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Sarcoidosis is a systemic inflammatory disorder with cutaneous involvement present in 25% of cases. We present a patient with ulcerative sarcoidosis to highlight this unusual presentation of a relatively rare cutaneous condition that was treated successfully using infliximab. The drug is effective in cutaneous sarcoidosis, but relapses can occur after discontinuation. In this article, we reviewed the clinical features and therapeutic modalities for ulcerative cutaneous sarcoidosis.

Purpose Pneumococcal vaccination (PV) is indicated for the elderly (age ≥65 years) and those with chronic disease or who are immunosuppressed. We aimed to study the rate and predictors of recommendation/receipt of 23 valent pneumococcal polysaccharide vaccine (PPSV23) in immunosuppressed systemic lupus erythematosus (SLE) patients. Methods Data were obtained through self-report questionnaires and medical chart review of 150 SLE patients. Information on rheumatologist recommendation or receipt of PPSV23 in the preceding 5 years was collected if self-reported in a questionnaire or documented in the medical chart. Chart review was also done to collect data on patient demographics, physician characteristics (if patients had a primary care physician and rheumatologist's SLE patient volume), and the disease characteristics of SLE. Comparisons using χ or t tests and logistic regression analyses were conducted for predictors of recommendation/receipt of PV. Results The mean (SD) age was 47.4 (15.9) years; 90% were women. Sixty-five of 94 eligible patients for PV (based on immunosuppressive medications use or age) had been either recommended or administered PPSV23. On univariate logistic regression analysis, age, duration of disease, current use of hydroxychloroquine or mycophenolate, and rheumatologist's SLE patient volume were significant correlates of recommendation/receipt of PPSV23. However, on multivariate analysis, the only significant predictor was rheumatologist's SLE patient volume after adjusting for the above correlates such that with every 50 patients increase in SLE patient clinic volume, the odds of recommendation/receipt of PPSV23 increased by 2.37 times. Conclusions The volume of lupus patients that rheumatologists see is strongly associated with the likelihood that their SLE patients will have PPSV23 recommended and delivered, suggesting a volume outcome relationship.

Objective Quality of life (QOL) and quality of care (QOC) in systemic lupus erythematosus (SLE) remains poor. Satisfaction with care (SC), a QOC surrogate, correlates with health behaviors and outcomes. This study aimed to determine correlates of SC in SLE. Methods A total of 1262 patients with SLE were recruited from various countries. Demographics, disease activity (modified Systemic Lupus Erythematosus Disease Activity Index for the Safety of Estrogens in Lupus Erythematosus: National Assessment trial [SELENA-SLEDAI]), and QOL (LupusPRO version 1.7) were collected. SC was collected using LupusPRO version 1.7. Regression analyses were conducted using demographic, disease (duration, disease activity, damage, and medications), geographic (eg, China vs United States), and QOL factors as independent predictors. Results The mean (SD) age was 41.7 (13.5) years; 93% of patients were women. On the univariate analysis, age, ethnicity, current steroid use, disease activity, and QOL (social support, coping) were associated with SC. On the multivariate analysis, Asian participants had worse SC, whereas African American and Hispanic patients had better SC. Greater disease activity, better coping, and social support remained independent correlates of better SC. Compared with US patients, patients from China and Canada had worse SC on the univariate analysis. In the multivariate models, Asian ethnicity remained independently associated with worse SC, even after we adjusted for geographic background (China). No associations between African American or Hispanic ethnicity and SC were retained when geographic location (Canada) was added to the multivariate model. Canadian patients had worse SC when compared with US patients. Higher disease activity, better social support, and coping remained associated with better SC. Conclusion Greater social support, coping, and, paradoxically, SLE disease activity are associated with better SC. Social support and coping are modifiable factors that should be addressed by the provider, especially in the Asian population. Therefore, evaluation of a patient's external and internal resources using a biopsychosocial model is recommended. Higher disease activity correlated with better SC, suggesting that the latter may not be a good surrogate for QOC or health outcomes.

Background/purpose To plan a quality improvement project, we need to understand the practice patterns of physicians. We undertook an online survey of systemic lupus erythematosus (SLE) patients and physicians providing care to SLE patients to determine the patterns of medical care provided to SLE patients. Materials and methods Two self-report surveys were developed. A 12-item survey for the patients and a 13-item survey for physicians enquired about longitudinal care for SLE. Surveys were administered online to physicians providing care to SLE patients, and to patients who self-identified as having SLE, through the Lupus Society of Illinois. Patient and physician data were analyzed for physician practice patterns for SLE care, using chi square tests and t tests. A P value of 0.05 or less was considered significant on two-tailed tests. Results A total of 283 patients completed the survey. Mean (SD) age and disease duration of patients were 45.9 (13.2) and 12.7 (9.7) years. Half of the participants were being seen at 3–4-month intervals. More than 70% of patients reported being tested for antinuclear antibody (ANA), and 20–30% anti-ENA antibody and Sjögren’s (SSA/SSB) antibodies, respectively, at each follow-up visit. Eighty-six rheumatologists completed the surveys. Mean (SD) age was 55 (12) years and 56% were men. More than half (54%) provided care only in a private practice setting. More than 80% of physicians reported seeing their SLE patients at 3–4-month interval. Only 2% reported performing ANA tests at each visit, while 4–5% performed anti-ENA and anti-SSA/SSB antibody tests at each visit for their SLE patients. More than 75% of physicians in private practice also ordered sedimentation rate at each visit for their SLE patients. Conclusions Unnecessary laboratory investigations may be being ordered routinely for patients at every visit. These results indicate a need for physician education on indications and utility of some of the laboratory tests such as ANA.

