Cat-scratch disease in Hawaii: etiology and seroepidemiology.

OBJECTIVE: To study the etiology and seroepidemiology of cat-scratch disease (CSD) in Hawaii. METHODS: Blood and fine-needle aspirate (FNA) from the lymph nodes of 39 consecutive patients with clinical CSD were cultured for Bartonella henselae, and blood samples from index cats, stray cats, and dogs were cultured and their sera were tested by indirect fluorescence antibody test for antibodies to B. henselae and Afipia felis. Sera from age- and sex-matched human subjects without cat exposure served as controls. RESULTS: Warthin-Starry staining showed positive results in only 4 of 32 FNAs, and B. henselae was isolated from only one FNA specimen. All of 38 patients who had two or more sera tested had elevated titers of antibody to B. henselae. Only 1 of 48 human control sera had antibody to B. henselae. Of 31 kittens, 21 had positive blood culture results and elevated antibody titers to B. henselae. Of three adult cats, all had negative blood culture results, but they had serologic evidence of past infection. Of 23 adult stray cats, 18 had elevated titers of antibody to B. henselae, but in only one was the blood culture result positive. Results of IFA tests were marginally positive for A. felis in 1 of 29 patients with CSD and in one adult stray cat and one dog. CONCLUSIONS: This study shows that the B. henselae IFA test is both highly sensitive and specific for the detection of infection caused by B. henselae and for the laboratory diagnosis of CSD, and that FNA is seldom helpful in confirming the diagnosis. We further demonstrated that CSD in Hawaii is due to B. henselae and that infection is directly linked to the scratch or bite of a kitten. Older cats seldom have bacteremia but often have serologic evidence of past infection. Our study fails to implicate dogs in the epidemiology of CSD in Hawaii, and A. felis was not etiologically implicated in CSD in the human subjects and animals we studied.

Ibuprofen suspension in the treatment of juvenile rheumatoid arthritis. Pediatric Rheumatology Collaborative Study Group.

Ninety-two children with juvenile rheumatoid arthritis were randomly assigned to treatment in a multicenter, double-blind, 12-week trial designed to compare the efficacy and safety of a liquid formulation of ibuprofen at a dosage of 30 to 40 mg/kg/day versus those of aspirin at a dosage of 60 to 80 mg/kg/day. No significant intergroup differences in response rates or in the amount of improvement in articular indexes of disease activity were observed. More children treated with aspirin discontinued treatment early because of adverse reactions. After this trial, 84 additional patients with juvenile rheumatoid arthritis entered a 24-week, multidose (30, 40, and 50 mg/kg/day), open trial of ibuprofen suspension. Favorable response rates for the three groups were similar, and continued improvement was observed throughout the 24-week period. A dose-response relationship was observed with respect to adverse reactions of the upper gastrointestinal tract. We conclude that ibuprofen suspension is an effective nonsteroidal antiinflammatory drug and that its tolerability in children is acceptable.

Hypermobility of the joints in juvenile episodic arthritis/arthralgia.

It has been suggested that hypermobility of the joints may predispose children to the development of arthritis or arthralgia. To determine the normal frequency of hypermobility, 260 normal schoolchildren (5 to 17 years of age) were examined. In addition, 34 patients with juvenile rheumatoid arthritis (JRA) and 32 children with juvenile episodic arthritis/arthralgia (JEA) were tested. Any child who met at least three of the following criteria was considered to have joint hypermobility: (1) passive apposition of the thumbs to the flexor aspect of the forearms; (2) passive hyperextension of the fingers so that they lie parallel with the extensor aspect of the forearms; (3) hyperextension of the elbows greater than 10 degrees; (4) hyperextension of the knees greater than 10 degrees; (5) flexion of the trunk with knees extended so the palms rest on the floor. Thirty-two (12%) of 260 normal schoolchildren and 21 (66%) of 32 with JEA had hypermobility. Further, a significantly higher proportion (23 of 126) of normal girls than normal boys (nine of 134) had hypermobility (chi 2 = 8.0, P less than 0.005). Hypermobility was not common in children with JRA. These findings support the hypothesis that hypermobility may be an important factor in the cause of JEA.

