A Case of Diffuse Thyroid Lipomatosis With Amyloid Deposits Presenting With Thyrotoxicosis.

Diffuse thyroid lipomatosis (DTL) is a rare entity of unknown etiology that can be associated with amyloidosis and rarely, thyrotoxicosis. Here, we present a case of DTL with amyloid deposits and concurrent thyrotoxicosis. A 64-year-old South-Asian woman with a several-year history of an enlarging goiter, unintentional weight loss, and work-up 10 months prior suggestive of thyroiditis presented with a viral syndrome in setting of several weeks of progressive fatigue. Her examination was notable for resting sinus tachycardia and massive painless goiter. Initial work-up revealed nephrotic range proteinuria with hypoalbuminemia, which progressed to end-stage-renal disease, elevated inflammatory markers, and elevated free thyroxine (FT4) with a suppressed thyrotropin. Hemodialysis was initiated. Further testing revealed a negative antithyroid antibody panel, an enlarged fatty thyroid per thyroid ultrasound and neck computed tomography, and normal 24-hour uptake on radioactive iodine uptake scan. Both renal and thyroid core biopsies showed amyloid deposits, with the latter confirming benign adipose tissue with entrapped thyroid follicles. Given her rising FT4 levels and persistent tachycardia, methimazole and atenolol were initiated. FT4 levels nearly normalized after uptitration of methimazole and dosing after dialysis. Although the etiopathogenesis and natural history of DTL remain unclear, we discuss the possible mechanisms of thyrotoxicosis in our patient.

Endoscopic Endonasal Transsphenoidal Surgery for Patients with Prolactinomas: Indications and Outcomes.

OBJECTIVE: Clinical paradigms and consensus recommend dopamine agonists (DAs) as the primary treatment for prolactinomas. However, medically treated patients also encounter challenges such as DA resistance, intolerable side effects, and recurrence of hyperprolactinemia after DA withdrawal. Technical advances in transsphenoidal resection, with an endoscopic endonasal approach, have led to improved visualization of tumor, decreased postoperative morbidity, and shortened length of stay. We examined the indications and outcomes in patients with prolactinomas who underwent surgical resection at our center. METHODS: A retrospective analysis was performed of 60 consecutive patients with prolactinomas who underwent endoscopic endonasal transsphenoidal resection between August 2010 and July 2019 and were followed by the same multidisciplinary team. RESULTS: Women comprised 73% of surgical cases, and 60% of the tumors were macroadenomas. The most common primary surgical indication was patient preference (26.6%) followed by DA intolerance (25%) and DA failure (18.3% inadequate shrinkage, 15% persistent hyperprolactinemia, 11.7% both). Gross total resection was noted in 83% and length of stay was 1 day in 92% of patients. Early remission (postoperative day 1 normalization of prolactin off DA therapy) was seen in 71% of all patients, 91% of microadenomas, 56% of macroadenomas, 65% of Knosp grade 0-2 macroadenomas, and 75% of macroadenomas operated on with expectation of a cure. Only 3 patients had recurrence, at 4.3, 3.3, and 1.6 years of follow-up, respectively. CONCLUSIONS: Endoscopic endonasal resection is a viable option for management of patients with prolactinomas in the setting of a high-volume pituitary center, with minimal postoperative complications.

Contribution of fetal magnetic resonance imaging in the evaluation of neurosonographically detected cases of isolated mild and moderate cerebral ventriculomegaly.