Background Center for Disease control and US department of Health and Human Services recommend Pneumococcal vaccination (PV) for chronic diseases and immunosuppressed. PV is a known quality indicator for patients with Systemic Lupus Erythematosus (SLE). We aimed to study the prevalence rates and predictors of PV in a cohort of SLE patients on immunosuppressive medications (ISM). Methods Data were obtained through self-report questionnaires and medical chart review of 150 patients with SLE seen in rheumatology clinic at an academic center. Ninety four patients were eligible for PV based on ISM use (current use of any ISM other than hydroxychloroquine or current prednisone 7.5 mg daily for 3 months or age 65 years). Information on rheumatologist recommendation/receipt of PV 23 in the preceding 5 years was collected by self-report in the questionnaire and/or from chart review. Information was also collected on demographics (age, gender, race, education, insurance), physician (having a primary care physician (PCP), the volume of SLE patients seen by each rheumatologist in the past 4 months) and severity and duration of SLE (ACR classification criteria, disease activity, damage, medications). Rheumatologists SLE volume was categorized as 0–50, 50–100 and >100. Univariate and Stepwise Binary logistic regression analysis were done to study predictors and most parsimonious model for PV (dependent variable). Results Mean (SD) age of the cohort was 45.9 (15.0) years, 90% were women: 52% African-American, 26% Caucasian, 7% Hispanic, 13% Asian and 2% other. Mean (SD) SELENA-SLEDAI and SDI were 4.1 (2.3) and 1.7 (0.9), respectively. Over 90% had a PCP. SLE patient volume of rheumatologist during the previous 4 months was: 21% had 0–50, 27% had 51–75, while 52% had >76 SLE patients. Sixty-five (69.1%) patients had been either recommended or given PV 23 in the preceding 5 years. Univariate correlates were older age, higher education, Caucasian race, having a PCP, rheumatologists SLE patient volume, greater number of ACR criteria met, longer disease duration, higher SLEDAI and SDI scores, lupus nephritis class III-V, treatment with steroids (ever), current mycophenolate mofetil or biologic use. On multivariate analysis none retained independent significance. On stepwise analysis odds of being recommended/receiving PV were twice with every increase in Rheumatologists SLE patient volume by 50. Conclusions The volume of lupus patients seen by rheumatologists is independently associated with pneumococcal vaccination. Physician and patient education towards importance of preventive measures in SLE are needed to meet this important quality index. Funding Source(s): None

Gastrointestinal (GI) manifestations are common in patients with systemic lupus erythematosus (SLE). Diagnosis of SLE is often delayed when GI symptoms are the initial presenting manifestation. GI symptoms in SLE are usually mild and often caused by infections or medication side effects. However, a wide variety of GI manifestations may be seen among patients with SLE, especially those with moderate to severely active disease. GI involvement in SLE can be life-threatening. Clinical presentations of GI lupus are nonspecific and can be difficult to differentiate from infectious, thrombotic, therapy-related, and non-SLE etiologies. Timely recognition, correct attribution, and appropriate treatment of GI manifestations in a patient with SLE are thus important to improve the prognosis.

Objective Systemic lupus erythematosus (SLE) predominantly affects women. Clinical phenotype and outcomes in SLE may vary by sex and are further complicated by unique concerns that are dependent upon sex-defined roles. We aimed to describe sex differences in disease-specific quality of life (QoL) assessment scores using the Lupus Patient-Reported Outcome (LupusPRO) tool in a large international study. Methods Cross-sectional data from 1,803 patients with SLE on demographics, self-identified sex status, LupusPRO, and disease activity were analyzed. The LupusPRO tool has 2 constructs: health-related QoL (HRQoL) and non-HRQoL. Disease activity and damage were evaluated using the Safety of Estrogens in Lupus Erythematosus National Assessment version of the Systemic Lupus Erythematosus Disease Activity Index and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, respectively. Nonparametric tests were used to compare QoL and disease activity by sex. Results A total of 122 men and 1,681 women with SLE participated. The mean age was similar by sex, but the damage scores were greater among men. Men fared worse on the non-HRQoL social support domain than women (P = 0.02). When comparing disease and QoL among men and women ages ≤45 years, men were found to have greater damage and worse social support than women. However, women fared significantly worse on lupus symptoms, cognition, and procreation domains with trends for worse functioning on physical health and pain-vitality domains. Conclusion In the largest study of a diverse group of SLE patients, utilizing a disease-specific QoL tool, sex differences in QoL were observed on both HRQoL and non-HRQoL constructs. Although men performed worse in the social support domain, women (especially those in the reproductive age group) fared worse in other domains. These observations may assist physicians in appropriately addressing QoL issues in a sex-focused manner.

OBJECTIVE An easy, quick tool requiring minimal training or health care provider input would potentially have greater uptake for clinical use among rheumatologists and primary care physicians for assessment of disease activity in systemic lupus erythematosus (SLE). SIMPLE (SIMple Disease Assessment for People with Lupus Erythematosus) index is a composite numeric tool that is easy and quick to calculate. We prospectively assessed the performance of the SIMPLE index as a disease activity surrogate against physician-based disease activity measures. METHODS Ninety-nine consenting patients meeting American College of Rheumatology SLE classification criteria were recruited. Safety of Estrogen in Lupus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI), physician global assessment, and SIMPLE index were obtained during routine visits. SIMPLE index is a 17-item patient-reported questionnaire that includes 2 laboratory tests. Health care provider input is needed only to provide laboratory results (normal/abnormal) and confirming patient-reported current use and dosing of glucocorticoids. We performed Spearman test to assess correlation of SIMPLE index with SELENA-SLEDAI and physician global assessment. RESULTS Mean age (SD) was 39.7 (12.3) years. The correlation coefficient between SIMPLE index and SELENA-SLEDAI was 0.56 (P = 0.0001), and that between SIMPLE index and physician global assessment was 0.54 (P = 0.0001). In SLE patients without fibromyalgia (FM), the correlation of SIMPLE index with SELENA-SLEDAI and physician global assessment was 0.58 (P = 0.0001) and 0.57 (P = 0.0001), respectively. CONCLUSIONS SIMPLE index is strongly correlated with formal physician assessments of disease activity in SLE, and correlation was marginally higher among those without FM. SIMPLE index can be performed easily in places with limited physician and laboratory resources.

