DOCSLIB.ORG

Subcutaneous Nodules of Still's Disease*

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Subcutaneous Nodules of Still's Disease* Ann Rheum Dis: first published as 10.1136/ard.17.3.278 on 1 September 1958. Downloaded from Ann. rheum. Dis. (1958), 17, 278. SUBCUTANEOUS NODULES OF STILL'S DISEASE* BY E. G. L. BYWATERS, L. E. GLYNN, AND A. ZELDISt From the Rheumatism Research Unit, Medical Research Council, Canadian Red Cross Memorial Hospital, Taplow, and the Postgraduate Medical School, London The observations of Collins (1937) and of Bennett, rather atypical features in the clinical presentation. Zeller, and Bauer (1940) established clearly the It is uncommon for the pathologist who is familiar pathological differentiation of the ordinary sub- with this field to make a wrong diagnosis. cutaneous nodules in rheumatic fever and in rheu- In juvenile rheumatoid arthritis, however, we have matoid arthritis. been surprised to find over the last 10 years that the In brief, the rheumatic fever nodule is charac- nodule resembles closely that of rheumatic fever, terized by much fibrinoid material arranged in a and we have therefore surveyed all our nodule lattice with apparently clear spaces between the material and correlated the findings with clinical strands, considerable oedema, but relatively little data. Apart from Findlay (1931), who illustrates a cellularity. What cells are present are usually nodule from a probable case of Still's disease fibroblasts or histiocytes; they are sparsely dis- resembling those of rheumatoid arthritis, we have tributed in the meshes of oedematous connective found no reference to such a surprising finding in the tissue and accompanied occasionally by lympho- extensive literature on rheumatic and rheumatoid cytes or rarely by polymorphs near the vascular nodules (reviewed up to 1938 by Keil (1938); and "islands" (Fig. 1, opposite). There is little attempt more recently by Horwitz (1949)). by copyright. at zoning, although vascular "islands" are a promi- nent feature. Finally, fibrosis is not often a Material and Methods conspicuous feature, and may be entirely absent. Material was available from the following sources: In contrast, the rheumatoid nodule, as seen in (1) Twelve cases of Still's disease or juvenile rheu- adults, is clearly arranged in three zones. There is matoid arthritis with onset at or before the age of 16 years. an outer zone of fibrosis with considerable infiltra- (2) 57 cases of rheumatic fever (age range 3 to tion by lymphocytes, plasma cells, sometimes poly- 49 years, including ten cases up to 10 years and morphonuclears, and rarely eosinophils. The inner- ten cases aged 21 and over, all except twelve most zone comprises necrotic debris, sometimes being below the age of 16). http://ard.bmj.com/ containing fibrinoid material but more usually (3) 22 cases of adult rheumatoid arthritis (age a grumous granular mass with fibrin, fibrinoid, and range 20 to 73 years, all except one being aged swollen collagen fibres mixed in it, sometimes con- 37 or over). taining nuclear debris, fat globules, and cholesterol This material was reviewed against a general clefts. Between the inner and outer zones lies a background of over seventy nodule examinations well-orientated layer of palisade cells, fibroblasts at the Postgraduate Medical School (unlisted and with large nuclei forming a compact border to the mostly from adult patients with rheumatoid arthritis on September 24, 2021 by guest. Protected necrotic centre zone (Fig. 2, opposite). While there is or rheumatic fever). some overlap in their individual features, a correct After formol-saline fixation, routine paraffin histological diagnosis can be made in nearly every sections (stained with haematoxylin and eosin, case (Bennett and others, 1940, give a figure of 68 thionine, periodic acid Schiff, Gomori's silver correct diagnoses in 69 patients with a firm diagnosis impregnation, Mallory's phosphotungstic acid and one wrong diagnosis in a patient in whom the haematoxylin, and