Granulomatous Mastitis with Erythema Nodosum That Responded to Low-Dose Steroid: Case Report and Literature Review of Nine Patients

A 31-year-old woman was referred with a painful mass in the left breast that was initially treated with antibiotics. Three weeks later, the mass had increased and polyarthritis and erythema nodosum had developed in both legs. A core needle biopsy led to a diagnosis of granulomatous mastitis with arthritis and erythema nodosum. Low-dose prednisolone (10 mg) rapidly improved the arthritis and the erythema nodosum. Granulomatous mastitis is a very rare, chronic inflammatory disease and only nine patients with granulomatous mastitis with erythema nodosum have been described. We reviewed the literature to determine the clinicopathological features and treatment of granulomatous mastitis. Appropriate diagnosis and steroid therapy should result in excellent outcomes.

Clinical features of gastroduodenal injury associated with long-term low-dose aspirin therapy

Low-dose aspirin(LDA) is clinically used for the prevention of cardiovascular and cerebrovascular events with the advent of an aging society.On the other hand,a very low dose of aspirin(10 mg daily) decreases the gastric mucosal prostaglandin levels and causes significant gastric mucosal damage.The incidence of LDAinduced gastrointestinal mucosal injury and bleeding has increased.It has been noticed that the incidence of LDA-induced gastrointestinal hemorrhage has increased more than that of non-aspirin non-steroidal anti-inflammatory drug(NSAID)-induced lesions.The pathogenesis related to inhibition of cyclooxygenase(COX)-1 includes reduced mucosal flow,reduced mucus and bicarbonate secretion,and impaired platelet aggregation.The pathogenesis related to inhibition of COX-2 involves reduced angiogenesis and increased leukocyte adherence.The pathogenic mechanisms related to direct epithelial damage are acid back diffusion and impaired platelet aggregation.The factors associated with an increased risk of upper gastrointestinal(GI) complications in subjects taking LDA are aspirin dose,history of ulcer or upper GI bleeding,age > 70 years,concomitant use of non-aspirin NSAIDs including COX-2-selective NSAIDs,and Helicobacter pylori(H.pylori) infection.Moreover,no significant differences have been found between ulcer and non-ulcer groups in the frequency and severity of symptoms such as nausea,acid regurgitation,heartburn,and bloating.It has been shown that the ratios of ulcers located in the body,fundus and cardia are significantly higher in bleeding patients than the ratio of gastroduodenal ulcers in patients taking LDA.Proton pump inhibitors reduce the risk of developing gastric and duodenal ulcers.In contrast to NSAIDinduced gastrointestinal ulcers,a well-tolerated histamine H2-receptor antagonist is reportedly effective in prevention of LDA-induced gastrointestinal ulcers.The eradication of H.pylori is equivalent to treatment with omeprazole in preventing recurrent bleeding.Continuous aspirin therapy for patients with gastrointestinal bleeding may increase the risk of recurrent bleeding but potentially reduces the mortality rates,as stopping aspirin therapy is associated with higher mortality rates.It is very important to prevent LDA-induced gastroduodenal ulcer complications including bleeding,and every effort should be exercised to prevent the bleeding complications.

Small-bowel mucosal injuries in low-dose aspirin users with obscure gastrointestinal bleeding

AIM: To investigate the clinical differences between small intestinal injuries in low-dose aspirin(LDA) users and in non-steroidal anti-inflammatory drug(NSAID) users who were examined by capsule endoscopy(CE) for obscure gastrointestinal bleeding(OGIB). METHODS: A total of 181 patients who underwent CE for OGIB were included in this study. Based on clinical records, laboratory data such as hemoglobin levels, major symptoms, underlying diseases, the types and duration of LDA and NSAID use, and endoscopic characteristics of CE were reviewed.RESULTS: Out of a total of 45 cases of erosive lesions, 27 cases were taking LDA or NSAIDs(7 were on NSAIDs, 9 were on LDA alone, 9 were on LDA and thienopyridine, and 2 were on LDA and warfarin).The prevalence of ulcers or erosion during chronic use of LDA, LDA and the anti-platelet drug thienopyridine (clopidogrel or ticlopidine), and NSAIDs were 64.3%, 80.0%, and 75.0%, respectively. Erosive lesions were observed predominantly in chronic LDA users, while ulcerative lesions were detected mainly in NSAID users. However, concomitant use of thienopyridine such as clopidogrel with LDA increased the proportion of ulcers. The erosive lesions were located in the whole of the small intestine(jejunum and ileum), whereas ulcerative lesions were mainly observed in the ileum(P < 0.05). CONCLUSION: Our CE findings indicate that chronic LDA users and NSAID users show different types and locations of small-bowel mucosal injuries. The concomitant use of anti-platelet drugs with LDA tends to exacerbate the injuries from LDA-type to NSAID-type injuries.

