Permanent Remission Research Articles

Childhood-onset IgA nephropathy: is long-term recovery possible?

IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. While studies have primarily focused on identifying risk factors for disease progression, very few data exist on the likelihood of achieving complete recovery from the disease. We conducted a single-center retrospective study on all consecutive patients with biopsy-proven IgAN diagnosed between 1986 and 2018 in our pediatric center. Biopsies were classified according to the MEST-C Oxford classification score. "Complete clinical remission" was defined as the absence of proteinuria, hematuria, and hypertension in patients with normal kidney function who had been off therapy for more than 2 years. Overall, 153 patients with age at onset of 10.6 ± 4 years were enrolled in the study. Of these, 41 achieved "complete clinical remission." The estimated probability of complete clinical remission at 10 years was 43% (95%CI 33-54). However, seven patients relapsed within 10 years. Multivariable analysis showed that higher age at onset (HR 0.89, 95%CI 0.80-0.98, p = 0.017) and segmental glomerulosclerosis lesions (HR 0.28, 95%CI 0.10-0.79, p = 0.017) decreased significantly the chances of achieving complete clinical remission. Immunosuppressive therapy was not significantly associated with clinical outcomes. Approximately one-third of patients with pediatric-onset IgAN achieve prolonged remission, in particular, very young children at disease onset without sclerotic glomerular lesions. Longer term follow-up is needed to assess if these patients have achieved permanent remission.

Return to Sports in Stress Reaction and Stress Fractures in Indian Athletes: A Case Series.

A stress fracture is a painful condition which occurs when the adaptive ability of the bone is unbalanced. This imbalance predominantly occurs due to increased intensity, frequency, or duration of training. Identifying the etiology of stress fracture and its proper treatment prevents recurrence. Besides, evidence-based and supervised rehabilitation is indispensable for permanent remission of pain and return to sports to preinjury functional levels. The case series discusses the continuum of stress reaction to stress fracture in athletes, causes of stress fractures, their management, and return to sport. The paper aims to give a clear discussion about the management with rehabilitation guidelines for metabolic causes of stress fractures. This study was a case series of five cases coming to Sports Medicine outpatient clinic of Sports Injury Centre, VMMC and Safdarjung Hospital, New Delhi, and physical medicine and rehabilitation outpatient clinic of Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow over a period of 1 year. The discussed cases are young Indian athletes, both male and females, who have presentation along the continuum of medial tibial stress syndrome (MTSS) to stress reactions and stress fracture. The findings of the paper highlight the significance of rehabilitation for individuals suffering from MTSS. Accurate diagnosis with targeted rehabilitation leads to quicker return to sports. The rehabilitation program comprises of identifying and treating the cause of stress fracture, removing any risk factors, biomechanical correction wherever indicated, structured exercise program, training in underwater treadmill, cyclical increase in loading, reducing activity every 3rd week.

Magnetic resonance imaging of the musculoskeletal system in the diagnosis of rheumatic diseases in the pediatric population.

Magnetic resonance imaging (MRI) of the musculoskeletal system is an examination increasingly performed for suspected juvenile idiopathic arthritis, chronic nonbacterial osteomyelitis and juvenile idiopathic inflammatory myopathies, as well as other rheumatic diseases of developmental age. T1-, T2- and PD-weighted with or without fat suppression or short tau inversion recovery/turbo inversion recovery magnitude (STIR/TIRM) sequences and post-contrast sequences are evaluated to diagnose pathological changes in the synovial membrane, subchondral bone marrow and surrounding soft tissues. Magnetic resonance imaging allows detection of synovitis, tenosynovitis, bursitis, and enthesitis as well as bone marrow edema and soft tissue edema. Several pediatric-specific MRI scoring systems have been developed and validated to standardize and facilitate the assessment of the extent of the inflammatory process and disease activity in MRI. Early detection of inflammatory changes allows the inclusion of comprehensive pharmacotherapy giving the possibility of permanent remission and objective measurement of the effectiveness of treatment.

