Efficacy of tocilizumab in COVID-19: A systematic review and meta-analysis.

The efficacy of tocilizumab (TOC), monoclonal antibody against interleukin-6 (IL-6) receptor, in patients with coronavirus disease-2019 (COVID-19) patients has led to conflicting results. We performed a systematic review and meta-analysis to compare the efficacy of addition of TOC to standard of care (SOC) versus SOC in patients with COVID-19. We performed a comprehensive literature search of PubMed, Embase, Web of Science, WHO COVID, LitCOVID, and Cochrane databases. Pooled outcomes (overall mortality, need for mechanical ventilation, intensive care unit admission, and secondary infections) were compared using DerSimonian-Laird/Random-effects approach. Risk difference (RD), confidence interval (CI), and p values were generated. A total of 23 studies with 6279 patients (1897 in TOC and 4382 in SOC group, respectively) were included. The overall mortality was lower in TOC group compared to SOC group (RD: -0.06; CI: -0.12 to -0.01; p = .03). Subgroup analysis including studies with only severe cases revealed lower mortality (RD: -0.12; CI: -0.18 to -0.06; p < .01) and need for mechanical ventilation (RD: -0.11; CI: -0.19 to -0.02; p = .01) in TOC group compared to SOC group. The addition of TOC to SOC has the potential to reduce mortality and need for mechanical ventilation in patients with severe COVID-19. Randomized controlled trials are needed to validate this.

HHV-6: an unusual cause of cerebellar ataxia.

Human herpesvirus 6 (HHV-6) infection is the cause of roseola infantum in children. The reactivation of HHV-6 is associated with multiple clinical syndromes including encephalitis and myelitis, especially in haematopoietic stem cell transplant recipients. However, the virus can cause encephalitis in other immunosuppressed as well as immunocompetent individuals. We report a case of a 70-year-old woman who was immunocompromised secondary to treatment of rheumatoid arthritis with leflunomide and methotrexate. The patient presented with acute ataxia, diplopia and dysarthria. MRI brain showed an enhancing lesion in the midbrain. The diagnosis of HHV-6 encephalitis was made after HHV-6 A DNA was detected in both serum and cerebrospinal fluid. Treatment consisted of a 3-week course of intravenous ganciclovir along with physiotherapy. At a 3-month follow-up, repeat MRI brain showed a decrease in size and oedema of the lesion and the patient's neurological function was improved.

From a stone to rupture: calyceal rupture secondary to obstructive uropathy.

Renal collecting system rupture is a rare manifestation of obstructive uropathy. The majority of cases are attributed to ureteric calculi and extrinsic ureteric compression. The optimal diagnostic image is contrast-enhanced CT scan with delayed phase protocol. Management is usually conservative and generally depends on the etiology, urinomas size, and the presence or absence of kidney failure or infections.

Acute disseminated encephalomyelitis following Influenza A pneumonia.

Acute disseminated encephalomyelitis (ADEM) is an autoimmune demyelinating disorder of the central nervous system and can present following influenza A infections as multifocal neurological deficits. ADEM remains a challenging diagnosis, and high clinical suspicious coupled with laboratory investigations and neuroimaging is required to exclude other primary and secondary demyelinating disorders.

Antiphospholipid Antibody Induced by Nivolumab.

Nivolumab is a monoclonal antibody against the programmed death protein 1 and is used for patients with advanced melanoma. It is associated with potentially immune-related adverse events, including disorders of the skin, GI tract, and the thyroid; these disorders were successfully treated with prednisone and infliximab. Other immunotherapeutic agents were observed to induce the formation of antiphospholipid antibody (APA) including α-interferon and interleukin-2. We present a case of APA development after the third dose of nivolumab in a 71-year-old male with advanced melanoma. The APA was detected after finding a prolonged aPTT; the lupus anticoagulant assay tested positive. The patient was treated with prednisone but, unfortunately, he expired a few days later.

A rare case of Epstein-Barr virus mucocutaneous ulcer of the colon.

Epstein-Barr virus mucocutaneous ulcer (EBVMCU) is a rare form of EBV lymphoproliferative disorder. The disease was recently described in 2010 for the first time in a case series and it was recently identified by the WHO classification of haematological malignancies as a separate category among the EBV lymphoproliferative disorders. We present a case of EBVMCU of the colon presenting as an ulcerating inflammatory mass in a female in her mid-60s who presented initially with abdominal pain and diarrhoea. The patient had extensive workup for her disease and due to progression of her symptoms, she was taken for an exploratory laparotomy. During the procedure, there was an inflammatory mass at the caecum and severe inflammation of the caecum and the terminal ileum and right hemicolectomy was performed. Diagnosis was confirmed by histopathology as EBV-positive lymphoproliferative disorder best classified as EBV-positive mucocutaneous ulcer.

Two gaps too many, three clues too few? Do elevated osmolal and anion gaps with crystalluria always mean ethylene glycol poisoning?

A 60-year-old African-American man with a medical history significant for heavy alcohol abuse, hypertension, delirium tremens, nephrolithiasis and seizure disorder was brought to the hospital with altered mental status. He was found to have high anion gap metabolic acidosis with significantly elevated lactate along with an elevated osmolal gap and calcium oxalate crystals in his urine. With this combination of findings, ethylene glycol poisoning was high in the differential. This case report describes why ethylene glycol poisoning was not the diagnosis in this patient despite the presence of these three classic laboratory findings, therefore emphasising the fact that these findings should not be taken at face value because they can be seen collectively in a patient yet each have a different cause.