Accuracy of physical examination in subacromial impingement syndrome.

OBJECTIVE: Shoulder pain is a common complaint, frequently caused by subacromial impingement syndrome (SIS). There are a number of physical examination (PE) manoeuvres that explore the subacromial space. MRI provides an accurate anatomic image of the subacromial space, being the current gold standard in the diagnosis of SIS. The aim of this study is to evaluate the accuracy of the PE in the diagnosis of SIS and/or subacromial-subdeltoid bursitis (SSB) confirmed by MRI. METHODS: Consecutive outpatients with an episode of shoulder pain were prospectively included in the study. They were examined by a rheumatologist and, within 3 days, an MRI was done. Sensitivity, specificity, positive and negative predictive values, and accuracy of PE manoeuvres were calculated using a 2 x 2 table. RESULTS: Fourteen males and 16 females were included. All the tests exhibited acceptable sensitivity. As a result Yocum manoeuvre was considered the most sensitive and most accurate for SIS. With regard to SSB, the Gerber test was the most sensitive. The majority of the PE manoeuvres showed low specificity. CONCLUSIONS: Most PE manoeuvres identify reasonably well subacromial impingement of the shoulder, although, in general, they have low specificity. The Yocum test has the best sensitivity and precision. Our data suggest that imaging techniques should be recommended to better define shoulder lesions.

Lupus erythematosus with an erythema multiforme-like eruption.

We describe a patient diagnosed with lupus erythematosus (LE) who developed an acute generalized eruption characterized by erythema multiforme (EM)-like lesions. Biopsy specimen showed foci of vacuolar alteration at the dermo-epidermal junction and frequent necrotic keratinocytes. Laboratory tests disclosed a speckled-homogenous antinuclear antibody titer of 1:640, leucopenia and hypocomplementemia. Anti-Ro/anti-La antibodies and rheumatoid factor were negative. Treatment with high-dose oral prednisone and azathioprine led to complete remission of the cutaneous lesions, although eruption recurred two years later. We believe that this patient presented a subacute cutaneous lupus eythematous with a distinctive erythema multiforme-like eruption. This case could be included in the so-called Rowell's syndrome, although it does not fit all the immunological characteristics reported in the original description, as in many of the previously reported cases. At the present time there seems to be enough evidence to classify Rowell's syndrome within the subacute cutaneous lupus erythematosus subset. Finally, a coexistence of LE and EM can not be completely discarded in our patient, although no causative factor was found.

Epidemiología. Factores etiológicos / Epidemiology. Progostic factors

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Intra-articular osteoid osteoma at the elbow: report of a case and review of the literature.

Osteoid osteoma is a benign tumor that may occur in almost any part of any bone. Diagnosis can be difficult, particularly when it is intra-articular. In these cases, osteoid osteoma may present initially with symptoms suggestive of inflammatory arthritis, degenerative joint disease, neoplasm, or infection. We report a case of intra-articular osteoid osteoma in a teenager who presented with a monoarthritis of the elbow. The patient did not have a typical pattern of pain, did not have the typical relief with anti-inflammatory agents, and misinterpretation of the radiographs led to a delay in the diagnosis and definitive treatment. Surgical excision confirmed the diagnosis and resulted in resolution of the monoarthritis. Intra-articular osteoid osteoma must be taken into account in cases of unexplained chronic monoarthritis, with a sterile and relatively noninflammatory synovial fluid. A definitive diagnosis depends on surgical excision and histologic confirmation. Ahigh index of suspicion is necessary to make the diagnosis.

Catastrophic antiphospholipid syndrome (CAS): a rare manifestation of the antiphospholipid antibody syndrome.

During the last decade, antiphospholipid antibodies and their clinical manifestations have given rise to increasing interest and have been associated with a wide spectrum of clinic expression, including arterial and venous thrombosis, thrombocytopenia, recurrent fetal wastage, Coombs positive haemolysis, livedo reticularis and neurological abnormalities, commonly present as isolated recurrent events, and rarely characterized by fatal outcome. Recently, an acutely disseminated vasculopathy, the so-called "catastrophic antiphospholipid syndrome" (CAS) characterized by non-inflammatory vascular occlusion and frequency of fatal outcome, has been described. We present yet another case report of this new and poorly understood entity and review its antecedents, clinical manifestations, serological profile, treatment and outcome.

Candida arthritis in adult patients who are not intravenous drug addicts: report of three cases and review of the literature.

Candida species are an uncommon cause of infectious arthritis, although the frequency has increased during recent years. Three cases of septic arthritis caused by Candida species are reported, and the literature is reviewed. The first patient developed a popliteal cyst infected by Candida albicans after multiple intravenous antibiotic treatments. The second patient had acute myelogenous leukemia and experienced knee arthritis after chemotherapy, and the third suffered oligoarthritis after a second heart transplantation. All patients received treatment with a standard dose of intravenous amphotericin B. Responses were achieved only in the first two cases; the third patient died despite therapy. Thirty-six previously reported Candida arthritis cases are reviewed, and epidemiologic, diagnostic, therapeutic, and prognostic features are analyzed. Cases are divided into two categories: direct inoculation of fungus and hematogenously disseminated disease; these two categories are compared in terms of sex, age, pathogen species, treatment, and survival. Arthritis induced through direct inoculation of fungus is seen in older individuals, is more frequently produced by species other than C albicans (Candida parapsilosis especially), and has a better prognosis than arthritis caused by disseminated candidiasis. Arthritis can be resolved even in the persistence of the systemic disease. It is believed that the first case of Baker's cyst infected by C albicans and the first case of Candida arthritis in a heart transplant patient are reported here.

[Still's disease in adults and polymyositis. An infrequent association]. / Enfermedad de Still del adulto y polimiositis. Una asociación infrecuente.

A case of coexistence of adult onset Still's disease and idiopathic inflammatory myopathy is reported in a patient with antecedent of Graves-Basedow disease. Although myalgias are common during the flares of adult onset Still's disease, a review of literature only disclosed two previous cases of polymyositis associated to adult onset Still's disease. A high index of suspicion is needed in order to diagnose such a rare association which has relevant prognostic and therapeutic implications. Treatment with methotrexate was started in order to control myopathy, resulting in improvement of both polymyositis and adult onset Still disease. A possible role of methotrexate in the management of adult onset Still's disease is suggested.

Double disease in rheumatology: coexistence of rheumatoid arthritis and psoriatic arthritis.

Since rheumatoid arthritis (RA) and psoriatic arthritis (PA) are common diseases, there should be a group of patients in which the two entities coexist, with an estimated prevalence ranging from 0.03/10,000 to 0.15/10,000. The two entities may share clinical, analytic and radiologic features that further complicate the diagnosis. We report here a patient in whom RA and PA coexisted. The features that differentiate peripheral arthritis in RA and PA are discussed.