Ari Stiel Radu Halpern

Chronic recurrent multifocal osteomyelitis primarily affecting the spine treated with anti-TNF therapy.

Study Design. A case report describing chronic recurrent multifocal osteomyelitis (CRMO) with initial presentation limited to spine, successfully treated by anti-TNF-&agr; therapy after failure of conventional treatment methods. Objective. To describe an unusual manifestation and treatment of a rare disease. Summary of Background Data. CRMO is a rare inflammatory bone disease that should be differentiated from bacterial osteomyelitis. Rarely, it can affect the spine and in this case the most important differential diagnosis is infectious spondylodiscitis. The disease has an unpredictable course with exacerbations and spontaneous remissions. Although the majority of cases remit spontaneously (or after the use of nonsteroidal anti-inflammatory drugs [NSAIDs]), some progressive and resistant cases have been reported. Methods. We describe a case of CRMO with an unusual clinical presentation emphasizing the importance of this finding as a differential diagnosis of spondylodiscitis and comment on the available treatment alternatives. Results. A 17-year-old man presented with debilitating dorsal spine pain. Magnetic resonance imaging of the spine revealed bone lesions at multiple vertebral levels. After failure of antibiotic treatment, the diagnosis of CRMO was suggested. An initial good response to NSAIDs was followed by a recurrent course and involvement of peripheral joints besides the use of corticosteroids and other drugs. The introduction of infliximab was followed by complete remission of the disease. Conclusion. Our observation highlights the need of awareness for the differential diagnosis in suspected cases of osteomyelitis not responding to antibiotics. Anti-TNF-&agr; agents should be considered in CRMO refractory cases.

Axial gout is frequently associated with the presence of current tophi, although not with spinal symptoms.

Study Design. Prospective cross-sectional study. Objective. To analyze the association of tomographically identified axial gouty lesions with clinical and laboratory characteristics. Summary of Background Data. Axial gout might be more common than previously thought. The true relationship of these lesions to symptoms or other gout-associated features is poorly understood. Methods. Forty-two patients with gout underwent thoracic and lumbar spine computed tomographic (CT) scans. CT scans were read by an experienced radiologist blinded to the features of the patients. Axial gout was defined as the presence of bony erosions, facet joints, or disc calcification and tophi in the axial skeleton. Epidemiological and clinical data were collected from medical records. At study entry, patients were evaluated for axial symptoms (back pain or neurological complaints) and subcutaneous tophi. The Fisher exact test and the Student t test were performed for statistical analyses of data. Results. Twelve (29%) of the 42 patients had CT evidence of axial gout. Axial tophi were identified in 5 patients (12%), interapophyseal joints erosions or calcifications in 7 patients (17%), and discal abnormalities in 9 patients (21%). Lumbar spine involvement was a universal finding. Five patients (42%) had thoracic spine involvement and 2 patients (18%) had sacroiliac lesions. No association was found between symptoms and axial gout (P = 0.62). Duration of gout, mechanism of disease (overproduction vs. underexcretion), and metabolic comorbidities were not related to axial involvement. A higher prevalence of axial gout was found between patients with current peripheral tophi (67% vs. 30%; P = 0.03); however, no association was found in patients with a past history of tophi (P = 0.72). Conclusion. Our study demonstrated a high prevalence of axial gout not associated with spine symptoms. This finding introduces a differential diagnosis in axial lesions in patients with gout. In addition, the unique association with a current but not previous history of peripheral tophi suggests that gout treatment might be effective in preventing or solving gout axial lesions. Level of Evidence: 3

Atualização do tratamento das vasculites associadas a anticorpo anticitoplasma de neutrófilos

In its various forms, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is characterized by a systemic inflammation of the small and medium-sized arteries (especially in the upper and lower respiratory tracts, as well as in the kidneys). The forms of AAV comprise Wegeners granulomatosis (now called granulomatosis with polyangiitis), microscopic polyangiitis, renal AAV, and Churg-Strauss syndrome. In this paper, we discuss the phases of AAV treatment, including the induction phase (with cyclophosphamide or rituximab) and the maintenance phase (with azathioprine, methotrexate, or rituximab). We also discuss how to handle patients who are refractory to cyclophosphamide.

Camptocormia secundária à polimiosite

Camptocormia is a postural affliction characterised by abnormal flexion of the thoracolumbar spine, which appears upon standing, increases with walking, and disappears in the supine position. Only five cases of camptocormia secondary to idiopathic inflammatory myopathies have been described in the literature. In this case report, we describe the case of a male patient 67 years of age who suffered from polymyositis for 18 years, which was associated with manifestations compatible with camptocormia. The clinical manifestations were stable and did not progress. Polymyositis is an idiopathic inflammatory myopathy clinically characterised by symmetric weakness that predominantly affects the proximal muscles. Nevertheless, polymyositis is a systemic autoimmune disease; therefore, the skeletal muscles may be diffusely affected, including the paravertebral muscles, which may manifest as camptocormia.

