An eosinophilic variant granulomatosis with polyangiitis involving the dura, bilateral orbits, and mastoids.

Granulomatosis with polyangiitis (GPA) formerly called Wegener's granulomatosis is a chronic necrotizing granulomatous inflammatory disease with systemic vasculitis involving the upper and lower respiratory tract, and kidneys. The typical histopathology is that of necrotizing granulomatous inflammation with palisading histiocytes, neutrophils, and lymphocytes. We report a case of a 57-year-old lady presenting with left eye swelling, left ear pain and discharge, but with no pulmonary or renal symptoms. Investigations revealed positive cytoplasmic antineutrophil cytoplasmic antibodies  and proteinase 3 antibodies. The CT and MRI showed meningeal thickening and bilateral structural changes of the orbits and mastoids. Lacrimal gland biopsy showed non necrotizing granulation with an eosinophilic infiltration. She was diagnosed with eosinophilic variant of GPA of the eyes and mastoid bones bilaterally extending to dura and sparing the lungs and kidneys. She responded to corticosteroids and rituximab.

Adverse drug reactions caused by methotrexate in Saudi population.

AIM: The aim of this study is to document adverse drug reactions (ARDs) of methotrexate (MTX) in Saudi patients. METHODS: Cross sectional study of adult patients on MTX, attending rheumatology drug monitoring clinics in a university hospital, over a period of 24 weeks. Adverse drug reactions were sought by patient interview, files review and laboratory abnormalities. RESULTS: Data collected included patients' demographics, diagnoses, co-morbidities, MTX dose and duration, other medications, laboratory abnormalities and adverse reactions, their severity, preventability, and outcome. Out of a total of 593 patients screened, 186 (31.4%) using MTX were interviewed. Most of the patients were female (88.5%). Adverse drug reactions (ADRs) were detected in 61 patients (32.8%). Patients with ADRs took a mean dose of 12.9 mg (2.5-22.5 mg). Ten ADRs (16.4% of total reactions) were preventable; they ranged between severe, moderate and mild. The most common ADRs were gastrointestinal (GI) (52.5%), followed by anemia (8.2%) and chest tightness (6.6%). The duration of the reaction ranged from few hours to 4 years. CONCLUSION: In conclusion our patients with adverse reactions were younger, took less medications and had less co-morbidities. Our results were different from those published in the literature relating MTX toxicity.

Nickel-induced allergy and contact dermatitis: does it induce autoimmunity and cutaneous sclerosis? An experimental study in Brown Norway rats.

Nickel sensitization is a growing problem and the most common cause of allergic contact dermatitis. The aim of this study was to investigate whether nickel chloride can induce autoimmunity and cutaneous sclerosis in immunosensitive rats. Nickel chloride, in a dose of 4.5 mg in 0.2 ml NS, was administered by the oral and subcutaneous routes to 20 Brown Norway rats. Autoantibodies (ANA, anti-RNP, anti-SCL70 and anti-centromere) were measured and compared in pre- and post-challenge serum samples. Histological studies were also performed in skin biopsies obtained from six positively responding rats and compared with an equal number of control rats at the 14th week post-challenge. Serum ANA was high in a significant number of rats in both the oral (P < 0.005) and subcutaneously nickel-treated groups (P = 0.02), while the anti-SCL70 was high in a significant number of rats in only the orally nickel-treated group (P = 0.04). Histologically, subcutaneous and oral nickel-treated groups showed sclerodermic features of the skin (P = 0.22, P = 0.5), respectively. It may be concluded that nickel chloride can induce scleroderma-related autoantibodies and cutaneous sclerosis. More prolonged duration of exposure is probably associated with greater risk. This is the first study showing the potential risk of nickel in triggering the development of cutaneous sclerosis in susceptible hosts.

Patterns of radiographic changes in hands and feet of rheumatoid arthritis in Saudi Arabia.

OBJECTIVE: The aim of the study was to characterize the pattern of radiographic changes in the hands and feet of rheumatoid arthritis in Saudi patients. METHODS: The radiographs of hands and feet of rheumatoid arthritis patients attending rheumatology outpatient clinics of King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia, over the period extending from March to June 2001, were examined and reported for the presence of osteopenia, joint space narrowing, and erosions. RESULTS: Fifty-six rheumatoid arthritis patients were studied. Their mean age was 50 + 1.9 years, and mean disease duration was 9.07 + 0.84 years. Generalized osteopenia was seen in 16/56 (29%) and periarticular osteopenia in 38/56 (68%). Joint space narrowing was present in 9/56 (16%) of feet and 35/56 (63%) of hand x-rays. Erosions were seen in 3/56 (6%) of feet and in 22/56 (39%) of hand x-rays. Significant correlation was seen between joints space narrowing, joint erosions, and disease duration. CONCLUSION: Radiographic changes in hands and feet of Saudi rheumatoid arthritis patients are less severe than those reported from the West, and the pattern is also different with less affection of the feet.

