Management of central nervous system demyelinating diseases during the coronavirus disease 2019 pandemic: a practical approach / Manejo de doenças desmielinizantes do sistema nervoso central na pandemia de doença do coronavírus 2019: uma abordagem prática

ABSTRACT Background: The novel coronavirus disease 2019 (COVID-19) pandemic poses a potential threat to patients with autoimmune disorders, including multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). Such patients are usually treated with immunomodulatory or immunosuppressive agents, which may tamper with the organism's normal response to infections. Currently, no consensus has been reached on how to manage MS and NMOSD patients during the pandemic. Objective: To discuss strategies to manage those patients. Methods: We focus on how to 1) reduce COVID-19 infection risk, such as social distancing, telemedicine, and wider interval between laboratory testing/imaging; 2) manage relapses, such as avoiding treatment of mild relapse and using oral steroids; 3) manage disease-modifying therapies, such as preference for drugs associated with lower infection risk (interferons, glatiramer, teriflunomide, and natalizumab) and extended-interval dosing of natalizumab, when safe; 4) individualize the chosen MS induction-therapy (anti-CD20 monoclonal antibodies, alemtuzumab, and cladribine); 5) manage NMOSD preventive therapies, including initial therapy selection and current treatment maintenance; 6) manage MS/NMOSD patients infected with COVID-19. Conclusions: In the future, real-world case series of MS/NMOSD patients infected with COVID-19 will help us define the best management strategies. For the time being, we rely on expert experience and guidance.

RESUMO Introdução: A mais recente pandemia causada pelo coronavírus SARS-CoV-2 (COVID-19, do inglês coronavirus disease 2019) representa uma ameaça potencial para pacientes com doenças autoimunes, incluindo esclerose múltipla (EM) e transtorno do espectro de neuromielite óptica (NMOSD, do inglês neuromyelitis optica spectrum disorders). Esses pacientes são geralmente tratados com medicamentos imunomoduladores ou imunossupressores que podem alterar a resposta normal do organismo a infecções. Até o momento, não há consenso sobre como o manejo dos pacientes com EM e NMOSD deve ser realizado durante a pandemia. Objetivo: Discutir estratégias para manejar esses pacientes. Métodos: Focamos em como 1) reduzir o risco de infecção por COVID-19, como distanciamento social, telemedicina e exames laboratoriais e de imagem em intervalos mais amplos; 2) manejo de surtos, incluindo evitar tratamento de surto leve e uso de corticoide oral; 3) gerenciar terapias modificadoras de doença, como a preferência por medicamentos associados a menor risco de infecção (interferons, glatirâmer, teriflunomida e natalizumabe) e infusão em intervalo estendido de natalizumabe, quando seguro; 4) individualizar a escolha da terapia de indução para EM (anticorpos monoclonais anti-CD20, alentuzumabe e cladribina); 5) manejar terapias preventivas de NMOSD, incluindo seleção inicial de terapia e manutenção do tratamento atual; 6) manejar pacientes com EM/NMOSD que foram infectados por COVID-19. Conclusão: No futuro, séries de casos de pacientes com MS/NMOSD infectados com COVID-19 nos ajudará a definir as melhores estratégias de manejo. Por enquanto, contamos com a experiência e orientação especializadas.

Metronidazole-induced encephalopathy in a patient with Crohn's disease

Metronidazole is a widely used antibiotic for the treatment of anaerobic bacterial infections. Metronidazole-induced encephalopathy (MIEP) is a rare but potentially reversible disease. The mechanism of MIEP remains unclear, and differences in the neurotoxic effects of oral versus intravenous (IV) metronidazole administration have not yet been determined. We report the case of a Crohn's disease (CD) patient who experienced encephalopathy immediately after a single IV dose of metronidazole following long-term exposure to the oral form of the drug. The 64-year-old man with intractable CD experienced a sudden change in mental status, aphasia, and muscle weakness after IV administration of metronidazole. He had previously taken metronidazole orally for 13 years and received intermittent IV metronidazole treatments for CD exacerbation. Brain magnetic resonance imaging (MRI) showed high-intensity signals in the bilateral medial thalamus and the midbrain and pontine tegmentum on fluid-attenuated inversion recovery images. After discontinuation of metronidazole, the high-intensity brain MRI signals resolved and the patient's mental status dramatically improved; however, the patient exhibited mild cognitive dysfunction 2 months after the onset of encephalopathy.

