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.

Antiphospholipid Syndrome with Antiβ2glicoprotein-1 Antibodies as the Cause of Recurrent Tibial Vein Thrombosis in SAPHO syndrome

The antiphospholipid antibody syndrome is defined by the presence of antiphospholipid antibodies in patients with recurrent venous or arterial thromboembolism (1). SAPHO syndrome is a rare disease, characterized by specific clinical manifestations of synovitis, acne pustulosis, hyperostosis, and osteitis. It is a disease that manifests with a combination of osseous and articular manifestations associated with skin lesions (2). Venous thrombosis complicating SAPHO syndrome seems to be uncommon with an unclear pathogenesis (3-9). Coexistence of antiphospholipid syndrome and SAPHO syndrome was not previously mentioned in literature. A 33-year-old white woman was diagnosed with SAPHO syndrome at the age of 31. The patient was previously diagnosed with polycystic ovary syndrome and depressive syndrome. She was treated with sulfasalazin (2 g daily) and methotrexate (20 mg weekly). Seven months before admission to our department she experienced an episode of deep vein thrombosis of the left leg, successfully treated with subcutaneous enoxaparin sodium (40 mg daily) that was continued for the following 6 months as secondary prophylaxis. Pustular skin changes on palmar surface of the hands and plantar surface of the feet (characteristic for palmo-plantar pustulosis), tenderness of sterno-clavicular joints, swelling and restricted motion of both wrists, and pain on motion in both elbows, shoulders, knees, and ankles were found on physical examination. There was also a moderate amount of effusion in her left knee. There was a 3-centimeter difference between the circumferences of the shins. The level of C reactive protein was increased (6.21 mg/L). The patient was positive for antiβ2glicoprotein-1 (anti-β2G-1) antibodies. Tests for anticardiolipin antibodies (aCL), antiannexin V antibodies, antiphosphatidylserine antibodies (aPS), and antiprothrombin antibodies (aPT) were negative. Prothrombin time, activated partial thromboplastin time, and D-dimer level were normal, and lupus anticoagulant was not present. Serum concentrations of protein C, protein S, factor V Leiden, and antiprothrombin III levels were normal. Tests for antinuclear antibodies, rheumatoid factor, and HLA-27 antigen were negative. Serum vascular endothelial growth factor (VEGF) level was 360 pg/mL, serum epidermal growth factor (EGF) level was 566 pg/mL. Bacteria culture of discharge from pustules was negative. Doppler ultrasound examination of the left leg confirmed thrombosis of one the posterior tibial veins at its lower third. Subcutaneous enoxaparin sodium was started and later replaced with acenocumarol. The dose of sulfasalazin was increased to 3.0 g daily, and azithromycin 1.0 g daily once a week (for 8 weeks) was added. After 3 months, the patient reported reduction of joint pain. The follow-up Doppler ultrasound examination of the left leg revealed resolution of thrombosis. Three months later, the anti-β2G-1 antibodies were positive, so the patient met the criteria of antiphospholipid syndrome (1). The treatment with acenocumarol was continued and hydroxychlorochine was started. Venous thrombosis complicating SAPHO syndrome seems to be uncommon with an unclear pathogenesis. There were reports of thrombosis of the following veins: subclavian, mediastinan, iliac, and the superior vena cava (3-8). We have diagnosed recurrent tibial vein thrombosis in a patient with SAPHO syndrome in the course of antiphospholipid syndrome. There were suggestions that the reason for some cases of vein thrombosis in SAPHO syndrome is a pressure of the hyperostotic skeleton or inflamed soft tissue on the vein walls (3,4,6,10), which was not the case in our patient. Legoupil et al. (6) suggested that the reason for iliac vein thrombosis in SAPHO syndrome was an impressive extension of the inflammatory process to the soft tissues within the lumbar spine. That patient was negative for aCL antibodies (6). Kawabata et al. (7) suspected that aCL antibodies could be the reason for thrombosis in this syndrome, but the patient with multiple venous thrombosis presented in his case report was negative for aCL antibodies; however, he was not tested for anti-β2G-1 antibodies. There was a paper demonstrating increased level of aCL antibodies in 5 of 12 patients with SAPHO syndrome (11). In our observations of 17 patients with SAPHO syndrome, only 1 had increased level of aCL antibodies without symptoms of thrombosis (12). That patient was negative for aCL antibodies, aPT antibodies, aPS antibodies, and antiphosphatidylserine antibodies, but she was positive twice for anti-β2G-1 antibodies. The presence of anti-β2G-1antibodies may be caused by an infectious agent, but in our case bacteria culture of the discharge from pustules was negative. One year after the first episode of deep vein thrombosis, our patient met the criteria of antiphospholipid syndrome. We conclude that antiphospholipid syndrome, especially the presence of anti-β2G-1 antibodies, could be the cause of increased risk of vein thrombosis in SAPHO syndrome.

