The erythrocyte sedimentation rate: old and new clinical applications.

BACKGROUND: The erythrocyte sedimentation rate (ESR) is a simple and inexpensive laboratory test. It is commonly used to assess the acute phase response. METHODS: A review of the recent literature was done to evaluate the role of the ESR and its importance in different clinical conditions both inflammatory and noninflammatory. RESULTS: Despite the critical role cytokines have in inflammatory conditions, the ESR still maintains its important role in the diagnosis and follow-up of rheumatoid arthritis and temporal arteritis. Recently, ESR has been reported to be of clinical significance in sickle cell disease, osteomyelitis, and, surprisingly, in noninflammatory conditions such as stroke, coronary artery disease, and prostate cancer. Erythrocyte sedimentation rate measured by the Westergren method is marginally affected by age, race, and blood storage. CONCLUSION: Despite its importance in many clinical conditions, ESR should be used only as a clinical guide to aid the diagnosis, management, and follow-up of these different clinical situations.

Dermatomyositis in association with tubulovillous adenoma: resolution after resection of adenoma.

Dermatomyositis (DM) has been associated with gastrointestinal malignancy but not with polyps or adenoma. We report a case of villous adenoma associated with DM. An 80-year-old white woman was referred for a rash of 2 months' duration that was suggestive of DM. On examination, Gottron's papules and heliotrope rash were seen. Muscle strength was 4/5 in the proximal upper and lower extremities. Despite normal muscle enzyme values, electromyographic and nerve conduction studies were supportive of the diagnosis of DM. DM was confirmed by deltoid muscle biopsy. Heme-positive stool was seen on rectal examination. Colonoscopy revealed a large tubulovillous adenoma in the cecum, which was resected. The patient was given oral prednisone, 60 mg/day. Within 4 weeks after surgery, steroids were tapered to one third the original dose. Within 9 months, steroid therapy had been discontinued with no evidence of disease activity.

Unusual presentations of gout. Tips for accurate diagnosis.

In cases of unusual presentations, such as the three cases described here, gout or gouty arthritis may be misdiagnosed as rheumatoid arthritis, septic arthritis, or other rheumatic conditions and thus inappropriately treated. Microscopic analysis using compensated polarized light and culture of synovial fluid helps distinguish gouty arthritis from other arthropathies, and the presence of monosodium urate crystals establishes the diagnosis of gout. When gout is suspected, yet the initial examination does not reveal the telltale crystals, reexamination of synovial fluid is warranted. It is important for physicians to remember, though, that diagnosis of gout does not rule out the possibility of concurrent arthritic conditions.

Options in the management of pneumonia caused by Pneumocystis carinii in patients with acquired immune deficiency syndrome and intolerance to trimethoprim/sulfamethoxazole.

The increased resistance, intolerance, or allergy to trimethoprim/sulfamethoxazole (TMP/SMX) has brought much attention to alternative treatment of pneumonia caused by Pneumocystis carinii (PCP). Pentamidine is considered when there is documented allergy or intolerance to TMP/SMX. Similarly, either dapsone/trimethoprim or clindamycin/primaquine is effective in the treatment of mild to moderate PCP, but both regimens are contraindicated in glucose 6-phosphate dehydrogenase (G6PD) deficiency. For this purpose, atovaquone should be used in patients who are deficient in G6PD or who are unable to be on TMP/SMX or pentamidine. On the other hand, in severe disease, adjunctive corticosteroids can enhance the efficacy of either TMP/SMX or pentamidine. If these therapies yield no response, trimetrexate with leucovorin has been approved as initial and salvage therapy in severe PCP. We review alternative treatment to TMP/SMX and propose ideal and practical therapeutic and prophylactic guidelines in the treatment and prevention of PCP.

Dermatomyositis: remission induced with combined oral cyclosporine and high-dose intravenous immune globulin.

Dermatomyositis is an uncommon idiopathic chronic inflammatory disorder. Oral corticosteroids are the treatment of choice. A few patients become resistant to steroids. We describe two patients who, after failure to respond to oral and high-dose intravenous corticosteroids, received a combination of oral cyclosporine and high-dose intravenous immune globulin, with apparent remission. The first patient was a 6-year-old girl with recurrent disease and vasculitis, despite prednisone therapy and normal muscle enzyme levels. The response was remarkable within 3 weeks of therapy. The second patient was a 30-year-old woman with progressive disease and secondary respiratory failure despite oral prednisone and methotrexate therapy. The response to treatment was optimal within 4 weeks. She received maintenance low-dose cyclosporine and a tapering dose of prednisone. The combination of high-dose immune globulin and cyclosporine can be useful and safe in the management of steroid-resistant dermatomyositis.

