1
|
Stone JH, Talor M, Stebbing J, Uhlfelder ML, Rose NR, Carson KA, Hellmann DB, Burek CL. Test characteristics of immunofluorescence and ELISA tests in 856 consecutive patients with possible ANCA-associated conditions. ACTA ACUST UNITED AC 2003; 13:424-34. [PMID: 14635320 DOI: 10.1002/1529-0131(200012)13:6<424::aid-art14>3.0.co;2-q] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the test characteristics of immunofluorescence (IF) and enzyme-linked immunosorbent assays (ELISA) in a consecutive series of patients under evaluation for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHODS Using stored sera, we performed a cross-sectional study on 856 consecutive patients tested prospectively for ANCA by IF, Based on guidelines from the 1994 Chapel Hill Consensus Conference (CHCC), we determined each patient's underlying diagnosis by a medical records review without regard to their ANCA status (the CHCC guidelines do not require ANCA as a prerequisite for diagnosis). We grouped patients with forms of vasculitis commonly associated with ANCA into one of 4 types of AAV: Wegener's granulomatosis (n = 45), microscopic polyangiitis (n = 12), Churg-Strauss syndrome (n = 4), and pauci-immune glomerulonephritis (n = 8). We also classified patients without clinical evidence of AAV (92% of all patients tested) into 5 predefined categories of disease (including "other") and an additional category for no identifiable disease. In a blinded fashion, we then performed ELISAs on the stored serum for antibodies to proteinase-3 (PR3) and myeloperoxidase (MPO) and calculated the test characteristics for both ANCA assay techniques. RESULTS Sixty-nine of the 856 patients (8.1%) had clinical diagnoses of AAV based on CHCC guidelines. The positive predictive value (PPV) of ELISA for AAV was superior to that of IF, 83% versus 45%. For patients with both positive IF tests and positive ELISA tests, the PPV increased to 88%. Both IF and ELISA had high negative predictive values (97% and 96%, respectively). Positive ELISA tests were associated with higher likelihood ratios (LR) than IF (54.2 [95% CI = 26.3, 111.5] versus 9.4 [95% CI = 6.9, 12.7]). The LR of both a positive IF and a positive ELISA was 82.1 (95% CI = 33.3, 202.5). CONCLUSIONS Compared with IF, an ELISA test fo ANCA was associated with a substantially higher PPV and LR for AAV. This fact, combined with the greater sensitivity of IF, suggests that an effective testing strategy is to perform ELISA tests only on samples that are positive for ANCA by IF.
Collapse
Affiliation(s)
- J H Stone
- Department of Medicine, Johns Hopkins University Vasculitis Center, 1830 E. Monument Street, Suite 7500, Baltimore, MD 21205, USA
| | | | | | | | | | | | | | | |
Collapse
|
2
|
Stone JH, Talor M, Stebbing J, Uhlfelder ML, Rose NR, Carson KA, Hellmann DB, Burek CL. Test characteristics of immunofluorescence and ELISA tests in 856 consecutive patients with possible ANCA-associated conditions. Arthritis Care Res 2003. [PMID: 14635320 DOI: 10.1002/1529-0131(200012)13: 6<424: : aid-art14>3.0.co; 2-q] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the test characteristics of immunofluorescence (IF) and enzyme-linked immunosorbent assays (ELISA) in a consecutive series of patients under evaluation for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHODS Using stored sera, we performed a cross-sectional study on 856 consecutive patients tested prospectively for ANCA by IF, Based on guidelines from the 1994 Chapel Hill Consensus Conference (CHCC), we determined each patient's underlying diagnosis by a medical records review without regard to their ANCA status (the CHCC guidelines do not require ANCA as a prerequisite for diagnosis). We grouped patients with forms of vasculitis commonly associated with ANCA into one of 4 types of AAV: Wegener's granulomatosis (n = 45), microscopic polyangiitis (n = 12), Churg-Strauss syndrome (n = 4), and pauci-immune glomerulonephritis (n = 8). We also classified patients without clinical evidence of AAV (92% of all patients tested) into 5 predefined categories of disease (including "other") and an additional category for no identifiable disease. In a blinded fashion, we then performed ELISAs on the stored serum for antibodies to proteinase-3 (PR3) and myeloperoxidase (MPO) and calculated the test characteristics for both ANCA assay techniques. RESULTS Sixty-nine of the 856 patients (8.1%) had clinical diagnoses of AAV based on CHCC guidelines. The positive predictive value (PPV) of ELISA for AAV was superior to that of IF, 83% versus 45%. For patients with both positive IF tests and positive ELISA tests, the PPV increased to 88%. Both IF and ELISA had high negative predictive values (97% and 96%, respectively). Positive ELISA tests were associated with higher likelihood ratios (LR) than IF (54.2 [95% CI = 26.3, 111.5] versus 9.4 [95% CI = 6.9, 12.7]). The LR of both a positive IF and a positive ELISA was 82.1 (95% CI = 33.3, 202.5). CONCLUSIONS Compared with IF, an ELISA test fo ANCA was associated with a substantially higher PPV and LR for AAV. This fact, combined with the greater sensitivity of IF, suggests that an effective testing strategy is to perform ELISA tests only on samples that are positive for ANCA by IF.
Collapse
Affiliation(s)
- J H Stone
- Department of Medicine, Johns Hopkins University Vasculitis Center, 1830 E. Monument Street, Suite 7500, Baltimore, MD 21205, USA
| | | | | | | | | | | | | | | |
Collapse
|
3
|
Abstract
The two principal aims in the treatment of Wegener's granulomatosis (WG) are to limit the extent and severity of permanent organ damage by controlling the disease promptly and to minimize the short- and long-term morbidity that often results from therapy. Remission is considered to be the absence of disease activity in any organ system. Once the disease has been controlled by the initial treatment regimen, which is dictated by the degree of disease severity, the focus of therapy shifts to maintaining disease remission, often with medications less toxic than those used to induce remission. The description of WG treatments in terms analogous to cancer chemotherapy (i.e., those designed to induce remissions and those intended to maintain them) is useful in the formulation of current disease management strategies and in the investigation of new therapies for WG.
