Lactococcus garvieae Endocarditis on a Prosthetic Biological Aortic Valve.

Lactococcus garvieae (LG) endocarditis is a rare disease in humans. There are only about 16 reported cases in the world. We report a 76-year-old male patient with LG endocarditis. In depth interview with the patient revealed that 2 weeks prior to admission, he had eaten sushi containing raw fish. Unlike many of the other infections reported, which were on a native mitral valve, our patient's vegetation was on a prosthetic aortic valve.

Pleural effusion associated with rheumatoid arthritis: what cell predominance to anticipate?

Pleural involvement is the most frequent manifestation of rheumatoid arthritis (RA) in the chest. We report here two patients who presented with large exudative pleural effusions and subsequently developed sero-positive RA. In both cases, the differential cell count of the pleural effusion suggested empyema. A literature review identified that RA-associated pleural effusion afflicts more men than women and 95% of the patients have high titers of rheumatoid factor (RF). In 46% of cases, RA-associated pleural effusion is diagnosed in close temporal relationship with the diagnosis of RA. The effusion is an exudate and is characterized by low pH and glucose level, and high lactic dehydrogenase (LDH) and cell count. At diagnosis there is a tendency for predominant neutrophils to occur consistent with an empyema and 7-11 days later, the cells in the pleural effusion are replaced by lymphocytes. Pleural effusion with predominant eosinophilia is rare. RA patients with acidic effusion and low glucose content with neutrophils predominance should be treated with thoracic drainage and antibiotics until an infection is ruled out. The histo-pathologic findings in pleural fluid of tadpole cells and multinucleated giant cells and the replacement of the mesothelial cells on the parietal pleural surface with a palisade of macrophage derived cells are described as pathogonomic for RA. Treatment with systemic steroids and intra-pleural steroids are effective in most cases.

Can the routine use of fluoroquinolones for community-acquired pneumonia delay the diagnosis of tuberculosis? A salutary case of diagnostic delay in a pilgrim returning from Mecca.

Guidelines advocate using fluoroquinolones as first-line treatment for community-acquired pneumonia (CAP). However, the use of fluoroquinolones in patients with undiagnosed tuberculosis may cause a delay in the diagnosis of tuberculosis and may also promote the development of resistance to these drugs if used as monotherapy in undiagnosed tuberculosis. We illustrate the former with the following case report of a patient who developed tuberculosis after a pilgrimage to Mecca.

Balneotherapy at the Dead Sea area for patients with psoriatic arthritis and concomitant fibromyalgia.

BACKGROUND: Balneotherapy has been successfully used to treat various rheumatic diseases, but has only recently been evaluated for the treatment of fibromyalgia. Since no effective treatment exists for this common rheumatic disease, complementary methods of treatment have been attempted. OBJECTIVES: To assess the effectiveness of balneotherapy at the Dead Sea area in the treatment of patients suffering from both fibromyalgia and psoriatic arthritis. METHODS: Twenty-eight patients with psoriatic arthritis and fibromyalgia were treated with various modalities of balneotherapy at the Dead Sea area. Clinical indices assessed were duration of morning stiffness, number of active joints, a point count of 18 fibrositic tender points, and determination of the threshold of tenderness in nine fibrositic and in four control points using a dolorimeter. RESULTS: The number of active joints was reduced from 18.4 +/- 10.9 to 9 +/- 8.2 (P < 0.001). The number of tender points was reduced from 12.6 +/- 2 to 7.1 +/- 5 in men (P < 0.003) and from 13.1 +/- 2 to 7.5 +/- 3.7 in women (P < 0.001). A significant improvement was found in dolorimetric threshold readings after the treatment period in women (P < 0.001). No correlation was observed between the reduction in the number of active joints and the reduction in the number of tender points in the same patients (r = 0.2). CONCLUSIONS: Balneotherapy at the Dead Sea area appears to produce a statistically significant substantial improvement in the number of active joints and tender points in both male and female patients with fibromyalgia and psoriatic arthritis. Further research is needed to elucidate the distinction between the benefits of staying at the Dead Sea area without balneotherapy and the effects of balneotherapy in the study population.

Balneotherapy for fibromyalgia at the Dead Sea.

The aim of this study was to evaluate the effectiveness of balneotherapy on patients with fibromyalgia (FM) at the Dead Sea. Forty-eight patients with FM were randomly assigned to a treatment group receiving sulfur baths and a control group. All participants stayed for 10 days at a Dead Sea spa. Physical functioning, FM-related symptoms, and tenderness measurements (point count and dolorimetry) were assessed at four time points: prior to arrival at the Dead Sea, after 10 days of treatment, and 1 and 3 months after leaving the spa. Physical functioning and tenderness moderately improved in both groups. With the exception of tenderness threshold, the improvement was especially notable in the treatment group and it persisted even after 3 months. Relief in the severity of FM-related symptoms (pain, fatigue, stiffness, and anxiety) and reduced frequency of symptoms (headache, sleep problems, and subjective joint swelling) were reported in both groups but lasted longer in the treatment group. In conclusion, treatment of FM at the Dead Sea is effective and safe and may become an additional therapeutic modality in FM. Future studies should address the outcome and possible mechanisms of this treatment in FM patients.

