Timur Pirildar

Effect of trimethoprim-sulfamethaxazole in Blastocystis hominis infection.

Objective:Blastocystis hominis (B. hominis) is a common intestinal parasite that has long been considered nonpathogenic. Recently there have been many reports supporting a role for the organism as a potential pathogen. We performed a study to examine the pathogenicity of B. hominis and the effect of trimethoprim-sulfamethaxazole (TMP-SMX) on this organism.Methods:Stool samples of patients, who came to the Department of Parasitology, Faculty of Medicine, Celal Bayar University, were examined by direct wet-mount, trichrome staining, formalin-ethyl acetate concentration, and Kinyoun acid fast techniques for intestinal parasites, and bacteriological stool cultures were performed. Fifty-three symptomatic patients (38 children and 15 adults) with two consequent stool samples positive for abundant B. hominis (five or more organisms per ×400 field) and negative for other parasitic and bacterial pathogens were treated with TMP-SMX for 7 days, children 6 mg/kg TMP, 30 mg/kg SMX, and adults 320 mg TMP, 1600 mg SMX, daily. On the seventh day, at the end of treatment, stool samples of all patients were examined by same methods, and clinical symptoms were again evaluated.Results:B. hominis was eradicated in 36 of 38 (94.7%) children, and 14 of 15 (93.3%) adults. Clinical symptoms disappeared in 39 (73.6%), decreased in 10 (18.9%), and no change was observed in one (1.9%) patient, whereas symptoms persisted in all three (5.7%) patients in whom B. hominis could not be eradicated. Mean number of stools per day was significantly decreased from 4.3 to 1.2 in the 33 children (p < 0.001), and decreased from 3.5 to 1.0 in the four adults (p= 0.06) with diarrhea.Conclusions:These results suggested that B. hominis may be pathogenic, especially when it is present in large numbers, and TMP-SMX is highly effective against this organism. Although there are some anecdotal reports, to our knowledge this is the first study examining the effect of TMP-SMX on B. hominis in humans.

Platelet-activating factor and P-selectin activities in thrombotic and nonthrombotic Behçet's patients

ObjectiveThe aim of this study was to compare plasma Platelet-activating factor (PAF) and P-selectin (CD62P) activities in Behçet’s disease patients with and without thrombosis.MethodsIn this cross-sectional and descriptive study, 30 consecutive Behçet’s patients were included, 15 of them with venous thrombosis. All patients were also divided into two subgroups according to the presence or absence of clinical activity. Plasma PAF levels, basal and Ca++ ionophore (A23187)-induced leukocyte (cellular) PAF activities, and platelet-rich plasma ΔCD62P activity (the mean fluorescent density difference between CD62P phycoerythrin-positive and -negative stains) were evaluated.ResultsIn the thrombotic group, plasma PAF (P=0.001), basal leukocyte PAF (P=0.017), induced leukocyte PAF (P=0.024), and ΔCD62P (P=0.023) levels were significantly higher than in the nonthrombotic group. In the whole group of Behçet’s patients, there was a positive correlation between plasma PAF and ΔCD62P levels (r=0.533, P=0.002). When we compared clinically active and inactive patients with respect to the above parameters, there was no significant difference, irrespective of thrombosis. Plasma PAF (P=0.001), basal leukocyte PAF (P=0.004), and ΔCD62P (P=0.038) levels were significantly higher in the presence of both clinical activity and thrombosis than of clinical activity alone.ConclusionPlatelet-activating factor and CD62P may contribute to endothelial injury and thrombosis development in Behçet’s disease. These two parameters seem related to the presence of thrombosis rather than clinical activity.

QT dispersion in rheumatoid arthritis patients with and without Sjögren's syndrome.

