The use of prostaglandin E2 vaginal pessaries in the treatment ofintractable late ... normally to ripen the cervix before induction of labour, hence, the side-effects ...
Journal of the Royal Society of Medicine Volume 82 August 1989 uterine segment was performed to exclude the possibility of any retained products, dehiscent scar or uterine rupture. There was moderate uterine atony with no Tesponse to uterine massage. Bleeding continued and the estimated blood loss was 800 mL Prostaglandin E2 suppository (3 mg) was inserted trans-cervically and was held against the, uterine wall for a few minutes. An immediate tetanic contraction was produced and mairntained andthe bleeding ceased. The postoperative recovery was uneventful and haemoglobin concentration-was 10A gidl. Histology reported inflamed degenerate decidua and blood clots, but no chorionic villi were seen. The patient was discharged to the care of her own doctor on oral iron treatment. Discussion The use of prostaglandin E2 vaginal pessaries in the treatment ofintractable late onset postpartum haemorrhage has been reported previously'. Bleeding subsided almost completely within 20 min of insertion. Post-insertion nausea, vomiting, abdominal cramps and fever necessitated medical treatment. In another study prostaglanoi`n'2 alpha, (intracervical and intramyometrial injection) was iused in the management of secondary postpartuin ha~morrhage2. Response was within 3 min, with uterine cramps that lasted for 30 min and intense headache that lasted for about 10 mnin Nausea and vomiting followedcthe initiation of headache and lasted for about half an hour. No medical treatment was given. Intravenous prostaglandin E2 has been shown to be successful in arresting uterine bleeding that is refractory to the routine oxytocics. The occurrence of diarrhoea and vomiting is an unwanted effect which has been noted3. The intrauterine insertion of prostaglandin E2 suppository in this case showed an obvious advantage of prompt arrest of bleeding and a long lasting uterine contraction. Although there were no reported side-effects in this case it is to be noted
Lupus anticoagulant in psoriatic-type arthropathy
C A Bowman MA mRCP M Greaves MRCP MRCPath Departments of Genitourinary Me;dicine and Haematology, Royal Hallamshire Hospital, Sheffield
J P Tullett MB ChB
Keywords: lupus anticoagulant; psoriatic-type arthropathy
We describe two cases of psoriatic arthropathy, associated with a false positive venereal disease research laboratory test (VDRL) and the presenc of lupus anticoagulant. We believe this is the- first time this association has been reported. This provides further evidence for the role of immunological factors in psoriatic arthropathy.-
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that the patient was under the effect of the general anaesthetic. The total dosage is not more than that used normally to ripen the cervix before induction of labour, hence, the side-effects are not expected to be different. An account needs to be made of the simultaneous use of Syntocinon intravenous infusion, as prostaglandins are known to increase the Syntocinon receptors and enhance the uterine contraction. The method seems to be.more simple and less invasive than the intravenous or intrauterine injection and- there is a quicker response than with the intravaginal insertion of prostaglandins. A controlled clinical trial would be advantageous to compare the use of prostaglandin intravenous injection, intrauterine injection, intravaginal suppositories andintrauterine suppositories-in the treatment of postpartum haemorrhage. A record would need to be made ofthe latent period between the use of the drug and the initiation of the uterine contractions, the minimal effective dose and the side-effects with each route. Since a statisticallysignificain number of patients may be difficult to obtain, -a multicentre study would seem appropriate. References 1 Goldstein AL, Kent DR, David A. Prostaglandin E2 vaginal suppositories in the treatment of intractable late onset postpartum hemorrhage. J Reprod Med 1983;2&425-6 2 Andrinopoulos GC, Mendenhall HW: Prostaglandin F2 and in the management of delayed post-partum-haemorrhage. Am J Obstet
Gynecol 1983;146:217-8 3 Henson G, Gough JD, Gillmer MDG. Control of persistent primary post partum haemorrhage due to uterine atony with intravenous prostaglandin E2. Case report. Br J Obstet Gynaecol 1983;90:280-1 (Accepted 27 June 1988)
