Lege Artis Medicinae

[Effective adalimumab treatment of a steroid-dependent Crohns’ disease patient suffering from general, abdominal and joint symptoms of multiple etiology]

JUHÁSZ Márk, TÓTH Zsuzsanna, MIHELLER Pál, SZŰTS Ildikó, GAÁL Ramóna, PÁPAY Judit, PREGUN István, TULASSAY Zsolt, RÁCZ Károly, MŰZES Györgyi

JANUARY 20, 2011

Lege Artis Medicinae - 2011;21(01)

[The 69-year-old male patient had been suffering from periodically relapsing rheumatological symptoms involving variable localisations (knee, ankle, MTP, sternoclavicular and hip joint) since 1964. On the basis of his joint symptoms, load-independent lower back pain, sacroileitis, recurrent iridocyclitis, urethroprostatitis and oral aphtous lesions, Reiter disease was diagnosed in 2000. The patient had Lyme-disease (confirmed Borrelia burgdorferi seropositivity) with peripheral facial paresis in 2003. The patients joint problems relapsed in 2006, accompanied by diarrhoea and fever, independent of any infecions. The possibility of IBD could not be confirmed either by macroscopic examination using colonoscopy or hystology. The patient was admitted to our department in March 2008 for the first time, presenting again with joint pain and disability of gait, 7-8 bowel movements a day, and fever. Taken together the clinical symptoms, the typical radiological findings and HLA-B27 positivity, Bechterew disease was diagnosed. Colonoscopy performed because of diarrhea revealed multiple segmental aphtoid lesions and irregular ulcers, suggesting Crohn disease that was confirmed by histology (cryptal abscess formation and microgranulomas). Sulfasalazin, 5-ASA, and other NSAIDs applied to treat rheumatological symptoms could not eliminate either the gastrointestinal or the rheumatological symptoms of the patient, which necessitated regular steroid therapy. Because of the patient’s steroid dependency, and considering his rheumatological symptoms, in June 2008 he was treated with adalimumab (ADA) induction therapy (80-40-40 mg s.c.). In two weeks, his gastrointestinal as well as extraintestinal symptoms substantially improved, and completely diminished through the course of maintenance ADA therapy (40mg weekly). The patient is still asymptomatic and is excercising (jogging) regularly.]

COMMENTS

0 comments

Further articles in this publication

Lege Artis Medicinae

[Autoimmune pancreatitis in Hungary: a national multicenter study]

CZAKÓ László, GYÖKERES Tibor, TAKÁCS Tamás, TOPA Lajos, SAHIN Péter, DUBRAVCSIK Zsolt, SZEPES Attila, PAP Ákos, FÖLDESI Imre, TISZLAVICZ László, WITTMANN Tibor

[BACKGROUND - Autoimmune pancreatitis (AIP) is an increasingly recognised, special form of chronic pancreatitis, which greatly differs from other forms of chronic pancreatitis. Most papers on this condition have been published in Japan. METHODS - In our multicenter study, we aim to present the characteristics (demographics, clinical symptoms, laboratory and morphological findings, extrapancreatic symptoms, response to therapy, remission) of the first 13 Hungarian cases of AIP. RESULTS - The mean age at presentation was 44.2 years (range: 19-74); 54% of patients were women. New-onset mild abdominal pain (77%), weight loss (38%) and jaundice (31%) were the most common symptoms, with ulcerative colitis as the most frequent (38%) extrapancreatic manifestation. Diffuse pancreatic swelling was seen in 7 patients (54%), and a focal mass in 5 (38%). Pancreatic duct strictures were present in all patients. Serum immunoglobulin-G4 level was elevated in 71% of the patients in whom it was measured. All percutaneous core biopsies (4 patients) and surgical specimens (2 patients), and 2 of the 4 biopsies of the papilla of Vater revealed hystological findings typical for AIP: periductal, diffuse lymphoplasmacytic infiltration, marked interstitial fibrosis, and obliterative phlebitis. Immunostaining revealed IgG4-positive plasma cells in 57% of the patients in whom it was examined. Granulocytic epithelial lesions (GEL) were detected in 3 patients. These patients were younger (mean age 34 years), 66% were women and 6% had ulcerative colitis, whereas the mean age of patients without GEL was 65 years, and the majority of them were men. Steroid treatment resulted in remission of the symptoms in all patients. Because of suspicion of pancreatic tumour, 2 patients with focal AIP underwent partial pancreatectomy. Symptoms relapsed in one patient, but an increased dose of steroid resulted in a remission, which was maintained by azathioprine therapy. CONCLUSIONS - In our first Hungarian cases, we have confirmed previously reported characteristics of AIP. AIP with GEL is frequent among our patients; this condition is more frequent among women and younger patients, and is often associated with ulcerative colitis. If AIP is suspected, the performance of percutaneous biopsy is highly recommended. The therapeutic response to steroid therapy was excellent.]