Peripheral ulcerative keratitis in the setting of rheumatoid arthritis: treatment with immunosuppressive therapy.

Peripheral ulcerative keratitis (PUK) is a rare but serious inflammatory eye condition that can complicate rheumatoid arthritis. PUK can be a warning sign of impending vasculitis, and cytotoxic therapy may be necessary to induce remission. We have encountered three patients with PUK in the past year. Two patients had long-standing quiescent rheumatoid arthritis who developed photophobia. Diagnosis was made by slit lamp examination. Treatment with local cyclophosphamide and prednisone resulted in prompt remission of the ulcer within 8 weeks. Cytotoxic therapy was discontinued altogether within 6 months. The third patient was also treated successfully with oral steroids and azathioprine. In all patients, sicca was noted. None of them had any evidence of systemic vasculitis. PUK, when recognized early and treated aggressively, can result in remission of the ulcer and in the prevention of vasculitis. Keratoconjunctivitis sicca can accompany PUK independent of the activity of rheumatoid arthritis.

Azathioprine in the treatment of chronic refractory steroid-dependent asthma.

We have described a patient with chronic, severe, steroid-dependent asthma resistant to all forms of anti-inflammatory therapy. Azathioprine alone effectively improved the patient's symptoms and decreased the daily steroid requirements. Further short- and long-term studies are needed to observe the effects of azathioprine in chronic asthma.

Soluble interleukin-2 receptors in children with Kawasaki syndrome.

We studied levels of soluble interleukin-2 receptors (IL-2R) in serial serum samples obtained from 93 patients with Kawasaki syndrome, using a double-antibody "sandwich" enzyme-linked immunosorbent assay technique. Concentrations of soluble IL-2R were significantly increased in Kawasaki syndrome patients in the first 4 weeks of illness when compared with either healthy adult or pediatric controls (P less than 0.02), and in the first 2 weeks of illness when compared with a group of children with measles (P less than 0.0001). Furthermore, in the second week of illness, levels of soluble IL-2R were significantly greater in children who subsequently developed coronary artery aneurysms than in patients with normal appearing coronary arteries. Serum concentration of soluble IL-2R is a useful marker for detecting early Kawasaki syndrome and identifies those patients who are at greater risk of developing coronary artery aneurysms.

Interleukin 2 receptor expression by T cells in human aging.

Aged individuals have depressed cell-mediated immunity and diminished T cell proliferation to mitogenic and antigenic stimuli. Because T cell responses depend on the surface expression and normal function of interleukin 2 receptors, we measured the quantities and affinities of cell surface IL-2R and the amount of soluble IL-2R alpha chain (p55) release in vitro in PHA-stimulated mononuclear cells from healthy aged (greater than or equal to 65 years old) and young (less than or equal to 39 years old) donors. At the peak of the PHA response, the fraction of cells expressing IL-2R alpha chain (CD25+) was lower in the aged (43% vs 56%, P = 0.033). Relative to the lower proliferation and CD25 expression, old donor cells released unexpectedly high quantities of soluble alpha chain into culture supernatants. However, the average affinities and the mean numbers of high- and low-affinity surface receptors per CD25+ cell were equivalent in cells from eight pairs of aged and young donors (1850 vs 1586 high affinity, and 20,655 vs 23,466 low affinity, P greater than 0.2 for both). The soluble IL-2R released by stimulated cells had no effect on proliferative responses, because addition of saturating doses of exogenous recombinant IL-2 did not increase cellular proliferation, and addition of soluble anchor-minus recombinant IL-2R alpha chain did not suppress it. These results indicate that in healthy older individuals, diminished numbers of T cells can be induced to express cell surface IL-2R following mitogenic stimulation, although aged CD25+ can express a normal complement of IL-2R molecules. In the aged, either CD25+ cells release excessive quantities or a subset of cells synthesizes and releases soluble IL-2R alpha chain into the extracellular environment without expressing it on the cell surface.