The effect of balneotherapy at the Dead Sea on the quality of life of patients with fibromyalgia syndrome.

Fibromyalgia (FS) is an idiopathic chronic pain syndrome defined by widespread non-articular musculoskeletal pain and generalised tender points. As there is no effective treatment, patients with this condition have impaired quality of life (QoL). The aim of this study was to assess the possible effect of balneotherapy at the Dead Sea area on the QoL of patients with FS. Forty-eight subjects participated in the study; half of them received balneotherapy, and half did not. Their QoL (using SF-36), psychological well-being and FS-related symptoms were assessed prior to arrival at the spa hotel in the Dead Sea area, at the end of the 10-day stay, and 1 and 3 months later. A significant improvement was reported on most subscales of the SF-36 and on most symptoms. The improvement in physical aspects of QoL lasted usually 3 months, but on psychological measures the improvement was shorter. Subjects in the balneotherapy group reported higher and longer-lasting improvement than subjects in the control group. In conclusion, staying at the Dead Sea spa, in addition to balneotherapy, can transiently improve the QoL of patients with FS. Other studies with longer follow-up are needed to support our findings.

Kingella endocarditis and meningitis in a patient with SLE and associated antiphospholipid syndrome.

We describe a patient with SLE and antiphospholipid syndrome who presented with severe headache and fever. Lumbar puncture analyses indicated meningitis. Kingella kingae was isolated from her blood cultures. A large mobile vegetation was seen on her mitral valve. The association between SLE, Libman-Sacks endocarditis and bacterial endocarditis is discussed.

Influenza virus vaccination of patients with systemic lupus erythematosus: effects on disease activity.

OBJECTIVE: To determine whether vaccination of patients with systemic lupus erythematosus (SLE) with influenza virus vaccine is associated with exacerbation of SLE. METHODS: The study population comprised 24 patients with SLE who received influenza vaccine (cases group) and 24 other SLE patients who did not receive the vaccine (controls group). The primary outcome measure was the SLE Disease Activity Index (SLEDAI) scores 6 weeks and 12 weeks after vaccination. Secondary outcome measures included: number of SLE flares, defined as any increase in the SLEDAI > or = 3 points, and activity of renal disease. Repeated measurements MANOVA was used to compare the SLEDAI scores of the cases and controls. RESULTS: All patients were women. The mean age at enrollment into the study was 46.1 and 40.6 years for the cases and controls, respectively. The mean disease duration was 9.1 for the cases and 9.3 years for the controls. SLEDAI scores for the cases and controls were 6.6 and 8.9 at vaccination, 4.9 and 6.8 at Week 6, and 5.1 and 6.7 at Week 12, respectively. The SLEDAI scores of the cases and controls at the 3 different assessments were not statistically different (p = 0.28). However, within each group the decrease in the SLEDAI over time was statistically significant (p = 0.02). Three and 6 flares were observed in the cases and controls, respectively, (p = 0.27) during the 12 weeks of followup. Improvement in the renal disease was observed in the cases and controls. CONCLUSION: Influenza virus vaccine is safe for patients with SLE. Patients with SLE should be encouraged to receive the vaccine according to the recommendation given by the Immunization Practices Advisory Committee.

The role of spa therapy in various rheumatic diseases.

Spa therapy seems to have a role in the treatment of a broad range of joint diseases. It cannot substitute for conventional therapy but can complement it. The improvement reported in some of the studies is of short duration, lasting for months. It should be considered for patients suffering from various types of inflammatory arthritides or noninflammatory arthritides who are symptomatic, despite accepted medical therapy and conservative physiotherapy, if they can afford the expense. The patients should be told that the effectiveness and success of this therapy cannot be predicted in advance. Because we have no way to date, of curing most rheumatic diseases, clinical trials of alternative therapeutic methods are justified. These methods may alleviate patient suffering and are almost totally devoid of serious adverse effects. No studies have been reported that evaluate their cost-effectiveness.

Balneotherapy at the Dead Sea area for knee osteoarthritis.

BACKGROUND: Balneotherapy at the Dead Sea area has been applied in various inflammatory rheumatic diseases such as rheumatoid arthritis and psoriatic arthritis. The efficacy of balneotherapy at the Dead Sea area for the treatment of degenerative rheumatic diseases has not yet been formally evaluated. OBJECTIVE: To evaluate the efficacy of balneotherapy at the Dead Sea area in patients suffering from osteoarthritis of the knees. METHODS: Forty patients were randomly allocated into four groups of 10 patients. Group I was treated by bathing in a sulphur pool, group 2 by bathing in the Dead Sea, group 3 by a combination of sulphur pool and bathing in the Dead Sea, and group 4 served as the control group receiving no balneotherapy. The duration of balneotherapy was 2 weeks. RESULTS: Significant improvement as measured by the Lequesne index of severity of osteoarthritis was observed in all three treatment groups, but not in the control group. This improvement lasted up to 3 months of follow-up in patients in all three treatment groups. CONCLUSION: Balneotherapy at the Dead Sea area has a beneficial effect on patients with osteoarthritis of the knees, an effect that lastas at least 3 months.

