Bilateral Sub-deltoid Bursitis in a Patient Receiving Infliximab for Crohn's Disease.

BACKGROUND: Infiximab has been shown to be effective in inducing and maintaining remission of intestinal bowel diseases. Infiximab has been associated with many adverse events. Articular manifestations are commonly reported, but they are of variable clinical expression and aetiology. Among them, inflammatory bursitis has rarely been described. OBJECTIVE: Herein a case of inflammatory bursitis in a patient with Crohn's disease after switching to biosimilar infliximab is reported. CASE REPORT: A 41-year-old man with Crohn's disease evolving from 3 years was referred to infliximab therapy at a dose of 5mg/kg because of an aggressive resistant perineal fistula. After 14 infusions of infliximab, the treatment was switched to infliximab biosimilar using the same dose and frequency of administration. Forty-eight hours after the second infusion, he developed an acute onset of muscle pain and stiffness on both of his shoulders. A musculoskeletal ultrasound was performed and revealed a hypoechoic widening of both subacromial bursae. It was more severe on the left side. DISCUSSION: The diagnosis of non-infective sub-acromial bursitis secondary to infliximab infusion was made as the patient's symptoms resolved rapidly without any antibiotics. Infliximab was definitively stopped and adalimumab was introduced. CONCLUSION: Musculoskeletal side effects of infliximab infusion are uncommonly reported. Among them, bursitis has been reported in only a few cases. Ultrasonography can help early diagnosis of bursitis. The time of occurring of this reaction regarding infliximab infusion, screening of Antibodies to Infliximab (ATI) and clinical outcome after drug discontinuation are the main helpful arguments.

Bone erosion and subacromial bursitis caused by diphtheria-tetanus-poliomyelitis vaccine.

Revaxis(®) is a vaccine against diphtheria, tetanus and poliomyelitis (dT-IPV). This vaccine should not be administered by the intradermal or intravenous route. Poor injection techniques and related consequences are rare. We report a case of bursitis associated with reactive glenohumeral effusion complicated by bone erosion occurring after injection of the dT-IPV vaccine. A 26 year old patient was admitted for painful left shoulder causing functional impairment. Control magnetic resonance imaging showed bone oedema on the upper outer part of the humeral head, with a slight cortical irregularity, indicating that the vaccine was injected in contact with the bone at this location, causing erosion. Outcome was favourable after intra-articular corticosteroids. Reports of articular or periarticular injury after vaccination are extremely rare, in view of the substantial number of vaccines administered every year. The potential complications of vaccination are well known to general practitioners but under-reported in the literature.

Voriconazole-associated soft tissue ossification: an undescribed cause of glenohumeral joint capsulitis.

Voriconazole-related periostitis has been increasingly described in the literature over the last several years as a recognizable disease entity, especially in lung transplant patients. This relationship should be considered when approaching immunosuppressed patients presenting with diffuse bone pain and imaging findings of periostitis. We present a case of voriconazole-associated periostitis, capsular and enthesial ossification and glenuhumeral capsulitis in a patient with a hematologic malignancy. To the authors' knowledge, soft tissue ossification associated with voriconazole has not been described in the radiology literature.

Magnetic resonance imaging of abnormal shoulder pain following influenza vaccination.

The influenza vaccine is increasingly available to the general public and mandated by many employers in the United States. The prevalence of post-vaccination complications is likely on the rise. Complications are well known to general clinicians, but are under-reported in the imaging literature. We present four cases of post-vaccination shoulder pain with magnetic resonance imaging (MRI) findings. An intrasubstance fluid-like signal in deep muscular and/or tendinous structures was the most common finding on MRI of these four cases. Focal bone marrow signal within the humeral head and inflammatory changes in the subacromial/subdeltoid bursa were also observed. The most likely reason for a humeral intraosseous edema-like signal was presumed injection of vaccine substance directly into osseous structures that might lead to focal osteitis. In the published literature, there is little emphasis on the imaging of local injection site complications accompanying influenza vaccination. We intended to increase familiarity of MRI findings in the setting of prolonged or severe clinical symptoms following influenza vaccination through the imaging findings of these four cases.

Subdeltoid/subacromial bursitis associated with influenza vaccination.

A 76-year-old male presented with subacromial/subdeltoid bursitis following influenza vaccine administration into the left deltoid muscle. This shoulder injury related to vaccine administration (SIRVA) could have been prevented by the use of a safe, evidence based protocol for the intramuscular injection of the deltoid muscle.

Refractory adhesive capsulitis under acitretin therapy.

BACKGROUND: Adhesive capsulitis (AC) is characterized by a limited active and passive motion. Although the exact pathology remains unknown, a number of contributing factors are discussed. OBJECTIVE: AC has probably been caused by the Re-PUVA therapy (PUVA irradiation plus acitretin) of a cutaneous T-cell lymphoma, type mycosis fungoides. Acitretin belongs to the group of retinoids and is often used in cornification disorders. METHODS: After non-successful initial conservative therapy with intraarticular steroid injections and physical therapy, a significant improvement of shoulder joint mobility was finally achieved by an arthroscopic juxtaglenoid capsulotomy and adhesiolysis. RESULTS: A therapy with acitretin should be considered as a possible trigger of AC. CONCLUSIONS: Patient's medication should be checked carefully on possible triggers of AC. The athroscopic adhesiolysis is an effective method for a frustrating conservative treatment of AC.

Clopidogrel-associated acute arthritis.

