John S. Percy

Correlation between levels of DNA antibodies and clinical disease activity in SLE.

Sera were tested from 23 patients with systemic lupus erythematosus followed over a period of 1 to 5 years. Antibodies to native DNA were measured and correlated retrospectively with clinical evidence of disease activity. The overall degree of correlation between the presence of DNA antibodies and evidence of disease activity was good (P less than 0-001). Of 206 sera tested, only 4 had a normal DNA antibody at a time when significant clinical activity was noted. In contrast, 34 sera had mild to moderately raised DNA antibody levels at times of clinical remission. Although DNA antibodies are a useful investigation in the monitoring of disease activity, changes in therapy should not necessarily be made on DNA antibody levels alone.

Deforming arthropathy in systemic lupus erthematosus.

Arthritis is a well-recognized feature ofsystemic lupus erythematosus (SLE), which may be confused with the joint manifestations ofrheumatoid arthritis (Tumulty, 1954). Two recent reviews of the articular disorders of SLE have emphasized that, apart from aseptic necrosis, destructive and deforming arthritis is rare in this disease (Pekin and Zwaifler, 1970; Labowitz and Schumacher, 1971). Arthritis without deformity has indeed been suggested as one of the preliminary American Rheumatism Association criteria for the diagnosis ofSLE (Cohen, Reynolds, Franklin, Kulka, Ropes, Shulman, and Wallace, 1971).

The scintigraphic findings in Paget's disease of bone

Bone scans and radiographic skeletal surveys have been done in 41 patients who had Pagets disease. The scintigraphic findings are consistent with what is known of the pathophysiology of Pagets disease. Diseased bone demonstrates increased vascularity, an increased degree of uptake of bone-seeking radiotracers and, in appropriate bones, evidence of marrow replacement. The bone scintiscan is a more sensitive indicator of the extent of polyostotic Pagets disease than conventional radiograph, demonstrating 34% more lesions. Because it reflects shorter term changes in osteoblastic activity the bone scan is of some value in providing immediate objective evidence of the therapeutic effectiveness of Mithramycin which has been used in this study in the treatment of the minority of patients with pain in Pagetoid bone. A technique for documenting alterations in uptake by diseased bone numerically is presented. Upon treatment with Mithramycin the ratio of abnormal uptake in relation to normal bone fell from 8.7 to 3.9.

Bone Scintiscanning Updated

Use of modern materials and methods has given bone scintiscanning a larger role in clinical medicine, The safety and ready availability of newer agents have led to its greater use in investigating both benign and malignant disease of bone and joint. Present evidence suggests that abnormal accumulation of 99mTc-polyphosphate and its analogues results from ionic deposition at crystal surfaces in immature bone, this process being facilitated by an increase in bone vascularity. There is, also, a component of matrix localization. These factors are in keeping with the concept that abnormal scintiscan sites represent areas of increased osteoblastic activity, although this may be an oversimplification. Increasing evidence shows that the bone scintiscan is more sensitive than conventional radiography in detecting focal disease of bone, and its ability to reflect the immediate status of bone further complements radiographic findings. The main limitation of this method relates to nonspecificity of the results obtained.

A follow-up study of 48 patients with Reiter's syndrome

A follow-up study of 48 patients with Reiters syndrome was carried out in an attempt to clarify the clinical course of the disease. The mean age at the onset of Reiters syndrome was 27.1 years (range 15 to 52 years) and when seen at follow-up 32.5 years (range 19 to 58 years). The average time from the onset of the first attack of peripheral arthritis to the time of follow-up was six and a half years (range 0.5 to 27 years). Only three patients had diarrhea prior to the onset of Reiters syndrome. At follow-up 22 per cent of the patients were asymptomatic, 24 per cent had recurrent minor symptoms, 24 per cent had recurrent moderate symptoms, and 30 per cent had recurrent major symptoms. However, even in the last group, all patients were in functional classes 1 or 2 between the flares of disease. No patients in the series were in functional class 3 or 4, and 30 per cent were in class 1.

Sacroiliitis detected by bone scintiscanning: a clinical, radiological, and scintigraphic follow-up study.

Twenty-four patients had abnormal sacroiliac joints detected by quantitative sacroiliac scintigraphy but no radiological evidence of sacroiliitis on original investigation. We studied them again after intervals of 12 to 36 months. Four patients developed radiological change. Two young, HLA B27-positive men had undoubted ankylosing spondylitis, and a young woman had possible ankylosing spondylitis. A middle-aged man had changes that could be attributed to post-traumatic osteoarthrosis. Of the remaining 20 cases 15 had symptoms and signs suggestive of inflammatory disease of the axial skeleton (and peripheral arthropathy in 5 cases). The sexes were affected equally (8 females, 7 males), and only 2 of the 15 were B27-positive. The response to anti-inflammatory medication was generally good to excellent, and scintiscans tended to improve. Of the remaining 5 patients, 3 had mechanical or traumatic problems, and in 2 there was no explanation for the abnormal sacroiliac scintiscan. We conclude that quantitative sacroiliac scintigraphy may detect ankylosing spondylitis prior to the develpment of radiological change and that it can identify an organic basis for backache in patients with a spondylitis-like syndrome. The clinical circumstances must be taken into account, as scintigraphic abnormalities are not diagnostic of any specific disease entity.

