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P415 Giant-cell arteritis. A retrospective study of 19 patients
Abstracts
I European
Journal
of Internal
23 patients (52.3%). None of the patients were treated with thrombolytic therapy. In our hospital there is not a stroke unit available. Conclusions: Most of quality of care indicators of ACOVE project were met succesfully in our patients with stroke. Achievement of carotid artery imaging and smoking status assessment should improve.
P415 Giant-cell arteritis. A retrospective E. Alonso, D. Blazquez, M. Ruiz, Rico (Madrid, E)
study of 19 patients A. Salinas. D. L6pez, A. Ruiz,
L.A.
Introduction; Giant-cell arteritis (GCA) is a multisystemic disease that involves large and medium-sized blood vessels in elderly people. Objectives: To analyse the main clinical and laboratory findings of GCA in our hospital. Methods; We enrolled in a retrospective study all patients diagnosed of GCA who had undergone a temporal artery biopsy between January 1997 and December 2002. Results: 19 cases were analysed (15 females, 4 males), with a mean age of 75.3 years at the first symptom. Headache was the most frequent symptom and the main reason for consultation (14 patients). with variable localization. Fatigue was present in 12 cases and jaw claudication in 11. Non specific loss of strength, myalgias and arthralgias were present in 10 cases; 3 of them were finally diagnosed of polymyalgia rheumatica. Less frequent symptoms were weight loss (8) temperature >38 “C (6) and visual loss (3). Upon physical examination the most frequent findings were palpable, thickened and pulseless temporal arteries. Ancillary tests showed normocytic anaemia, with a mean hemoglobin of 11.6 g/dl, mean corpuscular volume of 87.2 mm and erytrocyte sedimentation rate (ESR) of 80.6. Only 2 of the 13 patients in whom autoantibodies were determined showed positive antinuclear antibodies in low titers. In none or the cases was a bilateral biopsy needed for diagnosis. Conclusions: In our hospital GCA is a vasculitis predominant in older patients, most frequently in women, whose main presenting symptom is headache in patients with palpable and thickened temporal arteries. It is accompanied by normocytic anaemia and elevated ESR. The definitive diagnosis is a biopsy study; determination of autoantibodies is not necessary.
P416 Pseudo-angiocholitis I. Marie, G. Riachi, (Rouen-Boisguillaume,
revealing P. Ducrotte, F)
adult-onset Still’s disease A. Francois, H. Levesque,
H. Courtois
Whether liver impairment is frequent in patients with adult-onset Still’s disease (AOSD), it is typically asymptomatic and restricted to slight abnormalities of serum liver tests. We describe a case, which is original as the patient developed pseudo-angiocholitis pattern that revealed AOSD. A 59-year-old man was admitted with a 3-day history of jaundice and abdominal pain of the right hypochondrium area. He also complained of a daily spiking fever of 3 weeks’ duration and arthritis of the right knee and left ankle. Laboratory studies showed: ESR 150 mm/hour, CRP 355 mgll, white blood cell count 19 G/l (90% neutrophils), total bilirubin 70 pmol/l, alkaline phosphatase 1984 IU/l, gamma-glutamyltransferase 575 IU/l, aspartate aminotransferase 78 IU/l, alanine aminotransferase 179 IU/l and ferritin levels 3500 kg/l. Abdominal ultrasound was normal. Blood cultures, serologies for viruses and bacteria were negative. Needle aspiration of right knee effusion revealed sterile exudative fluid. Autoantibody screen was negative. Thoracic CT-scan showed mild bilateral pleural effusions. Other tests, e.g. bronchoscopy, transesophageal echocardiography and sternal bone marrow aspirate, were normal. The patient initially received ceftriaxone and ofloxacin. Because he remained febrile. liver biopsy was performed, showing inflammatory infiltrates in
Medicine
14 (2003)
s147
Sl-S159
portal areas with mild focal hepatocyte necrosis. A diagnosis of AOSD revealed by pseudo-angiocholitis pattern was made; percentage of glycosylated serum ferritin was decreased: 18% (N>50%), confirming that diagnosis. The patient was successfully given prednisone, resulting in resolution of all signs. Finally, our findings undercore that AOSD diagnosis should be considered in patients with febrile jaundice, particularly in those who exhibit blood ferritin values > 1000 kg/l without evidence of infections or lymphoproliferative disorders. We also suggest that in such patients, an evaluation for glycosylated serum ferritin should be done systematically, as decreased percentage of glycosylated ferritin was noted in 93% AOSD patients.
