Mycobacterium chelonae cutaneous infection in a patient with mixed connective tissue disease

Around 50 mycobacteria species cause human disease. Immunosuppressive states predispose to non-tuberculous mycobaterium infection, such as Mycobacterium chelonae: AFB, non-tuberculous, fast growth of low virulence and uncommon as a human pathogen. It may compromise the skin and soft tissues, lungs, lymph nodes and there is also a disseminated presentation. The diagnosis involves AFB identification and culture on Agar and Lowenstein-Jensen medium base. A 41-year-old female with MCTD (LES predominance) is reported, presenting painless nodules in the right forearm. She denied local trauma. Immunosuppressed with prednisone and cyclophosphamide for 24 months. Lesion biopsy has demonstrated positive bacilloscopy (Ziehl-Neelsen stain) and M.chelonae in culture (Lowenstein-Jensen medium base), therefore clarithromycin treatment has been started (best therapy choice in the literature).

Reunión clínica interhospitales / Diagnosis of mixed connective tissue disease

Se presenta el caso clínico de una paciente de 18 años, catalogado inicialmente como LES, con presencia de Ac antiRNP( +) y otras características que hacían planteable la posibilidad de enfermedad mixta del tejido conectivo (EMTC), quien evoluciona con cuadro de hipertensión arterial severa, llegando a emergencia hipertensiva, en relación a dos episodios de crisis convulsiva tónico-clónicas, no presentando deterioro de función renal. Su cuadro hipertensivo se manejó con uso de inhibidor de enzima convertidora de angiotensina (lECA) logrando normalización de cifras tensionales y desaparición de síntomas neurológicos, sin otros parámetros de enfermedad activa, lo que hizo pensar en la posibilidad de un cuadro similar a la crisis renal esclerodérmica, pero en el contexto de esta paciente con probable EMTC. Apoyaría lo anterior el hecho de la excelente evolución sin necesidad de aumentar la terapia esteroidal, ni de asociar otro inmunosupresor en ese momento.

We present the case of a 18-year-old woman, initially diagnosed with SLE. Laboratory exams were positive for anti RNP antibodies. This and some other characterisitics led to the diagnosis of mixed connective tissue disease (MCTD). She evolved into severe arterial hypertension, reaching hypertensive emergency related to two episodes of convulsive tonic-clonic crisis, without kidney failure. Her hypertension was managed with an angiotensin converting enzyme inhibitor (ACE inhibitor), achieving normal tension parameters and disappearance of the neurologic symptoms, without other parameters of active disease, which made us think of a clinical case similar to scleroderma renal crisis, but in the context of this patient with probable MCTD. This is sustained by the fact that the evolution was excellent without the need to in crease steroidal therapy, nor to associate another immune suppressor at that time.

Cetoacidosis diabética reversible con metotrexato: Resistencia al tratamiento insulínico. Caso clínico / Diabetic ketoacidosis responsive to methotrexate in a patient with a mixed connective tissue disease

We report a 42 year-old woman with a hypothyroidism and a mixed connective tissue disease treated with prednisone and methotrexate. The patient had normal blood glucose levels but when the methotrexate dose was tapered, she presented a diabetic ketoacidosis that required up to 520 units of insulin per day. Due to the intensification of the mixed connective tissue disease symptoms, the doses of methotrexate and prednisone were increased again with a simultaneous normalization of serum glucose levels and glucose tolerance. In the following six months, when the dose of methotrexate was tapered again, the hyperglycemia reappeared and was again controlled increasing the dose. Thirty months after the episode of keotacidosis, the patient was with a weekly dose of methotrexate, asymptomatic and with a normal glucose tolerance. Anti insulin antibodies were not detected and anti islet antibodies were indeterminate, due to interference with antinuclear antibodies. It is possible that the episode of ketoacidosis was unveiled by an autoimmune phenomenon.

