Chronic Monoarthritis Research Articles

Treatment of Early Undifferentiated Chronic Monoarthritis of the Wrist by Arthroscopic Wrist Synovectomy Combined with Partial Denervation.

Undifferentiated chronic monosecarthritis (UCMA) is a group of inflammatory joint diseases that has the potential to progress to other diseases and can seriously affect patients' quality of life. There is yet no unified consensus regarding treatment of UCMA. This study aimed to investigate the efficacy of arthroscopic synovectomy combined with partial wrist denervation in treating Larsen 1-3 UCMA. In this case series, we reviewed 14 patients with UCMA treated by arthroscopic synovectomy combined with partial denervation from February 2017 to June 2020. The mean duration of symptoms was 17.4 months (range, 4-60 months), and the mean follow-up was 13.3 months (range, 6-23 months). The anterior and posterior interosseous nerves were severed at the distal forearm, and the radiocarpal, midcarpal, and distal radial ulnar joint synovial membranes were arthroscopically resected at the wrist. The clinical evaluation indices included the visual analogue scale score (VAS) for pain, grip strength, range of (active) motion of the wrist, total active motion, and Mayo wrist score. Larsen's scoring method was used as the imaging evaluation index. At the last follow-up, significant clinical improvements were observed in the visual analogue scale (VAS) score for pain (6.0 (5.0-6.3) vs 1.0 (1.0-2.3), P = 0.001) and Mayo wrist score (42.1 ± 9.7 vs 61.8 ± 12.3, P < 0.0001). No significant changes were found in grip strength (15.9 ± 4.5 vs 16.6 ± 4.7, P = 0.230) or the flexion-extension arc (58.9 ± 39.0 vs 64.3 ± 36.5, P = 0.317), although the mean and median did show positive changes. Among the three patients who showed progress in imaging, there was no significant difference in their pain and functional scores compared to those who did not progress. One patient underwent total wrist fusion 17 months after the operation. Arthroscopic wrist synovectomy combined with partial wrist denervation can provide sustained pain relief and functional recovery for patients with Larsen 1-3 UCMA.

#6130 COMMON VARIABLE IMMUNODEFICIENCY WITH A TNFRSF13B GENE MUTATION IN A KIDNEY AND PANCREAS TRANSPLANT RECIPIENT: WHAT SHOULD WE AIM FOR?

