Low 25-Hydroxyvitamin D and Myofascial Pain: Association of Cancer, Colon Polyps, and Tendon Rupture.

BACKGROUND: Myofascial pain that has been associated with cancer and increased risk of morbidity and mortality in cancer patients is intrinsically associated with low magnesium and low 25-hydroxyvitamin D (25(OH)D). Therefore, this physical finding was used as a clinical diagnostic proxy. OBJECTIVE: The objective of this study was to assess the association and prevalence of disease in individuals with myofascial pain and low 25(OH)D in a county with low magnesium in the drinking water. DESIGN: This is a retrospective cross-sectional study of a chart review of 269 subjects to assess subjects presenting with myofascial pain (assessed by tender trigger points) and 25(OH)D concentrations below 30 ng/mL or a history of 25(OH)D deficiency compared to those without these exposures. RESULTS: The association between the exposure of low 25(OH)D levels and myofascial pain was compared to all cancers, colon polyps, and tendon ruptures. The odds of having cancer with the combined exposures was 10.14 times the odds of not having either exposure (95% confidence interval [CI], 5.08, 20.25, p < 0.001). For adenomatous colon polyps, the odds ratio (OR) was 7.24 (95% CI, 3.83, 13.69, p < 0.001), and for tendon rupture, the OR was 8.65 (95% CI, 3.76, 19.94, p < 0.001). Of 80 subjects who had both myofascial pain and 25(OH)D less than 30 ng/mL, 74 were tested for red blood cell (RBC) magnesium. Half of those subjects had RBC magnesium concentrations < 4.6 mg/dL, and 23% had levels below the reference range (4.0-6.4 mg/dL). CONCLUSION: Myofascial pain as assessed by tender trigger points and 25(OH)D deficiency showed a significant association with cancer, adenomatous colon polyps, and tendon rupture. Further studies to verify these results are needed, especially in areas where there is low magnesium in the drinking water.

Primary central nervous system amelanotic melanoma in a Hispanic male: Case report.

BACKGROUND: Primary melanotic neoplasms of the central nervous system (CNS) are uncommon; amelanotic melanomas in this region are extremely rare. Very few cases of amelanotic variation of primary melanoma in the CNS were reported on. General guidelines or recommendations to establish this diagnosis do not exist. CASE REPORT: A sixty-year-old male Hispanic patient presented with a 7-day history of numbness and dizziness. Initial laboratory work-up and physical examination were inconclusive. Cerebral radiological imaging showed a left frontal lesion. Further work-up after clinical deterioration revealed an increase in the lesion size consistent with hemorrhage and changes in T1WI. Biopsy and immunochemistry demonstrated the presence of amelanotic melanoma in the CNS without evidence of another primary lesion. CONCLUSIONS: Primary amelanotic melanoma of the CNS represents a challenge, clinically and diagnostically. Magnetic resonance imaging can be helpful in early stages. Final diagnosis is established with immunohistochemical testing. Physicians should be aware of the existence of this rare manifestation and difficulties faced while building this diagnosis.

Safety and Efficacy of Vadadustat Once-Daily and 3-Times-Weekly in Dialysis-Dependent Chronic Kidney Disease Patients with Anemia.

