Chronic Infection by Plasmodium falciparum.

Malaria by Plasmodium falciparum (P. falciparum) usually does not exceed one year, but chronic infection, although rare, is a possibility. We present the clinical case of a 37-year-old male who came to the emergency department with intermittent fever, chills, and malaise. He had malaria more than 1 year ago while working in Huíla province, Angola. On admission, Plasmodium testing by light microscopy and antigens was negative. Doxycycline was started empirically, but on the third day of hospitalization, he had a new fever spike. Plasmodium DNA and antibodies were tested, confirming P. falciparum. The therapy with artemether-lumefantrine, already after discharge, allowed the consolidation of the treatment and eradicator of the parasite. Detection of parasite DNA by PCR should not be routine, but it is a more sensitive method, which confirmed this chronic infection by P. falciparum after one year.

Image Significance in the Diagnosis of Another Case of Herpetic Encephalitis.

Herpes simplex virus 1 (HSV-1) causes necrotizing encephalitis, usually located in the temporal lobes and with a high mortality rate if not diagnosed and treated early. Cranial computed tomography (CT) scan, although not very sensitive, can help by highlighting hemorrhagic foci and edema in the frontotemporal lobes, given the tropism of the virus for these areas. We present the case of a 70-year-old male who came to the emergency department (ED) with fever and confusion. Despite an unclear cerebrospinal fluid (CSF) result, the CT scan showed a spot of hypodensity in the mesial aspect of the left temporal lobe. He was given 21 days of intravenous acyclovir, and his neurological condition normalized. These cranial CT alterations, although not pathognomonic, indicate a strong suspicion of herpetic encephalitis.

Periorbital Emphysema Due to Traumatic Pneumothorax.

Periorbital emphysema is rare and associated with facial trauma. Its main distinguishing feature is crepitation on palpation of the edema. It resolves spontaneously in a few days, but there are cases of orbital compartment syndrome that can lead to loss of vision. Here we present the case of a 55-year-old male who came to the emergency department for bilateral periorbital edema associated with non-steroidal anti-inflammatory drug (NSAID) usage, for pain following a fall from a ladder. He was treated with antihistamines and corticosteroids, for presumed allergic reaction, but without response, and subsequently developed acute onset dyspnea. Chest x-ray revealed a left pneumothorax in the context of chest trauma. Chest CT scan after drain placement shows extensive subcutaneous emphysema. In the differential diagnosis of periorbital edema, in addition to allergic, inflammatory, and systemic causes, the traumatic ones should not be excluded.

Biologic therapy in large and small vessels vasculitis, and Behçet's disease: Evidence- and practice-based guidance.

OBJECTIVE: Vasculitis are a very heterogenous group of systemic autoimmune diseases, affecting large vessels (LVV), small vessels or presenting as a multisystemic variable vessel vasculitis. We aimed to define evidence and practice-based recommendations for the use of biologics in large and small vessels vasculitis, and Behçet's disease (BD). METHODS: Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice on autoimmune diseases management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2022. Preliminary recommendations were drafted by working groups for each disease and voted in two rounds, in June and September 2021. Recommendations with at least 75% agreement were approved. RESULTS: A total of 32 final recommendations (10 for LVV treatment, 7 for small vessels vasculitis and 15 for BD) were approved by the experts and several biologic drugs were considered with different supporting evidence. Among LVV treatment options, tocilizumab presents the higher level of supporting evidence. Rituximab is recommended for treatment of severe/refractory cryoglobulinemic vasculitis. Infliximab and adalimumab are most recommended in treatment of severe/refractory BD manifestations. Other biologic drugs can be considered is specific presentations. CONCLUSION: These evidence and practice-based recommendations are a contribute to treatment decision and may, ultimately, improve the outcome of patients living with these conditions.

Biological therapy in systemic lupus erythematosus, antiphospholipid syndrome, and Sjögren's syndrome: evidence- and practice-based guidance.

Systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and Sjögren's syndrome (SS) are heterogeneous autoimmune diseases. Severe manifestations and refractory/intolerance to conventional immunosuppressants demand other options, namely biological drugs, and small molecules. We aimed to define evidence and practice-based guidance for the off-label use of biologics in SLE, APS, and SS. Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice in autoimmune disease management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2021. Preliminary recommendations were drafted by working groups for each disease. A revision meeting with all experts anticipated the consensus meeting held in June 2021. All experts voted (agree, disagree, neither agree nor disagree) during two rounds, and recommendations with at least 75% agreement were approved. A total of 32 final recommendations (20 for SLE treatment, 5 for APS, and 7 for SS) were approved by the experts. These recommendations consider organ involvement, manifestations, severity, and response to previous treatments. In these three autoimmune diseases, most recommendations refer to rituximab, which aligns with the higher number of studies and clinical experience with this biological agent. Belimumab sequential treatment after rituximab may also be used in severe cases of SLE and SS. Second-line therapy with baricitinib, bortezomib, eculizumab, secukinumab, or tocilizumab can be considered in SLE-specific manifestations. These evidence and practice-based recommendations may support treatment decision and, ultimately, improve the outcome of patients living with SLE, APS, or SS.

