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Neuropathic arthropathies is a destructive and deforming joint process related to a disruption of propioceptive and nocioceptive innervation. Growth factors, neurological and vascular factors might be involved. Diabetes, alcoholic neuropathy or syringomyelia appear as the most common causes. We report the case of a 61-year-old woman affected by syringomyelia, with a neuropathic arthropathy of the shoulder. Differential diagnosis includes neurological diseases, septic arthritis, tumours and other destructive arthropathies such as aseptic nechrosis, chronic osteomyelitis, synovial chondromatosis, metabolic diseases (gout, chondrocalcinosis) or repetitive haemarthrosis in haemophilia.
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PMID:[Neuropathic arthropathy of the shoulder]. 1822 3

Sternoclavicular septic arthritis is an unusual event in healthy patients. Cases have been reported in diabetes mellitus patients, intravenous drug abusers and patients affected by rheumatoid arthritis. We report a case of this unique infection that occurred in a patient who was not at risk of septic arthritis. Through this case and a review of the literature, we discuss the difficulty of diagnosing this disorder, and the consequences of delayed treatment in terms of life-threatening outcomes and therapeutic options.
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PMID:Sternoclavicular septic arthritis in a previously healthy patient: a case report and review of the literature. 1898 Aug 53

Melioidosis, an infection caused by the bacterium Burkholderia pseudomallei, has a wide range of clinical manifestations. Here, we describe rheumatological melioidosis (involving one or more of joint, bone or muscle), and compare features and outcome with patients without rheumatological involvement. A retrospective study of patients with culture-confirmed melioidosis admitted to Sappasithiprasong Hospital, Ubon Ratchathani during 2002 and 2005 identified 679 patients with melioidosis, of whom 98 (14.4%) had rheumatological melioidosis involving joint (n=52), bone (n = 5), or muscle (n = 12), or a combination of these (n=29). Females were over-represented in the rheumatological group, and diabetes and thalassemia were independent risk factors for rheumatological involvement (OR; 2.49 and 9.56, respectively). Patients with rheumatological involvement had a more chronic course, as reflected by a longer fever clearance time (13 vs 7 days, p = 0.06) and hospitalization (22 vs 14 days, p < 0.001), but lower mortality (28% vs 44%, p = 0.005). Patients with signs and symptoms of septic arthritis for longer than 2 weeks were more likely to have extensive infection of adjacent bone and muscle, particularly in diabetic patients. Surgical intervention was associated with a survival benefit, bur not a shortening of the course of infection.
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PMID:Rheumatological manifestations in patients with melioidosis. 1905 1

A 50-year-old woman with noninsulin-dependent diabetes and cirrhosis of the liver from hepatitis-B infection presented with right-sided neck and severe shoulder pain. Minimal tenderness and swelling of the right sternoclavicular joint were noted. After 8 days, extensive studies, and several attempts at therapy to relieve the shoulder pain, the right sternoclavicular joint had become more swollen, extremely tender, warm, and erythematous. An arthrotomy of the right sternoclavicular joint revealed pyoarthosis of the joint and osteomyelitis of the adjacent clavicle. Both tissue and blood cultures grew Prevotella melaninogenicus. A site of origin for the infection was never found. The patient had an uneventful recovery after treatment with open drainage and parenteral antibiotics. Although this anaerobic organism is known to cause infection at other joint sites, this seems to be the first report of infection of the sternoclavicular joint and proximal clavicle by Prevotella melaninogenicus.This case illustrates the following: 1) neck and shoulder pain may be the presenting symptoms of occult septic arthritis of the sternoclavicular joint, 2) clinical signs of infection, such as fever and leukocytosis, may be absent in the setting of anaerobic joint infections, 3) an arthrotomy should be performed as soon as an infection of the sternoclavicular joint is suspected, 4) anaerobic as well as aerobic cultures should be taken when evaluating septic arthritis 5) 2 or more weeks may be required for identification of an anaerobic organism, such as Prevotella melaninogenicus.
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PMID:Septic arthritis of the sternoclavicular joint and osteomyelitis of the proximal clavicle caused by prevotella melaninogenicus: a case with several features delaying diagnosis. 1907 30