BACKGROUND: Vadadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor for treating anemia in chronic kidney disease (CKD). This study investigated safety and efficacy of once-daily and 3-times-weekly dosing in patients with dialysis-dependent (DD)-CKD compared with darbepoetin alfa (DA). METHODS: This phase 3b, randomized (1:1:1; vadadustat once-daily [starting dose: 300 or 450 mg], vadadustat 3-times-weekly [starting dose: 600 or 750 mg], DA), open-label, active-controlled, noninferiority trial included conversion (weeks 0-20) and maintenance (weeks 20-52) periods. Primary and secondary efficacy endpoints were mean change in hemoglobin from baseline during the primary (PEP, weeks 20-26) and secondary (SEP, weeks 46-52) evaluation periods. Other endpoints included proportion of patients requiring ESA rescue (hemoglobin <9.5 g/dL or with increases in dose ≥50% or ≥100% in DA group). Safety endpoints included treatment-emergent adverse events (TEAEs) and serious AEs (SAEs). RESULTS: Least squares (LS) mean treatment difference between vadadustat once-daily and DA from baseline to PEP was -0.27 g/dL (95% CI, -0.55 to 0.01); the lower bound met the noninferiority threshold (-0.75 g/dL). The LS mean treatment difference between vadadustat 3-times-weekly and DA from baseline to PEP was -0.53 g/dL (95% CI, -0.80 to -0.25), which did not meet the lower bound noninferiority threshold. The LS mean change from baseline to the SEP between DA and vadadustat once-daily was -0.40 (95% CI, -0.79 to -0.02), and for vadadustat 3-times-weekly was -0.42 (95% CI, -0.81 to -0.02). Proportion of patients who received ESA rescue during weeks 2-52 was higher in the DA group than vadadustat groups. Similar TEAEs and treatment-emergent SAEs were observed across groups. CONCLUSIONS: Vadadustat once-daily, but not 3-times-weekly, was noninferior to DA in the correction and maintenance of hemoglobin in patients with DD-CKD converted from an ESA; safety profiles were similar across groups. TRIAL REGISTRATION: EudraCT 2019-004851-36/ClinicalTrials.gov identifier: NCT04313153.

An open-label, single-arm study evaluating the immunogenicity and safety of the hepatitis B vaccine HepB-CpG (HEPLISAV-B®) in adults receiving hemodialysis.

BACKGROUND: Hemodialysis patients are at increased risk of hepatitis B virus (HBV) infection and are poorly responsive to HBV vaccines. Current vaccine recommendations for hemodialysis patients utilize more than twice the amount of hepatitis B surface antigen (HBsAg) used for healthy adults and achieve lower immune responses. METHODS: An open-label, single-arm, multicenter trial was conducted among adults 18 years of age and older who were initiating or undergoing hemodialysis who had not previously received hepatitis B vaccine. Participants received four doses of HepB-CpG (HEPLISAV-B®) (20 mcg rHBsAg + 3000 mcg CpG 1018, a Toll-like receptor 9 agonist) administered at 0, 4, 8, and 16 weeks. Participants are being followed for 68 weeks. This paper reports the final immunogenicity analysis of the primary endpoint at study week 20 and an interim safety analysis. RESULTS: We enrolled 119 participants receiving hemodialysis who were followed for a median of 47.4 weeks. Of the 119 participants, 75 were in the per-protocol population. At week 20, the seroprotection rate (% with antibodies to hepatitis B surface antigen [anti-HBs] ≥ 10 mIU/mL) was 89.3% and the percentage of participants with anti-HBs ≥ 100 mIU/mL was 81.3%. The anti-HBs geometric mean concentration was 1061.8 mIU/mL. HepB-CpG was well tolerated with no observed safety concerns. CONCLUSION: In patients receiving hemodialysis, HepB-CpG given as four doses was well tolerated and induced very high anti-HBs concentrations and seroprotection in a very high proportion of recipients.

Opportunities for improving cardiovascular health outcomes in adults younger than 65 years with guideline-recommended statin therapy.

The impact of age, race/ethnicity, healthcare insurance, and selected clinical variables on statin-preventable ASCVD were quantified in adults aged 21 to 79 years from National Health and Nutrition Examination Surveys 2007-2012 using the 2013 American College of Cardiology/American Heart Association guideline on the treatment of cholesterol. Among ≈42.4 million statin-eligible, untreated adults, 52.6% were hypertensive and 71% were younger than 65 years. Of ≈232 000 statin-preventable ASCVD events annually, most occur in individuals younger than 65 years, with higher proportions in blacks and Hispanics than whites (73.0% and 69.2% vs 56.9%, respectively; P<.01). Among adults younger than 65 years, the ratio of statin-eligible but untreated to statin-treated adults was higher in blacks and Hispanics than whites (3.0 and 2.9 vs 1.3, respectively; P<.01), and blacks, men, hypertensives, and cigarette smokers were more likely to be statin eligible than their statin-ineligible counterparts by multivariable logistic regression. Two thirds of untreated statin-eligible adults had two or more healthcare visits per year. Identifying and treating more statin-eligible adults in the healthcare system could improve cardiovascular health equity.

