Inadequacies of the Lasègue test, and how the Slump and Bowstring tests are useful for the diagnosis of sciatica.

Diagnosis of sciatica mainly relies on pain reproduction by stretching of the lumbar roots since neurological examination and medical history are usually not sufficient to guarantee diagnosis. The Lasègue test is the most popular method, which starts with the straight leg-raising test (SLR). However it is not perfect, and is not always well performed or interpreted. Passive ankle dorsiflexion at the end of the SLR (Bragard test) is more sensitive, but can also remain normal in some cases of sciatica. Other stretching tests can help to recognise lumbar root damage in patients with poorly defined pain in a lower extremity: firstly, the Christodoulides test, i.e. reproduction of L5 sciatic pain by a femoral stretch test; secondly, the Slump test, performed on a patient in a sitting position, by slowly extending their painful leg then passively bending their neck (or the opposite); and thirdly, the Bowstring test, which requires, at the end of the Lasègue test, once the knee has been slightly flexed, pressing on the course of the peroneal and/or tibial nerves in the popliteal fossea to try and reproduce the exact pain felt by the patient. The combination of all these tests takes less than 2minutes, and could improve both the sensitivity and specificity of the physical examination for the diagnosis of sciatica. This article is a review of the limitations of the Lasègue/SLR tests and of the efficacy of these other tests for stretching the lumbar roots.

Long-term follow up after denosumab treatment for osteoporosis - rebound associated with hypercalcemia, parathyroid hyperplasia, severe bone mineral density loss, and multiple fractures: a case report.

BACKGROUND: The rebound effect after stopping treatment with denosumab may be associated with rapid loss of the gains in bone mineral density achieved with treatment, high levels of bone remodeling markers, the occurrence of vertebral fractures, and even hypercalcemia. CASE PRESENTATION: A 64-year-old osteoporotic Caucasian woman suffered from a fracture of her second lumbar vertebra in 2004. From January 2005, she was treated with denosumab for 9 years, with good densitometry results for her hip and lumbar areas, and no fractures over the last 6 years of treatment. Ten months after the treatment with denosumab was stopped, a cascade of vertebral fractures, including some in unusual locations (third thoracic vertebra), and multiple rib fractures in a context of hypercalcemia, suggested possible malignancy. A complete evaluation, including systemic, biological, and biopsy analyses, ruled out this hypothesis. The hypercalcemia was associated with normal plasma phosphate and vitamin D concentrations, and a high parathyroid hormone level, with an abnormal fixation of the lower lobe of the thyroid on sesta-methoxy-isobutyl-isonitrile scintigraphy. Histological analysis of the excised parathyroid tissue revealed hyperplasia. The associated thyroidectomy (goiter) led to the discovery of a thyroid papillary microcarcinoma. CONCLUSIONS: We consider the consequences of this rebound effect, not only in terms of the major loss of bone density (return to basal values within 3 years) and the multiple disabling fracture episodes, but also in terms of the hypercalcemia observed in association with apparently autonomous tertiary hyperparathyroidism. Several cases of spontaneous reversion have been reported in children, but the intervention in our patient precluded any assessment of the possible natural course. The discovery of an associated thyroid neoplasm appears to be fortuitous. Better understanding of the various presentations of the rebound effect after stopping treatment with denosumab would improve diagnostic management of misleading forms, as in this case. Bisphosphonates could partially prevent this rebound effect.

Pain catastrophising worsens RAPID3 in all rheumatologic conditions.

