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Protein S is a multifunctional plasma protein, whose deficiency, results in a rare congenital thrombophilia, inherited in an autosomal dominant pattern. It can aggravate the hypercoagulable state of pregnancy, when it presents in parallel with the condition, leading to adverse maternal outcomes and foetal loss. A 35-year-old female third gravida having previous 2 deliveries by Lower Segment Caesarean Section (LSCS) presented to emergency at 10 weeks pregnancy with chief complaints of pain and swelling in left thigh since 4-5 days. After thorough investigations and work-up, the patient was diagnosed with Protein S deficiency. She was managed conservatively and was delivered by elective LSCS with bilateral tubal ligation at 38 weeks of gestation with good foetal and maternal outcomes.The rarity of Protein S deficiency along with the successful outcome of the pregnancy makes this a unique case.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.
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Introduction: Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by pulmonary artery aneurysms (PAA) and widespread venous and arterial thrombosis. Fatalities in HSS resulted from unforeseeable fatal suffocating hemoptysis. It is critical to early detect pulmonary involvement to take timely measures against inevitable serious life-threatening complications. Case presentation: A 27 year old Filipino male patient presented to the emergency department with an acute attack of massive hemoptysis. The markers of inflammation were elevated with anemia and a normal coagulation profile. The patient had bilateral lower limb edema with tender calf muscles. Color Doppler ultrasound revealed bilateral deep vein thrombosis. Importantly, an urgent computerized tomography pulmonary angiography (CTPA) revealed bilateral large PAAs which matched the pattern of pseudoaneurysms described by the HSS international study group (HSSISG). There was no history of iridocyclitis, recurrent oral or genital ulcers. Accordingly, the patient was diagnosed with HSS. The patient received intravenous pulse methylprednisolone (1 g/3 days), then oral prednisone (1 mg/kg/d/3 months), and monthly pulse cyclophosphamide (1 g) for three months. The patient remained symptom-free, yet on the third pulse of cyclophosphamide;he patient contracted corona virus disease-2019 (COVID-19) infection and died three weeks later from a fatal episode of massive hemoptysis. The case was discussed and the recent literature was reviewed relative to fatal hemoptysis associated with pulmonary artery pseudoaneurysms (PAPs) pattern in HSS Conclusion(s): HSS presenting with massive hemoptysis could be lifethreatening and the PAPs are considered a double edged sword. Detailed description of such rare cases is warranted for optimum future management.Copyright © 2023
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Aim/Introduction: The etiology of SAT (subacute thyroiditis) is presumed to be usually viral (most commonly associated viruses include enterovirus, coxsackievirus, mumps, measles, and adenovirus). In this pandemic era, prevalence of SAT associated with the COVID 19 seems to be increasing either during or after the course of disease, characterized by neck pain or discomfort, goiter and transient hyperthyroidism. However, this is usually missed due to the wide spectrum of COVID syndrome, and a simple thyroid scan can be instrumental in diagnosing related thyroiditis. Material(s) and Method(s): We report 3 (1 male, 2 females) cases of thyroiditis detected using Tc99m pertechnetate scan. Thyroid scan was done 20 minutes after injection of 5 milicuries (170 MBq) of Tc99m pertechnetate and planar images were acquired. Result(s): 3 (1 male, 2 females) cases of thyroiditis detected using Tc99m pertechnetate scan. Mean age was 36.3 years. Symptoms such as goiter (n=1), neck pain and tenderness (n=2), weakness and fatiguability (n=3), palpitations (n=2), heat intolerance (n=1), restlessness (n=2) were observed along with raised T3, T4 hormone levels and suppressed TSH, 3-4 months after COVID infection (mean duration 3.3 months). Other possible causes of thyroiditis and drug interference were ruled out. Thyroid scan images revealed faint or absent tracer uptake in thyroid gland. Conclusion(s): The affinity of SARS-Cov-2 to the thyroid gland has been presumed via the ACE2 receptors which are more prevalent in thyroid cells than lung cells. Inflammatory response and apoptosis is another proposed factor. Ultrasound will show a normal or enlarged thyroid but typically, diffusely, or focally hypoechogenic, and the color Doppler sonography will demonstrate low flow but thyroid scan is easier to perform, is less user dependent and carries more diagnostic value. COVID related thyroiditis can present months after infection and is a part of long COVID syndrome. Possibility of post immunization also exists. Thyroid scan can be widely used in these scenarios.
