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Gómez-Puerta JA, Gente K, Katsumoto TR, Leipe J, Reid P, van Binsbergen WH, Suarez-Almazor ME. Mimickers of Immune Checkpoint Inhibitor-induced Inflammatory Arthritis. Rheum Dis Clin North Am 2024; 50:161-179. [PMID: 38670719 DOI: 10.1016/j.rdc.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
The differential diagnosis of inflammatory arthritis as an immune-related adverse event can be challenging as patients with cancer can present with musculoskeletal symptoms that can mimic arthritis because of localized or generalized joint pain. In addition, immune checkpoint inhibitors can exacerbate joint conditions such as crystal-induced arthritis or osteoarthritis, or induce systemic disease that can affect the joints such as sarcoidosis. This distinction is important as the treatment of these conditions can be different from that of immune-related inflammatory arthritis.
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Affiliation(s)
- José A Gómez-Puerta
- Department of Rheumatology, Hospital Clínic; University of Barcelona, Escala 11-2, Barcelona, Villarroel 170, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Karolina Gente
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Tamiko R Katsumoto
- Division of Immunology and Rheumatology, Department of Medicine, 300 Pasteur Drive Suite H305, Stanford, CA 94305, USA
| | - Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim, Heidelberg 68167, Germany
| | - Pankti Reid
- Division of Rheumatology, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Wouter H van Binsbergen
- Department of Rheumatology & Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ (AMC) & De Boelelaan 1117, Amsterdam 1081 HV (VUmc), The Netherlands
| | - Maria E Suarez-Almazor
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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2
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Herrán de la Gala D, Sáenz Aldea M, Azcona Sáenz J. [Skeletal sarcoidosis as an atypical presentation of the disease]. Semergen 2021; 47:e62-e64. [PMID: 34404585 DOI: 10.1016/j.semerg.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Affiliation(s)
- D Herrán de la Gala
- Servicio de Radiodiagnóstico, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
| | - M Sáenz Aldea
- Médico Interno Residente en Medicina Familiar y Comunitaria, Centro de Salud Dávila, Santander, Cantabria, España
| | - J Azcona Sáenz
- Servicio de Radiodiagnóstico, Hospital Universitario de Donostia, San Sebastián, Guipúzcoa, España
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Patil S, Hilliard CA, Arakane M, Koppisetti Jenigiri S, Field EH, Singh N. Musculoskeletal sarcoidosis: A single center experience over 15 years. Int J Rheum Dis 2021; 24:533-541. [PMID: 33559378 DOI: 10.1111/1756-185x.14068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/30/2020] [Accepted: 01/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Musculoskeletal (MSK) sarcoidosis presents with a variety of clinical phenotypes. Four subtypes of MSK sarcoidosis have been identified to date: Lofgren syndrome, chronic sarcoid arthritis, osseous sarcoidosis, sarcoid myopathy. Each subtype has been reported with varying incidence mainly due to lack of universal classification criteria. METHODS We performed a retrospective chart review of patients with MSK sarcoidosis at a single academic center between January 2000 and December 2014. Descriptive statistics were used to describe the proportion of patients with sarcoidosis who had the 4 MSK syndromes of interest, demographic characteristics and therapeutic agents used. RESULTS A cohort of 58 patients with MSK manifestations were identified among 1016 patients with sarcoidosis. Frequency of subtypes include: Lofgren syndrome 46.6%, osseous sarcoidosis 25.9%, chronic sarcoid arthritis 24.1% and sarcoid myopathy 6.9%. The cohort was predominantly female (43/58 patients, 74%) and Caucasian (48/58 patients, 82.8%). Mean age was 47.2 years. One patient had overlap of osseous sarcoidosis and chronic sarcoid arthritis, another patient initially had Lofgren syndrome and later developed chronic sarcoid arthritis. Sarcoid myopathy patients presented with myalgia more often than muscle weakness. CONCLUSION We identified a large cohort of MSK sarcoidosis and determined the prevalence of all 4 subtypes. In patients who do develop MSK manifestations of sarcoidosis, they are commonly a part of the initial presentation of sarcoidosis. There is an unmet need to establish standardized classification criteria for the 4 MSK sarcoidosis syndromes.
