Structural ultrasound of joints and tendons in healthy children: development of normative data.

BACKGROUND: Musculoskeletal ultrasound is a well accessible technique to assess disease activity in children with juvenile idiopathic arthritis. Knowledge of reference values of joint structures is indispensable to differentiate between physiological and pathological finding. The aim of this study was to assess the structural sonographic features of joints and tendons in healthy children from several age groups (0.2-18 year), and develop a set of normative data. METHODS: Greyscale ultrasound was performed in 500 healthy children (age 0.2-18 years) according to a predefined scanning protocol (Additional file 1) including the shoulder, elbow, wrist, second metacarpophalangeal joint, hip, knee, ankle, and first metatarsophalangeal joint). Demographic data and values of cartilage thickness, tendon diameters, and the degree of capsular distention measured by bone-capsular distance (BCD) were collected. Differences according to the sex were assessed by unpaired t-test. Single and multiple regression analyses were performed between the ultrasound outcomes and covariates such as age, height, weight and body mass index. Growth charts and tables were developed with respect to age. Nonparametric quantile regression was applied using the R-packages quantreg and quantregGrowth. RESULTS: A total of 195 male and 305 female volunteers were included between the age of 0 and 18 years (mean age 8.9; range: 0.2-17.9 years). Cartilage diminished markedly as children aged, and cartilage of the boys was significantly thicker compared to the girls in all joints (p < 0.001). In addition, cartilage became thinner as children's height and weight increased (beta regression coefficients between - 0.27 and - 0.01, p < 0.0001). Capsular distention (i.e., BCD > 0 mm) was uncommon in the ankle, wrist and MCP2 (resp. in 3, 6, and 3% of cases). It was more common in the suprapatellar and parapatellar knee, MTP1 and posterior recess of the elbow (resp. in 34, 32, 46, and 39% of cases). In the hip, some capsular distention was always present. Age was found to be the best predictor for BCD (beta regression coefficients between 0.05 and 0.13, p < 0.0001). Height was, in addition to age, a good predictor of tendon diameter (beta regression coefficients between 0.03 and 0.14, p < 0.0001). Growth curves and tables for each variable were developed. CONCLUSIONS: Reference values of sonographic cartilage thickness, BCD and diameters of tendons at several joints were established from 500 healthy children, aged between 0.2 and 18 years. Growth charts and tables were developed to distinguish normal findings from pathology in children with complaints suspicious of arthritis.

A case of anti-HMGCR myopathy in a patient with breast cancer and anti-Th/To antibodies.

Statins competitively inhibit the activity of HMGCR (3-hydroxy-3-methylglutaryl coenzyme A reductase), which is a key enzyme in cholesterol synthesis. These are effective drugs for the management of cardiovascular disease and are generally well tolerated but several side effects have been reported. Muscular adverse symptoms are various and, rarely, statin exposure may lead to authentic immune-mediated necrotizing myopathy (IMNM), namely anti-HMGCR myopathy. However, cases of IMNM associated with cancer have been described. We discuss herein a case of IMNM in a patient with breast cancer previously exposed to statins and with the presence of anti-Th/To antibodies without clinical correlation.

A case of left foot drop as initial symptom of granulomatosis with polyangiitis: Triggered by COVID-19 disease?

In Granulomatosis with polyangiitis (GPA), involvement of the peripheral nervous system is frequent but its occurrence as an initial presentation is unusual. This case highlights the importance of this occurrence to permit an early diagnosis. Moreover, GPA started after a coronavirus disease 2019 infection and could have been induced by this.

Pulmonary fibrosis and microscopic polyangiitis in a 75-year-old woman.

We present a case of a 75-year-old woman who admitted in the internal medicine department for a recent onset of persisting moderate daily fever and fatigue that started 30 days prior to her hospitalization. Her past medical history is remarkable for mild pulmonary fibrosis, megaloblastic anaemia, and hypergammaglobulinaemia of no obvious causes. On presentation, she was febrile (38°C) and had high ESR and CRP levels, but most of her laboratory tests were within normal levels and had no signs of arthritis or rash. She was hospitalized for suspected lower urinary tract infection and started on antibiotics. During hospitalization, her renal function deteriorated together with microscopic haematuria, proteinuria and granular urine casts in urine analysis and her inflammation markers raised further. A renal biopsy revealed glomerulonephritis with pauci-immune crescents, and serology tests were positive for anti-MPO p-ANCA, both suggesting a diagnosis of microscopic polyangiitis (MPA). While high-dose methylprednisolone pulses and cyclophosphamide were introduced intravenously, there was no remission, but respiratory failure occurred that led to patient's intubation and transfer to the ICU. She died a few days later due to septic shock. Asymptomatic pulmonary fibrosis can precede microscopic polyangiitis for several years and is associated with a poor prognosis.

