Autoimmune Screen Research Articles

Feasibility of screening for T1D and celiac disease in a pediatric clinic setting.

Type 1 diabetes (T1D) or celiac disease (CD) develops in at least 2% of the general population. Early detection of disease-specific autoimmunity and subsequent monitoring would be possible if screening tests were more widely available. Currently, screening for islet autoimmunity is available only in a research setting, and CD-specific autoimmunity screening is limited to those in high-risk groups. This study assessed the feasibility of incorporating T1D and CD autoantibody screening into a pediatric practice. Patient engagement strategies, blood collection preference, blood sample volume, rate of autoantibody detection in the general population, and parental satisfaction were assessed. Over 5 weeks, research staff recruited 200 patients, aged 2-6 yr from two pediatric practices in the Denver area to be screened for islet autoantibodies (IAs) and the transglutaminase antibody. Of the 765 parents approached, 200 (26%) completed the same-day screening. Of the 565 subjects who did not complete the screening, 345 expressed interest, but were unable to make a participation decision. A finger stick, compared with a venous draw, was the preferred method of sample collection. Both methods yielded sufficient blood volume for autoantibody determination. IAs or the transglutaminase antibody were detected in 11 subjects. Parents expressed satisfaction with all aspects of participation. The results of this study suggest that it is feasible to conduct this type of screening in a pediatric clinic. Such screening could lead to increased disease awareness and the possible benefits that can result from early detection.

An unusual urticarial eruption: Familial cold autoinflammatory syndrome.

This is a case of a 26-year-old Caucasian woman with a lifelong history of an episodic urticaria associated with arthralgia, precipitated by exposure to cold. She had no other significant past medical history. She reported several family members with a history of very similar episodic eruptions without definitive diagnoses. An examination showed an urticarial eruption over her limbs with no other systemic findings. A baseline full blood examination, serology and autoimmune screen were normal. A skin biopsy was consistent with urticaria, with dermal oedema and a perivascular infiltrate. Following genetic testing, she was found to be heterozygous for a mutation, p.Ala439Val in the NLRP3 gene, known to cause familial cold autoinflammatory syndrome (FCAS), which typically presents with urticaria, conjunctivitis and arthralgia, as described in this patient. FCAS is one subtype of a group of conditions known as cryopyrin-associated periodic syndromes (CAPS). CAPS are rare, autosomal dominant inherited conditions with a spectrum of phenotypes, characterised by increased interleukin-1β release with subsequent local and systemic proinflammatory and pyrogenic effects.

P36 Autoimmune hepatitis in a patient with hiv and hepatitis b co-infection along with latent tb: a therapeutic dilemma

Background/introduction Liver disease is an important cause of morbidity and mortality in patients infected with HIV infection. Abnormal liver function tests are frequently encountered in these patients and often attributed to HAART. Autoimmune Hepatitis is a rare disease with unclear pathogenesis; several viruses have been proposed to act as triggering agents for the inflammatory process of the disease. Case presentation We present a 46 year old afro Caribbean gentleman who presented with lethargy, weight loss and jaundice. He was diagnosed to be co-infected with HIV and Hepatitis B with a positive autoimmune screen. His persistently elevated liver enzymes warranted a liver biopsy which revealed interface hepatitis, necrosis with lymphocytes and plasma cell infiltrates with variable degree of fibrosis. A picture difficult to interpret in the light of HIV and Hepatitis B infections. His persistently high ALT made it challenging to initiate antiretroviral therapy and the need for steroids to suppress the autoimmune Hepatitis raised a concern regarding the reactivation of the latent TB infection as diagnosed by a positive IGRA test. A review of literature revealed 12 cases of HIV with AIH, but none co-infected with Hepatitis B. Conclusion There are no clear guidelines for management of autoimmune Hepatitis in HIV and treatment is with immunosuppressive agents. A multidisciplinary approach helped in the management of this gentlemen who now stable on antiretroviral therapy and tapering doses of steroids, along with chemoprophylaxis against latent TB.

