Raised Sedimentation Rate Research Articles

Primary tuberculosis of the oesophagus

There are only a few cases of primary tuberculosis of the oesophagus described in the literature. We report a 55-yearold Asian man who presented with dysphagia and at endoscopy appeared to have a carcinoma of the oesophagus. The patient reported an 8-month history of weight loss and dysphagia. Endoscopy showed a large, ulcerating, polypoid lesion, 25 cm from his incisors, with appearances typical of a carcinoma (figure, top). Histology of the lesion showed inflammatory exudate in the sub-mucosa with discrete epithelioid granulomas (figure, bottom). No acidfast bacilli were seen. Further questioning revealed a history of fever and night sweats but no known contact with tuberculosis. He had lived in the UK for the past 8 years. Examination was unremarkable and his chest radiograph was normal. A barium swallow confirmed mucosal irregularity, but showed no other abnormality. He had a mild normocytic anaemia with a raised erythrocyte sedimentation rate (30 mm/h). He was also noted to be hyponatraemic (120 mmol/L) and hypoalbuminaemic (30 g/dL). The next day he had a high fever and became drowsy. He was noted to have a transient, partial, left third-nerve palsy. Computed tomograph of his brain showed an area of contrast enhancement around the right sylvian fissure but no other abnormality. There was raised protein (2·44 g/dL) in cerebrospinal fluid and a lymphocytosis (120 cells 10/L). A diagnosis of tuberculous meningitis was suspected and antituberculosis treatment was started. Subsequently, gastric washings were found to contain acid-fast bacilli. Mantoux test and cultures were negative. He made an uneventful recovery. Most oesophageal tuberculosis appears to be secondary to spread from surrounding structures. This patient had a normal chest radiograph and barium swallow showed no evidence of extrinsic involvement. The development of tuberculous meningitis was considered a secondary phenomenon, perhaps related to the biopsy, 10 days earlier. When primary tuberculous oesophagitis does occur it may affect a previously abnormal mucosa. There was no suggestion of this in our case. The rarity of primary tuberculous oesophagus may be related to oesophageal protective mechanisms such as rapid transit and peristalsis as well as the natural defence of smooth squamous epithelium and swallowed saliva. Dysphagia is the most common presenting symptom and the endoscopic appearance often mimics carcinoma. This case underlines the important message that tuberculosis should always be considered when cancer is suspected, especially in at-risk populations.These include not only people migrating from endemic areas but also the increasing number of individuals infected with HIV.

Renal atheroembolic disease: the Cinderella of nephrology?

Atheroembolic renal disease is the Cinderella of nephrology in that often Cinderella (the patient and their clinical findings) and her shoe (the final diagnosis of atheroembolic disease) are not matched in life. Why is this and is it important? There are two major reasons that the diagnosis may not be made. The first is that the condition may mimic many other causes of renal impairment. Some of the features such as livedo reticularis [1], purpuric rash [1], severe hypertension [2,3], hypocomplementaemia [4], raised erythrocyte sedimentation rate [1], eosinophilia [4], or eosinophiluria [5,6], and even a necrotizing glomerulonephritis [7] may make a diagnosis of systemic vasculitis likely [1,8]. The characteristic presentation might be thought of as a sudden and catastrophic decline in function associated with systemic and skin features of atheroembolism [9]. A different and insidious presentation is now recognized with progressive renal dysfunction over a period of months [10,11]. In one series of patients over the age of 65 years biopsied for gradually progressive loss of renal function, atheroembolic disease accounted for 10% of all cases [10]. It is difficult to explain this insidious loss of function by purely mechanical occlusion. A common histological finding is the associated thrombosis seen in the vessels around the crystals [12]. Cholesterol crystals can activate complement and aggregate platelets in vitro and this may explain the progressive nature of the renal dysfunction [13]. In many cases the diagnosis of atheroembolic disease is not made premortem [1] and even if suspected the diagnosis may be made only on clinical suspicion without histological proof for reasons discussed below.

