Rheumatoid arthritis, corticosteroid therapy and hip fracture.

OBJECTIVE--To identify the risk of hip fracture in patients with rheumatoid arthritis and those taking corticosteroids. METHODS--In a population based case-control study, we compared 300 consecutive patients with hip fracture aged 50 years and over from a defined district and 600 age and sex matched community controls. RESULTS--The risk of hip fracture was increased in patients with rheumatoid arthritis (odds ratio (OR) 2.1; 95% confidence interval (CI) 1.0 to 4.7) and those receiving corticosteroids (OR 2.7; 95% CI 1.2 to 5.8). The risk attributable to rheumatoid arthritis was markedly reduced by adjusting for functional impairment, while that for steroid use remained after adjusting for body mass index, smoking, alcohol, and functional status. CONCLUSIONS--Hip fracture risk is approximately doubled amongst patients with rheumatoid arthritis and among those taking steroids. These risk increases are, to some extent, independent of each other. In rheumatoid arthritis, the risk was most closely associated with functional impairment, whereas steroid use did not appear to be confounded by this variable.     

Atherosclerotic cardiovascular disease in rheumatoid arthritis

The past 3 years have seen a remarkable growth in the inter-est of cardiovascular disease in rheumatoid arthritis. There have been studies published documenting an increased inci-dence and prevalence of cardiovascular conditions in patients with rheumatoid arthritis compared with individuals without rheumatoid arthritis. There has also been interest in the occurrence of cardiovascular risk factors in rheumatoid arthritis and in the role of antirheumatic therapy, including cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs, methotrexate, corticosteroids, and tumor necrosis fac-tor inhibitors. A number of studies using noninvasive means to detect atherosclerosis have shown that patients with rheu-matoid arthritis may be prone to atherosclerosis. This infor-mation should be important to physicians who provide care to patients with rheumatoid arthritis, given the difficulty of recognizing cardiovascular signs and symptoms among patients with the disease.     

Artritis reumatoide y tropismo infeccioso

Historically, pathogenesis, clinical evolution, and side effects of therapy in patients with rheumatoid arthritis have been linked with infectious disease. A number of possible causative infectious agents and their toxins has been postulated as a initial immunological step in rheumatoid arthritis pathogenesis in a genetically susceptible host. Anyway, immunosuppression associated to rheumatoid arthritis per se has been related to a high number of infections, specially on the joint, the most damaged tissue due to baseline illness. Immunosuppressive therapy (corticosteroids, disease-modifying antirheumatic drugs, biologic agents), diagnostic procedures (arthrocentesis, arthroscopies), and surgery (arthoplasties, joint replacements) has also been strongly associated with infection. All these reasons enable to understand the great importance of communitarian, nosocomial and opportunistic infections in the evolution and outcomes of this population. The relationship between rheumatoid arthritis and infection over different points of view has been extensive analysed in this review.     

Skeletal status in rheumatoid arthritis a preliminary report

Twenty-six women with classic or definite rheumatoid arthritis, according to the criteria of the AMERICAN RHEUMATISM ASSOCIATION, age-matched with controls were evaluated for bone mineral content and rigidity. Significant bone loss occurred in arthritics treated with corticosteroids. Bone losses at diaphyseal and metaphyseal sites were of similar magnitude—suggesting no preferential loss of trabecular bone. A significant decrease in relative ulnar rigidity was observed in patients with rheumatoid arthritis not receiving corticisteroids. An even larger decrease was noted in subjects receiving corticosteroids.     

