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Aseptic spondylodiscitis in a patient with polymyalgia rheumatica
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  1. Hidekatsu Yanai,
  2. Nobuyuki Furutani,
  3. Hiroshi Yoshida,
  4. Norio Tada
  1. The Jikei University School of Medicine, 163-1 Kashiwashita, Kashiwa, 277-8567, Japan
  1. Hidekatsu Yanai, yanaih{at}jikei.ac.jp

http://dx.doi.org/10.1136/bcr.02.2009.1555

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    An 85-year-old man was admitted to the Department of Orthopaedics with fever, polyarthralgia and back pain. Laboratory evaluation was notable for a C-reactive protein (CRP) level of 21.2 mg/dl (normal range, <0.3 mg/dl) and a leukocyte count of 13 400 cells/μl, however, no bacteria were detected in his blood culture. T2-weighted MRI of the lumbar spine revealed a high intensity in the L2–L3 disc (fig 1), and he was diagnosed as having suppurative spondylodiscitis and treated using antibiotics. However, his symptoms and serum CRP level (8.0 mg/dl) were not ameliorated, and the high intensity in the L2–L3 disc on lumbar spinal MRI still existed 2 weeks after the start of antibiotic therapy; he was then referred to our department. Symmetrical gallium-67 uptake in joints including shoulders and pelvic girdle on scintigraphy (fig 2), and elevated levels of serum matrix metalloproteinase 3 (136 ng/ml; normal range, 17.3–59.7 ng/ml) and vascular endothelial growth factor (1260 pg/ml; normal range, <115 pg/ml) as a synovial derived marker of inflammation suggested the presence of polymyalgia rheumatica (PMR).1,2 Gallium-67 uptake was also observed in the lumbar spine around L3, and gallium-67 uptake in the posterior image was more intense than that in the anterior image, suggesting the existence of spondylodiscitis. The patient’s clinical and biochemical characteristics showed a good agreement with the PMR diagnostic criteria.3 Corticosteroid therapy (20 mg/day) promptly ameliorated his symptoms and serum CRP (0.3 mg/dl at 10 days after corticosteroid therapy started), supporting the diagnosis of PMR.

    Figure 1
    Figure 1

    T2-weighted MRI of the lumbar spine revealed a high intensity (arrow) in the L2–L3 disc.

    Figure 2
    Figure 2

    Symmetrical gallium-67 uptake in joints including shoulders and pelvic girdle on scintigraphy (black arrows); gallium-67 uptake (posterior–anterior) was also observed in the lumbar spine around L3 (white arrows).

    LEARNING POINTS

    • This patient is the first case with polymyalgia rheumatica (PMR) who manifested aseptic spondylodiscitis.

    • PMR is occasionally accompanied with fever and an elevated serum C-reactive protein (CRP) level.

    • As this condition mimics infectious spondylodiscitis, it is important to recognise aseptic spondylodiscitis in PMR.

    REFERENCES

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      3. Franchimont N,
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      . Increased matrix metalloproteinase-3 serum levels in rheumatic diseases: relationship with synovitis and steroid treatment. Ann Rheum Dis 2002; 61: 161–6.
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Meliconi R,
      2. Pulsatelli L,
      3. Dolzani P,
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      . Vascular endothelial growth factor production in polymyalgia rheumatica. Arthritis Rheum 2000; 43: 2472–80.
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      1. Dasgupta B,
      2. Salvarani C,
      3. Schirmer M,
      4. et al
      . Developing classification criteria for polymyalgia rheumatica: comparison of views from an expert panel and wider survey. J Rheumatol 2008; 35: 270–7.
      OpenUrlAbstract/FREE Full Text

    Footnotes

    • Competing interests: None.

    • Patient consent: Patient/guardian consent was obtained for publication.