American College of Rheumatology Spring Clinical Meeting 2000. 10-12 March 2000, New Orleans, LA, USA.

The spring clinical meeting was independently planned by the American College of Rheumatology (ACR) CME Committee and the ACR Professional Meetings Committee. This meeting was intended to provide an update of knowledge in the broad field of rheumatology through appropriate reviews of established concepts from a clinical perspective. Mini-symposia on the advancements in osteoporosis and bone diseases and practical approaches to uncommon rheumatic syndromes, were attractive features of this meeting.

Antipolymer antibody reactivity in a subset of patients with fibromyalgia correlates with severity.

OBJECTIVE: To determine the prevalence of antipolymer antibodies (APA) in patients with fibromyalgia (FM) and autoimmune disease control groups and to determine if the presence of these antibodies correlates with severity in patients with FM. METHODS: Sera from patients with FM (n = 47), osteoarthritis (OA) (n = 16), and rheumatoid arthritis (RA) (n = 13) were analyzed. Patients with implants of any kind and patients with concurrent autoimmune conditions were excluded from study. Banked sera from autoimmune disease controls including poly/dermatomyosis (n = 15), RA (n = 30), systemic lupus erythmatosus (SLE) (n = 30), and systemic sclerosis (SSc) (n = 30) were also analyzed. To determine if seroreactivity correlates with severity, banked sera from patients with FM assessed as severe (n = 28) or mild (n = 37) and from controls (n = 21) were assayed. RESULTS: Following analysis, the prevalence of seroreactivity was found to be higher in patients with FM (22/47, 47%) compared to patients with OA (3/16, 19%; p<0.1) or RA (1/13, 8%; p<0.05) and the autoimmune disease control sera from poly/dermatomyosis (2/15, 13%; p<0.05), and patients with RA (3/30, 10%; p<0.01), SLE (1/30, 3%; p<0.01), and SSc (1/30, 3%; p<0.01). The prevalence of APA seroreactivity was also significantly higher in patients with severe FM (17/28, 61%) compared to patients with mild FM (11/37, 30%; p<0.05) and controls (4/21, 19%; p<0.01). In addition, both mean threshold and mean tolerance dolorimetry scores were significantly lower in the seropositive patients with mild FM (1.33+/-0.21, 1.95+/-0.25, respectively) compared to the seronegative patients (1.83+/-0.08, 2.53+/-0.11; p<0.05 for both comparisons, respectively). CONCLUSION: These results reveal that an immunological response, production of anti-polymer antibodies, is associated with a subset of patients with FM. The results also suggest that the APA assay may be an objective marker in the diagnosis and assessment of FM and may provide additional avenues of investigation into the pathophysiological processes involved in FM.

Use of antipolymer antibody assay in recipients of silicone breast implants.

BACKGROUND: Local complications (encapsulation, rashes, rupture, and leakage) can occur after placement of silicone gel-containing breast implants (SBI). Whether SBI exposure results in systemic manifestations in some recipients is controversial. We have carried out a blinded study to assess whether there is any difference between SBI recipients and non-exposed controls in the proportions positive for serum antibodies directed against polymeric substances. METHODS: We recruited female SBI recipients (including those without symptoms) who presented to a single rheumatology clinic. A physician global assessment was used to classify SBI recipients who did not meet criteria for specific autoimmune diseases according to the severity of local and systemic signs and symptoms. Controls were recruited from among clinic staff and their acquaintances. Results of the antipolymer antibody (APA) assay were compared with those of an assay for antinuclear antibodies (ANA) and with the severity of the signs and symptoms. FINDINGS: Positive APA results were found in one (3%) of 34 SBI recipients with limited symptoms, two (8%) of 26 with mild symptoms, seven (44%) of 16 with moderate symptoms, and 13 (68%) of 19 with advanced symptoms. Four (17%) of 23 healthy non-SBI-exposed controls and two (10%) of 20 non-exposed women with classic autoimmune diseases were positive for APA. Thus, women with moderate or advanced symptoms were significantly more likely than those with limited or mild symptoms, or non-exposed controls to have APA (p < 0.001). The proportion with positive ANA results was higher for women with classic autoimmune diseases 14 (70%) of 20 than for any SBI-exposed subgroup (0-33%). INTERPRETATION: The APA assay can objectively contribute to distinguishing between SBI recipients with limited or mild signs and symptoms. SBI recipients with more severe manifestations, and patients with specific autoimmune diseases. Further studies will be needed to define the signs and symptoms associated with exposure to SBI.

