[Pigmented villonodular synovitis of the hip. Results of a national survey apropos of 58 cases]

Pigmented villonodular synovitis is an uncommon synovial disease which only rarely involves the hip. In a multicenter retrospective study, we identified 58 histologically-proven cases. There were 33 females and 25 males. Mean age at diagnosis was 38 years. In all but two cases, only one hip was involved; the right hip was affected somewhat more often (33 cases) than the left. Two patients probably had bilateral hip disease. Mean delay to diagnosis was four years. Pain was the presenting symptom in most cases. A palpable mass in the groin was found in six patients. Plain roentgenograms were considered normal in only three patients. Bony cysts were seen in 39 patients and kissing cysts in 19. Joint space narrowing was found in 40 patients and was diffuse in half the cases. Roentgenograms suggested pigmented villonodular synovitis in 63% of cases, osteoarthritis of the hip in 16%, and inflammatory hip disease in 14%. Additional imaging studies included opaque arthrography in 21 subjects, computed tomography in 23, magnetic resonance imaging in 11, and arthroscopy in 9. Initial treatment was osmic acid synoviorthesis in 14 patients, partial synovectomy in 9, and total synovectomy in 21; in addition, eight patients had insertion of a cup prosthesis and 13 had total arthroplasty of the hip. Treatment was successful in 65% of cases after a mean follow-up of three years; among the 35% of failures, there were seven recurrences (14%). Total hip arthroplasty was performed secondarily in nine patients. This study illustrates the diversity of roentgenological changes in pigmented villonodular synovitis of the hip and the high frequency of osteoarticular lesions precluding conservative treatment. Magnetic resonance imaging and/or arthroscopy should be used to establish the diagnosis at an early stage when conservative treatment with total synovectomy and synoviorthesis is most likely to be successful.

[Hip diseases in hemorrhagic rectocolitis. Apropos of 4 cases]

Erosive hip lesions are uncommon in patients with ulcerative colitis. We analyzed features of chronic hip lesions in four ulcerative colitis patients seen over the last 30 years. Two patients also had axial disease. Both hips were involved in all four cases. Roentgenographic features resembled those seen in ankylosing spondylitis in two cases. Severe destruction occurred in two patients. Two patients developed acetabular protrusion. All four patients rapidly required total hip arthroplasty, illustrating the poor prognosis of hip lesions associated with ulcerative colitis.

[Cardiac complications in adult onset Still disease: from pericarditis to tamponade as manifestations]

Pericarditis is a common manifestation of adult still's diseases (ASD), observed in 20% to 3% cases. Pericardial tamponade is more seldom, less than ten cases have been reported in the literature. We reported two observations of patients with ASD and pericardial tamponade above a series of 18 patients with ASD, in one case revealed the disease. The first patient was a 32-year-old women and had fever, arthritis, high white blood cell count and developed pericardial tamponade. The evolution was favourable with bolus of methylprednisolone. In the second case, cardiac tamponade occurred several years after the onset of the disease. Surgical drainage was first required (800 ml) because of inefficacity of oral prednisone. A dramatic improvement was observed after bolus of methylprednisolone. In conclusion pericardial tamponade is a seldom but sometimes the first manifestation of ASD and may required in first intention bolus of methylprednisolone.

[Value of the assay of protein SAA and urinary antitrypsin activity in osteoarticular infections]

Erythrocyte sedimentation rate is normal in 20% to 25% of patients with discitis due to common pathogens. We evaluated serum amyloid A (SAA) protein and urinary trypsin inhibitory activity in osteoarticular infections comparatively with erythrocyte sedimentation rate and serum C-reactive protein in 20 patients including 14 with discitis due to common pathogens and 6 with septic arthritis. Assays were performed on D0, D8, D15, D30, and D60 after initiation of antimicrobial therapy. On D0, all four markers were significantly higher in patients with septic arthritis than in patients with discitis. C-reactive protein levels exhibited the fastest kinetics with a return to normal values within 15 days in both conditions. Urinary trypsin inhibitory activity was only slightly elevated in patients with discitis and returned to normal within 30 days in both conditions. Serum amyloid A levels required 30 to 60 days to return to normal. Erythrocyte sedimentation rate exhibited the slowest kinetics, with normal values being achieved only after 60 days. Although simple, rapid, and inexpensive, urinary trypsin inhibitory activity determination exhibits poor sensitivity. Serum amyloid A assay is not routinely available but may be a valuable parameter for monitoring patients whose erythrocyte sedimentation rate and C-reactive protein level are normal (as in 2 of our patients with discitis).

