Tenidap in patients with rheumatoid arthritis. A 4-week, placebo-controlled study

The present double-blind, placebo-controlled study was conducted to compare the safety and efficacy of tenidap in patients with rheumatoid arthritis (RA). Patients with flare of active RA following NSAID withdrawal were randomized to receive either placebo (n = 67) or tenidap (n = 131; 40-200 mg/day). The mean changes from baseline in efficacy and biochemical variables were compared between treatment groups at endpoint (4 weeks). The improvements in four of the five primary efficacy variables were significantly greater in the tenidap group compared with the placebo group (p < 0.01). Tenidap was also associated with an 18% reduction in erythrocyte sedimentation rate (ESR) and a marked, 51%, reduction in serum C-reactive protein (CRP) level, both of which were significantly greater than the changes in the placebo group (p < 0.05). The percentage of patients who discontinued because of side effects was the same in both groups (3%). In conclusion, tenidap 40-200 mg/day was effective and well tolerated in the treatment of patients with RA for 4 weeks.

Effect of ibuprofen use on muscle soreness, damage, and performance: a preliminary investigation

Twenty subjects were randomly assigned to: 1) prophylactic ibuprofen (N = 5) [400 mg TID initiated 4 h before collection of baseline data and strenuous eccentric exercise bout], 2) therapeutic ibuprofen (N = 5) [400 mg TID initiated 24 h after baseline], 3) placebo (N = 5), or 4) control (N = 5). Muscle soreness perception, plasma creatine kinase, knee extensor torque, and EMG of the quadriceps were evaluated at baseline, 24, and 48 h. The prophylactic ibuprofen group had between 40 and 50% less muscle soreness perception and significantly less decline in isometric, concentric, and eccentric torque at 24 h compared with the other three groups (P < 0.05). At 48 h both prophylactic and therapeutic ibuprofen had significantly less muscle soreness perception and decline in torque than the placebo and control groups (P < 0.05). There was no difference between the amount of muscle damage between the four groups at 24 and 48 h. Vastus medialis and lateralis EMG magnitude decreased across time. Vastus lateralis EMG magnitude had significantly less decline from baseline for prophylactic ibuprofen compared with the other three treatments at 24 h, while both prophylactic and therapeutic ibuprofen had significantly less decline at 48 h. These data indicate that a prophylactic dosage of ibuprofen does not prevent CK release from muscle, but does decrease muscle soreness perception and may assist in restoring muscle function.

Giant-cell arteritis in the southern United States. An 11-year retrospective study from the Texas Gulf Coast

Giant-cell arteritis (GCA) and polymyalgia rheumatica are systemic disorders that reportedly affect primarily white women older than age 50 years. We conducted an 11-year chart review to determine the relative occurrence and pattern of demographic involvement of GCA in the Gulf Coast region of the United States. Of 101,239 computer-coded entries for individual patients aged 40 years or older, 60 charts listed GCA as a differential diagnosis. Twenty-seven patients had temporal GCA; 21 temporal artery biopsy specimens were identified. Two patients had associated systemic GCA (one with aortitis). A striking finding was that 13 of the 27 patients were black women (about 50% of the entire study population). The group with GCA and polymyalgia rheumatica (17 patients) had a significantly higher mean erythrocyte sedimentation rate than the group with "pure" GCA. Jaw claudication and blindness were rare. We concluded that temporal GCA seems relatively uncommon in the Gulf Coast region and in the southern United States as a whole. Furthermore, GCA seems rare in Hispanics (only one patient identified). Nonetheless, this is the first report to document a proportionally high occurrence of GCA in black patients in this part of the country.

Ultrastructural and immunohistochemical evidence for release of eosinophilic granules in vivo: cytotoxic potential in chronic eosinophilic pneumonia

We studied a patient with relapsing idiopathic chronic eosinophilic pneumonia. Each one of four attacks observed during a 4-year period was characterized by dyspnea, wheezing, peripheral blood eosinophilia, elevated serum IgE levels, and pulmonary infiltrates. Glucocorticoid therapy caused prompt resolution of symptoms and disappearance of blood eosinophilia and pulmonary shadowing. Electron microscopy and tissue immunofluorescence studies for major basic protein documented extensive eosinophil degranulation and the presence of free granules within the pulmonary microvasculature. In addition, exfoliation of the alveolar lining cell was observed in association with a clustering of free intact and disintegrating extracellular eosinophil granules against a denuded basement membrane. These findings suggest a cytotoxic potential of the eosinophil at the level of the pulmonary parenchyma in a case of idiopathic chronic eosinophilic pneumonia.

