Sulphasalazine in ankylosing spondylitis: a double blind controlled study in 60 patients

Sulphasalazine has been reported to be effective in ankylosing spondylitis with peripheral arthritis, but its efficacy in spondylitis is unknown. Thus 60 patients with active ankylosing spondylitis without peripheral arthritis or gastrointestinal symptoms were randomly allocated to one of two therapeutic groups. One group received 2 g sulphasalazine daily for six months and the other a placebo. Thirteen patients (six given placebo and seven given sulphasalazine) dropped out of the trial and were considered to be treatment failures. After six months' follow up efficacy was rated as good or very good by 15 of the 30 patients given sulphasalazine and by only six of the 30 given placebo (p less than 0.02). Furthermore, in the patients given sulphasalazine the daily consumption of non-steroidal anti-inflammatory drugs, functional index, and plasma IgG concentrations had fallen significantly. These data suggest that sulphasalazine may be a safe and effective treatment for spondylitis in ankylosing spondylitis.

Pharmacodynamic effect of dipyridamole on thallium-201 myocardial perfusion in progressive systemic sclerosis with diffuse scleroderma

We evaluated the effect of dipyridamole on thallium-201 myocardial perfusion in 23 patients with progressive systemic sclerosis (PSS) with diffuse scleroderma. Thallium-201 single photon emission computed tomography (SPECT) was performed at rest and after coronary artery vasodilatation with intravenous dipyridamole (0.14 mg/kg/min for four minutes). The left myocardium was divided into nine segments; each segment was graded as 2.0, 1.5, 1.0, 0.5, 0 (zero represents no activity). Dipyridamole significantly improved resting thallium-201 myocardial perfusion: the mean (SD) number of segments with thallium defects decreased from 6.0 (2.1) at rest to 4.1 (2.5) after dipyridamole (p less than 0.0001); the mean (SD) score in segments with resting defects increased from 0.92 (0.24) at rest to 1.13 (0.38) after dipyridamole (p less than 0.0001); the mean (SD) global score per patient increased from 10.2 (1.8) at rest to 11.4 (2.1) after dipyridamole (p less than 0.02); the global score increased by at least 2.0 in 12 patients and worsened by at least 2.0 in three patients only (p = 0.05). The results of this acute study suggest that some drugs with potent vasodilator activity on small coronary arteries may be beneficial in the treatment of PSS patients with thallium-201 myocardial perfusion abnormalities.

Reduced coronary flow and resistance reserve in primary scleroderma myocardial disease

The maximum coronary vasodilator capacity after intravenous dipyridamole (0.14 mg X kg-1 X min-1 X 4 minutes) was studied in seven patients with primary scleroderma myocardial disease and compared to that of seven control subjects. Hemodynamic data and left ventricular angiographic data were not different in the two groups. The coronary flow reserve was evaluated by the dipyridamole/basal coronary sinus blood flow ratio (D/B CSBF) and the coronary resistance reserve by the dipyridamole/basal coronary resistance ratio (D/B CR). Coronary reserve was greatly impaired in the group with primary scleroderma myocardial disease: D/B CSBF was lower than in the control group (2.54 +/- 1.37 vs 4.01 +/- 0.56, respectively; p less than 0.05) and D/B CR was higher than in the control group (0.47 +/- 0.25 vs 0.23 +/- 0.04, respectively; p less than 0.05). Such a decreased coronary flow and resistance reserve in patients with primary scleroderma myocardial disease was not explained by an alteration of left ventricular function. It may be an important contributing factor in the pathogenesis of primary scleroderma myocardial disease.