occasionally by Weigert's elastin clinical diagnosis was somewhat doubtful). The stain and Masson's trichrome method) were sur- exceptions show a mixed picture which gives the veyed, and the findings were tabulated in four pathologist difficulty and leads him to issue an grades (0-3), the patient's name and clinical data uncertain report. This usually corresponds to being unknown. This grading was then correlated * Paper read at the IX International Congress of Rheumatic with the clinical diagnosis (based on detailed in- Diseases, Toronto, in June, 1957. patient observation, serological studies, joint biopsies t British Council Fellow: present address-Condell 1176, Depto. 60, Valparaiso, Chile. occasionally, and long-term follow-up), and with 278 Ann Rheum Dis: first published as 10.1136/ard.17.3.278 on 1 September 1958. Downloaded from SUBCUTANEOUS NODULES OF STILL'S DISEASE 279 ~~~~4 rc S FJ*s 4v*,4*w8g;- .,.S....... '* . * AhL ''*;^ *^ -r *e ,b abs *4a. : ; " *.~. *~r~~%t'4*04jb`~~~~~~~~5~4,4%~ -S Haematoxylin ig1.ersttvaed* efmaty 'u'. :,rheumaticfeerinafealae~~~~~~~~~~~~~~~~Y4 ~ ~ ~ ~ W 19. 1P a x 16* V ~~~~~~~~~~~~~<~~~~~~~~~~~W.75a..a a a g ~~ ~ ~ ~ % ^_w*trre., W ,~~~~~~, zXV-# ' *' v Sj~~~~~~~~~~~~~~~~''#t *:it,;#', 4 S ~~.; * * -. w , * 'A *; . * a o *a1AA' ~w ~ 4r'tN a V.L "ror ~ 9 ~ Fi.1-ersnaieaeAftpclndl rmatpcl aeo huai ee nafml gd1.Heaoyi andeosinx163. ~ ~ ~ ~ ~ ~ 4 4AP /~~~~~~~~~~~~~~~~~~~~~wN by copyright. http://ard.bmj.com/ on September 24, 2021 by guest. Protected Fig. 2.-Representative area of typical nodule from a typical case of adult rheumatoid arthritis in a man aged 40. Haematoxylin and eosin x 160. 3 Ann Rheum Dis: first published as 10.1136/ard.17.3.278 on 1 September 1958. Downloaded from 280 ANNALS OF THE RHEUMATIC DISEASES the age, sex, duration of disease, erythrocyte sedi- some necrosis (Grade 1), and a Grade 2 palisade mentation rate, and Rose-Waaler differential titre (Fig. 7, overleaf). (performed by Dr. Francis Scott using a slight Only one other boy (aged 14, onset of arthritis modification of the original method: Scott, 1952). at age 7 years) showed palisading, but in this case Nine of the twelve cases of Still's disease showed the other features (Grade 3 fibrinoid lattice, etc.) gross multiple erosions at follow-up, and one of the were such as to suggest a diagnosis of rheumatic remaining three showed a positive joint biopsy. fever. All the last three showed repeatedly negative Rose By contrast, in the adult rheumatoid arthritis tests and permanent residual deformities. group, twenty out of 22 were correctly diagnosed: the two exceptions being diagnosed as "rheumatic Results fever" and "query rheumatic fever" respectively. are tabulated in two ways (Table 1): The results The first was a girl aged 20 (onset at age 19 years, (1) The percentage of patients showing each erythrocyte sedimentation rate 34 mm./hr, Rose- feature in each group. Waaler titre 1 : 64), who 4 years later showed (2) The mean grade for each feature in each typical erosions and deformities, and the second group. was a man aged 53 with bronchiectasis and rheuma- The only feature in the Still's disease group in toid arthritis of 8 months' duration (erythrocyte which the findings resembled those in the adult sedimentation rate 90 mm./hr, differential agglutina- rheumatoid arthritis group was fibrosis. Here, both tion titre 1: 64), who later showed typical bony the incidence and the mean amount of fibrosis was erosions and deformities. The nodules appeared greater than in rheumatic fever, although not so between 2 and 12 weeks before biopsy (Fig. 8, over- great as in adult rheumatoid arthritis. Otherwise, leaf). In neither of these cases was there necrosis, the nodules of Still's disease resembled and in most fibrosis, or palisading, although fibrinoid lattice instances were indistinguishable from those of was present. rheumatic fever, showing absence of necrosis and In the larger group of rheumatic fever nodules, the by copyright. palisading and the presence of