905
Intraarticular Fragmentation of Synovial Biopsy Needle To the Editor:
Synovial biopsy using the technique and needle described by Parker and Pearson ( 1 ) has proved to be a safe and simple way to evaluate synovial disease. Potential complications of this procedure, including hemorrhage (2) and infection, are rare. But recently we encountered a complication which t o our knowledge has not previously been reported. A 52-year-old man with a chronic asymmetric seronegative arthritis underwent biopsy of the right knee. A Parker-Pearson needle (Popper and Sons, Inc) was inserted in the usual manner and three tissue specimens were removed. When we tried to take a fourth specimen, moderate resistance was encountered as the outer needle was advanced. On removal of the inner needle, the tip and biopsy cavity were absent. Roentgenograms revealed the location of the needle fragment (Figure I ) , which was subsequently removed through a 1 cm medial incision after visualization with a Wolf Arthroscope (Eder Instrument Co). The recovered portion of the needle had a twisted appearance. We feel the most logical explanation is that the inner needle bent during insertion or previous biopsy. When the outer needle was advanced and turned, the distorted needle tip became twisted and was severed.
Fig I . Lateral (left) and anteroposterior (right) roentgenograms reveal the needle ,/ragnwnt. The roentgenogram on the right. made at the tinw of surRerj.. shotis the arrhroscope. drain needle, and localization needles in place. Arthritis and Rheumatism, Vol. 20, No. 3 (April 1977)
I n light of this experience, it would seem prudent to inspect the inner needle carefully before each biopsy. I f increased resistance is encountered, the needles should be removed as a unit and examined for malalignment. DAVID A. BONG,M.D. DAVID NOALL,M.D ROBERT M. BENNETT,M.D. University of’Oregon Health Sciences Center Portland, Oregon 97201
REFERENCES 1 . Parker RH, Pearson CM: A simplified synovial biopsy needle. Arthritis Rheum 6:172-176, 1963 2. Schumacher H R , Kulka JP: Needle biopsy of the synovia’ membrane. Experience of the Parker-Pearson technique. N Engl J Med 286:416-419, 1972
“Mixed Connective Tissue Disease” or “Sharp Syndrome”? To the Editor: Since 1972, when Sharp et a1 (1) described the rheumatic syndrome characterized by clinical features of systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and polymyositis, and by circulating antibodies against ribonucleoprotein (anti-ENA and speckled ANA), it has become apparent that this is a distinct rheumatic syndrome. Apart from typical clinical and laboratory findings, this syndrome has an excellent prognosis and good response to conventional therapy. It is therefore both practically and theoretically significant to be able to establish the diagnosis of this condition. Sharp and most of the American authors introduced the term “mixed connective tissue disease” (MCTD), which describes this syndrome very well. However the term gives rise to some confusion because it is only one of a variety of mixed connective tissue syndromes. Furthermore, the translation of this term into other languages is even more inadequate and causes some trouble in identifying this condition. To prevent future misunderstandings, we introduced in the German-speaking countries and Dr. Kahn in the French-speaking countries the term “Sharp syndrome,” which seems to us for the time being to be the most suitable for this condition. Like Sj6gren’s syndrome, it describes not a disease, but a specific syndrome, which may or may not be associated with other rheumatic diseases. It also accounts for the fact that it is
906
only a distinct form of a variety of mixed connective tissue syndromes. In our opinion this term should be used until another etiopathogenetic term is found. Other proposed terms-Sharp connectivitis, rheumatoid lupus, and ENA syndrome-seem to be less suitable. We hope that other interested rheumatologists will offer their opinion on this issue in order to establish an easier and more acceptable terminology. MOSHEROSENTHAL, M.D. Department of Rheumatology University of Basel CH-4055 Basel, Switzerland
amoris and genu remoris, such as the result of pleading unsuccessfully for forgiveness while on one knee-genu divoris. JOELE. RUTSTEIN,M.D. MICHAELJ. COHEN,M.D. Division of Rheutnatology Department of Medicine JOHNW. MCCUTCHEN, M.D. Division of’ Orthopaedics Departttient of Surgery University of’ Texas Health Science Center San Antonio. Texas
