A Case of Painless Elderly-Onset Rheumatoid Arthritis.

Rheumatoid arthritis (RA) has multiple manifestations. Patients present with a variety of symptoms and varying levels of severity. Elderly-onset rheumatoid arthritis (EORA) is described as RA with onset after 60 years of age. EORA can present with different clinical and laboratory findings compared to RA in a younger patient, making awareness of the condition important. Diagnosing inflammatory arthritis can be especially challenging in an elderly population where symptoms are poorly reported and communication is often difficult. We report the case of an elderly patient whose presentation with persistent tachycardia and raised inflammatory markers led to a diagnosis of EORA. This case details an atypical presentation of EORA with convincing diagnostic features for the disease without any joint symptoms reported. Clinicians should be aware of the differences in the typical presentation of EORA versus RA, the challenges of diagnosing inflammatory arthritis in elderly, isolated patients, and the importance of early diagnosis.

Peripheral Vascular Compression in a Patient With Diffuse Tenosynovial Giant Cell Tumor of the Knee: A Case Report Focusing on the Role of the Ultrasound.

Tenosynovial giant cell tumors (TGCTs) are benign histo-fibrocystic tumors originating from the synovium of joints, bursae, or tendon sheaths. They are categorized into localized and diffuse types, each with distinct clinical presentations and management approaches. The diffuse form, which is rare, generally affects a single joint and is characterized by joint swelling, pain, functional limitation, and often hemarthrosis. While MRI is commonly used for diagnosis, we present a case highlighting ultrasound's significance in diagnosing and managing TGCTs, particularly for identifying vascular complications. A 59-year-old female with a 10-year history of recurrent swelling, pain, and functional limitation of the right knee was evaluated for persistent symptoms and unilateral right peripheral edema. Ultrasound revealed multiple hypoechoic, vascularized masses with both homogeneous and heterogeneous echostructures and a significant suprapatellar effusion. An ultrasound-guided biopsy confirmed the diagnosis of a recurrent diffuse TGCT complicated by vascular compression of the popliteal vein. The patient underwent mass resections, total synovectomy, and radiotherapy to reduce the risk of recurrence.  Ultrasound is cost-effective and highly beneficial for the diagnosis, treatment planning, and monitoring of diffuse TGCTs. Total synovectomy combined with radiotherapy or intra-articular yttrium-90 injection is the preferred treatment to prevent recurrence and complications.

Joint Involvement Can Predict Chikungunya in a Dengue Syndemic Setting in India.

Dengue and chikungunya have been endemic in India but have the tendency to cause periodic epidemics, often together, wherein they are termed 'syndemic'. Such a syndemic was observed in 2016 in India which resulted in a further scarcity of already resource-poor specific diagnostic infrastructure even in many urban conglomerates. A cross-sectional study was thus conducted, on 978 fever patients that consulted the ICMR-NIMR fever clinic, New Delhi, in September 2016, with an objective to identify symptom/s that could predict chikungunya with certainty. The overall aim was to rationally channelize the most clinically suitable patients for the required specific diagnosis of chikungunya. Based on their clinical profile, febrile patients attending NIMR's clinic, appropriate laboratory tests and their association analyses were performed. Bivariate analysis on 34 clinical parameters revealed that joint pain, joint swelling, rashes, red spots, weakness, itching, loss of taste, red eyes, and bleeding gums were found to be statistically significantly associated predictors of chikungunya as compared to dengue. While, in multivariate analysis, only four symptoms (joint pain in elbows, joint swelling, itching and bleeding gums) were found in statistically significant association with chikungunya. Hence, based on the results, a clinician may preferably channelize febrile patients with one or more of these four symptoms for chikungunya-specific diagnosis and divert the rest for dengue lab diagnosis in a dengue-chikungunya syndemic setting.

Patient-reported swelling in arthralgia patients at risk for rheumatoid arthritis: is it of value?

