Dysphagia Secondary to Myotonic Dystrophy Unveiled in a Case of Destructive Spondylitis With Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) Syndrome Presenting As Torticollis

To report an instructive case involving destructive spondylitis and synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome, presenting with torticollis and postoperative dysphagia without hoarseness, attributed to hidden myotonic dystrophy (DM). A 51-year-old male patient with a cervical deformity, who was previously managed conservatively for a metastatic tumor, underwent reconstruction surgery and subsequently experienced postoperative dysphagia. The presence of destructive spondylitis with torticollis, warranting prompt assessment to prevent paralysis, adds complexity to the delayed identification of DM. Given the rarity of DM, peculiar neurological symptoms and other systemic comorbidities did not lead to a preoperative diagnosis without prior knowledge. The patient's dysphagia induced respiratory arrest and required reintubation. Challenges in extubation and ventilator weaning arose due to hypercapnia. Superimposed COVID-19 infection elongated the duration of intubation. Extubation failed due to aspiration pneumonia and required a tracheotomy. Despite laryngeal elevation and preservation of the relaxation of the oesophageal entrance, the sensation and movement of the tracheopharynx were disturbed. The patient exhibited an oropharyngeal propulsive disorder, predominantly indicative of motor neuron disease. The patient's mother stated that his brother had been hospitalized for a long time after abdominal surgery. Finally, the patient was diagnosed with DM, which is known to cause post-anesthetic dysphagia. Recognizing the existence of severe destructive cervical spondylitis associated with SAPHO is crucial. Although DM is not very common, it is not classified as extremely rare. Therefore, surgeons should be mindful of the potential risks associated with general anesthesia in patients with DM. The complexity of preoperative conditions may hinder an accurate diagnosis. Recognizing and establishing preoperative expectations can assist surgeons in preventing complications, even if complex spinal surgery is required for patients with DM.

Prospective Comparison of the Imaging Value of 99m Tc-MDP Bone Scan and 68 Ga-FAPI-04 PET/CT in Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis Syndrome

PURPOSE

This study aimed to explore the imaging value of 68 Ga-FAPI-04 PET/CT in synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome and compare it with that of 99m Tc-MDP bone scan.

METHODS

Nineteen participants with SAPHO syndrome underwent 68 Ga-FAPI-04 PET/CT and 99m Tc-MDP bone scan. Demographic data and clinical features were recorded, SAPHO imaging features were analyzed, and the osteoarticular lesion detection rate in both methods was calculated.

RESULTS

This prospective study recruited 4 men and 15 women aged 52.4 ± 8.6 years. The anterior chest wall was involved in all participants (100%). Palmoplantar pustulosis was the most common (36.8%) skin symptom. 99m Tc-MDP bone scan and 68 Ga-FAPI-04 PET/CT together detected 84 osteoarticular lesions, of which 91.7% (77/84) were detected by the former and 96.4% (81/84) by the latter. Furthermore, 68 Ga-FAPI-04 PET/CT detected 5 cases of knee and hip joint synovitis.

CONCLUSIONS

68 Ga-FAPI-04 PET/CT was more sensitive than 99m Tc-MDP bone scan when evaluating osteoarticular lesions in SAPHO syndrome and could also evaluate synovial lesions. 68 Ga-FAPI-04 PET/CT could be a good imaging method for SAPHO syndrome but requires further verification in a more extensive research cohort.

A case of SAPHO syndrome: a DISH of radiological features to be considered

Background

The acronym SAPHO stands for synovitis, acne, pustulosis, hyperostosis, and osteitis. It is a rare heterogenous disease with unknown etiology and a chronic relapsing and remitting course¹. Its skin and osteoarticular manifestations including palmoplantar pustulosis (PPP) and synovitis may be transient which further complicate the diagnosis. So, awareness about all features of the syndrome throughout the time seems mandatory for correct diagnosis and avoidance of unnecessary procedures.

Case presentation.

A case of SAPHO syndrome being reported in a middle-aged man who presented with bilateral PPP and exacerbation of back pain which developed shortly after covid-19 vaccine injection with a history of more than 20 years of inflammatory thoracic back pain and psoriasis vulgaris who initially had been worked up for metastatic bony lesions based on radiologic studies, irrespective of his skin lesions. The patient had good response to alendronate 70 mg weekly and celecoxib 200 mg BID without aggravation of existing skin lesions or new psoriatic lesions.

