Diagnostic and Treatment Challenges of Emergent COVID-Associated-Mucormycosis: A Case Report and Review of the Literature.

Mucormycosis is a rare fungal infection, with high mortality, commonly associated with diabetes, malignancies, immunosuppressive therapy, and other immunodeficiency conditions. The emergence of mucormycosis cases has been advanced by the COVID-19 pandemic. Clinical presentation is variable, from asymptomatic to persistent fever or localized infections. We present a case of a Romanian old man, without diabetes or other immunodepression, with COVID-19 who developed severe rhino-orbital mucormycosis and bacterial superinfections, with Pseudomonas aeruginosa and Klebsiella pneumoniae. The late diagnostic and antifungal treatment was related to extensive lesions, bone and tissue loss, and required complex reconstruction procedures. We review the relationships between mucormycosis, COVID-19, and bacterial associated infections. The suspicion index of mucormycosis should be increased in medical practice. The diagnostic and treatment of COVID-19-Associated-Mucormycosis is currently challenging, calling for multidisciplinary collaboration.

Management of Epicardial Metastasis in Breast Cancer.

Background: Cardiac metastasis may be encountered more frequently than primary cardiac tumors. They are discovered at autopsies with an incidence between 1.5 - 20%. The primary tumors that generate cardiac metastasis are malignant melanomas, lymphoma, the lungs, the breast, the esophagus. The organ most affected is the pericardium (62-81%). In 90% of cases from a clinical point of view, they are generally silent. In the case of patients diagnosed with breast cancer and who have undergone radiotherapy, differential diagnosis with fibrosis post radiotherapy interferes. The treatment is palliative and should be administered according to the primary location of the tumor and the patient's performance status. Case presentation: We are presenting the case of a 73-year-old diagnosed and treated for a breast neoplasm in the left breast in 2006. After a period of time of 9 years, the patient presents secondary sternal bone determination, radio-treated and for which she once again goes under hormonal therapy. In 2018, patient performed an imaging evaluation that revealed lung metastases. At the moment of stage review, performed in 2020, secondary epicardial determinations are noted. We present the case, the therapeutic management, diagnostic procedures and treatment and also, we discuss the data from literature. Conclusion: Cardiac metastases are rare and and in most cases are silent. The incidence has changed due to treatment options and imaging investigations. Stereotactic body radiation therapy can be considereda a therapeutic option in the cases with good performance status and with oligometastatic disease.

Assessment of Transportation by Air for Patients with Acute ST-Elevation Myocardial Infarction from Non-PCI Centers.

The aim of this study was to assess the delays that can potentially occur in the emergency transfer of patients with ST-elevation myocardial infarction (STEMI) to percutaneous coronary intervention (PCI) centers. We conducted a retrospective study using the medical reports pertaining to 97 patients who presented to the Emergency Department of the Emergency County Hospital of Galati during the year of 2018 with the diagnosis of STEMI and meeting eligibility criteria for PCI, thus warranting transfer to a hospital with PCI facilities. The pick-up time of patients diagnosed with acute myocardial infarction from the emergency department by the transfer crew is significantly shorter (p < 0.05) than those transferred by air, regardless of the PCI center to which the transfer was performed, Iasi or Bucharest, when compared to the time required to process the patients transferred by land to the same PCI centers. The results of the study shows that the helicopter use for transferring acute myocardial infarction patients to a PCI center must be considered, given the distance between non-PCI and PCI centers is over 200 km.

NK/T-cell non-Hodgkin lymphoma: Case report and review of the literature.

