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Effect of temperature and humidity on daily pain score in a patient with rheumatoid arthritis.

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LETTERS
1627
Among the complications of this medical therapy, the
authors include 5 episodes of infection associated with open
lung biopsy, leptomeningeal biopsy, bowel resection necessitated by mesenteric infarction, and antibiotic therapy-related
Clostridium dificile enterocolitis. It is not possible to determine in such complex cases whether these infections might
also have occurred in the absence of any immunosuppressive
medications.
We remain concerned about any infectious complications of cyclophosphamide and glucocorticosteroid therapy. However, we believe that Bradley et al have observed
an unusually high incidence of such problems because they
did not adhere to our guidelines for reduction of glucocorticosteroid therapy, and they included 5 sequential complications of intestinal infarction and surgery in 1 patient. The
title of their report implicates cyclophosphamide as the
principal cause of infection. It would appear from their data
that a much stronger case could be made for the role of
glucocorticosteroid therapy.
Gary S. Hoffman, MD
Randi Y. Leavitt, MD, PhD
Anthony S. Fauci, MD
National Institute of Allergy
and Infectious Diseases
National Institutes of Health
Bethesda. MD
Bradley JD, Brandt KD, Katz BP: Infectious complications of
cyclophosphamide treatment for vasculitis. Arthritis Rheum 32:
45-53, 1989
Fauci AS, Haynes BF, Katz P: The spectrum of vasculitis:
clinical, pathological, immunological and therapeutic considerations. Ann Intern Med 89:660-676, 1978
Fauci AS, Haynes BF, Katz P, Wolff SM: Wegener’s granulomatosis: prospective clinical and therapeutic experience with 85
patients for 21 years. Ann Intern Med 98:76-85, 1983
Reply
To the Editor:
Hoffman et a1 correctly identified several important
features of our series of patients: 1) many infections occurred as complications of the underlying vasculitis (e.g.,
bowel infarction) or of procedures performed (e.g., placement of an indwelling catheter, thoracotomy); 2) the mode of
corticosteroid therapy (every other day versus daily) appeared to be related to the incidence of infection; and 3) the
duration of corticosteroid therapy, and particularly, daily
corticosteriod therapy, was longer than that previously
recommended (Cupps TR, Fauci AS: The Vasculitides.
Philadelphia, WB Saunders, 1981).
While we could not determine a causal relationship
with infection for either corticosteroid or cyclophosphamide
therapy, in 6 of 10 patients in our series who became
infected, infection occurred within 4 weeks of the initiation
of cyclophosphamide therapy. Only 2 of 10 developed an
infection within the first month of corticosteroid therapy.
While the average daily corticosteroid dosage at the onset of
the first infection was >40 mg, it was consistent with the
guidelines promulgated by Cupps and Fauci for the administration of concomitant corticosteroids during the first
month of cyclophosphamide therapy. As stated in our report, infection did not correlate with the dosage or duration
of corticosteroid therapy, but seemed more closely associated with the initiation of cyclophosphamide therapy.
We agree with Hoffman et al that in the complicated
cases we reported, it is difficult to determine the cause(s) of
the infections observed. Our report explored a number of
probable factors in addition to those mentioned herein. It
would be as much an oversimplification to attribute these
infections entirely to the corticosteroid component as it
would be to single out the cyclophosphamide component of
the therapeutic regimen.
John D. Bradley, MD
Kenneth D. Brandt, MD
Barry P. Katz, MD
Indiana University School of Medicine
Indianapolis, IN
Effect of temperature and humidity on daily pain
score in a patient with rheumatoid arthritis
To the Editor:
In studying the possible effects of weather on pain in
rheumatoid arthritis (RA), the problem arises that pain
cannot be measured. It can only be scored subjectively by
the RA patients themselves, as has been done in several
studies (1-3). Since January 1983, I have been quantifying
the RA pain of myself, a 42-year-old man, with classic,
seropositive RA, defined according to the criteria of the
American Rheumatism Association (4), who underwent joint
surgery in 1985, 1986, and 1988 (Figure 1). In order to
increase the reliability of my pain score, the scoring method
was standardized in 3 specific ways. First, scoring was done
in the morning, immediately after arising. Second, because
joint pain depends strongly upon the positioning and movements of the joints, the pain score was determined during the
execution of a standardized exercise program. Third, pain
was scored for each separate joint or group of joints (e.g.,
right hand) on a scale of &9, where 0 = no pain and 9 = very
severe pain. From January 1983 through June 1988, 21 RA
pain scores were collected daily for the hands, wrists,
elbows, shoulders, jaw, hips, knees, ankles, feet, and the
neck, back, and costosternal joints.
During scoring, I was not aware of the weather
parameters. The 24-hour means of temperature and vapor
pressure were taken from the monthly reports (5) of a local
weather station (Groningen Airport, Groningen, The Netherlands) located 3 km from my home. For time spent abroad,
data from the local weather station were substituted.
LETTERS
1628
Jan
feb
mar
apr
may
Jun
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1986
aug
sep
oct
nou
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Teb
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apr
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JW
1988
Figure 1. Plot of the daily rheumatoid arthritis (RA) pain score, vapor pressure, and temperature during the 5%-year study period. The window
and pajamas bars indicate when bedroom windows were closed overnight and when pajamas were worn. NSAID = the daily dosage of the
nonsteroidal antiinflammatory drug indomethacin (number of lines x 25 mg). Open circles depict the erythrocyte sedimentation rate (ESR;
mm/hour). Horizontal bars indicate time spent abroad. Syringes indicate the puncturing of the left or right elbow combined with injection of
a corticosteroid (triamcinolone hexacetonide, 10 mg). * = monthly mean of weather curve values. During the relatively warm, humid winter
of 1987-1988, the pain score did not decrease.
