Association between gold induced skin rash and remission in patients with rheumatoid arthritis

The coincidence of skin eruption and remission induced by gold has not previously been reported. In 50 out of 247 patients with rheumatoid arthritis treated with gold salts (Solganal) between 1977 and 1987 treatment was stopped owing to adverse reactions. Skin rashes were present in 31 patients, 10 had nephropathy, and nine patients had aphthous stomatitis. All 31 patients who developed skin eruption entered a concomitant clinical and laboratory remission. The remission satisfied the American Rheumatism Association preliminary criteria and was accompanied by a significant decrease of mean erythrocyte sedimentation rate from 43 (SD 13) to 25 (11) mm/h. Disease was exacerbated in 23 patients after three to 60 months. Eight patients are in remission at present, five to 68 months after gold treatment was discontinued. In contrast, no remission was noticed among the 19 patients with nephropathy or stomatitis.

Short term effects of low dose methotrexate on the acute phase reaction in patients with rheumatoid arthritis

Sequential daily measurements of erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) were performed for one week after an I.V. injection of 7.5-13 mg methotrexate (MTX) in 18 patients with rheumatoid arthritis. Early decreases of ESR and CRP were observed. Serum CRP was more sensitive than ESR, displaying more pronounced falls from baseline to both the minimal and to the 7th day levels. Patients receiving their first dose of MTX (n = 9) exhibited a more prominent reduction of CRP levels in comparison to veteran MTX users (n = 9). The prompt response of acute phase reactants to MTX may correspond to the relatively rapid clinical effect of the drug in RA. It may also support an antiinflammatory mechanism of action of low dose MTX.

Fatal aplastic anaemia and liver toxicity caused by D-penicillamine treatment of rheumatoid arthritis

A 65 year old woman with rheumatoid arthritis developed marrow aplasia and jaundice owing to D-penicillamine treatment. Recovery of bone marrow was ineffective, and the patient finally died despite intensive therapeutic measures. The rare coexistence of myelotoxicity and hepatotoxicity is presented and discussed.

Abdominal fat tissue aspirate in amyloidosis of familial Mediterranean fever

Abdominal fat tissue aspirates from 20 patients with biopsy-proved amyloidosis were investigated by polarized microscopy after staining with Congo-red. Positive results were obtained in 4 of 5 patients with primary amyloidosis (AL) and in none of 15 with amyloidosis (AA) of Familial Mediterranean Fever (FMF). We suggest that although this technique is simple, safe and effective in other forms of amyloidosis, it cannot be used as a diagnostic tool in FMF patients suffering from amyloidosis.

Accelerated nodulosis and vasculitis during methotrexate therapy for rheumatoid arthritis

Three women with classic rheumatoid arthritis, who were receiving weekly doses of methotrexate (MTX), developed accelerated subcutaneous nodulosis, despite good response to the drug. In 2 of the patients, the onset of nodulosis occurred within 3 months and 5 months, respectively, after starting MTX; in the third patient, it was observed only after 4 years of MTX therapy. In all 3 patients, the onset was unusually abrupt, with extensive distribution and remarkable nodule size. Additional manifestations of cutaneous vasculitis in 2 of the patients and Raynaud's phenomenon in the third appeared concomitantly with the nodulosis. Physicians prescribing MTX therapy for patients with rheumatoid arthritis should be aware of these potential complications.

Methotrexate in rheumatoid arthritis: a prospective study in Israeli patients with immunogenetic correlations

In a prospective open study 44 Israeli patients with rheumatoid arthritis were treated with weekly low dose methotrexate (MTX) for up to 36 months. Nine patients withdrew from the study: six because of side effects and three due to inefficacy. One patient died of septicaemia following septic arthritis. Significant improvement, graded by Ritchie articular index, grip strength, physician's global assessment, erythrocyte sedimentation rate (ESR), and platelet counts, was noticed in response to treatment. Seronegative patients had a better clinical response. Transient gastrointestinal symptoms were common and correlated with increases of serum aspartate transaminase (AST). HLA-DR1 and DR7 were significantly associated with increased serum AST concentrations.

The effects of leucovorin (folinic acid) on methotrexate therapy in rheumatoid arthritis patients

High-dose leucovorin (folinic acid) supplementation was tested in a prospective, unblinded manner for 4 weeks in 7 rheumatoid arthritis patients who were being treated successfully with low-dose methotrexate (MTX). Nausea caused by MTX disappeared; however, the underlying rheumatic disease worsened in all patients. Subjective clinical assessment, Ritchie articular index, grip strength, erythrocyte sedimentation rate, and levels of C-reactive protein showed statistically significant deterioration. All these parameters improved after the leucovorin was stopped. This is the first direct clinical evidence implying folate antagonism in the action of low-dose MTX therapy in rheumatoid arthritis patients.

