Evaluating the cutaneous involvement in scleroderma: torsional stiffness revisited.

OBJECTIVE: The pace, progression and extent of the skin lesions in scleroderma may parallel the risk of new internal organ involvement and the progression of existing internal lesions. Accurate assessment of cutaneous change permits an evaluation of patient prognosis and the response to therapy. The aim of this study was to assess a simple device for measuring skin stiffness for its ability to measure sclerodermatous skin in a quantitative and reproducible manner. Materials and methods. Torsional skin stiffness was measured in 56 normal subjects and 42 scleroderma patients (31 of whom had the limited form and nine the diffuse form, and two had mixed connective tissue disease). Data for the scleroderma patients were compared with data obtained by the use of the modified Rodnan clinical skin scoring technique. Intraclass correlation coefficients (ICCs) were calculated as a measure of intraobserver and interobserver variability. RESULTS: For the left and right hands respectively, the ICCs for intraobserver variability were 0.908 and 0.906 and those for interobserver variability were 0.871 and 0.628. There was a significant difference in mean angular rotation obtained by normal subjects compared with scleroderma patients (15.1 vs 11.3 degrees, P<0.001). There was a significant difference in the angular rotation with increasing severity of skin involvement (skin score 0, median rotation 16.3 degrees; score 1, 10.5 degrees; score 2, 8.5 degrees; score 3, 8.0 degrees; P<0.00001). CONCLUSIONS: The measurements obtained with the skin stiffness device are highly reproducible and are consistent with the current clinical method of assessment of skin involvement. The significant difference in angular rotation obtained by normal subjects and scleroderma patients indicates that the device can distinguish normal from sclerodermatous skin. The torsional stiffness measurements derived from the device may also be useful in longitudinal studies.

Direct erosion of lumbar spine by an abdominal aortic aneurysm, resulting in paraparesis: unusual presentation. Case report.

Abdominal aortic aneurysm is a condition affecting nearly 4% of the elderly population. It has a potential for producing a wide range of symptoms, including abdominal pain and back pain. The latter is particularly difficult to interpret in patients with chronic rheumatological conditions, and delayed diagnosis may be associated with a poor outcome. We present a patient with rheumatoid arthritis and chronic low back pain, who developed bilateral leg weakness and hesitancy of micturition, due to an abdominal aortic aneurysm invading the spine.

Psoas abscess in rheumatoid arthritis--an inperspicuous diagnosis.

Primary or secondary psoas abscess is infrequently seen but should not be forgotten. We report on two patients with RA who presented predominantly with back pain and who subsequently developed pyrexia. The correct diagnosis of psoas abscess was not immediately apparent. These cases and the discussion and comments which follow illustrate the difficulties that may be encountered and remind readers of this inperspicuous diagnosis.

Stress fractures of the pubic rami in rheumatoid arthritis.

OBJECTIVE: To draw attention to and detail the features of stress fractures of the pubic rami in patients with rheumatoid arthritis (RA). METHODS: Twenty two cases were collected prospectively over a four year period from patients undergoing active rheumatological surveillance in Leeds. Both old and new fractures were included. Information was obtained from the patients, clinical notes, and radiological investigations. RESULTS: All patients were women (mean age 68.1 years) with longstanding (mean disease duration 24.2 years) seropositive RA. Nineteen (86%) were receiving regular prednisolone treatment and all patients had radiological evidence of osteoporosis, with vertebral crush fractures in 10 (63%) of the 16 who had vertebral x ray examination. There was no biochemical evidence of osteomalacia. Nineteen (86%) presented with pain in the low back, groin, or hip and three were asymptomatic. Pain developed gradually in seven with an acute onset in the remainder. Six gave a history of a fall but only seven were x rayed at the onset of symptoms and initial radiographs were negative in five of these. In eighteen the fracture had either minimal or no effect on their mobility. Fractures affected all four pubic rami and in four all four were fractured. All but one patient (who had multiple fractures) made an uneventful recovery over two to four weeks with conservative management. CONCLUSIONS: Stress fractures of the pubic rami in RA appear to be more common than had been recognised. The low grade nature of symptoms, the minimal effect on mobility, and the absence of significant trauma are typical features and suggest that many more stress fractures may go unrecognised.

