Impact of urbanisation and environmental factors on spatial distribution of COVID-19 cases during the early phase of epidemic in Singapore.

Geographical weighted regression (GWR) can be used to explore the COVID-19 transmission pattern between cases. This study aimed to explore the influence from environmental and urbanisation factors, and the spatial relationship between epidemiologically-linked, unlinked and imported cases during the early phase of the epidemic in Singapore. Spatial relationships were evaluated with GWR modelling. Community COVID-19 cases with residential location reported from 21st January 2020 till 17th March 2020 were considered for analyses. Temperature, relative humidity, population density and urbanisation are the variables used as exploratory variables for analysis. ArcGIS was used to process the data and perform geospatial analyses. During the early phase of COVID-19 epidemic in Singapore, significant but weak correlation of temperature with COVID-19 incidence (significance 0.5-1.5) was observed in several sub-zones of Singapore. Correlations between humidity and incidence could not be established. Across sub-zones, high residential population density and high levels of urbanisation were associated with COVID-19 incidence. The incidence of COVID-19 case types (linked, unlinked and imported) within sub-zones varied differently, especially those in the western and north-eastern regions of Singapore. Areas with both high residential population density and high levels of urbanisation are potential risk factors for COVID-19 transmission. These findings provide further insights for directing appropriate resources to enhance infection prevention and control strategies to contain COVID-19 transmission.

Pericardial Effusion in Systemic Sarcoidosis: A Rare Manifestation of Cardiac Sarcoid.

We present a 65-year-old African American woman who was found to have pericardial effusion secondary to cardiac sarcoid. Pericardial effusion is a rare manifestation of cardiac sarcoid. All cases of sustemic sarcoid should be evaluated for cardiac involvement which can be difficult to detect.

An atypical presentation of POEMS syndrome with IgG kappa type M protein and normal VEGF level: Case report and review of literature.

POEMS syndrome is a multisystem disorder characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes. We present an atypical case of POEMS syndrome with subclinical polyneuropathy, splenomegaly, hypogonadism, and myeloma of immunoglobulin G kappa type. The typical osteosclerotic lesions and skin lesions were absent, and vascular endothelial growth factor (VEGF) level was normal. Our patient also had chronic kidney disease due to focal segmental glomerulosclerosis. The patient died due to multisystem complications nine months after presenting with acute on chronic renal failure. POEMS syndrome is an uncommon, potentially fatal paraneoplastic syndrome presenting with plasma cell neoplasm and multisystem involvement. Despite the normal VEGF level, our patient was diagnosed to have possible POEMS syndrome due to other clinical manifestations. It may be reasonable to expand the diagnostic criteria of POEMS syndrome if further atypical cases are reported in the future.

Cardiotoxicity associated with bortezomib: A single-center experience.

BACKGROUND: Studies evaluating the prevalence of cardiotoxicity associated with bortezomib are limited. We proposed this study to evaluate the prevalence of cardiotoxicity associated with bortezomib and its relation to multiple myeloma and other malignancies. MATERIALS AND METHODS: This is a retrospective, chart review study. Subjects who received bortezomib at the HealthEast care system for various oncologic conditions were evaluated after obtaining IRB approval. RESULTS: A total of 64 patients received bortezomib for various malignancies. Nine out of 64 (14%) patients developed cardiotoxicity during treatment with bortezomib, and the majority of these patients had a prior cardiac history and other cardiac risk factors. On further review, we did not find any significant causal relationship between these cardiac events and bortezomib. CONCLUSION: Cardiotoxicity is probably not related to bortezomib, even though there are some case reports suggestive of cardiac events related to bortezomib. Our findings need to be confirmed in multicenter, prospective studies.

Cerebral toxoplasmosis in a patient on methotrexate and infliximab for rheumatoid arthritis.

