Lessons of the month: Reemergence of rheumatic fever after a systemic streptococcal A infection: The role of cardiac MRI on the diagnosis of subclinical rheumatic carditis.

A 42-year-old man presented with fever, sore throat, rash and painful right knee swelling, preceded by self-medication with oral steroids. Blood and knee cultures yielded group A Streptococcus After 2 weeks of intravenous antibiotics and two arthroscopic knee debridements, he continued to experience spiking fevers, and electrocardiographic changes developed. We postulate that the patient suffered from the first presentation of acute rheumatic fever, following an invasive group A bacteraemic streptococcal infection. The possible role of cardiac magnetic resonance imaging in the diagnosis of rheumatic carditis is discussed.

Granulomatous infection of the hand and wrist due to Azospirillum spp.

We report a case of Azospirillum infection manifestating as granulomatous tenosynovitis of the right hand, in an immunocompetent middle-aged female. We highlight the unusual source of the infection, the diagnostic workup, as well as the treatment approach.

Cardiovascular disease is related to hypertension in patients with rheumatoid arthritis: a greek cohort study.

OBJECTIVE: To evaluate the incidence of cardiovascular disease (CVD) among Greek patients with rheumatoid arthritis (RA) under medical followup, and to assess the contribution of traditional CVD and RA-specific factors associated with CVD development. METHODS: This is a historic cohort study; information was collected from medical records of patients who had > 2 years' followup. Sociodemographic, clinical, laboratory, and therapeutic variables were evaluated for association with development of CVD. RESULTS: A total of 325 RA patients were studied: 250 women, mean age at RA onset 44 ± 15 years, and 75 men, mean age at RA onset 51 ± 15 years; median followup was 10 years. Fourteen women (5.6%) and 12 men (16%) developed CVD (p = 0.004). Multi-adjusted analysis revealed that hypertension (hazard ratio 3.76, 95% CI 0.99-15.06) was associated with incidence of CVD; late age at disease onset (HR 1.07, 95% CI 1.04-1.11), elevated C-reactive protein (CRP) level 1 year after start of followup (HR 1.03, 95% CI 1.00-1.05), and leflunomide treatment (HR per 1 year of treatment = 1.02, 95% CI 1.00-1.05) were also positively associated with CVD development. CONCLUSION: Hypertension was an important risk factor for CVD development in patients with RA. Late RA onset and inadequate early control of disease activity (as attested by CRP) remain additional risk factors. Leflunomide treatment may have a contributing effect. Early and effective treatment of RA and strict control of hypertension may modify the burden of CVD in RA patients.

Effect of anti-TNF treatment on body composition and serum adiponectin levels of women with rheumatoid arthritis.

The aim of this study was to investigate the effect of anti-tumor necrosis factor alpha (anti-TNF) treatment on body composition and serum adiponectin levels of women with rheumatoid arthritis (RA). Nineteen women with RA starting anti-TNF treatment were included in the study. Disease activity, body composition, lumbar spine bone mineral density (BMD) and serum adiponectin concentrations were measured at baseline and after 1 year of follow-up. No important changes on body composition and lumbar spine BMD were observed, while the serum levels of adiponectin levels increased after 1 year of anti-TNF treatment (p = 0.02). Anti-TNF treatment in women with RA does not have any significant effect on body composition; however, it is associated with increase in adiponectin levels which may ameliorate the systemic inflammatory response state associated with RA.

Peripheral neuropathy in two patients with rheumatoid arthritis receiving infliximab treatment.

Antitumor necrosis alpha agents have been successfully used for the treatment of rheumatoid and seronegative arthritis, Crohn's disease, psoriasis, and severe cases of vasculitis. Several side effects have been observed in patients receiving these agents including hypersensitivity reactions, infections, drug-induced lupus, or demyelinating syndromes. The presence of peripheral neuropathy has been reported only in isolated cases. We describe two cases of peripheral neuropathy which occurred in patients with rheumatoid arthritis receiving infliximab treatment, one with multifocal motor neuropathy with conduction block and another with axonal sensory polyneuropathy, reversed upon discontinuation of infliximab and intravenous gammaglobulin treatment.

Visceral leishmaniasis resembling systemic lupus erythematosus.

We describe three cases with visceral leishmaniasis (VL) associated with autoimmune manifestations. The patients presented with anemia, leukopenia, thrombocytopenia, renal involvement and low complement levels. Autoimmune features were present (antinuclear and anticardiolipin antibodies, VDRL, RF, positive direct Coombs' test), which subsided after therapy. Leishmaniasis should be taken into consideration in the differential diagnosis of autoimmune disorders.