Intravenous Immunoglobulins as a new opportunity to treat discoid lupus erythematosus: A case report and review of the literature

Discoid lupus erythematosus (DLE) is a chronic dermatological disease that can lead to scarring, alopecia and dyspigmentation, if not properly treated. Actually, no drugs are specifically approved for the treatment of CLE, although the first-line therapy usually consists of photoprotection associated to topical or oral steroids, topical calcineurin inhibitors and hydroxychloroquine (HCQ). In cases of DLE refractory to these medications, many other agents have been employed, such as dapsone, methotrexate, azathioprine, cyclophosphamide, biologic drugs and Intravenous Immunoglobulin (IVIG).We described the case of a DLE patient resistant to combination therapy with steroid and HCQ who was successfully treated with cyclical IVIG therapy. The treatment with IVIG resulted rapidly effective with persistent efficacy and low rates of relapses, although more cycles of IVIG are needed to achieve a stable clinical remission.We also discussed the beneficial and promising effects of IVIG in patients with Cutaneous Lupus reporting the previously published data.     

Oral beclomethasone dipropionate in patients with mild to moderate ulcerative colitis: A dose-finding study

Systemic glucocorticosteroids have demonstrated efficacy in ulcerative colitis (UC) but cause undesired systemic side effects. Beclomethasone dipropionate (BDP) has potent topical activity and is extensively metabolized. This randomized doubleblind study investigated an oral gastroresistant controlled-release preparation of BDP in 57 patients with mild to moderately severe extensive or left-sided UC. Patients were assigned to receive BDP 5 or 10 mg/d; a third group took a clinically inactive dose (1.6 g/d) of 5-aminosalicylic acid (5-ASA). Both BDP doses displayed excellent efficacy confirmed by results of endoscopy, biopsy, and clinical evaluation. Significant improvement from baseline occurred in most signs and symptoms of UC, particularly stool frequency, rectal bleeding, and mucus in the stool (P<.01). Tolerability was good in both BDP groups. Morning plasma cortisol levels decreased significantly from baseline with BDP 10 mg, but no significant changes in vital signs were observed at the end of treatment. Despite a small sample size and the open comparison with 5-ASA, this multicenter study showed the therapeutic equivalence of BDP 5 and 10 mg/d in alleviating clinical symptoms and improving endoscopic and biopsy scores in patients with mild to moderate UC. BDP 5 mg/d displayed better general tolerability and less reduction of plasma cortisol levels, however, and may be preferable to the higher dose in this indication.     

Esophageal hyperalgesia in patients with ulcerative colitis: role of experimental stress

OBJECTIVES: Intestinal inflammation is associated with enteric nervous system alterations, at both inflamed and noninflamed sites. The perception of stimuli from the GI tract is enhanced during inflammatory conditions, but it is unknown whether visceral hypersensitivity is limited to the inflamed area or diffuse throughout the entire GI tract. Moreover, although stress can reactivate inflammatory processes in the gut, it is unknown if this can alter perception from the GI tract. Our aim was to determine if patients with ulcerative colitis (UC) have increased esophageal sensitivity to distention and whether this is modified by experimental stress. METHODS: Ten UC patients and 12 healthy volunteers (HVs) underwent gradual balloon distension of the esophagus to assess their visceral sensitivity. Perceptive and pain thresholds were evaluated in basal conditions and after induction of experimental stress (cold water pressure test) while blood pressure and heart rate were monitored. RESULTS: Patients with UC had perceptive thresholds to distension similar to HVs (14.8+/-2.0 ml of air vs 14.5+/-3.0 ml); in contrast, the volume increment needed to evoke pain was significantly lower in UC patients than in HVs (58.9% vs 149.9%, p < 0.05). Physical stress caused a similar decrease in perceptive thresholds in HVs (-29.1+/-8.4%) and patients (-17.7+/-9.1%), but pain thresholds were significantly decreased only in HVs (-28.3+/-7.1% vs -11.5+/-12.3%). CONCLUSIONS: UC is characterized by increased esophageal sensitivity, indicating the existence of diffuse hyperalgesia during intestinal inflammatory processes. This increased sensitivity may account for the frequent upper GI symptoms these patients complain of when in clinical remission.     

Topical treatment of ulcerative colitis. Doubleblind study between beclomethasone dipropionate and mesalazine

Fifty-nine patients with ulcerative colitis localised in the rectum, sigmoid and colon entered the trial. Thirty were treated with BDP and twenty-nine with 5-Aminosalicylic (enemas and suppositories) for 8 weeks, in a doubleblind, controlled study. Clinical, endoscopic and histological assessment was carried out before and after 4 and 8 weeks of treatment. It is concluded that BDP is a new important treatment for mild and moderate activity ulcerative colitis.     

The hand: a reflection of arthritis

Hand joint involvement in rheumatic diseases is often precocious and predominant as compared to other skeleton-muscular regions. Clinical examination not always allows for easy detection of fluid outpouring and synovial involvement, and undoubtedly does not allow to diagnose pathognomonic bone alterations of several rheumatic conditions. Articular ultrasonography is an innocuous methodology, easily reproducible and directly applied by a rheumatologist. The aim of this vignette is to present ultrasonography elementary lesions of the hand for a prompt diagnosis.     

