Optimal duration of antibiotic therapy in vertebral osteomyelitis.

OBJECTIVES: To compare the risk of relapse of vertebral osteomyelitis (VO), according to the duration of antibiotic therapy (< or =6 weeks versus >6 weeks). METHODS: We performed a 10-year retrospective study to assess the risk of VO relapse and to verify that this risk was not enhanced in patients who received 6 weeks of antibiotic therapy (Group 1) as compared with those who received a longer treatment (Group 2). VO was diagnosed based on clinical manifestations, magnetic resonance imaging and/or computed tomography findings, and isolation of a pyogenic organism in blood cultures and/or a discovertebral biopsy. Relapse was diagnosed based on isolation of the same organism in blood cultures and/or a discovertebral biopsy. Outcome was evaluated 6 months post-treatment and in December 2004. RESULTS: Group 1 included 36 patients (mean age, 58 +/- 15 years) and Group 2 included 84 patients (mean age, 67 +/- 15 years) (P = 0.003). Clinical data and microorganisms were comparable in the 2 groups. In the first 6 months, 6 (5%) patients died (Group 1, n = 2; Group 2, n = 4), and 5 (4%) in Group 2 relapsed, 2 with recurrent VO and 3 with recurrent bacteremia. In 2004, 91 patients were evaluated (mean follow-up, 40.6 +/- 31 months): 77 (85%) were cured, 13 (14%) died (Group 1, n = 3; Group 2, n = 10), 1 had VO due to a different microorganism (Group 2), and no long-term relapses occurred. CONCLUSION: Our results suggest that antibiotic therapy of VO could be safely shortened to 6 weeks without enhancing the risk of relapse.

[Prognosis of generalized scleroderma. A retrospective study of 78 cases]. / Pronostic de la sclérodermie généralisée. Etude rétrospective de 78 observations.

From 1960 to 1984, 78 new patients with progressive systemic sclerosis were followed up: 60 women and 18 men whose ages ranged from 20 to 83 years, with a mean age of 58 years. Twenty nine are known to be dead and 3 were lost of follow-up. Forty six have been followed up to the present time for a mean period of 5 years. The cumulative survival rates were 88 +/- 7 p. 100 at one year, 62,5 +/- 11,5 p. 100 at five years and 50,5 +/- 15 p. 100 at ten years. These figures are significantly different from those found in a matched group from the French general population. Nine features at the time of diagnosis which might influence prognosis were studied. Seven factors apparently have not affected prognosis: sex, age, time elapsed between initial symptom and definitive diagnosis, location of scleroderma, blood pressure, erythrocyte sedimentation rate and creatinine clearance. On the other hand, survival declined significantly faster in the 28 patients with anemia than in the 50 patients without anemia (P less than 0,001). Similarly, the 47 patients with radiological pulmonary involvement or pulmonary function abnormalities were at significantly higher risk for death than the 31 patients without interstitial pulmonary fibrosis. Anemia and pulmonary involvement are predictors of mortality and important prognostic tools in the management of the different drugs that have been recommended for the treatment of patients with systemic sclerosis.

[RS3PE: a clinical diagnosis, a prognosis more simple than its name]. / RS3PE: un diagnostic clinique, une évolution plus simple que le nom.

INTRODUCTION: RS3PE syndrome (remittive symmetrical seronegative synovitis with pitting edema) was first described by MacCarthy in 1985. It is a rare type of seronegative polyarthritis occurring in the elderly. METHODS: Retrospective report of 13 cases (including eight male and five female patients; mean age 76.7 +/- 3.7 years) and search for previously reported cases, using the Medline database. RESULTS: Pitting edema was present at onset of disease in nine cases. Joint arthritis was bilateral, occurring in the wrist (13 cases), shoulder (six cases), elbow (six cases), knee (six cases), ankle (four cases), metacarpophalangeal (four cases) and hip (one case). Radiographies were normal. Mean erythrocyte sedimentation rate was 62 +/- 19 mm at the first hour and mean C-reactive protein level was 73 +/- 35 mg/L. Mild cholestasis was present in four of the seven patients for whom data were available. HLA B7 was present in five out of 12 cases (42%). Improvement was favorable, occurring over 7 months. Mean follow-up was 22.2 months. Fifty-nine other cases have been described in the literature. This syndrome, which affects the elderly, appears to be rare. Its clinical presentation is quite constant, with sudden onset, symmetrical polyarthritis and pitting edema. Its evolution, often long, is favorable. Rheumatoid arthritis and polymyalgia rheumatica are the main differential diagnoses. CONCLUSION: Due to its favorable outcome and the usefulness of a mild corticotherapy, this syndrome, though rare, should be diagnosed where necessary in elderly patients.

