Extraspinal tuberculous arthritis in HIV era.

A worldwide reemergence of tuberculosis is appreciable. Extrapulmonary tuberculosis has been observed to increase disproportionately from past incidence. One of the main attributing factors is the human immunodeficiency virus (HIV) infection. The objective of this study was to study clinical features, laboratory findings, and association with HIV infection in patients with peripheral tuberculous arthritis. The retrospective study was performed by reviewing the medical records of 27 patients with extraspinal tuberculous arthritis treated from January 1994 to December 2002. The diagnosis was made either by compatible clinical presentation and positive culture for Mycobacterium tuberculosis or histological finding of caseating granuloma in biopsy tissue or both. The average age of the patients' population was 49.3 years (range 27-74 years), made up of a 52% or 14 patients of male subjects. The mean duration of disease before seeking medical treatment was 10.2+11 weeks and from onset to diagnosis was 25 weeks. The most frequently affected joints were knees (36.6%) followed by wrists, ankles, shoulders, hips, sacroiliacs, and elbows, respectively. Monoarthritis was the main feature of this group, except for two patients who had two and three joints involvement, respectively. Dactylitis (tenosynovitis) was also found in two out of the 27 patients. Six patients (24%) had active pulmonary infiltration on chest X-ray. Of 11 patients with synovial polymerase chain reaction (PCR) testing for tuberculosis, seven patients had positive result. Only one patient with extraspinal tuberculous arthritis tested positive for HIV. Therefore, extraspinal tuberculous arthritis is observed to be usually present with chronic monoarthritis. The diagnosis is delayed in most occasions. PCR from synovial fluid may facilitate rapid diagnosis of tuberculous arthritis. Human immunodeficiency virus may not be a main contributing factor for extraspinal tuberculous arthritis.

Levels of plasma lipid peroxide products and antioxidant status in rheumatoid arthritis.

Oxygen free radicals have been implicated as mediators of tissue damage in patients with rheumatoid arthritis. The aim of our study was to assess the lipid peroxide products and antioxidant status in rheumatoid arthritis patients (RA). The study involved determination of two plasma lipid peroxide products, malondialdehyde (MDA) and conjugated dienes (CD), two plasma antioxidant vitamins (C and E) in 91 RA patients and 26 healthy subjects. The results showed that rheumatoid patients had increased plasma CD but not MDA and decreased plasma vitamin E, when properly expressed per unit cholesterol and triglyceride. This finding suggested that RA patients had increased oxidant stress that might play a role in the tissue damage and inflammation process of this disease.

Ocular toxicity of chloroquine among Thai patients.

BACKGROUND: Chloroquine has been prescribed for the treatment of various diseases. The most serious side-effect of chloroquine is retinopathy. The frequency of occurrence of retinopathy varies from 0.001 to 40% depending on the criteria used. The purpose of this study was to evaluate the incidence of ocular toxicity from chloroquine treatment among Thai patients. METHODS: A retrospective study was carried out in patients treated with chloroquine at Ramathibodi Hospital over the past 10 years (1987-1997). Patients eligible for review were followed by ophthalmic examination by an ophthalmologist for at least 6 months after starting treatment. RESULTS: One hundred and fifty-five patients were studied. Nineteen were men and 136 were women. They ranged in age from 10 to 70 years. Most patients received 250 mg of chloroquine per day. The duration of treatment varied from 6 months to 14 years, and the cumulative dose of chloroquine ranged from 26 to 1771 g. Fourteen patients (9%) had only corneal deposition, while 22 (14.2%) developed retinopathy. There were no correlations between corneal deposits or retinopathy and age, sex, duration of treatment, or cumulative dose of chloroquine. CONCLUSIONS: The present study confirms the finding reported by Mackenzie (Am J Med 1983; 75 (Suppl 1A): 40-45) that retinopathy is not related to the duration of treatment and cumulative dose of chloroquine. Based on our finding that retinopathy can be detected as early as 9 months after starting chloroquine therapy, we recommend routine ophthalmic examination before treatment and every 6 months thereafter.

Molecular defects leading to human complement component C6 deficiency in an African-American family.

