Objective. To examine the utility of the Framingham risk score (FRS) in estimating cardiovascular risk in psoriasis. Methods. We compared the predicted 10-year risk of cardiovascular events, namely, cardiovascular death, myocardial infarction, heart failure, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting using the FRS, to the observed risk of cardiovascular events in a population-based cohort of patients with psoriasis. Patients with incident or prevalent adult-onset psoriasis aged 30–79 years without prior history of cardiovascular disease were included. Results. Among the 1197 patients with predicted risk scores, the median FRS was 6.0%, while the observed 10-year cardiovascular risk was 6.9% (standardized incidence ratio (SIR): 1.14; 95% confidence interval (CI): 0.92–1.42). The SIR was not elevated for women nor for men. The differences between observed and predicted cardiovascular risks in patients <60 years (SIR: 1.01; 95% CI: 0.73–1.41) or ≥60 years (SIR: 1.26; 95% CI: 0.95–1.68) were not statistically significant. Conclusion. There was no apparent difference between observed and predicted cardiovascular risks in patients with psoriasis in our study. FRS reasonably estimated cardiovascular risk in both men and women as well as in younger and older psoriasis patients, suggesting that FRS can be used in risk stratification in psoriasis without further adjustment.

OBJECTIVE:Rheumatoid arthritis (RA) is associated with an increased risk of cardiovascular disease and mortality. Lipid-lowering therapy is reportedly underused in patients with RA. Longitudinal cohort studies comparing use of lipid-lowering medications in patients with RA versus the general population are lacking.METHODS:Cardiovascular risk factors, lipid measures, and use of lipid-lowering agents were assessed in a population-based inception cohort of patients with RA and a cohort of non-RA subjects followed from January 1, 1988, to December 31, 2008. The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATPIII) guidelines were assessed at the time of each lipid measure throughout followup. Time from meeting guidelines to initiation of lipid-lowering agents was assessed using Kaplan-Meier methods.RESULTS:The study population included 412 RA and 438 non-RA patients with ≥ 1 lipid measure during followup and no prior use of lipid-lowering agents. Rates of lipid testing were lower among patients with RA compared to non-RA subjects. Among patients who met NCEP ATPIII criteria for lipid-lowering therapy (n = 106 RA; n = 120 non-RA), only 27% of RA and 26% of non-RA subjects initiated lipid-lowering agents within 2 years of meeting the guidelines for initiation.CONCLUSION:There was substantial undertreatment in both the RA and the non-RA cohorts who met NCEP ATPIII criteria for initiation of lipid-lowering agents. Patients with RA did not have as frequent lipid testing as individuals in the general population.

Background Psoriasis is associated with an atherogenic lipid profile but longitudinal changes in lipids around disease onset are unknown. The purpose of our study is to examine the effect of psoriasis onset on serum lipid profiles. Methods We compared changes in lipid profiles in a population based incident cohort of 689 patients with psoriasis and 717 non-psoriasis subjects. All lipid measures performed 5 years before and after psoriasis incidence/index date were abstracted. Random-effects models adjusting for age, sex and calendar year were used to examine trends in lipid profiles. Results There were significant declines in total cholesterol (TC) and low-density lipoprotein (LDL) levels during the 5 years before and after psoriasis incidence/index date in both the psoriasis and the non-psoriasis cohorts, with a greater decrease noted in the TC levels (p=0.022) and LDL (p=0.054) in the non-psoriasis cohort. High-density lipoprotein (HDL) levels increased significantly both before and after psoriasis incidence date in the psoriasis cohort. Triglyceride (TG) levels were significantly higher (p<0.001), and HDL levels significantly lower (p=0.013) in patients with psoriasis compared to non-psoriasis subjects. There were no differences in prescriptions for lipid lowering drugs between the two cohorts. Conclusions Patients with psoriasis had a significant decrease in TC and LDL levels during the 5 years before psoriasis incidence. Higher mean TG and lower mean HDL levels were noted in the 5 years before psoriasis incidence. These changes are unlikely to be caused by lipid lowering treatment alone and require further exploration.

Adult onset Still's disease (AOSD) is a systemic inflammatory disease characterized by high-fevers, articular involvement, maculopapular rash, hepatosplenomegaly, lymphadenopathy, and a neutrophilic leukocytosis. Though systemic complications of AOSD or its treatment are well described in the literature, CNS involvement in AOSD is exceedingly rare and can have protean manifestations. We present a patient with AOSD who developed chronic meningitis and sensorineural hearing loss on treatment, with a review of prior reported cases of aseptic meningitis, to highlight this rare complication of this uncommon illness.

HenochSchonlein purpura (HSP) is the most common vasculitis of childhood. It is usually self-limiting and is characterized by an immune complexmediated vasculitis associated with IgA deposition. We present an unusual case of HSP with mucosal lesions and coronary artery thickening.

