Acute abdominal complications of systemic lupus erythematosus and polyarteritis nodosa

Fifteen (11 percent) of 140 patients with systemic lupus erythematosus (SLE) and five (31 percent) of 16 patients with polyarteritis nodosa (PA) developed disease-related signs and symptoms of an acute surgical abdomen. Peripheral vasculitis (p less than 0.025), nervous system involvement (p less than 0.05), ischemic necrosis of bone (p less than 0.05), thrombocytopenia (p less than 0.01), and circulating rheumatoid factor (p less than 0.01) are all significantly more prevalent in patients with SLE and abdominal involvement compared with those without an abdominal syndrome. Similarly, except for ischemic necrosis of bone, these same features are more prevalent in patients with PA and acute abdomens. Eleven (73 percent) of 15 patients with SLE had exploratory laparotomy for acute abdominal events. Nine were found to have evidence of intra-abdominal arteritis and only two had polyserositis without gross evidence of vasculitis. Eight (53 percent) of the 15 patients with SLE and acute abdomens died as a result of their abdominal crises. Six of the seven surviving patients represent those most recently seen and aggressively treated. All five patients with PA and acute abdomens required operative intervention and all had gross evidence of mesenteric arteritis with large ischemic segments resulting in infarction and perforation. All died in contrast to only two (18 percent) of the 11 PA patients without abdominal involvement.

Syndrome and pancreatic disease, subcutaneous fat necrosis and polyserositis. Case report and review of literature

Immunologic evaluation of a patient with pancreatitis, subcutaneous fat necrosis, pleuritis, pericarditis and synovitis is presented. The previously recognized syndrome of pancreatic disease, subcutaneous fat necrosis and arthritis is reviewed. Based on analysis of all the cases described in the English language literature it is suggested that this syndrome be expanded to include polyserositis rather than arthritis alone. Although experimental and clinical evidence tends to implicate physiocochemical tissue injury by pancreatic lipase as the primary pathogenic mechanism in this syndrome, studies in our patient suggest the possible contribution of immune-mediated injury. Supporting data include eosinophilia, biopsy demonstration of vasculitis antedating the subcutaneous fat necrosis, immunofluorescent identification of immunoglobulin G (IgG) and C3 in the pleura, and reduced levels of total hemolytic complement in the serum, and pleural and pericardial effusions.

Subacute cutaneous lupus erythematosus versus systemic lupus erythematosus: diagnostic criteria and therapeutic implications

BACKGROUND

The nosologic position of subacute cutaneous lupus erythematosus (SCLE) is controversial. More than four American Rheumatism Association (ARA) criteria for systemic lupus erythematosus (SLE) are found in a proportion of patients diagnosed as having SCLE; thus such cases could be classified as SLE.

OBJECTIVE

Our purpose was to determine whether ARA criteria for SLE are helpful in differentiating SCLE from SLE and whether cutaneous and visceral changes, immunologic findings, and photosensitivity provide a basis for diagnosis of SCLE.

METHODS

A cohort of 143 patients (79 with SCLE, 58 with SLE, and six with overlapping features of SCLE and SLE) was studied clinically, histologically, and immunologically as well as by phototesting. The patients were observed for up to 10 years, and the course of the disease and response to therapy were evaluated in each group.

RESULTS

SCLE differed from SLE by cutaneous changes, significantly less frequent kidney involvement, serositis and arthritis, and the rare presence of double-stranded DNA, U1RNP, and Sm antibodies characteristic of SLE. Ro(SS-A) and La(SS-B) antibodies were detected with similar frequency, and photosensitivity was not related to the presence of Ro antibody. In contrast, photoreproduction (appearance of LE lesion in irradiated area) was significantly more frequent in patients with SCLE. The course of SCLE in older patients was less severe than in younger patients, and aggressive therapy was usually not required.