Serum Interleukin-18, Fetuin-A, Soluble Intercellular Adhesion Molecule-1, and Endothelin-1 in Ankylosing Spondylitis, Psoriatic Arthritis, and SAPHO Syndrome

To examine serum interleukin 18 (IL-18), fetuin-A, soluble intercellular adhesion molecule-1 (sICAM-1), and endothelin-1 (ET-1) levels in ankylosing spondylitis (AS), psoriatic arthritis (PsA), and Synovitis Acne Pustulosis Hyperostosis Osteitis syndrome (SAPHO). We studied 81 AS, 76 PsA, and 34 SAPHO patients. We measured serum IL-18, fetuin-A, sICAM-1, ET-1, IL-6, IL-23, vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF). IL-18 levels were higher in AS (p = 0.001), PsA (p = 0.0003), and SAPHO (p = 0.01) than in controls, and were positively correlated with CRP (p = 0.03), VEGF (p = 0.03), and total cholesterol (TC, p = 0.006) in AS and with IL-6 (p = 0.03) in PsA. Serum fetuin-A levels were lower in AS (p = 0.001) and PsA (p = 0.001) than in controls, and negatively correlated with C-reactive protein (CRP) in AS (p = 0.04) and SAPHO (p = 0.03). sICAM-1 positively correlated with CRP (p = 0.01), erythrocyte sedimentation rate (ESR, p = 0.01), and IL-6 (p = 0.008) in AS, and with IL-6 (p = 0.001) in SAPHO. Serum ET-1 levels were lower in AS (p = 0.0005) than in controls. ET-1 positively correlated with ESR (p = 0.04) and Disease Activity Score 28 (DAS28, p = 0.003) in PsA. In spondyloarthritis, markers of endothelial function correlated with disease activity and TC.

SAPHO syndrome in the differential diagnosis of metastasis

SAPHO syndrome was proposed in the late 80s in order to group different osteoarticular manifestations with specific radiological findings such as the hyperostosis of the front part of the chest wall. Prevalence, etiology and pathogenesis of the disease are unknown, while diagnosis is made both clinically and by the specific gammagraphic image of «bull horn» in the sternoclavicular joint. The following case of a 64-year-old woman diagnosed with infiltrating ductal carcinoma of the right breast pT1N0Mx is reported. When studying the extent of the disease, a gammagraphic image of diffuse blast injury in the sterna manubrium was evidenced, which allowed the suspicion of Paget's disease or metastatic injury. Study was completed with a chest CT in which manubrium sclerosis was evidenced, suggesting metástasis. Res ults of the studies pointed out SAPHO syndrome as the most likely diagnostic option. The low tumor stage of the patient prompted the idea of possible alternative diagnoses. A deeper knowledge of this clinical condition may be crucial to avoid mistakes when classifying a subject in more advanced tumor stages, and consequently, to prevent the use of more aggressive chemotherapy and radiotherapy treatments.

Current knowledge and future prospects for SAPHO syndrome

SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome is a complex disorder characterized by osteoarticular and cutaneous symptoms. Most patients experience bone pain and dermatologic manifestations. Diagnosis of SAPHO syndrome is based on exclusion of infectious arthritis and septic osteomyelitis with findings of hyperostosis or chronic recurrent multifocal osteomyelitis involving axial or peripheral skeleton, with or without skin manifestations. The pathophysiology of SAPHO is unclear, although several hypotheses exist. Some of these hypotheses have led to the ever growing treatment options of medications. Broad varieties of medications have been used, such as nonsteroidal anti-inflammatory drugs and disease-modifying agents. New therapeutic options, such as tumor necrosis factor inhibitors have evolved and have shown promising results.

