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BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXIX NO. 5
The mean total testosterone was 11.6 nmol/1 (± 3.5 SD). In keeping with previous research, this is at the lower end of the physiological range (9.0-25.0 nmol/l). The demographic variables showed no correlation with free or total testosterone. The clinical variables of disease activity, duration and drug history showed no hormone associations. There was no correlation between rheumatoid factor titre and hormone levels. The ESR was negatively correlated with total testosterone (r = —0.4, P = 0.02) but positively associated with free testosterone (r = +0.4, P = 0.02). The 8 patients scoring 10 or more on the depression scale of the H ADS ('depressed') had a similar total testosterone (11.5 nmol/1 [± 2.2]) to the 22 scoring below this level (11.7 nmol/1 [± 3.9]). The 'depressed' patients had a higher mean free testosterone (447 pmol/1 [± 432] versus 286 pmol/1 [± 217]) but this was not significant on a Mann-Whitney U-test. Similar results were shown on the anxiety scale with those scoring 10 or more having a nonsignificantly higher level of free testosterone (417 pmol/1 [± 401] versus 291 pmol/1 [± 219]). We conclude that depression and anxiety are unlikely to account for lower levels of free testosterone in RA. An alternative explanation for this observation is still required. D. C. SWINDEN, C. M. DEIGHTON, K. NOIT, M. WATSON
Departments of Rheumatology, Psychology and Clinical Biochemistry, University of Newcastle upon Tyne NE1 4LP Received 3 May 1990 1. Spector TD. Sex hormone measurements in rheumatoid arthritis. Br J Rheumatol 1989;28(suppl l):62-8. 2. Frank GN, Beck NC, Parker JC, et al. Depression in rheumatoid arthritis. J Rheumatol 1988; 15:920-5. 3. Vogel W, Klaiber FL, Broverman DM. Roles of the gonadal steroid hormones in psychiatric depression in men and women. Prog Neuropsychopharmacol 1978;2:487-503. 4. Zigmoid AS, Snaith RP. The Hospital Anxiety and Depression Scale. Ada Psychiatr Scand I983;67:361-7O. 5. Anderson DC, Thorner MO, Fisher RA, et al. Effects of hormonal treatment on plasma unbound androgen levels in hirsute women. Ada Endocrinol 1975;199(suppl 1):224. Back Pain, Lung Cancer and Adrenal Metastases SIR—Adrenal metastases are a common occult finding in patients with lung tumours [1]. Although backache has been a presenting symptom in patients with primary adrenal tumours there are no reports in the literature of backache occurring in patients with adrenal metastases. We present two such cases. Case 1 A 43-year-old heavy smoker presented in Feb 1989 with a cough unresponsive to antibiotics. On examination he was clubbed and noted to have right supraclavicular lymphadenopathy. A chest radiograph showed an enlarged right hilum. Excision biopsy of the nodes was performed and showed metastatic adenocarcinoma. A bronchoscopy showed an infiltrating oat-cell tumour in the right upper lobe bronchus. A full blood count, liver function tests and an abdominal ultrasound were normal. He was treated with a split course of radiotherapy to the neck nodes and mediastinum which he tolerated well but 2 months later he developed pain in the right lower costal region on the posterior surface. A bone scan was normal and plain radiography of the lumbar spine was unremarkable, but an ultrasound showed metastases in the adrenal glands.
