188
it illustrates one of the first physicians, Dr. William
Oliver, together with a surgeon, Air. Peirce, examining a hand of a patient. This surely represents the first example of a combined rlieumatological and orthopaedic clinic. T h e man has a paralysis probably due to lead poisoning, and the boy a rash that is described as leprosy. M.D., M.R.C.P. Consultant and Senior Lecturer in Rheumatology Royal National Hospital for Rheumatic Diseases, Bath Department of Medicine, University of Bristol M.I.V. JAYSON,
Exophthalmos Associated with Systemic Lupus Erythematosus T o the Editor: Recent reports of previously unrecognized ocular manifestations of rheumatic disease (1-3) p-ompt us to describe a n occurrence of bilateral exophthalmos in a patient with systemic lupus erythematosus (SLE). A 52-year-old black woman was well until 1961 when a n indurated, centrally hyperpigmented malar eruption developed. LE cell preparations were negative. A skin biopsy was consistent with discoid lupus erythematosus. Chloroquine therapy was instituted, but the patient was lost to followup. Between 1967 and 1971 she was seen and treated symptomatically in a drop-in clinic for “cervical neuralgia,” “achilles tendonitis,” and on three occasions for pleuritis. In S e p tember 1971 she presented to an ophthalmologist with a 1-week history of pain and pruritis oE the left eye. She was found to have a marked chemosis in addition to a striking exophthalmos. Fundoscopic examination, sinus films, orbital fiilms, and thyroid chemistries were all normal. Institution of 60 mg of prednisone daily was followed by a rapid resolution of her exophthalmos. Over the ensuing 6 months the patient experienced three exacerbations before being evaluated by the medical service. She had never experiencd arthralgias, photosensitivity, or Raynaud’s phenomenon. Abnormal physical findings were limited to a ditiuse nonscarring alopecia and atrophic, pitted skin over the malar eminences. Creatinine clearance, urinary sediment, and 24-hour urinary protein were normal. T, resin retention was 38%, thyroxine iodine 8.5 mcg% with a resultant free thyroxine index of 3.2 (normal: 1.1 to 4.1). Direct and indirect antiglobulin tests with both anti-IgG and anti-B,C/B,A antisera were negative. Abnormal laboratory data consisted of a hemato-
crit of 34%, an absolute neutropenia (1900/m13), ERS’s of 3 8 4 0 mm/hr, positive antinuclear antibody tests (diffuse), and repeatedly positive LE preparations. Immunofluorescent studies on skin biopsies (kindly carried out by Dr. D. L. Tuffanelli) were positive in involved areas. Long-acting thyroid stimulator (LATS) was not detected (assayed by Bio-science Laboratories, Van Nuys, California). A T, suppression test was normal. Coincident with evaluation (while off steroids), symptomatic and objective exophthalmos recurred (Figure 1). Hertel exophthalmometry, at a baseline of 100, yielded 0s measurments of 20 mm and OD measurements of 17 mm. Prednisone therapy, 40 mg daily, was reinstituted with prompt resolution. While the steroids were being tapered, the patient developed findings in the right eye identical to those previously observed in the left. Remission again followed an increase in steroid dosage. We report a patient with recurrent exophthalmos believed to be a manifestation of SLE. T h e diag-
Fig 1. Exophthalmos of the left eye before steroid therapy.
189
nosis of SLE in this patient rests on characteristic laboratory and skin biopsy data (4) in a patient with a compatible clinical course. Taken together, the observations of alopecia, “pleuritis,” “tendonitis,” antinuclear antibodies, positive LE preparations, leukopenia, and anemia are consistent with SLE. Subsequent to the study of our patient, a similar case has been reported (3). T h a t patient, who presented with unilateral exophthalmos, came to surgery because of a palpable intraorbital mass and was shown to have pseudotumor of the lacrimal gland. She developed fulminent SLE in the immediate postoperative period. It seems possible that the exophthalmos in our patient also reflected a similar localized inflammatory process. Our patient is reported to emphasize that pseudotumor oculi can occur with SLE. T h e rheumatic diseases should be considered in the differential diagnosis of exoph thalmos.
