Poliartritis séptica y fascitis necrotizante en un paciente inmunocompetente. Reporte de caso / Septic polyarthritis and necrotizing fascitis in an immunocompetent patient. Case report

La presentación de poliartritis séptica en un paciente inmunocompetente es infrecuente, aún más lo es la presentación de la mencionada junto con fascitis necrotizante en el contexto de infección por Streptococcus Pyogenes (SP). Se presenta el caso de un paciente masculino de 54 años, recluido, sin antecedentes médicos relevantes, inmunocompetente, quien debuta con un cuadro clínico de poliartritis séptica en rodilla bilateral y tobillo izquierdo. Recibe manejo con múltiples lavados y desbridamientos quirúrgicos, desarrolla fascitis necrotizante de la cara posterior de la pierna izquierda, recibe a su vez manejo quirúrgico para dicha condición (incluyendo aplicación de terapia de vacío), al igual que antibioticoterapia enfocada al manejo del germen aislado (Penicilina + vancomicina). Sin embargo, tras un mes de manejo conjunto con servicios de Cirugía Plástica, Dermatología, Ortopedia, así como vigilancia en Unidad de Cuidados Intensivos, termina con un desenlace fatal tras presentar falla multiorgánica. La infección por el SP puede resultar en una elevada morbilidad para él paciente e incluso un desenlace mortal secundario a un compromiso sistémico de muy difícil manejo. El diagnóstico oportuno, así como un tratamiento médico y quirúrgico agresivo pueden no ser suficientes para el control de la infección, incluso en pacientes sin compromiso inmunológico previo. Asimismo, un enfoque multidisciplinario debe corresponder al estándar de manejo con el fin de controlar aquellas condiciones predisponentes de infección. Este es el primer caso reportado en la literatura nacional en relación con estas dos fatales condiciones. Finalmente se pretende resaltar que a pesar de que esta infección suele comprometer infantes y pacientes inmunocomprometidos, no se debe obviar su diagnóstico en pacientes previamente sanos, especialmente en casos de infecciones de rápida diseminación y poca respuesta al manejo adecuado.

Septic polyarthritis in an immunocompetent patient is highly rare, even more when it coexists with necrotizing fasciitis caused by Streptococcus Pyogenes (SP). A 54 year old, immunocompetent male patient is presented herein. The patient had no relevant previous illness, before the installation of a septic arthritis of both knees and he's left ankle. He receives treatment with sequential surgical debridement, then develops necrotizing fasciitis of the posterior aspect of the left leg requiring adequate treatment for such condition (including Vacuum Assisted Closure), as well as antibiotic therapy for the specific infecting microorganism (Penicillin + Vancomycin). Nonetheless, after a month of surgical management between Plastic Surgery, Dermatology, Orthopaedics as well as surveillance in the Intensive Care Unit, the patient dies after multi organic failure. Infection caused by SP might entail high morbidity for a patient and even end with death of the aforementioned caused by a hard to manage systemic organic failure. The adequate diagnosis, as well as aggressive medical and surgical management could not be enough for controlling the infection, even in patients without previous immunological compromise. At the same time, a multidisciplinary approach must be the standard of treatment, aiming to control predisposing infectious conditions. This is the first case reported in national literature related to these two fatal conditions. Finally, one of the purposes of this report is to highlight that despite reports of this microorganism infecting infants and immunocompromised patients, it must not be obviated in healthy patients, especially in cases of rapidly spreading infection and scarce response to adequate management.

Poliartritis séptica: Presentación de tres casos / Polyarticular septic arthritis: Report of three cases

La artritis séptica poliarticular se define como la infección de dos o más articulaciones, casi siempre de etiología bacteriana y diseminación hematógena. Es considerada una emergencia médica, lo que conlleva reconocerla precozmente, evitar la diseminación de la infección asociada con alta mortalidad y el riesgo de daño estructural articular. Presentamos tres casos de artritis séptica poliarticular, destacándose la importancia de la sospecha clínica y el estudio temprano del líquido sinovial para el diagnóstico y el tratamiento con antimicrobianos, evacuación y lavado articular.