SAPHO syndrome in an adolescent: a clinical case with unusual severe systemic impact

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome includes both dermatological and rheumatologic symptoms. Being a rare condition, the diagnosis is frequently late. The authors report a case of a 13-year-old boy diagnosed with synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome with unusual severe systemic repercussions. The patient presented with acne conglobata, inability to walk due to pain and weakness and weight loss. Bone scintigraphy was suggestive of sacroiliitis, and lumbar spine x-ray showed signs of hyperostosis. His clinical state improved after treatment with nonsteroidal anti-inflammatory drugs, methotrexate, clindamycin, and isotretinoin. A review of the clinical aspects of this syndrome is presented, emphasizing how this underdiagnosed syndrome can lead to severe weight loss and significant functional and psychological impairment at an early age.

Recurrent unilateral headache associated with SAPHO syndrome

A 57-year-old woman was admitted with recurrent episodes of right frontal headache. Head magnetic resonance imaging (MRI) revealed extensive thickening and enhancement of the right frontal dura, muscle and fascia, as well as abnormal signal intensity and enhancement of bone marrow at the lesions. Synovitis-acne-pustulosis-hyperostosis osteomyelitis (SAPHO) syndrome was diagnosed based on the patient's 8-year history of treatment of palmoplantar pustulosis and abnormal accumulations in the right temporal, sternum, and left medial clavicula on bone scintigraphy. SAPHO syndrome may be associated with skull lesions, which can contribute to the onset of repeated headache or dural thickening, thus these symptoms should be recognized as manifestations of this syndrome.

[A woman with pain, stiffness and skin abnormalities]

A young woman was diagnosed with SAPHO syndrome. She presented with retrosternal pain and lumbar stiffness in combination with hidradenitis. DXA scan indicated secondary osteoporosis of the lumbar spine caused by chronic inflammation. Bone scintigraphy showed increased sternal uptake. Treatment with immunosuppressive agents was started after which the stiffness improved.

Clinical features of the SAPHO syndrome and their role in choosing the therapeutic approach: report of four patients and review of the literature

Although the SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome was defined as a distinct entity more than 20 years ago, its classification within the spectrum of inflammatory rheumatic diseases and the proper therapeutic approach are still a matter of debate. We present four patients diagnosed with the SAPHO syndrome treated and followed-up in our Department, demonstrating the diversity of their clinical courses and their responses to different therapeutic approaches. We also review the clinical, laboratory, and imaging features of the SAPHO syndrome described in the relevant literature. Despite the growing quantity of published data on the clinical features of the syndrome and the recognition of two disease patterns (inflammatory and bone remodeling disease), it is still not clear whether these possible disease subsets require different therapeutic strategies. Tumor necrosis factor-alpha (TNF-α) inhibitors have been suggested to be effective in patients with the inflammatory pattern, whereas bisphosphonates seem to be effective in patients with bone remodeling disease; however, this is still a hypothesis not yet confirmed by adequately designed clinical studies. Further research is needed to assess disease features predicting favorable response to the two therapeutic modalities beyond the first line of therapy - TNF-α inhibitors and bisphosphonates.

[Uncommon acne-associated syndromes and their significance in understanding the pathogenesis of acne]

Acne is an intriguing model for the study of interactions between hormones, innate immunity, inflammation and wound healing (scarring). The manifestations and involvement of acne in different systemic diseases and some rare syndromes demonstrate its multifaceted nature. Synovitis-Acne-Pustulosis-Hyperostosis-Osteitis (SAPHO) and Pyogenic Arthritis-Pyoderma gangrenosum-Acne (PAPA) syndromes, both regarded as autoinflammatory diseases, highlight the attributes of inflammation in acne. While SAPHO syndrome can be used to explore the pathogenic role of Propionibacterium acnes in acne, PAPA syndrome and Apert syndrome can help understand the genetic influence on acne. The genetic defects in the gain-of-function of FGFR2 mutations in Apert syndrome and acne nevus of Munro lend further support to the hypothesis that the interaction of forkhead box class O (FoxOs)-mediated transcriptional regulation with androgen receptor transactivation and insulin/insulin like growth factor-1(IGF-1)-signaling is crucial in acne pathogenesis. Novel biologics, such as tumor necrosis factor (TNF) blockers and IL-1 inhibitors, appear promising in opposing the inflammation associated with SAPHO and PAPA syndromes, but it remains to seen if they can also improve severe acne particularly in the long term.

