Review article: coeliac disease in later life must not be missed.

BACKGROUND: The presenting symptoms of coeliac disease are often subtle and the diagnosis is frequently delayed or overlooked. Therefore, especially elderly patients may be denied the benefits conferred by gluten free diet which can be dramatically life-changing. AIM: To review the occurrence, clinical features, diagnosis and management in coeliac patients detected later in life. METHODS: To review manuscripts concerned with coeliac disease in the elderly and to derive subgroups of elderly people from publications on the disorder. RESULTS: Approximately a quarter of all diagnoses are now made at the age of 60 years or more and a fifth at 65 years or over. About 4% are diagnosed at 80 years or above. Around 60% remain undetected, since their symptoms are often subtle: tiredness, indigestion, reduced appetite. Good compliance with gluten free diet, resolution of symptoms and improvement in laboratory indices can be achieved in over 90% of patients. CONCLUSIONS: Coeliac disease not uncommonly presents for the first time in older patients and is an important diagnosis to make.

Bronchiolitis in rheumatoid arthritis.

Bronchiolitis in association with rheumatoid arthritis has been reported, to our knowledge, in 18 patients to date. In some cases use of penicillamine has been strongly associated with the development of bronchiolitis. Most of the reported cases are described as having marked irreversible airways obstruction and hyperinflation. We describe a patient with rheumatoid arthritis whose respiratory tract symptoms began during gold therapy. Physiologic studies showed marked lung hyperinflation without pathologic findings in forced dry spirometric study. On open lung biopsy a mild degree of granulomatous bronchiolitis was found. Immunofluorescent microscopy showed IgM- and IgG-containing plasma cells in the bronchiolar walls.

Ocular inflammation in Reiter's disease after Salmonella enteritis.

We studied characteristics of ocular inflammation in Reiter's disease after Salmonella enteritis in eight patients. After an acute onset with diarrhea, fever in six patients, and headache in three patients, all patients developed arthritis; six patients had myalgia; six patients, urethritis; and one patient, carditis. Sacroiliitis was found in four patients. All patients had HLA-B28 antigen. Conjunctivitis occurred in seven patients. It was mostly mild with no chemosis, follicles, or keratitis, and resolved in ten days. In one case palpebral edema, chemosis in the conjunctiva, and purulent exudate were seen. One patient had transient episodes of keratitis and corneal erosion for two months and episodes of conjunctivitis for 11 months. Three patients developed unilateral acute anterior uveitis with aqueous flare, cells, fine keratic precipitates, and fibrinous exudation from three to four years after the onset of the illness. One of these patients had vitritis and macular and papillary edema.

Cervical spine involvements in Reiter's syndrome.

Cervical spine radiographs of 38 patients originating from 145 consecutive cases with Reiter's syndrome (RS) were reviewed. Five of these 145 patients (3.4%) had cervical spine manifestations: anterior atlanto-axial dislocation 2, craniovertebral lesions typical for rheumatoid arthritis (RA), spondylitis typical for ankylosing spondylitis (AS) and anterior ossification, one each. Four of these patients were males. Cervical lesions in RS turned out to be rare. These lesions are alone indistinguishable from those of other chronic rheumatic inflammatory diseases.

Polymyositis associated with several immunological disorders.

A case of polymyositis associated with scleroderma, adult coeliac disease, diabetes mellitus and IgA nephropathy is reported in a 33-year-old male.

Urogenital involvements and rheumatic disorders in females. An interview study.

To study dependence between urogenital involvements and musculoskeletal complaints in females, 311 randomly selected women aged 15 to 54 were interviewed. In the analysis of these dependences musculoskeletal complaints were considered as a whole per person. A history of salpingitis, gonorrhoea, urinary tract infection (UTI) and Trichomonas vaginalis was revealed as constituting a relative risk factor of 4.4, 3.9, 3.1 and 4.5 respectively in connection with inflammatory rheumatic disease or suspicion of it, with or without dorsal pains of unknown cause. Anamnestic cervicitis was disclosed as constituting a relative risk factor of 1.9 in connection with joint pains in the extremities and 1.8 in connection with dorsalgia of unknown cause, but not a statistically significant relative risk of inflammatory rheumatic diseases or suspicion of them. Salpingitis is proposed as a diagnostic criterion for female Reiter's syndrome. In epidemiologic work the importance of considering the medical history of musculoskeletal complaints as a whole per person is emphasized.

Reiter's syndrome in male sexual partners of females with Reiter's syndrome or suspicion of it.

With sexually transmitted rheumatic diseases in mind we investigated 37 male sexual partners of females with Reiter's syndrome (RS) or suspicion of RS (SRS). Controls were 219 randomly selected interviewed males. A history of urogenital involvements was found in 19/37 (51,4%) as compared to 65/219 (29,7%). Anamnestic nonspecific urethritis, dysuria, gonorrhoea, condylomata acuminata and prostatitis occurred more frequently in the 37 males than in the controls (p less than 0.05 - p less than 0.025). Six out of 37 as compared to 5 of 219 had a history of balanitis (p less than 0.0025). Anamnestic synovitis was found in 8/37 (21,6%) and in 9/219 (4,1%) (p less than 0.001) RS or SRS was diagnosed in 6/37 (16,2%). Taking into consideration the consecutive females with RS or SRS, whose sexual partners were not investigated, the theoretical counting still shows clear differences in the anamnestic occurrence of synovitis and balanitis between the 37 males and the controls (p less than 0.0125 - p less than 0.05). The results emphasize the important role of sexually acquired and maintained RS in rheumatology.

Salpingitis and cervicitis in uro-arthritis.

