Evaluation of the Association between CD4, CD8 and CD25 Cell Counts and SLE in Active Disease and in Remission.

AIM: To evaluate the correlation between the levels of CD4, CD8 and CD25 cells and SLE disease in active phase and in remission. METHODS: A total of 25 SLE patients, aged between 18-60 years, and fulfilling the ACR criteria with preferential Renal and CNS involvement were included in this study. Baseline CD4/CD8 and CD25 counts, lab parameters etc were conducted. Approximately at the end of 6 months with the settlement of the disease activity blood sample was drawn for the CD4, CD8 and CD25 counts and other lab parameters. RESULTS: ESR showed a statistical significant decrease while the SLEDAI score and proteinuria showed a decreasing trend as the patients underwent remission. The C3 showed an increasing trend, while the C4 showed more or less a stable pattern. Rise in %CD4 and %CD25 count was statistically significant. There was negative correlation between % CD4 count and SLEDAI score, while positive correlation between % CD25 count and SLEDAI score. CONCLUSIONS: %CD4 count is a sensitive, specific, reliable and valid marker of active disease in SLE and can be used to follow disease activity. %CD25 count can also be used as a marker to follow disease activity.

Liposomal amphotericin B (Fungisome) for the treatment of cryptococcal meningitis in HIV/AIDS patients in India: a multicentric, randomized controlled trial.

BACKGROUND: There is need to investigate the use of liposomal amphotericin B in cryptococcal meningitis in India. AIMS: To compare the efficacy, safety, duration of treatment and cost of two doses of liposomal amphotericin B (Amp B) (Fungisome) in cryptococcal meningitis in HIV/AIDS patients. SETTINGS AND DESIGN: Prospective, randomized, multicenter study in tertiary care hospitals across India. MATERIALS AND METHODS: Adult patients with culture-proven cryptococcal meningitis with HIV/AIDS were randomized to receive either 1 (Group A) or 3 mg/kg/day of Fungisome (Group B). Clinical efficacy and tolerability, laboratory evaluations and mycological response were assessed daily, twice weekly and weekly respectively. The patients were assessed at four and eight-week follow-up. STATISTICS: We calculated average and standard deviation for the various parameters. RESULTS: The time to show clinical response was 13.66 days (1 mg) and 9.55 days (3 mg). In Group B (n=6 complete response), 50% patients responded within one week by microbial conversion, 83% in two weeks and 100% in three weeks. Patients with 1 mg dose (n=4 complete response), none showed microbial conversion within one week, 75% responded in two weeks, whereas one patient took four weeks. The average duration of treatment was 36.5+/-14.4 and 26.5+/-5.89 (S.D.) days in 1 and 3 mg/kg/day respectively. Drug was tolerated with little renal, hepatic or hematological toxicity. The cost was found to be 3.81 lacs and 1.74 lacs with 3mg/kg/day and 1mg/kg/day respectively. CONCLUSION: Higher dose showed better efficacy and quicker microbial conversion of Cerebrospinal fluid (CSF) (cerebrospinal fluid) than 1 mg/kg/day. It shortened the duration of treatment in days by 27% while drug cost almost doubled ( CLINICAL TRIAL REGISTRATION NUMBER: ISRCTN 52812742).

Pamidronate--a promising new candidate for the management of spondyloarthropathy.

Bisphosphonate group of agents are known for their anti-bone resorptive properties. However, recently their anti-inflammatory and anti-arthritis properties have come to light. Clinical trials of their use in spondyloarthropathy are showing promising results, especially in patients with shorter disease duration. The adverse event profile is mainly limited to postinfusion arthralgia, myalgia and fever. The concept of pamidronate in spondyloarthropathy management should be evaluated further in light of these clinical studies and could have a major impact on our resource-restricted setting.

Efficacy of a 14-day primaquine regimen in preventing relapses in patients with Plasmodium vivax malaria in Mumbai, India.

We studied the antirelapse efficacy of a supervised 14-d 15 mg/d regimen of primaquine therapy (n = 131) compared with no antirelapse therapy (n = 142) in 273 patients with confirmed Plasmodium vivax malaria in Mumbai, India, between July 1998 and April 2000. There were 6/131 (4.6%) recurrences in patients given primaquine compared with 13/142 (9.2%) in those not given antirelapse therapy. In the 14-d primaquine group, polymerase chain reaction-single strand conformational polymorphism (PCR-SSCP) genotyping analysis of pre- and post-treatment blood samples was done for the 6 patients who had a recurrence of parasitaemia and the results gave a true relapse rate of 2.29% (3/131), 2 samples were classified as reinfections and 1 sample did not amplify. Our results indicate probable resistance to the 14-d regimen of primaquine for the first time in India and illustrate the need to (i) monitor patients given this regimen and (ii) carry out comparative studies between primaquine and new drugs such as tafenoquine and bulaquine for preventing relapses.

Bronchoalveolar lavage (BAL) in newly diagnosed patients with collagen vascular diseases.

