Pub Date : 2023-08-10DOI: 10.17650/1818-8338-2023-17-1-k678
D. Y. Andriyashkina, N. Shostak, A. V. Aksenova, D. V. Abeldyaev
Rheumatic heart disease (RHD) is a preventable heart disease that remains endemic in developing countries. More than 30 million people in the world suffer from RHD, of which approximately 300,000 die every year, despite the fact that this disease is preventable and treatable. After a period of relative neglect of rheumatic heart diseases due to a decrease in the incidence in developed countries, interest in this problem has increased again over the past decade, due, apparently, to an underestimation of its true prevalence due to the subclinical course of carditis. Research over the past two decades has demonstrated the advantage of diagnosing RHD with echocardiographic screening based on World Heart Federation echocardiographic criteria, which is 10 times greater than the clinical auscultatory picture only and it allowsearly detection of it in patients, while prevention is to be more likely to be effective. Although understanding of the pathogenesis of the disease has advanced in recent years, key issues remain unresolved. Preventing or providing early treatment for streptococcal infections is the most important step in reducing the burden of this disease. The management of women with rheumatic heart disease before, during and after pregnancy remains a serious task requiring the efforts of a multidisciplinary team. In 2015, a civil society movement was launched aimed at raising awareness and supporting countries seeking to solve the RHD problem. In May 2018, the World Health Organization adopted a resolution aimed at intensifying global and national efforts to prevent and combat acute rheumatic fever/RHD. Ultimately, a combination of treatment options, research and advocacy based on existing knowledge and science provides the best opportunity to cope with the burden of rheumatic heart disease. The article summarizes the latest achievements in the science of RHD and presents priorities for current actions and future research.
{"title":"Acute rheumatic fever and rheumatic heart disease: what's new?","authors":"D. Y. Andriyashkina, N. Shostak, A. V. Aksenova, D. V. Abeldyaev","doi":"10.17650/1818-8338-2023-17-1-k678","DOIUrl":"https://doi.org/10.17650/1818-8338-2023-17-1-k678","url":null,"abstract":"Rheumatic heart disease (RHD) is a preventable heart disease that remains endemic in developing countries. More than 30 million people in the world suffer from RHD, of which approximately 300,000 die every year, despite the fact that this disease is preventable and treatable. After a period of relative neglect of rheumatic heart diseases due to a decrease in the incidence in developed countries, interest in this problem has increased again over the past decade, due, apparently, to an underestimation of its true prevalence due to the subclinical course of carditis. Research over the past two decades has demonstrated the advantage of diagnosing RHD with echocardiographic screening based on World Heart Federation echocardiographic criteria, which is 10 times greater than the clinical auscultatory picture only and it allowsearly detection of it in patients, while prevention is to be more likely to be effective. Although understanding of the pathogenesis of the disease has advanced in recent years, key issues remain unresolved. Preventing or providing early treatment for streptococcal infections is the most important step in reducing the burden of this disease. The management of women with rheumatic heart disease before, during and after pregnancy remains a serious task requiring the efforts of a multidisciplinary team. In 2015, a civil society movement was launched aimed at raising awareness and supporting countries seeking to solve the RHD problem. In May 2018, the World Health Organization adopted a resolution aimed at intensifying global and national efforts to prevent and combat acute rheumatic fever/RHD. Ultimately, a combination of treatment options, research and advocacy based on existing knowledge and science provides the best opportunity to cope with the burden of rheumatic heart disease. The article summarizes the latest achievements in the science of RHD and presents priorities for current actions and future research.","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":"499 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41310432","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-10DOI: 10.17650/1818-8338-2023-17-1-k677
E. Shmidt, M. Mazra, A. P. Raksha, A. Novikova, M. E. Dmitrieva, V. V. Azarovskaya
Aim. To present a clinical case of late diagnosis of granulomatosis with polyangiitis (GPA), which for a long time was interpreted as a pulmonary form of tuberculosis with the passage of anti-tuberculosis therapy without effect, which led to severe structural changes and resection of the lungs and deformation of the bones of the facial skeleton.Materials and methods. Patient S., 31 y. o., was hospitalized in the rheumatology department with complaints of bloody discharge from the nose with the formation of crusts, hearing loss on both sides, weakness, nose deformity. From the anamnesis: in 2012, a cough with mucous sputum appeared. During examination at the Center for Combating Tuberculosis, on the basis of multiple rounded foci of both lungs, despite a negative diaskin test and the absence of mycobacterium tuberculosis in the sputum analysis, infiltrative tuberculosis was diagnosed. For two years, combined therapy with anti-tuberculosis drugs was carried out. In 2013, a staged combined resection of the left lung was performed; in 2014, a resection of the lower lobe of the right lung was performed. In 2015, nasal discharge increased, large crusts began to stand out, followed by bleeding, and a change in the shape of the nose was observed. In 2016, due to hearing loss in the left ear, he turned to an otorhinolaryngologist, diagnosed with ulcerative necrotic rhinitis, perforation of the nasal septum. Antibiotic therapy - no effect. Blood tests revealed positive antibodies to proteinase-3. In March 2017, he was hospitalized in the rheumatology department.Results. There were CT signs of fibrotic changes in the lungs with calcifications, areas of compaction of the “frosted glass” type in the upper lobes of the lungs. Laboratory examination revealed positive antibodies to proteinase-3, decreased glomerular filtration and tubular reabsorption. Analysis of the biopsy material from