Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases
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Calcium pyrophosphate dihydrate (CPPD) deposition disease is a relatively common condition primarily affecting the elderly. Various clinical presentations ranging from an acute arthritis resembling gout (pseudogout) to fever of unknown origin have been reported. We describe four elderly patients with fever and altered mental status. ⋯ An acute arthritis missed by the health-care team in their initial evaluation was later identified, leading to rheumatologic consultation and subsequent diagnosis of CPPD disease after joint aspiration and synovial fluid analysis. Defervescence and resolution of mental status changes occurred after improvement of the arthritis. Awareness that CPPD disease may present with systemic symptoms, including fever and altered mental status, may assure careful examination of joints and can prevent unnecessary testing and diagnostic delay.
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Hansen's disease is a chronic granulomatous disease of infectious origin. It has a worldwide distribution and a variety of clinical manifestations often involving the skin, nasal mucosa, and peripheral nerves. Lepromatous leprosy characterizes the condition of a large group of patients with little or no resistence to the infection. ⋯ However, Lucio's phenomenon is frequently fatal as a result of bacterial infection or sepsis, and both patients reported here died. We call attention to this particular and unusual skin manifestation of lepromatous leprosy, which can mimic rheumatic disease and other causes of vasculitis. This is especially likely to be unrecognized in nonendemic countries but cases will occasionally be seen in this age of extensive international travel.
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Chronic pain disorders, including fibromyalgia and myofascial pain syndrome often do not respond adequately to standard therapy. The cases reviewed herein suggest the strain and counterstrain (SCS) technique, described in 1981 by Jones, may be helpful in reducing pain and improving function in patients with localized myofascial pain syndromes. This was a case study and retrospective review of 20 patients who had had chronic pain for an average of 2.7 years and were treated with SCS for pain relief. ⋯ Areduction in pain and an increase in function of 50%-100% occurred in 19 of 20 patients immediately after SCS therapy. Partial improvement was maintained for 6 months in 11 of 20 patients, and 4 were still pain free. We believe that SCS techniques should be considered and evaluated further as adjunctive therapy for patients previously unresponsive to standard treatment for myofascial pain syndrome.
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A 50-year-old woman with noninsulin-dependent diabetes and cirrhosis of the liver from hepatitis-B infection presented with right-sided neck and severe shoulder pain. Minimal tenderness and swelling of the right sternoclavicular joint were noted. After 8 days, extensive studies, and several attempts at therapy to relieve the shoulder pain, the right sternoclavicular joint had become more swollen, extremely tender, warm, and erythematous. ⋯ The patient had an uneventful recovery after treatment with open drainage and parenteral antibiotics. Although this anaerobic organism is known to cause infection at other joint sites, this seems to be the first report of infection of the sternoclavicular joint and proximal clavicle by Prevotella melaninogenicus. This case illustrates the following: 1) neck and shoulder pain may be the presenting symptoms of occult septic arthritis of the sternoclavicular joint, 2) clinical signs of infection, such as fever and leukocytosis, may be absent in the setting of anaerobic joint infections, 3) an arthrotomy should be performed as soon as an infection of the sternoclavicular joint is suspected, 4) anaerobic as well as aerobic cultures should be taken when evaluating septic arthritis 5) 2 or more weeks may be required for identification of an anaerobic organism, such as Prevotella melaninogenicus.
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Nonacetylated salicylates are frequently used in the treatment of musculoskeletal complaints and pain management in older patients because of their possible lower gastrointestinal and renal toxicity as compared with other nonsteroidal anti-inflammatory agents. We report five patients with chronic salicylate intoxication seen at the Atlanta VA Medical Center. All charts of patients diagnosed with salicylate toxicity were reviewed, and cases with acute, intentional intoxication were excluded. ⋯ A significantly decreased urate level and a wide anion gap were consistent findings as well. Two of the patients improved after hydration and discontinuation of use of the drug, two required alkalinization of the urine, and one required dialysis. Clinicians need to be more aware of the potential toxicity, including life-threatening complications, with the use of salicylates, particularly in high risk populations such as elderly patients and patients with multiple medical problems.