The effect of intra-articular triamcinolone preparations on blood glucose levels in diabetic patients: a controlled study.

OBJECTIVES: The objective of the study was to evaluate the effect of intra-articular (IA) triamcinolone hexacetonide (TAH) and triamcinolone acetonide (TA) on blood glucose levels in patients with controlled diabetes with symptomatic osteoarthritis of the knee (OAK). METHODS: Patients with controlled diabetes with symptomatic OAK who failed nonsteroidal anti-inflammatory medication and physical therapy and use modern versions of self-monitoring blood glucose devices were offered an IA injection of either 20 mg of TAH or 40 mg of TA. If agreed, patients were asked to document blood glucose levels before and 2 hr after meals for 1 week before and daily for 5 days then every other day for 1 week following the injection. The type of IA preparation was given on an alternating pattern. A sex- and aged-matched group of patients with controlled diabetes with symptomatic OAK of the knee was offered an IA hyaluronic acid (HA) injection. Significantly increased blood glucose level following the IA injection was defined as higher by at least 2 SDs than the mean comparable level before the injection. RESULTS: Thirty patients completed the study: 12 patients in the TAH, 12 patients in the TA group, and 6 in the HA group. All the patients who received triamcinolone preparations had significantly increased blood glucose levels with median initial levels of 227.5 and 201 mg% seen at a median of 8.5 and 13 hr following the IA injection and median peak levels of 288 and 239.5 mg% seen after a median of 24.5 and 32.5 hr following the IA injection of TA and TAH, respectively. Levels returned to normal after ∼2.5 to ∼4 days. There was no significant increase in the HA group except in 1 measurement only with marginal level in 2 patients. CONCLUSIONS: Intra-articular injection of either TAH or TA is associated with significantly increased blood glucose levels in patients with controlled diabetes with OAK. This increase is quite solely due to the injected steroids.

Lack of effect of corticosteroid injection at the shoulder joint on blood glucose levels in diabetic patients.

The effect of systemic glucocorticosteroids on the metabolism of glucose is well known; however, there are no reports on the effect of intraarticular steroids on the metabolism of glucose in diabetic patients. Controlled or near controlled diabetic patients who have self-monitoring devices for home monitoring of blood glucose with shoulder pain were offered an intraarticular crystalloid steroid injection of 35 mg of methylprednisolone acetate (MPA) at the shoulder joint after failure of pharmacological and physical therapy. Patients were asked to record blood glucose levels before and 2 h after breakfast, lunch, and supper (six times a day) every other day during 1 week before the injection and during the day of the injection, the next day and every other day for 2 weeks after the injection. Fructosamine levels were obtained just before the injection and 2 weeks after the injection. Wilcoxon signed rank test was used to compare the mean glucose levels before with those after the injection. Paired t test was used to compare the mean fructosamine values after the injection with those before the injection. Eighteen patients completed the study. Fifteen had adhesive capsulitis. The mean glucose levels before injection were 165.5, 195.5, 184.6, 199.4, 182.8, and 200.7 mg% before and 2 h after breakfast, lunch, and supper, respectively. There was no significant change between the mean glucose values before and after meals after the injection compared to those before the injection, respectively, except on a few occasions only throughout the study period. Mean fructosamine level before injection was 279 micromol/l+/-49.8 compared to 275 micromol/l+/-50.9 after the injection (P=0.125). Intraarticular injection of MPA at the shoulder joint in diabetic patients with shoulder pain has no significant effect on blood glucose levels.

A novel approach of local corticosteroid injection for the treatment of carpal tunnel syndrome.

