SAMT VOL. 74 17 SE PT 1988 295
South African Rheumatism and
XIth Biennial Congress, Durban, 14 - 16 March 1988
Relationship of anticardiolipin antibodies Anticardiolipin antibodies in ischaemic
to disease activity in systemic lupus heart disease
P. KLEMP, R. c. COOPER, F. J. STRAUSS, E R. JORDAAN,
R. c. COOPER, P. KLEMP, C. J. STIPP, S. BRINK J. Z. PRZYBOJEWSKI, N. NEL
Departments of Microbiology and Rheumatology/Internal Departments of Rheu matology, Card iology / Internal
Medicine, University of Stellenbosch and Tygerberg Medicine and Microbiology, University of Stellenbosch
Hospital, Parowvallei, CP and Tygerberg Hospital and Institute of Biostatistics of the
South African Medical Research Council, Parowvallei, CP
Several studies have reponed an association between anticardiolipin
antibodies (ACAs).and thrombosis, thrombocytopenia, fetal wastage IgG and IgM anticardiolipin antibodies (ACA) were assayed by
and CNS involvement in systemic lupus erythematosus (SLE), an ELISA technique in 86 patients with ischaemic hean disease
other auto-immune diseases, e.g. rheumatoid arthritis (RA) and (IHD) and compared with 124 healthy controls, and also to 61
infectious diseases, e.g. tuberculosis. In this study, sera from 124 patients with rheumatoid arthritis (RA) and to 20 with tuberculosis.
blood donors, 60 with RA, 20 with proven tuberculosis and 57 IgG ACA levels in IHD, RA and tuberculosis were comparable
SLE patients were measured for ACA IgG and IgM antibodies by and significantly higher than in controls (P < 0,0001). IgM ACA
ELISA. Significantly raised ACA IgG and IgM levels were found was significantly higher in IHD and RA patients than controls (P
in RA, tuberculosis and SLE sera (P < 0,0001). However, in SLE, < 0,0001) but not tuberculosis (P = 0,045). The number of IHD
both the ACAG and ACAM levels were significantly higher than patients with raised ACA (IgG and/or IgM) was significantly
in RA and tuberculosis (P < 0,0001). In view of this, we proceeded greater than in RA or tuberculosis (chi square test = 30,77; P < .
. to determine whether ACA levels monitored longitudinally at 0,0001). ACA levels were raised in 80,2% IHD patien'l:s on one or
monthly intervals were associated with episodes of disease activity more occasion during a 1-1 I-day (mean 4,7) hospital stay. There
in SLE. There was a good positive predictive value (70%) between was no difference in either ACA levels or in the frequency of ACA
ACA and overall disease activity. However, predictive values for elevation in panents with stable or unstable angina pectoris or
ACA activity in individual systems were poor. A strong association myocardial infarction.
between ACA and the presence of renal involvement irrespective We conclude that there is a strong association between IHD
of activity was also found. and ACA with potentially imponant therapeutic implications.
Recently criteria for a 'phospholipid syndrome' (APS) have
been proposed. Nine of 57 SLE patients fulfilled both the clinical
and serological criteria and a further 18 patients fulfilled the
serological criteria for APS.
Our results show that the measurement of ACA levels are of
value in predicting overall disease activity in SLE and are useful
in monitoring ·those patients who fulfil or partially fulfil the Occurrence of 3 phenotypes of human
criteria for the APS with a view to prophylactic therapy.
serum amyloid-A protein
A. F. STRACHAN, F. C. DE BEER
Research Co-ordination, Faculty of Medicine, University of
Stellenbosch, Parowvallei, CP
Reactive systemic amyloidosis complicating rheumatic diseases is
Antiphospholipid antibody in normal blood characterised by the deposition of fibrils containing amyloid-A
protein (protein AA). Protein AA is a proteolytic product of the
donors and patients with antinuclear factor l04-residue serum amyloid-A protein (apo-SAA). In response to
appropriate inflammatory stimuli, monocyte-derived factors are
D. J. PUDIFIN,JUNE DUURSMA released and act on the control sequence(s) in the 5' untranslated
Clinical Immunology Laboratory, University of Natal, Durban region of the apo-SAA gene(s) causing greatly increased trans-
cription and translation of the genes and a dramatic increase (up
An ELISA, using cardiolipin as substrate, was used to quantitate to 1 ooo-fold) in serum apo-SAA concentrations. Although apo-
antibodies to phospholipid. Results were expressed as an index SAA is the precursor of protein AA, elevated serum apo-SAA
calculated as follows: levels per se are not predictive of amyloid formation.
Test reading Apo-SAA is a polymorphic protein and the possibility exists
1,5 x control readmg that individual variations in the concentration of one isoform (or
Fifty blood donors from each race group - black, Indian and pattern of isoforms) may be more imponant in amyloidogenesis.
white - were tested. The mean indices were 0,89, 0,74 and 0,69. Previous attempts to show such variations have been unsuccessful.
In the black group, an index of>1 was found in 24%. In the white However, we repon for the first time the occurrence of 3 apo-
and Indian groups this was the case in 6% and 10% respectively. SAA isoform patterns. In addition to the major isoforms (pI 6,0 +
This difference clearly needs to be borne in mind when interpreting 6,4) the heterozygote pattern has pI 7,0, 7,4, 7,5 and 8,0 isoforms.
the results of this assay. One homozygote lacks the pI 7,4 and 8,0 isoforms. The occurrence
Examination of 149 serum samples containing antinuclear factor of different isoform patterns in individuals experiencing an ele-
(ANF) in a titre varying from 1 : 50 to 1 : 3 200 reveals a clear re- vation of the acute phase proteins, with or without amyloidosis,
lationship between the titres of ANF and of antibody to cardiolipin. will be discussed.
296 SAMJ VOL 74 17 SEPT 1988
Clinical assessment of disease activity in The New York and ARA criteria for active rheumatoid arthritis
(RA) were applied and the Rome criteria were considered for
rheumatoid arthritis - evaluation of a inactive RA. The results are tabulated below; 86,9% of coloureds
functional test and 86,9% of whites were seen.
While (%) Coloured (%)
A.A. KALLA,O.L.MEYERS,T.KOTZE Definite RA 0,98 0,23
Rheumatic Diseases Unit, Department of Medicine, Uni- Probable RA 0,49 0,46
Definite + probable RA -1,48 0,70
versity of Cape Town
Inactive 0,24 0,23
+ve RF 3,70 2,80
The findings of a cross-sectional study of markers of disease Psoriatic arthropathy was seen in I white woman and ankylosing
activiry in 98 patients with classical rheumatoid arthritis (RA) are spondylitis in 1 coloured man. Erosive arthritis of unknown
reported. The median age was 38 years, the median age at onset of aetiology was observed in 5, I % of whites and 2,7% of coloureds.
disease was 29 years and the median duration of disease was 7
years. The Keitel function test (KFT) showed good correlation
with the Ritchie articular index (RAI) (P < 0,001; r = 0,5) and
disability questionnaire (DQ) (P < 0,001; r = 0,56). The RAI and
DQ correlated weakly with laboratory variables, while the KFT
Are public facilities adequate for arthritis
showed significant correlation with ESR, CRP and PV. Only the patients?
KFT showed significant correlations with bone mass measurements
(P < 0,01; r = 0,3; 0,4) and the Larsen index at the right wrist A. C. DU TOIT, P. KLEMP, H. CARSTENS, D. CHALTON
(P < 0,0001; r = 0,41). Consensus analysis suggests that the KFT Departments of Occupational Therapy and Rheumatology /
is a useful single clinical test of disease activity in RA. The hand Internal Medicine, University of Stellenbosch and Tygerberg
function index (HFI), a component of the KFT, showed significant Hospital and Institute of Biostatistics of the South African
correlation with the total KFT (r = 0,873). Prospective drug trials
Medical Research Council, Parowvallei, CP
are needed to establish the value of HFI in the monitoring of
patients with RA.