Patients with systemic lupus erythematosus (SLE) frequently experience poor body image (BI), an important issue, though not well researched or understood thus far. BI is perception of one’s own body. The effects of disease activity, damage, sleep, stress, pain, fatigue, function, medications, depression and fibromyalgia (FM) on BI in SLE are not known. Objective: We aimed to evaluate the relative role of the specific variables listed above on BI in SLE patients. Methods: SLE patients receiving rheumatology care at two academic medical centers were recruited. Each patient completed questionnaire assessments evaluating target variables and BI. Disease activity was evaluated using SELENA-SLEDAI. Multivariate regression analyses including stepwise modeling were conducted with BI as the dependent variable for all patients and for patients with and without FM. Results: 115 SLE patients participated. Mean (SD) age was 40.1 (13.8) years. For all patients and patients without FM, depression (β -1.7, p 0.02), stress (β -1.8, p 0.05), ACR malar rash (β -13.5, p 0.03), and steroid dose (β -0.4, p 0.04) were found to be independent predictors of BI, and explained 54% of BI variance. On stepwise regression modelling, scores for depression (β -2.2, p

OBJECTIVE To determine whether sleep disturbance and symptoms of depression mediate the relationship between pain and cognitive dysfunction (CD) in a sample of 115 patients with systemic lupus erythematosus (SLE). METHODS A total of 115 patients with SLE completed questionnaires regarding pain, perceived stress, depression, sleep, and CD. Relationships among pain, sleep, depression, and CD were assessed using bootstrap mediation models, controlling for race/ethnicity, fibromyalgia diagnosis, current corticosteroid use, disease activity and damage, and perceived stress. RESULTS Mediation analyses indicated that the effect of pain on CD was mediated by sleep disturbance (β = 0.30) and depression symptoms (β = 0.33). These effects were maintained even after controlling for the aforementioned covariates, of which only disease activity (β = 0.20) and stress (β = 0.22) remained significantly linked to CD (overall model R2 = 0.53; all P < 0.05). CONCLUSION After controlling for disease activity and perceived stress, the relationship between pain and CD was explained by sleep disturbance and depression symptoms. Although these relationships need validation in longitudinal studies with additional measurement modalities, our findings may indicate promising, nonpharmacologic intervention avenues for SLE patients with pain and CD. Specifically, cognitive behavioral therapies for depression and sleep are known to reduce distress and enhance functioning across various psychosocial domains. Given the symptom burden of SLE, interventions that maximize potential benefits without the use of additional pharmacologic treatments may be of particular utility.

OBJECTIVE To compare the quality of care received by patients with systemic lupus erythematosus (SLE) in 2 settings within the academic institution (a dedicated lupus clinic and a general rheumatology clinic) using validated SLE quality measures. METHODS One hundred fifty consenting, consecutive SLE patients receiving longitudinal care at the Rush University general rheumatology clinic (n = 73) or the subspecialty lupus clinic (n = 77) were recruited. An updated quality measure survey and retrospective medical chart review were used to evaluate each quality measure (n = 20). The overall and individual quality measure performance was calculated and compared between the 2 groups. Data on the number of SLE patients seen by each rheumatologist were collected to assess the relationship between SLE patient volume and quality measures. RESULTS Overall quality measure performance was significantly better in SLE patients receiving care at the lupus clinic (85.8% versus 70.2% of patients receiving care at the general rheumatology clinic; P = 0.001). Differences between the 2 groups were observed for sunscreen counseling (98.7% and 83.6%, respectively; P = 0.001), antiphospholipid antibody testing (71.4% and 37%, respectively; P < 0.001), pneumococcal vaccination (84.8% and 48.8%, respectively; P < 0.001), bone mineral density testing (94.2% and 54.5%, respectively; P < 0.001), drug counseling (92.2% and 80.8%, respectively; P = 0.04), use of a steroid-sparing agent (100% and 82%, respectively; P < 0.007), use of an angiotensin-converting enzyme inhibitor (94.4% and 58.3%, respectively; P = 0.03), and cardiovascular disease risk assessment (40.3% and 15.1%, respectively; P = 0.01). There was a moderate correlation between physician volume and quality measure performance (ρ = 0.48, P < 0.001). CONCLUSION Compared with the general rheumatology clinic, the dedicated lupus clinic had better quality measure performance in this cross-sectional single-center study. In our health care system, we also observed indicators suggesting that rheumatologists with a higher volume of SLE patients provide higher quality of care.

Objective Interleukin-6 (IL-6), interleukin-10 (IL-10), interferon-alpha (IFN-α), and free light chains (FLCs: lambda, kappa) have all been noted to be of importance in systemic lupus erythematosus (SLE). Herein, we quantified and explored the relationship between these inflammatory mediators and disease activity in SLE; and stratified by their current anti-dsDNA antibody status. Methods Seventy-seven SLE patients underwent assessment of disease activity using the SLE disease activity index (SLEDAI). Serum FLC (lambda, kappa, and total), IL-6, IL-10, and IFN-α were quantified. Demographics of disease characteristics were determined by chart reviews. Statistical analyses included Mann–Whitney test, chi square, and linear regression analyses. Results Mean (SD) age of the patients was 44.9 ± 12.7 years; SLEDAI (mean ± SD) was 3.4 ± 4.0. Serum lambda FLC levels had a moderate correlation ( r = 0.46 with physician global assessment, 0.44 with SLEDAI) and the strongest correlation with disease activity as compared with other inflammatory mediators including current dsDNA antibody status. After adjusting for prednisone use, the correlation of lambda FLC with PGA ( r = 0.48) and SLEDAI ( r = 0.52) was better than of current dsDNA antibody status with PGA ( r = 0.33) and adjusted SLEDAI ( r = 0.24), respectively. IL-10 and IFN-α activity did not correlate with disease activity. Serum FLC and IL-6 levels could differentiate between active and inactive SLE patients. Serum lambda FLC and IL-6 levels differed significantly among patients with and without current dsDNA antibodies. Serum lambda FLC levels accounted for 31% of variance in SLEDAI scores. Conclusion Serum FLC and IL-6 are potentially useful biomarkers of disease activity in SLE. Further studies, with larger study sample and longitudinal design, are indicated.

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder punctuated by varied multiorgan complications all along the course of its natural history. Lymphoma represents a relatively well-recognized malignant phenomenon associated with lupus. The cause and effect relationships of lymphoma in SLE have been subject to extensive scrutiny with several studies reporting on clinic-pathologic characteristics and risk factors predicting lymphoma development in SLE. However, the pathogenic role of immunosuppressives in SLE-related lymphoma still remains unclear, and indices to help guide diagnosis, prognostication, therapy, and posttreatment monitoring are yet to be established. In this review, we describe 3 SLE patients who developed non-Hodgkin’s lymphoma at different time points of their disease. Through a careful dissection of the aforementioned cases, we intend to apprise readers of the currently available literature surrounding risk factors, management, and prognosis in SLE-related lymphoma. We will also review and discuss the implications of immunosuppressives in SLE-related lymphoma and the role of mycophenolate mofetil in SLE-related primary CNS lymphoma development.