Conclusion

This case report aims to inform rheumatologists and radiologists about various radiologic and dermatologic manifestations of SAPHO syndrome with emphasizing on taking into consideration of past and present skin lesions in the interpretation of the radiologic signs in order to prevent irrelevant procedures or hazardous imaging and to urge rheumatology societies to set up a SAPHO registry for future randomized controlled trials. Suggestion of PPP responsiveness to NSAIDs as a new potential diagnostic tool for SAPHO diagnosis is another goal. It also aims to point out the possible coexistence of SAPHO and SpA or DISH syndrome.

Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO): A Case Report

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) is an uncommon adulthood disorder that presents as focal swellings and pain accompanied by abnormal changes in bone and surrounding soft tissues. X-rays of the involved region are usually insignificant; however, CT and MRI show excellent visualization of the affected structures. Typical radiological images show cortical thickening leading to decreased marrow cavity, bony erosion, and ligament ossifications. Other associated findings are synovitis and joint effusions. It is usually diagnosed on the basis of clinical as well as radiological findings. The treatment initially relies on non-steroidal anti-inflammatory drugs (NSAIDs). Patients showing poor response are started on corticosteroids and disease-modifying antirheumatic drugs (DMARDs). We report two patients who presented with joint swellings. Their workup unmasked the underlying SAPHO, which was managed well with NSAIDs.

Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) Syndrome: Clinical and Therapeutic Aspects

Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare entity. It is frequently under-detected. We report the case of SAPHO syndrome in a 38-year-old woman, seen in consultation for pain and swelling of the anterior chest wall affecting the sternoclavicular and sternocostal joints predominantly on the right, and low back pain with an inflammatory appearance with peripheral damage, especially in the legs. We also found in our patient episodes of palmoplantar pustulosis. The diagnosis of SAPHO syndrome was retained in accordance with Kahn's diagnostic criteria, and the osteitis was confirmed by morphological examinations (CT scan, MRI, and bone scintigraphy). The patient was treated with non-steroidal anti-inflammatory drugs and methotrexate with good clinical improvement.

Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO): An Interesting Clinical Syndrome

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare disorder that classically involves the musculoskeletal system, i.e. bone, joint and skin. The exact pathogenesis of this syndrome is unknown. However, autoimmunity, infections, immune malfunction and genetic factors are attributed to its pathophysiology. Bone and joint involvements are the hallmark of SAPHO syndrome and not necessarily require cutaneous involvement at the time of diagnosis. X-ray of the affected joints could show osteitis with sclerosis. Anterior chest wall involvement particularly ''bullhead appearance'' seen on bone scan is a striking feature of the syndrome. Erythrocyte sedimentation rate (ESR) is usually elevated amongst the majority of patients. Diagnosis of SAPHO is always challenging and often delayed because of a multitude of symptoms. The mainstay of treatment is control of pain and inflammation with both non-steroidal anti-inflammatory drugs (NSAIDs) and rescue courses of systemic steroids. If failed to control symptoms with first-line agents and in those with severe disease, disease-modifying anti-inflammatory drugs (DMARDs) may be needed eventually. Despite a chronic inflammatory condition, it remains stable in the majority of cases. Here in this case report, we reiterate the importance of early recognition, timely diagnosis and prompt treatment initiation.

Rapid induction of clinical remission in SAPHO syndrome using high-dose Tripterygium glycosides: A case report

RATIONALE

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare disease without standard treatments. Tripterygium wilfordii hook f (TwHF) is a traditional Chinese herb with anti-inflammatory effect, and 1.0 mg/(kg·d) dose of Tripterygium glycosides has been reported to significantly improve the disease activity of a SAPHO patient in a case report. However, the optimal dose of TwHF is still unclear. Here, we report the first case of SAPHO patient who achieved rapid remission in clinical symptoms after receiving 1.5 mg/(kg·d) dose of Tripterygium glycosides treatment.

PATIENT CONCERNS

A 67-year-old woman noted palmoplantar pustulosis and pain in the anterior chest wall and waist. Bone scintigraphy demonstrated the typical tracer accumulation feature and magnetic resonance images showed bone marrow edema in lumbosacral vertebra.

DIAGNOSES

The diagnosis was made by dermatological and osteoarticular manifestations and classical signs in bone scintigraphy in accordance with the diagnostic criteria proposed in 2012.

