Should rheumatoid factor in rheumatoid arthritis be sent to Davy Jones's Locker?

This article reviews the characteristics and weaknesses of the rheumatoid factor (RF) assay compared with anti-citrullinated peptide antibody (ACPA) testing in the work-up of patients with synovitis. This should lead physicians to change their ordering habits and replace RF by ACPA. For RA diagnosis, good clinical judgement based on clinical history, physical examination and routine laboratory work exceeds the value of RF and ACPA assays. In settings of both low and high pretest probability, the added value of each of these assays is low. In cases with intermediate probability, ACPA assays are superior to immunoglobulin (Ig)M-RF because of their higher specificity, and they should be the first choice in a RA diagnostic work-up. Dual testing brings few additional advantages and increases costs significantly. ACPA and IgM-RF are both imperfect tests; around 30% of patients with manifest RA will test negative in both assays and therefore caution needs to be exercised when interpreting negative results. Since 2009, the anti-cyclic citrullinated peptide (anti-CCP) antibody assay has been the only assay available at our institution for RA work-up, with IgM-RF available on a case-by-case basis for non-RA diseases. This has led to a 70% reduction in RF assays performed annually.

Rapid growing mycobacteria and TNF-α blockers: case report of a fatal lung infection with Mycobacterium abscessus in a patient treated with infliximab, and literature review.

Rapid growing mycobacteria pose as a serious emerging threat for patients treated with TNF-α blockers. We report a case of a progressive and fatal pulmonary infection with M. abscessus in a patient previously treated with infliximab for Crohn's disease and review seven other previously reported patients. Five out of eight patients were female. The patients were treated with either anti-TNF-α antibodies or TNF-α blocking receptor. The diagnosis of RGM came in the first 6 months after initiation of TNF-α blockers in five out eight patients. The two patients with M. abscessus lung infection died in spite of antibiotic treatment, whereas the other patients with skin affection and lever affection due to M. Fortuitum had a resolution of their symptoms with discontinuation of TNF-α blockers and antibiotics.

[Cryptogenic stroke in a young patient with heart disease and kidney failure]. / Ictus criptogenico en un paciente joven con cardiopatia y fallo renal.

INTRODUCTION: Fabry's disease is an infrequent metabolic pathology linked to the X chromosome which causes a wide variety of signs and symptoms. CASE REPORT: A 39-year-old male who was admitted to our stroke unit with right-side hemiparesis (1 + 0) and dysarthria (1). The score on the National Institute of Health Stroke Scale was 2. The patient presented angiokeratomas in both thighs. A computerised axial tomography scan of the head showed left thalamic acute infarction. The duplex scan of the supra-aortic trunks was normal, and the transcranial Doppler reflected a generalised increase in the pulsatility indices. Transthoracic echocardiography showed left ventricular hypertrophy and left atrial dilatation. He was discharged five days later, with antiaggregating medication but asymptomatic. The prolonged Holter-electrocardiogram recording showed paroxysmal atrial fibrillation. One notable value in the urine analysis was microalbuminuria of 281 mg/L. In view of the multi-organic involvement and the family history, a study for Fabry's disease was performed. Activity of the enzyme alpha-galactosidase A was diminished, and the presence of a mutation in the GLA gene was found. The patient's brother, who suffered from kidney failure and atrial fibrillation, was positive for this mutation. The patient is on treatment with agalsidase beta. CONCLUSIONS: Fabry's disease must be suspected in young males with heart disease, stroke or peripheral neuropathy, skin lesions, kidney failure and a history of cases in the family. Hormone replacement therapy must be established at an early stage, as it can improve the prognosis.

TITLE: Ictus criptogenico en un paciente joven con cardiopatia y fallo renal.Introduccion. La enfermedad de Fabry es una patologia metabolica infrecuente ligada al cromosoma X, que provoca una amplia variedad de signos y sintomas. Caso clinico. Varon de 39 antilde;os que ingreso en nuestra unidad de ictus con hemiparesia derecha (1 + 0) y disartria (1). La puntuacion en la National Institute of Health Stroke Scale era de 2. Presentaba angioqueratomas en ambos muslos. La tomografia axial computarizada craneal mostraba un infarto agudo talamico izquierdo. El duplex de los troncos supraaorticos era normal, y el Doppler transcraneal reflejaba un aumento generalizado de los indices de pulsatilidad. El ecocardiograma transtoracico mostraba hipertrofia ventricular izquierda y dilatacion de la auricula izquierda. Recibio el alta cinco dias despues, asintomatico, con antiagregacion. El registro Holter-electrocardiografico prolongado mostraba fibrilacion auricular paroxistica. En la analitica de orina destacaba microalbuminuria de 281 mg/L. En vista de la afectacion multiorganica y la historia familiar, se curso estudio de enfermedad de Fabry. La actividad de la enzima alfa-galactosidasa-A se encontro disminuida, y se demostro la presencia de una mutacion en el gen GLA. Su hermano, que padecia insuficiencia renal y fibrilacion auricular, fue positivo para dicha mutacion. El paciente se encuentra en tratamiento con agalsidasa beta. Conclusiones. La enfermedad de Fabry debe sospecharse en varones jovenes con cardiopatia, ictus o neuropatia periferica, lesiones cutaneas, fallo renal e historia de familiares afectos. El tratamiento hormonal sustitutivo debe comenzarse precozmente, ya que puede mejorar el pronostico.

