Recent Advances in Psoriatic Arthritis from Obscurity to Prominence.

Psoriatic arthritis is a fascinating inflammatory arthritis. Till recently it did not generate interest for lack of understanding of its immunopathology, and lack of effective treatment. This has changed. PsA is now one of the hot topics - all due to elucidation of genetic susceptibility associations, immunopathogenesis and availability of effective therapy. In this communication we provide an overview of these aspects of psoriatic arthritis.

Anatomy of undiagnosed fever--a physician's perspective.

Undiagnosed fever is a vexing problem. The reasons why fever remains undiagnosed can be inherent to the underlying pathology, our shortcoming(s) or both. This article describes "our" causes based on cases seen over the years. It is apparent that with proper attention to details mystery of at least some undiagnosed fevers can be solved.

Infective endocarditis--a tale of two cases and the lessons (re)learned.

Infective endocarditis due to uncommon organisms or at uncommon sites presents a diagnostic challenge. Because signs and symptoms can be nonspecific and vary greatly, a high index of suspicion is necessary. We have recently treated two such cases, one due to HACEK organism (Eikenella corrodens) in a patient with established valvular heart disease and other of right sided endocarditis due to Pseudomonas aeruginosa. This report describes the diagnostic difficulties faced.

Giant cell arteritis in Mumbai.

OBJECTIVE: To study the clinical profile of patients with giant cell arteritis in Mumbai. METHODS: From our database, patients with a diagnosis of giant cell arteritis (GCA) over a fifteen year period (January 1990 to December 2005) were included. Clinical manifestations, temporal artery biopsy, treatment, and follow-up data of these patients were analyzed. RESULTS: Twenty one patients with GCA were identified. However, data were available only for 16 patients. The median age was 66.5 years (58-78 yrs) with male to female ratio of 1:1. The mean time from symptom onset to diagnosis was 5.18 months (0.5-24 months). Clinical manifestations included new onset headache (15), fever (9), weight loss (9), jaw claudication (9), polymyalgia rheumatica (5), visual disturbances (3), scalp nodule (1), temporal artery tenderness (11), tortuosity (9), and scalp tenderness (6). ESR was elevated in 15 patients with a median of 106.5 mm at 1 hr (25-135 mm/hr). Temporal artery biopsy was done in 11 patients and confirmed the diagnosis in 10 patients. Color doppler study of the temporal arteries (9 patients) revealed halo sign (indicating arterial wall edema) in 6 patients. Biopsy as per site by color doppler study was performed in 6 of these patients and was positive in 5. All patients had a good initial response to steroids, however, on follow up, 3 patients required addition of methotrexate. At a median follow up (n = 14) of 6 months (range 6-156), steroids were successfully stopped in 7 patients at 1 to 3 years interval. The disease relapsed in 1 patient. Of the remaining 7 patients, 2 were steroid dependent and 5 patients were doing well on low dose prednisolone. CONCLUSION: GCA, though uncommon in India, should be suspected in all elderly patients with a new onset headache, fever, jaw claudication, or high ESR. Color doppler sonography is a useful noninvasive method for the diagnosis of GCA and also helps to identify the site to biopsy. Most respond to steroid therapy while some need addition of steroid sparing agents.

Adult onset Still's disease: a study of 14 cases.

We studied the clinical profile, laboratory parameters, disease course, and outcomes of patients with adult onset Still's disease (AOSD). A retrospective analysis of adult patients with Still's disease diagnosed from 2000 to 2004 was carried out. Their clinical features and laboratory findings at presentation, disease course, and outcomes were analyzed. Data of 14 patients with Still's disease were analyzed. The age at disease onset ranged from 16 to 59 years with a mean of 29.85, the male to female ratio being 9:5. The mean duration of illness from onset of symptoms to presentation was 14.5 months (range). The most common clinical manifestations were fever (n = 14), articular symptoms (n = 14), rash (n = 8), weight loss (n = 12), and sore throat (n = 5). Elevated ESR was present in all patients with a mean of 98.3 mm at 1 h. Hepatic enzymes were elevated in seven patients at disease onset. The mean duration of follow up was 19.14 months (range). Three patients progressed to chronic arthropathy. Cyclosporine led to dramatic recovery in five patients. Macrophage activation syndrome (MAS) was present in two patients, one after sulfasalazine therapy. One patient with MAS died. Still's disease, although uncommon, has characteristic constellation of clinical and laboratory features and should be considered in the differential diagnosis of fever of unknown origin. Nonsteroidal anti-inflammatory drugs, steroids, and methotrexate may not be always effective, and cyclosporine is an effective drug in resistant cases. Sulfasalazine should be avoided in cases of AOSD.