Clinical features of septic arthritis of sternoclavicular joint.

We studied 21 patients with septic arthritis of the sternoclavicular joint at Chulalongkorn University Hospital between January 1987 and January 1997. There were 15 males (71.4%) and 6 females (28.6%). The mean age was 47.4 years with a range of 16 to 69. More than half of the patients (57.1%) were aged more than 50 years and most had associated diseases including diabetes mellitus and cirrhosis. Almost all of the younger age group had a history of intravenous drug abuse. All of the patients had fever and sternoclavicular joint pain. Most of the patients (66.7%) had monoarticular arthritis, whereas, the others had oligoarticular arthritis. Staphylococcus aureus was the most commonly or identified organism in the patients. Retrosternal abscess was seen by computerized tomography in 6 patients (28.6%). All patients received parenteral antibiotics, and 5 patients (23.8%) required surgical drainage of a retrosternal abscess. Eighteen patients recovered but there were 3 (14.3%) deaths. All of these had retrosternal abscesses. The major cause of death was septic shock. Septic arthritis of the sternoclavicular joint is an uncommon disease in Thai clinical practice. Although uncommon, retrosternal abscess is a life threatening complication.

Initial disease modifying antirheumatic drugs and prednisolone prescriptions for patients with rheumatoid arthritis: a 15-year study.

OBJECTIVE: To compare patterns and time trends of initial disease-modifying antirheumatic drugs (DMARDs) and prednisolone prescriptions for patients with rheumatoid arthritis (RA) by the rheumatologists at King Chulalongkorn Memorial Hospital, Bangkok, Thailand over a 15-year period, as well as their side effects. METHOD: Medical records of all patients with RA seen at the Rheumatology Clinic from January 1983 to June 1997 with a duration of follow-up of 6 months or more were reviewed. Information on the disease, initial DMARDs prescriptions and their side effects, prednisolone use, dosage and side effect(s) were focused and compared among three 5-year periods (1983-1987, 1988-1992 and 1993-1997). RESULTS: 236 patients were included in this study. There were 44, 82 and 110 patients in the first, second and third period, respectively. Methotrexate (MTX) was the most frequently prescribed DMARD in all time periods. Dapsone and intramuscular (i.m.) gold were prescribed in the first period while antimalarial drugs and sulfasalazine (SSZ) were increasingly used in the second and third periods. Combination treatment of DMARDs was first used in the third period. Side effects from MTX were observed in patients with a longer duration of treatment (p < 0.05). Patients prescribed combined DMARDs did not develop more side effects compared with those who had monotherapy. Prednisolone was prescribed in 57.2 per cent of the patients, most being newly prescribed at the clinic. Mean starting dose of prednisolone was 8.9 mg per day. 64 patients took prednisolone together with non-steroidal antiinflammatory drugs (NSAIDs). Gastrointestinal side effects did not increase in these patients. CONCLUSION: MTX was the most frequently prescribed DMARDs regardless of the time period. Antimalarial drugs, SSZ and combination of DMARDs (most were MTX + chloroquine) have been prescribed more in the last 5 years, while dapsone, auranofin and i.m. gold were rarely used as initial DMARDs. Low dose prednisolone was prescribed in more than half of the patients with RA. Side effects from DMARDs and prednisolone found in this study were comparable to previous reports.

IL-1beta, IL-6 and TNF-alpha in synovial fluid of patients with non-gonococcal septic arthritis.

Interleukin-1 beta (IL-1beta), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) are the main proinflammatory cytokines responsible for the inflammatory process and cartilage destruction of inflammatory arthropathies. The present study sequentially measured the concentrations of these cytokines and their proportions of detectable levels in the synovial fluid (SF) of 23 patients with non-gonococcal (GC) septic arthritis before and after treatment. Persistently high concentrations and proportions of IL-6 and TNF-alpha were found up to day 7 of treatment, while SF IL-1beta concentration declined significantly after day 7 (p = 0.036). SF IL-1beta and TNF-alpha correlated with each other significantly and with SF WBC counts (p < 0.01). Positive correlations between SF IL-1beta concentration and joint effusion (p < 0.01) and between SF TNF-alpha concentration and joint tenderness (p < 0.001) were observed. SF IL-1beta and TNF-alpha were significantly higher in patients with local complications of septic arthritis. In conclusion, high levels of IL-1beta, IL-6 and TNF-alpha were detected in SF of patients with non-GC septic arthritis. Only IL-1beta decreased significantly after day 7 of treatment, but IL-6 and TNF-alpha concentrations were persistently high. SF IL-1beta and TNF-alpha may be useful in predicting the outcome and complications of patients with this disease.

Streptococcal arthritis in Thai adults: case series and review.

