Co-presentation of human T-cell lymphotropic virus type 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis and adult-onset infective dermatitis associated with HTLV-1 infection

Background  Human T-cell lymphotropic virus type 1 (HTLV-1) is the etiologic agent of adult T-cell leukemia/lymphoma (ATLL), HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), infective dermatitis associated with HTLV-1 (IDH), and various other clinical conditions. Several of these diseases can occur in association. Objective  Report an association of diseases related to HTLV-1 infection, occurring in an unusual age group. Methods  Dermatological and laboratory exams were consecutively performed in HTLV-1-infected individuals from January 2008 to July 2010 in the HTLV Outpatient Clinic at the Institute of Infectious Diseases “Emilio Ribas” in São Paulo, Brazil. Results  A total of 193 individuals (73 HAM/TSP and 120 asymptomatic carriers) were evaluated, three of which were associated with adult-onset IDH and HAM/TSP. In all three cases, the patients were affected by IDH after the development and progression of HAM/TSP-associated symptoms. Limitations  Small number of cases because of the rarity of these diseases. Conclusion  We draw attention to the possibility of co-presentation of adult-onset IDH in patients with a previous diagnosis of HAM/TSP, although IDH is a disease classically described in children. Thus, dermatologists should be aware of these diagnoses in areas endemic for HTLV-1 infection.

Non-neoplastic bulky mediastinal mass presentation in an adolescent patient: a case report

Abstract : Introduction Mediastinal masses in pediatric patients are very heterogeneous in origin and etiology. In the first decade of life, 70% of the mediastinal masses are benign whereas malignant tumors are more frequent in the second decade of life. Among the mediastinal masses, lymph nodes are the most common involved structures and could be enlarged due to a lymphoma, leukemia, metastatic disease, or due to infectious diseases as sarcoidosis, tuberculosis and others. Case presentation. We report a case of a 13-year-old Caucasian girl who came to the emergency room with a history of intermittent fever, weight loss and night sweating for at least 1 month. A radiologic image work-up presented an anterior and posterior mediastinal mass. The 18F-fluorodeoxyglucose positron emission tomography presented a high maximum standard uptake value, which directed our decision for mediastinal biopsy for diagnostic elucidation. Histologic examination described the mass as granulomatous tuberculosis. The patient was treated with anti-tuberculosis therapy and developed a full clinical recovery. Conclusions . The present case report demonstrates that a bulky mediastinal lymphadenopathy detected on 18F-fluorodeoxyglucose positron emission tomography is not always a malignant lesion, and in countries where tuberculosis is endemic, this etiology should not be forgotten during clinical investigations. There is a need for more accurate cut-off values for this technology; meanwhile, the further investigation of patients with bulky mediastinal masses with procedures such as the open biopsy is indispensable.

Analysis of the influence of epitope flanking regions on MHC class I restricted antigen presentation

Peptides presented by MHC class I molecules for CTL recognition are derived mainly from cytosolic proteins. For antigen presentation on the cell surface, epitopes require correct processing by cytosolic and ER proteases, efficient TAP transport and MHC class I binding affinity. The efficiency of epitope generation depends not only on the epitope itself, but also on its flanking regions. In this project, the influence of the C-terminal region of the model epitope SIINFEKL (S8L) from chicken ovalbumin (aa 257-264) on antigen processing has been investigated. S8L is a well characterized epitope presented on the murine MHC class I molecule, H-2Kb. The Flp-In 293Kb cell line was transfected with different constructs each enabling the expression of the S8L sequence with different defined C-terminal flanking regions. The constructs differed at the two first C-terminal positions after the S8L epitope, so called P1’ and P2’. At these sites, all 20 amino acids were exchanged consecutively and tested for their influence on H-2Kb/S8L presentation on the cell surface of the Flp-In 293Kb cells. The detection of this complex was performed by immunostaining and flow cytometry. The prevailing assumption is that proteasomal cleavages are exclusively responsible for the generation of the final C-termini of CTL epitopes. Nevertheless, recent publications showed that TPPII (tripeptidyl peptidase II) is required for the generation of the correct C-terminus of the HLA-A3-restricted HIV epitope Nef(73-82). With this background, the dependence of the S8L generation on proteasomal cleavage of the designed constructs was characterized using proteasomal inhibitors. The results obtained indicate that it is crucial for proteasomal cleavage, which amino acid is flanking the C-terminus of an epitope. Furthermore, partially proteasome independent S8L generation from specific S8L-precursor peptides was observed. Hence, the possibility of other existing endo- or carboxy-peptidases in the cytosol that could be involved in the correct trimming of the C-terminus of antigenic peptides for MHC class I presentation was investigated, performing specific knockdowns and using inhibitors against the target peptidases. In parallel, a purification strategy to identify the novel peptidase was established. The purified peaks showing an endopeptidase activity were further analyzed by mass spectrometry and some potential peptidases (like e.g. Lon) were identified, which have to be further characterized.