A 54-year-old Japanese man was urgently admitted to our hospital because of "unmovable" polyarthralgia, high fever and pruritus. He had taken clopidogrel 3 weeks before this admission to prevent ischemic cerebrovascular events. On the laboratory values, acute phase reactants and serum IgE were elevated. Although his symptoms had promptly improved with non-steroidal anti-inflammatory drugs (NSAIDs) and cessation of the drug, the same phenomena were re-induced by re-administration of the drug. According to the above manifestations, he was diagnosed as suffering from clopidogrel-associated acute arthritis.

Olecranon bursitis in patients treated with sunitinib for renal cell carcinoma.

Sunitinib is a recently approved tyrosine-kinase inhibitor that targets the vascular endothelial growth factor receptors (VEGFR). We report two cases of patients with metastatic renal cell cancer who developed olecranon bursitis while receiving sunitinib. In both cases other causes of bursitis were excluded and the symptoms resolved after treatment with sunitinib was discontinued. Recurrence of symptoms during subsequent treatment cycles was also observed. This adverse event has not been previously reported for sunitinib and we believe it is directly attributable to the drug. This is an unexpected adverse event, given the mechanism of action of the drug. The pathophysiology of this event remains unexplained, although we describe some hypotheses.

Early diagnosis of bilateral sub-deltoid bursitis using clinic-based ultrasonography in a patient receiving infliximab therapy for ulcerative pouchitis.

BACKGROUND: Infliximab, a monoclonal chimeric antibody to tumour necrosis factor (TNF)α, is a novel therapy used in the management of chronic refractory pouchitis that is unresponsive to conventional medical therapy. METHODS: This report describes a case of non-infective bursitis following infliximab therapy and documents the role of musculoskeletal ultrasound in detecting soft tissue fluid collections and in guiding aspiration. CONCLUSION: A high index of suspicion is required when assessing new or worsening musculoskeletal pain in patients receiving infliximab and involvement of a rheumatologist at an early stage is essential in order to appropriately diagnose and manage this condition.

Vaccination-related shoulder dysfunction.

We present two cases of shoulder pain and weakness following influenza and pneumococcal vaccine injections provided high into the deltoid muscle. Based on ultrasound measurements, we hypothesize that vaccine injected into the subdeltoid bursa caused a periarticular inflammatory response, subacromial bursitis, bicipital tendonitis and adhesive capsulitis. Resolution of symptoms followed corticosteroid injections to the subacromial space, bicipital tendon sheath and glenohumeral joint, followed by physical therapy. We conclude that the upper third of the deltoid muscle should not be used for vaccine injections, and the diagnosis of vaccination-related shoulder dysfunction should be considered in patients presenting with shoulder pain following a vaccination.

Adhesive capsulitis of the shoulder in human immunodeficiency virus-positive patients during highly active antiretroviral therapy.

Many adverse events have been described in patients treated with highly active antiretroviral therapy (HAART). Recently, among these, adhesive capsulitis of the shoulder has been described in some patients using protease inhibitors. We report our experience with 6 human immunodeficiency virus-positive patients in whom adhesive capsulitis of the shoulder developed during HAART. All 6 patients were treated with the same antiretroviral drug combination (HAART) including nucleoside reverse transcriptase (stavudine and lamivudine) and protease inhibitors (indinavir). The clinical pattern of adhesive capsulitis during HAART is similar to the classical form of adhesive capsulitis. Examining our case studies, we postulate a correlation between HAART and adhesive capsulitis. Discontinuation or reduction of the dosage of protease inhibitors associated with conventional conservative treatment is effective in reducing the symptoms and resolving the disease.

Arthritis and bursitis in multiple sclerosis patients treated with interferon-beta.

Interferon-beta (IFN-beta) is a type I interferon used in the management of multiple sclerosis. Therapy with IFN-beta has rarely been associated with the development of autoimmune disorders. We present the cases of two female patients diagnosed with relapsing-remitting multiple sclerosis (RRMS) who developed inflammatory musculoskeletal manifestations, following IFN-beta therapy. The first patient developed a monoarthritis 2 weeks after initiation of IFN-beta, which persisted during the 14 months of therapy and resolved with discontinuation of the medication. The second patient developed both autoimmune thyroid disease and a refractory pre-patellar bursitis after 50 months of IFN-beta therapy. Our literature review revealed an additional six cases of onset of inflammatory arthritis in MS patients receiving IFN-beta. We review these reports with comparison to our two cases. The role of IFN-beta in inflammatory musculoskeletal disease is unclear. The potential autoimmune complications of this therapeutic agent should be comprehended when monitoring patients receiving such treatment.

Carrageenan-induced subacromial bursitis caused changes in the rat's rotator cuff.

This study was designed to investigate the histologic expression of the rat's supra- and infraspinatus tendons in carrageenan-induced subacromial bursitis. Thirty-two rats received subacromial injections with carrageenan (n = 28) or saline (n = 4). The tendons were analysed microscopically after staining with hematoxyline eosin, Van Giesons hematoxyline and immunofluorescent staining of fibronectin and fibrinogen. In the controls (saline x 10) and group A (carrageenan x 5) there were no changes in the tendons. In group B (carrageenan x 10) 3/8 rats showed macrophages between the collagen fibres and an increased staining of fibronectin. In group C (double dosis carrageenan) all rats had signs of fibrocartilaginous metaplasia in the supraspinatus tendon. In eight of these specimens even bony metaplasia was seen. The infraspinatus tendon showed fibrosis but no fibrocartilaginous metaplasia. The results showed that iatrogenic bursitis after carrageenan subacromial injections was associated with marked changes of the supraspinatus tendon.