Rare Presentation of a Metastatic Pancreatic Neuroendocrine Neoplasm Presenting with Atrial Flutter

Pancreatic neuroendocrine neoplasms (PanNENs) rarely secrete serotonin, which is the main cause of carcinoid syndrome. One of its unusual manifestations is carcinoid heart disease or Hedinger's syndrome which is seldom accompanied by cardiac arrhythmias. We report the case of an 88-year-old woman who presented with recently experienced episodes of palpitations and a newly developed atrial flutter with a ventricular rate of 130 beats per minute. Echocardiography revealed thickened and tethered tricuspid and pulmonary valve leaflets causing severe valvular regurgitation and right ventricular dilatation. Episodes of intermittent diarrhoea over the previous 2 years were mentioned, making carcinoid syndrome our working diagnosis. The 5-hydroxyindoleacetic acid (5-HIAA) levels in a 24-hour urine collection specimen were elevated. Conventional imaging studies and a Ga-68 dodecane tetraacetic acid tyrosine-3-octreotate (DOTATATE) positron emission tomography/computer tomography (PET/CT) scan revealed the presence of a metastatic PanNEN arising from the pancreatic tail. The patient was managed with lanreotide and telotristat with remarkable improvement of her symptoms. To our knowledge, this is the first reported case of carcinoid syndrome presenting with atrial flutter as the initial symptom.

LEARNING POINTS

Ultrasonography findings can indicate or lead to the diagnosis of carcinoid heart disease or Hedinger's syndrome.Clinicians should investigate rarer causes of atrial flutter when common ones are excluded.Even in advanced metastatic disease, complete remission of symptoms may be achieved with somatostatin analogues along with telotristat ethyl.

Early rheumatoid arthritis: does gender influence disease expression?

OBJECTIVE

To investigate whether gender is an independent factor associated with disease expression in early rheumatoid arthritis (RA) patients.

METHODS

438 patients with early RA (disease duration less than one year) were studied. They all were patients with early RA who presented at the Rheumatology Clinic of the University Hospital of Ioannina during the period 1991-2000. All patients fulfilled the American College of Rheumatology criteria for RA. The demographic, clinical, laboratory, radiological and therapeutic characteristics of the disease at diagnosis, and at the last follow-up were analyzed according to gender.

RESULTS

We studied 312 women and 126 men with early RA. The female to male ratio was 2.5:1 and the mean age at diagnosis was 49.4 +/- 14.9 years for women and 55.3 +/-15.6 years for men (P < 0.0003). Women had a longer duration of follow-up (P < 0.0003). There were no differences between genders in the general symptoms or the simmetricity of joint involvement at at disease onset. However at disease onset women had a higher erythrocyte sedimentation rate (ESR) (> 30 mm/1st hour), although there were no significant differences between the two groups concerninig the rest of the clinical, laboratory and radiological findings. At the last follow-up women still had a higher ESR (>30 min/1st hour), but no significant differences were found between the two groups concerning the rest of the parameters investigated independently of the follow-up duration. Finally, women and men showed the same degree of radiological changes and functional ability and were treated similarly except for the more frequent use of hydroxychloroquine in women.

CONCLUSION

It seems that gender does not signficantly influence the expression of RA.

Early rheumatoid arthritis patients: relationship of age

The aim of this study was to investigate if age at disease onset comprises a separate parameter for disease expression, prognosis, and outcome in early rheumatoid arthritis (RA) patients. Four hundred thirty-eight patients with early RA (disease duration less than 1 year) were studied. All of them fulfilled the American College of Rheumatology criteria for RA. The demographic, clinical, laboratory, radiologic, and therapeutic characteristics of the disease at diagnosis and during and at the end of follow-up (time period 1981-2000) were analyzed according to age at disease onset (young patients aged less than 60 years at disease onset vs elderly patients aged more than 60 years at disease onset). We found 317 young and 121 elderly patients with early RA. The male:female ratio, which was 1:3.2 in the young patients, was nearly equal in the elderly (1:1.4). In addition, at disease onset elderly patients showed more severe joint involvement (decreased grip strength) associated with high titers of acute phase response (erythrocyte sedimentation rate and C-reactive protein) than the younger patients. However, there were no differences between the two groups in the numbers of tender and swollen joints or acute phase response at the end of the study period. Furthermore, no differences were seen between the two groups concerning the presence of rheumatoid factor. Finally, the two patient groups showed the same degree of radiological changes and functional ability and were treated similarly, except for more frequent corticosteroid use in the elderly. We conclude that elderly patients present with more severe joint involvement at disease onset. However, at the end of the study, no differences were seen concerning radiological changes and functional ability. It seems that age at disease onset does not influence the clinical course and outcome of early RA patients.

