Transthoracic and transesophageal echocardiographic evaluation of the aortic root and subvalvular structures in ankylosing spondylitis.

OBJECTIVE: During the preclinical phase of cardiac involvement in ankylosing spondylitis (AS), examination, electrocardiography, and transthoracic echocardiography (TTE) may lack the sensitivity to detect cardiac abnormalities. Since transesophageal echocardiography (TEE) allows a closer view of the aortic root and subvalvular structures we investigated whether preclinical abnormalities of the aortic root and subvalvular structures could be detected. METHODS: Clinical and echocardiographic (TTE and TEE) evaluation of 29 male patients with AS and 13 age matched controls. RESULTS: No patient with AS had a high degree heart block. Aortic root dimensions were comparable between the study groups, but the anterior aortic wall was thinner in patients with AS than controls, 0.25 and 0.41 cm, respectively (p = 0.016). The posterior aortic wall was thicker and subjectively more echogenic than the anterior wall in 17/29 patients with AS compared to 4/13 controls. Aortic valve insufficiency was detected with TEE in 10/29 patients with AS. In 8/9 patients with AS studied with TEE, the subaortic structures were thickened and/or of increased echogenicity. This abnormal echo extended into the membranous septum. CONCLUSION: Abnormal subvalvular echoes consistent with fibrosis of the aortic root and membranous interventricular septum were detected with TEE but not TTE. The use of TEE may allow earlier diagnosis of cardiac involvement in AS.

Adrenal insufficiency in the antiphospholipid antibody syndrome.

OBJECTIVE: Adrenal insufficiency (AI) is a rare complication of the antiphospholipid antibody syndrome (APS). The objective of this report is to describe a case and review the published literature to enhance recognition of this potentially fatal disorder by emphasizing its course, diagnosis, and cause. DATA SOURCES: A bibliographic database with the indexing terms adrenal insufficiency, adrenal hemorrhage, adrenal thrombosis, APS, systemic lupus erythematosus, with the constraints of human subjects only, was used. STUDY SELECTION: All 27 reports meeting the indexing terms were selected for review. DATA EXTRACTION: The specific criteria used for data extraction articles included course of the disease, causation, clinical and laboratory diagnostic criteria, and therapeutic intervention. DATA SYNTHESIS: Our patient is a previously health woman who developed a respiratory tract infection, followed by a prolonged illness with fever, hypotension, nausea, depression, and venous thromboses. She was found to have AI and APS that was alleviated with hydrocortisone and anticoagulation. Initially, her adrenal glands were normal on CT scan but subsequently became enlarged and later atrophic. Of the 27 previous case reports, a majority had thromboses and typical clinical and laboratory manifestations of AI. Hemorrhagic infarction of the adrenal gland appears to be the mechanism for AI in the APS. IgG and IgM anticardiolipin antibodies are most commonly reported in association with AI in APS. CONCLUSIONS: The hypercoagulable state in the APS may lead to adrenal vein thrombosis and subsequently to hemorrhagic necrosis of the adrenal gland. This complication of APS is important to recognize because it may be fatal if untreated.

Do adults with high gliadin antibody concentrations have subclinical gluten intolerance?

Gliadin antibodies of the IgG and IgA isotypes and IgG subclasses were measured in 200 adults who were randomly selected from the Icelandic National Register. Those with the highest gliadin antibody concentrations were invited with negative controls to participate in a clinical evaluation. Neither the study subjects nor the physicians who recorded and evaluated the clinical findings were aware of the antibody levels. Significantly higher proportion of the gliadin antibody positive individuals reported unexplained attacks of diarrhoea (p = 0.03), and IgA gliadin antibodies were associated with increased prevalence of chronic fatigue (p = 0.0037). The gliadin antibody positive group also showed significantly decreased transferrin saturation, mean corpuscular volume and mean corpuscular haemoglobin compared with the gliadin antibody negative controls. Serum folic acid concentrations were significantly lower in the IgA gliadin antibody positive individuals. On blind global assessment 15 of the 48 participants were thought to have clinical and laboratory features that are compatible with gluten sensitive enteropathy, and 14 of these were in the gliadin antibody positive group (p = 0.013). Complaints that have not been associated with gluten intolerance had similar prevalence in both groups with the exception of persistent or recurrent headaches that were more common in the gliadin antibody positive group. These findings raise the possibility that a subclinical form of gluten intolerance may be relatively common.

Relation between bone erosions and rheumatoid factor isotypes.

Total rheumatoid factor (RF) activity and individual RF isotypes were measured in 62 patients with rheumatic diseases. Retrospective analysis of available x rays showed an association between IgA RF and the occurrence of periarticular bone erosions in hands. In contrast, IgG RF and IgM RF did not show any significant association with erosions. Furthermore, a close correlation was observed between the RF isotype levels in simultaneously drawn serum and synovial fluid samples. The possible significance of IgA RF in the pathogenesis of bone erosions is discussed.

Enzyme-linked immunosorbent assay (ELISA) screening test for detection of rheumatoid factor.

A new enzyme-linked immunosorbent assay (ELISA) screening test for total rheumatoid factor (RF) activity is described. Rabbit IgG was used as antigen and enzyme-conjugated monoclonal anti-kappa antibody as third layer. Of 183 samples measured for RF isotype levels, 60 were found to have one or more raised. In terms of raised isotypes the ELISA screening test had a sensitivity of 97% (58/60) while the Rheumaton had a sensitivity of only 75% (45/60). Nearly all discordant false-negative samples had only one RF isotype raised. The ELISA test gave 29% (53/183) and the Rheumaton 34% (63/183) false-positive results. Thus the ELISA test was more specific and sensitive for the detection of raised single RF isotypes than the Rheumaton and Rose-Waaler tests. Moreover, approximately 30% of RA patients were seronegative according to the conventional RF tests but only 8% in the new ELISA system.