[Fibromyalgia]. / La fibromyalgie.

PURPOSE: We review the current knowledge about fibromyalgia, adding to the clinical aspects, the nosology, epidemiology and pathogenesis. The therapeutic and social management of these suffering patients are discussed. KEY POINTS: The limitations of the American College of Rheumatology classification criteria used as diagnostic criteria are discussed. Fibromyalgia is not a simple psychiatric disorder, even if psychiatric symptoms are constantly found. Based on functional brain imaging, there is some evidence pointing to an abnormal function of the supra-spinal centres for pain regulation. CONCLUSION: Fibromyalgia is a clinical autonomous entity. Physiopathology knowledge is improving, but must be confirmed by new research. Patients will take profit of multimodal individualized treatment programs, including explanations about the diagnosis. In most cases, fibromyalgia is compatible with the maintenance of a professional activity, possibly adapted to the patient. Recognized disability requiring compensation is infrequent.

Bone density, parathyroid hormone, calcium and vitamin D nutritional status of institutionalized elderly subjects.

INTRODUCTION: Osteoporosis is characterized by a decrease in bone mass and a change in bone microarchitecture. This causes skeletal fragility and may result in fractures. Fractures of the femur neck (FM) are frequent and have major consequences in terms of morbidity and mortality in elderly subjects. We carried out a cross-sectional study to evaluate bone and nutritional status in an elderly population from a same geriatrics department. AIMS OF THE STUDY: We aimed to screen for nutritional deficiencies and to measure bone mineral density (BMD) in the femur neck by dual-energy X-ray absorptiometry (DEXA). RESULTS: The study included 64 white Caucasian subjects, 44 of whom were women. The mean age of the subjects was 80.6 +/- 7.1 years. The mean time since the menopause was 31.45 +/- 7.8 years and 31 subjects presented previous fractures, 12 of which concerned the FM. Mean body mass index (BMI) was 25.8 +/- 4.4 and mean calcium intake was 670 +/- 258.3 mg/d. Mean PTH level was 48.5 +/- 30.34. Thirty-five subjects presented vitamin D deficiencies (mean concentration 8.56 +/- 5.2 microg/L), and 11 of these patients had associated secondary hyperparathyroidism. Fifty-four subjects had osteoporosis (T score <-2.5 standard deviation). Mean bone mineral density (BMD) was 0.596 +/- 0.157 g/cm2 for the femur neck (T score = -3.15 +/- 1.39 standard deviation) and 0.501 +/- 0.169 g/cm2 for the trochanter (T score = - 2.55 +/- 1.68 standard deviation). CONCLUSIONS: Vitamin D deficiency and low calcium intake were observed in a large number of elderly subjects. The patients with the lowest BMD values had secondary hyperparathyroidism.

Femoral neuropathy secondary to ossification of the ligamentum flavum.

Radiculopathy resulting from ossification of the ligamentum flavum (OLF) is extremely rare and concerns only intercostal neuralgias. We describe a 37-year-old Caucasian woman with a lumbar radiculopathy revealing an OLF. Her symptoms were completely and definitively relieved by surgery.

Fourteen cases of sarcomatous degeneration in Paget's disease.

OBJECTIVE: To describe characteristics of cases of sarcomatous degeneration in Paget's disease (SDP) recorded over 10 years in 2 French university hospitals, with particular emphasis on the pattern of this entity on magnetic resonance imaging (MRI). METHODS: Fourteen cases are described. Epidemiological, clinical, radiological, histological, and MRI features (in 3 cases) are compared to others in the literature. RESULTS: Nine men and 5 women (mean age 75.2+/-7.7 yrs) were studied. Paget's disease was monostotic in 5 cases and polyostotic in 9. Neurological complications were present in 10 cases. The mean interval between the first clinical signs and diagnosis was 4.4+/-4.7 months. The locations were: limbs 2, skull 2, pelvis 7, sacrum 3. The radiological pattern was lytic in 9 cases, sclerotic in 3, and mixed in 2. MRI revealed a similar pattern in all 3 cases studied (heterogeneous low signal intensity of the tumor on T1 weighted images increased after intravenous gadolinium administration and high signal intensity on T2 weighted images), whereas the radiological pattern was lytic in 2 cases and sclerotic in one case. The diagnosis was proved by histological investigation in 11/14 patients (osteogenic sarcoma of different appearance in 7 patients, fibroblastic sarcoma in one, fibrous histiocytoma-like sarcoma in one, and undifferentiated sarcoma in 2). Four patients had pulmonary metastases and 4 patients are still alive with followup ranging from 5 months to 5 years. CONCLUSION: Paget sarcomas remain the most threatening sarcomas of bone, their prognosis being far more negative than primary sarcomas. Improvement in therapy strategies including surgery, radiation therapy, and chemotherapy might together provide better prognosis for SDP.

[Distribution of bone metastases of cancers. A scintigraphic study of 376 cases]. / La répartition des métastases osseuses des cancers. Une étude scintigraphique de 376 cas.

