Lupus erythematosus/lichen planus overlap syndrome: successful treatment with acitretin.

Lupus erythematosus/lichen planus overlap syndrome is a rare disorder combining the clinical, histological and immunopathological features of both lupus erythematosus (LE) and lichen planus (LP). Cutaneous lesions mostly affect the distal arms, legs, face and trunk. Palmoplantar involvement is felt to be characteristic of this condition. Plaques are often painful, centrally atrophic, bluish-red to hypopigmented in color, large, and scaly. On biopsy of clinically ambiguous lesions, histopathological features of one or both processes can be found, obscuring the diagnosis and complicating prognosis and treatment. Thus, direct immunofluorescence has become an essential tool in helping to diagnose this condition. In this report we describe the unique clinical and immunohistopathological manifestations of lupus erythematosus/lichen planus overlap syndrome along with a successful response to treatment with acitretin.

Evaluation of suspected stress fractures.

Stress fractures can occur if normal bone is exposed to repeated abnormal stress (fatigue fractures) or if normal stress is placed on bones with compromised elastic resistance (insufficiency fractures). This article describes two patients without a history of excessive stressful activity or apparent metabolic bone disease who developed bilateral distal tibial stress fractures. Different etiologies, clinical presentation, differential diagnosis, and diagnostic imaging modalities of stress fractures are discussed.

Prevalence of pulmonary disorders in patients with newly diagnosed rheumatoid arthritis.

Our objective was to determine the prevalence of airway hyperreactivity (AHR) in patients with newly diagnosed rheumatoid arthritis (RA) who had received no disease-modifying antirheumatic drugs (DMARDs) and to characterise the spectrum of lung diseases identifiable in these patients at the time of presentation. Eighteen consecutive patients with newly diagnosed RA referred to our medical centre's rheumatology clinic over 2 years underwent pulmonary evaluation with arterial blood gas analysis, chest radiographs, spirometry before and after bronchodilator medication, and body plethysmography. They returned on subsequent days in random order for methacholine inhalation challenge (MIC) and eucapnic voluntary hyperventilation (EVH) as bronchoprovocation techniques. One patient had severe obstructive disease at presentation and therefore did not undergo bronchoprovocation. We found a wide variety of pulmonary abnormalities, including two patients with hypoxia (12%), two with obstruction (12%), three with restriction (18%) and four with AHR (23%). The data also suggest a strong association between pulmonary diseases in RA and cigarette smoking. Although no single characteristic lung disease such as AHR was identified in patients presenting with RA, the association between lung disease and cigarette smoking is striking and underscores the need to emphasise smoking cessation in this patient population.

Eosinophilia in Wegener's granulomatosis.

Significant eosinophilia is a prominent feature in Churg-Strauss syndrome but has only rarely been described in Wegener's granulomatosis (WG). We describe two Wegener's granulomatosis patients with > 30% eosinophilia on their initial presentations. Other etiologies that could account for their eosinophilia were excluded. Both patients had pulmonary alveolar hemorrhage, sinusitis, arthritis, high-titer cytoplasmic antineutrophil cytoplasmic antibodies (cANCA), and proteinase-3 antibodies, but no evidence of renal disease. Herein we discuss eosinophilia, the differential diagnosis of pulmonary infiltrates and eosinophilia, the role of cANCA in vasculitis and autoimmune disease, compare Wegener's granulomatosis and Churg-Strauss syndrome, and review possible pathogenic mechanisms.

Minocycline hyperpigmentation.

Several recent studies have documented the efficacy and safety of minocycline in the treatment of mild rheumatoid arthritis. Reported side effects tend to be mild, with gastrointestinal disturbances, headaches, vestibular dysfunction, and photosensitive rashes being the most common. Hyperpigmentation of skin and other structures has also been reported but seems to be uncommon and usually dose-related. The different types of skin hyperpigmentation are reviewed, including their histopathologic and clinical distinctions, possible predisposing factors, and treatment.Our experience suggests that steroid use, advanced age, cumulative minocycline dosage, and possibly the brand of minocycline may be predisposing risk factors for developing hyperpigmentation. It is quite possible that this adverse effect is more common than previously recognized, and we suggest that physicians prescribing minocycline be observant for skin hyperpigmentation. Although most of our patients with hyperpigmentation chose to continue the medication (61 %), it must be discontinued for the hyperpigmentation to resolve.

Frostbite arthropathy.

