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Herpes zoster or shingles is a common cutaneous disorder caused by the reactivation of latent varicella-zoster virus dormant in the cranial nerve or dorsal root ganglia. It usually manifests as a dermatomal distribution of a vesicular eruption that can cause significant morbidity (1). Herpes zoster is known to be more frequent in patients with conditions that depress cell-mediated immunity, including malignancy, HIV, transplantation, immunosuppressive disorders and treatment with immunosuppressants (2). The overall rate of herpes zoster in patients with rheumatoid arthritis (RA) is increased compared to the general population, with a greater risk in individuals using traditional disease modifying antirheumatic drugs (DMARDs) or biologic therapies (3). Use of prednisone in RA is an important predisposing factor for herpes zoster, and its use in conjunction with DMARDs increases the risk beyond that seen with the DMARDs alone (4). Many unanswered questions remain regarding the relationship between RA and reactivation of herpes zoster, and how RA related disease features, treatment and herpes zoster prevention measures might be addressed to avoid recurrent and complicated herpes zoster in these patients. We performed a population-based study to assess the incidence, time trends, risk factors and severity of herpes zoster in a well defined population of patients with RA. This information should serve the eventual goal of identifying possible strategies that could be employed to minimize the risk of development of herpes zoster in patients with RA.

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.

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.

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.

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 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.

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

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.

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.

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 …