The importance of ultrasonography in detecting joint calcification in pregnant women with rhupus

Manuscript type : Brief Report | Article Date : 2015/07/06

  • Autors

    1. Kucuk Adem
    2. Basturk Abdulkadir
    3. Bagcaci Sinan
    4. Turac Cingoz Havva
    5. Kucuksen Sami
    6. Yesildag Ahmet
    7. Tunc Recep
  • Abstract

    Here we present a pregnant woman diagnosed with Rhupus (SLE and RA overlap syndrome) and CREST syndrome (calcinosis cutis, Raynaud"s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia) using ultrasonography for the diagnosis of calcinosis cutis while investigating the etiology of proteinuria. Since our case was pregnant, arthritis and hardness in her fingers were assessed by USG as a radiological imaging. The USG examination detected tenosynovitis, nodular calcification, and erosions in all PIP levels and the patient"s treatment was arranged. USG can be successfully used in the assessment of the involvement of musculoskeletal system in the ligaments diseases especially to avoid harmful effects of X-rays on the pregnancy, just as we did in our own case.
  • Description

    CASE REPORT

    Our case was a pregnant woman diagnosed with Rhupus and CREST syndrome using ultrasonography for the diagnosis of calcinosis cutis while investigating the etiology of proteinuria. The 28-year-old patient came to our clinic with complaints of constantly increasing proteinuria, and swelling and pain in joints at her 20th gestational week. The patient had received treatment of methotrexate, sulphasalazine, and steroid with the diagnosis of rheumatoid arthritis for 8 years, and had stopped all these drugs with her plan to become pregnant. Her physical examination revealed the presence of malar erythema, telangiectasia (in hands and face), 3 positive pretibial edema, arthritis in the 2, 3 and 4 metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in the fingers, and hardness in the finger dorsal side. Her wrist movements were painful. Moreover, the patient defined the Raynaud"s phenomenon. The patient had 3.4 g proteinuria in her 24-hour urine with antinuclear antibody titer of 1/320 (homogenous, centromeric) and positive anti-dsDNA. In addition, in the patient"s extractable nuclear antigen profile (ENA), Smith (Sm), Ribonucleoprotein (RNP), SS-A/Ro, and CENP-B were positive. Anticardiolipin IgG and M were negative. C3 and C4 levels were normal. Rheumatoid factor (RF) was negative. There was no abnormality in the calcium and phosphorous metabolism. As there were arthritis and hardness in fingers, USG, a non-invasive procedure, was used for the assessment. In the USG, there were mild tenosynovitis in the first finger bilateral flexor tendons and hypoechoic nodular calcified sites in all PIP joint levels (Figs. 1a, 1b and 1c). Mild erosion was observed in again all PIP levels. Clinical and laboratory findings led to the diagnosis of Rhupus and CREST syndrome and the administration of hydroxychloroquine 200 mg 2x1 and prednisolone 5 mg 2x1 tablets. The literature in English was searched, and no other case was found reporting the coexistence of Rhupus and CREST syndromes. This case is the first one in which Rhupus and CREST syndromes coexisted. Calcinosis cutis develops as a result of calcium deposition in the subcutaneous soft tissue and may occur in intramuscular, intracutaneous, subcutaneous, and facial sites (1, 2). Dermatomyositis and dystrophic calcinosis in scleroderma (SSc) can be observed rarely in the systemic lupus erythematosus, a collagen tissue disease (2, 3). Since our case was pregnant, arthritis and hardness in her fingers were assessed by USG as a radiological imaging, as Huseyin T et al. indicated in their article (4). The USG examination detected tenosynovitis, nodular calcification, and erosions in all PIP levels and the patient"s treatment was arranged.

    CONCLUSION

    USG can be successfully used in the assessment of the involvement of musculoskeletal system in the ligaments diseases especially to avoid harmful effects of X-rays on the pregnancy, just as we did in our own case.

  • Reference

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