[Epidural lipomatosis]. / Lipomatose épidurale.

UNLABELLED: ONSET: Epidural lipomatosis is a rare disorder defined as a pathological overgrowth of normal epidural fat. It is more often associated with administration of exogenous steroid with variable duration and doses. Furthermore, it may occur in some patients in the absence of exposure to steroids but generally associated with obesity. Whatever the predisposing factor, the majority of these patients are men. The causal effect of epidural lipomatosis in the development of spinal cord or radicular compression is generally well accepted. DIAGNOSIS: The diagnosis of epidural lipomatosis can be established by melography, computed tomography (CT) and magnetic resonance imaging (MRI). MRI is considered the imaging procedure of choice, allowing an assessment of the extent of lipomatosis and, as well as CT, an identification of the lipomatous tissue. Most cases of epidural lipomatosis with corticosteroid use occur in the thoracic region, while most idiopathic cases occur in the lumbar region. TREATMENT: Management of treatment depends on the severity of the neurological signs and the patient's background. The most common treatment for epidural lipomatosis with corticosteroid use consists in surgical decompression but with a high risk of postoperative mortality. In some cases however, medical treatment includes corticosteroid withdrawal or reduction and calorie restriction, leading to clinical improvement. Treatment for idiopathic epidural lipomatosis is more often medical, based on weight loss and physical therapy with generally successful outcome. The pathogenesis of epidural lipomatosis remains unknown but different suggested hypotheses may lead to a metabolic disorder as the underlying cause.

[Acute pancreatitis in rheumatoid purpura. Apropos of 2 cases]. / Pancréatite aiguë au cours d'un purpura rhumatoïde. A propos de deux cas.

Abdominal pain observed in Henoch-Schönlein purpura (HSP) is usually attributed to digestive tract involvement. Pancreatic involvement is a rare and benign complication. The authors report two cases of acute pancreatitis as a complication of HSP. Pancreatitis was confirmed in both cases by clinical presentation and increase of serum amylase levels. Abdominal echography has demonstrated ascites or alithiasic cholecystitis without pancreatic abnormality. The prognosis was favourable in each case. Pathophysiologic mechanism is presumably a vasculitis of the small vessels specially within the pancreas leading to inflammation. Abdominal pain can be explained by a digestive tract involvement but also by an acute pancreatitis. This later occurrence is not as exceptional as reported in the literature. Thus, serum amylase levels should be evaluated in patients with HSP who have intense epigastric or abdominal pain, in order to recognize a pancreatic involvement.

Chronic hepatitis during rheumatoid arthritis.

Chronic hepatitis is infrequently reported in the course of RA (1.9%). We report 6 cases with such an association. The six patients were all female (mean age: 59.5 years) with typical RA (ACR criteria), and sicca syndrome in 5 cases. Chronic hepatitis always developed after the onset of RA (delay: 1 to 47 years). Laboratory findings revealed a mild increase of transaminases. Alkaline phosphatase were increased in 3 cases. Liver insufficiency was present in 4 cases and polyclonal hypergammaglobulinemia in 6 cases. Rheumatoid factors were detected in 5 cases; antinuclear antibodies and anti-smooth muscle antibodies were also detected in 5 cases. Histological examination of liver biopsy disclosed active chronic hepatitis in 5 cases (with cirrhosis in 3 cases) and persistent chronic hepatitis in 1 case. Steroid therapy was administered in 4 cases of active chronic hepatitis with clinical and biological improvement (18 months to 6 years follow-up). One patient died of gastric bleeding.

[Efficacy, tolerability and therapeutic benefit of etodolac (Lodine 200) in rheumatologic practice]. / Efficacité, tolérance et bénéfice thérapeutique de l'étodolac (Lodine 200) en pratique rhumatologique.