Natural killer (NK)/T-cell lymphomas represent a rare type of lymphoid malignancy with mostly extranodal involvement, having NK cell or (rare) T cell lineage, classified by the World Health Organization into several subtypes which can involve the head and neck region, with the most frequent one being the nasal type. This article presents the case of a 31-year-old patient who presented at the Emergency Unit of Saint Andrew Emergency Clinical Hospital of Galati suffering from mycosis fungoides-like cutaneous lesions, associated with partial left eyelid ptosis of unknown etiology, as well as a poor health status with fever and respiratory failure. The final diagnosis was NK/T-cell non-Hodgkin lymphoma, possibly nasal type with medium sized T cells. The complexity of the rare diagnosis, associated with the unusual rapid patient evolution towards exitus 3 months after diagnosis, the intra-orbital metastatic involvement and the absence of a standardized treatment are case peculiarities, some of which are consistent with current literature data.

Troponin T changes in acute ischemic stroke.

Elevation of cardiac troponin T (cTnT) in serum reflects myocardial injury, but it was also observed in other conditions with cardiac injury including acute ischemic stroke. The objective was to identify the relationship between elevated cTnT and stroke severity, location and outcome, cTnT levels were prospectively performed in 385 patients with different subtypes of acute ischemic stroke admitted in NICU within 72 hours of onset, as TOAST criteria. The patients were divided into two groups: an elevated cTnT (group 1) (n = 42) and a normal cTnT (group 2) (n = 343). The short-term prognosis was assessed by 30-days modified Rankin Scale responder analysis and the NIHSS. Serum cTnT levels were determined using a high sensitive troponin T assay (Roche Elecsys Troponin, Mannheim, Germany), cut-off value of 0.01 ng/ml. Statistical analysis was performed. Serum cTnT level was elevated in 10.91% (42/385) of patients, cTnT positivity on admission is an independent and powerful prognosis predictor in acute ischemic stroke. It was observed a more frequent insular lobe involvement in elevated cTnT group (17/42) (31%) than in group 2 (55/343) (16%) (p = 0.040). Stroke severity was greater in elevated cTnT group. The outcome was worse in elevated cTnT group as compared to group 2 (13/43) (30.95%) vs. (68/343) (19.82%) (p = 0.013). cTnT in acute ischemic stroke is a marker of stroke severity, of insular lobe lesion and of prognosis prediction. cTnT is a highly specific and sensitive marker of myocardial damage in acute ischemic stroke due to insular lesion that induces disturbances of autonomic balance.

Cerebrovascular complications in patients with inflammatory bowel disease.

UNLABELLED: Cerebrovascular complications in 9 patients with inflammatory bowel disease (IBD) are presented, 6 with Crohn's disease (CD) and 3 with ulcerative colitis (UC), 7 men and 2 women, mean age 36.5 +/- 3.5 years, 4 of them during acute disease. Cerebrovascular complications were: cerebral venous thrombosis (CVT)--7 cases (5 CD and 2 UC) and ischemic stroke--2 cases (1 CD and 1 UC). Out of 7 cases with CVT 5 were superior sagittal sinus thrombosis (SSS), 2 SSS and transverse and sigmoid sinus thrombosis. Both ischemic strokes were infarctions in the middle cerebral artery area. No correlation between high doses of corticosteroids or their lowering, IBD activity, duration of the disease, and the appearance of cerebrovascular complications was observed. Tendency to hypercoagulation even in the inactive stage of the IBD was revealed. Investigations for thrombophilia were negative. Significantly high levels of homocysteine were observed in all patients. CONCLUSION: Neurovascular complications may be observed in IBD, both of venous and arterial type. Pathogenic mechanisms of these vascular complications are complex, low serum folate levels, of vitamin B6 and B12 being associated with elevation of homocysteine levels, high activation of platelets and microvascular endothelial dysfunction. A guide for the orientation of prophylaxis of cerebrovascular complications in IBD patients is necessary.

Evaluation of oxidative stress in patients with acute ischemic stroke.

