Parvovirus arthropathy outbreak in southwestern United States.

OBJECTIVE: We describe an outbreak of parvovirus (PV) arthropathy that was detected in a rheumatology clinic in San Antonio, Texas, during the winter of 1994. Parvovirus B19 causes acute symmetric polyarthritis (ASPA) in adults. In the US, the majority of cases described are from the northern US. METHODS: An outbreak of PV arthropathy was monitored in a San Antonio area rheumatology clinic. RESULTS: Of the 16 affected patients, 69% were female, ages ranging from 23 to 60 years; 75% had close contact with children, 58% of whom were exposed to children with clinical PV. All patients noted an acute arthritis except for 2 patients with polyarthralgias. The most common presentation was ASPA (9/16), with 10/16 complaining of viral prodrome, and 5/16 having a nonspecific rash, but none with the typical "slapped cheek" appearance. Eleven patients had an ASPA at some time in their illness. Of these, 3 had a true migratory arthritis that developed into an ASPA and another 2 were additive. Two additional patients had persistent asymmetric polyarthritis. The most common joints involved were the metacarpophalangeals, proximal interphalangeals, wrists, and knees. Most patients' syndromes lasted < 6 weeks, but 3 patients had symptoms that lasted longer than 6 months. Eight of 10 had elevated erythrocyte sedimentation rate. Rheumatoid factor was detected in 3 patients and antinuclear antibody in 2. All patients were treated symptomatically with nonsteroidal antiinflammatory drugs and a few also received low dose corticosteroids. Because of suspicious clinical presentations, 2 patients were presumed to have gonococcal arthritis before PV titers were available. CONCLUSION: This is the first large series on adults with PV arthropathy reported in the southern US. In contrast to the usual features of ASPA, the outbreak appears unique in that almost 40% of cases presented with a true migratory arthritis.

Rheumatic findings in Gulf War veterans.

BACKGROUND: Rheumatic symptoms were commonly described among soldiers who served in previous wars. OBJECTIVE: To describe the frequency of rheumatology consultations, along with the diagnoses, and abnormal results on serologic testing in Gulf War veterans evaluated for Gulf War syndrome. METHODS: The medical records of the first 250 consecutive Gulf War veterans referred to the comprehensive clinical evaluation program at Wilford Hall Air Force Medical Center and Brooke Army Medical Center, San Antonio, Tex, were reviewed for demographic characteristics and frequency of subspecialty consultations. A retrospective review of rheumatic diagnoses and the frequency of abnormal serologic test results was recorded. RESULTS: Of the 250 Gulf War veterans evaluated in the comprehensive clinical evaluation program, 139 (56%) were referred for rheumatology consultation, which was the most common elective subspecialty referral. Of the patients evaluated, 82 (59%) had soft tissue syndromes, 19 (14%) had rheumatic disease, and 38 (27%) had no rheumatic disease. The most common soft tissue syndromes were patellofemoral syndrome (33 patients [25%]), mechanical low back pain (23 patients [18%]), and fibromyalgia (22 patients [17%]). Of the 19 patients with rheumatic disease, 10 had osteoarthritis, 2 had rheumatoid arthritis, 2 had gout, and 1 each had systemic lupus erythematosus, Behcet disease, parvovirus arthritis, psoriatic arthritis, and hypothyroid arthropathy. Abnormal serologic test results were common among the Gulf War patients regardless of the presence or absence of rheumatic disease. CONCLUSIONS: The rheumatic manifestations in Gulf War veterans are similar to symptoms and diagnoses described in previous wars and are not unique to active duty soldiers. Overall, the results of serologic screening were poor predictors of the presence of rheumatic disease.

Physical and sexual abuse in female patients with fibromyalgia.

Sexual and physical abuse during childhood seem to be common. The purpose of this study was to determine the prevalence of sexual and physical abuse reported by female fibromyalgia (FM) patients in a referral-based rheumatology practice, and whether patients with FM report greater frequencies of abuse than do patients with rheumatoid arthritis (RA).Patients from two tertiary care centers, 205 with FM and 84 with RA, were mailed a self-administered questionnaire requesting information about demographics, mental health care use, and history of sexual and/ or physical abuse. There were responses from 105 FM and 44 RA patients.A history of sexual or physical abuse was reported by 54% of the sample. Any type of abuse was significantly more prevalent among patients with FM (62%) compared with those with RA (34%, p = 0.02). FM patients had a significantly increased prevalence of both sexual abuse (51% vs. 32%, p = 0.028) and physical abuse (39 vs. 16%, p = 0.006) compared with RA patients. FM patients were more likely than RA patients to report a history of multiple sexual abusers, increased duration of sexual abuse, and more violent physical abuse. Irritable bowel syndrome was more common in FM (44%) than RA patients (9%, p < 0.001), and 57% of FM patients had seen a mental health professional compared with 30% of RA patients (p = 0.002).

Prospective use of intramuscular triamcinolone acetonide in pseudogout.

OBJECTIVE: To prospectively assess the efficacy of intramuscular (i.m.) triamcinolone acetonide in the treatment of pseudogout. METHODS: Fourteen patients with crystal proven pseudogout presenting with an acute attack within 5 days of onset were treated with intramuscular triamcinolone acetonide 60 mg and followed for 30 days. Patients with inadequate response were eligible for a 2nd triamcinolone acetonide injection on Day 1-2. RESULTS: Twelve patients had contraindication to nonsteroidal antiinflammatory agents (NSAID). Acute arthritis was monoarticular in 10 patients, and involved 2 or more joints in 4 patients. All patients had good clinical response to triamcinolone acetonide based on restoration of near baseline joint range of motion and joint circumference, and at least 50% improvement in patient and physician global assessment. Major clinical improvement occurred by Day 1-2 (2 patients), Day 3-4 (11 patients), and Day 10-14 (one patient). Six patients required a 2nd triamcinolone acetonide injection on Day 1-2. Toxicities were not observed. CONCLUSION: I.m. triamcinolone acetonide appears to be safe, well tolerated, and effective in the treatment of pseudogout. It may be a reasonable alternative therapy when NSAID are contraindicated, and for polyarticular attacks where intraarticular corticosteroids are impractical.

