The frequency of PJP in SLE patients on cyclophosphamide remains low (0.1588%). Therefore, routine use of trimethoprim-sulfamethoxazole for PJP prophylaxis in SLE patients on cyclophosphamide does not appear to be substantiated by this study, except in those with elevated risk, ie, with severe leucopenia, lymphopenia, high dose corticosteroids, hypocomplementemia, active renal disease, and higher mean SLEDAI score. There is a need for consensus guidelines addressing prophylactic antibiotics in these patients.

Sarcoidosis is a systemic disease characterized by noncaseating granulomas in the involved organs. Neurologic manifestations involving the central and/or peripheral nervous system occur in about 5% of patients. Neurosarcoidosis is often refractory to conventional treatment and therefore more effective treatment options are needed. While the etiology of the disease is still unknown, there is now a better understanding of its pathogenesis on a molecular level. It is clear that tumor necrosis factor-α (TNFα) plays a pivotal role in the development of the granulomas and it is believed to be a key cytokine involved in the pathogenesis of the disease. Taking advantage of this better understanding of disease pathogenesis, anti-TNFα agents are being increasingly used to treat refractory sarcoidosis. We report a patient with refractory neurosarcoidosis who showed dramatic improvement in the clinical and radiological manifestations following treatment with infliximab; he suffered a relapse upon discontinuation of the medication.

Henoch Schonlein purpura is a systemic vasculitis that commonly affects children and teenagers but also affects adults of all ages. In most instances it has a benign course. Organ involvement, particularly in adults, and notably the kidneys and gastrointestinal tract may require therapeutic intervention and may have a less favorable outcome. We report a case of a 58-year-old man who presented with purpura and who rapidly developed catastrophic intestinal vasculitis, leading to his demise.

We investigated the association between seafood consumption and symptoms related to potential mercury toxicity in patients presenting to specialty medical clinics at Stony Brook Medical Center on Long Island, New York. We surveyed 118 patients from April–August 2012 about their seafood consumption patterns, specifically how frequently they were eating each type of fish, to assess mercury exposure. We also asked about symptoms associated with mercury toxicity including depression, fatigue, balance difficulties, or tingling around the mouth. Of the 118 adults surveyed, 14 consumed high mercury seafood (tuna steak, marlin, swordfish, or shark) at least weekly. This group was more likely to suffer from fatigue than other patients (p = 0.02). Logistic regression confirmed this association of fatigue with frequent high mercury fish consumption in both unadjusted analysis (OR = 5.53; 95% CI: 1.40–21.90) and analysis adjusted for age, race, sex, income, and clinic type (OR = 7.89; 95% CI: 1.63–38.15). No associations were observed between fish intake and depression, balance difficulties, or tingling around the mouth. Findings suggest that fatigue may be associated with eating high mercury fish but sample size is small. Larger studies are needed to determine whether fish intake patterns or blood mercury tests warrant consideration as part of the clinical work-up in coastal regions.

Thrombotic thrombocytopenic purpura (TTP) is rarely associated with undifferentiated connective tissue disorder. We present a patient with TTP, undifferentiated connective tissue disorder, and very high titer of anti-ribonucleoprotein antibodies. Her TTP did not respond to intravenous methylprednisolone and cyclophosphamide requiring her to remain dependent on plasmapheresis. Her disease remitted successfully after 4 doses of rituximab given at weekly intervals and she remained in continuous remission 6 months after therapy. We propose early and aggressive use of B-cell depletion therapy in TTP associated with autoimmune disorders.

Excellent adherence to disease-modifying antirheumatic drug therapy and management is likely due to targeting clinical remission. Assessment of disease activity and functional status not only rose each year, but also is higher compared with similar studies. This may be due to an increased awareness of QIs and the utility of objective measures of disease activity. Deficient documentation of prognosis may be due to a lack of awareness of its importance. Suboptimal tuberculosis screening may be an artifact of poor documentation. We propose interventions to improve adherence.

HighlightsMetastatic breast carcinoma rarely spreads to the Gastrointestinal Tract (GIT).GIT breast carcinoma rarely has triple: ER, PR and HER2-neu negative histology.We report a case of triple negative breast carcinoma that spread to the jejunum.This is the first reported case in the U.S.

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