Increased bone mineral density at the hypoxia prone site of the juxta-articular metacarpal bone in patients with limited systemic sclerosis: a cross-sectional study.

OBJECTIVES: Low levels of oxygen has been shown to be involved in the induction of osteogenesis, particularly in bone repair. It is unknown whether hypoxia leads to osteogenesis at the hypoxia prone skeletal sites in limited systemic sclerosis. This study determined the total and trabecular volumetric bone mineral density (vBMD) at the hypoxia prone site of the juxta-articular metacarpal bone. METHODS: In this cross-sectional study, female patients with limited systemic sclerosis were included and compared to healthy controls. Peripheral quantitative computed tomography was used to measure cross-sectional area, total vBMD, and trabecular vBMD at the radius, the tibia and the third metacarpal bone. Disease severity was assessed by the modified Rodnan Skin Score. RESULTS: Twenty consecutive patients were included in the sclerosis group and 20 in the control group. Mean age was 60 years (range 52-68 years), and mean disease duration was 45 months (range 4-156 months). Age, height, and weight were comparable between the groups. The mean modified Rodnan Skin Score was 1.78 (range 0 to 8). The sclerosis group showed both higher total and trabecular vBMD at the distal metacarpal bone (p=0.05 and 0.04, respectively). vBMD of the tibia and radius did not differ in both groups. CONCLUSIONS: vBMD at the juxta-articular metacarpal bone in patients with limited systemic sclerosis is increased, possibly due to an alteration in local bone metabolism and hypoxia induced local osteogenesis.

Changes in volumetric BMD of radius and tibia upon antidepressant drug administration in young depressive patients.

OBJECTIVES: To determine longitudinal changes in trabecular volumetric BMD (vBMD) at tibia and radius in young depressive patients under antidepressants using pQCT. METHODS: PQCT data on 26 patients (22 females, 4 males) on serotonin re-uptake inhibitors (SSRI), and 14 patients (12 females, 2 males) on non-SSRI (10 SNRI, 4 TCA) were obtained at 4% and 66% of radius and tibia at baseline and at 12-month. Depression was assessed by Beck Depression Inventory (BDI) at baseline and follow-up. Wilcoxon tests were performed to find longitudinal changes in bone parameters within each group, Mann-Whitney tests to detect differences between groups. RESULTS: The two groups were comparable with regard to age, height and BDI. None of the measured bone parameters changed in the SSRI group. In the non-SSRI group trabecular vBMD increased slightly but significantly from baseline to follow-up at radius and tibia (p<0.03). Between group differences were significant for trabecular BMD at the radius. BDI decreased significantly in both groups by the same amount. CONCLUSIONS: Bone properties were found to be stable over 12 months under therapy with SSRIs. Whether SNRI and TCA indeed increase trabecular vBMD need to be shown in larger cohort.

Atypical presentation of Behçet's disease with central nervous system involvement successfully treated with infliximab.

Central nervous system involvement is a rare and serious complication of Behçet's disease (BD). Herein, we describe a patient with an atypical central lesion, who experienced progressive hypesthesia of the right arm and sensory loss of the trigeminal nerve together with intense headache. A repeated biopsy was necessary to conclusively establish the diagnosis of BD. Therapy with infusions of infliximab led to a remarkable full remission. TNFα-blocking therapy was successfully replaced by azathioprine. The present well-illustrated case demonstrates the difficulty of establishing the diagnosis of BD with central nervous system involvement, the dramatic benefit of short given TNF-α-blocking agent, and the long-term remission with azathioprin.

Effect of rheumatoid arthritis and age on metacarpal bone shaft geometry and density: A longitudinal pQCT study in postmenopausal women.

