Allergic and toxic reaction to alprazolam.

the manubrio-sternal and sternoclavicular joints possess synovium,3'4 extension of synovial disease from adjacent costochondral joints, degenerative processes or trauma. Histological and microradiographic analysis has indicated active inflammation of the articulation in some patients and the absence of inflammation and presence offibrous replacement in others.5 Pathological problems with clinical manifestation in the manubriosternal joint of patients with rheumatoid arthritis are shown in the box. In the former case, bacteraemia and joint sepsis probably occurred secondary to a urinary tract infection in a joint previously compromised by rheumatoid arthritis. This case also illustrates the difficulty in eradication of joint sepsis despite adequate and prolonged administration of appropriate antibiotics. Both cases demonstrate the importance of excluding sepsis in any disproportionally warm and painful joint in a rheumatoid patient. In both patients, fever and peripheral blood leucocytosis were present, characteristic of infection. These responses may be reduced or abolished in rheumatoid patients especially in those debilitated or immunocomprised. Elimination of infection from a joint requires prolonged high-dose antibiotic administration, repeated arthocentesis and sometimes arthrotomy and surgical drainage. Infection is rapidly destructive of intra-articular structures, congruity and stability. We suggest that clinically obvious manubrio-stemal joint arthritis in a patient with rheumatoid arthritis should be regarded as septic until proved otherwise. GD WRIGHT