Intravascular degranulation of neutrophils: an important factor in inflammation?

Polymorphonuclear leukocytes are degranulated in the lumens of vessels in synovial membrane in humans with various types of inflammatory arthritis and in dogs with synovitis induced by urate crystals. This degranulation, accompanied by the release of lysosomal enzymes and vasoactive materials, may be an important part of the mechanism resulting in vascular injury.

Presenting features and outcomes in patients undergoing temporal artery biopsy. A review of 98 patients.

BACKGROUND: Although temporal arteritis is a well-recognized syndrome, controversy still exists regarding the optimal approach to diagnosis and treatment of this condition. We undertook this review to further define the spectrum of presenting features and outcomes of patients undergoing temporal artery biopsy. METHODS: We reviewed the records of all patients undergoing temporal artery biopsy over a 5-year period. Presenting features were compared in biopsy-positive and biopsy-negative patients. In patients with positive biopsy specimens, treatment regimens, disease, treatment-related morbidity, and outcomes were recorded. Alternative diagnoses and therapy were reviewed in biopsy-negative patients. RESULTS: Of 98 patients, 30 had positive and 68 had negative biopsy specimens. Biopsy-positive patients had an increased incidence of headache (93% vs 62%), jaw claudication (50% vs 18%), and prior polymyalgia rheumatica (23% vs 3%), but the sensitivity and specificity of these indicators were relatively low. Other clinical and laboratory parameters, including prior steroids and erythrocyte sedimentation rate, were similar between the two groups. In 30 patients with positive biopsy specimens, response to initial high-dose steroid was excellent. Serious manifestations after initial treatment were not seen, but mild flares were common after 1 year of therapy. Steroid-related morbidity was common, and steroids were seldom discontinued (0/22 patients at 1 year, 6/19 patients at 2 years, 5/11 patients at 3 years). In 68 patients with negative biopsy specimens, alternative diagnoses included neurologic diseases (15 patients), "pure" polymyalgia rheumatica (14 patients), and other inflammatory rheumatologic diseases (10 patients). Fourteen patients with negative biopsy specimens were treated for temporal arteritis, and were similar to biopsy-positive patients. CONCLUSIONS: Temporal arteritis remains a challenging condition to diagnose and to treat. Presenting features are seldom helpful in predicting biopsy results. Initial treatment is effective but frequently toxic. Although late disease-related complications are rare, most patients continue to take long-term low-dose steroid therapy.

Residual pulmonary abnormalities in adult patients with chronic paracoccidioidomycosis: prolonged follow-up after itraconazole therapy.

Itraconazole effectively controls active paracoccidioidomycosis but appears not to hinder lung fibrosis. Clinical records and chest radiographs from 47 itraconazole-treated patients with prolonged posttherapy follow-up (mean follow-up period, 5.6 years) were analyzed; the radiographs were interpreted following pneumoconiosis standards that consider the lungs as 6 fields and grade damage according to the number of fields involved. Infiltrative lesions were observed at diagnosis in 93.6% of the patients. Fibrosis was observed in 31.8% of the patients at diagnosis and had not cleared at the end of the observation period in any of these patients. Fibrosis also developed de novo in 11 patients (25%), so that by the end of the follow-up period it was seen in 53.2% of patients overall. Fibrosis correlated with severity of infiltrates at diagnosis: fibrosis was present in 83% of patients with very severe infiltration and in 12.5% of patients with minor infiltration. Among patients with severe infiltration, fibrosis was present in 30%; this increased (to 75%) when bullae were concomitantly present at diagnosis. Prompt initiation of treatment is necessary to avoid the development of fibrosis.

Musculoskeletal infections in patients with human immunodeficiency virus infection.