Collapse
Affiliation(s)
- M J Regan
- Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | | | | |
Collapse
|
4
|
Abstract
Important strides have been made in unraveling the pathophysiologic characteristics of some individual forms of vasculitis, but vasculitides continue to pose enormous challenges for clinicians. Over time, numerous myths and an occasional pearl have arisen from the care of patients with these disorders. In this collection of pearls and myths, we have attempted to pool our knowledge about the clinical care of vasculitis patients.
Collapse
Affiliation(s)
- J H Stone
- Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Vasculitis Center, Baltimore, Maryland, USA
| | | | | | | | | | | |
Collapse
|
5
|
Wasserman BA, Stone JH, Hellmann DB, Pomper MG. Reliability of normal findings on MR imaging for excluding the diagnosis of vasculitis of the central nervous system. AJR Am J Roentgenol 2001; 177:455-9. [PMID: 11461882 DOI: 10.2214/ajr.177.2.1770455] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We attempt to determine whether angiography is indicated in patients with suspected central nervous system (CNS) vasculitis who present with negative findings on MR imaging studies. CONCLUSION MR imaging findings may be negative in the setting of CNS vasculitis confirmed on angiography, indicating that advanced imaging techniques tailored to detect infarction (i.e., fluid-attenuated inversion recovery, diffusion-weighted, and perfusion imaging) may be necessary to enhance the sensitivity of an MR study and that despite the high sensitivity of MR imaging for CNS vasculitis, angiography may still be required to render an accurate diagnosis.
Collapse
Affiliation(s)
- B A Wasserman
- Department of Radiology, Neuroradiology Division, The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Phipps B-108, 600 N. Wolfe St., Baltimore, MD 21287-2182, USA
| | | | | | | |
Collapse
|
6
|
Scatarige JC, Urban BA, Hellmann DB, Fishman EK. Three-dimensional volume-rendering CT angiography in vasculitis: spectrum of disease and clinical utility. J Comput Assist Tomogr 2001; 25:598-603. [PMID: 11473192 DOI: 10.1097/00004728-200107000-00015] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Spiral computed tomographic angiography (CTA) coupled with three-dimensional volume-rendering image processing is a less invasive alternative to conventional catheter angiography. The technique has been used successfully in a variety of vascular diseases. In this pictorial essay, we review the CTA findings in selected cases of vasculitis. Technical considerations and the potential clinical value of this method are discussed.
Collapse
Affiliation(s)
- J C Scatarige
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | | | | | | |
Collapse
|
7
|
Stone JH, Uhlfelder ML, Hellmann DB, Crook S, Bedocs NM, Hoffman GS. Etanercept combined with conventional treatment in Wegener's granulomatosis: a six-month open-label trial to evaluate safety. ACTA ACUST UNITED AC 2001; 44:1149-54. [PMID: 11352248 DOI: 10.1002/1529-0131(200105)44:5<1149::aid-anr197>3.0.co;2-f] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the safety of etanercept (Enbrel) in patients receiving conventional treatment for Wegener's granulomatosis (WG). METHODS We performed a 6-month open-label trial of etanercept (25 mg subcutaneously twice weekly) which was added to standard therapies for WG (glucocorticoids, methotrexate, cyclophosphamide, azathioprine, cyclosporine) and prescribed according to disease severity. Evaluations of clinical response were determined by the Birmingham Vasculitis Activity Score for WG (BVAS/WG) in 20 patients with persistently active disease or with new flares of previously established WG. Fourteen of the 20 patients (70%) had etanercept added as the only new therapeutic variable. RESULTS Injection site reactions (ISRs) were the most common adverse event related to etanercept (8 episodes in 5 patients [25%]; < 1% of all injections). All ISRs were mild. Two patients had a combined total of 5 hospitalizations (1 patient had 4), but no hospitalizations were attributable solely to etanercept-related adverse events. One patient with severe subglottic stenosis developed pneumococcal tracheobronchitis and subsequently had a localized Herpes zoster infection. Nineteen patients (95%) were still taking etanercept at 6 months, the single exception being a patient who developed progression of orbital (retro-bulbar) disease at 4 months. There were no deaths. The mean BVAS/WG at entry was 3.6 (range 1-8), which decreased at 6 months to 0.6 (P < 0.001, 95% confidence interval [95% CI] -4.0 to -2.1). Among the 14 patients in whom etanercept was the only new treatment variable, the mean daily prednisone dose decreased from 12.9 mg at entry to 6.4 mg at 6 months. This comparison did not achieve statistical significance (difference -6.5; P = 0.19, 95% CI -16.6 to +3.6). Sixteen of the patients (80%) achieved BVAS/WG scores of 0 at some point. However, intermittently active disease was observed in 15 patients (75%). CONCLUSION In this open-label trial, etanercept used in combination with standard treatments was well-tolerated in patients with WG. Adverse events were few. BVAS/WG scores improved at 6 months, but intermittently active WG (occasionally severe) was common. A randomized, double-masked trial to assess the efficacy of etanercept in WG has begun.
Collapse
Affiliation(s)
- J H Stone
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | |
Collapse
|
8
|
Zaas A, Scheel P, Venbrux A, Hellmann DB. Large artery vasculitis following recombinant hepatitis B vaccination: 2 cases. J Rheumatol 2001; 28:1116-20. [PMID: 11361200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
We describe 2 women who developed large artery vasculitis shortly after receiving recombinant hepatitis B vaccination. One patient developed Takayasu's arteritis, the other a vasculitis involving subclavian and renal arteries. Both developed renal failure. Whether the vasculitis was caused by the vaccination is not known. Although small vessel vasculitis following hepatitis B vaccination has been reported a number of times, large vessel vasculitis associated with hepatitis B vaccination has been reported only once. These cases suggest that large artery vasculitis should be added to the list of possible side effects of hepatitis B vaccination.
