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CAPTOPRIL ASSOCIATED HEPATITIS: CLINICAL AND IMMUNOLOGICAL STUDY OF 7 CASES
Oral Communications / European Journal of Internal Medicine 19S (2008) (2008), S1–S59 So we confirmed the diagnosis of SLE associated to an APL by the presence of chronic anti beta 2 glycoprotein I. The patient was treated by corticotherapy, antipaludian and Sjögren’s syndrome treatment with a stability of her autoimmune disorders; but she is not yet compliant to a gluten free diet. Discussion: The celiac disease is an autoimmune pathology and it occurs in children rarely in adults. The association with other autoimmune diseases has been described in several studies essentially diabetes and thyroiditis. But the celiac disease, SLE and Sjögren’s syndrome combination is rarely reported in the literature. This association may be pathogenically explained by autoimmune mechanisms and a common genetic background. Conclusion: We insist to explore patients with autoimmune diseases to research other autoimmune disorders to improve their prognosis by specific therapies.
TH-73 ABCIXIMAB INDUCED THROMBOCYTOPENIA – “TWO CASES OF A KIND” Clarinda Neves, Paula Dias, Gonçalo Rocha, Fernando Friões, João Paulo Araújo, Jorge Almeida. Hospital S. João, Porto, Portugal Abciximab is widely used in patients undergoing percutaneous coronary intervention. Although rare, abciximab induced thrombocytopenia (AIT) may have different courses. Case 1: A 69 year old male was admitted at the emergency department with an acute myocardial infarction and was submitted to angioplasty and stenting of the anterior descendent artery. A bolus of unfractioned heparin and abciximab followed by a 12 hour infusion was administered. The platelet count previous to the procedure was 303×109 /liter, and at 12 hours and day 3 was 497 and 413 x109/liter. He was discharged on day 6 under state of the art therapy. Twelve days after the procedure he was readmitted with malaise and a petechial rash on the lower limbs. His platelet count was 13×109 /liter. Peripheral blood smear and coagulation screen were normal and myelogram suggested peripheral platelet destruction. He developed epistaxis, and on day 3 the platelet count was <10×109 /liter. Platelet infusion was initiated. On day 6 he became dysartric. The CT scan showed a thalamic haemorrhage. He became rapidly comatose, with hydrocephaly and an external ventricular derivation was placed without clinical improvement. Case 2: A 71 year old male was admitted to elective coronary angiography and submitted to angioplasty and stenting of the right coronary artery. He received clopidogrel, and a bolus of heparin and abciximab followed by a 12 hour infusion. The platelet count 8 hours after the procedure was 14 x109/liter. He was asymptomatic. The coagulation screen was normal. He remained under surveillance and the platelet count on day 1, 2 and 4 were <10, 19 and 75×109 /liter. He was discharged on day 5, without any complications. These 2 cases demonstrate the different course of AIT. The cases of delayed thrombocytopenia are scarce, but raise the question of a platelet count evaluation few days after the procedure. The patients should be advised for surveillance of symptoms associated with this complication.
TH-74 CAPTOPRIL ASSOCIATED HEPATITIS: CLINICAL AND IMMUNOLOGICAL STUDY OF 7 CASES Patrícia Howell Monteiro, Luís dos Santos Pinheiro, Adriana Albuquerque, Ana Espada Sousa, Margarida Lucas. Internal Medicine Department 2, Hospital de Santa Maria and Clinical Immunology Unit - IMM Introduction: Captopril (CP) is broadly used in clinical practice, with a low incidence of severe adverse reactions. CP associated hepatitis is described
S27
only as individual case reports and there are no references to structured series. CP hepatotoxicity is thought to be immunological and T-cell mediated, but there are no published immunological studies confirming this assumption. Report of Cases: We report a series of 7 cases of CP induced hepatitis, with application of the Clinical Scale for the Diagnosis of Drug-Induced Hepatitis (CSDDIH) by Maria VAJ and Victorino RMM in parallel with the results of in vitro T-lymphocyte proliferation assays (TL-PA) with the drug. There were 4 males and 3 females, mean age 53 years. Duration of CP use and onset of symptoms or laboratory changes varied from 6 to 90 days in 6 cases. In 1 case CP had been used for 7 years. Jaundice, pruritus, rash and fever were the most frequent symptoms. The pattern of liver injury was mainly cholestatic (hepatocelular in 2 patients). Bilirrubin, g-GT and alkaline phosphatase averaged 12, 13 and 5 times, respectively, the upper reference limit. Time until normalisation of liver enzymes exceeded 6 months in 2 cases and severity of clinical pictures lead to hospital admission in all patients. Liver ultrasound, performed in all patients, was normal in 5. Liver biopsy was performed in 3 patients. The CSDDIH yielded a score of probable in 3 cases and possible in 4 for CP hepatotoxicity. In vitro TL-PA with the drug were positive in 4 cases. Discussion: Captopril associated hepatic toxicity, although not frequent, constitutes an important clinical problem. Diagnosis requires a high index of suspicion and use of strict protocols for exclusion of alternative causes and establishing a consistent temporal relation between drug intake and the onset of clinical symptoms. Diagnostic clinical scales and, in selected cases, the use of TL-PA, are important elements in supporting the diagnosis of this situation.