Musculoskeletal infections constitute an unusual clinical manifestation in patients with human immunodeficiency virus (HIV) infection. Available information about patients' characteristics and their clinical course has been obtained mainly from case reports and small retrospective studies. Our retrospective study is the largest in the literature providing detailed information about the clinical and laboratory characteristics of HIV-infected patients with different musculoskeletal infections. We identified 30 patients with various infections of the musculoskeletal system during a 5-year period among a cohort of 3,000-4,000 HIV-infected patients, and we describe them along with all cases of musculoskeletal infections in patients with HIV reported in the literature since 1985. Septic arthritis was the most commonly reported infection of the musculoskeletal system. It usually affects young men with a median CD4 count of 241. The exact contribution of a previous history of intravenous drug abuse in the pathogenesis of septic arthritis is unclear from the present and previous studies. Staphylococcus aureus was the most commonly isolated agent (31.3%). Numerous atypical pathogens were also identified as causes of septic arthritis. Approximately 90% of patients recovered with appropriate antibiotic treatment. Osteomyelitis was a more serious infection which also affected young individuals but with lower CD4 counts (median, 41). Half the cases were due to atypical mycobacteria. The mortality rate in the previously reported cases and in our series was high (20%). Pyomyositis is an increasingly recognized infection of the striated muscles in HIV-infected patients. It affects almost exclusively males with advanced HIV infection (median CD4 count, 24). Most cases are due to Staphylococcus aureus (67%). Drainage of the involved muscle(s) accompanied by proper antibiotic treatment resulted in resolution of the infection in the majority of patients (90%). Although the incidence of musculoskeletal infections in patients with HIV from this and previous studies appears to be low (0.3%-3.5%), these infections add a significant morbidity and mortality in the affected individuals. Better understanding of their pathogenesis and clinical course would aid the proper diagnosis and management of these infections.

Human parvovirus B19 arthropathy in two adults after contact with childhood erythema infectiosum.

An arthropathy has been recently described in association with human parvovirus infection (HPV-B19). Human parvovirus B19 has also been implicated as the etiologic agent in erythema infectiosum, a childhood exanthem that may occur in adults in association with joint manifestations. In this study, two adults are described, in whom an acute arthropathy and rash developed after contact with children with erythema infectiosum.

Synovial fluid lipid abnormalities in various disease states: review and classification.

Although lipids are not usually present in large quantities in normal synovial fluids or in the usual synovial fluid seen in most rheumatologic conditions, their presence in synovial fluid may have diagnostic importance. As summarized in Table 2, analysis of synovial fluids for lipid constituents is relatively simple. On standing or after centrifugation, significant amounts of lipids may layer out and be visible as a supernatant. On microscopic examination, lipid droplets are usually easily seen and should be stainable with appropriate dyes (oil red O or Sudan III or IV), or may occasionally be visualized as intracellular or extracellular inclusions by polarized microscopy. Small (0.5 to 2.0 microns) intracellular inclusions containing triglycerides may be seen in neutrophils from most synovial fluids, and are of no diagnostic importance. Cholesterol crystals may be readily recognized microscopically by their characteristic flat, plate-like appearance and notched corners Synovial fluid may also be analyzed for cholesterol and triglycerides in routine clinical laboratories, and free fatty acids and lipolytic enzymes in special lipid laboratories. The presence of massive increases in cholesterol associated with microscopically visible cholesterol crystals is usually associated with chronic RA, occasionally in the setting of super-imposed bacterial infection. The presence of gross or microscopic lipid droplets is usually associated with trauma and hemorrhagic effusions. When present in this setting, the clinician should entertain a high suspicion for a significant intraarticular injury, such as fracture, meniscal tear, or severe ligamentous injury. In addition, however, several instances of non-traumatic inflammatory effusions associated with intracellular and extracellular lipid droplets have been reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Crystal-associated arthritis in the elderly.

The understanding of the clinical syndromes of gout and pseudogout, and the role of basic calcium crystals in arthritis has increased since the original descriptions of the involvement of crystals in arthritis. Gout is usually considered an affliction confined to middle aged males but has an increasing prevalence in older populations, with unique and often atypical features. Calcium pyrophosphate dihydrate crystal deposition disease is common in elderly patients. The diagnosis of these common forms of arthritis and the need to individualize therapy in patients with other medical problems remain important clinical challenges to the practicing physician.

Pain behavior of rheumatoid arthritis patients enrolled in experimental drug trials.

OBJECTIVE: This study examined the sensitivity of a behavioral observation method for the assessment of arthritis pain as an outcome measure in clinical drug trials. METHODS: The subjects were 33 rheumatoid arthritis patients who were receiving either an active experimental drug or a placebo. Disease activity measures, self-reports of pain, and pain behavior observations were completed for each subject prior to drug initiation, 6 weeks after drug initiation, and 12 weeks after drug initiation. RESULTS: Significant reductions in measures of disease activity and self-report of pain were found for the subjects who received an active drug, relative to those who received the placebo. The pain behavior scores produced by both groups of subjects remained relatively stable during the study. CONCLUSION: The lack of change in pain behavior suggests that arthritis pain behavior may lack sensitivity to short-term changes accompanying drug therapy.

