P045 Nothing is too 'cagey' for the rheumatologist

Abstract Background/Aims Rheumatological conditions can present with a number of non-specific features like arthralgia, fever, fatigue, weight loss along with raised inflammatory markers and positive antibodies. Due to this, when similar symptoms are referred for input it is very important to consider other ‘mimics’. We report a case of Pigeon fancier’s lung presenting with these symptoms which was referred as likely connective tissue disease. Methods A 52-year-old lady of South Asian origin was referred by her GP with six month history of 3kg weight loss, arthralgia, fatigue, low grade fever and persistently raised inflammatory markers (ESR ranging from 50-64 mm/hr, CRP 10-14 mg/L, normal BMI). On further questioning there was history of mouth ulcers, non-specific rash, occasional cough but no Raynaud’s or joint swelling. Blood investigations showed weakly positive ANA and RF but negative ENA, DNA, antiCCP , CK, C3,C4. C-ANCA was positive but PR3 negative. CXR was clear and tests for chronic infections including TB were negative. Due to lack of objective CTD signs, plan was to take a careful monitoring approach to see if clinical features evolved. A month later due to worsening cough, a CT chest/abdomen arranged by GP showed ground-glass changes consistent with pneumonitis and hence her rheumatology appointment was expedited to see if there was an autoimmune unifying diagnosis. She was also referred by her GP to the chest clinic in view of CT report and mild shortness of breath. Results On further review, again there were no objective CTD signs. On direct questioning there was history of travelling before worsening chest symptoms to South Asia. Also around a year before her symptoms started she was given an African grey parrot. Based on this, serology for Avian precipitin was checked which showed strongly positive IgG antibodies to avian antigens (Budgerigar droppings and feathers, Pigeon feathers IgG Abs) confirming the diagnosis of pigeon fanciers lung. She fulfilled the diagnostic criteria and was asked to avoid the trigger. Urgent respiratory input was arranged where diagnosis was agreed with and disease was deemed sub-acute in presentation. Due to PFTs showing low transfer factor of 38%, Prednisolone was started with significant improvement within few days. Review of CT chest only showed inflammatory changes and no established fibrosis predicting excellent prognosis as delay in treatment can cause irreversible pulmonary fibrosis. Conclusion A number of conditions can mimic rheumatological conditions which usually turn out to be either infectious or malignant in origin. This case highlights the importance of considering other differentials and along with taking a travel history also asking for other possible triggers like pets. In similar scenarios the diagnosis may be ‘cagey’ but as rheumatologists we are expected to answers questions which others can’t. Disclosure M.F. Kazmi: None.

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Serum and urinary concentrations of calprotectin as markers of insulin resistance and type 2 diabetes

Acta Endocrinologica ◽

10.1530/eje-12-0374 ◽

2012 ◽

Vol 167 (4) ◽

pp. 569-578 ◽

Cited By ~ 34

Author(s):

Francisco J Ortega ◽

Mónica Sabater ◽

José M Moreno-Navarrete ◽

Neus Pueyo ◽

Patricia Botas ◽

...

Keyword(s):

Insulin Resistance ◽

Type 2 Diabetes ◽

Weight Loss ◽

Lipid Metabolism ◽

Inflammatory Markers ◽

Low Grade ◽

Model Assessment ◽

Glucose And Lipid Metabolism ◽

Obese Subjects

ObjectiveIncreased circulating calprotectin has been reported in obese subjects but not in association with measures of insulin resistance and type 2 diabetes (T2D). The main aim of this study was to determine whether calprotectins in plasma and urine are associated with insulin resistance.DesignWe performed both cross-sectional and longitudinal (diet-induced weight loss) studies.MethodsCirculating calprotectin concentrations (ELISA), other inflammatory markers, homeostasis model assessment of insulin resistance (HOMA-IR), and parameters of glucose and lipid metabolism were evaluated in 298 subjects (185 with normal (NGT) and 62 with impaired (IGT) glucose tolerance and 51 T2D subjects). Calprotectin was also evaluated in urine samples from 71 participants (50 NGT and 21 subjects with IGT). Insulin sensitivity (SI, Minimal Model) was determined in a subset of 156 subjects, and the effects of weight loss were investigated in an independent cohort of obese subjects (n=19).ResultsCirculating calprotectin was significantly increased in IGT–T2D (independently of BMI) and positively associated with HOMA-IR, obesity measures, inflammatory markers, and parameters of glucose and lipid metabolism. Similar findings were reported for calprotectin concentrations in urine. In the subset of subjects, the association of calprotectin withSIwas independent of BMI and age. In fact,SItogether with C-reactive protein contributed to 27.4% of calprotectin variance after controlling for age and blood neutrophils count. Otherwise, weight loss led to decreased circulating calprotectin in parallel to fasting glucose and HOMA-IR.ConclusionThese findings suggest that circulating and urinary concentrations of calprotectin are linked to chronic low-grade inflammation and insulin resistance beyond obesity.