the lung and nasal mucosa revealed morphological signs of granulomatosis with polyangiitis. For the first time in 5 years, granulomatosis with polyangiitis was diagnosed, generalized form, chronic course, moderate activity, with damage to the upper respiratory tract (pansinusitis, rhinitis, chronic bilateral adhesive otitis media), lungs (nonspecific interstitial pneumonia), kidneys (microhematuria, proteinuria), joints (arthralgia). The activity index according to the Birmingham BVAS scale is 16 points, the VDI organ damage index is 6 points. In a retrospective analysis, tuberculosis was not confirmed. Therapy with prednisolone, cyclophosphamide (endoxan), biseptol was carried out, against which the patient's condition improved significantly.Conclusion. The presented clinical case demonstrates the difficulties of differential diagnosis of GPA with other granulomatous processes. Late diagnosis led to damage to vital organs: lungs, kidneys, deformity of the back of the nose, which, most likely, could have been avoided in case of timely diagnosis and early initiation of adequate
{"title":"Granulomatosis with polyangiitis under the guise of pulmonary tuberculosis: difficulties in diagnosis","authors":"E. Shmidt, M. Mazra, A. P. Raksha, A. Novikova, M. E. Dmitrieva, V. V. Azarovskaya","doi":"10.17650/1818-8338-2023-17-1-k677","DOIUrl":"https://doi.org/10.17650/1818-8338-2023-17-1-k677","url":null,"abstract":"Aim. To present a clinical case of late diagnosis of granulomatosis with polyangiitis (GPA), which for a long time was interpreted as a pulmonary form of tuberculosis with the passage of anti-tuberculosis therapy without effect, which led to severe structural changes and resection of the lungs and deformation of the bones of the facial skeleton.Materials and methods. Patient S., 31 y. o., was hospitalized in the rheumatology department with complaints of bloody discharge from the nose with the formation of crusts, hearing loss on both sides, weakness, nose deformity. From the anamnesis: in 2012, a cough with mucous sputum appeared. During examination at the Center for Combating Tuberculosis, on the basis of multiple rounded foci of both lungs, despite a negative diaskin test and the absence of mycobacterium tuberculosis in the sputum analysis, infiltrative tuberculosis was diagnosed. For two years, combined therapy with anti-tuberculosis drugs was carried out. In 2013, a staged combined resection of the left lung was performed; in 2014, a resection of the lower lobe of the right lung was performed. In 2015, nasal discharge increased, large crusts began to stand out, followed by bleeding, and a change in the shape of the nose was observed. In 2016, due to hearing loss in the left ear, he turned to an otorhinolaryngologist, diagnosed with ulcerative necrotic rhinitis, perforation of the nasal septum. Antibiotic therapy - no effect. Blood tests revealed positive antibodies to proteinase-3. In March 2017, he was hospitalized in the rheumatology department.Results. There were CT signs of fibrotic changes in the lungs with calcifications, areas of compaction of the “frosted glass” type in the upper lobes of the lungs. Laboratory examination revealed positive antibodies to proteinase-3, decreased glomerular filtration and tubular reabsorption. Analysis of the biopsy material from the lung and nasal mucosa revealed morphological signs of granulomatosis with polyangiitis. For the first time in 5 years, granulomatosis with polyangiitis was diagnosed, generalized form, chronic course, moderate activity, with damage to the upper respiratory tract (pansinusitis, rhinitis, chronic bilateral adhesive otitis media), lungs (nonspecific interstitial pneumonia), kidneys (microhematuria, proteinuria), joints (arthralgia). The activity index according to the Birmingham BVAS scale is 16 points, the VDI organ damage index is 6 points. In a retrospective analysis, tuberculosis was not confirmed. Therapy with prednisolone, cyclophosphamide (endoxan), biseptol was carried out, against which the patient's condition improved significantly.Conclusion. The presented clinical case demonstrates the difficulties of differential diagnosis of GPA with other granulomatous processes. Late diagnosis led to damage to vital organs: lungs, kidneys, deformity of the back of the nose, which, most likely, could have been avoided in case of timely diagnosis and early initiation of adequate ","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44707074","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-10DOI: 10.17650/1818-8338-2023-17-1-k666
Екатерина Витальевна Григорьева, М. А. Полиданов, И. С. Блохин, А. А. Бородай, E. Grigoryeva, M. A. Polidanov, I. S. Blokhin, A. A. Boroday, E. Grigorieva
The purpose of the study. Demonstration of differential diagnostic search for the causes of acute kidney injury (AKI) in a young man.Materials and methods. Clinical observation of a patient with Takayasu arteritis (TAK).Results. The presented clinical observation describes the late diagnosis of TAK at the stage of severe ischemic lesions of the internal organs (myocardial infarction, cerebral infarction, occlusion of the lumen of the arteries of the left lower limb with the development of gangrene, occlusion of the renal arteries with the outcome of left kidney shriveling). Most likely, thrombotic occlusion of the right renal arteries caused the development of severe AKI. During the examination, the diagnosis of TAK was made, other possible nosologies were excluded. Taking into account the late diagnosis of the disease, the minimal severity of the inflammatory process, the high risk of complications, therapy with glucocorticoids in a small dose, anticoagulants was carried out. Against this background, recovery of intrarenal blood flow and diuresis was noted, but high rates of azotemia remained, requiring continued dialysis. After 3 months, the loss of renal functions was detected.Conclusions. The development of vascular lesions of internal organs with signs of critical ischemia (heart, brain, vessels of the lower extremities, kidneys, etc.) in young patients, dictates the need for a differential diagnostic search for the cause, first of all, the exclusion of the systemic process (systemic vasculitis, antiphospholipid syndrome, diffuse connective tissue diseases). It is important to accumulate experience in managing patients with TAK in order to timely diagnose, start therapy early and prevent the development of irreversible lesions of internal organs.
