Radiologic case study. Multicentric reticulohistiocytosis.

MRH is somewhat similar to, and probably occasionally mistaken for, psoriatic arthritis, Reiter's syndrome, or less frequently, rheumatoid arthritis. However, several important features distinguish MRH from the other arthritides. Rheumatoid arthritis more commonly involves the metacarpophalangeal joints, while MRH ordinarily affects the distal interphalangeal and proximal interphalangeal joints. Furthermore, MRH rarely exhibits the degree of articular osteopenia that is the hallmark of rheumatoid disease. While psoriatic arthritis and Reiter's often affect the DIP joints, they rarely display the symmetry of MRH. In addition, MRH does not demonstrate the periosteal new bone formation that is seen in both psoriatic arthritis and Reiter's syndrome. Hence, the diagnosis of MRH may be made with reasonable confidence on the radiologic findings alone, even before the cutaneous nodules appear, which can then be biopsied to confirm the diagnosis.

Ceftriaxone therapy of chronic inflammatory arthritis. A double-blind placebo controlled trial.

To determine whether chronic inflammatory arthritis may respond to antibiotic therapy (implying a bacterial origin), we conducted a placebo-controlled, double-blind study. Sixty patients with inflammatory arthritis and antibody titers to Borrelia burgdorferi 1:64 or more were randomized to receive placebo (n = 20) or 2 g/d of ceftriaxone intravenously (n = 40) for 2 weeks. Two of 20 placebo- and 19 of 40 antibiotic-treated patients improved. At 1 month, the placebo-treated patients could elect to receive ceftriaxone. Altogether, 58 patients were treated with ceftriaxone and followed up for 13 to 24 months. Improvement was noted in 27 of the 58 antibiotic-treated patients. Patients with a wide diversity of inflammatory arthritis were studied. Response to ceftriaxone was seen in all groups, including 5 of 12 with rheumatoid arthritis, 5 of 8 with psoriatic arthritis, 3 of 5 with vasculitis, and 14 of 33 with less well-differentiated chronic inflammatory arthritis. In 16 of the 27 who responded to the antibiotic, the arthritis worsened 6 to 18 months after the initial response to ceftriaxone. Previous improvement of arthritis after oral antibiotic was a better predictor of response to ceftriaxone than either duration of disease or Lyme antibody titer. Side effects to ceftriaxone were frequent and included diarrhea (29/60) and acute allergic reactions (9/58). We conclude that some patients may have an occult bacterial infection underlying their chronic inflammatory arthritis, and may respond to antibiotic therapy. The response to ceftriaxone in patients with even weakly reactive Lyme titers encourages further prospective placebo-controlled studies of antibiotics in various subsets of chronic arthritis.

Apparent biliary pseudolithiasis during ceftriaxone therapy.

Biliary pseudolithiasis has been reported in patients who received ceftriaxone therapy. To examine this phenomenon further, serial gallbladder sonograms were evaluated in 44 adult patients who received intravenous ceftriaxone at 2 g or a placebo daily for 14 days in a double-blind controlled study. Ultrasound examinations of gallbladders were performed on days 1 and 14 of therapy and 2 weeks posttherapy if abnormalities were observed on day 14. Eight patients were unevaluable because of abnormal base-line gallbladder sonograms. Thirty-six patients (ceftriaxone, n = 28; placebo, n = 8) demonstrated normal baseline gallbladder sonograms and were evaluated for the development of change. A total of 6 of 28 (21.4%) ceftriaxone-treated patients and 1 of 8 (12.5%) patients who received the placebo demonstrated abnormal gallbladder sonograms on day 14 (P = 0.491). Four of the six ceftriaxone-treated patients demonstrating abnormal sonograms were clinically asymptomatic, while two patients reported vomiting. The abnormal sonograms of gallbladders of patients treated with ceftriaxone returned to normal between 9 and 26 days posttherapy. These data suggest an association between ceftriaxone treatment and the development of gallbladder abnormalities on ultrasound examination which resolve spontaneously on discontinuation of ceftriaxone therapy.

