Bioscientia Medicina - Journal of Biomedicine and Translational Research
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Unmasking BRASH Syndrome: A Rare and Reversible Cause of Cardiovascular Collapse in the Elderly
Full text linkBackground: BRASH syndrome (Bradycardia, Renal failure, AV nodal blockade, Shock, and Hyperkalemia) is an increasingly recognized but still underdiagnosed condition, particularly in elderly patients with multiple comorbidities and those taking AV nodal blocking agents. It represents a synergistic interplay between these factors, leading to a potentially life-threatening state of cardiovascular collapse. This case report aims to highlight the clinical presentation, diagnostic challenges, and successful management of BRASH syndrome in an elderly female patient.
Case presentation: A 65-year-old female with a history of stage 4 chronic kidney disease and congestive heart failure (ejection fraction of 65%) presented to the emergency department with worsening vomiting over the past week, generalized weakness, dizziness, and palpitations. Her medication list included amlodipine, bisoprolol, candesartan, nitrokaf, furosemide, and aminoral. On examination, she was hypotensive with a blood pressure of 90/60 mmHg and bradycardic with a heart rate of 40 beats per minute. An electrocardiogram (ECG) revealed a junctional escape rhythm with a heart rate of 38 beats per minute and a left bundle branch block. Laboratory investigations showed severe hyperkalemia (potassium 8.1 mmol/L), hyponatremia (sodium 113 mmol/L), elevated creatinine (4.06 mg/dL), and urea (112.3 mg/dL).
Conclusion: This case underscores the importance of recognizing BRASH syndrome as a distinct clinical entity, especially in elderly patients with pre-existing cardiac and renal conditions who are on AV nodal blocking medications. Prompt diagnosis and management, focusing on correcting hyperkalemia, discontinuing offending medications, and providing supportive care, can lead to favorable outcomes and prevent potentially fatal complications. Increased awareness and further research are crucial for establishing standardized guidelines for the diagnosis and management of this underrecognized syndrome
Traumatic Femoral Arteriovenous Fistula Mimicking Chronic Venous Insufficiency with Concurrent Iliac and Femoral Artery Aneurysms: A Case Report
Full text linkBackground: Traumatic arteriovenous fistulas (AVFs), constituting approximately 2.5% of emergency vascular cases, present diagnostic challenges due to their obscure nature. This report describes two cases of traumatic AVFs caused by gunshot wounds.
Case presentation: A 61-year-old male presented with right lower extremity pain and swelling, following a gunshot wound four months prior. Clinical findings included discoloration, edema, vein swelling, and pain from the femoral to pedis regions. CT angiography revealed multiple aneurysms from the lower abdominal aorta to the right common iliac arteries, stenosis in the right external iliac artery, and reduced blood perfusion. Additional findings were tubular aneurysms in the external and internal right iliac arteries and a combination saccular-tubular aneurysm in the right femoral artery. A second, separate case also involved a traumatic AVF from a gunshot wound.
Conclusion: Traumatic AVFs, particularly those resulting from gunshot wounds, can be difficult to diagnose early due to their rarity and obscure presentation. Early diagnosis is crucial to prevent disease progression and improve clinical outcomes. Open surgical SFA bypass has a good outcome, proven by ultrasound examination that there is good blood flow in the distal artery
Chemotherapy-Induced Cognitive Impairment and Neuroaxonal Damage: Investigating the Role of Serum Neurofilament Light Chain
Full text linkBackground: Chemotherapy-induced cognitive impairment (CICI), colloquially termed "chemobrain," represents a significant challenge for cancer survivors, potentially affecting up to 85% of patients undergoing treatment. Diagnosis often relies on neuropsychological testing and imaging, which may lack sensitivity for early detection or reflect chronic changes. Neurofilament light chain (NfL), a neuronal structural protein released into biofluids upon neuroaxonal damage, emerges as a promising biomarker. This study investigated the relationship between serum NfL levels and the degree of cognitive impairment in patients receiving chemotherapy.
Methods: An observational, cross-sectional study was conducted involving 50 cancer patients undergoing chemotherapy at Dr. M. Djamil General Hospital Padang between October and December 2024. Cognitive function was assessed using the Montreal Cognitive Assessment Indonesian version (MoCA-Ina), and depression was screened using the Patient Health Questionnaire-9 (PHQ-9). Serum NfL levels were quantified using an Enzyme-Linked Immunosorbent Assay (ELISA) method. The Kruskal-Wallis test was employed to analyze the relationship between serum NfL levels and cognitive function status (normal, mild impairment, moderate-severe impairment).