REFERENCES 1. Arnett FC, Michels RG: Inflammatory ocular myopathy
in systemic sclerosis (scleroderma). A case report and review of the literature. Arch Intern Med 132:740-748, 1973 2. Dorwart BB: Periorbital edema in progressive systemic sclerosis. Ann Intern Med 80:273, 1974 3. Burkhalter E: Unique presentation of systemic lupus erythematosus. Arthritis Rheum 16:428, 1973 4. Kay DM, Tuffanelli DL: Immunofluorescent techniques in clinical diagnosis of cutaneous disease. Ann Intern Med 7 1 :753-762, 1969 5. Manschot WA: The eye in collagen diseases. Adv Ophthalmol 11: 1-82, 1961 LEE S . WILKINSON, M.D. Department of Hematology University of California Medical Center Sun Francisco, California RICHARD S. PANUSH, M.D. Chief, Rheumatology Service Veterans Administration Hospital Gainemille, Florida
BOOK REVIEW ~
~
Total Management of the Arthritic Patient. Edited by George M . Ehrlich, M.D. Philadelphia, J.B.Lippincott Company, 1973,265 pages. Price: $20. What should one think of a book that devotes one of eleven chapters to sexual problems of the arthrit-
ic patient? Is this really a worry of that nice lady I thought was concerned only with remembering her aspirin, listening for tinnitus, and faithfully carrying out quadriceps exercises? You bet it is, and the presence of such a chapter proclaims that this book devotes at least as much attention to problems facing the rheumatic patient as it does to problems facing the rheumatologist. With seven contributors George Ehrlich discusses various aspects in the management of patients with chronic rheumatic diseases. Appropriately, the emphasis is on rheumatoid arthritis and, reflecting their own experience, the writers focus on patients with more severe disease and greater disability. Although such patients constitute a minority of all those with rheumatic diseases, this selection is appropriate too, because they are the ones who require the most help. It is an attractive book, strewn with 154 good photographic illustrations, even though not every one of them is worth a thousand words. I found no errors of typography and very few of fact-such as making a diagnosis of gouty arthritis of the spine by the response to uricosuric medication. T h e expected chapters on medical and surgical treatment are here, but detailed sections also deal with psychological and social problems, functional testing, return to employment, community resources, and, as mentioned, sexual function. T h e brief chapter on splinting is sensible and practical, although I would have placed the 26 photographs of steps in making a wrist splint in an appendix. There is no presentation of physical therapy modalities as such, and, to my surprise and delight, paraffin baths are never mentioned. By far the longest chapter-50 pages-is devoted to surgery. It presents the anatomy, various operations, indications, duration of hospitalization, anesthesia, complications, and expected outcome for each joint. T h e approach is aggressive and more optimistic in its anticipated results than I have found true. My reservations about this chapter reflect my difficulty in identifying the appropriate audience for whom the book is intended. Perhaps it is best to consider that different chapters offer something to almost everyone taking care of patients with rheumatic diseases, including primary physicians and other health professionals. While much of the contents will be familiar to rheumatologists, the basic message that there is more to evaluating outcome than sedimentation rate and grip strength provides a salutary reminder to all of us whose daily preoccupations incline us to look
it illustrates one of the first physicians, Dr. William
Oliver, together with a surgeon, Air. Peirce, examining a hand of a patient. This surely represents the first example of a combined rlieumatological and orthopaedic clinic. T h e man has a paralysis probably due to lead poisoning, and the boy a rash that is described as leprosy. M.D., M.R.C.P. Consultant and Senior Lecturer in Rheumatology Royal National Hospital for Rheumatic Diseases, Bath Department of Medicine, University of Bristol M.I.V. JAYSON,
Exophthalmos Associated with Systemic Lupus Erythematosus T o the Editor: Recent reports of previously unrecognized ocular manifestations of rheumatic disease (1-3) p-ompt us to describe a n occurrence of bilateral exophthalmos in a patient with systemic lupus erythematosus (SLE). A 52-year-old black woman was well until 1961 when a n indurated, centrally hyperpigmented malar eruption developed. LE cell preparations were negative. A skin biopsy was consistent with discoid lupus erythematosus. Chloroquine therapy was instituted, but the patient was lost to followup. Between 1967 and 1971 she was seen and treated symptomatically in a drop-in clinic for “cervical neuralgia,” “achilles tendonitis,” and on three occasions for pleuritis. In S e p tember 1971 she presented to an ophthalmologist with a 1-week history of pain and pruritis oE the left eye. She was found to have a marked chemosis in addition to a striking exophthalmos. Fundoscopic examination, sinus films, orbital fiilms, and thyroid chemistries were all normal. Institution of 60 mg of prednisone daily was followed by a rapid resolution of her exophthalmos. Over the ensuing 6 months the patient experienced three exacerbations before being evaluated by the medical service. She had never experiencd arthralgias, photosensitivity, or Raynaud’s phenomenon. Abnormal physical findings were limited to a ditiuse nonscarring alopecia and atrophic, pitted skin over the malar eminences. Creatinine clearance, urinary sediment, and 24-hour urinary protein were normal. T, resin retention was 38%, thyroxine iodine 8.5 mcg% with a resultant free thyroxine index of 3.2 (normal: 1.1 to 4.1). Direct and indirect antiglobulin tests with both anti-IgG and anti-B,C/B,A antisera were negative. Abnormal laboratory data consisted of a hemato-
crit of 34%, an absolute neutropenia (1900/m13), ERS’s of 3 8 4 0 mm/hr, positive antinuclear antibody tests (diffuse), and repeatedly positive LE preparations. Immunofluorescent studies on skin biopsies (kindly carried out by Dr. D. L. Tuffanelli) were positive in involved areas. Long-acting thyroid stimulator (LATS) was not detected (assayed by Bio-science Laboratories, Van Nuys, California). A T, suppression test was normal. Coincident with evaluation (while off steroids), symptomatic and objective exophthalmos recurred (Figure 1). Hertel exophthalmometry, at a baseline of 100, yielded 0s measurments of 20 mm and OD measurements of 17 mm. Prednisone therapy, 40 mg daily, was reinstituted with prompt resolution. While the steroids were being tapered, the patient developed findings in the right eye identical to those previously observed in the left. Remission again followed an increase in steroid dosage. We report a patient with recurrent exophthalmos believed to be a manifestation of SLE. T h e diag-
Fig 1. Exophthalmos of the left eye before steroid therapy.
