HLA Class I in Egyptian patients with Behçet's disease: new association with susceptibility, protection, presentation and severity of manifestations.

INTRODUCTION: Behçet's disease is an autoimmune disease with diverse clinical manifestations with vasculitis being the hallmark of the disease. The aim of this work is to study the genetic association between human leukocyte antigen (HLA) class-I molecules of Egyptians with Behçet's disease and the disease susceptibility and clinical patterns. METHODS: Fifty-seven patients diagnosed with Behçet's disease according to the 1990 International Study Group (ISG) criteria for Behçet's disease coming from Egyptian origin up to the third grandfather were included in the study. Healthy controls were taken from HLA Class-I case control studies in Egyptian population yielding a pool of 221 healthy controls. HLA Class-I typing for patients was done using Reverse Sequence specific oligonucleotide probes (rSSO). RESULTS: Male patients represented 89% of the sample. Mean age of onset was 25.81 (± 6.7) years and mean disease duration was 9.47 (± 7.4) years. Behçet's disease was associated with HLA-A*24 and HLA-B*42 (p = 0.001) and highly associated with HLA-A*68 and B*15 and B*51 (p < 0.001). While HLA A*03 and B*52 were protective for Behçet's (p = 0.002 and 0.007). Interestingly, HLA-B*51 and HLA-A*68 (p = 0.005 and 0.023) were associated with the blinding eye disease. HLA-B*51 was protective from Neurological and vascular involvement (p = 0.005 and 0.032, respectively). CONCLUSION: Behçet's disease is associated with HLA Class-I A*24, A*68 and B*15, B*42 and B*51 in Egyptian patients while A*03 and B*52 were found to be protective. Interestingly, HLA B*51 and A*68 could be considered as poor prognostic factor for eye involvement.

Distal Gastrectomy With Roux-en-Y Reconstruction for a Seriously Dilated Stomach With Gastric Outlet Obstruction Secondary to Sarcina ventriculi: A Case Report.

Sarcina ventriculi is an anaerobic gram-positive coccus that can resist the acidic media of the stomach and cause gastrointestinal symptoms. Here, we report the case of a 43-year-old male patient with a history of schizophrenia presenting with abdominal distention, nausea, vomiting, early satiety, and weight loss. Computed tomography of the abdomen and pelvis with contrast revealed a severely dilated stomach and signs of gastric outlet obstruction on multiple occasions. The endoscopic evaluation showed a dilated stomach, and biopsies revealed non-specific gastritis, negative Helicobacter pylori, and positive S. ventriculi with metaplasia. Medical treatment with proton pump inhibitors, pro-kinetics, ciprofloxacin, and metronidazole failed to improve his symptoms. Finally, the patient was managed surgically with distal gastrectomy with Roux en Y reconstruction, and gastrostomy tube placement was done with satisfactory improvement in his symptoms.

Fungal brain abscesses caused by Acremonium species.

Unusual fungal agents that exist environmentally as saprophytes can often lead to opportunistic infections, hyalohyphomycosis is a group of fungal infections caused by fungi characterized by hyaline septate hyphae and can infect both immunocompetent as well as immunocompromised patients, and Acremonium has drawn the attention of clinicians and microbiologists, as a potential pathogen in patients with and without underlying risk factors. It has also been increasingly implicated in systemic fungal diseases. Herein, we describe a case presentation of an immunocompromised patient with fungal brain abscesses due to Acremonium species.

Endobronchial mucormycosis diagnosed by fiberoptic bronchoscopy.

Introduction: Endobronchial mucormycosis is very rare with only few cases reported in the literature. Here, we report a rare presentation of pulmonary mucormycosis in a diabetic patient who presented with left lung collapse. Bronchoscopy revealed an endobronchial growth, mimicking a tumor, causing complete occlusion of the left main bronchus. Histopathology confirmed the diagnosis of invasive mucormycosis. Case presentation: Male patient 35 years old with accidental discovered Diabetes Mellitus, complained of hoarseness of voice and dry irritating cough that didn't respond to antitussives and nonspecific treatment. CT chest was done and revealed left total lung collapse. Fiberoptic bronchoscopy was done and revealed total occlusion of the left main bronchus with whitish fungating glistening tissue from which biopsies were obtained. Histopathological examination was consistent with mucormycosis. A trial of medical treatment failed after which the patient was referred for surgical resection. Conclusion: Successful treatment of mucormycosis requires early diagnosis; prompt administration of antifungal therapy, and surgical intervention when applicable. Aggressive surgical intervention to remove necrotic tissue is generally accepted as the therapeutic mainstay for endobronchial obstructing mucormycosis.