Abstract Background and Aims Common Variable Immune Deficiency (CVID) is a primary immunodeficiency disorder, where genetic defects are commonly present, with hypogammaglobulinemia (typically IgG) and increased susceptibility to recurrent infections, autoimmune disorders, granulomatous diseases and malignancy. It can also potentially lead to nephropathy, with increased risk of proteinuria and metabolic acidosis, higher risk of acute tubular injury caused by Immunoglobulin replacement therapy, and the data available in current literature shows a higher incidence of tubulointerstitial nephritis and membranous glomerulopathy, with IgG deposits on immunofluorescence in most cases. Our aim is to report the challenges of a kidney and pancreas transplant in a recipient with chronic kidney disease and a primary immunodeficiency disorder, to outline an immunosupression strategy with potential alternatives, and to report on the short-term outcomes. Case Report Here-in, we report the case of a 27-year-old patient, with type 1 diabetes mellitus, diagnosed with end-stage chronic kidney disease, who has a history of chronic inflammatory response dysregulation, with chronic monoarthritis, persistent elevation of inflammation markers, recurrent infections and low IgG levels. Genetic screening revealed a heterozygous pathological mutation in TNFRSF13B gene, and a Variant of Uncertain Significance (VOUS) in BACH2 gene. At 24 years-old, she experienced a high-risk pregnancy with HELLP syndrome, and serum creatinine and non-nephrotic proteinuria progressively worsened after postpartum. A native kidney biopsy revealed diabetic nephropathy, with C3 and IgG pseudolinear deposits on immunofluorescence. Eventually, disease progression led to hemodialysis induction. 10 months later, she received a kidney and pancreas cadaveric transplant from a standard criteria donor (SCD). Serum baseline donor creatinine was 0.9 mg/dL, and cause of death was a hemorrhagic stroke. Both donor and receptor had blood group type A (ABO system) and positive cytomegalovirus (CMV) IgG levels. Compatibility analysis showed donor Histocompatibility Leukocyte Antigens (HLA) class I: A 01,32; B08,64; C07,08; and class II: DR 17,07; DQ 02,02; DP 03,45; and receptor HLA class I: A 02,02; B 35,44; C 04,05; and class II: DR 03,04. Flow cytometry showed no receptor class I or class II anti-HLA antibodies. Panel Reactive Antibodies (PRA) test score was 0%, and flow cytometry cross-match (FCCM) was negative. Immunosuppression induction regimen included thymoglobulin, mycophenolate mofetil, tacrolimus and methylprednisolone, with optimal pancreatic graft function. Creatinine at discharge was 2.1 mg/dL. After discharge, maintenance immunosuppression protocol included tacrolimus, mycophenolate mofetil and prednisolone, and pancreas and renal graft function remained successfully stable, with no serious infections until current date. Discussion Common variable immunodeficiency with a heterozygous TNFRSF13B gene mutation is associated with increased risk of hypogammaglobulinemia, lymphoma, gastrointestinal cancer and autoimmunity. The VOUS BACH2 gene is also likely pathological, since there have been BACH2 polymorphisms associated with autoimmune endocrine diseases, including Addison's disease, Graves’ disease and type 1 diabetes mellitus. A hyper-regulated inflammatory state can accelerate kidney function deterioration, but chronic treatment with corticosteroids should be cautious due to the underlying diabetic nephropathy. After transplantation, recipients with CVID are at higher risk of atypical infections, autoimmune complications and disease recurrence with suboptimal long term graft survival. The evidence of current immunosuppression maintenance regimens is weak due to the paucity of CVID cases described in current literature. In the future, we believe that belatacept could offer benefits in terms of reducing the risk of graft loss or the incidence of serious infectious in a transplant recipient with a primary immunodeficiency disorder. Nevertheless, therapy management should be accomplished in a patient-to-patient basis.

Biochemical and behavioral effects of decreasing dietary linoleic acid and increasing eicosapentaenoic acid and docosahexaenoic acid in a rat chronic monoarthrits model

Clinical studies have demonstrated that decreasing linoleic acid (LA) while increasing eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in diets evokes an analgesic effect in headache sufferers. We utilized a rat chronic monoarthritis model to determine if these analgesic effects can be reproduced in rats and to and further probe potential analgesic mechanisms. We fed 8 rats a control diet (with fatty acid levels similar to standard US diets) and 8 rats a low LA diet with added EPA and DHA (H3L6 diet) and after 10 weeks, performed a unilateral intraarticular injection of Complete's Freund Adjuvant (CFA). We evaluated thermal and mechanical sensitivity as well as hind paw weight bearing prior to and at 4 and 20 days post CFA injection. At 28 days post CFA injection rats were euthanized and tissue collected. H3L6 diet fed rats had higher concentrations of EPA and DHA, as well as higher concentrations of oxidized lipids derived from these fatty acids, in hind paw and plasma, compared to control fed rats. LA and oxidized LA metabolites were lower in the plasma and hind paw of H3L6 compared to control fed rats. Diet did not affect thermal or mechanical sensitivity, nor did it affect hind paw weight bearing. In conclusion, the H3L6 diet evoked biochemical changes in rats but did not impact pain related behavioral measures in this chronic monoarthritis model.

Osteoarticular Tuberculosis of the Knee as a Unique Presentation in a 10-month-old Infant: A Rare Case of a Commonly Delayed Diagnosis.

