A case of anti-neutrophil cytoplasmic antibody-associated vasculitis masquerading as Sjögren syndrome

Anti-neutrophil cytoplasmic antibody (ANCA) -positive vasculitis is a small-vessel vasculitis that affects multiple body systems. Salivary gland involvement in ANCA-associated vasculitis is rare. When present, it mimics infection or malignancy, which might lead to misdiagnosis. In this report, we describe a 72-year-old man who presented with parotid and submandibular gland pain and swelling in addition to dry mouth and eyes. He had bilateral non-tender parotid gland lumps and no lymphadenopathies. Laboratory tests were positive for ANCA, hematuria, and proteinuria but negative for Anti-Ro and -La. He was treated with corticosteroids and cyclophosphamide for acute kidney injury. Unfortunately, the patient died a few months later. This case report sheds light on a rare manifestation of salivary gland involvement in ANCA-associated vasculitis that mimics Sjögren syndrome and the challenges associated with its diagnosis and treatment.

New-Onset Rheumatic Immune-Mediated Inflammatory Diseases Following SARS-CoV-2 Vaccinations until May 2023: A Systematic Review

A comprehensive, up-to-date systematic review (SR) of the new-onset rheumatic immune-mediated inflammatory diseases (R-IMIDs) following COVID-19 vaccinations is lacking. Therefore, we investigated the demographics, management, and prognosis of new R-IMIDs in adults following SARS-CoV-2 vaccinations. A systematic literature search of Medline, Embase, Google Scholar, LitCovid, and Cochrane was conducted. We included any English-language study that reported new-onset R-IMID in adults following the post-COVID-19 vaccination. A total of 271 cases were reported from 39 countries between January 2021 and May 2023. The mean age of patients was 56 (range 18-90), and most were females (170, 62.5%). Most (153, 56.5%) received the Pfizer BioNTech COVID-19 vaccine. Nearly 50% of patients developed R-IMID after the second dose of the vaccine. Vasculitis was the most prevalent clinical presentation (86, 31.7%), followed by connective tissue disease (66, 24.3%). The mean duration between the vaccine's 'trigger' dose and R-IMID was 11 days. Most (220, 81.2%) received corticosteroids; however, 42% (115) received DMARDs such as methotrexate, cyclophosphamide, tocilizumab, anakinra, IV immunoglobulins, plasma exchange, or rituximab. Complete remission was achieved in 75 patients (27.7%), and 137 (50.6%) improved following the treatment. Two patients died due to myositis. This SR highlights that SARS-CoV-2 vaccines may trigger R-IMID; however, further epidemiology studies are required.

Basal ganglia volumetric studies in affective disorder: what did we learn in the last 15 years?

Until today, morphometric neuroimaging studies on affective disorders concentrate on the limbic system, especially the hippocampus, amygdala, and anterior cingulate. In most of the studies and reviews available today, the basal ganglia are of secondary interest. It seems that the basal ganglia are interest of neurologist, whereas the limbic system is reserved for psychiatric neuroimaging studies. We follow a different approach in this review, studying all available papers on MRI research of the basal ganglia in unipolar depression and bipolar disorder. We found a possibly larger neostriatum in bipolar and possibly smaller one in unipolar patients. None of the unipolar studies found any larger basal ganglion, and only one out of 12 bipolar studies found smaller basal ganglia. Both findings seemed to depend on age (tendency toward smaller volumes in unipolar and bipolar with older age), sex (men tending to pathology in both disorders) and bipolar patients show a possible influence of medication, which is not assessed so far in unipolar depression. We conclude that several methodological shortcomings in volumetric MRI research on the basal ganglia in affective disorders make it necessary to imply more research in this area. We suggest (a) better MRI methods (we do not have a single volumetric 3 Tesla study in this patient group); (b) studies of medication-naïve patients (thus ruling out the medication effect); (c) Studies that directly compare unipolar depressed and bipolar patients are needed to determine whether these apparent differences in morphometric abnormalities, as observed through the mediating comparison with healthy subjects, are real.

Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial

CONTEXT

Activation of the coagulation system and depletion of endogenous anticoagulants are frequently found in patients with severe sepsis and septic shock. Diffuse microthrombus formation may induce organ dysfunction and lead to excess mortality in septic shock. Antithrombin III may provide protection from multiorgan failure and improve survival in severely ill patients.

OBJECTIVE

To determine if high-dose antithrombin III (administered within 6 hours of onset) would provide a survival advantage in patients with severe sepsis and septic shock.

