Insufficiency fractures of the distal tibia misdiagnosed as cellulitis in three patients with rheumatoid arthritis.

We describe 3 patients with rheumatoid arthritis who presented with diffuse pain, swelling, and erythema of the distal aspect of the lower extremity, suggestive of either cellulitis or thrombophlebitis, but were found to have insufficiency fractures of the distal tibia. The value of technetium-99m diphosphonate bone scintigraphy in the early recognition of these fractures and a possible explanation for the associated inflammatory symptoms are discussed.

Rheumatoid arthritis in American blacks: a clinical and radiological study.

Immunogenetic differences between American blacks and Caucasians have been described but a comparison of clinical and radiologic features between both groups has been lacking. Eighty-four American black and 166 Caucasian patients were randomly selected from our computer database and relevant clinical and demographic information obtained from records and interviews. Both groups were similar demographically, and no significant clinical differences were observed with regard to disease duration, frequency of extraarticular manifestations, use and toxicity from disease modifying antirheumatic drugs, RA related surgical procedures, disability, fatality rate and functional outcome. Our results suggest that seropositive RA is clinically and radiographically similar in both groups.

Radiographic assessment of disease progression in rheumatoid arthritis patients enrolled in the cooperative systematic studies of the rheumatic diseases program randomized clinical trial of methotrexate, auranofin, or a combination of the two.

OBJECTIVE: To determine the radiographic progression of disease in rheumatoid arthritis (RA) patients from the Cooperative Systematic Studies of the Rheumatic Diseases clinical trial of auranofin (AUR) versus methotrexate (MTX) versus a combination of the two. METHODS: Baseline (week-0) and study-end (week-48) hand/wrist radiographs in 200 of the 211 patients who completed this multicenter trial (95%) were scored blindly by 2 readers for the presence of erosions and joint space narrowing (JSN). Both intraobserver reliability and interobserver reliability were 0.80 for erosions (P < or = 0.001); intraobserver reliability and interobserver reliability were both 0.75 for JSN (P < or = 0.001). RESULTS: Worsening erosion and JSN scores occurred in all 3 treatment groups, but the difference from baseline reached significance only in the AUR group. CONCLUSION: Clinical improvement has been clearly documented in all 3 treatment groups in this trial. Radiographic deterioration occurs in RA even when clinical features improve, but progression of disease as determined radiographically may be slowed by treatment with MTX.

Should methotrexate be discontinued before elective orthopedic surgery in patients with rheumatoid arthritis?

To determine if methotrexate (MTX) contributes to early postoperative complications, we studied 38 patients with rheumatoid arthritis (RA) who underwent elective orthopedic surgery. There were 4 complications of prosthetic joint infection or wound dehiscence or infection among 19 procedures performed on patients who continued MTX until less than 4 weeks before surgery, compared to no complications among 34 procedures performed on patients who discontinued MTX 4 weeks before surgery or who were taking no remittive agent for 3 months before surgery (p less than 0.03, Fisher's exact, 2-tailed). No demographic, clinical, laboratory, nutritional, or intraoperative differences between the 2 groups were apparent, suggesting that MTX may play a role in early postoperative complications in patients with RA. A larger, prospective trial to study this issue is warranted.

Vasculitic neuropathy mimicking Guillain-Barré syndrome.

Vasculitic neuropathy classically manifests as a subacute mononeuritis multiplex or polyneuropathy. Patients with a Guillain-Barré syndrome (GBS)-like presentation are usually not considered to have an underlying vasculitis. We describe 2 patients with rapidly progressive areflexic paralysis that was initially diagnosed as GBS, in whom vasculitic neuropathy was found histologically.

Radiographic evidence of disease progression in methotrexate treated and nonmethotrexate disease modifying antirheumatic drug treated rheumatoid arthritis patients: a meta-analysis.

Methotrexate (MTX) has proven to be efficacious in the treatment of rheumatoid (RA), but it remains to be proven whether it can slow disease progression, as determined radiographically, in comparison with other disease modifying antirheumatic drugs (DMARD). We performed a meta-analysis of the available data to answer this question. A literature search, including abstracts, was conducted and inclusion criteria developed (description of patients, accountability of patients, inclusion of a control group of patients, specified radiographic endpoint, and appropriate reading of the radiographs). Publications were scored on a scale of 0 to 5 with a score > or = 3 required for inclusion in the study. For abstracts selected, additional data were obtained directly from the investigators. Data for 353 MTX treated and 205 non-MTX-DMARD treated patients with RA were gathered. Not all publications used the same scoring system, so some assumptions were required to analyze the combined data. Only the erosion score was included since not all publications included a reading of the joint space. All scores were transformed into Sharp scores (Arthritis Rheum 1985;28:1449), including the important contributions of 3 Larsen scored publications. Finally a monthly rate of disease progression was computed. Several comparisons were made. Overall, the rates of disease progression were similar for MTX and non-MTX-DMARD treated patients with RA. The non-MTX-DMARD treated patients with RA were separated into a group treated with gold salts (oral or parenteral) and a group treated with azathioprine with each group compared to the MTX treated patients. MTX had slower rates of disease progression than azathioprine, (rates 0.004 vs 0.012) but not slower rates than gold salts (0.008 vs 0.008). Despite its efficacy, the possible role of MTX in slowing disease progression more than other DMARD, as determined radiographically, appears to be evident only when compared to azathioprine.