Streptococcal endocarditis initially seen as septic arthritis.

Two patients were initially seen with culture-positive streptococcal arthritis as an early manifestation of bacterial endocarditis. The organisms were an alpha-hemolytic, nongroup D streptococcus and a beta-hemolytic, group b streptococcus. One patient had a persistent septic monarthritis; the other had migratory arthritis in which a positive synovial culture was followed by a negative culture from the same joint before antimicrobial treatment was started. This experience suggests that some sterile synovial aspirates encountered in patients with bacterial endocarditis may be explained by delay of arthrocentesis.

Diagnostic options for assessment of postmenopausal bleeding.

Postmenopausal women should undergo endometrial assessment when bleeding occurs in the absence of replacement hormone therapy, after a 1-year regimen of continuous-combined hormone replacement therapy, or at an unexpected time during cyclic replacement therapy. Endometrial assessment can be accomplished by endometrial biopsy, transvaginal ultrasonography, or hysteroscopy. Dilation and curettage should be reserved for those rare cases when the other methods are infeasible. Each method of assessment has advantages and disadvantages, and the choice of method should be made accordingly.

Prolonged over-suppression syndrome.

PIP: The syndrome of postpill amenorrhea was investigated retrospectively by studying records of diagnosed cases of amenorrhea (1300) treated or confirmed at the Mayo Clinic. Data are taken from records dating to 1960 (low use of contraceptives) and terminate in 1971. 12 cases are reviewed which were diagnosed as prolonged oversuppression syndrome. No particular oral contraceptive formulation was implicated. 4 of 12 patients had had irregular menstrual cycles before oral contraceptive therapy; whereas 8 had had regular cycles. Bioassay of urinary gonadotropins were consistently in the mid-low normal limits (only 1 determination was available for each patient); some patients had been radioimmunoassayed (single assay) for other pituitary hormones: LH (luteinizing hormone) was at normal basal levels and FSH (follicle stimulating hormone) was also in the normal range. Concentrations of total circulating estrogens were in low or subnormal range in each case. 4 cases had associated galactorrhea, which was attributed to exogenous steroid suppression of the prolactin-inhibiting center of the pituitary. Clomiphene citrate was used to restore functions of the hypothalamic-pituitary axis, and of the 8 receiving clomiphene, 5 responded and 2 conceived.^ieng

Forestomach neoplasms in Fischer F344/N rats and B6C3F1 mice exposed to diglycidyl resorcinol ether--an epoxy resin.

Repeated dose (14 days), subchronic (13 wk) and chronic (2 yr) studies were carried out in succession to evaluate the toxic and carcinogenic effects of diglycidyl resorcinol ether (DGRE), a liquid spray epoxy resin, in F344/N rats and B6C3F1 mice. DGRE in corn oil was administered by gavage for 14 consecutive days in the repeated dose study and 5 days/wk in the subchronic and chronic studies. The mortality rate was increased in rats and mice in the repeated dose and subchronic studies. Hyperkeratosis, basal cell hyperplasia and squamous cell papillomas of the forestomach were observed in a few treated rats and mice in the subchronic study. Based on the results of the subchronic study, F344/N rats and B6CF1 mice (50 males and 50 females/species/dose) were administered DGRE (rats--0, 12, 25 and 50 mg/kg body weight, mice--0, 50 and 100 mg/kg body weight) in corn oil by gavage 5 days/wk for 103 wk. The incidence of neoplastic and non-neoplastic changes of the forestomach was increased in rats and mice in the chronic study. Under the conditions of the study, DGRE is considered to be carcinogenic to F344/N rats and B6C3F1 mice.

Reiter's disease: modern concepts.

Reiter's disease (RD) is a reactive arthritis syndrome in which arthritis, conjunctivitis, dermatitis, and urethritis are the main features. It may be an acute and self-limited disease or it may cause severe debilitation. It generally follows an infectious episode, such as Shigella dysentery or nonspecific urethritis. Recent evidence has shown that patients in whom RD develops have a genetic disposition since the presence of HLA-B27 correlates highly with RD. Therapy of RD involves supportive care.

Subcutaneous inflammation (infection?) after synovial rupture: a complication of a complication.

Six weeks after presumptive acute synovial rupture at the knee, a patient was admitted with cutaneous induration over the medial calf. Roentgenograms showed gas shadows within the involved area. A fluctuant area at the center of the indurated mass yielded a Corynebacterium species.

Bone ankylosis. a rare manifestation of gout.

A 44 year old man with neglected tophaceous gout developed progressive bony and fibrous ankylosis of the lower leg articulations extending from a toe through the ankle, in spite of three years of otherwise successful therapy.

Ecchymosis of the lower leg. A sign of hemarthrosis with synovial rupture.

Four patients with hemarthrosis of the knee, synovial rupture, and ecchymoses are reported. The patients presented with calf pain and swelling and large ecchymoses, which eventually extended to the ankle as a crescent about one or both malleoli. Appreciation of this physical sign, which appears to be characteristic for the hemorrhagic subset of synovial rupture, should alert the physician to the correct diagnosis and steer him away from contraindicated anticoagulant therapy.

Hospital-acquired salicylate intoxication. report of a case with psychosis, acidosis, and coma.

