Search

Chronic treatment with glucocorticoids (GCs) leads to significant bone loss and increased risk of fractures. In chronically GC-treated patients, hip fracture risk is nearly 50%. The purpose of this investigation was to determine if there are differences in the quantities of trabecular and cortical bone and bone strength of the hip between GC-treated osteoporotic patients and controls. Methods: Study subjects were GC-treated osteoporotic postmenopausal women, and controls were postmenopausal women, recruited for separate clinical trials. Quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DXA) of the hip were obtained from all subjects. QCT outcome variables measured included total, cortical, and trabecular BMD of hip subregions (femoral neck and trochanter) and total hip. In addition, finite element modeling (FEM) was performed on a subset of 19 cases and 38 controls, matched on age (± 5 years), weight (± 5 kg), and history of hormone replacement (>1 year use) to assess failure load in stance and fall loading conditions. Generalized linear models were used to adjust the QCT variables for covariates between groups. Multiple regression was performed to identify independent predictors of bone strength from the QCT variables. Results: Compared with controls, GC-treated subjects were significantly (p<0.05) younger, weighed less, and had more years of hormone replacement. QCT of the hip in GC-treated subjects for total femoral integral, cortical, and trabecular BMD averaged 4.9-23.2% (p<0.002) less than controls, and similar results were seen by hip subregion including the trochanter and femoral neck. DXA of the total hip was 17% lower in GC subjects than controls (p<0.05). Compared with controls, FEM failure load in GC subjects was 15% (p<0.05) and 16% (p=0.07) lower for stance and fall loading conditions, respectively. Multiple regression analysis demonstrated that a combination of QCT measures was correlated with bone strength as measured by FEM. Conclusions: Chronic GC treatment in postmenopausal women resulted in significantly decreased BMD of the hip, measured by QCT, with loss of both trabecular and cortical bone. In addition, GC treatment decreased bone strength as determined by FEM. The reduced cortical and trabecular bone mass in the hip may contribute to the disproportionately high hip fracture rates observed in GC-treated subjects. [ABSTRACT FROM AUTHOR]

Reports on differences in antigen recognition and cytolytic activity of CD8[sup +] and CD8[sup -] T cells that express the same antigen-specific receptor. Binding of a syngeneic and an allogeneic peptide-MHC to the 2C T cell receptor on CD8[sup +] and CD8[sup -] T cells; Functional differences between CD8[sup +] and CD8[sup -] 2C cells.

Learning Objectives: Lepromatous leprosy is a rare disease affecting the skin and peripheral nerves that should be considered in patients from endemic areas who present with a rash. Rarely, leprosy may present with erythema nodosum. Early recognition of this disease is important as early leprosy treatment is essential to avoid complications. Case Presentation: A 23-year-old man presented to the emergency department with evolving rash over two weeks. The rash was non-pruritic and started on his lower limbs and gradually spread upwards to the rest of his body, including his face and ears. One week after the rash appeared, he developed fever and generalized pain in his hand and foot joints. The patient had no allergies and no family history of skin disease. He was born in the Marshall Islands but had been living in the United States for the past five years. He had no known history of STDs. He had no recent history of international travel and none of his close contacts had had a similar rash. Physical examination revealed multiple erythematous nodules and papules on the head and neck, disseminated brown and erythematous macules and papules on trunk and limbs, including hands. Palpable purpura and hyperpigmented patches were present on his lower anterior legs. Mild synovitis of his finger joints and bilateral inguinal lymphadenopathy were present. There was no mucosal involvement. Diagnostic testing revealed a white blood cell count of 3.0x109/L and erythrocyte sedimentation rate of 80mm/hr. A skin biopsy was performed and was histologically diagnostic of lepromatous leprosy. Cytology also demonstrated neutrophilic iniltrate and karyorrhectic debris consistent with erythema nodosumleprosum. Fite stain demonstrated numerous intracellular acid-fast bacilli. A modified treatment protocol consisting of dapsone, rifampin, and moxiloxacin was initiated. In addition, the patient was treated with prednisone for inflammatory symptoms. Discussion: This case describes erythema nodosum with systemic symptoms as an atypical presentation of lepromatous leprosy. It illustrates the importance of maintaining a high clinical suspicion for leprosy in a patient who presents with a disseminated erythematous nodular and maculopapular rash. Although it is rare, it should be included in the differential for an unexplained rash in a patient from an endemic area. [ABSTRACT FROM AUTHOR]

Learning Objectives: Moyamoya disease is a rare cerebrovascular disease characterized by stenosis or occlusion of the arteries around the circle of Willis with arterial collateral circulation. Patients with Moyamoya have significant risk for brain hemorrhage. Recognition of this disease in the patient with recurrent strokes requires a high degree of clinical suspicion. Case Presentation: A 57-year-old man with a past history of diabetes, hyperlipidemia and hypertension presented to the emergency department with right-sided weakness and aphasia. A head CT on admission without contrast showed a small left frontal gyrus stroke with no acute hemorrhage and he was managed medically. Laboratory testing on admission was remarkable for elevated hemoglobin A1c and LDL cholesterol. The patient's neurologic symptoms improved initially, however on Day 3 of hospitalization, the patient developed worsening of his symptoms. Physical examination was notable for a right-sided facial droop, hemiparesis in his right upper extremity, decreased strength in lower right extremity and mixed aphasia. Repeat head CT without contrast revealed a large left middle cerebral artery infarction and CTA of the neck showed multiple intracranial stenoses, specifically occlusion of the left M1 artery and moderate stenosis of the right M1 artery. Multiple collateral vessels reconstituting M2 segments were also noted, which were suspicious for Moyamoya disease. His proximal right upper extremity weakness improved mildly, but on Day 4 the patient again developed worsening right-sided weakness and a repeat head CT showed an evolving left middle cerebral artery infarction. Other stroke workup including transthoracic echocardiogram and carotid duplex ultrasound were unremarkable. He was medically managed with aspirin, atorvastatin, lisinopril, and insulin. He continued to receive speech, occupational, and physical therapy throughout his hospital stay and was transferred to an inpatient rehabilitation facility for further care after stabilization of his neurologic symptoms. Discussion: This case illustrates the clinical presentation of recurrent strokes, which is common in the context of Moyamoya disease. The diagnosis of Moyamoya disease is made with MRA or CTA which shows significant stenosis or occlusion of the cerebral arteries with a prominent collateral circulation. It is important to consider this disease in a patient with recurrent strokes because of the progressive nature of the disease and increased risk for cerebral hemorrhage. [ABSTRACT FROM AUTHOR]