Acute venous thrombosis as complication and clue to diagnose a SAPHO syndrome case. A case report

This report concerns a male adult admitted for sternal and left arm pain, who was diagnosed and treated for acute deep venous thrombosis in the left subclavian and axillary veins. X-ray and a hybrid single photon emission tomography and computed tomography (SPECT-CT) scintigraphy scan revealed high intensity uptake in both sternoclavicular joints, which corresponded to hyperostosis, thereby suggesting a SAPHO syndrome. Upon reviewing the patient's medical history, we found dermatological pustulosis disease and an intermittent sternal chest pain untreated since 10 years ago. In the biochemical study we found erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) elevation, hyperglobulinemia, and mild anaemia. Initial treatment included nonsteroidal anti-inflammatory drugs (NSAIDs) with low response, which then changed to methotrexate, sulfasalazine, and prednisone. The patient's pain was controlled almost completely in 10 months. A control bone scan revealed a marked decrease in intensity of bone deposits according to clinical response. To our knowledge, there are only a few cases of SAPHO and thrombosis and none are followed up with a bone SPECT-CT scan.

Reactive arthritis: developments and challenges in diagnosis and treatment

Reactive arthritis (ReA) has traditionally been described as a nonseptic arthritis occurring in the joint following an extra-articular bacterial infection. This concept became clinically associated with antecedent infections of either the gastrointestinal or genitourinary tract. Yet this operational definition of ReA has led to diagnostic uncertainty in different clinical settings. There are several scenarios in which the ReA has been complex. One is in the SAPHO syndrome, which shares many features with ReA. Another is the development of arthritis after infection with atypical organisms such as Clostridium difficile and Giardia lamblia. Treatment of ReA remains an area of ongoing investigation. There has been a randomized controlled trial of combination antibiotics in Chlamydia-induced ReA, which reported a positive result. There are several uncontrolled reports of anti-TNF agents being used successfully in refractory ReA. These studies in treatment modalities require validation on larger samples but do provide some encouraging preliminary findings from which to develop new therapeutic approaches.

Biologics for rare inflammatory diseases: TNF blockade in the SA PHO syndrome

INTRODUCTION

SAPHO is an invalidating syndrome characterised by Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis. The low prevalence and heterogeneous presentation often leads to a significant diagnostic delay. Here, we provide an up-to-date overview of current insights into the pathogenesis and different treatment options. In addition, we describe the effects of anti-TNF treatment in three refractory cases.

CASE REPORTS

Patient A is a 25-year-old female with hidradenitis suppurativa, inflammatory back pain and painful joints. After diagnosis, anti-TNF treatment was started resulting in clinical improvement. Patient B is a 44-year-old woman who presented with acne, palmoplantar pustulosis and anterior chest wall pain. Bone scintigraphy showed increased uptake at the anterior chest wall. Treatment with bisphosphonates resulted in temporary improvement and subsequent treatment with anti-TNF induced long-term clinical improvement. Patient C is a 37-year-old woman with palmoplantar psoriasis, relapsing hidradenitis and inflammatory back pain. MRI revealed osteitis of the pubic bone. Anti-TNF was started for SAPHO syndrome. However, despite a clinical response, our patient discontinued treatment, resulting in rapid deterioration. Anti-TNF treatment was re-introduced followed by clinical improvement.

CONCLUSION

These case reports illustrate, consistent with the current literature, that TNF blockers can be considered for treatment of refractory SAPHO syndrome.