The aim of this study was to assess the effect of secondary Sjögrens syndrome (SjS) on QT dispersion and corrected QT dispersion in patients with rheumatoid arthritis (RA). We performed electrocardiography and Doppler echocardiography on 58 patients with RA whom we divided into two groups according to the presence of secondary SjS, and on 29 healthy controls. All patients revealed significantly longer QT dispersion and corrected QT dispersion values (P < 0.05). Diastolic function variables were significantly different in all patients compared to controls. QT dispersion and corrected QT dispersion values were significantly longer in RA patients with secondary SjS than in those without. We concluded that secondary SjS could be a cardiovascular risk factor contributing to the well documented cardivascular disease in RA patients.

Endothelıal dysfunctıon ın patıents wıth prımary Sjögren’s syndrome

The aim of this study was to determine the endothelial function in patients with primary Sjögren’s syndrome (SS). We also aimed to determine whether endothelial (dys)function correlates with extraglandular manifestations, specific autoantibodies and the severity of salivary gland involvement of SS. Endothelium-dependent vasodilation and endothelium-independent vasodilation of the brachial artery were assessed by a high-resolution ultrasound on 25 patients with primary SS and on 29 healthy controls. Patients with primary SS had significantly less mean endothelium-dependent vasodilation than did controls (3.0±0.4% vs 4.2±0.3%; p=0.012). Endothelium-independent vasodilation induced by sublingual glycerol trinitrate was not different between the two groups (12.9±1.4% vs 14.1±1.2%; p=0.86;). We concluded that endothelium-dependent vasodilation was impaired in primary SS patients, in particular those presenting with Raynaud’s phenomenon, when compared with the healthy controls and this impairment was not associated with the presence of RF, ANA, anti-Ro/SS-A, anti-La/SS-B and with the other extraglandular manifestations of the disease.

Treatment of adult-onset Still's disease with leflunomide and chloroquine combination in two patients.

We report on two patients with adult-onset Still’s disease (ASD) who responded well to leflunomide and chloroquine combination therapy. Probably as a result of the rarity of ASD, studies of treatment have been not very common. Various DMARDS have been used in ASD [1]. To our knowledge, this is the first report regarding the beneficial effect of leflunomide and chloroquine in combination in ASD. Our patients were refractory to steroid therapy. Therefore, we started this combination therapy and succeeded in controlling the pericardial effusion in both patients. However, it is conceded that spontaneous improvement unrelated to therapy with DMARDS may have occurred in patients with ASD. Our two cases suggest that leflunomide, an isoxazole derivate [2,3], combined with chloroquine may have a beneficial therapeutic effect in recently diagnosed ASD. Additional studies are required to confirm the efficacy of this therapy and elucidate its mechanism of action in ASD.

An Unusual Presentation of Behçet’s Disease: Intestinal Perforation

Abstract: Behçet’s disease (BD), when first described in 1937, consisted of three symptoms: recurrent oral and genital ulcerations and iridocyclitis [1]. Today, it is known that BD is a multisystemic chronic vasculitic disorder which may involve both arteries and veins of all sizes, as well as the central nervous and gastrointestinal systems. The rate of gastrointestinal involvement of BD varies in different populations, being more common in Japan (50%–60%) and less common in the Mediterranean basin, including Turkey (0%–5%) [2,3]. We present a 34-year-old Turkish woman with BD who had ileal and colonic ulcerations complicated by perforation and gastrointestinal bleeding. Special emphasis was placed on the differential diagnosis between Crohn’s disease (CD) and BD with gastrointestinal involvement.

Sudden hoarseness due to unilateral cord vocal paralysis in a patient with Behçet's disease

Behçets disease is a systemic necrotising vasculitis affecting arteries and veins of all sizes in any location [1]. Here we report a patient with Behçets disease who presented with sudden hoarseness due to unilateral vocal cord paralysis from recurrent laryngeal nerve damage.

