Rituximab as a trigger factor of medication-related osteonecrosis of the jaw. A case report.

Rituximab, an anti-CD20 monoclonal antibody, is an effective treatment for rheumatoid arthritis. Here we report the case of a patient with rheumatoid arthritis, having taken risedronate for 14 months to prevent corticosteroid-induced osteoporosis, more than 2 years ago, who presented osteonecrosis of jaw following herpetic gingivostomatitis two weeks after the beginning of a rituximab treatment associated with her usual anti-rheumatic drugs. Eight weeks later, no bone and/or gum healing was observed and a stage 2 medication-related osteonecrosis of the jaw (MRONJ) was diagnosed. A conservative approach was decided with antiseptic mouth washes, low-level laser treatment (LLLT) and systemic therapy with teriparatide. Complete mucosal coverage was obtained after more two years of follow-up. We suggest that rituximab as immunosuppressant might be a cause or a decompensating factor of MRONJ. Non-surgical periodontal treatment with LLLT and teriparatide are candidates for the treatment of MRONJ.

[Polyarthritis and papular eruption revealing leprosy]. / Polyarthrite et éruption papuleuse révélant une lèpre.

Leprosy is generally revealed by cutaneous lesions often associated to nerve impairment. Rarely, it may be revealed by polyarthritis. The diagnosis, often delayed in the cutaneous-nevritic form because of the low prevalence of the disease in metropolitan France, is very difficult in case of rheumatic presentation. We report the case of a 28 year-old woman from Mali, who was diagnosed with lepromatous borderline leprosy with reversal reaction occurring in the postpartum as she presented with polyarthritis and skin lesions.

[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.

Reflex sympathetic dystrophy in pregnancy: nine cases and a review of the literature.

OBJECTIVE: To better understand the diagnosis of reflex sympathetic dystrophy of the lower extremities in pregnant women. SUBJECT: Disease analysis using a retrospective series of nine cases and a review of the literature (57 patients and 159 sites of reflex sympathetic dystrophy). RESULTS: This disorder should be considered in any painful pelvic girdle syndrome or lower extremity pain. The hip is involved in 88% of cases. Symptoms develop in the third trimester of pregnancy, between the 26th and the 34th weeks. Magnetic resonance imaging (MRI) provides an early, accurate, and very specific diagnosis, although standard radiography continues to be the first-line diagnostic tool. Fracture occurs in 19% of patients. The etiology and pathophysiology remain unclear, although pregnancy itself appears to play a significant role in this disease. Although locoregional mechanical factors partly explain reflex sympathetic dystrophy. Hypertriglyceridemia appears to be a risk factor. This disorder develops independently, but the conclusion of pregnancy appears to be necessary for cure. Reflex sympathetic dystrophy does not appear to affect the course of the pregnancy. Indications for cesarean delivery remain obstetrical and should be discussed when a fracture is involved. Simple therapeutic management using gentle physical therapy provides rapid and complete recovery in 2-3 months. CONCLUSION: Reflex sympathetic dystrophy during pregnancy remains poorly understood and underestimated. Only joints of the inferior limbs are involved. MRI appears to be the best diagnostic tool. Pathogenesis remains unclear. Fractures are not rare. Treatment should be non-aggressive.

[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.