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Alsayed AR, Al-Dulaimi A, Alkhatib M, Al Maqbali M, Al-Najjar MAA, Al-Rshaidat MMD. A comprehensive clinical guide for Pneumocystis jirovecii pneumonia: a missing therapeutic target in HIV-uninfected patients. Expert Rev Respir Med 2022; 16:1167-1190. [PMID: 36440485 DOI: 10.1080/17476348.2022.2152332] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii is an opportunistic, human-specific fungus that causes Pneumocystis pneumonia (PCP). PCP symptoms are nonspecific. A patient with P. jirovecii and another lung infection faces a diagnostic challenge. It may be difficult to determine which of these agents is responsible for the clinical symptoms, preventing effective treatment. Diagnostic and treatment efforts have been made more difficult by the rising frequency with which coronavirus 2019 (COVID-19) and PCP co-occur. AREAS COVERED Herein, we provide a comprehensive review of clinical and pharmacological recommendations along with a literature review of PCP in immunocompromised patients focusing on HIV-uninfected patients. EXPERT OPINION PCP may be masked by identifying co-existing pathogens that are not necessarily responsible for the observed infection. Patients with severe form COVID-19 should be examined for underlying immunodeficiency, and co-infections must be considered as co-infection with P. jirovecii may worsen COVID-19's severity and fatality. PCP should be investigated in patients with PCP risk factors who come with pneumonia and suggestive radiographic symptoms but have not previously received PCP prophylaxis. PCP prophylaxis should be explored in individuals with various conditions that impair the immune system, depending on their PCP risk.
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Affiliation(s)
- Ahmad R Alsayed
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Abdullah Al-Dulaimi
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Mohammad Alkhatib
- Department of Experimental Medicine, University of Rome "Tor Vergata", Roma, Italy
| | - Mohammed Al Maqbali
- Department of Nursing Midwifery and Health, Northumbria University, Newcastle-Upon-Tyne, UK
| | - Mohammad A A Al-Najjar
- Department of Pharmaceutical Sciences and Pharmaceutics, Applied Science Private University, Amman, Kingdom of Jordan
| | - Mamoon M D Al-Rshaidat
- Laboratory for Molecular and Microbial Ecology (LaMME), Department of Biological Sciences, School of Sciences, The University of Jordan, Amman, Jordan
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2
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Basetti B, Periakaruppan G, Murali A, Dev B, Radhakrishnan PR, Sai PMV. Breast involvement in granulomatosis with polyangiitis: a case report. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00569-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Granulomatosis with polyangiitis (GPA) previously known as Wegener's granulomatosis is a rare complex immune-mediated disease and a multisystem disorder with varying presentations where many of the imaging features of GPA overlap with those of other diseases, and hence its diagnosis can be challenging.
Case presentation
Here we report a case of a 48-year-old female who presented with complaints of hemoptysis, difficulty in speech, bilateral progressive hearing loss and, a palpable lump in the right breast. The case was initially misdiagnosed as breast carcinoma but biopsy proved to be GPA. Here we present the multisystem manifestations of GPA involving the head and neck, breast, lungs, spleen with involvement of the breast being very rare. The breast lesion showed improvement with steroids on follow-up.
Conclusions
GPA is a multisystem disease and though breast lesions in GPA are rare, a thorough knowledge about this uncommon manifestation is required and clinical, radiological, and histopathological correlation is of utmost importance in the evaluation of a breast lesion in cases of multisystem involvement to avoid unnecessary surgeries. The differential diagnosis of breast tumors should include such rare conditions that can sometimes mimic breast cancer. Early diagnosis and initiation of the immunosuppressive treatment help in a better prognosis of the disease.
