Methotrexate treatment for sarcoid-associated panuveitis

OBJECTIVE: To determine the safety and efficacy of low-dose methotrexate (MTX) for sarcoid-associated panuveitis. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Twenty eyes from 11 patients were analyzed. Eight patients had sarcoidosis. Three patients were clinically suspected of sarcoidosis despite negative laboratory testing. All charts of patients with sarcoidosis and idiopathic uveitis seen by the Duke Uveitis Service from 1989 to 1997 were retrospectively reviewed. Those with sarcoid-associated or sarcoid-suspected panuveitis treated with MTX with a minimum of 6 months of follow-up were studied. INTERVENTION: Low-dose MTX was administered to patients weekly and patients were followed with serial ophthalmologic and medical examinations. MAIN OUTCOME MEASURES: Visual acuity, oral and topical corticosteroid requirements, anterior chamber inflammation, and ability to undergo successful cataract extraction were used to measure the efficacy of MTX therapy. RESULTS: After MTX treatment was initiated, 90% of eyes had preserved or improved visual acuity. Mean initial Snellen visual acuity was 20/62 and mean final acuity was 20/40 (P = 0.044). Of those patients initially requiring oral corticosteroids, the dosage was decreased in 100%, and they were completely discontinued in 86%. The mean initial oral corticosteroid dose was 26.6 mg and the mean final dose was 1.5 mg (P = 0.012). Topical corticosteroids were decreased in 63% of eyes. The mean initial use was once every 1.6 hours, and the mean final use was once every 3.9 hours (P = 0.001). Ninety-five percent of eyes had stabilized or decreased inflammation. The mean initial inflammation score was 1.2, and the mean final score was 0.5 (P = 0.007). Five of six eyes previously unable to have cataract extraction because of uncontrolled inflammation became quiet on MTX and underwent surgery. One hundred percent of these eyes had improved vision after surgery. Side effects were mild and transient or reversible. CONCLUSION: Low-dose MTX is an effective and safe adjunct to treat chronic sarcoid-associated panuveitis.     

Methotrexate treatment in Felty's syndrome

Felty's syndrome is a rare disorder characterized as a systemic manifestation of severe rheumatoid arthritis associated with granulocytopenia and splenomegaly. We report a retrospective analysis of a series of seven patients treated successfully with low-dose methotrexate. leading to sustained clinical improvement (number of swollen joints) and normalization of the granulocyte count for an observation period of 1 yr. Our cohort is the largest ever published with methotrexate treatment of this rare condition. Our results confirm earlier single case reports suggesting methotrexate to be the first-choice treatment nowadays in Felty's syndrome.     

MRI appearances in amoebic granulomatous hepatitis: a case report

Amoebiasis is a common cause of liver disease usually presenting as single large or multiple smaller abscesses. Cases with granulomatous hepatitis have rarely been described. We report the case of a 7-year-old girl with amoebic granulomatous hepatitis in which multiple liver abscesses were demonstrated by MRI. A total of 14 abscesses were identified, ranging from 5 mm to 3 cm in diameter. The largest lesions appeared to T2-weighted images as heterogeneous, low-intensity areas surrounded by a double-layered wall, the inner layer of which was hyperintense and the outer layer hypointense. These signs, which have never been described in classic amoebic abscess, represent, we believe, a pattern of hepatic granulomatous amoebiasis lesions. We suggest that MRI should always be performed in cases of amoebic infection.     

Methotrexate treatment of ectopic pregnancy. A pilot study

The incidence of ectopic pregnancy is rising but the clinical presentation of the disease has changed simultaneously. Nowadays, the majority of ectopic pregnancies are diagnosed before rupture. This stimulated us to attempt methotrexate therapy (1 mg/kg body weight injected locally or 50 mg given orally) in 12 cases verified by transvaginal ultrasound and presenting with increasing beta-hCG values. The treatment proved successful in 67% of the cases, even though high levels of beta-hCG and foetal heart activity were accepted as inclusion criteria. Eight patients later achieved intrauterine pregnancies, and seven healthy babies were delivered. Randomized, controlled studies are needed.     

