Hatice Keles

Prevalence of occult hepatitis B and hepatitis C virus infections in Turkish hemodialysis patients

Background and Objective. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are important causes of morbidity and mortality in maintenance hemodialysis patients. Although their exact prevalence is not known, HBV and HCV viral infections and occult viral hepatitis are frequent in these patients. This study aimed to determine the prevalence of occult HBV and HCV infections in maintenance hemodialysis patients. Materials and Methods. One hundred and eighty-eight end-stage renal disease patients on maintenance hemodialysis (100 male, mean age 49±29 [16–80] years, and mean duration of hemodialysis 98±66 [12–228] months) were enrolled in this study. Serological markers for HBV and HCV were determined with immunoenzymatic assay (ELISA) by using commercial diagnostic kits (Access and BioRad, Beckman-Coulter). HCV-RNA (Cobas Amplicor HCV kit) and HBV-DNA (Artus GmbH HBV kit) were determined quantitatively by polymerase chain reaction. Results. Among the patients screened, 25 (13.3%) had HBV infection alone and 38 (20.2%) had HCV infection alone, while seven (3.7%) had dual infection of both viruses. Serological markers for occult hepatitis B and occult hepatitis C were positive in five (2.7%) and nine (4.8%) of the patients, respectively. Isolated anti-HBc was positive in 12 (6.4%) of all patients, three (7.9%) of the patients with anti-HCV and two (40%) of the patients with occult hepatitis B. Isolated anti-HBc positivity was more frequent in patients with occult hepatitis B than in those without (40% [2/5] vs. 5.5% [10/183], p=0.002). None of the patients with HCV had occult hepatitis B. Conclusions. Both occult and non-occult forms of HCV infection are more prevalent than HBV infection in hemodialysis patients. Especially the patients with isolated anti-HBc positivity should be tested for probable occult hepatitis B infection.

Effect of chronic diseases and associated psychological distress on health-related quality of life.

Background: The purpose of this study was to clarify the correlations between the presence of comorbidities and psychological distress and health‐related quality of life (HRQL). This was a population‐based cross‐sectional study.

Negative mood and quality of life in patients with asthma

The aim of this study was to evaluate the effect of negative mood states at the moment of questionnaire, and other patient and disease characteristics on quality of life (QoL) in patients with asthma. The study groups were composed of 116 stable adult asthmatic patients and 116 age and sex matched healthy subjects. We used Short-Form Health Survey-36 (SF-36) for the assessment of general QoL in all participants, and the Asthma Quality of Life Questionnaire (AQLQ) for the assessment of disease specific QoL in patients with asthma. We evaluated negative mood in all subjects with a questionnaire including six mood subscales in three categories (nervous-anxious, hostile-angry and fearful-panicky). Negative mood scores were not different between asthmatic and comparison groups (p=0.4), but both SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were significantly lower in asthmatic group (p=0.003 and p=0.001, respectively). Multiple linear regression analysis in all study population indicated that both reduced PCS and MCS scores of SF-36 were associated with negative mood score (β=−0.28, p<0.001 and β=−0.37, p<0.001, respectively) and with FEV1% (β=0.19, p=0.001 and β=0.25, p<0.001, respectively) after adjusting for age, female sex, and the presence of asthma. On the other hand, multiple linear regression analysis in patients with asthma revealed that negative mood score and disease severity score were significant predictors for overall score of AQLQ after adjusting for other patient and disease characteristics (β=−0.17, p=0.008 and β=−0.64, p<0.001, respectively). The level of negative mood and disease severity in asthmatics significantly impair QoL. Thus, considering that one of the main objectives of health care should be preserving a satisfactory QoL in asthmatics, the presence and seriousness of negative mood and their effects on QoL should be taken into account as part of the clinical evaluation in asthmatics.

Kimura's disease in a Caucasian male treated with cyclosporine

45 Correspondence Kimura’s disease in a Caucasian male treated with cyclosporine A 45-year-old Caucasian man was admitted to the Department of Dermatology with the complaint of erythematous lesions on the fingers and elbows present for 10 years. The physical examination revealed nontender, nonfluctuant, firm and fixed nodules localized in the right postauricular region, left parotid gland and submental region measuring 34 × 25 mm, 26 × 15 mm and 42 × 35 mm, respectively (Fig. 1). No warmth or redness was noted on the overlying skin. There were erythematous plaques on the metacarpophalangeal and interphalangeal joints in both hands and also in the right elbow. He was otherwise healthy. He had no fever, weight loss nor was he sweating. He was treated with systemic steroid two times in the past four years. The masses showed regression, but recurrence occurred when the dose was tapered. The patient’s eosinophil count was above normal (36%), and IgE level was markedly raised 1130 IU/ml. He tested negative cytomegalovirus, Epstein-Barr virus, toxoplasma serologies and stool parasitic infection. Bone marrow biopsy revealed moderate increase in eosinophilic lineage without atypia. A computed tomographic scan of the neck showed multiple lymph nodes located at the bilateral servical chain and heterogeneous areas in both of the parotid glands. Histopathological examination revealed dense mononuclear cell infiltration with eosinophils and numerous vascular structures. There was no atypia in the dermis (Fig. 2). Immunohistochemical staining for CD68, CD34, LCA and S100 were positive. Stains and cultures for bacteria, fungi, and mycobacteria were negative. Based on clinical findings, histology, peripheral eosinophilia, high IgE level, and negative serological testing for parasitic agents, a diagnosis of KD (Kimura’s disease) was made. Cyclosporine at an initial dose of 5 mg/kg/day was started. One month later, the lesions showed complete regression. We began tapering the dose by 1 mg/kg/day each month. The remission was not long lasting, the lesions began to appear again when the dose was 2 mg/kg/day. The therapy was stopped at the end of the fifth month. The exact pathophysiology of KD is unknown. The presence of eosinophils in the inflammatory infiltrate and the peripheral blood suggests that KD represents a self-limited allergic 1

