Picture Quiz: Abdominal Pain in a patient receiving low molecular weight heparin

A 63 year old lady with known ischaemic heart disease was admitted to hospital with cardiac sounding chest pain. Blood pressure was 161/80 on admission, and full examination was unremarkable. ECG showed ischaemic changes in the inferior leads, and a diagnosis of unstable angina was made. Troponin I was undetectable. She was treated with subcutaneous Enoxaparin 1.5mg/kg and an intravenous nitrate infusion. Her pain settled the following day, allowing the nitrate infusion to be weaned off, although the Enoxaparin treatment was continued, pending a cardiology opinion. On the third day after admission she collapsed on the ward with a blood pressure of 95/59mmHg; examination revealed lower abdominal tenderness with a mass in the right iliac fossa. Blood tests showed that her haemoglobin had dropped by 5 grams/decilitre,she underwent urgent abdominal ultrasound followed by CT.

Picture quiz (answer)

Subcutaneous low molecular weight heparins are widely used in hospitalised patients for the treatment of DVT, pulmonary embolism and acute coronary syndromes, as well as for thromboprophylaxis. Rectus sheath hematoma is a recognised, but sometimes misdiagnosed, complication of treatment with anticoagulant therapy,1 including full and prophylactic doses of low molecular weight heparin.

Pneumocystis carinii pneumonia complicating low dose methotrexate treatment for psoriatic arthropathy

A case of Pneumocystis carinii pneumonia complicating low dose methotrexate treatment for psoriasis and psoriatic arthropathy is described. This potentially fatal event was probably precipitated by an interaction between methotrexate and concurrent non-steroidal anti-inflammatory drugs, resulting in serious potentiation of the effects of methotrexate.

Effect of naproxen on renal haemodynamics in elderly patients with arthritis

The effects of naproxen on renal haemodynamics were observed in ten elderly arthritic patients who were otherwise healthy and without clinical evidence of renal disease. Glomerular filtration rate (GFR,51Cr-EDTA clearance) and effective renal plasma flow (ERPF, 125I-iodohippurate clearance) were measured after 2 weeks' treatment with naproxen 500 mg twice daily and again after 2 weeks off the drug, in random order. Baseline values for GFR and ERPF were within normal limits (mean 72 ml/min/1.73 m2, 110% predicted and 326 ml/min/1.73 m2, 111% predicted, respectively). On naproxen, ERPF and renal blood flow decreased by 10% and 9%, respectively (-32 ml/min/1.73 m2; p = 0.05 and -49 ml/min/1.73 m2; p less than 0.01). These events produced no untoward clinical effects. Nevertheless, this response might impair the kidney's ability to preserve GFR if a further stress were to supervene. Consequently, temporary withdrawal of non-steroidal anti-inflammatory drugs from elderly patients should be considered in response to intercurrent illness or drug therapy likely to compromise renal blood flow.

Thrombocytosis of active rheumatoid disease

Two cross-sectional and one longitudinal study of patients with rheumatoid arthritis showed that platelet number correlated with both clinical and laboratory parameters of disease activity, including erythrocyte sedimentation rate, zeta sedimentation ratio, viscosity of plasma and blood, white cell count, liver enzymes, rheumatoid factor, and several acute-phase proteins. There was also an inverse relationship between platelet number and the haemoglobin and serum albumin levels. III Indium-labelled platelet survival was reduced in 4 patients with active rheumatoid arthritis despite a raised platelet count, with labelled platelets being localised to inflamed joints in the 2 patients studied. Platelet aggregation was normal. We suggest that the raised platelet count of active rheumatoid arthritis may be a useful index of disease activity and may represent a bone marrow stress (syndrome) response to shortened platelet survival, with platelet sequestration occurring in areas of synovial inflammation.

A comparison between clinical and laboratory tests in rheumatoid arthritis

Five clinical measurements (clinical score, articular index, visual analogue pain score, visual analogue function score, grip strength) were compared with two laboratory tests (the erythrocyte sedimentation rate and serum C-reactive protein concentration) in 68 patients with rheumatoid arthritis (RA). Patients treated with nonsteroid anti-inflammatory drugs showed clinical deterioration when treatment was interrupted, followed by improvement on resumption; there was no change in the laboratory tests. Patients treated with remission-inducing drugs (RIDs) had improved clinical measurements and also reduced erythrocyte sedimentation rate and serum C-reactive protein levels. Treatment with RID's led to similar trends in both clinical and laboratory tests, but correlation coefficients between the tests at intervals rarely attained statistical significance. The different response times for each test and probably also errors inherent in clinical measurements introduced sufficient variability to account for the discrepancy. Of the clinical tests, 'clinical score' appeared the most satisfactory.