AIM: This study aimed to present the contribution of prenatal magnetic resonance imaging (MRI) in the diagnosis of fetuses that were previously identified as isolated mild and moderate cerebral ventriculomegaly (VM) by ultrasound (US). METHODS: The data between February 2013 and August 2020 were collected for women who were diagnosed with isolated mild or moderate fetal VM by US and subsequently underwent a fetal MRI. RESULTS: Among 321 women, 21 (6.5%) had a clinically important additional finding after MRI. Twelve of 276 (4.3%) fetuses with mild VM and 9 of 45 (20%) with moderate VM had turned out to have additional central nervous system abnormalities. Additional findings were detected more in fetuses with moderate VM, mothers with an anterior-located placenta, and mothers with higher body mass indexes (BMIs) with statistical significance (p = 0.001, p = 0.013, p = 0.036, respectively). The most common additional MRI finding was grade 3 or 4 germinal matrix hemorrhage, which was detected in 11 of 21 fetuses (52.3%). CONCLUSIONS: Considering the countries' health policies, prenatal MRI would contribute mostly to the diagnosis of fetuses with moderate VM, pregnancies with anterior-located placenta, and mothers with high BMIs. According to our data, we believe that MRI will be valuable, especially in the diagnosis of grade 3 and 4 intracranial hemorrhage group.

COVID-19 Knowledge, Attitudes, and Preventive Measures of University Students in Bahrain.

Background: The severe, acute respiratory syndrome COVID-19 that was first reported in China in December 2019 quickly became a global pandemic that has resulted in over 100 million infections and more than 2 million deaths. Study Design: This study aimed to assess the awareness level of university students regarding the possibility of becoming infected with COVID-19. In order to achieve this objective, we assessed the students' knowledge, attitudes, and behaviors using an online survey questionnaire offered to a total of 300 students. Results: A positive response regarding awareness of COVID-19 symptoms was registered by more than 70% of the students, whereas 62% felt that wearing a mask did not give full protection against infection, approximately 30% agreed that antibiotics and antivirals did not treat COVID-19, and 62% agreed that vitamin C was helpful in treating common symptoms of COVID-19. Moreover, around 31% of the students believed that COVID-19 is a man-made virus. Students who had gotten infected with SARS-CoV-2 believed that wearing a mask gives full protection (p=0.018). In response to survey questions related to attitude, 80% of students cancelled and postponed meetings with friends, and 90% agreed that mask-wearing is the most precautionary measure used to prevent the infection. In addition, 82% avoided coughing in public, 82% avoided contact if they felt flu-like symptoms and 80% washed their hands far more often due to the pandemic. Interestingly, 76% carried hand sanitizer, 66.5% avoided shaking hands, and 42.7% were taking vitamin C supplements. Conclusions: This study showed that the participants had a positive awareness of COVID-19 transmission, symptoms, and treatments misconceptions and mistaken beliefs related to treatments and the origin of the virus were also common and should be addressed. This study thus provides a baseline for a population-based surveillance program that could help local authorities to improve pandemic preparation plans, particularly with regard to governmental education and media campaigns.

A Rare Case of Gastrointestinal Amyloidosis Presenting as Dysphagia.

A 74-year-old male with an unintentional 20-pound weight loss over the past year presented with new-onset dysphagia to solid foods. Esophagogastroduodenoscopy showed a subtle stricture with ill-defined scar tissue-like findings in the distal esophagus and erosions in the antrum of the stomach without masses. Pathologic findings showed the presence of amyloidosis involving the proximal and distal esophagus, as well as gastric mucosa with chronic inflammation and reactive epithelial changes. We present a rare case of dysphagia as the initial presentation of gastrointestinal amyloidosis.

A Remarkable Response of Granulomatous Hypophysitis to Infliximab in a Patient With a Background of Crohn's Disease-A Case Report.

