Patients with rheumatoid arthritis may notice pain, stiffness, and loss of the ability to use the elbow for their usual activities when the elbow joints are damaged. If medication and rehabilitation therapy fail to alleviate the rheumatoid elbow pain, surgery such as synovectomy and total arthroplasty may be considered. In recent years, progress in total elbow arthroplasty has led to reliable clinical results, including good pain relief, restoration of stability and improvement of joint movement of the elbow damaged by rheumatoid arthritis. The principle choice in elbow implants is to use a linked or unlinked prosthesis. The Kudo type-5 prosthesis is an unlinked prosthesis. Between 1993 and June 2001, we carried out a total arthroplasty on 135 patients (162 elbows) who had rheumatoid arthritis using the Kudo type-5 prosthesis. The main indications for the surgery were intractable pain leading to loss of function. One hundred and fourteen patients with 139 elbows were followed for an average of eight years and ten months (range, 5 years to 14 years). There was almost complete pain relief, restoration of stability and improvement of joint movement of all elbows. At the time of the latest follow-up, the overall result was excellent in 76, good in 48, fair in 7, and poor in 8 elbows. Nine ulnar components and 1 humeral component were considered to be loose and have had revision surgery. With revision as the endpoint, the probability of survival of the Kudo 5 prosthesis at 13 years using the Kaplan-Meier method was 90%.

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    We reported 6 cases complicated by infections following administration of biologic agents for rheumatoid arthritis patients (bacterial pneumonia: 2 cases, tuberculosis: 1 case, buttocks abscess: 1 case, septic arthritis: 2 cases 〔elbow, ankle〕). The patients with bacterial pneumonia and the buttocks abscess were treated successfully with antibiotics. The patients with septic arthritis were treated with antibiotics and joint synovectomy operations. The patient with tuberculosis was treated with INH, REF, EB, and PZA. Because we stopped administration of biologic agents during infection treatments, their rheumatoid arthritis symptoms worsened. All 6 patients wanted to start administration of biologic agents again so we tried re-administration to all patients after explaining the risk of infection recurring. We re-administrated etanercept with INH to the patient suffering from tuberculosis associated with adalimumab. This patient had no recurrence of tuberculosis to date. There are few reports of re-administration of biologic agents to tuberculosis patients associated with biologic agents, so this is a very rare case. Unfortunately, 2 cases had relapses of the same infections after re-administration of biologic agents (bacterial pneumonia and elbow arthritis). There are no rules of regarding readministration of biologic agents so it is difficult to decide when and how to restart administration.

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    A clinical evaluation of low dose salazosulfapyridine (SASP) on patients with rheumatoid Arthritis (RA) was performed. Thirty-one cases of RA who had not taken disease modifying anti-rheumatic drugs (DMARD) prior to this study were treated over twelve months with a SASP dosage of 250 mg or 500mg per day. There were 19 cases with a dosage of 250 mg/day and 12 cases with a dosage of 500 mg/day. CRP levels decreased after treatment with SASP compared with the baseline in both groups (p＜0.001). ESR also decreased after treatment in both groups (p＜0.001). Although MMP-3 levels did not show the significant changes among total cases, there was a significant decrease of MMP-3 levels in 250 mg/day cases (p＜0.03). In addition, there were no severe adverse effects through the treatment with low dose SASP. In terms of these results, SASP treatment would be effective for RA patients who have not received DMARD in the past. Furthermore, we must know there are cases whose joint destruction would progress even though CRP levels are decreased.

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    A 54-year-old Japanese female suffered from high fever and persistent cough on February 2006. The patient went to previous doctor and a tumor in the right lung was indicated by pulmonary CT. Video-associated thoracoscopic surgery lung biopsy showed severe granulomatous inflammation with necrosis in the pulmonary specimen. The case then became complicated to acute renal failure. Renal biopsy specimens revealed pauci-immune type crescentic glomerulonephritis. MPO-ANCA was detected, however, she didn’t have bronchial asthma nor concern with eosinophils in the pathogenesis. The patient was diagnosed as having Wegener’s granulomatosis. Soon the patient was started on a prescription of glucocorticoid and cyclophosphamide. Delirium was seen after 55 days from starting the immunosuppression. Then the patient came to reject all treatments. The patient was introduced to Sapporo Medical University Hospital, and admitted to department of psychiatry on August 2006. The patient was diagnosed as steroid-induced psychosis, and prescribed with a major tranquilizer. Mental symptoms were gradually improved. Surprisingly, pulmonary and renal involvements naturally recovered without additional immunosuppression. Serum MPO-ANCA was declined to normal levels. About 15 months has past since treatments were implemented. No recurrence has occurred to the patient.

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    The differential diagnosis between polymyalgia rheumatica and elderly-onset rheumatoid arthritis is difficult because these diseases share similar clinical findings, especially at onset. We report a case of elderly-onset rheumatoid arthritis that was differentiate from polymyalgia rheumatica on the detection of synovitis of the acromioclavicular joint. A 73-year-old man was admitted to our hospital because of pain and bilateral stiffness in his shoulders and hips. Tests for rheumatoid factor and anti-cyclic citrullinated peptide antibody were negative. Bone erosions and joint space narrowing were not detected by radiographic examination of the glenohumeral and wrist joints, and polymyalgia rheumatica was suspected. Diagnostic treatment with prednisolone (15 mg per day) was started, but his arthralgia did not disappear. Further testing by radiography and magenetic resonance imaging (MRI) of the acromioclavicular joint showed synovitis and bone erosions. On the fourteenth day after initiation of steroid therapy, morning stiffness and arthralgia of the bilateral finger joints and wrist joints appeared, and synovitis and bone erosions of carpal bones were detected by MRI. Therefore, the diagnosis of elderly-onset rheumatoid arthritis was made. Acromioclavicular joint synovitis would be useful in the differential diagnosis between polymyalgia rheumatica and elderly-onset rheumatoid arthritis.

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    A 73-year-old woman presented at the department of dermatology because of alopecia and erythema of the outer ear (auricle) in August 2006. The results of tests for antinuclear antibodies were positive, and systemic lupus erythematosus was suspected. The patient was followed up with no medication because there was no evidence of organ disease. In April 2007, edema of the lower extremities developed. The patient was admitted to the hospital because of nephrotic syndrome. A renal biopsy revealed type IV lupus nephritis. Prednisolone was given in a dose of 60 mg. Because urinary findings did not improve, cyclophosphamide was additionally given intravenously. Pneumonia developed after 2 weeks, when the second dose of cyclophosphamide was administered. Cytomegalovirus pneumonia was diagnosed, and ganciclovir was given. Despite treatment, acute respiratory failure occurred, and the patient received artificial ventilation. Radiographic findings improved, along with an improvement in arterial-blood gases. While respiratory status was improving, however, interstitial pneumonia developed. Drug-induced lung damage was suspected, and all drugs were discontinued. Signs and symptoms of pneumonia improved. The results of a drug lymphocyte stimulation test were positive for ganciclovir and ciprofloxacin.
    We described our experience with a patient who had systemic lupus erythematosus associated with drug-induced lung damage, developing during treatment for cytomegalovirus pneumonia. Infection and underlying disease were difficult to distinguish from drug-induced lung damage on the basis of radiographic findings. A correct diagnosis required evaluations of physical findings and clinical course.

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