Spontaneous resolution of lupus nephritis following withdrawal of etanercept

INTRODUCTION

Etanercept, a systemic inhibitor of α-TNF, is used for treatment of various autoimmune disorders. We report a case of spontaneous resolution of etanercept-induced lupus nephritis.

CASE DESCRIPTION

A 57-year-old female patient taking etanercept for psoriasis presented with laboratory-and histology-confirmed lupus nephritis. After stopping etanercept, there was normalization of proteinuria, hematuria, serum complements, anti-dsDNA antibody, and resolution of the acute glomerular inflammatory process on repeat kidney biopsy.

CONCLUSION

This case demonstrates serology- and biopsy-confirmed resolution of active lupus nephritis upon withdrawal of etanercept.

Appraising osteoporosis care gaps

To evaluate physician response to dual-energy X-ray absorptiometry (DXA) report within the Geisinger Medical Center's Mobile DXA Program and treatment adherence at 1 year. Between 10/01/2004 and 3/30/2005, 1381 DXA scans were performed in our Mobile DXA Program. Within this cohort, we identified 366 high-risk, drug-naive patients and report the percentage of patients placed on prescription drug therapy within 90 days of DXA result. Additionally, we identified 191 patients with Z-score of -1.0 or worse and report whether laboratory tests were ordered within 90 days of DXA results in this group. Finally, we determined treatment adherence at 1 year. 269 patients (74%) were offered prescription therapy within 3 months of DXA results. Of those, 210 (57%) were still adherent to drug therapy at 1 year. The main reason for discontinuation of treatment was an adverse drug side effect. Additionally, in 50% cases, physicians ordered 1 or more laboratory tests to evaluate low Z-score. Within our Mobile DXA Program, 74% of high-risk, drug-naïve patients were treated. Interestingly, in 50% cases, when a low Z-score was reported, our physicians ordered 1 or more laboratory tests. Treatment adherence was 57% at 1 year.

Improved influenza and pneumococcal vaccination in rheumatology patients taking immunosuppressants using an electronic health record best practice alert

OBJECTIVE

To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications.

METHODS

A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fisher's exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites.

RESULTS

PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001).

CONCLUSION

The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.

Remitting seronegative symmetrical synovitis with pitting edema syndrome in a rural tertiary care practice: a retrospective analysis

OBJECTIVE

To review the clinical and laboratory features of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) in a rural tertiary care rheumatology practice, describe treatments and outcomes, and compare our results to previous reports in the literature.

PATIENTS AND METHODS

We performed a retrospective chart review of all patients diagnosed as having RS3PE who were seen in the Department of Rheumatology at Geisinger Medical Center, Danville, PA, from January 1, 1992, to December 31, 2005.

RESULTS

We identified 12 men and 2 women, all of whom were white. Mean +/- SD age was 74.0 +/- 6.6 years; mean +/- SD erythrocyte sedimentation rate was 35.9 +/- 21.1 mm/h at presentation. Onset of illness was sudden in 9 patients and insidious in 5. All patients were initially treated with prednisone (15-20 mg/d). Although the response in all was excellent, 9 patients received disease-modifying antirheumatic drugs, either because of ongoing disease activity or in an effort to decrease the use of corticosteroids. Hydroxychloroquine was used alone in 7 patients. At the mean +/- SD time of last follow-up (31.4 +/- 23.1 months), 5 patients continued to receive therapy. Complications of treatment included worsening of preexisting hypertension in 3 patients, gastritis in 2, and exacerbation of preexisting diabetes mellitus in 1. Carpal tunnel syndrome occurred in 6 patients. Duration of therapy ranged from 5 to 120 months (mean, 29 months). Three patients developed malignancies, ie, non-Hodgkin lymphoma, transitional cell carcinoma of the bladder, and prostate carcinoma.

