Ahmed M. Elsaman

Amyloid arthropathy associated with multiple myeloma: a systematic analysis of 101 reported cases.

OBJECTIVE Amyloid deposition in multiple myeloma (MM) may lead to an arthropathy resembling rheumatoid arthritis (RA). Since a systematic description of its natural history is lacking, we have performed a systematic analysis of all published cases. METHODS Literature review featuring backward and forward database searches and direct inspection of reference lists. Inclusion criteria were as follows: publication between 1931 and 2012, diagnosis of multiple myeloma, and demonstration of light chain amyloid (AL) in any organ or in synovial fluid, arthritis, or synovitis. RESULTS Overall, 101 cases were identified. Median age was 59 years and the male-to-female ratio was 1:1. A systemic manifestation of MM was reported in 88 cases. In 53 of these, characteristic physical findings (carpal tunnel syndrome, macroglossia, shoulder pad, and soft tissue swelling/masses) were present. Arthritis manifested before the diagnosis of MM in 63 cases, with 33 cases initially misdiagnosed as RA. There were 72 cases of poly-, 17 of oligo-, and three of monoarthritis. The shoulder joint was most commonly affected, followed by knees and small hand joints. Median synovial fluid leukocyte count was 2460 cells/mm(3), and was normal in seven cases. Synovial histopathology often featured mild synovitis without plasma cell infiltration. Imaging revealed articular or periarticular inflammation in many cases and bone lesions near 22% of affected joints. Treatments varied but led to some improvement in the majority of cases. CONCLUSIONS These results solidify previous experience that MM arthropathy tends to feature a symmetric RF-negative nonerosive polyarthritis. However, the results also highlight the diversity of its presentations and stress the importance of arthropathy as a potentially under-recognized presenting manifestation of MM.

Low-dose Spironolactone: Treatment for Osteoarthritis-related Knee Effusion. A Prospective Clinical and Sonographic-based Study.

Objective. To evaluate the effectiveness of spironolactone as a treatment for osteoarthritis (OA)-related knee effusion in comparison to ibuprofen, cold compresses, and placebo. Methods. This study was carried out on 200 patients, aged 40 years or older, attending the outpatient clinic of the Rheumatology Department of Sohag University Hospital with unilateral knee effusion related to OA based on clinical examination, musculoskeletal ultrasonography (US), and synovial fluid analysis. In group 1, 50 patients received spironolactone 25 mg daily for 2 weeks; in group 2, 50 patients took ibuprofen 1200 mg daily for 2 weeks; in group 3, 50 patients used cold compresses 2 times daily for 2 weeks; and in group 4, 50 patients received placebo for the same duration. Fluid > 4 mm was considered as effusion. Decrease in fluid to reach below 4-mm thickness was considered complete improvement, and any decrease that did not reach below 4 mm thickness was considered partial improvement. Results. The mean age of the participants was 51.2 ± 8.1 years. The mean duration of effusion was 16.5 ± 3.6 days. In group 1, 66% had complete improvement, 20% partial improvement, and 14% no response. In group 2, 24% had complete improvement, 12% partial improvement, and 64% no response. In group 3, 28% had complete improvement, 14% partial improvement, and 58% no response. In group 4, only 6% had complete improvement, 10% partial improvement, and 84% no response. Conclusion. Low-dose spironolactone is a safe and effective medical treatment for OA-related knee effusion.

Amyloid arthropathy associated with multiple myeloma: polyarthritis without synovial infiltration of CD20+ or CD38+ cells

Abstract Objectives: To describe histological, immunohistochemical and ultrastructural features of synovial biopsies of amyloid arthropathy associated with multiple myeloma (MM). Methods: Synovial biopsies from affected joints of two patients with MM and amyloid arthropathy were examined with light and electron microscopy, and immunohistochemically for expression of CD3, CD8, CD20, CD38, CD68, Ki-67 and vWF. Results were compared to values from osteoarthritis (OA, n = 26), rheumatoid arthritis (RA, n = 24) and normal (n = 15) synovial membranes. Results: There was no or only mild lining hyperplasia. Vascular density was not elevated, and there were few Ki-67+ proliferating cells in the stroma. The Krenn synovitis score classified one specimen as “low-grade” and one as “high-grade” synovitis. CD68+ and CD3+ cells were the predominant mononuclear inflammatory cells, whereas CD20+ and CD38+ cells were absent from both synovial membrane and synovial fluid sediment. Electron microscopy demonstrated amyloid phagocytosis by synovial macrophages. In hierarchical clustering the two amyloid arthropathy specimens were more closely related to OA than to RA or normal synovium. Conclusions: This first detailed immunohistological analysis of MM-associated amyloid arthropathy suggests that it is a chronic synovitis that evolves despite the loss of humoral immunity seen in advanced MM. Instead, amyloid phagocytosis by synovial macrophages likely triggers and perpetuates local disease.

Idiopathic Carpal Tunnel Syndrome: Evaluation of the Depth of the Carpal Tunnel by Ultrasonography.