A survey investigated the adequacy of public facilities in Cape
Town and surrounding areas for arthritis patients. A comprehensive
questionnaire was completed by 100 patients attending the_
Handedness and deformities, radiographic rheumatology clinic at Tygerberg Hospital. Fifry-six patients had
changes and hand function in rheumatoid rheumatoid arthritis, 23 seronegative spondarthritis, 14 osteo-
arthritis and 7 had miscellaneous rheumatological conditions. The
arthritis mean age was 50,7 years (range 19-85 years), 23 were men and 76
were women, 59 were SA caucasoid, 49 were Cape Coloured and I
G. M. MODY, o. L. MEYERS, s. G. REINACH was a SA black.
Rheumatic Diseases Unit, Department of Medicine, Uni- Fifry-three per cent of the patients experienced problems
versity of Cape Town and Groote Schuur Hospital, Cape anending hospital. Inadequate seating and examining couches
Town and Institute of Biostatistics of the South African featured significantly (P < 0,05). Transport was a major problem.
Medical Research Council, Johannesburg Seventy-two per cent had significant difficulties with trains; 70%
with buses; 54% with taxis or private cars and 48% with negotiating
A study was undertaken to determine whether there was a corre- pavements or roads. Steps at stations and gening in and out of
lation between handedness and deformities, radiographic changes vehicles were significant problems (P < 0,05). The 35% of patients
and hand function in rheumatoid arthritis (RA). who experienced difficulties with public buildings complained
A group of 210 patients with classical or definite RA and a mainly about steps and the lack of seating (P < 0,05). Two
dominant right hand were assessed, and the following points were recreational difficulties posed significant problems, theatres (51%)
noted: (i) presence of swan neck deformity (SND), bOUlonniere and spectator facilities (40%), steps being the problem in both
deformiry (BD), ulnar deviation (UD) and flexor tenosynovitis instances (P < 0,05). Shopping (68%) and public telephones (36%)
(FTS); (il) hand function - finger tip to proximal palmar crease caused significant difficulties (P < 0,05). Unemployment was due
distance; and (iil) severity of radiographic changes of the hands to arthritis-related factors in a significant number of patients (P <
based on the Larsen standard radiographs. 0,05) rather than due to inadequate facilities.
There was no significant difference in the proportion of patients The type of arthritis, functional grade and race had a significant
who had SND, BD, UD and FTS in the dominant and non- influence on the fmdings (P < 0,05).
dominant hands. Radiological changes were significantly more
severe in the dominant hand (P < 0,0001). There was also more
severe functional impairment of the dominant hand. Nutritional status in rheumatoid arthritis
In conclusion, we note that although there is no increase in
prevalence of deformities in the dominant hand, radiographic
and systemic lupus erythematosus
changes are more severe and there is greater impairment - of
function in the dominant hand. G. M. M. BROWN, A. A. KALLA, O. L MEYERS, T. KOTZE
Rheumatic Diseases Unit, Department of Medicine, Uni-
versity of Cape Town
Prevalence of rheumatoid arthritis in a small
A study was undertaken to evaluate nutritional status in rheumatic
urban community in the eastern Cape diseases. Patients from the clinics at Groote Schuur Hospital were
studied. One hundred patients with rheumatoid arthritis (RA) and
A. CLARK, G. M. BROWN, O. L MEYERS 72 patients with systemic lupus erythematosus (SLE) were com-
Rheumatic Diseases Unit, Department of Medicine, Uni- pared with 100 age-matched normal controls. Lean body mass
versity of Cape Town (LBM) was calculated using anthropomorphic measurements such
as height, weight, skin-fold thickness and body diameters using
A study was conducted in Bedford, eastern Cape, among white the formula of Sloan (S) (g/tnl) and Wilmore-Behnke (W-BI and
and coloured inhabitants. A preliminary study was performed and W-B2) (dm).
the universe was defined as the total adult population for each
group. A detailed questionnaire, musculoskeletal examination, Control RA SLE
radiographs of hands and feet, and blood samples for antinuclear Sloan 1,098 1,098 1,097
factor, rheumatoid factor (RF), serum uric acid value and serum W-Bl 70,51 70,06 68,98
total protein value tests were completed. W-B2 6,02 5,97 5,91
SAMT VOL. 74 17 SE PT 1988 297
No significant differences could be demonstrated in the com- Comparison of the spectrum of rheumatoid
parison of LBM in the three groups of subjects (P > 0,05). A
correlation matrix of the three tests showed that in SLE, W-B2 arthritis in three South African communities
was a more suitable measure of LBM than S or W-Bl. Our
findings suggest that secondary causes of malnutrition should be G. M. MODY, o. L. MEYERS
actively excluded in rheumatic subjects who have severe weight Rheumatic Disease Unit, Department of Medicine, Uni-
loss. versity of Cape Town and Groote Schuur Hospital, Cape
A study was undertaken to compare the spectrum of rheumatoid
Prevalence of the extra-articular features of arthritis (RA) in three South Mrican communities in Cape Town.
rheumatoid arthritis A group of 256 patients with classical or definite RA were studied
(coloured 104, caucasians 100 and blacks 52). All the patients were
G. M. MODY, O. L MEYERS assessed by history, clinical examination, immunological tests and
Rheumatic Diseases Unit, Department of Medicine, Uni- radiographs.
versity of Cape Town and Groote 8chuur Hospital, Cape The mean age of onset of RA in blacks (P = 0,0002) and
coloureds (P = 0,0012) was younger than in caucasians. There was
no significant difference in the functional classification and pre-
valence of malnutrition but obesity was commoner in black women.
A randomly selected group of 104 coloured patients with The serum IgG values were significantly higher in coloureds and
rheumatoid arthritis (RA) was studied to determine the prevalence blacks but no differences were noted for a positive rheumatoid
of the extra-articular features (EAF) of RA. The clinical records of factor, antinuclear factor, subcutaneous nodules and use of im-
all patients were reviewed. They were assessed clinically and had munomodulatory drugs·. Radiographic changes in the wrists were
specialised investigations such as lung function tests, echocardio- more severe in blacks. Surgery was performed less frequently in
graphy, nerve conduction studies and screening for keratocon- blacks than caucasians and significant differences were noted for
junctivitis sicca (KCS). carpal tunnel release, flexor tenosynovectomy and surgery to the
One or more EAFs were noted in 92 patients (88,5%). The 1st - 5th metatarsophalangeal joints.
commonest findings were anaemia (54,8%), subcutaneous nodules In conclusion, we noted that apart from the features mentioned
(29,8%), lymphadenopathy (23,1%) and KCS (21,2%). The only above, there are marked similarities in the spectrum of RA in the
significant cardiac abnormalities which were related to RA were three communities.
the presence of pericardial effusion in 5 patients (6%). Abnormal
nerve conduction studies were noted in 26,2% of patients but there
was a poor correlation between clinical findings and elecrrophysio-
logical tests. The pulmonary abnormalities noted were interstitial
lung disease (4,8%), pleural involvement (9,6%), impaired diffusion Treatment of Raynaud's phenomenon with
capacity (5,8%), pulmonary nodule (1%) and airways obstruction
(1%). large doses of tri-iodothyronine -
The survey showed that EAFs are common in RA and are a pilot study
detected more often with the use of specialised tests. However, the
routine use of these tests is of little value in clinical practice. P. H. DESSEIN, R. F. GLEDHILL
Although clinically overt systemic vasculitis is associated with an Department of Internal Medicine, University of Pretoria and
increased prevalence of nodules and seropositivity, there is no Kalafong Hospital, Pretoria
similar association with the milder abnormalities which are detected
with specialised tests.