CONCLUSION

Patients with SCLE (although the majority fulfill more than four ARA criteria for SLE) show significant differences from those with SLE in terms of cutaneous and visceral involvement, immunologic findings, photosensitivity, course of the disease, and the requirement for therapy. Therefore SCLE should be recognized as a separate subset. However, cases of overlapping SLE and SCLE suggest a close relation.

Osteosclerotic "plasmocytoma" with polyneuropathy, hypertrichosis and diabetes

The combination of osteosclerosis, polyneuropathy, monoclonal immunoglobulin, hypertrichosis, serositis and a number of other symptoms is described. It seems probable that this is a special type of myeloma. Similar cases have been described in Japan and out findings are compared with the Japanese picture. The age of the patients is unusually low. The M-component in the plasma is small. There is very little Bence Jones protein in the urine and osteolytic lesions in the skull do not seem to have occurred. The polyneuropathy may improve during treatment with cytostatic drugs.

Splenectomy in homozygous beta thalassaemia: a retrospective study of 30 patients

In order to clarify the indications for splenectomy in patients with homozygous beta thalassaemia we studied, retrospectively, the basal pre-transfusion haemoglobin levels and blood transfusion requirements before and after splenectomy, in a series of patients with this disorder. Thirty-six patients, of whom 20 underwent splenectomy, were included in this study. Three groups of patients with homozygous beta thalassaemia were identified on the basis of clinical and laboratory findings. Two of the three groups consisted of 24 patients with beta thalassaemia major, subdivided retrospectively according to their response to splenectomy. The third group consisted of six patients with beta thalassaemia intermedia who had a comparably mild clinical course. In the first group of 16 patients with beta thalassemia major, monthly transfusions were required from the age of 6 months to 24 months and splenectomy resulted in temporary improvement for a period of 1-2 years. Thereafter, the transfusion requirements returned to pre-operative levels with no sustained improvements in base-line pretransfusion haemoglobin levels. Despite the fact that haematological improvement was temporary, it is felt that splenectomy is indicated in this group since the development and the general well-being of the children was significantly improved. In the second group of eight patients with beta thalassaemia major, transfusion requirements were relatively infrequent before 1-2 years, but after several years the transfusion requirement increased simultaneously with the development of 'hypersplenism'.

Utility of T-cell interferon-γ release assays for diagnosing tuberculous serositis: a prospective study in Beijing, China

BACKGROUND

Diagnosis of tuberculous serositis remains a challenge. The aim of this study was to evaluate the diagnostic efficiency of T-SPOT.TB on serous effusion mononuclear cells (SEMC) for diagnosing tuberculous serositis in a high TB burden area.

METHODS

The present prospective study enrolled patients with suspected tuberculous serositis in a tertiary referral hospital in Beijing, China, to investigate the diagnostic sensitivity, specificity, predictive value (PV), and likelihood ratio(LR) of these tests. Clinical assessment, T-SPOT.TB on SEMC, and T-SPOT.TB on PBMC were performed. Test results were compared with the final confirmed diagnosis.

RESULTS

Of the 187 participants, 74 (39.6%) were microbiologically or clinically diagnosed as tuberculous serositis and 93(49.7%) were ruled out. The remaining 20 (10.7%) patients were clinically indeterminate and excluded from the final analysis. Compared to that on PBMC, T-SPOT.TB on SEMC showed higher sensitivity (91.9%vs73.0%, P = 0.002), specificity (87.1%vs.73.1%, P = 0.017), PPV (85.0%vs.68.4%, P = 0.013), NPV (93.1%vs.77.3%, P = 0.003), LR+ (7.12vs.2.72) and LR- (0.09vs.0.37), respectively. The frequencies of spot forming cells (SFCs) for T-SPOT.TB on SEMC were 636 per million SEMC (IQR, 143-3443) in patients with tuberculous serositis, which were 4.6-fold (IQR, 1.3-14.3) higher than those of PBMC. By ROC curve analysis, a cut-off value of 56 SFCs per million SEMC for T-SPOT.TB on SEMC showed a sensitivity of 90.5% and specificity of 89.2% for the diagnosis of tuberculous serositis.

