Daniel Flusser

The Effect of Balneotherapy at the Dead Sea on the Quality of Life of Patients with Fibromyalgia Syndrome

Abstract: Fibromyalgia (FS) is an idiopathic chronic pain syndrome defined by widespread non-articular musculoskeletal pain and generalised tender points. As there is no effective treatment, patients with this condition have impaired quality of life (QoL). The aim of this study was to assess the possible effect of balneotherapy at the Dead Sea area on the QoL of patients with FS. Forty-eight subjects participated in the study; half of them received balneotherapy, and half did not. Their QoL (using SF-36), psychological well-being and FS-related symptoms were assessed prior to arrival at the spa hotel in the Dead Sea area, at the end of the 10-day stay, and 1 and 3 months later. A significant improvement was reported on most subscales of the SF-36 and on most symptoms. The improvement in physical aspects of QoL lasted usually 3 months, but on psychological measures the improvement was shorter. Subjects in the balneotherapy group reported higher and longer-lasting improvement than subjects in the control group. In conclusion, staying at the Dead Sea spa, in addition to balneotherapy, can transiently improve the QoL of patients with FS. Other studies with longer follow-up are needed to support our findings.

Clinical and radiographic outcomes of rheumatoid arthritis patients not treated with disease-modifying drugs.

OBJECTIVE To compare the radiographic and clinical features of rheumatoid arthritis (RA) patients who were not given disease-modifying antirheumatic drugs (DMARDs) with those of RA patients who were followed up and treated with DMARDs at a rheumatology clinic. METHODS The population of this case-control study includes a series of RA patients who immigrated to Israel from the previous Union of Soviet Socialist Republics and who were treated only with nonsteroidal antiinflammatory drugs. Control patients who were followed up and treated with DMARDs at our rheumatology clinic were matched by sex, disease duration, number of actively inflamed joints, and the presence of serum rheumatoid factor. The outcome measures were the number of deformed and radiographically damaged joints. Radiographic damage was evaluated by the methods of Steinbrocker and Sharp. RESULTS The study population consisted of 22 RA patients (15 women, 7 men) who were not treated with DMARDs and 22 patients (15 women, 7 men) who were treated with DMARDs. The mean disease duration was 16.2 years for the study patients and 14.3 years for the controls. Compared with the matched controls, RA patients who were not treated with DMARDs were found to have a significantly higher mean number of deformed joints (13.8 versus 7.2), a higher mean number of damaged joints (24.4 versus 15.5), and a higher overall damage score by the Sharp criteria (146.1 versus 65.7). CONCLUSION RA patients who were not given DMARDs had a 1.57-fold increased number of radiographically damaged joints and a 2.22-fold increased overall Sharp damage score compared with patients who were treated with second-line agents.

Therapy with mud compresses for knee osteoarthritis: comparison of natural mud preparations with mineral-depleted mud.

Mud pack therapy is an alternative mode of treatment for rheumatic diseases. It is based on the application of heated mud packs to the entire body or to specific areas, such as over joints. The aim of the current study was to evaluate the efficacy of treatment with mud compresses at patients’ homes for osteoarthritis of the knee.Fifty-eight patients with osteoarthritis of the knee were enrolled in a prospective, double-blinded, controlled study. Forty patients were treated with natural mineral-rich mud compresses and 18 patients were treated with mineral-depleted mud compresses. Mud compresses were applied 5 times each week during 3 weeks for a total of 15 treatments. Patients were assessed at baseline, at completion of the 3-week treatment period, and twice after the conclusion of the treatment period—after 1 month and after 3 months.The main outcome measures were the Lequesne Index of severity of knee osteoarthritis, patient self-assessment of pain, and severity of knee pain on a visual analog scale. A reduction of 20% or more in the pain scores was considered clinically significant.In the group treated with natural mud compresses, a significant reduction in knee pain was observed at all assessments. Similarly, improvement in the Lequesne Index was seen at the end of therapy and a month after treatment. In the control group, given mineral-depleted mud compresses, no significant change in knee pain was seen at any assessment. Improvement in the Lequesne Index was seen 1 and 3 months after completion of the therapy, but not at the end of therapy. Seventy-two percent of the patients in the treatment group had an improvement of >20% in self-assessment of knee pain, compared with 33% in the control group (p = 0.005).The data suggest that treatment with mud compresses, but only in their natural form, temporarily relieves pain in patients with osteoarthritis of the knees. We believe that treatment with mud compresses might augment conventional medical therapy in these patients.

