First month prednisone dose predicts prednisone burden during the following 11†months: an observational study from the RELES cohort.

AIM: To study the influence of prednisone dose during the first month after systemic lupus erythematosus (SLE) diagnosis (prednisone-1) on glucocorticoid burden during the subsequent 11 months (prednisone-2-12). METHODS: 223 patients from the Registro Español de Lupus Eritematoso Sistémico inception cohort were studied. The cumulative dose of prednisone-1 and prednisone-2-12 were calculated and recoded into a four-level categorical variable: no prednisone, low dose (up to 7.5 mg/day), medium dose (up to 30 mg/day) and high dose (over 30 mg/day). The association between the cumulative prednisone-1 and prednisone-2-12 doses was tested. We analysed whether the four-level prednisone-1 categorical variable was an independent predictor of an average dose >7.5 mg/day of prednisone-2-12. Adjusting variables included age, immunosuppressives, antimalarials, methyl-prednisolone pulses, lupus nephritis and baseline SLE Disease Activity Index (SLEDAI). RESULTS: Within the first month, 113 patients (51%) did not receive any prednisone, 24 patients (11%) received average low doses, 46 patients (21%) received medium doses and 40 patients (18%) received high doses. There was a strong association between prednisone-1 and prednisone-2-12 dose categories (p<0.001). The cumulative prednisone-1 dose was directly associated with the cumulative prednisone-2-12 dose (p<0.001). Compared with patients on no prednisone, patients taking medium (adjusted OR 5.27, 95% CI 2.18 to 12.73) or high-dose prednisone-1 (adjusted OR 10.5, 95% CI 3.8 to 29.17) were more likely to receive prednisone-2-12 doses of >7.5 mg/day, while patients receiving low-dose prednisone-1 were not (adjusted OR 1.4, 95% CI 0. 0.38 to 5.2). If the analysis was restricted to the 158 patients with a baseline SLEDAI of ≥6, the model did not change. CONCLUSION: The dose of prednisone during the first month after the diagnosis of SLE is an independent predictor of prednisone burden during the following 11 months.

Sex hormones in chronic systemic lupus erythematosus. Correlation with clinical and biological parameters.

Sex hormones may play a major role in the pathogenesis and course of systemic lupus erythematosus (SLE). OBJECTIVE--To evaluate the immunoregulatory effect of gonadal steroids in SLE and their mechanisms of action, and to establish a correlation with the clinical and biological activity. DESIGN--Cross-sectional study of a cohort with SLE. SETTING--Outpatient SLE clinic. PATIENTS--27 patients with chronic SLE, 14 were fertile women, 8 postmenopausal women and 5 men. MEASUREMENT--Serum gonadotropins (FSH, LH), prolactin (PRL), progesterone (PG), testosterone (T), estradiol (E2) and total urinary estrogens (UE) were studied in SLE patients and in 35 healthy controls of similar age and sex. Blood and urine samples of several days of the study cycle were obtained for hormonal assay. RESULTS--An increased LH activity was observed in all groups of patients. There were no changes in serum T levels, but absence of steroid therapy increased their levels in fertile women. A decrease in E2 values in the fertile women was observed, but total UE was similar to those in controls. This suggests an alteration in intermediate estrogen metabolism. Men with SLE showed a higher levels in PG and UE than controls. Also, in both groups of women on steroid treatment, a decrease of PRL was observed compared to the controls. In the fertile women in luteal phase, there was a decrease in PG. In the fertile women with higher clinical activity in the midcycle phase, and those with higher biological activity in the luteal phase, a decrease in serum E2 was seen. CONCLUSIONS--Our results support the hypothesis that there is an alteration of intermediate metabolism of the estrogens and of the testosterone. As well, a lower production of PRL during steroid treatment, and a lower production of PG may be important contributing factors in immunomodulation of SLE. Mechanism for this action should be mediated through a stimulation of the gonadotropins as LH.

[Neoplasms associated with human immunodeficiency virus infection. Study of the clinical course of 70 patients]. / Neoplasias asociadas a la infección por el virus de la inmunodeficiencia humana. Estudio clínico y evolutivo de 70 pacientes.

BACKGROUND: A different epidemiologic pattern of the neoplasms associated to the human immunodeficiency virus (HIV) has been described in the Mediterranean area. The aim of the present study was to analyze the epidemiologic, clinical and evolutive characteristics of these patients. METHODS: A retrospective study of 74 neoplasms in 70 patients (15% of AIDS cases) was carried out. The following variables were analyzed: risk group, state of the infection (HIV), stage and type of tumor, immunohematologic data, opportunistic infections (OI), response to treatment, evolution and prognostic factors. RESULTS: Thirty-four Kaposi's sarcomas (SK) were diagnosed, 32 non Hodgkin's lymphomas (NHL), 4 Hodgkin's disease (HD), 2 seminomas, 1 cutaneous carcinoma and one undifferentiated tumor. Sixty-eight patients were males with a mean age of 32 years. The risk group was: homosexual (52%), drug abuse (24%), hemophilia (14%), and heterosexual contact (10%). The neoplasm was the first manifestation of HIV infection in 60% of the patients. Sixteen patients with SK were treated with chemotherapy (CMT), radiotherapy (RT) or interferon and stabilization of the disease was achieved in 50% of the cases. Twenty-six patients with NHL received treatment: 26 with CMT, 9 with RT and 4 with surgery. Complete remission was achieved in 27% and partial in 61% of the cases. Overall mortality was 56% and median survival 13 months. Most of the patients died due to progression of the tumor or infection. The prognostic factors associated to shortened survival were: advanced stage of AIDS, OI at the time of diagnosis of the tumor and a decrease in hemoglobin, total lymphocytes and CD4. CONCLUSIONS: The lower incidence of neoplasms among patients with acquired immunodeficiency disease and the differences in the distribution of the histologic types may be related with the demographic features of the risk groups in Spain. Survival is determined more by opportunistic infections than by the tumor itself.