Involutional lipoatrophy: macrophage-related involution of fat lobules.

Involutional lipoatrophy is an apparent idiopathic lipoatrophy with characteristic histopathologic features. We report a patient with a distant history of intramuscular injections and subsequent typical involutional lipoatrophy in whom macrophage invasion of the fat was prominent. Light microscopy revealed small, thin lobules of fat with focally prominent blood vessels and a variably hyaline background. Macrophages containing granular acid mucopolysaccharide material were present in direct apposition to lipocytes, around involuting lobules and between collagen fibers in the neighboring dermis. Focal deposits of iron were observed. Electron-microscopic examination revealed macrophages abutting lipocytes and containing lipid droplets, clear vacuoles and lysosomes in varying proportions. Lipocytes varied in size. The lipid appeared normal in most, but scattered cells contained electron-dense granules or needle-shaped clefts within the lipid. We speculate that previous injections in our patient stimulated a macrophage response, with subsequent regression of lipocytes of the neighboring fat lobules.

Evaluation of factors associated with glucocorticoid-induced osteopenia in patients with rheumatic diseases.

In 161 ambulatory rheumatic disease patients receiving long-term prednisone therapy, diaphyseal mass (DM) and metaphyseal mass (MM) of the forearm were measured by single photon absorptiometry, and bone radiographs were reviewed when available. Multivariate analysis of treatment and patient characteristics demonstrated that glucocorticoid-induced osteopenia (defined as an elevated DM:MM ratio) and bone fractures occurred with similar frequency in patients of each sex, in whites and blacks, in patients with various rheumatic diseases, and in patients receiving different regimens of prednisone therapy. However, large cumulative doses of prednisone were associated with elevated DM:MM ratios as well as with bone fractures, and menopause or age greater than or equal to 50 years (males or females) was associated with bone fractures. We conclude that long-term therapy with various prednisone regimens results in glucocorticoid-induced osteopenia and fractures. This affect is cumulative, occurs in all patient groups, and results in more bone fractures in certain groups.

Effect of oral 1,25-dihydroxyvitamin D and calcium on glucocorticoid-induced osteopenia in patients with rheumatic diseases.

Twenty-three rheumatic disease patients with glucocorticoid-induced osteopenia (defined by measurement of forearm bone mass) completed an 18-month double-blind, randomized study to assess the effect of oral calcium and 1,25-dihydroxyvitamin D (1,25-OH2D) or calcium and placebo on bone and mineral metabolism. Intestinal 47Ca absorption was increased (P less than 0.05) and serum parathyroid hormone levels were suppressed (P less than 0.01) by 1,25-OH2D (mean dose 0.4 micrograms/day); however, no significant gain in forearm bone mass occurred, and bone fractures were frequent in both groups. In the 1,25-OH2D group, histomorphometric analysis of iliac crest biopsy specimens demonstrated a decrease in osteoclasts/mm2 of trabecular bone (P less than 0.05) and parameters of osteoblastic activity (P less than 0.05), indicating that 1,25-OH2D reduced both bone resorption and formation. We conclude that 1,25-OH2D should not be used for treatment of glucocorticoid-induced osteopenia. Since patients receiving calcium and placebo did not exhibit a loss of forearm bone mass, elemental calcium supplementation of 500 mg daily might be useful to maintain skeletal mass in patients receiving long-term glucocorticord therapy.

Bone loss in adults receiving alternate day glucocorticoid therapy. A comparison with daily therapy.

Bone mineral content was measured by photon absorption densitometry in 25 patients with rheumatic diseases receiving glucocorticoids on an alternate day treatment schedule, and in 25 age-, sex-, and race-matched patients receiving daily steroid therapy. Mean values for cortical (diaphyseal) mass, trabecular (metaphyseal) mass, and the cortical/trabecular mass ratios were not different in the two groups. Steroid-induced osteopenia, defined as an elevated ratio of cortical to trabecular mass, occurred in both therapeutic regimens (8 of 25 on alternate day; 11 of 25 on daily). Therefore, bone loss was demonstrable in individuals on alternate day regimens. Serum levels of calcium, ionized calcium, alkaline phosphatase, and parathyroid hormone were similar in the two groups.