The use of Canakinumab in treating resistant gouty disease in patients with limited therapeutic options: The experience of the Rheumatology Clinic of Asklipeion General Hospital of Voula, Greece.

Gout is an autoinflammatory disease caused by monosodium urate mono hydrate crystal deposition in tissues or the supersaturation of extracellular fluids of uric acid. In this study, we are going to report the experience of the Asklepeion Voula Rheumatology Clinic, treating four patients with gouty arthritis who received Canakinumab.

Detection of subclinical synovial inflammation by microwave radiometry.

OBJECTIVE: Microwave Radiometry is a non-invasive method which determines within seconds the in vivo temperature of internal tissues at a depth of 3-7 cm with an accuracy of ±0.2°C. In this proof-of-concept study, we tested the hypothesis that, in absence of relevant clinical signs, increased local temperature detected by microwave radiometry reflects subclinical synovial inflammation, using ultrasound as reference method. METHODS: Knees of healthy controls, subjects with recent knee trauma and symptom-free patients with rheumatoid arthritis (RA) or osteoarthritis were examined by placing the microwave radiometry sensor, a) at the upper one third of the anterior surface of the thigh (control-point), and b) over the suprapatellar recess. Ultrasound was performed immediately after and the possible presence of fluid and/or synovitis was correlated with microwave radiometry findings. RESULTS: In 30 healthy and 10 injured knees the temperature was always lower than thigh (32.3±1.1 and 31.8±1.4 versus 34.1±0.9 and 33.6±1.2°C with a difference (ΔΤ) of -1.8±0.2 and -1.9±0.4°C respectively). Of 40 RA and 20 osteoarthritis knees examined, ultrasound findings indicative of subclinical inflammation (fluid effusion and/or Doppler signal) were found in 24 and 12, respectively, in which the temperature was higher than healthy knees and ΔΤ was lower (-0.9±0.7 in RA and -1.0±0.5 in osteoarthritis versus -1.8±0.2°C, p<0.001). The 5 RA knees with power Doppler findings indicative of grade 2 inflammation had a ΔΤ 3 times lower compared to healthy (-0.6±0.6, p = 0.007), whereas the 9 RA and the 7 osteoarthritis knees with additionally fluid effusion, had even lower ΔΤ (-0.4±0.7, p<0.001). CONCLUSION: Using a safe, rapid and easy-to-perform method, such as microwave radiometry, thermal changes within the knee joint may reflect non-clinically apparent joint inflammation. Refinement of this method, including production of sensors for small joints, could result to the development of the ideal objective tool to detect subclinical synovitis in clinical practice.

Vitamin D and rheumatoid arthritis.

OBJECTIVES: Vitamin D deficiency has been implicated in the pathogenesis of autoimmune diseases, such as diabetes mellitus type 1 and multiple sclerosis. Reduced vitamin D intake has been linked to increased susceptibility to the development of rheumatoid arthritis (RA) and vitamin D deficiency has been found to be associated with disease activity in patients with RA. The objective was to evaluate vitamin D status in patients with RA and to assess the relationship between vitamin D levels and disease activity. METHODS: In a cohort of 44 patients with RA, 25-hydroxyvitamin D(3) [25(OH)D(3)] levels, parathyroid hormone levels, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were measured. Disease activity was evaluated by calculating the 28-joint Disease Activity Score (DAS28). A control group (n = 44), matched for age and sex, was evaluated as well. RESULTS: In the cohort of 44 patients with RA 25(OH)D(3) levels were found to be low compared with the control group, 25(OH)D(3) being 15.26 ± 1.07 ng/ml [mean ± standard error of the mean (SEM)] and 25.8 ± 1.6 ng/ml in the patient and control group respectively (Student's t test, p < 0.001). Parathyroid hormone levels were 71.08 ± 7.02 pg/ml (mean ± SEM) (normal values 10.0-65.0 pg/ml), CRP 7.6 ± 1.57 mg/litre (mean ± SEM) (normal values < 3 mg/litre) and ESR was 38.0 ± 4.6 mm/h (mean ± SEM) in the group of patients with RA. Levels of 25(OH)D(3) were found to be negatively correlated to the DAS28, the correlation coefficient being -0.084. Levels of 25(OH)D(3) were also found to be negatively correlated to CRP and ESR, the correlation coefficient being -0.115 and -0.18, respectively. CONCLUSION: It appears that vitamin D deficiency is highly prevalent in patients with RA, and that vitamin D deficiency may be linked to disease severity in RA. As vitamin D deficiency has been linked to diffuse musculoskeletal pain, these results have therapeutic implications. Vitamin D supplementation may be needed both for the prevention of osteoporosis as well as for pain relief in patients with RA.