An unexpected cause of sacroiliitis in a patient with gout and chronic psoriasis with inflammatory arthritis: a case report.

BACKGROUND: Inflammatory back pain is a condition characterized by inflammation of the sacroiliac joints and lower spine. It is frequently seen in patients with spondyloarthropathies like ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis and reactive arthritis. Inflammatory back pain can be caused by many other conditions like infection and crystal deposition such as gout. In this case, it is difficult to specifically identify gout as a cause by ordinary imaging like magnetic resonance imaging (MRI) or ultrasound. CASE PRESENTATION: This case report describes a young man with severe psoriasis, presumptive psoriatic spondyloarthropathy and chronic extensive tophaceous gout which was difficult to treat because of non-compliance with medications and lifestyle. He presented with inflammatory type low back and buttocks pain with raised inflammatory markers. MRI of the lower back and sacroiliac joints showed features of active sacroiliitis. He was subsequently treated with a Tumor Necrosis Factor (TNF) alpha inhibitor for presumed axial psoriatic arthritis and had no significant benefit. Two attempts DECT of the lumbar spine was not executed correctly. CT lumbar spine and SIJs showed L2/3 endplate and left SIJ erosions mostly related to gout. Rasburicase was introduced. The tophi decreased in size peripherally with marginal improvement in back pain. From this study, we want to bring to the attention of physicians that gout can lead to back pain with inflammatory changes on MRI. We also want to address the importance of other imaging modalities if the cause of the back pain is not clear. CONCLUSION: This case is meant to highlight an important but overlooked cause of active sacroililitis and inflammatory type back pain in patients who have gout, and to bring to the attention that plain X-ray, MRI and ultrasound cannot differentiate between inflammatory sacroiliitis caused by seronegative arthritis versus gouty arthritis. CT scan can add more information but DECT is the preferred method for differentiation and identification of axial tophaceous gout.

[CRYOGLOBULINEMICVASCULITIS AS A MANIFESTATION OF PARANEOPLASTIC SYNDROME--A CASE REPORT]. / KRIOGLOBULINEMICNI VASKULITIS KAO MANIFESTACIJA PARANEOPLASTICKOG SINDROMA--PRIKAZ BOLESNIKA.

Cryoglobulinemia refers to the presence of circulating cryoglobulins in the serum which may lead to organ damage and systemic response characterized by fatigue, arthralgias, purpura, glomerulonephritis and neuropathy. The disease mainly affects small and medium-sized blood vessels and causes vasculitis due to cryoglobulin-containing immune complexes. Mixed cryoglobulinemia (type I and II) are most often associated with infections, especially hepatitis C virus (HCV), but may occur as part of lymphoproliferative and autoimmune diseases. We present a 75-year-old male patient with acrocyanosis and digital necrosis of the left hand and purpura of the lower extremities. Since 2001 the patient was treated for Non-Hodgkin's lymphoma of the stomach (MALT) and since 2002 for Sjogren's syndrome. Extensive diagnostic procedures revealed cryoglobulinemia type II, but without evidence of HCV infection or relapse of lymphoproliferative disorder. Furthermore, poorly differentiated prostate adenocarcinoma was diagnosed and antiandrogen treatment was initiated. One year after the onset of symptoms acrocyanosis and digital necrosis, gastric adenocarcinoma was diagnosed, without metastatic disease, and surgical treatment was performed. However, postoperatively recurrence of new digital necrosis of the hands occurred along with clinical deterioration and multiple organ failure leading to lethal outcome. Association of cryoglobulinemia and solid tumors is rarely described in the literature, so it is very important to perform comprehensive diagnostic evaluation and detect potential underlying disease as soon as possible.

[Antisynthetase syndrome - a case report]. / Antisintetaza sindrom - prikaz bolesnice.

Twenty-eight year-old woman with predominant signs of polymyositis, pulmonary interstitium involvement and with positive anti-Jo1 antibodies was suspected for antisynthetase syndrome. Over the next three months sores and ulcerations have appeared at the fingertips. In the later course of the disease clinical picture of mixed connective tissue disease associated with interstitial lung disease, with a dominant picture of systemic sclerosis have emerged. She was treated with glucocorticoides and immunosuppressive therapy. Patient condition was mostly stable, without significant progression of lung lesions. Early diagnosis and treatment antisynthetase syndrome significantly contributes to more favorable course and outcome of disease. A prerequisite for that are well-defined diagnostic criteria and an appropriate choice of treatment.