OBJECTIVE: Patients with Clinically Suspect Arthralgia (CSA) are at risk for developing Rheumatoid Arthritis (RA). These patients often report joint swelling while this is not objectified by physical examination. To explore the value of patient-reported swelling in CSA, we aimed to determine its association with subclinical joint-inflammation on imaging and RA-development. METHODS: In two independent, similarly designed CSA-cohorts from the Netherlands, symptomatic patients at risk for RA were studied. At baseline, patients indicated whether they had experienced swelling in hand joints. Subclinical joint-inflammation was assessed with MRI or ultrasound (US). Patients were followed for inflammatory arthritis development. RESULTS: In total, 534 CSA-patients from two independent cohorts were studied, patient-reported swelling was present in 57% in cohort 1, and in 43% in cohort 2. In both cohorts patient-reported swelling was associated with subclinical joint-inflammation. Using MRI, it associated specifically with tenosynovitis (OR 3.7 (95%CI 2.0-6.9)) and when using US with synovitis (OR 2.3 (95%CI 1.04-5.3)). CSA-patients with self-reported swelling at baseline developed arthritis more often, with hazard ratios of 3.7 (95%CI 2.0-6.9) and 3.4 (95%CI 1.4-8.4) in cohort 1 and 2, respectively. This was independent of clinical predictors (e.g. morning stiffness), autoantibody-positivity and US-detected subclinical joint-inflammation. However, when corrected for MRI-detected subclinical joint-inflammation, self-reported swelling was no longer an independent predictor. CONCLUSION: Patient-reported joint swelling in CSA relates to subclinical joint-inflammation and is an independent risk factor for RA-development, but it is less predictive than the presence of MRI-detected subclinical joint-inflammation.

Cinnamomi cortex extract mitigated monosodium urate-induced acute gouty arthritis in rats through nuclear factor-κB-NOD-like receptor thermal protein domain associated protein 3 signaling pathway.

Cinnamomi cortex was applied to mitigate joint injury since ancient China. However, the effect of Cinnamomi cortex on gouty arthritis (GA) was rarely reported. This study aimed to explore the effect of Cinnamomi cortex on monosodium urate (MSU)-induced acute GA (AGA) in rats, and clarify the underlying mechanism. The results showed that Cinnamomi cortex extract (CE) containing rich polyphenols and flavonoids alleviated joint swelling and inflammation by reducing programmed cell death in MSU-induced AGA rats. Network pharmacology analysis showed that CE's predictive inflammatory pathways included nuclear factor-κB (NF-κB) and necroptosis pathways. CE reduced expression of pyroptosis-related regulators including Gasdermin D and Caspase 1 via regulating NF-κB/NOD-like receptor thermal protein domain associated protein 3 signaling pathway in AGA rats. In conclusion, this study provided a theoretical basis for Cinnamomi cortex applied as a new veterinary medicine to protect against GA.

Association of the Clinical and Radiographic Findings at Onset With Future Joint Destruction in Patients With Rheumatoid Arthritis.

OBJECTIVES: Since inflammation can cause joint destruction in patients with rheumatoid arthritis (RA), it is assumed that joints that are symptomatic at onset are at higher risk of joint destruction; however, this theory remains controversial. This study aimed to investigate whether the progression of joint destruction in hands and feet could be predicted from the clinical and radiographic findings at onset. METHODS: This study included 75 patients who visited our hospital within one year after the onset of RA with at least 12 months of follow-up. We examined the positive predictive value (PPV) and the sensitivity of the clinical findings (swelling, tenderness, and squeeze test) and joint destruction at onset for the progression of joint destruction. RESULTS: Sixty joints (45 metacarpophalangeal and proximal interphalangeal joints, 15 metatarsophalangeal joints) exhibited progressive structural destruction during the study course. Both the PPV and the sensitivity of the clinical findings for the progression of joint destruction were low; however, only the sensitivity of the squeeze test for the feet was high. The PPV of joint destruction at onset was higher than the clinical findings, and the sensitivity of joint destruction at onset was as high as the squeeze test for the feet.  Conclusions: Regular follow-up with imaging is necessary regardless of symptoms and joint destruction at the onset. Adding the squeeze test for feet to routine clinical practice may help predict the risk of joint destruction for the feet.

Hairy Cell Leukemia (HCL) Presenting with Joint Swelling: Case Report and Literature Review of a Rare Rheumatological Manifestation of a Hematological Disease.

