Archives of The Medicine and Case Reports

Efficacy and Safety of CD19-Targeted Chimeric Antigen Receptor (CAR) T-Cell Therapy in Refractory Systemic Lupus Erythematosus: A Systematic Review of Clinical Outcomes and B-Cell Depletion Kinetics

2025-12-15T04:31:59+00:00

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune pathology characterized by a breakdown in self-tolerance, B-cell hyperactivity, and the production of pathogenic autoantibodies. While conventional B-cell depletion strategies utilizing monoclonal antibodies often fail to achieve deep tissue clearance, CD19-targeted chimeric antigen receptor (CAR) T-cell therapy has emerged as a transformative modality capable of inducing durable drug-free remission. This systematic review and meta-analysis evaluate the clinical efficacy, pharmacodynamics of B-cell depletion, and safety profile of both autologous and allogeneic CD19 CAR T-cell therapies in refractory SLE. We conducted a systematic literature review on manuscripts published between January 1^st, 2014, and March 1^st, 2025, focusing on interventional clinical trials and high-quality case series. Primary endpoints included the Definition of Remission in SLE (DORIS) and reduction in SLEDAI-2K scores. Secondary endpoints analyzed B-cell aplasia kinetics, seroconversion of anti-dsDNA, and adverse events, including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and novel autoimmune-specific toxicities. Statistical synthesis utilized weighted averages for continuous variables and event rates for categorical outcomes. The analysis synthesized data from 20 distinct patients with refractory SLE across three pivotal cohorts. The pooled rate of DORIS remission at three months post-infusion was 100%. The mean SLEDAI-2K score decreased from a baseline of 12.5 to 0.8 at three months. Deep B-cell depletion was achieved in all patients, with a mean duration of aplasia of 112 days. Reconstitution of the B-cell compartment was characterized by a naïve phenotype (IgD+/CD27-), indicating a comprehensive immunological reset. Safety analysis revealed that while CRS occurred in 88% of patients, it was predominantly Grade 1 or 2. No high-grade ICANS occurred. Unique toxicity signals, including local immune effector cell-associated toxicity syndrome (LICATS), were identified. In conclusion, CD19-targeted CAR T-cell therapy induces rapid, profound, and sustained drug-free remission in patients with refractory SLE. The mechanism involves deep tissue depletion of B-cells and plasmablasts, facilitating a reset of the humoral immune system.

The Healthy Weight Paradox: Unmasking High Dyslipidemia Prevalence in Normoweight Adults with Normal Waist Circumference

2025-12-30T01:29:54+00:00

The reliance on body mass index (BMI) as the sole anthropometric indicator for cardiovascular risk is increasingly debated. A distinct phenotype, metabolically obese normal weight (MONW), suggests that individuals with normal BMI and normal waist circumference (WC) may still harbor significant metabolic derangements. This study aims to quantify the prevalence of dyslipidemia in a normoweight occupational cohort and analyze the healthy weight paradox. This descriptive observational study utilized secondary data from the 2024 Medical Check-Up of employees at the Geological Agency, Bandung, Indonesia. A total of 142 subjects met the strict inclusion criteria: BMI 18.5–22.9 kg/m² and normal waist circumference (<90 cm for men, <80 cm for women). Lipid profiles—Total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and Triglycerides (TG)—were analyzed. Statistical evaluation included Chi-square testing for categorical variables and multivariate logistic regression to identify determinants of dyslipidemia. Despite normal anthropometry, 54.93% (n=78) of subjects exhibited dyslipidemia. The most prevalent abnormalities were borderline high TC (24.65%) and mixed dyslipidemia (20.42%). A significant gender disparity was observed, with 62.0% of males exhibiting dyslipidemia compared to 38.1% of females (p < 0.05). Age was a critical determinant; subjects aged 40 years or older had significantly higher rates of dyslipidemia (71.62%) compared to those younger than 40 years (p < 0.01). In conclusion, normal BMI and WC are insufficient to rule out metabolic risk. The high prevalence of dyslipidemia (>50%) in this healthy phenotype suggests a silent burden of cardiovascular risk driven by metabolic factors rather than overt adiposity. Routine lipid profiling and body composition analysis should be mandatory, irrespective of BMI.

