Double-balloon enteroscopy: Indications, approaches, diagnostic and therapeutic yield, and safety. Early experience at a single center. / Enteroscopia de doble balón: indicaciones, abordajes, eficacia diagnóstica y terapéutica y seguridad. Experiencia temprana de un solo centro.

INTRODUCTION AND AIMS: Double-balloon enteroscopy has been improving the visualization of the entire intestine for more than a decade. It is a complementary method in the study of intestinal diseases that enables biopsies to be taken and treatments to be administered. Our aim was to describe its main indications, insertion routes, diagnostic/therapeutic yield, and complications. MATERIALS AND METHODS: All patients referred to our unit with suspected small bowel pathology were included. The insertion route (oral/anal) was determined through diagnostic suspicion. The variables measured were: insertion route, small bowel examination extent, endoscopic diagnosis/treatment, biopsy/histopathology report, complications, and surgical findings. RESULTS: The study included 28 double-balloon enteroscopies performed on 23 patients, of which 10 were women and 13 were men (mean age of 52.95 years). The oral approach was the most widely used (n=21), the main indication was overt small bowel bleeding (n=16), and the general diagnostic yield was 65.21%. The therapeutic intervention rate was 39.1% and the procedure was effective in all the cases. The most widely used treatment was argon plasma therapy (n=7). The complication rate was 8.6%; one patient presented with low blood pressure due to active bleeding and another had deep mucosal laceration caused by the argon plasma. CONCLUSIONS: Double-balloon enteroscopy is a safe and efficacious method for the study and management of small bowel diseases, with an elevated diagnostic and therapeutic yield.

Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double-blind, placebo-controlled, prospective trial.

OBJECTIVE: Chlamydia trachomatis and Chlamydophila (Chlamydia) pneumoniae are known triggers of reactive arthritis (ReA) and exist in a persistent metabolically active infection state in the synovium, suggesting that they may be susceptible to antimicrobial agents. The goal of this study was to investigate whether a 6-month course of combination antibiotics is an effective treatment for patients with chronic Chlamydia-induced ReA. METHODS: This study was a 9-month, prospective, double-blind, triple-placebo trial assessing a 6-month course of combination antibiotics as a treatment for Chlamydia-induced ReA. Eligible patients had to be positive for C trachomatis or C pneumoniae by polymerase chain reaction (PCR). Groups received 1) doxycycline and rifampin plus placebo instead of azithromycin; 2) azithromycin and rifampin plus placebo instead of doxycycline; or 3) placebos instead of azithromycin, doxycycline, and rifampin. The primary end point was the number of patients who improved by 20% or more in at least 4 of 6 variables without worsening in any 1 variable in both combination antibiotic groups combined and in the placebo group at month 6 compared with baseline. RESULTS: The primary end point was achieved in 17 of 27 patients (63%) receiving combination antibiotics and in 3 of 15 patients (20%) receiving placebo. Secondary efficacy end points showed similar results. Six of 27 patients (22%) randomized to combination antibiotics believed that their disease went into complete remission during the trial, whereas no patient in the placebo arm achieved remission. Significantly more patients in the active treatment group became negative for C trachomatis or C pneumoniae by PCR at month 6. Adverse events were mild, with no significant differences between the groups. CONCLUSION: These data suggest that a 6-month course of combination antibiotics is an effective treatment for chronic Chlamydia-induced ReA.

Fibromyalgia syndrome in young children: onset at age 10 years and younger.