P417 Recurrent multiorgan toxicity of Methotrexate vasculitis A. Bourgarit, C. Toledano, C. Georges, D. Farge,
during
treatment
D. Sereni
(Paris,
of F)
Introduction: Methotrexate (MTX) treatment of systemic inflammatory disease and vasculitis is often limited by side effects. Case: A 68.year-old man was referred for a sudden right abdominal pain. This patient was treated since 15 months for an ANCA negative microscopic polyangeitis. Eight month before, he began a maintenance treatment associating steroids and 25 mglwk MTX. This abdominal pain used to occur every week, 3 days after the oral MTX intake and recover spontaneously 24 hours later. There was no evidence of pulmonary embolism, pleurisy, hepatic or cholostatic disorder, neither pancreatitis nor gastric ulcer. The patient had anemia and leucopenia, the MTX dose was lowered to 20 mg/wk without any effect on the abdominal pain. One month later, he was admitted to the hospital intensive care unit(ICU) for unbearable left abdominal pain and dyspnoea. The examination showed a dyspneic and hypoxic patient, with a basithoracic left pain. Chest CT scan disclosed bilateral basal interstitial pneumopathy with pleural effusion. No infectious agent was found. Renal biopsy did not show any sign of vasculitis activity. Treatment consisted of oxygen support, withholding MTX and 3 steroid attack associated with antibiotics. The patients respiratory condition improved and he was discharged from ICU 3 days later. The 13 days later, control chest CT scan showed the no more pleural effusion nor interstitial pneumopathy. We considered the diagnosis of toxic MTX interstitial pneumonitis revealed by recurrent abdominal toxicity. The patient remains free of abdominal pain since MTX was stopped. Discussion: The most common adverse effect of MTX is gastrointestinal (GI) toxicity, no description of such recurrent cyclic abdominal pain becoming after each MTX intake can be found in the literature. This case shows that MTX GI toxicity can be multiple and announce a serious pulmonary toxicity. This patient had cumulated unusual and recurrent GI, hematologic and pulmonary MTX toxicity.
P418 Integrated management system of the drug circuit - Internal Medicine Service Experience P. Carrola, P. Dias, N. Devesa, F. Machado, F. Parente, P. Moura, J. Feio, E. Cunha, 0. Isabel, .I. Abreu, J. Costa R., B. Alexandrine, A. Moura J. (Coimbra, P) Introduction: of an Internal Drug Circuit tal in January To this date, specialities. Objectives: implementation
Prescription is a basic medical action in the daily Medicine ward. The Integrated Management System (IMSDC) was implemented at Coimbra’s University 2000. The pilot-service was our Internal Medicine the system was extended to 387 beds, including To present the experience with the IMSDC, model, the computerized prescription
practice of the HospiService. several
including files and
the the
I European
Journal
of Internal
23 patients (52.3%). None of the patients were treated with thrombolytic therapy. In our hospital there is not a stroke unit available. Conclusions: Most of quality of care indicators of ACOVE project were met succesfully in our patients with stroke. Achievement of carotid artery imaging and smoking status assessment should improve.
P415 Giant-cell arteritis. A retrospective E. Alonso, D. Blazquez, M. Ruiz, Rico (Madrid, E)
study of 19 patients A. Salinas. D. L6pez, A. Ruiz,
L.A.
Introduction; Giant-cell arteritis (GCA) is a multisystemic disease that involves large and medium-sized blood vessels in elderly people. Objectives: To analyse the main clinical and laboratory findings of GCA in our hospital. Methods; We enrolled in a retrospective study all patients diagnosed of GCA who had undergone a temporal artery biopsy between January 1997 and December 2002. Results: 19 cases were analysed (15 females, 4 males), with a mean age of 75.3 years at the first symptom. Headache was the most frequent symptom and the main reason for consultation (14 patients). with variable localization. Fatigue was present in 12 cases and jaw claudication in 11. Non specific loss of strength, myalgias and arthralgias were present in 10 cases; 3 of them were finally diagnosed of polymyalgia rheumatica. Less frequent symptoms were weight loss (8) temperature >38 “C (6) and visual loss (3). Upon physical examination the most frequent findings were palpable, thickened and pulseless temporal arteries. Ancillary tests showed normocytic anaemia, with a mean hemoglobin of 11.6 g/dl, mean corpuscular volume of 87.2 mm and erytrocyte sedimentation rate (ESR) of 80.6. Only 2 of the 13 patients in whom autoantibodies were determined showed positive antinuclear antibodies in low titers. In none or the cases was a bilateral biopsy needed for diagnosis. Conclusions: In our hospital GCA is a vasculitis predominant in older patients, most frequently in women, whose main presenting symptom is headache in patients with palpable and thickened temporal arteries. It is accompanied by normocytic anaemia and elevated ESR. The definitive diagnosis is a biopsy study; determination of autoantibodies is not necessary.