{"title":"A long way to diagnosis: clinical case of acute renal injury in a patient with Takayasu arteritis","authors":"Екатерина Витальевна Григорьева, М. А. Полиданов, И. С. Блохин, А. А. Бородай, E. Grigoryeva, M. A. Polidanov, I. S. Blokhin, A. A. Boroday, E. Grigorieva","doi":"10.17650/1818-8338-2023-17-1-k666","DOIUrl":"https://doi.org/10.17650/1818-8338-2023-17-1-k666","url":null,"abstract":"The purpose of the study. Demonstration of differential diagnostic search for the causes of acute kidney injury (AKI) in a young man.Materials and methods. Clinical observation of a patient with Takayasu arteritis (TAK).Results. The presented clinical observation describes the late diagnosis of TAK at the stage of severe ischemic lesions of the internal organs (myocardial infarction, cerebral infarction, occlusion of the lumen of the arteries of the left lower limb with the development of gangrene, occlusion of the renal arteries with the outcome of left kidney shriveling). Most likely, thrombotic occlusion of the right renal arteries caused the development of severe AKI. During the examination, the diagnosis of TAK was made, other possible nosologies were excluded. Taking into account the late diagnosis of the disease, the minimal severity of the inflammatory process, the high risk of complications, therapy with glucocorticoids in a small dose, anticoagulants was carried out. Against this background, recovery of intrarenal blood flow and diuresis was noted, but high rates of azotemia remained, requiring continued dialysis. After 3 months, the loss of renal functions was detected.Conclusions. The development of vascular lesions of internal organs with signs of critical ischemia (heart, brain, vessels of the lower extremities, kidneys, etc.) in young patients, dictates the need for a differential diagnostic search for the cause, first of all, the exclusion of the systemic process (systemic vasculitis, antiphospholipid syndrome, diffuse connective tissue diseases). It is important to accumulate experience in managing patients with TAK in order to timely diagnose, start therapy early and prevent the development of irreversible lesions of internal organs.","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49182147","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-02-09DOI: 10.17650/1818-8338-2022-16-4-k668
G. R. Avetisian, Z. R. Tsinoeva, N. Altshuler, E. R. Moskalets, P. A. Glazunov, S. Bunova, E. V. Zhilyayev
The aim of the study was to describe a clinical case of noninsulinoma pancreatogenous hypoglycemia (NIPH).Materials and methods. Patient R. 42 years old, woman, was admitted with complaints on spastic abdominal pain, heartburn, flatulence, bloating. The patient had a history of cramping pains in the upper abdomen, episodes of hypoglycemia up to once a day, periodically diarrhea with undigested food up to 3 times a day, and frequent weakness during last 9 years. In 2013, she was diagnosed with a neuroendocrine tumor of the pancreas, and therefore distal pancreatectomy was performed that year. According to histological and immuno-histochemical studies, foci of islet-cell hyperplasia (nesidioblastosis) were noted in the tail of the pancreas against the background of tissue fibrosis. Non-insulinoma pancreatogenous hypoglycemia of adults (NIPH) was diagnosed, enzyme replacement therapy and Octreotide-depo were prescribed. Relapses were noted twice. Two weeks before admission, the patient noted episodes of hypoglycemia. Upon admission, the patient had state of moderate severity, irregular stools up to 3–4 times a day. Antibacterial treatment was carried out, enzyme replacement therapy, octreotide was continued.Results. On the 7th day of hospitalization, the patient was stabilized: the level of glycemia was 4.5–4.9 mmol / l, the frequency and consistency of stool normalized. No data for decompensation of the disease has been received. The patient was discharged in a satisfactory condition.Conclusion. This clinical case demonstrates the influence of NIPH on the patient’s quality of life and the need for constant vigilance against the recurrence of hypoglycemic episodes, despite the treatment. This case can improve the awareness about this rare but important disease.
