Mehmet Soy

Delay in the diagnosis of SLE: the importance of arthritis/arthralgia as the initial symptom.

Despite the current diagnostic and serologic testing for SLE, the interval between the onset of symptoms and the diagnosis is still long. In this study, we aimed to show the interval between the initial symptoms and the diagnosis of SLE and to investigate the presence of any relationship between the interval and the initial symptoms. One hundred and thirty-six patients were diagnosed with SLE using the 1982 ARA criteria. The mean age of the patients at diagnosis was 29.9 +/- 10.5 years. The mean interval between the onset of symptoms and the diagnosis of SLE was 21.82 +/- 30.32 months. The subjects were evaluated twice, at intervals of < or = 3 and < or = 12 months after the onset of symptoms. Although arthritis and/or arthralgia were the most common initial symptoms (60.3%), only 26.8% of the patients with these symptoms were diagnosed earlier than 3 months after the onset. If the first initial symptoms were butterfly rash or pericarditis, pleuritis, spontaneous abortion or cognitive dysfunction, they led to early diagnosis. In conclusion, since arthritis and/or arthralgia are the most common initial symptoms of the disease, every young woman with these symptoms should be carefully evaluated for SLE.

Erythema nodosum associated with granulomatous mastitis: report of two cases

Granulomatous mastitis is a rare breast disease characterized by chronic inflammation. Clinical presentation of granulomatous mastitis usually mimics malignancy or infection. Coincidence of granulomatous mastitis and erythema nodosum is a quite rare feature. In this paper, we aimed to present two young women with granulomatous mastitis accompanied by erythema nodosum and successfully treated with corticosteroids. Granulomatous mastitis should be kept in the mind for differential diagnosis of erythema nodosum.

Susceptibility to Atherosclerosis in Patients With Psoriasis and Psoriatic Arthritis as Determined by Carotid-Femoral (Aortic) Pulse-Wave Velocity Measurement

INTRODUCTION AND OBJECTIVES In this study we analyzed the susceptibility to atherosclerosis of patients with psoriasis and psoriatic arthritis (PsA) by determining the femoral-carotid pulse wave velocity (PWV), which is a measure of the viscoelastic properties of blood vessels. METHODS The study included 25 patients with psoriasis (age 18-63 years; 13 male), of whom nine had arthritis, as well as 39 sex- and age-matched healthy control subjects (age 24-70 years, 25 male). The systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate, body mass index (BMI) and waist-to-hip ratio (WHR) of all participants were recorded and, in patients, skin lesions were assessed using the psoriasis area and severity index (PASI). Arterial distensibility was determined by automatic carotid-femoral PWV measurement using the Complior Colson device. RESULTS Mean PWV, SBP and DBP were significantly higher in psoriatic patients than in control subjects (P=.036, P< .001, and P=.005, respectively). In PsA patients, the mean WHR, SBP, DBP and PWV were all significantly higher than in control subjects (P=.001, P=.031, P=.001, and P=.014, respectively). CONCLUSIONS The carotid-femoral PWV is increased in patients with psoriasis and PsA.

Response rate of initial conventional treatments, disease course, and related factors of patients with adult-onset Still's disease: Data from a large multicenter cohort.