Entheseal ultrasound abnormalities in patients with SAPHO syndrome

This study was conducted to investigate the presence and characteristics of the ultrasound lesions that may be found in the entheses of patients with SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome. This cross-sectional study included 15 patients with SAPHO syndrome and 30 healthy controls matched for age, sex and body mass index. Subjects with regular sport activities as well as those with other rheumatic conditions were excluded from the study. Ultrasonography was used in both groups to study 14 entheses of the upper and lower extremities. Different elementary lesions representative of enthesis damage were defined. A total of 210 entheses in the study group and 420 in the control group were evaluated. Only one patient presented clinical enthesitis. In the study group, seven of the 15 patients (47%) showed morpho-structural entheseal alterations, versus only four of the 30 controls (13.3%; p < 0.001). The subjects with SAPHO showed ultrasound alterations in 32/210 entheses (15%), while the controls showed alterations in 20/420 entheses (4.8%), p < 0.001. The entheses with the largest number of morpho-structural alterations were those of the patellar and Achilles tendon. None of the controls showed power Doppler signal at enthesis or perienthesis level. Ultrasound evidence of enthesopathy seems to be a common feature in this series of patients with SAPHO syndrome.

SAPHO syndrome--a pictorial assay

SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome is a distinct clinical entity representing involvement of the musculoskeletal and dermatologic systems. It is well known to rheumatologists because of characteristic skin manifestations and polyarthropathy. However, few reports exist in the orthopaedic literature. It is important to be aware of sAPHO syndrome as it can mimic some of the more common disease entities such as infection, tumor, and other inflammatory arthropathies. Anterior chest wall pain centered at sternoclavicular and sternocostal joints is an important and characteristic clinical finding which can point to its diagnosis. A patient may undergo different diagnostic tests and invasive procedures such as biopsies before a diagnosis is made. Imaging can be helpful by offering a detailed evaluation of the abnormalities. More importantly it helps in revealing subclinical foci of involvement due to the polyostotic nature of the disease. The treatment is mostly nonsurgical. NSAIDS are the first line agents. However multiple new agents are being used for refractory cases. Surgery is reserved to treat complications.

SAPHO: What radiologists should know

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) is an umbrella acronym for inflammatory clinical conditions whose common denominator is aseptic osteoarticular involvement with characteristic skin lesions. It involves all ages, can involve any skeletal site, and has variable imaging appearances depending on the stage/age of the lesion and imaging method. It mimics important differentials including infection and neoplasia. Awareness of the imaging features, especially in the spine, facilitates early diagnosis, prevents repeated biopsies, and avoids unnecessary surgery, while initiating appropriate treatment.

SAPHO syndrome associated with hidradenitis suppurativa successfully treated with infliximab and methotrexate

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a rare chronic inflammatory musculoskeletal disorder of unknown etiology observed in children and young adults, which involves both osteo-articular inflammation and skin abnormalities. We review the case of a 22-year-old male, who presented with a 5-year history of hidradenitis suppurativa (HS), acne vulgaris, joint stiffness, and pain. Previous ineffective treatments included isotretinoin and oral antibiotics. Marked improvement of all cutaneous features was noticed after the first dose of infliximab and methotrexate; continued treatment resulted in the complete remission of the arthritis and enthesopathy. This case report demonstrates the efficacy and safety of infliximab and methotrexate in refractory SAPHO syndrome.

[Case of SAPHO syndrome with significant sternocostoclavicular hyperostosis]

A 59-year-old man with hypertension developed general fatigue, fever, and precordialgia in early March 2007. An antibacterial agent was intravenously administered; however, no improvement in his symptoms or laboratory findings was observed. He had acne and pustulosis, and radiographs and CT of the chest revealed sternocostoclavicular hyperostosis. As a result, the diagnosis was revised to SAPHO syndrome, and he improved with steroid administration. SAPHO syndrome is a condition that is rarely found at the initial examination in the Department of Internal Medicine. We report a case with a discussion of the literature.