INTERVENTIONS

Tripterygium glycosides was given with a primary dose of 1.5 mg/(kg·d) for 1 month and then reduced at a rate of 10 mg every 2 weeks until 1.0 mg/(kg·d) for a long-term maintenance.

OUTCOMES

Fast-induced remission on clinical manifestations was achieved and magnetic resonance imaging abnormality was improved significantly. Additionally, no apparent side effects were observed.

LESSONS

1.5 mg/(kg·d) dose of Tripterygium glycosides seems to have fast-induced remission than 1.0 mg/(kg·d) with reliable safety. Besides, Tripterygium glycosides may also have a pharmacological effect of inhibiting osteolysis and enhancing bone strength.

Long-term remarkable remission of SAPHO syndrome in response to short-term systemic corticosteroids treatment in an immunoglobulin E elevated patient: A case report

RATIONALE

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare auto-inflammatory disease with no standardized treatment. Systemic corticosteroids are only transiently effective, but long-term use would bring complications and would not bring long-term remission. Bone scintigraphy is a first-line method for systematic evaluation of osteoarticular lesions but seems to show an "imprinting" pattern.

PATIENT CONCERNS

A 31-year-old female patient presented significant palmoplantar pustulosis and nail lesion as well as typical tracer accumulation feature on bone scintigraphy with normal hypersensitivity C-reactive protein and erythrocyte sedimentation rate, but an elevated serum immunoglobulin E level.

DIAGNOSIS

The diagnosis was made by dermatological manifestations and classical sign in bone scintigraphy in accordance with the diagnostic criteria proposed in 1988.

INTERVENTIONS

Methylprednisolone was given with a primary dose of 40 mg/day for 1 week followed with a subsequent 20 mg/day oral prednisone for another 1 week and then reduced in a rate of 5 mg/week until the eventual cessation.

OUTCOMES

Long-term remarkable remission on clinical manifestations, MRI performance, and quantitative analysis of bone scintigraphy was achieved.

LESSONS

Identification of specific subtype of SAPHO patient according to skin and nail manifestations as well as immunoglobulin E level may guide the selection of short-term systemic corticosteroids strategy, leading to remarkable long-term remission. Besides, the lesions on bone scintigraphy can hardly disappear in SAPHO patients, and instead, the quantitative analysis of bone scintigraphy and MRI performances may better reflect the change of disease condition and serve as indicator for treatment efficiency.

Diagnostic value of ultrasonography in synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome: A case report

RATIONALE

Synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome is a rare condition that affects the skin, bones, and joints. Diagnosis of SAPHO syndrome is established based on clinical manifestations and imaging features on radiography or magnetic resonance imaging.

PATIENT CONCERNS

We report a 44-year-old male with a 20-year history of pustulosis who presented with pain in the lower extremities. Plain radiography demonstrated hyperostosis with subperiosteal erosions in the right tibia. Magnetic resonance imaging and computed tomography showed inflammatory accumulation, whereas musculoskeletal ultrasonography clearly depicted a periosteal reaction, osteitis, and enthesitis with abnormal blood flow in the surface of the right tibia.

DIAGNOSES

A diagnosis of SAPHO syndrome was made.

INTERVENTIONS

The patient was treated with combination therapy comprising prednisolone, methotrexate, and infliximab, which resulted in clinical improvement.

OUTCOMES

The elevated levels of C-reactive protein and matrix metalloproteinase-3 normalized, and the abnormal ultrasonographic findings disappeared.

LESSONS

The present case report demonstrates that multiple imaging modalities are important for the definitive diagnosis of SAPHO syndrome. Ultrasonography might be a useful tool for evaluating local musculoskeletal inflammation in patients with SAPHO syndrome.

Case report: successful treatment of refractory SAPHO syndrome with the JAK inhibitor tofacitinib

INTRODUCTION

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is an autoinflammatory disorder without standardized treatment. Janus kinase (JAK) inhibitors can block a range of cytokines and might possess significant anti-inflammatory activity. Here, we report the first case of efficacious treatment of refractory SAPHO syndrome with the JAK inhibitor tofacitinib.

CASE PRESENTATION

A 44-year-old woman presented with arthralgia in the right wrist and complained of having difficulty in doing housework. Symptoms were unresponsiveness to nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs, and tumor necrosis factor inhibitors. A diagnosis of SAPHO syndrome was made based on previous dermatological and osteoarticular manifestations and bone scintigraphy findings. Oral treatment with tofacitinib at 5 mg twice daily in combination with the basic methotrexate treatment was initiated. After 4 weeks of using tofacitinib, the patient reported marked improvement of symptoms and also reported being competent in completing housework.

