[Neuropsychiatric lupus erythematosus]. / Il lupus neuropsichiatrico.

Neuropsychiatric involvement in patients with Systemic Lupus Erythematosus (SLE), first mentioned by Kaposi more than 100 years ago, still remains one of the main challenge facing rheumatologist and other physicians. The diagnosis of neuropsychiatric SLE (NPSLE) is complex not only because of the considerable prevalence variation (14-80%) but also because of the wide spectrum of NP manifestations. They vary from overt neurologic alterations (seizure, psychosis), to subtle abnormalities (neurocognitive dysfunctions). Different NP manifestations result from a variety of mechanisms including antibodies, vasculitis, thrombosis, hemorrhages and cytokine-mediated damages. Of note, despite the dramatic clinical manifestations, too often changes at the morphological neuroimaging techniques are minimal and non specific. There is no one diagnostic tool specific for NPSLE and diagnosis must be based on the combinated use of immunoserological tests, functional and anatomical neuroimaging and standardized specific criteria. Symptomatic, immunosuppressive and anticoagulant therapies are the main strategies available in the management of these patients. Therapy for CNS lupus should be adjusted according to the needs of the individual patients. The coming years promise to be an important time for the development of new neuroimaging techniques and for the study of disease mechanism. An early and objective identification of brain involvement will allow for appropriate treatment to avoid severe complications.

[A 52 year-old woman with fever, cough and dyspnoea]. / Donna di 52 anni con febbre, tosse e dispnea.

A 52 year-old woman with gastric cancer treated with surgery and chemotherapy, is admitted in our Internal Medicine Department because of the presence of fever (max 41.2 degrees C), dyspnoea, non-productive cough and mental confusion. The anamnesis and the physical examination address to the diagnosis of CAP (Community-Acquired Pneumonia); in particular the alteration of consciousness and the onset of symptoms after the insertion of a nose-gastric tube let us to consider the diagnosis of aspiration pneumonia. The clinical presentation and radiological imaging (Rx and CT of thorax) suggest the pattern of bronchiolitis obliterans with organizing pneumonia (BOOP). BOOP is not a disease, but a non specific pattern of answer to a lung injury. It can be either idiopathic or associated with a variety of causes, such as infections, drugs, radiations and connective tissue diseases. Besides the clinical course is complicated by the onset of an ARDS (Adult Respiratory Distress Syndrome). The gold standard for the diagnosis is represented by lung biopsy with hystopathologic confirmation but, if it cannot be done, it's necessary to start immediately steroid therapy because BOOP may be fatal. The patient received antibiotic and steroid therapy with success.

[A 74-year-old woman with macrocytic anemia]. / Donna di 74 anni con anemia macrocitica.

A seventy-four years old woman is assessed for asthenia, fatigue, non ulcerous dyspepsia with macrocytic anemia. The patient's medical history taking in Binswanger disease--diagnosed 5 aa before-, epilepsy-2 aa before- and a previous episode of TVP of the left leg, suggested the hypothesis that a B12 deficiency, by a chronic gastritis, would involve an increase of homocysteine cause of the clinical manifestations of megaloblastic anemia, Binswanger disease, tardive epilepsy and previous TVP. The fisic and blood and instrumental exams confirmed the clinical diagnosis. The patient is having vitamin B12.