The Diagnostic Utility of Low Neutrophil-to-Lymphocyte Ratio (NLR) as an Indicator of Severity in Adult Dengue Hemorrhagic Fever: A Retrospective Study from Bali

2025-12-31T01:31:18+00:00

Dengue hemorrhagic fever (DHF) remains a critical public health challenge in tropical regions. Unlike bacterial sepsis, where a high neutrophil-to-lymphocyte ratio (NLR) typically indicates severity, viral kinetics in dengue often present differently due to bone marrow suppression. This study evaluates the association between low NLR and disease severity in an adult cohort in Indonesia, aiming to identify a cost-effective marker for risk stratification. A retrospective cross-sectional study was conducted at Wangaya Regional General Hospital, Denpasar, Indonesia, from January to August 2025. We analyzed 92 confirmed adult DHF patients aged 18 years and older. Severity was graded using standard World Health Organization criteria (Grades 1–4). For the purpose of diagnostic performance analysis, severe DHF was defined as Grade 2 (spontaneous bleeding) and Grade 3 (circulatory failure) combined. The correlation between NLR and severity was analyzed using the Spearman rank test. Receiver Operating Characteristic (ROC) analysis determined the optimal cut-off for identifying severe cases. The cohort was predominantly young adults (18–25 years; 47.8%) with a male preponderance (68.5%). The severity distribution included Grade 1 (n=68; 73.9%), Grade 2 (n=21; 22.8%), and Grade 3 (n=3; 3.3%). A significant, moderate inverse correlation was observed between NLR and severity grade (r = -0.347; p < 0.001). Mean NLR decreased progressively from Grade 1 (2.90) to Grade 2 (1.20) and Grade 3 (0.65). ROC analysis for detecting Grade 2 or higher DHF showed an Area Under the Curve (AUC) of 0.82 (95% CI: 0.75–0.89). An NLR cut-off of less than 0.85 yielded a sensitivity of 87.5% and specificity of 72.0%. In conclusion, a low NLR is significantly associated with higher clinical severity in adult DHF. Unlike bacterial infections, a declining NLR below 0.85 serves as a potential marker for identifying patients at risk of bleeding and circulatory compromise in resource-limited settings.

Bronchoscopic Resolution of Refractory Atelectasis in a Toddler with Polymicrobial MDR Pneumonia: A Case Report

2025-12-31T01:41:11+00:00

Pediatric acute respiratory distress syndrome (PARDS) complicated by ventilator-associated pneumonia (VAP) poses significant management challenges, particularly when caused by multidrug-resistant organisms such as Stenotrophomonas maltophilia and Pseudomonas aeruginosa. A frequent and deleterious complication is plate-like atelectasis, which may prove refractory to conservative management due to anatomical constraints in the pediatric airway and biofilm formation. A 23-month-old male presented with severe PARDS and polymicrobial VAP. Despite extubation to High-Flow Nasal Cannula (HFNC), the patient developed persistent right upper lobe plate-like atelectasis refractory to aggressive physiotherapy and targeted antibiotic therapy with Levofloxacin and Ceftazidime for 21 days. On Day 75 of illness, a flexible bronchoscopy was performed. Intraoperative findings revealed hyperemic mucosa without macroscopic mucus plugging. However, the procedure, involving saline lavage and suctioning, resulted in immediate recruitment. Within 24 hours, the respiratory rate decreased from 45 to 24 breaths per minute, and the SpO₂/FiO₂ ratio improved significantly from 185 to 310, allowing weaning from respiratory support. In conclusion, in toddlers with multidrug-resistant VAP, atelectasis may persist due to biofilm-mediated micro-obstruction rather than macroscopic plugging. Flexible bronchoscopy is a safe and effective therapeutic adjunct in these cases, facilitating distal airway recruitment and breaking the cycle of chronic infection.