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3
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Andrada-Elena M, Ioana TT, Mihaela FM, Irina-Elena C, Andrei TI, Florian B. Wegener's granulomatosis with orbital involvement: case report and literature review. Rom J Ophthalmol 2021; 65:93-97. [PMID: 33817443 PMCID: PMC7995507 DOI: 10.22336/rjo.2021.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective: To describe the chronology and the extent of orbital involvement in a case of granulomatosis with polyangiitis. Methods: Descriptive case report and literature review. Results: A 45-year-old patient, formerly diagnosed with granulomatosis with polyangiitis due to otorhinolaryngologic manifestations, pulmonary lesions, renal impairment, left knee arthritis and high blood levels of antineutrophil cytoplasmic antibodies, addressed the Ophthalmology Department in November 2020, having the following complaints: left eye mild retro-orbital discomfort, proptosis and epiphora. On examination, Snellen’s best corrected visual acuity was 6/ 6 in both eyes. The anterior segment of the left eye displayed significant changes: proptosis, upper lid swelling, ptosis, slightly decreased ocular motility, mild conjunctival hyperemia and chemosis, thinning of sclera in the upper quadrant and mild posterior subcapsular cataract. Left eye funduscopy revealed a slightly elevated optic disc, with indistinct margins in the nasal quadrant. Spectral-domain optical coherence tomography (OCT) of the optic nerve confirmed the clinical findings, illustrating an increase in the retinal nerve fiber layers thickness in the nasal quadrant, with no corresponding visual field defect. The orbit magnetic resonance imaging (MRI) unveiled an intraconal mass surrounding the optic nerve on its entire intra-orbital path, confirming the diagnosis of left orbital granuloma. Conclusion: Considering the relapsing disease and the orbital involvement, the patient is currently a candidate for rituximab, a monoclonal antibody against CD20. Abbreviations: AAV = ANCA associated vasculitides, ANCA = antineutrophil cytoplasmic antibody, AOM = acute otitis media, BCVA = best corrected visual acuity, CRP = C-reactive protein, CT = computerized tomography, EGPA = eosinophilic granulomatosis with polyangiitis, ENT = otorhinolaryngology/ ear-nose-throat, ESR = erythrocyte sedimentation rate, GPA = granulomatosis with polyangiitis, LE = left eye, MPA = microscopic polyangiitis, MRI = magnetic resonance imaging, OCT = optical coherence tomography, RE = right eye, RNFL = retinal nerve fiber layers, TNF = tumor necrosis factor, WG = Wegener’s granulomatosis
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Affiliation(s)
| | - Teodora Tofolean Ioana
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Retina" Clinic, Bucharest, Romania
| | - Florica Milicescu Mihaela
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Rheumatology Department, "Dr. Ioan Cantacuzino" Clinical Hospital, Bucharest, Romania
| | | | | | - Baltă Florian
- Emergency Eye Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Retina" Clinic, Bucharest, Romania
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4
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Lau JSY, Korman TM, Woolley I. Life-long antimicrobial therapy: where is the evidence? J Antimicrob Chemother 2019; 73:2601-2612. [PMID: 29873746 DOI: 10.1093/jac/dky174] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The decision to prescribe long-term or 'life-long' antibiotics in patients requires careful consideration by the treating clinician. While several guidelines exist to help assist in this decision, the long-term consequences are yet to be well studied. In this review, we aim to provide a summary of the available evidence for patient populations where long-term antibiotic therapy is currently recommended in clinical practice. We will also discuss the pitfalls of this approach, including medication adverse effects, economic cost and any possible contribution to the emerging epidemic of microbial resistance.