Real-world results of venetoclax combined with hypomethylating agents in young adults with relapsed/refractory acute myeloid leukemia

ABSTRACTObjectivesYoung adults with acute myeloid leukemia (AML) often fail to achieve permanent complete remission (CR) and frequently relapse, indicating an urgent need to explore effective salvage therapies. Recent advances in AML treatment have been attributed to the combination of the B-cell lymphoma 2 (Bcl-2) inhibitor venetoclax (VEN) with hypomethylating agents (HMAs); however, the use of this combination in young adults with relapsed or refractory (R/R) AML has not been reported.MethodsWe retrospectively examined 31 young patients with R/R AML treated with VEN plus an HMA. We evaluated the demographic data, cytogenetic characteristics, AML types, response rates, and transplantation-related data for the patients in our cohort.ResultsThe combination of VEN + HMA yielded a CR rate of 48.4%. The most prominent hematologic adverse event was neutropenia, which occurred in all patients, with 90.3% of cases being grade ≥3. Non-hematologic toxicities were relatively mild and infrequent, with an incidence of 45.2%. More than half of the patients with sustained CR had received an allogeneic hematopoietic stem cell transplantation (allo-HSCT), of whom two died of transplant-related complications.ConclusionOur results showed that the combination of VEN + HMA appeared to be a highly effective and well-tolerated salvage therapy option for young patients with R/R AML, enabling more young patients to proceed to potentially curative allo-HSCT. However, additional, well-designed studies with larger numbers of patients are required to confirm the advantages of VEN + HMA in this population.

Physiological and Psychological Effects of Isotretinoin in the Treatment of Patients with Acne: A Narrative Review.

Isotretinoin (ISO) is a powerful vitamin A derivative that offers the potential for treatment of permanent remission of acne; however, its potential side effects on both physiological and psychological aspects limit its application. This article reviews the side effects of ISO from physiological and psychological aspects in detail, to better screen the suitable population of ISO and improve the efficiency of clinical treatment. Our findings indicate that ISO may cause teratogenicity, skin reactions, ocular reactions, changes in blood indicators, and occasional acne fulminans. To optimize clinical treatment, more attention should be paid to identifying the specific conditions under which these reactions occur, how severe they are, and how they subside to alleviate patient concerns. Regarding the controversial issue of psychological side effects caused by ISO, researchers should shift their focus to the psychological problems that acne itself may cause.

Electrical Status Epilepticus during Sleep: Risk Factors, Clinical Course, and Treatment Approaches

Abstract Background The efforts of clinicians are focused on determining the predictors for electrical status epilepticus in sleep (ESES) manifestation, due to the negative effect of ESES on cognition. Treatment approaches remain a leading problem because of therapeutic resistance. Objective We looked for potential risk factors for ESES manifestation and summarize the clinical course and therapeutic approaches in patients with idiopathic and symptomatic ESES. Patients and Methods We retrospectively reviewed the medical data of 51 children with idiopathic ESES and 20 children with symptomatic ESES. Results We observed an earlier age of seizure onset (p = 0.0002) and a higher percentage of cases with multiple seizures (p < 0.00001) and with postictal paralysis (p < 0.00001) in idiopathic ESES compared with childhood epilepsy with centrotemporal spikes. In the idiopathic ESES, the treatment consisted of corticosteroids in patients with permanent ESES remission and transient remission, levetiracetam (LEV) children with permanent ESES remission and transient, clonazepam (CZP) children with permanent ESES remission and transient, ethosuximide (ESM), and sulthiame. The patients with symptomatic ESES had more unfavorable evolution, as 19 children had persistent or relapsing ESES course. Conclusion We consider the earlier age of seizure onset (below 5 years) and the presence of multiple seizures and postictal paresis as risk factors for ESES manifestation. ESES is characterized by a significant therapeutic resistance, especially in the group of symptomatic cases. Good results are observed with LEV, ESM, CZP, and steroids.

The Relationship Between Early Maladaptive Schemas and Coping Styles, Reasons for Drinking, Craving and Remission in Patients with Alcohol Use Disorder.

Alcohol Use Disorder (AUD) is a serious mental disorder that affects the individual, family, environment and society as a whole. In this study, we aimed to analyze the relationship between early maladaptive schemas and coping styles, with craving, reasons for consumption and finally remission history. This is a cross sectional study. We included 90 Erenköy Mental Health and Neurological Diseases Training and Research Hospital AMATEM patients with AUD according to DSM-5. AUD diagnosis is confirmed by SCID-5 CV. Subjects with additional psychiatric conditions are excluded. Subjects without withdrawal symptoms by CIWA-Ar are included. Sociodemographic data form, Young Schema Questionnaire Short form-3, Young Rygh Avoidance Inventory, Young Compensation Inventory, Drinking Motives Questionnaire-Revised, Obsessive Compulsive Drinking Scale was applied. Our findings show that male subjects who have early maladaptive schemas, especially in Impaired autonomy and performance; Failure, Disconnection and rejection; Social İsolation/alienation, Impaired Limits; Insufficient Self-Control/Self-Discipline domains, experience more cravings. Individuals coping with the Psychosomatism, Activity and Distraction, and Rebellion schemes experienced more craving. Those who coped with 'schema avoidance' tended towards alcohol consumption with Coping Motivation, and those who coped with 'schema compensation' with Impact Enhancement and Social motivations. There was no significant difference between the scores of the scales and the craving levels between the groups with and without a history of permanent remission. The data in our study showed that early maladaptive schemas and ways of coping with schemas are associated with craving. In the early stages of treatment, it is important to consider cognitive intervention focused on schemas and coping styles.

