Progressive systemic sclerosis and Graves' disease. Report of three cases.

Progressive systemic sclerosis (PSS) is associated with a broad spectrum of autoimmune thyroid diseases. While an association between PSS and hypothyroidism is well established, a relationship between PSS and hyperthyroidism is less well defined. We treated three patients with PSS whose course was complicated by Graves' disease. Because hyperthyroidism can simulate many of the symptoms of PSS progression and treatment of hyperthyroidism can lead to resolution of clinical deterioration in such patients, it is important to recognize the simultaneous occurrence of these diseases.

Hemophilus influenzae septic arthritis in adults. A report of four cases and a review of the literature.

The clinical and diagnostic features of 29 adult patients with H. influenzae septic arthritis are reviewed. Twelve men and 17 women ranging in age from 22 to 82 years developed the infection. H. influenzae septic arthritis is an acute, febrile disease with a mean duration of symptoms before diagnosis of 4 days. Fifteen patients had monoarticular arthritis, 6 with an infected knee. Polyarticular involvement, with a range of 2 to 9 joints, was diagnosed in 14 patients. Nineteen patients had concurrent extraarticular sites of infection, including meningitis, pneumonia, pharyngitis, sinusitis, conjunctivitis, and cellulitis. Twenty-two of 29 patients had predisposing factors for infection, including ethanolism, trauma, rheumatoid arthritis, systemic lupus erythematosus, diabetes mellitus, splenectomy, multiple myeloma, lymphoma, gout, and acquired common variable hypogammaglobulinemia. Characteristic synovial fluid findings included purulent, greenish fluid, elevated WBC count, and gram-negative pleomorphic microorganisms. Treatment for these patients included antibiotic therapy, most often ampicillin and chloramphenicol, and joint drainage by repeated arthrocentesis or arthrotomy. A favorable outcome was reported in 25 of 29 patients. Hemophilus influenzae septic arthritis should be suspected in adults who are immunocompromised and have a concurrent extraarticular source of infection.

A clinician's approach to acute low back pain.

Two important goals in treating acute low back pain are to return the patient to regular activity as quickly as possible and to do so in a manner that is cost-effective. By following a logical treatment protocol, the clinician is often able to provide the treatment necessary to provide the patient with relief. Referral to an orthopedist or neurosurgeon may be appropriate in only a minority of cases. Thus, after the initial history and physical examination, ruling out (or in) conditions that require urgent or emergent care is essential. These conditions include cauda equina syndrome, circulatory collapse due to expanding abdominal aortic aneurysm, and tumor, infection, and other underlying disorders as a cause of low back pain. Patients without these conditions can be started on conservative therapy-without radiographic or laboratory tests-regardless of the specific diagnosis. Conservative therapy consists of passage of time, controlled physical activity, physical modalities (e.g., cryotherapy or thermotherapy), local injections, nonsteroidal anti-inflammatory drugs, and muscle relaxants. Because low back pain is so common, even the small proportion of patients who do not improve after 6 weeks of conservative therapy represents a sizable number. The location and radiation of pain are used as initial guides to classifying these patients into four groups: those with localized pain, sciatica, anterior thigh pain, or posterior thigh pain. Each follows a different diagnostic path, which will be described herein.

Recovery of the hypothalamic-pituitary-adrenal (HPA) axis in patients with rheumatic diseases receiving low-dose prednisone.

PURPOSE: To assess the status of the hypothalamic-pituitary-adrenal (HPA) axis in cortico-steroid-treated patients whose prednisone dose had been tapered to physiologic doses. PATIENTS AND METHODS: The design of the study was a retrospective chart review of 50 consecutive patients receiving 10 mg or less of prednisone daily at a university teaching hospital rheumatology clinic. Patients were given a rapid adrenocorticotropic hormone stimulation test, with cortisol levels obtained at baseline and after intravenous administration of cosyntropin. Charts were reviewed for duration of therapy, highest, current, and total cumulative steroid dose, and average daily steroid dose in each month of the preceding 2 years. RESULTS: Current steroid dose was the only significant indicator of HPA axis function. Patients receiving less than 5 mg of prednisone daily had a normal HPA axis response, whereas those receiving 5 mg or more had widely varied responses. Neither the total, the highest prednisone dose, nor the duration of therapy was a significant indicator of HPA axis recovery. CONCLUSIONS: Spontaneous recovery of the HPA axis is usual for patients who are taking prednisone at daily doses of 5 mg or less. Return of normal HPA axis function can be achieved without alternate-day therapy in patients whose disease allows tapering to daily prednisone doses of 5 mg or less.

