Gouty Tophus on the Tibial Tuberosity with Accompanied Chemical Cellulitis Localized at the Upper Tibia / 대한류마티스학회지

Gout is characterized by hyperuricemia and recurrent attacks of acute arthritis. Gout is a clinical syndrome resulting from the deposition of urate (monosodium urate monohydrate) crystals. Urate deposition occurs in articular cartilage, subchondral bone, synovial membrane, joint capsule and periarticular tissues, with articular cartilage being especially susceptible. The first metatarsophalangeal joint is commonly involved at presentation and other commonly affected joints are the ankle, knee and tarsal area. Gouty tophus located on the tibial tuberosity has never been reported in korea. We report a case of gouty tophus on the tibial tuberosity with (chemical) cellulitis occurred at the upper tibial area in a 46- year-old man.

A Case of Ruptured Popliteal Cyst in Gouty Arthritis / 대한류마티스학회지

Most cases of the popliteal cyst rupture in rheumatic diseases have been reported in patients with rheumatoid arthritis. A ruptured popliteal cyst is unusual in other diseases, especially in gouty arthritis. The clinical presentations of a ruptured popliteal cyst may include pain, swelling, tenderness and erythema of the calf, and mimic deep vein thrombophlebitis. It is therapeutically important to differentiate ruptured popliteal cyst from deep vein thrombophlebitis. A ruptured popliteal cyst in gouty arthritis has never been reported in Korea. We would like to report one case of the ruptured popliteal cyst into the calf in gouty arthritis mimicking deep vein thrombophlebitis.

Secondary Amyloidosis Involving Liver in Rheumatoid Arthritis Treated with Methotrexate and Low dose Prednisolone / 대한류마티스학회지

Amyloidosis is a heterogenous group of often fatal disorders characterized by extracellular deposition of a proteinaceous material with a unique fibrillar form in various tissues and organs. Presenting with severe hepatomegaly, a 46 year-old man who has suffered with rheumatoid arthritis lasting more than 12 years was confirmed to have secondary amyloidosis by liver biopsy. After treatment with methotrexate and low dose prednisolone, we have observed clinical improvement in which hepatomegaly was resolved remarkably. This is the first published case report of a patient with rhuematoid arthritis complicated by liver amyloidosis which partially regressed after treatment with methotrexate and prednisolone.

Effects of Vancomycin, Roxithromycin, and Rifampin on Biofilm Formed by Staphylococcus epidermidis / 감염

BACKGROUND: Catheter-associated peritonitis occurs frequently in patients with chronic renal failure with peritoneal dialysis. It can be controlled by antibiotics, but relapses are common due to biofilms that affect the pathogenesis of peritonitis. This study was designed to evaluate the efficacy of antibiotics against biofilm formed by Staphylococcus epidermidis which is the most common causative organism of peritonitis in patients with peritoneal dialysis. METHODS: After incubation of silastic plates for 24 hours in peritoneal dialysis fluid containing S. epidermidis, the establishment of bacterial biofilm on the plates was confirmed by scanning electron microscopy. Then the plates were incubated in dialysate containing various concentrations of antimicrobial agents, such as vancomycin, roxithromycin or rifampin, in combination or alone. The quantification of organisms on silastic plates was performed for evaluation of antibiotic efficacy against biofilm formed by S. epidermidis after getting samples of plates at 0 hour, 4, 24, and 48 hours after incubation. RESULTS: The reduction of colony counts in groups with antibiotics was significantly larger than that in the control group and the difference was increased as time passed. In vancomycin treated plates, the colony count per plate for 2xMIC (minimal inhibitory concentration) was significantly lower than that for 1/8xMIC or 1/64xMIC at 4 hour, but no significant differences were noted at 24 hours and 48 hours among those of the various concentrations. The reduction of colony counts in accordance with concentrations of roxithromycin was not significantly different at 4 hours, but the reduction for 1/8xMIC was larger than that for 1/64xMIC at 24 hours and 48 hours. The reduction of colony counts in accordance with concentrations of rifampin was not significantly different at 4 hours, but the reduction for 1/8xMIC was larger than that for 1/64xMIC at 24 hours and 48 hours. There was no significant difference in reduction of colony counts between groups of anti-biotic combination containing vancomycin and groups of vancomycin alone. CONCLUSIONS: It is suggested that the sub-inhibitory concentrations of vancomycin, roxithromycin, and rifampin might be effective on biofilm-forming S. epidermidis in in vitro model of infection related with peritoneal dialysis catheter. This result may be applicable for development of a new method to control biofilm-associated peritonitis during peritoneal dialysis.

