Carmen Gómez-Vaquero

Löfgren’s syndrome revisited: a study of 186 patients

PURPOSE To evaluate the clinical features, the results of noninvasive tests and biopsies, and the outcome of patients with Löfgrens syndrome. SUBJECTS AND METHODS Patients diagnosed as having Löfgrens syndrome at a university hospital in Barcelona, Spain, from 1974 to 1996, were prospectively followed. Löfgrens syndrome was defined as the association of erythema nodosum or periarticular ankle inflammation with unilateral or bilateral hilar or right paratracheal lymphadenopathy. RESULTS Löfgrens syndrome was diagnosed in 186 patients. The mean age was 37 +/- 11 years, and 157 (85%) were women. In 91 patients (49%), symptoms started during the spring (P < 0.0001). Erythema nodosum, periarticular ankle inflammation, or both were present at onset in 173 patients (93%). At the time of diagnosis, 161 patients (87%) had no respiratory symptoms; 151 (81%) had stage I abnormalities on chest radiograph, 29 (16%) stage II, and 6 (3%) stage 0. Five percent of patients had decreased forced vital capacity, and 15% had decreased carbon monoxide diffusing capacity. Extrathoracic involvement was infrequent. Serum angiotensin-converting enzyme levels were increased in 50% of patients. Gallium-67 scans showed hilar uptake in all the studied patients, but it yielded useful additional diagnostic information only in those with normal chest radiographs or with unilateral hilar lymphadenopathy. The diagnosis was proven with biopsy results in 63% of patients. None of the patients without histologic confirmation were subsequently found to have a diagnosis other than sarcoidosis. In the 133 patients who were followed for a mean of almost 5 years, 11 (8%) continued to have active disease, and 8 (6%) had several recurrences between 18 months and 20 years after a complete resolution. A normal serum angiotensin-converting enzyme level at diagnosis was associated with disease resolution without recurrence. CONCLUSION Löfgrens syndrome is usually a self-limiting form of sarcoidosis. Histologic confirmation is not necessary in typical cases. In a small number of patients, the disease may remain active or recur long after its onset, although usually with mild organ dysfunction.

Group B streptococcus (Streptococcus agalactiae) pyogenic arthritis in nonpregnant adults.

We analyzed the cases of pyogenic arthritis from group B streptococcus (GBS), or Streptococcus agalactiae, in nonpregnant adults diagnosed in the Hospital Universitari de Bellvitge, a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, during a 10-year period, and we reviewed the available literature to summarize the experience with this infectious entity. From the database of our institution, which does not attend pediatric, obstetric, or burn patients, we collected all microbiologically proven cases of infectious arthritis seen from January 1992 to December 2001. We excluded patients with infection limited to spine; patients with prosthetic joint infection; patients undergoing articular surgery during the year before diagnosis; and those with tuberculous, brucellar, or fungal arthritis. Of a total of 112 patients identified, GBS was the causative organism in 11 (10%) cases. We reviewed the literature using a MEDLINE search (1972–2001), and found 64 additional cases.Of the 75 patients, 34 (45%) were men and 41 (55%) women, with ages ranging from 20 to 87 years (mean age, 57.9 ± 14.9 yr); 37 patients (49%) were over 60 years. Sixty-eight percent (51/75) of the patients presented with monoarthritis, while in 32% (24/75) more than 1 joint was involved. The most common location was the knee (36%), followed by the shoulder (25%). In 66% (43/65) of cases, bacteremia was documented. In 64% (47/74) of patients, a systemic predisposing factor for infection was noted; the most common conditions were diabetes mellitus, malignancies, and chronic liver diseases. In 31% (23/75) of patients, a concomitant infectious process due to the same microorganism was found, mainly vertebral osteomyelitis and urinary tract infection. Penicillin was the main antibiotic used after bacterial identification; surgical drainage was performed in 36% (27/75) of cases. The overall mortality rate was 9% (7/75).GBS is now a significant causative agent of pyogenic arthritis in nonpregnant adults. In this population, joint infection by GBS is a disease that mainly affects aged patients with underlying medical illnesses; polyarticular involvement, bacteremia, and the presence of a concomitant infectious process are frequent conditions. The case-fatality rate is substantial.

Nutritional status in patients with rheumatoid arthritis

BACKGROUND Some chronic diseases have been associated to an impairment of nutritional status. OBJECTIVE To analyze nutritional status and its relation to dietary intake, disease activity and treatment in rheumatoid arthritis. PATIENTS AND METHODS We have included 93 patients (43 men and 50 women) and 93 age- and sex-matched healthy controls. The assessment of nutritional status included anthropometric (body mass index, tricipital skin fold and midarm muscular circumference) and biochemical (serum albumin, prealbumin and retinol binding protein) parameters. Dietary intake was calculated from a food frequency questionnaire. As a measure of disease activity, we used the Health Assessment Questionnaire, Ritchie index, tender and swollen joint count and C-reactive protein. Statistical analysis was performed in the whole series and in every functional class. RESULTS In the whole series, midarm muscular circumference and serum albumin were significantly lower in patients than in controls. All anthropometric parameters and serum albumin were significantly lower in patients in functional class IV than in their respective controls. The dietary intake of energy, carbohydrates, vegetal proteins and lipids was higher in patients than in controls. Midarm muscular circumference and serum albumin had a significant inverse relation with disease activity parameters; body mass index, midarm muscular circumference and serum albumin correlated inversely with the cumulative dose of glucocorticoids. CONCLUSIONS Patients with rheumatoid arthritis in functional class IV have an impairment of nutritional status without a deficient dietary intake. The differences found in other functional classes are explained by rheumatoid arthritis itself. Nutritional parameters are related to disease activity and glucocorticoid treatment.