Defective Epstein-Barr virus specific suppressor T cell function in progressive systemic sclerosis

Several immunoregulatory defects of Epstein-Barr virus (EBV) induced B cell activation have been described in patients with rheumatoid arthritis (RA), suggesting that EBV may have a role in the pathogenesis of RA. We assessed EBV specific T cell regulation in 20 patients with progressive systemic sclerosis (PSS) and immune to EBV and in 10 control subjects also immune to EBV by comparing the secretion of IgM into supernatants of 16 day cultures of B cells alone and cocultures of B and autologous T cells. In control subjects autologous T cells mediated a significant decrease in the secretion of IgM by B cells at 12 and 16 days of culture. Analysis of individual responses showed the existence of two subgroups of patients with PSS: group I (10 patients) had a suppressor T cell function similar to that of controls; group II (10 patients) had a defective T cell function. Differences in the duration or severity of the disease, the slow acting therapeutic agents, and anti-inflammatory drugs could not account for these subdivisions. These results suggest that several immunoregulatory defects of EBV induced B cell activation exist in different connective tissue diseases.

Nifedipine and thallium-201 myocardial perfusion in progressive systemic sclerosis

Heart disease in patients with progressive systemic sclerosis may be due in part to myocardial ischemia caused by a disturbance of the coronary microcirculation. To determine whether abnormalities of myocardial perfusion in this disorder are potentially reversible, we evaluated the effect of the coronary vasodilator nifedipine on myocardial perfusion assessed by thallium-201 scanning in 20 patients. Thallium-201 single-photon-emission computerized tomography was performed under control conditions and 90 minutes after 20 mg of oral nifedipine. The mean (+/- SD) number of left ventricular segments with perfusion defects decreased from 5.3 +/- 2.0 to 3.3 +/- 2.2 after nifedipine (P = 0.0003). Perfusion abnormalities were quantified by a perfusion score (0 to 2.0) assigned to each left ventricular segment and by a global perfusion score (0 to 18) for the entire left ventricle. The mean perfusion score in segments with resting defects increased from 0.97 +/- 0.24 to 1.26 +/- 0.44 after nifedipine (P less than 0.00001). The mean global perfusion score increased from 11.2 +/- 1.7 to 12.8 +/- 2.4 after nifedipine (P = 0.003). The global perfusion score increased by at least 2.0 in 10 patients and decreased by at least 2.0 in only 1. These observations reveal short-term improvement in thallium-201 myocardial perfusion with nifedipine in patients with progressive systemic sclerosis. The results are consistent with a potentially reversible abnormality of coronary vasomotion in this disorder, but the long-term therapeutic effects of nifedipine remain to be determined.

Experimental autoimmune spondylodiscitis in rats

Immunization of Lewis rats with nucleus pulposus in incomplete Freund's adjuvant, followed by in vivo injury of nucleus pulposus, induced spondylodiscitis characterized by mononuclear cell infiltration affecting the vertebral discs in 100% of experimental animals. Injury of the nucleus pulposus without prior immunization, or immunization without injury failed to induce spondylodiscitis. The nucleus pulposus, that is not antigenic normally, can lose its immunologic tolerance by the injection of syngeneic nucleus pulposus. When immunocompetent cells come into contact with the nucleus pulposus after tissue injury, an autoimmune response may appear.

[The coronary hyperemic reaction in scleroderma]

Functional, organic and vascular anomalies could play an important role in systemic scleroderma. We have studied the coronary hyperemic reaction in subjects with primitive sclerodermatous cardiomyopathy, in order to specify the vascular anomalies. The coronary hyperemic reaction consists of a transient rise in coronary flow after selective injection of a contrast agent into the left coronary artery. In sclerodermatous subjects this coronary hyperemic reaction is significantly smaller than in control subjects. This limitation of the hyperemic reaction reflects a decrease in the ability of small arteries or coronary arterioles to dilate in sclerodermatous subjects. This anomaly could play an important role in primitive sclerodermatous cardiomyopathy.