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Affiliation(s)
- Sanjeev Patil
- Rheumatology, The University of Vermont Medical Center, Burlington, VT, USA
| | - Carolyn A Hilliard
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Sreedevi Koppisetti Jenigiri
- Division of Nephrology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Elizabeth H Field
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Namrata Singh
- Division of Rheumatology, Department of Internal Medicine, University of Washington, Seattle, WA, USA
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Borhani-Haghighi A, Kardeh B, Banerjee S, Yadollahikhales G, Safari A, Sahraian MA, Shapiro L. Neuro-Behcet's disease: An update on diagnosis, differential diagnoses, and treatment. Mult Scler Relat Disord 2019; 39:101906. [PMID: 31887565 DOI: 10.1016/j.msard.2019.101906] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 02/08/2023]
Abstract
Neuro-Behcet's disease (NBD) is defined as a combination of neurologic symptoms and/or signs in a patient with Behcet's disease (BD). Relevant syndromes include brainstem syndrome, multiple-sclerosis like presentations, movement disorders, meningoencephalitic syndrome, myelopathic syndrome, cerebral venous sinus thrombosis (CVST), and intracranial hypertension. Central nervous involvement falls into parenchymal and non-parenchymal subtypes. The parenchymal type is more prevalent and presents as brainstem, hemispheric, spinal, and meningoencephalitic manifestations. Non-parenchymal type includes CVST and arterial involvement. Perivascular infiltration of polymorphonuclear and mononuclear cells is seen in most histo-pathologic reports. In parenchymal NBD, cerebrospinal fluid (CSF) generally exhibits pleocytosis, increased protein and normal glucose. In NBD and CVST, CSF pressure is increased but content is usually normal. The typical acute NBD lesions in brain magnetic resonance imaging (MRI) are mesodiencephalic lesions. The pattern of extension from thalamus to midbrain provides a cascade sign. Brain MRI in chronic NBD usually shows brain or brainstem atrophy and/or black holes. The spinal MRI in the acute or subacute myelopathies reveals noncontiguous multifocal lesions mostly in cervical and thoracic lesions. In chronic patients, cord atrophy can also be seen. Brain MRI (particularly susceptibility-weighted images), MR venography (MRV) and computerized tomographic venography (CTV) can be used to diagnose CVST. Parenchymal NBD attacks can be treated with glucocorticoids alone or in combination with azathioprine. For patients with relapsing-remitting or progressive courses, shifting to more potent immunosuppressive drugs such as mycophenolate, methotrexate, cyclophosphamide, or targeted therapy is warranted. For NBD and CVST, immunosuppressive drugs with or without anticoagulation are suggested.
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Affiliation(s)
| | - Bahareh Kardeh
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shubhasree Banerjee
- Division of Rheumatology, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anahid Safari
- Stem Cells Technology Research Center, Shiraz University of Medical Sciences Shiraz, Iran
| | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical sciences, Tehran, Iran
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Shanmugam VK, Phillpotts M, Brady T, Dalal M, Haji-Momenian S, Akin E, Nataranjan K, McNish S, Karcher DS. Retinal vasculitis with Chronic Recurrent Multifocal Osteomyelitis: a case report and review of the literature. BMC Rheumatol 2019; 3:29. [PMID: 31388650 PMCID: PMC6676622 DOI: 10.1186/s41927-019-0076-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 06/24/2019] [Indexed: 12/22/2022] Open
Abstract
Background Concurrent presentation of retinal vasculitis with mixed sclerotic and lytic bone lesions is rare. Case presentation We present the case of a 37-year old woman with a several year history of episodic sternoclavicular pain who presented for rheumatologic evaluation due to a recent diagnosis of retinal vasculitis. We review the differential diagnosis of retinal vasculitis, along with the differential diagnosis of mixed sclerotic and lytic bone lesions. Ultimately, bone marrow biopsy confirmed diagnosis of chronic recurrent multifocal osteomyelitis (CRMO). Concurrent presentation of CRMO with retinal vasculitis is extremely rare but important to recognize. The patient demonstrated clinical response to prednisone and tumor necrosis factor-alpha inhibition (TNF-i). Conclusion This case reports and unusual presentation of CRMO spectrum disease involving the sternum and sternoclavicular joint with concurrent retinal vasculitis.
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Affiliation(s)
- Victoria K Shanmugam
- 1Division of Rheumatology, The George Washington University School of Medicine and Health Sciences, 2300 M Street, NW, Washington, DC 20037 USA
| | - Marc Phillpotts
- 1Division of Rheumatology, The George Washington University School of Medicine and Health Sciences, 2300 M Street, NW, Washington, DC 20037 USA
| | - Timothy Brady
- 1Division of Rheumatology, The George Washington University School of Medicine and Health Sciences, 2300 M Street, NW, Washington, DC 20037 USA
| | - Monica Dalal
- 2Department of Ophthalmology, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Washington, DC 20037 USA
| | - Shawn Haji-Momenian
- 3Department of Radiology, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Washington, DC 20037 USA
| | - Esma Akin
- 3Department of Radiology, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Washington, DC 20037 USA
| | - Kavita Nataranjan
- 4Department of Hematology, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Washington, DC 20037 USA
| | - Sean McNish
- 1Division of Rheumatology, The George Washington University School of Medicine and Health Sciences, 2300 M Street, NW, Washington, DC 20037 USA
| | - Donald S Karcher
- 5Department of Pathology, The George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Washington, DC 20037 USA
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Ungprasert P, Ryu JH, Matteson EL. Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis. Mayo Clin Proc Innov Qual Outcomes 2019; 3:358-375. [PMID: 31485575 PMCID: PMC6713839 DOI: 10.1016/j.mayocpiqo.2019.04.006] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/26/2019] [Indexed: 12/14/2022] Open
Abstract
The focus of this review is current knowledge about the epidemiology, clinical manifestations, diagnosis, and treatment of both pulmonary sarcoidosis and extrapulmonary sarcoidosis. Although intrathoracic involvement is the hallmark of the disease, present in over 90% of patients, sarcoidosis can affect virtually any organ. Clinical presentations of sarcoidosis are diverse, ranging from asymptomatic, incidental findings to organ failure. Diagnosis requires the presence of noncaseating granuloma and compatible presentations after exclusion of other identifiable causes. Spontaneous remission is frequent, so treatment is not always indicated unless the disease is symptomatic or causes progressive organ damage/dysfunction. Glucocorticoids are the cornerstone of treatment of sarcoidosis even though evidence from randomized controlled studies is lacking. Glucocorticoid-sparing agents and biologic agents are often used as second- and third-line therapy for patients who do not respond to glucocorticoids or experience serious adverse effects.