{"title":"A rare cause of hypoglycemia in adults","authors":"G. R. Avetisian, Z. R. Tsinoeva, N. Altshuler, E. R. Moskalets, P. A. Glazunov, S. Bunova, E. V. Zhilyayev","doi":"10.17650/1818-8338-2022-16-4-k668","DOIUrl":"https://doi.org/10.17650/1818-8338-2022-16-4-k668","url":null,"abstract":"The aim of the study was to describe a clinical case of noninsulinoma pancreatogenous hypoglycemia (NIPH).Materials and methods. Patient R. 42 years old, woman, was admitted with complaints on spastic abdominal pain, heartburn, flatulence, bloating. The patient had a history of cramping pains in the upper abdomen, episodes of hypoglycemia up to once a day, periodically diarrhea with undigested food up to 3 times a day, and frequent weakness during last 9 years. In 2013, she was diagnosed with a neuroendocrine tumor of the pancreas, and therefore distal pancreatectomy was performed that year. According to histological and immuno-histochemical studies, foci of islet-cell hyperplasia (nesidioblastosis) were noted in the tail of the pancreas against the background of tissue fibrosis. Non-insulinoma pancreatogenous hypoglycemia of adults (NIPH) was diagnosed, enzyme replacement therapy and Octreotide-depo were prescribed. Relapses were noted twice. Two weeks before admission, the patient noted episodes of hypoglycemia. Upon admission, the patient had state of moderate severity, irregular stools up to 3–4 times a day. Antibacterial treatment was carried out, enzyme replacement therapy, octreotide was continued.Results. On the 7th day of hospitalization, the patient was stabilized: the level of glycemia was 4.5–4.9 mmol / l, the frequency and consistency of stool normalized. No data for decompensation of the disease has been received. The patient was discharged in a satisfactory condition.Conclusion. This clinical case demonstrates the influence of NIPH on the patient’s quality of life and the need for constant vigilance against the recurrence of hypoglycemic episodes, despite the treatment. This case can improve the awareness about this rare but important disease.","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45846052","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-02-09DOI: 10.17650/1818-8338-2022-16-4-k658
D. V. Khorolsky, A. Klimenko, A. Kondrashov, N. Shostak, N. Demidova
Systemic scleroderma (SSD) is a rare immune-inflammatory systemic disease of connective tissue with a typical lesion of skin, blood vessels, musculoskeletal system and internal organs (lungs, heart, digestive tract, kidneys). The SSD pathogenesis is based on activation of a cascade of complex immune interactions that lead to vasculopathy. The presence of many pathophysiological links in the progression of the disease causes a variety of clinical manifestations in various patients with SSD. A full assessment of all stages of SSD development is still being carried out and every newly open element of the interaction of immunological subjects completes the overall picture of the disease. A number of studies show a correlation between level of several biomarkers and both disease prognosis and estimated therapy effectiveness. Recent data confirm importance of the biomarkers for formation of patterns of a particular disease phenotype in a specific patient. Depending on relation of the biomarkers to various biological processes, several of their categories are distinguished: biomarkers expressed in lung tissue, cellular units of immunity, nucleic acids, acute phase indicators, connective tissue growth factors, matrix proteinases and their inhibitors, chemokines and cytokines, as well as biomarkers of endothelial activation. Discovery of a novel set of the indicators can be decisive in determining the management tactics and forecasting the response to therapy of some groups of patients with SSD. By combining the most recent data on significant markers obtained in the framework of extensive studies, we have described the most significant biomarkers of SSD and their link to interstitial lung disease (ILD) that is formed in SSD.
{"title":"Biomarkers of interstitial lung disease in systemic scleroderma and their significance","authors":"D. V. Khorolsky, A. Klimenko, A. Kondrashov, N. Shostak, N. Demidova","doi":"10.17650/1818-8338-2022-16-4-k658","DOIUrl":"https://doi.org/10.17650/1818-8338-2022-16-4-k658","url":null,"abstract":"Systemic scleroderma (SSD) is a rare immune-inflammatory systemic disease of connective tissue with a typical lesion of skin, blood vessels, musculoskeletal system and internal organs (lungs, heart, digestive tract, kidneys). The SSD pathogenesis is based on activation of a cascade of complex immune interactions that lead to vasculopathy. The presence of many pathophysiological links in the progression of the disease causes a variety of clinical manifestations in various patients with SSD. A full assessment of all stages of SSD development is still being carried out and every newly open element of the interaction of immunological subjects completes the overall picture of the disease. A number of studies show a correlation between level of several biomarkers and both disease prognosis and estimated therapy effectiveness. Recent data confirm importance of the biomarkers for formation of patterns of a particular disease phenotype in a specific patient. Depending on relation of the biomarkers to various biological processes, several of their categories are distinguished: biomarkers expressed in lung tissue, cellular units of immunity, nucleic acids, acute phase indicators, connective tissue growth factors, matrix proteinases and their inhibitors, chemokines and cytokines, as well as biomarkers of endothelial activation. Discovery of a novel set of the indicators can be decisive in determining the management tactics and forecasting the response to therapy of some groups of patients with SSD. By combining the most recent data on significant markers obtained in the framework of extensive studies, we have described the most significant biomarkers of SSD and their link to interstitial lung disease (ILD) that is formed in SSD.","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47368266","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-02-09DOI: 10.17650/1818-8338-2022-16-4-k669
A. Klimenko, N. Shostak, A. Gaffarova, A. Kondrashov, E. Schmidt
Objective: to describe a clinical case of polymorphic leukocytoclastic vasculitis (PLCV) associated with renal neoplasia.Materials and methods. Patient K., a man, 67 y. o., was admitted to the surgical department No. 2 of the N. I. Pirogov State Clinical Hospital No. 1 with cardiac complaints and heart failure decompensation symptoms, severe respiratory insufficiency associated right lower lobe pneumonia. Besides cardiac function evaluation and pneumonia managing there was a conducting of differential diagnostic search to clarify the genesis of ulcerative necrotic rashs among systemic vasculitis, paraneoplastic syndrome including hematologic problems and sepsis.Results. It was no data for systemic connective tissue diseases and systemic vasculitis during clinical examination and immunological diagnostics. On contrast-enhanced multispiral computed tomography of abdomen and retroperitoneal space there was latent malignant neoplasia of left kidney Т2аN1M0. PLCV was considered to paraneoplastic syndrome associated with malignancy. Due to the progression of vasculitis and the patient’s refusal of surgical treatment was prescribed GC 0.5 mg / kg / day as a result positive dynamics was noted.Conclusion. This clinical case demonstrates necessity of providing examination aimed at malignancy excluding for early neoplasm’s detecting for patients with vasculitis.
