MENINGO-ENCEPHALITIS IN A MIDDLE-AGED WOMAN HOSPITALIZED FOR COVID-19.

OBJECTIVE: The aim: To pay attention of clinicians to possible lesions of the central nervous system (encephalitis) in patients with COVID-19. PATIENTS AND METHODS: Case presentation: A 44-year-old woman was admitted to our clinic because of 2-month-history of mild fever, bilateral lower lobe pneumonia, respiratory failure, generalized weakness, and some neurologic symptoms. SARS-CoV-2 RNA was detected in nasopharyngeal swab. Chest CT demonstrated bilateral pulmonary poly segmental consolidations in the mid and lower zones. Focal hyper intensive abnormalities in various parts of the left hemisphere were found at MR brain imaging in T2WI, and T2 FLAIR mode. Cerebrospinal fluid (CSF) examination showed a white cell count of 31/uL (normal <5/uL), protein 0.73 g/L (0.15-0.45), and glucose 1.4 mmole/L (2.2-3.9). Standard CSF neuroviral PCR panel and PCR for SARS-CoV-2 were negative. She was treated with ganciclovir, and dexamethasone. Due to suspected tuberculosis meningitis (cytosis, decreased level of protein and glucose), she also received ex juvantibus a course of anti-TB therapy (isoniazid, kanamycin, and levofloxacin) and made a steady improvement. CONCLUSION: Conclusion: This case shows that SARS-CoV-2 in association with other pathogens may cause various lesions of the CNS accompanied by severe neurological manifestations in adults.

Influence of Alumina Addition on the Optical Properties and the Thermal Stability of Titania Thin Films and Inverse Opals Produced by Atomic Layer Deposition.

TiO2 thin films deposited by atomic layer deposition (ALD) at low temperatures (<100 °C) are, in general, amorphous and exhibit a smaller refractive index in comparison to their crystalline counterparts. Nonetheless, low-temperature ALD is needed when the substrates or templates are based on polymeric materials, as the deposition has to be performed below their glass transition or melting temperatures. This is the case for photonic crystals generated via ALD infiltration of self-assembled polystyrene templates. When heated up, crystal phase transformations take place in the thin films or photonic structures, and the accompanying volume reduction as well as the burn-out of residual impurities can lead to mechanical instability. The introduction of cation doping (e.g., Al or Nb) in bulk TiO2 parts is known to alter phase transitions and to stabilize crystalline phases. In this work, we have developed low-temperature ALD super-cycles to introduce Al2O3 into TiO2 thin films and photonic crystals. The aluminum oxide content was adjusted by varying the TiO2:Al2O3 internal loop ratio within the ALD super-cycle. Both thin films and inverse opal photonic crystal structures were subjected to thermal treatments ranging from 200 to 1200 °C and were characterized by in- and ex-situ X-ray diffraction, spectroscopic ellipsometry, and spectroscopic reflectance measurements. The results show that the introduction of alumina affects the crystallization and phase transition temperatures of titania as well as the optical properties of the inverse opal photonic crystals (iPhC). The thermal stability of the titania iPhCs was increased by the alumina introduction, maintaining their photonic bandgap even after heat treatment at 900 °C and outperforming the pure titania, with the best results being achieved with the super-cycles corresponding to an estimated alumina content of 26 wt.%.

A RARE BRAINSTEM INFLAMMATORY SYNDROME, CLIPPERS, MYTH OR FACT. CASE REPORT WITH CRITICAL REVIEW.

A very rare inflammatory disease of CNS, CLIPPERS syndrome, was recently described and only a few sporadic cases are reported in the medical literature. Its etiology and pathogenesis are unknown, that together with the polymorphic and sometimes confounding neurological manifestations, and radiological findings represent a real diagnostic and therapeutic challenge for clinicians. Aim: To highlight the importance of clear and specific diagnostic assessment. Here we present the case of a 40-year-old male with a subacute lymphocytic midbrain inflammation accompanied by vasculitis. We discuss the symptoms, imaging and treatment of this lesion.

Inverse design and demonstration of high-performance wide-angle diffractive optical elements.