Blood mercury reporting in NHANES: identifying Asian, Pacific Islander, Native American, and multiracial groups.

INTRODUCTION: Asians, Pacific Islanders, and Native Americans are a potentially high-risk group for dietary exposure to methylmercury through fish consumption. However, blood mercury levels in this group have not been identified in recent reports of the National Health and Nutrition Examination Survey (NHANES) for the years 1999-2002. METHODS: We used NHANES data from 1999-2002 to obtain population estimates of blood mercury levels among women of childbearing age classified as belonging to the "other" racial/ethnic group (Asian, Pacific Islander, Native American, and multiracial; n = 140). Blood mercury levels in this group were compared with those among all other women participants, classified as Mexican American, non-Hispanic black, non-Hispanic white, and "other" Hispanic. RESULTS: An estimated 16.59 +/- 4.0% (mean +/- SE) of adult female participants who self-identified as Asian, Pacific Islander, Native American, or multiracial (n = 140) had blood mercury levels > or = 5.8 microg/L, and 27.26 +/- 4.22% had levels > or = 3.5 microg/L. Among remaining survey participants (n = 3,497), 5.08 +/- 0.90% had blood mercury levels > or = 5.8 microg/L, and 10.86 +/- 1.45% had levels > or = 3.5 microg/L. CONCLUSIONS: Study subjects in NHANES who self-identified as Asian, Pacific Islander, Native American, or multiracial had a higher prevalence of elevated blood mercury than all other racial/ethnic participants in the survey. Future studies should address reasons for the high mercury levels in this group and explore possible interventions for lowering risk of methylmercury exposure in this population.

Interpretation of serologic tests in an HIV-infected patient with kidney disease.

BACKGROUND: A 32-year-old African American man with HIV infection presented with hemoptysis, shortness of breath and renal insufficiency. Serologic testing revealed the presence of anti-glomerular basement membrane antibodies and equivocal levels of anti-myeloperoxidase antibodies. INVESTIGATIONS: Physical examination, urine and blood analysis, kidney ultrasound, chest radiograph, sputum cultures, bronchoscopy and renal biopsy. DIAGNOSIS: Reactivation of tuberculosis infection, immune complex glomerulonephritis, and 'false-positive' anti-glomerular basement membrane and anti-myeloperoxidase antibodies. MANAGEMENT: Directly observed therapy with four-drug anti-tuberculosis therapy and conservative management of chronic kidney disease.

2013 ACC/AHA Cholesterol Guideline and Implications for Healthy People 2020 Cardiovascular Disease Prevention Goals.

BACKGROUND: Healthy People 2020 aim to reduce fatal atherosclerotic cardiovascular disease (ASCVD) by 20%, which translates into 310 000 fewer events annually assuming proportional reduction in fatal and nonfatal ASCVD. We estimated preventable ASCVD events by implementing the American College of Cardiology/American Heart Association (ACC/AHA) 2013 Cholesterol Guideline in all statin-eligible adults. Absolute risk reduction (ARR) and number needed-to-treat (NNT) were calculated. METHODS AND RESULTS: National Health and Nutrition Examination Survey data for 2007-2012 were analyzed for adults aged 21 to 79 years and extrapolated to the US population. Literature-guided assumptions were used including (1) low-density lipoprotein cholesterol falls 33% with moderate-intensity statins and 51% with high-intensity statins; (2) for each 39 mg/dL decline in low-density lipoprotein cholesterol, 10-year ASCVD10 risk would fall 21% when ASCVD10 risk was ≥20% and 33% when ASCVD10 risk was <20%; and (3) either all statin-eligible untreated adults or all with ASCVD10 risk ≥7.5% would receive statins. Of 175.9 million adults aged 21 to 79 years not taking statins, 44.8 million (25.5%) were statin eligible. Treating all statin-eligible adults would prevent an estimated 243 589 ASCVD events annually (ARR 5.4%, 10-year NNT 18). Treating all statin-eligible adults with ASCVD10 risk ≥7.5% reduces the number treated to 32.2 million (28.2% fewer), whereas ASCVD events prevented annually fall only 10.5% to 217 974 (6.8% ARR, NNT 15). CONCLUSIONS: Implementing the ACC/AHA 2013 Cholesterol Guideline in all untreated, statin-eligible adults could achieve ≈78% of the Healthy People 2020 ASCVD prevention goal. Most of the benefit is attained by individuals with 10-year ASCVD risk ≥7.5%.

