Possible association between eosinophilic fasciitis and subcutaneous heparin use

The association between the onset of eosinophilic fasciitis and exposure to a drug or a toxin has occasionally been reported. We describe 3 patients who developed eosinophilic fasciitis a few months after they received subcutaneous calcium heparin. In 2 patients, clinical manifestations and eosinophilia improved after interruption of the therapy. Although spontaneous occurrence of eosinophilic fasciitis cannot be excluded in our patients, the temporal relationship with the beginning of subcutaneous heparin therapy raises the possibility that the syndrome might be precipitated by the drug.

Therapy with cyclosporine in psoriatic arthritis

OBJECTIVE

To evaluate the efficacy and toxicity of cyclosporin A (CsA) in the treatment of patients with psoriatic arthritis (PsA).

METHODS

We reviewed the literature dealing with CsA treatment of PsA.

RESULTS

In the 1980s, some studies evaluating CsA in severe cases of psoriasis documented an improvement in the associated arthritis. Subsequently, open prospective studies included patients with active peripheral arthritis. Using initial CsA dose of 3 to 6 mg/kg/day, improvement in the clinical parameters was noted. A controlled trial showed that CsA and methotrexate (MTX) are equally effective treatment for PsA. CsA and MTX combination was effective in PsA patients resistant to previous second-line therapy. No studies have evaluated the efficacy of CsA on axial disease and on the progression of radiological damage. The most important side effect was nephrotoxicity. However, of 170 CsA-treated patients in 16 studies, only 10 (6%) discontinued the drug because of renal side effects.

CONCLUSIONS

CsA seems to be an effective and safe therapy for PsA. However, controlled studies on large number of patients are necessary.

Proximal bursitis in active polymyalgia rheumatica

BACKGROUND

The cause of musculoskeletal symptoms in the proximal extremities of patients who have polymyalgia rheumatica is not completely understood. The diffuse and severe discomfort can only be partially explained by the mild joint synovitis that is observed in these patients.

OBJECTIVE

To determine the involvement of the synovial structures of the shoulder girdle of patients who have active symptoms of polymyalgia rheumatica.

DESIGN

Case-control study.

SETTING

2 secondary referral centers of rheumatology.

PATIENTS

13 case-patients who had active symptoms of polymyalgia rheumatica seen during a 6-month period, 9 control-patients who had early symptoms of elderly-onset rheumatoid arthritis, and 10 age-matched healthy controls.

MEASUREMENTS

Magnetic resonance imaging of the shoulder was done on the 13 case-patients, 9 control-patients, and 10 healthy controls.

RESULTS

The frequency of subacromial and subdeltoid bursitis was significantly higher in the case-patients (who had polymyalgia rheumatica) than in the control-patients (who had elderly-onset rheumatoid arthritis). The frequencies of synovitis of the joints and tenosynovitis of the biceps did not significantly differ between the 13 case-patients and the 9 control-patients. None of the healthy controls showed evidence of fluid accumulation in the joints, bursae, or sheaths of the long head of the biceps.

CONCLUSIONS

Inflammation of subacromial and subdeltoid bursae in association with synovitis of the glenohumeral joints and tenosynovitis of the biceps may contribute to the diffuse discomfort in the shoulder girdle observed in patients with polymyalgia rheumatica.

Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis

OBJECTIVE

To identify isolated peripheral enthesitis and/or dactylitis as a subset of psoriatic arthritis (PsA) and to define the clinical characteristics of these patients.

METHODS

We examined 401 unselected patients with PsA seen in 3 Italian rheumatological centers over a 6 month period. The diagnosis of PsA was based upon the clinical experience of a rheumatologist. The clinical features of patients with PsA were assessed by clinical examination and review of the patients' charts, evaluating the presence of peripheral arthritis, spinal involvement, dactylitis, and enthesitis. A series of 483 rheumatological patients without psoriasis and spondyloarthropathy (European Spondylarthropathy Study Group criteria) seen consecutively in a one month period constituted the control group.

