Articular histoplasmosis.

Rheumatic manifestations of histoplasmosis are uncommon. Polyarthritis or arthralgias may occur as a part of a sensitization process in primary acute histoplasmosis. Infectious arthritis may accompany disseminated histoplasmosis or occur as solitary monoarthritis. Treatment of the latter traditionally consists of surgical excision followed by amphotericin B. Reports of clinical experience with the newer triazole compounds in treating articular histoplasmosis are lacking. We describe a patient with solitary monoarticular histoplasmosis of the knee who was successfully treated with oral fluconazole and required no surgical intervention. Specific issues that pertain to clinical presentation and management of articular histoplasmosis are discussed.

A study of adverse effects of high-dose intravenous (pulse) methylprednisolone therapy in patients with rheumatic disease.

OBJECTIVE: To determine the frequency of significant adverse effects associated with high-dose intravenous methylprednisolone therapy (HIVMP) given as methylprednisolone 1 g/d for three consecutive days. DESIGN: Retrospective study of consecutive patients. SETTING: Department of Veterans Affairs Medical Center (VAMC), university teaching hospital, and private outpatient clinic. PATIENTS: Eighty-four patients given HIVMP for systemic rheumatic disease. MEASUREMENTS: Subjective complaints were elicited via a standardized questionnaire that identified adverse effects through organ system review. Medical records were reviewed for adverse effects occurring within two weeks of HIVMP therapy. RESULTS: Two hundred seventy-five HIVMP treatments were examined by either patient questionnaire (76 patients) and/or chart review (78 patients). Sixty-five patients described symptoms after HIVMP treatment. Most symptoms were transient in duration, mild in severity, and required no medical treatment. Chart review found 42 possible complications occurring within two weeks of HIVMP therapy. In 18 instances medical intervention was required for problems that included hypertension, seizures, gastric erosions, sepsis, and other infections. It is impossible to attribute all of the complications to HIVMP alone because of underlying disease, use of other medications at the time of therapy, or both. CONCLUSIONS: HIVMP has an acceptably low risk of significant adverse effects.

Long-term nonsteroidal antiinflammatory drug use and Helicobacter pylori infection.

This study investigates whether patients who take nonsteroidal antiinflammatory drugs are more likely to have Helicobacter pylori gastritis than age-matched individuals who do not take nonsteroidal antiinflammatory drugs, and whether patients who take nonsteroidal antiinflammatory drugs who are also infected with H. pylori are more likely to have dyspepsia, mucosal damage, or ulcers than those who are not infected. Two studies were performed, one serological and the other endoscopic, both in arthritis patients receiving nonsteroidal antiinflammatory drugs chronically. The presence of H. pylori was identified with a sensitive enzyme-linked immunosorbent assay test. One hundred eighty-three patients participated in the serological study and 75 patients in the endoscopic study. The frequency of H. pylori infection increased with age, independent of nonsteroidal antiinflammatory drug use; the age-adjusted frequency of H. pylori infection in arthritis patients paralleled that of 351 asymptomatic individuals without arthritis. The frequency of H. pylori infection increased from 30.7% in age group 21-30 years to 73.4% in age group 61-75 years. Nonsteroidal antiinflammatory drug-induced mucosal injury, either hemorrhages or erosions, was more frequent in those without H. pylori infection than with infection (61% vs. 32% for hemorrhages and 57% vs. 34% for erosions for those without and with H. pylori infection; only the difference in the frequency of hemorrhages was significant, P less than 0.05). No difference was observed in the presence of dyspeptic symptoms between those with and without H. pylori infection. These data suggest that nonsteroidal antiinflammatory drug-induced damage to the gastroduodenal mucosa does not increase the susceptibility to H. pylori infection.

Decreased activity of Reiter's syndrome after urethrectomy.

Reiter's syndrome is a chronic rheumatic disease that develops after infective urethritis or gastroenteritis and has a strong association with the HLA-B27 antigen. How these factors interact remains unclear. We present a patient with Reiter's syndrome who exhibited 2 novel features: unusually severe urethritis that produced strictures requiring surgery, and dramatic regression of his rheumatic manifestations following a urethrectomy.

Dyspepsia in NSAID users: the size of the problem.

