Rheumatic Polyarthritis Research Articles

Appendicitis and Infectious Diseases.

The pre-eminently local character of appendicitis and its successful surgical treatment have undoubtedly served to distract the attention from its possible relations to infectious diseases in general. In the large majority of the cases local conditions appear to explain satisfactorily the development of appendicitis and its consequences, but there are also forms of appendicitis in which the etiology is not quite so simple, and it is to these forms that Finney and Hamburger¹direct attention. "Propagated appendicitis" is the term applied by M. Reclus to appendicitis developing from extension of enterocolitis. The nature of the appendix favors stagnation and increased bacterial virulence, which result in greater intensity of the resulting lesions of this part of the intestine. Then there are cases in which appendicitis seems to be a "local expression of a general infection." Finney and Hamburger cite three cases associated with rheumatic polyarthritis, and they also refer to

Jaccoud's Arthropathy with Radial Shaft Deformity in a Patient with a History of Mild Carditis and Sydenham's Chorea

Background: Jaccoud’s arthropathy was first described in 1869 in a patient with recurrent attacks of acute rheumatic fever and recurrent migratory polyarthritis. The typical features include characteristic joint deviation with metacarpophalangeal subluxation, ulnar deviation, swan neck deformity of the fingers, and Z deformity of both thumbs and hook formation and alignment disorders without noticeable erosions on radiographs. In this report, Jaccoud’s arthropathy presenting with deformity of shaft of the radius is described. Case presentation: A 12-year-old-girl was diagnosed to have chorea at the age of 8 years after she presented with irregular, jerky, rapid and involuntary movements that involved the face, the trunk and the distal extremities. She was treated with haloperidol. The chorea resolved after 3 months of treatment. Echocardiogram showed thickening of the mitral valve leaflets and mild mitral regurgitation. Three years later, the child presented with progressive symmetric deformity of the wrist joints. She reported no pain or limitation of movement. On physical examination, there was no cardiac murmur. There was varus deformity of both wrist joints. There was no tenderness or limitation of movement. Anti-streptolysin O was negative at the first presentation and on this visit. Rheumatoid factor was negative but antinuclear antibody test was positive. Echocardiogram showed complete resolution of the mitral regurgitation. X-ray of the wrists showed marked symmetric curving of the distal radius and varus deformity of the wrists. There was joint deviation with metacarpophalangeal subluxation and ulnar deviation of the hand. There was no Z deformity of the thumbs. Conclusion: The common presentation of Jaccould’s arthropathy is involvement of the wrist, metacarpophalangeal joints and joints of the feet. The metacarpal and metatarsal bones are the ones, which are commonly affected. Our patient has an unusual presentation of deformity of the distal radial bone. This has not been described, at least to our knowledge.

Authors' response to Hasan

Dr Hasan's helpful observation highlights the problems of diagnosing ailments from ancient texts written in languages that may provide difficulties with translation. The Arabic text by Muhammed ibn Zakariya′ al-Rāzī (commonly known as Rhazes) to which Dr Hasan refers was originally published in Persia in around 865 AD; versions in Arabic1 and German2 are available in modern sources. Meyerhof has also given an English translation of one of Rhazes' cases, labelled ‘Hay-fever (?), followed by Rheumatic Polyarthritis’, as follows:3 The son of Al-Hasan Ibn ‘Abdawaih suffered from attacks of coryza so heavy and severe that I have never witnessed a similar case before. Even the slighter form of it used to remain with the sufferer a month and more and to descend to the chest, causing coughing and expectoration. This patient showed an improvement about the middle of the day so that he did not feel any discomfort, but this caused him pain in the articulations. In 1565 Leonardus Botallus from Pavia also published an account of a case that might have been hayfever.4,5 However, in neither case does it seem to have been clear that the condition described was the same as that which Bostock described, which is clearly recognizable as hayfever; Bostock's paper is regarded as the first clear description.5