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease associated with greater comorbidity in comparison to the general population. Individuals with SLE are at increased risk of developing cardiovascular disease, stroke, cancer, osteoporosis, and infection among others. Some others, such as vitamin D deficiency in SLE, may have a dual role in disease activity and bone health. End-stage renal disease, infection, and cardiovascular disease remain the leading causes of death. Risk of cardiovascular disease continues to be poorly addressed in SLE, with an increased rate of hospitalization for acute myocardial infarction and ischemic stroke, in contrast to decreasing rate of hospitalization in the general population. Other increased risks for cardiovascular complications include hypertension, premature coronary artery disease, and cerebrovascular events. It can be difficult to distinguish between the contribution of disease activity and its duration and the enhancing effect of chronic glucocorticoid use. Infections commonly complicate the course of SLE with a higher risk of major infections in patients with steroids, even at moderate doses. A wide spectrum of infections has been reported in SLE, mostly bacterial, but opportunistic infections may occur. In addition, SLE is associated with an overall increase incidence of malignancy, mainly non-Hodgkin lymphoma, Hodgkin’s lymphoma, leukemia, and laryngeal, lung, liver, vagina/vulvar, and thyroid malignancies. A decreased risk in other malignancies especially cancers of the breast, endometrium, and prostate have been reported. Fibromyalgia may complicate the course of the disease. Physicians need to be alert in recognizing the onset when depression and widespread pain coexist. The burden of comorbidity is associated not only with higher mortality but also with poorer quality of life and increased utilization of hospital and medical resources. Clinicians should be aware of the increased risks and consider treatment of comorbidities as an integral part of the clinical care of these patients.

Systemic lupus erythematosus (SLE) may adversely affect body image in multitude ways. Development and validation of a brief and valid SLE specific body image tool were undertaken. Eleven items were identified on interview of 21 SLE patients for the Body Image Lupus Scale (BILS v1.0). The tool was administered to 70 SLE patients. Based on analysis, feedback, and refinement of items, the final iteration BILS v1.2 with five items was administered to 233 SLE patients along with validated body image measures (Situational Inventory of Body Image Dysphoria and Body Image Quality of Life Inventory) and health-related quality of life measures for a subsample. The BILS scores’ had an internal consistency reliability of .94. It correlated with both the referent body image measures, and with health-related quality of life. It differentiated participants by health status and disease activity. Test–retest reliability estimates exceeded .90. These results support the psychometric properties of BILS.

Objective To evaluate serum free light chains (FLC) as a putative biomarker of systemic lupus erythematosus (SLE) activity. Methods Seventy-five SLE patients and 41 age- and sex-matched rheumatoid arthritis (RA) controls were enrolled. Disease activity was assessed using the Safety of Estrogens in Lupus Erythematosus: National Assessment version of the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) definition and physician global assessments for SLE and the Disease Activity Score in 28 joints for RA. Serum FLC levels were compared against other biomarkers (IgG, C3, C4, double-stranded DNA [dsDNA] antibody). Nonparametric tests were used to compare 1) FLC and IgG in SLE versus RA and healthy controls, 2) FLC and IgG among different levels of activity in SLE, and 3) FLC in active versus nonactive RA. Correlation of FLC, C3, C4, dsDNA antibody, and IgG with the SLEDAI and modified SLEDAI (M-SLEDAI) were obtained. Results FLC was higher in SLE than in RA; both were higher than referent healthy controls. Total FLC was significantly higher in subjects with greater SLE disease activity than lower/no activity. There were no significant differences in IgG, C4, or dsDNA antibody stratified by disease activity. Total FLC and C3 showed moderate to strong correlation with the SLEDAI and M-SLEDAI. In RA, no differences were seen in FLC levels for different levels of disease activity. Similar results were seen after controlling for renal function, age, and sex. In multiple linear regression, FLC significantly explained 50% variance of the SLEDAI after adjusting for renal function, age, and sex. Conclusion Serum FLC levels correlate strongly with disease activity in SLE, but not in RA. Serum FLC may be used as a biomarker of SLE disease activity.

Objective.The LupusQoL-US instrument was recently validated in the US. We studied the benchmarks for a US patient cohort with systemic lupus erythematosus (SLE) and relevant demographic and disease correlates.Methods.LupusQoL-US was administered to 185 patients with SLE. Demographic data (age, sex, ethnicity, marital status) and disease features (duration, disease activity and damage) were assessed simultaneously. Descriptive statistics were obtained. LupusQoL-US domain scores were calculated, and compared by sex, ethnicity, and marital status using nonparametric tests. Correlation between LupusQoL-US domains and age, disease duration, disease activity, and disease damage were obtained.Results.Mean age of patients was 42.2 ± 14.5 years; 94% of subjects were women. African American patients comprised 60% of the study cohort. The most affected domains were Fatigue and Physical Health. The least affected was Intimate Relationships. Age correlated with Physical Health, Pain, and Body Image (r = 0.15–0.18). Differences were observed based on sex and marital status, but not by ethnicity; there the LupusQoL-US correlated inversely with disease activity (r = −0.001 to −0.36) and damage (r = −0.003 to −0.40).Conclusion.All domains of the LupusQoL-US based health related quality of life (HRQOL) were affected adversely. HRQOL varied by age, sex, and marital status in our SLE cohort.

Objective.The magnitude of the risk of reactivation of tuberculosis (TB) on use of etanercept, especially in patients with positive purified protein derivative (PPD) test, has not been assessed. We evaluated the risk of developing active TB among PPD-positive patients treated with etanercept.Methods.All patients with a positive PPD test, as defined by American Thoracic Society guidelines, who received etanercept at Cook County Hospital from 2001 to 2008 were retrospectively reviewed. The primary endpoint was the development of active TB either while receiving or after completing etanercept therapy.Results.Four hundred eighty-seven patients received etanercept, of whom 84 were PPD-positive and constituted the primary cohort. The cohort was composed largely of patients who were at high risk for development of active TB: born in endemic area (80%), ethnic/racial minorities (51 Hispanic, 16 African American, and 8 Asian), and low socioeconomic status (66, 78.57%). Overall etanercept exposure was a mean of 24.6 months (range 3 to 60 mo), with 196 patient-years of etanercept exposure in PPD-positive individuals. Indications for etanercept use included rheumatoid arthritis 58 (69%), ankylosing spondylitis 11 (13%), psoriatic arthritis 13 (15.5%), juvenile inflammatory arthritis 1 (1.2%), and vasculitis 1 (1.2%). Of the 80 subjects, 74 received treatment for latent TB infection (LTBI) prior to initiating etanercept. A comprehensive review of these patients’ medical records failed to reveal any active TB infection.Conclusion.This systematic analysis suggests that the risk of reactivation of LTBI during etanercept therapy is low in appropriately treated individuals.

