BACKGROUNDReactive arthritis is a form of spondyloarthritis characterized by sterile synovitis induced by an extra-articular infection, usually of the genitourinary and/or gastrointestinal tract. The most common cause is Chlamydia trachomatis, but Neisseria gonorrhoeae and Ureaplasma urelyticum are also implicated. Axial involvement is frequent: half of the cases involve the lumbar spine, sacroiliitis is described in 15-30% and enthesitis in 30%. We will describe an unusual case of gonococcal-induced atlantoaxial synovitis. CASE REPORTFemale, 50 years old, previously healthy, hospitalized for 7 days of evolution characterized by excruciating neck pain, with stiffness and limited range of motion. Fourteen days ago, she treated profuse vaginal discharge with nitroimidazole. At no time she presented fever, urinary, gastrointestinal, ocular and/or cutaneous manifestations. Initial laboratory tests showed leukocytosis without deviation and increased acute phase reactants, both of which were rapidly increasing. Magnetic resonance imaging (MRI) showed synovitis in the lateral atlantoaxial joints and a thickening with enhancement in the capsuloligamentous structures. Due to the possibility of a reactional condition, but not being able to exclude an infectious process and considering the topography, oral corticosteroids and antibiotics were started concomitantly, with satisfactory results. Finally, PCR for N. gonorrhoeae in urine was positive, and HLA B27 was absent, with the remaining autoantibodies negative. CONCLUSIONThe occurrence of atlantoaxial synovitis can be considered a very rare presentation of postgonococcal reactive arthritis, probably one of the first reported cases. It is worth remembering that in the case above, the main differential diagnosis was gonococcal arthritis, but no manifestation of disseminated disease was present.

BACKGROUNDPolyarteritis nodosa (PAN) is a systemic vasculitis of small and medium-sized arteries. Neurological involvement, mostly peripheral neuropathy, occurs in one fourth of cases. Subarachnoid hemorrhage (SAH), usually due to aneurism rupture, is a rare event in PAN. We herein describe a yet more unusual case of a non-aneurysmal medullary SAH as initial presentation of PAN. CASE REPORTThe patient, a 56-year-old woman, was admitted due to an excruciating dorsolumbar pain. A previous history of hypertension was referred. In hospital, refractory hypertension demanded intensive care for a week. Magnetic resonance image (MRI) disclosed a typical, extensive, medullary SAH. A cranial MRI showed a small focus of SAH in the posterior region. Arteriography demonstrated aneurisms of hepatic, splenic and small-sized renal arteries; no aneurisms were seen in cerebral or medullary arteries. C-reactive protein was raised (8 mg/dL), but no autoantibodies were detected. Given the high possibility of PAN, a combined pulse of methylprednisolone and cyclophosphamide was carried out, with satisfactory outcome. The patient is now on high-dose prednisone, monthly intravenous cyclophosphamide and antihypertensives.

BACKGROUNDGranulomatosis with polyangiitis (GPA) is a form of vasculitis associated with antineutrophil cytoplasmic antibodies, characterized by granulomatous inflammation and varied degrees of focal necrotizing vasculitis, affecting medium and small blood vessels. This disease has a tropism to the respiratory tract and kidneys. Among the neurological manifestations, peripheral neuropathy is the most common type of neurological involvement and central nervous system involvement has been reported in 7-11% of patients. We report a case of GPA in a patient with neurological symptoms and pachymeningeal thickening. CASE REPORTA 46-year-old female patient sought the Emergency Department due to two episodes of seizures, being hospitalized for investigation. Patient had been using hydroxychloroquine 400 mg daily for 1 year due to a history of bilateral parotitis, arthralgias, purpuric dermatitis, reagent ANA and reagent anti-SSA(Ro). Magnetic resonance imaging demonstrated an area of gadoliniumenhancing nodular thickening of the pachymeningeal lining in the left temporo-occipital transition, with a thickness of 0.6 cm, and vasogenic edema in the white matter of the adjacent parenchyma. She had elevated acute phase reagents, c-ANCA reagent up to 1/20, nonreactive antiproteinase-3 and antimyeloperoxidase. The biopsy of the meningeal lesion showed chronic inflammation with palisade granuloma and central necrosis, favoring the diagnosis of granulomatosis with polyangiitis involving the central nervous system. The patient was discharged from the hospital asymptomatic and on high-dose prednisone, with an outpatient plan to start immunosuppressants. CONCLUSIONWe report a case of granulomatosis with polyangiitis presenting central nervous system evidenced by imaging exam, an uncommon form of manifestation of this condition.

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BACKGROUNDBone and joint tuberculosis reaches up to 35% of cases of extrapulmonary tuberculosis (TB), especially in immunosuppressed patients. Skeletal TB most often involves the thoracic spine (Pott's disease), followed by tuberculous arthritis in weight-bearing joints and extraspinal TB osteomyelitis. The sacroiliac joint (SI) is an uncommon site of infection and its diagnosis is often delayed. CASE REPORTA 37-year-old woman, housewife, with no comorbidities, presents with a 6-month progressive inflammatory low back and right gluteal pain. During this time, she used several anti-inflammatory drugs with partial improvement of symptoms and frequent recurrence. Two weeks before admission, she started presenting evening fever and night sweats and was treated with amoxicillinclavulanate for seven days, with no improvement in symptoms. There was a loss of 5 kg throughout the period. She came to the emergency with disabling low back pain, no respiratory, genitourinary or gastrointestinal symptoms. Her physical examination revealed stable vital signs, pain in SI topography, and positive Patrick's and Gaenslen's tests. Laboratory tests were performed showing mild normocytic normochromic anemia, high levels of erythrocyte sedimentation rate and C-reactive protein, negative viral serology. Magnetic resonance imaging (MRI) of sacroiliac joints revealed sacroiliitis with inflammatory and infectious features (Figure 1). A computed tomography (CT) was carried out to guide a biopsy, also showing bone erosions (Figure 2). A chest CT demonstrated a miliary pattern (Figure 3). Joint fluid showed a rapid test (PCR) for Mycobacterium tuberculosis and negative acid-fast bacillus (AFB) test. Mycobacterium tuberculosis culture and IGRA (interferon gamma release assay) were performed with a positive result. Treatment with rifampicin, isoniazid, pyrazinamide and ethambutol were started.