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Purpose of review This review provides ten tips for improving clinical practice during COVID-19 as pandemic fatigue begins to complicate personal and professional lives of clinicians. Recent findings COVID-19 has created unique and unexpected challenges to healthcare delivery, but has also provided opportunities for re-evaluation of practice patterns to optimize high-value practices. With ongoing uncertainty, key factors to appreciate for patient and population health include the continued touchstones of empathy and compassion, the use of effective risk communication with shared clinical decision-making when appropriate, attention to resource stewardship and vulnerable populations, importance of health literacy and need for critical assessment of media and medical literature to mitigate misinformation, and the hidden costs of the pandemic on children. Although there has been some international concern for allergic reactions to the recently approved Pfizer-BioNTech COVID-19 vaccine, neither the United States Pfizer-BioNTech or Moderna COVID-19 vaccine emergency use authorizations exclude patients without a specific allergy to a vaccine component from receiving vaccination. Summary Practical adjustments to practice during COVID-19 are feasible and acceptable. Experience during COVID-19 reinforces the critical need for human connection while providing care and service in every encounter.

Introduction: Chronic urticaria is one of the growing problems worldwide and the prevalence is increasing. Around 2% of children have been shown to be affected with chronic urticaria. Objectives: To evaluate demographic, clinical and aetiological factors related to chronic urticaria in children and to assess investigations and treatment. Method: A retrospective study was done from January 2018 to December 2019 on 40 children aged 1-14 years who presented with chronic urticaria to the paediatric clinic, University Paediatric Unit, Batticaloa Teaching Hospital. Detailed information including demographic factors, duration of illness, main reasons for clinic attendance, treatment received from the out-patient department, caregiver reported allergens, family history of atopy and complications such as secondary bacterial infection were retrieved from clinic-based records. Information regarding laboratory investigations was also retrieved. Data were analysed using SPSS version 19.0 (IBM Corp., Armonk, NY). Results: Forty children were available for the analysis. The most common age category was four to eight years and 25 (62.5%) were females. Seventy percent of children had urticaria for one or more years. Thirty-six (90%) children had a family history of allergies such as allergic rhinitis, eczema, food allergies, medication allergies and bronchial asthma. The common precipitating factors were foods in 12 (30%) cases and insect bites in 10 (25%) cases. The main reasons for seeking medical advice were severe itchiness in 40 (100%) and sleep disturbances in 24 (60%). Only a limited number of investigations had been performed and they included white cell counts (differential eosinophil counts) and thyroid functions. Almost all had normal thyroid functions whilst 45% had eosinophilia. Conclusions: The majority of children with chronic urticaria had symptoms for over the one-year duration and reported a family history of allergy. All children reported severe itchiness as the main symptom and sleep was disturbed in the majority. The common precipitating factors were food and insect bites.

Introduction The allergic sensitization in childhood asthma is common and the prevalence varies in different geographical locations. The data on allergen sensitization to guide clinicians on allergy avoidance is limited. Method This prospective observational study was conducted between October 2019 and April 2020 on children aged two to 14 years attending an outpatient clinic. Those with recurrent wheezing or physician-diagnosed asthma were interviewed; eosinophil count, total serum immunoglobulin E (IgE) was measured; and skin prick test (SPT) was done using standardized reagents. Wheal size of ≥3mm was considered positive. Results A total of 80 children were enrolled. The mean age was 71.15 ± 33.52 months (M:F ratio =1.96:1). Allergic rhinitis, conjunctivitis, and dermatosis were seen in 76 (95.0%), 33 (41.3%), and 22 (27.5%) cases, respectively. The mean absolute eosinophil count was 576 ± 427per cmm. The mean total IgE was 800.9 ± 883.2IU/ml. Seasonal and diurnal variations were found in 34 (42.5%) and 79 (98.8%) cases. Out of 1753 skin pricks using 27 reagents, 355 (20.25%) were positive. Increasing age was significantly associated with increasing SPT positivity (P = 0.0001). The most common sensitive aeroallergens were Kentucky bluegrass (25%), Dermatophagoides pteronyssinus (22.5%), Dermatophagoides farinae (21.3%), Timothy grass, and Alternaria alternans (20% each). The most common sensitive food allergens were spinach (25%), banana (22.5%), carp (20%), shrimp and hen’s egg (18.8% each), and cow’s milk (17.5%). Conclusion Increasing age was associated with increasing SPT positivity in childhood asthma. The most common sensitive aeroallergens were Kentucky bluegrass and Dermatophagoides pteronyssinus; spinach and banana were the most common food allergen.

An 81-year-old female with a past medical history of myasthenia gravis presented to the Emergency Department with difficulty breathing. At presentation, the patient also complained of fatigue, diplopia, and ptosis. Vitals and laboratory tests were largely benign. The patient was diagnosed as having a myasthenia gravis exacerbation, which eventually advanced to myasthenic crisis, with the patient requiring admission to the intensive care unit and supplementation of high-flow oxygen. Throughout the course of the patient’s hospitalization, the measurements of her negative inspiratory force and vital capacity were found to be normal and unchanged despite shifting and unsteady respiratory symptoms. This uncommon case seeks to highlight the importance of complementing clinical context with the markers of respiratory function to assess the status of myasthenia-related respiratory distress.

Idiopathic CD4+ lymphocytopenia (ICL) is an extremely rare condition characterized by low numbers of CD4+ cells (GTG (p.Met1Val; p.M1V) mutation. Family screening showed that the patient’s mother, father, and brother all had a single p.M1V mutation, allowing for deleterious effects to be partially offset by the normal copy of the gene. We have provided an organized analysis of the existing literature in addition to a concise overview of this case, with the intention of identifying patterns in presentation, clinical course, and outcomes. This case discusses the effects of the loss of the CD4+ start codon in the patient. Although this specific form of lymphocytopenia is very uncommon, it illustrates the importance of genetic testing and the integral nature of laboratory testing in therapy charting.