Nodular and granulomatous form of periarteritis nodosa caused by the hepatitis B virus

Human herpesvirus type 6 DNA derived from human breath was discovered to contaminate PCR reactions during routine reaction preparation. Parallel PCR experiments were conducted in which expiratory secretions were blocked by a surgical mask, while others were performed without any attempt to circumvent respiratory contamination. The experimenter was previously determined to harbor HHV-6 DNA in the saliva. All reactions in which expiration was obstructed were negative for HHV-6 DNA via PCR. Reactions in which there was no attempt to obstruct respiratory secretions were positive for HHV-6 DNA. These data suggest that PCR assays investigating the presence of HHV-6 may be highly susceptible to contamination from the experimenter leading to false positive results.     

The treatment of idiopathic facial paralysis

Louisiana's new Medical Assistance Programs Provider Agreement Law creates a complex contractual relationship between the state and every person providing care, items or services to the Louisiana Medicaid Program. In privately funded healthcare, it is called a "network contract." This new law gives the Department of Health and Hospitals at least 12 express reasons to cancel a person's contract to provide care to Medicaid beneficiaries. The law also, however, gives a right to either party--either the provider or the state--to cancel the contract at will, and even without cause, by the mere giving of a 30-day advance written notice, and thus this new law might be said by some to stretch the notion that "any willing provider" may participate in Medicaid to near the breaking point. There are many new rules and conditions, some of which have not yet even found their way into privately funded healthcare.     

Methotrexate therapy

An association of schistosomiasis and endomyocardial fibrosis or cardiomyopathy has been suggested. Clinical, stool, abdominal ultrasound, electrocardiogram, and Doppler echocardiogram examinations were performed on 226 patients from an area endemic for schistosomiasis. The diagnosis of schistosomiasis was made in 152 patients (69%) but clinical, electrocardiographic, or Doppler echocardiographic evidence of a schistosome cardiomyopathy or endomyocardial fibrosis could not be detected in any patient.     

Methotrexate hepatotoxicity

Hepatoxicity is a major adverse reaction that can occur during methotrexate treatment of the rheumatic diseases. The pathologic lesions are nonspecific and the pathogenesis is poorly understood. Early studies in psoriasis clearly established a relationship between hepatic injury and several risk factors, particularly alcohol use. Methotrexate hepatoxicity occurs less frequently in rheumatoid arthritis than previously reported in psoriasis patients. Consequently, the American College of Rheumatology guidelines for methotrexate monitoring do not recommend baseline and surveillance liver biopsies in low-risk patients. These guidelines seem to be useful and cost-effective.     

Methotrexate for psoriasis

Methotrexate is an effective antipsoriatic agent and has been widely used to treat severe psoriasis since the 1960s. It is especially useful in acute generalized pustular psoriasis, psoriatic erythroderma, psoriatic arthritis and for extensive chronic plaque psoriasis in patients who are inadequately controlled by topical therapy alone. It has not, however, been formally compared with other systemic treatments for severe psoriasis such as cyclosporin, retinoids or photochemotherapy with psoralen and UVA (PUVA), but in comparison with these other therapies it is inexpensive, with correct use, its safety profile is favourable. In summary, therefore, it can be used as a short-term option to gain control of unstable psoriasis such as pustular psoriasis or erythroderma before returning to other modes of treatment, or more often, as long-term maintenance treatment. The most important potential side-effect is acute myelosuppression, which is the cause of most of the rare deaths attributable to this therapy for psoriasis. Myelosuppression is more likely in the elderly, in patients with renal impairment and/or folate depletion, and with overdose or drug interactions. Long-term therapy carries with it a risk of liver fibrosis which is related to the dosage regimen employed, and is increased by exposure to other hepatic toxins, particularly alcohol. The correlation between the risk of development of liver fibrosis, cumulative lifetime dose and duration of treatment with methotrexate is not clear-cut, but may have been overstated in some studies.     