Scintigraphy of Sacroiliac Joints in Acute Anterior Uveitis: A Study of Thirty Patients

HLA-B27 is a transplantation antigen found in a high proportion of patients with ankylosing spondylitis. Recently, an association has been shown to exist between HLA-B27 and acute uveitis, even in the absence of ankylosing spondylitis. We have examined the HLA antigen profile of 45 patients with acute nongranulomatous anterior uveitis and have confirmed this relation. In addition, using 90mtechnetium stannous pyrophosphate we have been able to demonstrate abnormal bone scan in 19 of 30 patients studied. Such abnormalities are limited to the sacroiliac joints but are otherwise the same as those seen in overt ankylosing spondylitis. Seven of the 19 patients did not have HLA-B27. These factors suggest that acute anterior uveitis may often represent a manifestation of a spondylitic diathesis even in the complete absence of any suggestive symptomatic or radiologic change and, in some cases, even though the antigenic marker HLA-B27 may be absent.

Quadriceps femoris activation in healthy women with genu varum and women with osteoarthrosis and genu varum.

This study was designed to determine whether abnormalities in individual or group activation of the knee extensors might be associated with the development of osteoarthrosis of the knee with varus deformity. The study consisted of nine healthy women with normal tibial alignment, nine agematched healthy women with genu varum and nine women with osteoarthrosis (OA) of the knee and genu varum. The outcome measures were normalized quadriceps femoris surface EMG amplitude parameters, recorded during maximal voluntary static and dynamic knee extension movements at 0° and 90° s(-1), expressed as a percentage and peak torque and rate of tension development at 0° s(-1). Under static conditions, the normalized EMG amplitudes, peak torque and rate of tension development of the knee extensors in those with OA differed significantly from the same parameters recorded for the healthy controls (P < 0.001). Although not significantly different under dynamic conditions (P = 0.1), there was a large effect size of f = 0.40 between the EMG amplitudes of the knee extensors of the two healthy groups, with a neglible effect size between the EMG amplitudes as well as a trend towards reduced tension-generating capacity of the knee extensors in those with varus deformity, irrespective of joint status. The latter findings suggest that the neural integration mechanisms governing the contractural pattern of the extensors surrounding a varus knee may abnormally reflect various aspects of the disease process of osteoarthrosis.

Dermatitis herpetiformis and rheumatoid arthritis.

Rectal ulcer associated with Levamisole Sir, Levamisole is effective in rheumatoid arthritis, but side effects are common. Mouth ulcers occurred in 6 of 24 in the trial of Scott et al. (1978) and in 15 of 253 patients in another (Multicentre Study Group, 1978). A patient of ours developed an ulcer in the rectum and later mouth ulcers, a complication not yet reported. He was aged 49 when rheumatoid arthritis begin in 1970, and this was treated with aspirin and indomethacin. He relapsed in 1976 but responded to gold, which was stopped after a total of 1-2 g because of intractable diarrhoea. During another relapse levamisole 50 mg daily was started in June 1977, increasing slowly, to 150 mg daily. He again responded well, but 6 weeks after starting, the haemoglobin had fallen from 13 * 3 to 7*4 g/dl. He admitted recent slight rectal bleeding, and rectal examination revealed a 2 cm diameter ulcer 4 cm from the anus. Proctoscopy showed this to be bleeding. Biopsies showed non-specific appearances with no evidence of malignancy or of the fibrosis and fragmentation of the muscularis mucosae characteristically seen in solitary ulcer of the rectum. Levamisole was stopped after he had taken about 9 g, and 2 months later the ulcer had healed. It was restarted at the same dosage at his request as his arthritis had deteriorated. Three months later he had a 0 * 5 cm ulcer on the soft palate and a similar one on the lower lip. Rectal examination and protoscopy showed that the rectal ulcer had recurred. Biopsies were histologically identical to those taken previously. Levamisole was again withdrawn and all 3 ulcers healed completely during the next 3 months. He has since taken indomethacin and the ulcers have not recurred. There seems little doubt that levamisole caused both the mouth and rectal ulcers. However, he was given large daily doses of the drug, which has since been found to be effective at a dose of 150 mg weekly (Di Perri et al., 1978), this now being the recommended amount. Side effects are less likely with this smaller dose but will still occur. Therefore proctoscopy should be considered when patients on this drug develop unexplained anaemia, particularly if mouth ulcers are present. G. V. H. BRADBY, M. F. SHADFORTH Queen Elizabeth Hospital, Birmingham B15 2TH A. M. HOARE Wycombe General Hospital, High Wycombe, Bucks References Di Perri, T., Auteri, A., Pasini, F. L., and Mattioli (1978). A weekly oral dose of levamisole in the treatment of rheumatoid arthritis associated with E-rosette lymphocyte reduction. European Journal of Rheumatology and Inflammation, 1, 155-164. Multicentre Study Group (1978). Levamisole in rheumatoid arthritis: a randomised double-blind study comparing two dosage regimens of levamisole with placebo. Lancet, 2, 1007-1012. Scott, J., Dieppe, P. A., and Huskisson, E. C. (1978). Continuous and intermittent levamisole: a controlled trial. Annals of the Rheuimatic Diseases, 37, 259-261.

Sympathetic Denervation and the Bone Scan

Three patients, all having sustained a unilateral lower limb sympathectomy, are described. In all three uptake of bone-seeking tracer in the affected limb was increased with this increase being accentuated at the metaphyses of the long bones.