Gastroduodenal intolerance is one of the major factors limiting the use of aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) in patients with rheumatic diseases. We previously demonstrated that dyspepsia was not a marker for ulcer in NSAID users. We have now evaluated dyspeptic symptoms in 245 arthritic patients (receiving 13 different NSAIDs) from the practices of two rheumatologists. Fifty-seven patients (23%) gave a history of previous peptic ulcers. Heartburn, indigestion, or sour stomach at least once within the past year was present in 62.5%; 36.7% had experienced these symptoms within the previous 2 months and 28.6% within the previous week. Only 39 patients (15.9%) had experienced dyspepsia more than once daily within the previous month, and 8 (3.3%) had dyspepsia greater than 5 times/day. Thirty-four of the 39 patients with daily dyspepsia claimed to obtain relief with cimetidine or antacids (34 patients) or food (2 patients), whereas 3 had not discovered anything that provided relief. Women smokers were more likely than nonsmokers to experience dyspepsia (p less than 0.001). Neither men smokers nor those with a history of previous ulcer were more likely to have dyspepsia than nonsmokers or those without a history of ulcer (p greater than 0.5). We were not able to find a statistical association between any NSAID, or combination of NSAIDs, and the frequency of dyspepsia.

Anterior sacral meningocele and tuberculous spondylitis of the sacrum in a patient with neurofibromatosis. Case report and review of the literature.

We report a case of an adult male with neurofibromatosis and chronic low back pain. Evaluation revealed an anterior sacral meningocele, pulmonary tuberculosis, and later in the course of his illness, an osteolytic tuberculous mass in the sacrum. The patient was treated medically with a good outcome. The nature of anterior sacral meningoceles and tuberculosis spondylitis, the differential diagnoses, and relevant treatment options are discussed.

Cerebral vasculitis in relapsing polychondritis.

Recurrent inflammation of cartilage in multiple sites is a hallmark of relapsing polychondritis (RP). Neurologic complications of this disease have begun to attract increasing attention, but the neuropathologic basis of these complications has not been described. We report a patient with RP whose autopsy showed extensive cerebral and systemic vasculitis.

Gastroduodenal mucosa and dyspeptic symptoms in arthritic patients during chronic nonsteroidal anti-inflammatory drug use.

Gastroduodenal intolerance is one of the major factors limiting the use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAID) in patients with arthritic conditions. We evaluated the endoscopic appearance of the gastroduodenal mucosa in 65 patients (63 men and two women) taking regular daily doses of NSAIDs over a long period for osteoarthritis or rheumatoid arthritis. Eight different drugs (indomethacin, ibuprofen, naproxen, sulindac, piroxicam, aspirin, salsalate, and tolmetin) had been taken continuously for at least 6 wk. Seven patients took two different NSAIDs. No other drug known to damage the mucosa was used. Twenty-one patients (32%) had an endoscopically completely normal stomach and duodenum, and 44 (68%) had evidence of injury (mucosal hemorrhage 44.6%, erosions 53.8%, both mucosal hemorrhage and erosions 34%). Ten patients had ulcers detected (seven gastric, two pyloric channel, one duodenal bulb) for a point prevalence of 15.4%. Ulcers were found in patients taking naproxen, indomethacin, tolmetin, sulindac, and ibuprofen, either alone, or in combination with aspirin. Dyspeptic symptoms were present in 19% of those with completely normal endoscopy and in only 9% of those with abnormal endoscopic findings. Only three of the 10 patients with ulcer had dyspeptic symptoms. There was no significant difference between drugs in tendency to cause gastroduodenal injury. We confirm that fairly severe gastroduodenal injury occurs in asymptomatic patients with rheumatoid and osteoarthritis, and that symptoms do not predict the presence of damage.

Congenital cytomegalovirus infection and maternal systemic lupus erythematosus: a case report.

We describe an infant with symptomatic congenital cytomegalovirus infection, who was born to a mother with active systemic lupus erythematosus. Infection in the child resulted from reactivation of maternal cytomegalovirus infection. The mother's use of prednisone may have contributed to the reactivation. The role of maternal immunosuppression in the acquisition of congenital viral infection by the neonate is discussed.

Cyclophosphamide-associated hepatotoxicity.