P416 Pseudo-angiocholitis I. Marie, G. Riachi, (Rouen-Boisguillaume,
revealing P. Ducrotte, F)
adult-onset Still’s disease A. Francois, H. Levesque,
H. Courtois
Whether liver impairment is frequent in patients with adult-onset Still’s disease (AOSD), it is typically asymptomatic and restricted to slight abnormalities of serum liver tests. We describe a case, which is original as the patient developed pseudo-angiocholitis pattern that revealed AOSD. A 59-year-old man was admitted with a 3-day history of jaundice and abdominal pain of the right hypochondrium area. He also complained of a daily spiking fever of 3 weeks’ duration and arthritis of the right knee and left ankle. Laboratory studies showed: ESR 150 mm/hour, CRP 355 mgll, white blood cell count 19 G/l (90% neutrophils), total bilirubin 70 pmol/l, alkaline phosphatase 1984 IU/l, gamma-glutamyltransferase 575 IU/l, aspartate aminotransferase 78 IU/l, alanine aminotransferase 179 IU/l and ferritin levels 3500 kg/l. Abdominal ultrasound was normal. Blood cultures, serologies for viruses and bacteria were negative. Needle aspiration of right knee effusion revealed sterile exudative fluid. Autoantibody screen was negative. Thoracic CT-scan showed mild bilateral pleural effusions. Other tests, e.g. bronchoscopy, transesophageal echocardiography and sternal bone marrow aspirate, were normal. The patient initially received ceftriaxone and ofloxacin. Because he remained febrile. liver biopsy was performed, showing inflammatory infiltrates in
Medicine
14 (2003)
s147
Sl-S159
portal areas with mild focal hepatocyte necrosis. A diagnosis of AOSD revealed by pseudo-angiocholitis pattern was made; percentage of glycosylated serum ferritin was decreased: 18% (N>50%), confirming that diagnosis. The patient was successfully given prednisone, resulting in resolution of all signs. Finally, our findings undercore that AOSD diagnosis should be considered in patients with febrile jaundice, particularly in those who exhibit blood ferritin values > 1000 kg/l without evidence of infections or lymphoproliferative disorders. We also suggest that in such patients, an evaluation for glycosylated serum ferritin should be done systematically, as decreased percentage of glycosylated ferritin was noted in 93% AOSD patients.
P417 Recurrent multiorgan toxicity of Methotrexate vasculitis A. Bourgarit, C. Toledano, C. Georges, D. Farge,
during
treatment
D. Sereni
(Paris,
of F)
Introduction: Methotrexate (MTX) treatment of systemic inflammatory disease and vasculitis is often limited by side effects. Case: A 68.year-old man was referred for a sudden right abdominal pain. This patient was treated since 15 months for an ANCA negative microscopic polyangeitis. Eight month before, he began a maintenance treatment associating steroids and 25 mglwk MTX. This abdominal pain used to occur every week, 3 days after the oral MTX intake and recover spontaneously 24 hours later. There was no evidence of pulmonary embolism, pleurisy, hepatic or cholostatic disorder, neither pancreatitis nor gastric ulcer. The patient had anemia and leucopenia, the MTX dose was lowered to 20 mg/wk without any effect on the abdominal pain. One month later, he was admitted to the hospital intensive care unit(ICU) for unbearable left abdominal pain and dyspnoea. The examination showed a dyspneic and hypoxic patient, with a basithoracic left pain. Chest CT scan disclosed bilateral basal interstitial pneumopathy with pleural effusion. No infectious agent was found. Renal biopsy did not show any sign of vasculitis activity. Treatment consisted of oxygen support, withholding MTX and 3 steroid attack associated with antibiotics. The patients respiratory condition improved and he was discharged from ICU 3 days later. The 13 days later, control chest CT scan showed the no more pleural effusion nor interstitial pneumopathy. We considered the diagnosis of toxic MTX interstitial pneumonitis revealed by recurrent abdominal toxicity. The patient remains free of abdominal pain since MTX was stopped. Discussion: The most common adverse effect of MTX is gastrointestinal (GI) toxicity, no description of such recurrent cyclic abdominal pain becoming after each MTX intake can be found in the literature. This case shows that MTX GI toxicity can be multiple and announce a serious pulmonary toxicity. This patient had cumulated unusual and recurrent GI, hematologic and pulmonary MTX toxicity.
P418 Integrated management system of the drug circuit - Internal Medicine Service Experience P. Carrola, P. Dias, N. Devesa, F. Machado, F. Parente, P. Moura, J. Feio, E. Cunha, 0. Isabel, .I. Abreu, J. Costa R., B. Alexandrine, A. Moura J. (Coimbra, P) Introduction: of an Internal Drug Circuit tal in January To this date, specialities. Objectives: implementation
Prescription is a basic medical action in the daily Medicine ward. The Integrated Management System (IMSDC) was implemented at Coimbra’s University 2000. The pilot-service was our Internal Medicine the system was extended to 387 beds, including To present the experience with the IMSDC, model, the computerized prescription
practice of the HospiService. several
including files and
the the