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Inflammatory Markers in Older Women with a History of Gestational Diabetes and the Effects of Weight Loss

Journal of Diabetes Research ◽

10.1155/2018/5172091 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 2

Author(s):

Alice S. Ryan

Keyword(s):

Weight Loss ◽

Body Composition ◽

Gestational Diabetes ◽

Glucose Tolerance ◽

Older Women ◽

Inflammatory Markers ◽

Normal Glucose Tolerance ◽

Diet And Exercise ◽

Normal Glucose ◽

History Of

The purpose of this study was to compare systemic inflammation in older women with a history of gestational diabetes (GDM) who developed impaired glucose tolerance (IGT) or type 2 diabetes (T2DM) to that in those with normal glucose tolerance (NGT) and to determine, in these women, the effect of weight loss (WL) induced by diet and exercise training on systemic inflammation and adipokine levels. This was a longitudinal clinical investigation of overweight/obese (BMI: 32 ± 1 kg/m2) women (59 ± 1 years) with a GDM history (n=19) who had normal glucose tolerance (NGT, n=7) or IGT/T2DM (n=12). Women completed 6 months of weight loss induced by diet and exercise and underwent VO2max, body composition, blood draw, glucose tolerance testing, and 2-hour hyperinsulinemic-euglycemic clamps (40 mU·m−2·min−1). Glucose utilization (M) was 42% higher in the NGT group (P<0.05). CRP was two-fold higher in the IGT/T2DM group than that in the NGT group (P<0.01). Adiponectin levels were 59% higher in the NGT group than those in the IGT/T2DM group (P<0.01). IL-6sR was higher in the NGT group (P<0.01). The women lost body weight, body fat, visceral fat, and subcutaneous abdominal fat (P<0.001). Fasting glucose (P<0.05), fasting insulin, glucose, and insulin AUC decreased (all P<0.005) after the intervention. M increased by 21% (P<0.05). CRP (−16%) and TNFR1 (−6%) tended to decrease, whereas TNFα, IL-6, SAA, and adiponectin did not change in the group. In conclusion, older women with a history of GDM who have developed IGT or T2DM have higher CRP and reduced adiponectin levels despite similar BMI and total and abdominal obesity to those with NGT. Six months WL induced by diet and exercise improves body composition and increases insulin sensitivity without a significant modification of inflammatory markers and adiponectin levels.

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Diagnosing Bird Fancier's Disease in Children

PEDIATRICS ◽

10.1542/peds.85.5.848 ◽

1990 ◽

Vol 85 (5) ◽

pp. 848-852

Author(s):

WILLIAM F. H. YEE ◽

ROBERT G. CASTILE ◽

AMIEL COOPER ◽

MARY ROBERTS ◽

ROY PATTERSON

Keyword(s):

Weight Loss ◽

Environmental History ◽

Respiratory Symptoms ◽

Hypersensitivity Pneumonitis ◽

Case Reports ◽

Low Grade ◽

Poor Appetite ◽

The Family ◽

History Of ◽

Respiratory Complaints

Bird fancier's disease is a form of hypersensitivity pneumonitis resulting from inhalation of various avian proteins. It is rarely diagnosed in childhood but should be considered in any child with persistent unexplained respiratory symptoms.1,2 We describe two patients referred to our pulmonary clinic with nonspecific respiratory complaints, in whom the diagnosis of avian protein-related hypersensitivity pneumonitis was initially not confirmed by serologic studies. CASE REPORTS Patient 1 An 11-year-old boy was admitted to the hospital with a 1-year history of a mild nonproductive cough, poor appetite, weight loss, malaise, and an intermittent low-grade fever. According to an environmental history, the boy's father had been breeding pigeons, canaries, and parakeets in the family yard for years.

