Cases reported • Rheumatic Diseases; Rheumatism; Enthesopathy

1/116. mycobacterium tuberculosis infection in patients with systemic rheumatic diseases. A case-series.

OBJECTIVE: To describe the clinical characteristics of patients with systemic rheumatic diseases and tuberculosis. A retrospective case series from 1987 to 1994, drawn from a tertiary-care hospital in mexico City, was studied. RESULTS: Thirty patients were included (20 women, 10 men), with mean age of 39.8 years (range 14-66), and a mean duration of the systemic rheumatic disease of 44 months (1-372). The rheumatic diseases included systemic lupus erythematosus (SLE) (n = 13), rheumatoid arthritis (7), polymyositis or dermatomyositis (5), and other diseases (5). During the six months previous to the diagnosis of tuberculosis, 22 patients had received corticosteroids, and 13 others immunosuppressants. mycobacterium tuberculosis was isolated from 18 patients. Pulmonary tuberculosis was found in 10 patients, and extrapulmonary tuberculosis in 20, seven of these with miliary disease. SLE was seen in 6 of the patients with miliary tuberculosis. The clinical manifestations were: fever (67%), weight loss (67%), diaphoresis (60%), cough and sputum (53%), lymph node enlargement (43%), and dyspnea (33%). Sixteen patients had an abnormal chest film. Of 18 patients tested by PPD RT-2, 8 had an induration > 10 mm. patients were initially treated with 3 or 4 anti-tuberculosis drugs for 15 days to 6 months, followed by 6 to 10 months of isoniazid plus rifampicin. Three relapsed, and 2 died of respiratory failure. CONCLUSIONS: This case series showed a particular pattern of tuberculosis in patients with systemic rheumatic diseases.

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2/116. Cardiac myxoma in a 6-year-old child--constitutional symptoms mimicking rheumatic disease and the role of interleukin-6.

A 6-y-old girl with right atrial myxoma presented with remittent fever attacks, general arthralgia and laboratory investigations mimicking rheumatic or autoimmune disease. interleukin-6 (IL-6) serum concentration was markedly elevated before and normal after tumour resection, whereas myxoma cells stained negatively for IL-6. IL-6 should be considered a myxoma marker: overproduction by myxoma cells and consecutive systemic passage are assumed to cause immunological features.

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3/116. Intracranial inflammatory tumors: a survey of their various etiologies by presentation of 5 cases.

Due to similar clinical and neuroradiological features, intracranial inflammatory tumors (IITs) are frequently misdiagnosed as brain neoplasms, from which they notably differ in respect to therapy and prognosis. In this article, five cases of such tumors are presented. Three of the patients with brain tumors (cases 3, 4 and 5) presented a history of 'pararheumatic' syndromes but no diagnosis of defined immunopathies. On the basis of radiological findings, all processes were classified as genuine brain neoplasms, but histology showed reactive inflammatory features. The possible etiologies of these 'tumors' are discussed on the basis of all clinical and histological data of the patients. The spectrum of diseases potentially leading to the manifestation of an IIT is reviewed. Additionally, the presentation of case 5, who developed a highly malignant B-cell-lymphoma 6 months after the removal of an IIT without any histological signs of atypia, shows that this differential diagnosis always has to be kept in mind.

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4/116. Greater trochanter enthesopathy: an example of "short course retinoid enthesopathy": a case report.

Irreversible skeletal changes have been described in patients with dermatologic disorders treated with isotretinoin (Accutane), a synthetic vitamin a derivative. Although retinoids were developed to avoid toxicity associated with vitamin a, skeletal lesions and rheumatologic consequences are possible hazards of isotretinoin treatment. Enthesopathy is one of the potential musculoskeletal sequelae and is characterized by pathologic, sometimes painful changes at the insertion sites (entheses) of tendons, ligaments, and articular capsules into bone. We report a patient who was referred secondary to an extended history of bilateral hip region pain. She was subsequently found to have a greater trochanteric enthesopathy. A detailed patient history revealed past use of Accutane for cystic acne. The subsequent treatment course, including medications, corticosteroid injections, physical therapy, and activity modifications, is described and the pertinent literature is reviewed. We believe that patients who are prescribed isotretinoin should be warned about this potential pathologic condition at the initiation of treatment and that physicians who are treating patients with a history of Accutane use should be suspicious of underlying enthesopathies as the etiology behind pain of musculoskeletal origin.

