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Hypersensitivity to RhD immune globulin (RhIG) used to prevent hemolytic disease of the fetus and newborn is rare. We present the management of a patient with a history of reaction to RhIG, including prenatal assessment and postnatal provision of RhIG.
[This corrects the article DOI: 10.3389/fped.2026.1811714.].
BACKGROUNDAcute interstitial nephritis (AIN) is a common cause of acute kidney injury (AKI), but the diagnosis may be missed as kidney biopsies are rarely obtained when acute tubular injury (ATI) is suspected.METHODSThe Kidney Precision Medicine Project is a cohort study that obtains kidney biopsies from individuals with AKI, which undergo pathologic and molecular interrogation. We compared ATI and AIN cases among the first 60 AKI participants.RESULTSOn clinicopathologic adjudication, 30 patients (50%) had a primary adjudicated diagnosis of ATI, 13 (22%) patients had AIN, 9 (15%) had diabetic nephropathy, and 3 (5%) had other conditions. There were increased interstitial white blood cells and tubulitis (P < 0.05 for both) in AIN compared with ATI. Prior to biopsy, the treating clinician suspected ATI in 83% of the cases with adjudicated ATI, while the treating clinician suspected AIN in 54% of the cases with AIN. Tissue transcriptomic signatures showed enrichment of proinflammatory signaling and increased expression of CXCL9, a chemokine induced by IFN-γ, in myeloid cells of participants with AIN. CXCL9 localized to inflammatory infiltration in spatial transcriptomic data.CONCLUSIONAdjudication of kidney biopsies revealed distinct pathologic and molecular profiles between ATI and AIN. Kidney biopsy should be considered more frequently in AKI, as AIN is clinically underrecognized.TRIAL REGISTRATIONClinicalTrials.gov NCT04334707.FUNDINGNational Institute of Diabetes and Digestive and Kidney Diseases grants U01DK133081, U01DK133091, U01DK133092, U01DK133093, U01DK133095, U01DK133097, U01DK114866, U01DK114908, U01DK133090, U01DK133113, U01DK133766, U01DK133768, U01DK114907, U01DK114920, U01DK114923, U01DK114933, U24DK114886, UH3DK114926, UH3DK114861, UH3DK114915, and UH3DK114937.
Renal disease in cattle is often suspected based on urinalysis and blood biochemical analysis, but prognostic biomarkers for survival are lacking. Identify blood and urine biomarkers predicting mortality or discharge in azotemic cattle. Thirty-four azotemic adult cattle referred to the Clinic for Cattle of the National Veterinary School of Toulouse. In our prospective cohort study, renal disease was suspected based on clinical signs and azotemia (plasma creatinine concentration > 228 μmol/L and urea concentration > 5 mmol/L) and confirmed by urinalysis or ultrasonography. When death or euthanasia occurred, confirmation was obtained by gross and histologic examination. To construct a decision tree for short-term prognosis, additional biochemical and cytological biomarkers were measured in urine and blood samples collected at hospitalization. Outcomes were defined as favorable (discharge) or unfavorable (death). Correlation analyses, univariate and multivariate statistics, receiver operating characteristic curves, and decision tree modeling were performed. Thirteen cattle survived and 21 died or were euthanized. Mortality was associated with higher plasma symmetric dimethylarginine (SDMA), creatinine, and urea concentrations, as well as hypocalcemia, hypochloremia, and lower hematocrit. Creatinine, SDMA, chloride, and albumin were the most consistent predictors of outcome. A decision tree combining creatinine and SDMA achieved 87.5% accuracy. Animals with plasma creatinine concentration < 605 μmol/L and SDMA < 33 μg/dL had the highest probability of survival. Plasma creatinine, urea, SDMA, chloride, and albumin concentrations are promising short-term prognostic biomarkers in azotemic cattle. Combined SDMA and creatinine assessment may assist clinical decision-making.
