Mitral valve surgery in a patient with rheumatoid arthritis being treated with methotrexate

We describe our experience of mitral valve surgery in a 74-year-old man with rheumatoid arthritis (RA). RA had been diagnosed 12 years previously and his symptoms were being controlled by drugs including methotrexate (MTX), which is potentially immuno- and myelo-suppressive. He was admitted for dyspnea, and surgery was indicated for severe mitral insufficiency due to posterior leaflet prolapse. According to the recommendations of orthopedic surgeons, the administration of the MTX was discontinued at two weeks prior to the operation, in which the prolapsed leaflet was excised, repaired, and annuloplasty were performed with a 30mm prosthetics ring. The patient recovered uneventflully and MTX was resumed one week after surgery. Since MTX has been recently approval for treatment of RA in Japan, Japanese surgeons should pay attention to the appropriate perioperative use of this drug.     

Septic arthritis in a patient with juvenile rheumatoid arthritis

The acute flare of joint inflammation in the child with known juvenile rheumatoid arthritis causes concern primarily regarding the need for additional or modified medical treatment. Acute joint inflammation in an otherwise healthy child creates concern regarding the existence of joint infection. In the early phase of disease, the clinical findings and symptoms of an inflamed joint attributable to juvenile rheumatoid arthritis or infection may be similar and difficult to differentiate from the other. Juvenile rheumatoid arthritis usually is well controlled by medical interventions, however, the initiation of specific treatment is more urgent in children with joint sepsis. The following case report is presented to emphasize the difficulty in evaluation of patients with known juvenile rheumatoid arthritis and coexistent septic arthritis, and to discuss the methods used to differentiate between the two conditions.     

Acupuncture-associated Listeria monocytogenes arthritis in a patient with rheumatoid arthritis

Septic arthritis is a rare complication of acupuncture. We present a patient with rheumatoid arthritis who developed septic arthritis of the right knee after consecutive weekly sessions of acupuncture therapy for 3 weeks. The infection was localized by musculoskeletal sonography and magnetic resonance imaging, with culture of the synovial fluid aspirated from the joint yielding Listeria monocytogenes. The patient responded well to antibiotic treatment and regained joint mobility. A high index of suspicion for an infectious process is required for prompt diagnosis and treatment of acupuncture-induced joint infections in rheumatoid arthritis patients who might have additional risk factors for infection.     

Cytomegalovirus infection in a patient with rheumatoid arthritis

Background. - Pulmonary dysfunction in rheumatoid arthritis (RA) patients treated with low-dose methotrexate is usually caused by bacterial infection and less frequently by an immunoallergic reaction to the drug (acute hypersensitivity pneumonitis). Opportunistic infections are a rare cause. We report a case of cytomegalovirus pneumonia during bone marrow aplasia in a patient with RA taking methotrexate and cyclosporine.Conclusions. - Cytomegalovirus infection is a rarely reported cause of pulmonary dysfunction. This diagnosis should be considered in immunocompromised RA patients with no other satisfactory explanation for pulmonary dysfunction.     

Tophaceous gout in a patient with rheumatoid arthritis

Chronic gout and rheumatoid arthritis are common medical manifestations with debilitating effects on patients. However, these conditions are not typically identified concomitantly and can be hard to distinguish from one another. We report a rare case of a 50-year-old white woman with a history of chronic gout and rheumatoid arthritis who presented with intradermal tophaceous gout. Physical examination and laboratory results are described.     

Cerebral vasculitis in a patient with rheumatoid arthritis

Inflammatory vasculitis of the central nervous system is exceedingly rare in patients with rheumatoid arthritis (RA). The symptoms may be misleading. Most of the reported cases occurred in males with long-standing, nodular, destructive, rheumatoid factor-positive disease. Severe constitutional symptoms and prominent extraarticular manifestations of vasculitis were usually present. We report a case of cerebral vasculitis in a 59-year-old woman with a 20-year history of destructive rheumatoid factor-positive RA that was well controlled by methotrexate. Headache that was unresponsive to symptomatic treatment developed abruptly, together with gait disorders. Magnetic resonance imaging of the brain showed dot-like areas of high-signal in a periventricular subcortical distribution on both sides. Magnetic resonance angiography visualized a long tight stenosis of the right internal carotid artery and a string-of-beads stenosis of the left internal carotid artery suggesting vasculitis. Pulse therapy with methylprednisolone (1 g/d for 3 days) and cyclophosphamide (1 g) once a month ensured resolution of the neurological symptoms and laboratory evidence of inflammation. There was no evidence of a relapse at last follow-up after 5 months. Cerebral vasculitis is usually treated with monthly glucocorticoid and cyclophosphamide boluses separated by continuous glucocorticoid therapy. TNFalpha antagonists may be effective in patients who fail to respond to conventional treatment. However, other vasculitides such as giant cell arteritis and Wegener's granulomatosis must be ruled out, as they are refractory to TNFalpha antagonist therapy.     

