Odontoid erosions in rheumatoid arthritis: utility of the open mouth view.

To determine if odontoid erosions are a marker for more severe cervical spine disease in rheumatoid arthritis (RA), 25 patients with RA were enrolled and had radiographs of the cervical spine including lateral and open mouth odontoid (OMO) views. The presence of odontoid erosions and of anterior atlantoaxial subluxation (AAS) was noted. Lateral cervical spine views were available for 19 patients, 11 of whom demonstrated odontoid erosions. Seven of 22 patients who had OMO views available demonstrated odontoid erosions. In only 3 of the 15 patients could odontoid erosions be seen on both views. Anterior AAS was present in 6 of 25 patients, 5 of whom had odontoid erosions. Anterior AAS was seen more commonly in patients with odontoid erosions. We propose that if erosions are present, patients should be more closely monitored for AAS and neurologic signs. OMO views are not as sensitive but are complementary to lateral cervical spine views in the detection of odontoid erosions.

Comparison of adrenocorticotropic hormone and triamcinolone acetonide in the treatment of acute gouty arthritis.

OBJECTIVE: To determine the best alternative therapy for acute gouty arthritis when nonsteroidal antiinflammatory drugs or colchicine are contraindicated. METHODS: Thirty-one patients with crystal proven gout presenting with an acute attack of < 5 days' duration were treated prospectively with either a single intramuscular injection of adrenocorticotropic hormone (ACTH) 40 IU or triamcinolone acetonide 60 mg. The patients were followed for 30 days. RESULTS: Resolution of all symptoms occurred at an average of 8 days for both groups. No adverse reactions were noted in either group; however, there were 11 reinjections in the ACTH group and 5 reinjections in the triamcinolone acetonide group. Two patients from the ACTH arm were transferred to the triamcinolone acetonide arm because of rebound arthritis. CONCLUSION: Although recent studies of ACTH and triamcinolone acetonide have demonstrated efficacy and safety comparable to indomethacin, in a direct comparison of the 2 at the doses used, triamcinolone acetonide resulted in fewer rebound attacks and treatment failures than ACTH and required fewer reinjections.

Coronary artery stenosis in Reiter's syndrome: a complication of aortitis.

Seronegative spondyloarthritis may be complicated by a variety of cardiac lesions including aortitis. We describe a patient with Reiter's syndrome who presented with angina and new onset heart murmurs. Cardiac catheterization revealed myocardial ischemia and aortic insufficiency. Our patient underwent bypass surgery with aortic valve replacement. Severe narrowing of the coronary ostia was noted and aortitis was documented by pathologic examination.

Diabetic muscular infarction.

In the evaluation of patients with a painful atraumatic mass in an extremity, the clinician should consider a number of clinical entities: primary tumor of muscle, focal or localized nodular myositis, local muscular abscess or soft-tissue infection, osteomyelitis, and thrombophlebitis. A rare complication of diabetes, viz, diabetic muscular infarction, heretofore not reported in the rheumatic disease literature is reviewed. This entity is compared with the conditions of focal and localized nodular myositis, which are nearly as rare.

Comparison of triamcinolone acetonide with indomethacin in the treatment of acute gouty arthritis.

Twenty-seven patients presenting within 5 days of the onset of crystalline proven acute gout were prospectively treated with either indomethacin 50 mg tid or triamcinolone acetonide 60 mg intramuscularly. Patients with contraindications to therapy with indomethacin received triamcinolone acetonide. They were followed for 30 days. Resolution of all symptoms occurred at an average of 8 days for the indomethacin patients and 7 days in the triamcinolone patients. No side effects or episodes of rebound gout attacks occurred with the triamcinolone acetonide therapy. It is as safe and effective as indomethacin in the treatment of acute gout, and is particularly useful in patients with contraindications to therapy with nonsteroidal antiinflammatory drugs.

Images in Rheumatology: a multimedia program for medical education.

In recent years, undergraduate medical education has benefited from the use of computer-based instructional programs. However, in the case of clinical and postgraduate medical education there is a scarcity of such programs, particularly those with access to high-resolution images. Having a fundamental knowledge base of disease-associated images is crucial for the physicians during the diagnostic process. To fill this gap in clinical instruction in the rheumatic diseases, Images in Rheumatology was developed. By using a hypertext format, one may select representative color images of a clinical disease or view x-ray changes typical for one of the rheumatic disorders. In addition, for each displayed image there is an associated sound-bite which explains in detail what abnormalities are present and how the user may differentiate the disease being viewed from other illnesses. An extensive review element is also included so that one can assess their fundamental knowledge of rheumatologic images. The Images in Rheumatology program has been implemented in the DOS (IBM Microchannel). and Windows environments.