Perception of dyspnea during exacerbation and histamine-related bronchoconstriction in patients with asthma

BACKGROUND Numerous studies have been performed concerning the perception of dyspnea during changes in airway caliber provoked in the laboratory setting, but studies of asthma exacerbation are scarce. OBJECTIVE To investigate whether the perception of dyspnea during histamine-induced bronchoconstriction might be used to identify patients with asthma who sense dyspnea poorly during exacerbation. METHODS The perception of dyspnea in 50 patients (45 female, 5 male) with asthma was evaluated at admission with exacerbation and during a stable period. Perceived intensity of dyspnea was estimated using a modified Borg scale. The perception of dyspnea in the stable period 4 to 6 weeks after exacerbation was measured with the histamine challenge test. Perception parameters were defined as the change in Borg score divided by the change in forced expiratory volume in 1 second (FEV1) as a percentage of the baseline FEV1 (deltaBorg/deltaFEV1) and as the Borg score at 20% decrease (PS20Histamine) or increase (PS20Exacerbation) in FEV1. RESULTS The perception of dyspnea during asthma exacerbation was unrelated to the perception of dyspnea during histamine-induced bronchoconstriction (for deltaBorg/deltaFEV1, beta = .08, P = .50; for PS20, beta = -.11, P = .40). The kappa value for the agreement of poor perceivers at exacerbation and during the stable period was -0.21 (P = .10). However, the intensity of dyspnea caused by histamine-induced bronchoconstriction was lower than that caused by asthma exacerbation (PS20: 1.6 +/- 1.1 vs 2.8 +/- 2.5, respectively, P = .004; deltaBorg/deltaFEV1: 0.08 +/- 0.05 vs 0.21 +/- 0.28, respectively, P = .001). CONCLUSION The perception of dyspnea during asthma exacerbation is not correlated with the perception of dyspnea during histamine-induced bronchoconstriction. Therefore, the perception of dyspnea during histamine-induced bronchoconstriction cannot be used to identify the asthmatic patients who perceive dyspnea poorly.

Melanocortin-4 Receptor Gene Polymorphisms in Obese Patients

Obesity is a complex disease caused by both genetics and environmental factors. Melanocortin-4 receptor (MC4R) (MIM 155541) gene polymorphisms were reported to be the cause of monogenic obesity in humans. We studied three polymorphisms (Val50Met, Val103Ile, and Ser58Cys) and a mutation (Asn274Ser) of the MC4R gene in 203 obese patients and in 110 healthy subjects in the Turkish population. A high incidence of Val103Ile and Val50Met polymorphisms as well as the Asn274Ser mutation was found in the obese patients, whereas no significant correlation was found regarding the Ser58Cys polymorphism. We conclude that there is a concordance between the polymorphisms (Val103Ile, Val50Met, Ser58Cys) that were first studied in the Turkish population with obesity.

Treatment characteristics in elderly asthmatics

In this study, we evaluated the effect of ageing on treatment response by comparing two groups of patients with asthma. All asthmatic patients in the study were assessed on repeated occasions once admitted to the hospital: soon after admission (0 h), and then at 5th, 10th, 24th, 48th, 72nd hour, 7th day and in stable period. We compared two groups of patients: younger asthmatics, which had 33 younger aged <60, and elderly asthmatics, comprised of 29 elderly aged ≥60 years. The Asthma Quality of Life Questionnaire (AQLQ) was used to assess health‐related quality of life in study. The increases in FEV1% values observed soon after the hospital admission (0 h), and at 5th, 10th, 24th, 48th, 72nd hour, 7th day and in stable period in younger group were similar that in elderly group. The Borg scores observed soon after the hospital admission (0 h), and 5th, 10th, 24th, 48th and 72nd hour in elderly asthmatics was usually higher than that in younger asthmatics. However, symptom scores observed in elderly asthmatics soon after the hospital admission and at 72nd hour were higher than those in younger asthmatics. Furthermore, decreases in the total AQLQ score and asthma severity score from exacerbation to stable period in both asthmatics were not different. Present study indicated that the airways obstruction, AQLQ and other diseases characteristics of younger and elderly asthmatics could improve at similar rates with treatment. In addition, similar exacerbation severity in elderly asthmatics was perceived more intense than younger asthmatics.

