Clinical importance of the presence of giant cells in temporal arteritis.

BACKGROUND: The clinical significance of giant cells seen on temporal artery biopsy in temporal arteritis is unknown. AIM: To help define the prognostic value of the presence of giant cells in temporal arteritis. METHODS: The clinical course of all patients with biopsy proven temporal arteritis from 1994 to 2004 was reviewed. The 92 patients were divided into those with giant cells (GC) (n = 76) seen on biopsy and those with no giant cells (NGC) (n = 16). Clinical findings were compared between groups. An additional analysis combined results with a previous study at the same institution to compare occurrence of blindness. RESULTS: The GC group had a higher proportion of polymyalgia rheumatica (PMR) (36.8%) compared to the NGC group (12.5%) (p = 0.059). There was no significant difference in patient age, sex, sedimentation rate, or presenting symptoms. The length of time treated with corticosteroids and relapse rate was nearly identical for both groups. When combining data with the previous study, in the GC group 21/109 (19%) developed blindness, while only 2/34 (6%) became blind in the NGC group (p = 0.11). CONCLUSION: The presence of giant cells is not a significant factor in determining treatment or clinical progression of temporal arteritis. However, results showed the GC group to have three times the occurrence of blindness and PMR compared to the NGC group. Although the differences were not significant, this analysis suggests an association with giant cells and more aggressive disease.

Glucocorticoid-Induced Osteoporosis Program (GIOP): a novel, comprehensive, and highly successful care program with improved outcomes at 1 year.

INTRODUCTION: Patients who take chronic glucocorticoids (GC) are at increased risk of osteoporosis and fracture. Only a minority of patients who take chronic GC receive optimal osteoporosis prevention, diagnosis, and/or treatment. METHODS: An organized program of care--GIOP (Glucocorticoid-Induced Osteoporosis Program)--was designed and implemented. The program goals were to identify patients at risk of fracture, provide education, redesign and implement new pathways of care, and monitor outcomes. Two hundred chronic GC users were seen at baseline, and follow-up visits scheduled at 6 months and 1 year. RESULTS: Patient retention of knowledge, frequent exercise, and 25-OH Vitamin D levels all significantly improved at 1 year. A significant decrease in GC dose was seen. In terms of adherence, 91% of patients considered at high risk were taking a bisphosphonate or teriparatide at 1 year, and 96% of patients overall were adherent to their prescribed regimen of calcium, vitamin D, and prescription treatment (if indicated). Bone density at the spine and total hip increased significantly. CONCLUSIONS: GIOP is the first organized program of care for patients who take chronic GC that has demonstrated a clinically significant improvement in outcome. The program's design can be adapted and used by other health systems and organizations.

Pyomyositis: clinical features and predisposing conditions.

OBJECTIVE: To describe the manifestations of nontropical pyomyositis and associated comorbid conditions that may predispose to pyomyositis. METHODS: A retrospective review of 13 patients with pyomyositis seen at our center including one illustrative case report. Reports of tropical and nontropical pyomyositis were found by review of Index Medicus, Medline, and references from published cases and clinical review papers. RESULTS: All 13 patients had variable presentations including fever, muscle pain, tenderness, and swelling. Eleven patients had comorbid conditions that may have led to their infection, including one with human immunodeficiency virus and 3 with history of trauma. Staphylococcus aureus was found to be a causative organism in 7 patients, 2 patients had multiple organisms isolated, and 2 had no organisms isolated. Eleven patients had successful treatment with intravenous antibiotics and either computerized tomographic scan guided percutaneous or open operative drainage. CONCLUSION: Onset of pyomyositis is usually insidious, with progression to purulent collections. Comorbid conditions likely predispose patients to pyomyositis and may contribute to delay in diagnosis and treatment. Increased awareness of this disease, especially in an immunosuppressed patient, should lead to earlier diagnosis and treatment with improved outcomes.

Sulfasalazine therapy in psoriatic arthritis: clinical and immunologic response.

Sulfasalazine therapy has been shown effective in rheumatoid arthritis and ankylosing spondylitis. We treated 10 patients with active polyarticular psoriatic arthritis with 2 g/day of sulfasalazine for 16 weeks. Significant improvement was seen in joint count score, morning stiffness, and patient/physician assessment of disease activity. Toxicity requiring drug cessation was seen in only 1 patient. Patients with psoriatic arthritis had elevated B cells and immunoglobulin levels which fell with sulfasalazine therapy. Minimal changes were seen in T cell subsets. Sulfasalazine appears to be an effective second line agent for the treatment of psoriatic arthritis. Its mechanism of action may in part relate to alteration of B cell number and function.

Plant thorn synovitis: an uncommon cause of monoarthritis.

Plant thorn synovitis (PTS) is an uncommon cause of monoarthritis. Seven cases of PTS were identified at our institution from January 1979 to July 1990, six of whom were men. Mean age was 27 years (range, 7 to 56 years). Symptoms included pain, swelling, and stiffness. Synovitis was present on examination along with decreased range of motion of affected joints in all patients. Roentgenograms were unremarkable in five patients, but disclosed demineralization in two others. Initial conservative treatment with nonsteroidal antiinflammatory drugs (NSAIDs), antibiotics, or splinting was usually unsuccessful; surgery was necessary in six patients. Findings included marked inflammatory synovial reactions with evidence of retained thorn in all patients. One patient had a positive operative wound culture (Enterobacter agglomerans) without evidence of osteomyelitis. All patients improved after surgery without sequelae. Despite a history suggesting thorn injury in many cases, diagnosis was often delayed; mean time to diagnosis was 10 weeks (range, 2 weeks to 9 months). PTS must be included in the differential diagnosis of monoarthritis. Histologically, PTS can mimic sarcoidosis, tuberculosis, or fungal infection. Optimal treatment of PTS is arthrotomy, foreign body removal, and extensive synovectomy.

