Can immunization precipitate connective tissue disease? Report of five cases of systemic lupus erythematosus and review of the literature.

OBJECTIVES: To report a series of five patients who developed systemic lupus erythematosus (SLE) after immunization and review the literature on vaccine-associated connective tissue diseases and the theoretical mechanisms that could explain such an association. METHODS: Uncontrolled retrospective analysis of cases identified sporadically over 7 years at three centers. RESULTS: In our series of 5 patients, symptoms of SLE developed within 2 to 3 weeks after secondary immunization. All patients met American College of Rheumatology (ACR) criteria for the diagnosis of SLE. In most patients, symptoms have been persistent. CONCLUSION: Although a coincidental association between vaccination and the onset of SLE cannot be excluded, the temporal relationship with the development of symptoms makes it immunologically plausible that vaccination triggered systemic autoimmunity in these rare cases. We propose that epidemiological studies be performed to examine this potential association in more detail to quantitate the risk and identify possible genetic risk factors.

Antigen-specific antibody responses in lupus patients following immunization.

OBJECTIVE: To determine the safety and efficacy of 3 clinically relevant vaccines in patients with systemic lupus erythematosus (SLE). METHODS: We studied 73 consecutive SLE patients immunized with pneumococcal, tetanus toxoid (TT), and Haemophilus influenzae type B (HIB) vaccines. Patients were evaluated preimmunization and 12 weeks postimmunization for disease activity and immunization side effects. RESULTS: Eighty-four percent of the SLE patients developed a 4-fold titer increase in response to at least 1 vaccine, with 51% developing a 2-fold titer increase with all 3 vaccines. The majority of SLE patients developed protective levels of antibody to TT (90%) and HIB (88%). Although protective antibody levels could not be determined for pneumococcus, almost half of the patients (47%) developed a 4-fold antibody response. There was a trend toward a lower antibody response in patients with active disease treated with immunosuppressive therapy. Overall lupus disease activity was unaffected by immunization. CONCLUSION: Immunization is safe in SLE patients, with the overwhelming majority developing protective antibody levels. Therefore, SLE patients should receive immunizations according to the recommendations of the Centers for Disease Control and Prevention and the Immunization Practices Advisory Committee.

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).

Variability of treatment for gouty arthritis between rheumatologists and primary care physicians.

Wide variability exists in the treatment of gout. We compared the treatment practices of rheumatologists with those of primary care physicians (PCPs) in the management of gout. Pharmacy records were reviewed to identify patients treated with colchicine, allopurinol, probenecid, or sulfinpyrazone. Forty PCP patients were compared with 33 patients followed by rheumatologists. Rheumatologists were three times more likely to confirm the diagnosis with joint aspiration and guide therapy with 24-h urine uric acid collections than were PCPs. Rheumatologists were more likely to use prophylaxis in acute gout before initiating uric acid-lowering therapy than were PCPs. All PCP patients were treated with allopurinol compared with 65% of rheumatology patients. Mean posttreatment uric acid levels were lower for rheumatology patients (5.0 mg/dL) compared with PCP patients (6.0 mg/dL). Previous studies have reported poor symptom control and increased toxicity in gouty patients with suboptimal treatment. With the vast majority of patients being treated by PCPs in a man-aged care setting, further studies will be necessary to determine whether treatment variability affects outcome between the two groups.

Chronic calcium pyrophosphate crystal deposition disease arthropathy associated with hypomagnesemia.

We describe a case of a young woman with a magnesium renal wasting syndrome leading to severe hypomagnesemia and a chronic pseudo-osteoaritis calcium pyrophosphate crystal deposition disease (CPDD) arthropathy. A chronic CPDD arthropathy secondary to hypomagnesemia has not been previously reported. The identification of CPDD, particularly in the young, can be a clue to the presence of a potentially treatable underlying metabolic disorder, such as hypomagnesemia.

Hypomagnesemia in postoperative spine fusion patients.

STUDY DESIGN: This was a retrospective review of 49 consecutive patient charts and a prospective study of 44 consecutive patients who underwent spinal fusion. OBJECTIVE: To determine the incidence and clinical significance of hypomagnesemia after spinal fusion. SUMMARY OF BACKGROUND DATA: Hypomagnesemia may be seen in 61% of patients in postoperative intensive care and may be associated with increased mortality. However, symptomatic hypomagnesemia is rare. METHODS: A retrospective review of the charts of 49 consecutive patients who underwent spine fusion was completed to determine postoperative magnesium levels. Twenty-seven patients with postoperative hypomagnesemia received routine magnesium replacement regardless of symptoms. Forty-four patients who underwent spine fusion were studied prospectively for postoperative hypomagnesemia. Prospectively studied observational patients who developed hypomagnesemia were treated only when clinical signs or symptoms of magnesium deficiency occurred. RESULTS: Postoperative hypomagnesemia occurred in 28 of 49 retrospectively studied patients who underwent spine fusion (57%) and 38 of 44 prospectively studied patients who underwent spine fusion (86%). Symptoms associated with hypomagnesemia developed in three of 44 prospectively studied and two of 49 retrospectively studied patients who underwent spine fusion (7% and 4%, respectively). The combined incidence for symptomatic hypomagnesemia was five of 93 patients. (5.4%). The majority of patients from the prospective study with postoperative hypomagnesemia were asymptomatic, and their magnesium levels returned to normal within 4 days, with or without treatment. CONCLUSIONS: This study confirmed a high incidence of hypomagnesemia in patients who underwent spine fusion, although only 5.4% developed clinical signs or symptoms of magnesium deficiency. The cause of hypomagnesemia remains speculative.