Biomedical subjects
Publications and source records attributed to A G Fam.
A 63-year-old man developed symmetrical polyarthritis, subcutaneous nodules at the elbows, olecranon bursitis, and recurrent tenosynovitis. He was later discovered to have idiopathic hemochromatosis. Staining of the subcutaneous nodule revealed iron deposits. These manifestations which are common to rheumatoid arthritis may be seen in hemochromatotic arthropathy.
Five cases of meningococcal arthritis are described. Two clinical forms were observed: an early-onset acute polyarthritis (Type I) and a late-onset subacute monoarthritis (Type II). The 2 clinical subsets may represent sequential stages, an early bacteremic and a late stage of joint localization. To improve patient classification, diagnostic criteria are proposed.
To determine the feasibility of twice daily dosing of enteric-coated aspirin (EntrophenR), a preliminary trial on 10 patients with rheumatic diseases was conducted. Three plasma salicylate levels on 2 separate occasions, 1 day apart, were determined. In 9 of the 10 patients studied at steady-state, therapeutic levels were attained (15-30 mg/dl). There were no gastrointestinal side-effects. One case developed tinnitus which resolved with a small reduction in dosage. On the basis of this short-term study, twice-daily EC-ASA appears to be effective in maintaining adequate plasma salicylate levels, and it seems to compare favourably to ASA given in multiple daily doses. On a long-term basis, it may improve patient compliance.
Fourteen cases of acute calcific periarthritis and 2 cases of acute calcific bursitis are described. All patients had radiologic periarticular calcific deposits. Synovial fluid was available from 8 patients. Hydroxyapatite crystals were positively identified in 1 by x-ray diffraction analysis and by scanning and transmission electron microscopy. Apatite-associated arthropathy likely represents a form of crystal-induced inflammation. Three articular syndromes can be recognized; acute calcific periarthritis, acute (calcific) arthritis and a subacute-to-chronic arthritis resembling osteoarthritis. To improve patient classification, diagnostic criteria are proposed.
A 61-year-old woman with bronchogenic carcinoma simultaneously developed hypertrophic osteoarthropathy (HOA), phalangeal metastases, and metastatic carcinoma of the synovium. The right knee synovium showed several blood vessels containing carcinomatous cells. Although the association of HOA phalangeal and synovial metastases in this case is likely a chance occurrence, awareness of this possibility is extremely valuable as it has important therapeutic implications.
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Enterocolitis is lesser known complication of gold therapy. Two cases of fulminant colitis, complicating chrysotherapy for rheumatoid arthritis are described. One patient required colectomy, whereas the other responded to intensive medical treatment. Colonic biopsies demonstrated extensive ulcerations, diffuse edema, multiple hemorrhages and a dense mononuclear cell infiltrate. Our experience emphasizes the paramount importance of early recognition and treatment of this serious complication.
Four cases of infectious arthritis due to beta hemolytic streptococci, Lancefield Group G are described. Three patients presented with acute polyarthritis involving unusual sites while the 4th patient had acute monoarthritis. All 4 cases had underlying diseases which predisposed them to infection: alcoholism (2 cases), malignant disease (1 case) and diabetes mellitus (1 case). Three patients had coexistent Group G streptococcal infection: endocarditis in 2 and skin infection in 1. With adequate parenteral antibiotic therapy and frequent joint aspiration, the prognosis for return of normal joint function following infection with Group G streptococcus appears to be excellent. These cases demonstrate the need for routine serogrouping of streptococcal isolates in patients with septic arthritis. The importance of recognizing this uncommon type of infectious arthritis is emphasized in view of its prognostic and therapeutic implications.
