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A case of paraparesis due to an apophyseal joint cyst is reported. Full recovery occurred following surgical removal of the cyst. A review of the literature found approximately 60 cases of nerve root pain due to a synovial apophyseal joint cyst. Only very few patients had neurological loss. Facet joint cysts must be differentiated from spinal tumors. Computed tomography and above all magnetic resonance imaging provide valuable diagnostic and therapeutic information.

The authors report a 31 year old patient who underwent L5-S1 chemonucleolysis. The prenucleolysis discogram disclosed intravertebral discal displacement. Severe spinal symptoms and development of geodes in the endplates adjacent to the treated disk occurred after the procedure. This case suggests that intraosseous discal displacement may be a risk factor for postchymopapain nucleolysis discitis and may contraindicate chemonucleolysis.

Extracorporeal photochemotherapy (EPC) has been used to treat cutaneous T-cell lymphomas as well as a number of immune-mediated disorders. Seven patients above 50 years of age with refractory rheumatoid arthritis (RA) were treated by EPC. Mononuclear cells were harvested, exposed to ultraviolet A light in the presence of 8-methoxypsoralen, then reinfused into the patient. This procedure was repeated eight times over a three-week period. Improvements in clinical parameters were seen in every case as early as the second week and persisted throughout the duration of EPC. Improvements for more than three months were observed in two patients. C-reactive protein levels declined during the treatment period. No adverse reactions were recorded. The mechanism of action of EPC in RA requires elucidation and a controlled study is needed to confirm the efficacy of this technique.

A case of infection of the scapulohumeral joint following articular infiltrations is reported in a female patient with alcohol-related cirrhosis of the liver. Joint destruction occurred despite appropriate treatment with fluconazole. Candida tropicalis joint infections are seen mainly in immunocompromised hosts and usually cause little destruction of the joint. Most are the result of dissemination via the bloodstream. Preexisting chondrocalcinosis in the patient reported here may have been a contributing factor to the development of extensive joint destruction.

"Camptocormism" in the elderly is an acquired kyphosis which increases during walking and is totally reducible in dorsal horizontal position in two thirds of cases. The authors report 16 cases of camptocormism in patients with a mean age of 76 (12 women, 4 men). Camptocormism was accompanied in 5 cases by an extrapyramidal syndrome, in 3 cases by articular chondrocalcinosis, in 1 case by giant cell arteritis and in 1 by rheumatoid arthritis. There was no inflammatory syndrome and muscle enzymes were raised in only 4 cases. Electromyogram of the paravertebral muscles was pathological in 5 cases, with neurogenic changes in 4 cases and a myogenic type tracing in one. CT scan or magnetic resonance imaging showed evidence in all cases of atrophy with fatty involution of the paravertebral muscles. Biopsies of the paravertebral muscles revealed moderate mononuclear cell infiltrates in 4 cases with similar abnormalities in peripheral muscles. Corticosteroids had a beneficial effect in 11 cases out of 13 and the most prolonged results were seen after bolus doses of methylprednisolone. These findings suggest that camptocormism in the elderly could be linked to inadequacy of the paravertebral muscles or, in certain cases, to interstitial myositis.

The results of an open retrospective study of 49 patients treated with salazosulfapyridine (SASP) (sulphasalazine) for rheumatoid arthritis (RA) are reported. The patients, 7 men and 42 women, had a mean age of 53 years, and their mean duration of evolution of RA was 13.3 years. Sixty percent of them had undergone more than 3 previous disease-modifying drugs. The mean length of SASP treatment was 15.3 months. The initial response was favorable in 34 patients (69%). Treatment was ineffective and stopped in 12 cases (24.5%); the inefficacy was primary in 6 and tachyphylactic in the other 6. Twenty patients (41%) experienced at least one side effect. SASP was stopped in 11 patients (20.4%) due to undesirable side effects; 9 of the 11 times were during the first 2 months of treatment. Digestive system intolerance was the most common but led to drug withdrawal in less than half the patients. In all cases, mucocutaneous, neurosensory, hematological and hepatic side effects regressed during the month following SASP withdrawal. The therapeutic maintenance level was 67% at 1 year, 60% at 18 months, 52% at 2 years and 45% at 3 years. SASP has a role in the treatment of relatively slightly evolved forms of RA, before prescribing methotrexate. The possibility of delayed intolerance reactions, notably hematological and hepatic, justify prolonged biological monitoring of these patients.