Cytomegalovirus (CMV) infections often occur as opportunistic infections among immunocompromised hosts. We report a case of CMV colitis that resulted in colonic perforation in a patient undergoing chemotherapy for more than 2 years for metastatic colorectal cancer (mCRC). A 61-year-old man receiving long-term chemotherapy for mCRC presented with persistent diarrhea and anorexia. Colonoscopy revealed ulcerating colorectal lesions. Following admission, he exhibited signs of peritoneal irritation and bloody stools. Computed tomography demonstrated intraperitoneal free air, prompting an emergency operation. Considering the perforations in the descending colon, we performed Hartmann's operation. However, in addition to the histopathological results, bloody stools persisted postoperatively; thus, enteritis caused by CMV infection was suspected. Furthermore, CMV pp65 antigen-positive blood cells were detected, leading to the diagnosis of CMV colitis. Consequently, ganciclovir was administered, and persistent bloody stools resolved. CMV infection occurs asymptomatically during childhood and then remains latent in the body over time. Although CMV colitis is common in patients undergoing chemotherapy for hematologic malignancies, it is rare in mCRC cases. However, immunocompromised patients receiving long-term steroid therapy for chemotherapy are at a high risk of CMV reactivation. Therefore, CMV colitis should be considered one of the differential diagnoses based on persistent diarrhea and bloody stools, as well as ulcer formation observed on colonoscopy. Although CMV enteritis during colorectal cancer chemotherapy is rare, CMV colitis should be suspected if patients experience prolonged diarrhea or bloody stools during chemotherapy. Therefore, early diagnosis by detecting CMV antigen-positive blood cells is important.
Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract, yet acute lower gastrointestinal bleeding as a presentation in adults remains uncommon and diagnostically challenging. This case highlights the importance of early surgical decision-making in this setting. A 20-year-old male with no medical history presented with 2 days of hematochezia. Hemoglobin levels declined over 72 hours. The patient developed hemodynamic instability and episodes of syncope, which were managed on the surgical ward without vasopressor support. Upper and lower endoscopies were unremarkable. Contrast-enhanced computed tomography (CT) identified a blind-ending ileal structure consistent with MD. Laparoscopic exploration confirmed a 7 × 2 cm MD located 140 cm from the ileocecal valve. A 10-cm ileal segment was resected, and a hand-sewn anastomosis was performed. Histopathology confirmed ectopic gastric fundic-type mucosa without ulceration. The postoperative course was complicated by a transient paralytic ileus (Clavien-Dindo grade II), which was managed conservatively, with discharge on day 6. MD should be considered in young adults with unexplained hematochezia when standard endoscopy is negative. CT imaging is key in identifying MD. Segmental bowel resection is preferred when ectopic mucosa is suspected. While technetium-99 m pertechnetate scanning may be considered in stable patients with suspected MD, its sensitivity in adults is lower than in children. Surgical resection remains the definitive treatment for symptomatic cases. Prophylactic excision of incidentally discovered MD may be considered in selected patients with risk factors for complications, though this decision should be individualized and weighed against surgical risks.
Patients with sitosterolemia (ST) are often misdiagnosed as familial hypercholesterolemia (FH) because of overlapping lipid phenotypes. Sitosterol is considered a disease-specific biomarker; however, its diagnostic utility in highly heterogeneous populations-particularly among children-remains unclear. To evaluate the diagnostic value of phytosterol biomarkers and develop a multivariate model to improve the diagnostic accuracy of ST. We conducted a cross-sectional study of 379 children with suspected lipid disorders: ST (n = 38), ABCG5/8 heterozygous carriers (n = 12), genetically confirmed FH (n = 54), individuals with FH-like (n = 50), and healthy controls (n = 225). Clinical characteristics, lipid profiles, phytosterols, liver enzymes, and genetic data were collected. The diagnostic performance of single biomarkers and a multivariate model was evaluated. A clinical gray zone based on sitosterol levels was defined to assess the models' ability. Sitosterol demonstrated near-perfect discrimination for ST in the overall population area under the curve ([AUC] 0.994; 95% CI, 0.988-1.000), outperforming conventional lipid markers. However, substantial overlap in phytosterol distributions was observed among ST, heterozygotes, and FH-related phenotypes. Within the gray zone (sitosterol: 17.7-50 μg/mL), the diagnostic performance of sitosterol declined markedly (AUC 0.653). The multivariable model demonstrated comparable overall performance (AUC 0.983) but significantly improved discrimination in the gray zone (AUC 0.806), with good calibration and greater net clinical benefit. Although sitosterol is highly effective for identifying ST, its diagnostic performance declines significantly in clinically significant gray zone cases. A combined sterol-based model improves diagnostic discrimination in these challenging scenarios and supports a stepwise diagnostic strategy for children with suspected ST.