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Affiliation(s)
- Jillian S Y Lau
- Monash University, Clayton, Victoria, Australia.,Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
| | - Tony M Korman
- Monash University, Clayton, Victoria, Australia.,Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
| | - Ian Woolley
- Monash University, Clayton, Victoria, Australia.,Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
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Li J, Li C, Li J. Thoracic manifestation of Wegener's granulomatosis: Computed tomography findings and analysis of misdiagnosis. Exp Ther Med 2018; 16:413-419. [PMID: 29896268 DOI: 10.3892/etm.2018.6154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 01/18/2018] [Indexed: 12/11/2022] Open
Abstract
The aim of the present study was to investigate the computed tomography (CT) manifestations of Wegener granulomatosis (WG) in the chest and potential reasons for misdiagnosis. Conventional CT scans and clinical data of 45 patients with WG were retrospectively analyzed. Patients typically presented with multiple system involvement, primarily in the upper and lower respiratory tract. The incidence of thoracic involvement was 75.56% (34/45). Radiographic features were varied between cases in the present study, with the most common features being numerous cavitary nodules and masses in the lungs. Cavitations were usually irregular, with uneven wall thickness, partial centrality, fuzzy inner edges and piecemeal necrosis. These results indicate that WG typically has multiple system involvement, with the chest being most prominent. Multiple variable-sized cavitary nodules with irregular edges and piecemeal necrosis were the most notable features revealed using CT scanning; however, in order to give a definitive diagnosis, biopsies should be performed.
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Affiliation(s)
- Jiakai Li
- Department of Radiology, The Hainan Branch of The Chinese PLA General Hospital, Sanya, Hainan 572013, P.R. China.,Department of Radiology, The Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Chuangui Li
- Department of Radiology, The First Affiliated Hospital, Northern Hebei College, Zhangjiakou, Hebei 075000, P.R. China
| | - Jiaojiao Li
- Department of Radiology, The General Hospital, Tianjin Medical University, Tianjin, Hebei 300052, P.R. China
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6
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Cao Y, Zhang W, Wu J, Zhang H, Zhou H. Peripheral Ulcerative Keratitis Associated with Autoimmune Disease: Pathogenesis and Treatment. J Ophthalmol 2017; 2017:7298026. [PMID: 28785483 PMCID: PMC5530438 DOI: 10.1155/2017/7298026] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/25/2017] [Indexed: 12/16/2022] Open
Abstract
Peripheral ulcerative keratitis (PUK) is type of crescent-shaped inflammatory damage that occurs in the limbal region of the cornea. PUK is always combined with an epithelial defect and the destruction of the peripheral corneal stroma. PUK may have a connection to systemic conditions, such as long-standing rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Wegener granulomatosis (WG), relapsing polychondritis, classic polyarteritis nodosa and its variants, microscopic polyangiitis, and Churg-Strauss syndrome. However, the most common connection is with RA, which is also the focus of this review. The pathogenesis of PUK is still unclear. It is thought that circulating immune complexes and cytokines exert an important influence on the progression of this syndrome. Treatment is applied to inhibit certain aspects of PUK pathogenesis.
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Affiliation(s)
- Yan Cao
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun City, China
| | - Wensong Zhang
- Department of Ophthalmology, The Second Hospital of Jilin University, Changchun City, China
| | - Jie Wu
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun City, China
| | - Hong Zhang
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun City, China
| | - Hongyan Zhou
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun City, China
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8
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Gonzalez Santiago TM, Wetter DA, Kalaaji AN, Limper AH, Lehman JS. Pneumocystis jiroveci pneumonia in patients treated with systemic immunosuppressive agents for dermatologic conditions: a systematic review with recommendations for prophylaxis. Int J Dermatol 2016; 55:823-30. [PMID: 27009930 DOI: 10.1111/ijd.13231] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 10/29/2015] [Accepted: 11/04/2015] [Indexed: 11/29/2022]
Abstract
Pneumocystis jiroveci pneumonia is an opportunistic infection associated with substantial rates of mortality in immunosuppressed patients. Prophylaxis recommendations are mostly targeted toward patients with non-dermatologic diagnoses. This study was conducted to determine when dermatology patients treated with immunosuppressive medications should be offered P. jiroveci pneumonia prophylaxis. We searched the literature from January 1, 1993, to December 31, 2013, using terms relating to P. jiroveci pneumonia and dermatologic diagnoses to analyze the clinical characteristics of previously affected patients. Guidelines for P. jiroveci pneumonia prophylaxis from other medical fields were also analyzed. Of 17 dermatology patients reported to have contracted P. jiroveci pneumonia, eight (47.1%) died of the pneumonia. Risk factors included lack of prophylaxis, systemic corticosteroid therapy, lymphopenia, hypoalbuminemia, low serum CD4 counts, comorbid pulmonary or renal disease, malignancy, and prior organ transplantation. The present conclusions are limited by heterogeneity among the selected studies and limitations in their identification and selection. However, P. jiroveci pneumonia in dermatology patients is associated with a high mortality rate. Based on our analysis, we propose that prophylaxis be considered in dermatology patients in whom treatment with systemic corticosteroids at doses exceeding 20 mg/day or treatment with corticosteroid-sparing immunosuppressive agents is anticipated for at least 4 weeks, and in patients with additional risk factors for P. jiroveci pneumonia.