REFERENCE I . Sharp G C , lrvin WS, Tan EM, et al: Mixed connective tissue disease. A n apparently distinct rheumatic disease syndrome associated with a specific antibody to an extractable nuclear antigen (ENA). Am J Med 52:148-159, 1972
An Unusual Complication of Genu Amoris To the Editor: Traumatic arthritis of the knee secondary to extraordinary athletic talents in love-making has been coined genu amoris in a case report by Pinals (A&R 19:637-638, 1976). We report an unusual complicaton of this entity. A 32-year-old woman was admitted to our hospital for left knee pain and swelling of 4 days duration. Four weeks earlier she had been treated with benzathine penicillin for a positive VDRL in the local health clinic and had been instructed not to have sexual relations for an unspecified period of time. When she violated these instructions, she was filled with remorse and attempted to atone with vigorous prayer, which included genuflexion and kneeling. Within 24 hours she had developed swelling of her left prepatellar bursa with minimal warmth and decreased flexion of the knee. A work-up including pelvic examination with gram strain and culture was completely negative. Fluid aspirated from the painful area had a W BC count of 650 cells per cubic millimeter, was sterile, and did not contain crystals. The prepatellar bursitis revolved promptly with heat and buffered aspirin. Borrowing Pinals’s nomenclature, we feel that this case could appropriately be termed genu remoris. .4nd we suggest the possibility of sequelae t o genu Arthritis and Rheumatism, Vol. 20, No. 3 (April 1977)
BOOK REVIEWS Infection and Immunology in the Rheumatic Diseases. Dudley Dumond, Editor. London, Beadsworth, 1976. 600 pages. By editing Infection and Immunology in the Rheutnatic Diseases, Dr. Dumonde has done a major service for those working in rheumatology, clinical immunology, and infectious diseases. This handsomely composed and printed volume of 600 pages comprises, in a sense, the proceedings of a memorable symposium held in London in 1974. However, because articles were submitted until the summer of 1975, the volume is quite current. Seventy-nine research or review contributions, seven edited discussions, and a WHO report are grouped into five broad areas: immunologic response to microbial infections; evidence associating various rheumatic diseases with infection; genetic and epidemiologic considerations: immunopathologic mechanisms: and a sometimes speculative, sometimes widely ranging section on future trends. The signal strength of Infection and Immunology is the comprehensive treatment of the subject of infectious processes in relation to rheumatic disease. Access to a sometimes otherwise difficult literature is afforded by authoritative contributions in this area. The treatment allotted to the immunologic aspects of the rheumatic diseases is rather more selective and limited, and appropriately so. The articles vary in perspective, some taking the form of reviews, others covering new experimental find-
Intraarticular Fragmentation of Synovial Biopsy Needle To the Editor:
Synovial biopsy using the technique and needle described by Parker and Pearson ( 1 ) has proved to be a safe and simple way to evaluate synovial disease. Potential complications of this procedure, including hemorrhage (2) and infection, are rare. But recently we encountered a complication which t o our knowledge has not previously been reported. A 52-year-old man with a chronic asymmetric seronegative arthritis underwent biopsy of the right knee. A Parker-Pearson needle (Popper and Sons, Inc) was inserted in the usual manner and three tissue specimens were removed. When we tried to take a fourth specimen, moderate resistance was encountered as the outer needle was advanced. On removal of the inner needle, the tip and biopsy cavity were absent. Roentgenograms revealed the location of the needle fragment (Figure I ) , which was subsequently removed through a 1 cm medial incision after visualization with a Wolf Arthroscope (Eder Instrument Co). The recovered portion of the needle had a twisted appearance. We feel the most logical explanation is that the inner needle bent during insertion or previous biopsy. When the outer needle was advanced and turned, the distorted needle tip became twisted and was severed.