Pyogenic sacroiliitis in a rural population.

We describe 10 cases of pyogenic sacroiliitis occurring in a rural population. Seven were male and 3 were female with a mean age of 22.4 years. None was a recent intravenous drug abuser. Five patients had a history of recent pelvic trauma. 99mTechnetium scintiscans revealed increased sacroiliac (SI) joint uptake in 8 of 8 cases. Blood cultures were positive in 60% of patients. Staphylococcus aureus was isolated in 7 cases from blood and/or SI aspirates and Hemophilus influenzae type B in one case. Nine of 10 patients recovered completely. One underwent arthrodesis for recurrent SI pain without evidence of relapse of infection. Median followup was 18 months.

Suppurative extensor tenosynovitis caused by Staphylococcus aureus.

Suppurative tenosynovitis is a rare infection, occurring almost exclusively in the flexor tendon sheath as a posttraumatic event. We report the case of a systemically ill woman with suppurative tenosynovitis of the extensor tendons caused by Staphylococcus aureus. Early recognition of this unusual infection may prevent unnecessary morbidity.

Acute calcific tendinitis of the hand and wrist: a report of 12 cases and a review of the literature.

Acute calcific tendinitis is a frequently unrecognized cause of hand and wrist tenderness and swelling. We report 12 cases seen over an 8-year period. Roentgenograms showed deposits in various peritendinous sites especially near the pisiform. Special views may be required for visualization. A correct diagnosis was made in 5/12 cases; other etiologies considered included closed-space infections. In most cases, treatment consisted of immobilization plus nonsteroidal antiinflammatory drugs or local steroid injections. Results were uniformly good. Seven of 7 patients demonstrated resolution of calcium deposits on subsequent roentgenograms. Failure to recognize this entity may cause unnecessary investigation and therapy.

Septic arthritis due to gram negative bacilli: older patients with good outcome.

Previous studies of gram negative bacillary septic arthritis conclude it is an uncommon disease of older patients with poor outcome, or of younger patients with good outcome. We reviewed 22 cases of gram negative bacillary septic arthritis in a rural population. The mean age was 61 years, symptoms were of short duration (6.5 days mean), and a chronic illness was frequently present (77%). The knee was involved in 73% and E. coli was the usual causative organism (32%). Antibiotics plus aspiration was a successful initial therapy. Overall survival was 95% and a good outcome was achieved in 68%. Gram negative bacillary septic arthritis affects older patients, and the outcome appears good.

Cholecystitis and cholelithiasis.

Cholelithiasis and cholecystitis, with their complications, remain major health problems in the United States. At this time, cholecystectomy is the treatment of choice for all patients with symptomatic gallstones and those with acute cholecystitis, except those who are too ill to undergo surgery. Present therapeutic options may be summarized as follows: Asymptomatic patients and those with flatulence and dyspepsia who have gallstones should be observed. Those who have symptoms of biliary pain, gallstone-induced pancreatitis, or common duct stones should have corrective surgery. Those who refuse surgery or who aren't surgical candidates might be treated with dissolution therapy. Dissolution of gallstones with chemical agents and extracorporeal shock-wave lithotripsy show some promise. We need a better understanding of the etiology and formation of gallstones to address the disease from a preventive standpoint and reduce the incidence of cholelithiasis and cholecystitis, and their complications.

Cricoarytenoid arthritis: a cause of laryngeal obstruction.

Cricoarytenoid arthritis, principally as a result of long-standing rheumatoid arthritis, is a disorder that may present to the emergency physician with a number of symptoms and signs referable to the larynx. The presentation of this disorder as acute laryngeal obstruction and collapse is uncommon. It is important to recognize early cricoarytenoid joint involvement and not mistakenly diagnose mild cases as asthma or psychoneurosis. The use of steroids in mild cases has been beneficial at times, but progressive airway obstruction and fatalities have occurred during their administration.

Tuberculosis of peripheral joints: an often missed diagnosis.

Eleven elderly patients with tuberculous arthritis of 12 peripheral joints were studied retrospectively. The disease usually presented as a monoarticular arthritis often in the absence of other signs of tuberculosis. A delay in diagnosis was a common feature and synovial biopsies provided the highest diagnostic yield.

Aortic arch arteritis in the elderly. An important manifestation of giant cell arteritis.

Five elderly patients with aortic arch syndrome secondary to large-vessel vasculitis all presented with upper-extremity claudication and absence of blood pressure and pulses in the affected extremity. Diagnosis was suspected by a markedly elevated erythrocyte sedimentation rate associated with constitutional symptoms and angiograms showing changes consistent with arteritis of the aortic arch vessels. Treatment with high-dose corticosteroids resulted in rapid resolution of constitutional symptoms and improved functional use of the upper extremity. Recognition of this steroid-responsive disease is essential to avoid unnecessary reconstructive surgery and to prevent catastrophic events such as aortic dissection or visual loss, which may result from the underlying disease process.