Environmental exposures, socioeconomics, disparities, and the kidneys.

Kidney disease disproportionately affects racial and ethnic minority populations, the poor, and the socially disadvantaged. The excess risk of kidney disease among minority and disadvantaged populations can only be partially explained by an excess of diabetes, hypertension, and poor access to preventive care. Disparities in the environmental exposure to nephrotoxicants have been documented in minority and disadvantaged populations and may explain some of the excess risk of kidney disease. High-level environmental and occupational exposure to lead, cadmium, and mercury are known to cause specific nephropathies. However, there is growing evidence that low-level exposures to heavy metals may contribute to the development of CKD and its progression. In this article, we summarize the excess risk of environmental exposures among minority and disadvantaged populations. We also review the epidemiologic and clinical data linking low-level environmental exposure to lead, cadmium, and mercury to CKD and its progression. Finally, we briefly describe Mesoamerican nephropathy, an epidemic of CKD affecting young men in Central America, which may have occupational and environmental exposures contributing to its development.

Hypertension in african americans aged 60 to 79 years: statement from the international society of hypertension in blacks.

A 2014 hypertension guideline raised goal systolic blood pressure (SBP) from <140 mm Hg to <150 mm Hg for adults 60 years and older without diabetes mellitus (DM) or chronic kidney disease (CKD). The authors aimed to define the status of hypertension in black adults 60 to 79 years from the National Health and Nutrition Examination Survey 2005-2012 and provide practical guidance. Black patients were more often aware and treated (P≤.005) for hypertension than whites and had higher rates of DM/CKD (P<.001), similar control to <140/<90 mm Hg with DM/CKD (P=.59), and lower control without DM/CKD (<140/<90 mm Hg and <150/<90 mm Hg, P≤.01). Limited awareness (<30%) and infrequent health care (>30% 0-1 health-care visits per year) occurred in untreated black and white hypertensive patients without DM/CKD and BP ≥140/<90 mm Hg. The literature suggests benefits of treated SBP <140 mm Hg in adults 60 to 79 years without DM/CKD. The International Society of Hypertension in Blacks recommends: (1) continuing efforts to achieve BP <140/<90 mm Hg in those with DM/CK, and (2) identifying hypertensive patients without DM/CKD and BP ≥140/<90 mm Hg and treat to an SBP <140 mm Hg in black adults 60-79 years.

The link between chronic kidney disease and cardiovascular disease.