Hairy cell leukemia (HCL) is a rare malignancy that primarily affects the bone marrow, peripheral blood, and spleen. The most common presenting features of HCL are splenomegaly or cytopenias causing fatigue, infections, or hemorrhagic manifestations. Symptoms involving the soft tissue or bone are rare. HCL can rarely present with immune-mediated polyarthritis. This presentation can be confused for other pathological entities, such as Felty's syndrome, and can be differentiated from this with bone marrow biopsy. This case report looks into a rare presentation of HCL in which transient polyarthritis of the knees was the presenting symptom.

Synovial Chondromatosis in a Rural Healthcare Setting.

Synovial chondromatosis is a rare, benign, and metaplastic cause of joint swelling resulting in the formation of cartilaginous nodules in the joint space. It is usually an oligoarticular disorder of large joints that typically manifests in the third to fifth decade of life. Synovial chondromatosis can be primary or secondary depending on whether an underlying etiology can be identified. Diagnosis can be made using imaging studies of the affected joint and confirmed on histopathology. Management of synovial chondromatosis can be done arthroscopically or surgically. We present a case of a 23-year-old male who presented with a long history of right knee pain, swelling, and limitation in range of motion. An X-ray of the knee showed multiple intra-articular and soft tissue calcifications. Due to the limitations of our setting, we proceeded with an open biopsy. During arthrotomy, clear straw-colored fluid with multiple nodules of varied sizes was found. A google image search helped put us in the direction of the diagnosis of synovial chondromatosis. We did a complete evacuation of loose bodies and a biopsy of synovium, which confirmed the diagnosis. The rarity of synovial chondromatosis results in a delay in the diagnosis. With the thoughtful application of resources and surgical principles, synovial chondromatosis can be safely and effectively managed in resource-limited settings.

Diagnostic accuracy of ultrasonography for occult femoral neck fracture.

Background: A delay in the diagnosis and treatment of an occult femoral neck fracture (OFNF) can negatively affect the subsequent quality of life. We investigated the diagnostic accuracy of ultrasonography for OFNF in patients confirmed with this condition by magnetic resonance imaging (MRI), and compared these results with other clinical findings. Methods: Ninety-four outpatients aged above 70 years with acute hip pain but without radiographic abnormal findings who were suspected of having an occult femoral neck fracture (11 men and 83 women with a mean age of 81.8 ± 6.0 years) were enrolled. Both ultrasonography and MRI were performed in all cases within 24 h. The ultrasonographic distance between the anterior aspect of the femoral neck and the anterior joint capsule (ultrasound joint swelling) was measured. Results: By MRI findings, 27 patients were assigned to an occult femoral neck fracture (OFNF) group (1 man, 26 women) and 67 patients to a non-OFNF group (10 men, 57 women). The mean ultrasound joint swelling in both groups was 7.53 ± 1.52 mm and 3.45 ± 0.89 mm, respectively (p = 0.006, 95% CI, 3.58-4.59). A cut-off value of 5.3 mm showed a sensitivity of 0.96 (0.89-0.96) and a specificity of 0.98 (0.92-1.00). Conclusions: Ultrasonography shows very high diagnostic accuracy for occult femoral neck fracture. This modality can thus contribute to initial bed-side examinations for this condition in patients over 70 years with acute hip pain.

A Case Report of Blau Syndrome / 罕见病研究

Blau syndrome is a rare genetic disorder characterized by the a mix of granulomatous arthritis, uveitis, and dermatitis. Patients typically manifest multisystem involvement, including ocular, skin, and skeletal abnormalities. Blau syndrome is extremely rare, with a global incidence of less than one in a million among children. In this multidisciplinary consultation, we present a case of a 21-year-old young female patient having multisystemic involvement since early childhood. She was presented with multiple joint swelling, skin lesions, increased eye discharge, and accompanied by hypertension and arterial abnormalities, and received a diagnosis of uveitis. The patient had been receiving steroid treatment since the age of 6 and has tried various medications, with some improvement in joint swelling and ocular symptoms. Through this rare disease multidisciplinary consultation, we aim to provide guidance in the molecular diagnosis of the patient, multisystem assessment, and the selection and formulation of treatment plans. Additionally, we hope that by reporting this case, clinical physicians can gain a better understanding of the diagnosis and comprehensive treatment strategies for Blau syndrome, thereby improving the management and treatment of rare diseases.

Acute joint swelling in psoriatic arthritis: Flare or "psout"-A 10-year-monocentric study on synovial fluid.