LETTERS
Each day, the scores of all joints were combined to
give a single score, henceforth called the pain score. Figure
1 shows that the pain score is generally low in winter, when
the temperature and the vapor pressure are low. A significant positive correlation was found between the pain score
and temperature or vapor pressure (r > 0.19, P < 0.005). The
value of the correlation coefficients increased when the pain
score curve and the weather curve were shifted in time in
relation to each other (weather preceding the pain score).
Maximum correlation for the relationship between pain
score and temperature was found at a time shift of 30 days (r
= 0.23, P < 0.005) and that between pain score and vapor
pressure at a time shift of 9 days (r = 0.21, P < 0.005). When
time shifts were made in the opposite direction (pain score
preceding the weather), the correlation decreased. These
results indicate a delayed effect of the weather on the pain
score, rather than a forecasting potency of the pain score
with respect to the weather.
In addition to the weather, the specific microclimate
directly surrounding the patient can affect RA pain. The
temperature and humidity of the microclimate will be affected by the weather, but also by the presence of barriers to
the transfer of heat and water vapor between the body and
the outside air, such as clothing, housing, and vehicles. At
night, such barriers separate the warm, humid air close to
the skin from the outside air, which loses water due to
condensation as the temperature decreases. In 1984, after
the removal of 2 of these nocturnal barriers (pajamas and
closed bedroom windows, but not blankets), the pain score
gradually fell to a much lower level and remained at this level
during the subsequent years (Figure 1). This improvement,
which is also expressed by a reduction in indomethacin
intake, suggests that dry air, and not warm air, diminishes
the severity of the symptoms of RA. This is supported by the
finding that stiffness in the fingers of RA patients diminishes
in dry weather (6).
Clinical interventions are both necessary and frequent in RA, but they can hamper the search for any
correlation between pain score and weather. This is illustrated by the effect of injection of corticosteroids into an
actively involved joint: A strong, but temporary (several
weeks), weather-independent reduction of the pain score is
observed (Figure 1).
These results show a relationship between the temperaturehapor pressure complex and pain score, but how
common is such a relationship in other RA patients? Three
considerations are important with respect to this question.
First, I did not feel “weather sensitive” until I started to
score my pain as previously described. Therefore, if patients
state that they are not weather sensitive, this does not
necessarily mean that the weather has no effect on their
disease symptoms. In addition, a study of 88 patients (2)
showed that I am not the only RA patient whose daily pain
score correlates significantly with temperature and humidity.
Finally, after the publication of a preliminary report of the
present study (7), many RA patients informed me that they
had experiences similar to those I had reported.
The results of this study, along with the considerations mentioned above, justify additional research on a
larger scale. If the effects found on myself turn out to be
1629
more or less widespread, manipulation of the microclimate
might become a valuable addition to the treatment of RA.
Wiebe R. Patberg, MD
University of Groningen
Groningen, The Netherlands
1. Dequeker J, Wuestenraed L: The effect of biometeorological
factors on Ritchie Articular Index and pain in rheumatoid arthritis. Scand J Rheumatol 15:28&284, 1986
2. Patberg WR, Nienhuis RLF, Veringa F: Relation between meteorological factors and pain in rheumatoid arthritis in a marine
climate. J Rheumatol 12:711-715, 1985
3. Sibley JT: Weather and arthritis symptoms. J Rheumatol 12:
707-710, 1985
4. Ropes MW, Bennett GA, Cobb S, Jacox R, Jessar RA: 1958
revision of diagnostic criteria for rheumatoid arthritis. Bull
Rheum Dis 9:175-176, 1958
5 . Koninklijk Nederlands Meteorologisch Instituut: Maandoverzicht van het weer in Nederland. 94a:7-8,January 1983-June 1988
6. Rasker JJ, Peters HJG, Boon KL: Influence of weather on
stiffness and force in patients with rheumatoid arthritis. Scand J
Rheumatol 15:27-36,1986
7. Patberg WR: Effect of weather on daily pain score in rheumatoid
arthritis. Lancet II:38&387, 1987
Arthropathy of Behcet’s disease: a case with
“pencil-in-cup” deformities
To the Editor:
Symptoms of mild joint involvement are a common
feature of BehGet’s disease. However, severe joint deformities are rare. The purpose of this report is to describe a case
of BehGet’s disease with pencil-in-cup deformities in the
fingers and toes.
The patient, a 48-year-old man, was referred for
evaluation of BehGet’s disease. He had been in good health
until 1973, when he noted pain, swelling, warmth, redness,
and stiffness in his wrists, fingers, and toes. Recurrent oral
aphthae, genital ulcers, folliculitis, and uveitis in both eyes
developed soon after the joint symptoms, and a diagnosis of
Behget’s disease was made. Subsequent therapy included
piroxicam (20 mg/day), gold sodium thiomalate (10 mg every
2 weeks), colchicine (0.5 mglday), and azathioprine (25
mg/day). These drugs and their dosages are standard for the
treatment of arthropathy of BehGet’s disease in Japan.
Arthritis in multiple joints occurred repeatedly.
The patient was referred to our clinic in 1985. Physical examination revealed arthritis in the wrists and distal
interphalangeal (DIP) joints of the fingers and toes. The
sacroiliac joints were unaffected. There were 2 oral aphthae
on the lip, and a genital ulcer in the scrotum was observed.
There was no nail-pitting or psoriasis of the skin; however,
acne-like skin eruptions were observed on his face. A needle
reaction was positive. Laboratory tests indicated an erythrocyte sedimentation rate (Westergren) of 51 mm/hour and a
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pain, scorm, effect, daily, patients, humidity, temperature, arthritis, rheumatoid
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