Objective: To look for the frequency and pattern of neuropathy in Indian patients with rheumatoid arthritis (RA). Patients and Methods: One hundred newly diagnosed patients with RA (ACR 1987 revised criteria) visiting our hospital, over a period of 3 years were screened. Diabetics, outstation patients, chronic alcoholics, those with any known cause for peripheral neuropathy and patients having an overlap with the other rheumatological illness were excluded. Clinical assessment included detailed history and examination with special reference to extra-articular features and neuropathy with relevant clinical parameters like tender joint count, swollen joint count, etc. Routine laboratory investigations and autoantibodies (RF, ANA, anti-CCP) were obtained on all patients. All the patients with or without clinical manifestations of neuropathy underwent nerve conduction studies. Autonomic function studies were performed in selected patients. Results: Subjects included 66 patients (M 13 : F 53) with mean age of 42 (±13.42) years and median disease dura- tion of 36 months (IQR-13.5, 60). Sensory symptoms were present in 9 patients (13.6%). None had motor symp- toms. On neurological examination, 16 patients had sensory (24.2%) and 6 (9.09%) had motor abnormalities. Nerve conduction studies showed abnormality in 25 patients (37.87%). Evidence of entrapment neuropathy was found in 6 patients (9.09%; 5 patients with median nerve involvement [unilateral, 3 and bilateral, 2] and 1 patient with unilateral ulnar nerve involvement), 3 patients had only sensory neuropathy, 5 had mixed sensory motor and 3 had only motor neuropathy. Eight patients (12.12%) had only small fibre neuropathy as detected by sympathetic skin response and quantitative sensory testing. Conclusion: This study shows high prevalence of subclinical neuropathy in Indian patients with RA. This may be an important contributor to disability.

Objective: A subnormal response of the hypothalamic-pituitary-adrenal (HPA) axis to inflammatory stimuli was found to be associated with the occurrence of chronic arthritis in Lewis rats. This study was carried out to determine the role of the HPA axis in patients with rheumatoid arthritis (RA). Methods: Thirty patients with RA of less than 2 years duration were studied. Laboratory tests including ESR, RF and X-ray hands were performed in all patients. All patients were subjected to the standard insulin-induced hypoglycemia test to determine the integrity of the HPA axis. Serum cortisol was estimated at 11 PM on the day prior to the test in eight of these patients. Results: Twelve out of 30 patients had subnormal cortisol response to insulin-induced hypoglycemia. (normal: cortisol >20 μg/dl and 7 μg > basal cortisol). Two patients had a maximal cortisol response 7 μg > basal but less than 20 μg/dl, i.e. a partial response. Seven patients had a supranormal basal cortisol with no further stimulation with hypoglycemia. Nine patients had an adequate response. Conclusion: 21/30 (70%) of patients showed some abnormality of HPA axis response. We propose that a primary abnormality of the HPA axis may play a significant role in the pathogenesis of RA.

Since the triggering factors causing primary vasculitides are by definition not (yet) known, we have to classify them to clinical syndromes based on the size, site, type and effect of the blood vessel involvement. ACR classification cri- teria and Chapel Hill nomenclature are useful tools to familiarize with the primary vasculitides, although a lot of crit- icism has been voiced in the literature indicating that they only represent the best available consensus. The present text takes advantage of the recent developments such as introduction of the anti-neutrophilic cytoplasmic auto (ANCA) antibodies, and divides the vasculitides to those affecting typically the large, medium and small arteries or only small blood vessels. In addition, some vasculitides, which are still difficult to place to the vasculitis map, like Bόrger's disease, Goodpasture's syndrome, primary angiitin of the central nervous system (PACNS) and panniculitis, are dealt with. As it is a long and winding road, attention has to be paid to the clinical details to follow the road sign to "pseudovasculitis", when that is the right way to go. They represent a bunch of non-vasculitic conditions, which lead to structural or vasospastic impairment of the blood flow, bleeding or thromboembolism and hyperviscosity. These imitators have to some extent, similar clinical symptoms and signs as well as laboratory and radiological findings to those found in true systemic vasculitides. This also emphasizes the importance of internal medicine as the intellectual (albeit not necessarily organizational) home of rheumatology and rheumatologists as we deal with conditions like atherosclerosis, antiphospholipid antibody syndrome, infectious endocarditic, myxoma of the heart and cholesterol embolism.

Behcet's disease (BD) is a vasculitis progressing by attacks and remissions. There are actually four nationwide sur- veys of BD; Iran (5059 patients), Japan (3316 patients), China (1996 patients), and Germany (590 patients). There are four major case series in the world, Turkey (2147 patients), Korea (1155 patients), Morocco (1034 patients), and UK (419 patients). Other series are based on less than 200 patients. Mucous membrane manifestations: Oral aphthosis is seen in 98% of patients (average from the above-mentioned countries). Genital aphthosis occurs less frequently (73%). Skin manifestations are seen in 74% of patients. Behcet's pustulosis (pseudofolliculitis) is seen in 61% of patients in Iran. Erythema nodosum is seen in 22% of patients in Iran. They are more frequent in China and Korea. Ocular manifestations are seen in 51% of patients (anterior uveitis, posterior uveitis retinal vasculitis). Joint manifestations are seen in 39% of patients (arthralgia, monoarthritis, oligo/polyarthritis, ankylosing spondylitis). Neurological manifestations are seen in 7.3% of patients. They are mainly central manifestations due to parenchy- mal lesions. Gastrointestinal (GI) manifestations are seen in 9% of patients (produced by aphthous ulcers of the intestinal tract). Vascular involvement occurs in 11% of patients. Arterial involvement is rare. In Iran it is seen in 0.6% of patients. Deep vein thrombosis is seen in 6%, large vein thrombosis in 1.2%, and superficial phlebitis in 2.3%. Other lesions: Orchitis and epididymitis were seen in 5.6% of patients in Iran. Cardio-pulmonary manifestations were rare, seen in only 1.4% of patients in Iran. Laboratory findings: Erythrocyte sedimentation rate was normal in 43.5% of cases in Iran. Urinary abnormalities were infrequent and transient (9.8% in Iran). Proteinuria was seen in 2%, hematuria in 4.6%, leukocyturia in 5.1%, and cast in 0.3% of cases. Pathergy test was positive in 57.4% and HLA-B51 in 34% of patients. Conclusion: BD is a systemic disease with various manifestations. It progresses by attacks and remissions. Lesions usually heal without sequela, except for eyes, brain, and vascular system. The main manifestations are mucocutaneous. The major cause of morbidity is the ocular lesion, which leads to severe loss of vision or blindness.