Introduction: Cutaneous adverse drug reactions (CADRs) are the most common adverse drug reactions reported in the literature. CADRs have resulted in disabling infirmities during hospitalization and complications following outdoor drug therapy. The pattern of CADRs and the responsible drugs usually changes with the introduction of newer drugs and evolving clinical practices. Moreover, several international studies showed variable prevalence, emphasizing the need for local data in light of different socioeconomic and demographic practices. Therefore, the purpose of this study is to evaluate the prevalence of adverse cutaneous drug reactions and identify the clinical spectrum and any potential risk factors. Methodology: The current study is a descriptive cross-sectional study conducted at Aga Khan University Hospital, Pakistan. One hundred ninety-three patients who met the study inclusion criteria were included. Data were collected from patients on a proforma after taking informed consent. Quantitative data were presented as simple descriptive statistics giving mean and standard deviation, while qualitative variables were presented as frequency and percentages. Effect modifiers were controlled through stratification to highlight the effect of these on the outcome variable. The post-stratification chi-square test was applied and the p-value of ≤0.05 was statistically significant. Results: A total of 193 patients who had cutaneous adverse drug reactions were included in the study. The mean age in this study was 47.78±8.33 years. One hundred eight (56%) were male and 85 (44%) were female. Out of 193 patients, 135 (69.9%), 50 (25.9%), 24 (12.4%), 12 (6.2%), 20 (10.4%), 11 (5.7%) and six (3.1%) had maculopapular rash, acneiform eruptions, Stevens-Johnson syndrome, erythema multiform, urticaria, fixed drug eruptions and toxic epidermal necrolysis, respectively. Conclusion: CADRs are a common clinical presentation and awareness and knowledge about their diagnosis and prevention is important. It can be assumed that in our local setup, the clinical trends and medications causing ADRs are strikingly similar to those found in other countries. Physicians commonly come across these cases and they should be well aware of the clinical spectrum of skin reactions to enable early diagnosis and management.

Tumor necrosis factor-alpha (TNF-α) inhibitors are frequently used for the management of type 1 helper T-cell (Th1) immune-mediated chronic inflammatory conditions such as psoriasis and Crohn’s disease. Although TNF-α inhibitors are usually well-tolerated, various cutaneous side effects are frequently observed, including eczematous or atopic dermatitis-like eruptions. It is postulated that the attenuation of the Th1 immune pathway with TNF-α inhibition causes a shift towards a type 2 helper T-cell (Th2) immune response, leading to the development of skin lesions grossly and histologically consistent with the Th2 mediated disease atopic dermatitis. Herein, we describe the development of an eczematous eruption in two patients with a history of Th1-mediated disease after months of therapy with a TNF-α inhibitor.

Aim The objective of the study was to observe the association of villous atrophy with anti-tissue transglutaminase levels in the identified subjects that met our addressed inclusion criteria. Methods A case series study was conducted among 40 patients presenting with dyspepsia along with signs and symptoms of celiac disease at the Bolan Medical Complex Hospital, Quetta over a period of five months from 25/5/17 to 25/10/17. The patients were referred to undergo tissue transglutaminase antibody serum test. The positive ones underwent biopsies to assess pathological entities including villous atrophy, blunting (focal or total), crypts, Intestinal layers and the number of Intraepithelial lymphocytes. The results collected were analyzed by using IBM SPSS version 20 (IBM Corp., Armonk, NY). Results There was a weak, negative correlation between tTGA and focal villous blunting (r = -0.345, p = 0.029) showing that high levels of tTGA are associated with lower risk of focal villous blunting. Correlation of tTGA and total villous blunting was a weak positive correlation (r = 0.282, p = 0.07) showing that high levels of tTGA are associated with increased risk of total villous blunting. There was a weak, negative correlation between tTGG and focal villous blunting (r = 0.409, p = 0.009) showing thathigh levels of tTGG are associated with a greater risk of focal villous blunting (p < 0.01) while tTGG and total villous blunting was a weak negative correlation (r = -0.330, p = 0.03) showing that high levels of tTGG are associated with lower risk of total villous blunting. Conclusion The study concludes by providing evidence of the absence of tissue transglutaminase antibodies in patients with histology-proven celiac disease. It implies that serology tests may be negative in some of the patients with typical chronic symptoms. Therefore, in such cases, histopathology may be conclusive in defining the status of celiac disease.

Introduction The endosomal toll-like receptors (TLR) TLR3, TLR7, and TLR9 are localized in immune cells, recognize the viral pattern associated molecular pattern (PAMPs), and start signaling cascades for immune defense response and genetic factor is known to affect the dengue virus infection therefore in our study we study the association of endosomal Toll-like receptors 3 polymorphism rs3775291, rs3775290, and rs3775296 with rs179008 A/T and rs179009C/T polymorphisms of TLR7 and rs187084 (C/T), rs5743836 (C/T) of TLR9 gene with dengue and controls. Materials and methods Ninety-eight cases of dengue virus (DV) infection and 98 healthy controls were enrolled. Clinical details were recorded and cases were classified as severe or non-severe dengue, based on WHO 2009 classification. Genotypes were determined by Sanger sequencing using the genetic analyzer. Results An increased risk of DV infection was observed in cases as compared to controls, with TLR 3 rs3775291 CT genotype (OR = 4.34, P-value: 0.031, CI = 1.14-16.5), Likewise in TLR7 rs179008 AT (OR = 2.12, P-value: 0.034, CI = 1.06-4.26) and rs179009 CT (OR = 2.04, P-value: 0.040, CI = 1.03-4.05) same as in TLR9 rs187084 CT (OR = 1.97, P-value: 0.046, CI = 1.013-3.84) and rs5743836 (OR = 2.38, P-value: 0.009, CI = 1.24-5.57). In the above polymorphisms, mutant allele was observed in a significantly higher number in cases. The values are: for TLR3 rs3775291 T allele (OR 2.167, CI = 1.3-3.61, P-value: 0.003). TLR7 rs179008 T allele (OR 1.90, P-value: 0.021, CI = 1.07-3.35) and in TLR9 rs187084 (OR 1.91, P-value: 0.014, CI = 1.137-3.24) rs5743836 (OR 2.29, P-value: 0.0018, CI = 1.36-3.87). No significant association was observed in the genotypic frequency of severe versus non-severe dengue. Conclusion TLR3, 7, and 9 gene polymorphism might confer host genetic susceptibility to dengue in the North Indian population.