Diffractive optical elements are ultra-thin optical components required for constructing very compact optical 3D sensors. However, the required wide-angle diffractive 2D fan-out gratings have been elusive due to design challenges. Here, we introduce a new strategy for optimizing such high-performance and wide-angle diffractive optical elements, offering unprecedented control over the power distribution among the desired diffraction orders with only low requirements with respect to computational power. The microstructure surfaces were designed by an iterative gradient optimization procedure based on an adjoint-state method, capable to account for application-dependent target functions while ensuring compatibility with existing fabrication processes. The results of the experimental characterization confirm the simulated tailored power distributions and optical efficiencies of the fabricated elements.

Subacute enterovirus-associated encephalitis in a young adult coinfected with borrelia burgdorferI.

OBJECTIVE: The aim: To pay attention of clinicians to sterile encephalitis in adults, which in fact may be caused by EVs. RESULTS: Results: A young woman was admitted to our clinic because of 3-month-history of mild fever, left-sided soft facial paralysis, and generalized weakness. MR brain imaging in T2W, FLAIR, and T1W mode showed focal hyper intensive abnormalities in various parts of the left hemisphere. EV RNA was detected in the patient's CSF on admission. IgM class antibodies to B.burgdorferi were present in the blood. Antibiotics and ribavirin have been administrated with a good effect. CONCLUSION: Conclusion: This case shows that EV infection may cause brainstem encephalitis accompanied by severe neurological manifestations in adults.

A CASE OF MRI-NEGATIVE HERPES VIRUS ENCEPHALITIS PRESENTED BY RAMSAY HUNT SYNDROME.

Ramsay Hunt syndrome (RHS) occurs due to reactivation of latent Varicella Zoster Virus (VZV) infection in the geniculate ganglion of the facial nerve. Major clinical symptoms include ipsilateral facial paralysis, otic pain, and herpetic vesicles (rashes) along the nerve with accompanying ear pain. Rarely clinical findings include retrograde transaxonal spread of the virus from the ganglion into the brain parenchyma with developing the encephalitis or multiple cranial nerve involvement. We describe here a patient with both RHS along with complicating brainstem encephalitis developed due to the coinfection of VZV and EBV.

Varicella-zoster virus cns disease clinical features in ukrainian patients. prospective study.

OBJECTIVE: Introduction: Herpes zoster (HZ), or shingles, is localized disease characterized by unilateral radicular pain and a vesicular rash limited to the area of skin innervated by a single dorsal root or cranial sensory ganglion. Whereas varicella, or chickenpox, results from primary exogenous varicella-zoster virus (VZV) infection, HZ is caused by reactivation of endogenous VZV that has persisted in latent form within sensory ganglia following an earlier episode of chickenpox. The aim: To explore the clinical features, diagnosis, and treatment of CNS injury caused by VZV infection in a prospective single center study from January 2014 to January 2018. PATIENTS AND METHODS: Materials and methods: 117 adult patients, among which young women predominated with confirmed VZV infection were analyzed in the study. CSF and blood contents, antibody for herpes zoster M and G classes, and MRI scans have been studied, but the crucial diagnostic sign was the presence of specific viral DNA in the CSF or blood. The main clinical manifestations of the disease were ganglionitis and ganglioradiculoneuritis. Another brain lesion like uveitis, encephalitis and vasculitis were observed also. A clinical case of an unusual course of VZV-infection is given. RESULTS: Results and conclusions: The most common clinical variants of HZ were ganglionitis (69.7%). Cranial localization was observed in 31% of patients, spinal one - in 38.7%, injury to the meninges was found in 16.3% of patients.

HIV/AIDS in the guise of a demyelinating disease.