test was positive at a titre of 1 in 4. Treponema pallidum haemagglutination test (TPHA) and fluorescent treponemal antibody (FTA) test were negative. A normochromic, normocytic anaemia (Hb 9.9 gll, platelets 550x109/1) and elevated. erythrocyte s-dimentation rate 120 mm/h were noted. Serum biochemistry was normal apart from a raised *yGT (82 U/1; normal ra 6-42). Autoantibody screen, ling tests for rheumatoid factor and antinuclear antibody were negative; HLA B27 was negative. Coagulation screening tests were normal. Dilute Russell -viper venomtime was prolonged (71.5 s, control 40.5 s; ratio .1.7X, and wvaoorrected by the addition of washed platelets (ratio 1.03). 'This is indicative of lupus-type anticoagulant -activity. Anticardiolipin antibodywas-detected by enzymelinked immunoassay (IgG 15.0 units, IgM 17.5 units; mean+2 SD in 30 healthy control subjects 5.2 and 4.4 units
respectivelyr)-
Case 2: A 37-year-old man presented with non-specific urethritis, and a recurrence of genital herpes. He also complained of back and leg pains. He was noted to have psriasis affecting the scalp, trunk and genital areas. Arthritic changes were present in all metatarsophalangeal vi Case reports joints and th} proxia intepaangeal joint- of hiia,left. Case 1: A 27-year-old man presented with genitalwart-He had developed psoriasis at 15 years -of age;, symptoms of` -middle finger. Limited spinal movement w;asnoted.-Hi simentation ratewas 7 Autoandlody screen :ryt o psoriatic arthropathy were noted one year'iater. Betwden revealed a negative rheuxhatoid factor,aid a lowtitre anti1977-1987, his knees, ankles, shoulder toes -and distal internuclear antibody (titre 200). HLA B27- was negative. phalangeal joints were affected. Sacroiliitis was present on pelvic X-ray. Examination in September 1987 -reveaed several penile warti, extensive psoriatic plaques on his trunk and -limbs, - His arthritis was consistent with Reiter's disease, with features of psoriatic arthropathyl. A false positive VDRL nail pitting and onycholysis, and an arthropathy affecting (titre I in- 16) was n6ted; TPHA and FTA were, negative. both shoulders and knees,-and the distal- interphalaageal Coagulation screening tests re*ealed a prolonged kaolin-,joints. Medications conisted of iisdomethacin slow release ehalindotting time (KCCT) (526s,control 41 s, laoratory 75 mg daily -and prednisolone 5 tag daily,.Routine VDRL
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Journal of the Royal Society of Medicine Volume 82 August 1989
normal range 32-45 s). Dilute Russell viper venom time was prolonged (45.5 s, control 35 s; ratio 1.3) and was corrected by addition of washed platelets (ratio 1.05) suggesting lupus anticoagulant activity. A low. titre of IgG anticardiolipin antibody was detected (5.6 units). Discussion The VDRL test gives a false positive result in a variety of conditions. Acute false positives occur in some bacterial and viral infections. (Recurrent herpes simplex and papilloma virus are not recognized causes of false- positive VDRL.) Chronic false positives may be due to autoimmune disease and may precede symptoms by years2J. Lupus-type anticoagulant activity is due to the presence in plasma of antibody with-reactivity against the holipid component of the prothrombin activator complex. It may result in prolongation of thromboplastin-dependent coagulation times (e.g. KCCT-), but the dilute Russell viper venom time is a more sensitive test for the presence of the abnormality. Anticardiolipin -activity may be detectable in association with lupus-type anticoagulant. Both have been described in a variety of clinical situations including collagen vascular disease, recurrent thrombosis, recurrent spontaneous abortion, as a drug-related phenomenon as well as in otherwise healthy subjects. Psoriatic arthropathy (case 1) and psoriatic arthropathy with Reiter's disease (case 2) were diagnosed on clinical, serological and radiological findings. Investigations did not support a diagnosis of connective tissue disorder in either patient. There is only one other report of anticardiolipin antibodies in psoriatic arthropathy4 (three out of 11 patients [28%]
Non-axial proptosis without diplopia secondary to maxillary pyomucocele
J F Sharp MA MB ChB Department of Ear, Nose and Throat Surgery, Selly Oak Hospitl, Raddlebarn Road, Birmingham B29 6JD Keywords: pyomucocele; non-axial proptosis
Localized bony erosion, secondary to extensive maxillary mucocele is rare'. The differential diagnoss include carcinoma and pyomucocele. A large pyomucocele causing inferior orbital plate destruction with propsis is described. Diplopia was not a presenting complaint as the contralateral eye was blind. The lesion was successfully treated via a Caldwell-Luc incision and intranasal antrostomy. The possible role of trauma, accidental or surgical, in predisposing to maxillary mucocele is discussed.