OBJECTIVES: To assess RAPID3 in various rheumatologic conditions, and the impact of pain catastrophising on RAPID3. METHODS: A set of questionnaires, including RAPID3 (0-30) and pain catastrophising score (0-52), was given to all outpatients seen in a one-month period: 518 patients fulfilled the questionnaires, including 127 RA (42% taking biologics), and 135 SpA (58% taking biologics). RESULTS: Mean pain catastrophising was 18.5±12.5, and 19% of patients could be classified as catastrophisers (>30). Higher RAPID3 scores were observed in the 33 osteoarthritis of lower limbs (16.44±5.20), 10 fibromyalgia (15.52±5.53), 47 back-pain (14.88±5.17), 17 osteoarthritis of upper limbs (13.61±7.42), and 38 tendinopathies (12.85±4.38). Lower RAPID3 were observed in the 135 SpA (12.79±6.03), 127 RA (12.18±6.30), 27 miscellaneous disorders (9.83±6.28), 7 entrapment neuropathies (9.81±4.51), 19 systemic connective tissue disorders (8.26±7.04) and 58 osteoporosis (7.85±6.95). Much higher RAPID3 scores were observed in the 19% with high pain catastrophising scores, whatever the conditions, and lower scores in the 15% with disablement benefits. RAPID3 was not associated with age or disease duration, but strongly correlated with daily fatigue, poor sleep, and length of daily pain. CONCLUSIONS: Thanks to progress made in RA and SpA treatment, higher RAPID3 scores were mostly observed in other rheumatic conditions, but co-morbidities and pain catastrophising might contribute to floor effects when assessing rheumatic disorders with RAPID3, hindering the recognition of low disease activity in some RA of SpA patients.

Multiple Vertebral Osteonecroses (Kümmell's Disease) After 10 Years on Denosumab: Is Osteocyte Apoptosis to Blame?

We report here a case of multiple vertebral osteonecroses with intrasomatic gaseous dissection (Kümmell's disease) occurring 1 year after the end of a 10-year course of denosumab treatment for osteoporosis without fractures. Histomorphometry and bone remodeling markers revealed major bone resorption and the persistence of an inhibition of bone formation. The presence of multiple empty lacunae in the bone provided evidence for high levels of osteocyte apoptosis. Osteocytes direct bone resorption (via the RANK/RANK-L/osteoprotegerin system) and formation (Wnt system, with SOST and DKK1) pathways. The vertebral osteonecrosis in our case may, therefore, have resulted from osteocyte apoptosis, decompensated by the sudden reactivation of bone remodeling after the cessation of denosumab treatment.

Efficacy of local glucocorticoid after local anesthetic in low back pain with lumbosacral transitional vertebra: A randomized placebo-controlled double-blind trial.

OBJECTIVE: The primary objective of this study was to compare the efficacy of local injection of a local anesthetic with a glucocorticoid versus a local anesthetic with saline to treat low back pain due to lumbosacral transitional vertebras (LSTV) with a pseudoarticulation. METHODS: A randomized placebo-controlled double-blind study was conducted in patients with unilateral low back pain ascribed clinically to LSTV. Patients were randomized to lidocaine plus saline (LS group) or lidocaine plus cortivazol (LC group) injected locally under computed tomography guidance. The primary outcome measure was the 24-hour mean visual analog scale (VAS) score for low back pain 4 weeks after the injection. RESULTS: Of 16 randomized patients, 15 were included in the analysis, 8 in the LS group and 7 in the LC group. The mean VAS pain score at week 4 was not significantly different between the two groups. In the two groups pooled, the mean VAS pain score decreased significantly from baseline to week 4, from 5.52±0.99 to 3.86±2.55 (P≤0.05). The difference remained significant at week 12. Significant improvements occurred in the EIFEL disability index and items of the Dallas Pain Questionnaire. No adverse events were recorded. CONCLUSION: In patients with chronic low back pain consistent with a symptomatic LSTV type II or IV in the Castellvi classification, a local injection of lidocaine with or without cortivazol may provide sustained improvements in pain and function. The underlying mechanism is unclear.

Development and validation of a questionnaire categorizing behavioral strategies in patients with chronic low back pain.

