DOCSLIB.ORG

Case Report Successful Treatment of Thrombocytopenia and Hemolytic Anemia with Ivig in a Patient with Lupus-Like Syndrome After Mismatched Related PBSCT

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Case Report Successful Treatment of Thrombocytopenia and Hemolytic Anemia with Ivig in a Patient with Lupus-Like Syndrome After Mismatched Related PBSCT Bone Marrow Transplantation (2001) 27, 337–340 2001 Nature Publishing Group All rights reserved 0268–3369/01 $15.00 www.nature.com/bmt Case report Successful treatment of thrombocytopenia and hemolytic anemia with IvIG in a patient with lupus-like syndrome after mismatched related PBSCT A Hartert, W Willenbacher, S Gu¨nzelmann, E Roemer, N Basara, AA Fauser and MG Kiehl Clinic of Bone Marrow Transplantation and Haematology/Oncology, Idar-Oberstein Germany Summary: weakness, edema, anemia, thrombocytopenia, and erosive cutaneous lesions. He had received a conditioning regimen Hematopoietic stem cell transplantation (HSCT) is a consisting of busulfan (4 mg/kg bw × day on days −7to treatment option for autoimmune diseases but can also −4) and cyclophosphamide (60 mg/kg bw × day on day −3 cause clinical features similar to those of autoimmune and day −2) before PBSCT. The donor was the patient’s diseases. In some of these cases the autoimmune-like sister. The patient’s blood group was A Rh positive, CMV- condition is associated with autoimmune cytopenia, a IgG seropositive and HLA-typing demonstrated HLA- complication that can be unresponsive to established A01/01, B 8/35, Cw 040/0701, DR 12/11, DRB1 120/110, treatment strategies and which may be fatal. The and DQB1 0301/0603. He received peripheral blood stem majority of cases reported on immune hemolytic anemia cells form his A Rh positive, CMV seronegative and HLA have been of alloimmune origin due to ABO red blood partially mismatched (DRB1 010×/110×; DQB1: cell antigen incompatibilities between donor and recipi- 0501/0603) sister. The graft contained 2.28 × 106 CD34+ ent. We now report a patient with a lupus-like syn- cells/kg/bw. drome, presenting with severe thrombocytopenia and GvHD prophylaxis consisted of cyclosporine (CYA) hemolytic anemia 9 months after HLA-mismatch, ABO starting on day −3, prednisolone starting on day +7 after compatible-related PBSCT who experienced no transplantation and MTX given as a short course on days response to high-dose steroids, but who had a sustained +1, +3 and +6 at a dose of 15 mg/m2 and twice at 10 mg/m2, response to repeated IvIG therapy. Bone Marrow Trans- respectively. Engraftment (leukocyte count Ͼ1000 × 109/l, plantation (2001) 27, 337–340. neutrophil count Ͼ0.5 × 109/l) occurred on day +21 after Keywords: autoimmune cytopenia; hematopoietic stem PBSCT. He developed slight cutaneous GVHD grade I–II cell transplantation; lupus-like syndrome; alloimmunity; which responded promptly to increased immunosuppres- IvIG sion with prednisolone (0.7 mg/kg bw × day) for 1 week, then tapered, and mycophenolate-mofetil (MMF) (2 g/day) for 3 months. CMV reactivation, as diagnosed by CMV-PCR, occurred Hematopoietic stem cell transplantation (HSCT) can cause 2 months after PBSCT (recipient CMV IgG positive, donor clinical symptoms characteristic of autoimmune diseases CMV IgG negative). This was successfully treated with like myasthenia gravis, immune thyroiditis, as well as ganciclovir, but the PCR became positive again shortly 1–11 immune cytopenia. Especially, autoimmune cytopenia is after cessation of therapy. He therefore received cidofovir 2,3 mostly refractory to standard therapeutic approaches. We as maintenance for 2 months. herein report a patient with a lupus-like syndrome associa- Immunosuppressive therapy on admission consisted of ted with hemolytic anemia and severe thrombocytopenia prednisolone 5 mg/day and CYA 150 mg/day given orally after HSCT. (blood level 284 ng/ml). Patient characteristics Clinical findings + Nine months (day 277) after a mismatched related allo- As papular cutaneous lesions were the main