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Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially life-threatening condition associated with variable clinical presentations including rash, fevers, eosinophilia, and visceral organ involvement. It is a hypersensitivity reaction, and most cases have an identifiable inciting factor of drug exposure. Case presentation: We present an interesting case of DRESS syndrome in a 97-year-old patient after she was treated with valacyclovir for herpes zoster. Her presentation included an exanthematous rash, acute kidney injury and progression to development of mildly elevated liver enzymes. Skin biopsy was consistent with DRESS. Patient initially responded to steroids but had a relapse during steroid taper. She eventually responded well to a slow prolonged steroid taper and had complete resolution of organ dysfunction and skin manifestations. Conclusion: Valacyclovir is a rare but important cause of DRESS. A thorough history of the illness timeline and a high index of clinical suspicion is required for the prompt diagnosis and treatment of the condition. Apart from withdrawal of the offending agent, a slow prolonged taper of steroids is the current recommended treatment as rapid reduction of steroid dosage can lead to a relapse of cutaneous and systemic symptoms.

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Mycobacterium avium-complex (MAC) is an infectious granulomatous disease which is associated with hypercalcemia especially in immunocompromised patients. We present an unusual case of MAC infection in an immunocompetent patient presenting as hypercalcemia.A 76-year-old immunocompetent male was admitted for hypercalcemia of 12.6 mg/dl found on outpatient evaluation for fatigue. PTH level was low 8 pmol/L, Vitamin D 25hydroxy was 29 ng/ml, 1,25 dihydroxy vitamin D (1,25(OH)2 vitamin D) levels was low at 11 pg/ml, PTH related peptide was 1.1 pmol/L. Hypercalcemia resolved with intravenous hydration and bisphosphonate administration. CT chest identified a nodule with central cavity in the right upper lobe. Pathology from percutaneous biopsy of thenodule demonstrated granulomatous inflammation. AFB culture came positive for MAC. Patient was treated with Azithromycin, Rifabutin and Ethambutol for twelve months.Granulomatous diseases like MAC cause hypercalcemia via activation of macrophages which express extrarenal 1- alpha -hydroxylase. It converts vitamin D to its active form 1,25(OH)2 vitamin D causing its excess, leading to hypercalcemia. Interestingly, in our patient calcium level was elevated with appropriately low PTH but 1,25(OH)2 vitamin D level was also low. There are few reported cases of hypercalcemia in granulomatous disease with normal levels of 1,25(OH)2 vitamin D levels, and our case is the first one to have MAC associated hypercalcemia with low 1,25(OH)2 vitamin D levels, suggesting an alternative mechanism for hypercalcemia in these patients.

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Expanding easily accessible community SARS-CoV-2 screening is essential in the response to the COVID-19 pandemic. In this report, we describe the findings from the initial 25 days of a SARS-CoV-2 drive-up and walk-up testing initiative was organized in Peoria, Illinois. Eighty-seven out of 4,073 individuals (2.1%) tested positive for SARS-CoV-2, and 46% of these were asymptomatic at the time of testing. There were ten frontline workers without symptoms consistent with COVID-19 who tested positive, including six that did not report any known exposure to SARS-CoV-2. These results stress the importance and effectiveness of widely available community SARS-CoV-2 testing and suggest a possible benefit to screening of asymptomatic individuals at higher risk for infection.

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Polyarteritis Nodosa (PAN) is a small and medium vessel necrotizing vasculitis that can affect any system in the human body. Rarely, PAN can be the primary manifestation of an underlying malignancy. The association between malignancy and vasculitis is an ongoing topic of research. Our patient's presentation suggests malignancy may be a trigger for acute onset vasculitis and therefore once a malignancy is identified, therapy should be targeted towards treating the malignancy rather than the vasculitis alone.