Musculoskeletal Manifestations of Brucellosis: A Study of 90 Cases in Israel

Rheumatological manifestations are frequently reported in patients with brucellosis. In a retrospective study of 90 patients diagnosed with brucellosis over a period of 18 years, 83 (92%) patients were Bedouins, 55 of whom (61%) reported ingestion of unpasteurized goat milk and goat milk products. The male/female ratio was 1:1, and the adult to child ratio was 3:2. The mean age of the patients was 25 years (range, 1-72 years). Rheumatological manifestations (myalgia, arthralgia, and arthritis) were reported in more than half of the patients. These manifestations started on days 3 and 4 of the disease and were mild to moderate in severity. Myalagia was evident in 49 (54%) patients and was more common in adults than in children (67% versus 37%; P < .01) and in men (67%) than in women (42%; P < .01). Arthralgia was the most common musculoskeletal manifestation, found in 55 (61%) patients, and occurred more often in children than in adults (74% versus 52%; P < .05). Arthritis was detected in 37 (41%) patients. The hip and knee joints were the most common sites of arthritis (31% each) followed by sacroiliac involvement (17%) and shoulder or spine involvement (5% each). Arthritis was also more common in children (63% versus 29%; P < .01). The prevalence of arthritis was similar in men and women. Cure was achieved in all patients after antibiotic therapy.

A rare case of enterobacter endocarditis superimposed on a mitral valve rheumatoid nodule.

We present the case of a 56-year-old man with longstanding seropositive active erosive and deforming rheumatoid arthritis with no peripheral rheumatoid nodules; he immigrated from the former Soviet Union (where he did not receive any disease-modifying antirheumatic drugs) to Israel in 1995. In February 2005, he had a buccogingival mucosal abscess on his lower lip, which was treated by surgical drainage, followed by prolonged antibiotic therapy. One and a half years later, he had 2 episodes of transient ischemic attacks characterized by speech difficulties and moderate weakness on his right side. Transesophageal echocardiogram revealed a mass on the anterior mitral valve leaflet. Repeated blood cultures were negative, and the patient was afebrile all the time. The patient underwent mitral valve replacement and the histologic findings of the mass were typical of both a rheumatoid nodule and bacterial endocarditis. The patient recovered fully after 6 weeks of antibiotic therapy. Emboli from a rheumatoid nodule should always be considered in patients with rheumatoid arthritis who present with transient ischemic attacks.

Kingella endocarditis and meningitis in a patient with SLE and associated antiphospholipid syndrome.

We describe a patient with SLE and antiphospholipid syndrome who presented with severe headache and fever. Lumbar puncture analyses indicated meningitis. Kingella kingae was isolated from her blood cultures. A large mobile vegetation was seen on her mitral valve. The association between SLE, Libman – Sacks endocarditis and bacterial endocarditis is discussed.

Cyclophosphamide therapy in a patient with membranoproliferative glomerulonephritis and essential mixed cryoglobulinaemia.

Renal involvement in mixed cryoglobulinaemia (MC) runs a variable course, but it is generally characterised by periods of remission and exacerbation which may lead to renal failure [1,2]. Several treatment protocols have been suggested for membranoproliferative glomerulonephritis (MPGN) in patients with essential MC, including long-term plasma exchange, plasmapheresis and cyclophosphamide (CP), or CP in combination with prednisone [1-3]. We present a patient with essential MC and severe MPGN who responded to oral cyclophosphamide without the use of other therapeutic modalities.

Poststreptococcal Vasculitis with Cutaneous and Central Nervous System Involvement

Background: Poststreptococcal vasculitis involving the central nervous system (CNS) is rarely seen. Objective: An unusual case of vasculitis of the CNS induced by a streptococcal infection is reported. Methods: A MEDLINE search was done, and an additional case is reported. Results: Behavioural changes with neurologic symptoms and brain lesions, presented on computerized tomography (CT) study were diagnostic of CNS involvement by vasculitis, induced by poststreptococcal infection. Conclusion: Poststreptococcal vasculitis involving the CNS is a rare event, but this possibility should be considered when a patient with cutaneous vasculitis develops behavioural changes or neurologic symptoms.