Results: Cognitive impairment (MoCA-Ina assessed) was identified in 41 (82%) of the 50 participants, with 30 (60%) exhibiting mild and 11 (22%) exhibiting moderate to severe impairment. The median serum NfL level across all subjects was 23.44 pg/ml (range: 13.81-68.71 pg/ml). A statistically significant relationship was observed between serum NfL levels and the presence and severity of cognitive impairment (p = 0.02). Median NfL levels progressively increased from the cognitively normal group (18.49 pg/ml) to the mild impairment group (23.5 pg/ml) and the moderate-severe impairment group (24.5 pg/ml). Post-hoc analysis revealed significant differences in NfL levels between the normal group and both the mild (p=0.03) and moderate-severe (p=0.01) impairment groups.
Conclusion: This study demonstrated a significant positive association between serum NfL levels and the presence and severity of cognitive impairment in cancer patients undergoing chemotherapy. These findings support the potential utility of serum NfL as an accessible biomarker for detecting chemotherapy-associated neuroaxonal damage and concomitant cognitive decline
Investigating the Landscape of Programmed Death-Ligand 1 (PD-L1) in Thymic Tumors: Implications for Histopathological Classification and Staging
Full text linkBackground: Thymic epithelial tumors (TETs) are uncommon malignancies originating in the mediastinum, characterized by considerable histopathological diversity and variable clinical trajectories. Programmed Death-Ligand 1 (PD-L1), an immune checkpoint protein, is implicated in mechanisms of tumor immune evasion. This study aimed to investigate the correlation between PD-L1 immunoexpression and distinct histopathological types, as well as the Masaoka-Koga stage, in TETs.
Methods: This cross-sectional investigation analyzed 29 archival cases of TETs diagnosed between January 2019 and December 2024 at the Anatomical Pathology Laboratory of Dr. M. Djamil General Hospital Padang. Samples were procured via consecutive sampling from formalin-fixed paraffin-embedded (FFPE) tumor tissues. Histopathological classification was reassessed according to the WHO 2021 criteria. PD-L1 expression was evaluated immunohistochemically and quantified using the Tumor Proportion Score (TPS). Masaoka-Koga staging was determined from clinical records. Statistical analysis of correlations was performed using the Chi-square test.
Results: PD-L1 immunoexpression was detected in the preponderance of cases. Low positive PD-L1 expression (TPS 1-49%) was observed in 82.8% of TETs, while high positive expression (TPS ≥50%) was noted in 10.3%. Thymic carcinoma constituted the most prevalent histopathological category (51.7%), and the majority of patients (91.7%) presented at an advanced Masaoka-Koga stage. Statistical analysis did not demonstrate a significant correlation between PD-L1 expression levels and histopathological type (p=0.195). Furthermore, no significant association was identified between PD-L1 expression and Masaoka-Koga stage (p=0.800).
Conclusion: This study indicated that while PD-L1 is frequently expressed in TETs within this cohort, its expression level did not exhibit a significant correlation with specific histopathological subtypes or the Masaoka-Koga clinical stage. Further investigations incorporating larger sample sizes are warranted to delineate the precise role of PD-L1 within the complex biological spectrum of thymic neoplasms
The Triad of Risk: Advanced Age, Female Gender, and High BMI in Patients Requiring Total Knee Replacement for Osteoarthritis at a Tertiary Indonesian Hospital
Full text linkBackground: Knee osteoarthritis (OA) imposes a substantial global burden, leading to significant disability, particularly within the elderly demographic. Total Knee Replacement (TKR) stands as the definitive surgical intervention for advanced knee OA cases that have proven refractory to comprehensive conservative management. A thorough understanding of the multifaceted characteristics of patients undergoing TKR is paramount for the development and implementation of targeted, effective healthcare strategies and resource allocation. This study aimed to meticulously identify and describe these characteristics in a cohort of patients receiving TKR at a tertiary referral hospital located in Bali, Indonesia.
Methods: This investigation employed a descriptive quantitative cross-sectional study design. It involved a retrospective analysis of medical records pertaining to 54 patients who underwent primary TKR for diagnosed knee OA at Prof. Dr. I.G.N.G. Ngoerah General Hospital. The data collection period spanned from November 2023 to November 2024. The primary variables assessed included chronological age at the time of surgery, biological sex, body mass index (BMI) calculated from recorded height and weight, and the documented incidence of postoperative periprosthetic joint infection (PJI). All collected data were subjected to descriptive statistical analysis.
Results: The demographic analysis revealed that the vast majority of patients were female, accounting for 85.2% (n=46) of the cohort. The predominant age group for TKR procedures was between 50 and 69 years, encompassing 85.1% of patients; specifically, the 50–59 years category included 44.4% (n=25), and the 60–69 years category included 40.7% (n=22). A notably high prevalence of overweight or obesity was observed, with 70.3% of patients falling into these BMI classifications (overweight: 37.0%, n=11; obesity class I: 27.8%, n=15; obesity class II: 9.3%, n=5). Periprosthetic joint infection, a significant postoperative complication, was documented in 5.6% of the patients (n=3) within this cohort.