Malignant External Otitis: Review and Personal Experience

Malignant external otitis (MEO) is an infrequent but severe infective disorder, generally due to Pseudomonas aeruginosa, which most often affects elderly diabetics patients. The clinical features rarely permit exact diagnosis of MEO to be made promptly, and initially at least they are difficult to distinguish from those of external otitis. This explains the frequent delay in diagnosis with respect to the onset of symptoms. Physical examination almost always reveals the presence of aspecific granulation tissue in the external auditory canal, while the most common laboratory finding is raised erythrocyte sedimentation rate (ESR). Imaging has great diagnostic relevance: CT and MRI are very useful for spatial resolution, while radionuclide scanning and, in our experience, SPECT are superior for detecting early osteitis and monitoring response to therapy. We present an extensive review of the literature and our personal experience. In particular, we stress the relevance of immunological study of MEO patients: all our 4 patients had defective immune defences. As regards therapy, like other authors we underline the fundamental importance of long-term antibiotic treatment. The availability of quinolones and latest generation cephalosporins has greatly simplified the choice of antibiotic treatment, although clinicians should be aware of the possibility of drug-resistant bacterial strains.

Predicting acute maxillary sinusitis in a general practice population

To evaluate the diagnostic value of symptoms, signs, erythrocyte sedimentation rate, and C reactive protein for acute maxillary sinusitis. Prospective cohort study. Danish general practice in cooperation with the otorhinolaryngology and neuroradiology department at Aalborg County Hospital. 174 patients aged 18-65 years who were suspected by the general practitioner of having acute maxillary sinusitis. The independent association of symptoms, signs, erythrocyte sedimentation rate, and concentration of C reactive protein in patients with acute maxillary sinusitis defined as purulent or mucopurulent antral aspirate. Only raised erythrocyte sedimentation rate (P = 0.01) and raised C reactive protein (P = 0.007) were found to be independently associated with a diagnosis of acute maxillary sinusitis. The combination of the two variables had a sensitivity of 0.82 and a specificity of 0.57. Erythrocyte sedimentation rate and C reactive protein are useful diagnostic criteria for acute maxillary sinusitis.

Serum haptoglobin and C-reactive protein in human skeletal fluorosis

Circulating levels of haptoglobin and C-reactive protein were studied in patients of skeletal fluorosis and compared with two types of controls. The first type of control included normal healthy individuals consuming water containing permissible levels of fluoride (up to 1 mg/L). The second type of control included individuals consuming water contaminated with fluoride (1.2–14.5 mg/L) but not exhibiting clinical manifestations of skeletal fluorosis. A significant increase in the levels of haptoglobin ( p < 0.01) and C-reactive protein ( p < 0.01) as well as a raised erythrocyte sedimentation rate were seen in patients of skeletal fluorosis as compared to both types of controls. The present study suggests the possibility of a subclinical inflammatory reaction occurring in patients with skeletal fluorosis.

Abdominal tuberculosis in Cairo, Egypt

Twenty-two abdominal tuberculosis patients seen at Abbassia Fever Hospital in Cairo, Egypt from January 1990 to August 1992 are described; their mean age was 21·5 years, range 9–54 years; 17 were female. Common symptoms were fever, malaise, abdominal pain (64%) and weight loss (82%). Chest X-rays were normal in 14 patients (64%), but ultrasonography/computerized tomography of the abdomen was abnormal in 20 patients (91%), with adenopathy the usual finding. Anaemia and a raised erythrocyte sedimentation rate were present in all patients, and purified protein derivative skin test (5 Tu) was positive in 82%. Predominant abnormal physical findings were abdominal (86%), including hepatomegaly/splenomegaly and abdominal mass. Diagnosis was made from biopsy material (caseating granulomas) in 6 patients by laparotomy, 1 by laparoscopy, and 3 by cervical or supraclavicular node biopsy; and from laboratory examination of excretions in only 4 patients (acid-fast bacilli in stools of 2, mycobacteria in urine and menstrual fluid). Eight patients required presumptive diagnosis after response to specific isoniazid (+ethambutol) antituberculous therapy.