Postural orthostatic tachycardia syndrome (POTS) is an impaction of the autonomic nervous system initiating orthostatic tachycardia. There are numerous triggers for POTS including viruses, vaccines, and an autoimmune basis. This case report is clinically relevant to better understand the pathophysiology behind the messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccine and the mechanism that triggers autonomic nervous system dysfunction. Furthermore, the overall goal of this case study is to report a unique side effect associated with the novel mRNA COVID-19 vaccine. A 42-year-old male, with no prior symptoms of sinus tachycardia and presyncope episodes, is diagnosed with POTS secondary to the first dose of the mRNA COVID-19 vaccine. Symptoms to this date include sinus tachycardia, dizziness, headaches, and fatigue that are often triggered after a large meal or standing for a longer duration. Numerous diagnostic tests and images failed to confirm any other diagnosis other than POTS. There was a sequential connection between the onset of symptoms approximately one week after taking the first dose of the mRNA COVID-19 vaccine. Currently, POTS in this patient is controlled by lifestyle modification. This case report has broader implications as it can help us understand how the mRNA vaccine works on the body relative to the immune system. Our theory is that the development of antibodies activates an autoimmune reaction that triggers POTS disease. The prevalence of the POTS dysautonomia post-vaccination will be clearer as more data and research are conducted on the side effects from the innovative mRNA vaccines created to combat severe acute respiratory syndrome coronavirus 2.

Anti-N-methyl-D-aspartate receptor encephalitis is a rare autoimmune disorder that involves N-methyl-D-aspartate (NMDA) receptors. It is the most common autoimmune encephalitis, and early detection and treatment are crucial for morbidity-free recovery. Distinguishing this disorder from a primary psychiatric illness is quite challenging as this disorder classically presents with psychiatric manifestations that often resemble schizophrenic psychosis. Therefore, this review intended to scope the psychiatric manifestations this disorder could present with and dissect how they differ from primary psychiatric disorders. A PubMed database search was done. The results yielded were analyzed; eventually, 50 papers were used to review the different signs and symptoms the disease can present with, including common and rare disease presentations. Diagnostic challenges and helpful clinical clues to recognize the disorder were reviewed as well.

Immune thrombocytopenia (ITP) is an autoimmune disease characterized by low platelet counts of

Crusted scabies causes extensive hyperkeratotic skin lesions, crusting, and scaling and is common in elderly and institutionalized patients. We present a case of crusted scabies in a patient with encephalopathy and diffuse exfoliative erythroderma. After extensive workup, the patient's condition was attributed to hypereosinophilic syndrome due to crusted scabies. Skin condition, mental status, and eosinophilia improved with high-dose steroids in conjunction with topical permethrin and oral ivermectin.

Toxic epidermal necrolysis (TEN) is a rare, acute, severe mucocutaneous reaction commonly presenting following medication use. Thorough history taking and clinical examination are key to early diagnosis and management; skin biopsy provides diagnostic confirmation. We present a 54-year-old man who developed a widespread erythematous rash soon after the use of trimethoprim for an episode of acute prostatitis. An initial diagnosis of Stevens-Johnson syndrome evolved into toxic epidermal necrolysis following the rapid progression of his condition to a severe, blistering, and desquamating rash affecting more than 60% of his body surface area and mucosa. Through careful management with best supportive care and clinical judgement regarding the role of pharmacological intervention, he made a steady recovery supported by the wider multidisciplinary team. This is one of the very few reports in the literature implicating trimethoprim alone as an etiological agent in a severe case of TEN.

We report the case of a 28-year-old male, with a past history of recurrent pharyngitis and tonsillectomy, who presented to the emergency department with fever, pharyngitis, and cervical adenitis. Inflammatory markers were elevated and the patient was initially started on ceftriaxone with remission after four days. However, the symptoms recurred three weeks later and an autoinflammatory disease was suspected. After exclusion of other illnesses, a diagnosis of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome was confirmed. The patient was successfully treated with a single dose of 60 mg of prednisolone at the beginning of the flare. PFAPA syndrome has been classically diagnosed solely in children but cases in adults are being increasingly recognized. Despite the increasing evidence of the delayed onset of PFAPA syndrome during adulthood, no specific tools are available to detect it and diagnosis is currently based on clinical diagnostic criteria, which have very low specificity and are tailored to pediatric patients. This case report stresses the need to consider this entity seriously despite its rarity, even among the adult population, so as to reduce iatrogenesis, start appropriate therapy in a prompt manner, and improve the quality of life of PFAPA patients.

Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune states which have presentational similitude. Both conditions test serologically positive for anti-nuclear antibodies and require exceptional differential diagnostic acumen to segregate one from the other. The hypothesized factors provoking these diseases may be immunological, genetic, hormonal, or environmental and can be better understood by large-scale controlled epidemiological studies. Biochemical factors such as variation in CXC (an α chemokine subfamily), CXCL13, and granulocyte-macrophage colony-stimulating factor levels are assumed to play a pivotal role in the pathogenesis of SLE and MG; however, further studies are required to understand their exact mechanism and effect on the underlying autoimmune diseases. Following this, another precipitating factor for this overlap is believed to be thymectomy which is performed to eliminate MG symptoms. Although thymectomy is the effective treatment modality in MG patients, other findings and data support the view that this procedure may lead to the development of other autoimmune states such as SLE. It is evident from previously published data and case reports that patients with one autoimmune disease who underwent thymectomy contracted SLE and became more susceptible to other autoimmune diseases compared to the general population. Post-thymectomy follow-up of patients provides us with mechanistic clues for understanding the development of SLE-MG overlap; hence, in MG patients who have undergone thymectomy, any clinical and immune serological SLE suspicion should be carefully evaluated.

Patients on immunosuppressant agents, including oral corticosteroids, are susceptible to fungal colonization despite being otherwise immunologically intact. This case report highlights a state-of-the-art biological modifier therapy for the complex care of a patient with refractory occupational asthma, allergic rhinitis, and mixed fungal colonization. A dyspneic 38-year-old male janitor with steroid-dependent occupational asthma refractory to omalizumab therapy was colonized with Candida and Alternaria following a promotion to a managerial position in a moldy office. He was treated with itraconazole and systemic steroids. Pulmonary workup revealed moderate obstructive ventilatory defect, peripheral airway hyperresponsiveness, and eosinophilic airway inflammation. Three additional biological modifiers (reslizumab, benralizumab, and dupilumab) were administered to this patient. His asthma was ultimately controlled with reslizumab and dupilumab. Fractional exhaled nitric oxide (FeNO) normalized after dupilumab monotherapy, enabling the patient to taper off chronic prednisone therapy. Various occupational exposures are crucial epidemiologic factors related to infection and go hand-in-glove with long-term prednisone treatment towards increasing susceptibility to fungal colonization. Steroid-sparing anti-interleukin-5 (IL-5) agents and dupilumab should be considered as alternative treatment options for patients, such as ours, with eosinophilic, prednisone-dependent asthma refractory to omalizumab therapy.

