When to try COX-2-specific inhibitors. Safer than standard NSAIDs in some situations.

COX-2-specific inhibitors, by sparing COX-1 enzyme and its physiologic functions, are a safer option than regular NSAIDs in patients who are at risk for gastrointestinal bleeding (e.g., patients with a history of peptic ulcer disease, gastritis, alcoholism, concomitant corticosteroid or anticoagulant use). They have been approved for use in arthritis, and their efficacy is comparable to that of other NSAIDs. Further clinical data are needed to establish the long-term safety profile of these newly introduced drugs.

The difficulties of differentiating vasculitis from its mimics.

The signs and symptoms of vasculitis are not specific, and tests for confirming the diagnosis can be misleading. Thus, when considering a diagnosis of vasculitis, physicians need to keep an open mind. With a case vignette, the author illustrates some of the difficulties in diagnosing "vasculitis."

Sarcoidosis Mimicking Sjögren's Syndrome: Histopathologic Observations.

The clinical manifestations of Sjõgren's syndrome (SS) and sarcoidosis can be identical. Of the 1600 patients whom we have evaluated for dryness of the mouth and eyes, 300 proved to have SS and 5 had sarcoidosis. The patients with sarcoidosis had combinations of salivary gland enlargement, elevated antinuclear antibody titers, reduced salivary flow rates, and keratoconjunctivitis sicca, findings typically associated with SS. Finding non-caseating granulomas in a labial salivary gland biopsy specimen may be the only way to definitively differentiate these two disorders.

Osteoarthritis. A continuing challenge.

Osteoarthritis is a disorder of cartilage that affects almost 85% of the population by age 75. A lack of rigorous clinical and radiographic criteria for defining the disorder makes precise determination of its prevalence impossible. The process of wear and tear explains many manifestations of osteoarthritis, but it does not account for some of the clinical findings or the biochemical changes in osteoarthritic cartilage. Thus, other factors such as heredity, hormones, and diet may play a role. Treatment consists of teaching patients about their disease, alleviating pain, and preserving joint function. Nonsteroidal anti-inflammatory drugs may be no more effective than simple analgesics in relieving the pain of this disorder. Moreover, some nonsteroidal anti-inflammatory drugs can adversely affect cartilage metabolism, and most are possibly dangerous in elderly patients. Drugs that inhibit the production or activity of chondrolytic enzymes can slow the degeneration of cartilage in some animals, but their effects on humans with osteoarthritis are unproved. The surgical repair of severely damaged joints can have gratifying results.

When vasculitis is not vasculitis.

Conditions that mask or mimic vascular inflammation are many, the paths to diagnostic distinction are varied, and the prognostic and therapeutic consequences of misreading the signposts are profound. Six cases illustrate.

Eosinophilia-myalgia syndrome: the aftermath.

We report here the long-term sequelae in 22 patients with L-tryptophan-induced eosinophilia-myalgia syndrome (EMS). The mean follow-up was 23 months (range, 5 to 40 months). Myalgia, rash, pruritus, edema, and respiratory symptoms often improved with the use of corticosteroids, but fatigue and weakness persisted in most cases. Other abnormalities that commonly persisted were arthralgia, muscle-cramping, peripheral neuropathy, and thickened skin. One patient had chronic pulmonary hypertension. These findings indicate that for most patients, EMS is a chronic disorder.

Pulmonary manifestations of the eosinophilia-myalgia syndrome associated with tryptophan ingestion.

Pulmonary manifestations are not infrequent in the L-tryptophan-induced eosinophilia-myalgia syndrome (EMS). However, previous reports have not described the results of longitudinal pulmonary function, exercise testing, high-resolution computerized tomographic (HRCT) scanning of the chest, or detailed bronchoalveolar lavage (BAL) analysis. We report six patients with EMS who had dyspnea. The diffusing capacity for carbon monoxide was decreased in five patients tested. Exercise testing with arterial blood gas sampling in three patients was consistent with pulmonary vascular or parenchymal disease. Serial exercise testing in two of these patients demonstrated marked improvement temporally associated with corticosteroid treatment. In four patients, HRCT scanning of the chest was abnormal. One of these patients showed no abnormality on routine chest roentgenogram. Two patients undergoing BAL exhibited increased eosinophils in the lavage fluid; a third had elevated lymphocytes. Serial measurements of fibroblast proliferation-stimulating-activity in samples of BAL fluid obtained from serial examinations in two patients exhibited heightened pretreatment activity that returned to the normal range following corticosteroid therapy. In these two patients, increased proportions of T-suppressor/cytolytic (CD8+) cells were observed in the BAL fluid. Despite aggressive immunosuppressive therapy, one of the patients died of respiratory failure. Another remains markedly dyspneic with pulmonary hypertension. Of the remaining four patients, two exhibited resolution of pulmonary symptoms after systemic corticosteroid therapy, and two experienced partial improvement.

Tryptophan-induced eosinophilia-myalgia syndrome.

Eight patients who became ill while taking tryptophan had myalgia, fatigue, rash, fever, edema, alopecia, arthralgias, diminished joint motion, skin tightening, muscle cramping, and distal paresthesias. Three had shortness of breath, and one had pulmonary hypertension. Laboratory abnormalities included peripheral eosinophilia, leukocytosis, thrombocytosis, raised erythrocyte sedimentation rate, and elevated serum levels of aldolase, lactate dehydrogenase, and liver enzymes. Of 4 chest radiographs, 3 were abnormal. Of 5 skin and muscle biopsies, 4 showed sclerosis or mixed inflammatory cell infiltration of the dermis, subcutis, and fascia. Eosinophils were often present, but vasculitis was absent. Muscle inflammation was minimal. We conclude that the "eosinophilia-myalgia syndrome" is related to the ingestion of tryptophan and that abnormalities in the secretion of lymphokines may be important in its pathogenesis.

Update on NSAIDS in the elderly.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can effectively reduce pain and inflammation. Although these agents are potent inhibitors of prostaglandin synthesis, they probably have other effects on the inflammatory process. NSAIDs produce a number of side effects, particularly in elderly patients. Understanding the effects of aging on drug pharmacokinetics will help minimize these complications.

Wegener's granulomatosis.

These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Homer A. Boushey, MD, Professor of Medicine, and John G. Fitz, MD, Assistant Professor of Medicine, under the direction of Lloyd H. Smith, Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA 94143.

Radiologist's guide to the use of the laboratory in diagnosing rheumatic diseases.

Laboratory tests that are commonly used in the evaluation of rheumatic diseases are described. The techniques for performing these tests; their use in screening, diagnosis, and follow-up; and the pitfalls in interpreting their results are discussed to provide the radiologist with an understanding of the current technology relating to rheumatic disorders.