Ryumachi. [Rheumatism]最新文献

Objective: The following is a retrospective study on lower extremity alignment of rheumatoid arthritis (RA) patients with a history of both Total Hip Replacement (THR) and Total Knee Replacement (TKR).

Methods: From 1992 to 2000, our department had 26 rheumatoid arthritis patients who underwent both THR and TKR. We classified these patients into three groups based on radiographic alignment of the lower extremities in the standing position: Knock-knee (valgus deformity of the knees), Bowleg (varus deformity of the knees) and Windswept Deformity (one knee in severe varus alignment with the other in severe valgus alignment). Furthermore, we identified dominant weight bearing points of the hip as classified by the following new criteria: Central Shift, Lateral Shift, and Upward Shift. Mal-alignment was then evaluated based on these two classification systems.

Results: Of the 26 patients, 22 patients met our criteria and 4 did not. In mal-alignment, we had 11 cases in the knock-knee group, 5 cases in the bowleg group, and 6 cases in the Windswept deformity. Using the new criteria, central shift had 6 cases; lateral shift had 6 cases; and upward shift had 10 cases. The groups of Lateral shift and Central shift demonstrated deformities of the lower extremities were influenced by moving weight bearing points, pelvis obliquity, and adduction contractures of the hip joint. In upward shift, weight bearing lines did not change. Consequently, destruction of the joint in this group progressed symmetrically. Windswept deformity was asymmetric and had severe destruction on the other side of the knee and forefoot.

Discussion: Moving of weight bearing point, pelvis obliquity, and adduction contractures of the hip joint affected the severity of mal-alignment of the lower extremities.

A 58-year-old Japanese woman developed spiking fever, polyarthralgia and hepatosplenomegaly, with highly elevated levels of c-creactive protein (CRP) and ferrtin, and elevated erythrocyte sedimentation rate (ESR). The AOSD was diagnosed according to the Yamaguchi-criteria of 1992. She was first treated with a combination of prednisolone (20 mg/day) and oral methotrexate (MTX) (7.5 mg/week). This combination, however, was not effective with tapering the dose of prednisolone. When a high dose of cyclosporin A (CyA) (5.5 mg/kg/day) was then added to MTX (5 mg/week), the patient's fever and polyarthralgia decreased, and her elevated serological parameters such as CRP and ESR also gradually declined. Finally, the dose of prednisolone was tapered to 10 mg/day. Only a few cases of AOSD treated with CyA plus MTX have been reported. Thus, further careful observation will be needed to establish the usefulness of this drug combination as a therapy for AOSD.

Non-specific interstitial pneumonia developed as an initial manifestation in a patient with microscopic polyangiitis. A 62-year-old man was admitted to our hospital in March 2001, because of fever and intermittent myalgia of lower extremities. Chest X-ray had revealed reticular shadows in the bilateral middle and lower lung fields since 1996. Just before admission, the patient had been diagnosed as having nonspecific interstitial pneumonia (NSIP) from the specimen obtained by video-assisted thoracoscopic surgery (VATS) in another hospital. Physical examination on admission revealed bilateral episcleritis. Laboratory data showed elevated levels of CRP and KL-6, polyclonal gammaglobulinemia, positive rheumatoid factor and myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA). Sensory and motor nerve conducting velocities were delayed in left peroneal nerve, but not other nerves, suggesting mononeuropathy. Biopsied specimens of the left quadriceps revealed vasculitis of arteioles. In spite of positive proteinuria and hematuria, no pathological lesion was found in the kidney. From all of these findings, the patient was diagnosed as having microscopic polyangiitis (MPA) without renal involvement. Methylprednisolone pulse therapy followed by intravenous cyclophosphamide pulse therapy improved his clinical conditions such as pyrexia, cough, myalgia, episcleritis and respiratory symptoms with decreased titer of serum MPO-ANCA. Thereafter, the dose of prednisolone was successfully tapered to 10 mg/day without clinical relapse. In the present patient who developed demonstrated non-specific interstitial pneumonia as an initial manifestation of MPA, VATS provided useful diagnostic and prognostic information, leading to an appropriate therapeutic choice.

