Treatment of psoriatic arthritis with tumor necrosis factor inhibitors: longer-term outcomes including enthesitis and dactylitis with golimumab treatment in the Longterm Extension of a Randomized, Placebo-controlled Study (GO-REVEAL).

OBJECTIVE: To assess longer-term outcomes, including enthesitis and dactylitis, in patients with active psoriatic arthritis (PsA), in a study of golimumab treatment. METHODS: Adult patients with active PsA were randomized to receive subcutaneous injections of placebo (n = 113), golimumab 50 mg (n = 146), or golimumab 100 mg (n = 146) every 4 weeks through Week 20. All patients received golimumab 50 mg or 100 mg from Week 24 onward. Entheses tenderness was scored in 15 body sites using the PsA-modified Maastricht Ankylosing Spondylitis Enthesitis Score (MASES). Dactylitis was assessed in 20 digits of the hands and feet. RESULTS: Among the 405 randomized patients, 77% presented with enthesitis and 34% dactylitis at baseline. At Week 24 of the placebo-controlled study phase, significant differences were observed between golimumab 50 mg and/or 100 mg and placebo for mean percent improvement in the PsA-modified MASES [46% (p < 0.001) and 52% (p < 0.001) vs 13%, respectively] and the dactylitis score [66% (p = 0.09) and 82% (p < 0.001) vs 28%, respectively]. By Week 52, improvements were maintained among patients randomized to receive golimumab (mean improvements of 54% for PsA-modified MASES and 77% for the dactylitis score). Those given placebo who had enthesitis or dactylitis at baseline and who crossed over to golimumab at Week 16 or 24 had somewhat less improvement at Week 52 (i.e., 39% for the PsA-modified MASES, 57% for dactylitis score). CONCLUSION: Treatment of PsA patients with the TNF inhibitor golimumab was effective across all components of disease, including enthesitis and dactylitis, and efficacy was maintained over longer-term followup.

Pachydermodactyly in a young girl: cutaneous manifestation of a psychiatric disorder?

; Pachydermodactyly is a benign process characterized by painless fusiform skin swellings affecting radial and ulnar aspects of the proximal interphalangeal joints of the fingers. We report a case of this condition in a young girl, suggesting a major role of psychiatric disorder in the development of cutaneous lesions.

Bilateral Tubercular Dactylitis: Unusual presentation of an usual disease.

INTRODUCTION: Bilateral Tubercular Dactylitis (TD) is an unusual presentation of tuberculosis and only handful numbers of cases are reported in the literature. Hence, very little is known about its clinical presentation, statistic, radiological features and its outcome. METHODS: We have included seven male and two female patients of mean age 7.2 years, of the proven cases of bilateral TD by histopathological or microbiological or PCR analysis from core biopsy. Radiological features were recorded from plain radiograph. All patients were given Antitubercular drugs according to WHO 2010 recommendation (four drugs for 3-5 months, three drugs for next 3-5 months and finally two drugs for 6-8 months). Debridement was done whenever required. RESULTS: Of total 26 lesions, the most common presentation was swelling with or without mild pain. Discharging sinus was present in four lesions. There were six phalanges, 18 metacarpal and two metatarsals. Radiographically, the most common type of lesion was soft tissue swelling followed by lytic lesion. Histopathologically tuberculosis was proven in 10 (55.6%) lesions, bacteria isolated in 5 (27.8%) lesions and PCR was done in 8 lesions and was positive in all. All lesions healed after giving ATT except one which developed psudo-arthrosis and one patient developed coronal plane deformity that was corrected by JESS. CONCLUSION: A clinician should always suspect tuberculosis while dealing with a pathology of hand and feet even if it is bilateral. Suspected case can be diagnosed by histopathological, microbiological or PCR analysis and it can be treated by ATT with a good functional outcome.

Cutaneous mucormycosis as a presenting feature of type 1 diabetes in a boy - case report and review of the literature.