Ultrasound (US) examination of the popliteal space is a noninvasive, reliable technique for the assessment of popliteal cysts. In order to determine the prevalence and significance of popliteal cysts in primary osteoarthritis (OA) of the knee, we conducted a prospective clinical, radiographic and US study on 50 patients and 25 controls. Popliteal cysts were demonstrated by US in 29 of 100 (29%) knees of 21 of 500 (42%) patients, 8 of whom (38%) had bilateral cysts. The majority of cysts were small and symptomless. Cyst rupture and the "pseudothrombophlebitis syndrome" occurred in only 2 of 29 (7%) knees. The occurrence of cysts correlated with the presence of knee effusion and the radiologic grade of OA. The results indicate of high incidence of clinically unsuspected popliteal cysts in patients with symptomatic knee OA. OA may be a more common cause of popliteal cysts than generally recognized.
The course of a patient with rheumatoid hyperviscosity syndrome is described. Manifestations of hyperviscosity included somnolence, circulatory overload, bleeding diathesis and dilated retinal veins. Serum hyperviscosity was associated with marked hypergammaglobulinemia, elevated IgM and IgG serum concentrations, and high titers of rheumatoid factor. High molecular weight IgG-IgM immune complexes shown in the serum were considered responsible for the increased viscosity. An unusual feature of the hyperviscosity, was spurious hyponatremia and a negative anion gap. Plasmapheresis rapidly controlled acute features of hyperviscosity, lowered gamma globulin concentrations and led to normal serum sodium and anion gap. Clinical improvement was maintained with moderate prednisone doses.
Cholesterol crystals were demonstrated in synovial fluids from 4 patients with knee osteoarthritis and recurrent synovial effusions. Large crystals (10-80 micros) were readily identifiable by their characteristic plate-like morphology. Some fluids also contained numerous smaller (1-5 microns) irregular, rod and needle shaped crystals. Identification of these crystals as cholesterol was established by x-ray diffraction analysis (2 fluids) and by ultrastructural studies (1 fluid). This study documents the occurrence of cholesterol crystals in osteoarthritic effusions, but their precise pathogenetic significance remains unclear.
To understand the role of cholesterol crystals in the pathogenesis of synovial effusions, we studied the articular tissue reaction to an intraarticular injection of cholesterol crystals in rabbits' knees. With the right knee as control, the left knees of 14 adult male, white, New Zealand rabbits were injected with 11 mg of cholesterol crystals suspended in 0.5 ml of saline. At 4, 8, 24, 48 h and at 7, 14, 28 and 56 d postinjection, the animals were autopsied and these tissues, including synovial fluid (SF), examined by light and transmission electron microscopy. Crystal injection produced an acute synovitis which peaked at 24 h coincident with phagocytosis of crystals in SF. Cholesterol crystals persisted within the synovium throughout the experiment resulting in cholesterol granulomata, synovial lining cell hyperplasia and synovial fibrosis. Relative to urate and pyrophosphate crystals, cholesterol crystals appear to have weak phlogistic potential. Because of their insolubility and resistance to cellular degradation, crystals persist within the synovium for prolonged periods. This results in a chronic proliferative synovitis and fibrosis.
Multiple myeloma developed in a woman with a 7-year history of seropositive rheumatoid arthritis (RA). An unexpected finding was the presence of massive amyloid deposits in the left femur and traces of amyloid in the synovium. Detailed histopathologic studies, however, conclusively excluded amyloid arthropathy. Although definitive tissue classification was not possible, this patient in all likelihood had 2 types of amyloid: massive bone lesions of myeloma-associated (AL) amyloid, and focal subsynovial deposits of RA-associated secondary (AA) amyloid.
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Arthritis is rarely caused by metastatic carcinomatous deposits in and about joints. Two patients with bronchogenic carcinoma and metastatic carcinomatous arthritis (MCA) are described. The diagnosis was established by the demonstration of malignant cells in the synovial fluid. Histology of the synovium, in 1 case, revealed several metastatic carcinomatous deposits. This report emphasizes the value of synovial fluid exfoliative cytology in the early recognition of MCA so that appropriate palliative therapy can be implemented.