Screening of endocrine organ-specific humoral autoimmunity in 47,XXY Klinefelter's syndrome reveals a significant increase in diabetes-specific immunoreactivity in comparison with healthy control men.

The aim of this study was to evaluate the frequency of humoral endocrine organ-specific autoimmunity in 47,XXY Klinefelter's syndrome (KS) by investigating the autoantibody profile specific to type 1 diabetes (T1DM), Addison's disease (AD), Hashimoto thyroiditis (HT), and autoimmune chronic atrophic gastritis (AG). Sixty-one adult Caucasian 47,XXY KS patients were tested for autoantibodies specific to T1DM (Insulin Abs, GAD Abs, IA-2 Abs, Znt8 Abs), HT (TPO Abs), AD (21-OH Abs), and AG (APC Abs). Thirty-five of these patients were not undergoing testosterone replacement therapy TRT (Group 1) and the remaining 26 patients started TRT before the beginning of the study (Group 2). KS autoantibody frequencies were compared to those found in 122 control men. Six of 61 KS patients (9.8 %) were positive for at least one endocrine autoantibody, compared to 6.5 % of controls. Interestingly, KS endocrine immunoreactivity was directed primarily against diabetes-specific autoantigens (8.2 %), with a significantly higher frequency than in controls (p = 0.016). Two KS patients (3.3 %) were TPO Ab positive, whereas no patients were positive for AD- and AG-related autoantigens. The autoantibody endocrine profile of untreated and treated KS patients was not significantly different. Our findings demonstrate for the first time that endocrine humoral immunoreactivity is not rare in KS patients and that it is more frequently directed against type 1 diabetes-related autoantigens, thus suggesting the importance of screening for organ-specific autoimmunity in clinical practice. Follow-up studies are needed to establish if autoantibody-positive KS patients will develop clinical T1DM.

Hepatitis e infection and acute liver failure

Background Hepatitis E (HEV) is uncommon in Australia. Infection is usually mild, does not require treatment, and frequently goes unrecognised. Rarely acute liver failure and death may ensue. Case report A 73-year-old female was admitted with acute LFT derangement and jaundice. She deteriorated following admission, developed respiratory failure, and was transferred to a specialist unit for ongoing care and consideration of liver transplant. She had travelled overseas four months prior to presenting and had a medical history significant for fluctuating monocytosis. She consumed multiple complementary medications and a drug-induced aetiology was suspected. Initial investigations for infectious causes including hepatitis A, B, and C were negative as was autoimmune screening. A liver biopsy demonstrated a viral type hepatitis. Further investigation confirmed HEV infection. Discussion There are 20 million cases of HEV infection globally each year. HEV is usually transmitted through consumption of contaminated water. It is however an uncommon infection in Australia where zoonotic infection plays a major role. An Australian study found antiHEV antibodies in 0.4% of subjects. In another study 8/42 patients with hepatic failure had evidence of acute HEV infection. HEV is an under-recognised infection that should be considered when standard infectious screening remains negative.

Eosinophilic angiocentric fibrosis of the orbit: A case report and review of literature

Eosinophilic angiocentric fibrosis is a rare condition presenting with tumefactive lesions of the nasal cavity, paranasal sinuses, upper respiratory tract and rarely the orbit; and has characteristic histopathological features. We report the case of a 38-year-old lady with a mass lesion in right orbit. Histopathological examination of the biopsy specimen revealed extensive areas of perivascular fibrosis showing a characteristic angiocentric whirling with onion skin pattern; along with perivascular exudates of eosinophils accompanied by collection of plasma cells and lymphocytes. Rheumatology review and autoimmune screening was negative. She underwent surgical debulking followed by tapering course of oral steroids and was completely free of orbital disease at her last follow-up visit.

