Acute pancreatitis as an initial symptom of systemic lupus erythematosus： A case report and review of the literature

Acute pancreatitis as an initial symptom of systemic lupus erythematosus (SLE) is rare. We present a report of a 46-year-old female patient who had fever, abdominal pain and vomiting, elevated pancreatic enzyme levels, hypocalcemia, hypoxemia, and various other laboratory abnormalities. She was first diagnosed with acute severe pancreatitis and then with SLE after further investigations. After a 2-mo treatment with somatostatin, the patient recovered.     

Nodular vasculitis as the cause of fever of unknown origin in elderly--case report

Fever of unknown origin (FUO) is one of the most interesting diagnostic problem in medicine. It may be the background of many different diseases. Infections, neoplasm and autoimmunological diseases are the main reasons of FUO. However, very often the course of main disease is nonspecific and symptoms are difficult to interpret. Then fever may be the only clinical symptom of the disease. FUO in elderly people may cause specific diagnostic problems. We present the case of 75-years old man with FUO. The fever had existed over 6 months before diagnosis. Nodular vasculitis was the reason of fever.     

不明原因发热449例临床分析

目的探讨不明原因发热(FUO)的原因。方法回顾性分析2000年1月∽2003年12月间在我院住院诊治的符合不明原因发热诊断标准的患者449例。结果449例患者中经各种检查或诊断性治疗最终明确诊断者387例,确诊率为86．2％。病因包括：感染性疾病220例(56．8％),其中结核病96例,占43．6％(96／220);结缔组织病76例(19．6％),其中Still病占34．2％(26／76),系统性红斑狼疮占18．4％(14／76),血管炎占13．2％(10／76);肿瘤性疾病64例(16．5％),其中淋巴瘤占39．1％(25／64);其他疾病27例(7．0％),其中坏死性淋巴结炎占33．3％(9／27),伪热占22．2％(6／27),药物热占26％(7／27);出院时仍未确诊的62例(13．8％)。结论感染性疾病是本组FUO患者的主要病因,结核病是其中的主要病种,结缔组织病和肿瘤性疾病在本组FUO病因中也占重要地位;大多数FUO经仔细的临床检查和分析是可以得到确诊的。     

Systemic lupus erythematosus: an unusual cause of cardiac tamponade in a young man.

Although pericarditis and pericardial effusion are common cardiac complications of systemic lupus erythematosus (SLE), cardiac tamponade is a very rare initial manifestation of this disease. We describe a case of a young male patient in whom cardiac tamponade secondary to a loculated pericardial effusion was the presenting symptom of SLE.     

Case series of pediatric systemic lupus erythematosus from Kerala: comparison with other Indian series

Aim: To determine the clinical and laboratory characteristics of patients diagnosed with pediatric systemic lupus erythematosus (pSLE) in the general pediatrics department of a tertiary level hospital in southern India and compare them to data of case series from other parts of the country. Methods: Retrospective chart review by two independent reviewers. All patients diagnosed with SLE in the pediatrics department of the Amrita Institute of Medical Sciences hospital between 1 January 2004 and 31 September 2008, were included in the study. Results: Twenty children were diagnosed with pSLE in the above‐mentioned period (female : male ratio 2.3 : 1.0). Fever (75% of patients) and arthralgia (65%) were the most common clinical presenting features. Many patients who were referred as ‘Fever of unknown origin’ (37.5%) or ‘idiopathic thrombocytopenic purpura’ (15%) fulfilled the diagnosis of SLE on detailed evaluation. Renal manifestations were present in 11 patients, seven of whom underwent a biopsy. Class IV lupus nephritis was the most common finding (4/7). A very high percentage of our patients had hypocomplementemia (85%). The statistical significance of the differences between our cohort and previously reported cohorts could not be determined. Conclusions: pSLE patients in our series, compared to previous literature from India had a much higher incidence of fever, thrombocytopenia and hypocomplementemia at presentation and much lower incidence of arthritis. It is unclear whether these differences represent unique characteristics of ethnically dissimilar subsets of the Indian population. A high index of suspicion should be maintained in order to make an early diagnosis of pSLE, since the most common presenting features in our cohort were arthralgia and fever.     