Role of intravenous cyclophosphamide in the treatment of severe neuropsychiatric systemic lupus erythematosus.

PURPOSE: We assessed the outcome of 31 patients with severe neuropsychiatric (NP) systemic lupus erythematosus (NPSLE) treated with intravenous cyclophosphamide (IV-CYC), and identified clinical predictors of response to therapy. METHODS: The authors performed a retrospective chart review and classified patients by NP manifestation and response to therapy as measured by serial anatomic imaging and neurodiagnostic studies coupled with clinical assessment of improvement. RESULTS: Neuropsychiatric manifestations occurred with the following frequencies: organic brain syndromes (OBS) 55%, stroke syndromes 35%, peripheral or mononeuropathy 32%, seizures 29%, psychiatric symptoms 26%, transverse myelitis 16%, cranial neuropathies 13%, other 16%. Most patients had multiple NP manifestations, with a median of two. Ninety percent of patients had failed therapy with corticosteroids with or without cytotoxic drugs prior to treatment with IV-CYC. Eight patients received synchronous plasmapheresis along with IV-CYC. After treatment with IV-CYC, NP deficits substantially improved in 61% (group I), stabilized in 29% (group S), and progressively deteriorated in 10% (group P). Patients in group I had significantly fewer NP manifestations than combined group S+P, two versus four, and a lower frequency of OBS, 37% versus 83%. CONCLUSION: Intravenous cyclophosphamide appears to be an effective treatment for some patients with severe NPSLE refractory to other forms of therapy. Higher number of NP manifestations and presence of OBS may predict poor outcome and identify a group of patients for whom early aggressive therapy may be indicated.

Autoantibodies to the insulin receptor as a cause of autoimmune hypoglycemia in systemic lupus erythematosus.

A 52-year-old black woman presented with clinical features of systemic lupus erythematosus (SLE) and severe fasting hypoglycemia. Hypoglycemia was secondary to autoantibodies to the insulin receptor that were detected in the patient's serum. There were no anti-insulin antibodies, and other causes of hypoglycemia were excluded. Treatment with high-dose glucocorticoids resulted in restoration of euglycemia associated with resolution of circulating anti-receptor antibodies and parallel improvement in clinical and laboratory features of SLE. This case is compared with other cases of autoimmune hypoglycemia due to anti-receptor antibodies.

Chronic low back pain.

Most episodes of low back pain are mechanical in origin and resolve within a 12-week period. These acute episodes of back pain are associated with muscle strain and intervertebral disc herniation with radiculopathy. A smaller proportion of individuals have back pain with a duration greater than 12 weeks. These patients have back pain secondary to a wide variety of mechanical and nonmechanical disorders. The mechanical disorders associated with chronic low back pain include osteoarthritis and lumbar spinal stenosis; the nonmechanical disorders include infectious, neoplastic, rheumatologic, endocrinologic, vascular, and gynecologic. The clinical symptoms associated with each variety of disorder helps guide the appropriate diagnostic evaluation. Plain roentgenograms are useful in documenting the presence of spinal stenosis, benign or malignant tumors, osteoporosis, sacroiliitis, and spondylitis. CT scan is helpful in defining the bony alterations associated with malignant tumors and the vascular abnormalities associated with aneurysms. MR imaging is the technique of choice to document the extent of malignant processes and the presence of endometriosis in the pelvis. The therapy of these entities are specific for the disease entity causing the chronic low back pain. Although most of the disorders that cause chronic low back pain cannot be cured, therapy can decrease pain and improve function of the symptomatic patient.

Cyclobenzaprine and naproxen versus naproxen alone in the treatment of acute low back pain and muscle spasm.

Two groups of 20 patients each, with mild to moderate acute low back pain with associated muscle spasm of ten days' duration or less, were treated with a combination of cyclobenzaprine and naproxen or naproxen alone in a randomized, 14-day open-label trial. Cyclobenzaprine was added to the naproxen regimen as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful, musculoskeletal conditions. The clinical characteristics of each study group, including the number of worker's compensation patients, were comparable. Combination therapy was associated with less objective muscle spasm and tenderness and greater motion of the lumbosacral spine (P less than 0.05). There were trends toward faster resolution of functional deficits and pain with combined therapy. Combination therapy was associated with more side effects, due primarily to drowsiness from the cyclobenzaprine. The results of this study demonstrated that patients with muscle spasm associated with acute low back strain benefited from the use of combination therapy consisting of a nonsteroidal anti-inflammatory agent (naproxen) and a muscle relaxant (cyclobenzaprine).