The development of guidelines for management of thyroid diseases in pregnancy – current status

The development of guidelines for management of thyroid diseases in pregnancy – current status

23. Non-specific interstitial pneumonia and polymyositis as a manifestation of antisynthetase syndrome with anti-EJ antibodies

We present a case of a 48-year-old woman who developed synchronous proximal myopathy and colorectal adenocarcinoma. Muscle biopsy demonstrated an inflammatory necrotizing myopathy, and routine autoimmune screens and paraneoplastic screens were negative. Testing was undertaken for antisynthetase antibodies, demonstrating positivity for anti-EJ antibodies. The patient developed progressive shortness of breath, and shortly thereafter succumbed to bronchopneumonia. Findings at autopsy confirmed the presence of interstitial lung disease, with a non-specific interstitial pneumonia pattern. Antisynthetase syndrome is a systemic autoimmune disease associated with autoantibodies to certain aminoacyl-tRNA synthetases, and is characterized typically by myositis, polyarthritis and interstitial lung disease. Aminoacyl-transfer RNA synthetases are a family of cytoplasmic enzymes that catalyze amino acid attachment to corresponding aminoacyl-tRNAs during the translation phase of protein synthesis. In this case, the autoantibody is to the glycyl-transfer RNA synthetase, one of the rarest described antisynthetase autoantibodies. We present a case of a 48-year-old woman who developed synchronous proximal myopathy and colorectal adenocarcinoma. Muscle biopsy demonstrated an inflammatory necrotizing myopathy, and routine autoimmune screens and paraneoplastic screens were negative. Testing was undertaken for antisynthetase antibodies, demonstrating positivity for anti-EJ antibodies. The patient developed progressive shortness of breath, and shortly thereafter succumbed to bronchopneumonia. Findings at autopsy confirmed the presence of interstitial lung disease, with a non-specific interstitial pneumonia pattern. Antisynthetase syndrome is a systemic autoimmune disease associated with autoantibodies to certain aminoacyl-tRNA synthetases, and is characterized typically by myositis, polyarthritis and interstitial lung disease. Aminoacyl-transfer RNA synthetases are a family of cytoplasmic enzymes that catalyze amino acid attachment to corresponding aminoacyl-tRNAs during the translation phase of protein synthesis. In this case, the autoantibody is to the glycyl-transfer RNA synthetase, one of the rarest described antisynthetase autoantibodies.

Acquired Haemophilia a after Allogeneic Stem Cell Transplant for Acute Myeloid Leukemia: Occurred during Cyclosporin a Used for Chronic Graft Versus Host Disease and Tolerance Induction with Rituximab