Assessment of endothelial dysfunction by measuring von Willebrand factor and exhaled nitric oxide in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a multisystemic disease, one of the leading causes of mortality and morbidity. The aim of this research is to assess the level of markers of endothelial dysfunction, vWf and the exhaled nitric oxide (NO) depending on the severity of COPD. The study included 100 subjects: 60 patients with COPD without adjoining cardiovascular comorbidity, and 40 patients as the controls. The subjects underwent a fractional exhaled nitric oxide test (FeNO), spirometric testing, and diffusing capacity of the lung for carbon monoxide test (DLCO), samples were taken of their vein blood to analyze the level of vWf (using the vWf:RCO method), C-reactive protein (CRP), fibrinogen, cholesterol, triglycerides as well as the acid base status. COPD patients then filled COPD assessment test (CAT test) and the modified dyspnea scale (mMRC). The results showed that in patient group that higher levels of vWf are associated with lower values of exhaled NO, which means that higher levels of vWf are associated with lower values of exhaled NO. By comparing the ill subjects from four groups (A, B, C and D), a difference was established between the level of vWf [F (3.56 = 0.24; p = 0.869], while, although statistically not significant, the highest level of exhaled NO was found in group A and the lowest in group D. The rise in the value of vWf is followed by the rise of fibrinogen values, which is another marker of endothelial dysfunction. The results of this research have shown that a systemic inflammation and hypoxia in the early stages of COPD, when no significant changes in the absolute values of FEV1 are present, stipulate the existence of endothelial dysfunction together with the clinically relevant differences in the levels of vWf and exhaled NO.

[Risk assessment for sleep apnea syndrome and excessive daytime sleepiness in patients with chronic obstructive pulmonary disease]. / Procjena rizika za sindrom apneje u spavanju i prekomjerne dnevne pospanosti u bolesnika oboljelih od kronicne opstruktivne pluíne bolesti.

AIM: The objective of this study was to examine the risk of sleep apnea syndrome in patients with chronic obstructive pulmonary disease (COPD) and to determine correlation with the associated cardiovascular comorbidity in these patients. Chronic and occasional sleep disturbances represent a problem for millions of people worldwide. COPD is a multisystem disease and the leading cause of mortality and morbidity in the world. It is estimated that it will be the third cause of death in the world by 2020. Poor quality of sleep in patients with COPD occurs as a result of reduced oxygen saturation, hypercapnia, and the use of auxiliary respiratory muscles. METHODS: The study included 47 patients with COPD, examined at the Department of Pulmonology, Clinical Department of Internal Medicine, Osijek University Hospital Center in 2011. The respondents answered questions from the Croatian version of the Snoring, Tired, Observed, Pressure (STOP) questionnaire, which examines the risk of sleep apnea syndrome, and the Epworth Sleepiness Scale, which examines excessive daytime sleepiness. The respondents also provided data related to the current smoking status, bronchodilation therapy they apply at home, the associated cardiovascular comorbidity related to coronary heart disease (previous myocardial infarction, angina pectoris), cerebrovascular incident, diabetes, asthma, gastroesophageal reflux disease (GERD) and anxiety-depressive disorder. RESULTS: According to the STOP questionnaire, the risk of sleep apnea syndrome was recorded in 35 (74.5%) respondents. Patients at risk had a higher frequency of comorbidities such as hypertension, diabetes mellitus type 2 and GERD. Excessive daytime sleepiness was recorded in 14.9% of patients with COPD and the mean daytime sleepiness scored 4.76 points. In patients at a high risk according to the STOP questionnaire, the mean daytime sleepiness was 6.24 points versus 3.72 points in the group at a low risk. Snoring was present in 23 (49%), excessive tiredness in 27 (57%), and cessation of breathing during sleep in every other person in 4 cases (8.5% of patients). The t-test showed no significant differences in oxygen saturation, partial O2 and CO2 pressures between the groups of non-risk and high-risk patients according to the STOP questionnaire. CONCLUSION: For assessing the risk of sleep apnea syndrome in patients with COPD, the STOP questionnaire as a screening method has a significant role. Because of the high risk of sleep apnea syndrome in patients with COPD and considering the high level of associated cardiovascular comorbidity, it is necessary to perform polysomnography in patients at risk for timely detection and treatment of the syndrome, thus preventing its harmful consequences, with special reference to reduction of mortality in this population.

[Pathophysiology of gout]. / Patofiziologija uricnog artritisa.

Hyperuricemia is rather often metabolic disorder in general population. It is multifactorial disorder influenced by purine rich diet, alcohol consumption, diuretics use and renal deterioration. In the presence of local urate superasturation and lower solubility, monosodium crystals are deposited in joints, kidneys and soft tissue leading to clinical manifestations, such as gout, tophaceus deposits, nephrolithiasis and uric nephropathy. Major advances in understanding the pathogenesis of hyperuricemia and gout have been made recently, including genetic studies of urate transporters in kidneys as well as innate immune inflammatory responses and cytokine production which will be discussed thoroughly in this paper.