Biomedical subjects
Publications and source records attributed to D Schapira.
This paper describes four patients with inflammatory joint diseases treated with methotrexate who developed lymphoma either of unusual type or with bizarre clinical features. The pathogenesis of this unusual condition is discussed and the difficulty in differentiating it from the features of the initial disease is emphasised.
OBJECTIVE: To draw attention to arthritis that developed in patients who underwent total proctocolectomy with ileal pouch construction for ulcerative colitis (UC). METHODS: The course of 4 patients who developed arthritis for the first time after ileal-anal pouch anastomosis is described. In addition, the relationship to the chronic inflammation of the pouch-pouchitis-is discussed. RESULTS: The clinical manifestations were very similar to seronegative arthritis affecting mainly the joints of the lower extremities. It was accompanied by enthesopathy (2 patients) and by sacroiliitis (2 patients). All had active pouchitis. The abnormal laboratory test results were nonspecific, indicating chronic inflammation. All 4 patients tested negative for human leukocyte antigen (HLA) B27, and none had other concomitant extraintestinal manifestations. Steroids rapidly improved both the arthritis and pouchitis; however, disease-modifying antirheumatic drugs were required to maintain remission with minimal daily steroids. Flares of the arthritis were always associated with active pouchitis, but the opposite was not necessarily true. CONCLUSIONS: Arthritis related to ileal pouchitis after total colectomy for UC has many similarities to the arthritis associated with inflammatory bowel disease and should be added to the list of enteropathic arthropathies.
Cutaneous reactions to non-steroidal anti-inflammatory drugs (NSAIDs) are rare in spite of their wide use. Only a few cases of hypersensitivity angiitis related to naproxen have been described. We report the case of a 62-year-old woman in whom leukocytoclastic skin vasculitis, peripheral neuropathy and nephritis developed after a short naproxen treatment, and gradually regressed after discontinuation of the drug and under glucocorticoid therapy. In the light of the relevant literature, the clinical and laboratory features of this reversible condition are described.
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A patient with Crohn's disease developed proximal muscle weakness, increased serum creatine phosphokinase activity and electromyographic abnormalities. A muscle biopsy was non-diagnostic. Although rare, myositis should be included in the differential diagnosis of muscle weakness in patients with inflammatory bowel disease.
OBJECTIVES: To analyze the factors which differentiate chronic tophaceous arthritis from rheumatoid arthritis. METHODS: We describe two cases of chronic gouty arthritis masquerading as rheumatoid arthritis. The characteristic features of each of these two conditions and the diagnostic approach are discussed in light of relevant literature. RESULTS: The correct diagnosis was reached by the combination of accurate history taking (family history of gout, alcoholism, previous diuretic therapy and renal stones), guiding clinical features (subcutaneous tophaceous deposits) and specific radiological (assymetrical erosions with sclerotic margins and overlying edges) and laboratory findings (hyperuricemia and hyperuricosuria). It was confirmed by the identification of monosodium urate (MSU) crystals in the synovial and subcutaneous tissues. CONCLUSIONS: Gout and rheumatoid arthritis rarely coexist. Chronic gouty arthritis may mimic rheumatoid arthritis, and vice-versa. Clinical suspicion supplemented by characteristic laboratory, radiological and histologic findings help at reaching an accurate diagnosis.
Four premature infants developed apnoeas severe enough to warrant resuscitation after immunisation with diphtheria, pertussis, and tetanus (DPT), and Haemophilus influenzae B (Hib). One required re-intubation and ventilation. Although apnoeas after immunisation are recognised, they are not well documented. It is time for further research to elucidate the best time to immunise such infants.
A patient with systemic lupus erythematosus (SLE) developed primary subcutaneous nocardiosis during steroid and cyclophosphamide therapy for diffuse proliferative glomerulonephritis. In spite of local process the patient manifested signs of general deterioration mimicking SLE exacerbation. The diagnosis was made by bacteriologic examination of the material obtained by CT guided aspiration. Surgical drainage and systemic treatment with trimethoprim/sulphamethoxazole (TMT/SMZ) 960 mg twice/d led to a clinical recovery and enabled the continuation of the steroid and cytotoxic regimen.
OBJECTIVE: To assess bone mineral status in a group of children with systemic type juvenile chronic arthritis (JCA), which places them at high risk to develop osteoporosis. METHODS: Bone mineral density (BMD) was measured in 17 children aged 6-18 yrs (mean 14.9 +/- 4.5) with systemic JCA and in 18 matched controls by dual energy x-ray absorptiometry. Bone turnover was determined by quantitative bone scintigraphy, using quantitative single photon emission computed tomography based on skeletal uptake of methylene diphosphonates (MDP uptake). Serum concentrations of minerals, osteocalcin, and bone alkaline phosphatase were determined. Nutrient intake was assessed by a 24 hour dietary recall. RESULTS: Patients with systemic JCA who received corticosteroid therapy had significantly reduced BMD in both the lumbar spine (p < 0.05) and the femoral neck (p < 0.05) compared to controls, whereas BMD values of the non-steroid systemic JCA patients were not different from controls. Bone turnover measurement by MDP uptake showed no difference between patients with JCA and controls. Levels of calcium, phosphorus, alkaline phosphatase. and osteocalcin were within normal limits in all patients. CONCLUSION: Patients with systemic JCA receiving longterm steroid treatment may develop a significant decrease in BMD. The normal MDP uptake values together with normal osteocalcin levels that we observed in our patients indicate that their disease is not associated with enhancement of bone turnover rates. These observations might have therapeutic implications for prevention and management of osteoporosis in JCA.