DESIGN AND SETTING

Double-blind, placebo-controlled, multicenter phase 3 clinical trial in patients with severe sepsis (the KyberSept Trial) was conducted from March 1997 through January 2000.

PATIENTS

A total of 2314 adult patients were randomized into 2 equal groups of 1157 to receive either intravenous antithrombin III (30 000 IU in total over 4 days) or a placebo (1% human albumin).

MAIN OUTCOME MEASURE

All-cause mortality 28 days after initiation of study medication.

RESULTS

Overall mortality at 28 days in the antithrombin III treatment group was 38.9% vs 38.7% in the placebo group (P =.94). Secondary end points, including mortality at 56 and 90 days and survival time in the intensive care unit, did not differ between the antithrombin III and placebo groups. In the subgroup of patients who did not receive concomitant heparin during the 4-day treatment phase (n = 698), the 28-day mortality was nonsignificantly lower in the antithrombin III group (37.8%) than in the placebo group (43.6%) (P =.08). This trend became significant after 90 days (n = 686; 44.9% for antithrombin III group vs 52.5% for placebo group; P =.03). In patients receiving antithrombin III and concomitant heparin, a significantly increased bleeding incidence was observed (23.8% for antithrombin III group vs 13.5% for placebo group; P<.001).

CONCLUSIONS

High-dose antithrombin III therapy had no effect on 28-day all-cause mortality in adult patients with severe sepsis and septic shock when administered within 6 hours after the onset. High-dose antithrombin III was associated with an increased risk of hemorrhage when administered with heparin. There was some evidence to suggest a treatment benefit of antithrombin III in the subgroup of patients not receiving concomitant heparin.

Hippocampal volume in primary unipolar major depression: a magnetic resonance imaging study

BACKGROUND

Previous studies have shown that major depression is frequently accompanied by hypercortisolemia. There is some evidence suggesting that an increase in the glucocorticoid levels may make hippocampal cells more vulnerable to insults caused by hypoxia, hypoglycemia, or excitatory neurotransmitters. Using magnetic resonance imaging (MRI), the hippocampi of patients with major depression were measured and compared with values observed in control subjects.

METHODS

Thirty-eight patients with primary unipolar major depression were recruited. Twenty control subjects were matched for age, gender, and years of education. The hippocampal volume was measured from coronal MRI scans in all of the subjects. Patients were also grouped and compared as responders and nonresponders to treatment with fluoxetine of 20 mg/day, for 8 weeks. Hamilton Depression Rating Scale (HDRS) was used to determine the severity of depression.

RESULTS

No significant differences were observed between the hippocampal volumes of patients with major depression and control subjects; however, a significant correlation was observed between the left hippocampal volume of men and their HDRS baseline values. In addition, female responders had a statistically significant higher mean right hippocampal volume than nonresponders.

CONCLUSIONS

The results of our study indicate no reduction in the volume of the hippocampus in patients with major depression. Nonetheless, the results do suggest that the effects of disease severity, gender, and treatment response may influence hippocampal volume.

Tuberculous pancreatic abscess in HIV-positive patients. A report of 3 cases and a review of the literature

Three cases of tuberculous pancreatic abscess (TPA) in HIV-positive patients are reported. Pancreatic tuberculosis (PTB) is a rare pathological entity with nonspecific symptomatology that presents a diagnostic challenge. Ultrasound or computed tomography-guided fine-needle aspiration biopsy (FNAB) is recommended, as this may be diagnostic and negate the need for operative intervention.

A quantitative magnetic resonance imaging study of caudate and lenticular nucleus gray matter volume in primary unipolar major depression: relationship to treatment response and clinical severity

The authors investigated whether there were differences in caudate and lenticular nucleus volumes in depressed patients relative to comparison subjects, and whether differences in basal ganglia volume were associated with treatment response to fluoxetine. Brain magnetic resonance images were obtained from 38 unipolar depressed patients and 20 matched comparison subjects. Patients were divided into groups of 'responders' and 'non-responders' based on change in the 17-item Hamilton Depression Rating Scale (HDRS) score after a 10-week open trial of fluoxetine, 20 mg/day. There were no group mean differences in caudate and lenticular nucleus volumes between patients and comparison subjects. Female treatment responders tended to have larger caudate nucleus volumes than male 'responders', and also larger right caudate nucleus volumes than their female 'non-responder' counterparts. Baseline HDRS scores correlated negatively with left caudate nucleus volume in depressed patients. Thus, in mild to moderately depressed patients, we were unable to find differences in caudate and lenticular nucleus-gray matter volumes relative to comparison subjects. One possible reason is that caudate nucleus-gray matter volume and severity of depression are inversely correlated, suggesting that severity of depression may be an important covariate when comparing caudate volumes in depressed patients and control subjects.

