Gout and hyperuricemia.

Gout is a condition characterized by the deposition of monosodium urate crystals in the joints or soft tissue. The four phases of gout include asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout and chronic tophaceous gout. The peak incidence occurs in patients 30 to 50 years old, and the condition is much more common in men than in women. Patients with asymptomatic hyperuricemia do not require treatment, but efforts should be made to lower their urate levels by encouraging them to make changes in diet or lifestyle. Acute gout most commonly affects the first metatarsal joint of the foot, but other joints are also commonly involved. Definitive diagnosis requires joint aspiration with demonstration of birefringent crystals in the synovial fluid under a polarized light microscope. Treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, corticosteroids and analgesics. In patients without complications, NSAID therapy is preferred.

Polyarteritis with symptomatic intracerebral aneurysms at initial presentation.

Polyarteritis rarely involves the cerebral vasculature, and has not been reported to have an initial presentation with intracerebral aneurysms. We describe the first case of polyarteritis presenting with symptomatic intracerebral aneurysms. A literature review from 1966 to 1997 identified 5 additional cases with evidence of intracerebral aneurysms and polyarteritis. The cases reviewed all had evidence of longstanding systemic symptoms suggestive of polyarteritis prior to diagnosis. Polyarteritis with intracerebral aneurysms is associated with significant morbidity and mortality, and therefore must be recognized and treated early.

Prospective use of intramuscular triamcinolone acetonide in pseudogout.

OBJECTIVE: To prospectively assess the efficacy of intramuscular (i.m.) triamcinolone acetonide in the treatment of pseudogout. METHODS: Fourteen patients with crystal proven pseudogout presenting with an acute attack within 5 days of onset were treated with intramuscular triamcinolone acetonide 60 mg and followed for 30 days. Patients with inadequate response were eligible for a 2nd triamcinolone acetonide injection on Day 1-2. RESULTS: Twelve patients had contraindication to nonsteroidal antiinflammatory agents (NSAID). Acute arthritis was monoarticular in 10 patients, and involved 2 or more joints in 4 patients. All patients had good clinical response to triamcinolone acetonide based on restoration of near baseline joint range of motion and joint circumference, and at least 50% improvement in patient and physician global assessment. Major clinical improvement occurred by Day 1-2 (2 patients), Day 3-4 (11 patients), and Day 10-14 (one patient). Six patients required a 2nd triamcinolone acetonide injection on Day 1-2. Toxicities were not observed. CONCLUSION: I.m. triamcinolone acetonide appears to be safe, well tolerated, and effective in the treatment of pseudogout. It may be a reasonable alternative therapy when NSAID are contraindicated, and for polyarticular attacks where intraarticular corticosteroids are impractical.

Mucormycosis in a patient with sarcoidosis.

Mucormycosis is a rare complication of sarcoidosis. We report only the third instance of mucormycosis occurring in a patient with sarcoidosis. Corticosteroid therapy, even short courses of less than one month duration, appears to be a major risk factor for the development of mucormycosis. Mucormycosis should be suspected upon the development of signs and symptoms of chronic sinusitis, necrotic nasal discharge, proptosis or periorbital edema. Mucormycosis is confirmed on routine hematoxylin and eosin stains by the identification of tissue invasion by the broad, aseptate mucor fungi. Prompt identification of the infection is essential to reduce morbidity and prevent mortality.

Mycobacterium marinum arthritis.

Mycobacterium marinum is an atypical acid-fast organism that is rarely associated with septic arthritis. Most often this is seen in patients with monarticular synovitis of the hands or wrists, especially in association with a history of periarticular trauma or exposure to marine environments. From tissue obtained by aspiration or synovectomy, Mycobacterium marinum can be identified by Ziehl-Nielson stain and has optimal growth in Lowenstein-Jenson medium. Therapy should consist of at least two antimycobacterial agents for a minimum 6 months. Surgical debridement also may be beneficial. The clinician must have a high index of suspicion that exposure to Mycobacterium marinum has occurred so appropriate stains and cultures can be obtained and antimycobacterial therapy initiated.

Quinidine-induced rheumatic syndromes.

Quinidine is a commonly used antiarrhythmic agent that is rarely associated with rheumatologic toxicity. However, quinidine-induced lupus, antinuclear antibody negative lupus-like syndrome, polymyalgia rheumatica-like illness, muscle weakness, and isolated creatine phosphokinase elevation have all been reported. We present one case of quinidine drug-induced lupus and another of a quinidine-induced polymyalgia rheumatica-like illness, and review the English literature for rheumatologic toxicity due to quinidine. Prompt recognition of quinidine associated rheumatologic toxicity is important because discontinuation of the medication leads to rapid resolution of clinical symptoms.

Comparison of adrenocorticotropic hormone and triamcinolone acetonide in the treatment of acute gouty arthritis.

OBJECTIVE: To determine the best alternative therapy for acute gouty arthritis when nonsteroidal antiinflammatory drugs or colchicine are contraindicated. METHODS: Thirty-one patients with crystal proven gout presenting with an acute attack of < 5 days' duration were treated prospectively with either a single intramuscular injection of adrenocorticotropic hormone (ACTH) 40 IU or triamcinolone acetonide 60 mg. The patients were followed for 30 days. RESULTS: Resolution of all symptoms occurred at an average of 8 days for both groups. No adverse reactions were noted in either group; however, there were 11 reinjections in the ACTH group and 5 reinjections in the triamcinolone acetonide group. Two patients from the ACTH arm were transferred to the triamcinolone acetonide arm because of rebound arthritis. CONCLUSION: Although recent studies of ACTH and triamcinolone acetonide have demonstrated efficacy and safety comparable to indomethacin, in a direct comparison of the 2 at the doses used, triamcinolone acetonide resulted in fewer rebound attacks and treatment failures than ACTH and required fewer reinjections.

High dose methylprednisolone for retroorbital Wegener's granulomatosis.

Wegener's granulomatosis (WG) is frequently associated with retroorbital involvement, which typically responds slowly to the standard therapy of oral corticosteroids and cytotoxic agents. We describe the case of a 61-year-old man with WG, who developed marked retroorbital granulomatous inflammatory tissue and experienced a dramatic clinical and radiographic response to the administration of high dose intravenous (iv) methylprednisolone. We believe that high dose iv methylprednisolone may have distinct advantages over standard therapies in the treatment of retroorbital WG.

Diabetic muscular infarction.

In the evaluation of patients with a painful atraumatic mass in an extremity, the clinician should consider a number of clinical entities: primary tumor of muscle, focal or localized nodular myositis, local muscular abscess or soft-tissue infection, osteomyelitis, and thrombophlebitis. A rare complication of diabetes, viz, diabetic muscular infarction, heretofore not reported in the rheumatic disease literature is reviewed. This entity is compared with the conditions of focal and localized nodular myositis, which are nearly as rare.

Comparison of triamcinolone acetonide with indomethacin in the treatment of acute gouty arthritis.

Twenty-seven patients presenting within 5 days of the onset of crystalline proven acute gout were prospectively treated with either indomethacin 50 mg tid or triamcinolone acetonide 60 mg intramuscularly. Patients with contraindications to therapy with indomethacin received triamcinolone acetonide. They were followed for 30 days. Resolution of all symptoms occurred at an average of 8 days for the indomethacin patients and 7 days in the triamcinolone patients. No side effects or episodes of rebound gout attacks occurred with the triamcinolone acetonide therapy. It is as safe and effective as indomethacin in the treatment of acute gout, and is particularly useful in patients with contraindications to therapy with nonsteroidal antiinflammatory drugs.