C3 nephritic factor and SLE: report of four cases and review of the literature.

We present four patients with C3 nephritic factor associated with partial lipodystrophy and/or mesangiocapillary glomerulonephritis type II. Each of these patients subsequently developed features of SLE, with an onset between 2 and 24 years after the development of the lipodystrophy or glomerulonephritis. All four patients had antinuclear antibodies and three of the four had anti-Ro antibodies. These patients bring to six the number of reported cases of this association. Possible explanations for the link between these two conditions are discussed.

Gender, depression, and ankylosing spondylitis.

Depression has been established as a common reaction to rheumatoid arthritis but has rarely been investigated among people with other forms of arthritis. The present study examined the prevalence and determinants of depressive symptoms in people with ankylosing spondylitis, focusing on gender differences and set in the context of widely held medical views concerning the psychosocial nature of ankylosing spondylitis patients. Results showed that approximately one third of the ankylosing spondylitis patients reported a high level of depressive symptoms and that women reported more depression than men. No evidence was found to support the stereotype of the "typical" ankylosing spondylitis patient as being less depressed than people with other forms of arthritis. Pain was found to be a major determinant of depression for women, but was of lesser importance for men. The implications of these findings are discussed.

Parasymphyseal and associated insufficiency fractures of the pelvis and sacrum.

Eleven post-menopausal women presenting with a parasymphyseal insufficiency fracture of the pubis are reported. The plain radiographs showed delayed healing with a mixed lytic and sclerotic area developed at the fracture site simulating a malignant lesion. Aetiological factors included post-menopausal osteoporosis, rheumatoid arthritis and steroid therapy, previous hip replacement and pelvic radiotherapy. Ten patients had concomitant fractures of the pelvis, including nine with sacral fractures. These were all initially missed on presentation because of the subtle radiographic signs of a longitudinal band of sclerosis, usually bilaterally, in the sacral ala. Bone scanning was shown to be the most sensitive technique in detecting the sacral fractures by demonstrating increased uptake in the sacral ala as well as the other fractures of the pelvis. Computed tomography in three cases was helpful in confirming the presence of fractures and excluding the possibility of malignancy.

Health locus of control, self-help and treatment adherence in relation to ankylosing spondylitis patients.

Ankylosing spondylitis (AS) is a form of arthritis characterised by an early onset and an active style of treatment involving regular exercise. Self-help groups for AS patients have developed in many countries as a means of promoting exercise treatment. The empirical section presents a comparative study of members and non-members of such groups along psychosocial dimensions including health locus of control, social support, and health behaviour. Self-help group members were distinguished by a combination of factors including a low reliance on powerful others health locus of control beliefs, greater satisfaction with available support, and increased frequency of exercise. A subsample showed improvements on physiological measurements over a 6-month period. The utility of including psychosocial variables in examination of rheumatic diseases is discussed and practical implications of these findings for health care professionals and future research are considered.

Septic arthritis and thigh abscess after dilatation and curettage.

A previously fit 57-year old housewife who developed a septic arthritis of the right knee and abscess in the right thigh after dilatation and curettage is described. This is the first report of joint and soft tissue complications occurring together after this procedure. Despite antibiotic therapy which eradicated the joint infection, the abscess required surgical intervention. This illustrates the potential morbidity of septic complications after a minor surgical procedure.

IgA-alpha 1 antitrypsin complexes in ankylosing spondylitis.

A study of 95 serum samples from 61 patients with ankylosing spondylitis (AS) showed that 21 patients (34%) had raised levels of IgA-alpha 1 antitrypsin complexes. These were associated with active disease as measured by a clinical index and also with erythrocyte sedimentation rate, C reactive protein, and serum IgA. In particular, an association was noted between 'extraspinal' manifestations of AS such as synovitis, uveitis, and active inflammatory properties of these complexes. It is suggested that these complexes may have a role in the pathogenesis of such clinical manifestations.

Do gold rings protect against articular erosion in rheumatoid arthritis?

