Chlamydial infection preceding the development of rheumatoid arthritis: a brief report.

Chlamydia trachomatis-triggered reactive arthritis is a well-documented entity that has been extensively described. We do not have a clear understanding about the inflammatory oligoarthritis associated with the presence of this organism. It is rarely cultured from the synovial fluid, but is usually detectable by molecular biological techniques. Typically, Chlamydia trachomatis causes a sterile but inflammatory oligoarthritis. We report an unusual case of inflammatory monoarthritis in a young woman in whom Chlamydia was isolated from the synovial fluid. This is the first case of documented isolation of Chlamydia from synovial fluid, which subsequently was diagnosed as rheumatoid arthritis.

Wegener's granulomatosis in pregnancy.

This report describes a case of severe limited Wegener's granulomatosis (WG) presenting in the third trimester of pregnancy with pansinusitis and necrotizing pneumonitis. The patient was treated successfully with a combination of corticosteroids and cyclophosphamide (CYC). The outcomes in the mother and the newborn were excellent. In a review of the English-language literature, we found 10 similar cases of WG with 13 pregnancies. WG occurring during pregnancy may have a more aggressive course and may require more aggressive treatment compared with WG occurring at other times. The treatment options for WG in pregnancy are discussed.

Knee laxity in symptomatic osteoarthritis.

Twenty-two patients with primary osteoarthritis (OA) of the knee were studied to determine the effects of OA on laxity of the knee joint. Laxity was measured with a Genucom Knee Analysis System. Ten knees had mild OA (> 50% preservation of joint space). Fifteen knees had moderate OA (some preservation of joint space, but < 50%). Eighteen knees had severe OA (no joint space). A group of 18 knees from 9 healthy (asymptomatic) subjects of ages similar to those of the OA patients were used as controls. Compared to control knees, severe OA knees had less total anteroposterior (AP) translation (12.2 versus 6.6 mm, p < 0.025) and less total tibial rotation (79 versus 59 degrees, p < 0.01). Compared to early OA knees, knees with severe OA had 57% less average total AP translation (15.2 versus 6.6 mm, p < 0.01), 31% less total varus/valgus rotation (15 degrees versus 10.4 degrees, p < 0.016), and 26% less total internal/external tibial rotation (80.1 degrees versus 59 degrees, p < 0.007). These data indicate that osteoarthritic knees tend to have less laxity than normal knees, probably because of a combination of contracture of the ligaments and pressure of osteophytes against ligaments and other capsular structures.

Late-onset, seropositive, erosive rheumatoid arthritis.

This report describes the natural history, clinical features, and therapeutic requirements of late-onset seropositive and/or erosive rheumatoid arthritis (LORA). One hundred twenty-nine patients with mean disease duration of 6 years and mean age of disease onset of 66 years were studied. All patients met American Rheumatism Association criteria for rheumatoid arthritis (RA). Ninety-one percent were seropositive for rheumatoid factor, 83% had erosive disease, and 58% had significant medical problems. Therapeutically, most patients required sequential use of multiple second-line agents. Functional classification did not change significantly despite treatment, and complete remissions were unusual even with remittive therapy. It is concluded that a subset of LORA patients have seropositive aggressive, destructive disease.

Amyloidosis in a case of ankylosing spondylitis with a review of the literature.

A 53-year-old man with a 20-year history of ankylosing spondylitis presented with proteinuria and acute renal insufficiency. Amyloidosis was diagnosed on renal biopsy. The association of secondary amyloidosis has been described with collagen vascular diseases, however, a review of the literature reveals few cases associated with the spondyloarthropathies. We were able to find only 2 cases in the American literature. Thus, although a rare complication, amyloidosis should be considered in the differential diagnosis of proteinuria and renal insufficiency in spondyloarthropathy.

Bilateral pigmented villonodular synovitis of the wrists.

The wrist is an unusual anatomic location for pigmented villonodular synovitis (PVNS). PVNS is generally a benign or minimally destructive process, but in our patient it resulted in progressive erosive changes in a bilateral wrist distribution. This is the first histologically documented case of bilateral PVNS in this anatomic distribution, to our knowledge. Although uncommon, PVNS should be considered a possible cause of unexplained upper extremity inflammatory arthritis.

Causes and management of shoulder arthritis.

We recommend that physicians distinguish shoulder arthritis from periarticular disorders. A specific diagnosis should be made in the former, if possible. A number of arthritides have frequent shoulder involvement, and they should be kept in mind. Septic arthritis should always be suspected when there is acute pain and swelling. Joint fluid aspiration should almost always be performed when fluid is present. The diagnosis of gout or CPPD deposition disease usually requires crystal identification from joint fluid for diagnosis. Treatment of shoulder arthritis with oral anti-inflammatory medication is usually indicated; appropriate treatment of the underlying disorder, e.g., rheumatoid arthritis, is necessary. Physical therapy started early, often combined with IA corticosteroids, helps to maintain or improve shoulder motion.

Scintigraphic detection of metoclopramide esophageal stimulation in progressive systemic sclerosis.