Psoriatic arthritis (PsA) is a multifaceted inflammatory disease associated with psoriasis that can affect peripheral joints, entheses, and the axial skeleton with a variable clinical course. Acute episodes of joint swelling in PsA patients can have different causes and require specific treatments. We aimed to describe the acute joint swelling in PsA patients via synovial fluid (SF) analyses, assessing in particular the presence of pathogenic crystals, to determine whether it is a flare or an acute episode of gout ("psout") during the course of the disease. This retrospective study was based on the results of SF analysis of samples collected from unselected adult PsA patients referred to our clinic for acute joint swelling. Demographic characteristics, disease involvement, laboratory findings on SF, and treatment options were recorded and reviewed. Among 5,478 SF samples analyzed in a 10-year time span, 213 complete SF records from PsA patients were evaluated. Overall, after adjustment for the degree of synovial inflammation, significant differences were observed in term of sex (p = 0.0017) and ongoing therapy (p = 0.0246). Non-inflammatory SFs, indeed, were mainly described for female PsA patients under therapy. Regarding serum uric acid levels, there were 19/213 (8.9%) PsA with hyperuricemia (HU), who were older, mostly male, patients with mild articular involvement and rare pathogenic crystals in their SF. Although it is known that the risk of gout is higher among patients with PsA ("psout"), monosodium urate crystals were reported only in 5/213 SFs (2.4%) of our cohort and in 2/19 SFs (10.5%) of HU PsA patients. Moreover, hyperuricemia seems not to modify the SF features in PsA patients. This study results seem to suggest that the convergence of gout and PsA, involving the role of urate crystals, is a more intricate relationship, which needs further insights to be unraveled.

A Rare Case of Bacillus cereus Septic Arthritis.

Joint infections are rare in pediatrics, and those caused by Bacillus cereus are practically unheard of. In this case report, we examine a singular case of B. cereus septic arthritis in a child, with the purpose of educating clinicians on the presentation, inpatient and outpatient management, and clinical outcome. We report the case of a previously healthy pediatric patient who presented to the emergency department with symptoms of septic arthritis of the left knee. The orthopedics team performed arthroscopy and debridement, and the synovial fluid culture grew B. cereus. To our knowledge, this is the first case report on septic arthritis caused by B. cereus in the pediatric population. The treatment protocol consisted of intravenous vancomycin for one week, followed by three weeks of oral ciprofloxacin therapy. The patient had an excellent clinical outcome and returned to normal mobility without limitations. Despite being ubiquitous in the environment, extra-intestinal B. cereus infection is exceedingly rare in immunocompetent individuals. It is so rare, in fact, that it is often dismissed as a lab contaminant. In this case, we demonstrated that cooperation between multiple disciplines offers good clinical outcomes for rare infections, especially those in pediatrics.

Painful pachydermodactyly in a 39-year-old woman: A case report and review of the literature.

We chronicle the case of a 39-year-old female who presented to the rheumatology clinic with a history of chronic, symmetrical polyarticular pain in her hands. Meticulous diagnostic workup to exclude ubiquitous culprit aetiologies, such as rheumatoid arthritis and psoriatic arthritis, was performed. A detailed clinical examination was performed and, coupled with the radiological imaging findings, divulged an underlying diagnosis of pachydermodactyly. The patient was commenced on etoricoxib to alleviate the pain, and was advised to avoid repetitive trauma to her hands. The present report delineates a unique case of painful pachydermodactyly, affecting both proximal interphalangeal joints as well as distal interphalangeal joints. To the best of our knowledge, this is the first case from the state of Kuwait. We further review the literature in order to better elucidate the varying clinical manifestations of an elusive and rare rheumatological condition.

[Postinfectious reactive arthritis after chlamydia infection in competitive sports : Clinical management and current literature review]. / Postinfektiöse reaktive Arthritis nach Chlamydieninfektion im Leistungssport : Klinisches Management und aktuelle Literaturübersicht.

