Chronic alcohol consumption as a predisposing factor for multiple tendon ruptures in unusual sites in a patient with rheumatoid arthritis.

Simultaneous bilateral patellar tendon ruptures are a rare complication of rheumatoid arthritis (RA). Systemic inflammatory diseases (RA, systemic lupus erythematosus (SLE), chronic renal failure, primary and secondary hyperparathyroidism, diabetes mellitus, obesity, sports activity, older age (>50) and drugs (prolonged use of high doses of steroids, local steroid injections and quinolones) are considered as potent predisposing factors for tendon rupture. We report a case of an alcoholic patient with RA and bilateral spontaneous tendon ruptures of the knees. Circumstantial evidence suggest that in this patient, chronic alcohol consumption, a very frequent cause of toxicity to striated and cardiac muscle, contributed to the injury.

Anti-TNF and fistulizing perianal Crohn's disease: use in clinical practice.

Perianal fistulas are a major problem of patients with Crohn's disease (CD), and occur in up to 40 % of patients. The treatment of fistulizing perianal CD has recently largely evolved as a result of improvements of pharmacological and surgical approaches and the introduction of anti-TNF treatment. Especially the use of anti-TNF agents in complex or refractory perianal fistulas has been proven as the most effective medical treatment of this difficult to treat disease. Infliximab and adalimumab are the two currently available anti-TNF agents that both have shown significant efficacy in the treatment and sustained remission of perianal fistulizing CD with comparable fistula closure rates. However, despite this treatment a large number of patients have continuous disease activity and high relapsing rates whereas only a small percentage of them have a complete fistula healing. Therefore the optimal outcome is still dependent on a multidisciplinary approach with a close interaction between gastroenterologists and surgeons. The individualised treatment based on anti-TNF agents with the rational combination of antibiotic use, surgery and immunosuppressive therapy is, currently, the suggested treatment in order to achieve remission of a persistent perianal fistula. Large randomised studies are required for the long-term evaluation of the efficacy in modifying the disease course of this combined approach.