Clinical comparison of ibuprofen, fenoprofen calcium, naproxen and tolmetin sodium in rheumatoid arthritis.

After baseline aspirin therapy, 89 rheumatoid arthritis patients completed a double-blind, crossover trial comparing ibuprofen, fenoprofen, naproxen, and tolmetin. Initially, patients took the manufacturer's recommended starting dose; this could be increased by 50% within the first 2 weeks of therapy. Patients remained at the chosen dose for 4 weeks and then changed to the next drug. All 4 drugs were tolerated better than aspirin (p less than 0.001). There were no statistically significant differences among the 4 drugs for any efficacy measurements. However, patients' and physicians' rankings showed the same order of preferences: naproxen, ibuprofen, fenoprofen, tolmetin, and aspirin.

Cryoglobulinemia in a patient with Sjögren's syndrome, and factors of cryoprecipitation.

The IgGK cryoglobulin in a patient with Sjögren's syndrome showed deviations from normal IgG involvine its amino acid composition as well as its carbohydrate components. The heavy chains showed abnormal numbers of arginine, threonine, valine and isoleucine residues, and there was an impressive reduction of fucose and hexose components. The carbohydrate deficits appear to be the reason for the incomplete solubility of the isolated IgGK(Ru) at 37 degrees C. with completion at 52 degrees C.

Lymphocyte reactivity in rheumatoid arthritis. Mixed lymphocyte culture.

Lymphocyte function in rheumatoid arthritis has been assessed by the mixed lymphocyte culture assay. In contrast to previous studies, no difference was found between lymphocytes from healthy volunteers and patients with rheumatoid arthritis. An occasional patient's lymphocytes failed to respond on a given day, but were normal on restudy. All 44 arthritic patient's lymphocytes underwent blast transformation on stimulation with lymphocytes from unrelated donors. By reaction in mixed lymphocyte culture, lymphocytes from patients with rheumatoid arthritis appear to be normal and no different from normal cells studied simultaneously.

Antiovulatory activity of synthetic corticoids.

A single dose of triamcinolone acetonide had antiovulatory properties in 7 of 11 women when injected on day 1 or 2 of the menstrual cycle. Daily blood studies in three subjects revealed that the FSH and LH surges were absent, and there was no rise in plasma progesterone. Follicular function, as manifested by estrogen levels, was maintained.

PIP: 17 healthy women (22-40 years) with a history of regular menstrual cycles were studied to determine the effect of synthetic corticoids on ovulation. 16 patients had a single plasma progesterone of more than 2. 5 ng/ml during the luteal phase of their cycles. Group 1 (6 subjects) received 12.5 mg/day of triamcinolone diacetate (TD) im on Days 1 and 2 or 2 and 3 of the menstrual cycle. Group 2 (11 subjects) received 25 mg triamcinalone acetonide (TA) im on Day 1 or 2 of their cycle. Daily plasma follicle stimulating hormone (FSH) and luteinizing hormone (LH) d eterminations were made, as well as determinations of plasma cortisone, progesterone, and estrogen (E 1 and E 2) were obtained in 3 subjects in Group 2. FSH, LH, estrogens, and cortisol were determined by radioimmunoassay. 1 subject in Group 1 had an anovulatory progesterone level. However, menstrual irregularities were absent. 7 subjects in Group 2 had anovulatory plasma progesterone levels, 6 noting changes in their cycle. In the 3 TA subjects who were sampled daily, morning plasma cortisols rose above 12 mcg/dl by Day 11. The normal midcycle surges of LH and FSH and subsequent rise in progesterone were absent. The effect of TD on ovulation was insignificant. The effect of TA was significant (p=.0001). The data provide evidence of delayed but normal follicular function and impaired luteinization of the follicle. It is of interest to synthesize corticoid compounds to provide a new class of antiovulatory steroids without the concurrent effect of the glucorticoid component.