James E. Brick

Herpes zoster in patients with rheumatoid arthritis treated with weekly, low-dose methotrexate

PURPOSE Herpes zoster occurred in nine patients with methotrexate-treated rheumatoid arthritis. We compared these patients to a large group of methotrexate-treated rheumatoid arthritis patients in order to uncover potential factors explaining the occurrence of herpes zoster. PATIENTS AND METHODS Data from 187 patients taking methotrexate were reviewed and compared with data from another nine patients who developed herpes zoster while taking the drug for rheumatoid arthritis, all from the same university-based arthritis clinic. Literature pertinent to infection in rheumatoid arthritis patients treated with methotrexate is reviewed. RESULTS Herpes zoster occurred in 14.5 cases per 1,000 patient-years in our methotrexate-treated rheumatoid arthritis patients, as compared with the general population incidence of 1.3 to 4.8 cases per 1,000 patient-years. The infection was unrelated to duration of methotrexate usage, prednisone treatment, or the co-existence of diabetes mellitus, but appeared to occur in patients with high titers of rheumatoid factor and an overall longer duration of rheumatoid arthritis. There were no cases of systemic dissemination or recurrence of herpes zoster despite 27.4 years cumulative follow-up on continued methotrexate therapy. CONCLUSIONS Herpes zoster may occur more frequently in patients with rheumatoid arthritis treated with low-dose methotrexate than in the general population. Herpes zoster in rheumatoid arthritis patients treated with methotrexate appears to be self-limited, benign, and statistically related to methotrexate use in the presence of longer-term rheumatoid disease.

Wernicke Encephalopathy in Nonalcoholic Patients

Background: Wernicke encephalopathy is associated with patients that have a history of alcohol abuse and other malnourished states. However, clinicians may be less likely to recognize this condition in nonalcoholic patients. This study was undertaken to evaluate the cause, diagnosis, treatment, and outcome of nonalcoholic patients with Wernicke encephalopathy. Methods: A retrospective review was conducted of all cases of Wernicke disease from 1984 to 1999 evaluated at a rural university hospital. Inclusion criteria consisted of patients diagnosed clinically with this disorder who improved after the administration of thiamin. Patients were also included in the series if they had classic pathologic findings of the disease on autopsy even without a prior clinical diagnosis. Results: Twelve patients were identified. Alcohol abuse was noted in only 50%. The patients without a history of alcohol abuse had other malnourished states, such as end‐stage cancer, intractable vomiting after gastric reduction procedure, and prolonged hospital courses on intravenous fluids without other sources of nutrition. The mortality rate was 4 of 12 (33%) but due to multiple causes. Autopsies were performed on all 4 patients. Three of these 4 patients had no history of alcohol abuse. Two of the nonalcoholic patients were not diagnosed until autopsy, whereas all the patients with a history of alcohol abuse were diagnosed clinically. Discussion: Our study reveals that Wernicke encephalopathy continues to be a rare but life‐threatening condition often overlooked in the nonalcoholic population, resulting in the further progression of an easily treatable condition.

Timber rattlesnake venom‐induced myokymia Evidence for peripheral nerve origin

Facial and limb myokymia occurred in four consecutive cases of timber rattlesnake envenomation and represents the “fasciculations” frequently reported in this entity. The facial myokymia disappears within hours of antivenin therapy and the limb myokymia by increasing serum ionized calcium. These observations suggest that the action of the venom is a biochemical one, increasing peripheral nerve excitability.

Evaluating the complaint of fatigue in primary care: Diagnoses and outcomes

PURPOSE This case series describes associated diagnoses and prognoses of persistent fatigue in a community-based, primary care population. PATIENTS AND METHODS All patients presenting to a private practice internist with a chief complaint of fatigue of more than 1 months duration were prospectively evaluated with clinically directed examination and diagnostic testing. Patients were excluded if they had a previously diagnosed illness associated with fatigue. Fatigue was attributed to newly established diagnoses or medication use based on explicit criteria. Change in the state of each patients fatigue was measured 6 months after entry. RESULTS Fifty-two consecutive patients entered the study. The diagnoses associated with fatigue were a medical disorder in 25 patients, depression in 10 patients, and no definitive diagnosis in 18 patients. The mean cost of diagnostic testing was

EEG and pathologic findings in patients undergoing brain biopsy for suspected encephalitis

131. At 6 months, 37 of 52 patients (72%) reported improvement in or resolution of their fatigue. CONCLUSION In a primary care setting, many patients presenting with persistent fatigue have an associated, treatable disease that can be determined using a cost-effective, clinically directed approach. Most will experience an improvement in their fatigue.