A case of salicylate intoxication from repeated therapeutic doses of aspirin is reported in an adult with impairment of salicylate elimination. Evolution of acid-base disturbance from respiratory alkalosis to metablic acidosis is documented. Serum salicylate levels during several years of therapy demonstrate the acquisition of impaired elimination of the drug. This case illustrates the practical importance of special features of salicylate accumulation kinetics emphasized in a recent review.

Reiter's syndrome following Shigella flexneri 2a: a sequel to traveler's diarrhea. Report of a case with hepatitis.

Shigella flexneri 2a was isolated from a patient with Reiter's syndrome (RS) following a family outbreak of traveler's diarrhea. Among 3 members at risk, only the patient was positive for HLA-B27. Data from 3 similar families support the hypothesis that susceptibility to RS is genetically transmitted. It is urged that every effort be made to culture and subtype Shigella and other enteric pathogens in RS following diarrhea. Concurrently, the patient had hepatitis, interpreted as a parallel enteric infection.

Management of ankylosing spondylitis with flurbiprofen or indomethacin.

The effects of flurbiprofen (150-200 mg daily) and indomethacin (75-100 mg daily) were compared in the management of 26 patients with active ankylosing spondylitis in a parallel, double-blind, and randomized trial of six weeks' duration. No patient in either group withdrew from the study because of lack of efficacy of the drugs. Both drugs were equally effectivein relieving the pain and tenderness of the affected joints. Overall subjective improvement, assessed by the patient and the investigator at the end of the trial, was present in 90% of the patients in the flurbiprofen group and in 75% of the indomethacin group. The mean values of all the spinal motion tests improved in the flurbiprofen group but not in the indomethacin group. Statistically significant improvement of the Schober test was achieved in the flurbiprofen group and of the chest expansion measurement in the indomethacin group. Untoward effects related to the central nervous system and gastrointestinal tract were present in a few patients in both groups.

Pseudogout associated with meniscal cysts - report of two patients.

Two patients with pseudogout developed large meniscal cysts at the knee. In the first case the diagnosis of meniscal cyst was confirmed surically. In the second case, the cyst resolved following thorough aspiration. Polarized microscopy of repeated aspirated from cyst in this case as well as of fluids from the knees of both patients consistently showed positively birefringent rhomboid crystals. X-ray diffraction of fluids from the knee of the second patient identified the crystals as calcium pyrophosphate dihydrate.

Fixed eruption and fever after urography.

We have described a patient with fixed bullous eruption, usually associated with severe fever, occurring on five occasions after a series of seven intravenous urograms between 1974 and 1979. Diagnosis was initially obscured because the onset of fever and dermatitis was delayed as long as 72 hours. This is only the second report of true ioderma ascribed to urographic contrast media.

Sternoclavicular joint arthritis: an unusual presentation of metastatic carcinoma.

Metastatic carcinoma presenting as sternoclavicular joint arthritis has only recently been reported. We describe a unique case of carcinoma arising from the tongue presenting with bilateral enlargement of the sternoclavicular joints. Diagnosis of metastatic squamous cell disease was made antemortem by Wright's stain and cytology of a joint fluid aspirate; the primary eluded detection until postmortem examination. Primary carcinoma of the tongue and oral cavity should be considered when confronted with metastatic squamous cell disease.

Comparison of phosphohydrolase activities from articular cartilage in calcium pyrophosphate deposition disease and primary osteoarthritis.

One abnormality in calcium pyrophosphate deposition disease (CPDD) which fosters consistently high synovial fluid pyrophosphate ion (PPi) and large accumulations of calcium pyrophosphate dihydrate crystals (Ca pyrophosphate) might be an aberration in chondrocytes involving elaboration of PPi and failure of its hydrolysis within cartilage matrix. Exploration of this hypothesis required further information on the phosphohydrolases in relevant human articular cartilages. Triton X-100 extracts of whole homogenized cartilage from 18 patients with primary osteoarthritis (OA), 10 patients with CPDD and secondary OA, as well as 6 "normal" subjects were partially purified by DE-52 chromatography and eluates studied for phosphohydrolase activity in a variety of substrates, inhibitors, and environmental conditions. Almost all the protein as well as crude alkaline phosphatase and pyrophosphatase activities were clustered in peaks designated I and II. Findings in CPDD cartilage not observed in OA controls were: 1) consistent alkaline phosphatase activity in the void volume of DE-52 columns, 2) high levels of 5'nucleotidase activity, 3) abundant generation of PPi by CPDD cartilage during in vitro incubation of cartilage extract fractions with ATP. This enzymatic behavior is likely to bear a regulatory relationship to PPi production by chondrocytes in CPDD.

Radiologic features of Reiter disease.

The radiologic manifestations of Reiter disease in 56 patients are described. Although the findings are often nonspecific, certain features are distinctive, particularly when present in combination. These include subtle periosteal bone apposition at bony prominences, the infrequency of regional panarthritis and hip and shoulder involvement, the tendency for destructive arthritis to be confined to small joints, particularly in the feet, and a typically "discontinuous" spondylitis characterized by eccentric, laterally positioned vertebral hyperostoses which tend to bridge around the contigous disk. Attention is drawn to similar hyperostoses which occur above the true sacroiliac joints. The significance of these features, particularly in terms of differential diagnosis, is discussed.