Tabetic arthropathy. A report of 43 cases.

Destructive tabetic arthropathy (TA) has become rare in the course of syphilis because of early diagnosis and treatment. TA is difficult to manage because of the severity of the handicap and the absence of a specific treatment. We describe the clinical, biological, and radiological characteristics of TA. In this paper, we performed a retrospective study of 24 patients with TA from 1983 to 2003. Inclusion criteria were typical radiological findings and positive syphilitic serology in blood and/or synovial fluid and/or cerebrospinal fluid. Included in the study were 15 men and 9 women, their mean age was 53.71+/-12.25 years, and the delay of diagnosis was 36.83+/-53.03 months. Thirteen patients (54.2%) had a known primary syphilitis. In the studied cases, 43 of the patients' joints were involved, which concerned knees, hips, the spine, and ankles in 91.66, 8.33, 8.33, and 4.16% of cases, respectively. TA was bilateral in 62.5% and multifocal in 8.3%. The neurological exam found signs suggesting tabes dorsalis in seven cases. The osteoarticular exam showed an abnormal range of mobility (n=25), hydarthrosis, and articular deformation (n=17). Syphilitic serology tests were positive in synovial fluid, cerebrospinal fluid, and blood in 12 (50%), 8 (33.33%), and 24 (100%) cases, respectively. Radiological exam showed atrophic and hypertrophic forms. The frequency and severity of TA in our study may be explained by the frequency of atypical forms of syphilitis and the absence of penicillin in Morocco in the 1950s.

Chronic osteomyelitis of the metacarpals. Report of a case.

UNLABELLED: Chronic osteomyelitis of the hand is uncommon and affects the metacarpals in only 3% of cases. We report a case of chronic osteomyelitis involving two metacarpals, and we present a review of the relevant literature. CASE-REPORT: A 41-year-old man with a 5-year history of psoriatic arthritis was admitted for a swelling over the dorsum of the left hand. At admission, he was in good general health and had no fever. In addition to the swelling, he had synovitis of the right ankle and psoriasis over the hands and elbows. The spine and sacroiliac joints were normal to physical examination. The erythrocyte sedimentation rate was 110 mm/h, the C-reactive protein level was 48 mg/l, and the leukocyte count was 9600/mm3. A radiograph of the hands disclosed a bone-within-bone image in the second and third metacarpals of the left hand and arthritis of the left carpal joints. A fluid collection over the dorsum of the left hand was visualized by ultrasonography. Aspiration recovered serous fluid that contained no organisms by microscopic examination or culture. Investigations for tuberculosis and a serological test for HIV infection were negative. Computed tomography showed a florid periosteal reaction encasing the diaphyses of the second and third metacarpals and enclosing bony sequestra; abnormal carpal bone architecture and thickening of the soft tissues related to joint effusions were seen also. The diagnosis was chronic osteomyelitis of the metacarpals. Two antimicrobials active against staphylococci were given and the bony sequestra were removed surgically. Histological examination of the operative specimens showed nonspecific osteitis. After 3 months of treatment, the outcome was favorable. CONCLUSION: Chronic osteomyelitis of the metacarpals is exceedingly rare but results in severe functional incapacitation and major social and economic burdens. Our case illustrates an unusual pattern with involvement of two metacarpals in the same hand. An early diagnosis followed by prompt treatment increases the likelihood of a favorable outcome.

IgD kappa myeloma: a new case.

UNLABELLED: IgD myeloma, which is particularly severe, accounts for only 1-3% of all myeloma cases, and the kappa subtype contributes only 10-30% of IgD myelomas. We report a new case. CASE-REPORT: A 59-year-old man was admitted for inflammatory low back pain with L5 sciatica and diffuse bone pain. The symptoms had been present for 3 months, during which he had experienced a severe decline in general health. Laboratory test abnormalities included an erythrocyte sedimentation rate of 70 mm/h, normochromic normocytic aplastic anemia, hypercalcemia (3.5 mmol/l), and serum creatinine elevation to 583 micromol/l. Tests were negative for cryoglobulinemia. Serum protein electrophoresis showed hypergammaglobulinemia but no monoclonal peak. Immunoelectrophoresis, however, detected a faint IgD kappa band in the blood and a homogeneous kappa band in the urine. Bone marrow aspirated from the sternum was found to contain 30% of malignant plasma cells. Biopsies for amyloidosis were negative. Radiographs disclosed multiple punched-out lesions with no evidence of spinal cord compression. Symptomatic treatment was given to correct the hypercalcemia, and combination chemotherapy was started. DISCUSSION: IgD kappa myeloma is a severe variant of myeloma often associated with extraosseous lesions, renal failure, and amyloidosis. The monoclonal component is absent or faint by serum protein electrophoresis, making the diagnosis difficult. The pathogenesis is unclear and the prognosis grim.

Idiopathic hypoparathyroidism and adhesive capsulitis of the shoulder in two first-degree relatives.

INTRODUCTION: Primary hypoparathyroidism and adhesive capsulitis of the shoulder in the same patient does not seem to have been reported previously. We report two cases in first-degree relatives. PATIENTS: Case 1: In 1999, a 41-year-old woman experienced seizures simulating epilepsy. She had been treated 5 years earlier for idiopathic adhesive capsulitis of both shoulders. Computed tomography of the brain showed calcifications in the basal ganglia meeting criteria for Fahr's disease, and incipient bilateral cataract was found. A diagnosis of idiopathic primary hypoparathyroidism was given. After 1 month of calcium and vitamin D supplementation, improvements were noted in the clinical symptoms, laboratory test, and electroencephalogram. Case 2: The 70-year-old father of case 1, who had an unremarkable medical history, had been receiving treatment for about 2 years for adhesive capsulitis of the left shoulder. Routine laboratory tests disclosed idiopathic primary hypoparathyroidism. The outcome was favorable with calcium and vitamin D supplementation. CONCLUSION: Our cases suggest that there may be a common immunological or genetic basis for primary hypoparathyroidism and adhesive capsulitis. Alternatively, adhesive capsulitis may be a manifestation of hypoparathyroidism. Although genetic factors involved in primary hypoparathyroidism have been elucidated, the pathophysiology of the disease remains unclear. Finally, a chance association remains possible.