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Clinico-demographic Characteristics of Patients with Cirrhosis of Liver : Experienced at a Tertiary Care Hospital

Journal of Medical Science & Research ◽

10.47648/jmsr.2013.v2001.02 ◽

2013 ◽

Vol 20 (Number 1) ◽

pp. 8-14

Author(s):

AKM S Kabir ◽

Md. F Alam ◽

C K Ghosh ◽

S N Ahmed ◽

S Sikder

Keyword(s):

Weight Loss ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Demographic Characteristics ◽

Global Perspective ◽

Low Grade ◽

Care Hospital ◽

Female Ratio ◽

History Of ◽

Cirrhosis Of Liver

Cirrhosis of liver is one of the commonest hepatobiliary problems in Bangladesh as well as in global perspective. The purpose of the present study was to find out the clinico-demographic characteristics of liver cirrhosis patients admitted at a tertiary care hospital. Patients who are clinically suspected to have cirrhosis of liver, admitted in medicine units of Holy Family Red Crescent Medical College Hospital, Dhaka have been analyzed regarding clinical presentation and complications profile. Total 100 patients were included of which 84% were cirrhosis of liver, 7% were chronic active hepatitis, 3% were chronic persistent hepatitis, 2% were Wilson's disease with cirrhosis and 4% were hepatocellular carcinoma (HCC) on the top of cirrhosis of liver. The peak age incidence was between 31-50 years with male-female ratio of 4.88:1. History of jaundice (42%), parenteral medications (14%), infusion (6%) and abdominal surgery (4.0%) were important findings from patient's past history. History of alcohol intake was found in only 4% cases. Overall, weakness (78%), anorexia (72%), abdominal swelling (74%), weight loss (64%), ankle swelling (42%), low grade fever (35%) and yellowish discolouration of eyes, skin and urine (37%) were the most common symptoms. Common signs, revealed by clinical examination as a whole, were anaemia (55%), ascites (68%), oedema (52%), jaundice (34%), palpable spleen (55%) and hepatic facies (37%). Cirrhosis of liver most commonly occurs in middle aged male patients. Weakness, weight loss, anorexia, abdominal discomfort/dyspepsia and swelling of the abdomen are the most prevalent symptoms.

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Disseminated Mycobacterium chimaera Presenting as Vertebral Osteomyelitis

Case Reports in Infectious Diseases ◽

10.1155/2017/9893743 ◽

2017 ◽

Vol 2017 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Daphne M. Moutsoglou ◽

Frank Merritt ◽

Ethan Cumbler

Keyword(s):

Weight Loss ◽

Cardiac Surgery ◽

Elderly Woman ◽

Chronic Back Pain ◽

Vertebral Osteomyelitis ◽

Nontuberculous Mycobacterium ◽

Low Grade ◽

History Of ◽

Soft Tissue Abscess ◽

Slow Growing

Mycobacterium chimaera, a member of the Mycobacterium avium complex, is a slow-growing, nontuberculous mycobacterium associated with outbreaks in cardiac-surgery patients supported on heart-lung machines. We report a case of an elderly woman on chronic prednisone who presented with a six-month history of worsening chronic back pain, recurrent low-grade fevers, and weight loss. Imaging identified multilevel vertebral osteomyelitis and lumbar soft-tissue abscess. Abscess culture identified M. chimaera.

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Leishmaniosis in a dog with no travel history outside of the UK

Veterinary Record ◽

10.1136/vr.105157 ◽

2019 ◽

Vol 184 (14) ◽

pp. 441-441 ◽

Cited By ~ 8

Author(s):

Myles McKenna ◽

Charalampos Attipa ◽

Severine Tasker ◽

Monica Augusto

Keyword(s):

Bone Marrow ◽

Weight Loss ◽

Blood Transfusion ◽

Endemic Area ◽

Canine Leishmaniosis ◽

Travel History ◽

Clinicopathological Findings ◽

History Of ◽

Skin Biopsies ◽

The Uk

A 3-year-old male neutered Shih Tzu cross was presented for investigation of a three-week history of weight loss, seborrhoea, vomiting and diarrhoea. Initial clinicopathological findings included pancytopenia, mild hypercalcaemia and marked hyperglobulinaemia. Subsequent bone marrow and skin biopsies revealed the presence of Leishmania amastigotes. Quantitative serology was positive for Leishmania species and PCR on the bone marrow sample confirmed a Leishmania infantum infection. The patient had been in the owner’s possession since a puppy, had no travel history outside of the UK and had never received a blood transfusion or been used for breeding. However, another dog in the household that had been imported from Spain had been euthanased six months previously due to severe leishmaniosis. To the authors’ knowledge, this is the first reported case of canine leishmaniosis in the UK without a history of travel to an endemic area, and most likely represents a case of dog-to-dog transmission.