Large dosages of tri-iodothyronine (T3) have been advocated as a
novel form of treatment for Raynaud's phenomenon (RP) (Kontos
HA, 1985). However, an extensive search of published reports
Osteoporosis in rheumatoid arthritis - failed to uncover a single descriptive account of such therapy. We
report our experience with T3 in the treatment of 14 patients with
clinical implications RP accompanying various connective tissue diseases.
The 14 cases included 12 women and 2 men and represented
A.A.KALLA,O.L.MEYERS,N.D.PARKYN,T.KOTZE the total of patients with RP under our care between February
Rheumatic Diseases Unit, Department of Medicine, Uni- and November 1987. Eleven were black and 3 were white; their
versity of Cape Town ages ranged from 20 years to 53 years. The underlying diseases
were systemic sclerosis (8 cases), systemic lupus erythematosus
Medical journals are replete with studies of osteoporosis in (4), overlap syndrome (1) and rheumatoid arthritis (1). None of
rheumatoid arthritis (RA). Controversy about pathogenesis is the patients had cardiovascular disease or was taking vasoactive
largely due to overlap with confounding factors (age, menopause, drugs. All were non-smokers and denied alcohol consumption.
disease and physical activity). We studied a selective group of The trial was open and uncontrolled. Mter giving informed
subjects with RA (young, independently ambulant, classic/definite consent, each patient was asked the number and duration of
RA), measuring metacarpal bone mass, clinical disease activity attacks they were experiencing at present. Blood pressure and
(Ritchie, Keitel, disability questionnaire, erythrocyte sedimentation pulse rate were also recorded. T3 was initially prescribed at a
rate, CRP, Larsen, etc). Two groups based on bone mass (CA%) dosage of 80 pg!d. Nine patients were reassessed monthly and 5 at
relative to the 10% value of an age-matched normal group, were weekly intervals. At this time symptoms of side-effects were
compared by discrIminant analysis. The classification was used to sought, blood pressure and pulse rate were measured and dosages
calculate sensitivity and specificity in order to defme the most adjusted accordingly. Compliance was assessed by regular moni-
suitable' clinical, laboratory or radiographic marker of osteoporosis toring of thyroid function tests.
in RA. Duration of disease was the best clinical marker (sen. 75%; All the patients experienced amelioration of Raynaud symptoms
sp. 60%). The most sensitive laboratory marker was the PV (70%; within 4 weeks of starting T3. Two patients experienced side-
60%). Radiology was the most sensitive test overall - the sums of effects necessitating a dosage reduction (to 40 pg/d and 60 pg/d),
the inner diameters and the outer diameters of 6 metacarpals while the remainder were maintained on 80-120 pg/d.
(90%; 85%). Consensus analysis was aimed at determining which Possible modes of action of T3 in RP include thermoregulation,
2nd metacarpal index best represented the 6 metacarpal score. In reflex vasodilation or increase in digital artery perfusion pressure.
this group of subjects, the most sensitive marker was the CA%. Its properties of a (false) neurotransmitter and neuromodulator
The Larsen index at the right wrist showed an equal correlation in may also be relevant.
the two tests (0,45; 0,43). The metacarpal bone mass may be a Large dosages of T3 appear to be an efficacious treatment for
useful radiological marker of disease activity in RA. RP and merit further investigation under controlled conditions.
298 SAMJ VOL 74 17 SEPT 1988
Mixed connective .tissue disease - ment of Internal Medicine, University of Stellenbosch,
the Baragwanath Hospital experience
M. TIKLY, H. MENDELSOHN, A. KARSTAEDT, H. J. At concentrations of 5 fig/ml and greater the non-steroidal anti-
inflammatory drug (NSAID) benoxaprofen caused dose-related
HODKINSON activation of superoxide generation by human polymorphonuclear
Department of Medicine, Baragwanath Hospital and the leucocyres (PMNL). Benoxaprofen-mediated release of superoxide
University of the Witwatersrand, Johannesburg by PMNL was increased by ultraviolet radiation (VVR) and was
particularly sensitive to inhibition by the selective protein kinase
Mixed connective tissue disease is an overlap syndrome charac- C (PKC) inhibitor H-7. To identify the molecular mechanism of
terised by features of scleroderma, systemic lupus erythematosus, the pro-oxidative activity of benoxaprofen, the effects of the
polymyositis and rheumatoid arthritis. The syndrome is thought NSAID on the activity of purified PKC in a cell-free system were
to be uncommon in black South Africans and, in fact, only I case investigated. Benoxaprofen caused a dose-related activation of
has been reported. PKC by apparent substitution for the physiological activator
The cases reported here were seen over a 4-year period with a phosphatidylserine, but could not replace diacylglycerol. When
mean follow-up period of 21,4 months. The clinical features were autologous mononuclear leucocytes (MNL) were co-cultured with
as follows: PMNL and benoxaprofen in combination, but not individually,
Mean age 36,2 Nephropathy 7% the frequency of DNA strand breaks in MNL was markedly
Sex ratio (F:M) i4: I Lymphadenopathy 47% increased. UVR significantly potentiated damage to DNA mediated
Neurological abnormalities 20% by benoxaprofen and PMNL. Inclusion of superoxide dismutase,
Arthralgia 100% Splenomegaly 20% H-7, and, to a much lesser extent, catalase during exposure of
Arthritis 60% Anaemia 20% MNL to benoxaprofen-activated PM L prevented oxidant damage
Raynaud's phenomenon 87% Leucopenia 20% to DNA. These results clearly demonstrate that potentially carcino-
Scleroderma 80% Thrombocytopenia 7% genic pro-oxidative interactions, which are unlikely to be detected
Vasculitis 67% Antinuclear factor by conventional assays of mutagenicity, may occur between phago-
Alopecia 33% (speckled) 100% cyres, UVR and certain pharmacological agents.
Oesophageal dysfunction 40% RNP antibodies 100%
Pulmomary dysfunction 87% Rheumatoid factor 27%
Cardiac dysfunction 33% Hypocomplementaemia 67% Auto-antibodies in chronic mycobacterial
While the response to steroids of the patients with vasculitis, infections
pericarditis and polymyositis was good, the pulmonary abnormali-
ties and scleroderma responded poorly in most patients. The B. L. RAPOPORT, A. J. GEAR, P. SUTEJ, R. C. A.
major causes of morbidity were pulmonary and cerebral complica- MORRISON, M. L. DOS SANTOS, R. SHER
tions. Two patients died of cor pulmonale and 1 from an unrelated
Rheumatology Unit, Department of Medicine and Depart-
In 'conclusion, in our experience, mixed connective tissue disease ment of Immunology, University of the Witwatersrand and
is not an uncommon syndrome in blacks and is a cause of the South African Institute for Medical Research, Johan-
significant morbidity and mortality. nesburg
Infections can cause auto-antibody production. A study was under-
Nosology of the heritable hypermobility taken to determine the prevalence of auto-antibodies in chronic
mycobacterial infections. Sera from 41 leprosy patients and from
syndromes 50 untreated and 73 treated tuberculosis patients were tested for
rheumatoid factor and against a panel of nuclear antigens. The
P. BEIGHTON antinuclear factor (ANF) was positive in 7,3% of the leprosy
MRC Research Unit for Inherited Skeletal Disorders and group, 6,1% of the untreated tuberculosis group and 15% of the
Department of Human Genetics, University of Cape Town treated tuberculosis patients. The ANF titres were low and there
was no specific pattern. No patients had antibodies against native
The heritable syndromes in which joint laxity is a major manifesta- DNA, RNP, Ro or La .antigens. The rheumatoid factor was
tion are individually rare but collectively not uncommon. These positive in 2,4% of the leprosy and 2,7% of the treated tuberculosis
conditions are important in rheumatological practice since affected patients but in none of the untreated tuberculosis group. The
persons experience a variety of articular complications. titres ranged from 40 IV to 160 IV.