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Key Words
- ATS, American Thoracic Society
- AV, atrioventricular
- CMRI, cardiovascular magnetic resonance imaging
- DLCO, diffusing capacity of the lung for carbon monoxide
- DMARD, disease-modifying antirheumatic drugs
- ECG, electrocardiographic
- ERS, European Respiratory Society
- FDG-PET, 18F-fluorodeoxyglucose–positron emission tomography
- FVC, forced vital capacity
- GI, gastrointestinal tract
- LVEF, left ventricular ejection fraction
- NSAID, nonsteroidal anti-inflammatory drug
- PFT, pulmonary function test
- TBB, transbronchial lung biopsy
- TNF-α, tumor necrosis factor α
- WASOG, World Association of Sarcoidosis and other Granulomatous Disorders
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Affiliation(s)
- Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Address to Patompong Ungprasert, MD, MS, Clinical Epidemiology Unit, 3rd Floor, SIMR Bldg, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Jay H. Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Eric L. Matteson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research (E.L.M.), Mayo Clinic, Rochester, MN
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Agarwal V, Agrawal V, Aggarwal A, Aggarwal P, Chowdhury AC, Ghosh P, Jain A, Lawrence A, Misra DP, Misra R, Mohapatra MM, Nath A, Negi VS, Pandya S, Reddy VV, Prasad S, Sharma A, Shobha V, Singh YP, Tripathy SR, Wakhlu A. Arthritis in sarcoidosis: A multicentric study from India. Int J Rheum Dis 2018; 21:1728-1733. [PMID: 30187668 DOI: 10.1111/1756-185x.13349] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/15/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Vishnu V. Reddy
- Vizag Rheumatology and Immunology Centre; Vishakhapatnam India
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Bechman K, Christidis D, Walsh S, Birring SS, Galloway J. A review of the musculoskeletal manifestations of sarcoidosis. Rheumatology (Oxford) 2018; 57:777-783. [PMID: 28968840 DOI: 10.1093/rheumatology/kex317] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Indexed: 01/09/2023] Open
Abstract
Sarcoidosis is a systemic disease of unknown aetiology that is characterized by granulomatous inflammation that can develop in almost any organ system. Musculoskeletal manifestations are seen in up to one-third of patients, ranging from arthralgia through to widespread destructive bone lesions. Inflammatory tendon lesions and periarticular swelling are more common than true joint synovitis. Despite advances in our understanding of the pathophysiology of the disease, diagnosis remains challenging. Definitive diagnosis, irrespective of organ site involvement, hinges on histological confirmation of non-caseating granuloma combined with an appropriate clinical syndrome. Musculoskeletal involvement usually develops early in the disease course. Imaging modalities, particularly fluorodeoxyglucose PET, are helpful in delineating the extent of involvement and measuring disease activity. Bone involvement may only become apparent following isotope imaging. Corticosteroids remain the cornerstone of treatment. MTX is the steroid-sparing agent of choice unless there is renal involvement. Biologic therapies are sometimes used in severe disease, although the evidence base for efficacy is inconsistent.
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Affiliation(s)
- Katie Bechman
- Academic Department of Rheumatology, King's College London, London, UK
| | - Dimitrios Christidis
- Rheumatology Department, Epsom and St Helier's Hospital NHS Foundation Trust, Carshalton, UK
| | - Sarah Walsh
- Dermatology Department, King's College Hospital NHS Foundation Trust, London, UK
| | | | - James Galloway
- Academic Department of Rheumatology, King's College London, London, UK
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9
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Abstract
Advanced imaging has demonstrated that musculoskeletal manifestations of systemic sarcoidosis are more common than previously thought. A definitive strategy for the management of osseous sarcoidosis has not been defined. Some lesions resolve spontaneously, and no systemic medication for sarcoidosis consistently resolves lesions. The orthopaedic surgeon treating patients with musculoskeletal sarcoidosis must make an appropriate diagnosis of bony lesions, seek multidisciplinary input from specialists in pulmonology and rheumatology regarding systemic treatment, and decide when surgery is necessary to prevent dysfunction.
