Migrated Inferior Vena Cava (IVC) Filter Strut: A Rare Cause of Chronic Distal Pancreatitis with Likely Malignant Transformation.

BACKGROUND Inferior vena cava (IVC) filters are indicated for patients with recurrent venous thrombosis despite proper anticoagulation or whenever anticoagulation is contraindicated. IVC filter deployment is an invasive procedure with various complications. One example is IVC filter limb fracture and migration, which is associated with significant morbidity and/or mortality. Extravascular migration toward pancreas may induce pancreatitis. Patients with chronic pancreatitis are known to have an increased risk of pancreatic malignancy. CASE REPORT We report an extremely rare case of IVC filter fractured limb in 44-year-old woman, which had migrated into the pancreatic tail and manifested as chronic distal pancreatitis. A pancreatic adenocarcinoma was found by biopsy at the pancreas tail. It is likely that a foreign body promoted this metaplasia and neoplastic transformation. CONCLUSIONS Early detection and retrieval of a displaced foreign body in organs, such as the pancreas, seem to be essential to reduce risk of subsequent complications, including chronic inflammation and possibly neoplasia.

Fusarium-Induced Cellulitis in an Immunocompetent Patient With Sickle Cell Disease: A Case Report.

Fungal infections due to Fusarium species are mostly present in immunocompromised and patients with poorly controlled diabetes mellitus. We report a case of lower extremity skin infection caused by Fusarium species in a 61-year-old woman diagnosed with sickle cell disease. Single skin ulceration caused by Fusarium species can result from fungal inoculation into damaged tissue, so any condition that damages the skin can be considered as a risk factor for inoculation. Long-standing sickle cell disease may develop vaso-occlusion in the skin that can produce lower extremity ulcers and myofascial syndromes. The mechanism is not completely characterized, but compromised blood flow, endothelial dysfunction, thrombosis, inflammation, and delayed healing are thought to contribute to locally compromised tissue that may eventually lead to opportunistic infection such as in our case. Other factors contribute to the pathophysiology of lower extremity ulcers such as diabetes mellitus, with the resulting peripheral vascular ischemia causing poor circulation to the lower extremity, and peripheral neuropathy, which can make patients with diabetes unaware of minor trauma leading to the development of skin infections.

Analysis of JAK2V617F mutation in Jordanian patients with myeloproliferative neoplasms.

OBJECTIVE/BACKGROUND: Myeloproliferative neoplasms (MPNs) are heterogeneous clonal bone marrow stem cell disorders and include polycythemia vera (PV), essential thrombocythemia (ET), and idiopathic myelofibrosis (IMF) neoplasia. In 2005, the JAK2(V617F) mutation was identified in Philadelphia chromosome-negative patients. The aim of this study was to sequence coding exons 12 and 14 of the JAK2 gene in Jordanian patients with MPN. METHODS: Both exons 12 and 14 of the JAK2 gene were amplified using polymerase chain reaction from DNA extracted from 68 blood and bone marrow samples belonging to 57 MPN patients and subjected to DNA sequencing. RESULTS: JAK2(V617F) mutations were detected in 26 of 57 Jordanian patients (45%) with different MPNs. JAK2(V617F) was identified in 70%, 31%, and 14% of PV, ET, and IMF cases, respectively. Five men diagnosed with PV were homozygous for JAK2(V617F), whereas the other 21 patients were heterozygous for the mutation. Neither the JAK2(V617F) mutation nor any DNA polymorphism in exon 12 or exon 14 of the JAK2 gene was detected among the 40 leukemic patients. A rare single nucleotide polymorphism, c.1860C→T (rs375442615), was detected in one patient with ET. CONCLUSION: This study is the first molecular investigation of the JAK2 gene in Jordan. We successfully identified the JAK2(V617F) mutation in Jordanian patients with Philadelphia chromosome-negative MPNs. Our results provide a basis for the early detection of this mutation and simplify the diagnostic workup for these disorders at the molecular level.

Rheumatoid arthritis in Jordan: a cross sectional study of disease severity and associated comorbidities.