Reversible Encephalopathy Due to Sulfasalazine

Sulfasalazine was devised by Swedish physician in the late 1930s in an attempt to treat "rheumatic polyarthritis." It is still a widely used anti-inflammatory agent especially in the treatment of rheumatologic disorders and inflammatory bowel diseases. Most of its side effects are benign, tolerable, and dose dependent, but less common severe systemic reactions have also been revealed. A 42-year-old woman diagnosed with rheumatoid arthritis was admitted to emergency service because of status epilepticus. Hepatitis and myelotoxicity were also present after laboratory investigations. The patient was on sulfasalazine treatment for 3 weeks with a daily dose of 2g. Cranial magnetic resonance imaging (MRI) revealed bilateral periventricular and subcortical lesions in the white matter of especially temporal and occipital regions. Cerebrospinal fluid (CSF) examination showed very high protein level (564 mg/L). After discontinuation of treatment, the clinical, CSF, and MRI findings regressed rapidly. Side effects of sulfasalazine include neurotoxicity such as status epilepticus, cranial MRI lesions, and CSF abnormalities that were diagnosed in our patient after excluding other etiologic factors causing encephalitis.

Radiogenic Lymphangiogenesis in the Skin

The time course of microvascular changes in the environment of irradiated tumors was studied in a standardized human protocol. Eighty skin biopsies from 40 patients with previously treated primary breast cancer were taken from irradiated skin and corresponding contralateral unirradiated control areas 2 to 8 weeks, 11 to 14 months, or 17+ months after radiotherapy (skin equivalent dose 30 to 40 Gy). Twenty-two biopsies of 11 melanoma patients who had undergone lymph node dissection were used for unirradiated control. We found an increase of total podoplanin(+) lymphatic microvessel density resulting mainly from a duplication of the density of smallest lymphatic vessels (diameter <10 microm) in the samples taken 1 year after radiation. Our findings implicate radiogenic lymphangiogenesis during the 1st year after therapy. The numbers of CD68(+) and vascular endothelial growth factor-C(+) cells were highly elevated in irradiated skin in the samples taken 2 to 8 weeks after radiotherapy. Thus, our results indicate that vascular endothelial growth factor-C expression by invading macrophages could be a pathogenetic route of induction of radiogenic lymphangiogenesis.

Transient diaphyseal tibial Tc-99m MDP uptake and bone marrow edema in acute rheumatic fever.

The authors describe a patient with acute rheumatic fever and polyarthritis in whom scintigraphy unexpectedly identified Tc-99m MDP uptake in the diaphyses of both tibiae. A dramatic rise in antistreptolysin-O titer and rapid resolution of tibial abnormalities paralleled marked articular improvement. Magnetic resonance imaging demonstrated a pattern consistent with marrow edema in the area of abnormal Tc-99m MDP accumulation. This finding has not been previously described in acute rheumatic fever, and it was suspected that the changes in the tibiae resulted from subclinical diaphyseal hyperemia from the inflammatory process observed in the contiguous joints.

Acute Rheumatic Polyarthritis

Antistreptococcal prophylaxis was discontinued in a group of 44 children who had acute rheumatic polyarthritis with no carditis or chorea during the initial attack and who had completed a mean period of 5 years of secondary prophylaxis and freedom from recurrences. Patients were then followed up for a mean period of 5 years (an observation period of 216 patient-years). Recurrence of disease occurred in 3 patients, with a recurrence rate of 1.4 per 100 patient-years. There was no evidence of carditis during these recurrences and all patients remained free of rheumatic heart disease 10 years after the initial attack. These data demonstrate the relative safety with which continuous antistreptococcal prophylaxis can be discontinued in a selected group of children with rheumatic fever.

Sulphasalazine in arthritis--an old drug rediscovered.

Sulphasalazine (salicyl-azo-sulphapyridine) has been in clinical use for over 40 years. Although the drug was originally introduced for the treatment of 'rheumatic polyarthritis' and ulcerative colitis, it is only in the past 10 years that its value in rheumatology has been appreciated. Controlled studies indicate that the drug is an effective remittive agent in both rheumatoid arthritis and ankylosing spondylitis. This is an area of great research interest since the drug is proving to be a useful tool for investigating the aeteology and pathogenesis of these diseases.

Rheumatic aortic stenosis in young patients presenting with combined aortic and mitral stenosis.

