Background/Objective Immunostimulatory drugs including immune checkpoint inhibitors and levamisole can induce inflammatory disease including vasculitis, rashes, tissue necrosis, and arthritis. Methods This prospective cohort study determined the 5-year outcomes of cocaine-levamisole–induced inflammatory disease as to outcomes and survival. Thirty-one consecutive cocaine-levamisole autoimmune patients and 45 primary vasculitis patients were characterized as to clinical differentiating features, antineutrophil cytoplasmic antibody (ANCA) status, treatment, the presence of acute and chronic arthritis, and 5-year outcome. Results Seventy-one percent (22/31) of cocaine-levamisole vasculopathy cases were ANCA positive (86% p-ANCA and 14% c-ANCA), whereas 53% (23/45) of the primary vasculitis were ANCA positive (p = 0.04). The ANCA-positive cocaine-levamisole cohort at onset were characterized by younger age (45 ± 12 vs 53 ± 14 years, p = 0.04), superficial skin necrosis (82% vs 54%, p = 0.036), depressed complement C3 (27% vs 4%, p = 0.33), antiphospholipid antibodies (50% vs 4%, p < 0.001), neutropenia (18% vs 0%, p = 0.044), and elevated antimyeloperoxidase (MPO) antibody levels (100% vs 67%, p < 0.001). Chronic cocaine-levamisole disease was characterized by severe cicatrical deformities of the face and extremities (45.5% vs 8.3%, p = 0.005). Arthralgias (71% vs 82%, p = 0.19) and acute arthritis (33% vs 32%, p = 0.25) were similar between the 2 groups. However, a substantial proportion cocaine-levamisole–induced autoimmune patients (18% vs 0%, p = 0.045) developed a chronic deforming inflammatory arthritis that was rheumatoid factor, anti–cyclic-citrillinated antibody antibody, and HLA-B27 negative, but p-ANCA-and MPO antibody positive. Conclusions Patients exposed to cocaine-levamisole may develop serious chronic sequelae including cicatrical cutaneous and facial deformities and an atypical seronegative, p-ANCA and MPO antibody–positive, HLA-B27–negative chronic deforming inflammatory arthritis.

Objectives –Aspiration of synovial fluid from non-effusive joints is undertaken for the diagnosis of crystal-associated arthritis, biomarker analysis, and to confirm intraarticular positioning. We hypothesized that pneumatic compression of the non-effusive knee would mobilize occult synovial fluid and improve arthrocentesis success. Methods – The absence of a knee effusion was determined by physical examination, imaging, and exclusion of confounding disease.  Conventional arthrocentesis was performed in 111 consecutive non-effusive knees and arthrocentesis volume (milliliters) determined. Pneumatic compression was then applied, and arthrocentesis was resumed. Results – Pneumatic compression improved fluid yield: conventional: 0.4±1.0 ml, compression: 1.8±2.5 ml (319% increase, 95% CI  -1.9<-1.4<-0.9; p=0.0001). Pneumatic compression reduced arthrocentesis failure (< 0.1 ml) from 74.8% (83/111) to 41.4% (46/111) (p=0.0001) and improved successful arthrocentesis in terms of adequate synovial fluid yield: 1) ≥ 0.1 ml from 25.2% (28/111) to 58.5% (65/111) (+132%, p=0.0001), 2) ≥ 0.5 ml from 22.5% (25/111) to 57.7% (64/111) (+156%, p =0.0001), 3) ≥ 2.0 ml from 11.7% (13/111) to 47.7% (53/111) (+300%, p =0.0001), and 4) ≥ 3.0 ml from 5.4% (6/111) to 36.0% (40/111) (+319%, p =0.0001). Conclusions: Pneumatic compression of the non-effusive knee improves the extraction of synovial fluid of various requisite volumes for conventional and biomarker analysis.

Aim: Complete arthrocentesis of the effusive knee ameliorates patient pain, reduces intra-articular and intraosseous pressure, removes inflammatory cytokines, and has been shown to substantially improve the therapeutic outcomes of intra-articular injections. However, conventional arthrocentesis incompletely decompresses the knee, leaving considerable residual synovial fluid in the intra-articular space. The present study determined whether external pneumatic circumferential compression of the effusive knee permitted more successful arthrocentesis and complete joint decompression.Methods: Using a paired sample design, 50 consecutive effusive knees underwent conventional arthrocentesis and then arthrocentesis with pneumatic compression.Pneumatic compression was applied to the superior knee using a conventional thigh blood pressure cuff inflated to 100 mm Hg which compressed the suprapatellar bursa and patellofemoral joint, forcing fluid from the superior knee to the anterolateral portal where the fluid could be accessed. Arthrocentesis success and fluid yield in mL before and after pneumatic compression were determined.Results: Successful diagnostic arthrocentesis (≥3 mL) of the effusive knee was 82% (41/50) with conventional arthrocentesis and increased to 100% (50/50) with pneumatic compression (P = .001). Synovial fluid yields increased by 144% (19.8 ± 17.1 mL)