Effect of diclofenac alone or in combination with alpha-tocopherol on the oxidative activity of polymorphonuclear leukocytes in healthy and osteoarthritic individuals.

OBJECTIVE: To investigate the effects of diclofenac alone or when combined with alpha-tocopherol on the oxidative activity of polymorphonuclear leukocytes (PMNs) in healthy and osteoarthritic (OA) patients. METHODS: The study was carried out at the College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia, over the period 1999 to 2000. Twelve healthy controls and 12 osteoarthritic patients were recruited to the study. Twelve healthy controls and osteoarthritic patients were given diclofenac 50 mg thrice daily orally, initially for 5 days then alpha-tocopherol at 200 mg thrice daily orally, was added for another 5 days. Blood samples were drawn before the start of the study (pre-treatment) and at 5 days following treatment with diclofenac alone and 10 days following treatment with diclofenac and alpha-tocopherol. Chemiluminescence (CL) response was measured for whole blood and isolated polymorphonuclear leukocytes (PMNs) on all samples. RESULTS: Diclofenac enhanced CL response of whole blood and of PMNs of healthy controls when stimulated with phorbol myristate acetate (PMA) and opsonized zymosan (OPZ). Co-treatment with alpha-tocopherol resulted in no appreciable change in the CL response of whole blood when stimulated with PMA or OPZ but a further significant enhancement of CL response of isolated PMNs when these cells were stimulated by either PMA or OPZ. In osteoarthritic patients, diclofenac alone and when combined with alpha-tocopherol showed no significant change in CL response of whole blood. The CL response of PMNs from OA patients was decreased by diclofenac alone. However, this inhibitory effect was not observed when alpha-tocopherol was used together with diclofenac. CONCLUSION: The effect of diclofenac alone or in combination with alpha-tocopherol did not produce a consistent effect on the CL response of whole blood or isolated PMNs of healthy or osteoarthritic patients.

Interaction of allopurinol and non-steroidal anti-inflammatory drugs on the carrageenan-induced rat paw edema.

OBJECTIVE: To find out the effect of combining allopurinol with non-steroidal anti-inflammatory drugs on carrageenan-induced rat paw edema. METHODS: The study was carried out at the College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia, over the period 1999 to 2000. Male wistar rats were randomly divided into 12-16 rats in each group. Edema was induced by subplantar injection of 0.1 ml of carrageenan (10 mg/ml) and the resulting edema volume was measured by plethysmograph, 3 hours after the injections. Saline of 0.9% (0.1 ml/100 g) was administered to the first group serving as control. The second and third groups received variable concentration of allopurinol (12.5, 25, 50 mg/kg) and tenoxicam (0.0625, 0.125, 0.25 mg/kg) 30 minutes before carrageenan injection. The fourth group received a combination of tenoxicam and allopurinol. Similar procedures were carried out with respect to diclofenac at 1.25, 2.5, 5.0 mg/kg and indomethacin at 0.25, 0.5, 1.0 mg/kg. The activities of the drugs were expressed as percentage inhibition of edema. RESULTS: Pre-treatment of the rats with the 4 drugs individually resulted in dose-dependent reduction of volume of paw edema. The combination of allopurinol and diclofenac acted synergistically to reduce edema. A similar synergistic action was obtained when allopurinol was combined with indomethacin. By contrast, tenoxicam-allopurinol combination resulted in antagonistic action and produced an effect on edema, which was less than their individual inhibitory action. CONCLUSION: Combining allopurinol with either diclofenac or indomethacin produced synergistic inhibitory action on rat's paw edema. However, tenoxicam, when combined with allopurinol, produced antagonism.

Musculoskeletal pain in the community.

OBJECTIVE: To estimate the prevalence of musculoskeletal (MSK) pain in Al-Qaseem province in central Saudi Arabia. METHODS: Over a period of 18 months extending from September 1993 through to the end of February 1995, a house-to-house survey was conducted in Al-Qaseem province and included 5,894 adults asking regarding musculoskeletal pain. RESULTS: We obtained a response from 5,823 (98.8%), 2,667 (45.8%) men, and 3,156 (54.2%) women. The mean age was 34.14 +/- 15.16 years. Musculoskeletal pain was reported by 1,477 (25.4%), 762 (13.1%) men and 715 (12.3%) women. Musculoskeletal pain was significantly correlated with age (r =0.454), married status (r=0.238), unemployment (r=0.122), lower educational attainment (r=0.347), frequent attendance at local doctor (r=0.703), consumption of medications for pain (r =0.551), and change in ability to work (r=0.492). We found no association with sex or body mass index. CONCLUSION: Musculoskeletal pain, although common in the community, is less prevalent than reported from Western countries, but has similar socio-medical consequences.