A quantitative magnetic resonance imaging study of cerebral and cerebellar gray matter volume in primary unipolar major depression: relationship to treatment response and clinical severity

The authors investigated whether there were differences in cerebral and cerebellar gray and white matter volumes in depressed patients compared to controls, and whether this was associated with treatment response to fluoxetine. Brain magnetic resonance images were obtained from 38 unipolar depressed patients and 20 age, gender, and educationally matched comparison subjects. Patients were divided into groups of "responders" and "nonresponders" based on change in 17-item Hamilton Depression Rating Scale (HDRS) after an 8-week standardized trial of fluoxetine, 20 mg/day. There were no group mean differences in cerebral or cerebellar tissue volumes between patients and controls, or responders and nonresponders. For nonresponders to fluoxetine treatment, cerebral and cerebellar gray matter volume, and total cerebellar tissue volume decreased as baseline HDRS increased. The results suggest an association between gray matter volume and severity of illness in nonresponders to fluoxetine treatment.

Basal ganglia choline levels in depression and response to fluoxetine treatment: an in vivo proton magnetic resonance spectroscopy study

We have investigated proton magnetic resonance spectra of the basal ganglia in 41 medication-free outpatients with major depression, prior to starting an 8-week standardized trial of open-label fluoxetine, and 22 matched comparison subjects. Upon completing the trial, depressed subjects were classified as treatment responders (n = 18) or nonresponders (n = 23), based on changes in the Hamilton Depression Rating Scale. Depressed subjects had a lower area ratio of the choline resonance to the creatine resonance (Cho/Cr) than comparison subjects. This statistically significant difference between the depressed subjects and comparison subjects was more pronounced in the treatment responders than in the nonresponders. There were no differences in the relative volumes of gray matter or white matter in the voxel used for proton spectroscopy in depressed subjects relative to comparison subjects. These results are consistent with an alteration in the metabolism of cytosolic choline compounds in the basal ganglia of depressed subjects and, in particular, those who are responsive to fluoxetine.

Psychiatric disorder in a South African general hospital. Prevalence in medical, surgical, and gynecological wards

The aim was to elicit the individual and comparative prevalence of psychiatric disorder in medical, surgical, and gynecological wards in a South African hospital comprising a predominantly Third World patient population. Results indicated that 21%, 95% confidence interval (16;26) of the total sample of 230 patients had a DSM-III-R psychiatric disorder. Fifty-six percent had a diagnosis of substance dependence and 33% were found to have depressive disorders. Comparative analysis between disciplines indicated that the highest prevalence was in surgical wards. There was a statistically significant difference between the sexes. The variables associated with the presence of a psychiatric disorder and implications for better recognition and treatment are discussed.

EEG abnormalities before clozapine therapy predict a good clinical response to clozapine

The purpose of this study was to test the hypothesis that minor EEG abnormalities predict a favorable response to clozapine. Eighty-six psychotic clozapine-treated psychiatric inpatients with EEG records before starting clozapine were included in the study. When all diagnostic groups were combined, there were no significant differences in clinical outcome between patients with abnormal EEGs and patients with normal EEGs. However, female patients with abnormal EEGs had a significantly greater improvement in Global Assessment of Functioning (GAF) scores compared to female patients with normal EEGs. In addition, patients with major depressive episodes (bipolar, schizoaffective, unipolar) and abnormal EEGs had a significantly greater improvement in GAF scores compared to the same subgroup of patients with normal EEGs. The results suggest that EEG abnormalities before clozapine treatment many predict a favorable clinical response in specific groups of patients.

Methylphenidate augmentation of serotonin selective reuptake inhibitors: a case series

BACKGROUND

The serotonin selective reuptake inhibitors (SSRIs) are effective in treating major depressive episodes. However, for the subgroups of patients who remain refractory to therapy, augmentation strategies can improve the efficacy of these agents.

METHOD

We report the results of an open trial of methylphenidate to augment SSRIs in the treatment of five consecutive cases of DSM-III- R diagnosed major depression.

RESULTS

Self-reported symptom reduction was achieved rapidly in all cases, with methylphenidate dosages ranging from 10 to 40 mg/day. Symptom remission was independent of the presence of attention-deficit/hyperactivity disorder. Also, the beneficial effects of the methylphenidate-SSRI combination appeared to be robust and sustained. No patients abused or misused methylphenidate.