CONCLUSION

Our population of patients with RS3PE is similar to those documented in previous reports: elderly, predominantly male, and responsive to corticosteroids. However, our series is clinically differentiated by a greater use of adjunctive disease-modifying antirheumatic drugs (primarily hydroxychloroquine). Confirming previous reports, we also observed a possible association between RS3PE and malignancy.

Glucocorticoid-Induced Osteoporosis Program (GIOP): a novel, comprehensive, and highly successful care program with improved outcomes at 1 year

INTRODUCTION

Patients who take chronic glucocorticoids (GC) are at increased risk of osteoporosis and fracture. Only a minority of patients who take chronic GC receive optimal osteoporosis prevention, diagnosis, and/or treatment.

METHODS

An organized program of care--GIOP (Glucocorticoid-Induced Osteoporosis Program)--was designed and implemented. The program goals were to identify patients at risk of fracture, provide education, redesign and implement new pathways of care, and monitor outcomes. Two hundred chronic GC users were seen at baseline, and follow-up visits scheduled at 6 months and 1 year.

RESULTS

Patient retention of knowledge, frequent exercise, and 25-OH Vitamin D levels all significantly improved at 1 year. A significant decrease in GC dose was seen. In terms of adherence, 91% of patients considered at high risk were taking a bisphosphonate or teriparatide at 1 year, and 96% of patients overall were adherent to their prescribed regimen of calcium, vitamin D, and prescription treatment (if indicated). Bone density at the spine and total hip increased significantly.

CONCLUSIONS

GIOP is the first organized program of care for patients who take chronic GC that has demonstrated a clinically significant improvement in outcome. The program's design can be adapted and used by other health systems and organizations.

Corneal melt in rheumatic disorders: effect of disease-modifying antirheumatic drugs on morbidity

OBJECTIVE

The objective of this study was to review the characteristics of patients with corneal melt and to assess if treatment with disease-modifying antirheumatic drugs (DMARDs) improved the visual outcome.

METHOD

We did a retrospective analysis of patients diagnosed with corneal melt between 1976 and 2002. Twenty-one patients with rheumatoid arthritis and 5 patients with primary Sjögren syndrome (26 patients, 42 eyes) were included in the analysis of visual outcome. Visual outcome was described as "fair" if the corrected visual acuity was 20/200 or better and as "poor" if the corrected visual acuity was worse than 20/200.

RESULTS

Visual outcome was fair in 9 patients (90%) in the DMARD group versus 2 patients (13%) in the no DMARD group (P= 0.001), and in 14 eyes (93%) in the DMARD group versus 7 eyes (26%) in the no DMARD group (P = 0.001).

CONCLUSION

The use of DMARDs improves visual outcome in patients with corneal melt.

Carpal tunnel syndrome due to tophaceous gout

Tophaceous gout is a recognized cause of carpal tunnel syndrome. Of 2649 carpal tunnel releases, 15 hands in 13 patients were identified with tophaceous gout in the carpal tunnel. The incidence of tophaceous gout in the carpal tunnel was 0.6%. Twelve of 13 patients were male, and 8 of 10 patients with a history of gout developed carpal tunnel syndrome despite adequate medical treatment. Thus, consideration should be given for tophi as a cause of carpal tunnel syndrome, especially in older men despite medical treatment for gout.

"The rheumatologist can see you now": Successful implementation of an advanced access model in a rheumatology practice

OBJECTIVE

To provide rheumatologic care to patients in a timely and patient-centered manner.

METHODS

We developed and implemented processes to measure and help eliminate backlog, created access time for same-day patients, and retooled the appointments process to be more efficient and patient focused. In addition, we developed a protocol to be used by our primary care colleagues to care for osteoarthritis of the knee in a standardized manner.

RESULTS

The third available rheumatology appointment fell from about 60 days to <2 days. Cancellations fell from 40% to <20%. Patient satisfaction measures (composite score, physician score, and accessibility score) improved significantly. The number of new patients seen for knee osteoarthritis decreased by 6.7%, whereas the number of new rheumatoid arthritis referrals increased by 50.4%. Financial performance improved as well.

