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Background: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem inflammation and is a common cause of pericarditis and pericardial effusion, but significant pericardial effusion and cardiac tamponade are rare and even rarer as the first manifestation. Case summary: We report the case of a young male who presented with fever, recurrent pericarditis, and polyserositis with pericardial and bilateral pleural effusion. On examination, he was haemodynamically unstable and the pericardial effusion had considerable dimensions and an urgent pericardiocentesis was performed. Antinuclear antibody with a speckled pattern was positive, complement C4 levels were low, and the remaining autoimmunity and infectious study was unremarkable. Considering the European League Against Rheumatism/American College of Rheumatology classification criteria for SLE, a score of 11 points was obtained, confirming the diagnosis of SLE. Discussion: This case report illustrates a rare form of presentation of SLE, in which the first manifestation was pericarditis with polyserositis and cardiac tamponade.

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Familial Mediterranean fever (FMF) is an autoinflammatory disorder, characterized by recurrent episodes of fever and polyserositis, and usually presents during the first two decades of life. Acute pericarditis is a rare manifestation of FMF and typically presents with other symptoms of the inflammatory disorder. A 27-year-old Arabian male presented to our hospital with pleuritic chest pain and shortness of breath while lying flat. His electrocardiogram showed changes suggestive of pericarditis, and his inflammatory markers and troponin were raised. His echocardiogram revealed a moderate-sized pericardial effusion with septa and a normal left ventricular function. He had a strong family history of FMF and consanguinity of the parents. He was treated for acute myopericarditis with colchicine and ibuprofen, and his symptoms improved gradually along with his inflammatory markers and troponin. Six weeks after discharge, he had a cardiac MRI, which revealed a thickened pericardium with profound enhancement (features suggestive of pericarditis) and no signs of myocarditis. He was asymptomatic, and his markers and troponin were within the normal range. His colchicine medication was continued indefinitely, and he was referred to a tertiary care hospital with a specialized periodic fever clinic for follow-up and genotype testing.

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Necropsies can reveal herd problems or comorbidities that can lead to management corrections, improvements in animal performance, and better decision making. Furthermore, the pattern and causes of mortality might differ when different systems are evaluated. The present study was conducted to establish the main causes of death in nursery pigs from different systems in Brazil, as well as the clinical, microbiological, and pathological aspects of these mortalities. Eighteen nurseries were analyzed (a total of 120,243 housed piglets), and 557 necropsies were performed. Streptococcus suis infection was the most prevalent cause of death (21.2%), followed by bacterial polyserositis (16.7%), chronic atrophic enteritis (13.5%), salmonellosis (8.8%), pneumonia (8.6%), and colibacillosis (6.1%). The increase in mortality rate in individual nurseries and, consequently, in the diagnoses was commonly associated with disease outbreaks. Infectious diseases constituted the largest portion of the diagnoses, making a great opportunity for improving production rates in herds. Moreover, the extensive range of observed diagnoses highlights the importance of conducting preliminary diagnostic investigations based on necropsy to determine the causes of death. This approach allows for the direction of complementary tests, which can diagnose agents with greater specificity. As a result, this allows for the implementation of more effective prevention and control strategies.