Paf-acether (paf) is a naturally occurring phospholipid involved in inflammatory processes. The presence of paf, its precursor lyso paf, and lipo-paf has been determined in blood and synovial fluid from 13 patients with rheumatoid arthritis (RA), 11 with spondylarthropathies, eight with other inflammatory rheumatisms, 13 with chondrocalcinosis, 15 with osteoarthritis, and also in blood from nine healthy subjects. Paf and lipo-paf were measured by rabbit platelet aggregation after isolation by high performance liquid chromatography, whereas lyso paf was first chemically acetylated to give paf. Lipo-paf in blood was higher in patients than in controls; lipo-paf concentrations in blood and in synovial fluid were significantly higher in rheumatoid arthritis than in osteoarthritis and chondrocalcinosis. By contrast, paf and lyso paf reached their lower values in rheumatoid arthritis. The amounts of lipid mediators were not correlated with biological parameters of inflammation. Lipo-paf, which is considered as a storage form of paf, may be the important form of paf in active inflammatory rheumatism.

Salazosulfapyridine (salazopyrin) (SASP) is effective basic treatment for rheumatoid arthritis (RA) after failure or intolerance of antimalarials or gold salts. Sulfapyridine is the active part of the molecule. Its mechanism of action probably involves anti-inflammatory activity as well as effects on cells participating in immune reactions. Adverse reactions occur in approximately one third of cases, in the majority of instances during the first three months of treatments. Simple digestive upsets are the commonest, but SASP may be responsible for sometimes severe cutaneous, hematological and hepatic reactions. The sometimes delayed onset of intolerance reactions justifies continuous monitoring of laboratory parameters. Results obtained with SASP are sometimes prolonged and therapeutic maintenance rates are similar to those seen with other basic treatment for RA. The use of SASP in RA should be tried before methotrexate in relatively early forms of the disease.

This retrospective study involved 60 patients (7 men, 53 women) with rheumatoid arthritis (RA) and given methotrexate between 1985 and 1990. The mean time that RA had been present was 12 years and more than half of the patients had received more than 3 types of general treatment in the past. The mean total duration of MTX was 17.3 months, with a total dose of 790 mg. The efficacy of MTX was confirmed by a significant improvement in clinical and laboratory parameters. Treatment was withdrawn permanently in 21 cases (35% of patients). Adverse reactions, responsible for two thirds of treatment withdrawals (14/21) occurred in most instances during the first year of treatment. Hepatic toxicity was commonest. Two cases of aplasia were reported as well as 3 cases of pneumonitis, one fatal. These involved two cases of secondary infection and one of pneumonitis directly imputable to MTX. Withdrawals for inefficacy were rare, occurring in less than 10 p. cent of patients. Treatment continuation rates were 77 p. cent at 1 year, 66 p. cent at 18 months, 55 p. cent at 2 years, 42 p. cent at 3 years and 32 p. cent at 4 years. MTX is effective treatment for RA but is not free of adverse reactions, sometimes potentially fatal. Prolonged monitoring is necessary because of the sometimes delayed onset of adverse reactions.

Methotrexate (MTX) is used as sequential treatment of rheumatoid arthritis in doses ranging from 5 to 20 mg per week, but its effectiveness is impaired by undesirable and sometimes severe side-effects, notably on the lungs. We report three cases of lung disease in patients with rheumatoid arthritis under MTX therapy. Two patients had a lung infection caused by Escherichia coli and Pneumocystis carinii respectively and the third patient was a case of fatal pneumonia imputed to MTX. The signs and symptoms of these acute infectious or iatrogenic lung diseases are not specific. Bronchial endoscopy with bronchoalveolar lavage usually leads to a diagnostic of opportunistic infection, but it may also show an isolated excess, in both number and percentage, of alveolar leucocytes, pointing to a drug-induced pneumopathy. Acute respiratory failure due to MTX-induced pneumonia is not uncommon. It rapidly regresses either spontaneously or under corticosteroid therapy, but a number of deaths, as in our last patient, have been reported. The occurrence of these lung diseases is unrelated to the total dose of MTX. Reintroducing MTX does not mean that the condition will necessarily recur, but this can only be done in the absence of any other possible treatment.