Nederlands tijdschrift voor geneeskunde, Jan 23, 2006
A 52-year-old man presented with polyarthritis and was negative for rheumatoid factor, anti-CCP a... more A 52-year-old man presented with polyarthritis and was negative for rheumatoid factor, anti-CCP and ANA. He was treated with low-dose methotrexate, the drug of first choice in rheumatoid arthritis. The arthritis disappeared, but the patient developed fever, progressive dyspnoea, appetite loss and weight loss. Upon hospital admission his medication was stopped and community-acquired pneumonia was diagnosed. The fever persisted despite antibiotic treatment. The tentative diagnosis of rheumatoid arthritis was changed to systemic lupus erythematosus, based on the change in clinical condition that could not be explained by polyarthritis and seroconversion to ANA- and anti-dsDNA-positive. The patient was treated with high-dose steroids and azathioprine and remained in remission for more than 1 year after treatment. The ANA test remained strongly positive, whereas anti-dsDNA was no longer detectable. This case stresses the limited value of classification criteria for the diagnosis of rheum...
We describe a solid-phase enzyme-linked immunosorbent assay (ELISA) for quantitation of antibodie... more We describe a solid-phase enzyme-linked immunosorbent assay (ELISA) for quantitation of antibodies to nucleoribonucleoprotein (nRNP/Sm). nRNP/Sm was purified from rabbit thymus acetone powder by immunoaffinity chromatography and characterized by counterimmunoelectrophoresis (CIE) and immunoblotting using sera with well-known specificities. The purified antigen was used in ELISA. Positive results in ELISA were obtained only in sera with anti-nRNP or anti-Sm specificity as determined in CIE. Levels of anti-nRNP/Sm as quantitated by ELISA were higher in the sera of patients with active connective tissue disease (n = 7) than in those with inactive disease (n = 6) (P less than 0.01). Differences in anti-nRNP/Sm levels were also found between patients with mildly active disease (n = 19) and those with active disease (P less than 0.01). Fluctuations of anti-nRNP/Sm levels related to disease activity were seen in longitudinal observation. Although anti-nRNP/Sm levels as quantitated by ELISA...
Since 1983 there have been several reports on Pneumocystis carinii pneumonia (PCP), complicating ... more Since 1983 there have been several reports on Pneumocystis carinii pneumonia (PCP), complicating low dose methotrexate (MTX) therapy for rheumatoid arthritis (RA). Two additional cases of this opportunistic infection are reported and a review of the literature on the complication is presented. It is concluded that PCP is a serious complication of low dose MTX therapy for RA and should always be ruled out when a patient presents with pulmonary symptoms. Several factors may play a role in the occurrence of this opportunistic infection, but the exact mechanism has not yet been elucidated.
Studies on the relationship between acute-phase protein (APP) production, clinical disease activi... more Studies on the relationship between acute-phase protein (APP) production, clinical disease activity and progression of radiological damage in RA have been hampered by three factors: patients are studied at different stages of the disease; APP levels are taken incidentally rather than serially; and inter-individual differences in the relationship between the extent of the acute-phase reaction and the progression of radiological damage are not accounted for. A group of 110 newly diagnosed (complaints < 1 year) patients with RA were analysed for a follow-up period of at least three years. Damage was assessed radiologically according to the modified method of Sharp. As radiological progression is a cumulative event, APP production was also calculated by plotting serial CRP levels over time. Overall, a highly significant correlation was found between CRP production and radiological progression; however, a wide variation was observed due to inter-individual differences. The greatest variation was found in the lower range of CRP values, where inter-individual variation could not be accounted for by HLA-DR4, positive RF, sex or age. In conclusion, the prognostic use of serial measurement of APPs for the assessment of radiological progression is limited due to inter-individual variation. Knowledge of the factors underlying these inter-individual differences will increase the applicability of CRP in the prediction of joint damage for individual patients.