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BACKGROUND: Glaesserella parasuis is the causative agent of Glässer's disease in pigs. Serotyping is the most common method used to type G. parasuis isolates. However, the high number of non-typables (NT) and low discriminatory power make serotyping problematic. In this study, 218 field clinical isolates and 15 G. parasuis reference strains were whole-genome sequenced (WGS). Multilocus sequence types (MLST), serotypes, core-genome phylogeny, antimicrobial resistance (AMR) genes, and putative virulence gene information was extracted. RESULTS: In silico WGS serotyping identified 11 of 15 serotypes. The most frequently detected serotypes were 7, 13, 4, and 2. MLST identified 72 sequence types (STs), of which 66 were novel. The most predominant ST was ST454. Core-genome phylogeny depicted 3 primary lineages (LI, LII, and LIII), with LIIIA sublineage isolates lacking all vtaA genes, based on the structure of the phylogenetic tree and the number of virulence genes. At least one group 1 vtaA virulence genes were observed in most isolates (97.2%), except for serotype 8 (ST299 and ST406), 15 (ST408 and ST552) and NT (ST448). A few group 1 vtaA genes were significantly associated with certain serotypes or STs. The putative virulence gene lsgB, was detected in 8.3% of the isolates which were predominantly of serotype 5/12. While most isolates carried the bcr, ksgA, and bacA genes, the following antimicrobial resistant genes were detected in lower frequency;  blaZ (6.9%), tetM (3.7%), spc (3.7%), tetB (2.8%), bla-ROB-1 (1.8%), ermA (1.8%), strA (1.4%), qnrB (0.5%), and aph3''Ia (0.5%).   CONCLUSION: This study showed the use of WGS to type G. parasuis isolates and can be considered an alternative to the more labor-intensive and traditional serotyping and standard MLST. Core-genome phylogeny provided the best strain discrimination. These findings will lead to a better understanding of the molecular epidemiology and virulence in G. parasuis that can be applied to the future development of diagnostic tools, autogenous vaccines, evaluation of antibiotic use, prevention, and disease control.

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Key Clinical Messages: The diagnosis of polyserositis due to tuberculosis (TB) is complex and challenging, which may cause delays in treatment. TB should be ruled out first before attributing polyserositis to any other cause like hypothyroidism, particularly in high TB burden countries. Abstract: Polyserositis has numerous causes and frequently occurs in neoplasia, autoimmune disorders, endocrine conditions like hypothyroidism, and infectious diseases like tuberculosis (TB). The diagnosis of TB polyserositis is complex and challenging, which may cause the start of definitive therapy to be delayed. Here, we report the case of a 32-year-old female patient who presented with abdominal distension for 3 weeks associated with shortness of breath, cough, excessive fatigue, and loss of appetite. Thyroid function tests were suggestive of primary hypothyroidism, and later on, sputum GeneXpert MTB/RIF test turned out to be positive. She was initially started on oral levothyroxine and then anti-TB medications. The polyserositis resolved a month after the initiation of anti-TB drugs. TB should be ruled out first before attributing polyserositis to any other cause like hypothyroidism, particularly in high TB burden countries. Microbiologic tests, such as GeneXpert, remain the most important tools to make a diagnosis of TB and start anti-TB medications early.

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Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal disease characterized by excessive immune response activation. Numerous conditions, including infectious etiologies, are implicated in its development. We report the case of a 16-year-old girl with HLH associated with polyserositis and Salmonella typhi infection. A 16-year-old girl presented with a high-grade fever and abdominal pain that had been ongoing for 20 days. She had been treated for malaria at a local hospital but was referred to our hospital due to the worsening of her condition. On examination, she was found to have an enlarged liver and spleen, pale skin, and hypotension, with bilateral basal crackles on chest examination. Her blood profile revealed pancytopenia, elevated C-reactive protein, and a deranged coagulation profile. Peripheral smears showed anisocytosis, microcytes, hypochromia in RBCs, and a few platelet clumps. A bone marrow biopsy revealed increased megakaryocytes and hemophagocytes. Ultrasound and computed tomography of the abdomen and pelvis showed hepatosplenomegaly, pericholecystic edema, mild ascites, and long-segment diffuse colonic wall thickening, suggesting pancolitis. Blood culture revealed S. typhi, which is rarely associated with HLH. The patient was started on the HLH-2004 protocol and showed improvement on the fourth day of initiating therapy, but due to a delayed diagnosis, the patient collapsed on the sixth day of admission. HLH is a rare but life-threatening disease with various underlying causes. The diagnosis of HLH is challenging, and early diagnosis and prompt treatment are crucial for a better prognosis. The association between HLH and S. typhi infection is rare, and this case highlights the importance of considering unusual etiologies in HLH. Clinicians should be vigilant about this association, especially in endemic regions, to ensure early diagnosis and prompt treatment.

