Christopher M. Wise

Gout: diagnosis, pathogenesis, and clinical manifestations.

Gout is a common form of arthritis, in which many of the risk factors, pathogenetic mechanisms, and clinical features have been recognized for years. Nevertheless, new information has become available regarding the normal physiologic role of uric acid as an antioxidant, and greater insight has been obtained regarding the inflammatory process in acute gout. New studies have improved our understanding of the role of genetic and environmental factors responsible for hyperuricemia, and we know more about the significance of the association of hyperuricemia with other diseases. Clinically, rare complications and disease manifestations in new populations continue to be discussed, and diagnostic methods continue to be refined.

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.

Nutritional Supplementation withChlorella pyrenoidosa for patients with fibromyalgia syndrome: a pilot study

Fibromyalgia syndrome is a common, chronic musculoskeletal disorder of unknown aetiology. While available therapy is often disappointing, most patients can be helped with a combination of medication, exercise and maintenance of a regular sleep schedule. The objective of the present study was to determine if adding nutritional supplements derived from the unicellular green alga, Chlorella pyrenoidosa, produced any improvements in the clinical and functional status in patients with moderately severe symptoms of fibromyalgia syndrome. Eligible patients had 2+ palpable tenderness at 11 or more of 18 defined tender points and had a tender point index (TPI) of at least 22. Each day for 2 months, participants consumed two commercially available Chlorella‐based products, 10 g of ‘Sun Chlorella’ tablets and 100 mL of liquid ‘Wakasa Gold’. Any amelioration of symptoms was validated and quantified using semi‐objective and subjective outcome measures systematically administered at clinic visits on days 0, 30 and 60 of the diet therapy. Eighteen of the 20 patients enrolled completed the 2 month trial. The average TPI for the group which at onset was 32, decreased to a mean of 25 after 2 months. This decrease was statistically significant (p = 0.01), representing a 22% decrease in pain intensity. Blood samples taken on each occasion indicated no significant alterations in serum chemistries, formed elements, and circulating lymphocyte subsets. Compilations of the results of patient interviews and self‐assessment questionnaires revealed that seven patients felt that the dietary supplement had improved their fibromyalgia symptoms, while six thought they had experienced no change, and five believed the symptoms had worsened over the time of the trial. The results of this pilot study suggest that dietary Chlorella supplementation may help relieve the symptoms of fibromyalgia in some patients and that a larger, more comprehensive double‐blind, placebo‐controlled clinical trial in these patients is warranted. Copyright

Chest wall syndromes.

Chest pain of musculoskeletal origin has not been reviewed on an annual basis in Current Opinion in Rheumatology because of the relative infrequency of important contributions in this area. Over the past 5 years, several studies have contributed to our knowledge of the epidemiology of musculoskeletal chest wall pain, particularly in the setting of noncardiac chest pain. In addition, a growing body of literature has further defined the various syndromes involving the sternum and its articulations, with particular emphasis on the seronegative spondyloarthropathies and arthropathy associated with pustular skin disease. Finally, small series and reviews have continued to address special syndromes of the anterior and posterior chest wall that are of interest to clinicians dealing with patients with pain in this area.

Nutritional Supplementation with Chlorella pyrenoidosa for Fibromyalgia Syndrome: A Double-Blind, Placebo-Controlled, Crossover Study

Objective: To determine if daily dietary supplementation with Chlorella for three months helps normalize body functions, relieve symptoms, and improve quality of life in patients with fibromyalgia syndrome [FMS]. Methods: A total of 43 subjects with FMS were enrolled and randomized such that approximately half consumed 50 Sun Chlorella™ tablets and 100 mL of liquid Chlorella extract known as Wakasa Gold™ each day for three months and the other half consumed 50 placebo tablets and 100 mL of placebo liquid each day for a comparable period. Neither the patient nor the physician conducting the assessments knew which of the dietary supplements the subject was consuming. Following a one month washout period, subjects crossed-over from Chlorella to placebo or vice versa. Results: Thirty-four subjects completed the entire trial. Six parameters of response were followed while each subject consumed each study diet; subjects answered questions relating to sleep, pain, global well-being, and fatigue while the physician assessed tender point index and global well-being. Subjects were considered as having a positive response to a diet if they demonstrated a 50 percent or more improvement in at least four parameters. Of the 37 FMS subjects who completed the Chlorella arm, seven [19 percent] were responders versus only 3/34 [9 percent] who completed the placebo arm [P = 0.311]. For the four self-assessment parameters, significantly more [21/37 or 57 percent] subjects who completed the Chlorella arm noted a 50 percent or better improvement in at least two parameters while only 10/34 [29 percent] who completed the placebo arm did [P = 0.031]. Patient self-assessment of functional abilities by the Fibromyalgia Impact Questionnaire [FIQ] showed that when they were consuming Chlorella, there was a steady, statistically significant, drop in the FIQ score while, when taking placebo, levels of improvement varied and were not statistically significant at the end of the three-month period. Comparisons of the FIQ for Chlorella and placebo indicated that the better response of participants in the Chlorella arm of the crossover was nearly statistically significant [P = 0.058]. A questionnaire dealing with issues of pain, anxiety, sleep, and gastrointestinal difficulties indicated that while participants were consuming Chlorella, there were steady, statistically significant improvements [P < 0.001] in scores compared to baseline. Comparing the two arms, there was a statistically significant [P = 0.004] improvement in FMS symptoms while the subjects were taking Chlorella. Conclusion: Taken together, the results of this randomized, placebo-controlled, double-blind crossover study lead us to conclude that dietary Chlorella supplementation may be useful in relieving symptoms of FMS.