Polyarticular septic arthritis is defined as the infection of two or more joints, almost always of bacterial etiology and hematogenous spread. It is considered a medical emergency, which should be recognized early, avoiding the spread of infection, associated with high mortality and the risk of joint structural damage. We present three cases of polyarticular septic arthritis, highlighting the importance of clinical suspicion and early synovial fluid study for diagnosis and treatment with antimicrobials, joint evacuation and joint lavage.

Polyarticular charcot: A rare case report and a literature review in Indian context

Charcot or neuropathic arthropathies are a progressive form of destructive, erosive and generally painless arthropathies.Prevalence of neuropathic joints has decreased globally with reduction in the cases of leprosy and syphilis. However,syringomyelia and diabetes mellitus have emerged as the major causes for upper limb and lower limb Charcot jointsrespectively. Literature evidence shows lack of India data pertaining to these arthropathies. The present study describesa case of polyarticular Charcot in a patient with syrinx and Chiari malformation. The patient history revealed a provisionaldiagnosis of rheumatoid arthritis and Koch’s elbow, and was treated with anti-tubercular treatment (ATT) and diseasemodifying anti-rheumatic drugs (DMARDS). Nervous system examination would have easily led to the diagnosis ofsyringomyelia. The present study also provides a review of Indian literature on neuropathic joints from 2001 to 2019.Diabetes mellitus, syringomyelia, leprosy and syphilis are major etiologies for Charcot joints.

A comparison of Streptococcus agalactiae septic arthritis and non-Streptococcus agalactiae septic arthritis

<p><b>INTRODUCTION</b>Streptococcus agalactiae (Group B Streptococcus, GBS) is an uncommon cause of septic arthritis in the adult population. In recent years, there has been an increase in the incidence of GBS septic arthritis. This study aims to compare the clinical presentation, investigations, microbiology and outcome of management in patients with GBS and non-GBS septic arthritis.</p><p><b>METHODS</b>Retrospective review of hospital surgical records was done to identify all patients treated surgically at our institution from January 2011 to January 2016 for primary septic arthritis. Patients were categorised into two groups: those with culture-proven GBS septic arthritis and those with causative pathogens that were not GBS. Patients who were medically unfit for surgical intervention as well as those who declined interventional procedures were excluded from the study.</p><p><b>RESULTS</b>A total of 83 patients were included in the study: 62 (74.7%) had non-GBS septic arthritis and 21 (25.3%) had GBS septic arthritis. Patients with GBS septic arthritis were more likely to have polyarticular involvement (p < 0.001) and involvement of less common sites such as the elbow joint. They were also more likely to have elevated inflammatory markers (C-reactive protein > 150 mg/L; p = 0.017) and positive blood cultures (p = 0.02), and were typically healthy adults with no medical comorbidities (p = 0.012).</p><p><b>CONCLUSION</b>Patients with GBS septic arthritis were more likely to present with polyarticular involvement, positive blood cultures and higher levels of C-reactive protein on admission, and tended to be healthier individuals with no medical comorbidities.</p>

Expression and clinical significance of plasma microRNA -766 in children with polyarticular juvenile idiopath-ic arthritis / 中华实用儿科临床杂志

