An uncommon presentation of eosinophilic granulomatosis with polyangiitis: a case report

INTRODUCTION: Eosinophilic granulomatosis with polyangiitis is a rare and potentially fatal disease if not readily diagnosed. Cerebral involvement is extremely rare and clinical presentation as hemorrhagic stroke is even rarer. CASE PRESENTATION: A 58-year-old Caucasian man was admitted to our medical unit because of a computed tomography-diagnosed hemorrhagic stroke with right-sided hemiparesis and fever. A chest computed tomography scan also revealed multiple bilateral pulmonary infiltrates; coronary artery, and carotid and left vertebral artery calcifications were also observed. Empiric antimicrobial therapy with cephalosporins was promptly undertaken; low-molecular-weight heparin was introduced as prophylaxis for venous thromboembolism. Over the following days, magnetic resonance imaging scans showed a regression of the hemorrhagic framework, also revealing hypoxic areas consistent with acute ischemic lesions. With a computed tomography scan showing a worsening of his pulmonary framework, antimicrobial therapy was modified and corticosteroids were introduced. A new blood cell count revealed further increased leukocytosis (17.49×10(3)μL), characterized by a surprising rise of eosinophilic cells (32.8%). Angiography of the coronary arteries found diffuse dilatations with severe signs of endothelial damage. Such an unexpected framework induced a strong suspicion that the stroke was the expression of a systemic vasculitis, which had triggered his cerebral, coronary, and pulmonary frameworks. The search for antineutrophil cytoplasmic antibody was positive for perinuclear antineutrophil cytoplasmic antibody, and eosinophilic granulomatosis with polyangiitis was diagnosed. Explaining to the patient the rarity of his disease, and what the most typical presentations of eosinophilic granulomatosis with polyangiitis were, he revealed that before admission he had had scalp injuries, in the nuchal region, and had taken corticosteroids as self-medication, with subsequent disappearance of the lesions. Therefore, high-dose corticosteroid treatment was started, and at discharge he was in good clinical condition with a slight right-sided hyposthenia. CONCLUSIONS: A diagnosis of eosinophilic granulomatosis with polyangiitis is often difficult, but we are convinced that intake of corticosteroids on a self-prescribed basis may have obscured the clinical presentation. Therefore, this case also suggests how the growing phenomenon of self-medication can be harmful, and that a careful investigation of clinical history is still an act of paramount importance

Bisphosphonate-associated femoral fracture: implication for management

Studies carried out on individuals being treated long term with bisphosphonates have provoked considerable interest and perplexity about the effect that these drugs have on bone turnover in the long run. In fact the experiences reported by numerous researchers tend to highlight how treatment with high doses of bisphosphonates over many years, of individuals with osteoporosis complicated by or secondary to neoplastic pathologies, causes a suppression of bone turnover that over time predisposes the bone to the accumulation of micro damage that can then result in complicated fractures, as in the case described here

PREVALENCE OF DIASTOLIC DYSFUNCTION IN PATIENTS WITH ARTERIAL HYPERTENSION AND CHRONIC KIDNEY DISEASE

Introduction: In patients with arterial hypertension and chronic kidney disease (CKD), the prevalence of diastolic heart failure (HF-PEF) is probably very high. However, in these patients the diagnosis is difficult, especially because the signs and symptoms suggestive of HF-PEF are very common in CKD; in these cases the detection of left ventricular structural and functional alterations (as reported in the 2012 ESC guidelines on heart failure), assumes a decisive role for the diagnosis of HF-PEF. Aim: To evaluate the prevalence of patients with diastolic dysfunction according to ESC guidelines 2012 in a population of Hypertensive patients with CKD. Methods: We studied 466 hypertensive patients with mean age of 62.3 ± 12.6 years (M/F = 262/204) suffering from chronic kidney disease (stages 3-4-5 KDIGO), with a mean value of GFR equal to 26.8 ± 15.1 mL/min/1.73 m2. The criteria for exclusion from the study were: EF\50 %, other cardiovascular diseases that could cause heart failure. Were considered with diastolic dysfunction, all patients with a value of Em (evaluated with tissue Doppler imaging at lateral mitral annulus) less than 10 cm/s. Results: We found a value of Em \10 cm/s in 331/466 patients (71 %). In order to determine the role of CKD to explain the very high prevalence of diastolic dysfunction, we selected 160 hypertensive patients with overlapping features to the previous group with regard to age, sex, BMI, etc. In this population the prevalence of diastolic dysfunction was 43.7 %. Conclusions: Our findings demonstrate a very high prevalence of diastolic dysfunction in the studied population; it is possible to assume that a large proportion of these patients had HF-PEF or is at high risk for its development. The finding of a lower prevalence of diastolic dysfunction in a hypertensive population supports the hypothesis of a decisive role of CKD in determining diastolic dysfunction and HF-PEF