We report the case of a 62-yr-old man who presented with Lyme pericarditis leading to cardiac tam... more We report the case of a 62-yr-old man who presented with Lyme pericarditis leading to cardiac tamponade shortly followed by an arthritis. IgM and IgG antibodies to Borrelia burgdorferi were demonstrated in serum by indirect immunofluorescence. Borrelia burgdorferi was demonstrated and identified in pericardial fluid by indirect immunofluorescence using serum from a patient with proven Lyme disease and by a monoclonal antibody immuno-gold silver stain. Spirochetes were also found in synovial biopsies using a silver stain. The tamponade was treated with pericardiocentesis; the arthritis was treated with intravenous ceftriaxone (2 g once daily) for 14 days. The patient recovered completely within days of commencing treatment. This case report demonstrates that borrelial infection may lead to pericarditis and cardiac tamponade.
... J. DE KONING, J. HEESEMANN, JAA HOOGKAMP-KORSTANJE, JJM FESTEN, PM HOUTMAN,PLM VAN OlJEN Labo... more ... J. DE KONING, J. HEESEMANN, JAA HOOGKAMP-KORSTANJE, JJM FESTEN, PM HOUTMAN,PLM VAN OlJEN Laboratory for Public Health in Friesland and Department of Rheumatology,Medical Centre Leeuwarden, Leeuwarden; and Department of Rheumatology ...
The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand, 1999
We present a case of synovitis of the wrist due to histoplasmosis, diagnosed only after extensive... more We present a case of synovitis of the wrist due to histoplasmosis, diagnosed only after extensive surgery and culturing. Treatment with amphotericin B in combination with radical surgery was effective in curing the disease. This manifestation was probably an exacerbation of a latent chronic infection with Histoplasma capsulatum, although it was unclear why the exacerbation occurred. Synovitis resistant to treatment should be assessed with great care, especially in view of the growing number of immunocompromised patients. Close collaboration between surgeon, rheumatologist, pathologist and microbiologist is paramount in such cases.
The case of a 6-year-old boy who presented with acute post-streptococcal glomerulonephritis is re... more The case of a 6-year-old boy who presented with acute post-streptococcal glomerulonephritis is reported. C3 levels and complement alternative pathway activity remained low for at least 10 months after presentation, before returning to normal. There was no evidence of other renal disease. This case highlights that hypocomplementaemia in acute post-streptococcal glomerulonephritis may persist for several months, and that prolonged hypocomplementaemia does not exclude this diagnosis.
The IgA and IgG antibody response to plasmid-encoded outer membrane proteins was studied in 59 pa... more The IgA and IgG antibody response to plasmid-encoded outer membrane proteins was studied in 59 patients with yersinia-associated spondylarthropathy during 15 months of follow-up. Initially, all patients had specific IgA and IgG antibodies to the 36 and 46 kDa and 30% also to the 26 and 58 kDa released proteins, which correlated with the finding of virulent Yersinia bacilli in intestinal biopsies. IgA disappeared in 69% of untreated patients after nine months and persisted in 31% after one year. IgA disappeared within three to six months in 81% of the patients treated with antibiotics for four to six weeks and persisted in 6% after one year (p less than 0.002). IgG antibodies to the 36 and 46 kDa outer membrane proteins persisted in 80% of all patients. Disappearance of IgA was coupled with disappearance of yersinia from intestinal biopsies.
Peripheral neuropathy is an uncommon complication in paediatric systemic lupus erythematosus (SLE... more Peripheral neuropathy is an uncommon complication in paediatric systemic lupus erythematosus (SLE). We report the case of a 10-year-old Chinese girl who developed peripheral neuropathy within 3 months of the onset of SLE and presented with bilateral foot drop and sensory symptoms of both hands and feet. There was no involvement of the central nervous system at the time of presentation. The patient was negative for anticardiolipin antibodies, but positive for lupus anticoagulant. She was treated with intravenous methylprednisolone followed by oral steroids, methotrexate, gabapentin and amitryptyline. Although peripheral neuropathy is a rare complication of paediatric systemic lupus erythematosus, one should be vigilant for this entity as part of the neurological spectrum. It may not be associated with involvement of the central nervous system. Antiphospholipid antibodies may have role in the pathogenesis of SLE associated peripheral neuropathy. We speculate that routine nerve conduction studies may have a role in detecting sub-clinical cases.
Plasma exchange was performed in two patients with classical rheumatoid arthritis, complicated in... more Plasma exchange was performed in two patients with classical rheumatoid arthritis, complicated in one case by necrotic vasculitis, in the other by mononeuritis multiplex. Immediate improvement in the peripheral circulation was observed in both patients with subsequent healing of ...