RESULTS

14 patients (3.5%) presented isolated episodes of peripheral enthesitis and/or dactylitis. No patient developed peripheral arthritis and/or axial involvement during the followup period (median 30 mo; range 3-72 mo). 10/14 patients (71%) presented at least one episode of finger and/or toe dactylitis. 5 of these 10 patients (50%) had additional episodes of peripheral enthesitis (Achilles tendinitis, plantar fasciitis, and posterior tibial tendinitis). Episodes of Achilles tendinitis and/or plantar fasciitis were present in 8/14 patients (57%). 3 of these 8 patients (37%) had associated peripheral enthesitis in other sites as well: lateral epicondyle, insertion of the patella tendon into the inferior pole of the patella, femoral quadriceps, and posterior tibial tendons. An additional case had posterior tibial tendinitis and 2 episodes of toe dactylitis. None of these 14 cases presented radiological evidence of sacroiliitis and only one of the 13 typed was HLA-B27 positive. 12 patients (2.4%) of the control group had episodes of peripheral enthesitis (11 plantar fasciitis and one Achilles tendinitis). No patient had episodes of dactylitis. The frequency of isolated Achilles tendinitis and/or dactylitis was significantly higher in patients with PsA compared to controls (3.5 vs 0.2%; p = 0.001).

CONCLUSION

In some patients PsA can occur only with peripheral enthesitis, particularly Achilles tendinitis, and/or dactylitis. These patients may represent a subset of PsA, not defined by Moll and Wright and spondyloarthritis classification criteria, and poorly recognized in the studies on PsA.

Use of ICRF-187 for prevention of anthracycline cardiotoxicity in children: preliminary results

The objective of this study is to assess the efficacy of ICRF-187 as a protective agent against anthracycline cardiotoxicity. Cardiac function was evaluated by echocardiography before and after each cycle of anthracycline chemotherapy associated with ICRF-187 and compared with that of a second group receiving anthracycline chemotherapy without ICRF-187. The patients were a group of 15 consecutive children affected with various types of solid tumors who were treated with either doxorubicin-daunomycin or epirubicin (average doses 340 and 280 mg/m2, respectively), and treatment was associated with ICRF-187. A second group of 15 consecutive children affected with different malignancies were simultaneously treated with either doxorubicin-daunomycin or epirubicin (average doses 309 and 270 mg/m2, respectively), but without ICRF-187 association. None of the patients treated with anthracyclines and ICRF-187 association showed abnormalities on echocardiographic examination. In the second group of patients treated with anthracyclines but without ICRF-187 association, we observed a decrease in the left ventricular ejection fraction to < 55% and a decrease in the left ventricular fractional shortening to < 28% in two patients (13.3%). One of these (6.6%) showed a dilatative cardiomyopathy. Both groups of patients were treated with low doses of anthracyclines. Although this study was not randomized, in patients without ICRF-87 cardioprotection, there was a trend for a worse evolution with one case of clinical cardiomyopathy as well as subclinical cardiac abnormalities.

Toe dactylitis in patients with spondyloarthropathy: assessment by magnetic resonance imaging

OBJECTIVE

To investigate using magnetic resonance imaging (MRI) the part played by flexor and extensor tenosynovitis and synovitis of the metatarsophalangeal (MTP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints in producing the "sausage-like" aspect of spondyloarthropathy (SpA) toe dactylitis.

METHODS

Twelve sausage-like toes and corresponding contralateral toes of 7 consecutive patients meeting Amor criteria for SpA were studied by MRI.

RESULTS

All dactylitic toes showed fluid collections in the flexor synovial sheaths on MRI. Due to the sheath distension the plantar bone to skin distance was significantly increased (p < 0.05) in the dactylitic toes compared to normal contralateral toes. Peritendinous soft tissues were not involved since these were significantly thicker (p < 0.05) in normal toes. Extensor synovial sheaths were involved in only 4 dactylitic toes. Of the 36 joints of the 12 dactylitic toes only 2 MTP joints showed capsule distension. Considering MRI as the "gold standard", examination showed 100% sensitivity and specificity for flexor sheath involvement but lacked sensitivity for extensor synovial sheaths and showed a low specificity for joint capsule distension.

CONCLUSION

Like finger dactylitis, toe dactylitis may also be due to flexor tenosynovitis and synovitis of MTP, PIP, and DIP joints may not be a required condition for sausage-shaped appearance. Extensor tenosynovitis may be present in addition to flexor tenosynovitis. Physical examination is a sufficient method for diagnosing toe dactylitis.

Iliolumbar ligament ossification in undifferentiated seronegative spondyloarthropathy

The case of a man suffering from undifferentiated seronegative spondyloarthropathy (uSpA) without spine involvement and with iliolumbar ligament ossification is reported. Unlike a similar previously published case showing ossification only of the middle part of the left ligament, our patient had ossification of the whole course of both ligaments.

