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BACKGROUND: Psoriasis has been linked to metabolic syndrome and non-alcoholic fatty liver disease (NAFLD). Data suggest that the prevalence of NAFLD is increased in patients with psoriasis. The aim of this study was to determine the prevalence and severity of NAFLD in this patient population. AIM: To determine the prevalence of both NAFLD and non-alcoholic steatohepatitis (NASH) in patients with psoriasis. METHODS: Patients between the ages of 18 and 70 years with a diagnosis of psoriasis or psoriatic arthritis and followed by either the Dermatology or Rheumatology Division within the Department of Medicine at San Antonio Military Medical Center were considered for enrollment. Each patient completed a questionnaire, underwent a thorough skin evaluation, and had a right upper quadrant ultrasound and fasting blood work. If the liver enzymes were elevated or fatty liver detected on imaging, percutaneous liver biopsy was recommended. RESULTS: One hundred and twenty-nine patients were enrolled and 103 completed all necessary studies. The participants were predominantly middle aged (52.7 ± 12) and overweight or obese (average BMI 30.1 ± 5.9, range: 19.8-52.5 kg/m(2)). 53% (n = 54) were male while 15% (n = 15) of participants identified themselves as being a diabetic. The overall prevalence of NAFLD was 47%. The overall prevalence of NASH was 22% in those who underwent biopsy. CONCLUSIONS: Non-alcoholic fatty liver disease is very common among our cohort of patients with psoriasis, occurring in roughly 47% of patients. The more progressive form of the disease, NASH, is found in approximately one in five patients. Health care providers should be mindful of this association given the high prevalence of both NAFLD and NASH in this cohort of patients.

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OBJECTIVES: To report a series of five patients who developed systemic lupus erythematosus (SLE) after immunization and review the literature on vaccine-associated connective tissue diseases and the theoretical mechanisms that could explain such an association. METHODS: Uncontrolled retrospective analysis of cases identified sporadically over 7 years at three centers. RESULTS: In our series of 5 patients, symptoms of SLE developed within 2 to 3 weeks after secondary immunization. All patients met American College of Rheumatology (ACR) criteria for the diagnosis of SLE. In most patients, symptoms have been persistent. CONCLUSION: Although a coincidental association between vaccination and the onset of SLE cannot be excluded, the temporal relationship with the development of symptoms makes it immunologically plausible that vaccination triggered systemic autoimmunity in these rare cases. We propose that epidemiological studies be performed to examine this potential association in more detail to quantitate the risk and identify possible genetic risk factors.

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OBJECTIVE: To determine the safety and efficacy of 3 clinically relevant vaccines in patients with systemic lupus erythematosus (SLE). METHODS: We studied 73 consecutive SLE patients immunized with pneumococcal, tetanus toxoid (TT), and Haemophilus influenzae type B (HIB) vaccines. Patients were evaluated preimmunization and 12 weeks postimmunization for disease activity and immunization side effects. RESULTS: Eighty-four percent of the SLE patients developed a 4-fold titer increase in response to at least 1 vaccine, with 51% developing a 2-fold titer increase with all 3 vaccines. The majority of SLE patients developed protective levels of antibody to TT (90%) and HIB (88%). Although protective antibody levels could not be determined for pneumococcus, almost half of the patients (47%) developed a 4-fold antibody response. There was a trend toward a lower antibody response in patients with active disease treated with immunosuppressive therapy. Overall lupus disease activity was unaffected by immunization. CONCLUSION: Immunization is safe in SLE patients, with the overwhelming majority developing protective antibody levels. Therefore, SLE patients should receive immunizations according to the recommendations of the Centers for Disease Control and Prevention and the Immunization Practices Advisory Committee.