Pulmonary autograft failure after aortic root replacement in a patient with juvenile rheumatoid arthritis.

We report a 12-year-old girl suffering from juvenile rheumatoid arthritis with severe aortic valve incompetence who died 5 months after an initially successful Ross procedure. Pulmonary autograft failure was a result of recurrence of aggressive valvulitis.     

Rapidly progressing polyarticular septic arthritis in a patient with rheumatoid arthritis

Septic arthritis is an orthopedic emergency that can lead to significant morbidity and mortality. Polyarticular involvement is a relatively rare phenomenon occurring primarily in high-risk patients. In this article, we report the rare case of a patient with rheumatoid arthritis presenting with an acute episode of septic arthritis involving most of the joints of the body. Surprisingly, his bilateral total hip arthroplasties were completely unaffected. Unusual polyarticular presentations of septic arthritis, though rare, must still be considered within the differential diagnosis by all healthcare providers when treating certain high-risk groups.     

Bucillamine-associated membranous nephropathy in a patient with rheumatoid arthritis

A case of bucillamine-associated membranous nephropathy in a patient with rheumatoid arthritis was reported. A 34 year-old woman was admitted to our hospital because of proteinuria in September, 1988. Rheumatoid arthritis had been diagnosed in April, 1988, and had been treated with bucillamine (disease modifying anti rheumatic drug) and amfenac (nonsteroidal antiinflammatory drug). The renal biopsy specimens showed Stage I membranous nephropathy, on both electron and immunofluorescence microscopy. Proteinuria decreased after the drugs were withdrawn despite continued RA symptoms. These results were consistent with drug induced nephropathy. Since bucillamine has some resemblances in its structure and pharmacologic action to D-penicillamine, which sometimes induces membranous nephropathy, it is thought that the nephropathy in this case was caused by an adverse reaction to bucillamine.     

Migratory pulmonary infiltrates in a patient with rheumatoid arthritis

The case history is described of an elderly man with rheumatoid arthritis receiving treatment with sulfasalazine and the cyclooxygenase-2 inhibitor celecoxib who presented with severe shortness of breath, cough, and decreased exercise tolerance. The chest radiograph showed unilateral alveolo-interstitial infiltrates and a biopsy specimen of the lung parenchyma showed changes consistent with acute eosinophilic pneumonia. Antibiotic treatment was unsuccessful, but treatment with steroids and discontinuation of sulfasalazine and celecoxib resulted in a marked clinical improvement confirmed by arterial blood gas analysis. The condition may have developed as an adverse reaction either to sulfasalazine or to celecoxib, although hypersensitivity to the latter has not previously been reported.     

Early rheumatoid arthritis

The diagnosis and treatment of early rheumatoid arthritis are presented.     

类风湿性关节炎全膝关节置换的临床疗效观察

目的:观察人工全膝关节置换术治疗严重类风湿性关节炎的临床疗效.方法:我院2003年3月-2005年12月对11例严重类风湿关节炎患者行人工全膝关节置换术,平均随访13个月,按美国特种外科医院膝关节评分系统(HSS)进行疗效评定.结果:所有患者没有一例行翻修手术,X线显示所有置换假体植入位置满意,没有假体松动、移位现象出现.11个膝关节的术后情况比较满意.HSS评分平均指数从术前的41分提高到术后的90分.结论:人工全膝关节置换术可作为类风湿性关节炎患者保存关节功能,改善疼痛的一种有价值的治疗方法.     

晚期类风湿关节炎患者的假体选择疗效对比

目的探讨晚期膝关节类风湿关节炎(RA)伴重度内翻屈曲畸形和严重骨质疏松患者行全膝关节置换术(TKA)假体选择及临床效果。 方法对2010年1月至2015年12月采用全膝关节置换治疗的晚期RA伴重度内翻屈曲畸形患者21例(27膝)进行回顾性分析。13例17膝采用后稳定型假体,8例10膝采用限制型假体。纳入标准：类风湿性关节炎合并膝关节重度内翻畸形;类风湿性关节炎合并膝关节患者骨密度T-Score<－2.8;无严重心肺疾病。排除标准：合并关节原发性或继发性活动期感染;合并关节外畸形通过单纯截骨无法矫正的患者。采用SPSS 16. 0统计软件分析,术前、术后屈曲挛缩度数、关节活动度及胫骨角均值比较采用配对样本t检验。 结果本组21例27膝均获得随访,病例随访时间2.0～5.3年,平均(3.8±1.1)年。后稳定组膝关节屈曲挛缩由术前(55. 5±12. 5)°(65.0°～85.0°)减少到末次随访时(5. 5±3. 5)°(0°～10.0°)(t ＝28.868,P < 0.01),关节活动度由(32. 5±6. 5)°(0°～40.0°)提高到末次随访时(105. 5±10. 5)°(85.0°～130.0°)(t ＝94.83,P < 0.01);股胫角由术前(31.0±3.5)°(23.0°～45.0°)修正为末次随访时(8.5±2.5)°(0°～12.0°)(t ＝116.913,P <0.01)。限制型假体组膝关节屈曲挛缩由术前(56.5±15.5)°(65.5°～80.0°)减少到末次随访时(6.0±5.0)°(5.0°～15.0°)(t＝25.486,P < 0.01),关节活动度由(32. 0±8.0)° ( 0°～40.0°)提高到末次随访时(100.0±5.5)°(85.0°～120.0°)(t ＝141.335,P < 0.01);股胫角由术前(31.5±5.5)°(22.0°～45.0°)修正为末次随访时(8.0±4.5)°(0°～12.0°)(t＝122.11,P < 0.01),均较术前明显改善,手术前后差异有统计学意义。两组之间术前及末次随访比较各指标得知,限制型假体组显著低于后稳定组关节活动度(t ＝5.716,P <0.01),差异具有统计学意义。 结论对晚期RA伴膝关节重度内翻屈曲畸形和严重骨质疏松患者在假体选择方面,后稳定型假体活动度更好,但在纠正内翻屈曲畸形和股胫角疗效比较方面,未见显著差异,所有患者近期疗效满意。     

