Levels of plasma lipid peroxide products and antioxidant status in rheumatoid arthritis.

Oxygen free radicals have been implicated as mediators of tissue damage in patients with rheumatoid arthritis. The aim of our study was to assess the lipid peroxide products and antioxidant status in rheumatoid arthritis patients (RA). The study involved determination of two plasma lipid peroxide products, malondialdehyde (MDA) and conjugated dienes (CD), two plasma antioxidant vitamins (C and E) in 91 RA patients and 26 healthy subjects. The results showed that rheumatoid patients had increased plasma CD but not MDA and decreased plasma vitamin E, when properly expressed per unit cholesterol and triglyceride. This finding suggested that RA patients had increased oxidant stress that might play a role in the tissue damage and inflammation process of this disease.

Ocular toxicity of chloroquine among Thai patients.

BACKGROUND: Chloroquine has been prescribed for the treatment of various diseases. The most serious side-effect of chloroquine is retinopathy. The frequency of occurrence of retinopathy varies from 0.001 to 40% depending on the criteria used. The purpose of this study was to evaluate the incidence of ocular toxicity from chloroquine treatment among Thai patients. METHODS: A retrospective study was carried out in patients treated with chloroquine at Ramathibodi Hospital over the past 10 years (1987-1997). Patients eligible for review were followed by ophthalmic examination by an ophthalmologist for at least 6 months after starting treatment. RESULTS: One hundred and fifty-five patients were studied. Nineteen were men and 136 were women. They ranged in age from 10 to 70 years. Most patients received 250 mg of chloroquine per day. The duration of treatment varied from 6 months to 14 years, and the cumulative dose of chloroquine ranged from 26 to 1771 g. Fourteen patients (9%) had only corneal deposition, while 22 (14.2%) developed retinopathy. There were no correlations between corneal deposits or retinopathy and age, sex, duration of treatment, or cumulative dose of chloroquine. CONCLUSIONS: The present study confirms the finding reported by Mackenzie (Am J Med 1983; 75 (Suppl 1A): 40-45) that retinopathy is not related to the duration of treatment and cumulative dose of chloroquine. Based on our finding that retinopathy can be detected as early as 9 months after starting chloroquine therapy, we recommend routine ophthalmic examination before treatment and every 6 months thereafter.

Age-related differences on clinical and immunological manifestations of SLE.

The clinical and immunological manifestations of 51 children with onset of systemic lupus erythematosus (SLE) before the age of 15 were compared with those of 308 adult patients with disease onset between the age of 15-49 and another 27 elderly lupus patients whose disease onset occurred at or after the age of 50. Overall disease activity determined by mean SLEDAI score was highest in the childhood group followed by the adult and the elderly group respectively. More severe form of cutaneous involvement, adenopathy, hypertension, renal involvement with renal insufficiency and anti-nDNA antibodies occurred predominantly in the childhood lupus. The clinical features distinguishing old-age lupus were chronic disease with a long interval between the time of onset and diagnosis, higher incidence of discoid rash and lower incidence of malar rash and renal involvement. Frequencies of anti-nDNA antibodies and renal involvement gradually decreased from childhood, to adulthood and to elderly lupus respectively. Anti-Sm antibodies were predominant in the adult onset group. Genetic markers, sex hormones and senility of the immune system may play a role in these age-related differences in clinical and immunological manifestations in SLE.

Antinucleolar antibodies and their disease association.

