1/11. Laryngeal involvement in systemic lupus erythematosus. Laryngeal involvement in systemic lupus erythematosus (SLE) can range from mild ulcerations, vocal cord paralysis, and edema to necrotizing vasculitis with airway obstruction. In this report, four cases showing the range of severity of this disease manifestation are presented, accompanied by a comprehensive review of the literature. The clinical course of 97 patients with laryngeal involvement with SLE are reviewed, of whom 28% had laryngeal edema and 11% had vocal cord paralysis. In the majority of cases, symptoms such as hoarseness, dyspnea, and vocal cord paralysis resolved with corticosteroid therapy. Other, less common causes of this entity included subglottic stenosis, rheumatoid nodules, inflammatory mass lesions, necrotizing vasculitis, and epiglottitis. The clinical presentation of laryngeal involvement in patients with SLE follows a highly variable course, ranging from an asymptomatic state to severe, life-threatening upper airway compromise. With its unpredictable course and multiple causations, this complication remains a diagnostic and therapeutic challenge to physicians involved in the care of patients with SLE. ( info) |
| Calcaneal osteomyelitis is uncommon and difficult to treat. Cases due to fistulization of an infected rheumatoid nodule are exceedingly rare. PATIENT: A 65-year-old patient with nodular rheumatoid arthritis (RA) experienced osteomyelitis of the left calcaneus due to inoculation from a fistula draining an ulcerated rheumatoid nodule. pseudomonas aeruginosa and enterobacter cloacae were recovered. The conventional treatment of calcaneal osteomyelitis relies on antibiotics and calcanectomy or foot amputation. We used two appropriate antibiotics and monthly intravenous injections of 90 mg of pamidronate. RESULT: One year into treatment, the patient was free of pain and the skin wound was fully healed. On a follow-up computed tomography (CT) scan, the fistulous tract was seen to be closed and the large calcaneal defect almost completely filled with new bone. CONCLUSION: Combining two antibiotics and pamidronate may be a viable alternative to excision surgery or amputation in some patients with bone infection carrying a risk of fracture. ( info) |
| Rheumatoid arthritis as a cause of medullary compression due to subluxation of rheumatically diseased joints is very common. However, spinal cord compression by rheumatoid nodules is seen rarely, usually by extradural lesions. We describe two cases of intradural rheumatoid nodules causing spinal cord compression. ( info) |
4/11. Subcutaneous nodules in rheumatic fever. Acute rheumatic fever is described in a six year old Ethiopian male child who first presented with subcutaneous nodules and later developed carditis. ( info) |
5/11. Immunofluorescence studies of florid rheumatic Aschoff lesions. We studied cardiac tissues of a patient who died of severe rheumatic myocarditis. Multiple Aschoff lesions were present throughout both ventricles and auricles. Immunofluorescence studies showed large monocytoid cells staining with OKM1 and anti-Leu M-3 as well as anti-Ia. Scattered T cells in areas of focal myocarditis stained with OKT3. Parallel staining for cardiac myosin-heavy chain antigens showed patchy dissolution of cardiac muscle fibers and traces of cardiac myosin within large monocytoid Aschoff cells. ( info) |
6/11. Superficial ulcerating rheumatoid necrobiosis: a perforating rheumatoid nodule. We report a case of superficial ulcerating rheumatoid necrobiosis (SURN), which is a recently described cutaneous manifestation of severe rheumatoid arthritis. As with classic rheumatoid nodule, there is evidence that this lesion may result from a vasculitis. SURN appears to represent a form of "perforating" rheumatoid nodule, and completes a triad of major necrobiotic processes (granuloma annulare, necrobiosis lipoidica, rheumatoid nodule) that have been reported to show epidermal perforation. ( info) |
7/11. Rheumatoid nodulosis. Sporadic and familial diseases. Two patients are described with longstanding, multiple, subcutaneous nodules with the histopathological features of rheumatoid nodules. Neither patient had any clinical evidence of rheumatic disease. One patient had a family history of smiliar nodules transmitted as an autosomal dominant trait. Leukocyte function studies failed to reveal any defect to account for the nodule formation. ( info) |
8/11. Acute rheumatic carditis: diagnostic and therapeutic challenges in the era of heart transplantation. heart transplantation as a treatment for end-stage heart failure has spawned numerous important challenges in patient care. A heart transplant patient with clinically unsuspected acute rheumatic carditis had an ultimately fatal course marked by refractory rejection and early death after transplantation. The patient had several immune abnormalities. Peripheral blood T lymphocytes (CD2 ) were significantly elevated (p < 0.05) by flow cytometry in active rheumatic carditis versus 76 healthy individuals. The CD4 :CD8 T-cell ratio was 5.5:1 in rheumatic disease and only 2.7:1 in healthy individuals. Numbers of peripheral blood B lymphocytes (CD19 ), macrophages (CD14 ), and interleukin-2 receptor-positive cells (CD25 ) were also elevated in rheumatic disease. Natural killer cells (CD16 ) were slightly reduced in number and appeared functionally deficient, and antibody-dependent cellular cytotoxicity was also reduced. Immunohistochemically, infiltrating cells in Aschoff lesions of the rheumatic native heart were mainly T cells, with putative TH/I cells predominating. The striking immune accompaniments of acute rheumatic fever may have heralded profound immune-mediated allograft intolerance leading to the patient's demise. Considering the recrudescence of rheumatic heart disease in this country and its remaining worldwide importance, such patients as the one discussed offer daunting clinical challenges when transplantation is an obvious management choice for severe, end-stage dilated cardiomyopathy. ( info) |
9/11. NERDS syndrome: an additional case report. NERDS is an eosinophilic disorder recently described by Butterfield and characterized by an association of nodules, eosinophilia, rheumatism, dermatitis and swelling. We describe an additional case, the third, of this new eosinophilic syndrome. The cardinal features included joint and cutaneous manifestations with prominent para-articular nodules and rheumatism, xerosis, recurrent urticarial eruption with angioedema associated with tissue and peripheral blood eosinophilia. A drug-induced (diclofenac) allergic rash and lymphadenopathy appeared during the course of the illness. Persistent leukocytosis with a maximum of 65% of eosinophils, mostly exhibiting the hypodense phenotype (activation index), was always present. During the acute phase of the disease, flow-cytometric analysis of blood and bone marrow revealed proliferation of activated CD4 /OKDR T helper cells and CD25 /OKDR eosinophils. ( info) |
10/11. Accelerated nodulosis in a patient with psoriasis and arthritis during treatment with methotrexate. A 66-year-old woman with longstanding psoriasis involving the skin presented with asymmetrical polyarthritis. methotrexate (MTX) was given initially intramuscularly and orally. Intramuscular MTX was discontinued, and a few months after she had been taking only oral MTX she developed nodules, first in surgical incisions, and subsequently in her buttocks, thighs, legs, and arms. Reduction of the dose of oral MTX was followed by gradual diminution in size of the nodules and then total disappearance. ( info) |