Shared epitopes and rheumatoid arthritis: disease associations in Greece and meta-analysis of Mediterranean European populations

OBJECTIVES

To assess the strength of the associations between HLA shared epitopes (SE) and rheumatoid arthritis (RA) susceptibility, articular disease severity, and extra-articular features in Mediterranean European populations.

METHODS

One hundred and seventy-four Greek RA patients and 103 controls were evaluated. Data were then included in a meta-analysis of 9 studies of Mediterranean European populations (959 RA patients and 1,405 controls).

RESULTS

In our study population, SE alleles were significantly more common in RA patients than in controls (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.4-4.3). Larsen radiologic score was predicted by SE and disease duration. SE did not increase the risk of any extra-articular manifestation. The meta-analysis showed a pooled OR of 3.7 (95% CI, 2.6-5.2) for susceptibility to RA conferred by SE (OR, 3.4 v 3.9 in Greek v non-Greek populations).

CONCLUSIONS

SE determine articular destruction without increasing the risk of extra-articular manifestations. The immunogenetic associations of RA susceptibility are consistent, but their strength may depend on the SE prevalence in different ethnic groups.

Disease modifying antirheumatic drugs in early rheumatoid arthritis: a longterm observational study

OBJECTIVE

To investigate the effectiveness, toxicity, and drug survival in an observational longterm study of patients with early rheumatoid arthritis (RA).

METHODS

Four hundred twenty-eight patients with early RA were investigated between January 1987 and December 1995. All patients had a disease duration of less than one year and had not been previously treated with any disease modifying antirheumatic drug (DMARD). The following drugs were introduced at the doses specified: hydroxychloroquine (HCQ) (200-400 mg/day), D-penicillamine (D-Pen) (500 mg/day), sulfasalazine (SSZ) (2-3 g/day), auranofin (6 mg/day), intramuscular gold (IM gold, 50 mg/week), methotrexate (MTX) (0.15 mg/kg/week, per os), cyclosporin A (CSA) (3 mg/kg/day), azathioprine (AZA) (2-3 mg/kg/day), cyclophosphamide (CYC) (1-2 mg/kg/day).

RESULTS

Three hundred eighty-three patients were treated with one DMARD for at least 6 months. Sixty-five percent of patients were seropositive. The disease duration was 9.2 (3.1) months and the followup period of 12.7 (4.8) years, ranging from 7 months to 13 years. The drugs of first choice were: D-Pen (32%), HCQ (30%), MTX (21%), CSA (8%), and IM gold (7%). After the 2nd, 3rd, and 4th prescriptions, MTX was the most popular drug (27%), while D-Pen and HCQ were prescribed less frequently. The longest drug survival was seen in MTX treated patients, followed by CSA, without significant differences between them. D-Pen, HCQ, and IM gold had the largest dropout rate. The main causes for drug discontinuation were drug inefficacy (HCQ), followed by adverse drug reactions (D-Pen).

CONCLUSION

It appears that MTX has the longest survival time, with CSA following in second place. The main reasons for discontinuation of treatment were drug inefficacy, followed by adverse drug reactions.

Clinical course and outcome of early rheumatoid arthritis

We studied whether patients with seropositivity in early rheumatoid arthritis (RA) comprise a different clinical group than those with seronegativity. Four hundred seventeen patients with early RA according to the American College of Rheumatology criteria (disease duration less than 1 year) were retrospectively studied by analysis of demographic, clinical, laboratory, radiological, and therapeutic disease characteristics from the time of diagnosis until the end of the study period (1981 1999) using a data base. There were 248 seropositive patients and 169 seronegative patients with RA. No statistically significant differences were seen between the two groups before commencement of the study period in relation to age of disease onset, male:female ratio, and disease duration. However, seropositive patients showed longer medical follow-up. In addition, at disease onset, seropositive RA patients presented more frequently with symmetrical polyarthritis and small joint involvement than seronegative patients. The seropositive group also had more tender and swollen joints, weaker grip strength, and higher erythrocyte sedimentation and C-reactive protein rates during the follow-up period. In contrast, the seronegative group had less severe radiological findings and greater functional ability at the end of the study. In Greek patients with early RA, rheumatoid factor seems to be a predictor of more severe disease activity.