The objective of the work described here was to evaluate the depth of the carpal tunnel (DCT) in patients with idiopathic carpal tunnel syndrome (CTS) and healthy volunteers by ultrasonography (US), through measurement of the distance from the flexor retinaculum to the surface of the capitate bone at the carpal tunnel outlet, and compare it with other ultrasonographic and electrophysiologic parameters in CTS. The study was conducted in 60 non-diabetic patients with idiopathic carpal tunnel syndrome (unilateral n = 37, bilateral n = 23) evidenced by electrophysiologic diagnosis according to the criteria of the American Association of Electrodiagnostic Medicine (AAEM). Furthermore, 40 hands from 20 healthy volunteers were examined. Median nerve cross-sectional area (CSA); flattening ratio (FR), the ratio of the length to the width of the median nerve; and DCT at the canal outlet were measured for all participants. The mean age was 35.6 ± 9.48 y. The female-to-male ratio was 47:13 in the CTS patients. The sensitivity and specificity were 82% and 95% for CSA, 75% and 60% for FR and 75% and 87.5% for DCT, respectively. Differences between patients and healthy controls were significant for all three parameters, greatest for DCT, followed by CSA and then FR. We conclude that DCT increased in CTS and this new parameter is comparable in sensitivity and specificity to CSA and FR. DCT increased independently of the cause of the CTS (decrease in size of canal or increase in contents).

Ankle Evaluation in Active Rheumatoid Arthritis by Ultrasound: A Cross-Sectional Study

Ankle joint evaluation is underestimated in many clinical and sonographic scores used for evaluation and follow-up of rheumatoid arthritis (RA) patients. Agreement on examination parameters is poor among sonographic scores that include the ankle joint. More effort is needed to detect the value of ankle joint examination in RA and assessment of ultrasonographic signs according to frequency, disease duration and activity. The objective of this study was to use ultrasound (US) to detect ankle involvement in active RA and to compare findings with disease duration, disease activity and assessment of ankle bone erosion. A total of 63 RA patients with active disease and 20 controls were included in the study. The tibiotalar and talonavicular joints were examined by US for synovitis and/or effusion in gray-scale and power Doppler modes. The anterior, lateral and posterior ankle tendons were examined for tenosynovitis and tendinosis. Mean age was 35.1 ± 8.3 y, mean disease duration was 22.7 ± 9.6 mo and the mean 28-joint Disease Activity Score-erythrocyte sedimentation rate was 3.05 ± 0.66. Ankle involvement was seen in 28 patients (44.4%). The most frequent pathologies detected were tenosynovitis (30.2%), followed by synovitis (18.3%), erosion (8.7%) and tendinosis (4%). The earliest sonographic signs were tenosynovitis, followed by synovitis, erosion and tendinosis. The right ankle exhibited greater involvement than the left ankle, which was significant with respect to erosions (p = 0.009). The most common tendon affected by tenosynovitis was the tibialis anterior (22.2%), followed by the tibialis posterior (20.6%). Tenosynovitis, especially of the tibialis anterior and posterior, tibiotalar synovitis and erosions should be considered in future US ankle scores for the assessment of RA.

AB0291 Epidemiology and comorbidity of rheumatoid arthritis in upper egypt, a hospital based study

Background Rheumatoid arthritis (RA) is one of the commonest autoimmune diseases. It affects about 1% of the population worldwide (1). The prevalence of RA varies widely between different countries (2). Not only the prevalence of the disease which differs among different continents, races, ages and socioeconomic levels but also the disease pattern. Studies explaining the epidemiology of RA in Egypt in general and in upper-Egypt, in particular, are very limited (3). Objectives To estimate the comorbidity of rheumatoid arthritis and its relation to disease activity, duration, disease pattern and demographic features of RA patients in upper Egypt. Methods This study was carried out on 923 patients who fulfilled ACR/EULAR criteria 2010. All of them live in Sohag governorate and aged 18 years or older DAS28-ESR score, first involved joint, joint distribution, disease pattern, extra-articular comorbidities including gastrointestinal, urinary, cardiac, haematological and neurological were estimated. The activity of daily living was valued by Erlangen score (E-ADL). Results The mean age of the participants was 45±10.9 years, with a range (19–70). The median of the disease duration was 5 years, with a range (0.5–40 years). Most of the participants were female (691, 74.9%). Disease onset was gradual or insidious in 94.3% of cases and acute in 5.7% of them. First joint group affected were the small joints of the hands (MCPs and PIPs), recorded in 48.9% of cases, Followed by wrist joints (29.3% of cases), then knees (9%), ankles and small joints of the foot (6%) and lastly other joints collectively recorded in only 6.8%. The commonest extra-articular comorbidities were haematological, seen in 323 cases; 35%, followed by gastrointestinal in 290 cases (31.4%), then ophthalmological in 31%, entrapment syndromes in 29.4%, pulmonary in 21.7%, urological in 12.4%, rheumatoid nodules in 11.4%, liver cirrhosis in 8.7%, renal impairment in 8.5% and Cardiovascular diseases in 6.5%. The activity of daily living (E-ADL) showed that most of the cases fell in score 4 (58.2%). Regarding DMARDs treatment of the study population, Methotrexate (MTX) was used regularly by 78.3% of cases, hydroxychloroquine (HCQ) by 78.1%, followed by Leflunomide (LEF) by 26.4% and sulfasalazine (SSZ) by 13.1%. The majority of cases used combination therapy of either MTX+HCQ, MTX+SSZ, MTX+HCQ+SSZ or MTX+LEF. Regarding other drugs, 99% of cases used NSAIDs (regularly in 30.2% and on demand in 68.8%). Steroids were regularly used by 28.8% of cases. Conclusions The commonest comorbidities were haematological, gastrointestinal, ophthalmological and neurological ones; respectively. Erosion, deformity and Das28-ESR score have a great impact on E-ADL score. References Gibofsky A. Overview of epidemiology, pathophysiology, and diagnosis of rheumatoid arthritis. Am J Manag Care. 2012;18(13 Suppl):S295–302. Ferucci ED, Templin DW, Lanier AP, editors. Rheumatoid arthritis in American Indians and Alaska Natives: a review of the literature. Seminars in arthritis and rheumatism; 2005: Elsevier. El-Labban AS, Omar HAA, El-Shereif RR, Ali F, El-Mansoury TM. Pattern of young and old onset rheumatoid arthritis (YORA and EORA) among a group of Egyptian patients with rheumatoid arthritis. Clinical medicine insights Arthritis and musculoskeletal disorders. 2010;3:25. Disclosure of Interest None declared