Two cases of late-onset drug-induced lupus erythematosus caused by ticlopidine in elderly men

Abstract

We have experienced two cases of drug-induced lupus erythematosus caused by ticlopidine in the last three years. Both were late-onset cases (1 and 4 years) that occurred in elderly men (76 and 81 years old). The common features were fever, arthralgia, myalgia, serositis, and the presence of anti-histone autoantibodies. Because ticlopidine is widely used in elderly people with ischemic vascular disease, ticlopidine-induced lupus should be considered when patients taking ticlopidine present lupus-like symptoms.     

Fever of unknown origin caused by multiple myeloma: a report of 9 cases

BACKGROUND: Most authorities regard multiple myeloma as a rare cause of fever and not a cause of fever of unknown origin (FUO). OBJECTIVE: To describe a series of patients with FUO caused by multiple myeloma. METHODS: We reviewed the clinical features of 9 patients seen at Mayo Clinic from January 1, 1975, to February 1, 2001, with FUO caused by multiple myeloma. RESULTS: Fever of unknown origin caused by multiple myeloma was found in 9 patients (6 men and 3 women). All patients satisfied accepted criteria for FUO. The mean +/- SD time from the onset of fevers to the initial physician evaluation was 4.8 +/- 2.0 weeks. The mean time from the initial physician evaluation to the diagnosis of multiple myeloma was 11.4 +/- 6.5 weeks. The mean age at diagnosis of multiple myeloma was 55.9 +/- 6.9 years. All 9 patients were anemic. Peripheral blood smears were available for 8 patients, and all had rouleaux formations. All 9 patients underwent exhaustive testing to determine the cause of fevers. Further testing was done in 6 patients subsequent to the diagnosis of multiple myeloma. Acetaminophen or nonsteroidal anti-inflammatory drugs or both relieved fevers in all patients who received them. All 8 patients who received chemotherapy experienced resolution of fevers. The median actuarial survival of the patient cohort was 38 months. CONCLUSIONS: Multiple myeloma can cause FUO. When appropriate, clinicians should include multiple myeloma in the differential diagnosis of FUO to reduce unnecessary testing, rapidly establish the diagnosis, and initiate effective treatments.     

Fever of unknown origin caused by late-onset rheumatoid arthritis

Fever of unknown origin (FUO) is always a diagnostic challenge. The causes of FUO are legion and may be due to malignancy, infection, collagen vascular disease, and a variety of other unusual disorders. Currently, malignancies-followed by infectious etiologies-are the most common cause of FUO. We present an elderly female patient with an FUO who was thought to have subacute bacterial endocarditis because of an antecedent history of recent dental work. Subacute bacterial endocarditis was ruled out on the basis of negative cultures and negative transesophageal echocardiography. No evidence for an infectious disease or neoplastic etiology could be demonstrated in this patient. The diagnosis of FUO is most difficult when there is a paucity of clues from the history and physical examination, as was the case in this patient. Nonspecific laboratory tests included highly increased erythrocyte sedimentation rate (>or=100 mm/h), highly increased C-reactive protein, relative lymphocytopenia, and chronic thrombocytosis. These findings are compatible with a variety of infectious and inflammatory disorders. No evidence could be found for vasculitis. The only laboratory diagnostic findings present in her case were a highly increased rheumatoid factor titer and perinuclear antineutrophilic cytoplasmic antibody level. Polymyalgia rheumatica/temporal arteritis, systemic lupus erythematosus, and adult Still's disease were ruled out. The patient's FUO was best explained by the finding of late-onset rheumatoid arthritis (LORA), which is characterized by acute onset in elderly patients without the usual musculoskeletal manifestations of rheumatoid arthritis. Both the highly increased rheumatoid factor titer and perinuclear antineutrophilic cytoplasmic antibody level in the absence of an alternate explanation indicate that the FUO in this patient was caused by LORA.     

Total colonic necrosis

Diffuse ischemic colitis leading to colonic necrosis is a rare complication of systemic lupus erythematosus. A 16-year-old girl who developed such a complication and underwent emergency subtotal colectomy is described. The incidence and significance of intestinal symptoms and the difficulties in the differential diagnosis in patients with systemic lupus erythematosus presenting with abdominal manifestations are discussed.     