Conclusion: The findings of this study strongly indicate that advanced age, female gender, and an elevated body mass index collectively constitute a significant triad of risk characteristics among patients undergoing TKR for severe knee OA within this specific Balinese hospital setting. These observations underscore the critical necessity for focused preventive measures and tailored management strategies, particularly directed towards older women with increased BMI, to potentially mitigate the progression of OA and optimize the outcomes following TKR
Baseline Visual Acuity as an Independent Predictor of Therapeutic Outcomes in HIV-Associated Cytomegalovirus Retinitis: A Three-Year Cohort Study in Indonesia
Full text linkBackground: Cytomegalovirus (CMV) retinitis is a severe opportunistic infection causing irreversible blindness in patients with advanced human immunodeficiency virus (HIV). In the modern era of highly active antiretroviral therapy (HAART), understanding the key determinants of visual prognosis is critical for effective patient management, particularly in resource-limited settings. This study aimed to evaluate the clinical spectrum of CMVR and identify independent predictors of short-term visual outcomes in a cohort of HIV-positive patients in Indonesia.
Methods: A retrospective cohort study was conducted on HIV-positive patients diagnosed with CMV retinitis between January 2021 and December 2023 at a tertiary referral hospital in Bali, Indonesia. Data on demographics, clinical features, CD4+ T-cell counts, HAART status, and visual acuity (VA) at baseline and three months were collected. Visual acuity was converted to the Logarithm of the Minimum Angle of Resolution (LogMAR) for analysis. A multivariable linear regression model was employed to identify independent predictors of three-month visual outcomes.
Results: The study included 26 patients (38 eyes). The cohort was predominantly male (61.5%) with a mean age of 36.73 years. Severe immunosuppression was common, with 65.4% of patients having a CD4+ count below 50 cells/mm³. Posterior uveitis was the most frequent presentation (68.4%). In the multivariable linear regression analysis, baseline LogMAR VA was the only significant independent predictor of three-month LogMAR VA (β = 0.71, p < 0.001) after adjusting for age, CD4+ count, and HAART status. The baseline CD4+ T-cell count was not a significant independent predictor of visual outcome (p = 0.841).
Conclusion: Baseline visual acuity, a direct functional measure of existing retinal damage, is the most powerful independent predictor of short-term visual prognosis in patients with HIV-associated CMV retinitis. This finding highlights the irreversible nature of retinal necrosis and underscores that the opportunity to save sight lies in preemptive action. We advocate for the urgent integration of routine ophthalmological screening into the care protocols for high-risk HIV populations to detect and treat CMVR before significant vision loss occurs
Single-Dose Intralesional Bacillus Calmette-Guérin (BCG) Immunotherapy Induces Complete and Sustained Remission of Recalcitrant Anogenital Condylomata: A Mechanistic Case Series
Full text linkBackground: Anogenital condylomata acuminata caused by Human Papillomavirus (HPV) presents a significant therapeutic challenge due to high recurrence rates after conventional cytodestructive therapies. Intralesional immunotherapy aims to induce a host-mediated immune response, offering a promising alternative. This report investigates the efficacy, safety, and immunological rationale of a novel, single-dose Bacillus Calmette-Guérin (BCG) protocol in an immunologically primed population.
Methods: In this prospective case series, three immunocompetent patients with extensive, therapy-refractory anogenital condylomata were enrolled. Following a standardized protocol, each patient received a single, calculated intralesional injection of BCG vaccine into the largest index lesion. The primary outcome was complete clinical and dermoscopic clearance. Patients were evaluated at regular intervals for efficacy and safety over a 12-month follow-up period.
Result: All three patients achieved complete clinical and dermoscopic clearance of both the injected and distant, untreated lesions within a rapid timeframe of 6 to 10 weeks. The treatment was well-tolerated, with adverse events limited to anticipated and transient local inflammatory reactions. No recurrences were documented in any patient during the 12-month follow-up period.
Conclusion: Single-dose intralesional BCG immunotherapy appears to be a highly effective, durable, and safe therapeutic strategy for recalcitrant anogenital condylomata. The observed pan-lesional clearance strongly suggests the induction of a systemic, cell-mediated anti-HPV immune response. These compelling preliminary findings provide a strong rationale for validation through larger, randomized controlled trials
Rapid Correction of Hypoalbuminemia and Promotion of Granulation Tissue in Pediatric Deep Partial-Thickness Burns via Targeted Immunonutrition: A Case Report
Full text linkBackground: Pediatric burns induce a profound hypermetabolic and hypercatabolic state, distinct from adults due to limited physiological reserves and high growth demands. The rapid onset of negative nitrogen balance and hypoalbuminemia significantly impairs wound healing and immune function.