These genetic hypermobility disorders are proving to be very It is concluded that owing to their low prevalence and frequency
heterogeneous and there has been confusion concerning syndromic in these chronic infections these auto-antibodies should not lead to
boundaries, nomenclature and classification. Resolution of these confusion in distinguishing these conditions from connective ·tissue
issues is a prerequisite for the accurate determination of the diseases.
natural history, prognosis and -response to therapy and for the
elucidation of the basic biomolecular defect.
A committee of international experts recently met in Berlin in
order to formalise a universal nosology and nomenclature for the Anti-Ro Antibodies (SS-A) and photosensi-
heritable connective tissue disorders. The recommendation con- tivity in systemic lupus erythematosus
cerning the Ehlers-Danlos syndrome, familial articular hyper-
mobility syndromes and skeletal dysplasias with predominant joint P. G. SUTEJ, A. J. GEAR, R. C. A. MORRISON, M. TIKLY,
laxity, form the subject of this presentation. R. SHER, M. DE BEER
Rheumatology Unit, University of the Witwatersrand,
Protein kinase C-dependent pro-oxidative Johannesburg
interactions of benoxaprofen, human poly- Previous studies have shown an association between anti-Ro (SS-
morphonuclear leucocytes and ultraviolet A) antibodies and photosensitivity in systemic lupus erythematosus
radiation promote superoxide-mediated DNA (SLE). A study was undertaken to determine the prevalence of,
and possible association between, anti-Ro antibodies and photosen-
strand breaks in co-cultured mononuclear sitivity in black patients with SLE. These fmdings were compared
leucocytes with those in white patients with SLE.
Fifty-six white and 36 black patients were studied. Anti-Ro
G. SCHWALB, A. D. BEYERS, R. ANDERSON, A. E. NEL antibodies were measured by gel double-immunodiffusion. Photo-
Institute for Pathology, University of Pretoria and Depart- sensitivity was significantly less common in black patients. Anti-
SAMT VOL 74 17 SEPT 1988 299
Ro antibodies were more common in blaGk SLE patients but this It has been a clinical impression that the auto-immune diseases
was not statistically significant. In the white SLE patients, there were more common in the Cape Coloured female. A study was
was a significant positive association between anti-Ro antibodies undertaken to evaluate their prevalence in the western Cape
and photosensitivity. However, in the black SLE patients, there population and more specifically to look at the demography of sys-
was a significant negative association between anti-Ro antibodies temic lupus erythematosus (SLE).
and photosensitivity: photosensitivity occurred in only 4% of All hospital medical admissions were reviewed for the period
patients who were anti-Ro antibody-positive but was present in 1975 - 1984. In this decade all SLE patients were documented and
55% of patients who were antibody-negative. over the period 1980 - 1984, all the established auto-immune
We conclude that in black patients with SLE, unlike in white, diseases were reviewed.
photosensitivity is uncommon and is not associated with anti-Ro Conclusion. Auto-immune diseases are more common in the
antibodies. Cape Coloured female, being most convincing in the SLE group.
DNA-receptor antibodies in auto-immune
disease Use of sulphasalazine in rheumatoid arthritis
P. BONAFEDE, R. M. BENNETT, MARCIE MERRITT, w. A. MeD. scan
s. HEFENEIDER Durban
Department of Rheumatology, Oregon Health Sciences
University, Portland, Oregon, USA A study was undertaken to evaluate the efficacy of sulphasalazine
as a remittive·drug in patients with classical or definite rheumatoid
Auto-antibodies characteristically occur in certain auto-immune arthritis (RA) (ARA criteria).
diseases and some have been well delineated although the target The clinical records of 143 patients with RA treated with
antigens are less well characterised. We have previously described su1phasalazine were reviewed. All these patients had been seen in
a cell receptor for DNA (DNAR) and now report the occurrence a private rheumatology practice by the same observer. They were
of antibodies to DNAR (a·DNAR) in patients with a variety of assessed clinically with the Ritchie articular score and erythrocyte
auto-immune diseases and their asymptomatic relatives. sedimentation rate, full blood count and rheumatoid factor were
DNAR was isolated from a PBMC membrane preparation by measured.
affinity chromatography utilising a murine IgG monoclonal anti- One hundred and four patients (72%) had shown and maintained
body to the DNA-binding portion of the DNAR (MAB No. 12) good response, based on clinical and laboratory assessment. Three-
conjugated to protein-A sepharose. Control and patient's sera quarters of the patients had been on treatment for between 1 and
were screened for a DNAR in a dot blot assay using serum 4 years and one-quarter for between 6 and 12 months. The
diluted to 1: 1000 and 50 ng/well of DNAR. The following remaining 39 patients had stopped therapy due either to gastro-
results were obtained: intestinal side-effects (11 patients; 7%) or to poor compliance,
transfer to other parts of the country, etc.
Normals SLE SLE/Rel MCTD 1 Sjog UCTD This open study confirms the efficacy of sulphasalazine in
(N = 256) (N = 48) (N = 20) (N = 18) (N = 16) (N = 27) assisting the control of disease activity in RA. The gastro-intestinal
2,3% 45,2% 65,0% 55,5% 62,5% 44,4% side-effects were of a minor nature and no major side-effects were
Hereafter a solubilised PBMC membrane preparation and serum
diluted 1: 15000 were used in an immunoblot assay that demon-
strated IgG binding occurring at 30 Kd in all positive dot blot Use of sulphasalazine in rheumatoid arthritis
sera. This Kd-binding was inhibited by previous incubation with
both cold DNA and MAB No. 12A and was identical to binding P. SMITH, G. M. BROWN, A. A. KALLA, O. L. MEYERS
by a DNA biotin probe. This provides evidence for immuno- Rheumatic Diseases Unit, Department of Medicine, Univer-
globulin binding to the DNAR. sity of Cape Town
These data indicate the presence of antibodies to a cell surface
DNA-receptor in auto-immune disease and in asymptomatic SLE
relatives. It is conceivable that anti-DNAR antibodies have patho- A total of 46 randomly selected patients with classical or definite
genetic significance in the genesis of auto-immune disease. rheumatoid arthritis (RA) treated with sulphasalazine were followed
up for a mean period of 13,7 months. There were 38 women and 8
men. Forry-one patients were seropositive, while 5 patients were
seronegative in the course of their disease. The study group
consisted of 18 whites, 16 coloureds, 4 Indians and 8 Africans.
Auto-immune disease in the western Cape Forty patients were independently ambulant (FC 1 + 2) while 6
were partially dependent (Fe 3). The mean age was 49 years and
B. D. SAREMBOGK, O. L. MEYERS the mean duration of disease was 8 years. The various inflamma-
Rheumatic Diseases Unit, Department of Medicine, Univer- tory indices, including MS (P = 0,01), ESR (P = 0,003) .uid
sity of Cape Town plasma viscosity (P = 0,003), showed a significant improvement
While While Coloured Coloured Black Black
men women men women men women Towl
No. 11 63 43 215 2 34 368
% 2,99 17,12 11,68 58,42 0,54 9,24
Auto-immune diseases requiring hospital isolation
While men While women Coloured men Coloured women Black men Black women
Rheumatoid arthritis 52 95 45 99 6 16
PSS 6 13 12 20 1 6
Graves' disease 9 12 15 38 7 18
Pernicious anaemia 12 12 3 24 3 3
300 SAMJ VOL. 74 17 SEPT 1988
on sulphasalazine. The exception was C-reactive protein (P = 0,2).