[Neurologic paraosteoarthropathy of the hand. Apropos of 2 cases]

The frequency of heterotopic ossification in neurological conditions averages 20-25% with variations according to the type of neurological disease and presence or absence of coma. The most common sites are the hips, knees, shoulders, and elbows. Involvement of the hands is an exceedingly rare event of which two instances are reported herein. In both patients evidence of inflammation developed four months after a deep, prolonged coma. Swanneck deformity of the fingers occurred in one case. Juxta-articular ossifications were seen on roentgenograms two months after the onset of symptoms. Both patients had heterotopic ossifications around the shoulders. Erythrocyte sedimentation rate and serum alkaline levels were elevated. Local injections effectively relieved pain in one patient.

Stimulation of the secretion of latent cysteine proteinase activity by tumor necrosis factor alpha and interleukin-1

OBJECTIVE

Cultured synovial fibroblast-like cells from 3 patients with rheumatoid arthritis (RA) and 3 patients with osteoarthritis (OA) were evaluated for their potential to secrete cysteine proteinases spontaneously and after stimulation by tumor necrosis factor alpha (TNF alpha) or interleukin-1 (IL-1).

METHODS

Culture media and cell lysates were analyzed before and after high performance liquid chromatography (HPLC) using the enzymatic substrate, Z-Phe-Arg-AMC, and by immunoblotting with anti-cathepsin B antiserum. Immunolocalization of cathepsin B was studied on cell monolayers.

RESULTS

Latent cysteine proteinase activity was found to be secreted spontaneously by cultured synovial fibroblast-like cells. This activity was increased after treatment with either TNF alpha or IL-1. Stimulated protease activity was eluted by HPLC at a peak coincident with that of purified cathepsin B. By immunoblot, cell supernatants contained a 43-kd form of cathepsin B, while cell lysates contained a 30-kd form, consistent, respectively, with cathepsin B before and after cleavage of its propeptide. An intracellular increase in cathepsin B after treatment with TNF alpha was also seen with immunohistochemical studies.

CONCLUSION

TNF alpha (in the 6 cases studied) and IL-1 (in 4 cases) stimulated the secretion of a latent cysteine proteinase activity from synovial fibroblast-like cells, which appears to represent primarily cathepsin B.

Labial salivary gland biopsy is a reliable test for the diagnosis of primary and secondary amyloidosis. A prospective clinical and immunohistologic study in 59 patients

OBJECTIVE

Reports of the detection of amyloidosis by labial salivary gland (LSG) biopsy have been mostly anecdotal. The aim of this study was to assess the value of this method in the diagnosis of amyloidosis.

METHODS

LSG biopsy tissues were studied with a combination method using Congo red stain and immunohistologic characterization using an antibody directed against the serum amyloid P (SAP) component. Electron microscopy was performed in all cases. In a prospective study, we evaluated 30 patients with biopsy-proven AA or AL amyloidosis. We compared these patients with a control group of 29 age-matched patients without clinical or biologic evidence of amyloid disease (14 had rheumatoid arthritis and 15 had plasma cell dyscrasia).

RESULTS

In 26 of the 30 patients with known systemic amyloidosis, amyloid deposits were identified on LSG biopsy (sensitivity of 86%). In 1 of the remaining patients, amyloid deposits were identified on LSG biopsy and systemic amyloidosis was confirmed by abdominal fat biopsy and 123I-labeled SAP scintigraphy.

CONCLUSION

This study emphasizes the high sensitivity of LSG biopsy in the diagnosis of amyloidosis, even in the absence of oral symptoms.

