Imitating the Great Imitator The Intersection of Sarcoidosis and Hodgkin's Lymphoma A Report of Two Cases.

Sarcoidosis and Hodgkin's lymphoma represent two distinct diseases with different pathogenic mechanisms, therapeutic interventions, and prognoses. Nevertheless, both diseases can have overlapping presentations, thus blurring the line between successful identification and treatment. A propensity to develop one of these diseases following diagnosis of the other has long been appreciated. Here we review two cases of presumed sarcoidosis that were ultimately diagnosed as Hodgkin's lymphoma. Both patients initially presented with non-specific symptoms and underwent a thorough workup, including histological evaluation demonstrating non-caseating granulomas without evidence of malignancy. Both patients started sarcoid-directed therapies with relapse of symptoms. Repeat imaging and tissue biopsy eventually led to the diagnosis of stage IVB Hodgkin's lymphoma. After the initiation of Hodgkin's-directed therapies, both patients showed marked clinical responses, and entered complete remission.

Ultrasound and treatment algorithms of RA and JIA.

Musculoskeletal ultrasound has emerged as a key tool for the diagnosis, prognosis, and management of patients with RA (rheumatoid arthritis) and other rheumatic diseases. The most important sonographic findings in RA include erosions, effusions, synovitis, and tenosynovitis. Investigators have suggested various "optimal" numbers of joints to scan in RA to assess disease activity, gauge treatment response, provide prognostic information, and guide management decisions. The complexity of pediatric sonoanatomy has delayed its validation in juvenile idiopathic arthritis, yet ultrasound reliably measures the extent of synovitis/tenosynovitis and guides precise injections.

Saturnine gout, redux: a review.

Illicitly distilled beverages (colloquially referred to as moonshine) account for approximately one third of alcohol consumption worldwide. Moonshine is often produced in makeshift distilling units composed of old, repurposed parts, whose component elements can leach into the distillate. Consequently, the resultant beverages may inadvertently contain harmful toxins, one of which is the metal lead. One manifestation of chronic lead toxicity-from moonshine or other forms of chronic lead poisoning-is the rheumatologic entity known as saturnine gout. With the increasing prevalence of gout over the past few decades, physicians should be aware of the association of moonshine consumption or lead toxicity with gouty arthritis. In this article, we present an overview of saturnine gout, beginning with a discussion of lead poisoning in antiquity and tracing its path to modern times. The contribution of lead to human disease and the clinical features of saturnine gout are outlined. After describing the role of lead in renal insufficiency and purine metabolism, we conclude with a discussion of specific strategies to manage this clinically important form of secondary gout.

Behcet's Syndrome.

Behcet's syndrome (BS) is a vasculitis, seen more commonly around the Mediterranean and the Far East, and manifests with oral and genital ulcerations, skin lesions, uveitis, and vascular, central nervous system and gastrointestinal involvement. Its natural history of getting less severe over time, more severe disease in males and lack of specific diagnostic testing separates it from other commonly seen conditions in rheumatology. Most of the serious manifestations respond well to immunosuppression, and these are the mainstays of treatment for BS. BS is more prevalent in regions along the Silk Road, from the Mediterranean to the Far East. The genetic risk factor most strongly associated with BS is the human leukocyte antigen (HLA)-B51 allele. While genetic factors seem to play a role in the development of certain features of BS, there is general consensus that as yet unidentified environmental stimuli are necessary for initiation of disease. Proposed exogenous triggers include both bacterial and viral infections, which may then lead to dysregulation of the immune system, ultimately leading to the phenotypic expression of disease. The clinical manifestations of BS are protean in nature. While most patients develop mucocutaneous and genital ulcers along with eye disease, other patients may also present with arthritis, frank vasculitis, thrombophlebitis and CNS disease. Interestingly, the manifestations of this illness vary considerably based on gender and ethnicity. As the phenotypic expression among patients with BS is quite heterogeneous, pharmacological therapy is variable and dependent upon the severity of the disease as well as organ involvement. Treatment for BS overlaps considerably with therapies for other autoimmune diseases, including systemic lupus erythematosus, rheumatoid arthritis and the vasculitides. Pharmacological agents utilized for treatment of BS include corticosteroids, colchicine, azathioprine, and tumour necrosis factor (TNF).α inhibitors, among others. In this article, we review the salient clinical studies for each drug class along with important side effects as well as drug toxicity monitoring. Management of the patient with BS is complex and oftentimes requires a multidisciplinary approach. We discuss strategies to assess and stratify patients based on clinical manifestations and disease severity. A summary of drug toxicities as they relate to the aforementioned pharmacological agents, as well as guidelines regarding vaccinations in this patient population, are offered. Finally, we conclude with treatment strategies for the common manifestations of BS along with a discussion of the management of thrombotic disease in these patients.