Iatrogenic Cushing's syndrome and secondary adrenal insufficiency after a single intra-articular administration of triamcinolone acetonide in HIV-infected patients treated with ritonavir.

The development of an iatrogenic Cushing's syndrome (ICS) followed by secondary adrenal failure remains an exceptional event after a single dose administration of a synthetic glucocorticoid. Medical attention has been drawn recently on the possible impact of ritonavir-based antiretroviral regimens on the systemic deleterious effects of a chronic administration of corticosteroids in HIV-infected patients. Three HIV-infected patients treated by a ritonavir-boosted protease inhibitor (PI) regimen received a single intra-articular injection of 40 mg triamcinolone acetonide in our university hospital. The three patients rapidly developed signs and symptoms of ICS followed by secondary adrenal insufficiency. Special attention must be paid when a single administration of corticosteroids has to be given in HIV-positive patients under ritonavir-boosted antiretroviral treatment, as these patients are at risk of developing early cushingoid features and a prolonged suppression of their hypothalamic-pituitary-adrenal axis.

Selective involvement of the choroid plexus on cerebral magnetic resonance images: a new radiological sign in patients with systemic lupus erythematosus with neurological symptoms.

The selective involvement of the choroid plexus on brain magnetic resonance (MR) images is described in 2 patients with systemic lupus erythematosus presenting with neurological symptoms. The decrease in choroid plexus abnormalities on followup MR examination paralleled the clinical recovery with glucocorticoid therapy in both patients. Our cases indicate that selective involvement of the choroid plexus should be included in the spectrum of the radiological signs for neurological lupus.

Serum levels of hyaluronan, antigenic keratan sulfate, matrix metalloproteinase 3, and tissue inhibitor of metalloproteinases 1 change predictably in rheumatoid arthritis patients who have begun activity after a night of bed rest.

OBJECTIVE: To evaluate whether and how moderate physical activity following a night of rest influences serum levels of matrix metalloproteinase 3 (MMP-3), tissue inhibitor of metalloproteinases 1 (TIMP-1), antigenic keratan sulfate (Ag KS), and hyaluronan (HA) in 10 normal subjects and 38 patients with rheumatoid arthritis (RA). METHODS: Blood was obtained from 20 RA patients before they arose from a night's sleep, and again 1 and 4 hours after they had begun to perform moderate physical activity. Another 18 RA patients remained in bed and blood was sampled at the same time periods. Serum levels of MMP-3, TIMP-1, Ag KS, and HA were measured by enzyme-linked immunosorbent assay. Clinical activity was evaluated by the Lansbury index. RESULTS: Both in normal subjects and in RA patients who did not remain in bed throughout the period of blood sampling, levels of HA, Ag KS, and MMP-3 increased significantly during the first hour after the subjects arose: the increase in HA and Ag KS correlated with the Lansbury index in the RA group. Three hours later, levels of Ag KS had dropped to baseline values in both groups of subjects. Levels of HA remained significantly and moderately elevated in the RA group but not in the control group, while levels of MMP-3 did not drop significantly in either group. In contrast, levels of HA, Ag KS, and MMP-3 did not change significantly in RA patients who had remained in bed. Unlike the other markers, the levels of TIMP-1 remained unchanged at the different time periods in all 3 groups studied. CONCLUSION: Significant changes in serum levels of some metabolic markers occur during the first hour after one arises from a night of sleep, especially in patients with RA. Measurement of the magnitude of these changes at different times in individual patients provides very different information about metabolic changes occurring in joint tissue than does measurement of the level of the markers at a single time point, as is usually currently reported.

Functional outcome of myositis patients: can a low-dose glucocorticoid regimen achieve good functional results?

OBJECTIVE: During the last few years, in an attempt to reduce the side effects of glucocorticoid (GC) therapy, we have been treating polymyositis-dermatomyositis (PM-DM) patients with a lower starting dose of GC than is classically recommended. In order to validate this approach, we performed a functional re-evaluation of these PM-DM patients. METHODS: A comprehensive protocol evaluating muscle strength, muscle function, CK levels, persistence of spontaneous activity on electromyography, disability in daily life activities and degree of dependence was applied in 25 non-cancer-associated biopsy-proven PM-DM patients, 15 of whom had been treated with a high-dose regimen (i.e. > 0.5 mg prednisolone/kg/day) and 10 with a low-dose regimen (i.e. < or = 0.5 mg prednisolone/kg/day). RESULTS: Our results indicate that the functional outcome of PM-DM patients given a low-dose starting regimen of GC does not differ from that observed in patients given higher doses. Interestingly, vertebral fractures were less common in patients treated with lower GC doses. CONCLUSIONS: Although our analysis has certain shortcomings, including the small number of patients investigated and their uncontrolled assignment to a low-dose or a high-dose GC regimen, the results of this retrospective study suggest that a low-dose starting regimen of GC can achieve a good functional outcome in PM-DM patients, with a reduction of treatment-related disability. This approach would be welcome as a step forward should it be validated by a longitudinal study.

The posterior interosseous nerve and the radial tunnel syndrome: an anatomical study.

Twenty anatomical specimens were carefully studied in order to establish a possible connection between the posterior interosseous nerve and the radial tunnel syndrome. Our results show that the posterior interosseous nerve distal to the supinator muscle may be compressed by various structures. These include the distal border of the supinator muscle, the ramifications of the anterior and posterior interosseous vessels, and the septum between the extensor carpi ulnaris and the extensor digitorum minimi. The posterior interosseous nerve is also stressed during passive supination (elongation and rotation), and during passive pronation (compression). This suggests that the interosseous nerve distal to the supinator muscle should be explored in radial tunnel compression syndromes.