Oxidative stress is involved in the pathogenesis of acute ischemic stroke. Antioxidants are consumed in the reaction with free radicals generated during the oxidative stress. The aim of the study was the to evaluate the oxidative stress in patients with acute ischemic stroke. Malondialdehyde (MDA), plasma glutathione, plasma glutathione peroxidase (GPX), catalase (CAT), uric acid, bilirubin, plasma superoxide dismutase (SOD), red blood cells superoxide dismutase (RBS SOD) (spectrophotometric assay), total antioxidant capacity (TAC) (enhanced chemiluminescence), ceruloplasmin, C-reactive protein (CRP), albumin, transferrin (nephelometric assay) were performed in 57 patients (mean age 73.4 +/- 6.5 years) with acute ischemic stroke within 24 hours and at 7 days after stroke onset as compared to 51 age-and sex-matched controls. Significantly lower values in the first 24 hours were: plasma glutathione, CAT, plasma SOD, RBS SOD (p < 0.001), plasma GPX, TAC, transferrin (p < 0.05). Significantly higher values in the first 24 hours were: CRP (p < 0.001), MDA, uric acid (p < 0.05). Significantly lower values at 7 days were: TAC, albumin, transferrin (p < 0.001), plasma glutathione, plasma SOD, CAT (p < 0.05). Significantly higher values at 7 days were: MDA, plasma GPX, RBC SOD, CRP, uric acid, bilirubin (p < 0.001), ceruloplasmin (p < 0.05). These results indicate that oxidative stress is increased and that the majority of antioxidants are reduced; this suggests the possibility of therapeutic intervention with antioxidant agents.

Could pro-BNP, uric acid, bilirubin, albumin and transferrin be used in making the distinction between stroke subtypes?

To establish the pathogenesis of ischemic strokes is very important in determining an adequate therapy. The objective was to observe if certain plasma parameters could be used as biomarkers in distinguishing between stroke subtypes. Plasma pro-BNP (chemiluminescence), serum uric acid, bilirubin (colorimetric assay), albumin and transferrin (nephelometric assay) levels were performed in 168 admitted patients (mean age 68.7 +/- 11.6 years, 52 men and 116 women) with different subtypes of acute ischemic strokes within 24 hours and at 7 days after stroke onset as TOAST and OCSP criteria, NIHSS and Glasgow Coma Score at baseline and at 7 days were used. The mean value of pro-BNP level was significantly higher in the cardioembolic stroke (CE), in patients, within 24 hours (p < 0.001) and at 7 days (p < 0.001) after stroke onset. A negative correlation between pro-BNP levels and GCS (r = 0.05, p < 0.0002) and a significant difference between pro-BNP levels of NIHSS groups were observed (p < 0.08, respectively (p < 0.01). We observed significantly higher values within 24 hours of uric acid (p < 0.05), significantly lower values within 24 hours of transferrin (p < 0.05), significantly lower values at 7 days of albumin and transferrin (p < 0.001), significantly higher values at 7 days of uric acid and bilirubin (p < 0.001). No significant statistical differences between the values of oxidative stress parameters and stroke subtypes, GCS and NIHSS score were observed. The level of plasma pro-BNP may be useful in distinguishing CE stroke from other stroke subtypes. Oxidative stress is increased in acute ischemic stroke, but oxidative stress parameters could not be used to differentiate stroke subtypes.

Acute intermittent porphyria--diagnostic and treatment traps.

Acute intermittent porphyria (AIP) is a rare metabolic disease defined by mutations coding the deaminaze enzyme of porphobilinogen (PBGD). Porphyrias are somewhat misdiagnosed as a consequence of light symptoms in patients. Acute forms of porphyria can be life-threatening, so a correct diagnosis and an accurate treatment are highly important. The authors presented the case of a 38-years-old patient admitted for persistent abdominal pain that previously presented two generalized convulsive seizures. The diagnosis of AIP was established by the raised concentration of urinary porphyrins. Despite treatment with carbohydrates and hemines, the clinical picture of the patient worsened, with tetraplegia and severe respiratory failure. The patient died seven weeks after the initial presentation of the disease.