Hymenal examination plays an important role in the forensic examination of suspected child sexual abuse. However, interpretation of hymenal findings remains challenging because of anatomical variation and subtle genital injuries, creating the potential for misinterpretation in medico-legal assessments. This study aimed to characterize hymenal morphology, hymenal injuries, and related forensic findings among female child sexual abuse victims in Vietnam and to examine patterns associated with repeated abuse. A retrospective analysis was conducted using forensic examination records of female children under 16 years of age referred for suspected sexual abuse at a specialized medico-legal center. Sociodemographic characteristics, assault-related information, hymenal morphology, and genital and extra-genital injuries were extracted from standardized forensic reports. Cases with diagnostic uncertainty or complex forensic findings were reviewed through expert consultation, and final conclusions were established by consensus within the forensic assessment team. A total of 443 children were included, with a mean age of 13.3 ± 2.6 years. The median interval between the alleged assault and forensic examination was 19 days (IQR: 4-89 days). Repeated sexual abuse accounted for 68.4% of cases. In multivariable analysis, older age (aOR = 1.25, 95% CI: 1.14-1.37), parental divorce (aOR = 1.95, 95% CI: 1.15-3.30), and abuse occurring in private or semi-private settings were independently associated with repeated sexual abuse. The annular hymen was the most frequently observed morphology (60.3%). Overall, 69.3% of cases showed combined hymenal dilatation and tear, followed by tear only (19.6%) and dilatation only (6.3%), while 4.7% had no hymenal injury. Most tears were old (81.7%) and located in the anterior region (65.2%). Additional genital and extra-genital injuries were uncommon. Repeated sexual abuse was common among examined victims. The annular hymen was the most frequently observed morphology, and combined hymenal dilatation and tear was the predominant injury pattern, while other genital and extra-genital injuries were uncommon. While these findings provide additional forensic reference data, no single hymenal morphology or injury pattern should be interpreted as diagnostic of sexual abuse in isolation and findings should be considered within the broader clinical and investigative context.
Diffuse lung diseases (DLD) also referred to as diffuse parenchymal lung diseases or interstitial lung diseases encompass diverse disorders affecting the lung parenchyma with possible multicompartment involvement in the chest. DLD include several hundred established clinical syndromes and pathologies, with a variety of possible etiologies. Imaging plays a central role during multidisciplinary discussion, which constitutes the current standard for diagnosis and monitoring of DLD. This document aims to establish guidelines for evaluation of diffuse lung diseases for 1) initial imaging of suspected diffuse lung disease, 2) initial imaging of suspected acute exacerbation or acute deterioration in cases of confirmed diffuse lung disease, and 3) surveillance of confirmed diffuse lung disease without acute deterioration. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Antibody testing has a pivotal role in the diagnosis of myasthenia gravis (MG). However, there are limited data on the accuracy of the different methods available for acetylcholine receptor (AChR) and muscle-specific kinase (MuSK) autoantibody (Ab) detection in a real-world setting. Our aim was to compare the diagnostic accuracy of in-house live cell-based assay (L-CBA), a commercially available fixed CBA (F-CBA), and an indirect ELISA in detecting AChR and MuSK antibodies in patients with suspected MG. Between July 2023 and December 2025, we prospectively recruited consecutive adult and pediatric patients with suspected MG across 4 Italian centers. Patients undergoing immunotherapy and those with incomplete diagnostic work-up or insufficient samples were excluded. Serum samples were tested blindly by L-CBA, F-CBA, and ELISA for AChR and MuSK antibodies. MG diagnosis was established independently based on neurologic examination, electrophysiologic studies, and/or sustained clinical response to pyridostigmine or corticosteroids as well as exclusion of other diagnoses. Diagnostic sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated using final diagnosis as the reference standard. Of the 327 included patients (median age 63 years, interquartile range 26, 52.9% female), 152 were diagnosed with MG and 175 with other diagnoses. For AChR antibodies, sensitivity was 71.7% (95% CI 63.8-78.7) for L-CBA, 69% (61.0-76.3) for F-CBA, and 63.8% (55.6-71.4) for ELISA, while specificity was 97.7% (94.2-99.3) for both CBAs vs 69.1% (61.7-75.9) for ELISA. ELISA showed lower concordance with CBAs and produced substantially more false positives (30.9%). For MuSK antibodies, sensitivity was similar (6.6 vs 7.2%) and specificity 100% across assays. ROC curve analysis confirmed higher diagnostic accuracy for L-CBA (AUC 0.85) compared with F-CBA (0.83) (p = 0.043) and ELISA (0.72) (p < 0.0001). The AUCs of MuSK-Ab were not significantly different between different tests. CBAs, especially live, demonstrated superior diagnostic performance for AChR antibody detection compared with ELISA, particularly in ocular MG. L-CBA showed a modest but significant diagnostic advantage over F-CBA, although fixed assays can be considered as a practical, nearly equivalent alternative, suitable for routine laboratories. By contrast, ELISA demonstrated lower specificity and should be interpreted cautiously. This study shows Class I data that L-CBA and F-CBA compare favorably with ELISA testing of AChR-Ab and MuSK-Ab, in the diagnosis of MG.