Giant Cell Arteritis and Hitler

The publication by Fritz C. Redlich 1 recalls to mind one of the most terrible figures in the history of mankind, the diabolic dictator and instigator of the hell of World War II. Adolf Hitler—the man whose fanaticism, racial prejudices, and National Socialism inflicted disaster on so many people. Redlich argued that from 1942 until Hitler's suicide in 1945 he may well have suffered from temporal arteritis. In support of this argument, he mentions symptoms of headache, disturbance of vision, hypersensitivity to pressure in the supraorbital and temporal regions, severely swollen temporal arteries, fever, mild anemia, cardiac symptoms, and a raised erythrocyte sedimentation rate. This author concluded, certainly with justification, that neither the previously suspected diagnosis of parkinsonism nor his own suggestion of temporal arteritis could possibly be regarded as excuses for Hitler's appalling conduct and criminal activities. With regard to the differential diagnosis, my own opinion is that Hitler

Ocular Myositis As First Presenting Symptom of Human Immunodeficiency Virus (HIV-1) Infection and Its Response to High-Dose Cortisone Treatment

A 30-year-old male presented with signs of ocular inflammation and motility disturbances in an early stage of HIV infection. The provisional diagnosis of an ocular myositis was confirmed by orbital echograms. A general check up revealed positive anti-smooth-muscle antibodies and antinuclear antibodies as well as a raised erythrocyte sedimentation rate. Oral steroid treatment in addition to steroid eyedrops achieved complete resolution of clinical and sonographic symptoms within 15 weeks. Autoimmune phenomena are well known presentations of HIV infection. In this case oral cortisone proved to be an effective therapy even in the setting of an HIV infection.

Ocular myositis as first presenting symptom of human immunodeficiency virus (HIV-1) infection and its response to high-dose cortisone treatment.

A 30-year-old male presented with signs of ocular inflammation and motility disturbances in an early stage of HIV infection. The provisional diagnosis of an ocular myositis was confirmed by orbital echograms. A general check up revealed positive anti-smooth-muscle antibodies and antinuclear antibodies as well as a raised erythrocyte sedimentation rate. Oral steroid treatment in addition to steroid eyedrops achieved complete resolution of clinical and sonographic symptoms within 15 weeks. Autoimmune phenomena are well known presentations of HIV infection. In this case oral cortisone proved to be an effective therapy even in the setting of an HIV infection.

Thrombocytosis and ischaemic complications in giant cell arteritis.

Patients, methods, and results We reviewed the medical records of patients with a diagnosis of giant cell arteritis who were admitted to the University Hospital of the Vrije Universiteit Brussel between 1984 and 1989. The diagnosis was based on clinical features, laboratory data (raised erythrocyte sedimentation rate), biopsy findings in temporal arteries, good response to corticosteroid treatment, and subsequent course. The study population consisted of 56 patients (31 women, 25 men) aged 60-89 years (mean 75-6 (SD 6 3)). Platelet count was determined as routine with an automated counter (normal range 150-400x 10O/l) before corticosteroid treatment. Patients were assigned to one of two groups based on the presence or absence of transient or permanent visual loss, transient cerebral ischaemic attack, or stroke. Age and sex distributions of the groups were similar (table). Eighteen patients (32%) had a history of ischaemic complications. Transient or permanent visual loss occurred in 13, transient cerebral ischaemic attacks in seven (all in the vertebrobasilar system), and stroke in two (one patient died from a brain stem infarction and the other had an infarction in the territory of the middle cerebral artery). In the whole study population thrombocytosis

Assessment of blood echogenicity as an alternative measure to erythrocyte sedimentation rate.

To determine the relation between erythrocyte sedimentation rate and blood echogenicity and whether measurement of erythrocyte sedimentation rate could be replaced by measurement of blood echogenicity in monitoring acute phase reactions. Simultaneous measurement of echogenicity of flowing blood and erythrocyte sedimentation rate in blood samples and comparison of results. A radiological department in a university hospital. 83 patients with a suspected venous thrombosis and 36 healthy volunteers. Correlations between the erythrocyte sedimentation rate, packed cell volume, and echogenicity of flowing blood. Blood echogenicity correlated poorly with the packed cell volume, but strongly correlated with the erythrocyte sedimentation rate (when the packed cell volume was within reference limits) (correlation coefficient = 0.73). Blood samples with a greatly raised erythrocyte sedimentation rate were highly echogenic. Only one of the 30 samples with an erythrocyte sedimentation rate below 10 mm in first hour had a higher echogenicity than the least echogenic sample of the 19 with a sedimentation rate above 30 mm in first hour. Echogenicity of flowing blood correlates with the erythrocyte sedimentation rate and its measurement may compete with conventional methods for evaluating the long term changes in acute phase reactions. Also, it has the added advantage that non-invasive in vivo measurements of blood echogenicity may become possible.