Estudo prospectivo de fatores prognósticos em lombalgia crônica tratados com fisioterapia: papel do medo‐evitação e dor extraespinal

OBJECTIVE To identify the prognostic factors for conventional physical therapy in patients with chronic low back pain (CLBP). METHODS Prospective observational study. PARTICIPANTS One hundred thirteen patients with CLBP selected at the Spinal Disease Outpatient Clinic. MAIN OUTCOME MEASURES Pain intensity was scored using the Numeric Rating Scale (NRS), and function was measured using the Roland-Morris Disability Questionnaire (RMDQ). RESULTS The Fear-Avoidance Beliefs Questionnaire work subscale results (FABQ-work; odds ratio [OR]=0.27, 95% confidence interval [CI] 0.13 to 0.56, p<0.001) and extraspinal pain (OR=0.35, 95% CI 0.17 to 0.74, p=0.006) were independently associated with a decreased response to conventional physical therapy for CLBP. CONCLUSION We identified high FABQ-work and extraspinal pain scores as key determinants of a worse response to physical therapy among CLBP patients, supporting the need for a special rehabilitation program for this subgroup.

A prospective study predicting the outcome of chronic low back pain and physical therapy: the role of fear-avoidance beliefs and extraspinal pain

OBJECTIVE To identify the prognostic factors for conventional physical therapy in patients with chronic low back pain (CLBP). METHODS Prospective observational study. PARTICIPANTS One hundred thirteen patients with CLBP selected at the Spinal Disease Outpatient Clinic. MAIN OUTCOME MEASURES Pain intensity was scored using the Numeric Rating Scale (NRS), and function was measured using the Roland-Morris Disability Questionnaire (RMDQ). RESULTS The Fear-Avoidance Beliefs Questionnaire work subscale results (FABQ-work; odds ratio [OR]=0.27, 95% confidence interval [CI] 0.13-0.56, p<0.001) and extraspinal pain (OR=0.35, 95% CI 0.17-0.74, p=0.006) were independently associated with a decreased response to conventional physical therapy for CLBP. CONCLUSION We identified high FABQ-work and extraspinal pain scores as key determinants of a worse response to physical therapy among CLBP patients, supporting the need for a special rehabilitation program for this subgroup.

SAT0369 Spinal Lesions due to Tophaceous Gout – a Differential Diagnosis not Related to Symptoms

Background Axial gout was first described in 1950, and, since then, only a few anecdotal cases with severe neurological manifestations and adverse outcomes have been reported. Although traditionally considered to be rare, some evidences suggest that axial lesions due to gout might be more common than previously thought. The true relationship of these lesions to symptoms or other gout-associated features is poorly understood. Objectives We, therefore, aimed to describe the frequency of axial skeleton lesions in gout patients and to analyze the possible association of tomographically-identified axial gouty lesions and patients’ clinical or physiopathological characteristics. Methods Forty-two patients with gout diagnosed according to the 1977 ACR criteria underwent thoracic and lumbar spine computerized tomographic (CT) scans. CT scans were read by an experienced radiologist who was blinded to the clinical features of the patients. Axial gout was defined when specific gout features such as bony erosions, facet joints or disc calcification and tophi were present in the axial skeleton. Patients were included and underwent the scans in a prospective fashion, and a cross-sectional analysis of data was performed. Epidemiologic and clinical data were collected from chart reviews. All patients were questioned about axial symptoms (back pain or neurological complaints) and examined clinically, in the inclusion visit, for subcutaneous tophi. Urate hypoexcretion was defined as a urate clearance of less than 7.5 ml/min. Hyperuricemia was defined as a serum uric acid higher than 7.0 mg/dL for men or higher than 6.0 mg/dL for women. Chi-square, Fisher’s exact test and Student’s T test were performed for statistical analyses of association between variables. Results Patients were mainly male (93%). Mean age was 62.7 ± 11.1 years. Twelve (29%) of the 42 patients had CT evidence of axial gout, with axial tophi being identified in 5 (12%) subjects, interapophyseal joints erosions or calcifications in 7 (17%) and discal abnormalities (erosions or calcifications) in 9 (21%) subjects. Lumbar spine was always affected. Five (42%) had thoracic spine involvement and 2 (18%) had sacroiliac lesions as well. Despite the high prevalence of back pain and/or neurological manifestations (48% of the total population), no association was found between axial symptoms and axial gout (p=0,62). Duration of gout, mechanism of disease (hyperproduction vs. hypoexcretion) and metabolic commorbidities were also not related to the presence of axial involvement. Interestingly, a higher prevalence of axial gout was found between patients with current peripheral tophi (67% v. 30%; p=0,03), however no association was found with a past history of tophi that had already vanished due to therapy (p=0,72). Conclusions Our study found out a striking 29% prevalence of spine lesions in gout patients. When dealing with axial lesions in these patients, a suitable differential diagnosis that should be remembered is axial gout itself, even in the absence of symptoms, since it might be more common than previously thought and no association with axial symptoms has been reported. The fact that axial lesions were associated to currently existing peripheral tophi but not to a previous history of tophi points out to the fact that gout treatment might be effective in preventing or solving axial lesions. Disclosure of Interest None Declared

Isolated necrotizing granulomatous vasculitis of the uterine cervix associated with human papillomavirus infection

Single organ vasculitis (SOV), or isolated vasculitis, has been described in several organs and it can be an accidental finding. We report a case of isolated necrotizing granulomatous vasculitis of the uterine cervix in a middle-aged woman, previously healthy, and sexually active, and whose human papillomavirus (HPV) DNA hybrid capture assay was positive. Systemic involvement was not detected and, since the lesion was completely removed, we opted for a clinical follow-up. The literature has very few reports on the isolated involvement of the female genital tract, and some had concomitant lesions that could be caused by the HPV, indicati.