CONCLUSIONS

This advanced access model in a busy academic rheumatology practice demonstrated considerable improvement in access, patient satisfaction, and finances. Using a team approach, we are now able to give the patient the rheumatologic care they want and need at a time they want and need it.

Pyomyositis: clinical features and predisposing conditions

OBJECTIVE

To describe the manifestations of nontropical pyomyositis and associated comorbid conditions that may predispose to pyomyositis.

METHODS

A retrospective review of 13 patients with pyomyositis seen at our center including one illustrative case report. Reports of tropical and nontropical pyomyositis were found by review of Index Medicus, Medline, and references from published cases and clinical review papers.

RESULTS

All 13 patients had variable presentations including fever, muscle pain, tenderness, and swelling. Eleven patients had comorbid conditions that may have led to their infection, including one with human immunodeficiency virus and 3 with history of trauma. Staphylococcus aureus was found to be a causative organism in 7 patients, 2 patients had multiple organisms isolated, and 2 had no organisms isolated. Eleven patients had successful treatment with intravenous antibiotics and either computerized tomographic scan guided percutaneous or open operative drainage.

CONCLUSION

Onset of pyomyositis is usually insidious, with progression to purulent collections. Comorbid conditions likely predispose patients to pyomyositis and may contribute to delay in diagnosis and treatment. Increased awareness of this disease, especially in an immunosuppressed patient, should lead to earlier diagnosis and treatment with improved outcomes.

Sulfasalazine therapy in psoriatic arthritis: clinical and immunologic response

Sulfasalazine therapy has been shown effective in rheumatoid arthritis and ankylosing spondylitis. We treated 10 patients with active polyarticular psoriatic arthritis with 2 g/day of sulfasalazine for 16 weeks. Significant improvement was seen in joint count score, morning stiffness, and patient/physician assessment of disease activity. Toxicity requiring drug cessation was seen in only 1 patient. Patients with psoriatic arthritis had elevated B cells and immunoglobulin levels which fell with sulfasalazine therapy. Minimal changes were seen in T cell subsets. Sulfasalazine appears to be an effective second line agent for the treatment of psoriatic arthritis. Its mechanism of action may in part relate to alteration of B cell number and function.

Plant thorn synovitis: an uncommon cause of monoarthritis

Plant thorn synovitis (PTS) is an uncommon cause of monoarthritis. Seven cases of PTS were identified at our institution from January 1979 to July 1990, six of whom were men. Mean age was 27 years (range, 7 to 56 years). Symptoms included pain, swelling, and stiffness. Synovitis was present on examination along with decreased range of motion of affected joints in all patients. Roentgenograms were unremarkable in five patients, but disclosed demineralization in two others. Initial conservative treatment with nonsteroidal antiinflammatory drugs (NSAIDs), antibiotics, or splinting was usually unsuccessful; surgery was necessary in six patients. Findings included marked inflammatory synovial reactions with evidence of retained thorn in all patients. One patient had a positive operative wound culture (Enterobacter agglomerans) without evidence of osteomyelitis. All patients improved after surgery without sequelae. Despite a history suggesting thorn injury in many cases, diagnosis was often delayed; mean time to diagnosis was 10 weeks (range, 2 weeks to 9 months). PTS must be included in the differential diagnosis of monoarthritis. Histologically, PTS can mimic sarcoidosis, tuberculosis, or fungal infection. Optimal treatment of PTS is arthrotomy, foreign body removal, and extensive synovectomy.

Pyogenic sacroiliitis in a rural population

We describe 10 cases of pyogenic sacroiliitis occurring in a rural population. Seven were male and 3 were female with a mean age of 22.4 years. None was a recent intravenous drug abuser. Five patients had a history of recent pelvic trauma. 99mTechnetium scintiscans revealed increased sacroiliac (SI) joint uptake in 8 of 8 cases. Blood cultures were positive in 60% of patients. Staphylococcus aureus was isolated in 7 cases from blood and/or SI aspirates and Hemophilus influenzae type B in one case. Nine of 10 patients recovered completely. One underwent arthrodesis for recurrent SI pain without evidence of relapse of infection. Median followup was 18 months.