The prevalence of the antinucleolar antibodies (ANoA) demonstrated by indirect immunofluorescence technique in 1,662 sera of patients with a known or suspected rheumatic disease increased from 1.97% when mouse kidney (MK) was used as substrate to 4.9% when HEp-2 cells were used as substrate. However, an appropriate commercial HEp-2 substrate must be selected in order to increase the sensitivity of ANoA positivity. There were 3 distinct staining patterns of the nucleolar immunofluorescence: homogeneous speckle, and clumpy. Irrespective of the patterns, the most common diagnoses among patients who had ANoA were systemic sclerosis (PSS) and systemic lupus erythematosus (SLE); 36% and 35%, respectively). On the contrary, the incidence of these antibodies in PSS was 41% while it was only 3% in SLE patients. Almost all patients with speckled nucleolar staining had PSS as their underlying disease while most of the patients with homogeneous nucleolar staining had SLE. No distinct correlation between the different nucleolar staining patterns and specific organ involvements in our lupus and PSS patients was found except for the higher frequency of clumpy staining in male scleroderma with no joint involvement. This study demonstrates that: 1) ANoA are uncommon in unselected sera although use of a cell line substrate doubles the rate of positivity; 2) the proper HEp-2 substrate is critical in the detection of ANoA; 3) PSS and SLE are the most frequent diseases associated with ANoA but the frequency of these antibodies in SLE patients was very low.; 4) there are 3 distinct nucleolar staining patterns which may be associated with different rheumatic diseases; and 5) compared with ANoA negative scleroderma, clumpy nucleolar staining had significantly higher incidence in men with no joint involvement but a tendency towards more lung manifestations.

Infection in systemic lupus erythematosus.

A review of 1,069 total admissions of 537 systemic lupus erythematosus (SLE) patients during a 10-yr period at Ramathibodi Hospital showed that 220 episodes which occurred in 137 patients (25.5%) were motivated by infection. Skin was the most common site (23%) with Herpes zoster being the most common organism (15.5%) found in our lupus patients. However, if we considered only major infections, pulmonary tuberculosis, salmonella septicemia and urinary tract infection by E. coli would be the most frequent complications respectively. In the absence of immunosuppressive therapy, infections coincided with the initial manifestation of SLE in 25 patients and were associated with exacerbation of the disease in 20 patients. Mean SLEDAI score in these patients was 8.8, suggesting that active lupus link together with infection. Steroid therapy influenced the rate of opportunistic infections (p = 0.006). Infections were determined to be the cause of death in 23 of 77 patients (29.9%). Opportunistic pathogens played an equal role as other common bacterial organisms in these fatal cases. SLE patients who died from infections were treated with cyclophosphamide in higher proportion than those with no infectious complication (p = 0.025). Our study demonstrated the rate, nature and predisposing factors of infection in SLE which may lead to better anticipation and diminution of morbidity and mortality related to infection in hospitalized patients with SLE.

Anti-Sm: its predictive value in systemic lupus erythematosus.

The clinical manifestations of 131 rheumatic disease patients with anti-Sm antibody were studied. A variety of standard tests was utilized in the study, namely, the FANA test with mouse kidney as substrate for the assay of ANA, the Crithidia test for anti-double stranded DNA (anti-dsDNA) and double immunodiffusion for detecting antibodies to extractable nuclear antigens. The patients were grouped according to the presence of anti-Sm alone, or anti-Sm with some other antibodies. There were 17 with anti-Sm alone; 55 with anti-Sm+anti-RNP; 15 with anti-Sm+anti-dsDNA; and 44 with anti-Sm+anti-RNP. The result of our study showed that although anti-Sm could be found in other diseases, it was exclusively detected in SLE only if anti-dsDNA was also present. Further, the SLE patients with anti-Sm alone had more frequent central nervous system manifestations than other groups of patients. The renal manifestation was observed more frequently in the group of SLE patients with anti-Sm+anti-dsDNA (92.9%). Among other major manifestations, haematologic involvement had a tendency to be less common in the group of patients with anti-Sm alone. The study concludes that the presence of anti-Sm antibody may be of some value to predict the clinical outcome.

Anti-VDRL antibodies by ELISA in cerebrospinal fluid and its value in the differential diagnosis of abnormalities of the cerebrospinal fluid.

