Successful treatment of acute kidney injury secondary to haeme nephropathy in paroxysmal nocturnal haemoglobinuria with alkaline diuresis

Paroxysmal nocturnal haemoglobinuria (PNH) also known as ‘Marchiafava Micheli syn-drome’ is a rare condition which can lead to both acute and chronic forms of renal failure through renal tubular haemosiderin deposition. A 45-year-old lady with underlying PNH, pre-sented with complaints of fever, productive cough followed by dark coloured urine. Investiga-tions revealed pancytopenia with a markedly raised creatinine from her baseline (from 65 mmol/L to 385 mmol/L) consistent with acute kidney injury (AKI). Renal biopsy con-firmed the diagnosis of haeme nephropathy. The renal impairment improved rapidly and nor-malised over a period of 5 days with alkaline diuresis (AD). The patient did not require hae-modialysis unlike most other reported cases of AKI secondary to haeme nephropathy in PNH. This is the second reported case of AKI in PNH which was successfully treated with AD alone emphasizing the role of AD as a promising therapeutic strategy in this condition

Beyond the joints in rheumatoid arthritis

Introduction: Tumor necrosis factor alpha (TNFα) is a multifunctional cytokine which plays a pivotal role in the pathogenesis of rheumatoid arthritis (RA). Apart from its well recognized pro-inflammatory properties, it is known to interfere with lipid metabolism and erythropoiesis. Materials and Methods: We evaluated the effects of adalimumab on hematologic, lipid and inflammatory parameters using data from patients on adalimumab 40 mg fortnightly from 2 centers in Malaysia. Mean changes in laboratory values from baseline to Weeks 4, 12 and 24 were compared using paired T test and Wilcoxon signed-rank test. Results: We studied 18 patients with RA who were on adalimumab 40 mg fortnightly. The inflammatory markers i.e. erythrocyte sedimentation rate and C reactive protein showed significant changes as early as at week 4 compared to baseline with p values of 0.003 and 0.005, respectively. From a baseline of high disease activity with a mean Disease Activity Score using 28 joint counts (DAS 28) of 5.3, there was a steady improvement in the disease activity and remission was achieved at week 24 with a DAS 28 of 2.4. The hemoglobin level improved at week 12 (p=0.013) and this was sustained till week 24. As opposed to previous studies, the LDL level significantly decreased at week 12 (p=0.015) and this change persisted till week 24 (p=0.001). The total cholesterol showed a similar pattern as the LDL. Conclusions: The pharmacodynamics of adalimumab therapy in rheumatoid arthritis extend beyond the joints with favorable effects on haemoglobin and lipid profile

Gender differences in clinical characteristics of rheumatoid arthritis

The most prevalent type of autoimmune inflammatory arthritis is rheumatoid arthritis (RA). Sex hormones are strongly associated in the pathogenesis and progression of RA. Hence, the core objective of this study was to compare the clinical features of RA among men and women. We consecutively recruited 23 men and 23 age-matched women with RA from our rheumatology clinic. Subjects were evaluated for their disease activities, radiographic joint damages and functional capacities. The above assessment was performed using DAS-28, Modified Sharp Score (MSS) and European League Against Rheumatism (EULAR) response criteria; respectively. The mean age for the male and female patients were 60.87 + 12.5 and 60.70 + 11.73, respectively. We found that the female subjects had significantly higher c-reactive protein (CRP) levels (p=0.05). The HAQ-DI(p<0.02) and MSS scores (p<0.001) of women were substantially higher than those of males. HAQ-DI and MSS remained to be independently associated with female gender in multivariate analysis, with p values of 0.017 and 0.014, respectively. The findings of this study suggested that in RA, compared to men, women had more severe joint damage and functional disability

Effects of Tumour Necrosis Factor Antagonists on Insulin Sensitivity/Resistance in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

Objective Beyond the joints, TNFi (tumour necrosis factor inhibitor) therapy may confer systemic benefits in rheumatoid arthritis (RA). Several studies have investigated the role of TNFi on insulin resistance/sensitivity (IR/IS). This question is of general interest given the emerging evidence linking inflammation and insulin resistance. The main aim of this review was to summarise the published data and to determine the effects of TNFi on IR/IS. Methods We searched the PubMed and ISI Web of Knowledge databases for studies which examined the effects of TNFi on IR/IS. The studies were assessed independently by two reviewers according to a pre-specified protocol. The data on Homeostatic Model Assessment for Insulin resistance (HOMA) and Quantitative Insulin Sensitivity Check Index (QUICKI) were pooled and reported as standard difference in means (SDM) with 95% confidence interval (CI) using a random-effects model. Results A total of eight studies with 260 subjects met the selection criteria. The duration of the studies was from 8 weeks to 12 months. There was statistically significant reduction in HOMA index in six out of eight studies and four reported significant increment in QUICKI. The pooled analysis revealed significant reduction in HOMA [SDM-0.148, 95%CI[-0.278 to -0.017], p=0.026] and increment in QUICKI [SDM 0.312, 95%CI[0.019 to 0.606], p=0.037] with TNFi

Eosinophilic gastroenteritis as the initial manifestation of hypereosinophilic syndrome.

Eosinophilic gastroenteritis, an inflammatory disease of unknown etiology, commonly involves the stomach and small intestine with eosinophilic infiltration. Here, we report an unusual case of eosinophilic gastroenteritis involving the entire digestive tract as a manifestation of hypereosinophilic syndrome (HES). A 22-year-old woman presented to us with diarrhoea, pleural effusion, ascites and marked peripheral oeosinophilia. Stool specimens were negative for parasites, ova, bacteria, and fungi. Endoscopic studies showed pangastritis and duodenitis. Biopsy specimens of the oesophagus, stomach, duodenum, ileum, and colon demonstrated oeosinophilic infiltration. A diagnosis of hypereosinophilic syndrome with eosinophilic gastroenteritis involving the entire digestive tract was made. Hence, she was treated with prednisolone. Symptoms and peripheral oeosinophilia rapidly resolved with treatment, and radiological investigations revealed resolution of effusion. This case illustrates the wide spectrum of clinical manifestation of the disease, whereby it involves the entire digestive tract and it also emphasizes the diagnostic yields of endoscopic biopsies