Chronic tophaceous gouty arthritis mimicking rheumatoid arthritis.

OBJECTIVES: To analyze the factors which differentiate chronic tophaceous arthritis from rheumatoid arthritis. METHODS: We describe two cases of chronic gouty arthritis masquerading as rheumatoid arthritis. The characteristic features of each of these two conditions and the diagnostic approach are discussed in light of relevant literature. RESULTS: The correct diagnosis was reached by the combination of accurate history taking (family history of gout, alcoholism, previous diuretic therapy and renal stones), guiding clinical features (subcutaneous tophaceous deposits) and specific radiological (assymetrical erosions with sclerotic margins and overlying edges) and laboratory findings (hyperuricemia and hyperuricosuria). It was confirmed by the identification of monosodium urate (MSU) crystals in the synovial and subcutaneous tissues. CONCLUSIONS: Gout and rheumatoid arthritis rarely coexist. Chronic gouty arthritis may mimic rheumatoid arthritis, and vice-versa. Clinical suspicion supplemented by characteristic laboratory, radiological and histologic findings help at reaching an accurate diagnosis.     

Acute hypoxic respiratory failure as the first manifestation of systemic-onset juvenile rheumatoid arthritis in a child

Systemic onset juvenile rheumatoid arthritis is the most common rheumatologic disorder of childhood. Pleuropulmonary manifestations are rare in children in this multiorgan disease, and are usually not severe. The diagnosis of systemic onset juvenile rheumatoid arthritis is made by exclusion, in the presence of clinical findings constellation. We present the case of an 8-year-old girl who developed acute hypoxic respiratory failure as the first manifestation of systemic onset juvenile rheumatoid arthritis, then severe respiratory relapse 16 months later. Clinical and radiological improvement were achieved at both times after high dose pulse methylprednisolone therapy.     

Progression of radiological changes in rheumatoid arthritis.

A prospective study over one year of patients who had active rheumatoid arthritis discovered 64 who had received treatment for an adequate time with second-line drugs. In these patients there was evidence of continuing joint destruction as shown by radiological progression. During the year there were highly significant correlations between improvements in clinical and laboratory measurements, but neither group of tests was related to the degree of radiological change. However, in the second 6 months of treatment there was evidence that radiological progression was reduced. In a second prospective study of 88 patients with rheumatoid arthritis given prolonged, intensive therapy with second-line drugs and followed up for 10 years two-thirds showed radiological progression. However, the number of joints damaged per year fell significantly during the study period. There was a divergence between deterioration in radiological features and improvements in the ESR and functional capacity, though patients with a persistently low ESR had less radiological progression. These studies provide evidence that treatment may be associated with a reduced rate of radiological progression but suggest that changes in radiological progression and clinical and laboratory measurements may result from different mechanisms.     

HLA-DR antigens and disease patterns of rheumatoid arthritis

HLA-DR antigens were determined in 111 patients with classic or definite rheumatoid arthritis. HLA-DR4 was significantly (P corr. less than 10(-6] increased in patients with rheumatoid arthritis (54%) compared with controls (23.2%). HLA-DR 5 was decreased in rheumatoid arthritis (12.6% vs 26.4% of controls); however, the corrected P value was not significant. There were no significant differences with regard to various clinical, radiological and serological parameters between HLA-DR 4 positive and negative patients. However, a milder course of rheumatoid arthritis was observed in DR 7 positive patients: Patients with this antigen were associated significantly with seronegativity and low titers of IgM-rheumatoid factor. Despite a similar disease duration patients with DR 7 had a significantly lower number of joints with inflammatory arthritis (synovitic swelling with limitation of movement) and developed less frequently severe radiological changes as joint ankylosis than DR 7 negative patients. In addition to the well known association between rheumatoid arthritis and HLA-DR 4, our data indicate that HLA-DR 7 may have a protective effect on the course of rheumatoid arthritis.     

Absence of Rheumatoid Arthritis in Schizophrenia*

Summary: Middle-aged women with a substantiated diagnosis of schizophrenia from Victorian Psychiatric Hospitals were examined for clinical, radiological and serological evidence of rheumatoid arthritis. Clinical or radiological evidence of rheumatoid arthritis was detected in none of the 301 patients studied, where-as the expected prevalences would be 7.7%; this difference is highly significant (p < 0.001). On the other hand, the prevalence of serologically demonstrable rheumatoid factor in the women with schizophrenia was similar to that in subnormal women in hospital under the same conditions and in women from a normal Australian population. The demonstrable polarity of schizophrenia and clinical rheumatoid arthritis in women might be explained either on a genetic basis or through the “protective” effects of one disease, schizophrenia, on the occurrence of the other, rheumatoid arthritis.     

