Recurrent pericarditis. Relief with colchicine

Recurrence is one of the major complications of pericarditis. Treatment of recurrence is often difficult, and immunosuppressive drugs or surgery may be necessary. We conducted an open-label prospective study of nine patients (seven men and two women; age, 18-64 years; mean age, 41.7 +/- 13.7 years). Patients were treated with colchicine (1 mg/day) to prevent recurrences. All patients had suffered at least three relapses despite treatment with acetylsalicylic acid, indomethacin, prednisone, or a combination. Pericarditis was classified as idiopathic in five patients, postpericardiotomy in two, post-myocardial infarction in one, and associated with disseminated lupus erythematosus in one. For statistical analysis, we conducted a paired comparison design (Student's t test). All patients treated with colchicine responded favorably to therapy. Prednisone was discontinued in all patients after 2-6 weeks (mean, 26.33 +/- 10.9 days), and colchicine alone was continued. After a mean follow-up of 24.3 months (minimum, 10 months; maximum, 54 months), no recurrences were observed in any patient; there was a significant difference between the symptom-free periods before and after treatment with colchicine (p less than 0.002). Our study suggests that colchicine may be useful in avoiding recurrence of pericarditis, although these results need to be confirmed in a larger, double-blind study.     

The clinical practice guidelines of the Sociedad Española de Cardiología on pericardial pathology

The pericardium is a serous membrane consisting of two layers (parietal and visceral), which may be involved by different infectious, physical, traumatic, or inflammatory agents as well as in metabolic or systemic diseases. The reactions of the pericardium to these insults result in rather nonspecific clinical features, such as the characteristic inflammatory findings in acute pericarditis, the development of pericardial effusion with the possible complication of cardiac tamponade, and a fibrous retractile reaction that may lead to constrictive pericarditis. These phenomena are not mutually exclusive and can be simultaneous or consecutive in the same patient; however, for the sake of clarity they are independently discussed.The aim of the present guidelines is to provide orientation about the management of patients with pericardial disease. Such management should basically rest on the knowledge of the clinical and epidemiological features (such as disease frequency) of the different types of pericardial disease that determine the diagnostic and therapeutic yield of the different invasive pericardial procedures (pericardiocentesis, pericardial biopsy and pericardiectomy), and, therefore, their respective indications. In addition, the indication of the different types of medical therapy are discussed. On the other hand, emphasis is made on the possible limitation of the validity of these guidelines for patients belonging to geographical areas or socioeconomic contexts with different etiologic spectra.     

Delayed-contrast enhancement cardioresonance in transient left ventricular apical ballooning

Transient left ventricular apical ballooning (TAB) is a condition that mimics acute coronary syndrome typically without coronary angiographic stenosis. Patients present with typical chest pain, ECG changes suggesting ischemia, and a slight elevation of myocardial injury markers such as Creatine kinase and Troponines. Ballooning during ventricular systole of the cardiac apex is a characteristic feature of this entity. It is transient and it usually resolves after a few days together with normalization of ECG changes. Initially, apical dyskinesis can be diagnosed by any cardiac imaging technique that allows myocardial wall motion assessment. Recent advances in cardiovascular magnetic resonance imaging (CMR) have made this technique to become the gold-standard method to assess myocardial infarction. CMR provides an excellent and reproducible assessment of segmental wall motion abnormalities and, more importantly, it allows an accurate depiction of myocardial necrotic area by means of delayed contrast-enhancement method. Therefore, it may be particularly useful in the assessment of TAB by demonstrating segmental dysfunction in the absence of myocardial irreversible damage. We report three cases of TAB in which contrast- enhanced CMR emerged as an excellent diagnostic tool.     

Electrophysiological mechanisms of the SI SII SIII electrocardiographic morphology

We studied three groups of individuals by means of spatial-velocity electrocardiograms and thallium-201 myocardial imaging to figure out the electrophysiological explanation of the SI SII SIII electrocardiographic morphology. We studied twelve healthy individuals without SI SII SIII, seven healthy individuals with SI SII SIII and fifteen patients with chronic obstructive pulmonary disease with SI SII SIII. The average values of the QRS-E and QRS-F intervals were higher in the second (P less than 0.05 and P less than 0.005) and third groups (P less than 0.01 and P less than 0.001) than in the first. One patient of the second group and thirteen of the third showed right ventricular enlargement. The slowing down of the right ventricular conduction explained the SI SII SIII morphology in normal individuals in more than half the cases. In patients with chronic obstructive pulmonary disease with SI SII SIII the conduction delay plays an important part in the electrogenesis of the right ventricular enlargement electrocardiographic morphology. We think that these observations can give further data about the electrophysiologic mechanism of the SI SII SIII morphology.     