Gout and hyperuricemia.

Although our understanding of hyperuricemia and gout has changed little over the past several years, questions remain in defining the many metabolic abnormalities that can result in these problems. In the past year, several papers have further addressed heritable mechanisms for the development of hyperuricemia, as well as environmental factors that contribute to its onset in adulthood. Consequences of hyperuricemia other than clinical gout have received further attention. Although typical gout is easily recognized and treated, several recent papers have addressed atypical presentations of gout, as well as other causes of podagra that might have been attributed previously to gout. The treatment of patients whose disease is uncomplicated by other conditions remains straightforward. However, the presentation of gout in patients with multiple comorbidities not only increases recognition of the toxicity of nonsteroidal anti-inflammatory drugs and colchicine, but often requires innovative approaches to its treatment.

Granulomatous myositis: a manifestation of chronic graft-versus-host disease

Abstract A case of granulomatous myositis as a manifestation of chronic graft-versus-host disease is presented. The clinical presentation, MR imaging appearances, pathologic features and excellent response to treatment with immunosuppression are described. To the best of our knowledge, based on a world literature search, this is the first report of graft-versus-host disease presenting as granulomatous polymyositis.,

Gouty arthritis and uric acid metabolism.

Important observations have continued to expand our understanding of gout. The increased risk of gout in black Americans has been linked more closely with the development of hypertension, and an increasing prevalence in African blacks and in England may have a similar association, possibly through the use of diuretics. The association of gout and insulin resistance appears to be related to fat distribution, and the link with hyperlipidemia may be related to genetic factors. The relationship between gout and renal disease and the frequency of gout in patients with renal failure continue to be areas of controversy. The mechanism and a possible therapeutic approach to the hyperuricemia associated with cyclosporine therapy are better understood. The potential for antibodies against urate crystals to potentiate further crystallization may explain some of the uncertainties about gouty attacks. Unusual manifestations of gout, including more cases of spinal involvement, were reported. The role of formalin in dissolving urate crystals in pathologic specimens was further clarified, and the use of atomic force microscopy to detect crystals was reported. Corticosteroids are increasingly accepted in treating acute gout, and the role of colchicine in acute and intercritical gout has come under increasing scrutiny. Urate-lowering drugs appear to be cost effective in patients with more than one or two attacks per year.

Comparison of Factor VIII-Related Antigen and Erythrocyte Sedimentation Rate in Outpatient Management of Vasculitis

Electroimmunodiffusion (Laurell rocket) determinations of factor VIII-related antigen in plasma were ordered to determine the cost/benefit ratio for factor VIII-related antigen as a putative test for endothelial damage in suspected vasculitis. Twenty-seven consecutive patients referred for vasculitis or suspected vasculitis were identified and followed up for an average of 9.1 ±months (range: one to thirty-three months) in a prospective, unblinded study performed in a clinic, associated with a 1054- bed inner-city university hospital. There was no difference in Westergren erythrocyte sedimentation rate (WESR) in patients with final diagnosis of systemic vasculitis (SV) (38 ± 12 mm/hour) compared to those without vasculitis (NV) (27 ± 7) as the final diagnosis. The mean plasma concentration of factor VIII-related antigen was significantly elevated in SV (344 ±100%) when compared with NV (147 ±39%) (P < 0.016). The factor VIII- related antigen test in this study was 2.56 times more likely (crude odds ratio) than the WESR to contribute to a change in diagnosis or therapy (P=0.016). Positive and negative predictive values (PPV and NPV) for factor VIII-related antigen (abnormal at greater than 220% of the normal value) were both 70%. PPV and NPV for WESR were 56% and 86%, respectively. The factor VIII-related test was less cost-effective than the WESR in the follow-up period unless it was important to define complete remission or differentiate vasculitis flare from infection. The authors conclude that factor VIII-related antigen is a useful test in the initial diagnosis of vasculitis.