Anti-glomerular basement membrane and anti-neutrophil cytoplasm antibody-positive vasculitis presenting with peripheral neuropathy and acute renal failure

We report a case of Epstein-Barr (EB) infection that presented as an acute monoarthritis of the knee. This formed a Baker's cyst which ruptured into the gastrocnemius. The peripheral and synovial white blood counts were dominated by neutrophils. After repeated aspirations, spontaneous resolution occurred.     

Unilateral joint inflammation induces bilateral and time-dependent changes in neuropeptide FF binding in the superficial dorsal horn of the rat spinal cord: implication of supraspinal descending systems

Using quantitative autoradiography, the effects of acute and chronic inflammation on specific 125I-1DMethyl-FLFQPQRFamide binding were investigated in the rat spinal cord dorsal horn superficial layers, at 6 and 24 h and 2, 4, 6 and 12 weeks after induction of monoarthritis produced by injection of killed Mycobacterium butyricum suspended in Freund adjuvant in one tibio-tarsal joint. Six hours after monoarthritis induction, no modification in specific 125I-1DMethyl-FLFQPQRFamide binding was observed, whereas a significant bilateral increase occurred after 24 h and 2 weeks in L4/L5 dorsal horns, with a return to control values at 4, 6 and 12 weeks. Specific 125I-1DMethyl-FLFQPQRFamide binding was also investigated 24 h after monoarthritis induction in rats submitted 4 days before the induction to spinal cord lesions at the thoracic level (T9-T10). Hemisection of the spinal cord contralateral to the affected ankle prevented the transient bilateral increase in specific 125I-1DMethyl-FLFQPQRFamide binding, whereas total spinal cord section induced a significant bilateral decrease. All of these modifications were restricted to the spinal segments receiving afferent input from the arthritic ankle (L4/L5); no modifications were found at the levels L1 or C6-C8. These data suggest that FLFQPQRFamide is involved in spinal nociceptive processing during sustained peripheral nociceptor activation. The effects of spinal cord lesions in monoarthritic rats indicate that the modifications seen in the FLFQPQRFamide system activity, during sustained peripheral inflammation, depend on afferent fiber activation as well as on supraspinal controls.     

Monoarthritis of the knee as an isolated manifestation of paracoccidioidomycosis

Osteoarthritis in paracoccidioidomycosis has been rarely reported. The present case describes a 36-"year"-old woman, with chronic monoarthritis in the knee lasting 4 years. The diagnosis was achieved only after synovial biopsy, by anatomopathological examination showing granulomatous reaction with a large number of the characteristic "pilot wheel"Paracoccidioides brasiliensis yeast cells. Specific therapy, initially with ketoconazole and followed by cotrimoxazole led to complete functional recovery of the compromised joint. No other affected site was detected by various propaedeutic methods, including computed axial tomography of the thorax and abdomen. The authors emphasize the rarity of the case and discuss its possible pathophysiology.     

Sporotrichal arthritis in south central Kansas

Sporotrichal arthritis is a rare disease, with only 51 cases reported in the English literature. Thirteen patients with sporotrichal arthritis have been treated at Wichita area hospitals since 1979. Most of the patients were middle aged men. Significant alcohol intake was noted in 77% of the patients. There were 17 joints involved in the cases, including 10 knees, three interphalangeal joints, one elbow, one midtarsal, one intercarpal, and one metatarsophalangeal joint. The typical appearance was an afebrile patient with a mildly swollen warm joint without erythema. The leukocyte counts were normal in 85% of patients, and the erythrocyte sedimentation rates were elevated in 100%. The patients had various treatments and responses. Response rates included intravenous amphotericin B (16%), ketoconazole (40%), and arthrodesis (100%). Sporotrichal arthritis may be more common than previously thought. It should be considered early in the differential diagnosis of monoarthritis.     

Sacroiliac joint pyarthrosis

Sacroiliac (SI) joint infection is rare, and symptoms are idiosyncratic and often confusing. This paper reviews six cases of SI joint infection with regard to their clinical manifestations, diagnostic imaging, and treatment. The six patients were seen over a 15-year period and had a mean age of 16.2 years and a mean follow-up of 44.2 months. The most common presenting symptom was fever (71.4%). The most common physical findings were elevated temperature and limited ipsilateral hip motion. In most cases the white blood cell count and erythrocyte sedimentation rate were elevated, and 71% of the cases had positive blood cultures. The most specific imaging study was the technetium bone scan. All patients were treated with 3 to 6 weeks of appropriate antibiotics and were asymptomatic and had a normal physical examination on follow-up. Routine anteroposterior roentgenograms of the pelvis demonstrated sclerosis of the affected SI joint in one third of the cases. There appeared to be no long-term sequelae in this group of patients.     

