Impact of antiplatelet therapy in the development of severe ischemic complications and in the outcome of patients with giant cell arteritis

OBJECTIVE

To evaluate whether concomitant treatment with low-dose aspirin or other antiplatelet agents have an impact on the risk of severe ischemic complications and in the outcome of patients with giant cell arteritis (GCA).

METHODS

A retrospective follow-up study of an unselected population of 121 patients with GCA.

RESULTS

Thirty-seven patients (30.5%) received antiplatelet therapy before the onset of GCA symptoms and continued taking it during the corticosteroid treatment (30 received aspirin and 7 other antiplatelet agents). No statistically significant reduction in the incidence of ischemic manifestations (including jaw claudication, visual manifestations, cerebrovascular accidents, ischemic heart disease, and limb claudication due to large artery stenosis) was observed in this group compared with the remaining patients. When we analyzed follow-up data, we found no significant differences between groups in terms of frequency of relapses and percentage of patients recovered from GCA. Corticosteroid requirements among patients in long-lasting remission were lower in those under antiplatelet therapy, but this reduction was fairly modest, statistically non significant and thus of uncertain clinical significance. Similar results were found when only aspirin exposed patients (n=30) were compared to non-exposed patients. Logistic regression analysis showed that antiplatelet therapy (p=0.54, OR 1.31; 95% CI: 0.54-3.19) had not an independent protective effect against ischemic events when adjusted for age, sex, and the presence of atherosclerotic risk factors.

CONCLUSION

We did not observe a significant benefit derived from the use of antiplatelet therapy in either the incidence of severe ischemic events or the disease outcome. Although our results do not discard a potential therapeutic effect of high-dose aspirin, they do not confirm its suggested protective effect in preventing ischemic complications when used at antiplatelet doses.

Pyarthrosis in patients with rheumatoid arthritis: a detailed analysis of 10 cases and literature review

OBJECTIVES

1) To analyze the clinical features and outcome of patients with rheumatoid arthritis and pyarthrosis seen in a rheumatology department during a 9-year period; 2) To review the available literature about this association in the last decade.

METHODS

From the database of our department, we collected all hospitalized cases of infectious arthritis in native joints between January 1990 and December 1998. In 10 cases (27%), pyarthrosis occurred in patients with rheumatoid arthritis. A detailed analysis of each patient was performed. The literature was reviewed by using MEDLINE from 1990 to 1999.

RESULTS

The mean age of patients was 63.2 years; six were female. Most patients had long-standing disease and poor functional class, and all received glucocorticoid treatment. Mean diagnostic delay was 7.3 days. Causative organisms were Staphylococcus aureus (4 cases), gram-negative bacilli (3 cases), anaerobic bacteria (2 cases), and Streptococcus pneumoniae (n = 1). Two patients died. In all but two patients who survived, joint function worsened.

CONCLUSIONS

Rheumatoid arthritis is a relevant host-related risk factor for septic arthritis. Pyarthrosis in these patients is associated with considerable morbidity and mortality.

Osteonecrosis of the knee: differences among idiopathic and secondary types

OBJECTIVE

To describe the clinical and imaging features of patients with osteonecrosis of the knee, emphasizing the differences among idiopathic and secondary types.

METHODS

A retrospective chart review of 37 consecutive patients (41 knees) with osteonecrosis of the knee confirmed by bone scintigraphy and/or magnetic resonance imaging (MRI), and a comparison of idiopathic and secondary types of osteonecrosis.

RESULTS

Twenty-four patients had idiopathic osteonecrosis, and in 13 patients one or more predisposing factors were identified (secondary osteonecrosis). Idiopathic osteonecrosis of the knee was typically a disease of the elderly, characterized by severe knee pain of sudden onset, unilateral involvement, and restriction of the lesions generally to one femoral condyle or tibial plateau, with predilection for the medial compartment of the joint. Secondary osteonecrosis generally occurred in younger patients and frequently had an insidious onset with mild or vague pain, the lateral compartment of the knee was often involved, and the lesions were generally larger than lesions arising spontaneously; in the great majority of cases they involved the femoral condyles and/or tibial plateaus. Bilateral distribution and multifocal involvement was also seen in these forms. Magnetic resonance imaging was helpful in confirming the suspected diagnosis when conventional radiographs were normal or equivocal, and demonstrated different patterns of abnormalities in idiopathic and secondary types.

CONCLUSION

There are significant differences between idiopathic and secondary osteonecrosis, especially in regard to clinical presentation and the location, extent and MRI appearance of the lesions. These differences are probably due to a difference in the pathogenetic mechanism.

