Are classification criteria for spondylarthropathy useful as diagnostic criteria?

The authors used data from a study conducted under the auspices of the Société Française de Rhumatologie to evaluate the sensitivity and specificity of the individual items of two sets of criteria for spondylarthropathy. The study included 124 patients with spondylarthropathy and 1,964 controls. They found that the spondylarthropathy criteria with the highest sensitivities and specificities were useful not only for classifying patients but also for assisting in the diagnosis of spondylarthropathy.

[In situ migratory algodystrophies of the knee. Value of modern imaging]

The authors report three cases of migratory algodystrophy of the knee. Repeated isotope bone scan, CT scan and nuclear magnetic resonance were used to monitor the movement in situ of the pathophysiological process of algodystrophy. In one case, CT scan revealed localised hypertrophy of the soft tissues located immediately over the bone lesions.

Regional intravenous guanethidine blocks in algodystrophy

Five-hundred-thirteen regional intravenous guanethidine blocks were carried out in 125 cases of algodystrophy (118 adults), after failure of other treatments in 120 cases (Group I) and without previous treatments in 5 (Group II). A positive result occurred in 85 cases of Group I (71%) and in the 5 cases of Group II, after 4.5 +/- 1.7 blocks. In Group I the results did not differ significantly between upper (33 cases) and lower (87 cases) limb or in regard to sex, age, duration of disease, nature of previous treatments. The presence of psychic disorders was accompanied by less frequent (p less than 0.02) positive results. The tolerance was satisfactory in 85.6% of cases: 22 moderate side effects authorized a continuation of the blocks, 22 serious ones indicated interruption, especially one case of thrombophlebitis and another one of very transitory acute ischaemia. The risk of intolerance was significantly raised (p less than 0.02) by age. The regional guanethidine blocks seemed to be a good treatment for algodystrophy after failure of other treatments.

[Treatment of algodystrophy by regional sympathetic blocks with guanethidine (410 blocks in 98 patients). Preliminary results]

In a preliminary retrospective study, 418 regional sympathetic blocks with guanethidine administered as treatment of 103 cases of algodystrophy gave 70 p. cent of positive results versus 55 p. cent in case of psychic disorders. The tolerance was correct in 85 p. cent but was decreased by old age.

[Shoulder bursitis in rheumatoid polyarthritis]

Shoulder bursitis seldom appears in rheumatoid arthritis. It is usually associated with an involvement of the omohumeral joint but it may be isolate and sometimes indicative. The production of foreign bodies is very rare (3 published cases). We report about one observation of subacromiodeltoid bursitis with rice bodies, associated with rheumatoid arthritis following a severe evolution.

[Algodystrophy and venous thrombosis of the lower extremities. Diagnostic discussion. Apropos of 3 cases]

The authors report 2 cases of probable algodystrophy of the lower extremities, associated to a definite deep venous thrombosis. They discuss the relationships between the two diseases and the difficulties of the differential diagnosis in light of a third case where the algodystrophy is definite and manifests itself as a deep venous thrombosis confirmed by phlebography. They insist on the absolute need to rule out a deep venous thrombosis before considering the exceptional diagnosis of algodystrophy with pseudo-phlebitic manifestations.

[Macrogeodic coxitis in ankylosing spondylitis]

The authors report 6 cases of hip disease with macrocavities during ankylosing spondylarthritis, including 5 cases from a series of 57 coxites which occurred in 34 patients out of 340 ankylosing spondylarthritis, observed at Hospital Begin, between 1973 and 1982. In light of their observations, they propose a classification of the hip manifestations of ankylosing spondylarthritis. The hip involvement with microcavities in ankylosing spondyloarthritis is quite different from coxites with macrocavities present in rheumatoid polyarthritis, and represent more likely a post-inflammatory arthritic type of hip disease than a particular form of coxitis. Hip disease with macrocavities in ankylosing spondylarthritis is a severe form of hip disease, and frequently requires the installation of a total prosthetic replacement.

[Algodystrophy in children and young adults with low isotope retention in the bones. Apropos of 5 cases]

The authors report 5 observations of young adults, 3 teen-agers and 2 children suffering from algodystrophy, and in whom isotopic exploration of the skeleton disclosed a clear bony hypofixation during the entire evolution. These observations confirm their 1981 work concerning a young adult suffering from algodystrophy with isotopic bony hypofixation. Recent Canadian and American studies emphasize also the frequency of isotopic hypofixation in children algodystrophy. It seems, therefore, that isotopic bony hypofixation (linked perhaps to a decreased blood flow), is rather specific of algodystrophy in young subjects.