目的:报道一例多形白细胞破裂性血管炎(PLCV)合并肾肿瘤的临床病例。材料和方法。患者K.，一名男性，67岁，因心脏主诉和心力衰竭失代偿症状，严重呼吸功能不全伴右下叶肺炎入住n.i. Pirogov国立第一临床医院第二外科。除了心功能评估和肺炎治疗外，还进行了鉴别诊断研究，以阐明全身血管炎、副肿瘤综合征(包括血液学问题和败血症)中溃疡性坏死性皮疹的发生。在临床检查和免疫诊断中未发现系统性结缔组织疾病和全身性血管炎。腹部及腹膜后间隙多螺旋增强ct显示左肾潜伏恶性肿瘤Т2аN1M0。PLCV被认为是与恶性肿瘤相关的副肿瘤综合征。由于血管炎的进展和患者拒绝手术治疗，给予GC 0.5 mg / kg / d，结果观察到阳性动力学。本病例说明对血管炎患者进行恶性排除检查以早期发现肿瘤的必要性。
{"title":"A case of polymorphic leukocytoclastic vasculitis associated with renal neoplasia","authors":"A. Klimenko, N. Shostak, A. Gaffarova, A. Kondrashov, E. Schmidt","doi":"10.17650/1818-8338-2022-16-4-k669","DOIUrl":"https://doi.org/10.17650/1818-8338-2022-16-4-k669","url":null,"abstract":"Objective: to describe a clinical case of polymorphic leukocytoclastic vasculitis (PLCV) associated with renal neoplasia.Materials and methods. Patient K., a man, 67 y. o., was admitted to the surgical department No. 2 of the N. I. Pirogov State Clinical Hospital No. 1 with cardiac complaints and heart failure decompensation symptoms, severe respiratory insufficiency associated right lower lobe pneumonia. Besides cardiac function evaluation and pneumonia managing there was a conducting of differential diagnostic search to clarify the genesis of ulcerative necrotic rashs among systemic vasculitis, paraneoplastic syndrome including hematologic problems and sepsis.Results. It was no data for systemic connective tissue diseases and systemic vasculitis during clinical examination and immunological diagnostics. On contrast-enhanced multispiral computed tomography of abdomen and retroperitoneal space there was latent malignant neoplasia of left kidney Т2аN1M0. PLCV was considered to paraneoplastic syndrome associated with malignancy. Due to the progression of vasculitis and the patient’s refusal of surgical treatment was prescribed GC 0.5 mg / kg / day as a result positive dynamics was noted.Conclusion. This clinical case demonstrates necessity of providing examination aimed at malignancy excluding for early neoplasm’s detecting for patients with vasculitis.","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42408528","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-02-09DOI: 10.17650/1818-8338-2022-16-4-k673
A. V. Novikova, N. Pravdyuk, E. Shmidt, A. Raksha, M. R. Mazra, A. R. Yunyaev, J. S. Zhulina
Introduction. One of the distinguishing features of systemic vasculitis is their manifestation under the guise of a lesion of one or another organ system, which is often multi-organ in nature with signs of systemic inflammation. The latter is interpreted primarily as part of an infectious or paraneoplastic process, which causes a delay in the diagnosis.The aim of the study was to present the diversity of the clinical picture in vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA), the speed and large volume of diagnostic measures with the effective cooperation of therapeutic and surgical specialists, radiologists on the way to verifying granulomatosis with polyangiitis in a young woman.Materials and methods. Patient K., 46 y. o., was hospitalized in the Otolaryngology Department of the N.I. Pirogov City Clinical Hospital No. 1 of the Moscow Health Department with complaints of hearing loss, pain and stuffiness in the left ear, unproductive cough, hoarseness and fever up to 38.5 °C. According to the radiography (RG) of the chest organs, right-sided pneumonia was detected. Conducted antibiotic therapy without effect. As part of the differential diagnostic search, the following nosologies were excluded: infective endocarditis, sepsis, tuberculosis, primary multiple or central lung cancer complicated by paracancer pneumonia, metastatic lesion, infectious, brucellosis spondylodiscitis.Results. In the blood test, attention was drawn to a decrease in the level of hemoglobin to 111 g / l, an increase in the rate of erythrocyte sedimentation to 45 mm / h and the level of C-reactive protein to 142 mg / l, microhematuria according to the general urine analysis. Instrumental research methods – RG of 16.02.22, MSCT of the chest organs on 17.02.22, 27.02.22, 10.03.22 showed progressive bilateral focal pneumonia with a focus of consolidation in the middle lobe, EchoCG, ultrasound of the abdominal cavity and small pelvis, RG of the temporal bone, bronchoscopy with bronchoalveolar lavage and microscopic analysis, for atypia and bacteriological culture. A gynecological examination and a smear from the cervical canal for microscopic analysis were performed, atypical cells, consulted by a phthisiatrician (no data for tuberculosis), consulted three times by a thoracic surgeon (exclusion of volumetric formation of the middle lobe of the right lung). Given the history and clinical presentation (female gender, young age, bilateral otitis media, hoarseness, and destructive nature of pneumonia), granulomatosis with polyangiitis was suspected, and tests for ANCA were prescribed. A transthoracic biopsy of the right lung was performed. A rheumatologist prescribed induction pulse therapy with corticosteroids, and after serological and histological confirmation (antibodies to Proteinase-3 Anti-PR3 > 200 IU / ml, productive pneumonitis, granulomas without signs of tuberculosis), immunosuppressive therapy with cyclophosphamide. Against the background of pathog
