Search

The failure of HIV vaccine clinical trials calls for novel vaccine development strategies. Studies on HIV highly exposed seronegative sex workers showed that focused virus-specific CD8+ T-cell responses are associated with the protection. Following the unconventional HIV vaccine approach targeting 12 highly conserved sequences surrounding the protease cleavage sites (PCS), we designed multi-epitope PCS mRNA-loaded lipid nanoparticles (MEPCS-mRNA-LNP) to promote more efficient antigen presentation. The modified LNP formulation produced stable and cold-chain-friendly MEPCS-mRNA-LNP. The mice study showed the vaccinated group generates PCS-specific CD8+ memory T-cells with cytotoxic function, both systemically and at the HIV-targeted tissue sites (like HESN group), with T-polyfunctional response. As expected, little to no significant activation of CD4+ T-cells was observed. The proof-of-concept study indicates that the MEPCS-mRNA LNP vaccine approach induces immunological memory against highly conserved HIV pro-polyprotein (limiting HIV’s mutability). The MEPCS-mRNA LNP vaccine could be a potential candidate for an effective prophylactic HIV vaccine.

Introduction: Transcatheter mitral valve-in-valve (ViV) & valve-in-ring (ViR) are relatively novel therapeutic alternatives for patients with degenerated bioprostheses or failed annuloplasty rings whose reoperative risk is too high. The predominant procedural access for both procedures is transapical or transseptal. However, whether there are differences in outcomes of this procedure using transseptal versus transapical access has not yet been defined. Methods: We conducted a systematic review of all published articles from MEDLINE and EMBASE to explore the outcomes of these two procedural approaches. Results: A total of 55 studies including 183 patients (154 ViV and 29 ViR) were included. Patients that underwent ViV (101 transapical and 53 transseptal) using the transseptal approach required more iatrogenic atrial septal defect (ASD) closure (19% versus 0.0 %; P

A 20 year old male with past medical history of Type 1 Diabetes and Hypothyroidism presented to our hospital with severe hypocalcemia. His calcium was 5.8 mg/dl (normal range 8.6–10.3 mg/dl). He had been complaining of generalized weakness for weeks. Vital signs were within normal limits. Physical exam was significant for positive Chvostek sign. Other labs revealed low magnesium, low potassium, low vitamin D, low albumin, metabolic acidosis and low ferritin. He was started on supplements. Tissue transglutaminase antibody IgG was elevated. Upper gastrointestinal endoscopy showed scalloped and blunted duodenal mucosa. Duodenal biopsy showed villous blunting with intraepithelial lymphocytosis suggestive of celiac disease. He was started on gluten free diet. His symptoms improved and he was discharged home. Celiac disease can present in fulminant form with hemodynamic instability and is called celiac crisis. Celiac crisis is usually manifested by severe gastrointestinal manifestations, hypoproteinemia and metabolic and electrolyte disturbances requiring hospitalization. It is diagnosed by criteria proposed by Jamma et al. Celiac crisis is a rare presentation of celiac disease and is associated with high morbidity and mortality. Most of the cases respond to gluten withdrawal and nutritional suport and few require steroids. Abbreviation: Type 1 DM -Type 1 Diabetes Mellitus

Antiphospholipid antibody syndrome (APS) is a disorder associated with both arterial and venous thromboembolic disease, including acute myocardial infarction (AMI). Given that management with anticoagulants is critical and differs from usual AMI care, identification of key discriminators of patients with AMI with APS is important.We performed an English-language systematic review of the literature of cases and case series of patients with AMI and APS from inception until 20 March 2016, collecting demographics, investigations, and outcomes.Forty cases of AMI because of APS were identified from 27 articles. Patients were younger than typical AMI patients (41.10±13.61 years) and 45% were women. STelevation myocardial infarction was the presentation in 45% (18/40) of cases. The average platelet count was 130 000±138 912 c/mm in the 10 cases reporting it and partial thromboplastin time was elevated in all four reporting it. Coronary arteries were described as normal or with acute thrombosis in 75%. Three died during hospitalization and six had recurrence of myocardial infarction within 3 months after admission.APS should be considered in young patients with AMI, especially if previous unprovoked thromboses, lower platelet counts, high partial thromboplastin times, and normal coronary arteries or coronary thromboses are identified.