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BACKGROUND Evans syndrome is characterized by 'warm' autoimmune hemolytic anemia and autoimmune thrombocytopenia, and is more common in the pediatric population than in adults. Evans syndrome is often associated with underlying autoimmune disease, connective tissue disease, immune deficiency disorders, lymphoproliferative disorders, or malignancy of the immune system. A case is presented of acute kidney injury due to hemoglobin cast nephropathy in an adult man with Evans syndrome. CASE REPORT A 60-year-old man was diagnosed with Evans syndrome, which was complicated by acute renal failure that required treatment with hemodialysis. Laboratory tests and renal histology confirmed a diagnosis of hemolysis-associated hemoglobin cast nephropathy. CONCLUSIONS The diagnosis of Evans syndrome is important as it may be associated with underlying hematological and immunological disorders. Although rare, hemoglobin cast nephropathy due to hemolysis can be a cause of acute kidney injury in patients with Evans syndrome.

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BACKGROUND AND AIM: Accurate diagnosis is essential in the appropriate management of biliary strictures. Our aim is to evaluate the efficacy of cholangioscopy-directed biopsies in differentiating biliary intraductal malignancies from benign lesions. MATERIALS AND METHODS: Articles were searched in Medline, PubMed, and Ovid journals. Pooling was performed by both fixed-effects and random-effects models. Only studies from which a 2×2 table could be constructed for true-positive, false-negative, false-positive, and true-negative values were included. RESULTS: Initial search identified 2110 reference articles for peroral cholangioscopy; of these, 160 relevant articles were selected and reviewed. Data were extracted from 15 studies (N=539) that fulfilled the inclusion criteria. Pooled sensitivity of cholangioscopy-directed biopsies in diagnosing malignancy was 71.9% [95% confidence interval (CI): 66.1-77.1] and pooled specificity was 99.1% (95% CI: 96.9-99.9). The positive likelihood ratio of cholangioscopy-directed biopsies was 18.1 (95% CI: 9.1-35.8), whereas the negative likelihood ratio was 0.3 (95% CI: 0.2-0.4). The pooled diagnostic odds ratio was 71.6 (95% CI: 32.8-156.4). All the pooled estimates calculated by fixed-effects and random-effect models were similar. Summary receiver operating characteristic curves showed an area under the curve of 0.98. The χ heterogeneity for all the pooled accuracy estimates was 5.62 (P=0.96). CONCLUSION: Peroral cholangioscopy with cholangioscopy-directed biopsies has a high specificity in differentiating intraductal malignancies from benign lesions. Cholangioscopy-directed biopsies should be strongly considered for biliary stricture evaluation.

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Since the discovery of neural regions in the monkey brain that respond preferentially to multisensory stimuli presented in proximal space, researchers have been studying this specialised spatial representation in humans. It has been demonstrated that approaching auditory or visual stimuli modulate tactile processing, while they are within the peripersonal space (PPS). The aim of the current study is to investigate the additional effects of tactile expectation on the PPS-related multisensory interactions. Based on the output of a computational simulation, we expected that as tactile expectation increases rapidly during the course of the motion of the visual stimulus, the outcome RT curves would mask the multisensory contribution of PPS. When the tactile expectation remains constant during the motion, the PPS-related spatially selective multisensory processes become apparent. The behavioural results on human experiments followed the pattern predicted by the simulation. That is, rapidly changing levels of tactile expectation, caused by dynamic visual stimuli, masks the outcome of the multisensory processes within peripersonal space. This indicates that both PPS-related multisensory interactions and tactile expectations play an important role in anticipating and responding to interactions with the body.

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BACKGROUND: Cryptococcal infections have been mostly associated with immunocompromised individuals, 80-90% of whom have been HIV-positive patients. Increasingly, cryptococcal infections are being reported in cirrhotic patients who are HIV-negative. The underlying immunologic defects in cirrhotic patients seem to play an important role in predisposing them to cryptococcosis and affecting their morbidity and mortality. CASE PRESENTATION: We present a case of disseminated cryptococcosis in an HIV-negative patient with underlying cirrhosis, who had rapid worsening of his hyponatremia with renal failure and was unable to recover, despite aggressive measures. CONCLUSION: Cryptococcus is a more common culprit of infections seen in cirrhotic patients than what it was previously known, and a high index of suspicion is required to diagnose these patients. Identification of poor prognostic factors, early diagnosis and intervention is crucial in the management of these patients.