Objective To discuss the expression and clinical significance of microRNA(miR)- 766 in chil-dren with polyarticular juvenile idiopathic arthritis (poly - JIA). Methods A total of 23 children with poly - JIA who received treatment at the Department of Rheumatology,the Affiliated Children′s Hospital of Capital Institute of Pediat-rics,from November 2014 to September 2016,were enrolled as research group,and 24 healthy children at the same age were selected as healthy control group,while 24 children with oligoarticular juvenile idiopathic arthritis (oligo - JIA) and 19 children with juvenile ankylosing spondylitis (JAS)were selected as case - control groups. The expression lev-els of miR - 766 in plasmas were detected by real - time quantitative polymerase chain reaction (qPCR). The clinical diagnostic values were analyzed by operating characteristic curve (ROC). Correlations between the expression levels of miR - 766 and clinical,laboratory results were analyzed by conducting Pearson correlation coefficient analysis. Results Compared with the healthy control group and case - control group,the expression levels of miR - 766 in poly - JIA group decreased,and the differences were statistically significant (t = 6. 897,6. 446,6. 218,all P < 0. 001). There was no statistical difference of miR - 766 levels in plasma between case - control groups and healthy control group (P >0. 05). Compared with the healthy control group,the area under ROC curve of miR - 766 was 0. 938 (95％ CI:0. 872 -1. 000),and when the cutoff value of miR - 766 was 6. 083 pmol/ L,the sensitivity was 87. 0％ and the specificity was 91. 7％ . Compared with oligo - JIA and JAS,the area under ROC curves of miR - 766 was 0. 908 (95％ CI:0. 819 -0. 996)and 0. 927 (95％ CI:0. 865 - 1. 000),respectively. Correlation analysis indicated that the level of miR - 766 in plasma of poly - JIA children was positively associated with hemoglobin (r = 0. 651,P < 0. 001),but negatively asso-ciated with the 28 - joint Disease Activity Score (DAS28)and the percentage of type 1 helper T cells(Th1％)(r =- 0. 434,P = 0. 038;r = - 0. 417,P = 0. 008). Conclusions The expression levels of plasma miR - 766 in poly - JIA are significantly decreasing. miR -766 may serve as an evaluation indicator for the diagnosis and prognosis of poly - JIA.

Características clínicas de niños y niñas con artritis idiopática juvenil del Instituto Teletón Santiago-Chile, año 2012-2013 / Clinical characteristics of children with juvenile idiopatic arthritis at Instituto Teletón Santiago-Chile, 2012-2013

Introducción: La artritis idiopática juvenil (AIJ) es un grupo heterogéneo de trastornos inflamatorios que se expresan con inflamación, dolor e impotencia funcional en una o más articulaciones en niños menores de 16 años. Las características clínicas y epidemiológicas planteadas por la literatura nacional e internacional son diversas. Objetivos: Describir las características clínicas de los pacientes con diagnóstico de AIJ, subtipos de clasificación, articulación más afectada, relación con género y edad promedio de incorporación al Instituto Teletón Santiago. Pacientes y Método: Estudio descriptivo, transversal. Se identificaron 217 pacientes en cubo OLAP con diagnóstico de AIJ, de éstos se revisaron 174 fichas clínicas (80,1 por ciento) de pacientes activos, con edades entre 7 y 18 años, que fueron atendidos en el Instituto Teletón Santiago durante los años 2012-2013. Los datos se procesaron mediante SPSS versión 17.0. Se calcularon medidas de resumen y la relación entre variables se estableció mediante test de asociación, con p < 0,05. Resultados: Según subtipo de artritis, las mayores frecuencias correspondieron a oligoarticular (31 por ciento) y poliarticular (22,4 por ciento). Las articulaciones más afectadas fueron rodilla (70 por ciento), tobillo (57,6 por ciento) y muñeca (45,9 por ciento). Un 70,1 por ciento del total de pacientes correspondieron al género femenino. Se verifica asociación al género femenino estadísticamente significativa (p = 0,002) en los subtipos poliarticular (razón femenino/masculino = 5,50), oligoarticular (razón femenino/masculino= 3,15) y sistémica (razón femenino/masculino = 1,83). La edad de incorporación al Instituto se registró en promedio a los 9,22 +/- 3,96 años. Conclusión: Las características clínicas generales, tuvieron similitud a lo descrito en literatura, sin embargo, sería conveniente realizar estudios posteriores a nivel nacional.

