Stéphane Varin

Treatment of shoulder calcifications of the cuff: A controlled study

OBJECTIVES About 1 in 10 patients with shoulder calcifications complains of chronic pain. Removal techniques have been developed. We carried out the first randomized study to validate bursoscopy (BS) and (needling fragmentation irrigation) (NFI) versus a control group (CT). METHODS 102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected using a corticosteroid; 49 shoulders improved by more than 70%. The other 53 shoulders were randomized in 3 groups: NFI (n=16), BS (n=20), and CT (n=17). All patients were reviewed at T 1-4-12-24 months. RESULTS After 4 months, we observed respectively in groups NFI-BS-CT: 62%, 65% and 29% patients showing global improvements >70% (NFI vs CT: p=0.03; BS vs CT: p=0.02); -37%, -29% and -11% pain VAS variation (ns), +16%, +12% and -15% Constant score variation (NFI vs CT: p=0.03; BS vs CT: p=0.02), and -58%, -77% and +4% area calcification variation (NFI vs CT: p=0.005; BS vs CT: p=0.0002; BS vs NFI: p=0.01). After 24 months, results were maintained in NFI and BS groups, and in the CT group only 6/17 patients were still improved. There were no significant differences between NFI and BS groups. Three partial tears of the cuff were found using MRI in failures, (1 in each group). CONCLUSION NFI and BS are now validated removal techniques of shoulder calcifications when there is chronic pain and other medical treatments have failed. Results were maintained after 24 months, and were similar between NFI and BS. However NFI could be preferred because of its simplicity and low cost.

Pseudomonas aeruginosa osteomyelitis of both ischia: a case report.

Osteomyelitis of the ischium is a very rare event; it usually occurs unilaterally and often is caused by tuberculosis1,2. To our knowledge, osteomyelitis of both ischia after a urological procedure has not been reported previously. In the case described here, Pseudomonas aeruginosa was identified by biopsy of one of the two ischial bones seven months after radical surgery of the bladder. Apreviously healthy fifty-six-year-old man underwent removal of the prostate and bladder, together with lymphadenectomy of the ilio-obturator lymph nodes, in September 1998, for the treatment of grade-III bladder cancer3. The lymph nodes were free of metastasis. The bladder was replaced by an ileal graft4. The findings on postoperative follow-up were normal, except for a transient infection of the urinary tract with Pseudomonas aeruginosa, which was diagnosed six days after surgery on the basis of urine culture. Antibiotic therapy was administered for ten days with use of gentamicin (150 mg twice daily) as well as ticarcillin and clavulanic acid (12 g and 800 mg daily, respectively). At the end of this treatment, the urine was sterile and the patient was discharged symptom-free. One month later, he complained of alternating pain in both buttocks. Bed rest and prednisone (40 mg daily for two weeks), together with morphine, were prescribed, despite obvious laboratory signs of systemic inflammation (9.74 109 polymorphonuclear leukocytes/L [normal range, 4 to 10 109 polymorphonuclear leukocytes/L], an erythrocyte sedimentation rate of 99 mm/hr in the first hour [normal value, £10 mm/hr], and a C-reactive protein level of 181 mg/L [normal range, 0 to 5 mg/L]). A dramatic reduction in pain was noted. The C-reactive protein level decreased to 16 mg/L, and the erythrocyte sedimentation rate decreased to 35 mm/hr. A urinary cytobacteriological examination performed at the end of November …

