Seronegative polyarthritis as severe systemic disease.

BACKGROUND: Severe extra-articular disease is associated with high levels of rheumatoid factor (RF ) in patients with seropositive rheumatoid arthritis (RA ) and a poor prognosis. It is said that patients with seronegative rheumatoid arthritis have a more benign course and less destructive disease. We observed several patients with seronegative non-rheumatoid polyarthritis, with aggressive extra-articular systemic disease. OBJECTIVES: Review of seronegative systemic polyarthritis with clinical presentation of typical cases. METHODS: Medline search for systemic manifestations of seronegative polyarthritis. CLINICAL PRESENTATIONS: 1. A 56-year-old woman was admitted to the cardiac intensive care unit with stabbing presternal chest pain aggravated by breathing and progressive dyspnoea, which gradually developed over a period of two weeks with one episode of fever at 38.0 degrees C. She had suffered chronic pain in her buttocks for three years with polyarthralgia and evanescent palmar-plantar rash. Imaging showed bilateral sacroiliitis (HLA B27 negative) and a large pericardial effusion. Extra-articular manifestations of SAPHO syndrome were proposed and she was successfully treated with combined therapy: pulse methylprednisolone, azathioprine, colchicine and prednisone. 2. A 47-year-old woman with psoriatic arthropathy developed high fever with leucocytosis and thrombocytosis and lung infiltrates during exacerbation of her joint disease . She was treated with pulse methylprednisolone followed by corticosteroid tapering, anti-TNF (infliximab) and methotrexate with complete resolution. 3. A 19-year-old man with inflammatory bowel disease developed acute pericarditis with response to 6-mercaptopurine, salazopyrine and prednisone. RESULTS: We discuss a range of seronegative arthritis diseases with possible systemic manifestations including the main procedures for early diagnosis. Infection, malignancy, hypersensitivity, granulomatous disease and other collagen diseases such as systemic lupus erythematosus should be excluded, but investigations for an underlying disease should not delay early corticosteroid and immunosuppressive therapy. CONCLUSION: A high level of suspicion of extra-articular disease should always be maintained when treating active seronegative polyarthritis.

Radiological findings of early invasive pulmonary aspergillosis in immune-compromised patients.

Data on the radiological features of invasive pulmonary aspergillosis (IPA) in early stages is scanty. Detection of Aspergillus (ASP) species in broncho-alveolar (BAL) fluid by polymerase chain reaction (PCR) enables early diagnosis of IPA. This study describes the radiological features of early stages of IPA. Chest computerized tomography (CT) films of 22 consecutive immune-compromised patients with IPA diagnosed with the aid of ASP PCR testing from BAL fluid were characterized and compared to that of 18 similar patients diagnosed with traditional bacteriological methods and to data from the literature. It was found that patients diagnosed with the aid of ASP PCR testing tended to have focal disease as manifested by more 11-30 mm nodules with halo (68% vs. 33%, p = 0.04), more focal ground glass (single area 32% vs. 6%, p = 0.05, patchy 32% vs. 0%, p = 0.01) and less diffuse ground glass (0% vs. 22%, p = 0.03), less cavitations (5% vs. 28%, p = 0.05) and less consolidations (segmental 14% vs. 50%, p = 0.02 and diffuse 14% vs. 67%, p = 0.001). It was concluded that the radiological appearance of early IPA diagnosed with the aid of PCR testing included mainly discrete small nodules with halo and focal ground glass, representing the early stage of the disease.

CT scout view as an essential part of CT reading.

Computed tomography scout view is a mode of operating a CT system. It is generally used to prescribe CT slices and to display slice locations rather than for direct diagnosis. However, we found that a careful study of CT scout view can contribute significantly to the diagnosis. We show seven abdominal, two chest and two head CT, where the study of CT scout view allowed diagnoses to be made that were not readily apparent from the axial slices.

The new technology of combined transmission and emission tomography in evaluation of endocrine neoplasms.