CONCLUSIONS

T-SPOT.TB on SEMC could be an accurate diagnostic method for tuberculous serositis in TB endemic settings. And 56 SFCs per million SEMC might be the optimal cut-off value to diagnose tuberculous serositis.

Arthritis Rounds: Ascites as the major manifestation of systemic lupus erythematosus

It is uncommon for ascites secondary to severe peritoneal inflammation to be the major manifestation of systemic lupus erythematosus. Chronic nonspecific inflammation with a granular type immunofluorescent staining along the mesothelial layer of the peritoneum and peritoneal blood vessels was demonstrated in peritoneal tissue obtained at laparotomy. Paramyxovirus-like structures were seen within vascular endothelium. The ascites diminished with high-dose prednisone and cyclophosphamide therapy.

Clinical analysis of 61 systemic lupus erythematosus patients with intestinal pseudo-obstruction and/or ureterohydronephrosis: a retrospective observational study

The objective of this article is to investigate the clinical features of intestinal pseudo-obstruction (IPO) and/or ureterohydronephrosis in systemic lupus erythematosus (SLE). Sixty-one SLE patients with IPO and/or ureterohydronephrosis were analyzed retrospectively. A total of 183 cases were randomly selected as controls from 3840 SLE inpatients without IPO and ureterohydronephrosis during the same period. Patients were assigned to 1 of the 3 groups (SLE with IPO and ureterohydronephrosis, SLE with IPO, and SLE with ureterohydronephrosis). The clinical characteristics, treatments, and prognosis were compared between the 3 groups. There were 57 females and 4 males, with a mean age of 32.0 years. IPO was the initial manifestation of SLE in 49.1% of the cases, whereas ureterohydronephrosis in 32.5%. All patients were initially treated with a high-dose steroid. Thirty-one of these patients (50.8%) also received intravenous methylprednisolone pulse therapy. Two patients died of bowel perforation and lupus encephalopathy, and the other 59 patients (96.7%) achieved remission after treatment. The incidences of fever, glomerulonephritis, nervous system involvement, serositis, erythrocyte sedimentation rate elevation, hypoalbuminemia, hypocomplementemia, and anti-SSA antibody positivity were significantly higher in patients with IPO and/or ureterohydronephrosis than in the control group (without IPO and ureterohydronephrosis). Also, patients with IPO and/or ureterohydronephrosis had higher SLE Disease Activity Index scores than control patients. Compared with SLE patients with IPO, the patients with IPO and ureterohydronephrosis had a significantly higher incidence of gallbladder wall thickening, biliary tract dilatation, and serositis, whereas the patients with ureterohydronephrosis had less mucocutaneous involvement and serositis. Eight of the 47 IPO patients who initially responded well to immunotherapy relapsed; however, all responded well to retreatment with adequate immunotherapy. Of these 8 patients, 4 relapsed following poor compliance and self-discontinuation of steroid or immunosuppressant therapy. The rate of poor compliance with immunotherapy and the number of organ systems involved in patients in the recurrent IPO group were significantly higher than those in the nonrecurrent IPO group. IPO and ureterohydronephrosis are severe complications of SLE. As patients usually respond readily to early optimal steroid treatment, early diagnosis and timely initiation of glucocorticoid are important to relieve symptoms, prevent complications, and improve prognosis.