[Hemolytic anemia due to cold-reacting antibodies: association with human immunodeficiency virus infection and non-Hodgkin's lymphoma]. / Anemia hemolítica por anticuerpos fríos: asociación a infección por el virus de la inmunodeficiencia humana y linfoma no hodgkiniano.

Hemolytic disease by cold-reacting antibodies is a rare form of hemolytic anemia. In most cases a subjacent cause is found. This disease is generally related with reactive lymphoproliferative processes (infections by the Epstein-Barr virus and cytomegalovirus) or uncontrolled lymphoproliferative disorders (lymphomas, Waldenström disease, chronic lymphatic leukemia). The presence of high titers of cryoagglutinins have recently been described in patients infected by the human immunodeficiency virus (HIV); however, clinical manifestation as hemolytic anemia is very rare. A 37 year old male diagnosed with infection by HIV, non Hodgkin's lymphoma of Burkitt type non convoluted cells, chronic hepatopathy by the B and C virus, Brouet type III cryoglobulinemia and hemolytic anemia by cold-reacting antibodies is herewith described. This multiple association is exceptional as is the important clinical repercussion of the hemolytic anemia derived from the high titers and above all the wide thermic interval of the cryoagglutinin present. Finally, the relation of cryoagglutinin with each of these entities, the concomitant presence of cryoglobulins and the evolution of the titers of the same with the chemotherapy treatment administered for the lymphoma is analyzed.

[Infection by Mucorales fungi]. / Infección por hongos mucorales.

Mucormycosis is a rare opportunistic fungal infection of immunosuppressed patients. We describe here 5 cases of mucormycosis: three with facial and eye involvement, one with lung involvement and one affecting skin and joints. All five patients had underlying diseases: diabetes, leukemia, lymphoma, neoplasia and AIDS. Four patients were treated with amphotericin B and also with surgical debridement. Infection could be controlled only in two patients. Both survived but with major sequelae. In two additional patients, death was directly related to the infection and the remaining patient was lost to follow-up.

[Angiothrombotic pulmonary granulomatosis in intravenous drug addicts]. / Granulomatosis pulmonar angiotrombótica en adictos a drogas por vía parenteral.

Two cases of angio-thrombotic lung granulomatosis in intravenous drug addicts are described. This entity has been previously described in drug addicts who inject oral drugs intravenously. Talc, which is used in the preparation of several drugs, cotton and other substances provoke at lung vessels level, thrombotic phenomena with strange body granuloma formations. Depending on the predominating localization of these lesions, interstitial pneumonia or pulmonary hypertension can later occur, such is the case in one of our patients who had a fatal evolution in a short period of time.

[Rhino-cerebral mucormycosis and hematological neoplasia]. / Mucormicosis rinocerebral y neoplasia hematológica.

Mucormycosis is a rare infection that occurs in immunocompromised patients. The rhinocerebral form presents in diabetics as a severe necrotizing sinusitis and is not frequent in patients with haematologic malignancies. Diagnosis requires direct examination and culture of biopsy specimens. Two patients with rhinocerebral mucormycosis and haematologic neoplasms (Non-Hodgkin's lymphoma and acute myeloblastic leukaemia) are described. Both patients had severe drug-induced neutropenia when the infection appeared. One patient died in spite of aggressive treatment with surgery and amphotericin.

[Drug surveillance for adverse reactions in patients with human immunodeficiency virus infection]. / Farmacovigilancia de reacciones adversas en pacientes con infección por el virus de la inmunodeficiencia humana.

Human immunodeficiency virus (HIV) carrier patients experience several secondary effects with drugs, being mainly skin reactions and myelosuppression. Owing to this, close observation of patients is necessary with regard to therapeutic and prophylactic schedules. In this paper, we describe the secondary effects of zidovudine in 60 patients of groups III and IV from CDC. The main toxicity was found in bone marrow; with anemia in 50% and leukopenia in 53% of patients. Finally, the more frequent secondary effects of therapy for opportunist infections are analysed. A guide for identifying the drugs' secondary effects is also included, based on our experience and on a wide range of literature reviews.

[Clinical study of tuberculosis in immunocompromised patients]. / Estudio clínico de la tuberculosis en pacientes inmunocomprometidos.

We have reviewed the clinical histories of 1,815 immunocompromised patients seen in "La Paz Hospital" over a period of 6 years, in order to study the incidence and clinical forms of tuberculosis (TB) in this group of patients. We have distributed the patients into three groups: Group A: 1,372 patients with neoplasia, Group B: 173 patients under immunosuppressor treatment, and Group C: 270 intravenous drug abusers (IVDA). 53 patients developed TB (2.9%): Of these, 31 belonged to group A (2.25%), 14 to group B (5.78%) and 8 to group C (2.96%), resulting in an incidence 50 to 100 times greater than the calculated for the Spanish general population (0.05%). There is a greater incidence of extrapulmonary and atypical forms in IVDA and patients under immunosuppressor treatment. Patients with neoplasia do not present differences in these aspects with regard to immunocompetent patients. If the TB is diagnosed and treated on time it is a potentially curable disease and the immunosuppressed state does not condition a worse response to treatment.