Endogenous lipoid pneumonia associated with undifferentiated connective tissue disease (UCTD)

BACKGROUND

Lipoid pneumonia is a rare pulmonary disease, a form of pneumonia that has no classical radiological appearance, thus it can imitate other lung diseases. Lipoid pneumonia is usually classified into two major groups, depending on whether the source of oil/fat in the respiratory tract is from an exogenous or endogenous source. Undifferentiated connective tissue disease is a term used by rheumatologists to define a group of diffuse connective tissue disorders that lack definitive characteristics of any particular well-defined disorder.

MATERIAL AND METHODS

A case study is reported of concomitant undifferentiated connective tissue disease and endogenous lipoid pneumonia.

RESULTS

Histologically the macrophages appeared filled with lipid and were similar to atherosclerotic foam cell macrophages. Antibiotic and antimycotic treatments were ineffective. However, with concomitant steroid treatment, the patient exhibited absence of lung infiltration as well as other symptoms and was discharged. Therefore it is concluded that the lipoid pneumonia was steroid dependent.

CONCLUSION

Since the patient's condition responded to steroid treatment, and it is clear that steroids inhibit phospholipase activity, the authors speculate that the subsequent decreased endoperoxide production may diminish lipid uptake by macrophages via decreasing modification of LDL or other lipid sources.

[Use of cefuroxime axetil in clinical practice]

This study summarizes the actual recommendations for cefuroxime axetil treatment in dermatology and general medicine. These include the well known clinical efficacies in therapy of upper and lower respiratory tract infections, genitourinary tract infections and skin and soft tissue infections, but also connective tissue diseases, such as morphea and SCLE. Though the immunomodulatory activity of the drug should be established by further controlled studies, there are some limited literature data, which show the modulatory effect of cefuroxime axetil on the lymphocyte proliferation and the production of selected cytokines.

Clinical experience with specific COX-2 inhibitors in arthritis

The common mechanism of action of aspirin and the chemically unrelated non-steroidal anti-inflammatory drugs (NSAIDs) is the inhibition of prostaglandin (PG) production due to interference with the enzymatic activity of cyclooxygenase (COX). These agents have long been used as effective treatments for arthritis. The recognition that the inducible isoform COX-2 was associated with inflammation and arthritis led to the hypothesis that PGs produced by a COX-2-dependent pathway were responsible for the inflammation, pain, and tissue destruction. Since the constitutive COX-1 enzyme was identified as responsible for gastroprotection and inhibition of platelet function, the potential for compounds that were both effective and safer than NSAIDs led to rapid development of agents that specifically inhibit COX-2. These agents have now been tested and approved for use by the US Food and Drug Administration for patients with osteoarthritis and rheumatoid arthritis. They have been shown equally effective to comparitor NSAIDs. More importantly, there is a 3.5-fold reduction in the incidence of endoscopic gastroduodenal ulcerations and early data suggesting a similar reduction in clinically significant perforations, symptomatic ulcers, and bleeds. In patients with arthritis at risk for gastrointestinal complications of NSAIDs, specific inhibitors of COX-2 provide an effective and apparently safer form of anti-inflammatory agent.

Thrombosis in patients with connective tissue diseases treated with specific cyclooxygenase 2 inhibitors. A report of four cases

Specific inhibitors of cyclooxygenase 2 (COX-2) have been approved for the treatment of osteoarthritis and rheumatoid arthritis. Unlike nonsteroidal anti-inflammatory drugs, specific COX-2 inhibitors do not inhibit platelet activation. However, these agents significantly reduce systemic production of prostacyclin. As a result, theoretical concerns have been raised that specific COX-2 inhibitors could shift the hemostatic balance toward a prothrombotic state. Patients with connective tissue diseases (CTD), who may be predisposed to vasculopathy and thrombosis, often have arthritis or pain syndromes requiring treatment with antiinflammatory agents. Herein we describe 4 patients with CTD who developed ischemic complications after receiving celecoxib. All patients had a history of Raynaud's phenomenon, as well as elevated anticardiolipin antibodies, lupus anticoagulant, or a history compatible with antiphospholipid syndrome. It was possible to measure a urinary metabolite of thromboxane A2 in 2 of the patients as an indicator of in vivo platelet activation, and this was markedly elevated in both. In addition, the patients had evidence of ongoing inflammation as indicated by elevated erythrocyte sedimentation rate, hypocomplementemia, and/or elevated levels of anti-DNA antibodies. The findings in these 4 patients suggest that COX-2 inhibitor-treated patients with diseases that predispose to thrombosis should be monitored carefully for this complication.

