October was a busy month.
The national arthritis charity 'Arthritis Research UK' held a patients' meeting on lupus at the Royal College of Physicians - a very welcome 'first' for this important charity. Two of my colleagues from the London Lupus Centre, Dr Chris Edwards, Professor Munther Khamashta and I gave talks, followed by a very lively question and answer session.
It is quite a while since I was last at the Royal College - a beautiful building in Regents Park which serves as a nerve centre for medical education, both in Britain and abroad.
Talking about abroad, in late October, my colleagues in Beirut, Lebanon, held their third annual 'Ten Topics in Rheumatology' meeting. Beirut is a glorious, naturally beautiful city, with the Mediterranean in front (and a promenade to rival Nice) and the mountains behind. The meeting was packed, with physicians from all over the middle east.
It was humbling to see colleagues from centres in Baghdad, Syria, Iran and other sometimes war-torn areas making the journey to Beirut simply to improve their medical knowledge. In particular, one of my ex-fellows, Dr Ikram, had made the journey down from Aleppo (which competes with Damascus as the oldest continuously inhabited city in the world) to attend. She runs a 'free' clinic in the Souk area of Aleppo - an area which suffered a direct hit from a missile one week previously, in the on-going civil war in Syria.
Nearer to home, I gave a talk at the annual nurses' meeting at London Hospital - my old training ground in Whitechapel. Many, many happy memories.
Finally, I gave a talk on Hughes syndrome and the treatment of recurrent miscarriage at a London meeting of the Aspirin Society. This venerable medical group, under the leadership of Dr Nick Henderson has, over the years, brought together doctors from very diverse backgrounds, all with experience and data on uses of aspirin. At this particular meeting, for example, striking data was presented on the improved outcome figures for bowel cancer with the use of regular aspirin.
Patient of the month
Dr P.L. aged 36, a gynaecologist from Seattle, USA had emailed me a number of times regarding her own clinical problems. These had included migraine, memory problems, fainting and a tendency to attacks of low blood pressure.
She decided to make the trip to London with her young son. One of the reasons was that her tests had suggested an auto-immune disease - possibly lupus - but the results had been inconclusive and her physicians weren't in agreement. She had been tested for antiphospholipid antibodies amongst other tests: the results showed a positive "lupus anticoagulant" and medium level IgM anticardiolipin antibodies. In fact she had been diagnosed back home as having "autonomic neuropathy" - problems with the nerves supplying internal organs such as the gut, the heart and the blood vessels. One of the manifestations of this condition is a tendency to falls in blood pressure, causing dizziness and even fainting.
Was this connected to her positive tests for Hughes syndrome? Her past history had included migraine, but no episodes of thrombosis and no miscarriages.
And, by the way, she had had eight metatarsal (foot) bone fractures while jogging...........
What is this patient teaching us?
Eight 'spontaneous' metatarsal fractures! And a fracture of a shin bone. She had been investigated for bone conditions such as osteoporosis but no obvious cause was found.
Back in 2004, we published a paper reporting a series of nineteen patients with antiphospholipid antibodies who developed spontaneous metatarsal fractures (*).
Since that report, a number of other case reports of metatarsal fractures in Hughes syndrome have been published. We are not sure of the mechanism, but it seems most likely that the fault line in the bone may be secondary to bone ischaemia (poor circulation) in patients who have not been on treatment.
And what about the "autonomic neuropathy"? Recognised in Sjogrens, but as yet not in Hughes syndrome.
I have now seen over a dozen Hughes syndrome patients with features of this condition, anecdotally improving with treatment of "sticky blood". Watch this space.
(*) - Sangle S, D'Cruz DP, Khamashta MA and Hughes GRV. Antiphospholipid antibodies, systemic lupus erythematosus, and non-traumatic metatarsal fractures. Ann Rheum Dis 2004, Oct 63 1241