Eosinophilic granulomatosis with polyangiitis (EGPA) is an exceptionally rare systemic necrotizing vasculitis. The disease is clinically characterized by asthma with concomitant blood and tissue eosinophilia, often progressing to eosinophilic vasculitis. From the onset of asthma, there is usually a three to nine year delay of EGPA diagnosis. We report a case of this highly uncommon disease identified in an early stage.

Aseptic viral meningitis is the most common cause of meningitis in the United States. Most cases of herpes simplex virus meningitis are caused by herpes simplex virus type 2 (HSV-2), with HSV-1 primarily causing viral encephalitis. In this report, we present a case of aseptic meningitis generated by the HSV-2 in an immunosuppressed 35-year-old female with a recent diagnosis of genital herpes that was left untreated due to reported side effects of medication.

Drug-induced immune hemolytic anemia (DIIHA) is a rare type of immune-mediated hemolytic anemia, and mainly it is caused by antibiotics. There have been few case reports of contrast medium-induced immune hemolytic anemia. Here, we report a case of a 70-year-old woman who was admitted with community-acquired pneumonia. She had a CT abdomen and pelvis using iohexol (omnipaque), which resulted in severe hemolytic anemia and contributed to the patient’s death. This case illustrates a very rare complication of IV contrast medium that may result in death.

We present a 44-year-old male patient, exposed to tobacco smoke and alcohol, with a locally advanced, multiple recurrent squamous cell carcinoma (SCC) of the vocal cord who had undergone resection four times. The patient rejected the mutilating surgery or radiation therapy due to the expected severe lifelong consequences. Instead, the patient opted for complex immunotherapy combining low doses of checkpoint inhibitors ipilimumab-nivolumab (0.3 and 0.5 mg/kg, respectively) with fever-inducing interleukin-2 (IL-2) and hyperthermia, which induced complete remission (CR). Restaging with MRI and laryngoscopy demonstrated lasting remission ongoing now for two years. The fact that this patient is free of any cancer-related signs or symptoms raises the possibility of a long-lasting remission even after the fourth recurrence of a locally advanced squamous cell vocal cord cancer by the induction of therapeutic fever combined with a safe low-dose ipilimumab plus nivolumab therapy to endorse T-cell function.

Fixed drug eruption (FDE) is a common cutaneous drug eruption. We are the first to report a case of polysensitive FDE to both trimethoprim-sulfamethoxazole (TMP-SMX) and doxycycline. Diagnosis of FDE is largely clinical, and it is important to establish a good medication history to identify the causative agent. Treatment depends on avoidance of the implicated drug.

Bacillus Calmette-Guérin (BCG) local scar inflammatory reactions have been mostly associated with Kawasaki disease in children and less commonly with other viral infections (i.e., measles). BCG scar inflammation associated with or following vaccine administration has only been reported with the influenza vaccine. We describe the first reports in the literature of local BCG inflammation following two different available messenger ribonucleic acid (mRNA) anti-severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2) vaccines (mRNA-1273, and BNT162b2) in two young healthy physicians, one from Costa Rica, and another from the United States of America, with normal cell blood counts, flow cytometries, and negative for human immunodeficiency virus (HIV). In both cases, BCG scar inflammation appeared after 24 hours of vaccination of the second dose, without signs of reaction on the injection site, and resolved within four days. Dermoscopic findings in one case showed arborizing and comma-shaped vessels. Pharmacovigilance surveillance of BCG scar reactions following coronavirus disease 2019 (COVID-19) vaccines should be considered particularly in countries where BCG is part of their national immunization programs.

Coronavirus disease 2019 (COVID-19) is a respiratory disease that has been reported to have a wide array of extrapulmonary manifestations. Our knowledge regarding this virus is constantly evolving, and new literature is being published every day. Children usually have a mild severity of COVID-19 infection. A variety of skin lesions have been documented in this disease. Similarly, our 18-month-old patient who was diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection had mild symptoms, but three days later he presented to the hospital with the development of urticarial lesions followed by angioedema. In this case report, we have attempted to highlight a possible association of angioedema and urticarial with coronavirus infection. Physicians should be aware of this association and should always inquire about symptoms of respiratory illness (SARS-CoV-2) while dealing with patients in whom a specific trigger for angioedema/urticaria is un-identifiable.

Kounis syndrome (KS) is defined as an allergic or hypersensitivity reaction leading to coronary vasospasm and acute coronary syndrome. The inflammatory mediators released during the body's reaction to an allergen causes vasoconstriction, plaque rupture, platelet aggregation, and even thrombosis of an existing coronary stent. Over the years, many allergens including drugs, environmental exposures, and animal and insect bites have been implicated in KS. Patients may present with elevated cardiac enzymes and electrocardiographic changes. We describe a case of a patient with no prior cardiac history who presented to the emergency department seeking treatment after multiple bee stings. The patient had non-specific electrocardiogram (ECG) changes and elevated cardiac enzymes consistent with a non-ST-elevation myocardial infarction. The patient underwent a pharmacologic stress test and myocardial perfusion imaging, which showed a perfusion defect consistent with ischemia. Selective right and left coronary angiography revealed a critical lesion at the proximal left circumflex artery. This was managed with percutaneous coronary intervention utilizing a bare-metal stent.

Pemphigoid diseases are a group of blistering autoimmune pathologies including pemphigus vulgaris (PV) and pemphigus foliaceous, which affect mucocutaneous tissues. Non-steroidal anti-inflammatory drugs, penicillamine, and angiotensin-converting enzyme inhibitors such as captopril and enalapril are associated with drug-induced pemphigoid. We present a case of lisinopril-associated PV which has not been previously reported.

