Background
Inflammation of unknown origin (IUO) is a challenging situation in internal medicine.
Objectives
To describe the final diagnoses in IUO and assess the helpfulness of ...18F‐fluorodesoxyglucose positron emission tomography with computerized tomography (18F‐FDG‐PET/CT) in the diagnosis strategy.
Results
A total of 317 IUO patients with 18F‐FDG‐PET/CT were enrolled. A diagnosis was reached in 228 patients: noninfectious inflammatory diseases (NIID) (37.5%), infectious diseases (18.6%), malignancies (7.9%), and non‐systemic‐inflammatory miscellaneous diseases (7.9%). The two leading causes of NIID were polymyalgia rheumatica and giant cell arteritis. 18F‐FDG‐PET/CT results were classified as true positive in 49.8% of patients and contributory in 75.1% of overall IUO patients (after the complete investigation set and a prolonged follow‐up). In multivariate analysis, only C‐reactive protein minimum level (≥50 mg/L) was associated with the contributory status of 18F‐FDG‐PET/CT.
Conclusion
Within the wide spectrum of IUO underlying diseases, 18F‐FDG‐PET/CT is helpful to make a diagnosis and to eliminate inflammatory diseases. Obese patients constitute a specific group needing further studies.
Malignancies can be associated with positive antiphospholipid antibodies but the incidence of cancer among women with the purely obstetric form of antiphospholipid syndrome (APS) is currently ...unknown. Our aim was to investigate the comparative incidence of cancers in women with a history of obstetric APS within a referral university hospital-based cohort (NOH-APS cohort). We performed a 17-year observational study of 1,592 non-thrombotic women with three consecutive spontaneous abortions before the 10
week of gestation or one fetal death at or beyond the 10
week of gestation. We compared the incidence of cancer diagnosis during follow-up among the cohort of women positive for antiphospholipid antibodies (n=517), the cohort of women carrying the
rs6025 or
rs1799963 polymorphism (n=279) and a cohort of women with negative thrombophilia screening results (n=796). The annualized rate of cancer was 0.300% (0.20%-0.44%) for women with obstetric APS and their cancer risk was substantially higher than that of women with negative thrombophilia screening adjusted hazard ratio (aHR) 2.483; 95% confidence interval (CI) 1.27-4.85. The computed standardized incidence ratio for women with obstetric APS was 2.89; 95% CI: 1.89-4.23. Among antiphospholipid antibodies, lupus anticoagulant was associated with incident cancers (aHR 2.608; 95% CI: 1.091-6.236). Our cohort study shows that the risk of cancer is substantially higher in women with a history of obstetric APS than in the general population, and in women with a similar initial clinical history but negative for antiphospholipid antibodies.
Objectives: Giant cell arteritis (GCA) is associated with severe outcomes such as infections and cardiovascular diseases. We describe here the impact of GCA patients’ characteristics and treatment ...exposure on the occurrence of severe outcomes. Methods: Data were collected retrospectively from real-world GCA patients with a minimum of six-months follow-up. We recorded severe outcomes and treatment exposure. In the survival analysis, we studied the predictive factors of severe outcomes occurrence, including treatment exposure (major glucocorticoids (GCs) exposure (>10 g of the cumulative dose) and tocilizumab (TCZ) exposure), as time-dependent covariates. Results: Among the 77 included patients, 26% were overweight (BMI ≥ 25 kg/m2). The mean cumulative dose of GCs was 7977 ± 4585 mg, 18 patients (23%) had a major GCs exposure, and 40 (52%) received TCZ. Over the 48-month mean follow-up period, 114 severe outcomes occurred in 77% of the patients: infections—29%, cardiovascular diseases—18%, hypertension—15%, fractural osteoporosis—8%, and deaths—6%. Baseline diabetes and overweight were predictive factors of severe outcomes onset (HR, 2.41 1.05−5.55, p = 0.039; HR, 2.08 1.14−3.81, p = 0.018, respectively) independently of age, sex, hypertension, and treatment exposure. Conclusion: Diabetic and overweight GCA patients constitute an at-risk group requiring tailored treatment, including vaccination. The effect of TCZ exposure on the reduction of severe outcomes was not proved here.
Background:
Few studies of daily practice for patients with giant cell arteritis (GCA) are available. This French study aimed to describe the characteristics and management of GCA in a real-life ...setting.
Methods:
Cross-sectional, non-interventional, multicenter study of patients ≥50 years old who consulted hospital-based specialists for GCA and were under treatment. Patient characteristics and journey, diagnostic methods and treatments were collected. Descriptive analyses were performed.