Brainstem Vascular Accidents and Cranial Arteritis

Cranial Arteritis (Giant Cell Arteritis) is a clinical diagnosis supported by a raised erythrocyte sedimentation rate (ESR) and if required confirmed by a temporal artery biopsy. This case reports on an unusual presentation where a delay in the diagnosis resulted in visual impairment, illustrating the need for awareness of diagnosis in acute strokes in the elderly.

Clinical aspects of 100 patients with Kawasaki disease.

We report 101 episodes of Kawasaki disease in 100 patients seen over a 12 year period. A total of 35 patients had cardiac involvement ranging from pericardial effusion to coronary artery aneurysms with ischaemic complications, which resulted in death in one patient. Laboratory investigations showed leucocytosis, thrombocytosis, and a raised erythrocyte sedimentation rate to be common features and the first two variables were significantly associated with cardiac involvement. Treatment regimens changed over the study period. Aspirin was used in most patients often in conjunction with dipyridamole and from 1986 intravenous immunoglobulin was given routinely to those patients seen early in the illness. Additional therapeutic measures in individual patients included prostacyclin, heparin, streptokinase, and plasma exchange/exchange transfusion. Attention is drawn to the uncertainity of the long term cardiovascular consequences in the light of adults reported with premature atherosclerotic lesions of similar appearance to those seen in Kawasaki disease.

帯状ほう疹にて入院し貧血，片麻ひをきたした高齢者ＳＬＥと思われる１例

An elderly case of systemic lupus erythematosus (SLE) with suspected hemolytic anemia was experienced. A 70 year-old female was admitted to our hospital on December 31 with complaints of herpetic eruption. She complained of arthralgia since 3 month prior to her admission. The positive findings on examination were skin eruption in the left chest, a systolic heart murmur and a palpable elastic hard liver. Laboratory data showed raised erythrocyte sedimentation rate of 149 mm per hour, decreased Hb (10.1 g/dl), decreased hematocrit (30.0%), increased reticulocytes (33%1000), decreased thrombocytes (73,000/mm3), increased gamma-globulin (33%) and positive rheumatoid factor. During admission, she developed anemia. A stool test for occult blood was negative. The haptoglobin was 38.8 mg/dl and bone marrow aspiration showed increased erythropoiesis, suggesting features of immune hemolytic anemia, except she was negative on Coomb'test. Eye fundi were similar to case of typical bleeding observed in SLE. Concerning immunological findings, the antinuclear factor was x 1280 and the anti-dsDNA antibody was x 80, on which a diagnosis of SLE was based. She experienced numbness of the left arm and developed left hemiparesis 2 days later. Therapy with 15 mg/day prednisone obtained a good response and anemia, abnormal immunological findings and hemiparesis disappeared.

Primary Sjogren's syndrome presenting as a case of sarcoidosis and a suspected pancreatic tumour.

A 45 year old man, previously diagnosed as having sarcoid, presented with signs and symptoms of a pancreatic malignancy. An explorative laparotomy, however, showed only chronic pancreatitis. He was found to have a raised erythrocyte sedimentation rate, normocytic normochromic anaemia, renal insufficiency, hypergammaglobulinaemia, and a strongly positive rheumatoid factor and antinuclear antibody titre. Bilateral hilar lymph node enlargement was noted on chest x ray. Subsequently, the patient complained of xerostomia and keratoconjunctivitis sicca. Large lymphocytic infiltrates and a shift in the relative number of IgA bearing plasma cells in favour of IgG and IgM bearing plasma cells were seen in tissue obtained by sublabial salivary gland biopsy. A transbronchial lung biopsy and review of the biopsies of the pancreas, the lung, liver, and a lymph node all failed to show granulomatous disease. These findings strongly suggested a diagnosis of Sjögren's syndrome instead of sarcoidosis. This case shows the difficulty sometimes encountered in differentiating between sarcoid and systemic Sjögren's syndrome, and the value of a sublabial salivary gland biopsy.