Ultrasound in the management of hepatic veno-occlusive disease in three children treated with dactinomycin and vincristine

Three children, treated with dactinomycin and vincristine without radiotherapy showed hepatic toxicity consistent with diagnostic criteria for hepatic veno-occlusive disease (VOD). Two patients were affected with Wilms' tumor and the third with malignant fibromatosis. The clinical manifestations of VOD were mild and regressed in all patients after supportive therapy. Serial ultrasonography (US) was performed in all cases and was useful in confirming the diagnosis and in evaluating the severity of the disease. US features of VOD were hepatomegaly, gallbladder wall thickening, ill-defined borders of the hepatic vessels, and ascites. Parenchymal heterogeneity was still present after several months as a result of the hepatic injury. The hazy appearance of the portal vessels and the gallbladder wall thickening seemed directly correlated with the degree of hepatic involvement in the early phase of VOD.

Dactylitis in patients with seronegative spondylarthropathy. Assessment by ultrasonography and magnetic resonance imaging

OBJECTIVE

To establish by means of ultrasound and magnetic resonance imaging (MRI) the role of tenosynovitis and arthritis in determining the "sausage-like" aspect of finger dactylitis and to compare the results of the 2 examinations.

METHODS

Twelve dactylitic fingers and their corresponding normal contralateral fingers belonging to 10 patients who met the Amor criteria for the diagnosis of seronegative spondylarthropathy (SpA) were studied by ultrasonography and MRI.

RESULTS

MRI revealed a significant increase in the volar bone-to-skin distance in dactylitic fingers with respect to that of the normal contralateral fingers (P < 0.001). This increase was due to distension of the flexor synovial sheaths (P < 0.00001) by fluid collection. Peritendinous soft tissues were not involved, since these were found to be significantly thicker in the normal fingers (P < 0.05). Of the 36 joints of the 12 dactylitic fingers, only 1 showed capsule distension. Using MRI as the "gold standard," ultrasonography showed a 100% sensitivity and specificity for flexor tenosynovitis, but lacked sensitivity for joint involvement because it failed to reveal joint capsule distension in the only joint involved. Similarly, physical examination showed a 100% sensitivity and specificity for flexor sheath involvement.

CONCLUSION

Dactylitis is due to flexor tenosynovitis. Enlargement of the finger joint capsule is not an indispensable condition for the "sausage-like" feature. Physical examination is a sufficient method for the diagnosis of dactylitis.

Bone marrow micrometastases in a patient with localized Wilms' tumor

The case of a 7-year-old boy presenting at diagnosis with a localized (stage III) Wilms' tumor of favorable histology is presented. Immunocytologic analysis of bone marrow aspirates revealed cells positive for neural cell adhesion molecule (NCAM) and negative for class I major histocompatibility complex (MHC) antigens. These cells were interpreted as deriving from the tumor blastemal component. Postoperatively the child underwent radiotherapy and chemotherapy, and he remains free of disease 12 months after completion of therapy. In patients with nonmetastatic Wilms' tumor at onset, the evaluation of the actual frequency of occult marrow involvement and the assessment of its clinical significance may necessitate further investigation.

Dactylitis with pitting oedema of the hand in longstanding ankylosing spondylitis

The case of a patient with seronegative spondyloarthropathy showing oligoarthritis of the hand together with large pitting oedema is reported. Unlike the patients with late onset peripheral spondyloarthropathy described by Dubost and Sauvezie who show minimal involvement of the axial skeleton, the patient has been suffering from AS for about twenty years.

Does chemotherapy have a role in low-grade astrocytoma management? A report of 13 cases

Surgery is the treatment of choice for low-grade astrocytoma while radiotherapy is carried out only when total resection is not possible. This study assessed the effectiveness of chemotherapy in nonresectable cases. Thirteen children with nonresectable astrocytoma were treated with carboplatin and etoposide and after four cycles the response to treatment was evaluated according to radiologic criteria. The results were: one with complete response (CR), three with minor response (MR), six with stable disease (SD), and three with progressive disease (PD). Moreover, in 77% there was an improvement in the neurologic picture. In particular, two cases with hypothalamic astrocytoma showed a regression of the diencephalic syndrome following chemotherapy. In six cases chemotherapy was carried out, at reduced dosage, after the first four cycles either because there was clinical improvement or because it was necessary to postpone radiotherapy in very young patients. After a follow-up period ranging between 11 and 63 months (average: 30 months), nine of the 13 patients are alive (69%) while four died of disease progression. Further studies would be useful to evaluate the role of chemotherapy in the management of low-grade astrocytoma.