The objective of the study was to compare the favorable response rate, time duration, and pain level of local corticosteroid injection using a novel approach for the treatment of carpal tunnel syndrome vs a classic approach. Patients with symptomatic carpal tunnel syndrome of less than 1-year duration were randomized for local corticosteroid injection using either the classic approach or a novel approach. In our approach (novel), we used a 29 gauge x 1/2-in. needle and a 1-ml insulin syringe containing 12 mg of methylprednisolone mixed with 0.15 ml of lidocaine 2%, and the site of the injection was 2-3 cm distal to the middle of wrist crease. In the classic approach, we used a 25 gauge x 3-cm needle and a 2-ml syringe injecting 35 mg of methylprednisolone mixed with 0.5 ml of lidocaine 2%, 3-4 cm proximal to the wrist crease and just ulnar to the tendon of the flexor carpi radialis muscle. Response rate was evaluated 1, 3, 6, and 12 weeks after the injection, and also the duration of time of the procedure and the level of pain using the visual analogue scale were compared between the two groups. Forty-two patients signed the consent form, and all of them completed the study [21 patients in the classic approach group (group 1) and 21 patients in the novel approach group (group 2)]. The favorable response rates were 100, 81, 71, and 57% in group 1 and 100, 71, 67, and 57% in group 2 after 1, 3, 6, and 12 weeks, respectively. There was no significant difference in the favorable response rate between the two groups (p=0.468, 95% CI=-12-31%, after 3 weeks). The average duration of time of the procedure in group 1 was 26.71+/-32.83 s compared to 8.48+/-1.123 s (p=0.021) in group 2. The average grade of pain expressed by the patients in group 1 was 4.38+/-1.523 compared to 3.62+/-1.071 in group 2 (p=0.065). In conclusion, local corticosteroid injection using the novel approach for the treatment of carpal tunnel syndrome is helpful, and the favorable response rates are comparable to those using the classic approach after 1, 3, 6, and 12 weeks. The novel approach is much less time consuming and is not more painful.

Penicillamine and nephrotic syndrome.

BACKGROUND: Penicillamine (PA) treatment may be associated with a wide spectrum of adverse effects. There are many case reports and small series of PA-induced nephrotic syndrome (NS). In addition to our patient, in this study, we review all the cases of NS due to PA treatment in the English literature. METHODS: A retrospective Medline search was done for the years 1963-2004 using the terms "penicillamine" and "proteinuria" or "penicillamine" and "nephrotic". Cases were also located through article references. Cases were included in our review only if they had enough clinical and laboratory data and if the NS was considered by the authors to be mainly or solely due to PA treatment. Diagnosis of the patient, dose and duration of PA treatment, maximal amount of proteinuria, kidney function, urine analysis, serological markers, clinical data, kidney biopsy results, treatment, and course of proteinuria were documented. RESULTS: Sixty-three patients met our criteria. The female/male ratio was 40:23. Seventy-five percent of the patients had rheumatoid arthritis (RA). Mean age at diagnosis of NS was 44 (+/-S.D. 14) years. Mean dose of PA at diagnosis was 1.09 (+/-S.D. 0.413) g. Mean duration of PA treatment prior to proteinuria was 7.6 (+/-S.D. 3.90) months and mean duration of PA treatment until diagnosis of NS was 11.9 (+/-S.D. 18.8) months. Peak level of proteinuria was 10.79 (+/-S.D. 9.436) g. Some 33% of the patients developed mild to moderate renal failure at the time of diagnosis of NS, and one patient developed acute renal failure. Fifty-five percent of the patients had membranous glomerulonephritis and 27% had minimal change disease. Twelve patients were treated with corticosteroids (CS) at a dose ranging from 40 to 90 mg/day. In the overwhelming majority of patients, the proteinuria decreased significantly or disappeared within 7 months after stopping PA treatment. Patients treated with CS had a faster response. Five patients died, two of them from the CS-treated group, due to sepsis. CONCLUSION: The mean duration of PA treatment prior to the development of NS is nearly 1 year (5 months after the development of proteinuria). The most common histopathological finding is membranous glomerulonephritis. Most patients will have a significant reduction in, or disappearance of, proteinuria within 7 months after stopping PA treatment. The decrease in proteinuria is faster with CS treatment.