Elevated levels of serum soluble Fas are associated with organ and tissue damage in systemic lupus erythematosus among Chinese

The aims of the present study are to evaluate the difference of the levels of soluble Fas (sFas) antigen between patients with systemic lupus erythematosus (SLE) and healthy controls and to explore whether sFas has a role in either the disease activity or the organ damage in SLE. Serum levels of sFas were measured in 40 Chinese patients with SLE and 15 age-, gender-, and race-matched healthy controls using double antibody ELISA. SLEDAI scores for disease activity were determined. Data of organ and tissue damage was obtained from clinical records. Serum sFas levels were significantly increased in both more active (mean=8043.8 pg/ml, P<0.001) and less active SLE patients (mean=4820.2 pg/ml, P<0.001) comparing to the healthy controls (mean=3253.4 pg/ml). There was also a significant difference in serum sFas levels between the more active SLE patients and less active SLE patients (P=0.04). But, the levels of sFas didn't correlate with SLEDAI. There was a significant difference in the serum sFas levels between patients with and without CNS disease (mean=9582.6, 6634.5 pg/ml; P=0.007). The same was true when patients with and without renal disease (mean=10972.7, 6520.1 pg/ml; P=0.019), as well as serositis (mean=10385.3, 6709.1 pg/ml; P=0.005) were analyzed. sFas is elevated in sera of SLE patients, especially in patients with active SLE. The elevated levels of sFas in the sera of patients with SLE may be closely associated with damage to the kidneys, central nervous system and serosa. Serum sFas may serve as a predictor of some organ and tissue damage in SLE.

Pericarditis and polyserositis as a side effect of clozapine in an adolescent girl

A case report describes an adolescent girl with a treatment-resistant bipolar disorder, who developed pericarditis and polyserositis while being treated with clozapine. The sparse literature about this rare, severe side effect of clozapine is discussed. Clinical recommendations with regard to monitoring are given. If myocarditis/polyserositis occurs, clozapine has to be discontinued immediately.

A case of erythema nodosum and serositis associated with myelodysplastic syndrome

Myelodysplastic syndrome (MDS) is a heterogenous group of stem cell disorders usually characterized by progressive refractory cytopenias, which could progress to acute myeloid leukemia. MDS may be associated with a wide spectrum of skin lesions, including neoplastic cell infiltration, Sweet's syndrome, pyoderma gangrenosum, erythema elevatum diutinum, vasculitis, and panniculitis. However, erythema nodosum is rarely associated with MDS. Unusual rheumatologic manifestations in patients with MDS also have been reported, which range from asymptomatic serological abnormalities to classic connective tissue disorders such as Sjögren's syndrome, relapsing polychondritis, systemic lupus erythematosus, rheumatoid arthritis and mixed connective tissue disease. However, concurrent erythema nodosum and serositis has rarely been reported. We describe a case of MDS with erythema nodosum and immune-mediated pericardial effusion in a 34-year-old woman.

Castleman disease mimicking systemic lupus erythematosus: A case report

RATIONALE

Castleman disease (CD) is a nonclonal lymphoproliferative disorder sometimes manifested systemic inflammatory symptoms. Systemic lupus erythematosus (SLE) is an autoimmune disease characterized with multi-system involvement as well as broad spectrum of serum autoantibodies. When these two conditions happened to have similar clinical spectrum features, the confusion with each other occurred.

PATIENT CONCERNS

A 46-year-old man suffered from chronic fever, nephrotic syndrome, acute kidney injury, anemia, thrombocytopenia and serositis, as well as hypocomplementemia and negative anti-nuclear antibody.

DIAGNOSES

Meeting the classification criteria for SLE, the patient was diagnosed as SLE at first. The renal biopsy showed that he had endocapillary proliferative glomerulonephritis with negative immunofluorescence. Finally, he was diagnosed with CD after lymph nodes biopsy.

INTERVENTIONS

The patient was treated with oral prednisone (50 mg daily) but got poor response. After being proved to have CD, he was treated with CHOP chemotherapy.

OUTCOMES

His condition was controlled by CHOP chemotherapy. After six course of chemotherapy, the proteinuria disappeared.

LESSONS

If patients, even qualified by classification criteria of SLE, had negative autoantibody or unsatisfied response to the standard treatment, the original diagnosis should be suspected. The biopsy may be help to identify the final criminals, such as CD.

