Melioidosis: Missed opportunities and opportunistic pathogens.

A 31-year Indian homemaker, known to have Systemic Lupus Erythematosus (SLE) and lupus nephritis, was admitted previously in another medical care unit with fever, hemoptysis, arthralgia, and joint swelling. She had been treated with antibiotics and corticosteroids for probable diffuse alveolar hemorrhage (DAH) with clinical and radiological resolution. She was readmitted one month later for similar complaints. Her autoimmune workup revealed evidence of active lupus. Her chest imaging showed the presence of well-circumscribed macronodular lesions with halo sign, but Bronchoalveolar Lavage (BAL) cultures and serum galactomannan were negative. BAL tested positive for hemosiderin-laden macrophages. She was treated with corticosteroids, plasmapheresis, and empiric antibiotics with partial clinical response. One week later, her fever recurred, and she developed new-onset myositis. Bactec blood cultures grew Burkholderia pseudomallei. She received treatment for 3 months with good clinical and radiological resolution. In hindsight, a CT-guided biopsy of the lung lesion may have provided an earlier diagnosis of melioidosis.

Cytomegalovirus in Indian systemic lupus erythematosus patients: troublemaker or onlooker?

INTRODUCTION: cytomegalovirus (CMV) infection has been reported to be associated with onset/exacerbation of systemic lupus erythematosus (SLE). In an attempt to verify this, we studied CMV infection in SLE patients. METHODS: forty-two SLE patients were studied at 3-time points; disease onset/flare, at peak of immunosuppression (at 6 weeks) and at low doses of immunosuppression (at 6 months). We studied healthy blood donors as controls, only once. Clinical assessment and SLE Disease Activity Index scoring were done at each visit. RT-PCR and ELISA were performed to detect CMV viral-load and anti-CMV antibodies (Ab) respectively. RESULTS: nine of 106 patients had detectable viral-load (145-50,000 copies/ml). Of these nine, three patients had significant viral-load, 6 patients had low viral-loads of doubtful clinical significance. None of the patients developed CMV disease. Six of 42 cases were positive for IgM Abs. All controls were negative for CMV DNA as well as CMV IgM Abs. All samples from patients and controls were positive for CMV IgG Ab indicating widespread prevalence. CONCLUSION: significantly, a higher seroprevalence of CMV IgM Abs against CMV observed in SLE patients when compared to controls, indicating possible reactivation due to immune modulation.

Role of Right Heart Catheterization in Rheumatologic Diseases - The Indian Perspective.

Pulmonary artery hypertension is an infrequent accompaniment of rheumatologic diseases. It could result as a complication of diseases like systemic sclerosis (SSc), systemic lupus erythomatosus (SLE), and mixed connective tissues diseases (MCTD). Very rarely, rheumatoid arthritis, dermatomyositis and Primary Sjogren's syndrome can also be complicated by a rise in pulmonary artery pressure. Pulmonary artery hypertension (PAH) can also be found in many other non rheumatologic diseases. Right heart catheterization (RHC) is the gold standard investigation in diagnosing pulmonary hypertension. This article aims to discuss the role of RHC in diagnosing pulmonary hypertension, its comparison with other modalities, the procedure, and its role in treatment of connective tissue disorders, especially with a special reference to the Indian context.

Autoimmune hemolysis in malaria: a report of three cases.

We have recently treated three patients with malaria who developed post malaria immune mediated hemolysis. These cases, seen with in a span of three month period (September 09 to November 09) form the basis of this report. Out of three patients, two were treated with steroids and both responded favorably.

Monoclonal gammopathies presenting as inflammatory arthritis: uncommon but important--a case series.