Thalidomide effects in Behçet's syndrome and pustular vasculitis

Pustular vasculitis is a new disease concept that links cutaneous, and possibly systemic, aspects of Behçet's, bowel bypass, bowel-associated dermatosis-arthritis, and disseminated gonorrhea syndromes. The pathomechanism of pustular vasculitic lesion generation may relate to circulating immune complex (CIC)-mediated vessel damage and serum enhancement of neutrophil migration. Thalidomide, an oral pharmaceutical available on strict protocol, has therapeutic effects based on proposed modulation of CIC- and neutrophil-mediated cytotoxicity. Thalidomide therapy was started for four patients with significant morbidity from Behçet's syndrome and for one patient with bowel-associated dermatosis-arthritis syndrome. Clinical benefit was dramatic in all patients who completed sequential four-week "on" and "off" thalidomide therapeutic cycles. In three of four patients, in vivo testing for CIC after histamine injection immunopathology converted from positive (immunoreactant deposition in dermal vasculature [four hours after histamine] and CIC-mediated vasculitis [24 hours after histamine]) to negative during therapy. No effects were noted on neutrophil migration or on the LFA-1/Mac-1/p150,95 family of glycoproteins associated with neutrophil adherence as assessed qualitatively by tritium labelling of neutrophil cell surfaces. In this small patient group, thalidomide was a clinically effective, safe (with rigid monitoring) therapy whose mechanism of action may relate more to inhibitory effects on CIC-induced vasculitis than to effects on neutrophil-mediated cytotoxicity.

Mechanism-oriented assessment of isotretinoin in chronic or subacute cutaneous lupus erythematosus

Eight of ten patients with chronic or subacute cutaneous lupus erythematosus completed 16 weeks of oral isotretinoin therapy (80 mg/day). All eight patients noted an excellent clinical response without significant side effects. (Two patients did not return to initial two-week follow-up.) Peripheral blood B- and T-cell counts were unaffected by therapy. Therapy was associated with resolution of routine histopathologic abnormalities, conversion of abnormal lesional direct immunofluorescence microscopy to normal, normalization of the epidermis on electron microscopy, and reduction of all T cells near the dermoepidermal junction without change in ratio of T-helper/inducer cells to T-suppressor/cytotoxic cells. Isotretinoin is a clinically effective short-term therapy for chronic or possibly for subacute cutaneous lupus erythematosus. The primary mechanism of action remains unestablished.

Coexistent systemic lupus erythematosus and tophaceous gout

Only seven patients with coexistent gout and systemic lupus erythematosus have been reported in the English-language literature. We describe an eighth case, which is the first, to our knowledge, in the dermatologic literature. The patient met four of the eleven new American Rheumatism Association criteria for the diagnosis of systemic lupus erythematosus, and clinical, laboratory, roentgenographic, and histologic assessments confirmed the diagnosis of gout.

Polymyositis presenting with panniculitis

Although microscopic areas of panniculitis may frequently occur in patients with dermatomyositis and polymyositis, large, clinically obvious plaques are unusual. We report a patient with polymyositis who initially had panniculitis of the thigh. Histologically, a lobular lymphoplasmacytic infiltrate was present in the subcutis.

Complex aphthosis: a forme fruste of Behçet's syndrome?

The evaluation of the rare patient who presents with oral and genital aphthae or almost constant, multiple (greater than 3) oral aphthae, but no systemic signs or symptoms (i.e., complex aphthosis), is difficult because no laboratory test is available to exclude Behçet's syndrome. Six patients with complex aphthosis were evaluated. In addition, patients with simple aphthosis, those with seronegative arthritis, and normal controls were assessed for circulating immune complexes (CIC) by in vitro and in vivo assays and for neutrophil migration by subagarose methods, since these tests have given significant results in patients with Behçet's syndrome. Patient 1, with complex aphthosis, had Raji cell evidence for CIC (51.2 mg aggregated human gamma globulin Eq/ml), C1q, and C3 in dermal blood vessels 4 hours post intradermal histamine injection and had a Sweet's syndrome-like vasculitis 24 hours post histamine injection. In addition, her serum enhanced the migration of patient neutrophils (3.6 +/- 0.6 to 4.6 +/- 0.5; N = 6, p less than or equal to 0.01). All other test and control patients had negative or normal CIC and neutrophil migration determinations. Sixteen-month clinical follow-up has confirmed that Patient 1, but not Patients 2 to 6, has developed overt manifestations of Behçet's syndrome.