Radiographic osteoarthritis and serum cholesterol.

OBJECTIVE: To find out the relationship between radiographic osteoarthritis (OA) of the knee, generalized OA and serum cholesterol. METHODS: Over a period of 7 months from September 1998 through to March 1999, 246 patients attending 14 primary care clinics in Northern Riyadh, Kingdom of Saudi Arabia, for different non-musculoskeletal complaints were recruited in the study. Their knees, hands and wrists were radiographed. Their ages, sex, weight, height, body mass index (BMI), fasting serum cholesterol, triglycerides and uric acid were recorded. RESULTS: There were 113 females and 133 males with average ages 46 14.2 and 51.54 16.0 years. One hundred and twenty-two (49.6%) cases of knee OA and 58 (23.6%) cases of generalized OA were found and analyzed for the association with serum cholesterol levels. Crude odds ratio (OR) for the relationship between knee OA and the third tertile of serum cholesterol was 2.33 (95% CI, 1.19-4.58) which on adjusting for age, sex, BMI, serum uric acid and triglycerides were 2.68 (95% CI, 2.00-3.64). For generalized OA, the crude odds ratio (OR) in relation to the third tertile of serum cholesterol was 1.65 (95% CI, 0.78-3.53), adjusted OR was 2.18 (95% CI, 1.55-3.15). CONCLUSION: The results showed an association between high serum cholesterol level and both knee and generalized OA.

Rheumatoid arthritis. Radiological changes in the cervical spine.

OBJECTIVE: To describe the radiographic cervical spine changes in rheumatoid arthritis patients. METHODS: Forty-nine patients (37 females and 12 males) diagnosed with rheumatoid arthritis at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, between June 1998 and June 2000, were studied for their radiographic cervical spine changes. Their mean age at disease onset was 41.4 +/- 13.4 years (range of 18-73) and mean duration of the disease was 9.1 +/- 6.28 years (range of 2-34). Their demographic data including rheumatoid factor status was obtained. Standard conventional radiographs of cervical spine were obtained to study the cervical spine changes. RESULTS: Cervical spine radiographic changes were found in 34 patients (27 females and 7 males), 10 had subluxation (7 with atlanto-axial subluxation, 2 with sub-axial subluxation, and one with lateral subluxation). No vertical impaction was seen. Erosion of odontoid process was seen in one patient. All were rheumatoid seropositive. CONCLUSION: Cervical spine changes in patients with rheumatoid arthritis are common, in particular subluxation in the upper cervical spine. Our study showed somewhat lesser prevalence of these changes. These were clinically correlated with disease duration, female sex, and rheumatoid factor, but were not statistically significant.

How common is back pain in Al-Qaseem region.

OBJECTIVE: The aim of this study was to estimate the prevalence of back pain in the adult population of Al-Qaseem Central Province, Kingdom of Saudi Arabia and to find associated features and factors. METHODS: A house-to-house survey covering 1,000 household in the towns and villages of Al-Qaseem province was carried out over a period of 18 months extending from September 1993 until the end of February 1995. A total of 5,894 adults, aged 16 years and above, were questioned by trained staff regarding back pain, and the demographic data in addition to general, medical and social history. RESULTS: A response was obtained in 5,743 (97.4%). Their mean age was 34.14 15.16 (range 16-99). Back pain was reported by 1,081 (18.8%), wherein 499 (8.8%) were men, and 574 (10%) were women. Back pain was more prevalent in married (23.3%) individuals than unmarried (6.4%). Adjusted odds ratio (OR) for back pain in married individuals was 1.88 (95% confidence intervals [CI] 1.49-2.37). Back pain was strongly correlated with age (correlation coefficient = 0.378 P < 0.01). It also showed significant correlation with weight and height, depression, family history of back pain, change in work ability, frequency of attendance at local doctor, use of medication and lower education level. The association with body mass index became evident only after comparing the heaviest 20th percentile to the lightest (OR 1.335 [95% CI, 1.279-1.402]). Certain occupational status (unemployed, farmers, professional workers and housewives) were associated with back pain. CONCLUSION: Back pain was relatively common in this largely unindustrialized community although its prevalence is lower than reported from some western countries.

Knee osteoarthritis in Al-Qaseem, Saudi Arabia.