Dr. Elsaman, et al reply

To the Editor: The theory that pain in osteoarthritis (OA) is due to effusion is not answered in our study1. All the patients included in our study initially had effusion on clinical and ultrasound examination1. To prove the theory that pain in OA had been due … Address correspondence to Dr. S. Ohrndorf, MD, Department of Rheumatology and Clinical Immunology, Charite Universitatsmedizin Berlin, Chariteplatz 1, Berlin, Germany. E-mail: sarah.ohrndorf{at}charite.de

SAT0434 Osteoarthritis Related Effusion: Follow up of Pain and Fluid Thickness after Treatment with Spironolactone. A Prospective Study

Background Osteoarthritis (OA) is a group of mechanical disorders leading to joint components degradation, including articular cartilage and subchondral bone. Incidence and prevalence of knee OA is rising by increasing average age of general population and increasing obesity (1). Treatment of knee effusion includes: rest, cold compresses, elevation, NSAIDS and aspiration (2). Spironolactone is a specific pharmacologic antagonist of aldosterone, acting primarily through competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule. (3). Objectives Evaulation of low dose Spironolactone as a treatment for osteoarthritis related effusion using ultrasound and pain VAS. Methods This study was carried out on 200 patients who aged 40 years or above with unilateral knee effusion related to osteoarthritis based on clinical examination, musculoskeletal ultrasonography (US) and synovial fluid analysis. Group 1 consisted of 50 patients received spironolactone 25 mg daily for 2 weeks, in group 2; 50 Patients took Ibuprofen 1200 mg daily for two weeks, in group 3; 50 patients used cold compresses two times daily for two weeks, and in group 4; 50 patients received placebo for the same time duration. Visual analog scale (VAS) for pain was done to the study participant at time 0 (baseline), after 2 weeks and after 4 weeks. Results The mean age of the participants was 51.2±8.1 years. The mean duration of effusion was 16.5±3.6 days. In group 1, 66% had complete improvement, 20% partial improvement and 14% no response. In group 2, 24% had complete improvement, 12% partial improvement and 64% no response. In group 3, 28% had complete improvement, 14% partial improvement and 58% no response. In group 4, 6% had complete improvement, 10% partial improvement and 84% no response. VAS had a strong relation to fluid thickness as it decreased with the improvement of effusion and increased again among those patients who developed recurrence after 4 weeks. Conclusions Low dose spironolactone is a safe and effective medical treatment for OA related knee effusion, especially in mild and moderate knee effusion. References Abraham AM, Pearce MS, Mann KD, Francis RM, Birrell F. Population prevalence of ultrasound features of osteoarthritis in the hand, knee and hip at age 63 years: the Newcastle thousand families birth cohort. BMC Musculoskeletal Disorders. 2014;15(1):162. Jones A, Doherty M. Osteoarthritis. Oxford: Clinical Pub.; 2013. Pratt JH, Eckert GJ, Newman S, Ambrosius WT. Blood pressure responses to small doses of amiloride and spironolactone in normotensive subjects. Hypertension. 2001;38(5):1124–9. Acknowledgement We thank Professor Dr. Marina Backhaus for providing ultrasonography training course in the rheumatologic department at the Charité Universitätsmedizin, Berlin, Germany, and also Dr. May Hasan for recruiting patients for the study at the Sohag University in Egypt Disclosure of Interest None declared