Frostbite injuries are typically associated with soft tissue damage, but deeper structures such as bones, joints, and cartilage may eventually be affected in more than half of all patients. We report a case of a 29-year-old man who presented with bilateral distal and proximal interphalangeal joint pain, decreased range of motion, and an examination and radiographs consistent with osteoarthritis (OA). The symptoms began two decades previously after a frostbite injury sustained to both hands at age 9. This case illustrates some important clinical sequelae resulting from frostbite injury, such as premature OA, Additionally, because the injury occurred before epiphyseal growth plate closure, he also developed brachydactyly. The thumbs were spared, as has also been reported by others, because the thumb is often protected in the palm.

Prospective use of intramuscular triamcinolone acetonide in pseudogout.

OBJECTIVE: To prospectively assess the efficacy of intramuscular (i.m.) triamcinolone acetonide in the treatment of pseudogout. METHODS: Fourteen patients with crystal proven pseudogout presenting with an acute attack within 5 days of onset were treated with intramuscular triamcinolone acetonide 60 mg and followed for 30 days. Patients with inadequate response were eligible for a 2nd triamcinolone acetonide injection on Day 1-2. RESULTS: Twelve patients had contraindication to nonsteroidal antiinflammatory agents (NSAID). Acute arthritis was monoarticular in 10 patients, and involved 2 or more joints in 4 patients. All patients had good clinical response to triamcinolone acetonide based on restoration of near baseline joint range of motion and joint circumference, and at least 50% improvement in patient and physician global assessment. Major clinical improvement occurred by Day 1-2 (2 patients), Day 3-4 (11 patients), and Day 10-14 (one patient). Six patients required a 2nd triamcinolone acetonide injection on Day 1-2. Toxicities were not observed. CONCLUSION: I.m. triamcinolone acetonide appears to be safe, well tolerated, and effective in the treatment of pseudogout. It may be a reasonable alternative therapy when NSAID are contraindicated, and for polyarticular attacks where intraarticular corticosteroids are impractical.

Reactive Arthritis Following Clostridium difficile Colitis in a 3-Year-Old Patient.

Reactive arthritis following antibiotic-associated Clostridium difficile (CD) colitis is becoming increasingly recognized in adults; 20 cases have been reported in the medical literature. We describe a 3-year-old patient with reactive arthritis following CD colitis, the first such reported case in a pediatric patient. The clinical features of reactive arthritis following CD colitis appear similar to those of more frequently described pathogens. The arthritis usually occurs 1-2 weeks after the onset of diarrhea, with an asymmetric oligoarticular distribution typically involving large lower extremity joints; resolution occurs in weeks to months. Reactive arthritis in children probably occurs less commonly than in adults, has fewer mucocutaneous manifestations, and follows infections caused by gastrointestinal pathogens much more frequently than genitourinary organisms.

Periorbital edema and mees' lines in systemic lupus erythematosus.

There are many cutaneous findings that have been described in systemic lupus erythematosus (SLE). These include disease-specific and nonspecific lesions. Periorbital edema in the absence of proteinuria or hypoalbuminemia has been only rarely described. We report three patients who developed marked periorbital edema in association with a flare of SLE. All patients were without proteinuria or significant hypoalbuminemia, and no other etiology for the periorbital swelling was identified. This occurred despite all three taking antimalarial therapy, but the edema resolved promptly and completely with glucocorticoids. One of these patients also had transverse leukonychia, or Mees' lines, present on several fingernails, that appeared to correspond with previous SLE flares.Mees' lines and periorbital edema may represent two additional nonspecific but disease-related dermatologic manifestations of SLE. Whereas periorbital edema usually develops in concert with other clinical evidence of a lupus flare and is easily treated, Mees' lines appear to serve as a time line for previous SLE activity.

Orbital inflammatory syndrome and systemic lupus erythematosus.

Orbital inflammatory syndrome (OIS) is a rare condition characterized by inflammation of orbital structures in the absence of underlying infection, neoplasm or endocrinopathy. The pathogenesis of OIS has not been fully described, but histopathology reveals diffuse lymphocytic infiltration of the involved structures. This disorder presents clinically as acute pain and swelling in the orbit and usually responds rapidly to high dose corticosteroids. This entity has been reported previously in seven patients with systemic lupus erythematosus (SLE). Herein, we describe a patient with SLE who developed OIS, review the previously reported cases that have occurred in association with SLE, and describe the diagnostic evaluation and therapy for OIS. This rare entity can pose both a diagnostic and therapeutic dilemma in SLE patients given immunoppressive therapy.