Integrated multiomics analysis to infer COVID-19 biological insights.

Three years after the pandemic, we still have an imprecise comprehension of the pathogen landscape and we are left with an urgent need for early detection methods and effective therapy for severe COVID-19 patients. The implications of infection go beyond pulmonary damage since the virus hijacks the host's cellular machinery and consumes its resources. Here, we profiled the plasma proteome and metabolome of a cohort of 57 control and severe COVID-19 cases using high-resolution mass spectrometry. We analyzed their proteome and metabolome profiles with multiple depths and methodologies as conventional single omics analysis and other multi-omics integrative methods to obtain the most comprehensive method that portrays an in-depth molecular landscape of the disease. Our findings revealed that integrating the knowledge-based and statistical-based techniques (knowledge-statistical network) outperformed other methods not only on the pathway detection level but even on the number of features detected within pathways. The versatile usage of this approach could provide us with a better understanding of the molecular mechanisms behind any biological system and provide multi-dimensional therapeutic solutions by simultaneously targeting more than one pathogenic factor.

Role of streptococcal infection in the etiopathogenesis of pityriasis lichenoides chronica and the therapeutic efficacy of azithromycin: a randomized controlled trial.

The exact aetiology of pityriasis lichenoides chronica (PLC) remains unknown. While phototherapy is the most investigated therapeutic modality, azithromycin has been used scarcely. The aim of this study is to evaluate the therapeutic efficacy of azithromycin in the treatment of PLC compared to NB-UVB and evaluating the presence of streptococcal infection as a possible etiological factor in PLC patients. The study was designed as a randomised controlled trial. Twenty-four patients with PLC were randomly allocated into either azithromycin (n = 13, standard dose every 10 days) or NB-UVB (n = 11, thrice weekly) groups. End of study (EOS) was either complete clearance of lesions or a maximum of 8 weeks. Therapeutic efficacy was defined as percent reduction in lesions and was calculated for the rash as a whole, erythematous papules alone, and hypopigmented lesions alone and graded into complete, very-good, good, poor or no response. Anti-streptolysin O titre (ASOT), anti-deoxyribonuclease B titre (anti-DNaseB) and throat culture were evaluated at day 0. No significant difference existed between both groups as regards therapeutic efficacy. At EOS, NB-UVB achieved significantly more percent reduction in the extent of hypopigmented lesions and consequently in the rash as a whole (p = 0.001, p = 0.034, respectively). The extent of the rash as a whole was significantly less in the NB-UVB at EOS (p = 0.029, respectively). The effect of NB-UVB on hypopigmented lesions appeared early at week 4 of treatment. Only two patients, one from each group, relapsed during the 3 month follow-up. Evidence of recent streptococcal infection was present in 79% of the cases, mainly in the form of elevated ASOT (94.7%). It was significantly more encountered in young children (< 13 years) (p = 0.03) and was associated with more extent of erythematous papules and consequently with more extent of the rash as a whole (p = 0.05 and p = 0.01, respectively). It did not affect outcome of therapy at EOS. Azithromycin did not show more favorable response in patients with recent streptococcal infection. Therapeutic efficacy of azithromycin is comparable to NB-UVB in treatment of PLC; however, NB-UVB is superior in management of hypopigmented lesions. It is highly suggested that PLC could be a post streptococcal immune mediated disorder.Registration number: ClinicalTrials.gov, NCT03831269.

Gastrointestinal involvement in systemic sclerosis: An updated review.

