Espinoza Lr

Rheumatic manifestations of human immunodeficiency virus infection

PURPOSE The prevalence and characteristics of the rheumatic and extra-rheumatic manifestations of human immunodeficiency virus (HIV) infection were determined in a prospective manner. PATIENTS AND METHODS One hundred one patients with HIV infection were consecutively interviewed and examined. The prevalence of autoantibodies and their association with rheumatologic symptoms were also determined. RESULTS The musculoskeletal system was involved in 72 patients. Thirty-five patients had arthralgias, 10 had Reiters syndrome, two had psoriatic arthritis, two had myositis, and one had vasculitis. Also found were two previously unreported syndromes. The first, occurring in 10 patients, consisted of severe intermittent pain involving less than four joints, without evidence of synovitis, of short duration (two to 24 hours), and requiring therapy (ranging from nonsteroidal antiinflammatory drugs to narcotics). The second, occurring in 12 patients, consisted of arthritis (oligoarticular in six patients, monoarticular in three patients, and polyarticular in three patients) involving the lower extremities and lasting from one week to six months. The synovial fluid of five patients (three with arthritis, one with Reiters syndrome, and one with psoriatic arthritis) was sterile and inflammatory. CONCLUSION Musculoskeletal complications are common in advanced stages of HIV infection. Persons in a high-risk group for HIV infection who manifest oligoarthritis with or without any other extra-articular manifestation suggestive of Reiters syndrome or other form of spondyloarthropathy should be tested for HIV.

Articular involvement in human Brucellosis: A retrospective analysis of 304 cases

Brucellosis is a zoonosis which in humans is caused by one of four species of the Brucella genus: B. melitensis, B. abortus, B. suis and B. canis. B. abortus is the species prevalent in North America and Europe and B. melitensis in most developing countries. Differences in disease manifestations may be accounted for either by differences in the species or by differences in the host. Articular involvement in brucellosis, although recognized since 1904, has been variably emphasized. Three hundred and four cases of human Brucellosis caused by B. melitensis, the prevalent species in Perú, were seen during a 12-yr period in one Lima hospital. Fever, malaise and hepatomegaly were the most frequent findings. Diagnosis was greatly improved when cultures were done in the biphasic Ruiz-Castañeda medium, rather than in trypticase soy broth. Serologic diagnosis is still important, and it should include standard tube testing, detection of IgG blocking antibodies and fractionation with 2-ME in chronic cases. The disease may take one of three courses: acute, (< 8 wk), chronic (> 8 wk) or undulant (periods of remissions and exacerbations). Four syndromes were recognized in a total of 33.8% of patients with Brucellosis. The most frequent pattern (in approximately 46.6% of patients with arthritis) was sacroiliitis, usually non-destructive and either uni- or bilateral. The second most frequent articular syndrome was peripheral arthritis (38.8%), manifested either as a single large lower extremity joint or as an asymmetric pauciarthritis. Rarely patients presented with a rheumatoid-like arthritis. Mixed arthritis (7.8%) was a combination of the first two. The above forms occurred in patients with an acute or undulant course. Spondylitis was the least common form of arthritis (6.8%), and differed significantly from the other forms of arthritis in the duration of symptoms (chronic course), age of patients (older individuals) and the paucity of fever and malaise. It also tended to be destructive. The arthritis usually resolved with the combined regimen of tetracycline (2 g p.o. for 21 days) and streptomycin (1 g i.m. for 21 days) without sequelae. Illustrative cases of these syndromes are presented. The relatively benign nature of most of the patients with bruccellar arthritis lead us to postulate that they are for the most part reactive arthritides. Host factors are thought to be important in determining the response to the infection, but they are yet to be identified. Our own genetic studies have failed to identify an increased frequency of B27 or CREG antigens in the patients with sacroiliitis.(ABSTRACT TRUNCATED AT 400 WORDS)