clinical finding geneic stem cell transplant (PBSCT) for CML in first CP, a viral infection was suspected, possibly herpes virus or a 38-year-old patient presented with weight gain, general VZV reactivation. CMV testing had been negative for the last 4 months. However, the CMV-PCR was positive at the time of admission. He was treated with foscarnet to avoid Correspondence: Dr MG Kiehl, Clinic of Bone Marrow Transplan- tation and Oncology/Oncology, Dr Ottmar-Kohler-Str. 2, 55743 Idar- further myelosuppression in a graft which was already Oberstein, Germany suboptimal. Testing for VZV and HSV was negative. Received 31 May 2000; accepted 4 October 2000 Within a few days of admission the patient developed Successful treatment of thrombocytopenia after PBSCT with IvIG A Hartert et al 338 fever, arthralgia, severe pancytopenia, generalized edema, resolved slowly. Colonoscopy demonstrated discrete polyserositis with pericardial and pleural effusions, and changes compatible with intestinal GVHD grade I. Thus, nephrotic syndrome. Creatinine levels increased to the prednisolone dose was increased from 5 mg/day to 176.8 ␮mol/l and creatinine clearance decreased to 12.5 mg/day, whereas the other immunosuppressive medi- 83 ml/min, with a mixed glomerular/tubular proteinuria of cation remained unchanged for the first days of inpatient 4.5 g/l. He had oliguria with a further weight gain of nearly treatment. Intestinal symptoms improved within 1 week. A 7 kg, and for 1 week he experienced diarrhea which com- few days after admission the patient developed a tempera- menced shortly after the onset of these symptoms. A bone ture up to 38.8°C. No infection focus was found. Testing marrow biopsy showed mild hypoplasia, incompatible with for other herpes viruses including VZV and EBV was nega- the severe peripheral cytopenia. Folic acid, vitamin B12 tive. With the onset of fever the hemoglobin and platelet and iron levels were within normal ranges; the ferritin level levels dropped to 4 g/dl and 6000/␮l, respectively, without was increased to 774 ng/ml. The hemoglobin decreased to increment after transfusion. Direct Coombs testing was 40 g/l, leukocyte count to 1.5 × 109/l from 3.1 × 109/l, and positive and blood smears showed fragmented cells due to platelet count to 6 × 109/l from 66 × 109/l (Figure 1). The hemolysis. The edema worsened with a further increase in reticulocyte count was 4.2%. Coagulation parameters were body weight up to 96.2 kg. Ultrasound and CT scan within the normal ranges. Endoscopy revealed no gastro- revealed a polyserositis. CYA medication for GVHD intestinal bleeding, but GVHD grade 2 of the bowel was prophylaxis was immediately stopped and replaced by diagnosed histologically. The pancytopenia was refractory MMF because of a possible CYA-induced microangiopa- to platelet and red cell transfusion. We observed a slight thy. Autoantibody screening was performed and findings increase in bilirubin levels to 27.36 ␮mol/l, but hapoglobins corresponded to an autoreactive process after allogeneic remained within the normal range (53 mg/dl). Blood smears PBSCT, comparable to a lupus-like syndrome that met six showed fragmented cells indicating severe haemolysis and of the ARC criteria for SLE (serositis, arthralgia, ANA, the direct Coombs test was positive. Further analysis Anti-ds-DNA, Coombs positive anemia, thrombocytopenia, revealed polyspecific antibodies and ANA titers which proteinuria, discoid skin lesions). We did not perform a increased from 1:20 000 to 1:40 000 within 3 weeks with kidney biopsy to assess the grade of renal involvement homogenous a IF-pattern, and concomitant slightly elevated because of the refractory thrombocytopenia. Neither patient anti ds-DNA antibodies (25 U/l and 30 U/l). Anti Scl 70, nor donor had a history of rheumatic disease. No other rela- Ro/SS-A, c-ANCA, p-ANCA, MPO, C3 nephritis factor, tive had suffered from autoimmune disease. anti-tubular and anti-glomerular basal membrane antibodies Treatment consisted of prednisolone 75 mg for 8 days, were negative. C3 complement was decreased to 68 mg/dl then reduced to 50 mg/day, and MMF 2 g/day. Intravenous (normal range 90–180 mg/dl) and C4 complement factor immunoglobulin (IvIG) treatment was started at a dose of was reduced to levels below 11 mg/dl (10–40 mg/dl). 