Marcelo J. Melero

Chylous ascites and chylothorax as presentation of a systemic progression of discoid lupus.

We describe a patient with a history of discoid lupus erythematosus who presented with chylous ascites and chylothorax. Analysis of peritoneal and pleural fluid showed a high level of triglycerides and the presence of antinuclear antibody and anti-dsDNA antibody. Further study revealed other diagnostic criteria for systemic lupus erythematosus and serologic markers of disease activity. The patient was successfully treated with methylprednisolone pulse therapy and high doses of prednisone, followed by immunosuppressants.

Bilateral diaphragmatic paralysis in an HIV patient: Second reported case and literature review

Human immunodeficiency virus (HIV) disease is widespread all over the world, and the neurological and respiratory complications have been described previously. Peripheral neuropathy is one of the commonest neurological complications of the HIV infection. In this report we describe a HIV positive male smoker who was admitted to the hospital because of community acquired pneumonia. Bilateral diaphragmatic paralysis was diagnosed for which no other cause was found and was attributed to the HIV infection. Isolated phrenic neuropathy and diaphragmatic paralysis in an HIV positive patient is extremely rare and only a single such association has been described previously.

Prevention of venous thromboembolism after acute ischaemic stroke

David Sherman and colleagues (April 21, p 1347) report that enoxaparin 40 mg subcutaneously once daily is preferable to unfraction ated heparin 5000 IU subcutaneously every 12 h for prevention of venous thromboembolism in patients with acute ischaemic stroke in view of its better clinical benefi t-to-risk ratio and convenience of administration. The systematic review of published randomised trials mentioned in the Discussion showed that unfractionated heparin 5000 IU twice daily reduced the relative risk of venous thromboembolism compared with placebo, but that it was less eff ective than unfractionated heparin 5000 IU three times daily. When comparing enoxaparin with unfractionated heparin, similar effi cacy in preventing venous thromboembolism in nonsurgical patients has been seen only when enoxaparin 40 mg once daily was compared with unfractionated heparin 5000 IU three times daily. One study did show that enoxaparin once daily was as eff ective as unfractionated heparin 5000 IU twice daily at preventing venous thromboembolism; however, enoxaparin was used at a dose (20 mg once daily) which the MEDENOX Study showed to be ineff ective for preventing venous thromboembolism in acutely ill patients. In light of these points, it is noteworthy that there are data to suggest better effi cacy with unfractionated heparin given on a three times daily basis, but no data to show that unfractionated heparin twice daily is as eff ective as either enoxaparin 40 mg once daily or unfractionated heparin 5000 IU three times daily.