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Affiliation(s)
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Amer N Kalaaji
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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9
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Isa H, Lightman S, Pusey CD, Taylor SRJ. Ocular manifestations of Wegener’s granulomatosis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.11.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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10
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Necrotizing scleritis and peripheral ulcerative keratitis associated with Wegener's granulomatosis. Ophthalmol Ther 2013; 2:99-111. [PMID: 25135810 PMCID: PMC4108142 DOI: 10.1007/s40123-013-0016-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Indexed: 11/06/2022] Open
Abstract
Introduction To evaluate the complications, efficacy of medical and surgical treatment, and outcome in patients with necrotizing scleritis and peripheral ulcerative keratitis associated with Wegener’s granulomatosis. Methods The authors reviewed a series of seven patients with Wegener’s granulomatosis treated in the Corneal Department of Zhongshan Ophthalmic Center and the Department of Ophthalmology of Kashgar First People’s Hospital. A detailed chart review was performed to determine demographic characteristics, ocular presentation, biopsy and laboratory testing results, treatment, and final outcome. Results Wegener’s granulomatosis was indicated by ocular and/or systemic findings; biopsy and immunohistochemistry results supported the diagnosis. Patients with necrotizing scleritis and/or peripheral ulcerative keratitis received cytotoxic immunosuppressive therapy; this, in conjunction with surgical treatment, halted the relentlessly progressive inflammation and preserved the integrity of the globe in 78% of eyes. Best-Corrected Visual Acuity remained stable in four of nine eyes, was improved in two of nine eyes, and decreased in three of nine eyes (secondary to cataract and/or stromal scarring). Although one patient died, treatment with corticosteroids and cytotoxic agents dramatically improved outcomes in these patients. Conclusion Necrotizing scleritis and peripheral ulcerative keratitis often have a poor visual outcome, and may herald an underlying systemic vasculitis. Wegener’s granulomatosis, with the associated necrotizing scleritis and peripheral ulcerative keratitis, should be managed with aggressive immunosuppression to avoid the associated morbidity and mortality. Thus, the ophthalmologist may play a significant role in its early diagnosis and treatment.
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11
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Grossi O, Généreau T. Corticoïdes et… infections, dopage, chirurgie et sexualité. Rev Med Interne 2013; 34:269-78. [DOI: 10.1016/j.revmed.2012.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 12/12/2012] [Indexed: 12/22/2022]
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12
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Hassan M, Andersson BS. Role of pharmacogenetics in busulfan/cyclophosphamide conditioning therapy prior to hematopoietic stem cell transplantation. Pharmacogenomics 2013; 14:75-87. [PMID: 23252950 DOI: 10.2217/pgs.12.185] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a curative treatment for several malignant and nonmalignant disorders. Busulfan (Bu) and cyclophosphamide (Cy) are the most commonly used alkylators in high-dose pretransplant conditioning for HSCT; a treatment that is correlated with drug-related toxicity and relapse. Pharmacogenetic investigations have shown that CYP450, as well as aldehyde dehydrogenase, are clearly involved with Cy metabolism and are associated with altered treatment response, Cy metabolism and the unique stem-cell sparing capacity. Moreover, glutathione-S-transferase isoenzymes have been associated with cellular outward transport of various alkylating agents, including Cy metabolites, melphalan, Bu and chlorambucil. A shift from genetic-based studies to whole-genome-based investigations of Cy- and Bu-associated markers may contribute to personalizing the conditioning therapy and enhancing the clinical outcome of HSCT.