Spatial and temporal flower presentation in Apiaceae-Apioideae

Alle Doldengewächse (Apiaceae), darunter die größte, weltweit verbreitete Unterfamilie der Apioideen, weisen in ihren Blütenständen sehr einheitliche Merkmale auf. Die ‚Doppeldolden´ werden aus kleinen, weißen oder gelben Blüten gebildet und von vielen unspezialisierten Insekten besucht. Der uniforme Eindruck, der damit erweckt wird, ist unter Umständen ein Grund, dass die zugrundeliegende Morphologie bislang wenig untersucht wurde. Gegenstand der vorliegenden Dissertation ist es daher, die ‚verborgene Diversität´ im Blütenstandsbereich der Apiaceae -Apioideen mit dem Ziel darzustellen, den Einfluss der Architektur der Pflanzen auf die Art der Blütenpräsentation in Raum und Zeit und damit auf das Reproduktionssystem der Art zu ermitteln. Im ersten Kapitel zeigt der Vergleich von neun ausgewählten Arten, dass in den selbstfertilen und unspezifisch bestäubten Pflanzen durch Synchronisation und Rhythmik in der Präsentation von Blüten Fremdbefruchtung gefördert wird. Entweder durchlaufen die Pflanzen dabei nur eine getrennte männliche und weibliche Blühphase (Xanthoselinum alsaticum) oder der moduläre Bau der Pflanzen führt zu einer Folge männlicher und weiblicher Blühphasen (multizyklische Dichogamie). Die Diözie in Trinia glauca kann in diesem Zusammenhang als eine Trennung der Blühphasen auf verschiedengeschlechtliche Individuen gesehen werden. Für die andromonözischen Arten wird gezeigt, dass der Anteil funktional männlicher Blüten mit steigender Doldenordnung nicht einheitlich zu- oder abnimmt. Dadurch fungieren die Pflanzen zu verschiedenen Zeiten und mit unterschiedlicher Stärke eher als Pollenrezeptoren oder Pollendonatoren. Es wird deutlich, dass das ‚uniforme Muster‘ der Apioideen mit Dolden verschiedener Ordnungen, dichogamen Blüten und deren diversen Geschlechtsausbildungen ein komplexes Raum-Zeit-Gefüge zur Optimierung des Reproduktionssystems darstellt. Das zweite Kapitel stellt die Ergebnisse von Manipulationsexperimenten (Handbestäubung, Bestäuberabschirmung, Entfernen von Dolden niedriger Ordnung) an Chaerophyllum bulbosum dar, die zeigen, dass das Raum-Zeit-Gefüge in der Präsentation der Blüten der Art erlaubt, flexibel auf Umwelteinflüsse zu reagieren. Es stellt sich heraus, dass mechanische Beschädigungen kaum Einfluss auf den Andromonöziegrad und prozentualen Fruchtansatz der Individuen nehmen. Grundvoraussetzung der Reaktionsfähigkeit ist wiederum deren modulärer Bau. Dieser erlaubt es den Pflanzen, zusammen mit dem andromonöziebedingten Reservoir an - geschlechtlich flexiblen - männlichen Blüten, in den später angelegten Dolden fehlenden Fruchtansatz der Blüten früh blühender Dolden zu kompensieren. Im dritten Kapitel wird eine vergleichende Merkmalsanalyse an 255 Apioideen-Arten vorgelegt, die alle Verwandtschaftskreise, Wuchsformen und Verbreitungsgebiete der Gruppe repräsentieren. Ziel der Analyse war die Identifizierung von Merkmalssyndromen, die den Zusammenhang zwischen Architektur und Reproduktionssystem verdeutlichen sollten. Interessanterweise sind die einzigen Merkmale, die miteinander einhergehen, Protogynie und die graduelle Abnahme männlicher Blüten mit steigender Doldenordnung. Alle anderen Merkmale variieren unabhängig voneinander und erzeugen auf vielen verschiedenen Wegen immer wieder das gleiche Funktionsmuster, das als ‚breeding syndrome‘ der Apioideae gedeutet werden kann. Die Arbeit leistet einen wichtigen Beitrag zum Verständnis der Blütenstände der Apiaceen und darüber hinaus zu morphologischer Variation in ‚unspezialisierten‘ Reproduktionssystemen. Offensichtlich liegt in den Apioideen der Selektionsdruck auf der Aufrechterhaltung der generalisistischen Bestäubung und überprägt alle morphologisch-phylogenetischen Merkmalsvarianten.