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At present, polyserositis (PS) remains a challenging entity, which resides both in the fact that there is confusion regarding the terminology, and that it is still understudied. We aimed to identify the etiologies of PS, reported in adult patients. METHODS: We performed a systematic review of the literature on PubMed(MEDLINE) database, using the following (MESH) terms: pleurisy/etiology, pleural effusion/etiology, pericarditis/etiology, pericardial effusion/etiology, pericardial effusion chronic, ascites/etiology, ascitic fluid/etiology, polyserositis, serositis, and serositides. RESULTS: A total of 1979 articles were identified, dating from 1973 onwards. After screening the articles, we included 114 patients from 23 articles (one case series including 92 patients and 22 case reports) in the final report. The most common diagnosis was neoplasia (30; 26.3%), followed by autoimmune diseases (19, 16.7%) and infections (16, 12.3%). Still, in 35 cases, the etiology of PS remained unkown. CONCLUSION: PS is a challenging and understudied entity, which is associated with a wide range of diagnoses. However, prospective studies should be developed in order to have a clear understanding regarding its etiologies and their prevalences.

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Mixed connective tissue disease (MCTD) is a complex rheumatologic condition whose diagnosis often presents a challenge to even specialists in the field. Many cases are therefore underrecognized or misdiagnosed due to the heterogeneity of the presentation and manifestations. This report highlights the intricacies of diagnosing a case of MCTD when the presenting symptom is atypical. Herein, we present a case of a young girl who had severe abdominal pain, initially concerning for acute peritonitis from cholecystitis, and was found to have polyserositis affecting the pleural space, pericardium, peritoneum and pelvis secondary to mixed connective tissue disease and adrenal insufficiency.

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The paper reported a case of a young male patient, with graft-versus-host disease (GVHD) multi-organ involvement lesions after allo-hematopoietic stem cell transplantation. The patient had diverse clinical manifestations, and overlapping acute and chronic disease processes. Acute GVHD were mainly hyperbilirubinemia, with or without elevated transaminase, bloody watery stools; chronic GVHD were highlighted by extensive skin depigmentation, oral mucosal ulcer, sick nails, etc., and chronic signs, such as membranous nephropathy, polyserositis and pulmonary restrictive ventilatory insufficiency. The diagnosis of chronic GVHD mainly relies on medical history combined with clinical manifestations, and it's needed to exclude infections, drugs and tumors. Besides, the rate of missed diagnosis and misdiagnose is high, and it requires multidisciplinary diagnosis and treatment. Combined with the literature review, it indicates that there is a greater risk of GVHD in the male recipient with female donor, and peripheral blood stem cell transplant patients have a higher incidence than bone marrow transplant patients after hematopoietic stem cell transplantation, but the effect of the graft-versus-leukemia exists. Currently, glucocorticoids therapy with or without calcineurin inhibitors are the first-line treatment for GVHD, but the overall prognosis is poor.