Cerebral toxoplasmosis is a rare disease predominantly found in immunocompromised hosts. However, cerebral toxoplasmosis has not been frequently described in association with the use of immunosuppressive medications. We herein report a case of cerebral toxoplasmosis in a 76-year-old Caucasian woman on methotrexate and infliximab for rheumatoid arthritis. The patient presented with right facial droop, slurred speech and difficulty walking. In addition to receiving methotrexate and infliximab and owning a cat, she had no other obvious risk factors. Imaging studies were not conclusive; however, brain biopsy confirmed the diagnosis. Serology was positive for anti-toxoplasma immunoglobulin G. Cerebral toxoplasmosis should be included in the differential diagnosis of patients under immunosuppressive medication who present with neurological manifestations.

Glioblastoma multiforme and papillary thyroid carcinoma - A rare combination of multiple primary malignancies.

We are describing a 19-year-old white woman who presented with two synchronous primary cancers, namely glioblastoma multiforme and papillary thyroid cancer. The patient was admitted with dizziness, headache, and vomiting. CT head revealed acute intraparenchymal hematoma in the right cingulate gyrus and the splenium of the corpus callosum. Carotid and cerebral angiogram were unremarkable. MRI of the brain demonstrated a non-enhancing and non-hemorrhagic component of the lesion along the lateral margin of the hemorrhage just medial to the atrium of the right lateral ventricle that was suspicious for a tumor or metastasis. Brain biopsy confirmed it as glioblastoma mutiforme. CT chest was done to rule out primary cancer that revealed a 11 mm hypodense lesion in the left lobe of the thyroid and ultrasound-guided fine-needle aspiration biopsy confirmed it as papillary thyroid carcinoma. We should evaluate for multiple primary malignancies in young patients who are found to have primary index cancer.

Spontaneous coronary artery dissection and acute myocardial infarction after cesarean section in a postpartum woman with untreated dyslipidemia.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI). We are presenting a case of a young woman with a history of untreated dyslipidemia presented with AMI secondary to left anterior descending coronary artery dissection during postpartum period. Physicians should be aware of this rare etiology of AMI which occurs during pregnancy and postpartum, since early diagnosis and treatment play a key role in saving both the mother and the baby. It is important to screen for other possible causes such as collagen vascular diseases, blunt injury to the chest, or cocaine abuse.

Effectiveness of d-dimer as a screening test for venous thromboembolism: an update.

Venous thromboembolism (VTE) is the leading cause of morbidity and mortality among hospitalized patients. We searched the PubMed database and reviewed the articles published until June 2011. Articles related to the D-dimer and VTE were considered to write this paper. Many factors play a key role in changing the sensitivity and specificity of D-dimer testing, including the extent of thrombosis and fibrinolytic activity, duration of symptoms, anticoagulant therapy, comorbidity due to surgical or medical illnesses, inflammatory diseases, cancer, elderly age, pregnancy and the postpartum period, and previous VTE. Many previous studies have shown that the D-dimer test is highly sensitive (>95%) in acute deep venous thrombosis or pulmonary embolism, usually with a cut-off value of 500 µg FEU/l, which reasonably rules out acute VTE, particularly in patients with low clinical probability (LCP) or intermediate clinical probability. Patients with high D-dimer levels upon presentation may prompt a more intense diagnostic approach, irrespective of pretest probability. Studies performed after a negative D-dimer for 3 months proved the high negative predictive value (NPV) of D-dimer testing together with LCP in patients with suspected VTE. Among oncology patients, D-dimer testing has the highest sensitivity and NPV in excluding VTE. The new cutoff values of D-dimer testing were analyzed in a recent prospective study of pregnant women; they are 286 ng DDU/ml, 457 ng DDU/ml, and 644 ng DDU/ml for the first, second, and third trimesters, respectively.

Spontaneous hemothorax associated with neurofibromatosis type I: A review of the literature.

