Severe statin-induced rhabdomyolysis mimicking Guillain-Barré syndrome in four patients with diabetes mellitus treated with fusidic acid.

BACKGROUND: An interaction between fusidic acid and HMG coenzyme A reductase inhibitors (statins), resulting in rhabdomyolysis, has been described. Pain and mild weakness are common presenting symptoms. CASE REPORT: We report four patients with Type 2 diabetes prescribed long-term statin treatment who, following treatment with fusidic acid, presented atypically with painless, severe flaccid paralysis suggestive of Guillain-Barré syndrome. This, together with nerve conduction studies consistent with Guillain-Barré syndrome, resulted in the delayed recognition of rhabdomyolysis in these cases. CONCLUSIONS: The addition of fusidic acid can precipitate rhabdomyolysis in patients with diabetes already taking a statin. This can present with rapidly progressive weakness resembling Guillain-Barré syndrome. We recommend that creatine kinase is checked in patients with diabetes on statin therapy who present with profound weakness and routinely in those commenced on prolonged courses of fusidic acid.

Increased prevalence of symptomatic macrovascular disease in systemic sclerosis.

OBJECTIVES: To determine the prevalence of symptomatic macrovascular disease, as defined by the World Health Organisation questionnaire for intermittent claudication, in patients with systemic sclerosis (SSc), and to compare the prevalence in this population with a cross sectional population study group reported in the Edinburgh Artery Study (EAS). METHODS: A group of 53 patients with a diagnosis of limited or diffuse systemic sclerosis were identified from our register. They were asked to complete the WHO questionnaire to establish the presence or absence of intermittent claudication. In addition, each patient's case notes were reviewed to establish the existence of definite peripheral vascular disease and to determine their risk factor profile. RESULTS: Forty six patients responded to the questionnaire, giving a response rate of 87%. Intermittent claudication was found in 10 SSc patients (21.7%) according to the questionnaire (two with diffuse and eight with limited SSc), compared with a prevalence rate of 4.6% for claudication in the EAS. Three SSc patients experienced clinical events attributable to occlusion of a major artery proven on angiography. Four patients had hypertension, there were three current and four ex-smokers, and two had increased total cholesterol. None of these patients had diabetes. CONCLUSIONS: This study demonstrated a greater prevalence of macrovascular disease in patients with SSc than had been found in a neighbouring population.

The glycoinositol phospholipids of Leishmania mexicana promastigotes. Evidence for the presence of three distinct pathways of glycolipid biosynthesis.

Most macromolecules at the cell surface of parasitic protozoa of the genus Leishmania, including the major surface glycoproteins and a complex lipophosphoglycan (LPG), are attached to the plasma membrane via glycosyl-phosphatidylinositol (GPI) anchors. Free glycoinositol phospholipids (GIPLs) which are not linked to protein or phosphoglycan have also been found. In this study, we show that L. mexicana promastigotes synthesize two distinct GIPL lineages, comprising at least 10 glycolipid species. These structures were characterized using a combination of gas-liquid chromatography-mass spectrometry, methylation linkage analysis, and chemical and exoglycosidase sequencing. The major lineage contains GIPLs with the glycan structures Man alpha 1-3Man alpha 1-4GlcN (iM2), Man alpha 1-6(Man alpha 1-3)Man alpha 1-4GlcN (iM3), and Man alpha 1-2Man alpha 1-6(Man alpha 1-3)Man alpha 1-4GlcN (iM4), which are linked to alkylacyl-PI containing predominantly C16:0 and C18:0 fatty acids and C18:0 alkyl chains (referred to as the hybrid type GIPLs). A proportion of the iM3 and iM4 species (32 and 4%, respectively) are substituted with an ethanolamine-phosphate residue. The location of this residue on the core glucosamine residue was inferred from the results of methylation analyses and alpha-mannosidase digestion. The minor GIPL lineage contains GIPLs with the same glycan sequences as the glycolipid anchor of LPG (referred to as the type-2 GIPLs). The alkylacyl-PI or lyso-alkyl-PI lipid moieties of these GIPLs differ from those of the hybrid type GIPLs and from the main pool of alkylacyl-PI in containing significant levels of C24:0 and C26:0 alkyl chains. The most polar of these GIPLs, LPGp, has the properties expected of a biosynthetic precursor to the LPG, having the structure, [formula: see text] Finally, the GPI anchors of the major promastigote proteins were found to contain the glycan sequence Man alpha 1-2Man alpha 1-6Man alpha 1-4GlcN, and an alkylacyl-PI lipid moiety which was highly enriched for C24:0 or C26:0 alkyl chains. These data suggest that L. mexicana promastigotes contain three distinct pathways of GPI biosynthesis. The possibility that the distinct alkyl chain compositions of the different GPI glycolipids reflects the subcellular compartmentalization of different GPI biosynthetic pathways is discussed.