Nederlands tijdschrift voor geneeskunde, Jan 23, 2006
A 52-year-old man presented with polyarthritis and was negative for rheumatoid factor, anti-CCP a... more A 52-year-old man presented with polyarthritis and was negative for rheumatoid factor, anti-CCP and ANA. He was treated with low-dose methotrexate, the drug of first choice in rheumatoid arthritis. The arthritis disappeared, but the patient developed fever, progressive dyspnoea, appetite loss and weight loss. Upon hospital admission his medication was stopped and community-acquired pneumonia was diagnosed. The fever persisted despite antibiotic treatment. The tentative diagnosis of rheumatoid arthritis was changed to systemic lupus erythematosus, based on the change in clinical condition that could not be explained by polyarthritis and seroconversion to ANA- and anti-dsDNA-positive. The patient was treated with high-dose steroids and azathioprine and remained in remission for more than 1 year after treatment. The ANA test remained strongly positive, whereas anti-dsDNA was no longer detectable. This case stresses the limited value of classification criteria for the diagnosis of rheum...
We describe a solid-phase enzyme-linked immunosorbent assay (ELISA) for quantitation of antibodie... more We describe a solid-phase enzyme-linked immunosorbent assay (ELISA) for quantitation of antibodies to nucleoribonucleoprotein (nRNP/Sm). nRNP/Sm was purified from rabbit thymus acetone powder by immunoaffinity chromatography and characterized by counterimmunoelectrophoresis (CIE) and immunoblotting using sera with well-known specificities. The purified antigen was used in ELISA. Positive results in ELISA were obtained only in sera with anti-nRNP or anti-Sm specificity as determined in CIE. Levels of anti-nRNP/Sm as quantitated by ELISA were higher in the sera of patients with active connective tissue disease (n = 7) than in those with inactive disease (n = 6) (P less than 0.01). Differences in anti-nRNP/Sm levels were also found between patients with mildly active disease (n = 19) and those with active disease (P less than 0.01). Fluctuations of anti-nRNP/Sm levels related to disease activity were seen in longitudinal observation. Although anti-nRNP/Sm levels as quantitated by ELISA...
Since 1983 there have been several reports on Pneumocystis carinii pneumonia (PCP), complicating ... more Since 1983 there have been several reports on Pneumocystis carinii pneumonia (PCP), complicating low dose methotrexate (MTX) therapy for rheumatoid arthritis (RA). Two additional cases of this opportunistic infection are reported and a review of the literature on the complication is presented. It is concluded that PCP is a serious complication of low dose MTX therapy for RA and should always be ruled out when a patient presents with pulmonary symptoms. Several factors may play a role in the occurrence of this opportunistic infection, but the exact mechanism has not yet been elucidated.
Studies on the relationship between acute-phase protein (APP) production, clinical disease activi... more Studies on the relationship between acute-phase protein (APP) production, clinical disease activity and progression of radiological damage in RA have been hampered by three factors: patients are studied at different stages of the disease; APP levels are taken incidentally rather than serially; and inter-individual differences in the relationship between the extent of the acute-phase reaction and the progression of radiological damage are not accounted for. A group of 110 newly diagnosed (complaints < 1 year) patients with RA were analysed for a follow-up period of at least three years. Damage was assessed radiologically according to the modified method of Sharp. As radiological progression is a cumulative event, APP production was also calculated by plotting serial CRP levels over time. Overall, a highly significant correlation was found between CRP production and radiological progression; however, a wide variation was observed due to inter-individual differences. The greatest variation was found in the lower range of CRP values, where inter-individual variation could not be accounted for by HLA-DR4, positive RF, sex or age. In conclusion, the prognostic use of serial measurement of APPs for the assessment of radiological progression is limited due to inter-individual variation. Knowledge of the factors underlying these inter-individual differences will increase the applicability of CRP in the prediction of joint damage for individual patients.