Hemodialysis vascular assessment by an ultrasound dilution method (transonic) in patients older than 65 years.

UNLABELLED: Malfunction of vascular access is one of the most frequent causes of morbidity and mortality in hemodialysis patients (HD). Early diagnosis makes possible the most frequent vascular access (VA) used in HD patients. The arteriovenous fistula (AVF), both autologous or heterologous, is the appropriate correction by an interventional radiologist or by surgery, before thrombosis appears. For this purpose, a follow-up of VA is mandatory. New technologies offer non-invasive methods for this purpose. In HD sessions ultrasound 'on line' and ultrasound-dilution techniques permit us to monitor vascular access in HD patients. Also transonic technology has been validated for this purpose, although the limitations of its use among elderly patients is unknown. Using the Transonic HD01 monitor, we studied vascular access in 45 patients in HD older than 65 years, and compared them with 47 patients who were younger than 65 years. The parameters analyzed were: effective flow Qt, recirculation, venous pressure and access flow. We found no significant differences between these parameters but in both groups found that the effective flow measure by Transonic was lower than that measured by a blood pump. Both groups contained patients who had no recirculation but had an access flow that was lower than expected. To rule out stenosis of VA in those patients, we performed an Eco Doppler confirming that all patients had stenosis. With this method, one can determines the access flow and thus predicts the possibility of future thrombosis. CONCLUSION: Our data confirm that one can evaluate VA in patients older than 65 years with Transonic HD01 monitor, and also in patients younger than 65 years. Due to the special characteristics of the vessels in elderly patients, Transonic HD01 monitor is a good method by which to monitor VA in them.

Post-streptococcal uveitis.

BACKGROUND: We report additional evidence supporting the association between the occurrence of bilateral nongranulomatous uveitis and previous infection by group A streptococci--i.e., post-streptococcal syndrome. METHODS: As shown through a series of case reports, physical examination and laboratory blood analysis--including antistreptolysin O (ASO) antibody titer--were ordered due to a recent history of sore throat and presence of nongranulomatous bilateral anterior uveitis. RESULTS: Serological laboratory testing revealed elevated ASO antibody titer. The etiology of the uveitis was attributed to streptococcal infection. Bilateral uveitis responded to topical corticosteroids. Systemic antibiotic treatment was used to treat possible post-streptococcal syndrome sequelae with resolution of symptoms. CONCLUSION: Uveitis should be considered a possible manifestation of post-streptococcal syndrome. ASO antibody quantification should be included in the serologic testing performed in evaluating the cause of seemingly idiopathic bilateral nongranulomatous anterior uveitis associated with signs and symptoms that suggest previous streptococcal infection.

[SURGICAL MANAGEMENT OF BILIARY TRACT INFECTIONS] / Manejo Quirúrgico de las Infecciones deVías Biliares.

Acute cholecystitis requires a prompt diagnosis and early surgical treatment, either open or laparoscopic surgery. Currently, most of the patients can be treated by laparoscopic surgery.Delayed surgery of acute cholecystitis must be considered only if the patient has other clinical conditions such as congestive heart failure, other uncontrolled disease, and whenever cholecystitis is not complicated (epyema, perforation, gangrene, cholangitis, etc.) Percutaneous cholecystostomy by interventionist radiologist or surgical cholecystostomy must be considered in the therapeutic armamentarium in patients with poor clinical conditions. Acute cholangitis management requires a multidisciplinary team approach of internists, gastroenterologists, interventionist radiologists and surgeons. Each patient requires an integral evaluation with an initial energic medical treatment, followed by drainage of the biliary tract, ideally by endoscopic sphincterectomy or by transhepatic percutaneous drainage. Only if these procedures do not solve the patient's problem, or if its application is not possible, we proceed with an emergency surgery in order to decompress the biliary tree.

Characteristics of late onset neutropenia in rheumatologic patients treated with rituximab: a case review analysis from a single center.