Postoperative joint infections in rheumatoid arthritis patients on methotrexate therapy.

The effect of low dose methotrexate (MTX) on postoperative complications in rheumatoid arthritis patients undergoing elective total joint arthroplasty was observed prospectively in 32 patients. Patients were assigned to discontinue MTX the week prior to and during the week of surgery (Group 1, n = 19) or to continue MTX throughout the perioperative period (Group 2, n = 13). Nineteen patients in Group 1 had 26 procedures, with no postoperative infections. Thirteen patients in Group 2 had 16 procedures, with 4 postoperative infections: 2 infected prostheses, 1 infected joint fusion, and 1 deep wound infection (P = .03). No patient had a postoperative flare of rheumatoid arthritis. Temporary discontinuation of MTX prior to joint arthroplasty appears to decrease the risk of postoperative infection.

Hydroxychloroquine in the treatment of erosive osteoarthritis.

OBJECTIVE: Hydroxychloroquine has been used successfully in the treatment of inflammatory arthritides such as rheumatoid arthritis and systemic lupus erythematosus, and less commonly in the seronegative spondyloarthropathies. Our objective was to determine the effectiveness of hydroxy-chloroquine in inflammatory or erosive osteoarthritis (OA). METHODS: We retrospectively reviewed clinical records of 8 patients prescribed hydroxychloroquine therapy whose symptoms of erosive OA were unresponsive to nonsteroidal antiinflammatory drugs (NSAID). RESULTS: Hydroxychloroquine was effective in 6 of the 8 patients treated; it was well tolerated by all patients. CONCLUSION: The use of hydroxychloroquine in patients with erosive OA unresponsive to NSAID appears promising. Prospective studies are needed to confirm our observations.

Polyarteritis nodosa in hairy cell leukemia: treatment with interferon-alpha.

Polyarteritis nodosa (PAN) is a rare but well described complication of hairy cell leukemia, with 17 cases reported. Treatment has been with prednisone or cyclophosphamide, with variable results. We describe a case of PAN associated with hairy cell leukemia treated with interferon-alpha with autopsy proven resolution of the vasculitis.

COMPARISON OF THE EFFICIENCY OF TWO DOSES OF BOVINE PPD TUBERCULIN IN SINGLE CAUDAL FOLD TESTS ON AUSTRALIAN CATTLE.

The sensitivity and specificity of 0.2 mg and 0.4 mg doses of bovine PPD tuberculin were compared in Northern Territory beef cattle from tuberculous herds and herds with a prevalence of tuberculosis of less than 0.1%. Reactions were interpreted subjectively by observation and palpation, and were also measured to the nearest mm with calipers at 24 h, 48 h, 72 h and 96 h after injection of tuberculin. All cattle were examined post mortem for the presence of macroscopic and microscopic tuberculous lesions. The apparent specificity of caudal fold tests with 0.2 mg and 0.4 mg doses was determined in cattle in Victoria from tuberculosis-free dairy and beef herds. Victorian cattle reacting to the caudal fold tests were subjected to a comparative intradermal test with 0.1 mg bovine PPD and 2,500 IU avian PPD not less than 42 days later. Tests with the 0.2 mg dose achieved the highest level of sensitivity of 95.6% at 48 h, 72 h and 96 h, while in tests with 0.4 mg the maximum reached was 94.7% at 72 h. The specificity of tests in Northern Territory cattle ranged from 85.0% to 88.3% with the 0.2 mg dose and from 80.6% to 82.3% with the 0.4 mg dose. The highest specificity was achieved with both doses at 96 h. The apparent specificity of 0.2 and 0.4 mg doses of bovine PPD in tuberculosis-free herds in Victoria was high, a false-positive reactor rate of only 0.6% occurring with caudal fold tests. All false-positive reactions were shown to be non-specific or due to previous experimental sensitisation.

The use of bovine PPD tuberculin the single caudal fold test to detect tuberculosis in beef cattle.

The efficiency of 2 different doses of bovine PPD tuberculin was compared using the caudal fold test for the detection of tuberculosis in beef cattle. Two matched groups of 98 cattle were selected on the basis of their reactivity to HCSM tuberculin. Cattle in each group were tested with a singl 0.1 ml dose of bovine PPD tuberculin containing either 0.1 mg or 0.2mg bovine PPD respectively. Two further groups of 100 young stock from a herd with an incidence of tuberculosis of less than 0.1% were selected as controls. Tests were interpreted subjectively by palpation and observation and objectively by caliper measurement at 48, 72 and 96h. All cattle were examined post mortem for the presence of visible lesions. The 0.2 mg dose of PPD detected 95% tuberculous cattle and caused false-positive reactions in 19% of cattle without lesions. The 0.1 mg dose detected 80% of tuberculous cattle and caused 11% false-positive reactions. No visible lesions of tuberculosis were found in either of the control groups although 11% reacted to 0.2 mg and 5% to 0.1 mg bovine PPD at 72h. The optimum time for reading tuberculin tests was found to be in the period 48 to 72h after the injection of bovine PPD and subjective interpretation was more efficient than caliper measurement as a means of detection of tuberculous cattle. The 0.2 mg dose of bovine PPD was found to be more specific than HCSM tuberculin.