A longitudinal study of pulmonary involvement in primary Sjögren's syndrome: relationship between alveolitis and subsequent lung changes on high-resolution computed tomography.

Eighteen non-smoking women suffering from primary Sjögren's syndrome (pSS) with previously documented alveolitis were re-examined, clinically and by pulmonary function tests (PFT), bronchoalveolar lavage (BAL), chest X-ray and high-resolution computed tomography (HRCT) after a 2 yr follow-up period. Longitudinal evaluation revealed unchanged PFT. The final BAL study showed a normal differential count in six of 14 patients with initial lymphocyte alveolitis, and a persistent alveolar lymphocytosis in the remaining eight patients, associated with an increased percentage of neutrophils in one of them. In four patients with initial mixed alveolitis, the BAL cell profile was unchanged 2 yr later. Five of 18 patients (28%) had abnormal HRCT, represented by isolated septal/subpleural lines in three patients, ground-glass opacities with irregular pleural margins in one patient, and ground-glass opacities associated with septal/subpleural lines in another. All these patients had abnormal BAL results with an increased proportion of both neutrophils and lymphocytes. The presence of alveolar neutrophils was associated with a significantly (P=0.005) greater mean rate of reduction of carbon monoxide diffusing capacity (DLCO) -- more than four times the normal rate of loss of DLCO. Chest X-ray, repeated at the end of the 2 yr follow-up period, showed parenchymal abnormalities in only one patient who had evidence of fibrosis on HRCT. This study provides evidence that lung involvement is not an uncommon extraglandular manifestation of pSS and that a BAL neutrophilia may play an important role in the pathogenesis of pulmonary disease in this autoimmune disorder.

Finger tendon involvement in rheumatoid arthritis. Evaluation with high-frequency sonography.

OBJECTIVE: To characterize finger tendon involvement in patients with rheumatoid arthritis (RA). METHODS: The finger tendons of 20 RA patients were studied by ultrasonography using a high-frequency (13-MHz) transducer. RESULTS: Eighteen patients (90%) showed finger tendon abnormalities: widening of the flexor tendon sheath (80%), loss of the normal fibrillar echotexture (60%), irregularity of the extensor (30%) and flexor (50%) tendon margins, tendon tear (10%), synovial cyst (20%). CONCLUSION: High-frequency sonography is helpful in assessing even minimal finger tendon lesions in RA patients.

[Pulmonary inflammation in systemic sclerosis. An assessment by bronchoalveolar lavage]. / L'infiammazione polmonare nella sclerosi sistemica. Valutazione mediante lavaggio broncoalveolare.

Interstitial pulmonary fibrosis is a common feature of systemic sclerosis (SS). Clinicopathologic observations suggest that interstitial and alveolar inflammation may appear prior to fibrosis. Using the bronchoalveolar lavage (BAL) technique, we have characterized the nature of the inflammatory process in the lower respiratory tract of 15 non-smoking scleroderma patients and compared the results with those found in eight normal subjects. Alveolitis was detected in 11 patients (73%). Abnormalities in the cellular constituent included a significant increase of the proportion of lymphocytes (20.8 +/- 3.2 vs 8.1 +/- 1.2; p = 0.01) and neutrophils (3.3 +/- 0.8 vs 0.8 +/- 0.2; p = 0.04). T cell subsets, evaluated by flow cytometry, showed a significant increase of CD8+ T cells (36.6 +/- 3.2 vs 25, 1 +/- 3.3; p = 0.04) and a decrease of CD4+/CD8+ ratio (1.1 +/- 0.1 vs 2.1 +/- 0.4; p = 0.04). Seven patients with an elevation of proportional BAL (lymphocyte count > 15%) had greater dyspnoea and chest radiographic score than patients without lymphocytic alveolitis (p = 0.02) and they had greater reduction in carbon monoxide diffusing capacity (DLco) (p = 0.04). Furthermore, a statistically significant correlation between the total lymphocyte cell count and the DLco (p = 0.03) was observed. Finally the stepwise multiple regression analysis identified lymphocyte count in lavage fluid as the predictor most strongly associated with an abnormal interstitial radiographic pattern (p = 0.001). Our results report the notion that the lymphocytes, in addition to the macrophages and neutrophils, may play roles in the pathogenesis of lung injury.

Raynaud's phenomenon in rheumatoid arthritis.

The prevalence of Raynaud's phenomenon in RA was retrospectively reviewed in 411 consecutive RA patients and in a control group of 919 consecutive outpatients with OA. Raynaud's phenomenon was found in 19 (4.6%) of 411 RA patients and in 52 (5.6%) of 919 patients with OA: its prevalence was 4.3% (13 cases) in RA inpatients and 5.4% (six cases) in RA outpatients. Among the RA patients, the prevalence of Raynaud's phenomenon was 7.5% in men (7% of inpatients, 8.8% of outpatients) and 3.2% in women (3% of inpatients, 3.9% of outpatients) (P = N.S.). Conversely, the prevalence of Raynaud's phenomenon in patients with OA was higher in women (6.5%) than in men (2.9%) (P = 0.045). Our study indicates that the reported association between Raynaud's phenomenon and RA cannot be confirmed on the basis of a retrospective assessment of its prevalence.

Labial capillary microscopy in systemic sclerosis.