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OUTCOME OF STRICTUROPLASTY IN PATIENTS WITH INTESTINAL TUBERCULOSIS

The Professional Medical Journal ◽

10.29309/tpmj/2012.19.03.2154 ◽

2012 ◽

Vol 19 (03) ◽

pp. 411-417

Author(s):

G. M. KHAN BALOCH ◽

KHALID HUSSAIN QURESHI ◽

ASIM BHATTI

Keyword(s):

Weight Loss ◽

Past History ◽

Intestinal Tuberculosis ◽

Case Series ◽

Wound Dehiscence ◽

Low Grade ◽

Pain Abdomen ◽

History Of ◽

Extra Pulmonary ◽

Easy Operation

Introduction: Abdominal TB is one of the most prevalent forms of extra-pulmonary disease and is prevalent all over the world.Gastrointestinal involvement had been reported to be 55-90%. This study aimed to determine the outcome of stricturoplasty in patients withintestinal tuberculosis. Objective: To determine the outcome of stricturoplasty in patients with intestinal tuberculosis. Study Design:Descriptive case series. Setting: Department of General Surgery, Nishtar Hospital Multan. Duration with dates: Three years from January2009 to December 2011. Subjects & Methods: 120 patients of intestinal TB, who presented with intestinal obstruction in emergency and withsigns and symptoms of intestinal TB in outdoor patient department were selected. History of contact, family history of tuberculosis,immunization, past history of tuberculosis was taken. Diagnosis was confirmed by histopathology. Laparatomy was done in all cases andstricturoplasty was performed. Patients were followed up during hospitalization. Postoperative complications were noted. All information wererecorded on a proforma. Results: Out of 120 patients, 56.7% were male and 43.3% were female having age between 14 to 70 years. Mainpresenting symptoms were pain abdomen, vomiting, distension of abdomen, weight loss, anorexia and low grade fever with sweats. Maincomplications after stricturoplasty were chest infection 40(33.3%), wound dehiscence in 16(13.3%), leakage in 12(10%), recurrence in20(16.7%), scar pigmentation in 12(10%), keloid in 12(10%) patients and herniation in 8(6.7%) patients. Conclusions: Stricturoplasty is a safe,simple and easy operation, particularly useful at small peripheral hospitals with limited staff and resources.

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Vnetje – skupni patogenetski dejavnik arterijske aterosklerotične in venske trombembolične bolezni

Slovenian Medical Journal ◽

10.6016/zdravvestn.2466 ◽

2017 ◽

Vol 86 (5-6) ◽

Author(s):

Mateja Kaja Ježovnik ◽

Pavel Poredoš

Keyword(s):