Observation of pain behavior in rheumatoid arthritis patients during physical examination. Relationship to disease activity and psychological variables.

This study examined the reliability and validity of a behavioral observation method for the assessment of arthritis pain in a clinical practice setting. Trained observers measured the occurrence of seven pain behaviors in a group of 61 rheumatoid arthritis patients undergoing physical examinations. These observations were compared with videotaped observations of the patients in a laboratory setting. Significant differences were found between the pain behavior frequencies observed during the examinations and those observed during videotaped sessions. Total pain behavior scores obtained in both settings were significantly correlated with patients' self-reports of pain and with disease activity measures. Pain behavior observed during the exams was significantly associated with patients' self-reports of anxiety and depression.

Ichthyosiform and morpheaform sarcoidosis.

Specific (usually papules and nodules showing a granulomatous histology) and non-specific (e.g. erythema nodosum) cutaneous lesions presenting manifestations of sarcoidosis have been well described. Two patients with unique presentations are here described; one with ichthyosiform cutaneous lesions and one with not previously described cutaneous lesions which mimicked linear morphea (localized scleroderma). The association of articular manifestations without pulmonary involvement was also unusual.

Clinical evaluation of radiographic progression in rheumatoid arthritis.

Four rheumatologists and 2 radiologists utilized 3 reading techniques to evaluate clinical radiographic progression in selected serial hand and wrist films from 5 rheumatoid arthritis patients. The carpometacarpal radio determinations were the most internally consistent; global assessment and total erosion + joint space narrowing scores showed the best between-method correlations; and the erosion + joint space narrowing scores depicted most sensitively the progression over time which was not affected by immunomodulating agent or non-steroidal anti-inflammatory agent therapy. In this study, instructed, non-experienced readers detected rheumatoid radiographic progression utilizing readily available scoring techniques.

Temporal arteritis in Sjögren's syndrome.

We report the first case of co-existing temporal arteritis and Sjögren's syndrome in the English language literature. Characteristic clinical and laboratory findings of both disorders were present. The combination of these two illnesses could be on the basis of chance alone or there may be a common etiology. Temporal arteritis could therefore be an addition to the spectrum of vasculitis diseases seen in Sjögren's syndrome.

Optimal management of gout in older patients.

Gout in older patients tends to be sub-acute to chronic, often tophaceous, polyarticular, erosive, symmetrical, and causes persistent, recurrent and chronic arthritis. Clinically, it may closely mimic rheumatoid arthritis; thus, a correct diagnosis requires a high index of clinical suspicion and the identification of uric acid crystals. An optimal therapeutic strategy for most older patients with chronic tophaceous gout could involve the following: avoidance of alcohol and diuretic use if possible; avoidance of long term nonsteroidal anti-inflammatory drug (NSAID) therapy; use of short term corticosteroids (systemic or intra-articular) for acute exacerbations; prophylactic colchicine daily or every other day according to the degree of renal dysfunction present; and long term allopurinol therapy in dosages adjusted to the degree of hyperuricaemia and renal dysfunction.

Psychological approaches to the management of arthritis pain.

The present review examines the literature regarding the efficacy of cognitive-behavioral and other self-control interventions in helping arthritis patients reduce their pain and functional disabilities. The evidence indicates that self-control interventions have produced significant and positive changes in the pain and functional disabilities of patients with rheumatoid arthritis and arthritis secondary to hemophilia. However, the literature suffers from deficiencies with regard to the use of small subject samples; inadequate control procedures and follow-up assessments; failure to demonstrate that positive outcomes are related to changes in subjects' covert experiences or control of physiological variables; and reliance upon self-report measures of outcome. The review is followed by a description of a multidisciplinary study of the efficacy of a biofeedback-assisted, cognitive-behavioral group therapy program for rheumatoid arthritis patients that features several methodological improvements relative to previous investigations. The preliminary outcome data show that the cognitive-behavioral intervention is associated with reductions in pain behavior and self-reports of pain and disability. It is concluded that, although the self-control interventions have shown promising results, psychologists must demonstrate positive and reliable outcomes among large numbers of arthritis patients over extended periods of time if the interventions are to be viewed as credible by rheumatologists.

Rheumatoid factor and monosodium urate crystal-neutrophil interactions in gouty inflammation.