oedema, well-marked only case incorrectly diagnosed as rheumatoid vascular islands, and a fibrinoid lattice (Figs 3-6). arthritis was a boy aged 8 with typical rheumatic In only one instance was a diagnosis of rheumatoid fever and chorea for 21 months (raised antistrepto- arthritis made. This nodule came from the elbow lysin-O titre, and an erythrocyte sedimentation rate of a boy aged 13 years whose rheumatoid arthritis which had fallen from 33 to 15 mm./hr), who was had started at the age of 5 years. The disease was left at the time of biopsy with residual apical systolic still active with an erythrocyte sedimentation rate and diastolic murmurs. This nodule showed some of 71 mm./hr and a Rose-Waaler differential titre fibrosis, Grade 2 necrosis, and Grade 1 palisading, of 1: 32. The nodule showed fibrosis (Grade 3), with no fibrinoid lattice (Fig. 9, overleaf). http://ard.bmj.com/ kBLE I HISTOLOGICAL FEATURES OF RHEUMATIC AND RHEUMATOID NODULES No. Fibrosis Palisade Necrosis Oedema Vascular Fibrinoid Diagnosis of Features Islands Lattice Histological CasesExamined (Grades (Grades (Grades (Grades (Grades (Grades Diagnosis Cases ~~~~0-3) 0-3) 0-3) 0-3) 0-1) 0-3) Percentage Rheumatic on September 24, 2021 by guest. Protected Present 33 19 10 74 89 91 Fever 56 Rheumatic Fever .. 57 Mean Rheumatoid Grade 0*4 0*3 0*1 1*2 - 2*3 Arthritis 1 Percentage Rheumatic Age 16 Present 83 17 8 75 91 100 Fever 11 or Under at Rheumatoid Onset 12 Arthritis 1 Mean (DAT ± Rheumatoid Grade 1*3 0*4 0*1 1*0 - 2*2 6/12) Arthritis . Percentage Rheumatic Present 91 87 91 14 27 59 Fever 2 Rheumatoid Age 17 Arthritis 20 or Over at 22 Onset Mean (DAT+ Grade 2-2 2-0 2-5 0-2 1*0 20/21) Ann Rheum Dis: first published as 10.1136/ard.17.3.278 on 1 September 1958. Downloaded from SUBCUTANEOUS NODULES OF STILL'S DISEASE 281 Figs 3-6.-Representative areas of typical nodules from four typical cases of Still's disease, aged 8, 10, 15, and 16 years.
Load more

Recommended publications
  • Accuracy of Ontario Health Administrative Databases in Identifying Patients with Rheumatoid Arthritis
    ACCURACY OF ONTARIO HEALTH ADMINISTRATIVE DATABASES IN IDENTIFYING PATIENTS WITH RHEUMATOID ARTHRITIS by Jessica Widdifield A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy in Health Services Research Institute of Health Policy, Management & Evaluation University of Toronto © Copyright by Jessica Widdifield 2013 Accuracy of Ontario Health Administrative Databases in Identifying Patients with Rheumatoid Arthritis (RA): Creation of the Ontario RA administrative Database (ORAD) Jessica Widdifield Doctor of Philosophy Institute of Health Policy Management and Evaluation University of Toronto 2013 Abstract Rheumatoid arthritis (RA) is a chronic, destructive, inflammatory arthritis that places significant burden on the individual and society. This thesis represents the most comprehensive effort to date to determine the accuracy of administrative data for detecting RA patients; and describes the development and validation of an administrative data algorithm to establish a province-wide RA database. Beginning with a systematic review to guide the conduct of this research, two independent, multicentre, retrospective chart abstraction studies were performed amongst two random samples of patients from rheumatology and primary care family physician practices, respectively. While a diagnosis by a rheumatologist remains the gold standard for establishing a RA diagnosis, the high prevalence of RA in rheumatology clinics can falsely elevate positive predictive values. It was therefore important we also perform a validation study in a primary care setting where prevalence of RA would more closely approximate that observed in the general population. The algorithm of [1 hospitalization RA code] OR [3 physician RA diagnosis codes (claims) with !1 by a specialist in a 2 year period)] demonstrated a ii high degree of accuracy in terms of minimizing both the number of false positives (moderately good PPV; 78%) and true negatives (high specificity: 100%).