He was given a course of chemotherapy (mitomycin C, cisplatin and ifosfamide) and following this, his symptoms of back pain improved. A repeat ultrasound showed a regression of the adrenal metastases and the patient is now asymptomatic. Case 2 A 70-year-old woman presented in 1981 with an adenocarcinoma of the left lower lobe which was treated by resection. Six years later she presented with upper lumbar back pain radiating to her abdomen. A bone scan showed hot spots over left lower ribs due to old rib fractures confirmed on plain rib radiographs and plain radiography of the lumbar spine revealed no lumbar metastases. An abdominal ultrasound showed bilateral adrenal metastases the larger metastases being in the right adrenal and measuring 10 by 7 cm. Following treatment with local radiotherapy there was a resolution of her back pain. Adrenal metastases from primary lung tumours are a common occurrence and may be present in up to 35% of cases. They are often clinically occult [1]. Back pain is a relatively common non-specific symptom but in a patient with a carcinoma of the lung the presence of bony metastases should first be excluded as a cause. Bone scans are the best method for excluding bony metastases [2]. If the back pain persists, the possibility of intra-abdominal metastases should be raised. The diagnosis may be made on abdominal ultrasound or on abdominal CT. Abdominal CT scans have been shown not to be useful in pretreatment staging and routine follow-up because other tumour masses are evaluable for treatment follow-up [3]. However, if a patient develops back pain following treatment of his primary lung tumour and has a negative bone scan, an ultrasound or CT scan of his abdomen should be performed to look for metastatic disease in the adrenal glands. Histological confirmation can be obtained by CT guided biopsy [4]. It is important to be aware that adrenal metastases can be a cause of back pain in the patient with known malignancy as treatment can result in a good symptomatic response as in our two cases. A. BANERJEE, P. CARVALHO
Department of Radiology, Westminster Hospital, Dean Ryle Street, London SW1P2AP Received 5 May ] 990 1. Dunnick NR, Ihde DC, Johnston-Early A. Abdominal CT in the evaluation of small cell carcinoma of the lung. Am J Radioll979;l33:\085-8. 2. Levenson RM, Sauerbrunn BJL, Ihde DC, Bunn PA, Cohen MH, Minna JD. Small cell lung cancer—radionuclide bone scans for assessment of tumour extent and response. Am J Radiol\98l;l31:3\-5. 3. Ihde DC, Dunnick NR, Johnston-Early A, Bunn PA, Cohen MH, Minna JD. Abdominal CT in small cell lung cancer: assessment of extent of disease and response to therapy. Cancer 1982;49:1485-90. 4. Papani JJ. Normal adrenal glands in small cell lung carcinoma: CT guided biopsy. Am J Radiol 1983;140:949-51. Acute Inflammatory Polyarthritis Following Streptokinase SIR—Streptokinase is now given routinely in cases of acute myocardial infarction. There have been several case reports of serum sickness-like reactions to streptokinase [1-8]. Such reactions may take the form of fevers with arthritis, but we would like to report a case with severe arthritis, initially suspected as a septic arthritis or polyarticular gout.
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXIX NO. 5
The mean total testosterone was 11.6 nmol/1 (± 3.5 SD). In keeping with previous research, this is at the lower end of the physiological range (9.0-25.0 nmol/l). The demographic variables showed no correlation with free or total testosterone. The clinical variables of disease activity, duration and drug history showed no hormone associations. There was no correlation between rheumatoid factor titre and hormone levels. The ESR was negatively correlated with total testosterone (r = —0.4, P = 0.02) but positively associated with free testosterone (r = +0.4, P = 0.02). The 8 patients scoring 10 or more on the depression scale of the H ADS ('depressed') had a similar total testosterone (11.5 nmol/1 [± 2.2]) to the 22 scoring below this level (11.7 nmol/1 [± 3.9]). The 'depressed' patients had a higher mean free testosterone (447 pmol/1 [± 432] versus 286 pmol/1 [± 217]) but this was not significant on a Mann-Whitney U-test. Similar results were shown on the anxiety scale with those scoring 10 or more having a nonsignificantly higher level of free testosterone (417 pmol/1 [± 401] versus 291 pmol/1 [± 219]). We conclude that depression and anxiety are unlikely to account for lower levels of free testosterone in RA. An alternative explanation for this observation is still required. D. C. SWINDEN, C. M. DEIGHTON, K. NOIT, M. WATSON
Departments of Rheumatology, Psychology and Clinical Biochemistry, University of Newcastle upon Tyne NE1 4LP Received 3 May 1990 1. Spector TD. Sex hormone measurements in rheumatoid arthritis. Br J Rheumatol 1989;28(suppl l):62-8. 2. Frank GN, Beck NC, Parker JC, et al. Depression in rheumatoid arthritis. J Rheumatol 1988; 15:920-5. 3. Vogel W, Klaiber FL, Broverman DM. Roles of the gonadal steroid hormones in psychiatric depression in men and women. Prog Neuropsychopharmacol 1978;2:487-503. 4. Zigmoid AS, Snaith RP. The Hospital Anxiety and Depression Scale. Ada Psychiatr Scand I983;67:361-7O. 5. Anderson DC, Thorner MO, Fisher RA, et al. Effects of hormonal treatment on plasma unbound androgen levels in hirsute women. Ada Endocrinol 1975;199(suppl 1):224. Back Pain, Lung Cancer and Adrenal Metastases SIR—Adrenal metastases are a common occult finding in patients with lung tumours [1]. Although backache has been a presenting symptom in patients with primary adrenal tumours there are no reports in the literature of backache occurring in patients with adrenal metastases. We present two such cases. Case 1 A 43-year-old heavy smoker presented in Feb 1989 with a cough unresponsive to antibiotics. On examination he was clubbed and noted to have right supraclavicular lymphadenopathy. A chest radiograph showed an enlarged right hilum. Excision biopsy of the nodes was performed and showed metastatic adenocarcinoma. A bronchoscopy showed an infiltrating oat-cell tumour in the right upper lobe bronchus. A full blood count, liver function tests and an abdominal ultrasound were normal. He was treated with a split course of radiotherapy to the neck nodes and mediastinum which he tolerated well but 2 months later he developed pain in the right lower costal region on the posterior surface. A bone scan was normal and plain radiography of the lumbar spine was unremarkable, but an ultrasound showed metastases in the adrenal glands.
