Active lupus and pregnancy: How to handle.

We report herein the case of a 20-year-old Thai woman who developed lupus flare in the second trimester of pregnancy, as manifested by autoimmune hemolytic anemia, thrombocytopenia and glomerulonephritis. The patient underwent treatment with intravenous dexamethasone and, subsequently, pulse methylprednisolone to control plausible lupus exacerbation in the central nervous system. The disease subsided after an inevitable development of spontaneous abortion. We reviewed the current status of knowledge on interactions between pregnancy and systemic lupus erythematosus, proper management, and safety immunosuppressive drugs to ensure a more favorable outcome. This will be helpful for physicians to provide sound advice regarding pregnancy for lupus patients in their reproductive years.

Gastrointestinal lymphoma in Thailand: a clinicopathologic analysis of 120 cases at Siriraj Hospital according to WHO classification.

Clinicopathologic information of gastrointestinal (GI) lymphoma in Southeast Asia is lacking. A retrospective analysis of 120 cases of GI lymphoma in Thailand diagnosed at Siriraj Hospital based on WHO classification was performed. All were non-Hodgkin lymphoma (NHL). The peak age was in the sixth and seventh decades; a slight male preponderance was observed. Sites of involvement included stomach (49.2%), intestine (46.7%), and multiple sites (4.2%). There were 104 cases of primary GI lymphoma (86.7%) and 16 cases of secondary GI lymphoma (13.3%). Presenting GI symptoms were more common in the former; while superficial lymphadenopathy and fever were more common in the latter. Mass lesions were observed in both groups (72.1% vs 56.3%). Localized and advanced diseases were found in 68.3% and 31.7% of primary GI lymphomas, respectively. The most common type of lymphoma in both groups was diffuse large B-cell lymphoma. Lymphoepithelial lesions (LEL) were not significantly different between the two groups (58.2% vs 42.9%), but Helicobacterpylori infection was significantly associated with primary gastric lymphoma (p < 0.0001). The treatment of choice for localized primary GI lymphoma is controversial. Complete surgical resection may increase the chance of complete remission, but mortality and relapse rates might be higher than those observed with combination chemotherapy alone. GI lymphomas in Thailand are mostly primary B-cell NHL. LEL is not indicative of primary GI lymphoma, but H. pylori infection is closely associated with primary gastric lymphoma. A prospective study to determine the treatment of choice for localized GI lymphoma is needed.

A grandma with two years of fever and agony.

A 72 year old woman living in Namuen District, Nan Province, was referred from a local hospital for having two years of fever and back pain. Her symptoms started with feeling malaise, intermittent fever with chills and body ache. All the symptoms got worse at night making her unable to sleep. She also experienced back pain all day night in additon to anorexia. She had no cough, petechia or abnormal bleeding. After having had medical consultations at a local hospital, no definite cause of her suffering was found. She then underwent various further investigations including a bone marrow examination at a local university hospital which did not reveal any malignant conditions. She was referred back to her home town hospital. However, she still suffered from recurrent high pyrexia, anorexia, progessive weight loss, etc. leading to many more hospital admissions. One year later, her symptoms, including fever and back pain, seemed to get worse and she was once again admitted to the hospital. The laboratory tests at that time revealed hematocrit 27%, white blood cell count 21,600 / mL, neutrophil 95%, lymphocyte 5%, platelet 563,000 /mL, ESR 120 mm/hr., Ca 7.6 mg/dl, phosphorus 4.5 mg/dl, BUN 14 mg/dl, Cr 0.9 mg/dl, Coomb\'s test megative. T3 179 ng/dl, TSH 1.27 mU/ml. Echocardiography showed LVEF 66% without evidence of infective endocarditis. An abdominal ultrasound revealed a mild degree of renal parenchymal disease, normal size liver with homogeneous parenchymal disease and a normal-appearing spleen. Gastroscopy was also performed without any significant finding. Because the clinical scenario was so obscure, she was referred to Siriraj Hospital Medical School for further management on May 6, 2003. There was no significant chronic medical condition prior to this agonic episode. She neither smoked nor drank alcohol. Her adult children ran a family business within her home so she was closely looked after by her daughter and did not have any financial difficulties.

Bone marrow examination: Beneft and complication.

Bone marrow aspiration and biopsy are useful, easily operated procedures in clinical practice. The procedures are helpful for diagnosis, staging and following up of many diseases. In spite of the decline of their roles in stem cell transplantation, they had been used as a part of bone marrow transplantation in the past. The capability of bone marrow examination, from either aspiration or biopsy, in establishing or supporting diagnosis, in the cases with abnormal complete blood count (CBC) is higher than that with normal complete blood count (CBC) (50-90% VS 8-9%). Complications are rare. From this study we find 3 in 4,347 episodes (0.07%). Thrombocytopenia and hematoma at puncture site are found in all of them. High caution should be paid in these patients when bone marrow aspiration and biopsy are considered.