    [Show full text]
  • Rheumatoid Nodules Injected Area Six Times Daily; Nodules Differential Diagnosis and Immunological Appeared in 37 of 82 of Their Patients (450/O)
    Matters arising 83 3 Paolaggi J B, Chaouat D, Auquier L. An rheumatic fever, though arthritis or arthralgia but my efforts to reproduce them additional test for the diagnosis and is of a more prolonged nature appearing early experimentally failed miserably! monitoring of giant cell arteritis and after infection. polymyalgia rheumatica. Arth Rheum 1985; F DUDLEY HART Ann Rheum Dis: first published as 10.1136/ard.53.1.83 on 1 January 1994. Downloaded from 28: 837-8. Massell et al' reported in 1937 that nodules 24 Harnnont House, closely resembling those of rheumatic fever 20 Harley Street, could be produced by injecting 3 cc of a London WIN IAN, patient's blood subcutaneously into the soft United Kingdom tissue of an elbow followed by rubbing the 1 Veys E M, De Keyser F. Rheuamtoid nodules: Rheumatoid nodules injected area six times daily; nodules differential diagnosis and immunological appeared in 37 of 82 of their patients (450/o). findings. Ann Rheum Dis 1993; 52: 625-6. 2 Schlesinger B E. The public health aspects of The recent Leader on rheumatoid nodules by I was unable to confirm these findings5 in 40 heart disease in children. Lancet 1938; 1: Veys and De Keyser' gave a very interesting children with rheumatic fever in acute or 593-9, 649-54. and useful review of the subject. When I was convalescent stages, five children with 3 Fink C W. The role of the streptococcus in post- registrar with Dr chronic juvenile arthritis (Still's disease), and streptococcal reactive arthritis in childhood working as a medical polyarteritis nodosa.
    [Show full text]
  • Rheumatoid Nodules Developing Under Methotrexate Treatment for Rheumatoid Arthritis
    Letters to the Editor 397 Rheumatoid Nodules Developing under Methotrexate Treatment for Rheumatoid Arthritis Sir, several punched-out radiolucencies and non-calcifying nodules Rheumatoid nodules have been reported to occur in about projecting in the soft parts surrounding the joints. 20% of patients with chronic rheumatoid polyarthritis (1, 2). In the recent literature, a correlation between treatment of rheumatoid arthritis with methotrexate and the development DISCUSSION or worsening of rheumatoid nodules has been suggested (2 ± 4). Methotrexate, a common drug for the treatment of rheuma- We describe here the explosive deterioration of rheumatoid toid arthritis, has been used successfully, but various side- nodules during the course of methotrexate treatment for effects have been reported. Among patients with rheumatoid rheumatoid polyarthritis in a 63-year-old woman and discuss arthritis under methotrexate therapy, the ones whose joint current aspects of possible pathogenetic mechanisms as well symptoms are improving due to administration of metho- as therapeutic options for methotrexate-induced rheumatoid trexate frequently develop subcutaneous nodules increasing in nodules. size and number (1 ± 3, 5). Nevertheless, only in rare cases the severity or the localization of the nodules, e.g. vascular, pulmonary or cardiac manifestation, necessitated discontinua- CASE REPORT tion of the drug (3). Cause and effect relationship between methotrexate treatment and the accelerated development of A 63-year-old woman presented to our department with a 15-year nodules is supported by the regression of the nodules after history of chronic rheumatoid polyarthritis affecting her ®ngers, discontinuation of the drug (2, 6). Although the predominant hand, elbow and knee joints. Ten years previously, she ®rst developed a few ®rm nodules on her ®ngers and feet.
