Clinical manifestations and outcome of polyarthralgia associated with chronic lymphocytic thyroiditis

OBJECTIVES

Arthralgia is among the most frequent musculoskeletal symptoms occurring in patients with chronic lymphocytic thyroiditis (CLT), often causing pain and physical impairment over extended periods of time. Our study aims to characterize arthralgia and, in particular, polyarthralgia (PA) associated with CLT and to evaluate the influence of thyroid replacement therapy.

METHODS

Of 130 patients affected with CLT attending the Division of Rheumatology for rheumatic complaints, the authors sequentially selected 20 patients with PA without any known rheumatic diseases. Of these 20 patients, 8 were euthyroid, 2 hyperthyroid, and 10 hypothyroid. The last group had never undergone therapy for thyroid disease; then, they were treated with thyroxine and followed up for 24 months. Clinical assessment included the number of joints affected by pain (NAJ), the visual analogic scale of pain (VAS), the duration of PA (number of days), and the intake of acetaminophen.

RESULTS

At baseline, the only correlations in the 20 patients with PA were between NAJ and antithyroid microsomal antibodies (r =.782; P <.001), thyroid stimulation hormone (r =.651; P =.001), and erythrocyte sedimentation rate (r =.511; P = 0.021), respectively. During follow-up, although symptoms improved in the 10 hypothyroid patients treated with thyroxine, a statistical significance was reached only after 12 months.

CONCLUSIONS

Patients with CLT may be affected with PA severely, even in absence of hypothyroidism. Replacement therapy with thyroxine in hypothyroid patients with CLT induced a progressive but gradual improvement of symptoms.

In vivo evaluation of intravascular stents at three-dimensional MR angiography

The aim of this study was to assess in vivo patency of seven commonly used non-ferromagnetic plain stents as regards demonstration of the contained lumen at 3D gadolinium-enhanced MRA in a 0.5-T MR environment. Twenty-one patients with 22 stents (1 aortic, 18 iliac, 3 popliteal) were imaged with MRA. Stent-related artefacts were evaluated. Images were assessed for the presence and size of stent artefacts, luminal patency, and were correlated with stent metal mass, composition, configuration and angulation with respect to the magnetic field. Four different types of stent (Symphony, Wallstent, Memotherm, SMART) showed major artefacts preventing assessment of intradevice luminal patency or restenosis, in two stents (ZAV stent, Intracoil) minor artefacts allowed assessment of high-degree stenosis, and only one type of stent (Strecker) was perfectly imaged. Based on our limited experience, Gd-MRA appears well suited for the evaluation of only a minority of MR-compatible stents.

Intravenous immunoglobulins control scleromyxoedema

BACKGROUND

Scleromyxoedema is a variant of papular mucinosis affecting the skin and internal organs. The different therapeutic approaches proposed for scleromyxoedema are still unsatisfactory. Intravenous immunoglobulin (IVIg) has been successfully employed in the treatment of connective tissue diseases and vasculitides.

PATIENTS

The successful treatment of three cases of scleromyxoedema with IVIg is reported here.

CONCLUSIONS

The relatively low risk of the drug and the high effectiveness seen in three patients suggest that IVIg is a new treatment potentially useful in scleromyxoedema.

Effect of sludge-amendment or nutrient addition on the biodegradation of the herbicide isoproturon in soil

Adding sludge to agricultural soil results in added organic matter, nutrients and metallic and/or organic pollutants. These components may modify the behaviour of pesticides in the soil. We monitored possible changes in the degradation of the herbicide isoproturon (production of CO2 and degradation products) in soil amended with sludge, heavy metals or nitrogen and phosphorus. The treated and control soils were incubated under controlled conditions for 60 days. The nitrogen and phosphorus had the greatest effect on isoproturon degradation, independent of the presence of pollutants. Mineralisation of the herbicide to CO2 was slow and seemed to be linked to a fast degradation and to the accumulation of a complex degradation product that was neither catabolized nor adsorbed, 4,4'-diisopropylazobenzene. This degradation pathway also produced smaller amounts of non-extractable residues. Sewage sludge had no significant effect on isoproturon degradation, despite a large increase of organic matter mineralisation (factor 2).

