Pneumococcal polyarticular septic arthritis in a patient with rheumatoid arthritis.

Rheumatoid arthritis is the most commonly reported host-related risk factor for septic arthritis. This risk is highest in severe, seropositive, long-standing (mean, 10 years) rheumatoid arthritis responsible for extraarticular symptoms and treated with systemic glucocorticoids. The clinical presentation of the joint infection is often atypical, leading to diagnostic wanderings. In 25% of cases, the infection is polyarticular, with 3.5 involved joints on average. Staphylococcus aureus is the most common causative organism. Streptococcus pneumoniae causes 5% of all cases of septic arthritis and is more often responsible for polyarticular infections than other organisms. Polyarticular septic arthritis carries a poor prognosis, with a mortality rate of 50% in rheumatoid arthritis patients. Despite its low incidence, polyarticular septic arthritis should be routinely considered in the differential diagnosis of rheumatoid flares. We report a case of pneumococcal septic arthritis involving five joints in a patient with known rheumatoid arthritis. Three other cases with involvement of more than four joints have been published.

Prospective study of the prevalence of bronchiectasis in rheumatoid arthritis using high-resolution computed tomography.

A prospective study of the prevalence of bronchiectasis in rheumatoid arthritis was conducted over an 18-month period in 46 patients (34 women and 12 men with a mean age of 60.1 years) meeting 1987 American College of Rheumatology criteria for rheumatoid arthritis. All patients underwent high-resolution computed tomography of the chest, whose results were confronted with a number of clinical, laboratory test and lung function testing parameters. Bronchiectasis or bronchiolectasis was found in 23 patients (50%) and was the most common abnormality detected by high-resolution computed tomography. When the four patients with isolated bronchiolectasis were excluded, the prevalence was 41%. Eighteen of the 23 patients had not been diagnosed with bronchiectasis before the study and 13 were free of respiratory symptoms. No significant differences were found between the 23 patients with and the 23 patients without bronchiectasis for age at onset or duration of the rheumatoid arthritis, extraarticular involvement, positive rheumatoid factors, bony erosions, use of corticosteroids or immunosuppressives, respiratory manifestations, smoking, or spirometry parameters. Patients without bronchiectasis were more likely to have impaired diffusion of carbon monoxide across the alveolar-capillary membrane. Among the patients with bronchiectasis, those with respiratory symptoms (n = 10) were more likely to have a history of lung disease and those without respiratory symptoms (n = 13) were more likely to have a diagnosis of bronchiectasis secondary to rheumatoid arthritis; no other differences were found between these two subgroups. Routine use of high-resolution computed tomography, a technique capable of demonstrating silent bronchiectasis, showed that bronchiectasis was the most common lung change in rheumatoid arthritis in our study. At the time of the study, there was no evidence that presence of bronchiectasis was associated with more severe joint or lung symptoms.

HLA DRB1* alleles in rheumatoid nodulosis: a comparative study with rheumatoid arthritis with and without nodules.

Rheumatoid nodulosis (RN) is a rare condition associating rheumatoid nodules, episodes of arthritis, cystic bone lesions and, generally, positive rheumatoid factors (RF). It is considered a benign variant of rheumatoid arthritis (RA). In this study, we determined the HLA DRB1* alleles of our RN patients and compared the distribution of these alleles to those of 74 healthy controls and 104 RA patients with and without nodules. Four RN patients were observed. All had subcutaneous nodules and RF were negative in three patients. Of the 104 RA patients, 18 had nodules (nodRA). Systemic manifestation (including vasculitis, peripheral neuropathy or lung involvement) were found in seven of these nodRA cases (33.8%) and most had positive RF and erosive changes on X-rays. Only one RN patient had a RA-associated allele (DRB1*0101). The frequencies of the HLA DRB1* alleles encompassing the "rheumatoid" shared epitope were similar to those of other RA series: *0101, 34.6% (P = 0.03 compared with controls); *0401, 26.9% (P < 0.0001); *0404, 12.5% (P = 0.04); *0405, 4.8% (P = 0.8); *1001, 8.6% (P = 0.5). Of the nodRA and seronegative RA patients, 77.7% and 53.3%, respectively, presented the shared epitope. Thus, there was a tendency to decreased expression of the RA-associated alleles in RN (25%) compared with nodRA and seronegative RA patients. This study is restricted by the small number of tested RN patients, but the results suggest that the RA-associated alleles are poorly expressed in RN.

Do minocycline and other tetracyclines have a place in rheumatology?

Tetracyclines are a family of antimicrobials with activity against a broad range of organisms including those that develop intracellularly. Links have been reported between some infections and some inflammatory joint diseases, with the most notable example involving mycoplasmas and rheumatoid arthritis. Reactive arthritides are known to be triggered by organisms found in the gastrointestinal or genitourinary tract, and antigenic material from these organisms has recently been demonstrated in synovial tissue from patients with reactive arthritis. These facts led to the hypothesis that tetracyclines may be useful in rheumatoid arthritis and reactive arthritis. Two controlled studies found that minocycline benefited rheumatoid arthritis patients when it was given either as an adjunct to another second-line treatment or as the only slow-acting drug. Lymecycline has been found to expedite recovery from reactive arthritis due to Chlamydia trachomatis, and tetracycline to decrease the incidence of reactive arthritis due to sexually-transmitted diseases. The safety profiles of these treatments were acceptable in all available studies but require further investigation during long-term administration. The benefits may be related to the immunomodulating effects of tetracyclines and/or to their ability to inhibit metalloproteases such as collagenases. Whether tetracycline therapy influences the course of radiologic lesions in rheumatoid arthritis remains unknown. However, minocycline therapy has given sufficient proof of its efficacy to make it an attractive alternative in rheumatoid arthritis.

