[Enoxaparin induced skin necrosis].

Skin necrosis due to the use of Coumarin congeners or intravenous standard heparin is a known side effect. This adverse effect is rarely described after the use of low molecular weight heparin. We report a case of Enoxaparin induced skin necrosis in a 77 years old female treated for Atrial Fibrillation and left ventricle thrombus. We reviewed the relevant literature on the subject.

Arthritis as the presenting symptom of diverticulitis.

We describe a patient in whom peripheral arthritis was the presenting symptom of diverticulitis. The joint inflammation resolved only after treatment for the gastrointestinal disease. The pathogenesis, clinical aspects and management of this condition are discussed.

Zinc metabolism in rheumatoid arthritis: plasma and urinary zinc and relationship to disease activity.

OBJECTIVE: To study zinc absorption in patients with active rheumatoid arthritis (RA). METHODS: We studied zinc tolerance tests and 24 hour urinary zinc excretion before and after ingestion of 50 mg elemental zinc in 8 healthy volunteers (Group 1) and 13 patients with low RA activity (Group 2) and 16 patients with high RA activity (Group 3). RESULTS: In Group 1, plasma zinc rose from 111 +/- 7 micrograms/dl to a peak of 200 +/- 24 micrograms/dl (mean +/- SEM) in 2 h. In Groups 2 and 3, plasma zinc before zinc ingestion was significantly lower than that of the control group (p < 0.00001 for both groups) and showed no significant increase in plasma after ingestion. Twenty-four hour urinary zinc excretions before and after zinc ingestion were significantly lower (p < 0.01, p < 0.0001 for Group 2; p < 0.05, p < 0.01 for Group 3, respectively) than those in the control group. CONCLUSION: These results are compatible with zinc malabsorption and consequent zinc deficiency in patients with RA. Whether zinc deficiency contributes to perpetuation of disease activity by compromising cellular immune function needs further investigation.

Insufficiency fractures of the pubic ramus.

Seven elderly women with insufficiency fractures of the pubic ramus are described. The predisposing factors for this condition were osteoporosis, rheumatoid arthritis, renal failure, prolonged corticosteroid treatment, pelvic irradiation, and mechanical changes after hip surgery. The clinical presentation included progressive inguinal pain, limping, and inability to walk. Because initial radiographs were diagnostic only in four cases, bone scintigraphy and computed tomography were necessary to confirm the diagnosis and detect additional fractures. In most patients, bed rest, non-weight-bearing ambulation, symptomatic treatment, and therapy for osteoporosis resulted in rapid improvement, and long-term follow-up showed complete or partial recovery. In one case, no recovery was achieved because of noncompliance with treatment. Insufficiency fracture of the pubic ramus should be suspected in cases of unexplained inguinal or hip-area pain and inability to walk in the elderly. The clinical suspicion should be supplemented by radiological investigation. Bone scintigraphy and computed tomography are useful means for early and accurate diagnosis. The risk factors for this condition should be identified and treated. If therapy is initiated early and pursued, this type of fracture has a benign outcome.

Spontaneous fracture of the sternum simulating myocardial infarction.

Spontaneous fractures of the sternum are rare but worth knowing as they may simulate acute cardiac and pulmonary emergencies. A case of an insufficiency sternal fracture mimicking myocardial infarction and subsequent anginal pain is presented. The risk factors of this condition, its clinical features and the diagnostic procedures are discussed. Spontaneous fractures of the sternum should be considered as a diagnostic possibility for unexplained chest pains in the elderly.

Systemic lupus erythematosus: predisposition for uterine cervical dysplasia.

A previous retrospective study has found an increased risk of uterine cervical atypia in women with systemic lupus erythematosus (SLE) who have been treated with cytotoxic drugs. Our objective was to prospectively reveal any increased incidence of cervical atypia in SLE patients and to evaluate the relationship to previous chemotherapy. A total of 39 SLE women were prospectively referred for cytologic PAP smears of the uterine cervix. A significantly higher incidence of cervical atypia was found in SLE women (35.9%) compared with non-SLE control groups (< or = 5%; P < 0.01). No significant difference was found between the incidence of atypia in patients previously treated by cytotoxic medications such as cyclophosphamide pulses or methotrexate (4 of 9) compared with SLE women not receiving cytotoxic drugs (10 of 30). Colposcopically directed biopsies revealed three cases of cervical intraepithelial neoplasia (CIN) I-III (23%) among the cases with atypia. We conclude that women with SLE should have regular cytologic cervical smears because of a significantly increased incidence of atypia, regardless of previous cytotoxic therapy.

Frequent induction of insulin autoantibodies by D-penicillamine in patients with rheumatoid arthritis.

D-Penicillamine is a drug known to induce various immunological abnormalities. We used a competitive radiobinding assay, to evaluate the presence of insulin autoantibodies in 42 patients with rheumatoid arthritis (RA), under various treatment modalities. In 11/42 (26.2%) patients, the levels of insulin autoantibodies (range 59-1970 nU/ml) exceeded our upper limit of normal range (50 nU/ml). Nine of these 11 (81.8%) insulin autoantibodies positive patients had been treated with D-penicillamine. Out of 21 D-penicillamine treated patients, 9 (42.9%) were insulin autoantibodies positive (range 80 to 1970 nU/ml). An inverse correlation was found between the concentration of insulin autoantibodies and the time interval since the last drug administration, R = -0.58 (p < 0.05). No correlation was found between the autoantibodies levels and age, or duration of D-penicillamine treatment. In summary, elevated concentration of serum insulin autoantibodies are most probably induced by D-penicillamine therapy in patients with RA and tend to decrease after the drug withdrawal.