Arthritis Induced by Interferon-alpha Therapy in a Patient with Essential Thrombocythemia

Sir, Recombinant interferon-alpha (IFN-a) is produced and marketed for its beneficial effects in the treatment of various diseases including chronic viral hepatitis and a variety of malignancies [1,2]. In addition to antiviral and antitumor activities, IFN-a may be associated with the development of autoimmune side effects [3]. Here, we describe a patient with IFN-a induced polyarthritis. A previously healthy 52-year-old man was admitted to our clinic with non-specific cerebral symptoms of headache and dizziness in August 2000. His medical, family, occupational and environmental histories were non-contributory. Physical examination showed splenomegaly that was confirmed by abdominal ultrasonography. Neurological examination was normal. Laboratory findings showed high thrombocyte counts of 1.034 £ 10/l, 1.367 £ 10/l and 1.484 £ 10/l in three different occasions. Other hematological and biochemical findings were within normal limits. Erythrocyte sedimentation rate (ESR) was normal, as well. The bleeding time and other screening tests of hemostasis (prothrombin time, partial thromboplastin time) were normal. In addition, antinuclear antibody (ANA) and rheumatoid factor (RF) were negative and thyroid function tests were normal. The bone marrow revealed marked hyperplasia and mild dysplasia of the megakaryocytes suggesting essential thrombocythemia. Cytogenetic study was normal. Additional examinations which excluded other possible causes of thrombocytosis such as infectious diseases, inflammatory diseases, malignancies, myeloproliferative syndromes supported the diagnosis of essential thrombocythemia, as well. In September 2000, he was started on subcutaneous injections of IFN-a (5 million units three times a week). Six months after the IFN-a treatment was started, partial improvement was achieved and the platelet counts decreased to 540 £ 10/l. So it was decided to keep him on the IFN-a therapy using a dose of 5 million units four times a week. Two months later, in May 2001, he began to suffer from morning stiffness, pain and swelling in the proximal interphalangeal joints of both his hands, which progressed in two weeks to involve both wrists and his right knee. ESR was 32 mm/h (Westergren method), C-reactive protein was slightly increased at 1.8 mg/dl. ANA was positive with 1/320 speckled pattern and RF was 23 IU/ml. The IFN-a therapy was now stopped because it was thought to be the cause of the clinical picture. Discontinuation of the IFN-a therapy resulted in partial resolution of symptoms and signs involving the joints in two weeks. One month later, methyl-prednisolone (8 mg/day) and chloroquine (250 mg once a day) were started, resulting in complete resolution of the arthritic symptoms within a week. Nevertheless, his thrombocyte counts started to increase again (up to 728 £ 10/l) in two weeks after the IFN-a therapy stopped. Hydroxyurea was now started for the relapsed high thrombocyte counts. Although it is well known that treatment with IFN-a may be associated with the development of autoimmune side effects, arthritis is still uncommon. Searching the literature, we found 42 cases developing arthritis in relation to IFN-a therapy [4–18]. Chronic myeloid leukemia, was the indication for IFN therapy in almost half of these patients, whereas hairy-cell leukemia, lymphoma, renal cell carcinoma, malignant melanoma, multiple myeloma, carcinoid tumors, chronic hepatitis B and C constituted the others. Only three of these patients had received IFN-a for essential thrombocythemia, as in our case. In most of these cases, IFN-a was consequently stopped, leading to improvement of the arthritis but along with exacerbation of the primary condition.

Assessment of alveolar epithelial permeability in Behçet’s disease with 99mTc-DTPA aerosol scintigraphy

