Sleep and rheumatic disease

Patients with rheumatic diseases often exhibit sleep disturbance. Identification of primary sleep disorders; medical, neurologic, and psychologic illnesses; circadian factors; and the use and effect of medications, drugs, and alcohol will provide a strong basis for pursuing both pharmacologic and nonpharmacologic intervention. Recent clinical research confirms the frequent comorbidity of sleep disturbance, pain, fatigue, stress, and mood disturbance in patients with rheumatic disease. It is essential for effective management to recognize these "symptom syndromes" that are often responsive to treatment (suggesting a common biologic action and effect of the drugs used) despite a continuing presence of underlying chronic disease. The pathophysiologic relationships of these comorbid symptoms are mostly unknown, so this is an area for further study.

Thrombocytopenia associated with auranofin therapy: evidence for a gold-dependent immunologic mechanism

Thrombocytopenia associated with gold therapy is thought to be due to an immune-mediated mechanism. Relatively few patients have been studied so far, and precise details of the pathophysiology of this disease remain undetermined. We report a patient with gold-induced thrombocytopenia resulting from auranofin therapy. The patient's plasma contained platelet-reactive antibodies detectable only in the presence of gold salts. Antibody binding occurred at gold concentrations ranging from 0.01 to 10,000 ng/ml. The binding occurred independently of gold salt used, suggesting that substitution of a different gold preparation in this patient would result in a similar thrombocytopenia. These data support a drug-dependent immune mechanism for platelet destruction.

Evaluation and differential diagnosis of fibromyalgia. Approach to diagnosis and management

The combination of widespread musculoskeletal pain, high tender point count, and nonrestorative sleep are sufficient criteria for the diagnosis of fibromyalgia. The condition is primary in the absence of underlying disease and is considered concomitant or secondary when closely associated with another organic disease. Despite more simplified diagnostic criteria, the work-up for fibromyalgia must always be directed toward excluding the underlying causes. In addition to general and rheumatic history and physical examination and selected laboratory studies, careful attention to defining any existing sleep and mood disturbances is important in designing a management program. Although 46 medical conditions have been associated with fibromyalgia, a practical differential diagnostic list included polymyalgia rheumatica, myofascial pain, connective tissue disease, endocrine myopathies, psychoneuroses, and other chronic fatigue syndromes.

Fibromyalgia. 1. Review of a common rheumatologic syndrome

Fibromyalgia is a nonarticular rheumatic syndrome of unknown cause characterized by diffuse musculoskeletal aching, pain and stiffness, easy fatigability, multiple discreet tender points, emotional distress, and often, light and restless sleep with intensification of symptoms upon awakening. Symptoms are modulated by environmental, physiologic, and psychological factors. Generally, findings from laboratory tests and roentgenograms are normal. In primary fibromyalgia, no underlying rheumatic or other systemic organic disease is present. Secondary fibromyalgia is a manifestation of underlying disease.

Fibromyalgia. 2. Management guidelines and research findings

Treatment of fibromyalgia includes various forms of therapy--physical, behavioral, psychological, and pharmacologic. No drug therapy has proved uniformly successful, but some drugs provide temporary relief from pain. After an initial therapy program has been established, patients can assume the major responsibility for management. Research studies aimed at defining the cause of fibromyalgia have linked it to sleep disorders, neurogenic mediators, immune mechanisms, muscle disease, and psychological disturbances.

Secondary fibrositis

Fibrositis is considered primary when there is no associated underlying disorder, and secondary when it occurs in patients with underlying rheumatic or other organic disease. Since fibrositis has become better defined, the list of underlying disorders has grown, and its identification requires careful diagnostic study. The differentiation of primary and secondary fibrositis has therapeutic implications. Secondary fibrositis should respond to treatment of the underlying disorder, whereas the primary syndrome may require additional management directed to the musculoskeletal pain and sleep and emotional disturbances commonly recognized as major manifestations of this syndrome.

Selective lymphocyte deficiency in seronegative rheumatoid arthritis

Prior studies have shown that in vitro infection with the Epstein Barr virus (EBV) is able to induce IgM rheumatoid factor production by normal lymphocytes, with a higher degree of production by seropositive rheumatoid arthritis lymphocytes. The present investigation demonstrates that EBV-infected lymphocytes from patients with seronegative rheumatoid arthritis produce in vitro significantly less IgM rheumatoid factor than do normal lymphocytes. The results suggest that the peripheral blood of seronegative patients is deficient in the rheumatoid factor precursor B cells responsive to stimulation by Epstein Barr virus.