OBJECTIVE: The identification of helpful or unhelpful behavioral strategies for coping with pain would assist in optimizing the management of patients with chronic low back pain (CLBP). The objective was to develop and validate a questionnaire for categorizing behavioral strategies in patients with nonspecific CLBP. METHODS: (1) Development of a preliminary questionnaire based on a qualitative study in 25 patients with CLBP; (2) Item reduction and questionnaire validation by a multicenter international prospective study in patients with CLBP, with multiple correspondence analysis to identify behavioral profiles, whose characteristics and internal and external validities were assessed; 12-month study of treatments in 58 patients; (3) Evaluation of reproducibility in 30 patients. RESULTS: (1) The preliminary questionnaire had 87 items in eight pain-coping domains. (2) Three behavioral profiles were identified: effective coping, emotional distress, and kinesiophobia. The questionnaire was reduced to 21 items in seven domains. Cronbach's α indicated moderate internal consistency (0.47-0.66). External validity versus anxiety, depression, and coping strategies was good. As expected, functional restoration program was used more often by patients with kinesiophobia than by those with effective coping (50% vs. 25%, P<0.05). (3) Reproducibility was good (κ=0.70). CONCLUSION: This new, simple questionnaire allows the identification of three behavioral profiles, thus guiding the development of personalized management programs for NCLBP.

Randomised study versus control group of customised therapeutic education for patients in follow-up for rheumatoid arthritis.

OBJECTIVE: We have evaluated customized objectives, predefined during a therapeutic education session for rheumatoid arthritis (RA). METHODS: Fifty-four RA patients were randomised into patient therapeutic education (PTE) group versus waiting list (WL). The final comparative evaluation involved solving 3 predefined problems. RESULTS: Fifty-four were evaluated after 6 months. The main criterion was defined for all three of the chosen themes at 76.9% in the PTE group and 42.4% in the WL group. Among the other positively evaluated criteria were: less corticotherapy, more occupational therapy, more demand for social aid, more physical activity, knowledge of the recognition of an RA attack and how to cope with it. On the other hand, knowledge of the treatments did not differ between the 2 groups nor did the RAPID scores, fatigue, stiffness, depression, compliance, number of consultations and hospitalisations. Patient satisfaction was excellent (between 85.3 and 93.9%). CONCLUSION: This study is a good illustration of the position occupied and value of PTE in solving the problems specific to each RA case, the resulting high level of patient satisfaction and its independently complementary aspects relative to the purely medical treatment of RA. Customized PTE could better respond to specific patients problems in RA.

Usefulness of a pre-procedure ultrasound scanning of the lumbar spine before epidural injection in patients with a presumed difficult puncture: A randomized controlled trial.

UNLABELLED: Ultrasound (US) is widely used in rheumatology to study and guide injection of peripheral joints. It can also provide useful information about the anatomy of the lumbar spine. Studies have shown that US examination of the spine was a useful tool to help perform epidural anaesthesia. The purpose of the study was to determine if the selection of the optimum puncture level by US may facilitate epidural steroid injection in case of presumed difficult puncture (BMI>30 kg/m(2), age>60 years or lumbar scoliosis). METHODS: We performed a prospective randomized controlled study. Eighty patients were randomized in two groups: US group (n=40) which underwent a pre-procedure spinal US to determine the optimal lumbar level for injection or control group (n=40) for which the level of injection was determined by palpation. Primary endpoint was the pain during the procedure assessed using the Visual Analogue Scale (VAS). RESULTS: We found a positive correlation between depth of the epidural space and BMI (P<0.001) and a negative correlation between size of the interspinous spaces and age (P<0.01). Visibility of the epidural space was not altered by obesity or age. We observed a trend toward a reduction in pain intensity during the procedure in the US group compared to the control group with a mean difference at -0.94 [-1.90; 0.02] but the difference was not significant (P=0.054). CONCLUSION: US of the lumbar spine was feasible in patients with lumbar conditions even in obese and old ones and allowed the visualization of the epidural space. However, pre-procedure US examination did not reduce pain during the procedure.