OBJECTIVE: To report our experience of fibromyalgia syndrome (FMS) in young children with onset at age 10 years and younger as compared to older children. METHODS: Clinical and laboratory data were reviewed in all patients that had been diagnosed with FMS between November 1994 and March 2003. Patients with onset above the of age 18 years, and patients with FMS and concomitant rheumatic diseases were excluded from this study. The study population included two groups: group "A", young children with onset at age 10 years and under and group "B", children with onset above 10 years old. A questionnaire was used at follow-up visits or by telephone interview to evaluate the outcome. RESULTS: There were 148 children with the diagnosis of FMS (based on ACR criteria), of these 46 children in group A and 102 children in group B. The mean age at onset and mean age at diagnosis were 7.5 years and 10 years in group A, and 13.2 years and 14.5 years in B, respectively. The mean interval between the age of onset and the age at diagnosis was 32 months in group A, and 18 months in group B (p= 0.007). There was a predominance of female gender and Caucasian ethnicity in both groups. Diffuse aching was reported in all patients in both groups. Stiffness, subjective joint swelling, abdominal pain and initial presentation on wheelchair were found more frequently in group A, compared with group B (p= 0.03, 0.001, 0.01, 0.03 respectively). The mean count of tender points at diagnosis was higher in group A, compared with group B (15.3 vs. 14.2, p = 0.004). The differences of other clinical features and laboratory tests in both groups were not statistically significant. Thirty-six patients in group A (78%) and 83 in group B (81%) were available for one or more follow-up visits and/or telephone interview. The mean follow-up period was 14 months in group A, and 19 months in group B (p value = 0.3). There was no difference in the type of treatment or outcome in both groups. CONCLUSION: FMS in young children of 10 years old and younger is frequently under-recognized. As compared with the older group, stiffness, subjective joint swelling, abdominal pain, initial presentation on wheelchair and a higher mean count of tender points at diagnosis were significantly more common in the younger age group. However, the type of medications used and outcome were similar in both groups. Prospective studies with large patient population are needed to clarify these findings.

Churg-Strauss syndrome associated with leukotriene receptor antagonists (LTRA).

Churg-Strauss syndrome (CSS) is a rare vasculitic disorder that generally occurs in patients with bronchial asthma. CSS is being increasingly recognized in asthmatic patients treated with leukotriene receptor antagonists. However, the nature of this relationship remains to be elucidated. The present report describes three asthmatic patients who developed clinical manifestations highly suggestive of CSS, although one patient lacked the presence of eosinophilia. The patient, however, exhibited biopsy-proven cutaneous necrotizing vasculitis, which improved after withdrawal of montelukast. The second patient presented with systemic constitutional signs including fever, malaise, arthralgias, clinical jaundice, peripheral blood eosinophilia, and biopsy-proven eosinophilic hepatitis. The third patient also had circulating eosinophilia, scleritis, and arthritis. All patients improved after discontinuation of the leukotriene receptor antagonist (montelukast).

Charcot-like arthropathy: A newly-recognized subset of psoriatic arthritis.

OBJECTIVE: The aim of the study is to describe a group of patients with a highly destructive and asymptomatic form of psoriatic arthritis, mimicking a Charcot-like joint disease. METHODS: We studied 180 patients with psoriatic arthritis and identified 4 patients with arthritis mutilans mimicking a Charcot-like joint disease. Clinical history, physical exam, and immunological testing were performed as well as X-ray of affected joints. Synovial membrane and sural nerve biopsies were performed and diagnosis of psoriasis was confirmed by skin biopsy. RESULTS: Four patients with psoriatic arthritis mutilans according to Moll and Wright classification criteria (1) and Charcot-like joint disease were identified and evaluated. There were 2 males and 2 females, all Caucasians. The mean age +/- SD was 57.8 +/- 14.2 years. Mean arthritis duration +/- SD was 6 +/- 4.6 years and mean cutaneous duration +/- SD was 13 +/- 10.4 years. All patients had polyarthritis and a sudden onset of bilateral, painless, and highly destructive arthropathy involving large, non-weight bearing (elbows) and weight bearing (knees), and also small joint of hands and feet. Synovial membrane biopsy showed findings similar to those found in Charcot joint disease, including ischemic neuropathy. CONCLUSION: A newly-recognized subset of patients with psoriatic arthritis and Charcot-like joint disease according to clinical, radiographic and histological features is described. The proposed neurovascular theory may explain the pathogenesis of this presentation.

The practice of rheumatology in Kenya: challenges and opportunities. ILAR visiting professorship program report.

International League of Associations for Rheumatology (ILAR) is committed to promoting the care of those with musculoskeletal diseases. To further this aim, ILAR sponsors visiting professorships to countries with minimal or underdeveloped rheumatology services to promote the awareness and improve skills in the management of musculoskeletal conditions. Professor Luis Espinoza was sponsored and visited Kenya in March 2005.

Renal involvement in juvenile rheumatoid arthritis: report of two cases.

