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Psoriatic arthritis is a fascinating inflammatory arthritis. Till recently it did not generate interest for lack of understanding of its immunopathology, and lack of effective treatment. This has changed. PsA is now one of the hot topics - all due to elucidation of genetic susceptibility associations, immunopathogenesis and availability of effective therapy. In this communication we provide an overview of these aspects of psoriatic arthritis., (© Journal of the Association of Physicians of India 2011.)

Undiagnosed fever is a vexing problem. The reasons why fever remains undiagnosed can be inherent to the underlying pathology, our shortcoming(s) or both. This article describes "our" causes based on cases seen over the years. It is apparent that with proper attention to details mystery of at least some undiagnosed fevers can be solved.

Objective: To study the clinical profile of patients with giant cell arteritis in Mumbai., Methods: From our database, patients with a diagnosis of giant cell arteritis (GCA) over a fifteen year period (January 1990 to December 2005) were included. Clinical manifestations, temporal artery biopsy, treatment, and follow-up data of these patients were analyzed., Results: Twenty one patients with GCA were identified. However, data were available only for 16 patients. The median age was 66.5 years (58-78 yrs) with male to female ratio of 1:1. The mean time from symptom onset to diagnosis was 5.18 months (0.5-24 months). Clinical manifestations included new onset headache (15), fever (9), weight loss (9), jaw claudication (9), polymyalgia rheumatica (5), visual disturbances (3), scalp nodule (1), temporal artery tenderness (11), tortuosity (9), and scalp tenderness (6). ESR was elevated in 15 patients with a median of 106.5 mm at 1 hr (25-135 mm/hr). Temporal artery biopsy was done in 11 patients and confirmed the diagnosis in 10 patients. Color doppler study of the temporal arteries (9 patients) revealed halo sign (indicating arterial wall edema) in 6 patients. Biopsy as per site by color doppler study was performed in 6 of these patients and was positive in 5. All patients had a good initial response to steroids, however, on follow up, 3 patients required addition of methotrexate. At a median follow up (n = 14) of 6 months (range 6-156), steroids were successfully stopped in 7 patients at 1 to 3 years interval. The disease relapsed in 1 patient. Of the remaining 7 patients, 2 were steroid dependent and 5 patients were doing well on low dose prednisolone., Conclusion: GCA, though uncommon in India, should be suspected in all elderly patients with a new onset headache, fever, jaw claudication, or high ESR. Color doppler sonography is a useful noninvasive method for the diagnosis of GCA and also helps to identify the site to biopsy. Most respond to steroid therapy while some need addition of steroid sparing agents.

Infective endocarditis due to uncommon organisms or at uncommon sites presents a diagnostic challenge. Because signs and symptoms can be nonspecific and vary greatly, a high index of suspicion is necessary. We have recently treated two such cases, one due to HACEK organism (Eikenella corrodens) in a patient with established valvular heart disease and other of right sided endocarditis due to Pseudomonas aeruginosa. This report describes the diagnostic difficulties faced.

Vitamin D deficiency is not uncommon even in the sunny land of India. Lack of sun exposure and inadequate oral intake are both responsible for vitamin D deficiency. This article provides a retrospective, examining the effects of Vitamin D deficiency in 71 patients. The study's inclusion criterion was low vitamin D level combined with musculoskeletal symptoms but without the presence of osteomalacia. All patients in this study were suspected to have vitamin D deficiency. The data were retrieved from the case-charts of patients seen between 1996 and 2001 at the rheumatology services of Hinduja Hospital, Mumbai, India. This study found no correlation between Vitamin D levels and symptoms, or between the severity of Vitamin D deficiency and the number of symptoms displayed. Subclinical vitamin D deficiency or preosteomalacic state was the term coined for individuals with vitamin D deficiency producing nonspecific musculoskeletal symptoms in the absence of clinical osteomalacia.

The use of bisphosphonates in the treatment of avascular necrosis of the femoral head is an encouraging but relatively new option with most published data being derived from small trials with limited follow-up. We present a clinicoradiological analysis of 395 hips with avascular necrosis which were treated with oral alendronate for three years with a mean follow-up of four years (1 to 8). Our results show an improvement in the clinical function, a reduction in the rate of collapse and a decrease in the requirement for total hip replacement, compared with the findings of other studies in which no treatment was given. This improvement is particularly marked if the treatment is begun in the pre-collapse stages of the disease. Even in Ficat stage-III hips some benefit was obtained from treatment with alendronate by at least a delay in the need for total hip replacement.