Helicobacter pylori infection in bleeding peptic ulcer patients after non-steroidal antiinflammatory drug consumption

AIM:To establish the prevalence of Helicobacter pylori (H. pylori ) infection in patients with a bleeding peptic ulcer after consumption of non-steroidal antiinflamma- tory drugs (NSAIDs). METHODS:A very early upper endoscopy was performed to find the source of upper gastrointestinal bleeding and to take biopsy specimens for analysis of H. pylori infection by the rapid urease (CLO) test, histological examination, and bacterial culture. IgG anti-CagA were also sought. The gold standard for identifying H. pylori infection was positive culture of biopsy specimens or contemporary positivity of the CLO test and the presence of H. pylori on tissue sections. RESULTS:Eighty patients, 61 males (76.3%), mean age 61.2 ± 15.9 years, were consecutively enrolled. Forty-seven (58.8%) patients occasionally consumed NSAIDs, while 33 (41.3%) were on chronic treatment with low-dose aspirin (LD ASA). Forty-four (55.0%) patients were considered infected by H. pylori . The infection rate was not different between patients who occasionally or chronically consumed NSAIDs. The culture of biopsy specimens had a sensitivity of 86.4% and a specificity of 100%; corresponding figures for histological analysis were 65.9% and 77.8%, for the CLO test were 68.2% and 75%, for the combined use of histology and the CLO test were 56.8% and 100%, and for IgG anti-CagA were 90% and 98%. The highest accuracy (92.5%) was obtained with the culture of biopsy specimens.CONCLUSION:Patients with a bleeding peptic ulcer after NSAID/LD ASA consumption frequently have H. pylori infection. Biopsy specimen culture after an early upper gastrointestinal tract endoscopy seems the most efficient test to detect this infection.

日本《消化性溃疡循证临床实践指南(2015年)》解读

2015年,日本胃肠病学会修订了消化性溃疡循证临床实践指南。修订的内容包括以下几项:出血性胃和十二指肠溃疡、幽门螺杆菌(Hp)根除治疗、非根除Hp治疗、药物诱发的溃疡、非Hp-非非甾体消炎药(NSAID)溃疡和外科手术治疗。该指南详细陈述了上述内容,是我们临床实践中良好的参考材料。为此,本文对该指南作详细解读。

低剂量短疗程抗胸腺细胞球蛋白治疗肾移植耐激素排斥反应

目的探讨低剂量、短疗程的抗胸腺细胞球蛋白（ATG）治疗肾移植后早期激素耐受性排斥反应的疗效。方法15例肾移植后早期发生的激素耐受性排斥反应患者给予ATG 1mg·kg^-1·d^-1，qod，总疗程4～10d，观察其排斥反应逆转率、术后6mo内排斥反应再次发生率和感染发生率。结果ATG治疗（3．4±1．5）次后，15例患者中12例逆转（80％），肾功能良好；2例（13．3％）治疗有效，未行肾切除；1例（6．67％）无效，血透维持。术后6mo内3例（20％）再次发生排斥反应，3例（20％）术后40d内发生肺部感染。随访期内受体存活率100％。结论低剂量、短疗程的ATG治疗能有效地逆转肾移植后早期激素耐受性排斥反应，且减少了感染及严重并发症的发生机会。

低剂量利妥昔单抗治疗成人激素依赖微小病变肾病综合征的疗效

目的观察低剂量利妥昔单抗(rituximab,RTX)预防成人激素依赖微小病变肾病综合征(steroid-dependent minimal change nephritic syndrome,SDMCNS)复发的疗效。方法回顾性分析2018年11月至2019年12月我院收治且随访时间大于18个月的接受低剂量RTX治疗的8例SDMCNS患者临床检验资料。结果(1)8例患者应用RTX时中位年龄28.5(18~53)岁,在中位24.5(18~28)个月随访中分别有5例、3例间歇使用RTX 0.375 g/m 22剂、3剂。(2)所有患者一年内无复发,其中4例监测CD19+B细胞数增加至绝对值大于6个/μL时重复使用RTX 0.375 g/m 2的SDMCNS患者,至随访期末复发。(3)对比RTX治疗前后一年临床资料发现,8例患者经RTX治疗后激素应用量减少,随访期末维持7.5(0~20)mg/d,其中2例患者停用激素,且复发次数、住院次数及并发症均显著减少。(4)8例患者应用RTX后,除1例患者出现皮疹及皮肤瘙痒外,其余患者无明显不良反应。结论低剂量RTX治疗成人SDMCNS,在监测CD19+B细胞数基础上重复使用RTX,可减少复发同时减少经济支出,且不良反应少。

低剂量与传统剂量糖皮质激素治疗成人原发免疫性血小板减少症疗效和安全性比较

目的 ：比较低剂量与传统剂量糖皮质激素治疗成人原发免疫性血小板减少症（ITP）的疗效和安全性。方法：对2011年1月1日至2013年8月31日在本院就诊的初治和既往激素敏感的复发ITP患者（n=49）给予口服醋酸泼尼松0.5 mg/（kg·d）,治疗3~4周,随后激素缓慢减量。同期接受醋酸泼尼松传统剂量[1 mg/（kg·d）]治疗的患者作为对照组（n=46）。随访资料收集截止期2014年8月31日。动态观察血小板计数,并监测生化指标、出血症状,记录不良事件。结果：低剂量组和传统剂量组治疗总体有效率（ORR）分别为81.6%和82.6%,其中初治的有效率分别为73.0%和80.0%,复发的有效率分别为94.7%和86.7%,2组间均没有统计学差异。2组患者血小板计数达到≥50×109/L和≥100×109/L中位时间均为2周,无统计学差异。血小板计数≥50×109/L维持时间大于6个月和12个月者,低剂量组分别为51.0%和30.6%,传统剂量组分别为45.7%和34.8%,没有统计学差异。2组患者治疗后出血表现均显著改善（均P〈0.000 1）。低剂量组不良事件发生率较低,失眠发生率较传统剂量组显著降低（P〈0.001）。结论：低剂量糖皮质激素治疗成人ITP疗效与传统剂量者相当,患者耐受性好。