A modified two-step treatment for actinomycetoma.

BACKGROUND: Combination antibiotic regimens are effective in the treatment of actinomycetoma but many treatment schedules require supervised parenteral therapy for prolonged periods. We describe a schedule that includes parenteral medication in an initial, short phase followed by a longer phase of oral medication. METHODS: Sixteen patients with clinically diagnosed mycetoma, who did not show any evidence of a fungal etiology, were treated presumptively for actinomycetoma. Evidence of actinomycotic infection was found on microscopy of granules / discharge and / or histopathological examination in eight (50%) patients. The treatment consisted of an intensive phase (Step 1) with gentamicin, 80 mg twice daily, intravenously and cotrimoxazole, 320/1600 mg twice daily orally for four weeks. This was followed by a maintenance phase with cotrimoxazole and doxycycline, 100 mg twice daily till all sinuses healed completely. The treatment was continued for 5-6 months. RESULTS: Treatment response was assessed monthly. At the end of the intensive phase, there was a significant improvement in all 16 patients. Nine patients who continued the maintenance phase of the regimen had complete healing of sinuses with marked reductions in swelling and induration in 2.4 +/- 1.7 months. Maintenance treatment was continued for a mean of 9.1 +/- 4.3 months in these patients. Six patients have remained free of disease activity during a follow-up period of 11.1 +/- 4.2 months after treatment was stopped. Two patients developed leucopenia and thrombocytopenia necessitating withdrawal of cotrimoxazole. CONCLUSION: This regimen was effective in treating actinomycetoma. The short duration of the phase requiring parenteral therapy makes it convenient to administer.

Sweet's syndrome with tendinitis.

A 30 years man presented with fever and skin manifestations in the form of multiple tender, erythematous, asymmetric nodules and papules predominantly over the upper arms and back. The nodules were coalescing to form irregular sharply demarcated plaques over the forearms and thighs. There were pustules over the nodules. He also had tendoachilles tendinitis. The total leucocyte count, differential count and skin biopsy confirmed the diagnosis of Sweet's syndrome (acute febrile neutrophilic dermatosis). This patient, a case of Idiopathic Sweet's syndrome with tendoachilles tendinitis responded to oral corticosteroids.

Pyomyositis in a HIV Positive Patient

A Humen Immunodeficiency Virus positive patient was referred to us to rule out polymyositis. Clinical examination revealed warm, indurated and tender swelling in the muscle plane at multiple sites. Ultrasonography revealed fluid collection in the muscle plane. Needle aspiration yielded pus and culture showed growth of staphylococcus aureus. The diagnosis of pyomyositis was made. The pus was drained and appropriate antibiotics were instituted.

Psoriatic arthritis.

AIM OF THE STUDY: To evaluate the clinical pattern of psoriatic arthritis in patients attending a tertiary referral centre in South India. METHODOLOGY: Case records of one hundred and sixteen patients with psoriatic arthritis (PsA) who had attended our Rheumatology Department were analysed using demographic, clinical, laboratory and radiographic variables and the data were compared with other studies. RESULTS: Among 116 patients, 78 were males and 38 were females (ratio 2:1). Peak incidence (69%) was in the fourth and fifth decades. One patient had juvenile psoriatic arthritis (onset <16 years of age). Symmetric polyarthritis (48.3%) was the commonest subtype. Arthritis followed the skin lesions in 50.8% of patients, preceded in 12.1% and occurred simultaneously in 37.1%. Knee (66.4%) was the commonest joint involved. Extra-articular features like sausage digits (19%), enthesitis (7.8%) and eye manifestations (1.7%) like conjunctivitis and uveitis were observed. Psoriasis vulgaris (81%) was the commonest psoriatic lesion. Scalp (57.8%) was the most common hidden site. All the three patients with DIP arthritis alone had nail lesions. ESR and C-reactive protein were elevated in 51.7% and 43.9% of patients respectively. Rheumatoid factor was positive in 3.4 % and antinuclear antibody (ANA) was present in 5.4% (3/56) of patients. HIV infection was detected in 2.3% (1/44) of patients. Radiographic features like sacroiliitis (11.2%), calcaneal spur (7.8%), erosions (5.2%) and syndesmophytes (5.2%) were observed. One patient had 'pencil-in-cup deformity'. CONCLUSION: Psoriatic arthritis is more common in males. Symmetric polyarthritis is the commonest subtype. Arthritis commonly follows the skin lesions. Psoriasis vulgaris is the most common skin lesion and scalp is the commonest hidden site. ESR and CRP can be normal in psoriatic arthritis.