Ultrasonography of the lumbar spine: sonoanatomy and practical applications.

Ultrasonography of the bones and joints has gained considerable ground in the field of rheumatology over the past decade and is now used in everyday practice both for diagnostic purposes and to guide local injections. However, the use of ultrasonography is virtually confined to the peripheral joints, whereas spinal diseases make a major contribution to rheumatology practice. Studies have established that ultrasonography of the lumbar spine is feasible. Adequate equipment and familiarity with spinal sonoanatomy are required. In this update, we suggest starting with a systematic examination of the lumbar spine to assess the various anatomic structures, from the thoracolumbar fascia superficially to the posterior part of the vertebras at the deepest level. The ligaments, erector spinae muscles, facet joints, and transverse processes can be visualized. Ultrasonography can serve to guide injections into the facet joints, about the nerve roots, and into the iliolumbar ligaments; as well as to identify relevant landmarks before epidural injection. Although diagnostic applications are more limited at present, systematic studies of abnormal ultrasonography findings will allow evaluations of the potential usefulness of ultrasonography for diagnosing spinal disorders. The depth of the spinal structures limits the ability to obtain high-resolution images. However, future technical improvements in ultrasound transducers and machines, together with the growing number of physicians trained in ultrasonography, can be expected to benefit the development of spinal ultrasonography in the near future.

Vitamin D insufficiency: evaluation of an oral standardized supplementation using 100,000 IU vials of cholecalciferol, depending on initial serum level of 25OH vitamin D.

OBJECTIVES: There is no protocol of vitamin D supplementation used worldwide due to a great disparity of vitamin D supplements available in different countries. The aim of this study was to evaluate the efficiency of the protocol most often used in France to correct vitamin D deficiency defined by a serum 25-hydroxy vitamin D (25OHD) level of less than 30 ng/mL. METHODS: This was a pragmatic multicentric study of vitamin D supplementation in 257 osteopenic/osteoporotic, vitamin D deficient patients who received 100,000 UI vitamin D3 vials every two weeks according to their initial serum 25OHD level (four vials when 25OHD less than 10 ng/mL, three when 25OHD was 10-19 ng/mL, two when 25OHD was 20-29 ng/mL). Blood samples were obtained at baseline, one (M1), two (M2), and three months (M3), after the end of the supplementation protocol. RESULTS: At M1, 198/257 (77%) patients had a serum 25OHD level more than 30 ng/mL. Eighty-five percent of those with a BMI less than 25 kg/m2 had a 25OHD concentration more than 30 ng/mL, whereas only 66% of those with a BMI more than 25 had a level more than 30 ng/mL. At M2 and M3, 25OHD levels decreased significantly with 55% and 46% having still a level more than 30 ng/mL respectively, without any significant difference according to the initial 25OHD level. CONCLUSION: This protocol was effective in rising serum 25OHD of most vitamin D insufficient patients with a BMI less than 25 kg/m2, but not in overweight patients. As almost one half of our patients had a serum 25OHD level less than 30 ng/mL at M2, we suggest that regular doses should be started quite soon after this initial supplementation.

Feasibility and safety of ultrasound-guided caudal epidural glucocorticoid injections.

OBJECTIVES: To assess the feasibility and safety of caudal epidural glucocorticoid injections performed with ultrasound guidance. METHODS: We studied 30 patients with low back pain and nerve root pain related to disk herniation or associated with lumbar spinal stenosis. A caudal epidural injection was performed under ultrasound guidance. Prednisolone acetate, 5 ml, was administered with 10 ml of saline and 5 ml of iodinated contrast agent, providing an epidurogram. Acceptability of the procedure by the patient was assessed. Adverse events occurring immediately after the procedure and within the first month were collected. RESULTS: The sacral hiatus was identified in 29 (96.6%) patients. Mean distance between the two sacral cornua was 1.42 cm (range, 0.83-2.13) and mean diameter of the sacral hiatus was 0.60 cm (0,2-1.28). The injection proved feasible in 28 of the 29 patients. The epidurogram indicated that the injection was successful in 27 patients. Mean procedure duration was 15 minutes (30-10). No cerebrospinal fluid reflux occurred. Blood reflux was noted in 9/29 patients and resolved in eight upon needle repositioning. All patients deemed the procedure acceptable. No complications were recorded during the first month. CONCLUSION: Ultrasound-guided caudal glucocorticoid injection is a fast, easy-to-perform, well accepted procedure. In our study, an epidurogram confirming that the needle was in the epidural space was obtained in 27 of 28 patients.

