Tolerability of opioids in patients with acute pain due to nonmalignant musculoskeletal disease. A hospital-based observational study.

OBJECTIVE: To evaluate the prevalence of adverse effects of opioids used to treat acute nonmalignant musculoskeletal pain. METHODS: Prospective, single-center, observational study in patients admitted to a rheumatology department for a nonmalignant painful musculoskeletal condition with onset within the last 3 months and a need for WHO Class III analgesics. The following side effects were recorded daily: nausea and vomiting, constipation, pruritus, urinary retention, drowsiness, confusion, and hallucinations. RESULTS: The 75 study patients (46 women and 29 men with a mean age of 56.4 years) were admitted for nerve root pain, osteoporotic vertebral fracture, inflammatory joint disease, or other disorders. First-line treatment was sustained-release morphine sulfate in a mean starting dosage of 55.2 mg/day. The dosage was increased if needed (mean maximum dosage, 78.3 mg/day). Mean treatment duration was 8.9 days. Adverse effects were recorded in 73.3% of patients but were usually minor, requiring no change in the treatment regimen. Eight patients experienced serious adverse effects (confusion in five and urinary retention in three) that resolved with no change in treatment in two patients, after dosage reduction in two patients and after substitution of fentanyl or hydromorphone hydrochloride in four patients. Treatment discontinuation was not associated with adverse effects. CONCLUSIONS: Morphine is often responsible for adverse effects in patients with acute nonmalignant musculoskeletal pain. These effects are usually moderate and very rarely require discontinuation of the drug.

Joint symptoms in patients on bupropion therapy.

OBJECTIVE: To describe joint symptoms related to bupropion therapy. METHODS: We retrospectively reviewed adverse events in bupropion-treated patients reported to the Bourgogne Drug Surveillance Center, France, between October 2001 and December 2002. Joint symptoms classified by the causality assessment as related to bupropion were identified and examined. RESULTS: Four cases were found. Three patients had semi-delayed hypersensitivity reactions resembling serum sickness, manifesting as urticaria and arthralgia with or without a fever. The remaining patient had an unusual presentation consisting in acute monoarthritis of the wrist that started a few days after bupropion initiation. CONCLUSION: Hypersensitivity reactions to bupropion are fairly common and include rare cases of serum sickness-like reaction. Urticaria and incapacitating arthralgia are at the forefront of the clinical picture and may require a brief period of inpatient care. Antihistamines are the treatment of choice. Other manifestations such as acute monoarthritis might occur, although this awaits confirmation as we identified a single case.

Nicolau's syndrome after local glucocorticoid injection.

We report three cases of Nicolau's syndrome induced by intraarticular glucocorticoid injections. Nicolau's syndrome is defined as livedo-like dermatitis secondary to acute arterial thrombosis occurring immediately after intravascular injection of an insoluble drug substance. The cases described by Nicolau occurred in association with injections of oily bismuth suspensions. In 1970s and 1980s, cases occurred with delayed-action penicillin suspensions injected intramuscularly. Typically, the injection is followed immediately by excruciating pain in the buttock, sometimes with syncope. Cyanotic patches and a livedoid pattern develop. Rapid resolution of the pain and slower clearing of the skin changes occur in most patients. We report three typical cases with both severe pain and skin changes. In addition, two other patients had incomplete variants without skin abnormalities. Each of these five patients had received an injection in or about a joint of a glucocorticoid in a crystalline suspension. The pathophysiology of this syndrome probably involves acute vascular spasm related to penetration of microcrystals into a blood vessel.

Magnetic resonance imaging in the assessment of synovial inflammation of the hindfoot in patients with rheumatoid arthritis and other polyarthritis.

OBJECTIVES: To describe the localisation of synovitis and tenosynovitis of the hindfoot observed on magnetic resonance imaging (MRI) in patients with chronic polyarthritis, and to correlate the findings of physical examination and MRI. METHODS: Patients with chronic polyarthritis, and one or two painful hindfoot were included. On physical examination and on MRI, the tibio-talar, talo-calcaneal, and talo-navicular and calcaneo-cuboidal joints were adjudged to have or not synovitis, and the tibialis anterior and posterior, the peroneus longus and brevis, the flector digitorum and hallucis longus tendons to have or not tenosynovitis. Criteria for synovitis and tenosynovitis were a high signal intensity on T2-weighted images, a low signal intensity on T1-weighted images, and enhancement after Gd-DTPA injection, in the joint area, and around the tendon, respectively. The correlation between the findings of physical examination and those of MRI were evaluated using the Kappa statistics. RESULTS: 12 patients (three men, nine women, mean age of 55.5 years+/-11.4 S.D.) with chronic polyarthritis (rheumatoid arthritis (RA): nine, ankylosing spondylitis: one; psoriatic arthritis: one, unclassified: one) were included. All presented with one (7 patients) or two (5 patients) painful hindfeet (and swelling for 16 out of 17 hindfeet). On physical examination, 25 joints and eight tendons were adjudged to have synovitis and tenosynovitis. MRI showed synovitis in 12 out of 25 of these joints (48%), and tenosynovotis in three out of eight of these tendons (37.5%). Moreover, MRI showed ten and seven clinically unsuspected synovitis and tenosynovitis, respectively. The proportion of agreements between physical examination and MRI were 54.9% (kappa=0.1) and 88.2% (kappa=0.27) for synovitis and tenosynovitis, respectively. CONCLUSION: A weak correlation was observed between the findings of physical examination and MRI in patients with chronic polyarthritis and a painful hindfoot. MRI might be used to localise synovitis in the area before performing some intra-articular injections. However, other studies are needed to address this question.

Diagnostic usefulness of routine Lyme serology in patients with early inflammatory arthritis in nonendemic areas.

OBJECTIVE: To evaluate the diagnostic usefulness of routine Lyme serology in patients who live in nonendemic areas and present with early inflammatory joint disease. METHODS: All patients admitted to a rheumatology department of a nonendemic area of France for evaluation of joint disease with onset within the last year. The evaluation included a medical history, a thorough physical examination, an electrocardiogram, and an ELISA for antibodies to Borrelia burgdorferi. RESULTS: We included 90 patients, 51 women and 39 men, with a mean age of 48.1 +/- 17.9 years. Mean duration of joint symptoms was 4.3 +/- 4.3 months, with a median of 3 months. A patient (1.1%) reported a tick bite and no patients had a history of erythema migrans. Lyme serology was negative in all 90 patients. CONCLUSION: These results do not support routine Lyme serology in patients living in nonendemic areas and presenting with early inflammatory joint disease. However, Lyme serology remains appropriate in patients with features suggestive of Lyme disease. Given that Lyme disease is amenable to curative treatment, a larger study is in order to confirm our findings.