[Chronic recurrent multifocal osteomyelitis in children]

We have studied retrospectively a series of 10 children presenting with chronic multifocal osteomyelitis (8 girls, 2 boys, 7 to 16 years). All patients had plain films, bone scintigraphies and histological studies. Three had CT scan and/or MRI. compared with literature data, we observed only one case of palmoplantar pustulosis and only 2 cases of lysis of the medial extremity of the clavicle; in addition, we report one case of lateral extremity of the clavicle and 2 vertebral locations. The radiological pattern was typical: at the beginning of the disease, plain films showed lytic areas which became progressively osteosclerotic with enlargement of the bone. In all the cases, bone scintigraphy revealed high uptake areas which were often infraclinical. The diagnosis was delayed from 3 months to 3 years. This emphasizes the difficulty of the diagnosis which relies on the association of clinical, biological and radiological elements. Biopsies are required to rule out an infectious bacterial osteomyelitis or a tumoral process. The pathogenesis of OCMR remains unknown, but the relation with the SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome is general accepted because of the similar features of the osteitis. The long term follow up appears to be uncertain 6 of our patients are still symptomatic after five years despite anti inflammatory treatment.

Peripheral neuropathy with necrotizing vasculitis in rheumatoid arthritis. A clinicopathologic and prognostic study of thirty-two patients

OBJECTIVE

To examine the clinicopathologic features of the noncompressive neuropathies in rheumatoid arthritis (RA).

METHODS

We studied 32 patients with RA and peripheral neuropathy whose nerve and/or muscle biopsy specimens exhibited necrotizing vasculitis. Morphologic analysis of nerve specimens included light and electron microscopy studies and teased fiber preparation. Survival was evaluated, and the prognostic values of clinical, biologic, and pathologic features were assessed by Cox proportional hazards model. A prognostic assessment based on the significant variables was devised to estimate the probability of survival of any individual patient.

RESULTS

Epi- and/or perineurial vasculitis was observed with the same frequency in the 17 patients with sensory and motor deficit and the 15 patients with sensory neuropathies and was associated with axonal degeneration of an average of 77.7% of the nerve fibers. The mean followup was 7.2 years, and the overall survival rate at 5 years was 57%. A full prolonged remission of the vasculitis was observed in 53% of the patients; relapse occurred in 25%. The factors correlated with mortality, in decreasing order of significance, were clinical cutaneous vasculitis (P = 0.0003), neuropathy affecting 3 or 4 limbs (P = 0.03), and depressed level of C4 (P < 0.05). The prognostic assessment indicated a wide range of 5-year probabilities of survival, from < 1% to 93%.

CONCLUSION

Necrotizing vasculitis is responsible for the different patterns of noncompressive neuropathies in RA, including mononeuritis multiplex and distal symmetric sensory or sensorimotor neuropathy. Cutaneous vasculitis, multifocal neuropathy, and depressed C4 level were the 3 independent variables which best predicted mortality. We propose a prognostic assessment according to these variables, to stratify patients to receive more aggressive or less aggressive therapy.

Monostotic Paget's disease involving the calcaneus. Diagnostic and therapeutic problems. Two case-reports

The authors report the cases of two patients who had chronic incapacitating heel pain unresponsive to standard therapy. They were both found to have Paget's disease of the calcaneus. The diagnosis was difficult because the typical roentgenological changes required time to develop and because no other sites were involved. Local corticosteroid injections, elimination of weight-bearing, and standard analgesic therapy were ineffective. Bisphosphonate therapy (pamidronate) given as intravenous infusions ensured prompt lasting pain relief, making ambulation possible.

[Spondylarthropathies in children]

The term juvenile spondylarthropathy is used for all the inflammatory articular diseases beginning before the age of 16 years and associating peripheral arthritis, enthesiopathy and sometimes spinal involvement, cutaneous or enteric manifestations. The disease occurs more often in boys (85% of cases) between the age of 10 and 12 years. A family history is found in a third of the cases and there is a close linkage to HLA B27 (85% of cases). Asymmetrical arthritis is mainly located on the lower limbs; spinal involvement (lumbar, dorsal spine or sacro-iliac joint) is rare at onset and may occur later. Enthesiopathies involve the calcaneus and the anterior tibial tuberosity. The diagnosis is easy with the usual set of criteria. Functional prognosis is usually good, except in severe cases with destructive hip involvement. Treatment is based on non steroidal anti-inflammatory drugs and/or local injections; long-term treatments (such as salazosulfapy-ridine) are sometimes useful in uncontrolled cases.