UNLABELLED: The clinical value of a novel technology of combined transmission and emission tomography (TET) was assessed in patients with endocrine tumors. METHODS: TET technology, which combines simultaneous acquisition of SPECT and CT images, using the same imaging device, allows correct fusion of images of both modalities. TET was performed on 27 patients with known or suspected endocrine tumors. The radiopharmaceuticals used for the emission part of the study were chosen according to the tumor type: (111)In-octreotide for patients with neuroendocrine tumors (n = 10), (99m)Tc-sestamibi for patients with primary hyperparathyroidism (n = 8), (131)I for patients with thyroid cancer (n = 4), and (123)I-metaiodobenzylguanidine and (75)Se-cholesterol for patients with adrenal masses (n = 3 and n = 2, respectively). The additional information provided by TET compared with scintigraphy was assessed for both image interpretation and clinical utility. RESULTS: TET did not provide any additional data in 16 patients (59%), including 5 patients with normal scintigraphy. In 11 patients (41%) with abnormal SPECT findings, TET improved image interpretation by providing a better anatomic localization of SPECT-detected lesions. It showed unsuspected bone involvement in 4 patients, it identified the organs involved and the relationship of the lesions to neighboring structures in 5 patients, and it differentiated physiologic uptake from tumor uptake in 2 patients. TET provided additional information of clinical value in 9 patients (33%). It assisted in better planning of surgery in 2 patients with neuroendocrine tumors and in 2 patients with ectopic parathyroid adenomas. It changed the treatment approach in 2 patients with neuroendocrine tumors and 1 patient with thyroid carcinoma, and it altered prognosis in 2 patients with thyroid malignancy. CONCLUSION: TET enhances the already unique role of nuclear medicine procedures in the assessment and management of patients with endocrine neoplasms.

Diffuse alveolar hemorrhage following thrombolytic therapy for acute myocardial infarction.

We describe a 66-year-old patient with hemoptysis, a drop in hematocrit, hypoxemia and new bilateral alveolar infiltrates after receiving streptokinase for acute myocardial infarction. Markedly increased carbon monoxide diffusion capacity suggested a diagnosis of alveolar hemorrhage. Underlying conditions included congestive heart failure. The patient recovered uneventfully within 7 days of conservative treatment. Alveolar hemorrhage is a rare and often unrecognized life-threatening complication of thrombolytic therapy. Particular attention should be paid to the pulmonary status of patients with congestive heart failure scheduled to receive thrombolytic therapy.

Recurrent, self-limited, menstrual-associated bronchiolitis obliterans organizing pneumonia.

A 39-year-old woman presented with recurrent acute illness, characterized by high-grade fever, pleuritic chest pain, and unilateral nodular infiltrate on chest radiograph. During the follow-up period, there were six similar episodes, each starting 2 to 3 days prior to her menstrual period and resolving within 5 to 10 days. Persistent symptoms in the seventh episode led us to perform an open lung biopsy; the specimen showed histologic changes compatible with the diagnosis of bronchiolitis obliterans organizing pneumonia (BOOP). To the best of our knowledge, this is the first report describing BOOP in association with a menstrual period. This exceptional case emphasizes the wide and unexpected spectrum of this disease.

The solitary pulmonary nodule: radiologic considerations.

The solitary pulmonary nodule is a commonly encountered radiologic finding that might represent lung cancer, particularly in individuals at high risk to develop lung cancer. Morphological characteristics including lesion size, contour and edge, calcification and nodule density, and contrast enhancement may be helpful in the attempt to differentiate malignant from benign nodules. In certain instances, the combination of morphological characteristics indicates a specific diagnosis, sometimes precluding the need for further workup. Growth rate is of paramount importance in evaluating the nature of a solitary pulmonary nodule, and 2-year stability is traditionally considered an indicator of benignity. Screening for lung cancer using low-dose CT has led to the detection of small pulmonary nodules in a large number of high-risk individuals. In the workup of these nodules, lung cancer, when present, should be diagnosed as early as possible, while unnecessary surgery and needle biopsies should be avoided. Computer analysis may prove to be a valuable tool in the evaluation of these nodules.

October 17, 2000 8:30-8:45. The New Technology of Combined Transmission and Emission F-18 FDG Tomography (FDG-TET) in the Diagnosis and Management of Cancer Patients.

