Case Reports in Rheumatology The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Occurrence of Psoriatic Arthritis during Interferon Beta 1a Treatment for Multiple Sclerosis Tue, 15 Apr 2014 14:07:38 +0000 Interferon beta (IFN-β) is the first line therapy of relapsing-remitting multiple sclerosis. IFN-β is a cytokine that can contribute to the development of systemic autoimmune disease including psoriasis. The development or the exacerbation of psoriasis during IFN-β treatment has been previously observed. We report the occurrence of arthritis and dactylitis in a multiple sclerosis patient with preexisting psoriasis diagnosed as a psoriatic arthritis. The IL-23/Th17 pathway is involved in psoriasis and psoriatic arthritis and it has been suggested that IFN-β therapy in patients with Th17-mediated disease may be detrimental. Together with previous similar reports, our case suggests that IFN-β should certainly be used with caution in patients with concomitant systemic autoimmune disease with IL-23/Th17 involvement. Éric Toussirot, Matthieu Béreau, Marie Bossert, Imad Malkoun, and Anne Lohse Copyright © 2014 Éric Toussirot et al. All rights reserved. A Case of Rheumatoid Arthritis and Limited Systemic Sclerosis Overlap Successfully Treated with Tocilizumab for Arthritis and Concomitant Generalized Lymphadenopathy and Primary Biliary Cirrhosis Tue, 15 Apr 2014 07:19:57 +0000 A 57-year-old woman with rheumatoid arthritis (RA) and limited systemic sclerosis (lSSc) was suspected to have lymphadenopathy and primary biliary cirrhosis (PBC). Lymph node biopsy showed reactive follicular lymphadenopathy with intrafollicular plasmacyte infiltration that was interleukin-6 positive by immunohistostaining. Because of gradually worsening arthritis, tocilizumab was administered and arthritis improved markedly. Interestingly, lymphadenopathy and PBC improved simultaneously. This suggested that interleukin-6 might play an important role in reactive lymphadenopathy and PBC associated with RA/lSSc. Eiko Saito, Shinji Sato, Shinichi Nogi, Noriko Sasaki, Naofumi Chinen, Kiri Honda, Takayuki Wakabayashi, Chiho Yamada, Naoya Nakamura, and Yasuo Suzuki Copyright © 2014 Eiko Saito et al. All rights reserved. Myelofibrosis-Related Arthritis Successfully Treated with Hydroxyurea Thu, 10 Apr 2014 12:37:43 +0000 A 62-year-old woman suffering from one-year lasting, nonerosive peripheral arthritides with general health impairment and high acute-phase reactant levels was admitted to rheumatology department. The patient had suffered from chronic polyarthralgia and a thrombocytosis had been discovered 9 years before, with a recent increase in platelet count. All immunological blood tests were negative. Corticosteroid and methotrexate treatments improved pain, swollen joint count, and systemic inflammation. However, joints remained stiff and painful with two swollen wrists and persistent thrombocytosis. An iliac bone marrow biopsy was performed, showing primary myelofibrosis. Hydroxyurea treatment (500 mg per day) allowed to achieve complete and prolonged clinical and biological remission. After 6 months, a new disease flare occurred. The patient reached remission again after hydroxyurea dose increased to 1500 mg per day. This supports the hypothesis of idiopathic myelofibrosis-associated seronegative polyarthritis. This is the first reported case in which haemopathy-targeted treatment using hydroxyurea induced arthritis remission. Xavier Guillot, Marius Moldovan, Claire Vidon, and Daniel Wendling Copyright © 2014 Xavier Guillot et al. All rights reserved. A Debilitating Orthopaedic Complication following Corticosteroid Therapy for Polymyalgia Rheumatica Sun, 06 Apr 2014 12:33:47 +0000 Avascular necrosis (AVN) of the scaphoid secondary to corticosteroid use is a rare entity. Previous reports in the literature refer to chronic steroid intake. We report a case secondary to low