A defrnite clinical improvement was noted as evidenced by an Cognitive-behavioural therapy in rheumatic
improvement in the joint count (P = 0,001) and Ritchie index (P disease
= 0,003). The side-effect profile of the drug will also be discussed.
W. A. MeD. scon
This study attempts to focus on the broader issues of rheumatic
disease and the increasing interest in the methods of alternative
Sulphasalazine in rheumatoid arthritis - a medicine in the Western world. These include: acupuncture;
radiological assessment osteopathy; homeopathy; faith-healing; and relaxation techniques.
The challenge of these methods to orthodox medicine should be
o. L MEYERS, A. A. KALLA,H. ANGUS, S. ISAACS met by a holistic approach with environmental stress assessed as
Rheumatic Diseases Unit, Department of Medicine, Univer- an imponant factor in all rheumatic disease.
The use of cognitive-behavioural therapy is considered because
sity of Cape Town
most patients have been misled by thoughts of 'arthritis' as
inevitably crippling. Explanation can be strongly reassuring and
Radiographs of hands and feet were taken at 6-montWy intervals counselling will help patients to change provocative factors rather
while patients were treated with 2,0 g sulphasalazine (Salazopyrin). than to suppress their effect with powerful, potentially toxic,
The radiographs were read using the Beaver Creek scoring system, medication. The effIcacy of physica1.methods needs to be stressed
which counts erosions, measures their size at 18 areas of the hand, with medication reduced to simple analgesics ~ere possible. The
and also measures joint space narrowing at 6 areas. The carpometa- incidence of iatrogenic illness has now become a matter of public
carpal ratio· and an improved radiogrammetry method for concern and inappropriate medication needs increasingly to be
measuring bone mass was also used. avoided.
A radiograph taken within a month of starting treatment was
used as the reference fIlm and the 6- and 12-month films on
treatment were compared with it.
Using a Friedman analysis of variance the 6-month fIlms showed
a worsening of the erosion count (chi-square test = 5,28; A preliminary evaluation of metronidazole
P = 0,021) and of the erosion size score (chi-square test = 12,12; v. placebo in patients with active rheumatoid
P = 0,009). The narrowing score showed a similar worsening (chi-
square test = 6,82; P = 0,009). After 12 months on treatment arthritis
these signifIcant differences were lost.
O. L. MEYERS
Rheumatic Diseases Unit, Department of Medicine, Univer-
sity of Cape Town
Eighteen patients (16 women, 2 men) with active rheumatoid
Hand exercises in rheumatoid arthritis arthritis were randomly entered into a trial of metronidazole v.
placebo for 6 weeks. Two patients were withdrawn - both on
L LUBBE, S. W. BRIGHTON metronidazole (1 absconded, 1 developed allergic reactions).
Department of Physiotherapy, University of Pretoria
Scart 6 weeks Scare 6 weeks
A 4-year follow-up of the use of a hand-exercise apparatus in
rheumatoid arthritis is reponed. Twenty-fIve patients who had Morning stiffness
regularly used the apparatus were compared with 19 controls. Tpe (min) 161 188 203 135.
parameters measured were grip strength, pinch strength and range Anicular index 24 23 28 26
of motion at the metacarpophalangeal and proximal interphalangeal No. swollen joints 15 14 19 18
joints. Although both groups deteriorated over the 4 years, the Pain score 6 4 7 5
experimental group showed statistically significantly less deteriora- Erythrocyte sedi-
tion than the control group. mentation rate
(Westergren) 42 58 56 56
(mg%) 5,0 3,0 5 4
Two patients in the metronidazole group developed a febrile
Isokinetic principles and muscle rehabilita- reaction. No significant improvement was found in the metronida-
tion in rheumatology
R. WINDT, s. W. BRIGHTON
Department of Rheumatology, University of Pretoria Prevalence of diffuse idiopathic skeletal
The concept of isokinetics was developed by James Perrine in the
hyperostosis in Africans
late 1960s and was followed by a revolution in exercise training
and orthopaedic rehabilitation. The basic principles of isokinetic B. CASSIM, G. M. MODY, D. L. RUBIN
testing and training will be reviewed with emphasis on the potential Department of Medicine, University of Natal, Durban
application of these principles in muscle rehabilitation.
The results of a pilot study on patients with osteo-anhritis of Retrospective and prospective studies were undenaken to deter-
the knee emphasised the need to establish standards in isokinetic mine (I) the prevalence of diffuse idiopathic skeletal hyperostosis
assessment of elderly patients. This study: (I) emphasises the (DISH) in Africans over 40 years old; and (il) the frequency of
imponance of muscle rehabilitation in rheumatology; (il) explains diabetes in patients with DISH.
the basic principles of isokinetic testing and training; (iil) explains In the retrospective analysis 961 consecutive patients who had
the potential application of these principles in rheumatology; (iv) had lateral chest radiographs were studied. The prospective study
discusses the fmdings of a pilot study; and (v) emphasises the need consisted of 419 consecutive patients admitted to medical wards
for further research. who were assessed clinically and radio10gically. DISH was diag-
SAMT VOL 74 17 SEPT 1988 301
nosed by the presence of the characteristic changes on lateral chest knee (41%), ankle (15%) and shoulder (12%). In 18 patients (53%)
radiographs. The overall prevalence of DISH was 3,5%. The PPNG were isolated.
prevalence in the different age groups is as shown below. This survey shows that involvement of more than one joint is
not uncommon in gonococcal arthritis. The high prevalence of
Age Relrospective Prospective Towl PPNG strains has considerable therapeutic implications.
group (yrs) (N = 961) (N = 419) (N= 1380)
40-49 0,6% 1,5% 0,85
50-59 2,2% 2,8% 2,3
60-69 6,1% 3,0% 5,0 Musculoskeletal manifestations of
>70 12,4% 8,2% 11,0
In the prospective study 46% of patients with DISH were
diabetic compared with 7,4% of the patients without DISH. P. KLEMP, F. L. MAJOOS, K. STEYN, T. VAN ROOYEN
In conclusion we note that: (z) in our hospital-based African Department of Rheumatology/Internal Medicine and Lipid
population the prevalence of DISH is similar to other community Clinic, University of Stellenbosch and Tygerberg Hospital,
studies; and (iz) there is an association between DISH and Parowvallei, CP
increasing age and diabetes as reported in other studies.