We describe a patient in whom peripheral arthritis was the presenting symptom of diverticulitis. The joint inflammation resolved only after treatment for the gastrointestinal disease. The pathogenesis, clinical aspects and management of this condition are discussed.
OBJECTIVE: To study zinc absorption in patients with active rheumatoid arthritis (RA). METHODS: We studied zinc tolerance tests and 24 hour urinary zinc excretion before and after ingestion of 50 mg elemental zinc in 8 healthy volunteers (Group 1) and 13 patients with low RA activity (Group 2) and 16 patients with high RA activity (Group 3). RESULTS: In Group 1, plasma zinc rose from 111 +/- 7 micrograms/dl to a peak of 200 +/- 24 micrograms/dl (mean +/- SEM) in 2 h. In Groups 2 and 3, plasma zinc before zinc ingestion was significantly lower than that of the control group (p < 0.00001 for both groups) and showed no significant increase in plasma after ingestion. Twenty-four hour urinary zinc excretions before and after zinc ingestion were significantly lower (p < 0.01, p < 0.0001 for Group 2; p < 0.05, p < 0.01 for Group 3, respectively) than those in the control group. CONCLUSION: These results are compatible with zinc malabsorption and consequent zinc deficiency in patients with RA. Whether zinc deficiency contributes to perpetuation of disease activity by compromising cellular immune function needs further investigation.
Seven elderly women with insufficiency fractures of the pubic ramus are described. The predisposing factors for this condition were osteoporosis, rheumatoid arthritis, renal failure, prolonged corticosteroid treatment, pelvic irradiation, and mechanical changes after hip surgery. The clinical presentation included progressive inguinal pain, limping, and inability to walk. Because initial radiographs were diagnostic only in four cases, bone scintigraphy and computed tomography were necessary to confirm the diagnosis and detect additional fractures. In most patients, bed rest, non-weight-bearing ambulation, symptomatic treatment, and therapy for osteoporosis resulted in rapid improvement, and long-term follow-up showed complete or partial recovery. In one case, no recovery was achieved because of noncompliance with treatment. Insufficiency fracture of the pubic ramus should be suspected in cases of unexplained inguinal or hip-area pain and inability to walk in the elderly. The clinical suspicion should be supplemented by radiological investigation. Bone scintigraphy and computed tomography are useful means for early and accurate diagnosis. The risk factors for this condition should be identified and treated. If therapy is initiated early and pursued, this type of fracture has a benign outcome.
Spontaneous fractures of the sternum are rare but worth knowing as they may simulate acute cardiac and pulmonary emergencies. A case of an insufficiency sternal fracture mimicking myocardial infarction and subsequent anginal pain is presented. The risk factors of this condition, its clinical features and the diagnostic procedures are discussed. Spontaneous fractures of the sternum should be considered as a diagnostic possibility for unexplained chest pains in the elderly.
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To assess the long-term effect of vitamin D or calcium supplementation on the skeletal metabolism of aging laboratory rodents, 1.5-month-old female Wistar rats were fed with diets containing twice the concentration of vitamin D (group 2) and of calcium (group 3) as in the usual rat chow. Follow-up to 24 months of age did not show significant differences between the enriched-diet groups and the controls (group 1) in terms of the vertebral body weight and protein content. Significantly higher bone mineral contents were found in groups 2 and 3 than were found in controls, as revealed by an increased bone mineral density (BMD: +62%, group 2; +48%, group 3) and vertebral calcium content (+73%, group 2; +84%, group 3). The vertebral alkaline phosphatase enzymatic activity was significantly lower in the enriched diet groups than in controls (-47%, group 2; -45%, group 3). The ratio alkaline phosphatase/acid phosphatase activity was markedly reduced in groups 2 and 3 (-57% and -59%, respectively), which might indicate a diminished rate of bone turnover. The trabecular bone volume (BV/TV) decreased in all groups during senescence, being significantly elevated in group 3 as compared to controls. Vitamin D and calcium dietary supplementations increase the axial mineral bone content in laboratory rats and might reduce the bone turnover. Their influence on the trabecular bone volume has yet to be examined.
Tumor-induced (oncogenic) osteomalacia is a rare clinicopathologic entity in which the clinical signs and symptoms of osteomalacia and the specific laboratory abnormalities of hypophosphatemia, hyperphosphaturia, and low serum levels of 1,25(OH)2 vitamin D are associated with the finding of a neoplastic process in the patient. To date, less than 100 cases of oncogenic osteomalacia have been described. We report a new case of adult-onset hypophosphatemic osteomalacia leading to the discovery of an asymptomatic phosphaturic mesenchymal lung tumor. Complete resection of the pulmonary neoplasia was followed by rapid normalization of the laboratory findings and clinical remission. The clinical, laboratory, and histopathologic spectrum of tumor-induced osteomalacia is presented, and the postulated mechanism of this condition is discussed in light of the relevant literature. The presence of occult neoplasms should be considered in cases of unexplained adult osteomalacia, with the physician's efforts being rewarded by the dramatic cure that follows excision of the tumor.
The effect of 17 beta-estradiol and progesterone on ocular lens in rats and untreated controls was studied. In the treated lenses, the activity of hexokinase and glucose-6-phosphate dehydrogenase remained unchanged. The activity of aldolase was increased in 18- and 20-month-old lenses as compared to controls. Aldose reductase activity was decreased at the age of 20 months (p < 0.001). Structural lens proteins studies by SDS polyacrylamide gel electrophoresis and immunodecoration with specific antibodies for crystallines alpha A + alpha B and beta + gamma suggest some protective effect in treated animals.