Psoriatic arthritis (PsA) is a chronic, autoimmune, seronegative inflammatory arthritis characterized by varying degrees of axial and peripheral arthritis. Here, we review the literature on the pharmacological management of PsA and present a simple treatment algorithm based on the available information. Although PsA management must be individualized to the degree and type of joint pain and inflammation, in general, nonsteroidal antiinflammatory drugs (NSAIDs) still represent first-line treatment of mild PsA. Second-line therapy includes older agents such as gold salts, methotrexate, sulfasalazine, and cyclosporine. The tumor necrosis factor alpha (TNF-alpha) antagonists represent the most recent major advance in the clinical management of PsA.

Raynaud's phenomenon is characterised by episodic vasospasm of the fingers and toes typically precipitated by exposure to cold. Mild Raynaud's is common and is not usually a harbinger of clinically important disability; its onset, however, can be startling and uncomfortable for patients, and the well recognised association in some cases with systemic rheumatic conditions often precipitates aggressive assessments for underlying diseases. Advances in vascular physiology have shed light on the role of the endothelium as well as endothelium-independent mechanisms in the altered vasoregulation of Raynaud's. We review clinical aspects of the disorder and new insights with respect to pathophysiology, and we discuss potential new therapeutics based on the disease mechanism, such as prostacyclin analogues, serotonin antagonists, and calcitonin gene-related peptides.

Coronary artery occlusive disease is a common though underappreciated complication of systemic lupus erythematosus (SLE), typically a disease of young women. A case of a premenopausal patient with SLE and an acute myocardial infarction is presented, and the etiology and management of coronary artery disease in SLE reviewed.To review the incidence, risk factors, pathology and treatment of coronary artery disease in systemic lupus erythematosus.MEDLINE search of articles in English-language journals from 1980 to 2000. The index words "systemic lupus erythematosus" and the following co-indexing terms were used: "coronary artery disease," "atherosclerosis," "vasculitis," "anticardiolipin antibodies," "antiphospholipid syndrome." SELECTION SYNTHESIS AND ABSTRACTION: Papers identified were reviewed and abstracted by the authors with a presentation of a summary.The prevalence of coronary artery disease among women with SLE between the ages of 35 and 44 years is at least 50-fold greater than among age-matched control subjects. Of these, coronary atherosclerosis accounts for the vast majority of cases; vasculitis of the coronary arteries and other causes generally believed to be more typical of SLE are comparatively rare.The evidence suggests that SLE is a significant risk factor for coronary atherosclerosis independent of the classic risk factors of hypertension, tobacco use, and hyperlipidemia.

Medications inhibiting 3-hydroxy-3-methyglutaryl coenzyme A (HMG-CoA) reductase are commonly used as lipid-lowering therapy. Myopathy has been reported as a rare adverse effect in up to 0.2% of patients; however, this complication appears to be more common in patients who are concurrently receiving cyclosporin A(CsA). We present a case of a 74-year-old woman tolerating a stable dose of simvastatin 80 mg daily for hyperlipidemia. After the addition of CsA for a corneal stem limbal cell transplant, the patient experienced a cholesterol-lowering agent myopathy syndrome (CLAMS), with creatine phosphokinase values up to 78,472 U/L. We explore the interaction between simvastatin and CsA, including effects on hepatic microsomal metabolism via the cytochrome P-450 pathway, cholestasis, and myoblast histology, with a review of previous literature regarding HMG-CoA reductase inhibitors (HMGRIs) and rhabdomyolysis. Caution should be exercised in patients receiving concomitant simvastatin and CsA, and a reduced dose of simvastatin is suggested. Inhibition of HMG-CoA reductase is an accepted therapy for hyperlipidemias. The development of a CLAMS is a known potential adverse effect (1), with an increased incidence during coadministration of lovastatin and CsA, first reported by Norman et al. and East et al. in 1988 (2, 3). The interaction between the HMGRIs and CsA, which leads to this muscle toxicity, appears to be related to altered clearance of the HMGRIs with resultant increased tissue exposure (4). The majority of experience with rhabdomyolysis has been in cardiac and renal transplant patients requiring lovastatin and CsA. Theoretically, however, any of the HMGRIs may predispose a patient requiring CsA to develop myositis. In particular, there is a suggestion of an increased sensitivity of myoblasts to both lovastatin and simvastatin (5). We present a case of rhabdomyolysis in a corneal stem cell transplant patient receiving simvastatin and CsA, with a review of the literature.

Interstitial lung disease (ILD) is now the most common cause of mortality in scleroderma, although its pathogenesis remains poorly understood. Management requires early detection and treatment before the onset of lung fibrosis. In a number of uncontrolled studies, the combination of daily oral cyclophosphamide and low-dose prednisone appears to be effective, although these conclusions have yet to be confirmed.

Posterior reversible encephalopathy syndrome (PRES) is an underrecognized and reversible condition in systemic lupus erythematosus (SLE) that could mimic neuropsychiatric lupus. Identification of any distinct clinical patterns is important as one would need to escalate rather than decrease or discontinue immune suppression in neuropsychiatric lupus.We retrospectively identified and described 5 patients with SLE who were hospitalized and diagnosed with PRES from 2008 to 2013 in a tertiary medical center and reviewed relevant literature.Posterior reversible encephalopathy syndrome in SLE occurred in young women with age distribution from 19 to 37 years. At the time of presentation, all had hypertension (systolic blood pressures ranging from 150 to 220), moderate to severe disease activity (Systemic Lupus Erythematosus Disease Activity Index scores ranging from 11 to 41), and prototypical magnetic resonance imaging findings of PRES and nephritis (4 of 5 patients had biopsy-proven lupus nephritis). Seizures, headache, and confusion were the most common clinical symptoms. One patient had intracerebral hematoma, and 2 patients had cerebral petechial hemorrhages. All patients improved without any neurological deficits, with a mean hospital stay of 11.2 days.Systemic lupus erythematosus should be considered in the differential diagnosis of patients who present with PRES. One should have a low threshold for magnetic resonance imaging especially when neurological symptoms occur in young women with or without an established diagnosis of SLE and especially among those with active SLE, lupus nephritis, renal failure, and/or poorly controlled hypertension. Given the good prognosis of PRES in SLE patients with early supportive treatment, prompt recognition is crucial to institute appropriate management.