TH-75 ANCYLOSTOMA DUODENALE INFESTATION PRESENTING WITH BICITOPENIA H.M.G. Martins, S. Lourenço, J.A.M. Araújo. Serviço de Medicina 1, Hospital Fernando Fonseca, Portugal Anemia is a very common clinical condition, but values below 4 g/dL are usually significantly symptomatic except in slowly progressive situations. At such lower levels it is frequent that more than one factor contribute to anemia and etiologies can range from frequent GI obscure bleeding or nutritional deficits, to bone marrow involvement, or chronic infections. Ancylostomic anemia has been classified into i) compensated; ii) hypocromic microcitic with reticulocitosis and iii) “aplastic anemia” or “irreversible type”. We present the case of a 61 year-old black male who had arrived from Guiné-Bissau two months before and was referred to our hospital for fatigue and an abnormal hemoglobin determination. He had no relevant medical history except complaints of fatigue in the last two months and possible dietary insufficiencies. Physical examination revealed wasting and pallor. Laboratory study showed bicitopenia (Hb - 3.3g/dL, MCV - 64.6fL, MCH 18.3pg; Reticulocytes – 0.02×106 /µL; Platelets – 51000/µL), serum iron - 40µg/dL and ferritin 16ng/mL. Endoscopy revealed duodenitis with filariform worms and stool testing confirmed an Ancylostoma Duodenale infestation. Inpatient treatment included 8 RBC units, mebendazole and oral iron. Patient was discharged asymptomatic, with Hb= 9.1g/dL and platelets = 37000/µL; thus, myelogram and bone marrow biopsy were preformed to exclude aplastic anemia. These exams were compatible with a moderately reactive marrow without iron deposits. There was a late recovery of hemoglobin and platelets levels. A diagnosis of bicitopenia due to type 2 ancylostomic anemia, without reticulocitosis due to concomitant severe nutritional iron deficit is proposed. This case highlights the interest of exploring undiagnosed chronic conditions in migrant populations, as well as, shows that often after initial stabilization of the patient further investigation is relevant to exclude concurrent/aggravating conditions and roll out underlying severe disease
TH-73 ABCIXIMAB INDUCED THROMBOCYTOPENIA – “TWO CASES OF A KIND” Clarinda Neves, Paula Dias, Gonçalo Rocha, Fernando Friões, João Paulo Araújo, Jorge Almeida. Hospital S. João, Porto, Portugal Abciximab is widely used in patients undergoing percutaneous coronary intervention. Although rare, abciximab induced thrombocytopenia (AIT) may have different courses. Case 1: A 69 year old male was admitted at the emergency department with an acute myocardial infarction and was submitted to angioplasty and stenting of the anterior descendent artery. A bolus of unfractioned heparin and abciximab followed by a 12 hour infusion was administered. The platelet count previous to the procedure was 303×109 /liter, and at 12 hours and day 3 was 497 and 413 x109/liter. He was discharged on day 6 under state of the art therapy. Twelve days after the procedure he was readmitted with malaise and a petechial rash on the lower limbs. His platelet count was 13×109 /liter. Peripheral blood smear and coagulation screen were normal and myelogram suggested peripheral platelet destruction. He developed epistaxis, and on day 3 the platelet count was <10×109 /liter. Platelet infusion was initiated. On day 6 he became dysartric. The CT scan showed a thalamic haemorrhage. He became rapidly comatose, with hydrocephaly and an external ventricular derivation was placed without clinical improvement. Case 2: A 71 year old male was admitted to elective coronary angiography and submitted to angioplasty and stenting of the right coronary artery. He received clopidogrel, and a bolus of heparin and abciximab followed by a 12 hour infusion. The platelet count 8 hours after the procedure was 14 x109/liter. He was asymptomatic. The coagulation screen was normal. He remained under surveillance and the platelet count on day 1, 2 and 4 were <10, 19 and 75×109 /liter. He was discharged on day 5, without any complications. These 2 cases demonstrate the different course of AIT. The cases of delayed thrombocytopenia are scarce, but raise the question of a platelet count evaluation few days after the procedure. The patients should be advised for surveillance of symptoms associated with this complication.