A number of musculoskeletal (MS) manifestations have been
described in patients with hyperlipidaemia. We report our findings
in 92 hyperlipidaemia patients anending the Lipid Clinic at Tyger-
Salmonella infections of bones and joints berg Hospital. There were 47 females and 45 males and their ages
ranged from 6 to 68 years (median 47 years). MS manifestations
P. R. CHOTAI, S. GOVENDER ascribed to hyperlipidemia occurred in 59 (64,1%). Patients were
Department of Orthopaedics, University of Natal, Durban subdivided into adult familial hypercholesterolaemia (AFH), juve-
nile familial hypercholesterolaemia (JFH) and those with combined
The authors reviewed 15 cases of infection of the bones and joints hypercholesterolaemia and hypertriglyceridaemia (lchoV1Tg) and
with Salmonella typhi. There·were 9 males and 6 females and the their MS manifestations were compared. These are summarised
age ranged from 12 years to 49 years. below:
The sites which were involved were the lumbar spine (3), sacro- Subgroup
iliac joint (3), hip (4), knee (2), femur (2) and tibia (1). The mode AFH lChol/1Tg JFH
of presentation was backache and inability to walk in those with MS manifeswtions (N = 48) (N= 27) (N = 17)
spinal and sacro-iliac joint involvement, pain and restriction of Tendon xanthomas 29 (60,4%) 11 (40,7%) 2 (11,8%)
movement in those with hip or knee involvement and localised Tendo achilles
pain and swelling in those with involvement of the femur or tibia. tendinitis 16 (33,3%) 7 (25,9%) 2 (11,8%)
All patients had a positive Widal test (titre range 1:640-1:5120) Xanthelasma!arcus 17 (35,4%) 6 (22,2%) 1 ( 5,9%)
and S. lyphi was isolated from a pus swab and or blood culture. Poly- or oligo-
Examination of the urine and stool was negative in all patients. arthritis 7 (14,9%) 2 ( 7,4%)
Treatment consisted of: (z) closed needle aspiration and biopsy Gout 6 (22,2%)
of the spinal lesion; (iz) open drainage, biopsy and debridement in Nonspecific
those with fen:lOral and tibial involvement and 1 patient with complaints 2 ( 4,2%) 2 ( 7,4%) 1 ( 5,9%)
sacro-iliac involvement; (iiz) therapy with chloramphenicol or
ampicillin in all the patients (4 weeks in 5 patients, 6 weeks in 9 . The majority of MS problems occurred in AFH with the
patients and 6 months in 1 patient; and (iv) bed rest, dressings, exception of gout, which was present exclusively in patients with
splintage with traction, plaster cast and cast brace. There was a lChoV1Tg. MS manifestations were very uncommon in JFH.
marked improvement in the general condition within 1 week of
the start of therapy.
In conclusion we note that S. typhi infection should be con-
sidered in patients with infections of bones and joints and that
there is a good response to medical and surgical therapy. Meningitis in systemic lupus erythematosus
Rheumatic Diseases Unit, Department of Medicine, Univer-
Gonococcal arthritis - prominence of sity of Cape Town
A retrospective study was undertaken to determine the incidence
A. A. HOOSEN, G. M. MODY, I. E. GOGA, A. B. M. and panern of meningitis in patients with systemic lupus erythe-
matosus (SLE) admined to Groote Schuur over the 10-year
KHARSANY, J. VAN DEN ENDE period, 1977-1986.
Departments of Microbiology, Medicine and Orthopaedics, The records of all patients admined with a diagnosis of SLE
University of Natal and King Edward VIII Hospital, Durban were reviewed and 13 episodes of meningitis were identified in 11
patients (2,9%). An organism was confirmed in 5 cases and
A study was undertaken to determine the frequency and panern of tuberculosis suspected in a 6th (no culture available). No organism
gonococcal arthritis and the prevalence of penicillinase-producing was cultured in the other 7 episodes.
strains of Neisseria'gonorrhoeae (PPNG). Lupus meningitis was suspected in 4 of the 7 episodes of
The clinical records of all patients with suspected gonococcal culture-negative meningitis. All had clear cerebrospinal fluid, with
arthritis from August 1983 to December 1987 were reviewed. a total protein of 0,1 - 1,0 g/l, and globulins of 0 - 1+. Polymorpho-
Patients who had a positive isolate from the joint aspirate and/or nuclear leucocytes were predominant in 3 of the 4 (14 - 78 cells). A
genital site were included in the analysis. further 3 episodes had findings suggestive of a bacterial meningitis
There were 34 patients of whom 32 were black and 2 Indian. with cloudy cerebrospinal fluid, a total protein of 0,4 - > 5 g/I,
The mean age of the patients was 23,5 years (range 14-46 years) and polymorph predominance in the range of 295-4800. All
and the female to male ratio was 2,8: 1. The diagnosis was made cultures were negative and as both patients had other evidence of
by the isolation of N. gonorrhoeae from -the joint aspirate alone ·in active lupus, it is possible that they may also have had lupus
65%, genital sites alone in 6% and from joint aspirate and genital meningitis.
site in 29%. The number of joints involved at the time of assessment Aseptic meningitis is an uncommon manifestation of central
were as follows: 1 joint in 73%, 2 in 21 %,3 in 3% and 4 in 3%. The nervous system involvement in SLE and differentiation from infective
joints which were most frequently involved were the wrist (44%), meningitis may be difficult.
302 SAMJ VOL 74 17 SEPT 1988
Nuclear magnetic resonance imaging in the HLA and rheumatoid arthritis in three South
early diagnosis of avascular necrosis of the African populations
hip in systemic lupus erythematosus
R. w. MARTELL, E. D. DU TOIT, D. TALJAARD, M.
P. KLEMP, A. M. HALLAND, A. LOXTON, A. DE KLERK, D. OUDSHOORN, A. KALLA, O. L MEYERS
W. BOTES Provincial Laboratory for Tissue Immunology and
Departments of Rheumatology/Internal Medicine, Radio- Rheumatic Diseases Unit, Department of Medicine,
logy and Orthopaedics: University of Stellenbosch and University of Cape Town
Tygerberg Hospital, Parowvallei, CP
A study was undertaken to evaluate the association between the
Avascular necrosis (AVN) of the hip is a serious complication in HLA system and rheumatoid arthritis (RA) in South Mrican
systemic lupus erythematosus (SLE). It is usually associated with caucasoids (N = 66), SA negroes (N = 33) and Cape Coloureds (N
severe disease and with few exceptions occurs in patients who = 183). The antigens of the HLA-A, B, C, DR and DQ loci were
have received corricosteroids. This longitudinal study investigates detected by the microlymphocyroxicity assay and their frequencies
the value of nuclear magnetic resonance (NMR) imaging in the in the three patient groups were compared with the corresponding
early diagnosis of AVN of the hip and compares it with radiology frequencies in normal individuals of the same population group.
and a technetium bone scan. High-risk SLE patients were selected HLA-DR4 was significantly associated with occurrence of RA in
and evaluated at 6-monthly intervals. Of 12 patients studied to the SA caucasoids (P < 0,0001), SA negroes (P = 0,001) and Cape
date 3 have developed AVN. The fmdings are summarised below: Coloureds (P < 10-6 ). The relative risk for RA in individuals
positive for HLA-DR4 was 3,2 in SA caucasoids, 3,9 in SA
Parienr NMR Radiology Scan Hip pain negroes and 3,7 in Cape Coloureds. Other significant associations
detected were HLA-A2 in SA caucasoids and HLA-B8 and
DQw3 in Cape Coloureds. In order to further investigate these
I + associations, we have studied II SA negro patients with RA, as
2 + + + part of a larger collaborative study ·during the 10th International
3 + ± + Histocompatibility Workshop. DNA from these patients was
examined by Southern blot hybridisation with probes specific for
NMR imaging was positive in all 3 cases and the bone scan
the DR and DQ region genes and compared with DNA from II
negative. Radiology was abnormal in 2 but in patient 3 the
HLA-matched normal individuals. Although we have not detected
abnormality was only detected retrospectively. Pain was present in
. new DNA markers for RA in the HLA region, this direction
2 of the patients at the time of diagnosis. Three of the 9 patients in
whom AVN had not occurred developed hip pain lasting 3, 4 and should be pursued using more sensitive oligonucleotide probes
rather than full length cDNA probes.
6 months respectively during the 12-month study period. In all,
the pain resolved completely. If the present trend continues in the
study, NMR imaging will be the most reliable method for diag-
nosing early AVN of the hip.