Statins are a group of drugs that reduce the levels of triglycerides and cholesterol in blood by inhibiting HMG-CoA reductase, an enzyme involved in rate limiting step in cholesterol synthesis. About 2-20% patients on statins develop toxic myopathies, which usually resolve on discontinuation of statin. More recently, an immune-mediated necrotizing myopathy has been found to be associated with statin use which in most cases requires treatment with immunosuppressants.To perform a systematic review on published case reports and case series of statin-associated autoimmune myopathy.A comprehensive search of PUBMED, EMBASE, Cochrane library and ClinicalTrials.gov databases was performed for relevant articles from inception until March 19, 2016 to identify cases of statin-associated necrotizing myopathy and characterize their symptoms, evaluation and response to treatment.A total of 16 articles describing 100 patients with statin-associated autoimmune myopathy were identified. The mean age of presentation was 64.72 years, and 54.44% were males. The main presenting clinical feature was proximal muscle weakness, which was symmetric in 83.33% of patients. The mean creatine kinase (CK) was 6853 IU/l. Anti-HMG-CoA reductase antibody was positive in all cases tested (n = 57/57, 100%). In patients with no anti-HMG-CoA antibody results, diagnosis was established by findings of necrotizing myopathy on biopsy. Among the 83 cases where muscle biopsy information was available, 81.48% had necrosis, while 18.51% had combination of necrosis and inflammation. Most (83.82%) patients received two or more immunosuppressants to induce remission. Ninety-one percent had resolution of symptoms after treatment.Statin-associated necrotizing myopathy is a symmetric proximal muscle weakness associated with extreme elevations of CK. It is common in males and can occur after months of statin use. It is associated with necrosis on muscle biopsy and the presence of anti-HMG-CoA reductase antibodies. It usually requires discontinuation and immune suppression for resolution. Rechallenge with statin is unsuccessful in most cases.

Background Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associated with sudden emotional or physical stress. Epinephrine use has been implicated in precipitating Takotsubo cardiomyopathy in multiple case reports and case series. We sought to systematically review the current English literature on this association. Methods We searched relevant articles on Takotsubo cardiomyopathy associated with epinephrine administration and extracted data on demographic characteristics, clinical features, investigations and clinical outcomes. Results We identified total of 41 cases from 36 articles. The mean age of presentation was (47.07±15.73years) with strong female preponderance (83%, P =0.0001). The most common symptom at presentation was chest pain (82%). Mean peak troponin I level was (7.12±11.22ng/ml). The most common EKG abnormality was ST elevation, seen in 40% of patients. The most common finding on echocardiography was apical hypokinesis, seen in 48.78% cases. Patients younger than 45 were less likely to have apical cardiomyopathy (n=5/20, 25%) compared to patients with age >45 (n=14/21, 66%, p value 0.001, OR 0.17). The most common route of administration of epinephrine was intravenous (65.85%). All patients except one survived with complete recovery of systolic function reported in most cases within an average of 14.7days. Conclusion Exposure to epinephrine in clinical practice can trigger Takotsubo cardiomyopathy, which is rapidly reversible with good prognosis in most cases. This review further supports the notion that both exogenous and endogenous catecholamines are associated with the pathogenesis of Takotsubo cardiomyopathy.

Background: Clozapine is a second-generation antipsychotic used in refractory schizophrenia. Clozapine can lead to pulmonary embolism (PE) by various mechanisms including immobility, weight gain and increased platelet aggregation. Objectives: We performed a systematic review on published cases of PE associated with clozapine. Methods: Comprehensive search of Medline, Embase and Cochrane library was done for relevant articles from inception until June 2017 Results: Total of 34 cases from 24 articles were included in the analysis. The mean age was 43.2 years with male predominance (63.6%). The mean dosage of clozapine was 281.4 mg daily. Duration of intake ranged from few days to many years. Nearly half of patients (47.82%) had no other co-morbidities for PE other than clozapine. For those reporting treatment, anticoagulation was chosen in 80%, thrombolysis in 10% and inferior vena cava filter placement in 5%. Mortality was 36.36% with three dying on presentation and an additional 9 dying during the follow-up period. Of the 18 patients in which follow-up data of clozapine were available, the drug was discontinued in 14 patients. Conclusion: PE can occur at doses lower than usual dose of clozapine (300 mg daily). It is important to consider this association especially in patients with no other risk factors for PE.

