Residual pulmonary abnormalities in adult patients with chronic paracoccidioidomycosis: prolonged follow-up after itraconazole therapy.

Itraconazole effectively controls active paracoccidioidomycosis but appears not to hinder lung fibrosis. Clinical records and chest radiographs from 47 itraconazole-treated patients with prolonged posttherapy follow-up (mean follow-up period, 5.6 years) were analyzed; the radiographs were interpreted following pneumoconiosis standards that consider the lungs as 6 fields and grade damage according to the number of fields involved. Infiltrative lesions were observed at diagnosis in 93.6% of the patients. Fibrosis was observed in 31.8% of the patients at diagnosis and had not cleared at the end of the observation period in any of these patients. Fibrosis also developed de novo in 11 patients (25%), so that by the end of the follow-up period it was seen in 53.2% of patients overall. Fibrosis correlated with severity of infiltrates at diagnosis: fibrosis was present in 83% of patients with very severe infiltration and in 12.5% of patients with minor infiltration. Among patients with severe infiltration, fibrosis was present in 30%; this increased (to 75%) when bullae were concomitantly present at diagnosis. Prompt initiation of treatment is necessary to avoid the development of fibrosis.

Gout: diagnosis, pathogenesis, and clinical manifestations.

Gout is a common form of arthritis, in which many of the risk factors, pathogenetic mechanisms, and clinical features have been recognized for years. Nevertheless, new information has become available regarding the normal physiologic role of uric acid as an antioxidant, and greater insight has been obtained regarding the inflammatory process in acute gout. New studies have improved our understanding of the role of genetic and environmental factors responsible for hyperuricemia, and we know more about the significance of the association of hyperuricemia with other diseases. Clinically, rare complications and disease manifestations in new populations continue to be discussed, and diagnostic methods continue to be refined.

Fever with acute arthritis in calcium pyrophosphate dihydrate deposition disease: a missed explanation for altered mental status in elderly patients?

Calcium pyrophosphate dihydrate (CPPD) deposition disease is a relatively common condition primarily affecting the elderly. Various clinical presentations ranging from an acute arthritis resembling gout (pseudogout) to fever of unknown origin have been reported. We describe four elderly patients with fever and altered mental status. Each patient underwent an extensive unrevealing work-up. An acute arthritis missed by the health-care team in their initial evaluation was later identified, leading to rheumatologic consultation and subsequent diagnosis of CPPD disease after joint aspiration and synovial fluid analysis. Defervescence and resolution of mental status changes occurred after improvement of the arthritis. Awareness that CPPD disease may present with systemic symptoms, including fever and altered mental status, may assure careful examination of joints and can prevent unnecessary testing and diagnostic delay.

Crystal-associated arthritis in the elderly.

The understanding of the clinical syndromes of gout and pseudogout, and the role of basic calcium crystals in arthritis has increased since the original descriptions of the involvement of crystals in arthritis. Gout is usually considered an affliction confined to middle aged males but has an increasing prevalence in older populations, with unique and often atypical features. Calcium pyrophosphate dihydrate crystal deposition disease is common in elderly patients. The diagnosis of these common forms of arthritis and the need to individualize therapy in patients with other medical problems remain important clinical challenges to the practicing physician.

Temporal arteritis in a patient with eosinophilia.

We present the case of a 69-year-old man with fever of unknown origin, headache, elevated sedimentation rate and peripheral eosinophilia. A biopsy of the temporal artery revealed transmural inflammation with eosinophilia. Therapy with corticosteroids resulted in resolution of the fever, headache, and eosinophilia, as well as normalization of the sedimentation rate. There have been only rare cases of eosinophilia associated with temporal arteritis. All of these cases were seen in patients with either juvenile temporal arteritis, acquired immunodeficiency syndrome, or Buerger's disease. This is the only case, to our knowledge, of eosinophilic temporal arteritis without association with any of these conditions. Our patient underwent extensive diagnostic studies and therapeutic trials en route to a long delayed correct diagnosis. The presence of eosinophilia should not deter physicians from considering a temporal artery biopsy in patients presenting with symptoms suggestive of temporal arteritis.

