A study on parasites in Mexican rheumatic disease patients.

Blastocystis hominis is a common human parasite with infection rates up to 50% in developing countries, and giardiasis is the commonest intestinal one in Mexico. No doubt, various parasites as Giardia lamblia and Entamoeba histolytica can cause rheumatic diseases. This study coproparasitoscopic analysis evaluated the cysts by B. hominis, G. lamblia, E. hartmani, E. coli and E. histolytica in Mexican rheumatic disease patients. Also, ELISA was used to detect E. histolytica, Ascaris lumbricoides, Toxocara canis, and Trichinella spiralis in Mexican patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Thirty-six patients (24 with AS and 12 with RA) and 77 healthy control individuals were enrolled in this study. The frequencies of protozoan cysts were comparable in rheumatic disease patients (AS and RA) and healthy control donors (33 and 25 vs. 26%, respectively; p > 0.05). The frequency of antibodies to T. canis was significantly higher in AS patients than in healthy control donors (16 vs. 2.6%, respectively; p = 0.027), whereas no differences were observed for the prevalence of antibodies for the other parasites (E. histolytica, A. lumbricoides and T. spiralis) (p > 0.05). This information indicates the need to intensify educational efforts for the prevention of parasite infections associated with AS disease that cannot be controlled only by drugs.

Disease activity, damage and survival in Mexican patients with acute severe systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a clinical syndrome of varying severity. Although the survival and prognosis of SLE have steadily improved, there is a group of patients who present an acute fatal outcome despite aggressive therapy. We designed this study to evaluate the factors associated with mortality in patients with acute severe SLE. During 2004-06, 41 Mexican SLE patients that could not be managed in the out-patient clinic and with acute severe major organ system involvement [nephritis, severe thrombocytopenia (platelet count below 20 000 per microL) acute neuropsychiatric pulmonary, gastrointestinal or cardiac disease and generalized vasculitis] were studied. During the first admission, disease activity (SLE Disease Activity Index (SLEDAI), SLE Activity Measured), damage [SLE International Collaborating Clinics (SLICC)], and therapy were assessed. Survival using Kaplan-Meier curves, odd ratios with 95% confidence interval and logistic regression analysis were used to determine risk factors for mortality. Ninety percent were female with a mean age of 29 +/- 19 years and mean disease duration of 21 +/- 9 months. The principal causes of first admission were renal (27%), SNC (22%) and cardiopulmonary (15%). After a mean follow-up of 9.7 +/- 6 months, 16 (39%) patients died. Deceased patients had significantly higher SLEDAI (P = 0.004), and SLICC (P = 0.03) scores. The manifestations associated with mortality were renal disease activity (odds ratio, OR 4.6, confidence interval, CI 95% 1.0-20.6), infections (OR 3.2 CI 95% 2.0-5.3) and thrombocytopenia (OR 4.0, CI 95% 1.0-15.9). The survival at 9.7 months was 72, 62 and 50% in patients with an SLEDAI score of 3-10, 11-20 and > or =21, respectively. The SLEDAI score, the presence of damage and infection were associated with death in patients with acute severe SLE.

Maternal age and family history are risk factors for ankylosing spondylitis.

OBJECTIVE: To investigate prevalence and gender distribution in parents of children with ankylosing spondylitis (AS). METHODS: Family history of AS (parents, uncles, and aunts), maternal age at delivery, and consecutive pregnancy number were assessed in the relatives of 40 Mexican Mestizo patients with definite AS (New York Criteria). RESULTS: We evaluated the family history of AS in 34 families of 40 AS patients; 12 with none, 4 with a paternal history (4 healthy fathers with a brother with AS) (odds ratio, OR, 1.37, p = 0.75), 15 with a maternal history of AS, (15 healthy mothers with a brother with AS) (OR 1.4, p = 0.55), and 3 with both lines (OR 0.84, p = 0.92). In these families AS was more frequent in males (29%) than in females (10%), OR 3.40 (95% confidence interval, CI: 1.43-8.29, p = 0.003). Juvenile onset was more common in the offspring of mothers with family history (72%) (OR 13.0, 95% CI: 1.68-147.48, p = 0.009). The number of first-born children with AS (18%) was similar to the later-born children (23%) (OR 1.37, 95% CI: 0.38-5.31, p = 0.78). The frequency of AS increased when the maternal age at delivery was < or = 30 years (OR 0.20, 95% CI: 0.04-0.75, p = 0.01). CONCLUSION: In Mexican Mestizo patients, there is no correlation between the risk for AS and the gender of the affected parent. However we found an association between juvenile onset and maternal family history with an increased incidence in patients with younger mothers.

