A cluster of three cases of aplastic anaemia in children

During a 2-week period three unrelated children presented with severe aplastic anaemia at a general hospital serving a population of 25,000 children aged 0-15 years. The probability of this occurring by chance alone was 0.00009 (exact probability cluster analysis). Serology for common viral infections including hepatitis A & B and infectious mononucleosis was negative. It was not possible to demonstrate IgM antibodies to human parvovirus (HPV) by radioimmunoprecipitation or HPV virions by DNA hybridization in the patients or any members of their families. Epidemiological investigation failed to demonstrate a common environmental toxin. It did reveal, however, that all three patients had spent time, within the preceding 3 months in a swimming pool and its surrounding area in a region of Cardiff where none of them resided. Pool maintenance was satisfactory and water analysis showed no abnormality. The possibility must remain that the cluster was caused by an undisclosed environmental toxin.

The total cost of care and the use of pharmaceuticals in the management of rheumatoid arthritis: the Medi-Cal program

Medicaid claims data were analyzed to investigate the prevalence and cost of rheumatoid arthritis (RA) in the Medi-Cal program. It was estimated that approximately 24,000 Medi-Cal recipients receive treatment for RA each year. The sample of Medi-Cal RAs studied averaged more than $2500 annually in total direct health care expenditures. The total cost of RA to Medi-Cal is projected to be $19.26 million (+/- $0.90 million) annually. Inclusion of possible gastrointestinal side effects of drug therapy increases the total cost to $20.49 million (+/- $0.91 million). While only 6.5% of the sample of RAs were hospitalized and 4.9% received nursing home care annually, these services are estimated to account for nearly 70% of RA-related expenditures. Less than 7% of Medi-Cal RAs receive disease modifying antirheumatic drugs (DMARDs). More than 75% of Medi-Cal RAs received aspirin or NSAIDs. These relieve pain and inflammation, but have not been demonstrated to halt the process of joint destruction.

The effect of aerobic exercise on serum creatine kinase activities

Aerobic exercise is now a common form of recreational exercise among young women. In a previous study, more than a third of a group of young mothers volunteering blood samples to establish a creatine kinase (CK) reference range for Duchenne muscular dystrophy (DMD) carrier detection regularly participated in aerobic exercise programs. Aerobic exercise programs include eccentric exercises. As eccentric exercise is known to produce a delayed CK peak, this study was carried out to determine the effect of aerobic exercise on serum CK activities. The postexercise serum CK activity peak was monitored in 15 young women (age range 20-23 years) following aerobic exercise classes (45 minutes on 3 consecutive days). Peak values at 24-48 hours following the last class ranged from 90 to 3473 U/liter, or 1.55 to 34.71 times resting values. It is concluded that aerobic exercise programs should be excluded in order to obtain accurate resting serum CK values for muscle disease diagnosis.

Analysis of deletions in DNA from patients with Becker and Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is an X-linked recessive genetic disorder for which the biochemical defect is as yet unknown. Recently, two cloned segments of human X-chromosome DNA have been described which detect structural alterations within or near the genetic locus responsible for the disorder. Both of these cloned segments were described as tightly linked to the locus and were capable of detecting deletions in the DNA of boys affected with DMD. In an attempt to determine more precisely the occurrence of these deletions within a large population of DMD patients and the accuracy of one of the segments, DXS164 (pERT87), in determining the inheritance of the DMD X chromosome, the subclones 1, 8 and 15 were made available to many investigators throughout the world. Here we describe the combined results of more than 20 research laboratories with respect to the occurrence of deletions at the DXS164 locus in DNA samples isolated from patients with DMD and Becker muscular dystrophy (BMD). The results indicate that the DXS164 locus apparently recombines with DMD 5% of the time, but is probably located between independent sites of mutation which yield DMD. The breakpoints of some deletions are delineated within the DXS164 locus, and it is evident that the deletions at the DMD locus are frequent and extremely large.

