Neurological involvement in patients with rheumatic disease.

Patients with multi-system rheumatic conditions may have disease affecting the central and peripheral nervous systems. Early assessment is often helpful in averting the development of serious complications, which in some conditions can be prevented by the prompt institution of treatment. We review the spectrum of neurological disease in patients with a rheumatological diagnosis. The wide variety of associated neurological complications is discussed in the context of specific rheumatic conditions, varying from spinal cord involvement in rheumatoid arthritis, to neuropsychiatric involvement in systemic lupus erythematosus and neurological sequelae in vasculitic disorders. We discuss diagnostic criteria and recommended management options (where available), and describe the role of new tools such as functional brain imaging in the diagnosis and monitoring of disease. We also discuss the potential for development of neurological complications from the use of anti-rheumatic drugs.

Candidal infection of bone. Assessment of serologic tests in diagnosis and management.

In this case report, 30 sera from a 25-year-old heroin abuser with intervertebral candidosis were treated for the presence of anti-Candida albicans antibodies by agglutination, counterimmunoelectrophoresis, and indirect immunofluorescent assay. Sera were also adsorbed with heat-killed blastospores to remove antibodies against yeast-phase cells and tested by indirect immunofluorescent assay for anti-C. albicans germ tube antibodies (CAGTAs). Humoral responses to candidal 47-kD antigen were studied by immunoblotting in 23 unadsorbed sera. Anti-C. albicans antibodies were found in high titers by the three procedures but correlated poorly with the clinical evolution of the disease. CAGTAs were present from the beginning of the infection: Titers decreased in association with antifungal treatment and the patient's improvement, eventually becoming negative. Only class IgG antibodies to the 47-kD antigen were detected. These were present during the full course of the infection, failing to disappear at the end of the study. In this case, detection of CAGTAs appeared to be an important aid to diagnosis of the bony candidal infection, as they are detected early during the illness and seemed to have a prognostic significance.

Impact of preoperative weight loss on postoperative morbidity.

Clinical observations in developing countries and experimental studies in animals suggest that preoperative weight loss adversely affects postoperative morbidity. Since it is not clear whether these findings can be applied to surgical series in European countries, we have studied 106 surgically-treated patients with inflammatory bowel disease. Patients were divided into three groups according to the degree of preoperative weight loss. The groups were well matched in all other respects. Postoperative morbidity was monitored independently. The outcome in all three groups was similar so that in these patients, at least, preoperative weight loss did not adversely affect the postoperative outcome.

Crystal deposition in the knee and great toe joints of asymptomatic gout patients.

Crystal deposition in asymptomatic knee and first metatarsophalangeal (MTP) joints has been studied in 31 patients with previously proven gout. All had had clinical gout in their MTP joints but their knee joints had never been the site of acute gout. Knee arthroscopy was performed permitting synovial membrane inspection, photography and biopsy. Crystalline material was seen in 9 knees (28%) and confirmed histologically as monosodium urate (MSU) in 4 (12.5%). Synovial fluid analysis on 26 samples using a polarizing light microscope demonstrated MSU crystals in 4 (12.5%) and calcium pyrophosphate dihydrate (CPPD) in 2 (6%). Fluid aspirated from 27 of the metatarsophalangeal joints revealed MSU crystals in 14 (52%) and no CPPD crystals.

Diuretic induced gout: a multifactorial condition.

Fifteen patients with clinical gout occurring after long term treatment with diuretics were studied retrospectively. In all 15 patients one or more additional factors were present which might have contributed to the hyperuricaemia and gout. The most common of these was the impairment of the glomerular filtration rate. Twenty five other patients receiving long term treatment with diuretics who did not have gout were also studied. The concentrations of uric acid, urea, and creatinine were, in general, markedly lower in these patients than in those who had developed gout. It is concluded that diuretic induced gout occurs in patients in whom there is an additional cause of hyperuricaemia, usually impaired renal function.

The uricosuric action of azapropazone: dose-response and comparison with probenecid.

Azapropazone is an anti-inflammatory agent with reported uricosuric properties. The aim of the present study was to extend these observations, by examining the dose-response and to compare the uricosuric effect of azapropazone with that of probenecid. Patients were given varying doses of azapropazone from 900-2400 mg daily for 4-day periods at separated intervals. Plasma uric acid levels were measured before and at the end of each treatment period. Three other patients maintained on low purine diets were given a 4-day course of 1200 mg azapropazone daily followed at an interval by a 4-day period of probenecid 1 g daily. Plasma uric acid levels and 24 h urinary uric acid excretion were compared. The mean fall in plasma uric acid level after four days of 900 mg azapropazone daily was 31.4% (n = 9) compared with 33.9% (n = 12) on 1200 mg daily; 42.3% (n = 10) on 1800 mg daily; and 46% (n = 6) on 2400 mg daily, indicating a graded dosage response. In the three patients on low purine diets the falls in plasma uric acid levels on probenecid 1 g daily were 50.5%, 46% and 29% compared with 33.5%, 32% and 20% respectively on azapropazone 1200 mg daily. Similarly the total amount of uric acid excreted in the urine by each patient during the 4-day period on probenecid 1 g daily was 14.01; 13.03 and 8.97 mmol compared with 23.53, 10.9 and 7.69 mmol on azapropazone 1200 mg daily.(ABSTRACT TRUNCATED AT 250 WORDS)

Crohn's disease of the distal ileum.