[Modern specificity of surgical infection of bones and joints in children]

A comparative study of frequency, structure and specific features of the clinical course was fulfilled in 2456 children with surgical infection of bones and joints (SIBJ) in the period from 1970 to 1985 and 1986 to 2006. The work used clinical, instrumental, radiation, laboratory, microbiological, immunological and statistical methods of investigations. Specific features of SIBJ in children at the present time are: 1) pathomorphosis of hematogenic osteomyelitis; 2) the appearance of previously not noted new forms of SIBJ--fetal osteomyelitis and arthritis, chronic recurring multifocal osteomyelitis, syndrome SAPHO and increasing frequency of previously rare BCG-osteomyelitis, exogenous osteomyelitis, sacroiliitis and inervertebral disciitis; 3) widening the spectrum of SIBJ pathogens with an increasing significance of involutionary forms of bacteria, elevation of their resistence to antibiotics and antiseptics, increase of the factors promoting the development of immunodeficient states in childhood.

Pancreatic hamartoma and SAPHO syndrome: a case report

We report the first case of an association of pancreatic hamartoma with SAPHO syndrome mimicking disseminated bone metastases. A 46 year old male with intermittent back pain for 10 years, relieved by NSAIDs and desquamation erythemathous palmo-plantar eruption one year before, presented with symptoms of duodenal stenosis, a cystic tumor at the head of the pancreas and osteoformative (hyperostosis) and osteodestructive (osteitis) lesions of the clavicle, mandible, lumbar spine. The bone lesions resembled bone metastases, but an inflammatory infiltrate and fibrosis were found on the excisional biopsy of left clavicle, compatible with the SAPHO syndrome. The pancreatic tumor grew rapidly and showed a histological aspect of malignancy at laparoscopy. A cephalic duodenopancreatectomy was performed, but the histological findings established the diagnosis of pancreatic hamartoma. Several months later, the bone Tc99m scintigraphy was normal.

[One case report of SAPHO syndrome and literature review]

To study the clinical features and diagnosis of synovitis, acne, pustulosis, hyperostosis, osteitis syndrome (SAPHO) syndrome. One case of SAPHO syndrome was reported and the related data of SAPHO syndrome were reviewed. The main clinical features of the patient were articulatio carpi synovitis, acne, cervical rib hyperostosis, articulatio sternoclavicularis and osteitis, So the diagnosis of SAPHO syndrome was made. Though SAPHO syndrome is rare with yet unknown prevalence, it still can be seen in clinical practice, and can be diagnosed by careful examination.

SAPHO syndrome: misdiagnosed and operated

SAPHO is a rare disorder that results in synovitis, acne, pustulosis, hyperostosis and osteitis. Patients with this syndrome typically present with musculoskeletal complaints, frequently localized to the anterior chest wall. However, diagnosis can be difficult in case of involvement of only one symptomatic bone without skin lesions. Awareness of SAPHO syndrome is necessary for accurate diagnosis and to prevent inappropriate and unnecessary treatment.

Two cases of synovitis, acne, pustulosis, osteitis--SAPHO syndrome

Synovitis, acne, pustulosis, osteitis (SAPHO) syndrome is rare with yet unknown prevalence. The difficulty in recognizing the syndrome is due to the very wide diversity of its signs and symptoms, the lack of skin manifestations in many cases and to confusion in medical terminology in describing this syndrome. In this paper, we present two cases with characteristic bone lesions in bone scan and in radiology images that are considered to be SAPHO syndrome. In the first case the characteristic bone single photon emission tomography scan findings in a patient with spine involvement supposed by bone biopsy but were not followed by characteristic skin manifestations. The point of interest of this case lies on the significant improvement of both symptoms and scintigraphic findings after treatment with biphosphonates. In the second case the diagnosis was also based on the characteristic bone scan findings, although the patient referred to us for staging of prostate cancer. Detailed history and clinical examination revealed skin manifestations of the syndrome.

[Back pain and acne conglobata: SAPHO syndrome]

We report on a young woman suffering from SAPHO syndrome with back pain and arthritis of the sternoclavicular joints. This inflammatory disorder of the osteoarticular system (synovitis, osteitis, and hyperostosis) is associated with severe acne or palmoplantar pustulosis. The patient was treated with pamidronate, NSAID and physiotherapy which improved the musculoskeletal symptoms completely. The acne was treated with isotretinoin.