We report the case of a 62-yr-old man who presented with Lyme pericarditis leading to cardiac tam... more We report the case of a 62-yr-old man who presented with Lyme pericarditis leading to cardiac tamponade shortly followed by an arthritis. IgM and IgG antibodies to Borrelia burgdorferi were demonstrated in serum by indirect immunofluorescence. Borrelia burgdorferi was demonstrated and identified in pericardial fluid by indirect immunofluorescence using serum from a patient with proven Lyme disease and by a monoclonal antibody immuno-gold silver stain. Spirochetes were also found in synovial biopsies using a silver stain. The tamponade was treated with pericardiocentesis; the arthritis was treated with intravenous ceftriaxone (2 g once daily) for 14 days. The patient recovered completely within days of commencing treatment. This case report demonstrates that borrelial infection may lead to pericarditis and cardiac tamponade.
... J. DE KONING, J. HEESEMANN, JAA HOOGKAMP-KORSTANJE, JJM FESTEN, PM HOUTMAN,PLM VAN OlJEN Labo... more ... J. DE KONING, J. HEESEMANN, JAA HOOGKAMP-KORSTANJE, JJM FESTEN, PM HOUTMAN,PLM VAN OlJEN Laboratory for Public Health in Friesland and Department of Rheumatology,Medical Centre Leeuwarden, Leeuwarden; and Department of Rheumatology ...
The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand, 1999
We present a case of synovitis of the wrist due to histoplasmosis, diagnosed only after extensive... more We present a case of synovitis of the wrist due to histoplasmosis, diagnosed only after extensive surgery and culturing. Treatment with amphotericin B in combination with radical surgery was effective in curing the disease. This manifestation was probably an exacerbation of a latent chronic infection with Histoplasma capsulatum, although it was unclear why the exacerbation occurred. Synovitis resistant to treatment should be assessed with great care, especially in view of the growing number of immunocompromised patients. Close collaboration between surgeon, rheumatologist, pathologist and microbiologist is paramount in such cases.
The case of a 6-year-old boy who presented with acute post-streptococcal glomerulonephritis is re... more The case of a 6-year-old boy who presented with acute post-streptococcal glomerulonephritis is reported. C3 levels and complement alternative pathway activity remained low for at least 10 months after presentation, before returning to normal. There was no evidence of other renal disease. This case highlights that hypocomplementaemia in acute post-streptococcal glomerulonephritis may persist for several months, and that prolonged hypocomplementaemia does not exclude this diagnosis.
The IgA and IgG antibody response to plasmid-encoded outer membrane proteins was studied in 59 pa... more The IgA and IgG antibody response to plasmid-encoded outer membrane proteins was studied in 59 patients with yersinia-associated spondylarthropathy during 15 months of follow-up. Initially, all patients had specific IgA and IgG antibodies to the 36 and 46 kDa and 30% also to the 26 and 58 kDa released proteins, which correlated with the finding of virulent Yersinia bacilli in intestinal biopsies. IgA disappeared in 69% of untreated patients after nine months and persisted in 31% after one year. IgA disappeared within three to six months in 81% of the patients treated with antibiotics for four to six weeks and persisted in 6% after one year (p less than 0.002). IgG antibodies to the 36 and 46 kDa outer membrane proteins persisted in 80% of all patients. Disappearance of IgA was coupled with disappearance of yersinia from intestinal biopsies.
Peripheral neuropathy is an uncommon complication in paediatric systemic lupus erythematosus (SLE... more Peripheral neuropathy is an uncommon complication in paediatric systemic lupus erythematosus (SLE). We report the case of a 10-year-old Chinese girl who developed peripheral neuropathy within 3 months of the onset of SLE and presented with bilateral foot drop and sensory symptoms of both hands and feet. There was no involvement of the central nervous system at the time of presentation. The patient was negative for anticardiolipin antibodies, but positive for lupus anticoagulant. She was treated with intravenous methylprednisolone followed by oral steroids, methotrexate, gabapentin and amitryptyline. Although peripheral neuropathy is a rare complication of paediatric systemic lupus erythematosus, one should be vigilant for this entity as part of the neurological spectrum. It may not be associated with involvement of the central nervous system. Antiphospholipid antibodies may have role in the pathogenesis of SLE associated peripheral neuropathy. We speculate that routine nerve conduction studies may have a role in detecting sub-clinical cases.
Plasma exchange was performed in two patients with classical rheumatoid arthritis, complicated in... more Plasma exchange was performed in two patients with classical rheumatoid arthritis, complicated in one case by necrotic vasculitis, in the other by mononeuritis multiplex. Immediate improvement in the peripheral circulation was observed in both patients with subsequent healing of ...
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