Typical Bone Scintigraphy Presentation of Erdheim-Chester Disease in a Patient Diagnosed With IgG4-Related Disease

ABSTRACT

A 50-year-old woman presented a dry syndrome, joint pain, inflammatory syndrome, polyclonal hypergammaglobulinemia, and tubulointerstitial nephritis. Imaging studies (including FDG PET/CT) revealed infrarenal retroperitoneal fibrosis with periaortitis and hypermetabolic osteosclerotic lesions. Bone scintigraphy demonstrated intense uptake in the femoral, tibial, and radial regions, suggestive of non-Langerhans histiocytosis, specifically Erdheim-Chester disease. A bone biopsy confirmed the presence of IgG4-positive plasma cells but no histiocytes. The patient received corticosteroid therapy followed by rituximab, resulting in a complete response. This case suggests an atypical manifestation of bone lesions in IgG4-related disease, emphasizing the diagnostic challenge between IgG4-related disease and Erdheim-Chester disease.

Prognostic factors in giant cell arteritis associated aortitis with PET/CT and CT angiography at diagnosis

BACKGROUND

Prognosis data on giant-cell arteritis (GCA)-associated aortitis are scarce and heterogeneous. The aim of this study was to compare the relapses of patients with GCA-associated aortitis according to the presence of aortitis on CT-angiography (CTA) and/or on FDG-PET/CT.

METHODS

This multicenter study included GCA patients with aortitis at diagnosis; each case underwent both CTA and FDG-PET/CT at diagnosis. A centralized review of image was performed and identified patients with both CTA and FDG-PET/CT positive for aortitis (Ao-CTA+/PET+); patients with positive FDG-PET/CT but negative CTA for aortitis (Ao-CTA-/PET+), and patients solely positive on CTA.

RESULTS

Eighty-two patients were included with 62 (77%) of female sex. Mean age was 67±8 years; 64 patients (78%) were in the Ao-CTA+/PET+ group; 17 (22%) in the Ao-CTA-/PET+ group and 1 had aortitis only on CTA. Overall, 51 (62%) patients had at least one relapse during follow-up: 45/64 (70%) in the Ao-CTA+/PET+ group and 5/17 (29%) in the Ao-CTA-/PET+ group (log rank, p = 0.019). In multivariate analysis, aortitis on CTA (Hazard Ratio 2.90, p = 0.03) was associated with an increased risk of relapse.

CONCLUSION

Positivity of both CTA and FDG-PET/CT for GCA-related aortitis was associated with an increased risk of relapse. Aortic wall thickening on CTA was a risk factor of relapse compared with isolated aortic wall FDG uptake.

Renal and vascular outcomes in patients with isolated antiphospholipid syndrome nephropathy

BACKGROUND

Antiphospholipid syndrome (APS) nephropathy (APSN) is a rare pattern with specific features resulting from microvascular lesions. The prognosis of APSN, outside of lupus nephritis, is unknown. The aim of this study was to describe the renal, vascular and overall outcomes of patients with APSN.

METHODS

Retrospective multicenter study of patients with antiphospholipid antibodies (aPL) associated with histological APSN lesions and no other nephropathy, identified through a national call for medical records. End-stage renal disease (ESRD)-free survival, thrombosis recurrence-free survival and overall survival were assessed.

RESULTS

Thirty patients were included (19 women) with a median age of 40 years (34-52 years). Fifteen patients had APS, 26/28 had lupus anticoagulant, and 15/26 had triple positivity for aPL. Median eGFR was 50 (31-60) mL/min/1.73 m². Glomerular thrombotic microangiopathy was found in 12/24 cases, fibrous intimal hyperplasia in 12/22 cases and focal cortical atrophy in 17/29 cases. Nineteen patients had moderate to severe interstitial fibrosis (>25%). Six patients developed ESRD at a median follow-up of 6.2 (1.8-9.1) years. The ESRD-free survival rates at 5 and 10 years were 80.0% (95% CI 57.6%-91.4%) and 72.7% (95% CI, 46.9%-87.4%) respectively. None of the histological factors considered was significantly associated with a decrease in eGFR at 12 months. Thrombosis recurrence-free survival was 77.8% (95% CI 48.2%-91.6%) at 10 years. Overall survival was 94% at 10 years (95% CI 65.0%-99.2%).

CONCLUSIONS

The renal prognosis of isolated APSN is poor. The severe fibrotic lesions observed are suggestive of late diagnosis.

FDG/PET-CT findings in a first series of 10 patients with polyarteritis nodosa

OBJECTIVE

18F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) is widely used in patients with large-vessel vasculitis. The benefits of FDG-PET/CT in polyarteritis nodosa (PAN) has only ever been assessed in three case reports. Our aim was to describe FDG-PET/CT findings in 10 patients with newly diagnosed PAN.

METHODS

This was a retrospective study of patients with PAN who underwent FDG-PET/CT at diagnosis, between 2017 and 2020. The FDG-PET/CT data were analysed retrospectively.

RESULTS

Ten patients were included: nine men and one woman with a median age of 67 (43-78) years. PAN was diagnosed according to ACR criteria in nine patients, and histologically in one case. All patients had high C-reactive protein levels (median, 223 mg/l). The main FDG-PET/CT abnormality was increased tracer uptake in the muscles, particularly in the connective tissue (perimysium, epimysium) (n = 7), in linear (n = 5) or focal (n = 2) patterns. Increased FDG uptake in large-diameter vessels was observed in four patients, in the humeral (n = 4), femoral (n = 1) and the common interosseous arteries (n = 1). Nine patients had bone-marrow FDG uptake, six had splenic FDG uptake. Three had synovitis and three had lymph-node uptake. One patient had subcutaneous FDG uptake, with a "leopard skin" appearance.