    [Show full text]
  • Complicated Rheumatoid Nodules in Lung
    Hindawi Case Reports in Rheumatology Volume 2020, Article ID 6627244, 3 pages https://doi.org/10.1155/2020/6627244 Case Report Complicated Rheumatoid Nodules in Lung Geetha Wickrematilake Sirimavo Bandaranayake Specialized Childrens Hospital, Kandy, Sri Lanka Correspondence should be addressed to Geetha Wickrematilake; [email protected] Received 18 October 2020; Revised 20 November 2020; Accepted 24 November 2020; Published 3 December 2020 Academic Editor: Gregory J. Tsay Copyright © 2020 Geetha Wickrematilake. ,is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A 65-year-old nonsmoker lady carrying a diagnosis of seropositive erosive rheumatoid arthritis for nine years presented with acute shortness of breath, following a spontaneous pneumothorax while on combination therapy with methotrexate, leflunomide, and tocilizumab. Imaging studies revealed multiple cavitory lung nodules, and a transbronchial lung biopsy favoured a diagnosis of rheumatoid lung nodules. Her initial pathological samples were negative for any infectious cause. A follow-up computerized tomography scan (CT scan) confirmed enlargement of lung nodules with a positive antibody test for aspergillosis which needed antifungal therapy, and currently, her arthritis is managed well with rituximab therapy, sulfasalazine, and hydroxychloroquine. 1. Introduction ,e oxygen saturation was 98% while breathing room air, but
    [Show full text]
  • Actemra® (Tocilizumab) Injection for Intravenous Infusion
    UnitedHealthcare® Community Plan Medical Benefit Drug Policy Actemra® (Tocilizumab) Injection for Intravenous Infusion Policy Number: CS2021D0043T Effective Date: September 1, 2021 Instructions for Use Table of Contents Page Commercial Policy Application ..................................................................................... 1 • Actemra® (Tocilizumab) Injection for Intravenous Coverage Rationale ....................................................................... 1 Infusion Applicable Codes .......................................................................... 4 Background.................................................................................. 14 Clinical Evidence ......................................................................... 14 U.S. Food and Drug Administration ........................................... 18 References ................................................................................... 18 Policy History/Revision Information ........................................... 19 Instructions for Use ..................................................................... 19 Application This Medical Benefit Drug Policy does not apply to the states listed below; refer to the state-specific policy/guideline, if noted: State Policy/Guideline Indiana Immunomodulators for Inflammatory Conditions (for Indiana Only) Kansas Refer to the state’s Medicaid clinical policy ® Kentucky Actemra (Tocilizumab) Injection for Intravenous Infusion (for Kentucky Only) Louisiana Refer to the state’s Medicaid clinical
    [Show full text]
  • Non-Bacterial Thrombotic Endocarditis in a Patient With
    Case Report http://dx.doi.org/10.4070/kcj.2016.46.3.425 Print ISSN 1738-5520 • On-line ISSN 1738-5555 Korean Circulation Journal Non-Bacterial Thrombotic Endocarditis in a Patient with Rheumatoid Arthritis Jung-Hye Choi, MD1, Jeong-Eun Park, MD1, Jang-Young Kim, MD2, and Taeyoung Kang, MD1 1Department of Rheumatology, 2Department of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea Rheumatoid arthritis (RA) is frequently associated with various extra-joint complications. Although rare, thromboembolic complications are associated with high morbidity and mortality. We experienced a very rare case of nonbacterial thrombotic endocarditis (NBTE) and subsequent embolic stroke in a patient with RA. A 72-year-old male with a 15-year history of RA suddenly developed neurologic symptoms of vomiting and dizziness. Brain magnetic resonance imaging revealed recently developed multiple cerebellar and cerebral lacunar infarctions. Echocardiography showed a pulsating mitral valve vegetation involving the posterior cusp of the mitral valve leaflet, which was confirmed as NBTE. Immediate anti-coagulation therapy was started. The NBTE lesion disappeared in follow-up echocardiography after 4 weeks of anti-coagulation treatment. (Korean Circ J 2016;46(3):425-428) KEY WORDS: Endocarditis, non-infective; Arthritis, rheumatoid; Mitral valve. Introduction of life. Although RA patients have an increased risk of cardiovascular events such as myocardial infarction, stroke, cardiac death and Nonbacterial thrombotic endocarditis (NBTE), a very rare condition thromboembolism compared with the general population,2)3) there that refers to a spectrum of noninfectious endocarditis of the has been no report of mitral valvular NBTE in a patient with RA.