BACKGROUND: Reactive arthritis following infection with chlamydia is a rare but important differential diagnosis in atraumatic joint swelling. A delayed diagnosis often leads to prolonged periods of absence from physical activity. This can have serious consequences, especially for the career of competitive athletes. OBJECTIVES: Recommendation for the clinical management of postinfectious reactive arthritis for rapid diagnosis and targeted treatment in the symptomatic clinical course. MATERIALS AND METHODS: Review of the literature on the topics "chlamydia", "reactive arthritis", "postinfectious arthritis" and "sexually acquired reactive arthritis", including presentation of two clinical cases of postinfectious reactive arthritis after chlamydia infection from competitive sports. RESULTS AND CONCLUSION: Reactive arthritis following chlamydia infection in competitive athletes is a rare entity. However, it can be accompanied by far-reaching individual consequences, especially with regard to possible downtime in sports. Long-term consequences such as chronic joint damage in maintained synovitis must also be considered. In order to make a diagnosis, a specific anamnesis and the direct detection of the pathogen in the specimen of synovial fluid by polymerase chain reaction is essential. This allows a reliable diagnosis to be made with immediate initiation of therapy. However, a prolonged course of the disease cannot be excluded even if therapy is started in due time.

Remitting seronegative symmetrical synovitis with pitting edema syndrome in maintenance hemodialysis.

INTRODUCTION: The remitting seronegative symmetrical synovitis with pitting edema syndrome primarily occurs in elderly individuals to represent symptoms of edema, pain, and joint swelling. It could be misdiagnosed in elderly maintenance hemodialysis patients, as hemodialysis patients often present with pain and joint swelling induced by hypervolemia, inflammation, amyloidosis, and/or chronic kidney disease. Here, we describe a maintenance hemodialysis patient with remitting seronegative symmetrical synovitis with pitting edema syndrome. CASE PRESENTATION: A 71-year-old man on maintenance hemodialysis who complained of continuous pain and swelling of joints was diagnosed with remitting seronegative symmetrical synovitis with pitting edema syndrome on his clinical findings that revealed tenosynovitis at the joint without joint erosions and no elevation of anti-cyclic citrullinated peptide antibody and rheumatoid factor. After administration of prednisolone, systemic edema, and pain improved in 2 days. CONCLUSION: Remitting seronegative symmetrical synovitis with pitting edema syndrome should be considered as a differential diagnosis in hemodialysis patients with edema and/or arthralgia.

Efficacy of high-intensity laser therapy on arthropathy of the hands in patients with systemic lupus erythematosus: a double-blinded, randomized controlled trial.

OBJECTIVE: To determine the efficacy of high-intensity laser therapy (HILT) on arthropathy of the hands in patients with systemic lupus erythematosus. DESIGN: A double-blinded randomized, controlled study. SETTING: Outpatient setting. PARTICIPANTS: Fifty patients, 30-50-years-old, suffering from arthropathy of the hands were randomly assigned either into the experimental group, received HILT plus the routine physical therapy program or the control group, received sham HILT plus the same routine physical therapy program. INTERVENTION: All treatment interventions were applied at a frequency of three sessions per week for eight weeks. OUTCOME MEASURES: Handgrip strength, joints swelling counts, joints tenderness counts, visual analog scale (VAS) were measured before and after eight-weeks of interventions. RESULTS: There were statistically significant differences in handgrip strength, joint swelling count, joint tenderness count and VAS in favor of the study group (P < 0.05). After eight-weeks of intervention, the mean (SD) for handgrip strength, joint swelling counts, joint tenderness count, and pain score was 28.34 ± 8.3 kg, 4.4 ± 2.18, 5 ± 2.1, and 35.6 ± 13.87 mm in the study group, and 22.96 ± 8.76 kg, 7.36 ± 2.14, 9.08 ± 1.63, and 58.8 ± 10.54 mm in the control group, respectively. The MD (95%CI) for handgrip strength, joint swelling counts, joint tenderness count, and pain score was 5.38(0.53,10.23) kg, -2.96(-4.19, -1.73), -4.08(-5.15, -3.01), and -23.2(-30.2, -16.2) mm between groups, respectively. CONCLUSIONS: Adding HILT to the routine physical therapy program might be more effective than routine physical therapy program alone in improving handgrip strength, decreasing joint swelling counts, joint tenderness counts, and pain in patients with arthropathy of the hands.

A Curious Case of Blastomyces Osteomyelitis.