介绍。全身性血管炎的一个显著特征是其表现在一个或另一个器官系统病变的幌子下，这通常是多器官的性质，具有全身性炎症的迹象。后者主要被解释为感染或副肿瘤过程的一部分，导致诊断延误。该研究的目的是展示与抗中性粒细胞细胞质抗体(ANCA)相关的血管炎的临床表现的多样性，在治疗和外科专家的有效合作下，快速和大量的诊断措施，放射科医生在验证年轻女性肉芽肿病合并多血管炎的过程中。材料和方法。患者K.， 46岁，住在莫斯科卫生部N.I. Pirogov市第一临床医院耳鼻喉科，主诉听力丧失，左耳疼痛和充血，咳嗽无效，声音嘶哑，发烧高达38.5°C。根据胸部器官x线片(RG)，发现右侧肺炎。抗生素治疗无效。作为鉴别诊断搜索的一部分，排除了以下疾病:感染性心内膜炎、败血症、结核病、原发性多发性或中枢性肺癌合并癌旁肺炎、转移性病变、感染性布鲁氏菌病脊柱炎。在血液检查中，注意到血红蛋白水平下降到111 g / l，红细胞沉降率增加到45 mm / h, c反应蛋白水平下降到142 mg / l，根据一般尿液分析出现微量血尿。仪器研究方法:16.02.22 RG, 17.02.22、27.02.22、10.03.22胸部脏器MSCT示进行性双侧局灶性肺炎，中叶病灶实变，超声心动图，腹腔及小骨盆超声，颞骨RG，支气管镜伴支气管肺泡灌洗及镜检，异型及细菌学培养。进行了妇科检查和宫颈管涂片进行显微镜分析，非典型细胞，咨询了一位肺结核医生(没有结核病的资料)，咨询了三次胸外科医生(排除右肺中叶的体积形成)。考虑到病史和临床表现(女性、年轻、双侧中耳炎、声音嘶哑和肺炎的破坏性)，怀疑肉芽肿病合并多血管炎，并开具了ANCA检查。行右肺经胸活检。一位风湿病医生开了糖皮质激素诱导脉冲治疗，在血清学和组织学证实后(蛋白酶-3抗pr3抗体> 200 IU / ml，生产性肺炎，无结核迹象的肉芽肿)，环磷酰胺免疫抑制治疗。在病理治疗的背景下，注意到明显的临床和实验室效果。在这种临床情况下，各种专家同时参与，进行了大量的实验室和仪器动力学研究，没有延迟组织学验证，可以快速排除人群中的常见疾病和疑似全身性血管炎，在住院期的5周内建立正确的诊断。
{"title":"Case of granulomatosis with polyangiitis: optimal possibilities for rapid diagnosis in a multidisciplinary hospital","authors":"A. V. Novikova, N. Pravdyuk, E. Shmidt, A. Raksha, M. R. Mazra, A. R. Yunyaev, J. S. Zhulina","doi":"10.17650/1818-8338-2022-16-4-k673","DOIUrl":"https://doi.org/10.17650/1818-8338-2022-16-4-k673","url":null,"abstract":"Introduction. One of the distinguishing features of systemic vasculitis is their manifestation under the guise of a lesion of one or another organ system, which is often multi-organ in nature with signs of systemic inflammation. The latter is interpreted primarily as part of an infectious or paraneoplastic process, which causes a delay in the diagnosis.The aim of the study was to present the diversity of the clinical picture in vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA), the speed and large volume of diagnostic measures with the effective cooperation of therapeutic and surgical specialists, radiologists on the way to verifying granulomatosis with polyangiitis in a young woman.Materials and methods. Patient K., 46 y. o., was hospitalized in the Otolaryngology Department of the N.I. Pirogov City Clinical Hospital No. 1 of the Moscow Health Department with complaints of hearing loss, pain and stuffiness in the left ear, unproductive cough, hoarseness and fever up to 38.5 °C. According to the radiography (RG) of the chest organs, right-sided pneumonia was detected. Conducted antibiotic therapy without effect. As part of the differential diagnostic search, the following nosologies were excluded: infective endocarditis, sepsis, tuberculosis, primary multiple or central lung cancer complicated by paracancer pneumonia, metastatic lesion, infectious, brucellosis spondylodiscitis.Results. In the blood test, attention was drawn to a decrease in the level of hemoglobin to 111 g / l, an increase in the rate of erythrocyte sedimentation to 45 mm / h and the level of C-reactive protein to 142 mg / l, microhematuria according to the general urine analysis. Instrumental research methods – RG of 16.02.22, MSCT of the chest organs on 17.02.22, 27.02.22, 10.03.22 showed progressive bilateral focal pneumonia with a focus of consolidation in the middle lobe, EchoCG, ultrasound of the abdominal cavity and small pelvis, RG of the temporal bone, bronchoscopy with bronchoalveolar lavage and microscopic analysis, for atypia and bacteriological culture. A gynecological examination and a smear from the cervical canal for microscopic analysis were performed, atypical cells, consulted by a phthisiatrician (no data for tuberculosis), consulted three times by a thoracic surgeon (exclusion of volumetric formation of the middle lobe of the right lung). Given the history and clinical presentation (female gender, young age, bilateral otitis media, hoarseness, and destructive nature of pneumonia), granulomatosis with polyangiitis was suspected, and tests for ANCA were prescribed. A transthoracic biopsy of the right lung was performed. A rheumatologist prescribed induction pulse therapy with corticosteroids, and after serological and histological confirmation (antibodies to Proteinase-3 Anti-PR3 > 200 IU / ml, productive pneumonitis, granulomas without signs of tuberculosis), immunosuppressive therapy with cyclophosphamide. Against the background of pathog","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44637259","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-02-09DOI: 10.17650/1818-8338-2022-16-4-k671
N. Asfandiyarova, E. Philippov, O. V. Dashkevich, A. G. Iakubovskaia, K. A. Moseichuk, N. S. Zhuravleva, S. A. Kulikov, E. N. Fedyaeva
