Updates-By Carol A. Kemper, MD, FACP
Updates-By Carol A. Kemper, MD, FACP
The Still’s that Wasn’t
Source: Sridharan S, et al. J Rheumatol 2000;27:1792-1795.
This unusual report describes a 42-year-old woman with a two-month history of fever, weight loss, generalized myalgias, and arthralgias. Within four weeks of the onset of these symptoms, she developed an evanescent pink rash on her torso and upper extremities, associated with an exacerbation of joint pain. Biopsies of the rash demonstrated perivascular inflammatory infiltrate. Her ESR was 78 mm/h, and she had a positive ANA at 1:160 (speckled); her rheumatoid factor and double-stranded DNA were negative. Based on a presumptive diagnosis of adult onset Still’s disease (AOSD), prednisone 30 mg daily was prescribed. The fever, rash, and joint pain resolved within days. Hepatitis A IgM titers were subsequently reported to be positive.
AOSD typically presents with an evanescent rash, fever, polyarthritis, and elevated ESR. Anti-nuclear antibodies are characteristically absent and RF is negative, although hyperferritinemia can occur. Of the three cases whose care I have participated in, all of whom were young women (2 Hispanic and 1 Black), all three presented with high fevers (103-105°F), a diffuse "blushing" rash, anemia, and immobilizing joint pain, especially of the larger joints (e.g., hips and knees). All three appeared "toxic" but remained hemodynamically stable. I almost missed the rash in one against her darker skin. Extensive work-ups on all three patients failed to identify a bacterial or viral etiology. A fourth possible case was ultimately diagnosed as parvovirus infection and not AOSD (interestingly, the joint pains in this case were not as severe).
Arthritis is a well-recognized feature of many viral infections, including parvovirus, mumps, measles, and hepatitis B and C. Arthralgias and synovitis have seldom been described with acute hepatitis A infection, but presumably occur through a similar process of circulating immune complex deposition. The symptoms in this case mimicked those of AOSD.
While a diagnosis of AOSD should be entertained for patients with fever of unknown origin, polyarthralgias, and rash, a careful search for other possible causes, such as anicteric hepatitis, should be performed, especially if there are any atypical features such as a positive ANA. The accuracy of the diagnosis is important, as most AOSD patients experience multiple, recurrent flare-ups of disease requiring large dosages of corticosteroids, and ~50% will ultimately develop progressive and disabling joint and spine disease within 10 years of diagnosis (Kemper CA. Infectious Disease Alert 1999;18:156-157).
Better Immunity Through Bridge
Source: Billingsley J. Health Scout Reporter, Nov. 8, 2000. http://www.healthscout.com.
My grandmother, sadly, recently passed away just shy of her 93rd birthday. Up until a few months ago, she played bridge at least four times a week, although it had been years since she competed for Master’s points. The family often commented that playing bridge seemed to keep her alive, although I thought this was more the result of good company and the mental challenge offered by the game. But could playing bridge benefit you in other ways?
A small study of bridge players has found an association between playing bridge and a possible immune system response. In a report presented to the Annual Meeting of the Society of Neuroscience, Nov. 4-9 in New Orleans, total white blood cell counts and lymphocyte cell subsets were examined in 12 healthy female bridge players before and after completing a round of bridge. All three bridge foursomes showed a marked increase in cell counts, and specific increases in T lymphocytes, although the responses were statistically significant in only two of the groups. Neurobehaviorists believe that stimulation of certain areas of the cerebral cortex (i.e., with a complex and competitive card game such as bridge), can result in activation of T-cell production at the level of the thymus, as has been shown in rodents. I’m all for telling patients to avoid colds and flus this winter by drinking fluids, getting plenty of rest, and playing bridge three times a week!
Smallpox Vaccine Contracts Awarded
Source: Pro-MED mail post, Sept. 20, 2000; www.promedmail.org.
The centers for disease control and Prevention (CDC) has announced the award of an estimated $343 million contract to OraVax, Inc., with the assistance of BioReliance Corp., to develop and manufacture a new smallpox vaccine. The CDC intends to stockpile vaccine for civilian use in the event of a bioterrorist threat or laboratory outbreak. Under a separate agreement, the U.S. Department of Defense in August awarded BioReliance Corp. a similar contract for developing and producing smallpox vaccine to be stockpiled for military use in the event of a bioterrorist threat.
These contracts may ultimately provide greater insight into this fascinating but deadly virus, assuming the information does not end up being classified. The use of smallpox as a weapon of war was even a concern of George Washington, who feared the British would use it against Revolutionary troops. As a result, he ordered all troops variolated in 1777, despite an associated rate of mortality of 2-3%. Although there were initial hopes that the end of the Cold War might allow the destruction of the smallpox virus stocks in Atlanta and Russia, concerns have been raised regarding the bioterrorist threat from an increasingly unstable Middle East.
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