Collagen vascular diseases (CVD) are commonly associated with interstitial lung diseases. Bronchoalveolar lavage (BAL) fluid analysis has important diagnostic value when considered in conjunction with other information. The present study was undertaken in newly diagnosed patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) at presentation to characterise BAL cellular constituents and elucidate the cellular picture in patients with and without pulmonary symptoms and in those with and without radiological (high resolution computed tomography) features of interstitial lung disease. All the patients were non-smokers and had not received any form of treatment for their diseases. The means of percentages of lymphocytes, neutrophils, and macrophages were 23.3%, 6.2%, 70.5% respectively. There was a significant BAL lymphocyte predominance in patients with pulmonary symptoms, and a lymphocyte and neutrophil predominance in those having radiological evidence of interstitial lung disease.

Transient low levels of antibodies at initial presentation of primary anti-phospholipid syndrome.

We present, herein, a case of venous thrombosis who was lupus anticoagulant negative and had low levels of anticardiolipin antibodies at the time of initial presentation. A definite diagnosis of antiphospholipid syndrome (APS) could be made only when repeat testing, six months later, revealed a dramatic rise of these antibodies.

Clinical utility of screening for antinuclear antibodies by enzyme immunoassay--a preliminary study.

AIMS OF THE STUDY: To evaluate the advantages and reliability of screening for antinuclear antibodies (ANA) by enzyme immunoassay (ELISA). METHODOLOGY: Sera from 96 patients comprising 51 with systemic lupus erythematosus (SLE), 11 with other systemic rheumatological diseases (SRD) and 34 with various other diseases (non-SRD) were tested using a commercial ELISA kit (ANA-Ease, Genesis Biotechnology, U.K.). These sera consisted of 53 immunofluorescence assay (IF) ANA-positive and 43 IF ANA-negative samples RESULTS: We observed that when compared to the IF for ANA the sensitivity, specificity, predictive values for positives (PPV) and negatives (NPV) of ELISA were 90.7%, 85.7%, 89.1% and 87.8% respectively. Exclusion of borderline ELISA positive by slightly raising the cut-off optical density (OD) increased the specificity and PPV to 93.1%, and 94.1% respectively. Importantly, none of the non-SRD sera were positive when this higher cut-off was used. ELISA was noted to be strongly positive in three IF ANA-negative SLE patients. However there was no correlation between the ELISA ANA semi-quantitative index and the IF ANA titers. CONCLUSIONS: ELISA appears to be suitable as a preliminary screening test for ANA. An appropriate cut-off should be identified to segregate low positive samples that could be false-positives. Nevertheless, IF will need to be performed to estimate the titers, identify patterns of ANA positive samples and confirm results of low positive "gray-zone" samples and ELISA negative sera from patients with a high index of clinical suspicion of SLE.

Favourable outcome in a patient with central nervous system lupus.

We report a case of paediatric lupus who during her admission developed near fatal central nervous system complication of status eilepticus with respiratory paralysis and was managed with intravenous immunoglobulins, extended course of methyl prednisolone with a favourable outcome.

Disseminated cryptococcal infection in immune competent patients.

Cryptococcal meningeal or cerebral infection has become an increasing global problem.(1) In this respect there are many anacedotal Indian case reports.(2) More than 50% of CNS infections occur in immunosuppressed patients and other debilitating conditions. Neurological form of cryptococcosis in immunocompetant patients needs to be considered in situations with intractable headache, papilloedema, hydrocephalus and prior to decisions on shunt placements.(3) We report on two such immunocompetent patients who presented with CNS involvement. Their clinical features and outcome is discussed.

Brucella spondylitis: an important treatable cause of low backache.

OBJECTIVES: This study was undertaken to see if brucella spondylitis existed as a cause of backache in Mumbai and to identify the clinical setting in patients of backache where brucella serology is indicated. METHODS: In 18 months (June 1996-Dec. 1997) we performed tube agglutination test (TAT) for Brucella melitensis and abortus on 72 patients of low backache from Orthopaedics Department of a teritary health centre. All 72 patients satisfied the inclusion and exclusion criteria designed to exclude radiologically detectable congenital or degenerative cause of backache. RESULTS: Six out of 72 patients were seropositive for brucellosis. All six patients had either history of animal contact or ingestion of raw milk or milk product (cheese or paneer). The lumbosacral backache was severe, radiating to the legs and straight leg raising test was significantly positive, they had marked tenderness on spinous process of lower lumbar vertebrae. Changes of brucella spondylitis were present on plain radiogram of lumbosacral spine in three patients. Four patients had abnormalities on bone scintigraphy. CONCLUSION: Low backache of brucella spondylitis closely simulates pain of prolapsed intervertebral disc. Serologic testing for brucellosis is an important step in management of such patients, especially when history of animal contact or raw milk or milk product ingestion is present, as the disease can be eminantly treated with antibiotics.

Myelitis as a presenting feature of systemic lupus erythromatosus.