Treatment of fibromyalgia with tropisetron, a 5HT3 serotonin antagonist: a pilot study

In this pilot study we investigated 10 women suffering from primary fibromyalgia. All patients received 5 mg of tropisetron in the evening, for a period of 4 weeks. Clinical disease variables included the measurement of a pain score, fatigue, sleep disturbances and measurement of the number of tender points. Five of our patients (50%) showed a statistical clinical improvement of all the above parameters starting after the first week of treatment. Two patients did not respond to the therapy and three discontinued the study because of side-effects. We conclude that administration of tropisetron in fibromyalgia patients could be useful in the management of this difficult and incurable syndrome.

Cyclosporine A in the treatment of early rheumatoid arthritis. A prospective, randomized 24-month study

OBJECTIVE

To investigate the efficacy, tolerability and safety of cyclosporine A (CSA) in early rheumatoid arthritis (RA) patients.

METHODS

Patients with an early diagnosis of RA, a disease duration of less than 3 years, and without prior disease modifying antirheumatic drug (DMARD) treatment were studied. They randomly received oral CSA (3 mg/kg/day) or oral methotrexate (MTX) (0.15 mg/kg/week). In addition, all patients in both groups received oral prednisone (7.5 mg/day).

RESULTS

Fifty-two patients were assigned to the CSA group and 51 to the MTX group. After 24 months of treatment, 48 patients from the CSA group and 48 from the MTX group showed significant clinical improvement. This was evaluated by the duration of morning stiffness, grip strength, the total joint count, joint swelling, and joint tenderness and pain, compared to pre-treatment values. The clinical improvement was also associated with a significant decrease in ESR and CRP values in both groups. No significant radiological deterioration was observed in the CSA patients compared to those treated with MTX after 24 months. Four patients from the CSA group dropped out of the study, two because of a synovitis flare, one because of severe hypertrichosis and one because of severe gingival hyperplasia. Three patients from the MTX group withdrew, one because of disease flare-up and two because of gastrointestinal disturbances.

CONCLUSION

Early immunointervention in RA patients appears to be crucial to limit the development of joint damage. Cyclosporine A appears to be effective, well tolerated and safe in the long-term treatment of RA and can therefore be used as a first immunomodulatory drug in the armamentarium for the treatment of RA.

Late treatment of brachial plexus palsy secondary to birth injuries: rotational osteotomy of the proximal part of the humerus

We retrospectively reviewed the results of rotational osteotomy that had been performed distal to the surgical neck of the humerus in twenty-two patients who had sustained an injury of the brachial plexus at birth. Eighteen patients had a lesion of the superior trunk of the brachial plexus (the fifth and sixth cervical nerve roots), and four had involvement of the entire brachial plexus. The patients ranged in age from four to seventeen years old (average age, ten years and three months old) at the time of the operation. The average duration of follow-up was fourteen years (range, two to thirty-one years). Preoperatively, the patients had been unable to perform self-care activities, such as grooming, feeding, and washing themselves, because of limited active external rotation or fixed internal rotation of the shoulder. All patients had decreased strength of the lateral rotator and abductor muscles and normal strength of the subscapularis and pectoralis major muscles. Radiographs showed some flattening of the humeral head, and four patients had posterior subluxation of the humeral head. A lateral rotational osteotomy of the proximal part of the humerus was performed between the insertions of the subscapularis and pectoralis major muscles. The site of the osteotomy was stabilized with catgut sutures in the periosteum in ten patients and with one or two staples in twelve. The extremity was immobilized in a plaster shoulder-spica cast for six weeks. At the latest follow-up evaluation, the average increase in active abduction was 27 degrees (range, 0 to 60 degrees) and the average increase in the arc of rotation was 25 degrees (range, 5 to 85 degrees). Supination of the forearm also had increased commensurate with the increase in external rotation. The appearance of the extremity had improved as well.