Suppurative extensor tenosynovitis caused by Staphylococcus aureus

Suppurative tenosynovitis is a rare infection, occurring almost exclusively in the flexor tendon sheath as a posttraumatic event. We report the case of a systemically ill woman with suppurative tenosynovitis of the extensor tendons caused by Staphylococcus aureus. Early recognition of this unusual infection may prevent unnecessary morbidity.

Acute calcific tendinitis of the hand and wrist: a report of 12 cases and a review of the literature

Acute calcific tendinitis is a frequently unrecognized cause of hand and wrist tenderness and swelling. We report 12 cases seen over an 8-year period. Roentgenograms showed deposits in various peritendinous sites especially near the pisiform. Special views may be required for visualization. A correct diagnosis was made in 5/12 cases; other etiologies considered included closed-space infections. In most cases, treatment consisted of immobilization plus nonsteroidal antiinflammatory drugs or local steroid injections. Results were uniformly good. Seven of 7 patients demonstrated resolution of calcium deposits on subsequent roentgenograms. Failure to recognize this entity may cause unnecessary investigation and therapy.

Septic arthritis due to gram negative bacilli: older patients with good outcome

Previous studies of gram negative bacillary septic arthritis conclude it is an uncommon disease of older patients with poor outcome, or of younger patients with good outcome. We reviewed 22 cases of gram negative bacillary septic arthritis in a rural population. The mean age was 61 years, symptoms were of short duration (6.5 days mean), and a chronic illness was frequently present (77%). The knee was involved in 73% and E. coli was the usual causative organism (32%). Antibiotics plus aspiration was a successful initial therapy. Overall survival was 95% and a good outcome was achieved in 68%. Gram negative bacillary septic arthritis affects older patients, and the outcome appears good.

Cholecystitis and cholelithiasis

Cholelithiasis and cholecystitis, with their complications, remain major health problems in the United States. At this time, cholecystectomy is the treatment of choice for all patients with symptomatic gallstones and those with acute cholecystitis, except those who are too ill to undergo surgery. Present therapeutic options may be summarized as follows: Asymptomatic patients and those with flatulence and dyspepsia who have gallstones should be observed. Those who have symptoms of biliary pain, gallstone-induced pancreatitis, or common duct stones should have corrective surgery. Those who refuse surgery or who aren't surgical candidates might be treated with dissolution therapy. Dissolution of gallstones with chemical agents and extracorporeal shock-wave lithotripsy show some promise. We need a better understanding of the etiology and formation of gallstones to address the disease from a preventive standpoint and reduce the incidence of cholelithiasis and cholecystitis, and their complications.

Cricoarytenoid arthritis: a cause of laryngeal obstruction

Cricoarytenoid arthritis, principally as a result of long-standing rheumatoid arthritis, is a disorder that may present to the emergency physician with a number of symptoms and signs referable to the larynx. The presentation of this disorder as acute laryngeal obstruction and collapse is uncommon. It is important to recognize early cricoarytenoid joint involvement and not mistakenly diagnose mild cases as asthma or psychoneurosis. The use of steroids in mild cases has been beneficial at times, but progressive airway obstruction and fatalities have occurred during their administration.

Tuberculosis of peripheral joints: an often missed diagnosis

Eleven elderly patients with tuberculous arthritis of 12 peripheral joints were studied retrospectively. The disease usually presented as a monoarticular arthritis often in the absence of other signs of tuberculosis. A delay in diagnosis was a common feature and synovial biopsies provided the highest diagnostic yield.