We studied the clinical profile, laboratory parameters, disease course, and outcomes of patients with adult onset Still's disease (AOSD). A retrospective analysis of adult patients with Still's disease diagnosed from 2000 to 2004 was carried out. Their clinical features and laboratory findings at presentation, disease course, and outcomes were analyzed. Data of 14 patients with Still's disease were analyzed. The age at disease onset ranged from 16 to 59 years with a mean of 29.85, the male to female ratio being 9:5. The mean duration of illness from onset of symptoms to presentation was 14.5 months (range). The most common clinical manifestations were fever (n = 14), articular symptoms (n = 14), rash (n = 8), weight loss (n = 12), and sore throat (n = 5). Elevated ESR was present in all patients with a mean of 98.3 mm at 1 h. Hepatic enzymes were elevated in seven patients at disease onset. The mean duration of follow up was 19.14 months (range). Three patients progressed to chronic arthropathy. Cyclosporine led to dramatic recovery in five patients. Macrophage activation syndrome (MAS) was present in two patients, one after sulfasalazine therapy. One patient with MAS died. Still's disease, although uncommon, has characteristic constellation of clinical and laboratory features and should be considered in the differential diagnosis of fever of unknown origin. Nonsteroidal anti-inflammatory drugs, steroids, and methotrexate may not be always effective, and cyclosporine is an effective drug in resistant cases. Sulfasalazine should be avoided in cases of AOSD.

Paget's disease is uncommon in Asians. We present 3 patients with varying manifestations. A 50 years old lady was detected to have raised alkaline phosphatase at a routine health check-up. Isoenzyme studies confirmed its bony origin. Bone scan revealed polyostotic disease. A 65 years old male patient with known Paget's disease of 6 years duration presented with pelvic girdle pain, progressive increase in alkaline phosphatase levels and worsening bone scan. A 45 years old male was admitted with chest pain. Cardiac evaluation was normal. Bone scan picked up a cough fracture in the left 7th rib and an incidental Paget's disease of the skull. All three had elevated markers of bone metabolism in the serum and urine. With monthly intravenous pamidronate there was significant improvement in the bone markers and follow-up bone scans.

Objective: To study the efficacy of alendronate, in the treatment of avascular necrosis (AVN) of the hip., Methods: Sixty patients with AVN of the hip (100 hips with AVN) were studied. The follow-up period ranged from 3 months to 5 yr. The most common cause of AVN was steroids. Parameters studied were walking time, standing time, pain and disability on a visual analogue scale (VAS), range of motion of the hip, X-ray and MRI of the hip. All patients were treated with alendronate 10 mg/day (or 70 mg/week) along with 500-1000 mg of daily calcium and vitamin D supplements, and were advised to avoid weight-bearing. NSAIDs and analgesics were permitted as needed and were recorded., Results: Forty-one patients (71 AVN hips) with AVN have been followed up for a minimum of 1 yr, 24 patients (42 AVN hips) for 2 yr and 21 patients (37 AVN hips) for more than 2 yr (average 37 month). Fourteen patients have been followed up for less than 1 yr (3-9 months). Significant reduction in pain and disability scores (P < 0.001) and significant increase in standing and walking time (P < 0.001) were observed. All hip movements improved at 1 yr (P value 0.000-0.009) with an insignificant decline after that (P > 0.001). Radiologically, the hips either stabilized in the same grade or progressed by one grade. MRI showed a decrease in marrow oedema in most cases at the 1-yr follow-up. Six patients (10 hips) required surgery and there were two (three hips) dropouts. The drug was well tolerated and there was a reduction in NSAID requirement., Conclusion: Alendronate reduces pain, improves function and retards AVN progression. Early surgical intervention can be avoided in most patients.

NSAIDs are commonly used drugs. Even with the advent of selective COX-2 inhibitors, nephrotoxicity still remains a concern. The adverse effects of NSAIDs are mediated via inhibition of prostaglandin synthesis from arachidonic acid by non-specific blocking of the enzyme cyclooxygenase leading to vasoconstriction and reversible mild renal impairment in volume contracted states. When unopposed, this may lead to acute tubular necrosis and acute renal failure. NSAIDs also produce interstitial nephritis with or without nephrotic syndrome secondary to minimal change disease. Although this presents as acute renal failure, it can progress in some cases to chronic renal failure. Papillary necrosis has been incriminated in the development of chronic renal failure secondary to NSAIDs. In patients on long term NSAIDs without acute or chronic renal failure, subclinical renal dysfunction such as reduced creatinine clearance and impaired urine concentrating ability has been shown to be present. Although this sub-clinical dysfunction is reversible on withdrawal of NSAIDs, some reports have suggested a persistent residual dysfunction. Even with a wide range of NSAIDs at our disposal, a renal safe NSAID is yet to be discovered.