    [Show full text]
  • SUPPLEMENTARY APPENDIX 4: Search Strategies Syntax Guide For
    SUPPLEMENTARY APPENDIX 4: Search Strategies Pubmed, Embase Perioperative Management - PubMed Search Strategy – March 6, 2016 Syntax Guide for PubMed [MH] = Medical Subject Heading, also [TW] = Includes all words and numbers in known as MeSH the title, abstract, other abstract, MeSH terms, MeSH Subheadings, Publication Types, Substance Names, Personal Name as Subject, Corporate Author, Secondary Source, Comment/Correction Notes, and Other Terms - typically non-MeSH subject terms (keywords)…assigned by an organization other than NLM [SH] = a Medical Subject Heading [TIAB] = Includes words in the title and subheading, e.g. drug therapy abstracts [MH:NOEXP] = a command to retrieve the results of the Medical Subject Heading specified, but not narrower Medical Subject Heading terms Boolean Operators OR = retrieves results that include at least AND = retrieves results that include all the one of the search terms search terms NOT = excludes the retrieval of terms from the search Perioperative Management PubMed Search Strategy – March 6, 2016 Search Query #1 ((((ARTHROPLASTY, REPLACEMENT, HIP[MH] OR HIP PROSTHES*[TW] OR HIP REPLACEMENT*[TIAB] OR HIP ARTHROPLAST*[TIAB] OR HIP TOTAL REPLACEMENT*[TIAB] OR FEMORAL HEAD PROSTHES*[TIAB]) OR (ARTHROPLASTY, REPLACEMENT, KNEE[MH] OR KNEE PROSTHES*[TW] OR KNEE REPLACEMENT*[TW] OR KNEE ARTHROPLAST*[TW] OR KNEE TOTAL REPLACEMENT*[TIAB]) OR (ARTHROPLAST*[TW] AND (HIP[TIAB] OR HIPS[TIAB] OR KNEE*[TIAB])) AND (("1980/01/01"[PDAT] : "2016/03/06"[PDAT]) AND ENGLISH[LANG])) NOT (((("ADOLESCENT"[MESH]) OR "CHILD"[MESH])
    [Show full text]
  • CONCOMITANT GOUT and RHEUMATOID ARTHRITIS - a CASE Presented with Multiple Nodular Swellings on REPORT Feet, Hands, Wrists and Elbows
    349 350 INDIAN JOURNAL OF MEDICAL SCIENCES CASE REPORT consulted various practitioners and took allopathic and indigenous medications but to no relief. Two months prior to admission he CONCOMITANT GOUT AND RHEUMATOID ARTHRITIS - A CASE presented with multiple nodular swellings on REPORT feet, hands, wrists and elbows. Patient’s past medical history is significant for hypertension, POOJA KHOSLA*, ATUL GOGIA**, P. K. AGARWAL***, AMIT PAHUJA**, SUNIL JAIN***, K. K. SAXENA# diabetes mellitus, chronic ethanolism and renal stones for which he underwent left nephrectomy about 25 years ago. Family Abstract history is non-contributory. Figure 1: Multiple nodules present on metatarsal joints of both feet (Gouty Tophi) We report a case of definite rheumatoid arthritis and co-existing gout. Although gout On examination multiple nodules were present and rheumatoid arthritis are relatively common entities individually, the co-existence on metatarsal joints of both feet, Achilles of these two conditions is rare. tendon bilaterally, left prepatellar bursa, bilateral metacarpophalangeal joint, right KEY WORDS: Gout, Rheumatoid Arthritis olecranon process. There was swelling and tenderness of PIP and MCP joints of both feet. (Figure 1) Laboratory data revealed INTRODUCTION metatarsophalangeal joint. He had hemoglobin - 8.9gm/dl, ESR 124 mm at the asymmetrical joint pains and swelling at end of first hour, leucocyte count 7400/cmm Gout and rheumatoid arthritis rarely co-exist in irregular intervals with exacerbations and with normal differential count. Random blood the same patient. As separate disease entities remissions. The symptoms subsided in sugar was 139 mg/dl, Creatinine- 1.6 mg/dl; they are relatively common. Rheumatoid between but there was no period when patient serum uric acid level was 10.9 mg/dl.
