DISEASES, DRUGS AND SYMPTOMS: A to Z
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Personal Encounter with Coxsackievirus A16
Coxsackievirus A16 is a major cause of Hand Foot and Mouth disease HMFD in children under 10 years. An encounter with this virus much later in life is clearly worthy of documentation. Contact was a patient with alcoholic cirrhosis presenting for routine HCC surveillance. He complained of a rash over his arms. I described a pruritic, papular rash over his upper arms and hands, which was not related to his underlying chronic liver disease. The next day, I developed a severe pharyngitis that I took to be a prodrome for an URTI. This was associated with worsening malaise and dysphonia. That rest of that evening, I had fevers and malaise with neck and shoulder pains. During the night, I also developed chest pain that lasted most of the night. The pain was unfamiliar and associated with soreness of the chest wall reminiscent of Bornholm's syndrome.
By morning, there were multiple sores and ulcers in my mouth. There were ulcers in the back of my throat and lips. I lost appetite and was unable to eat. My fever persisted. The dysphonia progressively worsened as did the malaise.
By evening, I noted large papules in my gluteal region bilaterally. These were larger than the lesions on my hands. They were smaller by the nxt day, and were almost gone within 48 hours.
The ulcers on my tongue were particularly painful and were especially so with spicy foods or foods with flavors that caused me to salivate. Application of 20% benzocaine gel reduced the pain, but removed much of the flavors from food. By day six, most of the ulers had healed except for one at the very tip of my tongue which made speaking difficult. One interest aspect of the disease was how quickly the ulcers healed. One ulcer on the inside of my lower lip, decreased in size and virtually dispeared within 12 hours.
By day seven, I was almost back to normal self. I still have small, pruriitic papules on the back of both hands and between my fingures. I also have itchy pauples on the extensor surface of my elbows and upper arms.
I would like to offer some comnents on my brush with Coxsackievarus 16 or Enterovirus 17 (EV17). I am not a pediatrician nor an infectious disease specialist. However, I am a transplant hepatologist with a reasonably solid background in virology and immunology. It is conceivable that I never encountered CA16 as a child, but given my upbringing, I would consider this unlikely. It is more likely that any long-term immunitiy I had acquired to the virus had waned; the current strain of virus of course, may have been a different variant.
CA16 is a non-enveloped RNA virus. RNAses are ubiquitous in the enviroment and are unlikely to survive outside the body for any prolonged period. Viable virus can persist in inn upper respiratory secretions for up to three weeks and in stool for eight weeks. The incuabtion period last one to two days. The source of my infectio seems clear.
One presumes that the pharyngisits and laryngitis are the direct result of viral replication and danage to the URT. The site of the rash may be interesting. Antibody concentrations are likely to be higher at putative portals of pathogen entry - hands, feet, mouth and gluteral areas. I observed dry, crusted skin around my lower lip, ears and nose of unclear etiology.
Symptoms last for a week to 10 days and the individual remains contgious for about a week. I am gald to say that I now feel fine and almost looking forward o going back to work.
Peanut Gastro-Intestinal Delivery Oral Immunotherapy in Adolescents
Oral immunotherapy to peanut is effective in desensitizing patients but has significant side effects including anaphylaxis and gastro?intestinal symptoms. In most protocols peanut is administered in a vehicle food.
In an exclusively adolescent population, we tested a new approach using sealed capsules of peanut (Gastro-Intestinal Delivery Oral Immunotherapy or GIDOIT) in order to bypass the upper gastro-intestinal tract. The primary aim was to assess the efficacy of the oral build?up phase of GIDOIT and the secondary aim to analyse its safety.
Adolescents with a history of a clinical allergic reaction after peanut ingestion were included in a two-armed, parallel-design, individually randomised, double-blind, placebo-controlled, multicentre trial after a positive double-blind placebo-controlled oral food challenge (DBPCFC1). A central randomisation centre used computer generated tables to allocate treatments. Peanut (or placebo) capsules were ingested daily over a period of 24 weeks with increments every 2 weeks from 2 to 400 mg of peanut protein. Primary outcome was tolerance of 400 mg of peanut protein at DBPCFC2.
Thirty patients were included between September 2013 and May 2014. At DBPCFC2, unresponsiveness to 400 mg of peanut protein was achieved in 17/21 peanut?group patients (2 withdrawn patients) and 1/9 in the placebo group (Intention-to-treat analysis, p < 0.001, absolute difference=0.7, 95%CI; 0.43; 0.96). Oropharyngeal symptoms were equally frequent in both groups. No dysphagia or other signs of eosinophilic oesophagitis occurred. Digestive adverse events were more frequent in the treated group (p=0.02), but mild and without compliance issues. Only one severe advent event led to withdrawal in a patient who ingested twice the investigated treatment. Peanut specific humoral immune responses were modulated.
The GIDOIT protocol demonstrated clinical and immunological efficacy and had an acceptable level of safety with weak oropharyngeal symptoms, no dysphagia, mild digestive events and few severe systemic adverse events.
ORLANDO — The use of artificial intelligence during colonoscopy appears to boost the accuracy and sensitivity of adenoma detection, even for lesions as small as 5 mm, according to recent studies.
The goal of integrating this technology into routine colonoscopy is to get the adenoma detection rate closer to the 50% reported in studies of screening-age populations, said William Karnes, MD, from the University of California, Irvine.
"Adenoma detection rates among different colonoscopists vary between 7% and 53%. The adenoma detection rate should equal prevalence," he told Medscape Medical News.
Convolutional neural network technology was able to distinguish between images with and without polyps with 96% accuracy in a study of 9000 screening colonoscopy images, he reported at the World Congress of Gastroenterology 2017.
The machine-learning system can read up to 170 images per second, making it "easily applied to live video," said Dr Karnes when he presented the research, which won the 2017 Presidential Poster Award for Colorectal Cancer Prevention.
"Artificial intelligence for polyp detection has the potential to help all colonoscopists achieve detection rates closer to true prevalence, and to further reduce the risk of interval colorectal cancers," he added.
The adenoma detection rate should equal prevalence.
Another computer-aided system, known as EndoBRAIN artificial intelligence, is easy to use and provides an automatic diagnosis at the push of a button, reported Yuichi Mori, MD, from Showa University in Shinagawa-ku, Japan.
"Recognizing a lesion as neoplastic is very useful information during a colonoscopy," Dr Mori emphasized at the recent United European Gastroenterology (UEG) Week 2017. With EndoBRAIN, lesions identified as neoplastic can be considered as such "with very high confidence."