Castleman disease (CD) is a disorder characterized by lymphoid proliferation. It is not usually the first differential for pyrexia of unknown origin (PUO) because of the extremely rare incidence worldwide. We report the case of a 24-year-old man with PUO for six months. He had been previously investigated for infective, rheumatological, and immunological causes. Extrapulmonary tuberculosis was considered as the most likely diagnosis because of his clinical presentation and locality. Based on this, he was given a trial of anti-tuberculous therapy. However, he did not show any signs of improvement despite being compliant with the medications. His condition was further complicated by the development of ascites. Upon treatment failure, the patient presented to our tertiary care hospital and was investigated for a possible revision of diagnosis. Based on clinical assessment and histopathology of the lymph nodes, he was diagnosed with idiopathic multicentric CD overlapping with systemic lupus erythematosus. He was started on azathioprine and prednisone and showed a positive response, indicated by a decreasing erythrocyte sedimentation rate and C-reactive protein. The patient continues to be healthy and in remission to date.

The prevalence of allergic rhinitis (AR), including symptoms of sneezing, nasal itching, airflow obstruction, and nasal discharge caused by histamine and immunoglobulin E (IgE)-mediated reactions, is ~30% in the U.S. Recent studies seem to suggest that the allergic inflammatory processes in AR may be induced by the interaction between an allergen (trigger) and the nasal microbiome (substrate). In this study, we have identified two agents with antihistaminic and microbiome-modulating characteristics that can be administered intranasally, namely, chlorpheniramine maleate (CPM) and xylitol (X). This study aimed to test the efficacy of intranasal CPM plus xylitol (CPM+X) nasal for the treatment of AR in an outpatient setting. A multicenter, randomized, double-blind, 30-day pilot study was conducted during the spring of 2019. After starting five days of placebo therapy (run-in period), patients with moderate-to-severe AR nasal symptoms were randomized to treatment with CPM+X (n=16) spray and nasal saline placebo (PLB; n=13). Both treatments were administered in the form of one spray dose (~100 µL of the solution containing 1.25 mg CPM) per nostril twice a day. Outcome variables were the changes in visual analog scale (VAS) and daily symptoms score (DSS) at days 1, 5, 10, 15, 25, and 30 after the initiation of the treatment. ANOVA (analysis of variance) with repeated revealed a significant treatment-by-time interaction such that the CPM+X group had a significant decrease (p < 0.05) in both DSS (∆-3.0 ± 2.7) and VAS (∆-3.8 ± 2.0) scores compared to PLB after 30 days. The difference in DSS and VAS scores between the groups was evident just after five days (day 10) of using CPM+X. The CPM+X scores were significantly lower (p < 0.008) starting from day 10 compared with day 1, whereas there were no statistically significant (p > 0.008) changes in the PLB during the 30-day treatment window. The present data suggest that nasal CPM+X use effectively improves AR symptoms. A large-scale study of the long-term effects of CPM+X for the treatment of other chronic respiratory disorders and the potential microbiome-modulating effects warrants further investigation.

Stevens-Johnson syndrome (SJS) is a life-threatening acute and fatal dermatological disease. It can present with many variations and rapidly worsens in a short period of time. Early diagnosis and management play an important role in stopping SJS from progression. Various drugs such as antibiotics, anticonvulsants and non-steroidal anti-inflammatory drugs can trigger the disease as an adverse effect. Oral and dental manifestation of SJS is uncommon. However, dentists should be clinically oriented towards signs and symptoms of the disease, both oral and systemic. We present a case of a 37-year-old male with no past medical history who presented to the dental emergency clinic complaining of dysphagia and burning sensation in the mouth. On oral examination, oral rash and blisters were observed. In addition, a bilateral forearm erythematous, non-blanching painful rash with some blisters was found after antibiotic administration three days earlier. The antibiotic was stopped and the patient was started on topical betamethasone for 14 days, topical chlorhexidine for 10 days, and oral nystatin suspension 100,000 units. A complete resolution of the oral and systemic manifestation was seen without the need for hospital admission.

In more recent years, the use of medical adhesives in lieu of sutures or staples has become increasingly common for the closure of post-surgical and traumatic incisions in areas of the skin where tension is low. While medical adhesives possess many advantages and little risk of adverse side effects, there are increasing numbers of accounts in the medical literature of allergic contact dermatitis (ACD) caused by specific components contained within the medical adhesives. The goal of this paper is to provide physicians with a differential diagnosis when faced with complications after the use of medical adhesives for wound closure. Additionally, this paper aims to delineate the differences among the most commonly used adhesives, provide a rationale for assessing an individual's personal risk of developing ACD, and to highlight the unique advantages and disadvantages of each adhesive. Dermabond® appears to be the most versatile adhesive with the lowest risk of ACD. However, because of its high cost, it may not be appropriate for all patients. While Mastisol® can only be utilized in combination with a dressing, such as Steri-Strips®, it is much more affordable than Dermabond and is still capable of providing an effective wound closure. Due to these factors, it is our recommendation that Dermabond is considered the first-line medical adhesive due to its versatility and strength, while Mastisol can be readily employed in situations with financial consideration. As the number of patients treated with medical adhesives continues to grow, physicians should anticipate an increase in the number of cases of ACD secondary to adhesive sensitization. It is imperative for physicians to be able to differentiate between a case of ACD and another potentially more serious complication, such as cellulitis. We hope that this paper will assist providers in distinguishing adhesive-induced ACD and other complications, identifying patients at risk of ACD from adhesive use, and provide a basis for which adhesives are most appropriate for any given patient.

We describe a case of a suspected cutaneous hypersensitivity reaction to ticagrelor. The patient displayed a localized bullous fixed drug eruption after being loaded with ticagrelor, which resolved with oral antihistamines and topical steroids after one week. Clopidogrel and rivaroxaban were successfully administered as alternative antithrombotic therapy without any apparent further hypersensitivity skin reaction.

Levetiracetam (LEV) is a commonly prescribed anti-seizure medication for the prophylaxis and treatment of focal and generalized seizures. However, a few significant LEV-associated adverse effects have been reported in the literature. Here, we describe a case of significant thrombocytopenia within 24 hours of IV LEV administration for generalized seizures in an anticoagulated immunocompetent patient that completely resolved following discontinuation of the medication. Increased awareness of this uncommon thrombocytopenic side effect of LEV especially in the setting of anticoagulation is important for clinicians providing care to patients with a history of seizures due to the heightened risk of clinically significant bleeding.