[Double-blind study of the treatment of disc lumbosciatica by chemonucleolysis]

A randomized, double-blind study was made of 39 patients with discolumbar hernias that were unresponsive to medical treatment. They were treated either by nucleolysis with chymopapain (4 000 U of discase), or by discography followed by injection of distilled water as a placebo. After one month, treatment was found to be successful in 55% of cases undergoing nucleolysis and in 26% of cases receiving the placebo. The results after 3 months were 65% and 42%. respectively. After one month, the intensity of lumbar pain decreased by 44% on average in the group treated by chymopapain, and by 0% in the placebo group. Radicular pain decreased by 53% in the first group and by 26% in the placebo group, and improvement in Lasègue's sign was 51% and 20%, respectively. Analgesic treatment was reduced in patients treated by chymopapain: 65% of patients in the first group report some or much improvement in their sciatica, whereas this figure was 26% in the placebo group (p less than 0.02). Contralateral sciatica was observed in 3 patients of the placebo group. The average give in the disc one month after nucleolysis was 34% in the chymopapain group and 27% in the placebo group, without correlation with the clinical result. On average, patients were monitored for one year after nucleolysis, and during this year 6 patients from the chymopapain group were operated upon, compared with 10 patients from the placebo group. Although these results are at the limit of statistical significance because of the number of patients studied, they confirm the innocuousness and effectiveness of chymopapain in the treatment of discolumbar hernias.

The induction of human antinuclear antibodies by D-penicillamine: activation of inducer helper T cells in the absence of irradiation sensitive suppressor T cells

The capacity of D-Penicillamine (DP) to induce or to potentiate the production of antinuclear antibodies (ANA), detected by immunofluorescence (IF), was investigated in vitro, using peripheral blood mononuclear cells (PBMC) from patients with systemic lupus erythematosus (SLE) and normal individuals. Except in one patient with SLE, DP did not enhance ANA synthesis when using unseparated PBMC. In contrast, when B cells were cocultured with irradiated T cells or irradiated enriched T4+ subset, DP induced or potentiated the production of ANA. These results indicate that DP acts by stimulating T4+ helper cells to promote ANA synthesis in the absence of radio-sensitive suppressor T cell function contained within the T4+ population.

D-penicillamine: a modulator of anti-DNA antibodies production

The effect of D-Penicillamine (DP) on the in vitro production of anti-DNA antibodies by peripheral blood mononuclear cells (PBMC) from patients with systemic lupus erythematosus (SLE) and from healthy individuals was studied. Anti-DNA antibodies were measured in culture supernatants using a sensitive microenzyme-linked immunoassay technique. The results of this investigation suggest that DP can act as an immunomodulator capable of potentiating or initiating anti-DNA antibodies synthesis as well as suppressing it. Although PBMC from both SLE patients and controls were responsive to this thiol compound, our results indicate that PBMC from patients with SLE were more susceptible to the enhancing effect of DP than did PBMC from controls. The cellular mechanism by which this drug can modulate anti-DNA antibodies production is discussed.

[Mycobacterial infection of the hip following total prosthesis. Study of 6 cases]

The authors present 6 cases of mycobacterial infection of the hip after total hip replacement: 5 cases of tuberculosis and 1 case of Mycobacterium fortuitum infection. They emphasise the clinical, radiological, bacteriological and histological signs which are generally very characteristic and unequivocal. A review of the literature reveals the rarity of these infections, but stresses the need for a complete bacteriological survey to avoid missing the diagnosis. A routine medicosurgical therapeutic approach is proposed.

[Tiopronine and rheumatoid polyarthritis]

This article summarises the authors' experience and the data of the literature concerning Tiopronine, a drug with a thiol function like D-penicillamine, in the treatment of rheumatoid arthritis. Two controlled trials versus placebo and two controlled trials versus D-penicillamine demonstrated the effectiveness of treatment and the identical action of 1 g of Tiopronine and 600 mg of D-penicillamine. The side effects of Tiopronine are very similar to those of D-penicillamine: essentially rash, toxiderma, aguestia, proteinuria, which resolve when treatment is stopped. Patients with a past history of side effects with D-penicillamine have an increased risk of developing side effects with Tiopronine, but this risk is not systematic, which constitutes the principal value of this drug.