Bone mineral density in patients with peripheral psoriatic arthritis

BACKGROUND

Little information is available on the occurrence of generalized osteopenia in psoriatic arthritis. The only two published studies of bone mass in psoriatic arthritis produced conflicting results.

METHODS

We compared bone mineral density measured at the lumbar spine and femoral neck using dual-energy X-ray absorptiometry in 52 patients with active peripheral psoriatic arthritis and in 52 controls. The psoriatic arthritis group included 19 males, 14 premenopausal women, and 19 post-menopausal women. Controls were matched to the patients on sex, age, and menopausal status.

RESULTS

In the overall study population no significant differences were found between psoriatic arthritis patients and controls. Postmenopausal psoriatic arthritis patients had a lower femoral neck bone mineral density than the relevant subgroup of controls. No significant differences in lumbar spine bone mineral density were found in the analyses of the male, premenopausal female, and postmenopausal female subgroups. Neither was femoral neck density significantly different between male or premenopausal female psoriatic arthritis patients and controls.

CONCLUSION

These results suggest that peripheral psoriatic arthritis is not associated with significant generalized bone loss.

Posterior tibial tendon dysfunction as a cause of acquired flatfoot in the adult: value of magnetic resonance imaging

Dysfunction of the posterior tibial tendon is the most common cause of acquired flatfoot in adults; despite this, the condition is not commonly recognized. We report three cases with flatfoot secondary to spontaneous tendon rupture, in whom magnetic resonance imaging (MRI) was a helpful non-invasive technique to confirm the suspected diagnosis. This disabling entity, and the usefulness of MRI in the diagnosis and planning the appropriate treatment, are reviewed.

Tertiary hyperparathyroidism after long-term phosphate supplementation in adult-onset hypophosphataemic osteomalacia

We report the development of tertiary hyperparathyrodism in a patient with a sporadic form of adult-onset hypophosphataemic osteomalacia who had been treated with vitamin D or calcitriol and large doses of phosphate. This observation suggests that even with concomitant vitamin D or calcitriol therapy, long-term oral phosphate supplementation may lead to the development of hypercalcaemic hyperparathyrodism. Caution is recommended when relatively large doses of phosphate are used to treat hypophosphataemic osteomalacia of diverse causes.

Hydatid disease. An unusual cause of chronic monarthritis

We describe a patient with granulomatous synovitis secondary to osseus hydatid disease that manifested with chronic monarthritis, eosinophilia, and urticaria.

Munchausen's syndrome simulating reflex sympathetic dystrophy

A 15 year old girl who had pain, oedema of her left hand, and fever of four months' duration is described. Marked demineralisation of her hand was shown by radiography, and increased articular uptake by technetium-99m bone scan. All these changes were indistinguishable from reflex sympathetic dystrophy. After two admissions to hospital and multiple explorations we discovered that she had induced her symptoms herself and a diagnosis of Munchausen's syndrome was made. As far as we know this presentation has not been previously reported and might help to explain the physiopathology of some signs of reflex sympathetic dystrophy.

Concept and limits of the reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) is a clinical syndrome defined in the English literature by pain, dystrophic tissue changes and local disturbance of autonomic function in a limb or part of a limb. Algodystrophy is the common name used for the condition in the French literature, in which the concept also includes the "transient regional osteoporosis" and the "regional migratory osteolysis". We want to discuss three points: 1) Are the RSD, transient regional osteoporosis and migratory osteolysis different diseases or different manifestations of a single condition? We believe that an objective differentiation is not possible between them. Our report about 28 cases of polytopic RSD shows the frequent association in the same patient of these manifestations and we believe that this represents the broad spectrum of a single disease. 2) Is the accepted classic pathophysiologic mechanism of RSD accurate? The conception of a disturbance of autonomic function is not easily linked with its association with conditions such as diabetes, hyperthyroidism, hyperlipidaemia and others. Even more difficult to explain is the association with malignancy and osteomalacia. The deposit of immunoglobulins that we have demonstrated in two cases in the palmar fascia of RSD associated with malignancy suggests a possible immunological mechanism. 3) What are the limits of RSD? The association between RSD and aseptic necrosis of the hip has been reported. Are they two different conditions or is the aseptic necrosis only a more developed form of RSD? Finally, we report the first single case of Munchausen syndrome mimicking a RSD of the hand with the same clinical, radiological and scintigraphic appearance.