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Action capability may be one of the factors that can influence our percept of the world. A distinction can be made between momentary action capability (action capability at that particular moment) and inherent action capability (representing a stable action capability). In the current study, we investigated whether there was a biasing effect of these two forms of action capability on visual perception of location. In a virtual reality room, subjects had to stop a moving ball from hitting a pillar. On some trials, the ball disappeared automatically during its motion. Subjects had to estimate the location of the ball's disappearance in these trials. We expected that if action is necessary but action capability (inherent or momentary) is limiting performance, the location of approaching objects with respect to the observer is underestimated. By judging the objects to be nearer than they really are, the need to select and execute the appropriate action increases, thereby facilitating quick action (Cole et al. in Psychol Sci 24(1):34-40, 2013. doi: 10.1177/0956797612446953 ). As a manipulation of inherent action capability in a virtual environment, two groups of participants (video game players vs. non-video game players) were entered into the study (high and low action capability). Momentary action capability was manipulated by using two difficulty levels in the experiment (Easy vs. Difficult). Results indicated that inherent and momentary action capabilities interacted together to influence online location judgments: Non-players underestimated locations when the task was Difficult. Taken together, our data suggest that both inherent and momentary action capabilities influence location judgments.

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BACKGROUND: Ebola virus disease (EVD) is a public health emergency of international concern. There is limited laboratory and clinical data available on patients with EVD. This is a meta-analysis to assess the utility of clinical signs, symptoms, and laboratory data in predicting mortality in EVD. AIM: To assess the utility of clinical signs, symptoms, and laboratory data in predicting mortality in EVD. METHOD: Study selection criterion: EVD articles with more than 35 EVD cases that described the clinical features were included. Data collection and extraction: Articles were searched in Medline, PubMed, Ovid journals, and CDC and WHO official websites. STATISTICAL METHODS: Pooled proportions were calculated using DerSimonian Laird method (random effects model). RESULTS: Initial search identified 634 reference articles, of which 67 were selected and reviewed. Data were extracted from 10 articles (N=5,792) of EVD which met the inclusion criteria. Bleeding events (64.5% vs. 25.1%), abdominal pain (58.3% vs. 37.5%), vomiting (60.8% vs. 31.7%), diarrhea (69.9% vs. 37.8%), cough (31.6% vs. 22.3%), sore throat (47.7% vs. 19.8%), and conjunctivitis (39.3% vs. 20.3%) were more often present in pooled proportion of fatal cases as compared to EVD survivors. CONCLUSIONS: Clinical features of EVD that may be associated with higher mortality include bleeding events, vomiting, diarrhea, abdominal pain, cough, sore throat, and conjunctivitis. These patients should be identified promptly, and appropriate management should be instituted immediately.

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BACKGROUND: Endoscopic ultrasound (EUS)-guided ethanol ablation has emerged as an efficacious and safe alternative management option for pancreatic cysts. We undertook a meta-analysis and systematic review to assess the overall safety and efficacy of EUS-guided ethanol ablation of pancreatic cysts. METHOD STUDY SELECTION CRITERIA: EUS-guided ethanol ablation of pancreatic cysts. DATA COLLECTION EXTRACTION: Articles were searched in Medline, Pubmed, and Ovid journals. STATISTICAL METHOD: Fixed and random effects models were used to calculate the pooled proportions. RESULTS: Initial search identified 1,319 reference articles, in which 120 relevant articles were selected and reviewed. Data was extracted from seven studies (n = 152) of EUS-guided ethanol ablation of pancreatic cysts, which met the inclusion criteria. With EUS-guided ethanol ablation, the pooled proportion of patients with complete cyst resolution was 56.20 % (95 % CI = 48.16 to 64.08) and partial cyst resolution was 23.72 % (95 % CI = 17.24 to 30.89). Postprocedural complications after ablation were significant for abdominal pain in 6.51 % (95 % CI = 3.12 to 11.04) and pancreatitis in 3.90 % (95 % CI = 1.39 to 7.60) of the pooled percentage of patients. Publication bias calculated using Harbord-Egger bias indicator gave a value of -1.09 (95 % CI = 10.21 to 8.03, p = 0.77). The Begg-Mazumdar indicator gave a Kendall's tau b value of 0.05 (p ≥ 0.99). CONCLUSIONS: EUS-guided ethanol ablation may be a safe alternative treatment modality for pancreatic cysts, with acceptable intraprocedural and postprocedural complications. However, due to the limited data available, prospective randomized controlled trials with a long follow up period are required in this area.