[SAPHO syndrome--clinical features]

OBJECTIVE

Presentation of clinical features of the SAPHO syndrome.

MATERIALS AND METHODS

Seventeen patients (15 women and 2 men) with confirmed diagnosis of the SAPHO syndrome was presented. The culture of biopsy of pustulotic skin lesions was performed in 11 patients. ESR, C-reactive protein level and Waaler-Rose test were determined in all patients, and antinuclear antibodies and bone scintigraphy were performed in 16 patients. X-ray of the sterno-clavicular joints was performed in 15 patients.

RESULTS

The age of patients was 22-59 yr. (mean: 47.1 yr). The duration of joint symptoms was 0.1-25 yr. (mean: 4.4 years). Pustulosis was presented in 16 patients, only 1 patient had acne. All patients suffered from pain localized on the anterior chest wall. Tenderness of the peripheral joints: wrist (in 7 patients), shoulder (in 7 patients), knee (in 4 patients) was shown. In 6 patients, skin changes preceded joint symptoms, in 2 patients skin changes followed joint symptoms after 5 and 10 yr., respectively. All patients had negative the Waaler-Rose test. Active inflammatory process characterized by an increased ESR and C-reactive protein level was present in 12 patients. Abnormalities in x-ray of the sterno-clavicular joints were present in 4 patients. Characteristic alternations for the SAPHO syndrome in scintigraphic picture of the skeleton were observed in 14 patients. All patients were treated with non-steroidal anti-inflammatory drugs. In 8 patients, treatment with antibiotics, in 11 patients--with sulfasalazine, in 3 patients--with methotrexate and low doses of glucocorticosteroids, in 1 patient--with colchicines was performed.

CONCLUSIONS

Association of typical skin changes with pain of the anterior chest wall is the key for diagnosis of the SAPHO syndrome. It seems that this syndrome is more common in Poland than it has been previously estimated.

[A pregnant woman with a SAPHO syndrome]

The association SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis) and pregnancy is very rare. Only one case is indexed in the literature. We report the case of a pregnancy in a 27-year-old patient with a SAPHO syndrome and we expose its history and its obstetrical, medical and anaesthetic following. Under this multi-field following, there was no evolutionary push of the disease neither during the pregnancy, nor in immediate postpartum. We will expose the different possible treatments during the pregnancy.

Síndrome SAPHO

We report two cases, one 23 and one 27 year old man, with several years background of sternal and sternoclavicular joints pain, respectively. The laboratory tests were normal. Based on the clinical, radiologic and scintigraphic findings, SAPHO syndrome was diagnosed. Bone scintigraphy makes it possible to obtain a whole body scan in a single whole body scan, and can be used for differential diagnosis of other osteoarticular diseases and for evolutive control and therapeutic response.

Is SAPHO syndrome a target for antibiotic therapy?

The etiology of the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome remains unclear. Infectious factors are proposed to be relevant in the etiopathogenesis of the disease. To our knowledge, this is the first reported case of a proposed relationship between Staphylococcus aureus cultured from plantar pustule and SAPHO syndrome, which was successfully treated with co-trimoxazole (CTM) (sulfamethoxazole/trimetoprim). CTM might be the drug of choice for therapy for SAPHO syndrome because of combined antibiotic and immunomodulatory properties. Hypersensitivity testing of the medication in vitro was performed to identify, in the preclinical stage, the hypersensitivity reaction to CTM, which may have been severe.

[SAPHO syndrome--clinical report]

SAPHO Syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis) was first described in the 80s by Chamot and Kahn. This disease affects both skin and bones, mainly in the costal area and anterior chest wall (Skin-Bone Disease). Clinical symptoms vary according to the age of onset and response to the treatment is uncertain. This is considered a rare disease, although its real prevalence is not known. SAPHO syndrome may occur in any age and both sexes are equally affected. In this article, we present a case of SAPHO Syndrome and review the most relevant aspects of the literature.

