Jean-Paul Eschard

Infliximab-induced hepatitis: absence of cross-toxicity with etanercept

We describe a patient presenting with acute hepatitis while receiving infliximab for ankylosing spondylitis. A slight increase in serum aminotransferases was first observed in this patient after 4 infusions of infliximab. The treatment was stopped after the 6th infusion when laboratory work-up revealed a 10-fold increase in serum levels of aminotransferases. A liver biopsy showed interportovenular bridging necrosis with macrophage accumulation consistent with the diagnosis of acute toxic hepatitis. After infliximab discontinuation, hepatic abnormalities resolved and the patient was treated with etanercept for more than 2 years without recurrence of hepatitis. This case underlines the lack of hepatic cross-toxicity between infliximab and etanercept making possible the continuation of anti-TNF-alpha therapy with etanercept in patients who have presented infliximab-related hepatic dysfunction.

Single-photon emission computed tomography combined with computed tomography (SPECT/CT) in bone diseases

Radionuclide bone scanning was proven effective many years ago. Its main advantages are good sensitivity, limited radiation exposure, and noninvasiveness. However, increased radionuclide uptake by a lesion is not specific, and differentiating malignant from nonmalignant disorders may therefore be difficult. An additional structural imaging study is often needed to establish the final diagnosis. Furthermore, the limited resolution of radionuclide bone scanning images does not allow accurate localization of the lesions. Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) provides both structural and functional information. SPECT/CT has been proven useful for interpreting radionuclide bone scan results in patients with bone malignancies, showing far better specificity than planar imaging or SPECT alone, most notably in the evaluation of spinal abnormalities. SPECT/CT provides an accurate evaluation of the site of the lesions and also supplies other information that can be useful in nonmalignant conditions such as injuries, infections, and degenerative disease. Nevertheless, there are only a few published studies on the usefulness of SPECT/CT in nonmalignant conditions. However, SPECT/CT is only starting to become available and may become a routine investigation for a number of rheumatic disorders.

Economic impact of lower-limb osteoarthritis worldwide: a systematic review of cost-of-illness studies

OBJECTIVE An overview of the economic consequences - overall costs as well as cost breakdown (direct and indirect) - of hip and knee osteoarthritis (OA) worldwide. METHODS A systematic literature search of EMBASE, MEDLINE, Scopus and Cochrane databases for articles was performed independently by two rheumatologists who used the same predefined eligible criteria. Papers without abstracts and in languages other than English or French were excluded. Extracted costs were converted to an annual cost and to 2013 euros (€) by using the Consumer Price Index of the relevant countries and the 2013 Purchasing Power Parities between these countries and the European Union average. RESULTS A total of 45 abstracts were selected, and 32 articles were considered for the review. The studied populations were heterogeneous: administrative, hospital and national health survey data. Annual total costs per patient ranged from 0.7 to 12 k€, direct costs per patient from 0.5 to 10.9 k€ and indirect costs per patient from 0.2 to 12.3 k€. The weighted average annual costs per patient living with knee and hip OA were 11.1, 9.5 and 4.4 k€ for total, direct and indirect costs, respectively. CONCLUSIONS This review highlights the heterogeneity of studies and lack of methodologic consensus to obtain reliable cost-of-illness estimates for lower-limb OA. However, costs induced by the disease seem substantial and deserve to be more extensively explored.

Urticaire chronique-macroglobulinémie (syndrome de Schnitzler): évolution vers un myélome à IgM. À propos d'un cas

Schnitzlers syndrome has been described in 1972. It associates a chronic urticaria with leukocytoclastic vasculitis, a macroglobulinemia, bone pains, hyperostosis. In the twenty three cases reported, the evolution is benign but three patients including the princeps case developed a Waldenströms disease or a lymphoplasmocytic lymphoma. We present the case of one patient, aged 65, with Schnitzlers syndrome, who, after 6 years evolution, presents a IgM myeloma. Schnitzlers syndrome appeared as a pre-hemopathic state which has to be taken care of regularly and for a long time.