Septic arthritis of the facet joint

OBJECTIVE Septic arthritis of the facet joint is a rare clinical entity. We report 11 cases of facet joint infections diagnosed in our institution. PATIENTS AND METHOD Patients were identified via the computerized patients record (PMSI). Their features were collected and compared with published data. RESULTS The clinical symptoms are similar to those of infectious spondylodiscitis: back pain with stiffness (11/11), fever (9/11), radicular pain (5/11), and asthenia. Ten patients presented with lumbar infection and 1 with dorsal infection. An inflammatory syndrome was observed in every case. A rapid access to spine MRI allowed making the diagnosis in every case, and assessing a potential extension of infection (epidural extension 5/11, paraspinal extension 5/11). Blood culture (8/11) or culture of spinal samples allowed identifying the causative bacterium in every case and adapting the antibiotic treatment. The bacteria identified in our series were different from previously reported ones, with less staphylococci. The origin of the infection was found in 4 cases. Another localization of infection was observed in 4 cases. The outcome was favorable with medical treatment in 10 cases. An abscess was surgically drained in 1 case. None of our patients presented with neurological complications, probably because of the rapid diagnosis. CONCLUSION Assessing the facet joint is essential in case of inflammatory back pain, and the radiologist must be asked to perform this examination.

Chronic, eventually fatal, Kawasaki-like disease in an adult with spondylarthropathy responding to IVIG therapy.

Abstract We report on an unusual case of a 40-year-old Caucasian male displaying severe Kawasaki-like symptoms. The disease lasted for seven years before diffuse coronary aneurysms occurred, leading to the patients death, despite ongoing treatment by intravenous immunoglobulins (IVIGs). The patient had also been suffering from a disabling inflammation of the spine, which was reported to have started at the onset of the disorder. Whereas neither NSAIDS, nor high doses corticosteroids, or anti-TNF drugs had a clear effect, the clinical features of spinal inflammation were highly sensitive to IVIGs, and were attributed definitively to HLA-B27-negative axial spondylarthropathy after bone scan and magnetic resonance imaging disclosed typical enthesitis of both heels and bilateral sacroiliitis.

Does immunodepression induced by TNF antagonists promote atypical scabies

Joint Bone Spine - In Press.Proof corrected by the author Available online since mercredi 14 aout 2013

Hairy-cell leukemia with inaugural joint manifestations

Hairy-cell leukemia is a chronic B-cell malignancy seen in adults. The presenting manifestations consist of splenomegaly, pancytopenia, and characteristic monocyte depletion. The presence in peripheral blood or bone marrow of hairy cells exhibiting the CD19(+) CD20(+) CD25(+) CD11c(+) phenotype establishes the diagnosis. Rarely, patients present with inaugural joint manifestations related either to the hematological malignancy or to immune dysfunction. The resulting polymorphic polyarticular symptoms may cause diagnostic wanderings. Monocytopenia is a valuable diagnostic clue. The identification of hairy cells in the joint fluid establishes the diagnosis of leukemia-related arthritis. The treatment rests on purine analogs. One of the main differential diagnoses is Feltys syndrome, which combines rheumatoid arthritis, splenomegaly, and neutropenia. Feltys syndrome is usually caused by T-cell lymphoproliferative disorders. Among 27 patients with hairy-cell leukemia managed at our institution, 1 presented with joint manifestations. We describe this case.

Hypercalcemia in a patient with tuberculous adrenal insufficiency

OBJECTIVES To raise awareness of hypercalcemia as a rare and at times inaugural manifestation of adrenal insufficiency. CASE REPORT Evaluation of hypercalcemia in a 43-year-old man showed adrenal insufficiency. Biopsies of the testes and adrenal glands revealed epithelioid and giant cell lesions indicating tuberculosis. Although tuberculosis can contribute to hypercalcemia, this possibility was ruled out in our patient by the low serum 1,25-dihydroxy-vitamin D3 levels and return to normal of serum calcium and renal function under hormone replacement therapy. It should be noted, however, that a course of pamidronate was given. CONCLUSION The mechanism of hypercalcemia associated with adrenal insufficiency is controversial. Hyperparathyroidism was ruled out in our patient. Adrenal insufficiency should be considered in some patients with hypercalcemia.