Total and peripheral bone mass in patients with psoriatic arthritis and rheumatoid arthritis

Summary Psoriatic arthritis is thought to be associated with periarticular osteoporosis while rheumatoid arthritis may be associated with generalised as well as periarticular bone loss. To assess the extent of total and peripheral bone loss in these two diseases, total body calcium was measured by in vivo neutron activation analysis and peripheral bone mass was assessed by metacarpal indices in age-matched patients with psoriatic arthritis and rheumatoid arthritis treated with nonsteroidal anti-inflammatory drugs alone. In comparison with age and sex-matched normal controls, total and peripheral bone mass was normal in psoriatic arthritis. There were significant reductions in total (6.2% in men; 7.9% in women) and peripheral (10.9% in men; 12.8% in women) bone mass in patients with rheumatoid arthritis compared with controls. Peripheral bone mass was significantly correlated with the degree of radiographic damage in male and female patients with rheumatoid arthritis. The mean annual loss of total body calcium was insignificant in psoriatic arthritis (0.6% in men; 1.9% in women) but markedly greater in rheumatoid arthritis (4.4% in men; 2.7% in women). The data suggested that total and peripheral bone loss is greater in rheumatoid arthritis than psoriatic arthritis. Substantial reductions in peripheral bone mass in patients with rheumatoid arthritis not receiving corticosteroids may account in part for the small reductions in total bone mass.     

The relationship between the leg muscle strength and physical capacity in patients with rheumatoid arthritis, with reference to the influence of corticosteroids

It has been shown that patients with rheumatoid arthritis have weak muscles, especially when they are treated with corticosteroids. Forty-six female patients suffering from rheumatoid arthritis were evaluated with regard to the physical capacity in the lower legs by measuring the walking speed and the climbing performance as correlated to the isokinetic muscle strength of the knee extensors and the plantar flexors. Twenty-six of the patients (average age 60 years, range 34-76) had been treated with corticosteroids. Twenty patients (average age 58 years, range 31-72) had never received corticosteroids. The mean maximal isokinetic muscle strength of the knee extensors in corticosteroid treated patients was 62 +/- 28 Nm (SD) at the angular velocity 30 degrees/s, and the mean maximal isokinetic muscle strength of the plantar flexors in the same group of patients was 33 +/- 21 Nm (SD) at the same angular velocity. Compared to patients with rheumatoid arthritis who had never been treated with corticosteroids the reduction in muscle strength was 37% and 28%, respectively (p less than 0.001 and p less than 0.01). The mean walking speed in patients with corticosteroid treatment was 0.9 m/s, which was a 36% reduction as compared with that found in patients who had not received corticosteroids (p less than 0.01). Half of the patients who had not received corticosteroids were able to climb a 50 cm step, while this was possible in only 16% of the group of corticosteroid-treated patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Three cases of rheumatoid arthritis with laryngeal stridor

The purpose of this is case-based review is to report a series of patients with rheumatoid arthritis who developed stridor and highlight this potentially life-threatening manifestation of the disease. We report three cases from the Rheumatology Department of University College Hospital, London and review the literature on the prevalence, clinical presentation, histopathological features and treatment of laryngeal involvement in rheumatoid arthritis. In two patients, emergency tracheostomy was necessary to maintain a patent airway. One patient improved with systemic corticosteroids without the need for surgical intervention. All patients were seropositive with anti-CCP antibodies and had long-standing erosive disease. Stridor in patients with rheumatoid arthritis is typically due to arthritis of the cricoarytenoid joints leading to fixation of the vocal cords in a midline position. Cricoarytenoid joint arthritis may be acute, chronic, or acute-on-chronic. Emergency tracheostomy may be life-saving in cases of acute stridor. Cricoarytenoid inflammation and airway compromise may respond to local or systemic corticosteroid therapy. Other causes of vocal cord paresis in rheumatoid arthritis include ischaemic neuropathy of the recurrent laryngeal and vagus nerves due to vasculitis or cervicomedullary compression due to rheumatoid involvement of the cervical spine.     

Bronchiolitis obliterans organizing pneumonia and rheumatoid arthritis

Bronchiolitis obliterans, with or without organizing pneumonia, can be a serious and life-threatening complication of rheumatoid arthritis. We describe a case of bronchiolitis obliterans organizing pneumonia in a patient who recently developed rheumatoid arthritis, presenting as a severe respiratory insufficiency. Diagnosis was made by means of open lung biopsy. Treatment with corticosteroids induced a quick response and substantial improvement of the respiratory symptoms. A simultaneous strong rise in titres of serological tests suggests a relationship between the bronchiolitis obliterans organizing pneumonia and the rheumatoid arthritis.     