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Affiliation(s)
- Moustapha Hassan
- Experimental Cancer Medicine (ECM), Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
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13
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Kim FS, Pandya AG. The use of etanercept in the treatment of peristomal pyoderma gangrenosum. Clin Exp Dermatol 2012; 37:442-3. [DOI: 10.1111/j.1365-2230.2011.04234.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Affiliation(s)
- Nichole Graves
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas, USA.
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15
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Santiago YM, Fay A. Wegener’s Granulomatosis of the Orbit: A Review of Clinical Features and Updates in Diagnosis and Treatment. Semin Ophthalmol 2011; 26:349-55. [DOI: 10.3109/08820538.2011.588662] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Corneal Disease Associated with Nonrheumatoid Collagen-Vascular Disease. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00100-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Sharma SM, Nestel AR, Lee RWJ, Dick AD. Clinical review: Anti-TNFalpha therapies in uveitis: perspective on 5 years of clinical experience. Ocul Immunol Inflamm 2010; 17:403-14. [PMID: 20001261 DOI: 10.3109/09273940903072443] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite a lack of robust evidence, anti-TNF therapies are in wide use for the treatment of noninfectious ocular inflammatory diseases. There is a clear rationale, based on mechanistic and preclinical efficacy data, for their use in posterior segment intraocular inflammation. However, their increasing use for other indications has been largely extrapolated from the benefit observed in autoinflammatory and autoimmune systemic diseases. Given their cost and the potential for significant adverse events, this review highlights the evidence for their continued use, possibilities for switching anti-TNF agents, and ways of reducing the risk of therapy.
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Utilization of the 1,2,3,5-thiatriazolidin-3-one 1,1-dioxide scaffold in the design of potential inhibitors of human neutrophil proteinase 3. Bioorg Med Chem 2009; 18:1093-102. [PMID: 20061159 DOI: 10.1016/j.bmc.2009.12.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Revised: 12/15/2009] [Accepted: 12/17/2009] [Indexed: 11/22/2022]
Abstract
The S' subsites of human neutrophil proteinase 3 (Pr 3) were probed by constructing diverse libraries of compounds based on the 1,2,3,5-thiatriazolidin-3-one 1,1-dioxide using combinational and click chemistry methods. The multiple points of diversity embodied in the heterocyclic scaffold render it well-suited to the exploration of the S' subsites of Pr 3. Molecular modeling studies suggest that further exploration of the S' subsites of Pr 3 using the aforementioned heterocyclic scaffold may lead to the identification of highly selective, reversible competitive inhibitors of Pr 3.
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Eloy P, Leruth E, Bertrand B, Rombaux PH. Successful endonasal dacryocystorhinostomy in a patient with Wegener's granulomatosis. Clin Ophthalmol 2009; 3:651-6. [PMID: 20054412 PMCID: PMC2801633 DOI: 10.2147/opth.s5920] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Indexed: 11/23/2022] Open
Abstract
Wegener's granulomatosis (WG) is one form of idiopathic autoimmune vasculitis. The disease has a predilection for the upper and lower respiratory tracts (lungs, nose, sinus), and kidneys. WG may be systemic, severe, and potentially lethal, but it may also be limited to the otolaryngological area or to the eyes and the orbits. Obstruction of the lacrimal pathway is a possible complication of the disease that affects approximately 7% of patients with WG. It usually occurs as a direct extension of sinonasal disease and typically is a late manifestation. Management of such a condition is generally viewed as difficult. We report the case of a patient with a quiescent WG limited to the otolaryngological area. This patient presented a bilateral obstruction of the nasolacrimal ducts caused by bilateral extensive adhesions in the nasal cavity. Because she had several episodes of left-side acute dacryocystitis which necessitated several courses of broad-spectrum antibiotics, she successfully underwent an endonasal endoscopic dacryocystorhinostomy using a diode laser and powered instrumentation. The authors describe the clinical case, the surgical technique, and review the literature.