Clinical and radiographic outcomes of rheumatoid arthritis patients not treated with disease-modifying drugs.

OBJECTIVE: To compare the radiographic and clinical features of rheumatoid arthritis (RA) patients who were not given disease-modifying antirheumatic drugs (DMARDs) with those of RA patients who were followed up and treated with DMARDs at a rheumatology clinic. METHODS: The population of this case-control study includes a series of RA patients who immigrated to Israel from the previous Union of Soviet Socialist Republics and who were treated only with nonsteroidal antiinflammatory drugs. Control patients who were followed up and treated with DMARDs at our rheumatology clinic were matched by sex, disease duration, number of actively inflamed joints, and the presence of serum rheumatoid factor. The outcome measures were the number of deformed and radiographically damaged joints. Radiographic damage was evaluated by the methods of Steinbrocker and Sharp. RESULTS: The study population consisted of 22 RA patients (15 women, 7 men) who were not treated with DMARDs and 22 patients (15 women, 7 men) who were treated with DMARDs. The mean disease duration was 16.2 years for the study patients and 14.3 years for the controls. Compared with the matched controls, RA patients who were not treated with DMARDs were found to have a significantly higher mean number of deformed joints (13.8 versus 7.2), a higher mean number of damaged joints (24.4 versus 15.5), and a higher overall damage score by the Sharp criteria (146.1 versus 65.7). CONCLUSION: RA patients who were not given DMARDs had a 1.57-fold increased number of radiographically damaged joints and a 2.22-fold increased overall Sharp damage score compared with patients who were treated with second-line agents.

[Chronic tophaceous gout].

A 51-year-old immigrant from the Caucasus had had chronic tophaceous gout for over 20 years, but had never been treated with anti-hyperuricemic drugs. He had developed large, multiple tophi in many locations, including both ankles and feet. The enormous size and unique location of the tophi caused considerable pain, and difficulty in standing and on walking. Since surgical removal of the tophi was refused by the patient, a course of allopurinol, 300 mg/day, was begun.

Balneotherapy in autoimmune disease.

The mechanisms of action of balneotherapy in the treatment of autoimmune disease are not sufficiently clear. Although this therapy does not replace but rather complements conventional drug therapy, it is certainly beneficial in suitable cases. Additional controlled studies are needed to delineate the mechanisms of actions and the effectiveness of balneotherapy in autoimmune disease.

Superior sagittal sinus thrombosis in a patient with systemic lupus erythematosus.

Cerebral venous thrombosis is a rare cause of focal neurological damage in patients with SLE. We describe a patient with SLE who presented with a focal neurological deficit and subsequently developed increased intracranial pressure. A superior sagittal sinus thrombosis was diagnosed by MRI. The association between SLE and superior sagittal sinus thrombosis is discussed. Early diagnosis is essential because treatment leads to a positive clinical outcome.

No correlation between prolactin levels and clinical activity in patients with systemic lupus erythematosus.

OBJECTIVE: To assess the frequency of hyperprolactinemia and its possible clinical significance in patients with systemic lupus erythematosus (SLE). METHODS: Concentrations of prolactin (PRL) were determined in 63 consecutive patients with SLE by an immunoradiometric assay. Antinuclear antibodies, anti-DNA, ribonucleoprotein, Sm, Ro, La, and anticardiolipin antibodies were determined by standard techniques. PRL concentrations were correlated with SLE clinical and serological activity. RESULTS: Elevated serum concentration of PRL (> 20 ng/ml) were found in 10 of 63 (15.9%) patients [21 to 57 ng/ml, mean (SD) 35.6 (13.4)]. No direct correlation between PRL levels and clinical disease activity of SLE was found (Pearson correlation r = -0.186, NS). In addition, hyperprolactinemia was not associated with serological activity. CONCLUSION: Mild hyperprolactinemia is present in a subset of patients with SLE but its clinical significance is still uncertain.

Teaching computer-based spelling to individuals with developmental and hearing disabilities: transfer of stimulus control to writing tasks.

Computer-based instruction may yield widely useful handwritten spelling. Illustrative cases involved individuals with mental retardation and hearing impairments. The participant in Study 1 matched computer pictures and printed words to one another but did not spell the words to pictures. Spelling was then taught using a computerized procedure. In general, increases in the accuracy of computer spelling were accompanied by improvements in written spelling to pictures. Study 2 extended these results with a 2nd participant. After initial training, spelling improved in the context of a retrieval task in which the participant (a) wrote a list of the names of objects displayed on a table, (b) selected the objects from a shelf, and (c) returned the objects to the table. Nearly perfect accuracy scores declined on some retrieval trials conducted without a list, suggesting that the list may have served a mediating function during retrieval. Transfer of stimulus control of computer-based teaching to the retrieval task may have been attributable to the existence of stimulus classes involving pictures, objects, and printed words.