Treatment of early seropositive rheumatoid arthritis: a two-year, double-blind comparison of minocycline and hydroxychloroquine.

OBJECTIVE: To compare the efficacy of minocycline with that of a conventional disease-modifying antirheumatic drug (DMARD), hydroxychloroquine, in patients with early seropositive rheumatoid arthritis (RA). METHODS: Sixty patients with seropositive RA of <1 year's duration who had not been previously treated with DMARDs were randomized to receive minocycline, 100 mg twice per day, or hydroxychloroquine, 200 mg twice per day, in a 2-year, double-blind protocol. All patients also received low-dose prednisone. The primary end points of the study were 1) the percentage of patients with an American College of Rheumatology (ACR) 50% improvement (ACR50) response at 2 years, and 2) the dosage of prednisone at 2 years. RESULTS: Minocycline-treated patients were more likely to achieve an ACR50 response at 2 years compared with hydroxychloroquine-treated patients (60% compared with 33%, respectively; P = 0.04). Minocycline-treated patients were also receiving less prednisone at 2 years compared with the hydroxychloroquine group (mean 0.81 mg/day compared with 3.21 mg/day, respectively; P < 0.01). In addition, patients treated with minocycline were more likely to have been completely tapered off prednisone (P = 0.03). Trends favoring the minocycline treatment group were seen when outcomes were assessed according to components of the ACR core criteria set, with the differences reaching statistical significance for patient's global assessment of disease activity (P = 0.004). CONCLUSION: Minocycline is an effective DMARD in patients with early seropositive RA. Patients treated with minocycline were more likely to achieve an ACR50 response and did so while receiving less prednisone. In addition, minocycline-treated patients were more likely to have discontinued treatment with prednisone at 2 years.

Primary angiitis of the central nervous system. Report of 8 new cases, review of the literature, and proposal for diagnostic criteria.

Primary angiitis of the central nervous system (PACNS) is a rare form of angiitis limited to the central nervous system. The diagnosis and classification of this disorder has been problematic, owing to the lack of uniform diagnostic criteria and the difficulty in obtaining pathologic material for diagnosis. This study proposes to establish diagnostic criteria for PACNS which would include 1) the presence of an unexplained neurologic deficit after thorough clinical and laboratory evaluation; 2) documentation by cerebral angiography and/or tissue examination of an arteritic process within the central nervous system; and 3) no evidence of a systemic vasculitide or any other condition to which the angiographic or pathologic features could be secondary. Utilizing these criteria, 8 new cases are reported and are combined with 40 previously diagnosed cases from the literature. The clinical findings of the combined series revealed that headache was the most common symptom (58%) with a combination of focal and diffuse neurologic deficits described in 79% of the group. The diagnostic approach to PACNS should include a variety of laboratory tests and examination of the cerebral spinal fluid primarily to rule out mimicking conditions. Special procedures including electroencephalography, computed axial tomography, and magnetic resonance imaging appear only marginally helpful in securing the diagnosis, but are extremely important in ruling out other conditions. Angiography appears to be the first invasive diagnostic procedure of choice and it has a high predictive value when properly interpreted. Leptomeningeal and cortical biopsy can be accomplished with acceptable mortality and should be performed along with a normal or non-diagnostic angiogram when the diagnostic likelihood is high. Therapy of PACNS with a combination of cytotoxic drugs and high-dose corticosteroids has greatly improved the prognosis for this condition.

Listeria monocytogenes endocarditis on a prosthetic heart valve.

Listeria monocytogenes endocarditis, an illness with a potentially high mortality developed in a patient with a porcine mitral valve heterograft. After treatment with parenteral ampicillin and streptomycin, blood cultures remained sterile and vegetations noted before treatment cleared. Delay in diagnosis and institution of appropriate antimicrobial therapy may occur because of the diverse morphologic features of L monocytogenes.