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10
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Muñoz C, Restrepo-Escobar M, Martínez-Muñoz M, Echeverri A, Márquez J, Pinto LF. Differences between patients with sarcoidosis with and without joint involvement treated for fifteen years in a third level hospital. ACTA ACUST UNITED AC 2018; 16:45-48. [PMID: 29456153 DOI: 10.1016/j.reuma.2018.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 12/21/2017] [Accepted: 01/06/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Sarcoidosis is a complex disease of unknown etiology, with a variable course and highly different forms of presentation. Our objective was to characterize all our patients with sarcoidosis with emphasis on their clinical presentation and to establish differences between patients with sarcoidosis with and without joint involvement. METHODS We reviewed the medical records of all patients with a diagnosis of sarcoidosis who were treated at the outpatient or inpatient services of the Pablo Tobón Uribe Hospital in Medellín, Colombia, from January 2002 to April 2017. RESULTS We identified 22 patients with sarcoidosis. There were joint symptoms in 13 of them. All but one of the patients with sarcoidosis affecting the joints had concomitant skin involvement (92%), which was much less frequent in patients without joint involvement (22%) (odds ratio=4.2; P<.001). CONCLUSIONS Patients with sarcoidosis who have joint involvement have a much higher frequency of concomitant skin involvement. The absence of cutaneous findings in a patient with joint symptoms decreases the likelihood of sarcoidosis.
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Affiliation(s)
- Carolina Muñoz
- Sección de Reumatología, Departamento de Medicina Interna, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Mauricio Restrepo-Escobar
- Sección de Reumatología, Departamento de Medicina Interna, Hospital Pablo Tobón Uribe, Medellín, Colombia; Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia.
| | | | - Andrés Echeverri
- Sección de Reumatología, Departamento de Medicina Interna, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Javier Márquez
- Sección de Reumatología, Departamento de Medicina Interna, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Luis Fernando Pinto
- Sección de Reumatología, Departamento de Medicina Interna, Hospital Pablo Tobón Uribe, Medellín, Colombia
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Affiliation(s)
- Alexandra P Saltman
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.
| | - Bindee Kuriya
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont
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12
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Sarcoidosis: Is It a Possible Trigger of Inclusion Body Myositis? Case Rep Rheumatol 2017; 2017:8469629. [PMID: 28523201 PMCID: PMC5420916 DOI: 10.1155/2017/8469629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/18/2017] [Indexed: 11/18/2022] Open
Abstract
Sarcoidosis is a multisystem disorder of unknown etiology, characterized pathologically by the presence of nonnecrotizing granulomatous inflammation in affected organs. Although skeletal muscle is involved in 50–80 percent of individuals with sarcoidosis, symptomatic myopathy has been shown to be a rare manifestation of the disease. Inclusion body myositis (IBM) is a rare acquired idiopathic inflammatory myopathy with the insidious onset of asymmetric and distal muscle weakness that characteristically involves the quadriceps, tibialis anterior, and forearm flexors. Moreover, dysphagia can be the presenting complaint in one-third of patients. Herein, we are presenting a case of 67-year-old African American female who presented with one-month history of new onset progressive dyspnea on exertion. She was diagnosed with stage IV sarcoidosis based on chest CT scan findings and transbronchial lung biopsy revealing nonnecrotizing granulomatous inflammation. Over the next three months after her diagnosis, she presented to the hospital with progressive dysphagia associated with asymmetrical distal muscle weakness. A quadriceps muscle biopsy revealed features consistent with inclusion body myositis. We are reporting this case as it may support the hypothesis of sarcoidosis being a trigger that possibly promotes the development of inclusion body myositis, leading to a very poor prognosis.