Sarcoidosis is a disease with an unknown cause that affects multiple organ systems and has a varied clinical presentation. Often, its symptomatology mimics other disease processes, such as lymphoma, tuberculosis, and amyloidosis. The reticuloendothelial involvement and typical B symptoms of weight loss, fatigue, night sweats, and lymphadenopathy can make sarcoidosis often easily confused with lymphoma. Sarcoidosis has a myriad of central nervous system (CNS) effects, which are often not recognized as symptoms of the disease. These neuropsychiatric symptoms can include, but are not limited to, cognitive decline, headaches, and personality changes. In this report, we discuss a case of a patient who presented with symptoms consistent with indolent lymphoma but was eventually diagnosed with sarcoidosis with extrapulmonary manifestations.

A 51-year-old female patient was admitted to our hospital for medical evaluation and treatment of a syncopal episode following multiple bee stings. The syncopal episode was attributed to an allergic reaction and the patient was treated with intravenous hydration and anti-histamines. Twenty-four hours later, the patient manifested an acute coronary syndrome with chest discomfort, electrocardiographic disorders, and myocardial enzyme motility (including troponin). Coronary angiography was performed without revealing pathological findings and she was diagnosed with Kounis syndrome type I. The management of the patient included administration of single antiplatelet therapy combined with a calcium channel blocker (CCB). The patient follow-up was uncomplicated. In patients with Kounis syndrome type I undergoing a normal coronary angiography, in the absence of specific guidelines, single antiplatelet therapy and CCB may be a reasonable approach.

We present the case of a 79-year-old man on hemodialysis with immunoglobulin A (IgA) vasculitis. He developed palpable purpura three weeks after having pneumonia. A skin biopsy showed leukocytoclastic vasculitis with IgA and C3 deposition. He received a topical corticosteroid for his IgA vasculitis. He was also diagnosed with a metastatic liver lesion, which was thought to be of colorectal origin because of the elevations in carcinoembryonic antigen and cancer antigen 19-9 levels. The skin biopsy played an important role in the diagnosis of the patient on hemodialysis. Pneumonia and a metastatic liver lesion thought to be from colorectal cancer might be related to the pathogenesis of IgA vasculitis.

Angiotensin-converting enzyme inhibitors (ACE-i) are commonly used medications to treat hypertension and congestive heart failure. Angioedema is a well-established side effect of ACE-i and most commonly manifests as swelling of the mucosal and extra-mucosal soft tissues in the head and neck. CT with contrast is generally used to evaluate for airway compromise and to exclude other etiologies of edema. Herein we present five cases that illustrate the radiological findings specific to ACE-i-induced angioedema on enhanced CT scans.

Background Kawasaki disease (KD) is an acute, febrile systemic vasculitis of early childhood. A small group of KD patients does not meet the classical presentation of KD, termed incomplete KD. Incomplete or atypical KD patients are usually infants and older children. Because of atypical manifestations of KD, timely diagnosis of KD is difficult, which leads to coronary artery complication Case presentation: We report the case of a nine-year-old boy who developed fever and right side parotitis with painful cervical lymphadenopathy leading to torticollis as the first symptom of Kawasaki disease (KD). A series of investigations revealed elevated inflammatory markers and aneurysmal dilation of coronary artery on echocardiogram, and thus he was diagnosed with atypical KD. Intravenous immunoglobulin was given and the child responded well. Coronary artery aneurysm resolved by six months. Conclusion A high index of suspicion should be maintained in children presenting with fever and unusual manifestations like lymphadenopathy and parotitis, especially where empiric antibiotics were ineffective. Evaluation of cardiac function and coronary artery status with echocardiography is helpful in defining the diagnosis of KD in such cases. As it is a noninvasive test, it should be undertaken at the first possible clinical suspicion.

Introduction The scientific merit of a paper and its ability to reach broader audiences is essential for scientific impact. Thus, scientific merit measurements are made by scientometric indexes, and journals are increasingly using published papers as open access (OA). In this study, we present the scientometric data for journals published in clinical allergy and immunology and compare the scientometric data of journals in terms of their all-OA and hybrid-OA publication policies. Methods Data were obtained from Clarivate Analytics InCites, Scimago Journal & Country Rank, and journal websites. A total of 35 journals were evaluated for bibliometric data, journal impact factor (JIF), scientific journal ranking (SJR), Eigenfactor score (ES), and Hirsch index (h-index). US dollars (USD) were used for the requested article publishing charge (APC). Results The most common publication policy was hybrid-OA (n = 20). The median OA publishing APC was 3000 USD. Hybrid-OA journals charged a higher APC than all-OA journals (3570 USD vs. 675 USD, p = 0.0001). Very strong positive correlations were observed between SJR and JIF and between ES and h-index. All the journals in the h-index and ES first quartiles were hybrid-OA journals. Conclusion Based on these results, we recommend the use of SJR and ES together to evaluate journals in clinical allergy and immunology. Although there is a wide APC gap between all-OA and hybrid-OA journals, all journals within the first quartiles for h-index and ES were hybrid-OA. Our results conflict with the literature stating that the OA publication model's usage causes an increase in citation counts.

Background Asthma is a common public health issue in the pediatric population. The prevalence of asthma in children in Saudi Arabia is increasing. All asthmatic children with continuous symptoms should use controller medications. These medications if used correctly by the patients will diminish the symptoms and avoid exacerbations that lead to hospitalization. Perception of parents toward a particular device can affect the adherence rate. Aim Assessing the parental perception about metered-dose inhalers (MDIs) and nebulizers differences among the Saudi population. Methods A cross-sectional study was conducted to assess Parental perception about MDIs and nebulizers among Saudi parents with an asthmatic child. The data were collected from the parents and caregivers by using an online questionnaire and informed consent was obtained. The questionnaire was focused on demographic characteristics, knowledge, perception and practice of treating the asthmatic child. Data were analyzed through the Statistical Package for the Social Sciences (SPSS) version 25 (IBM Corp., Armonk, NY) and the results were considered statistically significant if P < 0.05. Results A total of 1,021 participants included in this study. This study found asthma is predominant in males (64.4%) and the most affected age is between 8 and 14 years (56.3%). More than half of the parents (58.7%) had a bachelor's degree and above. MDI is the most method used for controlling asthma (32.7%) and the majority of them (70.2%) thought there is a therapeutic difference between MDI and nebulizer. Providing instructions and information on usage MDI was received from 65.2%. Significant relationships were found between the level of satisfaction and receiving enough information about MDI and level of education. Conclusion This study found that asthma is more prevalent in males, where MDI is more common. Majority of the parents had thought that there is a difference in the therapeutic effects between MDI and nebulizer. They believed that nebulizer is more effective, less side effect and cheaper while MDI is easier to use.

