Parameniscal cyst: an important differential diagnosis in slow growing masses of the knee.

INTRODUCTION: Parameniscal cysts are small cystic lesions, near the meniscus, involving medial and lateral compartments at equal frequency. Frequently, parameniscal cysts are so small that patients do not notice them, being asymptomatic. However, they can grow and exceed 2 centimeters in diameter, causing pain and alarm due to the slow growing mass. Magnetic Resonance Imaging (MRI) is the gold standard for diagnosis. METHODS: Case report of a patient admitted to rheumatology department in the Centro Hospitalar e Universitário de Coimbra. RESULTS: We report a case of a 47-year-old male with idiopathic juvenile arthritis, who presented with a slow-growing mass over the medial aspect of the right knee. MRI revealed a conspicuous cystic ovoid lesion, compatible with a parameniscal cyst, associated with structural heterogeneity of the posterior edge of the internal meniscus with a longitudinal fracture at this level. CONCLUSION: This is the first case of parameniscal cyst reported in patients with inflammatory rheumatic disease and the differential diagnosis with synovial cyst, baker cyst, ganglion cyst, bursitis, hematoma and neoplasms is of utmost importance.

Shear-Wave Elastography Evaluation of Major Salivary Glands in Primary Sjögren's Syndrome.

OBJECTIVES: Salivary glands ultrasonography has recently been shown to be useful in the diagnosis of Primary Sjögren's Syndrome (pSS). Shear-wave elastography (SWE) is a promising tool for the quantitative assessment of tissues stiffness, but studies evaluating its role in pSS diagnosis are limited. This study aimed at investigating the diagnostic performance of SWE in pSS. MATERIALS AND METHODS: Cross-sectional study including patients fulfilling the 2016 ACR/EULAR classification criteria for pSS and healthy subjects. The four major salivary glands were assessed using SGUS. B-mode scans were rated using the Hocevar score, and shear-wave velocity (SWV) values were obtained using SWE. Intraclass-correlation coefficient (ICC) estimates were used to assess reliability. Cut-off values for differentiating pSS patients from healthy subjects were calculated using Receiver-Operating Characteristics (ROC) curves. RESULTS: We included 50 pSS and 25 healthy subjects. Inter-rater reliability of SWE was moderate (ICC=0.64) and intra-rater reliability was moderate to good (ICC= 0.73 to 0.83). Total SWV (2.09 m/s (0.32); p < 0.001), parotid SWV (2.25 m/s (0.40)) and submandibular SWV (1.92 m/s (0.38)) were significantly higher in pSS patients. Total and parotid SWV presented good diagnostic performance for pSS diagnosis (AUROC= 0.80 and 0.81, respectively). The Hocevar score demonstrated excellent diagnostic performance (AUROC= 0.98) and combining it with total SWV did not result in statistically significant improvement (p=0.301). CONCLUSIONS: SWE may contribute to the diagnosis of pSS. Large prospective studies including sicca and secondary SS patients, as well as the standardisation of SWE protocols, are warranted to assess the role of SWE in pSS management.

Paraneoplastic sclerodermiform syndrome--case report.

Occasionally, auto-immune diseases may emerge as paraneoplastic syndromes. This is especially recognized in the case of polymyositis/dermatomyostis, but it is an extremely rare event in systemic sclerosis (SSc). The authors report the case of a sixty-year-old woman who presented with Raynaud's phenomenon and rapidly progressing skin thickness of the forearms, hands and lower limbs. Patient evaluation revealed a colorectal carcinoma. The patient was referred to the oncology department. This concomitance of cancer and SSc with rapid progression of the latter, suggests that the scleroderma might have a paraneoplastic origin. Such an hypothesis deserves consideration in every case as early diagnosis may be decisive to control the progression of either disease.

2011 Portuguese recommendations for the use of biological therapies in patients with psoriatic arthritis.

OBJECTIVE: To develop recommendations for the treatment of psoriatic arthritis (PsA) with biological therapies, endorsed by the Portuguese Society of Rheumatology. METHODS: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. A draft of the recommendations was first circulated to all Portuguese rheumatologists and their suggestions were incorporated in the draft. At a national meeting the recommendations were discussed and all attending rheumatologists voted on the level of agreement for each recommendation. A second draft was again circulated before publication. RESULTS: A consensus was achieved regarding the initiation, assessment of response and switching biological therapies in patients with PsA. Specific recommendations were developed for several disease domains: peripheral arthritis, axial disease, enthesitis and dactylitis. CONCLUSION: These recommendations may be used for guidance in deciding which patients with PsA should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

[Tracheal stenosis by extrinsic compression: a case of anterior cervical hypertrophic osteophytosis]. / Estenose traqueal por compressão extrínseca: um caso de osteofitose cervical anterior hipertrófica.