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Moccia LG, Castaldo S, Sirignano E, Napolitano M, Barra E, Sanduzzi A. Sarcoidosis with prevalent and severe joint localization: a case report. Multidiscip Respir Med 2016; 11:27. [PMID: 27358732 PMCID: PMC4926288 DOI: 10.1186/s40248-016-0064-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/05/2016] [Indexed: 02/01/2023] Open
Abstract
Background Sarcoidosis is a systemic granulomatous disease of unknown origin, characterized by the formation of granulomas without central necrosis. Each organ and tissue can be affected by the disease, but in most cases mainly the lungs and mediastinal lymph nodes but also skin, heart, eyes and joints are involved, the latter are mainly the metacarpophalangeal joints and bone lesions are often associated with involvement of the overlying skin. The diagnosis is often of exclusion, based on clinical and radiological suspicion, and should be confirmed by biopsy, although in each case it is necessary to exclude other possible causes of granulomatosis, including infections by mycobacteria. Here it is reported a case of particularly aggressive sarcoidosis with primitive involvement of the small joints of the hands and feet, and mediastinal lymph nodes. Case presentation The subject, a man, 60 years old, born in Morocco but living in Italy for many years, presented important involvement of bone structures and soft periarticular tissue, and was affected by the formation of granulomas without “caseum necrosis”. The painful symptoms and the skin ulceration had led to surgical amputation of the distal phalanges of most fingers of his hands and feet, but with subsequent resurgence of lesions in acral locations after surgery. The PET/CT scan showed an amount of radiotracer in mediastinal lymph nodes, while the lymph nodes sampled by TBNA were normal and the CD4/CD8 ratio was less than 3 in the bronchoalveolar lavage. We ruled out any possible infectious cause, including mycobacterial infection (both tubercular and atypical), so the patient was treated with systemic corticosteroids, with an excellent clinical and radiological response. Conclusions Such a case shows how the disease can have variable expressions, without primitive lung involvement; therefore, it should be necessary to consider any possible, unpredictable localization of the disease.
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Affiliation(s)
- Livio G Moccia
- Division of Pneumology, Department of Clinical Medicine and Surgery, University "Federico II" Medical School, Naples, Italy
| | - Sabrina Castaldo
- Division of Pneumology, Department of Clinical Medicine and Surgery, University "Federico II" Medical School, Naples, Italy
| | - Emanuela Sirignano
- Division of Pneumology, Department of Clinical Medicine and Surgery, University "Federico II" Medical School, Naples, Italy
| | - Maddalena Napolitano
- Division of Dermatology, Department of Clinical Medicine and Surgery, University "Federico II" Medical School, Naples, Italy
| | - Enrica Barra
- Department of Pathology, High Speciality Hospital "V. Monaldi", Naples, Italy
| | - Alessandro Sanduzzi
- Division of Pneumology, Department of Clinical Medicine and Surgery, University "Federico II" Medical School, Naples, Italy
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14
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Clinical and radiological features of extra-pulmonary sarcoidosis: a pictorial essay. Insights Imaging 2016; 7:571-87. [PMID: 27222055 PMCID: PMC4956623 DOI: 10.1007/s13244-016-0495-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/07/2016] [Accepted: 04/22/2016] [Indexed: 12/19/2022] Open
Abstract
Abstract The aim of this manuscript is to describe radiological findings of extra-pulmonary sarcoidosis. Sarcoidosis is an immune-mediated systemic disease of unknown origin, characterized by non-caseating epitheliod granulomas. Ninety percent of patients show granulomas located in the lungs or in the related lymph nodes. However, lesions can affect any organ. Typical imaging features of liver and spleen sarcoidosis include visceromegaly, with multiple nodules hypodense on CT images and hypointense on T2-weighted MRI acquisitions. Main clinical and radiological manifestations of renal sarcoidosis are nephrolithiasis, nephrocalcinosis, and acute interstitial nephritis. Brain sarcoidosis shows multiple or solitary parenchymal nodules on MRI that enhance with a ring-like appearance after gadolinium. In spinal cord localization, MRI demonstrates enlargement and hyperintensity of spinal cord, with hypointense lesions on T2-weighted images. Skeletal involvement is mostly located in small bone, showing many lytic lesions; less frequently, bone lesions have a sclerotic appearance. Ocular involvement includes uveitis, conjunctivitis, optical nerve disease, chorioretinis. Erythema nodosum and lupus pernio represent the most common cutaneous manifestations encountered. Sarcoidosis in various organs can be very insidious for radiologists, showing different imaging features, often non-specific. Awareness of these imaging features helps radiologists to obtain the correct diagnosis. Teaching Points • Systemic sarcoidosis can exhibit abdominal, neural, skeletal, ocular, and cutaneous manifestations. • T2 signal intensity of hepatosplenic nodules may reflect the disease activity. • Heerfordt’s syndrome includes facial nerve palsy, fever, parotid swelling, and uveitis. • In the vertebrae, osteolytic and/or diffuse sclerotic lesions can be found. • Erythema nodosum and lupus pernio represent the most common cutaneous manifestations.
