tIgE levels, FNO and AEC levels are higher in asthma, specifically in the atopic phenotype, as compared to normal. Total serum IgE levels have moderate correlation with FNO and AEC but FNO and AEC are weakly correlated.

Belimumab is a recombinant human IgG-1λ monoclonal antibody. It inhibits the B-cell activating factor (BAFF) and is approved for patients with systemic lupus erythematosus (SLE) older than five years with positive autoantibody. We aimed to evaluate the role of belimumab in the maintenance phase of treatment for lupus nephritis (LN). PubMed, PubMed Central (PMC), Cochrane Library, and Embase were searched using appropriate keywords. The screening of title and abstract was done in Covidence, followed by data extraction of the relevant studies based on inclusion criteria. Review manager (RevMan 5.4) was used for data analysis with random or fixed effects model based on heterogeneities. Two randomized controlled trials were included in the quantitative analysis. There were 1.71 times higher odds of complete renal response in the belimumab group than in the control group (odds ratio (OR), 1.71; 95% confidence interval (CI), 1.12-2.60; I-square (I 2 ) ​​​​= 0%). Similarly, there was 34% lower odds for having no response among the belimumab group (OR, 0.66; 95% CI, 0.45-0.96; I 2 = 0%). No significant differences between the two groups were observed for the occurrence of treatment-related adverse events (TRAEs) (OR, 1.07; 95% CI, 0.74-1.56; I 2 = 0%), treatment-related serious adverse events (OR, 0.54; 95% CI, 0.15-1.96; I 2 = 68%), and treatment-related infections (OR, 0.65; 95% CI, 0.27-1.55; I 2 = 21%).Therefore, belimumab and standard treatment were instrumental for beneficial renal response in patients with lupus nephritis and were not associated with increased odds of adverse effect compared with the standard treatment alone.

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FNO levels were higher in bronchial asthma (despite disease control) than in normal non-smoking adults and subjects with stable chronic obstructive pulmonary disease. Levels of FNO were similar between the chronic obstructive airway disease and normal groups.

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Diffuse alveolar hemorrhage (DAH) is a syndrome characterized by bleeding into the alveolar spaces of the lungs, secondary to disruption of the alveolar-capillary basement membrane. While numerous disease processes have been associated with DAH including certain malignancies, to the best of our knowledge, recurrent malignant melanoma has not been previously described in the literature as a cause of DAH. Here, we present a case of a 73-year-old female with a history of malignant melanoma of the left shoulder status post wide local incision two years prior, who presented with complaints of progressive shortness of breath without productive cough or hemoptysis. On examination, she was hypoxemic and required high-flow nasal cannula initiation. Initial investigation revealed a hemoglobin of 4.6 g/dL. Computed tomography of the chest with contrast revealed multiple areas of rounded infiltrates with air bronchograms, mediastinal adenopathy, and a right pleural effusion. Diagnostic bronchoscopy revealed findings of recent bleeding throughout the tracheobronchial tree with progressively bloody bronchoalveolar lavage (BAL) suggestive of DAH. BAL cytology was positive for malignant melanoma. After a comprehensive workup that excluded the common causes of DAH, we present the first case of DAH caused by recurrent malignant melanoma.

A usual presenting symptom for osteoarthritis (OA) is pain. However, OA of the spine can present as isolated nerve palsy. We present a case of isolated hypoglossal nerve palsy secondary to chronic OA of the cervical spine. A 68-year-old female presented to the emergency department with stroke-like symptoms of three-day duration. History revealed heaviness of the tongue with dysphagia to solid foods, tongue deviation to the right, and slurred speech over the past year. On examination, she had severe OA of the distal and proximal interphalangeal joints. Various imaging modalities revealed isolated right unilateral hypoglossal nerve paralysis secondary to craniocervical junction degenerative disease from C1-occipital osteophyte and juxta-articular atlantooccipital (AO) synovial cyst. This case is unique as evidenced by various imaging modalities which consistently revealed advanced OA of our patient’s AO joint leading to osteophytic and juxta-articular cyst development causing unilateral hypoglossal nerve palsy.

Babesiosis is an emerging health risk and a nationally notifiable disease in the United States.1 It can present as shock and multi-organ dysfunction in immunocompromised host. As babesiosis prophylaxis in patients with splenectomy is not common, it should be considered in post-splenectomy sepsis syndrome.1 This case describes a post-splenectomy patient with severe babesiosis presenting with refractory Acute Respiratory Distress Syndrome (ARDS).CASE PRESENTATION: 59-year-old man presented to emergency department with 2 weeks of worsening generalized weakness, fever, and headaches, not getting better on oral antibiotics prescribed outpatient. His Computed Tomography (CT) head, lumbar puncture was normal. He developed severe respiratory distress and was emergently intubated. Chest imaging revealed bilateral pulmonary infiltrates. Arterial blood gas analysis confirmed severe ARDS with a PaO2/FiO2 (P/F) ratio <100. The patient was managed with lung protective ventilation and prone positioning. Peripheral smear revealed intraerythrocytic ring inclusions consistent with Babesia microti trophozoites (Figure1). Testing for other bacterial infections, viral pathogens, and tick-borne illnesses were negative. Labs were significant for hemoglobin (Hb) 10.8 g/dl, platelet count 170 K/uL, haptoglobin <10 mg/dl, lactate dehydrogenase 373 U/L, aspartate aminotransferase 68 U/L and alanine aminotransferase 71 U/L. He was treated with atovaquone and azithromycin. Doxycycline was initiated for possible co-infection with other tick-borne illnesses. The patient also had red cell exchange transfusion given his critical condition and history of splenectomy. He was evaluated for Veno-venous extracorporeal membrane oxygenation (ECMO), but cannulation was deferred due to initial improvement with prone positioning. Though there was initial improvement, his hemodynamic status continued to decline requiring initiation of vasopressor support and was transitioned to comfort care after prolonged intubation with goals of care discussions with family.DISCUSSION: Early recognition and diagnosis of babesia, especially in patients with asplenia, is imperative as babesiosis can progress to refractory ARDS, shock and multi-organ dysfunction. Clinicians should have a high index of suspicion for a patient living in an endemic area who presents with unexplained nonspecific symptoms and laboratory findings including thrombocytopenia, hemolytic anemia, and/or elevation of liver enzymes. If clinical suspicion is high, sever real-time PCR assays are useful to detect low-grade parasitemia and are more sensitive than blood smears.2 Prone positioning has been shown to improve outcomes with ARDS if used early and for longer sessions and may help patients avoid need for ECMO.3 CONCLUSIONS: Our case reveals the importance of early recognition of babesiosis in immunocompromised patients living in endemic areas for preventing refractory ARDS.