Results:
In total, 306 patients (67% females, mean age 74 ± 8 years old) were recruited by 69 physicians (internists: 85%, rheumatologists: 15%); 13% of patients had newly diagnosed GCA (diagnosis-to-visit interval <6 weeks). Overall median disease duration was 13 months (interquartile range 5–26). Most patients were referred by general practitioners (56%), then ophthalmologists (10%) and neurologists (7%). Most common comorbidities were hypertension (46%), psychiatric disorders (10%), dyslipidemia (12%), diabetes (9%), and osteoporosis (6%). Initial GCA presentations included cranial symptoms (89%), constitutional symptoms (74%), polymyalgia rheumatica (48%), and/or other extra-cranial manifestations (35%). Overall, 85, 31, 26, and 30% of patients underwent temporal artery biopsy, high-resolution temporal artery Doppler ultrasonography,
18
FDG-PET, and aortic angio-CT, respectively. All patients received glucocorticoids, which were ongoing for 89%; 29% also received adjunct medication(s) (methotrexate: 19%, tocilizumab: 15%). A total of 40% had relapse(s); the median time to the first relapse was 10 months. Also, 37% had comorbidity(ies) related to or aggravated by glucocorticoids therapy.
Conclusion:
This large observational study provides insight into current medical practices for GCA. More than one third of patients had comorbidities related to glucocorticoid therapy for a median disease duration of 13 months. Methotrexate and tocilizumab were the most common adjunct medications.
Purpuric lesions in a 45-year old man Broner, Jonathan; Reymann, Valérie; Guilpain, Philippe
European journal of internal medicine,
10/2017, Volume:
44
Journal Article
Peer reviewed
Open access
Highlights • Scurvy is a rare issue but may not be overlooked as it can be severe. • Scurvy is often associated with inflammatory bowel diseases. • Purpuric lesions in scurvy can mimic cutaneous ...vasculitis. • Purple purpura of the palate as gingival inflammation are typical aspects of scurvy. • Supplementation has to be initiated before the diagnosis is confirmed.
The patient, a 64-year-old man, was admitted to our hospital with a 6-week history of intermittent neck pain, posterior headaches, fever (39°C), and inflammatory syndrome (persistently elevated ...C-reactive protein level ~200 mg/liter). Because of a dry cough, bronchopneumonia was initially suspected; however, antibiotics were not effective. He had not experienced vision loss or jaw or limb claudication and was not experiencing any headache at the time of admission. He had been diagnosed as having polymyalgia rheumatica (PMR) 3 years prior, which was still being treated with methotrexate.
Robilliard et al present a case of pembrolizumab-induced autoimmune haemolytic anaemia with polymyalgia rheumatica in a 79-year-old woman who was admitted for blood transfusion in a geriatric day ...hospital. The patient had been diagnosed with a choroidal melanoma discovered in 2011 and initially treated by proton therapy. In 2014, she had a complete removal of the eye. The follow-up showed evidence of hepatic metastasis in 2016 which led to four cycles of chemoembolisation. Checkpoint inhibitors are recent therapies against cancer, and their indications are currently undergoing rapid expansion. However, these treatments unleash immune activation that triggers potential autoimmune side-effects.
A 62-year-old man, who was a heavy drinker, presented with deep asthenia, isolated fever, inflammatory syndrome (CRP 120 mg/l) and cytopenias (Hb 6.5 g/dl, platelet count 100 G/l). A whole-body CT ...scan found dysmorphic hepatomegaly and splenomegaly. Endoscopy revealed bleeding gastrointestinal angiodysplasia and non-bleeding oesophageal varices. After coagulation for angiodysplasia and blood transfusions, the Hb level remained around 8.5 g/dl. To investigate blood malignancy, a bone marrow biopsy revealed small-vessel vasculitis (Fig. 1A, 2), fibrinoid necrosis affecting the small vessel walls (Fig. 1A, 3), multinucleated giant cells (Fig. 1A, 1) constituting microgranulomas (Fig. 1A, 4) and...
Inflammation of unknown origin (IUO) is a challenging situation in internal medicine.
To describe the final diagnoses in IUO and assess the helpfulness of
F-fluorodesoxyglucose positron emission ...tomography with computerized tomography (
F-FDG-PET/CT) in the diagnosis strategy.
A total of 317 IUO patients with
F-FDG-PET/CT were enrolled. A diagnosis was reached in 228 patients: noninfectious inflammatory diseases (NIID) (37.5%), infectious diseases (18.6%), malignancies (7.9%), and non-systemic-inflammatory miscellaneous diseases (7.9%). The two leading causes of NIID were polymyalgia rheumatica and giant cell arteritis.
F-FDG-PET/CT results were classified as true positive in 49.8% of patients and contributory in 75.1% of overall IUO patients (after the complete investigation set and a prolonged follow-up). In multivariate analysis, only C-reactive protein minimum level (≥50 mg/L) was associated with the contributory status of
F-FDG-PET/CT.
Within the wide spectrum of IUO underlying diseases,
F-FDG-PET/CT is helpful to make a diagnosis and to eliminate inflammatory diseases. Obese patients constitute a specific group needing further studies.
PDF
