Abdurrahman Tufan

Mean platelet volume (MPV) as an inflammatory marker in ankylosing spondylitis and rheumatoid arthritis

AIMS The aim of this retrospective study was to investigate the correlation between MPV and the clinical disease activity indices of rheumatoid arthritis and ankylosing spondylitis. METHODS The study consisted of 32 active RA patients (males/females: 7/25, mean age: 49+/-13) and 30 active AS patients (males/females: 15/15, mean age: 36+/-12) along with 26 osteoarthritis (OA) patients (males/females: 4/22, mean age: 52+/-8) and 29 age-matched healthy subjects (males/females: 5/24, mean age: 41+/-7) as control groups for RA and AS, respectively. RESULTS MPV was significantly lower in both AS patients and RA patients with active disease as compared to controls (RA vs OA p<0.001, AS vs healthy subjects p<0.001). After treatment MPV values significantly increased in AS and RA (p<0.001 for all). However, MPV values remained somewhat lower in RA patients than OA patients (p=0.019). There was a negative correlation between MPV values and BASDAI scores in AS patients after two months of treatment (r=-0.507; p=0.004). CONCLUSION Our results suggest that assessment of MPV may provide additional information about inflammation in AS and RA.

Rhabdomyolysis in a Patient Treated with Colchicine and Atorvastatin

Objective: To report a case of severe rhabdomyolysis that developed after administration of atorvastatin to a patient receiving regular colchicine treatment. Case Summary: A 45-year-old man with nephrotic syndrome and amyloidosis presented with dyspnea, altered mentation, and severe fatigue. He had been taking colchicine 1.5 mg/day for amyloidosis for 3 years without adverse effects. Atorvastatin 10 mg/day was prescribed for hypercholesterolemia one month prior to admission. After 2 weeks of atorvastatin treatment, he began to experience myalgia and reduced muscle strength. The creatinine and creatine kinase concentrations on admission were 8.1 mg/dL and 9035 U/L, respectively. The patient was diagnosed with rhabdomyolysis with the findings of myoglobinuric, oliguric acute renal failure, and more than 50–fold elevated creatine kinase concentration. His muscle strength improved after withdrawal of atorvastatin and colchicine. However, he died because of nosocomial pneumonia that developed during his hospital stay. The Naranjo probability scale indicated that atorvastatin and colchicine were probable causes of rhabdomyolysis. Discussion: Atorvastatin and colchicine have well-known myotoxic adverse effects. Despite atorvastatins proven safety, its use with certain drugs, such as colchicine, makes it a potential myotoxic drug. This might be because concomitant administration of P-glycoprotein substrates, such as statins, and colchicine, which is a P-glycoprotein inhibitor, modifies pharmacokinetics by increasing bioavailability and organ uptake of the substrates, leading to more adverse reactions and toxicities. Conclusions: We recommend checking the creatine kinase level one week after prescribing 2 or more potentially myotoxic drugs concomitantly, after dose increase of a myotoxic drug, or after prescribing a new drug to a patient already using other myotoxic agents.

The Association Between Neutrophil/Lymphocyte Ratio and Disease Activity in Rheumatoid Arthritis and Ankylosing Spondylitis

Elevated neutrophil count is associated with poor prognosis and increased mortality in many conditions. Neutrophil to lymphocyte ratio (NLR) has emerged as a marker of inflammation in neoplastic and cardiovascular disorders. Herein, we investigated utility of this simple tool in rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

Real-time sonoelastography of Achilles tendon in patients with ankylosing spondylitis.

ObjectiveReal-time sonoelastography (SE) is a new ultrasound-based imaging technique that provides information on tissue elasticity and stiffness. We determined the efficacy of SE for assessing Achilles tendon abnormalities in patients with ankylosing spondylitis (AS).Materials and methodsForty-one consecutive AS patients and 32 asymptomatic healthy subjects were enrolled. Achillodynia was scored on a 0- to 100-mm visual analog scale. A high-resolution ultrasound machine equipped with an elastography-compatible linear probe was used to perform bilateral B-mode ultrasound, Doppler ultrasound, and SE examinations of Achilles tendons. Tendons were divided into proximal, middle, and distal segments. B-mode examinations included tendon thicknesses, echotextures, and enthesopathic findings. SE using color-coded images was performed in the same areas. Normal consistent tendon structures were coded as blue or green, and moderately (yellow) or severely (red) softened areas were considered pathological.ResultsThe distal third of the Achilles tendons was the most commonly affected part in the AS patients compared with healthy subjects (p = 0.001), whose middle third was more commonly affected. Achillodynia intensity tended to be higher in patients with pathological B-mode or SE examination findings (p = 0.09 and p = 0.07 respectively). Softening detected by SE in the distal third was associated with enthesopathy findings such as calcaneal bone erosions (Fisher’s X2, p = 0.07) and tendinous enlargement (Fisher’s X2, p = 0.001). B-mode and SE findings had moderate to good correlation in the assessment of Achilles tendon abnormalities.ConclusionsSonoelastography may be useful for the evaluation of tendon abnormalities in patients with AS; in addition; it may be useful for the evaluation of other inflammatory rheumatic conditions.

