Enterohemorrhagic Escherichia coli: trigger for small vessel vasculitis.

We describe the case of a 19-year-old woman who presented with abdominal pain, vomiting, and a palpable purpuric rash. The patient subsequently developed dysentery and was found to have an infection from Shiga toxin-producing Escherichia coli. The patient also met diagnostic criteria for IgA vasculitis (also known as Henoch Schönlein purpura) but had negative immunofluorescence biopsies of the rash. The patient was treated with steroids and achieved recovery. To our knowledge, this is the first documented case of IgA vasculitis in the setting of an enterohemorrhagic E. coli infection. This case highlights an atypical presentation of IgA vasculitis and the need to include small vessel vasculitis as a differential diagnosis when treating patients of all ages.

Detection of myocardial dysfunction using global longitudinal strain with speckle-tracking echocardiography in patients with vs without rheumatoid arthritis: a systematic review and meta-analysis.

OBJECTIVES: Rheumatoid arthritis (RA) is a systemic autoimmune disorder primarily involving the peripheral joints. Systemic involvement can occur, including myocardial dysfunction. Speckle tracking echocardiography (STE) is a novel diagnostic study which is recently being used to detect subclinical cardiac dysfunction. Global longitudinal strain (GLS) by STE is more sensitive than standard echocardiographic parameters to detect occult cardiac dysfunction. METHODS: A systematic search of PUBMED, EMBASE, Cochrane, and Google Scholar databases was performed to identify studies comparing the STE parameters between RA and non-RA patients. RESULTS: Left ventricular (LV) GLS was significantly lower in patients with RA compared to non-RA patients with a standard mean difference (SMD) of -1.09 (-1.48--0.70, P < 0.001). LV Global Circumferential Strain (GCS) was reported in five studies, and it was found to be lower in RA patients with an SMD of -1.25 (-2.59--0.10; P < 0.0010). Meta regression analysis studies failed to show any significant impact of disease duration, activity, age, sex and BMI on LV GLS and RV GLS. CONCLUSIONS: RA patients have lower LV GLS and LV GCS compared to controls suggesting impaired myocardial dysfunction. Further studies need to be done to delineate the importance of lower GLS in asymptomatic rheumatoid patients to guide disease management and risk factor modification in this selected population.

A new dawn in internal medicine education curriculum-a project by the residents, with the residents, for the residents.

The academic half-day (AHD) curriculum is an alternative to the noon conference (NC) approach. To date, there is little literature evaluating the transition from NC to AHD in internal medicine residency programs. We investigated the effectiveness of AHD by comparing in-training exam (ITE) and American Board of Internal Medicine (ABIM) certifying exam scores of residents before and after implementation of AHD. In 2019, we transitioned to the AHD curriculum. Averages of three consecutive years of NC (2016-2018) and AHD (2019-2021) were used for statistical testing to determine ITE and ABIM score changes. The class of 2018 experienced both approaches. Cohen's d effect sizes were calculated to assess the magnitude of change in ITE and ABIM scores between NC (2016-2018) and AHD (2019-2021) cohorts. Residents' performance significantly improved (P < 0.05) on ABIM scores (513.80 ± 48.34) on average from 2019 to 2021 compared to ABIM scores (452.42 ± 49.72) on average from 2016 to 2018 with a large effect size of 1.27. Similarly, a significant (P = 0.005) improvement in ITE scores was observed from 2019 to 2021 with implementation of AHD compared to preceding NC scores (2016-2018) with a moderate effect size of 0.52. Participating residents in AHD sessions had higher ITE and ABIM scores compared to those in hourly NC didactic sessions with significantly improved resident attendance and overall satisfaction.

Safety Profile of Mutant EGFR-TK Inhibitors in Advanced Non-Small Cell Lung Cancer: A Meta-analysis.

Background: Despite the use of platinum-based chemotherapy, lung cancer continues to be the leading cause of cancer-related death in the world. To overcome the rate of lung cancer-related death, scientists discovered advanced therapies, including mutant epidermal growth factor receptor-tyrosine kinase (EGFR-TK) inhibitors. Observations: We conducted a meta-analysis to determine the safety profile of mutant EGFR-TK inhibitors in the management of advanced non-small cell lung cancer (NSCLC). Included in this study are 9 phase 3 randomized controlled trials designed to study the safety profile of mutant EGFR-TK inhibitors in patients with advanced NSCLC. The study showed that mutant EGFR-TK inhibitors have an incidence of adverse effects that is less reported when compared with platinum-based chemotherapy. Conclusions: We recommend continuing using mutant EGFR-TK inhibitors in patients with advanced NSCLC especially in patients having mutant EGFR receptors. Adverse effects caused by mutant EGFR-TK inhibitors are significant but are usually tolerable and can be avoided by reducing the dosage of it with each cycle or by skipping or delaying the dose until patient is symptomatic.