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Rolls S, Hyams C, Sheaff M, O'Shaughnessy TC. Is this still just sarcoidosis, or should we a-DRESS a different diagnosis? BMJ Case Rep 2015; 2015:bcr-2014-207778. [PMID: 26123453 DOI: 10.1136/bcr-2014-207778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An Afro-Caribbean woman presented with worsening breathlessness, weight loss, lethargy and fevers, developing a bilateral florid erythematous rash on her legs. She was recently diagnosed with rheumatoid arthritis and bilateral hilar lymphadenopathy was found on thoracic CT imaging. She was tachycardic and investigations revealed pancytopenia, eosinophilia, raised serum ACE, acute kidney injury and deranged liver function tests. Biopsy of the lymphadenopathy revealed mixed lymphoid cells and liver biopsy revealed extramedullary haematopoiesis, with hypercellular marrow found on bone marrow biopsy. Cardiac MRI was normal, excluding cardiac sarcoid. The patient developed status epilepticus and phenytoin was started. She subsequently developed skin desquamation, in keeping with toxic epidermal necrosis. Skin biopsies revealed atypical granulomas and multinucleated giant cells, which subsequently resolved on steroid treatment. This case highlights an overlap syndrome, with an unclear diagnosis between sarcoidosis, drug reaction or rash with eosinophilia and systemic symptoms and/or hypereosinophilic syndrome and Still's disease. Hence varied serological and clinical features can complicate the distinction between diagnoses.
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Affiliation(s)
- Sophie Rolls
- Department of Respiratory Medicine, Newham University Hospital, London, UK
| | - Catherine Hyams
- Department of Respiratory Medicine, Newham University Hospital, London, UK
| | - Michael Sheaff
- Department of Histopathology, Barts and The Royal London Hospital, London, UK
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Haddad N, Oliveira Filho JD, Nasser KDR, Corbett AMF, Tebet ACF, Reis MLJ. Musculoskeletal and cutaneous sarcoidosis: exuberant case report. An Bras Dermatol 2014; 89:660-2. [PMID: 25054759 PMCID: PMC4148286 DOI: 10.1590/abd1806-4841.20143053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 08/23/2013] [Indexed: 12/04/2022] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown cause. The
osteoarticular involvement in sarcoidosis is rare and is often associated with
cutaneous and long-standing chronic multisystem disease. More common in black
women, osseous sarcoidosis is difficult to diagnose, with an incidence of 3 to
13%. The most characteristic radiological clinical picture evidences rounded,
well-defined cysts, with no periosteal reaction and without peripheral
sclerosis. The small bones of hands and feet are the most frequently involved
sites. This report aims to demonstrate a rare case of osteoarticular sarcoidosis
with characteristic clinical presentation, and highlight the importance of
detecting osteoarticular involvement in this pathology.
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17
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Salari M, Rezaieyazdi Z. Prevalence and clinical picture of musculoskeletal sarcoidosis. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e17918. [PMID: 25237584 PMCID: PMC4166103 DOI: 10.5812/ircmj.17918] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 04/03/2014] [Accepted: 03/19/2014] [Indexed: 11/16/2022]
Abstract
Background: Sarcoidosis is a multisystem disease affecting different organs with different frequency rates depending on geographical location. Musculoskeletal abnormalities includes osseous lesions (small and large bone sarcoidosis), sarcoidal arthropathy, and sarcoidal myopathy. Musculoskeletal involvement is reported in a significant number of patients. Objectives: This study aimed to determine the prevalence and clinical picture of musculoskeletal sarcoidosis in Iranian cohort of patients with sarcoidosis. Patients and Methods: We designed a descriptive cross-sectional study including 30 patients with sarcoidosis who had hospitalized in the Rheumatology Department at Ghaem Hospital, Mashhad, Iran. The patients were evaluated for musculoskeletal symptoms using history, physical examination, and paraclinical data. Results: Of the 30 studied patients, 24 were female (80%) and six were male (20%). The mean age at diagnosis was 38 years. Sarcoidal arthropathy (arthritis and periarthritis) was observed in 26 patients (86.6%). Furthermore, the initial presentation was associated with joint symptoms in 19 cases (63.3%); acute arthritis developed in 17 (65%) while bone and muscle involvements each occurred in 2 (6.6%). Conclusions: Sarcoidosis is a common disease in women aged 20 to 40 years. The most common involved joint were consecutively ankles, knees, and wrists, reaching a accumulated frequency of 86.6%; however, bone and muscle involvements were uncommon.
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Affiliation(s)
- Masoumeh Salari
- Rheumatic Diseases Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Zahra Rezaieyazdi
- Rheumatic Diseases Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
- Corresponding Author: Zahra Rezaieyazdi, Rheumatic Diseases Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran. Tel/Fax: +98-5118410136, E-mail:
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18
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Requeno-Jarabo MN, Amorós-García R, Murillo-Díaz de Cerio II, Antoñanzas-Lombarte A. [Polyarthralgia as an initial symptom of sarcoidosis]. Semergen 2013; 39:325-9. [PMID: 24034761 DOI: 10.1016/j.semerg.2012.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 04/03/2012] [Accepted: 04/05/2012] [Indexed: 11/25/2022]
Abstract
A 39 year-old patient consulted his family doctor due to migratory polyarthralgia, with C-reactive protein 7.99mg/dl, ESR 89mm and normal anti-streptolysin O (ASO). A sample was taken for analysis in the Rheumatology Clinic: ACE 72 IU, with normal rheumatoid factor, C-reactive protein and ASO; HLA non-specific. Chest X-ray showed an increased pulmonary interstitial pattern, and his chest-CT showed multiple bilateral pulmonary nodules and mediastinal lymph nodes. A differential diagnosis of lymphoproliferative process was considered. A gallium scintigraphy was performed with no relevant findings. The patient was referred to Thoracic Surgery for a lymph node biopsy by mediastinoscopy, which showed a non-necrotizing granulomatous lymphadenitis consistent with a sarcoidosis. Treatment with prednisone and anti-osteoporosis drugs was started and the patient was evaluated at four months with a new chest X-ray. There was a clinical and radiological remission therefore it was decided to gradually reduce the corticosteroid therapy.