OBJECTIVE: Introduction: A significant part of patients with HIV / AIDS develops damage to the nervous system. There are also cases where opportunistic infections of the nervous system, especially herpes viral origin, can hide the underlying disease, making it difficult diagnosis. The aim: To show the possibility of HIV infection mimicry a neurological pathology. PATIENTS AND METHODS: Clinical case: A 41-years-old female presented to The Cеntег of Infectious disorders of the Nervous System (Kyiv, Ukraine) in August, 2018 after developing acute fever following by a left side hemiparesis, violation of coordination. Tuberculosis and HIV denied. Her physical examination showed tremor in her hands during a Barre-probe. She performed the coordination tests with intent, staggering in the Romberg pose. A small brain lesion was revealed at MRI. Antibodies to HSV1/2, CMV, Tox. gondii were found in the CSF and blood. Blood PCR was reported to be positive for EBV DNA, and HCV RNA. A rapid HIV test was negative. A repeated blood test performed 10 days after admission showed low level of CD4+ T cells (36 cells /1 µl), and HIV RNA (850,104 cp / ml). HIV antibodies were also revealed. As a result, patient was transferred to a specialized department for further treatment. CONCLUSION: Conclusion: Considering high clinical polymorphism of HIV/AIDS, physicians of all specialties should be alert for the possible neurologic manifestations of this disease to timely examine patients.

Diagnostic value of specific antibody synthesis in brain of patients with neuroinfections

Introduction: Viral encephalitis accounts for 40-70% of all cases worldwide, central nervous system infections pose a diagnostic challenge because clinical manifestations are not typically pathognomonic for specific pathogens, and a wide range of agents can be causative. The aim: To assess the diagnostic value of intrathecal synthesis of specific antibodies in patients with inflammatory lesions of the central nervous system. Material and methods: Within the framework of the study, two groups of 90 people in each were formed from the patients with neuroinfections admitted to our Center. Intrathecal synthesis (ITS) of total (unspecific) IgG in members of one of group (group of compare) was determined. Brain synthesis of specific antibodies (Ab) to some neurotropic pathogens (herpes simplex virus 1/2, cytomegalovirus, Epstein-Barr virus, varicella zoster virus, rubella virus, Borrelies) was studied in the second group of patients (group of interest). There were no statistically significant differences between groups by gender and age. Encephalitis and encephalomyelitis prevailed among patients of both groups. Results: ITS of total IgG was established in 30 (33.3 ± 6.1 %) patients of the first group with IgG index more than 0.6 indicating on inflammatory process in CNS and no marked changes of CSF. ITS of specific Ab was determined in 23 of 90 (25.6 ± 4.6 %) patients included into group of interest. In more than half of cases Ab to several infectious agents were detected simultaneously. ITS of various specificity, in particular, to measles and rubella viruses, and VZV, known as MRZ-reaction, is characteristic of some autoimmune lesions of CNS, multiple sclerosis first of all. In fact, further research of 5 patients with MRZ-reaction confirmed their autoimmune failure of CNS. Detection of ITS in the CSF samples didn't depend on concentration of specific Ab in serum and CSF and wasn't followed by HEB dysfunctions which were observed with the same frequency in patients with or without ITS (13.0 % and 13.6 % respectively). Conclusions: Specific Ab synthesis to several neurotropic pathogens in the CSF of significant part of examined patients was established. Thus, diagnostic value of ITS of specific immunoglobulins seems to be limited to cases in which autoimmune damage of the CNS is suspected.

Effect of probiotics on altered gut microflora in patients with severe systemic inflammatory response syndrome.

OBJECTIVE: The aim: To estimate intestinal microbial changes and study the efficacy of probiotic preparations in systemic inflammation. PATIENTS AND METHODS: Materials and methods: The study involved 202 patients with chronic infections various sites, including 58 (28.7 %) patients with respiratory tract infections, 56 (27.7 %) patients with infections of the genitourinary system, 48 (23.7%) - with purulent inflammatory postoperative complications, and 40 HIV-infected patients. We studied the quantitative and qualitative composition of intestinal microflora on the background correction of probiotic preparations. RESULTS: Results: We have found quantitative and qualitative changes of intestinal microflora in all patients with chronic infections. Dysbiotic changes manifested in reducing the number of major orders symbionts (Lactobacillus spp., Bifidobacterium spp, Escherichia coli with normal enzymatic properties) and increase the number of pathogenic microorganisms (Staphylococcus aureus, Clostridium spp., Candida spp.). In all study groups after using probiotics, the number of pathogenic microorganisms (S. aureus, S. saprophyticus, S. epidermidis, C. albicans, and Cl. perfringens) were decreased and tended to restore normal range of microbial landscape. CONCLUSION: Conclusion: So, dysbiotic disorders of the intestine in patients with chronic inflammation characterized by decrease in the number of basic gut symbionts and reducing its protective properties that accompanied the advent of pathogenic microorganisms. In our study probiotics demonstrated statistically significant improvements in the qualitative and quantitative composition of microflora.