Osteoarticular tuberculosis of the knee is an uncommon disease presentation, especially in children under 1 year old. Diagnosis based on classic methods (such as culture and anatomopathological examination) is a challenge due to the paucibacillary characteristic of the infection. Risk factors include contact with individuals with bacilliferous tuberculosis, living in a region with high disease prevalence, and pediatric age group. We describe a case of chronic monoarthritis caused by Mycobacterium tuberculosis and intermittent inflammatory manifestations in a 10-month-old male patient with no extra-articular symptoms and no history of contact with bacilliferous tuberculosis. The culture was negative, and the anatomopathological examination was inconclusive for the etiologic agent. The detection of traces of M. tuberculosis DNA by a rapid molecular test (GeneXpert) based on the polymerase chain reaction technique established the diagnosis. The treatment consisted of antituberculosis drugs and led to complete resolution of the clinical-radiographic picture. This case emphasizes the importance of considering tuberculosis in the initial differential etiologic diagnoses of arthritis and, therefore, the need for an early, specific investigation, even when the clinical suspicion is not high.

Clinical Profile of Patients with Tuberculous Arthritis Admitted in a Tertiary Hospital in the Philippines

Background. Tuberculous arthritis is a rare extra-pulmonary manifestation of tuberculosis (TB) that can lead to significant disability when left untreated. This study described the clinical profile of patients with TB arthritis admitted in a tertiary hospital in the Philippines.&#x0D; Methods. We reviewed medical records of 65 patients with TB arthritis admitted in the Philippine General Hospital from 2006 to 2019.&#x0D; Results. Majority of patients were male (41, 63.0%) and the mean age upon diagnosis was 46.7 ± 1.7 years (20– 85). Majority (33, 50.8%) had underlying co-morbidities including hypertension (16, 24.6%), type 2 diabetes mellitus (10, 15.4%), and chronic kidney disease (8, 12.3%). A history of previous TB treatment (10, 15.4%), intake of immunosuppressive drugs (7, 10.8%), and trauma on affected joints (13, 20.0%) were also reported. Majority presented with chronic mono-arthritis (50, 76.9%) involving the knees (27, 41.5%) and hips (21, 32.3%) with a mean duration of symptoms of 20.9 ± 3.9 months. The most frequent initial diagnosis upon admission was septic arthritis (21, 32.3%). Confirmed septic arthritis (10, 15.6%), pulmonary TB (9, 14.3%), and disseminated TB (4, 6.3%) were also observed. Majority were diagnosed based on positive acid-fast bacilli (AFB) smear, polymerase chain reaction (PCR) for Mycobacterium tuberculosis, or synovium biopsy (34, 54.0%). Anemia (43, 68.3%) and elevated inflammatory biomarkers (erythrocyte sedimentation rate, ESR [36, 97.3%] and C-reactive protein, CRP [40, 87%]) were also seen in majority of patients. The most common radiographic findings on x-ray were joint space narrowing (42, 84.0%), soft tissue swelling (22, 44.0%), and erosions (21, 42.0%). The mean length of hospital stay was 23.8 ± 2.8 days (2–113). Majority underwent surgical interventions (35, 55.6%) including debridement (28, 80.0%) and arthrotomy (25, 71.4%). All received anti-tuberculosis treatment upon diagnosis.&#x0D; Conclusion. Majority of patients with TB arthritis in this study were male, with mean age in the 5th decade of life, presenting with mono-arthritis, anemia, elevated inflammatory markers, and radiologic findings of joint narrowing. All patients received medical treatment while more than half underwent surgery. There should be a high index of suspicion for TB arthritis in a patient from an endemic country presenting with chronic mono arthritis in weight-bearing joints to prevent delay in diagnosis and significant joint destruction and disability

Monoarthritis of the Elbow Revealing Osteoid Osteoma: A Case Report and Literature Review

Osteoid osteoma is a rare benign osteoblastic tumor that mainly occurs in the extra-articular segments of lower limb long bones. The elbow is an exceptional location for osteoid osteoma.&#x0D; The diagnosis is usually delayed since the elbow is a rare site for this tumor and unspecific clinical signs, such monoarthritis, may mimic other more common conditions.&#x0D; We report the case of a 16-year-old girl who presented with chronic monoarthritis of the elbow which was treated falsely as tuberculous arthritis and monoarticular rheumatoid involvement.&#x0D; The laboratory tests were negative. Computed tomography scan and magnetic resonance imaging showed the focal nidus at the coronoid process of the ulna with mild synovitis. The diagnosis of osteoid osteoma was not made until the disease had been progressing for eighteen months and the elbow had already become stiff.&#x0D; Arthroscopic excision of the lesion was performed, and histopathology of the nidus was consistent with osteoid osteoma. Since then, the patient has been pain-free with an improved elbow range of motion.

