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Gastric volvulus and Felty's syndrome.

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LETTERS
“Last” bursitis-A
26 1
cause of ankle pain
To the Editor:
I have Seen
Of an unfamiliar
syndrome consisting of acute onset of bilateral ankle
pain and well circumscribed areas of tender swelling
around the lateral malleoli associated with the use of illfitting shoes. In each case the swellings seemed consistent with inflammatory bursae forming at soft tissue
sites subjected to recurrent irritation.
Patient 1, an elderly male with congestive heart
failure, had onset of ankle pain during an episode of
pedal edema when he noted his edematous ankles hanging over the edges of his shoes. Symptoms persisted after diuresis when localized swellings were noted around
both lateral malleoli under the area crossed by his shoe
tops. Patient 2, an adult female, noted similar swellings
within 4 days of purchasing and wearing new highheeled sandals that had only a strap for ankle support.
The tight-fitting straps directly crossed over the swollen
areas. In both cases pain was exacerbated by walking
and could be reproduced by direct palpation but not by
ankle motion. Neither patient demonstrated superficial
warmth or erythema. X-rays revealed only soft tissue
swelling. Aspiration yielded clear yellow viscous fluid
from one swollen area, but was dry in the others. Both
patients were treated with local steroid injections and
oral indomethacin and instructed to wear backless
shoes. Symptoms abated rapidly and each patient returned to wearing normal shoes within one week without recurrence of symptoms.
Bursitis as the cause of ankle pain in these 2 patients was suggested by the well-circumscribed nature of
the tender swellings, the associated soft tissue irritation
in the area, the synovial-like fluid in one of the swellings, and the response to antiinflammatory agents. Anatomically, a noninflamed subcutaneous bursa has been
described in this area, the bursa subcutanea malleoli lateralis (1,2), although reports of its involvement in disease states are unavailable. Superficial cellulitis or peroneal tendinitis are possible alternative explanations for
such symptoms around the lateral malleoli. Absence of
superficial warmth and erythema as well as lack of pain
on stretching the peroneal tendon or other ankle manipulation except direct palpation speak against these,
however.
Eponyms are a tradition for inflamed bursae.
Discussions of this syndrome at our institution suggested the name “last bursitis.” In shoemaker’s jargon
the “last” is the wooden mold or cast over which the
shoe is made and from which fit and shape are ulti-
mately determined, two characteristics which seemed
the source of soft tissue inflammation and irritation in
the present cases. Definitive identification of this ‘‘last’’
lesion as a bursitis, however, awaits further clinical experience. I would be interested in communicating with
readers who have Seen such a syndrome or a variant.
LAWRENCEF. LAYFER,MD
Section of Rheumutology
Department of Medicine
Rush Medical College
Chicago, Illinois 60612
REFERENCES
1. Cummins H: The skin and mammary glands, Morris’ Human Anatomy. Edition l l . Edited by JP Shaeffer. New
York, McGraw-Hill, 1953, pp 63-87
2. Crafts RC: A Textbook of Human Anatomy. New York,
Roland Press, 1966, p 393
Gastric volvulus and Felty’s syndrome
To the Editor:
Felty’s syndrome of rheumatoid arthritis, leukopenia, and splenomegaly occurs in somewhat less than
5% of the cases of rheumatoid disease that come to medical attention (1). The literature on this syndrome has
focused on the severity of arthritis, the prominence of
extraarticular manifestations, and the infectious complications of leukopenia and disordered leukocyte function. Gastric volvulus is an uncommon, acquired twist
of the stomach upon itself (2). To our knowledge, it has
not previously been reported as a complication of
Felty’s syndrome.
A 70-year-old white woman with American
Rheumatism Association stage 3, class 2 rheumatoid arthritis was hospitalized electively for research studies.
The duration of her rheumatoid disease was 23 years.
Extraarticular features included subcutaneous nodules
and longstanding Felty’s syndrome uncomplicated by
life-threatening infection or skin ulcers. Therapy consisted of aspirin, Naprosyn, and, in the past, brief
courses of prednisone for arthritic flares.