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BACKGROUND: Generalised oedema was occasionally reported associated with immune checkpoint inhibitors (ICPIs). The purpose of this study is to investigate immune-related generalised oedema (ir-GE) drug related to ICPI, through frequency, clinical and pathological characteristics, and patient's outcome. PATIENTS AND METHODS: Objectives of the study were to report on ir-GE associated with ICPI to define frequency, associated signs and symptoms, pathological characteristics, severity, and response to corticosteroids. To be included in the study, adult patients had to have ir-GE related to ICPI with certain or likely link, without any other known causes of generalised oedema. The study design was observational, over the period 2014-2020, from pharmacovigilance databases in France, including the prospective Registre des Effets Indésirables Sévères des Anticorps Monoclonaux Immunomodulateurs en Cancérologie (REISAMIC) registry. Calculation of the frequency of ir-GE was restricted to the prospective REISAMIC registry. RESULTS: Over 6633 screened patients, 20 had ir-GE confirmed drug related to ICPI. Based on the prospective REISAMIC registry, the frequency of ir-GE was 0.19% of ICPI-treated patients (3 cases out of 1598 screened patients). The 20 patients with ir-GE had a median (range) age of 62 (26-81) years, most frequent tumour types were melanoma (n = 9; 45%) and lung cancer (n = 6; 30%). The most frequent localisations of oedema were peripheral (n = 17; 85%), pleural (n = 13; 65%), and peritoneal (n = 10; 50%). Polyserositis was observed in 11 (55%) patients. The median (range) weight gain per patient was 9 (2-30) kg. Associated signs and symptoms met criteria for capillary leak syndrome (n = 4; 20%), sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) (n = 3; 15%), or subcutaneous autoimmune syndrome (n = 2; 10%). Corticosteroids were administered to 15 patients; of them, 10 (67%) improved clinically after corticosteroids. Based on CTCAEV5.0, the highest severity of ir-GE was grade ≥4 in 11 (55%) patients and four (20%) patients died due to ir-GE. CONCLUSIONS: Generalised immune system-related oedema is a new category of adverse event with immune checkpoint inhibitors and is often associated with a life-threatening condition. The pathophysiology may in some cases be related to endothelial dysfunctions, such as SOS/VOD or capillary leak syndrome.

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Fatal Mannheimia haemolytica (M. haemolytica) infections in cattle, which emerged in the Netherlands between 2004 and 2018, showed two distinct disease presentations: acute fibrinous polyserositis (FPS) in veal calves, and acute fibrinous pleuro-pneumonia (FPP) in adult dairy cattle. To determine whether these presentations were caused by different M. haemolytica genotypes, whole genome sequencing was performed on 96 isolates cultured after necropsy from inflamed sites of veal calves that died of M. haemolytica-associated FPS (n = 49) or with FPP lesions (n = 2), and from dairy cows that died of M. haemolytica-associated FPP (n = 45). Among the 96 M. haemolytica isolates, 93 were shown to belong to either of two large clusters, with 48/51 calf isolates belonging to one, and 43/45 cow isolates and two calf isolates from cases of FPP to the other. All M. haemolytica isolates from veal calves with FPS were of serotype A2, whereas the isolates from dairy cows and two calves with FPP were predominantly of serotypes A1 and A6. Most serotype A2 isolates from veal calves with FPS (95.6 %) contained multiple antibiotic resistance genes (ARGs) against three to five antimicrobial classes (phenicols, sulphonamides, tetracyclines, aminoglycosides or beta-lactams). In contrast, these ARGs were only present in 10.8 % of M. haemolytica A1 and A6 isolates from pneumonic adult cattle and absent in isolates from the two calves with FPP. These two disease presentations appear to be caused by genetically distinct strains with different antimicrobial resistance gene patterns. While M. haemolytica serotype A2 is generally considered to be a commensal microorganism of cattle, it was clearly associated with fatal FPS in veal calves in the Netherlands.

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Polyserositis mostly affects 4−8 weeks old piglets and is usually caused by Glaesserella parasuis, and/or Streptococcus suis, and/or Mycoplasma hyorhinis. The present study aimed to investigate the prevalence and etiology of polyserositis in a tricky pig herd. The concurrent effect of vaccination for Glässer's disease was also assessed. A total of 46 sows and 387 piglets were herein investigated, subdivided into three groups based on their immune status (i.e., vaccination of sows and piglets). All the piglets found spontaneously dead between the 2nd and 16th week of age were recorded and necropsied. Whenever polyserositis was diagnosed, biomolecular investigations were carried out to detect the above-mentioned pathogens. Mycoplasma hyorhinis was detected most frequently (n = 23), often as the only causative agent (n = 15), whereas S. suis was observed in 8 cases (6 as the only pathogen). Moreover, Glaesserella parasuis was demonstrated in 6 piglets, always in combination with Mycoplasma hyorhinis and/or Streptococcus suis. Vaccination did not significantly affect mortality rates. Overall, our data indicate that polyserositis is likely caused by an intricate puzzle of pathogens, even when dealing with a small herd and during a short time span. That makes it challenging to achieve the correct diagnosis and to properly manage this health issue.