dose, short term use. AVN has a multifactorial cellular and genetic aetiology and most frequently affects the femoral head. Diagnosis relies on a high index of suspicion and early magnetic resonance (MR) scanning. Treatment options are similar to those of traumatic scaphoid nonunions and include vascularised bone grafting and scaphoid excision. Polymyalgia Rheumatica is a common condition and its treatment is led by corticosteroid use. Mild to moderate strengths are advocated. However in our report we show that even with small doses serious adverse effects can be encountered. Paul Rai and Vinay Takwale Copyright © 2014 Paul Rai and Vinay Takwale. All rights reserved. Amyloidoma, an Unusual Cause of Fracture Sun, 16 Mar 2014 07:22:49 +0000 We report a case of a spontaneous hip fracture in a context of dysglobulinemia. The bone histologic examination found amyloidoma. Amyloidoma is an overload pathology and an unusual cause of fracture. In most of the cases, it is associated with myeloma and the difference between bone invasion of myeloma and amyloidoma in an osteolytic radiographic picture is not easy but is of importance because prognosis and treatment may be totally different. Thus, in the context of dysglobulinemia, one must keep in mind that spontaneous bone fracture may be due to amyloidoma with another prognosis. Frank Verhoeven, Clément Prati, and Daniel Wendling Copyright © 2014 Frank Verhoeven et al. All rights reserved. Coexistence of Ankylosing Spondylitis and Löfgren’s Syndrome Tue, 11 Mar 2014 00:00:00 +0000 A 46-year-old male patient diagnosed with ankylosing spondylitis presented to our polyclinic with complaints of pain, swelling, and limitation in joint mobility in both ankles and erythema nodosum skin lesions in both pretibial sites. The sacroiliac joint graphy and the MRI taken revealed active and chronic sacroiliitis. On the thorax CT, multiple mediastinal and hilar lymphadenopathies were reported. Mediastinoscopic excisional lymph node biopsy was taken and noncalcified granulomatous structures, lymphocytes, and histiocytes were determined on histopathological examination. The patients were diagnosed with ankylosing spondylitis, sarcoidosis, and Löfgren’s syndrome. NSAIDs, sulfasalazine, and low dose corticosteroid were started. Significant regression was seen in the patient’s subjective and laboratory assessments. Senol Kobak, Fidan Sever, Oya Sivrikoz, and Ahmet Karaarslan Copyright © 2014 Senol Kobak et al. All rights reserved. Developing of Granulomatosis with Polyangiitis during Etanercept Therapy Thu, 06 Mar 2014 12:11:32 +0000 We describe a 67-year-old woman who developed c-ANCA positive vasculitis with involvement in eyes, skin, kidney, peripheral nerves, and upper and lower airway during treatment with etanercept therapy for rheumatoid arthritis. A diagnosis of Granulomatosis with Polyangiitis was done. Thus, anti-TNF therapy may be associated with the development of ANCA positive vasculitis. María Clara Ortiz-Sierra, Andrés Felipe Echeverri, Gabriel J. Tobón, and Carlos Alberto Cañas Copyright © 2014 María Clara Ortiz-Sierra et al. All rights reserved. An Unusual Case of Adult-Onset Still’s Disease with Hemophagocytic Syndrome, Necrotic Leukoencephalopathy and Disseminated Intravascular Coagulation Tue, 04 Mar 2014 07:27:47 +0000 Case. A 34-year-old African-American female with a history of adult-onset Still’s disease presented to an outside hospital with oligoarthritis. She experienced a generalized tonic-clonic seizure en route via ambulance, was intubated upon arrival, and transferred to the intensive care unit for treatment of suspected pneumonia and sepsis. She subsequently developed generalized cutaneous desquamation that progressed despite the cessation of antibiotics and other potential offending drugs which required transfer to our hospital’s burn unit. She was suspected to have reactive hemophagocytic syndrome