Blastomycosis is an uncommon disease caused by the dimorphic fungus, Blastomyces dermatitidis, often found in endemic regions of Midwestern America. It can be found in forested, sandy soils, decaying vegetation, rotting wood near water sources, and even in bird feces. Most commonly, blastomycosis manifests as a pulmonary infection presenting as pneumonia, or in severe cases, respiratory distress syndrome (ARDS). Dissemination to the bone is less common but osteomyelitis of the lower thoracic and lumbar spine, ribs, skull, and long bones have been most frequently reported. Disseminated infection to the genitourinary system commonly manifests as prostatitis or epididymo-orchitis in men and as an endometrial infection or tubo-ovarian abscess in women. In the nervous system, blastomycosis can manifest as meningitis or with a cranial abscess. Having a high degree of clinical suspicion and obtaining a detailed medical and social history is important for making a diagnosis. Culturing a specimen will provide a definitive diagnosis. Sputum or tissue specimens stained in 10% potassium hydroxide under microscopy will reveal the classic appearance of B. dermatitidis (broad-based budding with a double-contoured cell wall). In mild to moderate disease without dissemination, itraconazole is the treatment of choice. In severe, life-threatening cases, patients with CNS involvement or in immunocompromised individuals, amphotericin B is the preferred initial drug of choice.  We present an interesting case of a 42-year-old African-American male with no significant past medical history who was admitted initially for suspicion of cellulitis/septic arthritis and was started on broad-spectrum antibiotics. However, he was eventually found to have Blastomyces osteomyelitis.

A Single and Un-Adjuvanted Dose of a Chimpanzee Adenovirus-Vectored Vaccine against Chikungunya Virus Fully Protects Mice from Lethal Disease.

The mosquito-borne chikungunya virus (CHIKV) has become a major global health problem. Upon infection, chikungunya fever (CHIKF) can result in long-term joint pain and arthritis, and despite intense research, no licensed vaccine for CHIKV is available. We have developed two recombinant chimpanzee adenovirus-vectored vaccines (ChAdOx1) that induce swift and robust anti-CHIKV immune responses with a single dose, without the need for adjuvants or booster vaccines. Here, we report the vaccines' protective efficacies against CHIKV infection in a lethal A129 mouse model. Our results indicate that a single, un-adjuvanted ChAdOx1 Chik or ChAdOx1 Chik ΔCap dose provided complete protection against a lethal virus challenge and prevented CHIKV-associated severe inflammation. These candidate vaccines supported survival equal to the attenuated 181/25 CHIKV reference vaccine but without the vaccine-related side effects, such as weight loss. Vaccination with either ChAdOx1 Chik or ChAdOx1 Chik ΔCap resulted in high titers of neutralizing antibodies that are associated with protection, indicating that the presence of the capsid within the vaccine construct may not be essential to afford protection under the conditions tested. We conclude that both replication-deficient ChAdOx1 Chik vaccines are safe even when used in A129 mice and afford complete protection from a lethal challenge.

Symptoms associated with inflammatory arthritis are common in the primary care population: results from the joint symptoms survey.

OBJECTIVES: To describe the prevalence of self-reported inflammatory joint symptoms, such as joint pain, stiffness and swelling, in UK primary care patients consulting for both musculoskeletal (MSK) and non-musculoskeletal (non-MSK) complaints. METHODS: A joint symptoms questionnaire survey was sent to 10 161 individuals, of whom 5050 had consulted for MSK problems. These were matched by age, gender and general practice to non-MSK consulters. Participants provided data on relevant symptoms such as joint pain, stiffness and swelling. The prevalence of these symptoms, their severity and impact were compared between MSK and non-MSK consulters. RESULTS: A total of 4549 adults responded to the survey (adjusted response 45.8%) of whom 52.3% consulted for a MSK problem. The mean (s.d.) age was 61.6 (14.8) years and 58.9% were female. Persistent (on at least half of the days in the last month) inflammatory symptoms were common even in non-MSK consulters, with 42% reporting joint pain, 36% reporting joint stiffness and 18% reporting joint swelling. This is in comparison with 62% reporting joint pain, 50% stiffness and 24% swelling among MSK consulters. CONCLUSIONS: Although symptoms such as persistent joint pain, swelling and stiffness are predictive of inflammatory arthritis, large numbers of people consulting primary care for non-MSK reasons report these symptoms when asked by questionnaire. This compounds the challenges of diagnosing inflammatory arthritis in a non-specialist setting where new approaches are needed to ensure accurate, early diagnosis, facilitating a treat-to-target approach.