TH-74 CAPTOPRIL ASSOCIATED HEPATITIS: CLINICAL AND IMMUNOLOGICAL STUDY OF 7 CASES Patrícia Howell Monteiro, Luís dos Santos Pinheiro, Adriana Albuquerque, Ana Espada Sousa, Margarida Lucas. Internal Medicine Department 2, Hospital de Santa Maria and Clinical Immunology Unit - IMM Introduction: Captopril (CP) is broadly used in clinical practice, with a low incidence of severe adverse reactions. CP associated hepatitis is described
S27
only as individual case reports and there are no references to structured series. CP hepatotoxicity is thought to be immunological and T-cell mediated, but there are no published immunological studies confirming this assumption. Report of Cases: We report a series of 7 cases of CP induced hepatitis, with application of the Clinical Scale for the Diagnosis of Drug-Induced Hepatitis (CSDDIH) by Maria VAJ and Victorino RMM in parallel with the results of in vitro T-lymphocyte proliferation assays (TL-PA) with the drug. There were 4 males and 3 females, mean age 53 years. Duration of CP use and onset of symptoms or laboratory changes varied from 6 to 90 days in 6 cases. In 1 case CP had been used for 7 years. Jaundice, pruritus, rash and fever were the most frequent symptoms. The pattern of liver injury was mainly cholestatic (hepatocelular in 2 patients). Bilirrubin, g-GT and alkaline phosphatase averaged 12, 13 and 5 times, respectively, the upper reference limit. Time until normalisation of liver enzymes exceeded 6 months in 2 cases and severity of clinical pictures lead to hospital admission in all patients. Liver ultrasound, performed in all patients, was normal in 5. Liver biopsy was performed in 3 patients. The CSDDIH yielded a score of probable in 3 cases and possible in 4 for CP hepatotoxicity. In vitro TL-PA with the drug were positive in 4 cases. Discussion: Captopril associated hepatic toxicity, although not frequent, constitutes an important clinical problem. Diagnosis requires a high index of suspicion and use of strict protocols for exclusion of alternative causes and establishing a consistent temporal relation between drug intake and the onset of clinical symptoms. Diagnostic clinical scales and, in selected cases, the use of TL-PA, are important elements in supporting the diagnosis of this situation.
TH-75 ANCYLOSTOMA DUODENALE INFESTATION PRESENTING WITH BICITOPENIA H.M.G. Martins, S. Lourenço, J.A.M. Araújo. Serviço de Medicina 1, Hospital Fernando Fonseca, Portugal Anemia is a very common clinical condition, but values below 4 g/dL are usually significantly symptomatic except in slowly progressive situations. At such lower levels it is frequent that more than one factor contribute to anemia and etiologies can range from frequent GI obscure bleeding or nutritional deficits, to bone marrow involvement, or chronic infections. Ancylostomic anemia has been classified into i) compensated; ii) hypocromic microcitic with reticulocitosis and iii) “aplastic anemia” or “irreversible type”. We present the case of a 61 year-old black male who had arrived from Guiné-Bissau two months before and was referred to our hospital for fatigue and an abnormal hemoglobin determination. He had no relevant medical history except complaints of fatigue in the last two months and possible dietary insufficiencies. Physical examination revealed wasting and pallor. Laboratory study showed bicitopenia (Hb - 3.3g/dL, MCV - 64.6fL, MCH 18.3pg; Reticulocytes – 0.02×106 /µL; Platelets – 51000/µL), serum iron - 40µg/dL and ferritin 16ng/mL. Endoscopy revealed duodenitis with filariform worms and stool testing confirmed an Ancylostoma Duodenale infestation. Inpatient treatment included 8 RBC units, mebendazole and oral iron. Patient was discharged asymptomatic, with Hb= 9.1g/dL and platelets = 37000/µL; thus, myelogram and bone marrow biopsy were preformed to exclude aplastic anemia. These exams were compatible with a moderately reactive marrow without iron deposits. There was a late recovery of hemoglobin and platelets levels. A diagnosis of bicitopenia due to type 2 ancylostomic anemia, without reticulocitosis due to concomitant severe nutritional iron deficit is proposed. This case highlights the interest of exploring undiagnosed chronic conditions in migrant populations, as well as, shows that often after initial stabilization of the patient further investigation is relevant to exclude concurrent/aggravating conditions and roll out underlying severe disease