Giant cell myocarditis: most fatal of autoimmune diseases

OBJECTIVE

To increase awareness of giant cell myocarditis (GCM), its pathogenesis, and treatment.

METHODS

Review of relevant publications from the English-language literature.

RESULTS

GCM is a rare, frequently fatal inflammatory disorder of cardiac muscle of unknown origin, characterized by widespread degeneration and necrosis of myocardial fibers.Congestive heart failure and ventricular tachycardia are common clinical manifestations. GCM occurs primarily in previously healthy adults, although it is frequently associated with various systemic diseases, primarily of autoimmune causes. The inflammatory infiltrate is characterized by the presence of multinucleated giant cells and is distinct from cardiac sarcoidosis. Animal models of GCM are similar to models of other autoimmune disorders such as rheumatoid arthritis. The prognosis, which is poor despite partial responsiveness to immunosuppressive medications, is improved with cardiac transplantation.

CONCLUSIONS

The clinical and immunopathogenetic similarities with classical rheumatologic diseases, the differential diagnosis with sarcoidosis and other inflammatory conditions, and the use of standard immunosuppressive medications make GCM a disease process that should be added to the rheumatologist's expertise.

Trace elements in the treatment of rheumatic conditions

The role of trace metallic elements (copper, selenium, zinc, gold) in chronic inflammatory states is of great interest because many of them are co-factors in metabolic processes involving articular tissues and immune system function. Deficiencies of several of these have been documented in patients with rheumatoid arthritis. Other than for the clinically approved gold compounds, there exists only inconsistent evidence for a therapeutic role of trace metallic elements in the management of rheumatoid arthritis.

Topical agents in the treatment of rheumatic disorders

Topical drug delivery may be the optimal route for the treatment of localized musculoskeletal disorders because higher drug concentrations can be achieved at the sites of clinical significance. The rationale for the use of topical salicylates and other nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of soft-tissue rheumatic complaints and osteoarthritis is reviewed. Topical capsaicin offers another potentially beneficial therapy for the treatment of osteoarthritis of selected joints. Although there are extensive, uncontrolled experiences with DMSO that suggests its effectiveness in the treatment of musculoskeletal disorders, controlled trials yield conflicting results. The basis for the use of physical modalities such as phonophoresis and iontophoresis to improve topical drug efficacy is summarized.

Refractory hyperglycemia complicating an evolving connective tissue disease: response to cyclosporine

A 33-year-old woman with longstanding rheumatoid arthritis and Sjögren's syndrome developed type B insulin resistance (diabetes mellitus due to anti-insulin receptor antibodies) simultaneous with the evolution of her rheumatic disease to mixed connective tissue disease. Cyclosporine therapy induced a remission of receptor antibody mediated insulin resistance and controlled clinical manifestations of her systemic lupus erythematosus and dermatomyositis, but had no effect on the sclerodermatous features of her illness.

A case of multicentric reticulohistiocytosis in a 6-year-old child

Multicentric reticulohistiocytosis (MR) is a rare disease in which an infiltration of histiocytic cells causes destructive polyarthritis and characteristic cutaneous lesions. It predominantly affects women between the ages of 40 and 50 years. Effective treatment has not been well established. We describe a case diagnosed in a 6-year-old girl. This is the youngest patient with MR reported to date.

Exacerbation of rheumatoid arthritis after termination of chemotherapy for breast carcinoma

Three women with breast carcinoma were treated with combination chemotherapy, including cyclophosphamide, 5-fluorouracil, and methotrexate, after mastectomy. Within two months of termination of chemotherapy, all 3 patients developed florid synovitis. Two patients had prior clinical manifestations consistent with rheumatoid arthritis; one patient had no antecedent history of arthritis. We suggest that this presentation may represent exacerbation of mild or subclinical rheumatoid arthritis as a consequence of withdrawal of methotrexate therapy.

Case report: Langerhans cell histiocytosis associated with elevation of angiotensin-converting enzyme levels

The authors describe a 22-year-old man with osteolytic mandibular and maxillary lesions. Biopsy substantiated the presence of Langerhans cell histiocytosis (eosinophilic granuloma). Levels of serum angiotensin-converting enzyme (ACE) were elevated repeatedly. After definitive therapy with excision and bone grafting, ACE levels returned to normal. The role of histiocytes in ACE production is discussed. Langerhans cell histiocytosis should be considered in the diagnosis of conditions occurring with elevation of serum ACE levels and clinical findings similar to sarcoidosis.