Introduction: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of inflammatory disorders, which manifest themselves with swelling, pain and loss of function in one or more joints, in children under 16 years of age. Clinical and epidemiological characteristics raised by the national and international literature are varied. Objectives: To describe the general clinical characteristics of patients diagnosed with JIA, regarding subtype classifications, most affected joint, gender and average age of admission at Instituto Teletón Santiago. Patients and Method: A descriptive cross-sectional study with 217 patients diagnosed with JIA identified through OLAP Cubes, was performed. Medical records for 174 (80.1 percent) active patients were reviewed, whose ages ranged from 7 to 18 years of age, and who were treated at the Instituto Teletón Santiago, between the years 2012- 2013. Data was processed using SPSS version 17.0. Summary measures and the association between variables were calculated using c2 Test of Association, with p < 0.05. Results: According to subtype of arthritis, olygoarticular obtained the higher frequencies (31 percent) and polyarticular (22.4 percent). The most commonly affected joints were, knee (70 percent), ankle (57.6 percent) and wrist (45.9 percent). A 70.1 percent of all patients, were female. Association to the female gender was statistically significant (p = 0.002) for the polyarticular subtypes (reason female/male = 5.50), oligoarticular (reason female/male = 3.15 ) and systemic (right female/male = 1.83). The age for admission to the Institute, was recorded at an average of 9.22 +/- 3.96 years. Conclusion: The general clinical characteristics of the population, were similar to those described in literature, however further studies would be useful at the national level.

Síndrome antisintetasa / Antisynthetase syndrome

El Síndrome Antisintetasa, es una enfermedad poco frecuente perteneciente al grupo de las miopatías inflamatorias de origen inmunológico. Su caracterización inmunológica es muy variable y de allí las distintas manifestaciones clínicas de su presentación y su difícil diagnóstico. Se presenta un paciente femenino de 42 años de edad, con diagnóstico de Artritis Reumatoide (AR), con 9/10 puntos por puntaje para AR por EULAR 2011, anti-CCP +, RF -, desde octubre de 2011, en tratamiento con Prednisona y Metotrexate. Acude en febrero de 2012 por presentar disnea progresiva y tos con expectoración verdosa. Recibe antibioticoterapia sin respuesta. Se realiza TC de Tórax dónde se evidencia fibrosis pulmonar y bronquiectasias por tracción, con imágenes en panal de abeja a predominio de segmentos inferiores y posteriores. Durante su estancia hospitalaria presenta debilidad muscular proximal con elevación de CK a 4.969 U/L. , se realiza biopsia de músculo, que reporta miopatía inflamatoria; electromiografía, con patrón característico de miopatía inflamatoria y perfil inmunológico, obteniéndose Anti-Jo1 positivo, 0,885 (Negativo < 0,250). En el contexto de un síndrome poliarticular inflamatorio, una enfermedad pulmonar intersticial y una miopatía inflamatoria proximal con Anti Jo-1 (+); se realiza diagnóstico definitivo de Síndrome Antisintetasa.

This is a rare disease, member of the inflammatory myopathies of immunological origin. It has a very variable immunologic profile which makes the diagnosis difficult. We present a female patient 42 years- old, with the diagnosis of Rheumatoid Arthritis (RA), with 9/10 points of EULAR 2011 Score for RA diagnosis and RF -, Anti CCP +, in October of 2011; her treatment at that time was prednisone and methotrexate. In February of 2012, she consulted to the emergency with dyspnea and productive cough. She received antibiotics with no response. The chest Computerized Tomography evidenced pulmonary fibrosis, traction bronchiectasis and honeycombe images in posterior and inferior segments of both lungs. During her hospitalization, she presented proximal muscular weakness with CK elevation to 4.969 U/L. The muscle biopsy, which concluded inflammatory myopathy, the electromyography had the characteristic pattern of inflammatory myopathy and the immunologic profile, with a positive Anti-Jo1 0,885 (Negative <0,250). In the context of a polyarticular syndrome, an interstitial lung disease and a proximal inflammatory myopathy with a positive Anti-Jo1, we made the final diagnosis of Antisynthetase syndrome.

The Clinical Significance of Anti-cyclic Citrullinated Peptide Antibodies in Juvenile Rheumatoid Arthritis