[Bone involvement in histiocytosis X in adults. 11 cases]

The authors report 11 cases of bone lesions associated with histiocytosis X in adults, with a total of 25 bone sites: 22 were detected on X-rays and 3 were detected on scintigraphy when the corresponding X-rays were normal. They stress the high incidence of cranio-facial involvement, predominantly in the maxillae, with premature localised loosening of the teeth. They recommend X-rays in the staging of histiocytosis X and reserve scintigraphy for the cases with normal or doubtful X-rays. The bone lesions do not affect the prognosis of histiocytosis X, which depends on the associated visceral lesions. It generally has a favourable outcome and requires careful treatment: limited to a localised procedure for the purposes of histological diagnosis or to control the local underlying visceral risk or the functional complications. Bone lesions do not usually participate in the decision to treat histiocytosis X by chemotherapy.

[Dissecting osteochondritis of the patella. Apropos of 12 cases]

The authors report 12 cases of osteochondritis dissecans of the patella. The relative rarity of this condition (one hundred published cases) is perhaps only apparent, as the diagnosis is sometimes difficult early in the disease. Drawing from their personal cases and from data in the literature, the authors recall the clinical and radiological signs, describe the place of complementary investigations and therapeutic indications and discuss the various pathogenic theories, none of which are fully satisfactory.

[Recurrent familial hyperparathyroidism. A propos of 7 adenomas in 3 members of the same family. Review of the literature]

Over a period of 23 years, 3 members of a family of 5 presented with 7 parathyroid adenomas (4 in the first case, 2 in the second case, 1 in the third case). Excision of each adenoma, with systematic pre-operative assessment of the remaining parathyroid tissue, led to complete clinical and laboratory cure of each episode. The delay in the appearance of recurrence was between 3 and 9 years. After reviewing the literature, the authors stress the importance, in any case of hyperparathyroidism, of routinely investigating the serum calcium levels in members of the patient's family, especially if the patient is young and if he has had several episodes or multiglandular involvement in one episode. The authors discuss the literature concerning recurrent familial hyperparathyroidism with endocrine polyadenomatosis and the "hypercalcaemia-hypocalciuria" syndrome.

[Clinical aspects of reactive arthritis caused by Chlamydia]

The authors compare a multicentered study of chlamydial reactive arthritis with their own personal series of 99 cases consisting of 58 cases of chlamydial reactive arthritis and 41 cases of non-chlamydial reactive arthritis. In the group with chlamydial reactive arthritis, mono-arthritis is more frequent and involvement of the knees, hands, wrists, the sausage appearance of the fingers and toes and heel pain are rarer than in non-chlamydial reactive arthritis. However, the genetic predisposition, in particular the presence of the HLA-B27 antigen, has an essential influence on the clinical features of reactive arthritis.

[Value of dapsone in the treatment of Horton's disease and rhizomelic pseudopolyarthritis]

The authors report two cases of Horton's disease and one case of rhizomelic pseudopolyarthritis treated initially with delta-cortisone with a very rapid favourable result. However, while under relatively high dose steroid therapy, there was recurrence of the disease in the three cases and the development of complications of steroid therapy prohibited the use of higher doses of delta-cortisone and even required its rapid weaning. In these three cases, the addition of 100 mg of dapsone per day led to a rapid control of the disease, with return to normal of the erythrocyte sedimentation rate and reduction of the doses of delta-cortisone. The authors discuss the place of dapsone in the treatment of Horton's disease and rhizomelic pseudopolyarthritis in the light of these three cases.

[Involvement of the thoracic was in algodystrophy. Apropos of a case report]

With reference to an unusually severe and extensive case of algodystrophia, the sternal and costal localizations of this disorder are described. These fit the definition of the painful anterior thoracic wall syndrome, described i 1955 by Printzmetal and Massumi, which may complicate chronic coronary insufficiency or myocardial infarction or occur as a primary disease.

[Familial and recurrent hyperparathyroidism. Apropos of 7 adenomas in 3 members of the same family. Review of the literature]

Over a period of 23 years, 3 members of a family of 5 presented with 7 parathyroid adenomas (4 in the first case, 2 in the second case, 1 in the third case). Excision of each adenoma, with systematic pre-operative assessment of the remaining parathyroid tissue, led to complete clinical and laboratory cure of each episode. The delay in the appearance of recurrence was between 3 and 9 years. After reviewing the literature, the authors stress the importance, in any case of hyperparathyroidism, of routinely investigating the serum calcium levels in members of the patient's family, especially if the patient is young and if he has had several episodes or a multiglandular involvement in the one episode. The authors discuss the literature concerning recurrent familial hyperparathyroidism with endocrine polyadenomatosis and the "hypercalcaemia - hypocalciuria" syndrome.