OBJECTIVE: To examine the hypothesis that gold rings might delay articular erosion at the metacarpophalangeal (MCP) joint of the left ring finger in ring wearers with rheumatoid arthritis (RA). METHODS: Consecutive patients with RA were recruited. They were classified as ring wearers if they had worn a gold ring on the left ring finger throughout most of the time since disease onset, or as non-ring wearers if they had never worn a gold ring. Standard hand radiographs (with rings removed, where possible) were taken and articular erosion was quantified at the MCP and proximal interphalangeal joints. RESULTS: Thirty ring wearers (27 female) and 25 non-ring wearers (12 female) were included. The median (25th-75th centile) Larsen score in the left hand ring MCP joint of ring wearers was 1.0 (1.0-2.0), which was significantly less than in their equivalent right hand joint (1.0, 1.0-5.0, p = 0.01). It also tended to be less than the equivalent left hand joint of non-ring wearers (4.0, 1.0-5.0, p = 0.06), with a similar but significant difference observed at the adjacent middle finger MCP joint (p = 0.01). CONCLUSIONS: The results of this preliminary study suggest that there may be less articular erosion at the left hand ring, and perhaps adjacent, MCP joints observed in ring wearers with RA. These data support the hypothesis that gold could pass from a gold ring through skin and local lymphatics 'downstream' to nearby MCP joint in sufficient quantities to delay articular erosion.

Use of interferon-2 alpha in the treatment of cryoglobulinaemic leg ulcers.

We report three cases of leg ulcers complicating cryoglobulinaemia which resisted conventional therapy but responded to interferon-2 alpha. All three cases improved with the complete resolution of painful vasculitic lesions and healing of deep ulcers. The dose of interferon to produce ulcer healing was determined by individual response with escalation of the daily dose to 4.5 x 10(6) units per day required in one case. A lower dose of maintenance interferon could be used to prevent subsequent relapses of disease.

The use of 'alternative treatments' by patients with rheumatoid arthritis.

In a study of 199 patients with rheumatoid arthritis, 68% were found to have tried 'alternative treatments'. Some treatments (acupuncture and faith healing) gave subjective benefit in nearly half those who tried them and were considered to be better than others (such as copper bracelets). No adverse reactions were reported. 'Alternative treatments' play an important role as self prescribed therapy in rheumatoid arthritis and their use should not be ignored nor underestimated.

The assessment of radiological changes in the hands and wrists in rheumatoid arthritis.

Two methods of assessing changes in hand and wrist radiographs, the Larsen Index and Amos Index, were compared and contrasted in 48 patients with rheumatoid arthritis (RA). X-rays were taken before and after 1 year of treatment with remission-inducing drugs and scored independently by three observers using both methods. Single readings of radiographs using the Larsen Index were highly reproducible (intra- and inter-observer correlations greater than 0.90 on all occasions), but reproducibility fell when changes were determined from paired films (intra- and inter-observer correlations 0.47-0.82). Variability was greatest in the proximal interphalangeal and wrist joints. The Amos Index, which assesses erosive progression and not the appearance of single films, was more reproducible (intra- and inter-observer correlations 0.72-0.94); it would therefore be better able to detect small changes in groups of patients. The scoring systems were significantly correlated (r = 0.63; P less than 0.001), and with both different observers scored the films at the same "level'. The Amos Index is simple, reproducible, and does not require standard films. It is the assessment of choice.

Fenclofenac-induced selective IgA deficiency in rheumatoid arthritis.

A 35-year-old man with seropositive rheumatoid arthritis developed selective IgA deficiency during treatment with fenclofenac. His arthritis remained quiescent while taking the drug and following its withdrawal his condition relapsed and his serum IgA level returned to normal. This case demonstrates the association of selective IgA deficiency with remission in rheumatoid arthritis induced by fenclofenac as well as aurothiomalate and sulphasalazine. It also shows severe relapse after withdrawal of fenclofenac.

Hereditary arthro-ophthalmopathy (Stickler syndrome): a diagnosis to consider in familial premature osteoarthritis.

A number of factors contribute to the pathogenesis of osteoarthritis. Genetic factors are predominant in some cases, including the syndrome of hereditary arthro-ophthalmopathy. The clinical features of the syndrome and the concept of genetic mutations in matrix components are discussed.

Basophils, histamine and gastric acid secretin in chronic myeloproliferative disorders.