Thoracic and lower cervical spine involvement in a case of rheumatoid arthritis

Summary The authors report a case of spine involvement in a severe case of rheumatoid arthritis treated with corticosteroids. First, the patient developed acute back pain, related to costovertebral joints arthritis at levels T9–T10. Then, neck pain and cord involvement yielded to diagnosis of cervical interapophyseal joints arthritis; there was a C5–C6 subluxation which necessitated surgical treatment. The conjunction of these two rheumatoid localizations is an uncommon feature. Study by the CT scan is valuable when rheumatoid arthritis of the spine is suspected. Lower cervical spine subluxation, even severe, may be well tolerated. Surgery is necessary when there is medullary involvement.     

Hemophagocytic syndrome complicating adult's seropositive rheumatoid arthritis

INTRODUCTION: Macrophage activation syndrome (MAS) is a severe complication of chronic rheumatic diseases, particularly juvenile rheumatoid arthritis. However, MAS is rarely described in adult rheumatoid polyarthritis. EXEGESE: We report a case of MAS complicating a seropositive rheumatoid polyarthritis after 20 years of evolution. Pancytopenia with fever, renal failure and hepatic dysfunction revealed the disease that was confirmed by multiple macrophages and monocytes invading the bone marrow specimen. CONCLUSION: Outcome has been spectacular under corticosteroids.     

Prolonged low-dose corticosteroid therapy and osteoporosis in rheumatoid arthritis.

Thirty-one patients with rheumatoid arthritis maintained on prednisolone 5 mg daily for an average period of 9.4 years were assessed radiologically to determine the degree of osteoporosis in their spine and peripheral skeleton. They were compared with a control group of 32 rheumatoid patients who had never received corticosteroids. The steroid-treated patients had more severe osteoporosis than the controls, though the difference was not statistically significant. In the female patients the spine appeared to be more sensitive than the peripheral skeleton to the osteoporotic effect of corticosteroids.     

Juvenile rheumatoid arthritis with cardiac tamponade.

A 4-year-old girl with seronegative systemic juvenile rheumatoid arthritis developed acute cardiac tamponade. Pericardiocentesis and systemic corticosteroids resulted in complete recovery of the pericardial involvement. This was followed by complete remission of rheumatoid disease.     

Effects of rheumatoid arthritis on bone

The effects of rheumatoid arthritis on bone include structural joint damage (erosions) and osteoporosis. The latter may lead to increased risk for fractures, which are associated with increased morbidity and mortality. Osteoporosis in rheumatoid arthritis is characterized by a complexity of risk factors, including primary osteoporosis risk factors in addition to inflammation, immobilization, and use of corticosteroids. Quantitative assessment of periarticular and generalized bone loss in rheumatoid arthritis may be reliable indicators of future disease course and potential response variables in intervention studies. The osteoclast cell in rheumatoid arthritis plays a crucial role in the development of erosions and periarticular and generalized osteoporosis, suggested to be mediated through the osteoprotegerin/receptor activator of Nuclear Factor (NF)-kappabeta/receptor activator of NF-kappabeta ligand signaling system. Based on an improved understanding of this biology, new treatment opportunities exist.     

Sickle cell crisis following intraarticular steroid therapy for rheumatoid arthritis

We describe 2 patients who had coexistent rheumatoid arthritis and sickle cell disease. Both patients developed sickle cell crises following intraarticular injection of corticosteroids to control their arthritis. The mechanism of this phenomenon is not clear, but it is suggested that intraarticular steroids be used with caution in patients with sickle cell disease.     