Takayasu arteritis with an initial presentation of chronic monoarthritis mimicking oligoarticular juvenile idiopathic arthritis.

Patients with Takayasu arteritis (TA) generally present with non-specific symptoms that, if unrecognized and untreated, may develop vessel stenosis and/or aneurysm. There is limited data regarding chronic monoarthritis as the initial presentation in children with TA. We report a 6-yearold girl diagnosed and treated as oligoarticular juvenile idiopathic arthritis (JIA). She later developed stroke with malignant hypertension and was definitively diagnosed with TA. She additionally developed proteinuria secondary to focal segmental glomerulosclerosis. This is the report of a patient with chronic monoarthritis mimicking oligoarticular JIA which chronic monoarthritis was the presentation of TA. Since JIA is a diagnosis of exclusion, any atypical features of oligoarticular JIA should illuminate the possibility of an alternative diagnosis. Our literature review focused on musculoskeletal presentations of children with TA.

Antinociceptive antibiotics-loaded into solid lipid nanoparticles of prolonged release: Measuring pharmacological efficiency and time span on chronic monoarthritis rats.

Pain is a sensory experience of a complex physiological nature in which is not only involved the nervous system. Among its many features is the development of chronic pain that is more complicated to treat because of the central somatization processes involved, becoming inefficient treatments used in other forms of pain. Among them is the role of glial cells, whose participation is such that some authors have proposed to chronic pain as a gliopathy. Because of this, the drug target of possible treatments focuses on modulating nociceptive response affecting transduction into the central nervous system through affecting synapses in the dorsal horn of the spinal cord. Solid lipid nanoparticles enter the central nervous system, protecting the drug, and in addition to the advantage of having greater absorption surface, all factors that improve drug activity. This work is based on the development and characterization of lipid nanoparticles of solid phase incorporating two antibiotics, minocycline, and ciprofloxacin with antinociceptive properties and challenged them with a rat monoarthritis model using Sprague-Dawley adult male rats. The solid lipid nanoparticles were prepared to modify the lipid, and surfactant amounts to obtain the best encapsulation capacity of the antibiotics, size and z potential. By using the Randall-Selitto test, we measured its pharmacological efficiency as an anti-inflammatory and measuring the time span the antibiotics are active. The encapsulated antibiotics were at least 50% more efficient than the antibiotic alone, and that is possible to measure anti-inflammatory activity up to seven days after the antibiotic application. The former is important for example, in the veterinary field, since a single application of the antibiotic will be necessary for the complete treatment, avoiding excessive stress for the animals. We can conclude that antinociceptive antibiotics encapsulation is a very effective, environmentally safe and inexpensive method for improving the pharmacological efficiency and time span the antibiotics are acting. Since these antibiotics are both anti-microbial and antinociceptive, his use in the field of veterinary presents the advantage of being adequate in single doses, with the saving of time and stress to the animals under treatment.

The effective diagnosis of chronic monoarthropathy: What are our options?