Complement component C6 deficiency (C6D) was diagnosed in a 16-year-old African-American male with meningococcal meningitis. The patient's father and two brothers also had C6D, but gave no history of meningitis or other neisserial infection. By using exon-specific polymerase chain reaction (PCR)/single-strand conformation polymorphism as a screening step and nucleotide sequencing of target exons, we determined that the proband was a compound heterozygote for two C6 gene mutations. The first, 1195delC located in exon 7, is a novel mutation, while the second, 1936delG in exon 12, has been described before to cause C6D in an unrelated African-American individual. Both mutations result in premature termination codons and C6 null alleles. Allele-specific PCR indicated that the proband's two brothers also inherited the 1195delC mutation from their heterozygous mother and the 1936delG mutation from their homozygous father.

Age-related differences on clinical and immunological manifestations of SLE.

The clinical and immunological manifestations of 51 children with onset of systemic lupus erythematosus (SLE) before the age of 15 were compared with those of 308 adult patients with disease onset between the age of 15-49 and another 27 elderly lupus patients whose disease onset occurred at or after the age of 50. Overall disease activity determined by mean SLEDAI score was highest in the childhood group followed by the adult and the elderly group respectively. More severe form of cutaneous involvement, adenopathy, hypertension, renal involvement with renal insufficiency and anti-nDNA antibodies occurred predominantly in the childhood lupus. The clinical features distinguishing old-age lupus were chronic disease with a long interval between the time of onset and diagnosis, higher incidence of discoid rash and lower incidence of malar rash and renal involvement. Frequencies of anti-nDNA antibodies and renal involvement gradually decreased from childhood, to adulthood and to elderly lupus respectively. Anti-Sm antibodies were predominant in the adult onset group. Genetic markers, sex hormones and senility of the immune system may play a role in these age-related differences in clinical and immunological manifestations in SLE.

Antinucleolar antibodies and their disease association.

The prevalence of the antinucleolar antibodies (ANoA) demonstrated by indirect immunofluorescence technique in 1,662 sera of patients with a known or suspected rheumatic disease increased from 1.97% when mouse kidney (MK) was used as substrate to 4.9% when HEp-2 cells were used as substrate. However, an appropriate commercial HEp-2 substrate must be selected in order to increase the sensitivity of ANoA positivity. There were 3 distinct staining patterns of the nucleolar immunofluorescence: homogeneous speckle, and clumpy. Irrespective of the patterns, the most common diagnoses among patients who had ANoA were systemic sclerosis (PSS) and systemic lupus erythematosus (SLE); 36% and 35%, respectively). On the contrary, the incidence of these antibodies in PSS was 41% while it was only 3% in SLE patients. Almost all patients with speckled nucleolar staining had PSS as their underlying disease while most of the patients with homogeneous nucleolar staining had SLE. No distinct correlation between the different nucleolar staining patterns and specific organ involvements in our lupus and PSS patients was found except for the higher frequency of clumpy staining in male scleroderma with no joint involvement. This study demonstrates that: 1) ANoA are uncommon in unselected sera although use of a cell line substrate doubles the rate of positivity; 2) the proper HEp-2 substrate is critical in the detection of ANoA; 3) PSS and SLE are the most frequent diseases associated with ANoA but the frequency of these antibodies in SLE patients was very low.; 4) there are 3 distinct nucleolar staining patterns which may be associated with different rheumatic diseases; and 5) compared with ANoA negative scleroderma, clumpy nucleolar staining had significantly higher incidence in men with no joint involvement but a tendency towards more lung manifestations.

Infection in systemic lupus erythematosus.

A review of 1,069 total admissions of 537 systemic lupus erythematosus (SLE) patients during a 10-yr period at Ramathibodi Hospital showed that 220 episodes which occurred in 137 patients (25.5%) were motivated by infection. Skin was the most common site (23%) with Herpes zoster being the most common organism (15.5%) found in our lupus patients. However, if we considered only major infections, pulmonary tuberculosis, salmonella septicemia and urinary tract infection by E. coli would be the most frequent complications respectively. In the absence of immunosuppressive therapy, infections coincided with the initial manifestation of SLE in 25 patients and were associated with exacerbation of the disease in 20 patients. Mean SLEDAI score in these patients was 8.8, suggesting that active lupus link together with infection. Steroid therapy influenced the rate of opportunistic infections (p = 0.006). Infections were determined to be the cause of death in 23 of 77 patients (29.9%). Opportunistic pathogens played an equal role as other common bacterial organisms in these fatal cases. SLE patients who died from infections were treated with cyclophosphamide in higher proportion than those with no infectious complication (p = 0.025). Our study demonstrated the rate, nature and predisposing factors of infection in SLE which may lead to better anticipation and diminution of morbidity and mortality related to infection in hospitalized patients with SLE.