Musculoskeletal manifestations in liver transplantation recipients.

BACKGROUND: The prevalence and type of musculoskeletal problems among liver transplant recipients have not been well characterized in the current literature. OBJECTIVE: We conducted a retrospective analysis of both outpatients and inpatients (total 234) who underwent liver transplantation or had rheumatologic consultation during 2002-2004, to document the cause for their rheumatologic symptoms. We hypothesized that infection, crystal diseases, and corticosteroid complications would be more common in this cohort of immunosuppressed patients as compared with de novo connective tissue disease. RESULTS: Among the outpatients, we found that arthralgia presumably secondary to tacrolimus/sirolimus; osteoarthritis, peripheral neuropathy, and myalgia were the most common diagnoses. The only autoimmune disease documented was Hepatitis C Virus-associated cryoglobulinemic vasculitis. Hyperuricemia was also prevalent in this patient population. Infection and gout were seen frequently among the inpatients. CONCLUSIONS: It is important for physicians to be cognizant of the variety and prevalence of musculoskeletal disorders in the liver transplantation patient population.

Rituximab Not Effective for Hearing Loss in Cogan's Syndrome.

Importance. Rituximab was not effective in ameliorating the hearing loss in a patient with atypical Cogan's syndrome. Observations. We report the case of a patient who developed acute bilateral uveitis and sensorineural hearing loss. A diagnosis of atypical Cogan's syndrome was made. The patient's hearing loss did not improve despite high dose steroids and azathioprine. Rituximab was administered given a recent report of its efficacy in a patient with refractory disease; however, our patient's hearing loss did not improve. Conclusion. Hearing loss in Cogan's syndrome is difficult to treat. Though rituximab was ineffective in our case, earlier administration in the disease course could be effective for future patients.

Acute Myopericarditis Likely Secondary to Disseminated Gonococcal Infection.

Disseminated gonococcal infection (DGI) is a rare complication of primary infection with Neisseria gonorrhoeae. Cardiac involvement in this condition is rare, and is usually limited to endocarditis. However, there are a number of older reports suggestive of direct myocardial involvement. We report a case of a 38-year-old male with HIV who presented with chest pain, pharyngitis, tenosynovitis, and purpuric skin lesions. Transthoracic echocardiogram showed acute biventricular dysfunction. Skin biopsy showed diplococci consistent with disseminated gonococcal infection, and treatment with ceftriaxone improved his symptoms and ejection fraction. Though gonococcal infection was never proven with culture or nucleic acid amplification testing, the clinical picture and histologic findings were highly suggestive of DGI. Clinicians should consider disseminated gonococcal infection when a patient presents with acute myocarditis, especially if there are concurrent skin and joint lesions.

Mycobacterium kansasii causing chronic monoarticular synovitis in a patient with HIV/AIDS.

Mycobacterium kansasii is a nontuberculous mycobacterium that primarily causes pulmonary disease in AIDS patients, however it has also been known, rarely, to result in skeletal infection. When skeletal infection occurs, the time from onset of symptoms to diagnosis is up to 5 years in previously reported cases. We describe a 48-year-old woman with HIV/AIDS who presented with chronic, isolated left knee pain and swelling of over two decades which had recently worsened. Radiographs and magnetic resonance imaging demonstrated marked subarticular erosions, synovial thickening, and bone marrow edema, which had progressed compared with prior imaging done seven years earlier. Synovial biopsy grew Mycobacterium kansasii. Following the presentation of our case, clinical and imaging findings, including the differential diagnosis, of monoarticular arthritis caused by Mycobacterium kansasii are reviewed and discussed.

Inflammatory arthritis in the elderly.

The three most common inflammatory arthritic conditions affecting the elderly are reviewed, along with current information about the various treatments.

Inflammatory arthropathy: a review of rheumatoid arthritis in older patients.

