Tuberculosis con prueba cutánea de tuberculina negativa en un paciente con artritis reumatoide / Tuberculosis in a patient with rheumatoid arthritis and negative tuberculin skin test

La artritis reumatoide es una enfermedad grave que necesita tratamiento adecuado y temprano utilizando el arsenal terapéutico que incluye fármacos como la leflunomida y los anticuerpos antifactor de necrosis tumoral alfa (TNF-alpha). Se presenta un paciente con artritis reumatoide de muchos años de evolución en el que han fracasado tratamientos previos habituales. Se describe la respuesta al tratamiento con infliximab (fármaco anti-TNF-alpha) y la aparición de tuberculosis hepatoesplénica con prueba cutánea negativa, lo que obligó a la suspensión del fármaco y a la introducción de leflunomida como medicación inmunomoduladora de la enfermedad. Se describen los aspectos de interés del caso clínico en relación con los mecanismos de defensa inmunológicos, el manejo farmacológico de estos medicamentos y su uso racional así como profilaxis adecuada (AU)

Rheumatoid arthritis is a severe disease that requires appropriate and early treatment using a therapeutic arsenal that includes drugs such as leflunomide and anti-tumor necrosis factor (TNF) alpha antibodies. We describe a patient with long-standing rheumatoid arthritis refractory to commonly used treatments. The response to infliximab (an anti- TNF alpha drug) is described. This treatment was discontinued due to the development of hepatosplenic tuberculosis with negative skin test and leflunomide was introduced as an immunomodulatory drug. Features of this case are described in relation to mechanisms of immunological defense, the pharmacological management of these drugs and their rational use, as well as appropriate prophylaxis (AU)

Artritis crónica juvenil / Juvenile chronic arthritis

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Laboratorio y líquido sinovial en la artritis reumatoide / The laboratory and synovial fluid in rheumatoid arthritis

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Leflunomida: un nuevo tratamiento para una vieja enfermedad / Leflunomide: a new therapy for an old disease

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Clinical significance of abdominal scintigraphy using 99mTc-HMPAO-labelled leucocytes in patients with seronegative spondyloarthropathies.

Abdominal scintigraphy shows silent gut inflammation in patients with spondyloarthropathies (Sp) without clinical evidence of gut inflammation. Abdominal scintigraphy images are different than those obtained in patients with ulcerative colitis or Crohn's disease and are not related to the anti-inflammatory drugs administered. The aim of this study was to examine the clinical associations of findings on abdominal scintigraphy in patients with Sp. A total of 204 Sp patients (European Spondylarthropathy Study Group 1991 criteria) and 54 non-Sp controls receiving non-steroidal anti-inflammatory drugs were studied. Abdominal scintigraphy images were obtained at 30 and 120 min after injection of technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO)-labelled leucocytes. 99mTc-HMPAO-labelled leucocyte scans were positive in 104 Sp patients (50.9%) and in six non-Sp controls (2.9%) (P<0.001; OR=8.32; 95% CI=3.23-22.67). Silent gut inflammation was not associated with any of the following: age of onset, duration of evolution, sex, family history of Sp or psoriasis, articular manifestations, extra-articular manifestations, radiological findings or HLA-B27 positivity. Positive abdominal scintigraphy was associated with active disease (P < 0.0001; OR=52.7; 95% CI=19-145.6) and an increase in the C-reactive protein (P < 0.005; OR = 3.4; 95% CI = 1.5-7.4). It is concluded that (a) abdominal scintigraphy using 99mTc-HMPAO-labelled leucocytes is of value in detecting the silent gut inflammation in Sp patients, and (b) silent gut inflammation is related to the clinical activity, but is not associated with any particular type of illness or with HLA-B27.

Clinical significance of abdominal scintigraphy using (99m)Tc-HMPAO-labelled leucocytes in patients with seronegative spondyloarthropathies.

Abdominal scintigraphy shows silent gut inflammation in patients with spondyloarthropathies (Sp) without clinical evidence of gut inflammation. Abdominal scintigraphy images are different than those obtained in patients with ulcerative colitis or Crohn's disease and are not related to the anti-inflammatory drugs administered. The aim of this study was to examine the clinical associations of findings on abdominal scintigraphy in patients with Sp. A total of 204 Sp patients (European Spondylarthropathy Study Group 1991 criteria) and 54 non-Sp controls receiving non-steroidal anti-inflammatory drugs were studied. Abdominal scintigraphy images were obtained at 30 and 120 min after injection of technetium-99m hexamethylpropylene amine oxime ((99m)Tc-HMPAO)-labelled leucocytes. (99m)Tc-HMPAO-labelled leucocyte scans were positive in 104 Sp patients (50.9%) and in six non-Sp controls (2.9%) (P<0.001; OR=8.32; 95% CI=3.23-22.67). Silent gut inflammation was not associated with any of the following: age of onset, duration of evolution, sex, family history of Sp or psoriasis, articular manifestations, extra-articular manifestations, radiological findings or HLA-B27 positivity. Positive abdominal scintigraphy was associated with active disease (P<0.0001; OR=52.7; 95% CI=19-145.6) and an increase in the C-reactive protein (P<0.005; OR=3.4; 95% CI=1.5-7.4). It is concluded that (a) abdominal scintigraphy using (99m)Tc-HMPAO-labelled leucocytes is of value in detecting the silent gut inflammation in Sp patients, and (b) silent gut inflammation is related to the clinical activity, but is not associated with any particular type of illness or with HLA-B27.