[Distribution of bone metastases of cancers. A scintigraphic study of 376 cases]. / La répartition des métastases osseuses des cancers. Une étude scintigraphique de 376 cas.

Technetium 99m methylene bisphosphonate bone scans of 376 patients with cancers of breast, prostate, lung, kidney, colon, and bladder and ENT cancer were reviewed, and the distribution of skeletal metastases was analyzed. Differences were not significant for rank order of metastatic involvement in 9 selected regions in any cancer, but the breast carcinoma. Patients with breast cancer had less pelvis and more skull involvement. The rate of skull metastases was significantly higher in breast cancer than in prostatic (p < 0.001), lung (p < 0.01) and kidney (p < 0.05) cancers. These results are weakly demonstrative of a role of the vertebral veins in hematogenous spread of breast and prostate cancer. The hypothesis is proposed that this pattern of dissemination, which is suggested by experimental and clinical features, is poorly perceptible in the distribution pattern of skeletal metastases because of the concurrent arterial spread of breast and prostatic tumors cells, which is likely preponderant.

[Disk calcinosis]. / Calcinoses discales.

Intervertebral disc calcification in children is a rare, primary and benign disease which often disappears after a single painful crisis, especially in cervical involvement. In adults, thoracic and lumbar discs are mainly involved; calcification is less expressive and is often detected during a casual radiograph. Intervertebral disc calcification is primary or secondary to chondrocalcinosis, apatite deposition disease, ochronosis and hemodialysis spondylarthropathy. Except CPPD deposits in chondrocalcinosis, calcium complex accounting for most discal calcinosis is hydroxy-apatite. Iatrogenic intervertebral disc calcification was recently described in patients treated with a discal injection of a long-acting corticosteroid.

[Association of rheumatoid arthritis and Kaposi disease. Apropos of a case arising after intraarticular corticotherapy]. / Association polyarthrite rhumatoïde--maladie de Kaposi. A propos d'un cas survenant au décours d'une corticothérapie intra-articulaire.

A 66 year old Corsican HLA A2 and DR5-positive male with moderately active seropositive destructive rheumatoid arthritis developed Kaposi's sarcoma after intraarticular administration of corticosteroids. He had no history of oral corticosteroid therapy, organ transplantation, AIDS, or cancer. Chlorambucil proved ineffective but the outcome was spontaneously favorable following discontinuation of oral corticosteroid therapy initiated after the development of the skin lesions. Six previous reports of concomitant rheumatoid arthritis and Kaposi's sarcoma were found. All six cases occurred following systemic corticosteroid therapy. The high incidence of rheumatoid arthritis and the small number of patients with rheumatoid arthritis and Kaposi's sarcoma suggest that concomitant occurrence of the two conditions may be fortuitous. However, the responsibility of corticosteroid therapy, which preceded development of Kaposi's sarcoma in every case, cannot be ruled out.

[Idiopathic retroperitoneal fibrosis and ankylosing spondylitis]. / Fibrose rétropéritonéale idiopathique et spondylarthrite ankylosante.

A case of ankylosing spondylarthritis in which retroperitoneal fibrosis developed 16 years after onset is reported. The patient also had aortic incompetence and cardiac conduction disorders. Eight other cases of ankylosing spondylitis with retroperitoneal fibrosis have been published. Potential relationships between the two conditions--including the possible role of indomethacin used by the patient for 16 years--are discussed.

[Chemonucleolysis of disk herniation with low back pain as the single symptom: 20 cases]. / Chimionucléolyse des hernies discales avec lombalgie pure: vingt cas.