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Affiliation(s)
- P Eloy
- ENT and HNS department, Cliniques Universitaires de Mont-Godinne, Université Catholique de Louvain, 5530, Yvoir, Belgium.
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Watkins AS, Kempen JH, Choi D, Liesegang TL, Pujari SS, Newcomb C, Nussenblatt RB, Rosenbaum JT, Thorne JE, Foster CS, Jabs DA, Levy-Clarke GA, Suhler EB, Smith JR. Ocular disease in patients with ANCA-positive vasculitis. J Ocul Biol Dis Infor 2009; 3:12-19. [PMID: 20835396 PMCID: PMC2933008 DOI: 10.1007/s12177-009-9044-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Accepted: 11/09/2009] [Indexed: 10/26/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis-the term recently applied to Wegener's granulomatosis-is a rare multi-system inflammation characterized by necrotizing granulomas and vasculitis. We investigated the ocular manifestations of this disease in a group of patients drawn from five inflammatory eye disease clinics across the United States. Of 8,562 persons with ocular inflammation, 59 individuals were diagnosed with ANCA-positive vasculitis; 35 males and 21 females, aged 16 to 96 years, were included in this study. Ocular diagnoses were scleritis (75.0%), uveitis (17.9%), and other ocular inflammatory conditions (33.9%) including peripheral ulcerative keratitis and orbital pseudotumor. Mean duration of ocular disease was 4.6 years. Oral corticosteroids and other systemic immunosuppressive agents were used by 85.7% and 78.5% of patients, respectively. Over time, patients with ANCA-positive vasculitis experienced 2.75-fold higher mortality than other patients with inflammatory eye disease.
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Gutenberg A, Landek-Salgado M, Tzou SC, Lupi I, Geis A, Kimura H, Caturegli P. Autoimmune hypophysitis: expanding the differential diagnosis to CTLA-4 blockade. Expert Rev Endocrinol Metab 2009; 4:681-698. [PMID: 30780785 DOI: 10.1586/eem.09.37] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Autoimmune hypophysitis is an increasingly recognized disorder that enters in the differential diagnosis of nonfunctioning pituitary masses. The differential diagnosis of these conditions is challenging because of similar clinical presentations and radiological signs. This review describes the essential features of hypophysitis and the other nonfunctioning pituitary masses. It also emphasizes a recently described feature of hypophysitis: its appearance with unexpectedly high frequency in patients receiving treatments that abrogate the function of cytotoxic T lymphocyte antigen 4.
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Affiliation(s)
- Angelika Gutenberg
- a Department of Neurosurgery, Georg-August University, Goettingen, Germany.