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OBJECTIVE: To assess the effects of delta wave sleep interruption (DWSI) on pain thresholds and fibromyalgia-like symptoms. To examine the potential correlations between DWSI and serum insulin-like growth factor 1 (IGF-1). METHODS: Thirteen healthy volunteers were subjected to 3 consecutive nights of DWSI (Group 1). Pain thresholds were measured by dolorimetry and symptoms by visual analog scale. Six subjects not undergoing DWSI served as dolorimetry and symptom controls (Group 2). Serum IGF-1 was measured by competitive binding radioimmunoassay before and after DWSI. RESULTS: No significant differences in pain thresholds as a function of condition (baseline, DWSI, recovery) or overnight change were detected between or within groups (p>0.05). Morning mean dolorimeter scores were lower than evening scores in both groups during all 3 conditions, and were lower in Group 1 than in Group 2 during DWSI. Group 1 subjects had higher composite symptom scores during DWSI (p< or =0.005), attributed largely to increases in fatigue. Serum levels of IGF-1 from Group 1 subjects showed no significant change after DWSI (p>0.05). CONCLUSION: In our study subjects, 3 nights of DWSI caused no significant lowering of pain thresholds compared with a control group. Subjects appeared to have lower pain thresholds in the mornings, and DWSI appeared to augment this effect. Symptoms were more apparent during DWSI, but were primarily related to fatigue. IGF-1 was not altered by 3 nights of DWSI. The low levels of IGF-1 seen in patients with fibromyalgia syndrome may result from chronic rather than acute DWSI, or may be dependent on factors other than disturbances of delta wave sleep.

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BACKGROUND: Rheumatic symptoms were commonly described among soldiers who served in previous wars. OBJECTIVE: To describe the frequency of rheumatology consultations, along with the diagnoses, and abnormal results on serologic testing in Gulf War veterans evaluated for Gulf War syndrome. METHODS: The medical records of the first 250 consecutive Gulf War veterans referred to the comprehensive clinical evaluation program at Wilford Hall Air Force Medical Center and Brooke Army Medical Center, San Antonio, Tex, were reviewed for demographic characteristics and frequency of subspecialty consultations. A retrospective review of rheumatic diagnoses and the frequency of abnormal serologic test results was recorded. RESULTS: Of the 250 Gulf War veterans evaluated in the comprehensive clinical evaluation program, 139 (56%) were referred for rheumatology consultation, which was the most common elective subspecialty referral. Of the patients evaluated, 82 (59%) had soft tissue syndromes, 19 (14%) had rheumatic disease, and 38 (27%) had no rheumatic disease. The most common soft tissue syndromes were patellofemoral syndrome (33 patients [25%]), mechanical low back pain (23 patients [18%]), and fibromyalgia (22 patients [17%]). Of the 19 patients with rheumatic disease, 10 had osteoarthritis, 2 had rheumatoid arthritis, 2 had gout, and 1 each had systemic lupus erythematosus, Behcet disease, parvovirus arthritis, psoriatic arthritis, and hypothyroid arthropathy. Abnormal serologic test results were common among the Gulf War patients regardless of the presence or absence of rheumatic disease. CONCLUSIONS: The rheumatic manifestations in Gulf War veterans are similar to symptoms and diagnoses described in previous wars and are not unique to active duty soldiers. Overall, the results of serologic screening were poor predictors of the presence of rheumatic disease.

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Musculoskeletal complaints are a common reason for outpatient visits to internists, and little training time is devoted to this in the majority of internal medicine residency programs. The objectives of this study were to determine whether rheumatology training improves accuracy in diagnosing common musculoskeletal syndromes and whether this results in decreased cost of diagnosis.Internal medicine residents (n = 43), staff internists (n = 27), and rheumatologists (n = 8) were given 15 written vignettes of common musculoskeletal syndromes. Participants' choices of laboratory tests, radiographs, and consultations were used to calculate cost of evaluation. Diagnostic accuracy for each physician group was compared with the physicians' rheumatology and orthopedic training and with their clinical experience. Cost for evaluation was also compared with diagnostic accuracy and physician experience.Rheumatologists accurately diagnosed 91% of the vignettes, staff internists 75%, and residents 68%. Rheumatologists tended to spend less for evaluation. Those who made correct diagnoses incurred significantly less cost for several vignettes. Rheumatology training for greater than 14 days correlated with improved diagnostic accuracy (p = 0.0001), whereas orthopedic training did not. Staff internists with greater than 6 years of experience had at least 80% diagnostic accuracy (p = 0.02). Internists trained in rheumatology had improved accuracy in diagnosing common musculoskeletal syndromes and tended to incur fewer costs.

