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Disappearance of chondrocalcinosis following reflex sympathetic dystrophy syndrome.

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747
LETTERS
Package inserts of antirheumatic and
antiarthritic drugs
To the Editor:
Gaysal, recommended as an analgesic and antiarthritic by the manufacturer, Geriatric Pharmaceutical
Corporation, is a mixture of acetaminophen, sodium salicylates, and 2 barbiturates. The package insert, however, does not warn against drowsiness. It is not clear to
me why an antiarthritic drug, which needs to be taken
frequently and throughout the day, should include
sedatives. In addition, the dosage recommendation is
open-ended, which can cause a great deal of harm when
using habit-forming drugs (“Two or more tablets, as
necessary, after meals and before retiring” [italics
mine]). There is also no mention about the possible effects of heavy sedation on driving, nor of glaucoma or
increased intraocular pressure in the target population,
who are likely to be composed of the elderly. This lack
of a glaucoma warning is all the more reprehensible because Geriatric also makes Gustase-Plus, which contains the same amount of phenobarbital as Gaysal and
contraindicates glaucoma in its insert.
The AMA Drug Evaluations (Third Edition,
page 375) notes that acetaminophen is not a substitute
for aspirin since it has no antiinflammatory action. The
medical community that treats arthritis and rheumatism
may be able to press for reformulation and improved
package inserts.
PETERBARNA,MSc
Anaheim, CA
B7-CREG in arthritis associated with
pyoderma gangrenosum
To the Editor:
In a recent article (1) Holt et a1 described the occurrence of arthritis in 8 of 15 patients with pyoderma
gangrenosum. Two of these patients had classic rheumatoid arthritis, 1 had ulcerative colitis, and the other 5
had symmetrical seronegative polyarthritis which in one
was accompanied by bilateral sacroiliitis. HLA typing
performed in 13 patients failed to disclose association of
pyoderma gangrenosum with any A or B loci antigens.
Since a public antigen common to the B7-CREG
(antigens B7, Bw22, B40, and Bw42) group has recently
been shown to have a stronger association than any of
Table 1. The occurrence of B7-CREG antigens in 13 patients
B7-CREG antigen
Group
Present
Absent
Arthritis
Nonarthritis
5
0
3
5
Total
8
5
these antigens with the seronegative spondylarthropathies (2), we analyzed Holt’s data for the occurrence of
B7-CREG antigens (Table 1). Interestingly, one of the
B7-CREG antigens was present in each of the 5 arthritis
patients, but in only 3 of the 8 subjects without joint involvement. Although the size of the sample does not
permit statistical analysis, the tendency observed appears to link the articular syndrome of pyoderma gangrenosum to the seronegative spondylarthropathies. Further studies should clarify the significance of this
observation.
MD
TOMASS. BOCANEGRA,
GARYSLADEK,
MD
BERNARDF. GERMAIN,
MD
FRANKB. VASEY,MD
LUISR. ESPINOZA,
MD
University of South Florida
Tampa, FL 33612
Holt PJ, Davies MG, Saunders KC, Fimls NG: Pyoderma
gangrenosum: clinical and laboratory findings in 15 patients with special reference to polyarthritis. Medicine
(Baltimore) 59:114-133, 1980
McLain DA, Luehrman LK, Rodey GE, Schwartz BD: An
HLA public antigen is more common than HLA-B27 in
patients with ankylosing spondylitis (abstract). Arthritis
Rheum 23:718, 1980
Disappearance of chondrocalcinosis following
reflex sympathetic dystrophy syndrome
To the Editor:
Articular chondrocalcinosis is the most conspicuous radiologic feature of calcium pyrophosphate
dihydrate (CPPD) crystal deposition disease (1). The
calcification, however, may be absent both early and
late in the course of the disease (2).
748
LETTERS
A 99"Tc-diphosphonate bone scintiscan showed
increased periarticular uptake in the left wrist and the
metacarpophalangeal and interphalangeal joints (Figure 4). Laboratory investigations revealed hemoglobin
of 12.8 gm/100 ml, leukocyte count 8,700/mm3 with a
normal differential, an erythrocyte sedimentation rate
of 22 mm/hour (Westergren), and negative rheumatoid
and antinuclear factors. Serum calcium, phosphorus, alkaline phosphatase, magnesium, uric acid, iron, and total iron-binding capacity were all normal.
A diagnosis of post-traumatic reflex sympathetic
dystrophy syndrome (RSDS) was made. The patient
was treated with analgesics and a program of graduated
exercises of the affected hand and made a favorable re-
Figure 1. Radiographs of the left wrist showing calcification of triangular cartilage (February 1980).