The incidence, clinical spectrum, types of streptococci in Thai adults with streptococcal arthritis in Chulalongkorn Hospital are similar to Western reports. The most frequently found organism was group A Streptococcus and the second was group G. Most of the patients were elderly who usually had underlying medical and/or joint diseases. There were 3 patients with underlying lepromatous leprosy which has never been reported before, while mixed types of streptococcal infection in the same joint, mixed types of streptococcal infection in the same patient and a patient with group C lumbar spondylodiskitis were also found. The most reliable diagnostic test is synovial fluid culture. All streptococcal isolates in our review were sensitive to penicillin and the clinical responses correlated with antibiotic sensitivity tests. Intravenous antibiotics and adequate drainage are the treatment of choice. The duration of treatment ranged from 4 to 6 weeks and most patients responded well. The overall mortality rate depended on host factors, organism virulence and treatment administered.

Lupus anticoagulant in Thai systemic lupus erythematosus patients.

In the past decade, interest in the potential clinical significance of lupus anticoagulant (LA) has grown tremendously. Recent reviews from the Western countries have found an average frequency of 34% for LA in patients with systemic lupus erythematosus (SLE). By using various laboratory procedures, namely, standard and diluted activated partial thromboplastin time, kaolin clotting time, tissue thromboplastin inhibition test and platelet neutralization test, we found the frequency of LA in 91 consecutive Thai SLE patients to be 17.5%, compared with 0.8% in the age-matched normal control population. The presence of LA was significantly associated with disease activity (p = 0.01). A statistically significant association was also observed between the presence of LA and convulsive disorders (p = 0.04), thrombocytopenia (p = 0.001) and autoimmune hemolytic anemia (p = 0.02).

Clinical comparison of patients with ankylosing spondylitis, Reiter's syndrome and psoriatic arthritis.

Between 1976 and 1989, 160 cases of seronegative spondyloarthropathy (SNSA) were admitted to the Department of Medicine at Chulalongkorn Hospital. The prevalence of idiopathic ankylosing spondylitis (IdAS) was 52 cases (32.5%), Reiter's syndrome (RS) 68 cases (42.5%), psoriatic arthritis (PsA) 28 cases (17.5%), reactive arthritis eight cases (5.0%) and Behcet's disease four cases (2.5%). Clinical comparison of the patients with IdAS, RS and PsA showed a male predominance in IdAS (90.2%), RS (97.1%) and PsA (71.4%). There was a significant difference (p < 0.01) between IdAS and PsA, and RS and PsA. The initial articular manifestation usually occurred in the younger age group (IdAS, 22.15; RS, 22.91; and PsA, 30.86 years); however, there was a significant difference (p < 0.05) between IdAS and PsA, and RS and PsA. Initial peripheral arthritis was found in IdAS (51.9%), RS (91.2%) and PsA (92.6%); there was a significant difference (p < 0.001) between IdAS and RS, and IdAS and PsA. The symptom of back pain was found in IdAS (78.8%), RS (38.2%) and PsA (21.4%); there was a significant difference (p < 0.001) between IdAS and RS, and IdAS and PsA. During physical examination, peripheral arthritis was evident in the IdAS (42.2%), RS (88.2%) and PsA (92.2%) patients; likewise sacroiliitis was found in the IdAS (100%) RS (54.4%), and PsA (57.2%) patients. Evidence of ankylosing spondylitis was found in the IdAS (100%), RS (22.1%) and PsA (46.4%) patients. These findings show a significant difference (p < 0.001) between patients with IdAS and RS, IdAS and PsA. Other associated symptoms were similar, particularly evidence of enthesopathy (tendonitis, heel pain, plantar fasciitis), the polyarticular pattern was more common than the mono-articular pattern. Hip joint was significantly (p < 0.05) more commonly involved in patients with IdAS than in those with RS and PsA. Associated symptoms, particularly genital lesion or skin lesion, are specific symptoms for RS and PsA, respectively.

Clinical features of systemic lupus erythematosus in Thai males and females.

From 1976 through 1988, 726 patients with systemic lupus erythematosus (SLE) were admitted to the Medical Service of Chulalongkorn Hospital, 666 cases (91.7%) being female and 60 cases (8.3%) male (the female-to-male ratio = 11:1). Clinical comparison of 60 males and 130 females (by randomized selection from the total of 666 females) was made. Onset of disease in males occurred later than in females (29.2 +/- 12.2 years vs 25.8 +/- 10.7 years, p less than 0.01). The majority of clinical manifestations were similar; however, musculoskeletal (63.3 vs 73.3%), cardiac manifestations (13.3 vs 26.1%) and Raynaud's phenomenon (18.3 vs 35.4%) were less common in males than females (p less than 0.01), whereas hematologic manifestations were more common in males than females (p less than 0.01).