Changes in plasma matrix metalloproteinase-9 levels in patients with acute ischemic stroke.

Matrix metalloproteinases (MMP) have been thought to be involved in stroke pathogenesis. MMP-9 contributes to tissue destruction. Our aim was to analyze the MMP-9 levels in blood within 24 hours of acute ischemic stroke onset to observe the role of MMP-9 in the pathogenesis of atherothrombotic stroke. In this study we investigated prospectively MMP-9 levels in serum from 106 patients (42 men and 64 women, mean age 71.52 +/- 6.32 years) with acute ischemic stroke in the middle cerebral artery area in the first 24 hours from the onset (mean duration 7.8 +/- 4.5 hours) as compared to 112 controls (48 men and 64 women, mean age 70.36 +/- 6.8 years). Serum samples were collected under sterile conditions and stored in aliquots at -70 degrees C until assay. Serum MMP-9 levels were determined by enzyme-linked immunosorbent assay (ELISA) in blood samples obtained on admission. Statistical analysis was performed by Mann-Whitney and Log-Likeliwood Ratio tests. All values reported are expressed as mean (x) +/- SD. Mean serum MMP-9 concentrations were higher in group with ischemic stroke 172 +/- 32.4 ng/mL, range 139.6-204.4 ng/mL vs. controls 57 +/- 9.6 ng/mL, range 47.4-66.6 ng/mL (95% CI, 3.17 to 14.18; p < 0.014). In conclusion, MMP-9 activity is associated with early acute ischemic stroke. The high levels of MMP-9 in acute ischemic stroke document the involvement of this enzyme in the regulation of inflammation in stroke.

A diagnosis challenge-L4 nerve root compression as the initial presentation of chronic inflammatory demyelinating polyneuropathy.

The authors present the case of a 65-year-old woman who was admitted for paraparesis and paresthesias in the inferior limbs. The neurological examination revealed the difficulty in extension of the right foot and of the right toe, accompanied by paresthesias located in the anterolateral area of the right leg, dorsum and plantar area of the foot, the reduction of the right knee jerk, and of the ankle tendon jerk both sides. The vertebro-spinal MRI showed lumbar canal stenosis with L4 intraforaminal compression on the right, and L2-L3 on the left. CSF examination revealed mild increase in protein concentration. The morphological picture of the sural nerve biopsy was compatible with a chronic inflammatory neuropathy and severe muscular lesions of neurogenic origin were observed on right gastrocnemius muscle biopsy. The diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) was established. Solu-medrol (0.5 g/d)-5 days, then medrol (prednisolone) was done, followed by improving of the symptomatology. For the relapse of the disease intravenous immunoglobulins (IVIG)-0.4 g/kg/d-5 days was the elective treatment. Six months later she presented a new relapse. IVIG were administered with the remission of the sensitive symptoms. A chronic treatment with medrol was recommended. The diagnosis of L4 disc herniation was obvious in the studied case, but the electroneurographic examination brought extra data for the associated diagnosis of CIDP whose onset was asymmetrical and initially paucisymptomatic. Neither the electroneurographic examination nor the CSF examination were total relevant for CIDP, imposing the sural nerve biopsy. The diagnosis of CIDP involves a team-work composed of neurologist, electroneurophysiologist and neuropathologist.

Study of interleukin-6 production in Alzheimer's disease.