Collapse
Affiliation(s)
- A Zaas
- Department of Medicine, Johns Hopkins Hospital, and the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | |
Collapse
|
9
|
Stone JH, Hoffman GS, Merkel PA, Min YI, Uhlfelder ML, Hellmann DB, Specks U, Allen NB, Davis JC, Spiera RF, Calabrese LH, Wigley FM, Maiden N, Valente RM, Niles JL, Fye KH, McCune JW, St Clair EW, Luqmani RA. A disease-specific activity index for Wegener's granulomatosis: modification of the Birmingham Vasculitis Activity Score. International Network for the Study of the Systemic Vasculitides (INSSYS). Arthritis Rheum 2001; 44:912-20. [PMID: 11318006 DOI: 10.1002/1529-0131(200104)44:4<912::aid-anr148>3.0.co;2-5] [Citation(s) in RCA: 331] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To refine and validate the Birmingham Vasculitis Activity Score (BVAS) as a disease-specific activity index for Wegener's granulomatosis (WG). METHODS Sixteen members of the International Network for the Study of the Systemic Vasculitides (INSSYS) revised the BVAS, with 3 goals: to reduce the redundancy of some component items, to enhance its ability to capture important disease manifestations specific to WG, and to streamline the instrument for use in clinical research. We defined the items and weighted them empirically as either minor (e.g., nasal crusting = 1 point) or major (e.g., alveolar hemorrhage = 3 points). We then validated the new, disease-specific BVAS/WG in 2 simulation exercises and a clinical case series that involved 117 patients with WG. RESULTS We removed 38 items from the original BVAS, revised 9 items, and added 7 new items. Correlations between the scores on the BVAS/WG and the physician's global assessment (PGA) of disease activity were high, even when patients in remission were excluded. In the clinical case series, Spearman's rank correlation coefficient between the BVAS/WG and the PGA was r = 0.81 (95% confidence interval 0.73-0.87). The interobserver reliability using intraclass (within-case) correlation coefficients in the 2 simulation exercises was r = 0.93 for the BVAS/WG and r = 0.88 for the PGA in the first and r = 0.91 for the BVAS/WG and r = 0.88 for the PGA in the second. There was no significant observer effect in the scoring of the BVAS/WG or the PGA. The discriminant validity of the BVAS/WG was good: r = 0.73 (95% confidence interval 0.43-0.83). CONCLUSION The BVAS/WG is a valid, disease-specific activity index for WG. Tested in simulation exercises and in actual patients, the BVAS/WG correlates well with the PGA, is sensitive to change, and has good inter- and intraobserver reliability. The INSSYS will use the BVAS/WG to assess the primary outcome in a phase II/III trial of etanercept in WG.
Collapse
Affiliation(s)
- J H Stone
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Brotman DJ, Eberhart CG, Burger PC, McArthur JC, Hellmann DB. Primary angiitis of the central nervous system and Alzheimer's disease: clinically and pathologically evident in a single patient. J Rheumatol 2000; 27:2935-7. [PMID: 11128690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Two years after being successfully treated for biopsy confirmed primary angiitis of the central nervous system (PACNS), a 69-year-old woman presented with cognitive decline. In contrast to her first presentation, her altered mental function developed gradually, was not associated with headache or abnormal cerebrospinal fluid analysis, and did not improve with immunosuppression. Reevaluation of her original brain biopsy not only confirmed the presence of PACNS, but also revealed neuritic plaques and neurofibrillary tangles, suggesting a concurrent diagnosis of Alzheimer's disease. Cerebral angiogram did not suggest vasculitis and magnetic resonance imaging showed generalized cerebral atrophy supporting the diagnosis of Alzheimer's. This case illustrates that Alzheimer's dementia and PACNS can coexist in a single patient and that Alzheimer's disease should be considered when a patient with successfully treated PACNS presents with cognitive decline months or years after initial diagnosis.
Collapse
Affiliation(s)
- D J Brotman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
| | | | | | | | | |
Collapse
|
11
|
Pretorius ES, Stone JH, Hellmann DB, Fishman EK. Wegener's granulomatosis: spectrum of CT findings in diagnosis, disease progression, and response to therapy. Crit Rev Diagn Imaging 2000; 41:279-313. [PMID: 10999239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- E S Pretorius
- Russell H. Morgan Department of Radiology and Radiologic Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | | | | | | |
Collapse
|
12
|
Affiliation(s)
- K D Fairbanks
- Department of Medicine, Johns Hopkins University, Baltimore MD 21205, USA
| | | | | | | | | |
Collapse
|
13
|
Abstract
OBJECTIVE To establish the validity of an index designed to measure activity in systemic necrotizing vasculitis (SNV). METHODS The Vasculitis Activity Index (VAI) was designed to incorporate appropriately weighted clinical measurements that reflect disease activity in SNV. We performed a pilot study to guide the modification and subsequent testing of the initial design. The data necessary to calculate the VAI are direct ratings by a clinical observer of the degree of activity in 9 organ systems and 3 indirect measures of vasculitis activity. These data are recorded on 0-4 visual analog scales. Physician's global assessment (PGA) is used as the "gold standard" measurement of disease activity. The VAI was validated using 2 independent data sets: the questionnaire data set, derived from test case histories ("paper cases") sent to 100 practicing rheumatologists, and the clinic data set, obtained from use of the VAI in 204 regular care visits of 74 patients with SNV. RESULTS The VAI correlated highly with the PGA: Pearson's correlation coefficient R = 0.84 (95% confidence interval [95% CI] 0.80-0.88) for the questionnaire data set, and R = 0.92 (95% CI 0.90-0.94) for the clinic data set. The mean of the interobserver coefficients of variation for the test case histories was lower for the VAI than for the PGA (mean difference 0.45; P = 0.002), indicating that the VAI has less interobserver variation than does the PGA. The change in VAI between clinic visits for individual patients correlated highly with the change in PGA (R = 0.88, 95% CI = 0.83-0.91). The VAI data collection form requires about 1 minute to complete, including computation of the score. CONCLUSION The VAI is a valid measure of vasculitis activity that correlates highly with the PGA. In addition, the VAI has less interobserver variation than the PGA and has a high level of sensitivity to change over time. Additional testing of the VAI appears warranted.