Assessment of calcific tendonitis of rotator cuff by ultrasonography: comparison between symptomatic and asymptomatic shoulders.

OBJECTIVE: Calcific tendonitis of rotator cuff is observed on plain radiographs in 10% of adults, but remains asymptomatic in half these cases. We looked for differences on ultrasound (US) and power Doppler findings between symptomatic and asymptomatic cases of shoulder calcific tendonitis. METHODS: US was performed in 62 patients (81 shoulders) with symptomatic (n=57) or asymptomatic (n=24) calcific tendonitis. Calcific plaque morphology, power Doppler signaling, and widening of the subacromial-subdeltoid bursa (SSB) were recorded. US-guided steroid injection into the SSB (n=21) or needle puncture of calcific deposits (n=29) was performed at the end of US evaluation in 50 of the 57 patients, and a questionnaire was sent to each patient after 11+/-6 months. RESULTS: Larger (p=0.0015) and fragmented (p=0.01) calcifications were associated with pain. A power Doppler signal and a widening of the SSB was identified in 21 and 17 of the 57 symptomatic calcification respectively, but in none of the cases of asymptomatic calcification (p<0,005). At least one of these signs was present in 31 of the 57 (54%) symptomatic shoulders (p<0.001). Long-term outcome was favourable for 60% of our patients after steroid injection. The presence of a SSB widening before bursal steroid injection was associated with an improvement of the symptoms (p=0.06). CONCLUSION: Positive power Doppler signal within the calcific deposit and SSB widening are US features strongly associated with pain. Moreover, larger calcifications are also more symptomatic. According to these results, US can help physicians to confirm that calcification is responsible for shoulder pain.

Treatment of shoulder calcifications of the cuff: a controlled study.

OBJECTIVES: About 1 in 10 patients with shoulder calcifications complains of chronic pain. Removal techniques have been developed. We carried out the first randomized study to validate bursoscopy (BS) and (needling fragmentation irrigation) (NFI) versus a control group (CT). METHODS: 102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected using a corticosteroid; 49 shoulders improved by more than 70%. The other 53 shoulders were randomized in 3 groups: NFI (n=16), BS (n=20), and CT (n=17). All patients were reviewed at T 1-4-12-24 months. RESULTS: After 4 months, we observed respectively in groups NFI-BS-CT: 62%, 65% and 29% patients showing global improvements >70% (NFI vs CT: p=0.03; BS vs CT: p=0.02); -37%, -29% and -11% pain VAS variation (ns), +16%, +12% and -15% Constant score variation (NFI vs CT: p=0.03; BS vs CT: p=0.02), and -58%, -77% and +4% area calcification variation (NFI vs CT: p=0.005; BS vs CT: p=0.0002; BS vs NFI: p=0.01). After 24 months, results were maintained in NFI and BS groups, and in the CT group only 6/17 patients were still improved. There were no significant differences between NFI and BS groups. Three partial tears of the cuff were found using MRI in failures, (1 in each group). CONCLUSION: NFI and BS are now validated removal techniques of shoulder calcifications when there is chronic pain and other medical treatments have failed. Results were maintained after 24 months, and were similar between NFI and BS. However NFI could be preferred because of its simplicity and low cost.

25 mg etanercept once weekly in rheumatoid arthritis and spondylarthropathy.