Background: Hypophysitis is primary or idiopathic or secondary to another disease process. The histologic subtypes of hypophysitis are lymphocytic, granulomatous, xanthomatous, xanthogranulomatous, or IgG4-related. Granulomatous hypophysitis is the second most common form and is characterized by multinucleated giant cells with granulomas and histiocytes. It can be idiopathic or secondary to another process such as infection, sarcoidosis, vasculitis, dendritic cell disorders, Crohn's disease (CD) or a reaction to rupture of a Rathke's cyst or pituitary adenoma. We present a case of granulomatous hypophysitis in a patient with CD who had resistance to corticosteroids but a dramatic response to immunosuppressive therapy with anti-tumor necrosis factor (TNF)-α therapy. Case description: A 43-year-old woman with a 9-year history of ileal and colonic CD presented to the Pituitary Center with headaches, visual disturbance, fatigue, nausea, and secondary amenorrhea. She was not on active therapy for her CD at the time of presentation and had no gastrointestinal symptoms. Hormonal evaluation revealed hyperprolactinemia, secondary hypothyroidism and adrenal insufficiency. MRI revealed a 12 × 12 × 19 mm sellar lesion abutting the optic chiasm, reported as a macroadenoma. The patient underwent endoscopic transsphenoidal biopsy of the pituitary mass. Pathology revealed granulomatous hypophysitis. Evaluation for secondary causes of hypophysitis, apart from CD, was negative. Despite a course of high dose prednisone, her symptoms and MRI findings worsened and she developed symptoms consistent with diabetes insipidus. Using a personalized medicine approach, she was started on anti-(TNF)-α therapy with infliximab combined with azathioprine, which are indicated for treatment of CD. Her headaches and polyuria resolved and her menstrual cycles resumed. MRI at 3 months and more than 1.5 years after initiation of anti-TNF-α therapy revealed durable resolution of the pituitary mass. Conclusion: To our knowledge, this is the first report of successful use of anti-TNF-α therapy for a patient with granulomatous hypophysitis, in this case associated with a previous diagnosis of CD. Although glucocorticoids are used frequently as first-line therapy for primary hypophysitis, granulomatous hypophysitis can be corticosteroid resistant and other immunosuppressive approaches may need to be considered within the context of the patient.

Development of a fast and low-cost qPCR assay for diagnosis of acute gas pharyngitis.

BACKGROUND: Group A streptococci (GAS) are the most common bacterial cause of acute pharyngitis and account for 15-30 % of cases of acute pharyngitis in children and 5-10 % of cases in adults. In this study, a real-time quantitative PCR (qPCR) based GAS detection assay in pharyngeal swab specimens was developed. METHODS: The qPCR assay was compared with the gold standard bacterial culture and a rapid antigen detection test (RADT) to evaluate its clinical performance in 687 patients. The analytical sensitivity of the assay was 240 cfu/swab. Forty-five different potential cross-reacting organisms did not react with the test. Four different laboratories for the reproducibility studies were in 100 % (60/60) agreement for the contrived GAS positive and negative swab samples. RESULTS: The relative sensitivities of the RADT and the qPCR test were 55.9 and 100 %; and the relative specificities were 100 and 96.3 %, respectively. Duration of the total assay for 24 samples including pre-analytical processing and analysis changed between 42 and 55 min depending on the type of qPCR instrument used. A simple DNA extraction method and a low qPCR volume made the developed assay an economical alternative for the GAS detection. CONCLUSION: We showed that the developed qPCR test is rapid, cheap, sensitive and specific and therefore can be used to replace both antigen detection and culture for diagnosis of acute GAS pharyngitis.

Hepatitis B surface antigen seroconversion is associated with favourable long-term clinical outcomes during lamivudine treatment in HBeAg-negative chronic hepatitis B patients.