Intravenous immune globulin therapy. Treatment of a patient with severe immunodeficiency, chronic malabsorption, and fulminant septicemia

Biweekly 200 mg/kg infusions of immune globulin (Gamimune) were given to a 46-year-old woman with severe common variable immunodeficiency, bronchiectasis, and chronic diarrhea with malabsorption. Failure to achieve therapeutically effective serum IgG concentrations in the face of fulminant sepsis was accompanied by a shortened serum IgG half-life of 10.6 days. Currently recommended doses of 200 mg/kg may prove inadequate in very ill patients with sepsis and malabsorption.

Evaluation of immune-enhancing effects of ibuprofen in an immunodeficiency model

Three children and one adult with chronic mucocutaneous candidosis with documented deficient cellular immunity to Candida antigen were evaluated as a model to study the specific cellular immune-enhancing potential of the prostaglandin synthetase inhibitor ibuprofen. Oral ibuprofen failed to have any consistent effect during sequential 4-week on and off cycles on the following parameters: delayed hypersensitivity skin testing; lymphocyte transformation to Candida antigen; T-cell subsets as determined by monoclonal antibody techniques; production of human immune interferon in response to staphylococcal enterotoxin A (SEA). Two patients showed a trend toward enhanced lymphocyte transformation to PHA while taking ibuprofen. In two patients who were studied 8-10 weeks after discontinuation of oral ketoconazole therapy, clinical recurrence of CMC was not prevented by oral ibuprofen therapy.

Immunologic safety of ibuprofen in rheumatoid arthritis: preliminary evidence

Some evidence indicates that ibuprofen and other prostaglandin synthetase inhibitors may have the potential for cellular immune enhancement in addition to their anti-inflammatory activity. If this is true, treatment of rheumatoid arthritis, a disorder of presumed autoimmune pathogenesis, would present a dilemma. These agents are widely used in rheumatoid arthritis for their anti-inflammatory effects. If they are found to enhance cellular immune function, however, the disease might be stimulated over the long term, rather than suppressed. Preliminary evidence from four patients with rheumatoid arthritis show that oral ibuprofen had no significant immunologic effect during sequential "on" and "off" cycles, as assessed by the following measures: delayed hypersensitivity skin testing; lymphocyte transformation to mitogen (phytohemagglutinin) or specific antigen (Candida albicans); T-cell subsets, as determined by monoclonal antibody techniques; or production of the lymphokine, human immune interferon, in response to phytohemagglutinin or to staphylococcal enterotoxin A. Early evidence, therefore, suggests that oral ibuprofen therapy may be 'immunologically safe' in patients with rheumatoid arthritis, but investigations of large series of patients also assessing local immune reaction in diseased joints may be necessary for confirmation.

Antinuclear antibodies in the serum of normal pregnant women: a prospective study

A prospective study was performed to determine the incidence of antinuclear antibodies in 214 normal pregnant women and in 50 age-matched controls. Serum samples of 23 pregnant women (10.7%) yielded positive results (1 + or more at a dilution of 1:20) in contrast with only one sample (2%) in the control group (p less than 0.05). Of the pregnant women found to be positive, five (9.2%) were in the second trimester, and 18 (13.4%) were in the last trimester. Only two also had positive anti-DNA antibodies. A review of their hospital records disclosed no reason to suspect systemic lupus erythematosus or other rheumatologic diseases nor any significant increase in neonatal morbidity of their infants. We conclude that the incidence of antinuclear antibodies in pregnant women is significantly higher than in nonpregnant women and that the finding probably does not correlate with any adverse clinical effect.

