Bilateral Subclavian Vein Occlusion in a SAPHO Syndrome Patient Who Needed an Implantable Cardioverter Defibrillator

Palmoplantar pustulosis and pustulotic arthro-osteitis associated with multiple venous occlusion: A case report and literature review

Pustulotic arthro-osteitis (PAO) is a rare chronic inflammatory arthropathy associated with palmoplantar pustulosis. The pathogenesis of PAO remains unclear. The most common musculoskeletal involvement in PAO is ossification of the sternoclavicular joints. A combination of parietal inflammation and hyperostosis-induced mechanical compression in this region is hypothesized to contribute to multiple venous thrombosis. Here, we present a 66-year-old man with PAO-associated multiple venous occlusion who was successfully treated with guselkumab. We also discuss its clinical manifestation and cause by reviewing the literature.

Candidacy for a Subcutaneous Implantable Cardioverter Defibrillator in Patients with Cardiac Resynchronization Therapy

In patients requiring an implantable cardioverter defibrillator (ICD), the combined use of a prior pacemaker and a subcutaneous ICD (S-ICD) could be an alternative treatment option to implantation of new leads or upgrading of pacemakers to an ICD if vascular access is limited. Here, we assessed the prevalence of S-ICD's eligibility according to surface electrogram screening in those receiving cardiac resynchronization therapy (CRT). S-ICD's eligibility was assessed in patients with a CRT pacemaker or a CRT defibrillator using the S-ICD template screening tool. Eligibility was defined as fulfillment of the template in both supine and upright positions in one or more leads during biventricular pacing. Among 44 patients (34 men, age: 67 ± 12), 36 (82%) were found to be eligible. The T/QRS amplitude ratio in lead II was significantly lower in those who were eligible (0.31 ± 0.16 versus 0.44 ± 0.18 in the ineligible group, P = 0.04). The lead position, underlying disease, and other electrocardiographic findings were not different between those who were eligible and those who were not. The majority of patients with biventricular pacing were eligible for S-ICD based on current screening tests and may benefit from this treatment. Further study is required.

Spontaneous bilateral subclavian vein thrombosis in a 40-year-old man: A case report

RATIONALE

Paget-Schroetter syndrome (PSS) is an uncommon condition that refers to primary (spontaneous) thrombosis of the deep veins that drain the upper extremities because of anatomical anomalies or repetitive strenuous arm activity. Bilateral spontaneous upper extremity deep-vein thrombosis (UEDVT) is an extremely rare phenomenon in adults, which may be misdiagnosed by physicians in acute settings.

PATIENT CONCERNS

A 40-year-old man presented to our emergency department because of progressive left upper arm swelling for 1 day. He denied fever, chest pain, dyspnea, trauma, or any other systemic disease before. The swollen left arm also had no local heat or redness with normal radius pulsation. He was a laborer who lifted heavy objects.

DIAGNOSES

Blood examination included tests for complete blood count, renal function, liver function, blood coagulation profile, cardiac enzyme levels, and D-dimer level. Results showed that the white blood cell count, renal and liver functions, and cardiac enzyme levels were all within their normal ranges, except for the elevated D-dimer level (1.93 mg/L). Chest radiography and electrocardiography were performed with nonspecific findings. Subsequently, computed tomographic angiography was recommended for the suspected deep-vein thrombosis. The report showed venous thrombosis involving the bilateral subclavian and internal jugular veins.

INTERVENTIONS

Heparin and enoxaparin were prescribed for this patient, with loading and maintenance doses. He was then admitted to our cardiovascular ward for further treatment.

OUTCOMES

The patient was discharged 9 days later in a stable condition.

LESSONS

Emergency physicians should consider the rare condition of UEDVT when a healthy patient presents with acute arm swelling. Patient history taking should be thorough, especially concerning the risk factors of secondary causes and possible frequent vigorous heavy lifting and overhead motion. Without secondary risk factors, primary upper deep-vein thrombosis might be suspected. Further laboratory tests and imaging studies, especially bilateral imaging, should be arranged to exclude secondary causes and to confirm the diagnosis.

Radiologists need to be aware of secondary central venous stenosis in patients with SAPHO syndrome

OBJECTIVES

We aimed to define central venous stenosis (CVS) caused by sternocostoclavicular hyperostosis as a feature of synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome on routine contrast-enhanced computed tomography (CT) images. The relationship between SAPHO syndrome and CVS without venous thrombosis caused by anterior chest wall compression has not been investigated. Therefore, the present study evaluated CVS in patients with SAPHO syndrome at our hospital.

METHODS

We retrospectively reviewed contrast-enhanced CT images of ten patients with suspected or diagnosed SAPHO syndrome between January 2007 and November 2015. The patients were assessed by contrast-enhanced CT using 16-, 64- or 128-detector row scanners. Two radiologists independently assessed the presence of CVS or obstruction and SAPHO syndrome in a retrospective review of CT images.

RESULTS

Six of the ten patients had findings of CVS with SAPHO syndrome. The mean diameter and patency rate at the site of CVS were 1.88 mm and 27.2%, respectively. Stenosis was more significant in terms of the mean diameter of CVS sites than of stenotic sites that crossed the anteroposterior vein (p < 0.05).

CONCLUSIONS

Radiologists who routinely assess contrast-enhanced CT images should be aware that sternocostoclavicular hyperostosis with SAPHO syndrome could cause secondary CVS.

KEY POINTS

• SAPHO syndrome can cause central venous stenosis. • Radiologists should consider central venous stenosis in patients with SAPHO syndrome. • Early diagnosis of central venous stenosis due to SAPHO syndrome is challenging.

Heart failure complicating with SAPHO syndrome

A 65-year-old man was referred to our hospital with dyspnoea due to acute heart failure. He presented with swelling in the left clavicle and pustulosis on both soles. An antihypertensive drug and non-invasive positive pressure ventilation improved his condition rapidly. Since all his physical symptoms were compatible with the criteria of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteomyelitis) syndrome, we suspected that the SAPHO syndrome might cause acute heart failure. The aetiology between SAPHO syndrome and heart failure is unclear. Further studies are needed to clarify their relationship.