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Background: Treatment of deep venous system obstruction of the lower limb is a challenge. There are few cases described in the literature even less with long-term follow-up which justifies this presentation. The objective is to report the case of a patient who underwent the May-Husni procedure for the treatment of femoral vein obstruction secondary to a stab wound with a 24-year follow-up. Method(s): Case report. Result(s): A 37-year-old male was stabbed in the left groin causing major bleeding and was operated on immediately 8 years ago. Since then he complained of edema, pigmentation, dermatofibrosis and recurrent ulcers in the left lower limb. Phlebography revealed femoral vein occluded from Hunter's canal to the saphenofemoral junction, obstruction of femoral vein, insufficient leg perforators, collateral venous circulation;the great saphenous vein (GSV) and external iliac vein were patent. He was operated on in 1997 and the left GSV was anastomosed to the popliteal vein above the knee (May-Husni procedure). The ulcers healed after 3 months with the help of compression therapy. After 18 months ulcer recurred. Echo color-doppler (ECD) showed four dilated perforating veins and patent saphenopopliteal anastomosis. Endoscopic subfascial perforation surgery (SEPS) was performed: The ulcer healed after 15 days. In 2019, another ulcer recurrence. During these 20 years patient became obese, diabetic and hypertensive. The ECD showed the saphenopopliteal anastomosis patent and GSV dilatated (11.4 mm) and insufficient with an insufficient dilated tributary in the middle third of the thigh finding several leg varicose tributaries.Ultrasound-guided foam sclerotherapy (UGFS) was performed under pharmacological prophylaxis for deep vein thrombosis (DVT) followed by compression therapy. The ulcer healed after one month. Patient was followed up until 2021 when he died of COVID-19. Conclusion(s): The ligation of veins in the deep venous system (DVS) can trigger severe manifestation and segmental obstructions should be restored;these restorations may have a high success rate and are durable;the patient must be accompanied throughout his life and treated as soon as the first signs of chronic venous disease appear.
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Introduction Objective evaluation of treatment response is the gold standard in ulcerative colitis (UC). In this setting, intestinal ultrasound (IUS) is a non-invasive alternative to endoscopy. Recent studies showed change in IUS parameters after treatment initiation but studies with an endoscopic reference standard are scarce. The aim of this study was to evaluate early change of IUS parameters and determine cut-off values for endoscopic endpoints in UC patients starting anti-inflammatory treatment. Methods In this longitudinal prospective study consecutive patients with moderate-severe UC (baseline endoscopic Mayo score (EMS)≥2) starting an anti-inflammatory treatment were included. Clinical scores, biochemical parameters and IUS parameters were collected at baseline, after 2 (T1), 6 (T2) and 8-26 weeks (T3) around time of the second sigmoidoscopy/colonoscopy. Bowel wall thickness (BWT), Colour Doppler signal (CDS), haustrations, inflammatory fat and wall layer stratification were measured as previously established1. Endoscopic remission (ER) and mucosal healing (MH) were evaluated in the sigmoid and defined as EMS=0 and EMS≤1, respectively. The ultrasonographist and endoscopist were blinded for the outcomes of endoscopy and IUS, respectively. Results 51 consecutive patients were included (Table 1) of whom 31 underwent a second endoscopy. Two additional patients underwent colectomy and were considered non-responders. 18 patients did not undergo second endoscopy due to the COVID-19 pandemic (n=2), refusal (n=5), loss to follow-up (n=1) or treatment escalation because of clinical deterioration confirmed by IUS and biomarkers before second endoscopy was performed (n=10). BWT was significantly lower from T2 onwards in patients reaching MH (p=0.026) and ER (p=0.002) at T3 (Fig 1). A significant decrease in BWT was already visible at T1 in patients receiving infliximab (median DBWT T0-T1: -26% [-43% - -6%], p=0.001) or tofacitinib (median ∆BWT T0-T1: -33% [-46% - -5%], p=0.001) but not in patients treated with vedolizumab (median ∆BWT T0-T1: -14% [-43% - 5%], p=0.11). Most accurate BWT cut-off values at T3 to determine MH and ER were 3.52 mm (AUROC: 0.95, 95% CI: 0.86-1.00, p<0.0001, sens:91%, spec:91%) and 2.98 mm (AUROC: 0.94, 95% CI: 0.85-1.00, p=0.001, sens:87%, spec:100%), respectively. At T2, BWT per 1 mm increase and CDS were inversely associated with MH (BWT: OR: 0.48 (0.24-0.96, p=0.038);CDS: OR 0.16 (0.03-0.83), p=0.028) and ER (BWT: OR: 0.30 (0.11-0.76), p=0.01). Conclusion BWT and CDS 6 weeks after start of treatment could predict MH and ER. In addition, treatment response at IUS is drug-specific. Furthermore, we have provided accurate BWT cut-off values for endoscopic outcomes. In a point-of-care setting, (early) treatment evaluation with IUS could guide treatment decision in UC in order to optimize treatment response. 1. Bots et al. JCC 2021
