Two Cases of Peritonitis due to Pantoea Species at One Center with Different Outcomes

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Peritonitisis a serious complication of peritoneal dialysis. A variety of microorganisms are identified in these cases and during recent years a new one was included, Pantoea species. In our report, we present 2 cases of patients on CCPD with a peritonitis episode caused by this organism. The source of infection in one of the cases was thought to be due to gardening of the plant Basil, while unknown in the other case. In microbiologic culture, this organism was identified and the patients were started on antibiotics with success in one case while the other requiring catheter removal. The number of reported cases with this organism has increased in last years and various infection localizations and clinical progress patterns have been identified. In peritoneal dialysis patients presenting with peritonitis, this organism must be kept in mind.

For patients on peritoneal diaysis, peritonitis is an important cause of mortality and morbidity. The treating physician needs to keep a high index of suspicion and treat peritonitis early to improve outcome and reduce complications. While usual gram positive and gram negative organisms make most of the cases, recently one unusual environmental gram negative family appeared to be the cause. The organism Pantoea, belongs to the family Enterobacteriaceae and is responsible for infectious diseases mainly from plant-thorn injuries, causing arthritis, osteoitis, osteomyelitis to bacteremia. Until now a number of clinical cases of peritonitis caused by this organism have been described. We present two cases (Case A and B) of peritonitis with Pantoea species at our center, both of which had different course and outcomes requiring different treatments.

Upon evaluation, there was diffuse abdominal tenderness but there were no signs of exit site or tunnel infection. The PD fluid was found to be cloudy and analysis showed White cell count of 1000 with 92% neutrophils. Other investigations revealed serum WBC count 7.6k/ul, ESR 30mm/hr, CRP 0.4mg/dl, Lactic acid 3.1mmol/L. Patient was started on empirical treatment including Intraperitoneal Ceftriaxone and Vancomycin. The Blood cultures were negative; however the PD fluid culture grew Pantoea species sensitive to Cephalosporins, Gentamycin and Tazobactam. The patient showed significant improvement and disappearance of symptoms on the third day. The PD fluid WBC dropped to 22k/ul with normalization of ESR and lactic acid levels and the fluid culture became negative after 5 days of treatment. Patient was discharged home and he completed 14 days of antibiotic therapy. Over the next one year, patient did not have any further episodes of peritonitis, and the repeated PET test did not show any changes on the membrane characteristics.

Response of Potato to Water Stress in Southern Serbia

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Aninvestigation was carried out on alluvium soil type in the river valley of Southern Morava, Southern Serbia during the seasons of 2008 and 2009, aiming to determine the response of potato to soil water deficit, using yield response factor. The values of yield response factor were derived from the linear relationship between relative seasonal evapotranspiration deficits and relative yield loss. Values of seasonal crop response factor of 1.14 indicate that potato is moderately sensitive to soil water stress in the climatic conditions of the Southern Serbia. Seasonal evapotranspiration was 495.0 mm and 291.2 mm in irrigated and rain-fed conditions respectively. A linear relationship was found between seasonal evapotranspiration and tuber yield. Potato yield in the variant with irrigation was 48.31 t ha-1 or 88.3% higher than in the variant without irrigation.

Production of potato (Solanum tuberosum L.) takes a very important place in world agriculture, with a production potential of about 368 million t harvested and 19.3 million ha planted area with an average yield of 19.1 t ha-1. Potato production ranks fourth in the world after rice, wheat and maize. In Serbia potato is grown at about 77,000 ha with an average yield of 10.2 t ha-1, and total production of 786,000 tones. In southern Serbia potato crop land is 55,000 ha with an average yield of 9.2 t ha-1, and total production of 55,000 tones. The yield of potato in Serbia is fourth times lower than this achieved in the leading potato growing countries. The low yields are the consequence of inadequate management practices, insufficient amount and unfavorable arrangement of precipitation in the growing season and inappropriate irrigation scheduling applied. In Serbia potato is cultivated under both irrigated and non-irrigated conditions. Portable sprinkler irrigation systems are commonly used. Due to the unpredicted amount and distribution of precipitation in the growing season, irrigation in Serbia is mainly supplemental. It is used primarily to supplement infrequent or irregular precipitation during drought periods.