Anti-histone antibodies in the serum of autoimmune MRL and NZB NZW1 F1 mice

Previous studies have suggested that EEG may be helpful in the diagnosis of herpes encephalitis (HE). To further define the value of EEG in an acutely ill, febrile, encephalopathic patient suspected as having encephalitis, we reviewed initial preoperative EEGs with the results of cerebral biopsies in 24 consecutive patients suspected of having encephalitis. Statistical analysis demonstrated that EEG patterns have only limited association with biopsy results. Since diseases which mimic encephalitis may also generate identical EEG changes, this is not an unexpected finding. EEG is useful in the evaluation and management of patients with encephalitis. However, the absence of specific wave forms or focal EEG abnormalities in the proper clinical setting should not deter consideration of HE or delay treatment.

Musculoskeletal disorders: When are they caused by hormone imbalance?

Anti-histone antibodies have been reported in a number of human autoimmune diseases, most notably idiopathic and drug-induced lupus erythematosus. In the current study, anti-histone antibody activity was detected using ELISA and electroblotting techniques in sera from autoimmune NZB/W, MRL-lpr, and MRL-(+)/+ mice. Anti-histone activity increased with age, maturing earlier in females, in both NZB/W and MRL-lpr mice. Testosterone treatment decreased anti-histone activity in NZB/W mice and estrogen treatment from 2 weeks of age increased anti-histone activity in MRL-lpr mice, suggesting that gonadal hormones modified the expression of autoantibodies recognizing these protein antigens. Estrogen also increased serum IgG levels in MRL-lpr mice. Sex hormones affected expression of antibodies recognizing soy milk proteins but not ovalbumin in a similar manner. Nitrocellulose Western blots of SDS gels probed with sera from both types of autoimmune mice most often demonstrated reactivity with histone1. Some mice, usually mature females, also recognized histone4, histone3, and histone2.

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Often, the source of a musculoskeletal problem can be traced to an endocrine disorder. For example, carpal tunnel syndrome is not uncommon in patients who are pregnant or have diabetes, hypothyroidism, or acromegaly. Joint problems and arthritis are other common findings in diabetes, pregnancy, and hyperparathyroidism. Muscle weakness or stiffness is seen in both hypothyroidism and hyperthyroidism, and muscle wasting is a characteristic of adrenocorticoid insufficiency. Bone disorders are common with glucocorticoid excess, acromegaly, and hyperparathyroidism. Some presentations are a classic picture of a specific endocrine condition and are readily recognized if the index of suspicion is appropriately high.

Giant cell arteritis and polymyalgia rheumatica.

The Robert C. Byrd Health Sciences Center of West Virginia University (RCB HSC) is located in Morgantown, WV and offers a full array of services (Figure 1). The central mission of the RCB HSC is service to the State of West Virginia. West Virginia is a state with an approximate population of 1.8 million, 55 counties, approximately 3,000 physicians, and 63 hospitals (over half of which have less than 100 beds). Because of its terrain and distance to urban areas, recruitment of primary care physicians to rural West Virginia is a problem. In order to reduce feelings of isolation and to increase retention of providers in rural areas, the RCB HSC has developed many programs to support rural providers. For example, in 1985, the WVU School of Medicine started a program called the Medical Access and Referral System (MARS). This toll-free service enables RCB HSC specialists to instantly provide medical information to West Virginias rural practitioners. MARS now receives over 1,500 calls a month. Rural practitioners that use MARS have indicated that it is a lifeline that allows them to provide better patient care. Another successful program at the RCB HSC designed to address the issue of isolation is the Visiting Clinicians Program. This program brings selected primary care physicians from rural West Virginia to the RCB HSC regularly to teach students in the morning and to be matched in the afternoon with a specialist of their choice. These rural doctors receive a stipend for their teaching, CME credit for their learning, and are appointed to the clinical faculty of the West Virginia University School of Medicine. These and other RCB HSC outreach programs now operate in 53 of West Virginias 55 counties (Figure 2). Briefly, other programs include:

Selective hyperexpression of c-jun oncoprotein by glass fiber- and silica-transformed BALB/c-3T3 cells

The close relationship between giant cell arteritis and polymyalgia rheumatica has not been clearly explained. These disorders affect the same patient population and often coexist in the same person. Monitoring of the erythrocyte sedimentation rate is a useful tool in both diagnosis and treatment. Management with varying doses of prednisone has proved effective in resolving symptoms.