Cutaneous vasculitis in adult polymyositis/dermatomyositis

Seven (9.2%) of 76 patients with adult-onset polymyositis/dermatomyositis (PM/DM) seen over an 11-year period had cutaneous vasculitis. This was manifest by dermal and/or subcutaneous nodules in 4, periungual infarcts in 3 and digital ulceration in 2. When these 7 patients were compared to the remaining 69, a significant association was noted between cutaneous vasculitis and DM (p = .025); only 1 of 31 patients with primary PM and none of 18 with overlap syndromes had vasculitis. Furthermore, 2 (28.6%) of those with vasculitis had an associated malignancy compared to only 4 (5.8%) of those without vasculitis. These data document the occurrence of cutaneous vasculitis in adult-onset PM/DM and suggest that its presence may be a marker of an underlying malignancy.

Validity and yield of a two-stage screening procedure for systemic lupus erythematosus

Sixty-six systemic lupus erythematosus (SLE) patients, 375 healthy female controls and 537 young Caucasian females were examined according to a recently suggested two-stage model for population screening for SLE. This model consisted in: a) administration of a 10-item questionnaire based on the ARA preliminary criteria for SLE; b) search of antinuclear antibodies (ANA) in the persons positive during the first stage. Among the SLE patients, the overall sensitivity of the two-stage screening was 90%, while its specificity in the healthy 375 normals reached 96%. 13% of 537 young Caucasian females answered affirmatively to 3 or more questions of the questionnaire. Out of these, 59 were tested for ANA. Two out of these 59 had a positive ANA test, but no one had SLE at a subsequent clinical survey. These data confirm the validity of this two-stage screening procedure for SLE. While the low prevalence of this disorder in the general population hardly justifies its massive application, the screening might be recommended for survey groups at high risk for SLE.

Serial pulmonary function in systemic sclerosis

The natural history of the pulmonary involvement in systemic sclerosis is not well studied. Reported here are the serial measurements of pulmonary function in a well defined population of patients with systemic sclerosis followed over a mean of 63 months. The mean rate of loss of vital capacity (0.10 liters per year) for the 38 patients serially studied was more than three times the expected rate of loss for a normal population. The mean rate of loss of diffusing capacity (0.33 ml/min/mm Hg per year) for the 27 patients serially studied was similar to that for a normal population. The percent forced vital capacity expired in the first second increased 0.53 percent per year consistent with a progressive restrictive ventilatory defect. Smokers tended to lose vital capacity at a slightly greater rate than nonsmokers (p = 0.069). Individual variability in the course of pulmonary function was observed. Although the overall trend in our population was towards a slowly progressive restrictive ventilatory defect, pulmonary function in the nonsmokers did not change at rates different from those in a nonsmoking reference population.

Identification of an inherited form of Peyronie's disease with autosomal dominant inheritance and association with Dupuytren's contracture and histocompatibility B7 cross-reacting antigens

Peyronie's disease is an inflammatory disorder with no confirmed etiology. We have documented the familial transmission of the disease as an autosomal dominant trait in 3 pedigrees. The occurrence of Dupuytren's contracture in 7 of 9 (78 per cent) affected individuals, which is a significant increase over the average 0 per cent reported in sporadic cases, suggests that both of these fibrosing disorders are pleiotropic effects of the same gene in these families. Similarly, the histocompatibility B7 cross-reacting antigens were present in 90 per cent of the patients with Peyronie's disease. Additional studies, including careful family histories and histocompatibility antigen typing, are necessary to elucidate the role of histocompatibility antigens as a relative risk factor.

Peyronie's disease: a newly recognized autosomal-dominant trait

Peyronie's disease, a connective tissue disorder of unknown cause, is characterized by the formation of thickened fibrous plaques on the dorsum of the penis. It often occurs simultaneously with other fibrotic changes, most notably Dupuytren's contracture of the hands or feet. There are no previous reports suggesting inheritance of this syndrome; however, Willscher et al reported an association between Peyronie's disease and antigens of the HLA-B7 cross-reacting group. Family studies were undertaken when three patients reported similarly affected first-degree relatives. One kindred showed father-to-son transmission of Peyronie's disease with Dupuytren's contracture in three generations. Pedigree analysis of the three families suggests that Peyronie's syndrome is a male-limited, autosomal-dominant trait. Antigens of the HLA-B7 cross-reacting group occurred in all three kindreds; however, the data ruled out close linkage of the disease and HLA.

Survivorship in systemic lupus erythematosus: effect of antibody to extractable nuclear antigen

The course of 81 patients with systemic lupus erythematosus (SLE) who had sera tested for antibody to extractable nuclear antigen (ENA) was studied to determine the effect of the presence of antiENA antibody on survivorship. There were no differences in percent survival between the patients with and without antibody to ENA or those with and without antibody to the ribonucleoprotein (RNP) component of ENA. We conclude that there is no prognostic advantage to the presence of either antiENA or antiRNP antibody in patients with SLE.