There is a growing body of evidence which supports the hypothesis of faulty immune regulation and autoimmunity or inflammatory processes as viable mechanisms of the pathogenesis of Alzheimer's disease. The aim of this study was to evaluate the IL-6 level in serum of patients with AD and to analyze the correlation between IL-6 and this disease. Serum samples from 47 patients with clinically diagnosed Alzheimer's disease (27 women and 20 men, mean age 70.43 +/- 10.82 years, range 40-89 years) as compared to 47 controls (25 women and 22 men, mean age 70.17 +/- 10.64 years, range 40-89 years) were analyzed for IL-6 by ELISA (R&D Systems). The interleukin-6 levels were significantly higher in AD patients (234 pg/ml, range 85-567 pg/ml) as compared to control group (67 pg/ml, range 38-181 pg/ml); p < 0.001. It was evident from the study that increased production of IL-6 cytokine is found in AD patients, suggesting abnormal cellular immunity in these patients. Interleukin-6 plays a role in the pathogenesis of Alzheimer's disease. Our results suggest that high peripheral IL-6 secretion levels may be responsible for acute-phase proteins observed in the serum of AD patients. We find these results very promising for the consideration of future treatment of AD patients.

Primary Sjögren's syndrome or multiple sclerosis? Our experience concerning the dilemma of clinically isolated syndrome.

The authors present the case of a 50 years old woman who during 3 years had a transient right limbs palsy, and numerous episodes of unilateral/bilateral optic neuropathy. The CSF and MRI examinations did not sustain the diagnosis of multiple sclerosis (MS). After 2 years from the onset, she presented bilateral trigeminal neuropathy, and after 9 months the anti-SS-A and anti SS-B antibodies were positive. The sialography and the minor salivary ducts biopsy (in the absence of xerostomia and xerophthalmia) have established the diagnosis of primary Sjögren's syndrome (pSS). Subsequently, the patient presented spastic paraparesis, the clinical and imagistical features have suggested the diagnosis of acute transverse myelitis C4-T4. The treatment administered (corticosteroids and IGIV) improved the clinical state. The authors analyse then cases with SLE and cases with pSS, whose initial diagnosis was MS possibly with no evidence of collagen tissue disorders (CD) for many years. In conclusion, screening for biomarkers of SLE or pSS should be systematically performed in a case of acute or chronic myelopathy. Some laboratory tests as CSF examination, the antibodies type, cranial and spinal MRI, are useful for the differential diagnosis with MS. In a neurological clinically isolated syndrome (CIS) the diagnosis of MS should be precautiously established; the close follow-up of patients is always necessary, those with atypical neurological symptoms for MS, relapsing-remitting form, or lack of response to the common treatment for MS, should be examined for CD.

Glutathione reductase levels in patients with unstable angina.

Experimental evidence suggests that free-radical damage and antioxidant defense may play an important role in the pathogenesis of coronary heart disease. We have examined the association between plasmatic glutathione reductase (GR) levels and the prognosis of patients with unstable angina. We have evaluated 37 patients, under the age of 75, diagnosed with unstable angina and 19 healthy volunteers. The patients were divided into two groups: the first group--10 patients with unstable angina with readmission in the following 6 months--and the second group--27 patients with unstable angina and favourable evolution. GR was measured in dynamics during hospitalization period. After discharge, the patients were monitored and the following data were recorded: months of follow-up, death due to cardiovascular cause and onset of major cardiovascular events. In patients with unstable angina there was a statistically significant higher increase of GR on admission to the values of the control group (p < 0.0001). Subsequently, plasmatic levels begin to decline, so that at discharge, the GR is similar to the control group. Plasmatic levels of GR were statistically significantly lower in patients with unstable angina without cardiovascular event than in patients with readmission in the following months (p < 0.05). In conclusion, patients who experienced unstable angina and without cardiovascular events during follow-up had lower GR plasmatic levels and that GR activity was an independent predictor of cardiovascular events during follow-up.

Dermatomyositis and polyradiculoneuritis, a rare association.

The association between dermatomyositis and polyradiculoneuritis is rarely citated in the speciality literature. Our patient had at first a disorder that looked like dermatomyositis, then she associated polyradiculoneuritis. At the presentation to our hospital the two diseases were combined, being very difficult to differentiate. The discrimination between these two had been made by performing a muscular biopsy and EMG studies. This emphasizes once again their importance in defining the muscular impairment from the neurogenic one.

Acute cerebellar infarcts in a young woman with beta-thalassemia major.