Efficacy, safety and therapeutic benefit of etodolac (Lodine 200) in rheumatological practice. An open clinical trial performed by 974 rheumatologists enabled an evaluation of efficacy, safety and therapeutic benefit of etodolac (Lodine 200) on 4,947 patients with rheumatoid arthritis, ankylosing spondylitis and osteoarthritis of the lower limbs; the initial dosage was 600 mg/d (for 2 weeks), then 400 to 600 mg/d (for 2 to 4 weeks, according to the indication). Efficacy, assessed by classical items for NSAID's, was shown to be excellent to good by 61-77 p. 100 of patients, according to the indication. 7.7 p. 100 of patients only dropped out for lack of efficacy. 20.4 p. 100 of patients developed adverse effect(s) (AE), but the relationship between etodolac and AE was assessed "possible" or "probable" only for 9.6 p. 100 of patients; this figure should be compared to the 7.6 p. 100 of patients who dropped out for AE and to the 92 p. 100 of patients who assessed the global safety as "excellent or good". The therapeutic benefit was estimated very favorable: 75 p. 100 of patients felt better than at the beginning of the study, 64.5 p. 100 of patients wished to continue the treatment and the (mean) benefit-risk ratio assessed with a logarithm scale (-1 to +1), ranged from 0.45 to 0.6 according to the indication. Therefore, this trial confirmed the good efficacy and safety profile of etodolac on a large scale in normal clinical practice in France, following assessments during controlled trials. It also permitted to perfect new items of evaluation for NSAID's, in particular for therapeutic benefit.

Spinal cord compression related to vertebral osteonecrosis.

The authors report 3 cases of spinal cord compression by vertebral collapse related to osteonecrosis. Two patients needed surgical decompression permitting pathological diagnosis. In the third case, osteonecrosis was ascertained by radiological evidence of an intravertebral vacuum phenomenon. Three etiologic factors were noticed: osteoporosis, corticotherapy, and radiotherapy. The relative frequency of neurologic complications in vertebral collapse related to osteonecrosis compared to those observed in osteoporosis is discussed.

[Mechanism of Felty's syndrome and long-term course]. / Mécanisme du syndrome de Felty et évolution à long terme.

The authors report 18 cases of Felty's syndrome followed, in an average, for 5 years (1 to 12 years). There were 3 deaths, 9 patients are in complete remission, 6 others still show signs of the disease: splenomegaly (4 cases), leucopenia (1 case) and only one complete Felty's syndrome. Steroid therapy has proved to be effective regardless of the mechanism of the neutropenia specified in 9 cases by an isotopic study. Prognosis and infectious risk are difficult to determine but the overall course was rather favorable.

[Juvenile-onset ankylosing spondylitis]. / Les spondylarthrites ankylosantes à début juvénile.

Ankylosing spondylitis (AS) with juvenile onset (under 17 years of age) is not infrequent. Thirty-six cases were studied, amounting to 18% of patients hospitalized between 1977 and 1981. The following criteria were used for diagnosis: radiologic sacroiliitis (typical AS), presence of HLA B27 and/or pelvic or vertebral clinical manifestations (possible AS). 31 patients (85%) were boys. Mean age at onset was 12.3 +/- 2.8 years. In three cases, AS was found in a member of the family of the propositus and in one case there was cutaneous psoriasis. Usually (29 cases) onset was in the lower limbs: arthritis of the knee (14 cases), hip (9 cases), ankle (7 cases) or painful heel (4 cases). During the course (with a mean follow-up of 11.2 +/- 7 years), 35 patients exhibited peripheral joint diseases and 25 had axial involvement. Ocular involvement was present in 5 cases. 10 patients had a modification of respiratory function. Radiologic sacroiliitis was found in 31 patients but with a delay of 5.3 +/- 2.6 years. Vertebral radiologic lesions were only seen in 11 patients. Radiologic hip involvement was frequent (20 cases) with complete destruction in 6 patients. Erosion and ossification of the calcaneum were observed in 15 cases. The ESR was above 20 mm/first hour in 26 cases (72%). 81% of these patients were HLA B27 positive. Functional prognosis was good: 16 patients (51.6%) led an almost normal life, 6 were bedridden (Steinbrocker's grade IV), 3 had severe impairment (grade III) and 6 had slight impairment (grade II).(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic articular manifestations of sarcoidosis. Apropos of 7 cases]. / Les manifestations articulaires chroniques de la sarcoïdose. A propos de 7 observations.

Chronic articular involvement is rare in sarcoidosis (approximately 0,2 p. 100). The authors report seven cases and describe the special features of chronic sarcoid polyarthritis: incidence of synovitis, possibility of destructive forms resembling rheumatoid arthritis, sensibility to steroids, relatively good functional prognosis. The diagnosis is essentially histological; it should be suspected in any chronic polyarthritis of obscure origin and confirmed by synovial biopsy. The physiopathology of sarcoid synovitis has not yet been determined.