This article will review current treatment options for multiple sclerosis (MS) while keeping our primary focus on alemtuzumab, as it is now approved in more than 65 countries. From a pathophysiological point of view, MS is a disabling disease impacting a patient's life both physically and mentally, leading to devastating social and economic impact. This review will elaborate on alemtuzumab's role in treating relapsing-remitting MS (RRMS) by comparing its efficacy, side effects, and monitoring with other disease-modifying therapies (DMTs) available in the market. It is a point of great concern not only for physicians but also for neurologists, nephrologists, endocrinologists, dermatologists, and oncologists when encountering long-term effects of alemtuzumab in the life of treated MS patients. We hope that our review will not only benefit treating faculties but also those who are suffering from this devastating disease.

The thalidomide molecule is a remarkable molecule that exists in a racemic mixture of optical isomers. In the 1950s, due to its teratogenicity, the levorotatory isomer led to its dramatic downfall. However, the molecule with its panoramic mechanisms of action and its uncanny ability to intercalate within the geometry of deoxyribonucleic acid (DNA), led to its remarkable renaissance; thalidomide being United States Food and Drug Administration (FDA)-approved for at least 13 different indications ranging from multiple myeloma to leprosy to glioblastoma. Thalidomide-induced polyneuropathy is usually reversible and is the rate-limiting step in its long-term use. The development of a polyneuropathy is invariably associated with a cumulative dose exceeding 20 grams. However, the polyneuropathy is almost always a sensory neuropathy. Asymmetry, bona fide weakness such as difficulty standing on the heels, a poly-ganglioneuropathy pattern with widespread or patchy numbness and sensory ataxia should raise a red flag and an alternative diagnosis should be considered. We present a typical case of a thalidomide-induced sensory neuropathy in order to highlight the resurgence of thalidomide use in clinical practice. We review the literature and outline the molecular biology of the thalidomide molecule.

COVID-19 has become a pandemic. It affects multiple systems of the body including the nervous system. It invades the nervous systems through multiple routes - either olfactory tract, bloodstream (by binding to endothelial receptors) or via ACE-2 receptors in the brain. We report a case of Guillain-Barre syndrome (GBS) variant (acute motor axonal neuropathy (AMAN type)) associated with COVID-19 infection with positive polymerase chain reaction (PCR) test for COVID-19 and positive contact history with infected family member. GBS and its variants like AMAN can occur due to COVID-19 infection through its immune-mediated effects. Diagnosis of GBS should depend on the clinical and supportive criteria. The treatment should be started early to prevent progression and disease co-morbidities.

Herpes simplex virus (HSV) and cytomegalovirus (CMV) infections are commonly seen in immunocompromised patients, particularly in patients with HIV. However, fulminant CMV infection and concurrent infection with HSV and CMV in non-HIV patients are quite rare. We present the case of a 72-year-old HIV-negative man with a history of oropharyngeal carcinoma in remission and recent treatment of immune thrombocytopenic purpura with high-dose steroids who was transferred from an outside hospital for Ear Nose and Throat (ENT) evaluation of a non-healing buccal ulcer. During initial presentation, the patient was found to be febrile with acute hypoxic respiratory failure and a chest x-ray suggestive of bacterial pneumonia, though he failed to improve with broad-spectrum antibiotic therapy. He underwent esophagogastroduodenoscopy for dysphagia, which revealed a discrete ulcer positive for CMV. Biopsy of his buccal lesion was ultimately positive for HSV-1 and HSV-2. The patient's clinical status improved significantly following the initiation of antiviral therapy.It is important to consider CMV infection in the setting of persistent fever, respiratory distress, or dysphagia in the non-HIV infected patient, especially in the setting of prolonged steroid use. CMV and HSV infection can occur simultaneously at distinct sites in the body, and CMV infection may predispose to HSV reactivation due to its long term effect on cell-mediated immunity. Early recognition of opportunistic infections and initiation of antiviral therapy in immunocompromised patients can greatly affect length of hospital stay, morbidity, and, ultimately, mortality.

This study aims to describe the clinical profile of severe vaso-occlusive retinal disorders in patients with systemic lupus erythematosus (SLE) and it is a retrospective case series. The clinical characteristics of three patients with SLE with vascular occlusions in four eyes were described. Branch retinal artery occlusion (BRAO) was present in all three patients with combined non-ischemic central retinal vein occlusion (NICRVO) in one patient and evolving ischemic CRVO in another patient. Additional branch retinal artery insufficiency was observed in the other eye of a patient with BRAO. Antinuclear antibody (ANA) titer was elevated in all patients. One patient had a positive lupus anticoagulant with elevated activated partial thromboplastin time (aPTT), and concurrent homocysteinemia was present in another patient. Intravitreal anti-vascular endothelial growth factor (ranibizumab) injection was administered to two eyes. Intravenous methyl prednisolone (IVMP) injection along with oral azathioprine was used in all patients with the need for anticoagulation in two patients along with SLE treatment. Vision in two eyes did not improve to the functional level despite aggressive therapy. Visually blinding severe vaso-occlusive retinopathy in the form of BRAO with or without CRVO can manifest in patients with SLE. Undetected antiphospholipid syndrome and homocysteinemia may be associated risk factors for such ophthalmic complications.

Symptoms of dry eyes or dry mouth, otherwise known as sicca symptoms, are not always present in patients with Sjögren's syndrome (SS). Approximately 20% of patients with SS do not have sicca symptoms. An unusual case of a patient presenting with complete left-sided facial hemiparesis, a history of partial bilateral sensorineural hearing loss who was found to have elevated antinuclear antibody (ANA) with high titer positive SSA/Ro antibody, evidence of bilateral parotitis on imaging and absence of sicca symptoms, prompted us to perform a literature review. Twelve case reports relating facial nerve palsy and Sjögren's were found and only one described a similar constellation of features of unilateral facial weakness and otalgia. Management of facial nerve palsy related to Sjögren's is unclear but pharmacological agents have included corticosteroids, intravenous immune globulin (IVIG), cyclophosphamide, and plasmapheresis. This case report describes a patient whose facial nerve palsy is attributed to SS, explores peripheral and central nervous system involvement in SS, and provides some recommended treatments.