Polyserositis in adult Still's disease with onset during pregnancy [corrected]

We report about a 25-year-old female patient, who met all the criteria of adult-onset Still's disease except for the typical nonpruric rash. The disease exacerbated during pregnancy. Polyserositis was the predominant clinical manifestation. The histological examination of the bone marrow biopsy revealed changes similar to those seen in a myelodysplastic syndrome. The clinical condition improved after therapy with high-dose steroids and cyclophosphamide.

Proposed modifications to 1982 ACR classification criteria for systemic lupus erythematosus: serositis criterion

The SLICC group believed that the definition of pleuritis should be expanded to include new pleural thickening and pericarditis to include characteristic history. Furthermore, SLICC suggested the addition of abdominal serositis to the current serositis criterion, manifested as either diffuse abdominal pain, with rebound or guarding, and/or ascites or bowel wall edema in the absence of other causes. Abdominal serositis can be secondary to either acute or chronic lupus peritonitis, with the former usually presenting as acute, generalized pain, and the latter as painless ascites.

Enrollment bias and variation in clinical manifestations: a review of consecutive cases of familial paroxysmal polyserositis

The effect of systematic enrollment bias was studied in a series of 158 patients with familial paroxysmal polyserositis (F.P.P.) from a special clinic in a university hospital. The characteristics of 79 patients seen for the first time at this special clinic in its first 16 months of operation, were compared with the characteristics of 79 patients presented during the last 6 yr of its operation. As a group the patients studied first at the clinic had a more severe form of the disease. This group had a significantly larger number of patients with multiple clinical manifestations, with proteinuria and amyloidosis. In addition, there were more males and more patients with positive family history of the disease in this earlier group. It is probable that much of the temporal variation in these clinical characteristics between patients studied in the earlier and later periods can be explained by case selection originating from differentials in referral patterns. Thus, a larger proportion of the earlier patients were referred following an episode of hospitalization. Differences in referral pattern, in case selection and in the sources of data, can account for the significant variation in the frequency of the various clinical manifestations in the different published F.P.P. case series from several countries. The effect of enrollment bias on the results of clinical studies and the importance of a population base for such studies is emphasized.

Hashimoto's thyroiditis concomitant with sequential autoimmune hepatitis, chorea and polyserositis: a new entity of autoimmune polyendocrine syndrome?

We herein report a case of Hashimoto's thyroiditis (HT) with sequential autoimmune hepatitis (AIH), chorea and polyserositis. The patient was a 24-year-old man who underwent subtotal thyroidectomy due to compression symptoms caused by goiter and was diagnosed with HT postoperatively based on pathological examinations two years previously. He had exhibited liver dysfunction and intermittent chorea since 2008. His liver function and polyserositis improved remarkably following the administration of ursodeoxycholic acid (UDCA) and methylprednisolone. This is a very rare case that can be classified as autoimmune polyglandular syndrome (APS) type 3. Early and adequate UDCA and glucocorticoid treatment may lead to a favorable prognosis.

Pelvic inflammatory disease with periappendicitis in a pediatric patient

Pelvic inflammatory disease (PID) is generally a disease of young, sexually active patients. However, there have been few reports of computed tomography (CT) and the histopathologic findings of periappendicitis with PID in children. We present a case of PID with periappendicitis in a 12-year-old girl. Her CT findings are described, and the histopathologic findings of periappendicitis are discussed.

EBV-associated nasal-type T/natural killer cell lymphoma presenting with polyserositis and rhabdomyolysis

Nasal-type T/natural killer (NK)-cell lymphoma, a distinct clinicopathological entity is highly associated with Epstein-Barr virus which shows an aggressive course. We present a CD56+ nasal-type T/(NK)-cell lymphoma case with systemic manifestations of rhabdomyolysis and polyserositis who died of multiorgan failure shortly after his admission to hospital in spite of adequate chemotherapy and supportive care.