Basic calcium phosphate (BCP) deposition disease is a crystal-induced inflammation syndrome. We report a beneficial effect of high-dose etidronate, one of the bisphosphonates, on periarticular calcinosis in a case of arterial and periarticular BCP crystal deposition disease. A 55-year-old woman was referred to St. Marianna University Hospital because of a 30-year history of recurrent acute periarthritis. The X-ray photographs revealed periarticular calcinosis of the hand and foot, wrist, and knee joints without bony erosions and the calcification of carotid and popliteal arteries. The biopsied specimen from periarticular tissue showed Alizalin-red and von Kossa staining-positive crystals. With the diagnosis of BCP crystal-induced periarthritis, she has been treated with colchicine and probenecid. This regimen was partially effective in terms of a decrease in the frequency of periarthritic attack. Despite the treatment, periarticular calcinosis increased in size and number. She was treated with 800 mg of etidronate 3 months after the etidronate therapy; periarticular calcinosis was diminished although arterial calcification was unchanged. This case suggests that high-dose etidronate might be useful for heterotopic calcification associated with rheumatic diseases.

We report a 54-year-old woman with systemic sclerosis who presented alveolar hemorrhage. She noticed shortness of breath in May 1997. She was diagnosed having interstitial pneumonitis and systemic sclerosis with sclerodactylia of bilateral fingers in December. She developed bloody sputum and dyspnea suddenly on March 12, 1999. Bloody lavage fluid with hemosiderin-laden macropharge was observed by bronchial fiber scopic examination. The elevated level of MPO-ANCA was detected without anti-DNA antibody. Administration of intravenous methylprednisolone(1g per day, 3 days) followed by 40 mg per day of prednisolone achieved complete response, and MPO-ANCA level was decreased. Mild proteinuria and microhematuria was detected on admission, but renal biopsy revealed no findings of crescent formation or angiitis. With coadministration of oral cyclophosphamide she doesn't have any renal involvement or recurrence of alveolar hemorrhage during these four years. MPO-ANCA level remains negative. Alveolar hemorrhage, which is uncommon pulmonary event in systemic sclerosis, is often coexist with renal angiitis in the context of "pulmo-renal syndrome". MPO-ANCA is said to be related to pulmo-renal syndrome and is sometimes induced by D-penicillamine. This patient is really important in considering the pathogenesis of alveolar hemorrhage because she had no renal vasculitic lesions or D-penicillamine intake.

A 78-year-old man who was undergoing hemodialysis therapy was admitted to our hospital because of sore throat, remittent cervical lymphadenopathy, and polyarthritis over the preceding 4 weeks. On admission, he had bilateral cervical lymphadenopathy. He complained of arthralgia associated with tenderness, warmth and swelling of both elbows, left side wrist and left shoulder joint. The C-reactive protein level on admission was 15.3 mg/dl. Rheumatoid factor, antinuclear antibodies, tuberculin skin test and blood culture were negative. Joint fluid was not aspirated. Radiographs of the joints did not reveal any abnormalities. Acid-fast bacilli were demonstrated in the smear of the cervical lymph node with a fluorochrome rhodamine-auramine stain. Mycobacterium tuberculosis DNA was identified by polymerase chain reaction. We found the presence of caseating granuloma on the biopsy specimens and M.tuberculosis was detected from culture. At that point, we diagnosed this patient as having tuberculous lymphadenitis. His general symptoms resolved rapidly after starting with a three-drug regimen consisting of isoniazid, rifampin and pyrazinamide. His polyarthritis also improved dramatically. Finally we considered that his polyarthritis was tuberculous rheumatism, also called Poncet's disease. Poncet's disease is characterized by sterile polyarthritis during active tuberculosis infection. It is considered a reactive arthritis, which is a different entity from tuberculous arthritis. Although this is a rare disease, we should be aware of it in hemodialysis patient clinics, because the incidence of tuberculosis infection has been reported to be increasing in patients with end-stage renal failure.

A 56-year old Japanese female was admitted to our hospital because of the increased levels of serum AST, ALT, and gamma-GTP. She was diagnosed with systemic lupus erythematosus in September, 1996 and had been on a regular glucocorticoid therapy since then. Abdominal ultrasonography showed the mild fatty liver, and hepatic histopathology revealed a typical and remarkable steatohepatitis, a remarkable neutrophil infiltration, and Mallory bodies. Because she had no history of alcohol-drinking, diagnosis of non-alcoholic steatohepatitis (NASH) was made. Treatment was started with a low-calorie diet, bed-rest, and an oral administration of alpha-tocopherol and bezafibrate with favorable effects on her serum levels of AST, ALT, gamma-GTP, and LDH. When a patient on a glucocorticoid therapy shows signs of fatty liver, diabetes mellitus, hyperlipidemia, an insulin resistance, NASH should be considered as one of the differential diagnosis. This is particularly important since proper therapy with a low-calorie diet and drugs with anti-oxidant activities improve this potentially progressive disease before resulting in liver cirrhosis and hepatic carcinoma.