Ukrainian priorities for herpesvirus infections that affect the central nervous system.

OBJECTIVE: Introduction: Herpesviruses (HVs) are ubiquitous pathogens that infect humans usually during childhood, followed by a life-long persistence in a latent state in many sites of a body including the nerve cells. After reactivation HVs can affect the Central Nervous System (CNS) becoming a major cause of morbidity and mortality worldwide as well as long-term neurological sequelae. Despite being an important public health problem very few population-based studies were conducted so far in the world and none in Ukraine. The aim: to explore the clinical features and etiology of herpesvirus encephalitis (HVE) in a prospective single center study from January 2014 to January 2017. PATIENTS AND METHODS: Materials and methods: 107 adult patients with confirmed herpesvirus infection and symptoms of possible encephalitis (CNS lesion) were analyzed in the study. CSF and blood contents, antibody for HVs M and G classes, and MRI scans have been studied, but the crucial diagnostic sign was the presence of specific viral DNA in the CSF or blood. RESULTS: Results: 74 (69.3%) out of 107 patients were females, the male to female ratio was 1:2.2. The median age of patients was 36.9 years (range 20-65 years). Most common clinical features were fever, meningism (stiff neck), and focal neurological signs. The genome of HVs was detected in CSF samples obtained from all patients as follows: Herpes simplex virus 1 and 2 - 13 (12.1 %), Varicella zoster virus - 2 (1.8), Cytomegalovirus - 14 (13 %), Epstein Barr virus - 22 (20.5 %), Human herpesvirus 6 - 5 (4.7 %), Human herpesvirus 7 - 13 (12.1 %). Co-infection (≥ 2 HVs) was observed in 38 patients (35.5 %). CSF of 27 patients contained two viral DNA, and 11 - three one in various combination. Human herpesvirus 8 was not found. CONCLUSION: Conclusions: The most frequently diagnosed infections in hospital based study were Human herpesvirus 5 (EBV), followed by HSV-1/2, CMV, and HHV-7. Significant part of patients (35.5 %) were co-infected with two or three HVs. Predisposing factor for Ukrainian population is sex.

Epstein-barr virus-associated encephalitis in a case-series of more than 40 patients.

OBJECTIVE: Introduction: Epstein-Barr virus (EBV) infection can present with neurologic manifestations including encephalitis, aseptic meningitis, Guillain-Barre syndrome, and many others. Most reported cases have been in children. Little is known about EBV encephalitis in adults. The aim: To describe the clinical presentations, investigational findings, management and outcome of adult patients with EBV encephalitis. PATIENTS AND METHODS: Materials and methods: This report conducted a retrospective review of all cases of EBV-associated encephalitis compiled in the Kyiv's referral hospital from January 2016 to December 2017. RESULTS: Review: Out of 226 adult patients hospitalized with acute encephalitis during the study period, 48 (21.2%) were identified as having evidence of EBV-infection: convincing EBV serology and/or positive cerebrospinal fluid (CSF) polymerase chain reaction (PCR) in patients that had no bacterial cause of encephalitis. EBV monoinfection was registered in 24 (50%) patients. Mixed herpesvirus infection with one to four viruses in addition to EBV was detected in the rest. The most common symptoms were fever, confusion, headache, focal neurological deficits, vestibulo-ataxic disorders. CSF cytosis, content of protein and glucose were close to normal. Magnetic resonance imaging (MRI) showed focal (28/58.3%) and diffuse (15/31.3%) changes of the brain parenchymal. All patients got antiviral medication: ganciclovir, valganciclovir or valaciclovir, as a rule. Outcome: 26 (54%) patients recovered without any disabling sequela, 21 (44%) patients with remaining preservations were transferred to a convalescence facility. One patient, which condition worsened against the background of the therapy, were moved to an intensive care unit. No patient died. CONCLUSION: Conclusions: CNS infection with EBV only and as a mixed infection is common in Ukraine. Presentation of EBV-infection is non-specific, both as MR imaging, sometimes reminding of HSV-1 infection. Prognosis of the disease is favorable.