based on her clinical presentation of fever, rash, polyarthritis, elevated liver enzymes, coagulopathy, splenomegaly, normocytic anemia, thrombocytopenia, hypertriglyceridemia, hyperferritinemia, and hemophagocytosis visualized in bone marrow biopsy specimen. Magnetic resonance imaging demonstrated necrotic demyelination of the deep white matter and corona radiata. The patient developed multiorgan dysfunction and DIC without any other attributable etiology. Despite aggressive broad spectrum therapy and high dose of steroids she progressively deteriorated and eventually expired. Conclusion. Previous publications have highlighted the prevalence of necrotic leukoencephalopathy in children with familial hemophagocytic syndrome. Our patient demonstrated some uncommon features complicating her HLH including DIC and necrotic leukoencephalopathy, which are very rare entities in AOSD. Rajaie Namas, Naveen Nannapaneni, Malini Venkatram, Gulcin Altinok, Miriam Levine, and J. Patricia Dhar Copyright © 2014 Rajaie Namas et al. All rights reserved. Ramsay Hunt Syndrome in a Patient with Rheumatoid Arthritis after Treatment with Infliximab Sun, 09 Feb 2014 07:04:03 +0000 A 39-year-old female patient with rheumatoid arthritis developed Ramsay Hunt syndrome after infliximab treatment. This condition is caused by the reactivation of varicella zoster virus infection in the geniculate ganglion of facial nerve in the host’s immunosuppression. She was treated immediately with valaciclovir and hydrocortisone, and the complete recovery was achieved at 6 months after the onset. This is the first report of Ramsay Hunt syndrome as an adverse effect of infliximab in rheumatoid arthritis. Yoshio Nagayama, Naoki Matsushiro, Akihide Nampei, Hideo Hashimoto, and Kenrin Shi Copyright © 2014 Yoshio Nagayama et al. All rights reserved. Leukocytoclastic Vasculitis in a Patient with Ankylosing Spondylitis Wed, 05 Feb 2014 08:09:40 +0000 A 26-year-old male patient presented to our rheumatology clinic with pain, swelling and limitation of movement in his right ankle, and also purpuric skin lesions in the lower extremity pretibial region. He was asked questions, and he said that he had been having chronic low back pain and morning stiffness for the last few years. His physical examination revealed that he had arthritis in his right ankle, purpuric skin lesions in pretibial regions of both legs, and bilateral FABERE/FADIR positivity. The sacroiliac joint imaging and MRI revealed bilateral sacroiliitis findings, and the lateral heel imaging revealed enthesitis. HLA-B27 was positive. Skin biopsy from lower skin lesions was reported to be consistent with leukocytoclastic vasculitis. Based on clinical, laboratory, radiological, and pathological examinations, the patient was diagnosed with ankylosing spondylitis and leukocytoclastic vasculitis. Administration of corticosteroid, salazopyrin, and nonsteroid anti-inflammatory medications was started. Notable clinical and laboratory regression was observed during his checks 3 months later. Senol Kobak, Hatice Yilmaz, Ahmet Karaarslan, and Murat Yalcin Copyright © 2014 Senol Kobak et al. All rights reserved. Primary Systemic Al Amyloidosis Presenting as Temporal Arteritis Sun, 19 Jan 2014 00:00:00 +0000 Temporal arteritis is most common vasculitis in elderly and imitated by miscellaneous disorders. Temporal artery biopsy is the gold standard test in the diagnosis of giant cell arteritis (GCA). Hereby, we describe a case of a 67-year-old man who presented initially with temporal arteritis; however, a lip biopsy then revealed AL amyloidosis. In this respect, temporal artery biopsy should be performed for definitive diagnosis of GCA particularly patients with systemic symptoms and treatment resistant. Hakan Emmungil, Melike Kalfa, Burcu Başarık, Hasip Kahraman, Ferhat Tanhan, Banu Yaman, Atiye Öztürk, Zehra Erdemir, Gülşen Kandiloğlu, Vedat İnal, and