David J. Nashel

Is atherosclerosis a complication of long-term corticosteroid treatment?

In clinical practice, arteriosclerotic heart disease has not been recognized as a complication of long-term corticosteroid treatment. Yet, an increasing body of evidence suggests that prolonged corticosteroid therapy accelerates the development of atherosclerosis. An important element in this process may be the fact that corticosteroids induce or exacerbate several known coronary risk factors, including hypertension, hypercholesterolemia, hypertriglyceridemia, and impairment of glucose tolerance. One group of patients that is often exposed to long-term corticosteroid treatment is that with rheumatoid arthritis. These patients have an increased mortality, with cardiovascular disease appearing to be a major contributor to this decreased survival. The weight of evidence relates the development of atherosclerosis to corticosteroid use. However, no long-term epidemiologic or morphologic studies have been performed to elucidate this issue. Until these are accomplished, prolonged therapy with this medication, particularly in younger persons, should be avoided whenever possible.

Diabetic muscular infarction

In the evaluation of patients with a painful atraumatic mass in an extremity, the clinician should consider a number of clinical entities: primary tumor of muscle, focal or localized nodular myositis, local muscular abscess or soft-tissue infection, osteomyelitis, and thrombophlebitis. A rare complication of diabetes, viz, diabetic muscular infarction, heretofore not reported in the rheumatic disease literature is reviewed. This entity is compared with the conditions of focal and localized nodular myositis, which are nearly as rare.

Rheumatic manifestations of hepatitis C infection

With the advent of serological testing for the hepatitis C virus (HCV) clinicians can better recognize disorders associated with a subset of non-A, non-B hepatitis. As with hepatitis A and B virus infections, HCV disease may be associated with arthritis. Three patients with atypical arthritis who were subsequently discovered to have HCV infection are described. HCV infection should be considered in the differential diagnosis in patients with atypical arthritis.

Significance of a Positive Test for Occult Blood in Stools of Patients Taking Anti-inflammatory Drugs

Physicians often attribute positive Hemoccult card tests in patients taking anti-inflammatory drugs to the irritant effects of these drugs on the gastrointestinal (GI) tract mucosa. A study of 167 patients attending a rheumatic disease clinic showed that 145 (86.8%) were taking an anti-inflammatory drug, but only eight of these patients (4.8%) had positive tests for occult blood. An investigation revealed that three patients had neoplasms, two had inflammatory bowel disease, one had a bleeding internal hemorrhoid, one had a bleeding diverticulum, and one had peptic ulcer disease. Anti-inflammatory agents appear to have caused or contributed to the GI tract bleeding only in the patient with peptic ulcer disease. The study shows that the Hemoccult card test is usually not positive in patients receiving anti-inflammatory medications. Accordingly, physicians should not attribute a positive Hemoccult card test to these drugs until other appropriate studies have ruled out the existence of underlying GI tract lesions.

IgD myeloma with amyloid arthropathy

Abstract A case of Immunoglobulin D (IgD) myeloma with amyloid arthropathy is described. The patient presented with bilateral symmetrical enlargement of multiple joints with subcutaneous nodules; the clinical picture suggested the diagnosis of rheumatoid arthritis. At necropsy, however, the joint swelling and nodules were proved to be amyloid deposition.

Enteroprosthetic Fistula Associated with Hypertrophic Osteoarthropathy

Infected vascular grafts with aortoenteric fistulae can be difficult to diagnose. We describe an interesting patient who developed hypertrophic osteoarthropathy of the lower extremities. This occurred one year prior to the diagnosis of an infected vascular prosthesis. With definitive surgical therapy, all symptoms of hypertrophic osteoarth ropathy resolved. Patients with arterial prostheses who present with hypertrophic osteoarthropathy should be carefully evaluated for occult graft infections.

Iliofemoral thrombophlebitis presenting as an acute abdomen: report and literature review

Iliofemoral thrombophlebitis characteristically presents as acute inflammation and swelling of the affected extremity. We report a patient in whom the presenting complaints of high fever, nausea and left lower quadrant pain mimicked an acute abdomen. The diagnosis was confirmed by venogram after gallium scan and computer tomographic scan revealed abnormalities consistent with iliofemoral thrombophlebitis. This is the first report of abnormal gallium uptake in iliofemoral thrombophlebitis. Current methods of diagnosing this disorder are discussed and the literature reviewed.