Introduction: Monoarticular arthritis which means inflammation, (infective or non-infective) of single synovial joint is a huge burden in the health care system. Chronic monoarthritis is characterized by its progressive onset and slow development, commonly presenting with mild inflammatory signs. The clinical presentation is usually nonspecific especially in the early stages. To evaluate the role of clinical, hematological and immunological features in the diagnosis of peripheral large joint monoarthritis and its correlation with radiographic studies and histopathological studies of the same. Materials: A total of 30 patients of a monoarticular joint disease were studied in which conventional radiography, MR imaging, arthroscopy and synovial biopsy as techniques for its diagnosis were compared. Results: The mean age in the present study was 21.23 years with a preponderance of male patients. MRI was found to have high sensitivity (87.5%) and specificity (85.7%) in the diagnosis of chronic inflammatory synovitis. Arthroscopy wasfound to have a sensitivity of 83-85% and specificity of 85-86% in diagnosing both inflammatory and infective synovitis. Conclusion: MRI is recommended as additional techniques in the initial diagnostic evaluation when radiography yields negative results. When assessed together with ahistopathological examination of the synovium and mycobacterial cultures, MRI imaging forms a powerful tool in diagnosing tubercular synovitis early. Arthroscopic joint evaluation should be used wherever feasible for a complete evaluation of the knee joint along arthroscopic guided biopsy. Not only does it increase the diagnostic yield of the biopsy but can also diagnose other associated conditions.

Chronic Monoarthritis Pain Accelerates the Processes of Cognitive Impairment and Increases the NMDAR Subunits NR2B in CA3 of Hippocampus from 5-month-old Transgenic APP/PS1 Mice.

Many factors impact cognitive impairment; however, the effects of chronic pain and the mechanisms underlying these effects on cognitive impairment are currently unknown. Here we tested the hypothesis that chronic pain accelerates the transition from normal cognition to mild cognitive impairment (MCI) in 5-month-old transgenic APP/PS1 mice, an animal model of Alzheimer’s disease (AD), and that neurotoxicity induced by N-methyl-D-aspartic acid receptor (NMDAR) subunits may be involved in this process. Chronic monoarthritis pain was induced in transgenic APP/PS1 mice and 5-month-old wild-type (WT) mice by intra- and pre-articular injections of Freund’s complete adjuvant (FCA) into one knee joint. Pain behavior, learning and memory function, and the distribution and quantity of NMDAR subunits (NR1, NR2A and NR2B) in hippocampal CA1 and CA3 regions were assessed. Our results showed that although persistent and robust monoarthritis pain was induced by the FCA injections, only the transgenic APP/PS1 mice with chronic monoarthritis pain exhibited marked learning and memory impairments. This result suggested that chronic monoarthritis pain accelerated the cognitive impairment process. Furthermore, only transgenic APP/PS1 mice with chronic monoarthritis pain exhibited an overexpression of NR2B and an increased NR2B/NR2A ratio in the hippocampus CA3. These findings suggest that chronic pain is a risk factor for cognitive impairment and that increased neurotoxicity associated with NMDAR subunit activation may underpin the impairment. Thus, NMDARs may be a therapeutic target for the prevention of chronic pain-induced cognitive impairment.

Features of extra-spinal musculoskeletal tuberculosis: A retrospective study from an North Indian Tertiary Care Institute

Background: The aim is to study the clinical features and diagnosis of primary extra-spinal musculoskeletal manifestations of tuberculosis (TB) in otherwise healthy individuals. Methods: In this retrospective study of 10 years duration electronic database and case records of patients with musculoskeletal TB were analyzed. Patient's positive for HIV and rheumatic diseases with or without immunosuppressive drugs or biological agents were excluded from the study. Results: Fifty-one patients were identified with the mean age at presentation of 33.35 years (range 4–72), male: female ratio of 1.1:1 and mean duration of disease was 14.65 months (range, 0.25–120). The most frequent manifestation was articular (arthritis/arthralgia n = 40, monoarthritis n = 28, oligoarthritis n = 10, polyarthralgia n = 2) followed by tenosynovitis (n = 6), tuberculous osteomyelitis (n = 5), isolated bursitis (n = 1), and pyomyositis (n = 1). Poncet's disease was diagnosed in five patients. Disseminated TB was detected in four patients. Pain (n = 50) followed by swelling of the involved site (n = 37) were the most common presenting symptoms. Fever was present in 15 (29.4%) patients. Nine patients had a previous history of TB. Concurrent pulmonary TB was present in two patients. Lymph node enlargement was present in 12 (23.5%) patients. A definite diagnosis of musculoskeletal TB was made in 31 (61%) patients and probable TB in 20 (39%) patients. Conclusion: Musculoskeletal manifestations of TB can occur at any age. Chronic monoarthritis is the most common presentation; however, oligoarthritis and/or tenosynovitis may be a presenting manifestation. The absence of fever should not discourage the diagnosis of musculoskeletal TB.