Yasemin Kabasakal Copyright © 2014 Hakan Emmungil et al. All rights reserved. Milwaukee Shoulder Syndrome Thu, 16 Jan 2014 11:07:31 +0000 Milwaukee shoulder syndrome (MSS) is a rare destructive, calcium phosphate crystalline arthropathy. It encompasses an effusion that is noninflammatory with numerous aggregates of calcium hydroxyapatite crystals in the synovial fluid, associated with rotator cuff defects. We describe a patient that presented with recurrent shoulder pain and swelling with characteristic radiographic changes and MSS was confirmed on aspiration of the synovial fluid. Channa Vasanth Nadarajah and Immo Weichert Copyright © 2014 Channa Vasanth Nadarajah and Immo Weichert. All rights reserved. Mycobacterium haemophilum as the Initial Presentation of a B-Cell Lymphoma in a Liver Transplant Patient Sun, 12 Jan 2014 00:00:00 +0000 A 66-year-old woman presented with pustular lesions of her face, trunk, and limbs and an acute arthritis of the knees and elbows. She had a complex medical background and had been on immunosuppressants for three years after a liver transplant. Tissue samples from her skin lesions and synovial fluid showed acid-fast bacilli. Mycobacterium haemophilum, an atypical mycobacteria, was later grown on culture. During her treatment with combination antibiotic therapy, she developed a pronounced generalised lymphadenopathy. Histology showed features of a diffuse B-cell lymphoma, a posttransplant lymphoproliferative disorder (PTLD). T. Doherty, M. Lynn, A. Cavazza, E. Sames, and R. Hughes Copyright © 2014 T. Doherty et al. All rights reserved. Diagnosis and Assessment of Disease Activity in Takayasu Arteritis: A Childhood Case Illustrating the Challenge Sun, 05 Jan 2014 14:18:59 +0000 Takayasu Arteritis (TA) is a rare, debilitating large vessel vasculitis occurring in patients of all ages, including infants, but the disease most commonly presents in the third decade. Diagnosis is often delayed and consequently TA is associated with significant morbidity and mortality. Accurate methods of monitoring disease activity or damage are lacking and currently rely on a combination of clinical features, blood inflammatory markers, and imaging modalities. In this report we describe a case of a 14-year-old boy with childhood-onset TA who, despite extensive negative investigations, did indeed have on-going active large vessel vasculitis with fatal outcome. Postmortem analysis demonstrated more extensive and active disease than originally identified. This report illustrates and discusses the limitations of current modalities for the detection and monitoring of disease activity and damage in large vessel vasculitis. Clinicians must be aware of these limitations and challenges if we are to strive for better outcomes in TA. L. Watson, P. Brogan, I. Peart, C. Landes, N. Barnes, and G. Cleary Copyright © 2014 L. Watson et al. All rights reserved. A Case of Granulomatosis with Polyangiitis Causing Hydroureter and Hydronephrosis Thu, 02 Jan 2014 10:04:37 +0000 Granulomatosis with Polyangiitis (GPA, formerly known as Wegener) is a systemic vasculitis characterized by granulomatous involving upper and lower respiratory tract and can also cause necrotizing glomerulonephritis (Umemoto et al. 2012 and Takala et al. 2011). GPA is associated with antineutrophil cytoplasmic autoantibodies (ANCA) against serine proteinase 3 (PR3) (Takala et al. 2011, Dufour et al. 2012, and Berthoux et al. 2011). This disease usually starts with involvement of the upper and lower respiratory tracts and also can involve kidney, eyes, skin, central and peripheral nervous systems, and gastrointestinal tract (Umemoto et al. 2012, Takala et al. 2011, and Berthoux et al. 2011). We describe a case of GPA that presented with abdominal pain. Computed tomography (CT) scan with contrast showed right sided moderate hydronephrosis and hydroureter, to the level of the right common