Prevalence of Trypanosoma cruzi and Leishmania chagasi infection and risk factors in a Colombian indigenous population.

This study was carried out in order to obtain base-line data concerning the epidemiology of American Visceral Leishmaniasis and Chagas' Disease in an indigenous population with whom the government is starting a dwelling improvement programme. Information was collected from 242 dwellings (1,440 people), by means of house to house interviews about socio-economic and environmental factors associated with Leishmania chagasi and Trypanosoma cruzi transmission risk. A leishmanin skin test was applied to 385 people and 454 blood samples were collected on filter paper in order to detect L. chagasi antibodies by ELISA and IFAT and T. cruzi antibodies by ELISA. T. cruzi seroprevalence was 8.7% by ELISA, L. chagasi was 4.6% and 5.1% by IFAT and ELISA, respectively. ELISA sensitivity and specificity for L. chagasi antibodies were 57% and 97.5% respectively, as compared to the IFAT. Leishmanin skin test positivity was 19%. L. chagasi infection prevalence, being defined as a positive result in the three-immunodiagnostic tests, was 17.1%. Additionally, 2.7% of the population studied was positive to both L. chagasi and T. cruzi, showing a possible cross-reaction. L. chagasi and T. cruzi seropositivity increased with age, while no association with gender was observed. Age (p<0.007), number of inhabitants (p<0. 05), floor material (p<0.03) and recognition of vector (p<0.01) were associated with T. cruzi infection, whilst age ( p<0.007) and dwelling improvement (p<0.02) were associated with L. chagasi infection. It is necessary to evaluate the long-term impact of the dwelling improvement programme on these parasitic infections in this community.

Crystal-associated arthritis.

Since the original descriptions of the involvement of crystals in arthritis, understanding of the clinical syndromes of gout and pseudogout and the role of basic calcium crystals in arthritis has increased. Gout is a common problem in middle-aged males but has an increasing prevalence in older patients, particularly women. Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is now a well-recognized problem in older patients. The diagnosis of both of these common forms of arthritis and the need to individualize therapy in patients with other medical problems remain important clinical challenges to the practicing physician.

Diagnosis and management of complicated gout.

Although a diagnosis of gout can be confirmed by the presence of monosodium urate crystals in synovial fluid, arriving at the suspected diagnosis and managing the disease can be a challenge for primary care physicians and specialists alike. Symptoms of gout can mimic other forms of inflammatory arthritis such as rheumatoid arthritis, pseudogout, or septic arthritis. Treatment can be complicated by the patient's need for drugs that contribute to hyperuricemia. Once other diagnoses are ruled out and urate crystals are detected under polarized light microscopy, treatment to end the acute attack and follow-up treatment designed to lower serum urate levels can be undertaken.

Musculoskeletal infections in patients with human immunodeficiency virus infection.

Musculoskeletal infections constitute an unusual clinical manifestation in patients with human immunodeficiency virus (HIV) infection. Available information about patients' characteristics and their clinical course has been obtained mainly from case reports and small retrospective studies. Our retrospective study is the largest in the literature providing detailed information about the clinical and laboratory characteristics of HIV-infected patients with different musculoskeletal infections. We identified 30 patients with various infections of the musculoskeletal system during a 5-year period among a cohort of 3,000-4,000 HIV-infected patients, and we describe them along with all cases of musculoskeletal infections in patients with HIV reported in the literature since 1985. Septic arthritis was the most commonly reported infection of the musculoskeletal system. It usually affects young men with a median CD4 count of 241. The exact contribution of a previous history of intravenous drug abuse in the pathogenesis of septic arthritis is unclear from the present and previous studies. Staphylococcus aureus was the most commonly isolated agent (31.3%). Numerous atypical pathogens were also identified as causes of septic arthritis. Approximately 90% of patients recovered with appropriate antibiotic treatment. Osteomyelitis was a more serious infection which also affected young individuals but with lower CD4 counts (median, 41). Half the cases were due to atypical mycobacteria. The mortality rate in the previously reported cases and in our series was high (20%). Pyomyositis is an increasingly recognized infection of the striated muscles in HIV-infected patients. It affects almost exclusively males with advanced HIV infection (median CD4 count, 24). Most cases are due to Staphylococcus aureus (67%). Drainage of the involved muscle(s) accompanied by proper antibiotic treatment resulted in resolution of the infection in the majority of patients (90%). Although the incidence of musculoskeletal infections in patients with HIV from this and previous studies appears to be low (0.3%-3.5%), these infections add a significant morbidity and mortality in the affected individuals. Better understanding of their pathogenesis and clinical course would aid the proper diagnosis and management of these infections.

