South African Rheumatism and Arthritis Association

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					                                                                                                     SAMT    VOL. 74   17 SE PT 1988    295




 South African Rheumatism and
 Arthritis Association
 XIth Biennial Congress, Durban, 14 - 16 March 1988


 Relationship of anticardiolipin antibodies                              Anticardiolipin antibodies in ischaemic
 to disease activity in systemic lupus                                   heart disease
 erythematosus
                                                                         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
                                                                        Town

                                                                        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
Town
                                                                        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,
                                                                        Parowvallei, CP
 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-
cause.
   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
                                                                        encountered.
   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



  SLE
                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
                                                                          Durban

                                                                          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
                                                                                                  Mecronidazole                Placebo
                                                                                                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
                                                                          C-reactive protein
                                                                          (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-
                                                                          zole group.
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
                                                                        hyperlipidaemia
   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
                                                                        H.M.ANGUS,A.A.KALLA
                                                                        Rheumatic Diseases Unit, Department of Medicine, Univer-
Gonococcal arthritis - prominence of                                    sity of Cape Town
penicillinase-producing strains
                                                                        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
                                                                           African blacks
                                                                           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
                                                                        disease process.
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
Witwatersrand, Johannesburg

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
 (15%).                                                                     hypermobility
                                                                            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.                 .

				
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