iliac artery. There was also mural segmental thickening in common iliac artery which was thought to be the cause of the ureteral obstruction and hydronephrosis. Our case shows that mural segmental thickening in common iliac artery happened due to GPA and caused hydronephrosis. In addition, most of the cases with hydronephrosis due to GPA went through urology intervention such as stent placement but in our case hydronephrosis resolved with medical management. Farzin Farpour and Adriana Abrudescu Copyright © 2014 Farzin Farpour and Adriana Abrudescu. All rights reserved. A Rare Cause of Pericardial Effusion: Giant Cell Arteritis Thu, 02 Jan 2014 09:17:55 +0000 Giant cell arteritis is a granulomatous vasculitis characterized by medium or large sized vessel involvement. Although extracranial branches of the carotid artery are typically involved, involvement of aorta and its major branches can also be seen. Cardiac involvement has been encountered less frequently and pericardial effusion is rarely encountered. In this paper, a case has been presented in which pericardial effusion was determined during the examination and diagnosis was giant cell arteritis. Turker Tasliyurt, Hakan Sivgin, Lutfu Bekar, Safak Sahin, Suheyla Uzun Kaya, Resit Dogan Koseoglu, Faruk Kutluturk, and Abdulkerim Yilmaz Copyright © 2014 Turker Tasliyurt et al. All rights reserved. Rheumatoid Arthritis and Familial Mediterranean Fever or Sacroiliitis Accompanied by FMF Sun, 22 Dec 2013 16:05:29 +0000 The coexistence of rheumatoid arthritis (RA) and familial Mediterranean fever (FMF) has been rarely seen in case reports in the literature. Herein, we wanted to present a patient who had been followed up and treated as RA, but on investigation we concluded that he really had FMF and its joint complaints associated with sacroiliitis. Recovery was achieved by etanercept administered as if he was an RA patient. Ali Şahin, Alparslan Yetişgin, and Mehtap Şahin Copyright © 2013 Ali Şahin et al. All rights reserved. Successful Use of Higher-Dose Etanercept for Multirefractory Systemic Flare of Adult-Onset Still’s Disease with Liver Failure with No Response to Tocilizumab Therapy Tue, 17 Dec 2013 11:34:34 +0000 A 21-year-old woman with refractory systemic flare of adult-onset Still’s disease with liver failure despite high-dose corticosteroids, cyclosporine, tacrolimus, and tocilizumab, was successfully treated with additional use of etanercept. Etanercept at a dose of 50 mg weekly was partially effective but could not reduce the dose of concomitant betamethasone from 5 mg/day. Etanercept at a dose of 75 mg weekly could lead her to clinical remission and enabled successful tapering off the corticosteroids and discontinuation of etanercept. Normalization of serum C-reactive protein and interleukin 6 and persistent elevation of serum tumor necrosis factor α under the treatment with high-dose corticosteroids and immunosuppressants suggest that tumor necrosis factor α was more deeply involved than at least interleukin 6 in the pathogenesis of refractoriness of the disease in this patient, and these findings might be indicative of potential efficacy for adjunctive use of a tumor necrosis factor inhibitor rather than an interleukin 6 inhibitor. Taio Naniwa, Shinya Tamechika, Shiho Iwagaitsu, Shinji Maeda, and Hiroyuki Togawa Copyright © 2013 Taio Naniwa et al. All rights reserved. A Unique Case of Relapsing Polychondritis Presenting with Acute Pericarditis Tue, 17 Dec 2013 08:50:00 +0000 Relapsing polychondritis (RP) is an inflammatory disease of the cartilaginous tissue primarily affecting the cartilaginous structures of the ear, nose, joints, and the respiratory system. Cardiovascular complications of RP are associated with high morbidity and mortality and occur most commonly as valvular disease. Pericarditis is a less common complication, occurring in 4% of patients with RP and has not previously