Respiratory and otolaryngologic manifestations of giant cell arteritis

OBJECTIVES

The classical presentation of giant cell arteritis (GCA) includes the new onset of headache, scalp tenderness, facial pain or jaw claudication in an older patient. Many patients with GCA have features consistent with the diagnosis of polymyalgia rheumatic (PMR) and nearly all have elevated markers of inflammation such as the erythrocyte sedimentation rate (ESR) or the serum C-reactive protein (CRP). Respiratory and ear-nose-throat (ENT) signs and symptoms such as cough, tongue infarction, trismus, hearing loss and facial swelling are less commonly described, yet they may be the initial presentation of GCA. Our aim was to review the published literature on the topic of respiratory and otologic manifestations of GCA.

METHODS

A literature search was performed on PUBMED and MEDLINE using the following keywords: GCA, temporal arteritis, pulmonary, respiratory, ENT, cough, tongue necrosis.

RESULTS

The upper and lower airways manifestations of GCA include a wide variety of conditions that could be caused by ischaemia due to the vasculitis.

CONCLUSIONS

It is important to recognize these atypical presentations because they may be the sole initial manifestation of the disease. Early suspicion and confirmation of the diagnosis of GCA can help to prevent more catastrophic consequences of unrecognized disease, including stroke and blindness.

Whither the drug specialist? The work-force development needs of drug specialist staff and agencies

Drug specialist staff and agencies have been identified as having a critical role in responding to alcohol and other drug-related harm. This role must be seen in the context of the broad needs of people affected by drug use and the services that they utilize. Unfortunately, as in generic mainstream services, skill development, expertise, organizational structures and resources do not always support the demands of the drug specialist role. In order to develop the drug specialist work-force we must first review the evidence about the factors that influence effective practice. The available research indicates that a range of strategies is required and that these should not only focus on building the capacity of individuals, but also on organizations and systems. Substantial effort in capacity building is required in order to fulfil the expectations created by the title "drug specialist".

Leflunomide-associated weight loss in rheumatoid arthritis

OBJECTIVE

To determine the frequency of weight loss in patients treated with leflunomide for rheumatoid arthritis at an arthritis referral center.

METHODS

We queried 35 rheumatologists at the Robert Breck Brigham Arthritis Center to determine if weight loss had occurred as an adverse event in patients treated with leflunomide between November 1998 and January 2000. Five such patients were identified and their clinical course was reviewed.

RESULTS

Five of 70 patients who had begun leflunomide therapy had significant weight loss that could not be linked to other identifiable etiologies. The amount of weight loss was substantial in this group of patients, ranging from 19 pounds to 53 pounds. All patients had normal levels of thyroid-stimulating hormone and no other gastrointestinal complaints; evaluation revealed no other cause for the weight loss. Despite the significant weight loss, 4 of the 5 patients continued to take the drug due to its efficacy.

CONCLUSION

Significant weight loss is a potential adverse event in patients with rheumatoid arthritis treated with leflunomide. Awareness of this may obviate the need for extensive medical evaluations.

Zileuton, a 5-lipoxygenase inhibitor in rheumatoid arthritis

The effects of zileuton, a new 5-lipoxygenase inhibitor, on leukotriene generation and clinical response in rheumatoid arthritis (RA) was studied in a 4-week randomized double blind placebo controlled study at 2 academic rheumatology centers. Zileuton decreased the mean (+/- SEM) ionophore induced synthesis of leukotriene B4 at Week 1 by 70% from 191.2 +/- 28.5 to 57.5 +/- 17.0 ng/ml. A parallel suppression of all major 5-lipoxygenase pathway products was observed. An improvement in clinical variables was observed in the zileuton and placebo treated population. No unique toxicity was identified in this study. Zileuton inhibited 5-lipoxygenase in RA with a suggestion of clinical response with limited toxicity.

The effects of cyclosporin A on eicosanoid excretion in patients with rheumatoid arthritis

Alterations in renal eicosanoid levels have been postulated as a factor in cyclosporin A (CSA) nephrotoxicity. The effects of CSA on renal eicosanoid excretion in rheumatoid arthritis were studied over a 24-week period, during which treatment with nonsteroidal antiinflammatory drugs was discontinued. The initial dosage of CSA was 4 mg/kg/day; at week 24, the mean dosage of CSA was 3.9 mg/kg/day. At week 24, the mean (+/- SD) serum creatinine level (1.04 +/- 0.24 mg/dl) was 32% above the baseline value; renal blood flow had decreased by 21% (P less than 0.03) and the glomerular filtration rate had decreased by 16%. There was a significant increase (P less than 0.03) in the 2,3-dinor thromboxane B2 level at week 2, but there was no significant change in the levels of the other eicosanoids. This study demonstrates that after CSA treatment, there is a selective increase in a thromboxane metabolite that parallels an increase in renal vascular resistance, even in the absence of nonsteroidal antiinflammatory drugs, and with unimpaired formation of other vasodilator eicosanoids.

Generalized skeletal response to 99mtechnetium methylene diphosphonate in rheumatoid arthritis

The total body retention (TBR) and the 5- and 24-h lumbar spine to soft tissue (LS/ST) ratios of 99mtechnetium methylene diphosphonate was studied in 19 patients with rheumatoid arthritis (RA), 16 patients with metastatic tumors that did not involve the lumbar spine, 10 patients with chronic renal failure and 17 controls. The TBR was significantly higher in all groups compared to the controls. The 5-h LS/ST did not differ between any of the groups although the 24-h LS/ST ratios were significantly elevated in RA and those with chronic renal failure. The 24-h LS/ST in RA was correlated only with disease duration. The results are consistent with a generalized increase in bone turnover in RA and may explain the recognized lack of sensitivity of quantitative scintigraphic techniques in this disorder.

Radiophosphate imaging of regional migratory osteoporosis

A patient with regional migratory osteoporosis had somewhat unusual features in that there was involvement of the small joints of the foot demonstrable by 99mTc-methylene diphosphonate joint imaging.