Technetium 99m methylene bisphosphonate bone scans of 376 patients with cancers of breast, prostate, lung, kidney, colon, and bladder and ENT cancer were reviewed, and the distribution of skeletal metastases was analyzed. Differences were not significant for rank order of metastatic involvement in 9 selected regions in any cancer, but the breast carcinoma. Patients with breast cancer had less pelvis and more skull involvement. The rate of skull metastases was significantly higher in breast cancer than in prostatic (p < 0.001), lung (p < 0.01) and kidney (p < 0.05) cancers. These results are weakly demonstrative of a role of the vertebral veins in hematogenous spread of breast and prostate cancer. The hypothesis is proposed that this pattern of dissemination, which is suggested by experimental and clinical features, is poorly perceptible in the distribution pattern of skeletal metastases because of the concurrent arterial spread of breast and prostatic tumors cells, which is likely preponderant.

Posterior rounded high-intensity zone on magnetic resonance images as a sign of painful disk. Report of a case.

In 1992, Aprill and Bogduk reported that a rounded high-intensity zone was seen in the posterior part of the annulus fibrosus on T2-weighted images of at least one of the last intervertebral disks in 29% of 500 patients with low back pain. This image was correlated with Dallas stage 4 disk disease and with reproduction of the spontaneous pain during discography coupled with computed tomography. We report a case and discuss the value of this image.

Strategy for identifying primary malignancies with inaugural bone metastases.

The diagnosis of primary tumors with inaugural bone metastases is a serious and difficult problem commonly encountered in rheumatology. Helpful information can be derived from the radiologic appearance of the metastases, history of the patient, clinical findings, chest film, standard laboratory tests, imaging studies, serum marker assays, and histologic findings. Based on our personal experience and on previously published data, we have developed a decision tree aimed at enhancing the efficacy of the diagnostic process while ensuring optimal patient comfort and containing costs.

[Chemonucleolysis of disk herniation with low back pain as the single symptom: 20 cases]. / Chimionucléolyse des hernies discales avec lombalgie pure: vingt cas.

Disk herniation can manifest as isolated low back pain, which is usually intermittent and accompanied with stiffness of the lumbar spine. There is almost general agreement that neither neurosurgical treatment nor chemonucleolysis is appropriate in patients with this clinical pattern. We used chemonucleolysis in 19 patients with recurrent episodes of isolated low back pain and one patient with severe permanent isolated low back pain dating back to a conservatively-treated episode of sciatica. All 20 patients had disk herniation documented by imaging studies. A very good or satisfactory outcome was recorded in ten patients after three months, 11 after six months and 12 in March 1993 after a mean follow-up of 72 months. The treatment was well tolerated, even in those patients who were not improved; a single patient developed an episode of acute low back pain that required surgical treatment. In patients with low back pain and disk herniation, there is currently no means of determining whether a causal relationship links these two abnormalities. Nevertheless, we believe that chemonucleolysis can be proposed in severe forms, provided the patients are apprised of current success rates.

[Treatment of Takayasu's disease with low-dose methotrexate. Apropos of a case]. / Traitement de la maladie de Takayasu par le méthotrexate à faible dose. A propos d'un cas.

Persistent evidence of inflammation at the occlusive phase of Takayasu's arteritis is of adverse prognostic significance. Low-dose weekly methotrexate therapy given in combination with a corticosteroid may be effective in such patients. We report a personal case which supports the data obtained by Fauci and coworkers, as well as the conclusions of the other two similar case-reports in the literature.

[Disk calcinosis]. / Calcinoses discales.

Intervertebral disc calcification in children is a rare, primary and benign disease which often disappears after a single painful crisis, especially in cervical involvement. In adults, thoracic and lumbar discs are mainly involved; calcification is less expressive and is often detected during a casual radiograph. Intervertebral disc calcification is primary or secondary to chondrocalcinosis, apatite deposition disease, ochronosis and hemodialysis spondylarthropathy. Except CPPD deposits in chondrocalcinosis, calcium complex accounting for most discal calcinosis is hydroxy-apatite. Iatrogenic intervertebral disc calcification was recently described in patients treated with a discal injection of a long-acting corticosteroid.

[Idiopathic retroperitoneal fibrosis and ankylosing spondylitis]. / Fibrose rétropéritonéale idiopathique et spondylarthrite ankylosante.

A case of ankylosing spondylarthritis in which retroperitoneal fibrosis developed 16 years after onset is reported. The patient also had aortic incompetence and cardiac conduction disorders. Eight other cases of ankylosing spondylitis with retroperitoneal fibrosis have been published. Potential relationships between the two conditions--including the possible role of indomethacin used by the patient for 16 years--are discussed.

[Association of rheumatoid arthritis and Kaposi disease. Apropos of a case arising after intraarticular corticotherapy]. / Association polyarthrite rhumatoïde--maladie de Kaposi. A propos d'un cas survenant au décours d'une corticothérapie intra-articulaire.

