Reports, Volume 5, Issue 2 (June 2022) – 13 articles

A COVID-19 patient (53-year-old woman from Japan) was admitted to our hospital. She had a high fever (38.3 °C), cough, fatigue, and loss of appetite. She was a smoker and took migraine medication. A thoracic computed tomography (CT) scan showed no evidence of pneumonia. She was treated with antibiotics, protease inhibitors, inhalant corticosteroids, and antivirals. Anti-interleukin-6 receptor antibody tocilizumab (TCZ 400 mg) was added on day 2. On day 4, her temperature decreased, but her vital signs suddenly worsened, with an SpO₂ of 70% in ambient air, a blood pressure of 70 mmHg (systolic), loss of consciousness, and tachypnea. Her CT showed bilateral lung consolidation and no pulmonary embolism. She was connected to the ventilator. On day 11, her respiratory condition improved (PaO₂/FIO₂ 400), and she was able to withdraw from the ventilator. Her laboratory data (white cell count, ferritin, d-Dimer, C-reactive protein, and β₂-microglobulin) did not increase even at the time of exacerbation, except for Galectin-9 (Gal-9). The plasma Gal-9 levels increased 2.3 times from before the administration of TCZ, followed by a swift decrease associated with improvements in respiratory status. She was discharged on day 16. Patients with TCZ-treated COVID-19 require careful observation. Full article

The term leishmaniasis includes multiple clinical syndromes: visceral, cutaneous, and mucosal leishmaniasis, resulting from an infection of macrophages throughout the reticuloendothelial system in the dermis and the naso-oropharyngeal mucosa, respectively. The clinical phenotype is mainly driven by the leishmania biologic characteristics and, ultimately, also by the host immune status. The disease is endemic in focal areas in the tropics, subtropics, and southern Europe, transmitted by the bite of female phlebotomine sandflies. Sandflies regurgitate the parasite’s flagellated promastigote stage into the host’s skin; promastigotes bind to receptors on macrophages are phagocytized and transformed within phagolysosomes into non-flagellated amastigotes which replicate and infect additional macrophages. Amastigotes ingested by sandflies transform back into infective promastigotes. Depending on the host’s innate and acquired immune status, systemic and visceral leishmaniasis can be characterized by irregular fever, weight loss, enlargement of the spleen and liver, and anaemia. We present a 42 year-old man with long-lasting type 1 autoimmune hepatitis under immunosuppressive treatment. In January 2017, the patient started to experience low-grade unresponsiveness to empiric antibiotic therapy. The patient developed severe anemia and progressive multilineage cytopenia accompanied by increased levels of inflammatory markers. FDG-PET revealed increased glucose uptake in the liver, spleen, and the whole bone marrow. The subsequently performed bone marrow biopsy evidenced Leishmania amastigotes inside macrophages, confirmed by serological positivity to anti-Leishmania antibody. Immunosuppressive therapy was suspended and replaced by treatment with amphotericin B at 4 mg/kg/day from day 1 to day 5, followed by a single infusion on days 10, 17, 24, 31, and 38. The bone marrow smear after treatment still evidenced few Leishmania amastigotes; in consideration of the patient’s immunosuppression status, two further doses of amphotericin B on days 45 and 52 were employed, leading to infection resolution. In real-life, as exemplified in this case, administering two additional doses of amphotericin B (concerning the guidelines) offered an additional therapeutic opportunity for a patient under long-term immunosuppressive treatment. Full article