The purpose of the study was to evaluate a new technology of simultaneous transmission and F-18 FDG emission tomography (FDG-TET) in tumor imaging and its impact on patient management.Emission and transmission devices were installed on the same gantry. 167 patients with histologically proven malignancy were evaluated at diagnosis or during follow up. Eight mCi of FDG were injected for PET and a low dose X-ray tube was used for CT. The FDG and CT were first interpreted independently, without knowledge of findings in other imaging modality. Subsequently fusion images were analyzed.FDG-TET changed the interpretation of PET or CT in 75 patients (45%). In 60 patients TET allowed for correct localization of lesions on the PET studies. In 15 patients, FDG uptake was found in sites of physiologic activity. In 12 patients lesions previously missed on CT were retrospectively identified. In 21 patients, TET detected 34 previously unknown sites of disease.FDG-TET changed the clinical management of 29 patients (17%). The stage of disease was changed in 9 patients. Early diagnosis of recurrence was made in 8 patients. Seven patients were referred for previously unplanned surgery. In 6 patients surgery was cancelled. Fifteen patients received additional chemo- or radiotherapy.Diagnosis of cancer on CT is based on a change in size or attenuation of a mass. PET shows the metabolic status of a lesion but lacks anatomical landmarks. FDG-TET improves the diagnostic accuracy in cancer and may have a significant impact on patient management.

Nitric oxide inhalation for paraquat-induced lung injury.

BACKGROUND: When ingested, concentrated paraquat can cause either rapid death from multisystem failure and cardiovascular shock or delayed death from progressive pulmonary fibrosis. Diquat ingestion does not usually cause pulmonary fibrosis, but produces early onset acute renal failure. CASE REPORT: A 52-year-old male ingested approximately 50 mL of a solution containing 13% paraquat and 7% diquat (about 6650 mg of paraquat and 3500 mg of diquat), and subsequently developed adult respiratory distress syndrome and pulmonary fibrosis. Survival prediction employing the criteria of Hart et al. for paraquat plasma levels was 30%. From the probable amount of paraquat ingested, severe toxicity was expected. The clinical course was not consistent with significant diquat toxicity. Treatment included oral Fuller's earth, forced diuresis, hemofiltration, N-acetylcysteine, methylprednisolone, cyclophosphamide, vitamin E, colchicine, and delayed continuous nitric oxide inhalation. The patient recovered and pulmonary function was subsequently normal. CONCLUSION: It is unclear which, if any, of the above treatments contributed to recovery, but the encouraging outcome suggests a possible benefit of nitric oxide inhalation in paraquat poisoning which deserves further study.

The utility of routine postoperative chest radiography in the postanesthesia care unit.

STUDY OBJECTIVE: To evaluate the clinical significance and cost effectiveness of routine chest radiographs in the postanesthesia care unit (PACU). DESIGN: Prospective study. SETTING: University hospital. PATIENTS: 100 patients who were admitted to the PACU following various surgical procedures, and in whom a postoperative chest radiograph was routinely performed. INTERVENTIONS: Chest radiograph was taken in each study patient soon after admission to the PACU. The indications for postoperative chest radiograph were: thoracotomy (30 patients), thoracoscopy (7), central vein catheterization (CVC) (75), pulmonary artery catheterization (3), and mechanical ventilation (36). A staff anesthesiologist examined each patient, evaluated each chest radiograph, and decided if a treatment action was to be taken. A chest radiologist later evaluated each chest radiograph, and her interpretation was compared with the anesthesiologist's interpretation to assess if this may affect patient management. MEASUREMENTS AND MAIN RESULTS: The anesthesiologist found eight abnormal chest radiographs (8%): three with pulmonary congestion, four in whom the CVC was in the right atrium, and one with malpositioned CVC. In four patients (4%), the chest radiographic findings directly affected patient management. The radiologist confirmed the anesthesiologist's interpretation and found four additional abnormalities: one pulmonary congestion, one malpositioned CVC, and two chest radiographs, each with a small pneumothorax. CONCLUSIONS: Abnormal chest radiographic findings resulted in a change in the management of only 4% of the patients. Therefore, the yield of a routine postoperative chest radiograph in the PACU is low. Performing a chest radiograph for a specific indication rather than on a routine basis, may decrease work load and save expenses. Postoperative chest radiography can be safely evaluated by a staff anesthesiologist.