Fever of unknown origin: subacute thyroiditis versus typhoid fever

Fever of unknown origin (FUO) is not infrequently a diagnostic dilemma for clinicians. Common infectious causes include endocarditis and abscesses in adults, and noninfectious causes include neoplasms and certain collagen vascular diseases, for example, polymyalgia rheumatica, various vasculitides, and juvenile rheumatoid arthritis (adult Still's disease). Subacute thyroiditis is a rare cause of FUO. Among the infectious causes of FUO, typhoid fever is relatively uncommon. We present a case of FUO in a traveler returning from India whose initial complaints were that of left-sided neck pain and angle of the jaw pain, which initially suggested the diagnosis of subacute thyroiditis. After an extensive FUO workup, when typhoid fever is a likely diagnostic possibility, an empiric trial of anti- Salmonella therapy has diagnostic and therapeutic significance. The presence of relative bradycardia, and response to quinolone therapy, was the basis of the clinical diagnosis of typhoid fever as the explanation for this patients FUO. This case illustrates the diagnostic difficulties in assessing patients with FUO with few diagnostic findings.     

Systemic lupus erythematosus presenting as cardiac tamponade-a case report

Although pericarditis and pericardial effusion (PE) are some of the common manifestations of systemic lupus erythematosus (SLE), the occurrence of cardiac tamponade is quite rare. We present herewith a young girl with cardiac tamponade presenting as initial manifestation of SLE.     

Fever of unknown origin due to preleukemia/myelodysplastic syndrome: the diagnostic importance of monocytosis with elevated serum ferritin levels

Fever of unknown origin (FUO) is a common clinical diagnostic dilemma. In the elderly, causes of FUO most commonly include malignancy or infection, and less commonly include collagen vascular diseases. Among the collagen vascular diseases causing FUO in the elderly, polymyalgia rheumatica/temporal arteritis, and adult Still's disease (adult juvenile rheumatoid arthritis) are difficult diagnoses to prove. Among the infectious causes of FUO in the elderly are subacute bacterial endocarditis, intra-abdominal abscesses, and extrapulmonary tuberculosis. In the elderly, neoplastic causes of FUO include lymphomas, hepatomas, renal cell carcinomas, and hepatic or central nervous system metastases. Acute leukemias, particularly during "blast" transformation, may present as acute fevers in the absence of infection, but are rare causes of FUO. Preleukemia/myelodysplastic syndromes are exceedingly rare causes of FUO. We present a case of an elderly man who presented with findings that initially suggested adult Still's disease. Prolonged and profound monocytosis provided the key clue to his subsequent diagnosis of preleukemia/myelodysplastic syndrome. In this patient, a positive Naprosyn test result also suggested a neoplastic cause for his FUO. After months of prolonged fevers, myelocytes/metamyelocytes were eventually demonstrated in his peripheral smear during hospital evaluation. These findings, in concert with the persistent monocytosis, highly elevated ferritin levels, polyclonal gammopathy on serum protein electrophoresis, and eventual presence of myelocytes/metamyelocytes on peripheral smear, prompted a bone marrow test that demonstrated blast cells confirming the diagnosis of preleukemia myelodysplastic syndrome as the cause of this patient's FUO.     

Intravenous immunoglobulin in the treatment of resistant subacute cutaneous lupus erythematosus: a possible alternative

Subacute cutaneous lupus erythematosus (SCLE) is a common manifestation of systemic lupus erythematosus. In many cases it appears to be resistant to various systemic or topical treatments. Three cases of resistant SCLE with good response to intravenous immunoglobulin (IVIG) are described here suggesting that IVIG could be an alternative treatment in these patients.     

系统性红斑狼疮并发蛛网膜下腔出血的临床特点

目的探讨系统性红斑狼疮(systemic lupus erythematosus,SLE)并发蛛网膜下腔出血(subarachnoid hemorrhage,SAH)患者的临床特点及预后。方法总结分析1983年1月至2012年1月就诊于北京协和医院的12例SLE并发SAH患者的临床资料。结果 SLE并发SAH患者住院期间的病死率高达42%(5/12)。SLE并发SAH的症状以头痛为主(75%)。系统性红斑狼疮疾病活动指数平均为(17.5±4.5)分。死亡患者在SAH发生早期即出现意识障碍者占80%(4/5),合并严重感染者占60%(3/5)。结论 SAH是SLE的少见且致命的并发症。对于出现意识障碍或合并感染的SLE患者,应当提高警惕,积极治疗SLE原发病及SAH,提高生存率。     

