Pulmonary nodules in a patient with rheumatoid arthritis: Which diagnostic approach is the most appropiate?

Background: Pulmonary nodular excavation should firstly evoke tuberculosis or necrosis broncho-pulmonary tumor, particularly: epidermoid carcinoma. The case discussed here illustrated these difficulties in patients with rheumatoid arthritis (RA). Case Presentation: A 63-year-old woman was presented with a-three-year history of RA and a recent discovery of an excavated pulmonary nodule. Initial investigations focused on a rheumatoid origin. The evolution of the disease was worrisome and surgical exploration was deemed mandatory. The result was the discovery of a nodule of a malignant nature. Conclusion: In this paper, we discussed the excavation of the pulmonary nodule, its diagnoses and management of the difficulties we encountered

Tophaceous hip gouty arthritis revealing asymptomatic axial gout

Background: Hip and axial involvement is uncommon during gout and may raise diagnostic challenges. We describe a rare case of tophaceous hip gout which lead to the diagnosis of asymptomatic axial tophaceous gout at a single rheumatology center. Case presentation: A 35-year-old man, diagnosed with tophaceous polyarticular gout 14 years before presentation, consulted for a gout attack with reduced hip range‐of‐motion on physical examination and an increased serum uric acid level (655 µmol/L). He had been regularly taking colchicine, allopurinol (300 mg/j), and occasionally non-steroidal antiinflammatory drugs. Plain Radiography of the hips revealed bilateral circumferential joint space narrowing, subchondral erosions of the right acetabular, a calcified soft tissue tophus of the left hip and bilateral sacroiliitis grade IV. Computed tomography (CT) showed total ankylosis of the upper segments of both sacroiliac joints and bilateral hip joint space narrowing, subchondral geode eroding the right acetabulum. Moreover, CT revealed soft-tissue tophi involving the major trochanter of the left acetabulum, the right coxofemoral joint and lowest two levels of lumbar facet joints (L4-L5; L5-S1). A spinal and plevis magnetic resonance imaging (MRI) concluded on a gouty tophi, locolized bilaterally intraarticularly in the coxofemoral joints, gluteus medius bursae, lumbar facet joints (L4-L5; L5-S1), and cofirmed bilateral sacroiliitis. Conclusion: The axial and hip gouty arthritis are exceptionnel localisation. Radiographic imaging tools, mainly CT and MRI, may show the monosodium urate crystals and tophi that can contribute to bone and joint lesions of gout. They also allow the exclusion of other possible etiologies such as spondylodiscitis, infection, and neoplasia. Keywords: Gout, Tophi, Hip, Sacroiliitis, Lumbar spin

Unexpected diagnosis of vertebral osteolysis

Abstract This is the case of a 50‐year‐old patient suffering from inflammatory low back pain. Radiological exploration showed posterior vertebral damage compatible with discovertebral pseudo‐tumor tuberculosis. Pathological examination found no malignant cells, but caseous necrosis was present. The patient was put on antitubercular drugs. The evolution was favorable under treatement

Dorsal costo-vertebral joint as a rare localization of Staphylococcus aureus sepsis

Background: Septic arthritis of the costovertebral thoracic joint is a rare site infection. We report an isolated case of septic arthritis of the 10th costo-vertebral right joint with osteitis due to Staphylococcus aureus. Case presentation: A 59 year old Tunisian man presented with a 2 months history of dorsal spinal pain with fever, associated with asthenia, anorexia and loss of weight. There was a raised C-reactive protein (176 mg/L) and erythrocyte sedimentation rate (100 mm/1st h). Tests for tuberculosis and brucellosis were negative. In the present patient, the clinical symptoms were unspecific with lack of obvious predisposing factors. He had neither history of taking immunosuppressors nor of any disease indicative of immunodeficiency. Thoraco-abdominal computed tomography (CT) showed a lytic lesion centered on the 10th costo-vertebral right joint and histo-pathologic exam of the costo-vertebral puncture confirmed chronic active osteitis and bacteriologic culture allowed identifying methicillin-sensitive Staphylococcus aureus. The patient was treated with ciprofloxacin 1500 mg/day, associated with daily rifampin (20 mg/kg) for total treatment duration of 12 weeks after consulting infectious disease specialists. After a follow-up of 6 months, the patient remained asymptomatic and the markers of inflammation negative. Conclusion: Septic arthritis of costovertebral joints should be considered when a patient presents with back pain, fever and elevated inflammatory markers. The diagnosis of septic arthritis of costovertebral joints remain a challenge to clinicians. CT is important to confirm a diagnosis and guide costovertebral biopsy and culture. Early and appropriate antibiotic therapy is important for a required outcome. Keywords: Costo-vertebral joint, Staphylococcus aureus, Septic arthritis, Dorsal spine, Computerized tomograph

Is improvement of fatigue in rheumatoid arthritis a proper effect of biologics?

Background. The objective of our present study is to assess the relation between persistent fatigue and rheumatoid arthritis (RA) disease activity and its functional impact and to determine if the positive effect of biologics on fatigue is due to good disease response or to a different pathway

Clinical and laboratory characteristics in septic arthritis patients with and without isolated germs

Background: The management of septic arthritis without bacteriological evidence is not well codified. Aim of the work: To compare the features of septic arthritis with and without isolated germs. Patients and Methods: This is a retrospective study including all patients with septic arthritis, discharged from the Rheumatology Department of Charles Nicolle Hospital, Tunisia over a period of 17 years [1998–2014]. The epidemiological and clinical data were evaluated. Patients were grouped according to the presence and absence of isolated germs. Results: Fifty-nine septic arthritis patients were collected with an average of 3.5 cases/year. The mean age of the patients was 54.6 ± 19 years [15–95] without sex predominance: 28 were male and 31 were female. At least one risk factor for SA was founded in 41 patients (69.5%). It was monoarticular in 50 cases (84.7%), oligoarticular in 6 (10.2%) and polyarticular in 3 (5.1%). The knee was the most often affected (49.2%). Germ was isolated in cultures and/or synovial fluids in 27 patients (45.8%). The age tended to be older in those with isolated germs and the elderly were more frequently infected compared to the non-elderly (51.8% versus 21.9%) (p = .01). The synovial fluid analysis, clinical and laboratory characteristics were comparable but the functional disability was significant higher in those without isolated germs (p = .024). Sternoclavicular joint was more common in patients with isolated germs (p = .016). There was no difference between the two groups regarding the course of the infection. Conclusion: Patients with isolated and non-isolated germs have similar epidemiologic, clinical, biological and radiological characteristics. Keywords: Septic arthritis, Isolated germs, Infection, Joint punctur