Identification of human herpesvirus 7 in the cerebrospinal fluid of adult ukrainian with relapsing-remitting multiple sclerosis. A case study.

OBJECTIVE: Introduction: In this study, we investigated the possible involvement of Human herpesvirus 7 in multiple sclerosis. The aim: To contribute to clarifying the controversy on the association between Human Herpesviruses 7 (HHV-7) and multiple sclerosis (MS) studying patient with relapsing-remitting MS (RRMS). PATIENTS AND METHODS: Case study: Young female admitted to adult tertiary referral, infectious diseases hospital, Kyiv, Ukraine, with signs of a focal neurological deficit. Meningeal symptoms were not detected. The preadmission illness lasted some years. Clinical diagnosis was relapsing-remitting multiple sclerosis (RRMS). On admission, general condition was of moderate severity. She has a mild fever, confusion, speech and coordination disorders, dizziness, worsening of memory, inability to walk (inferior paraparesis). Focal lesions were detected on MRI scan. The spinal fluid contained oligoclonal IgG-chains and HHV-7 DNA. After two weeks of intensive antiviral treatment, the patient's condition improved significantly,the function of the lower limbs recovered almost completely, and she was discharged home. CONCLUSION: Conclusion: Here we present a comprehensive clinical, radiological and virological analysis of the HHV-7-associated case of multiple sclerosis.

Bottom-up Fabrication of Multilayer Stacks of 3D Photonic Crystals from Titanium Dioxide.

A strategy for stacking multiple ceramic 3D photonic crystals is developed. Periodically structured porous films are produced by vertical convective self-assembly of polystyrene (PS) microspheres. After infiltration of the opaline templates by atomic layer deposition (ALD) of titania and thermal decomposition of the polystyrene matrix, a ceramic 3D photonic crystal is formed. Further layers with different sizes of pores are deposited subsequently by repetition of the process. The influence of process parameters on morphology and photonic properties of double and triple stacks is systematically studied. Prolonged contact of amorphous titania films with warm water during self-assembly of the successive templates is found to result in exaggerated roughness of the surfaces re-exposed to ALD. Random scattering on rough internal surfaces disrupts ballistic transport of incident photons into deeper layers of the multistacks. Substantially smoother interfaces are obtained by calcination of the structure after each infiltration, which converts amorphous titania into the crystalline anatase before resuming the ALD infiltration. High quality triple stacks consisting of anatase inverse opals with different pore sizes are demonstrated for the first time. The elaborated fabrication method shows promise for various applications demanding broadband dielectric reflectors or titania photonic crystals with a long mean free path of photons.

Facile deposition of YSZ-inverse photonic glass films.

An alternative all-colloidal and single-step deposition method of yttrium-stabilized zirconia (YSZ)-infiltrated polymeric photonic glass films is presented. Heterocoagulation of oppositely charged polystyrene (PS) microspheres and YSZ nanocrystals in aqueous dispersions created PS/YSZ core-shell spheres. These composite particles were deposited on glass substrates by a simple drop-coating process. Heterocoagulation impaired self-assembly of the particles, resulting in a disordered structure. Burn-out of the polymer yielded a random array of YSZ shells. The effect of the filling fraction of YSZ between these shells was explored. YSZ-inverse photonic glass films with a thickness below 40 µm achieved 70% reflectance of the incident radiation over a broad wavelength range between 0.4 and 2.2 µm. The YSZ structures demonstrated structural stability up to 1000 °C and maintained high reflectance up to 1200 °C for several hours, thus enabling applications as broadband reflectors at elevated temperatures.

Graded photonic quasicrystals.

