Severe deafness in systemic lupus erythematosus: its immediate relief by plasma exchange.

unusual numbness and weakness in his fingers in the absence of objective clinical signs.This resolved on withdrawal of the drug.Atrial flutter recurred in December 1980, in association with a respiratory tract infection; at this time he was taking only warfarin and digoxin.Reversion to sinus rhythm was achieved with the addition of quinidine, and once again he noticed pain and weakness in his fingers and wrists occurring within four days of starting the drug and resolving within a week of its withdrawal.With his informed consent he was formally rechallenged with quinidine to assess the response.He was given Kinidin Durules, two tablets twice a day, and his dose of digoxin was reduced from 0 25 mg to 0-125 mg daily.Within 24 hours he noticed a gradual onset of arthralgia in both hands, peaking five days after the start of quinidine.Quinidine was stopped two days later, and the symptoms settled over 48 hours.Symptoms consisted of mild pain but appreciable stiffness and weakness with slight swelling affecting in a symmetrical fashion the metacarpophalangeal joints, carpal, and wrist joints.He experienced difficulty in writing and with fine motor function of the hands.He also had mild aches and pains in both ankle and knee joints without limitation of movement.On examination at the peak of symptoms there was evidence of mild inflammation mainly affecting the metacarpophalangeal joints of both hands and also the proximal interphalangeal joints, with slight swelling over the dorsum of the hands.Moderate tenderness was noted over these joints, but there was no reddening and passive movements were limited only slightly.There was no associated rash and no other systemic disturbance.Grip strengths in both hands were measured using a dynamometer and showed an average 33 % reduction in power after challenge with the drug.The following variables were assessed before quinidine was given: full blood examination, platelet count, rheumatoid factor, complement concen- trations, erythrocyte sedimentation rate, antinuclear factor, microurine examination, serum electrolyte concentrations and renal function, and immune complexes.All these variables were assessed again on the last day of rechallenge with quinidine, and there was no appreciable alteration in any of the values.Serum quinidine concentration was measured at the peak of symptoms and was in the lower bracket of the therapeutic range.