Biomedical subjects
Publications and source records attributed to T M Harrington.
Eleven elderly patients with tuberculous arthritis of 12 peripheral joints were studied retrospectively. The disease usually presented as a monoarticular arthritis often in the absence of other signs of tuberculosis. A delay in diagnosis was a common feature and synovial biopsies provided the highest diagnostic yield.
Five elderly patients with aortic arch syndrome secondary to large-vessel vasculitis all presented with upper-extremity claudication and absence of blood pressure and pulses in the affected extremity. Diagnosis was suspected by a markedly elevated erythrocyte sedimentation rate associated with constitutional symptoms and angiograms showing changes consistent with arteritis of the aortic arch vessels. Treatment with high-dose corticosteroids resulted in rapid resolution of constitutional symptoms and improved functional use of the upper extremity. Recognition of this steroid-responsive disease is essential to avoid unnecessary reconstructive surgery and to prevent catastrophic events such as aortic dissection or visual loss, which may result from the underlying disease process.
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Thirty-two of 150 Caucasian patients (21%) with sarcoidosis studied had articular symptoms. Twenty-one had acute sarcoid arthritis with bilateral ankle arthritis/periarthritis. Joint symptoms resolved within 4 months and none developed chronic arthropathy or progressive systemic sarcoidosis. Eleven patients developed articular involvement during the course of chronic pulmonary sarcoidosis manifested by bilateral hilar adenopathy in 8 and parenchymal disease in 9. Joint symptoms were generally transient, however, persistent synovitis in excess of one year was seen in 2 patients. Acute sarcoid arthritis confers a favorable prognosis in North American Caucasians. Differences from previous American series likely reflects the racial compositions of the population studied. Sarcoid arthritis less often evolves during the course of chronic systemic sarcoidosis and even then rarely progresses to a chronic arthropathy.
Fourteen patients with cauda equina syndrome secondary to long-standing ankylosing spondylitis are described. The roughly symmetrical neurological deficits were very slowly progressive and began long after the onset of the spondylitis, usually well after the rheumatological symptoms had stopped. Eventually every patient had cutaneous sensory loss in the fifth lumbar and sacral dermatomes. All patients developed urinary sphincter disturbances of a lower motor neuron type. There was prominent loss of rectal sphincter tone, and all but 2 patients had bowel complaints, including incontinence and severe constipation. Seven patients had mild to moderate weakness in the lumbosacral myotomes. Seven patients had pain in the rectum or lower limbs. Electromyographic abnormalities were consistent with multiple lumbosacral radiculopathies. Myelography and computed tomographic scanning of the lumbosacral spine showed characteristic enlargement of the caudal sac and dorsal arachnoid diverticula that had eroded the laminae and spinous processes. Recognition of this syndrome, coupled with computed tomographic scanning of the lower spinal canal, allows one to omit myelography, a procedure that is difficult because of the associated spine abnormalities. Surgical intervention should be avoided.
Serum creatine kinase (CK) levels were recorded in 100 patients with amyotrophic lateral sclerosis (ALS). CK concentrations were elevated in 43% of the patients, with a mean level of 240 U/liter and a range of 59-1,327 U/liter (male normal less than 95 U/liter, female normal less than 59 U/liter). All patients with elevated CK had muscle weakness. Seven patients were initially misdiagnosed as having polymyositis and given high dose corticosteroids without clinical benefit, prior to the diagnosis of ALS. Such diagnostic confusion can be avoided by an awareness that CK levels cannot be used to reliably differentiate between ALS and primary muscle disease such as polymyositis.
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Osteoid osteoma is a benign bone tumor occurring primarily in patients under the age of 30 yr. Bone pain at night and relief by aspirin or other nonsteroidal antiinflammatory agents is a common symptom complex. The proximal femur and spine are frequent sites of involvement, but almost any bone can be involved. If plain roentgenograms do not demonstrate the lesion, tomography or a bone scan may be helpful. Complete surgical excision is the therapy of choice with a low recurrence rate. Osteoid osteoma may present initially with symptoms suggestive of inflammatory arthritis, degenerative joint disease, neoplasm, or infection. This lesion can therefore be a difficult diagnostic problem, especially if routine roentgenograms are normal. A high index of suspicion is necessary to make the diagnosis.