Aripiprazole-induced Tardive Dyskinesia in 13 Years Old Girl Successfully Treated with Biperiden: A Case Report

In the last years second-generation antipsychotics are increasingly prescribed in the pediatric population for the treatment of several psychiatric disorders. Among the long term adverse effects, extrapyramidal symptoms (EPS) are less reported compared to first-generation antipsychotics. Tardive dyskinesia (TD) is a iatrogenic rare syndrome characterized by persistent slow writhing and sudden involuntary movements mainly involving the oral-buccal-lingual area with masticatory movements. We report a young girl with mood disorders accompanied by mild intellectual disability and behavioral problems who had TD after treatment with Aripiprazole, which responded to Biperiden therapy.

Differences and risk factors of regimen modification in acquired immunodeficiency syndrome patients who initiated antiretroviral treatment / 中华传染病杂志

Objective To compare the rates of regimen modification between patients with different initial antiretroviral therapy, and to investigate risk factors associated with drug toxicity-related regimen modification.Methods A two-years retrospective cohort study was conducted in 14 060 patients who initiated antiretroviral treatment with Zidovudine (AZT)/Tenofovir disoproxil (TDF)+Lamivudine (3TC)+Efavirenz (EFV) since 2012.There were 5 126 patients initiated TDF+3TC+EFV therapy (TDF group) and 8 934 patients initiated AZT+3TC+EFV therapy (AZT group).Chi-square test was used to compare the rate of first-line regimen modification and the rate of toxicity-related regimen modification between two groups.Cox proportional hazard model was used to investigate the risk factors associated with regimen modification.Results A total of 14 060 acquired immunodeficiency syndrome patients were observed for a median period of 1.85 person-years.There were 2 795 patients who changed their initial antiretroviral regimen and the rate of initial regimen modification was 19.9%.Two hundred patients who changed their initial regimen due to pregnancy were excluded.There were 2 070 patients in AZT group who changed their initial regimen with a rate of 23.5%.Among them, 1 652 patients changed their regimen due to drug toxicity and the rate was 18.8%.There were 525 patients in TDF group who changed their initial regimen with a rate of 10.4% and the rate of toxicity-related regimen modification was 6.2%.The differences between two groups were statistical significance (χ2=366.68 and 416.89, respectively, both P45 years old, BMI<18.5 kg/cm2 and baseline CD4+ T cell count<200/mL were risk factors associated with regimen modification.

Efectos adversos a largo plazo de los inhibidores de la bomba de protones: Perspectiva desde la medicina basada en la evidencia / Evidence Based Medicine Perspective on Long-Term Adverse Effects of Proton Pump Inhibitors

Los inhibidores de la bomba de protones (IBP) son los supresores de la secreción gástrica más efectivos y se encuentran entre los medicamentos de mayor formulación y venta en Estados Unidos; en algunos casos son prescritos sin indicación justificada. En años recientes, el reporte de reacciones adversas importantes relacionadas con su uso ha suscitado preocupación. Sin embargo, la calidad de la evidencia no ha sido concluyente y, en algunos casos, la magnitud del riesgo no es de importancia clínica. El objetivo de esta revisión es presentar la evidencia disponible frente a los eventos adversos de mayor importancia relacionados con los IBP