Aim: to study risk factors of development of the post-COVID syndrome (PCS).Material and methods. 210 patients with a history of new coronavirus infection (COVID-19) (47 men, 163 women aged 18–85 years) were examined by doctors of various specialties. Patients were divided into several groups depending on the presence of PCS, as well as the severity of the disease.Results. The risk factors of the PCS development are moderate and severe course of the pathological process in acute period of COVID-19 disease (p < 0.001). In women, PCS is seen more often than in men (30 / 135 vs. 17 / 28, p < 0 / 001), other risk factors are age over 50 years (p < 0.05), polymorbidity (p < 0.01), treatment with glucocorticoids in acute disease period (76 / 165 vs. 4 / 45, p < 0.001). In cases of mild COVID-19 course, neither age nor polymorbidity increased the risk of PCS development (p > 0.05), however a dysfunction of cellular immunity was significant, specifically the proliferative activity of lymphocytes in response to mitogen: 50.6 ± 10.4 % vs. 54.0 ± 5.1 %, p < 0.05). In cases of severe COVID-19 course, the gender differences and dysfunction of the cellular immune system are not the determinants for the PCS development (p > 0.05), however the age (56.7 ± 13.1 years vs. 42.1 ± 15.4 years, p < 0.01) its linkage to somatic pathology (a cardiovascular disease) besides glucocorticoids threatment (64 / 89 vs. 3 / 9, p < 0.05) are important risk factors for PCS.Conclusions. The main risk factor for PCS development is the moderate and severe course of the pathological process in the acute period of COVID-19 infection, female gender, age over 50 years, polymorbidity, treatment with glucocorticoids in the disease acute period. In case of mild COVID-19 course, neither age nor the polymorbidity increased the risk of PCS development, but the dysfunction of cellular immunity is significant. In case of severe COVID-19, the gender differences and dysfunction of the cellular immune system are not the determinants for the PCS development, however age, concomitant somatic pathology (a cardiovascular disease) and glucocorticoids treatment in acute period are important risk factors for the PCS development. The titer of protective IgG class antibodies to SARS-CoV-2 is not linked to risk of the PCS development.
{"title":"Risk factors for development of the post-COVID syndrome","authors":"N. Asfandiyarova, E. Philippov, O. V. Dashkevich, A. G. Iakubovskaia, K. A. Moseichuk, N. S. Zhuravleva, S. A. Kulikov, E. N. Fedyaeva","doi":"10.17650/1818-8338-2022-16-4-k671","DOIUrl":"https://doi.org/10.17650/1818-8338-2022-16-4-k671","url":null,"abstract":"Aim: to study risk factors of development of the post-COVID syndrome (PCS).Material and methods. 210 patients with a history of new coronavirus infection (COVID-19) (47 men, 163 women aged 18–85 years) were examined by doctors of various specialties. Patients were divided into several groups depending on the presence of PCS, as well as the severity of the disease.Results. The risk factors of the PCS development are moderate and severe course of the pathological process in acute period of COVID-19 disease (p < 0.001). In women, PCS is seen more often than in men (30 / 135 vs. 17 / 28, p < 0 / 001), other risk factors are age over 50 years (p < 0.05), polymorbidity (p < 0.01), treatment with glucocorticoids in acute disease period (76 / 165 vs. 4 / 45, p < 0.001). In cases of mild COVID-19 course, neither age nor polymorbidity increased the risk of PCS development (p > 0.05), however a dysfunction of cellular immunity was significant, specifically the proliferative activity of lymphocytes in response to mitogen: 50.6 ± 10.4 % vs. 54.0 ± 5.1 %, p < 0.05). In cases of severe COVID-19 course, the gender differences and dysfunction of the cellular immune system are not the determinants for the PCS development (p > 0.05), however the age (56.7 ± 13.1 years vs. 42.1 ± 15.4 years, p < 0.01) its linkage to somatic pathology (a cardiovascular disease) besides glucocorticoids threatment (64 / 89 vs. 3 / 9, p < 0.05) are important risk factors for PCS.Conclusions. The main risk factor for PCS development is the moderate and severe course of the pathological process in the acute period of COVID-19 infection, female gender, age over 50 years, polymorbidity, treatment with glucocorticoids in the disease acute period. In case of mild COVID-19 course, neither age nor the polymorbidity increased the risk of PCS development, but the dysfunction of cellular immunity is significant. In case of severe COVID-19, the gender differences and dysfunction of the cellular immune system are not the determinants for the PCS development, however age, concomitant somatic pathology (a cardiovascular disease) and glucocorticoids treatment in acute period are important risk factors for the PCS development. The titer of protective IgG class antibodies to SARS-CoV-2 is not linked to risk of the PCS development.","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44984967","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-02-08DOI: 10.17650/1818-8338-2022-16-4-k670
N. V. Bunchuk
An analysis of causes leading to pain recurrence in patients with polymyalgia rheumatica (PR) after tapering down the dose of glucocorticosteroids (GCS) is presented. True exacerbations resulting from the main disease recurrence and pseudo-exacerbations when the resumption of pain syndrome is not due inflammation but because of other causes – steroid myopathy or chronic adrenal insufficiency (AI) are identified. The experience of using tocilizumab, an inhibitor of interleukin-6 receptors, as steroid-sparing agent in patients with PR is considered. The factors contributing to pain syndrome development, which can mimic exacerbations of PR (associated myofascial pain, vitamin D deficiency, etc.) are indicated. The methodology for AI diagnosis in patients receiving GCS therapy is discussed in detail. Recommendations for the rational AI therapy including acute cases are given.