Risk Factors ◽

Venous Thrombosis ◽

Inflammatory Markers ◽

Cardiovascular Events ◽

Close Association ◽

Vascular Wall ◽

Venous Thromboembolic ◽

History Of ◽

Hs Crp ◽

Inflammatory Changes

Inﬂammation is among the basic mechanisms of arterial atherosclerotc diseases and is most likely also involved in the onset of venous thromboembolic disease. Various risk factors for atherosclerosis cause damage to the vascular wall and trigger inﬂammatory changes, which may lead to the development of atherosclerosis. Therefore, people with advanced atherosclerosis, and particularly those with unstable atherosclerotic plaques as a result of intense inﬂammatory changes, are found to have elevated levels of inﬂammatory markers in the blood. The most frequent findings include elevated levels of highly specific C-reactive protein (hs-CRP), which is a non-specific systemic indicator of inﬂammation, and certain interleukins (interleukin–6, interleukin–8) that are considered to be more specific markers of vascular wall inﬂammation. Therefore, studies are underway to improve the prognostic value for cardiovascular events by the determination of inﬂammatory markers in the blood. However, due to the unspecifcity of individual inﬂammatory markers, diﬀerent methods of their determination and close relation between marker levels and the established risk factors, these have failed to contribute significantly to the evaluation of the role of inﬂammation in the occurrence of cardiovascular events. Currently, the determination of hs-CRP as one of the most prominent risk factors is recommended only in persons at high risk for cardiovascular events, in those that do not have classical risk factors and are at risk due to other causes, such as e.g. familial predisposition.Recently, it has also been found that inﬂammation is implicated in the pathogenesis of venous thrombosis. In the case of a damaged venous wall inﬂammation occurs as a response to injury, while in idiopathic venous thrombosis without the presence of risk factors the vascular wall inﬂammation is probably a primary event that is followed by coagulation activation. Namely, there is a close association between inﬂammation and coagulation. Inﬂammation stimulates procoagulant activity and inhibits endogenous fibrinolysis, and therefore patients with the history of venous thrombosis present with elevated levels of systemic inﬂammatory markers, particularly of hs-CRP and interleukin. However, it has not been fully explained yet whether the elevated systemic inﬂammatory markers are a cause of a consequence of venous thrombosis. Te results of our study show that they are most probably a cause for prothrombotic characteristics of the blood and stimulate the occurrence of venous thrombosis, as patients with a history of venous thrombosis even in their stable period (3–5 years) present with elevated inﬂammatory markers.The increased systemic inﬂammatory response in arterial atherosclerotic and venous thromboembolic disease is indicative of a close association between both diseases, which are similar as to their pathogenesis but have diﬀerent clinical features.The recognition of inﬂammatory basis of arterial and venous diseases is also important from the therapeutic point of view since until recently, in comparison with anticoagulants, medicines with anti-inﬂammatory activity were rather neglected. Not only has aspirin long been known for its antithrombocytic and also anti-inﬂammatory activity, it also appears to be eﬀective in long-term prevention of recurrences and progressions of venous thromboses.

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PRIMARY DIAPHYSEAL TUBERCULOUS OSTEOMYELITIS OF TIBIA

The Professional Medical Journal ◽

10.29309/tpmj/2014.21.06.2729 ◽

2014 ◽

Vol 21 (06) ◽

pp. 1282-1284

Author(s):

Ghulam Mustafa Kaim Khan ◽

Syed Mujahid Humail ◽

Kamran Hafeez

Keyword(s):

Weight Loss ◽

Developing Countries ◽

Differential Diagnosis ◽

Osteolytic Lesion ◽

Long Bone ◽

Low Grade ◽

X Rays ◽

X Ray ◽

Tuberculous Osteomyelitis ◽

History Of

Diaphyseal tubercular osteomyelitis of long bone is extremely rare and few cases have been reported in literature. We are presenting a case of 17 years old girl presented with pain and swelling over lower half of leg for 7 months. There was often low grade fever but no history of weight loss or pulmonary symptoms. X-ray chest was normal. X-rays and MRI of involved leg were suggestive of osteomyelitis. Curettage and biopsy was done, report was suggestive of tuberculous osteomyelitis. As tuberculosis is still common in developing countries, for an osteolytic lesion in bone, tuberculous osteomyelitis should be considered in differential diagnosis.

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Tubercular Osteomyelitis of Tibia: A Case Report

Nepal Medical Journal ◽

10.37080/nmj.27 ◽

2019 ◽

Vol 2 (1) ◽

pp. 92-94

Author(s):

Amin Kumar Shrestha ◽

Suman Raja Shrestha ◽

Gopesh Kumar Thakur ◽

Arjun Prasad Dumre

Keyword(s):

Weight Loss ◽

Differential Diagnosis ◽

Osteolytic Lesion ◽

Extrapulmonary Tuberculosis ◽

Long Bone ◽

Low Grade ◽

X Rays ◽

X Ray ◽

Tuberculous Osteomyelitis ◽

History Of

Tubercular osteomyelitis of long bone is extremely rare and very few cases have been reported in literature. We are presenting a case of 43 years gentlemen presented with pain and swelling over lower half of leg for 5 months. There was associated pus discharging sinus and often low-grade fever but no history of weight loss or pulmonary symptoms. X-ray chest was normal. X-rays of involved leg was suggestive of osteomyelitis. Curettage and Biopsy was done, report was suggestive of tuberculous osteomyelitis. As tuberculosis is still common in developing countries like Nepal, for any osteolytic lesion in bone, tubercular osteomyelitis should always be considered in differential diagnosis. Keywords: extrapulmonary tuberculosis; osteolytic lesion in bone; tubercular osteomyelitis.

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