Elsevier

Joint Bone Spine

Volume 70, Issue 3, June 2003, Pages 226-229
Joint Bone Spine

Case report
Late-onset spondyloarthropathy mimicking reflex sympathetic dystrophy syndrome

https://doi.org/10.1016/S1297-319X(03)00041-1Get rights and content

Abstract

Atypical presentations are common when spondyloarthropathy develops in older patients. We report two cases initially mistaken for reflex sympathetic dystrophy syndrome (RSDS). Both the patients were men, aged 62 and 75 years, respectively, with marked painful edema of a foot. One patient reported a moderate-energy trauma as the triggering event. Severe diffuse demineralization was noted on radiographs and diffuse hyperactivity on bone scans starting at the early vascular phase. These findings suggestive of RSDS led to treatment with calcitonin, griseofulvin, and pamidronate, all of which were ineffective. Laboratory tests showed severe inflammation, promoting investigations for other conditions. Spondyloarthropathy was diagnosed based on oligoarthritis with sacroiliitis, presence of HLA B27, and a favorable response to non-steroidal antiinflammatory therapy. In older patients, edema of the foot with severe demineralization and the laboratory evidence of inflammation should suggest a spondyloarthropathy.

Section snippets

Case-report 1

A 62-year-old farmer experienced spontaneous onset of painful swelling of his right foot in December 1999. In May 2000, radiographs showed severe demineralization of the ankle and entire foot. The erythrocyte sedimentation rate (ESR) was 57 mm/h and the C-reactive protein (CRP) level was 82 mg/l. Naproxen therapy provided only short-lived relief. In July 2000, a Tc99m bone scan revealed marked diffuse hyperactivity of the ankle and foot, starting at the early vascular phase (Fig. 1). RSDS was

Case-report 2

Painful swelling of the right ankle and foot developed in May 2000, in this 75-year-old man, after a moderate-energy trauma. Radiographs taken in August 2000 showed severe patchy demineralization of the tarsal bones, forefoot, and ankle, without joint space loss (Fig. 2). This pattern suggested RSDS. However, the results from the laboratory tests showing marked inflammation (ESR, 74 mm/h and CRP 78 mg/l) prompted admission of the patient. A low-grade fever of 37.8 °C was noted. He had no

Discussion

In these two patients, the diagnosis of spondyloarthropathy was based on the presence of rheumatoid-factor negative asymmetric oligoarthritis of the lower limbs with a relapsing course, presence of HLA B27, and sacroiliitis visible on radiographs in one patient and by bone scanning in the other. In both patients, NSAIDs were only partly effective, as is often the case in the elderly [3]. The laboratory test evidence of severe inflammation, decline in general health, and asymmetric lower limb

References (7)

  • J.J. Dubost et al.

    Rhumatismes séronégatifs à début tardif. Fréquence et atypies des spondylarthropathies

    Rev Rhum

    (1991)
  • J.J. Dubost et al.

    Late onset peripheral spondylarthropathy

    J Rheumatol

    (1989)
  • D. Caplanne et al.

    Late onset spondylarthropathy: clinical and biological comparison with earlyonset patients

    Ann Rheumatol Dis

    (1997)
There are more references available in the full text version of this article.

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