Intra-articular injection of Botulinum toxin A reduces neurogenic inflammation in CFA-induced arthritic rat model

Currently, administration of Botulinum toxin Type A (BoNT/A) to treat arthritic pain has promising efficacy in clinical research. However, the mechanisms underlying anti-neurogenic inflammation mediated by BoNT/A remains unclear. The aim of this study was to demonstrate the effectiveness in macro and micro levels and to explore the causal mechanism of BoNT/A.Wistar rats (n = 60) were injected with 50ul complete Freund's adjuvant (CFA) in the left ankle joint capsule to establish a model of chronic monoarthritis. Pain behaviour (Evoked pain assessment) and infrared thermal imaging testing were performed at the macroscopic level to assess the effectiveness of analgesia and anti-inflammation. Western blotting and immunofluorescence staining were used at the microscopic level in an attempt to determine the mechanisms of anti-nociceptive or anti-inflammatory effects of BoNT/A. Additionally, hematoxylin-eosin staining was also used to visualise the cartilage and the synovial degenerative conditions of arthritis. By comparing the outcome of the evoked pain test and immunofluorescence staining, there was a significant improvement in BoNT/A compared with the normal saline (NS) injected control group. In addition, thermal variations showed that the temperature of ipsilateral ankle joint increased between 1 and 2 weeks following injection of CFA, but decreased after 3 weeks (still above the contralateral side). However, the temperature showed no difference between the BoNT/A group and NS group after treatment. The expression of IL-1β or TNF-α in the ankle synovial tissue was significantly decreased in the BoNT/A group compared to the NS group (p < 0.05). Based on the HE assessment, cartilage degeneration and infiltration of inflammatory cells in the BoNT/A group was alleviated compared to the NS group after treatment. In conclusion, we proposed the hypothesis that intra-articular BoNT/A administration does play an important role in anti-neurogenic inflammation. The possible mechanisms might be that BoNT/A prevents the release of nociceptive nerve peptides at the injection site and then suppresses the expression of inflammatory cytokines.

Characterization of chronic arthritis in a multicenter study of 852 childhood-onset systemic lupus erythematosus patients.

Chronic arthritis (CA) is an unusual condition in childhood-onset systemic lupus erythematosus (cSLE) and data in children is very limited. The aim of the study is to assess CA in a large population of cSLE patients, in a multicenter cross-sectional study including 852 cSLE patients followed in ten Pediatric Rheumatology referral services in state of São Paulo, Brazil. CA was observed in 32/852 (3.7%) cSLE patients mostly in hands and ankles. Chronic monoarthritis was diagnosed in four cSLE patients, oligoarthritis in nine and polyarthritis in 19. In the latter group, six had rhupus syndrome. Two oligoarticular patients had Jaccoud's arthropathy. CA was an isolated manifestation observed at disease onset in 13/32 (41%) cSLE patients, and juvenile idiopathic arthritis (JIA) was the first diagnosis in 18/32 (56%). The comparison of last visit of patients with CA and without this manifestation revealed higher frequency of splenomegaly (28 vs. 11%, p=0.002). The median of SLICC/ACR-DI score [1(0-9) vs. 0(0-7), p=0.003] was significantly higher in CA patients compared to patients without this manifestation, likewise the frequency of musculoskeletal damage (31 vs. 9% p=0.001). Frequencies of treatment with nonsteroidal anti-inflammatory drugs (75 vs. 26%, p<0.0001), hydroxychloroquine sulfate (87 vs. 59%, p=0.001) and methotrexate (47 vs. 22%, p=0.001) were significantly higher in CA patients. This large multicenter study allowed us to characterize CA as a rare and early manifestation of cSLE, frequently mimicking JIA at disease onset. It is predominantly polyarticular, involving more often hands and ankles and it is associated with significant musculoskeletal accrual damage.