Localized cutaneous sporotrichosis lasting for 10 years.

A case of localized cutaneous sporotrichosis lasting for 10 years is being reported. The fixed cutaneous variety creates diagnostic difficulty by mimicking other conditions, chiefly lupus vulgaris.

A follow-up study of juvenile rheumatoid arthritis into adulthood.

AIM OF THE STUDY: To study the clinical profile of various subtypes of juvenile rheumatoid arthritis (JRA) in adulthood and analyse the outcome of the disease in terms of functional status, educational achievement, growth abnormalities, radiological progression and activity of the disease. METHODS: From a group of 150 JRA cases, 26 adult patients were included in the study. All of them were under follow up since the onset of disease in childhood. Clinical data at the onset were obtained from old medical documents. Detailed clinical and laboratory assessment of all cases were done. RESULTS: There were 10 oligoarticular, 13 polyarticular and three systemic onset cases. Mean age of onset of disease was 11.7 +/- 3.39 years (range 2-15). Mean duration of follow up was 11.4 +/- 4.46 years range (6-22). Twenty-one patients had active disease. Ninety percent of oligoarthritis group were in class 1 status whereas none of the systemic onset JRA cases were in class I. Micrognathia, short stiff neck and short stature were noticed among polyarticular and systemic onset JRA. Seventy percent of oligoarthritis group developed inflammatory low back ache. Bony ankylosis of tarsal and carpal bones were seen in eight cases. CONCLUSION: In our study there is a male predominance in JRA. Pauciarticular (oligoarthritis) JRA occurring in older boys had the best functional outcome. Growth abnormalities and radiological changes were more common in polyarticular and systemic onset JRA.

Mixed connective tissue disease--clinical and immunological profile.

AIM OF THE STUDY: To study the clinical and immunological profile of mixed connective tissue disease (MCTD) in rheumatic disease population. METHODS: We retrospectively analyzed 6400 cases of rheumatic disease population who took treatment in the Department of Rheumatology, Madras Medical College, Chennai during the period of 1996 to 1999, in which eight cases fulfilled the preliminary diagnostic criteria of mixed connective tissue disease devised by Kasukawa et al. All eight cases were studied in detail. RESULTS: All cases were females between 23 to 50 years of age. Polyarthritis, Raynaud's phenomenon and sclerodactyly were present in all eight patients. Oesophageal abnormalities, pulmonary changes and myositis were present in six patients. Facial erythema was observed in five patients. Alopecia and oral ulcers were seen in four patients. Two patients had pulmonary hypertension and migraine like headache. One patient had diffuse proliferative glomerulonephritis as an interesting feature by renal biopsy. Pleuritis, pericarditis and trigeminal neuropathy with lower cranial nerve palsies were present in one case each. Immunological tests showed presence of antinuclear antibodies and anti U1 ribonucleoprotein (anti U1RNP) antibodies in all eight patients. CONCLUSIONS: Mixed connective tissue disease should be considered as an important syndrome in any patient who presents with heterogeneous clinical presentation and who do not fit into any definite criteria of systemic connective tissue disorders.

Late onset rheumatoid arthritis--a clinical and laboratory study.

AIM: To analyze the clinical and laboratory profile of late onset rheumatoid arthritis in comparison with early onset rheumatoid arthritis. METHODS: Fifty patients who satisfied 1988 American College of Rheumatology criteria for rheumatoid arthritis with the disease onset at 60 years or over were studied. Handred cases of early onset rheumatoid arthritis were taken as controls. All of them were followed up for 18 months. RESULTS: Female to male ratio was 1.6:1 in late onset rheumatoid arthritis and 4:1 in early onset group. Shoulder joint involvement was 48% in late onset and 28% in early onset rheumatoid arthritis. Rheumatoid factors was positive in 36% cases in late onset compared to 60% in controls. Most other clinical, laboratory and radiological features were comparable in both the groups. CONCLUSIONS: Late onset rheumatoid arthritis is characterised by a less female preponderance, more shoulder joint involvement and more seronegativity.

Juvenile rheumatoid arthritis--Madras experience.