Background: Acquired haemophilia A (AHA) is a potentially life-threatening bleeding disorder occurring in patients without a previous personal or family history of bleeding. Development of immune-mediated autoantibodies against coagulation factor VIII is associated with a wide range of clinical disorders including pregnancy, autoimmune disorders, malignancy, or with no apparent disease. AHAs occurring after autologous hematopoietic stem cell transplantation (auto-HSCT) HSCT for an autoimmune disease have been reported by the EBMT Autoimmune Disease Working Party, but AHA secondary to allogeneic (allo-) HSCT was rarely reported, except for a literature by Lozier JN, et al reported a AHA occurred after allo-HSCT for sickle cell disease. Here we reported a AHA secondary to allo-HSCT for acute myeloid leukemia (AML).Case report: A 54 years old female patient was diagnosed as having AML on March 7th 2011 in Nanfang Hospital, Guangzhou, China. She acquired complete remission after induction therapy with IA protocol, and then she received consolation therapy with IA and high dose cytarabine. As having HLA 10/10 loci matched sibling donor, she underwent allo-HSCT on July 4th 2011. The conditioning regimen consisted of fludarabine and busulfan, and standard short term methotrexate and cyclosporin A (CsA) was used to prevent acute graft versus host disease. She acquired hematopoietic reconstitution on day 11 after transplantation. She had no acute GVHD, but she acquired limited chronic GVHD 11 months after transplantation. CsA, prednisone and azathioprine was given to treat chronic GVHD. After chronic GVHD was gradually controlled, azathioprine and prednisone were stopped, CsA was tapered step by step. On October 5th 2013, she experienced onset of severe soft tissue haemorrhage (left upper arm, right gluteal and lower right leg) associated with a long aPTT and low FVIII activity (1.3%). Other pertinent coagulation studies were normal. The Bethesda assay showed a factor VIII inhibitor at 2.8 Bethesda units (BU)/ml, confirming a diagnosis of acquired AHA. Autoimmune and viral screens were negative. Considering of AHA happened during CsA used for chronic GVHD treatment, CsA was stopped, cyclophosphamide (CTX) and prednisone were given to treat AHA. The patients underwent 3 episodes of severe soft tissue haemorrhage during treatment, and factor VIII inhibitor increased to 1587.2 Bu/ml. Rituximab were started concomitant with prednisone treatment. After one dose of 375 mg/m2 and 4 doses of low dose Rituximab 100mg per week treatment, the inhibitor titre to human FVIII declined, and the patient had no signs of haemorrhage, Concomitantly, the patient’s FVIII activity rose to >100%, and remained normal after completion of 2 doses of rituximab and a complete taper of prednisone over the next 3 months.Conclusions: This is rarely AHA case emerged after allo-HSCT for AML. Prednisone and CTX were ineffective for this patient. Low dose Rituximab combined with prednisone may be a useful choice for the treatment of AHA occurring after allo-HSCT. DisclosuresLiu:National Natural Science Foundation of China (81270647, 81300445, 81200388): Research Funding; National High Technology Research and Development Program of China (863 Program) (2011AA020105): Research Funding; National Public Health Grand Research Foundation (201202017): Research Funding; Natural Science Foundation of Guangdong Province (S2012010009299): Research Funding; the project of health collaborative innovation of Guangzhou city (201400000003-4, 201400000003-1): Research Funding; the Technology Plan of Guangdong Province of China (2012B031800403): Research Funding; the project of the Zhujiang Science & Technology Star of Guangzhou city (2013027): Research Funding.

73.: A unique case of central nervous system immune reconstitution inflammatory syndrome: Examination of antigen specific T cell immunity

This study aimed to investigate the pathogenesis of a sub-acute progressive asymmetric pancerebellar syndrome in a 54-year-old man with associated mood disturbance, mild cognitive impairment and weight loss. Examination revealed a cachectic man with a reactive, teary and dysthymic affect and mild cognitive impairment. Neurological assessment revealed an asymmetric pancerebellar syndrome with no long-tract signs. An MRI of the brain showed T2-weighted hyperintensity with subtle patchy enhancement in the transverse fibres of the pons, the superior and middle cerebellar peduncles with involvement of the cerebellar white matter. Other investigations including autoimmune, vasculitic and infectious serological screening, and antineuronal antibodies were normal. Paraneoplastic screening was negative. Cererbrospinal fluid (CSF) analysis showed and elevated protein 1.14 g/l, glucose 2.2 and leucocytes