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5/116. Rheumatism--parenteral nutrition. Report of a case.

A 26-year-old man with progressive rheumatic disease in spite of conventional therapy with antirheumatic drugs and physiotherapeutic exercises. The only therapy that gave temporary relief was, according to the patient, "fasting periods". He was treated experimentally with a period of complete intravenous nutrition ("total bowel rest") with certain subjective and objective improvement.

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6/116. Raynaud's phenomenon as a manifestation of parvovirus B19 infection: case reports and review of parvovirus B19 rheumatic and vasculitic syndromes.

infection with human parvovirus B19 is manifested as erythema infectiosum, transient aplastic crisis, or hydrops fetalis. Rheumatic manifestations include arthropathy and various vasculitic syndromes. Isolated Raynaud's phenomenon due to parvovirus B19 has never been described. We report on 2 previously healthy sisters with new-onset Raynaud's phenomenon accompanied by severe generalized polyarthralgia. A full workup was negative, except serology for parvovirus B19, which was positive. All symptoms gradually subsided within 3-5 months, and no recurrence has been noted during the 3 years since onset. We review all the studies in the English-language literature on parvovirus B19-induced rheumatic and vasculitic syndromes. We hypothesize that the pathogenesis of Raynaud's phenomenon in our patients involved immune-mediated endothelial damage leading to platelet activation and vasoconstriction. We recommend that in cases of unexplained Raynaud's phenomenon, serology for parvovirus B19 be included in the evaluation.

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7/116. 125Iodinated fibrinogen uptake in inflammatory joint disease as a complicating factor in the detection of deep vein thrombosis.

An enhanced uptake of 125I-fibrinogen observed in the arthritic knee joint of a patient suspected of deep vein thrombosis was confirmed in a number of patients with inflammatory joint disease in the absence of thrombosis. Whilst this is a potentially serious source of false positive diagnoses, the possibility also exists that this phenomenon could be used to evaluate the degree to which active disease is present in the joints of patients suffering from inflammatory disease.

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8/116. Malignant lymphoma and rheumatic symptoms.

A patient intially thought to have a connective tissue disease, later shown by biopsy to have Hodgkin's disease is described. The progress of her illness suggests that she is suffering from a connective tissue disease, too, or possibly secondary immune complex disease.

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9/116. mixed connective tissue disease.

Three patients with mixed connective tissue disease (MCTD) had clinical features that included a high incidence of Raynaud phenomenon, arthritis, myositis, and swollen hands. The diagnostic laboratory test result was the presence of high titers of antibody to extractable nuclear antigen. These antibody titers are notably reduced or abolished in patients with MCTD when the tanned red blood cells that are used in the test are pretreated with ribonuclease. Speckled antinuclear antibodies were present in all patients. patients with MCTD have a low incidence of renal disease, are responsive to treatment with prednisone, and have a good prognosis.

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10/116. [Psychsomatic aspects of rheumatic, especially soft tissue rheumatic diseases]

rheumatic diseases may be connected to varying degrees with psychic factors. On the one hand, rheumatic diseases may produce psychic reactions, while on the other hand rheumatic symptoms--especially in extra-articular rheumatism--may be induced by psychosomatic hysteric pararheumatic diseases and depressive mechanisms. Special reference is made to psychosomatically induced extra-articular rheumatic diseases in which not only the complex genesis but also the clinical symptomatology are discussed. During therapy more attention should be directed to psychic factors than in the past, as only an intensive psycho and/or psychopharmacotherapy can influence the disease.

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