Case presentation: We report the case of a 7-year-old male with pre-existing malnutrition (StrongKids Medium Risk) presenting with 23% total body surface area (TBSA) Grade IIB scald burns affecting the posterior humerus, lumbosacral, gluteus, and femoral regions. The patient exhibited acute hypoalbuminemia (2.3 g/dL) and anorexia due to pain. A specialized medical nutrition therapy (MNT) protocol was implemented using the Curreri Junior formula, targeting 2,500 kcal/day and 105 g protein/day. The intervention utilized a stepwise escalation of polymeric enteral nutrition enriched with immunonutrients (Glutamine, Zinc, and Vitamin C). Despite the severity of the injury, the patient demonstrated rapid nutritional rehabilitation. By day 5 of hospitalization, albumin levels normalized to 3.1 g/dL, and significant granulation tissue formation was observed. The patient achieved a weight gain of 0.4 kg during the acute phase, countering the expected catabolic weight loss.
Conclusion: Early, aggressive, and calculated nutritional support incorporating specific immunonutrients can reverse the catabolic effects of thermal injury in pediatric patients. This case highlights the efficacy of the Curreri Junior formula combined with Glutamine and Zinc in accelerating wound closure and correcting biochemical markers in resource-limited settings
Prevalence and Etiology of Ocular Morbidity in Maritime Environments: A Systematic Review and Meta-Analysis of Passenger and Crew Data
Full text linkBackground: The maritime environment constitutes a unique epidemiological enclosure characterized by isolation, specific occupational hazards, and distinct environmental stressors including hyper-salinity and high ultraviolet (UV) albedo. While gastrointestinal and respiratory outbreaks at sea are well-documented, the burden of ocular morbidity remains under-quantified. This study aims to determine the prevalence and etiology of ocular emergencies, stratifying risks between industrial seafarers (crew) and recreational travelers (passengers).
Methods: A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines. Data were extracted from eight observational studies (2014–2024) covering expedition cruises, commercial shipping, and leisure voyages. To address population heterogeneity, a stratified analysis was performed: Track A analyzed occupational trauma in crew, while track B analyzed environmental morbidity in passengers. A random-effects model was used to calculate pooled proportions with 95% Confidence Intervals (CI), accompanied by a leave-one-out sensitivity analysis.
Results: The dataset represented a combined population of over 5,000 maritime subjects. The pooled prevalence of ocular involvement in maritime trauma cases was 18.4% (95% CI: 12.1%–25.5%). Etiological analysis of crew injuries revealed a dominance of mechanical trauma, specifically metallic foreign bodies (40.5%), followed by chemical burns (26.2%). In contrast, passenger morbidity was driven by environmental factors (photokeratitis, dry eye) and infectious conjunctivitis.
Conclusion: Ocular emergencies represent a significant, preventable burden in maritime travel, with distinct risk profiles for crew and passengers. The high rate of occupational trauma suggests a failure in personal protective equipment (PPE) compliance, while the environmental burden reflects the dry ship phenomenon. Mandatory protective eyewear policies and the integration of anterior-segment tele-ophthalmology are critical interventions
Early-Onset Urticaria Pigmentosa in a 7-Month-Old Infant: A Case Report
Full text linkBackground: Urticaria pigmentosa (UP) is the most common form of cutaneous mastocytosis in children, accounting for 70-90% of cases. UP typically presents in infancy or early childhood with characteristic skin lesions that vary in appearance. The hallmark of UP is the presence of reddish-brown macules or papules that urticate or blister upon rubbing, a phenomenon known as Darier's sign. Histopathological examination of a skin biopsy is confirmatory, demonstrating an increased number of mast cells in the dermis.
Case presentation: We report a case of early-onset UP in a 7-month-old infant boy who presented with multiple hyperpigmented macules all over his body. The lesions were pruritic and had progressively increased in size and number over the past two weeks. Dermatological examination revealed multiple erythematous macules on the face, hyperpigmented macules on the chest, abdomen, and extremities, hyperpigmented plaques on the legs, and a nodule on the back. The lesions exhibited a positive Darier's sign, characterized by swelling and redness upon rubbing. Systemic examination was unremarkable, with no evidence of hepatomegaly, splenomegaly, or lymphadenopathy. Dermoscopy of the lesions revealed a central pigment network and a light brownish peripheral structure, suggestive of UP. Histopathological examination of a skin biopsy confirmed the diagnosis of UP, demonstrating an increased number of mast cells in the dermis. The patient was treated with oral antihistamines (cetirizine) and topical corticosteroids (hydrocortisone) for four weeks, resulting in significant regression of the lesions.
Conclusion: This case highlights the importance of recognizing the clinical features of UP in infants. Early diagnosis and appropriate management can help alleviate symptoms and improve the quality of life for affected children