[Imaging of pigmented villonodular synovitis]

Pigmented villonodular synovitis is a rare disease which is usually benign but sometimes causes wide articular destruction. Since its clinical signs and symptoms are not specific, the disease may remain undiagnosed, sometimes for long periods. The diagnosis is generally confirmed at pathology, but it can now be strongly suggested by modern imaging methods. Standard radiography may be normal, with a variety of images. Arthrography with an opaque material points to the diagnosis in only two-third of the cases. Ultrasonography is non-specific. Computed tomography may be strongly suggestive of pigmented villonodular synovitis in cases with high density synovia; when coupled with arthrography, it provides detailed information on lesions of the cartilage and on extension of the synovial process. The most sensitive and specific method is magnetic resonance imaging, the most characteristic sign being low-intensity signal areas on T1- and T2-weighted sequences, corresponding to haemosiderin-loaded nodules. Performed after standard radiography, magnetic resonance imaging is the best examination method for the diagnosis and pretherapeutic evaluation of suspected villonodular synovitis.

[Rheumatoid arthritis and multiple myeloma. Apropos of 22 cases. Results of a multicenter national survey]

Although studies of patients with rheumatoid arthritis have found no increases in overall cancer rates, significant elevations in rates of lymphoma and myeloma have been reported, suggesting a causal relationship between autoimmune disorders and lymphoid malignancies. Nevertheless, only 22 cases of concomitant rheumatoid arthritis and multiple myeloma were identified during a retrospective national multicenter study carried out in France. Neither disease exhibited unusual features. In every case, rheumatoid arthritis preceded multiple myeloma. Monoclonal gammopathy preceded multiple myeloma in two patients, by 3 and 7 years respectively. No patient had amyloid arthritis. Analysis of data from the cancer registry of the Somme district in northern France did not suggest a significantly increased risk of multiple myeloma in rheumatoid arthritis patients (relative risk 2.3). Use of interferon alpha to treat myeloma has been reported to exacerbate concomitant autoimmune disorders.

[Is the expression of TNF-alpha and cell adhesion molecules a marker of development of rheumatoid vasculitis?]

TNF-alpha, ICAM1, VCAM1, ELAM, CD44 and DR expression were studied (indirect immunoperoxydase methods) on labial salivary gland sections in 5 patients with proven rheumatoid vasculitis (before and after treatment), 5 patients with RA and 5 normal controls. TNF-alpha and cell adhesion molecules were particularly expressed in vasculitic areas of patients with systemic vasculitis and only before the onset of the treatment.

[Rheumatoid polyarthritis in the elderly--rhizomelic pseudopolyarthritis: what differences?]

The authors have conducted a comparative retrospective study between polymyalgia rheumatic (N = 26) and rheumatoid arthritis in the elderly (N = 44), including HLA DRB1 genotype determination by PCR-RFLP analysis. No clinical nor biological differences were significant between the 2 groups of patients. However 70% of RA patients had one ore more susceptibility alleles (shared epitope hypothesis) and 50% in polymyalgia rheumatica.

[Systemic manifestations of rheumatoid arthritis: prognostic value of the HLA DRB1 0405 allele]

The aim of the present study was to determine HLA DRB1* genotype by PCR-RFLP analysis in patients with rheumatoid arthritis (N = 122) associated with extra-articular manifestations (N = 24). A significant increased of DRB1* 0405 was found in RA patients with extra-cellular involvement (odd-ratio = 8.33, confidence interval = 1.44 - 56.7). In patients with RA, HLA DRB1*0405 allele might constitute a susceptibility marker of extra-articular involvement such as vasulitis or cardio-pulmonary manifestations.

[Cardiac complication of adult-onset Still's disease: from pericarditis to tamponade, sometimes a manifestation of the disease]

Cardiac tamponade is very seldom complication of adult onset-Still's disease. We reported 2 cases; it was the first manifestation of the disease in one case.

[Aspergillus spondylodiscitis. Apropos of 5 cases]

Five cases of Aspergillus discitis in male patients are reported. Three patients had impaired immune responses as a result of immunosuppressive therapy following a heart transplant (two cases) or hairy cell leukemia (one case). Two patients had a recent history of mycobacterial infection. All five patients were hospitalized for severe spinal pain suggestive of an inflammatory disease with no neurological abnormalities. Erythrocyte sedimentation rate was elevated in every case. The diagnosis of discitis was suspected on spinal roentgenograms and established by computed tomography and/or magnetic resonance imaging. In three patients the spine was the only site of Aspergillus infection (lumbar discitis in two cases and thoracic discitis in one case). One patient developed Aspergillus infection of several disks (L1-L2, L2-L3, and L4-L5) after Aspergillus endocarditis with embolization to the left lower limb. Another patient developed discitis after an Aspergillus lung infection. In every case, Aspergillus fumigatus was recovered in cultures of specimens harvested by a percutaneous needle biopsy of the intervertebral disk. All five patients were treated by itraconazole which was given as single drug therapy in one case and in combination with 5-flucytosine and amphotericin B in four cases. Recovery was achieved in every case after four to six months of this drug therapy. In contrast to most previously reported cases, none of the five patients reported herein required surgical treatment. Efficacy of conservative treatment in this study may be related to the use of itraconazole in every case.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of elastase and cysteine proteinases in synovial fluid of patients with rheumatoid arthritis, sero-negative spondylarthropathies, and osteoarthritis