ObjectiveBehçet’s disease (BD) is a multisystem disorder characterized by vasculitis, and consists of a triad of recurrent ulcers of the oral and genital mucosa with relapsing uveitis. The prevalance of pulmonary involvement varies in the range of 1–10% in various studies and its complications are severe and life threatening. In this study, we investigated the changes of pulmonary epithelial permeability of patients with BD using technetium-99m diethylene triamine penta-acetic acid (99mTc-DTPA) aerosol scintigraphy, so as to begin the therapy regimen as soon as possible.MethodsTwenty-one nonsmoking patients with BD (8 women, 13 men; mean age 38.67 ± 8.86 years) and 15 healthy volunteer nonsmoking controls (8 women, 7 men; mean age 50.87 ± 12.45 years) underwent 99mTc-DTPA aerosol inhalation scintigraphy and pulmonary function tests (PFTs). Subjects inhaled 1480 MBq of 99mTc-DTPA for 4 min in the supine position. Scintigraphic data were recorded dynamically (1 frame/min) in the posterior projection on a 64 × 64 matrix for a 30-min period using a double-headed gamma camera (Infinia, GE, Tirat Hacarmel, Israel) equipped with a low-energy all-purpose parallel hole collimator. Half time of 99mTc-DTPA clearance (T1/2) was calculated by placing a mono-exponential fit on the curves. Penetration index (PI) was also calculated by dividing the peripheral total counts by the sum of the peripheral and central total counts on the first minute image, in order to quantify the distribution of the inhaled aerosol.ResultsThe clearance half time of 99mTc-DTPA radioaerosols in the BD patients (24.81 ± 6.22 min) was faster than in the normal control group (46.53 ± 22.41 min) (P = 0.004). There was also a significant difference between PI of the patients with BD (0.15 ± 0.03) and that of the controls (0.21 ± 0.06) (P = 0.002). No correlation was found between the mean T1/2 values of 99mTc-DTPA clearance or the spirometric measurements in the BD patients. Penetration indices were not correlated with PFT in the BD patients.ConclusionsLung epithelial permeability of the patients with BD was significantly higher than that of the normal subjects. The results of this study demonstrated that the assessment of lung epithelial permeability using 99mTc-DTPA aerosol scintigraphy could predict the presence of lung involvement in the early stages of BD.

Coexistence of Behçet’s disease and myasthenia gravis in a patient

A wide variety of diseases may be associated with myasthenia gravis [1, 2, 3]. We report a case of myasthenia gravis in a patient with Behçet’s disease (BD). A 34-year-old woman was diagnosed with BD in 1998 on the basis of recurrent oral and genital ulcerations for 12 years, a 6-month history of arthralgias affecting her elbows and wrists, several episodes of uveitis and positive pathergy test [4]. By March 2003, when she stopped her treatment consisting of steroid, colchicum, and azathioprine for 6 months after an asymptomatic period, she developed ptosis of the eyelids along with generalized weakness including the limb muscles. She reported her weakness increased after prolonged effort and improved following rest or sleep. Further findings for ophthalmologic and neurologic status were normal. Her routine hematological and blood chemical tests, erythrocyte sedimentation rate, C-reactive protein concentration, thyroid function tests, anti-nuclear antibody and anti-DNA tests were all normal or negative. When studied electrophysiologically, 3-Hz repetitive stimulation of the right ulnar and accessory nerves resulted in a 40% decrement in the muscle action potential. Thus, the diagnosis of myasthenia gravis was made. We did not relate the myasthenic symptoms to the drugs she took for the treatment of BD, since they occurred after a drug-free period of 6 months. Magnetic resonance imaging of the head and orbits revealed no lesion. Thoracic computed tomographic scan revealed no evidence of a thymus pathology, which would be expected in the course of myasthenia gravis. Autoimmune thyroiditis is the most common disease associated with myasthenia gravis, followed by systemic lupus erythematosus and rheumatoid arthritis. Less commonly associated diseases are polymyositis, Sjögren’s syndrome, and mixed connective tissue disease. To our knowledge, our patient is the first case of myasthenia gravis developing in a patient with BD. Our patient with BD was diagnosed to also have myasthenia gravis on the basis of the clinical and neurophysiological findings. Myasthenia gravis is a neuromuscular disorder characterized by a decrease in the number of available acetylcholine receptors at neuromuscular junctions due to an antibody-mediated autoimmune attack. How the autoimmune response is initiated and maintained in myasthenia gravis is not completely understood. The pathogenesis of BD remains unknown too, and theories include many etiologic factors including genetics, infections, immune regulation, and inflammatory mediators. The etiology of the association of BD and myasthenia gravis is not clear. We believe that future studies and case reports are required to explain the coexistence of these two diseases. In conclusion, patients with BD presenting with weakness and/or ptosis can also be examined for myasthenia gravis. Patients with myasthenia gravis can be examined for generalized disorders, including BD as in our case.