[Immunologic aspects of ankylosing spondylarthritis]

The immunological profile of 63 men, 53 of whom were carriers of the HLA B27 antigen, and 10 of whom were not, all of whom suffered from ankylosing spondylarthritis (ASP) which was either quiescent or subject to exacerbations, were studied: lymphocytic colonies, quantity determination of serum proteins, investigations of auto-immune antibodies. Following a discussion of the techniques, the results are presented and compared with those obtained in healthy subjects. No significant difference was revealed between the averages obtained for the results on the patients and the controls, nor as regards the B and T lymphocytes, the IgG, IgA, IgM immunoglobulins, the C3 fraction of the complement, or orosomucoid. The haptoglobin and alpha-antitrypsin rates increased significantly in the patients. Tests for the auto-immune antibodies were always negative. The results are compared to other, often contradictory, studies which have already been published. These authors conclude that the ASP in question does not seem to be an immunological disease.

[Sympathetic reflex dystrophy with hypofixation of technetium 99 m pyrophosphates on bone scintigraphy (author's transl)]

A patient with sympathetic reflex dystrophy following injury to the right foot presented fairly typical clinical and radiological signs, though the hot phase was particularly short. Bone scan with technetium 99 m pyrophosphates demonstrated hypofixation, which, though extremely rare, has been previously reported in the published literature. The fact that isotopic bone hypofixation can occur during sympathetic reflex dystrophy should be recognised, as far from constituting an argument against the early diagnosis of this affection, it should enable the organic nature of the disorder to be confirmed, and assist the physician in making an early diagnosis.

[Fatigue fractures of the foot (author's transl)]

Fatigue fractures of the foot are the commonest fatigue fractures, still called walking fractures or "stress fractures". Formerly, they were metatarsal in more than 80% of cases: over the last few years, the calcaneal localizations mainly predominate (more than 70%). The fatigue fractures formerly described almost always in soldiers after a long march, are in fact encountered at all ages, including children, and in both sexes. The diagnosis in usually easy, provided that one thinks of it. It depends on the history, on clinical examination with pain on palpation of the bone, on a bone scan which shows early hyperfixation, on radiological examination, in which signs appear later than on clinical examination, and the bone scan, thus X rays often have to be repeated. The treatment is simple. Relief of weight bearing is usually sufficient. Plaster is usually neither necessary nor useful. Prophylaxis consists of avoiding physical activity, especially prolonged walking without prior gradual training.

[A new clinical entity: "the algodystrophic intermittent claudication of the lower limbs syndrome" (author's transl)]

A new clinical entity is proposed by the authors, "the algodystrophic intermittent claudication of the lower limbs syndrome", characterised by diffuse pains in the foot, having neither a constrictive nature, nor a radicular distribution. The pain appears after walking a certain distance, forcing the patient to stop, and reappears when he starts to walk again. Bone isotopic examinations and repeated radiographic investigations should be conducted when confronted with such a clinical syndrome in order to confirm the diagnosis of algodystrophy. In view of the polymorphic nature of this affection, it is not surprising that new clinical aspects can still be described at the present time.

[Anti-inflammatory treatment of ankylosing spondylitis (author's transl)]

Anti-inflammatory treatment of ankylosing spondylitis is based on the administration of the various non-steroid anti-inflammatory agents made available since the introduction of phenylbutazone. As with this later compound they each have a group of patients that respond to their administration and are able to tolerate them. In this way, physical education exercises can be undertaken for the spine and chest several times a day, which is the only therapy capable of improving prognosis and avoiding stiffening and spinal deformities. A study protocol is proposed that has the advantage of allowing a rapid evaluation of the efficacy and tolerance of the products successively administered for short periods, by using scored evaluation criteria. The most effective and better tolerated compound for each patient can thus be determined. This protocol is valid for both general practice or therapeutic study use, and in open or double-blind trials.

[The calcaneus in the Fiessinger-Leroy-Reiter syndrome]

The authors report on 43 cases of calcaneitis seen out of 121 cases of Fiessinger-Leroy-Reiter syndrome. They describe the three developmental stages and show that the polymorphism of the radiological aspects realized depend on the very great variability of the speed of development of the pathological process from one case to another. Calcaneitis of the Fiessinger-Leroy-Reiter syndrome always ends in cure.