OBJECTIVE: The aim of this study was to estimate the prevalence of clinical osteoarthritis (OA) of the knee in Al-Qaseem, a central province in the Kingdom of Saudi Arabia (KSA). METHODS: A house to house survey of randomly selected inhabitants of Al-Qaseem, KSA was conducted. A total of 10,406 persons were interviewed of whom 5,894 were above the age of 16 years. The study was carried out at King Khalid University Hospital and College of Medicine, Riyadh, KSA, from September 1993 to February 1995. They were questioned regarding musculoskeletal complaints, and those positively identified were interviewed further by a team of trained medical staff and later examined by trained doctors including rheumatologists. RESULTS: We found 766 (13%) cases of clinical OA of the knee in the 5,894 adult population (13%). The prevalence of OA increased with increasing age reaching 30.8% in those aged 46-55 years and 60.6% in the age group 66-75 years. The odds ratio (OR) for the association between clinical OA of the knee and age adjusted for sex and body mass index (BMI) was 1.0894 (95% CI, 1.08-1.09). The association of clinical OA of the knee with female sex was also significant [OR (adjused for age and BMI) was 1.261 (95% CI, 1.0456-1.5208)]. CONCLUSION: Clinical OA of the knee is common in this community, particularly in the older age groups.

Mouth and genital ulcerations in the community.

OBJECTIVE: To estimate the prevalence of mouth and genital ulceration in the community and its relationship to rheumatic diseases. METHODS: A house to house survey was carried out over a period of 18 months extending from September 1993 to February 1995, on 5,894 individuals utilizing detailed questionnaires on symptoms of musculoskeletal diseases and associated symptoms including history of mouth, genital ulcers, eye symptoms, and skin changes. After the initial phase, a 2nd phase was completed by trained nurses and paramedical staff, the purpose of which was to explore in detail, the history of those responding positively to any of the questions in phase one. The 3rd stage was conducted by general practitioners and rheumatologist to interview and examine those identified in phase 2 at King Fahad Hospital, Buraidah, Kingdom of Saudi Arabia. RESULTS: We identified 7 (0.1%) cases of genital ulceration, 43 (0.7%) cases of mouth ulceration, 263 (4.5%) cases of reddish eye or blurred vision, and 124 (2.1%) cases of skin rashes. Only 2 cases had both mouth and genital ulceration in addition to eye disease, skin rash and musculoskeletal pain. There was significant correlation between mouth ulcers and skin rash, eye symptoms, genital ulcerations, male sex, single status, weight loss and backpain. CONCLUSION: The vast majority of mouth and genital ulcers are not associated with a known rheumatic disease.

Radiographic osteoarthritis and obesity.

OBJECTIVE: To determine the association between obesity and radiographic osteoarthritis (OA) of the knee and generalized OA. METHODS: A cross-sectional survey of patients attending 14 primary clinics for a variety of medical complaints was conducted. They were consented, interviewed, examined and radiographed for the presence of knee and generalized OA. The association between OA and weight was then assessed. This study was carried out in 14 primary care clinics in North Riyadh, Kingdom of Saudi Arabia, between September 1998 through to March 1999. RESULTS: Two hundred and nineteen patients (118 males, 101 females) completed the study and their results were analyzed. We found a strong association between excess weight and knee OA in females [overall ratio (OR) 3.28 (95% confidence intervals (CI), 2.07-5.36)] and a weaker link with knee OA in males [OR 1.88 (95% CI, 1.24-2.92)]. Generalized OA was found to be associated with obesity in females only [OR 1.93 (95% CI, 1.09-3.43)]. Reporting of joint symptoms in patients with radiographic knee OA was also associated with obesity (P=0.0001). CONCLUSION: Excess weight is strongly associated with knee OA in females and symptoms of joint pain in all OA patients, with a weaker but still significant link with male knee OA and generalized OA in females.

Prevalence of radiographic osteoarthritis of the hands in Saudi Arabia.

We studied the radiographic evidence of osteoarthritis (OA) of the hands in 300 patients (167 male, 133 female) attending 14 primary care facilities for a variety of medical conditions. Radiographic OA was seen in 30.3% of males and 36.3% of females. Most commonly affected were the metacarpophalangeal joints, followed by the distal interphalangeal and carpometacarpophalangeal joints.

Prevalence of systemic lupus erythematosus in central Saudi Arabia.

OBJECTIVE: Although systemic lupus erythematosus of varying severity has been seen in our clinics, there is no information regarding the prevalence of the disease among Saudi nationals. We conducted this study to determine the prevalence of systemic lupus erythematosus in Al-Qaseem region of the Kingdom of Saudi Arabia. METHODS: A community survey of towns and villages in the Al-Qaseem area of central Saudi Arabia was conducted in 3 phases to determine the prevalence of systemic lupus erythematosus in the region. RESULTS: Of the 10,372 studied, 2 cases of systemic lupus erythematosus were identified using the criteria set for the diagnosis of systemic lupus erythematosus by the American College of Rheumatology. Based on that, the prevalence of systemic lupus erythematosus was estimated to be 19.28 per 100,000 population in the region. CONCLUSION: The estimated prevalence of systemic lupus erythematosus in Al-Qaseem area is similar to that found in western countries.