[Hypertransaminemia and methotrexate: not always a toxic effect?]. / Hipertransaminemia y metotrexato: es siempre un efecto tóxico?

Serial measurement of liver enzymes is useful to detect liver toxicity due to methotrexate in patients with rheumatoid arthritis or other rheumatic diseases. We have reviewed retrospectively 141 adult patients treated with methotrexate from 1988 to 1991. The more common diagnoses included rheumatoid arthritis (120 cases) and psoriatic arthritis (12 cases). In periodic studies carried our every 2-3 months, a transient increase in transaminase values associated with methotrexate in 13 patients (9.2%) was observed. Two patients developed a viral infection during therapy, one due to cytomegalovirus and the other due to the Epstein-Barr virus. Both patients had a favorable outcome once methotrexate was withdrawn.

[Clinical expression of systemic lupus erythematosus with anti-U1-RNP and anti-Sm antibodies]. / Expresión clínica del lupus eritematoso sistémico con anticuerpos anti-U1-RNP y anti-Sm.

UNLABELLED: The frequency of anti-U1-RNP and anti-Sm antibodies in systemic lupus erythematosus (SLE) varies according to the technique used for their detection. OBJECTIVE: To study the clinical manifestations associated with anti-U1-RNP and anti-Sm antibodies identified by different techniques. METHODS: 112 patients diagnosed with SLE were studied. Anti-U1-RNP and anti-Sm antibodies were detected by ELISA with a mixture of recombinant antigens, antigens obtained by immunoaffinity and by immunoblotting and counterimmunoelectrophoresis (CIE) with a saline extract of rabbit thymus. RESULTS: Anti-U1-RNP antibodies were detected in 70 (62.5%), 37 (33%) and 16 (14.2%) patients, and anti-Sm antibodies in 43 (38.3%), 36 (32.1%) and 10 (8.9%) patients by ELISA, immunoblotting, and CIE, respectively. Anti-U1-RNP antibodies are associated with edema in the dorsal hand region, sclerodactylia, Raynaud phenomenon and pericarditis (CIE); arthritis, hand edema, Raynaud phenomenon and sclerodactylia (anti-70 KD-U1-RNP and anti-A-U1-RNP by immunoblotting); and a lower incidence of discoid lupus and chronic renal insufficiency by lupus renal disease (ELISA). Anti-Sm antibodies are associated with Raynaud phenomenon and renal disease (CIE); cutaneous vasculitis, Raynaud phenomenon and thrombosis (anti-BB'-Sm immunoblotting); and arthritis and lower incidence of chronic renal insufficiency (ELISA). CONCLUSIONS: Anti-U1-RNP and anti-Sm antibodies detected by ELISA do not have the same clinical significance than those detected by immunoblotting or CIE. The clinical manifestations associated with such antibodies in the same SLE population vary according to the detection technique used.

[The reflex sympathetic dystrophy syndrome associated with breast cancer]. / Síndrome de distrofia simpática refleja asociado a cáncer de mama.

Reflex sympathetic dystrophy syndrome (RSDS) is a rare entity of unknown etiopathogenesis, associated to different precipitating factors such as malignant tumors of several localizations. A new clinical variety has been recently described which has been denominated palmar fasciitis and polyarthritis syndrome. We present here two patients with RSDS associated to breast cancer: one case presenting fasciitis and polyarthritis and another case also associated to polymyalgia rheumatica. We emphasize the importance of reducing the tumor mass in the treatment of this syndrome, as well as including it in the gammagraphic differential diagnosis of bone metastasis.

[Reiter's syndrome: considerations on the frequency and mid-term course of its juvenile form]. / Síndrome de Reiter: consideraciones sobre la frecuencia y la evolución a medio plazo de su forma juvenil.

Reiter's Syndrome (RS) is not common in children and adolescents. From 1982 to 1987 we have seen 13 pediatric patients (8 male and 5 female) with clinical manifestations that characterized RS. Age of onset was 13 years. Clinical findings have been arthritis (100%) involving the knee and ankle joints, heel pain (84%), lumbosacral pain (38%). One to three weeks before joint involvement, six patients (46%) complained of urethritis, 5 (38%) had enteritis and two patients had both. 46% of the patients had HLA-B27 antigen. Radiologic findings were sacroileitis in five patients and calcaneal spurs. All patients were treated with non-steroidal antiinflammatory therapy and, in general, there was a clinical remission in 1-3 months. Nevertheless, after 4 years of follow up, 2 patients had acute relapsing arthritis and 4 had chronic arthropathy. Three patients have developed secondary ankylosing spondylitis. RS is not all that infrequent in pediatric patients with joint involvements if one looks for urethritis, enteritis, eye involvement and cutaneous manifestations. The clinical course is favorable, but there might be some chronic or relapsing cases. Some patients can developed secondary ankylosing spondylitis. For that reason a prolonged follow up of these patients is necessary.