Effect of ticlopidine on platelet-derived microparticles in patients with connective tissue diseases

We evaluated the plasma concentrations of platelet activation markers and platelet-derived microparticles (PMP) in patients with connective tissue diseases complaining of peripheral circulation disorders (n = 16) and studied the effect of ticlopidine hydrochloride (ticlopidine) on PMP generation. There were significant differences in the levels of PMP and a platelet activation marker between before and after treatment with ticlopidine (PMP: 695 +/- 393 vs. 354 +/- 206/10(4) platelets, p < 0. 01; platelet CD63: 9.13 +/- 5.64 vs. 5.22 +/- 2.74%, p < 0.05). On the other hand, markers of vascular endothelium, such as vascular endothelium-derived small vesicles and serum thrombomodulin levels, were not affected by the administration of ticlopidine. Levels of cytokines and soluble adhesion molecules remained unchanged by ticlopidine administration. These findings suggest that ticlopidine may be useful for the inhibition of PMP-dependent vascular damage in patients with connective tissue diseases complaining of peripheral circulation disorders.

Magnetic resonance imaging in the evaluation of patients with aseptic meningoencephalitis and connective tissue disorders

OBJECTIVE

To describe the role of magnetic resonance imaging (MRI) in the evaluation of patients with chronic and recurrent aseptic meningitis.

METHOD

A retrospective study of five patients with aseptic meningoencefalitis diagnosed by clinical and CSF findings. CT scans showed without no relevant findings.

RESULTS

MRI showed small multifocal lesions hyperintense on T2 weighted images and FLAIR, with mild or no gadolinium enhancement, mainly in periventricular and subcortical regions. Meningoencephalitis preceded the diagnosis of the underlying disease in four patients (Behçet's disease or systemic lupus erythematosus). After the introduction of adequate treatment for the rheumatic disease, they did not present further symptoms of aseptic meningoencephalitis.

CONCLUSION

Aseptic meningoencephalitis can be an early presentation of an autoimmune disease. It is important to emphasize the role of MRI in the diagnosis and follow-up of these patients.

Efficacy of sulfamethoxazole-trimethoprim administration in the prevention of Pneumocystis carinii pneumonia in patients with connective tissue disease

The efficacy and adverse effects of prophylactic administration of Sulfamethoxazole-Trimethoprim (ST) for Pneumocystis carinii Pneumonia (PCP) were assessed in patients with connective tissue diseases (CTD). Eighty-four patients who were receiving more than 40 mg/day of prednisolone were entried in the present study. Patients with at least one of the two PCP risk factors (interstitial pulmonary fibrosis and lymphopenia), were administered either one (11 patients) or two (26 patients) ST tablets/day. The remaining 47 patients who did not receive ST served as the controls. Although PCP was detected in 4.3% of the patients in the no-ST group, none of the patients who received ST developed PCP. Five of these 26 patients who received two tablets of ST/day, experienced adverse reactions. However, no adverse reactions were detected in the patients who received one tablet of ST/day (p < 0.05). Abnormal laboratory data were obtained for 10 (38.5%) of the patients who received two tablets of ST/day and for 4 (36.4%) of the 11 patients who received one tablet of ST/day. The results of the present study suggest that the prophylactic administration of one tablets of ST in patients with CTD that have at least one of the two PCP risk factors is effective in preventing PCP.

Five-year follow-up of 165 Italian patients with undifferentiated connective tissue diseases

OBJECTIVE

To study those conditions with a proven or hypothesised immunologic pathogenesis and denominated under a working definition of undifferentiated connective tissue diseases (UCTD).

METHODS

A multicentre prospective study was organised involving 10 tertiary referral centers of internal medicine in Italy, with the aim of describing the natural history of UCTD and the prevalence of its different clinical and immunological manifestations.

RESULTS

After a five-year follow-up period, data on 165 patients were available for analysis. UCTDs occur mainly in females in their fourth decade of life. Articular and mucocutaneous features and Raynaud's phenomenon represent the most common findings. Nevertheless, we also detected a relatively high incidence of permanent major organ damage. Regarding the immunologic parameters, we documented some conflicting results in the correlation between serologic abnormalities and clinical features. In 10 patients UCTD evolved to a major disease, generally systemic lupus erythematosus or Sjögren's syndrome.

CONCLUSION

A low rate of evolution to a defined autoimmune disease, the limited use of steroid or immunosuppressive therapy, and a favourable course in the majority of cases are the main characteristics of patients with UCTDs.