Neuropathic arthritis, or Charcot arthropathy, is a rapidly destructive process associated with nerve damage and periarticular insensitivity. Most commonly it is associated with diabetes mellitus, tabes dorsalis, syringomyelia, or other peripheral nerve disorders. Clinical manifestations of this disorder classically include gross deformity, crepitus, lack of proprioception, joint effusion, calor, and decreased awareness of pain in the affected joint. Often the clinical picture is difficult to distinguish from septic arthritis. Radiographic findings are typically worse than portrayed during clinical examination. Rapid destruction of the articular surface with bony fragmentation is commonly found. The incidence of neuropathic arthritis among all diabetic patients is relatively small, ranging between 0.15% and 0.4%. Historically, there have been conflicting reports as to the efficacy of total knee arthroplasty (TKA) in patients with neuropathic arthritis. However, recent literature on the use of modern implants has been more optimistic as to the success of TKA. Difficulties associated with severe bone loss, poor bone quality, and ligamentous laxity may necessitate the use of structural allografts/augments, as well as stemmed and/or constrained TKA components. This article presents a case of a patient with Charcot arthropathy of the knee secondary to diabetes mellitus (type 2) treated successfully with a minimally constrained TKA and a porous tantalum cone (Zimmer, Warsaw, Indiana) as an "internal plate," for reconstruction of a combined segmental/cavitary defect of the proximal tibia. At 2-year follow-up, radiographs revealed stable TKA components with reconstitution of the fragmented proximal tibia around an osseointegrated porous cone.
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PMID:Proximal tibia reconstruction with a porous tantalum cone in a patient with Charcot arthropathy. 1947 57

Hansenula anomala (H. anomaly) is part of the normal flora in the alimentary tract and throat. It has been reported to be an organism causing opportunistic infections in immunocompromised patients. However, cases of fungal arthritis caused by H. anomala are rare. We encountered a case of H. anomala arthritis in a 70-year-old man who was treated with an empirical antibiotic treatment and surgery under the impression of septic arthritis. However, the patient did not improve after antibiotic therapy and surgery. Consequently, knee joint aspiration was performed again, which identified fungal arthritis caused by H. anomala. It was treated successfully with amphotericin B and fluconazole. When treating arthritis patients with diabetes, it is important to consider the possibility of septic arthritis by H. anomala and provide the appropriate treatment.
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PMID:A case of fungal arthritis caused by Hansenula anomala. 2019 Oct 3

There are many potential causes of joint pain in older patients. The most likely aetiology is OA. However, the differential diagnosis includes conditions which should not be missed such as septic arthritis and inflammatory disease. The pattern of joint involvement points to the diagnosis. Bilateral symmetrical small joint pain, swelling and stiffness should arouse the suspicion of RA. The wrist and knee are commonly affected by pseudogout and the first metatarsophalangeal joint or knee joint involvement may represent gout. Stiffness in the shoulder and hip girdles, worse in the morning, suggests polymyalgia rheumatica. In straightforward cases of OA no specific investigations are required. If doubt exists, however, tests may be necessary including FBC, ESR and CRP, uric acid for suspected gout and X-rays of the affected joints especially following trauma, or pseudogout. Patients with OA should be offered education and advice as well as strengthening exercises and aerobic fitness training (if physically possible). If the patient is overweight, weight loss is critical, especially in OA of the knee. Paracetamol and topical NSAIDs are the first-line drug treatments. Elderly onset RA differs from younger onset RA in the following ways: a more balanced gender distribution; a higher frequency of acute onset; an association with systemic features; more frequent involvement of the shoulder girdle and higher disease activity. DMARD therapy should be used according to disease severity, as in younger onset RA. The current approach is for early, intensive intervention with combination therapy. Corticosteroids may be very effective in the elderly, however, prolonged use and/or high dosage may lead to marked toxicity especially osteoporosis and diabetes.
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PMID:Diagnosing joint pain in the older people. 2019 31

