Synovial sarcoma masquerading as juvenile idiopathic arthritis

An early adolescent girl presented with chronic deforming monoarthritis. Initially misdiagnosed with skeletal tuberculosis, she received empirical treatment despite the absence of microbiological evidence. Her symptoms were managed intermittently with non-steroidal anti-inflammatory drugs, but the persistence and progression of her condition over the past 4 months raised suspicions of juvenile idiopathic arthritis. Her clinical presentation deteriorated, with severe knee arthritis and rapid calf swelling, prompting differential diagnosis including necrotising fasciitis or a ruptured Baker's cyst. Imaging confirmed synovitis with localised necrotising myositis, while persistent pain after fascial release and systemic inflammation without signs of infection indicated a more sinister underlying condition. Histopathological analysis of the biopsied tissue revealed synovial sarcoma, with subsequent PET-CT confirming skeletal and pulmonary metastasis. Despite timely diagnosis, the patient ultimately succumbed to her illness.

A Matched-Cohort Analysis of Outcomes in Patients with Hereditary Hemochromatosis After Anterior Cervical Discectomy and Fusion

BACKGROUND

Hereditary hemochromatosis (HH) is a common autosomal recessive disorder. This disease affects gut iron transport, leading to iron overload, which affects immune function, coagulation mechanics, and bone health. Within the spine, HH contributes to decreased bone mineral density and accelerated intervertebral disc degeneration. The purpose of this study was to discover the differences in the rates of common 90-day postoperative complications and 1-year and 2-year surgical outcomes in patients with and without HH after anterior cervical discectomy and fusion (ACDF).

METHODS

Using the PearlDiver database, patients with active diagnoses of HH before ACDF were matched to patients without HH using a 1:5 ratio on the basis of age, sex, body mass index, and comorbidities. Postoperative complications were assessed at 90 days, and 1-year and 2-year surgical outcomes were assessed. All outcomes and complications were analyzed using multivariate logistic regression with significance achieved at P < 0.05.

RESULTS

Patients with HH had significantly higher rates of 1-year and 2-year reoperation rates compared with patients without HH (29.19% vs. 3.94% and 37.1% vs. 5.93%, respectively; P < 0.001). The rates of 90-day postoperative complications significantly increased in patients with HH including dysphagia, pneumonia, cerebrovascular accident, deep vein thrombosis, acute kidney injury, urinary tract infection, hyponatremia, surgical site infection, iatrogenic deformity, emergency department visit, and hospital readmission.

CONCLUSIONS

Patients with HH undergoing ACDF showed increased 90-day postoperative complications and significantly increased rates of 1-year and 2-year reoperation compared with patients without HH. These findings suggest that iron overload may contribute to adverse outcomes in patients with HH undergoing 1-level and 2-level ACDF.

Rehabilitation Strategies for Wrist Pain in a Patient With Thalassemia Major and Distal Ulnar Hypoplasia: A Case Report

This case study examines the rehabilitation process of a 24-year-old female patient with thalassemia major (TM), a hereditary hemoglobinopathy, who also suffered from distal ulnar hypoplasia, a congenital anomaly that causes pain and affects the wrist joint's strength and range of motion. The patient underwent a comprehensive physical rehabilitation program that aimed to address the challenges posed by ulnar hypoplasia. This program included a combination of customized exercises, splinting, and orthotic interventions to improve hand and wrist function. By adopting a multidisciplinary approach, the patient experienced significant improvements in mobility, strength, and overall quality of life. This case highlights the significance of personalized rehabilitation strategies in managing complex medical conditions, demonstrating the potential for positive outcomes even in patients with dual diagnoses of TM and ulnar hypoplasia.

Overview of Ankle Arthropathy in Hereditary Hemochromatosis

Hereditary hemochromatosis (HH) is an autosomal recessive bleeding disorder characterized by tissue overload of iron. Clinical systemic manifestations in HH include liver disease, cardiomyopathy, skin pigmentation, diabetes mellitus, erectile dysfunction, hypothyroidism, and arthropathy. Arthropathy with joint pain is frequently reported at diagnosis and mainly involves the metacarpophalangeal and ankle joints, and more rarely, the hip and knee. Symptoms in ankle joints are in most cases non-specific, and they can range from pain and swelling of the ankle to deformities and joint destruction. Furthermore, the main radiological signs do not differ from those of primary osteoarthritis (OA). Limited data are available in the literature regarding treatment; surgery seems to be the gold standard for ankle arthropathy in HH. Pharmacological treatments used to maintain iron homeostasis can also be undertaken to prevent the arthropathy, but conclusive data are not yet available. This review aimed to assess the ankle arthropathy in the context of HH, including all its aspects: epidemiology, physiopathology, clinical and imaging presentation, and all the treatments available to the current state of knowledge.

A study of patient-reported pain during bone marrow aspiration and biopsy using local anesthesia alone compared with local anesthesia with intravenous midazolam coadministration at a tertiary academic hospital in South Africa

Introduction

During the bone marrow aspiration and biopsy (BMAB) procedure, patients report pain of widely variable intensity. There is limited literature on the factors associated with the pain. The use of local anesthesia (LA) only is still widespread although it does not abolish the pain. Midazolam is the most commonly used benzodiazepine for conscious sedation. Our center introduced universal midazolam sedation unless there is a contraindication to its use, 4 years ago. This study assessed the impact of the universal use of intravenous midazolam for BMAB compared to use of LA only. The factors associated with the pain of BMAB, were analyzed.

