[Calcyphylaxis in a patient with end-stage renal disease in the course of systemic lupus erythematosus, diagnostic problems--case report]

Calcyphylaxis consists in vascular calcium deposition and skin necrosis, which appears in the final stage of renal failure. Advanced forms of systemic connective tissue disease such as lupus erythematosus, especially with concomitant vasculitis, leading to renal failure and uremia may be conducive to calcyphylaxis. We are presenting a case of a 50-year-old male requiring chronic peritoneal dialysis since the age of 43, due to end-stage renal disease resulting from chronic glomeluronephritis. The patient presented to our Dermatology Department with large and painful coalescent cutaneous lesions on both lower extremities, fingertips and lips. Both clinical picture and disease history indicated systemic vasculitis that was previously unrecognized. Additional examinations revealed the following markers of inflammation: leukocytosis (11 G/I) with normal level of eosinophils, CRP > 0.6 mg/I, ESR 120 mm/h, and IgG 20 g/l, without any source of infection. Indirect immunofluorescence showed the absence of antineutrophil cytoplasmic antibodies (ANCA) on polynuclear leucocytes. A distinct fluorescence pattern observed in liver sinusoids was suggestive of the presence of some form of anti-granulocyte antibodies. Anti-nuclear antibodies (ANA) were detected in serum (1:1000) with homogenous and microgranular fluorescence pattern. Anti-extractable nuclear antigen panel (ENA), C3/C4 levels, anti-smooth muscle, anti-dsDNA and anti-glomerular basement membrane (GBM) antibodies were within normal limits. Lupus band test revealed IgA and IgG deposits at the dermis-epidermis junction. Histopathological examination of the skin showed calcification complicated by small vessel thrombosis, however, it was non-specific for vasculitis. Our case represents an example of calcyphylaxis associated with a widespread medial vascular calcification in a patient with end stage renal disease secondary to systemic lupus erythematosus. Although renal dialysis itself is known to trigger calcyphylaxis, there have been few reports in literature suggesting that collagen vascular disease may also contribute to this process.

[The importance of bisoprolol in prevention of heart left ventricular hypertrophy in patients with long term L-thyroxin suppressive therapy, after the operation of differentiated thyroid carcinoma]

INTRODUCTION

Patients with differentiated thyroid carcinoma have to undergo radical surgical treatment, which includes total thyreoidectomy, radioiodine therapy and a life-time suppressive therapy with L-thyroxine. The aim of this study was a prospective evaluation of left ventricular hypertrophy during L suppressive-thyroxine treatment in patients treated for differentiated thyroid carcinoma.

MATERIAL AND METHODS

The examined group comprised 50 patients with differentiated thyroid carcinoma, treated by total thyroidectomy and 131I therapy. Echocardiographic measurements were needed for estimation of left ventricular mass and its index, according to recommendations of American Echocardiography Society.

RESULTS

During two-years long suppressive therapy we observed a significant rise in left ventricular mass. In woman group left ventricular mass was increased from 168+/-39 g to 204+/-45 g (p<0.001) and in men from 205+/-60 to 320+/-21 g. Likewise, left ventricular mass index was increased in women group from 96+/-18 g/m(2) to 116+/-25 g/m(2) (p<0.001) and in men group from 107+/-37 g/m(2) to 158+/-28 g/m(2). Simultaneous treatment with bisoprolol caused a regression of left myocardial hypertrophy. Already after 6 months of simultaneous treatment with L-thyroxin and bisoprolol, for left ventricular mass was reduced to normal: in woman 165+/-35 g, and in men to 178+/-38 g. Analogous results were obtained left ventricular mass index. After 6 months it was reduced to 94+/-12 g/m(2) in woman and in men to 132+/-32 g/m(2).

CONCLUSIONS

1. In differentiated thyroid cancer patients, treated postoperatively with L-thyroxine suppressive therapy, left ventricular hypertrophy is observed already during the first year of suppressive therapy and progresses during the next year of treatment. 2 Addition of a beta-adrenergic antagonist to suppressive doses of L-thyroxine causes a regression of left ventricular hypertrophy, thus, beta-adrenergic antagonists should be administered in this group of patients.

[Evaluation of effects of L-thyroxine therapy in differentiated thyroid carcinoma on the cardiovascular system --prospective study]

Patients with differentiated thyroid carcinoma are treated by thyreoidectomy, followed by radioiodine treatment. A life-time suppressive therapy with L-thyroxine is also indicated. However, it may cause cardiovascular side effects. The aim of the study was a prospective evaluation of the left ventricle hypertrophy in patients treated with suppressive doses of thyroxine. A significant rise in left ventricular mass and mass index was noted during the first year of therapy and could be prevented by a simultaneous treatment with low doses of bisoprolol.

[Effects of L-thyroxine suppressive therapy on cardiac mass in patients with differentiated thyroid cancer]

Patients with differentiated thyroid carcinoma (DTC) receive a life time l-thyroxine therapy in suppressive doses and may exhibit signs of cardiac hypertrophy. The aim of the study was to analyze the left ventricle mass parameters by echocardiography in patients treated with suppressive doses of thyroxine and to relate them to the possible occurrence of cardiac arrhythmias. Ninety four patients aged 19-70 years treated chronically with l-thyroxine were randomly chosen from the population of patients with DTC without concomitant diseases of circulatory system. They were divided into two subgroups according to the length of thyroxine therapy (< 60 months and > or = 60 months). Control group consisted of 41 healthy volunteers, aged 22-73 years. Heart muscle dimensions were measured by echocardiography. Left ventricle mass (LVM) and mass index (LVMI) was calculated. Electrocardiography according to Holter was carried out in 57 patients. The results of echocardiography in the whole group of patients did not differ significantly from the control group, although a tendency towards higher dimensions of the left ventricle was observed. No correlation of hormonal parameters, or thyroxine dose, with LVM or results of Holters ecg was noted. When patients were subdivided into two groups, according to the duration of therapy, significantly higher values of LVM (215 +/- 64 g versus 186 +/- 55; p < 0.05) and LVMI (114 +/- 31 g/m versus 102 +/- 23 g/m; p < 0.05) were observed in patients treated > or = 60 months in comparison to the control group. When results of Holter's ecg in patients with increased LVMI were analyzed, cardiac rhythm disturbances were stated in 50% of them, but most were of minor clinical relevance. Suppressive l-thyroxine therapy does not induce significant left heart hypertrophy during the first 5 years of treatment. Patients treated through a longer period of time should be controlled by echocardiography because of the increasing risk of the left ventricle hypertrophy and arrhythmia.

[Insulin-like growth factor-I: pathophysiologic and clinical aspects]

The paper reviews the factors which affect synthesis and metabolic activity of the insulin-like growth factor-I (IGF-I), its receptor and binding proteins as age, nutritional state, hormonal state and liver function. Attention is also focused on the role of IGF-I in pathogenesis of osteoporosis and neoplastic diseases.