Neurofibromatosis is generally a benign disease, but has the potential for rare and fatal complications, such as spontaneous hemothorax. We report a case of massive hemothorax due to neurofibroma in a 49-year-old woman with neurofibromatosis type 1. The configuration of the radiological opacity and frank blood withdrawn on thoracentesis should suggest the diagnosis of hemothorax in a patient with neurofibromatosis. Surgical treatment for hemothorax is limited by arterial fragility and the prognosis is relatively poor. Any evidence of aneurysmal disease in the thoracic vessels should be aggressively managed percutaneously by coil embolization to prevent future rupture.

A young patient with multisystem complications after cytomegalovirus infection.

We are describing a case of an 18-year-old male patient with cytomegalovirus (CMV) associated guillain-barre syndrome (GBS) who presented with an acute onset of generalized weakness and numbness in the extremities, dysphagia, and facial diplegia, followed by respiratory failure, which led to mechanical ventilation. He had positive immunoglobulin G and immunoglobulin M antibodies against CMV, and CMV polymerase chain reaction was positive with <2000 copies of deoxyribonucleic acid. Human immunodeficiency virus test was negative. He received a course of ganciclovir, intravenous immunoglobulin, and plasmapheresis. After improving from acute episode, patient was transferred to a rehabilitation facility for physical and occupational therapy. At the rehabilitation facility, he exhibited signs of acute abdomen with pain in the left upper quadrant secondary to peritonitis from dislodged gastrostomy tube and underwent exploratory laparotomy. During the hospital course he was found to have splenic infarct and colitis on the computed tomography of abdomen. This case showed an immunocompetent young patient with multisystem complications including guillain-barre syndrome (GBS), splenic infarct, hepatitis, and colitis due to CMV.

Brain and multiorgan metastases from uterine leiomyosarcoma.

A 59-year-old woman, diagnosed 7 years ago with uterine leiomyosarcoma (ULMS), developed several intrathoracic, pelvic and lately intra-abdominal and brain metastases. On each occasion, surgical resection was followed by a course of failed chemotherapy. Lately she presented with acute neurological deterioration and focal signs. Magnetic resonance imaging demonstrated two presumed brain parenchymal lesions involving the supratentorial and infratentorial compartments. She underwent surgical resection of the left cerebellar lesion. Histological analysis of the brain specimen confirmed the presence of metastatic ULMS. Leiomyosarcoma of the uterus is an uncommon tumor with a very aggressive course and poor prognosis. Multiple organ metastases from ULMS are an extremely rare condition, and prognostically alarming despite current treatments.

Fatal hypersensitivity pneumonitis associated with docetaxel.

We present a patient with advanced breast cancer treated with three cycles of docetaxel who developed repeated episodes of hypersensitivity pneumonitis, progressed to respiratory failure and death despite treatment with corticosteroids and supportive care. Docetaxel-induced hypersensitivity pneumonitis was diagnosed by excluding infection and tumor spread with bronchoalveolar lavage and lung biopsy. Physicians should consider such a condition in all patients who present with interstitial pneumonitis and respiratory failure when they are receiving docetaxel and treat them aggressively with steroids and supportive care, as it can be fatal.

Prevalence of iron overload in pediatric oncology patients after blood transfusion.

BACKGROUND: Studies evaluating the prevalence of iron overload and its relationship to blood transfusion in pediatric oncology patients are limited. METHODS: Medical records of all pediatric oncology patients treated at Roger Maris Cancer Center (Fargo, North Dakota) were screened. Subjects with measurements of serum ferritin levels after completion of therapy (N=52) were further evaluated. RESULTS: Of the total study population, 37 patients (71.2%) underwent red blood cell (RBC) transfusion and 15 patients (28.8%) did not. Among the transfused patients, 20 patients (54%) had elevated serum ferritin values greater than 250 ng/mL. Among the patients who did not undergo blood transfusion, only 1 patient (6.6%) had an elevated serum ferritin value (P<.01; Fischer exact test). None of the nontransfused patients had ferritin levels greater than 501 ng/mL. CONCLUSION: This study demonstrated that ferritin levels were more likely to be elevated in transfused patients than nontransfused patients. The number of subjects in this study was limited, and further prospective studies are needed.