Uso de infliximab en pacientes de un centro reumatologico / Use of infliximab in patients of a rheumatologic center

The objective of this study was to obtain post-marketing information about the use of infliximab in an ambulatory setting. We studied--retrospectively and prospectively--the case records of patients with rheumatoid arthritis (n=37), psoriatic arthritis (n=5), mixed connective tissue disease (n=1), and ankylosing spondylitis (n=2) who received infliximab (3 mg/kg) from August 2000 to January 2003. Descriptive values were given as percentage, mean or median, and standard deviation or interquartile range. Wilcoxon test was used for paired analysis of pre/post doses of corticosteroids, non-steroidal anti-inflammatory drugs, and methotrexate therapy. A p value < or = 0.05 was considered significant. Forty-five patients were included. A total of 207 infusions were administered. In 4 patients the treatment was permanently discontinued due to severe back pain during the infusion (2 cases) and serious anaphylactic reactions (2 cases). Other adverse reactions occurring during infusions were mild and successfully managed with standard treatment. A case of staphylococcal septic arthritis resolved with standard antibiotic treatment. No patient had evidence of active tuberculosis. One patient with rheumatoid arthritis and chronic renal insufficiency, received treatment with infliximab 1.9 mg/kg, every 30 days, with no changes in renal function. Due to improvement of symptoms, 14/39 (35.9%) patients could decrease the doses of corticosteroids, 15/43 (34.8%) decreased the doses of antiinflammatory drugs and 12/34 (35.3%) decreased methotrexate dosage. Although some questions remain to be elucidated, this case series shows the drug safety profile, the possibility to reduce concomitant drug doses, as well as individual approaches for situations where there are not yet guidelines available, so that rheumatologists have to make decisions based on clinical needs.

El objetivo de este estudio fue obtener informacion postmarketing sobre el uso de infliximab en un centro reumatologico de atencion ambulatoria. Se realizo un analisis retrospectivo y prospectivo de las historias clinicas de pacientes con diagnostico de artritis reumatoidea (n=37), artritis psoriasica (n=5),enfermedad mixta del tejido conectivo (n=1) y espondilitis anquilosante (n=2) que recibieron infliximab (3 mg/kg) desde agosto de 2000 a junio de 2003. El analisis descriptivo se realizo con porcentajes, media o medianay desviacion estandar o intervalo intercuartilo. La prueba de Wilcoxon se utilizo para el analisis apareado dedosis de antiinflamatorios no esteroideos y metotrexato, anterior y posterior a la administracion de infliximab. Se consideraron significativos valores de p < o = 0.05. Se incluyeron 45 pacientes a los que se les administraron un total de 207 infusiones. En 2 pacientes el infliximab se discontinuó debido a lumbalgia severa durante la infusion y en otros 2 por anafilaxia intrainfusional. Otras reacciones adversas ocurridas durante las infusiones fueron moderadas y respondieron adecuadamente al tratamiento estandar. Se presento un caso de artritis septica de rodilla por estafilococos. Un caso de artritis reumatoidea con insuficiencia renal compensada recibio infliximab en dosis de 1.9 mg/kg cada 30 dias, sin cambios en la funcion renal. Al momento, ningun paciente ha desarrollado tuberculosis activa. Debido a la mejoria clinica, se redujo la dosis de corticoides en 14/39 (35.9%) pacientes, de antiinflamatorios no esteroideos en 15/43 (34.8%) y de metotrexato en 12/34 (35.3%). En estaserie de casos se muestra el perfil de seguridad de infliximab, la posibilidad de reducir la dosis de drogas concomitantes,asi como algunos enfoques individuales sobre situaciones para las cuales no disponemos de guias basadas en la evidencia medica, y en las que los reumatologos debemos tomar decisiones segun las necesidades clinicas.

Corticotherapie et maladies systemiques

Corticosteroid are an essential mean to overcome systemic disorders. Thirty years ago they changed the prognosis of most of these diseases. Adverse effects are numerous and dangerous, especially infectious diseases and bone disorders. Prednisone is the most used drug. The pulse of methyprednisone is less used. In this study, we discuss some principles of the use of corticosteroid and the problems encountered using corticotherapy in systemic disorders

Disseminated nocardiosis in a patient with mixed connective tissue disease

Se describe el caso de una paciente de sexo femenino de 35 años de edad, con diagnóstico de Enfermedad Mixta del Tejido Conjuntivo, la cual desarrolló Nocardiosis generalizada falleciendo a consecuencia de esta infección. Se discuten las manifestaciones clínicas y las alteraciones inmunológicas de la paciente, que junto con el tratamiento con esteroides creemos fueron factores importantes para el desarrollo de esta infección oportunista. Por otra parte, en la revisión de la literatura que realizamos, éste representa el primer informa en que se documenta tal asociación