Bowel-associated dermatosis-arthritis syndrome. Immune complex-mediated vessel damage and increased neutrophil migration

In a recent report we described a syndrome, identical to bowel-bypass syndrome, that occurred in four patients who had not had bypass surgery. Herein, circulating immune complexes (CICs) and neutrophil migration are evaluated in three of those four patients to test the hypothesis that the cutaneous lesions might have resulted from interaction between immune complex-mediated vessel damage and increased neutrophil migration. In vitro assays indicated that CICs were present in one of two patients and "histamine trap" test evidence for CICs was present in both patients tested. Although serum from the three patients appeared to increase neutrophil movement, statistically significant increases were not observed when data were pooled in this small study group. Preliminary results suggest that immune complex-mediated vessel damage, followed by extensive accumulation of neutrophils, may cause the pustular vasculitis in the bowel-associated dermatosis-arthritis syndrome.

Behçet's syndrome: immune regulation, circulating immune complexes, neutrophil migration, and colchicine therapy

Immune regulatory dysfunction, circulating immune complexes (CIC), and polymorphonuclear (PMN) cell migration were investigated in patients with Behçet's syndrome. Six patients meeting rigorous clinical criteria were evaluated. Only one patient showed evidence of immune regulatory dysfunction (increased T4/T8 ratio). Although C1q binding and Raji cell assays for CIC yielded positive results in only one of five patients, all five patients had in vivo "histamine trap test" evidence of CIC (all controls had normal results). Sera from all Behçet's syndrome patients increased migration of neutrophils to zymosan-activated serum. Colchicine therapy abolished the enhancing effect of the patient's sera on movement of PMN cells from patients and controls. An immune complex-mediated injury that is followed by an excessive accumulation of PMN cells may lead to the cutaneous lesions and other lesions in Behçet's syndrome. Further evaluation of colchicine therapy is warranted on the basis of these studies.

Sjögren's syndrome presenting with hypereosinophilia, lymphopenia and circulating immune complexes

Although mild peripheral eosinophilia is a common finding in Sjögren's syndrome (SS), severe eosinophilia with a clinical picture simulating hypereosinophilic syndrome is extremely rare. We report a 24 year old male with SS presenting with swelling of the parotid glands, redness and irritation of the eyes, polyarthralgias and polyarthritis, weight loss, exertional dyspnea, malaise, erythematous and urticarial skin lesions and enlarged lymph nodes. Laboratory tests showed hypereosinophilia (34%, total 3800/mm3), lymphopenia (2%, total 220/mm3), a positive RA factor (1:2560) and decreased C3 and C4. Biopsy of an enlarged submaxillary gland was consistent with SS. A Schirmer test showed decreased tear production. Salivary glands showed a marked decrease in uptake of radioactive (Tc99) dye. Circulating immune complexes (CIC) were markedly elevated by both C1q binding and Raji cell assays. T-cell subsets showed OKT3 = 63%, OKT4 = 32% and OKT8 = 16%. "Histamine trap" in vivo test for CIC revealed fluorescence in upper dermal blood vessels with IgM, C1q, C3 and fibrin. Biopsies of the liver, bone marrow and skin revealed eosinophilic infiltration. A notable response to therapy with high doses of corticosteroids was seen with recurrence of symptoms and laboratory abnormalities after the therapy was stopped. In conclusion, we present a case of SS which is remarkable for the age and sex of the patient, extreme hypereosinophilia, marked lymphopenia, and CIC.

Human T-cell subset changes during culture

When human peripheral blood lymphocytes (PBL) are cultured with either concanavalin A (Con A)-treated or control autologous T lymphocytes, the mitogenic responses of the PBL co-cultured with Con A-treated cells are much lower. We have investigated the cell surface receptor changes during culture of T cells with and without mitogen in an attempt to explain this differential regulatory phenomenon. We present data here which show that human T cells cultured in complete medium alone gain helper cells with time. Con A-treated T cells are known to lose helper cells during culture. Erythrocyte rosette-purified T cells were cultured with or without Con A for 84 h and the numbers of cells with receptors for the Fc regions of either IgM (T mu) or IgG (T gamma) were enumerated daily. T mu cells have been associated with helper activity while T gamma cells have predominantly suppressor activity. Treatment with 10 micrograms/ml of Con A decreased T mu by approximately 50%. Untreated cells, however, showed significant increases in T mu (44 +/- 30.5% in twelve individuals). The great variance in T mu increases is due to the fact that individuals having higher initial T mu values showed smaller increases. These changes probably represent the gain or loss of receptors because total cell numbers did not change. There was no significant change in the number of T gamma cells in either control or Con A-treated cultures during the same 84 h period. In co-culture experiments in which the responses of fresh autologous PBL were determined, 60-h control T-cell cultures enhanced the mitogen responses of the fresh cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Proportional and functional studies of the infiltrating lymphocytes in the parotid gland of Sjögren's syndrome associated with rheumatoid arthritis