Association of HLA alleles with Plasmodium falciparum severity in Malian children

Pre-erythrocytic immunity to Plasmodium falciparum malaria is likely to be mediated by T-cell recognition of malaria epitopes presented on infected host cells via class I and II major histocompatibility complex (MHC) antigens. To test for associations of human leukocyte antigen (HLA) alleles with disease severity, we performed high-resolution typing of HLA class I and II loci and compared the distributions of alleles of HLA-A, -B, -C and -DRB1 loci in 359 Malian children of Dogon ethnicity with uncomplicated or severe malaria. We observed that alleles A*30:01 and A*33:01 had higher frequency in the group of patients with cerebral disease compared to patients with uncomplicated disease [A*30:01: gf = 0.2031 vs gf = 0.1064, odds ratio (OR) = 3.17, P = 0.004, confidence interval (CI) (1.94-5.19)] and [A*33:01: gf = 0.0781 vs gf = 0.0266, 4.21, P = 0.005, CI (1.89-9.84)], respectively. The A*30:01 and A*33:01 alleles share some sequence motifs and A*30:01 appears to have a unique peptide binding repertoire compared to other A*30 group alleles. Computer algorithms predicted malaria peptides with strong binding affinity for HLA-A*30:01 and HLA-A*33:01 but not to closely related alleles. In conclusion, we identified A*30:01 and A*33:01 as potential susceptibility factors for cerebral malaria, providing further evidence that polymorphism of MHC genes results in altered malaria susceptibility.     

Biological markers of myocardial necrosis

New biological markers of myocardial injury have improved the management of patients with acute coronary syndromes. Among these markers, the most relevant are the cardiac troponins (troponin I and troponin T) because of their cardiospecificity, and myoglobin because of its combination of diagnostic sensitivity and usefulness for an early diagnosis. The serial analysis and combined use of both markers fulfill all diagnostic and prognostic requirements, and are helpful in indicating therapeutic strategies for acute coronary syndromes. However, these markers also have limitations, and their concentrations should always be interpreted in the light of the patient's clinical status.     

Impact of trimethoprim-sulfamethoxazole prophylaxis on falciparum malaria infection and disease

BACKGROUND: Trimethoprim-sulfamethoxazole (TS) prophylaxis is recommended for persons living with human immunodeficiency virus infection and acquired immunodeficiency syndrome in Africa. TS and the antimalarial combination sulfadoxine-pyrimethamine (SP) share mechanisms of action and resistance patterns, and concerns about the impact of TS resistance on SP efficacy have contributed to reluctance to implement TS prophylaxis in Africa. METHODS: To determine whether TS prophylaxis impairs SP efficacy for treatment of uncomplicated falciparum malaria, we conducted a randomized, controlled, open-label study of TS prophylaxis. Two hundred and forty children 5-15 years old were randomized in a 2 : 1 fashion to receive either thrice-weekly TS for 12 weeks or no prophylaxis and were treated with SP for subsequent episodes of malaria. The incidence of malaria, SP efficacy, and the prevalence of parasite mutations that confer antifolate drug resistance were measured. RESULTS. TS prophylaxis had a 99.5% protective efficacy against episodes of clinical malaria, with 97% efficacy against infection. Four SP treatment failures occurred in the control group, and none occurred in the TS group. No evidence was seen for selection by TS of antifolate resistance-conferring mutations in parasite dihydrofolate reductase or dihydropteroate synthase during subclinical infections. CONCLUSIONS. In this setting of low antifolate resistance, TS was highly effective in preventing falciparum malaria infection and disease and did not appear to select for SP-resistant parasites.     

A randomized trial of artesunate-mefloquine versus artemether-lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in Mali

The choice of appropriate artemisin-based combination therapy depends on several factors (cost, efficacy, safety, reinfection rate, and simplicity of administration). In this study, we tested the hypothesis that artesunate-mefloquine (Artequin) is as efficacious as artemether-lumefantrine (Coartem) in treatment of uncomplicated Plasmodium falciparum malaria. The study was carried out from August 2004 through February 2005 in Kambila, Mali. Subjects with weights >/= 10 kg and uncomplicated malaria were enrolled. Artesunate-mefloquine was given once a day for three days and artemether/lumefantrine twice a day for three days. A total of 470 (235 in each arm) patients were enrolled. The unadjusted 28-day cure rate was higher in artesunate-mefloquine arm than in the artemether-lumefantrine arm (79.7% versus 67.8%; P < 0.004). After correction for reinfection, the 28-day cure rates were similar in the two groups (96.04% versus 96.93%). Artesunate-mefloquine is well-tolerated and is as effective as artemether-lumefantrine for the treatment of P. falciparum malaria. Artesunate-mefloquine also prevented more new infections.     

A randomized trial of artesunate-sulfamethoxypyrazine-pyrimethamine versus artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria in Mali.

The choice of artemisinin-based combination that is being adopted for malaria treatment in sub-Saharan Africa may depend on several factors, including cost, efficacy, side effects, and simplicity of administration. We tested the hypothesis that artesunate-sulfamethoxypyrazine-pyrimethamine is as efficacious as the four-dose regimen of artemether-lumefantrine for treatment of Plasmodium falciparum malaria. The study was carried out during two transmission seasons (2003 and 2004) in Sotuba, Mali. Participants at least 6 months of age with uncomplicated P. falciparum malaria were randomly assigned to receive artesunate-sulfamethoxypyrazine-pyrimethamine or artemether-lumefantrine. Treatment efficacy was assessed using the World Health Organization 28-day protocol. A total of 606 (303 in each arm) patients were enrolled. The cure rate was higher for artesunate-sulfamethoxypyrazine-pyrimethamine than for artemether-lumefantrine (98.7% versus 89.6%; P < 0.0001). After correction for cases of re-infection, the cure rates were 100% and 99.0%, respectively (P = 0.08). No serious adverse events occurred. Artesunate-sulfamethoxypyrazine-pyrimethamine is well-tolerated and effective against P. falciparum malaria. It showed an additional benefit of preventing new infections.