Prolactin, immunoregulation, and autoimmune diseases

Cells of the immune system synthesize prolactin and express mRNA and receptors for that hormone. Interleukin 1, interleukin 6, gamma interferon, tumor necrosis factor, platelet activator factor, and substance P participate in the release of prolactin. This hormone is involved in the pathogenesis of adjuvant arthritis and restores immunocompetence in experimental models. In vitro studies suggest that lymphocytes are an important target tissue for circulating prolactin. Prolactin antibodies inhibit lymphocyte proliferation. Prolactin is comitogenic with concanavalin A and induces interleukin 2 receptors on the surface of lymphocytes. Prolactin stimulates ornithine decarboxylase and activates protein kinase C, which are pivotal enzymes in the differentiation, proliferation, and function of lymphocytes. Cyclosporine A interferes with prolactin binding to its receptors on lymphocytes. Hyperprolactinemia has been found in patients with systemic lupus erythematosus. Fibromyalgia, rheumatoid arthritis, and low back pain patients present a hyperprolactinemic response to thyrotropin-releasing hormone. Experimental autoimmune uveitis, as well as patients with uveitis whether or not associated with spondyloarthropathies, and patients with psoriatic arthritis may respond to bromocriptine treatment. Suppression of circulating prolactin by bromocriptine appears to improve the immunosuppressive effect of cyclosporine A with significantly less toxicity. Prolactin may also be a new marker of rejection in heart-transplant patients. This body of evidence may have an impact in the study of rheumatic disorders, especially connective tissue diseases. A role for prolactin in autoimmune diseases remains to be demonstrated.

Anticardiolipin antibodies in polymyalgia rheumatica-Giant cell arteritis: Association with severe vascular complications

PURPOSE We studied a group of patients with polymyalgia rheumatica (PMR) with or without biopsy-proven giant cell arteritis (GCA) in order to determine the prevalence of anticardiolipin antibodies (aCL) in these disorders and their association with vascular complications. PATIENTS AND METHODS The study consisted of 50 patients, 30 with PMR alone and 20 with associated GCA. Determinations of IgG and IgM aCL by enzyme-linked immunosorbent assay were done in the patients and in 50 age- and sex-matched healthy control subjects. We also measured von Willebrand factor (vWF) antigen, C-reactive protein, and erythrocyte sedimentation rate. RESULTS Twenty-four (48%) of the 50 patients had aCL. Eleven were positive for IgG and five for IgM, whereas eight were positive for both. In the group of patients with PMR alone, only eight (26.6%) had aCL, while 16 of 20 patients (80%) with GCA had these antibodies (p less than 0.01). In the control group, 10 of 50 patients (20%) had positive aCL, a finding that was statistically significantly different only when compared with the finding in patients with GCA (p less than 0.01). Both isotypes of aCL were seen mainly in patients with GCA, and five of these patients had severe vascular complications. Levels of vWF antigen were significantly higher in patients with GCA as compared with patients with PMR alone; however, the highest titers did not correlate with vascular complications. Erythrocyte sedimentation rate and C-reactive protein were increased but comparable in both groups. CONCLUSION This study demonstrates that aCL are prevalent in patients with GCA. These antibodies might imply severe vascular damage and could play an important role in the pathogenesis of the vasculopathy observed in this disease.