Acute arthritis in the hospital: comparison of rheumatologic with nonrheumatologic care

Certain health care reform proposals emphasize "primary" rather than specialty care, so it is important to document whether these changes might affect patients with rheumatic diseases. We therefore assessed outcome and costs of patients who were hospitalized with acute arthritis, comparing management by rheumatologists with nonrheumatologists. We reviewed charts retrospectively from 1991 to 1993 at our community medical center. Twenty patients with acute arthritis were managed by rheumatologists and 35 were managed by nonrheumatologists. Demographic, clinical, and rheumatologic features of patients were comparable.Rheumatologists ordered joint radiographs (65%) and performed diagnostic arthrocentesis (75%) significantly more often than nonrheumatologists (31 and 34%, respectively; p < 0.05). Rheumatologists' initial recorded diagnostic impressions were usually confirmed at discharge, whereas nonrheumatologists' more often were not (p < 0.05). Rheumatologists established definite diagnoses by American College of Rheumatology criteria significantly more often (75%) than nonrheumatologists (34%;p < 0.05). Nonrheumatologists selected antibiotics, systemic corticosteroids, nonsteroidal anti-inflammatory drugs, and allopurinol more often and intra-articular steroids (p < 0.05) and adrenocorticotropic hormone less often for a similar case mix than rheumatologists. Rheumatologists' clinical evaluations (p < 0.001), selection of diagnostic studies (p < 0.001), and therapeutic decisions (p < 0.005) were significantly more complete. Trends strongly favored rheumatologists' patients improving more rapidly (3.5 vs. 6.6 days; p = 0.06) and being hospitalized for shorter stays (7.4 vs. 14.7 days; p = 0.08) and favored rheumatologists' patients as managed at considerably less hospital cost ($8756 vs. $14,750).These limited observations suggest caution about equating nonspecialty with rheumatologic care and are consistent with suggestions that, at least for certain patients and as defined by our criteria above, rheumatologists offer more complete evaluation, more accurate diagnosis, more rational therapy, and better clinical outcome at lower cost than do nonrheumatologists.

Occult subacute thyroiditis mimicking classic giant cell arteritis

We report the case of a 60-year-old man who presented with fever, weight loss, generalized aching, left temporal and ear pain, and an erythrocyte sedimentation rate of 125 mm/hour. Due to the presumed diagnosis of giant cell arteritis (GCA), the patient was treated with prednisone (60 mg daily), with immediate improvement in his symptoms. Biopsy of the temporal arteries revealed no significant inflammatory infiltrate. Further evaluation included assessments of thyroid function, which revealed an elevated T4 level, low thyroid-stimulating hormone level, and suppressed radioactive iodine uptake on thyroid scintigraphy. A diagnosis of subacute thyroiditis was made, prednisone therapy was tapered over 3 weeks, and treatment with beta blockers was instituted. The patient remained asymptomatic and returned to a euthyroid state. This case illustrates that subacute thyroiditis should be considered in the differential diagnosis of GCA.

Recurrence of Wegener's granulomatosis following renal transplantation

A 43-yr-old man with a 19-yr history of Wegener's granulomatosis presented with recurrent haematuria, pulmonary infiltrate, cutaneous vasculitis, nasal mucosal involvement and elevation of ANCA levels, 2 yr following successful cadaveric renal transplantation, despite continued immunosuppressive therapy with cyclosporine, azathioprine and prednisone. Re-introduction of cyclophosphamide therapy resulted in prompt resolution of clinical and laboratory abnormalities. The superiority of cyclophosphamide over cyclosporine for maintaining suppression of Wegener's granulomatosis is substantiated in a critical review of the literature.

Modification of cytokine production by piroxicam

OBJECTIVE

Nonsteroidal antiinflammatory drugs have been thought to act by inhibiting the enzyme, cyclooxygenase (prostaglandin H synthetase). We sought to demonstrate additional biologic actions of this class of drugs including effects on cytokine production.

METHODS

We administered the nonsteroidal antiinflammatory drug piroxicam 20 mg to 6 healthy volunteers daily for 7 days. Before and for one week after drug administration, concentrations of interleukin 1 (IL-1), IL-2, IL-4, IL-6, tumor necrosis factor alpha (TNF alpha) and interferon-gamma (IFN-gamma), produced by anti-CD3 stimulated peripheral blood mononuclear cells, were measured.

RESULTS

Piroxicam treatment resulted in elevation of levels of IL-2, depression of IL-1, IL-6, TNF alpha and IFN-gamma, and no consistent effect on IL-4.

CONCLUSION

Piroxicam modulates production of various cytokines in a complex fashion when administered to healthy individuals.

Assessment and prognosis of rheumatoid arthritis

Efforts continue to identify and consistently utilize those clinical, laboratory, imaging, and other features of rheumatoid arthritis that best reflect the disease process and its impact on individual patients. We seek descriptions that are accurate, reproducible, simple, sensitive, and predictive. Such assessments will lead to development of prognoses for individual patients and to more rational patient management. The past year has witnessed reemphasis of health status indexes (instruments) and other simple approaches to clinical assessment of patients, eg, use of standardized grip strength, button test, walk time, and modified articular indexes. Computed tomography and magnetic resonance imaging provided clinically important and otherwise unappreciated (but expensive) information about joint integrity and inflammatory disease with sensitivity and resolution considerably beyond conventional techniques. Laboratory assessment of patients included consideration or reconsideration of the utility of measurements of C-reactive protein, rheumatoid factors, immune complexes, complement receptors and complement activation products, antiperinuclear factors, trace elements, interleukins and interleukin receptors, soluble cell surface receptors, lymphoid cell phenotypes, and synovial immunohistology; all are important in the pathogenesis of rheumatoid arthritis and all have contributed variably to predicting patient outcomes. None were shown to be more clinically informative than erythrocyte sedimentation rate or C-reactive protein. The variables that have been associated with unfavorable prognosis for rheumatoid arthritis are also discussed. We hope that continued study will lead to identification and adoption of simple assessments that will prove to be powerful predictors of good or poor patient outcomes and stratification of patient risk. This uniform measure of disease assessment will improve judgments of potential benefits of therapeutic interventions.