Non-Hodgkin's lymphoma presenting as polyarthritis / 대한내과학회지

Rheumatic manifestations in non-Hodgkin's lymphoma (NHL) are common but actual arthritis as a presenting feature appears to be very rare. We experienced a case of NHL presenting as polyarthritis in a 24-year-old woman. Eight months ago she was admitted to the hospital due to polyarthritis and skin rash. She had pleural and pericardial effusion. Antinuclear antibody was positive and rheumatoid factor was negative. Joint X-ray showed periarticular osteopenia at both knees, wrists, hands and feet. Prednisolone, salsalate and anti-tuberculosis drugs were administered under the impression of either probable lupus or rheumatoid arthritis and pleural tuberculosis. After then pleuropericardial effusion and skin rash improved. But polyarthralgia persisted and she developed right cervical lymphadenopathy. On her second admission she was found to have a round mass in left lower lung field and multiple mediastinal lymph node enlargement. Cervical lymph node biopsy revealed non-Hodgkin's lymphoma. She received 8 cycles of systemic chemotherapy until 1996 July. NHL was remitted completely and polyarthralgia disappeared. We report a case of non-Hodgkin's lymphoma presenting as polyarthritis and literatures are reviewed.

A case of spontaneous pneumomediastinum and subcutaneous emphysema in dermatomyositis: Including analysis of cases with dermatomyositis and pneumomediastinum in the literature / 대한내과학회지

Spontaneous pneumomediastnum is a very rare complication of systemic autoimmune diseases. The precise mechanism of pneumomediastinum in dermatomyositis is not well known. Pulmonary alveoli rupture secondary to interstitial pneumonitis or pulmonary infarctions consequent upon vasculitis are the suggested mechanisms. Among the idiopathic inflammatory myopathies, dermatomyositis and polymyositis show similar clinical manifestations except skin lesions. But pneumomediastinum occurs exclusively in cases with dermatomyositis, not in case with polymyositis. In a literature review, patients with dermatomyositis and pneumomediastinum had some characteristic features. As compared with dermatomyositis without pneumomediastinum, CK level was normal in about half and concomitance of interstitial lung disease and cutaneous vasculitis were very frequent. We experienced a case of dermatomyositis with spontaneous pneumomediastinum and subcutaneous emphysema. Thus we report that with a review of the literature and analysis of reported cases.

The Study on the Clinical Features of Gouty Arthritis / 대한내과학회지

OBJECTIVES: The aim of this study is to enhance understanding the clinical features, pathogenesis, diagnosis and treatment of gouty arthritis in Korea by analyzing the clinical manifestations of the patients with urate crystal-proven gouty arthritis. METHODS: 78 cases who had been diagnosed as gouty arthritis by confirming the urate crystals in synovial fluids or tophi in Seoul National University Hospital between January 1, 1989 and July 31, 1995 were analysed for their histories, symptoms, signs, laboratory data, and X-ray findings. RESULTS: 1) Male to female ratio was 18.5:1. The mean age of onset is 49.3 +/- 14.5 years(range 11-83 years); the mean duration of disease 6.5 +/- 7.0 years(range 0-30 years); the mean duration of gouty attack 7.2 +/- 5.5 days(range 1-30 days). 2) The frequent precipitating factors of gouty arthritis were hospitalization(37%) and alcohol drinking(15%). The most frequent accompanying disease was hypertension(24%). Obesity, diabetes, chronic renal failure, hyperlipidemia, ischemic heart diseases, or cerebrovascular diseases were also accompanied by gouty arthritis. 3) The patterns of joint involvement were devided into 3 groups: monoarthritis; 42%, oligoarthritis; 35%, polyarthritis; 23%, The most frequent site of the first gouty attack was the 1st toe(65%). The most frequently involved joint at gouty attack was also the 1st toe(68%). While only lower extremities were involved in most cases with monoarthritis and oligoarthritis(91% and 78%, respectively), both lower and upper extremities were involved in most cases with polyarthritis(78%). 4) Hyperuricemia was found in 74% of the cases at gouty attack. But serum uric acid level was normal in 26%. With respect to pathogenesis of hyperuricemia, 14% of the cases had uric acid overproduction and 86% had uric acid underexcretion. 5) Bony changes in radiologic findings were found in 47% of the cases and tophi in 33%. Bony changes and tophi was significantly related to the younger age of gouty onset and higher serum uric acid level at gouty attack. 6) Acute gouty arthritis responded well to colchicine and NSAIDs. There was no difference in efficacy and the frequency of side effects between them. CONCLUSION: The clinical features of the gouty arthritis in Korea showed no difference from those in foreign studies except higher prevalence of oligo-/polyarthritis and tophi. To be remarkable, 26% of the patients with gouty arthritis did not have hyperuricemia at gouty attack. This finding indicates that urate crystals should be confirmed by synovial fluid examination for diagnosis of gouty arthritis.