Pneumonitis caused by gold salts in psoriatic arthritis: report of 2 cases

The gold-salts compounds have been used for the treatment of rheumatoid arthritis and of psoriatic arthritis, they are generally tolerates and when have adverse effects they are minor. The gold-induced lung toxicity is a infrequent adverse effect of patients with rheumatoid arthritis characterized by three types: interstitial penumonitis, bronchiolitis obliterans with organizing pneumonia and bronchiolitis obliterans, usually the first is the more frequent. The diagnostic is supported by the clinical manifestations, chest roentgenogram, bronchoalveolar lavage fluid and chest computed tomography scan. Biopsy study of the lung, is only needed for exclusion of other pulmonary disease. The gold-induced lung toxicity in the psoriatic arthritis is rarelly described, we report two cases with gold-induced pneumonitis with benign clinical course after cessation of therapy and treatment with corticosteroids.     

Acute non-infectious arthritis of the hip in patients with rheumatoid arthritis.

Five patients with rheumatoid arthritis and no previous hip joint disease developed an acute disabling arthritis in one hip joint. Roentgenograms were negative and synovial fluid from the hip joint was inflammatory, but no crystals were seen and cultures were negative. Four of the five patients responded rapidly to intra-articular corticosteroids, and none of the five has had further hip joint symptoms during a mean follow up period of two years.     

Lymphedema of the leg associated with rheumatoid arthritis

A 14-year-old boy with a two year history of seronegative rheumatoid arthritis developed left leg lymphedema and subsequently a severe episode of lymphangitis. The diagnosis of "rheumatoid lymphedema" was confirmed by lymphscintigraphy and conventional lymphography. Treatment consisted of bedrest and antibiotic drugs. When the signs of inflammation had subsided, therapy with corticosteroids was started with improvement of both joint pain and leg swelling. Whereas lymphedema associated with rheumatoid arthritis has been described in the upper limb of adults, to our knowledge this is the first report of the coexistent condition in the lower leg of a child.     

Fatal coccidioidomycosis in collagen vascular diseases

Ten patients who died from coccidioidomycosis in Arizona from 1968 to 1975 had underlying collagen vascular diseases: 4 with rheumatoid arthritis, 4 with systemic lupus erythematosus, and 2 with dermatomyositis. All 10 patients had been treated with corticosteroids; 2 were taking cytotoxic drugs. Collagen vascular diseases and the use of corticosteroids and cytotoxic drugs may be associated with the depression of cell-mediated immunity. The potential for opportunistic coccidioidomycosis should be noted when corticosteroids and cytotoxic drugs are used for treating collagen vascular disease in patients residing in or coming from areas where coccidioidomycosis is endemic.     

Pure red cell aplasia in mixed connective tissue disease

We describe a patient with mixed connective tissue disease (MCTD), who developed pure red cell aplasia which responded favorably during treatment with corticosteroids. Pure red cell aplasia has been described in a few patients with rheumatoid arthritis and systemic lupus erythematosus, but, to our knowledge, this is the first report of an association between it and MCTD.     

Osteoporosis in rheumatoid arthritis: safety of low dose corticosteroids.

Fear of inducing generalised osteoporosis is one reason why corticosteroids are withheld in patients with rheumatoid arthritis (RA). No studies, however, have directly measured bone density in such patients at clinically relevant sites. To assess this risk we measured bone mineral density in the lumbar spine and femoral neck by dual photon absorptiometry in 84 patients with RA, 44 of whom had been treated with low dose prednis(ol)one (mean dose +/- SE 8.0 +/- 0.5 mg/day; mean duration of treatment 89.6 +/- 12.0 months). There were significant reductions in bone mineral density in patients treated with corticosteroids (lumbar 9.6%, p less than 0.001; femoral 12.2%, p less than 0.001) and in those who had not received corticosteroids (lumbar 6.9%, p less than 0.01; femoral 8.9%, p less than 0.001), but the differences between the two groups were not significant. We conclude on the basis of these studies that low dose oral corticosteroids do not increase the risk of generalised osteoporosis in patients with rheumatoid arthritis.