Multimodal Diagnostic Approach to Monoarthritis of the Wrist

Objective: The aim of this study was to evaluate both the performance characteristics of magnetic resonance imaging (MRI) in the differential diagnosis of monoarthritis of the wrist and the predictive ability of the 1987 American College of Reumatology (ACR) and 2010 ACR/European League Against Rheumatism (EULAR) criteria. Methods: The 29 patients with monoarthritis of the wrist retrospectively reviewed in this study underwent preoperative MRI with or without a white blood cell (WBC) scan. Their diagnoses were confirmed histologically after open synovectomy. Synovitis, bone erosion, and bone edema, as seen on MRI, were measured by 2 readers independently using the Outcome Measures in Rheumatology Clinical Trials (OMERACT) Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) system. Receiver operating characteristic (ROC) curves were used to calculate the cutoff differentiating rheumatoid arthritis (RA) from other diseases. The optimized cutoff point for each parameter was determined using Youden index. Results: The areas under the ROC curves for the synovitis, bone erosion, and bone edema scores were 0.892, 0.853, and 0.752, respectively. The cutoff values of these scores to predict RA were 5, 48, and 19, respectively. The sensitivity and specificity of the 1987 ACR criteria were 50% and 92% and those of the 2010 ACR/EULAR criteria were 60% and 75%. Conclusion: The OMERACT RAMRIS system provides a valuable tool to differentiate RA from tuberculosis and undifferentiated chronic monoarthritis in patients with wrist monoarthritis. A multimodal diagnostic approach using MRI, WBC scan, and histologic evaluation is recommended if the diagnosis cannot be established based on clinical, biochemical, and radiographic evaluations.

Managing monoarthritis in children

Monoarthritis, defined as inflammation of a single joint, requires a thorough physical examination in children, as pain may be lacking in 10% to 30% of cases and joint stiffness may be the only symptom. Joint aspiration is a crucial diagnostic tool that remains markedly underused. Joint aspiration may be unnecessary, however, when the family history or other investigations provide the diagnosis. Radiographs of the involved joint may supply information on the severity of the lesions. In doubtful cases and in patients with arthralgia, B-mode and Doppler ultrasound or magnetic resonance imaging (MRI) may confirm the presence of synovitis. Although suspected septic arthritis is an emergency and occurs frequently, particularly before 2 years of age, acute monoarthritis is often a post-infectious manifestation and therefore associated with a good outcome. Lyme disease should be sought, particularly when a lower limb joint is involved, as tick bites often go unnoticed. Chronic monoarthritis is very often a manifestation of juvenile idiopathic arthritis (JIA), which exists as several variants. Oligoarthritis is a specifically pediatric joint disease, whereas the other patterns of JIA have corresponding forms in adults, despite a number of specific features due to their onset during childhood. Tests for antinuclear antibodies should be performed routinely in children with monoarthritis persisting longer than 3 weeks. A decline in general health or a fever should suggest arthritis revealing a malignancy, which is a hematological disease in most cases. Finally, suggestive symptoms are often present in patients with less common causes such as auto-inflammatory diseases and connective tissue diseases.

A Case of Rheumatoid Arthritis Presenting as an Intra-articular Mass of the Wrist Joint in a Patient with Chronic Monoarthritis

A Case of Rheumatoid Arthritis Presenting as an Intra-articular Mass of the Wrist Joint in a Patient with Chronic Monoarthritis

Differential diagnosis of chronic monoarthritis in chidren

Juvenil chronic arthrits (JCA) is the most common chronic rheumatic disease in children an important cause of disability. When only one joint is involved it may be difficult to make an early diagnosis. A detailed history and clinical examination is important to reach a correct diagnosis and appropiated treatment.

