Epidemiology of crystal arthropathy

Gout is an inflammatory arthritis mediated by the crystallization of uric acid within the joints and often is associated with hyperuricemia. Data suggest that the overall disease burden of gout remains substantial and may be increasing. Identifying and characterizing modifiable risk factors for gout is a major step in preventing and managing this painful condition. As more scientific data on the risk factors and comorbidities of gout become available, their integration into gout prevention and care strategies may become essential. This article reviews the relevant epidemiologic data, with a focus on recent progress and data on other crystal arthropathies.     

Clinical trials in crystal arthropathy

A few clinical trials have evaluated therapeutic agents for crystal-associated arthropathy. Most of the studies are uncontrolled and observational. Management of patients who have acute crystal arthropathies usually is symptomatic with long-term management depending on crystal composition. In trials of gout, studies focus on acute symptomatic treatment, foregoing chronic management, which is aimed at reducing the concentration of serum urate. In those who have calcium crystals, however, there is no definitive or effective long-term treatment in chronic gout. The xanthine oxidase inhibitor and uricosurics are the agents used most commonly. Newer compounds in clinical trials show promise as effective and safe therapeutic options.     

Nail-patella syndrome associated with mixed crystal deposition arthropathy

Summary This report describes a case of nail-patella syndrome in a woman with a strong family history who presented with effusions in her shoulder and knees. Microscopic examination of the shoulder fluid suggested the presence of calcium pyrophosphate dihydrate (CPPD) crystals, and examination of the knee fluid suggested both hydroxyapatite (HAP) and CPPD crystals. To our knowledge, the coexistence of these two conditions has not been reported in the past. Moreover, it brings up a new element regarding the inflammatory origin of the nail-patella syndrome.     

Anti-tuberculous IgE antibodies. I. Immunodominant antigens

It is widely accepted that protection against tuberculosis is provided by the formation of type 1 immune response, which is characterized by the production of IFN-gamma and IL-2. However, type 2 antimycobacterial immune response is also present: specific IgE antibodies that are IL-4 dependent, are usually found in tuberculosis patients. There is elevated production of type 2 cytokines in some cases. Thus, both types of an immune response can simultaneously develop, probably counteracting with each other. It is unknown which of mycobacterial antigens are capable of inducing a preferential type 2 response. To detect these antigens, the authors studied tuberculosis IgE antibodies in the sera of 500 tuberculosis patients by using the ELISA assay with ultrasonic disintegrated M. Tuberculosis H37Rv (sonicate). Antigens recognized by IgE antibodies were found to be localized in the cell wall of mycobacteria. The IgE-response was specific since the sera did not react with the antigens of atypical mycobacteria and other bacterial species.     

Ochronotic arthropathy with calcium pyrophosphate crystal deposition a light and electron microscopic study

Synovial fluid from a patient with ochronotic arthropathy and calcification of the capsule of the right knee contained calcium pyrophosphate crystals and dark debris. Microscopic examination of an unstained fresh preparation showed these dark fragments to have a brown or golden brown color typical of ochronotic pigment. By electron microscopy there were identifiable cartilage fragments in the synovial fluid. These contained clumps of dense material deposited on the surface of collagen fibers. Similar brown staining and electron dense material probably representing ochronotic pigment was seen in synovial membrane and synovial fluid cells. Some of the intracellular calcium pyrophosphate crystals were in close relation with probable pigment.     

Vasodilator therapy-induced pacemaker syndrome

Disabling presyncopal attacks were provoked in a patient with a sinus nodal disorder and cardiac pacemaker by treatment with antianginal vasodilators. At cardiac catheterization a severe fall in aortic pressure was documented during ventricular pacing, when desynchronized atrial contractions coincided with ventricular systoles. After withdrawal of the medication, no obvious changes in arterial pressure were associated with ventricular pacing, and the patient became free of dizziness. Vasodilating drugs may provoke episodic hypotension with characteristic features of the pacemaker syndrome.     

糖尿病达标治疗中的低血糖不容忽视

糖尿病达标治疗无疑是延缓和降低糖尿病患者大小血管并发症的重要手段.遗憾的是在越来越强调达标治疗的今天,医生在许多情况下忽视了低血糖的存在.糖尿病治疗中达标诱发低血糖已经被糖尿病控制与并发症试验(DCCT)、英国前瞻性糖尿病研究(UKPDS)等著名的大型临床试验证明是一条铁律.     