BACKGROUND: Late onset neutropenia (LON) secondary to rituximab has been reported as an adverse event in the treatment of hematological malignancies but reports on autoimmune diseases are scarce. AIM: To review the characteristics of LON in rheumatologic patients from a single center. DESIGN: Retrospective case record study. METHODS: Clinical and laboratory data since the introduction of rituximab in our clinic in 2006 were collected and analyzed retrospectively. LON was defined as an absolute neutrophil count <1.0 × 10(9)/l occurring 4 weeks after the last rituximab infusion. RESULTS: LON was identified in eight patients (6% of all patients receiving rituximab). All patients had complicated and refractory disease and had been treated with a median of 4.5 different immunosuppressive drugs prior to rituximab. LON appeared after a median interval of 23 weeks with recovery of LON after a median of 6.5 days. Four patients had concomitant infection at the onset of neutropenia, when six patients had both low immunoglobulin M and immunoglobulin G. Six patients were rechallenged with rituximab without recurrence of LON. CONCLUSION: The characteristics of LON after rituximab treatment in patients with autoimmune disease are comparable with experiences from hematological malignancies. LON seems to precede B-cell recovery implying a perturbation of the granulocyte homeostasis. LON with its rapid recovery does not seem to increase the risk for serious infection in contrast to the sustained hypogammaglobulinemia that may follow rituximab. The risk of LON recurrence after rechallenge is low.

Clinical diagnosis of recurrent herpes simplex blepharitis in an adult: a case report.

BACKGROUND: Herpes simplex (HSV) blepharitis occurs usually in children as a primary infection. Though primary HSV blepharitis is also observed in adults, recurrent HSV blepharitis involving the same area of the eyelid is unusual in this group. Two clinical types have been identified, one consisting of vesicular type lesions and a second characterized by erosive-ulcerative insults. Presented in this article is a case of an adult with herpes simplex blepharitis (presumed recurrent at the same generalized eyelid region), manifesting erosive-ulcerative lesions. Review of this ocular condition, treatment modalities, and hypothetical modes of transmission is given.

[Pancreatoduodenectomy: myth or reality? Personal experience]. / Pancreatoduodenectomía: mito o realidad? Experiencia personal.

61 patients with malignant and benign pancreatoduodenal diseases were treated with Whipple operation during 1973-1993. 38 patients were males and 23 females. Ages varied between 18 and 74. Malignant tumors were more frequent: adenocarcinoma of the pancreas 27, ampulla of Vater 14, duodenum 5 and distal common duct 3. The other group of patients with benign and malignant tumors as cysto-adenocarcinoma 2, leiomyosarcoma 2, trauma to the pancreas 2, pancreatitis with pseudocyst and insulinoma etc. The morbidity has been reduced from 50% in the first 45 cases to 15% in the last 16. Also the mortality dropped from 17% to 0%. This improvement is related to knowledge the better of the surgical technique and reconstruction varieties, better control of hemorrhage, reduced operative time and good post operative control. We concluded, that this difficult surgery is a reality and should be managed in those hospitals with specialized surgeons and all of the technology must be used in any moment, to be considered a low risk surgery.

Hypothyroidism--a possible etiology of open-angle glaucoma.

BACKGROUND: Recent studies have shown an association between hypothyroidism and primary open-angle glaucoma (POAG). When hypothyroidism occurs, accumulation of hyaluronic acid within the trabecular meshwork may cause an increase in outflow resistance and intraocular pressure (IOP). This increase may be reversible with use of systemic treatment. METHODS: A hypothyroid patient is described whose IOP inversely varied with the use or the discontinuation of systemic hypothyroid medications. RESULTS: The patient's IOP was controlled when she complied with systemic treatment. CONCLUSIONS: In some cases, hypothyroidism may contribute to the genesis of open-angle glaucoma. Systemic treatment alone may be adequate to prevent progression of a glaucomatous diseased state. It may be prudent to investigate the presence of undiagnosed hypothyroidism in individuals with poorly controlled POAG, in individuals with normal-tension glaucoma, and in newly diagnosed cases.

Absent relative afferent pupillary defect in an asymptomatic case of lateral chiasmal syndrome from cerebral aneurysm.

INTRODUCTION: This report documents a case of an asymptomatic 34-year-old female who had right eye subtle temporal optic nerve pallor with absent clinically detectable relative afferent pupillary defect. CASE REPORT: This presentation was secondary to a fusiform paraclinoid aneurysm resulting in lateral chiasmal syndrome. Visual fields demonstrated a nasal depression OD. Neuroimaging studies revealed the presence of a fusiform paraclinoid aneurysm compressing the right optic nerve and optic chiasm. The lesion was treated surgically without additional visual loss nor systemic and neurological complications. CONCLUSIONS: A clinically detectable relative afferent pupillary defect may be absent in unilateral optic nerve pallor and/or visual field loss and does not preclude the need to attempt to identify an underlying etiology. Neuroradiological examination of orbital and cranial structures is an imperative protocol in the appropriate management of this potential life- and vision-threatening condition.