Ultrasonography and magnetic resonance imaging of heel fat pad inflammatory-oedematous lesions in rheumatoid arthritis

OBJECTIVE: To study heel fat pad (HFP) inflammatory-oedematous lesions in selected patients with rheumatoid arthritis (RA) using ultrasonography (US) and power Doppler US (PDUS), to describe and compare US features of these lesions with those obtained with magnetic resonance imaging (MRI), and to describe changes in the lesions after a short-term follow-up with conventional or anti-tumour necrosis factor-alpha (TNFalpha) therapy. METHODS: Twelve heels of eight RA outpatients with HFP inflammatory-oedematous lesions were studied by US, PDUS, and unenhanced MRI. All the patients were followed up and US was performed after 3 months. Five patients started on anti-TNFalpha therapy. RESULTS: HFP lesions appeared at US as a heterogeneous and hypoechoic subcalcaneal mass, with loss of normal lobular structure and increased thickness of HFP, because of focal rupture of fibrous septae with oedema and fluid. PDUS showed peripheral vascularization of HFP lesions in 9/12 heels. In 3/12 heels some vascular signals was also detectable inside the lesion, always along the residual echoic septa. No detectable flow was observed within the central fluid-filled spaces. MRI of the HFP lesions showed areas of mean intensity in T1-weighted sequences and high intensity in T2-weighted sequences, with poorly or well-defined margins. After 3 months, PDUS showed reduction in HFP lesion vascularity (associated with reduction in pain) in 10/12 heels, while poor regression of grey-scale US abnormalities was observed. CONCLUSIONS: Both US and MRI are capable of demonstrating structural abnormalities in the HFP. PDUS is useful to assess and monitor inflammatory vascularization of the HFP lesions.     

Hepatitis C virus infection in Italian intravenous drug users: epidemiological and clinical aspects

Abstract: The epidemological and clinical features of hepatitis C virus infection have been evaluated in a cohort of 227 intravenous drug users enrolled at a drug dependence treatment center in the Veneto area in 1992–1993 and followed periodically. Hepatitis C virus infection was detected using second-generation anti-HCV ELISA in 171 (75%) subjects at enrollment. Anti-HCV seropositivity correlated with: a) the duration of drug abuse: 91% of intravenous drug users injecting for more than 8 years were seropositive as compared to 40% of those with a history of abuse lasting 4 years or less, p<0.001; b) sharing of injection equipment: 85% anti-HCV positive intravenous drug users had shared at some time as compared to 64% seronegative subjects, p<0.001; c) seropositivity for immunodeficiency virus infection: 25% anti-HCV positive intravenous drug users were coinfected as compared to 3.5% anti-HCV negative, p<0.001; d) markers of ongoing (two cases) or previous hepatitis B virus infection were detected in 62% of anti-HCV positive but in 21% of anti-HCV negative cases, p<0.01. Two initially anti-HCV negative intravenous drug users seroconverted during follow up giving an incidence rate of hepatitis C virus infection of 6.2 per 100 person-years. During the survey abnormal alanine aminotransferase levels were detected in 75% anti-HCV positive but in 24% anti-HCV negative cases (p<0.001), with significantly higher levels in the former. These findings suggest that the circulation of hepatitis C virus among intravenous drug users has been decreasing in recent years, although new infections still occur. In agreement with the high rate of chronicization of parenterally transmitted hepatitis C, the majority of anti-HCV positive subjects had biochemical features of associated liver disease.     

Morphological, immunocytochemical and biochemical studies in human osteoarthritic chondrocytes exposed to IL-1b and cyclical hydrostatic pressure

OBJECTIVE: To investigate the in vitro effects of cyclic hydrostatic pressure (HP), of a magnitude and frequency close to those that presumably exist in articular cartilage, on human osteoarthritic chondrocytes cultivated for 48 hrs in the presence or absence of interleukin-1beta (IL-1beta). METHODS: Pressurization cycles in the form of sinusoidal waves (minimum pressure 1 MPa, maximum pressure 5 MPa) at a frequency of 0.25 Hz for 3h were assessed on cultured chondrocytes obtained from the femoral heads of osteoarthritic patients. Under these conditions, we evaluated proteoglycan (PG) levels and nitrites production in the culture medium by the immunoenzymatic method and examined the morphology of chondrocytes by transmission electron microscopy (TEM). Moreover, immunocytochemical investigations were performed to localize inducible nitric oxide synthase (iNOS). RESULTS: The presence of IL-1beta led to a very significant decrease in PG levels and to an increase in NO production. When the chondrocytes were cultured in the presence of HP, a statistically significant restoration of PG levels was observed, but pressurization did not significantly increase the PG levels in cells damaged by IL-1beta. After pressurization, there was a slight decrease in the concentration of NO under basal conditions and a statistically significant decrease in the IL-1beta induced release of NO. The results concerning metabolic production were further confirmed by the morphological findings obtained by TEM and immunocytochemical studies. CONCLUSION: This study confirms the protective role of HP which stimulates PG production and counteracts IL-1beta induced NO release. These data are supported by morphological and immunocytochemical findings.