Multidisciplinary genomic evaluation is increasingly recognized for its diagnostic and therapeutic implications in adults with suspected inborn errors of immunity (IEI) presenting with rheumatic and musculoskeletal disease (RMD) phenotypes. We retrospectively analyzed 50 adults with suspected IEI who underwent genetic testing and were pre-classified into immunodeficiency (ID), autoinflammatory disorders (AID), and non-ID/AID groups. Genetic findings, clinical classification, treatment modifications, and exploratory machine learning analyses were evaluated. A final genetic diagnosis consistent with IEI was identified in 15 patients (30.0%), with the highest yield in the non-ID/AID group (44.4%). Variants were most frequently associated with autoinflammatory diseases (40.0%). Four patients, all initially classified as non-ID/AID, were reclassified based on genetic findings and IUIS classification. Treatment was modified in 12 patients, including eight genetically diagnosed patients and three genotype-driven interventions. Two patients died from disease-related complications. Machine learning analyses provided heterogeneous feature contributions across groups. These findings highlight the utility of multidisciplinary genomic evaluation for refining diagnoses in challenging adult patients.
Hepatitis B virus (HBV) reactivation is a recognised complication in HBsAg-negative, anti-HBc-positive patients receiving cytotoxic cancer therapy. Guidelines place anti-HBc-positive patients exposed to anthracyclines in a moderate-risk band warranting on-treatment monitoring or selective prophylaxis, yet real-world data from non-prophylaxis breast cancer practice, where serial HBV DNA surveillance is often incomplete, remain scarce. We retrospectively studied HBsAg-negative, anti-HBc-positive breast cancer patients treated with systemic therapy between 2018 and 2024 at two centres in Turkey, none of whom received antiviral prophylaxis. We extracted demographic, oncological and virological data, including baseline anti-HBs titres and all available HBV DNA and alanine aminotransferase (ALT) results, and we quantified the completeness of virological surveillance. Because on-treatment HBV DNA was tested only when hepatitis was clinically suspected, the outcome captured was clinically detected reactivation; the study therefore describes surveillance quality rather than estimating true incidence. With a single event, analyses were kept descriptive. Among 139 patients (mean age 60.1 years), 89.2% were anti-HBs-positive and 65.5% received anthracyclines. Baseline HBV DNA was documented in all patients, but serial on-treatment monitoring was not. One clinically overt reactivation occurred (0.7%; 95% CI 0.02%-3.94%) in an anti-HBs-negative woman receiving doxorubicin-cyclophosphamide, presenting as icteric hepatitis at month 4 and responding to entecavir. Since subclinical events would have escaped detection, this figure is best read as a lower bound rather than a true incidence. The single reactivation we detected arose in the patient profile that the guidelines flag as moderate-risk-absent anti-HBs together with anthracycline exposure. These observations are consistent with, but do not establish, a risk-adapted approach, given one event and incomplete surveillance. Prospective studies using standardised serial HBV DNA monitoring are needed to estimate true reactivation incidence in this population.
