Erythema nodosum associated with streptococcal infection in pregnancy.

BACKGROUND: Erythema nodosum (EN) is a condition characterized by the presence of painful erythematous nodules on the pretibial aspects of the lower extremities. EN is thought to be a local inflammatory, immune-mediated reaction to a number of systemic antigenic stimuli. This condition is noted most often in women between menarche and menopause and is associated with certain drugs, infections, and pregnancy. However, no reports in the literature describe EN as a result of streptococcal infection during pregnancy. CASE: A 21-year-old, white woman, G(3)P(0020), presented at 13 weeks gestation with a 2-week history of erythematous, tender lesions on the pretibial aspects of both legs consistent with EN. The patient reported having had a "flu-like" illness at the same time the lesions developed. The "flu" symptoms resolved within 10 days without medical intervention, but the lesions on her legs persisted. An initial antistreptolysin-O (ASO) titer was elevated at 960 Todd units (normal values: preschool and adults <85; school-age and young adults <170). Six days later, she presented to the emergency department with complaints consistent with a urinary-tract infection. She was empirically treated with a 10-day course of amoxicillin, 500 mg t.i.d. Although the patient was treated with amoxicillin for a presumed urinary-tract infection (which was culture-negative), the lesions resolved after her completion of the antibiotics. Twelve weeks later, a repeat ASO was within normal limits. The EN lesions did not recur. CONCLUSION: Although many etiologic factors are identified as causes of EN, the condition is usually self-limiting, requiring only minimal supportive measures until it resolves. A careful history should be obtained and a physical examination performed to exclude other causes. If a recent streptococcal infection is identified or presumed, a 10- to 14-day course of antibiotics is warranted.

Intracardiac thrombosis and antiphospholipid antibodies: a case report and review of the literature.

A case report and review of the literature are reported concerning the relationship of intracardiac thrombosis and antiphospholipid antibody syndromes. Nine cases are identified, divided into three categories: three patients had antiphospholipid syndrome associated with systemic lupus erythematosus, three had primary antiphospholipid syndrome, and three had probable secondary antiphospholipid syndrome. All had intracardiac thrombosis. All patients were women, and the average age was 36 years. Although intracardiac thrombosis appears to be an unusual association with antiphospholipid antibody syndromes, young women with embolic events should be evaluated for antiphospholipid antibodies and intracardiac source of embolus.

Angiotropic lymphoma manifested by fever and painful swollen legs.

In summary, angiotropic lymphoma is generally of B-cell origin and can be manifested by isolated cutaneous lesions. More commonly, however, the disease involves the CNS. Angiotropic lymphoma should be included in the differential diagnosis of patients with clinical features of panniculitis or diffuse multisystem vasculitis.

A comparison of low dose methotrexate bioavailability: oral solution, oral tablet, subcutaneous and intramuscular dosing.

OBJECTIVE: To compare the relative bioavailability of low dose methotrexate (MTX) administered as tablet, oral solution, and subcutaneous (sc) injection to that of intramuscular (im) injection in patients with rheumatoid arthritis (RA). METHODS: Twelve patients meeting the American College of Rheumatology criteria for RA had serial blood MTX concentration samples drawn over a 24-h period after receiving their normal weekly MTX dose. Relative bioavailability (F) of the tablet and oral solution formulations was determined by comparison of the area under the time-versus-serum-concentration curves (AUC) for the 2 different oral formulations as a percentage of the AUC for im injection. Also, relative bioavailability of the sc formulation was compared to im in 6 of the patients. RESULTS: Mean F for the oral tablet was 0.85, while that for the oral solution was 0.87. Both oral formulations showed a statistically significant difference in mean F when compared to im (tablet vs im, p = 0.002, oral solution vs im, p = 0.009). No statistically significant difference, however, was found in mean relative bioavailability between tablet and solution (p = 0.744). The mean F for sc was 0.97; no statistically significant difference existed between the mean F values for the sc and im routes of administration (p = 0.657). CONCLUSIONS: Our data suggest the oral solution may be substituted for tablet dosing and sc injection substituted for im. Thus, a variety of different dosing methodologies may be considered providing the most appropriate route in each patient, given issues of compliance, medication cost, and preference.

STAR complexes: febrile illnesses associated with sore throat, arthritis, and rash.

Between January 1990 and February 1991 we evaluated the cases of 20 patients for a symptom complex consisting of Sore throat, elevated Temperature, migratory Arthritis, and a pruritic urticarial Rash (STAR). The patients ranged in age from 3 1/2 to 48 years; most were from central Texas. Duration of illness varied from 2 weeks to longer than 1 year. Results of laboratory studies included the following abnormal findings: elevated erythrocyte sedimentation rate, leukocytosis, anemia, and thrombocytosis. Eleven of 18 (61%) patients had low antinuclear antibody titers. HLA-A2 was noted in 8 of 10 (80%) of those tested. Test results were positive in eight cases for IgM antibodies to parvovirus and in six cases for IgM antibodies to rubella, suggesting that these entities may represent an underdiagnosed cause of STAR complex. In six cases no specific cause of disease was found; these cases may be attributable to other infectious agent(s) yet to be identified. Here we present a description of the cases, a discussion of the differential diagnosis, and an evaluation of STAR complex.

Temporal arteritis with normal erythrocyte sedimentation rates presenting as occipital neuralgia.

A retrospective review of 46 patients with biopsy-proven giant cell (temporal) arteritis revealed 8 (17%) whose initial presentation was occipital pain. The most likely etiology of occipital pain in these patients was occipital artery inflammation. A Westergren erythrocyte sedimentation rate less than 40 mm/hour was noted at presentation in 6 of these 8 patients. Giant cell arteritis should be considered in the differential diagnosis of elderly patients who present with occipital pain and demonstrate a normal erythrocyte sedimentation rate.

A unified approach to symptomatic juxtasternal arthritis and enthesitis.

Symptomatic arthritic and enthesopathic conditions of the sternum and its articulations have not been studied well as a group, despite previous reports of individual diseases and radiographic abnormalities that affect these structures. The lack of a unified clinical approach has been partly due to the absence of a name for the clinical condition, which we propose to call juxtasternal arthro-osteitis. Although juxtasternal arthro-osteitis may be caused by septic arthritis, this study was based on 24 adult patients with noninfectious juxtasternal arthro-osteitis, collected retrospectively from records of patients who had sternal tomography and from rheumatology clinic populations. Twelve of the patients had an underlying systemic arthropathy that met standard diagnostic criteria; three patients had an unclassifiable systemic arthropathy; and nine patients had the idiopathic localized disease, which has been termed sternocostoclavicular hyperostosis. Radiographic findings in the various diseases followed definite trends, but were not sufficiently distinct to provide the sole basis for diagnosis. Initial failure to correlate dermatologic, rheumatologic, radiographic, and laboratory findings led to prolonged delays in diagnosis in many cases. When juxtasternal arthro-osteitis is encountered, a thorough evaluation should be made for systemic disease. Idiopathic sternocostoclavicular hyperostosis can be diagnosed only after systemic arthropathy or enthesopathy has been excluded.