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A 15-day-old, female, captive Panthera tigris cub was hospitalized after developing severe hyperthermia, depression, and lack of appetite. The clinical condition rapidly worsened, and the tiger cub died in 72 h after the onset of neurological symptoms, septic shock, and multiple organ dysfunction syndrome. The postmortem main gross findings consisted of a severe and diffuse bilateral fibrino-suppurative meningoencephalitis and ventriculitis, mild fibrinous and sero-hemorrhagic polyserositis and cystitis, severe pulmonary edema, and hemorrhages. Microscopically, the meninges, ependyma, and choroid plexuses were diffusely expanded by abundant infiltration of neutrophils and macrophages, with multifocal fibrinous exudation. Histiocytic interstitial pneumonia, fibrinous and neutrophilic polyserositis, and pyelocystitis were also observed. Vascular thrombosis with multifocal vasculitis and vascular necrosis were frequently observed. Aerobic and anaerobic cultures performed on the brain, lungs, intestine, kidneys, and in pericardial effusion reported the presence of Salmonella enterica subsp. enterica serovar Enteritidis. Environmental and nutritional contamination were identified as putative sources of infections. To the best of the authors' knowledge, this is the first report of Salmonella Enteritidis septicemia with meningoencephalitis in a tiger cub, which highlights the need to further investigate the cause of acute perinatal death to reduce the risk of infectious disease outbreaks.

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The association of SARS-CoV-2 messenger ribonucleic acid vaccines with pericarditis in young adults has been reported. However, data regarding other types of vaccines are extremely limited. We presented a 94-year-old man with rapidly progressive dyspnea and fatigue six days after his first ChAdOx1 nCoV-19 vaccination. Impending cardiac tamponade and bilateral pleural effusion were found. Hence, massive yellowish pericardial and pleural effusion were drained. However, the pleural effusion persisted and pigtail catheters were inserted bilaterally. After serial studies including surgical pleural biopsy, acute polyserositis (pericarditis and pleurisy) was diagnosed. Anti-inflammatory treatment with colchicine and prednisolone was administered. All effusions resolved accordingly. This rare case sheds light on the presentation of ChAdOx1 nCoV-19 vaccine-related acute polyserositis. In conclusion, awareness of this potential adverse event may facilitate the diagnosis for unexplained pericardial or pleural effusion after vaccination.

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BACKGROUND: Myeloid Sarcoma (MS) are tumors containing myeloid blasts occurring in a location other than the bone marrow, including lymph nodes, skin, and soft tissues. MS presenting as polyserositis however is very rare, with only a few cases in the literature. CASE REPORT: A 20-year-old male presented with cough, shortness of breath and was found to have left upper lobe consolidation, left pleural effusion, pericardial effusion, and a large anterior mediastinal mass. A transthoracic echocardiogram showed pericardial effusion with tamponade physiology. He underwent emergent pericardiocentesis and thoracentesis. The fluid studies showed flow cytometry findings consistent with MS/ acute myeloid leukemia (AML) phenotype. A bone marrow aspirate and biopsy were unremarkable and showed no immunophenotypic findings diagnostic of acute leukemia or a lymphoproliferative disorder. Cytogenetics was negative for AML abnormalities per FISH analysis. Videoassisted thoracoscopy surgery (VATS) with biopsy of the mediastinal mass, pericardium, and left upper lobe of the lung was consistent with MS. He was treated with induction cytarabine and idarubicin, and a follow up PET-CT scan showed complete remission. He is currently day 200 + post stem cell transplant with no evidence of disease recurrence. CONCLUSION: To the best of our knowledge, this is the first case of isolated myeloid sarcoma presenting as polyserositis, without prior leukemia/ bone marrow involvement. Hence, fluid studies should involve cytometry analysis and MS should be entertained as a differential for polyserositis, even without a history of prior leukemia. Timely diagnosis can expedite aggressive chemotherapy required for a potentially life-threatening disease.