To compare anamnestic cervicitis and salpingitis as a relative risk for uro-arthritis the medical history of 60 consecutive females with uro-arthritis was compared with that of 311 interviewed controls. Salpingitis was revealed to be a relative risk factor of 3.2 as compared to cervicitis 1.4 in connection with uro-arthritis. HLA-B27 was tested in the 60 patients and in an additional 7 females with uro-arthritis, all of whom had a history of salpingitis. HLA-B27 was positive in 42% (28/67). There were no significant differences between those with or without cervicitis or salpingitis or both. Salpingitis could thus as justifiably be accepted as a diagnostic criterion for RS as cervicitis. These findings and clinical observations, including comprehensive histories of the patients concerned, serve as a basis for our hypothesis of rheumatic salpingitis. Further prospective and co-operative investigations will be needed to confirm or disprove this hypothesis.

Infectious involvements in males with Reiter's syndrome.

To obtain data on infectious involvements contributing to joint attacks in Reiter's syndrome (RS) 72 consecutive males with RS were investigated. Controls were 219 personally interviewed males. A history of some type of oro-naso-pharyngeal or pulmonary infectious involvements were reported as often in the patients as in the controls, but the frequency of persons with a history of joint manifestations followed by these infections was significantly higher in the patients (23/72) than in the controls (8/219) (p less than 0.0001). Gastrointestinal involvements occurred only in a minority of cases as a triggering infection. Histories of prostatitis, gonorrhoea, condylomata acuminata, haematuria and trichomonas vaginalis infections were significantly more common in patients than in controls (p less than 0.001 - p less than 0.025). This finding, as well as evidence of chlamydial infection in 61%, speaks in favour of the importance of sexually transmitted diseases as an etiologic agent. A case report of triggering infections during the course of RS is given and the possible role of these infections in the immunopathogenesis in RS is discussed.

Atlanto-axial dislocation in an 18-year-old female with Yersinia arthritis.

A case of anterior atlanto-axial dislocation in an 18-year-old female with arthritis due to Yersinia enterocolitica 3 is reported. We draw attention to the importance of investigating the cervical spine even in young patients with a short history of arthritis. Physical treatment indications and contra-indications should be taken into consideration.

Urogenital involvements in female sexual partners of males with Reiter's syndrome.

The occurrence of urogenital involvements in female sexual partners of males with Reiter's syndrome (RS) or suspicion of RS (SRS) was studied. The possible etiological role of Chlamydia trachomatis (Ct) was demonstrated by isolation and by immunofluorescence (IF) serology. Evidence of chlamydial infection (positive isolation and/or IF titre greater than or equal to 64) was found in 35 out of 56 (62,5%) males with RS and in 9 out of 16 (56,3%) males with SRS. 43 female sexual partners of these men were studied. Evidence of present or past chlamydial infection was demonstrated in 23 of these 43 females (53,5%). This was a significantly higher frequency than that evidenced among controls studied, 14/77 verified serologically and 3/81 by isolation, p less than 0.0025 and p less than 0.005, respectively. A history of dysuria occurred in 10 out of 43 female sexual partners and in only 20 out of 364 interviewed randomly selected controls (p less than 0.00025). Abnormal urinary findings were also more frequent among the sexual partners than among the controls (p less than 0.025). The results emphasize the role of Ct as a triggering factor in RS and stress the importance of urogenital investigations among couples with RS.

Musculoskeletal involvements in female sexual partners of males with Reiter's syndrome.

To examine the occurrence of signs and symptoms of Reiter's syndrome (RS) in female sexual partners of males with RS we have investigated 43 female consorts of 42 males, originating from 72 consecutive patients suffering from RS or suspicion of RS (SRS). Anamnestic mono-, oligo- or polyarthritis occurred in 14 of the 43 females (32,6%) as compared to 28 out of 311 randomly selected interviewed controls (9,0%). Five of the 43 females had RS and 7 had SRS, (27,9%). However, the diagnosis could have been possible with only anamnestic information in 6 (14%) as compared to 7 out of 311 controls (2,3%). Taking into consideration the 30 males whose sexual partners were not investigated, the theoretically counted values still differ significantly from those of the controls (p less than 0.01). A history of urogenital and, on the other hand, nasopharyngeal or pulmonary infections involvements preceded equally frequently the first or further joint attacks. Evidence of chlamydial infection was found in 53,5% (32/43) of the partners while Yersinia antibodies measured by ELISA occurred with the same frequency as among healthy blood donors. We would like to stress the importance of various infectious involvements, especially sexually transmitted diseases, as etiological agents in joint attacks in females who are sexual partners of males with RS.

The nature of urogenital involvements in female uro-arthritis, with special reference to chlamydial infection.

To study the nature of urogenital involvements in female uro-arthritis 73 consecutive patients with arthritis concomitant with any type of urogenital involvement were examined. The controls were 281 females interviewed only and an additional 83 also gynaecologically examined. A history of cervicitis, salpingitis, dysuria and pyelocystitis/-nephritis occurred significantly more often in patients than in controls. Clinical gynaecological examination revealed cervicitis in 26,8% (19/71) of the patients and 15.7% (13/83) of the controls (p less than 0.05). Aseptic pyuria was definitely more frequent in patients (19/73) than in controls (0/63). The isolation of Chlamydia trachomatis was positive in 14.7% (10/68) of the patients and 3.7% (3/81) of the controls (p less than 0.025). Serological evidence (titre greater than or equal to 64) for chlamydial infection was obtained in 53.4% (39/73) of the patients and 18.2% (14/77) of the controls (p less than 0.00025). The results indicate the importance of urogenital history and findings in females with rheumatic attacks. The most prominent and persistent urogenital involvements were cervicitis, salpingitis, pyuria and dysuria. Chlamydial infection appears in any case to be responsible for part of these involvements (42/73).