[Treatment of systemic scleroderma with factor XIII in 86 patients, with long-term follow-up]

Eighty-six patients with progressive systemic sclerosis were given coagulation factor XIII intravenously in different dosage regimens. The mean duration of treatment was 19 +/- 18 months and patients were followed up for 22.9 +/- 18.8 months. Improvement or stabilization of the lesions was obtained in 44/86 patients and exclusively concerned skin lesions; there was no improvement in visceral lesions. The drug was well tolerated in short-and long-term treatment. It is concluded that factor XIII demonstrated lasting effectiveness in one-half of the patients treated.

Different defects of T cell regulation of Epstein-Barr virus-induced B cell activation in rheumatoid arthritis

Several reports have shown a defective Epstein-Barr virus (EBV)-specific suppressor T cell function in rheumatoid arthritis (RA), suggesting that EBV may have a role in the pathogenesis of RA. EBV-specific T cell regulation was studied in 47 EBV-immune RA patients and in 14 EBV-immune control subjects by comparing the secretion of IgM into supernatants of 28-day cultures of B cells alone and cocultures of B and autologous T cells. In control subjects, autologous T cells mediated a significant decrease in the secretion of IgM by B cells at 12 and 16 days of culture. Analysis of individual responses demonstrated the existence of 3 subgroups of RA patients: group I (18 patients) had a suppressor T cell function similar to that of controls; group II (21 patients) had a defective T cell function; group III (8 patients) was characterized by a "late help phenomenon." Moreover, in RA group III, IgM secretion in cultures of B cells alone was lower than that seen in controls, RA group I, or RA group II. Differences in the duration or severity of the disease, or in the use of slow-acting therapeutic agents, corticosteroids, and nonsteroidal antiinflammatory drugs could not account for these subdivisions. Thus, our study demonstrates that several immunoregulatory defects exist in subgroups of RA patients.

Nifedipine and alpha 1-adrenergic blockade in Raynaud's phenomenon

The efficacy of nifedipine and prazosin in the treatment of Raynaud's phenomenon was assessed in a prospective double-blind randomized cross-over trial in 15 patients. Each patient received one week of nifedipine 20 mg TID, one week of prazosin 1 mg TID, and 2 weeks of placebo. Nifedipine was shown to be effective in reducing both the frequency and the severity of Raynaud's phenomenon, whereas prazosin was ineffective. Before initiation of therapy in the 15 patients, pressor responses to the intravenous alpha 1-agonist phenylephrine were assessed in the basal state, 30 min after 20 mg oral nifedipine, and 30 min after 1 mg oral prazosin; the shift to the right of the log dose-vasopressor response curves to phenylephrine was similar with nifedipine and prazosin.

Decreased coronary reserve in primary scleroderma myocardial disease

We assessed coronary reserve, by measuring the increase in coronary sinus blood flow (CSBF) after intravenous administration of dipyridamole (0.14 mg/kg/minute for 4 minutes), in 7 patients with primary scleroderma myocardial disease (PSMD) and in 7 control subjects. Coronary reserve was greatly impaired in PSMD: before administration of dipyridamole, CSBF was similar in patients with PSMD (89 +/- 32 ml/minute/100 gm, mean +/- SD) and in controls (100 +/- 15 ml/minute/100 gm); after dipyridamole infusion, CSBF was significantly lower in patients with PSMD (191 +/- 45 ml/minute/100 gm) than in controls (399 +/- 58 ml/minute/100 gm) (P less than 0.01). Six of the 7 patients with PSMD had angiographically normal epicardial coronary arteries and normal left ventricular function. Decreased coronary reserve may be an important contributor to the pathogenesis of primary scleroderma myocardial disease.

Libman-Sacks endocarditis: the diagnostic importance of two-dimensional echocardiography

In 1980, a 44-year-old woman with the diagnosis of systemic lupus erythematosus presented with fever and mitral and aortic valvular insufficiency. Blood cultures were sterile. M-mode echocardiograms of the mitral valve revealed an image resembling vegetations of infective endocarditis. The diagnosis was rejected after two-dimensional echocardiography which failed to demonstrate vegetation. Two-dimensional echocardiography should therefore be systematically utilized in the diagnosis of valvular lesions in patients with systemic lupus erythematosus.