[Cough in times of coronavirus]. / Husten in Corona-Zeiten.

The article describes the case of a hospitalized 58-year-old female patient with a chronic dry cough and increased inflammation values. Before hospital admission, the presence of coronavirus disease 2019 (COVID-19) was excluded by a normal chest X­ray and two negative PCR tests on throat swabs. On admission the only symptom was a dry cough with clinically inconspicuous auscultation findings. The laboratory investigations revealed anemia and increased inflammation parameters, e.g. C­reactive protein (CRP) 92.4 mg/l and erythrocyte sedimentation rate (ESR) 102 mm/h (according to Westergren). A large vessel vasculitis was demonstrated on magnetic resonance angiography (MRA). After the diagnosis of a giant cell arteritis, treatment with an oral glucocorticoid and subcutaneous methotrexate (MTX) was initiated, with good clinical and laboratory parameter responses. Dry cough has been described in rare cases in the literature as the first sign of large vessel vasculitis.

Elevated relapse rate under oral methotrexate versus leflunomide for maintenance of remission in Wegener's granulomatosis.

OBJECTIVES: Results from open-label trials suggest that methotrexate (MTX) and leflunomide (LEF) are effective for maintenance of remission in Wegener's granulomatosis (WG), but data from randomized controlled clinical trails are not yet available. METHODS: In this multicentre, prospective randomized controlled clinical trial, patients with generalized WG were treated either with oral LEF 30 mg/day or oral MTX (starting with 7.5 mg/week reaching 20 mg/week after 8 weeks) for 2 yrs following induction of remission with cyclophosphamide. The primary endpoint was the incidence of relapses. Secondary outcome parameters were DEI, BVAS, SF-36, cANCA-titre, ESR and CRP. RESULTS: Fifty-four patients were included in the study, 26 in the LEF-limb, 28 in the MTX-limb. In the LEF-group, six patients relapsed after a median time of 7 months, thereof one major relapse with a new pulmonary manifestation. In the MTX-group, 13 relapses occurred in 6 months, of which seven were major: rapidly progressive glomerulonephritis (n = 4), pulmonary haemorrhage (n = 2) and one cerebral granuloma. The significantly higher incidence of major relapses in the MTX-limb (P = 0.037) led to premature termination of the study. In the LEF-limb, four patients were withdrawn due to hypertension (n = 2), peripheral neuropathy (n = 1) and leucopenia (n = 1). CONCLUSION: LEF at a dosage of 30 mg/day appears to be effective in the prevention of major relapses in WG, however, this is associated with an increased frequency of adverse events. Further studies testing other dosing regimens of lower doses of LEF are needed to confirm these promising results in larger patients cohorts.

99mTechnetium pyrophosphate scintigraphy in the detection of skeletal muscle disease.

We aimed to assess the specificity and sensitivity of (99m)technetium pyrophosphate muscle scintigraphy in the diagnostic workup of patients with suspected myopathy. We reviewed the charts of 166 patients; 52% of the subjects had myalgias, 36% had muscle weakness, 45% had an elevated serum creatine kinase (CK), and 49% had an increased C reactive protein (CRP). Scintigraphy was positive in 34 patients (20%). The test was more sensitive in the presence of muscle weakness, elevated CK, or increased CRP. The presence of myalgias did not influence the odds. Sensitivity was 60% in patients with the final diagnosis of polymyositis, dermatomyositis, or inclusion body myositis, and 70% in noninflammatory myopathies. Eight percent had false positive scintigrams. In individuals with biopsy-proven myopathy (51 subjects), the diagnostic sensitivity was 43%, and its specificity was 60%. Low positive and high negative likelihood ratios (5.0 and 0.65, respectively) document an only limited diagnostic efficiency of (99m)Tc-PYP scintigraphy in the evaluation of inflammatory and noninflammatory myopathies and suggest that the test is not helpful in the routine diagnostic workup of muscle complaints, even after a priori selection of patients for CK plus CRP abnormalities.

Integrated head-thoracic vascular MRI at 3 T: assessment of cranial, cervical and thoracic involvement of giant cell arteritis.

Recently, high-resolution contrast-enhanced MRI has proven to be feasible for noninvasive diagnosis of giant cell arteritis in the cranium. In such examinations, thickening of the vessel wall and/or increased contrast enhancement demonstrate mural inflammation. Typically, the superficial cranial arteries with predominance of the superficial temporal artery are affected by the disease. However, giant cell arteritis can also involve other parts of the vascular system and an examination with extended coverage, including head, neck, and thorax would be advantageous. In this study, a novel approach for integrated head-thoracic vascular MRI at 3 T is presented. Combining first-pass imaging of a single-dose contrast agent with post-contrast imaging permits the assessment of both thoracic aortic geometry and wall, in addition to high-resolution head imaging needed for the analysis of the small superficial cranial arteries. Results from a patient feasibility study are presented and confirm that the protocol can successfully be completed in less than 40 min.

[Tissue-engineered cartilage in a prefabricated microvascularized flap]. / Gezüchtetes Knorpelgewebe in einem präfabrizierten, mikrovaskulären Lappen.

INTRODUCTION: In reconstructive surgery, the integration of tissue-engineered cartilage in a prefabricated free flap may make it possible to generate flaps combining a variety of tissue components to meet the special requirements of a particular defect. The aim of the present study was to establish the technique of prefabricating a microvascular free flap by implanting a vessel loop under a skin flap in a rabbit model. The second aim was to gather experience with prelaminating the flap with autologous tissue-engineered cartilage in terms of matrix development, inflammatory reaction and host-tissue interaction. METHODS: The microvascular flap was created by implanting a vessel loop under a random pattern abdominal skin flap. The tissue-engineered cartilage constructs were made by isolating chondrocytes from auricular biopsies. Following a period of amplification, the cells were seeded onto a non-woven scaffold made of a hyaluronic acid derivative and cultivated for 2-3 weeks. One cell-biomaterial construct was placed beneath the prefabricated flap, and the others were placed subcutaneously under the abdominal skin and intermuscularly at the lower extremity. In addition, a biomaterial sample without cells was placed subcutaneously as a control. All implanted specimens were left in position for 6 or 12 weeks. After explantation, the specimens were examined by histological and immunohistological methods. The prefabricated flap was analyzed by angiography. RESULTS: The prefabricated flaps showed a well-developed network of blood vessels formed by neovascularization between the implanted vessel loop and the original random-pattern blood supply. The tissue-engineered constructs remained stable in size and showed signs of tissue similar to hyaline cartilage, as evidenced by the expression of cartilage-specific collagen type II and proteoglycans. No hints of inflammatory reactions were observed. CONCLUSION: These results show the potential of prefabricated flaps as custom-made flaps for reconstructive surgery in difficult circumstances, more or less independent of anatomical prerequisites. Cartilage tissue engineering provides a 3-dimensional structure with minimal donor-site morbidity.