Infection with SARS-CoV-2, the causative agent of the COVID-19 pandemic, originated in China and quickly spread across the globe. Despite tremendous economic and healthcare devastation, research on this virus has contributed to a better understanding of numerous molecular pathways, including those involving γ-aminobutyric acid (GABA), that will positively impact medical science, including neuropsychiatry, in the post-pandemic era. SARS-CoV-2 primarily enters the host cells through the renin–angiotensin system’s component named angiotensin-converting enzyme-2 (ACE-2). Among its many functions, this protein upregulates GABA, protecting not only the central nervous system but also the endothelia, the pancreas, and the gut microbiota. SARS-CoV-2 binding to ACE-2 usurps the neuronal and non-neuronal GABAergic systems, contributing to the high comorbidity of neuropsychiatric illness with gut dysbiosis and endothelial and metabolic dysfunctions. In this perspective article, we take a closer look at the pathology emerging from the viral hijacking of non-neuronal GABA and summarize potential interventions for restoring these systems. Full article

Orbital emphysema after nose-blowing is an uncommon condition and can appear without a trigger. Herein, we reported a case of orbital emphysema after nose-blowing and performed a literature review. A 68-year-old man fell and sustained an injury near his left orbit. No symptoms were noted. He noticed a left periorbital swelling after blowing his nose. Through computed tomography examination, he was diagnosed with subcutaneous emphysema. There are no previous reports that have reviewed the clinical features, need for surgery, and severity of symptoms of subcutaneous emphysema after nasal swallowing due to different factors. We retrospectively analyzed a cohort of 48 cases by searching PubMed to clarify these issues. Regarding the emphysema trigger, 21 cases had an injury or had previously undergone surgery. In 34 cases, conservative treatment was required, while surgery was selected in the acute phase in 6 cases and after the acute phase as a radical cure in 8 cases. Reduced visual acuity, diplopia, exophthalmos, facial hypoesthesia, and color disorders were noted and were more common among surgical cases. The literature review revealed no association between fracture location and the need for surgery; furthermore, surgery was less required in non-trauma cases, excluding osteoma, than in trauma cases (p = 0.0169). Our study reveals that a strict follow-up examination of visual symptoms is necessary for the first 2 days in cases of subcutaneous emphysema caused by nose blowing after facial trauma. Full article

X-ray technology has been recently employed for the detection of the lethal human coronavirus disease 2019 (COVID-19) as a timely, cheap, and helpful ancillary method for diagnosis. The scientific community evaluated deep learning methods to aid in the automatic detection of the disease, utilizing publicly available small samples of X-ray images. In the majority of cases, the results demonstrate the effectiveness of deep learning and suggest valid detection of the disease from X-ray scans. However, little has been investigated regarding the actual findings of deep learning through the image process. In the present study, a large-scale dataset of pulmonary diseases, including COVID-19, was utilized for experiments, aiming to shed light on this issue. For the detection task, MobileNet (v2) was employed, which has been proven very effective in our previous works. Through analytical experiments utilizing feature visualization techniques and altering the input dataset classes, it was suggested that MobileNet (v2) discovers important image findings and not only features. It was demonstrated that MobileNet (v2) is an effective, accurate, and low-computational-cost solution for distinguishing COVID-19 from 12 various other pulmonary abnormalities and normal subjects. This study offers an analysis of image features extracted from MobileNet (v2), aiming to investigate the validity of those features and their medical importance. The pipeline can detect abnormal X-rays with an accuracy of 95.45 ± 1.54% and can distinguish COVID-19 with an accuracy of 89.88 ± 3.66%. The visualized results of the Grad-CAM algorithm provide evidence that the methodology identifies meaningful areas on the images. Finally, the detected image features were reproducible in 98% of the times after repeating the experiment for three times. Full article

Nocardiosis is an infrequent opportunistic infection that deserves more attention because of its increasing morbidity and high rate of misdiagnosis. Clinical and radiological manifestations as well as antibiograms of pulmonary nocardiosis are diverse. Herein, we report a patient with idiopathic thrombocytopenia treated with glucocorticoids, which later presented with severe pulmonary infection with widely distributed nodules on chest computed tomography. Fungal infection or tuberculosis was under initial suspicion and microbiological tests of bronchoalveolar lavage fluid eventually yielded an affirmative result of Nocardia cyriacigeorgica. The patient responded in the beginning; however, therapeutic strategies had to be altered several times due to adverse events. The patient eventually ended up with radiographic resolution at the end of six months. We wish to share some experience in dealing with this disease especially recognizing pulmonary nocardiosis in computed tomography imaging. Full article