Proton pump inhibitors (PPIs) are the most effective gastric secretion suppressors and are among the most widely prescribed and widely available drugs in the United States of America. In some cases they are prescribed without justification. In recent years, concerns have arisen over reports of major adverse reactions related to the use of PPIs. However, the quality of the evidence has not been conclusive, and in some cases the magnitude of the risk has not been clinically significant. The objective of this review is to present the available evidence regarding the most important adverse events related to PPIs

Neurological symptoms in psoriasis patients under treatment with inlfiximab

Objective:To study the neurological symptoms of psoriasis patients who used infliximab. Methods: We studied psoriasis patients who used infliximab in two referral general hospitals in Tehran from January 2013 to January 2014. We completed neurological symptoms checklists by questioning the patients. Results: Sixty patients with psoriasis were included in this study. Among them, 3 patients had sensory symptoms as side effect and one patient showed motor symptoms as side effect. There was no statistically significant difference between age, gender, and session count with the sensory and motor side effects (P > 0.05). Conclusions: Neurological symptoms can be detected among 6% of patients under treatment with infliximab and there is no significant association between symptoms and gender, duration of drug use as well as age.

Neurological symptoms in psoriasis patients under treatment with infliximab

Objective: To study the neurological symptoms of psoriasis patients who used infliximab. Methods: We studied psoriasis patients who used infliximab in two referral general hospitals in Tehran from January 2013 to January 2014. We completed neurological symptoms checklists by questioning the patients. Results: Sixty patients with psoriasis were included in this study. Among them, 3 patients had sensory symptoms as side effect and one patient showed motor symptoms as side effect. There was no statistically significant difference between age, gender, and session count with the sensory and motor side effects ( P > 0.05). Conclusions: Neurological symptoms can be detected among 6% of patients under treatment with infliximab and there is no significant association between symptoms and gender, duration of drug use as well as age.

Recent evidence and potential mechanisms underlying weight gain and insulin resistance due to atypical antipsychotics

Objective: Atypical antipsychotics (AAPs) promote obesity and insulin resistance. In this regard, the main objective of this study was to present potential mechanisms and evidence concerning side effects of atypical antipsychotics in humans and rodents. Method: A systematic review of the literature was performed using the MEDLINE database. We checked the references of selected articles, review articles, and books on the subject. Results: This review provides consistent results concerning the side effects of olanzapine (OL) and clozapine (CLZ), whereas we found conflicting results related to other AAPs. Most studies involving humans describe the effects on body weight, adiposity, lipid profile, and blood glucose levels. However, it seems difficult to identify an animal model replicating the wide range of changes observed in humans. Animal lineage, route of administration, dose, and duration of treatment should be carefully chosen for the replication of the findings in humans. Conclusions: Patients undergoing treatment with AAPs are at higher risk of developing adverse metabolic changes. This increased risk must be taken into account when making decisions about treatment. The influence of AAPs on multiple systems is certainly the cause of such effects. Specifically, muscarinic and histaminergic pathways seem to play important roles. .

Depressive symptoms in HIV-infected patients treated with highly active antiretroviral therapy / Sintomas depressivos em pacientes infectados pelo HIV tratados por terapia antiretroviral altamente ativa

INTRODUCTION: The prevalence of depressive disorders in HIV-infected patients ranges from 12% to 66% and is undiagnosed in 50% to 60% of these patients. Depression in HIV-infected individuals may be associated with poor antiretroviral treatment (ART) outcomes, since it may direct influence compliance. OBJECTIVE: To assess the presence of symptoms and risk factors for depression in patients on ART. METHODS: Cross-sectional study. Certified interviewers administered questionnaires and the Beck Depression Inventory (BDI), and participants' self-reported compliance to ART. Clinical and laboratory variables were obtained from clinical records. Patients with BDI > 12 were defined as depressed. RESULTS Out of the 250 patients invited to participate, 246 (98%) consented. Mean age was 41 ± 9.9 years; most were male (63%). Income ranged from 0-14 Brazilian minimum wages. AIDS (CDC stage C) had been diagnosed in 97%, and 81% were in stable immune status. One hundred ninety-one (78%) reported compliance, and 161 (68%) had undetectable viral loads. The prevalence of depressive symptoms was 32% (95% CI 26-40). In multivariate analysis, depressive symptoms were significantly associated with income (prevalence ratio [PR] = 0.85; 95% CI 0.74-0.97; p = 0.02). CONCLUSIONS: Depressive symptoms are frequent in patients on ART, and are associated with low income.

