[Autoimmune pancreatitis associated with rheumatoid arthritis: successful combination therapy with steroids and methotrexate]. / Autoimmunpankreatitis assoziiert mit rheumatoider Arthritis. Erfolgreiche Kombinationstherapie mit Steroiden und Methotrexat.

UNLABELLED: MEDICAL HISTORY AND CLINICAL FINDINGS: A 70-year-old female patient suffered from steatorrhea and upper abdominal discomfort for 8 weeks combined with new onset of arthralgia in both hands. Additionally she reported elevated fasting blood glucose levels. The physical examination was without pathological findings except for mild upper abdominal pressure pain. INVESTIGATIONS: Imaging studies, including MRI and ultrasound examinations showed diffuse pancreatic enlargement without peripancreatic vessel involvement. Serological examinations showed elevated Cancer Associated Antigen 19 - 9 (1289 U/ml) and hyperglobulinemia with an IgG level of 170 mg/dl. The inflammatory markers were within normal ranges other than a slightly elevated erythrocyte sedimentation rate (35mm/1 h). Subsequent pancreatic biopsy showed lymphoplasmocellular, neutrophile and eosinophile granulocyte infiltration causing damage of the acinar pancreatic cells, typical for autoimmune pancreatitis (AIP). Magnetic resonance imaging (MRI) confirmed arthritis of both hands. TREATMENT AND COURSE: Medical treatment was started with oral prednisolone (50 mg/day) for one week, tapered to 25 mg/day for another 2 weeks, followed by dose reductions of 5 mg/day every 2 weeks with a final maintenance dose of 5 mg/day for 8 months. After the first week of steroid therapy methotrexate (MTX) was started with an initial dose of 10 mg/week. Dose was raised until a final dosage of 30 mg/week. After 8 months without relapse, the maintenance therapy was reduced to 20 mg/week MTX and corticosteroids were stopped. CONCLUSION: With this treatment regimen the patient has showed complete remission of AIP and arthritis for 36 months. MTX may be successful as an initial basic treatment to reach better control of autoimmune-related extrapancreatic manifestations.

[Non-tuberculous mycobacterial infections of the hand and wrist: a retrospective review of five cases from a single centre]. / Nicht-tuberkulöse mykobakterielle Infektionen an Hand und Handgelenk: Eine retrospektive Analyse von fünf Fällen.

PURPOSE: A suggestion for a graduated diagnostic and therapeutic approach for patients with a suspected infection with non-tuberculous mycobacteria (NTM) of the hand and wrist is made. PATIENTS AND METHODS: Between March 2003 and February 2007, 2 women and 3 men with an average age of 64 years were treated for an NTM infection of the hand and wrist. 4 patients had a tenosynovitis of the wrist. In 1 patient both wrists were involved. 1 patient had a granuloma of the index finger. The patients' charts, the operation reports, histological and bacteriological findings and the antibiogram were evaluated. RESULTS: An inoculating trauma was identified in four patients. Intraoperatively rice bodies were present in the 4 patients with a tenosynovitis of the wrist. Histological findings showed acid-fast bacilli in 2 patients and chronic inflammatory reaction with/without granuloma (3/2) in 5 patients. Species identification was based on PCR and microbiological culture and revealed in three patients slow growing species (M. malmoense, M. nonchromogenicum, M. szulgai) and in two patients M. marinum (intermediate growth rate). Therapy consisted of immediate postoperative empirical combined drug treatment followed by antibiogram-based therapy. All patients showed healing of the infection at the final follow-up at an average of 25.2 months (range: 15-44 months) postoperatively. CONCLUSION: Consideration of non-tuberculous mycobacteria in the differential diagnosis in cases of localised tenosynovitis is paramount for diagnosis. Treatment based on graduated diagnostic steps, surgery and drugs (empirical followed by directed drugs) can achieve favourable clinical outcomes.