[Synthetic glucocorticoid in the treatment of connective tissue diseases]

Synthetic glucocorticoids are the most potent anti-inflammatory and immunosuppressive drugs, which have been used for almost 50 years as a core drug for the treatment of connective tissue diseases. The mechanism of action of glucocorticoids as anti-inflammatory or immunosuppressive drug is considered as the repression of inflammatory cytokines, receptors of cytokines, and adhesion molecules. When 60 mg of prednisolone is administered in 3 divided doses, the plasma concentrations are around 20-30 micrograms/dl during the day time, in which condition around 90% of GC receptors are occupied. However, the concentration will decrease almost to 0 microgram/dl in the next early morning. In case of methyl prednisolone pulse therapy, about 40 micrograms/dl of the steroid is present in the next morning. These kinetics are important when we consider the glucocorticoid therapy. In the treatment of connective tissue diseases, the combination of the steroid therapy with the immunosuppressive therapy should always be considered. In diffuse proliferative lupus nephritis, glucocorticoid dosage, started at high level to suppress the clinical activity of SLE, decrease rather rapidly while cytotoxic drugs are administered at least for 2 years. In the treatment of systemic sclerosis, normotensive scleroderma kidney is treated with moderate dose of glucocorticoid and cytotoxic drugs. It is our clinical impression that low dose glucocorticoid is quite effective in the treatment of rheumatoid arthritis. However, low dose glucocorticoid therapy is effective for the patient's sense of well-being, but is scarsely effective for the articular symptoms itself and shows intense rebound phenomenon when glucocorticoid is withdrawn.

[Immunosuppressive treatment strategy in connective tissue diseases]

In this review, we summarized important articles published about immunosuppressive agents in connective tissue diseases. Intravenous cyclophosphamide therapy for lupus nephritis and oral cyclophosphamide therapy for Wegener's granulomatosis are major progress in past one decade. Newer immunosuppressive agents such as cyclosporin, tacrorimus are also introduced in steroid refractory organ involvements. And we discussed also the monitoring and prevention of adverse effects of immunosuppressive agents. This review will focus on immunosuppressive treatment strategy of connective tissue diseases.

Pseudoporphyria associated with Relafen therapy

Various oral medications including nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with pseudoporphyria, although the pathogenetic basis has not been elucidated. A novel NSAID nabumetone (Relafen) has become popular because of its minimal gastrointestinal side effects. Its association with pseudoporphyria is not reported save for its listing in the Physician's Desk Reference (PDR) as a possible side effect. Biopsies of lesional skin from 4 patients manifesting blisters and erosions on the hands and face within 4 months of starting nabumetone were submitted for light microscopic and immunofluorescent (IF) studies. Histories and serology were obtained. Two patients had rheumatoid arthritis (RA), 1 had mixed connective tissue disease (MCTD), and 1 received diltiazem. All 4 had antinuclear antibodies. Characteristic clinical, light microscopic and IF features in the absence of elevated urine porphyrin levels confirmed a diagnosis of pseudoporphyria in all 4 patients. Biopsies in three patients showed features attributed to underlying connective tissue disease (CTD), including ectasia of the superficial vascular plexus, mild leukocytoclastic vasculitis, superficial and deep perivascular lymphocytic infiltrates with dermal mucinosis, granular deposition of IgM along the dermoepidermal junction indicative of a positive lupus band test, and of IgG and C5b-9 within keratinocytes. Nabumetone (Relafen) can provoke pseudoporphyria; an underlying CTD diathesis may be a predisposing factor.

[A case of pityriasis rubra pilaris associated with unclassified connective tissue disease and sepsis in clinical course]

The patient was a 23-year-old woman with HTLV-I carrier and was diagnosed as pityriasis rubra pilaris soon after her birth. In November 1990 at her age of 16, she began to have fever and polyarthralgia which were not improved despite the administration of antibiotics. Her laboratory findings showed the positive antinuclear antibody and anti-RNP antibody suggesting one of collagen diseases. A tentative diagnosis as unclassified connective tissue disease (UCTD) was made since her symptoms and laboratory findings were not satisfied with any criteria for rheumatic disorders. The steroid therapy was started in February 1991 and showed a good response. On April 9th, 1996, however, she was admitted to our hospital because of recurrence of high fever and chills. This time, she had sepsis because of the evidence that Enterococcus faecalis was detected in blood culture. Although her condition was improved by antibiotics on June 4th 1996, high fever re-appeared and followed by convulsion and disseminated intravascular coagulation. After the doses of prednisolone per day was increased to 40 mg with antibiotics and anticoagulant, her condition gradually improved. This patient was a rare case of pityriasis rubra pilaris associated with UCTD and sepsis in clinical course.