We introduce graded photonic quasicrystals and investigate properties of such structures on the example of a Luneburg lens based on a dodecagonal photonic quasicrystal. It is shown that the graded photonic quasicrystal lens has better focusing properties as compared with the graded photonic crystal lens in a frequency range suitable for experimental realization. The proposed graded photonic quasicrystals can be used in optical systems where compact and powerful focusing elements are required.

Nontuberculous mycobacterial infections of the skin: A retrospective study of 25 cases.

BACKGROUND: Absence of a pathognomonic clinical picture and variable histologic findings often delay diagnosis of nontuberculous mycobacteria (NTM)-induced cutaneous infections, and antimicrobial therapy varies. OBJECTIVE: We sought to investigate the clinical, microbiologic, and pathological findings of cutaneous NTM infections and response to different treatments. METHODS: Records of patients with NTM infections of the skin confirmed by positive cultures or histologic findings were reviewed. Clinical, microbiologic, and epidemiologic data were collected and skin biopsy specimens were reassessed. RESULTS: The series included 25 cases, one diagnosed by histology and 24 by positive culture: 16 cases with Mycobacterium marinum, 3 of atypical Mycobacterium without species identification, and one each with M chelonae, M xenopi, M abscessus, M gordonae, and M fortuitum. One of 16 patients with M marinum developed tenosynovitis. Mean interval between clinical presentation and diagnosis was 7.1 months (range: 1-27.3 months). All isolates analyzed for antimicrobial susceptibility pattern were sensitive to clarithromycin. LIMITATIONS: Limitations include methods of case collection, retrospective study, and relatively small number of patients. CONCLUSIONS: Diagnosis of NTM should be confirmed by histology and bacteriology studies of tissue cultures. Strong clinical suggestion of M marinum infection warrants initial empirical treatment to prevent progression to deep infection. The recommended treatment as indicated by the results of the in vitro susceptibility and clinical response is clarithromycin.

Sister Mary Joseph's nodule as a presenting sign of internal malignancy.

CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I.

Unusual skin and testicular lesions in a patient with CMML.

Chronic myelomonocytic leukemia (CMML) is a clonal disorder of hematopoetic stem cells with myelodysplastic and myeloproliferative features. Skin infiltration by leukemic cells is rare in CMML. A case is presented with severe dermatological involvement and concomitant testicular infiltration. An unusual feature was the evidence that the skin was the primary site of an acute leukemic transformation.

Hemodialysis-related pruritus and associated cutaneous manifestations.

BACKGROUND: Uremic pruritus is one of the most common disabling problems in patients with chronic renal failure. Few studies have evaluated itching and cutaneous manifestations in hemodialysis-dependent patients. OBJECTIVES: The aim of this prospective study was to identify the prevalence of pruritus and cutaneous changes affecting patients undergoing hemodialysis. METHODS: The degree of itching in 70 patients treated at the Haemek Medical Center Hemodialysis Unit, in northern Israel, was scored according to presence and severity. We examined the relationship between the quality of dialysis and the frequency of pruritus, and identified concurrent cutaneous disorders. RESULTS: Pruritus was a common problem in the study cohort and affected 74.3% of hemodialysis patients at some point. The main characteristics of pruritus were a general pattern in 65.7% and mild intensity in 78.3% of observed patients. Duration of hemodialysis varied between 3 months and 13 years. There was no correlation between occurrence of pruritus and demographic or medical parameters (sex, type of kidney disease, regular medications or duration of hemodialysis) of the patients. Higher dialysis efficacy, as expressed by dialyser clearance, volume distribution of area, dialysis duration (Kt/v), may reduce the prevalence of pruritus (P < 0.02). None of the blood and chemical values considered (hemoglobin, creatinine, urea, phosphorus, calcium, albumin, parathormone and alkaline phosphatase) revealed any statistically relevant differences between pruritus groups. The appearance of foot ulcers was different between diabetic and nondiabetic individuals undergoing hemodialysis (P < 0.001). CONCLUSIONS: Pruritus is still a common problem in hemodialysis-dependent patients. The prevalence of xerosis and excoriations was high in patients undergoing replacement therapy. Efficient replacement hemodialysis may provide a clinical benefit.