CONTEXT: It is well known that patients with chronic kidney disease (CKD) have a strong risk of cardiovascular disease (CVD). However, the excess risk of cardiovascular disease in patients with CKD is only partially explained by the presence of traditional risk factors, such as hypertension and diabetes mellitus. EVIDENCE ACQUISITIONS: Directory of Open Access Journals (DOAJ), Google Scholar, PubMed, EBSCO and Web of Science has been searched. RESULTS: Chronic kidney disease even in its early stages can cause hypertension and potentiate the risk for cardiovascular disease. However, the practice of intensive blood pressure lowering was criticized in recent systematic reviews. Available evidence is inconclusive but does not prove that a blood pressure target of less than 130/80 mmHg as recommended in the guidelines improves clinical outcomes more than a target of less than 140/90 mmHg in adults with CKD. CONCLUSIONS: The association between CKD and CVD has been extensively documented in the literature. Both CKD and CVD share common traditional risk factors, such as smoking, obesity, hypertension, diabetes mellitus, and dyslipidemia. However, cardiovascular disease remains often underdiagnosed und undertreated in patients with CKD. It is imperative that as clinicians, we recognize that patients with CKD are a group at high risk for developing CVD and cardiovascular events. Additional studies devoted to further understand the risk factors for CVD in patients with CKD are necessary to develop and institute preventative and treatment strategies to reduce the high morbidity and mortality in patients with CKD.

Recurrent Skin and Lung Infections in Autosomal Dominant Hyper IgE Syndrome with Transactivation Domain STAT3 Mutation.

Background. Hyper IgE is a rare systemic disease characterized by the clinical triad of high serum levels of IgE (>2000 IU/mL), eczema, and recurrent staphylococcal skin and lung infections. The presentation of hyper IgE syndrome is highly variable, which makes it easy to confuse the diagnosis with that of severe atopy or other rare immunodeficiency disorders. Case Report. A 23-year-old Hispanic presented with history of frequent respiratory and gastrointestinal infections as a child and multiple episodes of skin and lung infections (abscess) with Staphylococcus aureus throughout his adult life. He had multiple eczematous lesions and folliculitis over his entire body, oral/esophageal candidiasis, and retention of his primary teeth. The IgE was elevated (>5000 IU/mL). Genetic mutation analysis revealed a mutation affecting the transactivation domain of the STAT3 gene. Conclusion. The hallmark of hyper IgE syndrome is serum IgE of >2000 IU/mL. Hyper IgE syndrome is a genetic disorder that is either autosomal dominant or recessive. A definite diagnosis can be made with genetic mutation analysis, and in this case, it revealed a very rare finding of the transactivation domain STAT3 mutation. Hyper IgE syndrome is a challenge for clinicians in establishing a diagnosis in suspected cases.

Alogliptin; a review of a new dipeptidyl peptidase-4 (DPP-4) inhibitor for the treatment of type 2 diabetes mellitus.

Dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors) are effective and safe oral incretin-based antihyperglycemic drugs. In preclinical studies, DPP-4 inhibitors have demonstrated cardiovascular benefits, independent of glycemic control, in patients with type-2 diabetes mellitus. Since 2005, various DPP-4 inhibitors (sitagliptin, linagliptin and saxagliptin) have been clinically available in the United States. Since 2013, alogliptin is the 4(th) approved DPP-4 inhibitor available on the market. Studies have shown that alogliptinis non-inferior to comparator drugs among newly diagnosed type 2 diabetes mellitus patients. Alogliptin can effectively be used as a single agent or as an add-on drug in combination with other glucose lowering drugs with favorable outcomes on glycemic control and HbA1C levels.

Hepatitis C- and HIV-induced porphyria cutanea tarda.

