Immune-mediated inner ear disease and parvovirus B19.

Human parvovirus B19 (HP-B19), the etiologic agent of the common childhood illness erythema infectiosum, has been implicated in systemic immune disorders. Patients presenting with sensorineural hearing loss and/or dizziness, not readily categorized, were evaluated for immune-mediated inner ear disease. Appropriate serologic studies including parvovirus B19 antibody titers were conducted. Thirty patients with suspected immune-mediated inner ear disease were treated with corticosteroid trial for 5 to 7 days, then reexamined with repeat audiogram and/or vestibular testing. Seventeen patients with clinical response were treated with long-term corticosteroids and cyclophosphamide. Six patients had positive HP-B19 immunoglobulin M (IgM) titers and 8 patients had positive parvovirus immunoglobulin G (IgG) titers. All 14 patients responded to therapy. Parvovirus B19, therefore, is a possible etiology of immune-mediated inner ear disease.

The role of nutrition in sickness and in health.

This article reviews the importance of food and water for survival and the wide ranges of nutrient intake capable of sustaining reproduction and growth. It also reviews the different types of adverse reactions to foods including hypersensitivity or allergic reactions, pharmacologic and metabolic adverse responses to foods, and natural and industrial toxins in the food chains. The article concludes with recommendations for dealing with patients who advocate the use of "natural" foods and products.

Splenectomy as treatment for nonhealing soft tissue defect after total knee arthroplasty in a patient with Felty's syndrome.

We describe the apparent remarkable effect of splenectomy on wound healing in a patient with rheumatoid arthritis and Felty's syndrome. The patient had previously undergone a knee replacement with 4 months of failure of the surgical wound site to heal or close. The wound, which had broken down and dehisced on 3 separate occasions after plastic surgical attempts at closure, healed cleanly and without recurrence within 3 weeks of splenectomy and plastic repair at the same operation.

Rheumatoid arthritis. New developments in treatment.

If a patient with active rheumatoid arthritis does not obtain significant relief from nonsteroidal anti-inflammatory drugs, prompt institution of disease-modifying antirheumatic drugs (DMARDs) is recommended. If one agent fails, another may be tried. At present, hydroxychloroquine (Plaquenil) sulfate is one of the most widely used and best tolerated. Careful follow-up is essential with all DMARDs, however, because toxic effects may be severe and sometimes unpredictable.

Strokes and the carotid: myths and realities.

Cervical bruits in asymptomatic individuals identify persons at increased risk of future stroke and at even higher risk of ischemic heart disease. Strokes in these patients rarely occur in the same vascular distribution as the bruit. In prospective studies, an asymptomatic bruit does not identify patients at higher risk of perioperative stroke even in patients undergoing coronary bypass or other major vascular surgery. When a stroke occurs in the perioperative setting, it is much more likely due to embolism from the cross-clamped aorta or extraneous material from the bypass machine than from hypoperfusion of, or embolism from, the carotid arteries.

Clinical spectrum and treatment of rheumatic syndromes in the elderly.

Rheumatic diseases in the elderly are common and may be more difficult to diagnose than in younger patients. Treatment must be tailored to the patients' needs and functional reserve. Elderly patients need to be monitored even more closely for toxicity than younger adults.

Acute arthritis occurring in association with subcutaneous Dirofilaria tenuis infection.

A patient who developed a self-limited acute migratory arthritis in association with subcutaneous infection with Dirofilaria tenuis is described. There have been several reports of parasitic rheumatism and the possible association between arthritis and parasitic infection. Parasitic rheumatism in a patient infected with D tenuis has not been previously reported, however.

Silicone and rheumatic diseases.

Silicone generally has been regarded as a biologically inert material. However, recent reports suggest that inflammatory responses to silicone occur. There is some experimental and clinical evidence of a direct inflammatory response to the presence of liquid or particulate silicone. These include granulomatous skin reaction to injected silicone, synovitis around silicone prosthetic joints, and lymphadenopathy proximal to silicone prostheses. There are case reports of systemic rheumatic disease following silicone prostheses, but no definitive proof of a direct relationship between silicone prostheses and systemic disease. The clinical features of the reported cases following breast augmentation include breast tenderness, axillary adenopathy, sclerodermatous skin changes, arthritis, Raynaud's phenomenon, rheumatoid factors, and ANAs. Prior epidemiologic evidence and the number and consistency of our own and others' clinical findings suggest that silicone may indeed be associated with inflammatory processes and rheumatic diseases.

Syndrome of temporal arteritis with perivascular infiltration by malignant cells in a patient with follicular small cleaved cell lymphoma.

A patient with follicular small cleaved cell lymphoma presented with Sjögren's syndrome and symptoms of polymyalgia rheumatica and temporal arteritis. Biopsy of the temporal artery showed an extensive perivascular infiltrate by malignant cells without evidence of giant cells.

The role of diet in animal models of systemic lupus erythematosus: possible implications for human lupus.

Studies of diet in the mouse model of SLE have established the beneficial effects of a low calorie, low fat diet in these animals as well as the importance of the specific source of dietary fat. The role of zinc in murine and human SLE is less clear. The reported improvement of patients with SLE and other related diseases on a low phenylalanine and tyrosine diet high in fish content, and the lupus inducing capacity of a nonphysiologic amino acid present in alfalfa are also reviewed. The need for carefully controlled prospective studies of diet in patients with SLE is noted, and a diet of potential therapeutic benefit is described.

Effects of specific nutrients on the immune response. Selected clinical applications.

The importance of diet in multiple aspects of the immune response is inescapable. Although only a few trials have attempted to apply knowledge derived from in-vitro and animal data to humans, the ability to modulate or "reset" the immune response by manipulating dietary intake will surely continue to be studied in the future. The role of various nutrients in immunity is reviewed and clinical applications are noted.

Clinical utility of assays for circulating immune complexes.

There are now many assays for the quantification of circulating immune complexes, each with distinct specificity and sensitivity. In a wide variety of rheumatic, infectious, neoplastic, and metabolic conditions, levels of circulating immune complexes may be elevated. In select situations, determination of circulating immune complex levels may help clinicians in the management of their patients. In lupus erythematosus, circulating immune complex levels, in conjunction with other immune parameters, may provide more insight into the disease course and activity than assessment of end organ parameters alone. In the differential diagnosis of infective endocarditis, serial levels of circulating immune complexes may provide evidence of effectiveness or failure of treatment. There is evidence that assays for circulating immune complexes may be of potential benefit in the management of Lyme disease and acute myelogenous leukemia.

The relationship between nutrition, infection, and immunity.

The importance of nutrition in every aspect of human physiology slowly is being appreciated clinically. However, it is clear that immune function is highly dependent on the nutritional status of the individual. That status, in turn, is dependent on the nutritional intake and the metabolic machinery of the individual.