Tuberculose lors d'un traitement par agents inhibiteurs du TNF alpha

Key points The clinical forms of tuberculosis that occur during anti-TNFα treatment are frequently extrapulmonary or even disseminated and life-threatening. The paradoxical reactions that can occur under appropriate treatment after stopping TNFα inhibitors raise the question of an immune restoration phenomenon. Adverse drug reaction reporting and epidemiologic studies, despite their methodological limitations, appear to show an excess risk of tuberculosis. Experimental studies reinforce these data. The French drug agency (Afssaps) has issued guidelines for the prevention and management of tuberculosis occurring under anti-TNFα treatment. Analogous guidelines in Spain led to a reduction in the incidence of these cases.The clinical forms of tuberculosis that occur during anti-TNFalpha treatment are frequently extrapulmonary or even disseminated and life-threatening. The paradoxical reactions that can occur under appropriate treatment after stopping TNFalpha inhibitors raise the question of an immune restoration phenomenon. Adverse drug reaction reporting and epidemiologic studies, despite their methodological limitations, appear to show an excess risk of tuberculosis. Experimental studies reinforce these data. The French drug agency (Afssaps) has issued guidelines for the prevention and management of tuberculosis occurring under anti-TNFalpha treatment. Analogous guidelines in Spain led to a reduction in the incidence of these cases.

Efficacy but side effects of anakinra therapy for chronic refractory gout in a renal transplant recipient with preterminal chronic renal failure

Joint Bone Spine - In Press.Proof corrected by the author Available online since vendredi 27 juillet 2012

Neurogenic muscle hypertrophy

We report the case of a 48-year-old man who presented with left calf hypertrophy 6 years after an episode of left S1 sciatica related to a herniated disk. Magnetic resonance imaging disclosed muscle hypertrophy. Electromyography showed left S1 radiculopathy with abnormal spontaneous muscle activity. Neurogenic muscle hypertrophy is a rare phenomenon that is chiefly seen when denervation occurs slowly and gradually. The typical patient is a middle-aged man who has a history of S1 radiculopathy. The soleus muscle is the main site of involvement. The pathophysiology is unclear but may involve type I fiber hypertrophy in response to the complex repetitive discharges recorded by electromyography. The natural history of neurogenic muscle hypertrophy is incompletely understood.

Diagnostic contribution of a second percutaneous needle biopsy in patients with spontaneous diskitis and negative blood cultures and first biopsy.

OBJECTIVES The primary objective was to assess the diagnostic contribution of a second percutaneous needle biopsy in patients with spontaneous diskitis and negative findings from blood cultures and the first biopsy. We also assessed the sensitivity of the first biopsy and the diagnostic contribution of post-biopsy blood cultures. METHODS Multicenter retrospective study of patients managed between 2004 and 2014. We excluded patients with postoperative diskitis. RESULTS We identified 63 patients with spontaneous diskitis, negative blood cultures, and at least one percutaneous needle biopsy during the study period. The first biopsy established the diagnosis in 33 (52%) patients. Of the 30 remaining patients, 10 (33%) had a second biopsy, which was positive in 6 (60%), and 20 (67%) received probabilistic antibiotic therapy. There were 8 positive blood cultures after the first biopsy but, among them, 7 occurred in biopsy-positive patients. Biopsy yield varied with the guidance method (needle guidance software or imaging by computed tomography and/or fluoroscopy) and operators. Antibiotic therapy within the 6months preceding the first biopsy was significantly associated with having a negative first biopsy (15/30 versus 7/33; odds ratio, 3.13; 95% confidence interval, 1.07-9.13; P<0.05). CONCLUSION In our study, a second needle biopsy was useful, providing the bacteriological diagnosis in 60% of cases of spontaneous diskitis with negative findings from blood cultures and the first biopsy.

Bone erosion and subacromial bursitis caused by diphtheria–tetanus–poliomyelitis vaccine

Revaxis(®) is a vaccine against diphtheria, tetanus and poliomyelitis (dT-IPV). This vaccine should not be administered by the intradermal or intravenous route. Poor injection techniques and related consequences are rare. We report a case of bursitis associated with reactive glenohumeral effusion complicated by bone erosion occurring after injection of the dT-IPV vaccine. A 26 year old patient was admitted for painful left shoulder causing functional impairment. Control magnetic resonance imaging showed bone oedema on the upper outer part of the humeral head, with a slight cortical irregularity, indicating that the vaccine was injected in contact with the bone at this location, causing erosion. Outcome was favourable after intra-articular corticosteroids. Reports of articular or periarticular injury after vaccination are extremely rare, in view of the substantial number of vaccines administered every year. The potential complications of vaccination are well known to general practitioners but under-reported in the literature.

Failure of tocilizumab therapy in a patient with mouth and genital ulcers with inflamed cartilage syndrome complicated by aortic aneurysm

Giacomo Maria Guidelli, Marco Bardelli, Enrico Selvi, Mauro Galeazzi and Renato De Stefano Section of Rheumatology, Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, Siena, Italy Revised version accepted 24 June 2015 Correspondence to: Giacomo Maria Guidelli, Section of Rheumatology, Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte Siena, Italy. E-mail: giacoguidelli@hotmail.com