Leflunomide-induced toxic epidermal necrolysis in a patient with rheumatoid arthritis

IntroductionLeflunomide is an immunomodulating agent with proven efficacy in rheumatoid arthritis. Although its overall safety profile is good, a few cases of toxic epidermal necrolysis have been reported.Case reportThis 36-year-old woman had rheumatoid arthritis that proved refractory to sulfasalazine and methotrexate, which were used successively in combination with symptomatic drugs. Leflunomide was started. A maculopapular rash and a fever developed 2 weeks later. The skin lesions spread rapidly to most of the body, and ulcers of the ocular and oral mucosa appeared. Leflunomide was stopped. Cholestyramine washout and prednisolone (60 mg/day) were given. The skin lesions healed over the next month. Punctate keratitis with keratinization of the cornea led to complete loss of vision.DiscussionThe main adverse effects of leflunomide consist of diarrhea, nausea, liver enzyme elevation, hypertension, alopecia, and allergic skin reactions. A few cases of severe skin reactions such as toxic epidermal necrolysis have been reported. They require immediate discontinuation of the drug and a washout procedure to hasten drug elimination from the body.ConclusionClose monitoring for severe skin reactions is in order when using leflunomide.     

Candidal prosthetic hip infection in a patient with previous candidal septic arthritis

We describe the case of a patient with chronic monocytic leukemia who underwent total hip arthroplasty (THA) for hip arthrosis. The patient has a history of Candida albicans arthritis of the same joint 5 months before THA surgery. Seven months after the prosthetic joint surgery, the patient developed a C albicans prosthetic infection that was successfully treated with amphotericin B and prosthesis removal. At surgery, the patient was believed cured of the candidal infection. Risk of infection after prosthetic joint surgery in patients with previous fungal joint infections has not been fully investigated. A lengthy infection-free follow-up period is probably necessary but may not be sufficient to prevent the occurrence of postoperative infections in these patients.     

Management of shoulder hemiarthroplasty in a patient with rheumatoid arthritis

STUDY DESIGN: Case report. BACKGROUND: Rehabilitation after shoulder hemiarthroplasty for rotator cuff tear arthropathy (RCTA) represents a significant challenge to physical therapists. Limited goals have been defined for this patient population and include no pain or slight pain at rest, moderate pain with vigorous activity, shoulder external rotation active range of motion (AROM) greater than 20 degrees, and shoulder abduction AROM greater than 90 degrees. CASE DESCRIPTION: The patient was a 60-year-old female elementary school teacher with functional class III adult-onset rheumatoid arthritis, who came to physical therapy 2 weeks after undergoing a hemiarthroplasty for RCTA of the right shoulder. Physical therapy included 33 treatment sessions involving 4 to 11 exercises each session. All sessions were performed under the direct supervision of a physical therapist utilizing specially designed equipment. Physical therapy emphasized early active assisted elevation range of motion (ROM), graded progressive exercise, and functional training. All exercises were performed in a pain-free ROM or a ROM that did not increase shoulder pain. OUTCOMES: Following physical therapy, subjective pain scale at rest was 0/10 and during vigorous activity 1/10 to 2/10. Shoulder AROM was normal and shoulder rotation and elevation strength was good. There was a significant improvement in shoulder proprioception and the patient demonstrated a negative belly press test for subscapularis muscle integrity. Additionally, the patient's score on the self-report section of the American Shoulder and Elbow Surgeons Assessment Form increased from 0% at the initial examination to 70% at discharge. DISCUSSION: Despite limited expectations, this patient achieved normal shoulder ROM and near normal shoulder strength after 14 weeks of physical therapy. Overall, an early, aggressive, progressively graded exercise program appears to be a safe and effective form of treatment after shoulder hemiarthroplasty for RCTA.