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Introduction & Objectives: COVID-19 infection is hypothesized to have a potentially negative effect on male fertility through direct damage to the testes. The current trial is aimed at investigating the effect of SARS-CoV-2 on fertility and determining if viral bodies directly damage testicularfunction.Materials & Methods: This prospective study included controls comprising healthy participants and cases of patients suffering from pneumoniabased on chest CT and a positive of SARS-CoV-2 throat swab exhibited only moderate symptoms in accordance with the WHO classification.Extensive epidemiological, clinical, laboratory (hormonal levels, etc.) and ultrasound data (color doppler ultrasound of the scrotum) were collected. Asperm examination was performed in cases during their COVID-19 related hospital stay and 3 months after the discharge home. We also assessedthe testicles of COVID-19 patients who died of their disease (n=20) obtained during autopsies.Results: A total of 88 participants were included (44 controls and 44 cases). Blood testosterone levels were below normal (local reference values,5-50 nmol/ml) in 27.3% of the cases (12/44). The mean level (7.3±2.7 nmol/ml) was lower than that in the healthy controls (13.5±5.2 nmol/ml,p<0.001). At 3 months after discharge, the level returned to normal (13.7±4.5 nmol/ml) and was no different from that of the controls. An increase inLH and FSH was also detected compared to the healthy controls (p=0.047 and p=0.002). The spermogram revealed decreased motility in COVID-19patients (p=0.001), and higher number of immobile sperm (during COVID-19 – 58.8% and at 3 months 47.4%, p=0.005). All these parametersreturned to normal at 3 months after discharge. As for pathology findings, in the majority of autopsies (18/20) structural disorders of the testiculartissue, with signs of damage to germ cells were observed.Conclusions: COVID-19 and its treatment significantly affect hormone levels and sperm quality during the disease. Postmortem examinationconfirms inflammation and viral infiltration of the testicles. However, in those who had moderate to severe disease, decline in hormone levels andsperm quality was transient with values returning to baseline at 3 months
ABSTRACT
Background: Objective evaluation of treatment response is the gold standard in ulcerative colitis (UC). In this setting, intestinal ultrasound (IUS) is a non-invasive alternative to endoscopy. Recent studies showed change in IUS parameters after treatment initiation but studies with an endoscopic reference standard are scarce. The aim of this study was to evaluate early change of IUS parameters and determine cut-off values for endoscopic endpoints in UC patients starting anti-inflammatory treatment. Methods: In this longitudinal prospective study consecutive patients with moderate-severe UC (baseline endoscopic Mayo score (EMS)≥2) starting an anti-inflammatory treatment were included. Clinical scores, biochemical parameters and IUS parameters were collected at baseline, after 2 (T1), 6 (T2) and 8-26 weeks (T3) around time of the second sigmoidoscopy/colonoscopy. IUS parameters were measured as previously established1. Endoscopic remission (ER) and mucosal healing (MH) were evaluated in the sigmoid and defined as EMS=0 and EMS≤1, respectively. The ultrasonographist and endoscopist were blinded for the outcomes of endoscopy and IUS, respectively. Results: 51 consecutive patients were included (Table 1) of whom 31 underwent a second endoscopy (MH: n=15 (45%), ER: n=9 (27%)). Two additional patients underwent colectomy and were considered non-responders. 18 patients did not undergo second endoscopy due to the COVID-19 pandemic (n=2), refusal (n=5), loss to follow-up (n=1) or treatment escalation because of clinical deterioration confirmed by IUS and biomarkers before second endoscopy was performed (n=10). Bowel wall thickness (BWT) was significantly lower from T2 onwards in patients reaching MH (p=0.026) and ER (p=0.002) at T3 (Fig 1). A significant decrease in BWT was already visible at T1 in patients receiving infliximab (p=0.001) or tofacitinib (p=0.007), but not in patients treated with vedolizumab (p=0.11) (Fig 2). Most accurate BWT cut-off values at T3 to determine MH and ER were 3.52 mm (AUROC: 0.95, 95% CI: 0.86-1.00, p<0.0001, sens: 91%, spec: 91%) and 2.98 mm (AUROC: 0.94, 95% CI: 0.85-1.00, p=0.001, sens: 87%, spec: 100%), respectively. Other IUS parameters at T3 did not improve association with MH or ER. IUS parameters at T2 that predict MH and ER are demonstrated in Table 2. Conclusion: BWT and Colour Doppler Signal 6 weeks after start of treatment are associated with and could predict MH and ER. In addition, treatment response patterns at IUS are drug-specific. Furthermore, we have provided accurate BWT cut-off values for endoscopic outcomes. In a point-of-care setting, (early) treatment evaluation with IUS could guide treatment decision in UC in order to optimize treatment response.