Lege Artis Medicinae

[The Ethics of Publishing: Regulation of Monetary Conflicts of Interest in Medical Journals]

KAKUK Péter

Lege Artis Medicinae

[Osteonercosis of the femoral head during pregnancy]

KISS-POLAUF Marianna, TAKÁCS János, TASI Róbert, RÁKÓCZI István

[Osteonecrosis of the femoral head associated with pregnancy is a rare condition. Approximately 40-50 cases have been reported, the first one by Pfeifer in 1957. Avascular osteonecrosis is usually caused by factors that impair the bone’s blood supply (intraosseous arterious or venous occlusion, venous stasis, hypertension in the bone marrow). Owing to the cautious use of radiological imaging techniques during pregnancy and the limited experience with this condition, the correct diagnosis is usually made only retrospectively. Thus, total hip replacement is required in most cases. In the third trimester, MRI examination is safe to perform, and in some cases a simple X-ray should be also considered, as timely avoidance of weight-bearing and other therapeutic interventions might help to prevent the arthroplasty. Here, we would like to present a case observed and treated by us, and to overview the options that could facilitate making the correct diagnosis and finding the appropriate therapeutic program.]

Lege Artis Medicinae

[Ghostwriters or ghostbusters?]

KAPÓCS Gábor

Lege Artis Medicinae

[ART (Arterial Revascularisation Trial)]

MATOS Lajos

All articles in the issue

Related contents

Hungarian Immunology

[TNF-α blocking therapy in rheumatoid arthritis]

TAMÁSI László

[The research of pathomechanism of rheumatoid arthritis resulted in remarkable pragmatic results beyond the important theoretical knowledge. These observations led to the development of new effective agents, which were named as biological therapy and introduced in clinical praxis. The key factor of pathomechanism of rheumatoid arthritis is the proinflammatoric citokin TNF-α. It can be found on the top of the inflammation cascade where regulates many other inflammatory mediators and also plays an important role in the defence against infections and tumours. The author describes the TNF-α blocking agents used in clinical practice, their chemical and pharmacological feature, as well as their mode of action and the consequence of inhibition of TNF-α. He reviews the main results of the major clinical tests with infliximab, etanercet, and adalimumab. The results of these clinical studies demonstrate that the TNF-α blocking therapy gives clinical improvement in case of therapy resistant patients, decreases the number of swollen and tender joints, the pain, ESR and CRP, decreases the radiological progression, furthermore improves the quality of life. There are also some data about the favourable impacts observed during the early arthritis treatment. The TNF-α blocking therapy can be used effectively and safely in rheumatoid arthritis. In most cases the infusion reaction and the injection site reaction are not reasons for withdrawal from the study. The sideeffects, however, developed in increasing numbers during widespread applications. Among these the most important ones are the opportunist infection and the tuberculosis. In addition the sporadic occurrence of lupus-like symptoms, demyelinating disease, and aplastic anemia were reported. The fundamental requirements of the safety of the biological therapy are the professional indication and the careful monitoring during the treatment, the principle of which has been already prepared by the Professional College of the Rheumatology and Physiotherapy based on the international experience.]