In a prospective study of 1,053 consecutive children who attended the Rheumatic Care Centre, Government General Hospital, Madras from 1991 to 1995, 331 children fulfilled the criteria proposed by the American Rheumatism Association as modified by Cassidy et al for the diagnosis of Juvenile Rheumatoid Arthritis. These children were thoroughly examined and investigated and classified into 3 onset types which was then sub-classified into early entry and late entry groups based on the duration of illness. Other arthritic conditions were excluded. There were 44 cases belonging to Systemic onset, 171 belonging to polyarticular onset and 116 belonging to oligoarticular onset type. In the systemic onset type 44/44 patients had fever, 40/44 had lymphadenopathy and 19/44 had skin rash; wrists and knees 31/44 were the most commonly involved joints; neck involvement was present in 13/44 of the cases; ANA was positive in 5/44 cases and anaemia was seen in 24/44 cases. In polyarticular onset type wrists 119/171, knees 143/171, hip joints 105/171 and ankles 113/171 were commonly involved; in the RF +ve subtype 3/23 had subcutaneous nodules and 7/23 were positive for ANA; in the Rf -ve subtype 59/148 were positive for ANA. In the oligoarticular subtype-1 ANA was positive in all cases but iridocyclitis was not seen in any case. In oligoarticular subtype-2 HLA B27 was positive in 13/26 cases while Sacroilitis was seen in 16/26 cases. In oligoarticular type-3 HLA B27 was negative.

Problems in the diagnosis of AIDS related cryptococcal meningitis: a case report.

Cryptococcal meningitis in a 35-year old male who had a history of chronic alcoholism and sexual promiscuity, is presented here. The patient presented twice, 6 weeks apart, with altered sensorium. On the earlier occasion, CSF examination and CT head scan were entirely normal, while on the second occasion CSF abnormalities were found which led to the diagnosis of cryptococcal meningitis. The patient eventually tested positive for HIV by both the ELISA and Western Blot techniques. Diagnostic problems and management difficulties in AIDS-related cryptococcal meningitis are discussed.

Childhood systemic lupus erythematosus in south India.

Out of 330 adult Systemic Lupus Erythematosus (SLE) cases who attended the Rheumatic Care Centre, Government General Hospital, 59 children were analysed. There was no case with onset before the age of 5 years. There were 49 females and 110 males (M:F = 1:4.9). The initial manifestations were fever (67%), arthritis (61%), skin rash (59%) and lymphadenopathy (27.1%). There was no case of Raynaud's phenomenon. Only 10.1% of patients presented with thrombocytopenic purpura. In the cumulative clinical features, arthritis in 86.6%, fever in 79.8%, skin rash in 69.4%, lymphadenopathy in 61% and hepatosplenomegaly in 39.9% were observed. Renal involvement was seen in 49.1%, neuropsychiatric manifestations in 27.1%, pleuropulmonary in 22% and cardiac manifestations in 10.2%. Anaemia was seen in 50.8%, leukopenia in 18.4%, thrombocytopenia in 11.8%, ANA in 100%, anti-dsDNA in 92.3%, anti-Sm in 34.7%, anti-SSA in 38.5%, anti-SSB in 15.4%, ACL in 30.8%, low C3 in 50% and false positive VDRL in 3.3%. Death occurred in 8 children, 3 due to infection, 2 due to renal causes, 1 due to cardiac and 2 due to central nervous system involvement.

Progressive systemic sclerosis in south India.

Seventy eight patients with progressive systemic sclerosis (PSS) were seen over a period of 14 years. They were analysed after clinical, haematological, biochemical, immunological and radiological investigations for comparison with other Indian and Western studies. Nine of the 78 were cases of childhood PSS. There was a female preponderance (3.9:1) and the peak age of occurrence was the 4th decade (32.1%). Arthralgia (53.8%) and skin thickening (70.5%) were the common presenting symptoms. Raynaud's phenomenon (28.2%) was less common. Involvement of the skin was present in all the patients and skin biopsy was positive in 96% of the cases. Joints were affected in 66.7%; internal organs were involved in 52.6%. Antinuclear antibody was positive in 56.8%. Abnormal echocardiography (37.6%) and barium studies (20.4%) were seen. Restrictive airway pattern by pulmonary function test was present in 55%. Death occurred in 5 patients, of whom 3 died of severe pulmonary hypertension.