Pyrophosphate arthropathy: a clinical and radiological study of 105 cases.

105 consecutive patients who presented to a rheumatologist because of joint disease and who also had evidence of deposition of calcium pyrophosphate dihydrate (CPD) were studied clinically and radiologically. There were 76 women (mean age 73) and 29 men (mean age 62). Of only 18 patients below the age of 60 at presentation 12 were men. The majority of the younger male group suffered from acute attacks of synovitis, and had no clinical or radiological evidence of joint damage. In contrast the older female group had widespread destructive changes. Associated joint disease included generalised osteoarthritis (45), rheumatoid arthritis (8), joint hypermobility (13), previous knee surgery (8), and gout 92). Sixteen patients had received long-term steroid therapy. Severe destructive joint changes were seen in 16 patients. The radiological features in those with rheumatoid arthritis by ARA criteria were atypical. The relationship between CPD deposition and arthritis is discussed in the light of these findings.     

Prediction of radiological outcome in early rheumatoid arthritis in clinical practice: role of antibodies to citrullinated peptides (anti-CCP)

OBJECTIVE: To investigate the role of anti-cyclic citrullinated peptide antibody (anti-CCP) for the prediction of radiological outcome in patients with early rheumatoid arthritis. METHODS: Anti-CCP was assessed at baseline in 379 patients with early rheumatoid arthritis (disease duration <1 year). Radiological joint damage and progression were assessed by Larsen score after two years of follow up (end point) and used as outcome variables. The prognostic value of anti-CCP and other demographic and disease related baseline variables were assessed by univariate and multivariate analyses, including calculation of odds ratios (OR), predictive values, and multiple logistic regression models. RESULTS: The presence of anti-CCP was associated with significantly higher Larsen score both at baseline and at end point. Univariate predictor analysis showed that anti-CCP had the highest significant OR for radiological joint damage and progression after baseline Larsen score, followed by rheumatoid factor, erythrocyte sedimentation rate (ESR), C reactive protein, age, smoking status, and sex. In stepwise multiple regression analyses, baseline Larsen score, anti-CCP, and ESR were selected as significant independent predictors of the radiological outcomes. CONCLUSIONS: There is good evidence for an association of anti-CCP with radiological joint changes in rheumatoid arthritis. Anti-CCP is an independent predictor of radiological damage and progression. Though prediction in early rheumatoid arthritis is still far from perfect, the use of anti-CCP in clinical practice should make it easier for rheumatologists to reach judicious treatment decisions.     

Course of chronic polyarthritis

The great variety of rheumatoid arthritis is well known. By means of exemplary cases subgroups are described, which show more homogeneity in relation to onset and course than rheumatoid arthritis as defined by the ARA-criteria. As a result of treatment clinical signs of inflammation as joint pain and swelling and laboratory findings as ESR and Hb may improve, but there is no change in radiological progression. There are correlations between clinical and laboratory measurements but not to radiological findings. It is considered that inflammation and joint destruction may result from independent pathomechanisms. The conclusion is that the pathognomonic process of rheumatoid arthritis, i.e. destruction, shown by radiological progression, is not influenced by treatment and is reflecting the natural course of the disease.     

Lack of radiological and clinical benefit over two years of low dose prednisolone for rheumatoid arthritis: results of a randomised controlled trial

BACKGROUND: Evidence for disease modifying activity of low dose corticosteroid treatment in rheumatoid arthritis is contradictory. Studies showing radiological benefit suggest that continued treatment is required to sustain the effect. OBJECTIVE: To evaluate the effect of low dose oral prednisolone in early rheumatoid arthritis on disease activity over two years. DESIGN: Double blind placebo controlled trial. METHODS: Patients with rheumatoid arthritis, duration <3 years (n = 167), were started on a disease modifying antirheumatic drug (DMARD; sulphasalazine) and allocated by stratified randomisation to prednisolone 7 mg/day or placebo. Primary outcome measure was radiological damage, assessed by the modified Sharp method. Clinical benefit was a secondary outcome. A proactive approach to identifying and treating corticosteroid adverse events was adopted. Patients who discontinued sulphasalazine were offered an alternative DMARD. RESULTS: 90 of 257 patients eligible for the study refused to participate (more women than men). Of those enrolled, 84% were seropositive for rheumatoid factor, median age 56 years, median disease duration 12 months, female to male ratio 1.8:1. Prednisolone was given to 84 patients; of these 73% continued prednisolone and 70% sulphasalazine at 2 years. Of the 83 patients on placebo, 80% continued placebo and 64% sulphasalazine at 2 years. There were no significant differences in radiological score or clinical and laboratory measures at 0 and 2 years. CONCLUSIONS: Low dose prednisolone conferred no radiological or clinical benefit on patients maintained on a DMARD over two years. Low dose corticosteroids have no role in the routine management of rheumatoid arthritis treated with conventional disease modifying drugs.     