CONCLUSION

The empirical use of methylphenidate added to ineffective or only partially effective SSRI treatment appeared to be a rapid, safe, and efficacious alternative to existing augmentation strategies for the treatment of major depression. Prospective controlled studies are required to confirm or refute these findings.

Is there a relationship between clozapine and obsessive-compulsive disorder?: a retrospective chart review

The emergence of obsessive-compulsive symptoms during clozapine treatment has been reported in recent case studies, yet the incidence and significance of this finding is still unclear pending reliable data from a larger sample of patients. Hospital records of 142 randomly selected inpatients started on clozapine treatment at McLean Hospital before July 1, 1992, were reviewed retrospectively. Based on a limited retrospective chart review, there were no definitive cases of patients who developed obsessive-compulsive disorder (OCD) or whose OCD worsened as a result of clozapine treatment. Although some fluctuation of OCD symptoms may have occurred in two cases, it is unclear whether those symptoms were related to treatment with clozapine (or other psychotropic drugs) or to undulations in the natural history of OCD. No definitive relationship between OCD symptoms and clozapine treatment could be established in this limited study. Further clarification of this matter awaits outcome research using prospective methodologies.

Sporting 'groin strains': not always muscular!

A gluteal artery pseudoaneurysm presenting as a 'groin strain' following minor trauma is reported. Diagnosis was made by CT scan and arteriography. Treatment was with superselective catheterization and microcoil embolization.

Occurrence of seizures related to psychotropic medication among psychiatric inpatients

OBJECTIVE

Seizures associated with psychotropic medication are serious and reportable adverse drug reactions. This study examined the occurrence of seizures associated with psychotropic medication during psychiatric hospitalization.

METHODS

Among 10,994 admissions to a psychiatric teaching hospital over a 30-month period between 1990 and 1993, 29 patients were identified by a specially trained quality assurance nurse as having seizures that were probably related to psychotropic medication. These cases were verified by a clinical pharmacist and a psychopharmacologist. Two patients were excluded, and the records of 27 patients were reviewed in detail.

RESULTS

Nineteen of the 27 patients (70 percent) whose seizures were related to psychotropic medication had a preexisting seizure disorder, and eight had new-onset seizures. Psychotropic medications were primarily implicated as being associated with seizures in the cases of three of the 19 patients with preexisting seizure disorders (15.8 percent) and five of the eight patients with new-onset seizures (62.5 percent). In the group with preexisting seizure disorders, six patients (32 percent) had subtherapeutic blood levels of antiseizure medication, and four (21 percent) experienced pseudoseizures.

CONCLUSIONS

Seizures among inpatients on psychotropic medication were infrequent (.3 percent of psychiatric admissions); the majority (70 percent) occurred in patients with preexisting seizure disorders. Seizures were directly attributed to psychotropic medications in less than .1 percent of admissions.

Choline ingestion increases the resonance of choline-containing compounds in human brain: an in vivo proton magnetic resonance study

Choline is a crucial intermediate in several clinically relevant neurochemical processes. In this study, choline-containing compounds in human brain (principally phosphocholine, glycero-phosphocholine, and choline) were measured by 1H-magnetic resonance spectroscopy, before and after the ingestion of 50 mg/kg choline in four normal control subjects. Substantial and remarkably similar increases in the brain choline resonance occurred in each subject, with a nearly two-fold rise in the choline resonance observed 3 hr following choline ingestion (p = 0.008 versus baseline). One subject also received a dose of 200 mg/kg choline, and exhibited a proportionally larger increase in the brain choline resonance. The results are consistent with animal data reporting a rise in choline-containing compounds following choline administration. This is the first study to our knowledge where an oral nutrient has been shown to produce a detectable change in human brain composition in vivo. Studying choline transport and biotransformation in human brain may have relevance to several neuropsychiatric disorders, including affective disorders and dementia.

Group B streptococci in blacks

Vaginal swabs were taken from 60 Black women attending a family planning clinic and from 60 attending a special clinic for sexually transmitted diseases. Using selective media, the isolation rate for group B streptococci was 26,7% in the former group and 40,0% in the latter. The isolation rates of other streptococcal serogroups are also given. All group B streptococci isolated were uniformly sensitive to penicillin but resistant to gentamicin. Clinical details of 7 patients with group B streptococcal septicaemia are also given.