Treatment of therapy-induced preleukemic syndrome

Summary Two young adult patients with therapy-induced preleukemic syndrome and Hodgkin's disease as primary malignancy were treated with aggressive antileukemic regimens before the establishment of leukemic conversion. Pretreatment clinical staging procedures did not reveal recurrence of Hodgkin's disease. One of the regimens consisted of an HLA-identical allogeneic bone marrow transplant and the other of high dose cytosine arabinoside. Both therapeutic approaches have proved successful in restoring normal hematopoiesis with reversal to normal karyotypes and unmaintained remiisions 556 and 192 days post-treatment. The rationale for such a therapeutic approach in the preleukemic stage of therapy-induced leukemogenesis is discussed.     

Chemotherapy-related arthropathy

OBJECTIVE: To examine the characteristics of chemotherapy-related arthropathy in patients with cancer. METHODS: Eighteen patients developed joint symptoms after receiving chemotherapy. We reviewed their charts to obtain information on demographics, underlying tumor, chemotherapeutic agents, rheumatologic symptoms, and laboratory findings. Each patient was interviewed by telephone about his or her current joint symptoms. RESULTS: Patients comprised 14 women and 4 men with mean age 53.9 +/- 10.6 years. Five patients had breast cancer, 3 had advanced gastric cancer, 3 had lung cancer, 2 each had colon and cervical cancer, and 1 each had lymphoma, glioblastoma, and bladder cancer. The most commonly used drugs were 5-fluorouracil, cyclophosphamide, and cisplatin. Joint symptoms usually began 6 months after the first session of chemotherapy. Patients had an average of 8 tender joints and 6 hours of morning stiffness. Five patients were positive for antinuclear antibody and 3 for rheumatoid factor. Nonsteroidal antiinflammatory drugs and disease modifying antirheumatic drugs (DMARD) were prescribed. Five patients did not show improvement and were also given low dose oral corticosteroids. Followup was available for 15 patients: 14 showed favorable responses characterized by a significant decrease (more than 50%) in morning stiffness, pain, and tender joint counts after a mean of 3 months' treatment. Nine patients had complete resolution of symptoms and stopped all medications. CONCLUSION: Chemotherapy-related arthropathy is not rare and the prognosis is fairly good with early treatment using DMARD and corticosteroids.     

Ochronotic arthropathy

The authors report on 18 members of four generations of an alkaptonuric family. All three males in the third generation are clinically affected; two members of the family tree have undergone major joint surgery.     

Acromegalic arthropathy

Arthropathy was assessed in 19 patients with active acromegaly. Axial or peripheral arthropathy was present in 10 patients, was located most often in large joints or the lumbosacral spine, and was osteoarthritic in nature. The mean duration of acromegaly in patients with arthropathy was 21.6 years, while the mean duration in patients without arthropathy was 7.9 years. A mild-to-moderate improvement in symptoms, estimated functional ability, and crepitus occurred in 8 of 9 patients who were prospectively examined during therapy to lower production of growth hormone. We conclude that this therapy did improve the symptoms of acromegalic arthropathy. Whether objective structural improvements occur remains unclear.     

Beekeeper' arthropathy

OBJECTIVE: To describe the clinical, analytical, and radiological features of an observed arthropathy affecting beekeepers. METHODS: Prospective study of 34 patients (32 male, 2 female), mean age 42 years (range 16 to 66 years), evaluated for the presence of acute or chronic arthritis related to beekeeping. All patients were working and living in the same village, Fuenlabrada de los Montes (1300 habitants), where there is a census of 180 beekeepers. An epidemiologic inquiry reported that > 50% of them reported episodes of arthritis on the hands during the month of August, at the time of honey collection. RESULTS: Acute arthritis was observed in 10 patients. Pain, tenderness, joint swelling, and warmth were present in most cases. Chronic arthropathy was noted in 32 patients. Tenderness was present in 16 cases, synovial thickening in 12, limited joint mobility in 8, bony swelling in 15, and joint deformities in 13 patients. Radiological study showed periarticular soft tissue swelling, bone sclerosis, periostitis, bony erosions, subchondral cysts, geodes, osteophytes, and joint narrowing. CONCLUSION: Beekeepers have joint disease apparently related to bee stings. Etiopathogenesis is unknown. Mechanical trauma, venom compounds, infection, and foreign body synovitis are factors that are thought to influence the pathogenesis of this syndrome. We designate the condition "beekeepers' arthropathy," and consider it an occupational disorder.