Nonconvulsive Status Epilepticus Due to Ifosfamide

Objective: To report 2 cases of nonconvulsive status epilepticus (NCSE) following infusion of ifosfamide. Case Summaries: Two patients who received ifosfamide-containing chemotherapy developed NCSE. One woman received ifosfamide 1000 mg/m2 (1 h infusion on days 1–5); confusion, lethargy, and speech deterioration developed on day 3. The second patient developed similar symptoms on day 3 of treatment with 2500 mg/m2. Both patients responded to intravenous administration of diazepam 10 mg and were given levetiracetam as maintenance therapy. Discussion: The severity and presentation of central nervous system toxicity due to ifosfamide varies greatly and involves a spectrum ranging from subclinical electroencephalogram changes to coma. NCSE, an epileptic disorder in which typical convulsive activity is absent, has previously been reported in only 4 patients receiving ifosfamide. Levetiracetam may be used for maintenance antiepileptic therapy after diazepam administration. Conclusions: Among the many presentations of ifosfamide neurotoxicity, clinicians should consider NCSE as a possible explanation for changes in consciousness in a patient receiving this agent. An objective causality assessment by use of the Naranjo probability scale revealed that NCSE due to ifosfamide was probable.

Visceral Leishmaniasis Mimicking Autoimmune Hepatitis, Primary Biliary Cirrhosis, and Systemic Lupus Erythematosus Overlap

Visceral leishmaniasis (VL) is a life-threatening infection caused by Leishmania species. In addition to typical clinical findings as fever, hepatosplenomegaly, and cachexia, VL is associated with autoimmune phenomena. To date, VL mimicking or exacerbating various autoimmune diseases have been described, including systemic lupus erythematosus (SLE), rheumatoid arthritis, and autoimmune hepatitis (AIH). Herein, we presented a patient with VL who had overlapping clinical features with SLE, AIH, as well as antimitochondrial antibody (AMA-M2) positive primary biliary cirrhosis.

Spontaneous tumor lysis syndrome in a patient with diffuse large B cell lymphoma and Richter syndrome

A 77-year-old man with a past medical history of hypertension, coronary heart disease, a cerebrovascular accident, and squamous cell lung cancer cured only by surgery 5 years ago, was admitted to our emergency department with complaints of dyspnea, fatigue, lethargy, and vague abdominal pain. When the patient was hospitalized for a cerebrovascular accident about 1 month before, he was diagnosed as having stage 1 chronic lymphocytic leukemia by lymphocytosis and enlarged peripheral lymph nodes with a greatest size of 3×2 cm, and was taken to a watch and wait program. Upon the current admission, physical examination revealed arterial blood pressure of 140/60 mmHg, heart rate of 100 bpm, respiration of 26 bpm, body temperature of 36.2°C, cervical multiple lymphadenopathies that were slightly smaller than those revealed 1 month before, marked splenomegaly, and marked peripheral edema. Fine crackles were also heard from the lung bases. Laboratory findings on the patient in due course are been depicted in Table 1. Abdominal ultrasound disclosed a 175mm splenomegaly. Many uric acid crystals were observed upon urine analysis. Since the findings were consistent with hypervolemia and acute renal failure accompanied with many electrolite disturbances, emergent hemodialysis was employed. Peripheral flow cytometric analysis revealed cluster of differentiation 3 (CD3) 1%, CD5 95%, CD19 74%, CD20 98%, CD23 15%, kappa 17%, lambda 17%, CD38 5%, FMC-7 negative, and human leukocyte antigen-DR (HLA-DR) 63%, indicating a monoclonal B cell population bearing lambda weakly on their surfaces. Cervical lymph node biopsy exhibited diffuse large B cell lymphoma. On the patient’s second day of admission, hemodialysis was repeated for anuria. On his third day of hospitalization, he developed upper gastrointestinal bleeding and hypotension. Esophagogastroduodenoscopy revealed gastroesophageal junctional erosive ulcers that were not actively bleeding. Despite the proper management, he died due to ventricular fibrillation and shock. Consent for an autopsy was refused.