Vertebral and Rib Sarcoidosis: Long-Term Clinical Remission with Methotrexate

Abstract: We describe a patient with bilateral hilar lymphadenopathy shown on a chest radiograph and supraclavicular lymphadenopathy. Biopsy of a supraclavicular lymph node showed non-caseating granulomas. A diagnosis of sarcoidosis was made and no treatment was given. One year later she complained of cervical and lumbar pain and decreasing strength of the right hand. Magnetic resonance imaging of the spine showed multiple lesions within the vertebral bodies of six vertebrae, and thoracic computed tomography showed partial destruction of the first right rib. A biopsy of the second lumbar vertebra demonstrated non-caseating granulomas. Corticosteroid treatment was unsuccessful and long-term remission of the symptoms was achieved with a weekly low dose of methotrexate.

Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures.

Objective: To analyse whether bone mineral density (BMD) assessment is required in postmenopausal women presenting with low trauma vertebral fracture. Methods: Women with vertebral fracture diagnosed over a 10 year period were recruited from our database. The following were excluded: (a) patients with high energy trauma; (b) patients with malignancies; (c) patients with a metabolic bone disease other than osteoporosis. All postmenopausal women were included in whom BMD had been evaluated at both the lumbar spine and femoral neck by dual energy x ray absorptiometry during the six months after the diagnosis. Patients with a potential cause of osteoporosis other than age and menopause were not considered. A total of 215 patients were identified. Results: The mean (SD) age of the patients was 65.9 (6.9) years. BMD at the lumbar spine was 0.725 (0.128) g/cm2 and the T score was −2.94 (1.22); BMD at the femoral neck was 0.598 (0.095) g/cm2 and the T score was −2.22 (0.89). The BMD of the patients was significantly lower than that of the general population at both the lumbar spine and femoral neck. When the lowest value of the two analysed zones was considered, six patients (3%) showed a normal BMD, 51 (23.5%) osteopenia, and 158 (73.5%) osteoporosis. The prevalence of osteoporosis at the femoral neck increased with age; it was 25% in patients under 60, 35% in patients aged 60–70, and 60% in patients over 70. Conclusion: These results indicate that bone densitometry is not required in postmenopausal women with clinically diagnosed vertebral fractures if it is performed only to confirm the existence of a low BMD.

Évaluation de l’état nutritionnel chez les patients atteints de polyarthrite rhumatoïde

Resume Certaines maladies chroniques s’accompagnent d’une alteration de l’etat nutritionnel. Objectif. Analyser l’etat nutritionnel et ses relations avec les apports alimentaires, l’activite et le traitement de la polyarthrite rhumatoide. Patients et methodes. Nous avons etudie 93 patients (43 hommes et 50 femmes) et 93 temoins, apparies pour l’âge et le sexe. L’evaluation de l’etat nutritionnel a ete faite a l’aide de parametres anthropometriques (indice de masse corporelle, pli cutane tricipital et circonference musculaire brachiale) et biochimiques (albumine, prealbumine et retinol binding protein seriques). Les apports dietetiques ont ete calcules a partir d’un questionnaire de frequence des prises alimentaires. L’activite de la polyarthrite rhumatoide a ete evaluee a partir du Health Assessment Questionnaire, de l’indice de Ritchie, du nombre d’articulations douloureuses, du nombre d’articulations gonflees et de la mesure de la proteine C-reactive. L’analyse statistique a ete effectuee sur l’ensemble des malades et dans chaque classe fonctionnelle. Resultats. Chez l’ensemble des patients, la circonference musculaire brachiale et l’albuminemie etaient significativement diminuees par rapport aux temoins. Tous les parametres anthropometriques ainsi que l’albuminemie etaient significativement diminues chez les patients appartenant a la classe fonctionnelle IV, et ce par rapport a leurs temoins respectifs. Les apports alimentaires en calories, en hydrates de carbone, en proteines vegetales et en lipides etaient plus eleves chez les patients que chez les temoins. La circonference musculaire brachiale et l’albuminemie etaient inversement correlees aux parametres de l’activite de la polyarthrite. De plus, l’indice de masse corporelle, la circonference musculaire brachiale et l’albuminemie etaient inversement correles a la dose totale cumulee de glucocorticoides. Conclusion. Les sujets atteints d’une polyarthrite rhumatoide de classe IV ont une alteration de leur etat nutritionnel qui n’est pas liee a une carence des apports alimentaires. Les differences observees dans les autres classes fonctionnelles sont expliquees par la polyarthrite rhumatoide elle-meme. Les parametres de l’etat nutritionnel sont correles avec l’activite de la maladie et la corticotherapie.