On physical examination she was an alert, slender, elderly, white woman with subcutaneous nodules
on the left elbow, right thumb, and left big toe. There
was mild tenderness to palpitation in forty-five joints
and mild swelling of the wrists, knees, several digital
proximal interphalangeal (PIP) joints and several metatarsophalangeal (MTP) joints. The spleen tip was barely
262
palpable at rest and descended three finger breadths below the left costal margin on deep inspiration.
The white blood count was 2,100/mm’ with 20%
neutrophils; Westergren sedimentation rate 38; serum
latex titer 2,560; antinuclear antibody titer 256 by indirect immunofluorescence of calf thymus nuclei.
On the sixth hospital day she complained of abdominal pain and fullness, and vomited a small amount
of clear fluid. Examination revealed epigastric distentation. The spleen tip had descended to six finger
breadths below the left costal margin at rest and was
non-tender. There was no rub on auscultation. Splenic
radioisotope scan revealed homogeneous uptake and a
19 cm span. Radiograph of the abdomen revealed elevation of the left hemidiaphragm, gaseous distention of
the stomach with probable gastric rotation and secondary obstruction, and the spleen overlying the left ilium
(Figure I). Nasogastric suction yielded clear, hematestnegative fluid. An x-ray study with barium contrast revealed a mixed-type gastric volvulus with the greater
curvature rotated to the right and the fundus inferiorly
positioned. No barium reached the duodenum. Further
nasogastric suction yielded 1,700 ml of mucoid fluid,
dramatically relieved the patient’s abdominal pain, and
resolved the epigastric distention. The spleen returned
to the left costal margin. A followup upper gastrointestinal series showed a ptotic stomach, the spleen tip at the
left costal margin, and splenic indentation of the stomach along the greater curvature with medial displacement.
To our knowledge, this is the first report of gastric volvulus in a patient with Felty’s syndrome. There
are three anatomical types of gastric volvulus: In the organoaxial type, the stomach twists along its long axis
between the fixed cardioesophageal junction and the
second portion of the duodenum. Mesenteroaxial volvulus occurs at right angles to organoaxial volvulus, the
stomach twisting along an imaginary line from the
lesser to the greater curvature. Mixed volvulus is a combination of the two and may be the most frequent type.
Acute gastric volvulus produces the symptoms, signs,
and radiographic manifestations of gastric outlet obstruction (2). The patient reported here had an acute
mixed volvulus.
Enlargement of the spleen can displace the organs adjacent to it: stomach, left kidney, splenic flexure
of the colon, and the left hemidiaphragm. The splenic
hilus contacts the gastric fundus. In splenomegaly, the
stomach may be medially displaced and radiographic
studies can demonstrate pressure on the greater curvature with downward displacement of the fundus (3).
LETTERS
Figure 1. Flat plate x-ray of the abdomen showing gastric distention
and rotation (white arrows indicate the greater curvature), secondary
obstruction, and the spleen overlying the left ilium (black arrowheads).
Dalgaard (4) reported a series of 150 cases of
gastric volvulus. Ten were associated with splenomegaly
or splenoptosis of diverse causes, including malignancy;
none of these patients had rheumatoid arthritis. The author noted that the gastrosplenic ligament is crucial in
maintaining the normal anatomic position of the stornach. Experiments on cadavers have shown that a 180’
rotation of the stomach is impossible unless the gastrosplenic or gastrocolic ligaments are severed (4). It seems
reasonable that the progressive splenic enlargement of
Felty’s syndrome can stretch the gastrosplenic ligament
and lead to gastric volvulus.
This patient may represent the random coincidence of two uncommon syndromes, Felty’s syndrome
and gastric volvulus. The very low probability of such a
coincidence would explain why more patients have not
been noted and reported. Alternatively, gastric volvulus
may occur as a chronic, recurrent, spontaneously resolv-
LETTERS
263
ing condition in Felty’s syndrome and go undetected.
Symptoms of minor pain, bloating, and eructation may
be indistinguishable from other organic and functional
gastrointestinal conditions (2). On retrospective questioning, our patient gave a long history of such complaints.