Pegylated enzyme entrapped in poly(vinyl alcohol) hydrogel for biocatalytic application

A procedure for enzyme entrapment into matrices suitable for biocatalytic applications is reported. The method, which takes advantage of the stable formation of polyvinyl alcohol (PVA) hydrogels by freezing and thawing PVA aqueous solutions, was assayed using lipase as model enzyme. The leakage of lipase was minimised by using high molecular weight PVA and by previous conjugation of the enzyme to PEG. The immobilised PEG enzyme maintained its catalytic activity in organic solvents also, thus allowing enzymatic activity towards water insoluble substrates. The activity was largely increased reducing the diffusional constrain by cutting the matrices into slices of micron size. Matrix-entrapped lipase-PEG, when used in the hydrolysis of acetoxycoumarins, showed a conversion rate of about 10 times lower than the enzyme-PEG in the free form, and maintained regioselectivity when a diacetylated product was used as substrate.

Charcot-Marie-Tooth disease type I and related demyelinating neuropathies: Mutation analysis in a large cohort of Italian families

Charcot-Marie-Tooth neuropathy type 1 (CMT1), the most common hereditary neurological disorder in humans, is characterized by clinical and genetic heterogeneity. It is caused mainly by a 1.5 Mb duplication in 17p11.2, but also by mutations in the myelin genes PMP22 (peripheral myelin protein 22), MPZ (myelin protein zero), Cx32 (connexin 32; also called GJB1), and EGR2 (early growth response 2). In this study, we have screened 172 index cases of Italian families in which there was at least one subject with a CMT1 diagnosis for the duplication on 17p11.2 and mutations in these genes. Among 170 informative unrelated patients, the overall duplication frequency was 57.6%. A difference could be observed between the duplication frequency in familial cases (71.6%) and that observed in non-familial cases (36.8%). Among the non-duplicated patients, 12 were mutated in Cx32, four in MPZ, two in PMP22, and none in the EGR2. In the non-duplicated cases, the overall point mutation frequency for these genes was 25.0%. We describe the mutations identified, and consider possible genotype-phenotype correlation.

Hereditary spastic paraplegia associated with peripheral neuropathy: a distinct clinical and genetic entity

Hereditary motor and sensory neuropathy type V is a very rare disease in which hereditary spastic paraplegia is associated with peripheral motor and sensory neuropathy. The symptomatic onset of the disorder is usually in the second decade of life or later and the course is progressive over many years. Hereditary motor and sensory neuropathy type V is inherited as an autosomal dominant trait usually showing incomplete penetrance. So far, no molecular data are available in the literature about this disease. In our study we present clinical and molecular data from a large Italian family displaying hereditary motor and sensory neuropathy type V. Taking into account the clinical features in this family, we have performed a linkage analysis for markers strictly associated with all the known loci for autosomal dominant and autosomal recessive forms of hereditary spastic paraplegia and hereditary motor and sensory neuropathy type II, and have found no linkage to these loci. Our study suggests that hereditary motor and sensory neuropathy type V is not only a distinct clinical entity but also a distinct genetic entity.

Failing hemodialysis arteriovenous fistula and percutaneous treatment: imaging with CT, MRI and digital subtraction angiography

PURPOSE

To evaluate failing hemodialysis arteriovenous fistulas with helical CT angiography (CTA), MR angiography (MRA), and digital subtraction angiography (DSA), and to compare the efficacy of the three techniques in detecting the number, location, grade, and extent of stenoses and in assessing the technical results of percutaneous transluminal angioplasty (PTA) and stenting.

METHODS

Thirteen patients with Brescia-Cimino arteriovenous fistula malfunction underwent MRA and CTA of the fistula and, within 1 week, DSA. A total of 11 PTAs were performed; in three cases an MR-compatible stent was placed. DSA served as the gold standard for comparison in all patients. The presence, site, and number of stenoses or occlusions and the technical results of percutaneous procedures were assessed with DSA, CTA, and MRA.

RESULTS

MRA underestimated a single stenosis in one patient; CTA and MRA did not overestimate any stenosis. Significant artifacts related to stent geometry and/or underlying metal were seen in MRA sequences in two cases.