Several authors and research groups reported results of experiments aimed at determining optimum soil moisture under different environmental and technical conditions. Bošnjak and Pejić, Milić et al., Pejić et al. found that the lower limit of optimum soil moisture for potatoes is 70% of field water capacity when this crop is grown in a soil with medium texture. Wright and Stark, King and Stark, Costa et al.  indicated that maximum yield of high quality potato tubers could only be achieved if the soil’s available water in the maximum active root zone would not drop below the 50% limit.

Which Criteria to use for the Diagnosis of Behcet’s Disease: International Study Group (ISG) Criteria or International Criteria for Behcet’s Disease (ICBD)?

                                 http://austinpublishinggroup.com/immune-research/currentissue.php

It is interesting to note that Behcet’s Disease (BD) is one of those diseases which had an early diagnostic criteria (9 years after its official recognition, with the Curth criteria in 1946), having one of the largest number of classification/diagnosis criteria (17 sets, in 70 years, till 2016), among them only 2 real International Criteria (ISG and ICBD), and having one of the largest international participation (27 countries for ICBD). The ISG criteria were created by the collaboration of 7 countries (France, Iran, Japan, Tunisia, Turkey, UK, and USA) in 1990. The ICBD was first presented in 2006 to the International Conference on Behcet’s Disease in Portugal and the revised version in 2010 to the International Conference on Behcet’s Disease in London, and published in 2014.

The sensitivity of ISG criteria was very good, at 92%, when checked on the patients gathered from the 7 countries. The specificity was excellent at 97%. Originally, the accuracy was not checked and instead the relative value, which was 189 (the sum of sensitivity and specificity). When the performance of the criteria was checked, for validation, in different countries, the sensitivity was low, while the specificity was high. The problem came from two main biases. First, as the majority of BD patients gathered from the seven countries had oral aphthosis (OA), this manifestation was put as a mandatory symptom to be present for diagnosis, while all over the world, when patients are diagnosed by expert opinion, around 5% of patients diagnosed as having BD miss OA. Second, the patients’ selection: overall 886 BD patients and 97 control patients were selected from the seven collaborating countries, with 366 (41.3%) from Iran, 285 (32.2%) from Turkey, and 141 (16.9%) from Japan, which made 90.4% from 3 countries and less than 10% of the remaining 4 countries. From Western countries, only 5% had BD. To be classified as having BD, a patient must have oral aphthosis (mandatory), and two of he following manifestations: genital aphthosis, skin manifestations (pseudo-folliculitis, erythema nodosum), ophthalmologic manifestations (anterior uveitis, posterior uveitis, retinal vasculitis), positive pathergy test.

For ICBD, patients were gathered from 27 countries, all over the world. This time, it was paid enough attention to not make the same error in the patient selection, and to have enough patients from the Western world. A total of 2556 BD and 1163 controls were gathered, with 35.1% from 9 countries of the Western world. The revised ICBD performance in the cohort of the international patients was: sensitivity 96%, specificity 91.2%, and accuracy 94.5%. ICBD was validated in Germany, China, Iran, and Italy. The revised ICBD was validated in Iran with sensitivity 96.8% (ISG 78.1%), specificity 97.2% (ISG 98.8%), and accuracy 97% (ISG 85.5%). To be classified as having BD, a patient must get 4 points from the ICBD. Oral aphthosis, genital aphthosis, and ophthalmologic manifestations (anterior uveitis, posterior uveitis, retinal vasculitis) get each 2 points. Skin manifestations (paseudo-folliculitis, erythema nodosum, skin aphthosis), vascular manifestations, neurological manifestations, and positive pathergy test get each one point.