BACKGROUND: Mucormycosis is a potentially fatal complication of diabetes. The rhino-orbito-cerebral form is the most common presentation, however, rarely other types can also be seen. CASE PRESENTATION: We describe the case of a 4½ -year-old boy not previously known to be a diabetic who presented to the plastic surgery department for gangrene of the left middle finger with surrounding erythema and induration. After the diagnosis of diabetes and initial treatment, pus from the wound showed broad aseptate hyphae suggestive of mucormycosis which was further confirmed on culture. Aggressive surgical debridement including amputation, antifungal treatment and glycemic control achieved a complete cure. CONCLUSIONS: Cutaneous mucormycosis is a rare complication of type 1 diabetes mellitus and can even be seen at the onset of diabetes. High index of suspicion, timely antifungal treatment and aggressive surgical debridement usually lead to recovery in the localized form of the disease.

Multifocal plasmacytoma of hand and foot bones.

Simultaneous occurrence of localized plasmacytomas of both hands and feet has not been reported so far. Here we report a 40-year old female patient, who had at presentation pain and deformity. Of hands and feet, with numerous cystic lytic lesions of phalangeal, metacarpal and metatarsal bones, detected by X-rays. The biopsy of the affected bone showed moderately differentiated plasmacytoma of lambda light chain type (lambda-LC). Serum and urine biochemical analysis revealed the existence of lambda LC monoclonal component. The patient was treated by local radiotherapy and subsequent systemic chemotherapy, which consisted of 3 cycles of the M-2 protocol and 7 cycles of melphalan-prednisone. Five years after the diagnosis, the absence of plasmacytoma was confirmed by puncture biopsy of the left hand phalanx. Monoclonal protein in serum and urine was not detected.

Transient claw hand owing to a bee sting. A report of two cases.

We describe two patients with claw hand as a result of a bee sting. It is likely that this was caused by the apamin in the sting which has an effect on the upper limb, at the spinal cord and on the peripheral nerves. It is important to recognise that the claw hand is not owing to compartment syndrome. Both patients were treated conservatively with full resolution within 48 hours, without any lasting effects.

A two-year study of chondroitin sulfate in erosive osteoarthritis of the hands: behavior of erosions, osteophytes, pain and hand dysfunction.

The aim of this study was to evaluate the effect of 800 mg/die of chondroitin sulfate (CHS) per os plus naproxen versus naproxen over 2 years in patients with erosive osteoarthritis (EOA) of the hands. Joint count for erosions, Heberden and Bouchard nodes, Dreiser's algofunctional index and physicians' and patients' global assessment of disease activity were studied. A total of 24 consecutive patients (22 women and 2 men, mean age 53.0 +/- 6) suffering from symptomatic OA with radiographic characteristics of EOA were evaluated. The patients were divided into two groups of 12 patients each. The first group took naproxen 500 mg only. The second group was treated with CHS 800 mg orally plus naproxen 500 mg. Joint counts, radiological hand examinations and assessment of disease activity were performed at baseline, at 12 months and at 24 months. In the second year the treated group showed significant worsening in erosion, Heberden, Bouchard and Dreiser scores was recorded. Physician and patient global assessments of disease activity showed no significant difference from baseline scores. The untreated group showed significant worsening in erosion, Heberden and Bouchard nodes, Dreiser index and physician and patient global assessment scores. This study confirms the partial efficacy of oral CHS in improving some aspects of EOA.

Two cases of pachydermodactyly.

We report two cases of pachydermodactyly. Case 1 was a 16-year-old girl who complained of asymptomatic, bulbous, firm swellings which developed insidiously on both sides of the proximal interphalangeal (PIP) joint of her right middle finger. Case 2 was a 14-year-old boy with similar lesions on the sides of the PIP joints of the index and middle fingers of both hands. They both had histories of mild, repetitive mechanical trauma of the fingers. Radiologic findings showed soft tissue swellings without any bony or articular abnormalities. Histopathologic findings from the bulbous swellings revealed marked hyperkeratosis, slight epidermal hyperplasia, and a markedly thickened dermis with a deposition of mucinous material among the collagen fibers. Ultrastructural examinations of both cases showed decreased diameters of collagen fibrils. The lesions temporarily improved with intralesional injection of triamcinolone acetonide. Pachydermodactyly is more commonly found in boys and the affected fingers are more numerous in boys. Both of the present cases had the habit of rubbing and gripping their fingers unconsciously. Mechanical trauma of the fingers around puberty may play an important role in pachydermodactyly.