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Background: Recurrent pericarditis has been described as an unusual manifestation of autoimmune polyglandular syndrome type 2 (APS 2). Case report: We describe a case of a 44-year-old woman who was admitted to hospital due to 5 pericarditis, 3 of them with cardiac tamponade, and in the etiological study of this pathology she was diagnosed with an APS 2. Conclusion: The association of serositis with APS 2 is exceptional with less than 10 cases reported in the literature. The presence of recurrent pericarditis of unknown cause should make us consider APS 2 in the differential diagnosis. (AU)

Introducción: La pericarditis recidivante se ha descrito como una manifestación poco frecuente del síndrome poliglandular autoinmune tipo 2 (APS 2). Caso clínico: Presentamos el caso de una mujer de 44 años que ingresa en el hospital debido a 5 pericarditis, 3 de ellas con taponamiento cardiaco, y en el estudio etiológico de dicha patología se diagnostica un APS 2. Conclusión: La asociación de serositis con el APS 2 es excepcional, con menos de 10 casos publicados en la literatura. La presencia de pericarditis de casusa desconocida debe hacernos considerar el APS 2 en el diagnóstico diferencial. (AU)

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Introduction: Polyserositis in disseminated tuberculosis (TB) is an uncommon presentation. The exudative nature of effusion in disseminated TB can be masked by presence of malnutrition due TB. Case presentation: A 24-year-old female, diagnosed with disseminated TB, developed polyserositis with transudative nature of fluid. She was treated with anti-tubercular therapy (ATT). Clinical discussion: Polyserositis, though an uncommon presentation in disseminated TB, was the clinical manifestation in our case. But transudative nature of the fluid was an unexpected finding. Hypoalbuminemia as a result of malnutrition due to TB was the cause for masking exudative effusion in TB. Conclusions: Hypoalbuminemia as a result of malnutrition due to TB can be the reason for transudative nature of effusion in polyserositis.

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Familial Mediterranean fever (FMF) is an autoinflammatory disease characterized by recurrent attacks of fever and serositis. Diagnosis is made according to clinical findings and supported by genetic analysis. The most commonly used adult diagnostic criteria are the Tel-Hashomer criteria. Pediatric criteria for FMF diagnosis were described in 2009, but their reliability should be supported by additional reports. In this study, we aimed to compare the pediatric criteria and the Tel-Hashomer and 2019 Eurofever/PRINTO classification criteria using our FMF cohort. A total of 113 patients diagnosed with FMF were included. Demographic features and laboratory findings were retrospectively collected from the patients' files. The patients were evaluated with the Tel-Hashomer, pediatric and Eurofever/PRINTO classification criteria. At least two of five new pediatric criteria were as sensitive (89%) and specific (85%) as the Tel-Hashomer criteria (sensitivity 70%, specificity 96%). We also evaluated the Eurofever/PRINTO classification criteria using our cohort and found a sensitivity of 94% and specificity of 91%.   Conclusion: Using pediatric criteria for the diagnosis of FMF in children is a feasible and simple approach that can diagnose the disease based on at least two criteria. Therefore, our study supports the use of pediatric criteria in FMF diagnosis of children. Our results also confirm that the Eurofever/PRINTO classification criteria can be successfully applied for the diagnosis of FMF due to their high sensitivity (94%) and specificity (91%). What is Known: • The FMF diagnosis is made according clinical findings and supported by genetic analysis. • The use of adult diagnostic criteria in pediatric FMF patients is controversial since classical clinical presentation is often absent in children. What is New: • Our study supports both the use of pediatric criteria and Eurofever/PRINTO classification criteria in clinical practice.

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