| | - Melissa Landek-Salgado
- b Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Shey-Cherng Tzou
- c Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Isabella Lupi
- d Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | - Abby Geis
- e Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Hiroaki Kimura
- f Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Patrizio Caturegli
- g Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Wegener's granulomatosis of the breast: a rare entity with daily clinical relevance. Ann Diagn Pathol 2009; 13:351-7. [PMID: 19751914 DOI: 10.1016/j.anndiagpath.2009.04.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 04/15/2009] [Indexed: 11/24/2022]
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Martínez-Gutiérrez JD, Mencía-Gutiérrez E, Gutiérrez-Díaz E, Rodríguez-Peralto JL. Bilateral idiopathic orbital inflammation 3 years before systemic Wegener's granulomatosis in a 7-year-old girl. Clin Ophthalmol 2009; 2:941-4. [PMID: 19668449 PMCID: PMC2699785 DOI: 10.2147/opth.s3772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Wegener’s granulomatosis (WG) is a necrotizing granulomatous vasculitis characterized by the involvement of the upper or lower airways, lungs, and kidneys, but it can affect almost any organ including the orbit. WG is rare in childhood. This case report describes a 7-year-old girl who presented bilateral idiophatic orbital inflammation and antineutrophil cytoplasmic antibodies-negative titres. Computed tomography scan and magnetic resonance imaging showed enlargement of both lacrimal glands with infiltration. Treatment with corticosteroids achieved remission of the disease. Three years later, she developed a systemic affectation with tracheal stenosis, pulmonary affectation, renal failure, and respiratory tract mucosa inflammation. Lacrimal gland biopsy showed perivascular nonspecific granulomas and ANCA titres remain negative. Treatment with corticosteroids and cyclophosphamide was done. A relapse occurred 2 years later, with complete remission with antitumor necrosis factor-alpha. No other symptoms have appeared after 9 years of follow-up. Early diagnosis and treatment is crucial to increase the survival rate in these patients.
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Martinez Del Pero M, Chaudhry A, Jones R, Sivasothy P, Jani P, Jayne D. B-cell depletion with rituximab for refractory head and neck Wegener’s granulomatosis: a cohort study. Clin Otolaryngol 2009; 34:328-35. [DOI: 10.1111/j.1749-4486.2009.01968.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Current World Literature. Curr Opin Rheumatol 2008; 20:111-20. [DOI: 10.1097/bor.0b013e3282f408ae] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Boudny C, Nievergelt H, Braathen LR, Simon D. Wegener's granulomatosis presenting as pyoderma gangrenosum. J Dtsch Dermatol Ges 2007; 6:477-9. [PMID: 18076660 DOI: 10.1111/j.1610-0387.2007.06497.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Half of the patients with Wegener's granulomatosis develop skin lesions due to the systemic vasculitis. Wegener's granulomatosis should be included in the differential diagnostic considerations for necrotic ulcers, including leg ulcers. We present a case which demonstrates the importance of histological evaluation of a skin biopsy from the margin of the ulcer for establishing the diagnosis. Antineutrophil cytoplasmic antibodies with antigen specificity for proteinase 3 (PR3-ANCA) were detected supporting the diagnosis of Wegener granulomatosis. Further evaluation showed involvement of the eyes and kidneys. The ulcer rapidly healed under treatment with cyclophosphamide and corticosteroids.
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Affiliation(s)
- Clara Boudny
- Clinic and Polyclinic for Dermatology, Inselspital, University of Bern, Switzerland.
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Freshwater-Turner DA, Boots RJ, Bowman RN, Healy HG, Klestov AC. Difficult decisions in the intensive care unit: an illustrative case. Anaesth Intensive Care 2007; 35:748-59. [PMID: 17933163 DOI: 10.1177/0310057x0703500515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Difficult clinical decision-making is a common experience in intensive care units. There is often considerable pressure on time and decisions may have to be made in a stressful environment. Patients in the intensive care unit not infrequently present with extreme or rare manifestations of a disease process. Clinical evidence to guide management of such patients may be incomplete, non-existent, or its relevance to the problem at hand may be questionable. In this context, formal decision-making analytical tools are often impractical. Unconscious cognitive biases have been shown to play an important role in medical decision-making, particularly in these settings. While mostly these contribute to doctors making appropriate and timely decisions, occasionally they lead to errors. Despite 30 years of research into models of clinical reasoning, most doctors are unaware of how biases affect their thinking and are unfamiliar with techniques of detecting and neutralising bias in clinical practice. We present the case of a patient with Wegener's granulomatosis, which highlights many of the difficulties outlined above. We review the clinical evidence for our decisions at each stage and explain the rationale for our choices, highlighting the many situations for which high quality evidence was lacking. Examples of cognitive bias are identified and techniques of metacognition (thinking about thinking) that can be useful in limiting the effects of bias on complex decision-making are reviewed. The intensivist's evaluation of management alternatives has an important role in steering medical management towards optimal patient outcomes.