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Affiliation(s)
- M N Requeno-Jarabo
- Medicina de Familia y Comunitaria, Centro de Salud Delicias Sur, Zaragoza, España.
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19
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Abstract
Sarcoidosis is a systemic disease characterized by the development of epithelioid granulomas in various organs. Although the lungs are involved in most patients with sarcoidosis, virtually any organ can be affected. Recognition of extrapulmonary sarcoidosis requires awareness of the organs most commonly affected, such as the skin and the eyes, and vigilance for the most dangerous manifestations, such as cardiac and neurologic involvement. In this article, the common extrapulmonary manifestations of sarcoidosis are reviewed and organ-specific therapeutic considerations are discussed.
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Affiliation(s)
- Deepak A. Rao
- Division of Rheumatology, Brigham and Women’s Hospital, 45 Francis Street, PBB-3, Boston, MA 02115, USA
| | - Paul F. Dellaripa
- Division of Rheumatology, Brigham and Women’s Hospital, 45 Francis Street, PBB-3, Boston, MA 02115, USA
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20
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Abstract
Sarcoidosis as a distinct disease entity was diagnosed more than 100 years ago. The signs and symptoms of the disease are nonspecific, posing a challenge for early and accurate diagnosis. IgG4 disease or syndrome has various clinical manifestations, such as sclerosing pancreatitis, sclerosing cholangitis, prostatitis, tubulointerstitial nephritis, interstitial pneumonia, and enlargement of salivary glands. This article discusses the role of the different diagnostic imaging modalities in sarcoidosis and IgG4 disease, including radiographs, computed tomography, magnetic resonance imaging, and conventional nuclear medicine, with a special emphasis on positron emission tomography as a superior modality for assessing these inflammatory diseases.
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21
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Abstract
Sarcoidosis is a multisystem granulomatous disorder that most commonly presents with pulmonary involvement. The diagnosis is suggested on the basis of clinical and radiologic manifestations and is supported by the histological demonstration of noncaseating granulomas in affected tissues. Different imaging modalities, including chest radiography, X-rays, computed tomography, magnetic resonance imaging, and (67) Ga scintigraphy are currently employed to help diagnose and help plan treatment strategy in sarcoidosis patients. Here, we discuss the potential role of positron emission tomography in the diagnosis, assessment of disease activity, and management of patients with sarcoidosis. We also point out some of the limitations of this technique.
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Affiliation(s)
- Vivek Jain
- GW Medical Faculty Associates, Division of Pulmonary, Critical Care, and Sleep Medicine, George Washington University Hospital, Washington, DC, USA.
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22
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Mayerhoff RM, Pitman MJ. Atypical and disparate presentations of laryngeal sarcoidosis. Ann Otol Rhinol Laryngol 2010; 119:667-71. [PMID: 21049851 DOI: 10.1177/000348941011901004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Sarcoidosis is a multisystem chronic granulomatous disease of unknown cause that typically affects patients between 20 and 40 years of age. Laryngeal involvement most frequently involves the supraglottis and presents with dyspnea. We present a retrospective review of 4 patients with previously undiagnosed sarcoidosis who presented with atypical signs and symptoms of sarcoidosis: dysphonia with isolated vocal fold involvement; cough and globus pharyngeus; pediatric sarcoidosis; and severe bilateral vocal fold paresis and dysphagia. Our aim is to highlight disparate presentations of laryngeal sarcoidosis, as well as the treatment options. Laryngeal sarcoidosis may present with atypical signs and symptoms and occasionally presents in pediatric patients. A high degree of suspicion is necessary for a correct diagnosis in these patients. Early diagnosis and proper management of laryngeal sarcoidosis is important, as the symptoms are debilitating and possibly life-threatening. Treatment may consist of local and systemic chemotherapy, and adjunctive procedures.