Divergent Carcinogenic Risks of Domestic versus Ritual Combustion on Nasopharyngeal Carcinoma in Bali: A Matched Case-Control Study

2026-01-02T02:18:17+00:00

Nasopharyngeal carcinoma (NPC) is endemic in Indonesia, particularly among the ethnically distinct Balinese population. The interplay between Epstein-Barr virus (EBV) and environmental co-factors remains critical to its pathogenesis. A unique cultural duality exists in Bali regarding inhalant exposure: the utilitarian combustion of firewood and tobacco versus the ritual combustion of incense. This study aims to distinguish the carcinogenic risks of these disparate smoke sources using robust statistical methods to account for sparse data bias. A matched case-control study was conducted at a tertiary referral center in Denpasar, Bali. Forty-two patients with histopathologically confirmed WHO Type III Undifferentiated NPC were matched by age and sex with 42 non-cancer controls screened via Digby score. Exposures to firewood, passive and active smoking, and ritual incense were assessed. To address quasi-complete separation due to high exposure prevalence, Firth’s Penalized Likelihood Logistic Regression was employed to determine Adjusted Odds Ratios (AOR). Firewood smoke exposure emerged as the predominant risk factor (AOR 14.21; 95% CI 4.82–42.15; p < 0.001), significantly higher than previously estimated by standard models. Passive smoking was confirmed as a substantial independent risk factor (AOR 11.54; 95% CI 3.91–33.82; p < 0.001). Conversely, despite universal usage, ritual incense exposure showed no association with NPC (AOR 0.92; 95% CI 0.35–2.41; p = 0.865), likely due to the open-air ventilation of Balinese shrines. Salted fish consumption remained a significant co-factor (AOR 6.80; p = 0.002). In conclusion, the study establishes a clear etiological hierarchy: chronic domestic pollutants such as biomass and tobacco smoke are potent drivers of NPC in Bali, likely acting as tumor promoters via EBV reactivation. Ritual incense, in the context of Balinese architecture, is not a significant risk. Public health interventions must prioritize healthy kitchen ventilation and tobacco control.

Palatal Abscess of Odontogenic Origin Causing Dyspnea in an Elderly Patient: A Case Report and Critical Review of Management Strategies

2026-01-02T08:44:54+00:00

Odontogenic infections are prevalent clinical entities, typically presenting as localized pathologies within the alveolar process. However, a palatal abscess—a specific manifestation arising from the spread of infection through the palatal cortical plate of maxillary teeth—rarely escalates to cause life-threatening airway compromise. This report details an exceptional case of a palatal abscess causing significant dyspnea in an elderly patient, challenging the conventional understanding of the hard palate as a robust anatomical barrier preventing deep space extension. A 68-year-old female presented to the emergency department on October 1^st, 2022, with a five-day history of progressively enlarging palatal swelling, dysphagia, and dyspnea. Clinical examination revealed a massive, fluctuant mass extending from the hard to the soft palate, obstructing the oropharyngeal inlet. Despite a leukocyte count at the upper limit of normal and an afebrile status—indicative of geriatric immunosenescence—the patient exhibited objective tachypnea (24 breaths/min). Diagnosis was confirmed via needle aspiration. Management involved immediate airway stabilization, broad-spectrum antibiotics (Ceftriaxone and Metronidazole), and corticosteroids. On October 3^rd, 2022, the patient underwent incision and drainage under general anesthesia, yielding 15cc of purulent material. The source was identified as carious residual roots of the maxillary right second molar (FDI #17). Post-operative recovery was rapid, with discharge on October 6^th, 2022. In conclusion, this case underscores that palatal abscesses can evolve into critical airway emergencies, particularly in geriatric patients with diminished physiological reserves and blunted immune responses. Prompt recognition, aggressive multidisciplinary management, and definitive dental treatment are paramount to preventing mortality.

The Silent Sequelae: Irreversible Profound Sensorineural Hearing Loss Following Mumps Parotitis in a Pediatric Patient

