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Section on rheumatology. (Abstracts of Scientific Posters).

RH1-D. DIFFUSE SYSTEMIC SCLEROSIS AND PREGNANCY: A CASE REPORT AND LITERATURE REVIEW. Janine Serebro, BA, Kirk Beeson, BS, and William E. Davis, MD. LSUHSC School of Medicine and Ochsner Clinic Foundation, New Orleans, LA.

A 24-year-old African American G1P0 woman presented at 34 weeks' gestation with progressive dyspnea, worsening Raynaud's symptoms, and preterm labor. She had a 1-year history of diffuse scleroderma, confirmed by skin biopsy. The patient was tocolyzed with magnesium and vaginally delivered a 2040-gram infant 2 weeks later. Both mother and infant had an uneventful hospital stay. Older case reports and studies have suggested that women with scleroderma have increased rates of adverse outcomes, including small babies, miscarriage, premature delivery, and infertility. While recent data do support increased rates of premature delivery and delivery of small full- term infants, these studies have shown no increase in the frequency of miscarriage and no increase in infertility rates, except in patients with longstanding disease. Furthermore, the cutaneous disease seems unaffected by pregnancy and Raynaud's symptoms tend to improve. Thus, the increased risk of complications is not reason enough to avoid or terminate pr egnancy. Patients should be managed based upon the extent and severity of organ damage. One notable exception is patients with diffuse scleroderma disease of less than 4 years' duration. They are at increased risk of active, aggressive disease, including scleroderma renal crisis, and should delay pregnancy until the disease stabilizes. All patients with scleroderma should be considered high-risk pregnancies, and should be monitored closely by an obstetrician experienced in this area. Patients should be taught about the early signs of labor, and magnesium or calcium channel blocker should be used if tocolysis is necessary. Most drugs should be avoided during pregnancy, especially corticosteroids, which increase the incidence of renal disease during pregnancy. If there is any sign of renal disease, such as a mild elevation of blood pressure, ACE inhibitors should he used, despite the association with fetal birth defects. With appropriate prenatal and postnatal care, good maternal and fetal outcomes should be po ssible in all but the most severe instances.

RH2-D. A CASE OF PAN. Rakesh Shrivastava, MD, Jayaram S. Bharadwaj, MD, and Ali Akhavan, MD. Rochester, NY.

A 62-year-old woman who had no significant medical history was admitted to the hospital with fever, nausea, jaundice, and weight loss of 2 weeks' duration. She had occasional numbness of her both feet since four months prior to admission. The patient was postmenopausal, a nonsmoker, and had 3 children. She had a temperature of 102.9[degrees]F; pulse rate of 93 beats/min, BP of 124/58 mm Hg, and respiratory rate of 16 breaths/mm. She was icteric, with mild right upper quadrant pain. The rest of the examination was unremarkable She had a hemoglobin concentration of 11.8 g/dL; leukocyte count of l7,800/mm3 with differential of 69% segmented neutrophils, 15% bands, 4% monocytes, and 11% lymphocytes; and a platelet count of 570,000/mm3. Urinalysis was normal. Her SMA-7 was normal, with indirect bilirubin of 3.6 mg/dL, AST of 140 IU/L and alkaline phosphate of 853 IU/L. Her total protein level was 6.0 g/dL and albumin level was 2.8 g/dL. Her total complement was < 10, C3 level was 98 mg/dL (normal, 80-201mg/dL), C- reactive protein value was 8.9 mg/dL (normal, < 0.27 mg/dL), and rheumatoid factor was 90.6 IU/mL (normal < 20 IU/mL). She had a HIDA scan with nonvisualization of the gallbladder, and underwent cholecystectomy for emphysematous cholecystitis. During surgery, liver biopsy was done, as liver was not normal and liver function test abnormal as above. Later, the patient developed weakness of both upper and lower limbs that was of lower motor neurone in nature. She developed 3 episodes of convulsions that were satisfactorily controlled with dilantin therapy. During the hospital stay, she also developed deep venous thrombosis, gangrene of the left second index finger due to vasculitis, and bradycardia. She survived the stormy course and was sent to a long-term rehabilitation center. Both the liver biopsy and the gallbladder showed transmural, necrotizing vasculitis with both acute and chronic inflammation and periarteriolar fibrosis. Granulomas were not present. These changes were consistent with polyarteritis nodo sa. Patient was given 100 mg po qd of cyclophosphamide and 60 mg IV qd of solumedrol and etanercept 25 mg subcutaneously for two weeks. She was sent to the rehabilitation center for further management.

RH3-D. ASSESSMENT OF THE DIAGNOSTIC VALUE OF TEMPORAL ARTERY DOPPLER ULTRASOUND. Saliha Ishaq, MD, Robert J. Quinet, MD, Leonard H. Serebro, MD, and Julie Sossaman, MD. Ochsner Medical Institution, New Orleans, LA.

The purpose of this study was to test the clinical value of temporal artery Doppler ultrasonography in the diagnosis of temporal arteritis. The diagnosis of temporal arteritis usually requires a biopsy of one or both temporal arteries. Ultrasonography of the temporal arteries may detect characteristic signs of vasculitis, such as hypoechoic halo or stenosis. This is a retrospective chart review of 42 patients who underwent temporal artery ultrasonography at Ochsner Medical Institution between April 1995 and January 2001 for evaluation of signs or symptoms of temporal arteritis. Both color flow Doppler and duplex ultrasonography were performed with high frequency transducers using ATI HDI 3000 (Bothel, Washington). 10 ultrasonographic studies of patients clinically diagnosed and treated for temporal arteritis were retrospectively reviewed by two trained physician ultrasonographers. Patients included 30 females and 12 males. 10 patients were clinically diagnosed with temporal arteritis and treated with corticos teroids. Of these 10, 7 underwent biopsy and 4 were biopsy-positive for temporal arteritis. Ultrasonographic findings varied, including visualization of both temporal arteries with frontal and parietal rami in 4; temporal arteries with left parietal ramus only in 2; and only temporal arteries without visualization of frontal and parietal rami in 4. Only two ultrasonographic studies were abnormal. One showed wall thickening with an area of decreased attenuation surrounding the left parietal ramus of the temporal artery. The second study was initially considered negative, but on retrospective review had a halo finding around left temporal artery. Both of these patients had negative biopsies, but clinically responded well to therapy. An additional finding observed during the retrospective ultrasonography review was an undulating, irregular course of the temporal arteries of all the 10 clinically diagnosed patients. We conclude, therefore, that the value of a negative halo finding in a patient clinically suspecte d of having temporal arteritis may not indicate lack of disease. According to the results of this study, the sensitivity of this test was 20% and specificity was 100%. The applicability of the new ultrasonographic finding of the irregular vessel margin may be more predictive of the disease, but requires further investigation.
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Title Annotation:a discussion of the treatment of a woman with progressive dyspnea, Raynaud's symptoms, and preterm labor
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Dec 1, 2002
Previous Article:Section on radiology. (Abstracts of Scientific Posters).
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