No association between BMD and prevalent vertebral fractures in liver transplant recipients at time of screening before transplantation.

CONTEXT: Osteoporosis and fractures are prevalent after orthotopic liver transplantation (OLT), but data on these skeletal complications are scarce in patients with end-stage liver disease awaiting liver transplantation. OBJECTIVE: To evaluate the prevalence of vertebral fractures (VFs) in OLT recipients at the time of screening for transplantation and to establish the association between bone mineral density (BMD) and these fractures before transplantation. DESIGN AND SETTING: We conducted a retrospective study of consecutive OLT recipients at the Leiden University Medical Centre between 2000 and 2011 at the time of screening for transplantation. Clinical, laboratory, and BMD data were extracted from electronic hospital records. Conventional spinal radiographs were assessed for VF by two independent observers using Genant's semiquantitative method. PATIENTS: In total, 162 of the 223 OLT recipients (median age, 51 y; 75% men) who had available BMD and spinal radiographs but who were not receiving bone-modifying treatment at screening for OLT were included in the study. MAIN OUTCOME MEASURES: Association between BMD and VF before transplantation. RESULTS: Osteoporosis and osteopenia were prevalent at the lumbar spine in 19 and 38% of subjects, respectively, and in 10 and 42 % at the femoral neck. VFs, mostly grade 1, were prevalent in 56% of the subjects. There was no association between BMD and prevalent VF before transplantation. CONCLUSIONS: VFs were prevalent in liver transplant recipients at the time of screening for transplantation, but there was no association between BMD and prevalent fractures. Spinal radiographs should be routinely performed as part of screening protocols before liver transplantation to enable identification of VF and allow timely intervention to potentially decrease or prevent skeletal morbidity after transplantation.

Longitudinal changes in BMD and fracture risk in orthotopic liver transplant recipients not using bone-modifying treatment.

Osteoporosis is prevalent in end-stage liver disease, but data on long-term changes in bone mineral density (BMD) and related fracture incidence after orthotopic liver transplantation (OLT) are scarce. We evaluated BMD changes up to 5 years in consecutive recipients of a successful OLT at the Leiden University Medical Centre between 2000 and 2011, in whom sequential BMD data were available. Spinal radiographs were available at time of screening and at 6 and 12 months post-OLT and were assessed for vertebral fractures by two independent observers using Genant's semiquantitative method. Patients were excluded from the study when started on bisphosphonates. A total of 201 patients (71% men), median age 53 years (range, 18-70 years) were included in the study. Most common liver pathology was viral (27%) or alcoholic liver disease (25%). All patients received prednisone for at least 6 months after transplantation and the majority received either tacrolimus or cyclosporine for immunosuppression. At time of screening for OLT, osteoporosis and osteopenia were found in 18% and 36% of patients at the lumbar spine (LS), respectively, and in 9% and 42% at the femoral neck (FN), respectively. T-scores declined significantly at both sites 6 months after OLT, but increased thereafter at the LS, reaching pretransplantation values at 2 years and remaining stable thereafter. FN T-scores remained consistently lower than pretransplantation values. The prevalence of vertebral fractures increased from 56% at screening to 71% at 1 year after OLT, with a fracture incidence of 34%. BMD changes did not predict fracture risk. Osteoporosis, osteopenia, and vertebral fractures are prevalent in patients with end-stage liver disease. An overall decline in BMD is observed within the first 6 months after OLT, with subsequent recovery to pretransplantation values at the LS, but not at the FN. Vertebral fracture risk is high after OLT regardless of changes in BMD.

[Unusual use of nutmeg]. / Een ongebruikelijke toepassing van nootmuskaat.

A 20-year-old woman with borderline personality disorder was referred to the emergency department by a psychiatric clinic. After taking 10 g of nutmeg she complained of stomach ache and dizziness. A physical examination showed mild hypothermia and sinus tachycardia. She was admitted for observation and discharged after 24 h to the psychiatric clinic without sequelae. Nutmeg is a spice. Relatively unknown are the hallucinogenic and euphoric effects for which it is used by drug abusers and students. Symptoms appear 6 h after ingestion of at least 10 g of nutmeg and are related to its effects on the central nervous system. Use of the drug can lead to anxiety and feelings of doom and even to psychosis. Dry mouth, nausea and dizziness may also occur. A physical examination may show hypothermia, tachycardia or hypertension or, in rarer cases, hypotension and shock. Symptoms disappear without sequelae after 24-48 h. Treatment consists of supportive measures. In the event of haemodynamic instability, cardiovascular monitoring is indicated.

[Acrodermatitis chronica atrophicans: late manifestation of Lyme borreliosis]. / Acrodermatitis chronica atrophicans: late manifestatie van lymeborreliose.

A 71-year-old man was referred to our outpatient clinic because of arthralgia and swelling of his right hand. He also showed a subcutaneous nodule on his left knee. A second patient, a 57-year-old woman, was referred because of painful skin of her legs. Dermatologic examination revealed erythematous livid discoloration on both feet and legs. There were reticular varices, corona flebectatia paraplantaris medialis and minimal pitting oedema. Serology tested positive in both patients for Borrelia and they both recalled tick bites. A third patient, a 73-year-old woman, was referred because of erythema and maculae located at her lower legs and positive Borrelia serology. Pathologic examination was typical for acrodermatitis chronica atrophicans, a late skin manifestation of Lyme borreliosis. In all patients, symptoms improved after treatment with doxycycline for four weeks. A lack of familiarity with this skin condition may lead to unnecessary vascular investigations and considerable delay in adequate treatment.