OBJECTIVE: The aim of this study was to determine the clinical significance of anti-cyclic citrullinated peptide (anti-CCP) antibody in juvenile rheumatoid arthritis (JRA). METHODS: Sera for anti-CCP assay were obtained from 142 patients with arthralgia in our hospital during the period between November 2010 and October 2011. On the basis of medical records, 83 patients with JRA were designated to the study group, and 59 patients with arthralgia but were treated as transient arthritis to the control group. The values of anti-CCP were then analyzed retrospectively. We used the enzyme linked immunosorbent assay (ELISA) for detecting anti-CCP. RESULTS: Positive anti-CCP values were found in the sera of 11 patients with JRA (13.3%), one patient presented with pauciarticular JRA and the others with polyarticular JRA. There was a statistically significant difference in the anti-CCP values between the JRA group and the control group. However, patients with systemic JRA and arthralgia without JRA had no anti-CCP. Especially, 10 out of 14 (71.4%) patients with RF-positive polyarticular JRA had anti-CCP. In addition, the rate of positive anti-CCP was significantly higher in patients with polyarticular JRA than in the control group. CONCLUSION: We expect that the presence of anti-CCP may help to evaluate the severity of diseases in patients with JRA. Anti-CCP can be an important biomarker for making early intensive therapeutic decision in patients with polyarticular JRA, which might have more severe course and longer disease duration.

Application of Infliximab in treating of severe polyarticular juvenile idiopathic arthritis / 中华实用儿科临床杂志

Objective To investigate the safety and efficacy of infliximab in the treatment of severe polyarticular juvenile idiopathic arthritis(JIA).Methods Forty-four patients with severe polyarticular JIA were treated with infliximab (3 mg/kg) on week 0,2 and 6,respectively,and then they were treated every 8 weeks,plus methotrexate or and leflunomide for oral intake,and meanwhile physical therapy and functional rehabilitation were carried out.Patients were assessed by the American College of Rheumatology (ACR) response criteria (30,50,70) on week 2,6 and 14 and followed up,including swollen joint count,tender joint count,duration of morning stiffness and fever,body functions,lab inflammatory index like CRP,ESR changes.Results Among 44 cases,according to ACR response criteria,which represents 30％,50％,70％ improvement from baseline,the cure rates with infliximab therapy in swollen joint count,tender joint count,duration of morning stiffness,CRP,ESR were achieved in 47.7％ (21/44 cases),20.5％ (9/44 cases),and 11.4％ (5/44 cases) of patients with JIA on week 2 ; 63.6％ (28/44 cases),43.2％ (19/44 cases),and 13.6％ (6/44 cases) of patients on week 6 ;81.8％ (36/44 cases),52.2％ (23/44 cases),27.2％ (12/44 cases) on week 14,respectively.Inflammatory index like CRP,ESR with infliximab treatment decreased considerably compared that before treatment(P ＜0.05).Side effects from infliximab treatment were well-tolerated.There was no abnormality in the liver and kidneys or complicated infections,and no negative cases turned into the positive.Conclusions Treating severe polyarticular JIA with infliximab showed a rapid cure rate,safety and better tolerance.

A case of henoch-Sch?nlein purpura complicated by hemorrhagic gastroenteritis and IgA nephropathy in a patient suffering with juvenile rheumatoid arthritis / 대한내과학회지

Henoch-Sch?nlein purpura (HSP) is a systemic vasculitis with IgA dominant immune complex deposits that affect the small vessels in the skin, joints, gastrointestinal tract and kidneys. Gastrointestinal symptoms are common and the manifestations include abdominal pain, bleeding, bowel infarction, intussusceptions or even perforation. Polyarticular onset juvenile rheumatoid arthritis (JRA) is a rare form of arthritis that affects children and young adults. The relationship between HSP and JRA is uncertain. We report on a 24-year-old man with a history of polyarticular onset JRA and HSP that was complicated by hemorrhagic gastroenteritis. The gastroscopy and colonoscopic findings showed extensive hemorrhagic inflammatory changes of the gastric and intestinal mucosa. The patient had severe bloody diarrheal symptoms, abdominal pain and gross hematuria. The 24 hours urine chemistry profile showed the proteinuria was greater than 4.5 g/day, and immunofluorescent staining of the renal biopsy specimen showed diffuse granular mesangial deposits of IgA and C3. The abdominal manifestations and proteinuria were improved after methylprednisolone therapy.