0.4 mg/kg bw on 5 consecutive days. A total of four cycles Lupus-anticoagulant was negative. was given. Oliguria and edema were treated with furose- mide and xipermide. Renal function subsequently improved markedly. On day +329, 2 months after symptom onset, the Clinical course and therapy serum creatinine was within the normal range and pro- teinuria decreased from 4.5 g/l to 0.8 g/l. The patient’s body On admission (day +277 after PBSCT) skin rash, diarrhea weight declined from 96 kg (maximum) to his regular body three to four times a day, and pancytopenia were observed weight of 72 kg and he no longer required diuretics. Hemo- and interpreted as GVHD of the skin and bowel, associated globin level (50 g/l) and platelet count (23 × 109/l) were with graft dysfunction, possibly CMV associated. Joint still low at the time of discharge on day +368 and there pains were interpreted as symptoms of CMV disease. PCR were no clinical signs of anemia or bleeding. Hb and plate- testing was positive, but pp65 Ag was negative. Adminis- lets increased during the following 2 weeks to levels of tration of foscarnet, twice a day (90 mg/kg) improved the 70 g/l and 50 × 109/l, respectively. Three weeks later (day clinical symptoms of CMV disease and the cytopenia +398) the patient was readmitted with new self-limiting Platelet counts 140 120 IvIG /l) 9 100 80 60 40 Platelets (x10 20 0 270 275 279 283 291 297 305 335 341 370 400 421 447 533 590 751 Days post HSCT Figure 1 Response of platelet counts to IvIG treatment. ↓, IvIG treatment. Bone Marrow Transplantation Successful treatment of thrombocytopenia after PBSCT with IvIG A Hartert et al 339 episodes of arthralgia, decrease in platelet count Various drugs can induce an SLE-like syndrome. One (39 × 109/l) and Hb (37 g/l) associated with a slight of these is cyclosporine.
Load more

Recommended publications
  • Severe Asthma Associated with Myasthenia Gravis and Upper Airway Obstruction a Souza-Machado,1,2 E Ponte,2 ÁA Cruz2
    Severe Asthma and Myasthenia Gravis CASE REPORT Severe Asthma Associated With Myasthenia Gravis and Upper Airway Obstruction A Souza-Machado,1,2 E Ponte,2 ÁA Cruz2 1Pharmacology Department, Bahia School of Medicine and Public Health, Universidade Federal da Bahia, Salvador–Bahia, Brazil 2Asthma and Allergic Rhinitis Control Program (ProAR), Bahia Faculty of Medicine, Universidade Federal da Bahia, Salvador–Bahia, Brazil ■ Abstract An unusual association of asthma and myasthenia gravis (MG) complicated by tracheal stenosis is reported. The patient was a 35-year-old black woman with a history of severe asthma and rhinitis over 30 years. A respiratory tract infection triggered a life-threatening asthma attack whose treatment required orotracheal intubation and mechanical ventilatory support. A few weeks later, tracheal stenosis was diagnosed. Clinical manifestations of MG presented 3 years after her near-fatal asthma attack. Spirometry showed severe obstruction with no response after inhalation of 400 µg of albuterol. Baseline lung function parameters were forced vital capacity, 3.29 L (105% predicted); forced expiratory volume in 1 second (FEV1), 1.10 L (41% predicted); maximal midexpiratory fl ow rate, 0.81 L/min (26% predicted). FEV1 after administration of albuterol was 0.87 L (32% predicted). The patient’s fl ow–volume loops showed fl attened inspiratory and expiratory limbs, consistent with fi xed extrathoracic airway obstruction. Chest computed tomography scans showed severe concentric reduction of the lumen of the upper thoracic trachea. Key words: Asthma. Tracheal stenosis. Myasthenia gravis. Exacerbation. ■ Resumen En este caso informamos de una asociación infrecuente entre el asma y la miastenia grave (MG) complicada por estenosis traqueal.