Streptococcal arthritis in Thai adults: case series and review

The incidence, clinical spectrum, types of streptococci in Thai adults with streptococcal arthritis in Chulalongkorn Hospital are similar to Western reports. The most frequently found organism was group A Streptococcus and the second was group G. Most of the patients were elderly who usually had underlying medical and/or joint diseases. There were 3 patients with underlying lepromatous leprosy which has never been reported before, while mixed types of streptococcal infection in the same joint, mixed types of streptococcal infection in the same patient and a patient with group C lumbar spondylodiskitis were also found. The most reliable diagnostic test is synovial fluid culture. All streptococcal isolates in our review were sensitive to penicillin and the clinical responses correlated with antibiotic sensitivity tests. Intravenous antibiotics and adequate drainage are the treatment of choice. The duration of treatment ranged from 4 to 6 weeks and most patients responded well. The overall mortality rate depended on host factors, organism virulence and treatment administered.     

Postoperative infection following orthopaedic surgery in human immunodeficiency virus-infected hemophiliacs with CD4 counts < or = 200/mm3

Human immunodeficiency virus-infected hemophiliacs are at risk for bacterial and opportunistic infections with worsening immunosuppression. Thus, the risk of postoperative infection following orthopaedic surgery is of considerable concern. A survey of United States hemophilia treatment centers was conducted to determine the incidence of postoperative infection in human immunodeficiency virus-positive hemophiliacs with CD4 counts of 200 mm3 or less undergoing orthopaedic surgery. A total of 115 centers from 37 states reported that postoperative infection occurred in 10 (15.1%) of 66 patients undergoing 74 orthopaedic procedures, between several weeks and 5 months following surgery. In five (50%), pre-operative infection preceded postoperative joint infection. Staphylococcus was the most common organism isolated in a prosthetic joint infection, in 6 of 10 (60.0%), and the knee was the most commonly affected joint, in 9 of 10 (90.0%). Joint arthroplasty appeared to have 10 times the risk of nonarthroplasty procedures for postoperative infection (9 of 34 [26.5%] and 1 of 40 [2.5%], respectively, P < .01). Two subjects developed chronic osteomyelitis. The rate of postoperative infection in human immunodeficiency virus-positive hemophiliacs with CD4 counts of 200/mm3 or less appears to be high, when compared with the general population. Early, vigorous treatment should be instituted for suspected infection, antibiotic prophylaxis considered for invasive procedures, and surgical intervention individualized based on the balance of risks and benefits.     

Structure determination of the small ubiquitin-related modifier SUMO-1

The goals in the management of septic arthritis are joint decompression, joint sterilization, and preservation of joint function. Opinions on how these goals are best accomplished vary among medical disciplines. Although the literature supports both serial aspirations and arthrotomy as viable ways to treat pyarthrosis, most orthopedic surgeons prefer arthrotomy. There are advantages to surgical management, including more complete decompression, especially in infections characterized by thick, purulent fluid or loculations; a lower intra-articular bacterial count after lavage; the opportunity to perform a synovectomy; and no delay in cases that may be unresponsive to simple aspiration and antibiotics. Rehabilitation of the septic joint is paramount in preserving range-of-motion and cartilage protection. Although splinting and immobilization are necessary in treating acute infections, early range of motion is paramount in preserving long-term joint function.     

Septic sacroiliitis

Two cases of septic sacroiliac (SI) joint arthritis are presented to illustrate the difficulty of diagnosing and treating this uncommon osteoarticular infection. The patients presented are a 68-year-old woman with septic sacroiliitis caused by Streptococcus agalactiae and a 20-year-old man with Salmonella infantis infection involving the SI joint. The recent literature is reviewed and compared with previously published series. Of the 177 cases we reviewed, 47 (27%) occurred in pediatric patients. The mean age was 20 years. Only six patients (3%) were older than 60 years of age. Magnetic resonance imaging (MRI) is most useful for defining extent of infection, osteomyelitis, and abscess formation in the SI joint. Computed tomography (CT) is valuable for defining the extent of bone involvement and for guidance of percutaneous needle arthrocentesis. Other imaging modalities are useful primarily in the initial evaluation of patients with a nonspecific presentation. Four to six weeks of intravenous (i.v.) antibiotic therapy is recommended. Indications for surgical intervention include abscess formation, osteomyelitis, sequestrum of necrotic bone, and failure to respond to i.v. antibiotic therapy.     