Atorvastatin is the most commonly used statin medication to decrease cholesterol levels and prevent atherosclerosis. Myopathy is a reported side effect of atorvastatin which can happen even after more than six months after starting the medication. The side effect on the muscle tissue can range from simple reversible myalgia to respiratory muscle compromise. Here we present a 46-year-old male who presented with myopathy after taking atorvastatin for two years. Biopsy proved immune-mediated necrotizing myopathy which responded to a combination of Rituximab and intravenous immunoglobulin therapy.

Introduction Respiratory allergies represent an important public health problem, with increasing prevalence and severity in Europe during the last decades. The rise of pollen allergies is an issue that continues to negatively impact people's daily lives across the globe and has become more important in the light of global warming and increasing air pollution. The aim of our paper is to evaluate the prevalence of declared atopy and the influence of lifestyle on allergic diseases, particularly on pollen allergies, in the urban environment from Romania. Methods The study is based on the cooperation Interactive Qualifying Project (IQP) called "Pollen Allergies in Romania: Optimizing Data Analysis in Raising Awareness", agreed and carried on between a group of North-American students and teachers from Worcester Polytechnic Institute and a hospital-based allergy team from Carol Davila University of Medicine and Pharmacy and Colentina Clinical Hospital from Bucharest. The project aimed to evaluate the prevalence of atopy and lifestyle practices of allergic patients and to develop a data analysis tool to determine correlations between pollen counts and other environmental factors in the city of Bucharest. Results The lifestyle survey revealed that about one-third of allergic patients declared history of atopy. Some of the declared lifestyle practices can be considered environmental risk factors for allergies. This IQP can be considered a model of international, interdisciplinary and intercultural collaboration. Conclusion We concluded that Romania is facing an increasing pollen allergies trend and some actual lifestyle aspects can significantly influence the risk of pollen allergies in the big city environment.

The disease course in a young girl with chronic immune thrombocytopenia (ITP) at the initial age of 19 months, treated with eltrombopag, was evaluated retrospectively and is presented as a case record and discussed against the background of the available literature. A stable response and reduction in clinical symptoms, over several years and without frequent dose changes, was achieved. Bleeding symptoms were mild to moderate and occurred particularly frequently in combination with low platelet counts. Raising the platelet count, in turn, was accompanied by a decreased bleeding tendency. Eltrombopag was tolerated well. No new safety signals were observed during the treatment. Based on a follow-up of more than 2.5 years, our case confirms that a child with chronic ITP can benefit from treatment with eltrombopag in the regular care setting. We assume that early treatment with a thrombopoietin receptor agonist could save many children from repeated and lengthy hospitalizations with intravenous immunoglobulins and prolonged administration of corticosteroids.

Psoriasis is a chronic relapsing/remitting autoimmune disease affecting skin and fingernails. It is associated with many other autoimmune diseases such as rheumatoid arthritis, celiac disease, Crohn's disease, and thyroid diseases. Two important autoimmune thyroid diseases - Hashimoto's thyroiditis (hypothyroidism) and Grave's disease (hyperthyroidism) - affect the body's significant organs such as the brain, muscles, digestive function, and the skin. Although some studies have established the connection between psoriasis and thyroid diseases with autoimmunity, our article provides an in-depth analysis of the connection between these two diseases and other common etiological factors associated with them, along with autoimmunity. We reviewed articles from PubMed using regular keywords and Medical Subject Headings (MeSH) keywords and finalized 45 articles to find an association between these two diseases. These articles showed that this association is more prevalent in obese patients and late-onset psoriasis. Most of the articles showed a positive association, but few articles showed no connection between them. However, there is no concrete explanation to prove the association due to limited research; additional studies are necessary. It requires the attention of both clinicians and researchers to develop a universal drug that will work on both diseases, and also thyroid evaluation could be included in psoriatic patient care so that there is a possibility to decrease cost and efforts while treating these diseases.

Introduction Many comparisons have been made on the effect and impact of COVID-19 on influenza pandemics of history. Therefore, it is reasonable to infer that the strategies utilized by healthcare providers to improve influenza vaccination rates can similarly be applied to the administration of a COVID-19 vaccine. The purpose of this study was to determine the rationale of low influenza vaccination rates in an urban allergy clinic and how to improve patient education and knowledge regarding the importance of influenza vaccination. A three-year comparison of interventions is presented as well as its application to future COVID-19 vaccinations. Methods This study was performed at an outpatient allergy and clinical immunology practice (MSBI) with hospital affiliation in New York City, New York. A quality improvement medical committee was formed to optimize influenza vaccination rates to greater than 71% and established standardized protocols regarding patient intake workflows, vaccine counseling, and documentation. Patient records from four providers were used for this study to compare pre-and post-intervention rates. Results 984 patients met inclusion criteria, with a normal distribution of ages (18-80), race, and sex. Average vaccination rates prior to the intervention were 9.25-13.60%. The average vaccination rate after the intervention was 91.34%. Discussion The MSBI quality improvement study identified key areas to address in improving influenza vaccination rates. Vaccine hesitancy, public misinformation, and ambivalence surrounding vaccination with egg allergies or during a subcutaneous immunotherapy injection were all topics addressed during the 2018-2019 intervention year. Additional attention was also put toward provider education and standardization of documentation. Shared decision making and intensive education/outreach efforts are needed by physicians and patients alike to overcome vaccine hesitancy. In comparing this to upcoming COVID-19 vaccine challenges, similar barriers will likely also need to be addressed. Greater research is needed to understand patient motivations regarding hesitancy specific to the COVID-19 vaccine. Conclusion As evidenced in the yearly battle with influenza and now the COVID-19 pandemic, it has become essential to identify and implement multi-level strategies to maximize vaccination rates, especially amid a global pandemic. With COVID-19 vaccines reaching emergency approval stages, it is important for healthcare providers to start creating workflows and strategies to address patient inquiries. The influenza vaccination quality improvement project presented here can be used as a guideline for future evaluations of COVID-19 vaccination efforts.