    [Show full text]
  • Invasive Aspergillosis Poster IDSA FINAL Pdf.Pdf
    Invasive Aspergillosis Associated with Severe Influenza Infections Nancy Crum-Cianflone MD MPH Scripps Mercy Hospital, San Diego, CA USA Abstract Background (cont.) Results Results (cont.) Background: Bacterial superinfections are well-described complications of influenza • Typically, invasive aspergillosis occurs among severely immunosuppressed hosts Case-Control Study • Systematic Review of the Literature infection, however few data exist on invasive fungal infections in this setting. The Hematologic malignancies, neutropenia, and transplant recipients 48 medical ICU patients underwent influenza testing; 8 were diagnosed with influenza N=52 and present cases (n=5) = 57 total cases • All influenza-positive patients had ventilator-dependent respiratory failure A summary of the cases is shown in Table 2 pathogenesis of invasive aspergillosis may be related to respiratory epithelium • Isolation of Aspergillus sp. in the immunocompetent host without these conditions may be initially considered as a colonizer or non-pathogen Of the 8 patients with severe influenza infection, six (75%) had Aspergillus sp. isolated Increasing number of cases over time: disruption and viral-induced lymphopenia. • 4 A. fumigatus, 1 A. fumigatus and A. versicolor, and 1 A. niger isolated • First cases described in 1979, followed by three cases in the 1980s, two cases in the 1990s, two cases in • However, recent cases have suggested that Aspergillus may rapidly lead to invasive • Since A. niger was of unknown pathogenicity this case was excluded the 2000’s, and 48 cases from 2010 to the 1st quarter of 2016 demonstrating an increasing trend of aspergillosis superinfection (p<0.001) Methods: A retrospective study was conducted among severe influenza cases requiring disease in the setting of severe influenza infection [2,3] Of the 40 patients negative for influenza admitted to the same ICU, none had Aspergillus ICU admission at a large academic hospital (2015-2016).
    [Show full text]
  • Myasthenia Gravis
    FACT SHEET FOR PATIENTS AND FAMILIES Myasthenia Gravis What is myasthenia gravis? How is it diagnosed? Myasthenia [mahy-uh s-THEE-nee-uh] gravis is a disease Your doctor will ask you about your symptoms, where the body’s immune system attacks the perform a physical examination, and review all of connection between the nerve and muscle, causing your blood work and other tests. More blood work weakness. might be ordered to look for signs that the immune system might be attacking the muscles. A doctor may What causes it? What are the risk also perform a nerve conduction study known as factors? electromyography [ih-lek-troh-mahy-OG-ruh-fee} or EMG. Myasthenia gravis is an autoimmune [aw-toh-i-MYOON] An EMG records the electrical activity of muscles. disease. It occurs when the parts of the immune system that normally attack bacteria and viruses What are the complications? (antibodies) accidentally attack the connection If symptoms become severe, you may not be able between the nerve and muscle, also known as the to breathe normally or swallow saliva or food. This neuromuscular [noor-oh-MUHS-kyuh-ler] junction. results in aspiration [as-puh-REY-shuh n], where food or saliva goes into your airway. Serious complications The antibodies block a chemical called acetylcholine like these can result in injury or even death if left [uh-seet-l-KOH-leen], which is released by the nerve untreated. ending to activate the muscle, creating movement. Blocking this chemical causes weakness. How is it treated? Risk factors for myasthenia gravis include having a Mild symptoms are treated with a medicine called personal or family history of autoimmune diseases.