This article presents a case of a chronic, nonhealing thumb wound in a patient with diabetes mellitus. A 67-year-old right-hand-dominant man presented with progressive erythema and swelling of the right thumb several months after sustaining a paper cut along the eponychium. The patient had already completed an extensive laboratory evaluation, including bacterial and fungal cultures, as well as a punch biopsy that was inconclusive. In addition, the patient underwent several rounds of empiric antibiotic therapy without resolution of his symptoms. Despite these measures, the patient's thumb wound persisted and new lesions began to appear proximally along the forearm. Excisional biopsy of the lesions was ultimately required to obtain additional tissue for a pathologic analysis. Culture of the specimen on Saboraud dextrose agar revealed a definitive diagnosis of infection with Sporothrix schenkii. A subsequent course of oral antifungal therapy with itraconazole was well tolerated and resulted in disease regression. Early diagnosis of sporotrichosis is essential to prevent complications including septic arthritis, systemic infection, and death. This case illustrates the importance of maintaining a high index of suspicion for atypical infectious agents in patients with poor immune function.
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PMID:Sporotrichosis of the upper extremity. 2041 15

Melioidosis, an infection due to gram negative Burkholderia pseudomallei, is an important cause of sepsis in east Asia especially Thailand and northern Australia. It usually causes abscesses in lung, liver, spleen, skeletal muscle and parotids especially in patients with diabetes, chronic renal failure and thalassemia. Musculoskeletal melioidosis is not common in India even though sporadic cases have been reported mostly involving soft tissues. During a two-year-period, we had five patients with musculoskeletal melioidosis. All patients presented with multifocal osteomyelitis, recurrent osteomyelitis or septic arthritis. One patient died early because of septicemia and multi-organ failure. All patients were diagnosed on the basis of positive pus culture. All patients were treated by surgical debridement followed by a combination of antibiotics; (ceftazidime, amoxy-clavulanic acid, co-trimoxazole and doxycycline) for six months except for one who died due to fulminant septicemia. All other patients recovered completely with no recurrences. With increasing awareness and better diagnostic facilities, probably musculoskeletal melioidosis will be increasingly diagnosed in future.
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PMID:Burkholderia pseudomallei musculoskeletal infections (melioidosis) in India. 2041 12

Rhabdomyolysis is a known complication of statin therapy and may be triggered by a pharmacokinetic interaction between a statin and a second medication. Fatal statin-induced rhabdomyolysis has an incidence of 0.15 deaths/million prescriptions. We describe 4 cases of severe rhabdomyolysis with the common feature of atorvastatin use and coadministration of fusidic acid. All cases involved long-term therapy with atorvastatin; fusidic acid was introduced for treatment of osteomyelitis or septic arthritis. Three cases occurred in the setting of diabetes mellitus, with 2 in patients with end-stage renal disease, suggesting increased susceptibility to atorvastatin-fusidic acid-induced rhabdomyolysis in these patient populations. Of the 4 patients in this series, 3 died. Fusidic acid is a unique bacteriostatic antimicrobial agent with principal antistaphylococcal activity. There have been isolated reports of rhabdomyolysis attributed to the interaction of statins and fusidic acid, the cause of which is unclear. Fusidic acid does not inhibit the cytochrome P450 3A4 isoenzyme responsible for atorvastatin metabolism; increased atorvastatin levels due to inhibition of the glucuronidation pathway may be responsible. Considering the low frequency of fusidic acid use, the appearance of 4 such cases within a short time and in a small population suggests the probability that development of this potentially fatal complication may be relatively high.
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PMID:Severe rhabdomyolysis as a consequence of the interaction of fusidic acid and atorvastatin. 2088 3


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