Tryptophan-associated eosinophilic connective-tissue disease. A new clinical entity?

Seven patients who developed a syndrome of eosinophilia, connective-tissue disease, and cutaneous abnormalities while ingesting tryptophan were examined. Other clinical manifestations commonly seen were pulmonary symptoms, fever, lymphadenopathy, and the development of myopathy. Laboratory features included mild elevations of aldolase and lactate dehydrogenase levels, with essentially normal creatine kinase levels, erythrocyte sedimentation rates, and C-reactive protein levels. Biopsy findings included features of scleroderma, small-vessel vasculitis, fasciitis, and myopathy. Discontinuation of tryptophan administration and implementation of corticosteroid therapy were of some benefit in relieving the intense myalgias and cutaneous findings that developed. Although temporally related to tryptophan ingestion, it is unclear whether this substance, a metabolite, or a contaminant were causal. We speculate that the pathogenesis of this syndrome may relate to abnormalities in tryptophan metabolism.

Jaccoud's-type arthropathy: an association with malignancy.

We describe a patient who developed Jaccoud's type arthropathy as an initial manifestation of small cell anaplastic carcinoma of the lung. This is the first time this arthropathy has been reported as a musculoskeletal manifestation of malignancy.

Azathioprine induced hepatic veno-occlusive disease in rheumatoid arthritis.

A patient with rheumatoid arthritis developed hepatic veno-occlusive disease following the use of azathioprine. Although azathioprine induced veno-occlusive disease is suspected to occur more frequently in patients with autoimmune dysfunction, it has not previously been reported as a complication of treatment in rheumatoid arthritis. The mechanism responsible for this condition remains unknown.

Coexistence of Paget's disease and dermatomyositis.

The occurrence of Paget's disease and dermatomyositis in a single patient has not been previously reported. We present 2 patients with this combination of disorders and consider why these diseases might coexist.

Iliofemoral thrombophlebitis presenting as an acute abdomen: report and literature review.

Iliofemoral thrombophlebitis characteristically presents as acute inflammation and swelling of the affected extremity. We report a patient in whom the presenting complaints of high fever, nausea and left lower quadrant pain mimicked an acute abdomen. The diagnosis was confirmed by venogram after gallium scan and computer tomographic scan revealed abnormalities consistent with iliofemoral thrombophlebitis. This is the first report of abnormal gallium uptake in iliofemoral thrombophlebitis. Current methods of diagnosing this disorder are discussed and the literature reviewed.

Is atherosclerosis a complication of long-term corticosteroid treatment?

In clinical practice, arteriosclerotic heart disease has not been recognized as a complication of long-term corticosteroid treatment. Yet, an increasing body of evidence suggests that prolonged corticosteroid therapy accelerates the development of atherosclerosis. An important element in this process may be the fact that corticosteroids induce or exacerbate several known coronary risk factors, including hypertension, hypercholesterolemia, hypertriglyceridemia, and impairment of glucose tolerance. One group of patients that is often exposed to long-term corticosteroid treatment is that with rheumatoid arthritis. These patients have an increased mortality, with cardiovascular disease appearing to be a major contributor to this decreased survival. The weight of evidence relates the development of atherosclerosis to corticosteroid use. However, no long-term epidemiologic or morphologic studies have been performed to elucidate this issue. Until these are accomplished, prolonged therapy with this medication, particularly in younger persons, should be avoided whenever possible.

C-reactive protein: a marker for disease activity in ankylosing spondylitis and Reiter's syndrome.

Forty-four patients, 22 with ankylosing spondylitis (AS) and 22 with Reiter's syndrome (RS) were studied to determine the reliability of C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) as indicators of disease activity. CRP levels were significantly elevated in patients with active disease for both AS and RS while ESR values for active and inactive disease were not statistically different. Misdiagnosis was more likely when ESR rather than CRP was used as the variable for activity. CRP as measured by nephelometry is a more sensitive and specific indicator of disease activity in AS and RS than ESR.