English

Kikuchi-Fujimoto disease is a rare benign, condition of necrotizing histiocytic lymphadenitis. A case of a 21 year old gentleman is described here. He presented with fever, weight loss and non-tender cervical lymph nodes. Kikuchi-Fujimoto disease was diagnosed after cervical lymph node biopsy. Symptomatic treatment was provided and an uneventful full recovery was made. BACKGROUND: The presenting complaint of neck masses in association with non-specific systemic signs and symptoms prompt investigation towards the more common diagnoses. However, rarer conditions like Kikuchi-Fujimoto disease must be included in the differential diagnosis of necrotizing lymphadenopathies such as tuberculosis, lupus erythematosus and lymphoma as its course and treatment are entirely different. (1) Here in we discuss a case of male patient who presented with a CASE PRESENTATION: A 21 year old male patient presented with a two week history of fever, anorexia and weight loss. There were no other complaints. He had been previously fit and well and was on no medication. On examination, he was lethargic, but otherwise looked well. He was afebrile and hemodynamically stable. Significant findings were generalized lymphadenopathy, palpable in the cervical and axillary regions. There was no evidence of hepatosplenomegaly. Blood tests revealed neutropenia, hyponatraemia, raised alkaline phosphate and C-reactive protein. Electrocardiogram and chest radiographs were normal. His initial management consisted of fluid restriction and regular paracetamol, whilst results of further tests were awaited. These included blood and sputum cultures, autoimmune and viral screens. Subsequently there was a reduction in size and tenderness of the cervical lymph nodes. There were persistent intermittent temperature spikes and a two day episode of self-resolved diarrhea. Blood, urine and stool cultures were negative. Sputum cultures grew respiratory tract flora and were negative for acid-fast bacilli. The autoimmune screen was negative, as was toxoplasma and cytomegalovirus screens. Computerized tomography demonstrated cervical and axillary lymphadenopathy The abdominal viscera were normal. Excisional biopsy of a cervical lymph node confirmed a diagnosis of Kikuchi-Fujimoto disease (KFD). Histological analysis showed histiocytic granulomatous infiltration with widespread paracortical necrosis of the lymph node, extensive karyorrhectic debris and scattered fibrin deposits and sheets of foam cells. Special stains for acid fast bacilli (Ziehl-Neelsen) and fungi (Gomori's methanamine silver and periodic acid Schiff with diastase) did not reveal any micro-organisms.

THE TEST IS NEGATIVE: ETHICAL DILEMMA IN UROLOGY & NEUROLOGY

A 34 year old right handed male was admitted with a one day history of stuttering speech on a background of three months of low mood, sleep disruption, headaches and sweats. He developed writhing mouth movements, visual and auditory hallucinations and severe hypertension with sinus tachycardia. He acutely deteriorated with central apnoeas and generalised seizures necessitating intubation and ventilation. Cerebrospinal fluid examination revealed a lymphocytic pleocytosis; infective and systemic autoimmune blood and CSF screening yielded no abnormalities. An empirical diagnosis of autoimmune limbic encephalitis was made and intravenous steroids commenced. Body imaging revealed two testicular nodules in a small testis. A paraneoplastic syndrome was suspected; urgent orchidectomy was considered but the patient was unable to provide consent. Multidisciplinary opinions were sought from neurology, urology, oncology, immunology, radiology and legal advisors. After discussion with the patient9s family, a best-interests decision was taken to remove the testis and he was given intravenous immunogobulins. Testicular histology showed atrophy and fibrotic nodules but no malignancy. Tests for common onconeural and neuronal surface antibodies were negative. The patient made a rapid recovery, returning to independent living in one month and resuming his usual work in a further three months, on a reducing oral steroid regime.