Vitrified-Warmed Blastocyst Score Effects Pregnancy Outcomes: Towards a Single Blastocyst Vitrification and Transfer

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No a referable quality selection criteria for a single vitrified-warmed blastocyst transfer. Therefore, the present study aimed to investigate the relationship between vitrified-warmed blastocyst score and clinical pregnancy outcomes. This retrospective analysis consisted of 221 patients undergoing two blastocysts transfer on thawing day. Implantation rate, fetal heart pregnancy rate, live-birth rate, multiple birth rate were analyzed.

When a patient received two high-quality vitrified-warmed blastocysts (=3BB), implantation rate and fetal heart pregnancy rate were 48.2% and 65.5%, respectively. The multiple birth rates in this group were 44.4%. When two vitrified-warmed blastocysts (one =3BB and another <3BB) were available for transfer, implantation rate and fetal heart pregnancy rate were 34.5% and 52.7%. The multiple birth rate for this group was 29.6%. When only two generalquality vitrified-warmed blastocysts (<3BB) were transferred, implantation rate and fetal heart pregnancy rate were 21.7% and 35.9%, and the multiple birth rate was 21.7%.

The ability to transfer one good-quality vitrified-warmed blastocyst (=3BB) should lead to fetal heart pregnancy rates greater than 52% and live birth rates greater than 36%. Results of the present study can provide guidelines for a single vitrified-warmed blastocyst transfer, which is an effective means of eliminating multiple gestations and avoiding the complications associated with such pregnancies.

Searching Anti Leprosy Vaccine: Views to go Forward

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Apreventive anti leprosy vaccine can contribute considerably towards global control and even elimination of leprosy. However, there is no successful vaccine available as yet. M.leprae is known to evade/subvert the antimicrobial activity of the invaded antigen presenting cells (APCs; macrophages and dendritic cells). Therefore, the cause for failure towards developing anti leprosy vaccine could be lack of presentation of M leprae antigens to re-stimulate the candidate vaccine generated CD4+Th1 type of memory cells against M.leprae. Since, autophagy is known to kill M.leprae and present its antigens, intermittent induction of autophagy might help in improving vaccine efficacy by re-stimulation of vaccine induced memory cells and thereby persistence of vaccine generated immunity. On the other hand, T cell subsets other than CD4+Th1 are also known to be protective in leprosy. A strategy involving such immune cells towards formulating anti leprosy vaccine may also prove to be advantageous. Hence, investigations on these aforementioned approaches are worthwhile exploring.

Leprosy is a chronic contagious disease caused by infection with Mycobacterium leprae (M.leprae), an obligate intracellular microbe which harbours, primarily, macrophages and Schwann cells. During this disease, mainly, skin and nerves are affected where immunological complications can result in nerve damage and thereby neuropathy leading to disabilities. Over the years, despite remarkable global decrease in leprosy cases the new case detection rates have not changed much. The data from 106 countries documented occurrence of 210758 new cases during 2015. Of these, 22 countries have been reported to be high burdened. Though Multi Drug Therapy (MDT) has brought down the global number of leprosy patients, persistence of new cases could be due to limitations of MDT and/or due to prevalence of undetected leprosy cases.

The existing scenario points-out that leprosy infection is still going on in community and for many countries it is still an important public health problem. Though, leprosy has been controlled significantly; nevertheless, its further control and finally, elimination can be boosted by anti M.leprae vaccine. As yet, no efficient anti leprosy vaccine is available for its use for prevention of occurrence of leprosy. Hence, efforts towards searching better vaccine are underway in several laboratories. Through this communication, an attempt has been made to share views to further refine research on developing anti leprosy vaccine.