    [Show full text]
  • Multiple Sclerosis Associated with Defects in Neuromuscular Transmission
    Journal ofNeurology, Neurosurgery, and Psychiatry, 1972, 35, 385-394 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.3.385 on 1 June 1972. Downloaded from Multiple sclerosis associated with defects in neuromuscular transmission BERNARD M. PATTEN, AVERY HART, AND ROBERT LOVELACE' From The Neurological Clinical Research Center, Department ofNeurology, College ofPhysicians andSurgeons, Columbia University, New York City, U.S.A. SUMMARY Three patients with multiple sclerosis characterized by exacerbations and remissions of nervous system signs and symptoms disseminated in time and space also had the kind of easy fatigu- ability seen in myasthenia gravis. In each case abnormal decrements to repetitive stimulation were electromyographically demonstrated and treatment with ephedrine or anticholinesterase drugs increased the patient's functional capacity while improving the electromyographic abnormality. The suggestion is that these patients represent an overlap syndrome, analogous to the overlap syndrome existing between systemic lupus erythematosus and rheumatoid arthritis where clinical and laboratory features of two diseases coexist in the same patient at the same time. Presumably some patients with multiple sclerosis have deficient production of acetylcholine, just like patients with myasthenia, and treatment with agents useful in myasthenia is able partially to correct the the The cases illustrate how in neurology greater attention to the symptoms caused by deficiency. Protected by copyright. more immediate cause of clinical
    [Show full text]
  • The Rare Coexistence of Systemic Lupus Erythematosus and Myasthenia Gravis in a 17-Year-Old Female
    Bahrain Medical Bulletin, Vol. 42, No. 3, September 2020 The Rare Coexistence of Systemic Lupus Erythematosus and Myasthenia Gravis in a 17-Year-Old Female Ali Alsada, BSc, MD* Basem Mustafa, MBBS, MRCP** Systemic Lupus Erythematosus (SLE) and Myasthenia Gravis (MG) are two distinct diseases, which can coexist or precede each other; however, their occurrence in the same patient is rare. This rare phenomenon has already been observed; however, only sporadic clinical cases have been described. A seventeen-year-old female who is a known case of SLE developed MG years later. Nerve conduction studies showed the decremental response over facial muscles and right median nerve. Anti-acetylcholine receptor (AChR) antibodies were positive. She was treated with oral pyridostigmine 60 mg three times a day. Clinical improvement and resolve of muscular weakness was seen within a couple of days. The patient was discharged on prednisolone 10 mg OD and pyridostigmine 60 mg TDS. Bahrain Med Bull 2020; 42 (3): 224 - 225 Systemic Lupus Erythematosus (SLE) is an autoimmune disease noticed sometimes, especially on repeated movements but there with multi-organ involvement of unknown etiology, in which was no diplopia. there is an inter-play of genetic, epigenetic and environmental factors1. It is not uncommon to find more than one autoimmune Her investigations revealed normal CBC, ESR, RFT, LFT, CK, disease in the same patient2. It has been described that SLE LDH and TSH. Thyroglobulin and smooth muscle antibodies patients can have Primary Sjogren’s Syndrome (PSS), Systemic were negative. CXR and ECG were normal. HRCT was Sclerosis (SS), Hashimoto’s Thyroiditis (HT), Myasthenia normal with no evidence of interstitial lung disease and no Gravis (MG), Polymyositis (PM) and many other autoimmune thymoma.