Acute coronary syndromes in young patients: Presentation, treatment and outcome

Background: Acute coronary syndromes (ACS) in very young patients have been poorly described. We therefore evaluate ACS in patients aged 35 years and younger. Methods: In this prospective cohort study, 76 hospitals treating ACS in Switzerland enrolled 28,778 patients with ACS between January 1, 1997, and October 1, 2008. ACS definition included ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). Results: 195 patients (0.7%) were 35 years old or younger. Compared to patients N35 years, these patients were more likely to present with chest pain (91.6% vs. 83.7%; P=0.003) and less likely to have heart failure (Killip class II to IV in 5.2% vs. 23.0%; Pb0.001). STEMI was more prevalent in younger than in older patients (73.1% vs. 58.3%; Pb0.001). Smoking, family history of CAD, and/or dyslipidemia were important cardiovascular risk factors in young patients (prevalence 77.2%, 55.0%, and 44.0%). The prevalence of overweight among young patients with ACS was high (57.8%). Cocaine abuse was associated with ACS in some young patients. Compared to older patients, young patients were more likely to receive early percutaneous coronary interventions and had better outcome with fewer major adverse cardiac events. Conclusions: Young patients with ACS differed from older patients in that the younger often presented with STEMI, received early aggressive treatment, and had favourable outcomes. Primary prevention of smoking, dyslipidemia and overweight should be more aggressively promoted in adolescence.

Palatal swelling as the first and only manifestation of extranodal follicular non-Hodgkin lymphoma: a case presentation

Non-Hodgkin lymphomas (NHLs) in the head and neck region are malignant lymphoid neoplasms that usually originate from B-lymphocytic cell lines. Primary extranodal manifestations of this hematolymphoid tumor in the oral cavity are rare and involve the maxillary jaw including the palatal soft tissues, the mandible, and gingival tissues in patients between 60 and 70 years of age without sex predilection. This case report of an extra-nodal NHL in the palate of a 75-year-old patient emphasizes the importance of accurate clinical, radiographic, and histologic diagnostic procedures to avoid delayed diagnosis or inappropriate treatment strategies. Chemotherapy, radiotherapy, or a combination of the two with a regular clinical and hemic follow-up is recommended.

Primary tuberculosis of the TMJ: presentation of a case and literature review

Tuberculosis (TB) is a frequent health problem. The prevalence of extrapulmonary TB has increased in the last couple of years. Head and neck tuberculosis forms nearly 10% of all extrapulmonary manifestations of the disease. TB of the temporomandibular joint (TMJ) is rare; only a few cases have been reported. The clinical appearance of TB infection of the TMJ has been described as unspecific, resembling arthritis, osteomyelitis, cancer or any kind of chronic joint diseases. This article describes a 22-year-old woman with pain and left preauricular swelling. Magnetic resonance imaging and computed tomography showed an expansive process with destruction of the left condyle and condylar fossa. A fine needle aspiration examination of the swelling showed non-specific granulomatous inflammation. In the following days, a preauricular fistula developed, of which a swab and biopsy specimens were taken. Histological and microbiological examinations revealed an infection with Mycobacterium tuberculosis. The initial antituberculosis treatment consisted of a combination of four antibiotics and could be reduced to two antibiotics in the course of treatment. The treatment was completed successfully after 9 months.

Microscopic polyangiitis: Clinical presentation

Microscopic polyangiitis (MPA) is a member of the family of ANCA-associated vasculitides. Its characteristic histology shows a necrotizing small vessel vasculitis with little or absent immune deposits (pauci-immune vasculitis). In Western countries MPA shows a lower prevalence than Wegener's disease, it affects more men than women and commences at the age of > or = 50 years. The two organs most typically involved and often defining prognosis are the kidneys and the lungs. MPA may concomitantly or sequentially involve other organs such as the nervous system, the skin, the musculoskeletal system, but also the heart, the eye and the intestines. Treatment decisions should be based on severity and pattern of organ involvement and respect the five factor score (FFS). Life- or organ- threatening disease is treated with glucocorticoids and (pulse) cyclophosphamide. Plasmapheresis and i.v.immunoglobulins have been shown to be beneficial as additional measure in severe cases. If renal function is preserved, Methotrexate may be considered to induce remission, and if the FFS equals 0, remission may be induced with glucocorticoid monotherapy. Maintenance therapy is recommended with Azathioprin, mycophenolate mofetil may be used as a second line drug. Biologic agents such as monoclonal antibodies to tumor necrosis factor a and B cell depleting rituximab have been shown to bear remission-inducing quality.

Incidence, clinical presentation and imaging findings of cavernous malformations of the CNS. A twenty-year experience

Up to 88% of cavernous malformations (CMs) of the central nervous system can become symptomatic and cause long-term disability. The aim of this study was to document the characteristics of CMs in the catchment area of our institution.

Presentation and outcome of patients with acute coronary syndromes in eastern Nepal

The burden of ischemic heart disease (IHD) in developing countries is on the rise, due to urbanisation, industrialisation and the low availability of evidence based therapies and interventions.