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Song of an arthritis investigator.

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1113
CONCISE COMMUNICATIONS
anti-double-stranded DNA. More recently, the primary clinical manifestations were pleuropericardial irritation (chest
pain and pleural effusion) and intermittent arthritis; renal
findings included mild proteinuria (981 mg/day), a creatinine
clearance rate of 75-80 mllminute, and an inactive urinary
sediment. Because of penicillin and sulfonamide allergies,
the patient was prescribed ciprofloxacin for a recurrent
urinary tract infection with Escherichia coli; 1 month earlier,
a 10-day course of ciprofloxacin had been well tolerated.
Within 2 hours after the first dose, the patient developed
pruritus and a sense of incipient bronchospasm. These
symptoms progressed over several hours and, coupled with
myalgias, arthralgias, and frank arthritis, led to emergency
evaluation, treatment with epinephrine and 60 mg of methylprednisolone, and hospitalization. Further evaluation revealed an elevated creatine phosphokinase level (450 units/
dl) but no evidence of an SLE flare. Signs and symptoms
resolved over a 6-day period with tapering doses of methylprednisolone. One month later, in a controlled setting, the
patient was rechallenged with a single dose of noriloxacin
and developed transient pruritus, arthralgias, and myalgias.
Patient 2, a 24-year-old woman, had a 16-year history
of SLE manifested by malar rash, intermittent arthritis,
leukopenia, and positive ANA and LE cell preparations. She
had no evidence of renal disease or central nervous system
involvement. Ciprofloxacin was prescribed for treatment of
a urinary tract infection. Within 48 hours, the patient began
to experience generalized arthralgias in the upper and lower
extremities, which progressed in severity over the next 24
hours. No other signs or symptoms consistent with SLE
activity were evident. Ciprofloxacin was discontinued after
the third day of treatment, and the symptoms resolved over
the next several days.
Patient 3 was a 36-year-old woman with an 11-year
history of SLE manifested by rash, leukopenia, anemia,
nephritis, positive ANA (Fiax Index 3.97), positive
anti-DNA (80 units by radioimmunoassay; normal < 10
units), and low complement levels (CH50 75 mg/dl). She had
active renal disease with relative renal insufficiency (serum
creatinine 5.2 mg/dl) and was being treated with low-dose
prednisone and intermittent intravenous cyclophosphamide.
Several days after a renal biopsy, fever developed and the
patient was treated with ciprofloxacin. Within 24 hours she
experienced incapacitating upper and lower extremity arthralgias and arthritis, prompting hospitalization. Laboratory examination showed normal muscle enzyme levels.
Treatment with 30 mg of intravenous methylprednisolone
daily in divided doses was begun. Ciprofloxacin was discontinued, and the symptoms resolved in 12 hours.
Joint pain, joint stiffness, and generalized achiness
have been described in association with <1% of courses of
ciprofloxacin administration. These symptoms have typi-
cally been mild and have not required treatment. While we
cannot establish a true frequency of musculoskeletal reactions in SLE patients receiving ciprofloxacin, the recognition
of 3 cases within a 12-month period, 2 of which required
hospitalization and a significant increase in corticosteroid
dosage, seems at variance with the literature experience
across a broad spectrum of patients. Even if the frequency of
ciprofloxacin reactions is no different in SLE patients, the
potential for serious reactions that may mimic an acute flare
of SLE activity must be kept in mind.
Eduardo Mysler, MD
Stephen A. Paget, MD
Robert Kimberly, MD
The Hospital for Special Surgery
Cornell University Medical College
New York, N Y
1 . Schacht P, Arcieri G, Branolte J: Worldwide clinical data on
efficacy and safety of ciprofloxacin. Infection 16 (suppl l):S29S43, 1988
2. Ball P: Ciprofloxacin: an overview of adverse experiences. J
Antimicrob Chemother 18 (suppl D):187-193, 1986
3. Schacht P, Arcieri G, Hullman R: Safety of oral ciprofloxacin:an
update based on clinical trial results. Am J Med 87 (suppl
5A:98S-l02S, 1989
4. Reiter C, Pfeiffer M, Hullman R: Safety of ciprofloxacin based on
phase IV studies (“Anwendungsbeobachtung”) in the Federal
Republic of Germany (brief report). Am J Med 87 (suppl 5A):
103S-l06S, 1989
5 . Davis H, McGoodwin E, Reed TG: Anaphylactoid reactions
reported after treatment with ciprofloxacin. Ann Intern Med
111:1041-1043, 1989
Song of an arthritis investigator
To treat the diseases rheumatic
Seldom renders clinicians ecstatic,
For the swelling and heat
In the hands and the feet
Stem from origins quite enigmatic.
But as th’ causes 0’joint inflammation
Become known through experimentation,
Then the cures to divest ’em
Of the pain thak’s distressed ’em
In our patients will cause jubilation.
Joel D. Taurog, MD
University of Texas
Southwestern Medical Center
Dallas, TX
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