Felty's and pseudo-Felty's syndromes

Felty's syndrome, consisting of rheumatoid arthritis, leukopenia, and splenomegaly, has been recognized as a distinct clinical entity for more than 60 years. Clinical and laboratory manifestations of the condition are reviewed. The major sources of morbidity and mortality remain recurrent local and systemic infections. Immunogenetic analysis shows a strong association with HLA-DR4, in addition to DQ beta 3b and C4B null allele. Potential mechanisms of neutropenia are contrasted, including impaired granulopoiesis and neutrophil-immune complex interactions. Lithium carbonate and splenectomy may have a role in the treatment of fulminant disease. Maintenance therapy should be directed at control of the underlying inflammatory arthropathy. A syndrome of proliferation of large granular lymphocytes and neutropenia, associated with rheumatoid arthritis in 23% to 39% of cases, has been described recently. Cases of "pseudo-Felty's" syndrome are often confused with traditional Felty's syndrome, which has twice the prevalence. The clinical and laboratory distinctions between these two conditions are elaborated.

Takayasu's arteritis

Two recent cases of Takayasu's arteritis illustrate the wide spectrum of disease presentation. The first patient demonstrated rapid development of ischemic manifestations; the second patient presented with septal panniculitis. Worldwide distribution of Takayasu's arteritis has increased.

Acute central nervous system symptoms caused by ibuprofen in connective tissue disease

We describe 2 cases of acute encephalopathy in patients with connective tissue disease caused by small doses of ibuprofen. In addition to aseptic meningitis, both patients had altered mental status and focal neurologic signs, ophthalmoplegia in one and hemiparesis in the other. The spectrum of neurologic manifestations of ibuprofen hypersensitivity is reviewed.

Pyoderma gangrenosum complicating Felty's syndrome

The case of a 54-year-old woman with Felty's syndrome whose course was complicated by mucocutaneous lesions clinically typical of pyoderma gangrenosum is described. Necrotizing sinusitis and saddle nose deformity were distinctive clinical features. Lymphocytic vasculitis and rheumatoid nodule formation observed within panniculus at the base of a cutaneous lesion and in a nasal mucosal lesion were unexpected histopathologic findings.

Isolated, pupil-sparing third nerve palsy as initial manifestation of systemic lupus erythematosus

A 29-year-old woman had an isolated, pupil-sparing third cranial nerve palsy. Serologic and CSF abnormalities and the subsequent course were consistent with systemic lupus erythematosus. Corticosteroid therapy resulted in improvement of ocular palsy within 4 weeks. The pathogenesis of cranial neuropathy in systemic lupus erythematosus and the unique presentation in this patient are discussed.

Occupancy of adenosine receptors raises cyclic AMP alone and in synergy with occupancy of chemoattractant receptors and inhibits membrane depolarization

We have recently demonstrated that adenosine, acting via adenosine A2 receptors, inhibits generation of superoxide anions (O2-) by stimulated neutrophils. To determine the mechanism(s) by which adenosine inhibits O2- generation stimulated by the chemoattractant N-formylmethionylleucylphenylalanine (FMLP), we examined cyclic AMP (cAMP) concentrations, stimulated membrane depolarization and Ca2+ movements. Neither adenosine nor 5'-N-ethylcarboxamidoadenosine (NECA), the most potent agonist at adenosine A2 receptors, increases neutrophil cAMP content. However in the presence of the non-methylxanthine phosphodiesterase inhibitor, Ro-20-1724, both adenosine and NECA elicit a reversible increase in intracellular cAMP concentration. The chemoattractant FMLP also elicits an increment in the neutrophil cAMP content. NECA, in the presence of Ro-20-1724, synergistically enhances the increment in cAMP following stimulation by FMLP. However Ro-20-1724 does not potentiate the inhibition of O2- generation by NECA. Unlike other agents which increase neutrophil cAMP concentrations, NECA, even in the presence of a phosphodiesterase inhibitor, only trivially inhibits degranulation. We also found that adenosine markedly inhibits stimulated membrane depolarization but does not affect the stimulated increment in free ionized intracellular calcium. Moreover, inhibition by adenosine of O2- generation does not vary with the concentration of extracellular calcium. These results fulfil the last criterion for the demonstration of an A2 receptor on human neutrophils, and indicate that adenosine occupies an A2 receptor on neutrophils to raise intracellular cAMP in synergy with occupancy of the FMLP receptor. The results reported here also indicate that cAMP is not the second messenger for inhibition of O2- generation by adenosine and its analogues.