Treatment of digital ulcers in systemic sclerosis: Case series study of thirteen patients and discussion on outcome.

INTRODUCTION:: In systemic sclerosis (SSc), digital ulcers (DU) are debilitating and recurrent. They are markers of prognosis and are associated with disability and mortality. Treatment strategies have been developed to block the proposed mechanisms of this complication. OBJECTIVE:: Clinical description of a population of SSc patients with DU, treatment, complications and outcome. METHOD:: Analysis of 48 SSc patients meeting 2013 ACR-EULAR criteria, followed between 1999-2015; 13 patients had DU. Treatment protocol applied included cycles of 21 days of alprostadil, which can be repeated in the absence of DU healing. After DU healing, bosentan was initiated. RESULTS:: DU healing was achieved with intravenous prostanoid in 12 patients; seven patients required repeated treatment for DU healing. Twelve patients were later treated with bosentan; three of them experienced recurrence of DU, while one was anti-B2-GPI positive. Four patients had soft tissue loss and three other suffered digital amputation, these being late diagnosis. CONCLUSION:: Younger patients and early referrals had better outcomes. Endothelin receptor antagonist toxicity should be monitored, particularly in patients previously exposed to hepatotoxic drugs.

Treatment of digital ulcers in systemic sclerosis: Case series study of thirteen patients and discussion on outcome / Tratamento de úlceras digitais na esclerose sistêmica: série de casos de 13 doentes e análise crítica dos resultados

Summary Introduction: In systemic sclerosis (SSc), digital ulcers (DU) are debilitating and recurrent. They are markers of prognosis and are associated with disability and mortality. Treatment strategies have been developed to block the proposed mechanisms of this complication. Objective: Clinical description of a population of SSc patients with DU, treatment, complications and outcome. Method: Analysis of 48 SSc patients meeting 2013 ACR-EULAR criteria, followed between 1999-2015; 13 patients had DU. Treatment protocol applied included cycles of 21 days of alprostadil, which can be repeated in the absence of DU healing. After DU healing, bosentan was initiated. Results: DU healing was achieved with intravenous prostanoid in 12 patients; seven patients required repeated treatment for DU healing. Twelve patients were later treated with bosentan; three of them experienced recurrence of DU, while one was anti-B2-GPI positive. Four patients had soft tissue loss and three other suffered digital amputation, these being late diagnosis. Conclusion: Younger patients and early referrals had better outcomes. Endothelin receptor antagonist toxicity should be monitored, particularly in patients previously exposed to hepatotoxic drugs.

Resumo Introdução: As úlceras digitais (UD) são complicações incapacitantes e recorrentes, associadas a menor qualidade de vida e maior mortalidade na esclerose sistêmica (ES). O tratamento baseia-se em antagonizar os mecanismos fisiopatológicos em causa. Objetivo: Descrever uma amostra de doentes com diagnóstico de ES e UD, o tratamento, as complicações e os resultados clínicos. Método: Série de 48 casos diagnosticados com ES, critérios de classificação ACR-EULAR 2013, seguidos entre 1999 e 2015, dos quais 13 apresentavam UD. O protocolo aplicado incluía ciclos de 21 dias de alprostadil podendo ser repetidos no caso de não existir cicatrização. Nos casos em que houve cicatrização foi iniciado bosentano. Resultados: No tratamento das UD, 12 doentes realizaram prostaciclina endovenosa, com necessidade de tratamentos repetidos em sete doentes. Doze doentes foram posteriormente tratados com bosentano, com recorrência de UD em três doentes, um deles com presença de anti-B2-GPI. Quatro doentes ficaram com cicatrizes e em três houve amputação digital, sendo casos de diagnóstico tardio. Conclusão: Os doentes mais jovens tiveram melhores resultados, possivelmente em razão de melhorias globais nos cuidados de saúde prestados e de referenciação precoce. A toxicidade dos antagonistas dos receptores da endotelina deve ser monitorizada, sobretudo em doentes com exposição prévia a drogas hepatotóxicas.

A Rare Case of Mediterranean Spotted Fever and Encephalitis.

Mediterranean spotted fever is a tick-borne zoonotic disease caused by Rickettsia conorii. It is transmitted by the dog tick Rhipicephalus sanguineus. It usually presents as a benign self-limited disease characterized by a skin rash, high fever, and, sometimes, a characteristic ulcer at the tick bite site called tache noir. The course of this disease is usually benign, although severe manifestations have been previously described, mainly in adults. Neurological manifestations are very unusual. We present a case of Mediterranean spotted fever with encephalitis to highlight the importance of clinical suspicion, mainly in endemic areas, the potential severity of this disease, and the need of early initiation of therapy in order to prevent severe complications.