been described at presentation. We describe a case of relapsing polychondritis with acute pericarditis at presentation. John V. Higgins, Uma Thanarajasingam, and Thomas G. Osborn Copyright © 2013 John V. Higgins et al. All rights reserved. An Atraumatic Femoral Fracture in a Patient with Rheumatoid Arthritis and Osteoporosis Treated with Denosumab Sat, 07 Dec 2013 09:19:50 +0000 Osteoporosis is responsible for a significant burden both individually and socially, but is readily treated with antiresorptive agents and mineral supplementation. However, long-term usage of these agents, notably bisphosphonates, is rarely associated with atypical fractures. Denosumab is a monoclonal antibody that reduces osteoclast activity and thus increases bone mineral density. In this case report, we present a 78-year-old woman with a background of rheumatoid arthritis and osteoporosis who presented with an atypical diaphyseal femoral fracture. J. Villiers, D. W. Clark, T. Jeswani, S. Webster, and A. L. Hepburn Copyright © 2013 J. Villiers et al. All rights reserved. Coexistence of Sarcoidosis and Systemic Sclerosis Thu, 05 Dec 2013 11:06:58 +0000 Sarcoidosis is a multisystem granulomatous disease characterized by hilar lymphadenopathy, involvement of internal organs, and diverse skin lesions. Systemic sclerosis is an autoimmune disease characterized by skin hardening and different internal organ fibrosis, including vascular abnormality. Immune response associated with Th-2 has been shown in the early and active stage of the disease. In this paper, we report coexistence of systemic sclerosis with sarcoidosis in a female patient presenting with granulomatous dermatitis, interstitial lung disease, and Raynaud’s phenomenon complaints. Senol Kobak, Fidan Sever, Oya Sivrikoz, and Ahmet Karaarslan Copyright © 2013 Senol Kobak et al. All rights reserved. The Efficacy and Safety of Rituximab in a Patient with Rheumatoid Spondylitis Tue, 12 Nov 2013 14:13:42 +0000 Rheumatoid arthritis (RA) is considered as a connective tissue disease while ankylosing spondylitis (AS) is a prototype of spondyloarthritis. These diseases are seen concomitantly only very rarely. Also, rituximab has proven efficacy in the treatment of RA while its role in the treatment of AS is unclear. In this presentation, the concomitant presence of RA and AS in a 43-year-old male patient as well as the efficacy and safety of rituximab is discussed. Rituximab was given due to lack of response to treatment with anti-TNF-alpha. Evaluations made at the 6th and 12th months of treatment showed complete response for RA and partial response for AS. Şenol Kobak, Ahmet Karaarslan, and Fahrettin Oksel Copyright © 2013 Şenol Kobak et al. All rights reserved. Still's Disease in a Pediatric Patient after Liver Transplantation Tue, 05 Nov 2013 10:33:28 +0000 Still's disease (SD) is a multisystemic inflammatory disease characterized by persistent arthritis and in many cases with fever of unknown origin. Diagnosis of SD is challenging because of nonspecific characteristics and especially in the case of a patient with solid organ transplantation and immunosuppressive therapy where multiple causes of fever are possible. There is no diagnostic test for SD, even though some useful diagnostic criteria or laboratory findings, such as serum ferritin levels, have been proposed, and useful imaging studies for the diagnosis or followup of SD have not been developed. We report the case of a 9-year-old child who presented with high grade fever associated with joint pain after a history of liver transplantation and immunosuppressive therapy. Laboratory tests showed increased acute phase reactants, elevated ferritin, and leukocytosis. An 18 F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) was performed identifying abnormal hypermetabolic areas localized in spleen, transplanted liver, and bone marrow secondary to inflammatory process. All