The clinical and laboratory manifestations, roentgenographic findings, and treatment of 48 patients with renal tubular acidosis who were examined at the Mayo Clinic during a 10-year period were reviewed. The initial clinical presentations of the 48 patients in the series included rheumatic complaints in 25 and recurrent nephrolithiasis in 23. Of the 23 patients who presented with nephrolithiasis, 8 also had musculoskeletal symptoms. Thirty-three of the 48 patients had careful follow-up of a total of 68 musculoskeletal complaints. Forty of these symptoms (59%) diminished after treatment of the renal tubular acidosis with orally administered alkali. Associated connective tissue diseases were present in 12 patients. Thirty-four patients had roentgenographic evidence of renal calculi. Of this group, 19 were followed up with sequential roentgenographic studies of the kidneys for more than 1 year during therapy. Of 15 patients treated orally with alkali, 13 had metabolically inactive renal stone disease. Three of the patients treated orally with phosphorus supplements had persistent metabolically active renal stone disease. Patients with renal tubular acidosis often present with musculoskeletal manifestations and renal lithiasis, both of which frequently subside with the treatment of the renal tubular acidosis.
In order to determine the incidence of renal lithiasis in patients with renal tubular acidosis and the effect of therapy on further stone formation, we reviewed the clinical and laboratory manifestations, X-ray findings, and treatment of 48 patients with renal tubular acidosis who were seen at the Mayo Clinic during the years 1970-1980. Thirty-four patients (70%) had radiological evidence of renal lithiasis which was the presenting symptom in 23 (48%) patients. In every instance the calculi were multiple and, with one exception, bilateral. While receiving therapy, 19 patients with renal lithiasis were followed for longer than one year with sequential uroradiographic studies. Fifteen of these patients were treated with oral base alone and thirteen had no evidence of new stone formation or continued growth of existing stones during therapy. The two patients with X-ray evidence of continued stone formation admitted to poor compliance. Four patients received initial treatment with an oral phosphorus supplement. Three of these four patients had radiographic evidence of continued renal stone formation during three, five and eight years of phosphate therapy. We conclude renal lithiasis is a frequent complication of renal tubular acidosis, and adequate base replacement is effective therapy to stop continued stone formation while oral phosphate therapy alone is often ineffective.
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Anaerobic joint infections may be a more common occurrence than previously reported. A nine-year-old with a septic knee due to Clostridium perfringens following a puncture wound was seen in the emergency department. Diagnosis was established by isolating the organism from an anaerobic synovial fluid culture. The patient was treated successfully with open drainage and parenteral penicillin. This case illustrates the necessity for specifically requesting anaerobic cultures on synovial fluid of patients with acute septic monoarthritis.
A patient with psoriatic arthritis presented to the Geisinger Medical Center emergency department after the sudden onset of pain and swelling in his left calf. Initially, the patient was thought to have acute thrombophelebitis. Upon further examination, the diagnosis of a ruptured popliteal cyst was considered, and was confirmed with arthrography. The case illustrates an occurrence of a dissecting popliteal cyst simulating an cute deep vein thrombosis in a patient with an inflammatory process involving the knee.
Pleural pericarditis, fever, and a positive reaction for antinuclear antibody developed in a 50-year-old white woman while she was receiving methyldopa (500 mg daily). After withdrawal of the drug, there was complete resolution of the clinical signs and symptoms, as well as normalization of the patient's antinuclear antibody titer. To our knowledge, this is the first reported case of a clinical lupus-like syndrome induced by therapy with methyldopa.
A 30-year-old white male with hereditary angioedema developed substernal chest pain with multiple arterial stenoses at coronary angiography. Histopathologic studies of the fibromembranous thickening removed from the left coronary artery at the time of the revascularization procedure revealed an inflammatory lesion compatible with an arteritis. The significance of this association in the spectrum of immunologically-mediated disorders in hereditary angioedema is discussed.