    [Show full text]
  • Myasthenia Gravis
    A Guide for Patients and Families What is... Myasthenia Gravis Myasthenia gravis (MG) is a chronic autoimmune MG is not inherited, and it is not contagious. Although disease — a disease that occurs when the immune MG is not hereditary, genetic susceptibility appears to system mistakenly attacks the body’s own tissues. play a role in it. Occasionally, the disease may occur in more than one member of the same family. In MG, the immune system attacks and interrupts the connection between nerve and muscle, called the MG causes weakness in muscles that control the neuromuscular junction (NMJ). This causes weakness eyes, face, neck, and limbs. Symptoms include partial in the skeletal muscles, which are responsible for paralysis of eye movements, double vision, and droopy breathing and moving parts of the body. eyelids, as well as weakness and fatigue in neck and jaws with problems in chewing, swallowing, and holding In most cases of MG, the immune system targets the up the head. acetylcholine receptor — a protein on muscle cells that is required for muscle contraction. Muscle weakness in MG gets worse with exertion and improves with rest. About 85 percent of people with MG have antibodies against the acetylcholine receptor in their blood. The Approximately 10-20 percent of people with antibodies target and destroy many of the acetylcholine MG experience at least one myasthenic crisis, an receptors on muscle. Consequently, the muscle’s emergency in which the muscles that control breathing response to repeated nerve signals declines with time, weaken to the point where the individual requires a and the muscles become weak and tired.
    [Show full text]
  • Giant Cell Arteritis Claims Are Costly and Difficult to Defend RONALD W
    Missed diagnoses: a breakdown in communication, coordination, compliance, and situational awareness THE OPHTHALMIC RISK MANAGEMENT OPHTHALMIC MUTUAL INSURANCE COMPANY VOLUME 25 NUMBER 3 2015 Giant cell arteritis claims are costly and difficult to defend RONALD W. PELTON, MD, PhD, OMIC Committee Member, and ANNE M. MENKE, RN, PhD, OMIC Risk Manager 77-year-old male patient When the patient saw the were delayed for so long and presented for the first ophthalmologist about two weeks easy to erroneously conclude that A time to our insured later, he reported a new symptom, both physicians must have been ophthalmologist to report the a low-grade fever, with ongoing incompetent. The claims investigation sudden onset of intermittent diplopia headache and diplopia. Five days showed instead that these physicians six days prior and a headache over after that—a full three weeks after the had treated patients with giant cell his eyebrows for one day. Noting initial visit to the ophthalmologist— arteritis, knew its signs and symptoms right inferior oblique muscle paresis the patient lost vision in his left well, and understood that emergent but unable to determine its cause, eye. An emergency room physician treatment is needed to prevent and with no neuro-ophthalmologist diagnosed giant cell arteritis and imminent, bilateral vision loss. What, in the region, the eye surgeon began intravenous steroid treatment, then, led these physicians astray? referred the patient to a neurologist. but the patient never regained vision Severe vision loss, costly claims The patient told the neurologist in that eye. The malpractice lawsuit that the headache had actually against the ophthalmologist settled for This issue of the Digest will report on lasted for one month and that he $85,000; we do not know the outcome a study of OMIC claims involving 18 was also experiencing jaw pain.
    [Show full text]
  • Myasthenia Associated with Other Autoimmune Diseases: a Series of Cases
    Open Journal of Internal Medicine, 2020, 10, 44-50 https://www.scirp.org/journal/ojim ISSN Online: 2162-5980 ISSN Print: 2162-5972 Myasthenia Associated with Other Autoimmune Diseases: A Series of Cases Boundia Djiba, Nafissatou Diagne, Mohamed Dieng, Baidy Sy Kane, Atoumane Faye, Awa Cheikh Ndao, Maimouna Sow, Abdoulaye Pouye Department of Internal Medicine, Aristide Ledantec Hospital, Dakar, Senegal How to cite this paper: Djiba, B., Diagne, Abstract N., Dieng, M., Kane, B.S., Faye, A., Ndao, A.C., Sow, M. and Pouye, A. (2020) Myas- We report four observations of myasthenia gravis associated with other au- thenia Associated with Other Autoimmune toimmune diseases. Myasthenia gravis can be associated with all autoimmune Diseases: A Series of Cases. Open Journal of diseases with a predominance of dysthyroidism. Among the autoimmune Internal Medicine, 10, 44-50. diseases associated with myasthenia gravis in our series, there were associa- https://doi.org/10.4236/ojim.2020.101005 tions with hyperthyroidism, sjogren syndrome, Biermer’s disease. You would Received: December 3, 2019 have to know how to look for another autoimmune disease in front of all Accepted: February 23, 2020 myasthenia gravis by looking for the slightest sign of appeal that could point Published: February 26, 2020 you towards another pathology. Copyright © 2020 by author(s) and Scientific Research Publishing Inc. Keywords This work is licensed under the Creative Myathenia Gravis, Autoimmun Disease, Association Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access 1. Introduction Myasthenia gravis is defined as an autoimmune disease affecting the neuromus- cular junction.