Fig I . Lateral (left) and anteroposterior (right) roentgenograms reveal the needle ,/ragnwnt. The roentgenogram on the right. made at the tinw of surRerj.. shotis the arrhroscope. drain needle, and localization needles in place. Arthritis and Rheumatism, Vol. 20, No. 3 (April 1977)
I n light of this experience, it would seem prudent to inspect the inner needle carefully before each biopsy. I f increased resistance is encountered, the needles should be removed as a unit and examined for malalignment. DAVID A. BONG,M.D. DAVID NOALL,M.D ROBERT M. BENNETT,M.D. University of’Oregon Health Sciences Center Portland, Oregon 97201
REFERENCES 1 . Parker RH, Pearson CM: A simplified synovial biopsy needle. Arthritis Rheum 6:172-176, 1963 2. Schumacher H R , Kulka JP: Needle biopsy of the synovia’ membrane. Experience of the Parker-Pearson technique. N Engl J Med 286:416-419, 1972
“Mixed Connective Tissue Disease” or “Sharp Syndrome”? To the Editor: Since 1972, when Sharp et a1 (1) described the rheumatic syndrome characterized by clinical features of systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and polymyositis, and by circulating antibodies against ribonucleoprotein (anti-ENA and speckled ANA), it has become apparent that this is a distinct rheumatic syndrome. Apart from typical clinical and laboratory findings, this syndrome has an excellent prognosis and good response to conventional therapy. It is therefore both practically and theoretically significant to be able to establish the diagnosis of this condition. Sharp and most of the American authors introduced the term “mixed connective tissue disease” (MCTD), which describes this syndrome very well. However the term gives rise to some confusion because it is only one of a variety of mixed connective tissue syndromes. Furthermore, the translation of this term into other languages is even more inadequate and causes some trouble in identifying this condition. To prevent future misunderstandings, we introduced in the German-speaking countries and Dr. Kahn in the French-speaking countries the term “Sharp syndrome,” which seems to us for the time being to be the most suitable for this condition. Like Sj6gren’s syndrome, it describes not a disease, but a specific syndrome, which may or may not be associated with other rheumatic diseases. It also accounts for the fact that it is
906
only a distinct form of a variety of mixed connective tissue syndromes. In our opinion this term should be used until another etiopathogenetic term is found. Other proposed terms-Sharp connectivitis, rheumatoid lupus, and ENA syndrome-seem to be less suitable. We hope that other interested rheumatologists will offer their opinion on this issue in order to establish an easier and more acceptable terminology. MOSHEROSENTHAL, M.D. Department of Rheumatology University of Basel CH-4055 Basel, Switzerland
amoris and genu remoris, such as the result of pleading unsuccessfully for forgiveness while on one knee-genu divoris. JOELE. RUTSTEIN,M.D. MICHAELJ. COHEN,M.D. Division of Rheutnatology Department of Medicine JOHNW. MCCUTCHEN, M.D. Division of’ Orthopaedics Departttient of Surgery University of’ Texas Health Science Center San Antonio. Texas
REFERENCE I . Sharp G C , lrvin WS, Tan EM, et al: Mixed connective tissue disease. A n apparently distinct rheumatic disease syndrome associated with a specific antibody to an extractable nuclear antigen (ENA). Am J Med 52:148-159, 1972
An Unusual Complication of Genu Amoris To the Editor: Traumatic arthritis of the knee secondary to extraordinary athletic talents in love-making has been coined genu amoris in a case report by Pinals (A&R 19:637-638, 1976). We report an unusual complicaton of this entity. A 32-year-old woman was admitted to our hospital for left knee pain and swelling of 4 days duration. Four weeks earlier she had been treated with benzathine penicillin for a positive VDRL in the local health clinic and had been instructed not to have sexual relations for an unspecified period of time. When she violated these instructions, she was filled with remorse and attempted to atone with vigorous prayer, which included genuflexion and kneeling. Within 24 hours she had developed swelling of her left prepatellar bursa with minimal warmth and decreased flexion of the knee. A work-up including pelvic examination with gram strain and culture was completely negative. Fluid aspirated from the painful area had a W BC count of 650 cells per cubic millimeter, was sterile, and did not contain crystals. The prepatellar bursitis revolved promptly with heat and buffered aspirin. Borrowing Pinals’s nomenclature, we feel that this case could appropriately be termed genu remoris. .4nd we suggest the possibility of sequelae t o genu Arthritis and Rheumatism, Vol. 20, No. 3 (April 1977)
BOOK REVIEWS Infection and Immunology in the Rheumatic Diseases. Dudley Dumond, Editor. London, Beadsworth, 1976. 600 pages. By editing Infection and Immunology in the Rheutnatic Diseases, Dr. Dumonde has done a major service for those working in rheumatology, clinical immunology, and infectious diseases. This handsomely composed and printed volume of 600 pages comprises, in a sense, the proceedings of a memorable symposium held in London in 1974. However, because articles were submitted until the summer of 1975, the volume is quite current. Seventy-nine research or review contributions, seven edited discussions, and a WHO report are grouped into five broad areas: immunologic response to microbial infections; evidence associating various rheumatic diseases with infection; genetic and epidemiologic considerations: immunopathologic mechanisms: and a sometimes speculative, sometimes widely ranging section on future trends. The signal strength of Infection and Immunology is the comprehensive treatment of the subject of infectious processes in relation to rheumatic disease. Access to a sometimes otherwise difficult literature is afforded by authoritative contributions in this area. The treatment allotted to the immunologic aspects of the rheumatic diseases is rather more selective and limited, and appropriately so. The articles vary in perspective, some taking the form of reviews, others covering new experimental find-