HLA and rheumatoid arthritis in South
M. G. HAMMOND, G. M. MODY, P. D. NAIDOO
Natal Institute of Immunology and Department of Medicine,
University of Natal, Durban
Corticosteroid therapy and bone loss -
radiogrammetry of the metacarpals in three We tested 100 black rheumatoid arthritis patients for HLA A BC
diseases and DR antigens and compared the frequency of these antigens
with random controls.
This study confIrms the association of HLA-DR4 with rheuma-
A.A.KALLA,O. LMEYERS,N.D.PARKYN,T. KOTZE toid arthritis. The frequency of DR4 was 44% in the patients and
Rheumatic Diseases Unit, Department of Medicine, Univer- 10% in the controls giving a relative risk of 7,4 for this antigen.
sity of Cape Town An unusual fmding was a significant increase in the frequency
of HLA-B8 with a frequency of 35% in the patients and 12,5% in
The role of corticosteroid therapy in the genesis of bone loss is controls (P < 0,000 I). There was no linkage disequilibrium between
controversial. This study was performed on 287 subjects (98 DR4 and B8 to explain this. HLA-DR4 did show linkage disequi-
normal, 96 rheumatoid arthritis (RA), 63 systemic lupus erythema- librium with HLA-BI7 although Bl7 was not increased in
tosus (SLE), 50 asthma). Metacarpal bone mass was measured by frequency.
radiograrnmerry, using a digitiser interfaced with an IBM(PC)
(program driven). Demographic factors were recorded, together
with dose and duration of corticosteroid therapy. Young patients
(under 50 years) who were independently ambulant were selectively
studied. Bone mass was recorded for the right 2nd metacarpal
(Nordin) as well as for 6 metacarpals (Horsman). The 98 normal
The rheumatoid cervical spine
adults of comparable age and sex served as controls. The mean age
was 40 years and the majority of subjects were women. Subjects A. w. B. HEYWOOD, I. D. LEARMONTH, M. THOMAS
with SLE used 10 times more steroids than RA or asthma. No Department of Orthopaedic Surgery, University of Cape
statistical differences (P > 0,05) could be shown between the Town
treated and untreated subjects with asthma, RA or SLE. In
addition, patients with SLE had a significantly higher bone mass Approximately 46% of our rheumatoid population has atlanto-
than patients with RA, despite the larger cumulative doses of axial instability. Most are without symptoms and those with pain
corticosteroid therapy. Only the RA and SLE groups showed are usually controlled adequately in a collar.
significant cortical thinning when compared with the normal Spinal fusion was required in 26 (4,1%) out of a rheumatoid
controls (P < 0,0001). The Singh index at the left hip and Saville population of 635. Occipitocervical fusion was done in 9, atlanto-
index at L3 were not significantly different in treated and untreated axial in 10, posterior subaxial in 5 and anterior subaxial fusion in
groups. It is possible that the therapeutic indications need to be 2. Cord compromise in 9 patients was controlled by traction in
reviewed when treating younger patients. quadriplegics and cervical bracing when ambulant. Surgical
SAMT VOL. 74 17 SEPT 1988 303
decompression was done on 2 occasions only and it is thought to Use of core biopsy in the treatment of early
be unhelpful. At follow-up, 1- IS years after surgery, 2 patients
had died postoperatively, both from anterior fusions. Two atlanto- avascular necrosis of the femoral head
axial fusions required revision for failure of fusions. All other S.MALOON, I. D. LEARMONTH, G. DALL
patients' spines had fused and they had partial or complete Rheumatic Diseases Unit, University of Cape Town
neurological remission. We conclude: (1) atlantoaxial instability is
usually controllable by a collar, and does not contraindicate careful
extension of the neck for intubation. during anaesthesia; (il) a Core biopsy was performed on 50 hips in 41 patients with earlier
fusion is indicated only for intractable pain, neurological com- avascular necrosis (AVN) of the femoral head (Arlet and Ficat
promise or gross unstable subluxation; (iil) gentle traction is safe grades I and 11). Thirty-two patients with 41 hips were followed
and effective in controlling neurological complications before sur- up for a mean of 32 months (range 12 - 84 months). Alcohol was
gery; surgical decompression is unnecessary and dangerous; (iv) the commonest aeriologial agent.
anterior subaxial fusion for rheumatoid arthritis is hazardous in Resting metaphyseal pressure was measured in 32 of the 41
our hands; and (v) late extubation and early ambulation enhance patients and found to be raised in 27. All 41 core specimens were
survival. examined histologically.
Twelve hips were' radiologically classified as having grade I
osteonecrosis. Three of these hips had no evidence of necrosis in
the core specimen. After the core biopsy 8 of the remaining 9 hips
showed significant clinical and radiological deterioration.
A comparison of low friction hip arthroplasty Twenty-nine hips were radiologically classified as having grade
11 osteonecrosis. Three of these hips had no evidence of necrosis
in rheumatoid arthritis and osteo-arthritis in the core specimen. After core biopsy, 25 of the remaining 26
hips showed significant clinical and radiological deterioration.
I. LEARMONTH, M. SOLOMON, D. DALL, A. W. B. Pressure studies provide a fair indication of the presence of
HEYWOOD AVN of the femoral head. However, core biopsy was found to be
Rheumatic Diseases Unit, University of Cape Town an ineffective form of treatment, even in the earliest stages of the
A comparison is made between 517 Charnley total hip replacements
performed for osteo-arthritis (OA) and 60 Charnley low friction
arthroplasties performed for rheumatoid arthritis (RA). The mean Association between carpal tunnel
age at surgery was 63,6 years in the OA group and 44,1 years in
the RA group. Follow-up ranged from 3 to 18 years with a mean syndrome and primary osteo-arthritis of
of 7,5 years (OA) and 7,4 years (RA). Of the RA patients 53,3% the hands
had polyarticular involvement limiting locomotor function while
only 23% of the OA patients were similarly iJ;lvolved. Post opera- A. J. GEAR, S. BIDDULPH, M. A. MEKLER, R. C. A.
tively 81 % of the OA patients had little or no pain compared with MORRISON, P. SUTEJ
70% of the RA patients. Forty-six per. cent of the OA hips Rheumatology Unit, Department of Medicine, University of
regained a virtually normal range of mo\[ement against 26% of the
the Witwatersrand, Johannesburg
RA hips. Ten per cent of the hips of both groups had been
revised; 2,5% of the OA qips had been revised for fracture of the
femoral stem, but this complication was not encountered in the Although osteophyres are mentioned as a cause of the carpal
RA group. Ten per cent of the remaining umevised RA cups tunnel syndrome (CTS), primary osteo-arthritis (OA) of the hands
revealed radiological demarcation suggestive of the pending neces- and the CTS is an association that is not described in standard
sity for revision; only 1,3% of the OA cups were radiologically texts. The purpose of this study was to document an association
loose. between these two and to compare the frequency of primary OA
Total hip replacement is indicated earlier in patients with RA; with other causes of the CTS. The data on patients who had
apart from an increased incidence of loosening .of the acetabular carpal tunnel releases in the orthopaedic unit at Johannesburg
component and a reduced range.. of movement, these hips subse- Hospital in the 18-month period from July 1985 to December
quently performed as well as a control group of replaced OA hips. 1986 were analysed retrospectively. At least 6 months after surgery
29 patients were asked telephonically for their subjective assessment
of the results of the operations. Nineteen patients (43%) had
primary OA of the hands; 16 (36%) were regarded as idiopathic
and only 3 (7%) had rheumatoid arthritis. Other associated condi-
'Missing the boat' - foot orthoses in tions included pregnancy, diabetes, chondrocalcinosis, a previous
fracture, hypothyroidism and cerebral palsy. The results of surgery
rheumatoid arthritis were better in the OA than the idiopathic groups. This study
