The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

/pdf/european-position-paper-on-rhinosinusitis-and-nasal-polyps-mj734vsl7p.pdf

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic, which has resulted in global healthcare crises and strained health resources. As the population of patients recovering from COVID-19 grows, it is paramount to establish an understanding of the healthcare issues surrounding them. COVID-19 is now recognized as a multi-organ disease with a broad spectrum of manifestations. Similarly to post-acute viral syndromes described in survivors of other virulent coronavirus epidemics, there are increasing reports of persistent and prolonged effects after acute COVID-19. Patient advocacy groups, many members of which identify themselves as long haulers, have helped contribute to the recognition of post-acute COVID-19, a syndrome characterized by persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms. Here, we provide a comprehensive review of the current literature on post-acute COVID-19, its pathophysiology and its organ-specific sequelae. Finally, we discuss relevant considerations for the multidisciplinary care of COVID-19 survivors and propose a framework for the identification of those at high risk for post-acute COVID-19 and their coordinated management through dedicated COVID-19 clinics.

/pdf/post-acute-covid-19-syndrome-1bat2sg5js.pdf

Post-acute COVID-19 syndrome.

结节病易误诊,据王洪武等~([1])收集国内18篇关于此病误诊的文献,误诊率高达63.2%,当然有误诊就会有误治,如孙永昌等~([2])报道26例结节病在影像学检查诊断的第一印象中拟诊结核5例,其中就有2例完成规范的抗结核治疗,为此应引起临床对本病诊治的重视。

Sarcoidosis

Chimeric Antigen Receptor T Cells This review addresses T-cell engineering and synthetic immunity, with a focus on producing durable remissions in patients with treatment-refractory tumors. Toxic e...

https://www.nejm.org/doi/pdf/10.1056/NEJMra1706169

Chimeric Antigen Receptor Therapy.

Recently a novel DNA virus (Torque Teno Virus (TTV) has been identified in Japan and shown to be associated with elevated aminotransferase s levels after transfusion. However the exact role of TTV in pathogenesis of liver disease is yet to be established. The purpose of this study was to determine the prevalence of TTV in thalassemic patients and its relationship with elevated alanine-aminotransfrase (ALT) and aspartateaminotransfrase (AST). This cross-sectional analysis study was conducted on 452 thallasemic patients. Serums were collected from all of the patients, first ALT and AST levels were determined. Then, after DNA extraction, TTV DNA was amplified and detected using semi-nested PCR, followed by gel electrophoresis. Demographic characteristics and clinical data were collected from each participant for statistical analysis. The findings showed that 160 of 452 (35.4%) samples had TTV DNA detected by PCR. From 160 TTV DNA positive, 98 (61.20%) were female and 62 (38.80%) of them were male (P=0.549). The mean ALT and AST values in TTV positive group were higher than in TTV negative group, and the difference was statistically significant (p<0.0001). The result showed that the prevalence of TTV in thalassemic patients in Jahrom is less than other studies in Iran and the mean ALT and AST values in TTV positive individuals were about 2 times more than in TTV negative individuals.

/pdf/molecular-prevalence-and-clinical-importance-of-torque-teno-2fi9z1ixeg.pdf

Molecular Prevalence and Clinical Importance of Torque Teno Virus Infection in Thalassemia Patients as High Risk Individuals

Cryptococcosis is an invasive fungal infection most often caused by the encapsulated yeasts Cryptococcus neoformans and Cryptococcus gattii. C neoformans is the major pathogenic member of the genus, thought to account for approximately 80% of isolates worldwide, and is found in pigeon droppings, soil, and rotting vegetation.1 The incidence in the United States is approximately 5 cases per 100,000.2 However, the global burden is much more significant, with more than 1 million new cases and more than 600,000 deaths a year.3

Most patients with cryptococcosis are immunocompromised because of HIV infection, immunosuppressive therapy, or malignancy. Although cryptococcal infections begin in the lungs via inhalation of the basidiospore, the classical clinical manifestation is meningoencephalitis. Nonmeningeal, nonpulmonary symptoms are less common and generally reflect disseminated disease. Cutaneous manifestations are seen in approximately 15% of patients with systemic cryptococcosis and can have a variety of presentations, including papules, plaques, and ulcers.4 Here we present an uncommon case of cutaneous cryptococcosis presenting as cellulitis in a heart transplant recipient.

Cryptococcal cellulitis in a heart transplant recipient.