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BACKGROUND: Docetaxel (Taxotere) is a microtubule-stabilizing agent that is potentially important in chemotherapy for a variety of malignancies. METHODS: A clinical study of the cutaneous reactions experienced by a group of patients receiving docetaxel chemotherapy was undertaken. Patients were examined before initiation of therapy, before and after each cycle of therapy, and were followed subsequent to the completion of docetaxel chemotherapy. RESULTS: Three patients developed diffuse lower extremity edema (3-18 kg) and subsequent scleroderma-like changes after receiving multiple cycles of docetaxel therapy. These patients had different underlying malignancies and dissimilar prior therapy. Rheumatoid factor, antinuclear antibodies, anticentromere, and topoisomerase antibodies were not present in any patient. The diffuse lower extremity edema did not resolve with diuretic therapy. Cutaneous biopsies in two patients revealed diffuse sclerosis. One patient had a normal lymphangiogram during the edematous phase. Discontinuation of docetaxel correlated with resolution of edema and softening of the skin. CONCLUSION: The etiology of the scleroderma-like skin changes is unclear but appears to be either a toxic effect of docetaxel or an effect of polysorbate 80 (Tween 80), the vehicle for docetaxel.

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Chronic arthritis occurs in 10% of Lyme disease patients. A patient had chronic septic Lyme arthritis of the knee for seven years despite multiple antibiotic trials and multiple arthroscopic and open synovectomies. Spirochetes were documented in synovium and synovial fluid (SF). Polymerase chain reaction (PCR) analysis of the SF was consistent with Borrelia infection. Persistent infection should be excluded with silver stains and cultures in any patient with chronic monoarticular arthritis and a history of Lyme disease.

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Quantitative bone scan (QBS), computed tomography (CT), and magnetic resonance imaging (MRI) have each been used to confirm the diagnosis of active sacroiliitis (SI) in patients with low back pain (LBP). The authors prospectively evaluated 19 patients referred for symptoms of possible inflammatory LBP (group I), 26 seronegative spondyloarthropathy (SNSP) patients with LBP (group II, inflammatory or mechanical), and 5 SNSP patients without LBP (group III) to determine which radiological scan alone or in combination with other serological tests (Westergren erythrocyte sedimentation rate, C-reactive protein, HLA-B27, immunoglobulin A) was most useful in confirming a clinical diagnosis of active inflammatory SI. All patients were followed up for a minimum of 1 year to confirm the clinical diagnosis and evaluate response to therapy. Eight of 19 group I patients had active SI clinically or on plain radiographs on follow-up evaluation. Of these patients, 5 had abnormal QBS (71%), 3 had abnormal CT scans (38%), and 8 had abnormal MRI scans (100%, type I lesions). These type I MRI lesions were indicative of active inflammation manifested as subcortical bone marrow edema. The remaining 11 group I patients had negative scans for SI. Ten of 26 group II patients with LBP had SI diagnosed clinically and confirmed with positive QBS (60%), CT (100%), and MRI (100%, type I lesions). The remaining 16 group II patients had mechanical LBP without active SI clinically and had negative QBS (88%), CT (19%), and MRI (100%, normal or type II lesions). These type II MRI lesions represented old postinflammatory lesions with either fibrosis or fat replacement. All 5 group III patients had negative scans for active SI. Three patients (2 group I and group II) with inflammatory SI treated with sulfasalazine showed marked improvement on serial MRI scans. Westergren erythrocyte sedimentation rate, C-reactive protein, immunoglobulin A, and CT scan alone or in combination with other tests were not reliable predictors of active SI. Positive QBS and HLA-B27 tests were the best combination of screening tests with 82% predictability of inflammatory SI in whites, and QBS alone had an 80% predictability in black patients. However, MRI, which had 100% predictability, was the best single test for confirming active inflammatory SI.

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The Ramco latex agglutination test in the diagnosis of systemic candidiasis was utilized for 11 serum samples from 10 patients with systemic candidiasis, 21 serum samples from patients colonized with Candida species, and 20 control serum samples from patients with stable medical problems and no evidence of Candida albicans infection. This study was double-blind and the results of the latex agglutination test did not influence the decision for antifungal therapy. Nine of 10 patients with systemic candidiasis had positive titers (greater than or equal to 1:4); however, these were determined only 1 to 5 days before culture positivity. Nine of 21 (43%) of colonized patients were falsely positive (greater than or equal to 1:4) and all of the control samples were negative. The Ramco latex agglutination test was unreliable and inconsistent in this small sample group to establish an early diagnosis of systemic candidiasis.

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