suggests an important association between primary OA of the
J. GINSBERG hands and the CTS.
Department of Orthopaedic Surgery, University of the
Pertinent points are made regarding the anatomy and pathogenesis A foot survey in three population groups
of the rheumatoid foot. Attention is drawn to the maintenance of
the medial arch which is afforded by the capsules, ligaments, S. W. BRIGHTON, A. L DE LA HARPE, D. VAN STADEN
muscles and long flexor tendons. Once these structures have been Department of Rheumatology, University of Pretoria
damaged by disease the medial arch begins to collapse. The
disease is accompanied by subluxation, both at the subtalar and A clinical and radiological survey of the feet in three population
talonavicular joints. The eventual outcome results in a planovalgus groups is reported. A rural black population which had never
foot with consequent increased pronation and clawing of the toes. worn shoes was compared with an urban black population and
Thus the foot cannot supinate and acts as a rigid lever system and white population. The rural black population had a signifiantly
the function of the toes is impaired. wider foot angle than either of the other two populations. The
Emphasis has been placed on the routine early incorporation of hallux angle was significantly greater in the white population, but
foot orthotics that will prevent the deformities and thus also no significant difference between the rural and urban black popula-
prevent the need for surgery, which has to be conducted as a final tion was noted. The very wide foot of the rural black group would
salvage procedure. cause problems should they wish to wear shoes. Clinically, the
The boat will nor be missed if one embarks upon the use of fOOl rural population has a significant incidence of ankle pain, not
orthoses timeously. encountered in the two urban populations.
304 SAMJ VOL. 74 17 SEPT 1988
Clinical patterns of psoriatic arthritis lengths found at high altitude, is a powerful exacerbator of the
cutaneous manifestations of systemic lupus erythematosus (SLE).
in Indians The antinuclear factor (ANF) is the serological test found positive
in association with SLE and has been described as being increased
P. D. NAIDOO, G. M. MODY in certain environmental situations such as coal mining. Black and
Department of Medicine, University of Natal and King white patients have significantly different prevalences of photosen-
Edward VIII Hospital, Durban sitivity. We therefore wished to see if the prevalence of the ANF
was increased in the normal population at high altitude or altered
The aims of this study were: (I) to determine the panerns of in different racial groups. We investigated 798 normal healthy
psoriatic arthritis in Indians and to compare them with other non-pregnant individuals aged 15 - 35 years. Indians, coloureds,
Western communities; and (il) to determine whether there was a blacks and whites were equally represented. The ANF was
correlation between the prevalence of HLA B27 and sacro-iliitis or measured by routine immunofluorescence on animal tissue sub-
spondylitis. strates. Sera positive for ANF were tested for other auto-antibodies.
All patients with psoriatic arthritis who were seen in the Arthritis Four per cent of subjects had positive ANFs comparable with
Clinic over a 5-year period were studied. A clinical assessment, overseas studies using similar techniques. The majority of positives
radiographs and serological investigations including tissue typing were low-titre homogeneous panerns. None had other auto-anti-
were performed in all patients. - bodies. Prevalence in all racial groups ranged from 3% to 5%.
There were 85 patients with a female to male ratio of 1,3:1 and Indians and blacks had higher titres. On retesting after 6 months,
the mean age was 41,4 years (range 20 -71 years). An oligo- no individual remained positive. Altitude is not associated with
articular panern was noted in 42,3% and 23,7% had a panern increased ANF positivity in the normal population or in different
resembling rheumatoid arthritis (RA). None of the patients had racial groups.
overt arthritis mutilans. The remainder of the patients had overlap
panerns of arthritis. ail involvement was noted in 62,4% of
patients. There was no correlation between HLA B27 and spondy-
litis, and involvement of the nails and distal interphalangeal joints.
In conclusion we note that: (I) although the oligo-anicular
picture was the most common panern (42,3%), it was noted less
often than in other Western communities (75%); and (il) the RA- Long-term corticosteroid therapy and joint
like panern was commoner (23,7%) than reported in other studies
A. L DE LA HARPE, S. W. BRIGHTON
Department of Rheumatology, University of Pretoria
Survey of new patients seen by the
Long-term corticosteroid therapy has been implicated as a cause
ijheumatology Unit at Johannesburg and of joint hypermobility. The joint mobility of 25 patients who had
Hillbrow Hospitals been on oral corticosteroid therapy for asthma for at least 5 years
was compared with that of 40 control subjects. There was no
A. J. GEAR, P. SUTEJ, R. C. A. MORRISON, M. A. MEKLER significant difference between the two groups. It was concluded
Rheumatology Unit, Johannesburg Hospital and University that oral corticosteroids do not contribute to joint hypermobility.
of the Witwatersrand, Johannesburg
Ma:ny rheumatological conditions are common to all ethnic groups
while others show a marked discrepancy between different popula-
tions. The purpose of this study was to assess the rheumatic
diseases in patients presenting to two hospitals serving different
communities. From September 1986 to February 1987 all new The arthritic hand - the posterior
patients seen at Johannesburg and Hillbrow Hospitals were evalu- interosseus ganglion phenomenon
ated; 192 and III new patients were seen at the two hospitals
respectively. Seventy-seven per cent of the Hillbrow Hospital P. K. PYBUS
patients were Africans, the others being coloureds and Indians. Department of Orthopaedics and Pain Relief, Edendale
Both clinics see a biased group of patients with the emphasis on
inflammatory arthritis and the connective tissue diseases. Rheuma- Hospital, Pietermaritzburg
toid arthritis was the dominant disease in both groups making up
30% of the whites and 38% of the Africans. Not surprisingly, HLA The aims of ths study were to evaluate the use of injecting a
B27-associated diseases occurred in 9% of the whites but in no mixture of local anaesthetic and depot steroid into the posterior
Africans. Polymyalgia rheumatica and the fibromyalgia syndrome interosseous ganglion and to fmd an explanation of the phenomenon
were not recognised in the Africans but gout was nearly as that follows.
common in,the Africans (7,4%) as in the whites (9,8%). Over the past 8 years, at least 1 789 people with arthritic hands
We conclude that with some exceptions the panern of disease is from rheumatoid, osteo-, psoriatic or menopausal arthritis were
similar in blacks and whites. As most of these patients need long- studied. All cases were treated by injecting a mixture of local
term specialist care there is an urgent need for the expansion of anaesthetic and depot steroid into the posterior interosseous gang-
rheumatological services in Johannesburg. lion at the wrist.
In every case within a period of 2 - 5 seconds pain and stiffness
in all the joints of the hand and fingers was relieved and replaced
with a numb sc:;nsation, which was of the deep variety, the patient
Presence of antinuclear factors in a still appreciating superficial sensations of pinprick and fme touch.
As this local effect of numbness wore off, the hand, apart from
population at high altitude occasional local bruising, approached normality. The relief of pain
and stiffness became semipermanent, the oedema started to subside
R. c. A. MORRISON, A. A. WADEE, R. SHER and the patient was able to use the hand normally. Over 50% of
Departments of Rheumatology and Immunology, University patients followed up over 2 years have been relieved by 1 injection
of the Witwatersrand, Johannesburg only, the others requiring 1-2 repeat treatments.
This is a worthwhile procedure and should -be scientifically
Racial and environmental factors are known to play a role in auto- investigated. A suggested opus operandi will be given and some
immune disease. UV irradiation, particularly the shorter wave- objections to the procedure will be discussed. .