Late onset undifferentiated seronegative spondyloarthropathy

OBJECTIVE

To define the clinical spectrum of late onset undifferentiated seronegative spondyloarthropathy (uSpA) based on a large number of patients.

METHODS

All consecutive patients older than 45 years at the onset of SpA and not meeting criteria for any of the definite categories of the SpA complex seen in the 1988-1993 period were entered in a special register and were followed prospectively.

RESULTS

Twenty-three patients (mean age at onset 56.9, range 46-72; mean age at the last visit 61.7, range 48-79) were studied. Of these, 12 had 3 or more clinical and/or radiological manifestations of SpA, while 7 showed only 2, and 4 only one. Of the 10 patients with peripheral arthritis, only 3 had the large pitting edema of the lower limbs described by Dubost and Sauvezie. Of the 4 patients with only one manifestation, 2 had peripheral enthesitis and 2 acute anterior uveitis.

CONCLUSION

The clinical spectrum of late onset uSpA is as wide as in children and young and middle aged adults.

Immunohistochemical detection of high-affinity nerve growth factor receptor in neuroblastoma

High levels of mRNA (as assessed by northern blot) for the high-affinity nerve growth factor receptor (p140TRK) are predictive of favourable outcome in neuroblastoma. The feasibility of determining p140trk on frozen sections using a recently developed monoclonal antibody was evaluated, and immunohistochemical findings were compared to those obtained from northern blot analysis. Primary tumour samples from 28 untreated patients were quick frozen and an indirect immunofluorescence assay was performed on 4-microns acetone-fixed cryostat sections. 9 cases were positive with immunohistochemistry, and these were among the 15 cases also positive by northern blot. None of the cases negative by northern blot were positive with immunohistochemistry. The concordance rate was 79% (P < 0.03), with a sensitivity of 60% and a specificity of 100%. Immunohistochemistry can thus be rather reliable for assessing p140trk expression, even when only very small amounts of tissue are available, such as with needle biopsy.

Ossification of the posterior longitudinal ligament in one of a pair of identical twins concordant for ankylosing spondylitis

A pair of identical twins suffering from ankylosing spondylitis is reported. One brother developed an earlier-onset disease and showed ossification of the posterior longitudinal ligament and the flavum ligament in his cervical spine.

Seronegative spondylarthropathy without spine involvement in Behçet's syndrome

The case of a 49-year-old man affected by Behçet's syndrome (BS) without any clinical or radiological evidence of ankylosing spondylitis, exhibiting a peripheral enthesitis typical of seronegative spondyloarthropathy (SpA) is reported. The diagnosis of SpA is supported by computed tomographic evidence of sacroiliitis. This case confirms our hypothesis that patients with BS may have other forms of SpA than AS.

Late onset peripheral seronegative spondyloarthropathy: report of two additional cases

Two more cases of late onset peripheral seronegative spondyloarthropathy (SpA) are reported. Like the patients reported by Dubost and Sauvezie, they had extensive pitting edema of the lower limbs, constitutional symptoms, elevated erythrocyte sedimentation rate and minimal involvement of the axial skeleton with marked signs of diffuse idiopathic skeletal hyperstosis.

Longstanding HLA-B27 associated Achilles tendinitis

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Flow cytometric and molecular analysis of proliferative activity and DNA content in neuroblastoma: presence of stationary cells in S-phase

Twenty-nine previously untreated neuroblastomas were analyzed for DNA content and percentage of cells in S-phase, both determined by flow cytometry, and N-myc oncogene copy number. Twelve of them were also tested for histone H3 transcript levels as a marker of actual proliferative activity. A significantly higher S-phase fraction was associated with advanced stages of disease, unfavorable (i.e., near-diploid and near-tetraploid) DNA content, and N-myc amplification. The occurrence of six tumors with a remarkable (greater than or equal to 10%) S-phase fraction but lacking histone H3 transcripts suggests the presence of stationary S-phase cells in neuroblastoma.

Evaluation of cilofungin (LY121019) for treatment of experimental Candida albicans endocarditis in rabbits

The efficacy of cilofungin (LY121019) for aortic valve endocarditis caused by Candida albicans in rabbits was studied. Vegetation titers were similar for cilofungin-treated and untreated rabbits. No rabbit survived beyond 5 days in either group. All rabbits given amphotericin B survived, and titers were reduced. Cilofungin was ineffective in this model.