Methotrexate osteopathy in long-term, low-dose methotrexate treatment for psoriasis and rheumatoid arthritis.

BACKGROUND: In dermatology and rheumatology, methotrexate is frequently prescribed in low dosages per week; in oncology, high dosages per week are prescribed. Methotrexate osteopathy was first reported in children with leukemia treated with high doses of methotrexate. In animal studies, low doses of methotrexate proved to have an adverse effect on bone metabolism, especially on osteoblast activity. OBSERVATIONS: Methotrexate osteopathy is a relatively unknown complication of low-dose methotrexate treatment. We describe three patients treated with low-dose oral methotrexate in whom signs and symptoms were present that were similar to those found in children treated with high doses of methotrexate. All three patients had a triad of severe pain localized in the distal tibiae, osteoporosis, and compression fractures of the distal tibia, which could be identified with radiographs, technetium Tc 99m scanning, and magnetic resonance imaging. CONCLUSIONS: Methotrexate osteopathy can occur in patients treated with low doses of methotrexate, even over a short period of time. As pain is localized in the distal tibia, it is easily misdiagnosed as psoriatic arthritis of the ankle, but the diagnosis can be correctly made by careful investigation and use of imaging techniques. The only therapy is withdrawal of methotrexate. It is important that more physicians become aware of this side effect of methotrexate therapy, which can occur along with arthritic symptoms.

The Dutch version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ).

We report herein the results of the cross-cultural adaptation and validation into the Dutch language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Dutch CHAQ was fully validated with 3 forward and 3 backward translations while the CHQ was already published and therefore it was revalidated. A total of 180 subjects were enrolled: 100 patients with JIA (17% systemic onset, 31% polyarticular onset, 18% extended oligoarticular subtype, and 34% persistent oligoarticular subtype) and 80 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Dutch version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.

Sarcoidosis presenting with severe thrombocytopenia and arthritis.

In this case report a patient with biopsy-proven sarcoidosis is described, presenting with joint symptoms and severe thrombocytopenia, due to immune-mediated platelet destruction.

Arthritis associated with salmonella infection.

Six cases of arthritis caused by or associated with Salmonella infection are reported. It is stated that an arthritis associated with a Salmonella infection cannot be excluded on the negative results of the Widal test. Consequent upon Salmonella infection two different types of arthritis might develop: a) monoarticular infectious arthritis or b) a subacute reactive oligo-articular arthritis. In this study a patient with a chronic destructive "reactive" oligoarthritis is described, resembling experimental "Salmonella-associated arthritis" in rats. This form of arthritis might be regarded as an immune complex mediated disease associated with a chronic infection.

Quality of life assessment: a comparison of four questionnaires: for measuring improvements after total hip replacement.

Three experimental questionnaires were compared with the Influence of Rheumatic Diseases on Health and Lifestyle (IRGL) questionnaire, a Dutch version of the Arthritis Impact Measurement Scales. Sixty-two patients with osteoarthritis (OA) and 35 patients with rheumatoid arthritis (RA), all of whom underwent hip arthroplasty, completed the study. Results showed that visual analogue scales for pain, stiffness, fatigue, and anxiety were strongly correlated with a number of the IRGL scales. Patient preference scales were sensitive to change and provided additional information on aspects of the patients' quality of life (QOL) that were felt to be important by the patients themselves. The questionnaire on performance in various roles in life was insensitive to change. In existing questionnaires, there is an attempt to represent the concept of QOL in terms of its most important aspects. Such realizations of the concept of QOL are not entirely suitable for application in clinical trials. The IRGL is overly complex, and its sometimes comprehensive scales do not deal with the possible effects of treatment. Neither of these properties is conducive to sensitivity to change. Visual analogue scales reduce the complexity. A simpler representation of QOL that can evaluate aspects relevant to treatment is recommended.

Destructive joint disease in alpha-mannosidosis. A case report and review of the literature.

