she has been hospitalized six more times because of pain in the right hypochondrium, vomiting, and fever, but no definite diagnosis could be made. During one hospital- ization elsewhere (in 1974) she also had a maculopapu- lar eruption all over the body. In 1974 she underwent drainage of a perianal abscess, and thereafter she was hospitalized for prolonged fever of unknown origin with abdominal pain. A short time after this she was admit- ted to a psychiatric hospital for depression. In the last month she suffered pain in both hands, and these com- plaints prevailed during this last entire hospitalization. On examination her general condition was good, blood pressure was 130/80. Her temperature was subfebrile (37-38C) during many weeks. Occasional expiratory wheezing was heard over both lungs.
The main complaint during this hospitalization was pain in both hands accompanied by fever. There were no signs of arthritis, and x-rays of the joints were normal. A complete laboratory examination on admis- sion to the rheumatology department showed no special changes, except for a transient leukopenia (3000/mm3) and thrombocytopenia (60,000/mm3). A connective tis- sue disorder was suspected, but no definite diagnosis could be made.
Later on, during her hospitalization peripheral neuropathy appeared. A thorough checkup ruled out many causes of peripheral neuropathy, including metal poisoning, vitamin deficiency, and diabetes. Repeated neurological examinations disclosed bilateral distal hy- poalgesia of the hands (gloves-form, without sharply defined borders). The ulnar nerves on both sides and the greater auricular nerve on the right side seemed to be thickened and were tender on palpation. On the fore- head a faint reddish infiltrate was visible; the right ear- lobe was slightly reddish and swollen, and there was partial alopecia of the eyebrows. I n both legs and fore- arms there was an inability to discriminate sharp from blunt and changes of temperature or touch. Both optic discs were normal. X-ray of skull and EEG were nor- mal. A skin biopsy of the ear lobule and a nasal smear did not reveal acid-fast bacili. EMG revealed decreased conduction in the right ulnar nerve at the elbow region. Surgical decompression of the right ulnar nerve at this site was performed. During this procedure, a biopsy was done from a minor branch of this nerve, which micro- scopically showed signs of nerve fiber degenerations (in- cluding hydropic degeneration) and groups of acid-fast bacilli.
Thus, lepra reaction of Hansens disease could be diagnosed. After a short course of thalidomide therapy her pain disappeared. Later she was transferred to a
leprosarium for further treatment. She was seen again, 1 year after the treatment with thalidomide was started; she felt generally well, had no more pain, though she complained again of paresthesias in both hands.
One can wonder whether all the details of her past medical history belong to lepra, and in fact, without doubt, m a n y symptoms and signs were similar to those of lepra, for example, edema of the glottis, intermittent fever, typical neurological findings, and bone pain.
There was the fever and .pain in her hands which, eventually, has led us to the diagnosis of lepra.
D. RIMON, M.D. I . MACHTEY, M.D. M. HIMELSTEIN, M.D. Department of Medicine A and Rheumatology Service Hasharon Hospital Petah-Tiqva. Israel
Reiters Syndrome: Occurrence in Roommates
To the Editor: I n March 1976 a 27-year-old white male welder,
JH, was seen on referral from a neurosurgeon for evalu- ation of back pain of 5 months duration, pain in the right heel, swelling of the right ankle, right shoulder pain, and morning stiffness. Range of motion was lim- ited in the lumbar spine. Swelling was noted in the right ankle with tenderness and swelling over the first left metatarsal phalangeal joint. Slight limitation of motion of the right shoulder was present. Pelvic x-ray demon- strated erosions of the sacroiliac joints. Laboratory data included a Westergren sedimentation rate of 49 mm/hr, negative RA test, and a positive HLA B27. Indocin therapy was started, and over the next several months his symptoms improved, with arthritis and back symp- toms almost totally resolved by December 1976.
Approximately one year later, a 30-year-old white male lumber salesman, WL, JHs ex-roommate, sought treatment for a 6-month history of swelling in the right knee, low back pain, right shoulder pain, podagra. swelling and pain of the left heel, and morning stiffness of 2 hours duration. Unlike the previous patient, WL gave a history of having a urethral discharge prior to the onset of the arthritis and, more recently, a mild burning in his eyes. On physical examination a slightly warm, right swollen knee was noted. A tender, swollen left
Achilles tendon, swelling over the left calcaneal bursa, and tenderness of the right first metatarsal phalangeal joint, right shoulder, and right sternoclavicular joint were evident. Tenderness over the right sacroiliac joint and mild conjunctival suffusion were present. Synovia- nalysis revealed a 5,500 white blood cell count with 24% polymorphonuclear cells and 76% monocytes. The mu- cin clot was poor. Several white blood cells contained cytoplasmic inclusions. No crystals were identified. Sy- novial fluid complement was within normal limits. A rheumatoid arthritis test was negative; HLA B27 was positive. Questionable early erosive changes were pre- sent in the right sacroiliac joint, and the right heel con- tained a fluffy calcaneal spur. Sedimentation rate was 60 mm/hour. High dose salicylate therapy resulted in clini- cal improvement and followup over the last several months has indicated continual clinical improvement.
Interestingly, one month later, JH returned for followup visit and related that prior to the onset of the urethritis, he and WL had had sexual intercourse with the same female and both had contracted a urethral discharge at about the same time, although JH had initially denied urethritis.
Reiters disease has been known to occur after salmonella ( 1 ), shigella (2), and Yersinia infections (3). Sporadic cases are proposed to be secondary to venereal contraction of an offending agent (4). HLA B27 positiv- ity occurs in greater than 90% of these patients and has been postulated as a risk factor in the chronic form of
the disease (5,6). These two patients vividly invoke the concept of an offending agent or agents in a predisposed host.
JOHN G. PATY, JR. M.D. Appalachian A rthritis Foundation
and Section of Rheumatology Department of Medicine University of Tennessee Clinical Education Center Chattanooga. Tennessee 37403
REFERENCES Warren CPW: Arthritis associated with salmonella infec- tions. Ann Rheum Dis 29:483-487, 1970 Noer HR: An experimental epidemic of Reiters syn- drome. JAM A 198:693-698, I966 Ahvonen P, Sievers K, Aho K: Arthritis associated with Yersinia enterocolitica infection. Acta Rheumatol Scand
Aho K, Ahvonen P, Lassus A: HLA-27 in reactive arthritis, a study of Yersinia arthritis and Reiters disease. Arthritis Rheum 17521-526, 1974 Calin A, Fries J: An experimental epidemic of Reiters syndrome revisited. Ann Intern Med 86564-566, 1976 Bluestone R, Pearson C: Ankylosing spondylitis and Rei- ters syndrome: their interrelationship and association with HLA B27. Adv Intern Med 22:l-19, 1977
Erratum The legend to Figure I in the article by Arthur Bobrove and Patricia Miller, which appeared in the September- October 1977 issue of Arthritis and Rheumatism (pp 1326- 1333), should read: Pokeweed mitogen-induced develop- ment of cells containing intracytoplasmic immunoglobulin arising from cultured lymphocytes obtained from 20 patients with SLE (dark bars) and 21 normal controls (light bars), incubated for 7 days. The means f SEM are shown for immunoglobulin class studied. *P < 0.01, tP < 0.05.