The gastrointestinal tract (GI) is the second most affected organ system in individuals suffering from systemic/localized scleroderma (SSc) or localized scleroderma. SSc can affect any part of the GI, between the oral cavity and anorectum. The annual incidence of SSc in the United States is estimated to be 19.3 cases per million adults, with the highest incidence reported in people aged 44 to 55. Females are 5 times more likely than males to suffer from SSc. Morbidity and mortality rates associated with SSc are predominantly elevated among patients with GI manifestations. Esophageal and intestinal manifestations impact 90% and 40% to 70% of patients with systemic scleroderma, respectively. SSc patients are known to suffer from small bowel hypomotility and small intestinal bacterial overgrowth, which cause malabsorption and malnutrition, ultimately contributing to the 50% mortality rate. Fecal incontinence is a common symptom of SSc that can lead to depression. SSc patients may suffer from gastrointestinal complications that can negatively impact their quality of life on a daily basis. Multidisciplinary approaches are necessary for systematically managing gastrointestinal complications associated with SSc. A prospective study should focus on developing targeted therapies to improve recovery patterns and prognosis in cases of SSc. This article summarizes the epidemiology, commonly reported clinical manifestations, complications, and available treatments for treating GI pathology in SSc patients.

The Evaluation of Lymphadenopathy in a Resource-Limited Setting.

Lymphadenopathy (LAP) refers to abnormalities in the size or consistency of lymph nodes. A wide range of etiologies contributes to the difficulty in diagnosing LAP, from mild self-limited viral infections to grave autoimmune diseases and malignancies. Detailed history-taking and a thorough physical examination are essential. Some physicians in developing countries may consider therapeutic testing. Certain groups may require additional evaluations and special treatment. When treating LAP, the etiology is targeted, but corticosteroids should not be administered before a complete diagnosis has been established due to their ability to mask the histological diagnosis of lymphoma and malignancy. This review aims to provide more straightforward and affordable methods available in almost all healthcare settings, especially those with limited resources.

Comparative Assessment of the Long-Term Efficacy of Home-Based Versus Center-Based Cardiac Rehabilitation.

Cardiac rehabilitation programs support the health, wellness, and recovery of patients with cardiovascular conditions. This systematic review attempts to expand these findings while analyzing the latest randomized controlled trials (RCTs) focusing on the long-term advantages of home/center-based cardiac rehabilitation interventions. This study also comparatively analyzes the benefits of opting for home-based cardiac rehabilitation instead of center-based measures to improve the long-term clinical outcomes of cardiac patients. We extracted and analyzed 10 studies (based on 1,549 cardiac patients) concerning the therapeutic efficacy of center/home-based cardiac rehabilitation interventions. The included studies complied with the year range of 2000-2021. The risk of bias assessment was undertaken using the Cochrane Risk-of-Bias tool to evaluate random sequence generation, allocation concealment, blinding of subjects, outcome data completeness, and selective reporting patterns concerning the included RCTs. The findings of our systematic review confirmed the capacity of a home-based cardiac rehabilitation program to effectively improve left ventricular ejection fraction, health-related quality of life, physical fitness, recovery rate, self-efficacy, sedentary lifestyle, physical activity, satisfaction level, functional capacity, social support, and hemodynamic parameters of patients with cardiovascular diseases. Home-based cardiac rehabilitation had the potential to minimize the levels of triglycerides, anxiety, depression, waist circumference, and body mass index/weight of cardiac patients. The results of our systematic review affirmed the long-term therapeutic efficacy of a home-based cardiac rehabilitation program compared to a center-based cardiac rehabilitation program for adult cardiac patients.

Massive gastrointestinal bleeding in a patient with COVID-19.

Despite the emerging data about the thrombophilic effect of the novel coronavirus [1] , the relation between coagulation disorders and the COVID-19 pandemic is still not well understood. Various studies pointed to the significant role of the COVID-19 induced cytokine storm in development of the hypercoagulable state which leads to serious thromboembolic complications [2,3] . Some studies report the development of severe immune thrombocytopenia induced by the novel coronavirus [4] . Other studies found a correlation between COVID-19 disease and the development of disseminated intravascular coagulation (DIC) [5]. Patients with severe COVID-19 disease have an increased risk for development of gastrointestinal bleeding (GI) which may be related to stress [6] , critical illness or mechanical ventilation [7] . Further studies showed the ability of the novel coronavirus to infect the epithelial cells of the GI tract [8] . Moreover, some data pointed to the ability of the virus even to infect the endothelium of blood vessels [9]. The relation between the COVID-19 pandemic and GI bleeding deserves more studies [10]. We present a case of GI bleeding in a patient with severe COVID-19 disease. We assume that COVID-19 disease can be a predominant factor for the development of DIC and GI bleeding.

