Portal system thrombosis: a complication of long-term residence at extreme altitude.

BACKGROUND: With induction of the Indian Army to heights over 5,000 meters above sea level, complications of long-term stay at extreme altitude have come to light. We describe our experience with patients developing portal system thrombosis. METHODS: Clinical data were collected over 2 years on patients hospitalized for thrombotic complications from high-altitude (HAA) and non-high altitude (non-HAA) areas. Site of thrombosis was confirmed by imaging or at surgery. Patients were investigated for conditions that predispose to venous thrombosis. RESULTS: Ten cases of portal system thrombosis were seen during the period; of these, 9 (mean age 28 [SD 3.9] years; all men) were from HAA. Mean duration of residence in HAA was 12.4 (4.9) months; two were smokers and six drank 7-22 g alcohol/day at least 5 times a week. The first symptom was abdominal pain; this was later complicated by gastrointestinal bleeding (n=5), fever (7), vomiting (7), and weight loss (5). Average time between onset of first symptom and reaching a tertiary-care hospital was 9.5 (4.7) days. Clinical examination showed ascites (8 cases), splenomegaly (7), and hepatomegaly (6). Mean hemoglobin level at admission was 15.8 (3.4) g/dL. Ascites was hemorrhagic; five cases also had large splenic hematoma. The site of thrombosis was splenic vein (7 cases), portal vein (6), and superior (4) and inferior (1) mesenteric vein. None of 5 patients investigated had any prothrombotic condition. Endoscopic/ sonographic evidence of development of collaterals appeared as early as 12-20 days after onset of symptoms. CONCLUSION: Residence in HAA for extended periods is a risk factor for development of portal system thrombosis. Persistent pain in abdomen in such individuals should raise the possibility of portal system thrombosis.

Thrombosis as a complication of extended stay at high altitude.

BACKGROUND: There is limited knowledge about the medical problems of long term stay at high (> 3000 m) and extreme (> 5000 m) altitudes, as these areas are generally considered uninhabitable. METHODS: Prospectively collected clinical records of all patients hospitalized at Command Hospital, Western Command between November 1998 and February 2000 were reviewed to identify thrombotic complications among patients from high and extreme altitude areas as well as those from non-high altitude areas who were < 45 years of age. RESULTS: Of 20,257 hospital admissions during the study period, 1692 were from high and extreme altitude areas. Forty-six patients from these areas had thrombosis-related diseases compared to 17 from non-high altitude areas (odds ratio: 30.49; 95% CI: 17.06-51.67; p < 0.001). The mean (SD) age of all patients with thrombotic complications was 32 (8) years and all were men. The mean duration of stay at high and extreme altitudes of such patients was 10.2 (5.6) months. Only 25 were smokers (mean 5.2 pack-years) and 39 consumed alcohol (mean 54 ml/day). Apart from frostbite in 5, no other medical condition was noted in these patients. The vascular events were deep vein thrombosis (20), pulmonary thromboembolism (6), stroke (15), thrombosis of the abdominal veins (8), and retinal artery and peripheral arterial thrombosis (1 each). The presenting complaint in all patients with thrombosis of the abdominal veins was poorly localized pain in the upper abdomen followed by ascites (6/8). Five of these patients also had a large spontaneous splenic haematoma. None of the patients investigated was found to have a procoagulant disorder. CONCLUSION: Long term stay at high and extreme altitudes is associated with a 30 times higher risk of spontaneous vascular thrombosis. Veins are common sites of such thrombotic events. We also encountered thrombosis of the portal, splenic and superior mesenteric veins in our patients who had stayed at high and extreme altitudes.

Cytokines and inflammatory bowel disease.

Cytokines are the key mediators of inflammation in the IBD and are focus of renewed interest to plan therapeutic strategies against this disease. However, there are gaps in our knowledge at present and a lot of questions need clear answers. Even with a therapy as specific as anti-TNF antibody, it is not clear if the benefit is attributable to simple binding and clearance of TNF-alpha or to binding on the cell surface and subsequent deletion of the activated macrophage. When a drug appears to be less effective than pre-clinical models suggest, can failures in effectiveness from delivery or dosing the differentiated? The disappointing results of clinical trials with IL-10 is at odds with the prediction of benefit from animal models. It even brings into question the validity of those models as well as the soundness of design of the clinical trials on which efficacy of IL-10 is assessed. Other exciting new methods to treat IBD could be use of monoclonal antibodies to effector T cell molecules (such as CD4 or CD44v7) removal of such cytokine secreting cells (apheresis), antibodies to proinflammatory cytokines (such as TNF-alpha, IFN-alpha, IFN-gamma, and IL-12) or administration of anti-inflammatory cytokines (such as IL-10, IL-11). Challenges in developing new therapeutic strategies include not only identifying novel agents, but also improving the definitions of clinical endpoints and defining efficacy at the biologic level. There is also need to further refine our knowledge about genetic elements and environment initiators to comprehensively manage IBD.

Dapsone in cutaneous lesions of SLE: an open study.

This short report describes a possible beneficial effect of dapsone in the treatment of chronic unresponsive muco-cutaneous lesions of systemic lupus erythematosus (SLE) without any serious side effects.