Acute haematogenous periprosthetic joint infection due to Streptococcus sanguinis along with coexistent crystalline arthropathy after total knee arthroplasty: a rare combination.

A man in his 60s, with a medical history of gout, underwent total knee arthroplasty of his right knee followed by expeditious rehabilitation. Seven months after surgery, he was referred to the emergency ward with sudden onset of pain and swelling of his right knee accompanied with fever. Further inquiry revealed no trauma, infection or skin lesions besides a tongue bite several weeks earlier. An impaired range motion of the knee was seen on physical examination along with a tachycardia. Laboratory studies showed a C reactive protein of 345 mg/L, after which a debridement, antibiotics and implant retention procedure was performed. Intraoperatively obtained synovial fluid showed monosodium urate crystals consistent with crystalline arthropathy (ie, gout). However, unexpectedly, Streptococcus sanguinis was identified in all microbiological cultures too, confirming a coexistent periprosthetic joint infection. After comprehensive antibiotic treatment and gout flare therapy, this patient made a full recovery with retention of the implant.

Efficacy of anakinra in acute hydroxyapatite calcification-induced joint pain: A retrospective study of 23 cases.

OBJECTIVE: Hydroxyapatite (HA) crystal calcifications in or around the joint can induce acute flares with severe pain. A previous pilot study suggested that the interleukin-1ß (IL-1ß) inhibitor anakinra was effective. The goal of this observational study was to confirm these results in a larger set of patients and to report on the long-term follow-up. METHODS: Flare was defined as acute pain for<10 days. Calcification in or around a joint (rotator cuff: 15/23 patients) was confirmed by conventional radiography and/or ultrasonography (US). Anakinra 100mg daily was administered subcutaneously for 1 to 3 consecutive days. Clinical data collected before the injection and on days 3 and 21 included pain score on a visual analog scale (VAS, 0-10cm) and C-reactive protein (CRP) level. When available, US baseline and follow-up findings were compared. Long-term follow-up data were collected from patient charts and/or after a phone call. RESULTS: 23 patients (15 males, mean [SD] age 58 [11] years) were included. Baseline mean (SD) VAS pain was 7.7 (1) cm and CRP level was elevated in half of the patients. After therapy, mean (SD) VAS pain score decreased rapidly in the first 3 days to 1.6 (1.4) cm (P<0.001) and remained stable for 3 weeks at 1.8 (2.1) cm. US assessment revealed decreased Doppler intensity but no significant change in size of calcifications. No significant side effects were noted. After long-term follow-up (median duration 24 months), half of the patients still had some chronic pain, but only 4 experienced acute relapse. CONCLUSION: This study suggests that IL-1ß inhibition may be an efficient therapeutic approach for acute HA flare, with a good safety profile.

Recommendations for the assessment and optimization of adherence to disease-modifying drugs in chronic inflammatory rheumatic diseases: A process based on literature reviews and expert consensus.

BACKGROUND: Adherence to treatment is a key issue in chronic inflammatory rheumatic diseases (CIRDs). OBJECTIVE: To develop recommendations to facilitate in daily practice, the management of non-adherence to disease-modifying drugs in patients with rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, connective tissue diseases or other CIRDs. METHODS: The process comprised (a) systematic literature reviews of methods (including questionnaires) to measure non-adherence, risk factors for non-adherence and efficacy of targeted interventions; (b) development of recommendations through consensus of 104 rheumatologist and nurse experts; (c) assessment of agreement and ease of applicability (1-5 where 5 is highest) by the 104 experts. RESULTS: (a) Overall, 274 publications were analysed. (b) The consensus process led to 5 overarching principles and 10 recommendations regarding adherence. Key points include that adherence should be assessed at each outpatient visit, at least using an open question; questionnaires and hydroxychloroquine blood level assessments may also be useful. Risk factors associated to non-adherence were listed. Patient information and education, and patient/physician shared decision, are key to optimize adherence. Other techniques such as formalized education sessions, motivational interviewing and cognitive behavioral therapy may be useful. All health professionals can get involved and e-health may be a support. (c) The agreement with the recommendations was high (range of means, 3.9-4.5) but ease of applicability was lower (2.7-4.4). CONCLUSIONS: Using an evidence-based approach followed by expert consensus, this initiative should improve the assessment and optimization of adherence in chronic inflammatory rheumatic disorders.