Association of HLA-B35 with mucocutaneous lesions in Israeli patients with rheumatoid arthritis receiving gold treatment

Seventy-four Israeli patients with rheumatoid arthritis (RA) were studied for possible association between HLA antigens and adverse reactions to gold treatment (aurothioglucose). HLA-B35 was significantly increased in patients who developed gold induced mucocutaneous lesions. These results are in accord with earlier reports, despite the different genetic background of the Israeli RA population and the different type of gold compound used.

Analysis of the antigen specific helper T cell function and HLA-DR of Israeli patients with rheumatoid arthritis (RA)

Forty-three patients with rheumatoid arthritis (RA) were studied for their ability to respond to the synthetic polypeptide antigen (T, G)-A-L as measured by the production of a T cell helper factor by their antigen activated T cells. Sixteen patients (37%) responded to (T, G)-A-L by the production of an antigen specific helper T cell factor, a percentage not significantly different from healthy donors. The production of antigen specific T cell helper factors was affected, although not significantly, by immune modulating drugs and by the presence of rheumatoid factor in sera of patients. The high incidence of HLA-DR 4 reported for RA patients was not observed in this group of RA patients.

Classical rheumatoid arthritis associated with nondeforming relapsing polychondritis

Two patients with classical rheumatoid arthritis and a mild nondeforming relapsing polychondritis are presented. DR4 antigen and depressed C4 levels were found and possible autoimmune mechanisms are discussed. The need for specific questioning to detect this rare association is proposed.

Large-cell lymphoma presenting as acute cholecystitis

A 62-year-old woman presenting with a clinical picture of acute cholecystitis was found to have lymphoma upon pathological examination of the gallbladder. Such a presentation of large-cell non-Hodgkin's lymphoma is unique and has not been described before.

Purpura fulminans in an adult

Purpura fulminans is a rare disease of childhood, manifested by massive hemorrhage into the skin, widespread thrombosis of venules and arterioles and a hematologic picture of disseminated intravascular coagulation. An unusual case in a 68-year-old man is presented and the mode of therapy discussed.

Bronchoalveolar lavage--a sensitive tool for early diagnosis of pulmonary involvement in rheumatoid arthritis

Bronchoalveolar lavage (BAL) was performed to assess the nature of pulmonary involvement in 12 asymptomatic nonsmoking patients with rheumatoid arthritis (RA). All 12 patients had normal lung function tests, including diffuse capacity for carbon monoxide and normal blood gases. Four patients (33%) had mild basilar interstitial changes on chest radiographs. In these 4 patients an elevated lymphocytic count in BAL fluid (30.7 +/- 8.3%) was found, as compared to the 8 patients with normal chest roentgenograms (7.2 +/- 1.9%; p less than 0.001). We suggest that BAL may be used as a sensitive tool for early diagnosis of pulmonary involvement in patients with RA.

Nifedipine-induced hypokalemia

Nifedipine, a calcium-channel blocking agent, has been reported to cause many side effects, particularly in the cardiovascular system. A case of nifedipine-induced hypokalemia is presented, with a discussion on the presumable mechanism involved in this phenomenon.

Solitary pulmonary metastasis of choroidal malignant melanoma simulating primary lung cancer

A case is presented of a late solitary pulmonary metastasis from a choroidal melanoma, simulating primary bronchogenic carcinoma. The pattern of metastatic choroidal melanoma and the mode of therapy are discussed.

Systemic lupus erythematosus presenting as catatonic schizophrenia

A patient fulfilling the diagnostic criteria for systemic lupus erythematosus and presenting with catatonic schizophrenia is described. Psychiatric features of the disease and their management are discussed.

C-reactive protein levels in patients with rheumatoid arthritis: the impact of therapy

C-reactive protein levels were measured in sera of 111 patients with rheumatoid arthritis and were compared with erythrocyte sedimentation rate. The patients were divided into six groups according to drug therapy. Comparison between the groups suggests that CRP correlates best with ESR in patients treated with penicillamine and in patients in clinical remission. Patients treated with gold, NSAID or methotrexate have a weaker correlation between the two parameters, while steroid therapy yields the poorest correlation which is not statistically significant. Our data suggest that although CRP is a sensitive index of disease activity, the specific drug taken by the patient must be considered before interpreting the results.

Cimetidine-induced eosinophilia

Many adverse reactions have been reported in the literature as a result of cimetidine use. Generally they have involved the gastrointestinal and central nervous systems. We present a case of cimetidine-induced eosinophilia, and discuss the possible mechanisms of hematologic toxicity.

Pulmonary changes in angioimmunoblastic lymphadenopathy as demonstrated by computerized tomography

A case of angioimmunoblastic lymphadenopathy with pulmonary involvement is presented. The radiographic and computerized tomographic findings included multiple opacities, predominantly basal, of variable size. Associated pleural opacification was verified on both the chest roentgenogram and the computerized tomographic (CT) examination. The entity may mimic many more common clinical disease states and final diagnosis can only be established histologically.