[The risk/benefit ratio of low-dose cyclosporin in the treatment of severe rheumatoid arthritis]

Although the efficacy of cyclosporine therapy in rheumatoid arthritis has been established, there have been no long term studies of the risk/benefit ratio of cyclosporine A in severe rheumatoid arthritis. A prospective, open-label one-year study included 106 patients (83 women and 23 men; mean age 53 years; mean disease duration, 11 years) with rheumatoid arthritis. Mean number of previous second-line treatments was four and 69% of patients had failed methotrexate therapy. The initial dosage of cyclosporine was 3 mg/kg/d and was increased if needed up to 5 mg/kg/d. The dosage was reduced in the event of serum creatinine elevation (by more than 30% versus baseline) or diastolic blood pressure elevation (above 95 mmHg). The statistical analysis was performed on an intention-to-treat basis. In the 45 patients who completed the one-year study period, the mean dosage was 3.6 +/- 1 mg after six months and 3.3 +/- 1 mg/kg/d after one year. Significant improvements were seen in all the clinical efficacy parameters. The mean reduction in corticosteroid dosage was 0.5 mg/d. The study drug was discontinued prematurely in 61 patients (36 because of adverse events and 21 because of inefficacy). Twelve of the 56 patients with serum creatinine level elevation on at least one occasion and seven of the 35 patients with diastolic blood pressure elevation were taken off the study drug.

[Treatment of juvenile spondyloarthropathies with sulfasalazine]

The efficacy and safety of sulfasalazine for the treatment of juvenile spondyloarthropathy were evaluated in an open study. Twenty-three patients (17 boys and 6 girls) with juvenile spondyloarthropathy inadequately controlled by nonsteroidal antiinflammatory therapy were given sulfasalazine in an average dosage of 39 mg/kg/d. After 3 months, 20 patients exhibited marked clinical improvement; of these 20, 14 discontinued or reduced their nonsteroidal antiinflammatory drug. Mean erythrocyte sedimentation rate fell significantly from 36.8 to 13.7 mm/h. After 12 months. 78% of the patients were in remission. Sulfasalazine was stopped in five patients of which none had evidence of disease relapse 6 to 12 months later. Side effects were infrequent: 2 patients had a skin rash requiring drug withdrawal and two developed mild neutropenia. These data suggest that sulfasalazine is an effective and safe second-line drug for the management of severe juvenile spondyloarthropathies.

Does hypothyroidism increase the prevalence of chondrocalcinosis?

To investigate whether or not there is an association between hypothyroidism (HPT) and chondrocalcinosis (CC) 100 HPT patients and 100 controls matched for the age and sex were evaluated prospectively. All the patients were examined clinically, and X-rays of knees, wrists and pelvis, and biological evaluation of thyroid hormones, calcium, uric acid, iron and alkaline phosphatase levels were recorded. X-rays were assessed independently by two radiologists blind to the thyroid status of the patient. The prevalence of CC was 17% in the HPT patients and 10% in the controls (NS). No correlation was found between CC duration and mechanism or treatment of HPT. We suggest that HPT and CC are two diseases that may co-exist in patients but without any causal or mechanistic relationship.

Magnetic resonance imaging assessment of sacroiliac joint involvement in Gaucher's disease

A young woman with Gaucher's disease experienced acute pain in her right sacroiliac (SI) joint. Although pelvic radiographs and computed tomographic scan showed no significant change in the right SI joint, magnetic resonance imaging demonstrated an area of high signal intensity in the iliac part of the right SI joint, and a periosseous collection of blood. This skeletal location is rarely reported in Gaucher's disease; the mechanism of bone crisis is still controversial and our case suggests the occurrence of a bone infarct.

[Treatment of Still's disease with bolus methylprednisolone. Retrospective study of 7 patients]

The problems raised by the treatment of Still's disease in the child or adult led the authors to evaluate the short term clinical efficacy of bolus doses of methylprednisolone. Seven patients were given 12 boluses, followed by oral corticosteroids at 5 to 10 mg in 9 cases out of 12. Still's disease was active in all cases. A frank clinical improvement was seen on the fourth day. The response duration was 3 weeks to 20 months, with a mean follow-up period of 7 months. There were 3 early relapses, 5 late relapses between 2 and 20 months and 4 patients are still in remission at 5, 6, 15 and 19 months. There were no immediate adverse reactions. These results suggest the usefulness of boluses of methylprednisolone in exacerbations of Still's disease, avoiding the disadvantages of high dosage daily corticosteroids.

[Camptocormia in the elderly. A new entity by paravertebral muscle involvement?]