    [Show full text]
  • Giant Cell Arteritis Presenting with Superior Oblique Palsy
    Giant Cell Arteritis Presenting with Superior Oblique Palsy First author: Sarah Lopez, O.D. Second author: Mariya Gurvich, O.D. Abstract An 83-year old white male presents with acute intermittent diplopia, decreased vision OD, and symptoms of headache, scalp tenderness, and jaw claudication. Examination reveals right superior oblique palsy. Temporal artery biopsy confirms giant cell arteritis. I. Case History Chief Complaint o An 83-year old white male presents with sudden decreased vision OD and diplopia. Personal Ocular History o Cataracts OU Personal Medical History o Head trauma from fall one month ago o Hypertension o Hyperlipidemia o Congestive heart failure o Abdominal aortic aneurysm o Chronic low back pain Medications o Amlodipine besylate 10 mg o Aspirin 81 mg o Atorvastatin calcium 10 mg o Furosemide 40 mg o Isoniazid 300 mg o Metoprolol succinate 100 mg o Quetiapine fumarate 50 mg o Ranitine HCL 150 mg o Valsartan 80 mg o Prednisone 100 mg II. Pertinent Findings Best-corrected Visual Acuity o OD: 20/40+ OS: 20/40 EOM's: Full OU, right hypertropia in primary gaze, improved with left head tilt Pupils: PERRL, (-) APD Slit Lamp Exam o Anterior segment: 2+ NS OU Goldmann Tonometry: o OD: 17 mmHg OS: 17 mmHg Time: 9:00 am Dilated Fundus Exam o Optic Nerve: distinct margins, pink OU . C/D: 0.25 h/v OU o Macula . Mild ERM OD, clear OS o Vessels: . Normal caliber OU, (-) emboli OU o Periphery: . No holes, tears, breaks 360 OU Laboratory Testing and Imaging o Erythrocyte sedimentation rate: 58 mm/hr (0 - 22 mm/hr) o C-reactive protein: 10.1 mg/L (<10 mg/L) o Platelet count: 393,000 cmm (150,000 - 400,000 cmm) o Fibrinogen: 632 mg/dL (200 - 400 mg/dL) o Lipid profile: Normal o Temporal artery biopsy: Positive o MRI/MRA Brain: Possible focal narrowing of both M1 segments of the middle cerebral arteries.
    [Show full text]
  • CLINICAL PRACTICE GUIDELINE Giant Cell Arteritis
    CLINICAL PRACTICE GUIDELINE CLINICAL PRACTICE GUIDELINE: Emergency Department Giant Cell Arteritis Disclaimer: This Clinical Practice Guideline (‘CPG’) was written for use in The Royal Victorian Eye and Ear Hospital Emergency Department. It should be used under the guidance of an Ophthalmology or ENT registrar. If clinical advice is required, please contact the Eye and Ear Admitting Officer for assistance: EYE: +61 3 9929 8033; ENT: +61 3 9929 8032. Links to internal Eye and Ear documents cannot be accessed from the website CPG. Description: Giant Cell Arteritis (GCA), also known as Temporal Arteritis, is a systemic vasculitis affecting medium and large arteries with significant ocular and systemic morbidity. Red Flags: • This is an ocular emergency with risk of bilateral blindness if not diagnosed and treated immediately • Patient can present with transient visual loss, diplopia or any cranial nerve palsy • Do not wait for temporal artery biopsy (TAB) before initiating steroid treatment if suspicion of GCA high • Rarely GCA is possible with a normal ESR and CRP • GCA is possible without systemic symptoms (incidence of “occult GCA” can be up to 20%) • Not every patient with an elevated ESR and/or CRP has GCA • NOTE: COVID precautions: all suspected GCA patients given high dose steroids should consider self-isolation for 2 weeks with the exception of hospital attendance for TAB or neuro-ophthalmology appointments Background: • More common in Caucasian women • Average age: 71 years old. Most patients are over 60, very rare younger than 50
    [Show full text]
  • Diseases of the Immune System 813