Lymphocyte subpopulations and functions were examined in the salivary (parotid) gland lymphocytes (SGL) obtained as a cell suspension from a patient with Sjögren's syndrome associated with rheumatoid arthritis, in comparison with peripheral blood lymphocytes (PBL). Serial studies on the lymphocyte subsets in PBL using monoclonal antibodies to helper or suppressor T cell subsets (OKT4 or OKT8) demonstrated a decreased proportion of the OKT8 subset (OKT4/OKT8 ratio: 7.1-34.0). Major infiltrating cells in the gland were surface immunoglobulin-bearing B cells, and 23-35% of the SGL were T cells by both the E-rosetting method and OKT3-monoclonal antibody reactivity. Moreover, OKT4/OKT8 ratios were definitely lower in the SGL (1.0 and 1.7) than those in the PBL of the patient. Mitogen-induced lymphocyte proliferative responses of the SGL were markedly diminished, although the possible participation of defective macrophages was considered. The autologous mixed lymphocyte reaction was low in both PBL and SGL. PBL of the patient showed normal proliferative responses to mitogens except for PWM stimulation. Suppressor effects of the SGL for the proliferative responses of autologous and allogeneic PBL were demonstrated. Con A-induced suppressor function was inducible in the SGL, whereas that function could not be demonstrated in the patient's PBL.

Histamine-triggered localized vasculitis in patients with seropositive rheumatoid arthritis

To gain some insight into the pathogenesis of vasculitis in rheumatoid arthritis, and to investigate its relation to circulating immunoreactants, we injected 50 microliters of histamine intradermally in four seropositive and four seronegative patients with rheumatoid arthritis. Skin biopsies obtained before histamine and at 4 hours after histamine were studied by immunofluorescence microscopy, and skin biopsies 24 hours after histamine were studied by light microscopy. At 4 hours after histamine, all seropositive patients demonstrated deposits of IgM and complement components in dermal vessels; by 24 hours, various degrees of leukocytoclastic vasculitis were noted. Circulating material reactive with Raji cells, C1q, or both, was present in 3/3 seropositive patients. In contrast, none of the seronegative patients exhibited vascular deposits of immunoreactants or vasculitis. The results indicate that patients with rheumatoid arthritis who are seropositive may have circulating complexes with appropriate characteristics to induce vasculitis and that vasoactive substances may be used to trigger their local deposition in vessels.

Defective expression of OKT4 antigen on the cell surface of helper T lymphocytes in a patient with systemic lupus erythematosus

OKT-monoclonal antibodies directed to total T-cells (OKT3), inducer/helper (OKT4) or suppressor/cytotoxic (OKT8) T-cells recognize developmental antigens on human T-cells. We report here an 18 year old male patient with systemic lupus erythematosus who had a prominent decrease in the proportion of OKT4-reactive T-cells in his peripheral blood, although the proportion of OKT3- and OKT8-reactive T-cells were essentially normal. His peripheral blood lymphocytes (PBL) responded well to stimulation by phytohemagglutinin-P (PHA) or concanavalin-A (Con A), which are stimulators for OKT4-reactive T-cells or for both subsets. Furthermore, helper T-cell function for B-cell proliferation was demonstrable in the patient's T-cells which lacked both OKT4 and OKT8 antigens. Trypsinization of PBL from healthy individuals abrogated detection of the OKT4 antigen, and a complete recovery of the antigen was observed after 6 days of culture of the treated PBL. The OKT4 antigen, however, could not be expressed on the patient's PBL after this treatment and incubation. In addition, the patient's serum could not block the recovery of OKT4 antigen on trypsinized T-cells from healthy individuals. The decrease in the percentage of OKT4-reactive T-cells was relatively stable in the patient, while his clinical disease activity and medications were variable. Taken together, these results suggest a defective expression of OKT4 antigen on the helper T-cell subset in this patient.