Collapse
|
14
|
Abstract
OBJECTIVE To develop a compulsory ambulatory rotation in rheumatology for internal medicine residents and to evaluate the educational effect of this rotation. METHOD All year 2 residents in the program participated in the rotation. The perceived quality of the learning experience was assessed by resident self-evaluation using a visual analog scale. Residents used a similar scale to rate their confidence in managing common rheumatologic problems. A validated multiple choice test was used to measure pre- and post-rotation knowledge of rheumatology and skill in interpreting bone radiographs. RESULTS On a 1 (no learning) to 5 (superior learning) scale, the mean rating of the rheumatology learning experience was 4.7 +/- 0.5. Residents' confidence in clinical skills significantly increased as well. Scores on the post-rotation rheumatology knowledge test increased 15% compared with pre-rotation scores (P < 0.0001). Confidence and skills in interpreting bone radiology films also significantly improved (P < 0.0001 for both items). CONCLUSION A relatively brief, subspecialty ambulatory rotation can be developed to expose all residents to a rheumatology curriculum. Such a rotation can increase their confidence, knowledge, and skills in important domains of outpatient rheumatology.
Collapse
Affiliation(s)
- D B Hellmann
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | | |
Collapse
|
15
|
Abstract
OBJECTIVE To explore the utility of peer review (review by fellow interns or residents in the firm) as an additional method of evaluation in a university categorical internal medicine residency program. DESIGN/PARTICIPANTS Senior residents and interns were asked to complete evaluations of interns at the end-of-month ward rotations. MAIN RESULTS Response rates for senior residents evaluating 16 interns were 70%; for interns evaluating interns, 35%. Analysis of 177 instruments for 16 interns showed high internal consistency in the evaluations. Factor analysis supported a two-dimensional view of clinical competence. Correlations between faculty, senior resident, and intern assessments of interns were good, although varied by domain. CONCLUSIONS An end-of-year attitude survey found that residents gave high ratings to the value of feedback from peers.
Collapse
Affiliation(s)
- P A Thomas
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | | |
Collapse
|
16
|
Hennebry TA, Mann JJ, Hellmann DB. Diaphragmatic paresis as a manifestation of large artery vasculitis. J Rheumatol 1999; 26:1837-9. [PMID: 10451087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
We describe the initial presentation and followup of a 54-year-old Caucasian woman who presented in 1995 with bilateral arteritis of the axillary arteries and acute onset dyspnea. Chest radiograph, chest fluoroscopy, and pulmonary function studies confirmed the diagnosis of right hemidiaphragmatic paresis. Prednisolone and methotrexate therapy and short term anticoagulation were initiated and she experienced no further sequelae during 2 years of followup.
Collapse
Affiliation(s)
- T A Hennebry
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | | |
Collapse
|
17
|
Ho AC, Roat MI, Venbrux A, Hellmann DB. Cogan's syndrome with refractory abdominal aortitis and mesenteric vasculitis. J Rheumatol 1999; 26:1404-7. [PMID: 10381065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Cogan's syndrome is a rare multisystem disease characterized by ocular inflammation, vestibuloauditory dysfunction, and vasculitis. We report a 26-year-old Caucasian woman who died from Cogan's syndrome. Her case illustrates that patients with Cogan's syndrome can have abdominal aortitis and mesenteric vasculitis, and that the vasculitis can be refractory to methotrexate, cyclophosphamide, cyclosporine, and chlorambucil.
Collapse
Affiliation(s)
- A C Ho
- Department of Medicine, The Johns Hopkins Hospital and Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | | | | |
Collapse
|
18
|
|
19
|
Pomper MG, Miller TJ, Stone JH, Tidmore WC, Hellmann DB. CNS vasculitis in autoimmune disease: MR imaging findings and correlation with angiography. AJNR Am J Neuroradiol 1999; 20:75-85. [PMID: 9974060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND AND PURPOSE MR findings in CNS vasculitis and their correlation with angiography have not been clearly defined. We therefore explored three hypotheses regarding CNS vasculitis associated with autoimmune disease: 1) MR imaging is highly sensitive; 2) a typical MR appearance exists; and, 3) MR and angiographic findings correlate well. METHODS We studied 18 patients with CNS vasculitis associated with autoimmune disease, characterized the MR lesions by type, size, number, and location, and correlated the MR findings with those of angiography. RESULTS All patients with CNS vasculitis had abnormalities on MR studies. On average, four +/- two lesions per patient were detected on MR images. The lesions were located in the subcortical white matter (n = 20), cortical gray matter (n = 16), deep gray matter (n = 16), deep white matter (n = 9), and cerebellum (n = 9). Only 65% of MR lesions were evident on angiograms; 44% of the lesions revealed on angiograms were detected by MR. CONCLUSION MR imaging is sensitive for CNS vasculitis. Lesions attributable to CNS vasculitis in autoimmune disease are distributed nearly equally among cortical, subcortical, and deep gray matter structures. The modest correlation between MR imaging and angiography suggests that the two techniques provide different information about CNS vasculitis and that both types of studies are needed for the complete assessment of damage caused by vascular abnormalities.
Collapse
Affiliation(s)
- M G Pomper
- Department of Radiology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | | | | | | | | |
Collapse
|
20
|
Hwang JM, Girkin CA, Perry JD, Lai JC, Miller NR, Hellmann DB. Bilateral ocular ischemic syndrome secondary to giant cell arteritis progressing despite corticosteroid treatment. Am J Ophthalmol 1999; 127:102-4. [PMID: 9933015 DOI: 10.1016/s0002-9394(98)00313-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To report the development of a bilateral ocular ischemic syndrome despite corticosteroid treatment in a patient with giant cell arteritis. METHOD Case report. RESULTS Despite receiving high-dose intravenous methylprednisolone and oral prednisone for biopsy-proven giant cell arteritis that presented as a severe anterior ischemic optic neuropathy in the right eye, a patient developed progressive ocular ischemia in that eye as well as an ocular ischemic syndrome in the fellow eye. CONCLUSIONS Some patients with giant cell arteritis, possibly patients with other underlying systemic vasculopathies, are refractory to what should be adequate treatment with systemic corticosteroids and may develop a bilateral ocular ischemic syndrome.