Aortic arch arteritis in the elderly. An important manifestation of giant cell arteritis

Five elderly patients with aortic arch syndrome secondary to large-vessel vasculitis all presented with upper-extremity claudication and absence of blood pressure and pulses in the affected extremity. Diagnosis was suspected by a markedly elevated erythrocyte sedimentation rate associated with constitutional symptoms and angiograms showing changes consistent with arteritis of the aortic arch vessels. Treatment with high-dose corticosteroids resulted in rapid resolution of constitutional symptoms and improved functional use of the upper extremity. Recognition of this steroid-responsive disease is essential to avoid unnecessary reconstructive surgery and to prevent catastrophic events such as aortic dissection or visual loss, which may result from the underlying disease process.

Septic arthritis. Clinical approach to the 'hot joint'

Joint space infections continue to be among the most common forms of arthritis. Diagnosis can be difficult, particularly in the presence of underlying joint disease. Septic arthritis should be suspected in all patients who present with an acutely swollen joint. Immediate joint aspiration with Gram's stain and culture of the synovial fluid is essential. Intensive, long-term antibiotic therapy is necessary to prevent a high rate of morbidity and, possibly, death.

Sarcoid arthritis in a North American Caucasian population

Thirty-two of 150 Caucasian patients (21%) with sarcoidosis studied had articular symptoms. Twenty-one had acute sarcoid arthritis with bilateral ankle arthritis/periarthritis. Joint symptoms resolved within 4 months and none developed chronic arthropathy or progressive systemic sarcoidosis. Eleven patients developed articular involvement during the course of chronic pulmonary sarcoidosis manifested by bilateral hilar adenopathy in 8 and parenchymal disease in 9. Joint symptoms were generally transient, however, persistent synovitis in excess of one year was seen in 2 patients. Acute sarcoid arthritis confers a favorable prognosis in North American Caucasians. Differences from previous American series likely reflects the racial compositions of the population studied. Sarcoid arthritis less often evolves during the course of chronic systemic sarcoidosis and even then rarely progresses to a chronic arthropathy.

Hereditary angioedema and coronary arteritis

A 30-year-old white male with hereditary angioedema developed substernal chest pain with multiple arterial stenoses at coronary angiography. Histopathologic studies of the fibromembranous thickening removed from the left coronary artery at the time of the revascularization procedure revealed an inflammatory lesion compatible with an arteritis. The significance of this association in the spectrum of immunologically-mediated disorders in hereditary angioedema is discussed.

Cauda equina syndrome secondary to long-standing ankylosing spondylitis

Fourteen patients with cauda equina syndrome secondary to long-standing ankylosing spondylitis are described. The roughly symmetrical neurological deficits were very slowly progressive and began long after the onset of the spondylitis, usually well after the rheumatological symptoms had stopped. Eventually every patient had cutaneous sensory loss in the fifth lumbar and sacral dermatomes. All patients developed urinary sphincter disturbances of a lower motor neuron type. There was prominent loss of rectal sphincter tone, and all but 2 patients had bowel complaints, including incontinence and severe constipation. Seven patients had mild to moderate weakness in the lumbosacral myotomes. Seven patients had pain in the rectum or lower limbs. Electromyographic abnormalities were consistent with multiple lumbosacral radiculopathies. Myelography and computed tomographic scanning of the lumbosacral spine showed characteristic enlargement of the caudal sac and dorsal arachnoid diverticula that had eroded the laminae and spinous processes. Recognition of this syndrome, coupled with computed tomographic scanning of the lower spinal canal, allows one to omit myelography, a procedure that is difficult because of the associated spine abnormalities. Surgical intervention should be avoided.