Infections in outpatients with systemic lupus erythematosus: a prospective study.

The objective of this study was to assess the incidence and risk factors of infections in 200 SLE outpatients. All outpatients with active or inactive SLE without infections in the previous month were included. They were assessed every 3 months. Major infections were those requiring hospitalization and parental antibiotic therapy; minor infections required oral or topical therapy. Sociodemographic, disease activity using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), therapy and laboratory variables were evaluated. After a follow-up of 22+/-7 months, 65 (32%) patients had infections; 35% of those were major. The most common sites for infection were urinary (26%), skin (23%), systemic (12%), and vaginal (9%). At infection onset, 50 of 65 patients (77%) had disease activity, with a mean SLEDAI score of 6.1. The variables significantly associated with infection in the univariate analyses were the presence of disease activity, SLEDAI score, renal activity, prednisone dose, and IV cyclophosphamide. The only variable associated with infection in the multivariate analyses was a SLEDAI score of 4 or higher. Most infections in SLE outpatients were single, minor, non-life threatening, and associated with disease activity independently of sociodemographic and therapeutic factors.

Two-dimensional echo Doppler findings in juvenile and adult onset ankylosing spondylitis with long-term disease.

The authors' objective was to determine by 2-dimensional echo Doppler (2DECHO) the cardiac abnormalities in juvenile onset ankylosing spondylitis (JOAS) and adult onset ankylosing spondylitis (AOAS) in male patients with long-term disease. Twenty patients with JOAS, 31 with AOAS, and 20 healthy controls of the same age and gender without cardiopulmonary symptoms were studied. Using 2DECHO, the heart dimensions were determined according to American Society of Echocardiography guidelines. The left ventricle ejection fraction (LVEF) was calculated by Teichholz's formula. Cardiomyopathy was established when 2DECHO had diminished LVEF. Statistics used were the Student t and Fisher test, chi2, and ANOVA. Ninety percent of JOAS and 51% of AOAS patients were B27+ (p=0.005). The disease duration was 19.3 +/- 8.8 years in JOAS and 14.8 +/- 12.8 years in AOAS (p=NS). Age at the time of the study was 30.7 +/- 9.9 years in JOAS vs 40.3 +/- 12.7 in AOAS (p=0.003), and vs 40.2 +/- 17 years in controls (p=NS). There was a higher frequency of cardiomyopathy in AOAS (32.2%) than in JOAS (25%) and the controls (0%) (p=0.01). Patients with JOAS had a higher mitral valve gradient (25%) than AOAS patients (19%, p=NS) and controls (0%, p=0.04). Abnormal aortic ring reflectance was shown in 19% of AOAS vs 0% abnormalities in JOAS and controls (p=0.01). The aortic root diameter was increased in 58% of AOAS, 30% of JOAS, and 0% of controls (p=0.001). The frequency of 2DECHO abnormalities was increased in cardiopulmonary asymptomatic spondylitis patients. Despite the high frequency of B27+, JOAS had a lower frequency of aortic abnormalities than AOAS. Mitral valve gradient was found in JOAS and in AOAS that could contribute to a decreased ejection fraction and to left ventricular dysfunction.

Tamale foot: deposit of acid mucopolysaccharides in the synovial sheaths of extensor tendons of the foot, resembling tendinitis, in a patient with juvenile ankylosing spondylitis.