Collapse
Affiliation(s)
- J M Hwang
- Neuro-Ophthalmology Unit, Wilmer Eye Institute, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA
| | | | | | | | | | | |
Collapse
|
21
|
Stone JH, Hellmann DB. Questions regarding the design of the study of pulse versus oral cyclophosphamide in the treatment of Wegener's granulomatosis: comment on the article by Guillevin et al. Arthritis Rheum 1998; 41:1705-6; author reply 1707-9. [PMID: 9751110 DOI: 10.1002/1529-0131(199809)41:9<1705::aid-art28>3.0.co;2-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
22
|
Stone JH, Pomper MG, Hellmann DB. Histoplasmosis mimicking vasculitis of the central nervous system. J Rheumatol Suppl 1998; 25:1644-8. [PMID: 9712115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We describe a case of disseminated histoplasmosis that was erroneously diagnosed as central nervous system vasculitis and treated with immunosuppressive therapy. Our case emphasizes the importance of excluding infections before initiating treatment for presumed central nervous system vasculitis. Clinical clues to underlying Histoplasma infections are also discussed.
Collapse
Affiliation(s)
- J H Stone
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD 21205, USA
| | | | | |
Collapse
|
23
|
Hu PJ, Shih IM, Hutchins GM, Hellmann DB. Polyarteritis nodosa of the pericardium: antemortem diagnosis in a pericardiectomy specimen. J Rheumatol Suppl 1997; 24:2042-4. [PMID: 9330952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A 74-year-old white woman with diffuse myalgias, low grade fever, and pericardial effusion was found to have polyarteritis nodosa (PAN) in a pericardiectomy specimen. This diagnosis was confirmed at autopsy. Although pericardial involvement in PAN has been described, this is the first report of PAN diagnosed in a pericardiectomy specimen.
Collapse
Affiliation(s)
- P J Hu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | | | | |
Collapse
|
24
|
Jinnah HA, Dixon A, Brat DJ, Hellmann DB. Chronic meningitis with cranial neuropathies in Wegener's granulomatosis. Case report and review of the literature. Arthritis Rheum 1997; 40:573-7. [PMID: 9082947 DOI: 10.1002/art.1780400326] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We report the case of a 41-year-old man with chronic meningitis and cranial neuropathies in whom leptomeningeal biopsy demonstrated Wegener's granulomatosis. The literature on meningitis in this disease is reviewed. This case illustrates that Wegener's granulomatosis can cause chronic meningitis.
Collapse
Affiliation(s)
- H A Jinnah
- Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | | | | |
Collapse
|
25
|
Hellmann DB, Flynn JA. New ways to teach general internal medicine--the role of ambulatory subspecialty rotations. Trans Am Clin Climatol Assoc 1997; 108:259-270. [PMID: 9108682 PMCID: PMC2376600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- D B Hellmann
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | |
Collapse
|
26
|
Greidinger EL, Lemes V, Hellmann DB. Cardiac valve disease in Wegener's granulomatosis. J Rheumatol Suppl 1996; 23:1485-7. [PMID: 8856641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
27
|
Affiliation(s)
- P A Thomas
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | | |
Collapse
|
28
|
Abstract
Methotrexate has become the agent of choice for rheumatoid arthritis that does not respond to nonsteroidal anti-inflammatory drugs. In appropriately selected patients and with diligent monitoring, methotrexate in low weekly doses is effective and has a much better safety profile than was originally perceived.
Collapse
Affiliation(s)
- J A Flynn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | |
Collapse
|
29
|
Stone JH, Pomper MG, Roubenoff R, Miller TJ, Hellmann DB. Sensitivities of noninvasive tests for central nervous system vasculitis: a comparison of lumbar puncture, computed tomography, and magnetic resonance imaging. J Rheumatol Suppl 1994; 21:1277-82. [PMID: 7966069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine the sensitivities of lumbar puncture (LP), computed tomography (CT), and magnetic resonance imaging (MRI) for central nervous system (CNS) vasculitis. METHODS We reviewed the charts and radiologic studies of 20 patients with angiogram positive CNS vasculitis. RESULTS The patients ranged in age from 7-72 years, with a mean of 43.7 +/- 15.5 years. Twelve patients (60%) were women; 8 (40%) were men. Seven had primary angiitis of the CNS (PACNS), 8 had rheumatological illnesses (4 had systemic lupus erythematosus), and 5 had vasculitis due to other diverse etiologies, including 2 who had CNS infections. LP was positive in 8/15 angiographically proven cases, for a sensitivity of 53% [95% confidence interval (CI): 27-79]. The sensitivity of CT was 65% (11/17) (95% CI: 38-86), and that of MRI 75% (12/16) (CI: 48-93). The use of LP plus either CT or MRI was more sensitive than LP alone: for LP and CT, the sensitivity was 92% (11/12) (CI: 62-100), and for LP and MRI, 100% (12/12) (CI: 74-100). The combination of CT and MRI was not more sensitive than either test alone. CONCLUSION The sensitivities of LP, CT, and MRI for angiogram positive vasculitis are only modest. CT and MRI may be completely normal in cases of CNS vasculitis when the angiogram is positive. LP and either CT or MRI are of additive benefit in the diagnosis of CNS vasculitis, and should be done before angiography; and, in a patient with both a normal LP and a normal CT or MRI, a CNS angiogram is unlikely to be positive for vasculitis.
Collapse
Affiliation(s)
- J H Stone
- Division of Molecular and Clinical Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | | |
Collapse
|
30
|
McCarron DP, Hellmann DB, Traill TA, Watson RM. Neonatal lupus erythematosus syndrome: late detection of isolated heart block. J Rheumatol 1993; 20:1212-4. [PMID: 8371221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Heart block in neonatal lupus erythematosus is typically complete and detected in utero or in the neonatal period. We describe a child diagnosed with incomplete heart block at 9 years of age whose mother was diagnosed with Sjögren's syndrome and anti-Ro(SSA) 2 years after diagnosis of heart block in her child. This is the first case of late detection of incomplete heart block in a child felt to be causally related to the presence of anti-Ro(SSA) in the mother.