    [Show full text]
  • Acr23274 Am.Pdf
    Page 1 of 63 Arthritis Care & Research Key Words: Please choose key words for your manuscript. Choosing the best match of the journal’s keywords to your Arthroplasty, Rheumatoid Arthritis, Disease-Modifying Antirheumatic Drugs work will likely result in better (Dmards), Spondyloarthritis, Systemic lupus erythematosus (SLE) match to reviewers with expertise in your interest area. It may also help to speed the review process.: Optional Terms: You have the option to add additional key words that are not on the Perioperative Management, Complications, Prosthetic Infection, Biologic journal's list to more Response Modifiers specifically categorize your submission.: Accepted Article This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version record. Please cite this article as doi:10.1002/acr.23274. This article is protected by copyright. All rights reserved. Arthritis Care & Research Page 2 of 63 1 Words- 5517 Required 3880 2016 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Anti-rheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty 1* 2* 3 4 Susan M. Goodman, MD , Bryan Springer, MD , Gordon Guyatt, MD , Matthew P. Abdel, MD , Vinod Dasa, MD 5, Michael George, MD 6, Ora Gewurz-Singer, MD 7, Jon T. Giles, MD, MPH 8, Beverly Johnson, MD 9, Steve Lee, DO 10 , Lisa A. Mandl, MD, MPH 1, Michael A. Mont, MD 11 , Peter Sculco, MD 1, Scott Sporer, MD 12 , Louis Stryker, MD 13 , Marat Turgunbaev, MD, MPH 14 , Barry Brause, MD 1, Antonia F.
    [Show full text]
  • The Giant Rheumatoid Nodule: a Case Report
    icine: O ed pe M n l A a r c e c e n s e s G Gupta et al., Gen Med (Los Angeles) 2017, 5:3 General Medicine: Open Access DOI: 10.4172/2327-5146.1000291 ISSN: 2327-5146 Case Report Open Access The Giant Rheumatoid Nodule: A Case Report Sushilkumar Satish Gupta, Ankur Sinha and Vinod Namana* Maimonides Medical Center, Ny, United States Corresponding author: Vinod Namana, Cardiovascular Disease Fellow, Maimonides Medical Center, Brooklyn, NY 11219, Tel: 917-445-7267; E-mail: [email protected] Rec date: May 04, 2017; Acc date: June 5, 2017; Pub date: June 9, 2017 Copyright: © 2017 Namana V. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Rheumatoid arthritis is one of the most common debilitating rheumatological disorders. A subcutaneous rheumatoid nodule usually occurs in advanced cases of rheumatoid arthritis and is also a hallmark of the chronicity of the disease. They are also the most common extra-articular manifestation of rheumatoid arthritis. We present a case of a giant rheumatoid nodule, developed on the left elbow. Keywords: Rheumatoid nodule; Pain; Arthritis The nodule was pale in color, had doughy consistency, approximately 8 cm in diameter, and there was no signs of infections Case Report or ulcerations. She denied pain at the site of the nodule, but did complain of decreased range of motion. She had tried intra nodular An 87-year-old female presented to our hospital for pain and corticosteroid injections in the past without significant relief.