CONCLUSIONS

CT and MRI can provide information regarding the degree of vascular impairment, helping to stratify patients into those who can have PTA (single or multiple stenoses) versus those who require an operative procedure (occlusion). Conventional angiography can be reserved for candidates for percutaneous intervention.

[Anatomo-radiologic correlations in spontaneous hematoma of the rectus abdominis muscles]

PURPOSE

Rectus sheath hematomas are a frequent but sometimes misdiagnosed disease in patients under anti-coagulative drugs, hemodialysis, or simply in the elderly. The most frequent localization is in the lower part of the abdomen: the explanation lies in the anatomy of the abdominal wall, especially in the arcuate line of the rectus sheath. Aim of this work is to explain the reason of the almost constant location correlating the anatomy with the CT features.

ANATOMIC CONSIDERATIONS

The rectus abdominis muscle lies between the aponeuroses of the transverse and oblique muscles which form the so called rectus sheath. This arrangement is found from the costal arch to a level approximately between the umbilicus and the pubic symphisis, where the rear layer of the rectus sheath ends with a curved edge, called the arcuate or semicircular line of Douglas. Beneath this line the aponeuroses of the three muscles pass in front of the rectus which is separated from the peritoneum only by the fascia trasversalis, a thin connective layer between the rectus and the preperitoneal fat. In this lower aspect of the muscle the perforating branches of the inferior epigastric artery running in the preperitoneal fat may rupture causing a large hematoma widely spreading in this loose space.

MATERIAL AND METHODS

11 cases of rectus sheath hematoma diagnosed over 5 years were reviewed. They were referred to US because of a rapidly growing palpable mass or painful swelling of the abdominal wall with acute anemia. Sonography was performed in 11 patients and CT in 7.

RESULTS

10 hematomas were located in the lower third of the rectus muscle below the arcuate line in the pelvis, 1 was in the upper third of the muscle: the vast majority of pelvic hematomas is easily accounted for by the peculiar anatomy of the region.

DISCUSSION

The diagnosis of hematoma of the rectus abdominis, sometimes misleading, should be included as a differential in all the patients who present with acute abdominal pain and blood loss. The anatomy of abdominal wall correlates well with CT findings and explains the reason why most hematomas are found in the lower third of the muscle.

CONCLUSIONS

The diagnosis, whether clinical or based on imaging findings, needs accurate pathoanatomic knowledge of the anterior abdominal wall. Once the diagnosis has been confirmed (by US or CT) patients should be treated conservatively as those that are operated are at risk of developing complications, mainly hemorrhagic.

Morphologic study of microcirculation in acromegaly by capillaroscopy

Although wide range investigations on the heart and great vessels have been reported in acromegaly, the field of microcirculation is still largely vacant. The nailfold is a window through which we can observe in vivo the vascular bed. This study investigates through nailfold capillaroscopy the morphology of cutaneous microcirculation in acromegaly in relationship with the usual hormonal parameters of disease activity. Twenty-five acromegalic patients and 26 normal subjects, age and sex matched, were studied. A subgroup of acromegalics (8 patients) was considered in stable remission, and the remaining 17 had active disease. Capillaroscopy was performed in each subject by in vivo computer aided stereomicroscopy (magnification, x400). The following morphological parameters were calculated: the number of tortuous loops, meandering capillaries, and capillaries per millimeter; avascular areas; visibility of subpapillary plexus; the capillary length; and intercapillary distance. We were unable to perform the exam in 4 of 25 patients because visibility was poor. The capillary number and length were significantly reduced in acromegalics compared to controls [8.9 +/- 1.5 vs. 10.3 +/- 1.2 no./mm (P = 0.0010) and 174 +/- 49 vs. 255 +/- 24 microm (P < 0.0001)]. Moreover, in acromegalics, the numbers of tortuous loops and meandering capillaries were significantly increased [19 +/- 8 vs. 13 +/- 5 (P = 0.0027) and 10 +/- 12 vs. 0.7 +/- 1.1 (P < 0.0001)]. The capillaroscopic alterations were still observed in a smaller group of 8 nondiabetic and nonhypertensive acromegalics. We found branch-like capillaries in 4 acromegalic patients, but not in the control group. Finally, we observed a meaningful different and ameliorated capillaroscopic morphology in acromegalic patients in stable remission compared to active disease patients as far as the total number (density) and meandering capillaries were concerned. In conclusion, our study shows that in acromegaly, morphological alterations also affect the peripheral microcirculation, which seems to be influenced by the activity of the disease. We believe that nailfold capillaroscopy may represent an additional useful tool in the follow-up of acromegalic patients.