Case report: arthropathy as the presenting symptom in hereditary hemochromatosis.

Hemochromatosis is characterized by excessive absorption and subsequent deposition of iron in various organs and is prevalent in 1 out of 20,000 hospitalized patients. Most patients with hereditary hemochromatosis (HHC) become symptomatic between the ages of 50 and 60 years. Distinct forms of arthritis have been associated with HHC and may be the initial clinical manifestation in some patients. This is a case of a patient who had chronic hip and back pain and painless swelling over the knuckles. Radiographs revealed classical signs of HHC. Early recognition and prompt institution of phlebotomy can improve the outcome of patients with HHC.

Case report: coexistence of acute calcific periarthritis and infection.

Basic calcium phosphate (BCP) crystal deposition around the joints may sometimes lead to an acute inflammatory condition called calcific periarthritis. In this article, the authors describe a 62-year-old man with BCP crystal-induced periarthritis coexisting with an infection. Rheumatoid arthritis and crystal-induced synovitis complicated by infection has been described in the literature. To date, this is the first report of coexistent calcific periarthritis and an infection.

Gouty arthritis and uric acid metabolism.

Important observations have continued to expand our understanding of gout. The increased risk of gout in black Americans has been linked more closely with the development of hypertension, and an increasing prevalence in African blacks and in England may have a similar association, possibly through the use of diuretics. The association of gout and insulin resistance appears to be related to fat distribution, and the link with hyperlipidemia may be related to genetic factors. The relationship between gout and renal disease and the frequency of gout in patients with renal failure continue to be areas of controversy. The mechanism and a possible therapeutic approach to the hyperuricemia associated with cyclosporine therapy are better understood. The potential for antibodies against urate crystals to potentiate further crystallization may explain some of the uncertainties about gouty attacks. Unusual manifestations of gout, including more cases of spinal involvement, were reported. The role of formalin in dissolving urate crystals in pathologic specimens was further clarified, and the use of atomic force microscopy to detect crystals was reported. Corticosteroids are increasingly accepted in treating acute gout, and the role of colchicine in acute and intercritical gout has come under increasing scrutiny. Urate-lowering drugs appear to be cost effective in patients with more than one or two attacks per year.

Finger pad tophi in gout.

OBJECTIVE: To determine frequency and prevalence of finger pad tophaceous deposits in patients with chronic tophaceous gout. METHODS: We examined 36 consecutive patients with chronic tophaceous gout for intracutaneous tophaceous urate deposits in the fingers pads. Subjects were patients of outpatient clinics at 2 large university hospitals, Emory and the University of Pennsylvania Affiliated Hospital Systems. RESULTS: Finger pad tophaceous deposits were found in 30.5%, which was surprising, given how few cases are reported. CONCLUSION: Finger pad tophi may be more common than generally believed.

Severe anemia as the presenting manifestation of giant cell arteritis.

Giant cell (temporal, cranial) arteritis (GCA) is usually confirmed in patients presenting with classic features. Those who present with atypical features often undergo prolonged evaluations until a diagnosis is established. Severe anemia as an initial manifestation of GCA has rarely been described. We describe herein 2 patients with biopsy-proven GCA who presented with severe anemia and significant weight loss, which corrected after corticosteroid therapy.

Lupus panniculitis (profundus) involving the breast: report of 2 cases and review of the literature.

Breast involvement with lupus panniculitis has been infrequently reported. We describe 2 cases with breast involvement proven by biopsy to be lupus panniculitis. Our review emphasizes the clinical presentation of lupus panniculitis with mastitis and its possible clinical similarity to malignancy. In addition, other connective tissue diseases and vasculitis with breast involvement are noted.