Auranofin in the treatment of juvenile rheumatoid arthritis.

Auranofin (triethylphosphine gold) was administered to 21 patients with juvenile rheumatoid arthritis during an open-ended, open-label, noncontrolled trial designed to establish safety and preliminary efficacy. Initial dosage was 0.1 mg/kg/day; incremental increases to 0.2 mg/kg/day were allowed. Aspirin (80 mg/kg/day), tolmetin (20 to 40 mg/kg/day), and naproxen (400 to 600 mg/m2/day) were allowed as rapidly acting anti-inflammatory agents. All patients attained measurable plasma concentrations of gold during the study. Clinically significant improvement (greater than 25%) occurred in more than half the patients with regard to the number and severity of joints with swelling, pain on motion, and tenderness. The number of joints with active arthritis decreased by at least 25% in nine of the 19 patients. Group mean changes between the initial and final visit indicated improvement in all articular disease indices measured. Eleven of 16 patients with an elevated erythrocyte sedimentation rate showed decreases of at least 25%. The group given the higher dosage had a greater proportion of responders with decreases in erythrocyte sedimentation rate. Four of six patients whose sera contained rheumatoid factor showed decreases in its titer. Discontinuation of auranofin was necessary in two patients because of headaches and because of hematuria and anemia associated with a severe flare of polyarticular disease, respectively. The results from this trial are sufficiently encouraging to merit a double-blind trial of auranofin in children with juvenile rheumatoid arthritis.

Pulse methylprednisolone therapy in diffuse proliferative lupus nephritis.

The prognosis of patients with diffuse proliferative lupus nephritis is generally poor, and the majority of patients with this lesion develop progressive deterioration in renal function. Intravenous "pulses" of methylprednisolone have been advocated for the treatment of severe nephritis. In this study, 15 patients with biopsy-proven diffuse proliferative lupus nephritis were treated with oral high-dose prednisone therapy, initially 2 mg/kg/day. They were compared with seven patients with similar renal pathology treated with six daily pulses of methylprednisolone (30 mg/kg/day, not to exceed 1 gm/day), followed by prednisone orally, initially 2 mg/kg/day. There were no deaths in either group and the side effects of therapy were similar in the two groups. Pretreatment GFRs for the pulse and high-dose groups were similar. There was a more rapid improvement in GFR following pulse therapy, but the long-term effects on renal function for the two modes of therapy were the same.

Plasma exchange in selected patients with juvenile rheumatoid arthritis.

Plasma exchange with either fresh-frozen plasma or 5% albumin solution as replacement fluid was performed in four selected patients with juvenile rheumatoid arthritis unresponsive to standard therapy. One 13-year-old boy with life-threatening systemic disease experienced a partial remission of disease and tolerated a decrease in prednisone dose from 15 to 4 mg daily following 14 exchanges with FFP. A 14-year-old girl, dwarfed by systemic disease and long-term corticosteroid therapy, was able to discontinue prednisone and grew 6.3 cm in 11 months following 18 plasma exchanges with FFP. An 8-year-old girl with pauciarticular disease, antinuclear antibody, and uncontrollable iridocyclitis underwent 16 plasma exchanges with 5% albumin solution as replacement; despite removal of antinuclear antibody, her eye disease and arthritis were not helped. A 16-year-old girl with erosive, polyarticular JRA showed no detectable change in her articular disease following nine exchanges. Transient decreases in hematocrit, complement components, and immunoglobulin concentrations occurred. In three patients Westergren sedimentation rate decreased for up to five months after exchanges. One patient died suddenly during an exchange with FFP; the cause of death appeared related to microemboli of unknown nature found in the lungs at autopsy. Plasma exchange should be done only in an intensive care setting and as a research procedure for children with JRA.