We describe a clinical case of juvenile ankylosing spondylitis (AS) that developed "pseudo-chronic tendinitis" of the foot. A 20-year-old male patient had HLA-B27 positive juvenile AS since he was 13 years old. At the age of 19 he presented chronic pain in the dorsum of the left foot. Examination disclosed an increased volume of the tarsal dorsum, with rubbery consistency, with no evidence of venous or lymphatic insufficiency, godette, or inflammation in laboratory tests, giving the foot the appearance of a tamale. Synovectomy of the foot extensor tendon sheath was followed by relief of pain and swelling. Histopathological study showed a deposit of acid mucopolysaccharides (MPS) with no inflammatory cell infiltrate. Tamale foot in juvenile AS may develop as a consequence of acid MPS deposit with no evidence of synovial inflammation. The good response to synovectomy suggests this is the preferred treatment for tamale foot.

Measurement of damage in 210 Mexican patients with systemic lupus erythematosus: relationship with disease duration.

The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index is a validated instrument specifically designed to ascertain damage in SLE; this instrument has been applied mainly to Caucasians and African-American SLE patients. The objective of this study was to assess damage using the SLICC/ACR Damage Index in Mexican SLE patients. The SLICC/ACR Damage Index was applied to 210 consecutive SLE patients with disease of variable duration. The SLICC/ACR Damage Index was assessed by review of hospital clinical records, interview and physical examination. One hundred and seventeen (55.5%) patients had some damage. The proportion of patients with damage increased significantly with disease duration (33% at 1-60 months, 66% at 61-120 months and 70% at > or = 121 months, P < 0.001). The main organ systems involved were musculoskeletal (osteonecrosis), neuropsychiatric (neuropathy, seizures), gonadal (amenorrhea prior to age 40 years), ocular (cataracts), renal (glomerular filtration < 50%) and peripheral vascular (permanent damage by venous thrombosis). Damage was frequent, increased over time, particularly for ocular, renal, musculoskeletal and gonadal. Patients who experienced damage were older, had a longer disease duration, a greater number of ACR criteria at diagnosis, and were more likely to have renal involvement and antibodies to dsDNA. The damage occurred in many different domains and started to develop early after disease onset. Mexican patients had more peripheral vascular and gonadal involvement compared with published data from non-Hispanic SLE populations.

Epidermal growth factor and gastrin in scleroderma/CREST syndrome

Background. The objective of this study was to determine levels of epidermal growth factor (EGF) and gastrin (GA) in saliva, serum, and urine in scleroderma (Scl) and CREST syndrome. Methods. EGF and GA levels were mesured by radioimmunoassay in saliva, serum and urine in 10 patients (51 years, median; range, 35-66 years); 9 females and 1 male with Scl, 3 females with CREST syndrome, and 18 age-and sex-matched controls, 17 females and 1 male free of any systemic inflammatory disease. Results. In serum, the EGF was lower in Scl/CREST than controls (p=0.02), while GA serum concentrations were higher in Scl/CREST (p=0.02). In urine, EGF in Scl/CREST was slightly lower than controls (p=NS) and GA concentrations were higher than controls (p=0.03). In saliva, the EGF levels in Scl/CREST were also slightly lower than controls (p=NS), while GA concentrations in both Scl/CREST and controls were not different (p=NS). Conclusions. Low concentrations of EGF in serum probably play a role in the pathogenesis of Scl/CREST. GA concentration can be increased as a consequence of the low levels of EGF because of the structural homology of this peptide with urogastrone, a GA inhibitor factor