PATIENT: Male, 47 FINAL DIAGNOSIS: Porphyria cutanea tarda Symptoms: Chills • cough dry • thumb swelling MEDICATION: - Clinical Procedure: - Specialty: Metabolic Disorders and Diabetics. OBJECTIVE: Challenging differential diagnosis. BACKGROUND: Porphyria cutanea tarda (PCT) is the most common type of the porphyria. It occurs due to the deficiency of enzyme uroporphyrinogen decarboxylase (UROD), which is the fifth enzyme in the biosynthesis of heme and catalyzes the conversion of uroporphyrinogen to coproporphyrinogen. The risk factors for PCT include hereditary hemochromatosis, hepatitis C infection, ethanol abuse, estrogen use, HIV, smoking, chlorinated polycyclic aromatic hydrocarbons, and hemodialysis. CASE REPORT: A 47-year-old Hispanic man presented with right thumb swelling, redness, and pain for approximately 1 week. Past medical history included HIV/AIDS, hepatitis C infection, alcohol abuse, heroin abuse, and CMV retinitis. Skin examination revealed blistering and hypo/hyper pigmented lesions over the dorsal aspects of the hands and other sun-exposed areas. Serum porphyrins were discovered to be elevated. The quantitative urine porphyrins revealed elevation of uroporphyrins, heptacarboxyl-porphyrins, hexacarboxy-porphyrins, pentacarboxyl-porphyrins and coproporphyrin. Genetic mutation of UROD was not detected. Due to the classic cutaneous lesions, laboratory findings, and associated risk factors, we were able to confirm our suspicion of the sporadic (type 1) form of PCT. CONCLUSIONS: A strong correlation has been demonstrated between the sporadic (type 1) form of PCT and hepatitis C virus (HCV) infection in multiple studies. The mechanism through which HCV infection may cause or trigger PCT is unknown. PCT has been described for many years, but still eludes the differential diagnosis in a patient with cutaneous findings. The uniqueness of our case is the possibility that combined risk factors have an effect on PCT.

Bird fanciers' lung induced by exposure to duck and goose feathers.

PATIENT: Female, 60 FINAL DIAGNOSIS: Bird fanciers' lung Symptoms: Cough productive • hypoxia • short of breath • substernal chest pain MEDICATION: - Clinical Procedure: - Specialty: - OBJECTIVE: Rare disease. BACKGROUND: Hypersensitivity pneumonitis (HP) is a group of inflammatory interstitial lung diseases caused by hypersensitivity reactions from repeated insults of inhalation of fine particulate organic dusts derived from environmental sources. Bird fanciers' lung (BFL) is the most common form of HP, with an estimated prevalence of 0.5-7.5% and is observed in individuals who develop a hypersensitivity response to avian droppings or antigens on bird feathers. CASE REPORT: A 60-year-old woman presented to our care with shortness of breath with exertion. She was hypoxic with oxygen saturation of 70% on room air. The CTA of the chest revealed a diffuse bilateral ground glass density in the lung parenchyma with a mosaic attenuation pattern. On further questioning she explained that she collected many duck and goose feathers she found on the ranch and placed them in a vase at home. Transbronchial lung biopsy revealed non-caseating granulomas, aggregates of epithelioid macrophages, and patchy mononuclear cell infiltration with lymphocytes and fibrotic tissue. The patient clinically improved and was discharged home on the 6(th) hospital day with prednisone 20 mg daily, with clinical improvement noted on subsequent follow up visits. CONCLUSIONS: There is no specific clinical manifestation; abnormal laboratory test results help establish a definitive diagnosis. The best diagnostic tool is the correlation of symptom onset with the environmental exposure. The prognosis is excellent after a single episode of HP, but continuous re-exposure carries the risk of progressive pulmonary impairment.

Chorea, Hyperglycemia, Basal Ganglia Syndrome (C-H-BG) in an uncontrolled diabetic patient with normal glucose levels on presentation.