OBJECTIVE: This study aimed to elucidate the effects of changes in the geometry and density of the metacarpal bone of patients with rheumatoid arthritis (RA). METHODS: This prospective study included consecutive postmenopausal RA patients who met the American College of Rheumatology Criteria and healthy controls (HC). Peripheral quantitative computed tomography scans at 50% of the total metacarpal shaft (third metacarpal bone) were obtained at baseline and follow-ups. Use of bisphosphonates (BP), glucocorticoids (GC), biologics, and disease-modifying anti-rheumatic drugs (DMARD) was monitored (baseline to follow-up). Total cross-sectional area (CSA), cortical-transitional zone and compact zone CSA, cortical volumetric bone mineral density, and compact cortex porosity were measured. A linear mixed-effects model was used to determine significant differences in the rate of change in the RA and control groups and in RA patient subgroups. RESULTS: Thirty-nine RA patients and 42 consecutive postmenopausal HC were followed for 63 months. RA and HC depicted a time-dependent increase of medullary CSA (+0.41 mm2/year, P < 0.0001), while total CSA remained stable (P = 0.2). RA status was associated with a loss of cortical bone mineral density (interaction: -3.08 mg/mm3; P = 0.014). In RA subgroup analysis, GC use ≥5 mg/day was positively correlated with a fourfold increase of medullary CSA (0.67 mm2/year P = 0.009), which resulted in a three- to fourfold loss of cortical density (-6.6 mg/mm3/year; P = 0.002) and cortical CSA (-0.57 mm2/year, P = 0.004). Patients with high disease activity and high GC dose at baseline demonstrated an increase in the total CSA (0.29 mm2/y; P = 0.049) and a loss of cortical BMD (-5.73 mg/mm3/y; P = 0.05) despite good clinical response. CONCLUSION: Increase in medullary metacarpal CSA and thinning of the cortical CSA are physiological and time dependent. RA status is associated with loss in cortical density. Even upon biological therapy, low glucocorticoid dose affects metacarpal bone shaft geometry and density over time.

Induction of complete and sustained remission of rheumatoid pachymeningitis by rituximab.

Aseptic pachymeningitis is a rare and serious complication of rheumatoid arthritis (RA). Herein, we describe a patient with rheumatoid factor-positive and anti-cyclic citrullinated peptide-positive RA who experienced a focal seizure, with aphasia and convulsions of the right side of the body. The findings of magnetic resonance imaging and histologic analysis led to a diagnosis of rheumatoid pachymeningitis. Because the patient had a large number of CD20-expressing B lymphocytes, therapy with rituximab was started and has resulted in complete and sustained remission of both the pachymeningitis and the RA for >2 years. Despite a decrease in immunoglobulins, the patient has remained free of infections, which illustrates the favorable outcome that can result from therapeutic B cell depletion in this potentially lethal manifestation of RA.

Macrophage migration inhibitory factor and glucocorticoid sensitivity.

Glucocorticoids (GCs) are widely used in the treatment of inflammatory diseases including rheumatoid arthritis (RA). Treatment with GC is associated with significant dose-dependent side-effects. The pro-inflammatory cytokine macrophage migration inhibitory factor (MIF) has emerged in recent years as a candidate factor which could regulate GC sensitivity. MIF is induced by GC, and is able to override anti-inflammatory actions of GCs. In this review, we summarize the pro-inflammatory actions of MIF with respect to RA, describe the interactions between MIF and GC and examine new evidence, which identifies MIF as a specific target for steroid sparing.

Increase of peripheral CXCR3 positive T lymphocytes upon treatment of RA patients with TNF-alpha inhibitors.

OBJECTIVE: To explore the regulation of factors involved in lymphocyte trafficking in patients with rheumatoid arthritis (RA) undergoing treatment with tumour necrosis factor alpha (TNF-alpha) inhibitors. METHODS: We examined 14 consecutive patients with RA according to ACR criteria prior to and during treatment with TNF-alpha inhibitors (seven etanercept, seven infliximab) and determined disease activity using the Disease Activity Score (DAS-28). Peripheral blood mononuclear cells were isolated before and after 6 and 14 weeks of treatment and analysed immediately for CD3, CD4 and CD8, expression of chemokine receptors CXCR3 and CCR4, CD45RO phenotype and for expression of interferon gamma (IFN-gamma) and interleukin 4 (IL-4) using four-colour flow cytometry. RESULTS: We found significant increases in CD4 and CD8 T lymphocytes expressing CXCR3 after 6 and 14 weeks. The overall proportion of T lymphocytes expressing CCR4 appeared unchanged. More than half of peripheral CD4 T lymphocytes showed a memory phenotype (CD45RO), with a non-significant increase under TNF-alpha inhibition. Upon activation, up to 30% of CXCR3(+)/CD4 T cells expressed IFN-gamma, while IL-4-expressing cells were rare. There was a robust negative correlation between CXCR3(+)/CD4 T lymphocytes and DAS-28. CONCLUSIONS: TNF-alpha inhibition with infliximab and etanercept results in sustained accumulation of CXCR3 positive T lymphocytes in the peripheral blood of RA patients. This suggests altered lymphocyte trafficking during TNF-alpha inhibition.