He was given a course of chemotherapy (mitomycin C, cisplatin and ifosfamide) and following this, his symptoms of back pain improved. A repeat ultrasound showed a regression of the adrenal metastases and the patient is now asymptomatic. Case 2 A 70-year-old woman presented in 1981 with an adenocarcinoma of the left lower lobe which was treated by resection. Six years later she presented with upper lumbar back pain radiating to her abdomen. A bone scan showed hot spots over left lower ribs due to old rib fractures confirmed on plain rib radiographs and plain radiography of the lumbar spine revealed no lumbar metastases. An abdominal ultrasound showed bilateral adrenal metastases the larger metastases being in the right adrenal and measuring 10 by 7 cm. Following treatment with local radiotherapy there was a resolution of her back pain. Adrenal metastases from primary lung tumours are a common occurrence and may be present in up to 35% of cases. They are often clinically occult [1]. Back pain is a relatively common non-specific symptom but in a patient with a carcinoma of the lung the presence of bony metastases should first be excluded as a cause. Bone scans are the best method for excluding bony metastases [2]. If the back pain persists, the possibility of intra-abdominal metastases should be raised. The diagnosis may be made on abdominal ultrasound or on abdominal CT. Abdominal CT scans have been shown not to be useful in pretreatment staging and routine follow-up because other tumour masses are evaluable for treatment follow-up [3]. However, if a patient develops back pain following treatment of his primary lung tumour and has a negative bone scan, an ultrasound or CT scan of his abdomen should be performed to look for metastatic disease in the adrenal glands. Histological confirmation can be obtained by CT guided biopsy [4]. It is important to be aware that adrenal metastases can be a cause of back pain in the patient with known malignancy as treatment can result in a good symptomatic response as in our two cases. A. BANERJEE, P. CARVALHO
Department of Radiology, Westminster Hospital, Dean Ryle Street, London SW1P2AP Received 5 May ] 990 1. Dunnick NR, Ihde DC, Johnston-Early A. Abdominal CT in the evaluation of small cell carcinoma of the lung. Am J Radioll979;l33:\085-8. 2. Levenson RM, Sauerbrunn BJL, Ihde DC, Bunn PA, Cohen MH, Minna JD. Small cell lung cancer—radionuclide bone scans for assessment of tumour extent and response. Am J Radiol\98l;l31:3\-5. 3. Ihde DC, Dunnick NR, Johnston-Early A, Bunn PA, Cohen MH, Minna JD. Abdominal CT in small cell lung cancer: assessment of extent of disease and response to therapy. Cancer 1982;49:1485-90. 4. Papani JJ. Normal adrenal glands in small cell lung carcinoma: CT guided biopsy. Am J Radiol 1983;140:949-51. Acute Inflammatory Polyarthritis Following Streptokinase SIR—Streptokinase is now given routinely in cases of acute myocardial infarction. There have been several case reports of serum sickness-like reactions to streptokinase [1-8]. Such reactions may take the form of fevers with arthritis, but we would like to report a case with severe arthritis, initially suspected as a septic arthritis or polyarticular gout.