OBJECTIVE: To assess the clinical results at 6 months of etanercept 25 mg once weekly (half-dose), and etanercept 25 mg twice weekly (full-dose), in patients with rheumatoid arthritis or spondylarthropathy. METHODS: Case records of all patients treated by etanercept for at least 6 months in the same rheumatology unit were retrospectively studied, to assess the mean values of DAS-28 and BASDAI, just before (J0), and after 6 months (M6) of treatment, in patients with rheumatoid arthritis or spondylarthropathy treated with etanercept 25 mg given either once or twice weekly. RESULTS: 112 patients had been treated for at least 6 months (44 at half-dose, and 68 at full-dose). Values of DAS-28 or BASDAI both at J0 and M6 were available in 92 patients. DAS-28 dramatically improved both in the half-dose group (from 5.2+/-0.8 to 3.5+/-0.8) and in the full-dose group (from 5.5+/-1.0 to 4.1+/-1.0). BASDAI also strikingly improved both in the half-dose group (from 60+/-13 to 25+/-18), and in the full-dose group (from 58+/-15 to 37+/-23). CONCLUSION: Although this was not a double-blind, prospective, randomised study, the strong improvement noticed in the half-dose group suggests that etanercept 25 mg once a week can induce major clinical and biological relief in some patients with RA or spondylarthropathy.

Tachon's syndrome (suracute back and/or thoracic pain following local injections of corticosteroids). A report of 318 French cases.

OBJECTIVES: To assess the frequency, features, and outcome of excruciating lumbar, dorsal, and/or thoracic pain following injections of local corticosteroids in rare instances. METHODS: A questionnaire mailed to 500 French rheumatologists. RESULTS: Three hundred and eighteen cases were reported by 92 rheumatologists (one event per 8000 injections or 6.5 years of practice), following injections into lumbar epidural space (39%), an upper limb (30%), a lower limb (mostly the heel) (24%), or other locations (7%), of cortivazol (67%), hydrocortisone (25%), betamethasone (7%), or paramethasone (1%). Symptoms occurred 1-5 min (78%) or less than 1 min (22%) after injection, and highly acute axial pain usually lasted for less than 5 min (34%) or 5-15 min (51%). In addition to pain in lumbar (84%) and/or dorsal regions (25%) [often preceded or associated with thoracic pain (36%)], other signs were: anxiety (87%), shortness of breath (64%), facial flushing (64%), diffuse sweating (41%), agitation (29%), transient cough (23%), abdominal pain (20%), transient hypertension (15%), paleness (10%), hypotension (8%), diarrhoea (3%) and headache (3%). None of these patients was known to be allergic, and urticaria developed in only 2%. Outcome was favourable in all cases (even though 4/318 patients were transiently hospitalised) with an overall duration of 25 +/- 71 min. Another injection was performed later in 146/318 cases (46%), but Tachon's syndrome recurred in only 20 of these 146 patients (14%). CONCLUSION: The outcome of this impressive syndrome seems excellent. Tachon's syndrome might be the venous counterpart of Nicolau's syndrome (injection of corticosteroids in an artery).

Informing patients about serious side effects of drugs. A 2001 survey of 341 French rheumatologists.