A severe cutaneous reaction caused by acetaminophen in a pediatric patient

A small girl of 2 years-6-months was admitted to our hospital for widespread rash on the face, trunk and limbs that had begun 24 hours previously; she also complained arthralgia of small and large joints and fever. She had received acetaminophen at home for 3 days because of febrile gastroenteritis. Family history was positive for allergy (mother had allergic rhinitis and beta-lactam drug allergy). The rash was widespread and included confluent purpuric macules on the trunk, limbs and on the face. There was no mucosal involvement and no skin detachment. Blood work up showed a slight increase of CRP (1.1 mg/dl) and ESR (34 mm/1h), as well as elevated tryptase (19.2 ng/ml – nv 0-5) and total IgE (178 KU/I). Liver and kidney function was normal as well as electrolytes and coagulation; screening for autoimmunity (ANA, ENA, AMA, antiDNA, ASMA, ANCA, C3, C4, rheumatoid factor) and the infectious valutation (Ab anti CMV, EBV, HHV6 and 8, Mycoplasma, postnasal swab for virus) were negative. Skin biopsy was compatible with vasculitis from possible adverse drug reaction (slight oedema in the upper dermis associated with perivascular lymphohistiocytic infiltrate, without a relevant presence of eosinophils). The patient was treated with methylprednisolone with rapid alleviation of symptoms and a complete resolution within 10 days. The pediatric literature reports numerous hypersensitivity reactions with vascular involvement, caused by NSAIDs and beta-lactam agents (1), while cases regarding the assumption of acetaminophen are rare. Although adverse cutaneous reactions to acetaminophen are rare, considering the widespread use of this drug in pediatric age, we believe that the description of this case is useful inasmuch as a prompt diagnosis and an early treatment as well as drug suspension are crucial for improving the prognosis. Authors’ details Allergy and Immunology Unit, Niguarda Hospital, Italy. Niguarda Hospital, Pediatric Ward, Italy. Niguarda Hospital, Burn Unit, Italy.

Lesson of the month: extrinsic allergic (bronchiolo)alveolitis and metal working fluids

One of us was asked to consider a diagnosis of occupational asthma for a man who had worked for 20 years as a metal turner in a large, modern factory...

Two different presentations, one diagnosis

Acute confusion and hyponatraemia are common presentations in acute medicine. We report two cases of anti-voltage gated potassium channel (VGKC) antibody-related limbic encephalitis highlighting the variable presentation of this condition. Both patients were thoroughly investigated with MRI scan of brain, lumbar puncture, EEG as well as infective and autoimmune screens for encephalitis. Anti-VGKC antibodies were positive for both patients and prompt treatment with immunotherapy yielded good recovery. Patients presenting with confusion and seizures who have no demonstrable infectious or metabolic cause should have investigation for an autoimmune cause expedited. In addition, psychiatric presentations with atypical features such as drowsiness should prompt similar investigations. The outcome of anti-VGKCrelated limbic encephalitis is improved with early treatment employing steroids or immunotherapy.

Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) in the older adult

A 70-year-old woman presented to the hospital's general physicians with a 3-week exacerbation of pre-existing migrainous headache, speech and behavioural change. There was a 20-year history of slowly progressive bilateral...

Facial nerve compression by the posterior inferior cerebellar artery causing facial pain and swelling: a case report

IntroductionWe report an unusual case of facial pain and swelling caused by compression of the facial and vestibulocochlear cranial nerves due to the tortuous course of a branch of the posterior inferior cerebellar artery. Although anterior inferior cerebellar artery compression has been well documented in the literature, compression caused by the posterior inferior cerebellar artery is rare. This case provided a diagnostic dilemma, requiring expertise from a number of specialties, and proved to be a learning point to clinicians from a variety of backgrounds. We describe the case in detail and discuss the differential diagnoses.Case presentationA 57-year-old Caucasian woman with a background of mild connective tissue disease presented to our rheumatologist with intermittent left-sided facial pain and swelling, accompanied by hearing loss in her left ear. An autoimmune screen was negative and a Schirmer’s test was normal. Her erythrocyte sedimentation rate was 6mm/h (normal range: 1 to 20mm/h) and her immunoglobulin G and A levels were mildly elevated. A vascular loop protocol magnetic resonance imaging scan showed a loop of her posterior inferior cerebellar artery taking a long course around the seventh and eighth cranial nerves into the meatus and back, resulting in compression of her seventh and eighth cranial nerves. Our patient underwent microvascular decompression, after which her symptoms completely resolved.ConclusionHemifacial spasm is characterized by unilateral clonic twitching, although our patient presented with more unusual symptoms of pain and swelling. Onset of symptoms is mostly in middle age and women are more commonly affected. Differential diagnoses include trigeminal neuralgia, temporomandibular joint dysfunction, salivary gland pathology and migrainous headache. Botulinum toxin injection is recognized as an effective treatment option for primary hemifacial spasm. Microvascular decompression is a relatively safe procedure with a high success rate. Although a rare pathology, posterior inferior cerebellar artery compression causing facial pain, swelling and hearing loss should be considered as a differential diagnosis in similar cases.

