Long-term efficacy and safety of antitumour necrosis factor alpha treatment in rhupus: an open-label study of 15 patients

Background

The efficacy of antitumour necrosis factor alpha (anti-TNF-α) treatment is well recognised in rheumatoid arthritis (RA) but remains controversial in systemic lupus erythematosus (SLE). Therefore, the role of anti-TNF-α treatment in 'Rhupus', a disease sharing features of RA and SLE, is still debated.

Objective

To evaluate the efficacy and tolerance of anti-TNF-α in patients with rhupus.

Methods

Fifteen patients with rhupus with Disease Activity Score 28 (DAS 28) >3.2 despite conventional disease-modifying anti-rheumatic drugs were included in an open-label study. Patients were monitored at months (M) 3, 6, 12, 24 and 60 with SLE Disease Activity Index (SLEDAI) and DAS 28. Statistical analyses were performed using Bayesian methods and Prob >97.5% was considered significant.

Results

Twelve patients were treated with etanercept for a median duration of 62.5 (range: 6-112) months and three patients by adalimumab during 36.0 (range: 4-52) months. At baseline, median DAS 28 and SLEDAI were 5.94 (4.83-8.09) and 6 (4-8), respectively. DAS 28 and SLEDAI decreased significantly after 3 months, respectively, to 3.70 (1.80-6.42) and 4 (0-6) (Prob >99.9%, for both). These changes persisted at M6, M12, M24 and M60 (Prob >99.9%, for all). Median prednisone dose decreased significantly from 15 (5-35) mg/day to 5 (0-20) mg/day after 6 months and over the follow-up (Prob >99.9%, for all). Tolerance was acceptable, with a severe infection rate of 3.0 per 100 patient-years.

Conclusion

This pilot study suggests that anti-TNF-α is effective in patients with rhupus with refractive arthritis and has an acceptable safety profile.

Percutaneous Laser Photocoagulation of Osteoid Osteomas

Osteoid osteoma is a painful benign bone tumor. The curative treatment of this tumor consists of complete surgical or percutaneous excision of the nidus with immediate and dramatic relief of symptoms. Interstitial laser photocoagulation (ILP) is a low-invasive percutaneous technique of thermal destruction (coagulation) of deep-seated tumors elsewhere in the body, using low-power laser energy. The aim of ILP is the local destruction of osteoid osteoma without bone weakening. Twenty-two patients with osteoid osteoma were treated with percutaneous ILP of the nidus under computed tomography guidance. The laser energy was provided by a high-power semiconductor diode laser (805 nm) with a 400-&mgr;m optical fiber. Complete pain relief was obtained in 21 patients. Percutaneous ILP of osteoid osteoma seems to be a promising, simple, precise, and minimally invasive technique as an alternative to traditional surgical and percutaneous ablations.

Iliac bone defects revealing systemic sarcoidosis

Bone lesions are fairly uncommon in sarcoidosis (5 to 10% of cases). We report the case of a 40-year-old man in whom sarcoidosis of the lungs and bones was revealed by excruciating buttock and sacral pain. Computed tomography showed multiple punched-out defects in the left iliac bone. No similar cases have been reported in the literature.

[Drug-induced osteopathies]

Several drugs can induce bone disorders. Steroid-induced osteoporosis is the best known of all drug-induced bone disorders. However, bone disorders have also been described in association with newer drugs (LH-RH analogs, retinoids, cyclosporine, etc.). The purpose of this revue is to familiarize radiologists with drug-induced bone disorders in order to achieve earlier diagnosis, hence, improve treatment.

[Treatment of osteoid osteoma using laser photocoagulation. Apropos of 28 cases]

THE PURPOSE OF THE STUDY was to evaluate interstitial laser photocoagulation for local destruction of osteoid osteoma, with computed tomographic (CT) guidance.

MATERIAL AND METHODS

28 patients (age range from 5 to 48 years) with presumed osteoid osteoma were treated with CT-guided interstitial laser photocoagulation of the nidus. A high power semiconductor diode laser (805 nm) with a 400 microns optical fiber was used. The fiber was introduced into the nidus through a 18-gauge needle. Around the fiber tip, well-defined coagulative necroses from 5 to 9 mm (energy delivery, 400-1000J) were obtained.

RESULTS

27 patients had complete pain relief, which was effective within 24 hours in 18 patients. One patient had pain recurrence after 6 weeks. The remaining nidus was treated secondarily with complete relief. Treatment was unsuccessful in one patient, and surgical excision was performed. All patients were followed up for more than 1 year, with no sign of recurrence. The only notable complication was a mild reflex sympathetic dystrophy of the wrist in one patient. Sclerosis of the nidus was observed 6-12 months after the procedure.

CONCLUSION

Percutaneous interstitial laser photocoagulation of osteoid osteoma seems to be a promising, simple, precise, and minimally invasive alternative to traditional surgical and percutaneous ablations.