Collapse
Affiliation(s)
- D P McCarron
- Johns Hopkins Medical Institutions, Department of Medicine (Division of Molecular and Clinical Rheumatology, Division of Cardiology), Baltimore, MD
| | | | | | | |
Collapse
|
31
|
Hellmann DB. Immunopathogenesis, diagnosis, and treatment of giant cell arteritis, temporal arteritis, polymyalgia rheumatica, and Takayasu's arteritis. Curr Opin Rheumatol 1993; 5:25-32. [PMID: 8094625 DOI: 10.1097/00002281-199305010-00005] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Although the causes of giant cell arteritis, polymyalgia rheumatica, and Takayasu's arteritis are not known, the immune system participates in the pathogenesis of these disorders. Many reports indicate that cellular immunity is active in giant cell arteritis. The diagnosis of Takayasu's arteritis has been advanced by magnetic resonance imaging and ultrasonography. Neither technique has replaced angiography as the gold standard for diagnosis, but both may help monitor the response of Takayasu's arteritis to therapy. The diagnosis of giant cell arteritis with a low erythrocyte sedimentation rate is unusual but is more frequent in patients with a history of polymyalgia rheumatica or corticosteroid use. One recent retrospective study suggests that 20 mg/d of prednisolone is as effective as higher doses in treating giant cell arteritis. Other preliminary studies indicate that methotrexate may effectively spare corticosteroid use in giant cell arteritis and Takayasu's arteritis. Angioplasty for renal artery stenosis in Takayasu's arteritis initially cures 30% of patients and improves the condition in 70%; however, the long-term success rate is 50%. New studies demonstrate that patients with giant cell arteritis and polymyalgia rheumatica have an increased risk of hypothyroidism.
Collapse
Affiliation(s)
- D B Hellmann
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| |
Collapse
|
32
|
Roubenoff R, Roubenoff RA, Ward LM, Holland SM, Hellmann DB. Rheumatoid cachexia: depletion of lean body mass in rheumatoid arthritis. Possible association with tumor necrosis factor. J Rheumatol Suppl 1992; 19:1505-10. [PMID: 1464859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate body composition and serum tumor necrosis factor (TNF) levels in a series of 24 patients with rheumatoid arthritis (RA). METHODS Body composition assessment by anthropometric measures and bioelectrical impedance. Cytokine determination in serum by ELISA: RESULTS When compared to United States population norms, 16 of the subjects (67%) were cachectic. In regression models, lean body mass (LBM) was inversely associated with the number of swollen joints (p < 0.025). Elevated TNF-alpha was found in 3 of 5 flaring patients vs 0 of 18 patients with less active disease (p = 0.001). These 3 were all cachectic, while the 2 flaring patients without detectable TNF had normal LBM (p < 0.03). Among the whole group, there was a trend toward increasing disability with decreased LBM after adjusting for joint pain and disease duration (p < 0.07). CONCLUSION Cachexia is common in RA, and may be cytokine driven. Given the prognostic impact of LBM wasting in other diseases, the effect of rheumatoid cachexia on outcome in RA deserves further study.
Collapse
Affiliation(s)
- R Roubenoff
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | | | | | | | | |
Collapse
|
33
|
Hellmann DB. Spondyloarthropathy with hidradenitis suppurativa. JAMA 1992; 267:2363-5. [PMID: 1564778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- D B Hellmann
- Johns Hopkins University School of Medicine, Baltimore, MD 21205
| |
Collapse
|
34
|
Hellmann DB, Roubenoff R, Healy RA, Wang H. Central nervous system angiography: safety and predictors of a positive result in 125 consecutive patients evaluated for possible vasculitis. J Rheumatol Suppl 1992; 19:568-72. [PMID: 1593579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
To determine the complication rate of cerebral angiography and to identify variables associated with angiograms positive for vasculitis, we retrospectively evaluated 125 consecutive patients who had angiography because of possible central nervous system (CNS) vasculitis. Sixteen of 125 (12.8%) had angiograms positive for CNS vasculitis. Fourteen (11.5%) experienced a transient and 1 (0.8%) had a persistent neurologic deficit due to angiography. The complication rates between patients who were angiogram positive and angiogram negative did not differ (p greater than 0.05). Two clinical variables were significant risk factors for having an angiogram positive for CNS vasculitis: a preexisting rheumatic disease diagnosis (relative odds 3.39, 95% CI 1.08-10.62, p less than 0.033) and an abnormal lumbar puncture (relative odds 5.50, 95% CI 1.13-26.64, p less than 0.031). We conclude that the risk of persistent neurologic complications from angiography is low in patients who have or are suspected of having CNS vasculitis.
Collapse
Affiliation(s)
- D B Hellmann
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21205
| | | | | | | |
Collapse
|
35
|
Hellmann DB. Medical therapy for SLE. Md Med J 1991; 40:923-33. [PMID: 1943522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Today, the major therapeutic challenge in systemic lupus erythematosus is to preserve the gains provided by corticosteroids while reducing their side effects.