    [Show full text]
  • August-Infammatory-Arthritis.Pdf
    Disclaimer The information provided is intended to assist with support for the documentation accuracy of the diagnoses codes reported to Highmark and not intended to influence clinical or coding judgement. Information regarding any law or regulation does not constitute legal or tax advice and is subject to change based upon the issuance of new guidance and/or change in laws or regulations. Providers should still reference official ICD-10-CM coding guidelines and coding manuals or electronic coding software for accurate reporting of compliant diagnosis codes. Highmark Inc. CONFIDENTIAL AND PROPRIETARY Agenda 1. Identify types of arthritis 2. Discuss documentation requirements 3. Review related treatments Highmark Inc. CONFIDENTIAL AND PROPRIETARY Types of Arthritis Types of Arthritis • Non-Inflammatory • Osteoarthritis • Inflammatory • Ankylosing Spondylitis • Gout • Juvenile Idiopathic Arthritis • Psoriatic Arthritis • Rheumatoid arthritis Highmark Inc. CONFIDENTIAL AND PROPRIETARY Differences Rheumatoid arthritis Osteoarthritis Age of onset May begin at any time in life Usually begins later in life Relatively rapid, over weeks to Speed of onset months Slow, over years Joint symptoms Pain, swelling, stiffness Achiness and tenderness, but little or no swelling Often affects small and large joints Often begins on one side of the body and may spread on both sides of the body to the other side. Symptoms begin gradually and are Pattern of joints (symmetrical), such as both hands, often limited to one set of joints, usually the finger affected both wrists or elbows, or balls of joints closest to the fingernails or thumbs, large both feet weight-bearing joints (hips, knees) or the spine. Duration of morning Less than one hour – returns at the end of the day stiffness Longer than one hour or after periods of activity Presence of symptoms affecting Frequent fatigue and a general feeling the whole body of being ill Whole body symptoms are not present (systemic) Highmark Inc.
    [Show full text]
  • STILL's DISEASE and RHEUMATOID NODULE of the SCLERA*T by A
    Br J Ophthalmol: first published as 10.1136/bjo.52.11.853 on 1 November 1968. Downloaded from Brit. J. Ophthal. (1968) 52, 853 STILL'S DISEASE AND RHEUMATOID NODULE OF THE SCLERA*t BY A. J. LYNE and E. S. ROSEN From the Manchester Royal Eye Hospital THE following report concerns a patient suffering from Still's disease who developed a rheumatoid nodule of the sclera and subsequent scleral thinning of the right eye, a finding not previously recorded in the literature. Case Report A woman aged 31 years first developed joint symptoms at the age of 11 years. Stiffness and pain in the joints increased, until within 9 months all her joints were affected. She has undergone numerous orthopaedic operations, including arthroplasty of both elbow joints at the age of 13 years, a right transtrochanteric osteotomy at the age of 15 years, bilateral mandibular condylec- tomies at the age of 16 years, and further arthroplasties of the elbows at the age of 18 years. At present there is gross deformity with limitation of movement in the hands, elbows, shoulders, hips, knees, and ankles. She is undersized and underweight. Nodules are present on the fingers, copyright. elbows, and knees. A nodule removed from the scalp proved histologically to be a rheumatoid nodule. There is no lymphadenopathy and no skin rash and the liver and spleen are not palpable. She has been treated with prednisolone for the past 12 years in doses varying from 5 to 12-5 mg. daily. Investigations.-Hb varies between 9-6 and 12-8 g.
    [Show full text]