time was (7.8 ± 8.4) days. Six cases had a delayed diagnosis. The mean delay time from symptom onset to diagnosis was (11.0 ± 8.8) days. The time of presentation to diagnosis in patients initially admitted to the emergency department was less than one day, and was much shorter than the time in outpatients, (9.4 ± 7.5) days. Most of the patients were initially misdiagnosed with a respiratory tract infection. Most patients' values of Wells score or revised Geneva score were in the moderate or high clinical probability categories; 88% by Well score vs. 100% by revised Geneva score. CONCLUSIONS: PE was seldom considered in the adolescent patients by physicians, especially outpatient physicians, so the diagnosis was often delayed. If adolescent patients complain of dyspnea or chest pain or syncope with/without fever, and they had risk factors such as surgery, thrombocytopenia and trauma, PE should be considered and included in the differential diagnosis.