Cryptococcal meningitis and SLE: a diagnostic and therapeutic challenge.

Cryptococcal meningitis is a rare occurrence in systemic lupus erythematosus (SLE). The risk factors of developing this infection are duration of SLE, intensity of glucocorticoid use, and SLE-related intrinsic immune abnormalities. Early recognition and prompt initiation of antifungals can prevent complications and improve survival. There is a dearth of evidence with regards to optimal treatment of cryptococcosis in non-HIV infected and non-transplant patients. The general consensus is to follow treatment guidelines for HIV-positive patients with cryptococcal meningitis. We describe a girl with active SLE and cryptococcal meningitis, and discuss the diagnostic and therapeutic challenges faced in this case.

Myocardial infarction with normal coronaries: an unexpected finding in a 13-year-old girl with systemic lupus erythematosus.

We report a 13-year-old girl diagnosed with systemic lupus erythematosus (SLE) who presented with left-sided chest pain, with ECG changes and elevation troponins that were suggestive of an acute inferior wall myocardial infarction (MI). Her multi-slice computed tomography coronary angiogram and standard angiogram were normal. The cardiac magnetic resonance imaging revealed an area of infarcted myocardium that was in the right coronary artery territory. We believe her MI was most likely secondary to coronary vasospasm. MI is rare and coronary vasospasm is an uncommon cause of MI in children and adolescents with SLE.

Systemic lupus erythematosus in the multiethnic Malaysian population: disease expression and ethnic differences revisited.

OBJECTIVES: Ethnic differences in systemic lupus erythematosus (SLE) have been previously described in the multiethnic Malaysian population. However, there have since been many demographic and socioeconomic changes in the country. The aim of this study is to re-examine the clinical and immunological profiles of Malaysian SLE patients of different ethnic backgrounds. METHODS: Consecutive follow-up patients at the University Malaya Medical Centre (UMMC) from July 2010 until March 2011 were included in the study. RESULTS: The most common clinical manifestations were malar rash (61.3%), arthritis (52.3%), haematological disease (51.6%), oral ulcers (51%) and renal disease (40.6%). Ethnic Indians had fewer malar and discoid rashes but were at higher risk of arthritis, serositis, renal and neuropsychiatric disease compared to Malays and Chinese Malaysians. Antiphospholipid syndrome (APS) was less common in Chinese. A longer duration of SLE correlated with a lower SLEDAI score. CONCLUSION: Overall, the spectrum disease expression was similar to the earlier Malaysian study but the frequency of the more severe disease manifestations, viz. renal, haematological, neuropsychiatric involvements and serositis, were lower. This study further emphasises differences primarily between ethnic Indians and the other races in Malaysia.

Painless ascites and elevated CA125: initial presentation of lupus-associated protein-losing enteropathy.

Lupus associated protein loosing enteropathy (LUPLE) is a rare gastrointestinal manifestation of SLE. We presented a case of painless ascites from serve hypoalbuminaemia secondary to LUPLE. The patient responded to a course of intravenous cyclophosphamide. The remission was maintained by azathioprine and low dose prednisolone.

Chronic intestinal pseudo-obstruction: a rare first manifestation of systemic lupus erythematosus.

Chronic intestinal pseudo-obstruction (CIPO) is a rare clinical syndrome of ineffective intestinal motility characterised by clinical and radiological evidence of intestinal obstruction with no identifiable mechanical lesion. CIPO can either be idiopathic or secondary to a systemic disease, like systemic lupus erythematosus (SLE). Fewer than 30 cases of CIPO secondary to SLE have been reported so far. Here we describe a case of SLE with the initial presentation of CIPO. In SLE-related CIPO, treatment includes a combination of high-dose intravenous corticosteroids, immunosuppressants and supportive care. With awareness of this condition, unnecessary surgical intervention and repeated invasive procedures could be avoided. Early initiation of treatment would avoid complications and bring about resolution of symptoms.

Successful treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) in systemic lupus erythematosus (SLE) with oral cyclophosphamide.

Peripheral neuropathy is a known manifestation of systemic lupus erythematosus. However, the association of primary autoimmune inflammatory neuropathies such as chronic inflammatory demyelinating polyneuropathy (CIDP) with SLE is uncommon. We report a 26-year-old man who simultaneously presented with severe CIDP and photosensitive rash, but was unresponsive to intravenous immunoglobulin infusion and continued to progress. He was found to have underlying SLE and improved with combined corticosteroid and immunosuppressive therapy with oral cyclophosphamide. CIDP with underlying SLE may be more resistant to conventional therapy with IVIG, requiring the addition of other immunosuppressive agents.

Estimation of arterial carbon dioxide by end-tidal and transcutaneous PCO2 measurements in ventilated children.

Simultaneous measurements of arterial, end-tidal, and transcutaneous carbon dioxide (PaCO2, PetCO2, PtcCO2, respectively) were obtained in 134 children receiving mechanical ventilation (ages, 2 days to 16 years; mean, 2.5 years). The mean +/- SD PetCO2 bias (PaCO2 - PetCO2) was 3.4 +/- 6.6 mmHg. When the PetCO2 bias was plotted against the PaO2/PAO2 ratio, a change in the scatter was obvious at about 0.3. The PetCO2 bias for patients with PaO2/PAO2 under 0.3 was 7.8 +/- 7.3 mmHg compared to 0 +/- 3.4 in patients with PaO2/PAO2 above 0.3 (P less than 0.001). PetCO2 differed significantly from PaCO2 (P less than 0.001) only for patients with PaO2/PAO2 under 0.3. The slope (PaCO2 versus PetCO2) for these patients was 1.59, while the slope for patients with PaO2/PAO2 above 0.3 coincided with the line of identity (1.00). The mean +/- SD PtcCO2 bias (PaCO2 - PtcCO2) was -1.3 +/- 7.2 mmHg. Skin perfusion was recorded at the area close to the transcutaneous CO2 monitor electrode and was defined as normal when capillary refill was below 3 seconds. The PtcCO2 bias for patients with normal skin perfusion was -0.2 +/- 5.4 mmHg (P = 0.73) compared to -4.1 +/- 9.9 for patients with decreased skin perfusion (P = 0.01). The slope of PtcCO2 against PaCO2 was closer to identity in patients with normal skin perfusion (1.17) than in patients where it was decreased (slope, 1.40). We suggest that PaCO2 estimation by both PetCO2 and PtcCO2 is sufficiently precise and reliable for clinical use in critically ill children. Certain limitations stem from the nature of the techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

Infectious complications during peripheral intravenous therapy with Teflon catheters: a prospective study.

Infectious complication rates and associated risk factors occurring during peripheral intravenous therapy with Teflon catheters were determined during a prospective study of 286 cannula insertions. Suppurative phlebitis, cannula-related sepsis or suspected sepsis did not occur. Semiquantitative cannula cultures revealed a colonization rate of 10.4% (12 of 115). Coagulase-negative nonadherent Staphylococcus was the most common colonizing organism occurring in 10 of 12 positive catheters. Alpha Streptococcus and adherent coagulase-negative Staphylococcus colonized the remaining catheters. Colonization was not related to the rate of phlebitis, extravasation or cannulation time. No patient- or catheter-related factors increased the risk of colonization. In children in a general pediatric ward the risk of catheter colonization and subsequent sepsis should not be used as reasons for routinely removing complication-free peripheral Teflon catheters at 72 hours.