A day in the zoo.

A 32-year-old woman was referred with a diagnosis of acute kidney injury (AKI). She had initially presented to a regional district hospital with a short history of feeling generally unwell with flu-like symptoms, headache as well as conjunctivitis and photophobia. She had no previous medical history whatsoever and was on no medication. She then developed thrombocytopenia (platelet count 37 × 10/L [normal 140–440 × 10/L]), AKI (serum creatinine 449 μmol/L [normal 45–84 μmol/L]) and mildly deranged liver function tests (ALT 81 U/L [<41 U/L]). Lactate dehydrogenase was elevated at 900 U/L (240–480 U/L). Hepatitis and HIV serology were negative. A haematologist did not see any fragmented red blood cells in repeated films of peripheral blood, which were also negative for malaria and ehrlichiosis. Intravenous ceftriaxone was begun to cover meningoencephalitis although a subsequent sample of cerebrospinal fluid was normal. A computed tomography of the brain was also normal. On arrival here, her vital signs were stable and she was no longer photophobic. There was no neck stiffness. The remainder of the clinical examination was essentially unremarkable. The patient had not travelled abroad and all her family were well. She worked as a zookeeper in a wildlife park. During the last weeks, she had worked with a variety of captive birds, kangaroos, and primates, such as lemurs (Figure 1). The patient did not recall exposure to sick animals but had cleaned kennels recently. Urine dipstick was positive for blood and leucocytes but negative for protein and nitrite. Virology and autoimmune screen was negative. Ultrasound showed normal sized kidneys with no evidence of obstruction. Plans were made for an urgent renal biopsy but serum creatinine improved to 221 μmol/L on Day 4.

A rare case of peripheral ulcerative keratitis associated with Behçet’s disease

We report a rare case of peripheral ulcerative keratitis (PUK) associated with Behçet's disease. A 34-year-old female presented with right ocular pain persisting for 8 months. The patient had been treated for previously diagnosed Behçet's disease. The corrected visual acuity was 20/32 in the right eye. Ocular examination revealed mild conjunctival hyperemia and a deep ulcerative lesion with perilesional haziness in the peripheral cornea. Autoimmune screening and corneal culture were negative. One month following treatment with topical and systemic immunosuppressants, the symptom had resolved. Slit-lamp examination showed a healed corneal lesion, and visual acuity improved to 20/20. Despite its rare occurrence, PUK can develop in patients with Behçet's disease. Therefore, patients presenting PUK require examination for Behçet's disease using a systemic evaluation.

Khat (Catha Edulis) as a possible cause of autoimmune hepatitis

To investigate the potential role of khat in triggering auto immune hepatitis. Patients with a history of khat use and acute hepatitis were identified using the computer database in the hepatology department at the Royal Hallamshire Hospital. They were then assessed for probability of having autoimmune hepatitis using the revised autoimmune hepatitis scoring criteria. Six patients were identified. All of them had presented with acute hepatitis on a background of khat. All were male and five of these patients were of Somali origin, while one patient was from Yemen. The patients were given points on the modified autoimmune hepatitis score which is based on their liver enzymes, autoimmune screen, exclusion of viral hepatitis alcohol and drugs, immunoglobulin levels and liver histology. The patients were given a score of -4 for khat use due to its potential to cause drug induced liver injury. Five of these patients scored between 10 and 15 points, placing them in the probable group for having autoimmune hepatitis. All of these patients were treated with prednisolone and demonstrated a good response to immunosuppression. One possibile cause of hepatotoxicity with khat could be via triggering of autoimmune hepatitis in a genetically susceptible individual. Further studies are needed for confirmation.