Revue du rhumatisme et des maladies osteo-articulaires最新文献

Chorea as a manifestation of SLE is infrequent (1% of all cases of SLE). A new case is reported herein. The patient, a seventeen-year-old female, was admitted with a one-week history of choreic movements of the left half of the body and arthritis of both wrists. Biologic findings confirmed the diagnosis of SLE with presence of an antiprothrombinase circulating anticoagulant. Findings upon cerebral CT scan and magnetic resonance imaging were normal. Clinical symptoms worsened despite corticosteroids in a daily dosage of 1 mg/kg with three pulses of 800 mg methylprednisolone. High-dose neuroleptic therapy was given and three plasma exchanges were performed. A dramatic improvement in clinical symptoms and biological anomalies occurred and persisted during follow-up which now exceeds one year. The lack of MRI anomalies suggests that the pathogenesis of SLE-associated chorea involves functional neurone activation by immune complexes; the dramatic effectiveness of plasma exchanges may obviate the need for using immunosuppressant agents in patients who fail to respond to corticosteroids.

The number of subjects presenting articular manifestations associated with HIV-infection is constantly on increase due to the growing number of seropositive patients. The pathophysiological mechanism of this association is still unknown. A recent review of the literature has shown that spondyloarthritis are the most frequently observed articular manifestations in HIV-positive patients. Septic arthritis are rare but severe. The immunodepression due to HIV-infection makes it difficult to use immunosuppressors and renders local therapeutics preferable. The articular manifestations may allow to discover seropositivity that has not been diagnosed before. These data strongly suggest to include serological examination for HIV in the etiological screening for every articular manifestation of unknown origin, even if the patient presents no risk factors.

Complete remission can be achieved by extensive surgical exeresis in patients with benign chondroblastoma of the iliac wing despite the reputation of these tumors for aggressive behavior. The case of a 28-year-old male treated with extensive surgery and acrylic cement reconstruction is reported. After seven years follow-up, the functional result is satisfactory and there is no evidence of local recurrence. Use of cement obviated the need for bone grafting. However, subsequent removal of the cement proved necessary because of skin intolerance. Data from a review of the literature confirmed that iliac chondroblastoma carries a poor prognosis, mainly because of the potential for mechanical complications. The cases of malignant transformation reported occurred after radiotherapy. In the authors' opinion, extensive surgical exeresis performed as early as possible is the treatment of choice.

Results of 81 total knee replacements in 67 patients with rheumatoid arthritis were studied. Mean follow-up was three years. Pain was the main reason for knee replacement surgery; knee mobility was well preserved prior to surgery. Failure occurred in four patients, as the result of infection, due in three instances to skin necrosis. Arthrodesis of the knee proved necessary in these patients. The fourth patient developed delayed hematogenous infection which was treated by a change of prosthesis. At follow-up, 82% of patients reported no pain and 18% moderate pain. Mean passive flexion was 113 degrees +/- 17 degrees. HSS score was 83.6 +/- 1.3 and all the patients except for the four with prosthesis failure stated that they were satisfied on very satisfied. Mechanical results were satisfactory, with a mean mechanical femur-tibial angle of 180.4 degrees. A circling line was visible at follow-up in 40% of operated knees but was partial in every case. No reoperations for prosthesis loosening were required. These data show that total knee replacement is the only reliable and radical treatment of rheumatoid arthritis of the knee and should be performed as soon as fixed flessum or axial deviation develops.

Diagnosis of sacroiliitis may be difficult to establish in patients under 25 years of age since growth is not yet completed and joint damage is often still minor. A prospective study of 200 subjects with a median age of 22 years was carried out to compare the value of CT scan and conventional radiology. The study population included 32 healthy subjects and 168 consecutive patients with presumptive spondylarthropathy including 36 with bilateral sacroiliitis and 8 with unilateral sacroiliitis. Conventional roentgenograms and CT scans were performed in every patient. Blind reading of roentgenograms and CT scans was carried out by two pairs of observers with differing experience. CT scan provided no additional information when reading was done by experienced observers: rates of mistaken and doubtful results were similar with both investigations (10%); specificity of both tests was comparable (90%) but sensitivity was significantly greater for CT scan (91.2%) than for conventional roentgenograms (71.6%), reflecting improved detection of roentgenographically occult sacroiliitis. Less experienced observers obtained better results with CT scans, illustrating the ease of interpretation of CT scan images. Analysis of false-positive CT scans revealed that normal variations and, above all, features due to as yet uncompleted growth were the main sources of mistakes. These mistakes cancelled the advantage of increased sensitivity of CT scan studies and explained why CT scan failed to improve diagnosis.

Three cases of pustulosis palmoplantaris with erosive arthritis are reported. There were two females (aged 53 and 59 years) and one male (aged 39 years). Skin lesions preceded joint lesions in every case (by 2 years, several weeks, and 1 year, respectively). Joints involved were one wrist in two patients and both hips in one patient. Inflammatory joint pain occurred concomitantly with an exacerbation of the skin disease. In two cases, an upper respiratory tract infection preceded the joint manifestations by a few days. Synovial fluid from affected joints was obtained in all three cases and found to be sterile. In the two patients who had histologic studies of skin lesion biopsy specimens, unilocular non-spongiform lesions suggestive of nonpsoriasic disease were found. Erythrocyte sedimentation rate and C-reactive protein levels were raised in every case. HLA groups were [A2, A19, B12, B27], [A2, A9, B12, B19, B27, Dr4, Dr6], and [A2, A19, B12, B13, Dr7, Dr8]. All three patients were given a nonsteroidal antiinflammatory agent. Despite this therapy, destruction of the wrist occurred in both females and bilateral hip destruction required bilateral total hip replacement in the male. The rapidity with which joint destruction occurred suggested infectious disease, especially due to a saprophytic organism. Virtually all previously reported pustulosis palmoplantaris patients with bone and joint manifestations had arthralgia or non-destructive arthritis in appendicular joints, whereas bone and joint destruction has been described in axial structures.

Weight-bearing roentgenograms of 308 feet of rheumatoid arthritis patients were analyzed. Several angles were determined, including the metatarsus primus adductus angle (between the first and second metatarsals, > or = 10 degrees) and the forefoot spread angle (between the first and fifth metatarsals, > or = 30 degrees). Pes planus was diagnosed when the internal arch angle was equal to or greater than 130 degrees. Tarsal arthritis was defined as the presence of joint space narrowing. Varus of the first metatarsal was correlated with tarsal arthritis and pes planus but not with duration of the disease. Forefoot spread was correlated with duration of the disease and erosive metatarsal disease but not with involvement of the midfoot. These data demonstrate that orthopedic treatment should be initiated as soon as involvement of the first metatarsal is detected and should be directed at the hindfoot, midfoot, and first metatarsal whose deformations occur concomitantly.

The authors report a case of brucella osteomyelitis of the upper end of the humerus in a 77-year-old patient, presenting as a large swelling of the soft tissues of the shoulder, present for a year. The diagnosis was made by isolation of the organism and specific serology. The authors stress the value of magnetic resonance imaging, which provided confirmation of the diagnosis of osteomyelitis as well as an accurate topographic assessment.