infectious, autoimmune, and malignant causes were ruled out. A diagnosis of SD was performed and a steroid-based regimen was initiated with adequate response and no evidence of recurrence. To our knowledge this is the first case of SD following a solid organ transplant. Juan-Carlos Meza, Evelyn Muñoz-Buitrón, Fabio Bonilla-Abadía, Carlos Alberto Cañas, and Gabriel J. Tobón Copyright © 2013 Juan-Carlos Meza et al. All rights reserved. Psoriatic Juvenile Idiopathic Arthritis Associated with Uveitis: A Case Report Sun, 29 Sep 2013 18:05:12 +0000 According to the definition proposed by the International League of Associations for Rheumatology (ILAR), juvenile idiopathic arthritis (JIA) is defined as an arthritis of unknown etiology, starting under 16 years of age and lasting for at least 6 weeks, once other known conditions have been excluded. JIA represents the most common chronic rheumatic disease of childhood and is considered an important cause of short- and long-term acquired disability in children. It is currently estimated that psoriatic JIA represents up to 10% of all JIA subtypes, and chronic uveitis may occur in 10 to 15% of children with psoriatic JIA. In this report we describe a case of psoriatic JIA complicated by uveitis, in a child failing previous treatments with nonsteroidal anti-inflammatory drugs, methotrexate, and etanercept. Finally, adalimumab was prescribed, which led to sustained clinical remission in both arthritis and uveitis. Davide Moretti, Ilaria Cianchi, Gaia Vannucci, Rolando Cimaz, and Gabriele Simonini Copyright © 2013 Davide Moretti et al. All rights reserved. Inflammatory Arthritis, Sacroiliitis, and Morphea: Evidence of a Systemic Inflammatory Disease Wed, 07 Aug 2013 11:52:39 +0000 Morphea is a skin disease characterized by local skin inflammation and fibrosis. Extracutaneous manifestations have been described with this disease including inflammatory arthritis. We describe a case of morphea who developed inflammatory polyarthritis and sacroiliitis coincident with new skin lesions. Mohammed A. Omair and Sindhu R. Johnson Copyright © 2013 Mohammed A. Omair and Sindhu R. Johnson. All rights reserved. Pachymeningitis in Granulomatosis with Polyangiitis: A Case Report and a Review of the Literature Tue, 06 Aug 2013 09:08:17 +0000 Central nervous involvement, mainly with symptoms of cranial neuropathies, occurs in 2–8% of patients with granulomatosis with polyangiitis (GPA). Meningeal involvement, with persistent and severe headache as main manifestation and abnormal thickening and enhancement of the dural mater on postcontrast magnetic resonance imaging, is extremely rare. We present a case of pachymeningitis due to limited GPA, providing simultaneously a literature review. Grigorios T. Sakellariou and Nicoleta Kefala Copyright © 2013 Grigorios T. Sakellariou and Nicoleta Kefala. All rights reserved. A Case of Subacute Cutaneous Lupus Erythematosus in a Patient with Mixed Connective Tissue Disease: Successful Treatment with Plasmapheresis and Rituximab Sun, 28 Jul 2013 11:40:13 +0000 A 30-year-old woman affected by Mixed Connective Tissue Disease with scleroderma spectrum developed a facial eruption, a clinical and histological characteristic of subacute cutaneous lupus erythematosus (SCLE). Speckled anti-nuclear antibodies, high-titer anti-ribonucleoprotein1, anti-Sm, anti-Cardiolipin (aCL) IgG/IgM, and anti-Ro/SSA antibodies were positive. SCLE was resistant to Azathioprine, Hydroxychloroquine, and Methotrexate while Mycophenolate Mofetil was suspended due to side effects. Subsequently, the patient was treated with three cycles of therapeutic plasma exchange (TPE) followed, one month after the last TPE, by the anti-CD20 antibody Rituximab (RTX) (375 mg/m2 weekly for 4 weeks). Eight and 16 months later the patient received other two TPE and RTX cycles, respectively. This therapeutic approach has allowed to obtain