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Affiliation(s)
- Ross M Mayerhoff
- Stony Brook University School of Medicine, Stony Brook, New York, USA
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23
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Balan A, Hoey ETD, Sheerin F, Lakkaraju A, Chowdhury FU. Multi-technique imaging of sarcoidosis. Clin Radiol 2010; 65:750-60. [PMID: 20696303 DOI: 10.1016/j.crad.2010.03.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 03/16/2010] [Accepted: 03/22/2010] [Indexed: 01/12/2023]
Abstract
Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology. The diagnosis is suggested on the basis of wide ranging clinical and radiological manifestations, and is supported by the histological demonstration of non-caseating granulomas in affected tissues. This review highlights the multisystem radiological features of the disease across a variety of imaging methods including multidetector computed tomography (CT), magnetic resonance imaging (MRI) as well as functional radionuclide techniques, particularly 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography/computed tomography (PET/CT). It is important for the radiologist to be aware of the varied radiological manifestations of sarcoidosis in order to recognize and suggest the diagnosis in the appropriate clinical setting.
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Affiliation(s)
- A Balan
- Department of Clinical Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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24
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Affiliation(s)
- Juan Carlos Torre Alonso
- Unidad de Reumatología. Hospital Monte Naranco. Universidad de Oviedo. Oviedo (Asturias). España
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25
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Mansour MJ, Al-Hashimi I, Wright JM. Coexistence of Sjögren's syndrome and sarcoidosis: a report of five cases. J Oral Pathol Med 2007; 36:337-41. [PMID: 17559494 DOI: 10.1111/j.1600-0714.2007.00530.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sjögren's syndrome (SS) and sarcoidosis are diseases that can affect the salivary glands and result in the loss of salivary gland function. Most of the criteria used for the diagnosis of SS exclude sarcoidosis before establishing the diagnosis of SS. However, several reports have suggested the coexistence of both SS and sarcoidosis in the same patient. OBJECTIVE The purpose of this study was to present five cases that support a true coexistence of sarcoidosis and SS. METHODS Clinical and laboratory findings of patients with evidence of having both SS and sarcoidosis were reviewed. The diagnosis of SS was based on the European community criteria; the diagnosis of sarcoidosis was based on the presence of serological, radiographic and/or histopathologic findings that are consistent with sarcoidosis. RESULTS All patients fulfilled the criteria for the diagnosis of both diseases. CONCLUSION Our findings appear to support a true coexistence of sarcoidosis with SS. Therefore, it is reasonable to suggest removing the exclusion of sarcoidosis from the diagnostic criteria for SS.
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Affiliation(s)
- M J Mansour
- Baylor College of Dentistry, Texas A&M University Systems, Dallas, TX 75246, USA
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26
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Abstract
Dactylitis is considered a hallmark feature of psoriatic arthritis (PsA), but it is found in other spondyloarthropathies, especially reactive arthritis, and other conditions (eg, sarcoidosis, gout, sickle cell disease, and a variety of infections). Dactylitis is difficult to define and assess with any level of consensus and consistency in PsA. A new objective measure has been developed to make assessment more uniform for clinical trials. The underlying pathophysiology has also been difficult to determine in spondyloarthropathy: synovitis, tenosynovitis, and enthesitis have all been recognized. The pathophysiology in other conditions varies but usually involves soft tissue and sometimes involves bone or joint. In non-spondyloarthropathies,treatment is determined by the underlying cause. Research on dactylitis treatment in PsA suffers from a paucity of trials and inconsistent outcome measurement. The only drug with good evidence of benefit from randomized controlled trials thus far is infliximab.
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Affiliation(s)
- Paul J Healy
- Academic Unit of Musculoskeletal Medicine, University of Leeds, 36 Clarendon Road, Leeds LS2 9NZ, UK
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Revaz S, Dudler J, Kai-Lik So A. Fever and musculoskeletal symptoms in an adult: differential diagnosis and management. Best Pract Res Clin Rheumatol 2006; 20:641-51. [PMID: 16979529 DOI: 10.1016/j.berh.2006.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fever in the context of a patient with musculoskeletal symptoms is a sign of systemic inflammation. Initial management should be targeted at the identification of the organ systems affected and the search for a precise diagnosis. The main challenge is to differentiate between an infectious aetiology from an immune-inflammatory cause. Patient history and physical examination are key elements in the diagnostic work-up in order to direct appropriate laboratory investigations, as well as radiological and biopsy procedures. Advances in microbiological techniques and molecular genetics have provided additional tools for the clinician. Unfortunately, there is no simple algorithm to direct the diagnostic work-up, which still largely depends on the recognition of patterns of clinical presentations and the corresponding laboratory abnormalities.
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Affiliation(s)
- Sylvie Revaz
- Service de Rhumatologie, Médecine Physique et Réhabilitation, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland.
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28
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Yu JQ, Zhuang H, Mavi A, Alavi A. Evaluating the Role of Fluorodeoxyglucose PET Imaging in the Management of Patients with Sarcoidosis. PET Clin 2006; 1:141-52. [DOI: 10.1016/j.cpet.2006.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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