Role of daratumumab in relapsed or refractory multiple myeloma patient: A meta-analysis and literature to review.

Introduction: With an increase in number of cases of relapsed or refractory multiple myeloma (RRMM), scientist have discovered various combination of medications among which one is daratumumab, Daratumumab is a mono-clonal antibody which attacks CD-38 markers present in abundance on the surface of myeloma cells and is used universally for the treatment of primary newly diagnosed multiple myeloma patients. Methods and Methodology: This meta-analysis was conducted according to Cochrane Collaboration guidelines in which initially 679 articles were evaluated for relevance on abstract level followed by full text screening of final list of 45 articles. Out of the 45 articles, only 10 articles qualified for selection criteria for eligibility. Three Phase 3 randomized control clinical trials which includes primary outcomes of progression free span and secondary outcomes including complete response, partial response or very good partial response and adverse effects reported were included in this study. Results: A total of three studies including 1533 patients (849 in Daratumumab treatment group while 684 patients in control group) were included in the study. All three of these studies were phase 3 clinical trial conducted to observe the role of daratumumab in relapsed and refractory multiple myeloma. Mean age reported was 65 years in both treatment and control groups. This study showed that daratumumab improves primary and secondary outcomes including progression free span, overall response rate, very good partial response, and complete response. However, daratumumab increases drug induced adverse effects. Conclusion: Our study confirmed that daratumumab in combination therapy improved primary and secondary outcomes when compared with platinum-based chemotherapy, but more adverse effects were reported in the combination group. So, we recommend that combination therapy should include daratumumab in treatment of relapsed and refractory multiple myeloma patients.

Rituximab use for refractory anti-HMGCR immune-mediated necrotizing myopathy: A case report.

Immunosuppression is the cornerstone therapy for anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy. Typical immunosuppressants such as corticosteroids, methotrexate, and azathioprine have been used in conjunction with removal of the offending agent, yet the use of rituximab is more limited in this type of myopathy. Reported here is a case of a patient who responded well to rituximab (RTX) after the standard immunosuppressants had failed. This case illustrates the importance of further studies to evaluate the role of RTX in anti-HMGCR myopathy.

Chronic Hand Swelling and Dactylitis in Leprosy: A Case Report and Review of the Literature.

Leprosy is an infectious disease that is associated with various types of presentations. Diagnosis of the disease can be tricky in cases of atypical presentations. We report a unique case of leprosy characterized by chronic hand swelling, dactylitis, and seropositive laboratory markers, which was diagnosed in a rheumatology clinic.

Use of Anakinra in steroid dependent recurrent pericarditis: a case report and review of literature.

Non-steroidal anti-inflammatory drugs and colchicine are the cornerstone treatment for recurrent pericarditis. Corticosteroids are frequently used in patients with recurrent episodes of pericarditis. In patients with corticosteroid dependent and corticosteroid-resistant pericarditis, several steroid-sparing options like azathioprine, intravenous immunoglobulin (IVIG), and anakinra are being recently tried. In this article, we present the case of a 44-year-old male with recurrent pericarditis, who was successfully treated with anakinra. Abbreviations: Non-steroidal anti-inflammatory drugs, NSAIDS; Aspirin, ASA; Erythrocyte sedimentation rate, ESR; Serum Protein Electrophoresis, SPEP; Magnetic Resonance Imaging, MRI; C-Reactive Protein, CRP; Aspartate Aminotransferase, AST; Alanine Aminotransferase, ALT; Idiopathic recurrent pericarditis, IRP; Intravenous Immunoglobulin, IVIG.

Hemophagocytic lymph histiocytosis (HLH): etiologies, pathogenesis, treatment, and outcomes in critically ill patients: a review article and literature to review.