Collapse
Affiliation(s)
- D B Hellmann
- Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
36
|
Hellmann DB, Abribat M. Golf scores as a measure of giant cell arteritis. J Rheumatol 1991; 18:1116-7. [PMID: 1920323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
37
|
Roubenoff R, Drew H, Moyer M, Petri M, Whiting-O'Keefe Q, Hellmann DB. Oral cimetidine improves the accuracy and precision of creatinine clearance in lupus nephritis. Ann Intern Med 1990; 113:501-6. [PMID: 2393206 DOI: 10.7326/0003-4819-113-7-501] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To determine whether short-term use of oral cimetidine improves the precision of creatinine clearance (CCr) and reduces the overestimation of glomerular filtration rate (GFR) that occurs with this test in patients with lupus nephritis (because creatinine is secreted by injured renal tubular cells). DESIGN Double-blind, placebo-controlled, crossover clinical trial. PATIENTS Thirteen patients with lupus nephritis with mild renal insufficiency (mean serum creatinine, 230 mumol/L [2.6 mg/dL]; median, 106 mumol/L [1.2 mg/dL]). INTERVENTIONS Patients were given placebo or cimetidine tablets, 400 mg four times daily for 2 days, with ambulatory 24-hour urine collection during the second 24 hours ("outpatient study"). Simultaneous 4-hour technetium-99-diethylenetriamine penta-acetic acid (Tc99-DTPA) and CCrs were measured immediately after each 24-hour collection ("simultaneous study"). MEASUREMENTS AND MAIN RESULTS Use of cimetidine improved the accuracy of CCr, as measured by the CDTPA-to-CCr ratio (1.07 [cimetidine] compared with 1.33 [placebo]; P less than 0.05). Cimetidine use also improved the precision of CCr (P less than 0.05). In addition, when compared with standard clinical estimators of GFR, creatinine clearance with cimetidine rendered the most precise estimates of GFR and explained more of the variation in GFR estimation than did any other method (R2 = 0.78 compared with R2 = 0.52 to 0.63). These effects were shown under both simultaneous and outpatient conditions. No side effects due to cimetidine occurred. CONCLUSIONS In patients with lupus nephritis, the cimetidine-aided CCr offers a compromise between the precise and accurate but expensive and inconvenient research techniques (inulin, iothalamate, or DTPA clearances) and the grossly inaccurate and imprecise but convenient technique (CCr) for determining GFR.
Collapse
Affiliation(s)
- R Roubenoff
- Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | | | | | | | | |
Collapse
|
38
|
Ratain JS, Petri M, Hochberg MC, Hellmann DB. Accuracy of creatinine clearance in measuring glomerular filtration rate in patients with systemic lupus erythematosus without clinical evidence of renal disease. Arthritis Rheum 1990; 33:277-80. [PMID: 2306295 DOI: 10.1002/art.1780330219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We sought to determine whether creatinine clearance (Ccr) gives an accurate measurement of the glomerular filtration rate in patients with systemic lupus erythematosus (SLE) with no clinical evidence of renal disease. Eighteen such SLE patients underwent measurement of Ccr and 99mtechnetium-DTPA clearance (CDTPA). The mean +/- SD Ccr:CDTPA ratio was 1.12 +/- 0.15 (95% confidence interval 1.04-1.20). These results indicate that Ccr gives an accurate measurement of the glomerular filtration rate in the majority of SLE patients who do not have clinical evidence of renal disease.
Collapse
Affiliation(s)
- J S Ratain
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | | | | | | |
Collapse
|
39
|
Bilazarian SD, Baughman KL, Hutchins GM, Hellmann DB. Systemic lupus erythematosus presenting as acute severe mitral regurgitation. Am J Med 1990; 88:60N-63N. [PMID: 2195884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- S D Bilazarian
- Department of Internal Medicine, Johns Hopkins School of Medicine and Hospital, Baltimore, Maryland 21205
| | | | | | | |
Collapse
|
40
|
Simonson JS, Schiller NB, Petri M, Hellmann DB. Pulmonary hypertension in systemic lupus erythematosus. J Rheumatol 1989; 16:918-25. [PMID: 2769664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A prospective study was performed in our center on 60% (n = 36) of patients with systemic lupus erythematosus (SLE) to determine the prevalence and severity of pulmonary hypertension. Twenty-six healthy subjects of similar age and sex served as controls. Pulmonary artery systolic pressure was calculated from the sum of the peak tricuspid insufficiency Doppler pressure gradient and an estimate of right atrial pressure based on inferior vena cava size and its degree of inspiratory collapse. Five patients with SLE (14%) had pulmonary hypertension, defined as pulmonary artery systolic pressure greater than 30 mm Hg. Cardiac indices determined by planimetry of biplane apical 2-dimensional echocardiographic images were low or normal in the patients with pulmonary hypertension implying increased pulmonary vascular resistance as the etiology for elevated pulmonary artery pressure. The mean pulmonary artery systolic pressure in patients with SLE was 25 +/- 10 mm Hg vs 20 +/- 2 in controls (p = 0.002). No control had a pulmonary artery systolic pressure greater than 23 mm Hg. Patients with pulmonary hypertension had a shorter duration of SLE and steroid therapy and a higher prevalence of cytotoxic treatment and Raynaud's phenomenon in comparison to those with normal pulmonary artery pressures. The prevalence of systemic hypertension, interstitial lung disease, pleurisy, pericarditis, cutaneous manifestations, arthritis, renal disease, central nervous system involvement, and hematologic abnormalities was similar in patients with SLE with normal and elevated pulmonary artery pressure. Our study suggests that pulmonary hypertension in SLE is common but usually mild.
