Faculty Bibliography

One hundred seventy-six patients with breast prosthetic implants were evaluated. All women were symptomatic and were referred by either attorneys (152) or physicians (24) for rheumatic evaluation. The women ranged in age from 24 to 72 with a mean of 45 years. Indications for surgery were cosmetic (128), cancer (34), and other (14). Implants had been in place for 7 years or more in 120 patients and < 2 years in only 8. Eighty-three women required explantation of their original prostheses, and 63 had new implants inserted of which 47 were silicone and 16 were saline. Capsular contractures were present in 128 women, and documented implant rupture occurred in 67. Sixty-four women underwent manual closed capsulotomies. Of the 63 revisions, 37 resulted in contractures of the new implant. The most frequent symptoms seen in the women were chronic fatigue (77%) cognitive dysfunction (65%), arthralgia (56%), dry mouth (53%), dry eye (50%), alopecia (40%), and dysphagia (35%). The most common findings on physical examination were telangiectasias (60%), erythema of the chest wall (56%), carpal tunnel syndrome (47%), petechiae (46%), lacrimal gland enlargement (26%), thyroid tenderness (22%), thyroid enlargement (21%), and parotid enlargement (18%). Laboratory findings included elevated cholesterol (59%), elevated erythrocyte sedimentation rate (32%), elevated serum immunoglobulin (28%), and positive autonuclear antibody (25%) seen most often. Despite clinical features suggesting Sjogren's syndrome, antibodies to Ro (SSA) were seen in only 2 patients, and antibodies to La (SSB) were seen in only 4 patients. Siliconosis is a novel systemic disease with symptoms of chronic fatigue, cognitive dysfunction, sicca syndrome, and arthralgia.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiographs were reviewed in a group of nine patients with classical seropositive rheumatoid arthritis who on tissue typing were found to express the class I HLA-B27 allele. Radiographs were analyzed with regard to whether or not they demonstrated radiographic features of (1) classical rheumatoid arthritis, (2) seronegative arthritis, or (3) mixed features of rheumatoid and seronegative arthritis. Five patients (55%) displayed radiographic features consistent with a diagnosis of rheumatoid arthritis, two patients (22%) showed radiographic features of seronegative disorder (periostitis and sacroiliitis), and two patients (22%) showed a mixed picture with evidence of both rheumatoid arthritis and a seronegative disorder. Thus, the HLA-B27 allele contributed to the radiographic features in 44% of patients with rheumatoid arthritis and associated HLA-B27. Thus, the wide range of findings in our population indicates that the radiographic attributes are not specific enough to constitute a unique subpopulation of patients with rheumatoid arthritis.

One of the unanticipated consequences of infection with the human immunodeficiency virus (HIV) is the appearance of various rheumatic syndromes that traditionally have been thought to result from inappropriate overactivity of the immune system. This distinctive spectrum of rheumatic syndromes has been well described; however, the therapeutics and specific patient management as well as the significance of these disorders for diagnostic classification of the rheumatic disorders have not received a great degree of attention. This article focuses on these areas with emphasis on (1) the nosology of the arthrocutaneous musculoskeletal syndromes with HIV, (2) clinical presentation of the various syndromes, (3) current concepts regarding the etiopathogenesis of the spondyloarthropathic form of arthritis in this setting, and (4) an approach to therapy

STUDY OBJECTIVE: To describe the clinical, immunologic, and immunogenetic features of a diffuse infiltrative lymphocytic disorder resembling Sjogren syndrome in persons infected with human immunodeficiency virus (HIV). DESIGN: Clinical case study. SETTING: University-affiliated hospitals and outpatient clinics. PATIENTS: Consecutive sample of 17 patients. MEASUREMENTS AND MAIN RESULTS: All of the 17 patients had bilateral parotid gland enlargement; 14 had xerostomia and 6 had xerophthalmia. Of the 17 patients, 14 had generalized lymphadenopathy, 10 had histologically proved lymphocytic interstitial pneumonitis, 4 had neurologic involvement, and 3 had lymphocytic infiltration of the gastrointestinal tract. Gallium scanning in all of 11 tested patients showed abnormal salivary gland uptake. Minor salivary gland biopsies showed more than 2 lymphocytic foci per 4 mm2 tissue in all of 11 tested patients, the infiltrate consisting predominantly of CD8 cells. Fifteen patients had circulating CD8 lymphocytosis; the principal phenotype of these cells was CD8+ CD29+. Rheumatoid factor and antinuclear antibodies were infrequent, and none of the patients had anti-Ro/SS-A or anti-La/SS-B antibodies. HLA-DR5 was significantly more frequent in the black patients (10 of 12) compared with controls (13 of 45). Only one patient developed an opportunistic infection during 544 patient-months of study, and none has died of AIDS. CONCLUSIONS: A distinct syndrome primarily characterized by parotid gland enlargement, sicca symptoms, and pulmonary involvement occurs in HIV infection. This disorder is associated with CD8 lymphocytosis and the presence of HLA-DR5, and appears to be a genetically determined host immune response to HIV