The aims of this study were to assess hepatitis B surface antigen (HBsAg) seroconversion and to determine its impact on the natural course of the disease in patients with HBeAg-negative chronic hepatitis B (CHB) during lamivudine (LMV) treatment. A total of 183 consecutive patients with HBeAg-negative CHB who were treated with LMV were included in the study. Data were retrospectively collected from outpatient visit charts. The primary endpoint was HBsAg seroconversion to anti-HBs. The secondary endpoint was to determine the development of cirrhosis. Loss of HBsAg was confirmed in 10 patients and seroconversion to anti-HBs in nine patients during LMV treatment or after its discontinuation. HBsAg seroconversion was achieved on-treatment in four patients after a median treatment duration of 30 months and off-treatment in the remaining five patients in a median 61 months after LMV discontinuation. The cumulative probability of HBsAg seroconversion increased from 0.6% at 1 year and 1.9% at 5 years to 21.5% at 10 years of LMV during and after LMV treatment. HBsAg clearance was preceded by undetectable serum hepatitis B virus (HBV) DNA. The majority of the patients responding to treatment had undetectable HBV DNA levels at 24 weeks of treatment. The cumulative probability of LMV resistance increased from 2.2% at 1 year to 37.3% at 5 years. No baseline parameter predicting either HBsAg seroconversion or the emergence of LMV resistance was identified. None of the patients with HBsAg seroconversion experienced virological breakthrough or disease progression during the follow-up period. These results indicate that HBsAg seroclearance can occur in patients with HBeAg-negative CHB under LMV therapy and predicts better clinical outcome.

Increment in anaerobic hydrocarbon degradation activity of Halic Bay sediments via nutrient amendment.

In this study, hydrocarbon (HC) degradation activity of a HC-rich marine sediment was assessed in anaerobic microcosms during a 224 days incubation period. Natural TOC/N/P ratio of the sediment porewater (1,000/5/1) was gradually decreased to 1,000/40/6 which resulted in approximately ninefold increase in gas production (CH(4)+CO(2)) and HC removal. Addition of external HCs to the microcosms was also resulted in approximately twofold higher gas production and HC removal. A high proportion (92%) of aromatic HCs and all n-alkanes were removed from the microcosms under unlimited nutrient supply conditions without external HC addition. The microorganisms of the sediment degraded a wide range of aliphatic (n-C(9-31) alkanes and acyclic isoprenoids) and aromatic (18 different one- to five-ring aromatics) HCs. Monitoring functional gene and transcript abundances revealed that methanogenesis and dissimilatory sulfate reduction took place simultaneously during the first 126 days, afterwards, only the syntrophic methanogenic consortium was active. Genes and transcripts related to initial activation of HCs were highly abundant throughout the incubation period showing that fumarate addition was the main pathway of anaerobic HC degradation. In conclusion, biostimulation of highly polluted anoxic marine sediments via nutrient amendment is effective and may constitute a suitable and cost-effective field-scale bioremediation strategy.

Identification of nitrifiers in a full-scale biological treatment system using fluorescent in situ hybridization.

Diversity of nitrifying bacterial population was investigated in sludge samples taken from a full-scale biological wastewater treatment plant (WWTP) treating domestic wastewater by fluorescent in situ hybridization (FISH) during seasonal operation. Duplicate grab samples were collected in March 2003, June 2003, December 2003 and May 2004 from the aerobic tank of the treatment plant. FISH results were interpreted with system performance in terms of BOD5, TKN and NO3-N removals and also with operational parameters such as wastewater temperature and sludge age. BOD5 removal efficiencies were always greater than 90% whilst TKN removal in a range of 69-95% were achieved during the monitoring period. Although there were variations in operational conditions of the biological treatment system both Nitrosomonas and Nitrosospira genera from AOB and Nitrobacter genus from NOB were found to be present in all samples examined.

Effect of wastewater composition on archaeal population diversity.

