No abstract

Vasculitic neuropathy classically manifests as a subacute mononeuritis multiplex or polyneuropathy. Patients with a Guillain‐Barré syndrome (GBS)–like presentation are usually not considered to have an underlying vasculitis. We describe 2 patients with rapidly progressive areflexic paralysis that was initially diagnosed as GBS, in whom vasculitic neuropathy was found histologically.

We describe 3 patients with rheumatoid arthritis who presented with diffuse pain, swelling, and erythema of the distal aspect of the lower extremity, suggestive of either cellulitis or thrombophlebitis, but were found to have insufficiency fractures of the distal tibia. The value of technetium-99m diphosphonate bone scintigraphy in the early recognition of these fractures and a possible explanation for the associated inflammatory symptoms are discussed.Insufficiency (or nondisplaced) fractures, with or without a history of trauma, are not uncommon in elderly patients with osteoporosis. Such fractures have been reported to occur in the ribs, sacrum, pelvis, proximal femur, and proximal and distal tibia and fibula (1-5). Insufficiency fractures occurring near a joint in the proximal tibia have been reported in patients with rheumatoid arthritis (RA). These are generally mistaken as worsening knee synovitis or infectious arthritis (5-10) and may go undiagnosed for weeks or even months. We describe here 3 patients with RA and nondisplaced fractures of the distal tibia, who presented with swelling, tenderness, and pain of the distal aspect of the lower extremity, mimicking cellulitis. Case reports. Patient 1 , a 47-year-old white woman, had overlap RNsystemic lupus erythematosus (symmetric polyarthritis, leukopenia, pleural effusion, interstitial lung disease, positive antinuclear antibodies, and positive rheumatoid factor of 12 years duration), requiring as much as 60 mg of prednisone per day to control the disease manifestations. Most recently, she had been taking 5 mg of prednisone per day, parenteral chrysotherapy (50 mg every 2 weeks), and analgesics. During recent months, her level of ambulation had remained the same (mild to moderate), and her white blood cell (WBC) count had fluctuated between 3,2001mm3 and 4,500/mm3.Two weeks before presenting to our outpatient department, the patient noticed a gradual onset of pain, swelling, warmth, and erythema of the distal aspect of the left lower extremity. On examination, the patient was afebrile and exhibited diffuse swelling of the distal aspect of the left lower extremity from the ankle to the knee. The ankle was aspirated and lavaged, and the lavaged fluid was sent for cultures, the results of which were negative. A complete blood cell (CBC) count demonstrated a WBC count of 3,8001 mm3, with a normal differential cell count. The differential diagnosis included cellulitis and thrombophlebitis. Results of Doppler studies of the distal aspect of the patient's left lower extremity were normal. Intravenous (IV) antibiotic therapy with nafcillin was started.A radiograph of the patient's left leg demonstrated a nondisplaced fracture of the distal tibia. The leg was immobilized in a short cast and IV nafcillin therapy was discontinued on the second hospital day. The cast was removed after 4 weeks, and the patient

Clinical improvement has been clearly documented in all 3 treatment groups in this trial. Radiographic deterioration occurs in RA even when clinical features improve, but progression of disease as determined radiographically may be slowed by treatment with MTX.