Yimy F. Medina

The use of procalcitonin determinations in evaluation of systemic lupus erythematosus.

Background:Procalcitonin (PCT), the precursor of the calcitonin, is synthesized in the parafollicular C-cells of the thyroid. It has been used to detect and to differentiate systemic bacterial infections from flares of systemic lupus erythematosus (SLE). PCT in serum increases in severe bacterial and fungal infections, but not, or only slightly in viral infections. Objective:To measure PCT levels in patients with active SLE and to compare them with patients without lupus activity and to determine the possible association between activity and elevation of the PCT. Design:Prospective case control study. Patient and Methods:Measurements were made of PCT (METHOD: Essay immunoluminometric - and ultrasensitive - BRAHMS Diagnostika, Berlin, Germany), C-reactive protein, erythrocyte sedimentation rate, and blood and urine cultures. The index of activity of SLE was determined by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score of a serial group of patients seen by our rheumatology service. Samples from 53 patients were analyzed. The patients were divided in 2 groups: group I (n = 21) with little or no activity for SLE; group II (n = 32) with activity for SLE (SLEDAI >5). None of the patients had severe bacterial infection, sepsis, or systemic multiorgan failure. Results:Group I had a SLEDAI score of 1.8 [95% confidence interval (CI) 1.09–2.51] with mean levels of PCT 0. 08 ng/mL (Negative smaller than 0. 5 ng/mL). Group II SLEDAI score was 14.6 (95% CI 11.95–17.23) with mean levels of PCT 0.418 ng/mL with standard deviation 1.0021 (95% CI 0.0628–0.773). The measure of association calculated by Fisher method was not significant (1.927) (P = 0. 282). In the group II, 3 patients had frankly positive PCT (3.18, 3.42, and 3.95 ng/mL) and high activity indices (14, 13, and 24). None presented with severe infection, sepsis, or systemic multiorgan failure. They had pneumonia, renal failure (PCT 3.42 ng/mL) and urinary tract infection without systemic symptoms (3.95 ng/mL). Infection was not detected in the other patient (3.18 ng/mL) that was interpreted as a false positive. Conclusions:This study demonstrates that there is no association between the activity of SLE and PCT levels. The utility of the PCT resides is in raising suspicion of a concurrent bacterial or mycotic infection in the evaluation of patients with active autoimmune diseases.

Calcifying Lupus panniculitis in a patient without manifestations of systemic lupus Erythematosus

Summary Lupus panniculitis or lupus profundus is a variant of lupus Erythematosus cutaneous that primarily affects subcutaneous tissue. Clinically, it is characterized by one or several firm subcutaneous nodules and/or plaques with or without overlying epidermal changes. It is reported to occur with a frequency of 2-3% in patients with Systemic Lupus Erythematosus (SLE). Between 10 and 50 percent of patients with lupus panniculitis will have or eventually develop Systemic Lupus Erythematosus. In nearly all cases there are deep, erythematosus plaques and nodules, and some of them ulcers, which usually involve the proximal extremities, trunk, breasts, buttocks, and face. These lesions may be tender and painful and frequently heal with atrophy and scaring, turning as a chronic condition and subsequently heal with disfigurement. We describe a patient who suffers from lupus panniculitis with no association to SLE symptoms and complicated by several progressive and disabling cutaneous lesions. Resumen La paniculitis lupica o tambien llamada lupus profundus es una variante del lupus eritematoso cutaneo que afecta el tejido celular subcutaneo. Se caracteriza clinicamente por uno o varios nodulos subcutaneos que son firmes y/o placa con o sin cambios epidermicos. Se ha informado su frecuencia en 2% a 3% de casos de Lupus eritematoso sistemico. Entre el 10 al 50% de los casos de paniculitis lupica va a desarrollar lupus eritematoso sistemico. En casi todos los casos hay placas eritematosas y/o nodulos que en algunos casos se ulceran y que usualmente estan localizados en las areas proximales de las extremidades, tronco, mamas, nalgas y la cara. Estas lesiones pueden ser clinicamente dolorosas y sensibles a la presion y frecuentemente cicatrizan con desfiguracion del area circundante. Describimos un paciente que padece de paniculitis lupica sin asociacion de lupus eritematoso sistemico y que se complico con varias lesiones cutaneas progresivas y discapacitantes.

Asociación de lupus eritematoso sistémico y esclerosis múltiple: esclerosis lupoide. Descripción de cuatro casos

Resumen La esclerosis multiple (EM) y el lupus eritematoso sistemico (LES) con o sin sindrome antifosfolipido son enfermedades autoinmunes. Se ha descrito en varias ocasiones la asociacion de estas enfermedades o se ha descrito el cuadro clinico de la EM con caracteristicas de laboratorio de LES. Cuando afectan al sistema nervioso central pueden hacerlo en forma definida para cada enfermedad pero tambien pueden hacerlo en forma interpuesta o combinada de las dos enfermedades, a lo que se le ha llamado esclerosis lupoide, haciendo que en algunos casos sea dificil la diferenciacion de las dos enfermedades y por lo tanto direccionar el tratamiento. Presentamos cuatro casos de esclerosis lupoide, discutimos acerca de las caracteristicas clinicas y de laboratorio de esta entidad y hacemos una diferenciacion de la esclerosis multiple y de la afectacion neurologica del LES, especialmente por imagenes y resultados de laboratorio.

Massive gouty pseudotumor

T hese massive gluteal pseudotumors (Fig. 1A) in this 42year-old man from Colombia developed over a 15-year period. The patient also had typical joint involvement of gout and massive numbers of tophi on the hands, arms (Fig. 1B), and legs, including the pretibial skin. Only 3 months before this presentation, he had been noted to have a uric acid of 10.7 mg/dL. Gout was diagnosed, and the patient had initiated therapy with allopurinol and colchicine. Biopsy of a gluteal mass after formalin fixation revealed amorphous areas in the subcutaneous fat tissue typical of tophi from which urate crystals had been dissolved surrounded by granulomatous reaction and inflammatory leukocytic infiltrate (Fig. 2A). On polarizing microscopy of a wet preparation, there were negatively birefringent crystals consistent with monosodium urate, but cholesterol crystals were also seen as a possible source of confusion or a complication of the tophus (Fig. 2B). Gouty involvement in fat or as panniculitis is an uncommon form of gout, which has been described only in a few cases. Massive tophaceous deposits may be seen in cases of neglected gout, as was probably true in this patient from a rural area, or in patients with overproduction disorders of urate metabolism. The patient declined further evaluation.