Enzyme-linked immunoabsorbent assay (ELISA) techniques for the detection of antibodies to the Venereal Disease Research Laboratories (VDRL) antigen as well as for the estimation of antibodies to cardiolipin (aCL) in cerebrospinal fluid (CSF) were performed in several groups of patients, including those with definite paretic neurosyphilis (DPNS, 10 patients), probable paretic neurosyphilis (PPNS, 19 patients), systemic lupus erythematosus (SLE, 71 patients), and miscellaneous neurologic disorders (30 patients), and normal subjects (11 patients). In the DPNS group, all demonstrated positive VDRL by ELISA, and 7 also had positive aCL tests, whereas only 7 of the 10 had positive CSF fluorescent treponemal antibody absorption (FTA-ABS) and Treponema pallidum hemagglutination assay (TPH A) tests. Three had positive VDRL tests by flocculation. In the PPNS group, no patients had positive FTA-ABS, TPH A, or VDRL flocculation tests in CSF. However, 18 of the 19 had positive CSF VDRL by ELISA; two of these also had positive aCL tests. Four SLE patients had positive CSF aCL tests (three with positive ELISA VDRL). Only one patient in the miscellaneous group had positive CSF aCL (Guillain-Barre syndrome), and one had positive IgM VDRL tests (bacterial meningitis). The value of VDRL ELISA in the diagnosis of neurosyphilis in the face of other negative conventional tests is established by our study and had important therapeutic consequences in patients with possible/probable neurosyphilis. The aCL test often may be positive in patients with DPNS but is less useful in the PPNS group.

Serum IgE levels: correlation with skin test reactivity in Thai adults with respiratory allergy.

A history of respiratory allergic disorders was obtained in 68 patients. Allergic skin testing was performed with measurement of total IgE by enzyme immunoassay (EIA). The mean level of total IgE from the control group of 13 healthy adults with no history of allergic diseases was 24.7 IU per ml. The average serum IgE level among the allergic patients with positive skin tests was 97.6 IU per ml and it was significantly higher than that of the controls (p less than 0.005). It was also found that the positive skin test patients had significantly a higher mean serum IgE level than that of patients with negative skin test results (97.6 vs 33.6 IU per ml, p less than 0.01). Since 73.2% of the allergic patients with positive skin tests had serum IgE levels over 45 IU per ml while only 23.1% of the control group had IgE levels exceeding this figure, we consider that a patient with clinical symptoms and a serum IgE level over 45 IU per ml is likely to be suffering from allergic disease.

Diffuse systemic sclerosis and related diseases in Thailand.

Diffuse systemic sclerosis and the related syndromes were diagnosed in 115 patients during 1977-1987. Sixty-nine patients were available for clinical evaluation and analysis. These included 46 patients with diffuse systemic sclerosis, 2 with limited cutaneous systemic sclerosis, 2 with linear scleroderma, 18 with overlap syndrome (OS), and one with primary Raynaud's disease. The major clinical manifestations among the diffuse scleroderma patients were the involvement of the following systems; cutaneous (93.3%), musculoskeletal (69.6%), gastrointestinal (54.3%), and pulmonary (43.3%) while renal involvement (4.3%) was less common. Antinuclear antibodies were found in 89.7% with predominating speckle pattern (86.2%) and anti Scl 70 antibody (40.6%). In contrast to the Western series, HLA-DR2 was significantly increased in our diffuse systemic sclerosis patients (p less than 0.01). Among the 18 OS patients, the involvement of pulmonary system (44.4%) was the major cause of morbidity and renal involvement (55.6%) was found frequently although it was clinically mild. In conclusion, our diffuse systemic sclerosis and related diseases patients seem to have milder clinical manifestations than those of the Western series.

Antinuclear antibodies in Thai patients with connective tissue diseases.

A study of antinuclear antibodies (ANA) among Thai patients with various connective tissue diseases revealed that the prevalence of ANA was similar to that in other countries, but that the ANA patterns showed interesting contrasts in most diseases. Rather than the predominant homogeneous pattern seen elsewhere in systemic lupus erythematosus and rheumatoid arthritis, the speckled pattern was commonest among Thai patients with these two diseases (67.9% and 76.9% respectively). Patients with scleroderma exhibited a much lower percentage of the nucleolar pattern (17%) than reported elsewhere. The discrepancy between our findings and those from other studies may reflect differences in genetics, the environment or the severity of disease.

Hand deformities in a patient with chronic lung disease; Jaccoud's arthropathy.

Jaccoud's arthropathy is a syndrome of chronic progressive painless deformity of the hands and feet with surprisingly well preserved functions. The arthropathy has been known to develop subsequently to episodes of rheumatic fever. a patient is presented in this report with a clinical and radiologic finding indistinguishable from that of the Jaccound's arthropathy. However, the only associated illness is chronic lung disease.