Physiological variations in the urinary excretion of pyridinium crosslinks of collagen.

To further validate measurements of the pyridinium crosslinks of collagen as indices primarily of bone resorption in arthritis and other diseases, the effects of day-to-day and nyctohemeral parallel variations, and of renal impairment have been studied. Day-to-day variations measured over 3 weeks were between 16 and 24% for a group of post-menopausal women. Nyctohemeral variations in crosslink excretion of 10-15% were recorded. Although crosslink excretion relative to creatinine was generally higher in the morning than in the evening, no consistent pattern was observed between healthy male and female volunteers and a group of patients with OA or RA. For patients with impaired renal function, with or without arthritis, there was no correlation between crosslink excretion and either creatinine clearance rates or urinary N-acetyl glucosaminidase activity. These results suggested that there was no direct relationship between renal function, at the glomerular or tubular level, and crosslink excretion.

Sensorineural hearing loss in juvenile chronic arthritis.

An 18-year-old female with pauciarticular juvenile chronic arthritis is described who has developed a profound bilateral sensorineural hearing loss. The association of sensorineural hearing loss with juvenile chronic arthritis has not been reported before.

The effect of non-steroidal anti-inflammatory drugs on faecal flora and bacterial antibody levels in rheumatoid arthritis.

The faecal flora and bacterial antibody levels of 22 patients with active rheumatoid arthritis (RA) were compared with those of 26 patients with osteoarthritis (OA) undergoing comparable treatment with non-steroidal anti-inflammatory drugs (NSAIDs), and a further 22 patients with OA who were not receiving NSAIDs. Faecal counts of Clostridium perfringens were significantly higher in the RA patient group and in those OA patients receiving NSAIDs, compared with those OA patients not taking NSAIDs (P = 0.032, P = 0.0004 respectively). Total aerobic and anaerobic counts were, however, identical in all three groups. Levels of serum IgA antibody to the alpha toxin of Cl. perfringens were higher in the RA group and in the OA group taking NSAIDs than in OA patients not taking NSAIDs (P = 0.011, P = 0.055). Serum IgG antibody to alpha toxin was higher in the RA group than in OA patients both on and off NSAIDs (P = 0.019, P = 0.0072) and also a group of normal controls (P = 0.032). These results suggest that the increased faecal counts of Cl. perfringens together with the associated increased antibody levels seen in this and previous studies are more likely to result from NSAID therapy used to treat the disease than from a disease specific change in bowel flora.

Synovial cysts and sarcoid synovitis.

The case of a practice nurse who presented with painless cystic swellings in the popliteal and antecubital fossae and lymphoedema of the legs is reported. Biopsies of synovium, a breast lump, axillary lymph nodes and of the Kveim site demonstrated sarcoidosis. Prior to biopsy diagnosis was not obvious. Synovial cysts are a very rare manifestation of sarcoid joint disease and this case illustrates the importance of biopsy in establishing the diagnosis.

An infiltrating rheumatoid nodule?

The case is presented of a patient with mild rheumatoid arthritis who developed an enlarged painful tissue mass in the left lower leg. Although the history, clinical, and imaging appearances suggested that it was a soft tissue sarcoma, a biopsy specimen showed histological features consistent with either a rheumatoid nodule or subcutaneous granuloma annulare.

Human nocturnal blood melatonin and liver acetylation status.

The human dark phase melatonin concentrations exhibit a wide range of values. In an attempt to explain this variation, we measured 2250-2305 h melatonin levels by radioimmune assay in eleven fast and eleven slow acetylator phenotypes. No statistical difference between the two groups existed, suggesting therefore that such variations are not due to acetylator status. The study revealed a negative relationship between body weight or area and nocturnal melatonin concentration. No correlation was found between dark phase melatonin levels and age, anxiety, depression, or sleep rating.