PATIENT: Female, 66 FINAL DIAGNOSIS: Chorea • hyperglycemia • Basal Ganglia Syndrome (C-H-BG) Symptoms: Hemibalism • hemichorea MEDICATION: - Clinical Procedure: - Specialty: Endocrinology and Metabolic. OBJECTIVE: Challenging differential diagnosis. BACKGROUND: Hemichorea-hemiballism (HCHB) is a spectrum of involuntary, continuous non-patterned movement involving 1 side of the body. Possible causes of HCHB include hemorrhagic or ischemic stroke, neoplasm, systemic lupus erythematosus, HHNK, Wilson's disease, and thyrotoxicosis. This case illustrates the need to be aware of hyperglycemia as a cause of hemiballism/hemichorea, which is now referred to in the medical literature as C-H-BG (chorea, hyperglycemia, basal ganglia) syndrome. CASE REPORT: A 66-year-old Hispanic woman presented to our care with hemiballism/hemichorea of the right arm and leg of 1 week duration. She had been admitted 3 months prior with toxic metabolic encephalopathy secondary to hyperosmolar hyperglycemic non-ketotic syndrome with a blood glucose level of 984 mg/dL. Her blood glucose level was normal but hemoglobin A1C was 12.2%. A brain MRI revealed an asymmetric T1 hyperintensity of the left putamen. This specific finding was compatible with hyperglycemia-induced hemichorea hemiballism syndrome. The hemiballism/hemichorea slowly improved over the course of the hospitalization with strict glycemic control. At the 3-month follow-up visit she had no involuntary movements of her extremities, and she had well controlled blood glucose levels and a hemoglobin A1C of 9.0. CONCLUSIONS: In a patient with normal glycemic levels but a history of uncontrolled diabetes, C-H-BG syndrome should be on the top of the differential list when the characteristic MRI findings of a hyperintensity in the basal ganglia are observed. This is a rare disease that deserves attention because it is reversible with correction of hyperglycemia. Thus, prompt recognition and treatment is essential to avoid adverse outcomes.

Moyamoya in Hispanics: not Only in Japanese.

Moyamoya disease was first described in 1957 as hypoplasia of the bilateral internal carotid arteries, the characteristic appearance of the associated network of abnormally dilated collateral vessels on angiography was later likened to something hazy, like a puff of cigarette smoke, which, in Japanese, is moyamoya. This paper describes two cases of moyamoya presentations, including moyamoya disease and moyamoya syndrome. Moyamoya may rarely occur in North American Hispanic patients. The presentation can vary significantly and ranges bwtween fulminant outcome and prolonged survival. Awareness about moyamoya and its different presentations may be beneficial for the patients and can improve the outcome.

Idiopathic CD4+ lymphocytopenia in Hispanic male: case report and literature review.

INTRODUCTION: Idiopathic cluster of differentiation 4 (CD4+) T-cell lymphocytopenia (ICL) is a rare non human immunodeficiency virus (HIV)-related syndrome with unclear natural history and prognosis that was first reported and defined in 1992. ICL has been observed in patients after the onset of an opportunistic infection without known immunosuppression. CASE PRESENTATION: A 20-year-old Hispanic male patient without significant past medical history presented with progressive shortness of breath and cough for 3 weeks. Chest computed tomography showed bilateral cavitary lesions in the upper lung lobes. The HIV rapid screening test as well as the sputum acid-fast bacilli test were both positive. The patient was started on antituberculosis therapy. The CD4 count was noticed to be low. However, the HIV Western blot test was negative, and the HIV viral load was within normal limit. Further radiologic studies, hemato-oncologic, and autoimmune workups were normal. The patient was discharged on the treatment for tuberculosis. Follow-up after 8 weeks revealed a persistent low CD4+ count, and the repeated HIV tests were negative. CONCLUSION: The clinical features of ICL range from an asymptomatic condition to life-threatening complications that imitate the clinical course of HIV-infected patients. The differential diagnosis in adults comprises primarily HIV infection and other diseases or drug side effects. ICL is very rare and should be considered in the absence of any defined immunodeficiency or therapy associated with depressed levels of CD4+ T-cells. Early detection and recognition of the disease allow purposeful and systemic treatment approach and screening for the affected patients.

Sodium glucose co-transporter 2 (SGLT2) inhibition with canagliflozin in type 2 diabetes mellitus.

The sodium glucose cotransporter 2 (SGLT2) is expressed primarily in the kidneys and is involved in the reabsorption of filtered glucose in the renal tubule. Clinical trials of SGLT2 inhibitors in patients with type 2 diabetes mellitus demonstrate a significant clinical effect in decreasing serum glucose, hemoglobin A1C, body weight, systolic blood pressure, improving ß-cell function, and minimizing the risk of hypoglycemia. This report reviews the potentially beneficial effects of SGLT2 inhibitors in type 2 diabetes mellitus, specifically focusing on canagliflozin, the only SGLT2 inhibitor approved for use in the United States.