Stanko Težak

The lobster sign in SAPHO syndrome: unusually extensive osteitis of the anterior chest wall partially responsive to infliximab

The synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is an uncommon entity comprising several osteoarticular and cutaneous features [1]. Osteitis and hyperostosis remain key diagnostic features, since the proposed clinical criteria [2] have never been validated, especially regarding the distinction between the SAPHO syndrome and psoriatic arthritis [3]. Tumor necrosis factoralpha (TNF-a) antagonists are starting to play an important role in the treatment of patients inadequately responsive to conventional treatment [4]. We present a 48-year-old female patient diagnosed with SAPHO syndrome 5 years ago. She has been treated with nonsteroidal anti-rheumatics, sulfasalazine and methylprednisolone, with partial and unsatisfactory response in terms of clinical and laboratory features, as well as radiological and bone scan findings [5, 6]. Four years after initiating conventional treatment, she underwent a reevaluation to assess disease extent and activity. Physical examination revealed palmoplantar pustulosis and multiple joint tenderness, including sternoclavicular, costochondral, sacroiliac and peripheral joints. Laboratory investigation revealed elevated inflammatory markers, also suggesting disease activity. A technetium 99-m bone scan was subsequently performed [5]. Increased tracer uptake was observed in both sternoclavicular joints, the sternum, first ribs bilaterally, fifth and sixth ribs near the costosternal junctions and the anterior portion of the eighth left rib, resembling a lobster. It was also revealed in the right hip and pubic bone, as well as in the pubic symphysis (Fig. 1). Less pronounced accumulation was noticed in the L4 and L5 vertebrae. Infliximab was added to the treatment, leading to an almost complete regression of osteoarticular complaints and normalization of laboratory findings. However, a follow-up bone scan performed after the fourth application of infliximab revealed a pattern of tracer accumulation almost identical to the one described previously. Moreover, psoriasiform skin lesions developed on the palms and trunk following the introduction of the biological agent: although similar lesions were observed before, they were now more pronounced. The skin lesions disappeared within several weeks following the fifth application of infliximab. TNF-a antagonists are included in standard treatment strategies for seronegative spondyloarthropathies; however, their use in the SAPHO syndrome is still considered as off-label [4]. This might change in the future due to new insights into their role on the molecular level [7] and an increasing number of individual reports suggesting a positive impact on disease activity [4]. Nevertheless, some questions still remain to be answered. Our patient experienced a temporary aggravation of cutaneous lesions, which is in accordance with other authors’ findings [8]. The aggravation is probably a side effect of infliximab and not a result of worsening of the disease course. Furthermore, the impact of infliximab on bone tracer uptake should also be addressed. Although an alleviation of osteoarticular complaints was observed soon after the beginning of the biological treatment, no regression was observed on the control B. Anić I. Padjen (&) M. Barešić Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia e-mail: ivan_padjen@yahoo.ca

Estimated collective effective dose to the population from nuclear medicine diagnostic procedures in Croatia: A comparison of 2010 and 2015

Objective This study presents national surveys of patient exposure from nuclear medicine (NM) diagnostic procedures in 2010 and 2015 in the Republic of Croatia. Methods The survey was performed according to the European Commission Dose DataMed (DDM) project methodology. 28 most frequent NM diagnostic procedures were identified. Data about frequencies of procedures and average administered activities of radioisotopes used in those procedures were collected. Average administered activities were converted to effective doses according to the dose conversion coefficients. Then the collective effective dose to the population and an effective dose per capita were calculated based on the number of the most frequent NM diagnostic procedures and the average effective dose per procedure. Results In 2010, 41200 NM diagnostic procedures led to 146.7 manSv collective effective dose to the population and in 2015, 42000 NM diagnostic procedures led to 146.8 manSv collective effective dose to the population. The frequencies of NM diagnostic procedures were 9.7 and 9.8 annually per 1000 population with 34.1 μSv and 34.2 μSv effective dose per capita for 2010 and 2015, respectively. The main contributors to the annual collective dose from NM in Croatia are examinations of the bone, heart, thyroid and PET/CT tumour diagnostic. Average administered activities have not changed considerably from 2010 to 2015. Nevertheless, within the frequency of some of the procedures, significant changes were found in five-year period. Conclusions Frequencies, average administered activities and collective effective dose to the population from NM diagnostic procedures in Croatia are comparable to the values reported by other European surveys. Changes were found between 2010 and 2015 and we intend to perform this study periodically to identify possible trends, but also to raise awareness about the potential dose optimization.