We recently had occasion to see a patient in
whom local chondrocalcinosis disappeared following reflex sympathetic dystrophy syndrome.
A 64-year-old woman fell in February 1980, sustaining a bruise of the left upper arm. Eight days later,
the left wrist and hand became painfully swollen, and
joint movement was limited. Roentgenograms were mistakenly interpreted as showing a fractured scaphoid,
and a below-elbow cast was applied for 4 weeks. An incidental finding was the presence of calcification of the
triangular cartilage of the left wrist (Figure 1). A limited
radiologic survey revealed calcification of knee menisci
and the triangular cartilage of the right wrist. No calcification was evident in the symphysis pubis, shoulders, or
hips.
The left wrist and the entire hand remained
swollen after the cast was removed, and were very painful and cool with pitting edema, bluish-red discoloration, periarticular tenderness, and painful limitation of joint movement. Repeat roentgenograms
revealed complete disappearance of the left wrist
chondrocalcinosis without narrowing of joint space
(Figure 2) and marked patchy osteopenia of the wrist
and entire left hand (Figure )* The
in the
knees and opposite wrist persisted.
Figure 2. Repeat radiographs in April 1980 showing disappearance of
cartilaginous calcification.
LETTERS
Figure 3. Radiographs of the hands showing patchy osteopenia of the
left hand and wrist.
sponse. After 3 months, pain and swelling had markedly
diminished and movements in all joints had returned to
approximately 80% of normal. Repeat roentgenograms
in September 1980 were unchanged.
Chondrocalcinosis is generally irreversible, although in advanced pyrophosphate arthropathy, cartilage destruction may result in reduction or disappearance of radiologic calcification (2,3).
The exact mechanism by which cartilaginous
calcification disappeared in this patient with RSDS is
not clearly understood. Two possibilities were considered. First, CPPD deposits in cartilage are thought to be
749
in a thermodynamic equilibrium with ambient calcium
and phosphate ions (4). Conditions that either lower
ionized calcium or bind phosphate by chelation enhance the solubility and release of crystals from cartilage (5). Whether similar conditions exist locally in
RSDS is not known. Second, increased local blood flow,
a known mediator of demineralization (6), has been
suggested as the underlying mechanism for bone resorption and loss of mineral content in RSDS (7,8).
Thus, it is possible that the resolution of
chondrocalcinosis in our patient was indirectly related
to the enhanced synovial and bone vascularity observed
in RSDS (7,8). We hope that this interesting observation may stimulate further interest in the mechanisms of
CPPD crystal formation and dissolution in articular
cartilage. (9).
ADELG. FAM,MD, FRCP (C)
JACKSTEIN,MD, FRCP (C)
Rheumatic Disease Unit
Sunnybrook Medical Centre
University of Toronto
Toronto, Canada
1. Genant HK: Roentgenographic aspects of calcium pyro-
2.
3.
4.
5.
6.
7.
8.
9.
Figure 4. 99mTc-diphosphonatebone scan showing increased activity
in all joints of the left hand.
phosphate dihydrate crystal deposition disease (pseudogout). Arthritis Rheum 19(suppl 3):307-328, 1976
McCarty DJ, Editor: Calcium pyrophosphate dihydrate
crystal deposition disease: nomenclature and diagnostic
criteria. Ann Intern Med 87:240-242, 1977
Zitnan D, Sitaj S: Natural course of articular chondrocalcinosis. Arthritis Rheum 19(suppl 3):363-390, 1976
McCarty DJ: Calcium pyrophosphate dihydrate crystal
deposition disease (pseudogout syndrome): clinical aspects.
Clin Rheum Dis 3(1):61-89, 1977
Bennett RM, Lehr JR, McCarty DJ: Crystal shedding and
acute pseudogout: an hypothesis based on a therapeutic
failure. Arthritis Rheum 19:93-97, 1976
Feist JH: The biologic basis of radiologic findings in bone
disease: recognition and interpretation of abnormal bone
architecture. Radio1 Clin N Am 8(2):183-206, 1970
Stolte BH, Stolte JB, Leyten JF: De pathofysiologic von ist
schoulder-hand syndroom. Ned Tijdschr Geneeskd
114:1208-1214, 1970
Genant HK, Kozin F, Bekerman C, McCarty DJ, Sims J:
The reflex sympathetic dystrophy syndrome. Radiology
117:21-32, 1975
McCarty DJ, Palmer DW, James C: Clearance of calcium
pyrophosphate dihydrate crystals in vivo. 11. Studies using
triclinic crystals doubly labeled with 45Caand "Sr. Arthritis Rheum 22:1122-1131, 1979
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reflexi, syndrome, following, chondrocalcinosis, sympathetic, disappearances, dystrophy
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