A monolayer system was designed to study the interactions between human neutrophils and monosodium urate crystals important in gouty inflammation. The effects of rheumatoid factor on gouty inflammation were then examined in this system and in patients with acute gouty arthritis. Monosodium urate crystal phagocytosis was apparent at 30 min, and this phagocytosis was accompanied by lysosomal enzyme release and decreased neutrophil adherence to plastic petri dishes. Rheumatoid factor did not affect phagocytosis, adherence, or lactic dehydrogenase release and appeared to variably enhance lysosomal enzyme release. Two of 19 acute gouty patients were found to have low titers of rheumatoid factor and, of these, one exhibited mild disease and the other tophaceous destructive disease.

Case report: coexistence of acute calcific periarthritis and infection.

Basic calcium phosphate (BCP) crystal deposition around the joints may sometimes lead to an acute inflammatory condition called calcific periarthritis. In this article, the authors describe a 62-year-old man with BCP crystal-induced periarthritis coexisting with an infection. Rheumatoid arthritis and crystal-induced synovitis complicated by infection has been described in the literature. To date, this is the first report of coexistent calcific periarthritis and an infection.

Case report: arthropathy as the presenting symptom in hereditary hemochromatosis.

Hemochromatosis is characterized by excessive absorption and subsequent deposition of iron in various organs and is prevalent in 1 out of 20,000 hospitalized patients. Most patients with hereditary hemochromatosis (HHC) become symptomatic between the ages of 50 and 60 years. Distinct forms of arthritis have been associated with HHC and may be the initial clinical manifestation in some patients. This is a case of a patient who had chronic hip and back pain and painless swelling over the knuckles. Radiographs revealed classical signs of HHC. Early recognition and prompt institution of phlebotomy can improve the outcome of patients with HHC.

Crystal-associated arthritis.

Since the original descriptions of the involvement of crystals in arthritis, understanding of the clinical syndromes of gout and pseudogout and the role of basic calcium crystals in arthritis has increased. Gout is a common problem in middle-aged males but has an increasing prevalence in older patients, particularly women. Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is now a well-recognized problem in older patients. The diagnosis of both of these common forms of arthritis and the need to individualize therapy in patients with other medical problems remain important clinical challenges to the practicing physician.

Prevalence of Trypanosoma cruzi and Leishmania chagasi infection and risk factors in a Colombian indigenous population.

This study was carried out in order to obtain base-line data concerning the epidemiology of American Visceral Leishmaniasis and Chagas' Disease in an indigenous population with whom the government is starting a dwelling improvement programme. Information was collected from 242 dwellings (1,440 people), by means of house to house interviews about socio-economic and environmental factors associated with Leishmania chagasi and Trypanosoma cruzi transmission risk. A leishmanin skin test was applied to 385 people and 454 blood samples were collected on filter paper in order to detect L. chagasi antibodies by ELISA and IFAT and T. cruzi antibodies by ELISA. T. cruzi seroprevalence was 8.7% by ELISA, L. chagasi was 4.6% and 5.1% by IFAT and ELISA, respectively. ELISA sensitivity and specificity for L. chagasi antibodies were 57% and 97.5% respectively, as compared to the IFAT. Leishmanin skin test positivity was 19%. L. chagasi infection prevalence, being defined as a positive result in the three-immunodiagnostic tests, was 17.1%. Additionally, 2.7% of the population studied was positive to both L. chagasi and T. cruzi, showing a possible cross-reaction. L. chagasi and T. cruzi seropositivity increased with age, while no association with gender was observed. Age (p<0.007), number of inhabitants (p<0. 05), floor material (p<0.03) and recognition of vector (p<0.01) were associated with T. cruzi infection, whilst age ( p<0.007) and dwelling improvement (p<0.02) were associated with L. chagasi infection. It is necessary to evaluate the long-term impact of the dwelling improvement programme on these parasitic infections in this community.

Chlorpromazine-induced lupus with cardiac tamponade.

Although the association of the phenothiazines with immunologic abnormalities is well known, reports of clinical lupus erythematosus are rare. We describe a 52-year old schizophrenic man on chronic chlorpromazine therapy who developed fever and pleuropericarditis with cardiac tamponade. Examination of the pleural and pericardial fluids showed anti-nuclear antibodies. The clinical syndrome responded to a short course of steroids and discontinuation of the chlorpromazine. Drug-induced lupus is a self-limited illness that resolves without long-term sequelae. However, patients should be observed carefully because cardiac tamponade may occur.