Allergic Polysensitization Clusters: Newly Recognized Severity Marker in Urban Asthmatic Adults.

INTRODUCTION: While reliable, quantitative in vitro testing for sensitivity to aeroallergens has been available for decades, such information has largely been ignored in clustering analyses of asthma. Our aim is to explore allergic polysensitization as a possible marker of asthma severity and, as such, to be considered as an integral marker in future asthma clustering analyses. METHODS: We constructed a database of sensitizations to the 25 aeroallergens in our geographic area (zone 1, Northeastern US) using the ImmunoCAP® in vitro assay. We used the Scikit-Learn® machine learning library for model-based clustering to identify allergic polysensitization clusters. Clusters were compared for differences in common office-based clinical markers of asthma. RESULTS: The database consisted of 509 patients. Unbiased machine learning identified ten clusters of increasing allergic polysensitization of varying sizes (n = 1-339) characterized by significant increases in mean serum immunoglobulin E (p < 0.001), peripheral blood eosinophil count (p < 0.001), and DLCO (p = 0.02). There was a significant decline in mean age at presentation (p < 0.001), FEV1/FVC (p = 0.01), and FEF25-75 (p = 0.002) with increasing allergic polysensitization. Finally, we identified two divergent paths for the poly-atopic march, one driven by perennial and the other by seasonal allergens. CONCLUSION: This pilot study showed that allergic polysensitization, using readily available qualitative and quantitative in vitro sensitization data, largely ignored in cluster analyses to date, may add further clinical precision in cluster analyses of asthma. We suggest the methods used here can be applied and tested using larger databases and aeroallergens present in diverse geographic regions.

Too much of a good thing: Immune reconstitution inflammatory syndrome in a patient with Still's disease.

Immune Reconstitution Inflammatory Syndrome (IRIS) is a potential complication when treating non HIV immunosuppressed patients with opportunistic infections. We present a case of a 49-year-old female with Adult-onset Still's disease on prednisone 40 mg daily who came to ED with right leg weakness and intractable headache for one week. She was diagnosed with Cryptococcus meningitis. Patient completed the induction phase of antifungal therapy and the steroids were tapered over four weeks. One month after discharge, a patient was brought in to ED, minimally responsive to verbal stimuli and had new left hemiparesis with persistent right leg weakness was noted on exam. An MRI of the brain was consistent with diffuse leptomeningeal enhancement compatible with meningoencephalitis. LP was notable for elevated opening pressure of 36cmH2O and CSF studies were negative for recurrence of cryptococcal infection. Given the timeline of patients presentation one month after discontinuation of steroids, and workup consistent with sterile meningitis, immune reconstitution inflammatory syndrome was identified as the likely diagnosis. The patient was started on 50 mg of Prednisone daily. Six weeks after presentation, the patient's mental status returned to baseline, left hemiparesis resolved, and right lower extremity strength significantly improved. Clinicians should have a high index of suspicion for CNS IRIS in patients presenting with new neurologic findings in the setting of rapid discontinuation of steroids due to infection. IRIS in HIV patients with cryptococcal meningitis is a well-established entity; the purpose of this case report is to bring attention to similar inflammatory syndrome in non-HIV patients with cryptococcal meningitis.

Osteoarthritis in a fifty-year-old patient with unfused skeleton due to undiagnosed coexisting cleidocranial and spondyloepiphyseal dysplasia - Case report.

Background: Skeletal dysplasia's cause significant neurological symptoms and disrupt the development of many bones and cartilages in the body. Skeletal dysplasia, although a common presentation in paediatric population, rarely presents in older age group. Case presentation: This case presents a unique incidental finding of skeletal dysplasia in a fifty-year-old male patient who presented with osteoarthritis. Eventual workup uncloaked the presence of cleidocranial dysplasia and spondyloepiphyseal dysplasia. The patient in this case had both dysplasias at the same time. Discussion: Cleidocranial dysplasia and Spondyloepiphyseal dysplasia are two uncommon autosomal dominant dysplasia's that are often diagnosed in early life and can have serious consequences, including death. It is critical to diagnose a child early in life. Radiology findings from a thorough skeletal examination aid in the early detection of numerous dysplasia's, which helps improving quality of life and allowing for effective treatment. Conclusion: The novelty of our presented case lies in the rare presentation of CCD and SED occurring concurrently at an older age with accompanying collateral abnormalities usually emerging more commonly in infants. Early diagnosis is thus essential for optimal management.

Post-acute COVID-19 syndrome and its prolonged effects: An updated systematic review.

Objective: This systematic review aimed at estimating the prevalence of post-acute COVID-19 symptoms in view of published literature that studied prolonged clinical manifestations after recovery from acute COVID-19 infection. Methods: Relevant databases were searched for extraction of articles. For data synthesis, based on the distribution of quantitative variables, they were expressed as mean ± standard deviation (SD) or median and interquartile range (IQR). Qualitative variables were presented as frequency (n) and percentages (%). Results: Twenty-one articles qualified for the final analysis. The most common persistent clinical manifestations were fatigue (54.11%), dyspnea (24.38%), alopecia (23.21%), hyperhidrosis (23.6%), insomnia (25.98%), anxiety (17.29%), and arthralgia (16.35%). In addition to these symptoms, new-onset hypertension, diabetes, neuropsychiatric disorders, and bladder incontinence were also reported. Conclusion: Clinical features of post-acute COVID-19 infection can manifest even after 60 days of initial infection. Multidisciplinary care along with regular follow-up must be provided to such patients.