Disk herniation can manifest as isolated low back pain, which is usually intermittent and accompanied with stiffness of the lumbar spine. There is almost general agreement that neither neurosurgical treatment nor chemonucleolysis is appropriate in patients with this clinical pattern. We used chemonucleolysis in 19 patients with recurrent episodes of isolated low back pain and one patient with severe permanent isolated low back pain dating back to a conservatively-treated episode of sciatica. All 20 patients had disk herniation documented by imaging studies. A very good or satisfactory outcome was recorded in ten patients after three months, 11 after six months and 12 in March 1993 after a mean follow-up of 72 months. The treatment was well tolerated, even in those patients who were not improved; a single patient developed an episode of acute low back pain that required surgical treatment. In patients with low back pain and disk herniation, there is currently no means of determining whether a causal relationship links these two abnormalities. Nevertheless, we believe that chemonucleolysis can be proposed in severe forms, provided the patients are apprised of current success rates.

Comparison of whole-body diffusion MRI and conventional radiological assessment in the staging of myeloma.

PURPOSE: In multiple myeloma, skeletal radiographs are still regarded as the reference imaging examination because they help to establish the stage of the disease according to the Durie-Salmon Staging System. Whole-body MRI using T1 and STIR sequences increases the detection of myeloma lesions. MRI-measured diffusion has demonstrated high sensitivity in terms of detection in oncology. The main objective of this study is to compare conventional radiographic staging with an MRI whole-body diffusion technique (called DWIBS) in detecting bone lesion monoclonal plasma cell pathologies (multiple myeloma, plasma cell leukaemia, plasmacytoma and MGUS). MATERIALS AND METHODS: Twenty-seven patients were included (multiple myeloma: 24; plasma cell leukaemia, MGUS and plasmacytoma: 1 each). All of them had a whole-body MRI diffusion examination (using a DWIBS sequence). Diffusion MRI and conventional radiographs were compared according to the Durie-Salmon Staging System. In case of doubtful lesions, 12 months of monitoring was used as the reference method for the definitive diagnosis. RESULTS: The overall concordance rate between the two techniques was 63%. The DWIBS sequence detected a higher number of lesions leading to a higher Durie-Salmon stage in 37% of the patients: one stage I to II, seven stage I to III, and two stage II to III. In 18.5% of the patients, the MRI was positive while the radiographs were normal and these discrepancies were most often located in sites poorly explored by X-ray (spine, pelvis and ribs). In one patient (4%), the MRI provided a stage lower than that of the X-rays (stage II vs. III). In this case, the X-rays were positive at the humerus and femur, unlike the DWIBS sequence. Our per site analysis confirmed the clear superiority of the DWIBS sequence when compared with X-rays in the exploration of the cervical spine (56 vs. 0%, P<0.001), dorsal spine (81vs. 31%,P<0.0002), lumbar spine (70 vs. 35%, P<0.0124), pelvis (81 vs. 33%, P<0.0005) and ribs (74 vs. 36%, P<0.0009). CONCLUSION: The DWIBS MRI leads to an increase in the final Durie-Salmon stage. Although its place in the preoperative treatment of multiple myeloma still has to be assessed, this study suggests its potential interest.

Vertebral osteomyelitis due to Fusobacterium species: report of three cases and review of the literature.

We describe three cases of Fusobacterium spp. diskitis and review with attention to risk factors, clinical features, diagnosis, treatment and outcome. In most of the reported cases, a ear-nose-throat infection was found. Clinical manifestations were similar to those of classic bacterial vertebral osteomyelitis. Clindamycin is the most appropriate antibiotic. The outcome seems to be very good without relapse with appropriate treatment compared to pyogenic vertebral osteomyelitis.

Hemodialysis is not essential for the development of destructive spondylarthropathy in patients with chronic renal failure.

Since 1984, there have been several reports of a destructive spondylarthropathy occurring in patients who have received hemodialysis over a long period of time. Two cases of a similar syndrome were observed in nonhemodialyzed patients with chronic renal failure, one of whom underwent a lumbar disc excision. The results of disc examination and of radiographic and biologic investigations prompted reconsideration of factors previously considered to be pathogenetic (amyloidosis, hydroxyapatite crystal deposition, aluminum toxicity), except one: secondary hyperparathyroidism.

[Post-traumatic reactive arthritis. Etiologic, clinical and diagnostic aspects. Apropos of 6 cases]. / Arthrites réactionnelles post-traumatiques. Aspects étiologiques, cliniques et diagnostiques. A propos de 6 observations.