The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study.

BACKGROUND: In 1989, a group of sixty-seven asymptomatic individuals with no history of back pain underwent magnetic resonance imaging of the lumbar spine. Twenty-one subjects (31%) had an identifiable abnormality of a disc or of the spinal canal. In the current study, we investigated whether the findings on the scans of the lumbar spine that had been made in 1989 predicted the development of low-back pain in these asymptomatic subjects. METHODS: A questionnaire concerning the development and duration of low-back pain over a seven-year period was sent to the sixty-seven asymptomatic individuals from the 1989 study. A total of fifty subjects completed and returned the questionnaire. A repeat magnetic resonance scan was made for thirty-one of these subjects. Two neuroradiologists and one orthopaedic spine surgeon interpreted the original and repeat scans in a blinded fashion, independent of clinical information. At each disc level, any radiographic abnormality, including bulging or degeneration of the disc, was identified. Radiographic progression was defined as increasing severity of an abnormality at a specific disc level or the involvement of additional levels. RESULTS: Of the fifty subjects who returned the questionnaire, twenty-nine (58%) had no back pain. Low-back pain developed in twenty-one subjects during the seven-year study period. The 1989 scans of these subjects demonstrated normal findings in twelve, a herniated disc in five, stenosis in three, and moderate disc degeneration in one. Eight individuals had radiating leg pain; four of them had had normal findings on the original scans, two had had spinal stenosis, one had had a disc protrusion, and one had had a disc extrusion. In general, repeat magnetic resonance imaging scans revealed a greater frequency of disc herniation, bulging, degeneration, and spinal stenosis than did the original scans. CONCLUSIONS: The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. Individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality on the original, 1989 scans. Clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.

Evaluation and outcome of low-back pain of unknown etiology.

Between January 1980 and January 1985, 5,362 patients with low-back pain were evaluated prospectively using a standard approach. The majority improved with routine therapy or could be placed in a definitive diagnostic group. One hundred and nine (2%), however, failed to improve or could not be assigned a specific diagnosis. These patients, defined as having chronic low-back pain of unknown etiology, were referred to a rheumatologist for evaluation. The average time to referral was 6 months. A specific diagnosis was obtained for 14 of the 109 patients. The remaining 95 were placed on new treatment plans, which included detoxification, a change of physicians, and arbitrary changes in therapy. The results indicated that approximately 75% of the group had 50% or greater reduction of pain, and half of the workers' compensation patients returned to some form of employment (although perhaps only intermittent).

Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain.

Low back pain is a common medical problem but has decreased in frequency in the occupational setting over the past decade. The weather affects low back pain but to a minor degree. Physical factors, as well as job satisfaction, play a role in the development and perpetuation of low back pain. In contradistinction to previous measurements, intradiscal pressure has been determined in vivo to be greater in the standing than the sitting position. Adenovirus-mediated gene transfer to nucleus pulposus cells may be the initial stage of a new form of therapy for degenerative disc disease. Bed rest is not more helpful than activity as tolerated for the treatment of sciatica. The outcome of spinal stenosis surgery is more closely associated with the patient's perception of improvement than with the degree of canal narrowing.

Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain.

Epidemiologic studies report the prevalence of low back pain to vary from 7.6% to 37% in different populations. Genetic factors play an important role in the development of back pain and intervertebral disk degeneration in adults. An animal model of spinal fusion using osteoinductive growth factors has important implications for surgical spinal fusions in humans. Physical findings have significance in identifying patients with radiculopathy, spinal stenosis, and malingering. Magnetic resonance imaging differentiates metastatic spinal fractures from osteoporotic lesions. Clinical entities reviewed in the literature this year include herniated intervertebral disk-associated radiculopathy, facet joint syndrome, back pain during pregnancy, and spontaneous infectious diskitis. Primary care physicians do not follow published guidelines for treatment of low back pain. Surgical decompression of spinal stenosis is most successful for patients with severe disease.

Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain.