Comparison of topical therapy for striae alba (20% glycolic acid/0.05% tretinoin versus 20% glycolic acid/10% L-ascorbic acid)

BACKGROUND

Topical treatment of striae rubra with 0.1% tretinoin and laser treatment of striae rubra and alba with the 585-nm pulsed dye laser are proven therapeutic options. However, little efficacy has been shown for treatment of striae alba topically, and the laser is currently not a suitable treatment option for darker ethnic skin types.

OBJECTIVE

The purpose of this study was to demonstrate that selected commercial topical agents can improve the appearance of striae alba.

METHODS

Ten patients of varying skin types (I-V) having straie distensae alba on the abdomen or thighs were selected to evaluate the effectiveness of two topical treatment regimens. Patients were placed on daily topical application of 20% glycolic acid (MD Forte) to the entire treatment area. In addition, the patients applied 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine to half to the treatment area and 0.05% tretinoin emollient cream (Renova) to the other half of the treatment area. The creams were applied on a daily basis for 12 weeks. Improvement was evaluated at 4 and 12 weeks in an objective unblinded fashion at the follow-up visits, a objective blinded fashion by visual grading at the conclusion of the study, and in an objective blinded fashion with profilometry. Additionally, histopathologic analysis was performed.

RESULTS

Analysis of these data reveals: 1) both regimens can improve the appearance of stretch marks; 2) these topical therapy regimens are safe and effective in study patients with minimal irritation; 3) elastin content within the reticular and papillary dermis can increase with topical 20% glycolic acid combined with 0.05% tretinoin emollient cream therapy; 4) both regimens increased epidermal thickness and decreased papillary dermal thickness in treated stretch marks when compared with untreated stretch marks; 5) combined epidermal and papillary dermal thickness in stretch marks treated with either topical regimen approaches that of normal skin; and 6) profilometry can objectively measure differences in skin texture associated with striae treatments when compared to controls, however, it is not sensitive enough to justify comparison or quantitative improvements between similarly effective treatments.

Connective tissue disorders and pregnancy. Recommendations for prescribing

This report summarizes experience with drugs prescribed for women with connective tissue disorders who either are anticipating childbearing, are pregnant or are breast-feeding. Principles of maintenance therapy are the same as when nonpregnant. Comparative trials of drugs during gestation are uncommon because of a lack of sufficient case numbers. It is difficult to distinguish between any additional risks from the medication, from any other drug and from the underlying disease. Symptoms of pregnancy may mimic side effects or toxic reactions to certain drugs. Each drug crosses the placenta, and any additional risk of spontaneous abortion, malformation or stillbirth is either negligible or unproven. Potential fetal problems with long-term intrauterine exposure to these drugs may include pancytopenia, immunosuppression, craniofacial abnormalities or restricted growth. These agents are transferred into breast milk in small quantities. Descriptions are provided of perinatal outcomes after in utero exposure to prednisone, aspirin, other nonsteroidal antiinflammatory drugs, antimalarials, gold salts, methotrexate, cyclophosphamide and azathioprine.

Other rheumatic diseases in adolescence. Dermatomyositis, scleroderma, overlap syndromes, systemic vasculitis, and panniculitis

In addition to juvenile rheumatoid arthritis (JRA) and systemic lupus erythematosus (SLE), dermatomyosytis, scleroderma, overlap syndromes, systemic vasculitis, and panniculitis also present in adolescence. The authors discuss the complex epidemiology, diagnosis, clinical features, diagnostic testing, treatment, and prognosis of these diseases.

[Tuberculosis and systemic diseases. Apropos of 16 cases]

METHODS

We analyzed retrospectively 16 patients between 1976 and 1993 (six men, ten women, mean age: 49-year-old) suffering from connectivitis. HIV-negative and receiving corticosteroids, combined for six of them with immunosuppressive therapy, and suffering from tuberculosis.

RESULTS

The mean period between first signs and diagnosis was 51 days (3-190 d). Tuberculosis was pulmonary (n = 10) of which 4 miliary, pleurisy (n = 3), lymphadenitis (n = 5). We only observed one meningitis, one otitis and one female genital tuberculosis. Six patients had more than one localisation. Diagnosis was proven bacteriologically eight times, histologically six times and for three patients diagnosis was certain because of efficacy of antituberculosis antibiotherapy. Evolution was always good, with antituberculosis antibiotherapy of maximum 18 months, without sequella. Because rifampicin enzymatic induction, connectivitis worsened in five patients. An increase in corticotherapy was necessary for these five patients.

CONCLUSION

This series confirmed the frequently extrapulmonary feature of tuberculosis in immunosuppressed patients, the long delay of diagnosis and the risk of exacerbation of underlying disease with rifampicin.