Detritus synovitis in chronic polyarthritis: a clinical and operation histologic evaluation

In rheumatoid arthritis (RA) joint inflammation is due to two processes: 1) the underlying inflammatory process (UIP) characterized by a lymphoplasmacellular infiltration of the synovial tissue, as well as pannus formation, and 2) the detritogenic synovitis (DS), a synovial response to articular wear products from cartilage and bone (detritus) that induces a preferentially fibrinous inflammation. In order to estimate the role of DS in the clinical presentation of such joints, 40 patients with RA undergoing knee-joint surgery on 48 occasions were evaluated for clinical parameters, radiological stage (Larsen), and histopathological characteristics of UIP and DS. The clinical parameters were comparable in knee joints with predominantly UIP or DS. However, DS was regularly seen in knees with advanced destruction according to Larsen's stages 4 to 5, while UIP occurres in joints even without radiological damage. In conclusion, it is assumed that the poor response of patients with advanced RA to so-called long-term drug therapy may be in part explained by the modifying influence of joint detritus on the underlying "rheumatoid" inflammatory process.     

Large benign rheumatoid nodules of the trunk in an elderly patient: radiologic appearance mimicking a soft-tissue sarcoma

An 80-year-old woman without any evidence of rheumatoid arthritis presented with two large (maximum diameter: 6 cm and 7 cm), rapidly growing, rubbery nodules on the trunk. Although the clinical and radiological appearance suggested malignancy, the nodules were pathologically identical to rheumatoid nodules in rheumatoid arthritis, and the nodules regressed spontaneously. The final diagnosis was benign rheumatoid nodules. Recognition of this rare clinical entity is important to avoid unnecessary examination and treatment.     

Sequential joint scintigraphy in rheumatoid arthritis

In this sequential study joint scintigraphy was compared with clinical and r?ntgenological evaluation in 19 patients with rheumatoid arthritis. Scintigraphy sometimes preceded clinical and radiological abnormalities and scan results were independent of radiological findings showing no differences when large and small joints were compared. Scan findings in 2 patients with arthralgias only were negative, suggesting that arthritis was unlikely.     

Large benign rheumatoid nodules of the trunk in an elderly patient: radiologic appearance mimicking a soft-tissue sarcoma

Abstract

An 80-year-old woman without any evidence of rheumatoid arthritis presented with two large (maximum diameter: 6?cm and 7?cm), rapidly growing, rubbery nodules on the trunk. Although the clinical and radiological appearance suggested malignancy, the nodules were pathologically identical to rheumatoid nodules in rheumatoid arthritis, and the nodules regressed spontaneously. The final diagnosis was benign rheumatoid nodules. Recognition of this rare clinical entity is important to avoid unnecessary examination and treatment.     

Quantification of radiological damage in inflammatory arthritis: rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis

Quantification of radiological damage in inflammatory arthritis is important. It has proven its value in clinical trials, but its use in clinical practice is becoming more important as well. Scoring methods for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis are available. These differ in the joints and features assessed. This results in differences in the scoring range, but also in the method of performance. The various methods for the three diseases are detailed in this chapter. Most information is available for rheumatoid and for this disease the relationship between radiological damage and long-term outcome is summarised.     

Prediction of progressive joint damage in patients with rheumatoid arthritis receiving gold or D-penicillamine therapy.

Seventy two patients with classical or definite rheumatoid arthritis (RA) were randomly allocated to receive gold or D-penicillamine therapy (DPA) in a prospective study designed to evaluate whether it is possible to predict which patients will show radiological progression despite therapy. Forty five patients completed 12 months' treatment. There were no significant demographic or clinical differences between them and the 27 drop outs. Twenty of the 45 patients showed no radiological progression between six and 12 months. These patients had less severe initial radiological damage, lower levels of serum aspartate transaminase (serum AST) and lactic dehydrogenase (LDH), but higher levels of serum cholesterol. Twenty five patients did show progression during the six to 12 month period. This group included all the men with nodules. Of the 43 pretreatment clinical and laboratory variables examined, however, the majority failed to predict whether or not progression would subsequently occur. This included the acute phase response and seropositivity.     

