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Competing Interests: The authors declare that they have no conflict of interest

Objectives: A prospective longitudinal single-centre study to assess the mental health impact of COVID-19 on nurses working in the frontline during the first wave of COVID-19 hospitalizations in Belgium, 2020., Patients and Methods: The study was performed between April 1 st and 30 June 2020. Nurses who were actively and daily involved in the care of COVID-19 patients on selected intensive care units (ICU) and non-ICU wards were included. Depression, somatization, anxiety and distress scores were calculated using the Four-Dimensional Symptom Questionnaire (4DSQ). The Impact of Event Scale-Revised (IES-R) and Brief-COPE questionnaires were used to assess respectively the psychological impact and coping strategies. Participants were asked to fill in the questionnaire at the start of inclusion, 4 weeks later and 8 weeks later., Results: In total, 39/42 included nurses participated in the study. 4DSQ results showed low rates of depression, anxiety and somatization with a declining trend over time. Distress scores however were high throughout the study period. A past history of stress symptoms was significantly associated with higher distress scores at the inclusion and one month follow-up. As major psychological impact, more participants experienced 'intrusion' compared to 'avoidance' specifically among nurses working on ICU. In 10% of participants, IES-R-scores were predictive for post-traumatic stress disorder., Conclusion: Healthcare workers dealing with COVID-19 patients during the pandemic reported high and enduring distress scores and experienced a major impact on mental health, especially when employed at ICU. These results highlight the importance of psychological support and proper long-term follow-up to mitigate this impact.

There is a need for a quick assessment of severely ill patients presenting to the hospital. The objectives of this study were to identify clinical, laboratory and imaging parameters that could differentiate between influenza and COVID-19 and to assess the frequency and impact of early bacterial co-infection. A prospective observational cohort study was performed between February 2019 and April 2020. A retrospective cohort was studied early in the COVID-19 pandemic. Patients suspected of sepsis with PCR-confirmed influenza or SARS-CoV-2 were included. A multivariable logistic regression model was built to differentiate COVID-19 from influenza. In total, 103 patients tested positive for influenza and 110 patients for SARS-CoV-2, respectively. Hypertension (OR 6.550), both unilateral (OR 4.764) and bilateral (OR 7.916), chest X-ray abnormalities, lower temperature (OR 0.535), lower absolute leukocyte count (OR 0.857), lower AST levels (OR 0.946), higher LDH (OR 1.008), higher ALT (OR 1.044) and higher ferritin (OR 1.001) were predictive of COVID-19. Early bacterial co-infection was more frequent in patients with influenza (10.7% vs. 2.7%). Empiric antibiotic usage was high (76.7% vs. 84.5%). Several factors determined at presentation to the hospital can differentiate between influenza and COVID-19. In the future, this could help in triage, diagnosis and early management. Clinicaltrial.gov Identifier: NCT03841162.

Background: Belgium was among the first countries in Europe with confirmed coronavirus disease 2019 (COVID-19) cases. Since the first diagnosis on February 3rd, the epidemic has quickly evolved, with Belgium at the crossroads of Europe, being one of the hardest hit countries. Although risk factors for severe disease in COVID-19 patients have been described in Chinese and United States (US) cohorts, good quality studies reporting on clinical characteristics, risk factors and outcome of European COVID-19 patients are still scarce., Methods: This study describes the clinical characteristics, complications and outcomes of 319 hospitalized COVID-19 patients, admitted to a tertiary care center at the start of the pandemic in Belgium, and aims to identify the main risk factors for in-hospital mortality in a European context using univariate and multivariate logistic regression analysis., Results: Most patients were male (60%), the median age was 74 (IQR 61-83) and 20% of patients were admitted to the intensive care unit, of whom 63% needed invasive mechanical ventilation. The overall case fatality rate was 25%. The best predictors of in-hospital mortality in multivariate analysis were older age, and renal insufficiency, higher lactate dehydrogenase and thrombocytopenia. Patients admitted early in the epidemic had a higher mortality compared to patients admitted later in the epidemic. In univariate analysis, patients with obesity did have an overall increased risk of death, while overweight on the other hand showed a trend towards lower mortality., Conclusions: Most patients hospitalized with COVID-19 during the first weeks of the epidemic in Belgium were admitted with severe disease and the overall case fatality rate was high. The identified risk factors for mortality are not easily amenable at short term, underscoring the lasting need of effective therapeutic and preventative measures.

