Reactive arthritis (Reiter's syndrome).

Reactive arthritis, also called Reiter's syndrome, is the most common type of inflammatory polyarthritis in young men. It is sometimes the first manifestation of human immunodeficiency virus infection. An HLA-B27 genotype is a predisposing factor in over two thirds of patients with reactive arthritis. The syndrome most frequently follows genitourinary infection with Chlamydia trachomatis, but other organisms have also been implicated. Treatment with doxycycline or its analogs sometimes shortens the course or aborts the onset of the arthritis. Reactive arthritis may also follow enteric infections with some strains of Salmonella or Shigella, but use of antibiotics in these patients has not been shown to be effective. Reactive arthritis should always be considered in young men who present with polyarthritis. Symptoms may persist for long periods and may, in some cases, cause long-term disability. Initial treatment consists of high doses of potent nonsteroidal anti-inflammatory drugs. Patients with large-joint involvement may also benefit from intra-articular corticosteroid injection.

Candida lambica polyarthritis in a patient with chronic alcoholism.

We describe a patient with an indolent polyarthritis over a period of several years caused by Candida lambica probably acquired from a contaminated wound. C. lambica has not been previously reported to cause infectious arthritis. Hematogenous spread was manifest by 4 separate sites of involvement. Chronic alcoholism was the only apparent risk factor for dissemination. The infection seems to be environmentally acquired.

Giant Cell Arteritis in AJ Americans.

Giant cell arteritis is often considered less common in African Americans. In 1985, we reviewed 34 African American patients with biopsy-proven temporal arteritis. We report on 9 additional biopsy positive patients seen at the Washington Hospital Center (WHO between 1988 and 1996.Clinical presentations were similar to those reported in previous series, with the exception that only one patient had polymyalgia rheumatica. Two patients had visual symptoms, but only one patient had permanent monocular visual loss. In combining our 9 new patients with 41 biopsy-proven, well characterized, published patients and comparing them with a representative Caucasian group, we found statistically significant differences. Male gender, anemia, and visual loss were overall more common in African Americans, whereas constitutional symptoms and polymyalgia rheumatica were less common. The detection rate of temporal artery biopsies at WHC was lower than rates reported in other studies, but they did not differ by race.We conclude that giant cell arteritis should be pursued as a diagnosis in all patients presenting with appropriate clinical features, regardless of race, and that earlier recognition may account for the lower incidence of permanent visual loss.

Sclerotic lesions of the cervical spine in sarcoidosis.

Sarcoidosis is a common multisystem disorder characterized by noncaseating epithelial granulomata, with osseous involvement typically seen in 5% of patients. While the lace-like or cystic pattern frequently seen in radiographs of the phalanges is well appreciated, sclerotic lesions of the spine are uncommon. We review a case of sarcoidosis of the cervical spine with sclerotic changes that mimicked blastic metastatic disease.

Office evaluation of the patient with musculoskeletal complaints.

Many musculoskeletal complaints are accompanied by classic signs and symptoms that can be readily diagnosed by the primary care physician. Others are much less obvious and present a diagnostic challenge. In the office evaluation of patients with musculoskeletal complaints, the history is the most informative element. Least helpful are laboratory tests. Although erythrocyte sedimentation rate (ESR), rheumatoid factor, and other widely available tests are sensitive to the presence of rheumatic diseases, they are not specific for any of them. In the initial office evaluation, helpful points of differentiation include the number of joints involved, their location, and, when multiple joints are involved, whether they are symmetric or asymmetric. An acute monarthritis is associated mainly with trauma, infection, or a crystal-induced synovitis such as gout or pseudogout. Patients with polyarthritis may have symptoms that come and go very quickly, sometimes in < 24-36 hours. This migratory pattern characterizes diseases such as gonococcal arthritis, viral disease, and sarcoidosis. "Rheumatoid variants" such as Reiter's syndrome, psoriatic arthritis, and spondylitis may affect no more than a few joints and are accompanied by other signs, such as nail and skin lesions (psoriasis) or urogenital and enteric infections (Reiter's). Like erosive osteoarthritis, the rheumatoid variants may also cause swelling and inflammation of the distal interphalangeal joints. The classic example of symmetric joint disease is rheumatoid arthritis (RA). While RA often occurs in a progressive and additive pattern, its onset may be followed by a remission several months later. Patients who present with the "algias" may have no physical signs but manifest extensive musculoskeletal pain. Fibromyalgia occurs typically in younger women; polymyalgia rheumatica rarely occurs in patients < 50 years of age and is usually accompanied by a strikingly high ESR. Age and gender should be noted in the office evaluation because they can provide clues not only to these "algias," but other rheumatic diseases seen more frequently in one age or gender group than another.

Subacute bacterial endocarditis with polyarthritis mimicking thrombotic thrombocytopenic purpura: a case report.

Thrombotic thrombocytopenic purpura (TTP) is a serious multisystem disorder that is usually rapidly progressive and often fatal if not diagnosed or treated. Unfortunately, the clinical and laboratory features of TTP are not specific and can also be seen in both autoimmune and infectious diseases. We describe a case where the rapid institution of therapy for a TTP-like syndrome masked a culture-negative infectious endocarditis. The diagnosis of this unique patient was established at valvulotomy, necessitated by acute aortic insufficiency.

A swinging heart in limited systemic sclerosis.

We describe a 3rd patient with limited cutaneous systemic sclerosis (ISSc) complicated by a pericardial effusion sufficient to cause hemodynamic compromise. Although more commonly appreciated as a complication of diffuse systemic sclerosis, the recognition of hemodynamically compromising pericardial effusion presenting in the limited form of ISSc can be lifesaving.

Central nervous system herpesvirus infection in systemic lupus erythematosus: diagnosis by endoretinal biopsy.