This report describes 30 patients under the age of 30 years with rheumatic aortic stenosis, presenting with combined aortic and mitral stenosis. Three patients had additional tricuspid stenosis. Twenty-eight patients gave a history of rheumatic polyarthritis. The diagnosis was confirmed by right and left heart catheterisation in all. The murmur of aortic stenosis was not initially present in 8 out of 10 patients in congestive heart failure. Aortic valve calcification was not seen. Cineangiography showed a tricuspid aortic valve in all, unlike congenital aortic stenosis. A unique feature of this group was the raised pulmonary vascular resistance in 87 per cent of the patients. The present study shows that patients in India developing aortic stenosis after rheumatic fever do so early in the natural history of the disease.

On the determination of the activity of rheumatism by the concentration of sialic acid in the blood serum in children

Determination of the activity of rheumatism does not cease to interest practical doctors, despite the large number of methods proposed for this purpose. Along with the ROE that has become firmly established in clinical practice, a number of very sensitive laboratory methods for determining the activity of the rheumatic process have recently been proposed. One of them is the determination of C-reactive protein in blood serum, which disappears much earlier than ROE normalization (A.I. Vorobyova, A.P. Sleptsov, etc.). An increase in the amount of fibrin in plasma is also characteristic of the acute phase of rheumatism; the highest rates were observed in rheumatic polyarthritis, but with the subsidence of the activity of rheumatism, a rapid decrease to normal values ​​is observed, similar to the reaction to C-reactive protein (A.I. Vorobieva).

Relation of isolated recurrences of Sydenham's chorea to preceding streptococcal infections.

IT is now well established that rheumatic polyarthritis and carditis occur one to five weeks after infections of the throat due to the Group A streptococcus. Although the preceding infections may be asymptomatic, they are almost always detectable, in retrospect, by titration of streptococcal antibodies.1 , 2 On this fact the theory of the streptococcal etiology of rheumatic fever was based. This theory was confirmed by the reduction in the recurrence rate of rheumatic fever achieved through antistreptococcal prophylaxis3 , 4 and, further, by the close relation of the recurrences that do occur to preceding streptococcal infections.5 Contrariwise, in cases of Sydenham's chorea — . . .

The treatment of rheumatic fever

The treatment of rheumatic fever has been discussed in the light of current information regarding the use of antibiotics, cortisone and corticotropin, and salicylates. The importance of eradicating any possible hemolytic streptococci which the patient may carry by means of adequate doses of penicillin appears to be unquestionable, as is the need for continued prophylaxis against further infections with hemolytic streptococci. Although the value of cortisone and corticotropin in rheumatic carditis is not yet established beyond question, the evidence to date is encouraging, especially when therapy can be started within a few days of onset of illness. These hormones appear to be of little if any benefit in long-standing subacute and chronic carditis. The value of salicylates in carditis is still less clear, but the meager evidence available is sufficiently hopeful to warrant the combined use of this drug with cortisone. For the treatment of rheumatic polyarthritis without evidence of carditis, salicylate probably is preferable to cortisone or corticotropin. A plan of treatment employing these agents has been outlined.

Spontaneous rupture of the tendon of extensor pollicis longus as a complication of rheumatoid arthritis.