How are rheumatologists from Argentina managing patients with arthralgias suspicious for progressing to rheumatoid arthritis?

Clinical Rheumatology - Patients with arthralgias who could be at risk of progressing to rheumatoid arthritis (RA) represent a clinical challenge. Recommendations for their management and treatment...     

Remission of arthritis and radiological improvement after combination therapy for non-Hodgkin''s lymphoma in a patient with rheumatoid arthritis undergoing treatment with d-penicillamine

A patient receiving d-penicillamine for rheumatoid arthritis developed a lymphoma, therapy for which resulted not only in haematological resolution but marked remission of rheumatoid disease activity, including radiological improvement.     

Association of clinical, radiological and synovial immunopathological responses to anti-rheumatic treatment in rheumatoid arthritis.

OBJECTIVES: To compare immunohistochemical scoring with clinical scoring and radiology for the assessment of rheumatoid arthritis (RA) disease activity, synovial tissue (ST) biopsied arthroscopically was assessed from 18 patients before and after commencement of disease-modifying anti-rheumatic drug (DMARD) therapy. METHODS: Lymphocytes, macrophages, differentiated dendritic cells (DC), vascularity, tumour necrosis factor (TNF) alpha and interleukin-1beta levels were scored. Clinical status was scored using the American College of Rheumatology (ACR) core set and serial radiographs were scored using the Larsen and Sharp methods. Histopathological evidence of activity included infiltration by lymphocytes, DC, macrophages, tissue vascularity, and expression of lining and sublining TNFalpha. These indices co-varied across the set of ST biopsies and were combined as a synovial activity score for each biopsy. RESULTS: The change in synovial activity with treatment correlated with the ACR clinical response and with decreased radiological progression by the Larsen score. The ACR response to DMARD therapy, the change in synovial activity score and the slowing of radiological progression were each greatest in patients with high initial synovial vascularity. CONCLUSIONS: The data demonstrate an association between clinical, radiological and synovial immunopathological responses to anti-rheumatic treatment in RA. High ST vascularity may predict favourable clinical and radiological responses to treatment.     

Effect of age on 3 year outcome in early rheumatoid arthritis

OBJECTIVE: To investigate the effect of age on clinical and radiological outcome and on efficacy and tolerance of antirheumatic therapy in early rheumatoid arthritis (RA). METHODS: In a prospective 3 year study 113 patients (83 women, 30 men) were divided into 2 groups according to age at onset of disease: before (n = 55) and after 55 years of age (n = 58). For clinical outcome, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor, Ritchie index, and number of swollen joints were measured. Radiological progression was analyzed by Larsen score. The principles of the "sawtooth" strategy were applied in the treatment of all patients. RESULTS: At baseline, inflammatory activity (ESR, CRP) and the Larsen score for hands were significantly higher in patients with late onset RA (LORA) and they also developed more extraarticular symptoms compared to patients with early onset RA (EORA). However, no differences were found in Ritchie index, number of swollen joints, or CRP values between the groups. Also during the followup there was a trend toward increased inflammatory activity (ESR) among LORA patients. After the initiation of antirheumatic therapy a parallel improvement in clinical activity was observed in the 2 groups. The frequencies of remissions, side effects, and withdrawals due to drug inefficacy did not differ significantly between the 2 groups. The radiological progression was also comparable. CONCLUSION: The onset of RA was more active in patients with LORA. However, the clinical course and the radiological progression were parallel in LORA and EORA patients. The "sawtooth" therapy was equally tolerated in both patient groups.     

Biologics as first line therapy in the treatment of rheumatoid arthritis. An opposing point of view

The development of biologic therapies has improved the prognosis of rheumatoid arthritis (RA). However, at present there is not enough evidence supporting that TNF antagonists, anti CD20 therapy or abatacept used as first line therapy provide relevant long-term benefits in daily clinical practice. Furthermore, clinical trials that analyze the effect of the combination of methotrexate (MTX) plus TNF antagonists against MTX monotherapy have shown that the later provides significant clinical responses and relevant radiological damage arrest in patients with early RA. Therefore, considering that in 5-6 months we can detect which patients do not respond adequately to MTX, we can select those patients for biologic therapy avoiding the exposure to the putative adverse events of combination therapy to those patients with optimal response to MTX monotherapy.