[Bronchiectasis and rheumatoid arthritis. Incidence and etiopathogenic aspects. Review of the literature]. / Bronchectasies et polyarthrite rhumatoïde. Fréquence et aspects étiopathogéniques. Revue de la littérature.

Many pleural and pulmonary manifestations are described in rheumatoid arthritis, due to the disease itself or drug-induced. A literature review revealed 289 reports of bronchiectasis since 1928, the respiratory symptoms preceding the articular features in 90%. Although the frequency of bronchiectasis in the general population is difficult to assess, and thus maybe underestimated, the prevalence in rheumatoid arthritis seems higher. Thus the recent studies, using modern processes such as high resolution computed tomography of the lungs, assess this association to about 25%. Nevertheless, the methodology of these studies is open to criticism, so the high frequency must be qualified. The pathogenic and aetiological factors remain unknown, and miscellaneous hypotheses, especially immunological, have been suggested. The relationship between both affections can not be asserted, but the association is unlikely to be fortuitous.

Rheumatoid arthritis and bronchiectasis. A retrospective study of fourteen cases.

Since 1928, 288 cases of rheumatoid arthritis and bronchiectasis have been reported in the medical literature. The interactions between these two conditions and the etiopathogenic mechanisms they involve remain unclear. During a retrospective study of 100 rheumatoid arthritis patients and 80 bronchiectasis patients, we identified 14 additional patients with both conditions. There were 10 females and four males (ratio 2.5/1). Bronchiectasis was confirmed either by computed tomography of the chest or by bronchography. The respiratory manifestations antedated the joint disease in 12 patients, by a mean interval of 28.5 years. An infectious cause was identified in six cases. Neither the age at onset nor the duration of rheumatoid arthritis were influenced by the presence of bronchiectasis. Seven patients had 15 extraarticular manifestations suggesting potentially severe joint disease. The flares of joint and respiratory symptoms were concomitant in six patients. In six patients, the respiratory manifestations worsened after onset of the joint disease. Tests for rheumatoid factors were positive in 73% of cases. Panhypogammaglobulinemia was found in one case. Ten patients underwent lung function tests, which showed evidence of nonspecific obstructive disease. Overall, our findings are consistent with previous reports in the literature. In patients with predisposing immunogenetic factors, bronchiectasis may be involved in the genesis of rheumatoid arthritis.

Sarcoidosis and spondylarthropathy. Three case-reports.

Coexistent sarcoidosis and seronegative spondylarthropathy have rarely been reported. We add three new cases to the nine previously published. Two men and one woman with sarcoidosis met Amor's criteria for spondylarthropathy. The diagnosis of sarcoidosis was based on histologic findings in two cases and on roentgenographic and laboratory test findings in one case. The features of each of the two diseases were unremarkable. The two diagnoses were confirmed at about the same time. Osteoarticular manifestations of sarcoidosis are reviewed. Our case-reports illustrate the diagnostic difficulties raised by discovery of sacroiliitis in a patient with sarcoidosis: sarcoid osteitis, infection, or a spondyloarthropathy can be the cause of the sacroiliac lesions. Moreover, the pelvic and spinal manifestations of sarcoidosis can mimick a spondylarthropathy. Coexistence of sarcoidosis and spondylarthropathy is probably due to chance, since there are no shared predisposing genetic factors and the number of reported cases is small.

Proximal paraparesis following spinal anesthesia.

A 70-year-old man with prostatic cancer extending to the urinary bladder underwent transurethral resection of the bladder neck under spinal anesthesia and developed weakness of the proximal lower limbs a few hours after the procedure. The weakness persisted for several months. Because there were no local surgical complications (hematoma, infectious epiduritis, abscess) or bone metastases responsible for nerve root or spinal cord compression, a causal relation between the neurologic deficit and the spinal anesthesia was considered likely. Neurologic deficits are uncommon after spinal anesthesia and can be produced by complications of the surgical procedure (direct nerve injury, hematoma, abscess), arachnoiditis, neurotoxicity of disinfectants or of preservatives added to solutions of anesthetic drugs, or spinal cord ischemia. Precipitating factors for spinal cord ischemia include faulty patient position during the procedure, intraoperative arterial hypotension and injection of vasoconstricting agents.

Spontaneous fracture of the odontoid process in a patient with ankylosing spondylitis. Nonunion responsible for compression of the upper cervical cord.

Tetraparesis due to a spontaneous fracture of the base of the odontoid process occurred in a patient with undiagnosed, advanced ankylosing spondylitis. Few cases of insufficiency fractures of the proximal cervical spine in patients with loss of spinal mobility have been reported in the literature. The pathologic lesions that can cause severe neurologic compromise are reviewed. Because functional impairment and neurologic loss are common even after surgical decompression and stabilization, these lesions should be looked for during a careful physical evaluation followed by appropriate investigations.