Renal tubular acidosis. A new look at treatment of musculoskeletal and renal disease

The clinical and laboratory manifestations, roentgenographic findings, and treatment of 48 patients with renal tubular acidosis who were examined at the Mayo Clinic during a 10-year period were reviewed. The initial clinical presentations of the 48 patients in the series included rheumatic complaints in 25 and recurrent nephrolithiasis in 23. Of the 23 patients who presented with nephrolithiasis, 8 also had musculoskeletal symptoms. Thirty-three of the 48 patients had careful follow-up of a total of 68 musculoskeletal complaints. Forty of these symptoms (59%) diminished after treatment of the renal tubular acidosis with orally administered alkali. Associated connective tissue diseases were present in 12 patients. Thirty-four patients had roentgenographic evidence of renal calculi. Of this group, 19 were followed up with sequential roentgenographic studies of the kidneys for more than 1 year during therapy. Of 15 patients treated orally with alkali, 13 had metabolically inactive renal stone disease. Three of the patients treated orally with phosphorus supplements had persistent metabolically active renal stone disease. Patients with renal tubular acidosis often present with musculoskeletal manifestations and renal lithiasis, both of which frequently subside with the treatment of the renal tubular acidosis.

Elevation of creatine kinase in amyotrophic lateral sclerosis. Potential confusion with polymyositis

Serum creatine kinase (CK) levels were recorded in 100 patients with amyotrophic lateral sclerosis (ALS). CK concentrations were elevated in 43% of the patients, with a mean level of 240 U/liter and a range of 59-1,327 U/liter (male normal less than 95 U/liter, female normal less than 59 U/liter). All patients with elevated CK had muscle weakness. Seven patients were initially misdiagnosed as having polymyositis and given high dose corticosteroids without clinical benefit, prior to the diagnosis of ALS. Such diagnostic confusion can be avoided by an awareness that CK levels cannot be used to reliably differentiate between ALS and primary muscle disease such as polymyositis.

Osteoid osteoma: 95 cases and a review of the literature

Osteoid osteoma is a benign bone tumor occurring primarily in patients under the age of 30 yr. Bone pain at night and relief by aspirin or other nonsteroidal antiinflammatory agents is a common symptom complex. The proximal femur and spine are frequent sites of involvement, but almost any bone can be involved. If plain roentgenograms do not demonstrate the lesion, tomography or a bone scan may be helpful. Complete surgical excision is the therapy of choice with a low recurrence rate. Osteoid osteoma may present initially with symptoms suggestive of inflammatory arthritis, degenerative joint disease, neoplasm, or infection. This lesion can therefore be a difficult diagnostic problem, especially if routine roentgenograms are normal. A high index of suspicion is necessary to make the diagnosis.

Amyloidosis in adult onset Still's disease

A patient with adult onset of Still's disease who developed secondary amyloidosis is described. This is the first report of the association of these 2 disease states. The association of amyloidosis and other rheumatic disorders is discussed.

A dissecting popliteal cyst presenting as acute thrombophlebitis

A patient with psoriatic arthritis presented to the Geisinger Medical Center emergency department after the sudden onset of pain and swelling in his left calf. Initially, the patient was thought to have acute thrombophelebitis. Upon further examination, the diagnosis of a ruptured popliteal cyst was considered, and was confirmed with arthrography. The case illustrates an occurrence of a dissecting popliteal cyst simulating an cute deep vein thrombosis in a patient with an inflammatory process involving the knee.

Clostridium perfringens: an unusual case of septic arthritis

Anaerobic joint infections may be a more common occurrence than previously reported. A nine-year-old with a septic knee due to Clostridium perfringens following a puncture wound was seen in the emergency department. Diagnosis was established by isolating the organism from an anaerobic synovial fluid culture. The patient was treated successfully with open drainage and parenteral penicillin. This case illustrates the necessity for specifically requesting anaerobic cultures on synovial fluid of patients with acute septic monoarthritis.

Systemic lupus-like syndrome induced by methyldopa therapy

Pleural pericarditis, fever, and a positive reaction for antinuclear antibody developed in a 50-year-old white woman while she was receiving methyldopa (500 mg daily). After withdrawal of the drug, there was complete resolution of the clinical signs and symptoms, as well as normalization of the patient's antinuclear antibody titer. To our knowledge, this is the first reported case of a clinical lupus-like syndrome induced by therapy with methyldopa.