Glioblastoma is a highly aggressive and generally lethal brain tumor despite aggressive treatment. Treatment to ensure prolonged survival while maintaining quality of life has always been challenging, as glioblastoma occurs mostly in elderly population who already have multiple comorbidities. We present the case of a 75-year-old male who was evaluated for complaints of recurrent falls due to gait abnormalities and weakness, and was found to have multifocal glioblastoma. Despite rapid initiation of chemo radiation, he did not respond to therapy and died within 4 months of diagnosis.Keywords: brain tumor; elderly; glioblastomoma; MGMT; temozolomide(Published: 26 October 2016)Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 32372 - http://dx.doi.org/10.3402/jchimp.v6.32372

Pylephlebitis or infective suppurative thrombosis of the portal mesenteric venous system is an uncommon condition that can potentially be deadly if not recognized and treated early. Although most commonly associated with pancreatitis and diverticulitis, any intra-abdominal or pelvic infection occurring in the region drained by the portal venous system can cause this rare entity. We report a case of a 75-year-old woman who developed post polypectomy pylephlebitis following colonoscopy, a condition rarely reported in the literature.

Thrombosis is a frequent cause of morbidity and mortality in patients with nephrotic syndrome (NS). Though venous thromboses are common in NS, arterial thromboses are relatively rare. Commonly involved arteries include coronary, iliac, femoral, renal, cerebral, pulmonary, mesenteric, and axillary arteries, and the aorta. Arterial thromboses are associated with poor prognosis; treatment options are limited and patients may not always be amenable to treatment. We present the case of a 39-year-old female with NS who presented with thigh pain and was found to have sub-acute popliteal artery thrombosis.

A 41-year-old female presented to the hospital with sore throat and shortness of breath. She was hypoxic with an oxygen saturation of 87% in room air. Physical examination revealed swollen uvula with exudates. She had been started on topiramate for treatment of migraine few months ago. The dose of topiramate was increased to 100 mg twice daily 2 weeks ago. Complete blood count revealed an absolute neutrophil count (ANC) of 8 c/mm3. She was intubated and started on broad-spectrum antibiotics. She was transferred to our hospital on the fifth day of hospitalization. On arrival, her absolute neutrophil count was 10 c/mm3. Her agranulocytosis was attributed to topiramate after ruling out other possible causes. ANC improved after topiramate was stopped. ANC increased to 1000 after 5 days of stopping topiramate. We also reviewed published cases of topiramate-associated agranulocytosis. Agranulocytosis is a rare side effect of topiramate, and only 3 case reports have been published so far. In all cases, agranulocytosis developed after months of topiramate therapy and when dose was increased to 200 mg daily suggesting a dose-dependent effect. Next steps would be further research on the pathogenesis of agranulocytosis associated with topiramate and creation of registry for data synthesis.

Introduction Cosmetic injections with silicone and polymethylmethacrylate are not FDA approved for augmentation of body parts such as breast, buttock or legs, but they have been widely used for decades. Cosmetic injections can cause foreign body granulomas and occasionally severe and life-threatening hypercalcemia. We aimed to systematically analyze the published literature on cosmetic injection-associated hypercalcemia. Methods We searched relevant articles on hypercalcemia associated with various cosmetic injections and extracted relevant data on demographics, cosmetic injections used, severity of hypercalcemia, management and outcomes. Results We identified 23 eligible patients from 20 articles. Mean age was 49.83 ± 14.70 years with a female preponderance (78.26% including transgender females). Silicone was most commonly used, followed by polymethylmethacrylate and paraffin oil (43.48, 30.43, and 8.70% respectively). The buttock was the most common site followed by the breast (69.57% and 39.13% respectively). Hypercalcemia developed at mean duration of 7.96 ± 7.19 years from the initial procedure. Mean ionized calcium at presentation was 2.19 ± 0.61 mmol/L and mean corrected calcium at presentation was 3.43 ± 0.31 mmol/L. 1,25-Dihydroxyvitamin D (1,25(OH)2D or calcitriol) was elevated while 25-hydroxyvitamin D (25(OH)D) and PTH were low in majority of cases. Hypercalcemia was managed conservatively with hydration, corticosteroids and bisphosphonates in majority of cases. Surgery was attempted in 2 cases but was unsuccessful. Renal failure was the most common complication (82.35% cases) and 2 patients died. Conclusion Hypercalcemia from cosmetic injections can be severe and life threatening and can present years after the initial procedure. Cosmetic injection-associated granuloma should be considered a cause of hypercalcemia, especially in middle-aged females presenting with non-PTH-mediated, non-malignant hypercalcemia, which is often associated with elevated calcitriol; however, it should be noted that calcitriol level may be normal as well.