A pharmacist's audit of antirheumatic drugs

The results of an audit, by a hospital pharmacist, of antirheumatic drug use at four rheumatology units are presented. Profiles can be developed for each drug which indicate their efficacy and the adverse reaction rate in clinical practice. These can be used to make rational therapeutic choices. A pharmacist can effectively collate such data to provide an unbiased information source.

Rheumatoid arthritis: effects of a new agent (ICI 55 897) on serum acute phase proteins and the erythrocyte sedimentation rate

Thirty-four patients with rheumatoid arthritis (RA) were treated with a new agent (ICI 55 897) in addition to basic therapy with nonsteroid anti-inflammatory drugs. Five patients had the drug for less than 28 days; the remaining 29 were observed for periods up to a year. At 140 days, when all but 2 patients were in the study, there had been statistically significant improvement in clinical score, serum C-reactive protein, erythrocyte sedimentation rate, and plasma fibrinogen. Thereafter results continued to improve but were biased because some patients had stopped taking the drug. The final conclusion was that 17 patients had improved with 1 late relapse, and 15 had not responded. Adverse effects were trivial except in 2 instances: one patient had a transient unexplained rise in blood urea, another had a haematemesis. Neither effect could be attributed with certainty to the drug. ICI 55 897 has no intrinsic analgesic or anti-inflammatory properties. We suggest the findings of this study indicate that this agent, with low toxicity and the ability to lower acute-phase protein levels, may be an alternative to gold or penicillamine in the treatment of RA.

Effects of gold, dapsone, and prednisone on serum C-reactive protein and haptoglobin and the erythrocyte sedimentation rate in rheumatoid arthritis

Sequential measurements of serum C-reactive protein (CRP), serum haptoglobin (Hp), and erythrocyte sedimentation rate (ESR) were made in 209 patients with rheumatoid arthritis (RA); 78 of them were treated with gold, 71 with dapsone, and 60 with prednisone. The results were expressed as proportional changes in the measurements at 28-day intervals after treatment began. The period of study was 140 days. During treatment with gold and dapsone there were statistically significant gradual and progressive falls of similar magnitude in serum CRP and ESR. During treatment with prednisone serum CRP and ESR fell abruptly by 28 days and thereafter altered little. At 140 days prednisone had had the largest proportional effect on both measurements. During gold treatment the fall in serum Hp was similar to that of the ESR. In contrast, prednisone had little effect on Hp levels despite large falls in serum CRP and the ESR. Either prednisone stimulates Hp synthesis or the divergence is an expression of the difference in type of effect between gold and prednisone on RA. The effect of dapsone on serum Hp was large and progressive; it partly reflects haemolysis and, since the haemolysis was not progressive, partly improvement in the RA. The results show the relative efficacy of the drugs and suggest that dapsone may be a useful alternative treatment for RA.

Pulmonary hypertension complicating portal vein thrombosis

Images

Rheumatoid arthritis: relation of serum C-reactive protein and erythrocyte sedimentation rates to radiographic changes

Serum C reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR) were measured in 56 patients with rheumatoid arthritis. Radiographical damage, based on a count of erosions, was significantly more likely to occur when serum CRP and ESR were persistently raised, irrespective of the presence or absence of rheumatoid factor. Measurements of both CRP and ESR were more helpful than either alone, but CRP was probably the more informative. Serial measurements of CRP and ESR provide a reliable means of discriminating between drugs that provide symptomatic relief only and those with a more profound effect in rheumatoid arthritis.

Dapsone in rheumatoid arthritis

After a preliminary period of observation, 71 patients with consistently active rheumatoid arthritis (RA) were given dapsone 50 mg daily for one week, then 100 mg daily. There was a significant improvement in subjective clinical state and there were significant falls in serum C-reactive protein (CRP) and the ESR; the Rose-Waaler titre (RW) did not fall. The results were compared with those in 78 patients who had gold. Subjective clinical improvement was slower with gold, but from six weeks the pattern of changes in clinical score, CRP and ESR was similar for both drugs. The RW fell during gold treatment. The results suggest dapsone is effective in RA; over-all it appears to be slightly less effective than gold but much less toxic.