Complex regional pain syndrome (CRPS) is a neurologic chronic pain condition hard to diagnose and treat, and able to significantly impact the quality of life. Currently, the available multimodal, individualized treatments (i.e., pharmacological and non-pharmacological therapies including invasive procedures) are aimed only at symptom control. Herein, we report a 69-year-old Caucasian female who came to our attention due to a 3-year history of severe (10/10) burning pain in her right ankle, along with oedema and local changes in skin color and temperature, which occurred after the ankle sprain. Previous pharmacological attempts failed due to multiple drug intolerance. Clinical examination confirmed the CRPS type I diagnosis, and a weekly diamagnetic therapy protocol was started since the patient refused further medications and interventional procedures. After 10 weeks of treatment, a significant (p < 0.01) reduction in pain severity and absence of oedema (difference in ankles’ circumference: from 3 cm to 0) were observed, with consequent improvements in quality of life and no adverse events. Although high-quality clinical evidence is still lacking, our case report suggests further investigating the potential use of diamagnetic therapy as a non-invasive and safe adjunctive treatment for CRPS, and as an alternative when patients did not benefit from drugs and/or refuse invasive procedures. Full article

Multiple sclerosis (MS) is a chronic inflammatory disease of the immune system affecting the central nervous system. Several phenotypes are possible, and cases usually present with a relapsing-remitting (RR) course with disease onset at a young age. MS diagnosis can represent a traumatic event for the patient, possibly evolving into adjustment disorder (AD). AD is defined by the presence of emotional or behavioral symptoms in response to identifiable stress occurring within the prior three months and similarly to post-traumatic stress disorder (PTSD) can significantly affect quality of life. Usually, neuropsychological disorders are not associated with AD. Several treatments are available for AD, and among them, eye movement desensitization and reprocessing (EMDR) is one of the most effective in relieving depression and anxiety. However, little is known about AD and PTSD in the MS population and no data are available on the effectiveness of EMDR for cognitive impairment associated with AD. We describe a 25-year-old patient with RR MS developing an AD with a verbal memory deficit after being diagnosed. Both the psychological and cognitive deficits were diagnosed using an extensive neuropsychological battery. Considering the high impact of the verbal memory deficit, on the patient’s quality of life, an EMDR intervention was planned. After a six-month EMDR intervention performed by two trained neuropsychologists, the patient was retested. There was an improvement in verbal memory tests and depression anxiety scales and the Dissociative Experiences Scale. It is recognized that emotional changes and psychiatric disorders, frequently affect MS patients at diagnosis. It is imperative to recognize this and promptly set a neuropsychological treatment. Moreover, we suggest checking cognition along with depression and anxiety. Finally, to our knowledge, this is the first report of AD with an isolated neuropsychological deficit (verbal memory) developed after the MS diagnosis and treated beneficially with e EMDR. More studies are needed to confirm the efficacy of EMDR in treating cognitive impairment associated with AD in MS patients. Full article

Unlike ovarian carcinomas, borderline ovarian tumors (BOTs) are associated with a favorable prognosis: their recurrence rate is around 5–7%, and the survival rate is more than 97% when diagnosed early. There are only a few reports of recurrence and fatal outcomes. Herein, we report a novel case of recurrent mucinous BOT, with a literature review. A 63-year-old woman presented to a local doctor with abdominal fullness. She was diagnosed as having a polycystic tumor. The lesion was suspected to be a mucinous BOT (M-BOT) on magnetic resonance imaging. Upper and lower gastrointestinal endoscopy revealed no digestive cancerous lesions, and surgery was performed. Intra-operative diagnosis confirmed the diagnosis, and total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. The final pathological diagnosis was non-invasive M-BOT (stage I c1 (T1c1N0M0)). The result of immunohistochemical staining supported the diagnosis of primary ovarian mucinous tumor.Four months after surgery, relapse occurred. Blood tests revealed an elevated carbohydrate antigen 19-9 level, and computed tomography revealed multiple liver metastases, peritoneal dissemination, left ureter infiltration, and carcinomatous peritonitis. Although the patient underwent chemotherapy, she died. This case of a very short progression-free and overall survival in stage I M-BOT indicates that some M-BOTs could result in fatal clinical outcomes despite diagnosis at an early stage. Frequent follow-up appointments after surgery could help detect relapse and increase survival in such cases. Full article