Autoimmune cholangiopathy can mimic cholangiocarcinoma. This video highlights the presentation and management of a patient with obstructive jaundice in the setting of a biliary stricture concerning for hilar cholangiocarcinoma who had resolution of her symptoms with steroids. A 49-year-old woman without autoimmune history presented with abdominal pain and jaundice and was found to have elevated liver enzymes (total bilirubin, 4.7 mg/dL; alkaline phosphatase, 405 U/L; aspartate aminotransferase, 174 U/L; and alanine aminotransferase, 530 U/L), a mass at the hepatic duct confluence, and a filling defect in the common bile duct on cross-sectional imaging. Serum carbohydrate antigen 19-9 (9 U/mL) and immunoglobulin G4 (IgG4)/IgG (7.2%) were normal. After multiple negative samples obtained by EUS/ERCP, including brushing, biopsy, and fluorescence in situ hybridization, she opted to trial systemic steroids for suspected autoimmune cholangiopathy. After 4 weeks of prednisone, an EUS/ERCP was performed and noted improvement in biliary duct dilatation, duct wall thickness, and stricture size. The periductal mass was not appreciated. Repeat cholangioscopy noted gross improvement in duct stenosis and neovascular changes. At 4-month follow-up, she remained clinically asymptomatic, with normal laboratory values and no radiographic evidence of a hilar mass or bile duct stricture. Autoimmune cholangiopathy can mimic cholangiocarcinoma and should be considered when the cytopathology result of hilar strictures is repeatedly negative.
Given the current increase in the incidence of Neisseria gonorrhoeae infection, a rise in disseminated forms of the disease may also be expected. Within disseminated gonococcal disease, gonococcal arthritis has specific clinical, diagnostic and therapeutic characteristics. A retrospective search was conducted for synovial fluid samples that tested positive for N. gonorrhoeae by culture or molecular biology techniques between 2013 and 2023 at several hospitals in northern Spain. A descriptive analysis was subsequently performed. Fifteen patients were analysed. Monoarthritis was the most frequent presentation (60%), followed by polyarthritis, predominantly affecting the wrist or knee. Arthralgia or tenosynovitis at other sites, particularly the wrist, was common. Microbiological identification was performed by conventional culture (12/14) or PCR (7/7). Repeated ultrasound-guided drainage or surgical washout was required in 30% of cases. The mean duration of intravenous antibiotic therapy was 12 days, while the mean total duration of antibiotic therapy was 22 days. The clinical response was favourable in all cases. In the current context of increasing gonococcal infection incidence, gonococcal arthritis should be considered in patients with septic monoarthritis or polyarthritis and concomitant tenosynovitis, particularly when the radiocarpal joint is involved. Molecular biology techniques may be useful for identifying N. gonorrhoeae in suspected cases. The clinical course may vary and may require surgical washout and prolonged treatment. Ante el aumento actual de la incidencia de la infección por Neisseria gonorrhoeae, cabe esperar asimismo un incremento de las formas diseminadas de la enfermedad. Dentro de la enfermedad gonocócica diseminada, la artritis gonocócica presenta peculiaridades clínicas, diagnósticas y terapéuticas. Se realizó una búsqueda retrospectiva de muestras de líquido articular con resultado positivo para N. gonorrhoeae mediante cultivo o técnicas de biología molecular entre 2013 y 2023 en varios hospitales del norte de España. Posteriormente, se realizó un análisis descriptivo. Se analizaron 15 pacientes. La monoartritis fue la presentación más frecuente (60 %), seguida de la poliartritis, con afectación predominante de la muñeca o la rodilla. Las artralgias o la tenosinovitis en otras localizaciones, especialmente en la muñeca, fueron frecuentes. La identificación microbiológica se realizó mediante cultivo convencional (12/14) o PCR (7/7). En el 30 % de los casos fue necesaria la evacuación ecoguiada repetida o la limpieza quirúrgica. La duración media de la antibioterapia intravenosa fue de 12 días y la de la antibioterapia total, de 22 días. La respuesta fue favorable en todos los casos. En el contexto actual de incremento de la incidencia de la infección gonocócica, en los pacientes con monoartritis o poliartritis séptica y tenosinovitis concomitante, especialmente con afectación radiocarpiana, debe considerarse la posibilidad de artritis gonocócica. Las técnicas de biología molecular pueden ser relevantes para la identificación de N. gonorrhoeae en casos sospechosos. La evolución clínica puede ser variable y requerir limpieza quirúrgica y tratamientos más prolongados.