Methods

A retrospective cross-sectional study was performed on adult patients who had a BMAB procedure from July 1, 2018 to March 30, 2019. A questionnaire incorporating a visual analog pain scale, was used for data collection.

Results

A total of 182 BMAB procedures were included in the study. Pain was reported in all procedures performed under LA and only in 29.1% of procedures performed with midazolam. Age, sex, race, level of education, body mass index (BMI), indication and diagnosis had no influence on pain. Patients who had previous BMAB experienced less pain. Experience of operator had a significant effect on pain. Midazolam dose showed a negative correlation with pain.

Conclusion

LA only is not enough to abolish pain of BMAB. Midazolam conscious sedation used with LA reduces pain to acceptable levels. Patients with previous experience of BMAB under midazolam premedication reported less pain. Furthermore, the experience of operator reduced the pain significantly.

Acute Promyelocytic Leukemia Masquerading as Sero-negative Polyarthritis: Case Report

Musculoskeletal manifestations as the sole presentation in acute leukemia is rare in adults. Acute promyelocytic leukemia (APML) is a subtype of acute myeloid leukemia (AML) with reported incidence of 10 to 15% of total AML cases. APML presenting as polyarticular arthritis has never been reported in the literature. We present an interesting case of 20-year-old male patient who manifested with polyarticular arthritis mainly of small joints as the initial presentation, followed by pancytopenia and eventually was diagnosed as a case of APML on bone marrow morphology and molecular analysis for PML-RARα transcript. He was successfully treated with all-trans-retinoic acid (ATRA) and arsenic trioxide (ATO). Arthritis also resolved with complete remission of APML. Arthritis in a case with pancytopenia should promptly be evaluated prior to treatment with steroids and anti-metabolites. Arthritis can be a presenting manifestation of APML and responds to prompt management of leukemia as in other cases of leukemic arthritis.

[Synovial fluid cytodiagnosis]

Synovial fluid samples represent only a very small percentage of routine work in a cytology laboratory. However, its microscopic examination allows us to observe different types of cells, particles and structures that, due to their morphological characteristics, may provide relevant data for cytodiagnosis. We present certain aspects related to arthrocentesis, the relationship between the gross appearance of synovial fluid and certain pathological processes, as well as the different techniques for processing and staining the smears. Furthermore, we describe the main cytological findings in various pathological conditions of the synovial joints, such as infections (bacterial and fungal), non-infectious inflammatory type (osteoarthrosis, rheumatoid arthritis, connective tissue diseases) and tumoral, distinguishing between primary and metastatic, both solid and haematological neoplasms.

Rheumatic Manifestations of Haemoglobinopathies

PURPOSE OF THE REVIEW

To provide a clinically useful literature review on the rheumatic manifestations of haemoglobinopathies, critically analysing the literature from the past 5 years.

RECENT FINDINGS

There are limited new data to guide the management of rheumatic manifestations of haemoglobinopathies. Data further confirm the wide spectrum of potential rheumatic/MSK involvement in haemoglobinopathies, which poses both a diagnostic and therapeutic challenge. Inflammatory arthritis may be more common than previously believed. Steroid therapy by any route of administration can provocate a potential life-threatening vaso-occlusive crisis. Vitamin D deficiency is common. There are limited data to guide the drug treatment of reduced bone density in haemoglobinopathies. There have been a number of studies examining pain in sickle cell anaemia. Plasma levels of Klotho may represent a novel biomarker in patients with β-Thalassemia. There are little new data on the rheumatic manifestations in haemoglobinopathies and future high-quality research is needed.

[Rheumatoid symptoms in patients with hematologic neoplasms]

Paraneoplastic syndromes in lymphatic or myeloid neoplasms can present with musculoskeletal symptoms, vasculitis-like or febrile symptoms. Hematologic diseases are also associated with rheumatic diseases whereas inflammatory rheumatic diseases are often associated with an increased risk for lymphoproliferative disease. Atypical disease characteristics, lack of disease-specific antibodies or therapeutic response are red flags for diagnosing paraneoplastic or coexistent malignant diseases. New onset of systemic symptoms, worsening of general condition, night sweats or weight loss need to be considered during follow-up and differential diagnostics. This article focuses on musculoskeletal, vasculitis-like and systemic signs of lymphatic or myeloid neoplasms either because of coexistency, tumor association or paraneoplastic disease.

Polymyalgia rheumatica development in a patient under PI3K inhibitor therapy for chronic lymphocytic leukaemia

We report a patient with chronic lymphocytic leukaemia (CLL) who was treated with idelalisib, a PI3Kδ inhibitor with rituximab. After 20 weeks of treatment, the patient developed classical signs and symptoms of polymyalgia rheumatica (PMR) in association with an elevated C reactive protein of 74 mg/L. After 2 weeks of prednisolone 15 mg daily symptoms had resolved and acute phase markers normalised. To our knowledge, this is the first report of PMR developing as a complication of PI3Kδ inhibitor treatment of CLL.