Biomedical subjects
Publications and source records attributed to J J Calabro.
Acute adrenal insufficiency is rarely diagnosed in the pediatric age group. In this case report, an 11-year-old female with three previous admissions for dehydration was seen for dehydration and shock. Adrenal insufficiency was considered as a working diagnosis in the emergency department. Rapid intervention with intravenous hydrocortisone and fluid resuscitation resulted in a good outcome.
The comprehensive management of ankylosing spondylitis has both immediate and long-term objectives. The physician must first suppress the patient's articular discomfort and inflammation with NSAIDs, then begin long-range supportive measures such as postural training and daily exercise in order to prevent, delay, or correct deformity. Acute anterior uveitis and other systemic manifestations must be promptly recognized and treated, often with the help of specialists. While the capacity to function and work can be adequately maintained for most patients, it depends largely on patient education and compliance. Educational material for patients with AS may be obtained from either a local chapter or the national headquarters of the Arthritis Foundation (17 Executive Park Drive, NE, Suite 480, Atlanta, GA 30329), as well as the Ankylosing Spondylitis Association (ASA). Patients should be urged to join the ASA in order to receive the monthly newsletter. The address for ASA membership is 3985 Witzel Drive, Sherman Oaks, CA 91403.
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Of all the forms of nonarticular rheumatism, by far the most common are bursitis and tendinitis. Yet, the bursae and neighboring tendon sheaths are the most neglected anatomic structures of the body. Moreover, like the joints, they are lined by synovial membrane, secrete synovial fluid, and are common sites of rheumatic problems. The vast majority of painful shoulder problems are caused by acute subacromial (subdeltoid) bursitis and bicipital tendinitis. In the management of these periarticular disorders, the ultimate goal is to preserve shoulder motion. Although this is accomplished by daily range-of-motion exercises, it is clearly facilitated by suppression of periarticular inflammation and discomfort through the use of nonsteroidal anti-inflammatory drugs. Of these, sustained-release indomethacin provides the anti-inflammatory efficacy of indomethacin and by virtue of its sustained-release formulation, may promote patient compliance since it need be given only once or twice daily.
Ankylosing spondylitis is a systemic rheumatic disorder that is characterized by inflammation of the spine, sacroiliac, and large peripheral joints. Although back pain is the most frequent presenting symptom, disease can begin in peripheral joints--especially in children and women--and, rarely, even with acute iritis. Whatever the mode of onset, recurrent back pain that is frequently nocturnal and of varying intensity is an eventual complaint, as is early morning stiffness that is typically relieved by activity. The long-term prognosis is clearly enhanced by early diagnosis and patient education, both of which are central to preventing or minimizing disability. By suppressing articular inflammation, pain, and stiffness, the nonsteroidal anti-inflammatory drugs facilitate exercise and other supportive measures. Currently, among these agents, indomethacin occupies an important place. By virtue of its 12-hour dosage system, sustained-release indomethacin can be prescribed only once or twice daily, providing the anti-inflammatory efficacy of indomethacin while promoting patient compliance.
In the United States today, the number of persons 65 years of age or older is about 25 million. Two thirds of this group have musculoskeletal complaints severe enough to cause them to use considerable quantities of over-the-counter medications to alleviate discomfort. In treating elderly patients with osteoarthritis, one of the most common rheumatic diseases of the elderly, it is imperative for physicians to be aware of the numerous physiologic aspects of aging and how these may affect the pharmacokinetic activity of various prescribed agents. Drug therapy in the elderly should be determined by the principle of least toxicity. Dosage titration is particularly advisable when pharmacokinetic activity of a drug is not known.
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It appears that a tick introduces an agent--presumably a spirochete--into the skin (see Fig. 1). Immune complexes form and become systemic during the rash. Some patients (identified by the presence of cryoglobulins containing IgM, Clq-reactive material, and depressed IgG and IgA levels) then alter their immune response and may develop neurologic, cardiovascular, or joint involvement. Despite systemic clearing in some patients, the immune complexes localize to the joints where a chronic synovitis develops, similar to rheumatoid arthritis. Why the immune complexes localize to the joints is an enigma. It is tempting to postulate that this localization occurs because of an altered immune response in a genetically predisposed group. However, three of 10 patients with chronic arthritis did not have the B-cell alloantigen DRw2.
Two cases of scleroderma with isolated aortic regurgitation are described. Other known causes of aortic regurgitation were not apparent. None of the patients gave a history of rheumatic fever. It appears likely that aortic regurgitation is related to scleroderma in these two patients. Aortic regurgitation in scleroderma is, however, rare.
Ankylosing spondylitis (AS) is a heterogeneous and systemic rheumatic disorder that is characterized primarily by inflammation of the spine and sacroiliac joints. Consequently, back pain is a frequent presenting complaint although the disease can begin with peripheral arthritis as well as acute anterior uveitis. Unlike men, however, women appear to have milder or atypical AS that may go unrecognized for years. Moreover, the presentation in children rests on the recognition of two distinct subgroups that may be indistinguishable from juvenile chronic polyarthritis. The more frequent subgroup includes primarily teenage boys who present initially with an asymmetric peripheral pauciarthritis that most often affects lower-limb joints. Only some years later does sacroiliitis evolve, and, much later still, back complaints or other clinical and radiographic features typical of AS. A second subgroup includes mostly girls with a polyarticular onset that is subsequently characterized by cervical fusion, micrognathia, acute anterior uveitis, sacroiliitis, spondylitis, and rheumatoid-like hands that persist into adulthood.
The early diagnosis of juvenile chronic polyarthritis rests on the recognition of 3 district modes of onset that are important in preventing deformities, blindness, and even death. Systemic onset is characterised by typical systemic features, including high spiking fever and rheumatoid rash; polyarticular onset is characterised by arthritis of more than 4 joints; and pauciarticular onset by involvement of 4 joints or less, most often a knee initially. Management must be individualised, including the use of non-steroidal anti-inflammatory drugs of which aspirin remains the drug of choice. The course of progressive polyarthritis, found in 15% of children, necessitates the additional use of slow-acting agents, such as intramuscular gold. Supportive measures include rest, splinting and exercise. Regular slit-lamp examination is mandatory to screen for asymptomatic iridocyclitis, which if undetected and untreated may result in blindness.
Primary fibromyalgia is a common but often unrecognized rheumatic condition. The typical patient is a young woman who complains of diffuse aches, pains and stiffness in joints and muscles. The symptoms are affected by weather and activities. Patients sleep poorly, feel tired and are often anxious. Physical examination reveals multiple tender points without evidence of arthritis or muscle weakness. Laboratory findings are normal. Management requires a program of patient education and reassurance, analgesics, physical therapy, restful sleep and occasional injection of tender areas with lidocaine. Psychoactive drugs are frequently useful.
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