A case of methimazole-induced chronic arthritis masquerading as seronegative rheumatoid arthritis.

We report a 40-year-old woman with onset of oligoarthritis shortly after initiating treatment with methimazole for Graves disease. Over the course of 7 years, her arthritis became progressively severe, leading to a diagnosis of seronegative rheumatoid arthritis. Treatment with disease-modifying antirheumatic agents and surgical intervention was contemplated. Ultrasound and magnetic resonance imaging revealed exuberant synovitis, involving right elbow and knees. Upon withdrawal of methimazole, prompt resolution of all signs and symptoms of arthritis was observed within several weeks. Following a MEDLINE search of available literature concerning antithyroid drug-induced arthritis, it is evident that this case represents the lengthiest duration of inflammatory arthropathy ever described in a patient that nonetheless was rapidly reversible with discontinuation of methimazole.

Novel ANKH amino terminus mutation (Pro5Ser) associated with early-onset calcium pyrophosphate disease with associated phosphaturia.

This report describes a 32-year-old woman presenting since childhood with progressive calcium pyrophosphate disease (CPPD), characterized by severe arthropathy and chondrocalcinosis involving multiple peripheral joints and intervertebral disks. Because ANKH mutations have been previously described in familial CPPD, the proband's DNA was assessed at this locus by direct sequencing of promoter and coding regions and revealed 3 sequence variants in ANKH. Sequences of exon 1 revealed a novel isolated nonsynonymous mutation (c.13 C>T), altering amino acid in codon 5 from proline to serine (CCG>TCG). Sequencing of parental DNA revealed an identical mutation in the proband's father but not the mother. Subsequent clinical evaluation demonstrated extensive chondrocalcinosis and degenerative arthropathy in the proband's father. In summary, we report a novel mutation, not previously described, in ANKH exon 1, wherein serine replaces proline, in a case of early-onset severe CPPD associated with metabolic abnormalities, with similar findings in the proband's father.

Sarcoidosis in World Trade Center rescue workers presenting with rheumatologic manifestations.

The health consequences of the World Trade Center collapse are unknown, but likely to be significant and may take years to fully appreciate. Sarcoidosis is a multisystem inflammatory disorder of unknown etiology characterized pathologically by noncaseating granulomas. Inciting events, such as infectious agents or possible environmental exposures, have been postulated as the source of antigen exposure initiating an inflammatory cascade. We describe 2 cases of sarcoidosis in rescue workers with significant exposure from the World Trade Center collapse, who presented with extrapulmonary rheumatologic manifestations. Our first case involved a 33-year-old white New York City man detective found to have sarcoidosis following an evaluation of diffuse joint pain. The second case involved a 40-year-old African American man, New York City officer, who presented with uveitis, and was subsequently diagnosed with sarcoidosis. These 2 cases extend the spectrum of disorders resulting from the World Trade Center disaster and illustrate the need for clinicians to be aware of the diverse presentations of sarcoidosis in this patient population.

Osseous sarcoidosis treated with tumor necrosis factor-inhibitors: case report and review of the literature.

STUDY DESIGN: Report of 2 cases of sarcoidosis involving vertebrae successfully treated with tumor necrosis factor-α inhibitor (TNF-α antagonist). OBJECTIVE: To disseminate knowledge concerning successful treatment of sarcoidosis involving the axial skeleton with the use of TNF-α blockers. SUMMARY OF BACKGROUND DATA: Osseous sarcoidosis most commonly involves small bones of hands and feet; vertebral involvement is rare, and currently there is no consensus on optimal treatment. METHODS: Two cases are described detailing patients with extrapulmonary sarcoidosis involving vertebral bodies, retractable to conventional treatment, who were treated with TNF-α antagonists. RESULTS: We observed a remarkable response following the administration of TNF-α blockers in vertebral sarcoidosis with marked resolution of lytic lesions. The patients remained asymptomatic with no recurrence of their disease. CONCLUSION: Vertebral sarcoidosis is a rare manifestation of osseous sarcoidosis. Symptomatic patients are treated with various immunosuppressive therapies. We propose utilizing TNF-α blocking agents in patients who fail to respond to first-line therapy.

Prophylactic antibiotic usage for Pneumocystis jirovecii pneumonia in patients with systemic lupus erythematosus on cyclophosphamide: a survey of US rheumatologists and the review of literature.