We describe a case of 40-year-old woman who presented to our hospital with symptoms of non-radiating epigastric pain for 4–5 days associated with nausea and vomiting. Her history was significant for asthma with recurrent exacerbations, polyneuropathy and recurrent sinus infections. Liver function tests revealed cholestasis. Antinuclear antibody and antismooth muscle cell antibody were positive. Liver biopsy revealed active chronic hepatitis with cholestasis. A diagnosis of autoimmune hepatitis was made. All other causes of cholestatic jaundice were ruled out. Her history of recurrent asthma exacerbations, eosinophilia, recurrent sinus infections and positive myeloperoxidase antibodies was suggestive of eosinophilic granulomatosis with polyangiitis. She was found to have combination of autoimmune hepatitis and eosinophilic granulomatosis with polyangiitis, a rarely reported association in the medical literature. She was started on prednisone for her autoimmune hepatitis. On follow-up with her gastroenterologist, her transaminases were trending down and she was symptomatically better.

Epiploic appendagitis (EA) is an uncommon cause of abdominal pain. It is a benign condition but may mimic other serious causes of acute abdomen such as appendicitis, diverticulitis, and gynecological emergency in severe cases. Knowledge of this condition in the differential diagnosis of abdominal pain can save unnecessary hospital admission, antibiotics, and surgery. In this article, we present the case of a 43-year-old female who presented to our hospital with a 2-day history of right lower quadrant abdominal pain and diarrhea. She was diagnosed with EA with computed tomography of abdomen with contrast and was managed conservatively with good outcome.Keywords: abdominal pain; abdominal CT; conservative management; diverticulitis; epiploic appendagitis; epiploic appendage; hyperattenuating ring(Published: 15 December 2016)Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 32960 - http://dx.doi.org/10.3402/jchimp.v6.32960

Disseminated mucormycosis endocarditis is extremely rare, and only a few cases have actually been reported in the literature. It is almost universally fatal despite aggressive surgical and medical management. In this article, we present the case of a 48-year-old immunocompromised male with mucormycosis endocarditis, who presented with acute bilateral lower extremity ischemia and passed away due to subsequent multi-organ failure. To our knowledge, this is the first case report of disseminated mucormycosis native valve endocarditis presenting as acute bilateral lower extremity ischemia.Keywords: acute lower extremity ischemia; disseminated; fungal endocarditis; native valve; mucormycosis(Published: 15 December 2016)Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 33215 - http://dx.doi.org/10.3402/jchimp.v6.33215

Recent studies suggested that deferring percutaneous coronary intervention (PCI) on the basis of nonischemic fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in patients with an initial presentation of acute coronary syndrome (ACS) is associated with worse outcomes than those in

Gonococcus typically affects the mucosal surfaces but in rare cases can spread to bloodstream causing disseminated gonococcal infection (DGI). The usual presentation of DGI is rash, polyarthralgia, and tenosynovitis. We present the case of a 23-year-old female who presented to our hospital with pustular rash and tenosynovitis of hand and was sent home on Augmentin. Her symptoms worsened despite treatment and she presented back to the ED. On investigation, she was found to have DGI and was appropriately treated. DGI should be kept in mind in sexually active youngsters who have only one or two features of the classic triad of rash, tenosynovitis, and arthritis. Timely management and appropriate treatment of DGI is very important to avoid complications and morbidity.Keywords: disseminated; gonococcus; tenosynovitis; culture; rash; arthritis(Published: 6 July 2016)Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 31841 - http://dx.doi.org/10.3402/jchimp.v6.31841