Rapid resolution of protracted febrile myalgia syndrome with anakinra: Report of two cases

Protracted febrile myalgia syndrome (PFMS) is a very rare but severe manifestation of familial Mediterranean fever (FMF) which is characterized by severe debilitating pain in large muscle groups that may last for several weeks. Colchicine is ineffective and treatment is largely supportive. Demonstration of crucial role of interleukin-1 (IL-1) in the pathogenesis of FMF has increased the use of IL-1 blockers in colchicine resistant or intolerant patients. Herein, we reported successful use of an IL-1 inhibitor, anakinra, in treatment of two patients with PFMS.

Familial influence on tibiofemoral alignment

Background Tibiofemoral alignment has a role in knee osteoarthritis (OA), but which factors contribute to alignment is unknown. Objective To investigate familial aggregation of tibiofemoral alignment in participants of the GARP (Genetics ARthrosis and Progression) study. Methods The tibiofemoral anatomical angle on semiflexed knee radiographs was measured in sibling pairs (mean age 60 years, 81% women) with primary OA with multiple joint involvement. Radiographic OA was assessed according to the Kellgren–Lawrence (KL) method. Heritability estimates of the tibiofemoral angle were calculated by comparing twice the between-sibling variance with the total variance; adjustments were made for age, gender, body mass index, history of meniscectomy, lower limb fracture and in analyses including all knees, for KL score. Results 360 subjects representing 180 families were studied. The mean (SD) tibiofemoral angle of right and left knees in the probands was 182.7 (2.9)° and 182.8 (2.6)°, respectively; similar angles were measured in the siblings. Radiographic knee OA (KL score ≥2) was present in 27% of the knees. Stratified analyses in sib pairs with non-osteoarthritic right or left knees showed adjusted heritability estimates of the tibiofemoral angle of the right and left knees of 0.42 (95% CI 0.02 to 0.82) and 0.56 (95% CI 0.19 to 0.93). In addition, adjusted heritability estimates of the tibiofemoral angle in all right and left knees were calculated, being 0.48 (95% CI 0.18 to 0.78) and 0.50 (95% CI 0.21 to 0.79), respectively. Conclusion The alignment of the tibiofemoral joint is influenced by familial factors, implying that tibiofemoral malalignment may add to the genetic predisposition for knee OA development. These results need to be confirmed in other study populations.

Predictive value of neutrophil/lymphocyte ratio in renal prognosis of patients with granulomatosis with polyangiitis

Abstract Introduction: Granulomatosis with polyangiitis (GPA) is a rare necrotizing vasculitis, which usually involves the upper and lower respiratory systems and kidneys and often have a relapsing course. Neutrophil/lymphocyte ratio (NLR) has been shown to be a useful marker predicting not only progressive disease, but also mortality in various inflammatory diseases. We aimed to investigate the roles of NLR in predicting the extend of clinical involvement and prognosis of patients with GPA. Materials and methods: Consecutive newly diagnosed GPA patients who had follow-up for at least 6 months between 2010 and 2016 at Gazi University Internal Medicine-Rheumatology clinic were retrospectively analyzed. Results: Fifty-three newly diagnosed GPA patients were studied. NLR was significantly higher in the GPA group compared with the control group (4.50 [min–max: 0.07–34.81] vs 1.77 [min–max: 1.04–2.90], respectively, p < .001). NLR significantly correlated with ESR and CRP levels (r = .40 and r = .48, respectively, p < .001 for both). Discussion: GPA is a vasculitis with a significant morbidity and mortality (REF). Renal involvement usually presents with crescentric glomerulonephritis, resulting in significant and permanent loss of renal functions and end-stage kidney disease. Higher NLR at baseline is associated with worse renal outcome. Our findings suggest that baseline NLR could have a predictive value for renal prognosis. We have also demonstrated a significant correlation between NLR and BVAS activity scores. Our data suggest that GPA patients with a significantly high NLR at baseline might need closer follow-up for persistent disease activity.