Bone mineral density in patients with early rheumatoid arthritis treated with corticosteroids.

The aim of this study was to evaluate the bone mineral density (BMD) in patients with early rheumatoid arthritis (RA) prior to and 6 months after adding low-dose corticosteroid (CS) treatment. Adult patients (>21 years old) with early RA (symptom duration <1 year) and severe joint pain under maximal dose of nonsteroidal anti-inflammatory drugs (NSAIDS) were started on low-dose prednisone (10 mg/day). Patients were evaluated after 1, 3, and 6 months. Disease activity measures including swollen and tender joint count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were documented, and the dose of prednisone was adjusted according to the level of pain at each visit. BMD of the femoral neck (FN) and lumbar spine (LS) was measured using dual energy X-ray absorptiometry prior to and 6 months after starting CS treatment. Calcium supplements, vitamin D, bisphosphonates, or hormonal therapy that may affect BMD were not permitted during the study. Twenty patients were eligible and 16 completed the study; 75% were female. The mean age was 47.2+/-12 years and mean duration of symptoms was 7+/-2 months. The mean BMD at the FN prior to and 6 months after starting CS treatment were 0.8080 g/cm(2)+/-0.1145 and 0.8242 g/cm(2)+/-0.1122, respectively (p=0.04). The mean BMD at the LS prior to and 6 months after starting CS treatment were 0.9429 g/cm(2)+/-0.1406 and 0.9490 g/cm(2)+/-0.1277, respectively (p=0.423). There was a significant correlation between the mean change of BMD at the FN and mean change of tender joint count (p=0.01), ESR (p=0.008), and CRP (p=0.006) but not with swollen joint count (p=0.099). However, there was no correlation between the change of BMD at the FN or LS and the change of any of the disease activity measures of every patient. Also, no correlation was seen between the cumulative dose of CS and the change in BMD. BMD increases significantly at the FN in early RA patients 6 months after adding low-dose CS to the treatment.

Pure red cell aplasia and lupus.

OBJECTIVE: To review the clinical and laboratory features of all reported patients with systemic lupus erythematosus (SLE) and pure red cell aplasia (PRCA). METHODS: In addition to our patient, we identified cases reported during the years 1966-2000 by searching the MEDLINE literature (Winspirs). Clinical and laboratory features were compared with those reported in large series of patients with SLE but without PRCA. RESULTS: Twenty-three additional cases were identified. In most cases, SLE was diagnosed either before or concomitantly with the diagnosis of PRCA. The clinical and laboratory features were not significantly different from those reported in large series of patients with SLE, except for less pleuritis and a trend toward less proteinuria, hallucinations, thrombopenia, and leukopenia. The natural history of PRCA and SLE was similar to that reported for PRCA alone. The disease responded to prednisone in the majority of cases, but patients frequently remained steroid dependent. CONCLUSIONS: The association between SLE and PRCA is rare. The clinical and laboratory features of SLE in such patients are similar to SLE patients without PRCA with the exception of a decreased frequency of pleuritis. Response to treatment of PRCA in those with SLE is similar to patients with PRCA but without SLE.

Tumor lysis syndrome after hydrocortisone treatment in metastatic melanoma: a case report and review of the literature.

Tumor lysis syndrome (TLS) is 1 of the complications that usually follows chemotherapy treatment of myelo-lymphoproliferative diseases. Corticosteroids (CS) could also induce TLS in this type of malignancies. On the other hand, TLS in solid tumors is less frequent, and CS treatment was never reported to be associated with TLS in solid tumor. Here we report the first case of TLS in a solid tumor (melanoma) after CS treatment.

Hypergammaglobulinemic purpura in two sisters with Sjogren's syndrome responding to colchicine treatment.

Purpura is the hallmark of hypergammaglobulinemic purpura (HP). It appears mainly after strenuous activity in the dependent areas of the body. Treatment is mostly symptomatic. Here we report two sisters with Sjogren's syndrome (SS) and HP who had a remarkable response to colchicine treatment.