189
nosis of SLE in this patient rests on characteristic laboratory and skin biopsy data (4) in a patient with a compatible clinical course. Taken together, the observations of alopecia, “pleuritis,” “tendonitis,” antinuclear antibodies, positive LE preparations, leukopenia, and anemia are consistent with SLE. Subsequent to the study of our patient, a similar case has been reported (3). T h a t patient, who presented with unilateral exophthalmos, came to surgery because of a palpable intraorbital mass and was shown to have pseudotumor of the lacrimal gland. She developed fulminent SLE in the immediate postoperative period. It seems possible that the exophthalmos in our patient also reflected a similar localized inflammatory process. Our patient is reported to emphasize that pseudotumor oculi can occur with SLE. T h e rheumatic diseases should be considered in the differential diagnosis of exoph thalmos.
REFERENCES 1. Arnett FC, Michels RG: Inflammatory ocular myopathy
in systemic sclerosis (scleroderma). A case report and review of the literature. Arch Intern Med 132:740-748, 1973 2. Dorwart BB: Periorbital edema in progressive systemic sclerosis. Ann Intern Med 80:273, 1974 3. Burkhalter E: Unique presentation of systemic lupus erythematosus. Arthritis Rheum 16:428, 1973 4. Kay DM, Tuffanelli DL: Immunofluorescent techniques in clinical diagnosis of cutaneous disease. Ann Intern Med 7 1 :753-762, 1969 5. Manschot WA: The eye in collagen diseases. Adv Ophthalmol 11: 1-82, 1961 LEE S . WILKINSON, M.D. Department of Hematology University of California Medical Center Sun Francisco, California RICHARD S. PANUSH, M.D. Chief, Rheumatology Service Veterans Administration Hospital Gainemille, Florida
BOOK REVIEW ~
~
Total Management of the Arthritic Patient. Edited by George M . Ehrlich, M.D. Philadelphia, J.B.Lippincott Company, 1973,265 pages. Price: $20. What should one think of a book that devotes one of eleven chapters to sexual problems of the arthrit-
ic patient? Is this really a worry of that nice lady I thought was concerned only with remembering her aspirin, listening for tinnitus, and faithfully carrying out quadriceps exercises? You bet it is, and the presence of such a chapter proclaims that this book devotes at least as much attention to problems facing the rheumatic patient as it does to problems facing the rheumatologist. With seven contributors George Ehrlich discusses various aspects in the management of patients with chronic rheumatic diseases. Appropriately, the emphasis is on rheumatoid arthritis and, reflecting their own experience, the writers focus on patients with more severe disease and greater disability. Although such patients constitute a minority of all those with rheumatic diseases, this selection is appropriate too, because they are the ones who require the most help. It is an attractive book, strewn with 154 good photographic illustrations, even though not every one of them is worth a thousand words. I found no errors of typography and very few of fact-such as making a diagnosis of gouty arthritis of the spine by the response to uricosuric medication. T h e expected chapters on medical and surgical treatment are here, but detailed sections also deal with psychological and social problems, functional testing, return to employment, community resources, and, as mentioned, sexual function. T h e brief chapter on splinting is sensible and practical, although I would have placed the 26 photographs of steps in making a wrist splint in an appendix. There is no presentation of physical therapy modalities as such, and, to my surprise and delight, paraffin baths are never mentioned. By far the longest chapter-50 pages-is devoted to surgery. It presents the anatomy, various operations, indications, duration of hospitalization, anesthesia, complications, and expected outcome for each joint. T h e approach is aggressive and more optimistic in its anticipated results than I have found true. My reservations about this chapter reflect my difficulty in identifying the appropriate audience for whom the book is intended. Perhaps it is best to consider that different chapters offer something to almost everyone taking care of patients with rheumatic diseases, including primary physicians and other health professionals. While much of the contents will be familiar to rheumatologists, the basic message that there is more to evaluating outcome than sedimentation rate and grip strength provides a salutary reminder to all of us whose daily preoccupations incline us to look
