Case Study

The natural history of untreated Lyme arthritis is rarely observed as most cases are successfully treated with antibiotics. This Case Study discusses a patient with Lyme disease who refused antibiotic therapy during the first 4 years of her illness and demonstrates that antibiotic therapy is still likely to be effective, even following a long-term infection withBorrelia burgdorferi.

In this Case Study, the authors describe a patient with systemic lupus erythematosus and diffuse alveolar hemorrhage whose condition did not respond to high-dose corticosteroid therapy. Disease remission was achieved following treatment with umbilical-cord-derived mesenchymal stem cell transplantation.

Septic costochondritis is a rare presentation that is usually seen in intravenous drug users, patients with diabetes or those receiving long-term hemodialysis. In this Case Study, the authors describe the diagnosis and management of this condition in a previously healthy patient without any of the established risk factors.

In this Case Study, the authors describe a patient with Poncet disease, a rare form of polyarthritis associated with tuberculosis infection. They discuss their application of interferon-γ-release assays and PCR specific for DNA of theMycobacteria tuberculosis complex to make the diagnosis, despite a negative M. tuberculosisculture.

Song and colleagues describe the diagnosis and treatment of a 50-year old man with pansclerotic morphea with immune-mediated bone-marrow failure and cytopenias. Although standard therapies for fibrotic skin disorders were ineffective, the patient responded to T-cell-targeted treatment with antithymocyte globulin.

This Case Study presents a 70-year-old woman who was administered etanercept to treat rheumatoid arthritis that was active, despite therapy with conventional DMARDs. During follow-up, the patient's symptoms improved but she developed weakness and numbness in her arms and legs. Investigations revealed a mass in her cervical spine, which was histopathology confirmed to be a benign meningioma.

This Case Study describes a postmenopausal woman who sustained a vertebral compression fracture 1 year after discontinuing long-term alendronate therapy for osteoporosis. A bone biopsy specimen revealed numerous giant, multinucleated osteoclasts, in contrast to the current opinion that alendronate therapy reduces the number of osteoclasts. In the context of this case, the authors highlight diseases that might be associated with giant osteoclasts, and discuss how to discriminate between them in order to avoid unnecessary tests and referrals.

In this Case Study, the authors describe the unusually fulminant course of T-cell lymphoma in a 57-year-old Afro-Jamaican woman with an 8-year history of SLE, from the first presentation of symptoms to the patient's death shortly after the start of chemotherapy. The patient's ethnic and geographic background ultimately raised the suspicion of infection with an oncogenic virus.

Interstitial lung disease is a common manifestation of systemic sclerosis, and often leads to death in these patients. These authors describe the case of a previously healthy woman with acute systemic sclerosis who experienced an unusually fulminant course of interstitial lung disease, which did not respond to treatment with intravenous cyclophosphamide.

The authors present the case of a 49-year-old man diagnosed with chronic unilateral sacroiliitis who did not respond to conventional therapy with corticosteroids and NSAIDs. A single intra-articular injection of the tumor necrosis factor inhibitor infliximab resulted in gradual and steady improvements in pain, stiffness and inflammation.

This Case Study of a 14-year-old boy with juvenile-onset ankylosing spondylitis discusses the complexities of the nomenclature, classification, and diagnosis of the spondyloarthropathies in children, and how these matters have important implications for treatment.

Although arthroscopic removal is the usual treatment for intra-articular tophi, surgery is not always an option. This Case Study demonstrates that continuous urate-lowering therapy is a suitable alternative: in a 67-year-old man, painful locking of the knee secondary to intra-articular tophi was alleviated following continuous allopurinol therapy. Resolution of the tophi was demonstrated by CT.

This Case Study describes a 13-year-old girl with systemic juvenile idiopathic arthritis who developed features consistent with macrophage activation syndrome. The patient's disease remained active following treatment with high-dose steroids, immunoglobulin and ciclosporin, but was successfully controlled following the introduction of anakinra.

This Case Study illustrates the differential diagnosis and management of nephrogenic systemic fibrosis, a progressively debilitating fibrosing disorder. The authors describe the case of a 60-year-old woman with chronic renal disease who presented with progressive stiffness in her arms and legs following exposure to gadolinium-containing contrast media.

In this Case Study, Drs Flossmann and Jayne describe the treatment of a patient with refractory Wegener's granulomatosis and discuss the challenges associated with managing this disorder.

Drs Asherson, Giampaolo and Strimling describe a middle-aged patient with total alopecia, muscular spasms, diarrhea and gastric ulceration. She is only the fifth reported case of adult-onset Satoyoshi syndrome (usual age of onset is 5–19 years), and the first person reported to have a combination of Satoyoshi syndrome, gastric ulceration, and eosinophilic enteritis.

Optic neuritis and myelitis can occur as manifestations of idiopathic demyelinating syndromes, as well as of systemic rheumatic syndromes. In this Case Study, Drs Birnbaum and Kerr present a patient with systemic lupus erythematosus and concomitant neuromyelitis optica (also known as Devic's syndrome), and discuss the distinguishing clinical and radiographic features critical for an accurate diagnosis.

Undifferentiated connective tissue disease is characterized by a mild clinical picture, with a low level of disease activity during the entire disease course, and by the absence of manifestations specific to any major connective tissue disease. In this Case Study, Drs Mosca, Tani and Bombardieri present a case of stable undifferentiated connective tissue disease and argue that this condition might constitute a distinct clinical entity.

Palmar fasciitis and polyarthritis syndrome can mimic other rheumatic conditions, and the underlying mechanism for its development has not yet been defined. This syndrome is an uncommon paraneoplastic presentation. In this Case Study, Dr Haroon and Dr Phelan discuss a patient diagnosed with palmar fasciitis and polyarthritis syndrome associated with pancreatic carcinoma.