Notes

Clinical Link between Individuals along with Vogt-Koyanagi-Harada Disease Over 14 Many years at a Tertiary Heart.
Rheumatoid arthritis is a multisystemic in˜flammatory disease. Lungs are the commonest site of extra-articular involvement. Rheumatoid lung nodules occur infrequently and can undergo necrosis giving rise to necrobiotic lung nodules. Infections, malignancy and granulomatosis with polyangiitis are more common causes of cavitating lung nodules. Presence of rheumatoid factor, history of smoking and use of methotrexate increase the chances of developing rheumatoid lung nodulosis. Histopathological examination of the nodule is essential to make a correct diagnosis. We present a 74-year-old male with long-standing rheumatoid arthritis who had multiple cavitating lung nodules. Biopsy from the lung nodule could not be performed as the patient refused to consent. However, infection, malignancy and granulomatosis with polyangiitis were ruled out on the basis of blood investigations and bronchoscopy. He was empirically treated with a moderate dose of glucocorticoid along with conventional synthetic disease-modifying antirheumatic drugs. After three months of treatment, the lung nodules disappeared completely and his articular symptoms showed marked improvement.Chronic myeloid leukaemia (CML) is a clonal hematopoietic stem cell disorder. Phenformin clinical trial The annual incidence of CML is 1.5 cases per 100,000 individuals. Multiple myeloma (MM) represents a malignant proliferation of plasma cells derived from a single clone. The co-occurrence of two rare malignancies CML and MM in the same patient is an extremely rare incident, and simultaneous diagnosis of CML and MM is reported in only five cases in the literature. A 75-year-old male presented with complaints of easy fatigability, loss of appetite and unquantifed weight loss of four months' duration. On evaluation he was found to have normocytic normochromic anaemia, leucocytosis, elevated serum-calcium concentration and azotaemia. Peripheral blood for the BCR-ABL fusion gene product was positive by flourescence in situ hybridisation (FISH). However, bone marrow biopsy revealed CD138 positive, 15% plasma cells. Thus the diagnosis of CML and MM was established. Although we can't be certain regarding the cause of CML and MM in our patient, the hypothesis that they evolved from common malignant pluripotent hematopoietic stem cells still holds. However, at the age of 75 years, it might be just due to chance.We report a case of a 12-year-old male who initially presented with active systemic lupus erythematosus (SLE) with lupus nephritis and secondary macrophage activation syndrome (MAS). He went on to develop left-sided upper motor neuron (UMN) facial palsy secondary to lupus-related tumefactive demyelination. Tumefactive lesions secondary to demyelination are a very rare manifestation in neuropsychiatric SLE. This child responded to aggressive immunosuppression with steroids and cyclophosphamide.Takayasu arteritis which is reported more commonly from Asia and in females can present as middle aortic syndrome with lower limb claudication. We present a case of a young male with Takayasu arteritis with middle aortic syndrome and Winslow pathway collaterals with lower limb ischaemia, hypertension, coronary occlusion and stroke. The extensive collateral formation was visible as a clinical finding over the abdominal wall. The identification of these collateral pathways is essential in understanding the extent of haemodynamically significant disease and it alerts to the possibility of surgical injury during procedures like laparotomy or harvesting of internal thoracic artery for coronary artery bypass graft.Tenofovir disoproxil fumarate (TDF) is the foundation nucleotide reverse-transcriptase inhibitor in the recommended first-line regimen for all naive human immunodeficciency virus-1 (HIV-1) patients whose age is more than 10 years and body weight is more than 30 kg. Although it has a good safety profile overall, nephrotoxicity is a concern and its overall incidence is 1-6% with a long period of clinical latency. Nephrotoxicity may manifest as either proximal renal tubule dysfunction in the form of a partial or complete Fanconi syndrome or as decreased renal function leading to acute or chronic kidney injury. Osteomalacia can also develop secondary to complicating hypophosphataemia and low calcitriol levels. Here we report a 50-year-old HIV-positive male on tenofovir who presented with proximal renal tubular acidosis and fracture of left neck of femur four years after initiation of the drug.Granulomatosis with polyangiitis (GPA) is a type of granulomatous vasculitis that can involve any organ in the body. The pituitary gland is one of the uncommon sites to be involved in this condition, with only a few cases reported in the literature. Our patient initially presented with central diabetes insipidus, epistaxis and haematuria. Diagnosis was established by antineutrophil cytoplasmic antibodies (cANCA) positivity against a background of typical clinical features and a bulky pituitary on magnetic resonance imaging (MRI) scan. Patient was started on steroids and methotrexate which were later changed to mycophenolate mofetil due to intolerance. Due to the refractory nature of the disease the patient was treated with one course of rituximab. Since then she has not had epistaxis, joint pains or haematuria. She continues to have diabetes insipidus although the requirement of desmopressin has come down. We thus report a case of GPA with hypophysitis which is one of the rare manifestations of the disease.Cardiac involvement in sarcoidosis is often difficult to diagnose, and most alarmingly can lead to sudden cardiac arrest as its first manifestation. We report the case of a 45-year-old Indian woman with an implanted permanent pacemaker for atrioventricular block, who presented with haemodynamically stable ventricular tachycardia and was found to have impaired left ventricular function. Subsequent investigations established the diagnosis of cardiac sarcoidosis. The patient was treated with prednisolone initially at 40 mg a day for 3 months. Left ventricular function improved over 3 months of treatment and there was no further recurrence of ventricular tachycardia. Screening for cardiac sarcoidosis should be considered in a patient with unexplained atrioventricular block and ventricular tachycardia, particularly if young, even in the absence of clinical findings of extracardiac sarcoidosis. Treatment of the cardiac sarcoidosis could control ventricular tachycardia and improve left ventricular function.
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