OBJECTIVES: To investigate whether in vivo capillary microscopy of the lower lip mucosa can be used to assess microvascular disease in systemic sclerosis. METHODS: Thirteen patients with systemic sclerosis and 11 healthy control subjects were studied by conventional nailfold capillary microscopy and labial capillaroscopy. The following parameters were analysed: loop length; loop width (maximum distance between the arteriolar and venular limbs); loop density (number of capillaries/mm2); venular plexus visibility; megacapillaries; and the architectural arrangement of the capillary network. RESULTS: A typical 'scleroderma pattern' at the nailfold was observed in 12 of 13 (92%) patients with systemic sclerosis. Labial capillaroscopy showed a different morphological pattern of microangiopathy. A diffuse architectural derangement of the capillary network was the most striking abnormality in 12 (92%) patients. Labial capillaries in the patients with systemic sclerosis were shorter (mean (SD) loop length 133 (32.2) microns) than in healthy controls (211 (48.4) microns) and showed an increased loop width (41.7 (13.1) v 27.6 (5.5) microns in controls. The loop density was 10.5 (4.6) capillaries/mm2 in patients with systemic sclerosis and 9 (1.7) capillaries/mm2 in controls. Labial capillaroscopy in patients with systemic sclerosis did not provide definite evidence of enlarged capillaries or avascular areas, or both, even where such abnormalities were clearly evident at the nailfold. CONCLUSIONS: This study shows that labial capillary microscopy is a simple, non-invasive technique which allows a careful morphological assessment of the mucosal microcirculation. Labial capillaroscopy in patients with systemic sclerosis showed significant microvascular changes with respect to the controls. The results of labial and nailfold capillaroscopy are not superimposable, even if some common findings, such as architectural derangement, are present.

[Disability in rheumatoid arthritis: the predictive value of age and depression]. / La disabilità nell'artrite reumatoide: valore predittivo dell'età e della depressione.

Fifty rheumatoid patients were given the Health Assessment Questionnaire (HAQ) and the Arthritis Impact Measurement Scales (AIMS) in order to determine the contribution of clinical and demographic variables to the overall disability. Among the clinical variables, pain intensity and depression were carefully assessed along with the classic morning stiffness and the joint count and tenderness/Ritchie's index. Two main findings arose: age contributed on its own to the overall disability, while disease duration had no significant effects; joint count and tenderness (Ritchie's index) correlated in a highly significant manner with depression as derived from the AIMS subscale and the Zung Depression Inventory (ZDI). ZDI items were separated into a "somatic factor" and a "dysphoric factor", showing a clear-cut influence of the somatic factor on the disability score. Our results suggest that age of the patient, pain intensity and a depressive mood related to physical impairment are chief predictive factor of the overall disability in rheumatoid arthritis.

Personality pattern in rheumatoid arthritis and fibromyalgic syndrome. Psychological investigation.

This study reports the psychological symptomatology assessed in 50 rheumatoid arthritis patients (RA) and 50 with primary fibromyalgic syndrome (PFS). Depression and illness behavior were investigated by two self-report scales in their validated Italian translations: the Center for Epidemiologic Studies Depression (CES-D) and Illness Behavior Questionnaire developed by Pilowsky and Spence (IBQ). Our results suggest that the average RA patients were not depressed to a clinically significant level at the time of the investigation. The mean scores of CES-D by RA patients do not differ from those found in Italian patients affected by other organic diseases. On the contrary, mean score in the CES-D depression scale obtained from PFS patients was significantly higher than the cut-off point. In analyzing the pattern of illness behavior the significant difference between RA and PFS patients in scale of denial of problems is relevant. This means the RA patients have a tendency to deny life stresses and to attribute all problems to the effects of their illness. Such a result is in line with a classic psychosomatic point of view, that defines RA patients as alexitimic ones, that is, with poor capacity to recognize and express emotions. Our data support both the hypothesis that depressive symptoms are more common among PFS patients than RA patients, and that psychological factors may play a significant role in most patients with PFS.

HLA-B27 negative ankylosing spondylitis and hidradenitis suppurativa: report of a case.

The association between hidradenitis suppurativa and joint involvement is well recognized. We describe a 63-year-old man with a severe HLA-B27 negative ankylosing spondylitis associated with hidradenitis suppurativa. We are not aware of any reports of such an association in the literature.

Interactive image analysis in the rectal mucosa of rheumatoid arthritis.

Interactive measurements of 22 quantitative parameters concerning the status and inflammation of the mucosa were taken in the rectal biopsies of patients suffering from Rheumatoid Arthritis, or with mild nonspecific morphological abnormalities (M.N.M.A.) and inflammation of the lamina propria or with Infective Colitis. The results showed that mean and standard deviation values of the rheumatoid patients are generally intermediate between those of control cases and those of M.N.M.A. and Infective Colitis. The variance analysis revealed that significant differences in some of the features exist between the four groups. Stepwise discriminant analysis helped in identifying three parameters that contributed significantly to discriminating 96.30% of the cases: Mucin area/Mucosal area; Number of inflammatory cells in the lower half/Number of inflammatory cells in the upper half of the mucosal thickness; Number of Granulocytes/mm2 of the lamina propria. Of the 27 cases included in the study, only one belonging to the control group was allocated incorrectly by the computer to the Rheumatoid Arthritis category. High correlation coefficients were observed between some of the morphometric, serological and clinical data in the rheumatoid patients. The highest values were between Number of Mononuclear cells/mm2 of lamina propria and C-Reactive Protein (+0.920) as well as between Mucin area/Mucosal area and serum IgM level (-0.950).