[Solitary spinal plasmacytoma]. / Le plasmocytome solitaire vertébral.

The authors report 11 cases of solitary plasmocytoma of the spine. This tumour mainly affects men (9 cases) before the age of myeloma (average age 56 years). The back pain is associated with radicular irradiation (9 cases) and objective neurological signs (5 cases). The site was dorsal (5 cases), lumbar (5 cases) and rarely sacral (1 case). The vertebral lesion was either lysis (5 cases), a very characteristic polycystic appearance (5 cases) or common vertebral collapse (1 case). A lesion of the posterior arch was common (9 cases). A monoclonal immunoglobulin was demonstrated in the serum of 7 patients. Radiochemotherapy resulted in a reduction (2 cases) or complete regression (3 cases) of the monoclonal component. Radiotherapy alone did not prevent an increase of the monoclonal peak in 2 cases, nor the later occurrence of a monoclonal immunoglobulin in 2 other cases. An increase in polyclonal Ig. was an early sign of remission and their fall heralded myelomatous dissemination. The patients were followed up for an average of 6 years (range 1-16 years). The solitary course varied from 3 months to 16 years. Four patients developed metastatic plasmocytoma; 3 had medullary invasion after 1, 4, and 10 years.

[Juvenile polyarthritis complicated by recurring tamponade: treatment using pericardotomy and high dosages of corticoids]. / Polyarthrite juvénile compliquée de tamponade récidivante: traitement par péricardotomie et corticoïdes à forte dose.

Pericarditis is common in juvenile polyarthritis, but tamponade is a very rare complication and usually needs pericardiocentesis, pericardiotomy or pericardiectomy. We report an exceptionally rare recurrent tamponade after an 8 years interval in a patient with juvenile polyarthritis: the first tamponade was treated by pericardiotomy; the second episode of adiastole regressed after high dose steroid therapy.

[Destructive cervical spondylitis. An unusual initial manifestation of ankylosing spondylitis]. / Spondylite cervicale destructrice. Manifestation initiale exceptionnelle de la spondylarthrite ankylosante.

Erosions of vertebral bodies and intervertebral discs are usually considered as late manifestations of ankylosing spondylitis. Yet they may occur early and indeed constitute the first sign of the disease. This is illustrated by the case reported here, where a 19-year-old woman with an 18-months diagnosis of ankylosing spondylitis was found to have severe destructive lesions of the 6th cervical vertebra without discal lesion nor cervical ankylosis. Surgical biopsy excluded a tumoral or infectious process. Spinal fusion (C4-C7) was performed, and cervical pain was completely relieved with non-steroidal anti-inflammatory drugs.

[Treatment of lumbar disk hernias using chemonucleolysis]. / Traitement des hernies discales lombaires par chimionucléolyse.

The authors present 46 cases studies of herniated lumbar discs treated by chemonucleolysis in the previous 2 to 9 months. One patient suffered from recurrent acute lumbago; the other 45 patients suffered from lumbar root pain. The diagnosis of herniated disc was confirmed by radiography of the lumbar roots. Chemonucleolysis was performed under neuroleptanalgesia in the majority of cases, after failure of medical treatment and as an alternative to surgery. The patient treated for recurrent lumbago obtained a good result. After one month, 20 patients no longer suffered from sciatica and two had only a mild and intermittent sciatic pain. The results are lasting. Overall, chemonucleolysis is successful in 69% of cases. The success rate decreases with the age of the patient and the age of the symptoms. The results appear to be unchanged by the number of discs treated, their level or their discographic features. The results appear to be unchanged by the number of discs treated, their level or their discographic features. The results seem to be better when the disc being treated has not collapsed and when the hernia is not too large. Seven failed cases went to operation when, in each case, a non ruptured herniated disc was found. In 4 cases there was minimal tissue and in 2 cases the hernia was soft. The tolerance was excellent. Chemonucleolysis is effective in the treatment of herniated lumbar discs, but should be reserved for selected patients. Used with care, the treatment is safe. In cases where the treatment fails, the surgical procedure is not interefered with.