We report a retrospective study of 16 patients with seropositive rheumatoid arthritis who were placed on combination D-penicillamine and methotrexate therapy for a period of 5-86 months. Three patients were lost to follow-up, and one patient died of unknown causes at another institution. Among the 12 remaining patients, there was no withdrawal secondary to drug intolerance. All patients demonstrated improvement in functional class correlated with a reduction in joint count, duration of morning stiffness, erythrocyte sedimentation rate, rheumatoid factor, and prednisone requirement. Eight of the 12 patients achieved remission as defined by the American College of Rheumatology criteria. Remission was sustained for a period of 3-72 months. The dosage of D-penicillamine ranged from 250-1000 mg/d (mean = 750 mg); that of methotrexate ranged from 5-15 mg/week (mean = 10 mg). The study indicates that D-penicillamine and methotrexate combination therapy is effective in the treatment of severe rheumatoid arthritis and warrants further prospective investigation

Radiographs of symptomatic joints were retrospectively evaluated in 24 patients with inflammatory arthritis and human immunodeficiency virus (HIV) infection. Clinically, 20 patients had a seronegative arthritis including Reiter syndrome (54%), psoriatic arthritis (17%), and undifferentiated forms of spondyloarthropathy (13%). These patients were indistinguishable radiographically from patients with typical seronegative disorders except for the predominance of lower-extremity abnormalities. Four patients (17%) had a rheumatoidlike arthritis defined as acute symmetric polyarthritis (ASP). With the exception of extensive proliferative periostitis, ASP simulated classic rheumatoid arthritis. HIV-associated arthritis was manifest during various stages of HIV infection. It preceded acquired immunodeficiency syndrome in 64% of patients with stage IV HIV infection. Awareness of the coexistence of HIV infection in patients with the above-mentioned arthritides is important, since immunosuppressive therapy, commonly used in the treatment of arthritis, can have detrimental effects in patients with HIV infection

The association of the class II genes of the DRw10 haplotype from a cell line, NASC, initiated from a member of a well characterized family, was analyzed by sequencing cDNA clones corresponding to DR beta I, DQ alpha, and DQ beta genes. An identical haplotype was also identified in the Raji cell line. In addition to typing as DRw10 and DQw1 with HLA typing sera both, the NASC and Raji cell lines were shown to react strongly with the monoclonal antibodies 109d6 (specific for DRw10 beta 1 and DRw53 beta 2 gene products) and Genox 3.5.3 (specific for DQw1) and exhibited the restriction fragment length polymorphism indicative of a DRw10, DQw1 haplotype. The DR beta 1 gene corresponding to the DRw10 specificity was found to have a first domain sequence different from all other DR beta I genes. Sequence analysis of the 3'-untranslated region of this DR beta-chain gene showed a significant divergence from the 3' untranslated region of the DRw53 family of haplotypes and a lesser divergence from that of the DRw52 and DR1/DR2 families. The sequence of the DQ beta genes corresponding to the DQw1 specificity in the DRw10 haplotype was found to be identical to the DQ beta gene from a DR1, DQw1 haplotype. Surprisingly, however, the DQ alpha gene did not resemble other DQw1-like DQ alpha genes, but was identical in sequence to the DQ alpha gene found in DR4 haplotypes. The novel association of DQ alpha and DQ beta genes in the DRw10 haplotype revealed in these studies may result from a double recombinational event. More consequentially, these studies strongly suggest that the DQw1 specificity recognized by Genox 3.5.3 is determined by the DQ beta chain and is not affected by the DQ alpha-chain