OBJECTIVES: In May 2001, we surveyed French rheumatologists to determine how they inform their patients about serious side effects of drugs. RESULTS: Of the 600 rheumatologists invited to participate in the study, 341 completed and returned the questionnaire. Most respondents believed that full information on patients would become the rule (mean, 62.1 +/- 28.3, the items being scored on a 100-point scale where 0 was "not at all" and 100 "absolutely"). The answer to this item varied little across age groups. Respondents felt that patient information fell primarily on the physician, (78 +/- 23), followed by pharmaceutical companies (64 +/- 32) and pharmacists (46 +/- 33). The respondents believed that full information of patients about side effects would primarily benefit physicians (51 +/- 32), followed by pharmaceutical companies (43 +/- 30) and patients (38 +/- 28). The reaction of patients to information on drug-related risks was described as "always favorable" by 2% of the respondents and as "fairly often favorable" by 55%. Among respondents, 9% always gave information on serious side effects, 66% fairly often, and 4% never; 2% always communicated information on the approximate frequency of serious adverse events, 21% fairly often, and 33% never. Similarly, 3% of the respondents always warned their patients of lethal risks, 11% fairly often, and 44% never. When evaluated on a 100-point scale (0, not at all knowledgeable; 100, very knowledgeable), knowledge of serious side effects of drugs for musculoskeletal conditions was 73 +/- 23, whereas knowledge of the frequency of these effects was only 52 +/- 22. Eight percent of the respondents always recommended that patients read the package insert, 27% fairly often, and 32% never. Conversely, the possible adverse effects of not taking the treatment were always specified by 21% of the respondents and fairly often by 88%.

New pathogenic hypotheses for spondyloarthropathies.

Pathogenic hypotheses for spondyloarthropathies are evolving. Several candidates have been added to the list of inciting microorganisms, and genes other than HLA-B27 are under scrutiny. Above all, the chiefly 'immunological' theory of spondyloarthropathies incriminating a cross-reaction between self-proteins and bacterial peptides is giving way to a more 'microbiological' concept in which latent bacteria residing within macrophagic or dendritic cells undergo reactivation through a process facilitated by HLA-B27. This molecule is prone to misfolding, which decreases the presentation of bacterial peptides to the immune system and stimulates the Nf-KB inflammation pathway within infected macrophages and/or dendritic cells. Migration of these infected cells from the mucous membranes to the tissues targeted by spondyloarthropathies, particularly the bone marrow located near entheses, may facilitate transient reactivation of dormant intracellular bacteria by creating a favorable cytokine environment. This environment may include high levels of TGFbeta and IL-10, noted also at other sites that enjoy immune privilege, such as the eye. The reactivation may be stopped by a local response of CD4+ and/or CD8+ T cells at the expense of local inflammation responsible for clinical manifestations. This scenario seems consistent with results from studies of murine models transgenic for the HLA-B27 antigen: exposure to bacteria is necessary to the development of spondyloarthropathy, but the disease occurs even when only the heavy chain of HLA-B27 is present (i.e., beta2-microgloblin is not indispensable). Improved understanding of the mechanisms that confer to some bacterial strains a strong potential for persisting within cells, including macrophagic cells, may open the way toward new treatment approaches capable of complementing antagonists of TNF-alpha and other monokines, which merely suspend the disease process, and antibiotic therapy, which fails to kill dormant bacteria located within cells. Pathogenic hypotheses for spondyloarthropathies are evolving. This review presents the most recent concepts. These concepts have not all received confirmation from experimental data. However, the high degree of consistency among them prompted us to consolidate them into a single picture. Although this approach may yield a motley composite of fact and speculation, it may open up new avenues of thought for rheumatologists interested in the links between chronic intracellular infections and inflammatory joint disease.

Hypercalcemia in a patient with tuberculous adrenal insufficiency.

OBJECTIVES: To raise awareness of hypercalcemia as a rare and at times inaugural manifestation of adrenal insufficiency. CASE REPORT: Evaluation of hypercalcemia in a 43-year-old man showed adrenal insufficiency. Biopsies of the testes and adrenal glands revealed epithelioid and giant cell lesions indicating tuberculosis. Although tuberculosis can contribute to hypercalcemia, this possibility was ruled out in our patient by the low serum 1,25-dihydroxy-vitamin D3 levels and return to normal of serum calcium and renal function under hormone replacement therapy. It should be noted, however, that a course of pamidronate was given. CONCLUSION: The mechanism of hypercalcemia associated with adrenal insufficiency is controversial. Hyperparathyroidism was ruled out in our patient. Adrenal insufficiency should be considered in some patients with hypercalcemia.