Actigraphic measurements of sleep in rheumatoid arthritis: comparison of patients with low back pain and healthy controls.

Actigraphic recordings during sleep were carried out in patients with rheumatoid arthritis (RA), in patients with chronic low back pain, and in healthy controls for 4 consecutive nights. All derived measures of sleep quality showed that the sleep of patients with RA was significantly poorer than controls, while patients with chronic low back pain had sleep quality not significantly different from either group. Polysomnographically defined periodic movements in sleep were significantly related to sleep efficiency in patients with RA. Clinical status in these patients was significantly related to several actigraphic sleep measures.

Nonsteroidal antiinflammatory drug therapy in rheumatoid arthritis patients. Lack of association between clinical improvement and effects on sleep.

Thirteen patients with rheumatoid arthritis (mean +/- SD age 55.8 +/- 10.5 years) received 20 mg of tenoxicam daily for 90 days following a 3-7 day "washout" period and 4 days of placebo treatment. Clinical evaluations were conducted at the end of the washout period and at monthly intervals thereafter. All-night polysomnography was performed in a sleep laboratory during the last 2 days of placebo treatment and on days 13, 14, 89, and 90 of tenoxicam treatment. Although there was improvement in the patients' clinical condition, there were no treatment-related changes in any of the sleep parameters. Eight of the 13 patients, however, were found to have primary sleep disorders. Four had periodic leg movements during sleep, 3 had sleep apneas, and 1 had a combination of both disorders. The implications of these findings in the treatment of sleep disorders in patients with rheumatoid arthritis are discussed.

[Sulfasalazine in rheumatoid arthritis].

Sulfasalazine (SLZ) is now a second-line treatment in rheumatoid arthritis (RA), as well as in psoriatic arthritis and ankylosing spondylitis. 54 patients with active RA were treated with enteric coated SLZ (2 g daily) in a 24-week open study. Clinical and laboratory parameters of disease activity were monitored initially and thereafter at 2-week intervals for the first 2 months, and then at 4-week intervals until the end of the 24-week study. There was significant clinical improvement at the end, as shown by scores for joint pain (Ritchie), grip strength and morning stiffness (p less than 0.0001, less than 0.0001 and less than 0.01, respectively, by paired t test). Clinical improvement was accompanied by significant decrease in erythrocyte sedimentation rate and increase in hemoglobin (p less than 0.002 and less than 0.016, respectively). There was improvement in some cases as early as 3 weeks after starting therapy. The drop-out rate was significant: 19/54 (35%), most (13) due to side-effects, mainly gastrointestinal; none of the side-effects were serious. Our results, similar to those of other studies, indicate that despite the high rate of side effects, SLZ is an effective, second-line drug for RA.

Transient osteoporosis of the hip: case report and review of the literature.

A case of idiopathic transient osteoporosis of the hip is reported and the literature reviewed. The clinical and radiological features of this syndrome are described, as well as the diagnostic contribution of bone scintigraphy. The need for conservative treatment and avoidance of invasive diagnostic procedures is emphasized.

Interleukin-1 and interleukin-2 production by peripheral blood mononuclear cells of patients with rheumatoid arthritis.

Contradictory results have been reported concerning the secretion of interleukin-1 (IL-1) and interleukin-2 (IL-2) by mononuclear cells of rheumatoid arthritis (RA) patients. In the present study, peripheral blood mononuclear cells from 18 RA patients were stimulated in vitro to produce IL-1 and IL-2 and compared with monocytes of age-matched healthy control subjects. Endotoxin-stimulated monocytes of RA patients produced normal amounts of IL-1 compared with healthy controls (P = 0.5), whereas T-lymphocytes from the same patients produced decreased amounts of IL-2 compared with control T-lymphocytes (P less than 0.01). There was no difference in IL-1 or IL-2 production by mononuclear cells from patients with active or inactive disease. These findings could not be explained by concurrent therapy, and support the notion that defective immunoregulatory T-cell functions are involved in the pathogenesis of RA.

Recurrent massive alveolar hemorrhage, crescentic glomerulonephritis, and necrotizing vasculitis in a patient with rheumatoid arthritis.

A middle-aged man presented with recurrent alveolar hemorrhage, rheumatoid arthritis, and crescentic immune complex-mediated glomerulonephritis. Nail bed hemorrhages and necrotizing vasculitis were documented concomitantly with the clinical picture of Goodpasture's syndrome. Perusal of the literature disclosed two additional similar cases. It is suggested that Goodpasture's syndrome may evolve in the framework of rheumatoid vasculitis. While immunosuppressive therapy resulted in short-term remission, two of the three patients involved developed late-stage renal failure.

Calcified thoracic disc with herniation of the nucleus pulposus in a child.

A twelve year old boy presented with acute cervical and interscapular pain, torticollis and low grade fever. The neurological examination was normal. Roentgenograms showed calcification of the T3-T4 disc and posterior herniation of the nucleus pulposus was demonstrated by computed tomography. A rapid and dramatic amelioration of the symptoms was produced by treatment with a non-steroidal anti-inflammatory drug. Intervertebral disc calcification in childhood is an uncommon and usually benign condition. Its clinical and radiological features are discussed in the light of the relevant literature.

Reflex sympathetic dystrophy syndrome coincident with acute diabetic neuropathy.

Diabetes mellitus and peripheral neuropathies are considered to be unusual causes of the reflex sympathetic dystrophy syndrome. Their coexistence in a patient with this syndrome is rare and considered to be incidental. We report a case in which remission of the syndrome accompanied the resolution of the diabetic neuropathy. A possible pathophysiologic mechanism connecting these conditions is discussed.