Efficacy and tolerance of anakinra in acute calcium pyrophosphate crystal arthritis: a retrospective study of 33 cases.

Calcium pyrophosphate (CPP) deposition is a frequent joint disease with increased prevalence in older people in whom treatment of acute CPP arthritis with conventional therapies such as colchicine or non-steroidal anti-inflammatory drugs could be contraindicated or not used at an optimal dose. As recommended in gout, anakinra might represent an alternative treatment for arthritis. We aimed to analyze the efficacy and safety of anakinra in acute CPP arthritis in a large reported series. We retrospectively included all patients receiving anakinra for acute CPP arthritis between January 2011 and 2017. The following data were collected before and 4 days after the first anakinra injection: swollen joint count (SJC), tender joint count (TJC), pain score on a visual analog scale (VAS, 0-100 mm), and C-reactive protein (CRP) level. A good response was defined according the evaluation of the physician. We included 33 patients (24 women; mean age 79.2 ± 12.8 years). The number of good responders was 27 (81.8%). At day 4, patients showed decreased mean VAS pain score (from 64.8 ± 26.5 to 21.2 ± 19.7 mm, p < 0.0001), TJC (5.8 ± 5.0 to 1.0 ± 1.0, p < 0.0001), SJC (3.9 ± 2.7 to 0.9 ± 1.0, p < 0.0001), and CRP level (116.1 ± 71.6 to 26.0 ± 23.1 mg/l, p < 0.0001). Anakinra was well tolerated, without skin complications. Only one patient had pneumonitis that was resolved with oral antibacterial agents. Anakinra could be a relevant alternative for managing acute CPP arthritis when conventional therapies are ineffective or contraindicated.

Resveratrol attenuates the MSU crystal-induced inflammatory response through the inhibition of TAK1 activity.

TAK1 is closely associated with the NF-κB and MAPK signaling pathways. In the present study, we aimed to explore the relationship between TAK1 and gout as well as the effects of resveratrol on TAK1 activity and MSU crystal-induced inflammation. The expression levels of total TAK1 and phosphorylated TAK1 in gout patients were detected by western blotting. The influence of resveratrol on TAK1 activity and MSU crystal-induced inflammation was investigated in THP-1 cell and murine models of gout. The results showed that TAK1 and p-TAK1 were highly expressed in gouty arthritis patients. MSU crystals accelerated the expression of TAK1 and p-TAK1 in human PBMCs. The anti-inflammatory effects of resveratrol on MSU crystal-induced inflammation in vitro and in vivo included the alleviation of pro-inflammatory cytokines, inflammatory cell recruitment and foot swelling. Resveratrol limited the activation of TAK1 and its downstream signaling pathway, including the degradation of IκBα, the activation of NF-κB P65 and the phosphorylation of P38 and JNK. In conclusion, resveratrol may have a potential therapeutic effect on gouty arthritis by inhibiting TAK1 activity.

One year in review 2017: ultrasound in crystal arthritis.

Musculoskeletal ultrasound (MSUS) has become a relevant part of rheumatology practice and research. This imaging modality substantially allows us to optimise the management of inflammatory, degenerative and crystal-related musculoskeletal diseases. MSUS is a valuable point-of-care tool to accurately assess intra-articular and periarticular abnormalities involved in rheumatic diseases. Furthermore, MSUS is a bedside aid for guiding accurate and safe musculoskeletal diagnostic aspirations and therapeutic injections. This review provides an overview of the last year's literature on the role of MSUS in crystal arthritis.