Plasma cell myeloma – therapeutic opportunities

Introduction: Plasmocytic myeloma (PCM) is a neoplastic disease with a multistage course. Monoclonal plasmocytes undergo uncontrolled, multifocal growth in the bone marrow, which results in the production of monoclonal immunoglobulin or its fragments that damage the bone marrow.
 Aim: The aim of this study is to present selected therapeutic possibilities of multiple myeloma.
 Materials and methods: The work uses the method of non-systematic review and analysis of the available scientific literature. Databases such as PubMed, Google Scholar, Arianta, Scopus, Web of Science were searched. The years 2005-2022 were assumed as the review period.
 Discussion: Multiple myeloma accounts for 1-2% of all cancer cases, and 10-15% of all hematological cancers. It is the third most common lymphoid neoplasm after chronic lymphocytic leukemia and large B-cell lymphoma. The diagnosis of PCM requires the presence of a minimum of 10% clonal plasmocytes in the bone marrow or biopsy confirmed plasmocytoma. Moreover, the CRAB and SLiM CRAB criteria are also important. Treatment should be initiated in all symptomatic patients meeting the SLiM CRAB criteria. The first stage of treatment is to induce remission of the disease. 
 Conclusions: Thanks to the progress of medicine, an increasing percentage of patients achieve permanent remissions. The success of the therapy is a component of the earliest possible detection of the disease and the use of appropriate, individually selected drugs.

Long-term efficacy and safety of neridronate treatment in patients with complex regional pain syndrome type 1: a pre-specified, open-label, extension study.

No data on the permanent and curative effect of bisphosphonate treatment in patients with complex regional pain syndrome type-1 (CRPS-1) are currently available. The aim of this pre-specified, open-label, observational study was to evaluate the long-term efficacy and safety of neridronate treatment. A pre-specified, open-label, extension study. Patients treated with intramuscular (IM) placebo in the double-blind phase of the study were assigned to 100 mg intravenous (IV) neridronate treatment administered 4 times over 10 days. These patients, together with those previously treated with 400 mg IM neridronate, were followed for 1 year. Efficacy was assessed using a visual analogue scale (VAS) pain score. Changes in clinical signs and symptoms, quality of life (QoL) using the Short Form Health Survey (SF-36), and the McGill Pain Questionnaire were also assessed. Benefits on pain, clinical and functional measures were maintained and further improved over 12 months in most patients treated with neridronate administered either IM or IV. In IM-treated patients, the percentage of those defined as responders (VAS score reduction ≥ 50%) progressively increased up to day 360 to 32 of 35 patients (91.4%). Among the 27 patients referred to as responders at the end of the double-blind phase, 26 reported the same result at day 360 (96.3%). In IV-treated patients, a responder rate of 88% (22 out 25) was found at day 360 (p = 0.66 between groups). Consistent improvements were also observed for all clinical signs and functional questionnaire. No drug-related adverse events were reported during the study. In patients with acute CRPS-1, the benefit in pain, clinical, and functional measures observed a few weeks after neridronate treatment administered either IM or IV is maintained and further improved over 12 months. Parenteral neridronate induces permanent disease remission preventing chronic pain and motor dysfunction. EU Clinical Trials Register (EudraCT Number): 2014-001156-28.

Reinforcement of Sorafenib Anti-osteosarcoma Effect by Amentoflavone Is Associated With the Induction of Apoptosis and Inactivation of ERK/NF-κB.