Histocompatibility typing in the seronegative spondyloarthropathies: A survey

T HE FIRST association of a human disease (Hodgkin disease) and increased prevalence of a histocompatibility (HLA) antigen was described by Amiel in 1967.’ Since then, a large number of other diseases have been associated with increased or decreased frequencies of various HLA antigens.2-5 A number of different correlations have emerged; some are detectable at the population level, while some are detectable only at the haplotype level within families. The most significant and reproducible associations, however, have been reported in the seronegative group of rheumatic diseases. HLA-B27 has been shown to be a frequent genetic marker for rheumatic disease characterized by axial (spondylitis) types of arthritis. Ankylosing spondylitis (AS),“” Reiter syndrome (RS),“,‘* psoriatic spondylitis (PsS),“~‘~ and spondylitis associated with inflammatory bowel disease (IBD)15 are all characterized by significant increases in HLA-B27. Recently, we and others’6-‘9 reported a significantly increased prevalence of HLA-Bw38 in patients with peripheral psoriatic arthritis (PsA) in whom the frequency of HLA-B27 was within normal limits. Because HLA-Bw38 is a recently identified antigen, we concluded that it was useful to evaluate in other conditions characterized by seronegative peripheral arthritis. In this study of the association among HLAB27, Bw38, the DR antigens and seronegative arthritis, we evaluated clinically, radiologically, and by means of HLA typing, a large number of patients with seronegative arthritis. We confirmed the significant association of B27 and spinal involvement in the spondyloarthropathies and the association of Bw38 and DRw4 with psoriatic arthritis. Additionally, Bw38 and DRw4 were not found to be elevated in any other form of arthritis. No abnormal elevation and/or depression of a given HLA antigen was observed in patients with seronegative rheumatoid arthritis or osteoarthritis. MATERIALS AND METHODS

A Case of the Eosinophilia-Myalgia Syndrome Associated with Use of an L-Tryptophan Product

Excerpt L-Tryptophan has been used as a sedative hypnotic for insomnia and as an antidepressant for many years. Previously reported toxicity has included nausea, vomiting, ataxia, hyperreflexia, po...

Oral methotrexate therapy for chronic rheumatoid arthritis ulcerations

Eight patients with long-standing rheumatoid arthritis and cutaneous vasculitis ulcerations resistant to conventional therapy were treated successfully with a low-dose intermittent regimen of oral methotrexate. Objective clinical response was prompt and complete resolution was observed at about 12 weeks of therapy. The drug was well tolerated. Mild gastrointestinal side effects were the most common untoward reaction. We conclude that methotrexate therapy is an effective agent for some of the extraarticular manifestations of rheumatoid arthritis including vasculitis, and further clinical evaluation should be a consideration.

Hypocomplementemic Vasculitis and Renal Involvement

Hypocomplementic urticarial vasculitis is a disorder that not only affects the skin, but other organs as well. We are describing a patient with this rare disorder and serious renal involvement that was treated with immunosuppressive therapy with good response and stabilization of the renal function. We emphasize the fact that renal involvement can occur with this disease and that the renal involvement is of the immune-mediate type and cannot be considered as benign as thought in the past.

Circulating immune complexes in the seronegative spondyloarthropathies

Abstract Circulating immune complexes (CIC) were determined in a large population of patients with seronegative spondyloarthropathies. In addition, we attempted to correlate the presence and levels of CIC with other parameters of disease activity in a serial fashion. CIC were measured using the Raji cell assay and the solid-phase Clq assay. A total of 92 patients were studied. These included 30 with ankylosing spondylitis (AS), 30 with psoriatic arthritis (PsA), 20 with Reiters syndrome, and 12 patients with Crohns arthritis (CA). Elevated levels of CIC were found in 73.3% (22 of 30) of AS patients, 60% (18 of 30) of PsA patients, 80% (16 of 20) of Reiters patients, and 67% (8 of 12) of Crohns patients studied. Both assays yielded concordant results. There was a significant correlation with disease activity, in particular arthritis, and the levels and incidence of CIC markedly declined in all groups when disease activity was under better control. Density gradient analysis of several sera revealed immune complex reactive material mainly in the 19 S region. This study suggests that CIC may play a role in the pathogenesis of some of the clinical manifestation of these conditions.

The "active" rosette test in rheumatoid arthritis: correlation with disease activity.

Abstract A subpopulation of peripheral blood T lymphocytes characterized by their ability to form rapid rosettes with sheep erythrocytes (“active” RFC) was studied in a group of rheumatoid arthritis patients at different stages and levels of activity both initially and sequentially. These studies showed that patients with active rheumatoid arthritis appear to have depression of cell-mediated immunity as tested by the “active” RFC test. This abnormality correlated well with disease activity and disappeared with improvement of clinical status. Evidence suggesting that increased levels of circulating immune complexes may be responsible in part for the diminished T-cell function as measured by “active” RFC formation is also presented.