Clinical and laboratory manifestations of elderly onset psoriatic arthritis: a comparison with younger onset disease

OBJECTIVE

Although the influence of age on clinical and laboratory features has been widely demonstrated in many arthropathies, studies on elderly onset (> 60 years) psoriatic arthritis (EOPsA) are rare. This study compares manifestations at onset and two year outcome of EOPsA with those of younger onset PsA (YOPsA).

PATIENTS AND METHODS

Sixty-six consecutive PsA patients with disease duration < 1 year, 16 EOPsA (> 60 years) and 50 YOPsA (< or = 60 years) were admitted to a prospective study. Clinical, laboratory, and radiographic assessment were carried out at admission and after two years. HLA class I and bone scintigraphy were also recorded. In 10 patients with EOPsA and 24 with YOPsA it was possible to obtain synovial fluid, which was subsequently analysed for local inflammatory indices, including interleukin (IL) 1 beta, IL6, and IL8.

RESULTS

Presenting manifestations of EOPsA differed from YOPsA in number of active joints (mean (SD)) (12.2 (6.3) v 6.7 (4.6), p < 0.001), foot bone erosions (2.7 (1.2) v 1.1 (1.1), p < 0.001), erythrocyte sedimentation rate (64.2 (35.3) v 30.5 (30.0) mm 1st h, p < 0.001), C reactive protein (3.9 (2.0) v 1.3 (1.3) mg/dl, p < 0.001) and synovial fluid IL1 beta (8.0 (4.7) v 3.0 (3.0) pg/ml, p < 0.001) and IL6 (828.2 (492.6) v 469.3 (201.4) pg/ml, p < 0.005). No differences were found in the number of subjects with dactylitis, pitting oedema, HLA-B27, or signs of sacroiliac and sternoclavicular joint involvement at bone scintigraphy. After two years, progression was more evident in EOPsA than in YOPsA, as the number of new erosions in the hands and also the C reactive protein were higher in EOPsA patients.

CONCLUSION

PsA has a more severe onset and a more destructive outcome in elderly people (onset > 60 years) than in younger subjects. This behaviour may be influenced by immune changes associated with aging, as suggested by the higher concentrations of IL1 beta and IL6 found in the synovial fluid of EOPsA than in YOPsA.

Chondrocalcinosis is a feature of Gitelman's variant of Bartter's syndrome. A new look at the hypomagnesemia associated with calcium pyrophosphate dihydrate crystal deposition disease

The occurrence of chondrocalcinosis in patients with Bartter's syndrome has been reported as a typical example of hypomagnesemia-associated calcium pyrophosphate dihydrate crystal (CPPD) deposition disease. However, hypomagnesemia is a feature of Gitelman's variant of Bartter's syndrome, whereas serum magnesium levels are normal in Bartter's syndrome strictly speaking. We managed four patients with chondrocalcinosis and hypomagnesemia who met criteria for Gitelman's disease, including hypomagnesemia, hypokalemia with normal or high urinary potassium excretion, hypocalciuria, and normal blood pressure. Based on our experience with these patients, we argue that many cases of chondrocalcinosis and hypomagnesemia ascribed in previously published articles to Bartter's syndrome were due to Gitelman's syndrome.

[Diagnostic problems in reading chest radiographies of elderly patients at admission. Personal experience]

PURPOSE

More chest radiographs are presently performed in the elderly, especially the hospitalized ones. Reading these images is difficult because of the involutions in the thoracic cage, heart and lungs and the scars or calcifications from different abnormal causes. In the elderly, bronchogenic carcinoma may present as an occasional "coin" lesion and therefore such a finding may be an important diagnostic problem and require some expensive and dangerous examinations next. We investigated the relative frequency of questionable abnormal findings in the daily reading of the chest radiographs of elderly patients, the relative importance of the radiologist's experience and of the examination execution technique; the relative costs were also evaluated.

