647
LETTERS TO THE EDITOR
E. M. POTTER
, C. MCEWEN
RD 1 Box 818, South Harpswell, Maine 04079, USA Accepted 16 June 1992
1. McEwen C, Ziff M, Carmel P, Di Zata D, Tanner M. The relationship to rheumatoid arthritis of its so-called variants. Arthritis Rheum 1958;l:481-96. 2. BlumbergB, Bunim 3} etal. Nomenclature and classification of arthritis and rheumatism (tentative). Arthritis Rheum 1964;7:83-97. 3. Wright V. Psoriatic arthritis. Ann Rheum Dis 1956;15:348. 4. Wright V. Psoriatic arthritis. Ann Rheum Dis 1961; 20:723-32. 5. Wright V. In: Kelley WN, Harris ED Jr, Ruddy S, Sledge CB. Textbook of rheumatology. Philadelphia: Saunders, 1981; 1047. 6. Helliwell P, Marchesoni A, Peters M, Barber M, Wright V. A re-valuation of the osteoarticular manifestations of psoriasis. BrJ Rheumatol 1991;30:339-45. 7. Baker H, Golding DN, Thompson M. Psoriasis and arthritis. Ann Intern Med 1963;58:909-26. 8. Torre Alonso JC, Rodriguez Perez A, Arribas Castrillo JM, Lopez Larrea C. Psoriatic arthritis: a clinical immunological and radiological study of 180 patients. Br J Rheumatol 1991;30:245-50. 9. Cost F. Solnica J. La polyarthrite psoriaseque. Perrie Francoise Etudes. Clin Biol 1986; 11:578-99. 10. McEwen C, Di Tata D, Lingg C, Porrini A, Good A, Rankin T. Ankylosing spondylitis and spondylitis accompanying ulcerative colitis, regional enteritis, psoriasis and Reiter's disease. Arthritis Rheum 1971 ;14:291-318.
Adult Respiratory Distress Syndrome in Systemic Lupus Erythematosa SIR—I read the paper from Andonopoulos [1] with interest. The common cause of adult respiratory distress syndrome is endotoxaemia [2] but of course by the broad definition that is currently in use any disseminating pneumonitis might be included. One would certainly expect systemic lupus erythematosus (SLE) patients to be susceptible to endotoxaemia or infections because of the therapy that they receive. A paper that revealed that antibodies to lipid-A of endotoxins are elevated in SLE patients and in patients with juvenile rheumatoid arthritis has been published [3]. E. N. WARDLE
21 Common Road, North Leigh, Oxford OX8 6RD Accepted 1 April 1992 1. Andonopoulos AP. Adult respiratory distress syndrome: an unrecognized premortem even in systemic lupus erythematosus. Br J Rheumatol 1991;30:346-8. 2. Wardle EN. Shock lungs: the post-traumatic respiratory distress syndrome. Q J Med 1984;53:317-29. 3. Olds LC, Miller JJ. C3 activation products correlate with antibodies l-to-lipid-A in pauciarticular juvenile arthritis. Arthritis Rheum 1990;33:52(M.
Polymyalgia Rheumatica—A Delayed Sequelae of Borrelia Infection?