Background: Gastrointestinal metastasis from primary breast carcinoma is uncommon, anorectal involvement is extremely rare., Case Presentation: We present the case of a 65-year old woman who underwent treatment for an infiltrative lobular carcinoma of the left breast with bone metastases and who developed metastasis of the rectum and anal canal 4 years later., Conclusions: A patient with a history of breast cancer, especially lobular carcinoma, presenting with anorectal symptoms, should raise the suspicion of metastatic disease.

Unlabelled: Sialuria, a rare inborn error of metabolism, was diagnosed in a healthy 12-year-old boy through whole exome sequencing. The patient had experienced mild delays of speech and motor development, as well as persistent hepatomegaly. Identification of the 8th individual with this disorder, prompted follow-up of the mother-son pair of patients diagnosed over 15years ago. Hepatomegaly was confirmed in the now 19-year-old son, but in the 46-year-old mother a clinically silent liver tumor was detected by ultrasound and MRI. The tumor was characterized as an intrahepatic cholangiocarcinoma (IHCC) and DNA analysis of both tumor and normal liver tissue confirmed the original GNE mutation. As the maternal grandmother in the latter family died at age 49years of a liver tumor, a retrospective study of the remaining pathology slides was conducted and confirmed it to have been an IHCC as well. The overall observation generated the hypothesis that sialuria may predispose to development of this form of liver cancer. As proof of sialuria in the grandmother could not be obtained, an alternate cause of IHCC cannot be ruled out. In a series of 102 patients with IHCC, not a single instance was found with the allosteric site mutation in the GNE gene. This confirms that sialuria is rare even in a selected group of patients, but does not invalidate the concern that sialuria may be a risk factor for IHCC., Synopsis: Sialuria is a rare inborn error of metabolism characterized by excessive synthesis and urinary excretion of free sialic acid with only minimal clinical morbidity in early childhood, but may be a risk factor for intrahepatic cholangiocarcinoma in adulthood., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Dermatofibrosarcoma protuberans (DFSP) is a rare tumor that grows with tentacle-like projections. In particular, on the scalp this could explain the frequent incomplete resections and the high rate of multiple local recurrences. Adequate pre- and postoperative imaging methods to visualize these prolongations are required to determine the extent of the tumor and to intercept recurrences in a short time base., Methods: A retrospective study was performed on two cases of multiple recurrent scalp DFSP. The use of diffusion-weighted imaging (DWI) for pre- and postoperative assessment of DFSP was evaluated., Results: Diffusion-weighted imaging magnetic resonance imaging was able to visualize the horizontal extent of tumor prolongations in the periosteum. Also, residual tumor tissue was distinguished from scar tissue in a large area of previous surgical interventions., Conclusion: We found DWI magnetic resonance imaging a valuable tool in planning the multidisciplinary therapeutic approach and follow-up of DFSP on the scalp., (© 2015 The International Society of Dermatology.)

We present a case of angioleiomyoma, a benign angiomatous soft tissue tumor in a 52-year-old patient. We empha- size that small nodular tumors showing hypervascularity on MRI or ultrasound may be malignant and should be treated with tumor excision.