The Dual of Porphyria Cutanea Tarda and Hemochromatosis

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Porphyria Cutanea Tarda (PCT) is a condition characterized by accumulation of the carboxyl group substituent’s uroporphyrin I and heptacarboxyl porphyrin III resulting in increased iron storage and photosensitivity dermatitis. Here we present a case of a 51-year-oldman who presented with bilateral dorsal hand lesions and iron overload toxicity. Further screening revealed PCT resulting from a mutation in Uroporphyrinogen Decarboxylase (UROD) as well as from genetichemochromatosis (HFE) caused by C282Y homozygosity. The patient was treated successfully with phlebotomy.

Porphyria is an encompassing term for diseases in which Uroporphyrinogen Decarboxylase (UROD) deficiency results in overproduction of 4-8 carboxyl group substituents. Porphyria Cutanea Tarda (PCT) is characterized by the accumulation of uroporphyrin I, heptacarboxyl porphyrin III and iron overload toxicity. Deposition and photoexcitement of these porphyrins in the skin cause oxidative damage to the surrounding tissues resulting in classical PCT photosensitivity dermatitis. We present a case of a man who presented with sporadic season dependent bilateral cutaneous lesions on his dorsal hands and nailbeds, who was found to have new onset porphyria cutanea tarda as well as C282Y mutation homozygosity resulting in genetichemochromatosis (HFE) and underlying Hepatitis C (HCV) with undetectable viral load.

A 51-year-old male with a long-standing history of hepatitis C secondary to past intravenous drug use with undetectable viral load, and diabetes Type II presented to his primary care physician with worsening cutaneous lesions that had been appearing on his hands. During the past 7summershe would experience painful dorsal upper extremities resulting in disfiguration of his hands and nails (Figure 1). The patient’s daily medications were Lisinopril 20mg and Linagliptin 5mg once daily, Metformin 1000mg twice daily and insulin Detemir subcutaneously. He denied any supplemental iron usage or previous erythrocyte transfusions and denied any similar family history. At the time of his initial visit he had been referred to a dermatologist who performed a shave biopsy of the right index finger.

Yap Regulation of Hepatic Stellate Cells: Is there a Role for Metabolic Stress?s

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Mannaerts et al. recently reported that the effect or protein, Yap of the Hippo pathway regulates liver fibrosis by controlling the activation of hepatic stellate cells. The authors elegantly demonstrate that Yap activation induces fibrotic phenotype using in vitro as well as in vivo models. Besides contributing to liver failure, cirrhosis an advanced stage of fibrosis is known to be a major underlying disease of primary liver cancer, Hepatocellular Carcinoma (HCC). Thus experimental characterization of Yap’s role in fibrogenesis is clinically relevant due to the necessity for a viable antifibrotic therapy.

Emerging data show that Yap and hippo pathway in general are involved in liver enlargement and the associated clonal expansion of HCC. Yet, detailed mechanistic insights on the molecular regulation of fibrogenesis by Yap remain unclear. Recent reports document that energy producing pathways are altered in early/late cirrhotic stages and selective deregulation/ disruption of such metabolic alteration block fibrotic phenotype in vitro and in vivo.Thus, accumulating data indicate that metabolic alteration is indispensable for the progression of fibrosis/ cirrhosis.

Corroborating this, Yap and Hippo signaling mechanism have also been found to be regulated by energy stress. Importantly, glucose-mediated energy homeostasis has been shown to regulate Hippo pathway which in turn affects pro-glycolytic function of Yap. Multiple lines of evidence have established that metabolism-related oxidative stress is a major facilitator of fibrosis. Intriguingly, evidences also show that Yap- Hippo pathway is affected by oxidative stress. Taken together, it is thus far evident that cellular stress contributes for fibrogenesis and Yap-Hippo pathway is affected by such cellular stress during fibrogenesis. Future investigations focusing on molecular intricacies of Yap regulation by metabolic stress will be critical and relevant to identify potential therapeutic target (s) and development of any viable and translatable strategy to treat liver fibrosis/cirrhosis.