Brian E. Daikh

Montelukast reduces peripheral blood eosinophilia but not tissue eosinophilia or symptoms in a patient with eosinophilic gastroenteritis and esophageal stricture

BACKGROUND Eosinophilic gastroenteritis (EG) is an uncommon entity of which the pathogenesis is unclear. As no controlled treatment trials exist, treatment of EG remains largely empiric. Limited results have been achieved with oral cromolyn, ketotifen, and other antihistamines. Oral corticosteroids are effective, but long-term use is complicated by side effects including growth retardation, diabetes, and osteoporosis. OBJECTIVES We sought to determine whether treatment with montelukast would improve symptoms and decrease both peripheral blood and tissue eosinophilia (TE) in a patients with steroid-dependent EG for 20 years complicated by esophageal stricture. METHODS In an unblinded, n = 1 trial, we treated the patient for 5 months with montelukast (20 to 30 mg daily) while his baseline dose of prednisone (10 mg daily) was continued. Complete blood counts and symptoms were monitored weekly. Esophageal biopsies were obtained before and after 5 months of therapy with montelukast. After the posttreatment biopsy was obtained, montelukast was discontinued. Outcome measures included patient symptoms and peripheral and tissue eosinophil counts. RESULTS During treatment with montelukast, the mean peripheral blood eosinophil count fell from 5,064 cells/microL (average 28 determinations over 20 years; range 1,408 to 12,500 cells/microL) to 1,195 cells/microL (average 14 determinations over 16 weeks; range 556 to 2,193 cells/microL), a 76% reduction. The corresponding TE as calculated from esophageal biopsies was 31 eosinophils/high power field before and 70 eosinophils/high power field after treatment. The patient noted no appreciable improvement in esophageal symptoms. CONCLUSIONS Montelukast dramatically reduced peripheral blood eosinophilia, but did not affect TE or symptoms in this patient with severe, long-standing EG complicated by esophageal stricture.

Lyme Arthritis: A Comparison of Presentation, Synovial Fluid Analysis, and Treatment Course in Children and Adults

This case series examines differences in the presentation, management, and outcome of Lyme arthritis between the pediatric and adult population.

Pseudoxanthoma elasticum masquerading as Sjögren's syndrome.

Pseudoxanthoma elasticum is an inherited disorder of abnormal calcification of elastic fibers in the skin, retina, and cardiovascular system. Herein, we report a patient who had dry eyes and mouth, keratoconjunctivitis sicca, and a low titer ANA at presentation. A lip biopsy was performed to confirm a clinical suspicion of Sjögrens syndrome; however, the histologic findings were diagnostic of pseudoxanthoma elasticum. Antibodies to Ro and La were negative. Subsequently, she was found to have skin and eye findings consistent with pseudoxanthoma elasticum. Although a causal relationship between keratoconjunctivitis sicca and pseudoxanthoma elasticum is not proven, salivary gland involvement with pseudoxanthoma elasticum may explain this patients symptoms. Physicians should consider the diagnosis of pseudoxanthoma elasticum in patients who present with sicca symptoms without obvious cause, especially if cutaneous or ophthalmologic abnormalities, or both, are present. Careful monitoring for associated problems is needed as soon as pseudoxanthoma elasticum is diagnosed.

A benzyl–carbon bond dissociation energy of one-third the normal value: a quantitative study of benzyl–carbon bond homolysis in [CoIII(L2–CH2Ph)I], a cobalt-to-carbon benzyl migration product derived from the coenzyme B12 model complex [CoIII(L1)(CH2Ph)I]

Benzyl–carbon bond thermal homolysis studies using the TEMPO radical-trapping method reveals a low benzyl–carbon bond dissociation energy (BDE) in [CoIII(L2–CH2Ph)I] of 25 ± 3 kcal mol–1, a value one-third the normal BDE of ca. 76 kcal mol–1 and approximately equal to the cobalt–carbon homolytic BDE in the parent complex [CoIII(L1)(CH2Ph)I]; such little-documented low BDEs relate back to Gombergs classic example of Ph3C–C6H5CPh2 and its ca. 11 kcal mol–1 carbon–(p-phenyl)carbon BDE (1 cal = 4.184 J).