Storage of oligosaccharides due to a deficiency of alpha-mannosidase can lead to joint destruction in children and young adults. Treating hip destruction with a prosthesis might be successful in some of these patients, although diminished bone quality increases the risk of loosening of the prosthesis.

Radiosynoviorthesis of the knee: a doubleblind trial of 1 versus 5 mCi Gold-198.

Since the minimal effective dosage for radiosynovectomy is not known, we have performed a doubleblind controlled trial of 1 mCi vs. 5 mCi 198Au in 60 knees of 46 patients with persistent rheumatoid synovitis. The therapeutic effect was assessed with a clinical score, 99mTc pertechnetate uptake measurements and plain X-rays. With regard to clinical parameters no statistical differences between the two groups were found, but results indicate a trend towards a better outcome in patients treated with 5 mCi. 99mTc uptake improved significantly in patients treated with the higher dose and not in the low dose group. Weighing ease of treatment and risk of side effects against the small difference in effectiveness, we conclude that the use of less than 5 mCi of 198Au may be justified. During the study the injection technique was changed, enabling a comparison of two methods. Leakage to lymph nodes and liver decreased when the needle was flushed with normal saline after administration of the radiocolloid.

[Disease caused by lack of sunlight: rickets and osteomalacia]. / Ziek door te weinig zonlicht: rachitis en osteomalacie.

In three patients, a 12-year-old Muslim Moroccan girl with polyarthralgia and a wobbling gait, a 47-year-old emaciated Hindustani man with muscle weakness and on antiepileptic drugs, and a heavily-veiled native Dutch woman aged 34 years with polyarthralgia and psoriasis, clinical, laboratory and radiologic examination led to the diagnoses of rickets (the first patient) and of osteomalacia (the other two). They recovered after calcium and vitamin D suppletion. After the discovery of vitamin D and the beneficial effects of sunlight and cod liver oil rickets and osteomalacia became rare. Recently these diseases have to be considered more often again because of changes in the composition of the Dutch population: more immigrants and (institutionalized) elderly who are prone to develop a vitamin D deficiency. Dietary and clothing habits should be investigated when a patient complains about diffuse (bone) pains. In case of minimal exposure to sunlight and a diet low in vitamin D the symptoms may be explained easily by a vitamin D deficiency. Once hypovitaminosis D is diagnosed, the therapy is simple and effective.

[Bacterial joint infections: a retrospective study for the source of the infection]. / Bacteriële gewrichtsinfecties: een retrospectief onderzoek naar de infectiebron.

Bacterial arthritis causes rapid damage of the affected joint. Knowledge of the source of the infection that leads to septic arthritis is necessary to judge possible preventive measurements. In this study we tried to detect the source of the infection in 77 episodes of bacterial arthritis in 73 patients admitted in the period 1976-1986. The source of infection was: a joint operation in 21, the skin in 15, the respiratory tract in 7, the genital tract in 8, others in 5, and unknown in 21. A skin infection was the source in patients suffering from rheumatoid arthritis. To our surprise in none of our cases was non-sterile surgery the cause of infection. Our results suggest that since perioperative joint infection is frequent, prevention of such infection may be meaningful. Skin infections are often the source of infection in rheumatoid arthritis, preventive measures are to be considered. Our results do not allow a judgment on the possible preventive measures for the other sources of infection detected or undetected. Administration of antibiotics during non-sterile surgery is not supported by the results of this study.

[Polyarthritis in childhood]. / Polyarthritis op de kinderleeftijd.

As for chronic polyarthritis in childhood the polyarthritis due to JCA is the most frequently diagnosed one. Today pathogenesis and pathophysiology are still gloomy. But the characteristic clinical aspects of the disease at onset together with laboratory (serological) investigations enables us to identify the different types of polyarticular JCA. This is very important for course and outcome of the disease, especially for choosing the best therapeutic regime. This review will discuss the clinics, differential diagnosis, laboratory investigations, subtyping and course of the disease including therapy and prognosis.