The absence of back pain in classical ankylosing spondylitis

Despite the early description of painless spinal ankylosis, the existence of a clinical subset of ankylosing spondylitis with silent axial disease has largely been overlooked. Of 45 patients who met Rome diagnostic criteria for ankylosing spondylitis, five denied ever having back pain either as an initial symptom or during the subsequent course of their illness. All had decreased lumbar spine motion and bilateral radiographic sacroiliitis of at least grade III severity. Chest expansion was decreased in four, and radiographic involvement of the cervical and lumbar spine was observed in three and two patients, respectively. There were no differences observed in sex or race distribution, or frequencies of peripheral arthritis, heel pain, acute uveitis, genito-urinary infection or HLA-B27 positivity when these patients were compared with the remaining patients with back pain. These patients support the existence of a "latent" form of ankylosing spondylitis with silent axial disease.

HLA-C locus antigens in HLA-B27 associated arthritis

Frequencies of the HLA-C locus antigens, Cw1, Cw2, Cw3, and Cw4, were determined in 88 patients with spondylitic diseases and 88 matched and 64 B27-positive normal controls. Both Cw1 and Cw2 were significantly increased in B27-positive patients and B27-positive controls as compared to B27-negative patients and matched controls. Cw1 and Cw2 demonstrate strong linkage disequilibrium with B27. Their absence in B27-negative patients suggests disease susceptibility is related to HLA-B.

Acute leukemia following cyclophosphamide therapy for Sjögren's syndrome

A fatal myeloproliferative syndrome diagnosed as subacute myelomonocytic leukemia developed in a patient with Sjögren's syndrome following treatment with cyclophosphamide. Although patients with Sjögren's syndrome have a recognized increased risk of developing lymphoproliferative disorders, particularly reticulum cell sarcoma, there is no evidence to support a similar predisposition to leukemia. As immunosuppressive therapy is becoming more common in the treatment of patients with rheumatoid arthritis, there have been recent reports of patients developing fatal myeloproliferative disorders after receiving immunosuppressive therapy. Review of these cases shows similar duration of therapy, and cyclophosphamide, among others, has been implicated as the leukemogenic agent in other patients. We feel that great caution should be exercised in the use of immunosuppressive drugs in patients with chronic, nonfatal disorders sich as rheumatoid arthritis and Sjögren's syndrome.

Cross-reactive HLA antigens in B27-negative Reiter's syndrome and sacroiliitis

Proposed mechanisms to explain the association of HLA-B27 with Reiter's syndrome (RS) and ankylosing spondylitis (AS) include abnormal immune response genes linked to HLA or a direct role for HLA antigens in disease pathogenesis. Our studies provide indirect evidence to support the latter hypothesis. Seventy-nine patients (44 with RS, 27 with AS and 8 with idiopathic sacroiliitis [SI]) were evaluated clinically and by HLA phenotyping. Of the 10 patients with RS who were B27-negative, 7 (70%) had another B locus antigen that was immunologically cross-reactive with B27 (B7-group antigen). These included B7 in two, BW22 in four, and BW42 in one. Four of eight patients with sacroiliitis alone had B27, but the remaining four all had B7. Two B27-negative AS patients had no B7-group antigens. Thus, 69% of B27-negative patients had cross-reactive HLA antigens.

Homozygosity for HLA-B27. Impact on rheumatic disease expression in two families

The effect of homozygosity for HLA-B27 on the clinical expression of rheumatic disease was studied in two families. The 1 homozygous patient in each of two families demonstrated extraordinarily severe peripheral and axial arthritis compared to other affected heterozygous relatives. In addition, predominant peripheral or axial disease appeared to segregate with different B27 haplotypes. The 2 homozygous patients were not homozygous at the hla-a,c, or D loci.

Hypothyroidism presenting as a polymyositis-like syndrome. Report of two cases

Two patients with proximal muscle weakness and marked elevations of serum muscle enzymes were initially believed to have polymyositis; however electromyography and muscle biopsies were normal. Both patients were subsequently found to have hypothyroidism. Each regained her muscle strength, and serum enzymes normalized with thyroid hormone replacement. Because muscle weakness and an elevated creatine phosphokinase occur in most patients with hypothyroidism, thyroid dysfunction must be considered in the differential diagnosis of polymyositis.

Bromide intoxication

Bromide intoxication is now an uncommon disease. This report reviews the experience with this disorder at the Johns Hopkins Hospital over the last 23 years and reemphasizes the variable neuropsychiatric symptoms which these patients present. Impaired sensorium, fever, skin rash, abnormal serum chloride, and a history of proprietary drug abuse are clinical features which may suggest the presence of bromide intoxication. Treatment consisting of saline administration often augmented with mercurial, thiazide or "loop" diuretics was uniformly effective. The declining incidence of this disorder is felt to be due to the decrease in physicians' use of prescription bromides and the declining availability of proprietary bromide containing compounds.