Rhabdomyolysis in patients with acute lymphoblastic leukemia

The objective of this paper is to report 5 cases of rhabdomyolysis (RML) in patients with acute leukemia (AL). This occurred consecutively after the administration of chemotherapy, during the ensuing period of myelosuppression. Thirty-six patients with AL received, in a three-month period, 51 cycles of combined chemotherapy which included, in all of them, cytosine arabinoside (ARA-C); among them, along with myelosuppression, five experienced fever, infectious complications, gastrointestinal tract symptoms and severe myalgias. Serum creatine kinase (CK), liver function tests and a light microscopy muscle biopsy were performed on all of them. Ten - 17 days after receiving chemotherapy, five patients (4 males and 1 female) with acute lymphoblastic leukemia developed incapacitating myalgias in neck, thighs and arms. CK and/or alanine aminotransferase and spartate aminotransferase were increased 5-24 times above the normal range in four of these patients, and the muscle byopsy showed focal RML in all five. Myalgias were self-limited and lasted 4-10 days. In addition to the chemotherapy, other factors known to be capable of producing RML, such as sepsis, other medications, and dehydration were found. In conclusion, myalgias were due to focal RML produced probably by a combination of factor, particularly the chemotherapy along with dehydration due to gastrointestinal complications, infection, and the use of diverse antibioticas. The endemic nature of the finding in such a short period of time is outstanding

Disfunción ovárica en esclerosis sistémica progresiva/CREST / Ovarian disfunction in progressive systemic sclerosis/CREST

Objetivo. Estudiar la función ovárica en esclerosis sistémica progresiva (ESP)/CREST. Metodología. Se estudiaron 13 mujeres con ESP/CREST y 18 controles sanas, subdivididas en menstruantes y menopáusicas y analizadas desde los puntos de vista reumatológico, endocrinológico y ginecológico. Resultados. La ESP inició a edad más temprana que el CREST (p=0.02). Ocho enfermas menstruantes (Grupo 1) tuvieron opsomenorrea y amenorrea y 2 infertilidad. En las pacientes ESP/CREST menopáusicas (Grupo 2), 3 tuvieron menopausia temprana. En el Grupo 1, la hormona folículo estimulante (HFE) y la prolactina (PRL) en suero resultaron elevadas (p=NS) y el estradiol (E2) sérico disminuido en la fase preovulatoria respecto de las controles (p<0.05). En el Grupo 2 la HFE y la luteinizante estuvieron elevadas en suero (p<0.04 y p<0.03, respectivamente) y el E2 fue bajo (p=NS) respecto de las controles. El Grupo 1 tuvo inmunoglobulinas séricas (p=0.0001 y 0.004) y velocidad de sedimentación globular (VSG, p=0.016) mayores que las controles. En el grupo de ESP/CREST hubo correlación entre E2 e IgA (p<0.001) y los niveles de PRL e IgM (p<0.001), que fueron diferentes a los de las controles. Conclusión. En pacientes con ESP/CREST existe disfunción ovárica, con problable participación de E2 y PRL como intermediarias de la inflamación y/o de la respuesta inmunológica

Storage histiocytes and hemophagocytosis: a common finding in the bone marrow of patients with active systemic lupus erythematosus

We report the frequency of the finding of storage and hemophagocytic histiocytes in the bone marrow of patients with systemic lupus erythematosus with one or more hemocytopenias. The study was performed on bone marrows of ten patients with systemic lupus erythematosus during an episode of hemocytopenia. Four patients were not receiving any treatment and six had been takin oral prednisone (3.5 ñ 1.5 mg/day) for the previous 6 months. Hemocytopenia found were lymphocytopenia in five, thrombocytopenia in three, and neutropenia and anemia in two each. The bone marrow had variable cell content; megakaryocytes, the myeloid:erythroid ratio, as well as lymphocyte, plasma cell, and reticular cell contents were usually increased. Seven bone marrow samples showed storage distiocytes (sea-blue histiocytes and other histiocytes that contained unidentified intracytoplasmic material). These same samples revealed histiocytes phagocytosing erythoblasts, erythrocytes, polymorphonuclear neutrophils, lymphocytes in all seven patients was related to a decrease in serum complement and with lupus disease activity as mesured with the SLEDAI index (X ñ SD = 2.1 ñ 1.5). The SLEDAI score of the remaining three patients, who had no histiocytes in their bone marrow, was 0, 0, and 1, respectively. the present study reveals that the bone marrow in patients with systemic lupus erythematosus and peripheral hemocytopenia contains storage and hemophagocytic histiocytes and the significance of these cells is discussed

Ankylosing spondylitis: clinical course in women and men.