{"title":"Relapses of pain syndrome in patients with polymyalgia rheumatica during reduction of glucocorticoid therapy","authors":"N. V. Bunchuk","doi":"10.17650/1818-8338-2022-16-4-k670","DOIUrl":"https://doi.org/10.17650/1818-8338-2022-16-4-k670","url":null,"abstract":"An analysis of causes leading to pain recurrence in patients with polymyalgia rheumatica (PR) after tapering down the dose of glucocorticosteroids (GCS) is presented. True exacerbations resulting from the main disease recurrence and pseudo-exacerbations when the resumption of pain syndrome is not due inflammation but because of other causes – steroid myopathy or chronic adrenal insufficiency (AI) are identified. The experience of using tocilizumab, an inhibitor of interleukin-6 receptors, as steroid-sparing agent in patients with PR is considered. The factors contributing to pain syndrome development, which can mimic exacerbations of PR (associated myofascial pain, vitamin D deficiency, etc.) are indicated. The methodology for AI diagnosis in patients receiving GCS therapy is discussed in detail. Recommendations for the rational AI therapy including acute cases are given.","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41536193","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-01-15DOI: 10.17650/1818-8338-2022-16-3-k674
N. Shostak, N. Pravdyuk, A. V. Novikova
Back pain (BP) is a major public health problem worldwide with high prevalence and disability. In most cases are associated with degenerative spinal disease (degenerative disc disease, DDD), myofascial syndrome, facet joint syndrome, spinal spondylosis, scoliotic deformation, sacroilial joint dysfunction, lumbar stenosis and other causes. The article describes the basics of the doctor’s approach to the diagnosis of back pain, describes the main strategies of patients routing. The algorithm proposed here includes detection of dangerous conditions, verification of inflammatory rhythm of BP according to criteria ASAS 2009, revealing of persistent phenotype of the lower back pain, stratifying patients for the risk of chronic lower back pain StarT Back in mechanical rhythm; multidisciplinary approach with inclusion of the rheumatologist in specialists team, and after initial consultation the therapist gives direction to the rheumatologist, if necessary. A therapist who treats a patient with persistent BS and a high risk of chronization without symptoms of “red flags” should prescribe an magnetic resonance imaging of the spine. The detection of total lesion of the vertebral motor segments in the case of severe back pain is the basis for the diagnosis of spinal osteoarthritis and subsequent prescription of non-medicamentous and pharmacological therapy, including SYSADOA, in particular Alflutop. The developed algorithm allows to quickly diagnose spinal osteoarthritis at a young age and to suspect axial spondylitis. Presented triad of MR-traits associated with persistent phenotype pain, which will help the therapist to establish the diagnosis of spinal osteoarthritis. The algorithm clearly describes the routing of patients to related specialists (rheumatologist, neurologist, etc.) according to the identified data.
{"title":"Back pain in young people: algorithm of management in practice of primary physician","authors":"N. Shostak, N. Pravdyuk, A. V. Novikova","doi":"10.17650/1818-8338-2022-16-3-k674","DOIUrl":"https://doi.org/10.17650/1818-8338-2022-16-3-k674","url":null,"abstract":"Back pain (BP) is a major public health problem worldwide with high prevalence and disability. In most cases are associated with degenerative spinal disease (degenerative disc disease, DDD), myofascial syndrome, facet joint syndrome, spinal spondylosis, scoliotic deformation, sacroilial joint dysfunction, lumbar stenosis and other causes. The article describes the basics of the doctor’s approach to the diagnosis of back pain, describes the main strategies of patients routing. The algorithm proposed here includes detection of dangerous conditions, verification of inflammatory rhythm of BP according to criteria ASAS 2009, revealing of persistent phenotype of the lower back pain, stratifying patients for the risk of chronic lower back pain StarT Back in mechanical rhythm; multidisciplinary approach with inclusion of the rheumatologist in specialists team, and after initial consultation the therapist gives direction to the rheumatologist, if necessary. A therapist who treats a patient with persistent BS and a high risk of chronization without symptoms of “red flags” should prescribe an magnetic resonance imaging of the spine. The detection of total lesion of the vertebral motor segments in the case of severe back pain is the basis for the diagnosis of spinal osteoarthritis and subsequent prescription of non-medicamentous and pharmacological therapy, including SYSADOA, in particular Alflutop. The developed algorithm allows to quickly diagnose spinal osteoarthritis at a young age and to suspect axial spondylitis. Presented triad of MR-traits associated with persistent phenotype pain, which will help the therapist to establish the diagnosis of spinal osteoarthritis. The algorithm clearly describes the routing of patients to related specialists (rheumatologist, neurologist, etc.) according to the identified data.","PeriodicalId":82998,"journal":{"name":"The Clinician","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42637186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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