BACKGROUND Adult-onset Stills disease (AOSD) is a rare condition, and treatment choices are frequently dependent on expert opinions. The objectives of the present study were to assess treatment modalities, disease course, and the factors influencing the outcome of patients with AOSD. METHODS A multicenter study was used to reach sufficient patient numbers. The diagnosis of AOSD was based on the Yamaguchi criteria. The data collected included patient age, gender, age at the time of diagnosis, delay time for the diagnosis, typical AOSD rash, arthralgia, arthritis, myalgia, sore throat, lymphadenopathy, hepatomegaly, splenomegaly, pleuritis, pericarditis, and other rare findings. The laboratory findings of the patients were also recorded. The drugs initiated after the establishment of a diagnosis and the induction of remission with the first treatment was recorded. Disease patterns and related factors were also investigated. A multivariate analysis was performed to assess the factors related to remission. RESULTS The initial data of 356 patients (210 females; 59%) from 19 centers were evaluated. The median age at onset was 32 (16-88) years, and the median follow-up time was 22 months (0-180). Fever (95.8%), arthralgia (94.9%), typical AOSD rash (66.9%), arthritis (64.6%), sore throat (63.5%), and myalgia (52.8%) were the most frequent clinical features. It was found that 254 of the 306 patients (83.0%) displayed remission with the initial treatment, including corticosteroids plus methotrexate with or without other disease-modifying antirheumatic drugs. The multivariate analysis revealed that the male sex, delayed diagnosis of more than 6 months, failure to achieve remission with initial treatment, and arthritis involving wrist/elbow joints were related to the chronic disease course. CONCLUSION Induction of remission with initial treatment was achieved in the majority of AOSD patients. Failure to achieve remission with initial treatment as well as a delayed diagnosis implicated a chronic disease course in AOSD.

Werner’s syndrome: a quite rare disease for differential diagnosis of scleroderma

Werner’s syndrome (WS) is an autosomal recessive disorder characterized by premature aging. The main features of the disease are scleroderma-like skin appearance, premature atherosclerosis, short stature, diabetes mellitus, early osteoporosis and early aging. Herein, we describe a patient with WS, who has scleroderma-like skin changes and discuss the literature about WS as a disease in the differential diagnosis of systemic sclerosis.

Serum levels of visfatin, resistin and adiponectin in patients with psoriatic arthritis and associations with disease severity

Psoriatic arthritis (PsA) is an inflammatory form of arthritis typically associated with psoriasis and/or psoriatic nail disease. Adipocytokines were once thought to influence development of (only) insulin resistance and diabetes mellitus. However, it is now clear that adipocytokines play important roles in development of the inflammation associated with either autoimmune or auto‐inflammatory disorders. In the present study, we measured changes in the serum levels of adiponectin, resistin and visfatin, and the associations of such changes with the extent of disease activity and insulin resistance in PsA patients.

A rare form of SLE: pseudo–pseudo meigs syndrome and hydrocephalus

Pseudo–pseudo meigs syndrome or Tjalma syndrome is characterized with increased cancer antigen-125 (CA-125) level, pleural effusion and ascites in SLE patient without ovarian tumor [1]. Here, we present an unusual case with pseudo–pseudo meigs syndrome, who had had to total abdominal hysterectomy and bilateral salpingoophorectomy with misdiagnosis of ovarian malignancy. Forty-two-year-old female admitted to our hospital with complaints of vomiting, nausea, diarrhea and abdominal pain. Surgery was planned with prediagnosis of ovarian tumor and acute abdomen. Appendectomy, total abdominal hysterectomy and salpingoophorectomy were performed synchronously, and 3 l of ascites were drained. Ascites fluid was compatible with exudate, and cytology was found negative for malignancy. She had history of splenectomy 8 years ago due to a diagnosis of idiopathic thrombocytopenic purpura (ITP) and two abortions both in the first trimester. In physical examination, she was exhausted and tachypneic; she had distinctive abdominal distention and bilateral (?2) pretibial edema, bilateral axillary and cervical lymphadenomegaly. She had fever of 38.3 C, heart rate was 114/min, and blood pressure was 150/95 mmHg. In pulmonary auscultation, respiratory sounds were decreased in the right hemithorax. Blood, urine, stool and throat cultures were taken during the fevered periods and no microorganism was isolated. Laboratory tests were as follows: white blood cells 16,900 (85.6 % neutrophils), platelets: 85,000/mm, C-reactive protein (CRP) 124 mg/dl (normal range 0–3 mg/dl), erythrocyte sedimentation rate (ESR) 7 mm/h, albumin 2.7 g/dl, potassium 2.8 mg/dl, calcium 5.8 mg/dl, ferritine: 178 ng/ ml, proteinuria 1.2 g/day, CA-125: 91.3 U/ml (N: 0–35 U/ ml). In thorax, X-ray showed right pleural effusion. Abdominal computed tomography indicated cholelithiasis, cystic formation in right adnexal region (ovarian origin?), dilatation in all small bowel segments, ascites and right pleural effusion. Transthoracic echocardiography showed roundabout pericardial effusion (1 cm), pulmonary artery pressure and ejection fraction were normal. Cranial computed tomography revealed advanced hydrocephalus, infarct area in occipital lobe. Cranial MRI angiography was normal. As she had polyserositis, CA-125 elevation without existence of any ovarian tumor, thrombocytopenia, history of abortion, joint complaints and no infection focus was detected; some laboratory tests were planned for SLE and antiphospholipid antibody syndrome; ANA ???, anti-ds DNA positive, C3 level 41 mg/dl (normal range 83–193), C4 level 2.9 mg/dl (normal range 15–57), anticardiolipin antibodies (IgM and IgG) and lupus anticoagulant were also negative. All these clinical findings and laboratory test results pointed pseudo–pseudo meigs syndrome, and the patient was diagnosed with pseudo–pseudo meigs syndrome associated with SLE. 1 g/day pulse methylprednisolone therapy was given for 3 days. Subsequently, 1 mg/kg/day methylprednisolone was given as maintenance therapy and 1 g/month pulse cyclophosphamide was added. Patient’s body temperature, serum level of potassium, calcium and CRP had returned to normal within 1 week after treatment. One month later, daily urinary protein excretion was found 300 mg/dl. Cyclophosphamide was given every month for 6 months. Then, azathioprine instead of cyclophosphamide for maintenance therapy was started. The coexistence of ovarian tumor, pleural effusion and ascites is called meigs syndrome [2]. Pseudo–pseudo meigs C. Bes (&) Ü. Dağlı P. Memedoğlu M. Soy Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey e-mail: cemalbes@hotmail.com

