Carlos A. Agudelo

CRYSTAL-ASSOCIATED ARTHRITIS IN THE ELDERLY

The understanding of the clinical syndromes of gout and pseudogout, and the role of basic calcium crystals in arthritis has increased since the original descriptions of the involvement of crystals in arthritis. Gout is usually considered an affliction confined to middle aged males but has an increasing prevalence in older populations, with unique and often atypical features. Calcium pyrophosphate dihydrate crystal deposition disease is common in elderly patients. The diagnosis of these common forms of arthritis and the need to individualize therapy in patients with other medical problems remain important clinical challenges to the practicing physician.

Coexisting Sjögren's syndrome and sarcoidosis in the lung

CONTEXT Sjögrens syndrome (SS) and sarcoidosis are diseases of unknown origin that are considered to result from abnormal regulation of the immune system. Pulmonary involvement by SS and sarcoidosis may have similar clinical and radiographic manifestations, making it difficult for the clinician to distinguish between these diseases. OBJECTIVES This study was undertaken to analyze the characteristics of SS and sarcoidosis in the lung to identify distinguishing features that may assist clinicians in the differentiation of these conditions. DESIGN We present two cases with severe pulmonary impairment in which the distinction between SS and sarcoidosis required lung tissue biopsy. The literature regarding the pulmonary manifestations of these diseases is reviewed. RESULTS The clinical, pathological, radiographic, and physiological characteristics of lung disease in the setting of SS and sarcoidosis can be very similar, preventing a diagnosis solely on clinical grounds. This is exemplified in the two cases reported. In one patient who carried the diagnosis of sarcoidosis, examination of lung tissue revealed lymphocytic interstitial pneumonitis consistent with SS. In the other patient, who had previously been diagnosed with SS on clinical grounds, examination of lung tissue showed lymphocytic interstitial pneumonitis with scattered noncaseating granulomas, suggesting the possibility of coexisting SS and sarcoidosis. A literature review indicated that lung involvement by SS may be difficult to distinguish from that of sarcoidosis. Furthermore, several cases have been reported in which both diseases coexisted. CONCLUSIONS Because SS and sarcoidosis may coexist and present with similar pulmonary manifestations, aggressive evaluation including tissue biopsy may be required. However, even tissue biopsy may not distinguish between these entities unless noncaseating granulomas are seen (in the case of sarcoidosis) or isolated lymphocytic interstitial pneumonitis is detected (in the case of SS). When both features (ie; noncaseating granuloma and lymphocytic interstitial pneumonitis) are encountered in the same organ, we believe these diseases are coexisting. Distinguishing both conditions may have prognostic implications, because sarcoidosis may present as an autolimiting process and frequently resolves spontaneously without significant residual functional impairment. In contrast, pulmonary involvement with SS often leads to permanent defects and may progress to incapacitating disease.

Arthropathy as the presenting symptom in hereditary hemochromatosis

Hemochromatosis is characterized by excessive absorption and subsequent deposition of iron in various organs and is prevalent in 1 out of 20,000 hospitalized patients. Most patients with hereditary hemochromatosis (HHC) become symptomatic between the ages of 50 and 60 years. Distinct forms of arthritis have been associated with HHC and may be the initial clinical manifestation in some patients. This is a case of a patient who had chronic hip and back pain and painless swelling over the knuckles. Radiographs revealed classical signs of HHC. Early recognition and prompt institution of phlebotomy can improve the outcome of patients with HHC.

Chlorpromazine-induced lupus with cardiac tamponade.

Although the association of the phenothiazines with immunologic abnormalities is well known, reports of clinical lupus erythematosus are rare. We describe a 52-year old schizophrenic man on chronic chlorpromazine therapy who developed fever and pleuropericarditis with cardiac tamponade. Examination of the pleural and pericardial fluids showed anti-nuclear antibodies. The clinical syndrome responded to a short course of steroids and discontinuation of the chlorpromazine. Drug-induced lupus is a self-limited illness that resolves without long-term sequelae. However, patients should be observed carefully because cardiac tamponade may occur.

Salicylate toxicity in the older patient.

Nonacetylated salicylates are frequently used in the treatment of musculoskeletal complaints and pain management in older patients because of their possible lower gastrointestinal and renal toxicity as compared with other nonsteroidal anti-inflammatory agents. We report five patients with chronic salicylate intoxication seen at the Atlanta VA Medical Center. All charts of patients diagnosed with salicylate toxicity were reviewed, and cases with acute, intentional intoxication were excluded. In the study group, three patients took a nonacetylated salicylate, the other two took an acetylated salicylate. Our patients ranged in age from 51 to 78 years old. One patient died of respiratory failure and “sepsis-like syndrome,” a potentially lethal complication of salicylate toxicity. Four of the patients had altered mental status as a presenting complaint. The presence of a combined respiratory alkalosis and metabolic acidosis, present in all five patients, was the clue for diagnosis in three of the cases. Tinnitus was reported in only one patient. A significantly decreased urate level and a wide anion gap were consistent findings as well. Two of the patients improved after hydration and discontinuation of use of the drug, two required alkalinization of the urine, and one required dialysis. Clinicians need to be more aware of the potential toxicity, including life-threatening complications, with the use of salicylates, particularly in high risk populations such as elderly patients and patients with multiple medical problems.

Coexistence of Acute Calcific Periarthritis and Infection

ABSTRACT: Basic calcium phosphate (BCP) crystal deposition around the joints may sometimes lead to an acute inflammatory condition called calcific periarthritis. In this article, the authors describe a 62-year-old man with BCP crystal-induced periarthritis coexisting with an infection. Rheumatoid arthritis and crystal-induced synovitis complicated by infection has been described in the literature. To date, this is the first report of coexistent calcific periarthritis and an infection.

Blister as the initial presentation of gout.

We present a case of gout that presented initially as a bullous lesion. The patient had no history of gout, and the lesion was diagnosed initially as a simple pressure sore. Examination revealed a large blister over the right medial first metatarsophalangeal joint. Aspiration of the blister yielded cloudy fluid, with many monosodium urate crystals present on microscopic examination. There is scant literature on bullous lesions in gout. Such lesions can occur in patients known to have gout or can lead to the diagnosis of gout in previously undiagnosed patients. Gouty blisters likely form at sites of trauma, as has been proposed for gouty tophi. This case also emphasizes the importance of careful clinical and microscopic examination of aspirated fluid for crystals in the diagnosis of gout.

Of skin and bones.

1-9 Side, behind, side, cross rock, 1/4, 1/4, 1/2 with sweep, behind, side, cross 1-2& (1) Step R to R, (2) cross L behind R, (&) step R to R 12.00 3-4& (3) Rock L across R, (4) recover onto R, (&) turn 1/4 L stepping fwd. on L 9.00 5-6 (5-6) Turn 1/4 L stepping R to R turning your body towards L diagonal prepping to turn R (this is a slow move). As you do this swivel L toes to the side and look over your L shoulder 6.00