A young female patient was admitted with myelitis. She had oral ulcers, hair loss and redness of hand suggestive of lupus. Diagnostic work including an MRI confirmed lupus myelitis. Unusual features of this case along with relevant literature are reviewed.

Acute Campylobacter jejuni enteritis in 385 hospitalised patients.

Twenty healthy controls and 385 adult patients suffering from acute enteritis or gastroenteritis were enrolled for the study of Campylobacter Jejuni infection over a period of 2 years. Thirty five stool samples showed C jejuni on stool culture. The isolation rates were at peak in the monsoon season and from watery and bloody stool specimens. Pure C jejuni culture was obtained in 18 of 35 samples; the other 17 samples showed polymicrobial infection or infestation. Nine of 35 patients were treated with erythromycin 1 g in divided doses for 7 days. Repeat stool cultures did not grow C jejuni. There was no resistance to erythromycin therapy. C jejuni are fastidious organisms and require special medium and microaerophilic environment for culture.

Plasmapheresis: an adjunct therapy in severe progressive neuropsychiatric lupus.

OBJECTIVE: We report our experience with use of plasmapheresis (PP) as an adjunct therapy in severe progressive neuropsychiatric systemic lupus erythematosus (NPSLE). METHOD: Three patients of NPSLE (including 2 with status epilepticus) who were progressively worsening on steroids or combination of pulse cyclophosphamide (CPM) and steroids were treated with PP followed by synchronized CPM. Pre and post treatment SLE Disease Activity Index (SLEDAI) and laboratory tests were carried out. RESULTS: Significant clinical improvement with decrease in SLEDAI occurred immediately following PP. Mean SLEDAI before and after PP were 33 and 11. Mean erythrocyte sedimentation rate decreased from 121 to 31. Rebound flare of disease activity noted in two patients between 7th-10th day requiring additional immunosuppressants or steroids. CONCLUSIONS: PP used as an adjunct therapy in severe, progressive NPSLE is well tolerated and can turn the patient around. PP should be followed by synchronized pulse CPM to prevent disease flare.

Rapid diagnostic test of Campylobacter pylori infection in patients of gastritis, duodenal ulcer and gastric ulcer. A study of 100 cases.

Campylobacter pylori has been cultured from 85-90% of antral biopsies of patients of gastritis, duodenal ulcer and gastric ulcer at different centres in the world. It has been now firmly implicated in the aetiology of active gastritis as well as suspected to cause repeated recurrences of peptic ulcers. However, the organism is very fastidious and is difficult to grow by standard culture methods as a result of which low positivity is often obtained even in well equipped centres. The rapid biopsy urease test for the diagnosis of C pylori infection, in which the biopsy is directly cultured in a solid medium containing urea, is a very simple test. A change in colour indicates the growth of the organism. This test is 100% specific and 98% sensitive. We performed this test in 100 patients; 93 of gastritis, 6 of DU and 1 of GU during a three month period. 87 of 93 cases of gastritis (90%) and all 6 cases of DU (100%) were positive. The single case of gastric ulcer was negative. Treatment of C pylori positive cases showed that they responded poorly to 4 weeks therapy with tinidazole; 33% were cured after 2 weeks of 1.5 g amoxycillin daily, but all responded when the therapy was continued for 4 weeks.

Boerhaaves' syndrome.

A 47 year old male with Boerhaaves' syndrome is described. A brief review of the literature is also presented.

Retrospective treatment analysis of Salmonella infections.

Twenty four culture proved and nine postmortem histopathology proved cases of enteric fever were analysed retrospectively with special interest in use of various antisalmonella agents. Chloramphenicol resistance was noted in 91.7% and yet 70% of all patients received chloramphenicol alone or in combination with another antisalmonella agent. Time required for remission of fever with chloramphenical, cotrimoxazole and ciprofloxacin was 4.5, 4.1 and 6.9 days respectively. An interesting feature noted in post-mortem histopathology proved cases was enteric carditis which was documented on postmortem examination of the heart in three out of four patients who died of peripheral circulatory failure.

Health information on the internet: patient empowerment or patient deceit?

Internet is the biggest medical library in the world. It has transformed the way many health seekers find health information. Seekers on net have exponentially increased from 54 million in 1998 to 110 million in 2002 (U.S. figures) and are ever increasing. Act of looking for health or medical information is the third most popular activities online. Search engines are used by almost 81% of the e-patients to look for the information they want. Internet is fast becoming an influential force as more than 70% consumers say that the information on the net has influenced their treatment decisions. However, the reliability of all the health information available on the Internet is questionable. Numerous studies have indicated deficiencies in the quality of information on the Internet. Due to technical and commercial reasons, the results provided by various search engines can be potentially biased. Only about a quarter of health seekers thoroughly check the source, timeliness of information every time they search for health information. In fact, most adults from USA, Japan, France and Germany who participated in a recent survey thought online health care information to be trustworthy, of good quality, easy to understand and easy to find. Efforts are now being taken to ensure the quality of health information on the Internet. Patients need to be educated about the worthiness of a site and also be prescribed the right sites to be consulted for information.