[Fever of unknown origin as a sign of calcium pyrophosphate deposition disease]. / Fieber unklarer Ursache als Zeichen der Kalziumpyrophosphat-Ablagerungskrankheit.

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease may manifest clinically as septic fever (40 degrees C), acute pseudogout attack of knee, wrist and shoulders, or as a variety of patterns of chronic inflammatory or degenerative joint disease. The association of pseudogout with fever is less widely recognised and may lead to over-investigation, delay in appropriate treatment and disproportionate costs. We report on a 67-year-old woman with a history of recurrent episodes of fever and polyarthritis every 2 months for the last 3 years. Because of this she was hospitalised several times, finally with suspected culture-negative endocarditis, and was treated for 6 weeks with gentamicin, rifampicin and vancomycin. During this therapy the patient again developed septic fever and acute arthritis of the right wrist. Radiographs of the wrist, knee and symphysis pubis revealed prominent chondrocalcinosis and destructive arthropathy.

Predictive value of radiological criteria for disintegration rates of extracorporeal shock wave lithotripsy.

OBJECTIVE: To evaluate routinely applicable criteria to predict fragmentation of renal calculi by extracorporeal shock wave lithotripsy (ESWL). PATIENTS AND METHODS: Two hundred and two consecutive patients (121 men, 81 women), median age 48 (range 19-81) years, were treated with the original Dornier HM-3 lithotriptor at a single stone center. Inclusion criteria were: solitary stones, 10-30 mm in greatest diameter, located in renal pelvis or calyces. Based on plain radiographs, the calculi were classified according to their size, form, location, density (compared to the 12th rib), structure and surface. Furthermore, age of the patient, gender and body mass index were also considered for evaluation. Disintegration was documented on day 1 after ESWL by plain X-ray. A multivariate regression analysis was applied to all preoperative parameters, based on the dual variable stone free versus residual fragments. RESULTS: The overall disintegration rate was 95.5%; 42 patients (20.8%) were completely stone free, and 151 patients (74.7%) had clinically insignificant residual fragments (5 mm or smaller). 14.9% of men and 29.6% of women were stone free (p = 0.01). All other parameters did not reach statistical significance. CONCLUSIONS: The disintegration rate of the HM-3 is excellent for kidney stones; women did significantly better than men. However, because of this high disintegration rate, a much larger series would be necessary to define possible differences between preinterventional parameters, if there were any at all.

Pseudoarthrosis and ankylosis of the vertebral spine without sacroiliitis associated with Takayasu's arteritis: review of the association.

Pseudoarthrosis and ankylosis of the vertebral spine associated with Takayasu's arteritis is extremely rare. We present a patient with the entity who was HLA-B27 negative and had normal sacroiliac joints. The association between Takayasu's arteritis and ankylosing spondylitis appears real but seemingly rare.

Metastatic angiosarcoma of the liver preoperatively presenting as giant hemangioma.

BACKGROUND: Hepatic angiosarcomas are rare tumors most often associated with exposure to vinyl chloride or other carcinogens. Only a few cases have been published without such a history. CASE REPORT: We report the case of a 73-year-old woman who was admitted to our medical department with unclear upper abdominal pain, thrombocytopenia and anemia. Both computed tomography and magnet resonance imaging revealed a giant hemangioma in the right liver with multiple small hemangiomas. To cure the problem of thrombocytopenia due to sequestration of blood cells in the hemangioma, we decided to resect the large tumor. Intraoperatively, however, the diagnosis of angiosarcoma with multiple metastases was made. The patient died 6 weeks after surgery. CONCLUSION: Problems in diagnosing angiosarcoma include the brief duration of antecedent symptoms, difficulties in radiological diagnosis, and patients without a history of professional exposure to carcinogens.