[Lack of effectiveness of alternative non-surgical treatment procedures of Dupuytren contracture]. / Fehlen der Effektivität der alternativ nichtchirurgischen Behandlungsverfahren bei Morbus Dupuytren.

In the early stage of the disease a group of patients was treated with radiotherapy, later another group with injections of superoxid-dismutase. The results of follow-up examinations 7 years after radiotherapy and 3 years after treatment with superoxid-dismutase respectively do not differ clearly from spontaneous course of Dupuytren's contracture grade one. At present we cannot recommend an alternative treatment for early stage Dupuytren's contracture.

[Arthrosis of the hands]. / Arthrose des mains.

A GENETICALLY DETERMINED AFFECTION: For more than two centuries, successive studies have led one to consider arthrosis of the hands as a genetically determined affection, but the localization of the genes responsible is unknown. Other than this genetic factor, various etiological factors have been identified (age-related increase, predominance in women, influence of hormones and obesity, mechanical factors...). Its incidence is of 100 per 100,000 persons/year. IDENTIFICATION OF PATIENTS: The clinical criteria retained for arthrosis of the hands are those of the American College of Rheumatology (ACR). Radiological scores have been established to permit good identification. SELECTION AND EVALUATION: The selection requires the use of classical radiological criteria and the clinical criteria of the ACR or those proposed by Lequesne and Maheu for the study of symptomatic drugs. For drugs with structural effect, an X-ray alone is sufficient. The pain measured on a visual analog scale is the principle criterion of efficacy in clinical trials. It is also possible to measure pain using Maheu's weekly assessment, the daily consumption of analgesics and/or anti-inflammatories, or again Drieser's algofunctional index or the AUSCAN.

Chronic mucocutaneous candidiasis: a case report.

Chronic mucocutaneous candidiasis is a immuno deficiency disorder primarily due to T cell dysfunction characterized by persistent candidal infection of mucous membrane, skin, scalp and nails. Chronic mucous membrane candidiasis has an onset in infancy or childhood; the primary affected site is the oral cavity; however, lesions may occur on trunk, hands, feet and scalp. This paper describes a 12-year-old girl with candidial infection of the oral mucosa and extra oral involvement of fingers, nails, toes and intertragus area.

Bilateral claw hand: an uncommon presentation of regional Guillain-Barré syndrome.

We present an uncommon case of a 38-year-old man presented with bilateral subacute weakness of intrinsic hand muscles, manifesting as bilateral claw-hand, without sensory deficits and absent tendon reflexes in upper arms. Nerve conduction studies showed findings consistent with demyelinating GBS. During the fourth day of hospitalization the patient presented symmetrical distal leg weakness and was treated with intravenous immunoglobulin.

Late complications of clinical clostridium histolyticum collagenase use in Dupuytren's disease.

INTRODUCTION: While Dupuytren's disease can cause disabling contractures requiring open surgery, a less-invasive option using Clostridium Histolyticum collagenase (CHC) via percutaneous injection was recently reported. A recent prospective, randomized trial demonstrated few complications during 90 days follow-up, however did not assess any longer term follow-up for these patients. Long-term outcomes in this setting have not been adequately reported, and the current manuscript aims to identify late complications from the clinical use of percutaneous CHC. METHODS: The current manuscript reports an extended 12-month follow-up for a cohort of twelve of patients enrolled in the original prospective, randomized trial, treated at a single institution. An analysis of complications requiring surgical intervention was undertaken. RESULTS: Two of twelve patients reported debilitating pain and triggering requiring surgical intervention. Extensive deep-tissue scarring and adhesions were identified, providing the first visual and qualitative analysis of the pathologic effects of CHC. CONCLUSION: Late complications from CHC use can and have occurred, outside the follow-up period of the initial phase III trials. Longer term follow-up of such patients is thus essential, and further investigation and characterization of the late effects of CHC use is warranted.