Dragan Nikolic

Successful treatment of postvenereal reactive arthritis with synovectomy and 3 months' azithromycin.

Background:The effects of antibiotic therapy on the course of postvenereal reactive arthritis have not yet been elucidated. Objective:The objective of this study was to observe the clinical course and outcome of synovectomy and 3 months of azithromycin therapy in patients with reactive arthritis and previously diagnosed triggering bacteria. Methods:We performed an open, prospective study on 20 (14 male/6 female) patients with postvenereal reactive knee arthritis, aged 36.7 ± 14.8 years, and with 16.5 ± 20.4 months’ duration of the disease. Detection of bacteria triggers was done by polymerase chain reaction, isolation and identification, and electron microscopy. Synovectomy was performed in all patients at entry into the study. Azithromycin was given at a dose of 500 mg per day for 5 days, and then 500 mg twice a week, during a 3-month period. Patients without remission were treated with combined antibiotic therapy using a macrolide, quinolone, and tetracycline for the next 4 months. Outcome evaluations of therapeutic efficacy and azithromycin safety were done after 1 and 3 months and 2 years of follow up. Results:Remission, defined by the absence of joint swelling and tenderness, and extraarticular signs, was reached after 3 months in 15 of 20 (75.0%) patients (P = 0.025). Of 5 patients with persistent knee arthritis, remission was achieved with combined antibiotic therapy in 4. Visual analog scale scores (P < 0.01), the number of patients (P = 0.002), and the number of samples (P = 0.01) with a positive finding of bacteria or their DNA were significantly lower after 3 months of therapy. During the azithromycin therapy, there were no significant adverse effects. Conclusions:These patients with reactive arthritis did extremely well on the regimen described. In our study group, the number of patients and the number of samples with positive findings of bacteria or their DNA were lower after the antibiotic treatment combined with surgery, although not all bacteria were eradicated. Adverse effects of prolonged azithromycin administration were insignificant. This open treatment approach is recommended but does need a study with controls.

[Diagnostic significance of synovial biopsy in patients with Reiter's syndrome].

INTRODUCTION Arthritis in Reiters syndrome (RS) is a reactive synovitis associated with a localized infection of the urogenital or gastrointestinal tract with a genetic predisposition. The pathogenetic mechanisms for synovitis in RS are still unknown. Our aim was to examine some of the pathogenetic mechanisms in Reiters syndrome looking for morphologic changes, immunoprotein deposits and microorganism antigens in synovial biopsies and to determine whether synovial biopsy is useful in diagnosis of RS. MATERIAL AND METHODS Thirty patients with urogenital form of RS were examined within a four-year period. Table 1 illustrates laboratory findings in our patients. We performed synovial biopsies looking for histopathological changes, deposits of immunoproteins and microorganism antigens. Analysis of synovial biopsy specimens was performed using light and immunofluorescence microscopy and fluorescein-labelled monoclonal antibodies to Chlamydia trachomatis. RESULTS Histopathological examination of synovial membrane revealed marked proliferation of the synovial lining cells (SLC) with less or more abundant papillary projections, hypertrophic and edematous tissue with marked vascularisation in 28 (93.3%) cases. Fibrinoid necrosis foci were seen on the surface of synovial tissue. Chronic inflammatory cells (CIC) were diffusely distributed. Edema of the vessel walls, swollen endothelial cells, fibrinoid necrosis in vessel walls as well as multilaminated basement membranes were observed. All histopathologic changes are presented in Table 2. Immunofluorescent techniques in 12 out of 30 (40%) synovial membranes showed immunoglobulin deposits: IgG and IgA deposits were found in vessel walls in 7 cases each and IgM in 10 biopsy specimens. C3 was present perivascularly or within the vessel wall in 4 (13.3%) cases. Sections treated using fluorescein-conjugated antibody revealed Chlamydia in the synovial tissue in 2 patients. CONCLUSION Biopsy specimens with previously described changes in patients with suspected Reiters syndrome can be useful to confirm the diagnosis. According to our experience, multiple biopsies of abnormal synovia are recommended in these patients.

Lower back pain - silent symptom of chronic infrarenal abdominal aneurysm rupture

INTRODUCTION The rupture of infrarenal abdominal aortic aneurysm is a surgical emergency condition with a high rate of mortality before the patients arrive at hospital. The signs and symptoms of abdominal aortic aneurysm rupture into the retroperitoneal cavity are pulsatile mass, abdominal pain, hypotension and shock, but sometimes silent symptoms also hide a dangerous and life threatening condition, such as chronic aneurysm rupture of abdominal aorta into the retroperitoneal cavity. CASE REPORT We present a patient having had the lower back pain for 4 months, which had been recognized and treated as lumbar ischialgia but which was eventually diagnosed to be chronic infrarenal abdominal aortic aneurysm rupture by computed tomography angiography. The surgical intervention was successful and the patient was discharged from hospital after 6 days without any clinical complications. Preoperative imaging by computed tomography angiography of ruptured abdominal aortic aneurysm is highly sensitive for detection of several specific signs for rupture. This condition leads to urgent vascular surgery.

Osteoid osteoma: A ten-years treatment experience

Aim. To review ten-years experience in diagnostics and operative treatment of osteoid osteoma. Methods. A total of 15 patients were retrospectively analyzed in this study. Clinical diagnosis was based on medical check-up, aspirin test, and conventional laboratory and radiographic examinations. CAT scan radionuclide bone scan, and magnetic resonance were performed in certain cases. All the patients were operatively treated by local resection of the tumor-infested bone. The resected part of the bone was intraoperatively checked by X-ray. The aim of this examination was to verify nidus in the resected bone. Afterwards, the resected bone with nidus was histologically analyzed. Results. Osteoid osteoma was histologically verified in 86.6% of cases. Other forms of bone tumors were verified in 13.3%. In the early postoperative period patients were without previous discomforts. Future treatment consisted of regular medical check-up of all the patients. In order to verify the final results, in February 2002 another medical check-up was performed for 11 patients, upon their consent. All of the patients with verified osteoid osteoma were without discomforts. Medical findings were regular in each case. Conventional radiography showed a solid bone remodelling in place of resected bone. Conclusion. Osteoid osteoma is a benign bone tumor with typical clinical and radiographic findings. Operative treatment represents a method of choice and demands accurate preoperative localization of the lesion, with the help of computer-assisted tomography.