SIR—The aetiology of polymyalgia rheumatica (PMR) is unclear. Previous reports have implicated minor infective illnesses (mainly viral) triggering the onset of PMR [1]. A recent report from Germany found raised levels of antibody to Borrelia burgdorferi in 63% of a cohort of 19 patients with PMR/giant cell arteritis [2]. We describe a patient with PMR that was associated with elevated levels of antibody to Borrelia burgdorferi in the absence of clinical evidence of Lyme disease. A 59-year-old lady presented with a 6-week history of severe proximal girdle pain and stiffness, which was worse
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Michigan on September 6, 2015
arthritis with no clear correlation between the severity of the skin disease and that of the arthritis. There was marked asymmetry of joint involvement in 69 patients (83%) in the first few years. In 12 of those patients, involvement eventually became symmetrical and in 13 patients (16%) it was symmetrical from onset. The tendency for involvement of the DIPs of fingers and toes, often associated with psoriatic disease of the nails, has long been known, but the actual incidence of involvement of these joints has been given relatively infrequently. The studies of Verna Wright and his associates [3-5] have divided the patients into categories one of which is that of patients in whom DIPs were the only or chief joints involved. The number of such patients is stated but in the other categories the incidence of DIP involvement cannot be determined. That pattern of categories was used subsequently by other authors with the result that those reports also did not record the actual number of patients with DIP involvement. Articles that do state or permit estimation of the percentage of patients with DIP involvement include the following: Helliwell et al. observed them in 30-39% [6], Baker et al. [7] in 49%, Torre Alonso etal. in 49% [81, Cost and Solnica in 54% [9] and McEwen et al. in 67% [1]. We suggest that a probable explanation of these differences is the duration of the arthritis at the time the patients were observed. In Elizabeth Potter's series only 15 patients (18%) had had DIP involvement in their initial attacks and most of them had had psoriatic arthritis for many years. Indeed, her series included most of the patients in the earlier report by McEwen et al. [1] noted above. At the time they were entered in her study, 71 of the 83 patients had characteristic psoriatic involvement of the DIPs of one or more of the second to fifth digits and subsequently, in the 10-year follow-up period, this involvement appeared in two others making a total of 88%. In addition, four more patients had typical inflammatory involvement of the interphalangeal joints of thumbs with psoriatic nail changes, without arthritis of proximal interphalangeal joints of the other digits. If these patients are included, the total rises to 93%. Of the six patients without terminal interphalangeal arthritis, four had had psoriatic arthritis for less than 5 years. Therefore, the percentage may eventually have been still higher. In only two patients did DIP arthritis occur without corresponding psoriatic disease of the nails of at least some of the involved digits. Telescoping of the fingers occurred in eight patients and was especially disabling when in the thumbs. Marked, diffuse, sausage-type swelling of an entire finger occurred in five patients. Twenty patients (28%) had sacroiliitis which was asymmetrical in the degree of damage and was accompanied in 12 patients (15%) by spondylitis. This was characterized by syndesmophyr.es which were asymmetrical in location and degree and of which some in every patient were of the non-marginal type characteristic of psoriatic spondylitis [10]. Latex fixation tests were negative in all except two elderly women in whom it was weakly positive. This is within its percentage prevalence in the general population of that age group. Repeated tests using the sheep cell agglutination method were negative. Seven patients were treated with antimalarials. In two, complete exfoliative dermatitis occurred soon after the start of treatment and in two others the psoriasis became rapidly worse.
LETTERS TO THE EDITOR
E. M. POTTER
, C. MCEWEN
RD 1 Box 818, South Harpswell, Maine 04079, USA Accepted 16 June 1992
1. McEwen C, Ziff M, Carmel P, Di Zata D, Tanner M. The relationship to rheumatoid arthritis of its so-called variants. Arthritis Rheum 1958;l:481-96. 2. BlumbergB, Bunim 3} etal. Nomenclature and classification of arthritis and rheumatism (tentative). Arthritis Rheum 1964;7:83-97. 3. Wright V. Psoriatic arthritis. Ann Rheum Dis 1956;15:348. 4. Wright V. Psoriatic arthritis. Ann Rheum Dis 1961; 20:723-32. 5. Wright V. In: Kelley WN, Harris ED Jr, Ruddy S, Sledge CB. Textbook of rheumatology. Philadelphia: Saunders, 1981; 1047. 6. Helliwell P, Marchesoni A, Peters M, Barber M, Wright V. A re-valuation of the osteoarticular manifestations of psoriasis. BrJ Rheumatol 1991;30:339-45. 7. Baker H, Golding DN, Thompson M. Psoriasis and arthritis. Ann Intern Med 1963;58:909-26. 8. Torre Alonso JC, Rodriguez Perez A, Arribas Castrillo JM, Lopez Larrea C. Psoriatic arthritis: a clinical immunological and radiological study of 180 patients. Br J Rheumatol 1991;30:245-50. 9. Cost F. Solnica J. La polyarthrite psoriaseque. Perrie Francoise Etudes. Clin Biol 1986; 11:578-99. 10. McEwen C, Di Tata D, Lingg C, Porrini A, Good A, Rankin T. Ankylosing spondylitis and spondylitis accompanying ulcerative colitis, regional enteritis, psoriasis and Reiter's disease. Arthritis Rheum 1971 ;14:291-318.