Clinical observations of juvenile rheumatoid arthritis / 소아과

PURPOSE: Juvenile rheumatoid arthritis(JRA) is one of the most common rheumatic diseases of childhood and is an important cause of short- and long-term disability. The purpose of this study was to determine the disease course and outcome in childhood patients with JRA. METHODS: Fifty nine patients with JRA who were diagnosed and treated in the Department of Pediatrics, Asan Medical Center from August 1990 to November 2004 were enrolled in this study. Sex, age, type, affected joints, extra-articular manifestations, laboratory and radiologic findings, treatments, and outcomes of JRA patients were reviewed retrospectively. RESULTS: Among JRA patients, 32.2 percent had pauciarticular type, 30.5 percent had polyarticular type and 37.3 percent had systemic type. The ratio of boys to girls was 1.7:1 and the mean age at onset was 9.3+/-3.7(1.3-15.9) years. The most commonly affected joints were knee, ankle and wrist. The extra-articular manifestations observed were fever, rash, myalgia and lymph node enlargement, etc. The main laboratory findings observed were leukocytosis, anemia, thrombocytosis, elevated ESR, and elevated CRP. Rheumatoid factor and antinuclear antibody(ANA) were positive in 5.3 percent and 18.0 percent. Nonsteroid anti-inflammatory drugs(NSAID) were used most frequently and methotrexate with or without steroids was added in 27.1 percent of patients unresponsive to NSAID. 88.1 percent of patients were cured without functional disability and only one patient was in functional status IV. One patient, who had pulmonary involvement, died. CONCLUSION: Our results showed an even distribution in type of onset, male predominance, older age of onset, low incidence of iridocyclitis, and low positivity of ANA in JRA patients; this differs from occidental data. This study may suggest regional differences and variability in disease groups of JRA among different racies, but further multi-center trials and large scale epidemiological studies are needed to confirm our conclusion.

Gouty Polyarthritis-An Uncommon Presentation

Crystal arthropathies are a group of disorders produced due to deposition of crystals in and around joints. These are usually monoarticular, but some 10% of the patients with mono sodium urate crystal arthropathy (Gout) can be polyarticular. However, in present set up with much advancement in diagnostic and therapeutic modalities, the number of patients of gout with polyarticular involvement is less common. Here we present a case of gouty polyarthritis with a prolonged intercritical period.

A Clinical Study on Polyarticular Juvenile Rheumatoid Arthritis (JRA) (III. Polyarticular Type) / 대한류마티스학회지

OBJECTIVE: The purpose of this study was to analyse clinical manifestations and laboratory findings in childhood patients with polyarticularonset juvenile rheumatoid arthritis (JRA). METHODS: Eleven cases of polyarticular JRA who were diagnosed and treated in the Department of Pediatrics, Seoul National University Children's Hospital from June 1988 to May 1995 were investigated for clinical manifestations and laboratory findings. RESULTS: 1) There were 6 males and 5 females and their ages of onset were 4 years to 15.1 years(mean 10.9 years). 2) Systemic manifestations were not observed, but low-grade fever was noted in 5 patients. 3) The involvement of joints was symmetric in 9 patients and asymmetric in 2 patients. 4) The most commonly affected joints were knees and ankles, followed by proximal interphalangeal joints of hand, shoulder, elbow, temporomandibular joint, and other joints. 5) Roentgenographic changes of joints were detected in 6 patients and bone scan in 7 patients showed increased uptake in the involved joints. 6) The main laboratory findings observed were microcytic and hypochromic anemia (64%), thrombocytosis (82%), elevated eryhtrocyte sedimentation rate (100%), positive or increased C-reactive protein(100%), positive rheumatoid factor(RF) (18%), positive antinuclear antibody(ANA) (27%). RF was positive in 2 girls with later age of onset and the pattern of immunofluorescent ANA were all homogeneous. 7) Nonsteroid antiinflammatory drugs (NSAIDs) were used most frequently and steroid with or without sulfasalazine was tried in 4 patients unresponsive to NSAIDs. 8) At last follow-up, 6 cases(55%) were classified as functional class I, 4 cases(36%) as class II, and 1 case(9%) as class III. CONCLUSION: These data showed the clinical manifestations and laboratory findings of polyarticularonset juvenile rheumatoid arthritis in Korean children.