Monday, December 16, 2013

Autoantibodies commonly associated with Systemic Lupus Erythematosus (SLE)

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem inflammation and the presence of circulating autoantibodies directed against self-antigens.Read about ACR criteria for diagnosis of SLE.

The table below illustrates the antibodies associated with various risks in SLE. This is impotant table and a frequent MCQ question as well.

Anti–double-stranded DNA Correlates with disease activity, especially nephritis, in some with SLE
Anti-Smith antibody Specific for the diagnosis of SLE
Anti-ribonucleoprotein antibody
Increased risk for Raynaud phenomenon and pulmonary hypertension
High titer may suggest diagnosis of mixed connective tissue disorder
Anti-Ro antibody (anti-SSA antibody)
Anti-La antibody (anti-SSB antibody)

Associated with sicca syndrome
May suggest diagnosis of Sjogren syndrome
Increased risk of neonatal lupus in offspring (congenital heart block)
May be associated with cutaneous and pulmonary manifestations of SLE
May be associated with isolated discoid lupus
Antiphospholipid antibodies (including anticardiolipin antibodies) Increased risk for venous and arterial thrombotic events
Antihistone antibodies
Present in a majority of patients with drug-induced lupus
May be present in SLE

Monday, December 2, 2013

Tuberculosis in children- Treatment Regimen NTP

DOTS (Directly Observed Treatment, Short-course),  the World Health Organization-recommended tuberculosis control strategy follow the following regimens in treatment of tuberculosis in adult patients compared to children. Nepal Tuberculosis Protocol has been devised for use in TB treatment in Nepal.

Tuberculosis is a prevalent disease in the developing countries with severe consequences specially in children who are more likely to develop dissemination.

Treatment consits of 2 phases-

Initial Intensive Phase- Duration is generally 2 months and it achieves rapid killing of mycobacteria. Infectious patients are rendered non-infectious by 2 weeks. Majority of patients turn sputum positive to negative by 2 months of therapy. DOTS currently focuses more on Intensive phase as the drug resistance likelihood is higher at this phase when mycobateria are more.

Continuation phase- Usually 4-5 months durations. Fewer drugs are used but for a longer duration in this phase. Drugs eliminate the remaining bacilli including persister thus preventing TB repalse. If DOTS is not possible in this phase a close supervision is instituted.

Standard code of Treatment-
Each ATT drug has an abbreviation namely-
Isoniazid- H
Rifampicin- R

And two phases as described earlier.

Category 1- new sputum smear-positive PTB,sputum negative PTB and extra pulmonary TB.
Category 2 -relapse,treatment failure,treatment after default (interrupted treatment)

Severe Extra pulmonary TB- meningitis, miliary, pericarditis, peritonitis,, bilateral or extensive  pleural effusion, spinal , intestinal , genitor-urinary.
Less Severe Extrapulmonary TB-lymph node,pleural effusion (unilateral),bone (excluding spine), peripheral joint,adrenal gland

Following regimen is recommended by Nepal Tuberculosis Protocol- Click for full image

For Children combination packs have been developed as per weight wise catergory-

The regimens are modified in various Tuberculosis like TB meningitis, TB spine etc. Special scenarios require steroid at the start of therapy-
1. TB Meningitis
2.TB Pericarditis
3.TB Pleural effusion
4. Hypoadrenalism
5.TB laryngitis
6. Severe hypersensitivity reactions to ATT drugs
7.Renal tract TB
8. Massive lymphnode enlargement with compressive effect.

Steroid is given in TBM for 4 weeks then tapered, 8 weeks and tapered in TB pericarditis and 2 weeks in TB pleural effusion.