Adult Respiratory Distress Syndrome in Systemic Lupus Erythematosa SIR—I read the paper from Andonopoulos [1] with interest. The common cause of adult respiratory distress syndrome is endotoxaemia [2] but of course by the broad definition that is currently in use any disseminating pneumonitis might be included. One would certainly expect systemic lupus erythematosus (SLE) patients to be susceptible to endotoxaemia or infections because of the therapy that they receive. A paper that revealed that antibodies to lipid-A of endotoxins are elevated in SLE patients and in patients with juvenile rheumatoid arthritis has been published [3]. E. N. WARDLE
21 Common Road, North Leigh, Oxford OX8 6RD Accepted 1 April 1992 1. Andonopoulos AP. Adult respiratory distress syndrome: an unrecognized premortem even in systemic lupus erythematosus. Br J Rheumatol 1991;30:346-8. 2. Wardle EN. Shock lungs: the post-traumatic respiratory distress syndrome. Q J Med 1984;53:317-29. 3. Olds LC, Miller JJ. C3 activation products correlate with antibodies l-to-lipid-A in pauciarticular juvenile arthritis. Arthritis Rheum 1990;33:52(M.
Polymyalgia Rheumatica—A Delayed Sequelae of Borrelia Infection?
SIR—The aetiology of polymyalgia rheumatica (PMR) is unclear. Previous reports have implicated minor infective illnesses (mainly viral) triggering the onset of PMR [1]. A recent report from Germany found raised levels of antibody to Borrelia burgdorferi in 63% of a cohort of 19 patients with PMR/giant cell arteritis [2]. We describe a patient with PMR that was associated with elevated levels of antibody to Borrelia burgdorferi in the absence of clinical evidence of Lyme disease. A 59-year-old lady presented with a 6-week history of severe proximal girdle pain and stiffness, which was worse
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Michigan on September 6, 2015
arthritis with no clear correlation between the severity of the skin disease and that of the arthritis. There was marked asymmetry of joint involvement in 69 patients (83%) in the first few years. In 12 of those patients, involvement eventually became symmetrical and in 13 patients (16%) it was symmetrical from onset. The tendency for involvement of the DIPs of fingers and toes, often associated with psoriatic disease of the nails, has long been known, but the actual incidence of involvement of these joints has been given relatively infrequently. The studies of Verna Wright and his associates [3-5] have divided the patients into categories one of which is that of patients in whom DIPs were the only or chief joints involved. The number of such patients is stated but in the other categories the incidence of DIP involvement cannot be determined. That pattern of categories was used subsequently by other authors with the result that those reports also did not record the actual number of patients with DIP involvement. Articles that do state or permit estimation of the percentage of patients with DIP involvement include the following: Helliwell et al. observed them in 30-39% [6], Baker et al. [7] in 49%, Torre Alonso etal. in 49% [81, Cost and Solnica in 54% [9] and McEwen et al. in 67% [1]. We suggest that a probable explanation of these differences is the duration of the arthritis at the time the patients were observed. In Elizabeth Potter's series only 15 patients (18%) had had DIP involvement in their initial attacks and most of them had had psoriatic arthritis for many years. Indeed, her series included most of the patients in the earlier report by McEwen et al. [1] noted above. At the time they were entered in her study, 71 of the 83 patients had characteristic psoriatic involvement of the DIPs of one or more of the second to fifth digits and subsequently, in the 10-year follow-up period, this involvement appeared in two others making a total of 88%. In addition, four more patients had typical inflammatory involvement of the interphalangeal joints of thumbs with psoriatic nail changes, without arthritis of proximal interphalangeal joints of the other digits. If these patients are included, the total rises to 93%. Of the six patients without terminal interphalangeal arthritis, four had had psoriatic arthritis for less than 5 years. Therefore, the percentage may eventually have been still higher. In only two patients did DIP arthritis occur without corresponding psoriatic disease of the nails of at least some of the involved digits. Telescoping of the fingers occurred in eight patients and was especially disabling when in the thumbs. Marked, diffuse, sausage-type swelling of an entire finger occurred in five patients. Twenty patients (28%) had sacroiliitis which was asymmetrical in the degree of damage and was accompanied in 12 patients (15%) by spondylitis. This was characterized by syndesmophyr.es which were asymmetrical in location and degree and of which some in every patient were of the non-marginal type characteristic of psoriatic spondylitis [10]. Latex fixation tests were negative in all except two elderly women in whom it was weakly positive. This is within its percentage prevalence in the general population of that age group. Repeated tests using the sheep cell agglutination method were negative. Seven patients were treated with antimalarials. In two, complete exfoliative dermatitis occurred soon after the start of treatment and in two others the psoriasis became rapidly worse.