CONCLUSIONS

The efficacy of JAK inhibitors in treating refractory SAPHO syndrome should be noted.

Case report: remarkable remission of SAPHO syndrome in response to Tripterygium wilfordii hook f treatment

RATIONALE

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome is an autoinflammatory disease with no standardized treatment. Tripterygium wilfordii hook f (TwHF) is a Chinese herb with immunosuppressive effects and has been used to treat some chronic inflammatory diseases. However, it has not been reported as a therapeutic option in SAPHO syndrome. Here we present the first report in which a remarkable remission of SAPHO syndrome was achieved in response to TwHF.

PATIENT CONCERNS

A 57-year-old female patient noted swelling and pain at the anterior chest wall and scattered rashes like psoriasis vulgaris. Bone scintigraphy demonstrated the classic "bull's head" sign and magnetic resonance images indicated bone marrow edema on T5.

DIAGNOSES

The diagnosis was made by dermatological and osteoarticular manifestations and classical "bull's head" sign in bone scintigraphy.

INTERVENTIONS

TwHF with a priming dose of 20 mg 3 times per day and a gradual dose reduction of 20 mg per day in every 3 months. Four months later, methotrexate was added with 10 mg per week.

OUTCOMES

Osteoarticular symptoms and radiological abnormalities were improved dramatically.

LESSONS

This case illustrates a promising strategy to treat SAPHO syndrome.

The coexistence of SAPHO syndrome and rheumatoid arthritis: A case report

RATIONAL

SAPHO (Synovitis-Acne-Pustulosis-Hyperstosis-Osteitis) syndrome is a rare disease featured by its dermatological and osteoarthritic disorders, the latter of which mainly affecting the anterior chest wall, spine, and sacroiliac joint. However, rheumatoid arthritis (RA) is a chronic autoimmune disease, mainly affecting the synovial tissue of small joints in hands and feet. Here, we present an extremely rare case diagnosed with both SAPHO syndrome and RA, with an onset interval of 10 years. So far, only 1 similar case has been reported in the English literature.

PATIENT CONCERNS

In Sep 2015, a 59-year-old female patient presented to our hospital, complaining of refractory low back pain, left sternoclavicular joint pain, and palmoplanar pustulosis (PPP). In addition, RA had been diagnosed 10 years earlier in the patient, manifested as pain and swelling in bilateral hands and wrists, accompanied by morning stiffness, as well as positive serologic tests.

INTERVENTIONS

In our hospital, laboratory tests revealed elevated inflammatory markers, and imaging examinations of relevant sites showed specific osteoarthritic lesions for SAPHO syndrome.

DIAGNOSES

These findings lead us to make an easy diagnosis of the coexistence of SAPHO syndrome and RA in this petient.

OUTCOMES

Treatment with tripterygium wilfordii polyglycosidium and prednisone was introduced. Both dermatological and osteoarthritic symptoms improved during a 3-month follow-up. Symptoms of RA were successfully controlled with prednisone and leflunomide since 2005.

LESSONS

We present an extremely rare case diagnosed with both SAPHO syndrome and RA, with an onset interval of 10 years. With this case report, we want to draw attention to the diverse features of SAPHO syndrome.

A case report of severely damaged hip joint caused by SAPHO syndrome treated with 2-stage total hip arthroplasty

INTRODUCTION

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is an increasingly recognized entity. The hip joint is known as a less frequently affected site in SAPHO syndrome, and there has been limited reports about hip joint diseases caused by SAPHO syndrome, and as such adequate treatment for this disease spectrum is still not fully elucidated.

CASE

We describe the case of a 52-year-old man admitted for SAPHO syndrome who went on to be diagnosed with advanced secondary hip arthritis associated with disabling right hip pain. The diagnosis of SAPHO syndrome was delayed; the patient was given a clinical diagnosis of osteomyelitis and treated with prolonged courses of antibiotics and open surgical debridement at previous tertiary health facility. The patient underwent 2-stage joint replacement surgery in our hospital. At 1 year after the surgery, he is well, with minimal right hip pain and the prosthesis is functioning well.

CONCLUSION

This case shows the safety and effectiveness of the 2-stage joint replacement in treating destructive hip disease caused by SAPHO syndrome mimicking infectious arthritis.