MATERIAL AND METHODS

Four radiologists, two of them more experienced (FS, PT), read the consecutive chest radiographs of 811 elderly patients (273 men, 538 women) hospitalized May to December, 1997. Four hundred and ten of them were 65-75 years old and 401 over 75 (particularly, 28 were over 90). Five hundred and sixty-five chest radiographs were made with the AMBER technique and 246 with frontal views only. T-MAT G RA Kodak high-contrast films with Kodak Lanex green-transmitting intensifying screens were used in all cases. CT scans were made with conventional (CT Sytec 3000, GE) or spiral (X Vision, Toshiba) scanners.

RESULTS

Seven hundred and fifty-seven radiographs were considered adequate (93%) and 54 inadequate (7%) for diagnosis (25 in patients 65-75 years old, 25 in patients 75-80 and 4 in patients over 90). Thirty-eight of these 54 inadequate radiographs had been made with the AMBER technique and 16 with frontal views only. The more experienced radiologists read 27 (11%) and 19 (10%) of them and the less experienced ones read 4 (2%) and 4 (3%), respectively. The next examinations were other projections and/or radioscopy (4 cases), conventional tomography (7 cases), CT (43 cases), and US (2 cases). "Coin" lesions were the major cause of questionable diagnosis, especially in posterior (10 cases) and peripheral (7 cases) regions, where the differential diagnosis was with vertebral osteophytosis and small rib crowding, respectively.

CONCLUSIONS

More skilled radiologists have more doubts reading the chest radiographs of elderly patients. But the next examinations will likely balance the needless ones after an initial misdiagnosis. The chest of elderly patients remains a complex and very little known subject and the reader's experience plays an important role. The examination execution technique must be as accurate as possible in both optimal and suboptimal settings.

Successful treatment of gangrene in systemic necrotizing vasculitis with iloprost

Systemic necrotizing vasculitis is uncommon in children and may be rarely associated with gangrene. We describe a 3-yr-old girl with parvovirus B19-induced necrotizing vasculitis whose digital gangrene was successfully treated with iloprost, a prostacyclin analogue.

[The radiological exam of the chest in the elderly. Technical and methodological considerations]

PURPOSE

We investigated the capabilities of chest radiography in the elderly considering that the examination must meet the main clinical indications of this population and that it is necessary in the elderly because the correct clinical assessment is often difficult or impossible.

MATERIALS AND METHODS

We reviewed the chest radiographs of 756 consecutive elderly patients admitted to our hospital from September 1 to October 31, 1996. If possible, chest radiographs were performed with the AMBER technique (156 patients, 20.7%); 240 patients (31.7%) underwent conventional radiography and the others frontal projections only (360 patients, 47.6%). T-MAT G RA Kodak high contrast films with Kodak Lanex green transmitting intensifying screens were used in all cases. The AMBER examinations of 48/156 patients with hemodynamic clinical indications were repeated with conventional frontal projections. Radiographic reports were made separately by different radiologists who considered especially the diagnostic accuracy of every examination in determining the venous overload of pulmonary circulation.

RESULTS

Hemodynamic studies are the most frequent clinical indication of chest radiography in elderly patients (228/756 patients in our series, 30.2%); moreover, even if careful cardiac and pulmonary circulation studies are very important in these patients, only 52.4% of all radiographs could be made in two orthogonal projections. The blurred appearance of vascular landmarks indicating increased extravascular fluid is better depicted by conventional radiography (59.7% of cases) than by AMBER (40.3%).

CONCLUSIONS

We conclude that the reduced pulmonary contrast obtained with the so-called "hard X-ray" technique poorly depicts the blurred appearance of pulmonary vessels in pulmonary venous overload. Moreover, "hard X-ray" techniques can be only sporadically used because elderly patients are often in very critical conditions, which prevents this type of examination.