To evaluate the outcome and describe complications associated with use of Ahmed valve gonioimplants in the treatment of glaucoma in rabbits. Six client-owned rabbits with glaucoma. Medical records of rabbits that underwent Ahmed valve gonioimplantation between 2022 and 2025 were reviewed. All eyes received intracameral tissue plasminogen activator immediately postoperatively. Gonioimplantation was performed in eight eyes. The Holland Lop breed was overrepresented. Median age was 5 years and median pre-operative IOP was 32 mmHg (26-43 mmHg). 6/8 eyes were suspected to have primary glaucoma. Three eyes had developed presumed secondary glaucoma after phacoemulsification. Clinical signs at presentation included slow and incomplete pupillary light reflex (one eye), blepharospasm (three eyes), conjunctival hyperemia (one eye), periocular swelling (two eyes), corneal edema (one eye), ulcerative keratitis (two eyes), retinal vascular attenuation (one eye), and optic nerve cupping (five eyes). Three rabbits died of unrelated causes at 6, 10 and 22 months post-operatively. After gonioimplantation, median IOP was 17 mmHg (10-25 mmHg). Vision was retained in all eyes for a mean period of 11.6 months (2-22 months). Mean antiglaucoma medication use decreased from 1.75 to 1.38 post-operatively. Mean administration frequency reduced from 4 to 3.37 times daily. Post-operative complications included shallow anterior chamber (two eyes), Haab's striae (one eye), iridal and periocular hemorrhage (one eye). One rabbit experienced hypokalemia related to topical therapy. In rabbits with medically refractory glaucoma, gonioimplantation is effective in IOP control and maintaining vision in sighted rabbit eyes.
Septic arthritis of native joints requires prompt diagnosis to prevent joint destruction and sepsis. Traditional diagnostic methods, such as synovial fluid culture and cell counts, are time-consuming and can be unreliable. The Synovasure® Alpha Defensin Lateral Flow Test (Zimmer Biomet, Claymont, DE, USA) detects alpha defensin in synovial fluid and is well-established for diagnosing periprosthetic joint infections. However, its diagnostic value in native joints remains insufficiently studied. This prospective cohort study enrolled 25 adults presenting with suspected septic arthritis of the knee. Patients were excluded if they had prior knee arthroplasty or orthopedic implants. Demographics, comorbidities, vitals, and lab values were collected. Patients who tested positive for alpha defensin on aspirated synovial fluid were compared to those who tested negative. Infection was defined as a positive synovial culture, while gout was defined as positive synovial crystals. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Nineteen patients tested positive for alpha defensin, of whom four had culture-confirmed septic arthritis. All six alpha defensin test-negative patients had negative cultures. The test demonstrated a sensitivity of 100% (CI: 39%-100%), specificity of 29% (CI: 11%-52%), PPV of 21% (CI: 16%-25%), and NPV of 100% (CI: 54%-100%). Demographics, comorbidities, and serum inflammatory markers were similar between test-positive and test-negative groups. Alpha defensin test-positive patients had a significantly higher synovial polymorphonuclear neutrophil (PMN) percentage (p<0.001). All nine patients with positive synovial crystals tested positive (p=0.04). The high sensitivity and NPV of the Synovasure® Alpha Defensin Lateral Flow Test (Zimmer Biomet) demonstrate its potential utility to rapidly rule out septic arthritis in native knees. However, the test's low specificity warrants caution, as false-positive results may occur with noninfectious inflammatory processes. While the rapid turnaround may aid in early triage and exclusion of infection, confirmatory evaluation with synovial culture remains essential to prevent misdiagnosis and overtreatment.
Introduction. Gram staining is a fundamental and widely used technique in clinical microbiology because of its simplicity and diagnostic value, particularly in the diagnosis of bacterial meningitis. However, its reliability may be compromised by contamination and staining artefacts. Case Presentation. This report describes a case of pseudobacterial meningitis in a previously healthy 25-year-old woman who presented with fever, headache and nuchal rigidity. Cerebrospinal fluid (CSF) analysis revealed pleocytosis with a predominance of mononuclear cells. Gram staining revealed findings consistent with Gram-negative bacilli, prompting empiric antibacterial therapy with concurrent antiviral treatment. Comprehensive microbiological investigations, including CSF culture and broad-range 16S rRNA PCR testing, yielded negative results. Residual material or microscopic debris on supposedly 'clean' slides was suspected to produce artefact-like appearances that mimicked micro-organisms, leading to false-positive interpretations. Conclusion. This case highlights a potential laboratory pitfall in the interpretation of CSF Gram stains and underscores the importance of considering staining artefacts, particularly when Gram stain findings are discordant with the overall clinical and laboratory findings.