Sorafenib has been reported to show anti-osteosarcoma (anti-OS) efficacy by inhibiting metastasis; however, a phase II trial suggested that further combination with other agents could be necessary to achieve permanent remission. Herein, we aimed to identify whether amentoflavone, an abundant natural bioflavonoid found in many medicinal plants, can improve the treatment efficacy of sorafenib in OS. Cell viability, metastasis, apoptosis, and nuclear translocation of NF-κB after amentoflavone combined with sorafenib were assayed by MTT, transwell migration/invasion, western blotting, flow cytometry, and immunofluorescence staining, respectively. The sorafenib-induced cytotoxicity and apoptosis of U-2 OS was enhanced by combining treatment with QNZ (NF-κB inhibitor) or amentoflavone. NF-κB nuclear translocation, NF-κB phosphorylation, and metastasis capacity of U-2 OS cells were inhibited by amentoflavone combined with sorafenib. Amentoflavone may sensitize OS to sorafenib treatment by inducing intrinsic and extrinsic apoptosis and inhibiting ERK/NF-κB signaling transduction.

OUTCOME OF SPLENECTOMY IN THE TREATMENT OF ITP – ONE CENTER EXPERIENCE

Immune thrombocytopenia (ITP) is a disease with variable clinical presentation, requiring different treatment lines. Splenectomy is used as a second- or third-line therapy for ITP. The aim of our study was to evaluate the outcome of splenectomy in the treatment of ITP in our center. The study included 245 patients aged 18 years and older, diagnosed with ITP, treated at the Department of Haematology of the Jagiellonian University Hospital in Krakow from January 2006 to January 2021. Outcomes of splenectomy were analyzed. 14.3%of all ITP patients underwent splenectomy, including 51.5% of those who needed second-line treatment. As much as 60% of them underwent surgery immediately after first-line treatment, while the rest was fist subjected to second-line pharmacological treatment. The mean time from ITP diagnosis to splenectomy was 31.9 months. The mean value of PLT count at the day of splenectomy was 57.4 × 109/L. The initial response rate was 74.3% and post-splenectomy relapses occurred in 22.9% of cases. In our center splenectomy was performed in more than half of the patients within the second-line treatment and resulted in permanent remission of the disease in 50% of cases. It is still a considerable method of ITP treatment, however its frequency decreases over time due to introduction and wider availability of thrombopoietin receptor agonists.

HL-444: Autoimmune Lymphoproliferative Syndrome: A Case Presentation

<h3>Context</h3> Autoimmune lymphoproliferative syndrome (ALPS) is a disorder of lymphocyte homeostasis caused by defects in the FAS apoptotic pathway. ALPS is characterized by non-malignant lymphoproliferation, autoimmune disorders (primarily multilineage cytopenias), and an increased risk of B-cell lymphoma. <h3>Patient</h3> A 4-year-old girl presented with severe anemia and splenomegaly. Hb: 5 g/dL; Hct 16.6%; plt 82 × 10³; WBC: 2.3. Reticulocytosis, high LDH, and indirect bilirubin. Direct antiglobulin test (DAT) was negative, as was a super-Coombs assay. Osmotic gradient ektacytometry in red blood cells was compatible with antibody-mediated decreased surface-to-volume ratio. IVIG was given, with a good response, so the patient was diagnosed with warm-ab autoimmune hemolytic anemia. ALPS panel criteria were met, with increased double-negative T cells (DNTCs) by flow cytometry. A pathogenic variant, c.755delA, was identified in FAS. <h3>Interventions</h3> Sirolimus was targeted to a therapeutic dosage, with great response. The FAS gene is associated with autosomal dominant autoimmune lymphoproliferative syndrome (ALPS-FAS). Lymphadenopathy and hepatosplenomegaly, which are presenting symptoms in most affected individuals and usually manifest in early childhood, often improve with age. Autoimmunity typically develops 2–3 years later and shows no permanent remission with age. <h3>Results</h3> Penetrance of symptoms is highly variable, and some individuals are clinically unaffected. A more severe presentation is seen in individuals with biallelic pathogenic FAS variants. The risk of non-Hodgkin lymphoma is 60 times more than in healthy individuals and more than 150 times as high for Hodgkin lymphoma. Close relatives have an up to 50% chance of being carriers. Most distant relatives may also be carriers. Parental testing may clarify the inheritance of FAS gene mutations. <h3>Conclusions</h3> Autoimmune lymphoproliferative syndrome should be suspected in children with lymphadenopathy, splenomegaly, and multilineage cytopenias. Sirolimus is a disease-modifying therapy that is well-tolerated and efficacious for these patients.