Clinical study of culture-proven cases of non-gonococcal arthritis.

Between 1976 and 1988, 101 cases of culture-proven non-gonococcal arthritis seen at the Medical Service of Chulalongkorn Hospital were studied. Seventy-three cases (72.3% of the total) were diagnosed by positive synovial fluid culture; the remainder (27.7%), by positive hemoculture only. Males (55.4%) were more commonly affected than females (44.6%). In patients with Gram-positive coccal infection, age distribution was equal; however, in cases of Gram-negative bacillary infection younger patients were more frequently affected. Gram-positive cocci (85.1%), particularly Staphylococcus aureus (47.5%), was the most common infective agent, followed in frequency by beta hemolytic streptococcal infection (28.7%) and Gram-negative bacillary infection (13.9%). Among the former (serologically grouped), group A streptococci (7.9%) comprised the most common agent followed by group G (4.9%), B (2.0%) and F (2.0%). There was no difference in the incidence of causative micro-organisms between the 70 cases seen during the period 1976 to 1985 and the 31 cases seen from 1986 to 1988. Although Enterbacter (4.9%) was the most common causes of Gram-negative bacillary infection, Pseudomonas pseudomalei, Samonella A and Samonella B were the only infective agents found during the period 1986 to 1988. Acute onset of disease (93.1%) and monoarticular arthritis (73.3%) were the main manifestations. The most commonly affected joints were the knee (52.5%), ankle (16.8%), elbow (10.9%), wrist (9.9%), hip (8.9%) and shoulder (7.9%). Fever and leukocytosis were commonly observed with positive hemoculture (56.4%). The presence of foci of infection was evident in 50.5 per cent of patients. The skin was the main source of Gram-positive cocci; the urinary tract, for Gram-negative bacilli.(ABSTRACT TRUNCATED AT 250 WORDS)

A clinical comparison of females and males with gouty arthritis.

Twenty-two (11.3%) of 194 gouty patients were female. The age at onset was earlier than the 40th year in only 4.5 per cent of the females compared with 19.7 per cent of the males. However, in 54.5 per cent of the female patients compared with 38.4 per cent of the males, the age at onset was 60 years or more. Although the initial manifestation of the disease was acute monoarticular arthritis, with involvement of the ankle joint being more commonly observed in the female patients (63.3%) than in the males (37.2%), and by contrast, with involvement of the first metatarsophalangeal joint (podagra) being more frequently noted in the males (45.9%) than in the females (22.7%). In subsequent attacks, oligoarticular arthritis and arthritis of the ankle joints were predominant features of the disease in both sexes. However, podagra was less frequently evident in the female patients (31.8%) than in the males (68.5%) as were tophi (18.2 and 31.4%, respectively); specifically, in those females with tophi, the tophaceous manifestation developed in all of them within four years of the onset of the disease compared with only 27.8 per cent of the males with tophi. Moreover, although provocative factors and associated diseases were present in both sexes, haematologic malignancy was more common in the females (22.7%) than in the males (2.9%). In conclusion, although the clinical features of gout in females are similar to those in males, gout in females is characterized by later onset of the disease, earlier development of tophi and arthritis of the ankle joint.

Clinical pattern of females with crystal-induced arthritis: gout and pseudogout.

Of the 228 patients with crystal-induced arthritis (194 cases of gouty arthritis, 34 cases of pseudogout) seen between 1976 and 1985 at the Medical Service of Chulalongkorn hospital in Bangkok, 46 of them or 20.2 per cent of the total were female. The females with crystal-induced arthritis included 22 cases of gouty arthritis and 24 cases of pseudogout. Pseudogout was seen more commonly than gouty arthritis during the 10-year period. Both types exhibited a similar pattern with regard to late onset of disease at age 60 or more (75% of the cases with pseudogout and 54% of those with gouty arthritis), monoarticular arthritis as the initial manifestation (83.3% of those with pseudogout and 59.1% of those with gouty arthritis), intermittent pattern (54.2% of those with pseudogout and 86.4% of those with gouty arthritis) and the presence of precipitating factors (37.5% of those with pseudogout and 45.5% of those with gouty arthritis). However, different patterns were observed with regard to the joint of involvement: the knee joint was the most commonly involved joint in pseudogout (75%) but the ankle joint was seen in cases of gouty arthritis (86.4%). Podagra was not observed in cases of pseudogout, although in 22.7% of the patients with gouty arthritis, it was the initial manifestation of the disease. In subsequent attacks of arthritis, monoarticular arthritis (61.5%) and knee joint involvement (75%) were the main features of pseudogout. Oligoarticular arthritis (63.2%) and ankle joint involvement (86.4%) were the main feature of gouty arthritis.(ABSTRACT TRUNCATED AT 250 WORDS)