Lower limb pitting edema in systemic lupus erythematosus

We report two patients with lower limb pitting edema and systemic lupus erythematosus (SLE) who showed immediate response to systemic steroids. In one of the patients, the edema had been present for about 6 months and was the first manifestation of her SLE. In the second patient with a long history of SLE and antiphospholipid syndrome, a thrombosis was suspected, but not confirmed. Only after therapy with steroids did the edema disappear completely. Pitting edema of the lower limb could be a rare manifestation of SLE. Received: 11 August 1998 / Accepted: 11 September 1998     

Recurrent fractures in an elderly patient with systemic lupus erythematosus

Glucocorticoid‐induced osteoporosis (GIO) is an important problem that remains undertreated, even by rheumatologists. We present a case of an elderly patient with systemic lupus erythematosus diagnosed more than 40 years ago, who suffered from recurrent fractures and attendant complications despite a bone mineral density (BMD) score in the osteopenic range and treatment with bisphosphonates. With improved treatment and outcome of lupus, an increasing number of elderly patients who are susceptible to osteoporotic fractures are expected. This case serves to highlight that rheumatic disease patients on steroids should be screened for GIO, as effective treatment and preventive measures are available. Teriparatide is a promising treatment for patients who have failed bisphosphonate treatment or who are at high risk for fracture. We should also bear in mind that BMD scores alone are not indicative of fracture risk, and other tools such as the WHO‐FRAX (Fracture risk assessment tool), serum vitamin D3 levels and bone turnover markers should be used where appropriate. Other measures including attention to factors that contribute to falls should also be considered, necessitating a multi‐disciplinary approach.     

Fever of unknown origin: an evidence-based review

ABSTRACT:: Fever is a common problem for which patients seek medical advice. Fortunately, in most cases, fever is self-limiting or the etiology of fever is promptly established. Sustained, unexplained fever despite a comprehensive work up is recognized as fever of unknown origin (FUO), which frequently poses a clinical challenge. For a methodical approach, FUO is recently categorized into classic FUO, nosocomial FUO, neutropenic FUO and HIV-associated FUO based on the clinical setting and patient's underlying immune status. This review focuses on the key factors of classic FUO. The etiologic clues obtainable from the history, bedside physical examination findings and pertinent laboratory tests are discussed. Also, FUO in older patients and tuberculosis as a cause of FUO are briefly discussed.     

Fever of unknown origin in older adults

Evaluation of elderly patients who have fever of unknown origin (FUO) requires a different perspective from that needed for young patients. Differential diagnosis often varies with age, and presentation of the disease frequently is nonspecific and symptoms difficult to interpret. Noninfectious diseases are the most frequent cause of FUO in the elderly and temporal arteritis the most frequent specific cause. Tuberculosis is the most common infectious disease associated with FUO in elderly patients. FUO often is associated with treatable conditions in the elderly. Therefore, intensive, accelerated evaluation is necessary, as the lack of physiologic reserve makes this population vulnerable to irreversible changes and functional deterioration.     

Kikuchi-Fujimoto disease: a case report

Kikuchi-Fujimoto disease is a rare benign cervical lymphadenopathy, which often affects young adult women. Its etiology and pathogenesis are unknown. We present the case of Kikuchi-Fujimoto disease in the Polish population and analyse the difficulties in differentiating this disease from the systemic lupus erythematosus.     

Arterial occlusion in systemic lupus erythematosus: a good prognostic sign?

Arterial occlusion with subsequent amputation of extremities is a rare manifestation of systemic lupus erythematosus (SLE). It may be caused by local arteritis and/or thrombosis. We describe the clinical and laboratory manifestations and treatment administered to six SLE patients who developed peripheral arterial necrosis necessitating amputation of extremities secondary to the arterial occlusion. All patients were female, with ages ranging from 16 to 65 years. Arterial occlusion took place in the initial months of disease (median: 7 months). Only one of five patients tested for antiphospholipid antibodies had these antibodies who also had vasculitis and thrombosis in a histopathological study. Most patients presented a very benign outcome after the amputation of extremities and stayed in remission for several years. The satisfactory outcome of most patients after the vascular phenomenon allows us to consider the possibility that such a complication could be, for unknown reasons, a marker for good prognosis in SLE or, alternatively, that the aggressive therapy administrated for patients with this complication at the beginning of the disease could recover the balance of the immune system, avoiding future relapses.