A 31-year-old woman with systemic lupus erythematosus (SLE) developed meningoencephalitis, followed by transverse myelitis. The clinical picture was otherwise not consistent with a lupus flare. Extensive diagnostic evaluation was unrevealing. Acute visual loss ensued, associated with an unusual pattern of retinitis. Endoretinal biopsy established the diagnosis of herpesvirus infection. Reinstitution of antiviral therapy, and optic nerve sheath decompression, led to resolution of neurologic deficits and partial return of vision. Our report is the first that describes a patient with SLE with herpes meningoencephalitis, transverse myelitis, and rapidly progressive outer retinal necrosis, diagnosed antemortem by endoretinal biopsy, and successfully treated with acyclovir and optic nerve fenestration.

Systemic herpetic infection diagnosed by retinal biopsy.

We describe a patient with systemic lupus erythematosus who developed myelopathy, optic neuropathy, retinopathy, and aseptic meningitis unresponsive to immunosuppressive and antimicrobial therapy. Although cultures and brain biopsy were unrevealing, a Herpes virus was suggested by retinal biopsy. The patient recovered dramatically after institution of acyclovir therapy and optic-nerve-sheath decompression. This case demonstrates that herpetic retinitis can occur in an iatrogenically suppressed host and underscores the value of tissue diagnosis.

Diphosphonate bone scan in an unusual case of rhabdomyolysis: a report and literature review.

We describe a patient with bilobar pneumonia and acute renal failure, whose unusual skeletal muscle uptake on technetium methylenediphosphonate bone scan led to the diagnosis of rhabdomyolysis. The clinical and serologic findings were most consistent with Legionnaires' disease. Radioisotope scanning may occasionally be useful in the diagnosis and management of muscle disease, particularly myositis and rhabdomyolysis.

Longterm drug therapy for rheumatoid arthritis in seven rheumatology private practices: I. Nonsteroidal antiinflammatory drugs.

The probability of continuation of a particular nonsteroidal antiinflammatory drug (NSAID) over 5 years was estimated for 1,775 courses taken by 532 patients with rheumatoid arthritis treated in 7 rheumatology private practices. Similar results were seen for 15 different NSAID--48% of courses were continued at 12 months, 36% at 24 months, and 20% at 60 months. Only acetylated salicylates, other than plain aspirin, were continued significantly longer than any of the other NSAID. The probability of continuation of plain aspirin was similar to other NSAID, including nonacetylated salicylates and nonsalicylate NSAID. The first NSAID taken by an individual patient was continued only marginally longer than the 4th NSAID taken by the same patient. While most NSAID courses were not continued for long periods, 20% were continued for longer than 5 years, suggesting effective longterm results in this minority of courses.

Gonococcal pericarditis with tamponade in a patient with systemic lupus erythematosus.

Pericarditis is one of the most frequent manifestations of systemic lupus erythematosus; however, purulent pericarditis and tamponade are rare. We describe a patient with systemic lupus erythematosus and culture-proven gonococcal arthritis who developed purulent pericarditis with intracellular gram-negative diplococci. Evidence of tamponade was seen on echocardiography. There has not been a reported case of Neisseria gonorrhoeae in pericardial fluid or tissue since the introduction of antibiotics.

Subacute cutaneous lupus erythematosus during PUVA therapy for psoriasis: case report and review of the literature.

Lesions typical of subacute cutaneous lupus erythematosus developed in an elderly woman after 6 months of PUVA (8-methoxypsoralen and longwave ultraviolet light) therapy for psoriasis. Pancytopenia, antibodies to double-stranded DNA, and hypocomplementemia developed concurrently with the appearance of the cutaneous lesions. With discontinuation of photochemotherapy, the cutaneous lesions disappeared and the pancytopenia improved.

Kaposi's sarcoma in a patient with SLE.

A 31-year-old woman with systemic lupus erythematosus (SLE) taking chronic corticosteroid therapy developed Kaposi's sarcoma. Three weeks after a single intravenous dose of cyclophosphamide for central nervous system vasculitis she died. Autopsy revealed disseminated Kaposi's sarcoma involving the skin and lung, as well as other visceral organs. This is the first case of widespread Kaposi's sarcoma developing in a patient with SLE.

Necrotizing systemic vasculitis with features of both Wegener's granulomatosis and Churg-Strauss vasculitis.

We describe a patient who had nasal biopsy-demonstrated eosinophilic vasculitis and renal biopsy-demonstrated necrotizing glomerulonephritis with tissue eosinophilia. Despite corticosteroid therapy, the patient's renal function deteriorated, and nodular pulmonary infiltrates developed. Both conditions responded dramatically when cyclophosphamide was added to the treatment regimen. The renal disease activity was monitored with the aid of cytodiagnostic urinalysis, a technique of limited, albeit well-established, validity in monitoring renal allograft patients for signs of tissue rejection. This technique provided an improved, semi-quantitative method for examining urine sediment and, in this patient, was helpful as a measure of renal disease activity.

Quinidine induced lupus syndrome.

Five patients with a lupus-like syndrome secondary to quinidine are described. Eleven other cases have previously been reported. The quinidine induced lupus syndrome is similar to that seen with procainamide and hydralazine treatment but occurs less frequently. The lower incidence may reflect a difference in the metabolism of quinidine. Quinidine should be considered as potentially responsible when multisystem disease appears in patients receiving this drug.

Congenital complete heart block with maternal primary Sjögren's syndrome.

We have described a case of congenital complete heart block associated with maternal primary Sjögren's syndrome. This diagnosis should also be considered when evaluating mothers of children with congenital heart block, especially when no connective tissue disease is otherwise clinically apparent. The potential significance of antibodies to SSA in this association remains to be determined.