MICHAEL
A. CATALANO,
MD
JAMES A. USSELMAN,
MD
JOHN H. VAUGHAN,MD
Departments of Clinical Research
and Radiology
Scripps Clinic and Research
Foundation
La Jolla, CA 92037
REFERENCES
I . Decker JL: Extra-articular rheumatoid disease, Arthritis
and Allied Conditions. Eighth edition. Edited by JL Hollander, DJ McCarty. Philadelphia, Lea & Febiger, 1972, p
360
2. Raffin S: Diverticula, rupture and volvulus, Gastrointestinal Disease. Edited by MH Sleisenger, JS Fordtran. Philadelphia, WB Saunders Co., 1973, pp 612-615
3. Diix A: The spleen, Roentgen Diagnosis. Vol. V. Second
American Edition. Edited by LG Rigler. New York, Grune
and Stratton, 1967, pp 496-498
4. Dalgaard JB: Volvulus of the stomach. Acta Chir Scand
103:I3 1-153, 1952
Bed rest at home for rheumatoid arthritis
To the Editor:
Systemic and articular rest have been shown to
meliorate rheumatoid arthritis (RA) in hospitalized patients (l-4), and the amount of physical activity was reported not to influence the result (5): Hospitalized patients improved compared to outpatients, suggesting
that hospitalization alone was responsible for the
change (6,7), and yet recent reports consider bed rest
important in the therapy of RA (8,9). The data reported
here evaluate patients with RA on bed rest at home in
an effort to better define its role in the treatment of RA.
Twenty-two patients on bed rest at home for the
treatment of RA were evaluated in a retrospective
study. There were 17 women and 5 men whose average
age was 48 years (range 21 to 7 1 years) and average duration of RA was 67 months (range 3 to 360 months).
Three patients had rheumatoid nodules, and latex floc-
ulation was positive in 6 patients. All patients were classified according to the criteria of the American Rheumatism Association as definite or classic (10) and were
in Functional Classes I1 or I11 at entry into the study.
The patients were instructed to rest in bed at least 2
hours in the morning and afternoon and 10 hours at
night; some patients were placed on complete bed rest
except for self-care. After this period of bed rest, the patients were advised to have l to 2 hours’ bed rest midday and 10 at night, with additional rest as needed in an
attempt to prevent fatigue.
At each visit, subjective assessment of pain was
graded: none, grade 0 mild, grade 1; moderate, grade 2;
and severe, grade 3. Morning stiffness of less than one
hour was grade 1; 1 to 2% hours, grade 2; 3 to 4 hours,
grade 3; and more than 4 hours, grade 4. The onset of
fatigue 10 to 12 hours after arising was grade 1; 7 to 9%
hours, grade 2; 5 to 6% hours, grade 3; and 4% hours or
less, grade 4. The “subjective score” is the sum of the
grades of pain, morning stiffness, and fatigue for each
patient. Each joint was graded 0 if no synovial thickening, grade 1 mild, grade 2 moderate, and grade 3 if
marked. The sum of the grades of these joints is the
“joint score.” The number of tender joints was recorded. The patients were examined at the beginning
and at the end of the period of rest, and 21 patients were
examined on followup visit at 6 months. All patients
were seen at each visit by the same physician. The duration of the period of rest ranged from 14 to 150 days, averaging 47 days. No significant changes in drug therapy
occurred during the period of bed rest, except for a
slight reduction in the average dose of prednisone
(Table 1).
All 22 patients improved at least one subjective
grade. Fatigue was a major symptom in all 22 patients
and 13 also complained of “exhaustion.” No patient
complained of “exhaustion” at the end of the period of
rest or at the 6-month followup examination. The number of swollen joints improved in nearly all patients, esTable 1. Drug therapy
Study period
Total no. of patients
Aspirin. no. of patients
Average dose, gm/dl
NSAID,’ no. of patients
Prednisone, no. of patients
Average dose, mg/dl
Gold, no. of patients
Start
End
22
19
3.13
2
5
8.2
2
22
19
4.14
2
5
* Nonsteroidal antiinflammatory drug.
Followup,
6months
21
16
4.22
3
2
6.9
7
2
3
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