Numerous authors haverecently stressed thefrequent clinical evidence oftendon involvement in rheumatoid arthritis. Edstrom(1945)foundevidence of tendinitis ,orperitendinitis ,in48percent. of391cases ofchronic rheumatic polyarthritis. Thelongflexors tothefingers wereinvolved in38percent. ofhis cases, andtheextensors in10percent.Kellgren andBall(1950) analysed 100 oftheir owncases, andfound tendon lesions present in42,in37ofwhichthelong flexors ofthefingers wereaffected. Other tendons described asclinically affected weretheextensors ofthefingers, thetendons aroundtheankle, andAchilles' tendon, butnomention wasmadeoftheextensor pollicis longus. Fifteen oftheir caseswereexplored, andtheclinical findings confirmed atoperation. They emphasized that inmostcases ofrheumatoid arthritis thetendon lesions wereonly oneaspect ofageneralized process involving joints, muscles, andoccasionally viscera ,butthatinrarecases thetendon lesions maybethechief causeof disability. Thedisabilities described weresnapping fingers (Helweg, 1924; Sperling, 1949, 1950; Kellgren andBall, 1950), weakness ofgrip (Edstrom, 1945), andinability toclench thefist. Nocases ofrupture oftendon werequoted, nor wasthis described asapossible occurrence. Kersley (1948), inashort paper, described twocases ofspontaneous muscle rupture occurring inrheumatoid arthritic subjects. No similar caseshavebeen described elsewhere. Inhisfirst case, themuscle ruptured wasinthecalf (?gastrocnemius); inthesecond, multiple lesions weredescribed. Inaddition totherupture ofthequadriceps, whichappeared tobeatthemusculo-tendinous junction, there werespontaneous ruptures oftheextensor apparatus ofthefourth digit oftheright hand, andtheflexor digitorum profundus ofthethird digit ofthe left hand.Thepatient's description ofthespontaneous rupture oftheextensor digitorum wasaslight pain, like anelectric shock, running uptheforearm . Thesite ofthese lesions wasconsidered tobeintheforearm, probably atthemusculotendinous junction. Boththese cases weremales, oneaged56,theother 54.Inthefirst case, a typical rheumatoid arthritis hadbeenpresent foroneandahalf years, inthesecond thequadriceps rupture occurred twoyears after theonsetofthedisease, theextensor rupture afurther oneandahalf years later.

Cortisone in Sydenham's chorea; report of two cases.

Beneficial effects of cortisone and pituitary adrenocorticotropic hormone (ACTH) on acute manifestations of rheumatic fever have recently been described.¹In particular, the effects on rheumatic polyarthritis and carditis have been studied. Since acute chorea is generally believed to be another manifestation of rheumatic fever,²we considered it of interest to determine the effects of cortisone in two cases of chorea that have recently come under our observation. To one of the patients pituitary adrenocorticotropic hormone was also administered. <h3>REPORT OF CASES</h3><h3>Case 1.—</h3> J. S., a 3 year old boy, was admitted to Beth Israel Hospital on June 18, 1950. Four weeks previously he had experienced a gradual onset of weakness of both arms and legs, associated with uncontrollable, purposeless movements of his limbs and face. Difficulty in swallowing and in speaking followed, and the patient was unable to sit or stand without support. Two weeks prior to

Treatment of acute rheumatic fever and acute rheumatic heart disease

The treatment of acute rheumatic fever and acute rheumatic heart disease with failure was discussed in this morning's seminar. The efficacy of chemotherapy in the prevention of rheumatic recurrences was questioned. Massive salicylate therapy for acute rheumatic fever was considered effective in changing the course of rheumatic polyarthritis and early carditis. The benefits derived from sanatorium type of care for the protracted case of rheumatic disease were described and the principles underlying the aims of this type of care were delineated. Digitalis in the treatment of acute rheumatic carditis with failure was considered of limited value. Finally, the use of high concentrations of oxygen in the treatment of acute carditis was discussed. It was pointed out that while oxygen therapy may not influence the duration of rheumatic activity, it seems to lessen the cardiac disability resulting from carditis. Some of the physiologic principles responsible for the salutory effects of oxygen therapy were presented.

A case of Stevens-Johnson disease (erythemamultiforme bullosa) treated with penicillin