Collapse
Affiliation(s)
- J S Simonson
- Department of Medicine, University of California School of Medicine, San Francisco
| | | | | | | |
Collapse
|
41
|
Hong MK, Hellmann DB. Hemidiaphragm paralysis: a new pulmonary manifestation of giant cell arteritis. J Rheumatol 1989; 16:253-4. [PMID: 2746576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
42
|
Roubenoff R, Hoyt J, Petri M, Hochberg MC, Hellmann DB. Effects of antiinflammatory and immunosuppressive drugs on pregnancy and fertility. Semin Arthritis Rheum 1988; 18:88-110. [PMID: 3064307 DOI: 10.1016/0049-0172(88)90002-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- R Roubenoff
- Department of Medicine, Johns Hopkins University School of Medicine and Hospital, Baltimore, MD
| | | | | | | | | |
Collapse
|
43
|
Hellmann DB, Laing TJ, Petri M, Whiting-O'Keefe Q, Parry GJ. Mononeuritis multiplex: the yield of evaluations for occult rheumatic diseases. Medicine (Baltimore) 1988; 67:145-53. [PMID: 2835572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
We identified 35 patients who had electrodiagnostic evidence of mononeuritis multiplex and did not have diabetes or multiple nerve compressions. Their charts were reviewed to determine the etiologies of the mononeuritis multiplex and to determine how often the laboratory examination revealed a rheumatic disease in patients whose initial history and physical examination did not suggest that a rheumatic disease was present. In 11/35 (31%; CI = 17-49) a disorder capable of causing mononeuritis multiplex was diagnosed before the symptoms of mononeuritis multiplex began. Ten had a rheumatic disease; 1 had lymphoma. Nine of the other patients were suspected, on the basis of the history and physical examination, of having new onset of a rheumatic disease. Subsequent laboratory evaluation showed that 5/9 (56%; CI = 21-86) had a rheumatic disease, and 4/9 (44%; CI = 14-79) were unknowns. In 15/35 (43%; CI = 26-61) patients with mononeuritis multiplex, no rheumatic disease was suspected on the basis of the initial history and physical examination. The subsequent laboratory examination revealed an underlying rheumatic disease in 0/15 (0%; CI = 0-18). Mean clinical follow-up of 16 +/- 16 months in the patients with mononeuritis multiplex of unknown cause also failed to identify a rheumatic disease. Overall 19/35 (54%; CI = 37-71) did not have a rheumatic disease or any other known cause. Of the 14 patients with mononeuritis multiplex associated with a rheumatic disease, 5/14 (36%; CI = 13-15) had systemic lupus erythematosus; an additional patient had both lupus and the CREST syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- D B Hellmann
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | |
Collapse
|
44
|
Abstract
The causes of death were examined in patients with systemic lupus erythematosus (SLE) who were cared for at the University of California, San Francisco and who died after 1969. Of the 44 deaths analyzed, 33 patients had autopsies. Infections were common and often determined to be the cause of death. Overall, infections were present in 55 percent (22/44), and judged to be a cause of death in 30 percent (13/44) of all deaths. The infections could be divided into 2 groups: those due to common bacterial organisms and those due to opportunistic infections. These two types of infections occurred with similar frequency. When compared to common bacterial infections, however, the opportunistic infections were more likely to be first diagnosed at autopsy (p = .001). In only 3 of the 15 patients with an opportunistic infection was the diagnosis made antemortem. Failure to diagnose an opportunistic infection early occurred when the infection simulated active SLE, and when the possibility of an opportunistic infection was not aggressively investigated. The most common opportunistic infections were Candida albicans and Pneumocystis carinii. The most common site of opportunistic infection was the lung. Seventeen patients had 27 common bacterial infections, chiefly sepsis from Staphylococcus aureus and aerobic gram-negative organisms. Eight patients had both a common bacterial and an opportunistic infection. Stepwise linear regression analysis showed that death from infection correlated most strongly with prednisone and cytotoxic drug use in the 3 months before final admission. No measure of lupus activity was found to correlate with death from infection, except that hypocomplementemia correlated with death from bacterial infections.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
|
45
|
Abstract
We describe the initial course and followup of a 16-year-old white female patient who presented in 1983 with aortitis and rapidly progressive renal failure. Renal biopsy revealed crescentic glomerulonephritis. Segmental occlusions of the distal aorta and both common iliac arteries were demonstrated on aortography. Initially, her renal function and arterial occlusions markedly improved with pulse prednisolone therapy, but 34 months later, the glomerulonephritis and aortitis worsened. This case report, the first of its kind, documents both the association of Takayasu's arteritis with crescentic glomerulonephritis and a marked, though incomplete, response to pulse therapy.
Collapse
|
46
|
Abstract
Six cases of amateur athletes who have severe atypical degenerative joint disease (DJD) are presented; their histories suggest that chronic, repetitive trauma was causative in the development of their arthropathy. Although many examples of this process have been reported in professional athletes, it has not been reported in amateurs. As participation in athletic activities increases we can, perhaps, expect to see more of this type of DJD in the future.
Collapse
|
47
|
Hellmann DB, Stobo JD. The autologous mixed-lymphocyte reaction. Gastroenterology 1982; 83:140-2. [PMID: 6210598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
|
48
|
Smith CR, Lipsky JJ, Laskin OL, Hellmann DB, Mellits ED, Longstreth J, Lietman PS. Double-blind comparison of the nephrotoxicity and auditory toxicity of gentamicin and tobramycin. N Engl J Med 1980; 302:1106-9. [PMID: 6988713 DOI: 10.1056/nejm198005153022002] [Citation(s) in RCA: 314] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Two hundred fifty-eight patients with suspected sepsis were treated with tobramycin or gentamicin in a prospective, randomized, double-blind trial. One hundred forty-six patients received nine or more doses, had serial determinations of serum creatinine, and were evaluated for nephrotoxicity; 91 were able to cooperate with audiometry and were evaluated for auditory toxicity. Auditory toxicity developed in five of 47 (10 per cent) given gentamicin and five of 44 (11 per cent) given tobramycin. Nephrotoxicity developed in 19 of 72 (26 per cent) given gentamicin and nine of 74 (12 per cent) given tobramycin (P less than 0.025). The severity of the nephrotoxicity was not different; the mean increase in creatinine was 1.3 mg per 100 ml (114.9 mumol per liter) in both groups. Both the tobramycin and gentamicin groups had a similar mean age, initial serum creatinine level, total dose, serum aminoglycoside level, and duration of therapy. We conclude that tobramycin causes nephrotoxicity less frequently than does gentamicin.
Collapse
|
49
|
Abstract
The effect of ethyl adenosine-5'-carboxylate hydrochloride (EA) was determined in 17 dogs by the radioactive microsphere technique. In both experimental and control animals, microspheres were injected 5 min before (preocclusion period), 60 min after (occlusion period), and 75 min after (saline or vasodilation period) ligation of the left anterior descending coronary artery (LAD). Ten seconds prior to the third microsphere injection, saline was administered to five control animals, and saline with 0.5 mg/kg of EA was given to 12 experimental animals. There was no significant change in myocardial blood flow after saline injection. After EA, mean arterial pressure fell 10% (P less than .001); myocardial blood flow increased 275% (P less than .001) in the nonischemic left circumflex artery (CIRC) area and increased 82% (P less than .01) in the occluded LAD area. In addition, those animals with extensive collateral development showed a significantly greater increase in collateral blood flow than those with minimal collateral development (P less than .05). Thus, EA may increase flow to ischemic areas of myocardium dependent upon the extent of preexistent collateral supply.
Collapse
|