Rheumatoid arthritis (RA) is the most common inflammatory synovitis in older adults. The primary care physician may see its presentatiion as the late stage of a long-term disorder, or alternatively as an elderly-onset disease. These two presentations of RA may differ significantly with respect to mode of onset, prevalence of associated systemic symptoms (eg, fatigue, weight loss, depression), criteria for diagnosis (eg, rheumatoid factor or rheumatoid nodules), progression of diseases and functional outcomes. Because RA is responsive to treatmentt, and new treatments are available, diagnosis of this disorder is imperative. Differential diagnostic possibilities and therapies are reviewed, with particular emphasis on the cause and effect of comorbid disease such as infection, osteoporosis, and cardiovascular disease.

Rheumatologists on the road: a subspecialist's role in caring for the homebound.

OBJECTIVE: By 2030, the number of permanently homebound individuals in the US will increase by 50% to reach 2 million. However, no medicine subspecialty consult services exist for this rising subset of the population. This pilot program establishes a rheumatology consult service for the Mount Sinai Visiting Doctors, the largest primary care academic home visit program in the nation serving more than 1,000 patients in New York City. Our service addresses the unmet need for homebound patients with rheumatic diseases, and secondarily provides an educational opportunity for trainees in community-based rheumatology. METHODS: Using an electronic medical record, home-based primary care physicians sent consult requests to the Rheumatology Division. Initial assessments were made using the Routine Assessment of Patient Index Data 3 (RAPID3) questionnaire. RESULTS: Over 12 months, 57 home visits were made: 31 new consults and 26 followup visits. Reasons for referral included medical management of a known connective tissue disease, question of inflammatory arthritis, and procedures. The demographics for new consults were as follows: 94% women, 45% Hispanic, and 80% between ages 60 and 101 years. Thirty-nine percent of patients had rheumatoid arthritis. Treatment interventions included addition of a disease-modifying antirheumatic drug in 11 patients, 11 procedures, nonpharmacologic management in 8 patients, and a change in the dose of the existing medication in 5 patients. At the initial evaluation, the average RAPID3 scores for patients reflected high severity of disease. CONCLUSION: The number of consults and the severity of disease seen highlight the importance of a rheumatologist's role in the community, especially because the number of homebound patients will dramatically increase in the future.

Opportunistic infections mimicking gastrointestinal vasculitis in systemic lupus erythematosus.

Patients with systemic lupus erythematosus who are on chronic immunosuppressive therapy are at risk for developing infectious complications. We present 2 cases of immunosuppressed patients with systemic lupus erythematosus who presented with abdominal complaints without other systemic lupus symptoms. These patients were initially thought to have gastrointestinal vasculitis based on preliminary pathologic reports; however, further workup and careful review of the pathologic specimens confirmed an opportunistic infection as the etiology in each case. It is critical that physicians maintain a high index of suspicion for infection when treating immunocompromised patients with systemic lupus erythematosus with abdominal complaints to avoid delay in appropriate treatment.

Refractory pulmonary hypertension in a lupus patient with occult pulmonary vasculitis.

Primary pulmonary hypertension is a disease that has become increasingly recognized in lupus patients. Pathologic findings from lupus patients usually do not differ from those who have idiopathic pulmonary hypertension. In recent years, intravenous vasodilator therapy has improved morbidity and mortality in patients with primary pulmonary hypertension. In this case report, we describe a young woman with severe pulmonary hypertension refractory to aggressive parenteral vasodilator treatment. Steroid treatment was initiated after a tentative diagnosis of lupus was made on the basis of the presence of Raynaud's phenomenon, proteinuria, pericarditis with tamponade, and a positive anti-Ro antibody. Despite treatment with vasodilators and steroids, the patient's condition rapidly deteriorated and she died. Unexpectedly, active pulmonary arteritis was demonstrated at autopsy. This case suggests that immunosuppressive therapy should be considered in lupus patients with severe pulmonary hypertension who are refractory to aggressive vasodilator therapy and high-dose parenteral steroids.