Stephen R. Kaplan

Septic Bursitis in the Prepatellar and Olecranon Bursae: An Analysis of 25 Cases

Five cases of septic prepatellar and 20 cases of septic olecranon bursitis are reported. All were men, with a mean age of 47 years. Seventeen had a history of recent trauma to the affected limb or sustained pressure on knees or elbows, or both, required by certain occupations. Septic bursitis was not associated with septic arthritis and could be easily distinguished from it by the characteristic bursal swelling and joint examination. Septic bursitis was misdiagnosed as nonseptic bursitis in eight cases despite characterstic bursal fluid leukocytosis (greater than 1000 cells/mm3) and recovery of bacteria on culture. Staphylococcus aureus was identified in 22 cases; 76% were resistant to penicillin. Intravenous antibiotics and bursal fluid drainage were uniformly succesful. Oral antibiotic ttherapy was also successful unless the infection was extensive or there was underlying bursal disease. Early recognition, prompt therapy, and preventive measures are necessary to reduce the morbidity of septic bursitis.

Progressive systemic sclerosis: Mode of presentation, rapidly progressive disease course, and mortality based on an analysis of 91 patients

The overwhelming majority of patients with PSS present with combinations of Raynauds phenomenon, sclerodactyly, polyarthralgias, or swelling of an extremity. However, the clinical presentation of PSS may be atypical; 14% of patients in the present series initially sought medical attention for symptoms other than Raynauds phenomenon, tight skin, or joint pain. In the present series, only 31% of patients fulfilled the ARA criteria for PSS at the time of initial medical evaluation. Most patients manifested advanced disease by the time the criteria were fulfilled. The ARA criteria for the classification of PSS appear to have limited value with regard to making the diagnosis in an individual patient. Rapidly progressive PSS occurred in 17.6% of patients in this series and represents a particularly fulminant form of the disease whose course may not be predictable on clinical grounds at the time of initial medical evaluation or diagnosis. Patients destined to develop renal or cardiorespiratory failure usually do so in the first 3 years of disease. Close observation of PSS patients during the first 12 to 18 months may serve to identify those individuals who will undergo an accelerated disease course. Prognosis for patients with rapidly progressive PSS is poor and is associated with significantly higher mortality compared with patients with a more protracted disease course. Future therapeutic trials in PSS should be designed with the recognition that a subgroup of patients with this disorder will have a rapidly progressive disease course.

Treatment of Advanced Wegener's Granulomatosis with Azathioprine and Duazomycin a

Abstract Azathioprine (Imuran) was used in combination with duazomycin A, a glutamine antagonist, for treatment of two patients with advanced Wegeners granulomatosis with renal involvement. Prolon...

Gold Lung: Recent Developments in Pathogenesis, Diagnosis, and Therapy

Gold lung is a hypersensitivity pneumonitis to gold-containing compounds. It can be distinguished from rheumatoid lung by its subacute or acute onset, diffuse interstitial and/or alveolar filling pattern on chest roentgenogram, presence of lymphocytes on BAL with an inverse helper/suppressor ratio, and response to withdrawal of gold and/or corticosteroid therapy. Other in vitro assays of gold hypersensitivity using peripheral blood lymphocytes are only sporadically positive and, therefore, of limited value in making the diagnosis. Physicians prescribing organic gold compounds should elicit pulmonary complaints throughout the duration of therapy. When patients receiving gold therapy present with signs and symptoms consistent with an acute or subacute hypersensitivity pneumonitis, the gold therapy should be withheld and a diagnostic workup initiated.

Ultrastructure of myeloma cells in a case with crystalcryoglobulinemia

The bone marrow of a patient with multiple myeloma of the IgG2 Kappa type with spontaneously crystallizing cryoglobulin was studied by electron microscopy. The ultrastructure of the myeloma cells disclosed the presence of a crystalline material in the cytoplasm within the rough endoplasmic reticulum (RER) as well as in extracisternal sites. The crystalline material was also seen extracellulary with a distinctly unique subunit structure. The tubular units measured 200 ± 10 AÅ (SEM) externally with an internal diameter of 100 ± AÅ (SEM). The intracellular distribution did not indicate a characteristic organelle association usually observed in protein synthesizing cells. It is suggested, based on the present observations and the findings of others, that the crystalline material may represent polymerized protein synthesized by free ribosomes mostly in extracisternal locations, a pattern often seen in neoplastic plasma cells. Diffusion to extracisternal sites of precrystalline material through the membranes of the RER is a possible alternative mechanism.