[Epiphysis-metaphysis bone ischemia in hemorrhagic rectocolitis and Crohn's disease]

Aseptic osteonecrosis is a rare extraintestinal manifestation in patients with inflammatory bowel disease; its true prevalence is not precisely known. Steroid treatment undoubtedly participates in the pathophysiology of avascular osteonecrosis, however, other factors like hypercoagulability may be involved. Two cases of bilateral osteonecrosis of the knees--the first occurring during the course of ulcerative colitis, the second in a patient presenting with Crohn's disease--are described. Specific location of the lesions and regression of symptoms, as well as the importance of magnetic resonance imaging for early recognition of osteonecrosis, are noteworthy.

Interstitial laser photocoagulation of osteoid osteomas with use of CT guidance

PURPOSE

To evaluate interstitial laser photocoagulation (a minimally invasive percutaneous technique of thermal destruction of deep-seated tumors, with low-power laser energy) in local destruction of osteoid osteoma, with computed tomographic (CT) guidance.

MATERIALS AND METHODS

Fifteen patients (age range, 8-48 years) with presumed osteoid osteoma were treated with CT-guided interstitial laser photocoagulation of the nidus. A high-power semiconductor diode laser (805 nm) with a 400-microm optical fiber was used. The fiber was introduced into the nidus through an 18-gauge needle. Around the fiber tip, well-defined coagulative necroses from 5 to 9 mm (energy delivery, 400-1,000 J) were obtained.

RESULTS

Fourteen patients had complete pain relief, which was apparent within 24 hours in eight patients. One patient had recurrence of pain after 6 weeks. The remaining nidus was treated a second time, with complete relief. Treatment was unsuccessful in one patient, and surgical excision was performed. Daily activities were not restricted after the intervention. All patients were followed up for more than 1 year, with no sign of recurrence. The only notable complication was a mild reflex sympathetic dystrophy of the wrist in one patient. Sclerosis of the nidus was observed 4-6 months after the procedure.

CONCLUSION

Percutaneous interstitial laser photocoagulation of osteoid osteoma seems to be a promising, simple, precise, and minimally invasive alternative to traditional surgical and percutaneous ablations.

[Chronic recurrent multifocal osteomyelitis. A diagnosis to be called to mind]

Chronic recurrent multifocal osteomyelitis is a rare disorder that affects children and teenagers. Clinically, it is characterized by insidious onset of local swelling and pain in several metaphyses. A symmetric, recurrent and multifocal pattern is usual. Spinal involvement is possible. Inconstant association with a cutaneous affection (palmoplantar pustulosis, acne fulminans, psoriasis), or less frequently with an inflammatory chronic gut disorder is described. Pathogenesis usually recognized is an enthesopathy. Enthesitis may progress to the osseous part of the enthese and produce an aseptic chronic osteomyelitis. Biopsy specimen with culture is certainly necessary to rule out bacterial osteomyelitis and bone tumor. It is particularly true when the bone lesion is isolated. Disease course is benign and self-limited. The clinical course is characterized by recurrences and remission occurring for 6 to 10 years. Treatment based on non steroid antiinflammatory drugs is usually effective.

[Scaphoid fissure in algodystrophy: diagnostic value of MRI]

Stress fractures are exceptional in patients with reflex sympathetic dystrophy syndrome, even when bone loss is severe. We report a case of stress fracture of the navicular bone documented by magnetic resonance imaging. Recurrence of localized pain in patients with reflex sympathetic dystrophy syndrome suggests either a relapse of the syndrome or a bony fissure. Magnetic resonance imaging can provide early differentiation of these two conditions.

[Infectious osteoarthritis of the pubis in sportmen. Apropos of 2 cases]

In athletes, osteoarthritis of the symphysis pubis is an uncommon condition that should be promptly differentiated from pubic pain due to microtrauma. The symphysis pubis is infected via the bloodstream, usually by a staphylococcus. Pubic pain with fever and severe disability suggests the diagnosis. Increased uptake of bone-seeking radionuclides is an early finding. Microbiological and histological studies of specimens obtained under radiological guidance confirm the diagnosis. Two new cases of pubic osteoarthritis in young athletes are reported. In one case the causative organism was a Peptostreptococcus, a gram-positive commensal organism normally found on the skin and mucous membranes.

[Post-traumatic and symptomatic lumbar intertransverse process bone bridge. Apropos of a case: review of the literature]

Osseous bridging of lumbar transverse processes is very seldom seen. A review of the literature has revealed only thirty-six reports. The first cases were thought to be of congenital origin. Subsequently however, the post-traumatic nature of osseous bridging was proved in ten cases. It is obviously a peculiar localization of myositis ossificans. We report a new case, with proof of the post-traumatic nature, associated with symptoms of sciatica.

[Lesions of the rotator cuff and acromioclavicular joint. Data of arthrography. Apropos of 2 cases]

Arthrography using an opaque medium to explore the shoulder in two cases demonstrated rupture of the rotator muscles sheath associated with a communication into the acromioclavicular joint. Rupture of the sheath allows direct contact between the humeral head and the capsule of the acromioclavicular joint which becomes eroded progressively. Recent studies have produced data indicating participation of the acromioclavicular joint in the natural history of deteriation of the sheath of the rotator muscles.