Dermatology as a field encompasses a vast catalogue of over 3000 diseases, and the diagnoses which dermatologists manage range from the common to the obscure. Often, clinical/pathological correlation is essential in making a specific diagnosis, which can then guide evaluation for extracutaneous involvement and inform treatment decisions. As a field, we have a tendency towards ‘splitting’, dividing diseases into subtypes, which can sometimes benefit the patient and their care team. For instance, patients with MDA-5 dermatomyositis clearly behave quite differently than patients with Mi-2 dermatomyositis, and we may be honing in on specific antibody patterns more tightly associated with malignancy-associated cases. In other cases, ‘splitting’ may be more artificial, and confuse rather than inform – for instance, the various eponymous types of pigmented purpuric dermatoses or the many numbered types of pityriasis rubra pilaris, which often tell patients and clinicians little about prognosis, evaluation or treatment. Occasionally, ‘lumping’ diseases together under a common unifying umbrella term can provide more useful information to patients and physicians. Bolognia et al.’s ‘toxic erythema of chemotherapy: a useful clinical term’ remains a sterling example of the benefit of ‘lumping,’ creating a framework for conceptualizing the spectrum of cytotoxic chemotherapy reactions under one unifying term. The terms palisaded neutrophilic and granulomatous dermatitis (PNGD), interstitial granulomatous dermatitis (IGD) and interstitial granulomatous drug reaction (IGDR) each started with a fairly specific initial case definition, based on histological findings, and a narrow range of clinical findings. Over time, as more reports were published, the distinctions between the entities’ clinical and histological features have blurred. Importantly, for patients and their dermatologists, the significance of each of these diagnoses is similar: patients require evaluation for connective tissue disease, inflammatory arthritis or drug triggers, and uncommonly may develop these lesions in the setting of malignancy. The unifying term ‘reactive granulomatous dermatitis’ (RGD) was proposed by Joe English in our 2015 review of these entities. In this issue of JEADV, Kumar et al. provide additional support for the concept of RGD as an encompassing term for this family of diseases. They reviewed 65 patients from the Mayo clinic, 37 with IGD, 26 with PNGD, and 2 with IGDR. More than three-quarters of patients had an associated systemic condition, and there was no association between clinical or histologic subtype of RGD with specific diseases or treatment response. This work helps solidify the concept that patients with RGD, regardless of whether the clinical or histological features are more consistent with PNGD or IGD, require a similar approach. The concept of ‘RGD’ also allows room to expand this umbrella when necessary. Interestingly, Kumar et al. noted a significant subset of patients with gastrointestinal disease (generally inflammatory bowel disease), which may be important to consider in patients with suggestive symptoms. When considering rendering a diagnosis, it is important to consider both the patient (what does this diagnosis tell them) and their clinician (how does a histological diagnosis guide their care). ‘Lumping’ these terms under the unifying concept of RGD helps both patients and clinicians. RGD describes in simple terms what is happening – there is a reaction in the skin characterized by granulomas. It provides clear guidance to clinicians – evaluate patients for connective tissue disease and inflammatory arthritis, and consider whether there could be a medication driver, or specific types of malignancy.

Reactive granulomatous dermatitis: Lumping terms to split confusion

Background: Sarcoidosis is a multisystem granulomatous inflammatory disease of unclear etiology that involves the lung, skin and other organs, with an unknown antigenic trigger. Recently, evidence has been found in both immune deficient and immune competent patients for rubella virus in cutaneous granulomas. These granulomatous lesions share overlapping features with cutaneous sarcoidosis, raising the question of rubella virus in sarcoidosis. Objective: To investigate the presence of rubella virus in sarcoidosis lung samples. Methods: We employed metagenomic sequencing to interrogate extracellular virome preparations and cellular transcriptomes from bronchoalveolar lavage (BAL) of 209 sarcoidosis patients for rubella virus sequences. Results: We found no evidence for rubella virus genomes in acellular fluid or rubella virus gene expression in BAL cells of sarcoidosis patients. Conclusions: These findings argue against rubella virus infection or persistence within the lung at time of sampling as a sarcoidosis trigger.

Metagenomic sequencing of the bronchoalveolar lavage extracellular virome and cellular transcriptome of sarcoidosis patients does not detect rubella virus

https://link-springer-com-443.webvpn.jmu.edu.cn/content/pdf/10.1007%2F978-3-319-56591-0_31-1.pdf

Cutaneous Sarcoidosis Outcome Instruments: Reliability and Validity Among Dermatologists, Pulmonologists, and Rheumatologists

A woman in her 50s presented with low-grade subjective intermittent fevers and painful draining ulcerations on the legs of 7 months’ duration. Her medical history was remarkable for polymyositis and interstitial lung disease managed with prednisone and mycophenolate mofetil. While living in Taiwan, she developed lower extremity abscesses and persistent fevers. The patient denied any skin injuries or exposure to animals or brackish water. Mycophenolate mofetil was discontinued, and she was treated with multiple antibiotics alone and in combination without improvement, including amoxicillin–clavulanic acid, levofloxacin, azithromycin, moxifloxacin, rifampin, rifabutin, and ethambutol. She returned to the United States for evaluation. Physical examination revealed ulcerations with purulent drainage and interconnected sinus tracts with rare fluctuant nodules along the right leg. A single similar lesion was present on the right chest wall. There was no clinical evidence of disseminated disease.

Sporotrichoid fluctuant nodules.

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