Anterior Cervical Hypertrophic Osteophytosis (ACHO) is a clinical entity caused by degenerative changes of the cervical spine. ACHO may also be found in Diffuse Idiopathic Skeletal Hyperostosis (DISH)1-3, Ankylosing Spondylitis and Post-traumatic Osteophytogenesis. In a minority of cases it may lead to oesophagical manifestations and less commonly, to respiratory complaints. The authors report the case of a 75-year-old male with a personal history of chronic tophaceous gout and chronic obstructive lung disease. The patient presented with a history of progressive worsening of dyspnoea and dysphagia (for solid food) as well as foreign body sensation at the cervical level. On general examination, the patient presented with slightly diminished breath sounds and an increased expiratory time. On rheumatologic examination, the patient had moderate limitation of all cervical movements, crepitating knees and multiple gout tophi in both hands. Cervical plain radiographs showed large anterior osteophytes at the level of C4 and C5. Flexible videobronchoscopy was also performed, showing an angle of distortion in the upper third of the tracheal wall, caused by extrinsic compression. These changes were confirmed by cervical CT scan which also documented an anterior sliding of the oesophagus due to large anterior cervical osteophytes. Videofluoroscopic swallow study revealed the presence of paradoxal contraction of the cricopharyngeal muscle. The patient was treated with a non-steroidal anti-inflammatory drug (NSAID) and a skeletal muscle relaxant. Dysphagia improved but not the respiratory symptoms. Although there was indication for surgical removal of the hypertrophic osteophytes, the patient refused surgery and continues to be followed-up regularly at our outpatient clinic.

[Health-related quality of life and chronic pain experience in rheumatic diseases]. / Qualidade de vida e vivência da dor crónica nas doenças reumáticas.

OBJECTIVES: To assess differences among health-related quality of life, pain threshold and perception,and passive coping strategies with chronic pain(specifically retreating, worrying, and resting), as well as associations among variables in three groups of rheumatic patients - fibromyalgia (FM),rheumatoid arthritis (RA), and osteoarthritis (OA). MATERIAL AND METHODS: 86 participants diagnosed with FM (n = 25), RA (n = 31) and OA (n = 30) completed the following measures: Clinical and Sociodemographic Questionnaire (QSDC), Medical Outcomes Study 36-item Short Form Health Survey(SF-36v2), Pain Coping Inventory (PCI), visual analogic scale (VAS) for pain, and dolorimeter for threshold pain. SPSS software was used to perform statistical analyses. RESULTS: FM patients reported the lowest levels of quality of life and threshold pain, as well as the highest levels of pain perception and passive coping with chronic pain. Associations between variables support that experience with chronic pain is managed more successfully in OA patients, followed by RA patients and, finally, by FM patients. CONCLUSIONS: Our findings support the adoption ofa biopsychosocial model for assessment and intervention with rheumatic patients, considering specificities associated to each illness.

[Intersticial lung disease as the sole manifestation of antisynthetase syndrome]. / Doença pulmonar intersticial como manifestação isolada de sindrome anti-sintetase.

The authors report a clinical case of a woman who had a 3 years diagnosis of hipersensitivity pneumonitis based on intersticial lung disease without other manifestations. The diagnosis of antisynthetase syndrome was made three years after the initial symptoms upon the onset of systemic manifestations with articular involvement, myositis and determination of anti-PL 7 antibodies. In this syndrome, the isolated pulmonary involvement is rare.

[Primary Sjögren syndrome and inclusion body myositis]. / Síndrome de Sjögren primária e miosite de corpos de inclusão.

The authors report the case of a 69-years-old woman with Sjögren's syndrome. After 8 years of disease she developed muscle weakness and the diagnosis of inclusion body myositis was established. This is a rare association. The patient had a good response to the immunosupressive treatment. Similar cases can be found in the literature and there seems to be a subset of inclusion body myositis associated with autoimmune diseases that shows a better response to treatment and a more favourable prognosis.