Cyclophosphamide in the treatment of idiopathic nephrotic syndrome

Fifty-three patients 3 1/2 to 20 years of age with steroid-dependent idiopathic nephrotic syndrome (INS) were treated with cyclophosphamide and prednisone. Two dosage schedules were used: a short course (SC) at 3 to 5 mg/kg/day for six to eight weeks and a longer course (LC) at 3 to 5 mg/kg/day for eight weeks followed by 1.5 to 2.5 mg/kg for an additional four weeks. Prednisone was administered concurrently at 50 to 75 mg/sq M every other day. Twenty-nine patients were in the SC group and 24 in the LC group. The two groups did not differ significantly as to age at onset of idiopathic nephrosis nor as to the duration of the INS prior to cyclophosphamide therapy. All patients were followed for a minimum of 42 months after cyclophosphamide therapy. The SC was associated with a higher relapse rate during the first year than the LC (42% and 8% respectively, .01 larger than P less than .025). At 42 months 63% of the LC group were in remission compared with 21% in the SC group.     

Nimodipine for treatment of idiopathic epilepsy in dogs

OBJECTIVE: To evaluate efficacy and safety of the calcium channel antagonist nimodipine in dogs with idiopathic epilepsy. DESIGN: Prospective clinical trial. ANIMALS: 10 dogs with idiopathic epilepsy. Dogs were included if seizures were inadequately controlled despite treatment with barbiturates and serum phenobarbital concentrations were > 25 micrograms/ml, if dogs had intolerable adverse effects when treated with barbiturates, or if dogs had mild, inadequately treated seizures. PROCEDURES: Dogs were treated with nimodipine (2.5 mg/kg [1.1 mg/lb] of body weight, PO, q 12 h), and other medications were slowly withdrawn. Dogs were monitored for seizure frequency and severity as well as any adverse effects to the medication. RESULTS: Few adverse effects were reported. Seizure control, however, was generally inadequate. All but 2 dogs were withdrawn from the study because of poor seizure control. Plasma nimodipine concentrations were low, with a mean peak concentration of 105.3 ng/ml. CLINICAL IMPLICATIONS: Nimodipine was not successful in controlling seizures in dogs used in this study.     

Surgical versus medical treatment of idiopathic trigeminal neuralgia

The primary treatment of idiopathic trigeminal neuralgia is medical. Surgery is reserved for unresponsive patients or in case of long lasting, tedious or dangerous side effects of the medication. The surgeon has to inform the patient about risks and benefits of the different surgical methods and consider the patient's expectations and fears in order to choose the best surgical alternative. We describe the clinical picture of trigeminal neuralgia, the steps leading to the diagnosis. We also discuss the pathogenesis and the different treatment modalities with emphasis on surgical methods.     

Prevention and treatment of hepatitis C

Interferon is the only treatment shown to be effective on hepatitis C in controlled trials. The response to treatment is generally assessed in terms of a return to normal transaminase activity, but also negative PCR testing for viral RNA and histopathological examination of the liver. At a dose of 3 MU three times a week for 6 months, 25% of patients have a persistent return to normal transaminase activity, 25% relapse when interferon is withdrawn, and the remaining 50% have persistently high levels at the end of treatment and are considered resistant. The rate of persistent responses increases to 40% when treatment is extended to one year. Viral RNA becomes undetectable in the serum of 80% of these responders. Most also have a histological improvement, but so do a number of patients who relapse or who are resistant. In the longer term, interferon could prevent the onset of liver cancer in patients with viral C cirrhosis. Interferon is generally well tolerated at the doses currently used, most side effects (hematologic, neuropsychiatric and thyroid disorders) resolving when treatment is stopped. The following factors are clearly predictive of the response to interferon : young age, short time since onset, absence of cirrhosis, lower-level viremia, and infection by HCV genotypes other than 1b. Interferon is markedly less effective in immunodeficient patients (transplant, HIV infection, etc.). Several add-on treatments have been tried, but ribavirin appears to be the most promising, both during initial interferon therapy and for patients who relapse or are resistant to a first course. Interferon therapy of the acute phase of hepatitis C significantly reduces the risk of chronic liver disease. There is no vaccine against HCV infection.     

Superficial granulomatous pyoderma

Superficial granulomatous pyoderma (SGP) is a form of pyoderma gangrenosum (PG) characterized by superficial ulceration and chronic course. To date it has been described as a condition with specific histopathological findings. We report a new case with clinical characteristics of SGP and describe why we believe that the histological changes previously described are not typical of this entity.