Non-Hodgkin's lymphoma (NHL) is a common cause of Fever of Unknown Origin (FUO) but the presentation as a gynaecologic malignancy is exceedingly rare. To our knowledge, this represents the first report of an intravascular large B-cell lymphoma of the uterus presenting with fever of unknown origin. After a standard clinical work-up for FUO, the endometrial curettage directed by the finding of a localized fluoro-deoxyglucose Positron Emission Tomography (FDG-PET) hot spot in the pelvic area, yielded material revealing an intr avascular B-cell lymphoma. A total abdominal hysterectomy confirmed the presence of an intravascular large B-cell lymphoma in the lumina of small blood vessels of the uterus.

We present a case of miliary tuberculosis diagnosed 15 months after infliximab treatment despite negative screening for previous exposure to Mycobacteria on skin PPD and chest X-ray. This case shows that--although screening for TB with a skin PPD and a chest X-ray should be performed in all patients--this is not 100% effective and may be a problem in patients on concomitant immunosuppression. The clinical course of this patient further shows that in a patient treated with anti-TNF antibodies who's condition does not improve one should always be aware of the possibility of a tuberculosis infection. Even though tuberculosis is usually not rapidly fatal, the disease may show a fulminant course in immunocompromised patients.

We present a case of a newborn with Turner syndrome (TS) and a scalp skin lesion resembling cutis verticis gyrata (CVG). Several reports on CVG in TS describe the lesions and correlate it with lymphoedema frequently seen in foetuses and infants with Turner syndrome. Histological examination in this case, however, shows a congenital mucinous nevus. Possibly an abnormal amount of proteoglycans in the skin of patients with TS can clarify the occurrence of this type of skin lesion.

Uterine adenosarcoma (UAS) is microscopically characterized by a biphasic growth pattern. By definition, the epithelial component is benign, whereas the stromal component typically has the appearance of a low-grade sarcoma, usually an endometrial stromal sarcoma. CD10 acts by reducing cellular response to peptide hormones and is currently regarded as a specific marker for endometrial stromal tumors. In this international multicenter study, we further explored CD10 immunoreactivity in 30 UASs. We encountered CD10 positivity of the sarcomatous component in 18/20 (90%) of UASs, in five of eight (63%) of UASs with sarcomatous overgrowth as well as in both cases of recurrent UAS. The epithelial component stained negative in all cases. These findings suggest that CD10 can be used to differentiate UAS from cellular leiomyoma, or in case endometrial stromal cells exhibit muscle differentiation. Furthermore, CD10 positivity in recurrent UAS might guide the pathologist toward an endometrial stromal origin.

Background: Given the paucity of data regarding hormone dependency, it was the purpose of this study to screen for the presence of estrogen and progesterone receptors in uterine adenosarcoma (UAS)., Methods: One hundred and five centers were asked to screen their files for uterine adenosarcomas. A immunohistochemical estrogen and progesterone receptor determination was performed., Results: Twenty-eight primary UAS were stained, including one cervical adenosarcoma. Sarcomatous overgrowth could be observed in eight. Furthermore, two cases of recurrent UAS, one only consisting of endometrial stromal sarcoma, were stained. UAS lacking sarcomatous overgrowth showed estrogen receptor positivity in 17/20 (85%) and 16/20 (80%) in the epithelial and sarcomatous component, respectively. Progesterone positivity was observed in 13/20 (65%) and 12/20 (60%) in the epithelial and sarcomatous component, respectively. In 18/20 (90%) of the cases, either the estrogen or the progesterone receptor stained positive in the sarcomatous component. UAS with sarcomatous overgrowth showed estrogen receptor positivity in 4/8 (50%) and 0/8 (0%) in the epithelial and sarcomatous component, respectively. Progesterone positivity was observed in 2/8 (25%) and 1/8 (12%) in the epithelial and sarcomatous component, respectively. The stromal component of both recurrent cases stained moderately positive for estrogen receptor whereas progesterone receptor was considered negative., Conclusion: The observation that the sarcomatous component of UAS without sarcomatous overgrowth frequently expresses hormone receptors might be of significant clinical importance.