Coexistence of muscle anomalies and rheumatoid arthritis in patients with carpal tunnel syndrome

During a five-year period, surgical release of the carpal tunnel was performed on 150 patients with median nerve compression. Seventeen (11%) had rheumatoid arthritis. Among this subgroup, six patients had anomalous muscles in the wrist and proximal palm. An additional patient with psoriatic arthritis demonstrated a comparable abnormality. No other patients in this series had similar findings. This statistically highly significant occurrence is probably related to additive effects of the two disorders in producing median nerve compression.

Cogan's syndrome: acute vestibular and auditory dysfunction with interstitial keratitis

Two patients with Cogan's syndrome had acute bilateral hearing loss and vestibular dysfunction. Interstitial keratitis was discovered by slit-lamp examination. Both cases responded to corticosteroid treatment. Immediate recognition of this syndrome and the institution of high-dose corticosteroid therapy should lead to resolution of the hearing loss in patients with Cogan's syndrome.

Recurrent malignant melanoma presenting as monoarthritis

A 29-year-old woman had surgery for a level IV malignant melanoma of the right calf. After a disease-free interval of almost 4 years, she presented with right knee arthritis that proved to be due to recurrent melanoma in the femoral condyle. Metastatic carcinomatous arthropathy should be considered in the differential diagnosis of monoarthritis.

Early diagnosis of septic arthritis of the sacroiliac joint by use of computed tomography

Two cases of suspected septic arthritis of the sacroiliac joint with normal radiographs and nuclide scans were investigated by computed tomography. Bone and soft tissue abnormalities consistent with septic arthritis were found. Diagnosis was confirmed by needle aspiration of the sacroiliac joint. Computed tomography may be useful in the early diagnosis of the sacroiliac joint when plain radiographs and nuclide scans are normal.

Hereditary motor and sensory neuropathy of neuronal type with onset in early childhood

Eleven cases of a severe neuropathy with onset in early childhood are described. The condition commences with distal weakness and wasting of the lower limbs and subsequently involves the hands, causing severe paralysis of the hands and feet towards the end of the second decade. Sensory changes are common but are usually only mild. The peripheral nerves are not enlarged. Claw hand, scoliosis and other orthopaedic deformities are seen in the later stages. CSF protein is not elevated and there is only mild slowing of motor conduction velocities. The pathological changes in sural nerve biopsies are those of axonal degeneration affecting myelinated and unmyelinated fibres. Family studies suggested autosomal recessive inheritance in two kindreds and dominant inheritance in another. Five cases were sporadic. The condition is clinically more severe and of earlier onset than hereditary motor and sensory neuropathy (HMSN) type II and differs electrophysiologically and pathologically from Déjerine-Sottas disease.

The use of central auditory tests in a case of vasculitis

A central auditory test battery including dichotic digits, competing sentences, frequency patterns, and the staggered spondaic word test was administered to a patient diagnosed as having vasculitis. Test batteries were conducted before prednisone treatment and 2 months later. The central tests were not only helpful in indicating probable intracranial right hemisphere involvement, but seemed to be sensitive to the patient's improvement over this 2-month period. This case demonstrated a potentially valuable application of central auditory assessment.

Penicillamine-induced myositis in rheumatoid arthritis

A patient with rheumatoid arthritis who developed multiple mononeuropathies multiplex was shown to have vasculitis in nerve biopsy, but no evidence of inflammatory muscle disease in muscle biopsy. Treatment with penicillamine caused the rare complication of polymyositis, documented clinically, electrophysiologically, and by light and electron microscopy in a second muscle biopsy. The evidence presented supports the concept that penicillamine may induce polymyositis or aggravate a pre-existing low-grade myositis.

Non-giant cell temporal arteritis. Three cases and a review of the literature

We report two cases of polyarteritis and some of hypersensitivity angiitis diagnosed by temporal artery biopsy. Autopsies showed no evidence of giant cell arteritis. A review of the English literature provides seven further autopsy cases of necrotizing vasculitis diagnosed by temporal artery biopsy. The term temporal arteritis includes many types of vasculitis, giant cell arteritis being one of them.