Diabetic muscular infarction: emphasis on pathogenesis.

Diabetic muscular infarction is a rare complication of diabetes. It usually occurs in those with target organ involvement of diabetes, generally affecting one or a group of muscles of the thigh, and can recur. The pathogenesis of the disease is still not clear. Here we report an unusual case of extensive muscle involvement of both thighs and calves, with special emphasis on pathogenesis.

Sweet's syndrome affecting the external auditory canal and tympanic membrane.

We report a patient who developed left ear pain, dry cough, and fever. The external auditory canal was tender, swollen, erythematous and full of debris. Later the patient developed widespread tender and red skin nodules and pustules that subsequently coalesced to form plaques. Identical lesions developed also in the external auditory canal and the tympanic membrane of the affected ear. Skin biopsy showed dermal neutrophilia, compatible with the diagnosis of Sweet's syndrome. Rapid improvement was achieved with prednisone after the failure of antibiotics.

Systemic lupus erythematosus among Arabs.

BACKGROUND: The prevalence of clinical manifestations and laboratory parameters in systemic lupus erythematosus differ among various ethnic groups. Few studies have reported on SLE in Arabs. OBJECTIVES: To summarize the demographic, clinical and laboratory features of Arab SLE patients and to compare them with other series from different Arab countries. METHODS: We reviewed the charts of all Arab SLE patients who had been seen at the Carmel Medical Center in Halfa, the Nazareth Hospital and the Holy Family Hospital in Nazareth, and a professional clinic (a referral outpatient clinic of the largest health maintenance organization in Israel) in Acre--all cities in northern Israel. Only patients with symptoms of more than one year were included. Demographic, clinical and laboratory parameters were documented and compared with those of four series from different Arab countries. RESULTS: The study group comprised 34 patients. The majority of the patients was Moslem; there were a few Druze and one Christian. There was no statistical difference between our patients and any of the other Arab series in terms of arthritis, neuropsychiatric manifestations and VDRL. The presence of serositis and mucocutaneous manifestations was significantly lower in our series compared to some of the other series. However, there was significantly less renal involvement in our patients compared to each of the other series. CONCLUSIONS: The prevalence of most clinical and laboratory parameters in Israeli Arab SLE patients is comparable to that of other series of SLE patients from different Arab countries. The prevalence of renal involvement in Israeli Arab SLE patients seems to be lower than in SLE patients from different Arab countries.

The utility of gallium scintigraphy in the evaluation of fever of unknown origin.

BACKGROUND: Gallium scintigraphy is frequently used in the evaluation of fever of unknown origin, although its utility has been addressed in only a few studies. OBJECTIVES: To evaluate the utility of gallium scintigraphy in the evaluation of patients with FUO in our department. METHODS: We reviewed the charts of all patients from our department who had undergone gallium scintigraphy during the years 1995-2002 for the evaluation of FUO and who met the criteria for the definition of FUO. Demographic, clinical and laboratory data in addition to the results of gallium scintigraphy were documented. The patients were divided into two groups: those with a normal gallium study (group 1) and those with an abnormal gallium study (group 2). The second group was further divided into two groups: those whose gallium study results contributed to the diagnosis of the cause of FUO (group 2A) and those whose gallium study results did not (group 2B). RESULTS: A total of 102 patients met the study criteria. The male: female ratio was 54:48 and the mean age +/- SD was 62.4 +/- 20 years. A final diagnosis had been reached in 63 patients (62%), among whom the etiology was infectious in 54%, neoplastic in 19% and immunologic/ rheumatic in 16%. Forty-one patients (40% of all the patients) (group 2) had an abnormal gallium scintigraphy, and in only 21 patients (21% of all the patients) (group 2A) did the gallium study results contribute to the diagnosis of the cause of FUO. However, in only two patients from group 2A (2% of all the patients in our study) was the contribution of gallium study considered significant or crucial to the diagnosis of the cause of FUO. CONCLUSIONS: The utility of gallium scintigraphy in the evaluation of FUO is very limited.