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Affiliation(s)
- D A Freshwater-Turner
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospitals, Brisbane, Queensland, Australia
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Abstract
Sarcoidosis is a systemic inflammatory disorder of unknown etiology. Although any organ may be involved, the lungs are most frequently affected. The clinical course of the disease is highly variable, with up to two-thirds of untreated patients experiencing spontaneous remission within 12-24 months of onset of symptoms. When therapy is required, corticosteroids are considered standard, but studies demonstrating their ability to modify the long-term outcome in this disease are lacking. Often, the myriad of adverse side effects of corticosteroids necessitate the addition of immunosuppressants, cytotoxic agents or biologic therapies to maintain disease remission. Unfortunately, optimal therapeutic regimens have not been described. Patients who do not respond to therapy often experience progressive fibrotic changes and end-organ damage, which ultimately may result in significant morbidity or death. Agents commonly used to treat patients with sarcoidosis and emerging therapeutic options are discussed.
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Affiliation(s)
- Eric S White
- University of Michigan Medical Center, Division of Pulmonary and Critical Medicine, Department of Internal Medicine, 6301 MSRB III/0642, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-0642, USA.
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Ong AS, Hachelaf M, Capellier G, Kantelip JP, Davani S. Intoxication médicamenteuse volontaire au mycophénolate mofétil. Therapie 2007; 62:273-4. [DOI: 10.2515/therapie:2007037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Papiris SA, Manali ED, Kalomenidis I, Kapotsis GE, Karakatsani A, Roussos C. Bench-to-bedside review: pulmonary-renal syndromes--an update for the intensivist. Crit Care 2007; 11:213. [PMID: 17493292 PMCID: PMC2206392 DOI: 10.1186/cc5778] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The term Pulmonary-renal syndrome refers to the combination of diffuse alveolar haemorrhage and rapidly progressive glomerulonephritis. A variety of mechanisms such as those involving antiglomerular basement membrane antibodies, antineutrophil cytoplasm antibodies or immunocomplexes and thrombotic microangiopathy are implicated in the pathogenesis of this syndrome. The underlying pulmonary pathology is small-vessel vasculitis involving arterioles, venules and, frequently, alveolar capillaries. The underlying renal pathology is a form of focal proliferative glomerulonephritis. Immunofluorescence helps to distinguish between antiglomerular basement membrane disease (linear deposition of IgG), lupus and postinfectious glomerulonephritis (granular deposition of immunoglobulin and complement) and necrotizing vasculitis (pauci-immune glomerulonephritis). Patients may present with severe respiratory and/or renal failure and require admission to the intensive care unit. Since the syndrome is characterized by a fulminant course if left untreated, early diagnosis, exclusion of infection, close monitoring of the patient and timely initiation of treatment are crucial for the patient's outcome. Treatment consists of corticosteroids in high doses, and cytotoxic agents coupled with plasma exchange in certain cases. Renal transplantation is the only alternative in end-stage renal disease. Newer immunomodulatory agents such as those causing TNF blockade, B-cell depletion and mycophenolate mofetil could be used in patients with refractory disease.
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Affiliation(s)
- Spyros A Papiris
- 2nd Pulmonary Department, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - Effrosyni D Manali
- 2nd Pulmonary Department, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - Ioannis Kalomenidis
- 2nd Pulmonary Department, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - Giorgios E Kapotsis
- 2nd Pulmonary Department, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - Anna Karakatsani
- 2nd Pulmonary Department, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - Charis Roussos
- Department of Critical Care and Pulmonary Services, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece
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