Beta-thalassemia major (beta-TM) is a rare genetic disorder that benefits from regular blood transfusions. Nevertheless some major complications arise from this life long treatment: hemolysis, hemochromatosis and a hypercoagulability state. Ischemic stroke may be another major complication. We present a patient with severe beta-TM diagnosed in early childhood who encountered all the first three complications and suffered a cerebellar ischemic stroke. In this case report we look over the possible physiopathological mechanisms that may have interfered in the onset and deployment of the ischemic event. We specify the neuroimagistic approaches that may be used in monitoring of these patients. In conclusion, we point out that there are many prothrombotic risk factors contributors to the hypercoagulable state that concurs to a cerebral infarct in a beta-TM patient. Careful monitoring and imagistic examination may select the patients at risk for a stroke event.

Detection of serum of IgG anti-neuronal antibodies in systemic lupus erythematosus patients with central nervous system manifestations.

The objective of the study was to assess the frequence of serum IgG anti-neuronal antibodies (NA) in SLE patints with CNS manifestations. Serum anti-NA antibodies were measured in 47 patients with SLE with CNS manifestations (CNS-SLE), age 33-52 years, mean age 38.6 years, 18 men and 29 women, as compared to 31 patients with SLE without CNS manifestations, age 28-56 years, mean age 41.2 years, 13 men and 18 women and 56 healthy subjects. Serum IgG antineuronal antibodies were measured by indirect immunofluorescent assay. Thirty-five of out 47 CNS-SLE patients presented anti-NA (74.6%). Anti-NA were observed in 15 out of 15 patients with acute confusional state (100%), in 8 of 8 patients with cerebrovascular disease (100%), in 5 out of 7 patients with seizure disorder (76.3%), and in 4 out of 5 patients in intractable headache (86.8%). Out of 31 nonCNS-SLE patients 1 patient presented anti-NA (3.9%). Serum anti-NA were more frequently observed in CNS-SLE patients as compared to controls (p < 0.000001). The frequence of serum anti-NA was significantly higher in CNS-SLE patients as compared to non CNS-SLE patients (p < 0.00001). In conclusion, serum anti-neuronal antibodies are associated with CNS-SLE. These antibodies are more frequent in CNS-SLE than in nonCNS-SLE patients, demonstrating a strong association between serum anti-NA and CNS involvement of SLE. The presence of serum anti-NA could be a useful diagnostic tool for CNS-SLE, the test could help to distinguish SLE from other diseases with similar symptoms. Further studies are needed to evaluate the predictive value of anti-NA in SLE.

Study of endothelin-1 in acute ischemic stroke.

Endothelins (ETs) are potent vasoconstrictor and may play a role in the pathophysiology of several cardiovascular diseases. Endothelin-mediated vasoconstriction may enhance ischemic neuronal damage. The study aimed to find out whether the plasma ET-1 levels may serve as marker of early ischemic stroke. Plasma ET-1 levels were tested in 20 patients with acute ischemic stroke, mean age 63.7 +/- 5.03 years, 12 men and 8 women, within 24 hours of stroke onset as compared to 10 sex- and age-matched control subjects; only the patients with normal CT-scan at admission were included in the study. Plasma ET-1 was measured by ELISA. The results were statistically analyzed by Student test and a p < 0.05 (95% CI) was considered statistically significant. ET-1 levels in patients with hemiplegia and normal CT-scan at admission were significantly higher as compared to control group (0.0910 +/- 0.0256 pg/mL vs. 0.0490 +/- 0.0185 pg/mL, p < 0.0001) (95% CI). Ischemic stroke is associated with acute and marked increased levels of ET-1 in plasma. This may reflect enhanced production by damaged endothelial cells within the infarcted lesion. ET-1 may be used as additional marker of cerebral ischemia in selected cases to distinguish between the onset of an ischemic stroke and other non-vascular diseases presenting similar symptoms.