Local effects of intra-articular corticosteroids.

Intra-articular corticosteroid injection (IACI) is a very popular procedure. In this review, we wanted to review all that had been published about local effects of IACIs. English literature search was made through PubMed using the terms intra-articular and local effect. Effects on subjective, functional, structural, cellular, humoral, molecular, and imaging aspects were included. Also, all local adverse effects were documented. The main beneficial effect of IACI is pain relief. The duration of this effect is variable and depends on underlying disease, type of disease, amount of structural damage, type of IACI, dose of IACI, presence of joint effusion, level of inflammatory mediators, emptiness of joint effusion, availability of imaging, and others. At large, inflammatory problems had higher rate of favorable response in terms of pain and function. IACI at the knee joint in juvenile idiopathic arthritis patients resulted in remission for >6 months in >80% of the patients with a mean duration of approximately 1.2 years, while in the osteoarthritic knee there was a pain relief for 3 weeks only and in rheumatoid arthritis (RA) knee for 8 weeks. There was no joint space loss at the knee joint following multiple IACI in osteoarthritis and also no increase in cartilage or bone erosions in RA following a single IACI. IACI guide imaging is important in achieving better results in particular joints. Joint infection rate is very low. Other adverse effects included intra-articular and periarticular calcifications, cutaneous atrophy, cutaneous depigmentation, avascular necrosis, rapid destruction of the femoral head, acute synovitis, Charcot's arthropathy, tendinopathy, Nicolau's syndrome, and joint dislocation. IACI is associated with a wide range of local effects. Subjective and functional favorable response is prominent mainly in juvenile idiopathic arthritis patients. Adverse effects are either rare or insignificant.

Systemic effects of intra-articular corticosteroids.

The objective of this study was to review all the published articles in the English literature about the systemic effects of intra-articular corticosteroid injection (IACI) in humans. Reports were searched through Pubmed using the terms intraarticular or intra-articular and steroids, corticosteroids, or glucocorticosteroids up and including the year 2007. Reports were also located through references of articles. Only objective findings outside the injected joint were included. The overwhelming majority of the studies was done at the knee joint and in rheumatoid arthritis/juvenile idiopathic arthritis patients. Many of the studies were done on the hypothalamic-pituitary-adrenal axis. Serum cortisol decreased within hours with a nadir after usually 24-48 h following the IACI. Recovery to baseline takes 1-4 weeks and sometimes longer depending on the type and dose of IACI and on the number of injected joints. Serum cortisol levels were blunted following adrenocorticotropic hormone stimulation in a small proportion of patients following methylprednisolone acetate injection and more common following other preparations. IACI resulted in a transient increase in blood glucose levels over few days in controlled diabetic patients with knee osteoarthritis. Peak levels are around 300 mg%. IACIs are associated with reduction in inflammatory markers like C-reactive protein and erythrocyte sedimentation rate that start few days following the IACI and could last for months. The effect on inflammatory cytokines is immediate with significant decrease within hours. IACI may induce remission also in patients with oligo-/polyarthritis and/or in patients with extra-articular manifestations. Other metabolic, hematologic, vascular, allergic, visual, psychologic, and other effects were also reported.

Sweet's syndrome after pneumonectomy.

We report the case of a 38-year-old woman in whom typical skin lesions of Sweet's syndrome developed 2 days after undergoing left pneumonectomy, which was done because of severe bronchiectasis related to remote chemotherapy and radiotherapy given for lung sarcoma at the age of 8 years. Later fever and leukocytosis appeared, and biopsy results of the skin lesions showed neutrophilic infiltration of the dermis compatible with the diagnosis of Sweet's syndrome. Postoperative Sweet's syndrome has been reported only twice in the world literature. These other two cases and possible pathogenic mechanisms are reviewed.