It is clear that kidney is involved in rheumatoid arthritis (RA) with both glomerular and tubular damage. Renal disease in RA however is usually asymptomatic and is detected only on laboratory investigations. It is often difficult to differentiate between damage due to disease activity and that due to drugs used to treat RA. Although there are a number of parameters to study renal function, these cannot be applied to day to day practice and still remain research tools. In such a scenario, it is important to periodically monitor serum creatinine and carry out urine examination so as to pick up the earliest signs of renal dysfunction.

Immunosuppressive therapy related secondary haematologic malignancy is well reported. A 52 years lady with established rheumatoid arthritis developed reactive amyloidosis. This was initially treated with colchicine and cyclophosphamide and later with chlorambucil. Ten months after stopping chlorambucil she developed pancytopenia and vitamin B12 deficient megaloblastic anaemia. The pancytopenia was refractory to vitamin B12 supplements and a repeat bone marrow confirmed myelodysplasia (FABI RAEB-T). Within three weeks of this diagnosis she evolved into acute myeloid leukaemia and expired due to refractory thrombocytopenia and uncontrolled bleeding. This case stresses the need for long term follow up of RA patients treated with alkylating agents.

Aim: Primary: To study the effect of long term NSAID therapy on serum creatinine in patients of rheumatoid arthritis. Secondary: To study the effect of discontinuation, reduction in the dose or continuation of NSAID and of rechallenge., Material and Methods: Case records of RA patients with a minimum two years of follow up were analysed. Age, sex, duration of RA, type, dose and duration of NSAID and DMARD therapy, co-morbid conditions and serial serum creatinine levels were charted., Results: Ninety nine case records were studied. Incidence of abnormal creatinine level (renal insufficiency) defined as rise in creatinine equal to or above the upper limit of normal was 27.7%. This rise was asymptomatic in all patients. No NSAID was particularly associated with an increased risk in renal insufficiency. The rise of serum creatinine was reversible in most patients irrespective of discontinuation or continuation of NSAID but settled at a higher level. Rechallenge resulted in rise of serum creatinine in 50% patients. Hypertension, DM, IHD and diuretics carried a higher but not statistically significant risk of renal insufficiency., Conclusion: NSAID-induced asymptomatic rise of creatinine in patients of RA on long term NSAIDs is common. It is mostly reversible. Regular monitoring of serum creatinine is essential.

Purpose: Wound infection is an important cause of morbidity and occasional mortality after coronary artery bypass graft surgery (CABG). The aim of this study was to report postoperative wound infection in CABG surgery patients., Methods: Consecutive patients undergoing CABG surgery between January 1998 and October 1999 have been studied. The exclusion criteria included, age less than 30 years, penicillin / cephalosporin allergy and associated other cardiac pathologies. The parameters studied were age, sex, obesity, hypertension, diabetes, myocardial infarction, chronic renal failure, previous surgeries, alcohol consumption, smoking, length of pre and postoperative hospital stay, antibiotic prophylaxis, MRSA screening, and duration of surgery. Wounds were classified as per modified CDC's NNIS criteria. Suspected sites of infection were cultured and antibiotic susceptibility of cultured organisms was tested. Postoperative follow up was for two months., Results: Six hundred and fifteen patients were studied. Of these 116 (18.86%) developed SSI, involving sternum 75%, leg 21.3%, and forearm sites 3.44%. Organisms isolated at sternum site were MSSE, MRSA, and MRSE, at leg site E. coli and MSSE, and at forearm site MSSE and MSSA. Sternal site, obesity, diabetes mellitus and female sex were associated with significantly higher infection rates (p= 0.001). No antibiotic protocol proved more effective. SSI increased the postoperative hospital stay and the total treatment cost., Conclusions: Post CABG surgery SSI rate is high. Sternum and leg are the common infection sites. Obesity, uncontrolled diabetes mellitus and female sex are associated with higher infection rates. "Higher" antibiotics do not lower postoperative infection rates.

Joint disorders are common in the elderly population. Commonest conditions are rheumatoid arthritis, osteo-arthritis and crystal induced arthritis. Comorbid events in the elderly patients make disease management even more difficult. Some tests are needed to distinguish these conditions from more serious diseases like carcinomatous arthritis or multiple myeloma. Management strategies are usually similar to that of younger onset arthritis with dose adjustment of drugs due to underlying age related hepatic and renal dysfunctions.

