Collagenous colitis and sacroiliitis: a case report and literature review.

The seronegative spondyloarthropathies commonly occur in association with such enteropathic disorders as inflammatory bowel disease, enteric infections, and Whipple's disease. Only 3 cases of collagenous colitis have been reported in association with spondyloarthropathy. We describe a 51-year-old patient with bilateral sacroiliitis and collagenous colitis, who presented with chronic, recurrent low back pain, morning stiffness, and diarrhea. As with two of the three reported cases, we describe musculoskeletal complaints preceding the onset of diarrhea. The late occurrence of suggestive diagnostic features such as diarrhea may lead to a delay in the diagnosis of a potential enteropathic arthropathy, as in our patient. All patients with chronic diarrhea should undergo appropriate evaluation with an eye for any attendant musculoskeletal features known to be potentially attributed to the resulting diagnosis. A variety of other rheumatologic and autoimmune illnesses have been described with collagenous colitis. Whether the association between collagenous colitis and seronegative spondyloarthritis is causal or casual remains to be determined. We encourage clinicians to report cases of collagenous colitis associated with spondyloarthropathy in hopes that this issue will be resolved.

Fatal myocardial infarction resulting from coronary arteritis in a patient with polymyalgia rheumatica and biopsy-proved temporal arteritis. A case report and review of the literature.

Giant cell arteritis is frequently an attendant complication of polymyalgia rheumatica. While involvement of other arterial beds is occasionally identified, this syndrome is most frequently recognized when symptomatic involvement of the temporal arteries occurs. We describe such a patient who despite initial treatment with high-dose intravenous and standard (5-day) orally administered corticosteroid therapy suffered a fatal myocardial infarction, which at autopsy was shown to be a consequence of granulomatous coronary arteritis. The literature is reviewed and the clinical implications of this case are discussed.

Inflammatory abdominal aortic aneurysm and the associated T-cell reaction: a case study.

The immune response associated with an inflammatory abdominal aortic aneurysm was studied by determining the phenotypes of lymphocytes in the peripheral blood, the aortic aneurysm wall, and the perianeurysmal tissue. Increased numbers of activated T cells were found in all three areas. After aneurysm repair, peripheral blood analysis demonstrated normalization of the T-cell subsets. These data suggest that inflammatory abdominal aortic aneurysm is associated with a measurable immune response in peripheral blood with elevation of the same subset of inflammatory cells (CD4) as detected in abdominal aortic aneurysm tissue, and the immune response regresses after aneurysm repair.

Diagnosis and rehabilitation of the shoulder impingement syndrome in the overhand and throwing athlete.

The shoulder apparatus is of elegant structural design, affording great ROM with substantial power in many planes of movement. It is the underlying anatomic relationships that allow great mobility that also render the shoulder susceptible to injury. Injury in repetitive overhand activities is usually in the form of impingement, which may result from many factors, including multidirectional instability, anterior subluxation, and imbalanced force couple mechanisms, among others. Diagnosis requires a thorough history and physical examination. The impingement sign and test are among the most useful diagnostic maneuvers available. Rehabilitation is individualized, depending upon the cause of impingement, severity of injury, and response to therapy. Overuse syndromes mandate rest and control of inflammation through the use of ice, NSAIDs, and local injections of steroids followed by passive, active-assist, and active ROM; stretching; and mobilization exercises. As pain and inflammation subside, isometric or isotonic exercises are prescribed initially to strengthen the rotator cuff musculature and, therefore, the caudal glide mechanism. Subsequent strengthening exercises then are performed in other planes of movement to strengthen the remaining shoulder-complex muscles. The patient is then advanced to isokinetic training. Stretching is emphasized as an essential preparatory activity for all types of exercise. Maintaining contralateral and lower-limb strength, and cardiovascular conditioning is necessary if athletic activities are to be resumed at the previous level of performance. Following return to athletic performance, an analysis of training habits should be made and a prescription for exercise issued based on the avoidance of aggravating factors and cultivation of activities that enhance existing static and dynamic shoulder stabilizers. Any return of symptoms should prompt an immediate reappraisal with the proper intervention, including adjustment of activity level and exercises as deemed appropriate. With proper conservative therapy, relatively few athletes should require surgical treatment.

Whipple's disease with axial and peripheral joint destruction.

A seropositive white man had follow-up for 16 years with a diagnosis of palindromic rheumatism. Treatment had included parenteral gold, methotrexate, prednisone, hydroxychloroquine sulfate, and penicillamine before diarrhea led to a biopsy-proven diagnosis of Whipple's disease. Clinical and radiographic criteria for ankylosing spondylitis were met. In addition to classic Whipple's arthropathy, he had the combined but singular findings of pancarpal destruction and cervical apophyseal fusion. HLA typing revealed the B7 antigen. This case illustrates the pitfalls in diagnosis of a chronic polyarthritis that has, as a typical feature, a long latency before manifesting its more specific signs and symptoms (ie, diarrhea, malabsorption, and hyperpigmentation). Care should be taken during evaluation of any disease with atypical and nonspecific features (eg, positive rheumatoid factor in a patient with polyarthritis) and one should continue to reevaluate the original impression while confirmatory evidence is lacking. Moreover, the roentgenographic findings of pancarpal narrowing, apophyseal fusion, and advanced iliofemoral joint disease, in addition to sacroiliitis and syndesmophyte formation, challenge the generally held notion that Whipple's arthropathy is a nondestructive joint disease.

Congenital heart block in successive pregnancies: a case report and evaluation of risk with therapeutic consideration.

SS-A antibody has been found to bind to fetal cardiac tissue and is thought to mediate congenital heart block via transplacental passage. Recent papers have identified various risk factors thought to define subclasses of SS-A antibody-positive mothers at greater risk of delivering children with congenital heart block. Treatment modalities for antibody-mediated fetal insult are now expanding and being used clinically. We report a case of a clinically asymptomatic SS-A antibody-producing mother who gave birth to two SS-A antibody-positive children with congenital heart block. It is our hope that ongoing refinement of risk factors and effective therapy will result in successful in utero palliation of the effects of SS-A antibody.

Pellegrini-Stieda syndrome mimicking acute septic arthritis.

This case illustrates the potential severity of an uncommon and generally benign condition of the knee--the Pellegrini-Stieda syndrome. The regional bone scan clearly showed the etiologic role of the inflamed ligamentous attachment site. Therapy should include joint rest, nonsteroidal anti-inflammatory agents, and possibly ice for symptomatic relief.