Background An easy, quick tool, requiring minimal training or physician input for disease activity (DA) assessment in SLE, would have potentially greater uptake for routine use among rheumatologists and primary care physicians. Furthermore, integration into busy work flow processes would be easier for the same reason. Most DA tools for SLE are complex, require training and physician time; and are not performed during routine care visits for most SLE patients. SIMPLE (Simple Disease Assessment for People with Lupus Erythematosus) 1 is a numeric composite index based on patient reported questions and two laboratory values, and requires minimal input from health care provider which can be provided by nurse or a physician extender. Here, we prospectively evaluate the correlation of SIMPLE index with physician based DA measure. Objectives Prospectively validate SIMPLE index as a DA measure compared to traditional physician based DA assessment tools. Methods 72 consenting patients meeting ACR classification criteria for SLE were recruited from two academic center clinics. Primary outcome of interest was correlation between Simple Index (SI) and SELENA-SLEDAI (SS). Secondary outcome of interest was correlation between SI and Physician Global Assessment (PGA). Patients filled the self-reported components of SI in the waiting room prior to their visit. PGA and SS were assessed at the same visit by the physician. Descriptive and spearman correlational analyses were obtained. Stratified analysis by fibromyalgia status (FMS) was also conducted. P value of ≤0.05 was considered significant on two tailed tests. We considered correlation coefficient of 0.50 as weak, moderate and strong correlation, respectively. Results Mean (SD) age was 40.8+12.4 yrs, and 87.5% participants were women. Ethnic background of the participants was as follows: 52.8% Blacks, 25% Whites, 8.3% Hispanic, 6.9% Asians and 6.9% others. Median (IQR) SI was 21.7 (17.2). Median (IQR) values of PGA and total SS were 0.5 (1.0) and 4.0 (6.0), respectively. Spearman correlation coefficient between SI and PGA and SS were 0.507 (p 0.001), 0.568 (p 0.001), respectively. In a sub analysis excluding fibromyalgia patients, these correlations were 0.538 (p 0.001, n=60), 0.633 (p 0.001, n=59) respectively. Conclusions SIMPLE index is strongly correlated with PGA and SS in SLE patients, and the correlation is even stronger in SLE patients without FMS. SIMPLE index is quick, easy and requires negligible health care team input, which can be from a physician extender or a nurse or any physician. SIMPLE Index has the potential to be widely used in varied health care access levels and systems in different parts of the world. SIMPLE Index can potentially serve as a quality of care measure. Larger and longitudinal studies that include patients with greater DA and to test its responsiveness are currently ongoing. References Simple Disease Assessment for People with Lupus Erythematosus. AR 66 (11):s312 Disclosure of Interest N. Gandhi: None declared, M. Jolly Grant/research support from: Pfizer Inc, A. Nevares: None declared, W. Sequeira: None declared

Background Several outcomes and clinical response measures have been used in patients with polymyalgia rheumatica (PMR), but there is no consensus about the optimal endpoint for evaluating response to treatment. A PMR activity score has been proposed which includes three patient reported outcomes (PROs) 1 . RAPID3 is an index found on a multidimensional health assessment questionnaire (MDHAQ) only including PROs, which is effective to document improvement not only in RA but also in other rheumatic diseases 2 Objectives To prospectively evaluate the performance of RAPID3 and other PROs included on the MDHAQ to document improvement in clinical status over time in patients with PMR. Methods This study was conducted at an academic rheumatology center at which all patients complete a MDHAQ, which includes 0–10 scores for physical function (FN), pain (PN), and patient global estimate (PATGL), compiled into a 0–30 RAPID3. The MDHAQ also scores fatigue, morning stiffness, self-reported joint counts and demographic data. Data collection included MDHAQ, acute-phase reactants, and prednisone dose. PMR patients with complete data seen between 2010 and 2014 were included. A baseline visit and the most recent visit were compared using paired t-test and McNemar9s test. Spearman correlation analysis for non-normally distributed variables was performed between RAPID3 and ESR and CRP. Results 34 PMR patients seen in routine care were included: 59% were females, 71% Caucasian, and mean age was 71.6 years. The mean duration from a baseline visit to most recent visit was 15.5 months. At initial presentation, RAPID3 was 12.2, FN 2.2, pain 5.3, and PATGL 4.7, fatigue 3.9, and morning stiffness 63.1 minutes; 64.7% of the patients had painful hips, 79.4% had painful shoulders, 73.5% had abnormal ESR, and 70.6% had abnormal CRP. Significant improvement was seen between baseline and last visit in mean level of RAPID3 and all other MDHAQ measures, except fatigue (p Conclusions In patients with PMR, improvement was seen according to PROs included on a self-reported MDHAQ questionnaire in a similar range to ESR and CRP, documenting effective response to prednisone. References Leeb BF, Bird HA. Ann Rheum Dis 2004;63(10):1279–83. Castrejon I, Bergman MJ, Pincus T. J Clin Rheumatol 2013;19:169–74. Disclosure of Interest None declared

Background The Cutaneous Lupus Disease Area and Severity Index (CLASI) has not been validated using rheumatologist-conducted disease activity and damage assessments, especially cutaneous assessments. Active skin disease and skin damage may have substantial effects on patient-reported outcomes and on body image. Objective We sought to validate the CLASI against: (1) physician-assessed disease activity and damage measures; and (2) patient-reported assessment of quality of life and body image. Methods Cross-sectional data were collected from 31 patients with cutaneous lupus erythematosus. Cutaneous disease activity and damage were measured by using the CLASI. Disease activity (using the Safety of Estrogens in Lupus Erythematosus National Assessment–Systemic Lupus Erythematosus [SLE] Disease Activity Index [SLEDAI}), damage (Systemic Lupus International Collaboration Clinics–American College of Rheumatology Damage Index [SDI]), quality of life (LupusPRO), and body image (Body Image Quality of Life Inventory) were obtained. Descriptive statistics and Spearman correlations were ascertained. Results Mean (SD) age was 42.3 (12.8) years; 97% were women. The mean (SD) CLASI activity and damage scores were 10.5 (7.4) and 9.9 (9.5). Correlations noted were: total CLASI activity and SLEDAI-rash ( r = 0.42, P = .02), CLASI-mucosal and SLEDAI-mucosal ( r = 0.65, P = .001), CLASI-recent hair loss and SLEDAI-alopecia ( r = 0.61, P = .001), and total CLASI activity and LupusPRO symptoms domain ( r = −0.38, P = .04). Total CLASI-damage correlated with SDI-scarring/alopecia ( r = 0.51, P = .004), SDI-extensive scarring/panniculum ( r = 0.55, P = .003), and SDI-skin ulceration ( r = 0.36, P = .05). CLASI scalp scarring correlated with SDI-skin scarring/alopecia ( r = 0.94, P = .001). CLASI activity on the face and nose was associated with significant concerns on the Body Image Quality of Life Inventory. Limitations Limitations include small sample size. Conclusion CLASI activity and damage scores correlate with physician-assessed cutaneous activity and damage in cutaneous lupus erythematosus in patients with SLE. Cutaneous activity in visible areas may generate body image concerns.