The clinical presentation of COVID-19 is non-specific, and to improve and limit the spread of the SARS-CoV-2 virus, an accurate diagnosis with a robust method is needed. A total of 500 nasopharyngeal swab specimens were tested for SARS-CoV-2. Of these, 184 samples were found to be positive with Allplex™ 2019-nCoV Assay, which is fully automated. All the positive samples were retested with TaqPath™ COVID-19 CE-IVD RT-PCR Kit (after this, referred to as TaqPath™ COVID-19), semi-automated. The comparison of RT-qPCR for SARS-CoV-2 genes target points shows only one target point in common, the N gene. Therefore, the N gene was used to compare both assays. We noticed different Ct values between the tests. Therefore, samples were divided into four groups depending to the Ct value results: (1) Ct < 25, (2) Ct 25–30, (3) Ct 30–35, (4) Ct > 35. TaqPath™ COVID-19 Kit reconfirmed the results obtained from Allplex™ 2019-nCoV Assay. In conclusion, both the Allplex™ 2019-nCoV assay and TaqPath™ COVID-19 tests accurately confirm the diagnosis of SARS-CoV-2 infection. Even if TaqPath™ COVID-19 has a semi-automated workflow, it does not introduce bias in the diagnostic screening of SARS-CoV-2, and it supports the indirect identification of variants of concern to undergo sequencing. Full article

Antiepileptic drugs prescribed in the context of migraine have been reported to be potentially linked with an increased risk of suicidal ideation and behavior. Meta-analyses support the evidence that amongst antiepileptic drugs, Topiramate has the greatest potential for facilitating the occurrence of suicidal ideation and behavior. Studies indicate that this occurs via the increased incidence of mood disorders amongst the population with migraines using Topiramate as a treatment, with a slow and progressive onset of suicidal ideation (if any). We discuss the unique case of a 43-year-old man known to have chronic migraines, who presented with intense rapid-onset suicidal ideation and olfactory hallucinations, three weeks after the introduction of Topiramate for chronic migraines. After a negative extensive investigation panel to rule out common organic diseases, Topiramate was ceased. The suicidal ideation and olfactory hallucinations resolved in less than 24 h without further interventions. This case report highlights that rapid-onset suicidal ideation and olfactory hallucinations could be linked as an unusual side effect to the introduction of Topiramate. The removal of Topiramate from the patient’s pharmacological treatments prevented further psychological distress linked to ego-dystonic suicidal ideation and a resolution of olfactory hallucinations. He was discharged 48 h later. Full article

Tarlov Cysts is a pathological condition, with low incidence, characterized by a painful component with a strong impact on quality of life. The therapeutic options are surgery or analgesics and/or anti-inflammatory medications; however, the condition is still without resolution. Herein, we are reporting a case of a woman who expressly followed a low-calorie ketogenic diet program for 3 months. In addition to the change in diet, an appreciable decrease of weight (−5 kg) and body circumferences were recorded; there was also a marked improvement (evident from the questionnaires administered) in the quality of life, of sleep, and in the perception of pain. It is interesting to note how, in conjunction with the Christmas period, upon leaving the ketogenic regime, there was a recurrence of symptoms, confirming the beneficial effect of the low-caloric ketogenic diet at least on the management of pain and, very likely, on inflammation. Full article