Low back pain affects a minority of individuals over 65 years of age. Four years after the onset of sciatica, the number of individuals working is independent of their workers' compensation status. A complex interaction of metalloproteinases, cytokines, chondrocytes, and macrophages are necessary for the resorption of herniated intervertebral discs. Positional magnetic resonance imaging in the seated extended posture identifies foraminal narrowing that is not visualized with conventional magnetic resonance studies. Compression associated with cauda equina syndrome must be reversed within 48 hours to preserve neurologic function. The gene for transforming growth factor can be transferred to intervertebral discs, resulting in increased proteogylcan production in a rabbit animal model. An aerobic exercise program is as effective as more expensive exercise programs in the treatment of chronic low back pain. Complementary therapies, willow bark and magnets, have marginal benefit for low back pain. Surgical intervention results in improved function for spinal stenosis patients.

Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain.

Low back pain continues to affect a significant proportion of the younger, working population between 35 and 45 years of age. An important study has correlated macroscopic and microscopic intervertebral disc alterations starting in the second decade of life with oxidative stress manifested by the presence of N-(carboxylmethyl)lysine. Job satisfaction remains a strong predictive factor for the identification of individuals with acute back pain who will develop chronic pain. Patients with pyogenic vertebral osteomyelitis may have an increase in their erythrocyte sedimentation rate during the first 2 weeks of antibiotic therapy without requiring surgical intervention. Magnetic resonance imaging enhancement of migrated disc fragments identifies individuals who are likely to resolve sciatica without surgical intervention. As many as 25% of individuals with low back pain are symptomatic at 12 months, in contradistinction to the dictum of resolution of pain in 2 months. Nonsteroidal anti-inflammatory drugs and muscle relaxants are a very effective combination for the effective treatment of acute low back pain. A majority of chiropractic manipulations are performed for inappropriate indications.

Management of neck pain: a primary care approach.

Among the many disorders that cause neck pain, biomechanical stress is the most common. Nonoperative therapies offer relief in most patients within three months. Those with chronic or radicular pain require additional evaluation and multiple therapies for effective relief. Systemic illness and spinal compression require prompt intervention to prevent serious complications.

Exercise for the low back pain patient.

As 90% of patients with acute LBP recover within a 2-month period, irrespective of the type of treatment received, exercise probably plays little role in facilitating recovery from an acute episode of LBP. It may be a very important factor in both symptomatic and functional recovery in chronic LBP, as well as an integral factor in preventing recurrent injury. The most efficacious exercise regimen for treating LBP is currently unknown. Similarly, little is known about the efficacy of individual exercises. In certain patients, flexion or extension exercises may be inappropriate. A careful history and physical examination, observing the movements that cause pain, will assist the physician in tailoring the exercise programme to the individual patient to achieve the greatest likelihood of success. Communication between the patient, physician and therapist is vital to allow continual adjustment of the programme to best meet the patient's needs. As improvement occurs, more stressful exercises can be added to improve strength, endurance and aerobic fitness. Individualizing the exercise programme to the patient's symptoms and communication between the patient, therapist and physician lead to greater compliance with the exercise programme and a greater likelihood of improved outcome.

How to recognize and treat specific low back pain?

A wide variety of mechanical and non-mechanical disorders are associated with the clinical symptom of low back pain. Mechanical disorders are the cause of the vast majority of low back pain. Despite this frequency, the specific cause of mechanical low back pain can not be elucidated in spite of extensive diagnostic evaluation in a majority of individuals. Specific causes of low back pain are associated with less frequently occurring systemic illnesses including rheumatic, infectious, neoplastic, gynaecological and vascular disorders. The diagnostic process is more successful in identifying systemic disorders as the specific cause of low back pain. Non-surgical management is effective therapy with most patients with mechanical disorders of any form. Systemic illnesses require interventions directed specifically at healing the affected organ system.

Aqueductal stenosis: a possible late sequela of central nervous system inflammation in systemic lupus.

We have described a patient with a history of central nervous system lupus who had obstructive hydrocephalus secondary to stenosis of the aqueduct of Sylvius. The course of this patient's neurologic disease suggest that the obstruction was caused by a post-inflammatory lesion of CNS lupus. This report illustrates the importance of a complete neurologic evaluation of a patient with SLE who has CNS dysfunction.

Approach to initial medical treatment of rheumatoid arthritis.

In this article, we review the first line of therapy for rheumatoid arthritis. The components of first-line therapy include patient education, rest, physical therapy, occupational therapy, and nonsteroidal anti-inflammatory agents. We discuss each of these components in detail. Factors that might necessitate the addition of second-line agents (corticosteroids, antimalarials, gold salts, penicillamine, immunosuppressives, and surgery) are also outlined.