New-onset Type 1 Diabetes Mellitus with Diabetic Ketoacidosis and Pancreatitis in a Patient with COVID-19.

Coronavirus Disease 2019 (COVID-19) had struck the world with health and economic catastrophes and recently with unusual autoimmune presentations, including new-onset Type 1 Diabetes. Herein we present a 17-year-old male patient who presented to the outptient clinic with fever, palpitation, and cough of four-week duration; he was referred to the emergency room and was found to have DKA. CT of the chest showed ground-glass opacities suggestive of COVID-19 pneumonia, and abdominal cuts showed dilated intrahepatic biliary radicles with pancreatic loculations suggestive of pancreatitis. The patient was admitted to the ICU, started on intravenous fluids and insulin infusion then COVID-19 PCR returned positive. We hypothesize that SARS-CoV-2 has a vital role in eliciting an autoimmune response triggering type 1 diabetes, and further studies are needed to confirm this hypothesis. SARS-CoV-2 may cause pancreatitis, and the first presentation could be high blood sugar or DKA.

Adrenal Insufficiency in patients with cardiogenic shock: A meta-analysis.

BACKGROUND: Adrenal Insufficiency (AI) is rarely observed in patients with cardiogenic shock (CS). We aimed to identify the prevalence of AI in patients with CS and its effect on their clinical outcomes. AIMS: Our study aimed to determine the prevalence of AI in CS patients who underwent treatments for CS. METHODS: The articles concerning AI in CS were extracted for review from PubMed/Medline, Science Direct, World Wide Science.org, and Pro-Quest. The research articles included patients with CS, post-cardiac-arrest shock, out-of-hospital cardiac arrest, and CS after acute myocardial infarction. RStudio (version 1.0.136) was used for analyzing AI in CS patients. RESULTS: The search revealed 1463 unique publications, including 256 studies identified after screening the titles and the abstracts. Five observational cohort studies met the eligibility criteria for meta-analysis after the preliminary screening. The included studies reported a corticotropin stimulation test for AI diagnosis. The studies reportedly exhibited a low-to-fair quality. The random-effects pooled estimates indicated a 32% AI prevalence in the setting of CS [95% CI; 21%-45%; I2 = 81%]. The outcomes from the included studies were statistically significant for high heterogeneity (P = 0.001). The pooled results confirmed an 11%-51% AI prevalence in CS patients. CONCLUSIONS: This meta-analysis revealed a moderate level prevalence of AI in CS patients.

The association between COVID-19 and type 1 diabetes mellitus: A systematic review.

BACKGROUND: /Aim: Various reports of the occurrence of type 1 diabetes mellitus (T1DM) in patients with COVID-19 have been published, denoting an association between both diseases. Therefore, we conducted this systematic review to summarize the prevalence of T1DM in COVID-19 patients and to identify the clinical presentations and outcomes in this patient population. MATERIALS AND METHODS: Up to 10/27/2020, Medline, Embase, cochrane and google scholar databases were searched for original studies investigating the association between COVID-19 and T1DM. A manual search was conducted to identify missing studies. The quality of included studies was analyzed by the National Institute of Health (NIH) risk of bias tool. Outcomes included length of hospital stay, hospitalization, intensive care unit (ICU) admission, diabetic ketoacidosis (DKA), severe hypoglycemia, and death. RESULTS: Fifteen studies were included in the qualitative analysis. Included studies reported data of both adult and pediatric patients. The prevalence of T1DM in COVID-19 patients ranged from 0.15% to 28.98%, while the rate of COVID-19 in patients with T1DM ranged from 0% to 16.67%. Dry cough, nausea, vomiting, fever and elevated blood glucose levels were the most commonly reported presentations. The investigated outcomes varied widely among studied populations. CONCLUSIONS: The prevalence of T1DM in patients with COVID-19 ranged from 0.15% to 28.98%. The most common presentation of COVID-19 in patients with T1DM included fever, dry cough, nausea and vomiting, elevated blood glucose and diabetic ketoacidosis. The outcomes of COVID-19 in terms of length of hospital stay, hospitalization, ICU admission, DKA rate, and severe hypoglycemia were reported variably in included studies. Due to the heterogeneous study populations and the presence of many limitations, more studies are still warranted to reach a definitive conclusion.