OBJECTIVE:To determine the incidence, time trends, risk factors, and severity of herpes zoster in a population-based cohort of patients with newly diagnosed rheumatoid arthritis (RA) compared to a group of individuals without RA from the same population.METHODS:All residents of Olmsted County, Minnesota fulfilling for the first time the 1987 American College of Rheumatology criteria for RA between January 1, 1980 and December 31, 2007 and a cohort of similar residents without RA were assembled and followed by retrospective chart review until death, migration, or December 31, 2008.RESULTS:There was no difference in the presence of herpes zoster prior to the RA incidence/index date between the cohorts (P = 0.85). During followup, 84 patients with RA (rate 12.1 cases per 1,000 person-years) and 44 subjects without RA (rate 5.4 cases per 1,000 person-years) developed herpes zoster. Patients with RA were more likely to develop herpes zoster than those without RA (hazard ratio [HR] 2.4 [95% confidence interval (95% CI) 1.7-3.5]). Herpes zoster occurred more frequently in patients diagnosed with RA more recently (HR 1.06 per year [95% CI 1.02-1.10]). Erosive disease, previous joint surgery, and use of hydroxychloroquine and corticosteroids were significantly associated with the development of herpes zoster in RA. There was no apparent association of herpes zoster with the use of methotrexate or biologic agents. Complications of herpes zoster occurred at a similar rate in both cohorts.CONCLUSION:The incidence of herpes zoster is increased in RA and has risen in recent years. There also has been an increasing incidence of herpes zoster in more recent years in the general population. RA disease severity is associated with the development of herpes zoster.

Elevated levels of complement components, C3 and C4, are often seen in inflammatory diseases. They are generally not thought to be responsible for organ injury but simply reflect stimulation of the immune system. Extremely high elevations of these components are rarely seen. Such values are usually reported in patients with hematopoietic malignancies. We report here a case of C3 elevation to 9.22 g/L (5 times the upper limit of normal) and C4 elevation to 2.48 g/L (6 times the upper limit of normal). To our knowledge, no prior elevations of this magnitude have been reported previously from our institution or in the published medical literature (+/− MEDLINE search, using keywords hypercomplementemia, C3, C4, and lymphoplasmacytic lymphoma). In this case, there appeared to be no adverse end-organ damage from the excessive complement components or their activation.

Erdheim–Chester disease is characterized by long bone pain and symmetric sclerosis of the diametaphyseal portions of the long bones. It is an important differential diagnosis of sclerotic disease of the bones.

From the *Division of Rheumatology, Mayo Clinic, Rochester, MN; and †National Institutes of Health/National Institute of Environmental Health Sciences/Environmental Autoimmunity Group, Bethesda, MD. This study has no sources of support. The authors declare no conflict of interest. Correspondence: Bharath Manu Akkara Veetil, MBBS, Division of Rheumatology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905. E-mail: [email protected].

The perioperative care of patients with rheumatic diseases is hampered by a lack of evidence-based recommendations. Rheumatologists are called upon to 'clear' their patients for surgery, yet the evidence upon which to base decisions is fractionated and inconsistent. We have systematically reviewed the current literature and developed suggestions for three key areas that require particular deliberations in patients with rheumatic diseases scheduled for surgery: the management of cardiovascular risk, use of immunosuppressive drugs, and states of altered coagulation. For patients with rheumatic diseases associated with increased cardiovascular risk, such as rheumatoid arthritis and systemic lupus erythematosus, we suggest following the American College of Cardiology-American Heart Association guidelines using the underlying disease as a risk modifier. Most evidence suggests a neutral effect of conventional DMARDs in the perioperative period, with no need to discontinue them prior to surgery. Conversely, we suggest minimizing perioperative steroid use and unnecessary 'steroid preps'. The potential benefits of discontinuing biologic drugs in the perioperative setting needs to be carefully balanced with the risks associated with a disease flare. We discuss the American College of Chest Physicians guidelines, which classify individuals with antiphospholipid antibody syndrome as high-risk patients for perioperative thrombosis who are likely to require bridging therapy in most perioperative settings.

Erdheim-Chester disease is characterized by long bone pain and symmetric sclerosis of the diametaphyseal portions of the long bones. It is an important differential diagnosis of sclerotic disease of the bones.

Erdheim–Chester disease is characterized by long bone pain and symmetric sclerosis of the diametaphyseal portions of the long bones. It is an important differential diagnosis of sclerotic disease of the bones.

Tophaceous uric acid deposits are an important differential diagnosis when evaluating benign soft tissue masses, even in the absence of a history of inflammatory arthritis1,2. A 63-year-old man presented with a …

Erdheim-Chester disease is characterized by long bone pain and symmetric sclerosis of the diametaphyseal portions of the long bones. It is an important differential diagnosis of sclerotic disease of the bones.

ANCA associated vasculitides are a group of disorders characterized by the presence of necrotizing inflammation of blood vessels that involve venules, capillaries, arterioles, arteries, and veins. They are characterized by the presence of antineutrophil cytoplasmic antibodies (ANCA). ANCA associated vasculitis commonly affects the kidney producing proteinuria, hematuria and variable degrees of renal failure. Other organs involved include the lung, skin and peripheral nervous system. We present a patient with limited systemic sclerosis, who later developed pauci-immune glomerulonephritis with p-ANCA (antimyeloperoxidase) specificity and, whose disease was later complicated by cerebral vasculitis with multiple intracerebral hemorrhages.