Reversal of Monoarthritis-induced Affective Disorders by Diclofenac in Rats

Nonsteroidal anti-inflammatory drugs are effective for arthritic pain, but it is unknown whether they also benefit anxiety and depression that frequently coexist with pain. Using the monoarthritis model, the authors evaluated the activation of extracellular signal-regulated kinases 1 and 2 (ERK1/2) in structures implicated in both sensorial and emotional pain spheres, and it was verified whether analgesia can reverse monoarthritis-mediated affective responses. Monoarthritis was induced in male rats by complete Freund's adjuvant injection. Allodynia (ankle-bend test), mechanical hyperalgesia (paw-pinch test), anxiety- and depression-like behaviors (elevated zero maze and forced swimming tests, respectively), and ERK1/2 phosphorylation (Western blot) in the spinal cord, paragigantocellularis nucleus, locus coeruleus, and prefrontal cortex were evaluated at 4, 14, and 28 days postinoculation (n = 6 per group). Changes in these parameters were evaluated after induction of analgesia by topical diclofenac (n = 5 to 6 per group). Despite the pain hypersensitivity and inflammation throughout the testing period, chronic monoarthritis (28 days) also resulted in depressive- (control [mean ± SEM]: 38.3 ± 3.7 vs. monoarthritis: 51.3 ± 2.0; P < 0.05) and anxiogenic-like behaviors (control: 36.8 ± 3.7 vs. monoarthritis: 13.2 ± 2.9; P < 0.001). These changes coincided with increased ERK1/2 activation in the spinal cord, paragigantocellularis, locus coeruleus, and prefrontal cortex (control vs. monoarthritis: 1.0 ± 0.0 vs. 5.1 ± 20.8, P < 0.001; 0.9 ± 0.0 vs. 1.9 ± 0.4, P < 0.05; 1.0 ± 0.3 vs. 2.9 ± 0.6, P < 0.01; and 1.0 ± 0.0 vs. 1.8 ± 0.1, P < 0.05, respectively). Diclofenac decreased the pain threshold of the inflamed paw and reversed the anxio-depressive state, restoring ERK1/2 activation levels in the regions analyzed. Chronic monoarthritis induces affective disorders associated with ERK1/2 phosphorylation in paragigantocellularis, locus coeruleus, and prefrontal cortex which are reversed by diclofenac analgesia. (Anesthesiology 2014; 120:1476-90).

An Intraarticular Osteoid Osteoma: A Case Report &amp; Review of Literature

Osteoid osteoma (OO) is one of the common benign bone tumors but an uncommon cause of musculoskeletal pain. Its diagnosis is usually not difficult in classic clinical setup and in typical location in diaphyseal region. However, the diagnosis of juxta or intraarticular osteoid osteoma (IAOO) is challenging because of atypical clinical presentation responsible for delay in diagnosis and treatment. We report a rare case of IAOO as a cause of chronic shoulder pain to make clinician aware to help in its early diagnosis and management. A 28-year-old woman presented with chronic debilitating right shoulder pain. The diagnosis was established on CTscan after 2 years of onset of symptoms because of atypical clinical presentation as a chronic monoarthritis of the shoulder. CTscan demonstrated radiolucent nidus with central calcification with areas of surrounding sclerosis. The tumor was excised surgically and histopathologic examination confirmed the diagnosis of osteoid osteoma. So, in the scenario of an unexplained chronic monoarthritis, the possibility of intraarticular osteoid osteoma should also be kept in mind. CT-scan remains the investigation of choice for demonstrating the nidus and surgical exicision relieves the symptoms. DOI: http://dx.doi.org/10.3126/njr.v3i2.9615 Nepalese Journal of Radiology Vol.3(2)July-Dec, 2013: 77-80

Extra-pulmonary manifestations of paracoccidioidomycosis associated with acquired immunodeficiency syndrome: a case report

We present a patient with Paracoccidioidomycosis/HIV coinfection which has been investigated because of chronic monoarthritis and mucocutaneous lesions. A biopsy of the synovial membrane and skin revealed structures consistent with Paracoccidioides brasiliensis. At diagnosis, the count of CD4 + T cells was 44 cells/mm3. We emphasize the importance of clinical suspicion of Paracoccidioidomycosis in patients with HIV/AIDS who live in or are from risk areas.