Spondylitis without epidural abscess formation following short‐term use of an epidural catheter

A 42-year-old patient had undergone total hip replacement for aseptic femoral head necrosis 9 years previously. He now presented with loosening of the prosthesis and pseudoarthrosis sustained following a femoral shaft fracture 7 months earlier. A total hip replacement was carried out in general anaesthesia combined with an epidural catheter. The epidural catheter was removed on the third postoperative day, after which the patient complained of persistent lumbar pain which was associated with meningismus, fever, leucocytosis and a raised erythrocyte sedimentation rate. In spite of intensive laboratory and radiological investigation, 15 weeks elapsed before a radiological diagnosis of spondylitis of L1 and L2 could be made. Aspiration biopsy of the L1/L2 disc space yielded a growth of Pseudomonas aeruginosa. Antibiotic therapy was begun immediately but could not prevent spread of infection to the adjacent disc-space T12/L1 and the vertebral body T12. The patient made a slow recovery and was discharged in a satisfactory condition wearing a lumbar brace some 9 months after the operation. No evidence of epidural abscess formation was found at any stage and no direct connection between the use of the epidural catheter and spondylitis could be established.

EOSINOPHILIC FASCIITIS WITHOUT PERIPHERAL EOSINOPHILLA PRESENTING AS PYREXIA OF UNKNOWN ORIGIN

Eosinophilic fasciitis is a syndrome usually characterized by limb and joint pain, a raised sedimentation rate, hypergammaglobulinaemia, subcutaneous fasciitis and peripheral as well as tissue eosinophilia. We present a case with a positive tissue diagnosis, but who presented predominantly with marked nocturnal sweating and pyrexia.

Erythrocyte sedimentation in nephrotic syndrome.

The erythrocyte sedimentation rates of 185 patients with biopsy proven glomerular disease including 92 patients with clinical nephrotic syndrome and of 210 patients in a control group were reviewed. Patients with nephrotic syndrome were noted to have markedly elevated seimentation rates (x = 67 mm/hr; P< .001) weakly correlating with degree of fall in serum albumin (r = -.45; P < .001). A raised sedimentation rate should therefore be included among the other classical features of the nephrotic syndrome.

Pleuropulmonary Involvement during Bromocriptine Treatment

The use of bromocriptine in the treatment of Parkinson's disease is increasing. More than 20 cases of suggested drug-induced pleuropulmonary disorders during bromocriptine therapy have been reported. We describe four male parkinsonian patients taking bromocriptine in whom pleuropulmonary abnormalities were discovered in a pulmonary hospital during a one-year period. In only one case were the roentgenographic changes reversible after withdrawal of the drug. Pleural fluid from two patients was analyzed and showed lymphocyte-predominant chronic inflammatory changes. Raised erythrocyte sedimentation rate (ESR) and C-reactive protein values decreased after cessation of bromocriptine. Lung function studies demonstrated volume restriction with normal or high CO transfer coefficient. The frequency of pleuropulmonary changes during bromocriptine therapy may be greater than assumed, and such patients may initially present with nonrespiratory symptoms. Follow-up of patients during bromocriptine treatment by ESR, C-reactive protein, and chest roentgenogram is recommended.

Circulating acute phase reactive proteins as indicators of infection in poorly controlled diabetes mellitus

Serum levels of six acute phase proteins (APP)--C-reactive protein (CRP), serum amyloid A (SAA), alpha 1-antitrypsin, haptoglobin and complement fractions C3 and C4--were serially studied in 24 patients with poorly controlled diabetes mellitus, ten of whom had unequivocal evidence of an underlying infection. In diabetic patients without infection, no change in APP levels was noted suggesting that hyperglycaemia per se does not quantitatively influence the acute phase response. No correlation between the presence of infection, and fever, leukocytosis, a raised erythrocyte sedimentation rate, or serum levels of alpha 1-antitrypsin, haptoglobin or complement was apparent in these patients. However, serum CRP and SAA were initially increased 10-100 times above normal in diabetic patients with an underlying infection (P less than 0.01); during the following week circulating levels of CRP and SAA decreased steadily in response to the infection being brought under control. We conclude that serial measurement of CRP and/or SAA is a sensitive, albeit non-specific, parameter to detect and monitor the activity of infection in patients with diabetes.