D. J. Armstrong

Vitamin D deficiency is associated with anxiety and depression in fibromyalgia

Fibromyalgia is a complex problem in which symptoms of anxiety and depression feature prominently. Low levels of vitamin D have been frequently reported in fibromyalgia, but no relationship was demonstrated with anxiety and depression. Seventy-five Caucasian patients who fulfilled the ACR criteria for fibromyalgia had serum vitamin D levels measured and completed the Fibromyalgia Impact Questionnaire (FIQ) and Hospital Anxiety and Depression Score (HADS). Deficient levels of vitamin D was found in 13.3% of the patients, while 56.0% had insufficient levels and 30.7% had normal levels. Patients with vitamin D deficiency (<25xa0nmol/l) had higher HADS [median, IQR, 31.0 (23.8–36.8] than patients with insufficient levels [25–50xa0nmol/l; HADS 22.5 (17.0–26.0)] or than patients with normal levels [50xa0nmol/l or greater; HADS 23.5 (19.0–27.5); Kruskal–Wallis ANOVA on ranks p<0.05]. There was no relationship with global measures of disease impact or musculoskeletal symptoms. Vitamin D deficiency is common in fibromyalgia and occurs more frequently in patients with anxiety and depression. The nature and direction of the causal relationship remains unclear, but there are definite implications for long-term bone health.

Hypertrophic pulmonary osteoarthropathy (HPOA) (Pierre Marie-Bamberger syndrome): two cases presenting as acute inflammatory arthritis. Description and review of the literature.

We report the cases of two middle-aged male smokers who presented to the early synovitis clinic with an acute phase response, synovitis of the wrists and ankles and clubbing of the fingers, but no respiratory symptoms. Both proved to have primary lung tumours with hypertrophic pulmonary osteoarthropathy, in one case resolving promptly with treatment of the carcinoma. We review the literature, including theories on pathogenesis.

Infective endocarditis complicating rituximab (anti-CD20 monoclonal antibody) treatment in an SLE patient with a past history of Libman–Sacks endocarditis: a case for antibiotic prophylaxis?

We report a 54 year old female whose successful treatment of cerebral lupus with rituximab was complicated by the development of streptococcus intermedius, on valves damaged by Libman-Sacks endocarditis more than 20 years previously.

Accelerated apoptosis in SLE neutrophils cultured with anti-dsDNA antibody isolated from SLE patient serum: a pilot study

Increased numbers of apoptotic neutrophils are found in SLE, related to disease activity and levels of anti-dsDNA antibody. The mechanism of increased apoptosis is not clear, but anti-dsDNA antibody has been shown to induce apoptosis in neutrophils from normal subjects and in certain cell lines. In this study, polyclonal anti-dsDNA antibody was isolated from the serum of a patient with active SLE, and was shown to substantially accelerate apoptosis in neutrophils from SLE patients as compared with neutrophils from healthy control or rheumatoid arthritis subjects.

Relationship between homocysteine and body mass index in rheumatoid arthritis

We read with interest the report of Lopez-Olivo et al (1), in which they describe a cohort of 152 rheumatoid arthritis (RA) patients in whom median levels of homocysteine were significantly higher than controls, and in whom there was an association on multivariate analysis between homocysteine levels and both male gender and radiological damage. We have recently monitored fasting homocysteine levels in 100 RA patients [80 female, 20 male, age (median, 95% CI) 60.0 years, 57.0–62.0, duration of disease (median, 95% CI) 12.0 years, 9.0–17.0] in Belfast, and found comparable results for median homocysteine level (11.3 mmol/l, 9.7–11.8) and for percentage of patients with homocysteinew15 mmol/l (13%). However we found significantly higher body mass index (BMI) in our patients than Lopez-Olivo et al (median 28.0, 95% CI 26.0–28.0, compared with 25.0 in the Mexican cohort). We also observed a strong association between being overweight and higher homocysteine levels. RA patients with BMIv25 (normal weight) had a fasting homocysteine level (median, 95% CI) 9.7 (9.1–11.5) vs. 11.0 (10.3–12.2) in overweight patients (BMIw25), pv0.05. Moreover, when using referral to a dietician, an information programme and exercise advice we achieved a fall in median BMI after 1 year of follow-up to 27.0 (95% CI 25.0–28.0), we saw a related fall in median homocysteine [10.2 mmol/l (9.0–11.4) vs. 11.3 mmol/l (9.7–11.8), p50.1]. We agree with the authors’ observations on the controversy surrounding the interpretation of homocysteine levels, and also failed to find any link with whether or not our patients were taking methotrexate. However, given the two large negative studies published recently examining the effects of direct homocysteine reduction on coronary heart disease (2) and cognitive function (3), albeit in nonRA patients, we are inclined to feel that it is an epiphenomenon of inflammation rather than a causative agent of cardiovascular disease. For this reason we have chosen not to give folate or vitamin B supplements to patients with hyperhomocysteinaemia, but have identified them for careful monitoring and rigorous intervention on traditional risk factors for coronary artery disease, especially high BMI. References

Diastematomyelia presenting with neck stiffness.

A 37-year-old woman presented with a 2-week history of a stiff and slightly painful neck, which had come on when waking from sleep one morning. She denied a history of trauma or any previous problems with her neck and had no other past medical history of note. Examination revealed almost no movement in any direction at the cervical spine, but no neurological abnormality in the upper or lower limbs. Blood testing was unremarkable, but plain radiograph of the cervical spine showed congenital fusion of C5/6. MRI scan revealed diastematomyelia at T1/2, more obvious in the T2-weighted axial images (Fig. 1), with the cord re-uniting fully below T2. The patient received gentle physiotherapy, and her neck movements gradually improved, but a few months later, she developed spasticity and mild weakness in the lower limbs and was referred for neurosurgical intervention. Diastematomyelia is a congenital malformation of the spinal cord in which a variable length is divided into two hemicords. Each hemicord may have its own dural sheath, and the hemicords are sometimes divided by a septum of bone, cartilage or fibrous tissue. The abnormality is always associated with vertebral body abnormalities and frequently with spina bifida [1]. The presentation in this patient is unusual, as only 4% of diastematomyelia occurs above the level of T7 [2]. It is part of a group of disorders termed spinal dysraphism, literally defective fusion, but incorporating other forms of anomalous development, such as dermal sinus, dermoid cyst, neurenteric cyst, meningocoeles, abnormal nerve roots and spinal lipomas [3]. In the majority of cases, there are overlying skin abnormalities, but as in our patient, some forms of diastematomyelia have a normal surface appearance, are compatible with normal neurological function and may remain clinically silent for many years. If a septum is present, it may eventually cause traction or compression of the spinal cord leading to neurological symptoms and signs. Surgery is indicated if there is actively deteriorating neurological function.