"Camptocormism" in the elderly is an acquired kyphosis which increases during walking and is totally reducible in dorsal horizontal position in two thirds of cases. The authors report 16 cases of camptocormism in patients with a mean age of 76 (12 women, 4 men). Camptocormism was accompanied in 5 cases by an extrapyramidal syndrome, in 3 cases by articular chondrocalcinosis, in 1 case by giant cell arteritis and in 1 by rheumatoid arthritis. There was no inflammatory syndrome and muscle enzymes were raised in only 4 cases. Electromyogram of the paravertebral muscles was pathological in 5 cases, with neurogenic changes in 4 cases and a myogenic type tracing in one. CT scan or magnetic resonance imaging showed evidence in all cases of atrophy with fatty involution of the paravertebral muscles. Biopsies of the paravertebral muscles revealed moderate mononuclear cell infiltrates in 4 cases with similar abnormalities in peripheral muscles. Corticosteroids had a beneficial effect in 11 cases out of 13 and the most prolonged results were seen after bolus doses of methylprednisolone. These findings suggest that camptocormism in the elderly could be linked to inadequacy of the paravertebral muscles or, in certain cases, to interstitial myositis.

Chronic hepatitis during rheumatoid arthritis

Chronic hepatitis is infrequently reported in the course of RA (1.9%). We report 6 cases with such an association. The six patients were all female (mean age: 59.5 years) with typical RA (ACR criteria), and sicca syndrome in 5 cases. Chronic hepatitis always developed after the onset of RA (delay: 1 to 47 years). Laboratory findings revealed a mild increase of transaminases. Alkaline phosphatase were increased in 3 cases. Liver insufficiency was present in 4 cases and polyclonal hypergammaglobulinemia in 6 cases. Rheumatoid factors were detected in 5 cases; antinuclear antibodies and anti-smooth muscle antibodies were also detected in 5 cases. Histological examination of liver biopsy disclosed active chronic hepatitis in 5 cases (with cirrhosis in 3 cases) and persistent chronic hepatitis in 1 case. Steroid therapy was administered in 4 cases of active chronic hepatitis with clinical and biological improvement (18 months to 6 years follow-up). One patient died of gastric bleeding.

[Tibial valgization osteotomy in gonarthrosis with or without chondrocalcinosis. Results after 5 years]

The authors compare the results of valgisation tibial osteotomies in osteoarthrosis of the knee (146 cases) and osteoarthrosis of the knee with chondrocalcinosis (94 cases). The two groups were identical in terms of age, but differed by sex ratio (female predominance in CCA) and the initial radiological stage (more advanced forms in the CCA group). Results differed after the second year and reached significantly different values at 5 years (73% in knee osteoarthrosis as against 34% good clinical results in chondrocalcinosis). Study of two groups of patients paired for age, sex, weight and radiological stage showed that results at 5 years were significantly less good in the CCA group. These results are discussed and compared with those in the 1990 literature.

Administration of methylprednisolone pulse in chronic arthritis in children

The authors retrospectively evaluated the results of methylprednisolone pulse in 15 children with chronic arthritis (JRA - 13 cases, spondyloarthropathy - 2 cases). Methylprednisolone succinate was administered at a dosage of 700 mg/m2 by an I.V. infusion pump on 3 consecutive days. A dramatic clinical improvement was obtained in 12/15 cases at day 4. In 7 cases, multiple pulses (between 2 and 8 courses) were administered to obtain better control of the disease and a decrease in the daily dosage of corticosteroids. Only mild and transient side effects were observed; moreover, previous corticosteroid side effects (especially growth retardation) decreased. The duration of clinical benefit was between 2 weeks and 10 months. Disease modifying agents should always be associated with MP pulse therapy to obtain a prolonged response.

Complications of intra-articular injections of triamcinolone hexacetonide in chronic arthritis in children

Intra-articular injections of triamcinolone hexacetonide (THA) are a useful therapy in JRA and HLA B 27 related arthritis (B 27 RA). Published data have indicated good results and few side effects. We evaluate here the frequency of occurrence of local side effects in 35 children with JRA (115 joints treated) and 13 children with B 27 RA (29 joints treated). With a mean follow up of 25 months in JRA and 18 months in B 27 RA, we observed 12 cases (8.3%) of subcutaneous tissue atrophy with local depigmentation (knees 5 cases, wrists 2 cases, ankles 3 cases, metatarsophalangeal joints 2 cases) and 7 cases (4.9%) of intra-articular calcifications all in the JRA group (wrists 3 cases, knees 2 cases, ankles 2 cases). Youth and joint size are possible predisposing factors for subcutaneous tissue atrophy and intra-articular calcification. Spontaneous improvement previously reported for these local side effects was not observed in our study. These results underline the necessity of discussing on a case by case basis whether intra-articular, non long-acting corticosteroid or THA are indicated. THA must be injected with a rigorous technique and with a dosage adapted to the articular volume.

[Sciatica caused by a posterior articular cyst. Apropos of 8 cases]

The authors report 8 cases of sciatica secondary to a posterior articular cyst. They emphasize the clinical manifestations permitting to suspect this etiology of root compression, which, until now, was rather unusual. Computerized axial tomography makes the diagnosis possible along with posterior arthrography. This arthrography represents the first stage of the medical treatment by posterior joint infiltration of a steroid derivative. In 60 p. cent of the cases, a definite and persisting improvement permits to avoid a surgical procedure.