Renal involvement is a rare occurrence in juvenile rheumatoid arthritis (JRA). We report on two JRA patients with kidney disease. The first was a 14-year-old African-American female with a 12-month history of polyarthritis. On presentation she was found to have an ESR of 127 mm/h and a positive ANA, rheumatoid factor (RF), perinuclear antineutrophil cytoplasmic antibodies (pANCA), haematuria, proteinuria with normal BUN and creatinine. Renal biopsy showed focal segmental glomerulosclerosis. Her renal function deteriorated to end-stage renal failure requiring dialysis within a few months, despite aggressive treatment with steorids and monthly i.v. pulses of cyclophosphamide. The second patient presented with a 6-week history of polyarthritis and intermittent fever, and had a salmon-coloured evanescent rash. On presentation his laboratory evaluation was significant for elevated ESR and negative ANA, RF and ANCA tests. Within 8 months the patient had developed a persistent microscopic haematuria. Renal biopsy showed mild mesangial glomerulonephritis. On low-dose methotrexate therapy his JRA went into remission and his renal function remained normal. The haematuria persisted for 1 year and then resolved spontaneously. This is the first time that focal segmental glomerulosclerosis and mesangial glomerulonephritis have been described in JRA. Although the association may be just coincidental, further studies are needed to define the role of JRA in these renal conditions. In patients with JRA, urinalysis and renal function should be routinely monitored.

Poststreptococcal reactive arthritis in adults: long-term follow-up.

BACKGROUND: Poststreptococcal reactive arthritis (PSReA) is a recognized inflammatory articular syndrome that follows group A streptococcal infection in persons not fulfilling the Jones criteria for the diagnosis of acute rheumatic fever. Characteristic features include nonmigratory arthritis, lack of response to aspirin or nonsteroidal anti-inflammatory agents, and the presence of extra-articular manifestations, including vasculitis and glomerulonephritis. Whether or not patients with PSReA develop carditis is a point of contention. METHODS: We analyzed the clinical features, laboratory findings, response to therapy, and outcome in patients diagnosed with PSReA between 1983 and 1998 and observed through April 2000. All patients were contacted, reexamined, and repeat antistreptolysin, rheumatoid factor, C3 and C4 complement components, and echocardiograms were performed. RESULTS: Seventeen patients (4 men and 13 women) were included. All were of low socioeconomic status. All patients had acute severe arthritis that began shortly after a sore throat episode. Extra-articular involvement including tenosynovitis, vasculitis, and glomerulonephritis was relatively common. More importantly, none exhibited clinical and/or echocardiographic evidence of cardiac involvement. Longterm antibiotic therapy was not given. CONCLUSION: Cardiac involvement did not occur in this group of patients with PSReA. Prolonged prophylactic antibiotic therapy may not be required for adult patients presenting with PSReA.

Laboratory testing in the evaluation and diagnosis of vasculitis.

A multitude of tests are available for the diagnosis and management of the vasculitides. Most of them are nonspecific but provide useful information that, when appropriately used in conjunction with the patient's history and physical examination can be of great assistance in arriving at a final diagnosis. In addition, information gathered may be of great help in monitoring disease activity and clinical response to therapy, in indicating the presence of specific organ system involvement, in monitoring toxicity of medication used, and in assessing prognosis. Serial measurements of acute phase reactants, complete blood cell count with differential, biochemistry profiles, urinalysis, and C3 and C4 levels should be obtained in all patients. Antineutrophil cytoplasmic antibodies (ANCA) determination provides valuable information and is highly specific for the diagnosis of small-vessel vasculitides, particularly Wegener's granulomatosis and microscopic polyangiitis. ANCA levels can be particularly useful to assess disease activity in these disorders. Hepatitis-B and, more importantly, hepatitis-C testing is extremely useful, particularly in the presence of liver involvement and associated risk factors. Angiographic studies may confirm the diagnosis, particularly if there is laboratory and clinical evidence of specific organ involvement. It should be noted, however, that angiography may be normal even when vasculitis is present, or the findings may be nonspecific. A definite diagnosis is provided by a tissue biopsy. This should be performed whenever there is access to clinically affected tissue.

Rheumatic manifestations of HIV-AIDS.

Infection by human immunodeficiency virus is characterized by a myriad of clinical manifestations affecting almost every organ system in the body. If untreated, it follows an inexorable course, leading to a profound state of immunosuppression and eventually death from opportunistic infection and/or development of lymphoproliferative malignancy and Kaposi's sarcoma. Rheumatic manifestations may develop at any time of the clinical spectrum, but usually are more often seen in late stages. A variety of disorders may be seen, particularly Reiter's syndrome and undifferentiated spondyloarthropathy. Most patients do well with conventional anti-inflammatory therapy, but some will require the use of immunosuppressive-cytotoxic therapy.