Case report on 10 year child with Rosai Dorfman disease

Background: RDD is a rare proliferative histiocytic disease with a benign course. In children it is a rare cause of rapidly progressive lymphadenopathy, which sometimes mimics malignancy. Case presentation: This report describes a case of Rosai Dorfman disease of 10 year old female child. The clinical, radiological, histological evaluation and management are presented in case report. Conclusion: The course of RDD is unpredictable, episodes of remission and exacerbation may occur for several years. There may be a spontaneous and permanent remission or suffer progressive and generalized disease.

Topical Therapy Failure in Chronic Suppurative Otitis Media is Due to Persister Cells in Biofilms.

Chronic suppurative otitis media (CSOM) is characterized by a chronically draining middle ear. CSOM is typically treated with multiple courses of antibiotics or antiseptics which are successful in achieving quiescence; however, the disease is prone to relapse. Understanding why these treatment failures occur is essential. The minimum inhibitory concentration (MIC), minimal biofilm eradication concentration, and the inhibitory zone were determined for ototopicals and ofloxacin for the laboratory strains and CSOM-derived isolates. The percentage of persister cells and bacterial biofilm formation were measured. Disease eradication was tested in a validated in-vivo model of CSOM after treatment with ofloxacin. Microbiology Laboratory. Basic science experiments were performed to measure the effectiveness of a number of compounds against CSOM bacteria in a number of distinct settings. The minimal biofilm eradication concentration is higher than is physiologically achievable with commercial preparations, except for povo-iodine. Clincial isolates of CSOM have equivalent biofilm-forming ability but increased proportions of persister cells. Ofloxacin can convert to inactive disease temporarily but fails to eradicate disease in an in-vivo model. Higher percentages of persister cells in clinical CSOM isolates are associated with resistance to ototopicals. Current ototopicals, except povo-iodine, have limited clinical effectiveness; however, it is unknown what the maximum achievable concentration is and there are ototoxicity concerns. Fluoroquinolones, while successful in producing inactive disease in the short term, have the potential to encourage antimicrobial resistance and disease recalcitrance and do not achieve a permanent remission. Given these limitations, clinicians should consider surgery earlier or use of clinically safe concentrations of povo-iodine earlier into the treatment algorithm.

New Paradigms in the Treatment of Metastatic Hepatocarcinoma: Case Report

Permanent remissions have been attained in Crohn’s disease. Nevertheless, the current focus of therapy remains sclerosed with the prevailing drug therapy through which temporary remissions are attainable. FDA’s reliance on evidence-based validation through comparative, placebo controlled, double-blinded studies has created an impediment to acceptance of divergent alternated therapies as being within the standard of care. In so doing, FDA has basically surrendered the therapeutic dialogue of Crohn’s disease to those who can pay for such studies.

Crohn’s Disease: A Curable Disease Held Hostage?

Permanent remissions have been attained in Crohn’s disease. Nevertheless, the current focus of therapy remains sclerosed with the prevailing drug therapy through which temporary remissions are attainable. FDA’s reliance on evidence-based validation through comparative, placebo controlled, double-blinded studies has created an impediment to acceptance of divergent alternated therapies as being within the standard of care. In so doing, FDA has basically surrendered the therapeutic dialogue of Crohn’s disease to those who can pay for such studies.

Update on the treatment of steroid-sensitive nephrotic syndrome.

Steroid-sensitive nephrotic syndrome (SSNS) is a rare condition that develops primarily in preadolescent children after the age of 1 year. Since the 1950s, oral corticosteroids have been the mainstay of treatment of all children presenting with nephrotic syndrome, with most patients responding within 4 weeks to an oral course of prednisone (PDN). However, corticosteroids have important side effects and 60-80 % of patients relapse, developing frequently relapsing or steroid-dependent forms. For these reasons, many patients require second-line steroid-sparing immunosuppressive medications that have considerably improved relapse-free survival, while avoiding many PDN-related toxicities. Since most patients will eventually heal from their disease with a normal kidney function, the morbidity of SSNS is primarily related to side effects of drugs that are used to maintain prolonged remission. Therefore, treatment is essentially based on balancing the use of different drugs to achieve permanent remission with the lowest cumulative number of side effects. Treatment choice is based on the severity of SSNS, on patient age, and on drug tolerability. This review provides an update of currently available therapeutic strategies for SSNS.