MR imaging of pediatric musculoskeletal inflammatory and infectious disorders

Inflammatory and infectious disorders of the skeletally immature extraspinal musculoskeletal system affect the bones, contiguous soft tissues, muscles, and joints. MR imaging of osteomyelitis, soft tissue infection, inflammatory muscle disease, and acute and chronic joint disease are discussed in the context of underlying pathophysiology. Discussion includes imaging optimization, contribution of MR imaging to overall patient management, and differential diagnostic considerations for the pediatric patient.     

Difficult orthopaedic infections

Three difficult orthopaedic infections, infected non-union, MRSA infection and postoperative infection after joint replacement are presented. The Papineau method and continuous irrigation method are useful for infected nonunion. The choice of antibiotics for MRSA infection is described. The present state and treatment for post-operative infection after joint replacement are discussed.     

Hepatitis C: Part I. Routine serologic testing and diagnosis

Hepatitis C, which is caused by the hepatitis C virus (HCV), is a major public health problem in the United States. HCV is most efficiently transmitted through large or repeated percutaneous exposures to blood. Most patients with acute HCV infection develop persistent infection, and 70 percent of patients develop chronic hepatitis. HCV-associated chronic liver disease results in 8,000 to 10,000 deaths per year, and the annual costs of acute and chronic hepatitis C exceed $600 million. An estimated 3.9 million Americans are currently infected with HCV, but most of these persons are asymptomatic and do not know they are infected. To identify them, primary health care professionals should obtain a history of high-risk practices associated with the transmission of HCV and other bloodborne pathogens from all patients. Routine testing is currently recommended only in patients who are most likely to be infected with HCV.     

Acute renal failure associated with nonfulminant hepatitis A viral infection

Nonfulminant hepatitis A viral infection has rarely been associated with renal abnormalities, most commonly microscopic hematuria and minimal proteinuria. An unusual case is presented of a 37-yr-old female with serologically proven acute hepatitis A infection complicated by acute oliguric renal failure. The patient recovered, and laboratory tests returned to normal 1 month after initial hospitalization. Renal biopsy revealed acute tubular necrosis; dialysis was not necessary. The relevant world literature is reviewed.     

Chronic hepatitis C: early intervention

Chronic hepatitis C infection is the most common liver disease in the United States; it accounts for up to 12,000 deaths annually and is the most common referral for liver transplantation. Recognition of acute infection is desirable because treatment may prevent chronicity. Interferon remains the primary treatment, but new agents and combinations are being developed.     

Hydrophobic mismatch between proteins and lipids in membranes

During the evaluation of older adults with musculoskeletal complaints, it is necessary to differentiate periarticular conditions from intraarticular or arthritic conditions. It also is useful to classify the symptoms as acute or chronic and as mono-, oligo-, or polyarticular. Close attention should be paid to the history and physical exam findings, while laboratory tests and radiographs should only be used as supporting evidence of a clinical diagnosis. A search for the presence of joint inflammation is particularly important in the diagnostic process. Urgent evaluation is necessary in a patient with an acutely warm and swollen joint to rule out the presence of infection.     

Acute Weston Hurst necrotizing hemorrhagic leukoencephalitis

The clinical and pathological findings of a 43-year-old woman, diagnosed as having acute hemorrhagic leukoencephalitis at postmortem examination, are presented. The acute hemorrhagic leukoencephalitis affects mainly young adults and is the most fulminant from of demyelinating disease. It is frequently preceded by a respiratory infection. Diagnosis is facilitated by CT scanning and MRI, which reveal the massive lesion in the cerebral white matter. Many cases terminate fatally in 2 or 4 days, but in others survival is longer. The pathological findings are distinctive.     

The effect of fibronectin on re-epithelialization of rabbit cornea after alkali burn

As in other organ systems, there are ocular disorders largely unique to HIV such as Kaposi's sarcoma and cytomegalovirus retinitis. Other syndromes, such as acute retinal necrosis, although not unique to HIV infection, are well recognised in this group of patients and are sufficiently uncommon to make one consider HIV infection. However, most ocular signs and symptoms of HIV infection are common and non-specific, and require other clinical clues to raise the suspicion of HIV infection.     

Patellar whiskers and acute calcific quadriceps tendinitis in a general hospital population

Described is a case of acute calcific quadriceps tendinitis which presented as monoarticular arthritis. A survey of general hospital patients revealed a 7% incidence of calcification of the superior patellar tendon. The most common concurrent abnormality was degenerative joint disease (94%); concomitant chondrocalcinosis was not seen. The "patellar whisker" is a relatively common x-ray finding that may be the clue to an uncommon cause of acute arthritis.