A clinical and statistical analysis has been undertaken in a consecutive series of 227 patients with Crohn's disease involving the distal ileum under long-term review between 1944 and 1978. We have determined the long-term prognosis, cumulative reoperation rates after each resection, mortality rates, and their causes. Actuarial analysis has shown that the reoperation rates are similar after first, second, and third resections. There was no evidence that additional operations increase the risk of yet more resections. Reoperation rates were very little influenced by the age at diagnosis of the underlying Crohn's disease. A short interval from diagnosis of Crohn's disease to the first resection tended to increase the reoperation rate in the short term but there was no overall long-term effect. There was a two-fold increase in mortality risk when compared with the general population. Half the deaths were unrelated to the underlying Crohn's disease and, in this group, the incidence and causes were similar to those expected in the general population matched for age, sex, and years at risk. Of the disease related deaths many occurred in the early years of experience. Only four patients in the series have died of Crohn's disease in the last 10 years. One hundred and ninety-three patients are still alive after a mean interval of 16.1 years from the diagnosis of Crohn's disease. Full information is available on 185, of whom 161 are well and symptom free. Seven have minor problems, while 17 are unwell (nine with radiological evidence of recurrent disease).

Delayed hypersensitivity skin reactivity of patients with Crohn's disease: relationship with percentage ideal body weight and change after surgery.

Protein-energy malnutrition is common in patients with inflammatory bowel disease requiring surgery. Increased morbidity from sepsis may be associated with pre-operative weight loss due to associated diminished cellular immune defence mechanisms. Eighteen patients with Crohn's disease requiring elective abdominal surgery were divided into three nutritional groups before and after surgery, defined by their weight loss. The groups were well matched for other clinical variables. Delayed hypersensitivity skin reactivity to multiple antigens was measured before operation and during convalescence. The delayed hypersensitivity skin reactivity was depressed in the malnourished patients both pre-and post-operatively, although clinical outcome from surgery was not affected by nutritional status.

The use of sequential analysis to assess patient preference for local skin anaesthesia during knee aspiration.

Twenty-seven patients requiring bilateral knee aspiration showed no overall preference for or against the use of subcutaneous lignocaine during knee aspiration. The trial result attained a predefined level of significance (beta = 0.1; theta = 0.72) with fewest possible patients (27), using sequential analysis.

Impact of preoperative weight loss and body composition changes on postoperative outcome in surgery for inflammatory bowel disease.

One hundred and twenty seven patients undergoing elective surgery for inflammatory bowel disease were divided into three groups according to their preoperative ideal body weight (less than 80%, 80-90%, and greater than 90%). The groups were well matched in respect of age, sex, corticosteroid therapy, pre-existing sepsis, peroperative antimicrobial chemotherapy, and resection site. None received peroperative nutritional support. The postoperative outcome was similar in each of the three nutritional groups including the incidence of postoperative sepsis, duration of hospital stay, and mortality. Serial peroperative changes in weight, fat, and muscle bulk were assessed by anthropometric measurements in 21 of these patients. The deficits in weight, fat, and muscle bulk were similar at 10 and 21 days postoperatively in the three groups. At 84 days those malnourished preoperatively had recovered their nutritional status faster than the well nourished patients. We conclude that in these patients undergoing elective resection for inflammatory bowel disease preoperative weight loss did not adversely affect the postoperative outcome.

Intervertebral infection due to Candida albicans in an intravenous heroin abuser.

A 25 year old woman who had received intravenous heroin over one year previously developed an intervertebral abscess due to infection with Candida albicans. Immunological investigation of this patient showed no evidence of a specific defect in the host response to candida.

Spontaneous rupture of the spleen in rheumatoid arthritis.

Two patients with rheumatoid arthritis without splenomegaly or Felty's syndrome developed spontaneous rupture of the spleen. The histological appearance was consistent with involvement of the splenic capsule by the rheumatoid process, and this may have predisposed to splenic rupture.

A case of weak muscles.

BACKGROUND: Gut involvement in inflammatory myositis is rare but causes significant morbidity and mortality. CASE REPORT: A case of eosinophilic gastroenteritis and polymyositis occurring in the same patient is described. The interface of visceral and striated muscle involvement is discussed. The pathophysiology of eosinophilic gastroenteritis and the spectrum of gastrointestinal involvement in inflammatory myositis are also discussed. RESULTS: Both gastrointestinal and skeletal muscle symptoms improved with immunosuppression, suggesting a possible common underlying mechanism.

Double-blind trial of flurbiprofen and phenylbutazone in acute gouty arthritis.

Flurbiprofen has been compared with phenylbutazone in a double-blind study involving 33 patients with acute gout. Patients received either flurbiprofen 400 mg daily for 48 h followed by 200 mg daily, or phenylbutazone 800 mg daily for 48 h followed by 400 mg daily. The drugs were of comparable efficacy, while side-effects were uncommon and relatively mild. Flurbiprofen appears to be a satisfactory alternative to phenylbutazone in the management of acute gouty arthritis.