Hemophagocytic lymph histiocytosis (HLH) is not an independent disease but is instead a clinical syndrome that occurs in many underlying conditions involving all age groups. HLH is the consequence of a severe, uncontrolled hyperinflammatory reaction that in most cases is triggered by an infectious agent. Acquired HLH is much more common than primary HLH syndrome but primary is more fatal, and it does have the worst prognosis with no definitive treatment available to date. This review article mentioned all the latest advancements regarding etiologies, pathogenesis, treatment, and outcomes in critically ill patients who got diagnosed with HLH syndrome in last 15 years.

Role of steroids in critically-ill sepsis patients: a review article and literature to review.

Sepsis, a life-threatening condition, commonly affecting critically ill patients, is a major cause of death worldwide. It is thus of great importance to determine the optimum management to cure this condition. This review article summarizes the role and effects of corticosteroids in the treatment of sepsis and septic shock, and to determine its mortality benefits. We used PubMed, Google scholar, Scopus, and Embase databases for literature review, and terminologies commonly searched were 'sepsis', 'septic shock', 'therapeutic use' and 'corticosteroids'. In this review article, we reviewed a total of eight different articles being done in last 10 years, relevant to the clinical outcome and effects of corticosteroids. Among those, two demonstrated improved clinical outcomes, two showed both improved clinical outcomes and decreased mortality, three showed increased adverse effects, and the remaining one showed unequivocal results.

Multisystem inflammatory syndrome in adults: A rare sequela of SARS-CoV-2 infection.

Multisystem inflammatory syndrome in adults (MIS-A) came to attention back in June 2020, when the United States Center for Disease Control and Prevention (CDC) received initial reports regarding patients who had presented delayed and multisystem involvement of the disease, with clinical course resembling multisystem inflammatory syndrome in children (MIS-C). This study introduces a case of MIS-A, where the patient presented 3 weeks after initial COVID-19 exposure. His clinical course was consistent with the working definition of MIS-A as specified by the CDC. Aggressive supportive care in the intensive care unit, utilization of advanced heart failure devices, and immunomodulatory therapeutics (high-dose steroids, anakinra, intravenous immunoglobulin) led to clinical recovery. Management of MIS-A is a topic of ongoing research and needs more studies to elaborate on treatment modalities and clinical predictors.

A Rare Case of Malignant Mesothelioma Presenting with Systemic Lupus Erythematosus Seropositivity: A Case Report and Review of Literature.

While malignant mesothelioma may initially present in a variety of ways, it is uncommon to present with systemic lupus erythematosus (SLE) seropositivity and thus obscuring its diagnosis. Our case involves a 75-year-old Caucasian male with a past medical history of essential hypertension, remote prostate cancer status post prostatectomy, and lifetime nontobacco use presenting with progressive shortness of breath over one month. After a negative cardiac assessment, a postcardiac catheterization chest X-ray (CXR) revealed a right-sided moderate-to-large pleural effusion that, on further workup, was found to be exudative. Effusion studies were negative for malignancy and bacterial growth. Recurrent accumulation of fluid after a thoracentesis one week prior prompted an autoimmune work up. Positive markers included antinuclear antibodies, anti-double stranded DNA antibodies, and anti-histone antibodies, while anti-Smith antibodies were negative. Although SLE was initially suspected based on serologies, no clinical signs or symptoms were present to fulfill the diagnosis criteria. A trial of oral prednisone resulted in decreased pleural effusion size with no further recurrence. Additional studies included a CT scan of the chest that showed pleural masses confirmed with biopsy to be epithelioid mesothelioma. Given the patient's age and new diagnosis of malignant mesothelioma, we hypothesized that the presence of autoantibodies was likely false positives due to acquired autoantibodies with age, hyperactivity of the immune system from malignancy, and possible prior asbestos exposure.

Adult Onset Henoch-Schonlein Purpura and Intussusception: A Rare Presentation.

We present an unusual case of a young 26-year-old male who was diagnosed with Henoch-Schonlein Purpura (HSP). Initial presentation was primarily mild gastrointestinal symptoms, which progressed to a life threatening intussusception and subsequently resolved with prompt glucocorticoid use rather than typical surgical intervention. Of importance, the patient's initial gastrointestinal symptoms without associated skin manifestations made the diagnosis difficult. In conclusion, it is important to recognize uncommon presentations of HSP as it may lead to life threatening complications and surgical intervention may be avoided with prompt treatment.