2026-01-06T08:02:41+00:00

Mumps-associated Sudden Sensorineural Hearing Loss (SSNHL) is a rare but catastrophic complication of epidemic parotitis, historically estimated to occur in 1 per 20,000 cases. Despite global vaccination efforts, the re-emergence of mumps in adolescent populations due to waning immunity poses significant otologic risks. This report documents a case of unilateral, profound SSNHL in a vaccinated pediatric patient, highlighting the diagnostic challenges when auditory symptoms manifest after the resolution of systemic parotitis. An 11-year-old Balinese male presented with acute-onset tinnitus and hearing loss in the left ear, occurring one week after the clinical resolution of bilateral parotid swelling. The patient had a history of basic immunization. Audiometric evaluation revealed profound sensorineural hearing loss in the left ear with a Pure Tone Average of 110 dB, while the right ear remained normal. Serological analysis confirmed acute mumps infection with a highly positive IgM titer (Index 11.0). Hematological profiling demonstrated leukopenia with a neutrophil shift. Despite a prompt and aggressive multimodal treatment protocol including high-dose intravenous methylprednisolone, oxygen therapy, and neurotrophic support, follow-up audiometry at 14 days revealed no functional improvement (Pure Tone Average 91.25 dB). In conclusion, mumps-induced SSNHL is characterized by rapid, irreversible cochlear destruction that frequently exhibits resistance to corticosteroid therapy. The dissociation between the resolution of systemic parotitis and the onset of otologic sequelae requires high clinical vigilance. This case emphasizes the critical need for serological confirmation in pediatric SSNHL and underscores the poor prognosis associated with this specific viral etiology.

Ocular Salvage in Serratia marcescens-Associated Odontogenic Orbital Abscess: Unmasking Latent Diabetes Mellitus and the Role of Immunoparesis

2026-01-08T01:49:12+00:00

Odontogenic sinusitis accounts for up to 40 percent of chronic maxillary sinusitis cases. While typically polymicrobial, the isolation of Serratia marcescens, an opportunistic Enterobacteriaceae, is an aberration in community settings and often signals profound underlying immunodeficiency. This report documents a rare case of Serratia-induced subperiosteal orbital abscess that unmasked latent type 2 diabetes mellitus. A 64-year-old male farmer presented with unilateral proptosis, ophthalmoplegia (frozen globe), and severe orbital pain following chronic odontogenic symptoms. Initial assessment revealed a random blood glucose of 500 mg/dL and glycated hemoglobin of 11.5 percent, confirming undiagnosed type 2 diabetes mellitus. Computed Tomography demonstrated a right maxillary abscess with osteolytic destruction of the lamina papyracea and an extraconal collection. Microbiological analysis of deep tissue biopsy via Vitek 2 confirmed Serratia marcescens while histopathology ruled out invasive fungal sinusitis. Management involved a dual-front strategy: rapid glycemic stabilization and broad-spectrum antibiotics, followed by functional endoscopic sinus surgery and dental extraction on Day 3. Post-operative follow-up showed resolution of proptosis from 24 mm to 16 mm, restoration of intraocular pressure from 32 mmHg to 14 mmHg, and improvement in visual acuity from light perception to 6/18. In conclusion, the isolation of Serratia marcescens in odontogenic sinusitis serves as a sentinel marker for metabolic dysregulation. This case highlights the synergistic lethality of neglected dental pathology and diabetic immunoparesis. Early recognition, exclusion of fungal mimics, and aggressive multidisciplinary intervention are paramount for ocular salvage.

Ruptured Congenital Cholesteatoma Presenting as Atticoantral Chronic Suppurative Otitis Media in a 4-Year-Old: A Diagnostic Challenge

2026-01-14T01:59:03+00:00

Chronic suppurative otitis media (CSOM) of the atticoantral type is a distinct otologic pathology driven by cholesteatoma, characterized by enzymatic bone erosion and a high risk of intracranial complications. While typically acquired through retraction pockets, a subset of these cases represents congenital cholesteatomas (CC) that have silently expanded and ruptured the tympanic membrane. This presentation mimics acquired disease, creating a diagnostic blind spot. We report the case of a 4-year-old male presenting with a one-year history of persistent, foul-smelling otorrhea and otalgia in the right ear. Despite a history of recurrent cold, there was no prior trauma or otologic surgery. Physical examination revealed an attic perforation with purulent discharge. Computed tomography scan (CT-scan) identified a soft tissue mass filling the epitympanum and mesotympanum with significant erosion of the scutum and ossicles. The patient underwent a modified radical mastoidectomy with type II tympanoplasty. Intraoperative findings revealed an extensive cholesteatoma sac consistent with a congenital origin that had secondarily ruptured. In conclusion, congenital cholesteatoma must be considered in the differential diagnosis of pediatric CSOM, even in the presence of a perforation. This ruptured presentation highlights the necessity of early HRCT imaging over conventional radiography. The canal wall down approach remains a critical strategy for eradicating extensive pediatric disease to prevent recidivism.