Giant cell arteritis in Mumbai.

OBJECTIVE: To study the clinical profile of patients with giant cell arteritis in Mumbai. METHODS: From our database, patients with a diagnosis of giant cell arteritis (GCA) over a fifteen year period (January 1990 to December 2005) were included. Clinical manifestations, temporal artery biopsy, treatment, and follow-up data of these patients were analyzed. RESULTS: Twenty one patients with GCA were identified. However, data were available only for 16 patients. The median age was 66.5 years (58-78 yrs) with male to female ratio of 1:1. The mean time from symptom onset to diagnosis was 5.18 months (0.5-24 months). Clinical manifestations included new onset headache (15), fever (9), weight loss (9), jaw claudication (9), polymyalgia rheumatica (5), visual disturbances (3), scalp nodule (1), temporal artery tenderness (11), tortuosity (9), and scalp tenderness (6). ESR was elevated in 15 patients with a median of 106.5 mm at 1 hr (25-135 mm/hr). Temporal artery biopsy was done in 11 patients and confirmed the diagnosis in 10 patients. Color doppler study of the temporal arteries (9 patients) revealed halo sign (indicating arterial wall edema) in 6 patients. Biopsy as per site by color doppler study was performed in 6 of these patients and was positive in 5. All patients had a good initial response to steroids, however, on follow up, 3 patients required addition of methotrexate. At a median follow up (n = 14) of 6 months (range 6-156), steroids were successfully stopped in 7 patients at 1 to 3 years interval. The disease relapsed in 1 patient. Of the remaining 7 patients, 2 were steroid dependent and 5 patients were doing well on low dose prednisolone. CONCLUSION: GCA, though uncommon in India, should be suspected in all elderly patients with a new onset headache, fever, jaw claudication, or high ESR. Color doppler sonography is a useful noninvasive method for the diagnosis of GCA and also helps to identify the site to biopsy. Most respond to steroid therapy while some need addition of steroid sparing agents.

The sternoclavicular syndrome: experience from a district general hospital and results of a national postal survey.

OBJECTIVE: To report our local experience of the sternoclavicular syndrome and sample the experience of other rheumatologists in the UK. METHODS: We studied case records of 23 patients referred to the Southend rheumatology clinic and data obtained from a postal questionnaire survey of British rheumatologists. RESULTS: We describe 58 cases (20 males and 38 females, mean age 47.2 yr). The disease was unilateral in 40 patients. Shoulder and/or arm pain (38 cases) with limitation of shoulder movements was an important presenting feature; other presenting features were anterior chest wall pain (14 cases) and neck pain (15 cases). Peripheral joint involvement was seen in 12 cases. Skin rash was reported in 12 cases (psoriasis, 6; acne, 2; none had pustulosis). No patients had symptoms or signs of sacroiliitis, and HLA-B27 was negative in 22 out of 23 patients. 99Technetium scintiscanning showed increased uptake in the sternoclavicular region in 31/34 patients (91.1%), but not in the sacroiliac areas. Plain radiographs were abnormal in 18 cases (sclerosis, 9; erosions, 2; soft tissue swelling, 2; bony expansion, 5). CT and/or MRI scans (available in 27 cases) showed erosions in 12 and osteitis in 18. Available histology showed a variable picture, including inflammation, bone erosion, sterile osteomyelitis and fibrosis. The majority of patients (45) were treated with non-steroidal anti-inflammatory drugs: 12 received steroids and 10 received disease-modifying anti-rheumatic drugs (methotrexate, 4; sulphasalazine, 6). Follow-up information was available for 38 patients, of whom 14 became asymptomatic and 24 had chronic disease with intermittent flares. CONCLUSION: Sternoclavicular disease is not uncommon in the UK. It can present with pain in the shoulder, neck or anterior chest wall, and may be underdiagnosed. Our results do not show a link with acne or pustulosis. Features of spondyloarthropathies, such as sacroiliitis and HLA-B27 positivity, were rare in this survey.

A study of the health assessment questionnaire to evaluate functional status in polymyalgia rheumatica.

OBJECTIVE: To evaluate the Health Assessment Questionnaire (HAQ) in the assessment of functional status, its responsiveness to change with treatment and its correlation with conventional disease activity indices in polymyalgia rheumatica (PMR). METHODS: Newly diagnosed patients with PMR, satisfying modified Jones and Hazleman criteria, were recruited to the study. The clinical assessments, including early morning stiffness (EMS), pain measured on a horizontal 10 cm visual analogue scale (VAS), C-reactive protein (CRP) and the HAQ, were carried out 0, 6, 12 and 24 weeks after treatment had been started. Any comorbid condition likely to affect the HAQ was noted. RESULTS: Eighteen patients completed the 6-month assessment period. These included four males and 14 females, with a mean age of 68.5 years. Pretreatment mean disease activity showed EMS of 68 min, VAS pain of 69 mm, CRP of 46 mg/l and a HAQ score of 1.57. At 6 months, mean EMS had declined to 4 min, VAS pain to 11 mm, CRP to 9 mg/l and the HAQ score to 0.14. Linear regression analysis of HAQ vs EMS, VAS and CRP showed correlation coefficients of 0.72, 0.66 and 0.63, respectively. Standardized response means (SRM), a measure of responsiveness, for HAQ, EMS, VAS and CRP were 3, 1.7, 1. 8 and 1.6, respectively. We assessed each section of the HAQ individually to see if any particular daily activity was more responsive to change. Questions on dressing and grooming, rising and eating were more responsive to change (SRM 2.5, 2.7 and 1.8, respectively) than questions about walking, hygiene, reach, grip and activities (SRM 0.8, 1.4, 1.2, 1.1 and 1.1, respectively). CONCLUSION: The HAQ is useful in the assessment of functional status in PMR, is responsive to change and correlates well with conventional indices of disease activity. However, fixed disabilities like osteoarthritis, shoulder capsulitis and systemic diseases may affect its interpretation. The sections of the HAQ measuring disability related to inflammatory stiffness/proximal involvement showed greater responsiveness to change than other sections, and hence may have a greater role in evaluating disease activity in PMR.

