Destructive arthropathy of the hands in chronic hemodialysis patients. A report of seven cases with pathological documentation.

Destructive arthropathy of the hands is common in chronic hemodialysis patients. The clinical and histological features in seven cases are reported. There were five females and two males aged 45 to 78 years. Hemodialysis duration at the time of surgery was 48 to 228 months (mean 92 months). Four patients had arthrodesis, two had insertion of silastic implants and one had a diagnostic surgical biopsy. The site of the surgical procedure was a distal interphalangeal joint in three patients, a proximal interphalangeal joint in one, a trapeziometacarpal joint in two, and both a proximal and a distal interphalangeal joints in one. All seven patients had severe destructive arthropathy responsible for pain and instability. Roentgenograms showed joint space obliteration and subchondral erosions or lysis, without osteophytosis. Several finger joints were involved in six of the seven patients. Histologic studies of the synovial membrane (n = 7) and subchondral bone (n = 4) found no amyloid even in the three patients with clinical or roentgenographic evidence of amyloidosis at other sites. Electron microscopy studies were done in two patients and failed to disclose crystals or amyloid. Our findings demonstrate that destructive arthropathy of the hands in hemodialysis patients is not a manifestation of dialysis-related amyloidosis. The pathophysiology of the condition remains poorly understood.

[The reactive arthritis syndrome. Rheumatological limits]. / Le syndrome arthrite réactionnelle. Limites rhumatologiques.

The term reactive arthritis (RA) refers to an inflammatory joint disease in the absence of bacteria in the joint, but which is caused by a distant extra-articular infection. They occur as a result of a variety of infections, which are essentially genital or gastro-intestinal in subjects with a particular genetic predisposition characterized by the presence of the HLA-B27 antigen or one of the CREG group of antigens (B7 - B27 - BW22 - BW42). The most complete clinical expression of reactive arthritis is the Fiessinger-Leroy-Reiter syndrome. Apart from the reactive arthritis with a generally accepted aetiology such as those following infections of the genital tract (Chlamydia trachomatis, Ureaplasma urealyticum or of the gastrointestinal tract: Yersinia enterocolitica and pseudotuberculosis, Shigella flexneri, Salmonella minor, Campylobacter jejuni), the authors discuss the possibility of including, in a broader definition of RA, post-streptococcal arthritis and cases of arthritis following gonococcal, meningococcal and Brucella infections. RA does not always have a favourable clinical course. It is not exceptional to see a picture of recurrences with progression towards chronic inflammatory rheumatism.

[5-year treatment of rheumatoid polyarthritis with D-penicillamine]. / Traitement à cinq ans de la polyarthrite rhumatoïde par la d-penicillamine.

A series of thirty patients with rheumatoid arthritis in whom D-penicillamine therapy was initiated more than five years ago was analyzed. Results were satisfactory in nine patients: two (6.6%) are still taking D-penicillamine and seven (23%) have experienced stabilization of their disease. In nine patients (28%) therapy was discontinued before the end of the third year because of adverse side-effects; no harmful side-effects were recorded after the third year. In ten patients (33%) D-penicillamine was discontinued because of ineffectiveness, either during the first year because of non-responsiveness (3 patients) or after the first two years because of escape phenomenon (7 patients). The authors compare their series to those previously reported in the medical literature. They believe that D-penicillamine should be given in progressive and moderate doses (averaging 600 mg per day). The mean duration of therapy with D-penicillamine was 27 months, lower than that recorded with chrysotherapy or anti-malarials; in 30% of patients, D-penicillamine was discontinued because of adverse side-effects. These findings show that, though D-penicillamine may be useful, it should be considered only after chrysotherapy.

[Atypical metastases disclosing cancer of the esophagus. Apropos of 3 cases]. / Métastases atypiques révélatrices d'un cancer de l'oesophage. A propos de trois observations.

Bone metastases from cancer of the esophagus are believed to be uncommon. The authors report the cases of three patients in whom the secondary bone lesion revealed extensive yet asymptomatic epidermoid carcinoma of the esophagus. The first patient had osteolysis of the lower extremity of the right femur, while the other two had vertebral osteolysis. Bone metastases only exceptionally reveal cancer of the esophagus; usually they occur later in the course of the disease. Their prognosis is especially poor, with death occurring 3 to 6 months after their discovery. Digestive fiberoptic endoscopy is a requisite procedure in the investigation of cancerous bone lesions.

[Osteoporosis in pregnancy]. / Ostéoporose de la grossesse.

The authors report two cases of osteoporosis, complicated by collapse of corpus vertebrae, which occurred during the last three months of pregnancy. Results of the study of phosphorus and calcium balance are not different from those found in other types of osteoporosis occurring in young adults. There is no antecedent osteopathy. Calciuria is normal. From analysis of previously published studies addressing the metabolism of phosphorus and calcium during pregnancy, a few pathogenic hypotheses for this rare aspect of osteoporosis are discussed. Special attention is given to calcitonin activity during late pregnancy.

[Results more than five years after osmic acid synoviorthesis of the rheumatoid knee]. / Résultats à plus de cinq ans des synoviorthèses a l'acide osmique du genou rhumatoïde.

Osmic acid synoviorthesis is an adjuvant form of local treatment for rheumatoid arthritis, the value of which has been demonstrated by a large number of studies over some 30 years. However, it is widely considered that the stability of the results of this type of synoviorthesis is less satisfactory than that obtained with isotope synoviorthesis and that osmic acid may damage the articular cartilage. The authors analyzed the results of a retrospective study of 90 rheumatoid knees treated by this method with a follow-up of more than 5 years (mean period 9 years). With such a follow-up, a satisfactory clinical result was seen in 44.5 p. cent of cases and radiological evaluation of the knees treated showed no worsening in initial signs in an identical percentage of cases. Best results were obtained in joints where there was little radiological damage and in cases of inflammatory or only moderately progressive arthritis, good results may also be hoped for in more severe or advanced cases. The good overall quality of the results obtained with a mean follow-up of 9 years would be in favour of the value of osmic acid synoviorthesis in the local treatment of rheumatoid arthritis.