Serious menstrual bleeding associated with use of TNF alpha blocker: two cases

Menstrual disorders associated with the use of TNF alpha blocker have been rarely reported. Herein, we reported two cases aged 31 and 41, presenting with excessive menstrual bleeding occured after adalimumab administration which was subsequently discontinued.

Can bone quality be predicted accurately by Singh index in patients with rheumatoid arthritis

The aim of this study was to evaluate Singh index as a simple and inexpensive means of estimation of bone quality in patients with rheumatoid arthritis. Singh index evaluation was made on digital pelvis radiographs in 50 consecutive patients by three observers. Bone mineral density T scores of the spine and left proximal femur were assessed using dual energy X-ray absorptiometry. Singh index was correlated with densitometry measurements after grouping the patients as normal, osteopenia and osteoporosis. Intra- and interobserver agreements were evaluated by kappa correlations. Sensitivity, specificity, positive and negative predictive values and likelihood ratio’s of Singh index were calculated. Both intra- and interobserver agreements were 0.71 (range, 0.69 to 0.72) on average. Singh index proved highly sensitive for the diagnosis of osteopenia at the proximal femur (91%) and spine (90%), whereas the specificity of Singh index for identifying of osteoporosis at the femoral neck (93%) and spine (91%) was higher than sensitivity. Predictive values for osteoporosis at the proximal femur and spine were acceptable and positive likelihood ratios of Singh index for osteopenia and osteoporosis at the proximal femur were 2.4 and 10.1, respectively. Singh index can identify osteoporosis with a high specificity in patients with rheumatoid arthritis. However, the patients who are graded as osteopenia by the Singh index should undergo further evaluation with dual energy X-ray absorptiometry.

Anaplastic large cell lymphoma in a patient with rheumatoid arthritis

It is known that patients with rheumatoid arthritis (RA) have an increased risk for non-Hodgkin’s lymphomas in comparison with the general population. Although increased risk of lymphoma is attributed to the disease activity, the drugs used in the therapy of RA may also cause increased risk of malignancy. Herein, we report on an RA patient who developed non-Hodgkin’s lymphoma after methotrexate therapy and review the literature about it. A 74-year-old man with RA had been treated with low-dose methotrexate and subsequently developed anaplastic large cell lymphoma of the T-cell phenotype. Anaplastic large cell lymphoma has been reported rarely in rheumatoid arthritis.