Clinical trial of benidipine in mild to moderate hypertension.

Thirty four patients with mild to moderate hypertension, were put on benidipine 4 mg/day after two weeks of placebo therapy. Twenty five patients completed the trial successfully for 4 mg benidipine. The blood pressure of 20 patients was controlled with benidipine 4 mg/day (effective rate 80%). Five patients with unsatisfactory control on 4 mg/day benidipine were put on 8 mg/day. Four of them were controlled and one was considered as failure (effective rate 80%). Most of the patients tolerated the drug well. Three patients had mild side effects like headache and heaviness in the head. One of them also had puffiness of face and body (on benidipine 8 mg/day) and was withdrawn from the study. One patient had mild constipation. We conclude that benidipine is well tolerated in the dose of 4-8 mg/day and is an effective antihypertensive agent for treatment of patients with mild to moderate hypertension.

Echocardiography in systemic lupus erythematosus.

Two dimensional echocardiography with doppler examination was performed in 54 patients with systemic lupus erythematosus (SLE). Nine (17%) had significant cardiac involvement (four left ventricular hypertrophy, one moderate pericardial effusion, one severe aortic regurgitation, and three ventricular systolic dysfunction). We further studied diastolic function in 45 patients who did not have a major abnormality in echo. SLE was graded as active in 16 patients (SLEDAI > 5) and inactive in 29 patients. Twenty age- and sex-matched subjects acted as controls. The data were compared using one way ANOVA test. Patients with active disease had significant diastolic dysfunction compared to inactive patients and controls as indicated by increased peak A (P < 0.01) and decreased E/A ratio (P < 0.01). There was no linear correlation between disease activity and diastolic dysfunction if SLEDAI was considered as a continuous variable (r=0.29 for E/A). Anticardiolipin antibodies (both IgG and IgM) were elevated in five patients (13 studied). One of them had severe mitral regurgitation, one had trace mitral and aortic regurgitation and one had diastolic dysfunction. We conclude that asymptomatic diastolic dysfunction is present in SLE patients.

The spectrum of chronic autoimmune hepatitis.

Autoimmune hepatitis (AIH) is characterised by the presence of periportal hepatitis coupled with the presence of autoantibodies in the serum. We report our experience with 10 cases (females--8, males--2) who presented to the rheumatology clinic with either articular or extra-articular manifestations. Three patients (1 SLE, 1 Sjogren's and 1 RA), satisfied the criteria for an underlying rheumatic disease (secondary AIH) while, others had primary AIH. Median duration of hepatic involvement was 6 months and the varied presentations were noted. Articular disease ranged from arthralgias, palindromic arthritis to persistent non-erosive/non-deforming arthritis (Jaccoud's arthritis). Autoimmune thrombocytopenia was seen in 2 and autoimmune hypo and hyperthyroidism were seen in 3 patients each. Anti-nuclear antibody was positive in 9/10 (6 with speckled pattern and 3 with homogenous pattern) and anti-mitochondrial antibodies were positive in three. Hepatitis C virus (HCV) markers were positive in 1, who probably had viral hepatitis with dominant autoimmune features. All have been started on steroids (5 patients--1 mg/kg dose, 1 patient--0.5 mg/kg dose and 3 patients--0.25 mg/kg dose). The HCV positive patient was on a low dose steroid (0.25 mg/kg) and interferron treatment was contemplated before she was lost to follow up. Four patients are also on azathioprine in the dose of 2 mg/kg/day. Of the 6 patients who are under regular follow up, the liver parameters have normalised in 5 and one showed hypoalbuminaemia with normal enzyme levels at the last follow up.

Evaluation of the knee pathology by ultrasonography.

Fourteen patients undergoing total knee replacement for the arthritic conditions of the knee were evaluated by ultrasonography (USG) prior to surgery. USG findings (synovium, fluid, femoral cartilage, cyst and loose bodies) were compared with surgical findings. USG and surgical findings matched for synovial pathology in 57%, for presence fluid in 71% and for cartilage damage in 45%. Loose bodies and cyst present in one patient was not picked up by USG. Baker's cyst was detected in one patient.