CONCLUSIONS

FDG-PET/CT seems to be a useful non-invasive imaging technique for diagnosing PAN, particularly in patients with non-specific systemic features. Tracer uptake in muscular connective tissue seems to be a recurrent sign in patients with PAN and may be pathognomonic.

POS0822 NEW FACES OF POLYARTERITIS NODOSA: 18F-FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY FINDINGS IN A SERIES OF 10 PATIENTS

Background:

18F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) is widely used in patients with large-vessel vasculitis (1). The benefits of FDG-PET/CT in polyarteritis nodosa (PAN) has only been assessed in a few case reports (2-3).

Objectives:

Our aim was to describe FDG-PET/CT findings in 10 patients with newly diagnosed PAN.

Methods:

This was a retrospective study of patients with PAN who underwent FDG-PET/CT at the time of diagnosis, between 2017 and 2020. The FDG-PET/CT data were analysed retrospectively and compared with clinical, biological, histological and conventional imaging data.

Results:

Ten patients were included: 9 men and 1 woman, median age of 67 (43–78) years. PAN was diagnosed according to ACR criteria (6) in 9 patients, and histologically in the remaining patient. The clinical manifestations were: systemic (n=10), muscular (n=6), joint (n=3), skin (n=3), peripheral nervous system (n=3), and gastrointestinal (n=2). All patients had high C-reactive protein levels (median, 223 mg/L). One patient had incomplete FDG-PET exploration. Three patients had begun corticosteroid therapy before their FDG-PET/CT scan. The main FDG-PET/CT abnormality was increased tracer uptake in the muscles, particularly in the connective tissue (perimysium, epimysium) (n=7), in linear (n=5) or focal (n=2) patterns. Increased FDG uptake in large-diameter vessels was observed in 4 patients, in the humeral (n=4), femoral (n=1) and the common interosseous (n=1) arteries. Nine patients had bone-marrow FDG uptake, six had splenic FDG uptake. Three patients had synovitis. Three had lymph-node uptake. One patient had subcutaneous FDG uptake, with a “leopard skin” appearance.

Conclusion:

FDG-PET/CT seems to be a useful non-invasive imaging technique for diagnosing PAN, particularly in patients with non-specific systemic features. Tracer uptake in muscular connective tissue seems to be a recurrent sign in patients with PAN.

References:

[1]Prieto-González S, Depetris M, García-Martínez A, Espígol-Frigolé G, Tavera-Bahillo I, Corbera-Bellata M et al. Positron emission tomography assessment of large vessel inflammation in patients with newly diagnosed, biopsy-proven giant cell arteritis: a prospective, case-control study. Ann Rheum Dis. 2014;73(7):1388-92.

[2]Mino N, Yamashita H, Takahashi Y, Kaneko H. Polyarteritis Nodosa With Reversible FDG Accumulation in Vessels and Kidneys. Clin Nucl Med. 2019;44(11):889-891.

[3]Schollhammer R, Schwartz P, Jullie ML, Pham-Ledard A, Mercie P, Fernandez P et al. 18F-FDG PET/CT Imaging of Popliteal Vasculitis Associated With Polyarteritis Nodosa. Clin Nucl Med. 2017;42(8):e385-e387.

[4]Lightfoot RW Jr, Michel BA, Bloch DA, Hunder GG, Zvaifler NJ, McShane DJ et al. The American College of Rheumatology 1990 criteria for the classification of polyarteritis nodosa. Arthritis Rheum. 1990;33(8):1088-93.

Disclosure of Interests:

None declared

Nonhemorrhagic joint disorders and vitamin K antagonists: an under-recognized adverse drug reaction?

Isolated arthralgia, without hemorrhagic side effect, exists and is considered as a very rare adverse drug reaction according to vitamin K antagonists' (VKAs) summary of product characteristics. Up to now, there are no literature reports of isolated, nonhemorrhagic joint complications in patients receiving VKAs. Hence, the objective of this study was to describe cases of VKA-related nonhemorrhagic joint disorders (fluindione, warfarin, and acenocoumarol) reported in the French Pharmacovigilance Database (FPVD). Sixty-one reports (male : female ratio, 1.18; median [interquartile range (IQR)] age: 60 [49-72]) were found. Fluindione, warfarin, and acenocoumarol were respectively suspected in 42, 12, and 7 cases. Arthralgia was reported in 47 cases (77%), arthritis in nine cases (15%), capsulitis in three cases (5%), and bursitis in two cases (3%). Although the joint symptoms mainly concerned the lower limbs, all types of joints were affected. Arthralgia was associated with myalgia in 14 cases and with tendinitis in three cases. The median (IQR) time interval between VKA introduction and arthralgia onset was 26 (10-98) days (range: 1-6935). VKA was withdrawn in 44 cases, and a decrease in the intensity of joint symptoms was observed in 30 cases. In three cases, reintroduction of the same VKA led to the recurrence of symptoms. In view of the large prescription of this drug class worldwide, patients and clinicians (and especially primary care physicians and geriatricians) should be aware of this possible adverse drug reaction when confronted with joint disorders in patients of all ages taking VKAs.