Rheumatology (2nd Edition)

1. Nobel laureate Dorothy Hodgkin was one of the great British scientists of the 20th century. Her discovery of protein crystallography gave her the tools to describe the structure of many key biomolecules for the first time, including insulin and vitamin B12. The picture below illustrates a classic physical finding of her rheumatic disease, the extent of which is rarely seen in our age of disease-modifying drugs.

Dorothy Hodgkin, 1910-1994

2. Once again we visit the medical records of King George the VI. As mentioned in a previous post, one of the ways he dealt with his famous speech impediment was chronic cigarette smoking. This eventually lead to severe COPD, lung cancer, and a total left lung resection. In his last years he also suffered from episodes of pain, rash, and signs of decreased perfusion in his feet. During one episode in 1949, the arterial occlusion was so severe that his doctors severed his lumbar sympathetic nerves to avoid having to amputate his leg. The procedure was a relative success, and the king retained the use of his limbs until his death from coronary artery disease in 1953. Apart from atherosclerosis, what possible disease was the king suffering from?

3. In 1665, Rembrandt painted a portrait of fellow Dutch artist Gerard de Lairesse. Little is known about the medical history of this man, but the painting shows a very unique physical finding. What are two rheumatic diseases that could lead to this deformity, and what did he most likely have?

Gerard de Lairesse, 1641-1711

4. The annals of ancient medical history do not offer a wealth of rheumatology cases. However, one passage from Hippocrates gives a very clear description of a specific autoimmune disease. It wasn't until 1937 that the modern medical community fully described the condition.

"There were other fevers also, which I shall describe in due course. Many had aphthae and sores in the mouth. Fluxes about the genitals were copious; sores, tumours external and internal; the swellings which appear in the groin. Watery inflammations of the eyes, chronic and painful. Growths on the eyelids, external and internal, in many cases destroying the sight, which are called "figs". There were also often growths on other sores, particularly in the genitals. Many carbuncles in the summer, and other affections called "rot". Large pustules. Many had large tetters (herpetes)."

Hippocrates refusing the gifts of artaxerxes, 1792. by Anne Louis Girodet

5. In the later years of his acting career, Sir Laurence Olivier's poor health forced him to take smaller roles in "undistinguished films" due to his extreme weakness and fatigue. In 1974, he spent over three months in the hospital due to proximal muscle weakness and pain. After he recovered, he resumed his acting career, and a still from his 1976 movie Marathon Man shows the remnants of a subtle skin finding that may point to his diagnosis. What is it?

Take a close look at the hands.

6. Opera singer Maria Callas also had her career interrupted by this autoimmune disease. It began in 1958 during a performance for the Italian President. She was forced to leave during intermission because of weakness in her vocal chords and a sudden inability to control fluctuations in her voice. She was initially diagnosed with acute tracheitis, but as this became a chronic problem her personal doctor also noted her chronic generalized hypotonia, somnolence, and red discolorations around the base of her neck. She began symptomatic cortisone injections, but many critics commented on her gradual vocal decline and unsteadiness. She ultimately succumbed to cardiovascular complications of the disease (or possibly treatment) at the age of 53.

One of her most celebrated arias, from the opera Norma

7. One more exercise in physical diagnosis:

Michael Jackson, 1958-2009

 Answers: (highlight to see)
1. Rheumatoid Arthritis
2. Thromboangiitis Obliterans (Buerger's Disease)
3. Relapsing polychondritis, granulomatosis with polyangiitis. Most likely congenital syphilis.
4. Behcet's disease
5. Dermatomyositis - Gottron papules
6. Dermatomyositis
7. Malar rash (Discoid lupus in this case)