Fourteen patients with polycythaemia rubra vera (PRV) and four with chronic granulocytic leukaemia (CGL) were studied to examine the relationship between basophil counts, blood histamine, gastric acid secretion and dyspepsia or peptic ulceration. Basophil counts and blood histamine were markedly raised in untreated CGL but only marginally increased in other cases. Blood histamine and basophil counts were well correlated. Gastric acid secretion was normal in 10 out of 11 cases, and did not correlate with blood histamine values. The previously reported high incidence of dyspepsia and peptic ulceration is examined and its mechanisms are discussed.

Partial finger loss: an indicator of severe connective tissue disease with overlap features.

Six patients are described with partial finger loss due to severe Raynaud's syndrome. In all cases the vascular changes were an early feature of a connective tissue disease with overlap features. It was a poor prognostic feature often heralding severe multisystem involvement with life threatening and on one occasion fatal consequences.

Musculoskeletal disorders in patients with hyperlipidaemia.

We have assessed the nature and significance of musculoskeletal disorders in 166 patients with the commonly encountered forms of hyperlipidaemia attending a lipid clinic. The incidence of musculoskeletal disorders was determined by questionnaire to the patients, inquiries to general practitioners, and a review of hospital records. To ensure the sensitivity of these methods a series of negatively responding cases were seen and examined; none had identifiable musculoskeletal disease. Eight males with type IV hyperlipidaemia had recurrent acute attacks of gout. The only other musculoskeletal disorder possibly attributable to an association with hyperlipidaemia was a transient polyarthritis in 3 patients. This was inflammatory, recurrent, but nondeforming, and involved the small joints of the hand. It did not require any specific therapy or lead to disability. We suggest that, while we have confirmed the association of type IV hyperlipidaemia and gout, there is little evidence for clinically significant arthritis being associated with other commonly presenting forms of hyperlipidaemia, although we accept that the rarely met homozygous familial hypercholesterolaemia may also be complicated by a crystal arthropathy due to the presence of crystalline cholesterol in joints.

Progression of radiological changes in rheumatoid arthritis.

A prospective study over one year of patients who had active rheumatoid arthritis discovered 64 who had received treatment for an adequate time with second-line drugs. In these patients there was evidence of continuing joint destruction as shown by radiological progression. During the year there were highly significant correlations between improvements in clinical and laboratory measurements, but neither group of tests was related to the degree of radiological change. However, in the second 6 months of treatment there was evidence that radiological progression was reduced. In a second prospective study of 88 patients with rheumatoid arthritis given prolonged, intensive therapy with second-line drugs and followed up for 10 years two-thirds showed radiological progression. However, the number of joints damaged per year fell significantly during the study period. There was a divergence between deterioration in radiological features and improvements in the ESR and functional capacity, though patients with a persistently low ESR had less radiological progression. These studies provide evidence that treatment may be associated with a reduced rate of radiological progression but suggest that changes in radiological progression and clinical and laboratory measurements may result from different mechanisms.

Ultrastructural changes in the rectal mucosa of patients with rheumatoid arthritis.

The rectal mucosa from patients with severe rheumatoid arthritis has been examined by electron microscopy. Initially the patients were biopsied for investigation into the diagnosis of amyloidosis or vasculitis, which proved to be negative. A range of ultrastructural abnormalities was found which included proliferation of the rough endoplasmic reticulum, mitochondrial inclusions, association of the mitochondria with cytoplasmic filaments, and marked increase in the number of iron containing siderosomes. Most of these abnormalities have already been reported in rheumatoid synovial tissue, and attention is drawn to the similarity in findings between these two sites.

Whipple's disease diagnosed at hip arthroplasty.

A patient is reported with a six-year history of seronegative inflammatory arthritis, lymphadenopathy, and a rash. Many investigations, including repeat jejunal and synovial needle biopsies, failed to establish the diagnosis. Eventually right hip destruction led to arthroplasty. Synovial membrane obtained at operation was examined by electron microscopy and organisms were found with the morphological characteristics of those in patients where the diagnosis was firmly established as Whipple's disease. We propose that Whipple's disease should be seriously considered as a rare but distinct and treatable possibility in the differential diagnosis of seronegative inflammatory arthritis.