COVID-19 and Autoimmune Diseases: A Systematic Review of Reported Cases.

INTRODUCTION: Over 4.9 million cases of Coronavirus disease 2019 (COVID-19) have been confirmed since the worldwide pandemic began. Since the emergence of COVID-19, a number of confirmed cases reported autoimmune manifestations. Herein, we reviewed the reported COVID-19 cases with associated autoimmune manifestations. METHODS: We searched PubMed database using all available keywords for COVID-19. All related studies between January 1st, 2020 to May 22nd, 2020 were reviewed. Only studies published in English language were considered. Articles were screened based on titles and abstracts. All reports of confirmed COVID-19 patients who have associated clinical evidence of autoimmune disease were selected. RESULTS: Among the 10006 articles, searches yielded thirty-two relevant articles for full-text assessment. Twenty studies has met the eligibility criteria. The twenty eligible articles reported 33 cases of confirmed COVID-19 diagnosis who developed an autoimmune disease after the onset of covid-19 symptoms. Ages of patients varied from a 6 months old infant to 89 years old female (Mean=53.9 years of 28 cases); five cases had no information regarding their age. The time between symptoms of viral illness and onset of autoimmune symptoms ranged from 2 days to 33 days (Mean of the 33 cases=9.8 days). Autoimmune diseases were one case of subacute thyroiditis (3%), two cases of Kawasaki Disease (6.1%), three cases of coagulopathy and antiphospholipid syndrome (9.1%), three cases of immune thrombocytopenic purpura (9.1%), eight cases of autoimmune hemolytic anemia (24.2%), and sixteen cases of Guillain-Barré syndrome (48.5%). CONCLUSION: COVID-19 has been implicated in the development of a range of autoimmune diseases, which may shed light on the association between autoimmune diseases and infections.

Risk Factors, Screening, and Treatment Challenges in Staphylococcus aureus Native Septic Arthritis.

BACKGROUND: Staphylococcus aureus is the most common cause of native septic arthritis. Few studies have characterized this disease during the US opioid epidemic. The role of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening in this disease has not been elucidated. We sought to identify risk factors and outcomes for S. aureus native septic arthritis and to evaluate MRSA screening in this disease. METHODS: A retrospective cohort study of native septic arthritis patients (2012-2016) was performed. Demographics, risk factors, and outcomes were compared between Staphylococcus aureus and other native septic arthritis infections. Sensitivity, specificity, and predictive values of MRSA screening were assessed. RESULTS: Two hundred fifteen cases of native septic arthritis were included. S. aureus was cultured in 64% (138/215). MRSA was cultured in 23% (50/215). S. aureus was associated with injection drug use (odds ratio [OR], 4.33; 95% CI, 1.74-10.81; P = .002) and switching antibiotics (OR, 3.92; 95% CI, 1.01-21.38; P = .032). For every 10-year increase in age, the odds of S. aureus decreased (OR, 0.72; 95% CI, 0.60-0.87; P = .001). For 1-unit increases in Charlson comorbidity index score, the odds of S. aureus decreased (OR, 0.82; 95% CI, 0.73-0.91; P = .0004). MRSA screening during admission demonstrated a sensitivity of 0.59, specificity of 0.96, positive predictive value of 0.85, and negative predictive value of 0.84 for MRSA native septic arthritis. CONCLUSIONS: The opioid epidemic may be contributing to a demographic shift in native septic arthritis to younger, healthier individuals. S. aureus native septic arthritis has unique risks, including injection drug use. MRSA screening may be useful to rule in MRSA native septic arthritis.

Antibiotic Use and Resistance Among Prescribers: Current Status of Knowledge, Attitude, and Practice in Egypt.