Red lunulae in a patient with rheumatoid arthritis

Red nails, a distinctive, dusky red, blanchable erythema of the lunula area of the nail bed, has been previously reported three times in the English language literature, in each instance in association with alopecia areata. An identical case of red nails here in association with "classical" rheumatoid arthritis is reported.

Dermatologic conditions reported in patients with rheumatoid arthritis

Dermatologists, while becoming increasingly involved in the diagnosis and management of patients with connective tissue diseases, have left rheumatoid arthritis relatively unexplored. An increased awareness of possible pathomechanisms of rheumatoid arthritis may allow for generalizations that lead to increased understanding of other connective tissue disorders. The types of cutaneous disorders that occur in association with rheumatoid arthritis include: vasoreactive dermatoses (e.g., various forms of vasculitis), which may occur secondary to the circulating immune complexes present in rheumatoid arthritis; autoimmune bullous disorders, which may occur in the setting of a suppressor T cell defect in rheumatoid arthritis; and various miscellaneous cutaneous associations. Hopefully, this review will lead to an increased understanding of both rheumatoid arthritis and the wide array of cutaneous associations of rheumatoid arthritis.

Further characterization of mitogen-induced autorosette-forming cells: correlation with T-cell subsets and with lymphocyte proliferative responses to mitogens

Spontaneous autologous rosette-forming cells (ARFC), which form rosettes with autologous erythrocytes, have been of interest as a subset of thymus-derived lymphocytes (T cells). An association of these cells with concanavalin A (Con A)-induced ARFC has been suggested. Furthermore, the Con A-induced ARFC have been shown to be a suppressor T-cell subset in the Con A-generated suppressor system. We have previously reported the induction of ARFC from T cells by several T-cell mitogens such as phytohemagglutinin-P (PHA) and allogeneic non-T cells other than Con A. In the present report, we further characterized the mitogen-induced ARFC and have extended the study to patients with systemic lupus erythematosus (SLE). We have found that ARFC are also inducible from peripheral blood T cells by pokeweed mitogen (PWM). Studies of T-cell surface markers on the ARFC using OKT monoclonal antibodies confirmed the induction of ARFC from both OKT4- and OKT8-reactive T cells by either Con A, PHA, or PWM stimulation. However, OKT4-reactive T cells were the major cellular source of the ARFC induced by all of the mitogens. In studies of SLE patients, proportions of both Con A- and PWM-induced ARFC were found to be significantly low in PBL of SLE patients treated with moderate or large doses of prednisone, with or without concomitant immunosuppressants, but not in SLE patients without such treatment. Proportional analysis of the T cells and their subsets suggested association of these alterations in the mitogen-induced ARFC with the OKT4-reactive T cells, since a significant decrease in the OKT4-reactive T-cell subset was demonstrated in the PBL of these patients. Proportions of PHA-induced ARFC, however, were not significantly different between SLE patients and healthy adults. Moreover, positive correlations of the mitogen-induced ARFC with lymphocyte proliferative responses to each mitogen were established in both SLE patients and healthy adults. These results further support our previous observation that suggest the receptors for autologous erythrocytes are enhanced or reexpressed on those T cells which are highly activated by mitogens.

Reactivity of mitogen-induced autorosette-forming cells to interleukin 2 (T-cell growth factor)

The reactivity of mitogen-induced autologous rosette-forming cells (ARFC) to interleukin 2 (IL-2; T-cell growth factor) was studied in the present report. Both ARFC-enriched T cells and ARFC-depleted T cells, which were separated from concanavalin A (Con A)-activated T cells, were reactive to this factor. The IL-2 activity was absorbed by both ARFC-enriched and ARFC-depleted T cells, although ARFC-enriched T cells could absorb more IL-2 activity. Furthermore, ARFC were further inducible by IL-2 from non-ARFC. These results suggest the expression of the receptors for IL-2 on both ARFC and non-ARFC following mitogen stimulation. They further support the possibility that mitogen-induced ARFC, rather than being recruited only from such a minor T-cell subset as the spontaneous ARFC, are more likely the result of most T cells being responsive to mitogenic stimulation and expressing the receptors for autologous erythrocytes by the effects of IL-2 and mitogen.