Objective Quality of care received from physicians may impact health outcomes in systemic lupus erythematosus (SLE). We compared physician quality of care (P-QOC), health-related quality of life (HRQOL), and disease activity and damage between SLE patients receiving outpatient care at a university and a county rheumatology clinic. Methods Forty-two university and 41 county clinic SLE patients provided data on 5 P-QOC parameters and HRQOL health outcomes (Short Form 36 [SF-36] health survey and EuroQol 5-domain instrument [EQ-5D]). Disease activity and damage were measured. Chi-square analysis and Student's t-tests were used for comparisons. Results Overall satisfaction with medical care was similar; however, university patients had higher P-QOC scores than county patients in “perception of doctor's understanding of impact of SLE on patient's life” (P = 0.02) and “providing education/educational information to understand their disease” (P = 0.05). HRQOL, disease activity, and damage were similar in the 2 groups. Overall satisfaction with medical care was directly related SF-36 general health (r = 0.34, P = 0.03) and EQ-5D visual analog scale on state of health (r = 0.39, P = 0.01), and inversely related EQ-5D pain (r = −0.37, P = 0.02). Conclusion Patient perceptions of P-QOC differed across the 2 centers despite similar demographics, clinical and HRQOL outcomes, and significant overlap in the physicians serving each clinic. Patients' overall satisfaction with medical care is associated with better HRQOL.

Purpose Systemic lupus erythematosus (SLE) can significantly affect both health and non-health-related quality of life (HRQOL and non-HRQOL). However, of the existent published patient-reported outcome (PRO) tools, none were developed from US patients, an ethnically diverse population. Furthermore, these tools do not address men with SLE or assess non-HRQOL issues. Herein, we present the development and validation of the Lupus Patient-Reported Outcome tool (LupusPRO) and discuss its clinical utility and research value compared with other PRO tools currently available for SLE. Methods Beginning with a conceptual framework, items for LupusPRO were generated using feedback from women and men with SLE. The tool underwent iterations based on patient feedback and clinimetric and psychometric analyses. Validity (content, construct, and criterion) and reliability (internal consistency and test-retest) for the 44-item LupusPRO tool are presented. Results Consistent with the conceptual framework, items were identified that were related to HRQOL and non-HRQOL constructs. HRQOL domains included (1) lupus symptoms; (2) physical health (physical function, role physical); (3) pain–vitality; (4) emotional health (emotional function and role emotional); (5) body image; (6) cognition; (7) procreation; and (8) lupus medications. Non-HRQOL domains were (1) available social support and coping; (2) desires–goals; and (3) satisfaction with medical care. Internal consistency reliability (0.68-0.94), test-retest reliability (0.55-0.92), content, construct ( r > 0.50 with SF-36), and criterion ( r > −0.35 with disease activity) validity were fair to good. Conclusions LupusPRO is a valid and reliable disease-targeted patient-reported health outcome tool that is generalizable to SLE patients in the United States of varied ethnic backgrounds and either gender.

Systemic lupus erythematosus (SLE) is an autoimmune disease that disproportionately affects women of childbearing age during their most productive years. Current therapeutic measures have improved patient survival; however, the impact of interventions on general and specific domains of health-related quality of life requires further study. Medical Outcomes Survey Short Form 36 (SF-36), the most commonly used measure, has been included in some SLE randomized controlled trials, but the observed effect sizes were generally small and in some cases negligible. An SLE patient’s quality of life is known to be significantly worse than that of someone in the general population and perhaps worse than those with most other common chronic diseases. SF-36, although useful as a general measure, may not be the most sensitive way to gauge changes perceived by patients with SLE. Ongoing trials and observational longitudinal studies using lupus-specific health-related quality-of-life measures may help better determine health-related quality-of-life responses and determine the domains most amenable to interventions.

Systemic lupus erythematosus (SLE), a multisystemic disease of young women may be disfiguring and affect physical and emotional health. Body image literature in SLE is scant and controversial.We compared body image-related quality of life in subjects with (n = 87) and without (n = 78) SLE and determined its correlates using the body image quality of life inventory (BIQLI).The tool was self-administered to consenting individuals. Demographic information along with disease activity and damage assessments for SLE patients were obtained. T test, chi square test, correlational, and regression analyses were used to make comparisons.Mean age (±SD) were 42.4 ± 13.1 and 38.7 ± 13.2 years for SLE and non-SLE subjects, respectively. Mean (±SD) BIQLI scores were significantly worse in SLE than non-SLE subjects: 19.9 ± 33.2 and 41.6 ± 24.8 (p = 0.001). In SLE, BIQLI scores correlated inversely with overall damage, irreversible cutaneous damage, alopecia, and self-reported depression, and directly with age and health status.Body image in SLE is poor, and effective interventions may be directed at cutaneous disease activity, damage, and depression.

To the Editor: It has become the standard of care to screen patients for latent tuberculosis infection (LTBI) prior to initiating tumor necrosis factor-α (TNF-α) antagonists, and treat with isoniazid (INH). Unfortunately, INH has been associated with hepatotoxicity. Estimates suggest that transaminase elevations may be seen in as many as 0.1% to 10% of patients treated with INH1,2. Patients with rheumatic disease may already be receiving potentially hepatotoxic medications such as methotrexate (MTX). Although the doses of MTX typically employed to treat rheumatic diseases are generally considered to be safe, mild reversible hepatotoxicity is common, and isolated cases of irreversible liver damage have been described3,4. The combination of 2 potentially hepatotoxic medications raises significant concern regarding safety. We describe the results of concomitant treatment with MTX and INH on hepatic function in a retrospective case series. … Address correspondence to Dr. A.M. Manadan, Rush University Medical Center, 1725 W. Harrison St., Suite 1017, Chicago, IL 60612. E-mail: amanadan{at}rush.edu

We describe a patient with an episode of severe Raynaud's phenomenon and early or mild scleroderma who presented with a transient elevation of her serum creatinine that resolved spontaneously after 2 days. Vascular response to cold temperatures has been described in vascular beds other than the extremities, and a similar phenomenon in the kidney might have been responsible for the transient renal dysfunction. Possible mechanisms to explain this phenomenon are discussed. Vasospasm merits consideration as an uncommon but largely reversible cause of elevated creatinine in patients with Raynaud's phenomenon.