OBJECTIVE: To review the clinical profile of patients with plasma cell dyscrasias presenting with inflammatory arthritis. MATERIAL AND METHODS: Retrospective analysis was performed on clinical, laboratory and imaging data of patients who presented with inflammatory arthritis between May 2009 and April 2010 and were subsequently diagnosed as having plasma cell dyscrasias. Six out of 630 patients presenting with inflammatory arthritis were identified. The demographic, clinical and laboratory characteristics of these patients were analyzed. The diagnosis of monoclonal gammopathy was based on protein electrophoresis, immunoelectrophoresis and bone marrow biopsy. The outcomes of the treatments were analyzed. RESULTS: Four patients had monoclonal gammopathy of unknown significance and two patients had multiple myeloma. Mean age of the patients was 65 years (range 59-74). Three patients presented with oligoarticular arthritis, two with symmetrical polyarticular joint pains and one with fleeting periarticular pains. Wrist and shoulder were the most commonly involved joints. Three patients had carpal tunnel syndrome. Five patients were seronegative for both rheumatoid factor and anti-cyclic citrullinated peptide antibodies. Mean erythrocyte sedimentation rate (ESR) was high in all patients (range: 82-120 mm/h with a mean of 99.6 mm/h). Arthritis improved with chemotherapy in patients with multiple myeloma. CONCLUSION: Occurrence of inflammatory arthritis with plasma dyscrasias is more than a chance association. Plasma cell dyscrasias should be ruled out in any elderly patient presenting with atypical arthritis with disproportionately high ESR, high creatinine and hyperglobulinemia.

Oral cyclosporine therapy for refractory severe vernal keratoconjunctivitis.

We report the success of oral cyclosporine therapy in a patient with severe vision-threatening vernal keratoconjunctivitis. A child presented with severe allergy which was not controlled with topical steroids, cyclosporine and mast cell stabilizers. Oral steroids were required repeatedly to suppress inflammation. Child showed a dramatic improvement and stabilization with oral cyclosporine therapy. Oral cyclosporine therapy can be tried in severe vision-threatening allergy refractory to conventional therapy.

Correlation of HLA B27 subtypes with clinical features of ankylosing spondylitis.

AIM: The aim of the present study was to identify the B*27 subtypes associated with ankylosing spondylitis (AS) in our population and correlate them with clinical features of AS. METHOD: Whole blood samples were collected from 81 HLA-B27 positive AS patients and 29 controls (asymptomatic healthy unrelated individuals) positive for HLA-B27. Clinical details of the patients were recorded which included history of inflammatory back pain, sacroiliitis, spine involvement, enthesitis, peripheral arthritis and uveitis. HLA-B27 subtypes were detected using commercially available techniques. Fisher's exact test was used for statistical analysis. RESULTS: The subtypes observed in AS patients were B*2705 (67.9%, 55/81), B*2704 (28.4%, 23/81), B*2707 (2/81) and B*2702 (1/81). Subtypes in the controls were B*2705 (62.07%, 18/29), B*2707 (27.59%, 8/29) and B*2704 (10.34%, 3/29). Uveitis was observed more in B*2704-positive AS patients (34.78%, 8/23) compared to B*2705-positive AS patients (16.36%, 9/55). However, the difference was not statistically significant (P = 0.130). No major differences were found between B*2705 and B*2704 for other clinical features. CONCLUSION: B*2705 was the main subtype observed in both patient and control groups. Frequency of B*2704 was more in AS patients compared to controls. Occurrence of AS-associated uveitis was more often in B*2704-positive AS patients compared to B*2705-positive ones.

Bisphosphonate-induced osteonecrosis of the jaw.

Bisphosphonates are routinely used in the prevention and treatment of osteoporosis. Osteonecrosis of the jaw is known to be an important but rare complication of bisphosphonate usage. We present our experience with two patients of osteonecrosis of the jaw due to bisphosphonate usage.

Surgically induced necrotizing scleritis after pterygium surgery.

We report a case of surgically induced necrotizing scleritis following pterygium surgery with the bare sclera technique, without the use of adjunctive irradiation or mitomycin C. The patient was successfully treated with systemic immunosuppression.

Nocardiosis in a patient with common variable immunodeficiency.

We report a case of nocardiosis in a 42, years male with common variable immunodeficiency syndrome (CVID). He presented with arthritis, subcutaneous abscess and pleural effusion. Diagnosis of CVID was made during this presentation. Serum IgG, IgA and IgM levels were markedly decreased. Nocardia asteroides was cultured from pleural fluid. He was successfully treated with intravenous immunoglobulin and cotrimoxazole.

Acanthamoeba encephalitis in patient with systemic lupus, India.

We report a fatal case of encephalitis caused by Acanthamoeba in a 24-year-old woman from India with systemic lupus erythematosus. Diagnosis was made by identification of amebas in brain sections by immunofluorescence analysis and confirmed by demonstrating Acanthamoeba mitochondrial 16S rRNA gene DNA in brain tissue sections.