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In this study we aimed to explore the predictive link between visual stimuli moving towards the body and the tactile consequences that follow. More specifically, we tested if information derived from an approaching visual stimulus in the region directly surrounding the body (the peripersonal space) could be used to make judgments about the location and time of impending tactile contact. We used moving arm stimuli, displayed on a computer screen, which appeared to travel either towards the face (middle of the left/right cheek) or slightly away from the subject's face. This stimulus was followed by tactile stimulation of the left/right cheek. The time lag between the visual stimulus and tactile stimulation was also manipulated to simulate tactile contact at a time that was either consistent or inconsistent with the speed of the approaching hand. Reaction time information indicated that faster responses were produced when the arm moved towards the hemispace in which the tactile stimulation was delivered and was insensitive to whether the arm was moving towards the cheek or slightly away from the cheek. Furthermore, response times were fastest when the tactile stimulation arrived at the moment that was consistent with the speed of the moving arm. The effects disappeared when the arm appeared to be retracting from the subject's face. These results suggest the existence of a predictive mechanism that exploits the visual information derived from objects moving towards the body for making judgments about the time and location of impending tactile contact.

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Background. Histoplasma capsulatum is the most common endemic mycosis in the United States and is a frequent cause of opportunistic infection in immunodeficient hosts. Histoplasmosis is most often self-limiting and goes unrecognized in the immunocompetent population but can progress to disseminated histoplasmosis in patients with an impaired immune system. Liver involvement as a part of disseminated histoplasmosis which usually originates in the lung is well known. However, extrapulmonary hepatic histoplasmosis as a primary manifestation is extremely rare. Case Presentation. We report a rare case of histoplasmosis that presented as persistent fever and abnormal liver function tests in a 66-year-old female with rheumatoid arthritis, receiving infliximab. Conclusion. Emphasizing histoplasmosis as a major cause of acute granulomatous hepatitis and fever of unknown origin in cell mediated immunodeficient population, this case highlights the need for high index of suspicion and the importance of prompt diagnosis since any delay of treatment can be life threatening in this population.

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Organisms that are not known to cause serious infection in the immunocompetent population can, in fact, cause devastating illness in immunosuppressed neutropenic populations especially those who are undergoing hematopoietic stem cell transplantation (HSCT), and solid organ transplantation or a history of malignancy. One organism of interest isolated from immunosuppressed patients at our institution was Bordetella bronchiseptica. It is known to cause respiratory tract disease in the animal population which includes dogs, cats, and rabbits. This organism rarely causes serious infection in the immunocompetent population. However; in immunosuppressed patients, it can cause serious pulmonary disease. We present three cases of B. bronchiseptica pneumonia in patients with a history of malignancy.

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BACKGROUND: Most people show a remarkable deficit to report the second of two targets when presented in close temporal succession, reflecting an attentional blink (AB). An aspect of the AB that is often ignored is that there are large individual differences in the magnitude of the effect. Here we exploit these individual differences to address a long-standing question: does attention to a visual target come at a cost for attention to an auditory target (and vice versa)? More specifically, the goal of the current study was to investigate a) whether individuals with a large within-modality AB also show a large cross-modal AB, and b) whether individual differences in AB magnitude within different modalities correlate or are completely separate. METHODOLOGY/PRINCIPAL FINDINGS: While minimizing differential task difficulty and chances for a task-switch to occur, a significant AB was observed when targets were both presented within the auditory or visual modality, and a positive correlation was found between individual within-modality AB magnitudes. However, neither a cross-modal AB nor a correlation between cross-modal and within-modality AB magnitudes was found. CONCLUSION/SIGNIFICANCE: The results provide strong evidence that a major source of attentional restriction must lie in modality-specific sensory systems rather than a central amodal system, effectively settling a long-standing debate. Individuals with a large within-modality AB may be especially committed or focused in their processing of the first target, and to some extent that tendency to focus could cross modalities, reflected in the within-modality correlation. However, what they are focusing (resource allocation, blocking of processing) is strictly within-modality as it only affects the second target on within-modality trials. The findings show that individual differences in AB magnitude can provide important information about the modular structure of human cognition.

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