OBJECTIVE: To determine if structured teaching of bedside cardiac examination skills improves medical residents’ examination technique and their identification of key clinical findings. DESIGN: Firm-based single-blinded controlled trial. SETTING: Inpatient service at a university-affiliated public teaching hospital. PARTICIPANTS: Eighty Internal Medicine residents. METHODS: The study assessed 2 intervention groups that received 3-hour bedside teaching sessions during their 4-week rotation using either: (1) a traditional teaching method, “demonstration and practice” (DP) (n=26) or (2) an innovative method, “collaborative discovery” (CD) (n=24). The control group received their usual ward teaching sessions (n=25). The main outcome measures were scores on examination technique and correct identification of key clinical findings on an objective structured clinical examination (OSCE). RESULTS: All 3 groups had similar scores for both their examination technique and identification of key findings in the preintervention OSCE. After teaching, both intervention groups significantly improved their technical examination skills compared with the control group. The increase was 10% (95% confidence interval [CI] 4% to 17%) for CD versus control and 12% (95% CI 6% to 19%) for DP versus control (both P

Magnesium cold chamber diecastings are steadily making inroads into the automotive industry. Parts that are routinely diecast include instrument panels, valve covers, steering columns, transmission case covers, seat pans, and door frames to name a few. In a bid to take full advantage of weight savings, the majority of the parts are optimized during the design process. This means wall thickness are reduced, and ribs are used to reinforce the part for stiffness. As a part of the design and optimization process, generic load analysis is carried out on the part without taking into account the residual stress developed during the casting process. The iterative process is continued until the design responsible engineer is satisfied with the outcome of the analysis. However, during the diecasting process, variations in the thermal patterns are obtained in the die mainly due to section thickness changes of the part, placement of cooling lines and spray patterns. On ejection from the die, the part will inherit a thermal history, which upon cooling to room temperature in air or in a quenching medium will result in part distortion and development of residual stress. Part warpage, which is a consequence of distortion, results in problems during trimming, machining, and assembly. On the other hand, residual stress beyond certain limits might lead to cracking of the part after production or during service. This paper discusses some of these aspects for a high pressure diecast magnesium automotive part.

Tuberculous synovitis frequently presents as a monoarthritis of weight-bearing joints such as the hip, knee, or ankle. Owing to its low incidence in developed countries, the diagnosis is often delayed for months to years. Early diagnosis with a synovial biopsy permits prompt antituberculous therapy and substantially improves the prospect of preservation of joint structure and function. Initial treatment typically includes combination therapy with four drugs (isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol) because of the frequency of isoniazid resistance. Antimicrobial therapy should be of at least 9 months' duration, longer in immunocompromised hosts. Partial synovectomy and other surgical procedures should be restricted to joints with severe cartilage destruction, large abscesses, joint deformity, multiple drug resistance, or atypical mycobacteria.

Answers on p 378. A 59 year old African American woman presented to her primary care physician with acute pain and swelling of her left arm. The initial examination revealed oedema of her left upper extremity extending to her left breast and chest wall. An ultrasound done to exclude a deep venous thrombosis of her left upper extremity was …

MYCOPLASMA pneumoniae has been recognized as a cause of respiratory tract infections in adults and children for the past 20 years. 1 Since that time, sporadic reports of involvement of other organ systems have appeared in the literature. In 1975 Murray et al 2 reviewed the protean manifestations of this infection. A variety of skin and mucous membrane lesions, while often not of major clinical importance, may occur. 3 Arthritis associated with M pneumoniae infection, though rare, is also well documented. 4-6 Both monoarticular and polyarticular arthritis have been reported, and the duration has varied from a transient episode in the course of a febrile illness to a more chronic disease lasting up to 18 months. 5 This report describes a patient with an acute febrile disorder characterized by a varicella-like eruption, polyarthritis, and a fourfold increase in antibodies to M pneumoniae . There was no evidence of lower respiratory tract

Four cases of Pseudomonas aeruginosa infection of the pubic symphysis occurred in intravenous abusers of pentazocine hydrochloride and pyribenzamine. Symptoms included suprapubic pain when walking, bilateral inguinal pain, and pain caused by hip flexion and rotation. Cultures of material taken by joint aspiration and open biopsy yielded P. aeruginosa in three patients and P. aeruginosa, P. maltophilia, and Corynebacterium in the fourth. All four responded to antibiotic treatment and open debridement but were lost to follow-up. Recent reports of P. aeruginosa arthritis in intravenous drug abusers are discussed. The concept of infective synchondritis as a distinct entity is suggested.

We studied retrospectively the pattern of septic arthritis in childhood at a major municipal hospital during a ten-year period. Hemophilus influenzae was the most common organism in septic arthritis in patients less than two years old and was associated with upper respiratory tract infections in nine of 12 patients (75%). Staphylococcus aureus was seen in seven of eight (87.5%) children above the age of five and was associated with history of trauma. All patients were black. Despite the high incidence of sickle cell disease in our hospital population, not one patient had sickle cell disease.

Neutrophilic dermatosis (Sweet's syndrome) is a condition that presents with arthritis and a skin rash. A case report is presented, and an association with hydralazine and lupus is described.

The serum angiotensin-converting enzyme (SACE) level is elevated in 75% of patients with sarcoidosis and often is associated with disease activity. In an attempt to correlate the SACE level with sarcoid arthritis, we did a retrospective chart review of 116 patients with sarcoidosis. Of the 24 patients who complained of arthritis, five were excluded from the study because they were receiving corticosteroids, SACE levels were not determined, or another cause for their arthritis was found. The mean SACE levels were 65 units/mL for the patients with acute arthritis and 51 units/mL for the patients with chronic arthritis. Levels of SACE may be helpful in the differential diagnosis of patients with "seronegative polyarthritis." (Arch Intern Med1986;146:125-127)