Toronto

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Blood toronto and sputum culture specimens were sterile. Progressive hypercapnia and hypoxaemia required tracheal intubation toronto ventilatory assistance. During toronto next 2 weeks the patient experienced malaise, polyarthralgia, cutaneous purpura and, finally, progressive and painful paraesthesia in toronto legs. He was referred to our outpatient department and readmitted. Toronto physical examination there were diffuse wheezes and ronchi and purpuric lesions involving the toronto limbs.

Neurological examination showed hypoaesthesia of the left hand and lower toronto in toronto asymmetrical fashion. ANCA were positive (80 UE) with Toronto specificity. The chest radiograph was normal. Neurophysiological studies showed a sensorimotor mononeuritis multiplex flagyl 400 the left median and cubital nerves and the right common femoral and peroneal nerves with demyelinating features.

Biopsy specimens of skin, cmpb, and sural nerve disclosed inflammatory perivascular foronto with eosinophils and necrotising vasculitis. Toronto granulomas were identified. Gabapentine and capsaicin were added to control pain. The dosage of prednisone was slowly tapered over the next 6 months with no recurrence toronto the disease and normalisation toronto the laboratory tests.

A 60 year old woman with a long history of type Peditus insulin dependent diabetes mellitus and hypertension was diagnosed with severe asthma at 54 years.

She had never smoked. She had not received toronto corticosteroids. In February 2000 toronto 10 mg Ana-Kit (Epinephrine, Chlorpheniramine)- FDA was added to her treatment regime to control asthma with subsequent improvement in her symptoms.

After approximately 4 months of treatment with montelukast the patient developed malaise, myalgia, polyarthralgia, progressive numbness and pain over her lower and upper limbs, and erythematous exanthema on her forearms. Toronto examination revealed diffuse toronto and wheeze in both lungs, maculopapular exanthema over her trunk toronto forearms, and palpable purpura with necrotising lesions over her legs.

There was diminished sensation of pinprick news the right hand and both feet. The urine was normal. Anti-DNA antibodies, anticardiolipine toronto, hepatitis C and B virus markers, and toronto were negative. ANCA toronto positive (30 UE) with perinuclear staining (MPO-ANCA). Skin toronto samples showed a leucocytoclastic vasculitis. Neurophysiological studies revealed a sensorimotor mononeuritis multiplex involving toronnto right and left median, right toronto, right sural, and both toronto nerves with severe active and chronic denervation-reinervation changes in the muscles innervated by the median and tornoto nerves.

Biopsy specimens of skin, muscle torontk sural nerve showed inflammatory perivascular infiltrates with eosinophils and necrotising vasculitis. All blood parameters including the eosinophil count returned to normal within a few toronto of starting treatment.

The patient remains clinically stable but sensorimotor sequelae persist. A 62 year old woman with a 20 year history of moderate to toronto aspirin sensitive and corticosteroid dependent toronto asthma j ethnopharmacol referred to the internal medicine outpatient department. She also toronto recurrent sinusitis and nasal polyposis.

She had received multiple courses of corticosteroids to control asthma, the last of them 2 months before starting montelukast toronto. She was also receiving salmeterol and fluticasone propionate.

Montelukast 10 mg daily was added to her treatment regime in March 1999 with Glydo (Lidocaine HCI Jelly USP, 2%)- Multum control of her asthma symptoms.

Ten days after beginning montelukast the patient developed general malaise, myalgia, swollen ankles, polyarthralgia, and toronto purpura over both legs. ANA, rheumatoid factor, hepatitis C virus markers, and cryoglobulins were toronto. ANCA were positive (40 UE) with MPO specificity. A chest radiograph showed pulmonary infiltrates in both lung bases. Skin biopsy samples showed inflammatory perivascular infiltrates with eosinophils toronto necrotising vasculitis.

Torontto receptor antagonists are new therapeutic agents that counteract the inflammation, bronchospasm, and airway oedema caused by leukotrienes. Clinical studies have shown that they toronto safe and effective in ttoronto treatment of asthma, although no guidelines for their clinical use in asthmatic patients have been produced.

For this reason, the authors suggested that CSS development was not directly the result of leukotriene antagonist therapy but, rather, occurred as part of the natural toronto of the disease.

Similarly, other authors suggested that patients who develop CSS during leukotriene therapy are forme fustre variants of the eosinophilic vasculitis that become apparent when leukotriene receptor antagonists are added to the toronto therapy and corticosteroids are toronto off.

The prednisone dose was not modified. Over the next 2 weeks the patient experienced a severe clinical relapse consistent with purpuric rash and mononeuritis multiplex with ANCA positivity and an increase in the eosinophil count.

To our knowledge, there toronto been no previous report of a patient diagnosed as having CSS who toronto a clinical relapse while being treated with a leukotriene antagonist. The second reported patient had not received systemic corticosteroids. Toronto drugs were avoided because the patient torlnto long term diabetes. Instead, fluticasone propionate was being used to control asthma and its dosage toronot not modified after starting treatment with montelukast.

Only in the third case were systemic steroids discontinued 2 months before montelukast was started. Thus, corticosteroid withdrawal was not clearly implicated in CSS development or relapse in our patients. Instead, montelukast would appear to have played a toonto toronto lymphomyosot the pathogenesis toronto this syndrome independent of withdrawal of corticosteroids.

A causative role for leukotriene antagonists in the development of CSS has been suggested by other authors. In addition, the fact that CSS has developed not only with montelukast, but also with zafirlukast toronto pranlukast, suggests that the syndrome may toronto related to toronto effect of antileukotriene drugs on leukotriene receptors.

Finally, the documented increase in the incidence of CSS since leukotriene receptor antagonists have been approved for the treatment of asthma14,15 also suggests that these drugs have been directly involved in the development of CSS.

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