Cyclophosphamide, a potent alkylating agent, is effective therapy for some rheumatic diseases. Despite primary hepatic activation of the drug, hepatic toxicity has been reported only in one case. We have reported two episodes of hepatic dysfunction associated with oral cyclophosphamide administration in patients with systemic rheumatic diseases.

Anti-Fab' antibodies in rheumatoid arthritis. Measurement of the relative quantities incorporated in soluble immune complexes in sera and supernatants from cultured peripheral blood lymphocytes.

High levels of anti-immunoglobulins that react with Fab' fragments of IgG have been observed in sera of patients with rheumatoid arthritis (RA). To determine how much of these anti-Fab' antibodies are incorporated within immune complexes (IC), we added 125I-Fab' to sera and then measured the amount of labeled Fab' that could be precipitated by adding polyethylene glycol (PEG). Sera were either maintained at neutral pH during this procedure or acidified (pH 3) to dissociate IC. Acidification permitted the 125I-Fab' an equal chance to compete with other endogenous antigens for anti-Fab' antibodies, once excess hydrogen ion was removed. Quantities of anti-Fab' in sera of 20 seropositive RA patients were greater than in sera of 43 age- and sex-matched healthy controls, as measured by this assay and by a solid phase radioimmunoassay. However, significantly less anti-Fab' antibody was incorporated in ICs in the RA patients' sera. Supernatants from cultured peripheral blood lymphocytes of RA patients also contained relatively more "free" and less "hidden" anti-Fab' than culture supernatants from controls. Thus there appear to be qualitative as well as quantitative differences in the anti-Fab' antibodies synthesized by RA patients. This may reflect different proportions of IgM and IgG anti-Fab' in their sera, differences in the average avidity of these antibodies, or differences in the reciprocal relationships within the idiotypic network that result in release of antibodies by certain antibody-producing cells, but not by clones that produce complementary idiotypes.

Cubital tunnel syndrome in rheumatoid arthritis.

There has been an increase in reported cases of peripheral neuropathy and nerve entrapment syndromes in rheumatoid arthritis. (RA). To date, only a few incomplete studies on the prevalence of cubital tunnel syndrome (CuTS) in patients with RA have been reported. We investigated the prevalence of electrodiagnostic findings of CuTS in patients with RA and correlated them with the clinical findings. Forty-nine patients with the diagnosis of classic RA were evaluated clinically and by electrodiagnostic studies performed on the ulnar nerve, bilaterally, across the elbow. The study found 1 patient with slowing of both sensory and motor nerve conduction velocity (NCV), 8 patients with slowing of sensory NCV only, and 1 patient with slowing of motor NCV only. However, the correlation was poor between clinical and electrodiagnostic findings.

Clinical responses during gold therapy for rheumatoid arthritis. Changes in synovitis, radiologically detectable erosive lesions, serum proteins, and serologic abnormalities.

Gold therapy given to 73 patients with rheumatoid arthritis was associated with remission of synovitis for 3 months or longer in 27 patients and 50% or greater improvement in 20 patients. New joint deformities did not develop in patients who experienced remission, and progression of radiologically detectable erosive changes was prevented. Serum protein and serologic abnormalities were improved in all groups, but patients who had a good response experienced the greatest improvement. No single clinical or laboratory feature in the pretreatment assessment predicted response, but, as a group, the patients with the best response also ranked best for most prognostic indicators.

Polymyositis and diffuse interstitial lung disease. A review of the pulmonary histopathologic findings.

A retrospective analysis was performed of 105 patients with polymyositis for eight years. Roentgenographic evidence of pulmonary interstitial disease was present in ten adult patients (9%) with polymyositis unassociated with other connective-tissue disorders. Review of the pulmonary histopathologic findings indicated a spectrum of pulmonary diffuse interstitial infiltrates and fibroplasia of the alveolar septae. Response to glucocorticoids with regard to pulmonary symptoms was variable in the patients studied. Therapeutic response seemed to be influenced by both the cellularity of the chronic interstitial infiltrates and the degree of fibroplasia of the alveolar septae. Electron microscopic studies of the lung tissue from two patients with polymyositis and diffuse interstitial lung disease failed to demonstrate either immune complexes or viral particles.