Introduction: Autoimmune hepatitis (AIH) is a well-defined entity in the West but there are sparse Indian data on this disease., Aim: To study the clinical profile and response to treatment of Indian patients with AIH., Methods: This is a part retrospective and part prospective study of 50 patients (median age 48 years, range 11-82; 43 women) seen between 1995 to 2001, diagnosed to have AIH as per the revised scoring system. Clinical and laboratory profile, response to treatment, and complications of treatment were analyzed., Results: AIH accounted for 6% of all patients with liver disease seen during the period. The presenting symptoms were gastrointestinal in 43 and non-gastrointestinal in 7, with median symptom duration of 6 months (range 2 weeks to 40 years). Forty patients (80%) had chronic liver disease. Associated illnesses were present in 28 patients. Twenty-six patients were classified as definite and the rest as probable AIH. Forty-nine patients had Type 1 AIH. Five patients had overlap syndrome. Forty-five patients (90%) received immunosuppressive therapy. Twelve of 18 patients receiving only prednisolone and 21 of 27 patients receiving prednisolone and azathioprine combination responded. Thirteen (26%) patients had therapy-related complications (infectious 5, non infectious 8) with two treatment-related deaths., Conclusion: Type 1 AIH was the predominant type of AIH. The majority of patients with AIH presented with chronic liver disease. There was good response to immunosuppressive therapy. Therapy-related complications occurred in one-fourth of patients.

Objective: To study the utility of ultrasonography (US) in diagnosis and follow up of patients with idiopathic inflammatory myopathy (IIM)., Methods: High-resolution US of thigh muscles was recorded at baseline and after six months of treatment in eleven patients of early, active, untreated IIM. Parameters studied were muscle power, timed function tests (TFT), muscle enzymes, electromyography, muscle histopathology and US parameters such as echogenicity of muscle and perimysial septa count per 1 cm muscle width., Results: There was a significant increase in muscle echogenicity and septa count of patients as compared to those of controls (p = 0.002 and 0.00003, respectively). These abnormalities resolved on treatment. Muscle echogenicity and perimysial septa count showed mild positive correlation with walking time, 4-step climbing and myopathic pattern on EMG. Perimysial septa count in addition correlated weakly with creatine phosphokinase, lactate dehydrogenase and muscle fibre necrosis., Conclusion: US seems to be a useful, non-invasive, cheap modality to monitor the disease course in IIM. Larger studies to confirm these primary findings are warranted.

Four patients of rheumatoid arthritis (RA) with biopsy confirmed AA amyloidosis were treated with chlorambucil. All had established but uncontrolled RA with a persistently raised ESR. Moderate (> 1 gm, < 3.5 gm/d) to nephrotic range (> 3.5 gm/d) proteinuria and a relatively well preserved renal function was noted in three patients. One patient had deranged renal function and required dialysis. On chlorambucil, there was complete recovery, partial improvement and no improvement in one patient each. The fourth patient required haemodialysis, did not tolerate chlorambucil and succumbed to the illness. Therapy with chlorambucil can benefit some patients of RA with AA amyloidosis. Leucopenia is the most important dose limiting side effect.

Objective: To study the efficacy of isoniazid prophylaxis (INHP) in patients with systemic lupus erythematosus (SLE) receiving long term glucocorticosteroid treatment., Patients and Methods: Treatment with INHP (5 mg/kg/day, max 300 mg/day) together with pyridoxine 10 mg/day for one year was started in all patients with SLE seen between January 1994 and December 1999 and followed up thereafter. Clinical examination and chest radiography were carried out in all patients before the start of INHP treatment. A liver profile was obtained only if liver toxicity was suspected owing to nausea, loss of appetite, and icterus. Only the data of those patients who completed the INHP treatment or who were withdrawn owing to toxicity have been analysed. This was compared with the results of an earlier study of the incidence of tuberculosis (TB) in patients with SLE not receiving INHP., Results: Ninety seven patients were included, of whom 95 completed one year's treatment with INHP. Treatment was discontinued in two owing to toxicity: hepatitis in one and peripheral neuropathy in one, at eight and 10 months, respectively. One patient developed TB within one month of starting INHP. Seventy patients were followed up further for at least one year (mean 26.4 months, range 12-60 months) after completion of the INHP treatment. During this period one patient developed TB after one month. No deaths due to TB or hepatitis occurred. In comparison with earlier series the incidence of TB decreased from 11% to 2%, a reduction of 82%. The cost of treatment for each case of TB prevented in the first year was 5800 rupees., Conclusion: INHP is safe and effective in SLE.