BACKGROUNDMyositis ossificans is an uncommon form of metaplasia in which bone tissue forms in muscle after an injury to the muscle fibers, most commonly due traumatic injury-be it by repetitive minor trauma or one significant single event. This is a case report of a patient with myositis ossificans of femoral and hip muscles due to injury related to tonic-clonic seizures. CASE REPORTA 33-year-old female, with epilepsy associated with autoimmune limbic encephalitis since 2006, presented to the Rheumatology Clinic with chronic pain of both knee and hip joints bilaterally since the seizures began. The patient had begun previous treatment with a rheumatologist in another institution with loss of follow-up, presenting no response to treatment with alendronate. On physical examination, she presented with significantly limited range of motion of the hips, as well as swelling and pain during mobilization of both knees and hips; and also crackles during mobilization of the knees. X-rays showed heterotopic calcifications in both hips, as well as ossification of heterotopic calcification in the medial facet of both knees in the general topography of the medial collateral ligaments. Further investigation showed negative ANA, anti-DNA antibody and rheumatoid factor, as well as normal complement levels. The patient is currently undergoing treatment with risedronate, and awaiting computed tomography scans to be evaluated by an orthopedic surgeon; however, due to the severity of her neurologic symptoms and difficulty in controlling seizures, the risk of trauma to the already injured muscles persists. CONCLUSIONMyositis ossificans is a heterogeneous group of diseases that vary between post-traumatic and inflammatory injuries to genetic disorders; trauma being the most commonly associated etiology to the development of heterotopic ossification in muscles. It is believed that hematomas formed in muscle fibers related to injury are the main factor associated with the inflammatory cascade that leads to the formation of osteoblast in muscle and in turn ossification of said muscle. Treatment usually consists in controlling the risk factors (ongoing trauma) and avoiding formation or enlargement of muscle hematoma in acute cases; however, the use of bisphosphonates as an adjunct treatment, has been reported to be beneficial in some cases. In chronic cases, such as this one, surgical removal of these ossifications can be considered to improve range of motion of the joints and to better control pain.

BACKGROUNDGranulomatosis with polyangiitis (GPA) is a necrotizing vasculitis that predominantly affects small-sized arteries. The most affected organs include the upper respiratory tract (sinusitis, rhinorrhea, otitis media), lower respiratory tract (alveolar hemorrhage and pulmonary nodules) and kidneys (glomerulonephritis). It is strongly associated with antineutrophil cytoplasmic antibody (ANCA) and antiproteinase-3 (PR3) positivity. Central nervous system involvement may occur, but pituitary involvement is rare. This is a case report of panhypopituitarism due to granulomatous hypophysitis in a patient diagnosed with GPA. CASE REPORTA 40-year-old man, with a previous history of panhypopituitarism due to granulomatous hypophysitis without defined etiology. He reported sinusitis with purulent rhinorrhea, recurrent otitis media, chronic headaches, and reduced visual acuity. Magnetic resonance imaging of sella turcica showed areas of low signal intensity on T2 and pituitary stalk thickening. Chest computed tomography showed two granulomatous lesions measuring 1.6 and 0.9 cm. ANCA and PR3 were positive, all screenings for infectious diseases were negative; renal function and urinalysis were normal. Histology of pulmonary nodule obtained by excisional biopsy showed neutrophilic vasculitis with areas of necrosis and granulomas, compatible with GPA, further sample analysis was negative for fungi and mycobacteria. The patient was treated with pulse therapy (1 g methylprednisone) for 3 days, followed by prednisone 40 mg/day and monthly cycles of IV cyclophosphamide. Currently, the patient is being monitored by the rheumatology team. CONCLUSIONGPA is a small-size arteries vasculitis associated with ANCA positivity and presents a variability in relation to organ involvement as well as disease severity. The main sites affected are the upper respiratory tract, lungs and kidneys, but other organs can be affected, such as skin, eyes, heart, gastrointestinal tract, urinary tract and liver. The central nervous system may be involved, mainly in the form of mononeuritis multiplex, sensory alterations, cranial nerve alterations and tumors. Granulomatous hypophysitis due to GPA is rare, less than 100 cases have been described in the literature. Treatment consists of two phases, induction with glucocorticoids associated with rituximab or cyclophosphamide, aiming at disease remission followed by maintenance. Rituximab, azathioprine, methotrexate, and mycophenolate are options for maintenance therapy.

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