Diagnosis and classification of mandibular osteomyelitis

To establish a unified classification system for mandibular osteomyelitis, various diagnostic terms were critically assessed and clinicopathologic findings of the lesions were carefully reviewed. We recommend classifying mandibular osteomyelitis into bacterial osteomyelitis and osteomyelitis associated with the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Other diagnostic terms were excluded because they were not appropriate for classification. Diagnostic criteria for bacterial osteomyelitis are suppuration and osteolytic change. The lesions are easily cured by antibiotic treatments. Mandibular osteomyelitis in SAPHO syndrome is characterized by nonsuppuration and a mixed pattern on radiography, with solid type periosteal reaction, external bone resorption, and bone enlargement. The presence of osteomyelitis in other bones, arthritis, or skin diseases (palmoplantar pustulosis, pustular psoriasis, and acne) strongly suggests this syndrome. Antibiotic therapy is usually ineffective and the symptoms of SAPHO syndrome are often persistent.

[Arthritis and papulo-pustular skin changes]

Das SAPHO-Syndrom (Synovitis, Akne, Pustulosis, Hyperostosis, Osteitis) beinhaltet eine Kombination aus pustulösen Hautveränderungen und Osteoartikulären Manifestationen, insbesondere Osteitis, Synovitis und Hyperostosen. Prädilektionsstellen sind die vordere Brustwand, insbesondere die sternoklavikulare Region. Die betroffenen Gelenke sind geschwollen und schmerzhaft, üblicherweise kann kein Erreger nachgewiesen werden. Hilfreich bei der Diagnostik kann die Knochenszintigraphie sein, die auch klinisch stummen Gelenkbefall speziell an Prädilektionsstellen nachweisen kann. Ätiologie und Pathogenese der Erkrankung sind unklar, die Therapie besteht primär aus nichtsteroidalen Antirheumatika.

SAPHO syndrome with a tumour-like bony proliferative lesion in distal femur. A case report

SAPHO syndrome is a group of bone and joint abnormalities associated with skin lesions. A 29-year-old male presented with severe acne on his trunk and anterior chest wall, right knee and foot pain. Radiographs and magnetic resonance images showed hyperostosis in the sternocostoclavicular region, sclerosis of one-third of the right distal 5th metatarsal bone and bony outgrowth from the medial condyle of the right femur. The histological findings of the biopsy specimen were consistent with-those of old osteomyelitis. All fungal and microbacterial cultures were negative. Pain and swelling of the right knee and foot repeated remission and aggravation. There were no radiological changes of the above-mentioned lesions noted within 4-years follow-up.

Pulmonary adenocarcinoma associated with SAPHO syndrome difficult to differentiate from multiple bone metastasis

The patient was a 57-year-old man with a chief complaint of anterior chest pain who was diagnosed with clinical stage IV (c-T2N2M1) non-small-cell lung cancer (adenocarcinoma). Tenderness in the sternoclavicular joint, acne, periodontitis, and palmoplantar pustulosis were evident, and SAPHO syndrome was diagnosed. SAPHO syndrome is a rare disorder that results in synovitis, acne, pustulosis, hyperostosis, and osteomyelitis. Bone scintigraphy showed tracer accumulation in the costal cartilage, sternoclavicular joint, and cervical vertebrae 6-7. Although the bone lesions of SAPHO syndrome were difficult to differentiate from bone metastasis of pulmonary adenocarcinoma, metastatic bone tumors were ruled out by magnetic resonance imaging, computed tomography, and fluorodeoxyglucose positron emission tomography. There have been no previously reported cases of lung cancer with comorbid SAPHO syndrome. We report such a case and discuss the relevant literature, particularly that concerned with the evaluation of bone lesions.

SAPHO syndrome masquerading as metastatic bone disease

A 46-year-old woman who had had a right mastectomy for breast carcinoma a month before underwent bone scintigraphy. The examination revealed multiple pelvic, vertebral and sternal hot spots suggestive of bone metastases. Standard X-rays and CT confirmed the presence of bony lesions but they were not typical of bone metastases. As the radiographic appearance was reminiscent of SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), bone biopsies were performed. Histology showed fibrosis and hyperostosis but no tumour cells. On further questioning, the patient revealed she had had palmar pustulosis and sacroiliitis some years earlier. The purpose of the case report is to show that accurate diagnosis of SAPHO syndrome requires careful clinical and radiological examinations.