    Chapter 19 | Diseases of the Immune System 813 Chapter 19 Diseases of the Immune System Figure 19.1 Bee stings and other allergens can cause life-threatening, systemic allergic reactions. Sensitive individuals may need to carry an epinephrine auto-injector (e.g., EpiPen) in case of a sting. A bee-sting allergy is an example of an immune response that is harmful to the host rather than protective; epinephrine counteracts the severe drop in blood pressure that can result from the immune response. (credit right: modification of work by Carol Bleistine) Chapter Outline 19.1 Hypersensitivities 19.2 Autoimmune Disorders 19.3 Organ Transplantation and Rejection 19.4 Immunodeficiency 19.5 Cancer Immunobiology and Immunotherapy Introduction An allergic reaction is an immune response to a type of antigen called an allergen. Allergens can be found in many different items, from peanuts and insect stings to latex and some drugs. Unlike other kinds of antigens, allergens are not necessarily associated with pathogenic microbes, and many allergens provoke no immune response at all in most people. Allergic responses vary in severity. Some are mild and localized, like hay fever or hives, but others can result in systemic, life-threatening reactions. Anaphylaxis, for example, is a rapidly developing allergic reaction that can cause a dangerous drop in blood pressure and severe swelling of the throat that may close off the airway. Allergies are just one example of how the immune system—the system normally responsible for preventing disease—can actually cause or mediate disease symptoms. In this chapter, we will further explore allergies and other disorders of the immune system, including hypersensitivity reactions, autoimmune diseases, transplant rejection, and diseases associated with immunodeficiency.
    [Show full text]
  • Treatment Standards and Individualized Therapy of Myasthenia Gravis
    Review Paul Urban Peter et al. Treatment Standards and Individual- ized … Neurology International Open 2018; 00: 00–00 Treatment Standards and Individualized Therapy of Myasthenia Gravis Authors Peter Paul Urban1, Christian Jacobi2, Sebastian Jander3 Affiliations ABSTRacT 1 Neurologische Klinik, Asklepios Klinik Barmbek, Hamburg A wide range of established treatment options is currently 2 Neurologische Klinik, Krankenhaus Nordwest GmbH, available for myasthenia gravis. These include cholinesterase Frankfurt am Main inhibitors for symptomatic treatment and a broad spectrum of 3 Klinik für Neurologie, Universitätsklinikum Düsseldorf immunosuppressive, immunomodulating or cell-depleting options to modify the underlying immunological process. Ap- Key words propriate use allows the great majority of patients to lead a myasthenia gravis, neuromuscular disorder, treatment normal life. Specialized centers integrating outpatient and in-hospital resources as well as interdisciplinary competences Bibliography offer important advantages for optimum individualized therapy. DOI https://doi.org/10.1055/s-0043-124983 Neurology International Open 2018; 2: E84–E92 © Georg Thieme Verlag KG Stuttgart · New York ISSN 2511-1795 Correspondence Prof. Dr. med. Sebastian Jander, Klinik für Neurologie, Universitätsklinikum Düsseldorf, Moorenstr. 5 40225 Düsseldorf Germany [email protected] Introduction 1930s. In 1931 prostigmine (neostigmine) was first synthesized Myasthenia gravis is a well-treatable disease. Under optimal stand- and appeared to be a promising drug [2]. Lazar Remen, while work- ard therapy, approximately 85–90 % of all patients achieve good ing at the Münster University Hospital, was probably the first phy- treatment results with extensive remission of myasthenic symp- sician to treat a patient with myasthenia gravis using prostigmine, toms and recovery of everyday life skills [1].
    [Show full text]