Hungarian Radiology

[CT enteroclysis in small bowel Crohn’s disease]

TÓTH Géza, MAGYAR Péter

[PURPOSE - The aim of this paper is to demonstrate morphological changes of Crohn’s disease observed by CT enteroclysis and also to evaluate the role of the method in the diagnosis and the follow up of patients with known or suspected Crohn’s disease. PATIENTS AND METHODS - We evaluated retrospectively 50 typical cases who were examined earlier. Crohns’s disease was diagnosed in 42 patients before CT enteroclysis. Histological confirmation was available in 36 cases after colonoscopy and in six cases after surgery. In eight patients had a high suspicion of the disease, histological examination was not performed. CT enteroclysis findings were read by two radiologist independently and results were compared. RESULTS - CT enteroclysis showed typical signs of Crohn’s disease in all patients. Different degree of wall thickening was seen in all cases, pathological enhancement of small bowel wall (in cases 35), multilayered appearance (n=29), fibrofatty proliferation (n=33), enlarged lymph nodes (n=37), entero-enteric fistula (n=6), entero-cutan fistula n (=5), mesenteric abscess (n=5) was found. CONCLUSION - CT enteroclysis is an accurate method to detect mural and extramural abnormalities in patients with Crohn’s disease. CT enteroclysis proved highly accurate in detecting small bowel involvement and it also provides an estimation of clinical activity of the disease. CT enetroclysis can be considered as the first imaging method in patients with clinical signs of Crohn’s diseases and also in the follow up of patients with known disease.]

Lege Artis Medicinae

[Isolated anal form of Crohn’s disease with an extensive perianal septic complication]

DOBÓ István, JÓSVAY János

[INTRODUCTION - Perianal manifestations of Crohn’s disease are common. Treatment of advanced complications like strictures and incontinence may require a radical surgical intervention. We present a case of an extremely rare manifestation of Crohn’s disease. The disease localized exclusively to the anal canal for more than twenty years was complicated by an extensive perianal septic lesion. Besides our own surgical strategy, we discuss in detail other therapeutic options for perianal septic complications of Crohn’s disease. CASE REPORT - During 16 years of disease course the perianal process of the 34 year old female patient caused sphincter destruction and incontinence, and furthermore resulted in a chronic septic state by fistulous tracts involving the whole perineo-gluteal region. Following rectal extirpation, we performed a radical excision and a reconstructive operation using musculo- cutaneous/fascio-cutaneous advancement flaps. The final result of multiple operations of two years’ duration was functionally and aesthetically excellent. CONCLUSION - Fistulous tracts of perianal Crohn’s disease destructing widely their surroundings can only be cured by the radical excision of involved tissues. Extremely large consequent defects can also be covered with proper functional results by methods applying healthy tissues of good loadability i.e. musculocutaneous/ fascio-cutaneous advancement flaps.]

Hungarian Immunology

[Adalimumab treatment in inflammatory joint diseases]

SZÁNTÓ Sándor

[The development of anti-TNF-α agents represents a great advance in the treatment of inflammatory joint diseases. Adalimumab is the first fully human, recombinant IgG1 monoclonal antibody that blocks the interaction of TNF with the p55 and p75 cell surface TNF receptors, thereby neutralising the activity of this cytokine. In well designed, placebocontrolled trials adalimumab significantly reduced symptoms, improved quality of life, and reduced radiologically evident joint damage in patients with rheumatoid athritis, ankylosing spondylitis and psoriatic arhritis. The drug was generally well tolerated, and the follow up studies confirmed, that the incidence of serious adverse events was similar to that generally seen in patients not receiving anti-TNF agents. This review summarises the recent available data related to the efficacy and safety of adalimumab in inflammatory joint diseases.]

Lege Artis Medicinae

[THE GENETICS OF INFLAMMATORY BOWEL DISEASE]

LAKATOS Péter László, LAKATOS László

[The pathogenesis of inflammatory bowel disease is only partly understood; various environmental and host factors (e.g., genetic, epithelial, immune and non-immune) are involved. It is a multifactorial polygenic disease probably with genetic heterogeneity; some genes confer susceptibility to IBD in general, while others specifically increase the risk of ulcerative colitis or Crohn's disease or affect location (localized or extensive) and/or behaviour (e.g., mild, severe, aggressive). This review presents recent advances in the genetics of inflammatory bowel disease including chromosome segments newly recognized to be involved in inflammatory bowel disease as well as the role of NOD2/CARD15, SLC22A4/A5 and DLG5. The increasing genetic information provides, for the time being, a better understanding of the pathogenesis of the disease thus setting a basis for potential targets for therapeutic intervention. In the future, however, genetics may also help in refining the diagnosis or predicting disease course.]