Distribution and occurrence of Archaea and methanogenic activity in a laboratory scale, completely mixed anaerobic reactor treating pharmaceutical wastewaters were investigated and associated with reactor performance. The reactor was initially seeded with anaerobic digester sludge from an alcohol distillery wastewater treatment plant and was subjected to a three step feeding strategy. The feeding procedure involved gradual transition from a glucose containing feed to a solvent stripped pharmaceutical wastewater and then raw pharmaceutical wastewater. During the start-up period, over 90% COD removal efficiency at an organic loading rate (OLR) of 6 kg COD m(-3)d(-1) was achieved with glucose feeding, and acetoclastic methanogenic activity was 336 ml CH4 gTVS(-1)d(-1). At the end of the primary loading, when the feed contained solvent stripped pharmaceutical wastewater at full composition, 71% soluble COD removal efficiency was obtained and acetoclastic methanogenic activity decreased to half of the rate under glucose feed (166 ml CH4 gTVS(-1)d(-1)). At the end of secondary loading with 60% (w/v) raw pharmaceutical wastewater, COD removal dropped to zero and acetoclastic methanogenic activity fell to less than 10 ml CH4 gTVS(-1)d(-1). Throughout the course of the experiment, microbial community structure was monitored by DGGE analysis of 16S rRNA gene fragments. Five different archaeal taxa were identified and the predominant archaeal sequences belonged to methanogenic Archaea. Two of these showed greatest sequence identity with Methanobacterium formicicum and Methanosaeta concilii. The types of Archaea present changed little in response to changing feed composition but the relative contribution of different organisms identified in the archaeal DGGE profiles did change.

Quantification of C3 and C4 in infertile men with antisperm antibody in their seminal plasma.

PROBLEM: Previous studies showed that some infertilities are caused by antisperm antibodies (ASAs). It was shown that some major complement (C) components are present in seminal fluid. Due to the role of C in the pathogenesis of ASAs, the existence and amount of two key C components (C3 and C4) were investigated in seminal plasma (SP). METHOD OF STUDY: Single radial immunodiffusion assay and a sandwich-type enzyme-linked immunosorbent assay (ELISA) were used for C3 and/or C4 quantification, respectively, in serum and SP, and the tray agglutination test was used for ASA detection in 12 fertile and 53 infertile men (18 ASA-positive [ASA+] and 35 ASA-negative [ASA-] men). RESULTS: Of the 18 ASA + infertile men, 61.11% had positive C3, whereas 27.77% showed positive C4 levels. ASA + infertile men showed significant differences in seminal plasma C3 mean values compared with ASA- infertile (P < 0.01) and fertile (P < 0.05) men, but the seminal plasma C4 values only showed differences compared with ASA- infertile men (P < 0.05). No significant differences were observed in serum C3 and/or C4 levels of ASA+ infertile men compared with other groups. No significant correlation was found between ASA titer and C3 and C4 levels in SP. A significant correlation existed between SP and serum C3 levels of ASA+ (r = 0.522, P < 0.01) and ASA- (r = 0.451, P < 0.01) infertile men, but no correlation was observed between C4 levels. CONCLUSIONS: In the presence of ASAs, the C system has no definitive activity in blood serum or outside the male genital tract. In SP, and in association with ASAs, C has no lytic activity by the classical pathway. The excess of C3 in SP of ASA+ infertile men may participate in other C-mediated activities in the male reproductive tract.

Identical MHC markers in non-Jewish Iranian and Ashkenazi Jewish patients with pemphigus vulgaris: possible common central Asian ancestral origin.

Previous studies showed that almost all Ashkenazi Jewish patients with pemphigus vulgaris carried the extended haplotype [HLA-B38, SC21, DRB1*0402, DQB1*0302] or [HLA-B35, SC31, DRB1*0402, DQB1*0302] or class II fragments of them. Non-Jewish patients carried [HLA-B55, SB45, DRB1*1401, DQB1*0503] or its class II fragments. In the present study of 20 Iranian patients with pemphigus vulgaris, 17 were found to carry DRB1*0402, DQB1*0302 haplotypes, also found among normal Iranian haplotypes and the same as that of the Jews. These findings suggest that the pemphigus MHC susceptibility gene among Iranians derived from the same ancestor as that in the Ashkenazim. The ancient Jews were under Persian domination from 500 B.C. until 300 B.C. and in the 8th century A.D., a Tataric people living in the kingdom of Khazar on the Western shore of the Caspian Sea and the Northern shore of the Black Sea, near Persia, converted to Judaism, providing possible opportunities for gene mixing in two populations that are distinct and separate today.