Synovial fluid samples were collected from 45 patients with rheumatoid arthritis, spondylarthropathy, or osteoarthritis, to study their content of elastase (EC 3.4.21.37) and of cysteine proteinases (EC 3.4.22.1, 3.4.22.15). We measured both elastase complexed with alpha 1-proteinase inhibitor and elastase activity toward the substrate L-pyroglutamyl-L-prolyl-L-valine-p-nitroanilide. Cysteine proteinase activities were measured with the substrates N-benzyloxycarbonyl-L-phenylalanyl-L-arginine-7-amido-4-methylcoumarin (Z-Phe-Arg-AMC) and Z-Arg-Arg-AMC and the inhibitor E-64 [L-trans-epoxysuccinyl-leucyl-amido-(4-guanidino)-butane]. In all these enzyme assays, higher median values were obtained in inflammatory arthropathies than in osteoarthritis. The concentration of the elastase-alpha 1-proteinase inhibitor complex and of elastase and cysteine proteinase activities were statistically higher in patients with rheumatoid arthritis than in patients with osteoarthritis. The difference in results between patients with spondylarthropathy and patients with osteoarthritis was statistically significant only for the elastase-alpha 1-proteinase inhibitor complex. The median values of the complex and of both enzyme activities were higher in patients with rheumatoid arthritis than in patients with spondylarthropathy; however, the difference was statistically significant only for the cysteine proteinase activity measured with Z-Arg-Arg-AMC substrate. These results suggest that both elastase and cysteine proteinases, which are increased in patients with inflammatory arthritis, are involved in cartilage degradation in these arthropathies.

Antibodies in rheumatoid synovial fluids bind to a restricted series of protein antigens in rheumatoid synovial tissue

OBJECTIVE

By searching the synovial fluid of patients with rheumatoid arthritis (RA) for antibodies that react to protein antigens in synovial tissue, we sought to identify putative antigens present in RA synovial tissue that might drive the pathologic immune response believed to be responsible for the joint inflammation.

METHODS

Synovial tissue was homogenized in sodium dodecyl sulfate polyacrylamide gel buffer, electrophoresed, and analyzed by immunoblotting.

RESULTS

Antibodies from synovial fluids of patients with RA bound to several proteins in rheumatoid synovial tissues, including a series of low (27.5-, 29-, and 30-kd), middle (43- and 53-kd), and high (140-, 164-, and 182-kd) molecular weight proteins. Most of these antigens were also detected in normal synovial tissue, and the high molecular weight proteins were also present in normal dermal, muscle, and liver tissues. The low and middle molecular weight proteins were detected in some, but not all, of the other normal tissues and in Jurkat cell lysates. Antibodies to the low and high series of proteins were present in all rheumatoid synovial fluids tested, but were generally absent from synovial fluids from patients with other arthritic diseases.

CONCLUSION

These results show that antibodies in synovial fluids consistently react to several proteins in RA and normal synovial tissues. These antigens are possibly the same antigens provoking the T cell response in RA; therefore, understanding the mechanism of the immune response against these proteins will likely lead to important insight into the etiology of RA.

["Spontaneous" hematoma of the psoas in Gaucher's disease]

The authors report a case of iliac muscle haematoma responsible for inguinal pain in a patient with Gaucher's disease type I. This exceptional cause of pain must now be considered side by side with the classical femoral head osteonecrosis and infectious coxitis. Magnetic resonance imaging appears to be the most sensitive and most specific examination for the aetiological diagnosis of hip pain in Gaucher's disease. In the absence of thrombocytopenia and franck abnormality of coagulation, the spontaneousness of the haematoma is discussed.