Ultrasound abnormalities in septic arthritis are associated with functional outcomes

OBJECTIVES To describe the ultrasound abnormalities seen in septic arthritis and to assess their associations with clinical, biological, and radiological outcomes. METHODS We prospectively included 34 patients with septic arthritis of a native joint (knee, n=19; shoulder, n=6; hip, n=4; ankle, n=3; or wrist, n=2). Ultrasonography was performed to record synovial-membrane thickness and vascularity, joint effusion, and abnormalities of adjacent soft tissues, at baseline then 4days, 2weeks, and 3months later. Motion-range limitation of the affected joint was evaluated after 3months. Radiography was performed at inclusion and after 3months. RESULTS Mean age was 63.7±17.6years. After 3months, 20 (58.8%) patients had motion-range limitation with worsening of the total radiological score (P<0.001). The proportion of patients with synovitis was very high initially (96.4% at baseline, 96.3% after 4days, and 100% after 2weeks) then diminished to 77.8% after 3months (P=0.051). Synovial-membrane thickness was significantly higher after 4days and 2weeks compared to baseline (median, +17.3% and +20%, respectively; P=0.015) and was significantly lower after 3months compared to the earlier time points (median, -31.5%, P=0.015). A positive Doppler signal was common at baseline (n=18, 64.3%) then significantly less so after 3months (n=7, 25.9%; P=0.04). An unchanged or higher Doppler grade after 2weeks compared to baseline was associated with motion-range limitation at last follow-up (P=0.033). CONCLUSION We report the first study on ultrasound evidence of synovitis, joint effusion, and soft tissue alterations at baseline and over time in patients with septic arthritis. Persistent synovitis and joint effusion 3months after starting antibiotic therapy was not associated with treatment failure. However, Doppler signal changes over the first 2weeks were associated with the 3-month functional outcome.

Hypercalcémie associée à une insuffisance surrénalienne d'origine tuberculeuse

Resume Objectifs. Rappeler que si l’insuffisance surrenalienne n’est qu’une etiologie exceptionnelle d’hypercalcemie, elle ne doit pas etre oubliee, d’autant que l’hypercalcemie peut parfois etre revelatrice de l’atteinte surrenalienne. Patient et resultat. Nous rapportons le cas d’un patient chez qui le bilan d’une hypercalcemie a contribue a la decouverte d’une insuffisance surrenalienne. Celle-ci a ete rapportee a une origine tuberculeuse en raison de la presence de lesions epithelioides et gigantocellulaires sur des biopsies testiculaires et surrenales. L’infection tuberculeuse aurait pu etre un cofacteur de l’apparition de l’hypercalcemie, mais cette eventualite n’a pas ete retenue du fait de l’absence d’elevation de la 1,25(OH)2D3 (qui etait au contraire effondree) et de la normalisation de la calcemie et de la fonction renale sous opotherapie substitutive, associee il est vrai a une cure de pamidronate. Conclusion. Le mecanisme de cette hypercalcemie est discute, l’eventualite d’une hyperparthyroidie ayant ete eliminee. Il est important d’evoquer une insuffisance surrenalienne devant certaines hypercalcemies.

Sarcoidosis in Patients with Antisynthetase Syndrome: Presentation and Outcome

Objective. To investigate the uncommon co-occurrence of antisynthetase syndrome (AS) and sarcoidosis. Methods. From 2000 to 2015, patients with sarcoidosis were extracted from a retrospective multicentric cohort of 352 patients with AS. Results. Ten patients (2.8%; 6 men, 8 whites, 5 smokers, median age 50 yrs) had both AS and sarcoidosis. Most of the time, sarcoidosis and AS occurred simultaneously (n = 7). Antibody testing revealed anti-Jo1 (n = 5), anti-PL12 (n = 4), or anti-PL7 (n = 1). Finally, no patient had a worsening of muscular condition, 5 patients presented respiratory deterioration, 3 remained stable, and 2 showed improvement. Conclusion. Sarcoidosis may be underdiagnosed in patients with AS.