Panniculitis: a report of four cases and literature review.

Panniculitis is a disease with many causes and associations. The classification of clinical subtypes is unsatisfactory and hampered by the use of eponyms. Four children with recurring panniculitis are described and their histology presented. Three had subcutaneous fat atrophy with lobular panniculitis on biopsy; all responded well to corticosteroids. The fourth child had a septal panniculitis with no atrophy of subcutaneous tissues and only a partial response to treatment with corticosteroids. A widely accepted precise histological classification of panniculitis is needed to enable accurate predictions of the outcome of this serious disorder.

Drug treatment of progressive rheumatoid arthritis.

The drug treatment of progressive rheumatoid arthritis (RA) is discussed with emphasis on second line agents used both singly and in combination. NSAIDS play a supportive role in the management of RA. Low dose prednisolone is acceptably safe and effective in long term use whereas pulsed steroids and intra-articular use is reserved for short term control of disease. Antimalarials are rarely valuable as sole agents in progressive arthritis. The use of sulphasalazine, gold thiomalate, d-penicillamine, auranofin, methotrexate, azathioprine and cyclophosphamide in rheumatoid arthritis and their place in the therapeutic strategy are discussed. The reported use of combination chemotherapy has not shown the expected additive benefits although azathioprine, methotrexate and hydroxychloroquine combination may prove to be better than single agents. Recently cyclosporine and gamma interferon have not been shown to be highly efficacious. Of the new therapies monoclonal antibodies to CD4 and CD5 positive lymphocytes are showing promise of marked efficacy in the short term. Sustained control of synovitis appears to improve the long term outcome but better strategies and better drugs are needed.

Occurrence of Clostridium tetani in soil and horses.

The annual incidence of tetanus in the RSA is up to 300 cases with more than 50% of these coming from Natal/KwaZulu. The condition of playing fields and the excretion of Clostridium tetani by horses was therefore investigated. The overall contamination rate of soils in the Durban area is lower than that of published data from other parts of the world, for instance 28% for Durban in comparison with 31-42% for Japan and Quebec. A rugby field in the Transvaal showed 40% contamination and a pasture used for horses for more than 20 years 65%. No case of human or equine tetanus has ever been reported from either the playing field or the pasture. A permanent carrier state in horses could not be established; the organisms were only excreted for 3-4 days. At any one time only 2 out of 27 horses in a stable were excreting C. tetani. Only 7 of 118 faeces samples were positive over a period of 4 months (5-9%).

Is there more than one signal for an acute phase response?

Prealbumin was shown to be a sensitive indicator of disease activity in a prospective study of 21 patients with active ankylosing spondylitis (AS) who were treated with 3 intravenous pulses of methylprednisolone and its concentration was found to change at a different rate to C-reactive protein (CRP). In those diseases in which CRP concentration rises with active disease, i.e., rheumatoid arthritis, AS and Crohn's disease, prealbumin fell, but in those diseases in which CRP rises only slightly, i.e., systemic lupus erythematosus, progressive systemic sclerosis and ulcerative colitis, there was nevertheless a fall in serum prealbumin, indicating that there was an acute phase response occurring. Fever, arthritis and infection were the only disease manifestations that were associated with an elevated CRP in both groups of diseases. There is therefore more than one signal for an acute phase response depending on the nature of the disease pathology.

Changes in mononuclear cell function in patients with rheumatoid arthritis following treatment with auranofin.

Gold salts in vitro modulate lymphocyte proliferation to mitogens and antigens and macrophage phagocytosis. These effects are not confined to gold salts; D-penicillamine and chloroquine as well as some of the non-steroidal anti-inflammatory drugs (NSAIDs) have in vivo immunoregulatory effects. Peripheral blood mononuclear cells during treatment with Myocrisin (gold sodium thiomalate, GSTM) show changes that differ from in vitro effects and are related to therapeutic response rather than GSTM administration. This discrepancy between in vitro and ex vivo responses prompted us to measure cellular functions during auranofin therapy. Twenty-nine patients with rheumatoid arthritis took part in a placebo-controlled trial of auranofin. We examined the spontaneous immunoglobulin (IgG and IgM) and IgM rheumatoid factor (IgM RF) production by cultured mononuclear cells, lymphocyte transformation to concanavalin A and macrophage phagocytosis of Candida albicans. There was a significant fall in IgG synthesis (p less than 0.005) and IgM RF synthesis (p less than 0.005) over the first 4 months of treatment, whereas in the control group there were no significant changes. There was no significant change in IgM production. In the auranofin-treated group the lymphocyte response to concanavalin A fell progressively during 6 months of therapy (at 2 months p less than 0.05, at 4 months p less than 0.01, and at 6 months p less than 0.005). Auranofin therapy had variable effects on monocyte phagocytosis of C. albicans. Therefore, in contrast to GSTM, auranofin suppressed both in vitro and ex vivo lymphocyte functions. This effect is probably related to the direct effect of auranofin on lymphocyte membranes.

The effects of intravenous pulse methylprednisolone on immunological and inflammatory processes in ankylosing spondylitis.

Acute phase reactants, serum immunoglobulins and immune complexes and T cell function were measured in eight patients with active ankylosing spondylitis (AS) before and up to 3 months after three pulses of 1 g methylprednisolone. There was a two stage effect. The first stage was an early anti-inflammatory event with a fall in clinical disease activity mirrored by changes in acute phase reactants particularly prealbumin. The second stage occurred later and was an immunological event with a fall in serum IgA and IgG and a rise in mitogenic response, mixed lymphocyte response and delayed cutaneous hypersensitivity. Most of these changes returned towards pre-treatment levels by 3 months. This study has shown that pulse methylprednisolone has an immediate anti-inflammatory and a prolonged immunological effect in AS.

Circadian variation in disease activity in rheumatoid arthritis.

Disease activity in rheumatoid arthritis as measured by repeated estimation of joint pain, stiffness, articular index, and grip strength was shown to have a circadian rythm, maximal activity being seen between 0200 and 0400 and minimal activity in the early afternoon. This variation in disease activity may be related to circadian alterations in immune and inflammatory responses (such as immune complexes and neutrophil function) dependent on alterations in circulating concentrations of steroids. The circadian variation in disease activity has important implications in assessment of patients, prescription of drugs, and performance of drug trials.

Gold in psoriatic arthopathy.

It has been suggested that gold is not effective in psoriatic arthropathy. We did not agree and therefore did a retrospective study of 98 patients. Gold had been given to 27 and was effective in 22, 14 of whom are still receiving it. The incidence of side effects was low and comparable to those in rheumatoid arthritis.