We report a case of a 37-year-old woman who presented to our hospital with retrosternal chest pain following intramuscular administration of epinephrine due to presumed anaphylaxis. On arrival, she was found to have ST segment depression in the anterolateral leads on ECG and elevated cardiac troponins. She was diagnosed with stress cardiomyopathy based on left ventricle dysfunction and angiographically normal coronary arteries on cardiac catheterisation. To the best of our knowledge, this is the third reported case of takotsubo cardiomyopathy following appropriately dosed intramuscular administration of epinephrine for anaphylaxis. This case highlights the importance of considering stress cardiomyopathy in patients presenting with chest pain syndrome following systemic administration of epinephrine.

Vertebral osteomyelitis due to Streptococcus viridans following a dental procedure is a rarely reported phenomenon. We discuss the case of a 67-year-old immunocompetent woman who presented with low back pain of 3 weeks duration associated with subjective fever and chills. On admission, the MRI of the lumbar spine showed L5-S1 vertebral osteomyelitis with associated paravertebral and epidural abscesses. Subsequently, detailed history was retaken and the patient reported having had a maxillary tooth extraction followed by a dental implant 2 months prior to the onset of her symptoms. Blood and abscess fluid cultures grew S. viridans. Transthoracic echocardiogram showed no evidence of endocarditis. The patient was started on intravenous ceftriaxone but her treatment course was complicated by agranulocytosis requiring a switch to vancomycin. She required a total of 9 weeks of intravenous antibiotics for complete clinical cure.

A 36-year-old woman presented to the emergency department after she woke up with painful spasm of bilateral hands. She had been vomiting 10–15 times daily for the past few days. She denied any laxative or diuretic abuse. She had 18-year history of bulimia nervosa, primarily involving self-induced vomiting and excessive exercising. Her body mass index was 20.7 kg/m2. Vital signs and physical examination were unremarkable except for dry oral mucosa, poor oral dentition and classic bilateral carpopedal spasm (figure 1). Labs revealed hypocalcaemia (ionised calcium 0.88 mmol/L), hypokalaemia (potassium 2.8 mEq/L), hypomagnesaemia (magnesium 1.6 mEq/L), metabolic alkalosis (serum …

Thyrotoxic periodic paralysis is a potentially life-threatening condition associated with recurrent episodes of muscle weakness and hypokalaemia due to hyperthyroidism. Diagnosis is often delayed or misdiagnosed due to its rarity in the western world and subtle features of hyperthyroidism on initial presentation. Here we present the case of a 25-year-old man who presented to the emergency department (ED) with sudden onset weakness of bilateral upper and lower extremities. His labs revealed hypokalaemia with elevated T4 and suppressed thyroid-stimulating hormone and he was diagnosed with thyrotoxic periodic paralysis. He was treated with potassium repletion, atenolol and methimazole with complete reversal of his paralysis within the next day. Unfortunately, he failed to keep the follow-up appointment after discharge, ran out of his methimazole and landed up in the ED again.

Strongyloidiasis is a parasitic infestation caused by Strongyloides stercoralis . Most cases are asymptomatic; however, symptomatic patients may present with a wide range of non-specific cutaneous, pulmonary, or gastrointestinal symptoms posing a diagnostic dilemma and delay in diagnosis. We report a case of a 58-year-old female who presented with months of generalized pruritus and abdominal discomfort along with persistent eosinophilia due to strongyloidiasis, which completely resolved with treatment.

Isolated pulmonary valve endocarditis in intravenous drug users is a rarely reported phenomenon. We present the case of a 25-year-old male with history of intravenous drug use who presented with respiratory symptoms after failing outpatient treatment for community-acquired pneumonia. Further investigations identified multiple lung lesions with early cavitation, concerning for septic pulmonary embolism on computerized tomography scan, positive blood cultures with methicillin-susceptible staphylococcus aureus , and isolated vegetation of the pulmonic valve on transthoracic echocardiography. The patient had a complete recovery after being treated medically with intravenous oxacillin for a total of 6 weeks. Keywords: native pulmonary valve; bacterial endocarditis; staphylococcus aureus (Published: 26 October 2016) Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6 : 32827 - http://dx.doi.org/10.3402/jchimp.v6.32827