Charité Clinical Journal Club (English) by Fred Luft - 21.08.2019

The N Engl J Med image of the week concerns an 80-year-old man who presented to the emergency department with a 2-day history of abdominal pain in the right upper quadrant. On physical examination, he had abdominal tenderness in the right upper quadrant, and Murphy’s sign was positive. The alanine aminotransferase, aspartate aminotransferase, bilirubin, and lipase levels were normal. Computed tomography of the abdomen is shown. What is the diagnosis? You are offered ascending cholangitis, duodenal diverticulitis, subhepatic appendicitis, emphyssematous cholecystitis, and hepatic cyst rupture. We discuss these options. Type 1 diabetes is a chronic autoimmune disease that leads to destruction of insulin-producing beta cells and dependence on exogenous insulin for survival. Some interventions have delayed the loss of insulin production in patients with type 1 diabetes, but interventions that might affect clinical progression before diagnosis are needed. Investigators conducted a phase 2, randomized, placebo-controlled, double-blind trial of teplizumab (an Fc receptor–nonbinding anti-CD3 monoclonal antibody) involving relatives of patients with type 1 diabetes who did not have diabetes but were at high risk for development of clinical disease. The strategy was based on the rationale that as type 1 diabetes develops, lymphocytes, particularly CD8+ T cells, infiltrate and slowly kill beta cells. Patients were randomly assigned to a single 14-day course of teplizumab or placebo, and follow-up for progression to clinical type 1 diabetes was performed with the use of oral glucose-tolerance tests at 6-month intervals. Teplizumab delayed the onset of type 1 diabetes by about 2 years. Neuromyelitis optica spectrum disorder (NMOSD) is a relapsing, autoimmune, inflammatory disorder that typically affects the optic nerves and spinal cord. At least two thirds of cases are associated with aquaporin-4 antibodies (AQP4-IgG) and complement-mediated damage to the central nervous system...