A 66 year old Corsican HLA A2 and DR5-positive male with moderately active seropositive destructive rheumatoid arthritis developed Kaposi's sarcoma after intraarticular administration of corticosteroids. He had no history of oral corticosteroid therapy, organ transplantation, AIDS, or cancer. Chlorambucil proved ineffective but the outcome was spontaneously favorable following discontinuation of oral corticosteroid therapy initiated after the development of the skin lesions. Six previous reports of concomitant rheumatoid arthritis and Kaposi's sarcoma were found. All six cases occurred following systemic corticosteroid therapy. The high incidence of rheumatoid arthritis and the small number of patients with rheumatoid arthritis and Kaposi's sarcoma suggest that concomitant occurrence of the two conditions may be fortuitous. However, the responsibility of corticosteroid therapy, which preceded development of Kaposi's sarcoma in every case, cannot be ruled out.

[Unsatisfactory results of intradiscal injection of triamcinolone hexacetonide in the treatment of sciatica caused by intervertebral disk herniation]. / Mauvais résultats de l'injection intradiscale de l'hexacétonide de triamcinolone dans le traitement des sciatiques par hernie discale.

Sciatica caused by intervertebral disc herniation can be treated with intradiscal injection of chymopapain. A search for a cheaper and less allergizing product led to triamcinolone hexacetonide, this procedure being known as "nucleorthesis". The first results at 6 months were encouraging. In 3 centres where triamcinolone hexacetonide was tested with a more than 2 years' follow-up 92 patients could be evaluated. The results obtained were considered satisfactory in 34 patients (36.9 percent), but they were poor in 19 patients (20.6 percent), and 39 patients (42 percent) had to be operated upon within 2 years. Return to surgery took place within the 6 months following nucleorthesis in 18 patients (19.56 percent) and beyond this period in 17 patients (22.8 percent) with degradation of the results. Moreover, calcifications were found in 19 out of 38 patients; they were of varying size, sometimes detected only at computerized tomography, and some of them appeared to produce symptoms. All considered, the failure rates, the number of patients who required surgery and the occurrence of large and sometimes symptomatic calcifications make triamcinolone nucleorthesis unacceptable compared with the recognized percentages of success with papain nucleolysis and surgical operations. For these reasons, we consider that this treatment should be abandoned.

[Infectious spondylodiscitis. Analysis of a series of 105 cases]. / Spondylodiscites infectieuses. Analyse d'une série de 105 cas.

Among 105 cases of infectious spondylitis diagnosed and treated from 1971 through 1990, 23 were due to tuberculosis (TS) and 82 to other causes (NTS). The annual number of cases of NTS rose over the study period, partly because of an increase in iatrogenic spondylitis, whereas the number of TS cases fell. In both groups, mean age of patients was higher than in earlier studies. The leading causative agents in NTS were staphylococci, followed by streptococci, then Escherichia coli. Diagnosis of spondylitis was dependent on the imaging techniques used; among available methods, the most reliable was magnetic resonance imaging which improved diagnostic performance by detecting early, specific changes. Except in patients with positive blood cultures and in TS patients with Koch bacilli recovered from other visceral foci, bacteriologic diagnosis rested on studies of samples taken from the spinal infection site. Half the subjects underwent discovertebral needle biopsy, with a success rate of 47.5%, a figure comparable with those reported in other studies. In 30% of patients, bacteriologic documentation of the infection was not obtained and diagnosis rested on a set of clinical, biological, and radiological criteria.

[Lumbar inter-apophyseal arthrosis and bone mineral content: prospective study versus controls with dual photonic absorptiometry and tomodensitometry]. / Arthrose inter-apophysaire lombaire et contenu minéral osseux: étude prospective versus témoins par absorptiométrie di-photonique et tomodensitométrie.

Dual photon absorptiometry (DPA) is a non invasive and repeatable technique to measure vertebral bone mineral content (BMC). This method can be altered, in frontal incidence, by superposition of abnormal calcifications as calcified aorta or interapophyseal arthrosis. The authors studied nineteen females with lumbar apophyseal arthrosis compared with twenty one controls matched by age. Bone densitometry was performed by Am-Ba DPA and monoenergetic computerised tomodensitometry (CT) from L2 to L4. Arthrosis was studied by standard X ray radiographs and CT. Our results showed that inter-apophyseal arthrosis does increase BMC determined by DPA, especially when expressed as linear BMC (g/cm). The body mass index [weight (kg)/size (m2)] also increased these measures by DPA. CT results were, at the opposite, not influenced by osteo-arthrosis nor body mass index. Detailed analysis of DPA pictures allowed to recognize most of patients with osteo-arthrosis and to correct their results by using adjacent vertebral measures (L1) or abandoning pictures of unusual aspect. The authors mentionned necessity to match populations for age and body mass index and to include L1 in routine vertebral bone mineral content determination. By this way they supposed that osteo-arthrosis may not alter lumbar BMC measured with DPA technique.