A 46-year old man, affected by Darier's disease (DD), was seen because of right hand pain, later extended to shoulders and ankles. Physical examination showed swelling and tenderness of the wrist, metacarpophalangeal and metatarsophalangeal joints, of the right Achilles tendon's enthesis and of the left knee, with psoriatic-like lesions of the scalp. A diagnosis of seronegative spondyloarthritis, supported by HLA-B27 positivity and by the magnetic resonance imaging finding of hand synovitis and unilateral sacro-iliitis, was made. The correlation between DD, spondyloarthritis and psoriasis has been already anecdotally reported. Further observations may clarify if this association is more than casual.

A 57-year old woman with a history of multiple sclerosis, treated with interferon beta-1a in the last 5 months, was referred for hyperpyrexia (>40°C) that persisted for 15 days. At admission, there was elevation of transaminases, anemia (hemoglobin 8.9 g/dL), thrombocytopenia (platelet 135,000/mm3), and hypofibrinogenemia (fibrinogen 1.26 g/L). C-reactive protein was 10.7 mg/dL, lactate dehydrogenase 1270 U/L and ferritin 2380 ng/ mL, with hepatosplenomegaly and linfoadenomegaly. Hemophagocytic lymphohistiocytosis induced by direct stimulation of macrophages by interferon (IFN) was suspected. IFN was withdrawn as only measure and onemonth later signs and symptoms disappeared, with complete normalization of laboratory examinations.

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BackgroundThe modified Rodnan skin score (mRSS) is the validated method to evaluate the extension of skin involvement in systemic sclerosis (SSc) and to distinguish between patients with limited cutaneous skin involvement (lcSSc, skin involvement is confined to the extremities) or diffuse (dcSSc) (1,2). Recently several studies have demonstrated that skin high frequency ultrasound (US) is a valid and reproducible technique to measure dermal thickness (DT) in patients with SSc (3–6).ObjectivesTo compare the values of DT obtained by two ultrasound transducers with different frequency (18 MHz and 22 MHz) in evaluating the DT in lcSSc patients and healthy controls.MethodsThirty-seven lcSSc patients (mean age 62±13SD years, mean disease duration 5±5SD years) and 37 healthy controls (CNT) sex and age matched were enrolled after informed consent. Both US transducers of 18 and 22 MHz (Esaote, Genova) were used to evaluate DT in the seventeen areas of the skin (zygoma, fingers, dorsum of hands, forearms, arms, chest, abdomen, thighs, legs, feet) of SSc patients where Rodnan skin score (mRSS) is usually assessed. Skin US was also performed in the same seventeen areas of CNT, looking for DT differences in comparison with lcSSc patients. Statistical analysis was carried out by non parametric tests.ResultsDT evaluated with the 22 MHz probe was found significantly higher in all body areas in comparison with the 18 MHz transducer, both in lcSSc patients (p<0.01) and in CNT (p=0.05). The median difference of DT values between the two probes was of 0.11 millimetres in lcSSc patients (minimum 0.0023, maximum 0.28 mm) and 0.01 millimetres in CNT (minimum 0.0029, maximum 0.03 mm). Of interest, in lcSSc DT evaluated by 18 MHz transducer was recognized significantly higher (p<0.001) also in four out of six skin areas where the mRSS was found normal (score=0) (upper-arms, chest and abdomen), with exclusion of thighs (p=0.08), in contrast with the classification of lcSSc. However, by using the 22 MHz transducer a statistically significantly higher median DT was showed in all skin areas, included thighs (p<0.01). Finally, a positive statistically significant correlation was observed between the two transducers in the evaluation of DT (p<0.0001), as well as between both probes and mRSS (p<0.0001 for both).ConclusionsThis study suggests that subclinical dermal involvement may be detectable by skin high frequency US already in patients with limited cutaneous SSc. This study confirms that DT can be better assessed in SSc patients by using a 22 MHz US probe, and suggests that DT might be underestimated by using US probes of lower frequency (18 MHz). However, the DT values obtained using both probes resulted significantly correlated together and with the mRSS.References Clements PJ, et al. Arthritis Rheum 2000;43:2445–54.Moore TL, et al. Rheumatology 2003;42:1559–63.Sulli A, et al. Ann Rheum Dis. 2014;73:247–51.Czirják L, et al. Ann Rheum Dis. 2007;66:966–9.Hesselstrand R, et al. Rheumatology 2008;47:84–7.Kaloudi O, et al. AnnRheum Dis.2010;69:...

BackgroundMetatarsal pain is a frequent complaint in the general population. It is usually mechanical and associated with a variety of risk factors, including female sex, anatomical changes of the forefoot, joint laxity, overweight, and high-heeled shoes. In a minority of patients, metatarsal pain can be a symptom heralding an early arthritis, a condition sharing some of the previously mentioned risk factors. In this setting, where laboratory examinations and conventional radiography are often silent, MRI could be theoretically of help in the differential diagnosis by investigating synovitis, bone marrow oedema (BME), and erosions. BME, however, may be present also in traumatic, degenerative, and overload-associated conditions, such as osteoarthritis. To our knowledge, data regarding the MRI comparison between degenerative and inflammatory metatarsal pain are scanty.ObjectivesTo investigate if MRI of the metatarsophalangeal (MTP) joints could be useful in the differential diagnosis of mechanical MTP pain as compared to early arthritis.Methods10 patients with mechanical MTP pain (9 women, mean age 51.1±12.5 years, disease duration 14.1±12.2 months), without a history or clinical findings suggestive of arthritis or psoriasis were studied. They were compared to 13 patients with early (<6 months) rheumatoid arthritis (RA) (11 women, mean age 47.5±17.1 years, disease duration 3.3±2 months), 8 patients with long-standing RA (7 women, mean age 57.5±11.7 years, disease duration 40.1±27 months), and 8 patients with seronegative spondyloarthritides (SeS, 6 psoriatic arthritis and 2 reactive arthritis, 5 women, mean age 50.7±9.2, median disease duration 24 months, range 1-216 months). The diagnosis of arthritis was based on the relevant criteria. MRI was performed with a 0.2T extremity dedicated machine (Artoscan C, Esaote, Genova, Italy) using Turbo 3D (erosions) and STIR (synovitis and BME) sequences: Turbo 3D T1-weighted sequences (TR/TE=35/16 ms; matrix=192x160; FOV=140x140; slice thickness 0.8 mm; interslice gap 0 mm) in the coronal plane with subsequent reconstruction of the remaining planes; coronal and axial STIR sequences (TR/TE=1500/24 ms [coronal] and 2400/24 [axial]; matrix=192x160 [coronal] and 192x144 [axial]; FOV=160x160; slice thickness 3 mm [coronal] and 4 mm [axial]; interslice gap 0.3 mm [coronal] and 0.4 mm [axial]). All lesions were scored as present or absent.ResultsTable 1 reports the results of the study.Table 1Synovitis (%)BME (%)Erosion (%)Mechanical2/10 (20)0/10 (0)1/10 (10)Early RA10/13 (76.9)*2/13 (15.4)2/13 (15.4)RA7/8 (87.5)**5/8 (62.5)*3/8 (37.5)SeS7/8 (87.5)**0/8 (0)1/8 (12.5)*p=0.01,**p=0.02. ConclusionsThe only MRI feature differentiating mechanical MTP pain from arthritis was synovitis. BME was significantly more frequent only in established RA. MRI can help in the differential diagnosis between degenerative metatarsal pain and early arthritis because of the increased frequency of synovitis in the latter.Disclosure of InterestNone declared