Treating rheumatoid arthritis (RA) to target is advocated using disease activity measures. The impact of RA on the general health status of affected patients in Jordan is not well described. This study reported the severity of RA in Jordan and its association with consequent disabilities and comorbidities. A cross-sectional, observational study was conducted at King Abdullah University Hospital in the north of Jordan. All patients who were diagnosed with RA were included. Patients' demographics, comorbidities, disease activity score (DAS 28), and clinical disease activity index (CDAI) were collected. Both DAS 28 and CDAI were utilized to categorize RA disease activity. A total of 465 patients with RA were included: 82% were females; mean age ± standard deviation (SD) was 47.62±14.6 years; and mean disease duration ± SD was 6±4.45 years. The mean ± SD for the DAS 28 and CDAI was 5.1±1.5 and 23±14.2, respectively. According to the DAS 28, 51% of the patients were in the high disease activity category and only 5% were in remission. On the other hand, according to the CDAI, 44% were in the high disease activity category and only 1% were in remission. In Jordan, patients with RA have a high severe disease rate and a low remission rate. The disease is often progressive and associated with comorbidities that need to be managed.

Anti-TNF therapy in Jordan: a focus on severe infections and tuberculosis.

BACKGROUND: A high rate of infection has been reported in patients receiving treatment with anti-tumor necrosis factor (anti-TNF). This study describes the rate of and risk factors for serious infections in patients receiving anti-TNF agents in Jordan. METHODS: This retrospective observational study was conducted at a large tertiary referral center in the north of Jordan. Between January 2006 and January 2012, 199 patients who received an anti-TNF agent (infliximab, adalimumab, or etanercept) were included. Patients received the anti-TNF treatment for rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel disease, or other conditions. A serious infection was defined as any bacterial, viral, or fungal infection that required hospitalization, administration of appropriate intravenous antimicrobial therapy, and temporary withholding of anti-TNF treatment. RESULTS: The mean duration of anti-TNF treatment was 26.2 months. Steroids were used in 29.1% of patients, while 54.8% were given additional immunosuppressant therapy (methotrexate or azathioprine). Only one anti-TNF agent was given in 70.4% of patients, while 29.6% received different anti-TNF agents for the duration of treatment. Serious infections were documented in 39 patients (19.6%), including respiratory tract infections (41%), urinary tract infections (30.8%), and skin infections (20.5%), and extrapulmonary tuberculosis in three patients (7.7%). Exposure to more than one anti-TNF agent was the only factor associated with a significant increase in the rate of infection (relative risk 1.9, 95% confidence interval 1.06-4.0, P=0.03). CONCLUSION: Serious infections, including tuberculosis, were a common problem in patients receiving anti-TNF agents, and exposure to more than one anti-TNF agent increased the risk of serious infection.

Association between vitamin B12 level and anti-parietal cells and anti-intrinsic factor antibodies among adult Jordanian patients with Helicobacter pylori infection

OBJECTIVE: Evaluate the association of Helicobacter pylori infection with anti-parietal cell antibodies (APCA) and anti-intrinsic factor antibodies (AIFA) and their impact on vitamin B12 serum level. PATIENTS AND METHODS: One hundred patients (M/F: 43/57; age 46.5 ± 17.5 years) who underwent upper gastrointestinal endoscopy at King Abdullah University Hospital, Irbid, Jordan were enrolled in the study. The patients were grouped as H. pylori-infected (n = 81) or H. pylori negative (n = 19) by histopathological examination. Fasting serum vitamin B12 levels, antiparietal cell antibodies and anti-intrinsic factor antibodies for patients and controls were determined. RESULTS: Anti-parietal cell antibodies and anti-intrinsic factor antibodies were positive in 9.9% and 18.5% of H. pylori-positive patients respectively. None of the H. pylori negative subjects had anti-parietal cell antibodies or anti-intrinsic factor antibodies. Serum vitamin B12 level was lower in the H. pylori-infected patients (275 ± 70.4 pg/mL) than in controls (322.9 ± 60.7 pg/mL; p 0.05). H. pylori was positive in 94% of the low-vitamin B12 group compared with 64.6% of the normal-vitamin B12 group (p 0.5). CONCLUSION: Patients with H. pylori infection are more likely to have anti-parietal cell antibodies and anti-intrinsic factor antibodies. There was an association between H. pylori infection and lower vitamin B12 levels. H. pylori infection might be a significant factor in the pathogenesis of autoimmune gastritis.