a complete skin healing persistent even after 8-month follow-up. Moreover, mitigation of Raynaud's phenomenon, resolution of alopecia, and a decline of aCL IgG/IgM and anti-Ro/SSA antibodies were observed. M. Fantò, S. Salemi, F. Socciarelli, A. Bartolazzi, G. A. Natale, I. Casorelli, A. Pavan, S. Vaglio, R. Di Rosa, and R. D'Amelio Copyright © 2013 M. Fantò et al. All rights reserved. Role of -FDG PET Scan in Rheumatoid Lung Nodule: Case Report and Review of the Literature Thu, 25 Jul 2013 12:18:14 +0000 Flourine-18 fluoro-2-deoxy-glucose (18F-FDG) positron emission tomography combined with computed tomography (PET/CT) is a useful test for the management of malignant conditions. Inflammatory and infectious processes, however, can cause increased uptake on PET scanning, often causing diagnostic dilemmas. This knowledge is important to the rheumatologist not only because of the inflammatory conditions we treat but also because certain rheumatic diseases impose an increased risk of malignancy either due to the disease itself or as a consequence of medications used to treat the rheumatic diseases. There is an increasing body of evidence investigating the role of PET scans in inflammatory conditions. This paper describes a patient with rheumatoid arthritis who developed pulmonary nodules that showed increased uptake on PET/CT scan and reviews the use of PET scanning in the diagnosis and management of rheumatoid arthritis. Christine L. Chhakchhuak, Mehdi Khosravi, and Kristine M. Lohr Copyright © 2013 Christine L. Chhakchhuak et al. All rights reserved. Sterile Osteitis and Suppurative Arthritis Associated with Pannus Responding to Colchicine Wed, 24 Jul 2013 13:27:43 +0000 Sterile suppurative arthritis is characterized by neutrophilic infiltration of joints without any causative pathogen. Here, we present a 32-year-old man with refractory osteitis and erosive suppurative oligoarthritis with pannus. Treatments with multiple disease modifying antirheumatic drugs were all unsuccessful. However, he had clinical response to colchicine and the synovial hypertrophy and the pannus in the MRI of his left shoulder resolved. In this case, the effects of colchicine on neutrophils might have played a role in treating neutrophilic sterile suppurative arthritis, which, in adults, might be a distinct oligoarticular disease. Mehmet Engin Tezcan, Özgür Ekinci, Murat Uçar, and Berna Göker Copyright © 2013 Mehmet Engin Tezcan et al. All rights reserved. A Rare Side Effect due to TNF-Alpha Blocking Agent: Acute Pleuropericarditis with Adalimumab Thu, 18 Jul 2013 11:20:12 +0000 Tumor necrosis factor-alpha antagonism is an important treatment strategy in patients with rheumatoid arthritis, psoriatic arthritis, vasculitis, and ankylosing spondylitis. Adalimumab is one of the well-known tumor necrosis factor-alpha blocking agents. There are several side effects reported in patients with adalimumab therapy. Cardiac side effects of adalimumab are rare. Only a few cardiac side effects were reported. A 61-year-old man treated with adalimumab for the last 6 months due to psoriatic arthritis presented with typically acute pleuropericarditis. Chest X-ray and echocardiography demonstrated marked pericardial effusion. Patient was successfully evaluated for the etiology of acute pleuro-pericarditis. Every etiology was excluded except the usage of adalimumab. Adalimumab was discontinued, and patient was treated with 1200 mg of ibuprofen daily. Control chest X-ray and echocardiography after three weeks demonstrated complete resolution of both pleural and pericardial effusions. This case clearly demonstrated the acute onset of pericarditis with adalimumab usage. Acute pericarditis and pericardial effusion should be kept in mind in patients with adalimumab treatment. Hakan Ozkan, Ahmet Seckin Cetinkaya, Tekin Yildiz, and Tahsin Bozat Copyright © 2013 Hakan Ozkan et al. All rights reserved.