INTRODUÇÃO:A prevalência de transtornos depressivos em pacientes infectados pelo HIV varia de 12% a 66% e não é diagnosticada em 50% a 60% desses pacientes. A depressão em indivíduos HIV positivo pode se associar a resultados fracos do tratamento antirretroviral (TAR) porque pode influenciar diretamente a aderência ao regime. OBJETIVO: Avaliar a presença de sintomas e de fatores de risco de depressão em pacientes em TAR. MÉTODOS: Estudo em corte transverso. Entrevistadores certificados administraram questionários e o Beck Depression Inventory (BDI), e os participantes fizeram o autorrelato da aderência ao TAR. Variáveis clínicas e laboratoriais foram obtidas dos prontuários clínicos. Os pacientes com escore ao BDI > 12 foram definidos como deprimidos. RESULTADOS: Dos 250 pacientes convidados a participar, 246 (98%) concordaram. A média de idade foi de 41 ± 9,9 anos; a maioria dos pacientes era do sexo masculino (63%). A renda variou de 0-14 salários mínimos brasileiros. A AIDS (estágio C dos CDC) havia sido diagnosticada em 97% e 81% estavam em estado imune estável. Dos pacientes, 191 (78%) relataram aderência e 161 (68%) tinham carga viral não detectável. A prevalência dos sintomas depressivos foi de 32% (IC 95% 26-40). Em análise multivariada, os sintomas depressivos se associaram significativamente à renda (razão de prevalência [RP] = 0,85, IC 95% 0,74-0,97; p = 0,02). CONCLUSÕES: Os sintomas depressivos são frequentes em pacientes em TAR e se associam a uma renda baixa.

Reacciones adversas de la vacuna Pandemrix contra la influenza A (H1N1) en el municipio de II Frente Oriental / Side effects of Pandemrix vaccine against A (H1N1) influenza in II Frente Oriental municipality

Se analizaron las principales reacciones adversas de la vacuna Pandemrix contra la influenza A (H1N1) en el municipio de II Frente Oriental, provincia de Santiago de Cuba, en el bimestre abril-mayo de 2010, dadas fundamentalmente por: cefalea, fiebre, trastornos gastrointestinales y dolor en el sitio de la inyección, en consonancia con lo descrito en otros documentos al respecto.

The main side effects of Pandemrix vaccine against A (H1N1) influenza in II Frente Oriental municipality from Santiago de Cuba province were analyzed during the two-month period April-May, 2010. Cephalea, fever, gastrointestinal disorders, and pain on the injection site were more frequent, with respect to what was described in other documents.

Propylthiouracil-induced Diffuse Pulmonary Hemorrhage: A Case Report with the Clinical and Radiologic Findings

Propylthiouracil (PTU) is a drug that's used to manage hyperthyroidism and it can, on rare occasions, induce antineutrophil cytoplasmic antibody-associated vasculitis that involves multiple organ systems and it can also cause extremely rare isolated or diffuse pulmonary hemorrhage. We report here on a case of a patient who developed diffuse pulmonary hemorrhage after she had been taking PTU for five years. The patient is a 33-year-old woman who presented with hemoptysis. Simple chest radiographs and the chest CT showed bilateral ground-glass opacity, consolidation and pulmonary arterial hypertension. The bronchoalveolar lavage fluid revealed alveolar hemorrhage. The laboratory values showed increased perinuclear-antineutrophil cytoplasmic antibody (p-ANCA) and anti-peroxidase antibody titers.