Risedronate-induced intravascular haemolysis complicated by acute tubular necrosis

A 54-year-old woman presented to our internal medicine outpatient unit with acute onset of weakness, back pain and red urination. It was learnt that she had been taking alendronate 10 mg daily and oral calcium 1 g daily for 2 years for the treatment of osteoporosis and was prescribed risedronate 35 mg weekly instead of alendronate by her physician at her last visit. Seven hours after she had taken the first dose of this drug her complaints began. Her detailed history was negative for any other systemic disease or drug usage. On physical examination she had tachycardia (110 pulses/min) and fever (39.5 C). She was admitted to the hospital. Laboratory studies revealed anaemia with haemoglobin of 11.1 g/dl, mean corpuscular volume (MCV) of 95 fl and thrombocytopaenia with platelet count of 87,000/mm. There were findings of haemolytic reaction [white blood cell count 20,000/mm, lactate dehydrogenase 2591 IU/l (normal: 220–450 IU/l), aspartate aminotransferase 99 IU/l (normal: 5–40 IU/l), total bilirubin 2.9 mg/dl (normal: 0.2–1.2 mg/dl), direct bilirubin 0.9 mg/dl (normal: 0– 0.3 mg/dl), reticulocyte count 8%, haptoglobin <0.05 g/dl (normal: 0.3–2 g/dl) and haemoglobinuria]. Blood urea nitrogen and creatinine levels were increased (58 mg/dl and l.7 mg/dl, respectively) and creatinine clearance was calculated as 33 ml/min. Analysis of 24-h urine also revealed 974 mg daily protein excretion. The laboratory values in her previous visit 3 days before she took risedronate were as follows: haemoglobin of 13.1 g/dl, platelet count of 240,000/mm, white blood cell count 5100/mm, lactate dehydrogenase 256 IU/l, aspartate aminotransferase 24 IU/l, total bilirubin/direct bilirubin 0.9/0.2 mg/dl. Routine dipstick urinalysis was normal. Based on these findings, we concluded that acute intravascular haemolysis complicated by acute tubular necrosis had developed in this patient. Therefore, the possible causes of documented acute intravascular haemolysis, acute tubular necrosis and proteinuria were investigated. The laboratory tests including prothrombin time, activated partial thromboplastin time, anti-streptolysin O (ASO) titre, C-reactive protein, rheumatic factor (RF), cryoglobulin and complement (C3 and C4) levels were in normal ranges and antinuclear antibodies (ANA), antineutrophil cytoplasmic autoantibodies (ANCA) and direct Coombs’ tests were all negative. Cultures of nasopharynx, urine, stool and blood for any bacterial or fungal infectious agents and viral serology for Epstein–Barr virus, cytomegalovirus, herpes simplex virus, human immunodeficiency virus and hepatitis A, B and C viruses were all negative. For the management of the patient, risedronate was stopped and fluid and electrolyte balance was followed closely. Parenteral isotonic sodium chloride at a rate of about 150 ml/h associated with intravenous furosemide 40 mg twice daily was introduced. During the follow-up of the patient, although the creatinine level increased up to 2.3 mg/dl, oliguria and hyperkalaemia were not observed. Fever was not detected in subsequent measurements after hospitalisation and did not recur and neutrophilia improved in 48 h. Transfusion was not needed, and platelet count and serum creatinine level were improved. The patient was discharged from hospital on the 10th day of her admission. When she was seen after 4 weeks, complete blood count and renal functions were normal and proteinuria had completely disappeared. The patient has been followed at 3-month intervals for about 9 months without a problem, and also no signs and symptoms for the possible evolution to any autoimmune connective tissue disease have been observed. Z. N. Özkurt Æ S. Güliter Æ H. Keleş Department of Internal Medicine, Kırıkkale University School of Medicine, Kirikkale, Turkey

Diffuse plane xanthomatosis in a patient with Budd-Chiari syndrome and monoclonal gammopathy

Diffuse plane xanthomas are characterized by the presence of yellowish plaques on the eyelids, neck, upper trunk, buttocks, and flexural folds. Histology shows foamy histiocytes in the dermis. Approximately half of the cases are associated with lymphoproliferative disorders. Budd-Chiari syndrome is an uncommon condition induced by thrombotic or nonthrombotic obstruction of hepatic venous outflow. We present a case of diffuse plane xanthoma in a 62-year-old man who developed normolipemic plane xanthomas coinciding with Budd-Chiari syndrome and monoclonal gammopathy. We review the English-language literature regarding the rare association of xanthomas and Budd-Chiari syndrome.