Biomedical subjects
Publications and source records attributed to D E Trentham.
Anasarca with pronounced hypoalbuminemia developed in a young woman 15 months after the onset of a mild, arthralgic type of systemic lupus erythematosus (SLE) without evidence of active nephritis. Investigation indicated a gastrointestinal rather than a renal site for protein loss. A full clinical remission was achieved with low-dose corticosteroid therapy.
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A patient with a unique case of chronic episodic arthritis coincident with flares of acneform, pustular, nodular and ulcerating skin lesions was observed over a five-year period. This patient and a review of the literature on arthritis associated with the inflammatory dermatoses provide evidence which may interrelate several of these nosologically confusing skin conditions, e.g., the family of leukocytoclastic angiitides with the newly posited acute febrile neutrophilic dermatosis of Sweet. Systemic manifestations and a variety of acneform, pustular, nodular and ulcerating cutaneous lesions in the inflammatory dermatoses are best explained by small vessel involvement, with individual syndromes being determined by the type and degree of vascular change. Perivascular neutrophilic infiltration is the unifying histologic feature of these small vessel diseases. Neutrophil infiltration differentiates these entities, and our patient, from the histologically nonspecific inflammations of the skin, e.g., Behcet's disease and pyoderma gangrenosum, which, although capable of causing identically appearing skin lesions, consist predominantly of lymphocytic dermal infiltrates even in the earlier stages. It appears important to recognized these morphologically varied acute inflammatory dermatoses with perivascular neutrophilic infiltration in view of their systemic features and the dramatic efficacy of corticosteroid therapy.
A 41-year-old woman manifested a polyneuropathy, anasarca, pseudotumor cerebri, hyperhidrosis and hyperpigmentation of the skin, generalized lymphadenopathy, distal esophageal dysphagia, pleuritis, platelike pulmonary atelectasis, fluctuating renal insufficiency, hepatosplenomegaly, amenorrhea, and slight fever suggesting a connective-tissue disorder. Extensive clinical and laboratory evaluation did not support the initial impression of progressive systemic sclerosis or systemic lupus erythematosus but did show nonnecrotizing vascular changes, mild polyclonal gammopathy, and low thyroxin levels similar to the syndrome of polyneuropathy and endocrine disturbances recently reported from Japan. The impressive response to moderate-dose corticosteroids and exacerbation on withdrawal require diagnostic awareness of this insidiously progressive multisystem disorder. A bland vasculopathic process resulting from metabolic or immunologic disturbances appears to be the best explanation for this new syndrome, which has previously been recognized only in Japan.
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Bilateral wrist arthrograms performed on a randomly selected population of 100 adult males revealed an unexpected high prevalence of communications among the three wrist compartments. These findings warrant reassessment of wrist arthrographic criteris for synovial involvement of rheumatoid arthritis. Midcarpal joint extension correlated with increasing age and occupational trauma, suggesting a degenerative or "wear and tear" mechanism in the breakdown of the delicate interosseous intercarpal ligaments. Such extension was also found to a greater than expected frequency in gout. Radioulnar joint extension correlated with acute trauma secondary to wrist sprains or fractures, presumably through tears in the tough triangular fibrocartilage. Such extension was also found to a greater than expected frequency in RA. While midcarpal extension and inferior radioulnar extension correlate with gout and RA, respectively, their occurrence in a random adult male population is so frequent (as is three compartment communication) as to obviate their diagnostic value. However, synovial corrugation and lymphatic visualization were seen only in the wrists of patients with diagnosed inflammatory arthritic conditions and may have potential diagnostic significance. Selected anthropometric variables were analyzed by age in this randomly selected adult male population and compared with the gouty and RA patient groups. Significant continuously decreasing grip strength and hand mineralization occurred with age, which was opposite to the trend for osteoarthrosis. The hematocrit, erythrocyte sedimentation rate, and serum uric acid were impressively stable until the ninth or older decades, at which time a significant increase in sedimentation rate and decrease in hematocrit were found.
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Analysis of 878 hand films shows the carpo : metacarpal ratio to be a sensitive quantitative index of progression of carpal involvement in rheumatoid arthritis. This index, easily calculated by dividing the lengths of the carpus by the third metacarpal, showed marked consistency in the ratio regardless of age, race, or sex in normal adults. A decreased ratio correlated highly with recognized radiographic stages of rheumatoid arthritis and thus suggested utility in longitudinal studies of patients with this disease.
To determine which synovial fluid tests are most useful, we prospectively analyzed the synovial fluid test results of 100 consecutive patients undergoing diagnostic arthrocentesis. Each patient's diagnosis was established independently of synovial fluid laboratory test results; in 69 patients a definite inflammatory or noninflammatory categorization could be made. Sensitivity and specificity were estimated for synovial fluid white blood cell count (sensitivity, 0.84; specificity, 0.84), percentage of polymorphonuclear cells (sensitivity, 0.75; specificity, 0.92), glucose (sensitivity, 0.20; specificity, 0.84), protein (sensitivity, 0.52; specificity, 0.56), and lactate dehydrogenase (sensitivity, 0.83; specificity 0.71). Receiver operating characteristic regression analysis indicated that both white blood cell count and percentage of polymorphonuclear cells were found to contribute independent diagnostic information but lactate dehydrogenase did not. In a separate, retrospective analysis of 19 patients with definite septic arthritis, similar results were observed. We conclude that synovial fluid white blood cell count and percentage of polymorphonuclear cells perform well as discriminators between inflammatory and noninflammatory disease. Ordering chemistry studies of synovial fluid should be discouraged because they are likely to provide misleading or redundant information.
Although empiric principles still govern most therapies available for patients with rheumatoid arthritis (RA), strategies for the medical management of RA are beginning to be appreciated in terms of their actions on pathogenetic mechanisms relevant for this disease. Evidence suggests that anti-self-reactivity is central to the perpetuation of the articular manifestations of RA and that this autoimmune process is subserved, at least in part, by T cells. Data exist indicating that therapies effective in ameliorating RA inhibit T-cell replication and function. Experimental studies have provided results that, at present, are inconclusive in terms of the degree of clinical efficacy, but these trials have shown further that methods capable of influencing T cells are promising for the future treatment of this disease.