Laparoscopic percutaneous extraperitoneal closure (LPEC) is an established procedure for pediatric inguinal hernia repair. In adults, however, its application is technically more demanding because of a thicker abdominal wall, greater tissue resistance, and a deeper ligation plane. Based on our standardized pediatric LPEC technique, we describe technical refinements for adult indirect inguinal hernias and examine an important cautionary finding related to patient selection. Among adults with suspected indirect inguinal hernia treated between 2023 and 2025, 20 patients who underwent LPEC were evaluated. For adult cases, we incorporated several technical refinements, including double ligation, puncture-site enlargement, tension reduction during ligation, and needle-route straightening. The procedure was completed in selected adults, including those with a high body mass index and greater abdominal wall thickness. Recurrence occurred in two patients, both of whom had preoperative bowel protrusion. This finding suggests that bowel protrusion should be regarded as an important cautionary feature when considering the indication for adult LPEC. Standardized pediatric LPEC may be adapted for selected adults when appropriate technical refinements are applied. However, cases with preoperative bowel protrusion require particularly careful judgment when determining indication.
Renal cell carcinoma (RCC) is known for its potential for late recurrence; however, ultra-late recurrence occurring more than four decades after nephrectomy is extremely rare. Small-bowel metastasis causing intussusception is also uncommon. A 73-year-old man underwent right nephrectomy for RCC 41 years earlier. He was referred to our hospital because of rapidly worsening glycemic control. Contrast-enhanced computed tomography (CT) revealed two hypervascular pancreatic tumors and a hypervascular small-bowel mass near the ligament of Treitz. Multiple distant metastases from recurrent RCC were suspected. Endoscopic ultrasound-guided fine-needle aspiration and endoscopic biopsy were inconclusive. One week later, the patient developed abdominal pain and vomiting. Repeat CT revealed intussusception of the proximal jejunum caused by the small-bowel tumor, requiring surgical intervention. Partial resection of the duodenojejunal junction with bypass procedures was performed. Histopathological and immunohistochemical examination revealed metastatic RCC. RCC may recur even decades after nephrectomy, and atypical metastatic sites such as the small intestine should be considered. Adult intussusception is rare and often associated with an underlying malignant lesion. This case highlights that RCC can recur as small-bowel metastasis even more than four decades after nephrectomy and may present as intussusception.
Women with coronary artery disease (CAD) typically have less severe stenosis and lower plaque burden than men but have disproportionately high adverse cardiovascular event rate. This study evaluated sex-based differences in quantitative plaque burden and its association with ischemia. A post-hoc exploratory analysis of the CREDENCE trial included 612 symptomatic patients (184 women, 428 men) with suspected stable CAD who underwent CCTA and invasive coronary angiography with fractional flow reserve (FFR) measurements. Total, calcified, and total non-calcified plaque burden and volume were quantified. Ischemia was defined as FFR ≤0.8. Women were older (66.5 ± 9.1 vs. 63.5 ± 10.3 years, p = 0.001) with lower prevalence of smoking. They exhibited less high-risk plaque, shorter lesion length, and lower stenosis severity. Plaque burden and volume were significantly lower in women across all components (all p < 0.05), except for calcified plaque burden. A 5% increase in plaque burden was significantly associated with ischemia in women for total plaque (OR = 1.28, 95% CI [1.12-1.46], p < 0.001), calcified plaque (OR = 1.31, 95% CI [1.10-1.57], p = 0.003), and total non-calcified plaque (OR = 1.33, 95% CI [1.05-1.67], p = 0.017). In men, only total and total non-calcified plaque burden were significant predictors of ischemia. Significant sex interactions were observed for total (p = 0.015) and calcified plaque burden (p = 0.046), indicating differential effects in women and men, but not for diameter stenosis (p = 0.928). Despite having a lower overall plaque burden, women exhibit a stronger association between plaque burden and ischemia than men. Further investigation in prospective studies is warranted to better understand potential sex-related differences in CAD.