BACKGROUND: Use of cyclophosphamide in systemic lupus erythematosus (SLE) is associated with Pneumocystis jirovecii pneumonia (PJP) that has substantial morbidity and mortality. However, the frequency of PJP in these patients is unknown and there are no guidelines for prophylactic antibiotics. OBJECTIVES: The objectives of this study are to evaluate the frequency of PJP and the need for prophylactic antibiotics in these patients. METHODS: We estimated incidence of PJP and use of prophylactic trimethoprim-sulfamethoxazole in these patients by a literature search and an e-mail survey of US rheumatologists. RESULTS: We identified 18 manuscripts dealing with infections in SLE patients treated with cyclophosphamide. In these manuscripts, 121 cases of PJP were identified in 76,156 SLE patients with a frequency of 15.88 per 10,000 patients.Of 264 rheumatologists surveyed, 133 (50.37%) were using prophylactic antibiotics in these patients. One hundred thirty-one (49.63%) respondents did not use prophylactic antibiotics. 5,174 SLE patients received cyclophosphamide in last 5 years with 19.6 +/- 30.6 (mean +/- SD) patients per rheumatologist. 32 cases of PJP were reported. The total cumulative experience of 264 rheumatologists was 4742 years [(17.96 +/- 10.35) (mean +/- SD)] with a PJP rate of 67.48 per 10,000 years of practice. CONCLUSIONS: The frequency of PJP in SLE patients on cyclophosphamide remains low (0.1588%). Therefore, routine use of trimethoprim-sulfamethoxazole for PJP prophylaxis in SLE patients on cyclophosphamide does not appear to be substantiated by this study, except in those with elevated risk, ie, with severe leucopenia, lymphopenia, high dose corticosteroids, hypocomplementemia, active renal disease, and higher mean SLEDAI score. There is a need for consensus guidelines addressing prophylactic antibiotics in these patients.

Chemotaxis of human monocyte-derived dendritic cells to complement component C1q is mediated by the receptors gC1qR and cC1qR.

Dendritic cells (DCs) are recruited to inflammatory sites where they phagocytose and process antigens for subsequent presentation to the T lymphocytes in the lymphoid tissue. Several leukocyte chemoattractants and their specific receptors have been shown to induce the migration of DC. The complement protein C1q has multiple immune functions including acting as a chemoattractant for neutrophils, eosinophils and mast cells. Therefore, the objective of this study was to determine if soluble C1q can induce chemotaxis of DC. Culturing cells in GM-CSF and IL-4 for 5 to 7 days generated human monocyte-derived DCs. In addition, LPS was added from day 5 to 7 to induce DC maturation. Cells were classified as either immature or mature DC by assessing the cell surface markers by flow cytometry, phagocytosis of dextran-FITC and T cell proliferation in an allogenic MLR. Immature DCs express the C1q receptors (C1qR), gC1qR and cC1qR/CR and, accordingly, display a vigorous migratory response to soluble C1q with maximal cell movement observed at 10-50nM. In contrast, mature DCs neither express C1qR nor do move to a gradient of soluble C1q. Varying the concentration gradient of C1q (checkerboard assay) showed that the protein largely induces a chemotactic response. Finally, blocking gC1qR and cC1qR/CR by using specific antibodies abolished the chemotactic response to C1q but had no effect on a different chemoattractant C5a. These results clearly demonstrate that C1q functions as a chemotactic factor for immature DC, and migration is mediated through ligation of both gC1qR and cC1qR/CR.

Protease-activated receptor-2 (PAR-2) expression in human fibroblasts is regulated by growth factors and extracellular matrix.

Many cell types express a membrane receptor, activated by trypsin-like proteases, termed protease-activated receptor-2 (PAR-2). Previous studies describing PAR-2 expression on fibroblasts have been conflicting. In this report, we investigated in vitro PAR-2 expression on several fibroblast cell lines using flow cytometry, immunohistology, and immunoblots of cell lysates. Consistent PAR-2 expression was detected in cultured fibroblasts, although we observed heterogeneity of cellular expression among the cell lines. Some fibroblast lines expressed PAR-2 predominantly as an intracellular protein with differing cytoplasmic staining patterns, whereas other fibroblast lines displayed PAR-2 primarily as a cell surface receptor. Immunoblots of cell lysates with polyclonal anti-PAR-2 demonstrated a 44 kDa band, the predicted molecular weight for the PAR-2 core protein. Furthermore, we noted that expression of PAR-2 was subject to regulation. Fibroblasts grown within a collagen matrix downregulated receptor expression whereas increased PAR-2 expression was observed by the addition of fibroblast growth factors PDGF-BB and TGF-beta. This study may explain the previous inconsistencies in PAR-2 expression observed on tissue fibroblasts. Results indicate that the degree of fibroblast proliferation, attenuated by extracellular matrix and upregulated by growth factors, influences whether fibroblasts express PAR-2 and, thus, would be responsive to protease signaling.

Mast cells in the pathogenesis of fibrosis.

It has been appreciated for quite some time that a "round cell" inflammatory infiltrate is present in the dermis during the early stages of scleroderma. Considerable research has emanated from this basic observation, with the assumption that interactions between immune cells and fibroblasts are paramount in the genesis of fibrosis. The large number of mast cells that accumulate early in involved tissues has been less appreciated in recent studies. The purpose of this update is to demonstrate how mast cells interact with fibroblasts in a manner that leads to fibroblast activation and subsequent extracellular fibrosis. Furthermore, the notion that myofibroblasts represent a critical fibroblast phenotype in sclerosing disorders, such as scleroderma, has also gained considerable support. The relationship of tissue mast cells to the generation of a myofibroblast phenotype has been the focus of several recent reports and will also be discussed.

Statins and osteoporosis: can these lipid-lowering drugs also bolster bones?

The statins may not only lower cholesterol, they may stimulate bone formation, as suggested by a number of observational studies and animal research. Whether these drugs will be of benefit in treating osteoporosis awaits further clinical trials.