Beyond the guidelines management of juvenile idiopathic arthritis: a case report of a girl with polyarticular disease refractory to multiple treatment options and Leri Weill syndrome

BackgroundThe last two decades brought new treatment options and high quality guidelines into the paediatric rheumatologic practice. Nevertheless, a number of patients still present a diagnostic and therapeutic challenge due to combination of vague symptoms and unresponsiveness to available treatment modalities.Case presentationWe report a case of sixteen years old girl suffering from polyarticular type of juvenile idiopathic arthritis refractory to multiple treatment options. She first presented at the age of 4 with swelling and contractures of both knees. Her symptoms were initially unresponsive to nonsteroidal anti-inflammatory drugs and progressed despite treatment with intraarticular and systemic glucocorticoids and methotrexate. Throughout the years, she received several biologics together with continuous administration of nonsteroidal anti-inflammatory drugs and disease modifying anti-rheumatic drugs as well as intraarticular and systemic glucocorticoids in disease flares. However, none of this options provided a permanent remission, so various other modalities, as well as other possible diagnoses were constantly being considered. Eventually she became dependent on a daily dose of systemic glucocorticoids. In 2018, the treatment with Janus kinase inhibitor tofacitinib was initiated, which led to gradual amelioration of musculoskeletal symptoms, improvement of inflammatory markers and overall well-being, as well as to the weaning of systemic glucocorticoids. As the swelling of the wrists subsided for the first time in many years, Madelung’s deformity was noticed, first clinically, and later radiographically as well. Genetic analysis revealed short-stature homeobox gene deficiency and confirmed the diagnosis of Leri Weill syndrome.ConclusionsThis case report emphasizes the need for reporting refractory, complicated cases from everyday clinical practice in order to build-up the overall knowledge and share experience which is complementary to available guidelines. Individual reports of difficult to treat cases, especially when additional diagnoses are involved, can be helpful for physicians treating patients with common rheumatological diseases such as juvenile idiopathic arthritis.

Modern approaches to the treatment of meibomian gland dysfunction

The eyelids are a delicate and complex dynamic structure with primary function to protect the eye surface. The term «meibomian gland dysfunction» (MGD) first appeared in the mid-1980s. This lesion is known to result in a disturbance of the tear film, eye irritation symptoms, clinically significant inflammation and diseases of the eye surface. The progression of MGD leads to hyperosmolarity of the tear film, its instability, an increase in the bacterial load of the eyelid margin, blepharitis and generalized inflammation of the ocular surface. For patients who require surgical treatment, a healthy eyelid is very important. Despite postoperative functional recovery, most of these patients experience dry eye syndrome (DES), which can lead to symptoms of eye irritation and deterioration of visual acuity due to instability of the tear film. In the early stages of MGD, it is advisable to begin treatment with a conversation about correct frequent blinking, rest during visual activity, adequate water intake, and a specific diet. Later, patients are advised to use an ultrasonic air humidifier, warm dry compresses, practice proper eyelid hygiene and perform massages, apply preservative-free lubricants, azithromycin, omega-3 preparations, and undergo local anti-inflammatory therapy. In case of a tick-borne infestation, the International Expert Group recommends the use of scrubs with 50% tea tree oil for treating the eyelids. In order to achieve a long-term effect or permanent remission, it is necessary to practice daily eyelid hygiene with the help of gels, special napkins and shampoos over a long period of time. Correctly selected medical treatment in accordance with the stage of the disease supplemented with massages and warm dry compresses lead to a significant improvement in the quality of life of patients with MGD and DES. The simplicity of eyelid hygiene is currently ensured by the availability of tools specially designed for the safe treatment of its edges, which have a complex histological and anatomical structure.

Chronic pain and vitamin B12 deficiency, a challenging and important differential diagnosis. Case report

ABSTRACT BACKGROUND AND OBJECTIVES: The study’s objective was to present a case of diffuse chronic pain with 36 months of development, associated with recurrent oral aphthous ulcers and glossitis, highlighting the importance of the wide differential diagnosis and the possibility of vitamin B12 deficiency as a cause. CASE REPORT: Male patient, 39 years-old, white, reported diffuse pain predominantly in the cervical, thoracic, abdominal, thighs and left knee regions, besides the presence of frequent oral aphtae, lasting more than 5 days, multiple and painful, predominantly on the tongue, for 6 months. The condition was attributed to Behcet’s disease, but there was complete and permanent remission after treatment with vitamin B12. CONCLUSION: It’s important to insert vitamin B12 deficiency for differential diagnosis in chronic pain scenarios.