OBJECTIVE: To compare the clinical course; laboratory and radiological features of women and men with ankylosing spondylitis (AS). METHODS: Retrospective review of charts of 41 women and 41 men with AS (25 B27+ and 16 B27- in each group) individually matched for age at onset and disease duration. RESULTS: No differences were observed in the clinical picture in either sex, but the disease was less severe in women than in men with lesser duration of uveitis attacks, lower leukocyte counts (p < 0.05), lower levels of gamma-globulins (p < 0.05), and longer asymptomatic periods. At the end of the study, women had less restriction of spinal extension (p = NS), less sequelae of uveitis without significant visual loss (p = NS), required fewer hip replacements, had less frequency of bamboo spine (p < 0.02), and better functional class (p < 0.0027) than men. CONCLUSION: There are no significant clinical or radiographic differences between women and men with AS. However, the disease was more severe in men and these features may be due to sexual dimorphism.

Tomografía computada de las articulaciones sacroiliacas y esternoclaviculares en la espondilitis anquilosante juvenil y del adulto

Se empleó la tomografía computada (TC) con el fin de detectar la afección articular temprana de las sacroiliacas (SI) y de la esternoclavicular (EC) en 68 pacientes consecutivos con espondilitis anquilosante (EA) con una evolución de 14.5 ñ 2.7 años clasificándose según la edad de inicio y el sexo en: espondilitis juvenil (EJ) 19 pacientes (p), espondilitis de inicio en el hombre adulto (EHA) 33 p y espondilitis de inicio en la mujer adulta (EMA) 16 p. Para su análisis se empleó la prueba de Fisher. Resultados: La TC de SI fue anormal en 67/68 casos mostrando cambios erosivos desde los 8 meses de iniciada la enfermedad en adelante. En 1/49 hombres y 4/19 mujeres se detectó hipodensidad intraarticular compatible con gas (-13 UH), líquido (+19 UH) o grasa (+232 UH) (p< 0.001). Las EC estuvieron anormales en 27/66 (41 por ciento) de los casos B27 + (en 2 no se practicó TC por problemas técnicos), observándose disminución del espacio articular y erosiones sin anquilosis de inicio y predominio clavicular. Por grupos las TC de SI mostró alteraciones más tempranas en la EHA y en loe EJ que en la mujer (p< 0.001) con un predominio de las imágenes hipodensas en la mujer sobre los otros grupos (p< 0.001). Las alteraciones de las EC fueron más frecuentes y tempranas en la EJ que en la de los adultos (p< 0.001). Estos datos muestran diferente evolución tomográfica de la enfermedad entre los 3 grupos

Testicular function in active ankylosing spondylitis. Therapeutic response to human chorionic gonadotrophin.

Testicular function was studied in 22 patients with ankylosing spondylitis (AS) with serum measurements of hormone levels, seminal fluid analysis and testicular reserve test. Results were correlated with disease activity. The abnormal findings were elevated luteinizing hormone (LH), inversion of estradiol/testosterone ratio (E2:T) and diminished testicular reserve for testosterone (T) and slightly increased for estradiol (E2). Nine patients with severe active AS received biweekly 2,500 IU of human chorionic gonadotrophin injections with a resulting increase in E2 serum levels. When the values of E2 reached 40 pg/ml or higher, there was a decrease of the sedimentation rate (p less than 0.05) and a reversal to normal of the E2:T ratio. This was accompanied by an improvement in AS at the 10th week that lasted up to 9 weeks after discontinuation of treatment. Our findings suggest a possible role of sex hormones in the physiopathogenesis of AS and offers a possible therapeutic alternative.

Immunoreactive insulin levels in ankylosing spondylitis.

