María José Moreno Martínez

Artritis séptica esternoclavicular y empiema

Attention of a patient with a swollen joint and fever is a medical emergency due to the possibility of septic arthritis. The sternoclavicular joint is a rare localization for septic arthritis in patients without risk factors (intravenous drug users [IDU]), immunocompromised patients, diabetes, etc.).1 In this type of involvement there are serious possible complications such as abscesses, mediastinitis, osteomyelitis and empyema.1 Here, we report the case of a patient with sternoclavicular septic arthritis and secondary empyema. The patient, a 63-year-old male was admitted to our hospital for right shoulder pain lasting one week and three days with high fever. He had a painful tumor on the right sternoclavicular region and discrete pulmonary hypoventilation at the base of the same side. The rest of the examination was unremarkable and revealed no history of risk factors. He had leukocytosis with neutrophilia, elevated erythrocyte sedimentation rate (ESR) and fibrinogen, no other laboratory abnormalities. Chest X-ray showed a condensing image in the right upper lobe and a diffuse condensation of the right base (Fig. 1). Shoulder X-rays showed no abnormalities. The chest CT observed disintegration of the articular margins and periarticular fluid collection which continued to the subclavicular region, anterior pleural and right lung base (Fig. 1). We performed arthrocentesis of the acromioclavicular joint, isolating Staphylococcus aureus (S. aureus) in the synovial fluid and in blood cultures. According to the antibiogram, the patient

Vasculitis leucocitoclástica e infección. A propósito de un caso

Leukocytoclastic vasculitis is the most common cause of cutaneous vasculitis in clinical practice. Its causes are various, among which are certain infections. We report the case of a man (28 years old) who debuted with vasculitic lesions in inferior members compatibles leukocytoclastic vasculitis on pathology. The study of causation is the presence of a positive urethral discharge to Ureaplasma urealyticum, dramatically improving lesions after treatment thereof.

Relación de calprotectina fecal y anticuerpos antisacaromices con otros marcadores de actividad en pacientes con espondiloartritis

OBJECTIVE To assess the relationship between the increase of fecal calprotectin, anti-Saccharomyces cerevisiae antibodies (ASCA) and disease markers in a group of patients with spondyloarthritis. METHODS We evaluated patients who were at least 18-years-old and met the Assessment in Spondyloarthritis International Society (ASAS) criteria for spondyloarthritis or the New York modified criteria. We analyzed activity criteria, physical function, analytical criteria (human leukocyte antigen [HLA] B27, fecal calprotectin, presence of ASCA, among others) and demographic data. RESULTS We included 33 patients. All but one patient had normal ASCA values. We found statistical significance in the correlation of calprotectin with C-reactive protein (CRP) but not with other parameters. We also found a relationship between calprotectin levels and nonsteroidal anti-inflammatory drug (NSAID) intake (P=.001). We found no relationship between CRP levels and NSAID use. After discontinuation of NSAIDs for one month, we found no significant differences in calprotectin levels (P=.9). CONCLUSION Fecal calprotectin is elevated in patients with spondyloarthritis and correlates positively with CRP. Level of fecal calprotectin is not altered by NSAID use. The amount of ASCA present does not change and does not correlate with any clinical parameters in the study population.

Prevalencia de enfermedades reumáticas en población adulta en España (estudio EPISER 2016). Objetivos y metodología

AIMS To describe the methodology of the EPISER 2016 (study of the prevalence of rheumatic diseases in adult population in Spain), as well its strengths and limitations. The aim of this study is to estimate the prevalence of rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), Sjögrens syndrome (SS), osteoarthritis (knee, hip, hands, and cervical and lumbar spine), fibromyalgia, gout and clinical osteoporotic fracture. MATERIAL AND METHOD Population-based, multicenter, cross-sectional study, with the participation of 45 municipalities in the 17 Spanish autonomous communities. The reference population will consist of adults aged 20 years and over residing in Spain. A computer-assisted telephone interview (CATI) system will be used for data collection. Diagnostic suspicions and diagnoses received by the participants will be studied by rheumatologists in the referral hospitals in the selected municipalities. STATISTICAL ANALYSIS the prevalence of the rheumatic diseases will be calculated using estimators and their 95% confidence intervals. Weights will be calculated in each of the sampling stages in accordance with the probability of selection. The distribution of the population in Spain will be obtained from the Spanish Statistics Institute. CONCLUSIONS Sociodemographic and lifestyle changes over the last 16 years justify EPISER 2016. This study will provide current data about the prevalences of RA, AS, PsA, SLE, SS, osteoarthritis, fibromyalgia, gout and clinical osteoporotic fracture. The results will allow comparisons with studies from other countries and EPISER 2000.