INTRODUCTION: The problem of antimicrobial resistance (AMR) is rising worldwide. One of the most significant factors influencing antimicrobial resistance in low- and middle-income countries is the lack of the skills and knowledge of health care providers for proper antimicrobial use. AIM: To identify knowledge, characterize practices and describe the attitude of Egyptian prescribers towards antibiotic use. METHODS: A self-administered validated questionnaire was distributed among Egyptian prescribers. RESULTS: Five hundred Egyptian physicians responded to the questionnaire, 113 (22.6%) reported having Antibiotic Stewardship Program (ASP) at their workplace, 99 (19.8%) use international antibiotic guidelines as the main source for prescribing activity, 358 (71.6%) recorded adequate knowledge. Elder prescribers and those who work in private or university hospitals were significantly more knowledgeable (p=0.031 and 0.001, respectively). Forty-seven (9.4%) showed a positive attitude towards proper antibiotic prescription. The type of work institution; primary health clinics and private, or university hospital and the specialty are significantly associated with a positive attitude (p=0.009 and 0.015, respectively). Seventy-eight (15.6%) expressed a proper antibiotic prescription practice. Elder age, more experienced and trained prescribers showed more proper practice. The implementation of ASP and using proper sources of information were significantly associated with proper practice (p=0.012 and 0.008, respectively). CONCLUSION: Egyptian prescribers have a good level of knowledge about antibiotics. However, low rates of positive attitude and proper practice towards the problem of AMR and ASP are recorded.

Is there a link between pre-existing antibodies acquired due to childhood vaccinations or past infections and COVID-19? A case control study.

BACKGROUND: There is growing evidence indicating that children are less affected from COVID-19. Some authors speculate that childhood vaccinations may provide some cross-protection against COVID-19. In this study, our aim was to compare the circulating antibody titers for multiple childhood vaccine antigens, as an indicator of the state of immune memory between patients with COVID-19 and healthy controls, with a specific aim to identify the association between disease severity and antibody titrations which may indicate a protective function related to vaccine or disease induced memory. METHODS: This study is a case-control study including 53 patients with COVID-19 and 40 healthy volunteers. COVID-19 severity was divided into three groups: asymptomatic, mild and severe. We measured the same set of antibody titers for vaccine antigens, and a set of biochemical and infection markers, in both the case and control groups. RESULTS: Rubella (p = 0.003), pneumococcus (p = 0.002), and Bordetella pertussis (p < 0.0001) titers were found to be significantly lower in the case group than the control group. There was a significant decline in pneumococcus titers with severity of disease (p = 0.021) and a significant association with disease severity for Bordetella pertussis titers (p = 0.014) among COVID patients. Levels of AST, procalcitonin, ferritin and D-dimer significantly increased with the disease severity. DISCUSSION: Our study supports the hypothesis that pre-existing immune memory, as monitored using circulating antibodies, acquired from childhood vaccinations, or past infections confer some protection against COVID-19. Randomized controlled studies are needed to support a definitive conclusion.

Liver Kidney Crosstalk: Hepatorenal Syndrome.

The dying liver causes the suffocation of the kidneys, which is a simplified way of describing the pathophysiology of hepatorenal syndrome (HRS). HRS is characterized by reversible functional renal impairment due to reduced blood supply and glomerular filtration rate, secondary to increased vasodilators. Over the years, HRS has gained much attention and focus among hepatologists and nephrologists. HRS is a diagnosis of exclusion, and in some cases, it carries a poor prognosis. Different classifications have emerged to better understand, diagnose, and promptly treat this condition. This targeted review aims to provide substantial insight into the epidemiology, pathophysiology, diagnosis, and management of HRS, shed light on the various milestones of this condition, and add to our current understanding.

Coronavirus disease 2019 and renal transplantation.

Ever since the severe acute respiratory syndrome virus causing coronavirus disease 2019 (COVID-19) struck the world, global health strategies have changed significantly. According to the Centers for Disease Control and Prevention, kidney transplant recipients are stratified as being high risk of developing fatal illness from COVID-19 infection. Kidney transplant is the gold-standard treatment for end-stage kidney disease subjects. During the pandemic, significant concerns have emerged regarding continuation of kidney transplant surgeries and management of kidney transplant recipients post-transplant. The added risk of immunosuppression in this cohort was and remains a theoretical concern, posing a potential risk of transplantation rather than benefit. This comprehensive review aims to cover most of the faced challenges in kidney transplantation in different stages of the pandemic. In addition, it will elucidate the epidemiology, nature, course of the disease, surgical consideration in donors and recipients as well as role of immunosuppression and management of COVID-19 infected kidney transplant recipients during these extraordinary circumstances.