The relationship between trauma and reaction arthritis, although controverted must be interpreted in each specific cases, after chronological analysis of the events. The localizing role of a trauma occurring before the infectious episode and affecting, topographically, a specific joint, may be accepted. It is reasonable to admit that a trauma, following an infectious episode, may possibly trigger rheumatism, providing that one of these arthritis corresponds topographically to the trauma. On the contrary, it does not seem possible to accept, in the present state of our knowledge, that an isolated trauma occurring on a genetically predisposed individual, may generate, out of nothing, a Fiessinger-Leroy-Reiter syndrome.

[Infectious spondylodiscitis. Analysis of a series of 105 cases]. / Spondylodiscites infectieuses. Analyse d'une série de 105 cas.

Among 105 cases of infectious spondylitis diagnosed and treated from 1971 through 1990, 23 were due to tuberculosis (TS) and 82 to other causes (NTS). The annual number of cases of NTS rose over the study period, partly because of an increase in iatrogenic spondylitis, whereas the number of TS cases fell. In both groups, mean age of patients was higher than in earlier studies. The leading causative agents in NTS were staphylococci, followed by streptococci, then Escherichia coli. Diagnosis of spondylitis was dependent on the imaging techniques used; among available methods, the most reliable was magnetic resonance imaging which improved diagnostic performance by detecting early, specific changes. Except in patients with positive blood cultures and in TS patients with Koch bacilli recovered from other visceral foci, bacteriologic diagnosis rested on studies of samples taken from the spinal infection site. Half the subjects underwent discovertebral needle biopsy, with a success rate of 47.5%, a figure comparable with those reported in other studies. In 30% of patients, bacteriologic documentation of the infection was not obtained and diagnosis rested on a set of clinical, biological, and radiological criteria.

Strategy for identifying primary malignancies with inaugural bone metastases.

The diagnosis of primary tumors with inaugural bone metastases is a serious and difficult problem commonly encountered in rheumatology. Helpful information can be derived from the radiologic appearance of the metastases, history of the patient, clinical findings, chest film, standard laboratory tests, imaging studies, serum marker assays, and histologic findings. Based on our personal experience and on previously published data, we have developed a decision tree aimed at enhancing the efficacy of the diagnostic process while ensuring optimal patient comfort and containing costs.

Femoral neuropathy secondary to ossification of the ligamentum flavum.

Radiculopathy resulting from ossification of the ligamentum flavum (OLF) is extremely rare and concerns only intercostal neuralgias. We describe a 37-year-old Caucasian woman with a lumbar radiculopathy revealing an OLF. Her symptoms were completely and definitively relieved by surgery.

[An unrecognized cause of spinal pain : meningoradiculitis. Apropos of 3 cases with predominant spinal pain]. / Une cause méconnue de rachialgies : les méningo-radiculites. A propos de trois cas à prédominance rachialgique.

Meningoradiculitis can present as a very short episode of radicular pain in addition to vertebral column pain without stiffness, as described in these three cases. The diagnosis requires examination of the cerebrospinal fluid, which should be a routine part of the diagnostic work up for back pain when an inflammatory etiology can not be identified.

[Calcifications after intra-disk injection of triamcinolone hexacetonide in lumbar disk hernia. Evaluation of therapeutical results in 3 years]. / Etude des calcifications apparues après injection intradiscale d'hexacétonide de triamcinolone dans les hernies discales lombaires. Evaluation des résultats thérapeutiques à 3 ans.

The development of disk or epidural calcifications is a frequent possibility following intra-disk injection of triamcinolone hexacetonide. It was found 10 times in 26 follow-up CT scans obtained 2 to 3 years after the injection. These calcifications are often clinically silent, but they sometimes accompany a recurrence of the initial painful symptomatology. Furthermore, evaluation at 3 years of therapeutic results in a previously published series of patients who had received an intra-disk injection of triamcinolone hexacetonide showed a marked decrease in favourable results (30% vs 67% at 6 months). These two arguments: disappointing long term results and possibility of disk calcifications, are felt by the authors to justify abandoning the technique of triamcinolone hexacetonide by intra-disk injection in the treatment of lumbar disk prolapse.