Case report A previously fit 64-yearoldman prese witedwih a four month history of right sided epiphora andan -iatednon-tendr, unilateral, maxillary lling. Therewas no history of any nasal or maxillary surg and-he had never -uffered-any facial trauma. The vision in his left eye, *s seerely restricted by cataract. Examination confirmed the presence of the right sided, firm, smooth, maxillary swelling which was non tender. Upward displacement of -the right eye, with a mn-axial proptosis was also apparent. However, diplopia was not present because of the left sided cataract. The upper alveolar
were positive). VDRL and lupus anticoagulant status were not documented in these patients. The presence of lupus anticoagulant and anticardiolipin antibodies are suggestive of an autoimmune process. There is already some evidence to suggest that immunological factors may play a pathological role in psoriasis5. There is also evidence that immunological (and immunogenetic) factors are involved in the pathogenesis of the arthritis of Reiter's disease and of psoriasis. The association between lupus anticoagulant, anticardiolipin antibodies and a psoriatic arthropathy provide further evidence to support this theory. Acknowledgments: We are grateful to Dr J M H Moll (Consultant Rheumatologist), Dr R S Amos (Consultant Rheumatologist) and Dr G R Kinghorn (Consultant Genitourinary Physician) for their assistance in the preparation df this manuscript.
References 1 Wright V, Reed WB. The link between Reiter's syndrome and psoriatic arthritis. Ann Rheum Dis 1964;2:12-21 2 Wuepper KD, Bodily HL, Tuffanelli DL. Serologic tests for syphilis and the false positive reaction. Arch Derm 1966;94:152-5 3 Haseick JR, Long R. Sysemic lupus erythematos preceded by false positive tests for syphilis. Ann Intern Med 1952;37:569-65 4 lort JG, Gowchock FS, Abruzzo JL, Smith JB. Anticadiolipin antibodies in patients with rheumatic dies. Arthritis Rheum 1987;30.752-60 5 Rowland Payne CME. Psoriatic science. Br Med J 1987;26: 1158-9
(Accepted 6 July 1988)
margin was intact and palatal examination was normal. The patient had a deviated nasal septum but no lateral nasal abnormality was noted. There was no cervical lymphadenopathy. Sinus X-ray views showed destruction of the right antral roof (Figure 1). The patient was taken to theatre and after prnasal, antral puncture, mucopus was apparent with an asociated immediate resolution of the right cheek mass. The right antrum was formally entered, via a Caldwell-Luc incision. The anterior antral wall and bony orbital floor were not present. The antral mucosa was biopsied and an inrnasal antm y fashioned. The sinus was then packed. Histological examination of the biopsy material showed respiratory epithelium and fibrous connective tissue, with alight inflammatory infiltrate, overying bone. No evidence of malignancy was found. The patient made an uneventful postoperative recovery and at follow-up shows no signs of recurrence.
Discussion Paranasal mucoceles, mucus filled epithelial lined lesions within sinus- cavities, were first described in 17252. Conventionally mucoceles;occur most fiequently within the frontal and ethmoidal sinuses, in a ratio of 2::1. The disovery of sphenoidal or maxillary mucoceles is rare. The true incidence of maxillary mucoceles is debated, the figure of 3% of Natvig and Larsen' contrasts with the one of 10% found by Som and Shuga5, aittedly with the use of CT scanning to demonstrate smaller keions. The natural history of mu i that of slow, but urnemitting, growth. Expanding lesions within themaxillary antrum classically present with a combinationof nasal, dental, orbital and or frontalsymptoma, dependent upon the direction of spread. In this eas- the patient was effectively umocular and the nonjaxial proptosis caused by orbital; spr-ead did not induce diplopi -The delayed preeting-. omplaint was one of facial asymmetry aWd
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