Serum glucose, serum immunoreactive insulin and sedimentation rate (ESR) were measured in eighteen male patients with ankylosing spondylitis (AS) and seven male healthy controls. The findings were correlated with the presence or absence of inflammatory activity of the disease. Fourteen patients had active AS with ESR of 47.0 +/- 27.7 mm; they had increased insulin levels measured as area under curve (AUC) of a glucose tolerance test 107.4 +/- 44.1 cm2 vs controls 40.8 +/- 12.6 cm2 (p less than 0.03). In 4 patients with clinically inactive AS and with ESR of 17.0 +/- 4.0 mm the insulin levels as the AUC were 83.2 +/- 38.0 cm2 vs controls (p = ns). In the whole group there was a direct correlation between ESR and serum immunoreactive insulin levels (r = 0.47 p less than 0.05). Our study suggests that AS may be associated with hyperinsulinism, whose role in the physiopathogenesis of the disease remains unknown.

[Purine metabolism in ankylosing spondylitis: clinical study]. / Metabolismo de las purinas en la espondilitis anquilosante: estudio clínico.

We undertook a prospective study of 23 male patients with Ankylosing Spondylitis (AS) (New York Criteria), 18 HLA-B27 positive and 5 HLA-B27 negative, five of them had hyperuricemia. The following data of evolution were taken into consideration: age at onset of disease, time course of the disease, presence of urolithiasis, heart disease, flares of uveitis. Clinical activity and degree of disability were evaluated every one to 3 months; on each visit, every patient had determinations of serum and urinary uric acid levels, serum and phosphorus, erythrocyte sedimentation rate (ESR), serum protein electrophoresis, as well as X-ray films of the vertebral spine and pelvis. Three groups of patients were detected, all of them with equal age at onset, duration of disease, frequency of B27, peripheral arthritis, and leukocytosis. One group had hyperuricemia (5 of 23 patients, 80% of them HLA-B27 positive) and a lesser degree of clinical activity of the disease (p less than .001, a higher frequency of uveitis (40%, lower levels of serum gammaglobulins (p less than 0.05) and ESR (p less than 0.05), a lesser degree of ankylosis of the spine, and a better functional prognosis than the other groups. Another group (8 of 23 patients, 75% of them were HLA-B27 positive) had normouricemia and hyperuricosuria, and showed a higher frequency of fever (50%), an abnormal urinalysis, and urolithiasis (25%).

[Functional abnormalities of complement in familial and sporadic ankylosing spondylitis]. / Anormalidades funcionales del complemento en la espondilitis anquilosante familiar y esporádica.

Levels of complement fractions of 12 patients with sporadic ankylosing Spondylitis and 6 patients with familial Ankylosing Spondylitis (N. Y. Criteria) were studied by an hemolytic and functional method (microhemolysis in plate. Cordis Lab. Miami, Fla. USA). Abnormal levels were found in 94% of them high levels of C1 and C2 (p 0.002), and C3 (p 0.05) C8 and C9 (p 0.001) deficiencies, mixed or isolated, correlated with the severity of the diseases. C9 deficiency belongs to familial Ankylosing Spondylitis. These functional deficiencies of serum complement can favor the colonization and persistence of germs, which could mediate in the genesis of Ankylosing Spondylitis.

[Adult-onset Still's disease]. / Enfermedad de Still de inicio en la edad adulta.

Sixteen patients with adult onset Still's disease are reported and compared to 42 previously reported cases. The onset of this illness is sudden and is characterized by quotidian fever, evanescent rash, arthritis, leukocytosis and with variable frequency abnormalities of the liver function tests, adenopathy, splenomegaly and loss of weight. The response to anti-inflammatory therapy is satisfactory and the majority of patients will have a good functional prognosis even though they may require corticosteroids to suppress the signs and symptoms of the disease. It is stressed that Still's disease should be considered one of the diagnostic possibilities in cases of fever of unknown etiology and in cases of seronegative arthritis in adult patients. The pertinent clinical, laboratory, radiological and histological features of this illness are reviewed.