Sacroilitis por pirofosfato cálcico

We report the case of a 50-year-old woman who presented with a 3-month history of inflammatory low back pain and arthritis of the knees, with no other type of manifestations. Laboratory analyses demonstrated an elevated C-reactive protein level (2.5 mg/dL) and erythrocyte sedimentation rate (43 mm/h) and she was found to be negative for human leukocyte antigen (HLA) B27; there were no other abnormal findings. In the initial radiological study, plain radiography demonstrated meniscal calcification in both knees and sclerosis in both sacroiliac joints; magnetic resonance imaging (MRI) showed bone marrow edema in a short-tau inversion recovery (STIR) sequence (Fig. 1A and B). We observed no syndesmophytes affecting the axial skeleton. These findings led us to consider a differential diagnosis including spondyloarthritis (SpA) and pyrophosphate arthropathy. There were rectangular extracellular crystals with positive birefringence in synovial fluid obtained from knee. We requested computed tomography (CT) of the sacroiliac joints (Fig. 1C), which showed sclerosis with linear intra-articular calcifications in both joints. The patient was diagnosed with arthritis

Spine Fracture in Ankylosing Spondylitis. About a Case

We report the case of a 44 year old man diagnosed with AS, with peripheral involvement, ten years ago. The patient suffered an accidental fall and he was attended the emergency room for neck pain without motor or sensory disorders. In the cervical spine radiographs no obvious changes are evident, so it was performed computerized tomography (CT) (Figure 1). He was diagnosed with non-displaced odontoid fracture. Prior to this event, the patient had a normal densitometry and bone metabolism analytical. During follow-up he had remained stable, without signs of neurologic involvement.

Agonista del receptor de trombopoyetina como tratamiento de trombocitopenia asociada a lupus eritematoso sistémico

Systemic lupus erythematosus (SLE) is a disease that is characterized by both the clinical manifestations and the analytical findings. According to published series, up to 30% of the patients with SLE have thrombocytopenia.1 A number of approaches have been used to treat thrombocytopenia and other hematological disorders in SLE patients (glucocorticoids, intravenous immunoglobulins, cyclophosphamide, rituximab and splenectomy, among others).2 We present the case of a woman with SLE and associated autoimmune thrombocytopenia, refractory to conventional therapies, that responded satisfactorily to treatment with a thrombopoietin-receptor agonist. The patient was a 39-year-old woman who, in 2010, had been diagnosed with SLE on the basis of thrombocytopenia, arthritis and positive tests for antinuclear, anti-Sm, anti-Ro and anti-La antibodies. Treatment was started with hydroxychloroquine (200 mg/day) and low-dose glucocorticoids (5 mg of prednisone daily), which produced an improvement in all the manifestations except thrombocytopenia. The patient’s platelet count reached levels as low as 5000/ L, and she experienced occasional epistaxis, as well as metrorrhagia. Thus, treatment was attempted with prednisone at a dose of 0.5 mg/kg/day, which was changed, in succession, to mycophenolate (2 mg/kg/day), azathioprine (100 mg/day) and rituximab, with no improvement. This led us to consult with hematologists from our hospital, and a joint decision was made to initiate treatment with oral eltrombopag (a thrombopoietin-receptor agonist) at 50 mg once daily. After 1 month of treatment, we observed an increase in the platelet count, which reached a high of 168 000/ L, making it possible to reduce the prednisone dose to 2.5 mg/day. In the literature, we found six cases of refractory thrombocytopenia associated with SLE in which there was a good response to treatment with a thrombopoietin-receptor agonist. All the patients responded to this treatment within a period of 1–3 weeks, after their disease had proved refractory to a multitude of immunomodulatory therapies (corticosteroids, intravenous immunoglobulins, rituximab, cyclophosphamide, azathioprine and splenectomy).3 The mechanisms proposed as the major causes of thrombocytopenia in SLE are antibody-mediated platelet destruction,