A comparative study on the methods of echocardiographic measurement of left ventricular mass in normal subjects: M-mode, 2-dimensional area-length method and method using simpson's rule

BACKGROUND: Determination of left ventricular(LV) myocardial mass with echocardioraphy is feasible and validated. American society of echocardiography(ASE) issued recommendations for the quantitation of the left ventricle by M-mode and 2-dimensional echocardiography in 1978 and 1989, respectively. Although some controversies exist regarding the relative accuracy of M-mode and 2-dimensional techniques, many workers now agree that 2-dimensional methods are more accurate and can be applied to a higher percentage of patients. But sometimes the validated methods are not optimal when parasternal short axis view is difficult to obtain, when the ventricle is distorted, or when scar tissue constitutes a portion of the myocardial volume. METHODS: We measured left ventricular mass in 72 normal subjects using three different methods-ASE cube method with correction in M-mode(method A), area-length method from parasternal short axis view and apical four chamber view(method B), and the method using Simpson's rule from apical four chamber view(method C). RESULTS: 1) LV mass(index) was 161.8+/-30.3g(98.7+/-15.6g/m2) by method A, 166.2+/-32.8g(101.2+/-16.5g/m2) by method B, and 161.2+/-31.8g(98.2+/-15.5g/m2) by method C. 2) LV mass or index by method B was significantly different from that by method A(p0.05). 3) There was a strong correlation between LV mass or index by the method A and B(r=0.873, p<0.001), by the method B and C(r=0.923, p<0.001), and by the A and C(r=0.945, p<0.001). CONCLUSIONS: It is suggested that the method using Simpson's rule can reliably assess LV mass, although it results in smaller value that that by area-length method.

Evaluation of the effects of amlodipine on ambulatory blood pressure in hypertensive patients

BACKGROUND: A clinical trial was performed to evaluate the antihypertensive efficacy and side effects of amlodipine, a new long-action calcium antagonist, in patients with mild to moderate essential hypertension as measured by 24-h ambulatory blood pressure monitoring. METHODS AND RESULTS: 1) The study patients consisted of 4 men and 6 women, and the mean age was 51 years. Amlodipine monotherapy(5~10mg) was continued for 4 weeks, and blood pressure was measured by 24-h ambulatory blood pressure monitoring. 2) A smooth and sustained lowering of blood pressure was clearly achieved without affecting the circadian rhythm throughout dosing interval. The mean-pressure drop was 21.2/13.7mmHg after 4 weeks of amlodipine monotherapy. 3) The ambulatory pulse rate revealed virtually identical average hourly pulses during the recording period before and after amlodipine treatment. 4) All of the laboratory parameters including blood chemistry, glucose, lipid and electrolytes did not change significantly after 4 weeks of amlodipine monotherapy. 5) Amlodipine therapy resulted in minimal side effects that were well tolerated. CONCLUSIONS: Once-daily amlodipine monotherapy with 5 to 10mg in controlling blood pressure throughout each 24-h cycle is effective and well tolerated in the patients with mild to moderate essential hypertension.