Supine radionuclide esophageal scintigraphy (RES) and manometry were used to prospectively evaluate metoclopramide effect on esophageal function and pressure amplitudes in 14 patients (12 females and two males; median time since diagnosis: 2 yr) with progressive systemic sclerosis (PSS). Quantitation of RES included calculation of percent emptying at 30 sec, and standard manometric measurements were obtained. RES and manometry were performed before and 10 min following the i.v. administration of metoclopramide. RES showed a significant increase in mean percent emptying from 36% to 46% after drug administration (p less than 0.01), while mean lower esophageal pressure (end-expiratory) increased from 2 to 11 mm of Hg (p less than 0.001). Manometry failed to reveal a significant increase in either distal or proximal mean esophageal contractile amplitude, and no correlation was found between the increase in percent emptying at RES and the change in lower esophageal pressure in the individual patient. RES is the only quantitative method presently available to evaluate bolus propagation in the esophagus, and it documented improved esophageal function after metoclopramide administration in a PSS population. When drug therapy is directed at augmentation of esophageal emptying, RES is an ideal method to evaluate drug response.

Progressive systemic sclerosis: radionuclide esophageal scintigraphy and manometry.

Radionuclide esophageal scintigraphy (RES) and manometry were used for prospective evaluation of esophageal involvement and disease severity in 11 patients (nine women and two men; median time since diagnosis, 1 year) with progressive systemic sclerosis (PSS). Quantitation of RES included calculation of the percentage of emptying at 30 seconds, while manometry provided measurements of proximal, distal, and lower esophageal sphincter (LES) pressures. The findings of both RES and manometry were abnormal in all 11 patients. There was a high correlation between the percentage of emptying and either distal esophageal pressure (r = .86, P less than .01) or LES pressure (r = .79, P less than .01). No significant correlation was found between the percentage of emptying and proximal esophageal pressure (r = .28, P = .39). RES is a safe, simple procedure that is readily accepted by patients and can be used in place of manometry for the detection and staging of esophageal involvement in PSS.

Cells that mediate NK like cytotoxicity are present in the human delayed type hypersensitivity response.

By inducing delayed type hypersensitivity (DTH) responses under previously formed skin blisters we determined that cells which mediate natural killer (NK) like cytotoxicity are present in the DTH response in man. Similar levels of killing were not present in cells obtained from skin blisters not associated with positive DTH responses. The DTH response associated killer cell was found to be a mononuclear cell that had presumably undergone stimulation since it not only killed NK sensitive K-562 cells, but also NK resistant Daudi target cells.

NK cell activity and skin test antigen stimulation of NK like CMC in vitro are decreased to different degrees in pregnancy and sarcoidosis.

Peripheral blood mononuclear cells (PBMNC) isolated from normal subjects, pregnant women and patients with sarcoidosis were assayed for natural killer (NK) cell activity on day 0 and for NK like cell-mediated cytolysis (CMC) after 5 days of exposure, in vitro to Candida antigen, purified protein derivative (PPD), and human leucocyte interferon (IFN). Pregnant women and women with sarcoidosis had significantly decreased levels of NK cell activity compared to normal women. Pregnant women had the lowest mean NK cell activity. Cells from women with sarcoidosis and from pregnant women also had lower levels of killing than those from the normal women after in vitro stimulation of NK like CMC with Candida antigen, PPD and IFN. The lowest stimulations of NK like killing occurred in the cells from women with sarcoidosis. Skin test antigen stimulation of NK like CMC in vitro and the DTH response in vivo were strongly correlated for both Candida antigen and PPD in the sarcoidosis patients. There was no correlation between the level of NK cell activity in the PBMNC of sarcoid patients on day 0 and the amount of NK like CMC that was present in cells from those patients after 5 days of culture with Candida antigen, PPD or IFN. A significant correlation was found, however, between Candida antigen stimulation of NK like CMC and IFN stimulation of NK like CMC in both pregnant and sarcoid groups. Reduced NK cell activity on day 0 in a given patient thus did not necessarily indicate that skin test antigen or IFN stimulation of NK like CMC on day 5 would also be depressed. In addition, NK cell activity was often noted to be normal in patients with depressed in vitro stimulation of NK like CMC.

The skin test antigen stimulated killer (STAK) cell mediating NK like CMC is OKM1 positive and OKT3 negative.

Recently we demonstrated that candida antigen stimulated natural killer cell like cell-mediated cytolysis (NK like CMC) in peripheral blood mononuclear cells (PBMNC) isolated from normal individuals (Tartof et al., 1980). Utilizing monoclonal antibodies directed against human mononuclear cell subpopulations in conjunction with a fluorescence activated cell sorter (FACS) we determined that, similar to the previously described NK cell, the skin test antigen stimulated killer (STAK) cell is a larger OKM1 positive, OKT3 negative cell. We obtained similar results using two different skin test antigens. Thus, stimulation of NK like CMC in PBMNC by skin test antigens probably represents activation of NK or NK like cells.

Shoulder arthritis. Distinguishing among the many causes of inflammation.

Shoulder inflammation occurs in many rheumatic diseases. It is present in about half of the patients with rheumatoid arthritis but in a higher percentage of patients with less common diseases (eg, amyloid arthropathy, polymyalgia rheumatica). Shoulder arthritis, probably more than arthritis involving any other joint, requires prompt diagnosis and treatment to prevent loss of motion and function. For most patients, antiinflammatory medications, range of motion exercises, and instruction in joint protection constitute adequate treatment. A baseline shoulder roentgenogram is usually recommended. Intraarticular corticosteroid therapy may be a helpful adjunct, provided infection has been excluded.