A case of a 9-year-old boy with Stevens-Johnson syndrome is presented. 1.In the past this disease in its typical, severe form was marked by but oneserious sequela, that is, partial or total blindness due to eye involvement, possibly by bacterial agents. Staphylococcus aureus and sometimes mixed streptococcus and staphylococcus, are the most common bacteria cultured from the eye. 2.This patient was treated with sulfadiazine and penicillin, locally andparenterally, with decided improvement, which seemed to be related in dramatic time sequence to the use of penicillin, especially locally. 3.In a tabulation of twenty-one cases of erythema multiforme bullosawith mucous membrane lesions of varying severity, only five patients received adequate doses of sulfonamide or other antibacterial agents. In the seven most severe cases of the remaining sixteen, those that were typical of Stevens-Johnson disease, in which therefore, there was either purulent or membranous conjunctivitis, the patients were left with total or partial blindness. 4.It is suggested that such therapy as herein described, or modifications thereof, be used in the future to avoid eye complications. We do not know that penicillin is a “specific”; it may be, rather, an antibacterial agent useful against complications. Sulfonamides alone, in the past, prevented blindness, as did local Metaphen. 5.Six months after the onset of illness this patient was readmitted withacute rheumatic polyarthritis. A case of a 9-year-old boy with Stevens-Johnson syndrome is presented. 1.In the past this disease in its typical, severe form was marked by but oneserious sequela, that is, partial or total blindness due to eye involvement, possibly by bacterial agents. Staphylococcus aureus and sometimes mixed streptococcus and staphylococcus, are the most common bacteria cultured from the eye. 2.This patient was treated with sulfadiazine and penicillin, locally andparenterally, with decided improvement, which seemed to be related in dramatic time sequence to the use of penicillin, especially locally. 3.In a tabulation of twenty-one cases of erythema multiforme bullosawith mucous membrane lesions of varying severity, only five patients received adequate doses of sulfonamide or other antibacterial agents. In the seven most severe cases of the remaining sixteen, those that were typical of Stevens-Johnson disease, in which therefore, there was either purulent or membranous conjunctivitis, the patients were left with total or partial blindness. 4.It is suggested that such therapy as herein described, or modifications thereof, be used in the future to avoid eye complications. We do not know that penicillin is a “specific”; it may be, rather, an antibacterial agent useful against complications. Sulfonamides alone, in the past, prevented blindness, as did local Metaphen. 5.Six months after the onset of illness this patient was readmitted withacute rheumatic polyarthritis.

Salicylate therapy in rheumatic fever in children

Summary 1. Observations on the effect of massive salicylate therapy in rheumatic polyarthritis and carditis are presented. 2. Our observations suggest that large doses of salicylates sufficient to raise the plasma salicylate level to from 350 to 450 gammas per cubic centimeter produce a prompt and effective subsidence of all clinical and laboratory evidence of rheumatic activity in children having rheumatic polyarthritis. The oral route of administration is as effective as the intravenous. 3. Our experience further suggests that massive doses of salicylates in acute rheumatic carditis are equally effective in promptly suppressing all clinical and laboratory evidence of rheumatic activity. The intravenous route of administration seems to be hazardous. 4. The usual small doses of salicylates have no therapeutic value in rheumatic carditis in children.

The prognostic significance of age at onset in initial attacks of rheumatic fever

A clinical analysis was made of the incidence of cardiac damage during initial attacks of rheumatic fever. The data presented indicate that first attacks of rheumatic polyarthritis are less likely to be accompanied by clinically evident carditis in adults than in children, and that when carditis does occur it is very much less likely to result in serious cardiac damage in the adults.

Salazopyrin, a new sulfanilamide preparation. A. Therapeutic Results in Rheumatic Polyarthritis. B. Therapeutic Results in Ulcerative Colitis. C. Toxic Manifestations in Treatment with Sulfanilamide Preparations.

Salazopyrin, a new sulfanilamide preparation. A. Therapeutic Results in Rheumatic Polyarthritis. B. Therapeutic Results in Ulcerative Colitis. C. Toxic Manifestations in Treatment with Sulfanilamide Preparations.

Search for Microorganisms of the Pleuropneumonia Group in Rheumatic and Non-Rheumatic Children

SummaryCultures on 30% ascitic fluid agar of material obtained by swabbing the eyes, nose, and throat of rheumatic and non-rheumatic children and a few adults failed to reveal any pleuro-pneumonia-like colonies. No success was encountered in additional attempts to isolate microorganisms of the pleuro-pneumonia group from the blood of children in the febrile phase of acute rheumatic fever or Still's disease, from the joint fluid during the first attack of rheumatic polyarthritis, and from rheumatic pericardial, myo-cardial, and valvular tissues obtained at necropsy. Cultures of 58 pairs of excised tonsils, however, yielded in 3 cases peculiar microscopic colonies (“X” colonies) which were 20 to 40 μ in size and strikingly similar to those of certain members of the pleuro-pneumonia group. The “X” colonies could not be passaged beyond the first generation, and their nature remains unknown.