Polymyalgia rheumatica and giant cell arteritis. Avoiding management traps.

BACKGROUND: Polymyalgia rheumatica (PMR) needs to be considered in the patient over 55 years of age who presents with stiffness and pain. It appears to exist in a continuum with giant cell arteritis (GCA), and the differential diagnosis is large. It may affect one in 200 patients in this age group. Corticosteroid toxicity is a major problem, either because of inappropriate dosage or prolonged disease. OBJECTIVE: To provide an up to date understanding of the concepts of this group of disorders in order to allow rapid recognition, better management, and to minimise toxicity of the necessary treatment. The most important of these are the appropriate dose of corticosteroid and instituting preventive therapy for potential complications such as osteoporosis. DISCUSSION: As there is no specific test for PMR, the diagnosis is still made on clinical grounds from the presentation, symptoms and signs, and the presence of serological markers of inflammation. Because these are all nonspecific, alternative diagnoses must be actively excluded. Certain newer investigations, such as high resolution ultrasound of the temporal arteries may be very helpful in directing temporal artery (TA) biopsies. When the response to treatment does not follow the usual course (and this may be prolonged: 18 months to five years or more), then re-evaluation is imperative.

Retinal dystrophy in long chain 3-hydroxy-acyl-coA dehydrogenase deficiency.

BACKGROUND: Long chain 3-hydroxyacyl-CoA-dehydrogenase (LCHAD) is one of the enzymes involved in the breakdown of fatty acids. A deficiency of this enzyme is associated with life threatening episodes of hypoketotic hypoglycaemia during prolonged fasting. Neuropathy and retinopigmentary changes were mentioned in only a few cases. METHODS: The case histories of two girls, aged 8 and 15 years, with LCHAD deficiency are reported. RESULTS: Both children with LCHAD deficiency exhibited extensive macular pigmentary depositions and a 'salt and pepper' scattering of pigment in their retinas. The patients have decreasing visual acuity. CONCLUSION: The early recognition of LCHAD deficiency can increase the life expectancy in these patients through avoiding catabolism and through appropriate diets. Patients tend to be free of symptoms between attacks, however. Testing for the disorder, therefore, should be included in the diagnostic process for children with retinal dystrophy, in particular when other clinical symptoms are known to have occurred.

3-Hydroxydicarboxylic aciduria due to long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency associated with sudden neonatal death: protective effect of medium-chain triglyceride treatment.

Two siblings were found to be affected by long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency, one of which died suddenly and unexpectedly on the 3rd day of life suffering from extreme hypoketotic hypoglycaemia. The younger sibling started to have feeding problems, lowered consciousness, and liver dysfunction at the age of 5 months. Her urine contained large amounts of C6-C14 3-hydroxydicarboxylic acids and conjugated 3-hydroxyoctanoic acid, as verified by gas chromatography/mass spectrometry. Plasma long-chain acylcarnitine was increased. A clue to the diagnosis was given by the results of a phenylpropionic acid loading test. This revealed small, but significant amounts of conjugated 3-hydroxyphenylpropionic acid (phenylhydracrylic acid) in the patient's urine. Subsequently, the activity of long-chain 3-hydroxyacyl-CoA dehydrogenase was found to be deficient in cultured skin fibroblasts. Based on the findings obtained by a medium-chain triglyceride load, a diet enriched in this type of fat was prescribed. On this regimen the patient started to thrive, signs of cardiomyopathy disappeared, and her liver function normalized.

Synovial complications of spondylepiphyseal dysplasia of late onset.

We describe 2 patients with a late-onset type of spondylepiphyseal dysplasia who developed multiple synovial complications. The synovial manifestations in the first patient included recurrent episodes of acute arthritis due to calcium pyrophosphate dihydrate crystal deposition and, later, chronic synovitis with radiologically evident chondrocalcinosis. In the second patient, cholesterol crystals in synovial fluid, multiple osteochondromata, and a histologic appearance resembling pigmented villonodular synovitis on synovial biopsy were seen. Osteochondromata were identified in 4 other members of this patient's family. Synovial manifestations in the osteochondrodysplasias may be more common than previously recognized.

A double-blind crossover trial of diflunisal and naproxen in osteoarthritis.

Fifty patients with osteoarthritis were studied in a double-blind, crossover trial of diflunisal (1000 mg daily) and naproxen (750 mg daily). In the 45 patients who completed the study, no significant difference was noted between the drugs in most of the parameters studied, including evening pain intensity and effectiveness rating by patient and investigator. There was a trend towards greater patient preference for diflunisal, although this trend did not reach statistical significance. Naproxen produced significantly fewer side-effects, although side-effects with both drugs were mild.

Octanoic acidemia and octanoylcarnitine excretion with dicarboxylic aciduria due to defective oxidation of medium-chain fatty acids.

Five patients aged 7 to 21 months are described who developed attacks of coma after a short prodromal illness with diarrhea or vomiting or both. Four had concomitant hypoglycemia, and all had hypoketonemia, with excessive urinary excretion of medium-chain dicarboxylic acids, medium-chain (omega-1)-hydroxyacids, suberylglycine, hexanoylglycine, and octanoylcarnitine. All patients accumulated octanoic acid, decanoic acid, and cis-4-decenoic acid in plasma. Fibroblasts from three patients showed a decreased rate of octanoate oxidation (10%, 12%, and 29% of control values, respectively). These findings suggest a deficiency of medium-chain acyl-CoA dehydrogenase, most probably an autosomal recessive inherited metabolic disorder. Two of the patients died during an acute attack, and a third had severe neurologic sequelae; the two remaining patients recovered. Plasma free carnitine levels were low, but total carnitine was normal. The three surviving patients underwent a fasting test, which did not lead to hypoglycemia, although hypoketonemia, dicarboxylic aciduria, and excessive mobilization of fatty acids did occur. The surviving patients were maintained on frequent carbohydrate-enriched meals.

Salivary scanning in rheumatoid arthritis with sicca syndrome.

Forty-nine patients were studied prospectively by salivary scanning to assess the value of this investigation in possible Sjögren's syndrome (SS). Twenty-three had rheumatoid arthritis (RA) with sicca symptoms and a positive Schirmer's test. Fifteen had RA with no sicca symptoms and a negative Schirmer's test. Eleven had osteoarthrosis (OA) with no sicca symptoms and a negative Schirmer's test. Scanning differentiated only poorly between the three groups. We conclude that it has only limited application in the diagnosis of SS associated with RA.

Shoulder joint rupture and pseudothrombosis in rheumatoid arthritis.

A patient with rheumatoid arthritis developed sudden unilateral oedema of the right arm resembling vascular obstruction and was shown to have a ruptured shoulder joint.

Progressive infantile poliodystrophy (Alpers' disease) with a defect in citric acid cycle activity in liver and fibroblasts.

We present the case history of a boy, who died at the age of 3 1/2 years after a rapidly progressive neurologic disorder, characterized by psychomotor retardation, hypotonia, hemiparesis, seizures and myoclonic contractions. Histopathologic studies showed slight lipid storage in liver. Autopsy showed the characteristic features of progressive infantile poliodystrophy (Alpers' disease); ultrastructural examination showed an increased density of mitochondria in cerebral gray matter. Biochemical studies in leukocytes, cultured fibroblasts and liver indicated a deficiency in the citric acid cycle between succinate and fumarate; this deficiency was not present in muscle tissue. This study supports the view that progressive infantile poliodystrophy is associated with abnormalities in pyruvate metabolism and/or in cell mitochondria.