Association between vitamin B12 level and anti-parietal cells and anti-intrinsic factor antibodies among adult Jordanian patients with Helicobacter pylori infection.

OBJECTIVE: Evaluate the association of Helicobacter pylori infection with anti-parietal cell antibodies (APCA) and anti-intrinsic factor antibodies (AIFA) and their impact on vitamin B12 serum level. PATIENTS AND METHODS: One hundred patients (M/F: 43/57; age 46.5±17.5 years) who underwent upper gastrointestinal endoscopy at King Abdullah University Hospital, Irbid, Jordan were enrolled in the study. The patients were grouped as H. pylori-infected (n=81) or H. pylori negative (n=19) by histopathological examination. Fasting serum vitamin B12 levels, anti-parietal cell antibodies and anti-intrinsic factor antibodies for patients and controls were determined. RESULTS: Anti-parietal cell antibodies and anti-intrinsic factor antibodies were positive in 9.9% and 18.5% of H. pylori-positive patients respectively. None of the H. pylori negative subjects had anti-parietal cell antibodies or anti-intrinsic factor antibodies. Serum vitamin B12 level was lower in the H. pylori-infected patients (275±70.4pg/mL) than in controls (322.9±60.7pg/mL; p<0.05). H. pylori was positive in 94% of the low-vitamin B12 group compared with 64.6% of the normal-vitamin B12 group (p<0.5). CONCLUSION: Patients with H. pylori infection are more likely to have anti-parietal cell antibodies and anti-intrinsic factor antibodies. There was an association between H. pylori infection and lower vitamin B12 levels. H. pylori infection might be a significant factor in the pathogenesis of autoimmune gastritis.

Adult primary and secondary immune thrombocytopenic purpura: a comparative analysis of characteristics and clinical course.

This study was conducted to compare the platelet count and the presence of bleeding manifestations at initial diagnosis of immune thrombocytopenic purpura (ITP) between patients with primary and secondary ITP. Medical records for 67 consecutive adult patients with ITP were reviewed retrospectively and the relevant data were abstracted. Thirty-eight (56.7%) patients were diagnosed as having primary ITP and 29 (43.3%) were considered to have secondary ITP. At the time of diagnosis, the median initial platelet count (median: 60 × 10(9)/L) for patients with secondary ITP was significantly (P < .005) higher than that for patients with primary ITP (median: 3.5 × 10(9)/L). Ecchymosis and/or purpura was observed in 4 (13.8%) patients with secondary ITP and in 33 (86.6%) patients with primary ITP (P value <.005). In conclusion, patients with secondary ITP had higher platelet count at diagnosis and were less likely to present with bleeding manifestations than those with primary ITP.

High serum erythropoietin and ferritin levels in conjunction with anemia response in malignant lymphoma.

Anemia is a common finding in lymphoma. There are few data available regarding the erythropoietin (EPO) levels in conjunction with ferritin in lymphoma patients. We prospectively evaluated 55 patients diagnosed with malignant lymphoma during the period between November 2006 and March 2008 at the King Abdullah University Teaching Hospital, Jordan. Our data showed that 74.4% of lymphoma patients were anemic. Furthermore, serum EPO and ferritin levels were higher in lymphoma patients compared with the healthy controls (P=0.001). The observed versus predicted EPO ratio showed also significantly higher levels in anemic lymphoma patients compared to healthy controls (p=0.03). There was an improvement in the Hb level in lymphoma patients who were treated with at least 3-cycles of chemotherapy as compared with newly-diagnosed patients. An adequate increase of EPO levels was observed in anemic lymphoma patients and notably associated with higher ferritin levels and improvement of Hb (p<0.001).Our findings suggest that ferritin estimation in lymphoma patients may predict the level of erythropoiesis and possibly the degree of anemia. Further studies to confirm these findings are warranted.