Effect of heavy metals on human rheumatoid synovial cell proliferation and collagen synthesis.

The dose-dependent effects of heavy metals on cell proliferation, collagen synthesis, and non-collagen protein synthesis were studied in early passage cultures of human synovial cells exposed to 1-100 microM concentration of gold, silver, mercury, cadmium or lead for 5 days. The incorporation of [3H]thymidine into trichloroacetic acid insoluble material was inhibited 50% by each of the heavy metals at concentrations between 1 and 10 microM. Gold, lead and mercury (10 microM) decreased the DNA content of the cultures by less than 15%; silver (10 microM) and cadmium (10 microM) resulted in decreased DNA content, which was attributed to cytotoxicity. A dose-dependent inhibition of [3H]proline incorporation into bacterial collagenase resistant (non-collagen) protein was observed after incubation with 10 microM mercury, lead and silver. During incubations with 10 microM gold and cadmium, collagenase resistant protein accumulation increased. All the heavy metals except for gold inhibited collagen accumulation to a greater extent than non-collagen protein accumulation. Gold (10 microM) stimulated the amount of collagen produced per cell, and the percentage of collagen to total protein was increased 50%. The rate of collagen accumulation in medium decreased during incubation with 10 microM silver, mercury, cadmium and lead. The stimulation of collagen synthesis may be a unique property of gold related to the therapeutic indices of gold, compared to other heavy metals, in rheumatoid arthritis.

Effect of gold sodium thiomalate on proliferation of human rheumatoid synovial cells and on collagen synthesis in tissue culture

Abstract Synovial tissue obtained from patients with rheumatoid arthritis who were undergoing reconstructive joint surgery was used to obtain explant cultures of synovial cells. The experiments described were performed on growing monolayer cultures during the second to fifth passages. Synovial cells were exposed to gold sodium thiomalate (GST) in concentrations equivalent to levels attained in synovial tissues during chrysotherapy (3–50 μg/ml). After 5 days of exposure of cells to 10 or 50 μg/ml of GST, [ 3 H]thymidine incorporation into DNA was inhibited 94 or 99 per cent, respectively. After 10 days of exposure to 10 μg/ml of GST, cell number was decreased 50 per cent, although no change in cell number was found after a 5-day exposure to 100 μg/ml of GST. The total collagen content of the media was decreased in flasks of cells exposed to 50 μg/ml of GST for 15 days, which reflects the decrease in cell numbers observed at this concentration. However, after 15 days of exposure of synovial cells to 12 μg/ml of GST, incorporation of [ 14 C]proline into total collagen per cell increased 4-fold. This increase in [ 14 C]proline incorporation occurred predominantly in type I collagen. In these experiments, the percentage of type III collagen containing [ 14 C]proline and the amount found in media were suppressed 50 per cent by a fifteen day exposure to 3 μg/ml of GST. The ability of GST to increase the relative commitment of these cultures to make type I collagen is dose dependent in the range from 3 to 12 μg/ml. These data indicate that changes in cell proliferation and in the nature (genetic composition) of the extracellular matrix produced are direct effects of GST on the synovial cell in tissue culture and may represent one important mechanism of action of chrysotherapy in the treatment of patients with rheumatoid arthritis.

Synthesis of type I and type III collagen by synovial cells in tissue culture derived from patients with rheumatoid arthritis, osteoarthritis, and normal individuals.

Abstract Synovial tissues obtained from patients with rheumatoid arthritis, osteoarthritis, or traumatic damage (normal) were placed in culture, using the explant technique. The resulting monolayer cultures of cells were found to synthesize Type I and Type III collagen. In rheumatoid derived tissues labeled in primary organ culture, 31% of the mean total collagen produced was Type III. Rheumatoid synovial cells growing in monolayer culture at the second passage synthesized 18 ± 2% Type III collagen compared to 15 ± 2% in respective control cultures. The mean percentage of Type III collagen synthesized by rheumatoid synovial cells at the fourth passage in culture was 20 ± 3% compared to 14 ± 2% in fourth passage cells derived from osteoarthritic tissue or 13 ± 3% in fourth passage cells derived from normal human synovium. These data indicate that an increase commitment of rheumatoid synovium for Type III collagen synthesis, expressed in primary organ cultures, is not detectable in early passage cells growing in monolayer. Therefore, factors in the local tissue environment may participate in the modulation of collagen heterogeneity in the rheumatoid synovium.